Exam 3: NR324 / NR 324 Complete Review (New 2026–2027) | Adult Health I Comprehensive Questions & Answers | 100% Accurate Solutions – Chamberlain

Exam 3: NR324 / NR 324 Complete Review (New 2026–2027) | Adult Health I Comprehensive Questions & Answers | 100% Accurate Solutions – Chamberlain Q. A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1. Restrict fluids. 2. Assess for airway patency. 3. Administer oxygen as prescribed. 4. Place a cooling blanket on the client. 5. Elevate extremities if no fractures are present. 6. Prepare to give oral pain medication as prescribed. ANSWER 2. Assess for airway patency. 3. Administer oxygen as prescribed. 5. Elevate extremities if no fractures are present. Q. A client with no history of respiratory disease is admitted to the hospital with respiratory failure. Which results on the arterial blood gas report should the nurse expect to note, that are consistent with this disorder? 1. Pao2 58 mm Hg, Paco2 32 mm Hg 2. Pao2 60 mm Hg, Paco2 45 mm Hg 3. Pao2 49 mm Hg, Paco2 52 mm Hg 4. Pao2 73 mm Hg, Paco2 62 mm Hg ANSWER 3. Pao2 49 mm Hg, Paco2 52 mm Hg Q. A client is admitted to an emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal and vital signs are noted on the client's chart. The nurse should alert the health care provider because these changes are most consistent with which complication? 1. Cardiogenic shock 2. Cardiac tamponade 3. Pulmonary embolism 4. Dissecting thoracic aortic aneurysm ANSWER 1. Cardiogenic shock Q. A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed? 1. Defibrillate the client. 2. Administer digoxin (Lanoxin). 3. Continue to monitor the client. 4. Prepare for transcutaneous pacing. ANSWER 4. Prepare for transcutaneous pacing. Q. The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the health care provider and prepares to implement which priority interventions? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low Fowler's side-lying position ANSWER 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously Q. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? 1. Stridor 2. Crackles 3. Scattered rhonchi 4. Diminished breath sounds ANSWER 2. Crackles Q. A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? 1. Bradycardia 2. Ventricular dysrhythmias 3. Rising diastolic blood pressure 4. Falling central venous pressure ANSWER 2. Ventricular dysrhythmias Q. Which readings obtained from a client's pulmonary artery catheter suggest that the client is in left-sided heart failure? 1. Cardiac output of 5 L/min 2. Right atrial pressure of 9 mm Hg 3. Pulmonary capillary wedge pressure (PCWP) 20 mm Hg 4. Pulmonary artery systolic/diastolic pressures of 24/10 mm Hg ANSWER 3. Pulmonary capillary wedge pressure (PCWP) 20 mm Hg Q. The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats/minute. The nurse determines that the client is experiencing which dysrhythmia? 1. Sinus tachycardia 2. Ventricular fibrillation 3. Ventricular tachycardia 4. Premature ventricular contractions ANSWER 3. Ventricular tachycardia Q. A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? 1. It can develop into ventricular fibrillation at any time. 2. It is almost impossible to convert to a normal rhythm. 3. It is uncomfortable for the client, giving a sense of impending doom. 4. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia. ANSWER 1. It can develop into ventricular fibrillation at any time. Q. A client has developed atrial fibrillation, with a ventricular rate of 150 beats/minute. The nurse should assess the client for which associated signs/symptoms? 1. Flat neck veins 2. Nausea and vomiting 3. Hypotension and dizziness 4. Hypertension and headache ANSWER 3. Hypotension and dizziness Q. The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client's heart rhythm? 1. Atrial fibrillation 2. Sinus tachycardia 3. Ventricular fibrillation 4. Ventricular tachycardia ANSWER 1. Atrial fibrillation Q. The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous infusion at a rate of 150 mL/hour, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL most recent). The client's blood urea nitrogen level is 35 mg/dL and the serum creatinine level is 1.8 mg/dL, measured this morning. Which nursing action is the priority? 1. Check the urine specific gravity. 2. Call the health care provider (HCP). 3. Check to see if the client had a sample for a serum albumin level drawn. 4. Put the intravenous (IV) line on a pump so that the infusion rate is sure to stay stable. ANSWER 2. Call the health care provider (HCP). Q. The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse correctly interpret this rhythm? 1. Asystole 2. Atrial fibrillation 3. Ventricular fibrillation 4. Ventricular tachycardia ANSWER 3. Ventricular fibrillation Q. When developing a mechanically ventilated client's plan of care for prevention of ventilator-associated pneumonia (VAP), the nurse should include which measures in the plan? Select all that apply. 1. Suction the oral cavity whenever needed. 2. Apply topical antibiotics to the oral cavity. 3. Change the ventilator circuit tubing every 2 hours. 4. Maintain the client in a supine position at all times. 5. Practice frequent oral hygiene, including teeth brushing. 6. Practice meticulous hand hygiene, and wear gloves when suctioning or handling the endotracheal tube. ANSWER 1. Suction the oral cavity whenever needed. 5. Practice frequent oral hygiene, including teeth brushing. 6. Practice meticulous hand hygiene, and wear gloves when suctioning or handling the endotracheal tube. Q. The nurse should report which assessment finding to the health care provider (HCP) before initiating thrombolytic therapy in a client with pulmonary embolism? 1. Adventitious breath sounds 2. Temperature of 99.4° F orally 3. Blood pressure of 198/110 mm Hg 4. Respiratory rate of 28 breaths/minute ANSWER 3. Blood pressure of 198/110 mm Hg Q. Which should the nurse do when setting up an arterial line? 1. Tighten all tubing connections. 2. Use macrodrop intravenous tubing. 3. Level the transducer to the ventricle. 4. Raise the height of the normal saline infusion to prevent backup. ANSWER 1. Tighten all tubing connections. Q. During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action? 1. Call the health care provider (HCP). 2. Reassure the client that this is normal. 3. Turn the client onto his or her operative side. 4. Administer the prescribed pain medication and antiemetic. ANSWER 1. Call the health care provider (HCP). Q. The nurse recognizes that which arterial blood gas value indicates impending hypoxemic respiratory failure? 1. Pao2 65 mm Hg 2. Paco2 70 mm Hg 3. Pao2 55 mm Hg 4. Paco2 60 mm Hg ANSWER 3. Pao2 55 mm Hg Q. The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention should be initiated immediately? 1. Apply ice to the affected eye. 2. Irrigate the eye with cool water. 3. Notify the health care provider (HCP). 4. Accompany the client to the emergency department. ANSWER 1. Apply ice to the affected eye. Q. A client develops an anaphylactic reaction after receiving morphine sulfate. The nurse should plan to institute which actions? Select all that apply. 1. Administer oxygen. 2. Quickly assess the client's respiratory status. 3. Document the event, interventions, and client's response. 4. Leave the client briefly to contact a health care provider. 5. Keep the client supine regardless of the blood pressure readings. 6. