NURS 351: Exam #4 (Med-Surg)

Osteoporosis Concern

* fracture

Arthritis Concern

* pain
* deformity
* impaired mobility
* psychosocial concerns

Total Joint Arthroplasty Concerns

* pain
* venous thromboembolus
* dislocation
* infection

Osteoporosis

* chronic disease characterized by bone loss, decreased bone density, and possible fracture
* osteoclastic activity
* osteoblastic activity
* thin, fragile bones at risk for fracture

Osteoporosis Assessment

* may be asymptomatic
* back pain with lifting and bending
* fractures
* kyphosis

Osteoporosis Risk Factors

* older age
* family hx of osteoporosis
* history of low trauma fracture after age 50
* chronic low calcium or Vit D intake
* low body weight
* estrogen deficiency
* smoker
* high alcohol intake
* lack of physical exercise

Osteoporosis Diagnosis

* Dual X-ray Absorptiometry

Osteoporosis Pharmacologic Treatment

* Calcium and D3
* intake of these supplements alone is not sufficient but it is an important part of bone health
* Biphosphonates: slow bone resorption

Osteoporosis Implementation

* patient teaching to prevent falls
* lifestyle practices to prevent additional bone loss
* daily sun exposure
* adherence to medication regimen
* encourage exercise
* Nutrition Therapy
* promotion of a single nutrient will not prevent or treat osteoporosis as many are needed for bone health
* emphasize fruits/veggies
* low fat dairy
* protein sources
* increased fiber
* moderation in alcohol and caffeine intake

Osteoporosis Prevention

* patient teaching before age 30
* adequate dietary calcium and Vit D intake
* smoking cessation and weight loss
* limit carbonated beverages to < 40 oz per day
* weight bearing exercise

Arthritis

Rheumatic diseases affect joints, tendons, ligaments, bones, and muscles

Osteoarthritis

* progressive loss of bone + cartilage in one or more joints
* decreases water, chondroitin, and cartilage between joints
* narrowing of join space + formation of bone spurs
* joint pain
* Secondary joint inflammation can occur when damage is severe
* Also known as Degenerative joint Disease

Osteoarthritis Risk Factors

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* > 65 years


* aging
* obese
* trauma or occupation
* may affect only one joint
* weight bearing joints, spurs + hands
* crepitus
* not systemic
* one or more joints affected
* normal or slightly elevated ESR
* female
* genetic
* progressive joint stiffness and pain
* eventual joint deformity

Osteoarthritis Pharmacologic Interventions

* Acetaminophen (1st choice)
* Topical lidocaine patches
* NSAIDs (only if tolerated)

Osteoarthritis Non-Pharmacologic Interventions

* Application of heat/cold
* Weight loss for obesity
* Complementary treatments
* Rest balanced with exercise
* Functional position of joints


* Proper posture + lifting
* PT

Rheumatoid Arthritis

* chronic, progressive systemic inflammatory autoimmune condition
* affecting primarily synovial joints
* autoantibodies attacks synovium + cartilage
* fluid accumulates in joint + secondary osteoporosis occurs
* other body systems affected

Rheumatoid Arthritis Risk Factors

* age 35-45
* autoimmune emotional stress
* bilateral, symmetric
* affects upper extremities first
* systemic
* female
* genetic
* progressive joint stiffness and pain
* eventual joint deformity
* elevated rheumatoid factor, antinuclear antibody, + ESR

Rheumatoid Arthritis Symptoms

* early symptoms (fever, weakness, fatigue)
* late symptoms (fatigue, osteoporosis, kidney disease)

Rheumatoid Arthritis Pharmacologic Interventions

* NSAIDs
* Disease modifying anti-rheumatic drugs (DMARDs)
* biological response modifiers
* glucocorticoids

Rheumatoid Arthritis Non-Pharmacologic Interventions

* Application of cold to inflamed joints and heat to stiff joints
* Plasmapheresis
* Rest balanced with exercise
* Functional position of joints


* Proper posture + lifting
* PT

Promoting Mobility (Arthritis)

* OT and PT
* mobility aids
* encourage independence
* interventions to address fatigue

Encouraging Self-Management (Arthritis)

* physical activity
* don’t skip exercises on bad days
* don’t sub household chores or activities with exercise
* protect joints by adjusting habits of movement
* 2 hands
* large joint use

Psychosocial Concerns (Arthritis)

* disfigurement
* fear of pain or quality of life
* therapeutic communication
* discuss goals to improve self-esteem
* emphasize strengths
* identify coping strategies
* consult with mental health or spiritual leaders

Surgical Management (Arthritis)

