Test 1 - study guide Flashcards
Signs and symptoms for dehydration are…
- Thirst
- Rapid, Weak Pulse
- Low Blood Pressure
- Dry Skin and Mucous Membranes
- Skin Tenting
- Decreased Urine Output
- Increased Temperature
Causes of dehydration are…
- fluid loss from vomiting
- diarrhea
- GI suctioning
- sweating
- decreased intake
- inability to gain access to fluid
Laboratory data for dehydration are…
- 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
What is dehydration?
loss of water with no loss of electrolytes
Interventions for deficient fluid volume are…
- 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
Fluid volume overload signs and symptoms
- increased BP (bounding, tachy, jugular distention)
- abnormal lung sounds (crackles)
- increased RR
- edema
- weight gain
- increased urinary output
- confusion, lethargy
- hyponatremia and muscle cramping
Interventions for Excess fluid volume
- 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
Signs and symptoms for compartment syndrome
- dusky, pale appearance of extremity
- cool skin Temp
- delayed capillary refill
- paresthesia (tingling)
- extreme pain
- complaint of device tightness
- intensifying pain w/ movement
Interventions for compartment syndrome
- removal or loosening of restricting device (cast, splint)
- fasciotomy
- elevation of limb (no higher than heart)
signs and symptoms of osteoporosis
- joint pain
- intensifies w/ activity
- Stiffness
- Bony nodes on joints of fingers (heberden’s and Bouchard’s nodes)
lab diagnostics for osteoporosis
- X-rays
- CT (cat scan)
- MRI
- Analysis of Synovial Fluid
interventions for osteoporosis
- no cure
- activity
- pain/inflammation control
- rest and exercise
- heat or cold
- weight control
- surgery (joint replacement)
signs and symptoms of osteomyelitis
- localized pain
- edema
- erythema (reddening of skin)
- fever
- drainage
lab diagnostics for osteomyelitis
- Elevated WBCs
- elevated ESR
- MRI and CT can visualize areas of infection
- positive bone biopsy for infection
interventions for osteomyelitis
- primarily prevention is the goal
- hydration
- diet high in vitamins and protein
- also correction of anemia
- surgical debridement
signs and symptoms for gout
Acute
-swollen, red, hot, painfully inflamed joints
Chronic
- Urate deposits in skin
- Renal stones
lab diagnostics for gout
- Serum Uric Acid levels
- Microscopy of uric acid crystals in Joint Fluid
interventions for gout
Medications
- NSAIDS, colchicine, allopurinol, probenecid
- avoidance of foods high in purines
- avoid aspirin, diuretics, alcohol
- increase fluids
signs and symptoms pelvic fracture
- pain
- shock
- shortening/rotation of the leg
- genitourinary or intra-abdominal co-injury
lab diagnostics for pelvic fracture
- X-ray
- Angiography
- CBC
interventions for pelvic fracture
- apply antishock garment
- anticipate/assist with application of external fixator
signs and symptoms sprain
- Pain
- swelling
- bruising
- instability
- loss of the ability to move/use joint
- pop or tearing sensation when injury happens
lab diagnostics for sprain
x-ray to rule out fracture
interventions for sprain
- RICE
- rest
- ice
- compression
- elevate
- heat after inflammation is reduced
signs and symptoms shingles (herpes zoster)
- Vesicles
- Plaques
- Irritation
- Itching
- Fever
- Malaise
- Pain
- follows nerve distribution
lab diagnostics for shingles (herpes zoster)
- History
- culture and sensitivity
interventions for shingles (herpes zoster)
- vaccination
- anti-viral medications
- analgesics to relieve pain
signs and symptoms scabies infestations
- itching
- rash
- burrows
- localized in armpits, wrists, groin
lab diagnostics for scabies infestations
-microscopic examination of skin scraping of a lesion
interventions for scabies infestations
-scabicide applied to all areas of the body
signs and symptoms skin cancer
ABCD's! Asymmetry Border irregularity Color Diameter – big is bad :( (>5mm may be of concern)
lab diagnostics for skin cancer
- examination
- biopsy (Bx)
- also note changes in lesion
interventions for skin cancer
- prevention
- limit exposure to UV
- use sunscreen
- wear protective clothing
- report changes in moles
What is gout?
a type of inflammatory arthritis caused by hyperuricemia (uric acid)
- uric acid crystals form in joints
- phagocytosis of crystals causes pain
signs and symptoms lice
- intense itching (pruritus)
- rash
- red bumps on the skin.
