Week 4: Pain, Musculoskeletal... Flashcards

Question

___________________ involve 1-time or continuous infusion of local anesthetics into an area to produce pain relief. We also call these techniques regional anesthesia.

Answer 1

Nerve blocks

Answer 2

- Porous bone - Chronic, progressive metabolic bone disease characterized by -- Low bone mass -- Structural deterioration -- Increased bone fragility

Answer 3

- Over 54 million people in the United States - One in 2 women and 1 in 4 men over 50 will sustain an osteoporosis-related fracture. - Known as the “silent thief”

Answer 4

- Lower calcium intake - Less bone mass - Bone resorption begins earlier and accelerates after menopause. - Pregnancy and breastfeeding - Longevity .

Answer 5

- Regular weight-bearing exercise - Fluoride - Calcium - Vitamin D

Answer 6

- Advancing age (>65 yr) - Female - Low body weight - White or Asian ethnicity - Current cigarette smoking - Nontraumatic fracture - Sedentary lifestyle - Postmenopausal - Family history - Diet low in calcium. Vitamin D deficiency - Excessive use of alcohol (>2 drinks/day) - Low testosterone in men - Specific diseases - Certain drugs

Answer 7

- Peak bone mass (by age 20) determined by heredity, nutrition, exercise, & hormone function - Bone loss after age 35-40 inevitable, rate of loss variable - Rapid bone loss for women at menopause Remodeling - Osteoblasts – deposit bone - Osteoclasts – resorb bone

Answer 8

deposition

Answer 9

- Osteoblasts – deposit bone - Osteoclasts – resorb bone

Answer 10

- Occurs most commonly in spine, hips, and wrists - Back pain - Spontaneous fractures - Gradual loss of height - Dowager’s hump (kyphosis)

Answer 11

- Initial bone scan in women before age 65 - Repeat in 15 years if normal - Earlier and more frequent if high risk - Men screened before age 70 - By age 50 if high risk

Answer 12

-History and physical exam - X-ray and lab studies not diagnostic - Bone mineral density (BMD) - Quantitative ultrasound - Dual-energy x-ray absorptiometry (DXA) T-scores - Standard deviation below average -T-score -1 to 1 = normal bone density - T-score between -2.5 and < -1 = osteopenia - T-score > -2.5 = Osteoporosis Z-score compares with someone own age and ethnicity

Answer 13

Prevention - Proper nutrition - Calcium supplements - Exercise - Prevention of fractures - Drug therapy Treat if - T-score lower than -2.5 - T-score between -1 and -2.5 with additional risk factors - Prior history of hip or vertebral fracture

Answer 14

Adequate calcium intake - 1000 mg/day premenopausal and postmenopausal taking estrogen -1500 mg/day postmenopausal without estrogen Supplemental calcium - Must be taken in divided doses with food to enhance absorption Vitamin D - necessary for calcium absorption/function; bone formation - Sunlight for 20 minutes adequate - Supplemental (800-1000 IU/day) -- Postmenopausal -- Older adults -- Homebound/ Minimal sun exposure Good sources of calcium - Milk, Yogurt, Cottage cheese, Ice cream - Turnip greens, Spinach - Sardines

Answer 15

Weight-bearing exercise - Build up and maintain bone mass - Increase strength, coordination, balance - Walking, hiking, weight training, stair climbing, tennis, dancing -Quit smoking. - Decrease alcohol intake. -Treatment of existing disease -- Prevent further loss with supplements and meds -- Keep ambulatory -- Gait aid to prevent falls/fractures -- Brace for vertebral fracture -- Vertebroplasty and kyphoplasty to treat osteoporotic vertebral fracture

Answer 16

Bisphosphonates (Fosamax – alendronate) - Inhibit bone resorption - Side eff ects: anorexia, weight loss, gastritis - Proper administration - Take with full glass of water. - Take 30 minutes before food or other meds. - Remain upright for at least 30 minutes. Calcitonin - Inhibits bone resorption - Give IM form at night to minimize side eff ects - Alternate nostrils when using nasal form - Must use calcium supplementation Selective estrogen receptor modulators - Raloxifene (Evista) - Reduces bone resorption Teriparatide (Forteo) - Portion of parathyroid hormone - First drug to stimulate new bone formation Denosumab (Prolia) - Monoclonal antibody for postmenopausal women - Subcutaneous injection every 6 months Management of patients receiving corticosteroids

Answer 17

OSTEOMYELITIS - Severe infection of bone, bone marrow, and surrounding soft tissue

