NRSG3320 EXAM 2 COMBINED FLASHCARDS

type 1 diabetes

autoimmune destruction of beta cells, little/no insulin → needed for life

usually <30y/o, sudden wt loss, acute risk of DKA

type 2 diabetes

insulin resistance plus impaired secretion, enough insulin to block ketones (DKA uncommon)

usually >45y/o, develops gradually, acute risk of HHS

certified diabetes care and education specialist

aka CDCES, nurse/dietitian certified in diabetes education

A1C

lab value that reflects avg glucose over ~past 3 mo.

normal is <5.7%, goal for many diabetics is <7%

ketones

show up in urine if body breaks down fat for energy instead of glucose

T1DM check urine ketones if glucose >240 2x in a row or when ill, notify provider if elevated, could mean diabetic ketoacidosis

continuous glucose monitor

aka CGM, sensor that measures glucose of interstitial fluid in real time

goal for diabetics is 70-180 mg/dL, more time in normal range than not
(CGM reads interstitial fluid not blood, so fingerstick is needed if sudden change)

insulin types

insulin safety

rapid acting → pt eats w/in 5-15mins of injection
regular → give 15-30mins before meal

mixing → draw up regular (clear) before NPH (cloudy), but long-acting is NEVER MIXED w/ other insulins

too much insulin given → check glucose first, then monitor through peak, give carbs only if low, report once pt is safe

C. "A dietitian will help me build a meal plan around the foods I like."

A nurse is teaching a patient newly diagnosed with type 2 diabetes about

meal planning. Which statement indicates understanding?

A. "I need to stop eating all carbohydrates."

B. "I only need a dietitian if my A1C goes up."

C. "A dietitian will help me build a meal plan around the foods I like."

D. "A meal plan means eating the same meals every day."

B. Draw up the regular (clear) insulin first

A nurse is preparing regular and NPH insulin in one syringe. Which action is

correct?

A. Draw up the NPH (cloudy) insulin first

B. Draw up the regular (clear) insulin first

C. Substitute glargine for the NPH so both can be mixed

D. Mix the two insulins in the NPH vial before drawing up

hypoglycemia

blood glucose level <70mg/dL

causes → too much insulin/oral agent, too little food, extra activity, alcohol, sulfonylureas

early signs → sweating, shaking, fast HR, hunger

later signs → confusion, slurred speech, unusual behavior, seizures

hypoglycemia treatment

if alert/able to swallow → 15g fast-acting carb (4oz juice/soda, 304 glucose tablets, 1tbsp sugar/honey), recheck in 15min, repeat if still <70

if can’t swallow but has IV access → D50W per protocol, recheck per protocol

if can’t swallow and no IV access → glucagon SC/IM/intranasal, turn to side, food once alert

DKA vs. HHS

hyperglycemic crisis nursing care

• rehydrate rapidly, NS first, then ½ NS (watch older adults for fluid overload/HF)

• continuous IV regular insulin, hourly blood glucose

• K and ECG q2-4hrs early in treatment (give K once urine flows, even if level is normal)

• monitor blood/urine ketones until acidosis resolves

A. Add dextrose to IV fluids and continue insulin

A patient in DKA on IV insulin now has glucose of 240 mg/dL, and the acidosis has not resolved. Which prescription should the nurse anticipate?

A. Add dextrose to IV fluids and continue insulin

B. Stop the insulin infusion

C. Switch to subcutaneous insulin now

D. Give 15 g of carbohydrate by mouth

D. Give IV dextrose 50% per protocol

A hospitalized patient with diabetes is difficult to arouse. Fingerstick glucose is 42 mg/dL, and a saline lock is in place. Which action should the nurse take first?

