| Common Concerns During Infancy: Parental Concerns and Problems Posted: 20 Dec 2010 09:47 PM PST 
Parental Concerns and Problems Related to Normal Infant Development Teething - Instruct the parents that infants may be resistant to chewing for a day because of teething.
- Educate the parents that the following manifestations are not normal during toot eruption and any of these symptoms signifies an underlying infection or disease process requiring evaluation.
- High fever
- Seizures
- Vomiting
- Diarrhea
- Over-the-counter (OTC) medications sold for teething should be discouraged if they contain benzocaine. Benzocaine is a topical anesthetic that once applied in the throat can interfere with the gag reflex.
- For pain relief of teething, Acetaminophen (Tylenol) 10 to 15 mg/kg every 4 hours can be used.
- Encourage parents to always check their infant's health with a health care provider before administering OTC drugs.
- To provide soothing coolness against tender gums teething rings can be placed in the refrigerator.
- Check articles within baby's reach to be sure that they are safe to chew or edible as teething infants tend to place almost any object in the mouth.
Thumb Sucking - Parents should be educated that thumb sucking is normal and does not cause any jaw malformations on the jaw line as long as it stops by school age period.
- Thumb sucking peaks at about 18 months where it may begin as early as 3 months of age.
- Educate the parents that making an out of thumb sucking does not cause a child to stop the habit. It usually intensifies and prolongs the habit of thumb sucking. The best approach is to be certain an infant has adequate sucking pleasure and then ignore thumb sucking.
Head Banging - Educate parents that head banging is a normal mechanism of relief of infants for tension.
- Head banging begins during the second half of the first year of life and continuing through to the preschool period. It is associated with naptime or bedtime which lasts for about 15 minutes. This habit is normal as children use this measure to relax and fall asleep.
- Investigate stress factors in the house.
- Advise parents to pad the crib rails so that infants cannot hurt themselves.
- Excessive head banging suggests a pathologic condition and children with this condition needs counseling and further evaluation.
Sleep Problems - Educate mother that breast-fed infants tend to wake up more often than formula fed infants because breast milk is easily digested thus, infants fed in breast milk gets hungry sooner.
- Remaining awake for long periods of time and waking at night is common during the late infancy period.
- To eliminate night waking or cope with this situation the following should be done:
- Delaying bed time for 1 hour.
- Shortening the afternoon sleep period.
- Do not responding immediately to infants so that they can have time to sleep on their own.
- Providing soft toys and music to allow infant to play quietly alone.
Related posts: - Common Problems Among Elderly
- Physiology of Breast Milk Production
- Facts About Breastfeeding
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| Nebulizer Therapy Posted: 20 Dec 2010 09:41 PM PST 
- Nebulizer therapy aids bronchial hygiene by restoring and maintaining mucus blanket continuity, hydrating dried secretions, promoting secretion expectoration, humidifying inspired oxygen, and delivering drugs.
- It may be given through nebulizers that have a large or small volume, are ultrasonic, or are placed inside ventilator tubing.
- Large volume nebulizers such as Venturi Jet provide humidity for an artificial airway.
- Small volume nebulizer such as Mini Nebulizer is used to deliver drugs such as bronchodilators.
- Ultrasonic nebulizers are electrically driven and use high-frequency vibrations to break up surface water into particles; resultant dense mist can penetrate smaller airways, hydrate secretions, and induce coughing.
- In line nebulizers are used to deliver drugs to patients being mechanically ventilated.
Equipment For ultrasonic nebulizer - Untrasonic gas delivery device
- Large bore oxygen tubing
- Nebulizer couplet compartment
For a large-volume nebulizer - Pressurized gas source
- Flowmeter
- Large-bore oxygen
- Nebulizer bottle
- Sterile distilled water
- Heater
- Inline thermometer
For a small-volume nebulizer - Pressurized gas source
- Flowmeter
- Oxygen tubing
- Nebulizer cup
- Mouthpiece or mask
- Normal saline solution
- Prescribed drug
For an in-line nebulizer - Pressurized gas source
- Flowmeter
- Nebulizer cup
- Normal saline solution
- Prescribed drug
Preparation of Equipment For an ultrasonic nebulizer - Fill the couplet compartment to the indicated level.