Answer 18

Staphylococcus aureus

Answer 19

Indirect entry (hematogenous) - Young boys, scrapes - Blunt trauma - Vascular insufficiency disorders - GI & respiratory infections Direct entry – via open wound Foreign body presence

Answer 20

- Microorganisms grow →increase pressure in bone →ischemia and vascular compromise - Infection spreads through bone → leads to cortex revascularization and necrosis

Answer 21

- Infection of <1 month in duration Local manifestations - Pain unrelieved by rest; worsens with activity - Swelling, tenderness, warmth - Restricted movement Systemic manifestations - Fever, Night sweats, Chills - Restlessness - Nausea - Malaise - Drainage (late)

Answer 22

- Infection lasting longer >1 month or failed to respond to initial course of antibiotic therapy - Continuous and persistent or process of exacerbations and remissions - Systemic signs are diminished -Local signs of infection more common: Pain, swelling, warmth - Granulation tissue turns to scar tissue → avascular → ideal site for microorganisms to grow → away from antibiotic penetration

Answer 23

- Bone or soft tissue biopsy - Blood and/or wound cultures - WBC count (high) - Erythrocyte sedimentation rate (ESR) - X-rays - Bone scans - MRI/ CT scans

Answer 24

- Vigorous and prolonged IV antibiotic therapy - Cultures or bone biopsy - Surgical debridement and decompression - Course of IV antibiotic therapy 4-6 weeks minimum may last 3-6 months - May be completed at home or in skilled nursing facility Variety of antibiotics depending on microorganism; include penicillin, nafcillin (Nafcil), neomycin, vancomycin, cephalexin (Keflex), cefazolin (Ancef), cefoxitin (Mefoxin), gentamicin (Garamycin), and tobramycin (Nebcin)

Answer 25

- Surgical removal - Extended use of antibiotics - Antibiotic-impregnated polymethyl methacrylate bead chains - Intermittent or constant antibiotic irrigation of bone - Casts or braces - Negative-pressure wound therapy - Hyperbaric oxygen therapy - Removal of prosthetic devices - Muscle flaps, skin grating, bone grafts - Amputation - Oral fluoroquinolone (Cipro) for 6 to 8 weeks for chronic osteomyelitis - Monitor patient response to therapy with bone scans and ESR tests Long-term and mostly rare complications - Septicemia - Septic arthritis - Pathologic fractures - Amyloidosis

Answer 26

Subjective Data - IV drug and alcohol abuse, malaise - Anorexia, weight loss, chills - Weakness, paralysis, muscle spasms - Local tenderness, increase in pain - Irritability, withdrawal, dependency, anger Objective Data - Restlessness, high spiking temperature, night sweats - Diaphoresis, erythema, warmth, edema - Restricted movement, wound drainage, spontaneous fractures - ↑ WBC, + cultures, ↑ ESR, presence of sequestrum and involucrum

Answer 27

- Have satisfactory pain and fever control. - Do not experience any complications associated with osteomyelitis. - Cooperate with treatment plan. - Maintain a positive outlook on outcome of disease

Answer 28

- Immobilization and careful handling of affected limb - Assess and treat pain - Dressing care - Proper positioning to prevent complications of immobility Patient teaching re adverse and toxic reactions to antibiotic therapy - Ototoxicity, nephrotoxicity, neurotoxicity - Hives, diarrhea, bloody stools, throat and mouth sores - Tendon rupture - Monitor peak and trough levels of abx - Lengthy antibiotic therapy can result in overgrowth of Candida albicans. - Patient and family are often frightened and discouraged. - Continued psychologic and emotional support

Answer 29

- Patient teaching regarding antibiotic administration & management of venous access device - Wound care/dressing changes - Physical and psychologic support

Answer 30

A sprain is an injury to the ligaments surrounding a joint. A strain is an excessive stretching of a muscle and its fascial sheath, often involving the tendon.

Answer 31

A sprain is an injury to the ligaments and capsule of a joint in the body. A strain is an injury to muscles or tendons

Answer 32

open fracture - the skin is broken, and bone exposed, causing soft tissue injury; usually results from severe external forces. closed fracture - the skin is intact over the site.

Answer 33

Complete fracture - the break goes completely through the bone incomplete fracture - occurs partly across a bone shaft, but the bone is still intact; often the result of bending or crushing forces applied to a bone.

