Organs

After axillary node dissection the nurse posts a sign at the bedside, places a restricted-limb band on the wrist, and allows no blood pressure, blood draw, injection, or IV on that arm. The arm has lost part of its lymph drainage, so squeezing it or breaking the skin can trigger lymphedema that may last for life. If an assistant starts a cuff on that arm, the nurse stops it right away.

The nurse counts the apical pulse for one full minute before giving digoxin and holds the dose and notifies the provider if an adult's rate is below 60. Digoxin slows conduction through the heart, so a dose given into a slow rate can deepen the bradycardia, and a slow rate can itself be a sign of toxicity. Low potassium raises the risk of digoxin toxicity, so the nurse checks the potassium level too.

For an adult, the nurse places the heel of the hand on the lower half of the sternum, in the center of the chest, and pushes 2 to 2.4 inches deep at 100 to 120 per minute, letting the chest recoil fully each time. Compressions work by squeezing the heart between the sternum and the spine, so hands placed off the sternum move less blood.

Air enters the pleural space and cannot escape, collapsing the lung and pushing the heart and trachea to the other side: sudden severe dyspnea, absent breath sounds on one side, trachea shifted away, distended neck veins, and falling blood pressure. The nurse stays with the patient, gives high-flow oxygen, calls for immediate help, and prepares for needle decompression. If a chest tube is already in place, the nurse checks it for clamps or kinks, because a blocked tube traps the air.

The nurse keeps the drainage system upright and below the chest, expects the water seal to rise and fall with breathing, and treats continuous bubbling in the water seal as an air leak to find and report. The tube is never routinely clamped, because clamping a tube with an air leak can cause a tension pneumothorax. If the tube pulls out, the nurse covers the site with a sterile dressing taped on three sides so air can escape but not enter, and calls the provider; if the tube disconnects, the nurse places its end in sterile water until a new system is ready.

With an absolute neutrophil count below 1000, and especially below 500, a temperature of 100.4 F or higher is treated as sepsis until proven otherwise: the nurse draws blood cultures and gets antibiotics started within the hour. The nurse protects the patient with strict handwashing, a private room, no fresh flowers or standing water, no raw fruit or vegetables per facility policy, no rectal temperatures or suppositories, and limits on visitors with any illness.

Measure nose to earlobe to xiphoid and mark the tube, sit the patient in high Fowler position, and advance the lubricated tube along the floor of the nostril. At the throat, have the patient tuck the chin and swallow (sips of water, or dry swallows if NPO), because swallowing closes off the airway and guides the tube into the esophagus. Coughing, choking, cyanosis, or inability to speak means the tube is in the airway, so pull it back at once; placement is confirmed by X-ray before first use, aspirate pH of about 5 or less supports gastric placement, and listening for injected air is not accepted.

After a stroke, the nurse keeps the patient NPO, including water and pills, until a swallow screen is passed. The nurse checks that the patient is alert and sitting upright, gives a small sip of water, and watches for coughing, throat clearing, or a wet, gurgly voice. A failed screen means the patient stays NPO and speech therapy is consulted, because food can slip silently into the lungs and cause aspiration pneumonia.

In cirrhosis, blood backs up into thin-walled veins of the lower esophagus that can rupture and bleed heavily. The nurse teaches the patient to avoid alcohol, aspirin and NSAIDs, straining, and heavy lifting. Vomiting blood is an emergency: protect the airway, check vital signs, start large-bore IV access, and notify the provider.

After intubation, and any time the tube may have moved, the nurse listens to both sides of the chest and watches both sides rise. Breath sounds on the right only, with the left chest still and the oxygen saturation falling, mean the tube is in the right main bronchus and the left lung is getting no air. The nurse checks the depth mark at the lip or teeth against the documented depth, notifies the provider at once, and expects the tube to be pulled back and a chest x-ray to confirm the tip sits above the carina.

The nurse keeps the obturator, a spare tube of the same size and one size smaller, suction, and a bag-valve mask at the bedside at all times, because a new stoma can narrow or close quickly if the tube comes out. Ties are changed with a second person holding the tube, and the old ties come off only after the new ones are secured. Stoma care is sterile in the hospital, and the inner cannula is cleaned or replaced as ordered.