2900 Exam Three Flashcards
what is SIRS?
systemic inflammatory response syndrome
what are diagnostic criteria for SIRS?
temperature above 100.4 or below 96.8
tachycardia greater than 90 BPM
respiratory rate greater than 20/min
WBCs greater than 12000, less than 4000, or with greater than 10% as immature forms
what is sepsis?
SIRS plus confirmed bloodstream infection. sepsis is the body’s amplified response to an infection
what is septic shock?
sepsis induced hypotension (less than 90 SBP) despite adequate fluid and vasopressor resuscitation
what is MODS?
multiple organ dysfunction syndrome, it is dysfunction of the organs due to severe hypoperfusion. It is the end result of uncorrected SIRS and sepsis
what might fluid status and blood glucose look like in a sepsis patient?
positive fluid balance (fluid retention)
hyperglycemia (greater than `140 mg/dl) in the absence of diabetes
urine output will be less than what value in sepsis?
less than 0.5 ml/kg/hr for at least two hours despite fluid resuscitation
what are normal lactate levels?
between 0.5 and 1.0 mmol/L
what are lactate levels like in sepsis? what value is considered severe septic lactate?
septic: between 2 and 4, considered severe over 4 mmol/L
treatment for shock focuses on what two things?
volume expansion and vessel tightening
in what types of shock do you not want to focus on volume expansion?
cardiogenic and neurogenic
what are the initial types of fluid used for fluid replacement in shock?
normal saline and lactated ringers (crystalloids)
what do crystalloid fluids do in the body?
add more fluid to the intravascular system to increase preload, stroke volume, and cardiac output
what is the 3:1 rule for giving crystalloids and why do we use it?
give 3 ml of crystalloids for every 1 ml of fluid lost, because these fluids easily diffuse out through the capillary wall
what are the two types of colloids that can be used in shock treatment?
albumin and hetastarch
what does albumin do?
keep fluid in the bloodstream
what does hetastarch do?
increases the volume of blood plasma to help red blood cells circulate through the body
what are things to monitor for when giving colloids?
anaphylaxis and fluid volume overload
what should be done to large amounts of fluid before giving them?
warm them up, because hypothermia can alter clotting enzymes
what types of shock can be given blood or blood products?
all types
what do packed red blood cells do in the body?
replace fluids and provide hemoglobin
when are platelets given?
for patients with uncontrollable bleeding and low platelets
when is fresh frozen plasma given?
when patients need clotting factors
what should the nurse ask the patient about before giving a transfusion?
if they’ve had a previous transfusion and if they had any adverse responses to it
what is the number one vasopressor of choice to be given for shock? what does it do?
norepinephrine: increases perfusion and BP
what kind of vasopressor is given only in neurogenic shock?
phenylephrine
what are some examples of vasopressors with inotropic effects?
dobutamine and dopamine
what are some vasodilators used in shock?
nitroglycerine and sodium nitroprusside
why are corticosteroids sometimes given for shock?
to decrease inflammation and increase BP and HR
what is an intraaortic balloon pump?
a device that helps provide temporary circulatory assistance to a sick heart. Helps improve coronary blood flow
how does an intraaortic balloon pump help?
it reduces afterload on the heart
what is MAP?
mean arterial pressure, its the amount of pressure needed to perfuse organs adequately
what MAP is needed for adequate perfusion?
greater than 60 mmHg
how do you calculate MAP?
(SBP + 2DBP)/3
why do serum lactate levels go up in sepsis?
because cells arent getting enough oxygen and/or glucose, so they switch to anaerobic metabolism. lactic acid is produced as a byproduct of anaerobic metabolism
what are risk factors for sepsis?
Suppressed Immune System Extreme age (old or young) People who have received organ transplant Surgical procedure recently Indwelling devices Sickness (chronic)
what are the most common sites of sepsis?
GI tract
respiratory tract (#1)
urinary tract
what are early signs of sepsis? note you may not always see this stage
“warm” stage early: warm flushed skin, decreased BP, increased HR/RR, fever, increased CO, anxiety, restlessness
what are late signs of sepsis?
