Sheka Seid
Study guide MS 1 FINAL T2 2020
Nursing care for venous ulcers
Limb compression
Moist wound bed
Elevation
Prevent infection
Non healing
Administer and assist with treatments to improve circulation
Leave a dressing on for 3-7days
Administer antibiotic
Assess the client and monitor blood gas analysis, prepare for oxygen therapy
Client – diet high in zinc, protein, iron and vit a and c, understand use of compression
stocks, prepare to administer prescribed anticooagulation
Promoting vasodilation with peripheral artery disease
PVD- Vaccum blood back to heart (Elevate)
PAD – Push back to the he (Dangle/drop down)
PVD – V- Voluptious pulses (Warm legs). PADA –Absence of pulses (Absent hair - cool
E – Edema (blood pooling) R – Round red sores
I – Irregularly shaped sores T – Toes and feet pale
N- No sharp pain (Dull) S – Sharp calf pain (Intermident claudification)
Y – Yellow and brown ankles.
Treatment PVD &PAD
C – Constriction, Cross legs, Constrictive clothes, cigars, caffeine, cold temp, toes nails
trimmed by provider
Keep legs warm
No direct heat source!
Dangle legs to promote circulation
Elevation makes them more ischemic
No tight socks!
No compression
Provide a warm environment for the patient
- Have the patient wear insulated socks
- Tell the patient to never apply direct heat such as a heating pad, to the affected
extremity because sensitivity is decrease and this can cause a burn
- Instruct the patient to avoid exposure to cold (causes vasoconstriction and
decreased arterial flow)
- Instruct the patient to avoid stress, caffeine and nicotine (causes
vasoconstriction up to 1hr)
, Preventing DVT – clot in deep vein
S/S C- Calf pain and cramping. Treatment (During clot) D – Don’t walk
O – One sided swelling (unilateral) V- Venous return (elevate)
W – Warm and red T – Teach prevention
S – SOB and chest pain = PE (Call provider
Treatment After clot
C – Cals exercise and isometrics
H – Hydration
A – Ambulation
N – No long sitting
T – Ted and SCDS
Goal: avoid venous stasis
Increase activity
o Ambulation, active ROM
SCD, Teds
Encourage fluids
Promote venous return
Prophylactic anticoagulation
-teach ankle flexion, extension exercises
-apply elastic stocking, PCD
-avoid crossing legs
-possible prophylaxis with heparin, warfarin
high risk clients
Factors that make one at risk for fluid volume deficit
Dehydration and hypovolemia, vomiting, diurrhatic, laxative, hommorage
Excessive GI loss: vomiting, Nasogastric suctioning, diarrhea
Excessive skin loss: diaphoresis w/o sodium and water replacement
Excessive renal system losses: diuretic therapy, kidney disease, adrenal insufficiency
Third spacing: burns
Hemorrhage or plasma loss
Altered intake: anorexia, nausea, impaired swallowing, confusion, NPO
What are Kuss Maul respirations, when do you see them, what are they like and what do
they mean?
Kuss Maul respiration is deep breathing. It occurs in DKA. The body trying to get rid of
co2 in metabolic acidosis. Too acidic
Kussmaul respiration is increased respiratory rate and depth in attempt to excrete carbon
dioxide and acid due to metabolic actions
, Nursing care for Raynaud’s disease
Arterial vasospastic disorder
Transient spasm of small arterioles
Emotional stress or cold
Fingers and hands
No cure
Skin color changes with temperature
Pallor (white)
Cyanosis (blue) deoxygenation
Rubor (red)
AVOID – Sudden change in temp, gloves, stress, smoking, key meds -
nephedopine meds, avoid vasoconstriction)
- Pain can be managed by careful warming of the area when
vasoconstriction occurs. Hot water must not be used - this can result in
burns because of a lack of sensation during vasoconstriction.
Teach about smoking cessation; avoid cold; wear gloves & warm clothes; manage stress; avoid
caffeine. teach about nifedipine - do not eat grapefruit or grapefruit juice. S/S of vasodilators are
facial flushing, hypotension, HA.
