Have a manual resuscitation bag with a face mask and oxygen readily available

Have a manual resuscitation bag with a face mask and

This preview shows page 37 - 39 out of 57 pages.

Have a manual resuscitation bag with a face mask and oxygen readily available at the client’s bedside. Have reintubation equipment at bedside. Suction the oropharynx and trachea. Deflate the cuff on the endotracheal tube, and remove the tube during peak inspiration. Following extubation, monitor for signs of respiratory distress or airway obstruction, such as ineffective cough, dyspnea, and stridor. Assess SpO2 and vital signs every 5 min. Encourage coughing, deep breathing, and use of the incentive spirometer. Reposition the client to promote mobility of secretions. Older adult clients have decreased respiratory muscle strength and chest wall compliance, which makes them more susceptible to aspiration, atelectasis, and pulmonary infections. Older adult clients require more frequent position changes to promote mobility of secretions. Long term may have stress ulcers, fluid retention (Hyponatremia) due to decreased cardiac out, hypotense (Illness Mgmt) Hepatitis and Cirrhosis: Priority Finding to Report ALT: Expected reference range 4 to 36 units/L AST: Expected reference range 0 to 35 units/L ALP: Expected reference range 30 to 120 units/L Hepatitis CM: Elevated ALT AST and maybe ALP Failure to take personal precautions with blood and body fluid Influenza - like manifestations o Fatigue o Decreased appetite with nausea o Abdominal pain o Joint pain PHYSICAL ASSESSMENT FINDINGS Fever Vomiting Dark - colored urine Clay - colored stool Jaundice Cirrhosis: Elevated ALT AST and ALP Bilirubin, NH2, Decreased Serum protein, Serum albumin, RBC, Hb, Hct, platelets CM:
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Fatigue Weight loss, abdominal pain, distention Pruritus (severe itching of skin) Confusion or difficulty thinking (due to the buildup of waste products in the blood and brain that the liver is unable to get rid of) Personality and mentation changes, emotional lability, euphoria, depression Cognitive changes Altered sleep/wake pattern Gastroesophageal bleeding (enlarged esophageal veins [varices] develop and burst, causing vomiting and passing of blood in bowel movements) or portal hypertensive gastropathy, which is bleeding of gastric mucosa Splenomegaly caused from backup of blood into the spleen, which can cause thrombocytopenia and platelet destruction Ascites (bloating or swelling due to fluid buildup in abdomen and legs) Jaundice (yellowing of skin) and icterus (yellowing of the eyes) from decreased excretion of bilirubin, resulting in an increase of circulating bilirubin levels Petechiae (round, pinpoint, red - purple lesions), ecchymoses (large yellow and purple - blue bruises), nosebleeds, hematemesis, melena (decreased synthesis of prothrombin, deteriorating hepatic function ) Palmar erythema (redness, warmth of the palms of the hands) Spider angiomas (red lesions, vascular in nature with branches radiating on the nose, cheeks, upper thorax, shoulders) Dependent peripheral edema of extremities and sacrum Asterixis (liver flapping tremor): coarse
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