Adult Health HESI Study Guide Part 2

Connective Tissue   Connective Disorders: o Infection, injury, or genetic disorders that effect the “cellular glue” of the body that gives shape and strength of tissues Osteoarthritis: o Progressive deterioration and loss of cartilage and bone in one or more joints o Cartilage and bone disease Caused by aging, genetic factors, joint injury, and obesity PAIN IS WORSE AFTER ACTIVITY  BONE ON BONE HURTS Early assessment:  Similar to RA  Heberdens nodes: bony nodules at distal interphalangeal joints  Bouchards nodes: bony nodules at proximal interphalangeal joints  Crepitus heard  Joint effusions: fluid in joints o HUGE FALL RISK, IMMOBILITY RISK (treat with PT, give pain meds prior to activity) o NOT AN INFLAMMATIONAL PROCESS, HAPPENS WITH OLD AGE, WEAR AND TEAR OF THE BODY *** Rheumatoid Arthritis: o Chronic, progressive, systemic inflammatory autoimmune disease o Affects synovial joints o LIFELONG PROCESS o Autoantibodies form and attack healthy tissue, causing inflammation o o o  o o Women > men, mostly in hands and feet, linked to cardiac events (30-60% more likely) DRUGS VERY IMPORTANT  get them going in the morning so it can get better with the day, help with ADLs, wake up not exhausted Give NSAIDS, Tylenol, any anti-inflammation, and STEROIDS KEY ASSESSMENTS: o  Joint stiffness  Swelling  Pain  Fatigue  Generalized weakness  LOW GRADE FEVER Subluxation: o o   o o A single, hot, swollen joint Bone and vertebrae move slightly forward or backwards, hitÝng a nerve, cutÝng it, severing it, spinal cord issues  DAMAGE TO NERVES DRUG THERAPY:  INFLIXMAB (REMECADE)  Helps auto-immune problems  IV infusion over several hours… need to receive every 4 weeks, AT THE SAME TIME ON THE SAME DAY EACH MONTH ***  Help to stop autoimmune so the body does not want to harm itself Other therapies:   Get patients moving *** Want them to do weight bearing activities  yoga o   Lupus Erythematosus: o Chronic, progressive, inflammatory, connective tissue disorder *** o Leads to body organ and system failure o Everybody has different signs and symptoms of lupus o Labs are the confirming diagnosis o PAIN MEDS AND STEROID USE o  Belimumab (Benlysta)  decreases survival of B-cell First start: o o  Stiff joints  Hard to get up  Aches  Headaches  Tired all the time Exercise  feels better to be active Manifestations:  Butterfly rash **  Skin lesions **  Alopecia  Osteonecrosis  Muscle atrophy  Fever and fatigue  Anemia **  Leukopenia (neutropenia) **  Thrombocytopenia ** Scleroderma (Systemic Sclerosis) o Chronic, inflammatory, autoimmune, connective tissue disease o o   NO NON-WEIGHT BEARING SUCH AS SWIMMING  Get rest, get moving, get pain meds, heat and ice (20 mins on 20 mins off) INFLAMMATIONAL PROCESS, YOUNG PEOPLE, WORSE IN THE MORNING *** HARDENING OF THE SKIN  need to lotion Hard skin = breaks/cracks = open wound = infection **  Crest Syndrome o CALCINOSIS – calcium deposits o RAYNAUD’S PHENOMENON – when you touch cold, body turns white because of decreased circulation  go towards the heat … death of tissue *** Marfan Syndrome o Affects the connective tissue in many parts of the body (cardio) o SKINNY BODY o Fat protein *** o HUGE RISK FOR FALLS AND INJURY  Lyme Disease   o o o o One lesion  bulls eye, fever 3-30 days for symptoms to appear Common from deer dicks Treat with antibiotics for 1 month (complete entirely) o o Never cured  always a carrier Ticks love sweaty, moist areas Psoriatic Arthritis o Psoriasis  scaly, itchy rash elbows, knees, scalp o Not contagious o Attacks the joints o Acts like arthritis  stiffness in the morning Fibromyalgia o Not an inflammatory disorder o Treat with pain meds, sleep, exercise Musculoskeletal  Osteoporosis o