Reduction of Risk Potential – 2

Nasogastric Tubes Nursing Considerations:

Insertion:

  1. Client Positioning: Place the client in the high Fowler position (head elevated at 90 degrees).
  2. Measuring Depth: Measure from the tip of the nose to the earlobe to the xiphoid process to determine the insertion depth. Mark the tube with tape at the correct depth.
  3. Tube Lubrication: Lubricate the tube with a water-soluble jelly (not oil-soluble) to prevent pneumonia risk if the tube slips into the bronchus.
  4. Head Position: Instruct the client to bend the head forward to close the epiglottis and open the esophagus. For intubated or semiconscious clients, flex the head toward the chest while passing the tube.
  5. Insertion: Insert the tube into the nostril, advance it backward through the nasopharynx, and have the client sip water while advancing the tube as they swallow. Do not force the tube; if respiratory distress occurs during insertion, pull back and wait for distress to subside.
  6. Taping in Place: Advance the tube to the marked depth and tape it in place when placement is confirmed.
  7. Positioning: Position the client with the head of the bed elevated at 30 degrees unless contraindicated.
  8. X-Ray Confirmation: Prepare for an x-ray to confirm tube placement. If using a Salem Sump tube, keep the air vent unclamped and above stomach level. In case of leakage through the air vent, instill 30 mL of air and irrigate the main lumen with normal saline.

Assessing Placement:

  • X-Ray Confirmation: The most reliable method for assessing placement is an x-ray, to be performed after initial placement.
  • Non-Radiological Methods: If x-ray confirmation is not possible, aspirating fluid from the tube, measuring its pH (should be 4 or less), and describing its appearance are effective non-radiological methods.
  • Assessment Frequency: Assess tube placement every 4 hours and before medication or feeding administration. Confirm the tube length matches previous measurements.
  • Auscultation Limitation: Auscultation after inserting 5 to 10 mL of air into the tube is not reliable for verification because misplaced tubes may transmit sounds similar to those of air entering the stomach.

Residual Volume, Irrigation, and Removal:

  • Residual Volume: Check residual volume every 4 hours, before feedings and medications. Aspirate and measure the volume, and return it to the stomach unless it appears abnormal.
  • Irrigation: Irrigate every 4 hours to check tube patency. Gently instill 30 to 50 mL of water or normal saline and withdraw to check patency.
  • Tube Removal: To remove the tube, ask the client to take a deep breath and hold it. Slowly and evenly draw the tube out over 3 to 6 seconds, coiling it around the hand as it is removed.

Gastrointestinal Tube Feeding:

  • Positioning: Position the client in high Fowler (or semi-Fowler if continuous feeding is used) and warm the feeding solution to room temperature.
  • Residual Volume: Aspirate and measure residual volume before feedings; return it to prevent electrolyte imbalances.
  • Tube Placement: Assess tube placement and bowel sounds; notify the healthcare provider if bowel sounds are absent.
  • Post-Bolus Feeding Positioning: Keep the client in high Fowler for 30 minutes after bolus feeding.

Jejunostomy Tube:

  • Continuous Tube Feeding: If administering a continuous feeding, position the client in a semi-Fowler position.

Nursing Considerations for Administering Medication through Tubes:

  • Crushing Medication: Crush or use an elixir form if the medication allows.
  • Dissolving Medication: Dissolve crushed medication or capsule contents in 5 to 10 mL of water.
  • Checking Placement: Verify tube placement and residual volume before instilling medication.
  • Administration: Draw up the medication into a catheter-tip syringe, clear excess air, and insert medication into the tube.
  • Flushing: Flush the tube with 30 to 50 mL of water or normal saline solution after administering medication.
  • Clamping: Depending on the medication and agency policy, clamp the tube for 30 to 60 minutes.

Chest Radiography:

  • An imaging procedure (x-ray) for assessing the lungs and heart.
  • Nursing considerations: Assess the client’s ability to inhale and hold their breath.

Sputum Specimen Collection:

  • Obtaining specimens through expectoration or tracheal suctioning for identifying organisms or abnormal cells.
  • Nursing considerations: Follow agency policy for specimen collection, obtain a morning sterile specimen, instruct the client to rinse their mouth, obtain 15 mL of sputum, and transport the specimen promptly if a culture is needed.

Suctioning:

  • Removal of respiratory secretions in clients unable to clear them.
  • Nursing considerations: Hyperoxygenate the client, use aseptic technique, insert the catheter without suction initially, apply suction intermittently, and monitor the client’s tolerance and breath sounds.

Laryngoscopy and Bronchoscopy:

  • Invasive procedures for direct visualization of the larynx, trachea, and bronchi using a bronchoscope.
  • Nursing considerations: NPO after midnight, assess coagulation studies, remove dentures and eyeglasses, have suction equipment ready, administer sedation if prescribed, monitor for complications, and withhold food and drink until the gag reflex returns.

Pneumothorax:

  • Accumulation of atmospheric air in the pleural space due to a rupture of the pleura.
  • Nursing considerations: Monitor for signs of pneumothorax, air embolism, and pulmonary edema.

Thoracentesis:

  • Removal of fluid or air from the pleural space through transthoracic aspiration.
  • Nursing considerations: Prepare for ultrasound or chest radiography, assess coagulation studies, position the client correctly, instruct the client not to move or cough, and monitor for complications.

Skin Testing to Diagnose Respiratory Disease:

  • Intradermal injections used for diagnosing infectious diseases like tuberculosis.
  • Nursing considerations: Check for hypersensitivity, choose a suitable test site, document the procedure, and instruct the client not to scratch or wash the site.

Pulmonary Function Test:

  • Evaluates lung function using a spirometer.
  • Nursing considerations: Avoid scheduling after meals, consult regarding bronchodilator use, assess respiratory distress, and report abnormalities.

Oxygen Therapy:

  • Administration of supplemental oxygen for tissue hypoxia.
  • Nursing considerations: Assess client’s vital signs and color, use humidification, prevent smoking around oxygen, and store oxygen cylinders properly.

Nasal Cannula:

  • Delivers oxygen at flow rates of 1 to 6 L/min.
  • Nursing considerations: Ensure proper placement, add humidification as needed, assess mucosa and skin integrity, and apply water-soluble jelly if necessary.

Simple Face Mask:

  • Delivers oxygen concentrations of 40% to 60%.
  • Nursing considerations: Ensure a secure fit, assess skin under the mask, monitor for aspiration, and consider switching to a nasal cannula during meals.

Partial Rebreather Mask:

  • Provides oxygen concentrations of 70% to 90%.
  • Nursing considerations: Prevent twisting or kinking of the reservoir bag, adjust flow rate, and maintain bag inflation during inspiration.

Nonrebreather Mask:

  • Delivers oxygen concentrations >90%.
  • Nursing considerations: Ensure valve and flaps are intact, prevent kinking, and monitor for suffocation if the reservoir bag deflates.

High-Flow Oxygen-Delivery Systems:

  • Provide oxygen concentrations of 24% to 100% at flow rates of 8 to 15 L/min.
  • Nursing considerations: Maintain proper function, assess skin and airway, empty tubing condensation, and ensure adequate humidification.

Mechanical Ventilation:

  • Used when a client cannot breathe adequately to maintain proper oxygen and carbon dioxide levels in the blood.
  • Different ventilator modes are tailored to individual client needs.
  • Types of apparatus include negative-pressure and positive-pressure ventilators.

Controlled Ventilation:

  • Used for clients unable to initiate respiratory effort.
  • Delivers a set tidal volume at a set rate.
  • Blocks client’s attempts to initiate breaths.

Assist-Control (AC) Mode:

  • Delivers a preset tidal volume and rate.
  • Responds to the client’s inspiratory effort if they initiate a breath.
  • May lead to hyperventilation and respiratory alkalosis if spontaneous ventilatory rate increases.

Synchronized Intermittent Mandatory Ventilation (SIMV):

  • Allows clients to breathe spontaneously between ventilator breaths.
  • Can be used as a primary ventilatory mode or during weaning.
  • Weaning mode involves gradually decreasing SIMV breaths as the client resumes spontaneous breathing.

Mechanical Ventilation Nursing Considerations:

    • Prioritize client assessment.
    • Assess vital signs, lung sounds, respiratory status, and breathing pattern.
    • Monitor skin color, especially lips and nail beds.
    • Check chest for bilateral expansion.
    • Obtain pulse oximetry readings and arterial blood gas results.
    • Assess the need for suctioning and note secretions.
    • Review ventilator settings.
    • Monitor humidifier water level and temperature.
    • Ensure alarms are active and never disable them.
    • If alarm cause is unclear, manually ventilate with a resuscitation bag.
    • Empty ventilator tubing when moisture collects.
    • Turn the client every 2 hours or mobilize per prescription to prevent complications.
    • Keep resuscitation equipment at the bedside.
    • Monitor for signs and symptoms of complications related to mechanical ventilation.

