Complex Exam 2 Flashcards
What type of fracture causes the bone to be fragmented?
comminuted
What type of fracture is common with physical abuse?
spiral
What type of fracture is common in children?
greenstick
Does a greenstick fracture go all the way through the bone?
NO
What type of fracture might require a tetanus shot?
an open fracture
What is the grating sound created by the rubbing of bone fragments?
crepitus
What is the internal rotation of the extremity, a shortened extremity, or visible bone with an open fracture?
deformity
What causes ecchymosis with fractures?
bleeding from trauma into underlying soft tissues
What is a late finding with fractures?
subcutaneous emphysema
What causes compartment syndrome?
excessive swelling from a fracture
What does a neurovascular assessment consist of?
The 5 P’s
- pain
- paralysis
- paresthesias
- pallor
- pulses
How often should you do neuro checks with compartment syndrome?
q 15 mins
What is the hallmark sign of fat embolism?
petechiae on the chest and abdomen
What can a fat embolism result in? When are they most common?
- acute respiratory insufficiency or impaired organ perfusion
- long bone fractures
What can anticoagulants and ambulating prevent after a fracture?
DVT and PE
What type of fractures are most likely to cause infection?
open
What is important to determine with fractures?
mechanism of injury
What should you NOT do with fractures?
manipulate
What is malunion?
when a fracture heals incorrectly
What is nounion?
a fracture that never heals
What should you watch for with casts?
- skin breakdown
- ability to move fingers
- good perfusion
How do weights hang with skin traction?
over the edge of the bed but not touching the ground
How much weight can be used for skin traction?
no more than 10 pounds
What is Buck’s traction used for?
hip fractures and dislocation
How much weight can be used for skeletal traction?
15-30 pounds
What should you assess pin sites for?
drainage and redness
What is ORIF?
plates are added to straighten the bone during surgery
When would you use external fixation?
if surgery cannot be done yet or the fracture is not the priority problem
What is essential in improving circulation after a fracture?
fluids
How should you get out of bed after a fracture?
unaffected side first
Shoudl you elevate the extremity after an amputation or fracture?
YES
Shoudl you elevate the extremity affected with compartment syndrome?
NO
How can you monitor circulation after an amputation?
- angiography
- ankle-brachial index
When would an amputation be left open?
if there is an active infection
What does RICE stand for?
- rest
- ice
- compress
- elevate
How should you assess for perfusion after an amputation?
take pulses most proximal to amputation at the same time
What medication should you give for phantom limb pain within the first week?
calcitonin
What other medications can you give for phantom limb pain?
- BB
- gabapentin
- baclofen (muscle relaxer)
How can you help flexion contractures?
- ROM
- d/c elevation after 24-48 hours
- lie prone for 20-30 mins several times per day
What causes compartment syndrome?
a tight cast or splint or an internal source (accumulation of blood or fluid)
What is a fasciotomy?
a surgery to open the faschia to decrease pressure and increase perfusion
When might you see abrasions, hematomas, contusions, or deglovong?
with crush injuries
Why should you put a heart monitor on a patient with a crush injury?
crush injuries release potassium
What type of fluids should you give for crush injuries?
- warmed NS or LR
- blood products (PRBC’s or whole blood)
What should you check the urine for with crush injuries?
myoglobin (makes it concentrated and dark)
What type of pain arises from inflammation of tissue?
nociceptive
What can have somatice pain?
- joints
- bones
- muscles
- skin
- tissues
What can have visceral pain?
organs
What is referred pain?
pain comes from a different place than it is felt
What are the types of breakthrough pain?
- incident
- idiopathic
- end of dose medication failure
What can cause psychogenic pain?
depression, dewer endorphins
When should you use skin stimulation, distraction, relaxation, imagery, and elevation?
pain
What medications are most used for pain?
- analgesics (acetaminophen)
- PCA (morphine, delaudid)
What can happen to the urine with urinary calculi?
