Nursing Final Lecture Notes

NUR 1110 FINA FINAL L EXAM NOTE NOTES S UNIT 4 _ ** NEED TO KNOW ** Urine must be kept cold ¥ ¥ Specimen urinalysis must be a clean catch(when you wipe first then catch the urine med stream) 24 hour collection: discard the first void , collect all next voids into a bucket on ice for 24 hours ¥ For Foley specimen: collect with a syringe from second port (NOT FROM THE BAG) ¥ IMPO IMPORTAN RTAN RTANT T DIAG DIAGNOS NOS NOSTIC TIC TE TEST ST ¥ IVP- dye goes directly into vein to monitor for kidney abnormalities , ask pt. if they are allergic to shellfish PSA(normal vales is 0-4.0) greater than 4.0 is a sign of tumor/cancer ¥ Kidney Biopsy: tissue is taken from the nephron to test for damage ( NOT COMMON ) ¥ Retrograde pyelogram: Cystoscope is used to insert a catheter into the males ureter, dye is injected ¥ upward to look for kidney abnormalities) 1. Alterations in Urinary Elimination 1.Cystitis --PATIENT PATIENT E EDUCATIO DUCATIO DUCATION N - An inflammation of the urinary bladder , infection from the urethra ( ascending) Most comm common on in w woman oman often ccaused aused by: ( E. Coli, follow followss sexu sexual al inter intercourse course course)), wiping habits in women, irritation from bubble baths , masturbation, vaginal diagphraphs , pregnancy , DM, aging changes, indwelling catheters) Nonin Noninfectiou fectiou fectiouss may be caused by chemical exposure or radiation MEN: aging changes and prostate disease Signs & sym symptoms ptoms ptoms:: DYSURIA Urgency, frequency Burning pain on urination/HESITANCY PAIN agitated , nervous Nocturia , Pus bacteria in the urine Low back pain Malaise, chills, fever , nausea and vomiting(may be present) Diagn Diagnostics: ostics: Dipstic Dipstick: k: look for ± creatinine & nitrates, ± WBC(cloudy Urine + Strong smell) leukocytes , enzyme indicating pyuria Micro Microscopic scopic Urine Analys Analysis: is: confirm dipstick bacteria; pyuria Must be clea clean n catc catch h Cultur Culture: e: Growth , type for antibiotic prescription Treatm Treatment: ent: Urine culture and sensitivity is done Antimicrobial agents given based on organism Recurring infections can happen ( Follow-up urine studies are recommended for 2 weeks) Nursin Nursing g Inte Interventio rventio rventions: ns: Pt. hx. Asses hourly ( Pain , frequency ,urgency, changes in urine) Changes in voiding pattern Drug hx. (antibiotics taken now/ recently) Urine visual inspection ( Volume, color , cloudiness , odor) Relieve pain & discomfort ( Aspirin , heat to perineum , hot baths help relieve urgency, discomfort & spasms) CAFFIENE FIENE FIENE-- coffe coffee, e, tea a and nd col colas) as) Increase fluids ( AVOID CAF - 1 Encourage frequent voiding Pt. Ed Education ucation ucation:: Increase hygiene measure ( clean front to back , take showers not baths) Increase fluids Void q 2-3 hours Void immediately after sexual intercourse Take antibiotics after sexual intercourse Take prescribed long term therapy after emptying bladder before bed Regular follow-ups Medic Medications ations ations:: Phenazopyr zopyr zopyridine idine P Pyridiu yridiu yridium m -URINARY ANALGESIC AGENT ² relief burning, ¥ Phena pain, other symptoms w/ UTI ( USED FOR PYELONEPHRITIS , CAN CAUSE ORANGE URINE 2. Pyelone Pyelonephritis( phritis( Upp Upper er Urinary Tract Infect Infection) ion) -Bacterial infection of pelvis , tubules and intestinal tissues/ one or both kidneys ACUT ACUTE: E: active infection Clinica Clinicall mani manifestatio festatio festations: ns: Shills - fever flank pain - elevated WBC costovertebral PAIN (tenderness to touch) on physical examination leukocytosis - bacteria and pus in the urine Dysuria and increased frequency Lower back pain -headache , Nausea & vomiting Diagn Diagnostic ostic te test/ st/ Ev Evaluatio aluatio aluation: n: IV Pyelogram ÐTEST FOR abnormalities are found Ultrasound or CT scan used to locate an obstruction Diagnostic test used to locate an obstruction on the Urinary tract (relief of obstruction) Radionuclide imaging can visualize things not seen on ultrasound or CT Urine culture & sensitivity test to specify microbes present Treatm Treatment: ent: Pt. are treated on an outpatient basis if no complications present 2 week course of antibiotics , must stress importance of regiment completion Following treatment pt. may develop recurring asymptomatic infection for months to years If reoccurrence happens follow up regimen for 6weeks Follow up urine culture obtained 2 weeks after completion of antibiotic therapy. Increased hydration is important to flush urinary tract and reduce pain Fluroquinolones are used (- floxacin) CHRO CHRONIC: NIC: repeated acute pyelonephritis , no symptoms until exacerbation occurs ( CAN LEAD TO ESKD) Clinica Clinicall mani manifestatio festatio festations: ns: Fatigue -Headache Poor appetite - Polyuria + Polydipsia Weight loss ** persistent and recurring infection