exam 1 (IM 4) Flashcards
what factors influence the body fluid?
age
gender
body fat
skeletal
fluid inside the cell
intracellular space
fluid outside the cell
extracellular space
what is in the extracellular space
intravascular, interstitial , transcellular
contains plasma
intravascular
surround the cells
interstitial
working apart from the circulating system
(cerebral, spinal, pericardial, pleura)
transcellular
abnormal shifting of fluid
third spacing
what are some manifestations of third spacing?
-decrease urine output
-increase heart rate
- decrease bp, decrease cvp,
-edema
-increase body weight
what are the causes of third spacing?
-liver problems
-burns
-bowel obstruction
-trauma
what does homeostasis do in the body?
-promote neuromuscular activity
-maintain body fluid osmolality
-regulate acid base balance
- regulate distribution of body fluid compartments
what is the most important to assess with electrolyte balance?
-monitor daily weight
-i&o
what do you also assess with electrolytes?
-assess overall fluid balance
-assess neuro status (loc)
-evaluate sensory and motor function
-monitor vs, and electrolytes (trends)
-EKG changes
-nutritional status
-hx
-medical hx
what are your (+charge)
sodium
potassium
calcium
magnesium
what are your (- charge)
bicarbonate
chloride
phosphate
what are your regulations of fluid?
osmosis and osmolality
diffusion
filtration
sodium potassium pump
what are the routes of losses of electrolytes?
-kidneys
-skin
-lungs
-GI
what helps fluid balance? (regulators)
-kidneys
-hypothalamus
-pituitary gland
-adrenal cortex
what do kidneys need to have to work properly?
they have to have enough pressure
how to kidneys help with fluid balance?
they help filter
how does the hypothalamus help with fluid balance?
thirst
how does the pituitary gland help with fluid balance?
release and inhibits ADH which is an antidiuretic hormone
how does the adrenal cortex help with fluid balance?
regulates Na+ by releasing aldosterone
what can increase the hydrostatic pressure in the body?
venous obstruction
sodium and water retention
what occurs in the body when their is an increase in hydrostatic pressure?
edema
what causes a decrease in oncotic pressure?
loss or decrease in plasma albumin
what occurs in the body when their is a decrease in oncotic pressure?
edema
what causes an increase in capillary permeability?
-inflammation
-immune response
what occurs in the body if there is an increase in capillary permeability?
edema
what causes a obstruction the lymph channales?
tumors
inflammation
surgical removal
what can occur if their is a obstruction in the lymph channels?
edema
what does the lymphatic system absorb?
interstitial fluid and small amounts of protein
edema in the lungs is called?
pleural effusion
edema in cardiac
pericardial effusion
edema in the belly
ascietes
edema in the feet
peripheral edema
edema everywhere in the body?
anasarca
what are some complications of edema?
-pressure injuries
-infections
-life threatening (brain, lungs, larynx)
if sodium is low, what happens to the osmolality?
it is low
the osmolality of blood primary reflects what?
sodium
blood/urea (bun)
glucose
what is the normal osmolality?
280-300
if osmolality if less than 280 then the patient is?
fluid overload
if the patients osmolality is higher than 300 then the patient is?
dehydrated
what are other factors of increasing osmolality?
dehydration
free water loss
DI
hypernatremia
hyperglycemia
stroke of head injury
renal tubular necrosis
what are other factors decreasing osmolality?
fluid volume excess
SIADH
renal failure
hyponatremia
overhydration
what is an isotonic solution?
similar to osmolarity to the ECF
given to replace fluid loss
does not shrink or swell the RBCs
osmolality is 280-300 m0sm/kg
what are the isotonic solutions?
5% dextrose (D5W)
Normal saline (NS, NACL, 0.9%)
Lactated ringers (LR, RL)
what does D5W supply?
water and glucose
what happens to D5W when administered inside the body?
becomes hypotonic
which patients should you be cautious about when administering D5W?
diabetics
hypernatremia pt
head trauma patients
what can D5W cause in a patient with diabetes?
hyperglycemia
what does 0.9% sodium chloride do?
corrects extracellular deficit
what kind of patients can reicieve 0.9% sodium chloride?
hypovolemic states
resusicative efforts
shock
metabolic alkalosis
hypercalcemia
Na+ deficit
what does 0.9% sodium chloride help replace?
large sodium losses
who should not receive 0.9% sodium chloride solution?
CHF
pulmonary edema
renal impairment
does 0.9% sodium chloride provide callories?
no
what does lactated ringers contain?
potassium
calcium
sodium chloride
what does lactated ringer help with?
corrects dehydration
Na+ depletion
GI lossess
who should be cautious when recieving lactated ringers?
CHF
renal insuffiency
edema
Na+ retention
hyperkalemia
what is a hypotonic solution?
osmolarity is lower than the serum <280
dilutes the ECF, lowering the osmolality
causes water to move into the interstitial spaces
hypotonic solution is good for hypernatremia, true or false?
true
what are the hypotonic solutions?
0.45% sodium chloride (1/2 NS)
0.33% sodium chloride (1/3 NS)
0.225% sodium chloride (1/4 NS)
2.5% dextrose in water (D2.5W)
who cannot receive hypotonic solutions?
