Final Exam Flashcards
Priority risks of amputation
infection and mobility
Acute care setting considerations for amputation
hemorrhage, molding nub to fit with prosthesis without irritating the skin the prosthetic has a sock and then it fits over
dysmelia
limb isn’t formed correctly
congenital
nontraumatic amputation
amniotic baby syndrome
piece of amniotic sac tangles and cuts off blood supply to limb and can warrant amputation (1 in 2000 babies)
compartment syndrome
accident where fluid collects in fascia so it cuts off circulation
how often should a foot exam be done
once a year
what is done if revascularization is possible
angiography
5 Ps of neurovascular assessment
pain
pallor
pulse
paresthesia
paralysis
transtibial amputation
below the knee
transhumeral amputation
above elbows
two types of prosthetic limbs
cable operated limbs
myoelectric arms
transradial prosthesis-myoelectric arms
Myoelectric arms work by sensing with electrodes when the muscles in the upper arm moves, causing an artificial hand to open or close
transradial prosthesis-cable operated limbs
attaches a harness and cable around the opposite shoulder of the damaged arm
what to test in traumatic amputation
function of residual limb
neurovascular assessment
BOTH EXTREMITIES
meds for amputees
corticosteroids
anticoags
vasodilators/constrictors
skin perfusion test for amputation healing
look at hair growth
bleeding at operative site
pedal pulse
comparing both sides
rigid or soft compression bandage
can’t fit prosthetic device if swollen
gives uniform compression
wound drainage devices can control what 2 things
hematomas
wound drainage
what to do if amputation bandage comes off
reapply
don’t call doc
post-op bandage removal for amputees
unwrap q4-6h post op then once every day
compression band for amputees
MUST BE ON AT ALL TIMES
SHAPES THE STUMP
PREVENTS EDEMA
elevate the limb
meds for phantom pain
acetaminophen and NSAIDS
BB for dull pain, anticonvulsants for stabbing pain, antidepressants
nonpharm thing for phantom pain (medical thing, not mental)
epidural perineural catheter
how to remove hematoma in amputees
use drain to get rid of fluid accumulation
neuro pain in amputees
very common
usually for above the knee amputations
changes in peripheral and CNS
non-pharm methods for amputation pain
mirror therapy
massaging
guided imagery
acupuncture
post-op monitoring for edema for amputation
measure limb q8-12h after surgery for edema
consistent pressure
amputation for osteomyelitis
usually whole limb
when should you stop wearing artificial limb
if any sweating, breakdown, or infection until body heals
catheters and amputation surgery
catheterization immediately after surgery
why is position changing important with amputation
to prevent spasms
side to side for knee amputations should be frequent
what position is best for amputations
prone
decreases hip flexion and contractures
lower limb amputations are prone to what
contractures
avoid abduction and external rotation
causes issues with prosthetic
what to use before prosthetic is applied
assistive devices
what to keep at the side of the bed after amputation to prevent hemorrhage
a tourniquet
joint contracture
caused by poor positioning
can be caused by protective flexion withdrawal pattern associated with pain and balance
Prevention is key (pain control, ROM exercises)
Avoid abduction in lower extremities (kneecap pointed toward ceiling)
Raise foot of bed to elevate limb
Lie prone with leg fully extended
contracture
Abnormal shortening of joint or muscle
how should amputee lay down
on stomach to help stretch hamstring muscle to prevent flexion contractures for proper fit of prosthetics
color and temp of amputation site
Skin flap should appear pink in a light skinned person and not discolored in a darker skinned person
The area should feel warm but not hot
Pale cool skin could indicate inadequate blood flow to the sea
Notify provider if pale and cool
when should stump be washed
every day at night to prevent damp skin from swelling and sticking to the inside of the socket
Use mild fragrance-free soap or antiseptic cleanser
Dry the skin
The sock helps keep perspiration away from the skin
A client undergoes a surgical amputation of a lower extremity after a MVA. The client’s vital signs are stable. What is a priority nursing action in the early postoperative period to help prevent complications in this client?
A. fitting the client with a prosthetic device
B. inspecting the limb stump for signs of skin breakdown
C. positioning and ROM of affected extremity
D. Teaching the client and family how to apply shrinker stockings
C
A client is recovering from an above the knee amputation resulting from PVD. Which statement indicates that the client is coping well after the procedure?
A. “my spouse will be the only person to change my dressing”
B. “I can’t believe that this has happened to me. I can’t stand to look at it”
C. “I don’t want any visitors while I’m in the hospital.”
D. “it will take me some time to get used to this”
D
A nurse is caring for a client who is recovering from an above-the-knee amputation. The client reports pain in the limb that was removed. How should the nurse respond?
