WEEK1 ATI CHPS Advanced PDF

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keiser university 3rd semester ati notes...

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WEEK 1 – ATI CHAPTERS 18, 19, 24,25,26, 91 Chapter 18 – Chest Tube Insertion and Monitoring Chest tubes are inserted into the pleural space to drain fluid, blood or air; reestablish a negative pressure; facilitate lug expansion; and restore normal intrapleural pressure. Chest tubes can be inserted in the emergency department, at the bedside, or in the operating room through a thoracotomy incision. Chest tubes are removed when the lungs have re-expanded or there is no more fluid drainage.

Chest tube systems A disposable three-chamber system is most often used. 

First chamber: drainage collection

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Second chamber: water seal

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Third chamber: suction control

Water seals are created by adding sterile fluid to a chamber up to the 2 cm line. While this is the minimum amount required for functioning, recommended amounts can vary by manufacturer. The water seal allows air to exit from the pleural space on exhalation and stops air from entering with inhalation. 

To maintain the water seal, keep the chamber upright and below the chest tube insertion site at all times. Routinely monitor the water level due to the possibility of evaporation. Add fluid as needed to maintain the manufacturer’s recommended water seal level.

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Wet suction: the height of the sterile fluid in the suction control chamber determines the amount of suction transmitted to the pleural space. A suction pressure of -20 cm H2O is commonly prescribed. The prescribed amount of suction is applied by setting the regulator on the chest tube drainage device. The application of suction results in continuous bubbling in the suction chamber. Monitor the fluid level and add fluid as needed to maintain the prescribed level of suctioning.

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Dry suction: when a dry suction control device is used, the provider prescribes a level of suction for the device, typically -20 cm H2O. When connected to wall suction, the regulator on the chest tube drainage system is set to the manufacturer’s recommendation.

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Tidaling (movement of the fluid level with respiration is expected in the water seal chamber. With spontaneous respirations, the fluid level with rise with inspiration (increase in negative pressure in lung) and will fall with expiration. With positivepressure mechanical ventilation, the fluid level will rise with expiration and fall with inspiration.

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Cessation of tidaling in the water seal chamber signals lung re-expansion or an obstruction within the system.

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Continuous bubbling in the water seal chamber indicates an air leak in the system.

Chest tube insertion

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WEEK 1 – ATI CHAPTERS 18, 19, 24,25,26, 91 INDICATIONS POTENTIAL DIAGNOSES Pneumothorax: partial to complete collapse of the lung due to accumulation of air in the pleural space Hemothorax: partial to complete collapse of the lung due to accumulation of blood in the pleural space Postoperative chest drainage: thoracotomy or open-heart surgery Pleural effusion: abnormal accumulation of fluid in the pleural space Pulmonary empyema: accumulation of pus in the pleural space due to pulmonary infection, lung abscess, or infected pleural effusion CLIENT PRESENTATION 

Dyspnea

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Distended neck veins

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Hemodynamic instability

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Pleuritic chest pain

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Cough

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Absent or reduced breath sounds on the affected side

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Hyperresonance on percussion of the affected side (pneumothorax)

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Dullness or flatness of percussion of the affected side (hemothorax, pleural effusion)

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Asymmetrical chest wall motion

CONSIDERATIONS PREPROCEDURE 

Verify that the consent form is signed.

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Reinforce client teaching. Breathing will improve when the chest tube is in place.

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Assess for allergies to local anesthetics.

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Assist the client into the desired position (supine or semi-Fowler’s).

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Prepare the chest drainage system prior to the chest tube insertion per the facility’s protocol. (Fill the water seal chamber.)

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Administer pain and sedation medications as prescribed.

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Prep the insertion site with povidone-iodine or other facility-approved agent.

INTRAPROCEDURE 

Assist the provider with insertion of the chest tube, application of a dressing to the insertion site, and set-p of the drainage system.

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WEEK 1 – ATI CHAPTERS 18, 19, 24,25,26, 91 o

Place the chest tube drainage system below the client’s chest level with the tubing coiled on the bed. Ensure that the tubing from the bed to the drainage system is straight to promote drainage via gravity.