Bone loss caused from diminishing bone density o o o o Most common: thin Asian women, men with slow bone loss, white, middle aged women Worry about FALLING, BREAKING BONES, RESPIRATORY Secondary osteoporosis causes:  Diabetes  Cirrhosis  Bone cancer  Rheumatoid arthritis  Hyperparathyroidism, hyperthyroidism  Lack of calcium and vitamin D Most common after menopause because the lack of estrogen and testosterone  some treatment is giving estrogen or testosterone Caffeine, tobacco, and wine = BAD  CHANGE LIFESTYLE Body stops absorbing and storing calcium by age 30 Measure bone density with a DXA or DEXA Measuring T-Score: o  0 = normal  -1 to 1 = normal  -1 to -2.5 = low bone mass  -2.5 or lower = OSTEOPOROSIS Drug therapy: o o o o   Calcium and vitamin D *** Women: encourage estrogen    Men: encourage testosterone Osteomalacia o When we don’t produce enough bone collagen  inadequate mineralization o Bone loss due to vitamin D deficiency, but can also be caused by drugs o Happens in children = RICKETS Paget’s Disease of the Bone o Uncontrolled destruction of bone by large osteoclasts (destroying itself) o RISK FOR FRACTURES o Genetic link * Bowing of the long bones *** Pain in hips and pelvis most common  feel as though their hips hurt from how they must stand Osteomyelitis o Infection of a bone o Can occur from:  Skin open  Bone open  Trauma to the bone  Dental work (teeth rotÝng) o BONE IS INFECTED = BONE MARROW INFECTED = BAD BLOOD = SEPSIS = DEATH o Treatment:  Antimicrobial therapy  Need antibiotic *  Contact precautions **  Long IV therapy of 3 months  Need for PICC line  Wound irrigation  Wash it out with NORMAL SALINE  If needed, debridement **  Mechanical scraping  Bone grafting o PAIN & BACTEREMIA (leads to SEPSIS) o Procedure done: circulation? Does the blood get past the point of the problem? Pulse? Both sides? Color? Cap refill? Warm or cold? Benign Bone Tumors o Most common is OSTEROCHONDROMA (slow growing and cause pathologic fracture) o Non-cancerous, can remove it, give pain medications o o    Bone Cancer o Osteosarcoma   Prevalence age 10-30 Metastasizes   o  Acute pain and swelling Ewing o  Very rare but VERY CANCEROUS  Starts with pelvic and hip bone  Pain and anemia!!! Take a biopsy of the bone to find out if it is cancerous or not o Infection = osteomalitis Progressive Muscular Dystrophies o Muscle weakness **  every muscle in the body o Muscle atrophy from immobility  need to practice ROM Musculoskeletal Injury o Why did they fall? How did they fall? Injury on the way down? Brain damage? Lose consciousness? o Fractures:       o Compound fracture…  o Fracture: a break Complete fracture: the whole way through the bone Incomplete fracture: partially though the bone Closed fracture: maintained in the skin Open fracture: skin is broken above the fracture (INFECTION **) Compound fracture = open fracture, can also mean both bones are broken Check for pulse (posterior tibial or on foot… if not present, check up the leg – 5 minutes before there is ‘no pulse’), color of foot, check circulation, temperature, refill of the toes, COMPARE SIDES, sensation  Need to check if artery is severed **  use tunicate above the knee to shut off the artery  Medicate, immobilize, normal saline, sterile gauze, irrigate the wound  Check BP, then if needed, fluids … normal saline or isotonic solution, blood transfusion if needed Greenstick fracture… o  Most common  Bent bone – incomplete fracture * Spiral fracture      ABUSE UNTIL PROVEN OTHERWISE Need to twist the body with force on the body part Babies and older adults ** Treatment:  Closed manipulation  to get it back in place  Open reduction  placing the bones back in place (surgery)  Traction  Fixations:  Union  bones