Mid-State Technical College Learning Plan 1 Exam Guide PDF

Learning Plan 1 Exam Guide to Study =================================== **(4 SATA questions) (2 NGN questions) (60 questions total)** **[End-of-Life Unit 1: ]** **[End-Of-Life- Overview]- (2 questions)** **What is Multiple organ dysfunction syndrome (MODS)?** - **Inadequate blood flow = cells...

Learning Plan 1 Exam Guide to Study =================================== **(4 SATA questions) (2 NGN questions) (60 questions total)** **[End-of-Life Unit 1: ]** **[End-Of-Life- Overview]- (2 questions)** **What is Multiple organ dysfunction syndrome (MODS)?** - **Inadequate blood flow = cells deprived of O2 -- anaerobic metabolism with acidosis, hyperkalemia, and tissue ischemia** - **Dramatic changes in vital organs = leads to release of toxic metabolites and destructive enzymes** - **Metabolites trigger small clots to form = block tissue oxygenation and damages more cells** - **Triggers hypoxia, acidosis and lethal dysrhythmias = decrease in cardiac output** **What is a "good vs bad" death?** - **Good death = free from avoidable distress and suffering for client, family and caregivers -- in agreement with pts and family's wishes and consistent with clinical practice standards** - **Bad death = pain, not having wishes followed, isolation, abandonment, constant agonizing about losses associated with death** **What are the 4 goals for end of life?** - **Identify client needs** - **Control symptoms of disease** - **Promote meaningful interactions between the client and significant others** - **Facilitate a peaceful death** **[Palliative Care] - Definitions, what does it involve, what is the philosophy?** - **Philosophy that provides a compassionate and supportive approach to clients and families** - **A holistic approach that does not hasten or postpone death** - **Involves the interdisciplinary team** - **Other medical treatments may also be used** **[Hospice Care] -- D**efinition and philosophy? What does it involve? - An interdisciplinary approach facilitates both quality of life and a good death for clients who are nearing the end of their lives - Care is toward comfort -- not reversing or curing disease - Often affiliated with home care agencies, providing services to families at home, in an extended care facility, hospitals, and hospice homes **[End-Of-Life -Clinical Manifestations & Management] -- (2 questions)** **What are general S/SX AND Management of approaching death for:** - **Neurosensory system** - **Difficulty in communication** - **Decreased LOC** - **Sight: blurring vision, sinking and glassy stare of eyes, blink reflex absent, eyelids remain half open** - **Taste/Smell: decreasing as death approaches** - **Touch: decreased sensation, decreased perception of pain and touch** - **Hearing: last to go** - **Fatigue and weakness** - **Restlessness** - **Medication: lorazepam (Ativan)** - **Cardiovascular system** - **Decreased BP, heart rate, and respiratory rate** - **Problems regulating temperature -- too high or too low** - **Skin may become mottled or discolored; cyanosis on nose, nail beds, knees; "waxlike" yellowish, grey or pasty color as death approaches** - **Do not use electrically heated items** - **Assess skin, prevent skin breakdown, treat wounds if present, reposition Q2** - **Respiratory changes- Cheyne-Stokes Breathing & Dyspnea** - **Dyspnea and breathlessness** - **Morphine sulfate -- low dose** - **Alters the perception of air hunger and reduces pulmonary congestion by dilating blood vessels** - **Diuretics -- bronchodilators -- antibiotics** - **Sedatives, oxygen, and anti-anxiety drugs** - **Cheyne-Stokes: breathing becomes irregular, with brief periods of apnea or shallow breathing to terminal gasps** - **Elevate the person's head** - **Position the person on their side** - **Fan or air conditions to move air** - **Administer O2 as ordered** - **Congestion and gurgling -- death rattle** - **Turn client to side** - **DO NOT SUCTION** - **Medications** - **Scopolamine -- transdermal (3 days onset)** - **Glycopyrrolate (15-30 minutes)** - **Atropine drops (40 minutes)** - **GI system** - **Food and fluid need changes** - **Constipation** - **Slowing of digestive tract and cessation of function; distention and nausea** - **DO NOT FORCE A CLIENT TO EAT** - **Offer ice chips or small sips of liquids, frozen Gatorade, or juice at frequent intervals if the person is alert** - **Use glycerin swans to keep the mouth moist and comfortable** - **Coat the lips with lip balm or petroleum jelly** - **Anorexia and nausea/vomiting** - **Frequent meals with small portions of favorite foods** - **IV hydration can cause more issues** - **Fluid replacement can lead to respiratory secretions, increased GI secretions, N/V, edema and ascites** - **Ability to swallow goes away** - **Aspiration precautions** - **GU system** - **Decreased urinary output** - **Incontinence** - **Keep the area clean and dry** - **Use urine catheters if it provides more comfort** - **Pain** - **Causes:** - **Tissue damage** - **Bone metastasis, mucositis, skin lesions, fractures** - **Use opioids and anti-inflammatory medications, steroids and radiation** - **Stimulation of autonomic nervous system** - **Visceral gut pain syndrome** - **Use opioids and anticholinergics** - **Neuropathic pain** - **Shingles, neuropathy, HIV, chemo** - **Use opioids and tricyclic antidepressants or anticonvulsants** - **Medications should be scheduled to prevent any recurrence of pain -- "round the clock" works best** - **Use PRNs as well** **[End-Of-Life -- Psychosocial Support & Ethical Duty (3 question)]** **What are key concepts r/t cultural considerations at the End-of-life?