Show:
Nursing Assessment and Interventions 1
Nursing Assessment and Interventions 2
Nursing Assessment and Interventions 3
Nursing Assessment and Interventions 4
Nursing Assessment and Interventions 5
100
Pain, pallor, pulselessness, parathesia, paralysis
What is neurovascular assessment or status?
100
The nurse knows to use RICE for a patient with a musculoskeletal injury. If the nurse were to implement this acronym the nurse would do this.
What is rest, ice, compression, elevation? *the nurse would also immobilize the site and give an anti-inflammatory such as tordal *used with sprains, strains, and dislocation *heat is not used now because it can cause an increase in inflammation
100
A neurovascular assessment must be performed on a surgical site. You know as the nurse the assessment must be performed where in relation to the surgical site or injury?
What is distal to the surgical site or injury?
100
The nurse knows that death of a tissue secondary to poor perfusion and hypoxemia is known as this.
What is avascular necrosis? *seen with dislocations, bone transplantation, prolonged high doses of corticosteroids, chronic kidney disease, sickle cell anemia, and other diseases *tx: revitalize bone with surgical decompression, bone grafts, prosethetic replacement, or osteotomy
100
Infection that can occur with external fixation devices.
What is osteomyelitis?
200
Swelling occurred in your patient's arm, you must look at the area and assess temp, color but you must also look at this as part of your assessment.
What is compare with the other extremity?
200
The nurse admits a patient with a fracture where the bone is protruding through the skin. The nurse knows that this is an open fracture. The patient has theses signs and symptoms. Name 3.
What is acute pain, loss of function, deformity, shortening of the extremity, crepitus, localized edema, and ecchymosis? complete fracture: break across the entire cross section of the bone incomplete fracture: involves a break through only part of the cross section of the bone, occurs more commonly in children comminuted fracture: one that produces several bone fragments closed (simple) fracture: one that does not cause a break in the skin open fracture (compound or complex): one in which the skin or mucus membrane wound extends to the fractured bone
200
Patient has unrelieved pain even with administered medication. The nurse should do this.
What is report findings immediately to the doctor?
200
The nurse sees a patient with an amputated leg and knows that the reason for this amputation could be this. Name 2.
What is diabetes, osteomyelitis, trauma, and peripheral vascular disease? *remember that phantom leg pain is real and pain medications should be given *typical levels of amputation are above elbow, below elbow, above knee, knee disarticulation, below knee, syme (foot is gone) *assess cap refill, movement, color
200
Late signs of compartment syndrome. Name 2.
What is pallor and paralysis? *pallor indicates arterial injury *paralysis indicates prolonged nerve compression or muscle damage
300
The nurse knows that an injury to the peroneal nerve can cause this complication.
What is foot drop? *inability to maintain the foot in a normally flexed position
300
The nurse has a patient who has had a clavicle fracture and tells the patient not to elevate the arm above the shoulder for this many weeks.
What is 6 weeks?
300
The nurse notices atrophy and contractures at the affected limb. The nurse recognizes that this complication.
What is disuse syndrome?
300
The nurse has a patient with a possible cervical disk herniation. The nurse knows that the diagnosis will be confirmed by this.
What is MRI?
300
Pin site has serous drainage and mild redness (pink) on day 2. The nurse would document this finding as this.
What is normal? *redness, swelling, pain around site, warmth, purulent drainage indicate infection *the nurse assesses the pin site every 8-12 hours
400
The nurse knows that delayed infection (an infection 4-24 months after surgery) can occur with this type of surgery.
What is hip replacement or knee replacement? *infection can occur in the immediate post op period (within 3 months) *infection can spread spread to another site and occur more than 2 years later
400
The nurse has a client with an open fracture. The nurse knows that these treatments will be used. Name 1.
What is tetanus prophylaxis, antibiotics, cleaning/debridment of the wound? *watch for s/s of osteomyelitis
400
You perform a neurovascular assessment and find that the extremity is blue, mottled, hot and the capillary refill occurs immediately. The site has swelling that is distended, tense, and the tissues feel hard. This is a complication with peripheral vascular integrity.
What is inadequate venous return? *inadequate arterial supply: pale or white extremity, cool, and cap refill is >2 sec, swelling is hollow or prune like.
400
A patient just recently underwent a leg amputation. The nurse checks on her patient and notices that the elastic dressing has come off. The nurse immediately wraps the leg with an elastic compression bandage. The nurse does this because she knows that this complication can arise.
What is excessive edema and delayed rehabilitation? *If cast was applied the nurse would notify the surgeon so that another cast can be fitted immediately. *the residual limb can only be placed in and elevated position briefly after surgery due to the fact that a flexion contracture of the hip may occur
400
Patient comes into the ER with a fractured pelvis and presents with low O2 sats, SOB, chest pain, petechia on the upper part of the chest, dyspnea, increased HR, increased RR, increased BP. The nurse recognizes this complication.
What is fat embolism? *medical emergency *occurs from fatty tissue diffusing from the marrow and traveling into the vascular department *subtle personality changes, restlessness, irritability, or confusion in a patient who has sustained a fracture are indications for immediate ABG studies.
500
The nurse gives a muscle relaxant for pain. The nurse knows that these two common medications can be given.
What is robaxin (methocarbomal) and flexeril (cyclobenzaprine)? *contraindicated for patients with myasthenia gravis
500
A nurse has a patient who has a intra-articular fracture (fracture that extends into the joint surface of the bone). The nurse knows the diagnosis will be confirmed with this.
What is MRI or arthroscopy? *Xray will not show the fracture because cartilage is not radiopaque.
500
Signs and symptoms that can occur with a cast are persistent pain, swelling, changes in sensation and a foul odor is coming from the cast. The nurse should teach the patient to do this if these signs and symptoms appear.
What is report them? (alert the nurse, or if at home call the doctor)
500
A patient has (CRPS) complex regional pain syndrome in the right arm. The nurse knows that when taking vitals or getting labs he/she must do this.
What is use another site such as the left arm to obtain blood pressure measurements and perform venipuncture? *s/s severe burning pain, local edema, hyperesthesia, stiffness, discoloration, vasomotor skin changes and trophic changes *pain relief: analgesics, NSAIDs, corticosteriods, and muscle relaxants *prevent: elevation, ROM, early effective pain relief
500
The nurse has a patient in skeletal traction. The nurse knows that these complications can arise. Name 3 and tell me an intervention for each.
What is atelectasis: IS, deep breathing DVT: SCDs, lovenox, aspirin, heparin constipation: Colace and Synekot, fiber, fluids pressure ulcers: Monitor hips, heels, shoulders. Use pillows under boney prominences. Regular shifting using trapeze. urinary stasis/UTI: give fluids to prevent UTI, UTI--> give cranberry juice, antibiotics