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Rasmussen: Nursing 1 Exam 1

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Safety hazards in a home
* Poisoning - medication, household chemicals, lead, cosmetics.
* Carbon monoxide poisoning - treatment- 100% humidified oxygen.
* Scalds and burns
* Fires
* Falls - age >65 at highest risk
* Firearms injuries
* Suffocation/Asphyxiation- drowning, choking, smoke/gas inhalation, children 0-4yrs at highest risk.
* Take home toxins- pathogenic microorganisms, asbestos, lead, mercury, arsenic.
Safety hazards in hospital/care giving environment
Falls
Equipment-related accidents
Fires/electrical hazards
Restraints
Side rails
Mercury poisoning
Infection
Spills
Back injury - poor body mechanics
Needle stick injury
Combative patients
Poor staffing
Preventing of harm to client and self
Wash hands!
Complete fall risk assessment
Follow hospitals policies and procedures
Check equipment regularly
Actually assess your patients
Proper body mechanics
Proper disposal of sharps
Radiation precautions
Environmental Awareness
Prevention of choking
- Suffocation by smothering is the leading cause of death for infants younger than 1 year.
- Suffocation may be caused by drowning, choking, or inhaling gas or smoke.
- Beware of small foods with small children, including hot dogs, raw vegetables, popcorn, hard candies, nuts, and grapes. They are responsible for most non-fatal choking.
- Nonfood items, such as latex balloons and plastic bags, cause the majority of suffocation deaths in young children.
- Suffocation of infants is often related to bed or crib hazards, such as excess bedding or pillows, or toys hung from long ribbons inside the infant's crib.
Fire Precautions
R.A.C.E
Rescue
Alarm
Contain
Extinguish
Poisoning
Poisoning-household chemicals, lead, medicines, cosmetics. Prevention- cabinet locks, store poisons high, keep poison control number available. Treatment depends on the poison ingested -
antidotes most often activated charcoal.
Do NOT induce vomiting for acidic material ingested
Carbon Monoxide Poisoning
- Carbon monoxide (CO) is a colorless, tasteless, odorless toxic gas. Exposure can cause headaches, weakness, nausea, and vomiting; prolonged exposure leads to seizures, dysrhythmias, unconsciousness, brain damage, and death.
- Do not use unconventional heating inside such as grill, or gas range
- Use of detectors and change batteries every 6 months.
Mercury Poisoning
Products containing mercury include thermometers, thermostats, batteries, fluorescent light bulbs, blood pressure devices, and electrical equipment and switches.

To prevent have yearly facility training and follow facility policy
Communication
- Educate patients
- Communicate specifics to tech
- Shift-to-shift report
- Use SBAR - specifically with physicians
- Use patient names - more specific
- Follow-up - if you say an hour, do it!
- Never walk past a call light
- Document accurately
Walker
Handgrip at greater trochanter
Elbow flexed 20-30 degree
Walker followed by affected side then unaffected side.
Cane
Handgrip at greater trochanter
Elbow flexed 15-30 degree
Use on UNAFFECTED side
Place cane 4-6" to side stronger foot
Move cane and affected leg at same time when walking, then unaffected leg
Crutches
Arms/hands bear weight
Up stairs=good first
Down stairs=bad first
When walking crutch goes 6-10" in front
Crutches go to affected side when sitting
Pad 2 inches below axilla, 4 inches to side of heel Elbow flexed 20-30 degree when walking
Fall risks and prevention
Cognition, balance, gait, mobility, vision, peripheral neuropathy, awareness, medications. Toddlers, elderly most at risk.

Bed to lowest point, only 2 guardrails left up, non-slip socks, remove throw rugs, remove clutter, orient to room, make sure patient knows how to use canes/walkers/crutches, call light within reach, prepare a fall assessment, clean, dry floors
Infants (1month- 1 year) Safety
Falls
SIDS (back to sleep)
Injury from toys
Burns
Suffocation and choking
Electrocution
Ingestion of foreign bodies
Child mistreatment
Toddler (1-3years)
Drowning (second to MVA)
Falls (primary cause of non-fatal injury)
Cuts
Concussions
Guns and weapons (locked and unloaded)
Escape from home
Poison (Poison Control # on fridge)
Suffocation and choking
Child mistreatment
Preschooler (3-6 years)
Drowning
Falls
Cuts
Firearms
Strangers
Burns
Motor Vehicles
Poisoning
School-Age (6-12)
Sexual abuse
Burns
Broken bones
Concussions
Drowning
Guns and weapons
Use of Internet
Sports injuries (cognitive rest)
Abduction
Bullying (cyber bullying)
Child Mistreatment
Adolescent (12-20 years)
Piercing & Tattoos
Driving (distracted driving)..texting especially
Firearms
Suicide
Drugs and Alcohol and Tobacco
Sexuality and STIs
Sexual abuse
Use of Internet
Risk taking (diving into unfamiliar water)
Adults
Stress
Domestic Violence
MVA
Industrial accidents and exposure
Drugs and alcohol abuse

Accidental poisoning is number one cause of death from age 34-54
Elderly
Falls #1
Elder abuse and neglect
MVA
Sensorimotor changes
Fires (candles, heaters)..forgetfulness
Burns (electric blankets, hot water, heating pads)
Accidental overdosing and polypharmacy
Never Events - Senital Events
Foreign object left in patients after surgery
Administering the wrong type of blood
Symptoms resulting from bad blood sugar levels
Air embolism
Severe pressure ulcers
Falls and trauma
Infections from urinary catheters
Infections from intravenous catheters
Surgical site infections
Deep vein thrombosis or pulmonary embolism
Gout Pathophysiology
Body can't metabolize uric acid so it accumulates in the blood and tissues. Urate salts form needlelike crystals that form deposits especially in the smaller bones of the feet. Extremely painful.
Gout Signs and Symptoms
Painful, Erythema of joints or bursa
May have the appearance of cellulitis or septic joint
Fever
Leukocytosis (high WBC)
Usually occur in the coldest areas on the body
Common in the distal joints, bursa , pinnae of ears
Gout Diagnosis
Urine - Urinary uric acid levels
Blood - Serum Uric acid levels
Xray, CT, Ultrasound
Joint Fluid Test - Synovial Fluid Aspiration-synovial fluid drawn from joint and tested for high levels uric acid.
Kidney function test
Gout Medications
Nsaids and corticosteriods to reduce inflammation

Allopurinol - Reduces uric acid. Doesn't relieve acute gout attacks. Increase fluid intake May cause hypoglycemia.

