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Why is it important to ask about diabetes during the health history?
because of poor circulation, diabetics tend to have tissue damage in certain extremities that makes their skin very sensitive and can come off when friction is present
What things effect capillary refill?
decrease temp (including room temp)
What should you do before you stick someone in their radial artery?
make sure the Ulnar artery has good blood supply with the Allen Test
used to evaluate adequacy of collateral arterial circulation prior to cannulating the radial artery. Blood should return in 2-5 seconds
You should always document if someone has good circulatory supply before you stick them. True or False
Checks for DVT (Deep Vein Thrombus) have pt's knee slightly bent and then sharply dorsiflex the foot. Ask the pt is it elicits calf pain
Why is Homan's Sign not very reliable?
a + homan's sign is only present in about 15% of pt. with DVTs
unexpected swooshing or murmur sound over an artery or organ. Occurs with turbulent blood flow
What occurs with a positive Manual Compression Test?
people with incompetent valves, their valves do not stay close, which results and increase pressure of blood flow in veins back to the heart in the lower extremities. Because the valves to not stay close, they blood travels back and creates a wave on your other hand
When assessing peripheral circulation. You should use the 5 P's. What are they?
Remember that you should not ask questions when assessing peripheral vascular system and the musculoskeletal system. Why and What should you do instead?
Because people tend to just nod, you should always give demands such as "say yes if you feel any pain" or "move your big toe" or "say if the pain is sharp or dull"
Why is it important to ask a pt to name some of the activities they do daily?
because many pt will say they are capable of doing all ADLs but really just sit on the coach all day
It is very important for adolescence to do what before sports and activities and use what?
Active Assisted ROM
nurse helps client with ROM exercises, but the client still builds muscle strength
What should you do if the pt complains of pain or cramping while doing ROM activities?
stop, reestablish correct body alignment, let the pt rest, and see if they are willing to try again
Why is it important to do Passive ROM for pt that have experienced a stroke?
It does not take long for joints to become frozen. Sometimes if joints become frozen, it is impossible for pt to get movement back. This is why the nurse should perform Passive ROM frequently when a pt is in a bed for a long period of time
A pt clenches their teeth while you apply resistance on their chin. What cranial nerve are you assessing?
Cranial Nerve V: Trigiminal
How do you assess for Cervical Spine muscle strength?
place hand against side of head or jawline and have pt resist pushing
What are two ways to assess Cranial Nerve XI (Assessory Nerve)?
placing your hand on the pt head or jawline and have them resist pushing
placing your hands on pt shoulders and have them lift shoulders against resistance
How do you assess muscle strength for upper extremities?
placing hands on shoulders and have the pt shrug up against your hands
having the pt put their wrist together with their fingers facing the floor at a 90 degree angle
How do you assess muscle strength in lower extremities?
put your hand on the pt thigh and have them push upward
stroke medial aspect of the knee 3 times, tap the lateral side, watch for fluid wave on medial side
with knee extended use L hand to compress suprapatellar pouch, use R hand to push patella against femur, release pressure keep fingers in place, with fluid the patella displaces
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