TEST 3 Flashcards
Strain
muscle pull or tear of ligaments and tendons
Sprain
Twisting, stretching or tearing of ligaments
Ex: Knee strain
RICE
Rest, Ice, Compression, Evelate
Severe burning pain, frequent changes in skin from hot and dry to cool and clammy shiny skin that is growing more hair in the injured extremity
CRPS- complex regional pain syndrome
When is heat advised in a patient who has sprain or contusion
after 2 days since inflammation is no longer likely to increase. Heat relives localized edema and improves circulation
What is a late sign of compartment syndrome
pulselessness- it signifies lack of distal tissue perfusion
Which factor may contribute to compartment syndrome?
Hemorrage
how long does a plaster cast need to dry
72 hour
Plaster cast
needs 72 hours to dry, be careful when handling to avoid pressure points
Fiberglass cast
Dries within 15 minutes, light weight and does give off heat while drying, water proof liner
6 P’s
Pallor Pulselessness Paresthesia Paralysis poikilothermia
It is important to call your provider when having a cast if..
you notice cyanotic, skin breakdown, notice soft spots around cast, drainage and odor
Fat embolism syndrome:
Occurs at the time of a fracture, fat globules can diffuse from the marrow into the bloodstream and block off the lungs, kidneys and brain.
Highest risk for FES
fracture of long bones, hips, crash injuries, multiple fractures
S/S of FES can occur…
12-72 hours after
tachycardia, SOB, confusion, chest pain, cyanosis, petechiae from nipple to face, high ESR
MEDICAL EMERGENCY–>SUPPLY OXYGEN
What labs should be monitored with a fracture,
6 P’s, coagulation labs, vital signs, know weight baring status
DIC
widespread hemorrhage, microthrombosis with ischemia, bleeding from mucous membranes, ventricular sites, GI and urinary.
Bucks traction
skin traction, make sure there is no pressure ulcers that occur, teach patients to try and shift weight in bed, look for nerve damage of circulation problems.
Bucks traction is used for
Lower limb extremities to help with pain!
PET scan
used to assess cancer and metastasis. Forms “hot spots” in an event of a tumor. Have the patient be NPO for 4-6 hours before. Must lie still for 90 minutes.
Uses a radioactive substance
Ventilation Perfusion Lung Scan (assesses and primarily used for…)
assesses the blood flow and airflow in the lungs
Primarily used for pulmonary embolis
Measure the amount of radiopaque substance in the lungs (normal should be 1:1)
What is the purpose of a bronchoscopy?
diagnosis of lung conditions–biopsy–> treatment of lung conditions such as removal of small lesions,
Bronchoscopy provides a direct visualizations of..
the lungs and airways by fiber optics
Nursing care for bronchoscopy..
NPO for 6 hours, pre op meds, intra procedure: conscious sedations monitoring, spray zylocaine.
NPO until gag reflex returns, VS stable.
Complication of bronchoscopy
hemorrage and aspiration
Sputum culture:
best early in the morning, patient should rinse mouth with water but not brush teeth since it can affect the results, clear nasal mucus by blowingn ose, take 2 of 3 deep breaths and cough deeply from the diaphragm, expectorate into sterile specimen container.
Antibiotic therapy should be on hold until a sputum culture is given TRUE OR FALSE
TRUE- YOU CANNOT TELL WHICH BACTERIA IT IS IF AB IS TAKEN BEFORE
Thoracentesis
diagnostic test given to assess the presence of infectious organisms or cancer cells. Treatment for large pleural effusions that diminish lung function
Hgb value
12-16
Hct
35-50
platelet count
150,000-400,000
What might be elevated in COPD?
H&H
Elevated H&H with COPD because the body is trying to compensate. The body doesn’t have enough oxygen so it is made more .
WBCS will be elevated if…
inflammation or infection
Neutrophils
Acute infection
Lymphocytes will be elevated if..
chronic or inflammation
Monocytes will be elevated..
in bacterial infections but will be later
Eosinophils will indicate
allergies
Bands can indicate
immature WBC
RBC and H&H can be indicated in
respiratory disorders
Low H&H you would worry about..
poor oxygenation
Atelectasis is when
there is closure or collapse of the alveoli,
Atelectasis is commonly seen in what type of patients (3).
elderly, post op, bed ridden
what is key to not getting atelectasis..
PREVENTION (using IS, T, C, DB, early ambulation, getting out secretions, increase fluids)
Signs and symptoms of atelectasis
low grade fever, cough, sputum production, tachypnea, diminished breath sounds, fine crackles.=, dyspnea, cyanosis, pleual pain in severe cases.
can occur 48 hours post op
What is the most common type of atelectasis
obstructive, this occurs when patients are not deep breathing, and can be due to mucus and alveoli not being filled
XR for atelectasis shows :
patchy, airless or consolidated areas
Pneumonia can occur due to
atelectasis
Exudate can be formed from..
