week 4 & 5 & 6 principles med surg II

compression , elevation and joint extension are used to control
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ligaments hold articulating bones togetherwhile tendons connect muscle to bone; injury to either structure impairs movementweight baring activities , sex hormones, calcitonin, and calcium intakesupport bone formationinstruct on the importance of calcium ( 1,200mg) and vitamin D ( 600 IU) intake along with sources ( Low fat milk,yogurt,cheese) ;adults over 50 require 800-1000 IU of vitamin Dcalcium helps to maintain bonewhile vit D is essential for calcium absorptionexcessive cortisol and thyroid hormone production increase bone resorption andcould lead to osteoporosisestrogen stimulates osteoblastic (bone formation) activity andinhibits osteoclastic (bone resorption) activity ; thus menopause increases the risk for osteoporosisvertebral fractures and a loss in vertebral cartilage typicallyresult in a loss in heightlow molecular weight heparin does not requirelaboratory monitoring of bleeding timesinstruct clients to perform coughing and deep breathing every 2 hoursto prevent atelectasisfiberglass casts are light , water resistant and dry within 30 minuteswhile plaster casts are heavy, can not get wet and take up to 3 days to completely dry ; both casts give off heat when drying so prepare client for this feelingskin maceration could occur ifcasts that cover the heels and elbows are allowed to get wethandle plaster casts with the palms of the hands to preventindents which could cause skin breakdownplace plaster casts on a firm surface while drying andavoid placing on plastic ( heat is retained and drying is impaired)elevate the limb above the level of the heart for the first 24-48 hours followingthe application of a cast, splint, or brace, to limit edemareport signs of impairedneurovascular status ( pallor, pain, paralysis, paresthesia, polar, pulselessness) immediatelydetermine change sin arterial blood flow by assessing forpain, pallor , paresthesias, paralysis, polkilothermia/polar, pulselessness and capillary refillpain, tightness, and a localized feeling of heat over a bony prominence, in the setting of a cast, could suggesta pressure ulcercompartment syndrome is a medical emergency and must be identified immediately; pressure within the muscle compartment or cast increases as perfusion to the area decreaseswhich could lead to necrosis and irreversible neuromuscular damagecompartment syndrome is marked bysevere unrelieved pain that worsens with movementclassic signs of DVT includeedema to the extremity, warmth , tenderness or fullness in the legprevent pulmonary embolism or DVT by usinganticoagulants, anti-embolism stockings and/or sequential tedsorthopedic surgery increases the risk ofDVT and infectionlow molecular weight heparin -enoxaparin- may be prescribed to preventvenous thromboembolismexternal fixators increase the risk for osteomyelitis soperform pin site care using aseptic technique -use chlorhexidine 2mg/ml solution unless contraindicated -perform pin care bycleaning with a circular motion from the inner to the outer region and cleaning each site separatelyprovide patient controlled analgesia to help reducecomplications related to painavascular necrosis can occur followingsome fractures due to loss of blood to the bone so the clients must be closely monitored for increased pain and decrease in mobilityprevent hip dislocation following total hip arthroplasty byabducting legs, prevent internal rotation of leg, turn to the unaffected side while maintaining abduction , avoid flexing the hip more than 90 degrees , keep leg in a neutral position , keep head of bed < 60 degrees , and avoid crossing the legsinstruct the client following total hip arthroplasty to prevent dislocation byfollowing hip precautions for a minimum of 4 months -used raised toilet seats , avoiding crossing the legs, no bending at the waste, and sit with hips higher than the knees-signs of hip dislocation includelimb shortening , acute groin pain, external or internal rotation, limb deformity , crepitus and reduced mobilitysurgical drains help to reduce pain bylimiting fluid accumulation and hematomaprevent disease from immobilization byinstructing the client on isometric exercisespressure on the back or side of the knee increases the risk forperoneal nerve damage and could result in foot drop - neurovascular assessments is a priority -immobility increases the risk forpneumonia , decubiti , constipation and DVTcontinuous passive motion devices promote movement followingtotal knee arthroplasty; the rate and joint extension and flexion are ordered by the surgeonflexor muscles are stronger than extensor musclesso the risk for