A. Give 4 oz of orange juice

B. Recheck the glucose in 15 minutes

C. Give the scheduled breakfast insulin

D. Give IV dextrose 50% per protocol

diabetic neuropathy

nerve damage caused by long-term high blood sugar and high blood fat levels associated with diabetes, affects up to 50% to 70% of people with the condition

**LOSS OF PROTECTIVE SENSATION → injuries can go unnoticed

starts in toes/fingers, spreads in stocking-glove pattern, tingling/burning, often worse at night, then numbness

diabetic foot care teaching

• inspect tops, sides, soles daily; use mirror or family help

• wash in warm water tested w/ thermometer/elbow, never soak

• dry between toes, lotion on tops and soles only

• clean cotton socks daily, shoes/socks at all times

• trim nails straight across, see podiatrist for calluses and thick nails

• no heating pads

• break in new shoes slowly

• call provider if cut/blister/sore doesn’t begin to heal after 1 day!!

older adults & diabetes

• ~25% of adults >65 have diabetes

• higher risk of falls, polypharmacy, depression, cognitive impairment

• lows are dangerous → slower drug clearance, skipped meals, living alone

• A1C <8% may suit some older adults

• HHS more common → watch for fluid overload during treatment

• pens help w/ vision/dexterity limits

B. A prefilled insulin pen

An older adult with type 2 diabetes and low vision is being discharged on basal insulin. Which option best supports safe self-administration?

A. Vials and syringes drawn up each day

B. A prefilled insulin pen

C. A neighbor draws up a week of syringes

D. A standard-display glucose meter

C. Loss of protective sensation

During a foot exam, a patient with type 2 diabetes cannot feel the monofilament at three sites on the sole. How should the nurse interpret this finding?

A. An expected finding with aging

B. A sign of arterial insufficiency

C. Loss of protective sensation

D. An early sign of infection

hypopituitarism

undersecretion of one or more hormones from pituitary gland (if all anterior hormones → PANhypopituitarism)

causes → tumor, trauma, vascular lesion, head/neck radiation

thyroid, adrenal cortex, gonads will atrophy w/o tropic hormones (causing wt loss, hypoglycemia, hypometabolism, amenorrhea, hair loss)

treatment is to replace missing hormones

**total pituitary loss leads to COMA and DEATH if missing hormones are not replaced

acromegaly

chronic/dysregulated hypersecretion of growth hormone (most commonly from a benign anterior pituitary tumor) that causes abnormal excess growth in hands, feet, jaw, nose, brow bridge

diagnosis → visual field testing, CT, MRI, serum hormone levels

treatment → transsphenoidal hypophysectomy, radiation, medications

care after hypophysectomy

• HOB elevated → at home, 30° for at least 2wks

• no nose blowing (for at least 1mo.), sneezing, hard coughing, straws, bending, straining

• check nasal packing for blood/CSF, packing out 3-4 days

• check visual acuity and fields → falling vision suggests hematoma

• watch for DI → I&O, urine specific gravity, Na, daily wt

• oral care q4h → no toothbrushing until incision heals

• **salty taste or postnasal drip can be CSF leaking → REPORT IMMEDIATELY

diabetes insipidus

aka DI, ADH deficiency

high UOP (>250mL/hr), low urine specific gravity (1.001-1.005), low urine osmolality, high serum osmolality, high serum Na (dehydration), intense thirst (for cold water)

treatment → desmopressin, fluid replacement

syndrome of inappropriate ADH

aka SIADH, excess ADH

concentrated urine (water retained), high urine specific gravity (>1.012), low serum osmolality, low serum Na (dilutional, no edema), confusion/lethargy as Na falls

treatment → fluid restriction, correct the cause

diabetes insipidus management

• goals → replace ADH, replace fluids, treat underlying cause

• desmopressin (PO, intranasal) → drug of choice for central DI

• nephrogenic DI → thiazides, mild salt depletion, prostaglandin inhibitors

• monitor v/s, I&O, signs of dehyration

• fluid deprivation test → stop for tachycardia, excess wt loss

SIADH causes

lung cancer, pneumonia, head injury, brain surgery/tumor

higher risk → older adults, SSRIs, mechanical ventilation

B. "I will keep the head of my bed raised for at least 2 weeks."

A nurse is reviewing discharge teaching with a patient after transsphenoidal hypophysectomy. Which statement indicates understanding?

