Emergency Care and Assessment

Initial Assessment

• As a registered nurse, the first thing to do at the scene is to assess the situation and ensure the safety of the patient and others.
• A hip fracture is suspected when the leg is shortened or externally rotated.

Signs and Symptoms

• Reddened, warm to touch, and swollen knee are signs and symptoms likely related to inflammation.
• Osteoporosis is a contributing factor to fractured bones, and factors that contribute to osteoporosis include aging, genetics, and lack of calcium.

Immobilization and Emergency Care

• The ER Nurse should carefully monitor the patient for signs and symptoms of shock, bleeding, or further injury.

Using a Cane

• To teach a patient to use a cane, hold the cane on the unaffected side, with the hand grip at the level of the wrist.
• Hold the cane with the elbow flexed at a 30-degree angle.

Rehabilitation Phase

• During the rehabilitation phase, the nurse should intervene if the patient uses the cane incorrectly.

Mantoux Test

• The Mantoux Test is also known as the Tuberculin Skin Test.
• The solution is injected intradermally.
• A positive result is indicated by an induration of 10 mm or more.
• The patient should return after 48-72 hours to read the test result.
• If the result is positive, the nurse should refer the patient to a doctor for further evaluation and treatment.

TB Management

• In the Philippines, Mantoux test is not routinely done due to the high prevalence of Latent TB Infection.
• A patient with an active disease is categorized as Category 1 by the DOH.
• The duration of the maintenance phase of treatment is 4-6 months.
• Ethambutol is unlikely to be given during the maintenance phase.
• The most hazardous period for development of clinical disease is during the first 2 years.
• The DOH program to control TB in the country is called the National Tuberculosis Control Program (NTP).
• Susceptibility for the disease is increased markedly in those with HIV/AIDS, except for those with DM.

Level of Prevention

• Direct sputum examination and Chest X-ray of TB symptomatic is in the secondary level of prevention.

Colostomy Care

• A patient shows the best adaptation with the new colostomy if they show acceptance and independence in caring for the colostomy.
• The nurse should teach the patient about colostomy irrigation, using a colostomy irrigation set, and inserting the tube at approximately 15-20 cm from the stoma.
• The maximum height of irrigation solution for colostomy is 12-18 inches.
• The best initial step in learning to care for the colostomy is to practice and demonstrate the ability to care for the colostomy.
• If the patient complains of severe cramping during irrigation, the nurse should stop the irrigation and consult with a doctor.
• A prolapsed stoma is evident if the stoma is protruding from the abdomen.
• Foods that will help lessen the odor of the colostomy include yogurt, buttermilk, and parsley.
• The nurse should start to teach the patient about the techniques for colostomy care, including irrigation and stoma care.