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Med Surg 2 Exam 3 Blueprint Answers
Medical-Surgical Nursing II (NSG 223)
Herzing University
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Med Surg 2 Exam 3 Blueprint
NSG223.08.01 Addison’s Disease – clinical manifestations ● loss of mineralocorticoids leads to increased excretion of sodium, chloride, and water with increased retention of potassium ○ may lead to a deficiency in extracellular fluid causing decreased cardiac output ● loss of glucocorticoids results in hypoglycemia with complaints of muscle weakness, lethargy, and GI symptoms including anorexia, weight loss, nausea and vomiting ● increase in levels of adrenocorticotropic hormone (ACTH) results in hyperpigmentation of the skin and mucous membranes, especially of the knuckles, knees, and skin folds, elbow ● are at risk to develop an Addisonian crisis, a life-threatening complication in which severe hypotension, cyanosis, fever, nausea, vomiting, and signs of shock develop ○ may have pallor; complain of headache, abdominal pain, and diarrhea; and may show signs of confusion and restlessness ○ slight overexertion, exposure to cold, acute infection, or a decrease in salt intake may lead to circulatory collapse, shock, and death, if untreated ○ stress of surgery or dehydration resulting from preparation for diagnostic tests or surgery may precipitate an Addisonian or hypotensive crisis because of the inhibited feedback loop ● Fatigue ● Emaciation ● Low blood glucose ● Low serum sodium ● High serum potassium ● 20-40% of patients: Depression, emotional lability, apathy, confusion ● In severe cases, the disturbance of sodium and potassium metabolism may be marked by the depletion of sodium and water and severe, chronic dehydration. ● Tan Skin (dark pigmentated skin)
NSG223.08.01 Addison’s disease – dietary considerations ● Eat a high protein, carb, and sodium diet ● Eat high sodium foods during times of GI illness or very hot weather. ● Eat foods low in potassium as they are at high risk for hyperkalemia ● nurse encourages the patient to consume foods and fluids that assist in restoring and maintaining fluid and electrolyte balance which maintains adequate cardiac output ● Along with the dietitian, the nurse helps the patient select foods high in sodium during GI disturbances and in very hot weather ● may need to supplement dietary intake with salt during GI losses of fluids through vomiting and diarrhea. ● Increasing fluid intake and salt with excessive perspiration. ● LOW POTASSIUM
NSG223.08.01 Addison’s disease – pharmacologic mgt during crisis ● patient should have an emergency kit in the form of corticosteroid in pre-filled syringes, 100-mg vials of hydrocortisone or 4 mg of dexamethasone and 0% sterile saline to reconstitute the corticosteroid and syringes (Nieman, 2016c). ● During stressful procedures or significant illnesses, additional supplementary therapy with glucocorticoids is required to prevent Addisonian crisis. In addition, the patient may need to supplement dietary intake with salt during GI losses of fluids through vomiting and diarrhea.
● Antibiotics may be given if infection has precipitated adrenal crisis in a patient with chronic adrenal insufficiency ● Immediate treatment is directed toward combating circulatory shock ○ restoring blood circulation ○ administering fluids and corticosteroids ■ Hydrocortisone is administered by IV, followed by 3 to 4 L of normal saline or 5% dextrose solution. ■ Vasopressors may be required if hypotension persists ○ monitoring vital signs ○ placing the patient in a recumbent position with legs elevated
NSG223.08.01 Addison’s disease – routine pharmacologic mgt ● goal of treatment for Addison’s disease is to replace the adrenocorticoids to correct adrenal insufficiency ● Addison's disease, hydrocortisone is needed to replace the deficit from the adrenal gland ● is important to replace both the mineralocorticoid and adrenocorticoid. ● Hydrocortisone (glucocorticoid) ○ Substitute Corticosteroid ○ Take with food to decrease gastric irritation ○ Take in the morning at 9am ○ Space other doses evenly throughout the day ○ Do NOT stop medication abruptly ○ Increase dose if increased stress or illness ○ Wear medic alert bracelet ○ Report swelling, weight gain, muscle weakness, tarry stools, moon face, fever, infection, inability of wounds to heal, and fatigue ○ Do not receive live vaccines while taking hydrocortisone (ex: MMR) ● Fludrocortisone (mineralocorticoids) ○ Substitute Aldosterone ○ Take with hydrocortisone to enhance effectiveness and produce a more normal adrenal response ○ Store drug in airtight, light-protected container at 59-86 degrees ○ Monitor weight, alert provider if gain more than 5 pound in 1 week ○ Eat foods high in potassium and calcium ○ Supplement Vit A, D, B6, C, folate, zinc, phosphorus ○ Decrease sodium intake ○ Report muscle weakness, numbness, fatigue, depression increased urination, changes in heart rhythm, epigastric pain, tarry stools, swelling of feet/hands, SOB ○ Regular eye exams (risk for cataracts)