For a large-volume nebulizer - Fill with distilled water to the indicated level
- Avoid using normal saline solution, to prevent corrosion
- Add a heating device if ordered
- Ensure delivery of the prescribed oxygen percentage
For a small-volume nebulizer - Draw up the drug, inject it into the nebulizer cup, and add the prescribed amount of normal saline solution, or water.
- Attach the mouth piece, mask, or other gas delivery device.
For an in-line nebulizer - Draw up the drug and diluents, remove the nebulizer cup, quickly inject the drug, then replace the cup.
- If using an intermittent positive-pressure breathing machine, attach the mouthpiece and mask to the machine.
Procedure - Reinforce the explanation of the procedure to the patient
- Wash hands
- Take the patient's vital signs and monitor his respiratory status.
- Place the patient in a sitting or high fowler's position
For an ultrasonic nebulizer - Give an inhaled bronchodilator to prevent bronchospasm
- Turn the machine on and check the outflow port for proper misting
- Monitor the patient for adverse reactions
- Watch for labored respirations
- Take the patients vital signs and monitor his respiratory status.
- Encourage the patient to cough and expectorate, or suction him as needed.
For a large volume nebulizer - Attach the delivery device to the patient
- Encourage the patient to cough and expectorate, or suction him as needed
- Check the water level in the nebulizer and refill it, as indicated
- When refilling a reusable container, discard the old water
- Change the nebulizer unit and tubing according to hospital policy.
- If the nebulizer is heated, tell the patient to report discomfort.
For a small volume nebulizer - Attach the flow meter to the gas source
- Attach the nebulizer to the flowmeter and adjust the flow to at least 10L
- Check the outflow port to ensure adequate misting
- Remain with the patient during treatment
- Encourage the patient to cough and expectorate
- Change the nebulizer cup and tubing according to your facility's policy.
For an in-line nebulizer - Turn on the machine and check for proper misting
- Remain with the patient during treatment
- Take the patient's vital signs and monitor him for adverse reactions
- Encourage the patient to cough, and suction excess secretions as necessary.
- Monitor the patient's respiratory status to evaluate the effectiveness of therapy.
Nursing Interventions - The efficacy of aerosol therapy, what type of fluids to use, the types of drugs that can be delivered, and the effectiveness of therapy, haven't been established.
- Monitor for overhydration, especially in the patient with a delicate fluid balance.
- Carefully monitor for adequate flow if oxygen is being delivered at the same time.
- Encourage the patient to take slow, even breaths to derive maximum benefit.
Complications - Mucosa irritation, bronshospasm, dyspnea, airway burns, infection and adverse drug reactions.
Related posts: - Vacuum Assisted Closure Pressure Therapy Assistance
- ADDING MEDICATIONS TO AN INTRAVENOUS SOLUTION
- Oxygen Therapy
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| Pulse Oximetry Posted: 20 Dec 2010 09:37 PM PST 
- Used to noninvasively monitor arterial oxygen saturation.
- A photo detector slipped over the finger measures transmitted light as it passes through the vascular bed, detects the relative amount of color absorbed by arterial blood, and calculates exact mixed venous oxygen saturation without interference from surrounding venous blood, skin, connective tissue, or bone.
Equipment - Oximeter
- Sensor probe
- Alcohol pads
- Nail polish remover, if necessary
Preparation of Equipment - Review the manufacturer's instruction for assembly.
Procedure - Reinforce the explanation of the procedure to the patient.
Using a finger probe - Select a finger (usually index finger) on the patient's nondominant hand, if possible for placement of the probe.
- Remove fake fingernail and nail polish from the test finger.
- Place the transducer (photoprotector) probe over the patient's finger so the light beams and sensor oppose each other.
- Trim long fingernails or position the probe perpendicular to the finger.
- Position the patient's hand at heart level.
- Turn on the power switch. If the device is working properly, a beep will sound, a display will light momentarily, and the pulse search light will flash.
- After four to six heartbeats the pulse amplitude indicator will begin tracking the pulse.
- Rotate the sensor site according to the manufacturer's instructions.
- Clean the probe per facility policy between patients or, if disposable, discard.
Nursing Interventions - Some machines have a pleth wave. A steady, level, even wave form ensures that the numerical reading is accurate.
- The pulse rate on the oximeter should correspond to the patient's actual pulse. If it doesn't, monitor the patient, check the oximeter, and reposition the probe.
