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145 Cards in this Set
- Front
- Back
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S/S Fracture |
-pain (not always) -edema -deformity -shortening -loss of function -decreased sensation -tingling -bruising |
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Time frame for bone healing |
14 days - 1 year |
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Closed reduction vs. open reduction |
CLOSED: Bone externally manipulated into position & immobilized with a bandage, cast or traction (without surgery) - ORIF OPEN: Bone surgically exposed& realigned - OREF |
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Purpose of a cast; types of Casts |
External immobilization of affected structures -plaster of paris - heavier, intact longer -synthetic - lighter, dries quickly, more freedom |
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Nursing Considerations with Ortho |
-elevate cast -neurovascular assessment -manage pain -ice for 10-15 min -turning pt. - skin integrity -teaching about positioning -teach dalteparin injection |
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Cast Assessment |
-pain -edema -skin integrity -odour -itchiness -neurovascular assessment |
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What is traction?
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-extends and holds body part in specific position -uses ropes, pulleys and weights attached to a fixed point below injury -force of pull from weights is exerted on bone
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Why are the elderly at risk for hip fractures? |
-decreased reaction time -failing vision -lessened agility -decreased muscle tone -degeneration *1/3 of post-op hip replacement elderly pt. die |
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Total Hip Replacement (THP, THA) |
Acetabulum: Polyurethane socket Femur Head: metallic replacement Femoral Canal: stem of prosthesis femoral canal |
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Hip Precautions |
-don't lift knee above hip (>90 degrees) -don't cross legs -don't adduct past midline -don't twist legs -don't use low chairs -don't take long strides |
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Ortho Complications |
-compartment syndrome -hemorrhage -infection -DVT -fat embolism -dislocation of prosthesis |
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6 P's of compartment syndrome |
-paresthesia (tingling or numbness) -pain (that opioids don't help) -pressure - increased -pallor - coolness -paralysis -pulselessness (diminished/absent pulses) |
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Benign Prostatic Hypertrophy |
-Age-related -Men >50years at risk -Enlargement of the prostate gland -R/T hormonal changes |
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BPH S/S |
-Dysuria -Frequency/nocturia -Hesitancy -Urgency -Dribbling -UTI’s -Hematuria -Decreased force of stream |
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Complications of BPH |
-Increased pressure in bladder -Stasis in bladder…infection -Hydronephrosis -Renal insufficiency…failure |
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Diagnosing BPH |
DRE: Digital rectal exam Men>40 yrs should have DRE done annually PSA:Prostate Specific Antigen (Blood test)-Increased with BPH (PSA is even higher with cancer) |
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TUPR |
Transurethral prostatic resection(TUPR/TURP) -Preferred method; -fast recovery -Less complications -Removes inner portion of prostate, via urethra, with use of endoscope -Best for removal of small amounts of tissue -Spinal anesthetic |
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BPH Tx
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-Proscar (Finasteride): decreases PSA and slows growth
-Flomax CR (Tamulosin Hydrochloride): relaxes muscles in prostate and bladder – enables more complete bladder emptying
Temporary solutions / procedures:
-A catheter with a balloon is inserted into the urethra and inflated where urethra is narrowed by enlarged prostate – balloon is removed at the end of treatment procedure
-Stents may also be used to widen urethra – these need to be changed regularly(inserted as collapsed then opened as cylindrical tubes inside urethra) |
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Prostate Cancer |
- 2nd most common cancer in men -2nd leading cause of death Occurs>50yrs age; peak at 75Commonlymetastatic -Requires radical surgery and radiation; androgen suppression -Removal of prostate and adjacent tissues if tumour invasive -High risk of impotence; incontinence |
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Bladder Tumours |
-Common in men 50-70 yrs; as well as women -May require trans urethral resection of bladder tumour; cystotomy and resection of the bladder |
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Post-op TURP |
-Risk for DVT -bleeding -fluid overload -obstruction -incontinence -UTI *CBI |
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Why use CBI? |
-To prevent clot formation and prevent obstruction -Slows bleeding (d/t coolness and pressure from fluid influx) -Often up to 24hrs post-op; depending on color of returns |
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Rate of CBI |
-Irrigates 0.9% NS, through bladder, via triple lumen catheter -Rate of flow runs according to returns…rapid (wide open), moderate, slow. -Initially fast, then moderate/slow, as returns become lighter in color *Use nurses judgement |
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CBI Assessments |
