Last MS for nursing 2

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Last MS for nursing 2
2015-09-06 00:18:12

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  1. General complication of fracture
    fat embolism syndrome (FES)
    systemic fat globules from fractures are distributed into tissues and organsusually occurs within 12-48 hrs of injurymost common: long bones, ribs, tibia and pelvis
  2. FES risk factors
    total joint replacement, crush injuries, severe/multiplr fractures, men under age 40 yrs
  3. Patho of FES
    • Fat globules diffuse from the marrow to circulatory system
    • - pressure driven
    • - catecholamines (hormones release when body is under stress) released at the time of fracture, mobilize free fatty acids- fat globules
    • occulde small blood vessels (lung, brain, kidneys, heart, skin
  4. s/s FES
    • rapid onset:
    • resp: dyspnea, tachypnea, crackles, wheezes, chest pain, cough with large amt of white sputum
    • - hypoxemia (PaO2 <60)
    • cardiac: tachycardia, hypotension
    • mental: anxiety, restlessness, confusion, irritability
    • renal: dec urinary output- kidney not getting enough blood
    • skin: petechiae over the upper body, acillae, skin is pale can progress to cyanosis, subconjuctival and oral petechiae d/t the occulsion of dermal blood vessels
  5. Dx FES
    • no definitive test
    •  PEcxr
    • abg (hypoxia)
    • EKG changes
    • cbc
    • fat cells in sputum, blood and urine
  6. Tx of FES
    • 1. prevention
    • early immobilization of fracture
    • 2. accurate and early assessment and management
    • 3. resp support (oxygen, ventaliation w/PEEP_
    • 4. blood pressure assessment and management, IV fluids, IV vassopressin
    • 5. monitoring of renal function and urinary output
    • - i/o foley labs
    • 6. bed rest (careful re positioning)
    • 7. IV steroids to decrease inflammatory effects of fatty acid and dec lung inflammation
  7. Gen comp of fracture
    VTE venous thromboembolism
    • DVT and PE
    • high risk: fractures of lower extremities, hip and pelvis
    • factors Virchow's triad
    • - venous stasis
    • - vascular damage
    • - coagulation defect
    • brunner chart 31-7
  8. s/s dvt
    • unilateral edema
    • unilateral erthemma, warmth
    • extremity pain
    • calf
    • homan's sign is unreliable- flex lower extremities
    • dx: doppler studues, duplex scanning venogram U/s is the best show artieries and u/s
  9. Treatment of DVT
    • prevention is key
    • early mobilization position changes rom
    • TEDS: incr venous return prevent venous dilation
    • - work effectively, needs correct size
    • sequential stockings
    • adequate hydration
    • prophylactic anticoagulants
    • - heparin sc
    • - lovenox sc
  10. Gen comp of fractures
    delayed union, malunion and nonunion
    • delayed union: healing does not occur within the expected time frame
    • - healing occurs but is prolonged
    • - causes: infection, pulling apart of bone fragments, poor nutrition,poor blood supply, non compliant
  11. Gen complication of fracture
    malunion, nonunion
    • Malunion: failure of the bones fragments to unite in alignment
    • nonunion: failure of the end of the fracture bone to unite
    • - causes: infection, inadequate immobilization, limited bone contact poor blood supply
  12. Malunion and nonunion
    s/s dx
    • s/s:
    • - persistant pain and tenderness
    • - abnormal movement of the fracture
    • dx: x-ray/CT/MRI
  13. Tx nonunion
    • 1. surgery
    • internal fixation or bone graft depending on what is goin gon
    • 2. electrical stimulation of bone- used to help with circulation of bone and healing
    • 3. pulsating electromagnetic fields
  14. general complication of fracture
    avascular necrosis of bone AVN
    • occurs when bone loses it blood supply
    • after a fracture, blood supply can be disrupted to distal area
    • isechemia and necrosis can result
    • s/s: pain, limited movement
    • dx: PE xray
    • TX: accurate assessment and prompt intervention
    • - bone grafts, joint replacement
  15. Gen comp of fracture
    skin breakdown
    • assess skin for pressure points, breakdown, rashes, ischemia q 2hrs
    • - braden scale
    • - reposition
    • - early mobilization if possible
    • rub pressure areas you are bringing circulation
    • take wrinkles, no crumbs
    • document as much as you can
  16. Gen comp of fractures
    altered coping
    • changes to body image, self esteem, coping
    • pt teaching
    • social worker, case management
    • group therapy
    • for both pt and family
  17. Amputations
