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195 Cards in this Set
- Front
- Back
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Sensory Deprivation |
Reduced sensory input, the elimination of patterns or meaning from input, and restrictive environments that produce monotony and boredom. |
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Effects of Sensory Deprivation |
Inability to problem solve, disorientation, bizarre thinking, boredom, restlessness, increased anxiety, emotional liability, and reduced color perception. |
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Sensory Overload |
When a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli. |
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Effects of Sensory Overload |
Racing thoughts, scattered attention, restlessness, and anxiety. |
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Presbyopia |
A common condition in which the lens of the eye loses its ability to focus, making it difficult to see objects up close. |
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Cataracts |
Clouding of the lens of the eye. |
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Glaucoma |
Refers to a group of eye conditions that lead to damage to the optic nerve. This nerve carries visual information from the eye to the brain. In most cases, damage to the optic nerve is due to increased pressure in the eye, also known as intraocular pressure (IOP). |
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Open Angle Glaucoma |
Gradual onset, no early symptoms, slow loss of peripheral vision, blurred vision, and headaches. |
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Macular Degeneration |
Leading cause of severe vision loss in people over age 60. It occurs when the small central portion of the retina, known as the macula, deteriorates. The retina is the light sensing nerve tissue at the back of the eye. |
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Presbycusis |
Gradual hearing loss in both ears that commonly occurs as people age. This form of gradual hearing loss can be mild, moderate, or severe. Presbycusis that leads to permenant hearing loss may be referred to as nerve deafness. |
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Taste Deficit |
Xerostomia (dry mouth) |
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Balance Deficit |
Dizziness, disequilibrium. |
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Vertigo |
Sensation of whirling and loss of balance, associated particularly with looking down from a great height, or caused by disease affecting the inner ear or the vestibular nerve; giddiness. |
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Effects of Vertigo |
Related to Meniere's disease, lasts minutes to hours, nausea, vomiting, diaphoresis. |
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Interventions for sensory deprivation and overload |
Minimize overall stimuli and provide meaningful stimulation, minimize glare, manage pain, sleep and rest periods, amplify phones, season foods, reduce unpleasant odors, provide pleasant aromas. |
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Interventions for Vertigo |
Assess for vertigo, instruct of reinforce vestibular/balance therapy, administer medications, restrict activity when dizzy, recommend patient keep eyes open and stare straight ahead when lying down and experiencing vertigo. |
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Interventions for Visual deficit |
Patient education, yearly eye exam, compliance with medications, review administration of eye drops, keep all follow up appointments. |
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Health Promotion for Sensory Deficits |
Screenings, preventative safety, use of devices, promoting meaningful stimuli, safe environments, communication, environment, controlling sensory stimuli, safety measures, restorative and continuing care. |
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Beta Blockers |
Reduce the production of fluid and intraocular pressure. |
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Side effects of Beta Blockers |
Difficulty breathing, slowed heart rate, lower blood pressure, impotence and fatigue, assess for allergies. |
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Contraindications for Beta Blockers |
Asthma, COPD, heart block, and heart failure. |
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Special Directions for Beta Blockers |
Maintain pressure over lacrimal sac after administering to prevent systemic absorption. |
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What to assess for when taking Beta Blockers |
Bradycardia, hypotension, and depression. |
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Alpha-Adrenergic |
Reduce the production of aqueous humor. |
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Side effects of Alpha-Adrenergic |
Irregular heart rate, high blood pressure, fatigue, red, itchy, or swollen eyes, dry mouth. |
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Prostaglandins |
Increase the outflow of aqueous humor. |
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Side effects of Prostaglandins |
Mild reddening and stinging in the eye, darkening of the iris, changes in the pigment of the eyelid skin. |
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What to assess for when taking Prostaglandins |
Note eye color, presence of inflammation, exudate, or pain. Note vital signs, liver function and test results, report any side-effects. |
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Meclizine |
Used in vertigo and motion sickness |
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Side effects of Meclizine |
dizziness, drowsiness, blurred vision, hypotension, palpitations, tachycardia. |
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Post-op nursing care (Sensory Deficits) |
Assess and document vital signs, level of consciousness, and comfort. Assess eye dressing for bleeding or drainage following surgery. Maintain eye patch or shield in place. Place in semi-fowlers, or fowlers on unaffected side. Avoid coughing or sneezing. Assess ad medicate for complaints of pain, aching, or scratchy sensation in the effected eye. Approach client on unaffected side. Place personal items and call bell within client reach. |
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Stochastic (Theory) |
Biological Probability, error theory. Aging results as the result of chance or accidental events. |
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Activity |
Psychosocial Emphasizes the importance of ongoing social activity. Suggests that a person's self concept is related the the roles held by that person.