Colchicine - Used for initial prevention and chronic attacks. Decreases WBCs response to urate crystals. Avoid grapefruit juice.
Gout goals of treatment
Reduce painful attacks and lower amount of uric acid in patients blood and tissues.
Gout Client Teaching
Ice, weight loss, excercise. Drink plenty of fluids.
Restrict aspirin , diuretics, excessive physical or emotional stress can exacerbate the disease
Eat a low purine diet, no pork, lamb, red meats & seafood
Gout Complications
Limited range of motion
Joint damage
Kidney stones
Strains & Sprains Pathophysiology
A sprain is a stretching or tearing of ligaments, the tough bands of fibrous tissue that connect two bones together in your joints.

A strain is a stretching or tearing of muscle or tendon. A tendon is a fibrous cord of tissue that connects muscles to bones.
Strains & Sprains Signs and Symptoms
The most common location for a sprain is in your ankle.

Strains often occur in the lower back and in the hamstring muscle in the back of your thigh.

Sprain- Pain, Swelling, Bruising,Limited ability to move the affected joint, At the time of injury, you may hear or feel a "pop" in your joint

Strain- Pain, Swelling, Muscle spasms
Limited ability to move the affected muscle
Strains/Sprains Diagnosis
Physical Exam, X-ray, MRI

Grade One:
- Strain - Stretch on muscle fibers, less than 10% of muscle fibers involved.
- Sprain - Stretched ligament, 0-20% torn

Grade Two:
- Strain - Partial tear in muscle. Palpation reveals defect. 10-50% of muscle fibers involved.
- Sprain - Ligament 20-75% torn.

Grade Three:
- Strain - Extensive tear or complete rupture. 50-100% of muscle fibers torn to complete rupture of the muscle.
- Sprain - 75-complete rupture of ligament.
Strains/Sprains Medications
Initial treatment almost always includes RICE therapy - rest, ice, compression and elevation.

Pain & inflammation can be managed by an over the counter NSAIDs (ibuprofen) or acetaminophen (Tylenol)

Ibuprofen - take with full glass of water and to remain upright in an upright position for 15-30 min after administration
Treatment of Strains & Sprains
A partial tear can usually heal with rest, but a complete tear often requires surgery to stabilize the joint.
Initial treatment almost always includes RICE therapy - rest, ice, compression and elevation.
Adaptive devices, physical therapy and pain management.
Goals of Treatment for Strains & Sprains
Proper muscle, tendon or ligament healing and proper pain management.
Complications of Strains & Sprains
Pain, recurring swelling and possible surgery. Sometimes ligaments can heal incorrectly leaving them permanently stretched.
Back Pain Pathophysiology
one of the most common reasons people go to the doctor or miss work and a leading cause of disability worldwide.

Disc degeneration due to age or trauma.
Decrease in the disc height causes a shift in the load bearing in weight distribution.
Impaired healing of the intervertebral disc due to poor peripheral blood supply.
Back Pain Signs & Symptoms
Difficulty moving that can prevent walking and standing.
Achy, dull pain
Muscle Spasms
Soreness with Touch
Pain that can range from mild to a severely debilitating.
Back Pain Diagnosis
X-ray, CT, MRI
Back Pain Medications
NSAIDs and Analgesics

Muscle Relaxant- baclofen, cyclobenzaprine, carisoprodol

Narcotics- Tramadol

Medical procedures - electrical nerve stimulation, epidural steroid injection, or surgery.

Other treatments - joint manipulation, stretching, physical therapy and massage.
Back Pain Treatment
Self Care- Heating Pad and exercise

Preventing pain by maintaining good posture, using a firm mattress, using good body mechanics, and exercising.
Back Pain Goals of Treatment
Reduce acute symptoms and prevent future problems. It is debatable as to whether or not a herniated disk can ever completely heal.
Back Pain Complications
Disability
Bladder, Bowel, and intestinal functions- slipped disk can irritate, compress, and damage the spinal nerve which in severe and irreversible
Depression
Weight Gain
Osteoarthritis Pathophysiology
Non-inflammatory degenerative joint disease that affects the whole joint. Cartilage at the ends of bones wears down. Caused by repetitive movements and is not systemic. Occurs gradually and worsens over time. Most commonly affects the hands, neck, lower back, knees or hips.
Osteoarthritis Signs and Symptoms
- Pain, stiffness and tenderness in relation to activity and weather.
- Limited ROM especially after rest.
- Crepidus when joint moves
- Numbness and tingling which indicate bone
changes that interfere with nerves.
- Enlarged finger joints Heberden's or Bouchard's
nodes.
- Raynaud's phenomenon of the hand
- Shiny, taut skin with or without nodules
Osteoarthritis Diagnosis
X Rays- show cartilage loss specifically, joint damage and spurs. (Spacing between bones decreases as cartilage degrades) Also identify fluid build up.
MRI- soft tissue damage and changes in bone density. Used for tracking progression (cartilage, tendons, ligaments).
Blood and urine- Mostly used to rule out other forms of arthritis.
Joint fluid analysis- aspiration of synovial fluid from joint space.
osteoarthritis medications
Tylenol and/or narcotics, NSAIDs
Cortisone and lubrication injections
Vitamin D, phosphorus, calcium, selenium, proteins, and iron are basic needs for joints
Celebrex
Occasionally joint replacement surgery
Osteoarthritis Treatment
Physical therapy
Exercise
Weight Management
Vitamin D and Calcium
Ice packs and heating pads
Assistive devices
Joint taping
Osteoarthritis Complications
Sleep disruption
Brittle bones, contractures, muscle weakness, atrophy and foot drop.
Weight Gain
Gout because of biuldup of uric acid crystals
Chondrocalcinosis is a build up of calcium crystals due to osteoarthritis, which resembles gout.
Osteoarthritis Client Teaching
Maintain weight
Exercise
Increase Vitamin D and Calcium
Heat and cold for pain management,
Avoid repetitive bending and stress on joint.
Capsaicin/ OTC creams
Assistive devices and taping joints
Osteomalacia Pathophysiology
- The adult counterpart of rickets.
-Metabolic disease in which the patient has inadequate mineralization of bone and a defect in the bone building process.
-Typically caused by a deficiency of vitamin D, Calcium or phosphorus.
-Can also be caused by celiac disease, chronic pancreatitis, renal disease, lactose intolerance and certain medications.
-Soft bones are more likely to bow or fracture