ICP
CVA
head trauma
burns
trauma
malnutrion
liver disease
what is hypertonic solutions?
osmolarity is higher than >300
causes water to move out of the cells
decrease in edema, stabilizes BP, regulate urine output
what are hypertonic solutions used for?
-used to repair electrolytes and acid/base imbalances, TPN
-used cautiously in patient with diabetes, and impaired heart or kidney function
-monitor closely for circulatory overload
what are they hypertonic solutions?
5% dextrose in 0.9% sodium chloride (D5NS)
5% dextrose in 0.45% sodium chloride (D51/2NS)
5% Dextrose in 0.225% sodium chloride (D51/4NS)
5% Dextrose in Lactated Ringers (D5LR)
10% Dextrose in water (D10W)
what can hypertonics cause in the veins?
phlebitis
what are colloids?
large molecules that do not dissolve and can not pass through a membrane
-used clinically for volume expansion
-pull fluid into the bloodstream
what are colloids primarily used for?
volume expansion
what are the different colloid solutions?
albumin
dextran
hetastarch
mannitol
osmotically=to plasma
albumin
plasma volume expander
dextran
synthetic volume expanxer
hetastarch
alcohol-sugar
mannitol
what should you monitor if a patient is on colloids?
increase in bp
dyspnea
bounding pulse
fluid overload
anaphylaxis
what electrolytes should you watch when giving colloids?
potassium
sodium
what is fluid volume deficit?
decrease in circulating blood volume
what are the causes of fluid volume deficit?
vomiting
severe dehydration
trauma
burns
medication
what are the moderate symptoms of fluid volume deficit?
dry mucous membranes
excessive thirst
postural hypotension
thready pulse, rapid hr
dark urine
decrease LOC
what the symptoms of severe fluid volume deficit?
body will to compensate and vessels will try to vasoconstrict
HR increases
what are the nursing interventions for fluid volume deficit?
oral rehydration
increasing fluid intake
IV hydration
what is fluid volume overload? (hypervolemia)
overloading circulatory system with excessive IV fluid
what are the causes of hypervolemia?
rapid infusion rate
hepatic, cardiac or renal disease
can be more common in elderly patients
what are the signs and symptoms of hypervolemia?
edema
wt gain
palpable veins
crackles in the lungs
pulmonary edema
increase in BP and CVP
JVD
moist crackles, dypnea
shallow respirations
periorbital edema
decreased lab values
how to prevents fluid volume overload?
infuse ivf via pump
monitor pt closely
what are interventions for fluid volume overload?
decrease IV rate
monitor VS, assess respiratory status
high-fowlers positions
notify MD
what happens if albumin is low?
edema
what is the normal range of sodium
135-145
what is the major electrolyte in the ECF?
sodium
what follows sodium?
chloride
what is the normal range of chloride?
98-106
what are the functions of sodium?
blood pressure
blood volume
ph balance
what does sodium do to the body?
maintains proper water and minerals
water distribution
what are the regulators of sodium?
ADH
aldosterone
sodium potassium pump
what is ADH?
controls water retention
what is aldosterone?
water regulator, kidneys retain sodium and water
helps keep bp up
what does the sodium potassium pump do?
process of moving Na+ and K+ across the cell membrane by using atp
what are the causes of hyponatremia?
“N”a+ excretion increases w/renal problems, ng suction, vomiting, diuretics, sweating, diarrhea, decrease secretion of aldosteron (DI)
“O”verload of fluid (CHF, hypotonic fluid infusion
“N”a+ intake is low
“A”ntidiuretic hormone oversecretion (SIADH)
what are the symptoms of hyponatremia?
“S”eizures and stupor
“A”bdominla cramping, attitude change (confusion)
“L”ethargic
“T”endon reflex diminished, trouble concentrating
“L”oss of urine & appetite
“O”rthostatic hypotension
“S”hallow respirations
“S”pasms of muscles
what is the serum Na+ of hyponatremia?
<135
what is the serum osmolality in hyponatremia?
<280 mOsm/kg
what is the urinary Na+ of hyponatremia?
<20 mEq/L
what is the urine specific gravity of hyponatremia?
<1.010
what is the medical treatment of hyponatremia?
-Na+ replacement by mouth, IV, or NGT
-replacement depends on the rate lost
can use LR, NS
replacement depends on the rate lost, if so you can use?
lactated ringers
normal saline
what is the rule of thumb when it comes to hyponatremia?
serum Na+ must not be increased >12 mEq/L in 24 hours
what are the treatments for hyponatremia with water gain?
restrict h20 safer than giving Na+ (800ml/24hrs
hypertonic solution 3%-5% NaCL
edema only- restrict Na
edema and Na-restrict both
loop diuretics
what are the nursing interventions for hyponatremia?
identify pt at risk
monitor labs, i&o, daily weight
review medications
gi manifestations
monitor s/s of hyponatremia
monitor for neuro changes
oral hygiene
seizure precaution(suction at the bedside)
fall risk
what are the causes of hypernatremia?
“H”ypercorisolism (cushings syndrome, hyperventilation)
“I”ncreased intake of sodium
“G”I feeding w/o adequate water supplements
“H”ypertonic solution
“S”odium excretion decreases and corticosteroids
“A”ldosteronism (hyper)
“L”oss of fluids (infection, sweating, diarrhea, DI)
“T”hirst impairment
what are the signs and symptoms of hypernatremia?