- Factors that interfere with accuracy include:
- Elevated carboxyhemoglobin or methemoglobin levels
- Lipid emulsions and dyes
- Excessive light
- Excessive patient movement
- Hypothermia
- Hypotension
- Vasoconstriction
- Medications such as dapsone, vasopressors.
- Use the bridge of the nose if the patient has compromised circulation in his extremities.
- If an automatic blood pressure cuff is used on the same extremity as the saturation probe is placed, the cuff will interfere with oxygen saturation readings during inflation.
- If the light is a problem, cover the probes.
- If patient movement is the problem, move the probe or select a different probe.
- Notify the physician of any significant change in the patient’s condition.
Related posts: - CATHETERIZING THE FEMALE & MALE URINARY BLADDER (Straight & Indwelling)
- Pulmonary Embolus
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| Mucus Clearance Device Posted: 20 Dec 2010 09:33 PM PST 
- Is used for patients who need mucus secretions removed from the lungs and those with chronic respiratory disorders.
- A handheld mucus clearance device known as the flutter helps patients cough up secretions more easily.
- Vibrations propagate throughout airway during expiration, loosening the mucus. Mucus progressively moves up the airways until it can be coughed out easily.
Contraindications - Do not use the device in a patient with an ineffective cough reflex.
Equipment - Mucus clearance device
- Emesis basin
- Tissues
- Pulse oximeter
Procedure Overview - Remind the patient that this device will move mucus through his airway so he can eventually expectorate it.
- Position the patient sitting with his back straight and his head tilted back slightly to open his throat and trachea.
- If the patient places his elbows on a table, the height should prevent slouching.
- Have the patient hold the device so that the stem is horizontal, draw a dep breath, hold it for 2 to 3 seconds, place the device in his mouth and exhale at a steady vibration and flutter.
- Quick or forceful exhalations prevent vibration and flutter.
- Remind the patient to keep his cheeks as flat and hard as possible while exhaling.
- To reinforce the teaching related to the technique, have the patient hold his cheeks lightly with his other hand.
- After the patient exhales completely, he should remove the device from his mouth, take in another full breath, and cough. Repeat several times.
- Alternatively, after completely exhaling, the patient can leave the device in his mouth, draw another full breath through his nose, hold it for 2 to 3 seconds, and repeat the exhalation maneuver.
- The patient can breathe through the device up to five times before taking the final breath and coughing.
- Provide an emesis basin and tissues.
Nursing Interventions - To help the patient achieve the best fluttering effect, place one hand on his back and the other on his chest as he exhales through the device.
- If the patient is achieving the maximum effect, you'll feel vibrations in his lungs as he exhales.
- If results are unsatisfactory at first, tell the patient to adjust the angle at which he's holding the device until optional fluttering occurs.
- If the patient final cough doesn't seem to work, he can try repeated, controlled, short, rapid exhalations to avoid mucus removal.
- After the procedure, thoroughly clean the device. All parts should be rinsed under a stream of hot tap water, wiped with a clean towel, reassembled, and stored in a clean, dry place.
- Monitor the patient's respiratory status.
- Reinforce why the procedure is necessary.
- Encourage adequate hydration to liquefy thin secretions.
- Reinforce that the patient should avoid milk and milk products, which tend to make secretions more difficult to remove.
Note: This technique may cause a mucus plug to become lodged in the patient's airway. Related posts: - Nebulizer Therapy
- Ineffective Airway Clearance r/t secretions in the bronchi
- Vacuum Assisted Closure Pressure Therapy Assistance
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| Blood Glucose Tests – IGTT Posted: 20 Dec 2010 09:19 PM PST 
IV Glucose Tolerance Test (IGTT) 
The intravenous glucose tolerance test (IGTT) is rarely used. In this test, glucose is injected into the vein for 3 minutes. Indication: Diabetes Mellitus Purpose: Chose for patients who can't absorb an oral dose of glucose such as in cases of: - Malabsorption disorders
- Those who underwent gastrectomy
Mechanism: The test measures blood glucose after an intravenous (IV) infusion of 50% glucose over 3 to 4 minutes. After the administration of glucose intravenously, the body absorbs the dose rapidly. This causes the plasma glucose levels to rise and reach its peak of 300-400 mg/dl which is accompanied by glycosuria. Insulin is secreted by the pancreas in response thus, causing the glucose levels of the body return to its normal state. It is during this period that plasma and urine glucose are monitored to assess the insulin secretion of the pancreas and the ability of the body to metabolize glucose. The normal glucose curve falls steadily, reaching fasting levels within 1 to 1 ¼ hours. Failure to achieve fasting glucose levels within 2-3 hours is indicative of diabetes. Procedure - Explain intravenous (IV) glucose tolerance test to the patient.
