Exam 1 Flashcards
advanced practice registered nurse
a nurse educated at the master’s or doctoral level, with advanced education in pathophysiology, pharmacology, and health assessment and expertise in a specialized area of practice
case management
a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes
telehealth nursing
the delivery of health care and information through telecommunication technologies, including high-speed Internet, wireless, satellite, and video communications.
critical thinking
your ability to focus your thinking to get the results you need in various situations, has been described as knowing how to learn, be creative, generate ideas, make decisions, and solve problems
clinical reasoning
using critical thinking to examine and analyze patient care issues
interprofessional team
made up of providers from various disciplines, working together and sharing their expertise to provide customized care
clinical pathways
interprofessional care plans that outline the care and desired outcomes for a specific time period for patients with a specific diagnosis
delegation
allows a care provider to perform specific nursing activity, skill, or procedure that is beyond their usual role
serious reportable event (SRE)
to describe serious, largely preventable, and harmful clinical events
electronic health record (EHR)
a computerized record of patient information
not interoperable
single-time use
evidence-based practice (EBP)
a problem-solving approach to clinical decision making
uses the best available evidence combined with the nurse’s expertise to make the best decisions for the client
determinants of health
influence the health of individuals and groups
help explain why some people experience poorer health than others
health status
a holistic concept that is more than the presence or absence of disease
health disparities
differences in the incidence, prevalence, mortality rate, and burden of diseases that exist among specific population groups
a time period, location, quantification on a topic that has a gap, need, concern
health equity
when every person has the opportunity to attain his or her health potential, and no one is disadvantaged
culture
a way of life for a group of people
values
the set of rules by which persons, families, groups, and communities live
acculturation
the lifelong process of incorporating cultural aspects of the contexts in which a person grows, lives, works, and ages
stereotyping
an overgeneralized viewpoint that members of a specific culture, race, or ethnic group are alike and share the same values and beliefs
ethnocentrism
the belief that one’s own culture and worldview are superior to those of others from different cultural, ethnic, or racial backgrounds
transcultural nursing
a specialty that focuses on the comparative study and analysis of cultures and subcultures
cultural competence
the ability to understand, appreciate, and work with people from cultures other than your own
culture-bound syndromes
illnesses or afflictions that are recognized only within a cultural group
teaching plan
assessment of the patient’s ability and readiness to learn
identification of teaching needs
development of learning goals with the patient
implementation of the teaching
evaluation of the patient’s learning
teaching
a complex process intended to facilitate learning
learning
the act of a person acquiring knowledge, skills, or attitudes that may result in a permanent change
motivational interviewing
nonconfrontational interpersonal communication techniques to motivate patients to change behavior
self-efficacy
the belief that one can succeed in a given situation
caregivers
people who care for those who cannot care for themselves
health literacy
the degree to which a person can obtain and understand basic health information needed to make appropriate decisions
learning needs
the new knowledge and skills that a person must have to meet a goal
how does a nurse help?
physical
psychological
support, safety, situational awareness, sex
spirituality, specialty
encourage
health history
nursing process
assessment
diagnose
plan
intervention
evaluate
SBAR
situation
background
assessment
recommendation
what do we do for culturally competent care?
know culture norms
ask about cultural values
same gender preference
what do we not do for culturally competent care?
stereotype
ethnocentrism
cultural imposition
what are some national patient safety goals
identify patients correctly
get important test results to the right staff person on time
use medicines safely
prevent infection with handwashing
prevent mistakes in surgery
what does the joint commission do?
monitor hospitals to make sure they are performing patient safety goals
what is part of the nursing assessment?
patient’s health history
physical examination
identify patient’s current and past health status
provide baseline for further evaluation
formulate nursing priority problem
what is subjective data?
important health information
health history
medications
allergies
surgery or other treatments
functional health patterns
what are the functional health patterns needed for the assessment?
health perception-health management
nutritional-metabolic
elimination
activity-exercise
sleep-rest
cognitive-perceptual
self-perception–self-concept
role-relationship
sexuality-reproductive
coping-stress
value-belief
what do you collect for patient-reported symptoms?
pain
quality
radiation
severity
time
unilateral
what is objective data?
general survey
physical examination
what is the proper sequence for physical examination?
inspection
palpation
percussion
auscultation
what are the types of assessments?
