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Exam 2 nurs 209

Sensory fxn, Hematology, Musculoskeletal, Peripheral Vascular

Refraction bending of light rays into eye
emmetropia perfect/normal refraction
hyperopia farsightedness, eye does not refract light enough
myopia nearsightedness, eye over refracts (over bends) light
astigmatism surface has irregularities, distorted vision
miosis constriction due to increase light
mydriasis dialation due to decrease in light
arcus senilis opaque, bluish white ring within the outer edge of hte cornea due to fat deposits in eye, does not affect vision. age related
age related changes of eye arcus senilis, cornea flattens and curve becomes irregular, lens changes, decreased color perception (green, blue, violet) increased intraocular pressure.
Age related lens changes becomes yellow & has less elacticity which causes less accommodation & decrease far point of vision & Prespyopia which is the near point of vision gets longer and must hold stuff farther away.
How to give eye drops: pull down lower lid, hold head back , put punctual pressure to prevent systemic absorbtion, wait 15 min between applying different eye medications.
How often to have eye exam: 3-5 years if you have no problems, if >40yrs then annually
Eye assessment considerations How long have you had the problem, What kind of work do you do, Drugs such as antihistamine or decongestants (increase occular pressure), Neutrition (lack of vit A = blindness, need green leafy , red, yellow veg and fruit)
exophthalmos protrusion of eye
enophthalmos sunken appearance of the eye
ptosis drooping eyelid
anisocoria noticeable difference in pupil size
Pupillary assessment consensual response (R-responds to light in L pupil), Brisk (<1sec), Sluggish (>1sec), nonreactive or fixed
Nystagmus involuntary/rapid twitching (normal for far lateral gaze)
Snellen chart measures distance of vision,how what you see 20 ft away compares to how far away a person with normal vision would have to be to see the same as you. ex: 20/70 = you see at 20ft what a normal person would see at 70ft.
Near vision charts Jaegar card and the Rosenbaum pocket vision screener. read from 14" away. for people with known near vision problems
ishihara chart tests color vision
Ophthalmoscope to see eye internal and external structors. Look for red reflection on the retina. Opacity = cateract (absence of red light reflex)
tonometry measures innier occular pressure (normal is 10-21)
slit-lamp exam magnifies the anterior structure of the eye (cornea, lens, vitrus humor)
corneal staining orange fluoresceint dye is applied to eye and a blue light is shined. assess eye for trauma and irregularities/debree
fluorescein angiography looks at eye circulation
electroretinography graphs retina's response to light
before giving antibiotics for eye: do a smear or lab test. take a smear from conjunctiva
used for eye imaging: CT, MRI, Ultrasound
Cateracts: s&s, etiology, diagnostics S&S: blurry vision, decreased color perception, decreased visual acuity. Etiology: age, DM, Truama, U/V exposure. Diagnostics: Ophthalmoscope (red reflex), Visual acuity test (Snellan chart & brightness acuity test (bat) which tests vision in diff lights
Cateracts: cure Surgery only cure. Post op: avoid activities which ^ IOP (give Collace), Antibiotic eye drops, photophobia at 1st. Report: pain (mild ok-tylenol), floaters, nausea/vomiting, bleeding.
Glaucoma ^IOP, can lead to permanent blindness. Types: primary (due to age, heredity, retinal vascular occlusion), secondary (disease caused-DM, trauma etc)
Primary open-angle glaucoma (POAG) Cause, S&S Cause: SLOWLY clogged drainage canals, or ^occular fluid. S&S: GRADUAL visual field loss, tunnel vision, halos around lights, NO PAIN
Angle-closure glaucoma Cause, S&S Cause: SUDDEN clogged drainage canals, or ^occular fluid.S&S: SUDDEN onset, Emergency!, PAIN, nausea/vomiting, halos around lights, blurred vision, corneal edema
Glaucoma diagnostic tests, TX Ophthalmoscope (changes to the optic disc-cupping), Tonometry (^IOP(10-21 normal): POAG 22-32, Angle-closure >30), Perimetry (screen peripheral vision), Gonioscopy (determines POAG or angle-closure), Optic nerve imaging. TX: drugs, surgery
Glaucoma drug therapy dose not reverse damage. Beta-adrenergic blockers (topical), Cholinergic agents (miotics)(topical), Carbonic anhydrase inhibitors, Prostaglandin agonists, Adrenergic agonists, systemic drug therapy
Glaucoma use: Beta-adrenergic Blockers Topical, decrease aqueous production, Med: Timolol (Timoptic), SE: eye pain, blurred vision, bradycardia, hypotension, bronchospasm
Glaucoma use: Cholinergic agents miotics (constric pupil), topical, Contract iris (miosis) & ^angle, facilitate outflow of aqueous humor & reduce production, Med: Pilocarpine (Isopto Carpine). SE: decreased visual acuity in dim light (d/t pupil constriction)
Glaucoma use: Carbonic anhydrase inhibitors inhibit production of aqueous humor, Med: Dorzolamide (Trusopt), SE: monitor for allergy to sulfa(similar) or pregnancy
Glaucoma use: Prostaglandin agonists dilate trabecular mesh blood vessels facilitating outflow of aqueous humor, Med: Latanoprost (Xalatan), SE: makes iris darker in color (think Latisse-dont get in eye)
Glaucoma use: Adrenergic agonists reduce aqueous humor production, Med: Apraclonidine (Lopidine), SE: cause pupil dilation (mydriasis), photosensitive, do not take with MAO inhibitors (causes hypertension)
Glaucoma use: Systemic drug therapy For angle closure emergencies. Shifts fluid, hyper osmolar meds. Oral: Glycerin (Osmoglyn), IV: Mannitol (Osmitrol)
Glaucoma surgery Laser trabeculoplasty: increases size of spaces in trabecular mesh and increases outflow of aqueous humor. Filtering microsurgery creates drainage hole in iris. Shunting if not successful.
