exam 3 Flashcards
Preparation and discharge teaching for surgical patients (fractures)
○ Preparation: Before fracture reduction and immobilization:
■ Consent
■ Analgesics
■ Anesthesia may be used.
■ Education: How to assess neurovascular symptoms, IS, Controlling edema and pain.
○ Medical Management:
■ Reduction is the restoring of fracture fragments (taking pieces and putting them back together)
● Closed Reduction: anatomic alignment through manipulation and manual traction (Taking our hands and putting the bones back together), Extremity held while a cast, splint, or traction is used.
○ Healing may take 6-8 weeks
● Open Reduction: Surgical approach to anatomic alignment. Surgical incision to put the bones back together.
○ Use of internal fixation devices (pins, wires, screws, plates, nails, rods) during surgery.
■ Immobilization: Bones fragments will be positioned and aligned until union occurs.
● Immobilization may be accomplished by external or internal fixation. Methods of external fixation include bandages, casts, splints, continuous traction, and external fixators.
■ Maintaining and Restoring Function: Primary Nursing Assessment)
● Neurovascular status (circulation, motion, and sensation) monitored routinely: Numbness, tingling, blood flow, pulses, pain
● Edema controlled by elevating injury and applying ice
● Pain control through analgesics and position changes
● Isometric exercises
Priority assessment and nursing interventions for fractures and surgical patients
■ Priority Assessment:
● Neuro Checks
● Pain level
● Vitals signs
● Labs
■ Emergency Management:
● Closed Fracture: Immobilize!!! Splint wrapped in ace wrap to keep it from moving or displacing further.
● Open Fracture: Immobilize (Splint) Wound Care, cover with sterile dressing
● Neuro Checks: Done before and after you splint or immobilize
○ Check sensation
○ Check vascular status (numbness, tingling, temperature, look for pallor or color
○ Check pulses distal (below) fracture site to see if the area is getting blood flow
■ Nursing Management:
● Control edema with elevation and ice; RICE: Rest, Ice, Compress, Elevate
● Control pain with medications and nonpharmacologic techniques
● Monitor neurovascular status
● Exercises to maintain the health of unaffected limbs
● Use of assistive devices
● Educate on self-care, medications, monitoring potential complications
● Monitor and prevent infection (Open Fractures): Sterile!!
Compartment syndrome – clinical manifestations, priority nursing assessment and interventions, treatment
■ Compartment pressure is so high the blood cannot get to the extremity.
■ Develops quickly, but presents 48 hours after
■ Manifestations: 5 P’s
● Pain: Crucial in early recognition
● Paresthesia: Numbness, tingling, pinprick sensation
● Pallor: Late sign, no blood getting to extremity
● Pulselessness: BAD SHAPE, should always have a pulse distal to the fracture
● Paralysis: Very late sign
■ Nursing Management:
● Frequently assess pain and neurovascular status
● Report any negative changes to doctor immediately
● Pain management- opioids
● Educate pt on s/s at discharge: 5 P’s
● Prompt management is essential
● Conservative measures to restore tissue perfusion and relieve pain first
■ Treatment: If other measures do not work a fasciotomy is performed.
● Fasciotomy: Incision and diversion of the muscle fascia to relieve muscle constriction
○ After the wound is left open covered with a moist, sterile saline dressing.
Fat embolism syndrome – clinical manifestations, priority nursing care for prevention, treatment
■ Fat globules go into circulation and occlude small blood vessels that supply blood to vital organs.
■ Rapid onset
■ Manifestations: tripod of ss hpn
● Hypoxia: FIRST SIGN
● Petechial Rash (Chest and mucous membranes)
● Neurologic Compromise: Restless, agitated, seizures, focal deficits, encephalopathy
■ Prevention: As little movement of fracture as possible
● Immediate Immobilization
● Minimal fracture manipulation
● Support of fracture bones during turning and positioning.
● Fluid/Electrolyte balance
■ Treatment: Supportive
Stable vs unstable pelvic fractures and what is priority nursing assessment and interventions
■ Pelvic Fracture:
● CM’s:
○ Ecchymosis: Bruising
○ Tenderness over fracture site
○ Local edema
○ Numbness or tingling of pubis, genitals, proximal thighs
○ Inability to bear weight without pain/discomfort
○ Severe back pain
○ Alterations in neurovascular status of lower extremities
● Hemorrhage and shock are two of the most serious consequences!!