“cold” stage: cold clammy skin, severe hypotension, increased HR and RR, hypothermia, oliguria (less than 400 ml/day), coma, decreased cardiac output
what are the top two nursing interventions for septic shock/shock?
fluid replacement (crystalloids or colloids) vasopressors if fluid replacement isnt enough (norepinephrine is drug of choice)
how does the nurse evaluate whether fluid resuscitation is successful in shock?
check for rising BP, especially SBP, and monitor hemodynamic status
why is it crucial to keep o2 sats above 95 percent in septic shock?
patients are at high risk for developing respiratory failure due to ARDS
what must the nurse do in sepsis/septic shock before administering antibiotics?
obtain blood cultures
what type of nutrition is preferred in sepsis?
enteral nutrition given early
why is nutritional support so important in sepsis?
because there is decreased GI perfusion, and nutrition helps preserve GI integrity and prevent stress ulcers
what can sepsis and shock do to blood glucose levels?
increase them
why is hyperglycemia bad in shock and sepsis?
because it alters the way the immune system and cells work
what might the nurse need to do for hyperglycemia in shock and sepsis? where do we want blood glucose?
insulin drip may be needed, want blood glucose less than 180
what lab levels should be monitored closely in shock and sepsis?
glucose
lactate
what urine output do we want in shock and sepsis?
greater than 30 ml/hour
what respiratory interventions may be needed in shock and sepsis?
supplemental oxygen or intubation and mechanical ventilation
what body position should you put someone in shock in?
modified trendelenburg: supine with lower half of body elevated 45 degrees
what is cardiogenic shock?
condition in which the heart cannot pump enough blood to meet the body’s perfusion needs, leading to inadequate organ perfusion
what is the number one cause of cardiogenic shock?
myocardial infarction
what signs and symptoms would you see in cardiogenic shock?
signs of either right sided or left sided heart failure
mental status changes/confusion/agitation
decreased urine output and nocturia
pale dusky skin, shiny extremities, edema
what are the three treatment goals with cardiogenic shock?
reperfusion (may need cardiac stent)
increase cardiac output (with meds)
ventilation (mechanical ventilation and diuretics)
what lab values will we see specific to cardiogenic shock?
increased troponin and BNP, as well as increased lactate
what are some drugs that may be given for cardiogenic shock?
diruetics
vasopressors (norepi)
vasopressors with inotropic effects (dopamine, dobutamine)
vasodilators (nitro or sodium nitroprusside)
what surgical intervention might help with cardiogenic shock?
placement of intraaortic balloon pump
what is hypovolemic shock?
low fluid volume in the intravascular space, leading to inadequate perfusion
what will happen in the body when fluid moves from intravascular to intersititial space?
edema, decreased cardiac output, hypotension
what are the two types of hypovolemic shock?
relative and absolute
what are some causes of relative hypovolemia?
internal bleeding
severe burns and third spacing
long bone fractures
sepsis
what are some causes of absolute hypovolemia?
massive bleeding
vomiting
excessive urination
diarrhea
how much fluid can the body lose and still compensate?
15% loss or less
what will activate in the body once enough fluid has been lost?
RAAS
what are overall symptoms of hypovolemic shock?
tachycardia hypotension increased respirations decreased urine output cool clammy skin with poor capillary refill mental status changes/confusion low central venous pressure
what are nursing goals with hypovolemic shock?
fluid replacement (crystalloids, colloids, blood/blood products) correct underlying cause of fluid loss oxygenation circulation (stop any active bleeding) maintain/monitor for adequate perfusion
what kind of IV access is needed in hypovolemic shock?
at least 2 large gauge (18 or larger) IV sites to give fluid fast
how should oxygen be given in hypovolemic shock?
