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NSG 308 Adult Health
Exam 3 Study Guide
| Question | Answer |
|---|---|
| Greenstick fracture | partial break - one side of bone cracks and other bends (common in children) |
| Comminuted fracture | more than 2 bone fragments - indicative of high energy mechanism |
| open (compound) fracture | bone pierces skin - high infection risk (eg. osteomyelitis, tetanus, gas gangrene) |
| closed fracture | skin intact over fracture |
| impacted fracture | bone ends forced together - possible nonsurgical tx |
| closed reduction | manipulation and manual traction w/o surgical incision |
| open reduction (ORIF) | open reduction and internal fixation - surgical alignment with internal fixation devices |
| Fracture Emergency Management (Priorities) | - Immobilize before moving w/ proximal + distal splints - assess neurovasc status before and after splinting (Pain/Pallor/Pulselessness/Paresthesia/Paralysis/Pressure) - cover open fracture w/ sterile dressing (no reduction) - Elevate extremities + ice for edema |
| Acute compartment syndrome pathophysiology | - increased pressure within confined fascial compartment compresses blood vessels + nerves - Med emergency - Loosen constrictive dressing/cast STAT, no elevation above heart level S/S: [pain disproportionate to injury, not better w/ opioids], pallor, paresthesia, paralysis, pulselessness, pressure feeling Tx: notify provider STAT, fasciotomy |
| Hip fracture pathophysiology | - Old age + osteoporosis risk factor - Extracapsular vs intracapsular vs periprosthetic Tx: surgery within 1-2 days -> reduce immobility complications (atelectasis, PNA, VTE, pressure injury, delirium) - Complications: avascular necrosis (AVN), nonunion, infection, delirium |
| Hip fracture post-op intervention | - pain management - VTE ppx (LMWH/enoxaparin + compression devices) - early ambulation - Incentive spirometry |
| Total hip arthroplasty dislocation prevention | - Maintain hip abduction (pillow splint) + operative leg in neutral position (no leg adduction over midline) - Use raised toilet seat + high chairs + walker (hip flex >90 dg) - Do not internally/externally rotate operative leg or allow to dangle |
| Osteoarthritis pathophysiology | Noninflammatory degenerative joint disease - weight bearing joints (knee, hip, spine), DIP joints - Heberden's (DIP) + Bouchard's (PIP) S/S: <30 min morning stiffness (short), worsen w/ activity, no systemic sx Dx: clinical H/P, XR (narrow joint space, osteophytes) |
| Rheumatoid arthritis clinical presentations | - affect symmetric small joints (MCP, PIP) - possible ulnar deviation S/S: 1hr +, morning stiffness (prolonged), pain at rest and improve with movement, low grade fever, fatigue, weight loss, raynaud phenomenon, anemia, lymph node enlargement, small joints first to large joints |
| Osteoarthritis management | - low impact aerobic/LE strength training - weight loss - Assistive device (cane, walker, raise toilet seat) - Medication timing - Diagnosis - Surgery (arthroplasty in severe case) |
| Osteoporosis pathophysiology | Reduced bone mass + bone matrix deteroriation (bone resorption > bone formation) - T/L vertebrae compression fractures, hip, wrist (Colles fracture) - Screening in postmenopausal females 50+, Hx of fragility fracture Dx: DEXA (>-2.5) |
| Primary vs Secondary Osteoporosis | Primary: postmenopausal females (10% bone loss in first 5 yr post-menopause) Secondary: d/t corticosteroids, anticonvulsants, EtOH abuse, thyroid meds, SSRI, PPI |
| Osteoporosis treatment/management | Tx: bisphosphonates, Ca+Vit D, estrogen antagonist/agonist, RANKL inhibitor, synthetic PTH - 30 min weight bearing exercise - Avoid EtOH, smoking, caffeine - Fall precautions (lighting, grab bars, footwear) - Avoid bending trunk w/ vertebral compression fractures |