flexion contractures increases when voluntary muscles control is lostprevent flexion contractures to the knee byavoiding pillows behind the knee or not using the knee gatch on the bedtraction helps to maintain bone alignment andto decrease pain from muscle spasmscare for the client with traction byensuring traction is continuous and uninterrupted , weights hang freely , knots are away from the pulley and the clients body is in proper alignmentprevent skin breakdown from skin traction byre positioning - while maintaining a supine position- , using pressure relieving mattresses, inspecting the skin three times a day and assessing from tendernessinstruct on proper body mechanics and strategies to prevent low back pain;weight reduction , strengthening exercises , lift objects using a wide base of support and use the leg and arm muscles - not the back - bend at the knees, avoid twisting the back , keep objects close to the body , push don't pullconditions that increase PTH secretion could contribute tobone demineralization and pathological fracturesbone tumors can weakenbone and contribute to pathological fracturesdual energy x-ray absorptiometry (DEXA) scan is used tomeasure bone density and diagnose osteoporosis - T score of -2.5 -long term antibiotic use increases the risk forsuper infections - oral or vaginal candidiasis , pseudomembranous colitis -biophosphonates - alendronate- inhibitosteoclastic activity and promote calcium deposition into boneosteonecrosis of the jaw is a potential risk withbisphosphonates so encourage yearly dental evaluationsinstruct patients to take oral bisphosphonates on an empty stomach , with 8 ounces of waterand to sit upright for at least 30-60 minutes - risk for esophageal ulcers -provide non-pharmacological pain management strategies such asphysical modalities , mind-body methods, biologic and energy based therapieswhen osteoclastic activity is greater than osteoblastic activitybones become porous and brittle - osteoporosis -osteomyelitis weakens the bone andtypically requires weight-bearing restrictionsosteomyelitis is marked bypain, swelling, warmth , elevated erythrocyte sedimentation rate, and leukocytesosteoporosis could lead topainful vertebral compression fractures and reductionthin, Asian or Caucasian women have the greatest risk forosteoporosispain stimulates the sympathetic nervous system and could result inan increase in blood pressure, heart rate and respiration'sa comprehensive pain assessment includesduration, -when it started - type - includes intensity, associated factors, influencing factors -what makes it better or worse and locationmanage noceceptive pain withlocal anesthetics, non opioids or opioidsprevent flexion contractures following amputations; prone position to prevent hip contractures following an above the kneeand supine position without pillows under the knees following a below the knee amputation - except first 24 hours-extend the limb following an amputation to prevent flexion contractures , keep legs close together and avoid hip or knee flexion;instruct on not sitting for prolonged periods of time - hip flexion-apply uniform compression to the amputation toreduce limb edemafractures are marked bycrepitus , deformity , edema , loss of function, limb shortening and paincomplications following fractures includehypovolemic shock( hemorrhage) , fat embolism ( long bones) and compartment syndromeclinical manifestations of pulmonary embolism consist ofchest pain, cough , dyspnea, hypoxemia, tachycardia, tachypnea, petechiae, and restlessnessobtain an ABG ifconfusion , restlessness, and irritability occur in the setting of a fractureencourage range of motion to the fingers and shoulder followinga wrist fractureavascular necrosis may follow joint dislocation's if the bone injury impairsperfusion and leads to unresolved ischemiause opioids to manage phantom limb pain,which is actual pain that is felt after an amputationtreat tissue injury with rest , ice,compression and elevationduring the first 72 hours to limit inflammation and promote healingbuck's traction helps to decrease pain and muscle spasmsand immobilize fracturenatural ( innate) immunity arethe parts of your immune system that you are born withtumor markers ( fro ex: CEA, CA 125) are monitored to helpdetermine the effectiveness of chemotherapyeducate on avoiding carcinogens ( smoking ) limitingalcohol and caloric intake and increasing activity level, using sunscreen with a minimum spf 5 , limiting sun exposure and using condomsscreen for cancer; annual mammogram starting at age 40, colonoscopy at age 50 every 10 years ,annual fecal occult blood test , at age 50, prostate specific antigen at age 50, pap test every 3 yearsstaging of a tumor is done