100% high flow oxygen through non-rebreather
what is the best position for patients in hypovolemic shock?
modified trendelenberg
what labs need to be closely monitored in hypovolemic shock?
hemoglobin hematocrit ABGs lactate liver enzymes CBC electrolytes, BUN, creatinine
what happens in anaphylactic shock?
introduction of an allergen leads to release of massive amounts of histamine
what are signs and symptoms in anaphylactic shock?
vasodilation, causing decreased BP and CO
decreased HR
increased capillary permeability (intravascular fluid loss and edema)
itching
bronchoconstriction
nausea, vomiting, and abdominal pain
anaphylactic shock is what type of shock?
distributive shock
what happens in distributive shock?
the blood is present but the small vessels in the body has a hard time getting it to the organs
what respiratory issue do we worry about with anaphylactic shock?
respiratory failure
what is intervention for anaphylactic shock focused on?
reversing the effects of histamine (so tightening blood vessels and relaxing airway)
what can the nurse do to prevent anaphylactic shock?
always ask patients about their allergies
monitor patient during first dose of antibiotic or other sensitizing drug
if anaphylactic reaction to something occurs, what must the nurse do immediately?
remove the allergen if possible manage the airway and monitor vitals call rapid response trendelenberg position give drugs as needed
what drug should be given for anaphylaxis/allergy that involves the airway?
epinephrine
what are some other drugs that can be given for allergic reactions?
albuterol
antihistamines
corticosteroids
what is biphasic anaphylaxis?
when patient recovers but has a relapse/second reaction, even if not re-exposed to allergen. continue monitoring patient
what should the patient be taught regarding anaphylaxis?
avoid allergen wear medical alert bracelet always carry epi-pen go to ED after using epi-pen throw away epi pen when expired know how to prepare and administer epi massage injection site for 10 seconds for faster absorption
what is neurogenic shock?
when the sympathetic nervous system loses its ability to stimulate nerve impulses, usually because of spinal cord injury. the patient then experiences massive vasodilation with decreased BP and HR because parasympathetic nervous system takes over
neurogenic shock is what kind of shock?
distributive shock
what are manifestations of neurogenic shock?
hypotension and bradycardia
venous pooling (DVT risk)
warm dry extremities but cold core (hypothermia)
what are nursing management priorities for neurogenic shock?
manage ABCs protect spine (if spinal cord injury) assess and manage airway maintain tissue perfusion keep them warm monitor urine output (risk for retention)
what are considerations for fluid resuscitation in neurogenic shock?
crystalloids can help, but must be given with caution. fluid loss is not the issue so patient can easily get fluid overloaded
what drugs might be given in neurogenic shock to increase HR?
vasopressors and positive inotropes
what drug can be given in neurogenic shock to help with bradycardia?
atropine
how can DVT be prevented in neurogenic shock?
ROM
compression stockings
anticoagulants
SCDs
what is a vasopressor specifically used for neurogenic shock?
phenylephrine
which system usually shows signs of dysfunction first in SIRS and MODS?
respiratory system
what are top nursing management goals for SIRS and MODS?
prevent and treat infection
maintain tissue oxygenation
nutritional support
what is the goal of nutritional support in SIRS/MODS?
preserving organ function!
what are some labs that will be specifically monitored in septic shock?
cultures and coagulation tests
what are tests that will be done/monitored in cardiogenic and obstructive shock?
ECG echocardiogram CT cardiac cath chest x-ray
what are major defining manifestations of DKA?
uncontrolled hyperglycemia (greater than 300 mg/dL) dehydration metabolic acidosis ketones in blood and urine kussmaul respirations
is onset for DKA rapid or slow?
rapid onset
what are defining characteristics of HHS?
hyperglycemia greater than 600 mg/dL
hyperosmolarity and dehydration
absence of ketosis
osmotic diuresis
what is onset like for HHS?
gradual, usually occurring over several days
who is normally affected by HHS and why?
type two diabetics, often over the age of 60. type 2 diabetics are more likely to be affected because their body has enough endogenous insulin to prevent full ketosis
what are manifestations of hypoglycemia?
cold clammy skin dizziness decreased alertness shakiness/faintness jitters vision issues
what are general manifestations of diabetes?