NSG223.08.02 Cushing’s Syndrome – clinical manifestations ● overproduction of the adrenocortical hormone occurs, arrest of growth, obesity, and musculoskeletal changes occur along with glucose intolerance ● classic picture of Cushing’s syndrome in the adult is that of central-type obesity ○ fatty “buffalo hump” in the neck and supraclavicular areas ○ heavy trunk ○ relatively thin extremities ● skin is thin, fragile, and easily traumatized
○ results in enlargement of peripheral body parts and soft tissue, after the fusion of the epiphyseal plates has occurred, without an increase in height ○ If acromegaly begins during adult life, the excessive skeletal growth occurs only in the feet, the hands, the superciliary ridge, the molar eminences, the nose, and the chin ● Pediatric ○ Is called gigantism ○ Rare, oversecretion of GH in children before the fusion of epiphyseal growth plates results in pituitary gigantism ■ Happens before puberty ○ may grow to 7-8 feet tall
NSG223.08.02 Pharmacologic Mgt of Acromegaly and Cushing’s ● Cushing’s Disease treatment the goal of drug therapy is to inhibit one or more enzymes contained in cortisol synthesis ● If Cushing’s syndrome is a result of the administration of corticosteroids, an attempt is made to reduce or taper the medication to the minimum dosage needed to treat the underlying disease process (e., autoimmune or allergic disease, rejection of a transplanted organ). ○ Frequently, alternate-day therapy decreases the symptoms of Cushing’s syndrome and allows recovery of the adrenal glands’ responsiveness to ACTH. ● Treatment for acromegaly is aimed at inhibition of growth hormone ● Cushings ○ Ketoconazole ■ Antifungal ■ Inhibits first step in cortisol biosynthesis and the conversion of deoxycortisol to cortisol ■ Caution with hepatic impairment ● Monitor liver enzymes ● Report clay-colored stools, extreme thirst, and yellowing of skin or eyes ○ signs and symptoms indicate elevated liver enzymes. ■ Take with water, coffee, tea, or fruit juice (acidic drinks enhance absorption) ■ Do not take antacids ■ Assess blood sugar ● Acromegaly ○ Octreotide
■ Actions similar to the anterior pituitary hormone somatostatin ● Inhibits serotonin release ■ Also inhibits gastrin, vasoactive intestinal peptide, insulin, glucagon, secretin, motilin, pancreatic polypeptide ■ inhibit the production or release of GH and may bring about marked improvement of symptoms ■ Suppresses GH and IGF- ■ IM injection ■ necessary to withdraw the drug for four weeks once per year ■ Monitor blood glucose. ■ Have follow-up gallbladder ultrasounds to detect cholelithiasis. ■ Monitor thyroid function tests ● T3,4, 7 and TSH ■ Monitor BP ■ Monitor blood glucose ■ assesses for diminished bone growth ○ Lanreotide ■ Suppresses GH ■ SubQ injection
NSG223.08.03 Diabetes Insipidus – clinical manifestations ● Without the action of ADH on the distal nephron of the kidney, an enormous daily output (greater than 250 mL per hour) of very dilute urine with a specific gravity of 1.001-1 occurs ○ urine contains no abnormal substances such as glucose or albumin. ○ Decreased urine specific gravity ○ Decreased urine osmolality ● Due to intense thirst, the patient tends to drink 2 to 20 L of fluid daily and craves cold water. ● In adults, the onset of DI may be insidious or abrupt. ● disease cannot be controlled by limiting fluid intake, as the high-volume loss of urine continues even without fluid replacement. ○ Attempts to restrict fluids cause the patient to experience an insatiable craving for fluid and to develop hypernatremia and severe dehydration. ● Tachycardia ● Hypotension ● Dry Inside ● Dehydration S/S
NSG223.08.04 SIADH – nursing process ● Close monitoring of fluid I&O, daily weight, urine and blood chemistries, and neurologic status is indicated for the patient at risk for SIADH. ● Supportive measures and explanations of procedures and treatments assist the patient in managing disorder. ● Soaked Inside
NSG223.08.04 Pharmacologic Mgt of DI and SIADH ● Diabetes Insipidus (DI) ○ Desmopressin (DDAVP) ■ Synthetic vasopressin without the vascular effects of natural ADH
○ Crepitus ■ When the extremity is gently palpated, a crumbling sensation, called crepitus, can be felt or may be heard ■ caused by the rubbing of the bone fragments against each other. ○ Localized Edema and Ecchymosis ■ occur after a fracture as a result of trauma and bleeding into the tissues. ■ Ecchymosis is the discoloration of the skin resulting from bleeding underneath