-Bed rest (flat) until CBI d/c’d(easier fluid evacuation and decrease clot buildup & less pressure on operative site) -Monitor returns for bleeding/clots and color of returns; constant flow Hydrate patient; VS -Check irrigation bags and returns frequently; Bags staggered and should not empty -May need to change bags q20-40 min -Empty drainage bag/ bucket frequently -Check tubing for kinks -Slow irrigation as returns become pink |
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Pt assessments with CBI |
-Assess bladder -Pain?Spasms? -Slight distension/firm? -Normal to feel bladder fullness and need to void -Acute pain abnormal; obstruction? -Can relieve spasms with B&O supps -DVT-Homan’s sign? Calves? -Excessive bleeding? Hemorrhage? Clots? |
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24-36 hours post-op CBI |
CBI d/c’d…when returns are light pink -Ambulate after CBI d/c’d; cautiously -If bleeding occurs/persists-rest; increase fluids, decrease activity |
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Post-CBI Teaching |
-Increase fluids -Assess urine flow, color… -Avoid heavy lifting; prolonged sitting for 4 – 6 weeks (pressure may cause bleeding) -Mild burning when urinating -Avoid constipation -Call physician if fever; severe burning; dysuria; bright red urine; blood clots in urine -No sex for 6 weeks (pressure may cause bleeding) |
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Terminal signs of increased ICP |
-coma -bilaterally fixed and dilated pupils -respiratory arrest -absence of motor response (flaccid) |
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Late Signs of increased ICP |
-decreased LOC -unilateral or bilateral pupilary changes -ineffective breathing pattern -abnormal motor response - decorticate or decerebrate |
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Early signs of increased ICP |
-altered LOC -unilateral pupil change in size, equality and or reactivity -altered resp pattern -unilateral hemiparesis |
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What happens earlier than decreased LOC |
LOC changes |
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What happens to the pupils when cranial nerve is compressed? |
pupils dilate and become more sluggish |
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What are you testing with verbal response? |
-long term memory -short term memory -intermediate memory |
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Pronator Drift |
Pt sits or stands with eyes closed, arms out straight, slightly lateral, palms up.Watch for drift of the arms out of position. (Symtpomatic of cerebellar damage – proprioception = unconscious perception of movement and spatial orientation) |
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One side of brain swells - pupils? |
same side pupil will dilate |
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Motor Response - Localizes |
nurse squeezes trapezius on each side. pt attempts to move opposite hand towards affected tapezius |
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Motor Response - Withdraws |
pt withdraws from a pain stimulus to all 4 limbs |
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Motor Response - Flexion |
-decorticate posturing with trapezius squeeze |
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If you can't wake pt, what do you do? |
Call a code |
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Motor Response - Extension |
Decerbrate posturing with trapezius squeeze |
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documentation accronym for PERL (for GCS assessment) |
Pupils equal and reactive to light |
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Seizure Precautions |
1. Padded Side Rails 2. Suction and O2 available 3. IV insitu 4. Oral Airway |
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What is ORIF? |
-open-reduction internal fixation- Incision closed with staples - May or may not have drain in place |
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What is OREF? |
-Open-reduction external fixation -immobilizes bones to facilitate healing -surgeon percutaneously places pins or screws into the bone on both sides of the fracture -pins are secured together outside the skin with clamps and rods (i.e. the "external frame”) |
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What are some assessments and interventions with a patient with a cast? |
1) Neurovascular assessment 2) Pain…types of medications: opioids 3) Edema…elevate above heart 4) Skin care at edges…actions? 5) Foul odour…S & S of infection...take V/S, check labs for infection, inform surgeon 6) Itchiness…actions? 7) Documentation |
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Necrotizing fasciitis |
- commonly known as flesh-eating disease - is a rare infection of the deeper layers of skin and subcutaneous tissues which easily spreading across the fascial plane within the subcutaneous tissue - is a severe disease of sudden onset that progresses rapidly |
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Cachexia |
- weakness and wasting of the body due to severe chronic illness |
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Chemo precautions |
-the need to protect the patient from the outside world (positive pressure room to keep air from outside out) -PPE to be worn by staff and visitors |
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review of how to clean a wound |
from clean to dirty (center, side, side) |
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Is it okay for LPNs to d/c a wound drain? |
YES (according to CLPNBC), but check facility policy and also WITH A DOCTORS ORDER, of course! |
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What are 4 types of Skin/Wound closure procedures?
