2900 Exam Three Flashcards
(298 cards)
1
Q
what is SIRS?
A
systemic inflammatory response syndrome
2
Q
what are diagnostic criteria for SIRS?
A
temperature above 100.4 or below 96.8
tachycardia greater than 90 BPM
respiratory rate greater than 20/min
WBCs greater than 12000, less than 4000, or with greater than 10% as immature forms
3
Q
what is sepsis?
A
SIRS plus confirmed bloodstream infection. sepsis is the body’s amplified response to an infection
4
Q
what is septic shock?
A
sepsis induced hypotension (less than 90 SBP) despite adequate fluid and vasopressor resuscitation
5
Q
what is MODS?
A
multiple organ dysfunction syndrome, it is dysfunction of the organs due to severe hypoperfusion. It is the end result of uncorrected SIRS and sepsis
6
Q
what might fluid status and blood glucose look like in a sepsis patient?
A
positive fluid balance (fluid retention)
hyperglycemia (greater than `140 mg/dl) in the absence of diabetes
7
Q
urine output will be less than what value in sepsis?
A
less than 0.5 ml/kg/hr for at least two hours despite fluid resuscitation
8
Q
what are normal lactate levels?
A
between 0.5 and 1.0 mmol/L
9
Q
what are lactate levels like in sepsis? what value is considered severe septic lactate?
A
septic: between 2 and 4, considered severe over 4 mmol/L
10
Q
treatment for shock focuses on what two things?
A
volume expansion and vessel tightening
11
Q
in what types of shock do you not want to focus on volume expansion?
A
cardiogenic and neurogenic
12
Q
what are the initial types of fluid used for fluid replacement in shock?
A
normal saline and lactated ringers (crystalloids)
13
Q
what do crystalloid fluids do in the body?
A
add more fluid to the intravascular system to increase preload, stroke volume, and cardiac output
14
Q
what is the 3:1 rule for giving crystalloids and why do we use it?
A
give 3 ml of crystalloids for every 1 ml of fluid lost, because these fluids easily diffuse out through the capillary wall
15
Q
what are the two types of colloids that can be used in shock treatment?
A
albumin and hetastarch
16
Q
what does albumin do?
A
keep fluid in the bloodstream
17
Q
what does hetastarch do?
A
increases the volume of blood plasma to help red blood cells circulate through the body
18
Q
what are things to monitor for when giving colloids?
A
anaphylaxis and fluid volume overload
19
Q
what should be done to large amounts of fluid before giving them?
A
warm them up, because hypothermia can alter clotting enzymes
20
Q
what types of shock can be given blood or blood products?
A
all types
21
Q
what do packed red blood cells do in the body?
A
replace fluids and provide hemoglobin
22
Q
when are platelets given?
A
for patients with uncontrollable bleeding and low platelets
23
Q
when is fresh frozen plasma given?
A
when patients need clotting factors
24
Q
what should the nurse ask the patient about before giving a transfusion?
A
if they’ve had a previous transfusion and if they had any adverse responses to it
25
what is the number one vasopressor of choice to be given for shock? what does it do?
norepinephrine: increases perfusion and BP
26
what kind of vasopressor is given only in neurogenic shock?
phenylephrine
27
what are some examples of vasopressors with inotropic effects?
dobutamine and dopamine
28
what are some vasodilators used in shock?
nitroglycerine and sodium nitroprusside
29
why are corticosteroids sometimes given for shock?
to decrease inflammation and increase BP and HR
30
what is an intraaortic balloon pump?
a device that helps provide temporary circulatory assistance to a sick heart. Helps improve coronary blood flow
31
how does an intraaortic balloon pump help?
it reduces afterload on the heart
32
what is MAP?
mean arterial pressure, its the amount of pressure needed to perfuse organs adequately
33
what MAP is needed for adequate perfusion?
greater than 60 mmHg
34
how do you calculate MAP?
(SBP + 2DBP)/3
35
why do serum lactate levels go up in sepsis?
because cells arent getting enough oxygen and/or glucose, so they switch to anaerobic metabolism. lactic acid is produced as a byproduct of anaerobic metabolism
36
what are risk factors for sepsis?
```
Suppressed Immune System
Extreme age (old or young)
People who have received organ transplant
Surgical procedure recently
Indwelling devices
Sickness (chronic)
```
37
what are the most common sites of sepsis?
