Maintain cervical spine stability until cleared by an

- Maintain cervical
spine stability until
cleared by an x-ray.
- Report presence of
cerebrospinal fluid
(CSF) from nose or ears
to the provider.
- Provide a calm, restful
environment (limit
visitors, minimize
noise).
- Implement measures
to prevent
complications of
immobility (turn every
2 hr, footboard, and
splints). Specialty beds
can be used.
- Monitor fluid and
electrolyte values and
osmolarity to detect
changes in sodium
regulation, the onset of
diabetes insipidus, or
severe hypovolemia.
- Provide adequate
fluids to maintain
cerebral perfusion and
to minimize cerebral
edema. When a large
amount of IV fluids are
prescribed, monitor for
excess fluid volume
which could increase
ICP.
- Maintain safety and
seizure precautions
(side rails up, padded
side rails, call light
within the client's
reach).
- Even if the level of
consciousness is
decreased, explain to
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[Type here]
the client the actions
being taken and why.
> Hearing is the last
sense affected by a
head injury
10. Pituitary disorder:
Monitoring client at
risk for Diabetes
Insipidus
Excretion of a large
quantity of diluted
urine
Inappropriate
antidiuretic hormone
(SIADH)--> kidneys
retain water, urine
output decreases, and
extracellular fluid
volume is increased
11. Disorders of the
eye: Evaluating
teaching following
cataract extraction
-signs of infection:
yellow or green
drainage
-pain with
nausea/vomiting
-lid swelling, decreased
vision, bleeding or
discharge, a
sharp/sudden eye pain,
and/or flashes of light
or floating shapes
-preventing infection
-admin ophthalmic
meds
-providing pain relief
-teaching the pt about
self care and fall
prevention
Avoid after surgery:
-bending over at the
waist
-sneezing, coughing,
straining
-head hyperflexion
-restrictive clothing,
such as tight shirt
collars
-sexual intercourse
12. Acute and
infectious respiratory
illnesses: Caring for a
toddler who is
postoperative following
a tonsillectomy
Look for bleeding
Monitor for diff
breathing
Assess airway and vital
signs
- Analgesics
(acetaminiphine and
codeine)
- Provide ice collar
- Offer ice chips or sips
of water
- Discourage coughing,
throat clearing or
blowing nose
- Refrain from putting
objects in the back of
the mouth
- Alert parents that
there may be clots or
blood-tinged mucus in
vomit
13. Fractures:
Discharge instructions
Educate the client and
parents about the
length of treatment
that can be needed and
long - term antibiotic
therapy.
Remind the client and
parents to limit
movement of the
affected limb and avoid
bearing any weight
until cleared by the
provider
Advise the parents to
provide for diversional
activities consistent
with the client’s level
of development.
Educate the client
about the need for
proper nutrition
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