Osteomalacia is not the same as osteoporosis, another bone disorder that also can lead to bone fractures. Osteomalacia results from a defect in the bone-building process, while osteoporosis develops due to a weakening of previously constructed bone.
Osteomalacia Signs and Symptoms
Early in the disease there may be no symptoms. Muscle weakness and dull/achy bone pain, decreased ROM and unsteady gait.
weakness and achy bones
Numbness around the mouth
Numbness of the arms and legs
Spasms of the hands or feet

o Patient presents a history of generalized skeletal pain and tenderness without a history of an injury including back pain, pain in the ribs, feet, hands, and hips. Patient may be waddling
Osteomalacia Diagnosis
blood: serum calcium, phosphate, alk-phos, parathyroid hormone, Vit D, bun, and creatinine
x-ray and bone density scan

- X-Ray, blood and urine to detect vitamin D deficiency, bone biopsy (not usually done).
Osteomalacia Medications
Replenishing low levels of vitamin D and Calcium through supplementation and sun exposure. Treating any underlying disorders that may be causing the deficiencies.
Osteomalacia Complications
Fracture of the bones
Widespread bone pain, especially in the hips
Skin integrity due to impaired perfusion, Impaired physical mobility, bone cell mineralization problems.
Osteoporosis Pathophysiology
The most common bone disease, Osteoporosis is a progressive and chronic. It is systematic and caused by low bone mass and bone tissue deterioration. This break down leads to fragile and brittle bones; making them more susceptible to fractures. In healthy bones, the relationship between absorption and bone formation is equal. In osteoporosis, there is an imbalance. The body can't maintain homeostasis, the bone becomes less and less and the ratio is uneven.
Osteoporosis Signs and Symptoms
early shows no signs and symptoms, later = back pain, fractured or collapsed vertebrae, loss of height, kyphosis, compressed fractures
Osteoporosis Diagnosis
Dual X-ray absorptiometry (DXA): most common, uses the lumbar spine and hip

Quantitative Computerized tomography (QCT): used if pt has lots of arthritis in back, which makes DXA less reliable; uses standard CT scanner.

Lateral radiographs: thoracic and lumbar spine used.
increased creatinine, decreased calcium, increased TSH, bone density: -2.5 or lower
Osteoporosis Teaching
reposition every 2 hr or as needed, ROM, assist with transfer and ambulating, encourage exercise, balanced diet. More common in women.
Osteoporosis Medications
- Alendrontate: take in am, empty stomach with water. Remain upright for 30 min
- Calcium & Vitamin D Supplementation; -
- Bisphosphonates- increase bone mass and reduce fractures
- SERMs - selective estrogen receptor modulators
- Calcitonin - naturally occurring hormone, can slow rate of bone loss
- Raloxifene - acts like estrogen, reduces fractures, can increase risk of blood clots and hot flashes
- Parathyroid Hormone or teriparatide- helps body build new bone faster than the old bone is broken down
- Testosterone for men- increase bone mass
Osteoporosis Treatment
- Weight-bearing and strengthening exercises -
walking, jogging, resistance.
- Vitamin D and Calcium supplementation
- .Screening for bone density if age 65 or older.
- Drink moderately and no smoking.
Osteoporosis Complications
Fractures: most commonly: hip , wrist, and spine
Side Complications: UTI's, Blood clots in legs or lungs, pneumonia, and bedsores
Mobility issues
Joint stiffness
Chronic pain and weakness
Dental disease: due to many medications used to treat osteoporosis
Osteopenia
Low bone density - the step between normal bone density and osteoporosis
Osteosarcoma Pathophysiology
Bone tumor that can occur in any bone, but usually occurs in the long bones near metaphyseal growth plates. The most common bones are femur, tibia, humerus, skull/jaw, and pelvis.
Osteosarcoma Signs and Symptoms
Pain - Pain in affected bone, worse at night, increases with activity

Swelling - May start weeks after pain develops. May feel like a lump or mass

Bone fractures - Osteosarcoma can weaken the bone it develops in and can cause fractures
Osteosarcoma Diagnosis
Imaging tests - X-ray, MRI, CT, Bone scan, PET

Biopsy - Only certain way to diagnose osteosarcoma. Needle biopsy or surgical biopsy.

