- Good oxygenation
- Adequate circulation
- Peripheral vasoconstriction
- Insufficient oxygenation of tissues
No category found.
- Advanced wound care
- Infection control
- Surgical asepsis
- Pain management
- Check residual volume and tube placement.
- Administer the feeding cold.
- Clamp the tube during administration.
- Bounding peripheral pulses and distended neck veins.
- Crackles in the lungs and weight gain.
- Dry mucous membranes, decreased skin turgor, and thirst.
- Normal blood pressure and clear lung sounds.
- Improved patient outcomes.
- Communication breakdown and potential errors in care.
- Enhanced nurse-patient relationships.
- Faster patient discharge.
- Blink vigorously after instillation.
- Look straight ahead.
- Look up and away while pulling the lower eyelid down to create a pouch.
- Close their eyes tightly immediately after.
- Try to prevent the fall by holding the patient up firmly.
- Immediately let go of the patient.
- Guide the patient gently to the floor, protecting their head, and call for help.
- Yell for help without acting.
- Subjective assessment.
- Objective assessment.
- Nursing diagnosis.
- Patient's problem list.
- Physiological needs
- Safety and Security
- Love and Belonging
- Self-Actualization
- Cleaning the stoma with tap water.
- Maintaining strict aseptic technique during suctioning and dressing changes.
- Avoiding suctioning to prevent irritation.
- Changing the tracheostomy tube daily.
- Cause
- Character
- Comfort
- Chronicity
- Slow, sustained absorption.
- Rapid onset of action.
- Topical effect only.
- Localized effect.
- Greater than 5 seconds
- Less than 2 seconds
- 3-5 seconds
- Not indicative of circulation
- Right time
- Right route
- Right dose and right drug
- Right documentation
- Administer an antihistamine without physician order.
- Continue the medication and monitor.
- Stop the medication immediately, assess the patient for other signs of reaction, and notify the physician.
- Document the rash and itching.
- Subjective data
- Objective data
- Indirect data
- Historical data
- Dependent intervention
- Collaborative intervention
- Independent nursing intervention
- Interdependent intervention
- Is occlusive and non-absorbent.
- Is non-absorbent to prevent moisture.
- Absorbs exudate, protects the wound, and provides a moist environment for healing.
- Sticks firmly to the wound bed.
