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Nursing Semester 3 > Cyndi - Week 7 - Exam 4 > Flashcards

Cyndi - Week 7 - Exam 4 Flashcards

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1
Q

What does ABCDE stand for?

A 
■ Airway with cervical spine protection
■ Breathing and ventilation
■ Circulation and hemorrhage control
■ Disability and neurological evaluation
■ Exposure and environmental control
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2
Q

what does AMPLE stand for?

A 
■ Allergies
■ Medications
■ Past illness
■ Last meal
■ Events leading to the episode
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3
Q

what are the Trauma Assessment ‐ Emergency Care Priorities?

A
  • Assessment should proceed systematically from head to toe
  • Glasgow Coma Scale – evaluate LOC
  • Bleeding ‐ compression
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4
Q

what are the characteristics of suspected fractures that need immediate evaluation?

A
  • Immobilize, support, and splint above and below affected area
  • Monitor and maintain tissue perfusion
  • PRICES
  • MonitorVS, LOC, O2 status, NV, pain
  • Prevent infection
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5
Q

what does PRICES stand for?

A

Protection, Rest, Ice, Compress, Elevate (but

caution!!), Support

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6
Q

what are the diagnostic tests for MS trauma?

A

Xray
CT
MRI

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7
Q

what are the 3 ways of preventing fractures?

A

Safety (Throw rugs, little dogs - stable leash, good lighting, clear hallways)
• Hip protectors
• Maximize bone density: calcium,Vit D, bone loss prevention meds

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8
Q

how does a patient’s general health affect recovery?

A

• Esp if pt smokes, has vascular disease, orthostatic hypotension, HR problems,
diabetes, cognitive and/or physical limitations, balance problems, continence
issues, poor vision, medications that affect pt safety, etc.
• Living environment
• Family, financial, stairs, clutter, pets, rugs, etc.

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9
Q

what are the 5 different weight bearing statuses?

A
  • Non–weight‐bearing
  • Toe‐touch weight‐bearing
  • Partial–weight‐bearing
  • Weight bearing as tolerated
  • Full–weight‐bearing
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10
Q

T/F: Know the prescribed weight‐bearing status
before getting any fracture or orthopedic
surgery patient out of bed!

A

TRUE

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11
Q

what is a fracture?

A

a disruption or break in bone structure

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12
Q

what are the causes of a fracture?

A 
■ Traumatic injury
– Cause of most fractures
– Watch for blood vessel laceration
■ Pathologic
■ Fatigue (stress)
■ Compression
**Soft tissue and neurovascular injury may also occur
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13
Q

what is the process of bone healing?

A
  • Hematoma phase – 72 H
  • Granulation phase – 14 days
  • Ossification/Callus phase – 3 w‐ 6 months
  • Remodeling phase – 6 mo +
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14
Q

what are the 7 different types of fractures?

A
  • transverse
  • linear
  • oblique, nondisplaced
  • oblique, displaced
  • spiral
  • greenstick
  • comminuted
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15
Q

what are the 4 categories of fractures?

A
  • extent of break
  • displacement
  • closed fracture
  • open fracture
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16
Q

what are the 3 extent of breaks?

A
  • complete
  • incomplete (greenstick)
  • comminuted
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17
Q

what are the two different displacements?

A
  • nondisplaced

displaced

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18
Q

what are the clinical manifestations of fractures?

A
  • Deformity
  • Edema, swelling
  • Ecchymosis
  • Pain, muscle spasm
  • Loss of function – can’t bear weight
  • Decreased sensation distal to injury
  • Open wound
  • Crepitus
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19
Q

what is important to assess with a fracture?

A 
Assess neurovascular status!
• Especially distal to injury
• Compare one side to the other
• Peripheral vascular assessment
• Peripheral neuro assessment
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20
Q

what are the 5 tx for fractures?

A
  • Immobilization, possible ATBs, pain control
  • closed reduction - non surgical
  • open reduction - surgical
  • traction
  • cast
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21
Q

what are the characteristics of closed reduction?

A
  • Stable Fracture

* Requires bedrest and limited activity

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22
Q

what are the characteristics of open reduction?

A
  • Surgical debridement and culture of wound
  • Administer tetanus
  • Stabilize bone
  • Repair visceral injuries
  • May have external fixation
  • Critical to evaluate arterial bleeding
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23
Q

what are the potential complications of fractures?

