S/S of DVT
- Red
-Warmth
-Edema in the calf
-Key symptom is
unilateral edema
-Pain
- Increased HR
how to diagnose a DVT
ultrasound doppler
risk factors for DVT
age
smoking
surgery
birth control pills
over weight
risk factors for osteoperosis
Smoking
○ Alcohol
○ Caffeine
○ Postmenopausal females
at high risk
○ Occurs greatest in Caucasian and Asian females
a common condition in which the stomach contents move up into the esophagus.
GERD
risk factors of GERD
obesity,
old ppl.
laying flat
hiatal hernia
edem and inflammation of the rectum and sigmoid colon. It has periods of remission and exacerbation. Increase risk of colon cancer.
ulcerative colitis
ulcerative colitis S/S
LLQ pain
weight loss
fever
diarrhea 15-20 days , high pitched bowel sounds
risk factors for ulcerative colitis
genetics
caucasian
stress
low fiber
infection and autoimmunity
treatment of an MI
baby aspirin
nitro
venous or arterial?
lower leg edema
venous
venous or arterial? no edema
arterial
venous or arterial?
no pulse
arterial
venous or arterial? pulse present drainage
venous
venous or arterial? black eschar
arterial
venous or arterial? yellow slough or ruddy skin
venous
venous or arterial? dull, achy pain
venous
venous or arterial? location of sores : ankles
venous
venous or arterial? location of sores : toes and feet
arterial
metatarsophalangeal joint of the great toe is swollen, hot, red, and extremely painful
GOUT
s/s of a stroke
- Difficulty walking or maintaining balance
- Face and arms drooping on one side (hemiplegia)
- Double or blurry vision in one or both eyes
- Sudden nausea
- Unusual pain in the upper back or jaw
- Slurred speech
risk factors for stroke
hypertension
smoking
hyperlipidemia
uncontrolled diabetes
During an assessment of an infant, you note that when the infant's head is turned to the right side, the leg and arm on the right side will extend, while the leg and arm on the left side will flex. You document this as what type of reflex?
tonic neck reflex
Stroke the inside of the infant's hand with an object and assess if the hand closes around the object.
palmar grasp reflex
You note that when a finger is placed under the toes of a newborn, the toes will curl downward. This is known as the __________?
plantar grasp reflex
When the Moro Reflex is stimulated in an infant, the infant will _____________the arms with the palms of the hands turned ___________ and then move the arms ___________ the body.
extend, upward, back to
In a 3-month-old infant you assess the Babinski Reflex. What is the appropriate response in an infant at this age?
The big toe dorsiflexes and the other toes spread outward.
You note when a 2-month-old is held upright with the legs and feet touching the surface, the infant will appear to be walking on the surface. This reflex is called the?
Step Reflex
The nurse wants to assess the crawling reflex in a newborn. How is this reflex assessed?
The nurse places the infant in the prone position and applies pressure with the hand to the sole of the foot. In response, the infant should attempt to push against the hand and move the arms and legs in a crawling like motion.
Intact skin, no involvement of underlying tissue
Does not blanch
stage 1
Skin open through epidermal skin layer, could involve the dermis
stage 2
Through the subcutaneous tissue
stage 3
Involves muscle and bone
stage 4
subjective symptoms of fluid overload
- shortness of breath
- weight gain
- swelling
- abdominal pain
- nausea
objective symptoms of fluid overload
- weight gain
- decreased hemoglobin and hematocrit (Hct)
- oliguria
- edema
- pleural effusion
- orthopnea
- changes in heart sounds
- pulmonary congestion
- JVD
- positive hepatojugular reflux
- respiratory distress, abnormal breath sounds
- changes in mental status
- BP changes
- pulmonary artery pressure changes
- pulmonary edema
- altered electrolytes
- anxiety, restlessness
- increased central venous pressure
- positive hepatojugular reflux
- ascites
- fluid and electrolyte imbalance
s/s of lupus
1. A butterfly-shaped rash
(cheeks & nose) NCLEX
TIP
2. Fever higher than 1000F
Report to HCP
3. Joints
(painful & swollen)