Answer 34

displaced fracture - the 2 ends of the broken bone are separated from each other and out of their normal positions. Displaced fractures are often comminuted (more than 2fragments) or oblique In a nondisplaced fracture, the bone fragments stay in alignment; usually transverse, spiral, or greenstick

Answer 35

*Closed reduction * Open reduction – Internal fixation (ORIF) *** Intramedullary rod (IM rodding)

Answer 36

* Fracture hematoma * Granulation tissue * Callus formation * Ossification * Consolidation * Remodeling

Answer 37

Casts – Short arm vs. long arm – Body jacket – Hip spica ***** Double vs. single – Short leg vs. long leg – Knee immobilizer * External fixation * Internal fixation – Pins, screws, plates, rods

Answer 38

(A) Bleeding at fractured ends of the bone with hematoma formation. (B) Organization of hematoma into fibrous network. (C) Invasion of osteoblasts, lengthening of collagen strands, and deposition of calcium. (D) Callus formation: new bone is built up as osteoclasts destroy dead bone. (E) Remodeling is accomplished as excess callus is resorbed and trabecular bone is laid down.

Answer 39

* Assessment – neurovascular * Medications – Muscle relaxants – Tetanus – Antibiotics – Analgesics * Nutrition * Reinfusion drain * Drains

Answer 40

(1) non–weight-bearing (no weight on the involved extremity), (2) touch-down/toe-touch weight bearing (contact with floor for balance but no weight borne), (3) partial–weight-bearing ambulation (25% to 50% of weight borne), (4) weight bearing as tolerated (based on pain and tolerance), and (5) full–weight-bearing ambulation (no limitations).

Answer 41

* Cane * Walker * Crutch walking – Two-point gait – Four-point gait – Swing-to gait – Swing-through gait

Answer 42

* Infection – Surgical debridement * Compartment syndrome * Venous thromboembolism – Pulmonary embolus * Fat embolism * Integumentary

Answer 43

* Early recognition and treatment essential * May occur initially or may be delayed several days * Ischemia can occur within 4 to 8 hours after onset. * Early recognition via regular neurovascular assessments – Notify of pain unrelieved by drugs and out of proportion to injury * Assess urine output and kidney function.

Answer 44

increased pressure

Answer 45

* Colles’ fracture * Humeral shaft fracture * Pelvic fracture * Hip fracture * Femoral shaft fracture * Tibial fracture * Vertebral fracture * Facial fractures – Mandible – Maxilla

Answer 46

Epistaxis congestion can they eat/see/hear? Body image pain scarring ADL Infection prevention/ cleanliness

Answer 47

* PVD * Diabetes * Atherosclerosis * Trauma * Injury * Prosthetics – Bandage – Elastic stocking

Answer 48

* Pain in missing limb [phantom pain] – Mirror therapy – Opioids – Adjuvants * Neuropathic * Prosthetics – Bandage – Elastic stocking * Flexion contractures – Hip flexion *** prone

Answer 49

* Pain in missing limb [phantom pain] – Mirror therapy – Opioids – Adjuvants * Neuropathic * Prosthetics – Bandage – Elastic stocking * Flexion contractures – Hip flexion *** prone

Answer 50

synovial membrane

Answer 51

Debridement

Answer 52

Arthroplasty

Answer 53

Arthrodesis

Answer 54

Chronic central pain syndrome - Widespread, non-articular musculoskeletal pain and fatigue - Multiple tender points May also have - Nonrestorative sleep - Morning stiff ness - Irritable bowel syndrome - Anxiety

Answer 55

-Fibromyalgia is a commonly diagnosed musculoskeletal disorder and a major cause of disability. -Fibromyalgia and systemic exertion intolerance disease (SEID) (formerly called chronic fatigue syndrome) share many common features -It affects an estimated 2% of the general U.S. population. -4 to 10 times more common in women than men.

Answer 56

worsens and improves

Answer 57

- Pain is experienced in 11 of 18 tender points on palpation - History of widespread pain is noted for at least 3 months -Widespread pain is defined as pain that occurs on both sides of the body, and above and below the waist. Fatigue, cognitive symptoms, somatic symptoms help establish diagnosisFIBROMYALGIA TREATMENT

Answer 58

Symptomatic; Rest

Answer 59

Drug therapy for chronic widespread pain - Pregabalin (Lyrica) - Duloxetine (Cymbalta) - Milnacipin (Savella) -Low-dose tricyclic antidepressants (TCAs), SSRIs, or benzodiazepines -Muscle relaxants -Nonopioid analgesics -Zolpidem (Ambien)

Answer 60

-Chronic, systemic autoimmune disease -Inflammation of connective tissue in diarthrodial (synovial) joints -Periods of remission and exacerbation -Extraarticular manifestations -Affects all ethnic groups -Incidence ↑ with age, peaks between ages 30 and 50 -Estimated 1.5 million Americans -Three times as many women as men

