Question

You are the RN caring for Mrs. M.T., a 72 year old female patient who

is admitted for a UTI. M.T. has a history of UTIs, urinary retention,

HTN, hyperlipidemia, asthma, glaucoma, and a left femoral-popliteal

bypass. (#11-20)

11. Upon admission M.T. opens her eyes only when her name is called out, she states she is in the

hospital and that the year is 1975. When asked to hold her arms out in front of her, she is

reluctant, but is able to hold both arms out. What is M.T.’s GCS and explain your reasoning for

each category.

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12. After determining that M.T. is altered, what is your priority nursing action?

a.

Determine M.T.’s baseline GCS

b. Call the MD

c.

Chart the findings as normal

d. Ask M.T. if she is experiencing any numbness or tingling in her extremities.

13. From the patient’s history of a left femoral-popliteal bypass you know that M.T. has vascular

insufficiency. Upon examining her extremities, you suspect that M.T. may have arterial

insufficiency. What types of findings could lead you to suspect this? (List at least 4)

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14. The student nurse who is working with you is educating M.T on what signs and symptoms

someone may see with venous insufficiency. You know that the student needs further

education when she states...

a.

“People with venous insufficiency should elevate their legs often”

b. “People with venous insufficiency may have swelling and superficial wounds around their

ankles”

c.

“People with venous insufficiency may have deep black wounds on their feet”

d. “People with venous insufficiency should wear compression stockings”

15. While educating M.T., the patient states, “Some of those signs and symptoms sound like what

my sister had when she was diagnosed with a DVT.” How can you explain the difference

between vascular insufficiency and DVT to this patient? (explain patho and signs and symptoms)

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Answer 1

m.t's GCS

E3 V4 M6

Her eye-opening score is 3 out 4 because she is only opening her eyes to speech not spontaneously.

Her verbal response score is 4 out of 5 because she states the year 1975 that back in time, it seems she is confused.

Her motor response score is 6 out of 6 because she is reluctant but she is obeying the command.

12. After finding the gcs is slightly altered we have to record the abnormalities with the time of measurement and we should inform the duty doctor.

13. While examining her lower extremity for arterial insufficiency we may find

painful cramping of calf and thigh muscles

leg weakness and numbness

while comparing with another leg the affected leg is very cold

cyanosis of the affected leg

hair loss in affected leg

weak pulse in leg and feet

sores on heal and feet

14. Venous insufficiency is a condition where the walls of veins or the valves of veins are damaged and it affects the blood flow and has trouble in sending blood back to the heart.

the most common cause is a blood clot which blocks the veins or varicose veins.

people with Venous insufficiency should elevate their legs often because it will help in blood flow by gravity and reduce swelling.

people with Venous insufficiency has leg ulcers and black deep wound due to the poor blood supply and blood drainage.

The best treatment for Venous insufficiency is compression stockings, it helps in improving blood flow and reduce swelling.

exercise regularly also improve in blood flow and helps in reducing swelling.

diuretics help in reducing swelling and anticoagulant helps to dissolve the clot and prevent from DVT, which is the most common complication in Venous Insufficiency.

15. you have to explain that DVT(deep vein thrombosis) and Venous insufficiency is two different things.

DVT is a condition which leads to venous insufficiency.

Venous insufficiency is a condition where the walls of veins weaken and valves are not functioning properly or there is a blood clot(DVT) in the deep veins. which will affect or block blood circulation in peripheral veins.

when a blood clot or thrombus form in deep peripheral veins we can call it DVT. it may lead to venous insufficiency(affected circulation in peripheral veins)