● Priority Nursing Assessment:
○ Assess for bleeding: VS (Blood pressure) and labs (Hemoglobin)
● Stable Pelvic Fracture: Won’t move a whole lot and will heal spontaneously
○ Treatment:
■ Bed rest and symptom management
■ Fluids, dietary fiber, ankle and leg exercises, anti embolism stockings, logrolling, deep breathing (IS), and skin care.
■ Monitor Bowel Sounds
● Unstable Pelvic Fracture: Results in rotational instability, having the potential to move or rotate the pelvis.
○ Treatment:
■ Stabilize the pelvic bones and compress bleeding with pelvic girdle.
■ Surgery with open reduction and internal fixation.
Hip fractures – clinical manifestations, priority nursing assessment and interventions, treatment, bucks traction
■ Hip Fracture: Fracture of the upper femur ● Older adult, women, osteoporosis ● Predisposes the older adult to: ○ Atelectasis Pneumonia Sepsis ○ VTE ○ Pressure ulcers ○ Delirium ○ Dehydration/poor nutrition ○ Loss of muscle strength ● CM’s: ○ Leg Shortening ○ Leg adducted (middle of body) and externally rotated (Toes point toward the wall) ○ Pain in hip and groin ○ Immobility of affected leg ○ Muscle spasms of affected leg ● Medical Management: ○ Buck’s Traction (Skin traction): Does not fix the fracture, but helps relieve symptoms such as muscle spasm, immobilize the extremity, and relieve pain. ● Surgical Treatment ● Nursing Priorities: ○ Hydration ○ Respiratory Support ○ Circulation Checks: Neuro Checks ○ Pain Control ○ Prevention of immobility Complications ○ Hx of chronic conditions and medications ● Nursing Management After Surgery: ○ Reposition: ■ Turn on uninjured side ■ Use of abduction pillow ○ Promote Exercise: ■ Use of over bed trapeze ■ Up to chair POD #1 ■ Consult physical therapy ■ Use of walker/cane ■ Modifications to home environment ○ Monitoring and Managing Potential Complications: ■ Monitor Neuro status of affected leg. ■ Prevent VTE: SCD’s, ted hose, lovenox, increase fluids ■ Pulmonary complications: Deep breaths, coughing, IS, change positions ■ Skin breakdown: Monitor
Internal vs external fixation
■ Internal Fixation: Stabilization of the reduced fracture by the use of Metallic pins, wires, screws, plates, nails, rods.
■ External Fixation: Use of bandages, casts, splints, continuous traction.
○ Phantom pain – understand what it is and priority nursing interventions
■ Phantom limb pain: Pain perceived in the amputated section, caused by severing of the peripheral nerves. Pain in a body part that is no longer there. Crushing, cramping, twisting pain. ■ Relieve Pain ● Use of analgesic medications ● Position change ● Acknowledge phantom pain as real ■ Limb Shrinkers- To help with Edema
○ In general – what is the priority nursing assessment and interventions w/ amputations
■ Uses:
● Relieve symptoms
● Improve function
● Save/improve quality of life
■ Goal of surgery is to conserve as much limb length as needed to preserve function and achieve a good prosthetic fit.