polyuria polyphagia polydipsia weight loss GI issues blurred vision weakness headaches kussmaul respirations fruity breath odor metabolic acidosis mental status changes
what are risk factors for DKA?
undiagnosed or untreated T1DM
reduced or missed insulin dose
emotional stress
illness/infection/surgery/trauma
what is the number one cause of DKA?
infection
how does increased hormone production lead to DKA?
it stimulates the liver to produce glucose and decreases the effects of insulin
what are risk factors for HHS?
undiagnosed T2DM
inadequate fluid intake or poor kidney function
age over 50
infection or stress
medical condition like MI, CVA, or sepsis
what are the three key treatment elements for DKA?
hydration
insulin
electrolytes
what needs to be remembered for fluid administration with DKA?
IV access needed
need rapid isotonic fluid administration (normally 0.45 or 0.9% NaCl)
monitor for adequate urine output
monitor for fluid volume excess
how do we calculate insulin needs for DKA?
0.1 unit/kg/hour
what should be done to insulin infusion when serum glucose approaches 250 mg/dL? why?
5-10% glucose should be added to infusion to prevent hypoglycemia and prevent risk of cerebral edema
what is the blood glucose goal for DKA treatment?
less than 200 mg/dL
how often should BG be checked in DKA?
hourly
what will potassium levels look like initially in DKA and how will they change?
they will initially be elevated, but will decrease as insulin is administered and potassium shifts back into the cell. monitor for hypokalemia
what electrolyte should be included in all IV fluids for DKA patients?
potassium
when administering potassium, what else should be monitored?
cardiac rhythm
what should the nurse teach diabetic clients to do when ill to avoid DKA?
monitor BG every four hours continue taking insulin/diabetes meds drink 4 oz liquid every 30 minutes meet carb needs with soft foods 6-8 times/day test urine for ketones rest
when should a sick diabetic patient call their provider? (worrisome s/s)
if BG over 240 if fever over 101.5 feeling disoriented/confused breathing rapidly vomiting more than once more than 5 episodes of diarrhea in a day illness longer than 2 days
what is a mechanical bowel obstruction?
when the bowel is blocked by something outside or inside the intestines
what are some causes of mechanical bowel obstructions?
adhesions tumors hernias fecal impactions strictures diverticulitis
what is the most common cause of mechanical bowel obstruction?
surgical adhesions
what is a volvulus?
an intestinal obstruction where the bowel twists upon itself
how are complete mechanical obstructions taken care of?
surgery
what causes non-mechanical obstruction?
diminished peristalsis, often due to paralytic ileus
what is the focus of bowel obstruction treatment?
fluid and electrolyte balance
decompressing the bowel
relief or removal of obstruction
what are the four hallmark signs of intestinal obstruction?
colicky abdominal pain
vomiting
distention
constipation
what does “colicky” mean?
pain that comes and goes
what is obstipation?
inability to pass stool or flatus for more than eight hours despite feeling the urge to defecate
what is the difference in onset between small and large bowel obstructions?
small bowel has rapid onset
large bowel has gradual onset
what is the difference in vomiting between small and large bowel obstruction?
small bowel has frequent, often projectile vomiting that may contain bile
large bowel has delayed or absent vomiting. If present, will have a more fecal smell
what is the difference in pain between small and large bowel obstructions?
small: colicky/intermittent
large: persistent cramping
what is the difference in bowel movements for small and large bowel obstructions?
small: some feces may pass
large: complete constipation
what lab results might be seen with bowel obstruction?
increased BUN, hgb, hct, and creatinine due to dehydration
potential increased WBC
potential metabolic imbalances
orthostatic vitals
decreased urine output and increased urine SG
what will an endoscopy help determine in bowel obstruction?
cause/location of obstruction
what needs to be closely monitored and prevented with bowel obstruction?
fluid and electrolyte imbalances or deficiencies
what are some key nursing cares for non-mechanical bowel obstructions? (think paralytic ileus)
NPO for bowel rest NG tube for decompression assess bowel sounds oral hygeine IV fluids and electrolyte replacement manage pain ambulation semi-fowlers position
what kind of suction will an NG tube for bowel obstruction have?
intermittent
how often should an NG tube be irrigated?
every four hours
what should the nurse monitor in the client with an NG tube?
gastric output vitals skin integrity weight intake and output
how often should oral hygiene be done for a client with an NG tube?
every two hours
what nursing cares should be done for a client with a mechanical bowel obstruction?
prepare for surgery
withhold oral intake until peristalsis resumes
what is parenteral nutrition?