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus. ANSWER 1. Administer oxygen. 2. Quickly assess the client's respiratory status. 3. Document the event, interventions, and client's response. Q. The nurse in the emergency department is caring for a client who was in a motor vehicle crash and is experiencing hypovolemic shock. A pneumatic antishock garment (PASG), also known as shock trousers, is applied for treatment until the client can be transferred to the intensive care unit (ICU). While awaiting client transfer to the ICU, the emergency department nurse should perform which critical assessment? 1. Assessing radial pulses 2. Monitoring hemoglobin and hematocrit levels 3. Assessing vascular status of the upper extremities 4. Monitoring vascular status of the lower extremities ANSWER 4. Monitoring vascular status of the lower extremities A left atrial catheter is inserted into a client during cardiac surgery. The nurse is monitoring the left atrial pressure (LAP) and documents the following pressure. Which readings are within normal limits (WNL) for the client? Select all that apply. 1. 6 mm Hg 2. 8 mm Hg 3. 15 mm Hg 4. 25 mm Hg 5. 32 mm Hg 1. 6 mm Hg 2. 8 mm Hg A client who sustained an inhalation injury arrives in the emergency department. On initial assessment, the nurse notes that the client is very confused and combative. The nurse determines that the client is most likely experiencing which condition? 1. Pain 2. Fear 3. Hypoxia 4. Anxiety 3. Hypoxia A client is brought to the emergency department immediately after a smoke inhalation injury. The nurse initially prepares the client for which treatment? 1. Pain medication 2. Endotracheal intubation 3. Oxygen via nasal cannula 4. 100% humidified oxygen by face mask 4. 100% humidified oxygen by face mask The nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. The nurse suspects that the client received this therapy for which condition? 1. Heart failure 2. Pulmonary edema 3. Cardiogenic shock 4. Aortic insufficiency 3. Cardiogenic shock The emergency department nurse is monitoring a client who received treatment for a severe asthma attack. The nurse determines that the client's respiratory status had worsened if which is noted on assessment? 1. Diminished breath sounds 2. Wheezing during inhalation 3. Wheezing during exhalation 4. Wheezing throughout the lung fields 1. Diminished breath sounds The client who has experienced a myocardial infarction (MI) is recovering from cardiogenic shock. The nurse knows that which observation of the client's clinical condition is most favorable? 1. Urine output of 40 mL/hr 2. Heart rate of 110 beats/min 3. Frequent premature ventricular contractions 4. Central venous pressure (CVP) of 15 mm Hg 1. Urine output of 40 mL/hr A client in cardiogenic shock has a pulmonary artery catheter (Swan-Ganz type) placed. The nurse would interpret which cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) readings as indicating that the client is most unstable? 1. CO 5 L/min, PCWP low 2. CO 3 L/min, PCWP low 3. CO 4 L/min, PCWP high 4. CO 3 L/min, PCWP high 4. CO 3 L/min, PCWP high A client in cardiogenic shock had an intra-aortic balloon pump inserted 24 hours earlier via the left femoral approach. The nurse notes that the client's left foot is cool and mottled and the left pedal pulse is weak. Which action should the nurse take? 1. Call the health care provider immediately. 2. Re-evaluate the neurovascular status in 1 hour. 3. Increase the rate of intravenous nitroglycerin that is infusing. 4. Document these findings, which are expected because of the catheter size. 1. Call the health care provider immediately. A client who is experiencing an anaphylactic reaction from eating shellfish is brought to the emergency department. Which immediate action should the nurse implement? 1. Maintain a patent airway. 2. Administer a corticosteroid. 3. Administer epinephrine (Adrenalin). 4. Instruct the client on the importance of obtaining a Medic-Alert bracelet. 1. Maintain a patent airway A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The client's central venous pressure (CVP) is rising, and the arterial blood pressure is falling. Which condition should the nurse interpret that the client is experiencing? 1. Fat embolism 2. Mediastinal shift 3. Mediastinal flutter 4. Hypovolemic shock 3. Mediastinal flutter Barium enema examination of large intestine; Before: give laxatives and enemas until clear of stool evening before -clear liquid diet evening before -NPO 8hr before After: give fluids, laxatives or suppositories to assist in expelling barium -observe stool for passage of contrast medium -educate pt stool may be white for up to 72 hr With a barium enema what do you want to explain to the patient in regards of what they might feel They might feel cramping and the urge to defecate may occur -pt will be placed in various positions What is Enteral nutrition (EN) Indications Tube feeding -nutritionally balanced liquefied food or formula into the stomach, duodenum, or jejunum Indications: -anorexia -orofacial fractures -head/neck cancer -neurologic -psychiatric conditions -extensive burns -critical illness -chemotherapy -radiation therapy Contraindications to enteral nutrition -intentional obstruction -ileus -peritonitis -bowel ischemia -intractable vomiting and diarrhea Enteral nutrition formulas and delivery options -variety of formulas for patients with diabetes, liver, kidney, and lung disease -concentrations from 1 to 2 cal/mL -osmolarity, amount of protein, sodium, and fat vary Delivery options: -continuous infusion by pump -cyclic feeding by pump -intermittent by gravity -intermittent bolus by syringe Esophagastroduodenoscopy (EGD) Visualize esophagus, stomach, duodenum -detects inflammation, ulcerations, tumors, varices, or mallory-weiss tears Before: -NPO for 8 hrs -explain that local anesthesia may be sprayed on throat -verify signed consent After: -keep NPO after procedure until gag reflex returns -gently tickle back of throat to test gag reflex -use warm saline gargles for relief of sore throat -check temp q15-30min for 1-2 hr Colonoscopy Examination of colon, biopsies and polyps removed; bowel prep before and observe for perforation Before: low residue or full liquid diet the day before until bowel cleansing begins -pt drinks 2L dose of oral polyethylene glycol the night before -second 2L 4-6 hr before procedure -explain pt will be side-lying position and sedation given After: observe for complications -monitor vital signs Complications of a colonoscopy -Abdominal cramps -Rectal bleeding -Perforation (malaise, abdominal distention, tenesmus) Nasogastric tube Nutrition, medication and decompression; proper technique during use, verify placement -bc of small diameter they are more easily clogged when feedings are thick and are more difficult to use for checking residual volumes They are particularly prone to obstruction when oral drugs have not been thoroughly crushed and dissolved in water before administration -Can be dislodged by vomiting or coughing -Can be knotted/kinked in GI tract NG tube management Check Aspiration risk before inserting Obtain x-ray to confirm tube placement If intermittent delivery is used HOB should remain elevated 30-60 min after feedings Check gastric residual volumes before each feeding and every 4 hours during the first 48 hrs Mark exit site at time of initial x-ray and check tuber external length at regular intervals Observe for negative pressure when attempting to withdraw fluid from feeding Provide skin care around tube and assess daily (rinse with sterile water ) What are the main complications of tube feedings? Vomiting Dehydration Diarrhea Constipation -Elevate HOB a minimum of 30 degrees but preferably 46 degrees to decrease complications and risk for aspiration Nursing management of tube feedings 1. Check tube placement before feeding and each drug administration. 