Skin and wounds
A sprain affects these tissues and a strain affects these tissues:
Sprains: ligaments
strains: muscle, tendon, fascial sheath
Teach the client that COMPRESSION STOCKINGS AND MOBILITY are integral. Patient should be instructed to stay mobile, and to avoid sitting and standing as a dependent position of the legs causes increased pain and insufficient venous return. Moisturizing the ulcers is also very important, completing wound care and skin care.
hypercapnia (CO2 increase), hypoxemia (O2 decrease), obstructions that last 10-90 seconds, snorts and gasps during startle response, desaturation of SPO2 below 90%, 5 obstruction events per hour, terrible morning headaches due to reduced oxygen during sleep
What else may you see in a patient suffering from a CVA of this cerebral hemisphere?
Right sided CVA
an individual with a right sided CVA has poor perception of space, denial or minimization of their condition, rapid performance and short attention span, problems with impulses and safety, impaired judgement, unaware of activities they are able and unable to do.
The stress response is characterized by which pathophysiological responses:
Sympathetic nervous system activation (ALL VITALS spike due to Epinephrine and NE), we see a CO spike due to HR increase. Short term stress or low stress may even cause INCREASED PERCEPTION and ALERTNESS.
Immune system suppression due to increased Cortisol. Our WBC's don't munch up bad pathogens, our cytokines decrease, our Lymphocytes don't proliferate, HUGE DISEASE RISK especially CV disease.
A cast, dressing, splint, and traction or infection, bleeding, inflammation, and edema can cause this condition which is characterized by the 6 P's. What is the condition and what are the 6 P's?
Compartment syndrome
Pain, Paresthesia, pallor, paralysis, pulselessness, and poikilothermia
A nurse should notify the provider asap if pain or paresthesia is present, before the nerves and vasculature is completely compressed.
Which condition is marked by intermittent claudication (when ischemic muscle pain increases due to increased physical activity and oxygen demand at the tissues):
Peripheral artery disease
A nurse should expect that a client in this stage of sleep will have their lowest vital signs (Lowest HR and lowest RR)
Stage 3 NREM
What should client teaching include when providing care to a patient with Epilepsy/seizure disorder?
Teaching should include safety measures such as wearing a helmet for protection during the seizure, helping the patient identify events or situations that cause the seizures, practicing good general health habits, avoiding excessive alcohol use as they may induce seizures, coping with stress, maintaining a health weight, KEEPING A SEIZURE JOURNAL THAT TRACKS TIME OF SEIZURE ONSET/ PRECIPITATING FACTORS/ AURA SENSATIONS/ HOW LONG THE SEIZURE LASTED, PRECIPITATING EVENTS.
mental health measures since a patient with epilepsy is AT GREATER RISK FOR PSYCHOSOCIAL PROBLEMS such as stigma and depression.
This stage of pressure ulcers is characterized by a NON-BLANCHABLE redness at the site
Stage 1
When doing a skin assessment of an individual with melanoma, findings should appear as this:
Asymmetry of the cancerous lesion, border irregularities, color variation or changes, diameter over 1/4 of an inch, and an evolving cancerous lesion that can readily metastasize to any organ.
Aggressive mobilization in the form of walking 4-6 times a day, flexing and extending extremities every 2-4 hours, anticoagulation meds, Compression stockings (TED hose), angioplasty if all else fails.
Important for patient to stop smoking, avoid restrictive clothing, activity planning, diet planning, hydration to prevent coagulation
Changing sleep position such as elevating the head of the bed or sleeping on your side, physical activity to lose weight and take pressure off the airway, avoiding CNS depressants and these decrease respirations, CPAP if you have severe Sleep apnea (over 15 events an hour), oral appliances to keep the airway open, surgical interventions are possible.
Promotion of a safe environment in case the patient wanders, importance of nutrition due to the person unable to feed themselves or forgetting when to eat, regularly toileting to reduce incontinence and UTI's, Mobility to decrease pneumona/cv events/pressure injuries, the importance of DAILY ROUTINES, MEMORY AIDS such as notes/pictures/calendars, reducing RISK OF FALLS
These two pathogens are the primary causes of skin infection, if infected by one of these two pathogens, how would we go about treating it?
Stapholococcus Aureus and B-hemolytic Streptococci.
Antibiotics, maintaining good skin hygiene and infection control practices to prevent the spread of infection
Stage 3 pressure injury/ulcer
What should a nurse recognize that is the greatest risk for a patient with Peripheral Artery disease?
Amputation due to infection. Peripheral Artery disease leads to decreased blood flow to extremities and decreased wound healing due to reduced blood flow. A person should have their feet inspected daily. Clotting is also a risk, so aspirin should be used daily. A nurse should also promote exercise to reduce weight and control blood pressure.
What are some strategies a nurse should promote for an individual with Narcolepsy?
REM sleep
Sleep hygiene (reducing stimuli before bed, not exercising within 6 hours of bedtime, not going to bed hungry or eating large meals before bed), and the BENEFITS of having 2-3 SHORT 15 MINUTE NAPS a day.
What manifestations should a nurse be on the lookout for when providing care to a patient who has Parkinsons?
A nurse should identify that Parkinsons has both motor and non motor manifestations.
Characteristic motor manifestations seen in parkinson's includes: bradykinesia (slow movement), SHUFFLING GAIT, decreased/reduced arm swing, hunched forward, masked like facial expressions, TREMORS
Non motor: mood disorders and manifestations such as DEPRESSION, ANXIETY, HALLUCINATIONS, orthostatic hypotension which further increases risk of falls, memory and attention issues, incontinence, early satiety, dysphagia, big SLEEP PROBLEMS such as nightmares/insomnia/daytime sleepiness
A nurse should recognize that this form of Ultraviolet radiation is responsible for the TANNING and skin elasticity issues
UVA
When assessing a client, a nurse should expect basal cell carcinoma to affect this area of the body most:
The neck, and back of the head
What are the 3 main causes of a Deep vein thrombosis?
Stagnant blood (i.e A. fib), damage to the endothelium (platelet aggregation), hypercoagulation.
This is where we spend most of our time during sleep. How long is our cycle in this stage?
Stage 2 Non-REM: 60-90 minutes
What may a nurse do to help a patient experiencing chronic migraines, what may they teach the individual?
Reduce stimuli such as lights, noise, people, and stress.
A nurse should promote the use of a headache diary that tracks onset, treatment of headache, time that the headache dissipated, how often they occur, time of day, precipitating factors.
You can promote the use of Tylenol and NSAIDS to manage the pain.
CAM such as massages and heat/cold therapy may help as well.
We want to promote HEALTHY LIFESTYLE in the form of DIET AND EXERCISE, we want to promote optimal blood flow
We should also promote STRESS REDUCTION and RELAXATION TECHNIQUES. Good SLEEP HYGEINE to promote restoration and proper regulation of hormones.
This stage of sleep is most important for MEMORY CONSOLIDATION
REM