- frequency/urgency
- hematuria
- oliguria/anuria
How can you catch stones with urinary calculi?
strain the urine
What does shock wave lithotripsy do?
breaks up the kidney stone to help it pass
What does stenting do?
dilates the ureter
What surgeries can be done for urinary calculi?
- uterolithotomy
- pyelolithotomy
- nephrolithotomy
What should be limited with urinary calculi?
- sodium
- calcium
- animal protein
- purine sources
What should be avoided with urinary calculi?
- oxalate sources
- high phosphate foods
What electrolyte imbalances should seizure precautions be implemented for?
- sodium
- hypocalcemia
What electrolyte imbalance should you restrict fluids for?
FVO (hypervolemia)
What electrolyte imbalance should you encourage fluids for?
hyponatremia
How much sodium replacement can be done in 24 hours?
12 mEq
How should calcium gluconate/carbonate be given to someone with hypocalcemia?
as a bolus diluted in dextrose and water
What type of medications are important to avoid with hypocalcemia?
nephrotoxic (vancomycin, NSAIDS)
What electrolyte imbalance causes a positive Chvostek’s and Trousseau’s sign?
hypocalcemia
How can hyperkalemia be treated?
- glucose/insulin
- kayexelate/calcium gluconate
What marks the end of the onset phase of AKI?
the development of oliguria
How long does the onset phase of AKI last?
hours to days
How long does the oliguria phase of AKI last?
1-3 weeks
How long does the diuresis phase of AKI last?
2-6 weeks
How long can the recovery phase of AKI last?
up to 12 months
What are the main manifestations of AKI?
- anemia
- FVO
- hyperkalemia
What electrolyte imbalance shows peaked T waves and a wide QRS on the EKG?
hyperkalemia
What type of AKI has lack of perfusion to the kidney?
prerenal
How is the prerenal type of AKI reversed?
restoration of blood flow
What type of AKI has direct damage to the kidney from lack of oxygen?
intrarenal
What type of AKI is the hardest to reverse?
intrarenal
What type of AKI is the bilateral obstruction of structures leaving the kidney?
postrenal
What type of AKI is the easiest to reverse?
postrenal
What might you feel with postrenal AKI?
- full bladder
- flank pain
Does urine output usually increase or decrease with AKI?
decrease
What are the biggest risk factors for AKI?
- CKD
- HF
What should you watch for with hemodialysis?
- proteinuria
- metabolic acidosis
- oliguria
- dark urine
What is the antidote for anticoagulants?
protamine
What should be put in place to prevent infection from hemodialysis?
- aseptic technique
- standard precautions
What should you avoid doing to the arm with AV access?
compressing (BP, laying on it)
What is important to assess for with AV access?
palpable thrill and audible bruit
What causes disequilibrium syndrome from hemodialysis?
rapid increase in BUN and circulating blood volume
When should you slow the flow rate of hemodialysis?
- hypotension
- disequilibrium syndrome
What should you give for anemia caused by hemodialysis?
erythropoietin and blood products
What are manifestations of end stage renal disease?
- anuria
- proteinuria
- azotemia
- electrolyte imbalances
- FVE (HF, pulmonary edema)
What must match between the donor and recipient during a renal transplant?
tissue
What ages should be considered before having a kidney transplant?
> 70 or < 2
What type of meds will you take for the rest of your life after a kidney transplant and why?
immunosuppressants to prevent rejection
Why should you weight a kidney transplant patient everyday?
to assess for fluid retention
Why are hemodynamics so important after a kidney transplant?
internal bleeding
What might the urine look like after a kidney transplant?
pink tinged, bloody
When does a hyperacute rejection reaction occur after a kidney transplant?
in the first 48 hours
When does an acute rejection reaction occur after a kidney transplant?
1 week to 2 years after
What type of pain is caused by a UTI?
- lower back or abdominal
- urination
What symptoms do older adults have from UTI?
- confusion
- incontinence
- loss of appetite
- hypotension
- tachycardia, tachypnea
When would you experience frequent urination, foul smelling urine, dysuria, feeling of incomplete bladder, hematuria, nocturia, and voiding in small amounts?
with a UTI
Why should you increase fluids with a UTI?
to flush out bacteria
What type of medications should you take for a UTI?
antibiotics
What medication makes your urine orange?
phenazopyridine
How can you relieve UTI discomfort?