“F”ever “flushed skin
“R”estless, really agitated
“I”ncreased fluid retention
“E”dema, extremely confused
“D”ecreased urine output, dry mouth/skin
what happens to patients with hyponatremia and taking lithium?
can cause lithium toxicity, due to urinary sodium loss
what is the serum Na+ for hypernatremia?
> 145mEq/L
what is the serum osmolality for hyernatremia?
> 300mOsm/L
what is the urine specific gravity of hypernatremia?
> 1.015
what is the medical treatment for hypernatremia?
-decrease Na+ level gradually
-decrease 0.5mEq/L/hr over 48 hours
-monitor for neuro changes and cerebral edema
-D5W or 0.45NS
-desmopressin (DDAVP)
how much should be decreased in hypernatremia?
0.5mEq/L/hr over 48 hours
what treatments are used for hypernatremia?
loop diuretics
desmopressin
D5W
what are nursing interventions for hypernatremia?
-identify pt at risk
-monitor fluid loss/gain
-labs and oral Na intake
-neuro precautions and behavior changes
-offer fluids
-note medicaton with increase Na+ content
-daily wts
what are foods with high sodium?
chips
cheese
fast food
tv dinner
canned foods
crackers
popcorn
fish
poultry
bacon
what should be restricted with hyponatremia?
fluid intake
what is the normal range for potassium?
3.5-5.0
what are the regulators for potassium?
kidneys and aldosterone
what is the function of potassium?
influences both skeletal and cardiac muscle activity
what is the major electrolyte in the intracellular fluid?
potassium
where do you obtain most of the potassium?
diet
where is potassium absorbed?
intestines
what are some foods that help with potassium intake?
bananas
watermelon
spinach
avocadoes
sweet potatoes
white beans
dried fruit
what causes hypokalemia?
“D”rugs (diuretics, laxatives, insulin, IV fluids
“I”nadequate consumption of K+
“T”oo much water intake
“C”ushings syndrome
“H”eavy fluid loss
NPO, anorexia, TPN, high aldosterone secretions
what are the signs and symptoms of hypokalemia?
“SLOW”
-weak irregular pulses
-orthostatic hypotension
-shallow respirations
-confusion,weak
-deep tendon reflex decreased
-decreased bowel sounds
“Low”
-lethargy
-low, shallow respirations
-lethal cardiac dysrhythmias***
-lots of urine
-leg cramps
-low bp and heart
what are some causes for renal loss of potassium?
diuretics
hyperaldosteronsim
high dose of sodium PNCs
large dose corticosteroids
what are the cardiac changes caused from hypokalemia?
-decrease strength of contractions
-myocardium irritablility
-<2.7 may result in cardiac arrest
-<3.5 alkalosis, high ph and high HCO3
-digoxin toxicity
what are signs and symptoms of digoxin toxicity?
irregular pulse
fast heartbeat
confusion
vision change
n/v
what are risk factors of digoxin toxicity?
low potassium and magnesium
high potassium and calcium
what are the is the lab result for lethal dysrhythmias?
<2.7
what lab increases with hypokalemia?
ph and HCO3
what are the medical treatments for hypokalemia?
k+ replacement (po or IV)
increase on a daily basis (40-80mEq/day)
at risk patients 50-100mEq/day
k+ rich foods
treat underlying cause
how much should you increase on a daily basis for someone with hypokalemia?
40-80 mEq/day
how much should you increase on a patient high risk with hypokalemia?
50-100mEq/day
how to minimize oral supplementation of potassium?
dilute liquid and effervescent supplement
give tabs and capsules with 8 oz of water
give medication with food
what are adverse reactions to oral k+ supplements?
N/V/D
GI blood
what are nursing interventions for intravenous potassium supplements?
-must be diluted
-NO IVP
-max dose is 60mEq at a time
-must use IV pump
monitor renal output
CHS policy-heart monitor
monitor iv site
what is the max dose of intravenous potassium supplement?
60 mEq at a time
what are nursing interventions for hypokalemia?
-identify pt at risk-esp if on digoxin
-monitro ECG and BP
-monitor serum K+
-pt education -diuretics and laxatives
-administer K+ supplements PO or IV
- increase dietary K+
-monitor urine output
what are the causes for hyperkalemia?
“C”ellular movement (intracellular to extracellular)
“A”drenal insufficency w/Addison’s diease
“R”enal failure
“E”xcessive K+ intake
“D”rugs (ace inhibitors, NSAIDS, beta blockers
what are the signs and symptoms of hyperkalemia?
“M”uscle weakness
“U”urine production little/none
“R”espiratory failure
“D”ecrease cardiac contractility
“E”arly signs of muscle twitches/cramps
“R”hythm changes
what are hyperkalemia cardiac changes?
slow heart rate
ECG changes
risk for heart block, a-fib, v-fib
-severe increase K+
decreased heart contraction strength
dilated and flaccid heart
what is the serum potassium for hyperkalemia?
> 5.0
what are the arterial gases for hyperkalemia?
low ph indicating acidosis
what are medical treatments for hyperkalemia?
K+ restricted diet
stop K+ containing medication
monitor for digoxin toxicity
cation exchange resins -kayexelate (polystyrene sulfonate)
dialysis
what are emergency treatment for hyperkalcemia?