emergency
comprehensive
focused
learning
surgery
the art and science of treating diseases, injuries, and deformities by operation and instrumentation
malignant hyperthermia (MH)
rare disorder characterized by hyperthermia with skeletal muscle rigidity
life-threatening complication that occurs during general anesthesia
airway obstruction
the patient’s tongue blocking the airway
atelectasis
alveolar collapse
may be the result of bronchial obstruction caused by retained secretions, decreased respiratory excursion, or general anesthesia
emergence delirium
a short-term neurologic change manifested by behaviors such as restlessness, agitation, disorientation, thrashing, and shouting
delayed emergence
problem after surgery
patient-controlled analgesia (PCA)
allows the self-administration of predetermined doses of analgesia and maintain an acceptable level of pain control
postoperative ileus (POI)
the temporary impairment of gastric and bowel motility after surgery
characterized by bowel distention, lack of bowel sounds, accumulation of GI gas and fluid, and delayed passage of flatus and stool
what is surgery used for?
diagnosis
cure
palliation
prevention
cosmetic
exploration
what are the surgical settings?
elective
emergency
inpatient
ambulatory
elective surgery
planned, cosmetic
emergency surgery
not planned, cancer
ambulatory surgery
same day, outpatient
what is the nurse’s role in preop
have knowledge of the nature of the disorder requiring surgery and co-morbidities
identify the individual patient’s response to the stress of surgery
have knowledge of the results of preoperative diagnostic tests
identify potential risks and complications associated with surgery
speak with patient regarding feelings of surgery “tell me more…”
what kind of diagnostic tests do you perform for preop?
any change is significant, you want baseline information
type and screen
urinalysis
what can patient anxiety do?
impair cognition, decision making, and coping abilities
influence vital signs
where does patient anxiety come from?
lack of knowledge
unrealistic expectations
conflict with interventions and religious/cultural beliefs
what are patient’s fears?
death/disability
pain and discomfort
mutilation/alteration in body image
disruption of life functioning
what is the purpose of the patient interview?
obtain health information, including drug and food allergies
provide and clarify information about the surgery and anesthesia
assess emotional state and readiness
determine expectations
what are the nursing assessment goals?
establish baseline data to compare
determine psychologic status to reinforce coping strategies
determine physiologic factors of procedure contributing to risks
identify and document surgical site
identify drugs, OTC, medications, and herbs taken that may affect surgical outcome
review results of preoperative diagnostic studies
identify cultural and ethnic factors that may affect surgical experience
determine if patient received adequate information from surgeon to sign informed consent; if not, RN notifies surgeon
determine that consent form is signed and witnessed
why do we need to know drugs taken?
can affect postoperative care
vitamin E, saw palmetto, ginko biloba, and blood thinners affect clotting time
why do we perform a nursing assessment?
to communicate all concerns to surgical team
what is the psychosocial assessment?
excessive stress response can be magnified and affect recovery
what are the influencing factors of the psychosocial assessment?
age
past experiences
current health
socioeconomic status
what is included in the past health history of the nursing assessment in preop?
diagnosed medical conditions
previous surgeries and problems
menstrual/obstetric history
familial diseases
reactions/problems to anesthesia (patient and family)
addictions
allergies
WE NEED TO KNOW EVERYTHING
what kind of medications do we need to know about in the preop?
prescription
OTC
herbs
dietary supplements/vitamins
antiplatelets/NSAIDs
recreational
drug intolerances and allergies
why do we need to review the body systems?
confirms the presence or absence of diseases
alerts to area to closely examine
provide essential data to determine specific preoperative tests
cardiovascular system assessment
note cardiac problems, so they can be monitored
use of cardiac drugs
presence of pacemaker or ICD
what are some cardiac problems a patient might have?
hypertension
angina
dysrhythmias
heart failure
myocardial infraction
hypovolemic
deep vein thrombosis
why do we need to know if they have a pacemaker?
need to know how it works
respiratory system assessment
inquire about recent or chronic respiratory disease
respiratory infections
history of dyspnea, coughing, or hemoptysis reported to operative team
COPD or asthma
encourage smokers to stop smoking at least 6 weeks before surgery
sleep apnea, obesity, and airway deformities affect respiratory function
why do we need to know if the patient has COPD or asthma?
they are high risk for atelectasis and hypoxemia
nervous system assessment
evaluation of neurologic functioning
vision or hearing loss
cognitive deficits can affect informed consent and cause adverse outcomes during and after surgery
genitourinary system assessment
history of renal and urinary tract diseases
what is renal dysfunction is associated with?
fluid and electrolyte imbalances
increased risk of infection
impaired wound healing
altered response to drugs and their elimination
hepatic system assessment
liver detoxifies many anesthetics and adjunctive drugs
hepatic dysfunction may increase risk of perioperative complications (alcoholics)
why is the liver so important?