2. Assess for bowel sounds before feeding. 3. Use liquid medications rather than pills. • Dilute viscous liquid medications. • Do not add medications to enteral feeding formula. 4. If using tablets, crush drugs to a fine powder and dissolve in water to avoid clogging 5. Follow measures to decrease aspiration risk: • Keep HOB elevated to 30- to 45-degree angle. • Check for residual volumes per facility policy. 6. Assess regularly for complications (e.g., aspiration, diarrhea, abdominal distention, hyperglycemia, constipation, and fecal impaction). NG tube insertion Use a guide wire to help with correct placement **never put guidewire back in Goes in through the nares through the esophagus and into the stomach and may go into the duodenum -Have patient swallow when passing through the throat For a patient with an NG tub, what task can be delegated? LPN: • Insert NG tube for stable patient. • Irrigate NG and gastrostomy tubes. • Give bolus or continuous enteral feeding for stable patient. • Remove NG tube. • Give medications through NG or gastrostomy tube to stable patient. • Provide skin care around gastrostomy or jejunostomy tubes. UAP: • Provide oral care • Weigh pt .• Position and maintain patient with the head of bed elevated. • Notify RN or LPN about patient symptoms (e.g., nausea, diarrhea) that may indicate problems with enteral feedings. • Alert RN or LPN about enteral feeding infusion pump alarms. • Empty drainage devices and measure output. Gastrostomy tube nutrition, medication; proper technique for use, verify placement, monitor for infection, HOB elevated Ileostomy semiliquid, fluid needs increased -should be observed for signs and symptoms of fluid and electrolyte imbalance, particularly potassium, sodium, and fluid deficits. Colonostomy Ascending- semiliquid stool, fluid needs increased Transverse- semiliquid to semiformed stool, possibly increased fluid needs Sigmoid- formed stool, no change in fluid needs, can regulate bowel patterns Diarrhea Assessment- loose stools, abdominal cramps, pain, fever Complications: dehydration, electrolyte imbalance, intestinal perforation Management: self limiting, replace fluids and electrolytes, diet, protect skin, isolation, stool culture, anti-diarrheals, antibiotics Constipation Assessment- stools are absent or hard, dry, and difficult to pass, abdominal distention, bloating, increased flatulance and increased rectal pressure Complications- hemorrhoids, perforation, rectal mucosal ulcers and fissures Diagnostics: abdominal x-rays, barium enema, colonoscopy, sigmoidoscopy Management: increasing dietary fiber, fluid intake (2L/ days), exercise, laxatives, enemas, do not delay defecation gastroesophageal reflux disease (GERD) Assessment- heartburn, dyspepsia, regurgitation, coughing Complications- esophagitis, asthma, Barrets esophagus, pneumonia Tests: endoscopy, biopsies, barium swallow, motility studies -Management- smoking cessation, nutrition (no alcohol/caffeine/acidic foods), weight loss, HOB elevated, medications, surgery, endoscopic therapy GERD acronym G- generally known as heartburn E- epigastric pain and spasm usually follow a meal R- radiating pain to arms arms and chest is common D- diet therapy Hiatal hernia Two types: sliding and rolling (can be emergency) Assessment: asymptomatic or resemble GERD Complications: strangulation, GERD, esophagitis, hemorrhage, ulcerations Tests: esophagram (barium swallow) Management: similar to GERD, surgery Peptic ulcer disease condition characterized by erosion of the GI mucosa from the digestive action of hydrochloric acid and pepsin -pH increases to 3.5 or more when foods or antacids neutralize stomach acid or drugs block acid secretion -H. pylori is main organism of PUD - Any portion of the GI tract that comes into contact with gastric secretions is susceptible to ulcer development Gastric or duodenal (differ in their incidence and presentation Lifestyle factors: alcohol and coffee stimulate acid secretion and smoking and psychologic distress What does Helicobacter pylori cause? Ulcers bc of its production of enzyme urease -•Urease activates immune response •Antibody production •Release of inflammatory cytokines •Response to H. pylori is variable What effect does Aspirin and NSAIDs have on peptic ulcers? •Inhibit prostaglandin synthesis •Increase gastric acid secretion •Reduce integrity of the mucosal barrier •Responsible for majority of non-H. pylori peptic ulcers •NSAIDs in presence of H. pylori increase risk of PUD What is released from damaged mucosa with peptic ulcers? Histamine is released from the damaged mucosa, resulting in vasodilation and increased capillary permeability and further secretion of acid and pepsin Acute vs. Chronic peptic ulcers Acute: is associated with superficial erosion and minimal inflammation -short duration and resolves quickly when cause is identified and removed Chronic: one of long duration, eroding through the muscular wall with the formation of fibrous tissue -present continuously for many months or intermittently throughout lifetime --More common Gastric ulcer Nutrition-client education: Nursing care: Patient teaching: Nutrition-client education: dietary modifications, including avoiding foods that may cause epigastric distress such as acidic foods Nursing care: NPO for few days with NG tube insertion and intermittent suction, and IV fluid -regular mouth care bc of analysis of gastric contents (pH testing and analysis for blood or bile) -Stomach empty of gastric secretions - pain diminishes - ulcer healing -Monitor I&O and take VS hourly to detect and treat shock -physical and emotional rest help healing -mild sedative or tranquilizer has beneficial effects when the patient is anxious and apprehensive Patient teaching: Take NSAIDs with food , avoid cigarettes, and reduce or eliminate alcohol intake -limit stress, avoid OTC drugs, take all meds prescribed Gastric ulcer risk factors, s/s, diagnostics and assessment ulcer located in any portion of the stomach -less common that duodenal ulcers Risk factors: --alcohol, nicotine, stress, drugs such as aspirin, corticosteroids and NSAIDs, Female, 50 yrs of age, bile reflux, H. pylori S/S: food aggravates rather than alleviates pain, discomfort high in epigastrium 1-2 hrs after meals -burning or gaseous feeling -can be the cause of upper GI bleeding Diagnostics endoscopy, biopsy of antral mucosa with testing for urease -serology, stool, and breath testing -barium contrast, serum gastrin levels will be elevated -CBC, liver enzyme studies, serum amylase, and stool examination Assessment: High epigastric pain occurring 1-2 hr after meals. Pain may be precipitated or aggravated by food Which type of peptic ulcer is most commonly found in the antrum? Gastric ulcer Which type of peptic ulcer is more likely to result in obstruction? Gastric ulcers are more likely Stress ulcers risk, S/S, diagnositcs and assessment a continuum of conditions ranging from stress-related injury (superficial mucosal