may produce scarring of kidneys and renal failure , hypertension and formation of kidney stones Assess Assessment ment ment/Diagn /Diagn /Diagnostics ostics : IV Program BUN & Creatinine Treatm Treatment: ent: Long term use of prophylactic antimicrobial therapy (LIMIT RECURRANCE OF INFECTION) Close monitoring of kidney function - 2 Nursin Nursing g inte interventio rventio rventions: ns: (wh (when en hos hospitalize pitalize pitalized) d) Fluid intake and output monitoring 3-4L of fluid per day is encouraged to dilute urine , and decrease burning Asses temperature q 4 hours Administer antipyretic and antibiotic as prescribed Educate patient on prevention of further infection ( adequate fluid intake , emptying bladder regularly, preforming proper perineal hygiene, completing all meds as prescribed, follow-up appts.) 3. Acute g glomerulone lomerulone lomerulonephritis phritis - im immunolog munolog munological ical - Inflammation of the glomeruli of the kidney , follows a streptococcal infection of the threat or skin. Characterized by oliguria, edema, hypertension and circular- tory congestion, hematuria, and proteinuria. Acute poststreptococcal glomerulonephritis (APSGN) is the most common Mostly boys , uncommon younger than 2 affects primarily early school-age children, with a peak age of onset of 6 to 7 years old. W/n 10-20 days of streptococcal infection clinical manifestation begins An access accumulation of water and retention of sodium causes circulatory congestion and edema Diagn Diagnostic: ostic: Pt. Ha Hass no si signs gns or symp symptoms toms u until ntil Gro Group up A strepto streptococca cocca coccall infect infection ion 1-3 week weekss perio period d Edema is minimal in early period Urinaly Urinalysis sis will show hema hematuria turia a and nd pro proteinuria teinuria teinuria(3+ (3+ or 4+) Disco Discoloration loration of uri urine ne ( RB RBC C and hemog hemoglobin lobin in urin urine) e) Elevat Elevated ed BU BUN N and creatin creatinine ine The ant streptolysin O(ASO) titer is the most familiar and readily available test for streptococcal infection. elevated ant hyaluronidase (AHase), anti-deoxyribonuclease B (ADNase-B), and streptomyces. Serum C3 levels decreased during disease and rise with treatment (should be at normal range by 8 weeks) chest x-ray examination, which generally shows cardiac enlargement. pulmonary congestion, or pleural effusion during the edematous phase of acute disease Renal biopsy only used in atypical cases Assess Assessment ment : Fatigu Fatigue e edem edema a( facial in the morning , spreads throughout the day)- periorbital Anore Anorexia xia Oligur Oliguria ia Cloud Cloudy y smok smoky y brow brown n (urin (urine) e) Ð R RUSTY USTY TEA C COLOR OLOR Increa Increased sed U Urine rine sp specific ecific g gravity ravity Flank/ Flank/abdom abdom abdominal inal p pain ain Weigh Weightt gain Pallor/ Pallor/low low gr grade ade fe fever ver Irritability Lethargy Child appearing ill Older children complain of headaches discomfort dysuria Vomiting Elevat Elevated ed BP Medic Medical al man managem agem agement: ent: Goal: supportive measures , early recognition and treatment of complications Norm Normal al BP + UO ccan an be ttreated reated at hom home e Those with substantial edema, hypertension, gross hematuria, or significant oliguria should be hospitalized because of the unpredictability of complications Foods high in potassium are restricted during oliguria( no urine) - 3 - Moderate sodium restriction and even fluid restriction may be instituted for children with hypertension and edema. Comp Complication lication: acute kidney injury with oliguria and fluid and electrolyte imbalance( hyper kale is, acidosis , hypocalcemia, or hyper phosphatemia) - peritoneal or hemodialysis Nursin Nursing g Man Managem agem agement: ent: RESTRICT ICT F FLUIDS LUIDS Ð GIVE 500M 500ML L+V VOIDED OIDED FRO FROM M Bed rest is encouraged for acute phase(OLIGURIA) Ð RESTR PREVI PREVIOUS OUS D DAY) AY) measurement of vital signs, body weight. and intake and output for complications of the disease PRIOR PRIORITY ITY IN INTERVE TERVE TERVENTIO NTIO NTION N: weight check for fluid balance, frequent bp monitoring( q 4 hours) (preserve renal function and prevent circulatory overload) Antihy Antihyperten perten pertensives sives & diure diuretics tics m may ay be ordere ordered d if di diastolic astolic pressu pressure re is 10 100mm 0mm Hg or more more,, Antib Antibiotics iotics iiff positiv positive e strep is fou found nd Asses for sig signs ns of H HYPERK YPERK YPERKALEM ALEM ALEMIA IA Asses for signs of cerebral complications Seizure precautions & IV equipment readily No added salt in diet ( explain and reinforce fluid restrictions) Parents not allowed to bring salty snacks Plan activities with frequent rest periods Discha Discharge rge Te Teaching aching aching:: Education in home management( MONITOR FOR EDEMEA) Monitor Urinary output( 1ml/kg/hour/day) Dietary restrictions ( DECREASE SODIUM + POTASSIUM , LIMIT PROTEIN) Infection prevention ( PREVENT INFECTIONS DURING HEALING PERIOD) Follow up with PCP Weekly then monthly visits with Urinalysis - 4. Nephro Nephrotic tic Syndrom Syndrome e - Disorder that is characterized by increased protein in the urine(proteinuria, hypoalbuminemia. hyperlipidemia, and edema. ) minimal-change nephrotic syndrome (MCNS} is the most common 80% of all cases The disorder is characterized by increased. glomerular permeability to plasma protein, which results in massive urinary protein loss.