Fall history Elimination problems Cognitive impairment Depression Medications or medical conditions Mobility concerns Deconditioning Poor judgment Acute illness Sensory deficits Alcohol use Environmental factors Assistive devices
What components should you identify with a fall patient?
Activity at the time of the fall
Location and witnesses
History of previous falls
Past medical history
What should you look for during a physical exam?
Visual acuity (glasses in use, etc)
Cardiovascular system (carotids, heart, BP, chest pain, etc)
Extremities and injuries (bruises, fractures, signs of abuse, head injuries)
Neuro system (alert, oriented, signs of CVA, PERRLA, Loss of consciousness)
Labs (UA, pulse ox, blood sugars, lytes, H&H)
Assistive devices in use or not used
List the intrinsic factors that can prevent falls and minimize injuries
Review medications Assess alcohol use Assess cognitive function Assess mood Provide and maintain devices for sensory deficits Are they deconditioned. Need referral to PT to increase strength Evaluate gait and balance. Emphasize and assess use of assistive devices for ambulation. Assess continence needs Caregiver understanding of fall risk and prevention
List the extrinsic factors that can prevent falls and minimize injuries
Evaluate environment Evaluate footwear and feet Utilize bed exit alarms as appropriate Use shower and toilet grab bars Elevated toilet seats Frequently used items on lower shelves in the home Remove clutter and clear pathways
A lower respiratory tract infection of the lung parenchyma with onset in the community or during the first 2 days of hospitalization. Result from bacteria, fungal, virus; most common is strep.
Pneumonia occurring 48 hours or longer after hospital admission and not incubating at the time of hospitalization. Mostly from influenza, pseudomonas, E. coli, strep and staph.
Refers to the sequelea occuring from abnormal entry of secretions or substances into the lower airway. Food, water, vomitus, or toxic fluids are the triggering mechanisms for the pathology of this type of pneumonia.
Pneumonia seen patients who have the following conditions: 1. Malnutrition 2. Immune deficiencies 3. Transplants and been treated with immunosuppressive drugs 5. Receiving radiation therapy, chemotherapy, or corticosteriods Caused by viral and bacterial agents, carinii, fungi and CMV.
The most common cause of bacterial pneumonia and is caused by Streptococcus pneumoniae organism.
Signs and Symptoms of Pneumonia
Fever ranging from 99-101 F Chills Productive cough with purulent sputum Pleuritic chest pain Confusion Hypoxia Nausea Loss of appetite (more on pg. 567)
Nursing Care for Pneumonia
Antibiotics and medication teaching Fluid intake Rest Analgesics and antipyretics O2 therapy if appropriate Deep breathing exercises Takes several weeks to recover
Right-sided heart failure; an enlargement of the right ventricle due to high blood pressure in the lungs usually caused by chronic lung disease.
Etiology and Pathogenesis of Cor pulmonale
Genetic causes and unknown causes --> pulmonary endothelial injury --> vasoconstriction --> remodeling (vessel wall thickening) --> sustained pulmonary hypertension --> right ventricular hypertrophy The most common cause is COPD and almost any disorder that affects the respiratory system.
Physical Assessment Findings of Cor pulmonale
Dyspnea Chronic productive cough Wheezing respirations Retrosternal or substernal pain Fatigue Hypoxemia Polycythemia Peripheral edema Weight gain Distended neck veins (JVD) Full, bounding pulses Enlarged liver Chest x-ray that shows an enlarged right ventricle and pulmonary artery.
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