avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign, increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety, increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea, prolonged QT interval and prolonged ST segment -vasoconstriction (reduces blood flow to injury body part, preventing edema from onset injury; reduces inflammation)
-local anesthesia (reduces localized pain)
-reduced cell metabolism (reduces oxygen needs of tissues)
-increased blood viscosity (promotes blood coagulation at injury site)
-decreased muscle tension (relieves pain)
examples of conditions treated: direct trauma (sprains, strains, fractures, muscle spasms), superficial laceration or puncture wound, minor burn, suspected malignancy in area of injury or pain, injections, arthritis, joint trauma K >5.0 mEq/L
causes: Hemolyzed serum sample produces pseudohyperkalemia, Oliguria, Acidosis, Renal failure, Addison disease, Multiple blood transfusions
manifestations: Muscle weakness, Bradycardia, low BP, Dysrhythmias, Flaccid paralysis, Intestinal colic, diarrhea, irritability, anxiety, flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves K <3.5 mEq/L
causes: diuretics, diarrhea, vomiting, excessive gastric suction, chronic use of corticosteriods, renal disease, alkalosis, uncontrolled diabetes, Cushing's syndrome
manifestations: lethargy, weakness, shallow respirations, tachycardia, thready pulse, confusion, decreased or absent reflexes, hypoactive bowel sounds and ileus, ST depression and prominent U waves -Airway: is it obstructed, are they choking, is their gag reflex absent?
-Breathing: vital signs, assess for cyanosis (late sign), are the restless and irritated (early sign), raise the head of the bed and give emergency O2, auscultate lung, are they aspirating from fluid in their lungs?
-Circulation: are they hemorrhaging, do they have a board like abdomen or ecchymosis pooling, are they pale and cool, are they having tachycardia and hypotensive (shock) -Primary Care: health promotion ex: exercise, nutrition services, family planning
-Preventive Care: immunizations, blood pressure screening, cancer screenings, legislation
-Secondary Acute Care: ER, Acute care facilities, ER test such as X rays
-Tertiary Care: intensive care, sub acute care
-Restorative Care: Sports rehab, cardio rehab
-Continuing Care: assisted living, psychiatric faculties Stage 1
-Intact skin with nonblanchable redness: just stays red if pressed on, indicated deeper tissue damage
-Warmth
-Edema
-Hardness over area: tautness from buildup
-Painful to touch
Stage 2
-Partial thickness loss
-Loss of dermis layer: blister that popped
-Shallow open ulceration: Red-pink wound bed; Shiny or dry shallow: shallow big blister that popped and caused opening; NO sloughing: whitish connective tissue; NO bruising
-Blistering: Serum filled
-Serosanguineous filled
Stage 3
-Full thickness loss
-Loss of subcutaneous fat: Staging varies by anatomical location: some areas like abdomen and hip have more SQ fat, more rapid in areas without fat
-Bone, tendon, muscle are NOT exposed; Sloughing may be present: whitish stringy material is sloughing, needs to be removed for wound to heal
Stage 4
-Exposed bone, tendon, muscle and SQ fat
-Directly palpable
-Undermining and tunneling
-Depth varies by anatomical location: needs to be addressed, moves faster where there is less fat
-Damage can extend to fascia, tendon
-joint capsule: can be permanent
-Osteomyelitis or osteitis: infection of bone, septic or limb loss
-Osteitis: inflammation of bone
Suspected deep tissue injury
-Purple or maroon localized area
--Skin is intact
--Blood filled blistering: could be from hemorrhaging
-Caused by damage to soft tissue
--Pressure
--Shear force
-Painful
-Firm, mushy, boggy
-Warm or cool when compared to skin: cool would be with ischemia
Un-stageable
-there is lots of sloughing and eschar built up so you can't see actual wound bed to stage it: wound requires debridement so you can stage it
-Depth of ulcer is obscured: Slough; Eschar: has to be debrided
-Debridement is needed for evaluated depth
-Use wet healing with eschar
*packing sterile gauze b/c Want wound to heal FROM INSIDE OUT -Check Id band, check call light, proper markings about precautions or patient status (airborne, NPO)
-Check equipment: make sure IV pump works, alarms, tubing
-Morse Fall risk assessment: highest risk in elderly with history, dementia, sensory deficit, medication effects
--If a patient falls, assess them, maintain alignment and ABCs, notify family and Dr., fill out incident report form
--Always follow hospital policy: bed locked and in low position, light on, call bell within reach, close to nursing station if fall risk, clear pathways, 3 side rails up causes: vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy
manifestations: increased respirations and heart rate, decreased central venous pressure (CVP) (normal CVP is between 4 and 11 cm H2O), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. 7th Edition•ISBN: 9780323402118Gary A. Thibodeau, Kevin T. Patton1,505 solutions
7th Edition•ISBN: 9780323087896 (1 more)Julie S Snyder, Linda Lilley, Shelly Collins388 solutions
4th Edition•ISBN: 9781259989827David M Allan, Rachel Basco2,732 solutions
3rd Edition•ISBN: 9781284050547Richard Skolnik188 solutions