( Proteinuria, hypoalbuminemia, edema , excessive cholesterol in the blood) Mostly male predominantly occurs in children between 2 and 7 years old. It is rare in children younger than 6 months old, uncommon in infants younger than 1 year old, and unusual after 8 years old. Glomuler Because permeable to protein , causing hyperalbumiuria and albumin to leak in the urine, causing serum albumin loss, (hypoalbumenia) this loss cause a decrease in osmotic pressure w/n the capillaries. Fluid accumulates cause edema & asities , majority of fluid is in the abdomen Hypovolemia is caused Because if fluid shift causing tubular reabsorption of sodium and water Assess Assessment/ ment/ ment/diagno diagno diagnosis: sis: Diagn Diagnosed osed b based ased o on n 4 cli clinical nical m manifest anifest anifestations( ations( edem edema a , pr proteinu oteinu oteinuria, ria, hyp hypalbum album albumenia, enia, and hyper hypercholes choles cholesterolem terolem terolemia ia w/o hem hematuria aturia a and nd hy hyperten perten pertension sion in childr children en 2-8 years o old) ld) Proteinuria results is 2+ Pt. Appears edematous Stead Steady y weig weight ht gain, then sudden weight loss, anorexic and irritable , less active Facial edem edema a ( arou around nd ey eyes es mo mostly) stly) - P PERIOR ERIOR ERIORBITAL BITAL Abdominal swilling Pleura Pleurall effus effusion ion Scrotal swelling 4 Increased cholesterol in the blood Diarrhea Ankle/ leg swelling Slightly increase in bp Susceptible to infection Frothy urine , decreased volume Comp Complication lication lications: s: acute kidney failure Tubular necrosis Interstitial nephritis Infection Circulatory insufficiency Thromboembolism if patient does not respond to 8 week steroid treatment a biopsy is required to identify other types of nephrotic syndrome Medic Medical al man managem agem agement: ent: Reducing excretion of urinary protein Reducing fluid retention in the tissues Preventing infection Decrease complications related to therapy Diet restrictions of salt If increasing edema , fluid restrictions If complications from edema a diuretic is given Prednisone corticosteroid therapy is the first line of defense 2mg /kg/day for 6 weeks the. 1.5 mg/kg/day for another 6 weeks Most children have a relapse , it is noticed by high amounts of protein in the urine and can be caught early with educating parents on using dip stick to monitor the level of protein in the urine. Relapse is treated with high dose short term steroids Steroid side effects: increased appetite, weight gain, rounding of the face, and behavior changes. Longterm therapy may result in hirsutism, growth retardation, cataracts, hypertension, gastrointestinal bleeding, bone demineralization, infection, and hyperglycemia. cyclophosphamide, chlorambucil, or cyclosporine are used in children who do not respond to steroid therapy or steroid therapy is affecting their growth Relapse are triggered by allergies , immunizations bacterial and viral infections Nursin Nursing g Man Managem agem agement: ent: Priorit Priority: y: fluid reten retention tion or excre excretion tion m monitor onitor onitoring ing Bed re rest st Strict I&O, using diapers may be necessary for children , collection bags are irritation to the skin Urine exam, daily weight , abdominal girth Edema assessment around eyes (degree of pitting and skin color) Predn Prednisone/ isone/ isone/glucoc glucoc glucocorticoi orticoi orticoids ds ma may y be u used sed to reduc reduce e prote proteinuria inuria inuria,, decre decreased ased w weight eight and a abdom bdom bdominal inal gir girth th Change positions frequently to prevent skin break down, Monitor vitals for signs of complications Children are prone to URTI , keep them away from infectious children , keep they warm dry and active Vaccines are recommended Nutriti Nutrition on is important , salt is restricted but not eliminated, PROTEIN IS INCREASED) , nurses must try to serve attractive food , must entice the child to eat without fuss during steroid therapy due to decreased appetite Diuretics given for severe edema When appetite returns must insure the child does not overeat and gain weight Keep the children active , they may not want to play, steroid therapy makes them moody and irritable - 5 6. Benign Prostatic H