IV administration of nutrition that bypasses the GI tract to deliver nutrients to the body. people can be on it for as long as necessary
what is special about the TPN solution?
it is sterile and specifically made for each patient each day
what are some common indications for administration of TPN?
complicated surgery or trauma bowel obstruction GI fistulas critically ill patients acute pancreatitis
what supplies the bulk of calories in TPN?
carbs (dextrose and fat emulsion)
when is central parenteral nutrition used?
for long term support or when patient has high calorie needs.
how is central parenteral nutrition administered?
through a CVC or PICC line with a tip in the superior vena cava
when is peripheral parenteral nutrition administered?
when short term nutritional support is needed
when protein/calorie needs arent as high
when a CVC is too big a risk
as a supplement to oral intake
what is the biggest complication that can develop from TPN administration?
refeeding syndrome
how does refeeding syndrome manifest and what issues can it cause?
manifests as fluid retention and electrolyte imbalances
it can cause dysrhythmias, respiratory arrest, and neurological disturbances
how long is TPN good for?
24 hours
how long should TPN be out of refrigeration before adminstration?
30 minutes
how often should TPN tubing be changed?
every 24 hours
how should TPN flow be regulated?
by using an IV pump
what are important things to monitor in the patient receiving TPN?
vitals daily weights intake and output blood glucose BUN electrolytes
what are the two most common causes of acute liver failure?
viral hepatitis and drugs/toxins
what three major things characterize acute liver failure?
jaundice
coagulopathy
encephalopathy
hepatitis A
occurs in crowded conditions and passes on through fecal matter
hepatitis B
passed through contaminated needles, syringes, blood products, or sexual activity with an infected partner
hepatitis C
passed through blood and blood products
will hepatitis manifest immediately?
no, so patient can be contagious with no symptoms
what are symptoms of acute hepatitis?
anorexia weight loss fatigue lethargy jaundice low fever dark urine clay colored stool
what is jaundice?
yellow coloring of body tissues due to altered bilirubin metabolism
what is bilirubin?
an orange/yellow pigment made in the liver by hemoglobin breakdown
what is icterus?
yellowing of the eyes from bilirubin buildup
what can the accumulation of bile salts cause?
generalized itching (pruritus)
what changes in lab values will be seen with acute liver failure?
increased AST increased ALT decreased albumin increased bilirubins prolonged prothrombin time
what is the most definitive diagnostic test for liver failure?
liver biopsy
what are the two methods of liver biopsy?
open and closed method
what are some nursing cares for patients post liver biopsy?
have patient lie on right side for several hours to apply pressure on site
assess for bleeding
assess for pain
assess for signs of pneumothorax
how long is the convalescent phase in acute viral hepatitis?
2-3 months on average
what are the four key items for management of acute viral hepatitis?
well balanced diet
rest
vitamin supplements
avoid alcohol and drugs
what infection precautions should be followed for hepatitis?
contact precautions
what is the most common cause of acute liver failure?
drugs (normally combo of alcohol and acetaminophen)
how is acute liver failure defined?
rapid onset of severe liver dysfunction in patient with no prior history of liver disease. often occurs with hepatic encephalopathy
what are signs of hepatic encephalopathy?
changes in mentation
changes in neuro and mental responsiveness
impaired consciousness
inappropriate behavior
hepatic encephalopathy coexists with an increase in what substance in the body?
ammonia
what is the goal in treating hepatic encephalopathy?
reduce ammonia formation
what drug reduces ammonia formation? how?
