Rasmussen Spring 2024
Multidimensional Care I (MDC I) Exam 2
Abduction - ANSWER-movement away from the midline
acceleration/deceleration injuries - ANSWER-cause direct trauma to the brain, spleen or
kidneys when the organs are moved from their fixed location
Active Range of Motion (AROM) - ANSWER-Independent joint movement
Acute Compartment Syndrome - ANSWER-muscle, blood vessels, and nerves are
caught within the fascia leading to increase in venous pressure and resulting edema
leads to increased pain unrelieved by pain meds
increased edema leads to tissue necrosis/infection
can lead to amputation
can appear 6-8 hours following injury or up to 2 days
common in forearm and tibia
Acute Compartment Syndrome Interventions - ANSWER-•Loosen the bandage or wrap
to reduce the symptoms of the syndrome
•If a cast is present, follow the policy for cast removal
•Notify the PCP immediately
•Do Not Elevate or ICE the extremity it may affect the circulation to the extremity.
•May be treated with fasciotomy - a surgical opening in the fascia of the affected
compartment to relieve the pressure and restore circulation. This results in an open
wound
•Wound is packed and dressed daily for 4 - 5 days until the wound is ready to be
sutured closed or ready for wound vac therapy. The wound may still be sutures shut or
require a skin graft.
Acute Compartment Syndrome P's - ANSWER-Pain
Pressure
Paralysis
Paresthesia
Pallor
Pulselessness
Adduction - ANSWER-Movement toward the midline of the body
,Ambulating with assistive devices key points - ANSWER--When ambulating a client,
always stand on affected side
-Where the assistive device goes, the affected leg is next. The assistive device leads
the way!
-Doesn't matter if it's a Cane or a Crutch.... But place 4-6 in to the side of the foot
-Moving something forward? 6-10 inches
-Measuring the height of a cane or walker?.... Doesn't matter the type of cane or walker
measure all to the greater trochanter (which is approximately where the wrist falls)
-Elbow angles:None (crutch, cane, or walker) should ever be more than 30 degrees...
-Stairs: Going up is going up is Good going down is Bad
Assess trauma to pelvis - ANSWER-check the urine for blood
if patient cannot void suspect damage to the urethra or bladder
Assessing side for possible fracture, observe - ANSWER--change in the bone alignment
-internal or external rotation of the limb
-one or more bones may be dislocated
-extremity shortening
-change in bone shape
-ecchymosis over the area of the fracture
Associated Glaucoma - ANSWER-Related to another disease process
Auditory: Age Related Changes Cerumen - ANSWER-Ear or hearing change
Cerumen is drier and impacts more easily, reducing hearing function.
Nursing Adaptations and Actions
Teach the patient and caregiver to irrigate the ear canal weekly or whenever he or she
notices a change in hearing.
Auditory: Age Related Changes hair - ANSWER-Ear or hearing change
Hair in the canal becomes coarser and longer, especially in men.
Nursing Adaptations and Actions
Reassure the patient that this is normal.
More frequent ear irrigation may be needed to prevent cerumen clumping.
Auditory: Age Related Changes Hearing acuity - ANSWER-Ear or hearing change
, Hearing acuity decreases (in some people).
Nursing Adaptations and Actions
Assess hearing with the voice test or the watch test. If a deficit is present, refer the
patient to a specialist to determine hearing loss and appropriate intervention.
Do not assume that all older adults have a hearing loss!
Auditory: Age Related Changes High Frequency Sounds - ANSWER-Ear or hearing
change
The ability to hear high-frequency sounds is lost first. Older adults may have particular
problems hearing the f, s, sh, and pasounds.
Nursing Adaptations and Actions
Provide a quiet environment when speaking (close the door to the hallway) and face the
patient.
Avoid standing or sitting in front of bright lights or windows, which may interfere with the
patient's ability to see your lips move.
If the patient wears glasses, be sure that he or she is using them to enhance speech
understanding.
Speak slowly, clearly, and in a deeper voice and emphasize beginning word sounds.
Some patients with a hearing loss that is not corrected may benefit from wearing a
stethoscope while listening to you speak.
Auditory: Age Related Changes Pinna - ANSWER-Ear or hearing change
Pinna becomes elongated because of loss of subcutaneous tissues and decreased
elasticity.
Nursing Adaptations and Actions
Reassure the patient that this is normal.
When positioning a patient on the side, do not "fold" the ear under the head.
Auditory: Age Related Changes tympanic membrane - ANSWER-Ear or hearing change
Tympanic membrane loses elasticity and may appear dull and retracted.
Nursing Adaptations and Actions
Do not use this finding as the only indication of otitis media.