A
  • Venous thromboembolism
  • Dislocation
  • Compartment Syndrome
  • Infection
  • Fat embolism syndrome
  • Shock
  • Other (• Fracture blisters
  • PosttraumaticArthritis
  • Ischemic necrosis/Avascular Necrosis
  • Delayed union
  • Nonunion
  • Malunion
  • Pseudoarthrosis)
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24
Q

what is compartment syndrome?

A

Pressure within compartment area exceeds the ability to perfuse tissue
• Increased volume ‐ ie: blood, edema, swelling
• External restriction ‐ ie: cast, or muscle

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25
Q

what is cellular ischemia?

A

When pressure in compartment exceeds capillary perfusion

pressure

26
Q

how is compartment syndrome diagnosed?

A

Compartment Pressure Test

27
Q

what are the sxs of compartment syndrome?

A

a cascade of deterioration
• Area already swollen from trauma
• Six P’s
• Treatment not helping
• Neuromuscular status and pain continue to worsen
(Ischemia can occur 4‐8 hours after onset
• 4‐6 hours after onset neuromuscular damage can be irreversible
• Limb useless within 24 to 48 hours)

28
Q

what is the tx for compartment syndrome?

A
  • No elevation or ice !!
  • Surgery (Emergent)
  • Fasciotomy = surgical decompression
29
Q

what are the characteristics of infection?

A

May result from contamination at time of injury or during surgery
• May lead to osteomyelitis
• Any complication decreasing blood supply increases infection risk
• Organisms include Pseudomonas, Staphylococcus, or Clostridium
• ATBs
• Sterile dressing change technique!!

30
Q

what is dislocation?

A

an emergency d/t the potential for vascular necrosis

31
Q

what are the sxs of dislocation?

A

Edema, erythema, discoloration
• Pain
• Limitation of movement
• Deformity or shortening of the extremity

32
Q

what is subluxation?

A

minimal displacement, less severe

33
Q

what is fat embolism syndrome and what are the characteristics?

A

Fat globules from bone get into vascular circulation
• Risk of causing a pulmonary embolism (PE)
• Most likely to occur 24‐48hrs after injury
• Fat cells in urine, blood, sputum, etc

34
Q

what are the risk factors of fat embolism syndrome?

A
  • Large bone fractures
  • Total joint replacements
  • Spinal fusion
  • Liposuction
  • Marrow transplants
35
Q

what are the sxs of fat embolism syndrome?

A

• Can be rapid onset
• CP, tachypnea, cyanosis, dyspnea, anxiety, tachycardia,
hypoxemia, altered LOC, feeling of impending doom
• Same symptoms as VTE caused – PE, without local s/s

36
Q

what are the diagnostics for fat embolism syndrome?

A

ABGs, EKG, CXR, CT chest

37
Q

what is the tx for fat embolism syndrome?

A
  • Greenfield, or IVC, filter
  • Supportive care
  • ABC’s
  • Fluid resuscitation
  • Correction of hypoxia
  • Supplemental oxygen – intubation
38
Q

what are the characteristics of shock?

A 
Bone is very vascular
Trauma can sever the adjacent arteries
• Watch out for those pelvic fractures!!!
• Hemorrhage
• Hypovolemic shock
• Too little circulating blood volume
• Decreased MAP (hypotension)
• Body demand for O2 not met by supply
■ Emergency!
39
Q

what is the purpose of traction?

A
  • Minimize muscle spasms
  • Immobilize fracture and reduce deformity
  • Prevent soft tissue damage
40
Q

what are the different types of traction?

A

• Skin (sling) – short term, like Buck’s (boot)
– **Care of weight – must hang freely
• Skeletal– pin/wire inserted into bone – internal/external
– May be internal for stabilization
– May be external fixation device that needs:
– **Skin inspection, pin site care
• Countertraction – keeps pt stable during traction
Helpful to provide trapeze to help with mobility
**Frequent neurovascular status assessment

41
Q

what is a cast?

A

a temporary circumferential immobilization device

42
Q

what are the characteristics of a cast?

A
  • Protects fracture and limits movement until ossification occurring
  • Encircles area for immobilization
  • Allows for movement of limb
43
Q

what are the NI for a cast?