Example: Retiring might not be so harmful if the person actively maintains other roles, such as familial roles, recreational roles, volunteer, and community roles. |
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Diengagement |
Psychosocial Refers to a process in which many of the relationships between a person and other members of society are severed and those remaining are altered in quality. As people age they experience greater distance from society and they develop new types f relationships with society. Older people are less involved with life than they were as young adults.
First formal theory that attempted to explain the process of growing older. |
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Continuity |
Psychosocial States that older adults try to preserve and maintain internal and external structures by using strategies that maintain continuity. Meaning that older people may seek to use familiar strategies in familiar areas of life. In later life, older adults tend to use continuity as an adaptive strategy to deal with changes that occur during normal aging, Continuity theory has excellent potential for explaining how people adapt to their own aging. |
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Nonstochastic |
Biological (Programmed) Aging occurs due to intrinsic timing mechanisms and signals. |
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Erickson's Developmental Theory |
Integrity vs. Despair Those who are unsuccessful during this stage will feel that their life has been wasted and will experience many regrets. The individual will be left with feelings of bitterness and despair. Those who feel proud of their accomplishments will feel a sense of integrity. Successfully completing this phase means looking back with few regrets and a general feeling of satisfaction. These individuals will attain wisdom, even when confronting death. |
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Wear and Tear |
Cumulative changes occuring in cells age and damage cellular metabolism |
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Free Radical |
Aging caused by effects of free radicals |
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Cross Link |
Abnormal "links" or binding between collagen protein and glucose |
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Immune |
Decline of the body's immunological system |
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Neuroendocrine Theory |
Progressive loss of receptor sensitivity of the hypothalamus. |
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Normal Cardiovascular Changes |
CO decreased by 40% Decreased vessel elasticity Decreased stroke volume Increased peripheral vascular resistance Increased BP Changes in heart valves Peripheral pulses are often weaker Feet are cold |
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Normal Respiratory Changes |
After age 55 respiratory muscle strength decreases. Decreased vital capacity, more barrel chest Decreased number of alveoli Decreased gas exchange rate |
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Normal GI Changes |
Decreased peristalsis Decreased digestive enzyme Less active gag reflex More protuberant abdomen due to loss of abdominal muscle strength. Decreased taste sensation Gum atrophy Decreased saliva |
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Normal Urinary Changes |
Nephrons lost Decreased renal blood flow Decreased filtration rate Decreased muscle tone and bladder capacity Decreased urge and sphincter control Men - prostate enlarges |
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Normal Reproductive Changes (Male) |
Thinner pubic hair Smaller testes Decreased testosterone and sperm production (4th decade) Prostate enlarges Decreased ability to initiate and maintain erection, weaker ejaculation. |
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Normal Reproductive Changes (Female) |
Thinner pubic hair Menopause accelerates aging Ovaries smaller and sclerotic Fallopian tubes and uterine atrophy occurs Vagina becomes smooth and dry Decreased muscle tone, elasticity, resulting in sagging of breasts, breasts become smaller. |
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Normal Musculoskeletal Changes |
Loss of height Kyphosis Bones more porous and brittle Joint changes Decrease in flexibility Cartilage degeneration Loss of muscle mass |
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Normal Integumentary Changes |
Loss of elasticity Sagging, tears easily Dry skin Age spots Decreased sweat glands with less efficient cooling changes |
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Normal Taste Changes |
Decreased number of taste buds Decreased ability to distinguish tastes especially bitter, sour, and salty. |
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Normal Touch Changes |
Sense of touch dulls Decreased ability to distinguish temperature and feel pain.
