NUR 405 Final - Answer NV (pallor, pain, paresthesia, pulses, p...

NUR 405 Final

• Fracture assessments

Answer

NV (pallor, pain, paresthesia, pulses, paralysis), VS, ROM (wiggle fingers, move hand, move hip)- helps rule out

• Fracture interventions

Answer

x-ray, ORIF, external fixator/traction

• Fracture post op ORIF

Answer

DVT, infection, bleeding, pain management

• Fracture teaching

Answer

watch pin sites, pin care 2 times a day, increase protein

• Total hip replacement assessments

Answer

NV (5 Ps), musculoskeletal assess, ROM of hip, leg will be shorter 1 / 4

• Total hip replacement interventions

Answer

ORIF, must stop blood thinners (Vit K) before surgery, Buck's traction before surgery

• Total hip replacement teaching

Answer post op infection, protein, don't cross legs, don't bare all weight, higher up chairs/toilet seats, use grabbers to pick things up

• Amputation assessments

Answer

ABCs, vitals, pain (could be phantom limb pain), NV

• Amputation interventions

Answer

STOP BLEEDING ASAP (tourniquet), IV SITE FIRST (2 sites, >20), prep for admin blood, O2

• Amputation teaching

Answer

infection, pain control, wound care, home health care, get them up and moving right away, protein, calories, psychosocial 2 / 4

• Osteomyelitis assessments

Answer

pulses, NV, fracture hx, temp, pain, site (swelling, warmth, redness), not feeling well (malaise)

• Osteomyelitis causes

Answer

open fracture, open wound, untreated DM, staph infections

• Osteomyelitis interventions

Answer

CBC (wbc), cultures, debridement, start with broad spectrum abx after blood cultures

• Osteomyelitis teaching

Answer

increase protein for wound healing, dietary teaching, wound care, abx via PICC w/ homecare, s/s of infection spreading, finish all abx

• Traction assessments

Answer

neurosensory, skin (possible pressure ulcers develop- ing), ROM

• Traction interventions

Answer 3 / 4

leave weights in same spot before surgery

• Traction teaching

Answer

pt/fam CANNOT move the weights, no sudden movements, teach it's temporary

• Increased ICP

Answer herniation after head injury, too much bleeding, initial HR increase and rapid HR decrease, resp status decreases, BP increases due to excess pressure (causes herniation), pupils fixed and dilated, mannitol/diuretic (increases UO = EXPECTED FINDING), don't suction too often = increases ICP, HOB 30 degrees, decreased stimuli

• Increased ICP

Answer decorticate arms and elbows in towards chest

• Increased ICP

Answer decerebrate

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