Points To Remember

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After a urinary catheter is removed, the client may have some burning on urination, frequency and dribbling. These symptoms should subside. After a TUR (transurethral resection), tell the client that, because the three-way foley catheter has a large diameter, he will continuously feel the urge to void. After prostatic surgery, it is normal for the client's urine to be blood tinged and for him to pass blood clots and tissue debris. Because the prostate gland receives a rich blood supply, it is important to observe the client undergoing a prostatectomy for bleeding and shock. Breast cancer starts with the alteration of a single cell and takes a minimum of two years to become palpable. At the time of diagnosis, about one-half of clients with breast cancer have regional or distant metastasis.

About Insulin • • • • • • • • •

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In the pancreas's islets of Langerhans, beta cells secrete insulin-the islet-cell hormone of major physiological importance; Without sufficient insulin, the body develops diabetes mellitus. Exploration of a number of new delivery systems for insulin is ongoing. Implanted insulin delivery systems, in combination with a glucose sensor may create an "artificial pancreas." Exercise increases the body's metabolic rate to result in a decrease in blood sugar and an increase in insulin sensitivity. Signs of hypoglycemia often occur. Illness can disrupt metabolic control and raise blood sugar, which results in an increased need for insulin. Insulin-dependent clients should be well controlled for at least one week prior to any surgery. Special care for any client with either type of diabetes mellitus should be taken to monitor blood glucose during and after surgery and adjust insulin accordingly. After hip replacements, pulmonary embolism may occur even without thrombosis in foot or leg.

Clients should sit in a straight, high chair; use a raised toilet seat; and never cross their legs. In hip or knee replacement, clients will need assistive devices for walking until muscle tone strengthens and they can walk without pain. After an amputation, the home must be assessed for any modifications needed to ensure safety. Some clients will need transportation to continue rehabilitation. Amputee support groups can help clients and family. After arthroscopy, outpatient rehab may be prescribed depending on procedure; health care provider may prescribe knee immobilizer. External Fixator - If possible, prepare the client preoperatively to reduce anxiety. Device looks clumsy, but patient should be reassured that discomfort is minimal. After a hip pinning or femoral-head prosthesis, caution client not to force hip into more than 90 degree of flexion, into adduction or internal rotation which will cause dislocation and severe pain and this would be a nursing emergency. Caution clients with a new prosthesis not to use any substances such as lotions, powders etc. unless prescribed by the health care provider. Osteoporosis cannot be detected by conventional X-ray until more that 30% of bone calcium is lost. Foods high in calcium include milk, cheeses, yogurt, turnip greens, cottage cheese, sardines, and spinach.

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When performing a musculoskeletal assessment on a client with Paget's disease, note the size and shape of the skull. The skulls of these clients will be soft, thick and enlarged. Clients at high risk for acute osteomyelitis are: elderly, diabetics, and clients with peripheral vascular disease. When clients receive corticosteroids long-term, evaluate them continually for side effects. Immunosuppressed clients should avoid contact with persons who have infections. Steroids may mask the signs of infections, so client should promptly report slightest change in temperature or other complaints. Photosensitive clients should avoid the sun, limit outdoor activities during peak sun hours and wear sun block. Radiation has local effects; chemotherapy is more systemic. Only certified nurses may administer chemotherapeutic agents. Ionizing radiation will damage both normal and cancerous cells, and cause side effects. Clients who receive external radiation are not radioactive at any time. Clients receiving internal radiation are not radioactive: the implant or injection is. If the source of radiation is metabolized, the client's secretions and excretions may be radioactive for a time, based on the half-life of the isotope.

I.Cardiac Arrest

A.CPR (illustration 1 illustration 2 ) 1.Determine unresponsiveness a.shake and shout "are you okay?" b.call for help 2.Position the client, if no evidence of trauma (if trauma, see section III of this lesson) 3.Open the airway c.head-tilt, chin lift d.jaw thrust (if spinal injury suspected) 4.Assess for breathing: look, listen and feel 5.Give rescue breaths e.assess if breaths go into lungs by chest movement f.if air does not go in, reposition airway (see #3 above) g.if air still does not go in, check for foreign body

i.abdominal thrust (Heimlich manueuver) (illustration 1 illustration 2 ) ii.do not proceed until airway and rescue breathing established h.when airway is clear, check for abscence of pulse i.begin chest compressions iii.be sure client is on a firm surface iv.hand position is critical • two finger-widths above xiphoid

• lower one-half of sternum v.for adult, 1.5 to 2 inch compression depth vi.two rescuers, 80 to 100 compressions per minute vii.one rescuer, 80 compressions per minute j.alternate compressions and breaths viii.one and two rescuers, 15 compressions to two breaths k.reassess cardiopulmonary status after one minute and every few minutes thereafter B.Early defibrillation 3.In adults, the arrhythmia most correctable is ventricular fibrillation if treated promptly 4.Before starting CPR for ventricular fibrillation, call for help B. Airway with simultaneous cervical spine immobilization 6.Must use jaw thrust 7.Do not use head-tilt chin-lift: it could injure neck C.Breathing 8.Look, listen and feel for respirations 9.Follow CPR procedure D.Circulation 10.Assess pulses l.carotid pulse: BP at least 60 m.femoral pulse: BP at least 70 n.radial pulse: BP at least 80 11.Stop any active, visible bleeding