- Remind the patient not to smoke, drink alcohol and coffee and not to eat anything 8-12 hours before the test or during the test.
- Exertion of strenuous activities is also contraindicated 8-12 hours prior to the test and during the test.
- Measure insulin levels before the injection of 50% glucose.
- Administer the 505 glucose intravenously.
- Perform venipuncture to the patient to monitor the blood glucose levels after 30 minutes, 1 hour, 2 hours and 3 hours.
- Inform the patient that he or she may feel a slight discomfort from the needle punctures and the pressure of the tourniquet. However, reassure him or her that collecting blood sample only takes less than 3 minutes.
- Inform the patient that he should not discard the first urine specimen voided after waking up.
image from wellsphere.com Related posts: - Blood Glucose Tests – OGTT
- Fasting Plasma Glucose
- Blood Glucose Monitoring
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| Blood Glucose Tests – OGTT Posted: 20 Dec 2010 09:15 PM PST 
Oral Glucose Tolerance Test (OGTT) Indication: Diabetes Mellitus Normal Glucose Levels: 70-110 mg/dl Purpose: Measures carbohydrate metabolism after the ingestion of a challenge dose of glucose. Mechanism: After the ingestion of challenge glucose dose, the body absorbs the dose rapidly. This mechanism causes the plasma glucose levels to rise and reach its peak within 30 minutes to 1 (one) hour. Insulin is secreted by the pancreas in response thus, causing the glucose levels of the body return to its normal state within 2-3 hours. It is during this period that plasma and urine glucose are monitored to assess the insulin secretion of the pancreas and the ability of the body to metabolize glucose. Medications avoided 3 days before the test: - Diuretics (usually thiazides)
- Corticosteroids
- Synthetic estrogens
- Phynetoin (Dilantin)
Procedure - Explain oral glucose tolerance test (OGTT) to the patient.
- Instruct the patient to maintain a high carbohydrate diet for 3 days.
- Tell that patient that he or she needs to fast for 10 to 16 hours before the test as ordered by the physician.
- Remind the patient not to smoke, drink alcohol and coffee, and not to eat 8-12 hours before the test or during the test.
- Exertion of strenuous activities is also contraindicated 8-12 hours prior to the test and during the test.
- Obtain a blood sample before offering the challenge dose.
- Offer a challenge dose of 50, 75 or 100 grams of carbohydrate (as ordered by the physician) which is usually a sweetened carbonated drink or a gelatin.
- Perform venipuncture to the patient to monitor the blood glucose levels.
- Inform the patient that he or she may feel a slight discomfort from the needle punctures and the pressure of the tourniquet. However, reassure him or her that collecting blood sample only takes less than 3 minutes.
- Inform the patient that he should not discard the first urine specimen voided after waking up.
Watch Out For Hypoglycemia should be assessed throughout the test manifested by the following signs and symptoms: - Weakness
- Nervousness
- Hunger
- Restlessness
- Sweating
Signs of hypoglycemia should be reported immediately to the doctor. Nursing Interventions during the test: - Encourage the patient to drink plenty of water.
- Provide bedpan, urinal or specimen container.
- Watch out for signs of hypoglycemia.
- Inform the patient about the progress of the test.
World Health Organization Diagnostic (WHO) Criteria for Diabetes Mellitus in Nonpregnant Adults On at least two occasions: - Random plasma glucose >200 mg/dl
- Fasting plasma glucose >140 mg/dl
- 2-hour sample during 75-g OGTT >200 mg/dl
References - Brunner and Suddarth's Medical-Surgical Nursing by Smeltzer and Bare
- Lippincott's Perfecting Clinical Procedures
image from pre-diabetes.com Related posts: - Blood Glucose Tests – IGTT
- Fasting Plasma Glucose
- Blood Glucose Monitoring
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