Ca Gluconate-IV
Hypertonic glucose & insulin
Sodium Bicarbonate
how long should calcium gluconate be given
over 3 minutes
what does calcium gluconate do?
protects the heart
what does hypertonic glucose & insulin, and sodium bicorbonate do with hyperkalemia?
K+ shifts into cells
what are the nursing interventions for hyperkalemia?
be aware of pt at risk
monitor for:
generalized weakness and dysrhythmias
irritability & GI symptoms
nausea and intestinal colic
ECG or lab abnormalities
what are some preventions of hyperkalemia?
educate pt on medication and diet
do NOT draw blood about K+ infusion site
what is the normal range for magnesium?
1.5-2.5
what is critical labs for magnesium?
<1.2 or >4.9
what is the function of magnesium?
regulating muscle and nerve function
blood sugar levels
immune system
important for normal cardiac function
stimulates PTH (regulates calcium)
what is hypomagnesemia associated with?
hypokalemia
low mg makes low K resistant to treatment, true or false
true
what are signs and symptoms of hypomagnesemia?
tight airway: stridor, laryngospasm, difficulty swallowing
Neuromuscular: muscle twitiching
GI: N/V/D
Heart: increase BP, increase HR
what are the causes of hypomagnesemia?
Mg absorbed in the intestines
renal loss
chronic alcoholism (most common)
antibiotics
GI (N/V/D)
malabsorption (crohns, celiac disease)
what are some nursing interventions with hypomagnesemia?
Safety with swallowing
IV Mg+Sulfate (Give slowly)
Monitor respiratory status and reflexes
what are food rich in magnesium?
dark chocolate
avocados
milk
peas
peanut butter
oranges
nuts
bananas
what are the causes for hypermagnesemia?
antacids
renal failure
potassium excess
what are signs and symptoms of hypermagnesemia?
heart: calm and quiet
low and shallow respirations, bradycardia, hypotension
Lung: low and shallow respirations
GI: hypoactive bowel sounds
Neuro: drowsiness, lethary
MS: weakness
what is the normal lab value for calcium?
9-11
where is calcium mostly stored?
bones and teeth
what are the functions of calcium?
bones
blood
beats
how does calcium help with the blood?
clotting
how to calcium help with beats?
helps to regulate the heart
relaxing and contracting muscles
to proteins (less than 50%)
calcium
bound
found in serum (50% of calcium and is most important)
ionized
combined with nonprotein anions: phosphate, citrate, and carbonate
calcium
complexed
how does ionized calcium help the body?
-activate body chemical
-muscle contractions and relaxation
-promote transmission of nerve impulses
-cardiac contractility and automaticity
-formation of prothrombin
what are the calcium regulators?
PTH
vitamin D
calcitonin
phosphate
how does the parathyroid hormone (PTH) help regulate calcium?
“pulls”
-release Ca from the bone
-increase Ca absorption from GI
-increases Ca absorption from renal tubles
how does calcitonin regulate calcium?
“keeps”
-antagonist of PTH
-secretion stimulated by high serum Ca++
-inhibit Ca reabsorption from bone
where is calcitonin secreted?
thyroid
calcium has a reciprocal relationship with?
phosphate
why is vitamin D needed for calcium?
necessary for absorption and utilization of Ca
what are sources of vitamin D?
mushrooms
egg yolk
fatty fish
safe sun exposure
spinach
tuna
dairy
what are causes of hypocalcemia?
“L”ow parathyroid hormone
“O”ral intake inadequate
“W”ound drainage
“C”eliac, crohn’s, & corticosterids
“A”cute pancreatitis
“L”ow vitamin D levels
after thyroid surger
alcohol drinkers
malabsorption
what are signs and symptoms of hypocalcemia?
“C”onfusion
“R”eflexes hyperactive
“A”rrythmias
“M”uscle spasms, tetany*** seizures
“P”ositive trousseau’s
“S”igns of chvosteks (facial nerves hyperexcitalbe
what is trousseau’s sign?
carpopedal spasms of hand when
blood supply decrease
pressure on nerve
what is chvisteks sign?
spasms of muscles innervated by facial nerves
tap facial nerve anterior to ear lobe below zygomatic process
what is a goiter? and what causes it?
-develops as a result of iodine deficiency or inflammation of the thyroid gland
-seen in hypocalcemia and hypercalcemia
what are the cardiac effects of hypocalcemia?
-prolonged QT interval
-prolonged ST segment
-decrease cardiac contractility
-decrease sensitivity to digoxin
what is an important cardiac event caused by hypocalcemia?
torsades de pointis
ventricular tachycardia
what is the lab for hypocalcemia?
<9
what can give incorrect levels of calcium?
albumin and protein
what labs should be obtained for accurate results of calcium
ionized serum
what can effect levels of calcium
PTH
what should also be obtained with calcium labs?
magnesium and phosphate
what is considered an emergency for hypocalcemia?
symptomatic symptoms
what is required for acute symptomatic hypocalcemia?
prompt admin of IV calcium
what is given for severe symptoms of hypocalcemia?
10% ca-gluconate
what can happen if given calcium to fast?
cardiac arrest
what should you watch when given calcium supplements through IV?