    • removal of body part
    • most distal point to be successful for prosthesis
    • objectives of surgery
    • - conserve as much as possible
    • - preserve function
    • - good prosthetic fit
    • - positive circulation
    • pysche- tough decision to make
  18. Amputations
    • site assessment for amputation:
    • circulation
    • function
    • Types:
    • therapeutic
    • traumatic
  19. Therapeutic Amputations
    • clinical indicators for amputation:
    • - depend on the underlying cause
    • - circulatory impairment (PVD), trauma, wide spread infection, malignant tumors
    • s/s: loss of sensation, lack of pulses, pallor, cool, pain, s/s of infection/sepsis
  20. Therapeutic amputation
    • Assessment
    • depending on underlying cause of amputation
    • CT
    • Vascular and doppler studies
    • CBC
  21. Amputation Management
    pre op
    • pre op teaching (prevent complications, mobility, pain, phantom limb sensation)
    • nutritional status
    • emotional support
    • support systems
    • rehab- pt/ot
    • resources available
  22. Post op amputation care
    • Goal is to achieve healing of the amputation wound, the result being a nontender residual limb with a healthy skin for a prosthetic use
    • 1 Assessment of VS and post op care
    • assess for bleeding
    • 2. pain management
    • - phantom limb sensation or pain- phantom pain is pain that feels lie it coming from body part thats no longer there
    • - acknowledge the feelings, keep the limb active (ROM)
    • - opioids, muscle relaxant (muscle spasms), antianxiety meds/support , position
    • TENS
    • - meds: neurotin and amitriptyline (bc 2 calm nerve pain)- chronic
  23. Post op amputation
    dressing/wound care
    • dressing type will be determine by md
    • depending on the type of amputation
    • - rigid dressing or firm elastic bandage- prevents bleeding and edema
    • prosthetic may be applied in the OR or be delayed (wound infection, elder)
    • not all patients are candidates for prosthesis
  24. Post Op
    gentle care of extremity
    • dressing change initially by md folled by aseptic technique
    • elastic wraps, residual limb shinker, pylon (temp prosthtic extension) compression dressing/bandages: reduce bleeding and edema, limb shaping, improves healing
    • - care- apply snug not tight
    • - removed at times in the day
    • - careful, continue assessment
  25. Post op care
    • extended position
    • avoid pillows and sitting for one hour (avoid flexion contractures)
    • prone position if possible (lower extremity amp)- prevents contraction
    • resposition from side to side
    • avoid flexion, abduction and external rotation
    • early rom and activity to prevent joint contractures
    • PT: position changes (safety), strength and endurance exercises, assistive devices, use of prosthetic device
  26. post op care
    control edema
    • 1st 24 hour elevate followed by extended position
    • edema can occur quickly
    • keep stump with compression wrap/dsg
  27. post op care
    referral prosthetist
    • identification of correct prosthesis
    • cont teaching
    • avoid complications that dec a good fit
    • - flexion deformities
    • - non shrinkage of the limb
    • - abduction deformities of the hip
  28. post op care sump.incision, emotional, outpt rehab
    • sump incision
    • inspect daily for skin breakdown, blisters, pressure points, edema, infectionts
    • wash incision with mild soap, keep dry avoid products like powder
    • emotional support
    •  changes in body image, function, adl and job
    • out pt rehab
    • resources in community
  29. complications of amputation
    • hemorrhage
    • - assess vs, dressing, tourniquet at bedside
    • assess shock
    • notify md immediately
    • infection
    • assess signs of infection- swollen, redness warmth, odor
    • aseptic technique
    • post op antibiotics
    • teach pt and fam things to watch out for
  30. complication of amputation
    • contractures
    • - joint contractures of the hip
    • prevention is key
    • phantom limb sensation/pain
    • keep limb active
    • skin breakdown edema
    • prevention is key
    • assess once a shift
    • residual limb stocking
  31. traumatic amputation
    • immediate care
    • wrap in cloth in plastic and stored in ice (avoid inflammation)
    • immediate emergency care
    • inc risk of infection
    • may/may not be able to be replanted
  32. review
    • priorities of care- pain nutrition, contractures
    •  essential assessments for pt care
    • pt teaching- infection
    • support pt and fam