A. "I can brush my teeth as usual tonight."

B. "I will keep the head of my bed raised for at least 2 weeks."

C. "I can drink through a straw once I get home."

D. "I can blow my nose gently after a few days."

C. Fluid restriction

A patient with SIADH has a serum sodium of 128 mEq/L and mild headache. Which prescription should the nurse anticipate?

A. 0.45% sodium chloride IV at 125 mL/h

B. D5W IV bolus

C. Fluid restriction

D. Encourage 3 L of oral fluids daily

hypothyroidism

too little thyroid hormone, most commonly caused by Hashimoto’s disease

TSH high, free T4 low, fatigue, wt gain, cold intolerance, slow pulse, constipation, dry skin

emergency → myxedema coma

hyperthyroidism

too much thyroid hormone, most commonly caused by Graves disease

TSH low, free T4 high, heat intolerance, wt loss, more appetite, fast pulse, tremor, nervousness, diarrhea

emergency → thyroid storm

levothyroxine

drug of choice in hypothyroidism

start low, increase slowly → usual start 12.5 mcg, dose titrated to TSH

take every morning on an empty stomach w/ full glass of water, continued for life even after symptoms improve

hypothyroidism nursing care

• sedatives, opioids, anesthetics have prolonged effects

• teach → keep taking meds even after symptoms improve

• teach when to seek care and importance of nutrition

• older adults → fatigue, aches, confusion often blamed on aging

myxedema coma

life-threatening, severe hypothyroidism emergency → mortality 20-50%

often follows stopping thyroid meds, or infection/sedatives/cold

key signs → confusion, low body temp
support breathing, give fluids cautiously

hyperthyroidism medications

radioactive iodine

most common treatment for Graves, one dose works 80-90%

pregnancy test 48hrs before, avoid conception for at least 6mo., no shared bed/utensils, no close contact w/ children, hypothyroidism often follows (needs lifelong monitoring)

fever, sore throat, mouth ulcers → stop drug and call provider

hyperthyroidism nursing care

• monitor HR/rhythm, temp; watch for HF

• high-calorie, high-protein foods → record wt/intake (avoid coffee, tea, cola, seasoned foods, alcohol)

• keep environment cool, quiet, calm

• eye protection for exophthalmos → artificial tears

• reassure family → irritability comes from disorder and will improve w/ treatment

thyroid storm

abrupt/severe hyperthyroidism, almost always fatal if untreated, fever >101.3°F, HR >130bpm, delirium, psychosis, somnolence, coma

triggers → infection, surgery, DKA, stopping antithyroid drugs, rough palpation

treatment → propranolol, PTU, methimazole, iodine, hydrocortisone, oxygen

cooling blanket, cool/quiet room, continuous cardiac monitoring

**use acetaminophen for fever → salicylates worsen hypermetabolism!!

thyroidectomy

indications → thyroid cancer, large goiters, hyperthyroidism when drugs not an option

surgery once thyroid fxn is normal (4-6wks), antithyroid drug until signs resolve, propranolol to slow the heart

stop aspirin and other drugs that prolong clotting several wks before

high-calorie diet high in carbs and protein

avoid tea, coffee, cola, other stimulants; ensure good night’s sleep

post-operative thyroidectomy care

• airway first → glottic edema, hematoma, laryngeal nerve injury

• check dressing front/sides/back of neck for bleeding, P/fullness at incision means possible hematoma

• semi-fowler position → support the head, avoid tension on sutures

• watch for tetany → tingling of mouth/fingers, Chvostek/Trousseau signs need to be reported at once and treated w/ IV calcium gluconate

• **keep tracheostomy set at bedside → call surgeon at first sign of distress

B. "My grandson can nap on my lap."

A nurse is reviewing home safety with a patient after radioactive iodine treatment. Which statement requires follow-up?