** - **Must understand the cultural beliefs around death for different clients as well as pain treatment** **What are vision like experiences/hallucinations at the end-of-life? What is the key concept?** - **The person may talk to people you cannot see or hear and objects and places not visible to you** - **This does not indicate hallucination or a drug reaction** - **Do not deny, argue, contradict, explain or belittle what the person claims** - **Keep them safe however** - **Affirm the experience as part of transient form this life -- they are normal and natural** **What is the Principle of Double Effect?** - **Involves taking and action intended to have a good effect, which also has a known harmful effect** - **This is not active euthanasia** **Withdrawing/Withholding life-sustaining therapy (Passive Euthanasia) and Active Euthanasia**---what are these, what do they mean, how are they different? - **Passive euthanasia -- withholding or withdrawing treatment** - **For example: mechanical ventilation, tube feeding, ABX, IV** - **The withdraw does not directly cause the death** - **Active Euthanasia -- purposefully taking an action to directly cause death of a client** - **THIS IS NOT SUPPORTED IN THE US** **[Physical and Emotional Support]---how to best provide this to the dying patient and family members** - **Being realistic** - **Encouraging reminiscence** - **Promoting spirituality** - **Assess for and assist with spiritual distress** - **Avoiding explanations of the loss** - **Avoid trite assurances** - **Don't cry, things will be fine** - **Presence = being there** - **Provide information about the signs of death** - **Communicating with the client** - **Providing referrals to bereavement specialists** **[Postmortem Care]---**what does this include? - Legal considerations - Death certificate -- MD or coroner must pronounce the client dead - Determination of the need for an autopsy - Transfer the body **[Musculoskeletal Disorders:]** **[Osteoporosis] (1 question)** What is osteoporosis vs osteopenia? - Osteoporosis: metabolic disease in which bone demineralization results in decreased density and possible fractures - Osteopenia: low bone mass, occurs wen there is a disruption in the bone remodeling process What are the most common sites affected? - Wrist, hip, vertebral column [Three classifications of osteoporosis] - Cause of each? Examples of each? Risk factors for each? - Primary - Postmenopausal women and men over the age of 70 - Secondary - Results from an associated medical condition - Hyperparathyroidism - Long term drug therapy - Long term immobility - Regional - Occurs when a limb is immobilized - Fracture - Injury - Paralysis What are the key teaching points for prevention? - Teach: - Ensure adequate calcium intake - Avoid a sedentary lifestyle - Do weight-bearing exercises daily - Limit alcohol intake - Quit smoking **[Osteoporosis Assessment & Diagnosis] (1 question)** What are the physical Assessment findings for osteoporosis? - Inspect: - Posture - Kyphosis - Loss of height - Occurrence of back pain - With lifting, bending or stooping - Relieved by rest - Restricted movement - Constipation - Abdominal distention - Reflux esophagitis - Respiratory compromise Lab Assessments for Osteoporosis--- Phosphate levels and ALP/BSAP levels - No definitive lab test to confirm What are the 3 Types of Radiographic Assessments- What does each measure? - Dual-energy X-ray absorptiometry (DEXA) - Baseline should occur at 65 - Measure BMD in spine or hip - Two dimensional - Quantitative computed tomography (QCT) - Three dimensional - Very high radiation dose - Quantitative ultrasound (QUS) - Effective, low cost, measures BMD of heel What is BMD- What are the T-score thresholds for normal, osteopenia & osteoporosis? - Normal: T-score of +1.0 to -1.0 - Osteopenia: T-score between -1.0 to -2.5 - Osteoporosis: T-score of less than -2.5 - THE LOWER THE T-SCORE = THE LOWER THE BMD **[Osteoporosis Treatment] (1 question)** Calcium & Vit. D \--Recommended amount needed per day - Calcium: 1000 (women) -- 1200 (men) - Vitamin D: 400-800 ui/day Signs/Symptoms of **Hypercalcemia** - **Increased heart stimulation** - **Increased muscle weakness** - **Decreased GI stimulation** **[Osteoporosis specific medications- For each: What is the method of action, side-effects, examples (including types of patients they would be used for), route, important