NSG223.09.01 Medical Mgt of Fractures ● Reduction ○ Fracture Reduction ■ refers to restoration of bone fragments to anatomic realignment and positioning with immobilization ■ Either closed reduction or open reduction may be used to reduce a fracture. ● specific method selected depends on the nature of the fracture ○ underlying principles are the same ■ Usually, the primary provider reduces a fracture as soon as possible to prevent loss of elasticity from the tissues through infiltration by edema or hemorrhage ■ most cases, fracture reduction becomes more difficult as the injury begins to heal ■ Before fracture reduction and immobilization, the patient is prepared for the procedure ● consent for the procedure is obtained ● analgesic agent is given as prescribed. ○ Regional anesthesia can be very useful for pain control with fractures and dislocation reduction ■ injured extremity must be handled gently to avoid additional damage ○ Closed Reduction ■ most instances, closed reduction is accomplished by bringing the bone fragments into anatomic alignment through manipulation and manual traction ■ extremity is held in the aligned position while a cast, splint, or other device is applied ■ Reduction under anesthesia with percutaneous pinning may be used ■ immobilizing device maintains the reduction and stabilizes the extremity for bone healing ■ X-rays are obtained after reduction to verify that the bone fragments are correctly aligned ■ Traction (skin or skeletal) may be used until the patient is physiologically stable to undergo surgical fixation ○ Open Reduction ■ Through a surgical approach, bone fragments are anatomically aligned. ■ Internal fixation devices (e., metallic pins, wires, screws, plates, nails, or rods) may be used to hold the bone fragments in position until solid bone healing occurs ● may be attached to the sides of bone, or they may be inserted through the bony fragments or directly into the medullary cavity of the bone. ● ensure firm approximation and fixation of the bony fragments ■ Open reduction internal fixation (ORIF) is a common orthopedic surgical procedure used to treat severe fractures ● Immobilization ○ After the fracture has been reduced, the bone fragments must be immobilized and maintained in proper position and alignment until union occurs. ○ may be accomplished by external or internal fixation
■ Methods of external fixation include bandages, casts, splints, continuous traction, and external fixators. ● Maintaining and Restoring Function ○ Reduction and immobilization are maintained as prescribed to promote bone and soft tissue healing. ○ Edema is controlled by elevating the injured extremity and applying ice as prescribed. ○ Neurovascular status is monitored routinely ■ primary provider is notified immediately if signs of neurovascular compromise develop. ○ Restlessness, anxiety, and discomfort are controlled with a variety of approaches ex. reassurance, position changes, and pain-relief strategies, including the use of analgesic medications. ○ Isometric and muscle setting exercises are encouraged to minimize atrophy and to promote circulation. ○ Participation in activities of daily living (ADLs) is encouraged to promote independent functioning and self-esteem. ■ Gradual resumption of activities is promoted as prescribed. ■ With internal fixation, the surgeon determines the amount of movement and weight- bearing stress the extremity can sustain and prescribes the level of activity
NSG223.09.01 Fractures and patient education ● Patients With Closed Fractures ○ has no opening of the skin at the fracture site ■ fractured bones may be nondisplaced or slightly displaced, but the skin is intact ○ nurse educates the patient regarding the proper methods to control edema and pain ○ important to educate about exercises to maintain the health of unaffected muscles and to increase the strength of muscles needed for transferring and for using assistive devices ex. crutches, walkers, and special utensils ○ patient is educated to use assistive devices safely. ○ Plans are made to help patients modify the home environment as needed and to ensure safety ex. removing floor rugs or anything that obstructs walking paths throughout the house. ○ Patient education includes ■ Self-care ■ medication information ■ monitoring for potential complications ■ need for continuing health care supervision ○ Fracture healing and restoration of strength and mobility may take an average of 6 to 8 weeks, depending on the quality of the patient’s