WBC, RBC, Fibrin
Bacterial pneumonia S/S:
pleuritic pain, chills, fever, cough with purulent sputum, cyanosis, dyspnea, fine crackles, diminished lung sounds, wheezes, friction rub
Viral pneumonia S/S:
HA, fever, fatigue, malaise, aching, dry cough
Hospital acquired pneumonia can occur within how many days?
48 hours after admission
most often gram negative
Bronchopneumonia
patchy areas of consolidation, can occur in both lungs
lobar pneumonia
entire lobe is consolidated (one love) such as Right lower lobe pneumonia
general signs and symptoms of pneumonia
fever sob fine crackles tachypnea increase pulse and RR consolidation- sputum dullness in percussion pleuritic pain egophony confusion in elderly
How do we diagnose pneumonia
ABG, XR, labs, h&p, bronchoscopy
pulmonary embolism
pleuritic pain, SOB, cough, hemoptysis, dypnea, tachypnea, anxiety, tachycardia, diaphoresis, hypoxemia, syncope, shock
Diagnostic test for PE
XR, ABG, ECG, CT, pulmonary angiography, ventilation/ perfusion scanner, d-dimer
PE medication:
anticoagulants: 5-7 days such as heparin
Coumadin 3-6 months
Thrombolytics: streptokinase
Complications for bucks traction:
infection, skin intergrity, UTI, respiratory issues, mental health issues, muscle atrophy, constipation, aspiration, osteoporosis
surgery for highest risk for DVT
Total knee replacement
stage 1: primary infection of AIDS
Window period 1A:
period from infection exposure to appearance of antibodies, tests negative for antibodies, may have symptoms but not be associated with HIV, (fever, fatigue and rash)
Stage 1B: antibodies begin to develop in 2-3 weeks, CD4 count >500
Stage 2: Latent phase of HIV
200-499 CD4 count. or CD4 and t-lymphocytes 14-28%
Tests positive for HIV
Cd4 and t-lymph fall overtime
symptomatic conditions develop that are NOT associated with AIDS
Stage 3: AIDS phase
At CD4 count of
immune system is compromised
stage 3
Remains stage 3 even if Cd4 and T cells increase with treatment
Is HIV screening recommended for all persons seeking evaluation and treatment for STIs
YES
Does HIV testing need to be voluntary and free of coercion
yes. patient must not be tested without their knowledge!!! Do not convince, bribe or make them take the test
Before testing for HIV
patient must give consent
If a positive HIV antibody test is confirmed, there will need to be a supplemental test given such as
EAI test–if comes back positive do second test for Blot test. Do not repeat EAI test
ONLY the patient can tell someone their results
TRUE
EAI test will tell you whether..
you have antibodies
Blot test
will be done second to confirm the diagnosis
OraQuick
onyl takes 20 minutes and is reliable, in-home HIV test
CD4 tells you..
what stage you are in, how bad it is and what is your therapy.
indicates the level of immune dysfunction
Viral load
measured HIV RNA of plasma, for those whose EAI TEST came back negative
What happens if the patient gets tested with EAI test and it comes back positive
do the blot test
If the patient gets tested for EIA test and it comes back negative..
Viral load (RT-PCR)
Despite the HIV infection, this does not mean that the patient particularly has AIDS
TRUE
window period for HIV
may be between 3 weeks to 6 months
What is the greatest challenge for therapy for HIV
compliance. Are they being compliant with meds?
PCP (pneumocystitic pneumonia)
clinical manifestation of HIV/AIDS
Most common life threatening condition
Definitive diagnosis: sputum induction, bronchoalveolar lavage, biopsy,
may have nonspecific symptoms such as nonproductive cough, fever, chills, dyspnea, chest pain
oral candidiasis
clinical manifestation of AIDS
may progress to the stomach and esophagus, treat with mycelex, swish and swallow (ketoconazole), nystatin
Diarrhea
clinical manifestation of AIDS
Realted to HIV infection enteric pathogens
Wasting syndrome
10% weight loss and chronic diarrhea and chonic weakness with fever and absence of other cause, protein energy malnutrition, anorexia, diarrhea, GI malabsorption, lack of nutrition
Kaposis sarcoma
Clinical manifestation of AIDs
cutaneous lesions that may involve multiple organ systems, biggest concern is skin integrity, lesions cause discomfort, disfigurement, ulcerations and potential for infection. Can cause hemorrhage and avoid scratching skin since it can become infected
B-Cell lymphomas can be..
