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less than 1 week old.Assess vital signs every 15 min throughout the transfusion for fluid overloadAdminister the blood transfusion over 2 to 4 hr for older adult clients.Without giving other IV fluid to prevent fluid overloadRisk for HF and fluid overload= cardiac and renal dysfunction PtCentral Venous Access Devices - (1)oCardiovascular Diagnostic and Therapeutic Procedures: Teaching About Care of a Peripherally Inserted Central Catheter (Active Learning Template - Nursing Skill, RM AMS RN 10.0 Chp 27)Clean the insertion port with alcohol for 15 seconds and allowing it to dry completely prior to accessing it. Valve disinfection caps which contain alcohol are available for single use.dressing changes, usually every 7 days and when indicated (wet, loose, soiled).Use transparent dressing to allow for visualization.Educate the client not to have venipuncture or blood pressure taken in arm with PICC lineAdvise the client not to immerse his arm in water. To shower, cover dressing site to avoid water exposureFlush with 5 mL heparin (10 units/mL) when the PICC is not actively in use.Flush w/ 10 cc 0.9% NS before, between, and after meds Flush w/ 20 cc 0.9% NS after blood drawMedication Administration - (1)oHypertension: Client Education About Beta Blockade Agents (Active Learning Template - Medication, RM AMS RN 10.0 Chp 36)can cause fatigue, weakness, depression, and sexual dysfunctionStopping suddenly can cause rebound hypertensionTeach the client manifestations of hypoglycemia that do not include tachycardia
Med surgPotential for Complications of Diagnostic Tests/Treatments/Procedures - (1)oArthroplasty: Postoperative Care for Total Hip Replacement (Active Learning Template - Basic Concept, RM AMS RN 10.0 Chp 68)Monitor H&H. Can still drop 48 hr after surgeryMonitor the neurovascular status (cap refill, movement, sensation, pulse and compare to other leg)every 2 to 4 hrTransfer the client out of bed from his unaffected side into a chair or wheelchair. (ambulate early)Use assistive (walker) and adaptive (raised toilet seat, grab bars, and shower chairs) devices when caring for the clientApply ice after walking to relieve painPlace the client supine with the head slightly elevated and the affected leg in a neutral position.Place a pillow or abduction device between the legs when turning to the unaffected side.The client should notbe turned to the operative side, which could cause hip dislocationMonitor for new joint dislocation: acute onset of pain, reports hearing “a pop”,internal rotation of the affected extremity, and shortened affected extremitySystem Specific Assessments - (1)oNeurologic Diagnostic Procedures: Determining a Glasgow Coma Scale Score (Active Learning Template -Nursing Skill, RM AMS RN 10.0 Chp 3)Eye opening (E): The best eye response, with responses ranging from 4 to 14 = Eye opening occurs spontaneously.