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1

List at least three possible complications associated with fractures

Acute compartment syndrome, crush syndrome, hypovolemic shock, fat embolism syndrome, venous thromboembolism, infection, chronic complications such as ischemic necrosis, and delayed union.

2

What are the signs and symptoms of compartment syndrome?

Increased compartment pressure
No change Increased capillary permeability
Edema
Release of histamine
Increased edema Increased blood flow to area
Pulses present
Pink tissue
Pressure on nerve endings
Pain
Increased tissue pressure
Referred pain to compartment
Decreased tissue perfusion
Increased edema
Decreased oxygen to tissues
Pallor Increased production of lactic acid
Unequal pulses
Flexed posture
Anaerobic metabolism
Cyanosis Vasodilation
Increased edema
Increased blood flow
Tense muscle swelling
Increased tissue pressure
Tingling
Numbness
Increased edema
Paresthesia
Muscle ischemia
Severe pain unrelieved by drugs
Tissue necrosis
Paresis/paralysis
Monitor for and document early signs of ACS. Assess for the “six Ps” (i.e., pain, pressure, paralysis, paresthesia, pallor, and pulselessness) (rare or late stage). Pain is increased even with passive motion and may seem out of proportion to the degree of injury. Analgesics that had controlled pain become less effective or noneffective. Numbness and tingling (paresthesia) is often one of the first signs of the problem. The affected extremity then becomes pale and cool as a result of decreased arterial perfusion to the affected area. Capillary refill is an important assessment of PERFUSION but may not be reliable in an older adult because of arterial insufficiency. Losses of movement and function and decreased pulses or pulselessness are late signs of ACS! Fortunately, ACS is not common, but it creates an emergency situation when it does occur.

3

What is the treatment for compartment syndrome

If the condition is not treated, cyanosis, tingling, numbness, paresis, and necrosis can occur. If ACS is suspected, notify the primary health care provider immediately and, if possible, implement interventions to relieve the pressure. For example, for the patient with tight, bulky dressings, loosen the bandage or tape. If the patient has a cast, follow agency protocol about who may cut the cast. Do not elevate or ice the extremity because that could compromise blood flow.
In a few cases, compartment pressure may be monitored on a one-time basis with a handheld device with a digital display, or pressure can be monitored continuously. Monitoring is recommended for comatose or unresponsive high-risk patients with multiple trauma and fractures.
If ACS is verified, the surgeon may perform a fasciotomy, or opening in the fascia, by making an incision through the skin and subcutaneous tissues into the fascia of the affected compartment. This procedure relieves the pressure and restores circulation to the affected area. No consensus exists on what pressure requires fasciotomy (normal is 0 to 8 mm Hg). Compartment pressures must be considered in relation to the patient's hemodynamic status. After fasciotomy, the open wound is packed and dressed daily or more often until secondary closure occurs, usually in 4 to 5 days, depending on the patient's healing ability.
Some surgeons use negative-pressure wound therapy (e.g., Wound Vac) over a fasciotomy to decrease edema and contain the blood from the site. Once the swelling has decreased in about 3 days, the surgeon may try to close the incision with sutures or may need to apply a skin graft.
When caring for a patient with an open fracture, use aseptic technique for dressing changes and wound irrigations. Check agency policy for specific protocols. Immediately notify the primary health care provider if you observe inflammation and purulent drainage.

4

What are the signs and symptoms of a fat embolism?

The earliest signs and symptoms of FES are a low arterial oxygen level (hypoxemia), dyspnea, and tachypnea (increased respirations). Headache, lethargy, agitation, confusion, decreased level of consciousness, seizures, and vision changes may follow (Hershey, 2013). Nonpalpable, red-brown petechiae—a macular, measles-like rash—may appear over the neck, upper arms, and/or chest. This rash is a classic manifestation but is usually the last sign to develop (Hershey, 2013). Abnormal laboratory findings include: • Decreased PaO2 level (often below 60 mm Hg) • Increased erythrocyte sedimentation rate (ESR) • Decreased serum calcium levels • Decreased red blood cell and platelet counts • Increased serum level of lipids
Altered mental status (earliest sign)
Increased respirations, pulse, temperature
Chest pain Dyspnea
Crackles
Decreased SaO2
Petechiae (50%-60%)
Retinal hemorrhage (not common)
Mild thrombocytopenia
Treatment includes: Bedrest Gentle handling Oxygen Hydration (IV fluids) Possibly steroid therapy Fracture immobilization

5

What are the benefits and uses of a splint in regard to fracture care?