Lab tests - Pathology for biopsy

Blood tests - Helpful after diagnosis if disease is more advanced than appears
Osteosarcoma Medications
Surgery: amputation, bone grafting, wide local excision),
Chemotherapy: methotrexate, carboplatin, cisplatin, doxorubicin, and ifosfamide
Radiation Therapy:
Osteosarcoma Teaching
Client teaching will include when to seek medical attention for a possible advancement in your disease. If you experience any of the following, you will need to contact your physician immediately:
Osteosarcoma Complications
Bone fractures may occur
Limited range of motion
Limping from pain and discomfort
Swelling, Tenderness and Redness at the site
Limb Removal
Spread of Cancer to Lungs
Side Effects related to Chemotherapy
Paget's Disease Pathophysiology
The second most common type of bone disease, after osteoporosis.

Most commonly affecting older males and causing thickening and hypertrophy of the long bones and deformity of the flat bones

Normal bone remodeling: New bone is formed and bold bone is absorbed

Paget's disease: New bone is placed where it is not needed and old bone is removed where it is needed.
Paget's Disease Signs and Symtoms
Most of the time no symptoms, but if there are the most common is bone pain.

Mental changes may occur due to compression of the spinal cord- known as small hat syndrome
bone pain, joint pain, stiffness, may be severe and constant, other signs include deformities, enlargement, fractures, headaches, hearing loss, back pain.
Paget's Disease Diagnosis
X-ray, bone scan or Alk-phos blood test

Bone biopsy: rarely done.
Paget's Disease Medications
- Bisphosphonates (osteoporosis drugs) are the most common treatment for Paget's disease
- Calcitonin (Miacalcin), a naturally occurring hormone
- Alendronate or Cholecalciferol to help relieve pain and keep disease from progressing
- Calcium supplements
Paget's Disease Treatment
Surgery:
Total knee or hip replacement
Help fractures heal
Replace joints damaged by severe arthritis
Realign deformed bones
Reduce pressure on nerves

Paget's disease of bone often causes the body to produce too many blood vessels in the affected bones, increasing the risk of serious blood loss during an operation.
Paget's Disease Complications
Osteoarthritis.
Broken bones or fractures.
Nervous System problems.
Hearing loss, tinnitus, headache, dizziness, trouble with walking and balance and numbness in an arms or leg
Heart Failure.
Bone Cancer (osteogenic sarcoma).
Kidney stones and/or calcium deposits
Paget's Disease Teaching
Bisphosphonates don't cure, but can help slow progression of disease, important to stick to medication regiment. More common in men
Rheumatoid Arthritis Pathophysiology
Systemic autoimmune disease involving chronic inflammation of the joints and surrounding connective tissue. There is no cure and is more common in females.
Rheumatoid Arthritis Signs and Symptoms
Joint pain, deformity, loss of function, fever, fatigue, weakness, weight loss. RA usually seen in fingers, wrists, elbows, ankles and knees
Rheumatoid Arthritis Diagnosis
Blood tests:
Erythrocyte sedimentation rate (ESR or sed rate), C-reactive protein (CRP): test for inflammation.
Rheumatoid factor and anti-cyclic cirtullinated peptide (anti-CCP) antibodies

Imaging:
X-Ray, MRI and Ultrasound
Rheumatoid Arthritis Treatment
DMARDSs - Disease-modifying antirheumatic drugs like methotrexate and sulfasalazine, NSAIDs, Prednisone, Celecoxib, Abatacept and infliximab.

Alternative medicines: Fish oil, plant oils, tai chi

Surgery: to help repair joint damage Synovectomy,
Tendon repair, Joint fusion, Total joint replacement
Rheumatoid Arthritis Complications
Osteoporosis
Rheumatoid nodules
Dry eyes and mouth
Infections
Carpel tunnel syndrome
Hardened and blocked arteries
Inflammation and scarring of the lung tissue
Lymphoma
Rheumatoid Arthritis Teaching
Rest when needed
Use ice and heat to decrease swelling and pain
Diet, Weight, Excercise
Do not smoke
Get physical and occupational therapy as directed
Crutches, cane, walker
Rheumatoid Arthritis vs Osteoarthritis
Rheumatoid arthritis is autoimmune and is always on both sides. May begin at any time, rapid progression, joints are painful/swollen/stiff.

Osteoarthritis is due to wear and tear, and is only on a specific joint. OA=One Arm. Occurs later in life, slow progression, joints ache and are tender with little to no swelling
R.I.C.E.
o Rest, ice, compression, evaluation
o No longer than 30 minutes, check every 15 min, wait at least 1 hour between applications
o Check for erythema, cyanosis, or blanching
Scoliosis Pathophysiology
Scoliosis is condition that causes side to side curving of the spine. For example, one hip or one shoulder may stand higher than the other. This is a progressive condition, so if it is left untreated it can cause major complications and chronic pain due to the constant pressure on the nerves and spinal cord. More common in girls.
Scoliosis Signs and Symptoms
"S" curve of the spine - uneven shoulders and uneven waist.
Scoliosis Diagnosis
X-ray or MRI
Scoliosis Treatment
Observation until skeletal muscle maturity has been achieved.

When it's needed due to severity: Bracing - painful, time consuming, self image affected.

The younger the age, the more likely for future curvature

Surgery and Exercises also options for treatments
Pain and inflammation medication therapies
Scoliosis Goal of Treatment
Straightening of spine, increased self esteem, and pain management if necessary. Often goal of surgery is simply to allow a child to be able to sit upright in a wheelchair.
Scoliosis Complications
Breathing problems may occur in severe cases
Low back pain or persistent pain
Lower self-esteem
Spinal infection after surgery
Spine or nerve damage from an uncorrected curve or spinal surgery
Curvatures worsen as child ages.
Scoliosis Teaching
Most of the time the cause is unknown, or idiopathic. No one did anything wrong to cause scoliosis, and it can't be prevented.

Scoliosis usually occurs in early adolescence and becomes more noticeable during a growth spurt.

