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Anatomy and Physiology of the GI Tract
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Anatomy and Physiology of the GI Tract

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Questions and Answers

What is the primary function of the mucosa in the GI tract?

  • Absorption (correct)
  • Peristalsis and movement
  • Secretion of digestive enzymes
  • Structural support

    • Which assessment technique should be performed first during an abdominal examination?

  • Percussion
  • Auscultation (correct)
  • Inspection
  • Palpation

    • What does maroon or purple jelly-like stools indicate?

  • Iron supplement intake
  • Normal digestion
  • Intestinal obstruction
  • Massive bleeding (correct)

    • Which part of the GI tract is directly after the stomach?

    <p>Duodenum</p> Signup and view all the answers

    What might bright red stool indicate?

    <p>Bleeding in the lower GI tract</p> Signup and view all the answers

    What is the primary transmission route for Hepatitis A and E?

    <p>Fecal–oral route</p> Signup and view all the answers

    Which type of hepatitis is characterized by inflammation and necrosis due to alcohol consumption?

    <p>Alcoholic hepatitis</p> Signup and view all the answers

    Which dietary modification is recommended for patients with hepatic cirrhosis at risk for encephalopathy?

    <p>Daily protein intake of 1.2 to 1.5 g/kg</p> Signup and view all the answers

    What is a common complication associated with hepatic cirrhosis?

    <p>Hepatic encephalopathy</p> Signup and view all the answers

    What are the typical symptoms of non-alcoholic fatty liver disease?

    <p>Malaise, nausea/vomiting, and abdominal discomfort</p> Signup and view all the answers

    What is the recommendation for managing fluid volume excess in patients with hepatic cirrhosis?

    <p>Fluid restriction</p> Signup and view all the answers

    What is the maximum recommended dose of acetaminophen for adults in a 24-hour period?

    <p>4000 mg</p> Signup and view all the answers

    Which medication is used to reduce ammonia levels in patients with hepatic dysfunction?

    <p>Lactulose</p> Signup and view all the answers

    Which of the following is NOT a manifestation of hepatic cirrhosis?

    <p>Hypoglycemia</p> Signup and view all the answers

    What is a common underlying risk factor for non-alcoholic fatty liver disease?

    <p>Obesity</p> Signup and view all the answers

    What is one primary function of the musculoskeletal system?

    <p>Facilitating blood circulation</p> Signup and view all the answers

    Which type of joint allows for the greatest range of motion?

    <p>Freely moveable joints</p> Signup and view all the answers

    Which nutrient is essential for maintaining bone health?

    <p>Calcium</p> Signup and view all the answers

    What does the term 'flaccidity' refer to in the context of muscle function?

    <p>Decreased muscle tone</p> Signup and view all the answers

    Which characteristic is associated with osteoarthritis?

    <p>Joint stiffness and swelling</p> Signup and view all the answers

    What are the '6 P’s' used to assess in a neurovascular status examination?

    <p>Pallor, Pain, Paresthesia, Pulselessness, Poikilothermia, Paralysis</p> Signup and view all the answers

    What does bone densitometry primarily detect?

    <p>Osteopenia</p> Signup and view all the answers

    Which of the following is an example of an IADL related to functional ability assessment?

    <p>Shopping</p> Signup and view all the answers

    What is the recommended dietary approach for managing peptic ulcers?

    <p>Low fat diet, avoiding caffeine and tobacco</p> Signup and view all the answers

    What is a common complication of constipation?

    <p>Rectal prolapse</p> Signup and view all the answers

    What type of pain is characteristic of a duodenal ulcer?

    <p>Relieved by eating</p> Signup and view all the answers

    What symptom is most associated with appendicitis?

    <p>Intensifying pain in the right upper quadrant</p> Signup and view all the answers

    Which medication is typically used to decrease stomach acid production?

    <p>Proton Pump Inhibitors (PPIs)</p> Signup and view all the answers

    What is the primary cause of cholecystitis?

    <p>Gallstones</p> Signup and view all the answers

    What symptom indicates a potential perforation in a patient with appendicitis?

    <p>Sudden increase in pain</p> Signup and view all the answers

    Which is NOT an effective strategy for managing diarrhea?

    <p>Prolonged fasting</p> Signup and view all the answers

    In patients with chronic constipation, which medication should be used cautiously?

    <p>Stimulant laxatives</p> Signup and view all the answers

    Which condition is most likely to be caused by the overuse of laxatives?

    <p>Chronic diarrhea</p> Signup and view all the answers

    What type of pain separates chronic pancreatitis from acute pancreatitis?

    <p>Constant dull pain</p> Signup and view all the answers

    Which factor is NOT a risk for developing intestinal obstruction?

    <p>Increased fluid intake</p> Signup and view all the answers

    What dietary recommendation is given to patients suffering from pancreatitis?

    <p>Clear liquids and low fat</p> Signup and view all the answers

    How is megacolon typically caused?

    <p>Chronic laxative use</p> Signup and view all the answers

    What is the primary characteristic of rheumatoid arthritis in relation to joint pain?

    <p>Pain is worse in the morning and after periods of inactivity.</p> Signup and view all the answers

    What is the main purpose of neurovascular assessments after the reduction of a dislocation?

    <p>To assess circulation and nerve function.</p> Signup and view all the answers

    What would be a common early complication following a fracture?

    <p>Vascular complications.</p> Signup and view all the answers

    How are closed fractures typically managed?

    <p>Manipulation and manual traction are used.</p> Signup and view all the answers

    What is the first symptom typically associated with fat embolism?

    <p>Tachycardia.</p> Signup and view all the answers

    Which of the following is a complication associated with amputations?

    <p>Phantom limb pain.</p> Signup and view all the answers

    What symptom is indicative of compartment syndrome which requires urgent attention?

    <p>Increasing pain despite analgesia.</p> Signup and view all the answers

    What management approach is recommended for stable pelvic fractures?

    <p>A few days of bed rest with symptom management.</p> Signup and view all the answers

    What type of fracture extends into the joint surface of a bone?

    <p>Intra-articular fracture.</p> Signup and view all the answers

    Which intervention helps promote healing of a residual limb after amputation?

    <p>Wound shaping and compression.</p> Signup and view all the answers

    What should a nurse monitor for in a patient following an open fracture?

    <p>Signs of wound contamination.</p> Signup and view all the answers

    What is a distinction between rheumatoid arthritis and osteoarthritis?

    <p>Rheumatoid arthritis causes joint deformity.</p> Signup and view all the answers

    Which approach is part of effective planning for amputation rehabilitation?

    <p>Setting realistic goals and providing psychological support.</p> Signup and view all the answers

    Which layer of the GI tract is primarily responsible for absorption?

    <p>Mucosa</p> Signup and view all the answers

    In an abdominal physical assessment, what should be performed before percussion to avoid false findings?

    <p>Auscultation</p> Signup and view all the answers

    What does coffee ground emesis most likely indicate in a patient?

    <p>Upper GI bleeding</p> Signup and view all the answers

    What are maroon or purple jelly-like stools generally associated with?

    <p>Massive GI bleeding</p> Signup and view all the answers

    During a focused GI assessment, which aspect is considered a chief complaint?

    <p>Changes in bowel patterns</p> Signup and view all the answers

    Which of the following is NOT a component of the post-operative assessment for Total Hip Arthroplasty?

    <p>Detailed dietary history</p> Signup and view all the answers

    What position should be maintained to prevent dislocation after hip arthroplasty?

    <p>Hip in abduction when turning</p> Signup and view all the answers

    Which of the following nursing diagnoses is appropriate for a patient following hip arthroplasty?

    <p>Impaired physical mobility</p> Signup and view all the answers

    How soon after hip arthroplasty should early ambulation be encouraged?

    <p>1 day after surgery</p> Signup and view all the answers

    Which of the following statements regarding drain use postoperatively is correct?

    <p>Assessing the character and amount of output is essential.</p> Signup and view all the answers

    What is the primary purpose of continuous passive motion (CPM) after knee surgery?

    <p>To promote range of motion and circulation</p> Signup and view all the answers

    Which of the following is NOT a potential post-operative complication after knee replacement?

    <p>Psoriasis</p> Signup and view all the answers

    Which assessment technique is crucial during the evaluation of low back pain?

    <p>Detailed pain assessment using OPQRST</p> Signup and view all the answers

    What is included in the planning and implementation phase for a patient with low back pain?

    <p>Education on back conservation techniques</p> Signup and view all the answers

    What should physical therapy for knee replacement primarily focus on?

    <p>Maximizing mobility and reducing dependency</p> Signup and view all the answers

    Which condition is most likely to cause radiculopathy resulting in leg weakness?

    <p>Herniated disc</p> Signup and view all the answers

    How long is the typical duration for acute rehabilitation following a knee replacement?

    <p>1 to 2 weeks</p> Signup and view all the answers

    What should be the first activity encouraged for a patient post knee surgery?

    <p>Ankle and calf-pumping exercises</p> Signup and view all the answers

    What condition is associated with the risk of developing pernicious anemia after bariatric surgery?

    <p>Intrinsic factor removal</p> Signup and view all the answers

    Which complication can occur due to a rapid fluctuation in fluid volume?

    <p>Fluid overload</p> Signup and view all the answers

    Which statement accurately differentiates rheumatoid arthritis from osteoarthritis?

    <p>Rheumatoid arthritis involves joint swelling and deformity primarily in the morning, while osteoarthritis pain worsens throughout the day.</p> Signup and view all the answers

    What symptom is NOT typical of dumping syndrome?

    <p>Constipation</p> Signup and view all the answers

    During pre-operative care for a colonoscopy, what is a critical nursing intervention?

    <p>Ensure bowel preparation is completed</p> Signup and view all the answers

    Which sign is NOT typically associated with a complete joint dislocation?

    <p>Increased range of motion</p> Signup and view all the answers

    Which of the following complications can arise from a fracture?

    <p>Hypovolemic shock</p> Signup and view all the answers

    Which nursing intervention is essential when managing a patient with esophageal varices?

    <p>Monitor the patient for signs of hepatic encephalopathy</p> Signup and view all the answers

    What intervention is essential before and after the reduction of a dislocation?

    <p>Neurovascular assessment</p> Signup and view all the answers

    What dietary habit should a patient with GERD avoid to reduce symptoms?

    <p>Increased caffeine intake</p> Signup and view all the answers

    Which of the following is a management strategy for preventing bile reflux in gastric surgery patients?

    <p>Administration of Protons Pump Inhibitors (PPI)</p> Signup and view all the answers

    What is the purpose of using traction in the management of fractures?

    <p>To realign and stabilize the bones</p> Signup and view all the answers

    What is a critical assessment for detecting fat embolism post-fracture?

    <p>Monitoring for hypoxemia and neurologic compromise</p> Signup and view all the answers

    Which assessment finding following gastric surgery may indicate a complication?