Answer 61

-Autoimmune etiology - combo of genetics and environmental triggers -Antigen triggers formation of abnormal immunoglobulin G (IgG) -Autoantibodies develop against the abnormal IgG; Rheumatoid factor (RF); The autoantibodies are known as rheumatoid factor (RF). -The exact cause of RA is unknown. However, it probably results from a combination of genetics and environmental triggers. -Rheumatoid factor combines with IgG immune complexes → deposit on synovial membranes or cartilage in joints → activates complement → inflammatory response -Neutrophils → proteolytic enzymes → damage cartilage and thicken synovial lining

Answer 62

-Other inflammatory cells include T helper (CD4) cells, which stimulate cell-mediated immune responses. Activated CD4 cells cause monocytes, macrophages, and synovial fibroblasts to secrete the proinflammatory cytokines interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor (TNF). - These cytokines drive the inflammatory response in RA. ---Without adequate treatment -More than 60% may develop marked functional impairment within 20 years -Need of mobility aids -Loss of self-care ability -Need for joint reconstruction By end-stage patients experience loss of independence, require daily care

Answer 63

-Genetic link -Genetic predisposition is important in the development of RA. -- HLA-DR4 and HLA-DR1 antigens -- Smoking increases risk in patients genetically predisposed

Answer 64

Stage I - Synovitis - X-ray: soft tissue swelling, possible osteoporosis, no joint destruction Stage II - Increased joint inflammation - Gradual destruction in joint cartilage - Narrowing joint space from loss of cartilage Stage III - Formation of synovial pannus - X-ray: extensive cartilage loss, erosion at joint margins, possible deformity Stage IV - Inflammatory process subsides - Loss of joint function - Formation of subcutaneous nodules

Answer 65

-Onset typically insidious -Fatigue, anorexia, weight loss, generalized stiffness -May report history of precipitating event -Infection, stress, exertion, childbirth, surgery, emotional upset -Specific joint involvement -Pain, stiffness, limited motion, and signs of inflammation -Symptoms occur symmetrically -Often affects small joints -Larger joints and cervical spine may be involved

Answer 66

-Joint stiffness after inactivity -Morning stiffness 60 minutes to several hours or longer -MCP and PIP joints typically swollen -Fingers spindle shaped -Joints tender, painful, warm to touch -Pain ↑ with motion, intensity varies -Tenosynovitis -Deformity and disability -Subluxation -Walking disability -Deformities in the hands

Answer 67

A: Ulnar drift B: Boutonnière deformity C: Hallux valgus D: Swan neck deformity

Answer 68

-Rheumatoid nodules -Nodular myositis -Sjögren’s syndrome -Felty syndrome -Flexion contractures -Cataracts -Depression

Answer 69

-A diagnosis is often made based on history and physical findings, but some laboratory tests are useful for confirmation and monitor disease progression -Laboratory studies -Rheumatoid factor (RF) -ESR and C-reactive protein (CRP) -Antinuclear antibody (ANA) -Antibodies to citrullinated peptide (anti-CCP) -Synovial fluid analysis -X-rays of involved joints -Bone scan

Answer 70

-Care of the patient with RA begins with a thorough program of education and drug therapy. Patient teaching - Drug therapy - Disease process - Home management strategies --Physical therapy --Occupational therapy --Individualized treatment plan

Answer 71

-Bind with TNF, inhibiting inflammation

Answer 72

Corticosteroid therapy- Intraarticular injections; low-dose oral for limited time NSAID and salicylates - Antiinflammatory, analgesic, and antipyretic Not commonly used - Antibiotics (minocycline) -Immunosuppressants (azathioprine [Imuran]) -Penicillamine (Cuprimine) -Gold preparations (auranofin [Ridaura])

Answer 73

-Balanced nutrition important -Loss of appetite or inability to shop for and prepare food → weight loss -Corticosteroid therapy → weight gain

Answer 74

-Relieve severe pain -Improve function -Synovectomy -Total joint replacement (arthroplasty) can be done for many different joints in the body.