healed and aligned properly  Non-union  take a long time to heal and still not healed correctly  Malunion  joined incorrectly Compartment Syndrome o Muscle swelling compresses blood vessels and nerves o o o o     Can’t feel their body and no pulse  swelling has gotten so bad that it is happening from the inside Causes: cast, injury with horrible swelling CUT THE CAST OFF, IF THAT DOESN’T WORK, CUT THE SKIN (FASCIOTOMY)  do this because patient is losing circulation and ABCs quickly… no circulation = no feeling IV infiltrates, insect bites, severe burns Rhabdomyolysis o Complication of the internal body reacting to this compartment syndrome o KIDNEY IS THE FIRST ORGAN TO GO o Crush syndrome  crushing the extremity … LOOK FOR CLASSIC TRIAD  Muscle pain ***  Weakness ***  Dark urine *** Volkmann’s Contracture o Shortening of the muscle and nerve, 12 hours after pressure has increased, irreversible, most common in the ankle/wrist Fat Embolism Syndrome o When the bone and muscle fat goes to the LUNGS *** (CANT BREATHE AND THEN HEART ATTACK AND THEN STROKE) o Broken bone = fat gets released o Chest pain, crackles, increased respirations, change in MENTAL STATUS ** o Keep them on a pulse ox … decreased respiratory drive Bilateral Infiltrates o Lungs are filled up and cannot breathe o CHECK OXYGEN  Venous Thromboembolism o Blood clots (most common in calf), also called a DVT  Hypovolemic Shock o Loss of blood or fluids  vitals messed up  treat with fluids Hip Fractures o Severe, most common in elderly o Can’t stand up, can’t move o Use abductor pillow, log rolling side to side, watch femoral artery     Amputations o DIABETES **** o HUGE RISK FOR FALLS, PRESSURE ULCERS o Phantom pain = real pain even when the limb is not there  Treat with pain meds or antipsychotic meds Carpal Tunnel o PHALEN TEST ** back of hands placed together Management o Closed reduction o Immobilization o Splints o Casts o Traction ***      o pulling motion of a bone from the external point to realign it and alleviate muscle spasms do not TOUCH THE WEIGHTS EVER need to plan nursing care around the weight movers if the weights move, the BONE IS NOT STRAIGHT ANYMORE bucks traction = used for hip and femur fractures Surgery   Internal fixation = pins, rods, inside body External fixation = pins and rods outside of the body  Worry about infection ***  PIN CARE EVERY 2 HOURS, MINIMUM 2X PER DAY  Crusty pin = culture then clean   Minimal blood loss, early mobilization, maintains alignment in closed fractures, easy access to wound of healing bone CLEAR DRAINAGE FOR THE FIRST 72 HOURS IS OK – PUSS NOT OK Neuro  MRI Safety o Only way to shut off the machine is the quench button  want to prevent doing this, costs BILLIONS TO REBOOT o IRON, COBALT, NICKEL never to be taken into the room … watch for brain aneurysm clip, pacemakers, welding, rods or pins, internal fixation, knee replacement, braces, titanium rods, implant, radiation implant, snap boxers, bra underwire, belly button rings, glasses, jewelry, VAGUS NERVE STIMULATORS (seizure patients) *** o SCREEN EVERYONE GOING INTO THE ROOM  Headaches o Migraines:      Recurrent episodic attacks of head pain, unilateral Lasts 4-72 hours Triggered by alcohol, aged cheese, caffeine (withdrawal too), chocolate, MSG, smoked fish, artificial sweeteners 3 types:  Migraines with Auras o Aura: precursor to migraine or seizure, sensation that signals onset o See halos, blindness, vomiting, smell chocolate, pizza, weird things  Migraines without Auras o Nausea/vomiting o Photophobia  light sensitivity o Phonophobia  sound sensitivity  Atypical Migraines Meningitis o Viral – cannot treat with antibiotics o Bacterial – can treat with antibiotics, prevent with vaccine o Symptoms:      