it is a filter system
impaired liver=impaired clearances
musculoskeletal system assessment
identify joints affected with arthritis
mobility restrictions may affect positioning and ambulation
report problems affecting neck or lumbar spine to ACP
why is the supine and left lateral position good?
can affect airway management and anesthesia
integumentary system assessment
history of pressure injuries
body art such as tattoos, piercing (remove)
why is the history of pressure injuries important to know in the integumentary system assessment?
may need extra padding procedure during procedures
affects postoperative healing
immune system assessment
compromised immune system or use of immunosuppressive drugs can have
delayed wound healing and increased risk for infection
immunosuppressive drugs may need to be tapered before surgery
endocrine system assessment
patient with diabetes
patient with thyroid dysfunction
patients with Addison’s disease
fluid and electrolyte status assessment
vomiting, diarrhea, or preoperative bowel preps can cause imbalances
identify drugs that change F and E status, such as diuretics
evaluate serum electrolyte levels
NPO status
why do we add place an NPO status?
used to prevent vomiting and potential sx complications
nutritional status assessment
deficits include undernutrition and overnutrition
obesity
why is it important to know if the patient under nourished in the nutritional assessment?
need to provide extra padding to underweight patients to prevent pressure ulcers
may be protein and vitamin deficient
identify dietary habits that may affect recovery
why is it important to know if the patient is obese in the nutritional assessment?
stresses cardiac and pulmonary systems
increased risk of wound dehiscence, evisceration, infection, and incisional hernia
slower recovery from anesthesia
slower wound healing
Why do we have to do an examination as part of the nursing assessment?
the joint commission (TJC) requires a history and physical
findings enable ACP to rate patient for anesthesia administration
indicator of perioperative risk and overall outcome
what do you do for the exam in the nursing assessment?
complete a physical examination
document relevant findings and share with the perioperative team
obtain and evaluate results of laboratory tests
monitor blood glucose for patients with diabetes
what is the preoperative teaching for post-op information?
deep breathing, coughing
incentive spirometer
SCDs
inform if tubes, drains, monitoring devices, or special equipment will be used postoperatively
early ambulation as appropriate
diet
what are SCDs?
compression sleeves to promote circulation
what is ambulatory surgery information?
basic information before arrival
what is the basic information before arrival in the OR?
NPO after midnight
time and place
what to wear and bring
responsible adult needed
ride home
fluid and food restrictions
what is the legal preparation you have prepare in nursing management in preop?
check that all required forms are signed and in chart
legally appointed representative of family may consent if patient is minor, unconscious, or mentally incompetent
emancipated minor is younger than legal age but able to provide legal consent
what are the required signed forms you need in preop?
informed consent
blood transfusions
advance directives
power of attorney
what must you have before you enter to OR?
consent
preop checklist
IV antibiotics
what must be included for informed consent?
adequate disclosure (diagnosis, purpose, risk, consequences, probability of outcome, benefits, prognosis if not done)
clear understanding by patient
voluntarily given consent
permission may be withdrawn at any time
What are the roles involved in the consent process?
surgeon is ultimately responsible for obtaining consent
nurse can witness signature
what is done day of surgery preparation?
final preoperative teaching
assessment and communication of pertinent findings
verification of signed consent/forms
laboratory and diagnostic results
consultations done
baseline vitals
valuables are returned to family member or locked up
dentures, contact, glasses, prostheses are removed
proper skin preparation
nursing notes
surgical site identification
hospital gown
identification and allergy bands on wrist
void before surgery
patient should not wear any cosmetics
observation of skin color is important
remove nail polish for pulse oximeter
preop checklist completed
how do people’s blood type change?
radiation
bone marrow transparent
major amount of blood transfusion done
what are some preoperative medications (that are sometimes ordered)?
benzodiazepines
anticholinergics
opioids
antiemetics
antibiotics
beta blockers
insulin
eyedrops
how do you transport to the OR?
via stretcher or wheel chair
caregivers directed to holding areas with patient initially then waiting room
hand-off communication
SBAR!
what are some special concerns in the preop phase?
culturally competent care
geriatric considerations
what are some culturally competent care concerns in the preop stage?
patient’s expression of pain
family expectations
ability to verbally express needs
decision-making
what is special about a patient being in Jehovah’s Witness?
no blood transfusions
ask open ended questions to get answers
what is intraoperative care?
historically took place in the OR
many done as ambulatory surgery
what is considered minimally invasive surgery (MIS)?