    <p>Persistence of gastric drainage</p> Signup and view all the answers

    In the context of endoscopic procedures, what is a significant post-operative care consideration?

    <p>Monitoring return of gag reflex</p> Signup and view all the answers

    Which complication of amputation involves joint contracture due to improper positioning?

    <p>Contractures</p> Signup and view all the answers

    Which symptom is indicative of avascular necrosis as a delayed complication of a fracture?

    <p>Progressive joint stiffness and non-healing</p> Signup and view all the answers

    What is a critical factor influencing the surgical management of patients with Barrett’s Esophagus?

    <p>Risk of progression to adenocarcinoma</p> Signup and view all the answers

    Which aspect of rehabilitation is crucial for a patient post-amputation?

    <p>Encouraging ambulation as soon as possible</p> Signup and view all the answers

    Which symptom is most likely to occur with hiatal hernia, specifically the paraoesophageal type?

    <p>Chest pain after eating</p> Signup and view all the answers

    What is a primary nursing diagnosis for patients undergoing amputation?

    <p>Acute pain</p> Signup and view all the answers

    Which condition is characterized by dysphagia and a 'fullness' sensation in the neck?

    <p>Zenker Diverticulum</p> Signup and view all the answers

    What is one of the first actions a nurse should take if a patient's stoma appears dusky post-operatively?

    <p>Notify the healthcare provider</p> Signup and view all the answers

    In the management of pelvic fractures, what is a primary focus?

    <p>Symptom management and bed rest</p> Signup and view all the answers

    Which condition is characterized by the presence of fat globules in the bloodstream after specific injuries?

    <p>Fat embolism</p> Signup and view all the answers

    What immediate intervention should be performed for an open fracture to prevent complications?

    <p>Cover the wound with a sterile dressing</p> Signup and view all the answers

    Which of the following describes a common chronic condition that may develop after limb injury that involves severe pain?

    <p>Complex regional pain syndrome (CRPS)</p> Signup and view all the answers

    What condition results from a lower motor neuron lesion characterized by weakness and muscle wasting?

    <p>Flaccidity</p> Signup and view all the answers

    Which musculoskeletal consideration is particularly relevant for older adults experiencing osteoarthritis?

    <p>Inflexible joints</p> Signup and view all the answers

    Which physical assessment finding is NOT included when evaluating neurovascular status in musculoskeletal injuries?

    <p>Joint flexibility</p> Signup and view all the answers

    What diagnostic test is primarily used to investigate the rate of bone metabolism through the use of a tracer?

    <p>Bone scan</p> Signup and view all the answers

    Which mineral is essential for maintaining bone health along with vitamin D, particularly in preventing osteopenia?

    <p>Calcium</p> Signup and view all the answers

    What radiological test is most effective for detailed imaging of joint structures and soft tissue?

    <p>Magnetic resonance imaging</p> Signup and view all the answers

    Which of the following symptoms is NOT typically associated with osteoarthritis?

    <p>Redness and warmth</p> Signup and view all the answers

    What is the hallmark of upper motor neuron lesions related to muscle function?

    <p>Spasticity</p> Signup and view all the answers

    Which form of hepatitis is transmitted solely through fecal–oral routes?

    <p>Hepatitis E</p> Signup and view all the answers

    What is a characteristic manifestation specifically associated with biliary cirrhosis?

    <p>Band of scar tissue surrounding bile ducts</p> Signup and view all the answers

    In managing a patient with hepatic encephalopathy, what is the recommended daily protein intake?

    <p>1.2 to 1.5 g/kg per day</p> Signup and view all the answers

    Which type of liver disease is primarily caused by the accumulation of lipids in the hepatocytes?

    <p>Non-alcoholic steatohepatitis (NASH)</p> Signup and view all the answers

    What is a critical complication that can arise from hepatic cirrhosis?

    <p>Hepatic encephalopathy</p> Signup and view all the answers

    Which of the following statements regarding non-viral hepatitis is correct?

    <p>It results from toxins and drugs.</p> Signup and view all the answers

    What dietary change is essential for managing a patient with non-alcoholic fatty liver disease?

    <p>Monitor and reduce sugar and processed foods</p> Signup and view all the answers

    Which medication is commonly prescribed for reducing liver-generated ammonia levels in hepatic dysfunction?

    <p>Lactulose</p> Signup and view all the answers

    What is a typical presentation in a patient with alcoholic fatty liver disease?

    <p>Jaundice and liver enlargement</p> Signup and view all the answers

    What is the primary reason older adults are at increased risk of liver dysfunction?

    <p>Decreased liver function and altered drug metabolism.</p> Signup and view all the answers

    What is the primary purpose of using a cast in musculoskeletal care?

    <p>To immobilize a reduced fracture</p> Signup and view all the answers

    Which type of brace is specifically custom-fitted for conditions requiring long-term use?

    <p>TLSO Brace</p> Signup and view all the answers

    What nursing intervention is required post-biopsy to monitor potential complications?

    <p>Monitor the site for bleeding and edema</p> Signup and view all the answers

    What is the significance of the '6 Ps' in neurovascular assessments?

    <p>They represent signs of potential complications</p> Signup and view all the answers

    Which statement correctly describes the preparation of a patient for MRI?

    <p>The patient should be educated about possible sounds during the scan</p> Signup and view all the answers

    In which situation is a splint primarily indicated?

    <p>For temporary immobilization with expected swelling</p> Signup and view all the answers

    What nursing diagnosis should be priority for a patient with severe hip pain after a fall?

    <p>Acute pain</p> Signup and view all the answers

    Which nursing intervention is recommended to facilitate isotope distribution during a bone scan?

    <p>Encourage fluid intake post-scan</p> Signup and view all the answers

    Which materials are commonly used for making casts?

    <p>Fiberglass and plaster of Paris</p> Signup and view all the answers

    Which of the following is an important assessment component before applying a cast?

    <p>Performing a neurovascular assessment</p> Signup and view all the answers

    What is the main characteristic of rheumatoid arthritis regarding the timing of pain?

    <p>Pain is worse in the morning and after inactivity</p> Signup and view all the answers

    Which statement about joint dislocations is incorrect?

    <p>Subluxation involves complete misalignment of bones.</p> Signup and view all the answers

    What is the primary complication associated with a fat embolism following certain injuries?

    <p>Neurologic compromise</p> Signup and view all the answers

    Which type of fracture is characterized by a break that extends into the joint surface?

    <p>Intra-articular fracture</p> Signup and view all the answers

    What is NOT a major goal in the planning of amputation care?

    <p>Complete avoidance of pain at all costs</p> Signup and view all the answers

    Which early complication of a fracture requires immediate interventions?

    <p>Compartment syndrome</p> Signup and view all the answers

    What indicates a possible infection at the site of an amputation?

    <p>Change in color and warmth of the residual limb</p> Signup and view all the answers

    What does the term 'malunion' refer to in the context of fracture complications?

    <p>The bone heals but in an incorrect alignment.</p> Signup and view all the answers

    Which intervention is key for managing unstable pelvic fractures?

    <p>Stabilizing pelvic bones and managing bleeding</p> Signup and view all the answers

    What symptom is typically assessed during neurovascular assessments post-dislocation reduction?

    <p>Numbness or tingling sensation</p> Signup and view all the answers

    Which activity is least appropriate after a femoral shaft fracture?

    <p>Prolonged immobilization with no movement</p> Signup and view all the answers

    What is a common psychological concern patients might face after an amputation?

    <p>Disturbed body image</p> Signup and view all the answers

    Which condition occurs when bone tissue dies due to a lack of blood supply?

    <p>Avascular necrosis</p> Signup and view all the answers

    What is a typical first symptom of fat embolism reported by patients?

    <p>Dyspnea</p> Signup and view all the answers

    What percentage of adults older than age 60 are likely to have diverticulosis?

    <p>58%</p> Signup and view all the answers

    Which of the following is NOT a goal in the management of Inflammatory Bowel Disease?

    <p>Reduction of urination frequency</p> Signup and view all the answers

    What is a common complication of portal hypertension?

    <p>Ascites</p> Signup and view all the answers

    Which of the following types of jaundice is characterized by hemolysis?

    <p>Hemolytic jaundice</p> Signup and view all the answers

    Which complication is associated with intussusception?

    <p>Peritonitis</p> Signup and view all the answers

    Which assessment should be performed when evaluating ascites?

    <p>Daily abdominal girth and weight measurements</p> Signup and view all the answers

    What is the role of lactulose in hepatic encephalopathy treatment?

    <p>It reduces serum ammonia levels</p> Signup and view all the answers

    Which of the following conditions commonly leads to intestinal obstruction?

    <p>Hernia</p> Signup and view all the answers

    Which type of hepatic dysfunction presents with involuntary flapping of the hands?

    <p>Hepatic encephalopathy</p> Signup and view all the answers

    In managing bleeding esophageal varices, which medication is administered as an emergency measure?

    <p>Somatostatin</p> Signup and view all the answers

    What is the main consequence of liver dysfunction that results from the buildup of toxic by-products?

    <p>Hepatic encephalopathy</p> Signup and view all the answers

    What is indicated by the presence of clay-colored stools in a patient?

    <p>Obstructive jaundice</p> Signup and view all the answers

    Which physical blockage can lead to a functional obstruction in the intestines?

    <p>Paralytic ileus</p> Signup and view all the answers

    What procedure involves the removal of a portion of the esophagus to manage varices?

    <p>Esophageal banding</p> Signup and view all the answers

    Study Notes

    Anatomy and Physiology of the GI Tract

    • The GI tract encompasses the mouth, esophagus, stomach, small intestine (duodenum, jejunum, ileum), large intestine (colon), rectum, and anal canal.
    • The wall of the GI tract is composed of four layers: mucosa, submucosa, muscularis, and serosa.
    • The mucosa is responsible for absorption.
    • The muscularis layer enables peristalsis (wave-like muscle contractions) and movement of the GI tract.

    Focused GI Assessment

    • Focused Interview: Questions should include Chief Complaint, Present Health Status (change in appetite, weight gain/loss, dysphagia, food intolerance, N/V, change in bowel patterns, abdominal pain, dyspepsia, jaundice), Past Health History, Current Lifestyle, Psychosocial Status, and Family Health History.
    • Coffee ground emesis (vomit) indicates bleeding in the upper GI tract.
    • Maroon/purple jelly stools suggest massive bleeding in the lower GI tract and a foul odor.
    • Dark stools can be caused by iron supplements or Pepto Bismol.
    • Bright red stool indicates bleeding in the lower GI tract.
    • Physical Assessment: A thorough oral assessment (lips, gums, mucosal membrane, teeth, tongue) and abdominal assessment (inspection, auscultation, percussion, palpation) are essential.
    • Auscultation should precede percussion and palpation to prevent false bowel sounds.
    • Percussion helps assess organ size and density, identifying air-filled, fluid-filled, or solid masses.