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1) skin glue (for small tears like on a finger) 2) steristrips 3) staples (surgical clips) 4) sutures
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What is the purpose of having a wound closure? |
to close surgical wounds & to repair lacerations *Goal is to promote healing by primary intent.* |
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What is primary intent?
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-wound edges come together neatly -stops any bleeding -preserves tissue function -prevents infection -restores cosmetic appearance -promotes rapid healing -this type of healing is usually from a surgical incision, not laceration |
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What are the phases of wound healing? |
Inflammatory Phase: 0-4 days Proliferation Phase: 5-21 days Maturation Phase: up to 1 year |
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What is secondary intention healing? |
-wound edges are not well approximated -takes way longer to heal that primary intention -usually seen with a laceration (instead of surgical incision) -scarring will be more evident -may have increased chance of being dirty/contaminated (higher risk of infection) |
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Patient teaching for wound healing |
-Nutrition: increase vit C & protein to speed healing time up -splinting when moving around, coughing to prevent dehisence |
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When you have an order to d/c staples/sutures, what should you check? |
*Use Nrg Judgment when assessing wound prior to removing sutures/staples. -check dr's order/facility policy -assessment (edema, infection, no dehisence) -if wound starts to open, STOP!! -take sutures/staples out alternately, to see how wound will take it -apply steristrips to reinforce where the staples/sutures were -document how many were taken out |
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types of sutures |
1) continuous (LPNs cannot remove these!) 2) Interrupted (similar to staples - we can remove these!) 3) Retention - rubber or elastic (LPNs cannot remove these either!!) |
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Hemovac |
-a portable wound suction device that is compressed to provide gentle suction - an internal spring slowly expands to create a negative suction pressure of approximately 45 mg Hg. -enhances healing by removing fluid or air from the peri-wound area -suction is lost as drainage accumulates (empty regularly) |
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Jackson-Pratt |
-small wound drain that uses negative pressure to draw out drainage from a wound -enhances healing by removing fluid or air from the peri-wound area -suction is lost as drainage accumulates (empty regularly) |
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Penrose Drain |
-no suction, passive drainage -drains onto gauze surrounding drain sponge -surgeon will say when to pull/cut drain sponge -REMEMBER to pin drain sponge to gauze, as it could slip into wound if not secured! |
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What types of acute or chronic conditions put someone at higher risk for dehiscense? |
-smoking -DM - longer healing time -HTN -obesity -poor nutrition -life style -immunosuppressant -Resp issues -other infection -age |
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What is the difference between a complex and surgical wound? |
Complex - secondary intention: longer healing time, may need packing, more frequent changes Surgical - primary intention: faster healing time |
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What are you assessing when emptying a wound drain system? |
1) Colour 2) amount 3) consistency/substance (clots or other debris) 4) odour 5) that the drain is insitu 6) that suture is in place (if you are changing dressing) |
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What are 4 potential complications an LPN might observe for in surgical wound? |
1) infection 2) dehiscence 3) eviseration 4) hematoma |
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What is tertiary intention? |
-delayed primary intention -wound is left open to drain toxins, and then will be closed when infection |
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What do you do if you are doing your QPA and your patient is falling asleep, or cannot be woken up?
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DO NOT MOVE ON!! This needs to be resolved before moving to other assessments.
REMEMBER A, B, C's!