GI tract
respiratory tract (#1)
urinary tract
38
what are early signs of sepsis? note you may not always see this stage
"warm" stage early: warm flushed skin, decreased BP, increased HR/RR, fever, increased CO, anxiety, restlessness
39
what are late signs of sepsis?
"cold" stage: cold clammy skin, severe hypotension, increased HR and RR, hypothermia, oliguria (less than 400 ml/day), coma, decreased cardiac output
40
what are the top two nursing interventions for septic shock/shock?
```
fluid replacement (crystalloids or colloids)
vasopressors if fluid replacement isnt enough (norepinephrine is drug of choice)
```
41
how does the nurse evaluate whether fluid resuscitation is successful in shock?
check for rising BP, especially SBP, and monitor hemodynamic status
42
why is it crucial to keep o2 sats above 95 percent in septic shock?
patients are at high risk for developing respiratory failure due to ARDS
43
what must the nurse do in sepsis/septic shock before administering antibiotics?
obtain blood cultures
44
what type of nutrition is preferred in sepsis?
enteral nutrition given early
45
why is nutritional support so important in sepsis?
because there is decreased GI perfusion, and nutrition helps preserve GI integrity and prevent stress ulcers
46
what can sepsis and shock do to blood glucose levels?
increase them
47
why is hyperglycemia bad in shock and sepsis?
because it alters the way the immune system and cells work
48
what might the nurse need to do for hyperglycemia in shock and sepsis? where do we want blood glucose?
insulin drip may be needed, want blood glucose less than 180
49
what lab levels should be monitored closely in shock and sepsis?
glucose
| lactate
50
what urine output do we want in shock and sepsis?
greater than 30 ml/hour
51
what respiratory interventions may be needed in shock and sepsis?
supplemental oxygen or intubation and mechanical ventilation
52
what body position should you put someone in shock in?
modified trendelenburg: supine with lower half of body elevated 45 degrees
53
what is cardiogenic shock?
condition in which the heart cannot pump enough blood to meet the body's perfusion needs, leading to inadequate organ perfusion
54
what is the number one cause of cardiogenic shock?
myocardial infarction
55
what signs and symptoms would you see in cardiogenic shock?
signs of either right sided or left sided heart failure
mental status changes/confusion/agitation
decreased urine output and nocturia
pale dusky skin, shiny extremities, edema
56
what are the three treatment goals with cardiogenic shock?
reperfusion (may need cardiac stent)
increase cardiac output (with meds)
ventilation (mechanical ventilation and diuretics)
57
what lab values will we see specific to cardiogenic shock?
increased troponin and BNP, as well as increased lactate
58
what are some drugs that may be given for cardiogenic shock?
diruetics
vasopressors (norepi)
vasopressors with inotropic effects (dopamine, dobutamine)
vasodilators (nitro or sodium nitroprusside)
59
what surgical intervention might help with cardiogenic shock?
placement of intraaortic balloon pump
60
what is hypovolemic shock?
low fluid volume in the intravascular space, leading to inadequate perfusion
61
what will happen in the body when fluid moves from intravascular to intersititial space?
edema, decreased cardiac output, hypotension
62
what are the two types of hypovolemic shock?
relative and absolute
63
what are some causes of relative hypovolemia?
internal bleeding
severe burns and third spacing
long bone fractures
sepsis
64
what are some causes of absolute hypovolemia?
massive bleeding
vomiting
excessive urination
diarrhea
65
how much fluid can the body lose and still compensate?
15% loss or less
66
what will activate in the body once enough fluid has been lost?
RAAS
67
what are overall symptoms of hypovolemic shock?
```
tachycardia
hypotension
increased respirations
decreased urine output
cool clammy skin with poor capillary refill
mental status changes/confusion
low central venous pressure
```
68
what are nursing goals with hypovolemic shock?
```
fluid replacement (crystalloids, colloids, blood/blood products)
correct underlying cause of fluid loss
oxygenation
circulation (stop any active bleeding)
maintain/monitor for adequate perfusion
```
69
what kind of IV access is needed in hypovolemic shock?
at least 2 large gauge (18 or larger) IV sites to give fluid fast
70
how should oxygen be given in hypovolemic shock?
100% high flow oxygen through non-rebreather
71
what is the best position for patients in hypovolemic shock?
modified trendelenberg
72
what labs need to be closely monitored in hypovolemic shock?
