21) B.

ineffective airway clearance

Nursing

Diagnoses: Based on assessment data, the patients major nursing diagnoses may include: Impaired gas exchange related to underlying illness, ventilator setting adjustment during stabilization, or weaning. Ineffective airway clearance related to increased mucus production associated with presence of the tube in trachea or continuous positive- pressure mechanical ventilation. p748
Reference: Textbook of Medical-Surgical Nursing, Brunner & Suddarths, 11th edition, vol 1

22) D. Improve venous return

ACTIONS & INTERVENTIONS Maintain immobilization of affected part by means of bed rest, cast, splint, traction Elevate and support injured extremity Avoid use of plastic sheets/ pillows under limbs in cast RATIONALE Relives pain and bone displacement extension of tissue injury. Promotes venous return decreases edema, and may reduce pain. Can increase discomfort by enhancing heat production in the drying cast

elevate bed covers: keep linens off toes.

Maintains body warmth without discomfort due to pressure of bedclothes on affected parts Influences effectiveness of interventions. Many factors, including level of anxiery, may affect perception of /reaction to pain. Note; Absence of pain expression does not necessarily mean lack of pain.

Evaluate document report of pain/discomfort, noting location and characteristics, including intensity (0-10 scale), relieving and aggravating factors. Note: non-verbal pain cues (changes in vital signs and emotions/behavior)

ACTIONS & INTERVENTIONS

RATIONALE

Encourage patient to discuss problems related to injury Explain procedures before beginning them.

Helps alleviate anxiety. Patient may feel need to relieve the accident experience. allows patient to prepare mentally for activity and to participate in controlling level of discomfort.

Medicate before care activities. Let Promotes muscle relaxation and patient know it is important to request enhances paticipation. medications before pain becomes severe.

Reference: http://www.scribd.com/doc/17471571/Nursing-Care-Planfor-Cast

23) D. Suggest communication strategies

Nursing Management Supporting cognitive function As the patients cognitive ability declines, the nurse provides a calm, predictable environment that helps the person interpret his/ her surroundings and activities. Environmental stimuli are limited, and a regular routine is followed. Promoting physical safety A safe environment allows the patient to move about as freely as possible and relieves the family of constant worry about safety. p208

Reducing anxiety and agitation Despite profound cognitive losses, the patient will, at times, be aware of his or her rapidly diminishing abilities. The patient will need constant emotional support that reinforces a positive self image. Improving communication To promote the patients interpretation of messages, the nurse remains unhurried and reduces noises and distractions.p 209
Reference: Textbook of Medical-Surgical Nursing, Brunner & Suddarths, 11th edition, vol 1

24) C. Reduce carbohydrates intake to 25% of total calories.

NUTRITIONAL MANAGEMENT CALORIC REQUIREMENTS Calorie-controlled diets are planned by first calculating the individuals energy needs and caloric requirements based on the patients age, gender, height, and weight. An activity element is then factored in to provide the actual number of calories required for weight maintenance. To promote a 1- to 2-pound weight loss per week, 500 to 1,000 calories are subtracted from the daily total. The calories are distributed into carbohydrates, proteins, and fats, and a meal plan is then developed. p156
Reference: Textbook of Medical-Surgical Nursing, Brunner &
th

Caloric Distribution A diabetic meal plan also focuses on the percentage of calories to come from carbohydrates, proteins, and fats. In general, carbohydrate foods have the greatest effect on blood glucose levels because they are more quickly digested than other foods and are converted into glucose rapidly. Several decades ago it was recommended that diabetic diets contain more calories from protein and fat foods than from carbohydrates to reduce postprandial increases in blood glucose levels. However, this resulted in a dietary intake inconsistent with the goal of reducing the cardiovascular disease commonly associated with diabetes (ADA, Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Related Complications, 2003).

Tracheoesophageal Fistula
Tracheoesophageal fistula(TEF) is commonly a birth defect, with the trachea connected to the esophagus. In most cases, the esophagus is discontinuous, causing immediate feeding difficulties. TEFs may develop in adult life, secondary to the invasion of cancer in the area. In addition, TEFs may be deliberately constructed with surgery to aid talking in a patient who has the larynx removed (a laryngectomy). The trachea, or windpipe, carries air to the lungs. The esophagus carries food to the stomach. Sometimes during development, these two tubes do not separate completely, but remain connected by a short passage. When this happens, air enters the gastrointestinal system, causing the bowels to distend, and mucus is breathed into the lungs causing aspiration pneumonia and breathing problems.