This does not mean that elders do not need pain medication. |
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Normal Smell Changes |
Decreased olfactory nerve fibers Diminished sensation to distinguish specific odors |
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Normal Hearing Changes |
Progressive loss which starts with high frquency tones Decreased discrimination Excessive cerumen Thickened eardrums |
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Normal Vision Changes |
Decreased pupil size Decreased tear production Decreased lens clarity, color discrimination, and focusing. Decreased adjustment to light and dark Presbyopia |
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Normal cognitive changes |
Basic intelligence is maintained Learning is not seriously altered Attention span decreases Memory slows No drastic personality changes |
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Normal Neurological changes |
Slowing of thinking, reacting Slowing of reaction time Slower reflexes Sleep changes Decreased sensation Slow response to heat and cold Decreased cerebral blood flow Decreased sense of balance and uncoordinated motor movements |
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Normal Functional Changes |
Changes are usually linked to illness or to disease |
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Abnormal Sensory Perception changes |
Hearing Loss Cataracts/Glaucoma Senile macular degeneration Loss of appetite |
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Abnormal Cardiovascular Changes |
Hypertension Heart Disease Stroke Peripheral Vascular Disease |
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Abnormal Respiratory Changes |
Chronic Lung disease Increased risk of infection |
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Abnormal Urinary Changes |
Men: Urinary retention from enlarges prostate Women: stress incontinence, infection, adverse drug effects. |
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Geriatric Syndrome |
Multifactorial health conditions that occur when the accumulated effects of impairments in multiple systems render an older person vulnerable to situational changes. |
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What are geriatric syndromes? |
Clinical conditions, NOT diseases. |
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Five most Common Geriatric Syndromes |
Pressure Ulcers Incontinence Falls Delirium Functional Decline |
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Risk Factors for Geriatric Syndromes |
Old age Cognitive impairment Functional impairment Impaired mobility Poor nutritional status Female Gender Depressive symptoms |
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Causes of Geriatric Syndromes |
Multi-factorial Interactions between intrinsic and extrinsic factors Interactions between predisposing and precipitating factors. |
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Medication problems with Geriatric Syndromes |
Altered pharmacokinetics Atypical adverse drug effects Misunderstandings about medications Cost of Medications Physical disabilities in the elderly Polypharmacy
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Adverse drug reactions if Geriatric Syndromes |
Number of drugs and prior history of and ADR strongest predictors for subsequent ADR. Risk doubles for those prescribes 5-7 meds. Fourfold for those receiving 8 or more meds. |
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Post Hospital Med Problems (Geriatric Syndromes) |
One or more medication discrepancies were experienced in %14.1 of patients post hospitalization.
14.3% of patients with discrepancies re-hospitalized in 30 days compared with 6.1% without discrepancies. |
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Medication safety (Geriatric Syndromes) |
Accurate medication hx Barriers to compliance Education about medications Home medication record Pill box and other organizers Schedule for admin. Teaching safety Reassessment Try again if not effective |
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Risk factors for Urinary Incontinence |
Immobility Impaired cognition Medication High impact physical activities Environmental barriers Diabetes Stroke Estrogen depletion Pelvic muscle weakness Childhood nocturnal enuresis |
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Types of urinary incontinence |
Transient Established |
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Transient Incontinence |
DRIP
Delirium Retention or restricted mobility Impaction (fecal) Polyuria and pharmaceutical |
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Established incontinence |
Urge incontinence (reflex) Stress incontinence (mixed) Overflow incontinence Functional incontinence |
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Interventions for Stress incontinence |
Teach pelvic floor muscle Provide toileting assistance and bladder Pharmacological or surgical therapies |
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Interventions for Functional incontinence |
Provide individualized, scheduled toileting, times voiding, or prompted voiding. Provide adequate fluid intake. |
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Interventions for Urge incontinence |
Bladder training Teach pelvic floor muscle exercise Pharmacological intervention |
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Interventions for Overflow incontinence |
Allow sufficient time for voiding If catheterization is necessary, sterile intermittent is preferred over indwelling catheterization. pharmacological or surgical intervention |
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Fratility |
State of high vulnerability for adverse health outcomes, including disability, dependency, falls, need for LTC, and morality. |
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Must meet 3/5 following symptoms (Fratility) |
Decreased walking speed Decreased grip strength Decreased physical activity Exhaustion Weight loss |
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Interventions for Fratility |
Exercise including resistance, strength, physical movement (gait and balance) training, and lingual exercise. Nutritional maintenance and/or supplementation Maintenance of oral health Environmental modifications Family and professional caregiver education |
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Dysphagia |