- warm sitz baths
- warm ice packs
- heating pads
What should you drink for UTI’s? What should you avoid drinking?
- drink cranberry juice
- avoid caffeinated beverages
What is urosepsis a complication of?
UTI
What is the first sign of urosepsis?
hypotension
What is the different sign with pyelonephritis?
costovertebral tenderness
What gets inflammed with pyelonephritis?
renal pelvis and parenychma
What gets inflammed with glomerulonephritis?
glomerular capillary membrane
What color is urine with glomerulonephritis?
cola colored
What are clinical manifestations of pyelonephritis?
- fever
- chills
- malaise
- flank pain
- urinary frequency
- costovertebral tenderness
What is the most important sign of glomerulonephritis?
HTN
What are clinical manifestations of glomerulonephritis?
- FVE
- HTN
- LOC changes
- anorexia/nausea
- HA
- back pain
- fever
Is there a cure for glomerulonephritis?
no
What is pyelonephritis usually caused by?
E. coli
What should you restrict with glomerulonephritis?
- sodium
- potassium
- fluids
What does a plasmapheresis do?
filters antibodies
What should you watch for after a plasmapheresis?
- hypovolemia
- tetany
- infection
Do you give fluids or diuretics for pyelonephritis?
fluids
Do you give fluids or diuretics for glomerulonephritis?
diuretics
What is a pediatric hyperthermic temperature?
102
What is an adult hyperthermic temperature?
101-106
What vitals increase with hyperthermia?
- temp
- HR
- RR
What antipyretics can be given for hyperthermia?
ibuprofen, tylenol
What can you do for a patient with hyperthermia?
- cool washcloths
- ice
- cooling blanket
- decrease room temp
- remove clothing
What is a pediatric hypothermic temperature?
82
What is an adult hypothermic temperature?
95
What can you do for a patient with hypothermia?
- dry clothing
- warm blankets
- warm fluids
- warming pads
If coma is suspected in a patient with hypothermia, what temperature should be used to rewarm them? How long should it be used for?
104-105 degrees for 20-30 mins
What are patients with hypothermka at risk for?
clots
When can angioedema occur?
anaphylactic shock
What order should meds be given in for anaphylactic shock?
epi, diphenhydramine, corticosteroid (methylprednisolone)
How should hypotension be helped in a patient with anaphylactic shock?
laying flat with legs elevated
What temperature is indicative of SIRS?
> 100.9 or < 96.8
What WBC count is indicative of SIRS?
> 12 or < 4
What causes tachypnea, tachycardia, and a PaCO2 < 32?
SIRS
What can cause SIRS?
- hospitalization
- debilitating chronic illness
- poor nutritional status
- post-invasive surgery
- old age
- immunocompromised
What lab is important to check for SIRS?
lactate
How should fluids and antibiotics be given for a patient with SIRS?
through a central line
What kind of infections are present with sepsis?
septicemia and bacteremia
What clinical manifestation is added when moving from SIRS to sepsis?
hypotension
What lactate level indicates sepsis?
> 2
What HR and RR indicate sepsis?
- HR: >90
- RR: > 20
What happens to CVP with sepsis? What CVP is ideal?
decreased, want 6-8
What happens to SVR with sepsis?
decreased
What happens to cardiac output with sepsis?
increased
What electrolytes decrease with sepsis? Which ones increase?
- decrease: glucose and sodium
- increase: potassium
What should PaCO2 level be with sepsis?
> 80
What does norepi do for sepsis patients?
increases BP
Does dobutamine increase BP?
no
What happens with MODS?
loss of function of 2 or more organs
What organs should be monitored with MODS?
- lungs
- kidney
- heart
- liver
- GI tract
What labs should be monitored for MODS?
- BUN/creatinine
- ABG’s
- ammonia
- BNP
What pH indicates acidosis?