Causes and symptoms

Tracheoesophageal fistulas arise as a developmental abnormality. At birth, the infant has difficulty swallowing. Eating produces severe coughing spells that interfere with breathing. Aspiration pneumonia can develop from fluid breathed into the lungs

Treatment
Babies with all but H type fistulas are unlikely to survive without surgical separation and repair of the trachea and the esophagus. Surgery cannot always be performed immediately because of prematurity, the presence of other birth defects, or complications from aspiration pneumonia. It is usually done at a hospital that has special facilities for treating seriously ill newborns. While awaiting surgery, the infant's condition is stabilized. Preoperative care concentrates on avoiding aspiration pneumonia and includes: elevating the head to avoid reflux and aspiration of the stomach contents using a suction catheter to continuously removed mucus and saliva that could be inhaled when necessary, placement of a gastrostomy tube withholding feeding by mouth When surgery is performed, the esophagus is reconnected to make it continuous and separate from the trachea. If the two ends of the esophagus are too far apart to be reattached, a piece of tissue from the large intestine is used to join the parts.

Nursing Diagnoses:
Based on assessment data, the patients major nursing diagnoses may include: Impaired gas exchange related to underlying illness, ventilator setting adjustment during stabilization, or weaning. Ineffective airway clearance related to increased mucus production associated with presence of the tube in trachea or continuous positivepressure mechanical ventilation.

Alzheimer's disease
Alzheimer's disease (AD) is a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception. Many scientists believe that Alzheimer's disease results from an increase in the production or accumulation of a specific protein (beta-amyloid protein) in the brain that leads to nerve cell death.

SIGNS OF NORMAL CHANGE VS. EARLY ALZHEIMERS SYMPTOMS

Normal Cant find your keys Early Alzheimers disease Routinely place important items in odd places, such as keys in the fridge, wallet in the dishwasher Forget names of family members and common objects, or substitute words with inappropriate ones Frequently forget entire conversations Dress regardless of the weather, wear several skirts on a warm day, or shorts in a snow storm Cant follow recipe directions Can no longer manage checkbook, balance figures, solve problems, or think abstractly Withdraw from usual interests and activities, sit in front of the TV for hours, sleep far more than usual

Search for casual names and words

Briefly forget conversation details Feel the cold more

Cant find a recipe Forget to record a check

Cancel a date with friends

The three stage Alzheimers disease model

Description Mild/Early Duration 2-4yrs Characteristics Frequent recent memory loss, particularly of recent conversations and events. Repeated questions, some problems expressing and understanding language. Mild coordination problems: writing and using objects becomes difficult. Depression and apathy can occur, accompanied by mood swings. Need reminders for daily activities, and may have difficulty driving. Can no longer cover up problems. Pervasive and persistent memory loss, including forgetfulness about personal history and inability to recognize friends and family. Rambling speech, unusual reasoning, and confusion about current events, time, and place. More likely to become lost in familiar settings, experience sleep disturbances, and changes in mood and behavior, which can be aggravated by stress and change. May experience delusions, aggression, and uninhibited behavior. Mobility and coordination is affected by slowness, rigidity, and tremors. Need structure, reminders, and assistance with the activities of daily living. Confused about past and present. Loss of ability to remember, communicate, or process information. Generally incapacitated with severe to total loss of verbal skills. Unable to care for self. Falls possible and immobility likely. Problems with swallowing, incontinence, and illness. Extreme problems with mood, behavior, hallucinations, and delirium. In this stage, the person will need round the clock intensive support and care.

Moderate/ Middle

2-10 yrs

Severe/Late

1-3+ yrs

Nursing Management
Supporting cognitive function As the patients cognitive ability declines, the nurse provides a calm, predictable environment that helps the person interpret his/ her surroundings and activities. Environmental stimuli are limited, and a regular routine is followed. Promoting physical safety A safe environment allows the patient to move about as freely as possible and relieves the family of constant worry about safety

Reducing anxiety and agitation Despite profound cognitive losses, the patient will, at times, be aware of his or her rapidly diminishing abilities. The patient will need constant emotional support that reinforces a positive self image. Improving communication To promote the patients interpretation of messages, the nurse remains unhurried and reduces noises and distractions