* Total Joint Arthroplasty
* failure of conservative treatments
* severe compromise of client’s functional ability
* significant pain

Total Joint Arthroplasty Lower Extremity Complications

* Dislocation of Hip
* Infection
* Venous Thromboembolism

Dislocation of Hip Prevention

* position correctly
* keep legs slightly abducted
* prevent hip flexion beyond 90 degrees
* prevent hyperextension
* assess for acute pain
* perform neurovascular assessments
* report dislocation immediately to surgeon

Infection Prevention

* use aseptic technique
* wash hands thoroughly
* culture drainage fluid
* monitor temp
* report excessive inflammation or drainage to surgeon

Venous Thromboembolism Prevention

* have pt wear elastic stockings and/or compression device
* teach leg exercises to pt
* encourage fluid intake
* observe for signs of DVT
* observe for changes in mental status
* administer anticoagulant as needed
* do not massage legs
* do not flex knees for prolonged period of time
* ambulation TID

Preventing Dislocation (Posterior Total Hip Arthroplasty)

* abductor pillow
* help pt stand or move

Interventions Total Knee Arthroplasty

* no pillow under operative knee
* cryotherapy
* continuous passive motion machine (CPM)

Burns Key Concerns

* impaired tissue integrity
* pain
* fluid and electrolyte imbalances
* impaired gas exchange
* infection
* mobility

Burn Types

* chemical
* electrical
* radiation
* smoke
* thermal

Burn Risk Factors

* elderly
* co-morbidities

Burn Complications

* inhalation injury or hypoxia
* hypovolemic shock
* infection
* scarring
* contractures

Respiratory Assessment

* airway edema
* tachypnea
* airway constriction
* alveoli damage

Carbon Monoxide Poisoning Assessment

* headache
* slight dyspnea
* decreased cerebral function
* nausea
* drowsiness
* vertigo
* confusion
* stupor
* pale to reddish purple skin
* convulsions
* coma
* cardiopulmonary instability
* death

Skin Assessment

1. Location


1. Worse if face, hands, feet, perineum or major joints
2. Extent


1. total body surface area
3. Depth


1. partial thickness
2. full thickness

Stage 1 Burn

* superficial burn
* damage to only top layer of skin
* healing occurs in 3-6 days S

Stage 2 Burn

* superficial partial thickness burns = entire epidermis and variable portions of dermis layer are destroyed
* uncomplicated healing
* 2-6 weeks

Stage 3 Burn

* full-thickness burn reaches through the entire dermis and sometimes into the sub-q fat
* skin cannot heal on its own

Phases of Recovery

1. emergent (resuscitation)
2. acute (healing)
3. rehabilitation (restorative)

Emergent (resuscitation)

* onset of injury through 24-48hrs
* initial third-spacing involved
* secure airway
* O2, elevate HOB, intubate if needed
* high flow O2 + 6hrs for carbon monoxide poisoning
* support circulation and perfusion
* maintain body temp
* provide emotional support
* treat pain

Acute (healing)

* 36-48hrs post injury
* after resolution of third spacing through wound closure
* Maintain CV and respiratory systems
* Wound care to maintain tissue integrity
* hand hygiene
* antibiotics
* proper dressing technique
* tetanus vaccine
* teach signs of infection
* Pain control
* medicate at least 30min before dressing change
* Psychosocial interventions

Rehabilitative (restorative)

* Wound closure through highest possible level of functioning
* collaborate with other care members
* assist with psychosocial adjustment
* prevent scars and contractures
* compression dressings
* assist with resumption of pre-burn activities

Education and Prevention

* sunscreen
* clean chimneys yearly
* smoke detectors
* fire extinguishers
* escape route for home fires
* keep hot water tanks below 120 degrees
* never smoke in bed or when drinking
* keep lighters/matches away from kids
* no smoking when home O2 in use
* keep flammable objects away from space heaters

Musculoskeletal Trauma Concerns

* Sprains + Strains
* pain
* Amputations
* pain
* decreased tissue perfusion
* Fractures
* hemorrhage
* VTE
* Fat embolism
* Infection
* Compartment syndrome

Sprain

* Ligaments (attach bones together)
* RICE
* rest, immobilize with soft splint PRN
* ice intermittently for first 24-48hrs
* compression first 24-48hrs
* elevate extremity
* Analgesics

Strain

* Muscles and Tendons
* Apply heat/cold
* Activity limitations
* NSAIDs or muscle relaxants
* Possible surgical tendon repair

Amputation Types

1. Elective: planned
2. Traumatic: unplanned, accident

Tissue Perfusion (Elective Amputation)

* Monitor for hemorrhage + adequate perfusion at end of residual limb
* proximal pulse
* VS
* assess capillary refill

