Test 1 - study guide Flashcards
1
Q
Signs and symptoms for dehydration are…
A
- Thirst
- Rapid, Weak Pulse
- Low Blood Pressure
- Dry Skin and Mucous Membranes
- Skin Tenting
- Decreased Urine Output
- Increased Temperature
2
Q
Causes of dehydration are…
A
- fluid loss from vomiting
- diarrhea
- GI suctioning
- sweating
- decreased intake
- inability to gain access to fluid
3
Q
Laboratory data for dehydration are…
A
- elevated BUN in relation to serum creatinine
- increased hematocrit
- Hypokalemia occurs with GI & renal losses
- Hyperkalemia occurs with adrenal insufficiency
- Hyponatremia occurs with increased thirst & ADH release
- Hypernatremia results from increased insensible losses and Diabetes Insipidus
- tenting
4
Q
What is dehydration?
A
loss of water with no loss of electrolytes
5
Q
Interventions for deficient fluid volume are…
A
- Identify those at risk
- Monitor Weight & vital signs
- Assess skin turgor
- Monitor Intake and Output – all types of loss
- Evaluate urine specific gravity >1.025
- Monitor labs
- Increase Fluid Intake
- Treat Underlying Cause
- Encourage PO intake
- Teach about adequate fluid intake
- Do Not Overhydrate Elderly Patients
6
Q
Fluid volume overload signs and symptoms
A
- increased BP (bounding, tachy, jugular distention)
- abnormal lung sounds (crackles)
- increased RR
- edema
- weight gain
- increased urinary output
- confusion, lethargy
- hyponatremia and muscle cramping
7
Q
Interventions for Excess fluid volume
A
- Monitor for changes in LOC
- Monitor weight and urine output
- Elevate head of bed
- administer oxygen
- administer diuretics
- restrict fluid and sodium
- encourage mobility
- monitor electrolytes
- communicate proper fluid intake
8
Q
Signs and symptoms for compartment syndrome
A
- dusky, pale appearance of extremity
- cool skin Temp
- delayed capillary refill
- paresthesia (tingling)
- extreme pain
- complaint of device tightness
- intensifying pain w/ movement
9
Q
Interventions for compartment syndrome
A
- removal or loosening of restricting device (cast, splint)
- fasciotomy
- elevation of limb (no higher than heart)
10
Q
signs and symptoms of osteoporosis
A
- joint pain
- intensifies w/ activity
- Stiffness
- Bony nodes on joints of fingers (heberden’s and Bouchard’s nodes)
11
Q
lab diagnostics for osteoporosis
A
- X-rays
- CT (cat scan)
- MRI
- Analysis of Synovial Fluid
12
Q
interventions for osteoporosis
A
- no cure
- activity
- pain/inflammation control
- rest and exercise
- heat or cold
- weight control
- surgery (joint replacement)
13
Q
signs and symptoms of osteomyelitis
A
- localized pain
- edema
- erythema (reddening of skin)
- fever
- drainage
14
Q
lab diagnostics for osteomyelitis
A
- Elevated WBCs
- elevated ESR
- MRI and CT can visualize areas of infection
- positive bone biopsy for infection
15
Q
interventions for osteomyelitis
A
- primarily prevention is the goal
- hydration
- diet high in vitamins and protein
- also correction of anemia
- surgical debridement
16
Q
signs and symptoms for gout
A
Acute
-swollen, red, hot, painfully inflamed joints
Chronic
- Urate deposits in skin
- Renal stones
17
Q
lab diagnostics for gout
A
- Serum Uric Acid levels
- Microscopy of uric acid crystals in Joint Fluid
18
Q
interventions for gout
A
Medications
- NSAIDS, colchicine, allopurinol, probenecid
- avoidance of foods high in purines
- avoid aspirin, diuretics, alcohol
- increase fluids
19
Q
signs and symptoms pelvic fracture
A
- pain
- shock
- shortening/rotation of the leg
- genitourinary or intra-abdominal co-injury
20
Q
lab diagnostics for pelvic fracture
A
- X-ray
- Angiography
- CBC
21
Q
interventions for pelvic fracture
A
- apply antishock garment
- anticipate/assist with application of external fixator
22
Q
signs and symptoms sprain
A
- Pain
- swelling
- bruising
- instability
- loss of the ability to move/use joint