Causes of Ventilator Alarms:

High-Pressure Alarm:

  • Increased secretions in the airway.
  • Wheezing or bronchospasm, leading to a narrowed airway.
  • Displacement of the endotracheal tube.
  • Obstruction of the endotracheal tube by water or a kink in the tubing.
  • Coughing, gagging, or biting on the oral endotracheal tube.
  • Anxiety on the part of the client, especially if they resist the ventilator.

Low-Pressure Alarm:

  • Disconnection or leak in the ventilator or in the client’s airway cuff.
  • Cessation of spontaneous breathing by the client.

Endotracheal Tube:

  • A device used to maintain a patent airway and is indicated when a client requires mechanical ventilation.
  • Tracheostomy may be considered for long-term airway management.
  • Nasotracheal tubes, although discouraged in clients with bleeding disorders, are more comfortable and prevent manipulation by the tongue but are rarely used due to increased risk of sinusitis.

Complications of Mechanical Ventilation:

  • Hypotension.
  • Pneumothorax or subcutaneous emphysema (crepitus).
  • Gastrointestinal alterations, including stress ulcers.
  • Malnutrition.
  • Infection.
  • Muscle deconditioning.
  • Ventilator dependence or inability to be weaned.

Mechanical Ventilation Nursing Considerations for Weaning:

Weaning Process:

  • Transition from ventilator dependence to spontaneous breathing.

SIMV (Synchronized Intermittent Mandatory Ventilation):

  • Client breathes between preset ventilator breaths per minute.
  • Gradually decrease the SIMV rate until the client can breathe without the ventilator.

T-Piece or Constant Partial Airway Pressure:

  • Replaces the ventilator with a T-piece delivering humidified oxygen.
  • Initially, the client is taken off the ventilator for short periods to breathe spontaneously.
  • Weaning progresses as the client tolerates longer periods off the ventilator.

Pressure Support:

    • Predetermined pressure on the ventilator assists the client’s respiratory effort.
    • Gradually reduce the amount of pressure as weaning continues.

Endotracheal Tubes Nursing Considerations Placement and Ventilation:

  • Confirm proper placement with an end-tidal CO2 detector by noting the presence of exhaled CO2 from the lungs and chest x-ray.
  • Auscultate both sides of the chest during manual ventilation with a resuscitation bag.
  • Monitor for stomach auscultation to rule out esophageal intubation.
  • Secure the tube with adhesive tape or a commercial holder.
  • Monitor tube position at the lip or nose and skin/mucous membrane integrity.
  • Perform suctioning as needed and hyperoxygenate before suctioning.
  • Move the oral tube to the opposite side of the mouth daily to prevent pressure and necrosis.
  • Avoid client pulling or tugging on the tube.
  • Keep a resuscitation bag at the bedside.
  • Maintain cuff inflation for a seal and control of respiration.Nasotracheal tube: A smaller tube inserted through the nose.
  • Increases airway resistance and the client’s breathing effort.
  • Generally discouraged in clients with bleeding disorders.
  • Provides greater comfort for the client.
  • Prevents manipulation of the tube by the tongue.
  • Rarely used due to an elevated risk of sinusitis.

Tracheostomy Tubes:

  • Tracheostomy is an opening created during tracheotomy.
  • Types of tubes:
    • Single-lumen tracheostomy tube (no inner cannula) for clients with thick necks.
    • Double-lumen cannula with outer, inner cannula, and obturator for insertion.
    • Cuffed tracheostomy tube for mechanical ventilation.
    • Cuffless or metal tracheostomy tube for long-term airway management.
    • Fenestrated tracheostomy tube for weaning and speech.
    • Cuffed fenestrated tube for mechanical ventilation and speech.

Nursing Considerations for Tracheostomy Tubes:

  1. Assess respirations and bilateral breath sounds.
  2. Monitor arterial blood gases and pulse oximetry.
  3. Encourage coughing and deep breathing.
  4. Keep the client in a semi-Fowler to high Fowler position.
  5. Watch for bleeding, difficulty breathing, absence of breath sounds, and crepitus.
  6. Perform suctioning, hyperoxygenate before suctioning.
  7. Sit the client up for meals, inflate the cuff if the tube is not capped.
  8. Monitor cuff pressures as prescribed.
  9. Check stoma and secretions for blood and purulent drainage.
  10. Follow cleaning procedures for the tracheostomy site and inner cannula.
  11. Administer respiratory treatments as prescribed.
  12. Provide humidified oxygen as prescribed.
  13. Obtain assistance for changing tracheostomy ties.
  14. Never insert a cap or plug into the tube until the cuff is deflated and the inner cannula is removed.
  15. Keep resuscitation equipment and supplies at the bedside.

Preventing Tracheostomy Complications:

  • Tube Obstruction:
    • Help the client cough and deep-breathe.
    • Provide humidification.
    • Perform suctioning as needed.
    • Regularly clean the inner cannula.
  • Tube Dislodgment:
    • Ensure a tracheostomy tube of the same type and size is available at the client’s bedside.
    • Follow agency policy for tracheostomy tube replacement.
  • Tracheoesophageal Fistula (TEF):
    • Excessive cuff pressure can cause erosion, leading to a hole between the trachea and the esophagus.
    • Administer oxygen by mask to prevent hypoxemia.
    • Consider using a small, soft feeding tube instead of a nasogastric tube for feedings.
    • Gastrostomy or jejunostomy may be performed.
  • Trachea-Innominate Artery Fistula (TIAF): (Emergency situation)
    • Mispositioning of the tube can lead to erosion of the innominate artery.
    • Remove the tracheostomy tube immediately.
    • Apply direct pressure to the innominate artery at the stoma site.

Tube Dislodgment Interventions: Within 72 Hours After Tracheostomy Construction:

  • Manually ventilate the client with a resuscitation (Ambu) bag.
  • Have another nurse call the resuscitation team for assistance.

More Than 72 Hours After Tracheostomy Construction:

  • Extend the client’s neck and open the stoma tissues to secure an airway.
  • Grasp the retention sutures (if present) to spread the opening.
  • Use a tracheal dilator (curved hemostat clamp) to hold the stoma open.
  • Prepare to insert a tracheostomy tube if allowed by the agency.
  • Place a saline solution-lubricated obturator into the tracheostomy tube
  • Replace the tube
  • Remove the obturator from the tube.
  • Maintain ventilation using a resuscitation (Ambu) bag.
  • Assess airflow and breath sounds in both lungs.
  • If unable to secure the airway, call the resuscitation team and anesthesiologist for assistance.

Chest Tube Drainage System:

  • Device used to restore negative pressure to the intrapleural space or remove abnormal accumulations of air and fluid from the pleural space.

Nursing Considerations:

  • Monitor drainage in the collection chamber.
  • Notify the primary health care provider if drainage exceeds 100 mL/hour or becomes bright red or suddenly increases.
  • Mark chest tube drainage in the collection chamber at 1- to 4-hour intervals.
  • Observe water oscillation in the water seal chamber with client’s inhalation and exhalation.
  • Note that fluctuation stops if the tube is obstructed, has a dependent loop, suction issues, or if the lung has re-expanded.
  • Continuous bubbling in the water seal chamber indicates an air leak.
  • Notify the primary health care provider if continuous bubbling is observed.
  • Suction-control chamber provides adjustable suction.
  • Gentle bubbling in this chamber is expected; vigorous bubbling indicates an air leak.
  • Maintain an occlusive sterile dressing at the insertion site.
  • Use chest radiography to assess tube position and lung re-expansion.
  • Monitor the client’s respiratory status and auscultate lung sounds.
  • Keep the drainage system below chest level and ensure tube integrity.
  • Ensure secure connections.
  • Encourage coughing and deep breathing.
  • Change the client’s position frequently.
  • Do not strip or milk the chest tube without specific direction from the primary health care provider.
  • Keep a clamp and sterile occlusive dressing at the bedside.
  • Do not clamp a chest tube without a written prescription.
  • If the drainage system breaks, replace it immediately with a new system.
  • If the chest tube is accidentally pulled out, apply an occlusive dressing and notify the primary health care provider.
  • During removal of the chest tube, have the client take a deep breath or exhale (depending on provider preference) and perform the Valsalva maneuver.
  • Apply a sterile dressing or non-adherent dressing after tube removal.

Electrocardiography (ECG):

  • Noninvasive diagnostic test recording heart’s electrical activity.

Nursing Considerations:

  • Instruct the client to lie still, breathe normally, and refrain from talking.
  • Reassure the client about the absence of electrical shocks.
  • Document the client’s cardiac medications.