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The nurse should continually monitor vital signs and response to the procedure.

POSTPROCEDURE 

Assess vital signs, breath sounds, SaO2, color, and respiratory effort as indicated by the status of the client and at least every 4 hr.

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Encourage coughing and deep breathing every 2 hr.

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Keep the drainage system below the client’s chest level, including during ambulation.

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Monitor chest tube placement and function. o

Check the water seal level every 2 hr, and add fluid as needed. The fluid level should fluctuate with respiratory effort.

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Document the amount and color or drainage hourly for the first 24 hr and then at least every 8 hr. Mark the date, hour, and the drainage level on the container at the end of each shift. Report excessive drainage (greater than 70 mL/hr) or drainage that is cloudy or red to the provider. Drainage often increases with position changes or coughing.

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Monitor the fluid in the suction control chamber, and maintain the prescribed fluid level.

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Ensure the regulator dial on the dry suction device is at the prescribed level.

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Check for expected findings of tidaling in the water seal chamber and continuous bubbling on I the suction chamber.

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Routinely monitor tubing for kinks, occlusions, or loose connections.

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Monitor the chest tube insertion site for redness, pain, infection, and crepitus (air leakage in subcutaneous tissue).

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Tape all connections between the chest tube and the chest tube drainage system.

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Position the client in the semi – to high – Fowler’s position to promote optimal lung expansion and drainage of fluid from the lungs.

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Administer pain medications as prescribed.

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Obtain a chest x-ray to verify the chest tube’s placement.

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Keep two enclosed hemostats, sterile water, and an occlusive dressing located at he bedside at all times.

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Due to the risk of causing a tension pneumothorax, chest tubes are clamped only when prescribed in specific circumstances, such as in the case of an air leak, during drainage system change, accidental disconnection of tubing, or damage to the drainage system.

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Due no strip or milk tubing; only perform this action when prescribed. Stripping creates a high negative pressure and can damage lung tissue.

COMPLICATIONS Air leaks

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WEEK 1 – ATI CHAPTERS 18, 19, 24,25,26, 91 Air leaks can result if a connection is not taped securely. NURSING ACTIONS 

Monitor the water seal chamber for continuous bubbling (air leak finding). If observed, locate the source of the air leak, and intervene accordingly (tighten the connection, replace drainage system).

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Check all connections.

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Notify the provider if an air leak is noted. If prescribed, gently apply a padded clam to determine the collation of the air leak. Remove the clamp immediately following assessment.

Accidental disconnection, system breakage, or removal These complications can occur at any time. NURSING ACTIONS 

If the tubing separates, instruct the client to exhale as much as possible and to cough to remove as much air as possible from the pleural space.

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If the chest tube drainage system is compromised, immerse the end of the chest tube in sterile water to restore the water seal.

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If a chest tube is accidentally removed, dress the area with dry, sterile gauze.

Tension pneumothorax 

Suctioning chest wounds, prolonged clamping of the tubing, kinks or obstruction I the tubing or mechanical ventilation with high levels of positive end expiratory pressure (PEEP) can cause a tension pneumothorax.

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Assessment findings include tracheal deviation, absent breath sounds on one side, distended neck veins, respiratory distress, asymmetry of the chest, and cyanosis.

Chest tube removal 

Provide pain medication 30 min before removing chest tubes.

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Assist the provider with sutures and chest tube removal.

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Instruct the client to take a deep breath, exhale, and bear down (Valsalva maneuver) or to take a deep breath and hold it (increases intrathoracic pressure and reduces risk of air emboli) during chest tube removal.

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Apply airtight sterile petroleum jelly gauze dressing. Secure in place with a heavyweight stretch take.

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Obtain chest x-rays as prescribed. This is performed to verify continued resolution of the pneumothorax, hemothorax, or pleural effusion.

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Monitor for excessive wound drainage, signs of infection or recurrent pneumothorax.

Chapter 19 – Respiratory Management and Mechanical Ventilation Oxygen is a tasteless and colorless gas that accounts for 21% of atmospheric air.

