REDUCTION OF RISK POTENTIAL

Specimens

 Obtain all specimens using gloves and sterile equipment.

 Seal all specimen containers tightly.
 Label all specimens with client's name, content and date obtained.
 Specimens should be delivered to the laboratory as quickly as possible - do not allow specimens
to sit at room temperature.
X-rays and other diagnostic tests

 Correct views to isolate possible fracture: two-view minimum.

 Include joints above and below suspected fracture.
 Not all fractures show on x-ray; diagnosis relies on clinical evidence.
 Especially in children, x-rays of unaffected limb may be needed for comparison.
 Following a laparoscopy, carbon dioxide trapped in the abdomen may cause discomfort and
even shoulder pain.
 Cardiac output (CO) = (heart rate x stroke volume)
Nasogastric or Intestinal Intubation

 Placement of tube is confirmed by x-ray when first inserted.

 Check placement of tube by aspirating stomach contents and testing for pH thereafter (for
gastric placement - should be less than 5).
Ostomies

 A stoma has no feeling, so touching it does not hurt client.

 A colostomy may not function for a number of days after surgery.
 Initially ileostomy drainage may be copious and green in color changing to brown after client
resumes normal diet.
 The bowel must be totally healed before attempting irrigation of colostomy.
 Infection, diet or medication may cause spillage between colostomy irrigations.
 Findings of bowel perforation include rigid, painful abdomen with absence of bowel sounds, no
output from colostomy except small amount of blood.
 There will always be some mucus in urinary diversions that involve segments of bowel, such as
ileal loop or continent urinary diversion.
Casts
 A cast may be heavy or impair mobility due to its location and type of casting material.
 Analgesics may be given 20 to 30 minutes before casting to reduce pain.
 A cast should be snug but not restrict circulation.
 For proper drying, casts must dry from inside out; covering will delay drying.
 Cast may smell sour but should never smell foul.
 Elevation and use of ice reduces swelling.
 Report signs of neurovascular impairment immediately (compartment syndrome is a medical
emergency).
Traction

 Maintain established line of pull and counter traction continuously.

 Prevent friction between device and body.
 Maintain proper body alignment.
 Effective traction correctly aligns affected body parts.
 Pain and spasms should be relieved by traction.
 Client does not have to keep other body parts immobile.
Tracheostomy

 Clients with new tracheostomy tubes may have bloody secretions for a few days after the
procedure or after a tube change.
 Tracheostomy obturator should be attached to head of bed at all times.
 Pediatric tracheostomy tubes do not usually have an inner cannula.
 Children have shorter necks so stoma care may be more difficult.
 Yeast infections can form under moist tracheostomy dressings.
 Clients with these issues may need more frequent tracheostomy care:
o Tracheal stomatitis
o Pneumonia
o Bronchitis
o Short, fat neck
o Excessive perspiration
 Always have another staff or family member assist with tracheostomy care in case of accidental
dislodgement or extubation.
 Because upper airway is not functioning, expect more secretions.
 Ventilator

 When caring for a client on a ventilator, if an alarm sounds, assess the client first.
 See if the alarm resets or if the cause is obvious.
 If the alarm continues to sound and the client develops distress
o Disconnect the client from the ventilator
o Use a manual resuscitation bag
o Call the respiratory therapist immediately
Suctioning and chest physiotherapy

 Suction no sooner than 2 to 3 hours after client has finished eating.

 Apply suction for no longer than 10 seconds; apply oxygen prior to and immediately after
suctioning.
 Be sure to have emesis basin and tissues at hand.
 Administer any bronchodilator medication at least 30 minutes before chest physiotherapy.
Chest tubes

 Gentle bubbling in suction control chamber is expected and indicates there is suction.
 Bubbling in water seal chamber indicates an air leak.
 Notify physician if drainage is more than 100 mL/hour or if drainage becomes bright red or
increases suddenly.
Oxygen

 A nonrebreather mask provides highest percentage of O2 available from any mask.

Catheterization

 Intermittent catheterization at home may be a clean, not sterile, procedure.

 Full bladders in clients with high thoracic spinal cord injuries may stimulate hypertensive crisis.
Surgery

 Primary responsibility for obtaining surgical consent rests with the surgeon.
 Informed consent cannot be obtained from the client if the client has an altered level of
consciousness, is mentally incompetent, or is under the influence of mind-altering drugs; the
health care power of attorney may need to be contacted.
 Essential to all pre-op teaching is an explanation of all pre-op and post-op routine procedures,
along with a demonstration of post-op exercises.
Radiation
 Radiation is more effective on local or regional neoplasia while chemotherapy is more systemic
in its effects.
 Only certified nurses may administer chemotherapeutic agents.
 Ionizing radiation will damage both normal and cancerous cells resulting in side effects.
 Clients receiving external radiation are not radioactive at any time.
 Clients receiving internal radiation are not radioactive; however, the implant or injection is
radioactive.
 If the source of radioactivity is metabolized, the client's secretions and excretions may be
radioactive for a time, based on the half-life of the isotope.
o Restrict contact - no contact with children or pregnant women for three to seven days.
o Urinary and bowel excretions - flush toilet twice afterwards.
Wounds

 Never touch a wound without wearing gloves.

 First post-operative dressing change is performed by the health care provider.
 Give analgesic before dressing change so that it peaks during dressing change.
 Maintain surgical asepsis for all wounds and dressing changes
 If drains are present, remove dressing one layer at a time to avoid dislodging drain.
 Pressure dressings should not be removed
 If dressing must be changed frequently, Montgomery straps will prevent skin breakdown from
frequent tape removal.
 Wounds out of client's field of vision or reach require help in dressing.
Hemodyalysis

 NEVER take a blood pressure or draw blood from the arm with the fistula.
 Monitor patency of fistula; auscultate for a bruit and palpate for a thrill.