tocommunicate the size of the tumor, if lymph nodes are involved and if there is metastasisextravasation of a vesicant could result in tissue necrosisso never use the hand or wrist and prevent extravasation by confirming patency of I.V deviceseratonin receptor blockers ( ondansetron, granisetron) , dopaminergic receptor blockers ( metoclopramide, prochlorperazine) ,bland foods and small, frequent meals are used to decease nausea and vomitingmylosuppression , induced by chemotherapy , results in pancytopenia andincreases the risk for infection , bleeding and fatiguesome chemotherapy agents could induce hemorrhagic cystitis which could lead to a life threatening hemorrhage soprotect the bladder with I.V hydration and diuresissuspect an increase risk for extravasation if resistance is met while flushing I.V catheter ,blood return is absent or there is burning pain or swelling to the sitefollwing a extravasation ,neurovascular assessments of the affected extremity should be performedgraft verses host disease could presentblistering skin rash, diffuse inflammation to the G.I tract with massive diarrhea or hepatomegalysepsis and bleeding are major complications followingbone marrow transplantation until new marrow engraftment occursbeing immunocompromised reduces clinical manifestations ofinfection so a temp >100.4 for an hour is significant and should be reportedreduce the risk for infection by implementing neutopenic precautions ( WBC <1,000)avoiding rectal or vaginal procedures , using electric razors , avoid using stagnant water and reduce exposure to sources of infectionadvise the client with stomatitis to avoid mouthwashes that contain alcohol or tobacco becausethey dry the mucosa , use a soft toothbrush , avoid rough , hot or spicy foods and remove dentures unless eatingimprove oral intake in the setting of nausea byserving cold foods since they are less odorous , encouraging oral hygiene , provide small frequent meals, and make sure pain managedcommon signs of thrombocytopenia includepetechiae and eccymosisavoid rectal route for medication administration for patients whoare thrombocytopenicsigns of superior vena cava syndrome includeincreased dyspnea, facial and neck edema, jugular vein distention, visual disturbances, and headachehypercalcemia is an oncologic emergency and is marked by a progressive change inlevel of consciousness , hyporeflexia, ileus, constipation, polyuria, and polydipsiaclinical manifestations of tumor lysis syndrome includehyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia; bradydysrhthmias, wide QRS complexes, tented T waves, tetany, seizures, and flank painpreventing renal failure and achieving electrolyte balance is a priority in the setting oftumor lysis syndromemalignant neoplasms invade other areas ( metastasis ) and branch offwhile benign tumors do not metastasizecancer develops when the immune system fails to recognize anddestroy abnormal cellsmonitor for hypersensitivity reactions which could be acute -within 15-30 minutes -or delayed -several courses after the medication - and stop the medication immediatelycolony - stimulating factors stimulate RBC production decreasing the need for blood transfusions -erythropoietin-or stimulate neutrophil production to decrease the risk for infection ( neupogen)provide patient controlled analgesia to help reducecomplications related to painmethotrexate contributes to folic acid deficiency and results in cell deathis typically prescribed with folic acida comprehensive pan assessment includesduration( when it started) type ( intensity , associated factors) influencing factors ( better or worse) and locationprovide non-pharmacological pain management strategies such asphysical modalities , mind body methods, biologic and energy based therapiesprevent dislodgement of intracavitary low dose radiation by maintaining the client onbed rest, in a private room , provide low-residue foods , give anti-diarrheal agents to prevent dislodgement of device, and insert a foleyradiation safety precautions ( brachytherapy) includelimiting time with the client, wearing dosimeter badges, keeping pregnant staff or visitors and children out of the room, limiting visits to 30 minutes and keeping 6 feet away from the radiation sourcekeep a lead container in the room in casea radioactive device dislodgestreat wet desquamation by leaving blisters intact and notify primary care provider , avoid frequent washing of the area because ofincreased irritation, obtain an order for a cream or ointment and use a nonadhesive pad over the areareduce the risk for infection with elderly ; drink plenty of fluids unless contraindicated, use lotion, assessing for signs of skin breakdown, change incontinence pads frequentlyvoid