Hyperplasia yperplasia (Enlarged Prostate) - RED URINE AFTER TU TURP RP IS EXPE EXPECTED CTED - Non-cancerous enlargement of the prostate (most common) Interferes with normal daily activities/ sleep patterns Occurs in men older than 40 years old ( 50% of all men have BPH by 60) Dihydrostetesrone(DHT) is the mediator of prostatic growth Estrogen also plays a role Occurs when men have elevated estrogen levels Prostate tissue becomes less sensitive to DHT and more sensitive to estrogen Enlargement of the prostates because obstruction tot the bladder neck or urethra causing incomplete emptying of bladder and urinary retention Hydroureter and Hydronephrosis occurs Can cause UTI from urine remain in the urinary tract Risk fa factors: ctors: c Smoking c heavy alcohol consumption c obesity c reduced activity level c hypertension c heart disease c diabetes c Western diet (high in animal fat and protein and reneed carbohydrates, low in fiber) Clinica Clinicall Mani Manifestatio festatio festations: ns: c Urinary frequency c Urgency w. difficulty Ð dribbling c Nocturia- FROM INCREASED BLADDER CONTRACTIONS c Hesitancy in starting urination c Decrease in force of treat c Sensation of incomplete bladder emptying / pressure on the urethra c Abdominal straining Ð inability to urinate when the prostate completely blocks the urethra / causes UTI c Decrease in volume c Acute urinary retention c Recurrent UTI ** additionally: Fatigue, anorexia , nausea , vomiting , pelvic discomfort c Diagn Diagnostic ostic T Test: est: c Family hx of prostate disease c Digital rectal exam c Lab test for urine & blood c c c c c Prostate biopsy Ð if alarmed about cancer Fitness for surgery Voiding diary used to record frequency and volume DRE Urinalysis for hematuria and UTI c c c c c PSA level obtained Recording urinary flow and rate Measurement of postvoid residual urine Urodynamic studies Urethrocytoscopy c c Ultrasound CBC 6 Cardiac status and respiratory function ( due to age , high incidence of cardiac and respiratory disorders as well) Medic Medical al man managem agem agement: ent: c Improve quality of life (cut down alcohol & caffeine, drink small amounts all day, avoid fluids at bedtime, avoid decongestants & histamines, go when there is an urge, double void, , stress free, exercise regularly) c Prevent disease progression c Minimize complications c Pt. Admitted for emergency unable to void is immediately catheterized c A think wire(stylet) is introduced by a urologist into the catheter to prevent it from collapsing when it encounters resistance c If obstruction is severing a Cystostomy( incision in the bladder may be needed) or a medical catheter to provide urinary drainage c IF DIAGNOSIS DOES NOT AFFECT ADLS PATIENT IS MONITORED YEARLY WITH NO INTERVENTIONS MEDI MEDICATIO CATIO CATION: N: 1.Alpha-adrenergic blockers relax the smooth muscles of the bladder neck and prostate to improve urine flow and relive symptoms -Alfuzosin(Uroxatral) -terazosin (Hytrin) -doxazosin (Cardura) - tamsulosin (Flomax) Side effects: Side effects include dizziness, headache, asthenia/fatigue, postural hypotension, rhinitis, and sexual dysfunction c 2. 5-Alpha-reductase inhibitor (6 months to feel benefits)prevent the conversion of testosterone to DHT and decrease the prostate size. -Finasteride (Proscar) -dutasteride (Avodart) Side effects: decreased libido, ejaculatory dysfunction, erectile dysfunction, gynecomastia (breast enlargement), and ushing. ** Using both has decreased side effects SURG SURGERY: ERY: Minim Minimally ally Inv Invasive: asive: c Transurethral microwave thermotherapy( TUMT), the application of heat to the prostatic tissue c Transurethral needle ablation ( TUNA) by radiofrequency delivered by think needles Surgic Surgical: al: c TURP- Transurethral resection of prostate - most common surgical treatment for BPH , a n instrument ( catheter is inserted through the penis and into the urethra to remove parts of the prostate gland(outpatient setting) - lest post pop bleeding g than traditional surgery c done under general anesthesia ENTIO ENTIONS NS FO FOR R SU SURGER RGER RGERY Y: NURS NURSING ING IN INTERV TERV TERVENTIO Preop Preopp: p: asses general health, urinary characteristics , pain associated, establish kidney function, reduce c anxiety , education on prostate, enema is given to prevent post app straining , Antiembolic stockings are applied c POST POSTopp: opp: fluid volume balance, relief of pain, ability to perform ADLs , irrigation record of amount of fluid used , as well as intake and output record, monitor for electrolyte imbalance , increased BP, confusion and respiratory distress , Pt. Is asked to sit and dangle legs same day of surgery. Next morning pt. Beings ambulating . Watch for bladder spasm( increased need to void , fullness in the bladder, bladder from the urethra) c Bright red bleeding with increased viscosity and numerous clots usually indicates