Only $2.99/month

Terms in this set (149)

Pulses in the Mitral area (the apex of the heart) are considered normal and are referred to as PMI, located at the fifth intercostal space in the midclavicular line. If it appears in more than one intercostal space and has shifted lateral to the midclavicular line, the PT may have left ventricular hypertrophy.
Mosby: Definition:
1. the point on the chest wall at which the maximal cardiac impulse is seen and/or palpated.
Synonyms: point of maximum intensity or Apical impulse
WEB: Now turn your attention to the patient's anterior chest wall, or precordium. Have the patient bare his chest. Inspect for an apical pulsation. This pulse, also called the point of maximal impulse (PMI) occurs as the apex of the heart bumps against the chest wall with each heartbeat. The apical impulse is not always visible and is more easily seen in patients who have thin chest walls or enlarged hearts, or in patients who are in high cardiac-output states, such as with exercise or fluid-volume overload. Having the patient sit upright or lean forward is useful, as it brings the heart closer to the chest wall. Breast tissue, of course, may make the PMI difficult to see. If the PMI is visible, be sure to note its location and size. Normally, the PMI is located near the fourth or fifth intercostal space near the left midclavicular line and covers an area no larger than that of a nickel. If the left ventricle is enlarged, as with left ventricular hypertrophy, the apical impulse may be visible over a larger area or displaced leftward or both. Be sure to inspect for pulsations all over the precordium and upper abdomen for any abnormal findings. Next, palpate the PMI. A visible PMI is usually palpable as a brief thump against your fingers. A pulsation that is so forceful it seems to "lift" your fingers upward is called a lift. A pulsation that feels rolling under your fingers is called a heave. Using a bony part of your hand, palpate for a thrill, or vibration, over the PMI.
WEB: Joint contractures are one of the most challenging aspects of burn management and are the main source of disability for burn patients. Proper positioning of the patient, range of motion exercises and splinting are vital in bringing about the best functional outcomes in the rehabilitation of the patient. Proper positioning and range of motion exercises should be initiated from the beginning. Initial edema may make movement difficult, but the patient should be encouraged to do daily exercises.
Normally burn contractures only occur in patients with full-thickness burns (third degree burns) but they can occur in superficial burns that get infected and convert to full-thickness and take longer to heal.
Positioning is very important in the prevention of contractures and deformities. For burn patients, the "position of comfort" is the position that most leads to contractures. Scar contractures tend to occur more in areas where skin is loose or more pliable. Because scars continue to mature over a long period, it is critical to continue the positioning long enough to prevent the contractures. Scars in adults do not reach maturation for 6-24 months and in children, the time period is 12-24 months.
In the African context, it is the family members who are available and provide most of the daily care of the patient. It is most beneficial to explain to the family the proper positioning for the patient and then encourage them to help follow through during the day. There are basic items available to help position the patient that the family can use. They can use a rolled up towel to place behind the neck to keep the neck in extension if the burn is over the anterior portion of the neck. They can put pillows at the end of the bed between the patient's feet and the foot board to help keep the ankles at 90 degrees. They can use pillows or a rolled up blanket to put between the arm and the body to help keep the shoulder in abduction.
Inflammation and clot formation
• Problem: The IV site is swollen, red, and warm.
• Possible cause: Inflammation of the vein with possible clot formation due to trauma, bacteria, or irritating solutions
• Assessment: The patient reports tenderness, burning, and irritation along the accessed vein. The rate of infusion has slowed. (With clot formation, the vein might have a palpable band along its path and the patient might have fever, leukocytosis, and malaise.)
• Intervention: Stop the infusion and discontinue the IV line. If you suspect clot formation, apply a cold compress first to decrease blood flow and to increase platelet aggregation at the site and follow it with a warm compress and elevation of the extremity to help reduce or eliminate the irritation. Establish new IV access proximal to the original site or in the other extremity if IV therapy must continue.