A 
• Check edges (no sharp areas)
• Circulation distal to cast
• Circulation impairment
• Infection risk
• Compartment syndrome
• Peripheral nerve damage
• Complications of immobility
– Atrophy, incontinence, skin, nutrition deficit
Partial casts, splints, braces
44
Q

what are the risk factors/causes of hip fractures?

A
  • Osteoporosis
  • Minor trauma
  • Direct trauma
  • Falls
45
Q

what are the sxs of hip fractures?

A
  • Discoloration
  • Lack of voluntary control
  • External rotation, shortened leg
  • Muscle spasms, severe pain
46
Q

what are the diagnostic tests for hip fractures?

A
  • X‐ray, CT scan, MRI

* Labs – UA, CBC, H&H, platelets, PT, PTT

47
Q

what is the tx for hip fracture?

A

Stabilization prior to surgery
• Pain control
• Is pt on blood thinners?
• Monitor neurovascular status distal to break

48
Q

what are the common location?

A

intracapsular fracture
intertrochanteric fx
subtrochantaric fx

49
Q

what are the characteristics of surgery for hip fx?

A

Surgery – educate, consent,ATBs
• Anterior vs posterior approach for hip replacements
• May have more activity restrictions with posterior

50
Q

what are the characteristics of post op collaborative care?

A
  • Physical therapy
  • Mobilize, trapeze on bed, safety
  • Teach precautions if indicated
  • Weight bearing status – important to know!
51
Q

what is the post op nursing care for hip fx?

A
  • Wound and drain assessment – monitor distal leg CMS
  • IS – mouth care‐ turn every 2 hours – maintain alignment
  • DVT prophylaxis
  • Pain meds/ATBs
  • Sterile dressing changes
  • Assess discharge, education, home care needs
52
Q

what are the complications of post op hip fx?

A 
Complications – many!
• Nonunion – Avascular necrosis due to disruption of circulation
• Pneumonia/ atelectasis
• Decreased circulation to affected limb
• Infection
• Dislocation
• Skin breakdown/ poor wound healing
• Nutrition deficits
• Constipation (opiates, immobility)
53
Q

what is “pinning”?

A 
“ORIF
= Open Reduction Internal Fixation”
• No abductor pillow
• Non
‐weight bearing
• No total hip precautions
54
Q

what is posterior approach replacement?

A
  • Abductor pillow
  • Able to weight bear
  • Danger of dislocation
  • Total hip precautions
55
Q

what is the goal of a total knee replacement?

A

to restore motion of the joint, to relieve pain, or to correct
deformity

56
Q

what is the post op care for a TKR?

A
  • Pain management
  • Trapeze, CPM machine – flexion, extension
  • Neuro checks, CMS distal,VS
  • Promote respiratory function
  • Up with PT until cleared for nursing to mobilize
  • Sterile dressing change (surgeon does first one)
  • Diet as ordered
57
Q

what re the indications for amputation?

A
  • Peripheral vascular disease ‐Atherosclerosis
  • Vascular changes due to diabetes
  • Malignant tumors, congenital deformities, infections
  • Trauma (accident, MVA, war, terrorism)
58
Q

what are the NI for amputation?

A

Preoperatively educate pt on reason, plan, pain
Psychological implications
Phantom Limb Pain
• Frequently occurs
• Intense, burning, crushing, cramping, or feels like it is in a weird position
• Mirror therapy
• Pain interventions – it is still medicated!

59
Q

what is the tx for amputation?

A

Goal of amputation to remove damaged tissue, preserve function and length
• Disarticulation removes at joint
• Open (called “guillotine”)
• Closed (has flap)
• Level of limb determined by many factors
***Goals for surgery after a traumatic amputation – repair, clean, close

60
Q

what is the post op care for amputation?

A

• Elevate to prevent edema; change position to prevent contractures – prone
• Compression bandage (stump care)
• Educate regarding plan for prosthetic device if used
• When is it going to be fit/placed?
– Healing of area necessary with reduced swelling for a good fit
• Using prosthetic takes a great deal of energy
• Pain, including phantom pain
• Mobilize – ROM, strengthening safety
• Monitor for complications such as infection, poor healing

Nursing Semester 3 (29 decks)

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