```
hemoglobin
hematocrit
ABGs
lactate
liver enzymes
CBC
electrolytes, BUN, creatinine
```
73
what happens in anaphylactic shock?
introduction of an allergen leads to release of massive amounts of histamine
74
what are signs and symptoms in anaphylactic shock?
vasodilation, causing decreased BP and CO
decreased HR
increased capillary permeability (intravascular fluid loss and edema)
itching
bronchoconstriction
nausea, vomiting, and abdominal pain
75
anaphylactic shock is what type of shock?
distributive shock
76
what happens in distributive shock?
the blood is present but the small vessels in the body has a hard time getting it to the organs
77
what respiratory issue do we worry about with anaphylactic shock?
respiratory failure
78
what is intervention for anaphylactic shock focused on?
reversing the effects of histamine (so tightening blood vessels and relaxing airway)
79
what can the nurse do to prevent anaphylactic shock?
always ask patients about their allergies
| monitor patient during first dose of antibiotic or other sensitizing drug
80
if anaphylactic reaction to something occurs, what must the nurse do immediately?
```
remove the allergen if possible
manage the airway and monitor vitals
call rapid response
trendelenberg position
give drugs as needed
```
81
what drug should be given for anaphylaxis/allergy that involves the airway?
epinephrine
82
what are some other drugs that can be given for allergic reactions?
albuterol
antihistamines
corticosteroids
83
what is biphasic anaphylaxis?
when patient recovers but has a relapse/second reaction, even if not re-exposed to allergen. **continue monitoring patient**
84
what should the patient be taught regarding anaphylaxis?
```
avoid allergen
wear medical alert bracelet
always carry epi-pen
go to ED after using epi-pen
throw away epi pen when expired
know how to prepare and administer epi
massage injection site for 10 seconds for faster absorption
```
85
what is neurogenic shock?
when the sympathetic nervous system loses its ability to stimulate nerve impulses, usually because of spinal cord injury. the patient then experiences massive vasodilation with decreased BP and HR because parasympathetic nervous system takes over
86
neurogenic shock is what kind of shock?
distributive shock
87
what are manifestations of neurogenic shock?
hypotension and bradycardia
venous pooling (DVT risk)
warm dry extremities but cold core (hypothermia)
88
what are nursing management priorities for neurogenic shock?
```
manage ABCs
protect spine (if spinal cord injury)
assess and manage airway
maintain tissue perfusion
keep them warm
monitor urine output (risk for retention)
```
89
what are considerations for fluid resuscitation in neurogenic shock?
crystalloids can help, but must be given with caution. fluid loss is not the issue so patient can easily get fluid overloaded
90
what drugs might be given in neurogenic shock to increase HR?
vasopressors and positive inotropes
91
what drug can be given in neurogenic shock to help with bradycardia?
atropine
92
how can DVT be prevented in neurogenic shock?
ROM
compression stockings
anticoagulants
SCDs
93
what is a vasopressor specifically used for neurogenic shock?
phenylephrine
94
which system usually shows signs of dysfunction first in SIRS and MODS?
respiratory system
95
what are top nursing management goals for SIRS and MODS?
prevent and treat infection
maintain tissue oxygenation
nutritional support
96
what is the goal of nutritional support in SIRS/MODS?
preserving organ function!
97
what are some labs that will be specifically monitored in septic shock?
cultures and coagulation tests
98
what are tests that will be done/monitored in cardiogenic and obstructive shock?
```
ECG
echocardiogram
CT
cardiac cath
chest x-ray
```
99
what are major defining manifestations of DKA?
```
uncontrolled hyperglycemia (greater than 300 mg/dL)
dehydration
metabolic acidosis
ketones in blood and urine
kussmaul respirations
```
100
is onset for DKA rapid or slow?
rapid onset
101
what are defining characteristics of HHS?
hyperglycemia greater than 600 mg/dL
hyperosmolarity and dehydration
absence of ketosis
osmotic diuresis
102
what is onset like for HHS?
gradual, usually occurring over several days
103
who is normally affected by HHS and why?
type two diabetics, often over the age of 60. type 2 diabetics are more likely to be affected because their body has enough endogenous insulin to prevent full ketosis
104
what are manifestations of hypoglycemia?