damage) to stress ulcers (focal deep mucosal damage) At risk: critically ill pts who have severe burns, trauma or surgery S/S: bleeding Diagnostics: endoscopy Assessment: dark, digested blood on surface of the stomach, can be present in a ventilated client in ICU Nutrition-client education: --------- Nursing care: proton pump inhibitor prophylaxis, Histamine 2-receptor antagonists Patient teaching: notify health care provider or any GI bleeding (coffee ground emesis), complete prescribed medications What are the three major complications of chronic PUD? Hemorrhage (most common), perforation, and gastric outlet obstruction -considered emergency situations and may require surgical intervention What is the difference between diverticulitis and diverticulosis Diverticulitis- inflammation of one or more diverticula resulting in perforation into peritoneum outpouching with infection/inflammation -symptomatic with complications Diverticulosis- presence of multiple noninflamed diverticula outpouching without inflammation -asymptomatic and uncomplicated Etiology of duodenal ulcers associated with high HCL acid secretion Duodenal ulcers 80% of all PUD S/S: burning, cramping, pressure like pain across midepigastrium and upper abdomen, back pain with posterior ulcers -midmorning, mid afternoon, middle of night, periodic and episodic, pain relief with antacids and food -food helps buffer the acid Risk factors: smoking, alcohol, men, postmenopausal women, age 35-45, can occur from other diseases (COPD, pancreatic, liver cirrhosis, hyperparathyroidism, Zollinger, Renal failure) Assessment: penetrating ulcers, lesions in first 1-2 cm of duodenum, increased gastric secretion, H.pylori -Burning, midepigastric or back pain occurring 2-5 hr after meals and relieved by food; nocturnal pain common Diagnostics: endoscopy, biopsy of antral mucosa with testing for urease -serology, stool, and breath testing -barium contrast, serum gastrin levels will be elevated -CBC, liver enzyme studies, serum amylase, and stool examination Duodenal ulcers Nutrition-client education: Nursing care: Patient teaching: Nutrition-client education: dietary modifications, including avoiding foods that may cause epigastric distress such as acidic foods Nursing care: NPO for few days with NG tube insertion and intermittent suction, and IV fluid -regular mouth care bc of analysis of gastric contents (pH testing and analysis for blood or bile) -Stomach empty of gastric secretions - pain diminishes - ulcer healing -Monitor I&O and take VS hourly to detect and treat shock -physical and emotional rest help healing -mild sedative or tranquilizer has beneficial effects when the patient is anxious and apprehensive Patient teaching: Take NSAIDs with food , avoid cigarettes, and reduce or eliminate alcohol intake -limit stress, avoid OTC drugs, take all meds prescribed What are the most common types of ulcers? Diverticulitis inflammation of a diverticulum -outpouching with infection/inflammation Develops from a more serious case of diverticulosis Manifestations: acute pain in left lower quadrant, palpable abdominal mass, N/V, and symptoms of infection Management and treatment: Acute care: antibiotic therapy, NPO, IV fluids, NG suction, surgery, possible resection of involved colon, possible temp. colostomy (let colon rest) Tests- colonoscopy, CT,with oral contrast, abdominal and chest x-ray Teaching: importance of high fiber diet and encourage fluid intake of 2L/day -avoid straining, vomiting, bending, heavy lifting, and wearing tight restrictive clothing Why might a patient with diverticulitis need to be hospitalized? Hospitalization is necessary if symptoms are severe, the patient is unable to tolerate oral fluids, there are systemic manifestations of infection (fever, significant leukocytosis), or the patient has co-morbid conditions (e.g., immunosuppression). -kept on NPO status w/ IV fluids and antibiotics ****Observe for signs of abscess, bleeding, and peritonitis, and monitor the WBC count How do we help prevent diverticulosis from turning into diverticulitits Most people never develop diverticulitis Pt should eat a high fiber diet, exercise regularly and avoid intra abdominal pressure -Eat plenty of fruits and vegetables and limit intake of fat and red meat Diverticulosis -main factor thought to contribute to the development diverticulitis -decreases stool size and firmness allowing pressure on weak point Risk factors: low fiber diet, obesity, inactivity, smoking, excessive alcohol use, and immunosuppression Assessment- asymptomatic, abdominal pain, bloating, flatulence and bowel habit changes, blood culture, barium enema, stool testing Complications- bleeding, diverticulitis Tests- Management- avoid nuts, foods with seeds, high fiber, exercise, weight reduction, avoid intraabdominal pressure, stool softeners, clear liquid diet, anticholinergics, oral antibiotics Teaching- high levels of exercise are needed, importance of high fiber diet and encourage fluid intake of 2L/day, weight reduction helps -avoid straining, vomiting, bending, heavy lifting, and wearing tight restrictive clothing What type of diet should patients with Diverticulosis and Diverticulitis be placed on? Clear liquid diet High fiber diet --avoid nuts and foods with seeds --decrease intake of fat and red meat Intake fiber mainly from fruits and vegetable Celiac disease Autoimmune disease that damages the small intestine mucosa Assessment- foul smelling diarrhea, steatorrhea, abdominal distention, malnutrition, osteoporosis, iron and folate deficiencies, reproductive problems, rash Tests- biopsy, serologic testing Management- gluten-free diet -increase risk of non-Hodgkins lymphoma and GI cancers if left untreated Nursing interventions and client teaching for celiac disease Interventions: Using phone apps to help with gluten free foods Teaching: gluten free diet is needed, teach food and medications labels -avoid wheat, barley, oats, and rye products What foods should celiac patients avoid? • Baked goods, including muffins, cookies, cakes, pies • Barley • Bread, including wheat bread, white bread, "potato" bread • Flour • Gluten stabilizers • Oats • Pasta, pizza, bagels • Rye • Wheat Colorectal cancer Affects both men and women -2nd leading cause of cancer-relate deaths -3rd most common form of cancer -More common in men - Highest mortality rates among African American men and women -Risk of disease increases with age Colorectal cancer S/S Insidious onset Change in bowel habits Unexplained weight loss Vague abdominal pain Weakness and fatigue Rectal bleeding Change in stool caliber Alternating constipation and diarrhea Obstruction Sensation of incomplete evacuation When should people being getting a colonoscopy? Ages 50-75 -earlier if family hx Flexible sigmoidoscopy every 5 years Colonoscopy every 10 years Double-contrast barium enema every 5 years CT colonography every 5 years BMI body mass index- a measure of body fat and is used to categorize if a person is underweight, normal, overweight, or obese. People with increased BMI have increased health risk factors 18.5 is underweight 18.5-24.9 is normal 25-29.9 is overweight 30 or higher is obese Waist Circumference (WC) People with visceral fat and truncal obesity are at an increased risk for cardiovascular disease and metabolic syndrome Obesity: Men 40in Women 35in Obesity High risk for hypertension, obesity, CO, morbidities Primary obesity: excess