| Osteomyelitis pathophysiology | Infection of bone -> inflammation, necrosis, new bone formation - common S. Aureus - hematogenous (bloodborne), contiguous focus (open fracture/surgery), vascular insufficiency Acute S/S: sudden onset fever, chills, tachycardia, local pain/swelling/warmth/tenderness Chronic S/S: nonhealing ulcer, pus drainage, lowgrade/afternoon fever Risks: older adult, PVD, DM, immunosuppression, IV drugs Dx: elevated WBC/ESR/CRP, bone change on MRI/bone scans |
| Osteomyelitis treatment/management | Tx: IV Abx x 6-12 wks, immobilization, surgical debridement - Aseptic technique for all dressing change - Continue FULL course abx |
| Rheumatoid Arthritis pathophysiology | Immune activation -> joint destruction (synovium breaks down collagen = edema + pannus) - Ag presentation to T-cell (initiation) - T/B-cell proliferation -> small joint swelling, pain/stiffness, fatigue - Neutrophil accumulation -> warmth, swelling, effusion, rheumatoid nodules - Synovitis/early pannus invasion -> chondrocyte activation + cartilage degradation (proteinases) - Subchondral bone erosion -> joint instability, contractures, dec ROM Dx: RF titer, anti-CCP, ESR/CRP, 6+ weeks duration |
| pannus | abnormal growth of fibrous tissue in RA - made up of inflammatory cells/neutrophils - release enzymes destructive to cartilage + bone |
| Rheumatoid arthritis risk factors | - FHx, environmental, nulliparity - Modifiable: smoking, obesity (elevated BMI = worse outcome) |
| Rheumatoid arthritis treatment | - PT/OT + weight management + hot/cold applications - Relaxation/imagery - DMARDs: Methotrexate (first line), sulfasalazine, hydroxychloroquine - Biologic DMARDS: TNF blocker, IL-6, B-cell, T-cell - JAK inhibitors - NSAID - Corticosteroids (shortest duration + lowest dose) |
| Rheumatoid arthritis nursing management | - Address pain/sleep/mood/mobility/fatigue disturbances - Patient education - Smoking cessation - Diet consult - Regular labs + TB screening before biologics - Monitor cardiovascular disease + medication S/I |
| Gout risk factors | - Old age - High BMI - EtOH + purine rich (red meats/seafood) - HTN + diuretic use - Fructose rich drinks |
| Gout pathophysiology | hyperuricemia (purine metabolism byproduct) = crystalization in joints - Urate deposit in joints -> macrophage phagocytize crystals = inflammation - Possible CKD + kidney stone risk S/S: severe sudden joint pain (nocturnal common), big toe*, hot/red/swollen/tender joint, tophi, renal impairment Dx: serum uric acid (normal during acute flare), polarized light microscopy of synovial fluid |
| Tophi | urate crystal deposits in peripheral tissues eg. ears/joints |
| Gout management | Tx (acute): colchicine, NSAID, corticosteroids (PO or intraarticular), IL-1 receptor agonist Tx (chronic): allopurinol/febuxostat, probenecid, pegloticase |
| Gout nursing intervention/education | - Avoid purine rich + EtOH + fructose - Increase hydration - Weight loss - Pain management in acute episodes - Medication compliance + early tx in acute attack - Thiazide = increase uric acid/gout |
| Cushing's Syndrome Causes | - Iatrogenic: most common d/t long term corticosteroid use - pituitary tumor (cushing's disease): excess ACTH from pituitary adenoma - Adrenal tumor: direct cortisol production independent of ACTH - Ectopic ACTH: non-pituitary tumor producing ACTH (often SCLC) |
| Cushing Syndrome Pathophysiology | - Prolonged exposure to excess glucocorticoids (cortisol) Manifestations: humpback appearance, muscle wasting, hyperglycemia/HTN, hypokalemia/hypernatremia, immune suppression, amenorrhea, osteoporosis, depression Dx: serum cortisol, 24h urine free cortisol, low dose dexamethasone suppression test (failure to suppress = positive), ACTH, MRI pituitary, CT adrenal |
| Cushing Syndrome Nursing Management | - Monitor for infection, BP/glucose, electrolytes (K*) - Fall precaution (osteoporosis) - Skin care (fragile skin) - Emotional support for body image change - Daily weight, I/Os - Diet: low Na, low calorie, high protein] - Med alert bracelet |
