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46 Cards in this Set
- Front
- Back
CMS
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-Cirulation: color, temp, cap refill, pulse
-Motion: weak, paralysis -Sensation: parasthesis, unrelenting pain, or pain with passive stretch, numbness or absence of feeling |
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Musculoskeletal Trauma
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-Contusions: blunt force, bruising of the brain surface
-Strain: muscle that has been overstretched -Sprain: ligament trauma -Dislocation: bone displaced from normal location -Subluxation: incomplete dislocation -Factures:Any break in the continuity of the bone |
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RICE
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-R: rest (not using affected part)
-I: ice (20-30min intermittenly) for first 24-48hours of injury then switch to heat -C: Compression: wrapping with ace wrap from distal to proximal -E: elevation above level of heart if possible |
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S/S fracture
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-Swelling
-Pain -Deformity/spasm -Bruising -Decreased function -Change in mobility -Crepitus (sounds of rice crispies, hair rubbed together) |
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Types of Fractures
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-Closed (simple)
-Open (compound) -Comminuted (3 or more pieces) -Greenstick (usually seen in kids) -Impacted (bones are pushed together) -Pathologic (underlying bone disorder) |
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Early, Systemic Complication of Fractures
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-Shock: from hemorrhage
-Fat embolism -Compartment Syndrome -Thromboembolism/pulmonary embolism -Disseminated Intravascular Coagulopathy (DIC): bleeding disorder -Infection: open fractures or surgical interventions (breaks in skin) -DVT |
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Fat Embolism
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-Fat globules may move into the blood because the marrow pressure is greater than the capillary pressure, usually occurs 24-72hours bone fracture
-S/S: SOB, coughing, thick white sputum, tachypnea, tachycardia, crackles or wheezes, confusion, mental status change Tx: O2, steroids, immobilize fractures, maintain F&E balance Dx: ABG, Chest X-Ray, |
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Compartment Syndrome
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-A complication that develops when tissue perfusion in the muscles is less than that required for tissue viability, not enough O2 to tissues and nerves
-S/S: changes in CMS, pt complains of deep throbbing unrelenting pain that cannot be controlled by opioids, when muscle is stretched pain increases, loss of sensation and absence of feeling -D/T: a reduction in the size of the muscle compartment because the enclosing muscle fascia is too tight or a cast or dressing is constrictive; an increase in muscle compartment contents because of edema or hemorrhage associated with a variety of problems; permanent damage occurs in anoxic tissue in just 6 hours Tx: Raise extremity, relieve constriction, Prevention: raise extremity above heart, check casts and dressing not too tight, fasciotomy: (done within 1 hour after other methods if not relieved) surgical decompression with excision of the fibrous membrane that covers and seperates muscles, passive ROM q4-6hours |
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Nursing Care of Fractures
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-RICE
-Splinting -CMS checking -Avoid unnecessary movement |
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Medical Treatment of Fractures
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-Reduction
-Immobilization until healed *splints *external fixation *internal fixation *casts *traction -Rehabilitation |
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Nursing Assessments and Casts
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Types of Cast:
*Plaster of Paris *Synthetic -5Ps and CMS checks *pulse, pallor, pain, paralysis, parathesias -Alert to prevent complications -Assess specific peripheral nerves that could be damaged by cast pressure |
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Complications of Casts
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-Compartment Syndrome
-Disuse Syndrome -Prssure Ulcers -Nerve Damage |
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Traction
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-The application of a pulling force to a part of the body while a counter traction pulls in the opposite direction
-Helps to establish proper alignment -Helps to immobilize extremity -Can correct deformities |
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Principles of Traction
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-Maintain established line of pull and continuous line of pull
-Prevent Friction -Maintain counter traction -Maintain body alignment |
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Types of Traction
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-Manual: never done anymore unless emergancy situation
-Skin: pulling force to skin with tape or traction straps; types: *Buck's, Russell, Bryant's, Dunlop's, Pelvic Sling, Pelvic Belt -Skeletal: a pin or wire is inserted directly into the bone |