```
cold clammy skin
dizziness
decreased alertness
shakiness/faintness
jitters
vision issues
```
105
what are general manifestations of diabetes?
```
polyuria
polyphagia
polydipsia
weight loss
GI issues
blurred vision
weakness
headaches
kussmaul respirations
fruity breath odor
metabolic acidosis
mental status changes
```
106
what are risk factors for DKA?
undiagnosed or untreated T1DM
reduced or missed insulin dose
emotional stress
illness/infection/surgery/trauma
107
what is the number one cause of DKA?
infection
108
how does increased hormone production lead to DKA?
it stimulates the liver to produce glucose and decreases the effects of insulin
109
what are risk factors for HHS?
undiagnosed T2DM
inadequate fluid intake or poor kidney function
age over 50
infection or stress
medical condition like MI, CVA, or sepsis
110
what are the three key treatment elements for DKA?
hydration
insulin
electrolytes
111
what needs to be remembered for fluid administration with DKA?
IV access needed
need rapid isotonic fluid administration (normally 0.45 or 0.9% NaCl)
monitor for adequate urine output
monitor for fluid volume excess
112
how do we calculate insulin needs for DKA?
0.1 unit/kg/hour
113
what should be done to insulin infusion when serum glucose approaches 250 mg/dL? why?
5-10% glucose should be added to infusion to prevent hypoglycemia and prevent risk of cerebral edema
114
what is the blood glucose goal for DKA treatment?
less than 200 mg/dL
115
how often should BG be checked in DKA?
hourly
116
what will potassium levels look like initially in DKA and how will they change?
they will initially be elevated, but will decrease as insulin is administered and potassium shifts back into the cell. monitor for hypokalemia
117
what electrolyte should be included in all IV fluids for DKA patients?
potassium
118
when administering potassium, what else should be monitored?
cardiac rhythm
119
what should the nurse teach diabetic clients to do when ill to avoid DKA?
```
monitor BG every four hours
continue taking insulin/diabetes meds
drink 4 oz liquid every 30 minutes
meet carb needs with soft foods 6-8 times/day
test urine for ketones
rest
```
120
when should a sick diabetic patient call their provider? (worrisome s/s)
```
if BG over 240
if fever over 101.5
feeling disoriented/confused
breathing rapidly
vomiting more than once
more than 5 episodes of diarrhea in a day
illness longer than 2 days
```
121
what is a mechanical bowel obstruction?
when the bowel is blocked by something outside or inside the intestines
122
what are some causes of mechanical bowel obstructions?
```
adhesions
tumors
hernias
fecal impactions
strictures
diverticulitis
```
123
what is the most common cause of mechanical bowel obstruction?
surgical adhesions
124
what is a volvulus?
an intestinal obstruction where the bowel twists upon itself
125
how are complete mechanical obstructions taken care of?
surgery
126
what causes non-mechanical obstruction?
diminished peristalsis, often due to paralytic ileus
127
what is the focus of bowel obstruction treatment?
fluid and electrolyte balance
decompressing the bowel
relief or removal of obstruction
128
what are the four hallmark signs of intestinal obstruction?
colicky abdominal pain
vomiting
distention
constipation
129
what does "colicky" mean?
pain that comes and goes
130
what is obstipation?
inability to pass stool or flatus for more than eight hours despite feeling the urge to defecate
131
what is the difference in onset between small and large bowel obstructions?
small bowel has rapid onset
| large bowel has gradual onset
132
what is the difference in vomiting between small and large bowel obstruction?
small bowel has frequent, often projectile vomiting that may contain bile
large bowel has delayed or absent vomiting. If present, will have a more fecal smell
133
what is the difference in pain between small and large bowel obstructions?
small: colicky/intermittent
large: persistent cramping
134
what is the difference in bowel movements for small and large bowel obstructions?
small: some feces may pass
large: complete constipation
135
what lab results might be seen with bowel obstruction?
increased BUN, hgb, hct, and creatinine due to dehydration
potential increased WBC
potential metabolic imbalances
orthostatic vitals
decreased urine output and increased urine SG
136
what will an endoscopy help determine in bowel obstruction?
cause/location of obstruction
137
what needs to be closely monitored and prevented with bowel obstruction?
fluid and electrolyte imbalances or deficiencies
138
what are some key nursing cares for non-mechanical bowel obstructions? (think paralytic ileus)
```
NPO for bowel rest
NG tube for decompression
assess bowel sounds
oral hygeine
IV fluids and electrolyte replacement
manage pain
ambulation
semi-fowlers position
```
139
what kind of suction will an NG tube for bowel obstruction have?
intermittent
140
how often should an NG tube be irrigated?
every four hours
141
what should the nurse monitor in the client with an NG tube?