| Addison's disease pathophysiology | Primary adrenal (cortisol w/ or w/o aldosterone) insufficiency - D/t autoimmune destruction, infection, adrenal hemorrhage, steroid withdrawal Manifestations: bronze skin coloring, hypoglycemia/hypotension, hyponatremia/hyperkalemia, salt craving, anorexia, weakness/fatigue, GI upset, depression Dx: ↓ serum cortisol, ACTH stimulation test (failure to rise = primary insufficiency, plasma ACTH, ↓ Na+, ↑ K+, ↓ glucose |
| Addisonian Crisis | - Life threatening emergency S/Sx: severe hypotension/shock, hyponatremia/hyperkalemia, hypoglycemia, profound weakness Tx: IV hydrocortisone STAT, IV NS, IV dextrose, treat hyperkalemia |
| Addison's disease treatment | - Lifelong hormone replacement - Stress dosing = 2x/3x dose during illness/surgery/major stressors - Addisonian crisis management (IV hydrocortisone 100mg STAT, NS bolus, IV dextrose, K management) |
| Addison's disease nursing intervention/teaching | - Monitor BP/HR, daily weight, I/O, electrolyte, glucose - Adequate sodium, high carb (small frequent) - Medical alert bracelet! - Stress dosing teaching - Emergency IM hydrocortisone home kit - Med compliance -> cessation = crisis risk |
| Hyperkalemia pathophysiology | - Elevated K S/Sx: muscle weakness, paresthesia, peaked T waves, arrhythmia Tx: kayexalate, calcium gluconate (stabilize myocardium first), insulin + glucose, bicarb, dialysis |
| CKD pathophysiology | - kidney damage or decrease GFR in 3+ month - ESRD = need dialysis/transplant - CV disease = top cause of death in CKD - DM/HTN/CV disease + age/FHx + obesity risk factors Dx: ↑ BUN/Cr, ↑ BUN, hyperkalemia, metabolic acidosis, ↓ Ca, ↑ phosphorus, H/H, uremia |
| AKI pathophysiology | rapid (reversible) loss of kidney function 2/2 serious event (shock, sepsis, nephrotoxins) Dx: elevated serum Cr >0.3 in 48h or 1.5x baseline within last 7 days, <0.5 mL/kg/h urine output >6 hr |
| Prerenal AKI | D/t: hypoperfusion (shock/sepsis, hypovolemia, HF) Dx: BUN/Cr >20:1, urine Na <20, urine osmolality >500 |
| Intrarenal AKI | d/t parenchymal damage (nephrotoxin, glomerulonephritis, ATN) Dx: urine Na >40, low urine osm, abnormal casts |
| Postrenal AKI | d/t obstruction (stones/BPH/tumor/strictures) Dx: sudden anuria, hydronephrosis on imaging |
| 4 phases of AKI | 1. Initiation - initial insult until development of oliguria 2. Oliguria - increase waste, hyperkalemia risk, uremic sx 3. Diuresis - increase urine output, lab stabilization 4. Recovery - function improves (may take months) |
| Acute nephritis syndrome pathophysiology | AKA glomerulonephritis - d/t group A b-hemolytic strep -> 1-2 week post complication of pharyngitis/impetigo Sx: hematuria (cola color), proteinuria, edema, HTN, dec GFR Tx: penicillin (for strep), supportive care, BP control |
| Nephrotic Syndrome pathophysiology | - massive proteinuria (>3.5g/day) + hyperlipidemia - hypoalbuminemia + diffuse edema (anasarca) - Hypercoagulable state (inc DVT/PE risk) Tx: ACE inhibitor, corticosteroid, diuretic, low Na diet |
| Hemodialysis | Blood pumped thru semipermeable membrane in external dialyzer (multiple types) - usually 3-4 hrs per session 3x/week - Complications: hypotension, muscle cramp, dialysis disequilibrium, lowest infection risk, longest lasting |
| AV fistula | Vascular access dialysis (preferred access mode) - artery to vein anastomosis - 4-6 week maturation - lowest infection risk - longest lasting |
| AV graft | synthetic tube connecting artery-vein - 2 week maturation - higher clot/infection risk |
| CV catheter | - Internal jugular or subclavian site - immediate access - highest infection risk (last resort) - short term ONLY |
| Hemodialysis considerations | Fistula/graft arm: NO BP/IV/blood draw/tight jewelery or sleeves - Assess thrill (palpate buzzing) and bruits Q shift - Absence of thrill = emergency -> call dialysis center STAT |
