Med-Surg Exam 11
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. What would you like to do?
When performing a CMS check, what things do you check?
- Circulation: Color, pulse, temp, cap refill
- Motion: purposeful movement, ability to wiggle fingers/toes w/o telling them to move them
- Sensation: response to touch/ability to feel, no numbess/tingling
- assess paain and edema: trace, small, moderate, pitting...ect
- assess for 6 Ps: pain, pressure, pulselessness, pallor, paresthesia (numbness and tingling), paralysis
What is a break in continuity of the bone?
What are some causes of fractures?
- direct blow
- crushing force
- sudden twisting motion (torsion)
- extreme muscle contraction
- disease process that weakened bone
- repeated stress to bone
What are some causes of falls?
(I used the "Fall prevention is crucial! how can we prevent falls?" on page 5 of the handout. Couldn't find anything else)
- slippery or uneven surfaces
- lack of exercise/activity
- poor nutrition
- hormone balance
- lack of assistance
- medication s/e
What are the s/s & things you should assess for a pt with a possible fracture?
- loss of function
- muscle spasms
- CMS changes
- and hypovalemic shock
What should you worry about first when a pt has a fracture?
ABCs! Airway, breathing, circulation
What should you do when a victim is suspected to have a fx?
- do not move unless in danger
- control bleeding
- splint as it lies; DO NOT attempt to set fx
- RICE: rest, ice, compression, elevation
- prevent shock
- keep pt calm/warm
- only allow small amount of fluid (water)
What does RICE stand for?
What are the stages of healing in order? Describe each stage:
- inflammation/hematoma: edema, bleeding from ends of bone, blood oozes from torn blood vessels, clot forms at ends of fractured bones
- fibrocartilage formation: phagocytes migrate to injury area, fibroblasts enter and fibrous network forms hematoma, bibrin meshwork is formed
- callus formation: osteoblasts invade area and produce collagen, framework for new bone, strengthen fx site, collagen fibers bind bone tissue together, callus formation begins, new bone forms., but very spongy and weak; callus visualized by x-ray
- ossification: immature bone gradually replaced with mature cells; callus continues to strengthen; Ca and phosphorus crystals continue to fill in the collagen framework, osteoblasts continue to build new bone, and osetoclasts destro/resorb dead bone
- consolidation and remodeling: final step of bone repair; osteoclasts resorb last remnants of callus; bone contues to strengthen with time and exercise
To avoid adhesions and buildup of scar tissue, what is important for a pt with a total knee replacement to do?
What is the anticipated result of the healing process of a fx bone?
You want a successful union
What type of fx or break is described as: skin broken, open skin wound and fx site?
What type of fx or break is described as: skin intact, no skin wound a fx site?
What type of fx or break is described as: unstable fx, bone separated and moved out of alignment, NEEDS IMMEDIATE TX to realign bone?
What type of fx or break is described as: more stable fx, bones remained in alignment?
What type of fx or break is described as: involves entire width of bone?
What type of fx or break is described as: only partial width of bone?
What type of fx or break is described as: fx with injury to surrounding tissues?
What type of fx or break is described as: crushing or pressure on verebrae?
What type of fx or break is described as: bone fragments in many pieces
What type of fx or break is described as: broken ends forced or wedged into each other?
What type of fx or break is described as: bone breaks incompletely; one side partially and the other side bent?
What type of fx or break is described as: segment or portion of bone broken away (involves break in 2 areas)?
What type of fx or break is described as: fx is diseased or weakened area of bone, produced by force that normally would not have fx a heathy bone?
What type of fx or break is described as: normal or abnormal bone subjected to repeated stress (common in runners)?
What type of fx or break is described as: fragment of bone connected to ligament breaks off from main bone (ankle?)
What are the classifications/types of fractures?
- open vs. closed
- displaced vs. nondisplaced
- location on bone (proximal, mid shaft, distal...ect.)
- type of break (comminuted, greenstick...ect.)
How long do fractures take to consolidate/heal? What is it monitored by?
anywhere from 6 weeks to 2 years; monitored by x-ray
How would you prevent shock?
- position victim flat
- cover with blankets
- only small amount of liquids/water
- monitor VS: every 15 minutes!
What is the hospital tx for a person with a fx?
- bleeding control
- frequent VS
- x-ray to confirm fx/characteristics
- reduction/setting of the fx; surgery as indicated
- immobilization of part
- if open fx: tetanus injection as needed
- pain management
- elevation to heart level to prevent edema
- CMS checks; assess for 6 Ps
- continued assessment for bleeding, schock, DVT, compartment syndrome, fat embolism
What does ORIF stand for? What does it do?