Having difficulty swallowing which may affect any part of the swallowing pathway from the mouth to the stomach. |
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Risk factors for Dysphagia |
People with stroke and neuro dysfunction Up to 50% of patients with Parkinson's disease are susceptible to dysphagia GERD Swallowing tract dysfunction |
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Complications of Dysphagia |
Malnutrition Respiratory Problems Need for invasive feeding devices |
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Interventions for Dysphagia |
Concentration during meals Quiet, minimal to no conversation during meals Minimum stimuli, limited interruptions, and supervision. Position upright 30 minutes before and after feeding. Liquid, semisolid foods, never offer food and liquid together. Foods should be cold or warm. |
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Iatrogensis |
Any unintended and untoward consequence of well intended healthcare interventions |
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Risk Factors for Iatrogensis |
Diminished physiologic reserve Impaired compensatory mechanisms Atypical presentation of illness, which complicates accurate diagnosis and treatment. More co-morbid, chronic medical conditions, that require more diagnostic procedures and medications Polypharmacy Increased cognitive and functional impairment |
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CAM |
Confusion Assessment Method
1. Status altered from baseline 2. Inattention 3. disorganized thinking 4. Altered level of consciousness
Takes 5 minutes, and is easily incorporated. |
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SPICES |
Sleep Disturbances Problems with eating and or feeding Incontinence Confusion Evidence of Falls Skin Breakdown |
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ACES |
A grant funded initiative to foster gerontologial nursing education for pre-licensure nursing students. Three nursing domains: Individualized aging Complexity of Care Vulnerability during transitions |
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Vulnerability (Atypical Presentations) |
Illness complicated by physical changes in aging. Multiple medical problems. Essential for nurses to: Recognize commonly seen atypical presentations of illness
Subtle changes such as decrease in function Diminished appetite Know risk factor Know the consequences |
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Vulnerability (Strategies for assessing atypical presentations) |
Vague presentation of illness Altered presentation of illness Non-presentation of illness. |
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Vague Presentations of Illness (Vulnerability) |
Confusion, self neglect, falling, incontinence, apathy, anorexia, dyspnea, and fatigue. These changes in behavior are a "prodrome" meaning symptoms that indicate an approaching disease or acute illness. |
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Hidden Illnesses in Older Adults |
Depression Incontinence Musculoskeletal Stiffness Falling Alcoholism Osteoporosis Hearing Loss Dementia Dental Problems Poor Nutrition Sexual Dysfunction Osteoarthritis |
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Reasons for under-reporting illnesses |
Insidious nature of the illness and vague symptoms. Tendency to regard symptoms as a normal part of aging. Reluctance of older people to complain about problems. |
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Vulnerability in Transitional Care |
Transitional care consists of a broad range of services that promote the passage of patients between levels of health care and across health care settings.
These breakdowns include: poor handoff of older adults and their family caregivers from hospital to home. |
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Multifactorial Reasons for gaps in Transitions |
Increasing older adult's access to proven community based transitional care services. Improving transitions within acute care hospital settings. Improving patient handoffs to and from acute care hospitals. |
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Specific Interventions (Vulnerability) |
Team approach that is nurse lead. Early and active family or caregiver involvement. Proactive patient roles and self advocacy High quality and individualized patient and family discharge instruction. Apply interventions for improving low health literacy and impaired cognitive impairment. Patient and caregiver empowerment through education.
Etc. |
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Nursing diagnoses (Vulnerability) |
Risk for impaired skin integrity Risk for confusion Risk for cognitive impairment |
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Interventions for Sensory Perception |
Hearing aids Glasses Nightlights Communication problems Safety |
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Interventions for Cardiovascular |
Risk for Falls Activity/Exercise intolerance |
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Interventions for Respiratory |
Activity intolerance Encourage rest periods Teach deep breathing exercises
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Interventions for GI |
Increase fluid and fiber Laxatives with caution Monitor drug effects carefully |
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Interventions for urinary |
Increase fluid intake Monitor output Regular toileting Good skin care |
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Interventions for Reproduction |
Sexual counseling Use of lubricant Medication such as viagra for those men healthy enough for sexual activity Use of estrogen |
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Interventions for Musculoskeletal |
Encourage exercise and activity Weight loss Safety |
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Physiology of Movement (Skeletal system) |
Provides attachment for muscles and ligaments Provides leverage for movement |
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Physiology of Movement (Muscles) |
Help movement of bones and joints When they contract, they cause movement Skeletal muscle moves the skeleton |
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Physiology of Movement (Nervous system) |
Regulates movement and posture Motor nerves: autonomic or somatic. |
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Body Mechanics |
Describes coordinated efforts of the musculoskeletal and nervous system.