A. "I will sleep in a separate bed than my husband."

B. "My grandson can nap on my lap."

C. "I will use my own dishes and utensils."

D. "I can go for a walk outside with my pregnant daughter."

D. "Take it first thing in the morning on an empty stomach with a full glass of water."

A nurse is teaching a patient who has a new prescription for levothyroxine. Which instruction should the nurse include?

A. "Take it with your evening meal."

B. "Skip a dose on days you feel well."

C. "Expect to take it for about 6 months."

D. "Take it first thing in the morning on an empty stomach with a full glass of water."

calcium regulation

>99% of body Ca in bone/teeth, normal total serum Ca 8.5-10.5mg/dL

low Ca triggers PTH from parathyroids (releases bone ca, raises gut/kidney absorption), high Ca triggers calcitonin from thyroid (slows Ca release from bone, lowering serum Ca)

hypocalcemia

serum Ca <8.5mg/dL
causes → hypoparathyroidism, pancreatitis, vit. D deficiency, massive citrated transfusion
neuromuscular → tingling, tetany, hyperactive reflexes, seizures
other → laryngospasm, bronchospasm, diarrhea, low BP
ECG → prolonged QT

hypercalcemia

serum calcium >10.5mg/dL
causes → hyperparathyroidism, malignancy, prolonged immobility, thiazides
neuromuscular → weakness, hypoactive reflexes, lethargy
other → constipation, polyuria, bone pain, kidney stones
ECG → shortened QT, heart blocks

hyperparathyroidism

PTH excess → bone decalcification, Ca kidney stones

most common in females and >50 → many have no symptoms (fatigue, weakness, constipation, mood ∆)

treatment → parathyroidectomy (often minimally invasive and outpatient), fluids >2L daily, avoid thiazides, encourage walking

hypercalcemia management

• IV NS → dilutes Ca and increases its excretion

• stop Ca-containing fluids, meds, food

• calcitonin IM/intranasal, bisphosphonates slow bone resorption

• treat cause → parathyroidectomy, cancer treatment

• crisis (Ca >13mg/dL) → rapid IV saline plus calcitonin, target UOP 100-150mL/hr, watch for fluid overload

• encourage walking and 3-4 quarts fluid daily, add fiber

hypoparathyroidism

PTH deficiency → Ca low, P high

most common cause is parathyroid removal during surgery
goal → serum Ca 9-10 mg/dL
chronic → oral Ca, calcitriol, thiazide, phosphate binders after meals
diet high in Ca, low in P (limit milk, milk products, egg yolk, spinach)

hypocalcemia and tetany

• Latent: numbness, tingling of fingers, toes, around the mouth

• Overt: carpopedal spasm, laryngospasm, bronchospasm, seizures

• Chvostek: tap the facial nerve; mouth, nose, and eye twitch

• Trousseau: inflate a BP cuff above systolic; hand and wrist spasm

• Prolonged QT; risk of torsades de pointes

• Highest risk: first 24 to 48 hours after neck surgery

B. Hypocalcemia

While taking the blood pressure of a patient with acute pancreatitis, the nurse notes the patient's hand and wrist go into spasm as the cuff inflates. Which imbalance does this finding suggest?

A. Hypokalemia

B. Hypocalcemia

C. Hypercalcemia

D. Hypernatremia

Addison Disease

aka too little cortisol, most often autoimmune (or stopping steroids), HOTN, hypoglycemia, low Na, high K, wt loss, weakness, hyperpigmentation

emergency → Addisonian crisis

Cushing Syndrome

aka too much cortisol, most often corticosteroid meds, HTN, hyperglycemia, Na retention, low K, moon face, buffalo hump, striae, thin skin, infection risk, muscle wasting, osteoporosis

Addisonian crisis

life-threatening emergency in Addison disease

severe HOTN, signs of shock, cyanosis, fever, N/V/D, abd pain, confusion

triggers → infection, cold, overexertion, emotional stress, low salt intake

treatment → IV hydrocortisone, then 3-4L NS or D5W, recumbent position w/ legs elevated, vasopressors if HOTN persists, monitor vitals/glucose/Na/K