endoscopes
robotics
other advanced technology
what are the physical environments of intraoperative care?
surgical suite
holding area
operating room
what is the surgical suite?
controlled environment
designed to minimize spread of pathogens
allows smooth flow of patients, staff, and equipment to give safe surgical patient care
what are the three zones in the surgical suite?
unrestricted
semi restricted
restricted
what are the unrestricted areas in intraoperative care?
holding area
locker room
nurses station
what are the semi restricted areas in preoperative care?
support area
corridor
surgical staff
what are restricted areas in intraoperative care?
masks worn
minimal traffic
includes OR
what is the holding area in intraoperative care?
unrestricted zone
final identification and assessment
friends/family allowed
when patient is taken to OR, family/friends will be asked to wait in the waiting room and the surgeon will be out when done to update on patient status
what is the admission, observation, and discharge area in intraoperative?
early morning admissions
- outpatient surgery
- same-day admission
- inpatient holding
what is the operating room?
restricted zone
- geographically, environmentally, and aseptically controlled
preferred location is next to PACU and surgical ICU
what is a preoperative nurse?
registered nurse
what are the 3 domains of the perioperative nurse?
pre-op RN
OR RN
PACU RN
what are the goals of periop RN?
patient advocacy
safety, dignity, confidentiality
communication with patient, team, and other HCP
nursing care
what does the circulating nurse do?
nonsterile
prepares room
supplies and equipment available and checked
monitors hcp practices
conducts pre-procedure verification (TIME OUT)
assesses patient
confirms and implements facility and safety protocols
records intraoperative care
coordinates activites
sponge count (2 RNs needed)
report to PACU RN
“runner”
calls family
gets blankets
what does scrub nurse do?
sterile
prepares room
maintains sterility during procedure
prepares instruments and equipment for surgery
conducts pre-procedure verification (TIME OUT)
assists surgeon during procedure
accepts, verifies and reports drugs used during procedure
sponge count (2 RNS needed)
what does nursing management look like in intraoperative care?
initial greeting
proper identification
human contact and warmth
reassessment
last-minute question
final questioning about valuables, prostheses, last intake of food/fluid
confirm correct preoperative drugs given
cover patient’s hair
keep patient warm
what does nursing management look like in intraoperative care? PART 2
accessibility of operative site
administering and monitoring of anesthetic agents
maintaining patient airway
provide correct musculoskeletal alignment
prevent pressure on nerves, skin over bony prominences, earlobes, eyes
provide for adequate thoracic excursion
prevent occlusion of arteries and veins
provide modesty in exposure
recognize and respect needs such as pain or deformities
what does nursing management look like after surgery (still in intraoperative care)?
ACP anticipates end of procedure
what does ACP want at end of procedure in intraoperative care?
gives proper types and doses of anesthetic agents so that effects will be minimal at end of surgery
ACP goes with patient to PACU
what is in the hand-off report after surgery?
patient’s status
procedure done
medications
fluids given
what are the safety considerations of intraoperative care?
communication
surgical care improvement project (SCIP)
time out
what is the surgical care improvement project? (SCIP)
prophylactic ATP started within 30-60 minutes of Sx
warm blanket to prevent hypothermia
intermittent pneumatic compression device to minimize risk for VTE
what is time out?
verification
consent
documentation
what is general anesthesia?
loss of sensation with loss of consciousness
hypnosis, analgesia, amnesia
skeletal muscled relation
requires an advanced airway
what is local anesthesia?
loss of sensation to one specific area without loss consciousness
what is regional anesthesia?
loss of sensation to a region of the body
no loss of consciousness
involves blocking a specific nerve group
what is the postoperative period?
begins immediately after surgery
initial recovery period in PACU
where is the postoperative period taken place?
PACU
right next to OR, limited transportation
gives ready access to anesthesia and OR staff
what is the nursing care focus in the postoperative period?
maintain patient safety
identify actual and potential patient problems
frequent assessment and monitoring is required
ECG and more intense monitoring required
what is in the PACU admission report?
general information
patient history
intraoperative management (anesthesia, meds, blood loss, fluids, urine)
intraoperative course (unexpected events during procedure, VS trend, lab tests during procedure)
What is the “A” of the ABC of the postoperative assessment?
airway
oxygenation and ventilation can be affected by residual neuromuscular blockade, use of opioids, and patient characteristics such as sleep-disordered breathing (e.g. central or obstructive sleep apnea (OSA), abnormal airway anatomy)
patency
artificial airway
what is the “B” in the postoperative assessment?
breathing
RR and quality
breath sounds
supplemental oxygen
pulse oximetry and capnography
what is the “C” in the postoperative assessment?
circulation
ECG monitoring
vital signs
peripheral pulses
capillary refill
skin color and temperature
what is part of the neurologic postop assessment?