Holter Monitoring:

  • Client wears a monitor for continuous 24-hour electrocardiographic tracing.
  • Identifies dysrhythmias and assesses the effectiveness of antidysrhythmics or pacemaker therapy.

Holter Monitoring Nursing Considerations:

  • Instruct the client to continue normal activities (except bathing) and maintain a diary of activities and symptoms.

Echocardiography:

  • Noninvasive ultrasound-based procedure to evaluate heart structure and function.

Echocardiography Nursing Considerations:

  • Instruct the client to lie still, breathe normally, and avoid talking.
  • May require position changes during the test.

Positron Emission Tomography (PET) Scan:

  • Uses radionuclides to evaluate myocardial perfusion and metabolic function.
  • Matching scans indicate normalcy, differing scans suggest ischemia or damage.

Nursing Considerations:

  • Explain the procedure to the client.
  • Ensure glucose levels are between 60-140 mg/dL.
  • Advise NPO status and avoidance of tobacco/caffeine 24 hours before the test if exercise is included.

Exercise Testing (Stress Test):

  • Evaluates heart function during activity, often involving treadmill testing.

Stress Test Nursing Considerations:

  • Encourage adequate rest before the procedure.
  • Advise a light meal 2 hours before the test.
  • Instruct to avoid smoking, alcohol, and caffeine pre-test.
  • Confirm medication instructions with the healthcare provider.
  • Recommend non-constrictive clothing and supportive shoes.
  • Advise reporting chest pain, dizziness, or shortness of breath.
  • Avoid hot baths/showers for 1-2 hours after the test.

Cardiac Catheterization:

  • Involves catheter insertion to inject dye for heart and vessel evaluation.

Cardiac Catheterization Nursing Considerations:

  • Assess for allergies.
  • Withhold fluids/food as prescribed.
  • Document height, weight, vital signs, and peripheral pulses.
  • Explain local anesthetic administration.
  • Prepare insertion site and administer pre-procedure medications.
  • Insert IV line if prescribed.

Post-Cardiac Catheterization Nursing Considerations:

  • Monitor vital signs and cardiac rhythm.
  • Check for chest pain, notify if dysrhythmia occurs.
  • Monitor peripheral pulses, extremity color, warmth, and sensation.
  • Report numbness, tingling, coolness, paleness, cyanosis, or pulse loss.
  • Watch for bleeding or hematoma formation, apply pressure if necessary.
  • Follow prescribed bed rest and extremity positioning.
  • Administer pressure device as prescribed.
  • Encourage fluid intake to promote dye excretion.
  • Monitor for hypersensitivity signs.

Percutaneous Transluminal Coronary Angioplasty:

  • Balloon catheter dilation of coronary artery to improve blood flow.

Nursing Considerations:

  • Administer anticoagulants and antiplatelet agents.
  • Monitor IV nitroglycerin administration.
  • Instruct the client on medication administration and lifestyle modifications.

Coronary Artery Stent:

  • Device placement to reduce acute vessel closure risk and improve long-term patency.
  • Balloon catheter with stent inserted into coronary artery at occlusion site.
  • Stent reopens blocked artery.

Coronary Artery Stent Nursing Considerations:

  • Monitor for acute thrombosis post-procedure.
  • Administer antiplatelet and anticoagulation therapy for several months.
  • Monitor for complications (e.g., stent migration/occlusion, coronary artery dissection, anticoagulant-induced bleeding, dysrhythmias).

Renal System Procedures: 

Urine Testing:

  • Urinalysis to evaluate renal system and detect renal disease.
  • Specific gravity measures kidney’s urine-concentrating ability.
  • Increase in specific gravity with insufficient fluid intake and decreased renal perfusion.
  • Decrease in specific gravity with increased fluid intake, diuretics, and diabetes insipidus.
  • Culture and sensitivity identifies microorganisms and effective antibiotics.

Nursing Considerations:

  • Instruct client to wash perineal area and provide clean container for urine collection.
  • Best to collect specimen from first or second morning voiding.
  • Refrigeration may alter specific gravity.
  • Note menstruation on lab requisition form.
  • Specific gravity testing methods: dipstick tests, refractometer, urinometer.
  • Normal range: 1.016 to 1.022.
  • Culture and sensitivity: Clean perineal area, collect midstream sample in sterile container.
  • Send specimen to lab immediately.
  • Urine too dilute for culture if client forces fluid intake.
  • Do not initiate prescribed antibiotics until specimen is collected.

24-Hour Urine Collection:

  • Evaluates kidney function.
  • May require blood draws at start and end of collection.
  • Discard first voided specimen and start collection.
  • Encourage adequate fluid intake before and during test.
  • Check with primary health care provider regarding medications and substance restrictions.
  • Maintain specimen on ice or refrigerate; check for preservative use.

Imaging Studies:

  • KUB (kidneys, ureters, and bladder) radiograph for urinary calculi detection.
  • Bladder ultrasonography for bladder urine volume measurement.
  • Renal angiography to visualize renal blood vessels and arterial supply.
  • Intravenous pyelography (IVP) outlines renal system for identifying abnormalities.

Nursing Considerations:

  • No specific preparation needed for KUB radiograph.
  • Renal angiography pre/post-procedure care similar to cardiac catheterization.
  • Monitor urine output closely after renal angiography.
  • Assess client for allergies before IVP; withhold food/fluids after midnight.
  • Inform client of possible sensations during IVP.
  • Encourage fluid consumption after IVP (unless contraindicated).
  • Monitor venipuncture site for bleeding and urine output after IVP.

Cystoscopy and Bladder Biopsy:

  • Examination of bladder mucosa for inflammation, calculi, or tumors using a cystoscope.
  • Biopsy specimen may be obtained.

Nursing Considerations:

  • Cystoscopy without biopsy requires no preparation.
  • Procedure can be done in the primary health care provider’s office or ambulatory care department.
  • Biopsy preparation may involve fasting after midnight before the test.
  • Encourage fluid intake and monitor urine output for color and consistency.
  • Pink-tinged or tea-colored urine is common; watch for bright-red urine or clots.
  • Notify primary health care provider if unusual signs/symptoms or urinary tract infection occur.

Renal Biopsy:

  • Needle inserted into kidney to obtain tissue sample for examination.

Nursing Considerations:

  • Assess baseline clotting studies before the procedure.
  • Withhold food and fluids after midnight before the test.
  • During the procedure, have the client lie prone with a pillow under abdomen and shoulders.
  • After the procedure, monitor hemoglobin and hematocrit levels.
  • Bed rest for 24 hours as prescribed.
  • Apply pressure on the biopsy site for 30 to 60 minutes.
  • Check the biopsy site for bleeding.
  • Encourage fluid consumption (1500 to 2000 mL) as prescribed.
  • Instruct client not to take anticoagulant or antiplatelet medications without permission from primary health care provider.
  • Advise against heavy lifting and strenuous activity for 2 weeks.
  • Monitor urine for blood and be alert for signs/symptoms of infection; notify primary health care provider if these occur.

Ureteral Catheterization and Nephrostomy Tube Placement:

  • Ureteral catheter placed through the ureter and advanced into the renal pelvis.
  • Nephrostomy tube placed in the renal pelvis when the ureter is completely obstructed.

Nursing Considerations:

  • Maintain patency; never clamp the tube.
  • Monitor urine output closely; report output less than 30 mL/hr or lack of output for more than 15 minutes to the primary health care provider immediately.
  • Irrigate the tube with sterile normal saline using strict aseptic technique only if prescribed by the primary health care provider.
  • During irrigation, instill a maximum of 5 mL of sterile normal saline solution slowly and gently.
  • If patency cannot be established with prescribed irrigation, notify the primary health care provider immediately.

Corneal Staining:

  • Instillation of a topical dye into the conjunctival sac to reveal irregularities of the corneal surface.
  • Eye is viewed through a blue filter; bright-green areas indicate non-intact corneal epithelium.

Nursing Considerations:

  • Remove contact lenses if the client wears them.
  • Instruct the client to blink after dye application to distribute it evenly across the cornea.

Tonometry:

  • Used primarily to check for increased intraocular pressure, which may indicate glaucoma.
  • Normal ocular pressure is 10 to 21 mm Hg.

Nursing Considerations:

  • Client should stare forward at a point above the examiner’s ear.
  • Contact tonometry, which requires a topical anesthetic, uses a flattened cone to measure the pressure needed to flatten the cornea.
  • Instruct the client not to rub the eye after anesthetization to avoid corneal scratching.

Glaucoma:

  • Increased intraocular pressure resulting from inadequate drainage of aqueous humor from the canal of Schlemm or overproduction of aqueous humor.
  • May cause damage to the optic nerve and potentially lead to blindness.