    Peptic Ulcers

    • Peptic ulcers form when stomach acid erodes the lining of the digestive tract.
    • There are two main types: Gastric ulcers and duodenal ulcers.
    • Pain associated with gastric ulcers typically occurs 30 minutes to an hour after meals.
    • Duodenal ulcer pain often occurs 90 minutes to 2-3 hours after meals or during the night.
    • Duodenal ulcers are more common, linked to increased parietal cells (acid-secreting cells).
    • H. pylori infection and use of NSAIDs are major contributing factors to both ulcer types.

    Peptic Ulcer Management

    • Nursing Interventions: Medication regimen, dietary restrictions (low-fat diet, avoiding caffeine, tobacco, beer, milk, and foods with peppermint, spearmint, or soda), pain management (medication and relaxation techniques).
    • Medications: Proton pump inhibitors (PPIs) are used to decrease acid formation, and NSAIDs/aspirin should be avoided.
    • Complications: Hemorrhage, Perforation (leading to peritonitis, characterized by a tender, rigid abdomen, nausea, and vomiting), Peritonitis, and Paralytic ileus.

    Intestinal and Rectal Disorders

    • Constipation: Defined as fewer than three bowel movements weekly or bowel movements that are hard, dry, small, or difficult to pass.
    • Diarrhea: Increased frequency of bowel movements (> 3/day) with altered consistency (increased liquidity) of stool.
    • Appendicitis: The most frequent cause of acute abdomen, commonly requiring emergency surgery.
    • Cholecystitis: Inflammation of the gallbladder, commonly caused by gallstones (cholelithiasis).
    • Pancreatitis: Inflammation of the pancreas, often due to gallstones or heavy alcohol consumption (acute), or excessive alcohol intake (chronic).
    • Diverticular Disease: Outpouchings in the colon that can become inflamed.
    • Inflammatory Bowel Disease: Chronic inflammation of the digestive tract (Crohn's disease and Ulcerative Colitis).
    • Intestinal Obstruction: A blockage in the intestines.

    Constipation

    • Causes: Medications, chronic laxative use, weakness, immobility, fatigue, inability to increase intra-abdominal pressure, diet, ignoring the urge to defecate, and lack of regular exercise.
    • Assessment: Fewer than three bowel movements per week, abdominal distention, pain, and bloating, decreased appetite, sensation of incomplete evacuation, straining at stool, small-volume hard, dry stools.
    • Complications: Hypertension (from the Valsalva maneuver), Fecal impaction, Hemorrhoids, Anal fissures, Rectal prolapse, Megacolon.

    Medications to Treat Constipation

    • Stool softeners: Lubricate the stool, easing passage.
    • Bulk-producing laxatives: Increase stool bulk, promoting regularity.
    • Osmotic laxatives: Draw water into the colon, softening the stool (short-term use only).
    • Stimulant laxatives: Increase peristalsis (caution required).
    • Suppositories: Directly stimulate the rectal area to promote evacuation.
    • Enemas: Administered rectally to flush the colon.

    Diarrhea

    • Causes: Infections, medications, tube feeding formulas, various diseases, and disorders.
    • Assessment: Increased frequency and fluid content of stools, abdominal cramps, distention, borborygmi (stomach gurgles), anorexia, thirst, painful spasmodic contractions of the anus, tenesmus (rectal pain).
    • Complications: Fluid and electrolyte imbalances, Dehydration, Cardiac dysrhythmias, Skin breakdown (irritant dermatitis).

    Medications to Treat Diarrhea

    • Antibiotics: If bacterial origin.
    • Antidiarrheals: Short-term use (no longer than 3 days).
    • IV fluids: For severely dehydrated patients.
    • Electrolyte replacement: Pedialyte or oral rehydration solutions.

    Appendicitis

    • Causes: Inflammation of the appendix, often due to kinking or occlusion by a fecalith or lymphoid hyperplasia.
    • Assessment: Sudden onset of intense pain in the right lower quadrant of the abdomen, nausea, vomiting, fever, loss of appetite.
    • Complications: Perforation, Peritonitis, Paralytic ileus.

    Cholecystitis

    • Causes: Inflammation of the gallbladder, primarily due to gallstones (cholelithiasis).
    • Assessment: Intensifying pain in the right upper quadrant of the abdomen, radiating to the right shoulder (biliary colic), nausea, vomiting, fever, jaundice.
    • Treatment: Cholecystectomy (surgical removal of the gallbladder), T-tube drain, antibiotics, analgesics, antispasmodics.

    Pancreatitis

    • Causes: Gallstones, heavy alcohol consumption (acute), or excessive alcohol intake (chronic).
    • Assessment: Severe pain in the upper abdomen, radiating to the back, N/V, fever, jaundice, abdominal distention, tachycardia.
    • Treatment: Pain management, IV fluids, bowel rest, antibiotics, nutritional support.

    Hepatitis

    • Viral Hepatitis: A systemic viral infection causing liver cell necrosis and inflammation, characterized by specific symptoms and cellular changes.
    • Types: Hepatitis A, B, C, D, and E.
    • Hepatitis A and E: Spread via the fecal-oral route.
    • Hepatitis B and C: Spread through blood or bodily fluids.
    • Hepatitis D: Only affects individuals with hepatitis B.

    Hepatic Cirrhosis

    • Types: Alcoholic, Post-necrotic, Biliary.
    • Manifestations: Liver enlargement, portal obstruction, ascites (fluid accumulation in the abdomen), infection and peritonitis, GI varices (enlarged veins in the esophagus and stomach), edema, vitamin deficiency, anemia, mental deterioration (hepatic encephalopathy).
    • Treatment: Medications (diuretics, anti-hypertensives, ammonia reducers, antibiotics), promoting rest, improving nutritional status, providing skin care, reducing risk of injury.

    Medications to Treat Liver Dysfunction

    • Lactulose: To reduce ammonia levels.
    • Immunizations: Hepatitis A, B, annual influenza, pneumonia.
    • Nutritional Supplements: Vitamins (folic acid, vitamin B1, B6, B12).

    Fatty Liver Disease (Steatosis)

    • Non-Alcoholic (Simple): Lipids accumulate in the liver cells, potentially reversible with lifestyle changes.
    • Nonalcoholic steatohepatitis (NASH): Inflammation present that can lead to cirrhosis.
    • Alcoholic: Due to heavy alcohol use, causing liver damage and potentially leading to alcoholic hepatitis and cirrhosis.

    Acetaminophen

    • A leading cause of acute liver failure in the US.
    • Maximum Dosage: 4g per 24 hours.

    Functions of the Musculoskeletal System

    • Protects vital organs, provides structural support and mobility, facilitates movement, produces heat, maintains body temperature, aids in blood return to the heart, serves as a reservoir for immature blood cells and essential minerals.
    • The musculoskeletal system comprises bones, muscles, and joints.
    • Joint Types: Arthritic (limited movement), Anti-arthritic (limited movement), Freely movable (shoulder).
    • Muscle Tone: Flaccidity (decreases in muscle tone, lower motor neuron lesion) and Spasticity (increased muscle tone, upper motor neuron lesion).

    Musculoskeletal Assessment

    • Health History: Includes functional ability (ADLs and IADLs), past health, social, and family history, general health maintenance, occupation, medications, learning needs, and socioeconomic factors.
    • Physical Assessment: Pain, tenderness, altered sensation; posture and gait; bone integrity; joint function; muscle strength and size; skin; neurovascular status (circulation, motion, sensation exams - 6 Ps: Pallor, Poikilothermia, Pulselessness, Paralysis, Pain, Paresthesia).

    Diagnostic Tests for Musculoskeletal Disorders

    • Radiographs (X-rays): To visualize bones and joints.
    • Computed Tomography (CT scan): Detailed images of bones, muscles, and soft tissues.
    • Magnetic Resonance Imaging (MRI): Detailed images of soft tissues, including muscles, ligaments, and tendons.
    • Bone Densitometry: Detects osteopenia (weak bones due to rapid bone breakdown) and osteoporosis.
    • Bone Scan: Used to assess bone metabolism, identifying areas of increased activity, such as bone tumors or fractures.

    Rheumatoid Arthritis

    • Chronic autoimmune disorder that affects the lining of joints, causing pain, swelling, bone erosion, and joint deformity.
    • Pain is worse in the morning and after inactivity.
    • Most common in females aged 40-60 years.
    • Anti-rheumatic drugs slow progression, and NSAIDs are used for pain relief.
    • Tai chi and fish oil are alternative forms of treatment.
    • Compared to osteoarthritis, which involves cartilage degeneration, pain in rheumatoid arthritis is worse in the morning and after inactivity.

    Joint Dislocations

    • Dislocation occurs when the bones forming a joint are no longer in anatomical alignment.
    • Subluxation is a partial dislocation, causing less deformity than a complete dislocation.
    • Signs and symptoms include pain, swelling, and deformity of the affected joint.
    • Interventions involve immobilization, analgesia, muscle relaxants, and reduction of the dislocation.
    • Neurovascular assessments are performed before and after reduction.
    • Physical therapy is crucial for restoring range of motion and strength.
    • Complications like increasing pain despite analgesia, numbness, and tingling can indicate compartment syndrome.

    Fractures

    • Closed or simple fractures do not involve a break in the skin.
    • Open or compound/complex fractures have a wound extending to the bone.
    • Intra-articular fractures extend into the joint surface of a bone.

    Manifestations of Fracture

    • Acute pain, loss of function, deformity, shortening of the extremity, crepitus (caused by rubbing of bone fragments), local swelling, and discoloration.
    • Diagnosis is made based on symptoms and radiography.

    Emergency Management of a Fracture

    • Immobilize the body part by splinting the joints distal and proximal to the fracture.
    • Assess neurovascular status.
    • In open fractures, prevent contamination and cover with sterile dressing.
    • Do not attempt to reduce the fracture.

    Medical Management of Fractures

    • Closed fractures are treated with manipulation and manual traction, possibly using skin or skeletal traction.
    • Open fractures are treated with internal fixation devices to hold bone fragments in position (pins, wires, screws, plates).
    • Immobilization is achieved using external devices like casts or splints or internal fixations.

    Management of Specific Fractures

    • Pelvic fractures:
      • Management depends on type, extent, and associated injuries.
      • Stable fractures are treated with bed rest and symptom management.
      • Unstable fractures at joint surfaces require stabilization of pelvic bones and compression of bleeding vessels.
    • Femoral shaft fractures:
      • Exercises for lower leg, foot, and hip to preserve muscle function and improve circulation.
      • Physical therapy, ambulation, and weight-bearing are prescribed.
      • Knee exercises are crucial to prevent restriction of movement.
      • Risk of vascular compromise and muscle spasms.
      • Skeletal traction may be required.

    Complications of Fractures

    • Early complications:
      • Hypovolemic shock, fat embolism, compartment syndrome, venous thromboembolism (DVT, PE).
    • Delayed complications:
      • Delayed union, malunion, or nonunion (failure to heal properly within 6 months), avascular necrosis of bone, complex regional pain syndrome (CRPS), heterotopic ossification.
    • Secondary complications:
      • Pressure ulcers, disuse syndrome.