Splints are orthopedic devices that are used to protect and support fractured or injured bones and joints. They help to immobilize the injured limb to keep the bone in place until it fully heals.
Because upper-extremity bones do not bear weight, splints may be sufficient to keep bone fragments in place for a closed fracture. Thermoplastic, a durable, flexible material for splinting, allows custom fitting to the patient's body part. Splints for lower extremities are also custom fitted using flexible materials and held in place with elastic bandages (e.g., ACE wrap).

6

Why would you choose a splint over a cast?

When possible, splints are preferred over casts to prevent the complications that can occur with casting. Splints also allow room for extremity swelling without causing decreased arterial PERFUSION.

7

What is the purpose of traction?

The purpose of traction is to guide the body part back into place and hold it steady. Traction may be used to: stabilize and realign bone fractures, such as a broken arm or leg.

Traction is the application of a pulling force to a part of the body to provide reduction, alignment, and rest.

It is also used as a last resort to decrease muscle spasm (thus relieving pain) and prevent or correct deformity and tissue damage.

A patient in traction is often hospitalized; but in some cases, home care is possible even for skeletal traction.

8

List at least three interventions for care of a patient with an amputation

-Nursing Safety Priority- Critical Rescue
If the patient has decreased tissue perfusion, notify the surgeon immediately to communicate your assessment findings! If the patient's blood pressure drops and the pulse increases, suspect covert (hidden) bleeding and notify the surgeon or Rapid Response Team. To check for the presence of overt (obvious) bleeding, be sure to lift the residual limb and feel under the pressure dressing for dampness or drainage. If bleeding occurs, apply direct pressure and notify the Rapid Response Team or health care provider immediately. Continue to monitor the patient until help arrives.

-*Monitor pain, promote mobility, prevent infection, promote self-esteem, home care management and self-care management education.


The Patient With a Lower-
Extremity Amputation in the Home
Assess the residual limb for:
• Adequate circulation
• Infection
• Healing
• Flexion contracture
• Dressing/elastic wrap Assess the patient's ability to perform ADLs in the home.
• Evaluate the patient's ability to use ambulatory aids and care for the prosthetic device (if available).
• Assess the patient's nutritional status.
• Assess the patient's ability to cope with body image change.

Collaborate with the prosthetist to teach the patient about prosthesis care after amputation to ensure its reliability and proper function. These devices are custom made, taking into account the patient's level of amputation, lifestyle, and occupation. Proper teaching regarding correct cleansing of the socket and inserts, wearing the correct liners, and assessing shoe wear and a schedule of follow-up care are essential before discharge. This information may need to be reviewed by the home care nurse.

-For a person who has a traumatic amputation in the community,
first call 911. Assess the patient for airway or breathing problems. Examine the amputation site and apply direct pressure with layers of dry gauze or other cloth, using clean gloves if available. Many nurses carry gloves and first-aid kits for this type of emergency. Elevate the extremity above the patient's heart to decrease the bleeding. Do not remove the dressing to prevent dislodging the clot. The fingers are the most likely part to be amputated and replanted. The current recommendation for prehospital care is to wrap the completely severed finger in dry sterile gauze (if available) or a clean cloth. Put the finger in a watertight, sealed plastic bag. Place the bag in ice water, never directly on ice, at 1 part ice and 3 parts water. Avoid contact between the finger and the water to prevent tissue damage. Do not remove any semidetached parts of the digit. Be sure that the part goes with the patient to the hospital.