A. “the pain you are feeling does not exist”
B. “this is common and will go away”
C. “”Would you like to learn how to use imagery to minimize your pain?’
D. “how you would describe the pain you are feeling?”
D
A nurse cares for an older adult client who is recovering from a leg amputation surgery. The client states, “I don’t want to live with only one leg. I should have died during the surgery.” Nurse response…
A. “your vitals are good, and you’re doing fine right now”
B. “your children are waiting outside. do u want them to grow up without a father?”
C. “This is a big change for you. what support system do you have to help you cope?”
D. “You will be able to do some of the same things as before you became disabled”
C
A nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. The nurse immediately:
A. Calls the physician
B. Applies ice to the site
C. Rewraps the stump with an elastic compression bandage
D. Applies a dry sterile dressing and elevates it on one pillow
C
ROM in musculoskeletal injury
on unaffected side
palpate gently
check for metabolic bone disorders
kyphosis
Forward thoracic curve of the spine
Called dowagers hump
Hunchback
scoliosis
Sideways curvature of the spine
Can cause lung problems depending on severity of curve
Can wear a brace while young but need surgery when older
lordosis
Inward curve of the lumbar spine
Abdominal fat, “swayback”
Common in pregnant women
Weak back, causes fatigue
joint and bone ROM
gentle
see if they can lift their arm
do they have osteoarthritis?
noninvasive tests for testing musculoskeletal structure
DXA: most significant, done bc not detected on xray until 30-50% bone mass gone, follow ups
fluoroscopy: another type of xray, moving images
CT
MRI
invasive tests for testing musculoskeletal structure
radionuclide imaging (bone/gallium scans)
-scans entire body, inject tiotropium IV, pain but no harm
arthrocentesis (pain, rest, pressure, bandage to prevent hematoma and bleeding), injecting into the joint, analgesics given, rest 8-24h before
other scans for musculoskeletal
arthrocentesis
arthroscopy
electromyography
biopsy
arthrocentesis for musculoskeletal
Pain
Rest
Pressure
-Bandage to prevent hematoma (may put pressure on nerve endings)
-Bleeding can occur
Injecting into the joint, analgesics given
Pt must rest for 8-24 hours after testing
arthroscopy for musculoskeletal
Infection
Hematoma
Could be bleeding and be painful because it will put pressure on the nerve endings in the area
Inject a needle and aspirate blood or fluid from the joints (diagnosis)
Assesses internal structure of the joint
May also inject medication into joint (treatment)
Ex: corticosteroids, meniscus tears
Must be done in sterile technique
Neurovascular checks, the 5 P’s
Patients receive local anesthesia, patient is allowed to walk after surgery, must avoid strenuous exercises for a few days
electromyography for musculoskeletal
looking at muscle and nerve area
biopsy for musculoskeletal
for any kind of pain or complaint (swelling or suspicious)
blood tests for musculoskeletal
ANA
CRP
ESR
mineral metabolism
muscle enzymes
electrolytes
ANA for musculoskeletal blood test
to detect immunologic abnormality such as RA
CRP for musculoskeletal blood test
detects inflammation in the body
ESR for musculoskeletal blood test
looking for elevations and conditions such as RA, osteomyelitis, infection
mineral metabolism for musculoskeletal blood test
looking for breakdown of minerals (Ca+, phosphorus, uric acid, K+)
muscle enzymes for musculoskeletal blood test
muscle breakdown and weakness/pain
electrolytes for musculoskeletal blood test
Ca+, phosphorus, uric acid, K+
metabolic bone disorders
osteoporosis
paget’s disease (osteitis deformans)
remodeling for bones
removes pieces of old bone and replaces them with new, fresh bone
paget and remodeling
causes this process to shift out of balance, resulting in new bone that is abnormally shaped, weak, and brittle
osteoporosis
disruption in remodeling process
Osteoclastic (bone resorption) > osteoblastic (bone building)
Low bone mass
Loss of calcium
Bone deterioration
Porous bones → spongy
Systemic skeletal disease
WHO standard for osteoporosis
t-score from DXA
osteopenia
osteoporosis in postmenopausal women
t-score for osteoporosis
the number of standard deviation above or below the average BMD for young, healthy white women
osteopenia for osteoporosis
T-score is between 1 and 2.5 SD below normal
Precursor to osteoporosis
Can be corrected with certain meds (bisphosphonates) to help with bone building to prevent osteoporosis
osteoporosis in postmenopausal women
BMD T-score of more than 2.5 SD below normal
-2.5 or below
Mostly seen in here bc it’s so low
bone density peak
10-35
why do postmenopausal women have high risk for osteoporosis
low estrogen=body needs calcium and takes it from bones
bone fragility
HIP FRACTURES
osteoporosis risk factors
female (thinner and decrease in estrogen)
postmenopause
breastfeeding
ethnicity (caucasian and asian)
family hx
sedentary lifestyle, alcohol, smoking
calcium and vit d deficiency
med conditions (malabsorption, liver, hyperparathyroid, thyrotoxicosis)
meds (thyroid, corticosteroids, furosemide, anticonvulsants)
med management of osteoporosis
prevention of loss of bone mass
increase Ca and vit d intake, exercise, and reduce alcohol and stop tobacco
prevent bone reabsorption (HRT estrogen be aware of SE)
patient education of osteoporosis
dairy, calcium supplements (w food), calcium fortified foods
green veggies, sardines, salmon w bone, broccoli, milk, OJ with calcium, almonds
avoid high protein, sodium, and caffeine
perform weight bearing exercise (not cycling or swimming)
diphosphonates (boniva upright for 1 hr, fosamax upright for 30 mins, empty stomach, first thing in morning with 8oz water to prevent esophagitis)