bone tissue ● Patients With Open Fractures ○ there is a risk for osteomyelitis (infection of the bone), tetanus, and gas gangrene ○ objectives of management are to prevent infection of the wound, soft tissue, and bone, and to promote healing of bone and soft tissue. ○ Intravenous (IV) antibiotics are given upon the patient’s arrival in the hospital along with intramuscular (IM) tetanus toxoid as indicated ○ Wound irrigation using a sterile isotonic saline solution and débridement (removal of tissues and foreign material) are initiated in the operating room as soon as possible ○ wound is cultured, and bone grafting may be performed to fill in areas of bone defects. ○ fracture is carefully reduced and stabilized by external fixation, and the wound is usually left open.
○ Pallor ○ Pulselessness ○ Paresthesia ○ Paralysis ● Swelling is a concern ○ Elevate extremity so that it is above the level of the heart during the 1st 24-48 hours after application ● Notify provider ASAP if any sign of compromised neurovascular status ● Remember that uncontrolled pain is a sign of compartment syndrome ● Severe burning pain over bony prominences warns of impending pressure ulcer ● Prevent disuse syndrome: ○ Tense or contract muscles without moving underlying bone ● Before the cast, splint, or brace is applied, the nurse completes an assessment of the patient’s general health, presenting signs and symptoms, emotional status, understanding of the need for the device, and condition of the body part to be immobilized ● Physical assessment of the part to be immobilized must include a thorough assessment of the skin and neurovascular status, including the degree and location of swelling, bruising, and skin abrasions ● To promote healing, any skin lacerations and abrasions that may have occurred as a result of the trauma that caused the fracture must be treated before the cast, brace, or splint is applied ○ nurse thoroughly cleanses the skin and treats it as prescribed ○ patient may require a tetanus booster if the wound is dirty and if the last known booster was given more than 5 years ago ○ Sterile dressings are used to cover the injured skin ○ If skin wounds are extensive, an alternative method (e., external fixator) may be chosen to immobilize the body part ● nurse gives the patient or family information about the underlying pathologic condition and the purpose and expectations of the prescribed treatment regime ○ promotes the patient’s active participation in and adherence to the treatment program. ● nurse prepares the patient for the application of the cast, splint, or brace by describing the anticipated sights, sounds, and sensations (e., heat from the hardening reaction of the fiberglass or plaster) that they may experience ● Asking the patient and family what they know about the application and care of the cast can help determine opportunities for education ● patient needs to know what to expect during application and the reason the body part must be immobilized. ● main concern following the application of an immobilization device is assessment and prevention of neurovascular dysfunction or compromise of the affected extremity ○ Assessments are performed at least every hour for the first 24 hours and every 1 to 4 hours thereafter to prevent neurovascular compromise related to edema and/or the device. ○ Neurovascular assessment includes ■ assessment of peripheral circulation, motion, and sensation of the affected extremity, assessing the fingers or toes of the affected extremity, and comparing them with those of the opposite extremity ● assessing peripheral circulation, the nurse must check peripheral pulses as well as capillary refill response (within 3 seconds), edema, and the color and temperature of the skin ● assessing motion, the nurse should note any weakness or paralysis of the injured body part
● assessing sensation, the nurse monitors for paresthesia (i., numbness or tingling) or absence of feeling in the affected extremity, which could indicate nerve damage ● Nurses must be vigilant in assessing for subtle neurovascular changes in these patients ● The “6 Ps” indicative of symptoms of neurovascular compromise, described previously, including pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia, are assessed ● Early recognition of diminished circulation and nerve function is essential to prevent loss of function. ● Swelling is a concern and can create excessive pressure under the cast ● To augment the flow of fluid, the nurse elevates the extremity so that it is above the level of the heart during the first 24 to 48 hours post-application to enhance arterial perfusion and control edema and notifies the primary provider at