IV site for necrosis and infiltration
what are nursing interventions for hypocalcemia?
identify pt at risk
seizure precautions if severe decrease
monitor airway
monitor ECG
educate patient Ca loss and risks and Ca rich foods
what are causes for hypercalcemia?
“H”yperparathyroidism
“I”ncreased intake of calcium
“G”lucocorticoids usage
“H”yperthyrodism
“C”alcium excretion w/thiazide diuretic and renal failure, bone CA
“A”drenal insufficiency (Addison’s)
“L”ithium usage
what does lithium affect with calcium
parathyroid
what are the signs and symptoms of hypercalcemia?
“W”eakness of muscles
“E”KG changes (arrhythmias)
“A”bsent reflexes (absent minded, abdominal distention from constipation
“K”idney stone formation
excessive urination
what are cardiac changes in hypercalcemia?
calcium:inotropic effects oh heart and reduces heart rate
-shortens ST segment and QT interval
-prolonged PR interval
-potentiate digoxin toxicity
what are the labs for hypercalcemia?
serum calcium: >11
ECG: dysrhthmias
PTH:increased
Xray:osetoporosis
urine-dense
what are the medical treatments for hypercalcemia?
-treat underlying cause
-dilute serum Ca with NS
-lasix/furosemide
-IV phosphate
-calcitonin
-glucocorticoids
-hemodialysis or CAPD
what are the nursing interventions for hypercalcemia?
-monitor for pt risks
-increase activity and fluid if possible
-decrease Ca intake
-safety measures for confusion
-monitor ECG, I&O, breath sound
-monitor for digoxin toxicity
-prevent Ca renal stones
what is normal phosphorus?
2.5-4.5
what is the inverse relationship with calcium?
phosphorus
where is phosphorus found?
teeth
bones
what are the functions of phosphorus?
-bone and teeth formation
-repair cell tissue/energy production through ATP
-nervous system
-muscle function
what are the regulators of phosphorus?
parathyroid and calcitrol
what are good sources of phosphorus?
dairy
meats
beans
nuts
what are the causes of hypophosphatemia?
-malnutrition/starvation
-increase phosphorus excretion
-hyperparathyroidism (calcium increases)
-malignancy
-diuretics/diarrhea
-use of magnesium/aluminum antacids (increase Ca, deplets phos)
what are the signs and symptoms of hypophosphatemia?
cardio: decreased BP/HR
gi: hypoactive bowel sounds
gu: kidney stones
neuro: altered loc
musc: severe muscle weakness
bone pain/fractues
what are interventions for hypophosphatemia?
replace phosphorus IV/PO
give slowly
administer oral phosphorus with vitamin D
fracture precautions
what are the causes for hyperphosphatemia?
increase phosphorus intake
overuse of laxative
renal insufficiency
decreased excretion
hypoparathyrodism
hypocalcemia
what are the signs and symptoms of hyperphosphatemia?
GI: diarrhea, hyperactive bowel sounds
Neuromuscular: positive trousseau’s/chvostek’s
painful muscle spasms
hyperactive deep tendon reflex
irritable skeletal muscles-twitches, tetany, seizures
osteoporosis-body trying to get more calcium
what are the composition of musculoskeletal system?
bone
connective tissue
voluntary muscle
bone-forming cells
osteoblasts
breakdown bone tissue
osteoclasts
what are the risk factors associated with musculoskeletal disorders?
-autoimmune disorders
-calcium deficiency
-falls
-hyperuricemia
-metabolic disorders
-neoplastic disorders
-obesity
-post-menopausal states
-trauma and injury
what are the diagnostic for Musculoskeletal Disorders
Radiography (x-ray) and MRI
Arthrocentesis
Arthroscopy
Bone scan
Bone or muscle biopsy
Electromyography (EMG)
what are the interventions for musculoskeletal?
-handle injured areas carefully
-stabilize/support above and below injured joint
-administer analgesics as prescribed
-remove any radiopaque and metallic objects (jewelry)
-needle aspiration to joint
-used to diagnose joint inflammation and infection
-aspirating synovial fluid, blood, or pus via needle in joint cavity
-corticosteroid may be injected to decrease inflammation
arthrocentesis
what are the interventions for arthrocentesis?
consent
administer analgesia are prescribed
rest 8-24 hours post-procedure
notify HCP if fever/swelling of joint
what is arthroscopy?
used to diagnose and treat acute and chronic disorders of joint
-biopsy can performed during arthroscopy
what are the interventions for arthroscopy?
-NPO 8-12 hours prior to procedure
-consent
-administer analgesics
-neurovascular assessment per policy
-elastic compression 2-4 days post-op
-wt bearing activity encouraged but should be limited 1-4days
-elevate and ice prn for swelling 12-24 hours post-op
-notify physician of fever, swelling, or increased pain >3days post-op
what are the subjective data in nursing assessment?
past health hx
medications
surgery or other treatments
health perception
nutritional-metabolic pattern
activity-exercise pattern
sleep-rest pattern
coping-stress tolerance pattern
what are the nursing assessments for objective data?