paget’s disease
Metabolic disorder of bone remodeling
Insidious onset
Increase in osteoclastic activity
Weak
Large
Disorganized
Asymptomatic
Increased rate of bone tissue breakdown and osteoclastic activity, then a rapid bone formation
Bone is weak, large, and disorganized
Abnormal bone architecture
2nd most common bone disease after osteoporosis
Affects skull, long bones, spine, and ribs (enlarged and deformed)
Symptoms depend on which bones affected
fatal after 40
etiology and manifestations of paget’s
Unknown etiology
Virus
Heredity
Normal bone marrow replaced by vascular, fibrous connective tissue (causes bone pain, arthritis)
Bone pain
Nerve compression (Puts pressure on nerves because bones are enlarged)
Painful Deformities
Arthritis (Damage to joint and cartilage)
Changes in skin temperature
Pathologic fracture
med treatment for paget’s
pain control with NSAIDS or COX-2 inhibitors
diphosphonates (fosamax)
calcitonin
surgical joint replacement
pain management of paget’s
Applying heat, gentle massage, giving pain medications
Need an order for cold or heat therapy
osteoarthritis
Slowly progressive chronic joint disease
degeneration and loss of articular cartilage covering joint surfaces in synovial joints
Bones are going to grate against each other
Symptoms: pain/cramping, immobility of area, loose bone fragments in X-rays, crepitus
Seen in weight-bearing joints like knees, hips, back
Most common form of arthritis
risk factors of osteoarthritis
age (middle to older adults)
obesity (arthritis of the knee)
sports/work injuries
genetics (defective cartilage or a defective joint)
clinical manifestations of osteoarthritis
early morning stiffness
dull pain worse by the end of the day (rest!)
crepitus (sound of rough joints rubbing and breakage of bone)
deficits in ROM
joint enlargement
Heberden’s nodes in osteoarthritis
raised bony growths over DISTAL interphalangeal joints
bouchard’s nodes
raised bony growths over PROXIMAL interphalangeal joints
aleve for pain
don’t take large doses
take with food or milk (can lead to ulcers)
alternative therapy for musculoskeletal injury
glucosamine chondroitin
arthroplasty
Total Hip Replacement
Total Knee Replacement
Replaced with prosthesis (metal or plastic)
Eliminates pain, improves quality of life
Contraindicated by recent active infection or arterial impairment to extremities (PVD), unable to follow post-op regimen, cardiac problems
postop goals for musculoskeletal injury
Prevent deformity and contractures of knee, foot, and hip
Restore weight-bearing (ambulation or assistive devices)
Pain relief
Prevent complications
Maintain optimal physiologic function
complications of musculoskeletal surgery
DVT (most common)
Pneumonia
Skin breakdown
Sepsis
Delirium from long surgery and anesthesia
Dislocation
Infection
Immobility
Compartment syndrome
preventing DVTs after musculoskeletal injury
anticoags (fixed dose SC hep or warfarin)
SCDs
thigh high compression stockings (top is loose)
leg exercises (pROM)
monitor vitals and ROM on both sides
avoid knee gatch (cuts off circulation)
don’t massage legs
postop teaching for musculoskeletal injury
continuous passive motion (8h/day to prevent stiff joints, need opioids)
teach s/s of infection (foreign object in body, give abx)
s/s of DVT
PT
total hip replacement precautions
total hip replacement precautions
90 degree flexion for 4-6 weeks
high chair with arms
abduction pillow (don’t adduct, wedge device between knees)
elevated toilet seats
NO INTERNAL ROTATION ANYWHERE
don’t cross legs
don’t twist to reach for objects (use reachers or sock pullers)
don’t drive
no baths for 4-6 weeks
strain
trauma to muscle, ligament, or tendon from overuse or misuse
RICE for strains
rest
ice for 24-72 hours (follow with heat)
compression (maybe splinting)
elevation
care for mild sprain
RICE
care for moderate sprain
RICE
care for severe sprain
surgery
if acute, ligament is torn from attachment or from the body of the ligament itself
may need cast or brace for 4-6 weeks
fracture
break in continuity of bone
closed (simple) fracture
Bone breaks, skin remains intact
Can’t see broken bone
May see deformity, but not bone itself (no bleeding)
open (compound) fracture
Broken ends of bone penetrates skin
Skin is the first line of defense which fights off bacteria
Person is at high risk for infection
complete fracture
Break across entire substance of bone
Bone is often misplaced
Ends are removed from normal position
incomplete fracture
Break through part of cross section of bone
“Green-stick fracture”
comminuted fracture
Several bone fragments
Within the bone
depressed fracture
bone fragments driven inward
repair of fracture is called
reduction
buck’s extension traction
returns bone to normal position
tension helps to realign the bone
grade 1 fracture
Clean wound <1 cm
Minimum contamination (least severe)
grade 2 fracture
Larger wound
No extensive soft tissue damage
>1 cm
Moderate contamination
Skin and muscle contusions
grade 3 fracture
> 6 cm
Heavy contamination
Extensive soft tissue damage (most severe)
Skin, muscle, nerves, blood vessels are all involved
3 stages of bone healing
inflammatory
reparative
remodeling
inflammatory phase of bone healing
First thing that happens during fracture
Holding breath
Hematoma forms at fracture site (forms within 1-3 days after fracture)
reparative phase of bone healing
Fibrocartilage formation
Calcium is deposited in area
remodeling phase of bone healing
callus formation
ossification
clinical manifestations of fractures
hematoma (first, 1-3 days after)
pain (from hematoma putting pressure on nerves, inflammatory)
edema
bruising
deformity (may need buck’s extension)
spasm (from nerve pressure)
loss of function
abnormal mobility
crepitus
neurovascular changes
shock
medical management of fracture
stimulate healing!!