after intercourse, pneumococcal and influenza vaccine , cough and deep breathing exercises , sit up while eatingCD4 cells ( helper T cells) stimulatethe immune system and help to destroy organismsnatural immunity allows the body to resist infection by responding to foreign substances with WBC,an inflammatory response and chemicals ( all are used to remove or destroy pathogens )acquired immunity is the type of response that allows the body torespond to pathogens either actively or passivea vaccine or prior exposure to a disease provides active immunitysince your immune system will actively generate antibodies in response to the antigenbreastfeeding and immune globulin are types of acquired immunity since they containantibodies that are given to you . ( note you have immediate protection although the duration of protection is shorter than active immunity )immunodeficiency is marked by frequent infections that could be severe,infections from organisms that do not typically cause a problem, poor treatment response and chronic diarrheaall increase in neutrophils indicates bacterial infection whilean increase in lymphocytes indicate a viral infection ( although lymphocytes are also elevated in some bacterial infections as well)protein deficiency increases risk forinfectionthe reduction in T cells increases the risk foropportunistic infectionsinstruct on factors that increase the risk for infection;excess alcohol consumption , poor nutrition, smoking, glucocoticosteroids , and diabetes mellitusnotify the provider if a culture and sensitivity reveals that theorganism is resistant to the prescribed antibioticredness , swelling , tenderness, purulent drainage fever and chills and an elevated WBC count are classic signs ofinfectionmetformin should be stopped 48 hours before and after theadministration of iodinated contrast mediumacute respiratory failure is manifested by adecrease in Pa02 ( <50 mm hg) and an increase in paco2 (>50mm/hg) with respiratory acidosisdiarrhea could lead tometabolic acidosis and electrolyte imbalances ( specifically hypernatremia and hypokalemia)encourage clients who have diarrhea to avoid foods that stimulate peristalsis ( fiber rich foods, lactulose)and avoid nicotine which could also stimulate bowel motilitya positive human immunodeficiency virus test shows thatthe individual has antibodies and has been infected with the virusinstruct on the use of latex condoms to decrease the risk ofautoimmune deficiency , lambskin is not effectivehuman immunodeficiency virus is primarily transmitted throughblood , breast milk, semen and vaginal secretions and is also found in urine , saliva and tearshuman immunodeficiency (virus targets CD4+ cells ( T cells) and impairsimmunity which could lead to life threatening opportunistic infectionstypical clinical manifestations of H.I.V arefever, chills, night sweat , weight loss, lymphadenopathy and fatiguepneumocystis pneumonia is caused by the bacteria P. jiroveci and isthe most common life threatening infection that individuals with autoimmune deficiency will encounteroral candidiasis could make swallowing difficult andpainful and could extend from the mouth to the esophagus and stomach if left untreatedautoimmune diseases increase the risk for cancerkaposi's sarcoma and non hodgkins lymphomacytomegalovirus attacks the retina and is the leading cause ofblindness when individuals have autoimmune deficiencyassess nutritional status bymonitoring serum albumin, protein and transferrin level along with food intaketypical clinical manifestations of H.I.V arefever, chills , night sweat , weight loss, lymphadenopathy and fatigueimplement standard precautions for all clients to help decreasethe risk of bloodborne pathogens -hepatitis B , H.I.Vclients with pneumonia may present withdyspnea , tachypnea , crackles, tachycardia , labored breathing, dullness on percussion, and a decrease in oxygen saturation'strimethropin -sulfamethoxazole (TMP-SMZ) is used asprophylactic therapy to prevent pneumocystis pneumonia and is started with T-cells count less than 200 cells/mm3antifungal agents ( clotimazole, ketoconazole or fluconazole) can be used totreat oral candidiasisherpes simplex or zoster is typically treated with anantiviral medication ( acyclovir, famciclovir or valacyclovir)encourage the client to rest before meals help tominimize fatigue which could decrease appetiteCAM extends beyond the use of nutritional therapies and includesspiritual therapy , guided imagery , positive affirmations, reflexology and yogahypersensitivity reactions ( type I-IV) typicallyoccur after re-exposure to an allergen that the body has been sensitized toanaphylaxis is a life threateningsudden allergic reactionwhen the body mistakenly creates