Cannot move your neck (chin to chest*****) Fever over 103 for 27 days straight Increased ICP = mental status, loss of LOC, low BP, NAUSEA AND VOMITING ** Kernig’s positive – lift the leg Brudzinskis – hip/knee flex Tests:  Blood cultures: if it got to the brain, it can get to the blood easily  Lumbar puncture (spinal tap)  position is on the side with legs to chest  Obtain CSF or inject anesthetics  Lay down FLAT for at least 12 hours after puncture  fluid will drain down from the brain (spinal headache) so need to balance out fluid in entire body by laying  Puncture can result in seizures if + for meningitis  Put patients in droplet precautions ISOLATION – WEAR MASK … IMMUNOCOMPROMISED PATIENTS  CT scan Seizures o Sudden, excessive, uncontrolled electrical discharge of neurons into the brain o Causes LOC, motor or sensory ability, or behavior o LOSS OF FUNCTION TO THE BODY o Epilepsy: two or more seizures over a lifetime o FALL RISK **** o Types of seizures: o    o Generalized/Partial/Unclassified, Idiopathic Generalized/ Tonic/Clonic Seizure AKA Grand Mal AKA General Seizure **  Tonic: stiff, rigid muscles  Clonic: rhythmic jerking of extremities Help Patients: o  Help them down to the floor  Put something UNDER THE HEAD  Turn them onto their side, if impossible, turn the head  Don’t put anything in the mouth  SUPPORT BUT DO NOT RESTRAIN THEM  Time entire length of seizure  Check vitals after seizure Seizure ABCs:  o AIRWAY  Start nasal airway if needed  DO NOT PUT ANYTHING IN MOUTH  Get ready to intubate patients at all times  Ambu-bag  Suction equipment in the room  Padded side rails 3 Stages of Seizures:  Pre-Ictal:  Before a seizure (aura) – can stop the seizure before it even happens o  First person: go into the room and check for airway  Second person: get meds to push to prevent  Ictal:  Active stage of the seizure  Post-Ictal:  Seconds up to 6 hours  Can be as simple as staring into the distance or can’t breathe for hours  AIRWAY AND PULSE OX ******** Acute Seizure Medication:   o o ATIVAN AND VALIUM  very similar drugs but Ativan drug of choice Combined, only give 4 doses of these meds (together)… if that does not work, switch to Phenytoin (Dilantin) or Fosphenytoin (Cerebyx)  Ativan:  Considered the rescue med of seizures  Give IV  Valium:  Can be given rectally  Phenytoin (Dilantin) and Fosphenytoin (Cerebyx)  give loading dose, maintenance drugs  PHENYTOIN = TOXICITY … too much of dose, they might seize Status Epilepticus  “status seizure”  THE WORST SEIZURE THERE CAN BE  Lasts more than 5 minutes, or repeated more than once in 30 minutes  Over 10 minutes of seizure = brain death  Push IV drugs (Ativan or Valium)  DO NOT ADMINISTER WARFARIN WITH PHENYTOIN ***** Seizure Control   Vagal Nerve Stimulation (VNS)  Pacemaker-type device to stimulate according to a schedule of auras  used to abort a seizure  VNS magnet placed on wrist/bracelet Guillian-Barre Syndrome o Autoimmune attack on the nerves o o o o o Ascending weakness (start from the bottom and works its way up) Does not attack the heart enough to kill it but it does attack the lungs very badly (patient eventually stops breathing) If patient goes into respiratory distress  intubate  Its literally the lungs not working. Not oxygen problem – lung problem DELAYED REFLEXES, WEAKNESS IN THE LEGS, FOOD POISONING TWO WEEKS AGO… YOU HAVE GBS Electromyogram = stimulates nerves so we know when to intubate or not ** o o o o o  Want to get them back to normal = speech therapy (for communication) and decrease fear and anxiety (tell them it will get better/you will return) Three Stages:  Acute period: symptoms build up until they don’t get any worse (6 weeks)  Plateau: may last for several days to 2 weeks  