D.M., a 25-year-old man, hops into the emergency department (ed) ...

[RYAN BANYAN]

D.M., a 25-year-old man, hops into the emergency department (ed) with complaints of right ankle pain. He states that he was playing basketball and stepped on another player's foot, inverting his ankle.
 
  You note swelling over the lateral malleolus down to the area of the fourth and fifth metatarsals, and pedal pulses are 3+ bilaterally. His vital signs (VS) are 124/76, 82, 18. He has no allergies and takes no medication. He states he has had no prior surgeries or medical problems.
  In assessing D.M.'s injured ankle, what should be evaluated?

Question 2

You instruct L.B. in the proper use of a metered-dose inhaler (MDI) using a spacer.
 
  How would you explain proper MDI use?
 
  Because L.B. is taking two puffs twice daily of triamcinolone (Azmacort), how long should
  the inhaler last? The canister label states that it contains 200 inhalations.
 
  As you are concluding your session, L.B. looks at you and says, This is absolutely, utterly
  overwhelming. What should you tell her to reassure her?
 
  You would recognize the need for additional teaching if L.B. says which of the following?
  Select all that apply.
  a. I will use the albuterol inhaler 30 minutes before exercising.
  b. My husband needs to know what to do in case I have an attack.
  c. If the reading is in the yellow zone, I need to use rescue drugs and seek help immediately.
  d. I will keep a diary of all of my PEFR measures.
  e. I will place a plastic cover on our mattress and my pillows.
  f. The bed linens need to be washed in cold water to reduce dust mites.

[nothere]

Answer to Question 1

Pulses, pain (at rest or with movement), paresthesia, paralysis, pallor. Note swelling, discoloration
(bruising), range of motion

Answer to Question 2

Answer: 50 days
An inhaler typically has 200 inhalations: 200/4 (2  2) = 50 days. The ordered dose is two puffs
two times a day. The canister has a total of 200 puffs. You complete the following calculations to
determine how long the MDI will last:
2puffs  2 times a day = 4puffsper day
200puffs  4puffs per day = 50 days

Acknowledge that it is normal to feel overwhelmed and fearful and assure her that the health care
team will be there to help her. Validate that the feelings she is having now will evolve and she will
get to a point where she will find her situation manageable. To improve her self-confidence, reassure
her that she has the education and resources to control her asthma and that she will feel much better
than she does now. Encourage her to use ways of coping that she has used in the past in stressful
situations and to talk with people in her social network. Link her with community resources, such
as a support group, and make sure she has the appropriate contact information should she have
questions after she leaves.

Answers: a, c, f
The treatment of asthma is aimed at avoiding known allergens and respiratory irritants and
controlling symptoms and airway inflammation. Beta2-adrenergic agonists are most successful
at maintaining bronchodilation during exercise when they are inhaled 10 to 20 minutes before
exercise. If the PEFR is in the red zone, not the yellow, it indicates a serious problem and action must
be taken. Bedding should be washed in hot water to reduce or destroy dust mites. A family member
or significant other should be taught what can be done to help the patient during an asthmatic
attack. This person should know where the patient's inhalers, oral medications, and emergency
phone numbers are located. The significant other can also be instructed on how to decrease the
patient's anxiety if an asthma attack occurs. All PEFRs should be written down in a journal that
should be brought to each visit with the health care provider.