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The nurse should try to approximate as much as possible the home schedule of insulin acne 5 months after baby buy discount acticin line, meals acne questions purchase acticin uk, and activities skin care industry order 30gm acticin amex. The results of blood glucose monitoring provide information needed to obtain orders for extra doses of insulin (at times when insulin is usually taken by the patient) skin care laser center purchase cheap acticin on line, an important nursing function. It is important to avoid overly vigorous treatment of hypoglycemia, which may lead to hyperglycemia. Treatment of hypoglycemia should be based on the established hospital protocol (usually 15 g carbohydrate in the form of juice, glucose tablets, or, if necessary, 0. Extra sugar should not be added to Chapter 41 Assessment and Management of Patients With Diabetes Mellitus 1197 the juice. If the initial treatment does not increase the glucose level adequately, the same treatment may be repeated. Hypoglycemia During Hospitalization Hypoglycemia in a hospitalized patient is usually the result of too much insulin or delays in eating. These patients should receive dextrose infusions to provide some calories and limit ketosis. To prevent these problems resulting from the need to withhold food, diagnostic tests and procedures and surgery should be scheduled early in the morning if possible. It is important for hospitalized patients to maintain their nutritional status as much as possible to promote healing. Thus, the use of reduced-calorie substitutes such as diet soda or diet gelatin desserts would not be appropriate when the only source of calories is clear liquids. Simple carbohydrates, when eaten alone, cause a rapid rise in blood glucose levels; thus, it is important to try to match peak times of insulin with peaks in glucose. This results in increased levels of glucose in the diabetic patient receiving tube feedings. If insulin is administered at routine (prebreakfast and predinner) times, hypoglycemia during the day may result from patients receiving more insulin without more calories, and hyperglycemia may occur during the night when feedings continue but insulin action decreases. A common cause of hypoglycemia in patients receiving continuous tube feedings and insulin is inadvertent or purposeful discontinuation of the feeding. The nurse must discuss with the medical team any plans for temporarily discontinuing the tube feeding (eg, when the patient is away from the unit). If the patient is receiving continuous parenteral nutrition, the blood glucose level should be monitored and insulin administered at regular intervals. If the parenteral nutrition is infused over a limited number of hours, subcutaneous insulin should be administered so that peak times of insulin action coincide with times of parenteral nutrition infusion. Successive doses of subcutaneous regular insulin should be administered no more frequently than every 3 to 4 hours. To avoid hypoglycemic reactions caused by delayed food intake, the nurse should arrange for a snack to be given to the patient if meals are going to be delayed because of procedures, physical therapy, or other activities. Common Alterations in Diet Dietary modifications common during hospitalization require special consideration when the patient has diabetes. Another approach is to use frequent (every 3 to 4 hours) dosing of regular insulin only. Even when no food is taken, glucose levels may rise as a result of hepatic glucose production, especially in patients with type 1 diabetes and lean patients with type 2 diabetes. Because diabetic patients are at increased risk for periodontal disease, it is important for the nurse to assist patients with daily dental care. The patient may also require assistance in keeping the skin clean and dry, especially in areas of contact between two skin surfaces (eg, groin, axilla, and, in obese women, under the breasts), where chafing and fungal infections tend to occur. For the bedridden diabetic patient, nursing care must emphasize the prevention of skin breakdown at pressure points. The heels are particularly susceptible to breakdown because of loss of sensation of pain and pressure associated with sensory neuropathy. Feet should be cleaned, dried, lubricated with lotion (but not between the toes), and inspected frequently. If the patient is in the supine position, pressure on the heels can be alleviated by elevating the lower legs on a pillow, with the heels positioned over the edge of the pillow. When the patient is seated in a chair, the feet should be positioned so that pressure is not placed on the heels. If the patient has a foot ulcer, it is important to provide preventive foot care to the unaffected foot as well as to carry out special care of the affected foot. As always, every opportunity should be taken to teach the patient about diabetes self-management, including daily oral, skin, and foot care.