■ Complications:
● Hemorrhage: Bleeding
● Infection
● Skin breakdown
● Joint contracture
■ Medical Management
● Achieve healing of the amputation wound
● Edema control with limb shrinkers
■ Nursing Management:
● Promoting Wound Healing
○ Residual limb should be measured once every 8-12 hours for edema
○ Frequent neuro checks
○ Dressing changes as ordered
○ Monitor s/s of infection
● Enhancing Body Image
○ Establish trusting relationship
○ Encourages to look at, feel, and care for residual limb
○ Help regain independence in self-care
● Help Patient Resolve Grieving
○ Create an accepting and supportive atmosphere
○ Encourage patient to express and share feelings
○ Encourage family support
○ Educate patient on realistic rehab goals and future independent functioning
○ Refer to support groups
● Promoting Independent Self-Care
○ Encourage patient to be active participant
○ Provide supportive, relaxed, not rushed environment
○ Maintain positive attitude
○ Consult physical and occupational therapy
● Help Patient to Achieve Physical Mobility
○ Frequent position changes to prevent contractures
○ Consult physical therapy
○ Increase activity gradually
○ Use assistive devices
○ Remove environmental barriers
○ Prepare patient for prosthesis
● Monitoring and Managing Potential Complications
○ Hemorrhage
■ Monitor for s/s of bleeding
■ Monitor VS: BP
■ Monitor lab results (Hgb)
○ Infection
■ Administer antibiotics as prescribed
■ Monitor incision, dressing, and drainage
○ Skin Breakdown
■ Assess for breaks in skin
■ Perform careful skin hygiene
■ Assess skin for erythema, pressure areas, dermatitis, and blisters
■ Use of residual limb sock
Explain the factors that affect the severity of burn injury- depth/degree, total body surface area (TBSA), and rule of palm (measure the size)
● Depth: First degree, second degree, third degree ○ First degree: ■ Involves only epidermis ■ Skin is red, painful, blanches with pressure, dry ■ A few days to heal ■ Minimal or no residual scarring ■ Causes: ● UV radiation ● Scald ● Brief flash ○ Second degree: ■ Partial thickness injury: Involves epidermis & part of dermis ■ Skin: red, blistered, swollen, painful ■ May or may not heal in 2-3 weeks ■ May or may not produce scarring ■ Causes: ● Flash/flame: ● Scald: ● Contact: ○ Third degree: ■ Full thickness injury: Involves all of epidermis & dermis ■ Whitish or charred appearance. Tough, leathery ■ Sensation is lost. ■ Takes several weeks to heal. ■ Will result in scarring ■ Causes: ● Flame ● Chemical/Tar ● Scald ● Contact ● Electrical ● Total Body Surface Area (TBSA) Will be a calculation on the exam. ○ Head: 9% ○ Chest: 18% ○ Back: 18% ○ Each Arm: 9% ○ Each Leg: 18% ○ Groin: 1% ○ First degree burn is NOT calculated in TBSA. ● Rule of Palm (Measure the size) ○ Client’s palm = 1% TBSA ○ Used to estimate the extent of burns in those with scattered burns ● Location: ○ Face, hands or feet ● Treatment ● Age: Young children and older adults have increased morbidity and mortality ● Past medical history
Use the nursing process as a framework of care for the patient with burns (chemical burn) in the emergent/resuscitative
○ Chemical
■ Severity of the injury depends on the mechanism of action of the substance, the penetrating strength and concentration, and the amount of skin exposed to the agent
■ Immediately flush the skin with running water from a shower, hose, or faucet
● Note: Lye or white phosphorus should be brushed off the skin dry
■ Protect healthcare personnel from the substance
■ Determine the substance
■ Some substances may require prolonged flushing or irrigation
■ Follow-up care includes reexamination of the area at 24 hours, 72 hours, and 7 days
■ ACIDS:
● Cleaning solvents, hydrofluoric acid, hydrochloric acid, muriatic acid, oxalic acid, & sulfuric acid
● Hydrofluoric acid burns are unique:
○ Treat w/calcium: topical calcium gluconate & water soluble lubricant
○ IV & intrarterial for severe hypocalcemia
■ ALKALINE:
● Alkalis lye, cement, lime, drain openers
● Combines w/lipids & dissolves tissue. Almost turns skin into gel-like substance.
● Etiologies:
○ Work-related
○ Assault
○ improper use of household products
● Treat:
○ Dilute w/ copious amounts of water irrigation (15-20 minutes)
○ pH test of skin until the result is neutral
○ Do NOT attempt to neutralize with other substances
○ This causes an exothermic reaction & thermal injury
Compare priorities of care and potential complications for each phase of burn recovery.
● Initial Care ○ Stop the burning ○ Cool the burn ● Emergent/Resuscitative ○ From onset of injury to completion of fluid resuscitation ○ Primary survey: A, B, C, D ■ Airway ■ Breathing ■ Circulation ■ Disability ■ Environment/Exposure ■ Fluids ■ Head-to-toe Assessment ■ Labs. History. Tubes. Drains. IV lines. Meds. Dressings ○ Priorities: Replacing fluids is the main thing with burns!! ■ Prevent of shock ■ Prevent respiratory distress ■ Detect & treat concomitant injuries ■ Wound assessment ■ Initial care ● Acute/Intermediate phase ○ From beginning of diuresis to near completion of wound closure ○ Priorities: ■ Wound care & closure ■ Prevent or treat complications, including infection ■ Nutritional support ● Rehab ○ From major wound closure to return to optimal level of physical & psychosocial adjustment ○ Priorities: ■ Prevent & treat scars, contractures ■ Physical, occupational, & vocational rehab ■ Functional & cosmetic reconstruction ■ Psychosocial counseling
Plan fluid replacement requirements during the emergent/resuscitative phase of a burn injury.