Answer 75

Subjective

Answer 76

-Satisfactory pain management -Minimal loss of functional ability -Participate in therapeutic regimen -Maintain positive self-image -Perform self-care -Prevention not possible at this time -Early treatment to prevent further joint damage -Community education programs - Symptom recognition to promote early diagnosis and treatment

Answer 77

Nondrug relief of pain -Therapeutic heat and cold -Rest -Relaxation techniques -Joint protection -Biofeedback -Transcutaneous electrical stimulation -Hypnosis Lightweight splints -Removed at regular intervals -Perform ROM exercises -Reapply as prescribed -Occupational therapist → additional self-help devices -Plan care around morning stiffness -To relieve joint stiffness and ↑ abilty to perform ADLs -Sit or stand in warm shower -Sit in tub with warm towels around shoulders -Soak hands in warm water

Answer 78

-Alternate rest periods with activity -Avoid total bed rest -8–10 hours of sleep + daytime rest -Modify activities to avoid overexertion -Firm mattress or bed board -Encourage positions of extension -Avoid flexion positions -No pillows under knees -Small, flat pillow under head and shoulders -Modify tasks for less stress on joints -Energy conservation -Work simplification techniques -Pacing and organizing -Use of carts -Joint protective devices -Delegation Occupational therapy -Assistive devices

Answer 79

Ice - Especially beneficial during periods of disease exacerbation - Application should not exceed 10–15 minutes at one time Moist heat -Heating pads, moist hot packs, paraffin baths, warm baths, or showers; -Should not exceed 20 minutes at a time

Answer 80

-Slowly progressive noninflammatory disorder of the synovial joints -27 million Americans affected - Numbers expected to increase as population ages -Gradual loss of articular cartilage -Formation of osteophytes -Not normal part of aging process -Cartilage destruction -Begins between ages 20 and 30 - Symptoms do not manifest until after age 50–60 -After age 50, women > men

Answer 81

- Caused by direct joint damage or instability - However, many persons with OA cannot identify a single cause. Risk Factors - Age -Decreased estrogen at menopause -Obesity - Anterior cruciate ligament injury -Frequent kneeling and stooping -Regular exercise can help prevent

Answer 82

- New joint tissue forms in response to cartilage destruction Cartilage becomes: - Dull, yellow, and granular - Softer and less elastic - Less able to resist wear with heavy use - Articular surfaces cracked and worn - Formation of osteophytes

Answer 83

- Fatigue, fever, and organ involvement are not present in OA. - This is an important distinction between OA and inflammatory joint disorders such as rheumatoid arthritis. Joint pain - Primary symptom ranging from mild discomfort to significant disability - Pain worsens with joint use - Early stages: rest relieves pain - Later stages: pain with rest and trouble sleeping due to increased joint pain As OA progresses, increasing pain can contribute significantly to disability and loss of function.

Answer 84

-Pain may be referred to groin, buttock, or outside of thigh or knee -Sitting down becomes difficult, also getting up from a chair when hips are lower than knees -OA in intervertebral joints causes local pain and stiffness -Joint stiffness occurs after periods of rest or unchanged position -Early morning stiffness usually resolves within 30 minutes -Overactivity → mild joint effusion, temporarily ↑ stiffness -Crepitation - a grating sensation caused by loose cartilage particles in the joint cavity, can also cause stiffness. -Asymmetrical - OA usually affects joints on one side of the body (asymmetrically).

Answer 85

-Specific to involved joint Nodes - Red, swollen, and tender - No significant loss of function -Visible deformity -Knee: bowleg, knock-kneedas a result of cartilage loss in one joint compartment -Hip: one leg shorter as the joint space narrows.

Answer 86

- Bone scan, CT scan, MRI - Early joint changes - X-rays - Detect joint space narrowing, bony sclerosis, osteophyte formation - No specific lab abnormalities - Synovial fluid analysis

Answer 87

-Managing pain and inflammation -Preventing disability -Maintaining and improving joint function -Nondrug interventions are the basis for OA management -Drug therapy supplements nondrug treatment -Balance rest and activity -Rest during acute inflammation [functional positioning, Do not be immobilized > 1 week] -Modify activities to ↓ joint stress -Avoid prolonged standing, kneeling, squatting (knee OA) -Assistive device as needed

Answer 88

- Ice for acute inflammation - Heat therapy for stiffness

Answer 89

Mild to moderate joint pain - Acetaminophen (1000 mg every 6 hours) – DRUG OF CHOICE FOR OLDER ADULTS - Topical agent (e.g., capsaicin cream [Zostrix]) - OTC creams (BenGay, ArthriCare) - Topical salicylates (e.g., Aspercreme) Moderate to severe joint pain -nonsteroidal antiinflammatory drug (NSAID) - Ibuprofen 200 mg 4x/day -Misoprostol to decrease GI side effects -Arthrotec (combination of misoprostol and NSAID) -Diclofenac gel - COX-2 inhibitor celecoxib (Celebrex) – USE WITH CAUTION CARDIAC DISEASE RISK - Intraarticular corticosteroid injections