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What is one thing you can tell your patient to raise their oxygen level? |
Deep breathing and coughing exercises |
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How do you measure a wound? |
Length (head to toe direction) Width (from side to side) Depth (use sterile cotton-tipped applicator to measure) |
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Description of surrounding skin of wound... |
Intact, macerated, hard, red, scaly |
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what is maceration? |
the softening and breaking down of skin resulting from prolonged exposure to moisture. |
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What is exudate? |
is any fluid that filters from the circulatory system into lesions or areas of inflammation (It can be a pus-like or clear fluid) |
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what is sanguineous drainage? |
-This type of wound exudate is also known as the fresh blood that comes from a recent wound, and is characterized by a bright red color -Most commonly, it is seen in partial thickness and full thickness wounds. |
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what is serous drainage? |
bodily fluids that are typically pale yellow and transparent |
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What is serosanguineous drainage? |
-containing or relating to both blood and the liquid part of blood (serum)-it usually refers to fluids collected from or leaving the body (fluid leaving a wound that is serosanguineous is yellowish with small amounts of blood) |
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What is purulent drainage? |
consisting of, containing, or discharging pus. |
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Induration |
-Localized hardening of soft tissue of the body -The area becomes firm, but not as hard as bone |
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Debridement |
-the process of removing nonliving tissue from pressure ulcers, burns, and other wounds. -LPNs can only rinse out wounds, no surgical removal of necrotic tissue (RNs/Wound care RNs would be doing this - collaboration) |
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Discharge Teaching |
-Keep dressing clean and dry -Splint area before coughing -Good nutrition, adequate rest -Call MD or go to ER if: Excessive bleeding Redness, pain, excessive swelling Increased or foul smelling exudate Fever Flu-like symptoms |
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Hematoma
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bleeding that is trapped within tissues or organs |
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slough |
dead tissue that has been shed |
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granulation |
soft pink/red tissue comprised of capillaries and fibrous collagen |
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absess |
a cavity containing pus and surrounded by inflamed tissue, formed as a result of localized infection |
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approximation |
drawing two tissue surfaces close together as in the repair of a wound |
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dehiscence
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the separation of a surgical incision or rupture of a wound closure, typically an abdominal incision.
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epithelialization |
the regrowth of skin over a wound |
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evisceration |
the protrusion of an internal organ through a wound or surgical incision, especially in the abdominal wall |
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necrosis |
localized tissue death that occurs in groups of cells in response to disease of injury |
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vacuum assisted closure (VAC) |
-a dressing or filler material is fitted to the contours of a wound (which is covered with a non-adherent dressing film) and the overlying foam is then sealed with a transparent film -A drainage tube is connected to the dressing through an opening of the transparent film. A vacuum tube is connected through an opening in the film drape to a canister on the side of a vacuum pump |
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staples |
-pieces of stainless steel wire that are used to close certain surgical wounds |
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Sutures |
-surgical stitches taken to repair an incision, tear, or wound -material used for sutures are silk, catgut, wire, or synthetic material |
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chest tube clamps |
called "Kelly Clamps" - RNs use these when there is a suspected air leak in the chest tube system |
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mediastinal shift |
-The build-up of pressure in the pleural cavity causes the mediastinum (which contains the heart, trachea, esophagus and great vessels) to shift to the unaffected side -also causes compression of the lung on the unaffected side. -also called "Flail Chest" |
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What is the purpose of a chest tube? |
to remove air/fluid from the pleural space and to restore normal intra pleural pressure so that the lungs can re-expand -also used to measure drainage from lungs |
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Types of chest tube drainage systems |
Wet (collection chamber, water seal chamber, suction control chamber) Dry (contains no water, but works similarly by having a regulator to dial the desired negative pressure (ex:Heimlich Valve) |
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collection chamber |
-receives fluid and air from the chest cavity -fluid stays in this chamber while air vents into the 2nd compartment |
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water seal chamber |
-contains 2cm of water, acting as a one-way valve -incoming air from the collection chamber bubbles up through the water |
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suction control chamber |
applies controlled suction to the chest drainage system by regulating the negative pressure when it exceeds a certain pressure |
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pleural effusion |
-an abnormal accumulation of fluid in the intra pleural spaces of the lungs -characterized by: chest pain, dyspnea, adventitious lung sounds, nonproductive cough |
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hemothorax |
a collection of blood in the pleural cavity |
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pneumothorax |
-the presence of air or gas in the pleural space, causing a lung to collapse -characterized by: sudden sharp chest pain, followed by rapid breathing, decreased breath sounds and cessation of normal chest movements of the affected side; tachycardia, diaphoresis, elevated temp, dizziness, anxiety |
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negative pressure |
a less than ambient atmospheric pressure, such as in a vacuum |
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negative pressure isolation rooms |
-used for patients with an airborne transmitted disease -airflow goes from the corridor into the patients room, and is then exhausted/vented outside |
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fluctuation |
a wavelike motion of fluid in a body cavity or apparatus; also called tidaling.
