Aging Process
Newborn Assessment: Expected Findings
● Normal Assessment Findings for Head: Should be 2-3 cm larger than chest.
● Anterior
... [Show More] fontanel should be palpated and approximately 5 cm on average and diamond shaped.
● Posterior fontanel is smaller and triangle-shaped. Should be soft and flat. Molding of sutures is normal.
Psychosocial Integrity
Crisis Intervention
Sexual Assault: Priority Intervention
● Provide a private environment and limit personnel who examine the client.
● Assess client emotions and provide support
● Assess, treat, and document all injuries
● Use a non judgemental and empathetic approach
Abuse/Neglect
Psychosocial Issues of Infants, Children, and Adolescents: Caring for a Child Who Reports Sexual Abuse
● Remove the child from the situation
● Mandatory reporting for all health care workers; there are civil and criminal penalties for not reporting
● Assess for unusual bruising on ABD, back and buttocks
Sensory/Perceptual Alterations
Effective Communication: Responding to a Client Who Is Obese and Is Crying Psychotic Disorders: Caring For a Client Who Is Experiencing Delusions
● Ask the client directly about hallucinations. The nurse should not argue or or agree with the client’s view of the situation.
● Do not argue with a client’s delusions, but focus on the client’s feelings and possibly offer reasonable explanations.
● Assess the client for paranoid delusions, which can increase the risk for
violence against others.
Basic Care and Comfort
Elimination
Postpartum Physiological Adaptations: Interventions to Promote Voiding
● Assist with frequent urination
● Provide noninvasive measures to promote urination
● Perform bladder scan
Nutrition and Oral Hydration
Burns: Supporting Nutritional Requirements
● Client with a large burn injury will be in a hypermetabolic state and may exceed 5,000 calories/day
● Increase protein intake to prevent tissue breakdown and promote healing
● Enteral or total parenteral therapy is often necessary Medications for Depressive Disorders: Food and Medication Interaction
● MAOIs- avoid foods containing tyramine (meats, cheeses, alcohol)
● SSRI & SNRI- avoid alcohol
● Tricyclic- do not administer with MAOIs or St. John's Wart Renal Disorders: Teaching a Client Who Has Chronic Kidney Disease
● Strict I&Os
● Monitor electrolytes
● Monitor and treat hypertension as prescribed Stroke: Assisting a Client Who Has Dysphagia
● place client in an upright or high Fowler's position to facilitate swallowing
● stay with client due to risk for aspiration
● refer to speech therapist for evaluation
● make diet alterations, avoid thin liquids and sticky foods [Show Less]