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WEEK 1 – ATI CHAPTERS 18, 19, 24,25,26, 91 Oxygen is used to maintain adequate cellular oxygenation. It is used in the treatment of many acute and chronic respiratory problems. Oxygen is administered in an attempt to maintain an SaO2 of 95% to 100% by using the lowest amount of oxygen without putting the client at risk for complications. Clients who cannot spontaneously breath on their own require mechanical ventilation. This can include clients who need respiratory assistance due to sever respiratory disease, general anesthesia, trauma or other illnesses. Oxygen delivery devices Supplemental oxygen can be delivered by a variety of methods based on the client’s particular circumstances. The percentage of oxygen delivered is expressed as the fraction of inspired oxygen (FiO2). LOW-FLOW OXYGEN DELIVERY SYSTEMS These delivery varying amounts of oxygen based on the method and the clients breathing pattern. Nasal Cannula 

A length of tubing with two small prongs for insertion into the nares

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FiO2 24% to 44% at flow rates of 1 to 6 L/min

ADVANTAGES 

Safe, easy to apply, comfortable, and well tolerated.

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The client is able to eat, talk, and ambulate.

DISADVANTAGES 

FiO2 varies with the flow rate, and the client’s rate and depth of breathing.

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Extended use can lead to skin breakdown, and drying of the mucous membranes.

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Tubing is easily dislodged.

NURSING ACTIONS 

Assess patency of the nares.

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Ensure that the prongs fit in the nares properly.

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Use water-soluble gel to prevent dry nares.

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Provide humidification for flow rates of 4 L/min and greater.

Simple face mask 

Covers the client’s nose and mouth.

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FiO2 40% to 60% at flow rates of 5 to 8 L/min. (The minimum flow rate is 5 L/min to ensure flushing of CO2 from the mask.)

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WEEK 1 – ATI CHAPTERS 18, 19, 24,25,26, 91

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WEEK 1 – ATI CHAPTERS 18, 19, 24,25,26, 91 Chapter 24 – Pulmonary Embolism A pulmonary embolism (PE) occurs when a substance (solid, gaseous, or liquid) enters venous circulation and forms a blockage in the pulmonary vasculature. Emboli originating from venous thromboembolism, also know as deep-vein thrombosis (DVT), are the most common cause. Tumor, bone marrow, amniotic fluid, air, and foreign matter also can become emboli. Increased hypoxia to pulmonary tissue and impaired blood flow can result from a large embolus. A PE is a medical emergency. Prevention, rapid recognition, and treatment of a PE are essential for a positive outcome.

HEALTH PROMOTION AND DISEASE PREVENTION  Promote smoking cessation. 

Encourage maintenance of appropriate weight for height and body frame.

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Prevent DVT by encouraging clients to do leg exercises, wear compression stockings, and avoid sitting for long periods of time.

ASSESSMENT RISK FACTORS 

Long-term immobility

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Oral contraceptive use and estrogen therapy

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Pregnancy

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Tobacco use

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Hypercoagulability (elevated platelet count)

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Obesity

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Surgery (especially orthopedic surgery of the lower extremities or pelvis)

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Central venous catheters

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Heart failure or chronic atrial fibrillation

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Autoimmune hemolytic anemia (sickle cell)

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Long bone factures

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Cancer

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Trauma

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Advanced age o

Older adult clients have decreased pulmonary reserves due to normal lung changes, including lung elasticity and thickening alveoli. Older adult clients can decompensate more quickly.

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Certain pathological conditions and procedures that can predispose clients to DVT formation (peripheral vascular disease, hypertension, hip and knee arthroplasty) are more prevalent in older adults.

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Many older adult clients experience decreased physical activity levels, thus predisposing tehm to DVT formation and pulmonary emboli.