- pop or tearing sensation when injury happens
23
Q
lab diagnostics for sprain
A
x-ray to rule out fracture
24
Q
interventions for sprain
A
- RICE
- rest
- ice
- compression
- elevate
- heat after inflammation is reduced
25
signs and symptoms shingles (herpes zoster)
- Vesicles
- Plaques
- Irritation
- Itching
- Fever
- Malaise
- Pain
- follows nerve distribution
26
lab diagnostics for shingles (herpes zoster)
- History
| - culture and sensitivity
27
interventions for shingles (herpes zoster)
- vaccination
- anti-viral medications
- analgesics to relieve pain
28
signs and symptoms scabies infestations
- itching
- rash
- burrows
- localized in armpits, wrists, groin
29
lab diagnostics for scabies infestations
-microscopic examination of skin scraping of a lesion
30
interventions for scabies infestations
-scabicide applied to all areas of the body
31
signs and symptoms skin cancer
```
ABCD's!
Asymmetry
Border irregularity
Color
Diameter – big is bad :( (>5mm may be of concern)
```
32
lab diagnostics for skin cancer
- examination
- biopsy (Bx)
- also note changes in lesion
33
interventions for skin cancer
- prevention
- limit exposure to UV
- use sunscreen
- wear protective clothing
- report changes in moles
34
What is gout?
a type of inflammatory arthritis caused by hyperuricemia (uric acid)
- uric acid crystals form in joints
- phagocytosis of crystals causes pain
35
signs and symptoms lice
- intense itching (pruritus)
- rash
- red bumps on the skin.
36
lab diagnostics for lice
- combing of hair
| - nits at base of hair shaft
37
interventions for lice
- permethrin topical ointment
| - treat others in household
38
types of skin cancers include
- basal cell carcinoma
- squamous cell carcinoma
- malignant melanoma
39
squamous cell carcinoma are
- 2nd most common
- grow rapidly
- can metastasize
40
basal cell carcinoma are
- most common
| - rarely metastasize
41
melanomas are
- least common
- highly metastatic
- genetic component
42
signs and symptoms of skin ulcers
- pain
- open ulcerated area
- color tip
- black = necrosis
- yellow = infection
- red = healing
43
diagnoses for skin ulcers
- physical exam
- culture and sensitivity
- blood supply studies
- wound biopsy
44
A stage 1 ulcer is
nonblanchable erythema of intact skin
45
A stage 2 ulcer is
partial-thickness skin loss
46
A stage 3 ulcer is
- full-thickness skin loss
| - not involving underlying fascia
47
A stage 4 ulcer is
-full-thickness skin loss with exposed bone, tendon or muscle
48
An unstageable ulcer is
-full-thickness tissue loss in which the base of the ulcer is covered.
49
A deep tissue injury is
- purple or maroon
| - localized in area
50
pressure ulcers can occur due to ___ and _____
pressure and stasis (blood pools)
51
interventions for ulcers
- identify at risk pt
- keep pt dry
- use lube and skin barriers
- turn q 2h
- relieve pressure points
- nutrition and hydration
- use lift sheet to move
52
signs and symptoms of psoriasis
Plaques of red, inflamed skin, often covered with loose, silver-colored scales
53
Dx of psoriasis
- physical assessment
| - biopsy
54
Interventions for psoriasis
- baths to remove scales
| - medications
55
signs and symptoms of cellulitis
- inflammation and edema
- warmth
- redness
- pain and tenderness
- fever
56
Dx tests for cellulitis
-culture and sensitivity
57
interventions for cellulitis
- antibiotics
- only if immune system working
- debridement
58
Signs and symptoms of eczema
- vesicles
- surrounding redness
- rupture of vesicles, open areas
- secondary infection
59
Dx of eczema
- clinical symptoms
- culture and sensitivity
- rule out allergies
- biopsy if nonresponsive to Tx
60
Interventions for eczema
- 1:40 Burow solution
- drain large vesicles
- antibiotics
- corticosteroids topical
- botulinum toxin A injection
- biofeedback
- bedrest if on feet.
