Examine the legs for color, capillary refill time, and tissue integrity when evaluating a client at risk for thrombosis.
Deep vein thrombosis is a condition when a blood clot (a thrombus) develops in a vein (DVT). This can dislodge and go into the bloodstream prior to reaching the lungs, where it can cause a pulmonary embolism (PE), a blockage in the pulmonary circulation that can be fatal.
In both primary and secondary care, nurses will be required to recognize and screen for deep vein thrombosis, therefore they must have the ability to evaluate the patient's clinical risk.
To utilize the Wells screening equipment properly, the leg must be extensively checked. Nurses ought to:
- Find any asymmetry or unilateral swelling, skin changes, wounds, oedema, erythema, or varicosities on both legs by keeping an eye out for them.
- Before palpating both legs, feel for heat with your hand over the suspected DVT location. Also feel for pain and any cracks in the skin.
- DVT symptoms can include deep venous system-specific pain.
- The difference in the calves' circumference is measured 10 cm below the tibial tuberosity.
- A DVT is the likely diagnosis if there is a discrepancy of more than 3 cm from the asymptomatic side.
- Check capillary refill time is between two and three seconds; this is a sign of peripheral perfusion by palpating the foot pulses.
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Answer:
Flexor capro ulnaris
Explanation:
<u>Muscle that extends and adducts the hand at wrist is called Flexor capro ulnaris. This muscle is innervated by the ulnar nerves. It consists of two heads, humeral head and ulnar head.</u>The humeral head initiates at the medial epicondyle of the humerus.The ulnar head initiates at the olecranon of the humerus. It inserts on the pisiform, the hook of hamate and the fifth metacarpal.
The nurse administers cimetidine to a 75-year-old client diagnosed with a Gastric ulcer the nurse should monitor the client for the following adverse reactions Headache, Sleepiness, Confusion, Dizziness, Nausea which contribute for the change in Metal status.
- Cimetidine is a H
Receptor Antagonist. - Gastric partial cells contains receptors for Histamine.
- Histamine is released from the Enterochromaffin cells upon the stimulation from food intake or from Vagus nerve stimulation.
- Thus Histamine released from Enterochromaffin cells binds to H receptors on the parietal cells and increases the secretion of HCl.
- Cimetidine has totally opposite effect and decreases the secretion of HCl from the parietal cells.
- Not only on gastric cells H receptors are also present in CNS where they stimulate brain cells.
- The above point justifies the adverse effects of Cimetidine.
- Patients over the age of 50 or those who are severely ill may experience transient confusion while taking H
blockers, particularly cimetidine.
Hence from these points we can conclude that patients who are above 50 years and receiving Cimetidine medication for gastric ulcer should be monitored for the above mentioned adverse reactions.
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