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

Answer 1

1. Dyspnea or wheezing:

Dyspnea or wheezing is sign of breathing difficulty. Dyspne can occur as a result of asthma, heart failure and myocardia ischemia, COPD and many other causes

Contraindication: Environmental polution should be avoided. As example, chemical, fumes, dust and smoke can trigger and aggrevate the condition of dyspnea hence should be avoided.

Nursing implication: Inhaled steroid like Baclomethasone can be beneficial to reduce the dyspea. The condition should be monitored. If it becomes severe oxygen therapy should be started.

2. Bleeding:

Bleeding is blood loss from the body. Bleeding can be internal or external. There are different causes for internal as well as external bleeding.

Contraindication: Anticoagulants like heparin and warfarin is contraindicated if there is bleeding occurs as it can aggrevate theclotting difficulty or overall clotting process.

Nursing implication: When there is bleeding, there is always a risk for the decrease blood volume in the body. At risk patients should be educated regarding the precautionary measures for bleeding. When bleeding occurs in a patient, the nurse should gather information to assess the cause for bleeding. There should be intravenous fluid started to conpensate the body fluid volume to avoid any hypovolemic shock. There should be continous monitoring of hemoglobin, heart rate and blood pressure. If required blood products should be administered.

3. Hypotension: Hypotension is low blood pressure and it it usually not considered as major problem. If it get severe then there may some underlying causes for this.

Contraindication: Diuretics, antihypertensives and betablockers are contraindicated in hypotension.

Nursing implication; Hypotension is a symptom not a medical diagnosis, so it is imp.ortant to gather information to identify the cause. has to monitor for decrease cardiac output and activity intolerance . Immediate IV fluid intervention required if ithe sytolic and dyastolic pressure is significantly low. If required oxygen therapy should be started