LOC/glasglow coma scale
orientation
sensory and motor status
pupil size, equality and reaction
what is the glasglow coma scale?
3 is dead
15 is fine
why do we assess the sensory and motor status in post op?
hearing is the first sense to return, so be sure to explain all activities to the patient
what is part of the genitourinary postop assessment?
intake
output
estimated blood loss
what is part of the gastrointestinal postop assessment?
bowel sounds (check prior to eating)
NG– verify placement to suction or clamped
nausea
what is part of the surgical postop assessment?
dressing… check for drainage or swelling under the badge
what is part of the pain postop assessment?
incisional
see if patient can use PCA
what is part of the lab and diagnostic postop assessment?
review results of ordered exam
what are some respiratory postop complications and how do you check them?
airway obstruction (check airway)
hypoxemia
aspiration (listen for cough when swallowing)
bronchospasm (assess lungs)
hypoventilation (check pulse ox or capnography)
what could cause hypoxemia and how do you check for it?
atelectasis (incentive spirometer, cough, deep breath)
pulmonary edema (assess lungs)
what are some nursing interventions to prevent respiratory complications in postop?
proper patient positioning (lateral to supine)
oxygen therapy
coughing and deep breathing
incentive spirometer
sustained maximal inspirations
change patient position every 1-2 hours
early mobilization
pain management
adequate hydration
chest physical therapy
what are some fluid and electrolyte postop complications?
fluid overload
fluid deficit
electrolyte imbalances
acid-base imbalances
what would hypokalemia affect?
contractility of the heart
decreased cardiac output
tissue perfussion
when would acid-base imbalances be seen?
patients who have irregular breathing patterns or respiratory depression
what are some cardiovascular postop complications and what causes them?
hypotension (hypoperfusion to vital organs; unreplaced fluid and blood loss)
hypertension (pain, anxiety, bladder distention, respiratory distress, hypothermia)
dysrhythmias (hypoxemia, hypercapnia, electrolyte and acid-base imbalances, circulatory instability, hypothermia, pain, surgical stress, many anesthetics, and preexisting heart disease)
VTE (inactivity, body position, and pressure)
syncope (decreased cardiac output, fluid deficits, or defects in cerebral perfusion)
what are some vital signs you can look for to prevent cardiovascular complications in postop?
Q15
compare
what do you do if a patient has hypotension in postop cardiovascular complications?
continued observation if everything is normal
immediate treatment is pulse is weak/rapid, pale skin
assess surgical site for excessive loss of bleeding
what can you do for BP in cardiovascular complications in postop?
IV fluid boluses
pain medication
BP meds
monitor orthos as you increase mobility
what are some nursing interventions to prevent postop cardiovascular complications?
continuous ECG monitoring
adequate fluid replacement
assess surgical site for bleeding
intake and output
monitor laboratory results
VTE prophylaxis
slow changes in the body
early ambulation
what are some neurologic/psychologic postop complications?
emergence delirium
delayed emergence
postop cognitive dysfunction
anxiety/depression
alcohol withdrawal delirium
emergence delirium
restlessness
disorientation
thrashing
agitation
delayed emergence
failure to regain consciousness 30-60 minutes after surgery
postop cognitive dysfunction
memory loss
inability to concentrate for weeks and months
anxiety/depression
grieving for a lost body part or function
increased likelihood of complications
alcohol withdrawal delirium
restlessness
insomnia
nightmare
irritability
auditory/visual hallucinations
what are some nursing interventions to prevent neuropsychologic complications?
monitor O2 levels with pulse ox
oxygen therapy
pain management
reversal agents (phase I)
assess for anxiety and depression
alcohol protocols
safety
fluid/electrolyte balance
nutrition
sleep
listening
what are some postoperative complications involving temperature?
hypothermia
shivering
fever
malignant hyperthermia
hypothermia
less than 96.8F
contributing factors: skin exposure during the surgical procedure, use of cold irritants, d skin preparations, un-warmed inhaled gases
shivering
can increase resting energy expenditure and oxygen consumption, CO2 production
fever
infection?
what kind?
why would there by a fever within 12 hours postop?
hypothermia r/t anesthesia
body heat loss
why would there be a fever in the first 48 hours postop?