lab diagnostics for lice
- combing of hair
- nits at base of hair shaft
interventions for lice
- permethrin topical ointment
- treat others in household
types of skin cancers include
- basal cell carcinoma
- squamous cell carcinoma
- malignant melanoma
squamous cell carcinoma are
- 2nd most common
- grow rapidly
- can metastasize
basal cell carcinoma are
- most common
- rarely metastasize
melanomas are
- least common
- highly metastatic
- genetic component
signs and symptoms of skin ulcers
- pain
- open ulcerated area
- color tip
- black = necrosis
- yellow = infection
- red = healing
diagnoses for skin ulcers
- physical exam
- culture and sensitivity
- blood supply studies
- wound biopsy
A stage 1 ulcer is
nonblanchable erythema of intact skin
A stage 2 ulcer is
partial-thickness skin loss
A stage 3 ulcer is
- full-thickness skin loss
- not involving underlying fascia
A stage 4 ulcer is
-full-thickness skin loss with exposed bone, tendon or muscle
An unstageable ulcer is
-full-thickness tissue loss in which the base of the ulcer is covered.
A deep tissue injury is
- purple or maroon
- localized in area
pressure ulcers can occur due to ___ and _____
pressure and stasis (blood pools)
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
signs and symptoms of psoriasis
Plaques of red, inflamed skin, often covered with loose, silver-colored scales
Dx of psoriasis
- physical assessment
- biopsy
Interventions for psoriasis
- baths to remove scales
- medications
signs and symptoms of cellulitis
- inflammation and edema
- warmth
- redness
- pain and tenderness
- fever
Dx tests for cellulitis
-culture and sensitivity
interventions for cellulitis
- antibiotics
- only if immune system working
- debridement
Signs and symptoms of eczema
- vesicles
- surrounding redness
- rupture of vesicles, open areas
- secondary infection
Dx of eczema
- clinical symptoms
- culture and sensitivity
- rule out allergies
- biopsy if nonresponsive to Tx
Interventions for eczema
- 1:40 Burow solution
- drain large vesicles
- antibiotics
- corticosteroids topical
- botulinum toxin A injection
- biofeedback
- bedrest if on feet.
S/s of dermatitis
- redness
- pruritis
- skin lesions
Dx tests for dermatitis
-culture and sensitivity
interventions for dermatitis
- antihistamines
- analgesics
- antibiotics
- antipruritics
- steroids
- colloidal oatmeal baths
- wet dressings
A macule or patch is
- freckles
- moles
- petechia
- rubella rash
- ecchymosis (bruising)
A plaque is
- dry buildup
- may flake off
- psoriasis
A papule is
- warts
- tissue buildup (solid)
- causes a bump on the skin
A vesicle/bulla is
- tissue buildup (fluid filled)
- burns
- dermatitis
- poison ivy
- acne
- chicken pox
- herpes
A wheal is
- a large raised area
- uticaria (hives)
- generalized edema/swelling
- allergic responses
- insect bites
Aging causes what in the musculoskeletal system?
- bone calcium loss
- articular cartilage wears down
- muscle strength declination
What do you look for when assessing the neurovascular system?
5-p’s
- pain
- pulse
- pallor
- paresthesia
- paralysis
What are the diagnostic evaluations of the musculoskeletal system?
- x-rays
- CT
- MRI
- arthrography
- bone densitometry
- bone scan
- arthroscopy
- electromyography
- biopsy
- lab studies
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
ligaments attach ____ to ____
bone to bone
tendons attach ____ to ____
muscle to bone
Anaerobic pathways in muscle use ____ and result in a buildup of _____
glucose
lactic acid
osteoblasts
function in bone formation
osteocytes
are mature bone cells
function in maintenance
They are on site!
osteoblasts
function as destroyers, resorbing, and remodeling located in Howship's lacunae
A comminuted fracture is
splintered with fragments
Stage 1 of fracture healing is
hematoma and inflammation
Stage 2 of fracture healing is
angiogenesis and cartilage formation
Stage 3 of fracture healing is
- cartilage calcification
- cartilage removal
- bone formation
- remodeling
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
Interventions for joint injury
- immobilize joint
- Assess/reassess neurovascular fx
- anticipate/assist w/reduction
symptoms of joint injury
- pain
- deformity
- edema
- inability to move
- abnormal ROM
- neurovascular compromise
symptoms of femur fracture
- pain
- can’t bear weight
- shortening
- rotation (in or ex)
- edema
- deformity
- hypovolemic Shock (2-3 Units blood)
Interventions for femur fracture
- immobilize
- anticipate traction pin/dressing
- anticipate OR/admission
Symptoms of Open fractures
- skin disruption
- pain
- neurovascular compromise
- bleeding
- bone protrusion
Interventions for open fractures
- irrigate wound
- wound culture
- sterile dry dressing
- continued bleeding assessment
- anticipate/prepare for OR
complications of fractures
- nonunion of bone
- neurovascular compromise
- infection
- hemorrhage
- thromboemolitic comp.
- acute compartment syn
- fat embolism syn
Types of closed reductions
- manual realignment
- bandages/splints
- casts
- traction
- skin
- skeletal