caloric intake for bodys metabolic demands, kidney issues, skin issues and cancers Secondary obesity: chromosomal and congenital anomalies, metabolic problems, CNS lesions and disorders, drugs (corticosteroids, antipsychotics Gynoid body shape- pear shape Android body shape- apples Obesity etiology, assessment, nursing interventions, client teaching Contributing factors: greater access to food with poor nutritional quality -lack of exercise -low socioeconomic status -mindless eating -eating is social and often associated with pleasure and fun Assessment: V/S, height and weight, skin fold measurements, waist to hip ratio, skin inspection (under breast and abdomen), BMI -height, weight, waist circumference, BMI Client education: drugs will not cure obesity, teach proper administration of drugs, effective diets and importance of exercise Nursing implementation: motivation is key, help obese patients explore and deal with their neg. experiences, diet, exercise, and behavior modification, monitor weight, VS, glucose, lipids Health risk associated with obesity Heart disease, cancer, type 2 diabetes, arthritis, pregnancy complications, shortened life expectancy, musculoskeletal, cancer, respiratory problems, endocrine complications, depression Waist to hip ratio WHR Method of describing distribution of subcutaneous and visceral Bariatric surgery surgical reduction of gastric capacity to treat morbid obesity -Criteria for surgery BMI equal or more than 40 kg/m2, OR BMI equal or greater than 35 kg/m2 with other significant comorbilities (hypertension, type 2 diabetes, heart failure, sleep apnea) Surgical therapy for obesity Adjustable Gastric Banding (AGB) (Lap-Band, kealize Band) Sleeve Gastrectomy (Gastric Sleeve) Gastric Plication Intragastric Balloon Biliopancreatic Diversion (BPD) With or Without Duodenal SwitchRoux-en-Y Gastric Bypass (RYGB) Maestro Rechargeable System Post op care for patients with obesity Careful assessment and immediate intervention for cardiopulmonary complications, thrombus formation, anastomosis leaks, and electrolyte imbalances -make sure airway is open during transfer -maintain HOB at 35-40 degrees -As adipose cells release anesthetics back into blood, sedation may occur so know to do a head-tilt or jaw-thrust maneuver and keep the patient's oral and nasal airways open -Turning and ambulation to help prevent complications -Monitor vitals and especially breathing and O2 stats -Monitor for DVT -Wound infection, dehiscence, and delayed healing are potential problems Special post op care for an obese patient who had Bariatric surgery -They have considerable pain, administer meds PRN during first 24 hrs ----be aware pain could be from an anastomosis leak rather than typical surgical pain. -Observe abdominal wounds for drainage and type and about -Monitor for signs of infection -Water and sugar free liquids are given 30mL every 2 hrs -before discharge instruct a high protein liquid diet and to eat slowly and stop when feeling full and not to consume all the liquids with solid food -Vomiting is common -Refer a dietitian Wounds Any break or opening in the skin -can be caused by surgical or nonsurgical -acute or chronic -superficial, partial thickness, full thickness Partial thickness wound The dermis and epidermis of the skin are broken Superficial wound a wound that involves only the epidermis Full thickness wound the dermis, epidermis, and subcutaneous tissue are penetrated; muscle and bone may be involved Skin tear Wound caused by shear, friction, and/or blunt force -Results in separation of skin layers -Common in older adults, and critically or chronically ill adults Types of wound healing Primary intention- incision w/ blood clot, edges approximated with suture, fine scar Secondary intention- Irregular, large wound w/ blood clot, granulation tissue fills in wound, large scar Tertiary intention- Contaminated wound, granulation tissue, delayed closure, deep scars Complications of wounds healing and Nursing management Complications: Dehiscence Hypertrophic scarring Keloid scarring Nursing management: Clean the wound --dressing that keeps wound surface clean and slightly moist is optimal for healing --transparent film may be used --dryness is an enemy of wound healing --topical antimicrobials and antibacterials used with caution For contaminated wounds --debridement may be necessary --absorption or hydrocolloid dressing may be used Infection control --culture should be done --concurrent swab specimens obtained using Levine's technique Dehiscence Wound opens back up Nursing management for wound healing -Assess on admission & regular basis -Identify factors that may delay healing -Wound management & type of dressing depends on (type, extent, and character of wound, and phase of healing) -Clean wound ( dressing keeps wound surface clean & slightly moist, Transparent film may be used, Dryness is an enemy, Topical antimicrobials and antibacterials used with caution -Infection control (culture, Levine's technique) -Debridement may be necessary (absorption or hydrocolloid dressing) Wound measurement Made in centimeters -first measurement oriented from head to toe and the second from side to side, and the third is the depth -if there is tunneling (movement when cottontipped applicator is placed in wound) or undermining (when cottontipped applicator is placed in wound there is a "lip" around wound Jackson-Pratt drain drainage system that uses a compressed bulb, applies slight suction within the wound -maintain suction pull out excess fluid Negative pressure wound therapy (NPWT) - suction removes drainage and speeds healing - monitor serum protein levels, fluid and electrolyte balance, and coagulation studies Hyperbaric O2 therapy (HBOT) Delivery of O2 at increased atmospheric pressure -allows O2 to diffuse into serum -last 90-120 minutes, with 10-60 treatment For optimal wound healing, what type of diet should the pt have? Diet high in protein, carbohydrates, and vitamins with moderate fat Pressure ulcer Localized injury to skin and or underlying tissue -results from pressure or pressure in combination with shear -Most common sites are the sacrum and heels Influencing factors- -amount of pressure (intensity) -length of time pressure is exerted -ability of tissue to tolerate externally applied pressure Contributing factors- Shearing force: pressure exerted on skin when it adheres to bed and skin layers slide in direction of body movement --Moisture: excessive increases risk for skin breakdown What are the risk factors for a pressure ulcer? Advanced age Anemia Contractures Diabetes mellitus Elevated body temperature Friction Obesity Pain Immobility Impaired circulation Incontinence Low diastolic BP Mental deterioration Neurologic disorders Prolonged surgery Vascular disease Suspected deep tissue injury Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Pressure ulcer stages Stage 1: intact skin non-blanchable redness usually over bony prominence Stage 2: partial thickness loss of dermis, shallow open ulcer with red pink wound bed, present as an intact or ruptured serum-filled blister Stage 3: full thickness loss, w/o undermining, see fat, subcutaneous tissue may be visible but bone, tendon, or muscle are nor Stage 4: 3+ undermining, full-thickness loss can extend to muscle, bone, or supporting structures see tendon, muscle --undermining and tunneling may also occur Unstageable ulcer Full-thickness tissue loss