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air leak |
-indicated by rapid, vigorous bubbling in the water seal -consistent with a tear in the pleura, bronchopleural fistula, or a crack or leak in the drainage system |
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tension pneumothorax |
-characterized by: chest pain and resp distress, tachycardia, tachypnea in the initial stages; quieter breath sounds on one side of the chest, low O2 SAT and BP, and displacement of the trachea away from the affected side |
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thoracotomy |
surgical incision into the chest wall. |
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pleura |
is the thin fluid-filled space between the two pulmonary pleurae (visceral and parietal) of each lung. |
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intrapleural space |
-place between the parietal and visceral pleura -also called pleural cavity |
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empyema |
the collection of pus in a cavity in the body, especially in the pleural cavity. |
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valsalva maneuver |
-the action of attempting to exhale with the nostrils and mouth, or the glottis, closed -This increases pressure in the middle ear and the chest, as when bracing to lift heavy objects, and is used as a means of equalizing pressure in the ears |
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the purpose of a neurovascular assessment |
-a systematic approach for recognizing neurological &/or circulatory impairment of an extremity -used by nurses to assess pulses, CWMS, cap refill,radial nerve, ulnar nerve, median nerve, femoral nerve, peroneal nerve, tibial nerve |
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A patient on the unit develops diarrhea, which is confirmed to be caused by C. difficile. What type of isolation should this patient be placed on? |
Contact precautions (gloves, gown, hand hygiene) |
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What type of isolation precautions should someone with necrotizing fasciitis be on? |
CONTACT & DROPLET PRECAUTIONS (gloves, gown, mask, eye protection, hand hygiene) |
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What type of isolation precautions should someone with SARS/TB be on? |
AIRBORNE PRECAUTIONS -N95 mask, hand hygiene -private room with negative pressure -highly suggested that they stay inside (not to go outside without PPE on themselves) |
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How is someone who is on chemotherapy being protected while in the hospital? |
-positive pressure rooms (so that air from outside their room is kept out) -bed linens changes daily -separate washroom (not shared) -staff should double gloves for handling any bodily fluids, gown, mask |
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If your patient is MRSA positive and has an open wound, what PPE would you wear as staff working with them? |
CONTACT PRECAUTIONS -gloves, gown, hand hygiene |
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What is the "U" & the "V" mean in the pain scale?
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U - understanding your pain. What do you think it is? V - what are your values around controlling pain, and pain itself? |
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What is included in the "perioperative" period for your patient? |
Pre-op, intra-op, post-op (the entire surgery process) |
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What are some things you need to assess while your patient is on a PCA? |
-Vital signs, especially resp's & sedation -PRN meds should include Naloxone as the antidote for opioid toxicity -monitor amount being delivered -monitor how many times pt is accessing, and monitor how many times it was denied -monitor lockout time -assess IV site for DRIPS -ability of patient to understand how to use PCA |
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Indications for an NG Tube |
-relief of GI obstruction or ileus -decrease abd distention after surgery -administration of meds or eteral feed(when pt. can't swallow) -obtain specimen of gastric contents -gastric lavage for overdose (stomach pump) |
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Why do we clamp an NG tube? |
-when patient is ambulating -when PO meds have been given -when we are testing patient tolerance for clear fluids (tube would be clamped and tolerance to clear fluids for 3 hours without N/V to be able to remove NGTube) |
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low continuous suction |
between 40-80 |
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indication for tracheostomy |
-obstruction -trauma -surgery (Cancer) -injury to the spine (C4 and above) -stroke -a need for mechanical ventilation (life support) |
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CLPNBC entry-to-practice limits |
"Well established sites, following anticipated pathway" -Assessment (insitu, chest assess) -integrity of dressing (S/S of infection) -the flange (that keeps the canula in place): just monitoring! **No suctions or changing the canula.** **Collaborate with RN about them doing deep suctions prior to dressing change.** |
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Complication with tracheostomy |
-Infection -cyanosis -gurgling (need for deep suctioning) |
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What is a tracheostomy? |