    Fat Embolism

    • Fat globules move into the bloodstream after fractures, crush injuries, or orthopedic surgery.
    • Can be dangerous and fatal.
    • Assess for classic manifestations like hypoxemia, neurologic compromise, and petechial rash.
    • Early symptoms include tachypnea, dyspnea, tachycardia, hypoxia, and chest pain.
    • Notify the provider immediately and call rapid response or a code depending on the level of consciousness.

    Amputations

    • Can be congenital, traumatic, or caused by conditions like peripheral vascular disease, infection, or malignancy.
    • Used to relieve symptoms, improve function, and quality of life.
    • Positive communication from the healthcare team is crucial for acceptance and participation in rehabilitation.

    Amputation: Assessment

    • Neurovascular status and function of affected and unaffected extremities.
    • Signs and symptoms of infection.
    • Nutritional status, concurrent health problems, and psychological status/coping.

    Amputation: Nursing Diagnosis

    • Acute pain, impaired skin integrity, disturbed body image, grieving, self-care deficit, and impaired physical mobility.

    Amputation: Planning/Implementation

    • Major goals include pain relief, absence of altered sensory perception, wound healing, acceptance of altered body image resolution of grieving, restoration of physical mobility, and absence of complications.
    • Pain relief strategies include analgesic medications, positioning changes, and alternative methods like mirror box therapy, distraction, and TENS units.
    • Wound healing is promoted via gentle handling, residual limb shaping, and prone positioning to prevent flexion contractures.

    Amputation: Evaluation

    • Assess pain relief, educational understanding, and readiness for self-care.

    Amputation: Complications

    • Phantom limb pain, postoperative hemorrhage, infection, skin breakdown, and joint contractures.

    Amputation: Rehabilitation Needs

    • Psychological support, prosthesis fitting and use, physical therapy, vocational/occupational training/counseling, multidisciplinary team approach, and patient teaching.

    Anatomy & Physiology of the GI Tract

    • The GI tract is a long, continuous tube that begins at the mouth and ends at the anus.
    • The organs of the GI tract include the mouth, esophagus, stomach, small intestine (duodenum, jejunum, ileum), large intestine (colon, rectum, anal canal).
    • The walls of the GI tract are made up of four layers: mucosa, submucosa, muscularis, and serosa.
    • The mucosa is the innermost layer and is responsible for absorption.
    • The muscularis layer is responsible for peristalsis, which is the wave-like movement of food through the GI tract.

    Focused GI Assessment

    • Focused Interview:
      • Chief complaint.
      • Present health status: changes in appetite, weight gain/loss, dysphagia, food intolerance, nausea/vomiting, changes in bowel patterns, abdominal pain, dyspepsia, jaundice.
        • Coffee ground emesis indicates bleeding in the upper GI tract.
        • Maroon/purple jelly stools indicate massive bleeding (foul-smelling) in the lower GI tract.
        • Dark stools can be from iron supplements or Pepto-Bismol.
        • Bright red stool indicates bleeding in the lower GI tract.
      • Past health history.
      • Current lifestyle.
      • Psychosocial status.
      • Family health history.
    • Physical assessment:
      • Oral assessment: lips, gums, mucosal membrane, teeth, tongue.
      • Abdominal assessment:
        • Inspection: color, bulges, masses, hernias, ascites, spider/enlarged veins, pulsations or movements, inability to lie flat.
        • Auscultation: done before percussion & palpation to prevent production of false bowel sounds.
        • Percussion: used to assess size & density of organs & detect air-filled, fluid-filled, or solid masses.
    • Monitor indicators of fluid balance and electrolyte levels:
      • I&O, daily weights, blood glucose levels.
    • Patient education:
      • Goals and purpose, potential complications and actions.
    • Nursing process: Evaluation:
      • Patient education, improved nutritional status.
    • Document.

    Parenteral Nutrition Complications

    • Pneumothorax: air enters the pleural cavity, related to central venous access.
    • Air embolism: air enters the circulatory system, related to central venous access, potentially fatal.
    • Clotted catheter or displaced catheter: related to central venous access.
    • Line sepsis: infection of the catheter.
    • Hyperglycemia: due to dextrose in the solution.
    • Rebound hypoglycemia: occurs when D10 is not hung following parenteral nutrition.
    • Fluid overload.

    Endoscopic Procedures

    • Endoscopy: visualization of the esophageal, gastric, and duodenal mucosa.
    • Colonoscopy: visualization of the large intestine, anus, and rectum; larger in diameter and longer than endoscopy.

    Management of Diagnostic Testing Patients

    • Endoscopy:
      • Upper GI: esophagus, stomach, duodenum.
      • Pre-Op: education, monitor vital signs, NPO (nothing by mouth).
      • Post-Op: education, return of gag reflex, vital signs.
    • Colonoscopy:
      • Lower GI: rectum, sigmoid colon, descending colon, transverse colon, ascending colon.
      • Pre-Op: education, monitor vital signs, bowel prep, NPO.
      • Post-Op: education, vital signs.

    Colonoscopy

    • Direct visualization of the rectum, sigmoid, descending, transverse, and ascending colon.
    • Used to detect diverticulosis, polyps, colon cancer, and other abnormalities.

    Surgeries & Ostomies

    • Gastric surgery: procedures performed on the stomach, often for weight loss or other gastric conditions.
    • Bariatric surgery: a type of gastric surgery specifically for morbid obesity.

    Care of the Gastric Surgery Patient: Assessment

    • General health assessment.
    • Patient and support system knowledge.
    • Nutritional status.
    • Abdominal assessment.
    • Postoperatively assess for potential complications.

    Care of the Gastric Surgery Patient: Nursing Diagnosis

    • Anxiety.
    • Pain.
    • Deficient knowledge.
    • Imbalanced nutrition.

    Care of the Gastric Surgery Patient: Planning/Implementation

    • Reducing anxiety: education, meditation, breathing exercises, medications, movies.
    • Preventing post-operative complications: gastric and general post-operative concerns.
    • Managing Pain: administer analgesics, position in semi-Fowler's position, maintain function of NG tube.
    • Patient education:
      • Diet: delay stomach emptying and prevent dumping syndrome, assume low semi-Fowler's position after meals, lie down for 20-30 minutes, avoid fluids with meals, limit high carbohydrate and sugar intake, eat frequent small meals, take supplements as prescribed, reduce fat intake, administer loperamide (Imodium) for steatorrhea.
    • Evaluation: pain relief, surgical site, education.
    • Document.

    Care of the Gastric Surgery Patient: Complications

    • Gastric outlet obstruction: narrowing of the pyloric outlet, may require NG tube suction to decompress the stomach, NPO, contraindicated in bariatric patients.
    • Hemorrhage.
    • Dietary deficiencies.
    • Bile reflux: treated with PPIs.
    • Dumping syndrome: develops after surgery, rapid movement of food into the small bowel, N/V/D, weakness, sweating, palpitations, syncope, prevent by eating smaller meals and limiting high sugar foods, medications or surgery to repair the pylorus might be necessary.
    • Steatorrhea: reduce fat intake or use loperamide to treat.

    Bariatric Surgery

    • Performed for morbid obesity: body weight greater than 2x ideal body weight, BMI > 30 kg/m2, or 100 lbs heavier than ideal body weight.
    • Surgical options are considered after non-surgical methods fail.
    • Selection factors: body weight, patient history, failure to lose weight using other means, absence of endocrine disorders, and psychological stability.
    • Average weight loss after bariatric surgery is 25-35% of previous body weight.
    • Increased risk for osteoporosis: duodenum is bypassed, which is the primary site for calcium absorption.
    • Risk for pernicious anemia: intrinsic factor for vitamin B12 absorption might be removed during surgery, affecting nutrient absorption.
    • Calcium deficiency.

    Care of the Bariatric Surgery Patient

    • Preoperative care: evaluation and counseling.
    • Postoperative care: similar to gastric resection, but patients are at greater risk for complications due to obesity.
    • Postoperative diet: clear liquids, then slowly advance to six small meals daily.
    • Psychosocial interventions to modify eating behaviors.
    • Prevent complications: VTE, hemorrhage, bile reflux, dumping syndrome, steatorrhea.
    • Education: long-term effects, follow-up care.
    • Evaluation and Document.

    Care of the Ostomy Patient: Assessment

    • Stoma: post-op, color: beefy red, then pink, never dusky (notify provider if dusky).
    • Peristomal skin.
    • Scant bleeding only.
    • Size of stoma for proper fitting ostomy appliances.
    • Diet tolerance.
    • Readiness for learning.

    Care of the Ostomy Patient: Nursing Diagnosis

    • Disturbed body image related to new colostomy.
    • Anxiety related to bowel incontinence.
    • Risk for impaired skin integrity related to irritation of the peristomal skin by effluent.

    Care of the Ostomy Patient: Planning/Implementation

    • Fit wafer to stoma to prevent excoriation.
    • Empty bag when about half full.
    • Check for fungal infection of skin, may need nystatin powder.
    • Encourage verbalization of concerns and fears.
    • Invite significant other to participate in discussions about sexual/intimacy concerns.
    • Monitor fluid balance.
    • Education:
      • Cleansing the peristomal skin.
      • Preparing the appliance for installation, adequate fit, emptying, and irrigation (if necessary).
      • Signs and symptoms of irritated/inflamed skin.
      • Diet: avoid foods that increase peristalsis and gas (nuts, seeds, prunes, bananas).
      • Monitor fluid balance (daily weights, adequate hydration, skin turgor, appearance of tongue).
    • Evaluation and document.

    Oral & Esophageal Disorders

    • Impaired oral health.
    • Dysphagia.
    • Hiatal hernia.
    • Barrett’s esophagus.
    • Zenker Diverticulum.
    • Esophageal Varices

    Impaired Oral Health

    • Changes in the oral cavity: influence the type and amount of food ingested.
    • Diseases of the mouth: interfere with communication.
    • Esophageal problems: affect food and fluid intake, jeopardizing general health.
    • Connection to systemic disease: CV, DM, rheumatoid arthritis.

    Impaired Oral Health: Management

    • Promoting mouth care: dental care before surgery or radiation therapy, frequent gentle brushing and flossing, mouthwashes and alternative cleaning methods for patients who cannot tolerate brushing.
    • Patient education: related to oral hygiene.
    • Encourage fluid intake: to reduce dry mouth.
    • Use of synthetic saliva or saliva production stimulants.

    Dysphagia: Management

    • Assessment: Bedside swallow evaluation, barium swallow (x-ray), inability to manage secretions.
    • Nursing diagnosis: Impaired swallowing, Risk for aspiration, Imbalanced nutrition: less than body requirements.
    • Nursing interventions:
      • Aspiration precautions: HOB raised, OOB, eat small amounts slowly, thicken liquids, avoid use of straws, avoid distractions, suction at the bedside.
    • Patient/support system education.