antibodies that attack the tissue of the host ( type II hypersensitivity )diseases like myasthenia gravis can occureosinophils are typically elevated in anactive allergic responseskin testing for allergies shouldnot be performed if bronchospasms are presenta hypersensitivity reaction (type III) occurs when the immune complex isdeposited into tissue or vascular endothelium ( rheumatoid arthritis , systemic lupus erythematosus )the radioallergodorbent test (RAST) uses serum to measure allergen-specific IgE whichdecreases the risk of systemic reactiondepending on the severity and system involved,anaphylaxis could result in angioedema, anxiety, bronchospasms, cough, dyspnea , dysphagia, dizziness, edema, hypotension, pruritis and wheezingeducate on the importance of informing health care providers and wearing medical IDwhen clients have allergieshistamine contributes to bronchspasms , wheezing , pruritis and localized edemawhile leukotrienes trigger bronchial constriction; increase in mucus production and skin reactionsthe formation of immune complexes istypically followed by phagocytic clearingafter immune complexes are formedphagocytic clearing typically followsprepare to give antihistamines ( diphenhydramine) for mild allergic reactions( urticaria, pruritis , flushing) epinephrine , corticosteroids and vasopressors for severe reactions ( bronchospasms, hypotension, shock, laryngeal edema)antihistamines (H1 Blockers ) prevent histamine from binding to receptor sites thuspreventing the development of new symptoms ( this drug does not stop the release of histamine from mast cells so administer early)allergen injections could induce systemic reactions and should only be given whereepinephrine is readily availabletreatment for anaphylaxis includesepinephrine, antihistamines, and corticosteroidsinstruct clients who are prescribed an EPIpen auto injector toseek medical attention following the use of this medication since a rebound or delayed reaction could occur several hours latereducate on the importance of never injecting an EpiPen into thebuttocks and to call 911 after injecting into the thighlimit adrenergic agents ( vasoconstriction ) to a few daysbecause of the risk for rebound congestioncorticosteroids inhibit inflammatory response, suppress adrenal gland activity, increase the risk of hyperglycemia and hypernatremia, and hypokalemiaand could mask infectionrinse mouth after using corticosteroidmetered dose inhalerlong term use of corticosteroids (prednisone) contributes to adrenal atrophy and hypofunction and abrupt cessation of corticosteroids could lead toaddisonian crisis ( acute adrenal failure)leukotriene modifiers ( zafirlukast, montelukast, zileuton)limit production or block the inflammatory effects of leukotrienesrhinitis medicamentosa is a rebound rhinitis that occurs with overuse ofnasal decongestants ; nasal mucosa is more edematous with medication use prompting the use of more medicationinstruct clients that gout attacks can be triggered byalcohol ingestion , foods high in purines ( shellfish , organ meats) or illnessgout is typically marked bypain and edema to the joint of the big toean increase in erythrocyte sedimentation rate suggeststhat there is an infection or inflammationin systemic lupus erythematous the immune system creates antibodies to a part of the cells nucleusthis disease affects nearly every organ in the bodyclinical manifestations of osteoarthritis includeheberden's nodes ( distal interphalangeal joint ) and bouchards nodes (proximal interphalangeal joint) pain, loss of function, ambulating with a limp and crepitus in the affected jointtypical manifestations of rheumatic disease ispain, joint swelling with limited movement , stiffness, weakness and fatigueosteoarthritis is initially treated withacetaminophenbiological disease modifying antirheumatic drugs help tosuppress inflammation and prevent joint erosion; however these drugs increase the risk for infection so monitor closelymovement to inflammed joints can be limited byapplying splints to the area and allowing the joint to restmaintaining or improving functional status and joint mobility ; reducing inflammation and controlling painare key goals in the management of rheumatic diseasemanage pain in the setting of rheumatic disease withexercise , joint protection, relaxation, foam mattress , splints and the application of heat or coldRA is marked by symmetrical joint pain and swelling involving the small joints ( hands, wrists, and feet) that lasts more than 1 hour;osteoarthritis is a noninflammatory degeneration of articular cartilage marked by joint pain that lasts < 30 minutes and resolves with restdrying of the mucus membranes in sjogrens syndrome couldmake swallowing difficult