How long should a PICC line stay in
40-65 cms
Study guide MS 1 FINAL T2 2020
Nursing care for venous ulcers
Limb compression
Moist wound bed
Elevation
Prevent infection
Non healing
Administer and assist with treatments to improve circulation
Leave a dressing on for 3-7days
Administer antibiotic
Assess the client and monitor blood gas analysis, prepare for oxygen therapy
Client – diet high in zinc, protein, iron and vit a and c, understand use of compression
stocks, prepare to administer prescribed anticooagulation
Promoting vasodilation with peripheral artery disease
PVD- Vaccum blood back to heart (Elevate)
PAD – Push back to the he (Dangle/drop down)
PVD – V- Voluptious pulses (Warm legs). PADA –Absence of pulses (Absent hair - cool
E – Edema (blood pooling) R – Round red sores
I – Irregularly shaped sores T – Toes and feet pale
N- No sharp pain (Dull) S – Sharp calf pain (Intermident claudification)
Y – Yellow and brown ankles.
Treatment PVD &PAD
C – Constriction, Cross legs, Constrictive clothes, cigars, caffeine, cold temp, toes nails
trimmed by provider
Keep legs warm
No direct heat source!
Dangle legs to promote circulation
Elevation makes them more ischemic
No tight socks!
No compression
Provide a warm environment for the patient
- Have the patient wear insulated socks
- Tell the patient to never apply direct heat such as a heating pad, to the affected
extremity because sensitivity is decrease and this can cause a burn
- Instruct the patient to avoid exposure to cold (causes vasoconstriction and
decreased arterial flow)
- Instruct the patient to avoid stress, caffeine and nicotine (causes
vasoconstriction up to 1hr)
, Preventing DVT – clot in deep vein
S/S C- Calf pain and cramping. Treatment (During clot) D – Don’t walk
O – One sided swelling (unilateral) V- Venous return (elevate)
W – Warm and red T – Teach prevention
S – SOB and chest pain = PE (Call provider
Treatment After clot
C – Cals exercise and isometrics
H – Hydration
A – Ambulation
N – No long sitting
T – Ted and SCDS
Goal: avoid venous stasis
Increase activity
o Ambulation, active ROM
SCD, Teds
Encourage fluids
Promote venous return
Prophylactic anticoagulation
-teach ankle flexion, extension exercises
-apply elastic stocking, PCD
-avoid crossing legs
-possible prophylaxis with heparin, warfarin
high risk clients
Factors that make one at risk for fluid volume deficit
Dehydration and hypovolemia, vomiting, diurrhatic, laxative, hommorage
Excessive GI loss: vomiting, Nasogastric suctioning, diarrhea
Excessive skin loss: diaphoresis w/o sodium and water replacement
Excessive renal system losses: diuretic therapy, kidney disease, adrenal insufficiency
Third spacing: burns
Hemorrhage or plasma loss
Altered intake: anorexia, nausea, impaired swallowing, confusion, NPO
What are Kuss Maul respirations, when do you see them, what are they like and what do
they mean?
Kuss Maul respiration is deep breathing. It occurs in DKA. The body trying to get rid of
co2 in metabolic acidosis. Too acidic
Kussmaul respiration is increased respiratory rate and depth in attempt to excrete carbon
dioxide and acid due to metabolic actions
, Nursing care for Raynaud’s disease
Arterial vasospastic disorder
Transient spasm of small arterioles
Emotional stress or cold
Fingers and hands
No cure
Skin color changes with temperature
Pallor (white)
Cyanosis (blue) deoxygenation
Rubor (red)
AVOID – Sudden change in temp, gloves, stress, smoking, key meds -
nephedopine meds, avoid vasoconstriction)
- Pain can be managed by careful warming of the area when
vasoconstriction occurs. Hot water must not be used - this can result in
burns because of a lack of sensation during vasoconstriction.
Teach about smoking cessation; avoid cold; wear gloves & warm clothes; manage stress; avoid
caffeine. teach about nifedipine - do not eat grapefruit or grapefruit juice. S/S of vasodilators are
facial flushing, hypotension, HA.
How long should a PICC line stay in
40-65 cms