once if signs of compromised neurovascular status are present. ● nurse must carefully evaluate pain associated with the musculoskeletal condition, asking the patient to indicate the exact site and to describe the character and intensity of the pain using a pain rating scale. ○ Pain associated with the underlying condition (e., fracture) is frequently controlled by immobilization. ○ Pain due to edema that is associated with trauma, surgery, or bleeding into the tissues can frequently be controlled by elevation and, if prescribed, intermittent application of ice or cold packs ■ Ice bags (one third to one half full) or cold application devices are placed on each side of the cast, if prescribed, making sure not to indent or wet the cast. ○ Unrelieved or pain out of proportion following cast application may indicate complications. ■ Pain associated with acute compartment syndrome is relentless and is not controlled by modalities such as elevation, application of ice or cold, and usual dosages of analgesic agents. ■ Severe burning pain over bony prominences, especially the heels, anterior ankles, and elbows, warns of an impending pressure injury ● may occur from too-tight elastic wraps used to hold splints in place ● nurse must never ignore complaints of pain from the patient in a cast because of the possibility of problems, such as impaired tissue perfusion, acute compartment syndrome or pressure injury formation. ○ A patient’s unrelieved pain and increasing analgesic requirements must be reported immediately to the primary provider to avoid necrosis, neuromuscular damage, and possible paralysis. ● nurse observes the patient for systemic signs of infection, which include ○ unpleasant odor from the cast, splint, or brace ○ purulent drainage staining the cast ○ more common from an open wound, but the moist, warm environment of a splint or cast can be an ideal conduit for infection ○ Foul-smelling casts should be removed to prevent skin and wound infections ■ If the infection progresses, a fever may develop ○ nurse must notify the primary provider if any of these signs occur ● some degree of joint stiffness is an inevitable complication of immobilization ○ Every joint that is not immobilized should be exercised and moved through its ROM to maintain function ○ nurse encourages the patient to move all fingers or toes hourly when awake to stimulate circulation
NSG223.09.01 Complications of Casts, Splints & Braces Acute Compartment Syndrome
○ Muscle setting exercises (e., quadriceps and gluteal setting exercises) are important in maintaining muscles essential for walking. ○ should be performed hourly while the patient is awake
NSG223.09.01 Nursing Care for Body Casts, External Fixation & Traction – normal vs abnormal findings ● Body Cast: trunk of body ○ Used to immobilize spine ○ Casts that encase the trunk of the body (body cast) and portions of one or two extremities (spica cast) require special nursing strategies ○ Hip spica casts are utilized to treat various fractures of the hip or femur or to correct or maintain the correction of hip deformities after reduction or surgery ■ typically remain in place for 4 to 6 weeks ○ Shoulder spica casts are used for some humeral neck fractures ○ Nursing responsibilities include ■ preparing and positioning the patient ■ assisting with skin care and hygiene ■ monitoring for complications ○ Explaining the casting procedure helps reduce the patient’s apprehension about being encased in a large cast ○ nurse reassures the patient that 7 people will provide care during the application, support for the injured area will be adequate, and care providers will be as gentle as possible. ○ Patients immobilized in large casts may develop superior mesenteric artery syndrome, known as cast syndrome ■ a rare condition characterized by compression of the third portion of the duodenum between the aorta and superior mesenteric artery ● partial or complete obstruction of the duodenum can occur within days or weeks after the cast has been applied ■ includes psychological or physiologic manifestations ● psychological component is similar to a claustrophobic reaction ○ patient exhibits an acute anxiety reaction characterized by behavioral changes and autonomic responses (increased respiratory rate, diaphoresis, dilated pupils, increased heart rate, elevated blood pressure) ○ nurse needs to recognize the anxiety reaction and provide an environment in which the patient feels secure ■ administration of pain and antianxiety medications prior to the casting procedure may help to reduce reaction ● decreased physical activity, gastrointestinal motility decreases, and intestinal gases accumulate ○ Physiologic manifestations include ■ abdominal distention and discomfort ■ nausea ■ bilious vomiting, which can lead to food aversion, poor intake, malnourishment, and weight loss ■ Eventually, increased abdominal pressure and ileus may occur ○ patient is treated conservatively with decompression (nasogastric intubation connected to suction) and IV fluid therapy until gastrointestinal motility is restored ■ If conservative measures are ineffective, surgical intervention is