immobilization above and below fracture with splints (don’t want to displace bone)
good blood supply
adequate nutrition
weight bearing depending on orthopedic surgeon, can lead to malformation
closed reduction
External manipulation to realign bones
No surgical incision
Pins to hold bones together
Fixation
open reduction
Surgical procedure to realign the bones
Open the area
Pins and screws also used
ORIF (open reduction with internal fixation)
fixation
pins, screws
holds the bones together
traction
Manually realign displaced fractured bone fragments
Reduces types of spasm or pain
Prevent deformities from occurring
Ex: Buck’s, cervical/neck, upright extremity, arms
Nurse is trying to prevent neuromuscular compromise
Neuromuscular check to make sure it is not too tight
nonsurgical management of fractures
closed reduction and immobilization
-bandage (wrap)
-splint
-cast
-traction (has wrap underneath which the nurse doesn’t remove)
-extremity elevated above heart
prevent deformities (malunion, nonunion, or malformation)
prevent neuromuscular compromise
nursing management of fractures
assess 5 Ps of neurovascular status
elevate above heart level
ice for first 24-48 hours, one hour at a time
immobilize joints
sterile dressing
analgesics for pain
nursing interventions post-op for external fixation
pin assessment and care q8h
drainage (odor, amount, type)
loosening of pins
tenting of skin
sterile technique (high chance of contamination)
one cotton swab per pin
prevent infection with hydrogen peroxide, iodine to clean pins
prophylactic abx
neurovascular assessment q1-2h for first 24h
bandaging, may be too tight if pt has unrelieved pain
assess for complications
compartment syndrome
Fluid tissue from injury fills up compartment, pressure from compartment increases
Capillary blood flow decreases, greater swelling
Sensory nerves affected = pain, numbness, tingling
Arterial blood flow compromised
Motor function impaired, can lead to amputation
IF PAIN ISN’T RESOLVED BY MEDS, SUSPECT THIS!!
Impairment of circulation within fascia
Affects nerve
Caused by external pressure
Casts, splints, tight bulky dressings, crushing injury, surgery, trauma from accident
open fascia to relieve pressure or else tissue death, nerve injury
ischemic edema cycle
Ischemic bc circulation compromised from worsening edema (fluid has nowhere to go)
Myoglobin released from damaged tissue
renal failure from compartment syndrome
myoglobin trapped in renal tubules
clinical manifestations of compartment syndrome
pain w elevation (nerve damage irreversible after 4-6h)
diminished or absent pulses distal from injury
cyanosis of extremity
paresthesia
pallor
coolness
weakness
irreversible neuromuscular damage
functionless limb (may need amputation after 24-48 hours)
buck’s traction
may be used before surgery
Returns bone fragments to original position
Partial weight bearing
30%-50% of weight on the affected extremity
Add/remove weights slowly
Physician may write script, physical therapist can perform the skill
Weights hang freely form pulleys
No tangling of rope in pulleys
ROM must be done
impaired physical mobility
NO FOWLER POSITION
joint ROM except those proximal and distal to fracture
cast application
more effective than splint
can’t take it off (malunion)
applied AFTER swelling subsides bc compartment syndrome
support extremity from underneath w palms w even pressure
fingertips SHOULDN’T be pressed in cast
don’t rest cast on hard surface
cleanse pt of excess casting material
wait 30 min before weight bearing activity (drying time)
musty odor=infection
wrap in plastic bag during showers
nursing care of cast
check for edema
position to prevent or relieve swelling
elevate extremity (higher than heart for 24-48h, may use pillows, sling attached to IV pole, support ENTIRE arm, fingers HIGHER than elbow)
widowed or bivalved cast care
cut cast in half to detect or relieve pressure
cut windows out to assess wounds or circulation
-surgeon can inspect or clean
allow removal of cast for wound care or x-rays
remaining half of a bivalve cast as intermittent splint (can be removed and reapplied as pt adjusts)
do not pinch pts skin between half halves
secure halves with elastic tape
what to assess with windowed or bivalved cast
neurovascular status
cast (don’t put things in there to scratch)
complications (infection or drainage, OUTLINE DRAINAGE)
Open Reduction and Internal Fixation (ORIF)
fracture immobilization with metal device (screws, pins, or plates, insertion to realign fracture)
may use traction before surgery
total knee replacement: wrapped in bandage
neurovascular check
frequent x-rays