teaching points]** - Bisphosphonates - Method of action: takes calcium from blood and puts it back into bone by binding it to crystal elements within the bone that prevents bone from breaking down - Side-effects: bone and joint pain, diarrhea, nausea, heartburn, irritation of the esophagus - Alendronate (Fosamax), Risedronate (Actonel) and Ibandronate (Boniva) - Take orally - Early in the morning - Wait 30-60 minutes before eating - Take with a full glass of water - Sit up after taking - IV -- when oral does not work - Zoledronic Acid (Reclast) - Given once a year - Pamidronate (Aredia) - Given every 3-6 months - Complications - rare -- afib - decreased kidney function - osteonecrosis (in the jaw) - Used for prevention and treatment - Offset the progression from osteopenia to osteoporosis - As well as treatment and prevention of paget disease and hypercalcemia - Who shouldn't take - PTs with GERD, hypocalcemia, and poor kidney function - Calcitonin - Treatment of osteoporosis -- not prevention - Also paget's disease and hypercalcemia - Drugs: - Miacalcin and fortical - Nasal spray and sub Q - Method of action: produced by thyroid naturally -- thyroid hormone inhibits osteoclastic activity and this decreases bone loss - Side effects: facial flushing, flushing of hands and feet - Teaching: - Used short term -- need break - Salmon based med -- needs to be refrigerated - Alternate nostrils - RANKL Inhibitors - LAST OPTION KIND OF DRUG - Treatment of osteoporosis when other drugs are not effective - Drugs: - Denosumab (Prolia) and Romosozumab (Evenity) - Given SQ twice a year - Method of action: block osteoclast maturation and function -- reduce bone reabsorption and decrease loss of bone - Side effects: back pain, joint pain, peeling of skin, redness/swelling of extremities - Parathyroid Hormones - Treatment of osteoporosis in clients with a previous fracture - Drugs: - Teriparatide (Forteo) - Daily SQ injection short-term - No more than 2 years before a break - Method of action: stimulate new bone to be formed -- increases bone density - Side effects: leg cramps. Osteosarcoma What dietary recommendations are important? What nutrients are needed for bone formation? What nutrients post-fracture period? - Need: - Protein, magnesium, vitamin K, trance minerals, calcium and vitamin D - Avoid: - Alcohol and caffeine - Post-fracture: - Protein, vitamin C, and iron Interventions for Osteoporosis \--Exercise, Pain Management, Orthotic devices- what is involved? - Hazard-free environment - Hip protectors that prevent hip fracture in case of a fall - Exercise - Pain management - Opioid, non-opioid, muscle relaxants, NSAIDS - Watch for side effects of these drugs - Orthotic devices - Immobilizes the spine, provides support **[Osteomalacia] (2 questions)** What is this? Who is at risk? - Softening of the bone tissue due to inadequate mineralization of calcium and phosphorus in the bone - (Rickets in children) - Risk - Malnutrition/poor diets - Not going outside What causes it? - Caused by vitamin D deficiency Lab values- including how labs are different than osteoporosis - Osteomalacia - Lack of vitamin D - Low to normal calcium - Low to normal phosphate - High or normal parathyroid hormone - High alkaline phosphate - Osteoporosis - Lack of calcium and estrogen or testosterone - Low calcium - Normal phosphate - Normal parathyroid hormone - Normal alkaline phosphate Looser Lines or Zones\-\--What do these mean? What disease has these? - Radiolucent bands - Represent stress fractures that have not mineralized - Diagnostic findings in osteomalacia patients - Often seen in femoral neck, ribs, and pelvis How is it treated? - Vitamin D supplements - 50,000 units weekly for 8 weeks - 800-4000 units daily for life - Diet high in Vitamin D - Oily fish - Salmon, mackerel, sardines - Egg yolks - Cereals, breads, milk and yogurts - Almonds - Tofu - Fortified rice milk - Fortified soy products **[Paget's Disease] (1 question)** What is this? Most common sites affected? - Metabolic disorder of the bone which is excessively broken down (osteoclastic activity) and reformed (osteoblastic activity) - Most common - Skill, spine, pelvis, femur, tibia What are the clinical manifestations? - Single bone or joint pain - Low back or sciatic nerve pain - Bowing of long bones - Loss of normal spine curve - Enlarged, thick skull - Pathologic fractures - Osteogenic sarcoma Interventions for Paget's Disease\-\--All 7 of them from PowerPoint- - Pain control - Aspirin, NSAIDS - If calcium level more than twice the normal - Calcitonin -- retards bone resorption - Bisphosphonates -- inhibits bone resorption - Mithramycin - Application of heat - Gentle massage - Exercise - Strengthening and weight-bearing - Orthotic devices - A diet to promote bone health When is medications used? What meds are used: **Know how the meds work, classifications, side effects, and any special interventions/teaching needed** - **For pain control** - **If calcium level is more that twice the normal** **[Osteomyelitis] (2 