| Peritoneal dialysis | Peritoneum serves as semipermeable membrane - dialysate instilled -> dwell time -> drainage CAPD: 4-5 manual exchanges per day CCPD: machine cycles overnight - home dialysis, convenience/flexibility, better hemodynamic stability - peritonitis risk |
| Peritonitis pathophysiology | Infection of peritoneum d/t dialysis - strict sterile technique for prevention S/Sx: cloudy effluent, abd pain, fever, rebound tenderness, N/V, elevated WBC in dialysate - Obtain effluent Cx Tx: empiric intraperitoneal abx |
| Kidney transplant | - donor kidney placed in iliac fossa -> native kidneys remain usually - lifelong immunosuppression (tacrolimus or cyclosporine + mycophenolate + prednisone) - Rejection sign: fever, tenderness over graft, oliguria, elevated Cr, wt gain, edema |
| Kidney transplant nursing priorities | - Infection prevention (immunosuppression) - Strict I/Os (report <30 mL/h urine output) - Strict med adherence teaching |
| kidney trauma | - blunt (65%, MVC usually) vs penetrating (gunshot, stabs) Sx: hematuria (gross or microscopic), flank pain/mass, ecchymoses, hypovolemic shock (if severe) - Medical alert bracelet if nephrectomy Tx: 1 month activity restriction post injury |
| kidney trauma nursing priorities | - I/Os + vital sign monitoring - bed rest until hematuria clears - pain control - infection prevention - Monitor for late HTN |
| PaCO2 | normal value 35-45mmHg - lungs control this (respiratory component) |
| HCO3- | normal 22-26 mEq - metabolic component (renal control) |
| PaO2 | normal >80 mmHg - below normal = hypoxemia |
| ABG interpretation | - Acidosis vs alkalosis (7.35-7.45) - PaCO2 = respiratory (CO2 is acidic) - HCO3 = metabolic (bicarb is basic) - Compensation = If secondary value moves in same direction as primary disorder |
| Respiratory Acidosis pathophysiology | d/t COPD, drug OD, pneumothorax, atelectasis, pulm edema (lung disease) - low pH, high PaCO2 + ↑ HCO3 (compensation) Sx: neuro change, hypotension, bradypnea, hyperkalemia - think slow breathing -> decreased CO2 out = acidosis |
| Respiratory alkalosis pathophysiology | d/t anxiety, fever, pain, mechanical ventilation, infection - think quicker breathing = low CO2 = alkalosis - high pH, low PaCO2 + ↓ HCO3 (compensation) |
| metabolic acidosis pathophysiology | d/t DKA, renal failure, diarrhea, gastric fluid loss - low pH, ↓ PaCO2 (compensation) + low HCO3 Sx: kussmaul breathing, weakness, fatigue, hyperkalemia |
| metabolic alkalosis pathophysiology | d/t loop diuretics, vomiting, gastric suctioning - high pH, ↑ PaCO2 (compensation) + high HCO3 Sx: bradypnea, hypovolemia, hypotension, hypokalemia, weakness |
| Emphysema (COPD) pathophysiology | "pink puffer": barrel chest, pursed lip breathing, thin - alveolar wall destruction + loss of elastic recoil -> air trapping + hyperinflation Sx: DOE (main complaint) Dx: 3+ month disease over 2 consecutive years, FEV1/FVC <70% |
| Chronic bronchitis pathophysiology | "blue bloater": cyanotic, overweight, edematous - chronic inflammation + excess mucus + airway obstruction Sx: chronic productive cough w/ purulent sputum Dx: FEV1/FVC <70% |
| COPD nursing priorities | - Titrate SpO2 88-92% in chronic CO2 (hypercapnia risk due to hypoxic drive suppression) - New confusion/lethargy + RR <8 = respiratory failure (call provider STAT) - Purse lip breathing - Smoking cessation - flu + PNA vaccination - Pace activity + energy conservation, small frequent meals - Monitor for PNA, ARDS, pulm edema, resp failure during exacerbations |
| TB pathophysiolgy | d/t mycobacterium tuberculosis (airborne transmission/droplet) Sx: low grade fever, chronic cough (hemoptysis), night sweat, fatigue, wt loss - Latent (not active/contagious) vs active (symptoms/contagious) Dx: (+) sputum Cx (PPD/IGRA does not distinguish latent from active) Tx: abx 6-12 months |
| TB nursing priorities/education | - isolation w/ AIRBORNE precaution + negative pressure room - N95 respirator for ALL - D/C isolation w/ clinical criteria + neg sputum - Teach med compliance (relapse + resistance risk) |
