Nurse Care Plan

1. Px w/ R pneumonectomy, post-op position = R side lying
2. Post liver biopsy = placed R side lying
3. Rales at L lower lobe of lungs, px must be positioned for chest PT = on his R side w/ hip slightly higher than the head
4. When inserting TPN to a central line, w/c position shld. the RN place the px to prevent introducing air to the system = Trendelendburg
5. How shld. the RN position in hypovolemic shock = flat w/ legs slightly elevated
6. Pregnant in labor is exhibiting late deceleration in fetal monitor; RN shld change her position to = L lateral recumbent position
7. Pregnant experienced lightheadedness, dizziness,what position to relieve S/sx = L lateral recumbent position
8. Post supratentorial craniotomy, the RN shld. place the px in = low Fowler’s position
9. After hip repair, px makes the ffg. statements, w/c one reflects need for further teaching = “I will make sure to separate my legs when I have to tie my shoe lace.”
10. A px experiences lightheadedness, diaphoresis, diarrhea. History reveals px had gastrectomy in the past = relieve symptoms by lying down
11. After cataract surgery, px shld. be position = unaffected side to prevent edema
12. Px w/ hiatal hernia, w/c is C/I = lying supine immediate after meals
13. Post tonsillectomy position of a child = on the abdomen w/ head turn to side
14. Post R carotid endarterectomy = R position – supine w/ head elevated at 30degree
15. Px w/ abruptio placenta, w/c position appropriate = Supine
16. Px w/ emphysema , what position shld. px assume = Sitting while leaning forward
17. Px to undergo Ba enema, w/c position is appropriate = L side lying
18. Post femoro-popliteal bypass, RN shld. = keep leg of px elevated on a pillow
19. Post spinal anesthesia, to prevent hypotension, RN shld. = place px in supine position
20. Px w/ CVP reading of 3 shld. be placed in what position = lower extremity elevated
Px w/ TOF exhibits cyanosis, RN shld. place in what position = Squatting position
21.Mastectomy=semi fowler's 30 with the affected arm elevated on a pillow,turn only on the unaffected side and back
22.Hypophysectomy=elevate head of the bed
23.Thyroidectomy=semi fowler's- sandbags/pillows support head and neck
24.HEMORRHOIDECTOMY=lateral side lying
25.GERD=reverse trendelenberg
26.LIVER BIOPSY=during procedure:supine right side right arm extended on the left shoulder
after procedure:right lateral(side lying)place small pillow or folded towel under the punctured site
27.NG TUBE-
a)insertion-high fowler's
b)irrigation/feeding-semi fowler's head of bed 30*
28.Rectal enemas=left sim's position
29.COPD=sitting position,leaning forward with clients arms over several pillows
30.Laryngectomy=semi fowler's to fowlers
31.Bronchoscopy=semi fowler's
32.Postural drainage=the lung segment should be in the uppermost position
33.Thoracentesis=during procedure:sitting the edge of the bed
after procedure: fowler's position
34.Abdominal Resection (ANEURISM)
limit to 45*(FOWLER'S)
35.Amputtion of the lower limbs=elevate foot of the bed;prone 20-30 mins
36.Arterial vascular Grafting
a)bedrest 24* with extremities straight
b)limit movement
37.Cardiac catherization
a)bedrest 3-4 hrs,side to side after
b)keep straight ang head of bed elevated no more than 30*
38.Congestive heart failure with pulmonary edema=high fowler's position
39.Perpheral arterial disease=elevate feet at rest but not raise above heart level
40.Deep vein thrombosis=bed rest with leg elevation,out of bed after 24*
41.Varicose veins=leg elevation above heart level
42. Venous leg ulcers=leg elevated
43.Autonomic dysreflexia=elevate head of bed to fowlers
44.Cerebral aneurism=semi fowler's
45.cerebral angiography=bed rest