12.After initial assessment, start large-bore IVs (illustration 1 illustration 2 illustration 3 ) E.Airway with simultaneous cervical spine immobilization 13.Must use jaw thrust 14.Do not use head-tilt chin-lift: it could injure neck F.Breathing 15.Look, listen and feel for respirations 16.Follow CPR procedure G.Circulation 17.Assess pulses o.carotid pulse: BP at least 60 p.femoral pulse: BP at least 70 q.radial pulse: BP at least 80 18.Stop any active, visible bleeding

19.After initial assessment, start large-bore IVs (illustration 1 illustration 2 illustration 3 )

H.Airway with simultaneous cervical spine immobilization 20.Must use jaw thrust 21.Do not use head-tilt chin-lift: it could injure neck I.Breathing 22.Look, listen and feel for respirations 23.Follow CPR procedure J.Circulation 24.Assess pulses r.carotid pulse: BP at least 60 s.femoral pulse: BP at least 70 t.radial pulse: BP at least 80 25.Stop any active, visible bleeding

26.After initial assessment, start large-bore IVs (illustration 1 illustration 2 illustration 3 ) II.Trauma Care

A.Airway with simultaneous cervical spine immobilization 1.Must use jaw thrust 2.Do not use head-tilt chin-lift: it could injure neck B.Breathing 3.Look, listen and feel for respirations 4.Follow CPR procedure C.Circulation 5.Assess pulses a.carotid pulse: BP at least 60 b.femoral pulse: BP at least 70

c.radial pulse: BP at least 80 6.Stop any active, visible bleeding

7.After initial assessment, start large-bore IVs (illustration 1 illustration 2 illustration 3 ) K.Disability: brief neurological exam 27.Level of consciousness 28.Pupil response to light 29.Ability to move extremities 30.Ability to move against resistance L.Expose 31.Undress client 32.Inspect for injuries or deformities M.Fahrenheit 33.Take temperature 34.Maintain warmth u.warm blankets v.warming lights N.Get vitals 35.Pulse 36.Respiratory rate 37.Blood pressure O.History and head-to-toe full assessment 38.How did injury occur - mechanism of injury 39.Client's medical history 40.Full body system assessment P.Inspect the back 41.Roll the client over - log roll with help 42.Inspect for injuries or deformities

CPR • •

Early defibrillation is the key to successful resuscitation for many adults. Continually reassess during CPR to see if the client regains a pulse or begins breathing. Reassess to see that the chest moves and pulses are palpable during CPR. SHOCK • In shock, the first hour of treatment is most critical. Early detection is key. • There are different ways to categorize shock. Basically, shock presents three potential problems: 1.Not enough fluid in the blood vessels (hypovolemia) OR 2.Fluid has moved outside the vessels, so cannot be pumped to the organs (distributive) OR 3.Heart cannot pump fluid that is present (cardiogenic) Shock and Temperature • In septic shock, the skin and body temperature may increase. In other shock states, body and skin temperature will decrease. Shock and Heart Signs • Early stages of shock activate the sympathetic nervous system. So in early stages, the client will not always be hypotensive. • Bradycardia is a very late sign in shock.

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Another late sign is cardiac arrhythmia (other than sinus tachycardia). Arrhythmias reflect less perfusion of the coronary arteries and myocarditis. • As the myocardium receives less perfusion, heart pumps less. • Because less blood perfuses the brain, level of consciousness drops. Shock and Urinary Output • Average adult urinary output is 0.5 to 1.0 ml/kg/hr. Less than 35 ml/hour reflects decreased renal blood flow. Acute renal failure can result. Shock and Respiration • As blood flow to lungs decreases, less gas exchange will occur. • When tissues receive less oxygen, they produce more lactate and metabolic acidosis sets in. Metabolic acidosis increases risk of cardiac arrhythmias. • For a client in shock, body cells receive less oxygen and nutrients. Thus treatment aims at increasing both available oxygen and volume of blood in vessels (unless the heart has failed). • Medications can improve tone of blood vessels (inotropes) or treat the cause of shock (corticosteroids, antibiotics). • When treating a trauma client, you must quickly assess ABCs. After you know the client is breathing and has a pulse, vital signs can wait while you stop any bleeding and start other interventions (such as starting IVS). Don't rely only on the vital sign numbers. Head and Spine Injury • If client has head injury, the most important assessment is level of consciousness; next is pupil response to light. Changes in vitals are very late sign. • With trauma clients, assume spine is injured until proven otherwise. While you open the airway, you must keep cervical spine immobile.