-For patients with a planned surgical amputation,
the nurse's primary focus is to monitor for signs indicating that there is sufficient tissue PERFUSION and no hemorrhage. The skin flap at the end of the residual (remaining) limb should be pink in a light-skinned person and not discolored (lighter or darker than other usual skin pigmentation) in a dark-skinned patient. The area should be warm but not hot. Assess the closest proximal pulse for presence and strength and compare it with that in the other extremity. However, if the patient has bilateral vascular disease, comparison of limbs may not be an accurate way of measuring blood flow. Use a Doppler device to determine if the affected side is being perfused. Monitor vital signs per agency protocol.

9

What is cirrhosis?

Cirrhosis is extensive, irreversible scarring of the liver, usually caused by a chronic reaction to hepatic inflammation and necrosis. This scarring process directly impairs CELLULAR REGULATION. The disease typically develops slowly and has a progressive, prolonged, destructive course resulting in end-stage liver disease. The most common causes for cirrhosis in the United States are chronic alcoholism, chronic viral hepatitis, nonalcoholic steatohepatitis (NASH), bile duct disease, and genetic diseases.

10

What are the common causes of cirrhosis?

• Alcoholic liver disease
• Viral hepatitis
• Autoimmune hepatitis
• Steatohepatitis (from fatty liver)
• Drugs and chemical toxins
• Gallbladder disease
• Metabolic/genetic causes
• Cardiovascular disease

11

List at least three possible complications of cirrhosis

Common problems and complications associated with hepatic cirrhosis depend on the amount of damage sustained by the liver.

In compensated cirrhosis, the liver is scarred, and CELLULAR REGULATION is impaired, but the organ can still perform essential functions without causing major symptoms. In decompensated cirrhosis, liver function is impaired with obvious signs and symptoms of liver failure. The loss of hepatic function contributes to the development of metabolic abnormalities. Hepatic cell damage may lead to these common complications:
• Portal hypertension
• Ascites and esophageal varices
• Coagulation defects
• Jaundice
• Portal-systemic encephalopathy (PSE) with hepatic coma
• Hepatorenal syndrome
• Spontaneous bacterial peritonitis

12

What are the stages of hepatic encephalopathy and list at least 3 symptoms of each stage

Stage 1-4

Stage I • Subtle manifestations that may not be recognized immediately • Personality changes • Behavior changes (agitation, belligerence) • Emotional lability (euphoria, depression) • Impaired thinking • Inability to concentrate • Fatigue, drowsiness • Slurred or slowed speech • Sleep pattern disturbances

Stage II • Continuing mental changes • Mental confusion • Disorientation to time, place, or person • Asterixis (hand flapping)

Stage III • Progressive deterioration • Marked mental confusion • Stuporous, drowsy but arousable • Abnormal electroencephalogram tracing • Muscle twitching • Hyperreflexia • Asterixis (hand flapping)

Stage IV • Unresponsiveness, leading to death in most patients progressing to this stage • Unarousable, obtunded • Usually no response to painful stimulus • No asterixis • Positive Babinski's sign • Muscle rigidity • Fetor hepaticus (characteristic liver breath—musty, sweet odor) • Seizures

13

What are 3 priority problems for patients with cirrhosis?

-Ascites: swelling and fluid in the abdomen and lower body caused by increased pressure in the blood flow to the liver

-called portal hypertension)

-Hepatic encephalopathy: loss of brain function that happens when the liver doesn't remove toxins in the blood.

• A sudden decrease in urinary flow (<500 mL/24 hr) (oliguria)
• Elevated blood urea nitrogen (BUN) and creatinine levels with abnormally decreased urine sodium excretion
• Increased urine osmolarity

14

What are signs and symptoms of hepatitis A and how is it transmitted?

The causative agent of hepatitis A, hepatitis A virus (HAV), is a ribonucleic acid (RNA) virus of the enterovirus family. It is a hardy virus and survives on human hands. The virus is resistant to detergents and acids but is destroyed by chlorine (bleach) and extremely high temperatures.

