- Information
- AI Chat
NSG430 Broad Topics Exam 3
Adult Health Nursing II (NSG-430)
Grand Canyon University
Recommended for you
Related Studylists
430Preview text
NSG430 Broad Topics – Exam 3
TOPIC 7 – Management of Acute Musculoskeletal Disorders
Fractures/Amputations
FRACTURES
Open fracture – break in skin where you can see bone in skin o Worry about osteomyelitis/infection Closed fracted – skin intact but bone broken o Neurovascular check + Mobility o Complications: Loss of function Loss of body part i if broken wrist is not in alignment then cannot use proper use of hand. Infection, impairment of healing with patients with comorbidities (i. DM) o Treatment: OR : open reduction Closed reduction Sling/soft cast KEY TAKEAWAY – Check neurovascular status o How do you assess neurovascular status? Skin color compared to unaffected sign. Pale, perfusing, healthy Temperature. Is it cool? (Not enough blood flow) Capillary refill Pulses o i. if pt arrives at the ED with swelling – check leg/pedal pulses/and sensation o if pt develops confusion after fracture – check O2 sat for fat embolus Compartment Syndrome o 5 P’s Pain, paresthesia, pallor, pulses, pressure, paralysis o Treatment: If suspected: place extremity flat, notify provider, loosen bandage or cast, remove any ice that was applied (ice makes it worse) – fasciotomy Fat embolism – direct result of manipulation of a long/large bone (typically femur, hip, thorax) o S/S: KEY THING: 1st signs and symptoms is petechia on chest Other s/s: difficulty breathing/shortness of breath, tachypnea, chest pain, O sat, petechia, can be fatal. Confusion is sign of fat embolism – CHECK O o Treatment: Highest priority is ensure adequate O2 = and administer O2 4L/min HCP should be notified AFTER O2 is started AMPUTATIONS– removal of an extremity by trauma or surgery Worried about loss of body part/loss of function
Get amputated piece and get them in the OR to be attached as soon as possible o Infection is big priority o Getting stump ready for prosthesis o Phantom pain – big priority o Nurse should always monitor for hemorrhage after surgery o Administer prescribed analgesics to relieve pain in an amputation – phantom limb sensation is treated like any other type of post op pain. o Teach patient to lay flat on abdomen for 30 minutes 3 or 4 times a day to prevent flexion contractures of the hip.
Traction – Skin & Skeletal o What to do for patient. Overhead trapeze – movement around the bed Free hanging (no leaning, ropes are intact, nothing on floor) Skin (no breaking down, skin is intact) o Buck’s Traction To assess for pressure areas on back and sacral area to provide skin care, have pt lift buttocks by bending and pushing with opposite leg. (Going into a bridge while keeping alignment). Check pain level for effectiveness of Bucks traction because Bucks traction can reduce painful muscle spasm.
o External fixators Put into place to help a bone heal correctly and put in alignment without traction Pin care – huge risk of osteomyelitis Patient teaching to teach about pin care Teach pt’s to wear comfortable shoes with good support – help decrease falls o ORIF – Open reduction and internal fixation Always check the weight bearing orders for the pt Risk for infection related to disruption of skin integrity/wound infection & osteomyelitis Osteomyelitis – immobilize leg to reduce risk of pathologic fractures After ORIF, pt’s will be mobilized first day post op
Femur/leg Fractures o Assess bowel sounds, abdominal pain, N/V to detect the development of cast syndrome. o Move crutches and injured leg at the same time then move unaffected leg Pelvic Fracture o Abdominal distention and absent bowel sounds may be due to complications of pelvis fractures such as paralytic ileus or hemorrhage or trauma to bladder, urethra, or colon. o Leaning over flexes hip greater than 90 degrees and can cause hip dislocation (i. nurse should intervene if the pt leans over to put shoes and socks on) o Pain
o If pt has numbness and tingling, ensure to compare it to a preoperative assessment because the pre-op and post-op shouldn’t change or should’ve been improved o Treatment: Spine should always be kept in alignment after surgery
Muscular Dystrophy – progressive wasting of skeletal muscles with no neurological involvement o Biggest concern is decreased mobility/falls/injuries related to falls. o Will affect respiratory muscle as the disease progresses which will involve airway Pt will not be able to manage secretions (drooling – big sign they can’t control secretions) o S/S: Weakness, dysphagia, aspiration risk, GERD, also might put them at risk for stress ulcers, o Diagnostics: Creatine kinase, EMG testing, Muscle fiber biopsy, and ECG o TREATMENT: Ambulatory devices, braces, PT, activity -goal is to keep pt active as long as possible by assisting with ambulation Ventilator- Cpap with trach Steroids delay progression for 2 years Guillain Barre o Rapid onset of muscle weakness caused by immune system attacks peripheral nervous system Risk of acute respiratory failure so monitoring respiratory function is priority
Fibromyalgia & Systematic Lupus Erythematosus
Systematic Lupus Erythematosus (SLE) o Severe skin reactions can occur in pt’s with SLE if exposed to sun. Birth control can exacerbate lupus and stress so by balancing exercise with rest periods will help keep away flare ups. o NSAIDs can help with musculoskeletal manifestations (flare ups) o Anti-Smith antibody (Anti-Sm) – is an antibody found exclusively in SLE and will provide the most specific findings. o Live virus vaccines (varicella) are contraindicated in a pt taking a immunosuppressive o Elevated BUN and creatinine levels indicate possible lupus nephritis
Fibromyalgia – Chronic condition of pain in muscles and soft tissues o Limit caffeine and sugar intake because they are muscle irritants. o Mild exercise is recommended but vigorous exercise will make symptoms worse o S/S: Sleep disturbances, multiple tender points, widespread bilateral burning of musculoskeletal pain.