-general overview with focused exam
-physical examination
-inspection
-palpation
-motion
-measurement
other
-use of assistive devices
-posture and gait
-straight-leg raising
what are the soft tissue injuries?
sprains
strains
dislocations
subluxations
an injury to ligaments around a joint
sprain
what is grade 1 sprain?
few fiber tears, mild tenderness and swelling
what is a grade 2 sprian?
partial disruption of tissue; increased swelling and tenderness
what is grade 3 sprain?
complete tear with moderate to severe swelling
excessive stretching of muscle and fascia; may involve tendon
strain
what is grade 1 strain?
mild or slightly pulled
what is grade 2 strain?
moderately torn muscle
what is grade 3 strain?
severely torn or ruptured muscles
what are the manifestations of sprains and strains?
pain
edema
decreased function
bruising
what are the complications of sprains and strains?
avulsion fracture
subluxation
dislocation
hemarthrosis
whats the acute care/interventions for sprains and strains?
RICE
what does RICE stand for?
r-rest, stop activity and limit movement
i-ice 24 to 48 hours ;20-30 minutes at a time
c-compression, elastic bandage, apply distal to proximal
e-elevate above the heart
analgesia
what are the treatments for sprains and strains?
self-limiting
rice
surgical repair
what are the interventions for compression?
-decrease edema and pain
-50-70% tightness
distal to proximal
cap refill
what are fractures?
disruption or break in continuity of structure of bone
-some fractures secondary to disease process
what is open fracture?
skin broken; bone exposed
what is closed fracture?
skin intact
what is displaced?
two ends separated from one another
-often comminuted or oblique
what is nondisplaced?
periosteum is intact, and bone is aligned
-transverse, spiral, or greenstick
what are the manifestations of a fracture?
-damage to surrounding tissue
-peri-osteum
-blood vessels in the cortex/marrow
-hematoma
-bone tissue triggers inflammatory response
-thick callus
-remodeling-aka bone turnover
what are signs and symptoms of fracture?
-edema/swelling
-pain and tenderness
-muscle spasm
-deformity
-contusion
-loss of function
-crepitation
-guarding
what is crepitation?
cracking, crunching, rattling as bones move together
what are the nursing objective data for fractures?
-apprehension
-guarding
-skin laceration, color changes
-hematoma, edema
-decrease or absent pulse, decrease skin temp
-delayed capillary refill
-paresthesia
-absent or decrease or decrease sensation
-restricted or loss of function
-deformaties
bleeding at fractured ends of the bone
hematoma
hematoma organized into fibrous network-hematoma converts into
granulation tissue
new bone is built up as osteoclasts destroy dead bone
callus formation
of the callus occurs (3 weeks to 6 months)
ossification
callus continues to develop, closing the distance between bone fragments (up to 1 year after injury)
consolidation
is accomplished as excess callus is reabsorbed and trabecular is laid down
remodeling
what is traction?
prevent or decrease pain and muscle spasm
-pulling force to attain realignment -countercontraction pulls opposite direction
-immobilized joint or part of body
-reduce fracture or dislocation
-treat a pathologic joint condition
what are the different tractions?
skin traction
skeletal traction
what is bucks traction?
skin traction used for hip, knee, or femur fracture
can be used for 24 to 48 hours to relieve painful muscle spasms
what is skeletal traction?
-long term pull to maintain alignment
-pin or wire inserted into bone
-weight 5 to 45 pounds
-risk for infection
-complications of immobility
what should be done with skeletal traction?
-maintain counter traction
-elevate end of bed
-maintain continuous traction
-keep wts off the floor
what should be done with lower extremity immobilization?
-elevate extremity above heart
-do not place in dependent position
-observe for signs of compartment syndrome and increased pressure
Do’s for cast care?
-frequent neurovascular assessment
-apply ice for first 24 hours
-elevate above heart for first 48 hours
-exercise joints above and below
-use hair dryer on cool setting for itching
-check with health care provider before getting wet
- dry thoroughly after getting wet
-report increase in pain despite elecation, ice, and analgesia
-report swelling assoc. with pain and discoloration or movement
-report burning or tingling under cast
-report sores or foul oder
-keep app to have fx and cast checked/removed
DONT’S of case care
-do not get plaster cast wet
-discourage pulling out cast padding
-do not place foreign objects inside cast
-do not bear wt on new cast for 48 hr
-do no cover cast with plastic for prolonged periods of time
what is external fixation?
-metal pins and rods on the outside
-applies traction
-compress fracture fragments
-immobilize and holds fracture fragments in place
-mostly used for long bones
what should be assessed for external fixation?
-assess for pin loosening and infection
-pin site care per MD order
-pt teaching
what is internal fixation?
-pins, plates, rods, and metal surgically repaired in the inside
- continuous xrays to see that pins etc.. are in proper place
why is nutritional therapy important bone surgeries?
-optimal for soft tissue and bone healing
-promotes muscle strength and tone
-builds endurance
-provides energy
what are the peripheral vascular assessments?
-color and temp
-capillary refill
-pulses
-edema
what is the peripheral neurologic assessment
sensation and motor function
pain
what are the 6p’s
pain
pallor
pulse
paresthesia
paralysis
poikilothermia
when assessing peripheral assessment, what should you do?
compare to both extremities to obtain accurate assessment
what are nursing implementation to bone safety?
-teach safety precautions
-advocate to decrease injuries
-encourage moderate exercise
-safe environment to reduce falls
-calcium and vit d intake
what are clinical manifestations for hip fractures?
-external rotation
-muscle spasms
-shortening of the affected extremity
-severe pain and tenderness
what are the preoperative care considerations?