*Hepatitis A usually has a mild course similar to that of a typical flu-like infection and often goes unrecognized. It is spread most often by the fecal-oral route by fecal contamination either from person-to-person contact (e.g., oral-anal sexual activity) or by consuming contaminated food or water. Common sources of infection include shellfish caught in contaminated water and food contaminated by food handlers infected with HAV.

The incubation period of hepatitis A is usually 15 to 50 days, with a peak of 25 to 30 days. The disease is usually not life threatening, but its course may be more severe in adults older than 40 years and those with pre-existing liver disease such as hepatitis C (McCance et al., 2014). In a small percentage of hepatitis, A cases, severe illness with extrahepatic signs and symptoms can occur. Advanced age and conditions such as chronic liver disease may cause widespread damage that requires a liver transplant. In some cases when the patient's IMMUNITY is irreparably affected, death may occur. The incidence of hepatitis A is particularly high in nonaffluent countries in which sanitation is poor; however, cases are diagnosed internationally across the globe (World Health Organization, 2016). Some adults have hepatitis A and do not know it. The course is similar to that of a GI illness, and the disease and recovery are usually uneventful.

15

What are signs and symptoms of hepatitis B and how is it transmitted?

*The hepatitis B virus (HBV) is not transmitted like HAV. It is a double-shelled particle containing DNA composed of a core antigen (HBcAg), a surface antigen (HBsAg), and another antigen found within the core (HBeAg) that circulates in the blood.

*HBV may be spread through these common modes of transmission:

• Unprotected sexual intercourse with an infected partner
• Sharing needles, syringes, or other drug-injection equipment
• Sharing razors or toothbrushes with an infected individual
• Accidental needlesticks or injuries from sharp instruments primarily in health care workers (low incidence)
• Blood transfusions (that have not been screened for the virus, before 1992)
• Hemodialysis
• Direct contact with the blood or open sores of an infected individual
• Birth (spread from an infected mother to baby during birth) In addition, patients whose IMMUNITY is compromised either by disease or drug therapy are more likely to develop hepatitis B.

*The clinical course of hepatitis B may be varied. Symptoms usually occur within 25 to 180 days of exposure and include:
• Anorexia, nausea, and vomiting
• Fever
• Fatigue
• Right upper quadrant pain
• Dark urine with light stool
• Joint pain
• Jaundice Blood tests confirm the disease, although many individuals with hepatitis B have no symptoms. Most adults who get hepatitis B recover, clear the virus from their body, and develop IMMUNITY. However, a small percentage of people do not develop immunity and become carriers.
Hepatitis carriers can infect others even though they are not sick and have no obvious signs of hepatitis B. Chronic carriers are at high risk for cirrhosis and liver cancer.

Because of the high number of newcomers from endemic areas, the incidence of hepatitis B has increased in the United States.

16

What are two terms that mean yellowing of the skin?

Jaundice- yellowing skin
sclerae (icterus)-yellow eyes due to increased bilirubin levels

17

What patient population is at greatest risk for cholecystitis?

**Risk factors for cholecystitis are listed in Table 59-1. TABLE 59-1
Risk Factors for Cholecystitis
• Women
• Aging
• American Indian, Mexican American, or Caucasian
• Obesity
• Rapid weight loss or prolonged fasting
• Increased serum cholesterol
• Women on hormone replacement therapy (HRT)
• Cholesterol-lowering drugs
• Family history of gallstones
• Prolonged total parenteral nutrition
• Crohn's disease
• Gastric bypass surgery
• Sickle cell disease
• Glucose intolerance/diabetes mellitus
• Pregnancy
• Genetic factors

Cholecystitis is an inflammation of the gallbladder that affects many adults, very commonly in affluent countries. It may be either acute or chronic, although most patients have the acute type.

**The main risk factors for developing gallstones are
-obesity,
-type 2 diabetes,
-dyslipidemia, and
-insulin resistance.
-Independent risk factors for developing gallstones are increase in age, female gender, and family history.