```
gastric output
vitals
skin integrity
weight
intake and output
```
142
how often should oral hygiene be done for a client with an NG tube?
every two hours
143
what nursing cares should be done for a client with a mechanical bowel obstruction?
prepare for surgery
| withhold oral intake until peristalsis resumes
144
what is parenteral nutrition?
IV administration of nutrition that bypasses the GI tract to deliver nutrients to the body. people can be on it for as long as necessary
145
what is special about the TPN solution?
it is sterile and specifically made for each patient each day
146
what are some common indications for administration of TPN?
```
complicated surgery or trauma
bowel obstruction
GI fistulas
critically ill patients
acute pancreatitis
```
147
what supplies the bulk of calories in TPN?
carbs (dextrose and fat emulsion)
148
when is central parenteral nutrition used?
for long term support or when patient has high calorie needs.
149
how is central parenteral nutrition administered?
through a CVC or PICC line with a tip in the superior vena cava
150
when is peripheral parenteral nutrition administered?
when short term nutritional support is needed
when protein/calorie needs arent as high
when a CVC is too big a risk
as a supplement to oral intake
151
what is the biggest complication that can develop from TPN administration?
refeeding syndrome
152
how does refeeding syndrome manifest and what issues can it cause?
manifests as fluid retention and electrolyte imbalances
| it can cause dysrhythmias, respiratory arrest, and neurological disturbances
153
how long is TPN good for?
24 hours
154
how long should TPN be out of refrigeration before adminstration?
30 minutes
155
how often should TPN tubing be changed?
every 24 hours
156
how should TPN flow be regulated?
by using an IV pump
157
what are important things to monitor in the patient receiving TPN?
```
vitals
daily weights
intake and output
blood glucose
BUN
electrolytes
```
158
what are the two most common causes of acute liver failure?
viral hepatitis and drugs/toxins
159
what three major things characterize acute liver failure?
jaundice
coagulopathy
encephalopathy
160
hepatitis A
occurs in crowded conditions and passes on through fecal matter
161
hepatitis B
passed through contaminated needles, syringes, blood products, or sexual activity with an infected partner
162
hepatitis C
passed through blood and blood products
163
will hepatitis manifest immediately?
no, so patient can be contagious with no symptoms
164
what are symptoms of acute hepatitis?
```
anorexia
weight loss
fatigue
lethargy
jaundice
low fever
dark urine
clay colored stool
```
165
what is jaundice?
yellow coloring of body tissues due to altered bilirubin metabolism
166
what is bilirubin?
an orange/yellow pigment made in the liver by hemoglobin breakdown
167
what is icterus?
yellowing of the eyes from bilirubin buildup
168
what can the accumulation of bile salts cause?
generalized itching (pruritus)
169
what changes in lab values will be seen with acute liver failure?
```
increased AST
increased ALT
decreased albumin
increased bilirubins
prolonged prothrombin time
```
170
what is the most definitive diagnostic test for liver failure?
liver biopsy
171
what are the two methods of liver biopsy?
open and closed method
172
what are some nursing cares for patients post liver biopsy?
have patient lie on right side for several hours to apply pressure on site
assess for bleeding
assess for pain
assess for signs of pneumothorax
173
how long is the convalescent phase in acute viral hepatitis?
2-3 months on average
174
what are the four key items for management of acute viral hepatitis?
well balanced diet
rest
vitamin supplements
avoid alcohol and drugs
175
what infection precautions should be followed for hepatitis?
contact precautions
176
what is the most common cause of acute liver failure?
drugs (normally combo of alcohol and acetaminophen)
177
how is acute liver failure defined?
rapid onset of severe liver dysfunction in patient with no prior history of liver disease. often occurs with hepatic encephalopathy
178
what are signs of hepatic encephalopathy?
changes in mentation
changes in neuro and mental responsiveness
impaired consciousness
inappropriate behavior
179
hepatic encephalopathy coexists with an increase in what substance in the body?
ammonia
180
what is the goal in treating hepatic encephalopathy?
reduce ammonia formation
181
what drug reduces ammonia formation? how?