| TB risk factors | - close contact w/ active TB - immunocompromised/HIV/substance abuse - homelessness/institutionalization - endemic areas |
| PPD mantoux | positive w/ induration over 10mm (5mm for immunocompromised/HIV) - indicate exposure NOT active disease |
| ARF manifestations | acute respiratory failure - Early signs (act now): restlessness/anxiety, tachycardia/tachypnea, mild HTN, inc work of breathing, fatigue, headache, mildly low PaO2 - Late signs (emergency): profound confusion, lethargy, unresponsiveness, bradycardia/bradypnea, severe hypotension, respiratory arrest, central cyanosis, diaphoresis, severe hypoxemia unresponsive to O2 (PaO2 <55 on O2) |
| ARF management | - Identify and tx precipitating cause - Semi-fowler for lung expansion - Reduce client anxiety (family OK) - Enteral > parenteral feeding when GI functional - Provide alternative communication (if intubated) - Opioid induced tx: nalaxone + supplemental O2 + prep intubation + call HCP |
| Tracheostomy | Surgical opening into trachea w/ tube inserted (temp vs permanent - for intubations over 14-21 days, upper airway obstruction, chronic ventilator dependence - 20-25 mmHg O2 (high = tracheal mucosal ischemia/necrosis/stenosis vs low = aspiration risk) - Humidification needed (prevent secretion drying/plugging) |
| Tracheostomy nursing priorities | - Sterile technique + PRN suctioning (assess lung sound) - Pt unable to speak -> alternative communication - Semi-fowlers position (comfort + aspiration risk) - Monitor stoma for infection |
| CMV (Ventilator) | Continuous mandatory ventilator - controls ALL breaths (most supportive) - ARF, apneic patients |
| SIMV (Ventilator) | Synchronized Intermittent Mandatory Ventilation - preset mandatory breaths, allow for pt to take own spontaneous breaths - for pts beginning to breathe spontaneously |
| PSV (Ventilator) | - Pressure support ventilator - Assist pt initiated breaths only -> RR + tidal volume driven by pt - least supportive - for pt who can initiate breaths |
| CPAP/BIPAP | Continuous positive airway pressure + bilevel positive airway pressure - noninvasive (facemask) = no intubation - for COPD, HF, sleep apnea, mild ARF |
| PEEP | positive ends expiratory pressure - keeps alveoli open between breaths - essential in ARDS |
| FiO2 | fraction of inspired oxygen - 0.21-1.0 - titrate to maintain SpO2 ≥90-95 |
| Post intubation priority | Confirm ET tube placement STAT - B/L breath sounds auscultate - capnography - CXR |
| Barotrauma/Pneumothorax | - ventilator complication Sx: sudden absent breath sounds + tracheal deviation = tension pneumothorax |
| VAP | ventilator associated PNA Sx: new fever, purulent secretions, worsening infiltrates - most common serious ventilator infection complication |
| Hemodynamic effects (ventilator) | - positive pressure increase intrathoracic pressure -> decrease venous return -> decreased cardiac ouput -> hypotension |
| ICU delirium | - New confusion + agitation in ventilated patient - assess and treat - common complication in intubation |
| intubation weaning | - gradual process - use PSV (pressure support ventilator) for weaning - frequent assessment + collaboration |
| Acute respiratory distress syndrome (ARDS) | Sudden progressive noncardiogenic pulmonary edema w/ B/L infiltrates and severe refractory hypoxemia - Hypoxemia REFRACTORY to supplemental O2 - systemic inflammatory response = alveolar-capillary membrane damage -> fluid flood alveoli Early manifestation: rapid onset SOB, air hunger, tachycardia/tachypnea, crackles, AMS Late manifestations: cyanosis, severe hypoxemia, chest retraction, respiratory failure Dx: CXR (B/L infiltrates), BNP, Echocardiogram, pulm artery catheterization |
| what distinguishes ARDS from cardiogenic edema | ARDS has no elevated left atrial pressure (its not HF) |
| ARDS risk factors | - Direct lung injury: aspiration, severe PNA, pulmonary contusion, inhalation injury, near drowning - Indirect systemic injury: sepsis, massive blood transfusion, severe trauma/fractures, drug OD/toxin exposure, shock, pancreatitis, burns |