in which actual depth of ulcer is completely obscured by slough or eschar Slough or eschar must be removed to expose the base of the wound for true depth to be determined Clinical manifestations of infection and complications of pressure ulcer Signs-leukocytosis, fever, Increased ulcer size, odor, draignage, necrotic tissue, indurated Complications: most common- recurrence, cellulitis, chronic infection, osteomyelitis, possible death Assessment of pressure ulcers on patients with dark skin Look for areas of skin darker than surrounding Use natural or halogen light Assess skin temperature using your hand --an ulceration may feel warm initially, then become cooler Touch the skin to feel its consistency --boggy or edematous tissue may indicate a stage 1 pressure ulcer Ask about pain or an itchy sensation Patient teaching, treatment and preventive care for pressure ulcers Preventive care: assess pressure ulcer risk on admission and at intervals -thorough head to toe on admission (braden scale) -remove excess moisture -avoid massage over bony prominences -use lift sheets -frequent repositioning and mobilizing -position with pillows or elbow and heel protectors -use specialty beds -cleanse skin if incontinence occurs -use pads or briefs that are absorbent Treatment: relieve pressure, debride -cleanse with nontoxic solution -keep ulcer bed moist, assess for S/S of infections -surgery, maintain adequate nutrition -patient and caregiver teaching Patient teaching: teach techniques to care for incontinence, teach correct bed position and importance of repositioning every 2 hours -teach the no touch technique when changing dressings -inspect skin daily and report any significant findings -importance of good nutrition to enhance ulcer healing Sarcoma a malignant tumor in the bone, muscle, fat, or cartilage. -most common is osteochondroma Osteochondroma primary benign bone tumor characterized by overgrowth of cartilage and bone at the growth plate Manifestations: painless, hard, immobile mass; one leg or arm longer than other; and pressure or irritation with exercise Treatment: none if no symptoms -if pt has pain or neurologic symptoms due to compression, surgical resection is usually done Osteosarcoma painless, hard, immobile mass; one leg or arm longer than other; and pressure or irritation with exercise Location: pelvis and the metaphyseal region of the long bones of the extremities, particularly in the distal femur, proximal tibia, and proximal humerus S/S: pain and swelling especially around knee Treatment: preoperative chemo used to decrease tumor pelvis and the metaphyseal region of the long bones of the extremities, particularly in the distal femur, proximal tibia, and proximal humerus Osteoarthritis Slow, progressive noninflammatory disorder of the synovial joints Risk factors: age, obesity, decreased estrogen levels Assessment: joint pain, stiffness, crepitation, asymmetrical Test: bone scan, CT scan, MRI, x-ray, synovial fluid analysis Management: pain assessment, analgesics, NSAIDs, corticosteroid injections, applications of heat and cold, assistive devices, nutrition, exercise, joint rest, arthroscopic surgery Osteoarthritis nursing interventions and client teaching Nursing intervention: -manage pain and inflammation, preventing disability, an maintaining and improving joint function - medication, joint rest, heat and cold, nutrition, and exercise Client Teaching: -the nature and treatment of OA, pain management, posture and body mechanics, use of assistive devices, principles of joint protection, energy conservation OA teaching regarding daily care/activity and home safety recommendations • Maintain healthy weight . • Use assistive devices, if indicated. • Avoid forceful repetitive movements. • Avoid awkward positions that stress joints. • Use good posture and body mechanics. • Seek help with needed tasks that may cause pain. • Organize routine tasks and pace yourself to decrease fatigue and joint pain. • Modify home and work environment to perform tasks in less stressful ways. -encourage warm bath to decrease joint stiffness What modifications should a patient with OA make to their home? -Removing scatter rugs, providing rails at the stairs and bathtub, using night-lights, and wearing well-fitting supportive shoes. -Canes, walkers, elevated toilet seats, and grab bars What type of exercise activities might be recommended for a patient with osteoarthritis? Meditation and yoga Tai Chi Heat therapy Do not use on areas being treated with radiation, is bleeding, has decreased sensation -Use 24-48 hrs after injury -Cover heat source with towel or cloth before applying to skin Heat- up to 20 min Cold therapy Cover with cloth or towel before applying to the skin -Do not apply to areas being treated with radiation, have open wounds, or have poor circulation -if too painful to apply to site, try to apply right above or below area Cold- up to 10-15 minutres Purpose of traction Pulling force to attain realignment countertraction Purpose: -prevent or decrease pain and muscle spasm -immobilize joint or part of body -reduce fracture or dislocation -treat a pathologic joint condition Two most common types -skin traction and skeletal traction Skin traction -Short-term (48-72 hours) -Tape, boots, or splints applied directly to skin -Traction weights 5 to 10 pounds -Skin assessment and prevention of breakdown --Tape, boots, or splints are applied directly to the skin to maintain alignment, primarily to help diminish muscle spasms in the injured extremity. --traction weights are usually limited to 5 to 10 lbs -Assess key pressure points every 2-4 hrs Buck's traction Type of skin traction used preoperatively for the patient with a hip fracture to reduce muscle spasms -used to immobilize a fracture, prevent hip flexion contractures, and reduce muscle spasms Skeletal traction Maintain alignment by providing pull -pin or wire in the bone -weights 5-45 lbs -risk of infection at pin site -complications of immobility -Use of too much weight can result in delayed union or nonunion. -Keep weights off the floor -maintain continuous traction -Balanced suspension traction Care of patient in TRACTION T - temperature (extremity, infection) R - ropes hang freely A - alignment C - circulation check (5 ps) T - type and location of fracture I - increase fluid intake O - overhead trapeze N - no weights on bed or floor •Inspect exposed skin •Monitor pin sites for infection •Pin site care per policy •Proper positioning •Exercise as permitted •Psychosocial needs Cast for fracture immobilization Temporary -allows patient to perform many normal activities of daily living -made of various materials -typically incorporates joints above and below fracture Materials: •natural (plaster of Paris), synthetic acrylic, fiberglass-free, latex-free polymer, or a hybrid of materials. •Synthetic casting materials •Lightweight, stronger, waterproof •Early weight bearing •Activated by submersion in cool or tepid water, then molded Applying a cast •Cover affected part with stockinette and padding •Immerse plaster of paris material in warm water, wrap and mold it •Sets in 15 minutes •24-72 hours before weight bearing •Do not cover - risk for burn •No direct pressure; petal edges Cast care includes •Do •Frequent neurovascular assessments •Apply ice for first 24 hours •Elevate above heart for first 48 hours •Exercise joints above and below •Use hair dryer on cool setting