• Prevention: Make sure the medication's concentration is appropriate for peripheral administration. Medications like potassium are more concentrated for central IV access and more dilute for peripheral access. Also be sure to use the appropriate-size catheter for the vein and aseptic technique for IV insertion. Anchor the IV well to prevent movement of the catheter and irritation of the vein. Change and rotate IV sites according to your agency's policy. To prevent clot formation, avoid trauma to the vein at the time of insertion. Make sure all medications and fluids are compatible. Observe the IV site every hour during medication infusions to ensure patency and to watch for early signs of complications.
Preoperative Interventions
Instruct the client in preoperative, operative and postoperative management including diet, medications, ng tube placement, IV lines, NPO status, pain control, coughing, and deep breathing, leg exercises and postoperative activity.
Demonstrate appliance application and use for patient's who will have stoma.
Arrange an enterostomal nurse consult and visit with someone who has a ur diversion.
Administer antimicrobials for bowel prep as prescribed
Encourage discussion of feelings including effects on sexual activities
Postoperative Interventions
Monitor vitals
Assess incision site
Assess stoma every hour for first 24 hours-should be red and moist
Monitor for edema in the stoma-it may be present in the immediate postoperative period
Notify HCP if stoma appears dark and dusky-indicates necrosis
Monitor for stoma prolapse
Assess bowel function. Monitor for expected return of peristalsis (3-4 days)
Maintain NPO as prescribed-until bowel sounds return
Monitor for continuous urine flow (30-60 ml/hr) Notify HCP if urine output is <30 ml/hr or if no urine output for more than 15 min
Monitor urinary drainage pouch for leaks and check skin integrity (Box 52-19)
Monitor urine pH-highly alkaline or acidic urine can cause skin irritation and facilitate crystal formation (do not stick dipstick in the stoma)
Ureteral stents or catheters, if present, maintain stability with catheters to prevent dislodgement-they may be in place for 2-3 weeks or until healing occurs
Monitor for hematuria
Monitor for signs of peritonitis
Monitor for bladder distention following a partial cystectomy
Monitor for shock, hemorrhage, thrombophlebitis, and lower extremity lymphedema after a radical cystectomy.
Instruct the client regarding the potential for UTI or development of calculi
Instruct the client to assess skin for irritation, monitor urinary drainage pouch and report any leakage
Encourage client to express feelings about changes in body image, embarrassment, and sexual dysfunction
-Background: Bone Mineral Density (BDM): Determines bone strength and peaks between 25-30 years of age. BDM, decreases most rapidly in postmenopausal women as serum estrogen levels diminish. Although estrogen does not build bone, it helps prevent bone loss.
-Diagnosis: There are no definitive laboratory test that confirm a diagnosis of primary osteoprosis, although a number of biochemical markers can provide information about bone resorption and formation activity. X-rays can show bone loss, but only after 25%-40% bone loss, mostly seen after a fracture has occurred through x-ray ("silent disease").
-Planning: Expected outcome is that the pt avoids fractures by prevention of falls, managing risk factors, and adhering to preventative measures and treatment for bone loss.
-Intervention: Nutritional therapy (protein, mag, vit k, calcium, and vit D. Pts should avoid alcohol and caffeine consumption
Exercise/Life style changes: Strengthen abdominal and back muscles, muscle tightening, active ROM, improve joint mobility. SWIMMING, LOW IMPACT good resistance and strengthening. Walking for 30 min 3-5 times a week is the single most effective exercise for osteoporosis PREVENTION.

-Drug Therapy:
Calcium and vit D supplements, Biophoshponates (BPs) slow bone resorption (FOSAMAX, BONIVA, ACTONEL) these should be taken early in the morning with 8 oz of water and wait 30-60 min in an upright posistion before eating. If esophageal irritation discontinue (CHOCKING) and consult with HCP.
-Community Based Care:
Pts are typically managed at home, DXA scan done annually, possible long term care facility (but after numerous falls/fractures), refer pts to National Osteoporosis Foundation.