a side effect of HIV
HIV encephaly
manifestations of HIV
progressive, cognitive and behavioral motor decline. Probably directly related to HIB infection, get baseline LOC, patient can develop lesions on the brain and can make them confused
DEPRESSION
Nursing assessment for HIV
assess: knowledge, skin integrity, respiratory function, nutrition status, fluid and electrolytes
assess risk factors
Assessing for skin integrirty in HIV patients
check perianal area, mouth for ulcerations, infected areas and bony areas, culture wounds for infections
Assessing respiratory status in HIV patients
check sputum, color, SOB, chest pain, tachypnea, breath sounds.
monitor with : ABG, XR, pulse ox, pulmonary function test
Fluid and electrolyte imbalance
assess for muscle twitching, irregular pulse, nausea and vomiting, shallow respirations
Ineffective airway clearance in HiV
pneumonia, TB, weakness and poor cough therefore they cannot get out the secretions. Also cant control the saliva. Something can be stuck in the trachea and you cannot get it out.
If a patient is immunocompromised and in stage 3
arrange for a portable XR machine to be used in the patients room. DO NOT HAVE THE PT LEAVE THE ROOM
interventions for skin integrity for HIV
reposition patient ever 2 hours,
pressure reduction devices
perianal skin care- cleaning after voiding
Interventions for usual bowel patterns
do not eat raw fruits and veggies, carbonated beverages, foods of extreme temperatures, spicy foods
Eat small frequent meals
lower UTI
cystitis-bladder
Prostatitis- prostate
Urethritis- urethra
Upper UTI
pyelonephrotic- kidneys
Complicated UTI
UTI with kidney stones or renal failure or lead to something else. Foleys like a permanent foley or paraplegics who use foleys all of the time
uncomplicated
just UTI lower or upper
urethrovesical reflux
coughing, sneezing, straining forces urine into the urethra. When pressure is back to normal the urine flows back into the bladder, also bringing bacteria from the urethra
ureterovesicular or vesicoureteral reflux
backward flow of urine from the bladder into both ureters
women bacterial count for uropathogenic bacteria
10^5
*only if you see these results you will do a urine culture. If less than you arenot doing a urine culture. Urine culture is done to determine which type of bacteria it is
men bacteria count for uropathogenic bacteria
!0^4
transurethral route
most common route of infection.. ascending infection
bloodstream
route of infection, hematogenous spread septic
uncomplicated UTI
may be asymptomatic, burning on urination, frequency, urgency, nocturia, incontinence, suproaubic or pelbic pain, hematuria
Complicated
asymptomatic if they have bacteruria, gram negative sepsis with shock (generally they can have tachycardia, fever, hypovolemia, urosepsis
Patient has low grade fever, altered LOC, incontinence
gerontolic considerationn
teach patients about urine sample
front to back wiping, catch midstream, no gloves for the patient
Medical management
longer medication courses for men since they are less susceptible to UTI
!!relieving pain in UTI
AVOID coffee, tea, citus drinks, alcohol, pop
drink WAWA!!!
frequent voiding every 2 houra
antispasmodic agent
cath care:
empty bag every 8 hour
inspect urine, color odor constitency
maintain a closed system
secure cath to prevent movement so the cath isnt sliding in and out
perform meticulous daily care with soap and water
Patient recovering from a UTI
BATHE IS NOT THE ANSWER
shower rather than bathe
after each bowel movement, clean the perineum and urethral meatus from front to back.
Drink liberal amounts of fluid
void every 2-3 hours
vitamin c (ascorbic acid or cranberry juice)
acute pyelonephritis
inflammation of renal pelvis and kidney.
chronic pyelonephritis
inflammation and scarring and intestinal tissue.
common cause of CRF
chronic pyelonephritis
may develop from hypertension, vascular changes, obstruction
chronic pyelonephritis
clinical manifestations for acute pyelonephritis
acutely ill, chills, fever, leukocytosis, bacteriuria, pyuria, low back pain, n&v, headache, malaise, painful urination
Chronic pyelonephritis
asymptomatic, fatigue, headache, poor appetite, polyuria, excessive thirst, weight loss over a long period, renal failure
Acute pyelonephritis: assessment
UA and culture, ultrasound and CT
Chronic pyelonephritis-assessment
Cr clearance, BUN, creatinine levels
diagnostics for urolithiasis and nephrolithiasis
KUB- abdominal xr
ultrasound- if it was thought that there was fluid buildup
ct and mri
lithotripsy can cause
bruising and irritation on whichever side was treated
percutaneous nephrolithotomy
invasive. generally not done that often
medical management for calculi
thiazide diuretics- reduces Ca excretion in urine, allopurinol for uric acid, potassium citrate for uric acid, nsaids
INCREASE FLUIDS TO 2L A DAY
calcium stone restriction
protein and soium
uric acid stones restriction
low purine diet (shell fish, anchovies, asparagus, mushrooms, organ meat)
cystine stones restriction
low protein diet
oxalate stones
low oxalate diet (strawberries, chocolate, spinach, rhubarb, tea, peanuts)
complications of a sstone
infection, urosepsis, obstruction
nursing interventions for calculi
relieve pain, continue care, self care, education, monitor and manage potential complications
Patient teaching for kidney stones
signs and symptoms to report.