    Hiatal Hernia: Management

    • Assessment:
      • Sliding: none, regurgitation, heartburn.
      • Paraoesophageal: none, fullness, chest pain after eating (reduced space in heart).
    • Nursing Interventions: frequent small meals, do not recline for 1 hour after eating, elevate HOB 4-8 inches at bedtime, medications, prepare for surgery (torsion), patient/support system education.
    • Evaluation and document.

    Barrett's Esophagus: Management

    • Untreated GERD: lining of esophagus changed from pink to red, squamous cells replaced by columnar epithelium, precursor to cancer.
    • Diagnosed by EGD (esophagogastroduodenoscopy) and confirmed by biopsy.
    • Management similar to patients with GERD.
    • Close monitoring by gastroenterologist: biopsies, endoscopic ablation, esophagectomy (if severe).

    Zenker Diverticulum: Management

    • Assessment: dysphagia, fullness in the neck, belching, regurgitation of undigested food, gurgling noises after eating, halitosis, sour taste in mouth.
    • Avoid NG tube and esophagoscopy: risk of perforation and mediastinitis (inflammation of chest cavity).
    • Treatment:
      • Surgical removal
      • Observe incision for evidence of leakage from esophagus and fistula development.
      • NPO post-operatively until X-rays show no leakage.
      • Start with liquids, advance as tolerated.

    Esophageal Varices: Management

    • Abnormal, enlarged veins in the esophagus.
    • Most often occurs in individuals with serious liver diseases: blocked blood flow to the liver due to a clot or scar tissue.
    • Bleeding esophageal varices is life-threatening and fatal in 50% of patients.
    • Variceal ligation is effective in controlling first-time bleeding episodes in about 90% of patients.

    Conditions of the Esophagus: Nursing Diagnosis

    • Imbalanced nutrition: less than body requirements related to dysphagia.
    • Acute pain related to dysphagia, ingestion of an abrasive agent, tumor, or frequent episodes of gastric reflux.
    • Deficient knowledge about the esophageal disorder, diagnostic studies, medical management, surgical intervention, and rehabilitation.
    • Risk for aspiration related to difficulty swallowing or tube feeding.

    Conditions of the Esophagus: Planning/Implementation

    • Encouraging adequate nutritional intake.
    • Decreasing risk of aspiration.
    • Relieving pain.
    • Providing patient education.
    • Evaluation.
    • Document.

    Gastric & Duodenal Disorders

    • Gastroesophageal Reflux Disease (GERD).
    • Gastritis.
    • Peptic ulcers:
      • Gastric ulcers.
      • Duodenal ulcers.

    GERD: Management

    • Assessment: burning sensation, indigestion, pain on swallowing, hypersalivation (can mimic MI).
    • Nursing interventions:
      • Dietary restrictions: low-fat diet, avoid caffeine, tobacco, beer, milk, foods with peppermint/spearmint, carbonated beverages, avoid eating/drinking 2 hours before bedtime.
      • Medications: treat and avoid: PPIs, avoid aspirin, NSAIDs, anticoagulants, antiplatelets (erode stomach lining and increase gastric acid secretion).
      • Elevate HOB at bedtime, maintain a healthy body weight.
    • Patient/support system education and document.

    Gastritis

    • Inflammation of the stomach: bile reflux, alcohol, NSAIDs, stress, H. pylori.
    • Assessment:
      • Acute: abdominal discomfort, headache, weakness, nausea, vomiting, hiccupping.
      • Chronic: epigastric discomfort, anorexia, heartburn after eating, belching, sour taste in mouth, nausea & vomiting, food intolerance, potential B12 deficiency (decreased intrinsic factor, leads to pernicious anemia).
    • Diagnosis: upper GI x-ray or endoscopy with biopsy.

    Care of the Patient with Gastritis: Diagnosis

    • Acute pain.
    • Anxiety.
    • Imbalanced nutrition.
    • Deficient knowledge.
    • Risk for fluid volume imbalance.

    Care of the Patient with Gastritis: Planning/Implementation

    • Reduce anxiety: calm approach, explain procedures and treatments.
    • Promote optimal nutrition: for acute gastritis, patients should take no food or fluids by mouth.
    • Document.

    Joint Replacements

    • Treat severe joint pain and disability, repair and management of joint fractures, or joint necrosis.
    • Common replacements include hip and knee.
    • Other joints that may be replaced include the shoulder, elbow, wrist, fingers, and ankle.

    Nursing Process: Total Hip Arthroplasty

    • Assessment (post-op):
      • General health assessment.
      • Emotional status (fear, anxiety).
      • Readiness to learn.
      • Level and type of discomfort.
      • Limitations in function.
      • Neurovascular assessment of the affected extremity.
    • Nursing Diagnosis:
      • Acute pain.
      • Impaired physical mobility.
      • Activity intolerance.

    Plan/Implement: Hip Arthroplasty

    • Preventing dislocation of hip prosthesis:
      • Correct positioning using splints, wedges, pillows.
      • Keep hip in abduction when turning.
      • No hip flexion greater than 90 degrees.
    • Mobility and ambulation:
      • Early ambulation: 1 day after surgery, using a walker or crutches.
      • Weight-bearing as prescribed by the surgeon.
    • Drain use postoperatively:
      • Assess for character and amount of output.
      • Drain removed within 24 to 48 hours.
    • No crossing legs, maintain a 90-degree angle when sitting, do not turn toes inward!

    Nursing Process: Knee Replacement

    • Continuous passive motion (CPM):
      • Promotes ROM, circulation, and healing.
      • Prevents scar tissue in the knee.
      • Placed in the device immediately after surgery.
    • Physical therapy:
      • Strength and ROM exercises.
      • Ankle and calf-pumping exercises.
      • Assistive devices.
      • Ambulation on the first post-op day.
    • Acute rehab:
      • 1 to 2 weeks.
      • Total recovery 6 weeks.

    Potential Post-Operative Complications:

    • Hypovolemic shock.
    • Atelectasis (collapsed lung).
    • Pneumonia.
    • Urinary retention.
    • Constipation or fecal impaction.
    • Thromboembolism: DVT or PE.
    • Infection (surgical site, sepsis).

    MSK Disorders

    • Common Upper/Lower Extremities Conditions.
    • Low Back Pain.
    • Osteomalacia & Osteoporosis.
    • Osteomyelitis.
    • Rheumatoid Arthritis.

    Common Upper/Lower Extremity Conditions

    • Upper Extremity:
      • Impingement syndrome: inflammation of tendons and bursa in shoulder.
      • Carpal tunnel syndrome: compression of the median nerve in the wrist.
      • Dupuytren's contracture: thickening and tightening of the fascia in the palm of the hand.
    • Lower Extremity:
      • Hallux valgus: bunion, deviation of the big toe toward the other toes.
      • Hammer toe: abnormal flexion of the toe.
      • Plantar fasciitis: inflammation of the plantar fascia, the thick band of tissue on the bottom of the foot.

    Low Back Pain: Assessment

    • Interview:
      • Detailed pain assessment: OPQRST (onset, provocation, quality, radiation, severity, timing)
      • Leg weakness?: Radiculopathy (pinched nerve, sciatica, cervical, thoracic).
      • Description of how the pain has been managed by the patient.
      • Work and recreational activities.
    • Physical exam:
      • Spinal curvature, back and limb symmetry.
      • Palpate paraspinal muscles.
      • Assess movement ability and effects on ADLs (Activities of Daily Living)
      • DTRs (Deep Tendon Reflexes), sensation, muscle strength.
      • Assess posture, position changes, and gait.

    Low Back Pain: Diagnosis

    • Acute pain.
    • Impaired physical mobility.
    • Activity intolerance.
    • Self-care deficit.

    Low Back Pain: Planning/Implementation

    • Education:

      • Pain management: educate and administer.
      • Exercise: as tolerated.
      • Back conservation techniques: body mechanics.
      • Stress reduction.
      • Health promotion: activities to promote a healthy back.
      • Dietary plan and encouragement of weight reduction.

    • Work modifications: sitting vs. standing as needed.### Rheumatoid Arthritis

    • Chronic, autoimmune, inflammatory disorder.

    • Attacks the lining of joints, causing painful swelling, bone erosion, and joint deformity.

    • Pain is worse in the morning and after inactivity.

    • Most common in females aged 40-60 years.

    • Anti-rheumatic drugs slow progression and NSAIDs can help with pain.

    • Tai chi and fish oil are alternative forms of treatment.

    Osteoarthritis

    • Degeneration of cartilage.
    • Pain worsens with activity throughout the day.

    Joint Dislocations

    • Dislocation: distal and proximal bones forming a joint are no longer in anatomical alignment.
    • Subluxation: partial dislocation that does not cause as much deformity as a complete dislocation.
    • Signs and symptoms include:
      • Pain
      • Swelling
      • Deformity of the affected joint
    • Interventions include:
      • Immobilization of the joint (splint, cast, traction).
      • Analgesia, muscle relaxants, and possibly anesthesia to reduce the dislocation.
      • Neurovascular assessments before and after reduction.
      • Physical therapy to restore range of motion (ROM) and strength.
      • Patient education.
    • Complications include:
      • Increasing pain despite analgesia, numbness, and tingling (6 Ps) → Compartment syndrome.

    Fractures

    • Closed or simple fracture: No break in the skin.
    • Open or compound/complex fracture: Wound extends to the bone (may involve amputation if severe).
    • Intra-articular fracture: Extends into the joint surface of a bone.

    Manifestations of a Fracture

    • Acute pain
    • Loss of function
    • Deformity
    • Shortening of the extremity (e.g., hip fracture = shortened, externally rotated).
    • Crepitus (note on assessment, never try to feel for this, but note if it happens)
    • Local swelling and discoloration.
    • Diagnosis by symptoms and radiography.
    • Patient usually reports an injury to the area.

    Emergency Management of a Fracture

    • Immobilize the body part.
    • Splinting: Support and immobilize joints distal and proximal to the fracture.
    • Assess neurovascular status.
    • Open fracture: Prevent contamination, cover with a sterile dressing.
    • Do not attempt to reduce the fracture.

    Medical Management of a Fracture

    • Closed fracture: Uses manipulation and manual traction (skin or skeletal traction may be used).
    • Open fracture: Internal fixation devices hold bone fragments in position (metallic pins, wires, screws, plates).
    • Immobilization: External (cast, splints) or internal fixations.

    Management of Specific Fractures

    • Pelvic fractures:
      • Management depends on the type and extent of the fracture and associated injuries.
      • Stable fractures are treated with a few days of bed rest and symptom management.
      • Early mobilization reduces problems related to immobility.
      • Unstable fractures happen at articulating surfaces like at joints and ligaments; treated by stabilizing pelvic bones and compressing any bleeding vessels with the pelvic girdle.
    • Femoral shaft fractures:
      • Lower leg, foot, and hip exercises to preserve muscle function and improve circulation.
      • Physical therapy, ambulation, and weight bearing are prescribed.
      • Active and passive knee exercises are begun as soon as possible to prevent restriction of knee movement.
      • Risk for vascular compromise, muscle spasms.
      • Anticipate skeletal traction for stabilization.