Answer 90

Arthroscopic surgery - For patients with loss of function, unmanaged pain, and decreased independence - Common for patients with knee OA - May provide no additional benefit over PT and medical treatment Arthroplasty - Total knee and hip replacements

Answer 91

Excision or removal of

Answer 92

Destruction of

Answer 93

Creation of opening into Cutting into or incision of

Answer 94

Repair or reconstruction of

Answer 95

observing [with scope]

Answer 96

* Preoperative phase – Prior to surgery * Intraoperative phase – Operative phase * Postoperative phase – PACU period and beyond

Answer 97

Preoperative

Answer 98

Problematic

Answer 99

* Informed consent * Surgical consent * Blood transfusion consent * DNR or Advance Directive

Answer 100

* Labs * EKG * Chest x-ray * Pregnancy test * Cardiac catheterization, stress test, echocardiogram * Type and cross match * NPO status

Answer 101

* Surgical preps * Medication regimen * Discuss indwelling catheters * NPO * Removal of jewelry, makeup, prostheses, contact lenses, dentures * Prevention of complications – Splinting incision (prn) – Coughing and deep breathing * Incentive spirometer * Ambulation * Explain TEDs and SCDs

Answer 102

Post Anesthesia Care Unit.

Answer 103

– Frequent monitoring – Lack of visitation – Pain management – Dietary alterations – Postoperative nausea/vomiting – Elimination – Ambulation restrictions

Answer 104

– Ride home with responsible adult – Post-operative instructions – Explain new medications – Expected discharge criteria – Device teaching * JP drain care *Crutch teaching * Foley care

Answer 105

* Benzodiazepines * Antibiotics * PPIs or H2-receptor blockades * Beta-blockers * Opioids * Antiemetics * Anticholinergics

Answer 106

– Regional * Spinal * Epidural * Nerve blocks – General – MAC (Monitored Anesthesia Care) – Local anesthetics – Conscious sedation

Answer 107

– Circulating nurse – Scrub technician – Surgeons – Anesthesiologist (or CRNA)

Answer 108

* Before anesthesia induction, ask the patient to confirm name, birthdate, procedure, site, and consent. * All surgical team members stop what they are doing just before the procedure starts to verify patient identification, procedure, and surgical site.

Answer 109

* Malignant hyperthermia – Results from general anesthesia * Inhalation agents * Succinylcholine – Manifestations * Body temperature * Skeletal muscles – Treat as emergency * Dantrium (dantrolene) * Hospital protocol * Look for signs in PACU too!

Answer 110

* Retained foreign object * Estimated blood loss (EBL) * Infection * Intraoperative injuries

Answer 111

Proper patient positioning * Lateral “recovery” position * Once conscious – supine position

Answer 112

c. Has not voided since before surgery

Answer 113

b. Increases the rate of the IV fluids.

Answer 114

b. Ensure the patient's identity with a formal identification process.

Answer 115

c. "Who is available to help you at home after the surgery?"

Answer 116

c. Check the patient's oxygen saturation with pulse oximetry

Answer 117

A. “Tell me what you know about your surgery and the risks involved.”

Answer 118

B. Inform the anesthesiologist of the patient’s recent use of kava. Kava may prolong the effects of certain anesthetics. Thus, the anesthesiologist needs to be informed of recent ingestion of this herbal supplement. Patients should not take anything before surgery without the health care provider’s knowledge.

Answer 119

After a surgical scrub, the surgical technologist puts on a sterile gown and one pair of sterile gloves. After a surgical hand scrub is completed, the surgical technologist should put on a sterile surgical gown and two pairs of gloves to prevent the transmission of microorganisms. Surgical hand antisepsis is completed by scrubbing fingers and hands first followed by progression to forearms and elbows. The hands always should be held away from surgical attire and higher than the elbows to prevent contamination. After performing a surgical hand scrub and applying a sterile gown and two pairs of sterile gloves, the person may manipulate and organize all sterile items for use during the procedure.

Answer 120

D) Skin integrity Skin of older adults has lost elasticity and is at increased risk for injury from tape, electrodes, warming or cooling blankets, and dressings.

Answer 121

d. Patient, surgical procedure, and site checked During the surgical time-out, the Universal Protocol is used to verify the patient's identity, surgical procedure, and site to prevent mistakes in surgery. Prevention of infection is to be done at all times. Improved staff communication relates to getting important test results to the right staff on time. Identifying patient's safety risks for suicide usually is not vital before surgery and does not occur during the time out.

