TEST 4 Flashcards
What subjective data do we ask for musculoskeletal?
Joint: Pain, stiffness, ROM
Muscles: Pain, cramping, weakness
Bones: Pain, deformity, accident/trauma
*Do you have any limitations in movement
What are you inspecting for on musculoskeletal?
Color (fracture- may see brusing)
Swelling
Masses
Deformities
What are you inspecting for on musculoskeletal?
Color (fracture- may see brusing)
Swelling
Masses
Deformities
What are you palpating for on musculoskeletal?
Extremities - crepitous
Joints - tenderness
Temp (hot = autoimmune disorder)
What is AROM and PROM?
ActiveROM - Patient is able to do themselves
PassiveROM - patient is being assisted
What is ROM checking?
Joint mobility
Should not cause pain
What is the muscle strength grading scale?
5 - FULL ROM/ FULL RESISTANCE
4 - FULL ROM/ LIGHT RESISTANCE
3 - FULL ROM / gravity/no resistance from nurse
2 - FULL ROM / gravity eliminated /only horizontal but not vertical
1 - Slight contraction
0 - no contraction
What is osteoporosis?
Loss of bone mass/density resulting in decreased ability to maintain structural integrity of skeleton
Kyphosis present / aging / etiology unknown
What are the treatments for osteoporosis?
Biphosphonates - inhibit bone resorption
(fosamax, boniva, actonel) side effect - esophageal ulcers / give 8oz water
Calcitonin - inhibit bone resportion
(Miacalcin, Fortical)
What is Osteomalacia
Softening of bone tissue due to inadequate mineralization of osteoid - *calcification does not occur
Caused by Vit D deficiency (lack of sun, dietary, malabsorption - crohns)
What is Osteomyelitis?
Infection of the bone
- caused by invasion of microorganisms that stim inflam response in bone tissue
What is definition of a fracture?
A break or disruption in the continuity of bone
(not in 2 separate parts)
What is a simple fracture and a compound fracture?
Simple - Break but not exposed to the atmosphere // skin intact
Compound - bone sticking out of body - even if skin is broken but bone is not out//still compound
What are these types of fractures?
Comminuted
Displaced
Spiral
Impacted
Greenstick
Comminuted - Bone is in several fragments
Displaced - fracture in 2 parts but they are misaligned
Spiral - goes down in spiral
Impacted - bone against bone, (jump off cliff - impact)
Greenstick - bones are not fully formed and it is bowed or bent
Define a strain.
Excessive stretching of a muscle or tendon
Define Sprain
Excessive stretching of a ligament
What are the classifications of strains and sprains?
1st degree - stretched too much
2nd degree - stretched or pulls and tears
3rd degree - big tears, complete disruption, ripped apart
How do you manage strains and sprains?
Cold & heat
Activity limitations
Anti inflam drugs
Muscle relaxants
Surgery
How do you manage the different degrees of strains and sprains?
1st - Rest, Ice for 24-48, Compression bandage, Elevation
2nd - immobilization, partial weight bearing
3rd - longer immobilization, possible surgery
Sprains or strains are what part of body?
Muscle
Tendon
ligament
Define osteoarthritis
-Most common type of arthritis
(weight-bearing joints and hands)
-Joint pain and loss of function
-Progressive deterioration
What are Heberdens nodes and Bouchards nodes?
Heberdens nodes - enlargement of distal joint
Bouchards nodes - enlargment of proximal joint
What are the clinical manifestation of Osteoarthritis?
Pain worsens with activity / better with rest
Hypertrophy of bone joints
50% of hand have heb or bouc nodes
Define Rheumatoid arthritis
Chronic progressive systemic inflam autoimmune disease primarily affecting joints
How does rheumatoid arthritis work?
Autoantibodies attack healthy tissue (RFacotrs)
Affects synovial tissue of any organ or body system - thickened inflam cells (erode cartilage and bone)
Starts in upper extremities & works down
Not genetic
What are the clinical manifestation of rheumatoid arthritis?
Joint deformity
Bilateral and symmertric
25% have subQ nodules - soft tissue growth pop up and go away
**hyper extension of thumb always present
What is the treatment for rheumatoid arthritis?
Pain management
Plasmapheresis - take blood out from remove RF and put blood back in
Assistive devices
What is a comparison of Osteo and Rheumatoid?