-consider chronic health problems
-discharge planning
-analgesics or muscle relaxants
-comfortable positioning
-traction placed properly
what are postoperative care considerations?
-vital signs
-i&o
-monitor respiratory function
-encourage TCDB and IS
-pain management
-observe dressing site and monitor bleeding
-neurovascular checks
DO’s for hip replacement
-use elevated toilet seat
-place chair inside shower or tube and remain seated while washing
-use pillow between legs for 6 wks after surgery when lying on nonoperative side or when supine
-keep hip in neutral, straight position when sitting, walking or lying
-notify HCP at once if severe pain, deformity, or loss of function occur
-discuss risk factors for prosthetics join infection with HCP and dentist before dental work
DON’Ts with hip replacement
-flex hip greater than 90º
-adduct hip
-internally rotate hip
-cross legs ant knee or ankles
-put on own shoes or stockings w/o adaptive device for 4-6wks
-sit on chairs without arms
what assessments are done with amputations?
-physical appearance of soft tissue
-preexisting illness
-skin temperature
-sensory function
-quality of peripheral pulse
what are nurse managements with amputations?
phantom limb sensation
ambulatory and home care
pt and caregiver teaching
what are direct complications with fractures?
infection
incorrect union
necrosis
what are indirect complications of fractures?
-compartment syndrome
-venous thromboembolism
-fat embolism
-rhabdomylosis
-hypovolemic shock
what increases risk of infection?
open fractures
soft tissue injuries
what is compartment syndrome?
decrease in compartment size
increase in compartment contents
collaborative care with compartment syndrome?
-no elevation above the heart
-no ice
-loosen bandage and split
-reduce traction wt
-surgically decompression (fasciotomy)
what is fat embolism?
originates in bone marrow
-occurs after fracture from crushing injury or to long bone
what are signs and symptoms of fat embolism?
restlessness
hypoxemia
mental status change
dyspnea/tachypnea
tachycardia
hypotension
what is osteoarthritis?
-gradual loss of articular cartilage
-cartilage becomes dull, yellow, and grandular
-soft and less elastic
-less able to resist wear with heavy use
formation of osteophytes
-bones rub together increasing pain
what are risk factors of osteoarthritis?
age
menopause
obesity
anterior cruciate ligament injury
frequent kneeling and stooping
smoking
possible genetic link
how does osteoarthritis occur?
initial inury
attempts at cartilage repair
stimulates cartilage degradation
outgrowth and hyperplasia
what is the clinical manifestation of osteoarthritis?
joint pain
deformity
non-systemic
what is the nursing assessment with osteoarthritis?
bilateral joint assessment and check for
tenderness, swelling
limitation of movement
crepitation
drug therapy for osteoarthritis with mild to moderate pain
acetaminophen
topical agents
otc creams containing camphor, eucalyptus oils and menthol
drug therapy for moderate to severe pain in osteoarthritis?
nonsteroidal antiinflammatory drug;start low does and increase if needed
-ibupfron 200mg up to 4 times a day
arthrotec
-celebrex
what is osteomyelitis?
severe bone infection, bone marrow, and surrounding soft tissue
what is the common microorganism in osteomyelitis?
staphylococcus aureus
etiology and path of osteomyelitis?
-indirect entry (hematogenous)
-young boys
-blunt trauma
-vascular insufficiency disorders
-GI and respiratory infection
direct entry-via open wound
foreign body presence
what is acute osteomyelitis?
infection <1 month in duration
local manifestation
-pain unrelieved by rest; worsens with activity
-swelling, tenderness, warmth
-restricted movement
what are systemic manifiestations of acute osteomyelitis?
fever
night sweats
chills
restlessness
nausea
malaise
drainage
what are the diagnostics for osteomyelitis?
bone or soft tissue biopsy
what is the interprofessional care of acute osteomyelitis?
course of IV antibiotics therapy for 4-6 weeks minimum
what is the interprofessional care of chronic osteomyelitis?
surgical removal
extended use of antibiotics
-iv and/or oral up to 8 weeks
what is the objective data of osteomyelitis?
-restlessness, high spiking temp, night sweats
-diaphoresis, warmth, edema
-restricted movement, wound drainage, spontaneous fractures
-increase in WBC
what is osteoporosis?
chronic, progressive metabolic bone disease
-low bone mass
-deterioration of bone tissue that leads to increased bone fragility
where does osteoporosis often affect?
hips
pelvis
wrists
vertebrae
why does osteoporosis occur?
osteoclasts increase and osteoblasts decrease
-reabsorption occurs faster than bone deposition
what are causes of osteoporosis?
< estrogen in females
< testosteron in males
< exercise/activity
< calcium, vitamin D
why is osteoporosis most common in women?
lower calcium intake
less bone mass
bone resorption begins earlier and becomes more rapid at menopause
pregnancy and breastfeeing
longevity
what are risk factors of osteoporosis?
advancing age >65 yr
steroids
female gender
low body wt
white or asian ethnicity
current cigarette smoking
nontraumatic fracture
sedentary lifestyle
what are some prevention factors of osteoporosis?
regular wt bearing exercises
fluoride
calcium
vitamin d
what age is peak bone mass
20
what age does bone loss begin?