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Some surgeons attempt to salvage the tube with a salpingostomy acne xylitol buy acticin australia, which involves opening and evacuating the tube and controlling bleeding skin care collagen order 30 gm acticin. More extensive surgery includes removing the tube alone (salpingectomy) or with the ovary (salpingo-oophorectomy) skin care insurance cheap 30 gm acticin overnight delivery. Depending on the amount of blood lost acneorg purchase 30gm acticin visa, blood component therapy and treatment of hemorrhagic shock may be necessary before and during surgery. Surgery may also be indicated in women unlikely to comply with close monitoring or those who live too far away from a health care facility to obtain the monitoring needed with nonsurgical management. Patients must be hemodynamically stable, have no active renal or hepatic disease, have no evidence of thrombocytopenia or leukopenia, and have a very small, unruptured tubal pregnancy on ultrasound. The medication Assessment and Diagnostic Findings During vaginal examination, a large mass of clotted blood that has collected in the pelvis behind the uterus or a tender adnexal mass may be palpable. Levels under 5 ng/mL are considered abnormal; levels over 25 ng/mL are associated with a normally developing pregnancy. Ultrasound can detect a pregnancy between 5 and 6 weeks from the last menstrual period. Detectable fetal heart movement outside the uterus on ultrasound is firm evidence of an ectopic pregnancy. Studies using ultrasound with Doppler flow, in which color indicates perfusion, are helpful. However, when the clinical signs and symptoms are Chapter 46 Assessment and Management of Female Physiologic Processes 1405 is administered intramuscularly or intravenously. Complete blood count, blood typing, and tests of liver and renal function are conducted to monitor the patient. The patient is advised to refrain from alcohol, intercourse, and vitamins with folic acid until the pregnancy is resolved because these may exacerbate the adverse effects of methotrexate. Abdominal pain may occur within 5 to 10 days and may indicate termination of the pregnancy. Side effects of methotrexate include stomatitis and diarrhea, bone marrow suppression, impaired liver function, dermatitis, and pleuritis. If the pregnancy is wanted, loss may or may not be expressed verbally by the patient and her partner. Even if the pregnancy was unplanned, a loss has been experienced, and a grief reaction may follow. Severe and persistent psychological distress may require referral for psychological counseling. Continuous monitoring of vital signs, level of consciousness, amount of bleeding, and intake and output provides information about the possibility of hemorrhage and the need to prepare for intravenous therapy. Hematocrit, hemoglobin, and blood gas levels are monitored to assess hematologic status and adequacy of tissue perfusion. Significant deviations in these laboratory values are reported immediately, and the patient is prepared for possible surgery. Blood component therapy may be required if blood loss has been rapid and extensive. If hypovolemic shock occurs, the treatment is directed toward re-establishing tissue perfusion and adequate blood volume. See Chapter 15 for a discussion of the intravenous fluids and medications used in treating shock. Therefore, it may be later that the patient begins to ask questions about what has happened and why certain procedures were performed. Procedures are explained in terms that a distressed and apprehensive patient can understand. After the patient recovers from postoperative discomforts, it may be more appropriate to address any questions and concerns that the patient and her partner have, including the effect of this pregnancy or its treatment on future pregnancies. It is important to review signs and symptoms with the patient and instruct her to report an abnormal menstrual period promptly.

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Chapter 36 Cetacaine (tetracaine/benzocaine) to numb the nasal passage and suppress the gag reflex acne extractor purchase cheapest acticin. Having the patient gargle with a liquid anesthetic or hold ice chips in the mouth for a few minutes can have the same effect skin care 85037 generic acticin 30gm free shipping. Encouraging the patient to breathe through the mouth or to pant often helps skin care lounge 30 gm acticin mastercard, as does swallowing water acne diagram buy generic acticin on-line, if permitted. To make the tube easier to insert, it should be lubricated with a water-soluble substance (K-Y jelly) unless it has a dry coating called hydromer, which, when moistened, provides its own lubrication. When the tube reaches the nasopharynx, the patient is instructed to lower the head slightly and to begin to swallow as the tube is advanced. The patient may also sip water through a straw to facilitate advancement of the tube. The oropharynx is inspected to ensure that the tube has not coiled in the pharynx or mouth. Gastrointestinal Intubation and Special Nutritional Modalities 989 Confirming Placement To ensure patient safety, it is essential to confirm that the tube has been placed correctly, particularly because tubes may be accidentally inserted in the lungs, which may be undetected in highrisk patients. Examples of high-risk patients are those with a decreased level of consciousness, confused mental state, poor or absent cough and gag reflexes, or agitation during insertion. Presence of an endotracheal tube and recent removal of an endotracheal tube also increase the risk for inadvertent placement of the tube in the lung (Metheny, 1998). However, each time liquids or medications are administered, and once a shift for continuous feedings, the tube must be checked to ensure that it remains properly placed. The traditional recommendation has been to inject air through the tube while auscultating the epigastric area with a stethoscope to detect air insufflations. However, studies indicate that this auscultatory method is not accurate in determining whether the tube has been inserted into the stomach, intestines, or respiratory tract (Metheny et al. Instead of the auscultation method, a combination of three methods is recommended: feedings, because aspirate often looks like the formula that is used for the feeding (Metheny & Titler, 2001). Determining the pH of the tube aspirate is a more accurate method of confirming tube placement. The pH method can also be used to monitor the advancement of the tube into the small intestines. The pH of intestinal aspirate is approximately 6 or greater, and the pH of respiratory aspirate is more alkaline (7 or greater). A pH sensor enteral tube is available which does not require fluid aspirate to obtain pH values; it can be useful in distinguishing gastric from small bowel placement of the tube. The pH method is less helpful with continuous feedings, because tube feedings have a pH value of 6. Studies suggest that aspiration may be performed more easily with polyurethane tubes and tubes with a size 10 Fr diameter. If step 2 is ineffective, insufflate another 20 mL of air and replace the large syringe with a smaller one (12 mL); attempt to aspirate. The prepared area is covered with a strip of hypoallergenic tape or Op-site; the tube is then placed over the tape and secured with a second piece of tape. This keeps the tube from dislodging when the patient moves but still allows it to pass into the intestine. Instead of tape, a feeding tube attachment device (Hollister) can be used to secure the tube. This device adheres to the nose and uses an adjustable clip to hold the tube in place. After the nasoenteric tube has progressed into the intestine (after approximately 24 hours), the tube may be taped in place. The nurse measures the exposed tube length every shift and compares it with the original measurement. An increase in the length of exposed tube may indicate dislodgement, or a leaking or ruptured balloon if the tube has a balloon. Pleural fluid is usually pale yellow and serous, and tracheobronchial secretions are usually tan or off-white mucus. Researchers suggest that the appearance of the aspirate may be helpful in distinguishing between gastric and intestinal placement but is of little value in ruling out respiratory placement. This method is less helpful when the patient is receiving continuous Advancing the Nasoenteric Decompression Tube After the tube has passed through the pyloric sphincter, it may be advanced 5 to 7. To enable gravity and peristalsis to assist in the passage of the tube, the patient is generally asked to lie in the following positions in this order: on the right side for 2 hours, on the back for 2 hours, and then on the left side for 2 hours.