● Factors to consider: ○ Burn size/depth ○ Inhalation injuries ○ Associated injuries ○ Age (children need more; older adults need less) ○ Escharotomies ○ Delay in resuscitation ○ Alcohol/drug involvement ● Over resuscitation: ○ Pulmonary edema ○ Peripheral edema ○ Compartment syndromes ● Under resuscitation: ○ Inadequate perfusion ○ Renal failure ○ Conversion ● Adults w/ in 24 hours post-thermal or chemical burns: ○ 2 mL LR x wt in kg x % TBSA 2nd, 3rd, & 4th degree burns ● Adults w/ electrical burns: ○ 4 mL LR x wt in kg x % TBSA 2nd, 3rd, & 4th degree burns ● The infusion is regulated so that one half of the calculated volume is administered in the first 8 hrs. ● Adjust rate of fluid resuscitation to: ○ Urine output: ■ ½ mL/kg/hr for adults ■ 1 mL/kg/hr for children ● Only a guideline! Fluid resuscitation must be tailored to specific needs!
Discuss the nurse’s role in burn wound management during the acute/intermediate phase of burn care.
Nonsurgical wound management
○ Drug Therapy:
■ Topical antimicrobials
■ Topical/systemic antibiotics
■ Pain management
■ No single topical medication is universally effective. Different agents may be used at different times post-burn.
○ Wound Dressing:
■ Cover in several layers of dressing (lighter dressing over joints to promote mobility)
■ Apply circumferential dressings distally to proximally: promote return of excess fluid
■ Fingers & toes wrapped individually: promote function while healing
■ Burns to face usually left open to air
■ Occlusive dressings for skin grafts: protect the graft
■ Use water to gently remove dressings
■ Documentation
● Surgical wound management
○ Wound debridement: Remove devitalized tissue
■ Goals: Remove devitalized tissue or burn eschar to prepare for grafting or wound healing. Remove tissue contaminated by bacteria, foreign bodies
○ Natural: Devitalized tissue separates from viable tissue spontaneously
■ May take weeks to months
○ Mechanical: Use of surgical tools to separate & remove eschar
○ Chemical: Topical enzymatic agents to promote debridement of burn wounds
○ Surgical: Removal of full thickness burned skin down to fascia or shaving of burned skin layers down to freely bleeding, viable tissue
● Cleaning a wound
○ Goals: Debride nonviable tissue. Remove previously applied topical agents. Apply new topical agents.
○ Methods:
■ Mild soap & water: prevent infection of the wound surface
■ Ambulatory clients may clean burn wounds in the shower
■ Nonambulatory clients have burn wounds washed at the bedside
○ Comfort:
■ Client participation is encouraged to promote exercise of extremities
■ Nurse inspects skin/wounds for any signs of infection or breakdown
■ Continuously assess for hypothermia
■ Maintain temperature of water at 100o F & temperature of the room 80-85o F
■ Assess fatigue, changes in hemodynamic status, pain control
Liver Function Tests:
· When the liver has a problem, ALT, AST, Ammonia will be elevated!
· Alanine aminotransferase (ALT): Know 40
o Normal:8-40 U/mL: Elevated in liver cell damage.
o Used to monitor course of hepatitis, cirrhosis
· Aspartate aminotransferase (AST): Know 40
o Normal: 10-40 U/mL: Elevated in liver cell damage.
· Gamma-glutamyl transferase (GGT): elevated with alcohol abuse
· Alkaline phosphatase (ALP)
o Injury to biliary tree (i.e. obstruction, tumors)
· Serum bilirubin: 0.3-1 mg/dL, Know 1, associated with Jaundice
o Associated with jaundice
· Serum albumin: 3.5-4.8 mg/dL, Know 4
o Affected in cirrhosis, chronic hepatitis, edema, and ascites.
o Albumin will be lowered, shows malnutrition
· Prothrombin:
o Normal: 9.0-11.5 sec: Prolonged in liver disease
· INR: 0.9-1.1
· Ammonia: Know 40
o Normal: 15-45 mcg/dL: Rises in liver failure
o Elevation causes mental status confusion (hepatic encephalopathy), this can lead to comatose.