< 7.35
What pH indicates alkalosis?
> 7.45
What is a normal PaCO2?
35-45
What is a normal HCO3?
22-26
What is a normal FiO2?
21-40%
What indicates respiratory acidosis (hypoventilation)?
pH: < 7.35 (low)
PaCO2: > 45 (high)
HCO3: 22-28 (normal)
What indicates respiratory alkalosis (hyperventilation)?
pH: > 7.45 (high)
PaCO2: < 35 (low)
HCO3: 22-28 (normal)
What indicates metabolic acidosis?
pH: < 7.35 (low)
PaCO2: 35-45 (normal)
HCO3: < 22 (low)
What indicates metabolic alkalosis?
pH: > 7.45 (high)
PaCO2: 35-45 (normal)
HCO3: > 26 (high)
What type of pressure is generated when we breathe on our own?
negative
What type of pressure is generated by ventilation, bag, or mouth-to-mouth?
positive pressure
What happens to the pH with right shift?
decreases, acidosis
What happens to the pH with left shift?
increases, alkalosis
What causes right shift?
hyperthermia and increased 2,3 dpg
What causes left shift?
hypothermia and decreased 2,3 dpg
What does 2,3 dpg do?
tells hgb to let go of oxygen
How should right shift be treated?
increasing pressure and giving oxygen
How should left shift be treated?
give 2,3 dpg
What is a pneumothorax?
air in the pleural space causing lung collapse
What happens to the affected side with a pneumothorax?
- decreased movement
- diminished/absent breath sounds
- hyperrresonance
Chest tube insertion with a flutter valve or chest drainage system is the priority intervention for what?
pneumothorax
What type of dressing is used for chest tubes?
petroleum
What causes cyanosis, air hunger, trachial deviation away from the affected side, SQ emphysema, neck vein distention, and hyperresosance to percussion?
tension pneumothorax
What is the treatment for tension pneumothorax?
thoracentesis until chest tube
What is a hemothorax?
blood in the pleural space
What is heard on percussion if a hemothorax is present?
dullness
What is the treatment for hemothorax?
a chest tube with a drainage system, autotransfusion of collected blood, treatment of hypovolemia
What is the fracture of 2+ adjacent ribs in 2+ places with loss of chest wall stability?
flail chest
What type of ventilation is used for flail chest?
- positive pressure (BiPAP, CPAP)
- intubation and mechanical ventilation
Do you want bubbling or tidaling in the chamber of a chest tube?
yes, but not excessive
Does wall suction control the suction applied with a chest tube?
no, the water (wet) and drainage system (dry) control it
What can clamping a chest tube for an extended period of time cause?
tension pneumothorax
When can you clamp a chest tube?
- changing drainage
- checking air leak
What should be done if the chest tube gets disconnected?
put in sterile water until it can be replaced
What should be done if the chest tube gets removed?
cover insertion site with 3 sided dressing
How much blood in the collection chamber of a chest tube indicates notifying the provider?
70-100 ml/hr
Should you ever elevate the drainage system of a chest tube above the heart?
NO
What is the first sign of status asthmaticus?
expiratory wheezing
What is silent chest a really bad sign of?
status asthmaticus
What do you want to keep the RR below for status asthmaticus? What do you want the SaO2 to be greater than?
RR < 30, SaO2 > 90%
What medication should you give first for status asthmaticus?
albuterol
What can lethargy, changes in LOC, agitation and restlessness indicate with status asthmaticus?
cabon dioxide narcosis
What can cause oxygen toxicity?
high FiO2 for a long period of time
What is the classic triad of a PE?
- dyspnea
- chest pain
- hemoptysis (coughing up blood)
What happens to heart sounds with a PE?
accentuation of pulmonic heart sounds
A PE can cause hypoxemia. What can hypoxemia cause?
sudden change in mental staus
How is a PE diagnosed?
spiral CT with contrast
What is the hallmark sign of fat emboli syndrome?
petechial rash to upper chest
What diagnostic can be done for a PE if contrast cannot be used?