Lactulose: its a laxative like drug that traps ammonia in the gut and then expels it in feces
182
what is asterixis?
a flapping tremor of the arms and hands that is characteristic of hepatic encephalopathy
183
why is safety a priority for patients with hepatic encephalopathy?
because they are at very high risk for falls
184
what is cirrhosis?
extensive scarring of the liver caused by necrotic injury or prolonged inflammatory response. normal liver tissue is replaced with fibrotic tissue. cirrhosis is end stage liver disease
185
what are expected findings in cirrhosis?
```
fatigue
weight loss
abdominal pain
distention
pruritus
confusion and mental changes
ascites
jaundice/icterus
```
186
what are other integumentary changes in cirrhosis?
petechiae
ecchymoses
spider angiomas
187
what is fetor hepaticus?
liver breath, a fruity or musty odor from digestive by-products that the body cannot break down
188
why is bruising and bleeding an issue in cirrhosis?
because the liver can no longer adequately make clotting factors
189
why do many cirrhosis patients have breathing issues?
because of ascites and plasma volume excess
190
what should the nurse do/assess in relation to fluid balance for cirrhosis patients?
```
monitor for indications of fluid volume excess
strict intake and output
daily weights
assess ascites and peripheral edema
restrict fluid and sodium if necessary
```
191
what nutrients are especially important for clients with cirrhosis?
carbs and protein
192
how often should abdominal girth be measured and how should it be measured for the patient with ascites?
measured daily over the largest part of the abdomen
193
what is a t-tube?
a tube placed in the bile duct that helps drain bile from the liver
194
what will stool look like if client has impaired bile production or movement?
greasy, fatty, pale/white stool
195
how does a t-tube bag drain and how should it be stored?
it drains by gravity and should rest at or below the client's waist level
196
what amount of drainage from a t-tube would warrant a call to the physician?
over 500 ml/day
197
what should t-tube drainage NOT be like?
should not be thick, foul smelling, or bloody
198
what is necessary for a nurse to clamp or flush a t-tube?
physician order
199
what are some common causes of fractures?
falls and accidents
twisting injuries
disease processes like cancer or osteoporosis
200
how long do fractures take to heal?
3-12 weeks (shorter time for kids, longer for adults)
201
what are some complications of fractures?
infection (osteomyelitis)
compartment syndrome
fat embolism
nerve and vessel damage
202
open fracture
fracture where bone breaks through the skin
203
closed fracture
fracture that does not pierce skin
204
complete fracture
bone is broken all the way through
205
incomplete fracture
bone doesnt break all the way through
206
greenstick fracture
one side of bone is bent and the other side is fractured
207
who is most likely to get a greenstick fracture?
children
208
comminuted fracture
bone is broken into many fragments
209
transverse fracture
broken straight across the bone
210
oblique fracture
fracture is slanted across the bone at an angle
211
spiral fracture
fracture that twists around the bone
212
what is the most definitive diagnostic tool for a fracture?
x ray
213
what are common manifestations of a fracture?
```
bruising
pain and swelling
reduced movement
odd appearance of limb
crackling sound from bone fragments
edema and erythema
neurovascular abnormalities
```
214
what do we want to assess for neurovascular status with a fracture?
area distal to the fracture to check for perfusion/pulses
215
what are the 6 P's of neurovascular assessment for fractures?
```
pain
pallor
paralysis
paresthesia
pulselessness
poikilothermia (inability to regulate body temp)
```
216
how often should neurovascular assessment be done with a new cast?
every hour
217
how should the nurse initially immobilize a fracture?
with a splint above and below the fracture site to decrease pain, bleeding, and nerve damage
218
what should the nurse do if the fracture is open/compound?
cover it with a sterile dressing
219
how should the extremity be positioned initially with a fracture?
elevated to decrease swelling
220
how can pain be managed initially with a fracture?
ice and pain meds
221
why should the patient with a new fracture be kept NPO?
in case surgical procedure needed
222
how long after the onset of compartment syndrome will it become irreversible?