Girls and boys are affected equally by idiopathic scoliosis, but girls are more likely to develop curves big enough to require treatment.
Immobility on the GI system
Decreased motility/peristalsis: get them walking, increase fiber and fluids
Immobility on DVT formation
Assess with Homan's sign - passively dorsiflex the foot feeling for clonus with slight involuntary pushing, while asking if patient has pain in the calf. Positive=extreme pain with or without clonus means DVT.

Do not massage or elevate.
Immobility causing decreased muscle mass and strength:
ROM is decreased, atrophy & contractures

To prevent, do ROM exercises, turning, bring in PT and nutrition
Immobility causing stasis of bronchial secretions
Bronchial stasis, atelectasis; educate the client, use incentive spirometer, deep breathing technique and coughing exercises/hold cough
Immobility on Orthostatic hypotension
Get up slowly, sit before standing, increase fluids
Immobility on decreased cardiac contraction
Decreased contractibility, blood pooling in distal areas; monitor vitals, promote activity, elevate the feet, turn patient onto left side, use TED hose, SCD's
Immobility on pressure ulcers
Skin breakdown; do skin assessments, turn and move, watch bony prominences closely
Immobility on urinary stasis
Incomplete bladder emptying, dehydration, UTI; increase patients fluids and encourage them to empty bladder fully
Psychological effects of immobility
monitor for signs of depression, promote activity, create achievement goals, encourage support groups, validate their feelings
Immobility of the Integumentary System
- Pressure
- Shearing
- Bony prominences
- Pressure ulcers
Immobility of the Respiratory System
Decreased respiratory movement resulting in atelectasis, hypostatic pneumonia, and decreased cough response.
Immobility of the Cardiovascular System
- Orthostatic hypotension
- Less fluid volume in the circulatory system
- Stasis of blood in the legs,
- Diminished autonomic response,
- Decreased cardiac output
- Increased oxygenation requirement
- Increased risk of thrombus development.
- Deep Vein Thrombosis
Immobility of the Metabolic/Endocrine System
- Decreased appetite and altered nutritional intake, - Decreased protein - muscle and weight loss
- Alterations in calcium/fluid/electrolytes, -
- Reabsorption of calcium from bones
- Decreased Metabolic Rate
- Negative Nitrogen Balance
- Negative Calcium Balance
Immobility of the Genitourinary System
- Urinary Stasis / Retention
- UTI
- Renal Calculi
Immobility of the Gastrointestinal System
- Decreased peristalsis
- Decreased fluid intake
- Constipation/fecal impactions/diarrhea
- Anorexia
Immobility of the Musculoskeletal System
- Decreased muscle endurance/strength/mass
- Impaired balance
- Atrophy of muscles
- Decreased stability
- Osteoporosis
- Contractures
- Foot drop
- Altered joint mobility
Immobility effect on the Neurological System
Changes in emotional status: depression, alteration in self-concept, anxiety, behavioral changes: withdrawal, altered sleep/wake pattern, hostility, inappropriate laughter and passivity, altered perception, ineffective coping.
Prevention of Immobility
- Turning the client every 2 hours to prevent ulcers
- Use assistive devices to help them get out of bed and to move around
- Perform ROM
- Helping the client to use the bathroom
Bone Functions
- Enable movement
- Protect vital organs
- Store minerals
- Blood production
- Support body structure
- Provide form
Aging and Muscles
- Lean muscle mass decreases
- Osteopenia - bone loss
- Muscle contraction time is decreased
- Fatigue often increased
- Endurance decreased
- Ligaments and tendons lose elasticity/resiliency
- With trauma or repetitive stress, ligaments and tendons shorten - results in stiffness, loss of flexibility and ROM
- During the reparative phase, calcium can be deposited in muscle, tendon and ligamentous structures, creating pain and further decreasing function.
Malabsorption/Celiac Disease Pathophysiology
Autoimmune disorder that causes gluten to damage to small intestines. Gluten can be found in wheat barley and rye.
Malabsorption/Celiac Signs and Symptoms
Diarrhea, fatigue, weight loss, bloating and anemia, Orthostatic hypotension, abdominal distention, hyperactive bowel sounds, pallor, ecchymosis, peripheral edema.
Malabsorption/Celiac Diagnosis
If you start a gluten free diet before your test, it may alter your results. Serology testing looks for antibodies in your blood. Elevated levels of certain antibody proteins indicate an immune reaction to gluten.
Malabsorption/Celiac Treatment
Diet - barley, wheat and rye free

Gluten-free to stop progression of celiac disease and malabsorption

Lactose-free to treat lactase deficiency

Dietary supplementation and Vitamin B12 injections
Malabsorption/Celiac Complications
Developmental delays and cognitive impairment
Anemia
Gallstones or Kidney stones
Osteoporosis or Osteomalacia
Itchy/blistery skin rash
Damage to dental enamel or mouth ulcers
Headaches and fatigue
Nervous system injury
Joint pain
Reduced functioning of the spleen
Acid reflux and heartburn.
Constipation Pathophysiology
Constipation is broadly defined as an unsatisfactory defecation characterized by infrequent stools, difficult stool passage or both
Constipation Signs and Symptoms
Lower abdominal discomfort
A sense of incomplete evacuation (the feeling that you still have to "go")
Straining to have a bowel movement
Hard or small stools
Rectal bleeding and/or anal fissures caused by hard stools
Constipation Diagnosis
Sigmoidoscopy or colonoscopy
Colorectal transit studies-Colorectal transit studies are tests that show how well stool moves through your colon.
Anorectal function tests- Anorectal function tests can show problems in your anus or rectum.
X-Ray, MRI or CT scan to check for obstructions
Constipation Treatment
Exercise, high fiber diet, drink more fluids

Medications:
Bulk-forming agents- Citrucel, FiberCon
Osmotic agents-Milk of Magnesia, Miralax
Stool softeners- Colace, docusate
Lubricants-Fleet, Zymenol
Stimulant laxative- Dulcolax