    Complications of Fractures

    • Early complications:
      • Hypovolemic shock
      • Fat embolism
      • Compartment syndrome
      • Venous thromboembolism (VTE) (deep vein thrombosis (DVT), pulmonary embolism (PE))
    • Delayed complications:
      • Delayed union, malunion, and nonunion (failure to reach proper healing by 6 months).
      • Avascular necrosis of bone (bone tissue dies).
      • Complex regional pain syndrome (CRPS): Chronic condition that affects a limb after injury.
      • Heterotopic ossification: New bone grows in unexpected areas.
    • Secondary:
      • Pressure ulcers
      • Disuse syndrome

    Fat Embolism

    • Fat globule moves into the bloodstream after a fracture of a long bone, pelvis, crush injury, or orthopedic surgery.
    • DANGEROUS: CAN BE FATAL.
    • Nurse should assess for:
      • Classical manifestations: Hypoxemia, neurologic compromise, petechial rash.
      • First symptoms: Tachypnea, dyspnea, tachycardia, hypoxia, chest pain.
    • Interventions:
      • Notify the provider immediately.
      • Call rapid response or code depending on level of consciousness (LOC).

    Amputations

    • May be congenital, traumatic, or caused by conditions:
      • Progressive peripheral vascular disease, infection, or malignant tumor.
    • Used to relieve symptoms, improve function, and improve quality of life.
    • The health care team needs to communicate a positive attitude to facilitate acceptance and participation in rehabilitation.

    Amputation Assessment:

    • Neurovascular status and function of the affected extremity or residual limb and of the unaffected extremity.
    • Signs and symptoms of infection.
    • Nutritional status.
    • Concurrent health problems.
    • Psychological status and coping.

    Amputation Nursing Diagnoses:

    • Acute pain
    • Impaired skin integrity
    • Disturbed body image
    • Grieving
    • Self-care deficit
    • Impaired physical mobility

    Amputation Planning/Implementation

    • Major goals include:
      • Relief of pain.
      • Absence of altered sensory perceptions.
      • Wound healing.
      • Acceptance of altered body image.
      • Resolution of grieving processes.
      • Restoration of physical mobility.
      • Absence of complications.
    • Relief of pain:
      • Administer analgesics or other medications as prescribed.
      • Changing position.
      • Alternative methods of pain relief: Mirror box therapy, distraction, transcutaneous electrical nerve stimulation (TENS) unit.
    • Promoting wound healing:
      • Handle limb gently.
      • Residual limb shaping (compression stocking, conditioning, prone positioning): Prone positioning to prevent flexion contractures in the residual limb.

    Amputation Evaluation

    • Pain relief
    • Understanding of education
    • Readiness to participate in self-care.

    Amputation Complications:

    • Phantom limb pain
    • Postoperative hemorrhage
    • Infection
    • Skin breakdown
    • Joint contracture (happens from positioning and protective flexion withdrawal patterns that occur due to pain and muscle imbalance as a result of amputation).

    Amputation Rehabilitation Needs

    • Psychological support:
      • Set realistic goals.
      • Encourage acceptance.
    • Prostheses fitting and use.
    • Physical therapy.
    • Vocational or occupational training and counseling.
    • Use a multidisciplinary team approach.
    • Patient teaching.

    ### Diverticulosis

    • About 30% of adults aged 50 years or younger have diverticulosis.
    • About 58% of those older than age 60 have diverticulosis.

    Inflammatory Bowel Disease

    • Crohn's disease is a chronic, recurrent inflammation of the mucosa in the bowel.
    • Crohn's disease causes deep ulcers that penetrate all layers of the bowel wall.
    • Crohn's disease can cause 3-4 stools a day with fat present in the stool.
    • Ulcerative colitis is a diffuse inflammation of the mucosal and submucosal layers of the large intestine and rectum.
    • Ulcerative colitis causes ulcers that are not deep and thickening and edema of the mucosa.
    • Ulcerative colitis can cause 5-over 20 stools a day with blood and mucus.

    ### Inflammatory Bowel Disease: Assessment

    • Assess for onset, duration and characteristics of pain, diarrhea, urgency, tenesmus, nausea, anorexia, weight loss, bleeding, and family history.
    • Assess for any alcohol, caffeine, or nicotine intake.
    • Assess bowel elimination patterns and stool.

    ### Inflammatory Bowel Disease: Planning/Implementation

    • Major goals include attainment of normal bowel elimination patterns, relief of abdominal pain and cramping, prevention of fluid deficit, maintenance of optimal nutrition and weight, avoidance of fatigue, reduction of anxiety & promotion of effective coping, absence of skin breakdown, increased knowledge of disease process, therapeutic regimen, and avoidance of complications.
    • Identify the relationship between diarrhea and food, activities, or emotional stressors.
    • Provide ready access to the bathroom or commode.
    • Encourage bed rest to reduce peristalsis.
    • Administer medications as prescribed.
    • Record stool characteristics: frequency, consistency, character, and amounts.
    • Assess and treat pain or discomfort, anticholinergic medications before meals, analgesics, positioning, diversional activities, and prevention of fatigue.
    • Assess for fluid deficit, monitor I&O, daily weight, assess for symptoms of dehydration or fluid loss, encourage oral intake, and measure to decrease diarrhea.
    • Provide optimal nutrition: elemental feedings that are high in protein and low residue or PN may be needed.
    • Reduce anxiety, use a calm manner, allow the patient to express feelings, listen, and provide patient education.
    • Educate on disease process, nutrition and diet, medications (NSAIDS, corticosteroids, anticholinergics, immunosuppressants), information sources: National Foundation for Ileitis and Colitis, and bowel resection (Crohn’s), Ileostomy (UC or Crohn’s) care if applicable.
    • Avoid complications.

    Inflammatory Bowel Disease: Complications

    • Electrolyte imbalance
    • Cardiac dysrhythmias
    • GI bleeding
    • Perforation of the bowel → peritonitis
    • Fistulas
    • Megacolon

    Gerontologic Considerations: Inflammatory Bowel Disease

    • Ulcerative Colitis is 3 times more common than Crohn’s disease.
    • Ulcerative colitis can occur at any age, but peaks between 15-30 years and again between 50-70 years old.
    • Crohn’s Disease can occur at any age, most likely diagnosed around 30 years old.

    Intestinal Obstruction

    • Intestinal obstruction prevents the normal flow of intestinal contents through the intestinal tract.
    • Mechanical obstruction:
      • Intraluminal obstruction or mural obstruction from pressure on the intestinal wall.
    • Functional or paralytic obstruction:
      • The intestinal musculature cannot propel the contents along the bowel.
      • The blockage also can be temporary and the result of the manipulation of the bowel during surgery.

    ### Mechanical Obstructions (physical blockage)

    • Strangulated hernia
    • Tumors
    • Adhesions (from scar tissue)
    • Fecal impaction
    • Volvulus (twisting of bowel)
    • Intussusception (telescoping of bowel)

    ### Functional/Paralytic obstruction

    • Paralytic ileus (absence of peristalsis)
      • Due to abdominal or spinal surgery
      • Due to peritonitis
      • Lack of blood supply to intestines
      • Electrolyte imbalances (e.g., low potassium)

    Intussusception

    • Check for blood and mucus in stools (red currant jelly appearance)
    • This is an emergency!
    • Blood and mucus may be in stools, jelly stools

    Intestinal Obstruction: Management

    • Maintain the function of the nasogastric tube.
    • Assess and measure the nasogastric output.
    • Assess for fluid and electrolyte imbalance.
    • Monitor nutritional status.
    • Assess for manifestations consistent with resolution.
      • Return of normal bowel sounds, passage of flatus or stool, decreased abdominal distention, subjective improvement in abdominal pain and tenderness.
    • Slowly reintroduce diet and monitor tolerance.

    Metabolic Functions of the Liver

    • Glucose metabolism
    • Drug Metabolism
    • Protein metabolism:
      • Ammonia byproduct
    • Fat metabolism
      • Bile formation
    • Ammonia conversion:
      • Converts ammonia to urea (water soluble substance secreted in urine)
    • Vitamin and iron storage
    • Bile formation
    • Bilirubin excretion
      • Buildup plays a role in jaundice

    ### Assessment: Manifestations of Liver Dysfunction

    • Jaundice
    • Portal hypertension
    • Ascites and varices
    • Hepatic encephalopathy or coma
    • Nutritional deficiencies

    Assessment: Liver Function Studies & Diagnostic Studies

    • Serum aminotransferase:
      • AST, ALT, GGT, GGTP, LDH
        • Indicates hepatitis, cancer, cirrhosis
    • Serum protein studies.
    • Direct and indirect serum bilirubin, urine bilirubin, and urine bilirubin and urobilinogen.
    • Clotting factors
    • Serum alkaline phosphatase (ALP)
    • Serum ammonia:
      • Can build up and affect LOC (reduce protein to avoid this)
    • Lipids
    • Diagnostic tests:
      • Liver biopsy
      • Ultrasonography, CT, MRI

    Jaundice

    • Hyperbilirubinemia:
      • Signs and symptoms:
        • Malaise, fatigue, weakness
        • Dark orange-brown urine, clay-colored stools
        • Lack of appetite, nausea or vomiting, weight loss
        • Dyspepsia, intolerance of fats
        • Pruritus:
          • Bile salt accumulation
    • Three types:
      • Hepatocellular: result of liver disease/injury
      • Hemolytic: hemolysis
      • Obstructive: obstruction along biliary tree/liver disease

    ### Portal Hypertension

    • Obstructed blood flow through the liver results in increased pressure throughout the portal venous system.
    • Commonly associated with hepatic cirrhosis and can also occur with non-cirrhotic liver disease.
    • Results in:
      • Ascites
      • Esophageal varices
      • Caput medusae
        • Sign of severe portal hypertension

    Ascites

    • Seen with cirrhosis, cancer, heart failure.
    • Contributing factors:
      • Portal hypertension resulting in increased capillary pressure and obstruction of venous blood flow.
      • Vasodilatation of splanchnic circulation (blood flow to the major abdominal organs).
      • Changes in the ability to metabolize aldosterone, increasing fluid retention.
      • Decreased synthesis of albumin, decreasing serum osmotic pressure.
      • Movement of albumin into the peritoneal cavity.

    Ascites: Assessment

    • Daily abdominal girth and weight.
    • Striae, distended veins, or umbilical hernia.
    • Potential fluid and electrolyte imbalances.

