Question

in the table given below, mention the contraindications and nursing implications to specific health assessment findings

Health assessment findings Contraindications

32.1 Dyspnea or wheezing

32.2 Bleeding

32.3 Hypotension

32.4 Allergy to seafood

32.5 Past history of Mastectomy

32.6 Neutropenia

Answer 1

Answer 32.1 ) A wheeze is a high pitched musical adventitious lung sound which is heard when the air passes through an abnormally compressed airway. Dyspnea is defined as shortness of breath. These two signs are found in respiratory and cardiovascular diseases. During health assessment, a wheeze can be heard while auscultation and dyspnea may be presented by breathlessness, chest tightness.

Nursing implications:

• Assess the respiratory status, vital signs, and pulse oximetry.
• Position the patient at semi or high fowlers position.
• Oxygenate as per the saturation level of the patient.
• Administer the medication and vapourisers as ordered.
• Assess the allergic history of the patient and remove those allergens.
• Avoid exposure to extremes of cold and hot.
• Keep patient hydrated.
• Treat the underlying cause.

Bleeding: Bleeding in a patient can be internal or external from many source like from a injury site, gastrointestinal bleeding, intracranial bleeding, menstrual bleeding, bleeding disoreders like hemophilia, rupture of blood vessel like in aneurysms. It may result in little or major loss of blood from the body especially in external bleeding. internal bleeding may result in formation of hematoma, blood clots. This may lead to death, obstruction in the normal blood flow, hypotension.

Nursing implications:

• Watch for amount of blood loss, site in external bleeding. Stop bleeding by use of a sterile gauze pad.
• Check patients vital signs especially blood pressure, heart rate.
• Watch for signs of circulatory collapse, shock.
• Fluid resuscitation is done using intravenous fluids and colloids.
• Test patients blood for grouping, in case patient may require blood transfusion in massive hemorrhage.

Hypotension: A systolic blood pressure of less than 90mmHg and diastolic blood pressure of less than 60 mmHg is considered as hypotension. Primary symptoms shown by patient is lightheadedness or dizziness. Hypotension may occur by low blood volume, hormonal changes, widening of blood vessel, medication side effects, anaemia, heart and lung problems, hemorrhage, starvation, fluid loss. Hypotension may result in decreased blood supply to vital organs and thereby causing damage to it.

Nursing implications:

• Check blood pressure periodically.
• Hydrate the patient with intravenous fluids.
• Treat the underlying causes.
• Assist patient while performing activities of daily living and during locomotion.
• Apply patient safety measures to prevent injury from falls.
• Patient may be required to be kept in trendelenburg position to increase venous return.

Allergy to seafood: Allergic reaction to seafood may be mild like hives,utricaria, swelling, vomiting, nausea. Severe reaction include dyspnea, hypotension and collapse. This allergic reaction to seafoods are basically due to presence of specific proteins of animals.

Nursing implications:

• Avoid seafoods in diet.
• Watch for vital signs.
• Place the patient flat and donot allow him to move.
• Inject the medication that would immediately trigger immune response. example adrenaline.
• Provide dietary support through means of a dietician.