Age related macular degeneration. Dry vs wet, risk factors, management Central vision problem, S&S: blurry & distorted vision. Wet: Immature capilaries leak, laser surgery to remove them. Dry: retinal capilaries blocked->die->decrease blood flow. Dry risk factors: smoking, vitamin deficiency. Dry management: health promotion
Retinal detachment types Rhegmatogenous: from a hole/tear d/t machanical force, vitreous moves under the retina. Traction: retina pulled away by fibrous bands in vitreous. Exudative: d/t fluid collecting under retina, d/t systemic disease or ocular tumors (no retinal breaks)
retinal detachment S&S painless, photopsia (bright flashes of light), floating dark spots, loss of corresponding visual field (curtain)
Types of retinal detachment tx & nursing care Surgery: scleral buckling, laser photocoagulation, cryopexy. Post-op: limit eye movement, eye patch/sheild, activity varies, avoid activities ^IOP, monitor for repeat detachment
Eye trauma: Contusion, cause and tx subconjunctival hemorrhage, corneal edema, hyphema (hemorrhage in the anterior chamber), diplopia & photophobia. Ice and get eye exam.
Eye trauma: Foreign body, cause and tx discomfort/pain, tearing, photophobia. Flush with isotonic solution
Eye trauma: Lacerations & penetrating injuries, cause and tx Eye pain, photobphobia, tearing, decreased visual acuity, inability to open eyelid. Close eye & ice
Common ophthalmic therapy groups Topical anesthetics, Topical steroids, Anti-infectives, Antibiotic-steroid combinations, NSAIDs
age related changes of ear Elongated pinna: bigger ears, Coarser/longer hair in canal, Dryer cerumen (wax impacts easily), Tympanic membrane loses elasticity, Presbycusis (Decreased hearing acuity, inability to hear high frequency sounds - f, s, sh, pa sounds)
Presbycusis age-related hearing loss
Vertigo spinning sensation
Tinnitus ringing in the ears
Ototoxic damaging to the ears ie: Gentamycin, Salicylates (aspirin)
Hyperacusis intolerance for sound levels that do not bother other people
Frequency highness/lowness of tones
Intensity expressed in decibels (dB)
Threshold lowest level of intensity at which pure tones/speech are heard 50% of the time
Conductive hearing loss physical obstruction of transmitted sound waves. Due to: foreign body, tympanic membrane changes, fused bony ossicles correctabel
Sensorineural hearing loss defect in cochlea (damage to cochlear hair cells), creanial nerve, or brain. Due to: Exposure to loud noise/music, Ototoxic drugs (renal aging patients at ^risk), presbycusis
Mixed conductive-sensorineural hearing loss tx: hearing aid
Audiometry measurement of hearing acuity. Pure-tone audiometry: tests pts hearing of frequencies for speech, music, common sounds, Can test air & bone conduction. Speech audiometry: test ability to hear spoken words (reception-loudness, discrimination-similar sounds
Tympanometry assesses the mobility of tympanic membrane & structures of the middle ear by changing air pressure in external canal
Otosclerosis, diagnostics, S&S, Tx overgrowth of soft bony tissues. Fixation of the stapes, conductive hearing loss. Diagnostics: rinne- BC>AC, S&S: hearing loss, tinnitus, TX: hearing aid, surgery (stapedectomy)
Otosclerosis Post-op look for facial asymitry, changes to taste or touch. Avoid: nose blowing, coughing, sneezing. May have: dizziness, N/V, loss of balance (get up slow & watch gait). Dressing: cotton ball, band-aide
Meniere's Disease Inner ear disease (affects balance & hearing). Idiopathic (infections, allergic rxns, fluid imbalances). Excessive accumulation of endolymphatic fluid (distorts the entire inner-canal system)
Meniere's Disease S&S, Diagnostics S&S: tinnitus, one-sided sensorineural hearing loss, vertigo, headaches, N/V, nystagmus. Diagnostics: Hx & Physical, Vestibular & audiometric tests. If not tx then loss of frequency of sounds is 1st to go
Meniere's Disease Tx: Nutrition (low Na+ diet, avoid caffeine, limit ETOH, no smoking). Meniett device, decrease activity, Drug therapy: Diuretics, Antihistamines/Anticholinergics,
Meniere's Disease: Diuretics Furosemide, decreases fluid
Meniere's Disease: Antihistamines/Anticholinergics Stop severity of acute attack, Meclizine (Antivert), SE: drowsiness, dry mouth, blurred vision
Meniere's Disease: Antiemetics for nausea
Meniere's Disease: Anxiolytics Calms patient, promotes rest (vertigo & N/V stimulates pt), Diazepam (Valium)
Meniere's Disease tx (non-med,nutrition or surgery) Meniett device: use of low-pressure micropulses to inner ear, 5 min 3x/day, causes displacement. Activity: bedrest during acute attacks, move head slowly to prevent vertigo
Meniere's Disease Surgery Tx: Conservative Endolymphatic shunt: improves fluid drainage, vertigo common immediately after surgery d/t manipulation of vestibular structures.