urine pH monitoring
avoid protein intake, restricted to 60g/day
sodium intake 3-4 g/day
low calcium diets are not recommended
avoid intake of oxalate
drink every 1-2 hours
drink 2 classes of water at bedtime
avoid activities leading to sudden increase in temp (excessive sweating causing dehydration)
cystocele
downward displacement of the bladder into the vaginal orifice
rectocele
upward pouching of the rectum that pushes up to the posterior wall of the vagina forward
enterocele
protrusion of intestinal wall into the vagina
Clinical manifestations for all 3..
sensation of pelvic pressure or fullness down below, urinary problems (incontinence, urgency, frequency) back or pelvic pain
rectocele
has rectal pressure as an additional symptom to unusual urination pattern such as incontinence, back or pelvic pain and fullness
Non surgical management for cystocele, enterocele,
kegels, pessary- treatment for prolapse of uterus
kegel exercises
important to strengthen the pelvic floor muscles, Sustain contraction for 10 seconds, perform 30-80 X a day
Pessary
inspected annually by the doctor. in place to support uterus, rectum, bladder in place
Uterine prolapse
when structures that support the uterus weaken (from childbirth) allowing the uterus to work its way down the vaginal canal.
HAVE PT DO KEGELS, pessary
hysterectomy can be done
symptoms of uterine prolapse are aggravated when a woman:
coughs, lifts heavy objects (nothing more than 10lbs), stands for long periods of time, normal activities such as walking up stairs
what can happen as a result of getting a hysterectomy
you can develop a cystocele
Those having a rectocele repair may need to know that BEFORE surgery …
a laxative and cleaning enema may be prescribed
what position for surgery for uterine prolapse or hysterectomy
lithotomy with special attention to the placement of legs which can easily develop a blood clot. MOVE BOTH LEGS DOWN AT THE SAME TIME
POST-OP care for hysterectomy, cystocele, rectocele, etc surgeries
void a few hours after surgery for cystocele
if no void and reports pain after 6 hours- indwelling cath may be indicated for 2-4 days. CALL DOCTOR IF NO VOID IN 6 HOURS
After each BM, perineum may be cleanred with saline solution and dried with sterile absorbent material if an incision was made
ice pack applied locally. 20 min on 20 min off
What to report after surgery of cystocele, rectocele, , etc.
report pelvic pain, unusual discharge, personal hygeine, vaginal bleeding, ( a little blood in the beginning is normal but by the time of arriving home there should be NONE)
Hysterectomy (3 types)
subtotal, total and radical
surgical approaches for hysterectomy
laparoscopic- small holes
vaginal
abdominal-incisions, transverse and vertical
subtotal hysterectomy
uterus is removed but cervix is spared
total hysterectomy
removal of cervix and uterus
radial hysterectomy
removal of uterus as well as the surrounding tissue, including the upper third of vagina and pelvic lymph nodes
hysterectomy preop management
prevention of DVT
discontinue anticoagulants
pregnancy is ruled out on day of surgery
prophylactic ab agents may be administered
postop management for hysterectomy (risks)
major risk are infection and hemorrage, DVT
voiding problems may occur due to edema or nerve loss
oophorectomy
surgical removal of ovaries. Can be done alone or as part of a hysterectomy
Salpingectomy
surgical removal of fallopian tube- often related to tubal pregnancies
indications for a hysterectomy
fibroids, pelvic pain, uterine prolapse, pelvic prolapse, uterine bleeding, malignancy, endometriosis
nursing interventions for patients undergoing hysterectomy
relive anxiety- allow pts to express feelings, provide emotional support
Improve body image- listen and address concerns, provide appropriate reassurance, address sexual issues
Nursing Intervention: relieving pain ofr hysterectomy
post op pain and discomfort can be relieved with PCA pump, analgesics
When there is return of bowel sounds- may begin soft diet
do not stuff pillows behind the knees when preventing a venous thromboembolism
TRUE
after a hysterectomy, patient must pee before discharge
TRUE
why do we not want post op hysterectomy patients to drive
in the event of a car accident the steering wheel can hit the area causing hemorrage
lambskin condoms will not protect against HIV
TRUE- nonlatex condoms will not protect someone from HIV
Spiral fractures occur when..
often occur when the body is in motion while one extremity is planted.
FES can occur within how many hours
12-72