Surgery
Constipation Complications
Hemorrhoids
Anal fissures
Rectal prolapse
Fecal impaction
Acute Abdominal Pain Pathophysiology
three major pathological processes, inflammatory, obstructive, and vascular, can produce acute abdominal pain.
Acute Abdominal Pain Signs and Symptoms
Fever.
Inability to keep food down for more than 2 days.
Any signs of dehydration.
Inability to pass stool, especially if you are also vomiting.
Painful or unusually frequent urination.
The abdomen is tender to the touch.
The pain is the result of an injury to the abdomen
Acute Abdominal Pain Diagnosis
blood and urine tests
X-ray, ultrasound, CT scan
Acute Abdominal Pain Treatment
Pain meds
Surgery
Antibiotics if infection related
Acute Abdominal Pain Complications
Peritonitis is a medical emergency caused by an infection in the abdominal cavity. This condition, which can result from a ruptured organ often causes sudden, severe abdominal pain, hardness of the abdomen, and fever.

Bleeding, Bloating, Changes in bowel habits, Fatigue, Fever, Constipation, Loss of appetite, Pain, Weight loss, Vomiting.
Appendicitis Pathophysiology
Inflammation of the appendix. When the appendix becomes inflamed or infected, rupture may occur within a matter of hours leading to peritonitis and sepsis.
Appendicitis Signs and Symptoms
Pain in the periumbilical area that descends to the right lower quadrant.
Rebound tenderness and abdominal rigidity
Low-grade fever
Elevated WBC
Anorexia, nausea and vomiting
Constipation or diarrhea
Appendicitis Diagnosis
Blood and urine tests
X-ray, CT scan or Ultrasound
Appendicitis Treatment
Surgery to remove the appendix. If your appendix has burst and an abscess has formed around it, the abscess may be drained by placing a tube through your skin into the abscess. Appendectomy can be performed several weeks later after controlling the infection.
Appendicitis Medications
Antibiotics for infection, pain relief and surgery to remove.
Appendicitis Complications
Ruptured appendix. A rupture spreads infection throughout your abdomen (peritonitis). Possibly life-threatening.

A pocket of pus that forms in the abdomen. Tube placed in abdomen to clear the infection.
Diverticulitis Pathophysiology
diverticulosis- is a herniation of the intestinal mucosa. This disorder can occur in any part of the intestine but is most common in the sigmoid colon.

diverticulitis- is inflammation of intestinal mucosa.
Diverticulitis Signs and Symptoms
Left lower quadrant abdominal pain that increases with coughing, straining, or lifting. Fever, gas, cramp like pain, abdominal distention and tenderness, blood in stools.
Diverticulitis Diagnosis
CT Scan, Barium, Colonoscopy, antibiotics, analgesics, and anticholenergics to reduce bowel spasms. Increased WBCs. Bulk forming laxatives, and possibly surgery.
Diverticulitis Treatment
Fiber diet containing no seeds, indigestible roughage, nuts or popcorn

Antibiotics, analgesics, and anticholinergics to reduce bowel spasms.

Bulk-forming laxatives

Surgery
Diverticulitis Complications
- Infection, Inflammation and Sepsis
- Abscess, which occurs when pus collects in the pouch.
- Blockage in your colon or small intestine caused by scarring.
- Peritonitis, which can occur if the infected or inflamed pouch ruptures, spilling intestinal contents into your abdominal cavity. Peritonitis is a medical emergency and requires immediate care.
Bowel Obstruction Pathophysiology
Intestinal obstruction is a blockage that keeps food or liquid from passing through your small intestine or large intestine (colon).
Bowel Obstruction Signs and Symptoms
Crampy abdominal pain that comes and goes
Loss of appetite
Constipation
Vomiting
Inability to have a bowel movement or pass gas
Swelling of the abdomen
Bowel Obstruction Diagnosis
X-ray, CT or Ultrasound
Air or barium enema
Bowel Obstruction Treatment
Intravenous (IV) line for fluids.
Nasogastric tube to suck out air and fluid and relieve abdominal swelling.
Catheter to drain urine
Low fiber diet for partial bowel obstruction
Surgery
Bowel Obstruction Complications
Tissue death and infection.
Crohn's Disease Pathophysiology
One of the most common types of inflammatory bowel disease - the other is Ulcerative Colitis. Bowel inflammation, irritation and swelling. Can affect any part of the colon, both the small and large intestines. Thickens the lining of the digestive tract causing fissures and ulcers.
Crohn's Disease Signs and Symptoms
Fatigue, weakness, fever, flatulence, nausea, diarrhea, abdominal pain that usually occurs in the right lower abdominal quadrant, weight loss.
Crohn's Disease Diagnosis
CT scan, X-ray, Barium enema, Colonoscopy, Biopsy, Occult blood.

Hemoglobin (Hb), hematocrit, WBCs, erythrocyte sedimentation rate, serum potassium, calcium, magnesium, and Hb levels

Vitamin B12 and folate deficiency may occur.
Crohn's Disease Medications
Corticosteroids, Immunosuppressant, Sulfonamides, Anti-inflammatories, Antibacterials and antiprotozoals, Antidiarrheal, Opioids, Vitamin supplements, Antispasmodics.

Surgery -- Indicated for acute intestinal obstruction colectomy with ileostomy
Crohn's Disease Treatment
Stress reduction

Avoidance of foods that worsen diarrhea such as raw fruits and vegetables.

Adequate caloric, protein, and vitamin intake, parenteral nutrition, if necessary

Reduced activity
Crohn's Disease Complications
Anal fistula
Perineal abscess
Fistulas of the bladder or vagina or to the skin in an old scar area
Intestinal obstruction
Perforation
Nutritional deficiencies caused by malabsorption and maldigestion
Ulcerative Colitis Pathophysiology
Autoimmune disease. Ulceration of the colon that causes inflammation of the digestive tract. Innermost lining of the large intestine that may lead to ulcers, which may bleed and interfere with digestion.