-Also, individuals who experience rapid weight loss and intestinal diseases affecting the normal absorption of nutrients, such as Crohn's disease, are at risk for gallstones. The highest frequency of gallstone production lies among the American-Indian and Mexican-American populations.

18

What gender and age is more likely to develop gallstones?

What are the four F’s?

Women between 20 and 60 years of age are twice as likely to develop gallstones as men.

Obesity is a major risk factor for gallstone formation, especially in women. Pregnancy and drugs such as hormone replacements and birth control pills alter hormone levels and delay muscular contraction of the gallbladder, decreasing the rate of bile emptying.

The incidence is higher in women who have had multiple pregnancies. Combinations of causative factors increase the incidence of stone formation, especially in women.

*Therefore some clinicians refer to the patient most at risk for acute cholecystitis and gallstones by the four Fs: • Female • Forty • Fat • Fertile

19

What is the pathophysiology for acute pancreatitis?

Acute pancreatitis is a serious and, at times, life-threatening inflammation of the pancreas. This process, which affects the body's IMMUNITY, is caused by a premature activation of excessive pancreatic enzymes that destroy ductal tissue and pancreatic cells, resulting in autodigestion and fibrosis of the pancreas. The pathologic changes occur in different degrees.

The severity of pancreatitis depends on the extent of inflammation and tissue damage. Pancreatitis can range from mild involvement evidenced by edema and inflammation to necrotizing hemorrhagic pancreatitis (NHP). NHP is diffusely bleeding pancreatic tissue with fibrosis and tissue death.

20

. List at least 4 possible complications of acute pancreatitis

*
• Pancreatic infection (causes septic shock)
• Hemorrhage (necrotizing hemorrhagic pancreatitis
• Acute kidney failure
• Paralytic ileus
• Hypovolemic shock
• Pleural effusion
• Acute respiratory distress syndrome (ARDS)
• Atelectasis
• Pneumonia
• Multi-organ system failure
• Disseminated intravascular coagulation (DIC) • Type 2 diabetes mellitus

Acute pancreatitis may result in severe, life-threatening complications (Table 59-3) that affect the body's ability to protect itself via its IMMUNITY. Jaundice occurs from swelling of the head of the pancreas, which slows bile flow through the common bile duct. The bile duct may also be compressed by calculi (stones) or a pancreatic pseudocyst. The resulting total bile flow obstruction causes severe jaundice. Intermittent hyperglycemia occurs from the release of glucagon, as well as the decreased release of insulin due to damage to the pancreatic islet cells. Total destruction of the pancreas may occur, leading to type 1 diabetes mellitus

21

After a client had a transjugular intrahepatic portosystemic shunt (TIPS) placement, which finding indicates that the procedure has been effective?
A. higher bilirubin levels
B. Increased serum albumin levels
C. Decreases in variceal bleeding
D. Increase in abdominal girth

C. Decreases in variceal bleeding

22

The health care provider plans a paracentesis for a client with ascites caused by liver cancer. The nurse does which of the following to prepare the patient for the procedure?
A. Places the client on NPO status
B. Assists the client to lie flat in bed
C. Asks the client to empty the bladder first
D. Places the bed in reverse Trendelenburg position

C. Asks the client to empty the bladder first

23

The nurse performs an abdominal assessment for the client diagnosed with pancreatitis. Which of the following findings are consistent with pancreatitis. Select all that apply.
A. Jaundice
B. Bluish gray discoloration of the periumbilical area
C. Gray-blue discoloration of the flanks
D. Borborygami

B. Bluish gray discoloration of the periumbilical area
C. Gray-blue discoloration of the flanks

24

Due to the pain of pancreatitis, the nurse may find which of the following positions to be most comfortable for the client?
A. Prone
B. Side lying with knees drawn up
C. On the back with no pillows beneath the head
D. Reverse Trendelenburg

B. Side lying with knees drawn up