Audiometry:

  • Testing of hearing acuity, which includes pure-tone audiometry and speech audiometry.
  • Pure-tone audiometry identifies problems with hearing various sounds.
  • Speech audiometry measures the client’s ability to hear spoken words.
  • Audiogram patterns are depicted on a graph to determine the type and level of hearing loss.

Audiometry Nursing Considerations:

  • Instruct the client to identify sounds heard during the test.

Skull and Spinal Radiography:

  • Radiography of the skull reveals skull bone size, shape, fractures, defects, and more.
  • Spinal x-rays identify fractures, dislocations, injuries, curvatures, spinal cord issues, and degeneration.

Nursing Considerations:

  • Maintain neck immobilization if a spinal fracture is suspected.
  • Remove metal items from the body.
  • Note thick or heavy hair because it can affect radiograph interpretation.
  • Maintain immobilization until results are known.

Computed Tomography of the Brain (CT Scan):

  • Used to detect intracranial bleeding, lesions, edema, infarctions, hydrocephalus, atrophy, and brain structure shifts.
  • May involve dye injection (invasive if dye is used).

Nursing Considerations:

  • Assess for dye allergies if it’s used.
  • Instruct the client to remain still and flat during the test.
  • Advise holding breath when requested.
  • Initiate an IV line if prescribed.
  • Remove objects from the head.
  • Check for claustrophobia.
  • Inform about possible sensations during dye injection.
  • Monitor for allergic reactions to the dye.
  • Withhold metformin if iodinated contrast dye was used due to lactic acidosis risk.

Magnetic Resonance Imaging (MRI):

  • Noninvasive procedure to identify tissues, tumors, and vascular abnormalities.
  • Contraindicated in pregnant women (harmful to fetus).

Nursing Considerations:

  • Remove all metal objects.
  • Check for pacemakers, defibrillators, metal implants, or hip prostheses.
  • Remove IV fluid pumps.
  • Be cautious with pulse oximeter attachment.
  • Assess for claustrophobia and administer prescribed medication.
  • Follow instructions regarding contrast agent use (considered invasive) regarding food, fluids, and medications.
  • Instruct the client to remain still.
  • Normal activities can resume after the procedure.
  • Mention the possibility of diuresis if a contrast agent was used.

Cerebral Angiography:

  • Involves injecting contrast material into arteries (typically femoral or carotid) to visualize cerebral arteries and check for lesions.

Nursing Considerations:

  • Assess for allergies.
  • Review history for anticoagulation or antiplatelet therapy.
  • Encourage hydration for 2 days before the test.
  • Maintain NPO status for 4 to 6 hours before the test or as prescribed.
  • Obtain a baseline neurological assessment.
  • Mark peripheral pulses.
  • Remove hair metal items.
  • Administer premedication as prescribed.
  • Monitor neurological status and vital signs.
  • Watch for neck swelling and difficulty swallowing.
  • Maintain bed rest for 12 hours or as prescribed.
  • Elevate the head of the bed 15 to 30 degrees if prescribed.
  • Keep the bed flat if the femoral artery is used.
  • Assess peripheral pulses using pre-procedure markings.
  • Immobilize the limb with sandbags or other devices.
  • Apply a pressure dressing to the puncture site as prescribed.
  • Use ice on the puncture site as prescribed.
  • Encourage fluid intake.

Electroencephalography (EEG):

  • Records electrical activity of the cerebral cortex.

Nursing Considerations:

  • Withhold stimulants, antidepressants, tranquilizers, and possibly anticonvulsants for 24 to 48 hours before the test.
  • Allow the client to have breakfast if prescribed.
  • Administer premedication for sedation as prescribed.
  • Wash the client’s hair before the procedure.
  • Explain that electrodes are attached to the head but do not deliver electricity.
  • Wash the client’s hair again after the procedure.
  • Enforce safety precautions if the client was sedated.

Lumbar Puncture:

  • Involves inserting a spinal needle through the L3-L4 interspace into the lumbar subarachnoid space to obtain cerebrospinal fluid (CSF), measure CSF fluid or pressure, or instill air, dye, or medications.
  • Contraindicated in clients with increased intracranial pressure due to the risk of rapid CSF pressure decrease leading to brain herniation.

Nursing Considerations:

  • Ensure the client empties the bladder before the procedure.
  • Assist the client into the lateral recumbent position.
  • Have the client draw the knees up to the abdomen and place the chin on the chest.
  • Aid in the collection of specimens and label them sequentially.
  • Maintain strict asepsis.

Increased Intracranial Pressure:

  • Results from various conditions like trauma, hemorrhage, growths, hydrocephalus, edema, or inflammation.
  • May impede circulation to the brain and CSF absorption, affecting nerve cell function and potentially leading to brainstem compression and death.

 

Musculoskeletal Procedures:

Radiography:

  • Commonly used to diagnose musculoskeletal system disorders and injuries.
  • Interventions:
    • Handle the injured area carefully.
    • Administer analgesics as prescribed before the procedure, especially if the client is in pain.
    • Inquire about the possibility of pregnancy in female clients.
    • Follow agency procedures and policies for radiation protection, including the use of protective shielding.

Arthrocentesis:

  • Involves aspirating synovial fluid, blood, or pus from a joint cavity using a needle.
  • Medication may be instilled into the joint to alleviate inflammation.
  • Nursing Interventions:
    • Apply a compression bandage after the procedure as prescribed.
    • Ice application may be prescribed to reduce pain and swelling.
    • Advise the client to rest the joint for 8 to 24 hours after the procedure.
    • Instruct the client to report any fever or joint swelling to the primary health care provider.

Arthrography:

  • A radiographic examination of soft tissues of joint structures used to diagnose joint capsule or ligament trauma.
  • Involves injecting contrast medium or air into the joint cavity while moving the joint through a range of motion for radiographs.
  • Nursing Considerations:
    • Instruct the client to fast for 8 hours before the procedure as prescribed.
    • Assess for allergies.
    • Local anesthetic is used.
    • Advise the client to remain still during the procedure, except when asked to change position.
    • Minimize joint use for 12 hours after the procedure.
    • Explain potential post-procedure edema and tenderness, which can be treated with ice and analgesics.
    • Notify the primary health care provider if edema and tenderness persist beyond 2 days (knee arthrography).
    • Mention that if air was used for injection, crepitus may be felt in the joint for up to 2 days.

Arthroscopy:

  • Allows endoscopic examination of various joints.
  • Can assess articular cartilage abnormalities, remove loose bodies, and trim cartilage.
  • Biopsy may be performed during the procedure.
  • Nursing Considerations:
    • Instruct the client not to eat or drink for 8 to 12 hours before the procedure as prescribed.
    • Administer pain medication as prescribed after the procedure.
    • Assess the neurovascular status of the affected extremity.
    • Elevate the extremity.
    • Apply an elastic compression bandage for 24 to 48 hours.
    • Ice application may be used to minimize swelling.
    • Limit activity as prescribed after the procedure.
    • Instruct the client to notify the primary health care provider if fever, increased knee pain, or swelling occurs after the procedure.

Bone Mineral Density Measurements and Quantitative Ultrasound:

  • Used to measure bone mass and evaluate bone density, strength, and elasticity.
  • Nursing Considerations:
    • These procedures are painless.
    • Metallic objects may need to be removed before testing.

Bone Scan:

  • Involves injecting a radioisotope to detect areas of abnormal bone metabolism.
  • Used to detect certain fractures.
  • Nursing Interventions:
    • Food and fluids may be withheld before the procedure.
    • Remove all jewelry and metal objects.
    • Ensure the client drinks 32 oz (1 L) of water after the injection.
    • Have the client void 1 to 3 hours after the injection.
    • Maintain the supine position during the procedure.
    • No special precautions are required after the procedure.
    • Monitor the injection site for redness and swelling.
    • Encourage fluid intake after the procedure.

Bone or Muscle Biopsy:

  • Collects tissue specimens for analysis and can be done using various techniques.
  • Nursing Considerations:
    • Mild to moderate discomfort is normal after the procedure.
    • Monitor for bleeding, swelling, hematoma, and severe pain.
    • Elevate the site for 24 hours.
    • Apply ice packs as prescribed.
    • Teach the client to recognize signs of infection and report them to the primary health care provider.

Electromyography (EMG):

  • Measures electrical potential associated with skeletal muscle contraction.
  • Involves inserting needles into muscles to record electrical activity.
  • Nursing Considerations:
    • Needle insertion can be uncomfortable.
    • Instruct the client not to take stimulants or sedatives for 24 hours before the procedure.
    • Inform the client that mild bruising may occur at needle insertion sites.