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Buck's Traction
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-Decreases muscle spasms and aligns while waiting for surgery
-5-8 pounds -Concerns include heel pressure, place small towel under ankle to help get heel off of bed |
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Dunlap's
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For a fracture at the elbow
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Nursing Care for Traction Patient
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-Avoid pressure
-Monitor neurovascular status-CMS checks -Pain control -Encourage use of trapeze -Educate pt to decrease anxiety -Pin site care for skeletal traction (NS for cleaning unless ordered otherwise) |
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Maxillo-Facial Trauma
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-Mandibular fracture
-Interal Maxillary fixation post-op care: *Assess *Wire cutters in room *Prevent vomiting *Provide oral care *Meet caloric and fluid needs *Promote communication |
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Rheumatic Diseases
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-Over 100 different types
-Affects skeletal muscles, bones, ligaments, tendons, and joints -Periods of remission and exacerbation -S/S: systemic inflammation, low grade fever, erthrocyte sedementation rate increases (sed rate = 20) |
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Diffuse Connective Tissue Disorders (CTD)
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-Scleroderma
-Ststemic Lupus Erthrematosus (SLE) -Rheumatoid Arthritis -Polymyositis -Polymyalgia Rheumatica |
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Scleroderma
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-Systemic insoluble collagen accumulates affects major organs
-Symptoms: *C: calcium deposits in the skin *R: Raynaud's (low circulation to hands and feet) *E: esophogeal hardening *S: scleradactyly (hardening of the digits) *T: Telangiectasis (vascular lesion) |
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Treament for Scleroderma
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-Moderate exercise
-Control HTN, NSAIDS, Penicillamine to decrease skin thickening -Dx is not simple: ANA (antinuclear antibodies) and skin biopsy with CREST syndrome |
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S/S Scleroderma
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-Mask like face
-Drawn pursed lips -Shiny skin over cheecks and forehead -Atrophy of the muscles of the temple and face |
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Systemic Lupus Erythematosus
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-Autoimmune disease: genetic, hormonal, environmental causes
-S/S: Skin changes, butterfly rash, musculoskeletal changes, affects heart, lungs, kidneys, and brain. Thought to be due to an abnomral suppressor T-cell function -Dx: +ANA, anemia, thrombocytopenia, leukocytosis or leukopenia -Tx: corticosteroids |
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Rheumatoid Arthritis
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-Chronic, systemic progessive
-Symmetric, proximal, synovial joint involvement -Autoimmune -S/S: depression, bilateral reddened and swollen joints, ulnar drift (d/t continued steroid use), joint deformity -Remissions and exacerbations -Dx: arthrocentesis cloudy synovial fluid, RA factor, increased ESR, x-ray shows progression, +ANA -Tx: ASA, Cox-2 inhibitors, NSAIDS, steroids, gold preps, penicillamine, antimalarials -Methotrexate: inhibits DNA synthesis by supressing the immune system |
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Gout
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-A defect in purine metabolism (crystal induced arthropathy)ua>7
-Genetic defect -Symptoms: recurrent attacks of joint pain, swelling, and inflammation -Men >30 age in hospital have increased occurance of developing gout -Big toe usually involved -Tx: colchine or NSAIDs for acute pain -Brobenecid: prohibits renal reabosorption of uric acid -Mlopurinol: prohibits production of uric acid -Cutlacine: provents uric acid from depositing in joints |
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Osteoarthritis
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-Cartilage in joints cracks and wears
-S/S: pain, stiffness, functional impairment -Dx: physical assessment, x-ray shows loss of joint cartilage -Tx: rest and support for affected joints, ROM and postural exercises -NSAIDs, and corticosteroid intrarticular injection |
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Osteoporosis
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-Loss of bone mass
-S/S: compression fractures, dowager's hump -Risk factors: -Dx: -Tx: -Prevention: |
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Joint Replacement
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-Surgical removal of diseased/deformed joint replaced with an artificial joint
-Total hip replacement (THA): *Complications: dislocation!, nerve injury, infection, thromboembolism, bleeding, fat emboli *Post-op care: PT, positioning, wound care and drainage, pain control, immobility care, hip precautions for 6 months -Total knee replacement (TKA) *Complications: nerve injury, infection, thromboembolism, fat emboli (less likely) *Post-op care: PT, continuous passive motion (CPM) |