use this when casts and tractions aren’t appropriate for this fracture
complications after fractures
Nerve Injury
Compartment Syndrome
Volkmann’s Contracture
Fat Embolism Syndrome
Deep Vein Thrombosis
Infection (pain, warm, tenderness, chills, malaise, discoloration)
Dislocation (sudden pain and cannot move)
High-back chairs with armrest
volkmann’s contracture
permanent flexion contracture of the hand at the wrist (like a claw)
painful restricted passive extension of fingers
white or blue fingers
radial pulse absent
more common in children
caused by obstruction of brachial artery (from cast or compartment syndrome)
fat embolism syndrome
just as crucial as a blood clot
fat globules released from bone marrow
corticosteroids! not anticoags
ARDS (acute resp distress syndrome)
PE
complications of idk something
DVT:
death
cool extremities (NOT in fat embolism)
calf pain and tenderness
swelling and edema
PE: give heparin
infection:
wound drainage, fever, pain, odor, foreign objects
long term complications of something idk
Joint Stiffness
Post-traumatic Arthritis
Avascular necrosis
Nonfunctional Union after a Fracture
Mal-union
-Delayed Union
-Non-union
-Fibrous Union
What findings can be identified with the use of radiography of the spine?
A. Fracture, dislocation, infection, osteoarthritis, or scoliosis
B. Infections, tumors, and bone marrow abnormalities
C. Soft tissue lesions adjacent to the vertebral column
D. Spinal nerve root disorders
A
B is bone scan
C is CT scan
D is electromyography
How long does a patient taking bisphosphonates need to stay upright after administration?
A. 10 minutes
B. 20 minutes
C. 30 minutes
D. 120 minutes
(or 60 if monthly) ON AN EMPTY STOMACH WITH A LARGE GLASS OF WATER
What is a cast?
A. Bandage used to support a body part
B. Rigid external immobilizing device molded to contours of body part
C. Device designed specifically to support and immobilize a body part in a desired position
D. Externally applied device to support the body or a body part, control movement, and prevent injury
B
A is a sling
C is traction?
D is a brace
Is the following statement true or false?
A patient’s unrelieved pain should be reported to the physician 30 minutes after administered pain medication
false, it should be reported immediately
Is the following statement true or false?
The nurse never adjusts the clamps on the external fixator frame
True, only provider can
Is the following statement true or false?
The nurse must never remove weights from skeletal traction unless a life-threatening situation occurs
true bc life threatening
How often must the nurse inspect the traction pin site for signs of inflammation and evidence of infection?
A. Every 8 hours
B. Every 12 hours
C. Every 16 hours
D. Every 24 hours
A
What is a contusion?
A. A musculotendinous injury
B. Blunt force injury to soft tissue
C. A break in the continuity of a bone
D. An injury to ligaments and other soft tissues at a joint
B
A is a strain
C is a fracture
D is a sprain
Is the following statement true or false?
Testing for crepitus can produce further tissue damage and should be avoided
true
Is the following statement true or false?
Avascular necrosis is prolongation of expected healing time for a fracture
false, it is called delayed union
epidermis
Thickest over the hands and soles of feet
Melanin
Merkel cells,
Keratinocytes
Langerhans cells (immune system reactions)
Replaced every 3-4 weeks
Prevents excessive fluid loss
Melanocytes give pigmentation
dermis
Largest portion of the skin
Collagen
Elastic fibers
“True skin”
Gives strength and structure to bodies
Contains blood vessels, lymph nerves, sweat/sebaceous glands, hair root
subcutaneous layer (hypodermis)
Regulates heat loss (thermoregulation)
Adipose
Connective tissue
Provides cushion between skin layers and bones and muscles
functions of the skin
protection
sensation
fluid balance (epidermis absorbs water, burns cause fluid loss)
temp regulation (based on CORE temp, not skin temp)
vitamin production (need vit d 2x?)
immune response function (cells of langerhan have immunoreceptors for immunoglobulin [IgE], prevents secondary infection)
skin changes with aging
losing moisture, collagen, and elasticity
skin tears (allows for shearing from dragging)
vascular changes (decrease causing decreased wound healing)
hormonal changes (decreased androgens and sebaceous gland function)
sensory perception, thermoregulation, and barrier function
skin care normally
soap that is mild and free of lipids (like dove)
dry skin by blotting gently with soft cloth
loofah is fine while young
avoid harsh chemicals and perfumes
sunblock!