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Because the prognosis for gastric cancer is so poor acne chart buy acticin online, the nurse may need to assist the patient and family with decisions regarding end-of-life care acne prevention order acticin 30 gm. Manages tube feedings Chart 37-3 Home Care Checklist the Patient With Gastric Cancer At the completion of the home care instruction skin care 2 in 1 4d motion cheap acticin 30 gm with visa, the patient or caregiver will be able to: Demonstrate safe management of enteral or parenteral feedings skin care wiki order genuine acticin line, if applicable. Patient Caregiver Chapter 37 Management of Patients With Gastric and Duodenal Disorders 1025 Gastric Surgery Gastric surgery may be performed on patients with peptic ulcers who have life-threatening hemorrhage, obstruction, perforation, or penetration or whose condition does not respond to medication. Surgical procedures include a vagotomy and pyloroplasty (disconnecting nerves that stimulate acid secretion and opening the pylorus), a partial gastrectomy, and a total gastrectomy (removal of the stomach) with either an end-to-end or an end-to-side esophagojejunal anastomosis (see Table 37-3). In this event, the nurse caring for the patient after surgery should anticipate the concerns, fears, and questions that are likely to surface and should be available for support and further explanations. It is important to avoid sedating the patient so as not to impair his or her ability to perform pulmonary care activities (deep breathing and coughing) and to ambulate. These explanations need to be reinforced after surgery, especially if the patient had emergency surgery. After surgery, parenteral nutrition may be continued to meet caloric needs, to replace fluids lost through drainage and vomitus, and to support the patient metabolically until oral intake is adequate. The nurse adds foods gradually until the patient is able to eat six small meals a day and drink 120 mL of fluid between meals. It also may indicate that edema along the suture line is preventing fluids and food from moving into the intestinal tract. Bile Reflux Bile reflux gastritis and esophagitis may occur with the removal of the pylorus, which acts as a barrier to the reflux of duodenal contents. The nurse assesses for the presence of bowel sounds and palpates the abdomen to detect masses or tenderness. After surgery, the nurse assesses the patient for complications secondary to the surgical intervention, such as hemorrhage, infection, abdominal distention, or decreased nutritional status. General postoperative care for the patient who has received general anesthesia, as discussed in Chapter 20, should be followed. Agents that bind with bile acid, such as cholestyramine (Questran), may be helpful. Aluminum hydroxide gel (an antacid) and metoclopramide hydrochloride (Reglan) have been used with some success. It may be the mechanical result of surgery in which a small gastric remnant is connected to the jejunum through a large opening. Foods high in carbohydrates and electrolytes must be diluted in the jejunum before absorption can take place, but the passage of food from the stomach remnant into the jejunum is too rapid to allow this to happen. The symptoms that occur are probably a result of rapid distention of the jejunal loop anastomosed to the stomach. The hypertonic intestinal contents draw extracellular fluid from the circulating blood volume into the jejunum to dilute the high concentration of electrolytes and sugars. The ingestion of fluid at mealtime is another factor that causes the stomach contents to empty rapidly into the jejunum. Early symptoms include a sensation of fullness, weakness, faintness, dizziness, palpitations, diaphoresis, cramping pains, and diarrhea. Later, there is a rapid elevation of blood glucose, followed by increased insulin secretion. This results in a reactive hypoglycemia, which also is unpleasant for the patient. Vasomotor symptoms that occur 10 to 90 minutes after eating are pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and even drowsiness. It is partially the result of rapid gastric emptying, which prevents adequate mixing with pancreatic and biliary secretions. In mild cases, reducing the intake of fat and administering an antimotility medication can control steatorrhea. Vitamin and Mineral Deficiencies Other dietary deficiencies the nurse should be aware of include malabsorption of organic iron, which may require supplementation with oral or parenteral iron, and a low serum level of vitamin B12, which may require supplementation by the intramuscular route. Unless this vitamin is supplied by parenteral injection after gastrectomy, the patient inevitably will suffer vitamin B12 deficiency, which eventually leads to a condition identical to pernicious anemia.

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