Avascular Necrosis - ANSWER-Related to disrupted blood flow to the bone
Caused by the hardware used to repair the fracture
Common in hip fractures
Common in patients treated with long term prednisone therapy
Multidimensional Care I (MDC I) Exam 2
Abduction - ANSWER-movement away from the midline
acceleration/deceleration injuries - ANSWER-cause direct trauma to the brain, spleen or
kidneys when the organs are moved from their fixed location
Active Range of Motion (AROM) - ANSWER-Independent joint movement
Acute Compartment Syndrome - ANSWER-muscle, blood vessels, and nerves are
caught within the fascia leading to increase in venous pressure and resulting edema
leads to increased pain unrelieved by pain meds
increased edema leads to tissue necrosis/infection
can lead to amputation
can appear 6-8 hours following injury or up to 2 days
common in forearm and tibia
Acute Compartment Syndrome Interventions - ANSWER-•Loosen the bandage or wrap
to reduce the symptoms of the syndrome
•If a cast is present, follow the policy for cast removal
•Notify the PCP immediately
•Do Not Elevate or ICE the extremity it may affect the circulation to the extremity.
•May be treated with fasciotomy - a surgical opening in the fascia of the affected
compartment to relieve the pressure and restore circulation. This results in an open
wound
•Wound is packed and dressed daily for 4 - 5 days until the wound is ready to be
sutured closed or ready for wound vac therapy. The wound may still be sutures shut or
require a skin graft.
Acute Compartment Syndrome P's - ANSWER-Pain
Pressure
Paralysis
Paresthesia
Pallor
Pulselessness
Adduction - ANSWER-Movement toward the midline of the body
,Ambulating with assistive devices key points - ANSWER--When ambulating a client,
always stand on affected side
-Where the assistive device goes, the affected leg is next. The assistive device leads
the way!
-Doesn't matter if it's a Cane or a Crutch.... But place 4-6 in to the side of the foot
-Moving something forward? 6-10 inches
-Measuring the height of a cane or walker?.... Doesn't matter the type of cane or walker
measure all to the greater trochanter (which is approximately where the wrist falls)
-Elbow angles:None (crutch, cane, or walker) should ever be more than 30 degrees...
-Stairs: Going up is going up is Good going down is Bad
Assess trauma to pelvis - ANSWER-check the urine for blood
if patient cannot void suspect damage to the urethra or bladder
Assessing side for possible fracture, observe - ANSWER--change in the bone alignment
-internal or external rotation of the limb
-one or more bones may be dislocated
-extremity shortening
-change in bone shape
-ecchymosis over the area of the fracture
Associated Glaucoma - ANSWER-Related to another disease process
Auditory: Age Related Changes Cerumen - ANSWER-Ear or hearing change
Cerumen is drier and impacts more easily, reducing hearing function.
Nursing Adaptations and Actions
Teach the patient and caregiver to irrigate the ear canal weekly or whenever he or she
notices a change in hearing.
Auditory: Age Related Changes hair - ANSWER-Ear or hearing change
Hair in the canal becomes coarser and longer, especially in men.
Nursing Adaptations and Actions
Reassure the patient that this is normal.
More frequent ear irrigation may be needed to prevent cerumen clumping.
Auditory: Age Related Changes Hearing acuity - ANSWER-Ear or hearing change
, Hearing acuity decreases (in some people).
Nursing Adaptations and Actions
Assess hearing with the voice test or the watch test. If a deficit is present, refer the
patient to a specialist to determine hearing loss and appropriate intervention.
Do not assume that all older adults have a hearing loss!
Auditory: Age Related Changes High Frequency Sounds - ANSWER-Ear or hearing
change
The ability to hear high-frequency sounds is lost first. Older adults may have particular
problems hearing the f, s, sh, and pasounds.
Nursing Adaptations and Actions
Provide a quiet environment when speaking (close the door to the hallway) and face the
patient.
Avoid standing or sitting in front of bright lights or windows, which may interfere with the
patient's ability to see your lips move.
If the patient wears glasses, be sure that he or she is using them to enhance speech
understanding.
Speak slowly, clearly, and in a deeper voice and emphasize beginning word sounds.
Some patients with a hearing loss that is not corrected may benefit from wearing a
stethoscope while listening to you speak.
Auditory: Age Related Changes Pinna - ANSWER-Ear or hearing change
Pinna becomes elongated because of loss of subcutaneous tissues and decreased
elasticity.
Nursing Adaptations and Actions
Reassure the patient that this is normal.
When positioning a patient on the side, do not "fold" the ear under the head.
Auditory: Age Related Changes tympanic membrane - ANSWER-Ear or hearing change
Tympanic membrane loses elasticity and may appear dull and retracted.
Nursing Adaptations and Actions
Do not use this finding as the only indication of otitis media.
Avascular Necrosis - ANSWER-Related to disrupted blood flow to the bone
Caused by the hardware used to repair the fracture
Common in hip fractures
Common in patients treated with long term prednisone therapy