Diagnostic Tests, Treatments, and Procedures Points to Remember:

  • Ensure informed consent for invasive procedures.
  • Check for the return of the gag reflex after local anesthesia to the throat area.
  • Consider metformin withholding for 48 hours after iodinated contrast dye injection.
  • Monitor nasogastric tube placement and check residual volume regularly.
  • When suctioning, apply intermittent suction for up to 10 seconds while rotating and withdrawing the catheter.
  • Assess the client first, then the ventilator for those on mechanical ventilation.
  • Do not shut off ventilator alarms; if uncertain, ventilate the client manually until the issue is resolved.
  • Maintain proper tracheostomy care and ensure cuff deflation before inserting a cap or plug.
  • Monitor chest tube drainage and report any abnormal findings.
  • Continuous bubbling in the water seal chamber of a chest tube system indicates an air leak.
  • Replace a cracked or broken chest tube system with a new one.
  • If a chest tube is accidentally pulled out, take immediate measures and notify the primary health care provider.
  • Initiate prescribed antibiotics only after specimen collection for culture and sensitivity.
Insert, Maintain, or Remove a Urinary Catheter: 

   Insertion:  

  • Review the physician’s order! Also, as a nurse taking care of this particular patient, it is important to understand why they need the internal urinary catheter as this greatly increases their chance for a UTI. Many facilities now must qualify urinary catheters with a reason such as upcoming procedure or large decubitus ulcers on coccyx region.
  • Ensure proper hand hygiene and use aseptic technique during insertion to minimize the risk of infection. 
  • Perfection of Sterile Technique is key and should be practiced regularly in the lab before attempting with patients. Also, even seasoned nurses will usually ask for a second person to help–either a nurse or a tech, especially in more difficult situations so that sterile field and catheter can be maintained throughout the procedure.
  • Choose the appropriate catheter size and type based on the patient’s age, gender, and medical condition.
  • Educate the patient about the procedure, including the importance of maintaining hygiene and the potential discomfort. 

Maintenance: 

  • Ensure the catheter is securely taped and positioned to prevent pulling or kinking.
  • Provide education regarding catheter care and infection prevention with “teach back” method to ensure that the patient fully understands the education provided.
  • Monitor urine output, color, and clarity to detect any changes that may indicate infection or obstruction. 
  • Maintain a closed drainage system and empty the drainage bag regularly. 
  • If patient remains in hospital provide catheter care as directed (this relates to the nursing diagnoses of increased potential for infection)

Removal: 

  • Remove the catheter as soon as it is no longer medically necessary to reduce the risk of infection. 
  • Instruct the patient to report any discomfort, burning, or urgency during and after removal. 
  • Monitor for any signs of urinary retention after removal.

Insert, Maintain, or Remove a Peripheral Intravenous (IV) Line: 

Insertion: 

  • Review the Physician Order for Placement of IV (some facilities have “standing orders” or “batch orders” that include IV placement)
  • Ensure that the IV site is clean, and use a sterile dressing and transparent dressing to cover the insertion site. 
  • Size of the IV catheter, site placement, and site rotation depend on many factors. If the patient is a trauma patient, for example, they may have 2 large-bore IVs emergently placed in the first available site. (Usually bilateral Antecubital) 18 or 16 Gauge)
  • On the other hand, if the patient is a child having outpatient surgery, they might have as small an IV as possible placed in their hand after numbing gel has been applied for 2 hours prior to coming to the surgery center. (probably a 22G)
  • Secure the IV catheter with appropriate securement devices to  prevent dislodgment. 
  • Administer IV medications and fluids as prescribed, following compatibility guidelines. 

Maintenance: 

  • Regularly assess the IV site for signs of infection, infiltration, or phlebitis. (swelling, redness or extreme pain) After the initial prick, an IV should not be painful–just “annoying”, if the patient is complaining of pain, then something may be wrong, even if there are no immediate signs of redness or swelling.
  • Change IV tubing and dressings as per facility policy to minimize infection risk. 
  • Educate the patient to report any discomfort, swelling, or pain at the IV site. 

Removal: 

  • Remove the IV line promptly when it is no longer needed or if complications arise, such as infection or infiltration. 
  • Apply pressure and a sterile dressing to the site after removal to prevent bleeding or infection. 
  • Document the removal and the condition of the site. 
  • EXAMINE THE CATHETER AFTER REMOVAL to make sure that it is intact and that you have all of it. Now that biotech is improving it is extremely rare for a piece of a peripheral catheter to break off, however this would be an emergency and should always be known as a possibility.
  • As a nurse you should always be looking to keep your patient safe. When something is removed, make sure you have it all and it appears intact. This is a habit to keep throughout your entire career for the sake of every patient.

Maintain Percutaneous Feeding Tube:  Commonly referred to as “PEG tube”

Enteral Nutrition Administration: REVIEW the physician’s orders!

  • Administer enteral nutrition via the feeding tube according to the prescribed schedule and formula. 
  • Check for residual volumes before each feeding to assess gastric emptying and tube placement. 
  • Elevate the head of the bed at a 30–45-degree angle during and after feedings to reduce the risk of aspiration.

Tube Care: 

  • Clean around the tube insertion site daily with mild soap and water and assess for signs of infection or skin breakdown. 
  • Use dressings to prevent leakage onto patients’ clothes as per doctor orders or facility protocols.
  • Flush the tube with water before and after medication administration and feedings to prevent clogs. 
  • Ensure the tube is securely taped and that it is not being tugged or pulled. 

Patient Education: 

  • Educate the patient or caregiver about proper feeding tube care, signs of complications, and emergency procedures.
  • Encourage questions and provide written instructions for reference. 

Apply and/or Maintain Devices Used to Promote Venous Return:

Anti-Embolism Stockings (Compression Stockings): 

  • Measure the patient’s legs to ensure proper sizing for stockings. 
  • Assist the patient in applying the stockings, ensuring they are snug but not overly tight. 
  • The holes are NOT for the toes but so that skin can be monitored at the bottom of the foot.
  • These stockings are EXTREMELY slippery and may cause falls if worn by themselves for ambulation–be sure that patients are wearing non-skid socks or footwear OVER the compression stockings if they are ambulatory. Monitor for any signs of skin irritation or pressure ulcers.
  • Be sure to leave Anti-Embolism Stockings on for the prescribed time and then take them off when it is time so that there is proper blood flow to the legs.

Sequential Compression Devices (SCDs): 

  • Properly position the SCD sleeves on the patient’s legs and secure them in place. 
  • Ensure that the device is functioning correctly and is set to the prescribed pressure. 
  • Assess the patient for any discomfort or skin irritation caused by the SCDs. 

Patient Education: 

  • Explain the purpose of these devices in preventing blood clots and deep vein thrombosis. 
  • Instruct the patient to report any discomfort, pain, or changes in sensation related to the devices. 

Use Precautions to Prevent Injury and/or Complications: 

Body Mechanics: 

  • Use proper body mechanics, such as bending at the knees and not the waist, to avoid back injuries when lifting or moving patient.
  • Ask for help, and also find out if there is an official “lift team” available for helping transfer patients.
  • Utilize assistive devices like transfer belts or mechanical lift for patient transfers. 
Aspect of Body
Mechanics
ExamplesNursing
Interventions
Maintain Proper
Posture
- Lifting patients-- Transferring patients-- Bending to pick up objects- Keep a straight
back-- Maintain.
natural spine curves-- Avoid twisting the
body
Use Assistive Devices- Patient lifts--
Transfer belts-- Slide sheets
- Utilize appropriate equipment-- Educate patients on
participation
Engage Core Muscles- Lifting and
transferring--
Assisting with
ambulation
- Activate abdominal and back muscles-- Distribute the load evenly
Lift with the Legs- Picking up objects-- Patient transfers- Bend at hips and knees-- Keep objects close to the body
Get Help When
Needed
- Transferring heavy or immobile patients- Collaborate with
colleagues-- Request assistance as required
Alternate Tasks- Rotating
responsibilities--
Avoiding prolonged lifting
- Change tasks
periodically-- Prevent overuse injuries
Maintain Fitness- Regular exercise and strength training- Stay physically fit-- Enhance the ability to handle physical
demands
Report Injuries/
Discomfort
- Musculoskeletal
strain or discomfort
- Promptly report any issues-- Seek medical attention as needed
Aspect of Body
Mechanics
ExamplesNursing
Interventions
Maintain Neutral Spine- When pushing a
patient bed-- During patient transfers
- Keep the spine in a neutral, aligned
position-- Avoid.
excessive bending or arching of the spine
Minimize Repetitive Movements- Repeatedly turning patients-- Frequent bending to pick up objects- Alternate tasks to reduce repetitive
motions-- Use
ergonomic aids and devices when available
Use Proper Footwear- Providing patient care for extended
periods
- Wear comfortable, supportive shoes with good arch support-- Use anti-slip soles for safety
Plan and
Communicate
- Patient transfers and repositioning- Collaborate with the healthcare team on a transfer plan--
Communicate clearly with the patient about the transfer process
Assess Patient's
Weight and Mobility
- Assessing the
patient's ability to
assist with transfers
- Determine if
additional assistance or equipment is
needed-- Avoid
attempting transfers that exceed your
physical capabilities
Protect the Patient- Safeguarding the patient’s dignity and safety during transfers- Use proper
techniques to prevent patient falls or
discomfort-- Explain the transfer process to the patient to reduce anxiety
Promote Teamwork- Working together with colleagues during patient care- Encourage a culture of teamwork and
mutual assistance-- Assist colleagues
when needed and
seek help when
required

Fall Prevention: 

  • Assess the patient’s fall risk and implement fall prevention measures, such as placing non-slip mats in the bathroom and using bed alarms. 
  • Educate the patient and family on fall prevention strategies. 