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WEEK 1 – ATI CHAPTERS 18, 19, 24,25,26, 91 EXPECTED FINDINGS 

Anxiety

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Feelings of impending doom

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Pressure in chest

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Pain upon inspiration and chest wall tenderness

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Dyspnea and air hunger

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Cough

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Hemoptysis PHYSICAL ASSESSMENT FINDINGS

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Pleurisy

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Pleural friction rub

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Tachycardia

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Hypotension

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Tachypnea

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Adventitious breath sounds (crackles) and cough

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Heart murmur in S3 and S4

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Diaphoresis

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Low – grade fever

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Decreased oxygen saturation levels (expected reference range is 95% to 100%), low SaO2, cyanosis

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Petechiae (red dots under the skin) over chest and axillae

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Pleural effusion (fluid in the lungs

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Distended neck veins

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Syncope

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Cyanosis

LABORATORY TESTS ABG analysis  PaCO2 levels are low (expected reference range is 35 to 45 mm Hg) due to initial hyperventilation (respiratory alkalosis). 

As hypoxemia progresses, respiratory acidosis occurs.

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Further progression leads to metabolic acidosis due to buildup of lactic acid from tissue hypoxia.

CBC analysis To monitor hemoglobin and hematocrit D-dimer Elevated above expected reference range in response to clot formation and release of fibrin degradation products (expected reference range is 0.43 to 2.33 mcg/mL).

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WEEK 1 – ATI CHAPTERS 18, 19, 24,25,26, 91 DIAGNOSTIC PROCEDURES Chest x-ray and computed tomography scan These provide initial identification of a PE. A computed tomography (CT) scan is most commonly used. A chest x-ray can show a large PE. Ventilation-perfusion scan Ventilation-perfusion (V/Q) scan images show circulation of air and blood in the lungs and can detect a PE. Pulmonary angiography  This is the gold standard and most thorough test to detect a PE, but is invasive and costly. A catheter is inserted in the vena cava to visually see a PE. 

Pulmonary angiography is a higher risk procedure than a V/Q scan. NURSING ACTIONS: o

Verify that informed consent has been obtained.

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Monitor status (vital signs, SaO2, anxiety, bleeding with angiography) during and after the procedure.

PATIENT – CENTERED CARE NURSING CARE 

Administer oxygen therapy to relieve hypoxemia and dyspnea. Position the client to maximize ventilation (high-Fowlers = 90⁰).

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Initiate and maintain IV access.

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Administer medications as prescribed.

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Assess respiratory status at least every 30 min.

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Auscultate lung sounds.

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Measure rate, rhythm, and ease of respirations.

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Inspect skin color and capillary refill.

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Examine for position of trachea.

Assess cardiac status. o

Compare blood pressure in both arms.

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Palpate pulse quality.

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Check for dysrhythmias on cardiac monitor.

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Examine the neck for distended neck veins.

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Inspect the thorax for petechiae.

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Provide emotional support and comfort to control client anxiety.

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Monitor changes in level of consciousness and mental status.

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WEEK 1 – ATI CHAPTERS 18, 19, 24,25,26, 91 MEDICATIONS Anticoagulants Heparin, enoxaparin, warfarin, and fondaparinux are used to prevent clots from getting larger or additional clots from forming. NURSING CONSIDERATIONS:  Assess for contraindications (active bleeding, peptic ulcer disease, history of stroke, recent trauma).  Monitor bleeding times: prothrombin time (PT) and international normalized ratio (INR) for warfarin, partial thromboplastin time (aPTT) for heparin, and complete blood count (CBC).  Monitor for side effects of anticoagulants (e.g., thrombocytopenia, anemia, hemorrhage). Direct factor Xa inhibitor Rivaroxaban binds directly with the active center of factor Xa, which inhibits the production of thrombin. NURSING CONSIDERATIONS:  Assess for bleeding from any site. (Clients have experienced epidural hematomas, as well as intracranial, retinal, adrenal, and GI bleeds.)  Risk for spinal or epidural hematoma. Should discontinue mediation for 18 hr prior to removing and epidural catheter, and wait another 6 hr to restart. Thrombolytic therapy  Alteplase, reteplase, and teneceteplase are used to dissolve blood clots and restore pulmonary blood flow. 

Similar side effects and contraindications as anticoagulants. NURSING CONSIDERATIONS:  Assess for contraindications (known bleeding disorders, uncontroll...