warranted ○ Rarely, abdominal distention can place added pressure on the superior mesenteric artery, reducing the blood supply to the bowel, which can result in gangrenous bowel ■ descending aorta may sustain pressure, as it may be compressed between the spine and pressure of abdominal distention, which results in ischemia ■ complications can be severe, and the pressure needs to be relieved as soon as possible by cutting a window in the abdominal portion of the cast or bivalving the cast ● measures may be sufficient to prevent or relieve pressure on the duodenum ○ Caring for a patient with a body or spica cast at home can be very stressful for the caregiver(s) ■ essential that nurses provide appropriate support and discharge education ○ To minimize complications after the cast is applied, the nurse should give the patient a comprehensive discharge package that supplements home care instructions with visual training instructions, as well as provide telephone counseling after discharge ■ nurse educates the family about how to care for the patient, including ● providing hygienic ● cast and skin care ● proper positioning ● preventing complications ● recognizing symptoms that should be reported to the primary provider ○ nurse monitors the patient in a large body cast for potential superior mesenteric artery syndrome, noting bowel sounds every 4 to 8 hours, and reports abdominal discomfort and distention, nausea, and vomiting to the primary provider ● External Fixation ○ Clothing may need to be altered to cover the device ○ After application, extremity to be elevated to heart level to reduce swelling ○ Sharp points or pins are covered with caps ○ Monitor for issues from pressure from the device on the skin, nerves, or blood vessels ○ Monitor for compartment syndrome ○ Monitor neurovascular status ever 2-4 hours ○ Monitor for s/s of infection ○ 1st 48-72 hours after application: ■ Some serous drainage, skin warmth, and mild redness at the pin sites are expected ■ Should subside after 72 hours ○ Only the provider should adjust the clamps ○ Patients should be prepared psychologically for application of the external fixator, as they may be at risk for an altered body image related to the size and bulk of the apparatus ○ To promote acceptance of the device, patients should be given comprehensive information about the frame and reassurance that the discomfort associated with the device is minimal and that early mobility is anticipated ■ patients who have had significant trauma, there may not be time to engage them in this type of preparation ○ Nurses should initiate open discussions to help patients describe their concerns about the apparatus and expectations about care ○ After the external fixator is applied, the extremity is elevated to the level of the heart to reduce
at home) and to promptly report any signs of pin site inflammation, irritation, infection, or pin loosening ■ nurse instructs the patient or family to monitor neurovascular status and report any changes promptly ■ patient or family members are instructed to check the integrity of the fixator frame daily and to report loose pins or clamps ■ physical therapy referral is helpful in educating the patient how to transfer, use ambulatory aids safely, and adjust to weight-bearing limits and altered gait patterns ● Traction ○ Uses a pulling force to promote and maintain alignment ○ Goals: ■ Reduce muscle spasms and pain ■ Realign bone fractures ■ Correcting/preventing deformities ○ May need to be applied in more than one direction to achieve the desired line of pull ○ Used primarily as a short-term intervention until external or internal fixation are possible ○ Traction must be continuous to be effective and never interrupted ○ Any factor that might reduce the effective pull must be eliminated ○ Patient must be in good body alignment in the center of the bed when traction is applied ○ Weights must hang freely and not rest on the bed or floor ○ Knots in the rope or the footplate must not touch the pulley or the food of the bed ○ Ensuring Effective Skin Traction ■ important to avoid wrinkling and slipping of the traction bandage and to maintain countertraction. ■ Proper positioning must be maintained to keep the leg in a neutral