questions)** What is this? What causes it? - Infection of the bone - A condition caused by the invasion by one or more pathogenic microorganism that stimulates the inflammatory response in bone tissue - Endogenous -- infection from themselves - Exogenous -- comes from outside source - Contiguous -- infection at same location and moved into the bone at the same location Differences between exogenous, endogenous (hematogenous), contiguous, or Chronic \--Know examples of each - Exogenous -- comes from an outside source - Endogenous -- most common -- from bacteremia, underlying disease, nonpenetrating trauma - Contiguous -- from staphylococcus aureus - Chronic -- most commonly from gram negative bacteria Clinical manifestations of Acute vs Chronic - Acute - Temp greater than 101 - Erythema and swelling of affected area - Tenderness of affected area - Constant localized pulsating bone pain - Chronic - Ulceration of skin - Sinus tract formation - Localized pain - Drainage from affected area Interventions \--Know details about them --length of treatment, who is a candidate, etc - Drug: Antibiotics -- need IV abx for a long time - Pain control - Irrigated wounds with antibiotic solution - Infection control - Contact precautions (if drainage) - Hyperbaric Oxygen therapy - Surgical management if it is bad enough - Sequestrectomy -- remove the infected segment of bone - Bone grafts - Muscle flaps - Amputation Post-op Care for Surgeries for Osteomyelitis---Interventions, priorities, what is included in a neurovascular assessment - Elevate extremities at all times - Neurovascular assessment: - 5 Ps - Pain - Pallor - Pulselessness - Parethesia - Paralysis - Any changes notify provider ASAP **[Bone Tumors] (2 questions)** Know the examples given for each type -- when do they show up- who do they affect? - Osteochondroma -- Chondrogenic Type (from cartilage) - Onset -- childhood 10-25 - Grows until skeletal maturity - Dx -- usually adulthood - Typically painless - 40% of benign bone tumors are this type - 10% change into sarcomas - Effects more males than females - Chondroma -- Chondrogenic Type (from cartilage) - Lesion of mature hyaline cartilage affecting primarily hands and feet - Other areas often affected: ribs, sternum, spine, long bones - Often cause pathological fractures after minor fractures - Slow growing - Osteoid Osteoma -- Osteogenic type (from bone) - Pinkish, granular appearance d/t proliferation of osteoblast - Single lesion - Occurs in children and young adults -- mostly males - Usually less than 0.4 inch (1 cm) in diameter - 10% of benign bone tumors are this type - Osteoblastoma -- Osteogenic type (from bone) - Affects vertebrae and long bone - Larger than osteoid osteoma - Reddish, granular appearance - 1% of benign tumors - Affects adolescent boys and young adults -- both genders - Giant Cell Tumor -- Osteogenic Type (from bone) - Origin uncertain - Lesions are gray to reddish brown and may involve surrounding soft tissue - Arises form osteoclast cells - Affects women older than 20 -- peaks in 30s Which type is most likely to become malignant? - Ewing's Sarcoma What interventions are done? - Pain control - Non-surgical - Surgical - Curettage - Joint replacement - Arthrodesis Know the differences between primary bone tumors: Which parts of the body does each affect? Who does it affect? What are the sign/symptoms of each? (especially the differences between) - Osteosarcoma - Most common site -- femur, tibia, knee and upper arm - 50% occur in the distal femur - Affects children and young adults between the ages of 10 and 20 - Lesion typically metastasizes to the lung within 2 years - 5 year survival - Cancer that starts in the bone - Starts in areas where the bone is growing quickly - Causes acute bone pain and swelling - Warmth of area - Bone fractures - Ewing's sarcoma - Affects children and young adults between the ages of 10 and 20 - Affects bone and soft tissue - Usually develops on the shaft portion of long bones - Pelvis, scapula, clavicle, femur, tibia, ribs, humerus - Metastasis to lungs and other bones - 5-year survival - 5% of malignant bone tumors - Systemic S/S - Low-grade fever, leukocytosis, anemia, pain in area of tumor, lump or swelling, fatigue, weight loss - Chondrosarcoma - 10% of all malignant bone tumors - Typically affects pelvis, proximal femur - Causes - Dull pain and swelling for a long period of time - Lesions destroy bone and often calcifies - Better prognosis than osteosarcoma and Ewing's sarcoma - Affects middle age and older adults more What assessment is done? What labs do we look at and why? - Pain, swelling, masses and areas of tenderness - Fever, systemic problems, fatigue - Think Ewing's Sarcoma here - Functional assessment - Labs - Serum alkaline phosphatase - Hgb (anemia) - Leukocytes - Serum calcium levels - Erythrocyte sedimentation rate **[Hand and Foot Disorders] (2 questions)** What nerve does carpal tunnel syndrome affect? What is the cause of carpal tunnel? - Median nerve in the wrist becomes compressed, causing pain and