Exam 3 Flashcards
Pain scales
Children: Wong’s Faces
Adults: numerical 0-10
Who should not receive PCAs?
People who are not cognitively intact or little kids
What does the nurse need to do more often when a pt is on a PCA?
Assess vitals signs because of the risk of respiratory depression
-O2, BP, RR
What is a big side effect of PCA?
Constipation
Who determines if a pt needs a PCA?
anesthesiologist
How much Tylenol can be given to the elderly in one day?
1g/day
Alternative methods to ease pain
- Sleep
- drink lots of water
- thermal treatments
- acupuncture
- acupressure
- exercise
What do you document with pain patches?
Must mention that the old patch was removed and disposed of properly
PQRST pain assessment
P=provokes (what causes the pain) Q=quality (what does it feel like) R=radiates (where does the pain radiate) S=severity (scale of 0-10) T=time (time pain started)
Where are epidurals administered?
in the epidural space
Factors affected by cognitive disorders
Orientation Attention Memory Vocabulary Calculation ability Abstract thinking
What is the most common psychiatric syndrome in hospitals?
Delirium
-50% of occurrence in elderly inpatients
What is the priority care for patients experiencing delirium?
Safety
Delirium
Usually results from an acute disruption in the homeostasis of the brain
Dementia
-Results from primary brain pathology that usually is irreversible, chronic, and a slow progression
Diagnostic criteria for delirium
- Disordered cognition
- attention deficit
- disturbed consciousness
- disturbed sleep-wake cycles
- abnormal psychomotor behaviors
How many Americans are affected by Alzheimer’s? Prevalence in ages >65 and >85?
- 5 million
- occurs in 10% of people >65 years
- almost 50% of people >85
Deficits related to dementia
- impaired learning
- compromised ability for complex tasks
- impaired reasoning
- compromised spatial ability and orientation
- language deficits
- behavioral problems
Apraxia
inability to perform motor tasks despite intact motor function
Aphasia
loss of language
Sundowning
change in behavior after sunset
Agnosia
inability to recognize familiar objects
Risk factors for delirium
- aging
- postop status
- metabolic disorders
- drug withdrawal
- toxicity secondary to drugs or other exogenous substances
How is dementia characterized?
- several cognitive deficits that result from a general medical condition, use of substance, or multiple biologic etiologies
- gradual onset
Hallmark sign of Alzheimer’s
Post-mortem findings of beta-amyloid plaques in the brain
What does forensic mean?
Law
T or F:
You will always be in a forensic milieu even if you aren’t a forensic nurse.
True
Forensic nursing environments
- community based outpatient clinics
- secure units in general hospitals
- state psych hospitals
- forensic psych hospitals
- custodial type setting
Who has the highest population of incarcerated people in the western world?
The U.S.
Factors contributing to growing forensic population
- more drug-related activities
- rising interpersonal & urban violence
- anticrime & antidrug legislation
- poor economic conditions and associated homelessness
- criminalization of the mentally ill
T or F.
Correctional facilities have become the country’s front-line mental health providers representing the mental health institutions of the 21st century.
True
Approaches to prevent incarceration of the mentally ill
- Forensic assertive community treatment
- Sequential intercept model
Forensic assertive community treatment
integrates assertive community treatment and community justice intitiatives
Sequential intercept model
Envisions 5 points of interception, from law enforcement to community corrections and support, to prevent people from entering the criminal justice system
Characteristics of forensic clients
- demonstrate poor judgment
- have limited reasoning
- have a history of not learning from mistakes
- report an exceptionally high level of substance abuse at the time of arrest
Role of forensic nurse
To come up with alternatives to incarceration of offenders with mental illness
T or F
People with substance use disorders are at increased risk for mental illness
True
Forensic Populations
- suspects or convicts
- sentenced or unsentenced
- not guilty by reason of insanity
- incompetent to stand trial
- not criminally responsible because of mental disorders
What percentage of any prison or jail population has a mental disorder?
15%
Types of offenders in the prison population
- mentally ill
- violent
- juvenile
- female
- older adult
- offenders with HIV/AIDS or hepatitis
- offenders with terminal illness
Expressive violence
interpersonal altercations, usually with people known to the assailant and of similar age, ethnicity, and cultural background
Instrumental violence
usually involves premeditated, motive-driven acts
Gang violence
associated with group alliances and committed for retaliation or revenge
Custody vs caring
Doing what is beneficial for the community while advocating for the client
Characteristics of skilled forensic nurses
- Good communicators
- wide range of physical and psychosocial assessment skill
- solid critical thinking and decision making
- social maturity, adaptability, professionalism, and analytical skills
- confidence
- nonjudgmental attitudes
- ability to work independently and within teams
- decisiveness
- ability to work in a secure environment
A forensic psychiatric nurse performs crisis intervention for an inmate in a prison setting. What level of prevention does this action reflect?