V/Q lung scan
What can be done for fat emboli syndrome?
thrombectomy
What meds can be used for PE?
anticoagulants and alteplase
What puts a patient at risk for a PE?
- recent surgery
- immobility
- stroke, DVT
- paralysis
- birth control
- HTN
- smoking
- obesity
How often should PTt and INR be drawn when taking anticoagulants?
q 2 weeks
Why is an embolectomy a last resort for PE?
50% mortality rate
What happens to HR and RR with ARF?
they increase and then decrease below normal limits
Where will crackles be heard with ARDS?
all over the lungs
What oxygen should be used for ARF?
- high flow O2
- intubation/mechanical ventilation
- PEEP
What is the most common cause of ARDS?
sepsis
What is the hallmark sign of ARDS?
incurable hypoxemia
What PaO2/FiO2 ratio happens with ARDS?
< 200
What is a normal PAP? What is a normal PAP for pulmonary HTN?
normal: 12-16
PHTN: < 25
What happens to O2 sat with ARF?
hypercarbic
What does increased workload of the RV cause from pulmonary HTN?
hypertrophy
What does a chest x-ray showing enlarged pulmonary arteries with clear lung fields and an enlarged right heart indicate?
pulmonary HTN
What interventions (meds) should be done for pulmonary HTN?
- diuretics
- anticoagulants
- oxygen
- CCB
- sildenafil
What is cor pulmonale?
enlargement of the RV leading to HF
What is the most common cause of cor pulmonale?
COPD
What heart sound has increased intensity from cor pulmonale?
the second heart sound
What interventions (meds) should be done for cor pulmonale?
- diuretics
- O2
- anticoagulants
- CCB
- sildenafil
What breathing pattern is rapid, deep breathing?
Kussmaul breathing
What breathing pattern is irregular with temporary apnea?
Cheyne-stokes breathing
What breathing pattern is rapid, shallow breathing followed by apnea?
biot breathing
hat breathing pattern is seen near death?
cheyne-stokes
What type of intubation is preferred?
oral because it can be secured rapidly
When should nasal intubation be avoided?
- facial or skull fractures
- cranial surgery
When should you intubate?
- agonal breathing
- RR < 6
- GCS < 8
What medications are used for intubation?
- sedatives (etomidate, propofol)
- paralytics (succinylcholine)
How long should each intubation attempt be?
< 30 seconds
What should you do between each intubation attempt?
ventilate w ambu bag
What color should the ET tube change to with successful intubation?
from purple to yellow
What does tidal volume measure?
the amount of air delivered with each breath
What does FiO2 measure?
% of O2 being delivered
What does PEEP measure?
amount of pressure in the lungs at the end of expiration - helps keep alveoli open
What does PIP measure?
reading on the ventilator showing the greatest airway pressure at the end of the inspiratory cycle
What does assist control (AC) ventilation do?
takes over/controls the work of breathing
When is assist control (AC) ventilation used?
really sick patients because the ventilator does all of the work
What ventilation allows the pt to take spontaneous breaths?
SIMV
What does PSV ventilation do?
maintains a set airway to assist with spontaneous breaths
What is the difference between PSV and CPAP ventilation?
for CPAP you dont have to be intubated
When can you NOT use CPAP ventilation?
COPD
When is BiPAP ventilation used?
COPD
What are ventilation complications?
- trauma
- aspiration pneumonia
- barotrauma - pneumothorax
How long can you suction at a time?
10 seconds
When should suction be discontinued?
- if HR increases by 40 or decreases by 20
- if dysrhythmias occur
- if SpO2 decreased below 90%
How many suction passes can be done at a time?
3
What is a normal PaO2?
80-100
What is a normal SaO2?
92-100%
What does a pan culture assess?
blood, urine, sputum, stool
When is a pan culture done?
hyperthermia
Can you insert chest tubes in a patient with flail chest?
NO
What is the most common ventilation for ARF?
CPAP or BiPAP
What is the biggest sign of ARF?
hypercarbia
Does ARDS or ARF have crackles?
ARDS