Four components: body alignment, balance, coordination, and joint mobility. |
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Body alignment |
Posture Center of Gravity Correct body alignment Comfort Muscle tone Strain Balance and energy |
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Balance |
Line of gravity (imaginary line) Center of gravity (below the umbilicus) Base of support (feet)
The broader the base of support, the lower the center of gravity, the easier to maintain balance. |
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Coordination |
Skillful and balanced movement of different parts of the body at the same time.
Proprioception Proprioceptors |
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Joint Mobility |
Flexion Extension Range of Motion Active Assistive Range of Motion Passive Range of Motion |
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Tips for Safe Lifting |
Wide base of support and use large muscles Size up your load and get help when you need it Face direction of movement Carry/Lift heavy objects close to you Use mechanical/physical lifts if necessary Raise patients bed to your working height Lower the side rails only while at bedside Lower the patients head if tolerates Do not twist or turn while lifting |
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Effects of Immobility on Metabolism |
Inactivity = increase level of serum lactic acid and decrease in ATP level.
As a result, metabolic rate DROPS, protein and glycogen synthesis DECREASE, and fat store INCREASE. |
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Effects of Immobility of Elimination |
Increase in urinary stasis Increased risk of renal calculi Increased risk of urinary tract infection Decreased bladder muscle tone Decreased urinary output |
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Effects of immobility on Nutrition |
Disturbance in appetite Altered protein metabolism Altered digestion and utilization of nutrients Decreased peristalsis resulting in constipation, poor defecation reflex and inability to expel flatus. Can lead to a paralytic ileus |
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Effects of immobility on Oxygenation |
Decreased muscle strength involved in chest wall expansion Stasis of secretions Distribution of mucous in the bronchi increases and it accumulates With decreased lung expansion and weakened respiratory muscles, secretions stagnate and pool which increases the risk for pneumonia. Impaired gas exchange. |
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Effects of immobility on Perfusion |
Increased Cardiac workload Increased risk of orthostatic hypertension Increased risk of venous thrombosis |
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Effects of immobility on Infection control-Skin integrity |
Increased risk for skin breakdown Increased formation of pressure ulcers |
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Activity and Exercise Problems (Diagnoses) |
Activity intolerance Risk for activity intolerance Impaired physical mobility Sedentary lifestyle Risk for disuse syndrome |
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Mobility Problem becomes the Etiology (Diagnoses) |
Fear Ineffective coping Low self esteem Powerlessness Risk for falls self care deficit |
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Prolonged Immobility (Diagnoses) |
Ineffective airway clearance Risk for infection Risk for Injury Risk for disturbed sleep pattern Risk for situational low self esteem |
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Interventions for Metabolism |
Provide high protein Provide high caloric diet Provide vitamin B and C
Goal: to repair damaged/injured tissues and rebuild depleted stores. |
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Interventions for Elimination |
Observe urine for color, clarity, and presence of sediment. Observe frequency and amount of urine. Assess for bladder distention to ensure that the patient is not having reflex incontinence. Record the frequency and consistency of BM's Diet rich in fluids, fruits, veggies, and fiber to facilitate peristalsis and maintain regularity. |
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Interventions for Mobility |
Encourage patients to participate in active ROM Determine a progressive exercise program to increase the patients physical abilities. Proper body alignment Use assistive devices Reposition and turn every two hours Individualized progressive exercise program Refer to book for exercise guide. |
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Interventions for Nutrition |
Provide a high protein, high caloric diet with vitamin B and C supplements. Patients need between 2000 to 3000 ml of fluids per day diet rich in fluids, fruits, veggies, and fiber. 5-6 small meals Allow family to bring favorite foods Provide a small social engaging environment to eat. |
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Interventions for Oxygenation |
Cough, and breathe deep every 1-2 hours and use the spirometer. Chest physiotherapy Elevate head of the bed when applicable Instruct on deep breathing exercises Encourage activity such as shifting or exercising upper body in bed Keep well hydrated |
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Interventions for Perfusion |
Mobilize the patient as soon as it is possible even if to sit on the side of the bed Slowly get patient OOB allowing them to rest and dangle their legs Discourage patient from using the valsalva maneuver when defecating or moving up in the bed.