Addison disease nursing care

• orthostatic v/s → systolic drop of >20mmHg signals fluid loss

• monitor daily wt, skin turgor, glucose, Na, K

• lifelong hydrocortisone or prednisone, plus fludrocortisone (take w/ meals or antacids)

• extra salt for V/D, heavy sweating

• stress can trigger crisis → dose may need adjusting (if vomiting use emergency injection and seek care)

cushing syndrome medical management

diagnosis → 2 of 3 abnormal tests (serum cortisol, 24hr urine cortisol, dexamethasone suppression

cortisol normally peaks in morning and falls at night (in Cushing it stays high all day)

pituitary tumor → transsphenoidal hypophysectomy
adrenal tumor → adrenalectomy

medication-induced → taper to lowest dose, alternate-day dosing

after surgery, adrenal insufficiency may appear in 12-48hrs

cushing syndrome nursing care

• Prevent falls and fractures; assist weak patients when walking (Osteoporosis and muscle wasting raise fracture risk)

• Assess for subtle infection: cortisol masks inflammation

• Protect fragile skin; reposition often

• Diet high in protein, calcium, vitamin D; low sodium and calories

• Monitor BP, glucose, weight, potassium (Low potassium risks arrhythmias: cardiac monitoring and replacement)

corticosteroids

meds used for inflammation, autoimmune disease, allergy, transplant, adrenal insufficiency

give daily dose between 7-8am to match natural cortisol rhythm, alternate-day dosing reduces adrenal suppression in long-term use, taper gradually never stop abruptly

corticosteroid side effects

C. Assist the patient when walking and keep pathways clear

A patient with Cushing syndrome is weak and has osteoporosis. Which intervention should the nurse include in the plan of care?

A. Encourage a high-sodium diet

B. Limit calcium and vitamin D intake

C. Assist the patient when walking and keep pathways clear

D. Keep the patient on bed rest

A. A patient 24 hours after adrenalectomy for Cushing syndrome with BP 84/50 and new weakness

A nurse receives report on four patients. Which patient should the nurse see first?

A. A patient 24 hours after adrenalectomy for Cushing syndrome with BP 84/50 and new weakness

B. A patient with Cushing syndrome who reports trouble sleeping

C. A patient with Addison disease asking how much salt to eat before a hike

D. A patient taking prednisone with a glucose of 168 mg/dL

osteoarthritis

noninflammatory, degenerative joint disease where articular cartilage breaks down and the bone beneath it thickens narrowing the joint space and forming osteophytes (bone spurs)

(most common joint disease, limited to the affected joints → no systemic signs)

osteoarthritis risk factors

older age, female sex, obesity, prior joint injury, muscle weakness, genetic predisposition, occupational/sports joint stress

manifestations of osteoarthritis

pain worsens with activity and eases w/ rest, onset over years, morning stiffness lasts <30min, weight-bearing joints most affected (hips, knees, cervical/lumbar spine), Heberden (distal)/Bouchard (proximal) nodes in the hands, enlarged joints, decreased ROM, crepitus

diagnosis of osteoarthritis

x-ray → narrowed joint space, osteophytes, dense subchondral bone
labs and joint fluid rule out other causes (ex: RA)

management of osteoarthritis

exercise and weight loss, OT/PT, acetaminophen first than NSAIDs w/ caution or topical/injected agents

arthroplasty

surgery that replaces damaged joint surfaces w/ metal/synthetic parts for severe pain or lost fxn from OA, RA, trauma, AVN

total hip arthroplasty

arthroplasty type w/ a posterior approach → causes dislocation risk w/ flexion, adduction, internal rotation

needs hip precautions → no hip flexion past 90°, never cross legs, abduction pillow/wedge, turn to unaffected side only, raised toilet seat, high chair w/ armrests

