Keep the client on NPO until an order is written.
Check the vital sign.
Check the gag reflex and swallowing reflexes.
Encourage deep breathing and coughing.
Redness greater than 5mm.
Swelling greater than 7mm.
Induration greater than 20mm.
Exudates covering more than 12mm.
On the affected side
On the unaffected side
On his back
Check the doctor's order
Lower the oxygen rate at 2L/min
Take the vital sign
Put the client in Fowler's position
Administering injections, changing dressing and chest physiotherapy
Taking the blood pressure, pulse rate and monitoring serum glucose
Suctioning and caring for tracheostomies and tracheostomy tube
Tube feeding, taking aerosol medications and taking blood pressure
Complete blood count
Chest and lower backpain
Headache and fever
Fever, night sweats, chills, hemoptysis
Fever of more than 140F and nausea
AST and ALT
BUN, serum creatinine
Serum glucose level
Blood uric acid level
Paraaminosalicyclic acid (PAS)
No fluctuation in the water - seal tube
Intermittent, slight bubbling from the water-seal tube
Bright-red blood bloody drainage
Continuous bubbling in the water-seal tube
Take a full nursing history
Administer bronchodilator by nebulizer
Provide emotional support to the client
Administer oxygen 6L/m
ABG and breath sounds
Level of consciousness and a pulse oximetry values
Breath sounds and reflexes
Heart sounds and reflexes
Alveoli are overdistended.
Alveoli are fluid filled.
Alveoli are filled with mucus secretions.
Alveoli have increased perfusion.
Lie the client down on the left side.
Lie the client on the right side.
Apply an occlusive dressing over the site.
Reinsert the chest tube that fell out.
Sitting upright leaning forward
The nurse dons sterile gloves and uses sterile suction catheter.
The nurse administers 100% oxygen before and after the suctioning.
The nurse applies suction for 30 seconds at a time.
The nurse applies suction during withdrawal of the suction catheter tip.
Avoid coughing and cleaning the throat the first week postoperatively.
Do not eat or drink anything for the first 24 hours.
If your stool is black for the first few days postop, notify the doctor.
Avoid cold beverages to prevent irritation of the throat.
Push on abdomen during exhalation.
Sit in high-Fowler's position with legs extended
Lean forward 30 to 40 degrees with each exhalation.
Sit up with shoulders back.