arterial bleedÈ ing. Venous blood appears darker and less viscous. Arterial hemorrhage usually requires surgical intervention (e.g., suturing or transurethral coagulation of bleeding vessels), whereas venous bleeding may be 7 controlled by applying prescribed traction to the catheter so that the balloon holding the catheter in place applies pressure to the prostatic fossa. Comp Complication lication of TU TURP: RP: Transurethral resection syndrome is a rare but potentially serious complication of transurethral prostatectomy (TURP). absorption of the solution used to irrigate the surgical site during the surgical procedure. Hyponatremia, hypovolemia, and occasionally hyperammonemia may occur Signs & Symptoms: Collapse, Headache, Hypotension, Lethargy and confusion Muscle spasms, Nausea and vomiting, Seizures ,Tachycardia Additional complications: c Hemorrhage and shock, Infection, Venous thromboembolism (VTE), Catheter obstruction(Complications with catheter removal, Urinary incontinence, Sexual dysfunction 6. Urolithia Urolithiasis sis - Calculi(stones) in the urinary tract or kidney Certain factors cause the formation of kidneys stones: infection , urinary stasis, and periods of immobility (slows kidney drainage & alters calcium metabolism) Anti-acids vitamin D, and laxatives, high doses of aspirin can also cause gallstones Types of stone: Calcium m Ox Oxalate alate(most common) forms acidic urine due to increase amounts of calcium & oxalate in urine, 1. Calciu low activity. Calcium- increase is caused by hypercalcemia , hyperparathyroidism , increased intake of sodium Oxalate- GI disorders ulcerative colitis (Fats cannot digest , oxalates are left in the urine) , high intake of foods that contain oxalate ( Spinach , rhubarb , beets, chocolate, strawberries, cabbage, tomatoes , nuts , wheat bran , tea) 2. Uric A Acid cid: too much uric acid in the urine from gout , dehydration , diabetes , high intake of animal protein & purine foods( Organ meats, beer , pork, red meats, seafood) Cystine e - uncommon/ genetic Ð form when too much amino acid in urine 3. Cystin 4. Struvit Struvite e Ð rare from chronic UTI bacteria causing urine to be alkaline (magnesium ammonium phosphate) Calcium m phosphate: forms in alkaline urine Ð renal tubule issue 5. Calciu Clinica Clinicall man manifestati ifestati ifestations: ons: Pain ( depends on presence of obstruction, infection or edema) Flank pain/c pain/costove ostove ostovertebral rtebral area Renal colic- llocated ocated in kid kidney( ney( re renal nal pe pelvis) lvis) ( d dull ull dee deep p ach ache e in fla flank nk or ccostove ostove ostovertebra rtebra rtebrall area) Ureter colic Ð in the urete ureterr- inten intense se sha sharp rp wa wave ve like and ra radiates diates to scro scrotom tom o orr vagi vaginal nal area Discomfort, & possible signs of UTI Urge to void w/ dribbling Nausea + vomiting from pain Hematuria Signs of UTI/w. retention Diagn Diagnosis: osis: KUB- xr-ay of kidney ureter bladder IVP **metformin decreased Asses allergies Urinalysis Control pain when passing stone Radiography Blood chemistry - 8 24-hour urine test Measurement of calcium , uric acid , creatinine, sodium, pH, and total volume Dietary Medications hx Family hx of kidney stones Stone analysis (Strain all urine & save stones )- to determine the cause of kidney stones Usually found ( in right and left kidney, ureters, and bladder) Pt. Ed Educatio ucatio ucation/ n/ Nurs Nursing ing Hot baths/ moist heat to the flank area. Fluids are encouraged (2L per day) Allopurinol- decrease uric acid levels Hydrochlorothiazide Ð for calcium stones Reporting signs & symptoms Follow-up care Urine PH monitoring Preventing recurring stones Fluid intake increased ( 8-10, 8oz glasses of water daily) Dietary- decrease calcium supplements , DO NOT LIMIT CALCIUM IN DIET , limit protein for uric acid stones Limit foods high in sodium ( calcium stones 2-3g a day) , limit Purine food for uric acid stone , limit foods in oxalates When PT returns from ESWL (NON INVASIVE)Ð strain urine and send stones to lab , keep patient mobile to facilitate , Control pain Ð medication as prescribed , Blood in the urine is possible , Medication education WHEN STONE IS TOO LARGE- Percutaneous invasive surgery- remove stone fragments from the tube, empty bag, keep tube secure , monitor for infection , empty & strain urine) 3-4 L per day - UNIT 1 _ 1.Nursing Management & Delegation Five Rights of delegation 1. Right task 2. Right circumstance 3. Right person 4. Right direction & communication 5. Right supervision The WÕs of Delegation: Whom to delegate What to delegate What to do during delegation What to do after delegation Four AÕs of Delegation: Assessment Assignment Authority Accountability THE LLPN PN CA CAN N NO NOT T EAT ( Eva Evaluate, luate, A Asses sses , Teach Teach)) , can only a assist ssist w with ith stab stable le clie clients nts , C CAN AN