Shock (Hypovolemia/Hypovolemic Shock
Hypovolemic Shock o S/S: anxious, tachypnea, increase in cardiac output (HR) initially because they’re losing blood. o If loss is greater than 30% of fluid volume then they will not be able to compensate and they will start to brady down o Treatment: Hang fluids bolus IV (prep 2 large bore IV’s) if it’s just fluids > check central venous pressure 8-12mmHg), if it’s low it suggests more volume replacement. hang blood if it’s 30% lost in blood How do you know if it’s working? VS better Capillary refill better Urinary output will be better Hang vasopressor if needed – norepinephrine o Do not hang if CVP is low
TOPIC 8 – Trauma and Medical Emergencies
Emergency & Disaster Nursing
ABC’s/CABs LOC/VS Control Bleeding IV access, fluids, blood products Systolic BP – ALWAYS greater than 90 but anything less than 90 = hypoxia o Lost blood – look at BP and what to do Primary Trauma Survey Table 68. o Identify life threatening conditions and start appropriate interventions (know steps in order) scenario – we did x,y,z what do we do next? B (bleeding first), A,B,C,D,E A = Alertness and Airway Airway: even with airway patency – problems can compromise ventilation so best to assess patients breathing and observe respiratory effort. Check alertness by LOC o AVPU: A = alert, V = responsive to voice, P = responsive to pain, U = unresponsive B = Breathing
o Penetrating Trauma: gunshot or stabbing (open wound) TREATMENT: Apply occlusive dressing – seal on 3 sides because it allows air to move out of the pleural cavity but not enter Any impaled object should have a “bulky dressing” or gauze to stabilize object so it can remain in place until surgery
Tetanus Vaccine o Anyone with open wound (lacerations/tissue avulsion) will need a tetanus shot When did they last receive it? If there is no proof = give TIG, tetanus-diphtheria toxoid, and pertussis (Tdap) o Include in med hx when last immunization was – tetanus immunization are good for 10 years unless pt sustains a wound, then it’s given if it is more than 5 years. o Given in any injury if anerobic metabolism of organisms may occur o Types of immunizations or passive/immediate immunity TIG (immune globulin) Td-Tetanus-diphtheria toxoid Tdap-Tetanus, diphtheria, acellular pertussis TIG-Tetanus immune globulin (human) o Unimmunized (unknown) : give booster AND TIG for high risk wounds o Immunized but greater than 5 years : high risk wound, should give booster o Provider will be called to determine pt need based on the wound
Heat Related Emergencies
HEAT CRAMPS: severe cramps in large muscle groups fatigue by heavy work o Brief and intense cramps, occurs during rest after heavy labor o Seen in healthy athletes with inadequate fluid intake o Treatment: Gentle massage, elevation, analgesia to minimize pain Avoid strenuous activity for 12 hours Salt replacement via sports drinks (not salt tablets). Sports drinks will help replace fluid and electrolytes lost Resolve with rest and oral/parenteral replacement of sodium + water
HEAT EXHAUSTION – Prolonged exposure to heat over hours or days o S/S: headache, fatigue, N/V, extreme thirst, tachycardia, dilated pupils, ashen color, weakness, profuse diaphoresis, orthostatic/hypotension (low BP), tachycardia, confusion and anxiety mild to severe temp elevation (99 – 105/ 37 – 41C). o CAUSE: decreased fluid intake, high heat exposure, high activity o TREATMENT:
Place pt in cool area, remove constricting clothing, monitor ABC’s, start normal saline IV if oral isn’t tolerated. Place moist sheet over pt to decrease core temp.