Osteo - Assymetric, pain with movement, hypertrophy - not warm or red
Rheumatoid - symmetric, pain when touched, warm and red
ALtruism
Wanting to care for others/help others
Autonomy
Ability to make own decisions
Human dignity
Respect all human life
Integrity
Follow standards
Social justice
Treating everyone equal / fairly
What are laws vs ethics?
Laws - rules establishing society’s behavior, created and enforced by the government, breaking results in a penalty
Ethics - Standards of behavior, based on morals, may or may not be penalized
Autonomy
Patients choice to make decisions
Beneficence
do good for patients/prevent harm
Fidelity
Keeping your word/ promise to care for them
Justice
Treat fairly
Nonmaleficence
Do no harm to patient
Veracity
Tell truth at all times
TORTS what are the 2 main categories?
Unintentional - negligence/malpractice
Intentional -
What are the types of intentional torts?
Defamation - ruining someone’s character
False imprisonment - restrict patients freedom of movement
Invasion of privacy - look up info that’s not assigned
Fraud - don’t ID yourself correctly
Assault - verbally threaten to touch someone
Battery - physically touch someone/ doing a procedure w/o consent for invasive procedure such as surgery
What are the 2 types of defamation?
Slander - verbal
Liable - typing it
Informed consent includes
-Explanation of treatment
-anticipated risk
-potential benefits
-possible alternatives
-answers to questions
-a statement that consent can be withdrawn at any time
Emergency medical treatment and active labor law?
Make sure every hospital gives emergency care and stabilizes before kicking out regardless of insurance status
Patient safety and quality improvement act?
All care provided is of quality and its safe. Protects nurse when report on safe acts or quality and no retaliation
americans with disabilities act
Everyone gets treated the same - provides accommodations
Child abuse and prevention and treatment act
Mandatory reporter and protects against retaliation
Common incident reports
Med errors
Complications from treatment/procedure
Failure to report change in condition
Falls
Break is aseptic technique
Patient refuses treatment/consent
HIPAA
Health insurance portability and accountability act of 1996
Protects the privacy of pt info / health info can be released for treatment, payment, routine health care operations
Nurse practice acts
Delegation to LPN/CNA
- Delegate tasks not in nursing process
What are the 5 rights of delegation?
Right person
Right task
Right circumstance
Right directions
Right supervision
What is an advanced directive?
to communicate wishes regarding to end of life care should patient become unable to do so
What is the patient self-determination act (PSDA)
Requires that all patients be asked if they have advanced directives
What is a living will?
A list of all thing you want or don’t want done. YES OR NO. Does not kick in until the person cannot advocate for self
Durable power of attorney for health care
name of person who will make health care decisions if patient cannot make own decisions
If there is no DNR order what does nurse do
Do CPR when a patient has no pulse or respirations
What is the food samaritan law?
Nurses are held to a different standard, bc your always a nurse -
IF you walk up to someone and tell them your a nurse, it auto creates a nurse/patient relationship
What are some purpose of records?
Communication
Care plan
Financial reimbursement
Auditing/monitoring
legal documentation
What 3 things should always be on my nurses note?
What did I observe/assessments findings?
What did I do about the findings?
How did the patient respond?
HIPAA violation can result in
$250,000 fine
10 years in prison
What are 5 guidelines for quality documentation?
Factual
Accurate
Complete
Current/timeliness
organized
Documenting guidelines for paper charting
Pen
Date and Time
Mistakes - no whiteout, no scribbling
only 1 line through mistake with error and signature with credentials
no blank lines
When do you document? when you are writing or time of event
When you are writing note
Initial nursing assessment includes
Baseline
Sample narrative note
date time age, admitted for
AAoX3, assessments in head to toe format
name and credentials
What is PIE documentation
Problem
Intervention
Evaluation
What is DAR documentation
Data
Action
Response
What is SOAP documentation
Subjective
Objective
Assessment/analysis
Plan
What is SOAPIE documentation?
Subjective
Objective
Analysis - nursing diagnosis
Plan/goal
Intervention / what did you do
Evaluation / how did the patient respond
What is ISBARR
Introduction/introduce self and patient
Situation
Background
Assessment
Recommendation
Read back and verify order from provider
What are the aims of patient education
Promote health
prevent illness/injury
Restore health
facilitate coping
how to develop self care abilities -knowledge, skills attitudes
What are the 3 learning domains
Cognitive - knowledge
Psychomotor - skills
Affective - attitudes
What are some factors that affect learning?
Age & development level
Support & resources
Culture and language
literacy
What is the teaching-learning process?
Assess
Identify actual learning needs
Develop - plan
Implement teaching plan
Evaluate the learning