    Ascites: Treatment

    • Low-sodium diet.
    • Diuretics
      • Potassium sparing
    • Bed rest and positioning to promote respiratory efficiency, decrease risk for injury.
    • Paracentesis
      • Monitor during this is over 1 liter in a session is removed.
    • Administration of salt-poor albumin (SPA)
    • Transjugular intrahepatic portosystemic shunt (TIPS)
      • Shunt

    Hepatic Encephalopathy

    • Two major alterations underlie its development in acute and chronic liver disease:
      • Hepatic insufficiency: the inability of the liver to detoxify toxic by-products of metabolism (e.g., salts, urea, ammonia)
      • Portosystemic shunting: collateral vessels develop allowing elements of the portal blood (laden with potentially toxic substances usually extracted by the liver) to enter the systemic circulation.
    • Early signs: mental changes and motor disturbances.
      • Can be reversed when caught early.
    • Later stages: Life-threatening.

    Hepatic Encephalopathy: Assessment

    • Assess for:
      • Confusion
      • Lethargy
      • Drowsiness
      • Coma

    Stages of Hepatic Encephalopathy

    • Stage 1: Mild confusion, changes in mood, sleep disturbances
    • Stage 2: Lethargy, slurred speech, disorientation,asterixis (flapping tremor)
    • Stage 3: Stupor, confusion, inappropriate behavior, increased deep tendon reflexes, asterixis
    • Stage 4: Coma

    Hepatic Encephalopathy: Treatment

    • Eliminate the precipitating cause.
    • Lactulose to reduce serum ammonia levels.
    • Protein restriction.
    • Reduction of ammonia from GI tract by gastric suction, enemas, oral antibiotics.
    • Discontinue sedatives, analgesics, and tranquilizers.
    • Monitor or treat complications and infections.

    Portal Systemic Shunts

    • Treats portal pressure

    Transjugular Intrahepatic Portosystemic Shunt (TIPS)

    • TIPS is a shunt (tube) placed between the portal vein which carries blood from the intestines and intraabdominal organs to the liver and the hepatic vein which carries blood from the liver back to the vena cava and the heart.
    • Complications: bleeding, sepsis, HF, thrombosis, organ perforation, progressive liver failure.
    • Second line therapy for refractive ascites.

    Abdominal Paracentesis

    • Sterile, invasive procedure to drain peritoneal fluid.
    • Fluid specimen for analysis.
    • Nursing Diagnoses:
      • Ineffective breathing pattern
      • Activity intolerance
      • Risk for infection
    • Complications:
      • Infection, shock, bleeding, peritonitis
      • Do not remove over 1 liter during each episode.
    • Interventions:
      • Monitor vital signs, daily weights, measure abdominal girth daily, nutritional supplementation.

    Esophageal Banding

    • Treats esophageal varices.
    • Removes varix

    Endoscopic Sclerotherapy

    • Sclerosing agent is injected through a fiberoptic endoscope into bleeding esophageal varices to promote local coagulation and eventual sclerosis of bleeding site → slough off.
    • Complications: chest pain, mucosal ulcerations, rebleeding, bacteremia → sepsis and pleural effusions.
    • Replaced by esophageal banding.

    Hepatic Disorders

    • Esophageal varices
    • Hepatitis
    • Hepatic cirrhosis
    • Fatty liver

    Esophageal Varices

    • Occurs in ~1/3 of patients with cirrhosis and portal hypertension.
    • First bleeding episode has a mortality rate of 10—30% depending on severity.
    • Manifestations:
      • Hematemesis, melena, general deterioration, and shock.
      • Patients with cirrhosis should undergo screening endoscopy every 2—3 years.

    Esophageal Varices: Nursing Diagnoses

    • Esophageal Varices
      • Risk for bleeding
      • Imbalanced Nutrition (NPO)
    • Bleeding Varices
      • Risk for aspiration
      • Fluid volume deficit
      • Risk for shock

    ### Treatment for Bleeding Varices: Medications

    • EMERGENCY.
    • Treat for shock; administer oxygen.
    • IV fluids, electrolytes, volume expanders, blood and blood products.
    • Vasopressin, somatostatin, octreotide to decrease bleeding.
    • Nitroglycerin in combination with vasopressin to reduce coronary vasoconstriction.
    • Propranolol and nadolol to decrease portal pressure; used in combination with other treatment.

    ### Treatment for Bleeding Varices: Procedures

    • Balloon tamponade:
      • Tube placed in the esophagus that compresses the walls to stop bleeding.
    • Endoscopic sclerotherapy.
    • Endoscopic variceal ligation (esophageal banding therapy).
    • Transjugular intrahepatic portosystemic shunt.
    • Surgical management.

    Bleeding Esophageal Varices: Management

    • Maintain a safe environment; prevent injury, bleeding and infection.
    • Administer prescribed treatments and monitor for potential complications.
      • chest pain, mucosal ulcerations, re-bleeding, bacteremia sepsis.
    • Encourage deep breathing and position changes. Education and support of patient and family.

    Hepatitis

    • A systemic viral infection that causes necrosis and inflammation of liver cells with characteristic symptoms and cellular and biochemical changes.
      • A and E: fecal–oral route.
      • B and C: bloodborne.
      • D: only people with hepatitis B are at risk.
    • Non-viral hepatitis: toxin and drug induced.

    5 Types of Hepatitis

    • A: from poor hand hygiene.
    • B: from blood or body fluid; major cause of cirrhosis and liver cancer.
    • C: from blood, sexual contact, needle sticks, most common blood borne infection.
      • Screening, safe needles.
    • D: only people who had Hep B are at risk.
    • E: only people who had Hep A can get it.

    Hepatic Cirrhosis

    • Types:
      • Alcoholic: scar tissue characteristically surrounds the portal areas.
      • Post-necrotic: broad bands of scar tissue.
      • Biliary: scarring occurs in the liver around the bile ducts.
    • Manifestations:
      • Liver enlargement, portal obstruction, ascites, infection and peritonitis, GI varices, edema, vitamin deficiency, anemia, mental deterioration.

    Hepatic Cirrhosis: Planning/Implementation

    • Medications:
      • Diuretics, anti-HTN, ammonia reducers, antibiotics.
    • Promoting rest:
      • Rest and supportive measures.
      • Positioning for respiratory efficiency.
      • Oxygen.
      • Planned mild exercise and rest periods.
      • Measures to prevent hazards of immobility.
    • Improving nutritional status:
      • I&O.
      • Encourage small frequent meals.
      • High-calorie diet, sodium restriction.
      • Protein modified if the patient is at risk for encephalopathy.
      • Keep daily protein between 1.2 and 1.5 g/kg per day.
      • Supplemental vitamins, minerals, B complex, provide water-soluble forms of fat-soluble vitamins if the patient has steatorrhea.
    • Providing skin care:
      • Frequent position changes.
      • Reduce scratching related to pruritus.
      • Gentle skin care, creams, antihistamines.
    • Reducing risk of injury:
    • Prevent falls, trauma related to risk for bleeding.
    • Monitoring and managing potential complications.

    Hepatic Cirrhosis: Complications

    • Hemorrhage
    • Hepatic encephalopathy
    • Fluid volume excess
    • Death

    Medications to Treat Liver Dysfunction

    • Lactulose to reduce ammonia levels.
      • Results in bowel movements
    • Immunize for hepatitis A, B; pneumonia; and annual influenza.
    • Nutritional supplements.
    • Vitamins (folic acid, vitamin B1, B6, B12).

    Gerontologic Considerations

    • Many older adults take multiple medications for a variety of health conditions.
    • Drug metabolism occurs mainly in the liver, and thus, may result in hepatotoxicity.
    • Due to aging, the underlying liver function is reduced, therefore, predisposing the elderly to reduced ability to tolerate adverse drug effects and the effects of alcohol

    Fatty Liver Disease (Steatosis)

    • Non-Alcoholic (simple):
      • Lipids accumulate in the hepatocytes.
      • Liver failure symptoms.
      • Reversible with lifestyle change.
      • Symptoms: malaise, N/V, discomfort in the abdomen
    • Subtype = Nonalcoholic steatohepatitis (NASH):
      • Inflammatory.
      • More extreme form, inflammation present that can lead to cirrhosis “scarring”
    • Alcoholic:
      • Due to heavy alcohol use.
      • Causes liver damage.
      • Liver failure symptoms + jaundice.
      • Symptoms: jaundice, malaise, N/V, discomfort in the abdomen
      • Leads to alcoholic hepatitis and cirrhosis.
    • Risk factors: obesity, diabetes, high blood pressure

    Acetaminophen

    • Most common cause of acute liver failure in the USA.
    • What is the maximum dose of acetaminophen for a 24-hour period?
      • 4g
    • Educate patients on meds they are taking.

    ### Functions of the MSK System

    • Protect vital organs, framework that supports body structures and mobility, movement, producing heat, maintaining body temperature, facilitating return of blood to heart, reservoir for immature blood cells and vital minerals.
    • Bones, muscles, joints
    • Joints:
      • Arthritic, moveable joints (skull)
      • Anti-arthritic joints, limited movement (vertebral)
      • Freely movement joints (shoulder
    • Flaccidity: lower motor neuron lesion (muscle dystrophy)
    • Spasticity: upper motor neuron lesion (CP)
    • Bone is in a constant state of turnover.
      • Nutrients in the diet (Ca, vitamin D)
      • Environment (physical activity)

    Gerontologic Considerations

    • Fragile bones.
    • Stumbling and falls from muscle weakness.
    • Stiff joints.
    • Osteoarthritis, joint swelling
      • Dependent on diet, lifestyle, and comorbidity

    Assessment: Health History

    • Include data related to functional ability
      • ADLs
      • IADLs
    • Past health, social, and family history
    • General health maintenance; occupation
    • Medications
      • Prescription & OTC
    • Learning needs; socioeconomic factors

    Assessment: Physical Assessment

    • Pain, tenderness, altered sensation.
    • Posture and gait.
    • Bone integrity.
    • Joint function
    • Muscle strength and size.
    • Skin
    • Neurovascular status
      • Important because musculoskeletal injury can cause other tissue and nerve damage.
      • Circulation, Motion, Sensation exams.
      • 6 P’s:
        • Pallor
        • Poikilothermia: inability to regulate temp, cold
        • Pulselessness
        • Paralysis
        • Pain
        • Paresthesia

    Diagnostic Tests

    • Radiographs
    • Computed tomography
    • MRI
    • Bone densitometry:
      • Detects osteopenia (weak bones from bone breakdown faster than its being replaced); predecessor to osteoporosis
    • Bone scan:
      • Injection of tracer or radioisotope distributed throughout the body and gets picked up in hotspots where there is increased bone metabolism (i.e.

    Nursing Interventions: Diagnostic Studies

    • MRI
      • Patients may hear knocking sounds
      • Assess for contraindications, such as implanted metal objects.
      • Screen for allergies to contrast media.
    • Biopsy
      • Monitor biopsy site for signs of bleeding and edema.
      • Administer analgesics and antibiotics to prevent infection.
    • Bone Scan
      • Screen for allergies to radioisotopes.
      • Encourage patients to hydrate before and after the scan to help distribute and flush out the isotope.
      • It typically takes 2-4 hours for the isotope to circulate.