Exact cause unknown, may be related to an abnormal immune response in the GI tract, possibly associated with genetic factors.
Ulcerative Colitis Signs and Symptoms
Liquid stools with visible pus, mucus, and blood
Possible abdominal distention
Abdominal tenderness
Perianal irritation, hemorrhoids, and fissures
Jaundice
Joint pain
Ulcerative Colitis Diagnosis
Stool specimen to check for blood or pus, colonoscopy.
Ulcerative Colitis Treatment
Corticotropin and adrenal corticosteroids, Sulfasalazine, Mesalamine, Antispasmodics and antidiarrheals, Fiber supplements

Surgery --Treatment of last resort -- Proctocolectomy with ileostomy, Pouch ileostomy, Ileoanal reservoir with loop ileostomy, Colectomy (after 10 years of active disease).
Ulcerative Colitis Complications
Nutritional deficiencies, sepsis, anal fissure, anal fistula, abscesses, perforation of the colon, hemorrhage, anemia, toxic megacolon, cancer, coagulation defects, cirrhosis, ankylosing spondylitis, strictures, pseudopolyps, stenosis, toxemia, arthritis.
Ulcerative Colitis Client Teaching
Rest periods during exacerbations

Can cause developmental delays in children.

Ileostomy care if necessary.

Importance of diet change.
Irritable Bowel Syndrome Pathophysiology
Large intestines. No cellular change so can't detect with lab testing. Can be induced by stress or anxiety related and women are more commonly affected. A change occurs in bowel motility, reflecting an abnormality in the neuromuscular control of intestinal smooth muscle.
Irritable Bowel Syndrome Signs and Symtpoms
Chronic constipation and/or diarrhea
Lower abdominal pain
Small stools with visible mucus or pasty
Dyspepsia, Abdominal bloating, Heartburn, Faintness and weakness
Contributing psychological factors, such as a recent stressful life change.
Anxiety and fatigue.
Irritable Bowel Syndrome Diagnosis
Stool examination is negative for occult blood, parasites, and pathogenic bacteria.

Complete blood count, serologic tests, serum albumin, and erythrocyte sedimentation rate are normal.

Barium enema reveals colonic spasm and a tubular appearance of the descending colon.

Sigmoidoscopy may disclose spastic contractions.
Irritable Bowel Syndrome Medications
Anticholinergic, antispasmodic drugs, Antidiarrheals, Laxatives, Antiemetics, Simethicone, Mild tranquilizers, Tricyclic antidepressants
Irritable Bowel Syndrome Treatment
Reduce anxiety and stress

Dietary factors, such as fiber, raw fruits, coffee, alcohol, and foods that are cold, highly seasoned, or laxative in nature

Regular exercise
Irritable Bowel Syndrome Complications
Diverticulitis and colon cancer
Chronic inflammatory bowel disease
Urinary Tract Infection Pathophysiology
Infection of the urinary system; kidneys, bladder or urethra. More common in women.
Urinary Tract Infection Signs and Symptoms
Pain or tenderness over the bladder
Hematuria
Fever
Cloudy, foul-smelling urine
Mental changes
Urinary Tract Infection Diagnosis
Urinalysis, Ultrasound, MRI, CT scan to check for obstructions.
Urinary Tract Infection Treatment
Antibiotic - bactrum must be taken with water, analgesic for discomfort.

Sitz bath, warm compress, Cranberry juice, proper cleaning after toileting, wear cotton underwear, no bubble baths, wipe front to back
Urinary Tract Infection Complications
Damage to the urinary tract lining
Infection of adjacent organs and structures
Renal Calculi Pathophysiology
Crystals in urine that accumulate in the kidneys and cause stones.
Renal Calculi Signs and Symptoms
Extreme pain
Changes in frequency, color and smell
Hematuria (blood in urine)
Abdominal distention
Costovertebral tenderness on palpation, Tachycardia
Elevated blood pressure
Renal Calculi Diagnosis
Urinalysis, 24 hour urine collection, Xray, KUB (kidney ultrasound bladder), CT scan
Renal Calculi Medications
Percutaneous ultrasonic lithotripsy
Extracorporeal shock wave lithotripsy
Vigorous hydration (more than 3 qt [3 L]/day)

Antibiotics, Analgesics, Diuretics, Methenamine mandelate, Allopurinol (for uric acid calculi), Ascorbic acid, Nonsteroidal anti-inflammatory drug ketorolac (Toradol), Desmopressin (DDAVP)

Surgery: Cystoscopy, Ureteral stent, Percutaneous nephrostomy
Client teaching for renal calculi
prescribed diet and importance of compliance
drug therapy
ways to prevent recurrences
how to strain urine for stones
immediate return visit to hospital for fever, uncontrolled pain, or vomiting
Urinary Retention Pathophysiology
Ischuria - inability to completely empty the bladder. External sphincter does not open for release of urine or blockage of urethra.
Urinary Retention Signs and Symptoms
Increased urine volume and bladder distention
Back-flow to the upper urinary tract
Dilation of the ureters and renal pelvis
Pyelonephritis and renal atrophy
Urinary Retention Diagnosis
Urinalysis, blood urea nitrogen (BUN), creatinine, culture, occult blood
X-rays, CT or Ultrasound
Direct observation tests
Colonoscopy, cystoscopy, uroscopy
Bladder stress testing, urine flow studies
Urinary Retention Treatment
Treatment for urinary retention includes catheterization, treating prostate enlargement, and surgery.
Urinary Retention Complications
Complications include urinary tract infections (UTIs), bladder damage, and chronic kidney disease
Pyelonephritis Pathophysiology
Kidney infection. Bacteria reach the kidney by ascending from the lower urinary tract.
Pyelonephritis Signs and Symptoms
Fever and chills, costovertebral angle pain (flank pain), nausea and vomiting, urge/frequency, blood in urine, loss of appetite, fatigue, cloudy, dark, strong smelling urine. In elderly mental status changes.
Pyelonephritis Diagnosis
Urinalysis to detect bacteria and WBCs in urine. Gram stain, urine culture, CBC, ESR, C-reactive protein, blood culture, creatinine, BUN. Check for obstructions using ultrasound or CT.
Pyelonephritis Treatment
Antibiotics. Fluids ,antipyretic or analgesic for fever and pain. Narcotics are complimentary. Sometimes requires hospitalization.
Pyelonephritis Teaching
Encourage increased fluid intake, apply heating pad to lower back. Female - wipe from front to back, void every 2-3 hours. No NSAIDs.
Restraint Definition
Mechanical device/material/equipment such as cloth vests or side rails