Tissue Perfusion (Traumatic Amputation)

* pressure, elevation
* do not remove dressing to prevent dislodging clot
* finger amputation care

Pharmacologic Pain Interventions (Amputations)

* opioids ineffective for phantom limb pain
* Beta-blockers
* Antiepileptic drugs (gabapentin)
* Antispasmodics (baclofen)

Psychosocial Concerns (Amputations)

* grieving process
* interprofessional collaboration
* support groups

Promoting Mobility (Amputations)

* collaborate with PT, and OT
* mobility aids
* assistive devices
* prosthetics
* ROM and PT exercises
* Dressings
* elastic + rigid
* removable dressings sculpt limb for prosthesis

Preventing Infection (Amputations)

* antibiotics
* monitor for s/s of infection
* redness
* swelling
* fever
* WBC count

Fractures

* any break or disruption in continuity of bone
* Extent of break
* complete
* displaced
* incomplete
* open (through skin)
* Associated with soft-tissue damage
* Cause
* after trauma or related to a disease
* fatigue (stress) leads to excessive strain on bone
* compression: vertebrae of elderly

Fractures Complications

* Hemorrhage
* VTE
* Fat Embolism
* monitor for hypoxemia, dyspnea, tachypnea
* Infection
* osteomyelitis especially with open fracture
* Acute Compartment Syndrome
* ischemia and edema caused by increased pressure within fascial compartment
* limb-threatening condition

Compartment Syndrome

* can be caused by external pressure or internal pressure
* Can occur whenever a new cast is placed
* can also occur due to severe burns, extensive insect/snake bites or massive infiltration of IV fluids
* can lead to…
* infection
* persistent motor weakness
* contracture
* amputation

6 P’s of Compartment Syndrome

* paresthesia: burning or prickling sensation
* pain
* pressure
* pallor
* paralysis
* pulseless

Fracture Assessment

* Objective
* possible trauma to other body systems
* deformity
* edema
* bruising, bleeding
* guarding
* crepitus
* neurovascular changes
* shock
* shortening of extremities
* Subjective
* spasms
* decreased function/movement
* pain

Increased Mobility (Fracture)

* collab with PT and OT
* mobility aids
* prevent complications of immobility

Prevent Infection (Fracture)

* use aseptic technique
* administer antibiotics as ordered
* monitor for symptoms of infection

Prevent Neurovascular Compromise

* Assess 6 P’s
* Loosen dressings if needed
* prepare surgical fasciotomy if needed

Pain Management (Fractures)

* opioids, NSAIDs, Acetminophen
* Splints, boots, casts
* closed reduction
* PT

Traction

* Skeletal traction
* pins inserted into bones
* monitor drainage and infection
* weights hang from ropes/pulleys
* monitor consistent application of weights
* weight should not touch floor
* monitor for neurovascular compromise

Surgical Methods

* Open Reduction with Internal Fixation
* cut open, move bones
* External Fixation
* monitor pin sites for infection, purulent exudate, and severe redness (clear drainage, and slight erythema are expected)

Patient Teaching Casts

* Elevate extremity to reduce swelling
* Ice x 24-48hr
* use sling for first few days
* self-monitor for neurovascular compromise
* do not insert anything into cast or get it wet

Dietary Recommendations (Liver, Gallbladder, Pancreas)

* small frequent meals
* Cholelithiasis + Pancreatitis: low fat
* Hepatic Encephalopathy: moderate protein
* FVE: low sodium

Acute Cholecystitis

* stones obstruct duct
* leads to inflammation
* gallbladder distension, ischemia, infection
* causes possible perforation and peritonitis

Risk Factors Acute Cholecystitis

* obesity
* type II diabetes
* dyslipidemia
* family history
* female
* increase in age
* rapid weight loss

Cholecystitis Assessment

* episodic pain
* RUQ radiating to right shoulder
* pain worse after eating high fat foods
* belching, gas
* N/V, anorexia
* feeling or abdominal fullness
* rebound tenderness
* jaundice (inability to excrete bilirubin)
* clay-colored stools
* dark urine
* steatorrhea

Cholecystitis Diagnosis

* Treatment depends on stone placement
* Elevated WBCs (inflammation)

Elevated w/ Bile Obstruction

* Altered liver function
* elevated AST and ALT
* Biliary Obstruction
* bilirubin elevated
* alkaline phosphate elevated
* Amylase and Lipase elevated

Cholecystitis Planning

* maintain nutritional status
* high fiber, low fat
* small, frequent meals
* improve comfort
* opioids, antemetics, antibiotics (infection)
* meds to dissolve stones
* extracorporeal shock wave lithotripsy
* surgical cholecystectomy (removal of stone)

