NUR 2 Final

• Pain: (location, severity)
• Pallor: (paleness, coolness, discolor)
• Paralysis: (deficit in movement, strength)
• Paresthesia: (changes in sensation)
• Pulse: (distal to injury decreased/absent)

• Instruct importance of reporting any signs of impaired
• circulation
• Teach the 5 P’s
• Teach pt. to wiggle extremities, elevate if s/s of impaired circulation continues call Dr.

• Due to obstructed arterial blood flow to the end of the forearm and hand
• s/s: pain, inability to straighten fingers, cyanosis,
• swelling

• Numbness
• Burning in foot
• Foot drop

• *Cough produces large amounts of thick white sputum
• Chest pain
• Increased heart & respiratory rate

*Unrelieved pain following analgesics

Prevent internal rotation of the affected leg

• Cold & Heat
• NSAIDS

• Rest
• Ice
• Compression
• Elevation

• Spotting
• Weight gain
• Increased risk for DVT

Halts progression of disease but will not restore lost bone

• Idiopathic secondary to trauma to joint
• *Non-inflammatory joint disease
• Generally a part of aging

• Pain
• Crepitus (sounds)
• Herberdens Nodes
• Stiffness (most common)

• Joint deformities
• Bone spurs
• Narrowing of joint spaces

• Poorly nourished
• Elderly
• Obese
• Impaired immune systems
• Chronic illnesses
• Long-term corticosteroid tx

Sepsis

• Systemic inflammatory disease that affects the synovial lining of joints
• *Inflammation*

• NSAID (ASA can cause tinnitus)
• Prednisone
• Corticosteroid injection into joint

• Red butterfly rash across the cheeks and bridge of the nose
• Early AM joint stiffness
• Malaise & weakness

• Blood vessels
• Mucous membranes
• Joints
• Skin
• Kidneys
• Muscles
• Brain
• Heart

• Excess collagen causing stiff skin, small blood vesseldamage
• Early symptom is Raynauds phenomenon
• CREST

• Calcinosis (Ca deposits on skin)
• Raynauds phenomenon
• Esophageal dysfunction (acid reflux & decreased motilityof esophagus)
• Sclerodactyly (thickening/tightening of skin on fingers&hands)
• Telangiectasias (dilation of capillaries causing red markson skin)

Excessive accumulation of Uric acid causing crystal formations

• Microscopy of synovial fluid
• Uric acid > 7mg/dL

• Uricosuric agents (Probenecid)
• Antigout agents (allopurinal) *can cause decreased platelets*

• Inflammation
• Chronic infection

• Impaired circulation (5 Ps)
• Pressure sore

Isometric and ROM exercises

• Muscle damage
• Non-specific to which muscle

• Pain in multiple muscles
• Corticosteroids have dramatic decrease in pain & inflammation

Multiple muscle inflammation

Bent spine

• Monitor blood glucose q3-4hrs
• Continue medications as usua
• lDiet of easily digested foods and liquids
• Call provider is blood glucose >300 or unable to retain fluids

Irrigate eye for at least 10 min

SE of gastric surgery causing rapid stomach emptying into the duodenum when high carbs and liquids are consumed.

• High fiber
• Low fat

• Reduce anxiety
• Teach pt. to about appropriate diet (bland, high protein, vit. & calories, low residue)

• Bland
• High protein, vit. & calories
• Low residue

• Cardiac dysfunction
• Fever
• Neuro impairment

• Seafood
• Iodine salt
• Dairy products

Explain procedure and why it’s performed

• Increase in “floaters”, flashing lights, pain
• s/s of retinal detachment

Risk of falls r/t vertigo

Chronic inflammatory disease of the airways

Abnormal pattern of breathing characterized by progressively deeper & faster breathing followed by gradual decrease resulting in temporary stop of breathing

• Rales- small clicking, bubbling, or rattling
• Rhonchi- resembles snoring
• Stridor- wheeze-like sound
• Wheezing- high-pitched sounds produced by narrow airways

Atherosclerosis and increased demand for O2 causing pain from insufficient coronary blood flow

• Fluid retention
• Jugular distention
• Cyanosis
• Enlarger liver

Usually extensive exposure to sun

• Diuretic
• Monitor potassium lvls
• Monitor for dehydration (BUN, creatinine, electrolytes)