Answer 122

Vital signs baseline or stable Minimal nausea and vomiting Responsible adult taking patient home

Answer 123

b. Identify possible reasons for denial of pain. Encourage older adults to report pain, especially those who are reluctant to discuss pain or deny pain when it is likely present, such as after surgery. Older patients may be hesitant to request pain medication, believe pain is an inevitable consequence of surgery, and may not understand how to use patient-controlled machines. Some cultures discourage the expression of pain. The nurse should encourage the use of analgesics, explaining to the patient that untreated pain has a negative effect on recovery.

Answer 124

■ Somatic either superficial (skin, mucous membranes, or subcutaneous tissue) or deep (bone, muscle, tendons, or joints) a deep aching or throbbing. ■ Visceral arises from organs or body cavities (e.g., appendicitis or pancreatitis).

Answer 125

*Neuropathic pain relates to peripheral or central nervous system *○ Numbing, burning, shooting, stabbing, sharp, or electric. *○ Responsive to opioids but often requires other medications.

Answer 126

three months

Answer 127

* Heat, cold (need physician’s order), acupuncture or massage, exercise, herbs, distraction.

Answer 128

*Signs and symptoms decreased arousability, decreased respiratory rate (normal is 12 -20) ■ narcan or naloxone can reverse a narcotic overdose. Use small doses rather than giving the entire dose at once if this is necessary. Bag valve masks (Ambu Bag) or oxygen can be applied if you are concerned about oxygenation. Naloxone’s half life is shorter than that of most opiates, so patient’s respiratory rate should be monitored because it can drop again as soon as 20 minutes after naloxone administration.

Answer 129

equal effect

Answer 130

Condition in which swelling causes increased pressure within limited space (muscle)🡪 squeezing the nerves and blood vessels in the compartment * usually involves leg but can occur in any muscle group

Answer 131

* decreased compartment ______ resulting from restrictive dressings, splints, casts, excessive traction, or premature closure of fascia; also by excessive trauma (object crushing leg) * increased compartment _________ r/t bleeding, inflammation, edema, or IV infiltration * __________ → ischemia→ contracture, disability, loss of function

Answer 132

Pain distal to the injury that is not relieved by opioid analgesics Pallor & Poikilothermia: loss of normal color & temp of the extremity & inability to regulate body temp Paresthesia: tingling, numbness early sign Pulselessness: diminished/absent peripheral pulses; late sign Paralysis or loss of function; late sign

Answer 133

OSTEOARTHRITIS

Answer 134

OSTEOARTHRITIS

Answer 135

systemic systems or inflammation (usually)

Answer 136

* chronic, systemic autoimmune disease; inflammation of connective tissue in synovial joints * remissions and exacerbation * incidence increases with age, peaks at 30-50. * More common in women

Answer 137

Combo of genetics and environmental triggers

Answer 138

DMARDS (disease-modifying antirheumatic drugs) prescribed early to prevent joint degeneration that occurs as soon as the first year with RA; ↓ Permanent effects of RA; start DMARD (such as Rheumatrex) ASAP BRMS (biologic response modifiers): slows progression, treats moderate/severe cases if DMARDS not working; includes tumor necrosis factor inhibitors (TNF) Other: corticosteroid therapy, NSAIDs and salicylates nutritional: balance; often have loss of appetite or inability to shop/prepare food due to reduced mobility/pain surgical therapy: relieves severe pain, improves fx, total joint replacement (arthroplasty)

Answer 139

OSTEOMYELITIS - severe INFECTION of bone, bone marrow, and surrounding soft tissue *most common microbe: Staph. aureus.

Answer 140

* indirect entry (hematogenous): common in young children (blunt trauma), vascular insufficiency (DM) disorders, GI/respiratory infections * direct entry via open wound * foreign body presence

Answer 141

For acute: infection of < 1 month; local manifestations 1. pain unrelieved by rest; worsens with activity; swelling, tenderness, warmth, restricted movement 2. systemic: fever, night sweats, chills, restlessness, nausea, malaise, drainage (late sign) For chronic: infection > 1 month or failed to respond to initial ABX therapy 3. continuous and persistent, or exacerbations and remissions 4. local signs more common: pain swelling warmth 5. granulation tissue turns to scar tissue 6. avascular is ideal site for microorgs since ABX do not work there

Answer 142

For acute: vigorous and prolonged IV Abx; get culture or bone biopsy before initiating * Do not delay ABX treatment! * Course of IV antibiotic therapy 4-6 weeks minimum; may last 3-6 months * May be completed at home or in SNF * Various ABX available; this is why culture is important. “-illin” and “-in” * bed rest and immobilization to reduce pain For chronic: surgical removal may be necessary and extended use of ABX