pruritus
nerve endings in skin trigger itching sensation
may indicate diabetes, blood disorders, and liver issues
seen more in elderly (dry skin, meds, and comorbidities)
what meds can trigger pruritus (4)
ASA
abx
hormones
opioids
vicious cycle of itch
scratching causes inflamed cells to release histamine making it more itchy
plus altered skin integrity allows portal of entry
how to resolve pruritus (nonpharm)
lukewarm bath, cold compress, and humidifier for cool environment
medical management of pruritus
lidocaine
capsaicin (capzasin): good for nerve pain from conditions causing pruritus, acts as an antihistamine
hydrocortisone (alleviates pruritus with inflammatory responses)
diphenhydramine (benadryl)
hydroxyzine (atarax)
acne vulgaris
common
affects hair follicles of face, neck, and upper trunk
more prevalent in males during adolescence
females during adulthood
-androgens stimulate sebaceous glands during puberty
-secrete sebum
-when they get clogged, inflammation causes acne
can be genetic, hormonal, bacterial, or a combo
topical therapy for acne
removes sebaceous oils
salicylic acid (can be harsh on sensitive skin, suppresses sebum production)
benzoyl peroxide (harsh)
vitamin A (clears keratin plugs)
systemic therapy for acne
oral abx
retinoids (synthetic vit A compounds)
-when other methods are ineffective
last type of therapy to be used
for nodular/cystic acne
hormones for acne
estrogen
reduces oily skin by suppressing sebum production
only used in women
pyodermas
Bacterial skin infections
caused by staph aureus or A. streptococcus
impetigo
folliculitis
furuncles
carbuncles
impetigo
superficial skin infection
caused by strep, staph, or a combo
bullous or nonbullous
begin as small, red macules that crust over
seen in young children
CONTAGIOUS!!
treated with abx
antibacterial soap!! not dove
bullous
blisters
if they rupture, area is left raw and red
nonbullous
from compromised skin integrity (cuts, abrasions, bruises that are open or shearing)
medical management of impetigo
topical abx therapy (mupirocin/bactroban): used best when affected area is small, applied 5-7x/day
systemic agents (augmentin, trimethoprim/sulfamethoxazole/bactrim, clindamycin, vancomycin if MRSA is present or systemic manifestations)
Folliculitis, Furuncles, Carbuncles
Inflammatory condition
Can be bacterial or fungal in nature
Papules or Pustules form close to hair follicles
Commonly occur in areas or shaving
Like razor bumps
Usually caused by Staphylococci (gram negative)
furuncles
boils, deep inflammation
carbuncles
abscess of skin and subcutaneous tissue, extension of furuncle
med management of Folliculitis, Furuncles, Carbuncles
systemic abx therapy (C&S, dicloxacillin or cephalosporins, clinda or bactrim if MRSA +)
incision and drainage to evacuate pus (cover drainage lesion with dressing!)
nursing management of Folliculitis, Furuncles, Carbuncles
IV fluids
fever reduction in bacterial infection
warm, moist compress
ensure cleanliness of surrounding skin
wear gloves!
herpes zoster
shingles!
VZV
increased prevalence in elderly and immunocompromised
virus lies dormant in brain and spinal cord
reactivation causes virus to multiply (looks like chicken pox)
elderly lose natural immunity
immunocompromised (HIV, cancer) high risk
3 phases of herpes zoster
pre-eruptive
acute eruptive
post perpetic neuralgia (PHN)
pre-eruptive phase of herpes zoster
Previously dormant VSV becomes reactivated
Very painful and itchy
Besides the itching and pain, the person is also beginning to have blisters
Can last 1-10 days (usually 48 hours)
acute eruptive phase of herpes zoster
Appearance of patchy, red areas all over
Rupture, curst over
Extremely painful period
Lasts 10-15 days
post-herpetic neuralgia (PHN)
Localized pain for 30 days or longer
Much longer in elderly
Person may continue to experience pain for the next 2 months or so
oral antiviral agents for herpes zoster
aciclovir (zorivax)
Valaciclovir (Valtrex)
Famciclovir (Famvir)
analgesic agents
IV in first 24h of initial eruption
systemic corticosteroids for herpes zoster do what
reduce duration of PHN
vaccines for herpes zoster
Zostavax
Was found to be only 50-64% effective, taken off the market bc it causes necrotizing retinitis
Shingrix
New vaccine
97% effective
Recommended for immunocompromised elderly individuals
nursing management of herpes zoster
apply wet dressings to affected area
assess pain and administer meds
teach care
herpes simplex
HS1: lips, mouth, gums, tongue
HS2: genitals
tinea
Most common fungal skin infection
Affects head, body, groin, feet, nails
Scales
From the margin on the lesion and tested for a definitive diagnosis
tinea capitis
on the head
Common in children
Oval, scaling, erythematous patches on scalp
Brittle hair, temporary hair loss in the area
Can be treated
Oral antifungals for 4-6 weeks
Nizoral (anti-dandruff) shampoo 2-3 times
Oils can help dryness of area
tinea pedis
Athlete’s Foot
Most common in adults
Scaling
Mild redness on soles of feet
Maceration in the interspaces of the toes
treatment of tinea pedis
Topical antifungals (lotrimin once or twice daily)
Put socks on before underwear to avoid cross contamination to groin (can lead to tinea pubis)
Topical agents or shampoo
Instruct hygiene with clean towels every day
Keep soles of feet and between the toes dry
Plastic shoes and wet swimwear for very long time can cause fungal infection
pediculosis
lice
body lice
from poor hygiene unlike head lice
spread by sexual contact
bathe in soap and water
use scabicides (permethrin)
vaseline to eyelashes make nits easier to remove
scabies
caused by mites
involves fingers
common in areas with substandard hygiene
takes symptoms 4 weeks from contact to appear
small raised burrows with itching at night
treated with scabicides (permethrin)
apply thin layer on body for 10-24h, wash off, done for a week
wash clothes at high temp
elderly pts at high risk
med applied after bathing while skin is wet
wear gloves!