total hip arthroplasty postop care

• ambulate w/ walker/crutches w/in day of surgery

• PT/OT early

• neurovascular checks → compare w/ preop findings

• VTE → compression devices, ankle pumps q30 min, anticoagulants

• monitor drain output, report excessive/foul-smelling drainage

• infection → strict hand hygiene, antibiotics 60min before incision

mobility/assistive devices

crutches → partial or NWB, weight on hands never axillae, tripod stance for stability

walker → most stable of the 3, pick-up for poor balance, rolling if unable to lift, never pull up to stand on it

cane → held opposite affected leg, advance w/ affected leg, takes load off wt-bearing joints

total knee arthroplasty

surgery for severe pain/disability unrelieved by nonsurgical care

D. compare sensation, movement, color, and pulses w/ preop findings

A client is 1 day postop after a total knee arthroplasty and says, “My foot on that side feels numb.” Which action should the nurse take first?

A. loosen the compression bandage
B. reposition the leg in neutral alignment
C. notify surgeon of new numbness
D. compare sensation, movement, color, and pulses w/ preop findings

A. help the client turn to the unaffected side w/ the abduction pillow in place

Which task can the nurse delegate to assistive personnel for a client 2 days after a total hip arthroplasty?

A. help the client turn to the unaffected side w/ the abduction pillow in place
B. teach the client hip precautions
C. assess pulses and sensation in the operative leg
D. evaluate the amount of wound drainage

osteoporosis pathophysiology

osteoclast resorption outpaces osteoblast formation → bone mass drops and becomes porous/brittle/fragile

common sites → thoracic/lumbar spine, hip, wrist

osteoporosis risk factors

menopause, aromatase inhibitors, small frame, low calcium/vit. D intake, inactive lifestyle, current tobacco use, 3+ alcoholic drinks/day, corticosteroids >3mo., low BMI, family h/x, adult fractures, diabetes, rheumatoid disease

osteoporosis diagnosis/screening

• DEXA scan measures bone mineral density at spine and hip (screen all females >65 or postmenopausal >50 w/ RF)

• FRAX estimates fracture risk from BMD and history

calcium sources

dairy, fortified juice, cereal, tofu, canned salmon/sardines w/ bones, kale, broccoli

osteoporosis medications

• bisphosphonates (alendronate, risedronate, ibandronate, zoledronic acid)

• denusomab, raloxifene, romosozumab, teriparatide

• **alendronate must be taken in morning w/ empty stomach, 250mL water, sitting upright and remaining upright for >30min

osteoporotic fracture nursing care

• back pain → brief bed rest, knee flexion, local heat, back rubs

• move trunk as unit, avoid twisting

• constipation → fiber, fluids, prescribed stool softeners

• prevent falls → home hazard review, balance exercise

• teach calcium, vit. D, medication regimen

osteoporotic fracture priority nursing diagnoses

• acute pain from fracture and spasm

• risk for constipation

• risk for more fractures

• lack of knowledge

osteomalacia

inadequate bone mineralization from low activated vit. D

signs → bone pain, tenderness, bowed legs, kyphosis, waddling gait

pathologic fractures → distal radius, proximal femur

labs → low Ca/P, elevated ALP

osteomalacia causes

fat malabsorption (celiac disease, bowel resection), kidney/liver disease, poor intake, little sunlight, long-term anticonvulsants

Paget’s disease of the bone

localized rapid bone turnover → disorganized mosaic bone (dense on x-ray but structurally weak)

often affects skull, femur, tibia, pelvis, vertebrae

deep/aching pain (worse w/ wt-bearing), tenderness.warmth over bone, bowed legs, hearing loss

treatment → NSAIDs, bisphosphonates, walking aids, shoe lifts

osteomyelitis

bone infection → inflammation, necrosis, new bone formation (more than 50% from S. aureus or MRSA)

osteomyelitis types

bloodborne → sudden onset, chills, high fever, rapid pulse

local → swollen, warm, very tender, constant/pulsating pain

chronic → non-healing ulcer w/ sinus that drains pus (diabetic foot ulcers larger than 2cm is highly suspicious for osteomyelitis)

osteomyelitis diagnosis/treatment

• early x-ray only shows soft tissue edema → bone changes in 2-3 wks

• MRI/bone scan can give earlier diagnosis

• acute → leukocytosis, elevated ESR

• cultures are often negative → antibiotics may start before results (IV antibiotics 6-12 weeks)