Lactulose: its a laxative like drug that traps ammonia in the gut and then expels it in feces
what is asterixis?
a flapping tremor of the arms and hands that is characteristic of hepatic encephalopathy
why is safety a priority for patients with hepatic encephalopathy?
because they are at very high risk for falls
what is cirrhosis?
extensive scarring of the liver caused by necrotic injury or prolonged inflammatory response. normal liver tissue is replaced with fibrotic tissue. cirrhosis is end stage liver disease
what are expected findings in cirrhosis?
fatigue weight loss abdominal pain distention pruritus confusion and mental changes ascites jaundice/icterus
what are other integumentary changes in cirrhosis?
petechiae
ecchymoses
spider angiomas
what is fetor hepaticus?
liver breath, a fruity or musty odor from digestive by-products that the body cannot break down
why is bruising and bleeding an issue in cirrhosis?
because the liver can no longer adequately make clotting factors
why do many cirrhosis patients have breathing issues?
because of ascites and plasma volume excess
what should the nurse do/assess in relation to fluid balance for cirrhosis patients?
monitor for indications of fluid volume excess strict intake and output daily weights assess ascites and peripheral edema restrict fluid and sodium if necessary
what nutrients are especially important for clients with cirrhosis?
carbs and protein
how often should abdominal girth be measured and how should it be measured for the patient with ascites?
measured daily over the largest part of the abdomen
what is a t-tube?
a tube placed in the bile duct that helps drain bile from the liver
what will stool look like if client has impaired bile production or movement?
greasy, fatty, pale/white stool
how does a t-tube bag drain and how should it be stored?
it drains by gravity and should rest at or below the client’s waist level
what amount of drainage from a t-tube would warrant a call to the physician?
over 500 ml/day
what should t-tube drainage NOT be like?
should not be thick, foul smelling, or bloody
what is necessary for a nurse to clamp or flush a t-tube?
physician order
what are some common causes of fractures?
falls and accidents
twisting injuries
disease processes like cancer or osteoporosis
how long do fractures take to heal?
3-12 weeks (shorter time for kids, longer for adults)
what are some complications of fractures?
infection (osteomyelitis)
compartment syndrome
fat embolism
nerve and vessel damage
open fracture
fracture where bone breaks through the skin
closed fracture
fracture that does not pierce skin
complete fracture
bone is broken all the way through
incomplete fracture
bone doesnt break all the way through
greenstick fracture
one side of bone is bent and the other side is fractured
who is most likely to get a greenstick fracture?
children
comminuted fracture
bone is broken into many fragments
transverse fracture
broken straight across the bone
oblique fracture
fracture is slanted across the bone at an angle
spiral fracture
fracture that twists around the bone
what is the most definitive diagnostic tool for a fracture?
x ray
what are common manifestations of a fracture?
bruising pain and swelling reduced movement odd appearance of limb crackling sound from bone fragments edema and erythema neurovascular abnormalities
what do we want to assess for neurovascular status with a fracture?
area distal to the fracture to check for perfusion/pulses
what are the 6 P’s of neurovascular assessment for fractures?
pain pallor paralysis paresthesia pulselessness poikilothermia (inability to regulate body temp)
how often should neurovascular assessment be done with a new cast?
every hour
how should the nurse initially immobilize a fracture?
with a splint above and below the fracture site to decrease pain, bleeding, and nerve damage
what should the nurse do if the fracture is open/compound?
cover it with a sterile dressing
how should the extremity be positioned initially with a fracture?
elevated to decrease swelling
how can pain be managed initially with a fracture?
ice and pain meds
why should the patient with a new fracture be kept NPO?
in case surgical procedure needed
how long after the onset of compartment syndrome will it become irreversible?