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Hip Precautions
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Fill in later
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Amputation
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-Reasons: circulatory impairment, accidents, bone tumor, osteomyelitis
-Types: below the knee (BKA), above the knee (AKA) -Nursing care: *need consent to dispose of limb *Assess for: hemmorrhage, infection, pain control, psychosocial adjustment, incision healing -Limb care: elevate FOB and limb for 24hours only, limb shrink wrap, skin care -Rehab |
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Pressure Ulcers
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-Compression or collapse of the blood vessel, starving the area of blood supply
-At Risk: -Pressure points: |
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Wound Assessment of Pressure Ulcers
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-Location
-Size and depth -Stages: *I: red to dusky blue-grey (non blanching) *II: break in skin epidermis or dermis *III: into subcutaneous layer *IV: muscle and maybe bone -Condition of tissue -Exudate -Signs of infection |
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Prevention of Pressure Ulcers (Decubiti)
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-By knowing what actually causes them
-Turning and positioning properly -Good nutrition -Identify pts that are at risk |
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Wound Care for Pressure Ulcers
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-Wound cleansing
-Debridement *autelytic *surgical *chemical *mechanical -Surgical Repair -Dressings *hydrocolloid *transparent *wicking |
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Burns
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-Ultimate trauma
-Affects all organs -Types: thermal, chemical, electrical, flame -Prognosis depends on 3 itmes: *Depth of burn *Size of burn *Parts of body affected |
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Characteristics of Burn Depth
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-Superficial partial thickness
*1st degree: epidermis may involve part of the dermis -Deep partial thickness *2nd degree: epidermis, upper layers of dermis and involves deeper dermis -Full thickness *3rd degree: entire dermis, may involve muscle, bone, nerves, etc. |
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Size of Burn: Rule of Nines
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-Head:9%
-Each Arm:9% -Anterior Chest:18% -Posterior Chest:18% -Each Anterior Leg:9% -Each Posterior Leg:9% |
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Phases of Burn Injury
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-Emergent
-Acute Phase -Rehab Phase |
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Emergent Phase of Burn Injury
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-Onset: 24-36 hours
*airway, breathing, circulation *Stop burn, extinguish and apply cool water *Remove restrictive clothing *Cover the wounds *Chemical burns: continuous rinse *IV catheter with 16-18 gauge *Nasogastric tube if >25% BSA *Indwelling urinary catheter -F&E Knowledge: *Plasma leaks through capillaries d/t increase in capillary permeability *Results in hemodynamic instability *Fluids shift from to *Cardiac output decreased therefore decreased BP *Sympathetic NS releases ca *Increased vaso *Increased perl -look at pg 1708 |
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Acute Phase of Burn Injury
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-48-72 hours later
-Respiratory/Circulatory status *temp >100.6, check ABGs with any distress think ET tube -F&E balance/PA catheters *expect diuresis, may need blood products -GI function: NG prevents vomiting -Burn wound care -Nutritional support -Pain control -Major cause of Death in acute phase is due to septic shock |
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Rehap Process of Burn Injury
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-Parts of body affected present serious complications for rehab
-Psychosocial impact: body image and self concept -Prevention of contractures and scarring -Teaching self care |
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Back Injuries
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-Lumbar area most affected
-Intervertebral disc disease *Sharp shooting pain *Follows sciatic nerve frequently *Lumbar damage creates weakness in legs -Tx: *Muscle relaxants *Bedrest, often not recommended anymore *Surgery |
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Spinal Surgery
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-Laminectomy: Removal of the bone between the spinal process and facet pedicle junction to expose the neural elements in the spinal canal, relieve compression of the cord and roots
-Fusion: to bridge over the defective disk to stabilize the spine and reduce the rate of recurrence -Discectomy: removal of herniated or extruded fragments of intervertebral disk -Complications: damage to the nerve root, spinal cord, carotid or vertebral artery injury -Anterior approach: lumbar and cervical -Posterior approach |
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Post-op Care of Spinal Surgery
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-Alignment of the spinal column is critical
-Log roll patient -Drain -CMS check -Pain control -Teach pt good body mechanics |