Recovery Phase: 4-6 months, return to 100% normal Altered respiratory function and presence of protein in CSF (happens through lumbar puncture) FROM INTUBATION, TO GETTING BETTER, TO TOTALLY FINE Common in people 20-40 years old Myasthenia Gravis (MG) o Sporadic (fine one day, not the next), autoimmune, chronic, progressive disease o FATIGUE AND SEVERE WEAKNESS ** o RESPIRATORY DISTRESS  CAUSED BY STRESS o DO NOT STRESS THESE PATIENTS OUT … make sure to meditate, yoga, sit and relax o Blocks and destroys neurons o Symptoms: o o o o o  Muscle fatigue: risk for falls, no ADLs *  Ptosis: not important  Facial mobility: need to communicate *  Chewing/swallowing: aspiration risk *  Voice: need to communicate *  Intercostal: respiratory complications *  Bladder/Bowel: constipation ***  STRESS, TACHYCARDIA, DYSPNEA, DYSPHAGIA ****** GIVE THEM A CHOLINERGIC DRUG – relaxation Very short life = very toxic Too much of a drug = EXACTERBATION Too little of a drug = EXACTERBATION Small window for toxicity o o MG = stress causing, outside world, other factors Cholinergic = what the drug causes  o GET DRUG LEVELS CHECKED 24/7 TO PREVENT CHOLINERGIC CRISISES o NEED TO KNOW CPR Amyotrophic Lateral Sclerosis (ALS) o Still have cognitive function, but the body does not follow  affects upper and lower motor neurons o Progressive, degenerative disease involving voluntary motor system o Ventilation prolongs survival but does not alter progression of disease o Eventually cannot use hands, forearms, legs, BODY SHUTS DOWN o THINK ABOUT THE LUNGS – need to trach o NO: o  Cause  Cure  Treatment  Standard pattern of progression  Prevention  Sensory, ANS, mental status  Research Symptoms  Fatigue while talking, tongue atrophy, dysphagia, weakness, fasciculation (twitching) of the face, nasal quality of speech, dysarthria o NUTRITION IS KEY o ALWAYS CHECK GAG REFLEX BECAUSE YOU NEVER KNOW WHEN THIS WILL BECOME IMPAIRED o ALS will eventually kill them  Multiple Sclerosis (MS) o Demyelinating disease o o o o Activation and remission, HIGHS AND LOWS CT brain scan will show MS NYSTAGMUS – WHEN EYES GO CRAZY BACK AND FORTH  FALL RISK ** Cognitive changes  do not remember everything, not themselves, etc. o LHERMITTE’S SIGN ***  chin to chest, shooting pains from the back of the neck to toes TREAT WITH STEROIDS (corticosteroids) Not worried about respiration o o  o Worry about weakness Huntington’s Disease o Male to male (father to son) * o Mental status changes o Jerky movements o 3 stages, die in about 15 years … affects very quickly … lose all function o No cure, no treatment  Parkinson’s Disease ********* o Progressive, neurodegenerative, INCURABLE disease o Common in older adults o Affects motor ability (fine and large motors) o FALL RISK *** o GIVE MEDS ON TIME AT THE SAME TIME o o o o o Before getÝng up in the morning: take pill, put hard sole shoes so feet do not curl ADLs compromised  brush teeth, showering, etc. Depression **  incurable disease First sign: pill rolling motion of the fingers, then mild tremor, slight limp, arm swing, then PARKINSON’S GAIT (lean forward, knees bent, feet shufÒing/dragging, takes a while for them to get moving, but then hard to stop)  There are technically 5 stages  Tremors and limp  Masklike  also high risk for depression  Instability  Rigidity  Then bad and can’t perform ADLs DIAGNOSIS OF PARKINSON’S ****   o 1) must have 2/4 characteristics of classic 4 symptoms 2) give Parkinson’s meds and see if there is a positive reaction (if there is, symptoms will disappear) Classic Triad: (4)   1) Tremor  pill rolling 2) Rigidity  cogwheel rigidity- rhythmic interruption of muscle movement  plastic-mildly restrictive movements  lead pipe – totally resistance to movement