N NOT OT A ADMIN DMIN DMINISTER ISTER IV Types of Leadership: - Autocratic: Gives orders and makes decisions for the group - Democratic: Shares leadership and decisions with team -Laissez-Fair: Little planning or decision making , fails to encourage others 2. Alterations in Mobility A. Comp Compartment artment Sy Syndrome: ndrome: 9 - serious condition where pressure increases within one or more muscle compartment of extremity, compromises circulation to the area. - usually the distal portion of extremities (Usually lower leg and forearm) - usually after trauma ( fracture) Assess Assessment: ment: 6 PÕs ( Paralysis , Pain, Paresthesia, Pulse, Pallor, poikilothermic) Unrelenting pain on passive motion after medications Muscle tissue ischemia( LATE SIGN) Treatm Treatment: ent: Limb positioned at level of the heart Hourly neuro assessment 6hours to intervene before neuromuscular damage Evaluate pain, after administering meds Surgical Fasciotomy or bivalve cast may be done to relive pressure DO NOT ELEVATE THE LIMB ABOVE THE HEART OR APPLY COLD COMPRESS ( CONDITION MAY WORSEN) B. Fat Embolism RESPIRATORY ORY EME EMERGENCY RGENCY, complication after pelvis or long bone fracture - RESPIRAT - when molecules of fat are forced into the blood stream, causing obstruction to the vessels, causing interstitial hemorrhage, edema and atelectasis. Assessme Assessment: nt: - Petechiae (classic sign) - Angina - Restlessness, agitation, irritability, confusion , lethargy Treatmen Treatment: t: - Elevate head of the bed - Turn , and deep cough - Administer O2 - Fluid replacement - Corticosteroids & diuretics may be administered - Monitor intake & output C. Fractur Fractures es Types of Fra Fractures ctures ctures:: 1. Greenstick: one side of bone broken; other side is bent ( mostly in children) 2. Transverse: break across the bone 3. Oblique: line of facture at an oblique angle Vascular V.S. NEURO 4. Spiral: line of fracture encircles bone -sensation -blood flow 5. Compressed: bone has been crushed - movement -Palkiothermia Types of inte intervent rvent rventions: ions: - Paralysis -pallor 1. Closed reduction- Alignment of bone using manipulation ( cast or braces) - Pain & Paresthesia -Pulse 2. Open reduction- Surgical incision made to expose fracture site 3. Internal Fixation- orthopedic hardware (pins, screws, rods and wires) 4. External Fixation- External application of rods and wires through the bone Phase Phasess of Bo Bone ne He Healing: aling: 1. Granulation- Blood is supplied via medullary circulation ( 48-72 hours post fracture) 2. Reparative Phase: callus formation & consolidation Ð granulated tissue, matured callus , cartilage & fibrous tissue unites fracture ( 6-10 days post fracture) 3. Remodeling- Callus become calcified (6-12 months post fracture) 10 Tractio Tractions: ns: 1. Skeletal- Direct pull on the bone, an open wound , daily cleaning 2. Skin: - Bryant Traction: Under 2 years old , 35lbs , continuous and unable to move until cast is applied, usually moved into Spica cast, asses skin integrity. - Bucks Tension: 5-10lbs pulls on skin, body weight is the countertraction, used for muscle spasms , release q 8 hours for skin assessment, monitor for body alignment, weight falling free, and patient in slight Trendelenburg. DO N NOT OT SIT PATI PATIENT ENT U UP P FOR EATI EATING NG , T TURN URN S SIDE IDE TO SIDE SIDE.. D. Hip Frac Fractures tures Chara Characterize cterize cterized d by: Adduction of the leg Shortening and external rotation Pain Leg shortening Nursin Nursing g Care Care:: Complete doctorsÕ orders Turn q 2 hours to inoperative side Cough Deep breath Monitor I&O - Risk fa factors: ctors: Increased age Female Hx of osteoporosis - Treatm Treatment: ent: Internal fixation , traction Post-o Post-opp pp co complica mplica mplications: tions: Aseptic necrosis Dislocation Fat embolism Confusion Paralytic ileus Infection - UNIT 2_ 1.Alterations In mobility Continued A. Slipped Capital Fem Femoral oral Epiph Epiphysis ysis -Spontaneous displacement of proximal femoral epiphysis gradually in a posterior and inferior direction - between ages 10-16 , from rapid growth or being overweight (really thin or obese) Signs & Sym Symptoms ptoms ptoms:: Leg held externally to relieve pain Chief complaint in the knee first Limping on affected side Groin/thigh pain Unable to internally rotate hip on assessment Diagn Diagnosed: osed: Verified with an X-RAY Treatm Treatment: ent: Surgical stabilization Correct deformity Bucks traction, PREOPP - B. Osteog Osteogenesis enesis Imp Imperfecta(NO erfecta(NO CURE) Nursin Nursing g Inte Interventio rventio rventions: ns: Support extremities Turn often with care Monitor circulatory and neuromuscular Look for s+s of fat embolism and compartment syndrome Teach nutrition( high i hi h i i - A genetic disorder that effects the production of collagen - Type 1: occurs later in childhood - Type 2: recognized at birth (severe: born with bone fractures) Diagn Diagnostics: ostics: Skin biopsy - X-rays Ultra-sound - Radiograph - Bone densitometry Treatm Treatment: ent: Bisphosphonates inhibits osteoclast Growth hormone & Tetrapartite( for adults) Intramedullary rods when there are painful deformities Sufficient vitamin d and calcium intake in diet & Muscle strengthening Signs & Sym Symptoms ptoms Blue sclera of eyes May develop kyphosis Multiple bone Deaf - Dental deformities Bowed leg Brittle teeth Short stature Breathing problems C. Osteom Osteomyelitis yelitis Diagn Diagnostic ostic te test: st: - an infection of the bone, less than 4 weeks is an acute inflammation more than -CBC(increased WBC) - treatment is based on symptoms 4 weeks is a chronic inflammation, usually caused by S.aureus and S. pyogens Types Types:: Direct(open) Ð from an open wound, surgery or gun shot. Signs usually appear 46-48 hours after surgery Indirect (Hematogenous)- Blood borne, bacteria enters from an infection Signs & Sym Symptoms ptoms ptoms:: Malaise, weakness, aching , tenderness over long bone , muscle spasms, flexing and holding the joint area. Localized swelling , redness and tenderness, elevated temp Treatm Treatment: ent: Acute- Large IV antibiotics , complete bed rest , transfusions with anemia, surgical infection , immobilized limb , hot moist dressings Chronic- Low grade fever will be present , Antibiotic therapy , sequestra surgically removed, saucerization cast applied(Closed irrigation and suction) Nursin Nursing g Man Managem agem agement: ent: - Irrigation -pain relief - Dressing and cast care - positioning of extremity D. Osteop Osteoporosis orosis - reduction in skeletal mass, demineralization of bone. Increa Increase se risk risk:: Over 60 y.o. Female Lack of estrogen Diets decreased in calcium Excessive caffeine Endocrine dysfunction Too little or too much protein Increased alcohol consumption Cigarette smoking Increased corticosteroid use Treatm Treatment: ent: Signs & symp symptoms toms toms:: Back pain Kyphosis Hip fractures w/ elderly Pain along nerve that progresses Nursin Nursing g Inte Interventio rventio rventions: ns: Gentle when positioning Support joints Raise bed and bend knees to relieve back pain Pillow between legs and log rolling Pt. Te Teaching aching aching:: Avoid bending Sleep on firm mattress Supportive shoes Avoid ice and snow - 12 - Hormone prep Exercise (weight bearing) Diet increased in calcium Calcium supplement(1,000-5,000) Estrogen replacement Calcitonin Calcium carbonate Fosamax (Taken first in the am with 8oz o off water and m must ust re remain main u up p righ rightt and NPO ffor or 30 m min in aft after er) E. Scoliosis - a sideways curvature of the spine, can be caused by cerebral palsy , muscular dystrophy, birth defects, spinal injury, more likely in girls then men , may have a family history, curves in the center worsen more often than upper + lower. Diagn Diagnostic ostic te test st Treatm Treatment: ent: Neuro test( Muscle strength, numbness, abnormal reflex) 1. Braces(when less severe) Pt. Hx. & X-rays Infantile- 0-3 years old 2. Only remove for physical activity or for shower MRI 3. Discontinued in girls when they being to Juvenile- 3-9 years old CT menstruate , & when boys grow hair braces stop. Adolescent- 10-18 years old Bone Scan Under arm/low profile- invisible under clothing Ben test - F. Osteoa Osteoarthritis rthritis - degenerative joint disease, joint inflammation from cartilage degeneration - caused from aging primarily or hereditary, injury, trauma, obesity, gout, and diabetes secondary. - pain is found in weight bearing joints (Knees, hips , spine) ,pain increases at the end of the day. *THE GOAL IS TO REDUCE JOINT PAIN AND INFLAMMATION AND IMPROVE JOINT FUNCTION. Signs and Sy Symptom mptom mptoms: s: Pain in affected joint after use Develops gradually Moring pain first 30 minutes Joints may be creaky ( crepitus) Bony enlargements developed in the fingers that cause pain Diagn Diagnostics: ostics: Examination of joints X-rays Treatm Treatment: ent: Physical therapy ( flexibility and strength , hot and cold therapy) Supportive splints and braces Anti-inflammatory medications Pain relief creams (topical) Steroid injections Nursin Nursing g inte interventio rventio rventions: ns: Hot and cold compress Assess pain Rest joints ROM exercise - G.Amput G.Amputations ations -removal of body part/limb - related to injury , or diabetes complication **GO **GOAL AL IS T TO O PRE PRESERV SERV SERVE E JOIN JOINTS TS A AND ND CO CONSER NSER NSERVE VE LE LENGTH NGTH NGTH** ** Nursin Nursing g inte interventio rventio rvention: n: -Pre OPP: neuro assessment , x-rays , assess extremity, nutritional status, medication reconciliation, angiograph 13 -Post OPP: pain relief , wound care, psychosocial, activity rom , mirror therapy , encourage self-care, elevate limb 24hours-48 hours post opp *DO NOT PUT LIMB ON PILLOW** Comp