warm soapy baths
meds for only a week even if itching continues
ectoparasites
outside of host, feed on host 5x/day
back of the head and below the ears
shampoos for lice
Lindane (Kwell)
Toxic effects
Should be used only as recommended
Pyrethrin (RID)
Permethrin (NIX)
temp for washing things when you have lice
130F
scabies treated with what
5% permethrin
psoriasis
Chronic, non-communicable skin disease
Silvery plaques over elbows, knees, scalp, lower back, or buttocks
Exacerbations and remissions
Triggered by stress, anxiety, trauma, seasonal and hormonal changes
Autoimmune-based
Issues with body image
med management of psoriasis
blue lagoon?
slow rapid turnover of epidermis
management of stress and anxiety
remove scales with mineral oil
ammonium lactate (lac-hydrin, used after bathing)
phototherapy (UV, 2-3x/week for outbreak, 48h breaks)
systemic treatment (corticosteroids avoided bc flareup when withdrawn)
nursing management of psoriasis
not infectious or poor hygiene
identify stressors and stress management
bathe in warm water and DRY the skin
avoid scratching and picking
psoriatic arthritis is a long term complication
basal cell carcinoma
most common type
from sun exposure
assess for skin abnormalities
fair skin is a risk
usually no metastasis
recurrence common
a type of melanoma
what does basal cell carcinoma look like
pearl-like bump, small, waxy nodule with central crater, flay, gray/yellow
on head, neck, arms, hands, and face
irregular shape
squamous cell carcinoma
Epidermis
Not as aggressive as melanoma
Can lead to fatality if it grows
May metastasize by blood or lymph
Rough, thick, and scaly tumor
May be asymptomatic or start bleeding
Border is wide and infiltrates deep
More inflamed
melanoma
From a mole
Irregular shape
Reddish, bluish tint, dark
Diameter > 6mm
Can spread
Seen in dermis and epidermis
Change or new growth on skin
Very dark
Rapid growth and bleeding
Surgical excision of tumor needed and possibly chemotherapy
carposi’s sarcoma
Melanoma
Endothelial cells
Older men (mediterranean, Jewish, East Africa)
Immunosuppressed (HIV, organ transplant)
Inspect skin daily, assess for knowledge
basal and squamous cell carcinoma treatment
Depends on location, type, depth
Eradicate tumor
Radiation
Topical
Chemotherapy
Surgery
-Skin grafts
-Reconstruction
-Rhytidectomy (face lift, usually for wrinkles)
-Electrosurgery
-Cryosurgery
melanoma nursing process
analgesics
anxiety
depression (emotional support, try to get them to talk)
involve the family
knowledge deficit
stevens-johnson syndrome
medical emergency
Reaction to medication
Flu Like symptoms
Painful rash
Necrosis of skin
Remove cause
Toxic epidermal necrolysis (TEN) is more severe form of this condition
Damage to more than 30% of skin and mucous membrane
HOSPITALIZATION
Can take weeks or months to recover
If caused by meds, need to permanently avoid those meds
Is the following statement true or false?
Malignant tumors spread by way of blood and lymph
channels to other areas of the body
true
Which specific agents or factors are associated with the
etiology of cancer?
A. Dietary and genetic factors
B. Hormonal and chemical agents
C. Viruses
D. All of the above
D
Which type of surgery is being done when lesions that are removed are likely to develop into cancer?
A. Diagnostic
B. Palliative
C. Prophylactic
D. Reconstructive
C
Is the following statement true or false? For patients with chronic bronchitis, the nurse expects to see the major clinical symptoms of tachypnea and tachycardia
False?
What is the primary clinical symptom of emphysema?
A. Chest pain
B. Productive cough
C. Sputum
D. Wheezing
D?
Is the following statement true or false?
Bradypnea is the most common sign for a possible pulmonary embolism
false?
Is the following statement true or false? An initial characteristic symptom of a simple pneumothorax is
sudden onset of chest pain
true
The nurse is caring for a patient with
hypercholesterolemia who has been prescribed
atorvastatin (Lipitor). What serum levels should be
monitored in this patient?