Answer 143

OSTEOPOROSIS

Answer 144

metabolic bone

Answer 145

* T-scores: (NEGATIVE SCORE = BAD) * Standard deviation below average🡪 the units are compared to someone who is healthy *-1 to 1 = normal bone density *-2.5 to -1 = Osteopenia * T-score lower than -2.5 = Osteoporosis * Z-score compares with someone else with same age and ethnicity

Answer 146

* bisphosphonates (Fosamax-alendronate): inhibits bone resorption by inhibiting osteoclasts; take with water and on empty stomach; remain upright for ~30 min due to S/E of GI upset & esophagitis * calcitonin: For post-menopausal osteoporosis. Inhibits bone resorption; must use calcium supplementation. * selective estrogen receptor modulators: Raloxifene (Evista); mimics effect of estrogen * teriparatide (Forteo): form of PTH; stimulates new bone formation (osteoblasts) * denosumab (Prolia): MAB for postmenopausal women; subQ injection q6 months

Answer 147

Gout - ● Type of arthritis characterized by elevation of uric acid crystals and deposits in 1+ joints

Answer 148

More common in men than women (3x), obesity big factor or other metabolic conditions

Answer 149

NSAIDs and oral colchicine, corticosteroids last resort

Answer 150

* Infection by spirochete Borrelia burgdorferi * Bite from infected deer tick * Not transmitted person to person * Circular “bullseye” rash * Diagnosis based on manifestations (arthritis is second most common manifestation, flu like symptoms) * Treat active lesions with abx PO (ie: doxycycline and amoxicillin) * Educate on reducing exposure to ticks and hiking locations

Answer 151

released home

Answer 152

Diagnostic

Answer 153

○ Exploratory - looking for evidence of pathology suggested by patient’s symptoms ○ Curative alleviates symptoms or cure condition ○ Preventive removing moles that could become cancerous, for example ○ Reconstructive for example, breast implants after mastectomy ○ Palliative does not cure (terminal disease), but provides relief of symptoms

Answer 154

○ Elective surgery that is not physiologically necessary, but patient would like for it to occur (e.g., knee replacement even though patient can still ambulate) ○ Urgent - emergent appendicitis would be considered emergent; emergent might involve a trauma victim who requires surgery to stop the bleeding

Answer 155

-Multi-system inflammatory autoimmune disease. -Affects skin, joints, serous membranes. Renal, hematologic, and neurologic systems affected. Periods of remission and exacerbation.

Answer 156

* Severity is variable. No typical progression * Skin: Vascular lesions on skin (butterfly rash, photosensitivity, discoid rash) * Joints: Arthritis and morning stiffness, may cause deformities * Respiratory/Cardiac: Tachypnea and cough, dysrhythmias * Renal: problems present within 5 yrs of diagnosis * Neuro: Generalized onset or focal onset seizures * Blood: Anemia, leukopenia, thrombocytopenia, coagulation disorders * Increased susceptibility to infection. Pneumonia most common

Answer 157

* NSAIDs * Antimalarial drugs (hydroxychloroquine) * Min possible dosing corticosteroid for shortest time * Immunosuppressive drugs for fatigue and skin/joint issues * Topical immunomodulators for skin issues

Answer 158

Scleroderma - Cause unknown - risk factors= environmental exposure to coal, plastics, silica dust * Body makes too much collagen

Answer 159

Calcinosis- painful deposits of calcium in skin of fingers, forearms, pressure points Raynoud’s phenonmenon- intermittent vasospasm of fingertips (blanching phase, blue cyanotic phase, then erythema) Esophageal dysfunction-hard to swallow due to scarring Sclerodactyly- tightening of skin on fingers and toes Telangiectasia- red spots on hands, face, forearms, palms, lips from capillary dilation

Answer 160

Paget’s Disease - Chronic skeletal bone disorder where excessive bone resorption followed by replacement of normal bone marrow with vascular, fibrous connective tissue (chaotically organized). Common areas: pelvis, long bones, spine, ribs, sternum, skull. New bone is larger and weaker. Men more affected.

Answer 161

* Unknown cause, might be viral or genetic * Affects older adults (like osteoporosis)

Answer 162

x-ray or serum chem shows high alkaline phosphatase (means high bone turnover)

Answer 163

* Bisphosphonates to slow bone resorption. If can’t tolerate this, then calcitonin * Calcium and vit D * Pain mgmt. via NSAIDs

Answer 164

* Symptomatic and supportive care * Physical therapy to build muscle * Nutrition * Assistive devices to prevent falls