Secondary
Factors affecting the provision of forensic psychiatric nursing care
- context of care
- number of clients
- lengths of stay
Recurring themes dominating therapeutic intervention
- power
- control
- negotiation
- trust building
when can children go back to regular activities after loss of function in a limb?
when they regain strength in that limb
how do you manage shoulder dislocation?
sling
difference between sprain and strain
- strain effects the muscles and tendons and could happen over time
- sprains effect the ligaments and happen immediately
therapeutic management of soft tissue injuries
RICE:
Rest Ice Compression Elevation Immobilization and support
how do you diagnose fractures?
xray
5 Ps of fracure assessments
Pain and point of tenderness Pulse Pallor Paresthesia Paralysis
DDH
developmental dysplasia of the hip
-test if child isn’t walking by 12 months
talipes carus
inversion, or bending inward
talipes valgus
eversion, or bending outward
talipes equinus
plantarflexion with the toes lower than the heel
talipes calcaneus
dorsiflexion with the toes higher than the heels
osteogenesis imperfecta
- excessive fragility and bone defects
- defective periosteal bone formation and reduced cortical thickness of bones
- hyperextensibility of ligaments
therapeutic management of osteogenesis imperfecta
- primarily supportive care
- caution with handling to prevent further fractures
- family education
- occupational planning and genetic counseling
most common spinal deformity
scoliosis
at what age should kids be screened for scoliosis?
girls 10-12 years
boys 13-14 years
hematocrit values
36-52%
erythrocyte sedimentation rate values
0-30
calcium values
3.9-4.6 mg/dl
When would C-reactive protein be elevated?
in RA
fracture definition
an interruption and/or disruption in the normal continuity of a bone that results from excessive force or stress
6 different directions of force for fractures
tensile, compressive, shearing, torsion, pulling, greenstick
causes of fractures
traumatic, pathologic, stress
closed vs open fractures
closed- skin is intact; open- skin is broken
complete vs incomplete fractures
- complete- both cortices are penetrated, producing two bone fragments
- incomplete- only one of the cortices are penetrated
clinical manifestations of fractures
- pain (immediate, severe, aggravated)
- loss of or unusual function (crepitus)
- structure, malalignment/ deformity
- exessive motion at sight
- local changes: edema, warmth, ecchymosis
- bleeding
- discoloration
- loss of sensation
- signs of shock
- evidence on xray
goal of fracture therapy
- reduce fracture by aligning the fragments
- maintain fragments in correct alignment
- restore function and prevent loss of mobility and muscle tone
optimal reduction treatment for fractures
(reduction: replacing bone fragments in their correct anatomical position)
- traction
- manual manipulation: moving fragments into position by applying traction and pressure to distal fragment (closed fractures only)
- open reduction (surgery)
immobilization treatments for fractures
- external fixation
- internal fixation
- traction
most common external fixation device
casts
plastic/fiberglass casts
- lightweight, dry quickly (30 mins), may feel warm during application, can get wet
- skin integrity is a major issue regardless of cast type
plaster of paris casts
cannot get wet- cover for bathing
traction
a pulling force applied to a part of the body while a counter traction pulls in the opposite direction
when would you use traction?