6-12 hours
223
what is the earliest sign of compartment syndrome? what is the latest?
pain is the earliest sign, pulselessness is a late sign
224
how should the extremity be positioned if the nurse suspects compartment syndrome?
at heart level
225
what kind of fractures are most likely to have fat embolism as a complication?
long bone fracture
226
what are some signs and symptoms of fat embolism?
changes in mental status
| increased respirations and difficulty breathing
227
what is a closed reduction for a fracture?
manual resetting of the bone done under general anesthesia, with a cast placed afterward
228
what are some general cares/instructions for after a cast is placed?
put ice on it for the first 48 hours and have patient wiggle fingers to prevent stiffness and improve circulation
elevate above heart for first 24 hours
monitor for infection and keep cast clean
229
why should a nurse only use her palms when handling a new cast?
because they don't dry fully for about 48 hours, and nurse could indent cast with fingertips
230
what is an internal open reduction for a fracture?
setting the bone on the inside using pins, rods, or plates
231
what is an external open reduction?
bone set on the outside of the skin using metal braces and screws
232
what is a key concern with external open reduction?
infection
233
what is traction?
applying a pulling force to an injured or diseased extremity or body part to help align the bone
234
what are benefits of traction?
reduces pain and muscle spasm
immobilizes joint
keeps fracture or dislocation from becoming more severe
prevents soft tissue damage
expands a joint before an arthroscopic procedure
235
what are some things to remember about traction weights?
they should hang freely, and never rest on the floor
| never remove the weights
236
what are things that should be closely monitored for the client in traction?
```
pin care (look for foul drainage or smell)
maintain skin integrity
monitor the 6 P's looking for compartment syndrome
```
237
what is skin traction?
tape, boots, or splints used for 2-3 days until patient can do skeletal traction or surgery. decreases muscle spasms
238
what is bucks traction?
a type of skin traction used for fractures of the hip and femur before hip surgery
239
what is skeletal traction?
traction that aligns bones and joints to allow for healing
240
how will the patient on skeletal traction move? (and not move)
patients cannot move from side to side, but can lift using a trapeze bar and are encouraged to do isometric exercises
241
what are isometric exercises?
exercises in which joint angle and muscle length do not change during contraction
242
what will usually be done for orthopedic surgery patients to prevent VTE?
prophylactic anticoagulants
compression stockings
SCDs
dorsiflexion and plantar flexion of feet and ankle
243
what are some ways to minimize infection risk for patients with fractures?
```
post op antibiotics
wound cleaning and debridement
monitor labs and vitals
encourage coughing and deep breathing
encourage nutrient and fluid intake
```
244
what can be done to prevent fat embolism?
reposition patient as little as possible until fracture is stabilized to reduce risk of fat droplet dislodging
245
what might be seen if the patient has a fat embolism?
```
confusion
tachypnea
cyanosis
dyspnea
apprehension
```
246
what are some treatments when patient has a fat embolism?
fluid resuscitation
correct acidosis
blood transfusion
247
what is a sprain?
an injury to a ligament around a joint from a twisting motion
248
how should sprains be treated?
rest
ice
compression
elevate
249
what is a dislocation?
the surface of the joint separates, and the affected limb might be shorter and internally rotated
250
what is arthroplasty?
reconstruction or replacement of a joint
251
what are some post-op management items for arthroplasty?
```
vitals
intake and output
pain meds
PT
monitor respiratory and encourage breathing
watch for bleeding
```
252
what are some things to remember for after a hip replacement?
do not flex hip more than 90 degrees
do not cross legs at knees/ankles
do not adduct hips
do not put on shoes without adaptive device
253
what are nursing cares for after an amputation?
monitor vitals
assess for hemorrhage
use sterile technique for dressing changes
properly bandage limb
254
what is a compression bandage?
a bandage used after amputation to reduce edema and minimize pain for quicker healing. should be worn at all times except when bathing
255
what is autonomic dysreflexia?
uncompensated cardiovascular reaction mediated by the SNS due to stimulation of sensory receptors below level of spinal cord injury
256
what are the most common causes of autonomic dysreflexia?
distended bladder or rectum
257
what are manifestations of autonomic dysreflexia?