position ■ To prevent bony fragments from moving against one another, the patient should not turn from side to side ● patient may shift position slightly with assistance ○ Monitoring and Managing Potential Complications ■ nurse monitors for complications of skin traction ● skin breakdown ○ During the initial assessment, nurse identifies sensitive, fragile skin (common in older adults) ■ nurse inspects the skin area that is in contact with tape, foam, or shearing forces, at least every 8 hours, for signs of irritation or inflammation ○ nurse performs the following procedures to monitor and prevent skin breakdown ■ Removes foam boots to inspect the skin, the ankle, and the Achilles tendon at least 2x daily ● second person is needed to support the extremity during the inspection and skin care. ■ Palpates the area of the traction tapes daily to detect underlying
tenderness. ■ Provides frequent repositioning to alleviate pressure and discomfort ● patient must remain in a supine position is at increased risk for development of a pressure injury. ■ Uses advanced static mattresses or overlays rather than standard hospital foam or alternating-air/low-air-loss mattresses to reduce the risk of pressure injury formation ● nerve damage ○ Skin traction can place pressure on peripheral nerves ○ Care must be taken to avoid pressure on the peroneal nerve at the point at which it passes around the neck of the fibula just below the knee when traction is applied to the lower extremity. ■ Pressure at this point can cause footdrop ○ nurse regularly questions the patient about sensation and asks the patient to move the toes and foot ■ nurse should immediately investigate any complaint of a burning sensation under the traction bandage or boot. ○ Dorsiflexion of the foot demonstrates function of the peroneal nerve ■ Weakness of dorsiflexion or foot movement and inversion of the foot might indicate pressure on the common peroneal nerve ○ Plantar flexion demonstrates function of the tibial nerve ○ nurse should promptly report altered sensation or impaired motor function ● circulatory impairment ○ After skin traction is applied, nurse assesses circulation of the foot within 15 to 30 minutes and then every 1 to 2 hours. ○ Circulatory assessment consists of ■ Peripheral pulses ■ color ■ capillary refill ■ temperature of the fingers or toes. ■ Manifestations of DVT include unilateral calf tenderness, warmth, redness, and swelling ● nurse encourages the patient to perform active foot exercises every hour when awake ○ nurse checks the traction apparatus to see that the ropes are in the wheel grooves of the pulleys, ropes are not frayed, weights hang freely, and knots in the rope are tied securely. ○ nurse evaluates the patient’s position, making sure that the traction force is always in correct alignment with the leg, with the patient in the mid-line position ○ nurse must maintain alignment of the patient’s body in traction as prescribed to promote an effective line of pull ○ nurse positions the patient’s foot to avoid footdrop (plantar flexion), inward rotation (inversion), and outward rotation (eversion) ■ patient’s foot may be supported in a neutral position by orthopedic devices (e., foot supports) ○ If the patient reports severe pain from muscle spasm, the weights may be too heavy, or the patient may need realignment. ■ Pain must be reported to the primary provider if body alignment fails to reduce
● Sheets and blankets are placed over the patient in such a way that the traction is not disrupted ○ Monitoring Neurovascular Status ■ nurse evaluates the body part to be placed in traction and compares its neurovascular status (color, temperature, capillary refill, edema, pulses, ability to move, and sensations) to the unaffected extremity every hour for the first 24 hours after traction is applied ● every 4 hours after the first 24 hours ■ nurse instructs the patient to report any changes in sensation or movement immediately so that they can be promptly evaluated. ■ VTE formation is a significant risk for the patient who is immobilized ● nurse encourages the patient to do active flexion–extension ankle exercises and isometric contraction of the calf muscles (calf-pumping exercises) 10 times an hour while awake to decrease venous stasis ● anti-embolism stockings, compression devices, and anticoagulant therapy may be prescribed to help prevent thrombus formation ■ nurse must immediately investigate every report of discomfort expressed by the patient in traction. ● Prompt recognition of a developing neurovascular problem is essential corrective measures can be instituted quickly ○ Providing Pin Site Care ■ wound at the pin insertion site requires attention ● important to follow the facility’s specific policy pertaining to skeletal pin care ■ goal is to avoid infection and development of osteomyelitis. ■ For the first 48 hours after insertion, the site is covered with a sterile absorbent nonstick dressing and a rolled gauze or Ace-type bandage. ● After this time, a loose cover dressing or no dressing is recommended (a bandage is necessary if the patient is exposed to airborne dust). ■ Expert consensus-based recommendations for pin site care include ● Pins located in areas with soft tissue are at greatest risk for infection. ● After the first 48 to 72 hours following skeletal pin placement, pin site care should be performed daily or weekly. ● Chlorhexidine 2 mg/mL solution is the most effective cleansing solution. ○ If contraindicated (due to known hypersensitivity or skin reaction), saline solution should be used for cleansing. ● Strict hand hygiene before and after skeletal pin site care should always take place ■ nurse must inspect the pin sites at least every 12 hours for signs of hypersensitivity/allergic reaction (contact dermatitis, pruritus, urticaria, angioedema), irritation (normal changes that occur at the pin site after insertion) and infection ● Signs of irritation may include redness, warmth, and serosanguineous drainage at the site, which tend to subside after 72 hours. ● Signs of infection may mirror those of reaction but include the presence of purulent drainage, pain, pin loosening, tenting of skin at pin site, odor, and fever. ■ Patient descriptions of their pin sites might be helpful as they are often the first to notice subtle changes in their symptoms and may be able to differentiate between different pin site states ■ Prophylactic broad-spectrum IV antibiotics may be given for 24 to 48 hours post-
insertion to prevent infection ● Minor infections may be readily treated with antibiotics, and infections that result in systemic manifestations may additionally warrant pin removal until the infection resolves ■ controversy exists about skeletal pin care, showering, and the overall management of pin site crusts, which are the hardened plugs of exudate that adhere to and block the pin sites. ● Current evidence suggests that crusting at the pin site should be retained as long as the pin site remains uninfected as the retained crusts provides a natural barrier from the external environment, which can prevent bacterial contamination ■ patient and family should be educated on the performance of any prescribed pin site care prior to discharge from the hospital and should be provided with written follow-up instructions that include the signs and symptoms of infection ○ Promoting Exercise ■ Patient exercises, within the therapeutic limits of the traction, assist in maintaining muscle strength and tone, and in promoting circulation. ■ Active exercises include ● pulling up on the trapeze ● flexing and extending the feet ● range-of-motion and weight-resistance exercises for noninvolved joints ■ Isometric exercises of the immobilized extremity (quadriceps and gluteal setting exercises) are important for maintaining strength in major ambulatory muscles ■ Without exercise, the patient will lose muscle mass and strength, and rehabilitation will be greatly prolonged
NSG223.09.01 Nonopioid pharmacologic mgt for acute pain Nonopioid Analgesic Agents ● Acetaminophen and NSAIDs comprise the group of nonopioid analgesic agents ● appropriate alone for mild to some moderate nociceptive pain (e., from surgery, trauma, or osteoarthritis) and are added to opioids, local anesthetics, and/or anticonvulsants as part of a multimodal analgesic regimen for more severe nociceptive pain ● Unless contraindicated, surgical patients should routinely be given acetaminophen and an NSAID in scheduled doses throughout the postoperative course, which can be initiated preoperatively ● Ibuprofen, naproxen, and celecoxib are the most widely used oral NSAIDs in the United States
NSAIDS (non-steroidal anti-inflammatory drugs) ● Aspirin ● Naproxen ● ibuprofen (Motrin, Advil). ○ antipyretic properties ○ relieve mild to moderate pain ○ Patient Education Points ■ total daily dose should not exceed 3200 mg ■ Take this drug with food or liquid to decrease gastric irritation. ■ Drink 2 to 3 quarts of fluid daily when taking this drug regularly. ■ Report any signs of bleeding (e., nose bleed, vomiting blood, bruising, blood in the urine or stool), difficulty breathing, severe stomach upset, swelling, or weight gain to your health care provider
Med Surg 2 Exam 3 Blueprint Answers
Course: Medical-Surgical Nursing II (NSG 223)
University: Herzing University
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