Cholecystectomy

* laparoscopic (less invasive)
* open cholecystectomy
* remove gallbladder via cutting/incision
* standard post-op care + patient edu both procedures

Pancreatitis

* premature activation of pancreatic enzymes leads to autodigestion of pancreas
* necrotizing hemorrhagic pancreatitis (sometimes)

Pancreatitis Risk Factors

* ideopathic
* CAN BE LIFE THREATENING
* biliary tract disease (especially gallastones)
* gallstones can block common duct and prevent pancreatic enzyme release
* trauma from surgical procedure
* alcohol use disorder
* specially chronic pancreatitis

Pancreatitis Assessment

* severe, constant epigastric/LUQ pain
* pain often worse lying supine, improves in fetal position
* N/V
* weight loss
* may have jaundice or dark urine
* steatorrhea (fat deposit in stool)
* \

Pancreatitis Complications

* pancreatic infection
* hemorrhage
* acute kidney disease
* paralytic ileus
* hypovolemic shock
* pleural effusion
* ARDS
* Atelectasis
* pneumonia
* multi-organ system failure
* type 2 diabetes mellitus

Pancreatitis Diagnosis

* Decreased
* amylase
* lipase
* trypsin
* calcium
* Increased
* WBC
* AST/ALT
* Bilirubin
* CT abdomen w/ contrast

Acute Pancreatitis Interventions

* opioids
* NPO 24-48hrs
* IVF
* NG tube (if vomiting)
* antiemetics
* enteral feeding while NPO
* small frequent meals
* high protein
* low fat
* mod-high CHO
* avoid future episodes
* prevent chronic pancreatitis

Chronic Pancreatitis Interventions

* opioids
* pancreatic enzyme replacement
* if severe autodigestion
* may require TPN
* prevent exacerbations

Pancreatic Enzymes Purpose

* prevent malnutrition, malabsorption and excessive weight loss
* capsules contain amylase, lipase, and protease

Pancreatic Enzymes Admin

* must be taken PO with ALL meals to ensure absorption
* record number and consistency of stools per day
* stool should become less frequent and less fatty with effective treatment

Chronic Pancreatitis Patient Education

* avoid things that make symptoms worse such as caffeine
* avoid alcohol ingestion (self help groups)
* avoid nicotine (patch options)
* eat bland, low-fat meals
* avoid spices
* eat small meals
* take pancreatic enzymes with meals
* rest frequently
* restrict activity to one floor until strength is regained

Liver Immune Function

1. Phagocytes
2. Antigen-presenting
3. Interferon Production

Liver Secretion

Bile

Liver Metabolic Function

* ammonia → urea
* conjugates bilirubin
* proteins, carbs, and fats

Liver Synthesizes

* plasma proteins (albumin)
* phospholipids
* cholesterol
* clotting factors
* gluconeogenesis

Liver Detoxification

* meds
* chemicals
* hormones

Liver Stores

* Vitamins A, D, E, K, B12
* Glycogen
* Iron

Liver Assessment

1. Lifestyle Factors


1. alcohol intake
2. IV drug use
3. unprotected sex
2. Occupational Exposures


1. needlestick injury
2. family history of alcohol abuse or liver disease
3. recent consumption of contaminated food (Hep A)

Hepatitis

* liver inflammation
* acute
* Hep A
* binge drinking
* chronic (inflammation > 6 months)
* Hep B and C
* alcohol use

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Hepatitis Causes

* viruses (Hep A, B, C)
* hepatotoxic substances (ETOH, drugs/alcohol)

Hepatitis A

* source = feces
* transmitted oral-fecal route
* no chronic infection (body resolves)
* **prevention:** pre/post exposure immunization

Hepatitis A Prevention

* hand-washing
* clean drinking water

Hepatitis B

* **source** = blood or blood-derived body fluids
* transmitted percutaneous permucosal
* chronic infection
* **prevention:** pre/post exposure immunization
* blood-borne pathogen

Hep A and B Symptoms

* flu-like symptoms
* fever
* fatigue
* arthralgia/myalgia
* RUQ pain
* pruritis
* jaundice
* changes in color of urine or stool
* N/V (common w/ Hep A)
* Diarrhea/constipation
* anorexia
* Hep B may become chronic (often goes unnoticed)
* Hep A resolves after initial reaction

Hepatitis C

* **source** = blood or blood-derived body fluids
* transmitted percutaneous permucosal
* chronic infection
* blood-borne pathogen
* **prevention:** blood donor screening and risk behavior modification

Hep C Symptoms

* asymptomatic
* infection becomes chronic
* no jaundice

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