- to reduce a fracture
- immobilize a limb while healing
- overcome muscle spasm
- stretch adhesion
- correct deformities
5 types of traction
- Bucks and Russel: skin traction used to align a lower extremity fracture
- Skeletal: ex. crutchfiled tongs to correct cervial spine
- Bryants
- Pelvic
- Cervical: ex. halo- heavy and requires education regarding balance
weights and pulleys
should always be free hanging- no one should touch them
surgical management of fractures
- external
- internal
fat embolism syndrome
most frequently seen after long-bone fx., multiple fx, or pelvic fx., or surgery to these sites
clinical manifestations of fat embolism syndrome
look up
compartment syndrome
- high pressure in the muscle compartment in the close fascial space
- causes capillary blood perfusion to be reduced below the level of tissue viability
causes of compartment syndrome
- external compression (tight dressing, cast, brace)
- increased compartment content trauma
- bleeding
6 Ps of compartment syndrome
pain, paresthesia, paresis, pressure, pallor, pulse
hallmark signs of compartment syndome
- unrelenting pain (even with opioids)
- pain on passive stretch
what is often the FIRST sign of compartment syndrome
sensory deficit- feeling of “pins and needles”
most common surgical procedure in adults over 85
surgery for hip fractures
s/s of hip fracture
pain, immobility, *external rotation, *one leg shorter than the other
hip fracture treatment
pins or hip replacement
discharge teaching for post-hip replacement
advice to get an elevated toilet seat
knee trauma
cartilage (meniscus) or ligament
dx/tx of knee injuries
arthroscopy
meniscetomy
surgery for damaged cartilage
release surgery
for knee malalignment
osteotomies
surgery for joint restructuring
total knee replacement
metal/ polyethylene prostheses
post-op care of total knee replacement
- narcotic analgesics
- anti-infectives for the first 24hrs
- anticoagulants
- leg elevation
- hemovac
- CPM machine
- early ambulation with progression from non-weight bearing to partial weight bearing
amputation
removal of a limb/ appendage for ischemia, trauma, malignancy, infection
types of amputation
- closed or “flap”
- guillotine
post-op amputation
- pressure dsg
- elevate stump 24 hrs; after 24 hrs position prone
pathophysiology of gout
the overproduction of uric acid and the underexcretion (renal) of uric acid
prevention of renal calculi in pts with gout
2-3 liters of fluid per day
Risk factors for aggression
- impulsivity
- unfair application of rules
- unjust practice
- discrimination
- shaming
- humiliation
Manifestations of Negative Emotionality
- irregularity in biologic function
- behavioral inhibition
- slow adaptability
- intense and negative mood
Contributing factors to problems with anger and violence
- psychiatric illness
- medical conditions
- traumatic life events
- biologic factors and temperament
- social environmental factors
Staff behavior contributing to anger in clients
- rules that prevent clients from leaving activities
- power disputes over medications
- blocked access to phones, televisions, or rooms
- denials of requests in general
- physical restraint
- ignoring clients
- ordering clients to do or not to do something
Criteria for involuntary outpatient commitment
There must be imminent danger to themselves or others
T or F
Regarding the rights of clients in hospitals and clinics, voluntary clients may refuse any treatment, although staff at the facility may then ask clients to leave
True
Which of the following is a result of the Tarasoff decision?
Mandatory reporting of threats with intent to harm people
Overall goal for aggressive or violent clients
- not threatening or harming anyone
- gaining insight into, and skill at, managing aggressive impulses
5 steps to communication
- Making personal contact
- Discovering the source of distress
- Relieving the distress
- Keeping everyone safe
- Assisting with alternative behaviors and problem solving
Diagnoses relevant to aggression
- Risk for self directed violence
- Risk for other directed violence
- Ineffective coping r/t psychopathology
- Poor impulse control
Goals of therapy
- impulse control
- aggression control
- abusive behavior self-restraint
- coping
Treating pain in the elderly
- start low
- be careful with ice packs because of vasoconstriction in already-low areas of blood flow, could cause ischemia
- may need more time between doses of medication
Who might have problems being on a PCA (of those who are eligible)?
People with sleep apnea
hallmark sign of dementia
aphasia
perioperative nursing diagnoses
- risk for imbalanced fluid volume
- risk for perioperative positioning injury
preoperative nursing diagnoses
- anxiety
- risk for infection
postop assessments for early detection of complications
- frequent vitals
- respiratory status
- BP
- wound
- temp
- CNS status (alertness, movement, shivering)
- fluid status
- GI status (N/V, movement of bowels)
signs of thrombophlebitis
- pain on the calf or thigh of the involved extremity
- redness, swelling in effected area, elevated temp and increased diameter of the extremity
safety measures during intraoperative period
-positioning: body alignment is a must, lifting rather than sliding to prevent shearing
DIC (disseminated intravascular coagulation)
phenomenon where the patient is clotting and bleeding at the same time; all the clotting factors get sent to the site of damage and leave no clotting factors in the rest of the body
malignant hyperthermia s/s
- muscle stiffness
- hypercarbia (increase in CO2), tachycardia, tachypnea, hypoxia,
- temp will rise 1-2 degrees Celsius every 5 minutes
treatment of hyperthermia
DISOCONTINUE the agent, stop surgery, 100% oxygen, and administer DANTROLENE SODIUM stat
-COOL the patient (ice lavage open cavities)
alkaline phosphatase values
adults 25-100 U/L