6-12 hours
what is the earliest sign of compartment syndrome? what is the latest?
pain is the earliest sign, pulselessness is a late sign
how should the extremity be positioned if the nurse suspects compartment syndrome?
at heart level
what kind of fractures are most likely to have fat embolism as a complication?
long bone fracture
what are some signs and symptoms of fat embolism?
changes in mental status
increased respirations and difficulty breathing
what is a closed reduction for a fracture?
manual resetting of the bone done under general anesthesia, with a cast placed afterward
what are some general cares/instructions for after a cast is placed?
put ice on it for the first 48 hours and have patient wiggle fingers to prevent stiffness and improve circulation
elevate above heart for first 24 hours
monitor for infection and keep cast clean
why should a nurse only use her palms when handling a new cast?
because they don’t dry fully for about 48 hours, and nurse could indent cast with fingertips
what is an internal open reduction for a fracture?
setting the bone on the inside using pins, rods, or plates
what is an external open reduction?
bone set on the outside of the skin using metal braces and screws
what is a key concern with external open reduction?
infection
what is traction?
applying a pulling force to an injured or diseased extremity or body part to help align the bone
what are benefits of traction?
reduces pain and muscle spasm
immobilizes joint
keeps fracture or dislocation from becoming more severe
prevents soft tissue damage
expands a joint before an arthroscopic procedure
what are some things to remember about traction weights?
they should hang freely, and never rest on the floor
never remove the weights
what are things that should be closely monitored for the client in traction?
pin care (look for foul drainage or smell) maintain skin integrity monitor the 6 P's looking for compartment syndrome
what is skin traction?
tape, boots, or splints used for 2-3 days until patient can do skeletal traction or surgery. decreases muscle spasms
what is bucks traction?
a type of skin traction used for fractures of the hip and femur before hip surgery
what is skeletal traction?
traction that aligns bones and joints to allow for healing
how will the patient on skeletal traction move? (and not move)
patients cannot move from side to side, but can lift using a trapeze bar and are encouraged to do isometric exercises
what are isometric exercises?
exercises in which joint angle and muscle length do not change during contraction
what will usually be done for orthopedic surgery patients to prevent VTE?
prophylactic anticoagulants
compression stockings
SCDs
dorsiflexion and plantar flexion of feet and ankle
what are some ways to minimize infection risk for patients with fractures?
post op antibiotics wound cleaning and debridement monitor labs and vitals encourage coughing and deep breathing encourage nutrient and fluid intake
what can be done to prevent fat embolism?
reposition patient as little as possible until fracture is stabilized to reduce risk of fat droplet dislodging
what might be seen if the patient has a fat embolism?
confusion tachypnea cyanosis dyspnea apprehension
what are some treatments when patient has a fat embolism?
fluid resuscitation
correct acidosis
blood transfusion
what is a sprain?
an injury to a ligament around a joint from a twisting motion
how should sprains be treated?
rest
ice
compression
elevate
what is a dislocation?
the surface of the joint separates, and the affected limb might be shorter and internally rotated
what is arthroplasty?
reconstruction or replacement of a joint
what are some post-op management items for arthroplasty?
vitals intake and output pain meds PT monitor respiratory and encourage breathing watch for bleeding
what are some things to remember for after a hip replacement?
do not flex hip more than 90 degrees
do not cross legs at knees/ankles
do not adduct hips
do not put on shoes without adaptive device
what are nursing cares for after an amputation?
monitor vitals
assess for hemorrhage
use sterile technique for dressing changes
properly bandage limb
what is a compression bandage?
a bandage used after amputation to reduce edema and minimize pain for quicker healing. should be worn at all times except when bathing
what is autonomic dysreflexia?
uncompensated cardiovascular reaction mediated by the SNS due to stimulation of sensory receptors below level of spinal cord injury
what are the most common causes of autonomic dysreflexia?
distended bladder or rectum
what are manifestations of autonomic dysreflexia?
hypertension bradycardia throbbing headache diaphoresis flushing of skin above and below level of injury
what are the worst complications of autonomic dysreflexia?
stroke, MI, and death
what are nursing interventions for autonomic dysreflexia?