for itching •Check with health care provider before getting wet •Dry thoroughly after getting wet •Report increasing pain despite elevation, ice, and analgesia •Report swelling associated with pain and discoloration OR movement •Report burning or tingling under cast •Report sores or foul odor under cast Do Not •Elevate if compartment syndrome •Get plaster cast wet •Remove padding •Insert objects inside cast •Bear weight for 48 hours •Cover cast with plastic for prolonged period Assistive devices for ambulation Cane- can relieve up to 40% of the weight normally borne by a lower limb -held in the hand opposite of the involved extremity -advance leg simultaneously with the leg opposite of affected side Walker or crutches- may allow for complete non-weight-bearing ambulation - advance one foot with opposite crutch for 2-point gait Sling (upper extremity immobilization) To support and elevate arm Ensure axillary area is padded Encouraged movement of fingers and non immobilized joints Body jacket brace - vertebral immobilization Immobilize and support for spine -monitor for superior mesenteric artery syndrome (cast syndrome) -assess bowel sound -treat with gastric decompression What is a fracture? Disruption or break in continuity of bone -open fracture (compound fracture where bone goes through skin) -worried about infection and bleeding -closed fracture -complete fracture (goes all the way through) ---greenstick fracture -worried about internal bleeding, additional damage from unstable bone Complete- break through the bone Incomplete- bone is still in one piece External fixation a metallic device composed of metal pins that are inserted into the bone and attached to external rods to stabilize the fracture while it heals -often used in an attempt to salvage extremities that otherwise might require amputation •Metal pins and rods •Applies traction •Compresses fracture fragments •Immobilizes and holds fracture fragments in place Assessment: •Assess for pin loosening and infection •Patient teaching •Pin site care External fixation nursing care and interventions Chlorhexidine 2mg/ml is often used for pin cleaning, but each physician has protocol Monitor for exudate, erythema, tenderness, and pain (may require removal) Monitor for pin loosening and infection Internal fixation pins, plates, intramedullary rods, and metal and bioabsorbable screws) are surgically inserted to realign and maintain position of bony fragments -•These metal devices are biologically inert and made from stainless steel, vitallium, or titanium. -evaluated regularly by x-rays Fractures overall goals Anatomic realignment (reduction) Immobilization Restoration of normal or near-normal function Closed reduction: -nonsurgical, manual realignment of bone fragment -traction and countertraction applied -under local or general anesthesia -immobilization afterwards Open reduction -surgical incision -internal fixation -risk for infection -early ROM of joint to prevent adhesions -facilitates early ambulation Nutritional therapy and patient teaching for fractures includes Nutrition therapy •↑ Protein (1 g/kg of body weight) •↑ Vitamins (B, C, D) •↑ Calcium, phosphorus , and magnesium •↑ Fluid ( mL/day) •↑ Fiber •Body jacket and hip spica cast patients: six small meals a day Patient teaching •Immobilization •Assistive devices •Expected activity limitations •Assure that needs will be met •Pain medication Counter traction the reduction of a fracture by traction from two opposing directions at once Clinical manifestations of a fracture Localized pain Decreased function Inability to bear weight or use Guard against movement May or may not have deformity ***immobilize if suspect a fracture Complications of fractures Majority heal without complication. If death occurs, usually a result of -Damage to underlying organs and vascular structures -Complications of fracture or immobility Infection -Direct -Indirect Open Fractures Soft Tissue injuries --can lead to chronic osteomyelitis --antibiotics, irrigation, impregnated beads, and IV What is Compartment syndrome Swelling and increased pressure within a confined space -compromises neurovascular function of tissues within that space -Usually involves the leg but can occur in any muscle group Two basic types of compartment syndrome- decreased compartment size and increased compartment contents -arterial flow compromised - ischemia - cell death - loss of function What are the two basic causes of compartment syndrome? (1) decreased compartment size resulting from restrictive dressings, splints, casts, excessive traction, or premature closure of fascia and (2) increased compartment contents related to bleeding, inflammation, edema, or IV infiltration Compartment syndrome clinical manifestations six Ps Pain Pressure Paresthesia Pallor Paralysis Pulselessness --early recognition and treatment are essential --may occur initially or delayed several days --ischemia can occur within 4-8 hrs after onset What is important to remember when caring for a patient with compartment syndrome? •NO elevation above heart •NO ice •Surgical decompression (fasciotomy) may be needed •Assess urine output and kidney function Fasciotomy for compartment syndrome left open for several days to ensure adequate soft tissue decompression -infection from delayed wound closure can be problem --amputation may be needed Venous thromboembolism Veins of the lower extremities and pelvis are highly susceptible after a fracture, especially a hip fracture -may occur after total hip or total knee replacement surgery •High susceptibility aggravated by inactivity of muscles •Prophylactic anticoagulant drugs •Antiembolism stockings •Sequential compression devices •ROM exercises (dorsiflex and plantar flex ankle) What is a hip fracture and what are the types? fracture of the proximal (upper) third of the femur, which extends 5 cm below the lesser trochanter Intracapsular- within the joint capsule (often associated with osteoporosis (1) capital (fracture of the head of the femur) (2) subcapital (fracture just below the head of the femur), (3) transcervical (fracture of the femoral neck) Extracapsular- occurs outside the joint capsule (severe trauma or a fall) (1) intertrochanteric (in a region between the greater and lesser trochanter) (2) subtrochanteric (below the lesser trochanter) With a patient who has just fractured their hip what should be used to temporarily immobilize it? Bucks tractions until patients physical condition is stabilized and surgery can be performed -Bucks can relieve painful muscle spasms, and can be used for 24-48 hrs Who is most likely to get hip fractures? Older adults with 95% caused by a fall -Many older adults with a hip fracture develop disabilities that require long-term care -1 in 5 ppl experiencing a hip fracture will die within 1 year of injury Hip fractures that are often associated with osteoporosis are called Fragility fractures Hip fractures assessment, clinical manifestations and teaching Clinical manifestations: external rotation, muscle spasms, shortening of the affected extremity, severe pain and tenderness around fracture site --displaced femoral neck may cause disruption of blood supply Teaching: Often done in the emergency department bc quick surgical intervention is standard -teach method for exercising unaffected leg and both arms -activities and positions that place pt at risk for dislocation ( more than 90 degrees of flexion, adduction