Safe Environment: 

  • Ensure that the patient’s room is free of obstacles and clutter to prevent tripping hazards. Follow isolation precautions and proper disposal procedures for biohazardous materials.

Evaluate Client Responses to Procedures and Treatments: 

  • Continuous Monitoring: Monitor the client’s vital signs (blood pressure, heart rate, respiratory rate, temperature, oxygen saturation), pain levels, and other relevant parameters as appropriate to the procedure or treatment. 
  • Assessment Skills: Utilize your clinical assessment skills to identify subtle changes in the client’s condition, such as alterations in skin color, mental status, or respiratory effort. 
  • Communication: Maintain open and effective communication with the client, their family, and the healthcare team to gather information and report findings promptly. 

Recognize Trends and Changes in Client Condition and Intervene as Needed: 

Critical Thinking:

Employ critical thinking and clinical judgment to analyze data and identify trends or patterns that may indicate a positive or negative response to treatment. 

Timely Intervention: 

Act promptly when you notice any deviations from the expected response or any signs of deterioration. This may involve adjusting medications, initiating interventions, or escalating care as necessary. 

Perform Focused Assessments: 

  • Targeted Examination: Conduct assessments that focus on the specific aspects of the client’s condition or treatment. For example, if a client is receiving intravenous (IV) antibiotics, assess the IV site for signs of infection or infiltration.
  • Documentation: Document your findings accurately, including objective data and subjective observations. Ensure that your documentation is thorough and timely. 

Educate Client About Treatments and Procedures: 

  • Clear Communication: Use clear and simple language to explain the purpose, benefits, and potential risks of treatments or procedures to the client. 
  • Informed Consent: Verify that the client fully understands the information provided and obtains their informed consent before proceeding with any procedure or treatment. 

Fetal heart monitoring

  • Electronic Fetal Monitoring (EFM) purpose: Assess fetal oxygenation during labor.
  • Monitor’s role: Detect interruptions, prompt evaluation, and interventions for fetal oxygenation improvement.
  • If interventions fail: Monitor helps make decisions on optimal timing and method of birth to prevent fetal hypoxia consequences.
    • Two EFM modes:
    • External mode: Uses transducers on maternal abdomen to assess Fetal Heart Rate (FHR) and Uterine Activity (UA).
    • Internal mode: Uses a spiral electrode on fetal presenting part for FHR and an intrauterine pressure catheter (IUPC) for UA and uterine resting tone assessment.

Fetal Heart Rate (FHR):

    • Ultrasound transducer:
    • Uses high-frequency sound waves to detect fetal heart activity.
    • Noninvasive and doesn’t require membrane rupture or cervical dilation.
    • Utilized in both antepartum and intrapartum periods.
    • Spiral electrode:
    • Converts fetal ECG to FHR using a cardiotachometer.
    • Requires ruptured membranes and sufficient cervical dilation during intrapartum period.
    • The electrode penetrates fetal presenting part by 1.5 mm and must be securely attached for a good signal.

Uterine Activity:

    • Tocotransducer:
    • Monitors contraction frequency and duration through a pressure-sensing device on the maternal abdomen.
    • Applicable during both antepartum and intrapartum periods.
    • Intrauterine pressure catheter (IUPC):
    • Monitors contraction frequency, duration, and intensity.
    • Two types: fluid-filled system and solid catheter.
    • Both measure intrauterine pressure at the catheter tip and convert it into millimeters of mercury on a uterine activity strip chart.
    • Requires ruptured membranes and sufficient cervical dilation during intrapartum period.

External Monitoring – FHR (Fetal Heart Rate) and UCs (Uterine Contractions):

    • FHR monitoring using ultrasound transducer:
    • Utilizes high-frequency sound waves reflecting off the fetal heart and valves.
    • Continuous and precise FHR recording can be challenging due to potential artifacts from fetal and maternal movement.
    • Factors like maternal obesity, fetal occiput posterior position, and anterior placenta attachment can lead to weak or absent signals.
  • FHR data is printed on specialized monitor paper.
  • Standard paper speed in the United States is 3 cm/min.
    • To ensure accurate monitoring:
    • Conductive gel is applied to the ultrasound transducer’s surface.
    • The transducer is securely positioned over the area of maximal FHR intensity using an elastic belt.

Baseline Fetal Heart Rate:

  • FHR is controlled by the intrinsic rhythmicity of the fetal heart, the central nervous system (CNS), and the fetal autonomic nervous system.
  • Increased sympathetic response leads to FHR acceleration, while increased parasympathetic response results in FHR slowing.
  • During contractions, there is typically a balanced increase in sympathetic and parasympathetic responses, with no observable change in the baseline FHR.
  • Baseline FHR is the average rate during a 10-minute segment.
  • It excludes periodic or episodic changes, periods of marked variability, and segments with differences exceeding 25 beats/min.
  • Requires at least 2 minutes of interpretable baseline data within a 10-minute tracing segment to determine.
  • After 10 minutes of tracing, the approximate mean rate is rounded to the nearest 5 beats/min interval.
  • Normal FHR range: 110 to 160 beats/min.

FHR Variability:

  • FHR variability is described as irregular waves or fluctuations in the baseline FHR.
  • It is measured in beats per minute and quantified from the peak to the trough of a single cycle.
  • Four categories of FHR variability have been identified: absent, minimal, moderate, and marked.
  • Variability is a characteristic of the baseline FHR and excludes accelerations or decelerations.
  • Absent variability is when fluctuations are not detectable to the naked eye.
  • Minimal variability has detectable fluctuations but is less than 5 beats/min; can be abnormal or indeterminate.
  • Causes of absent or minimal variability include fetal hypoxemia, metabolic acidemia, fetal sleep cycles, tachycardia, prematurity, CNS depressant medications, congenital anomalies, and preexisting neurologic injury.
  • Moderate variability is considered normal and predicts a normal fetal acid-base balance.
  • Moderate variability indicates FHR regulation is not significantly affected by various factors.
  • The significance of marked variability is unclear, often representing a normal variant.
  • A sinusoidal pattern, a smooth undulating wavelike pattern, is not considered part of FHR variability and is associated with severe fetal anemia.
  • Variations of the sinusoidal pattern can occur with chorioamnionitis, fetal sepsis, and opioid analgesic administration.

Tachycardia:

  • Definition: FHR >160 beats/min lasting >10 minutes.
  • Possible Causes: Early fetal hypoxemia, fetal cardiac arrhythmias, maternal fever, infection (including chorioamnionitis), parasympatholytic drugs (e.g., atropine, hydroxyzine), β-sympathomimetic drugs (terbutaline), maternal hyperthyroidism, fetal anemia, drugs (caffeine, theophylline, cocaine, methamphetamines). Tachycardia can also result from abnormalities in fetal cardiac pacemakers and the cardiac conduction system.
  • Persistent tachycardia in the absence of periodic changes may not appear serious in terms of neonatal outcome, especially if associated with maternal fever. Tachycardia is considered abnormal when associated with late decelerations, severe variable decelerations, or absent variability.
  • Nursing Interventions: Interventions depend on the cause. These may include reducing maternal fever with antipyretics, cooling measures, and oxygen therapy as ordered by the healthcare provider.

Bradycardia:

  • Definition: FHR <110 beats/min lasting >10 minutes.
  • Possible Causes: Atrioventricular dissociation (heart block), structural defects, viral infections (e.g., cytomegalovirus), medications, fetal heart failure, maternal hypoglycemia, maternal hypothermia.
  • Baseline bradycardia alone is not specifically related to fetal oxygenation. The clinical significance of bradycardia depends on the underlying cause and accompanying FHR patterns, including variability, accelerations, or decelerations.
  • Nursing Interventions: Interventions depend on the cause.

During fetal monitoring, changes in the fetal heart rate (FHR) from the baseline are categorized as either periodic or episodic changes.