Chemical restraint such as medication- sedatives and psychotropic.

Avoid when possible, use the lowest level of restraint available for the least amount of time needed
Restraint Rules/Regulations
One-on-one viewing of patient in restraints/seclusion, document episodes in detail and void when possible.

Remove restraints every 2 hours to provide skin care. Re-evaluation is every 4 hours.

Reapplication of restraints can be delegated to an AP.

Anew order for restraints must be given at least every 24 hours.
Body mechanics
Bend at knees, spread feet apart to lower your center of gravity (shoulder width apart) & broaden base support (greater stability and support), use leg/arm muscles to lift, not back, carry things close to you.
X-ray
Quick, painless test that produces images of structures inside your body, minimal risk of radiation exposure, bones show up white
Angiogram
X-ray of blood or lymph vessels with barium. Catheter inserted into vein and injects dye. Then watch to see where dye moves and if there is a blockage.
Arthrography
Injection of air or contrast medium into a joint, which is then examined using X-ray, CT or MRI
Bone scan
Nuclear medicine test uses small amount radioactive substance called a tracer, tracer injected into vein, areas where too much is absorbed or too little may indicate area of cancer.
CT Scan
Series x-ray images at different angles, computer then processes and creates cross sectional images of bones, vessels, soft tissues
MRI
Magnetic resonance imaging, powerful magnetic field, radiowaves and computer used to produce detailed pictures of inside the body.
Dual energy x-ray absorptiomentry
Preferred technique for measuring bone mineral density, mainly spine, hip, forearm, minimal radiation exposure.
Myelogram
Uses a contrast dye and X-rays or computed tomography (CT) to look for problems in the spinal canal, including the spinal cord, nerve roots, and other tissues.
Elimination Laboratory Testing
Urinalysis, blood urea nitrogen (BUN), Creatinine, Culture, Occult blood.

Glomular Filtration Rate - test to see if kidneys are functioning properly. Loss of volume can cause kidney failure. Unrelieved retention can cause kidney damage.
Elimination Assessment
TACO - Time, Amount, Character, Odor
Elimination Problem Prevention
Avoidance of environmental contamination
Regular toileting practices
Adequate Fiber
Regular exercise
Hydration
Osteomyelitis
Serious infection of the bone that often is difficult to treat, Can be acute or chronic. Chronic lasts longer than 3 months.

Periods of remission and exacerbations, pain, and soft tissue abscesses and draining wounds may occur in those with chronic osteomyelitis
Osteomyelitis Treatment
Pharmacology is 4-6 weeks of IV antibiotic therapy for acute, and 6-8 weeks of oral antibiotic for chronic. Localized wound debridement will be necessary.
Specimen collection
Always take the specimen to the lab to get evaluated.

Urine must be kept on ice for 24 hour urine collection.

Take stool immediately.
Elimination Problems
Control, Retention, Discomfort
Retention
An inability to completely empty the bladder. Can be caused by obstruction, inflammation & lack of nerve stimulation.
Consequences of Urinary Retention
Increased urine volume and bladder distention.
Back-flow to the upper urinary tract.
Dilation of the ureters and renal pelvis.
Pyelonephritis and renal atrophy.
Consequences of Bowel Retention
Retention of stool in the rectum.
Stool dries and hardens.
Constipation
Impaction
Controll
Loss of control can lead to skin breakdown, changes in daily activities and changes in social relationships.
Stress Incontinence
Stress incontinence happens when physical movement or activity — such as coughing, sneezing, running or heavy lifting — puts pressure (stress) on your bladder. Stress incontinence is not related to psychological stress.
Urge Incontinence
Sometimes referred to as " overactive bladder" or "spastic bladder," urge incontinence is an involuntary loss of urine that usually occurs when a person has a strong, sudden need to urinate.
Overflow Incontinence
is a form of urinary incontinence, characterized by the involuntary release of urine from an overfull urinary bladder, often in the absence of any urge to urinate.
Functional incontinence
is a form of urinary incontinence in which a person is usually aware of the need to urinate, but for one or more physical or mental reasons they are unable to get to a bathroom. The loss of urine can vary, from small leakages to full emptying of the bladder.
When to get a Colonoscopy
Screening at the age of 40. Screening for colon cancer for an average risk individual includes a colonoscopy every 10 years or a sigmoidoscopy every 5 years, in addition to a hemacult (blood in the stool) test every year.

History of colon cancer, polyps, or IBS.
When to get Occult Blood
A test whereby stool is examined for minute amounts of blood loss (possibly from polyps or cancer) by way of a chemical reaction resulting in a color change. While FOBT is not a test to examine the colon, it is recommended annually to individuals over age 50. If occult blood is found in the stool, a follow up colonoscopy will be necessary.
When to screen for Prostate Cancer
You should get a digital rectal exam and PSA test every year starting at age 45 to check for prostate cancer if you are African American or have a family history (father, brother, son) of prostate cancer.