61
S/s of dermatitis
- redness
- pruritis
- skin lesions
62
Dx tests for dermatitis
-culture and sensitivity
63
interventions for dermatitis
- antihistamines
- analgesics
- antibiotics
- antipruritics
- steroids
- colloidal oatmeal baths
- wet dressings
64
A macule or patch is
- freckles
- moles
- petechia
- rubella rash
- ecchymosis (bruising)
65
A plaque is
- dry buildup
- may flake off
- psoriasis
66
A papule is
- warts
- tissue buildup (solid)
- causes a bump on the skin
67
A vesicle/bulla is
- tissue buildup (fluid filled)
- burns
- dermatitis
- poison ivy
- acne
- chicken pox
- herpes
68
A wheal is
- a large raised area
- uticaria (hives)
- generalized edema/swelling
- allergic responses
- insect bites
69
Aging causes what in the musculoskeletal system?
- bone calcium loss
- articular cartilage wears down
- muscle strength declination
70
What do you look for when assessing the neurovascular system?
5-p's
- pain
- pulse
- pallor
- paresthesia
- paralysis
71
What are the diagnostic evaluations of the musculoskeletal system?
- x-rays
- CT
- MRI
- arthrography
- bone densitometry
- bone scan
- arthroscopy
- electromyography
- biopsy
- lab studies
72
When assessing the musculoskeletal system you look at...
- data related to ADLs
- health hx of pt and family
- assess pain and altered senses
- physical - posture, gait, joint fx, muscle strength and size
- spine abnormalities
- ROM
- use of mobility aids
- symmetry
- redness
- edemma
- tenderness
73
ligaments attach ____ to ____
bone to bone
74
tendons attach ____ to ____
muscle to bone
75
Anaerobic pathways in muscle use ____ and result in a buildup of _____
glucose
| lactic acid
76
osteoblasts
function in bone formation
77
osteocytes
are mature bone cells
function in maintenance
They are on site!
78
osteoblasts
```
function as destroyers, resorbing, and remodeling
located in Howship's lacunae
```
79
A comminuted fracture is
splintered with fragments
80
Stage 1 of fracture healing is
hematoma and inflammation
81
Stage 2 of fracture healing is
angiogenesis and cartilage formation
82
Stage 3 of fracture healing is
- cartilage calcification
- cartilage removal
- bone formation
- remodeling
83
Nursing care for bone fracture is
- splint and immobilize
- remove jewelry
- avoid movement
- assess neurovascular
- apply ice/cold pack
- elevate
- Anticipate analgesics, antibiotics, stabilization, OR
- provide psychosocial support
84
Interventions for joint injury
- immobilize joint
- Assess/reassess neurovascular fx
- anticipate/assist w/reduction
85
symptoms of joint injury
- pain
- deformity
- edema
- inability to move
- abnormal ROM
- neurovascular compromise
86
symptoms of femur fracture
- pain
- can't bear weight
- shortening
- rotation (in or ex)
- edema
- deformity
- hypovolemic Shock (2-3 Units blood)
87
Interventions for femur fracture
- immobilize
- anticipate traction pin/dressing
- anticipate OR/admission
88
Symptoms of Open fractures
- skin disruption
- pain
- neurovascular compromise
- bleeding
- bone protrusion
89
Interventions for open fractures
- irrigate wound
- wound culture
- sterile dry dressing
- continued bleeding assessment
- anticipate/prepare for OR
90
complications of fractures
- nonunion of bone
- neurovascular compromise
- infection
- hemorrhage
- thromboemolitic comp.
- acute compartment syn
- fat embolism syn
91
Types of closed reductions
- manual realignment
- bandages/splints
- casts
- traction
- skin
- skeletal