across the midline [crossing of legs and ankles], internal rotation of hip) DO • Use elevated toilet seat. • Place chair inside shower or tub and remain seated . • Use pillow between legs for first 6 wk after surgery when lying on nonoperative side or when supine. • Keep hip in neutral, straight position when sitting, walking, or lying. • Notify surgeon y if severe pain, deformity, or loss of function occurs. • Discuss personal risk factors for prosthetic joint infection with surgeon and dentist before dental work. DO NOT • Flex hip greater than 90 degrees (e.g., sitting in low chairs or toilet seats). • Adduct hip (i.e., bring legs together at knees). • Internally rotate hip (i.e., turn toward planted foot on affected side). • Cross legs at knees or ankles. • Put on own shoes or stockings without adaptive device (e.g., long-handled shoehorn or stocking-helper) until 4-6 wk after surgery. • Sit on chairs without arms Sprain clinical manifestations, assessment, management and teaching injury to the ligaments surrounding a joint, usually caused by a wrenching or twisting motion Manifestations: extreme pain, swelling, tenderness Assessment: pain, edema, decreased function, and contusion Management: RICE, cold therapy, restrict movement, stop activity immediately when sprain is suspected, elevate injury above heart level Teaching: Bandages are too tight if numbness or tingling is felt, apply ice no longer than 20-30 min, elevate and use ice for 24-48 hrs, use mild analgesics Strains clinical manifestations, assessment, management and teaching excessive stretching of a muscle, its fascial sheath, or a tendon -most occur in large muscle groups including lower back, calf and hamstrings Manifestations: edema, pain aggravated by continued use of the joint, tendon, or ligament, inflammation, decreased function Assessment: mild or slightly pulled muscle, severely torn or ruptured muscle Management: RICE, cold therapy, restrict movement, stop activity immediately when strain is suspected, elevate injury above heart level Teaching: Bandages are too tight if numbness or tingling is felt, apply ice no longer than 20-30 min, elevate and use ice for 24-48 hrs, use mild analgesics Soft tissue injuries Sprain- injury to the ligaments surrounding a joint, caused by wrenching or twisting motion Strain- excessive stretching of a muscle, its fascial sheath, or a tendon Management- Health promotion, NSAIDS , RICe (rest, ice, compression, elevate) Avoid applying ice For more than 20-30 minutes at a time Osteomyelitis a severe infection of bone, bone marrow, and surrounding soft tissue. -acute (1 month) or chronic (1 month) Assessment- pain, edema, warmth, fever, chills, night sweats, malaise, constant bone pain, restricted movement at infection site Diagnostics/labs -bone or soft tissue biopsy Treatment -aggressive, prolonged IV antibiotic therapy if ischemia has not yet occured -oral antibiotics, hyperbaric oxygen therapy, surgery Nursing management -caring for acute pain -some immobilization of affected limb (splint, traction) -bed rest may be needed With osteomyelitis, infecting organisms can invade the bones and lead to what? -Increased pressure and eventual bone ischemia -once ischemia occurs the bone can die Carpal tunnel syndrome Compression of the median nerve -assessment- weakness, pain, numbness -- +Tinels sign -- +Phalens sign -management is to wear splints at night, PT, NSAIDS, surgery Manifestations- pain, discomfort, hand dysfunction, clumsiness, numbness, tingling Teaching- stop aggravating movement by resting the hand and wrist Fat embolism FES characterized by systemic fat globules from fractures that are distributed into tissues, lungs, and other organs after a traumatic skeletal injury -a contributory factor in mortality associated with fractures -most often associated include long bones, ribs, tibia, and pelvis -can occur after total joint replacement, spinal fusion, liposuction, crush injuries, and bone marrow transplantation •Mechanical theory •Fat released from marrow and enters circulation where it can obstruct •Biochemical theory •Hormonal changes caused by trauma stimulate release of fatty acids to form fat emboli Clinical manifestations of a fat embolism •Early recognition of FES is crucial •Symptoms 24 to 48 hours after injury •Fat emboli in the lungs cause a hemorrhagic interstitial pneumonitis. •Respiratory and neurologic symptoms •Petechiae - neck, chest wall, axilla, buccal membrane, conjunctiva •Clinical course of fat embolus may be rapid and acute •Patient frequently expresses a feeling of impending disaster •In a short time skin color changes from pallor to cyanosis •Patient may become comatose •Fat cells in blood, urine, or sputum •↓ PaO2 60 mm Hg •ST segment and T-wave changes •↓ Platelet count, hematocrit levels •Elevated ESR •Chest x-ray →bilateral pulmonary infiltrates Care for a patient with a fat embolism •Treatment is directed at prevention •Careful immobilization and handling of a long bone fracture probably the most important factor in prevention •Management is supportive and related to symptom management •Coughing and deep breathing •Administer O2 •Intubation/ intermittent positive pressure ventilation Gouty arthritis (gout) Acute arthritis characterized by elevation of uric acid and the deposit of uric acid crystals in one or more joints -Assessment- sudden swelling, severe pain, low-grade fever Inflammation of the great toe is most common Test- synovial fluid aspiration, serum uric acid, x-ray Risk factors- obesity, excessive alcohol intake and some medications Nutrition- adequate hydration, limited use of alcohols and foods high in purine (red and organ meats) When examining a patient with gouty arthritis what might you expect to find on the affected joints? -sodium urate crystals (tophi) -joints may appear dusky or cyanotic and are extremely tender and swollen Osteoporosis Chronic, progressive metabolic bone disease -more common in women -assessment- back pain, spontaneous fractures, loss of height, kyphosis Tests- H&P, bone mineral density Management- nutrition, Ca, Vitamin D, weight bearing exercises, no tobacco, decrease alcohol intake, medication What is the biggest difference between RA and OA? OA is slow, progressive, non inflammatory process that is not systemic RA is autoimmune and systemic Comparison of hands in osteoarthritis and rheumatoid arthritis OA: Affects one side -Heberden's nodes on DIP joints due to osteophyte formation and loss of joint space -Bouchard's nodes on PIP joints -red, swollen, and tender RA: Both hands affected -swan neck -ulnar drift -boutonniere deformities -nodules are firm, nontender, granuloma-type masses With RA many pts have severe pain at what time of ay? In the morning , when they wake up -been immobile all night rheumatoid arthritis (RA) chronic systemic disease with inflammation of connective tissue in synovial joints (smaller joints); remissions and exacerbations -genetic Assessment: fatigue, anorexia, weight loss, joint stiffness after inactivity, symmetrical, signs of inflammation (morning stiffness lasts 60 min -several hrs) Diagnostics: RF, ANA, ESR, CRP, x-ray, bone scan, synovial fluid analysis Management analgesics, DMARDs, BRMs, anti inflammatories, corticosteroids, PT, OT, rest, nutrition, heat and cold application, non drug management, assistive devices The onset of RA is typically slow, but the early complaints include fatigue,