numbness - Common repetitive strain injury via occupational or sports motion What symptoms does it cause? - Pain and numbness What is Phalen's maneuver? Tinel's sign? EMG study? - Phalen's : involves flexing both writs to 90 degrees by pressing the backs of the hands together and holding the position for 30-60 seconds - Tinel's : diagnostic test for nerve irritation or compression -- examiner taps lightly over the median nerve at the wrist - EMG study: evaluates the electrical activity of muscles and the nerves controlling them What is Dupuytren's contracture? What area does it affect? - Slow progressive thickening of the palmar fascia - Results in flexion contracture of the 4^th^ or 5^th^ digit of the hand Differentiate these foot disorders: What area of the foot is affected? What is the cause? Risk factors? What is the treatment? Any specific symptoms? - Morton's Neuroma - A plantar digital neuritis -- a small tumor grows in a digital nerve of the foot - Symptoms: - Pain -- acute in the entire surface of the 3^rd^ and 4^th^ toes - Burning sensation in the web space - Surgery: remove the neuroma and apply pressure dressing - Hallux Valgus - Bunion - The great toe drifts laterally at the 1^st^ metatarsophalangeal joint - Enlarges and causes pain - Causes: - Poor fitting shoes - Arthritis - Surgery: Bunionectomy - Hammertoes - Often occurs with hallux valgus deformities - Cause: - Dorsiflexion of any metatarsophalangeal joint - Most commonly affects second toe - Surgery: Osteotomies - Plantar Fasciitis - Inflammation of the plantar fascia = pain in the arch of the foot, worse with weight bearing - Located in the area on the arch of the foot - Affects: - Middle age - Older adults - Athletes - People trying to exercise more - 90% respond to conservative tx - Rest, ice, stretching exercises, strapping of the foot to maintain the arch, shoes with good support, orthotics, NSAIDS **[Pediatric Disorders] (3 questions)** What does x-linked mean? Who is affected? - Genetic inheritance where a gene is located on the x chromosomes - Males are more frequently affected, females can be mildly affected Differentiate Duchenne and Becker - What age of diagnosis? - Duchenne -- preschool age 2-6 years - Becker -- ages 5 15 - What clinical manifestations? - Duchenne: - Pelvic weakness and waddling gait - Cardiac involvement - Cognitive impairment in 1/3 of clients - Severely progressive - Inability to walk between 7-11 years - Death from cardiac or respiratory failure in mid 20s - Becker - Wasting of pelvic, thigh, and shoulder muscles - Rare cardiac and cognitive functions abnormalities - Graudal progression - Inability to walk 25 years ager onset - Longer life span - What body systems are affected? - Duchenne -- Cardiac, neuro, respiratory - Becker -- muscular - What is the progression? - Duchenne -- severely progressive - Becker -- gradual progression - Life span? - Duchenne -- mid 20s - Becker -- longer life span What happens in scoliosis? How is it different from Lordosis and Kyphosis? - Changes in muscles and ligaments of the spinal column - Cause the spinal column to move into a lateral curve more than 10 degrees - Lordosis -- concave curvature, lumbar spine - Kyphosis -- front to back curvature of the thoracic spine, typically 20-40 degrees, usually accompanies scoliosis How does the nurse assess for scoliosis? - Pain, posture, and gait - Standing assessment and forward bending assessment What is the treatment for the three varying degrees of scoliosis? - Less than 20 degrees: exercises to strengthen torso, moist heat, pain medications - 20-40 degrees: brace on along with exercises. Halts progression but does not re-establish normal curvature. Needs to be worn a minimum of 18 hours a day - More than 45-50 degrees: spinal fusion with rod or cable to bring spine back within normal alignment What is Legg-Calves-Perthes (cause)? What age range and sex is affected most? - Unknown etiology - Seen in children with peak age 4-8 - Boys 4-5 times more likely than girls What is the classic presentation of Legg-Calves-Perthes? - Presents with a painful limp and loss of motion with internal rotation and abduction What is the first line treatment? - Nonsurgical treatment -- physical therapy, NSAIDS, Hip Spica casting What is Talipes Equinovarous? - Club foot - Congenital malformation of the bones, muscles, ligaments, blood vessels and nerves of the foot causing foot adduction. What are the signs & symptoms of Talipes equinovarous? - Affected foot is rotated in - Flexed and rigid position - Difficult to move the foot What is the preferred treatment? - Ponseti casting - Manipulation and serial casting starting right after birth What is Osteogenesis Imperfecta? - Rare genetic disorder in which the bones are fragile and fracture easily resulting in bone deformity What are the clinical manifestations? - Poor skeletal development - Hx multiple fractures - Blue sclerae - Soft, brownish teeth - Hearing loss - Elevated serum alkaline phosphatase levels What treatment options are available? - No cure - Goal: prevent deformities and fractures - Bisphosphonates, synthetic parathyroid hormone, steroids, calcium, vitamin C, sodium, fluoride - PT, casting, bracing, implanted rods **[Musculoskeletal Trauma:]** **[Classification of fractures, assessment & healing] (2 questions)** Differentiate the [classifications] of fractures --understand the medical terms - Any associated risks? - Complete -- break is across entire width of bone - Incomplete -- break is through one portion of bone - Open (compound) -- bone breaks through the skin and causes soft tissue damage - Closed (simple) -- break does not extend through the skin - Displaced -- alignment of the broken bone is altered - Non-displaced -- bone remains aligned after break - Pathologic -- fracture that occurs spontaneously or with little trauma - Stress -- results after excessive strain and stress on the bone - Compression -- caused by loading force on the long axis of the bone What are the different [types] of fractures? - Normal - Transverse - Oblique - Spiral - Comminuted - Segmental - Avulsed - Impacted - Torus - Greenstick What assessment findings are r/t fractures? - Changes in bone alignment - Alteration in length of extremity - Change in shape of bone - Pain upon movement - Numbness/tingling - Decreased ROM or change in movement - Subcutaneous emphysema/crepitus - Skin color/skin temperature - Swelling at fracture site - Capillary refill - Peripheral pulses Know the stages of bone healing --what happens in each stage? What is the time of each stage? - Hematoma formation -- within 24 -- 72 hours after injury - Hematoma to granulation tissue -- 3 days -- 2 weeks - Callus formation -- 3 -- 6 weeks - Osteoblastic proliferation -- 3 -- 8 weeks - Bone remodeling -- 4- 6 weeks and continues for up to 1 year Differentiate ORIF and external fixation - ORIF -- open reduction with internal fixation - Surgical procedure -- internal fixation like rods and plates - External fixation - Traction, casting, braces **[Fractures of the upper and lower body] (2 questions)** What is the biggest concern r/t rib fractures? - Potential for puncture of the lungs, heart, or arteries by bone fragments or ends What are compression fractures? What disease process are they associated with? - Multiple hairline fractures result when bone mass diminishes - Most are associated with osteoporosis rather than acute spinal injury What are the clinical manifestations associated with compression fractures? - Pain -- especially with movement - Kyphosis - Neurological changes What are the minimally invasive surgical options? - Non-surgical -- bedrest, analgesics, nerve blocks, and physical therapy - Minimally invasive surgeries - Kyphoplasty -- expansion of the vertebral body with a balloon - Vertebroplasty -- percutaneous injection of bone cement into the fracture site Post-procedure care considerations & client teaching? - Supine position for 1-2 hours - VS and respiratory and neurological assessments - Pain management - Observe puncture site for bleeding - Ambulate - Discharge teaching - Monitor for sign of infection at the puncture site - Keep dressing dry, may remove in 24 hours - No tub bathing for 1 week - Resume normal activity in 24 hours gradually - Continue pain control as needed What is the biggest risk associated with femur fractures? Why? How long to heal? - Extensive hemorrhage is the biggest risk -- femur is very vascular - Healing time = 6 months or longer What is the most common cause of Tibia-Fibula fractures? - most common cause = trauma What are the treatment options and length of treatment for each? - Closed reduction with casting -- 6-10 weeks in the cast - Internal fixation with nails or a plate and screws, followed by a long cast -- 4-6 weeks for cast - External fixation if soft tissue damage -- 6-10 weeks, followed by application of a cast until healed How is mobility affected w/ external fixation? - Greatly affected -- joints can be fixated in place, loss of muscle mass, loss of movement What is the biggest complication risk associated with pelvic fractures? Why? - Risk of hemorrhage because the pelvis is very vascular Differentiate weight-bearing from non-weight bearing pelvic fractures and treatment time. - Non-weight bearing - Treatment is often minimal - Bedrest on a firm mattress or bed board - Usually heals in 2 months - Weight-bearing - Difficult to stabilize - Require surgery w/external fixation, ORIF or both - May need traction for up to 12 weeks **[Fracture Treatment and nursing care] (2 questions)** What are the three types of Traction? What is the purpose of each? When are they used? - Skin (Buck's) - w/use Velcro boot - purpose = decrease painful muscle spasm - Skeletal - Use of pins, wires, tongs, screws - Surgically inserted into bone - Purpose = aids in bone realignment - Plaster - Combines skeletal traction and a plaster cast What are components of traction care? Assessment needed? - Assessment of neurovascular status - Skin assessment at least every 8 hours - Assess for pin site infection at least every 