• surgical debridement needed if chronic

sequestrum

dead bone inside an abscess → can’t drain so must be removed for bone to heal

osteomyelitis nursing care

splint, handle gently, elevate to reduce swelling, restrict wt-bearing to protect weakened bone, gentle ROM of joints above/below, ADLs w/in limits, watch IV site for superinfection, watch for candidasis/loose stools, report new painful/warm sites or sudden temp rise

septic arthritis

joint infection from blood, trauma, injection, surgery

highest risk → >80y/o, diabetes, RA, joint replacement, IV drug use

warm/painful/swollen joint, less ROM (~50% are knees), chills, fever, leukocytosis (sometimes)

aspirate/culture, prompt IB abx, drain, splint 203 days

delay risks joint destruction/sepsis, mortality nears 50% in high-risk cases

B. a client with a new hot, swollen knee, temp 101.8°F, who had knee injection last week

A nurse receives report on 4 clients. Which client should the nurse assess first?

A. a client with osteoarthritis who reports 20min of morning knee stiffness
B. a client with a new hot, swollen knee, temp 101.8°F, who had knee injection last week
C. a client on day 10 of IV antibiotics for osteomyelitis, temp 98.8°F
D. a client with osteoporosis who asks when to take alendronate

older adults and musculoskeletal health

falls → environmental hazards, diminished senses, meds
home → remove scatter rugs, clutter; add lights, rails, grab bars
calcium, vit. D, 15-30min of sun daily
after THA → analgesia is harder w/ cognitive impairment or comorbidities
infection may present w/o fever

degenerative/metabolic pain

• worse w/ activity or wt-bearing (OA, Paget)

• nonpharmacologic measures first

• treating disease eases pain (bisphosphonates in Paget)

• evaluate by fxn → walking, ADLs, exercise

infectious/postoperative pain

• often severe, constant/pulsating in osteomyelitis

• immobilize, elevate, give analgesics as prescribed

• assess pain before surgery to plan postop control

• new/worsening pain is red flag (dislocation, infection

types of soft tissue injury

contusion → blunt-force bruising (most resolve in 1-2wks)
strain → muscle/tendon overstretch, 1st-3rd degree
sprain → ligament injury from twisting, grade I-III
dislocation → joint surfaces out of alignment, orthopedic emergency

PRICE for soft tissue injury

Protection → sling, brace, splint, taping, compression bandage
Rest → prevent further injury, promote healing
Ice → ice for first 24-48h, 15-20min at a time
Compression → elastic bandage limits bleeding/edema
Elevation → at/just above heart level controls swelling

fracture classifications

clinical manifestations of fractures

pain/function → continuous pain until immobilized, spasm w/in 30min worsens pain, loss of fxn, false motion
deformity/shortening → angulation/rotation vs. other limb, shortening from compression/overlap
crepitus/swelling → grating of bone fragments on palpation, edema/ecchymosis may take hrs to appear

fracture emergency management

immobilize before moving → splint joints above/below
leg → bandage to other leg
arm → bind to chest or use sling

check neurovascular status distal to injury and before/after splinting

open fracture → cover w/ sterile dressing

in ED → remove clothing from uninjured side first

fracture reduction/fixation

reduction restores alignment → done early before healing begins
closed reduction → manipulation/traction, then cast/splint
ORIF (open reduction internal fixation) → surgery w/ pins, screws, plates, rods, nails

elevate, ice as prescribed, monitor neurovascular status
isometric/muscle-setting exercises, ADLs, gradual activity