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)