4-8 hours Weights? Skin care? Pin care? - Maintain correct balance between traction pull and countertraction force - Care of weights -- weights not removed without an order - Pin care Teaching client on proper crutch use and sizing- - What is the correct height and fit for crutches? Canes? Walkers? - Crutches: - Height: The top of the crutch should be 1-2 inches (2-3 finger widths) below the axilla when the patient is standing upright. - Handgrips: Adjust so the elbows are slightly bent (about 15-30 degrees of flexion). - Fit: The patient should not rest weight on the axilla to prevent nerve damage (brachial plexus injury). - Canes: - Height: The top of the cane should be at the level of the wrist crease when the patient stands with arms relaxed at their sides. - Elbow Flexion: About 15-30 degrees when holding the cane. - Fit: The cane should be used on the stronger side of the body to support the weaker side. - Walkers: - Height: The top of the walker should be at wrist level when the patient stands with arms relaxed. - Elbow Flexion: About 15-30 degrees when hands are placed on the walker. - Fit: The patient should stand upright and step into the walker, not behind it while ambulating. - What are the three differences in types of gait for crutches? - Two-Point Gait - Pattern: Move the right crutch and left foot together, then move the left crutch and right foot together (mimics normal walking). - Use: For partial weight-bearing on both legs with good balance. - Three-Point Gait - Pattern: Move both crutches and the affected leg forward together, then move the unaffected leg forward past the crutches. - Use: For non-weight-bearing or partial weight-bearing on one leg. - Four-Point Gait - Pattern: Move the right crutch, then the left foot, then the left crutch, then the right foot (one at a time). - Use: For partial weight-bearing on both legs, providing maximum stability but slower movement. What are the major complications of immobility? - Skin breakdown - Pneumonia - Atelectasis - Thromboembolism - Constipation - Joint contraction - Muscle atrophy What diet is important for healing of fractures? - Diet high in protein, calories, and calcium and vitamin D, supplemental vitamins B and C - Frequent small feedings and supplements of high-protein liquids - Intake of foods high in iron What are considerations r/t risk of infection for clients with fractures? - Wound - Osteomyelitis -- infection in bone - Osteonecrosis -- death of the bone - Interventions - Use of aseptic technique for dressing changes, wound care and pin care - Assess for local inflammation - Report purulent drainage or s/s of infection immediately to provider - Administer broad-spectrum antibiotics prophylactically as ordered **[Amputation] (2 questions)** Differentiate Surgical and Traumatic - Surgical - planned - Traumatic -- unplanned What are complications of amputation, including clients w/ underlying medical conditions? - Hemorrhage - Infection - Phantom limb pain - Immobility or ADL issues - Neuroma -- benign tumors - Flexion contracture What is phantom limb pain? What medications are best for treating? - Frequent complication of amputation - Client complains of pain at the site of the removed body part, most often shortly after surgery - Pain is an intense burning feeling, crushing sensation or cramping - Some clients feel that the removed body part is in a distorted position - Must be distinguished from stump pain because they are managed differently - Opioids are not as effective - Other drugs: intravenous infusion calcitonin, beta blockers, anticonvulsants -- like Gabapentin and antispasmodics **[Acute Compartment Syndrome] (2 questions)** What are important assessments and interventions to prevent peripheral neurovascular dysfunction? - Assess for neurovascular problems every hour x 24 hours, then every 4 hours - Elevate the fractured extremity - Apply ice for 1^st^ 24-28 hours - Assess dressings, splints, casts and traction - Assess for pain unrelieved with analgesics - If early s/s of problems notify provider STAT What is acute compartment syndrome? What is the cause? - increased pressure within one or more compartments -- leads to massive reduction of circulation to the area Understand the Ischemia-edema cycle pathophysiology. - Capillaries dilate = raises capillary pressure - Capillaries become more permeable d/t release of histamine by the ischemic muscle tissue - Plasma proteins leak into the interstitial fluid space = edema - Edema causes pressure on the nerve endings and pain - Blood flow reduce = further ischemia What are the clinical manifestations of ACS? What is an early sign of complications? - Sensory deficits -- paresthesia, pain- this is the first S/S - Pallor tissue - Pulses begin to weaken but rarely disappear - Area is palpably tense = edema - Pain with passive motion of the extremity - Cyanosis, tingling, numbness, paresis/paralysis, severe pain = if condition is not treated What is the emergency care time factor? - Within 4-6 hours after the onset of acute compartment