Meniere's Disease Surgery Tx: Destructive Labrynthectomy: Resection of vestibular nerve or total removal of labyrinth, Indicated for those w/near complete hearing loss, Vertigo an issue X several wks until "good" ear takes over balance
Heme part of Hgb, carries O2, need iron to carry O2, O2 dissociation- transfers from hemoglobin to tissues
Globin part of Hgb, carries CO2, helps maintain acid base balance
Tissue hypoxia leads to erythropoietin->bone marrow-> increase RBC production
Polycythemia too many RBC's = coagulation
Erythropoietin made in kidney's and released when tissues become hypoxic. Meds: Procrit or Epogen act like erythropoietin
Erythrocytes RBCs: produced in bone marrow, destructed in spleen & liver, regulated by erythropoietin (kidney hormone), contains hemoglobin, 4.2-6.1 million/uL
Hematocrit (Hct) percentage of RBCs in a volume of whole blood, 37-52%
Hemoglobin (Hgb) main component of RBCs (erythrocytes), intracellular protein that carries O2, 11-16g/dL
Types of anemia Increased RBC destruction (hemolytic anemia), Decreased RBC production
Anemia: increased RBC destruction Hemolytic anemia: sickle cell disease, Glucose-6-phosphate dehydrogenase deficiency, immunohemolytic. Will have jaundice.
Glucose-6-phosphate dehydrogenase(G6PD)Deficiency Anemia Due to increase RBC destruction,inherited, as RBC age G6PD levels fall and RBC hemolysis when exposed to these meds: ASA, Sulfonamides, Thiazide diuretics, Vitamin C
Immunohemolytic Anemia Due to increase RBC destruction, automimmune, RBC hemolysis due to body attacking RBCs
Anemia: decreased RBC production Iron deficiency anemia, Vitamin B12 deficiency anemia, Folic acid deficiency anemia, aplastic anemia
Iron deficiency Anemia Due to decrease RBC production. Decrease iron in Hgb-> Microcytic RBCs (=decreased fxn), Ferritin <10ng/mL (evaluates iron storage & most specific diagnosis of iron defiency anemia), Causes: inadequate diet, blood loss, malabsorption
Vitamin B12 deficiency Anemia Vit B12 activates folic acid for DNA synthesis, Improper DNA synthesis->Macrocytic RBCs (too big so they break), Nerve fxn, Causes: Inadequate diet, pernicious anemia (failure to absorb: can't produce intristic factor d/t gastric bypass, elderly, vegan)
Folic Acid deficiency Anemia Due to decrease RBC production. Normal nerve fxn but otherwise same as B12 deficiency, Causes: malnutrition, ETOH abuse, malabsorption (Chrohn's dx)
Aplastic Anemia Due to decrease RBC production. Decrease production of RBCs by bone marrow, Pancytopenia: anemia, leukopenia, thrombocytopenia (at risk for infection, bleeding)
Polycythemia Vera Cancer of the RBCs. Excissive production of RBCs, Leukocytes, and Platelets. They are all abnormal and poor fxn.
Polycythemia Vera S&S Hypoxia (can't carry O2), HTN (thick), distended superficial veins (thick), vascular statis->thrombosis, plethoric facial skin (dark flushed) & mucous membranes, bleeding (platelets abnormal), gout (increased uric acid)->hyperkalemia (due to dying cells)
Polycythemia Vera TX Phlebotomy (remove RBCs 2-5x/wk), hydration, promote venous return, anticoagulants, hydroxyurea/Droxia (med makes RBC more flexable, used in sickle cell alot)
WBC (Leukocyte)disorders Leukimia, Malignant Lymphomas (Hodgkin's and Non-Hodgkin's), Multiple Myeloma
Leukemia, deff and how diagnosed Cancer with Excissive production of Immature WBCs in the bone marrow. Stops normal production of other cells. Diagnosed by bone marrow aspiration or biopsy
Leukemia S&S no time to produce other cells so: Leukopenia, thrombocytopenia, anemia. RBC can be normal or high but either way they're abnormal cells. Can't have a fever due to WBC not fxn so they can't fight inction via fever.
Malignant Lymphomas solid cancer tumors of the lymphoid tissues. Abnormal Overgrowth of Lymphocytes (mature WBC). 2 types: Hodgkin's Lymphoma (nodes contain Reed-Sternberg cancer cell) & Non-Hodgkin's Lymphoma
Hodgkin's Lymphoma Malignant Lymphoma. Nodes contain Reed-Sternberg cell, Starts in a single or chain of lymph nodes, Spreads in orderly fashion, S&S: enlarged lymph node(s)-usually neck
Non-Hodgkin's Lymphoma Arises from lymph nodes in any tissue, spreads to any organ, S&S: enlarged lymph nodes (cervical, axillary, inguinal, femoral)
Multiple Myeloma: Abnormal Overgrowth of B-lymphocyte (mature WBC)plasma cells in bone marrow. ^produxn of antibodies (gamma globulins)->clogs blood vessels, esp kidneys. ^producxn of cytokines->cancer cell growth rates^ & bonde destruciton. Decreased producxn of normal WBCs, RBCs & platelets->immunosuppression, anemia, bleeding
Multiple Myeloma tx incurable. supportive therapy, pain management, chemotherapy, stem cell transplant
coagulation disorders Platelet disorders & Clotting Factor Disorders
Platelet disorders Autoimmune thrombocytopenic purpura, Thrombotic thrombocytopenic purpura
Clotting factor disorders Hemophilia, Disseminated intravascular coagulation (DIC)
Autoimmune thrombocytopenic purpura Platelet disorder. Platelets coated w/antiplatelet antibody & destroyed by macrophages faster than produced-> Thrombocytopenia. S&S: ecchymosis, petechiae, mucosal bleeding, intracranial bleed (rare)
Thrombotic thrombocytopenic purpura Platelet disorder. Abnormal aggregation of platelets in capillaries->tissue ischemia (renal failure, MI, CVA)& decreased circulating platelets->decreased clotting w/trauma & thrombocytopenia
Desseminated intravascular coagulation (DIC) def & TX *on test* Clotting factor disorder. Involves both Hemorrhage & Thrombosis. Triggers: sepsis, traumatic injury, obstetric complications, metastatic CA, immunologic disorders. Tx: eliminate the trigger, control thrombosis, maintain organ fxn.
Desseminated intravascular coagulation (DIC) S&S *on test* Microvascular thrombosis & microemboli: (Cyanosis/gangrene, decreased pulses, altered LOC, decreased Urine output, decreased bowel sounds), Decreased clotting factor: (bruising & petechiae, hemoptysis, blood in urine, oozing blood)
Transfusion Reaction, what to do 1)Stop the infusion, 2)Disconnect blood tubing, 3)0.9% NS w/ NEW TUBING, 4)Don't discard blood or tubing so lab can test. 5) dont pull the IV, may need to give a med.
Transfusion Reaction S&S SOB, flushing, itching, backache, headache, chest pain, tachycardia, hypotension, N/V, ^temp, decreased urine output.
Types of Transfusions Packed RBCs, Platelets, Fresh frozen plasma, Cryoprecipitate, WBC, Autologous
Packed RBC Transfusion Hgb<8g/dL, S&S: anemia, give over 2-4hrs. If CHF go slower but still w/in 4hrs. If pt resp getting worse etc then slow down infusion but keep w/in 4 hrs
Platelet Transfusion Platelets<100,000mm3, Thrombocytopenia w/active bleeding, Platelet filter (smaller) & tubing (shorter)-removes RBCs, give over 15-30 min because they break apart easily
Fresh frozen plasma (FFP) Transfusion decreased clotting factors, PTT>1.5 X normal, give over 15-30 min
Cryoprecipitate Transfusion Hemophilia, Usually IVP
WBC Transfusion Neutropenic, Controversial, give over 1hr
Autologous Transfusion Collection & infusion of pt's own blood
Transfusion therapy best practices: Assessment Baseline assessment: pertinent labs, VS, skin color, urinary output, hx of transfusion rxns, Temp (>100.5 F call doctor before proceeding)
Transfusion therapy best practices: Supplies 22 gauge peripheral IV or larger, Filtered blood tubing (removes sedement), Normal saline ONLY (due to risk of clotting or hemolysis rxn in line)
Transfusion therapy best practices: Verify Verify w/another RN: Physician order, Pt ID (name band, blood band, blood bag), compatibility (type O+ universal donor), expiration (also discoloration, cloudiness, bubbles.
Transfusion therapy best practices: How to give Transfuse immediately. Start infusion slowly, RN must remain w/pt 1st 15min due to hemolyic Rxn occurs w/in 1st 15 min or 50 mL!, Monitor VS (baseline 5 min before, 5 min after blood reaches pt, 15 min later, 15 min later)
Peripheral Arterial Disease (PAD) Risk factors: Atherosclerosis, DM, smoking, obesity, ^age, family Hx, ^BP, ^cholesterol, High levels of homocysteine, a protein component that helps build and maintain tissue. Besides S&S check bilateral pulses & arterial ulcers.
Peripheral Arterial Disease (PAD): S&S intermittent claudication (cramping/muscle burning sensation w/movement, stops w/rest), rest pain (later S&S- pain when legs^, pain leaves when legs hang), numbness, hair loss, dry/scaly, pale/mottled/cyanotic, cold, thickened toenails, dependent rubor
Peripheral Arterial Disease (PAD): Diagnostic assessment Arteriography (contrast medium-degree of occlusion), Ankle-brachial index (ABI): ankle BP/Brachial BP normal is <0.9 & a drop w/activity = PAD, Plethysmography (monitors ABI w/pulse waves on a screen), Exercise tolerance testing (time until claudication)
Intermittent claudication cramping/muscle burning sensation w/movement that stops w/rest, due to lack of O2, Sign of Peripheral Arterial Disease (PAD).
Arterial Ulcer Due to Peripheral Arterial Disease (PAD). Ishcemia due to arterial insuficiency. Little to no wound drainage. Use a moist dressing.
Peripheral Arterial Disease (PAD): Interventions (non med/surgical) Inspect feet daily, Exercise (to develope collateral circulation to take over where its occluded, exercise until it hurts), positioning, promote vasodilation w/heat. NO SCDs, No heating pad, NO vasoconstriciton (cold, meds)
Peripheral Arterial Disease (PAD): Interventions - Meds Hemorheologics: Pentoxifylline/Trental(make RBCs flexable), Antiplatelets: ASA, Clopidogrel/Plavix (^blood viscosity), Control HTN
Peripheral Arterial Disease (PAD): Interventions - Surgical Percutaneous transluminal angioplasty (& maybe stent), Laser-assisted angioplasty (vaporize plaque), Atherectomy (scraps plaque), Arterial revascularization (bypass occlusion: monitor graft occlussion, Compartment syndrome, infection)
Six P's of Ischemia Pain, Pallor, Pulselessness,Paralysis , Parethesia (pins & needles, burning,numbness) Poikilothermia (coolness)
Abdominal Aortic Aneurysm (AAA): Cause, S&S, complication Artery dilation >2X normal. Causes: atherosclerosis, blunt trauma. S&S: Usually Asymptomatic. Abd, flank,or back pain. Pulsation, bruit (>5cm). Complication: Rupture>hemorrhagic/hypovolemic shock. Sudden onset of abd or back pain, abd distended from blood
Abdominal Aortic Aneurysm (AAA): Interventions Monitor growth (CT scan), Maintain BP WNL (antihypertensives-compliance), AAA Resection: assess for graft occlusion or rupture, AAA endovascular repair: put stent in place w/catheter
Abdominal Aortic Aneurysm (AAA) Dissection: S&S, Interventions Sudden tear->blood enters aortic wall. S&S: Pain (ripping, tearing, stabbing, referred), Diaphoresis, N/V, faintness, apprehension, ^BP, decreased or absent peripheral pulses, altered LOC. Interventions: decrease pain & SBP, surgery
Raynaud's Syndrome Intermittent vasospasms of arterioles & arteries of upper and lower extremities unilaterally or bilaterally.
Raynaud's Syndrome: S&S Blanching, & cyanosis during vasospasm. Reddened & hyperemia when vasospasm relieved. Numbness, cold, pain, edema, ulcers, gangrene.
Raynaud's Syndrome: Interventions Patient education (avoid caffeine, cold), Medications (Vasodilators- contra-indicated if BP low), Surgery (rare)
Peripheral Venous Disease Properly fxn veins require: 1) Patency (venous thrombosis + PE = Venous thromboembolism (VTE), 2) Competent valves (venous insufficiency->varicose veings, 3) Skeletal muscle contractility (vascular trauma)
Thrombus Formation Virchow's Triad: Blood stasis, Endothelial injury, Hypercoagulability.
Deep Vein Thrombosis (DVT): S&S, Diagnostic tests, Interventions S&S: Calf or groin tenderness/pain, unilateral edema, warmth, redness, induration (NO Homan's). Diagnostic test: D-Dimer, Venous ultrasound. Intervention: Anticoagulants, surgical management.
Venous Insufficiency Venous stasis due to damaged valves. Cause: obesity, thrombosis, Job w/ ^ standing or sitting. S&S: edema, stasis dermatitis (brown skin), venous ulcers, cellulitis. Interventions: SCDs/Ted hose, ^legs, wound care (absorbent dressing), nutritionist.
Ossification Ossification is the formation of bone by the activity of osteoblasts (make bone) & osteoclasts (take away bone). Osteoblasts come from cells in the periosteum of bone, & in the bone marrow. Osteoclasts are derived from macrophages.
Bone regulation Parathyroid hormone (PTH), Vit D, Calcitonin, Growth hormone, Adrenal glucocorticoids, Estrogen.
Bone fxn Framework, support, movement, protection, hematopoiesis, storage
Joints Space where 2 or more bones come together. Diarthrodial (synovial) fluid, Synarthrodial cavity (allows lots of movement), Amphiarthrodial (little movement: intervertebral discs, sternebrae, sacro-iliac joints, pelvic symphyses, and mandibular symphyses)
Synovial Joints Ball-&-socket (shoulder & hip joints), Hinge (elbow), Condylar (writst), Biaxial (wrist), Pivot (knee, ulna-radius)
Skeletal Muscle: main fxn, tendons, ligaments Main fxn: movement. Tendons: join muscles to bone. Ligaments: join bones to bones.
Musculoskeletal changes in older adult Decreased: muscle mass, mobility, ROM. Weakness, joint pain & swelling,, more prone to fracture due to osteopenia & kyphosis. Safety is 1st priority due to ^fall risk.
Arthralgia Joint pain
myopathy muscle tissue problems
Neuropathy nerve problems
crepitus (musculoskeletal) grating sound from bone fragments rubing. heard on passive ROM
Effusion joint fluid increase and joint swells. restricts movement.
Neurovascular assessment pulses, color, temp, sensation, movement, pain
Musculoskeletal Posture Lordosis (sway back due to obeisty, pregnancy), Scoliosis, Kyphosis (can be due to osteoperosis).
Musculoskeletal questions to ask patient to assess what they're prone to: diet, exercise, family Hx, allergy (dairy etc), smoking (restricts blood flow>affects bone growth/regen), caffiene (>40 oz depleats the bone)
Musculoskeletal diagnostic studies: Labs Labs: Ca+, CK (^muscle tissue damaged), AST & ALD (muscle disorders ie M.S.), LDH (skeletal muscle necrosis)
Musculoskeletal diagnostic studies: Imaging X-ray, CT (ask pt if iodine/shellfish allergy), MRI (ask if about metal pins, rods!), Bone scan, Ultersound
Musculoskeletal diagnostic studies: (besides labs/imaging) Electromyography (EMG)(looks for muscle weakness, carpal tunnel, uses electricity), Arthrooscopy, Biopsy (bone/muscle).
Musculoskeletal diagnostic studies: Arthroscopy Diagnostic or Tx. Knee or shoulder. assess knee bend 40degree or procedure may damage. Repair: ligement, meniscus. *OT & PT after surgery & straight leg lifts, quadrocep seating exercises. Post-op: assess blood flow, neuro/vasc, circ. Ice & ^joint 12-24hr
Osteopenia decrease in bone mass. can lead to osteoporosis. men >50 due to less testosterone (^bone growth), women after menapause: decrease estrogen (protects bone).
Osteoporosis: causes bone reasob>bone bldg = decrease BMD (bone mineral density) Risk factors: gender, sedentary/immobile, >30yrs, Ca+ deficiency, menopause, smoking, ^ETOH, Steroids, DM, thyroid problems, immunosupressed
Osteoporosis: manifestations Dowager/s hump (kyphosis), Pain (compression fracture)(tender w/palpation, movement), Restricted movement (affects GI fxn), Fractures (wrist, ^1/3 femor (hip))-look for semetry, swelling.
Osteoporosis: Diagnostics Assessment (health Hx, physical & psychosocial), X-ray (when 25-40% of Ca+lost), Dual x-ray absorptiometry (DXA), Peripheral quantitative ultrasound (pQUS)
Osteoporosis: Diagnostics: Dual x-ray absorptiometry (DXA) Measures BMD (bone mineral density), T-score (shows osteoporosis and osteopenia)
Osteoporosis: Diagnostics: Peripheral quantitative ultrasound (pQUS) Detects Osteoporosis & predicts risk of hip fracture. No radiation, men >70yrs and women >40yrs.
Osteoporosis: Meds ERT (estrogen) & HRT (estrogen + progesterone), Parathyroid hormone, Supplements (Ca+, D), Bisphosphonates, Selective Estrogen Receptor Modulators
ERT (estrogen) and HRT (estrogen + progesterone) Osteoporosis med, Only give to patient's who have gone thru menopause
Parathyroid Hormone Osteoporosis med, Bone bldg agent, only for pts post-menopause, can cause dizzynesss & leg cramping.
Supplements for Osteoporosis & Paget's Disease (Osteitis) Calcium and Vitamin D, take together
Bisphosphonates Inhibits bone absoption/breakdown. Can cause gastritus. take 30 min before eating (most end in -ate), sit up and drink 8oz H2O. Can cause weightloss & anorexia. If taking w/ Ca+ then space 2 hr apart.
Oral Bisposphonates *alendronate (Fosamax), Ibandronate (Boniva), *risedronate (Actonel), *can be used for Paget's, Wait until Ca+ 2X normal (9.5-10 is normal).
IV Bisposphonates zoledronic acid (Reclast), pamidronate (Ardia) Osteoporosis, Paget's, bone cancer. Can cause osteonecrosis of jaw. monitor oral care.
Selective Estrogen Receptor Modulators Osteoporosis, Sub Q, inhibits osteoclast. raloxifene (Evista)contra in pt w/ clotting disorder, can cause hot flashes & leg cramps.
Calcitonin osteoporosis - nasal, pagets - subQ, inhibits osteoclast activity.
Paget's Diseases Excessive bone breakdown (osteoclastic/active phase) & reformation (osteoblastic/mixed phase), structural disorganization. Bone weakness: bowing of long bones, fractures.
Paget's Diseases: S&S Asymptomatic (80%), >50, pain, pathologic fractures, abnormal spinal curve, systemic (ex: pinched nerves), skull: ^size, pain, neuro defficits. Spin compression fractors. Hip & pelvis common. worsens w/ weight bearing exercises. Aches like arthrytis.
Paget's Diseases: Diagnostics: Labs Serum alkaline phosphatase (ALP)- ^do to overactive bone formation. Look for a decrease to make sure tx is working. Urinary hydroxyproline- The ^the level the ^severe the disease (^bone/cartilage broke down). ^uric acid can be misdiagnosed has gout.
Paget's Diseases: Diagnostics: Imaging X-ray (fracture), Bone (will show ^areas of bone turnover), CT/MRI
Paget's Diseases: Treatment & Goal of tx Relieve the pain - NSAIDs. Biphosphonates, Calcitonin, Nutrition (Ca+, D), Surgery, other care.
Paget's Diseases: Surgery Arthroplasty (realigning or reconstructing a joint), Osteotomy (surgical resection of bone)
Paget's Diseases: Other tx/care Back support by firm mattress, Teaching about use of Splints or braces to support bones & joints & help revent weakened bones-skin care, circulation, etc. Teach correct use of canes/walkers, physical therapy.
Osteomyelitis Infection in bony tissue caused by: bacteria, virus, fungus, DM, anything which decreases bloodflow to bones (fx, open fx, external fixator/pin)
Osteomyelitis: Assessment Bone pain: constant, pulsating & worsens w/movement. ^temp w/acute & inflamation, redness, edema, hot to touch, tunneling, purulent (pus) drainage.
Osteomyelitis: Treatment Antibiotics (usually develope resistant strains so on contact precautions), irrigate wound, dressings, surgical: debrieve bone. Do circ checks (pulse, color, temp etc below site of infection)
Osteomyelitis: Goal of tx Halt the infection, relieve pain, maintain mobility.
Osteosarcoma Primary bone cancer, localized. Most common, age 10-39, large tumor, acute pain & swelling. goes to lung. Chondrosarcoma, Fibrosarcoma
Ewing's Sarcoma Primary bone cancer, localized. Found in distal femor. : most malignant & affects peds mostly (to age 20), low survival, goes to soft tissue, low grade fever, leukocytoisis, anemia.
Chondrosarcoma, Fibrosarcoma Primary bone cancers
Metastatic Cancer, Orgin Secondary cancer, systemic. *Bone seeking cancers. *Site of orgin: prostate, breast, kidney, thyroid, lung. Commonly affected areas: acetabulum (hip socket), proximal femor.
Metastatic Cancer: S&S Pain, palpapble mass, mobility issue, ^alkaline phosphate (ALP)(enzyme produced in liver,kidney,intestine, blile duct, & bone, in bone: byproduct of osteoblast activity).
Metastatic Cancer: Diagnostics ^Ca+ (2x or 3x), x-ray or CT (shaddowy margins), bone biopsy.
Bone Cancer: Treatment Control pain & help w/mobility. Drugs: Chemotherapy (best w/small tumors, Ewing most sensitive, goal is decreased size), Biologic agents, Bisphosphonates (IV), Radiation (goal to decrease size, palative), Surgery.
Fractures, Classifications Affect mobility, circulation, sensation (nerves). Complete, Incomplete, Open (compound), Closed (simple), Pathologic (spontaneous), Fatigue (stress), Compression.
Fractures: Assessment Angle of fall, height of fall, how long ago, kind of pain, causes of fall/trauma, hx of breaks, crepatis w/bone.
Fractures: Neurovascular Assessment Hospital: circ test ever hr for 24hr then every 1-4hr. At home: teach pt to do at home. Color, temp, pulses, sensation, pain, movement, cap refil (least reliable).
Fractures: bone healing continuous process, 3 or more weeks. with some conditions such as depressed immune system the bone may take a year or more or never completely heal.
Fractures: Complications Acute Compartment Syndrome: Swelling compresses and kills tissue (O2 deprived). Irreversable damage (loss of limb), infection, weakness, contractures, myoglobinuric renal failure.
Acute Compartment Syndrome: The Six P's Pain (early, intense, ^w/passive motion, meds don't help), Pressure, Paralysis, Parethesia (early, numbness & tingling), Pulselessness (late).
Acute Compartment Syndrome: Treatment Monitor pressures, Fasciotomy (incision to release pressure)-wet to dry dressing changed 4-6hrs, keep moist.
Acute Compartment Syndrome: Complications Infection. Persistent motor weakness. Myoglobinuric renal failure due to rhabdomyolysis (musclebreak down, leads to myoglobin release which damages kidneys)
Myoglobinuric renal failure: cause and Tx Compartment Syndrome complication. Due to large compartments involved. Rhabdomyolysis (muscle breakdown = myoglobin release) ^K+ release: cardiac dysrhythmia/arrest. Flush w/a lot of fluid. Low dose Dopamine (^renal perfussion) & Kayexalate (K+ binder)
Crush Syndrome Large muscle damage. Injuries most at risk: twisting motion, car accident, drunk sleeping on limb for hrs.
Crush Syndrome: Affects Severe injury->Localized affects (Acute Compartment Syndrome)->Systemic affects (hypovolemia, ^K+, rhabdomyolysis, ATN)->Life Threatening!
rhalbdomyolysis Result of crush syndrome. Muscle damage = release of Myoglobin from muscles (give fluids), low dose dopamine (^renal perfusion), Kayexalate + dialysis (to remove K+)
Fracture: bone healing Continous
Fractures: other complications Hypovolemic shock (result of hemorage), Fat embolism syndrome (FES), Venous Thromboembolism (VTE = DVT+PE), Infection (MRSA, Osteomyelitis), Aseptic (avascular) necrosis, Delayed union (>6 mo)
Fat Embolism Syndrome (FES) Fracture complication. 12-48hrs fat enters blood. Highest risk: hip fx. S&S: confused mental changes, sleeping etc. Due to decreased arterial blood flow. Decreased O2, tachy, chest pain, hymotisis. *Petechia on chest & trunk due to decreased circ (late)
Petechia on chest & trunk is S&S of... *Fat embolism Syndrome (FES) and not PE* late sign, due to decreased circulation.
Fat Embolism Syndrome (FES): Treatment Bed rest, move patient carefully, hydration, steroids (decrease swelling).
Aseptic (avascular) necrosis Osteonarcrosis. Decreased bone blood supply = dead bone. Long term Predisone use increases chance.
Delayed Union of fracture: Due to, Tx >6 months to heal. Due to : nonunion of bones, malunion (weak). Tx: electrical stimulatetion (contrindicated w/pacemaker), bone graft
Fracture: Tx Closed reduction: most common for simple fracture, pop in place, pt concious w/moderate sedation. Casts or splints(plasar of paris stronger than fiber glass, want not too tight or loose), Traction, Surgery
Fracture: Tx: Traction types Skin (Buck's), Skeletal
Fracture: Tx: Traction: Skin (Buck's) 5-10 lbs, to decrease muscle spasm, temporary until pt can have surgery, keep weight free hanging & don't remove. Check skin under boot every shift, neurovascular checks.
Fracture: Tx: Traction: Skeletal wt up to 30 lb. Use pins, risk of infection. keep weight free hanging & don't remove. Check skin around pins. Neurovascular chesks.
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Fracture: Traction: Check Check: all ropes secured & not tangled, knobs, pulleys every shift. Check: ordered wt (pain if too ^or low), neurovascular, allignment (^pain if not)
Fracture: Traction: Moving Patient, Patient position 3 people to move pt, 1 hold leg & wt. Use pillow to move pressure & prevent skin breakdown
Fracture: Surgical: External fixation (w/closed reduction) Can do dressing changes, less blood loss, used for complex things like ankles & broken skin. Pins- serous drainage 1st couple days. ^risk of Osteomyelitis. Clean pins w/Hosp protocal (ex: clorahexadine, neosporin)
Fracture: Surgical: Open reduction interanl fixation. Surgery to set then cast. Better alignment & can view damage. ^Risk infection, ^blood loss, anesthesia risks.
Crutches Need strong upper body strength, elderly can use cane or walker due to less balance & less body strength. 3pt walk (move 1crutches, 2bad leg, 3good leg), 2-3" below armpit d/t nerve pressure risk, keep arm @ 15-30 degree angle, crutch post @ 6 degree.
Hip Fracture: Types,S&S, Complications Intracapsular: top 2/3 femor & in hip capsul. Extracapsular: outside hip capsul. S&S: pain, rotated externally out, shorter leg. Complications: bleeding, PVT. 40% elderly die w/in yr due to: PE, pneumonia, blood loss, osteoporosis (decreased bone healing)
Hip Fracture: Assess Infection, blood clot, skin integrity (heels), hip proper alignment (don't adduct legs/bring inward)
Hip Fracture: Activity Don't adduct legs (bring together inward). Use pillow between legs to prevent adduction-disclocation. Prevent pneumonia: get pt ^1st post op day (not wt bearing), put pt in chair.
Amputation: Types Elective usually to lower legs r/t DM etc. Traumatic usually to ^ extremities.
Amputation: complications Phantom pain is real nerve pain. Hemorage, lack of blood flow. Suture line should be pink & not pale or blue, if it is notify Dr.
Amputation: Psychosocial support Refer to stump as leg because some pts offended. Give/help pt obtain psychosocial support.
Amputation: Meds IV Calcintonin given during 1st wk to diminish the pain. Neurontin when pt returns home.
Amputation: hip contractor Varies by Dr. (some use pillows). Avoid semi fowlers for extendid periods. Have pt push hip into bed. Can lay prone for 20 min 4X/day.
Amputation: Site care/prepare for prostheses Put neoprene stocking net on or wrap w/ace bandage (figure 8) to mold stump into shape. Have pt rub from incission line outward to break up keloids & prevent scar tissue.
Calcium Carbonate calcium supplement of choice for osteoporosis
Calcium Citrate used if the patient has GI upset from the calcium carbonate
OS-Cal Contains Ca+ and Calcium Carbonate. Affordable. Keeps bones strong.
Created by: imsuzanne