hyperthermia r/t inflammation response to surgical stress
lung congestion
dehydration
why would there be a fever after 48 hours postop?
hyperthermia r/t infection
what are come nursing interventions to prevent hypothermia and fever?
passive warming
active warming
oxygen therapy
opioids
meticulous asepsis
airway clearance… coughing/deep breathing
dantrolene (dantrium) for MH
what are some gastrointestinal postop complications?
absent bowel sounds
nausea/vomiting postop (PONV)
constipation
postoperative ileus
hiccups
constipation risk factors
use of opioids/meds
change in diet and fluid intake
immobility
hiccups
phrenic nerve irritated after sx by gastric distention or intestinal obstruction
what are some nursing interventions to prevent GI complications?
PONV
adequate hydration
assess bowel sounds
check for flatulence
early mobilization
PONV
NPO, IV fluids, clear liquids
anti emetics
prokinetics
alternative therapy
what are some urinary postop complications?
retention
oliguria
anuria
catheter-associated UTI (CAUTI)
retention measurement
800-1500 mL in 24 hours
oliguria measurement
<400 mL in 24 hours
anuria measurement
<100 mL in 24 hours
average urine output
0.5 mg/kg/hour
what are some nursing interventions to prevent urinary complications?
monitor urine output
adequate hydration
normal positioning for elimination
no void? palpate bladder
bladder scan/straight cath per orders
remove urinary catheter when no longer indicated
surgical site infection (SSI)
contamination of the wound from the following:
exogenous flora (environment and skin)
oral flora (usu to lungs)
intestinal flora
who is at high risk for SSIs?
immunosuppressed, malnourished, older traumatic injury, bowel sx, accumulation of fluid in the wound, diabetes, colitis, alcoholism
what are the signs of SSIs?
local redness, swelling, and increase in pain
systemic fever and leukocytosis
wound descence
surgical incision reopens either internally or externally
it tends to happen most often within 2 weeks of surgery and following abdominal or cardiothoracic procedures
notify surgeon
wound evisceration
surgical incision opens (dehiscence) and the abdominal organs then protruded or come out of the incision (evisceration)
cover the wound with a saline soaked gauze and notify surgeon
what is discharge like from PACU?
patient awake (or neurologically at baseline)
vital signs at baseline or stable
no excess bleeding or drainage (>50 mL/15 minutes)
no respiratory depression
oxygen saturation >92%
pain managed
nausea and vomiting controlled
patient safe to discharge
SBAR report give to nurse or instructions given to patient if discharged
when back on hospital unit, encourage c, db, is, ambulate, medicate before getting OOB for the first time, check bowel sounds before eating or drinking
what is the ambulatory surgery discharge criteria?
all PACU discharge criteria met
no IV opioids in past 30 minutes
able to tolerate fluids
voided
able to ambulate, if not contraindicated
responsible adult present to drive patient home
written discharge instructions given and understood
what is the ambulatory surgery discharge teaching?
provided patient and caregiver
specific to type of surgery and anesthesia used
care of incision(s) and dressings
actions and side effects of any medications
activities allowed and prohibited
dietary restrictions and modifications
symptoms that should be reported
where and when to return for follow-up care
reasons to seek after discharge
answers to questions
what are the common reasons to seek help after discharge in postop?
unrelieved pain
questions about medications
wound damage and/or bleeding
increased drainage from a drainage device
fever >100F
what are some gerontologic considerations in the postop patient?
decreased respiratory function
altered vascular function
drug toxicity… slows elimination of drugs
mental status changes… anesthesia concerns
pain control
sprain
an injury to the ligaments surrounding a joint
strain
an excessive stretching of a muscle and its fascial sheath, often involving the tendon
dislocation
the complete displacement or separation of the articular surfaces of the joint
subluxation
a partial or incomplete displacement of the joint surface
repetitive strain injury (RSI)
injuries resulting from prolonged force or repetitive movements and awkward postures
carpal tunnel syndrome (CTS)
caused by compression of the median nerve, which enters the hand at the wrist through the narrow carpel tunnel
phantom limb sensation
amputated limb may feel like it is still present after surgery
synovectomy
removal of synovial membrane
osteomy
removing a wedge or slice of a bone to restore alignment (joint and vertebral) and to shift weight bearing, thus relieving pain
debridement
the removal of debris, such as pieces of bone or cartilage (loose bodies) or osteophytes, from a joint using a fiberoptic arthroscope
arthroplasty
the reconstruction or replacement of a joint to relieve pain, improve or maintain ROM, and correct deformity
osteomyelitis
a severe infection of the bone, bone marrow, and surrounding soft tissue
osteochondroma
the most common primary benign bone tumor
sarcoma
a malignant tumor that develops in bone, muscle, fat, nerve, or cartilage
osteosarcoma
an extremely aggressive primary bone cancer that rapidly spreads to distant sites
what is the structure of musculoskeletal system?