```
hypertension
bradycardia
throbbing headache
diaphoresis
flushing of skin above and below level of injury
```
258
what are the worst complications of autonomic dysreflexia?
stroke, MI, and death
259
what are nursing interventions for autonomic dysreflexia?
elevate HOB to 45 degrees or sit patient upright
determine the cause
call PCP
do bladder scan and relieve bladder or constipation if indicated
260
what are some drugs that can be given for autonomic hyperreflexia if symptoms persist after cause is eliminated?
nitroglycerine
nitroprusside
hydralazine
261
what are manifestations of pneumothorax?
dyspnea
decreased movement of affected chest wall
diminished or absent breath sounds on affected side
262
what is the primary intervention done for pneumothorax?
chest tube placement
263
what is common emergency treatment for pneumothorax?
cover the wound with an occlusive dressing on three sides
264
what is tidaling?
the movement of fluid in chest tube chamber as the client breathes in and out
265
what might rapid bubbling in the chest tube chamber indicate?
an air leak somewhere in the system
266
what are manifestations of tension pneumothorax?
```
cyanosis
air hunger
extreme agitation
tracheal deviation away from affected side
neck vein distention
```
267
what are emergency interventions for tension pneumothorax?
needle decompression followed by a chest tube insertion with drainage system
268
in what order should the patient be assessed if they are unresponsive?
circulation, airway, breathing
269
in what order should the patient be assessed if they are responsive?
airway, breathing, circulation
270
what is the most important part of CPR?
chest compressions
271
what are the A-G components of a primary survey in care of an emergency patient?
```
alertness and airway
breathing
circulation
disability
exposure/environmental control
facilitate adjuncts, involve family
get resuscitation adjuncts
```
272
how is disability assessed?
assessing LOC/response to stimuli/glasgow coma/pupil reactivity
273
what are some resuscitation adjuncts that might be needed in emergency patient care?
```
labs
ECG
NG or orogastric tube
ventilation monitoring and support
manage pain
emotional support for families
provide comfort
```
274
what is included in secondary survey once the patient is more stable?
history, head to toe, complete skin inspection
275
what are priority cares for a client with hypothermia?
ABCs
rewarming
correcting dehydration and acidosis
treat cardiac dysrhythmias
276
what is involved in passive rewarming?
removing wet clothes
warming the area
using heat lamps
warm blankets
277
what is involved in active rearming?
warm IV fluids
heated humidified oxygen
warm water immersion
cardiopulmonary bypass
278
what are nursing interventions for heat exhaustion?
```
remove patient from heat/sun
give cool drink (ideally with electrolytes)
remove excess clothing
get a fan
wet sheet over patient
```
279
why should tylenol not be given to the patient with heat exhaustion?
because it is not effective on fever caused by heat exhaustion
280
what are the two types of abdominal trauma?
blunt and penetrating
281
what is a risk if the liver or spleen is penetrated?
profuse bleeding and hypovolemic shock
282
what are signs and symptoms of abdominal trauma?
```
guarding/splinting
distended/hard abdomen
decreased or absent bowel sounds
bruising
pain
hematemesis or hematuria
decreased urine output
```
283
what is cullens sign?
ecchymosis around the umbilicus
284
what is grey turners sign?
ecchymosis around the flanks
285
what is the best diagnostic tool for abdominal trauma?
abdominal ultrasound
286
what are nursing interventions for suspected or confirmed renal trauma?
```
assess cardiovascular status and monitor for shock
ensure adequate fluid intake
monitor intake and output
pain relief
monitor for hematuria and myoglobinuria
```
287
what is the most common tick-borne disease?
lyme disease
288
what are manifestations of lyme disease?
flu like symptoms (headache, stiff neck, fatigue)
| bulls eye rash around tick site
289
what are long term issues if lyme disease is not treated?
arthritis
heart disease
peripheral radiculoneuropathy
290
what is the treatment for lyme disease?
doxycycline
291
how should a tick be removed?
ASAP with tweezers
292
what are common treatments for poison ingestion?
activated charcoal
dermal cleansing
eye irrigation
gastric lavage
293
what is gastric lavage?
using a tube passed into the stomach to sequentially administer and remove small volumes of liquid
294
what should not be done for frostbitten skin?
do not squeeze, massage, or scrub area
| avoid heavy blankets/clothing
295
what should be done for frostbite?
rewarm slowly by immersing in warm water
| give analgesia
296
how should pin sites for halo vest be cleaned?
twice daily with half strength peroxide/normal saline
297
when is a TLSO brace used?
when patients have stable thoracic or lumbar spine injuries
298
when is a TLSO brace worn?
whenever a patient is out of bed