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Interventions for Infection Control/Skin Integrity |
Teach leg, foot, and ankle exercises Administer fluids Provide frequent position changes Use TEDS |
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Interventions for Psychosocial Integrity |
Get patient OOB Orient Patient x3 Provide stimulation and diversions Encourage family and friends to visit Get patient out of room if possible |
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Osteoporosis Diagnosis |
Quantitative ultrasonography CT scan Dual energy X ray (DEXA)
Gold standard Measurements vary by site Heel and forearm are easy but not as accurate Hip site is the best Vertebral spine gives false high scores |
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Nursing Diagnoses for Osteoporosis |
Pain Risk of fractures Self care deficit Chronic pain Disturbed body image Impaired physical mobility Risk for impaired skin integrity |
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Interventions for Osteoporosis |
Explain all treatments, tests, and procedures Tell client to report pain Make sure that patient and family understand drug regimen Encourage patient to eat foods rich in calcium |
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Bisphosphonates |
Prevention and treatment of postmenopausal osteoporosis and osteoporosis in men. |
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Action of Bisphosphonates |
Inhibits resorption of bone by inhibiting osteoclast activity. |
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Dose of Bisphosphonates |
Alendronate 10 mg/day or 70 mg/week Risedronate 5 mg/day or 30 mg/week |
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Side effects of Bisphosphonates |
Acid reflux Esophageal ulceration
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Calcitonin |
Management of postmenopausal osteoporosis. |
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Mechanism of Calcitonin |
Decreases bone resorption |
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Side effects of Calcitonin |
Anaphylaxis |
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Estrogen Repplacement Therapy |
Used to prevent and treat osteoporosis |
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Mechanism of Estrogen Replacement Therapy |
Decreases Osteoclast Activity |
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Goals for Fractures |
Ensure perfusion and oxygenation Limit further damage Preserve structure Reduce anxiety and pain Achieve optimal realignment Maintain rigid immobilization Acquire methods for adapting to alterations in mobility. |
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Casts |
Do FACTS.
When applying: Smooth edges to protect skin from abrasions Keep uncovered until hardened, rest area on pillow to prevent flattening.
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Splints |
Rest/Protect/Support injured area Decrease muscle spasms Correct deformities
Braces: custom fitted Slings: used to support splints or casts on upper extremity and to support extremity in tractions. |
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Tractions |
Force applied for realignment with immobilization
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Skin traction |
Indirect force applied with rope, pulley, weight |
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Skeletal traction |
Direct force applied with rope, pulley, weight and pins, rods, and screws. |
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Complications Avascular Necrosis |
Arterial damage from fracture or constricting immobilization devices
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Clinical Manifestations of Avascular Necrosis |
Cool, pale skin Decreased or absent pulses Edema Pain |
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Interventions for Avascular Necrosis |
Maintain adequate perfusion through reduction, surgery.
Readjust/remove constricting immobilization devices |
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Complications Compartment Syndrome |
A serious condition that involves increased pressure in a muscle compartment. It can lead to muscle and nerve damage and problems with blood flow. |
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How to Identify Compartment Syndrome |
5 P's
Pain Parasthesia Pallor Paralysis Pulselessness |
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Venous Thromboembolism Deep Vein Thrombosis
Clinical Manifestations |
Warmth Tenderness Pain Edema Erythema Phlegmasia Cerulea Dolens |
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Diagnosis of DVT |
D-Dimer, Duplex ultrasonography |
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Interventions of DVT |
IV anticoagulation |
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Venous Thromboembolism Pulmonary Embolism
Clinical Manifestations |
Dyspnea Tachypnea Pleuritic Chest PainD |
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Diagnosis of PE |
CTPA Ventilation perfusion scanningI |
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Interventions of PE |
IV anticoagulation |
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Fat Embolism
Clinical Manifestations |
Hypoxia CNS depression Petichiae Tachycardia Fever Unexplained anemia Thrombocytopenia |
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Diagnosis of Fat Embolism |
Contrast venography |
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Interventions ofr Fat EMbolism |
Oxygen therapy IVF Bedrest Steroid (Controversial) |
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Infection/Osteomyelitis
Clinical Manifestations |
Fever Increased WBCs Purulent drainage Swelling Erythema Pain |
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Diagnosis of Infection/Osteomyelitis |
Cultures |
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Interventions of Infection/Osteomyelitis |
Antibiotic therapy Dibridement Dressing changes |
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Nonunion, Delayed Union, Malunion
Clinical Manifestations |
Pain Decreased mobility Deformity Palpable gap at fracture site
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Interventions for nonunion, delayed union, malunion |
Non surgical Surgical Debridement Bone Grafting Internal fixation |
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Pressure Ulcers |
Monitor vulnerable areas Encourage participation in PT and prescribed exercises Implement actions to prevent the effects of immobility |
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Canes |
Length should extend from greater trochanter Handpiece should allow for 20-30 degree elbow flexion Holding cane on side of stronger leg supports natural walking stride Place weight on cane and effected leg before lifting and moving stronger leg forward. |
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Walkers |
Height of walker: handgrips adjusted below waist to allow for slight flexion of elbows.