Accelerations:

  • Definition: Acceleration of the FHR is defined as a visually apparent, abrupt (onset to peak <30 seconds) increase in FHR above the baseline rate, with the peak being at least 15 beats/min above the baseline, lasting 15 seconds or more, and returning to baseline in less than 2 minutes.
  • Clinical Significance: Accelerations are considered an indication of fetal well-being and are highly predictive of a normal fetal acid-base balance.
  • Nursing Interventions: Typically, no interventions are required for accelerations.

Early Decelerations:

  • Definition: Early deceleration is a visually apparent, gradual (onset to lowest point ≥30 seconds) decrease in and return to baseline FHR associated with uterine contractions (UCs). It is thought to be caused by transient fetal head compression and is considered a normal and benign finding.
  • Clinical Significance: Early decelerations are considered normal and are not associated with fetal hypoxemia, acidemia, or low Apgar scores.
  • Nursing Interventions: No specific interventions are required for early decelerations.

Late Decelerations:

  • Definition: Late deceleration is a visually apparent, gradual (onset to lowest point ≥30 seconds) decrease in and return to baseline FHR associated with UCs. The deceleration begins after the contraction has started, and the lowest point of the deceleration occurs after the peak of the contraction.
  • Clinical Significance: Late decelerations are abnormal and associated with fetal hypoxemia, acidemia, and low Apgar scores, especially when associated with absent or minimal baseline variability.
  • Nursing Interventions: Interventions for late decelerations include discontinuing oxytocin if infusing, assisting the woman to a lateral (side-lying) position, administering oxygen at 10 L/min by a nonrebreather face mask, correcting maternal hypotension, and increasing the rate of maintenance intravenous solution. Further interventions may be necessary based on the clinical situation.

Variable Decelerations:

  • Definition: Variable deceleration is defined as a visually abrupt (onset to lowest point <30 seconds) decrease in FHR below the baseline, with the decrease being at least 15 beats/min or more below the baseline, lasting at least 15 seconds, and returning to baseline in less than 2 minutes.
  • Clinical Significance: Occasional variable decelerations have little clinical significance, but recurrent variable decelerations indicate repetitive disruption in the oxygen supply of the fetus and can lead to hypoxemia, hypoxia, metabolic acidosis, and metabolic acidemia.
  • Nursing Interventions: Interventions for variable decelerations include discontinuing oxytocin if infusing, changing maternal position, administering oxygen at 10 L/min by nonrebreather face mask, notifying the physician or nurse-midwife, assessing for cord prolapse, and assisting with amnioinfusion if ordered. Further interventions may be required if the pattern cannot be corrected.

Prolonged Decelerations:

  • Definition: Prolonged deceleration is a visually apparent decrease (may be either gradual or abrupt) in FHR of at least 15 beats/min below the baseline, lasting more than 2 minutes but less than 10 minutes.
  • Clinical Significance: Prolonged decelerations are considered abnormal patterns and require immediate attention and intervention.
  • Nursing Interventions: Nurses should notify the physician or nurse-midwife immediately and initiate appropriate treatment for abnormal patterns when they observe a prolonged deceleration.

 

Preoperative Care:

  • Surgeon obtains informed consent for surgery, including additional consents if needed.
  • Sedation should not be administered before obtaining consent.
  • Assess surgeon’s instructions regarding food and fluid intake before surgery.
  • If intestinal or abdominal surgery is planned, bowel cleansing may be required.
  • Ensure the client voids before surgery and empty any Foley catheter if in place.

Preoperative Care: Surgical Site, Medications, Psychosocial Preparation:

  • Clean surgical site with mild antiseptic soap as prescribed.
  • Shave hair only if necessary for the surgical procedure.
  • Note all medications, including herbal products.
  • Check with the surgeon regarding medication administration and oral hypoglycemics/insulin for diabetics.
  • Assess and address client’s anxiety and provide privacy for psychological preparation.

Preoperative Care: Client Teaching:

  • Describe post-surgery expectations.
  • Instruct client to report pain, reassure them about pain medication.
  • Teach the use of client-controlled analgesia pump if prescribed.
  • Instruct in noninvasive pain-relief techniques.
  • Advise against smoking before surgery.
  • Teach deep-breathing, coughing, and incentive spirometry.
  • Instruct in leg and foot exercises, incision splinting, and mobility.
  • Explain invasive devices and their removal after surgery.

Preoperative Care: Preoperative Checklist:

  • Verify identification and allergies.
  • Document laboratory test results, ECG, and chest radiography.
  • Remove jewelry, makeup, dentures, etc.
  • Secure valuables.
  • Check vital signs.
  • Review the preoperative checklist for completeness.
  • Administer preoperative medications as prescribed.

Intraoperative Care: Operating Room:

  • Verify correct client and surgical site.
  • Check identification bracelet and consent.
  • Review surgeon’s prescriptions.
  • Surgical team includes surgeon, anesthesia provider, assistants, and nursing staff.

Intraoperative Care: Guidelines to Prevent Surgery on Wrong Site:

  • Surgeon marks the surgical site with indelible ink.
  • Verify surgical site in the operating room.
  • Conduct a time-out to confirm the surgical site before the procedure.

Intraoperative Care: Post-anesthesia Care Unit (PACU):

  • PACU nurse monitors client for stability and recovery.
  • Assess airway, consciousness, oxygen saturation, cardiac status, and vital signs.
  • Conscious sedation may be used for certain procedures.
  • Maintain body temperature and prevent heat loss.

Postoperative Care: Stages of Recovery:

  • Immediate postoperative stage (1-4 hours after surgery).
  • Intermediate postoperative stage (4-24 hours after surgery).
  • Extended postoperative stage (at least 1-4 days after surgery).

Postoperative Care: Respiratory System:

  • Monitor airway patency, respirations, and pulse oximetry.
  • Encourage deep breathing, coughing, and incentive spirometry.
  • Assess breath sounds and monitor for respiratory complications.

Postoperative Care: Cardiovascular System:

  • Assess circulatory status, peripheral pulses, edema, and numbness.
  • Monitor for bleeding, hypertension, hypotension, and thrombophlebitis.
  • Use compression devices or antiembolism stockings as prescribed.

Postoperative Cardiovascular Complications:

  • Cardiovascular complications include hemorrhage, shock, thrombophlebitis, and pulmonary embolism.
  • Indications of hemorrhage and shock include bleeding, restlessness, weak and rapid pulse, hypotension, tachypnea, cool and clammy skin, and decreased urine output.
  • Signs and symptoms of thrombophlebitis include vein inflammation, increased skin temperature at the site, aching or cramping pain, a hard-cordlike feel to the affected vein, and tenderness to touch.
  • Indicators of pulmonary embolism include dyspnea, anxiety, sudden sharp chest or upper abdominal pain, tachycardia, tachypnea, and cyanosis.

Nursing Considerations for Cardiovascular Complications:

  • Monitor the client closely for signs and symptoms of postoperative complications.
  • If bleeding is observed, apply pressure to the bleeding site and elevate the client’s legs to help prevent shock.
  • Be cautious when elevating the legs of a client who has had spinal anesthesia to avoid impairing diaphragm function.
  • Notify the surgeon immediately if any complications occur.
  • Monitor the client’s level of consciousness, vital signs (including pulse oximetry and peripheral pulses), and intake and output.
  • Prepare to administer oxygen, IV fluids, and medications as prescribed to address cardiovascular complications.

Postoperative Care: Musculoskeletal System:

  • Assess client positioning and movement.
  • Place client in low Fowler’s position for lung expansion.
  • Encourage ambulation and range-of-motion exercises.

Postoperative Care: Neurological System/Temperature Control:

  • Assess level of consciousness and orientation.
  • Monitor temperature and prevent hypothermia with warm blankets.

Postoperative Care: Integumentary System:

  • Assess surgical site, drains, and dressings.
  • Monitor for drainage, bleeding, and signs of infection.
  • Reinforce dressings and manage drains as prescribed.

Postoperative Care: Fluid and Electrolyte Balance/GI System/Renal System:

  • Monitor IV administration, intake, and output.
  • Watch for fluid and electrolyte imbalances.
  • Assess for nausea, vomiting, abdominal distension, and bowel sounds.
  • Encourage oral fluids when appropriate.
  • Monitor bladder distention and urine output.

Fluid and Electrolyte Balance:

  • Monitor intravenous (IV) administration of fluids and electrolytes.
  • Keep a record of the client’s intake and output of fluids.
  • Monitor the client for signs and symptoms of fluid and electrolyte imbalances.