voluntary muscle
connective tissue
what are the different types of connective tissue in the musculoskeletal system?
bone
cartilage
ligaments
tendons
fascia
bursae
what are the purposes of the musculoskeletal system?
protect body organs
provide support and stability
store minerals
allow coordinated movement
what is the microscopic structure of the musculoskeletal system?
cortical bone
cancellous bone
what are the components of cortical bone?
compact and dense
osteons
lamellae
canaliculi
what are the component of the cancellous bone?
spongy
red or yellow bone marrow
what are the three types of cells found in bones?
osteoblasts
osteocytes
osteoclasts
osteoblasts
bone-forming cells
osteocytes
mature bone cells
osteoclasts
breakdown bone tissue
what is the bone remodeling process?
removal of old bone by osteoclasts
deposit of new bone by osteoblasts
what is the anatomy of a long bone?
epiphysis
diaphysis
metaphysis
epiphyseal plate
periosteum
what are the different bone types?
long
short
flat
irregular
what is the joint?
ends of 2 bones are close in proximity and move in relation to each other
what is the capsule
encloses joint in fibrous connective tissue (synovial membrane and fluid)
what is diarthrodial?
most common
what are the different types of cartilage?
hyaline
elastic
fibrous
what are the functions of cartilage?
support
articulation
protection
growth
what are the layers of muscle?
epimysium
perimysium
endomysium
what is the neuromuscular junction?
motor endplate
myoneural or neuromuscular junction
presynaptic neurons release acetylcholine
sarcoplasmic reticulum releases calcium which triggers contraction of myofibrils
tetany can occur in low calcium
what is the energy source of muscles?
ATP
tendons
attach muscles to bones
ligaments
attach bones to bones
fascia
layers of connective tissue that provide strength to muscles
bursae
small sacs of connective tissue found at bony prominences or joints to relieve pressure and decrease friction
bursitis
inflammation of bursa sac
what are the gerontologic considerations effects of aging on MS system?
functional problems
decreased bone density
decreased muscle mass and strength
decreased flexibility
increased risk for osteoarthritis
risk for falls
what is the subjective data of the musculoskeletal assessment?
past health history
medications
surgery or other treatments
functional health patterns
what is the objective data of the musculoskeletal assessment?
physical examination
motion
use of assistive devices
posture and gait
straight-leg raises
what is the normal physical assessment of the musculoskeletal system?
normal spinal curvatures
no muscle atrophy or asymmetry
no joint swelling, deformity, or crepitation
no tenderness on palpation of spine, joints, or muscles
full ROM of all joints without pain or laxity
muscle strength of 5/5
serologic studies of musculoskeletal system
aldolase
alkaline phosphatase
anti-cyclic citrullinated peptide (anti-CCP)
anti-DNA antibody
antinuclear antibody (ANA)
calcium
C-reactive protein
creatine kinase
human leukocyte antigen
potassium
phosphorus
rheumatoid factor
diagnostic studies of musculoskeletal system
standard x-ray
bone scan
computed tomography (CT) scan
diskogram
dual energy x-ray absorptiometry (DEXA)
electromyogram (EMG)
MRI
myelogram with or without CT
somatosensory evoked potential (SSEP)
thermography
quantitative ultrasound (QUS)
interventional studies
arthrocentesis
arthroscopy
pathophysiology of osteomyelitis
most common microorganism is s. aureus
what is the process of osteomyelitis
healthy intact bone is resistant to infection
the bone becomes susceptible to disease with the introduction of a large inoculum of bacteria, from trauma, ischemia, or the presence of foreign bodies because bone sites to which microorganisms can bind are exposed
what are the risk factors of osteomyelitis?
older age
debilitation
hemodialysis
sickle cell disease
IV drug use
where are the direct entry sites for osteomyelitis?
open wound
foreign body presence
diabetic or vascular ulcers or pressure injuries
generally multiple organisms
what is the process of osteomyelitis?
microorganisms enter blood
increase pressure in bone
infection spreads
dead bone leaves
new bone is formed
sequestrum
WBCs and antibiotics can’t reach through the blood
becomes a reservoir for microorganisms that can spread to other sits
if not resolved or surgically debrided, a nus tract may develop with chronic, purulent cutaneous drainage
acute osteomyelitis
initial infection or infection <1 month in duration
what are the local manifestations of acute myelitis?
