Question

Based on the given example in the table given below, mention the contraindications and nursing implications to specific health assessment findings Health assessment findings Contraindications Eg: Edema Edema may be a sign of fluid overload. Therefore, IV Fluids are likely to be contra indicated. Nursing implications: -Monitor Fluid balance -Assess for skin integrity and implement strategies to prevent skin breakdown -Position client comfortably to assist with breathing and to prevent friction and shear -Administer diuretics and other medications as prescribed Health assessment findings Contraindications

34.1) Dyspnea or wheezing

34.2) Bleeding

34.3) Hypotension

34.4) Allergy to seafood

34.5) Past history of Mastectomy

34.6) Neutropenia

Answer 1

34.1, Dyspnea: dyspnea due to hypoxemia, heart disease and respiratory distress.

Nursing implications:

- monitor vital signs and check oxygen saturation

- find out the underlying causes and monitor closely for symptoms like chest pain and shortness of breath.

- make Patient in a comfortable position with head elevated

- admiinister oxygen as per patient condition and saturation level.

- provide bronchodilator, corticosteroid as per Physician advice..

- check ECG, X ray chest,and arterial blood gas level.

- provide psychological support to avoid anxiety..

34.2, Bleeding:. Bleeding is a loss of blood from the circulatory system due to deep cuts, injury and due to any medication

Nursing implications:

- check Patient conscious level and make the patient lie down with head elevated to Avoid hypotension

- check breathing level and check vitals and provide oxygen.

- findout the underlying causes and provide treatment accordingly.

-assess the bleeding site whether it is major or minor

- if it is arrest the bleeding first,if it is major may be surgical intervention required

- if it is internal bleeding it is a life threatening condition serious action required to avoid further complication..

34.3, hypotension: hypotension is a low blood pressure below 90/60 mmHg due to heart arrhythmia,loss of blood,a severe allergic reaction

Nursing implications:

- make the Patient comfortable with head elevated

- connect Patient to cardiac monitor for continuous blood pressure checkup..

- provide IV fluids administration as per doctor advice..

- findout the cause for hypotension and treatment should be given accordingly.

- provide fluids with salt to avoid giddiness..

- administration of oxygen and medication as per doctor advice.

34.4, Allergy to seafood:. Allergy to seafood due to immune system reaction.

Nursing implications:

- be aware when you go for dining

- avoid outside food.

- avoid place where seafood processed and prepared.

- in case of emergency treatment epinephrine is the first line treatment to avoid symptoms and control allergic reaction..