A. Complete blood count (CBC)
B. Blood cultures
C. Na and K levels
D. Liver enzymes
D
The nurse is caring for a patient who has severe chest
pain after working outside on a hot day and is brought
to the emergency center. The nurse administers
nitroglycerin to help alleviate chest pain. What side
effect should concern the nurse the most?
A. Dry mucous membranes
B. Heart rate of 88 bpm
C. Blood pressure of 86/58 mm Hg
D. Complaints of headache
C
The nurse is caring for a patient after cardiac surgery.
Which nursing intervention is appropriate to help prevent complications arising from venous stasis?
A. Encourage crossing of legs
B. Use pillows in the popliteal space to elevate the knees in the bed
C. Discourage exercising
D. Apply sequential pneumatic compression devices as
prescribed
D
The nurse is teaching a patient diagnosed with peripheral arterial disease (PAD). What should be included in the
teaching plan?
A. Elevate the lower extremities
B. Exercise is discouraged
C. Keep the lower extremities in a neutral or
dependent position
D. PAD should not cause pain
C
Which pt is at highest risk for venous thromboembolism
A. A 50-year-old postoperative patient
B. A 25-year-old patient with a central venous catheter in place to treat septicemia
C. A 71-year-old otherwise healthy older adult
D. A pregnant 30-year-old woman due in 2 weeks
A
For patients with uncomplicated hypertension and no specific indications for another medication, what is the initial medication?
A. Thiazide diuretic
B. Calcium channel blockers
C. Vasodilators
D. Angiotensin-converting enzyme inhibitors
A
The nurse is preparing an education plan for a patient
newly diagnosed with hypertension. What should be
included in the education plan?
A. Engage in regular aerobic physical activity such as brisk walking (at least 30 min/day most days of the week)
B. Eliminate alcoholic beverages from the diet
C. Reduce sodium intake to no more than 200 mmol/day
D. Maintain a normal body weight with BMI between 18
and 30 kg/m2
A?
What is a priority nursing assessment when caring for the patient in a hypertensive crisis receiving intravenous vasodilators?
A. Pain
B. I&O
C. Vision
D. Family history
C?
Which performance improvement strategy
helps to prevent blood transfusion reaction?
A. Confirming patient identification with two health
professionals
B. Obtaining baseline vital signs
C. Instructing the patient about signs and symptoms of
blood reaction
D. Priming the blood transfusion tubing with normal
saline
A
What is a nasogastric tube?
A. Tube inserted through the nose into the beginning
of the small intestine
B. Tube inserted through the nose into the stomach
C. Tube inserted through the nose into the second
portion of the small intestine
D. Tube inserted through the mouth into the stomach
B
Is the following statement true or false?
Cyclic feedings are administered into the stomach in
large amounts and at designated intervals
False?
The nasogastric tube is secured to the nose with tape to prevent injury to the nasopharyngeal passages
True
What position should the patient’s head be in when
receiving a tube feeding to prevent aspiration?
A. Flat
B. 10 to 20 degrees of elevation
C. 30 to 45 degrees of elevation
D. 60 to 90 degrees of elevation
C
What is xerostomia?
A. Protrusion of an organ in the mouth
B. Difficulty swallowing
C. Heartburn
D. Dry mouth
D
Is the following statement true or false?
After a radial neck dissection, when the endotracheal tube or airway has been removed and the effects of the anesthesia have worn off, the patient may be placed in the supine position to facilitate breathing and promote comfort
False
Is the following statement true or false?
The most common site for peptic ulcer formation is the
pylorus
False
What is the best time to teach a client to take proton
pump inhibitors?
A. 30 minutes before a meal
B. With a meal
C. Immediately after the meal
D. One to three hours after a meal
A
Is the following statement true or false?
The most common site for diverticulitis is the ileum
False
Is the following statement true or false?
Abdominal pain and constipation are common
clinical manifestations of Crohn’s disease
False
Is the following statement true or false?
Regular bowel habits can be established for a patient
with an ileostomy
false
What is an example of a laxative osmotic agent?
A. Bisacodyl (Dulcolax)
B. Dioctyl sodium sulfosuccinate (Colace)
C. Magnesium hydroxide (Milk of Magnesia)
D. Polyethylene glycol and electrolytes (Colyte)
A
Is the following statement true or false?
Myasthenia gravis is an autoimmune attack on the peripheral nerve myelin
True
What is dysphonia?
A. Double vision or the awareness of two images of the same object occurring in one or more eyes
B. Impaired ability to execute voluntary movements
C. Difficulty swallowing, causing the patient to be at risk for aspiration
D. Voice impairment or altered voice production
D
Is the following statement true or false?
Parkinson disease is a slowly progressing neurologic
movement disorder that eventually leads to disability
True
What is an anticholinergic medication used to treat Parkinson disease?
A. Benztropine mesylate (Cogentin)
B. Diphenhydramine hydrochloride (Benadryl)
C. Orphenadrine citrate (Banflex)
D. Phenindamine hydrochloride (Neo-Synephrine)
A