HEAT STROKE – most serious form of heat stress due to failure of hypothalamic therm process. Considered a medical emergency. increase sweating and RR deplete fluids and electrolytes (sodium). S/S: Sweat glands stop functioning (IMPORTANT) Core temp increases within 10- greater than 105/41C – know how to convert can place the pt at risk for kidney injury to rhabdo (skeletal muscle breakdown) Altered mental status/ataxic (no mobility)/coma o Due to cerebral edema (brain swelling) or hemorrhage can occur from a direct thermal injury Circulatory Collapse o Hypotensive/Tachycardia (hot, dry, ashen skin with a range of neurological symptoms). TREATMENT: Stabilize ABC’s and then rapidly decrease core temperature (O2 that is given will be given 100% O2 through non-rebreather mask) o Remove clothing o Cover with wet sheet and a large fan to cool the patient o Cool water bath, apply ice pack to groin and axilla o Peritoneal lavaging (put cath in the peritoneal cavity and insert with cool water). Monitor temp Control shivering – shivering causes core temp to rise o Give IV chlorpromazine o Giving antipyretics (antifever, Tylenol, ibuprofen) is NOT effective, because it is not an infection. o DIC, and Myoglobinuria, promote evaporative cooling Monitor for signs of Rhabdomyolysis (skeletal muscle breakdown) Myoglobinuria – monitor kidney function o Color of urine o Urinary output Disseminated intravascular coagulation (DIC) Worst case scenario – obtain clotting studies Place on continuous ECG monitoring and pulse ox. Correct electrolytes TEACHING Teach to stay out of the sun and drink lots of water
TREATMENT:
Priority = ABC’s (breath sounds should be assessed after airway) Active rewarming or core warming: o Heated humidified O2 (up to 111) o Warm IV fluids (98) o Peritoneal lavage (113F) o Extracorporeal circulation with cardiopulmonary bypass, rapid fluid infuser, and hemodialysis. , warm central trunk first, keep pt head covered. Rewarm core before extremities Risks: o Afterdrop o Hypotension o Dysrhythmias Discontinue active rewarming once core temp reached 90 – 95F
Drowning – submersion injury
ABC’s = main priority and frequently o Respiratory impairment after submersion in water or other fluid/causes hypoxia o Cold water/freezing water can slow progression of hypoxic brain injury + has better outcomes o Pulmonary edema results when pt aspirates and can also cause ARDS TREATMENT: Correct hypoxia Cervical spine Correct acid-base/fluid imbalances Rewarm if hypothermia present Observe pt for 23 hours Correct hypoxia with mechanical vent, PEEP, CPAP o Improved gas exchange in presence of pulmonary edema o Vent and O2 are primary techniques for treating resp failure
BITES
Snake bites o Coagulation abnormalities are due directly to snake venom interference o TREATMENT: CroFab – a venom specific fragment of IgG. Binds and neutralized venom toxin and helps remove the toxin from the target tissue and eliminate it from the body. Bug Bites o Tick Bites: Two different diseases to get from Ticks
Lyme disease – 48 hour attachment, flu-like symptoms, bullseye rash Long term immune systemic response causes chronic illness. Rocky Mountain - spotted, fever 2-14 days, pink macular rash-palms, wrists, feet, can be fatal o TREATMENT: Safe removal 1st because neurotoxic venom is released and we want to minimize venom release – tweezers at the head/stinger area Doxycycline – treatment of choice Bee Stings o Hymenoptera stings: bees, yellow jackets, hornets, wasps, fire ants Remove rings if brought into ED because swelling can occur Mild discomfort or life-threatening Venom can be cytotoxic, hemolytic, allergenic, vasoactive Anaphylaxis – number of stings worsens Human Bite – worse than animal bites o Can cause infection, hepatitis, tissue damage o TREATMENT: Copious irrigation, debridement, analgesics Prophylactic tetanus & antibiotics DO NOT suture closed-open or loose sutures due to infection/abscesses Anaphylaxis o Airway edema can affect airway + breathing o O2 sat is most critical assessment.
