Nursing Interventions
Immobility
reposition every two hours, cushion on chair or mattress (egg-crate or gel), change position in the chair every hour, Perform Passive ROM if indicated, adequate nutrition, consult with OT/PT, declutter environment, assistive devices
6 P's of Peripheral Circulatory Assesment
Pallor, Pain, Paresthesia, Paralysis, Polar, Pulselessness
Role of Tissue
barrier protection
heat regulation
vit D synthesis
sensory perception
excretion of metabolic wastes
vasomotor response
wound repair
nonverbal communication, identity
Osteoporosis
decreased calcium in bone,
bone demineralization
weak and brittle bones
Poor Perfusion
Nicotine --> vasoconsts, Elevated serum lipids, sedentary lifestyle, obesity, DM II, HTN,
Genetics
men>women
AGE - stiffening and thickening of myocardial tissue, decreased wall elasticity, orthostatic hypotension, valves less efficient, decrease coronary blood flow
DVT
early ambulation, compression stockings, OOB for most days, Foot/ankle pumps, anticoagulants
Diagnostic Cardiac Lab values
Cardiac Troponins - released with Myocardial injury
Homocysteine - PAD, CVD, ischemic Heart disease, VTE
CRP - liver --> acute inflammation somewhere in body
Serum lipids - hyperlipidemia
Wound healing Phases
Inflammatory - 3-5 days WBC, platelets, cells, debris removed my macrophages
Granulation - new vessels and collagen form - pink vascular wound
Maturation - maturing of collagen fibers and scar contraction can continue
Ventricular septal defect
Holosystolic murmur
Left to right shunt -> O2 leaking into right heart
tachypnea, SOB, difficulty to gain weight
Immobility
Age, chronic pain, Chronic condition, injury, CVA, Parkinsons, SP injury, Metastasis of bone,
LONG TERM MEDS- Chemo, steroids
metabolic dysfunction --> bone demineralization
SE status, culture, Lifestyle, Mood
Moisture intervention
toileting program, use briefs for dignity, barrier cream (dimethicone or zinc oxide) cleanse moisturize and protect skin
Skin
Facultative and constitutive colors,
Purpura, Petechiae (tiny hemorrhages), hematoma, bruising, platelet count, anticoagulation?
moist, dry, intact,
skin abnormalities
secondary intention
a wound with distant edges, granulation tissue filling gaps, high bacterial burden
ex. (open burn edges)
Overuse Syndrome
AKA osteoarthritis
Loss of ROM and flexibility
Heberden nodes - hard and painless, closest to the tip of finger
Bouchard nodes --> less common, closer to you
Pressure injury
immobility, decrease activity, inadequate nutrition, decreased sensory perception, incontinence, DM, Comorbidities, poor perfusion,
Hip flexion Precaution - nobending past 90 degrees, no adducting (internal rotation), no crossing legs
Abductor pillow to prevent adduction
ice, reposition, pillows, wound care, skin barriers, pain control
Incentive spirometry 10x per hour
Neurological
what are
mental status intact? Symmetry of actions? LOC? A/O
12 cranial nerves
Reflexes
rhomberg
point to point, graphesthesia, proprioception
motor function - coordination, muscle strength
sensory functions - pain and temp, proprioception, light touch, vibration, participate in reflex activity
Pressure Injury stages
Stage 1 - unblanchable redness
Stage 2 - partial thickness with skin loss
Stage 3 - full thickness, necrosis of SQ
Stage 4 - full thickness skin loss w exposed or palpable bone (nerves, ligaments)
Coartication of the Aorta
PEDS- prior to ductus, PDA, diminished femoral pulse, lower extremity cyanosis, higher BP in upper extremities (and adults), can have a heart murmur
osteoporosis
old age
bone demineralization
smoker and heavy drinkers
malnutrition - LOW BMI
female - decreased estrogen - menopause*****
Cane Instruction
What is
Two points on the ground at all times, cane on the stronger side, only move the cane 6-10 inches, Move weaker leg to cane followed by advancing stronger leg past cane
Musculoskeletal
gait, scoliosis, the curvature of the spine,
Active and passive ROM of (neck, wrists, elbows, knees, ankle), crepitus, joints
muscle strength - biceps, triceps, quads, and hamstrings
inspection - inflammation, nodules
Arterial Ulcer characteristics
pale wound bed, painful, hair loss around wound bed, defined punched-out look, skin cool to touch, +1 posterior tibial pulse,
Compartment syndrome
How do you treat it
the build-up of pressure within the spaces of the muscle
hairless, pale, cold, shiny, pain with passive stretch and excercise, inflammation/redness
CUT THAT LEG!!!!