To stand, push off bed or chair with arms.
DO NOT use walker for support to stand. |
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Crutches |
Length should be from axillary fold to heel with 1.5-2 inches between axillary fold and top of crutch bar.
Handpiece should allow for 20-30 degree elbow flexion.
Four point gait, two point gait: weaight bearing on both legs
Three point gait: Partial or nonweight bearing on affected leg Can also be used with a walker |
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Nursing Diagnoses for Fractures |
Risk of hypovolemia and shock Risk of bone inflammation Risk of fat embolism Pain Immobility Risk of respiratory complications Risk of cardiovascular complications |
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Interventions for Fractures |
Provide emergency care Provide fracture fixation Observe signs of Fat embolism Monitor I&O Monitor vital signs Administer IV fluids Prepare Client for surgery Provide care to patient in traction Pin site care Provide respiratory exercises Teach appropriate crutch walking techniques Provide emotional support |
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Common joint replacements |
Fingers Wrists Shoulders Hips Knees Ankles |
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Osteoarthritis |
Second most common chronic condition in the US, affects over 32 million people, total costs over 82 billion per year.
WEAR AND TEAR |
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Trauma |
Hip Fracture
Fracture of the proximal third of femur Common in the elderly More frequent in women Up to 35% of clients will die within the first year |
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Rheumatoid Arthritis |
A long-term disease that leads to inflammation of the joints and surrounding tissues. It can also affect other organs.
Autoimmune |
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Goals for Joint Replacement |
Relieve pain Restore function and mobility |
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PACU |
Post Anesthesia Care Unit |
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Total Hip Replacement |
Removes the top of the femur and metal stem and ball joint are fitted into its place. New ball joint rotates against a plastic liner implanted in pelvic socket. Remove worn bone from hip joint and replace it with a metal ball and plastic socket. |
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Total Knee Replacement |
Femoral component made of metal, tibial component made of plastic, plastic patellar. |
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Management/Interventions (Joint Replacement) |
DO NOT Flex hip greater than 90 degrees Place hip in adduction Allow hip to internally rotate Cross legs Put on shoes/socks without adaptive device
DO Use elevated toilet seat Use chair in shower Use pillow between legs on good side Keep hip in neutral position when sitting, walking, and lying |
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PAtient education for Joint Replacement |
No kneeling or deep knee bends No pillows under knee and no activation of knee gatch on bed May allow pillows to elevate leg Knee immobilizer/splint |
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Complications of Joint Replacement |
Sublacation, dislocation of Prosthesis Infection, Septic arthritis VTE Hypotension Anemia Neurovascular Compromise and Impaired Skin Integrity |
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Prevention of sublaxation, dislocation of prosthesis |
Maintain activity restrictions |
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Treatment of sublaxation, dislocation of prosthesis |
Manual reduction, repeat arthroplasty |
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Prevention of Infection, septic arthritis |
Postpone elective surgery for suspected/known infections or recent history of infection, hand hygiene, aseptic technique, prophylactic antibiotics |
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Treatment of Infection, septic arthritis |
Cultures, antibiotics, debridement, repeat arthroplasty |
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Prevention of VTE |
Anti-Coagulants, ankle foot exercises, safe/early ambulation, TEDS, SCDs, or venous foot pumps. |
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Treatment of VTE |
Anti-coagulants |
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Hypotension anemia interventions |
IV fluids Transfusion of RBCs |
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Neurovascular Compromise and Impaired Skin Integrity |
Monitor circulation, sensation, movement. Monitor skin integrity. |