- Surgically puts bones in place with hardware
What is the term for the application of mechanical straghtening, pulling force to part of the body?
What are the actions that are taken when taking care of a cast?
- don't lift cast by parts: support the whole (w/ palms only)
- apply mole skin to pad around edges
- peri area padding and use fx pan
What are some complications of a fx?
- compartment syndrome
- fat embolism
What is the term for a claustrophobic feeling from a cast?
What are the nursing interventions for a pt with a cast?
- assessment to prevent complications/infection, osteomyelitis, DVT, fat embolism, and compartment syndrome
- careful handling of fractured extemity
- assess for "cast syndrome"
- monitor closely for edema and pressure areas
- CMS checks
- ice bags against the area, but not directly on top of cast
- elevations to heart level
- pain assessment/management
- drainage/odor (circle area/monitor)
- external fixators/hoffman device
What is the difference between a sprain and a strain?
- sprain: pull or tear of ligament, bleeding in soft tissue, ankle most common, RICE tx; edema
- strain: pull or tear to muscle, tendon, or both, resolves naturally, RICE
What are some things you should teach the pt about cast care?
- keep it dry
- do not apply shoe polish/spray pain to cast- prevents it from "breathing"
- ask about cast seal for showering/swimming
- keep extremity out of tub/use seal/plastic
- use cast shoe if necessary
- walker/crutch when walking as needed
- appointments with orthopedist for x-rays/follow-up care
What are the basic principles of traction?
- countertraction must be maintained
- traction may be continuous or intermittent
- never interrupt skeletal traction
- do nto add or remove weights unless ordered
- keep pt aligned in the center and at the head of the bed
- weights should hang freely
- ropes should be unobstructed in straight alignment
- knots in the rop or the footplate should not touch the pulley or the foot of the bed
What are the nursing implications/outcomes for the pt in traction?
- relieve pain and discomfort
- reduce anxiety
- improve mobility/ROM exercises
- increase ADLs to extent possible
- maintain neurovascular status
- maintain adequate nutrition and fluid intake
- prevent complications and other issues related to immobility, such as anorexia, dehydration, constipation, skin breakdown, infection/oseomyelitis, pneumonia, kidney stones, UTI.....
- pt teaching
- reinforce info provided by physician concerning condition, bone healking, other issues
What attaches bone to bone?
What attaches muscle to bone?
What are the 7 things should you NOT do if you have a hip replacement? DO NOT:
- stand with toes turned in
- bend way over
- cross legs
- pull blankets over you with legs straight out & reaching (like this? [pictures]) toward toes
- lie without pillow between legs
- get up (like this)?
- sit low on toilet or chair
What are the complications of a hip fx?
- avascular necrosis (femoral head loses blood supply and dies)
What are three types of arthritis?
- rheumatoid arthritis
- gouty arthritis/ gout
What is the most crippling, auto-immune, systemic, chronic, inflammatory disorder?
What is the most common type of arthritis that is a noninflammatory, non-systemic degenerative joint disease that can affect any weight bearing joint?
What is the type of arthritis that is described as uric acid in the blood? What is the most common site?
gout; great toe
What is the most common cause of an amputation of an upper extremity?
What is the most common cause of an amputation of a lower extremity?
PVD usually r/t diabetes
What are the pre-op nursing implications/pt teaching for a pt getting an amputation
- explain procedures
- explain word "stump" and meaning
- teach pt what to expect, TCDB, IS, exercies
- encourage questions
- teach about phantom limb sensation/pain
- assess CV, neurovascular, and functional status
- pedal pulses
- nutritional status
What are the post-op nursing implications/pt teaching for a patient who has had an amputation?
assess for complications, esp hemorrhage, infection, edema, non-healing stump incision, skin breakdown
What are the nutrients needed for bones to heal?
vitamin D, Ca, P
What are the nutrients needed for skin, collagen repair, and wound healing?
vitamin C, vitamin E, and Zn
What are the nutrients needed for tissue repair?
protein (assess albumin level)
What are the nutrients needed for energy?
B complex, iron
What is the nutrient needed for GI function?
What should you avoid if you have gout?
high purine foods: liver/organ meats, anchovies, sardines, yeast, sweetbreads, alcohol
What is the most common complication after a total joint replacement?