Poisonings- Table 68.
o Within 1 hour of ingestion: Gastric lavage – risks & benefits – if altered LOC (unconscious) then intubate first to prevent aspiration Activated Charcoal – binds and passes through – must have a working GI system Not effective with ethanol, hydrocarbons, alkali, iron, boric acid, lithium, methanol, or cyanide Skin and eye lavage “the solution to pollution is dilution” Powders – brush off visible powder on skin and clothing Liquids – brush off Acetaminophen Overdose o ANTIDOTE: acetylcysteine (PO can cause vomiting, IV acceptable) Tylenol can kill the liver with 3g o PHASES/S&S: Phase 1 (24 hours of ingestion) – malaise (lethargic), diaphoresis, N/V Phase 2 (24-28 hours hour of ingestion) - right upper quadrant pain, decrease urine output, decreased nausea, increase LFTs (liver function test AST/ALT) Phase 3 (72-96 hours after ingestion) – jaundice, hypoglycemia, enlarged liver, coagulopathies, DIC
TOPIC 9
Intracranial Pressure (ICP)
Cushing’s Triad – Where becomes hypertensive, bradycardic, and dyspneic o Signs that ICP has increased. Monitoring: o Headache, visual disturbances, N/V = early signs o Assess LOC – Glascow Coma Scale – know it and look at the behavior o As brain becomes more and more swollen – there will be a change in motor function Decorticate = flexing towards the bod Decerebrate = extending away from the body Any inflammatory Brain disorder – would be confused with a brain abscess, meningitis (bacterial or viral), and encephalitis Dangerous because there is inflammation in the brain. o Concerned about cerebral edema > if not controlled then leads to herniation (everything pushes to unaffected side) Headache, visual disturbances, N/V = early signs o TREATMENT Mannitol (Osmitrol) is DRUG OF CHOICE to decrease ICP. It is a diuretic so monitor fluids and electrolytes Monitor ICP pressure = 5 – 15mmHg (healthy) Hypertonic Saline = moves water out of cells and into blood Monitor BP and serum sodium levels Corticosteroids – dexamethasone Increases glucose levels so monitor glucose Elevate HOB 30 degrees Suctioning needs – keep it to a minimum Keep as relaxed as possible NG tube for pt WITHOUT facial or basal skull fractures Monitor ABG’s (hypoxia, hypercapnia)/Fluid & electrolyte balances/Monitor IV fluids/Daily electrolytes Monitor for DI or SIADH Maintain vent support Pain/anxiety
Glasgow Coma Scale – KNOW IT
Scale score of less than or equal to 8 is bad (less than 8, you wanna intubate) o 15 is the best o 8 = intubate (comatose pt) o 3 is totally unresponsive Abnormal CT scans or MRI
1 point is the lowest score possible
Neurogenic Shock vs Spinal Shock
Spinal Cord Injury o Primary Injury: SCI due to cord compression – traction, penetrating trauma, bone displacement, or interruption of blood supply o Secondary Injury: ongoing, progressive o Complete: total loss of function o Incomplete: partial loss o Vagal nerve dysfunction will cause bradycardia and hypotension o Maintain Mean Arterial Pressure between 85-90 mm Hg Might be put on Vasopressor agents o Cauda Equina = multiple nerve root compression S/S: severe low back pain, progressive weakness, increased pain, bowel and bladder incontinence Surgical intervention to prevent permanent loss of function Spinal Shock o Spinal show = temporary loss of reflexes, sensation, and motor activity o S/S: Reflexes, loss of sensation, absent thermoregulation, flaccid paralysis BELOW level of injury o Can last days to weeks Neurogenic Shock o There will be change in hemodynamic status – in BP (bradycardia/hypotension) o S/S: Loss of vasomotor tone = hypotension (NOT orthostatic) + bradycardia Warm/dry skin Causes peripheral vasodilation Loss of SNS innervation (peripheral vasodilation, venous pooling, decreased cardiac output) T6 or HIGHER injury Treatment: Atropine, obtain baseline VS, provide O2 100% nonrebreather, prepare for intubation and mechanical ventilation Cervical Spine Precautions o The higher you are in spinal injuries – the more concerned we are about airway o C4 Injuries Tetraplegia = results in complete paralysis below the neck Above C4 – Total loss of respiratory muscles (need to be ventilated, intubated first then trached) Below C4 – diaphragmatic breathing – respiratory insufficiency (need help) o C6 Injuries Results in partial paralysis of hands and arms as well as lower body
NSG430 Broad Topics Exam 3
Course: Adult Health Nursing II (NSG-430)
University: Grand Canyon University
- Discover more from:
