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Exam 2 nurs 209
Sensory fxn, Hematology, Musculoskeletal, Peripheral Vascular
| Term | Definition |
|---|---|
| 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. |
| Who's awesome? | You are! |
| Why I will do well on this exam_________ | Because I can not take another semester! |
| What's worse, being beaten with a metal chair or repeating 209? | Repeating 209... or 210, or any semester. |
| 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. |
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imsuzanne
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