What meds do you treat DVT with?
lovenox, coumadin, heparin
Class: nonopoid analgesic
relives mild pain
no more than 4 g/day
avoid alcohol; do not give if liver disease
relieves moderate to severe pain
CNS, respiratory depression
potential for tolerance/dependence
- tramadol (Ultram)
- hydrocodone (1/2 Lortab, Lorcet, Vicodan)
- oxycodone (Oxycontin, Percocet, Percodan)
Local topical anesthetic
prevents nerve impulse conduction for localized pain management
Topical (transdermal patch)
apply directly to area of pain
may cut patch before removing liner if need smaller size; can apply up to 3 patches in one side (on 12 hrs, off 12 hrs)
avoid heat to area
remove before MRI
lidocain patch (Lidoderm)
decreases inflammation and relieves mild pain
give w/ food/milk or take enteric coated to protect stomach
risk of bleeding
saliclate toxicity; tinnitus, hearing loss, dizziness, bleeding
aspirin (Ecotrin, Bufferin)
pulled from market once; back on now with new labeling to warn of a/e; heart attack, stroke, GI bleed
give w/ food
report fluid retention/weight gain
avoid in pregnancy
decrease inflammation and supress immune system
PO, Intraarticular (directly into joint)
PO: best taken between 0600-0900 w/ food/milk
every other day dosing; taper when d/c
a/e: delayed healing, masked infection, wt gain/edema, HTN, hyperglycemia, mood/behavior changes
repeated injections may cause joint destruction; limit injections 2-3 anually
may have pain at injection site
- prednisone (Deltasone)
- methylprenisolone (DepoMedrol)
- dexamethasone (Decadron)
- betamethasone (Celestone)
skeletal muscle relaxant
relieve muscle spasms
s/e: CNS depression (esp dizziness & drowsiness) & anticholinergic effects (esp dry mouth, blurry vision, constipation, and nurinary retention) with chronic use
decreases uric acid levels by inhibiting production; prevents not treats attacks
Monitor I & O closely and encourage 2500-3000 mL/day fluids to decrease risk of uric acid stone formation
look for signs of rash; d/c med if rash
inhibits inflammatory and immune responses
IM weekly/every other week
may take months for effects to take place
chrysiasis: gray/blue skin discoloration
Gold toxicity; rash, pruritus, stomatitis, metallic taste
give deep IM into dorsogluteal
give PO w/ food to decrease GI s/e
frequrent mouth/skin care
- gold salt (Myochrysine, Aurolate)
- auranofin (Ridaura)
interferes with folic acid metabolism and inhibits immune response
give w/ folic acid
a/e: GI, liver toxicity, blood dyscrasias
frequent LFT and CBC
avoid pregnancy; birth defects/miscarriage
biologic agents/disease modifying antirheumatic drugs (DMARD)
supress immune response in RA and psoriatic arthritis
SC once or twice weekly or every other week/weekly
teach reconstitution & self administration
Enbrel: made from Chinese hamster ovary cells; assess for allergy to hamsters
a/e: pancytopenia, CNS demyelination (MS)
monitor for CNS effects and infection
usually pain at injection site
- etanercept (Enbrel)
- adalimumab (Humira)
suppress immune system in RA
gum hyperplasia risk; frequent mouth care
immunosuppressant effect; pancytopenia; monitor for/prevent infection
frequent LFT and CBC
avoid pregnancy; toxic to fetus
- azathioprine (Imuran)
- cyclosporine (Sandimmune)
replace synovial fluid in knee joints in those dx w/ osteoarthritis
is NOT a med
may take weeks for effects
made from rooster combs; don't give if chicken/egg allergy
weekly inj given on exact day every week (Synvisc 3 weeks; Hyalgan 5 weeks)
- hyaluronan (Synvisc)
- hyaluronate (Hyalgan)
bone reorption inhibitor
inhibits osteoclast activity/keep Ca in bone to treat and prevent osteoporosis
to prevent esophageal erosion; must take first thing early a.m. on empty stomach w/ 6-8 ox plain water, before any other meds/beverages/foods; then must remain upright for 30 minutes after dose
protect from sun
replace Ca to treat and prevent osteoporosis
ensure adequate vitamin D intake
encourage fluids; risk of calculi
monitor Ca level periodically
- calcium carbonate (Tums, 1/2 Caltrate-D)
- calcium citrate (Citracal)
regulates balance of Ca and phosphorus; promote Ca absorption
monitor Ca level
usually given w/ Ca supplementation
cholecalciferol (vitamin D, 1/2 Caltrate D)
What would you like to do?
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