    Nursing Interventions: MRI Studies

    • Remove all metal objects from patients before the MRI, including the following.
      • Credit cards with magnetic strips; non-removable cochlear devices.
      • Check pacemakers for compatibility with the MRI.
      • Remove transdermal patches that have a thin layer of aluminized backing.

    Musculoskeletal Care Modalities

    • Splints, Braces, and Casts
      • Provide support and immobilization, custom fitted with various materials.
    • External Fixators
      • Used for complex fractures to stabilize the bone and hold it in place.
    • Traction
      • Skin traction and skeletal traction are used to immobilize and realign fractures and reduce deformities.
    • Orthopedic Surgery
      • Joint replacement surgery is performed to repair damaged joints.

    Splints & Braces

    • Splints
      • Contoured splints made of plaster or thermoplastic material are ideal for:
        • Conditions that do not require rigid immobilization.
        • Patients who may experience swelling.
        • Individuals who require extra skin care.
    • Braces
      • Custom-fitted, longer-term orthopedic devices used to:
        • Provide support.
        • Control movement.
        • Prevent further injury.
        • TLSO brace (thoracolumbosacral orthotic): Used for sustained spinal surgery.

    Casts & Cast Care

    • Casts
      • Rigid, external immobilizing devices used for:
        • Immobilize reduced fractures.
        • Correct or prevent deformities.
        • Apply uniform pressure to underlying soft tissues.
        • Support weakened joints.
    • Cast Materials
      • Non-plaster (fiberglass) and plaster of Paris (heavy, white, thicker) materials are both used.
      • Plaster Casts: Used for more severe injuries.

    Cast Types

    • Arm cast
      • Applied to either the entire arm, or just the forearm.
    • Leg cast
      • Applied to either the entire leg, or just the lower leg.
    • Walking cast
      • Rocker boot is used to aid in walking.
    • Spika cast
      • Shoulder spika: Encircles the trunk, shoulder, and elbow.
      • Hip spika: Encircles the trunk and extremities, with an open center for bowel and urinary elimination.

    Nursing Process: Casts, Splints, Braces

    • Assessment
      • Perform general health assessment.
      • Evaluate the patient's emotional status and readiness to learn.
      • Identify the patient's presenting signs and symptoms and condition of the affected area.
      • Conduct neurovascular assessments using the “6 Ps”.
    • Nursing Diagnosis
      • Acute pain
      • Impaired physical mobility
      • Risk for disuse syndrome: Encourage patients to perform exercises to help prevent muscle atrophy.
    • Planning/ Implementation
      • Prepare the patient for the procedure by explaining the process and purpose.
      • Treat lacerations and abrasions before applying the cast, brace, or splint.
      • Document the exact site, character, and intensity of pain.
      • Implement Rice therapy:
        • R = Rest: Limit movement of the affected area.
        • I = Ice: Apply ice packs to the affected area for 15-20 minutes on and off, every hour, for the first 24-48 hours to prevent swelling.
        • C = Compression: Elevate the affected area to promote venous return and reduce swelling.
        • E = Elevation: Raise the affected area above the level of the heart to encourage venous return.
      • Monitor neurovascular status for potential complications.
    • Evaluation
      • Assess patient understanding of patient education, including RICE therapy, complications, and emergency contact information.
      • Evaluate the effectiveness of pain medication.
      • Continuously assess for neovascular changes.
    • Documentation
      • Accurately document findings, interventions, and patient response.

    Rheumatoid Arthritis

    • Character
      • Chronic autoimmune disease that causes inflammation and pain.
      • Attacks the lining of the joints, leading to swelling, bone erosion, and joint deformity.
      • Pain is often worse in the morning and after periods of inactivity.
    • Epidemiology
      • Most common in women aged 40-60 years.
    • Treatment
      • Anti-rheumatic drugs slow the progression of the disease.
      • NSAIDs are used to manage pain.
      • Alternative forms of treatment such as Tai chi and fish oil.
    • Difference from Osteoarthritis
      • Osteoarthritis (OA) involves the degeneration of cartilage in the joints, leading to pain that worsens with activity later in the day (PM).

    Joint Dislocations

    • Description
      • A dislocation occurs when the distal and proximal bones that form a joint are no longer aligned.
      • Subluxation is a partial dislocation that causes less deformity than a complete dislocation.
    • Signs/Symptoms
      • Pain
      • Swelling
      • Deformity of the affected joint
    • Interventions
      • Immobilize the joint with splints, casts, or traction.
      • Administer analgesics, muscle relaxants, and possibly anesthesia to reduce the dislocation.
      • Conduct neurovascular assessments before and after reduction.
      • Refer to physical therapy for range of motion and strength restoration.
      • Provide patient education about the condition and recovery process.
    • Complications
      • Increased pain despite analgesia, numbness, tingling (6 Ps) may indicate compartment syndrome.

    Fractures

    • Types
      • Closed or simple: No break in the skin.
      • Open or compound/complex: Wound extends to the bone, may involve amputations if severe.
      • Intra-articular: Extends into the joint surface of a bone.

    Manifestations of Fracture

    • Common Signs and Symptoms
      • Acute pain
      • Loss of function
      • Deformity
      • Shortening of the extremity, for example: Hip fracture = shortened and externally rotated.
      • Crepitus: Note on assessment, never try to feel for this, but note if it happens. It's caused by rubbing of bone fragments against each other.
      • Local swelling
      • Discoloration
    • Diagnosis
      • Diagnosis is typically made based on symptoms and radiography.

    Emergency Management of a Fracture

    • Immobilization
      • Immobilize the affected body part.
      • Splinting supports and immobilizes joints distal and proximal to the fracture.
    • Neurovascular Assessments
      • Assess neurovascular status.
    • Open Fractures
      • Prevent contamination by covering the open fracture with a sterile dressing.
    • Reduction (do not perform)
      • Do not attempt to reduce the fracture.
    • Medical Management
      • Closed Reduction: Uses manipulation and manual traction. Traction may be used (skin or skeletal).
      • Open Reduction: Internal fixation devices hold bone fragments in place (metallic pins, wires, screws, plates).
      • Immobilization: External immobilization (casts, splints) or internal fixation devices.

    Management of Specific Fractures

    • Pelvic Fractures
      • Treatment depends on the type, extent of fracture, and associated injuries.
      • Stable fractures are treated with limited bed rest and symptom management.
      • Early mobilization can prevent complications.
      • Unstable fractures require stabilization of the pelvic bones and compression of any bleeding vessels.
    • Femoral Shaft Fractures
      • Patient requires lower leg, foot, and hip exercises to preserve muscle function and promote circulation.
      • Physical therapy, ambulation, and weight bearing are prescribed as tolerated.
      • Perform active and passive knee exercises ASAP to prevent restrictions.
      • Watch for signs of vascular compromise and muscle spasms.
      • Anticipate skeletal traction for femoral shaft fractures.

    Complications of Fractures

    • Early Complications
      • Hypovolemic shock
      • Fat embolism
      • Compartment syndrome
      • Venous thromboembolism (VTE): DVT, PE
    • Delayed Complications
      • Delayed union, malunion, and nonunion: Failure to reach proper healing by 6 months.
      • Avascular necrosis of bone: Bone tissue dies from a lack of blood supply.
      • Complex regional pain syndrome (CRPS): Chronic condition affecting a limb after an injury.
      • Heterotopic ossification: New bone growth in unexpected areas.
    • Secondary Complications
      • Pressure ulcers
      • Disuse syndrome

    Fat Embolism

    • Description
      • Fat globules enter the bloodstream after trauma, such as a fracture of a long bone, pelvis, or crush injury, or following orthopedic surgery.
    • Danger
      • Can be fatal.
    • Assessment
      • Monitor patients for signs of fat embolism, including:
        • Classical manifestations: Hypoxemia, neurologic compromise, petechial rash
        • Early symptoms: Tachypnea, dyspnea, tachycardia, hypoxia, chest pain
    • Intervention
      • Immediately notify the provider.
      • Call for a rapid response or code blue, depending on the patient's level of consciousness.

    Amputations

    • Causes
      • Congenital birth defects or traumatic injuries.
      • Conditions such as progressive peripheral vascular disease, infection, or malignancy.
    • Purpose
      • Relieve symptoms
      • Improve function
      • Enhance quality of life
    • Role of the Healthcare Team
      • Communicate a positive attitude to facilitate acceptance and participation in rehabilitation.

    Amputation: Assessment

    • Neurovascular Status
      • Assess the neurovascular status and function of the affected extremity, residual limb, and unaffected extremity.
    • Signs of Infection
      • Screen for signs and symptoms of infection.
    • Nutritional Status
      • Evaluate nutritional status.
    • Concurrent Health Problems
      • Identify concurrent health problems.
    • Psychological Status and Coping Skills
      • Assess the patient's psychological status and coping skills.

    Amputation: Nursing Diagnosis

    • Potential Nursing Diagnoses:
      • Acute pain
      • Impaired skin integrity
      • Disturbed body image
      • Grieving
      • Self-care deficit
      • Impaired physical mobility

    Amputation: Planning/Implementation

    • Major Goals:
      • Relief of pain
      • Absence of altered sensory perceptions
      • Wound healing
      • Acceptance of altered body image
      • Resolution of grieving processes
      • Restoration of physical mobility
      • Absence of complications.
    • Pain Relief
      • Administer analgesics or other medications as prescribed.
      • Change the patient's position.
      • Use alternative pain relief methods, including:
        • Mirror box therapy
        • Distraction
        • TENS unit
    • Promoting Wound Healing
      • Handle the limb gently.
      • Engage in residual limb shaping techniques:
        • Compression stockings
        • Conditioning exercises
        • Prone positioning to prevent flexion contractures in the residual limb.
    • Evaluation
      • Evaluate pain relief.
      • Assess patient understanding of education.
      • Determine the patient's readiness to participate in self-care.

    Amputation: Complications

    • Common Complications:
      • Phantom limb pain
      • Postoperative hemorrhage
      • Infection
      • Skin breakdown
      • Joint contracture, often caused by positioning and protective flexion withdrawal patterns due to pain and muscle imbalance.

    Amputation: Rehabilitation Needs

    • Psychological support
      • Develop realistic goals with the patient.
      • Encourage acceptance of the amputation.
    • Prosthetic fitting and use
      • Provide prosthesis fitting and instruction on use.
    • Physical therapy
      • Refer to physical therapy for strengthening and conditioning.
    • Professional Counseling
      • Provide vocational or occupational training and counseling as needed.
    • Multidisciplinary Approach
      • Utilize a multidisciplinary team approach to assist with rehabilitation.
    • Patient teaching
      • Provide thorough patient education about the condition, recovery process, and self-care techniques.

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