an incision in the windpipe made to relieve an obstruction to breathing |
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Different types of tracheostomy tubes |
-cuffed tube with disposable inner canula -cuffed tube with re-usable inner canula -outer canula with holes in it (for speaking) |
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Possible complications of a tracheostomy and tracheostomy tube |
-Bleeding and infection -Pneumothorax -Subcutaneous emphysema (air gets trapped beneath the skin) -fistula or abnormal connection may form between the windpipe and esophagus (Symptoms include severe coughing and trouble breathing) -narrowing of the airway -obstruction from dried mucous (called plugs) |
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What should the nurse do prior to doing a trach dressing change? |
-DB/C to loosen secretions
-Can hyper oxygenate patient prior to procedure -HOB should be semi-fowlers to high fowlers position -Pain assessment |
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Safety equipment for patient with trach |
-2 trach tubes (with flange & everything): 1 the same size and 1 size smaller -extra disposal inner canula -opturator (to aid with putting the canula in) -connector for ambubag (resusitation kit) -trachial dilators (looks like kelly clamps) -10-12 cc syringe (to deflate/inflate balloon) |
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Can LPNs care for patient's with well-established tracheas? |
YES! It is within our scope-of-practice! |
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Is cleaning of a patient's trach faceplate & stoma considered medical aseptic technique or sterile aseptic technique? |
Sterile technique! Supplies needed: normal saline, trach kit to include sterile q-tip swabs, clean gloves, sterile gloves, cleaning solution, ties, sterile 2x2 gauze, and sterile scizzors). |
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What does the CLPNBC scope-of-practice state about LPNs caring for a patient with an artificial opening in the body? |
LPNs only provide tracheostomy care to clients: a) with well-established tracheostomies b) who have stable and predictable states of health c) after successfully completing additional education |
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What are some reasons to call a CODE BLUE? |
1) Not breathing 2) Not breathing/No circulation 3) Unresponsive to verbal and/or painful stimuli 4) Controlled code (dropping BP, dropping HR, dropping resp's: you can see that your patient is heading for a code situation) |
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When doing CRP/rescue breathing in acute care, what do you need to make sure to hook up to the Ambubag? |
O2! If there isn't O2 available, remember to pull off the little plastic bag on the end of the ambubag. |
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What do we do immediately when entering a patient's room in order to start caring for our patient? |
1) collect data & deal with pressing issues! 2) Cluster the data (along with any lab results) 3) anticipate diagnosis and treatment plan |
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What are the steps in asking a patient about their pain? |
Onset: When did it begin? How long does it last? Provoking: What brings it on? What makes it worse/better? Quality: What does it feel like? Can you describe it? Region/Radiating: Where is the pain? Does is spread anywhere? Severity/Scale: 0-10; Tolerance: What is your pain tolerance on the scale? Understanding: What do you believe is causing this symptom? How is it affecting you/family? Values: What is your goal for this symptom? Are there any views or feelings that are important to you about your pain? |
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Epistaxis |
bleeding from the nose |
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What are the most common causes of epistaxis? |
-local trauma to nose/face -prolonged breathing of dry air -mucosal irritation -septal abnormalities -inflammation -tumours (cancer) -systemic HTN |
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Which are the most common areas of the nasal cavity to bleed? |
90% - anterior bleed 10% - posterior bleed |
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What are my priorities and nursing interventions in acute care for epistaxis? |
1) prolonged bleeding (>15 mins) - needs to be dealt with ASAP 2) ABC's (limit talking/coughing, position pt in recumbant position, cold pack to area/back of neck (if posterior bleed), have patient suck on ice chips (this also limits talking), assess pain) |
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Can LPNs pack posterior bleeds? |
NO!!! But we could be asked to assist the doctor at the bedside. |
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Can LPNs pack anterior bleeds? |
YES!! If you can see the nares - okay to pack (loosely) |
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What are you assessing with a patient who has a nose bleed? |
- assess if it's anterior or posterior bleed - assess amount of blood in basin/kleenex's - chest assessment (nasal prongs are okay to put on if needed) - assess when the bleeding started (question pt) -chest X-Ray? - order for ativan (for anxiety for pt) - Blood work to order: CBC, lytes, INR, Platelets, -Physician will probably get Phenylcaine or cauterization kit for posterior bleed. |