syndrome = neurovascular and muscle damage is irreversible - Limb can become useless within 24-48 hours What is the surgical treatment for compartment syndrome? - Fasciotomy = an incision is made through the skin and subcutaneous tissues into the fascia of the affected compartment - Relieves the pressure to restore circulation to the affected area What is Crush syndrome? How is it different from acute compartment syndrome? What 4 complications can result from crush syndrome? What labs are drawn to assess each? - Occurs when an injured extremity involves multiple compartments - Characterized by acute compartment syndrome - Dark brown urine - Muscle weakness - Extreme pain - Leads to - Hypovolemia - Hyperkalemia - Rhabdomyolysis - Acute tubular necrosis **[Fat Embolism & PE] (2 questions)** What causes a fat embolism to develop? Which type of fracture is it most often seen? When does it usually occur (timing)? - Serious complication resulting from a fracture -- most often of the LE long bones - Usually occurs within 12-48 hours of the fracture What are the early clinical manifestations? What symptom helps distinguish it from PE? - Altered mental status - Hypoxemia, dyspnea and tachypnea - HA, vision changes - Lethargy - Fever - Non-palpable, red-brown petechiae (late) - Labs - Hypocalcemia - Thrombocytopenia - Elevated ESR - Decreased Sao2 What is the treatment for a fat embolism? - Oxygen - Hydration (IV fluids) - Corticosteroids - Bedrest w/gentle movement - Fracture immobilization **[Renal Disorders Unit 1: ]** **[Immunologic Renal Disorders-] (4 questions)** What are these? What happens to the kidney? - 3^rd^ leading cause of end-stage kidney disease - Diseases that cause direct injury and inflammation to the glomerulus - Proteinuria and hematuria - Decreased glomerular filtration rate - HTN and edema - Anemia [Acute Glomerulonephritis---]What causes it -examples? When would onset of symptoms start? What are the clinical manifestations? What is the priority nursing diagnosis? - Triggered by an infection (Primary) or a disease (secondary) before the onset of renal clinical manifestation - Symptoms onset = 10 days from the time of infection - Clinical Manifestations - Edema of the face, eyes, and hands - Increased weight - HTN - Fatigue - Fluid overload s/s - Change in urination - Color, amount, dysuria, hematuria - Oliguria What labs are assessed and the results vs what is normal? - **Urinalysis** - **Hematuria** - **Proteinuria** - **24-hour urine** - **Serum albumin** - **Serum creatinine** - **BUN** - **GFR** What are the interventions and client teaching? What is Erythropoietin? When would Epogen or Procrit be indicated? - Interventions - Prevention of complications - Diuretics for fluid overload, HTN and Edema - Sodium and fluid restriction - Antihypertensive drugs - Erythropoietin (Epogen, Procrit) - Management of infection - Antibiotics - Basic infection control principles - Teaching - Daily wight - Daily BP - Diet and fluid restrictions - Prescribed medications [Chronic Glomerulonephritis---]How long for this to develop? What happens to the kidneys? What are the clinical manifestations and how do we assess each? - Slow process over 10-30 years or more - Kidneys become atrophied - Significantly reduced number of functional nephrons - Glomerular changes - Cell function loss - Protein and collagen deposits - Assess for systemic circulatory overload - Assess lungs - Crackles, increased RR and depth of respirations - Assess heart - Increased BP, presence of S3 heart sound, JVD, increased weight, edema - Assess for uremic symptoms - Slurred speech, ataxia, tremors, asterixis - Assess skin - Yellow color, changes in texture or dryness, rashes, bruises or excoriation from scratching What are the late-stage interventions that clients should be taught about? - Diet changes - Fluid intake sufficient to prevent reduced blood flow volume to the kidneys - Drug therapy to control problems from uremia - Dialysis - Transplantation [Nephrotic Syndrome---]What is happening here? What lab value identifies this is occurring? What are the dietary interventions? - Caused by altered immunity w/inflammation and defect in glomerular filtration - Increased glomerular permeability that allows larger molecules to pass through the membrane into the urine be removed from the blood - Leads to massive protein loss, edema formation and decreased plasma albumin levels - Labs - Severe proteinuria - 3-4+ - Hypoalbuminemia - Hyperlipidemia - Lipiduria - Renal insufficiency - Elevated BUN and serum creatinine - Delayed clotting factors - Diet changes - Protein: Moderate intake (not high) -- lean meats, fish, eggs, dairy, plant-based proteins. - Sodium: Low-sodium diet (\ 0.3 mg/dL within 48 hours or 1.5 times or more from baseline in previous 7 days** - **Urine output** - **\90 mL/min - 2 -- slightly reduced kidney function -- 60-89 mL/min - 3 -- moderately reduced kidney function -- 30-59 mL/min - 4 -- severely reduced kidney function -- 15-29 mL/min - 5 -- end-stage kidney disease -- \