| ARDS treatment | - mechanical ventilation - PEEP: keep alveoli open between breath (prevent collapse)* - sedation (reduce O2 demand in severe case) |
| ARDS nursing priorities | - Fluid management (avoid fluid overload and tx hypovolemia) - Prone positioning -> recruit collapsed dependent alveoli = improve V/Q matching - enteral feedings preferred |
| Pulmonary embolism | - emboli in pulm vasculature = obstructed blood flow (V/Q mismatch + hypoxemia) - commonly thrombus (DVT) - Virchow's triad Sx: dyspnea + pleuritic chest pain + hemotypsis, tachycardia/tachypnea, hypoxemia, restlessness, cough, syncope Dx: CT pulm angiography, V/Q scan, D-dimer, echocardiogram Tx: heparin (prevent new clots), thrombolytics (tPA - for massive PE) |
| Virchow's triad | - venous stasis - endothelial injury - hypercoagulability |
| VTE prevention | - early frequent ambulation (most effective) - intermittent pneumatic compression device - Ppx anticoagulations - Ankle pump + foot flexion exercise in bed - hydration - Avoid prolong immobility + restrictive clothing + crossing leg - No massaging legs + vigorous ambulation with suspect DVT |
| pulmonary embolism risk factors | - immobility/stasis - surgery - hypercoagulability - vessel injury - obesity/old age - varicose vein - dehydration |
| Pneumothorax | d/t air in pleural space = lung collapse Types: spontaneous vs open vs closed vs tension Tx: thoracentesis, chest tube, needle decompression (tension) |
| Tension pneumothorax | pneumothorax cause mediastinal shift -> tracheal deviation AWAY from affected side - emergency Sx: absent breath sound, JVD, hypotension Tx: emergency needle decompression (2nd intercostal space midclavicular line) -> chest tube |
| Hemothorax | blood in pleural space Tx: chest tube drainage, surgery if massive |
| Open (sucking) chest wound | air enters pleural space thru chest wall wound during inspiration Tx: occlusive dressing taped on 3 sides (flutter valve) - NEVER 4 sides |
| flail chest | - 3 consecutive ribs broken in 2+ places -> paradoxical chest wall movement Tx: O2, analgesia, possible intubation + mechanical ventilation |
| cardiac tamponade | - blood in pericardial sac -> decompress ventricles -> decreased ventricular blood fill and lowered cardiac output - Beck's triad (muffled heart sounds + hypotension + JVD) Tx: emergency pericardiocentesis |
| Rib fractures | Most common on rib 5-9 - PNA/atelectasis risk from splinting + shallow breathing Tx: NSAIDS/opioid/nerve block, deep breathing, incentive spirometry - NO chest binding/strapping |
| Chest tube water seal drainage system normal vs abnormalities | Normal: tidaling (fluctuation in water chamber when breathing), gentle intermittent bubbling in suction control chamber Abnormal: vigorous bubbling in water seal chamber (air leak), 200+ mL drainage (hemorrhage), subcutaneous emphysema/crepitus at insertion site, stoppage of drainage + resp distress (tube obstruction/kink), drainage unit above chest level (move for gravity drainage) |
| Chest tube nursing priorities | - drainage system always below chest - encourage deep breathing/coughing/incentive spirometry - monitor + document drainage mL/character - cover site with sterile occlusive dressing if dislodged - place distal end in sterile water if break in system - Premedicate before tube removal |
| Chest tube DO NOT do | Do NOT: - clamp tube unless ordered - milk/strip chest tube (lung tissue trauma) - reinsert dislodged tube - leave system open to air - remove chest tube w/o order + analgesia - elevate drainage system above chest |
| chest tubes removal | remove when lung re-expand + minimal drainage - valsalva maneuver during removal - sterile occlusive dressing STAT after removal - post removal CXR - Monitor for respiratory distress |
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sleepingbear