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In the event of an evisceration, the nurse should first all for help. Notify the provider immediately due to the need for surgical intervention. Stay with the client, cover the wound and any protruding organs with sterile towels or dressings soaked with sterile normal saline solution to decrease the chance of bacteria invasion and drying of the tissue. Do not attempt to reinsert the organs. Next position the client supine with the hips and knees bent. Observe for indications of shock, maintain a calm environment, and keep the client NPO in preparation for returning to surgery. Respiratory Management and Mechanical Ventilation: Priority Finding to Report Following Extubation (Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 19)It is an important role of the nurse to find and report any abnormal finding when caring for a patient following extubation.It is important to maintain a patent airway, have a resuscitation bag with a face mask available at the bedside at all times in case of ventilator malfunction or accidental extubation.Following extubation, monitor for signs of respiratory distress or airway obstruction, such as ineffective cough, dyspnea, and strictor. Unexpected Response to Therapies (2 items)Blood and Blood Product Transfusions: Caring for a Client Who Is Experiencing a Febrile Reaction (RN QSEN – Safety, Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 40)Complications of blood transfusions may relate to your patient’s physical ability to tolerate the procedure or to the blood product or administration process.First stop thetransfusion and maintain IV access by infusing normal saline solution through new tubing at a slow rate. For any suspected reaction, perform a physicalassessment. Many reactions have similar symptoms or mimic the symptoms of other acute or chronic conditions.Febrilenon-hemolytic transfusionreactionsaccount for about 90% of all reactions. Mostcommon in patients who are immunosuppressed or pregnant, these reactions develop as the recipient’s antibodies react to the antigens contained in donor blood, usually to leukocytes or plasma proteins.Renal Calculi: Identifying Nephrostomy Tube Complications (RN QSEN - Safety, Active Learning Template – System Disorder, RM AMS RN 10.0 Chp 61)
The majority of calculi are composed of calcium phosphate or calcium oxalate, but they can contain other substances. Flank pain suggests calculi are located in the kidney or ureter, pain intensifies as the calculus moves through the ureter.Calculus can be removed by open surgery. A surgical incision is used for large or impacted calculi or for calculi not removed by other approaches.Expected findings of renal calculi are; fever, diaphoresis, pallor, nausea/vomiting, tachycardia, tachypnea, increased blood pressure (pain), or decreased blood pressure.