35-40
what are clinical manifestation for osteoporosis?
occurs mainly in spine, hips, and wrists
spontaneous fx
gradual loss of height
dowager’s hump
what are the screening guidlines for women with osteoporosis?
initial bone density test for women over age of 65
what is the adequate calcium intake for premenospausal and postmenopausal taking estrogen?
1000mg/day
whats the adequate calcium intake for a postmenopausal w/o estrogen?
1500mg/day
how should calcium be taken?
divided doses with food to enhance absorption
what are good sources of calcium?
milk
yogurt
turnip greens
cottage cheese
ice cream
sardines
spinach
what are agents treat osteoporosis?
agents that decrease bone resorption
agents that promote bone formation
what kind of drug is raloxifene?
hormone drug therapy
serm
what are the antiresorptive drugs?
estrogen
raloxifene
biphosponate
calcitonin
densumab
what is raloxifene (evista) similar to?
structurally similar to estrogen and binds to estrogen receptors
what does raloxifene (evista) do?
reduces bone resorption
what are the therapeutic uses for raloxifene (evista)
helps with osteoporosis and breast ca
what are the adverse effects of raloxifene (evista)
venous thromboembolism
fetal harm
hot flashes
what class is alendronate (fosamax)
bisphosphonate
what does alendronate (fosamax) do?
inhibit bone resorption
what are side effects of alendronate (fosamax)
anorexia
wt loss
gastritis
how to administer oral alendronate(fosamax)
take with full glass of water
take 30 min before food or other med
remain upright at least 30 min
what does calcitonin do?
inhibits bone resorption
inhibits the activity of osteoclast
what is denosumab (prolia) used for?
used for postmenopausal women and men at risk for fracture
how to admin denosumab (prolia)
sub q every 6 months
what is teriparatide (forteo)
form of parathyroid horom
produced by recombinanat DNA
only drug that increases bone formation
what are the side effects of teriparatide (forteo)
nausea
headache
backpain
leg cramps
what is the black box warning for teriparatide (forteo)
increased risk for osteosarcoma
most widely used antibiotic?
cephaosporins
first generation cephalosporins
cefazolin (ancef)
most widely used
fourth generation Cephalosporins
cefepime (maxipime)
prophylatically used before surgery
cefazolin (ancef)
what are the adverse reactions of Cephalosporinsi
allergic reaction
bleeding
thrombophlebitis
what does vancomycin do?
inhibits cell wall synthesis
used for severe infections only
what are the adverse effects of vancomycin
red man syndrome
ototoxicity
thrombophlebitis
thrombocytopenia
use of gram negative bacilli
aminoglycosides
what should walker do to work properly?
8-12 inches
lift up and move
utilize arms rest in chairs
wear appropriate footwear
take time ambulating
what should you not do with walker?
drag
when standing don’t grab handles to pull self up instead push off armrest or bed
what should you do with cane to properly function?
measure 15-30º elbow flex (measure at the wrist)
hold with unaffected extremity
when walking up stairs with cane what leg do you use good or bad? when walking down the stairs what leg do you used good or bad?
up-good
down-bad
what to do with crutch to work properly?
15-30º elbow measure with wrist
2-3 finger width under armpits
about 6 inches each side of feet
what should you not do with crutches?
lean on crutch
swing through rapidly
what to do with arm sling?
continually check peripheral neurovascular
promote good blood flow
assess for breakdown
what should you not do with arm sling?
keep extremity in dependent position
leg fingers fall in dependent position
fasten too tightly
what should you do with gait belt?
assess skin prior to placement
use with caution in pts with abd surgery/injury, breast cancer/
proper lift tech
what to not do with gait belt
leave on pt
place too tightly
healthcare reform agenda
basic care for all citizens
ANA
over 65 years old
disabled
medicare
mother and children
nursing home care
medicaid
primary and preventive care
physicians officers
nurse managed clinics
schools
community health centers
parish and block nursing
-health and nutrition education
immunizations
occupational health programs
what is secondary care?
medical units
surgical untis
mother/baby care
focus: early dx treatment prevent worsening of conditons
what is tertiary care?
icu
oncology pt
burn centers
psychiatric facilities
rural hospitals
what is quaternary care?
transplant centers
level 4 nicu
what are the practitioners?
physicians
midlevel practioners
what are the assistive?
cna
pca
unit secretaries
what are the nursing team members
rns
lvs/lpn
what are the supportive team memeber
pharmacist
therapist
what are the specialty team member?
social worker
case manager
registered dieticians
spiritual care
what is the ancillary
evs
food and nutrition
security
they find assistance for medications, housing, transportation, financial needs
social worker
develops, implements, & reviews healthcare plans for patients– recovering from serious injuries or dealing with chronic illnesses
case manager
what is direct care?
interaction between the nurse and patient
Examples
Administering medications
Providing education for patients and their families
Dressing changes
what is indirect care?
working on behalf of the patient
creating nursing care plans
serving in the ethics committee
documenting in pts chart
model of nursing care
tpcn
case method
functional
team
primary
differentiated practice
what are causes of phlebitis?
Poor aseptic technique
High osmolarity infusions
Improperly diluted medications
Incorrect cannula gauge
Too rapid infusion rate
what is thrombophlebitis?
Formation of clot and inflammation in the vein
Usually occurs after phlebitis