elevate HOB to 45 degrees or sit patient upright
determine the cause
call PCP
do bladder scan and relieve bladder or constipation if indicated
what are some drugs that can be given for autonomic hyperreflexia if symptoms persist after cause is eliminated?
nitroglycerine
nitroprusside
hydralazine
what are manifestations of pneumothorax?
dyspnea
decreased movement of affected chest wall
diminished or absent breath sounds on affected side
what is the primary intervention done for pneumothorax?
chest tube placement
what is common emergency treatment for pneumothorax?
cover the wound with an occlusive dressing on three sides
what is tidaling?
the movement of fluid in chest tube chamber as the client breathes in and out
what might rapid bubbling in the chest tube chamber indicate?
an air leak somewhere in the system
what are manifestations of tension pneumothorax?
cyanosis air hunger extreme agitation tracheal deviation away from affected side neck vein distention
what are emergency interventions for tension pneumothorax?
needle decompression followed by a chest tube insertion with drainage system
in what order should the patient be assessed if they are unresponsive?
circulation, airway, breathing
in what order should the patient be assessed if they are responsive?
airway, breathing, circulation
what is the most important part of CPR?
chest compressions
what are the A-G components of a primary survey in care of an emergency patient?
alertness and airway breathing circulation disability exposure/environmental control facilitate adjuncts, involve family get resuscitation adjuncts
how is disability assessed?
assessing LOC/response to stimuli/glasgow coma/pupil reactivity
what are some resuscitation adjuncts that might be needed in emergency patient care?
labs ECG NG or orogastric tube ventilation monitoring and support manage pain emotional support for families provide comfort
what is included in secondary survey once the patient is more stable?
history, head to toe, complete skin inspection
what are priority cares for a client with hypothermia?
ABCs
rewarming
correcting dehydration and acidosis
treat cardiac dysrhythmias
what is involved in passive rewarming?
removing wet clothes
warming the area
using heat lamps
warm blankets
what is involved in active rearming?
warm IV fluids
heated humidified oxygen
warm water immersion
cardiopulmonary bypass
what are nursing interventions for heat exhaustion?
remove patient from heat/sun give cool drink (ideally with electrolytes) remove excess clothing get a fan wet sheet over patient
why should tylenol not be given to the patient with heat exhaustion?
because it is not effective on fever caused by heat exhaustion
what are the two types of abdominal trauma?
blunt and penetrating
what is a risk if the liver or spleen is penetrated?
profuse bleeding and hypovolemic shock
what are signs and symptoms of abdominal trauma?
guarding/splinting distended/hard abdomen decreased or absent bowel sounds bruising pain hematemesis or hematuria decreased urine output
what is cullens sign?
ecchymosis around the umbilicus
what is grey turners sign?
ecchymosis around the flanks
what is the best diagnostic tool for abdominal trauma?
abdominal ultrasound
what are nursing interventions for suspected or confirmed renal trauma?
assess cardiovascular status and monitor for shock ensure adequate fluid intake monitor intake and output pain relief monitor for hematuria and myoglobinuria
what is the most common tick-borne disease?
lyme disease
what are manifestations of lyme disease?
flu like symptoms (headache, stiff neck, fatigue)
bulls eye rash around tick site
what are long term issues if lyme disease is not treated?
arthritis
heart disease
peripheral radiculoneuropathy
what is the treatment for lyme disease?
doxycycline
how should a tick be removed?
ASAP with tweezers
what are common treatments for poison ingestion?
activated charcoal
dermal cleansing
eye irrigation
gastric lavage
what is gastric lavage?
using a tube passed into the stomach to sequentially administer and remove small volumes of liquid
what should not be done for frostbitten skin?
do not squeeze, massage, or scrub area
avoid heavy blankets/clothing
what should be done for frostbite?
rewarm slowly by immersing in warm water
give analgesia
how should pin sites for halo vest be cleaned?
twice daily with half strength peroxide/normal saline
when is a TLSO brace used?
when patients have stable thoracic or lumbar spine injuries
when is a TLSO brace worn?
whenever a patient is out of bed
