Nursing 211

N211: Health Differences Across the Lifespan I of 148 Include supplemental oxygen therapy, maintain patent airway. Be prepared to initiate mechanical ventilation. Maintain IV access and provide circulatory support as needed. Anticoagulant and/or thrombolytic therapy. Opioid analgesics and anti-anxiety medications as needed. Place client in semi-fowler’s position for comfort. Elevate legs to increase venous flow to heart and lungs. Monitor urinary output for signs of renal perfusion. Ambulation and leg exercises to prevent venous stasis. Passive and active range of motion exercises. Apply and maintain anti-thrombolytic elastic stockings and/or intermittent pneumatic leg compression devices to prevent venous pooling. Promote comfort by administering analgesics as needed. Utilize non-pharmacological methods such as guided imagery and distraction. Instruct patient taking anti-coagulants to watch for bleeding and report to physician immediately. To prevent further pulmonary emboli, a vena cava filter may be inserted to trap emboli. Medications Includes Heparin and Warfarin (Coumadin) therapy. Monitor activated partial thromboplastic time (APTT) for heparin therapy. Coumadin therapy is initiated while the patient is on heparin therapy because heparin has a short half-life. Coumadin therapy is monitored by the prothrombin time (PT). The international normalized ratio (INR) is a standardized form of the PT. 2.28 Influenza Influenza is a viral infection that causes respiratory and systemic symptoms. Influenza is highly contagious and is airborne and is transmitted by droplets from the respiratory tract of the infected person. The incubation period lasts from 24 to 72 hours. Influenza may lead to bronchopneumonia, myocarditis and Meningoencephalitis. Nursing Assessment Includes chills, fever, malaise, generalized aches, cough, sore throat, nasal obstruction and discharge, nausea, vomiting and diarrhea. Nur ing Interventions Include prevention of complications and relief of symptoms. Expectorants/antitussive for cough; acetaminophen for headache and myalgia’s. Increased fluid intake to thin secretions and help reduce fever. Encourage older patients, young children and clients with chronic medical conditions to receive the influenza vaccination prophylactically before flu season. 2.29 Pulmonary Edema ©2012 Achieve Page 74

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