constant pain that worsens with activity
unrelieved by rest
swelling
warmth
restricted movement
what are the systemic manifestations of acute osteomyelitis?
fever
night sweats
chills
restlessness
nausea
malaise
drainage (late)
chronic osteomyelitis
infection lasting longer than 1 month or has failed to respond to initial antibiotic treatment
continuous and persistent or process of exacerbations and remissions
systemic manifestations reduced
what are the local signs of infection with chronic osteomyelitis?
pain
swelling
warmth
granulation tissue turns to avascular scar tissue which is an ideal site for microorganism growth because it cannot be penetrated by antibiotics
what are the complications of chronic osteomyelitis?
septicemia
septic arthritis
pathologic fractures
what are the priority problems with osteomyelitis?
acute pain
impaired mobility
lack of knowledge
what are the overall goals of osteomyelitis?
have satisfactory pain and fever management
no complications associated osteomyelitis
adhere to treatment plan
maintain a positive outlook on outcome of disease
diagnostic studies of osteomyelitis
bone or soft tissue biopsy
blood/wound cultures
WBC count
erythrocyte sedimentation rate (coagulants)
c reactive protein
x-rays/MR/CT scans
bone scans
radionuclide WBC scan
interprofessional care with acute osteomyelitis
aggressive, prolonged IV antibiotic therapy
cultures or bone biopsy before antibiotics
surgical debridement and drainage of abscess or ulcer
IV antibiotics via CVAD
IV antibiotics 4-6 weeks or longer
variety of antibiotics depending on microorganism and resistance
interprofessional care with chronic osteomyelitis
surgical removal
extended use of (oral) antibiotics
acrylic bead chains containing antibiotics to assist with deep infections
intermittent or constant antibiotic irrigation of bone to assist with deep infections
other osteomyelitis interprofessional care
casts/braces
negative-pressure wound therapy
hyperbaric oxygen therapy
removal of prosthetic devices
muscle flaps, skin grafts, bone grafts
amputation to improve quality of life
what are some nursing implementations of acute care with osteomyelitis?
immobilization and careful handling of affected limb to decrease pain and risk of injury
assess and treat pain and muscle spasms
dressing care: use sterile technique
proper positioning/support of extremity
prevent complications of immobility
patient teaching adverse and toxic reactions to antibiotic therapy
monitor peak and trough levels
lengthy antibiotic therapy can cause an overgrowth of candida albicans and c. diff
patient and family are often anxious and discouraged
continued psychologic and emotional support
what are some nursing implementations of health promotion with osteomyelitis?
control other current infections
persons at risk
patient/caregiver education
encourage to casl HCP for systemic or local signs of infection
what are some nursing implementations of ambulatory care with osteomyelitis?
patient/caregiver teaching regarding IV antibiotic administration and management of CVAD at home and follow-up testing
complete entire antibiotic prescription
wound care/dressing changes
physical and psychologic support
what will the patient do for the osteomyelitis evaluation?
have satisfactory pain management
adhere to recommended treatment plan
show a consistent increase in mobility and ROM
first degree sprain
few fiber tears
mild tenderness and swelling
mild or slightly pulled
second degree sprain
partial disruption of tissue
increased swelling and tenderness
moderately torn muscle
third degree sprain
complete tear with moderate to severe swelling
severely torn or ruptured muscle
strain and sprain manifestations
pain
edema
decreased function
bruising
assessment of neurovascular sprains and strains
bruising
decreased sensation
assessment of musculoskeletal sprains and strains
decreased movement
assessment of peripheral vascular strains and sprains
decreased pulse
cool extremity
pallor
edema
capillary refill > 2 seconds
sprains and strain complications
avulsion fracture
subluxation
dislocation
hemarthrosis
how do you diagnose sprains and strains?
x-ray
how do you treat sprains and strains?
RICE
pain med
surgical repair
how can nurses implement strains and sprains
teach health promotion
acute care
analgesia
treatment of repetitive strain injury
identify precipitating activity
modify equipment or activity
pain management
rest
physical therapy
lifestyle changes
manifestations of carpal tunnel syndrome
impaired sensation
pain
numbness
weakness
clumsiness
tinel’s sign
phalen’s sign
late stages of carpal tunnel syndromes
atrophy
recurrent pain
dysfunction of hand
priority problems of strains and sprains
impaired mobility
risk for infection
acute pain