Complication lication lications: s: Phantom limb pain Pain Bony overgrowth Hemorrhage Infection Join contracture Skin breakdown - 2.Alterations in Endocrine A. Addiso Addison n Disease( A Adrenal drenal Hyp Hypofunction) ofunction) Ð STRESS ( SALT , SU SUGAR, GAR, SEX SEX& & HAIR) - Acute adrenal cortisol insufficiency (no cure), caused by the body killing the adrenal or pituitary, cancer, infection of TB/HIV or adrenal hemorrhage. Corticosteroid use of over 4w is a high risk for AddisonÕs disease. Signs & Sym Symptoms ptoms ptoms:: (SAL (SALT T CRA CRAVING) VING) Muscle Weakness & Fatigue Slow or absent menstrual Decreased weight Decreased BP(Hypotension) Muscle spasms - - decreased glucose(Hypoglycemia) - decreased sodium & Dehydration - decreased temperature(cold intolerance) - decreased mood (apathy) - Increased Potassium & Pigmentation Prima Primary ry Ð adrenal glands are damaged & cannot produce cortisol with increased ACTH levels Secon Secondary dary dary-- inadequate secretion of ACTH from pituitary gland , decreased ACTH levels Treatm Treatment: ent: Steroid therapy ( Prednisone, hydrocortisone) ADDI ADDISONIA SONIA SONIAN N CRI CRISIS: SIS: Increased diet of protein , carbs and sodium Hypotension, cyanosis, fever, nausea, Fluid replacement & glucose administration shock, and vomiting **NEVER STOP STERIODS ABRUPTLY Can be caused by increased stress , over Lifelong treatment exposer to cold , Nursin Nursing g inte interventio rventio rventions: ns: acute infection decreased salt intake. Monitor BP and pulse w/o immediate intervention can lead to Seizure precautions SHOC SHOCK! K! Skin assessment Restore fluids & Measure I&O - B. Cushing Syndrome (Hyperco (Hypercortisolism) rtisolism) Ð glucocortic glucocorticoids oids and an androgens drogens Treatm Treatment: ent: removal of tumor or slowly - hypersecretion of ACTH from pituitary, chronic alcoholism, chronic use of decreasing steroid use corticosteroids, depression , adenomas, carcinomas. Signs & Sym Symptoms ptoms ptoms:: Increased weight -Increased glucose Increased sodium ( increased fluid retention) Nursin Nursing g inte interventio rventio rventions: ns: Increased BP -Truncal obesity & abdominal striae Observe diet Buffalo Hump - Moon face Record urine -Admin insulin Red cheeks - Hair Activity w. rest , Skin hygiene Brittle bones( easily bruising & decreased wound healing) Safe environment Muscle wasting( kyphosis) Emotional support - C. Hypert Hyperthyroidism( hyroidism( G GravesÕ ravesÕ Dise Disease) ase) Treatm Treatment: ent: Increased diet ( calories , protein ,carbs) Frequent meals( 6-8 times a day) AVOID: ( fiber, caffeine and spicy foods) Medic Medications ations ations:: Methimazole , RAIU , PTU , SSKI , beta blockers, - an auto-immune disease when tissues are exposed to excessive quantities of thyroid hormones Signs & symp symptoms toms toms:: High BP, Increased T3 & T4, Iodine excess Levothyroxine increased, Exophthalmos (bulging eyes) Tachycardia , Weight loss , Goiter , Diaphoresis , Heat intolerance , Diarrhea THYR THYROID OID ST STORM ORM( sever hyperthyroidism) Caused by physiological stress , or excessive antithyroid medication Sign & Symp Symptoms toms: Tachycardia over 130bpm, temp above 40.7C(105.3F) , altered mental status Nursin Nursing: g: decrease the temperature , with blankets Increase oxygen, IV dextrose, Hydrocortisone to treat SHOCK THYR THYROIDEC OIDEC OIDECTOM TOM TOMY Y( after Surgery) Airway Airwayss- Laryngeal stridor, noisy breathing, hoarseness) ** endotracheal. at bedside Breath Breathinging- Monitor , voice strength and quality Circula Circulationtion- Monitor for bleeding , around pillow, HOB 30-45 degrees, DO NOT EXTENT NECK Calciu Calciumm- hypocalcemia , first sign is circumoral tingling , trousseaus & ChvostekÕs sign, monitor calcium levels Hypothyro Hypothyroidism idism ( Cre Creationism ationism , H Hashimoto ashimoto ashimotos, s, Myxedem Myxedema a Coma) - deficiency in thyroid hormone from birth to old age Creati Creationism onism onism-- In fetal life and first few months, interrupts physical and mental development Must be treated during the first 3 months of life to prevent permanent retardation or irreversible cerebral brain damage. Characterized by excessive sleep , poor appetite and sluggish. Signs & Sym Symptom ptom ptomss of Hy Hypothy pothy pothyroidism roidism roidism:: Myxe Myxedema dema Coma Coma:: Low BP - constipated Hypothermia , drowsiness , hypoventilation, Decreased libido - Depressed hypothermia, sensitivity to cold, decreased urine Weight gain, husky voice - lethargic & hair loss , dry skin output, mental apathy Cold intolerance - decreased T3 & T4 Treatm Treatment: ent: Tracheostomy kit at bedside always Decrease calories Frequent reset periods Levot Levothyroxin hyroxin hyroxine e (lifelong use) 3-4W before relief , do not take at night , take 1 hour before breakfast avoid painkillers when taking 15