Gastrointestinal System:

  • Monitor the client for nausea and vomiting; reposition them to a side-lying position if vomiting occurs, and have suctioning equipment ready.
  • Maintain the patency of the nasogastric tube if one is present.
  • Monitor the client for abdominal distension and the return of bowel sounds.
  • Note that motility in the small intestine typically resumes within 24 hours of surgery and within 3 to 5 days in the large intestine.
  • Food and oral fluids should not be given until the gag reflex has returned and peristalsis has resumed.
  • Provide mouth care frequently.
  • Continue IV fluids as prescribed until the client can tolerate oral fluids.

Renal System:

  • Assess the client for bladder distention.
  • Monitor urine output, which should be at least 30 mL per hour.
  • Expect the client to void 6 to 8 hours after the surgical procedure, depending on the type of anesthesia, and ensure that the voided amount is at least 200 mL.

Postoperative Urinary and Bowel Complications:

  • Complications include urine retention, paralytic ileus, and constipation, often associated with anesthetics and opioid analgesics.
  • Urinary retention can be expected to resolve within 6 to 8 hours after surgery, depending on the anesthesia type.
  • Percussion of the bladder in a client with urine retention produces a drum-like sound.
  • Normal motility in the small intestine typically resumes within 24 hours post-surgery, while in the large intestine, it may take 3 to 5 days.
  • Paralytic ileus manifests as nausea, vomiting, abdominal distension, absence of bowel sounds, and lack of flatus.
  • Constipation is characterized by abdominal distension, absence of bowel movements, anorexia, nausea, and headache.

Nursing Considerations for Urinary and Bowel Complications:

  • Assist clients experiencing urine retention by providing privacy, helping them stand, and using noninvasive techniques (e.g., running water sound) to stimulate urination; catheterization is considered if noninvasive methods fail and are prescribed.
  • Treat paralytic ileus by decompressing the bowel through nasogastric tube insertion with intermittent to constant suction; clients should be kept from eating or drinking until bowel sounds return.
  • Prevent constipation by promoting fluid intake of up to 3000 mL/day (unless contraindicated), encouraging early ambulation, consumption of fiber-rich foods (unless contraindicated), and using stool softeners and laxatives if prescribed.
  • Ensure clients have privacy and adequate time for elimination to facilitate the resolution of these complications.

Postoperative Care: Pain Management:

  • Assess and manage client’s pain.
  • Consider cultural beliefs.
  • Administer pain medication as prescribed.
  • Use noninvasive pain relief measures.
  • Document effectiveness of pain management.

Postoperative Pain Management:

  • Assess the client for pain, considering their cultural practices and beliefs.
  • Inquire about any pain medications received during the post-anesthesia period and assess their effectiveness.
  • Ask the client to describe the type and location of pain and rate its severity on a scale of 1 to 10, with 10 being the most severe.
  • Monitor the client for objective signs related to pain, such as facial expressions, body gestures, increased pulse rate, increased blood pressure, and increased respirations.
  • Administer pain medication as prescribed, with special attention if an opioid analgesic is prescribed.
  • If an opioid analgesic is administered, assess the client every 30 minutes during the initial administration for respiratory rate and the degree of pain relief.
  • Utilize noninvasive pain relief measures, including distraction, relaxation, guided imagery, and creating a quiet and restful environment.
  • Document the effectiveness of pain medication and any noninvasive measures used to manage postoperative pain.

Postoperative Complications:

  • Monitor for respiratory, cardiovascular, urinary, bowel, and wound complications.
  • Take appropriate nursing actions and notify the surgeon if complications arise.

Perioperative Care: Discharge Teaching:

  • Instruct client on incision care, dressing changes, and follow-up appointments.
  • Educate on medication use, diet, and gradual return to normal activities.
  • Provide information on recognizing complications and when to seek help.

Important points to recall:

  • Administer sedation after obtaining the client’s consent for surgery.
  • Document all medications, including herbal products, as some may interact with anesthesia.
  • Inform the client about what to expect after surgery.
  • Instruct the client in deep-breathing and coughing techniques and the use of incentive spirometry.
  • Take measures to ensure client safety after administering preoperative medications.
  • Monitor the client’s airway patency and circulatory status after surgery.
  • Assess and document the return of bowel sounds; refrain from eating and drinking until the gag reflex returns and peristalsis resumes.
  • Expect the client to urinate 6 to 8 hours after surgery.
  • Prevent respiratory complications by encouraging deep breathing, coughing, and using the incentive spirometer; promote fluid intake and early ambulation.
  • Monitor for bleeding and signs/symptoms of shock.
  • Watch for signs of paralytic ileus, including nausea, vomiting, abdominal distention, and absent bowel sounds.
  • In case of wound dehiscence or evisceration, position the client in the low Fowler’s position with knees bent, notify the surgeon, and cover the wound with a sterile normal saline dressing.
  • Ensure the client has the necessary resources for home care support.
Organ
System
IndicationsParameters to
Monitor
Signs of
Complications
Preoperative
Nursing
Considerations
Intraoperative and Postoperative
Nursing
Considerations
Cardiovascular
System
Heart or
vascular
surgeries
Blood
pressure, heart rate, ECG,
oxygen
saturation
Dysrhythmias,
hypotension,
myocardial ischemia
-
Administer
medications, -
Monitor
for
dysrhythmias, -
Provide
oxygen
-
Administer
anesthesia, -
Monitor
cardiac
function, - Assess for bleeding.
or
hematoma
Respiratory SystemThoracic
or lung
surgeries
Respiratory rate,
oxygen
saturation, breath
sounds
Hypoxia,
atelectasis,
respiratory distress
-
Encourage deep
breathing, - Assess.
for lung
disease, - Assess for smoking.
history
- Maintain airway, -
Monitor
ventilation and
oxygenation, -
Prevent
atelectasis
Renal
System
Kidney or urinary
surgeries
Urine
output,
serum
creatinine, BUN,
Electrolytes
Oliguria,
electrolyte
imbalances, acute
kidney
injury
- Assess
baseline
renal
function, - Administer fluids
cautiously
- Monitor urine
output, -
Prevent
dehydration
on, -
Assess for signs of
AKI
Gastrointestinal
System
Abdominal or
Gastrointestinal surgeries
Bowel
sounds,
abdominal distension, flatus/
stool
Paralytic
ileus,
bowel
obstruction,
infection
-
Administer bowel
prep if
needed, - NPO.
status
before
surgery
- Assess
surgical
site for
complications, -
Monitor
bowel
function, - Prevent.
infection
Neurological
System
Brain or
spinal
surgeries
Level of
conscious ness,
pupil size, motor
function
Altered
mental
status,
neurologic al
changes
- Assess
neurological status, - Evaluate medications that.
affect
CNS
- Monitor neurologic al status
throughout surgery, - Prevent increased ICP
Musculoskeletal
System
Orthopedic
surgeries
Range of motion,
strength, surgical
site
condition
Compartment
syndrome, DVT,
surgical
site issues
- Assess
mobility
and
strength, - Consider post-op.
mobility
- Prevent DVT with prophylaxis, -
Monitor
surgical
site for
complications
Integumentary
System
Skin
grafts,
plastic
surgery
Surgical
site
condition, wound.
drainage, infection
Wound
dehiscence,
infection, delayed.
healing
- Assess
wound
condition, -
Administer pre-op
antibiotics if
indicated
- Maintain wound
dressings, - Monitor for
infection, - Educate on wound care
Hematological
System
Surgeries with
significant blood loss
Hemoglobin,
hematocrit,
coagulation profile
Hemorrhage,
thrombosis, anemia
- Assess
for
bleeding
disorders, -
Administer iron or
blood
products
- Monitor blood
loss, -
Administer blood
products as
needed, - Prevent.
thrombosis

All procedures done with any type of sedation present certain risks and possibilities to changes in health conditions. Therefore, it is truly important to assess the patient and ensure the healthcare team is aware of any unusual findings in your assessment before moving forward with the procedure.

The patient will be identified before the procedure and consent is verified that they had discussed WITH THE OPERATING SURGEON the risks and benefits of the surgery (it is up to the operating surgeon to address all of their concerns before surgery, NOT the nurse!) then a TIME OUT is performed once the patient is wheeled into the operating theater—EVERYONE and everything in the room must stop and agrees that the patient is properly identified, and every single person present also agrees on the TYPE of procedure and BODY PART. Then the procedure moves forward.

Many facilities will have specialized departments and teams of nurses who will prepare and assess patients prior to procedures and then also monitor them directly after a procedure in pre- and post-op areas. Some procedures are done emergently such as in the Emergency Department.

Each individual patient will have different needs and different reactions to having a procedure. Nursing must closely monitor them for changes which can constitute a change in health condition or an emergent condition resulting from their sedation or directly from their procedure. This, while simultaneously attempting to provide comfort and education on how to adapt to their new body or health condition after their procedure is challenging but the core of what nursing truly does.

Otito-Umoren