Stroke (CVA) Cerebralvascular accident: caused by change in the normal blood supply to the brain.
Rehab POC: PT and OT, and nursing management
-Managing of impaired swallowing: Pt is expected to avoid aspiration and have adequate nutrition to promote health and prevent complications, including major weight loss
Post CVA, pt should remain NPO until further swallowing ability is assessed and a plan of care is developed for impaired swallowing. Before ANY medciations or liquids are given. The pt swallowing needs to be assessed.
Improving mobility and promoting self care: pt with a CVA is expected to ambulate and provide self care independently with or without assistive devices.
Pts typically have flaccid or spastic paralysis. It is crucial that the nurse supports the affected flaccid side of the stroke patient, and to avoid pulling on the arm to prevent dislocation of the shoulder. Place arm on a pillow while sitting to prevent hanging of the arm, PT or OT may provide sling in order to support the arm during ambulation.
DVT and VT are big risk factors that can lead to PE. Prevent this complication by applying sequential compression stockings (SCDs), changing of the pts position regularly (Q2 Turns), and ambulation of the patient as frequently as possible if possible. Report any indications of DVT to health care provider and document accordingly.
Promoting Effective Communication: pt with CVA is expected to receive, interpret and express spoken, written and nonverbal messages, IF POSSIBLE.
Pictures, assistive devices, reassuring the pt when they become confused, irritated or frustrated when they are unable to express there speech or understand.
Promoting continence: The pt with a stroke is expected to control elimination of urine and stool.
Find the cause of pts incontinence first, may be due to being unconscious, impaired innovation of the bladder, or the inability to communicate the need to urinate or defecate. Before any training is started establish a bowel training program determine any routine that may help the patient with toileting
encourage the pt to drink prune juice and eat foods high in fiber to increase to help promote bowel elimination.
If pt has a cath, remove as soon as possible.
Managing Sensory Perception: pt with a stroke is expected to adapt to sensory changes in vision, proprioception (position sense) and sensation, along with free from injury.
Always approach the pt from the unaffected side, which should face the door of the room. Place objects within the pts field of vision. Mirrors may make it better or easier to visualize the entire room.
To assist with memory impairment that MAY or may not be present after stroke. Reorient the pt to the year, month and day of the week and the circumstances that surround the hospitalization.
Preventing Unilateral Body Neglect: The pt with a stroke is expected to adjust and use technique to compensate for unilateral body neglect.
Most commonly seen in right sided cerebral stroke. Teach the pt to touch and use both side of the body. When dressing, dress the affected side first.
Inflammatory response resulting in random or patchy areas of plaque in white matter of CNS > myelin sheath is damaged and becomes demyelinated
Nerve impulses still transmitted, but not as effective > over time may become completely blocked
Areas affected: optic nerves, pyramidal tracts, posterior columns, brainstem nuclei, ventricular region of brain and axons connecting neurons to brain and spinal cord
clinical manifestations
muscle weakness and spasticity, fatigue, intention tremors, parasthesia, hypalgesia, ataxia, dysarthria, dysphagia,diplopia, nystagmus, scotomas,decreased visual and hearing acuity, tinnitus,bowel and bladder dysfunction, impotence, cognitive changes > memory loss, impaired judgment, decreased ability to solve problems
4 types of MS
Relapsing-Remitting MS (RRMS) > occurs in most MS case
symptoms develop and resolve in a few weeks to months, pt then returns to baseline
during relapsing phase pt reports loss of function and continues to develop new symptoms
Primary Progressive MS (PPMS)
steady and gradual neurological deterioration without remission
no acute attacks occur
pt's age of onset tends to be between 40-60 yrs old
Secondary Progressive MS (SPMS)
begins as relapsing-remitting type MS, then later becomes steadily progressive
about half of all people with RRMS develop SPMS within 10 yrs
Progressive Relapsing MS (PRMS)
characterized by frequent relapses with partial recovery, but pt does not return to baseline
only seen in small % of patients
progressive, cumulative symptoms and deterioration over several years