Evaluating Signs & Symptoms by Springhouse

By Springhouse

This quantity of the recent Nursing Know-How sequence deals how-to suggestions at the most recent thoughts for comparing over 250 vital signs. each one signal or symptom is gifted on a web page or two-page unfold in bulleted layout. a number of illustrations and circulation charts supplement the text.

Know-How Nugget icons supply professional counsel for eliciting or assessing an indication or symptom. Case Clip icons current real-life responses to an pressing signal or symptom—the nurse's review findings and the speedy reaction team's interventions. Quick Action! icons current pressing responses to an alarming signal or symptom and interventions for keeping off a life-threatening emergency.

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QUICK ACTION If the patient has severe distention, insert an indwelling urinary catheter to help relieve discomfort and prevent bladder rupture. qxd 8/17/08 36 3:25 PM Page 36 Bladder distention 700 ml is emptied from the bladder, compressed blood vessels dilate and may make the patient feel faint. Typically, the indwelling urinary catheter is clamped for 30 to 60 minutes to permit vessel compensation. History Ⅲ Ask about voiding patterns and characteristics. Ⅲ Find out the time and amount of the patient’s last voiding.

Battle’s sign is caused by a force that’s strong enough to fracture the base of the skull. Such an impact damages supporting tissues of the mastoid area and leads to a seepage of blood from the fracture site to the mastoid. Battle’s sign usually develops 24 to 36 hours after the fracture and may persist for several days to weeks. QUICK ACTION Basilar skull fracture, if untreated, can be fatal. Place the patient flat on his back in bed and monitor his neurologic status. If the patient has a large dural tear, prepare him for a craniotomy.

Eventually, limb ataxia, dysarthria, static tremor, nystagmus, cramps, paresthesia, and sensory deficits occur. Stroke Ⅲ Infarction in the medulla, pons, or cerebellum may lead to ataxia, which may remain as a residual symptom. Ⅲ Worsening ataxia during the acute phase may indicate extension of stroke or severe swelling of the brain. Ⅲ Accompanying signs and symptoms include motor weakness, sensory loss, vertigo, nausea, vomiting, oculomotor palsy, dysphagia and, possibly, altered LOC. Wernicke’s encephalopathy Ⅲ Gait ataxia occurs.

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