Things You See Over And Over Again Part 1

Study Guides

First, here's a really nice link with common nursing interventions written very, very succinctly.

Link To Common Interventions

The Topics for Today are BLEEDING and DVTs

Bleeding

Look for:

·         Hematuria

·         Black, tarry stools

·         Petechiae

·         Ecchymosis

·         Bleeding gums

·         Coffee-ground emesis

Think bleeding precautions if the person has leukemia, or is on anticoagulants or has thrombocytopenia.

• Avoid injections if possible
• Use the smallest gauge possible for IV therapy
• Maintain pressure after a venipuncture for at least 5 minutes
• Tell patient to use an electric razor
• Avoid contact sports
• Use a soft toothbrush
• Prevent straining at stool
• Monitor Hgb, Hct
• Avoid salicylates
• Avoid rectal thermometers and suppositories

DVTs

Think about this any time your patient is immobile or has just had surgery or a fracture or is pregnant. Also if on hormone replacement therapy or has a coagulation disorder.

Look For:

•         Homan’s sign (but do not elicit if already confirmed)
•        Red, tender calf
•        Difference in calf size bilaterally
•        Edema and warmth

Prevention:

• Early ambulation
• SCDs
• TED hose
• Anticoagulants
• Avoid prolonged sitting and crossing legs
• Leg exercises
• No pillows under knees
• Hydration
• Elevate foot of be with knees slightly flexed

Monitor:

• Signs and symptoms of pulmonary embolism
• INR/PT/PTT if on anticoagulants
• Peripheral pulses, cap refill, color of extremities
• Assess respiratory status frequently