Exam 3 Adult Health

H2 receptors

are found on gastric parietal cells

T cells, or T lymphocytes

participate in cellular immunity (also called cell-mediated immunity), a type of adaptive immunity.

nonatopic disorders

lack the genetic component and organ specificity of the atopic disorders. Latex allergy can present as an IgE-mediated anaphylaxis, type I reaction, or a type IV hypersensitivity referred to as contact dermatitis.

prototypical type IV hypersensitivity reaction

occurs in response to the subcutaneous injection of purified protein derivative (PPD) antigen from Mycobacterium tuberculosis. Patients who have had previous exposure or have tuberculosis (TB) infection will demonstrate a reaction of erythema and induration due to sensitized T cells

First-generation antihistamines

readily absorbed, are most effective when administered orally at the first occurrence of symptoms because they prevent the development of new symptoms.

Heparin (preformed in mast cells)

Anticoagulant

CHAPTER 33 Assessment and Management of Patients with Allergic Disorders

CHAPTER 33 Assessment and Management of Patients with Allergic Disorders

white blood cell (WBC) count

Eosinophils, which are granular leukocytes, normally make up 2% to 5% of the total number of WBCs. They can be found in blood, sputum, and nasal secretions. A level greater than 5% to 10% is considered abnormal and may be found in patients with allergic disorders

Primary Mediators Preformed and Found in Mast Cells or Basophils Basophil kallikrein (preformed in mast cells)

Frees bradykinin, which causes bronchoconstriction, vasodilation, and nerve stimulation

It can be obtained from blood samples or smears of secretions. During symptomatic episodes, smears obtained from nasal secretions and sputum of patients with allergies usually reveal an increase in eosinophils, indicating an active allergic response

How can an actual count of eosinophils can be obtained?

famotidine

If H1 antihistamines are not completely effective, H2 antihistamines such as ____________, which blocks the H2 receptors found in the stomach, vascular smooth muscle, and elsewhere, can be added to the drug regimen. It is given twice a day with the same total dose as for gastroesophageal reflux. H2 antihistamines do not relieve urticaria on their own, but can augment the effect of H1 antihistamines

Haptens

Low-molecular-weight substances, such as medications, function as ________ (incomplete antigens), binding to tissue or serum proteins to produce a carrier complex that initiates an antibody response

Common Causes of Anaphylaxis

Medications: Antibiotics, especially penicillin and sulfa antibiotics, allopurinol, radiocontrast agents, anesthetic agents (lidocaine, procaine), vaccines, hormones (insulin, vasopressin, adrenocorticotropic hormone), aspirin, nonsteroidal anti-inflammatory drugs

Serotonin (preformed in platelets)

Smooth muscle contraction, increased vascular permeability

Type IV, or delayed hypersensitivity,

T cell-mediated immune reaction after exposure to an antigen. This immune reaction typically occurs 24 to 48 hours after exposure to an antigen.

mast cells or basophils

Two or more IgE molecules bind together to an allergen and trigger ____ _____ or _________ to release chemical mediators, such as histamine, serotonin, kinins, slow-reacting substances of anaphylaxis, and the neutrophil factor, which produces allergic skin reactions, asthma, and hay fever

A negative response on a skin test

cannot be interpreted as an absence of sensitivity to an allergen

anaphylactoid reaction occur with medications, food, exercise, or cytotoxic antibody transfusions. The reaction may be local or systemic. Local reactions usually involve urticaria and angioedema at the site of the antigen exposure. Although possibly severe, nonallergenic anaphylaxis reactions are rarely fatal.

caused by the release of mast cell and basophil mediators triggered by non-immunoglobulin E (IgE)-mediated events.

Anaphylaxis

clinical response to an immediate (type I hypersensitivity) immunologic reaction between a specific antigen and an antibody. The reaction results from a rapid release of IgE-mediated chemicals, which can induce a severe, life-threatening reaction

Corticosteroid nasal sprays

derived from hydrocortisone and are divided into first-generation and second-generation agents. Beclomethasone, flunisolide, triamcinolone, and budesonide are first-generation agents, whereas flucatisone, mometasone, and ciclesonide are second-generation agents

Allergy

inappropriate and often harmful response of the immune system to normally harmless substances, called allergens (e.g., dust, weeds, pollen, dander). **Chemical mediators released in allergic reactions may produce symptoms that range from mild to life-threatening.

allergic reaction

is a manifestation of tissue injury resulting from interaction between an antigen and an antibody

Venom immunotherapy

is an effective treatment for people with systemic reactions to an insect sting

Primary Mediators Preformed and Found in Mast Cells or Basophils Platelet-activating factor (requires synthesis by mast cells, neutrophils, and macrophages)

is responsible for initiating platelet aggregation and leukocyte infiltration at sites of immediate hypersensitivity reactions. It also causes vasodilation, bronchoconstriction, and increased vascular permeability Smooth muscle contraction Incites platelets to aggregate and release serotonin and histamine

Mast cells

located in the skin, respiratory tract, and gastrointestinal tract, play a major role in IgE-mediated immediate hypersensitivity. When mast cells are stimulated by antigens, powerful chemical mediators, such as histamine, are released, causing a sequence of physiologic events that result in symptoms of immediate hypersensitivity

antihistamines

major class of medications prescribed for the symptomatic relief of allergic rhinitis

Mild systemic reactions

peripheral tingling and a sensation of warmth, possibly accompanied by a sensation of fullness in the mouth and throat. Nasal congestion, periorbital swelling, pruritus, sneezing, and tearing of the eyes can also be expected. The onset of symptoms begins within the first 2 hours after the exposure.

B cells, or B lymphocytes,

produce one specific antibody. On encountering a specific antigen, _____________ generate plasma cells, at the site of antibody production. The plasma cells secrete antibodies for the purpose of destroying and removing the antigens. ____________ participate in humoral immunity (also called antibody-mediated immunity), which is one kind of adaptive immunity

B lymphocytes differentiate into plasma cells

secrete antibodies that attack the antigen

Immunoglobulins

stimulate mast cells to release histamine and other inflammatory mediators.

Antigen

stimulates activation of a B cell (B lymphocyte), which then transforms into a plasma cell that secretes immunoglobulins.

High total serum IgE levels

support the diagnosis of allergic disease. In the majority of cases, the antibody typically responsible for an allergic reaction belongs to the IgE isotype. Patients with this disorder are said to have an IgE-mediated allergic disease

Cimetidine

targets H2 receptors to inhibit gastric secretions in peptic ulcer disease.

In allergic reactions,

the body encounters allergens that are types of antigens, usually proteins that the body's defenses recognize as foreign, and a series of events occurs in an attempt to render the invaders harmless, destroy them, and remove them from the body

urticaria

type I hypersensitive allergic reaction of the skin character the sudden appearance of pinkish, edematous elevations that vary in size and shape, itch, and cause local discomfort.

contact dermatitis Manifestations associated with allergic contact dermatitis related to latex include blisters, pruritus, erythema, swelling, and crusting or other skin lesions. Laryngeal edema, rhinitis, and angioedema would be noted with a latex allergy.

type I immediate hypersensitivity disorder characterized by

Avoidance therapy for allergic rhinitis

use of air conditioners, air cleaners, humidifiers, and dehumidifiers; removal of dust-catching furnishings, carpets, and window coverings; removal of pets from the home or bedroom; the use of pillow and mattress covers that are impermeable to dust mites; and a smoke-free environment .Additional measures include changing clothing when coming in from outside, showering to wash allergens from hair and skin, and using an over-the-counter nasal irrigation device or saline nasal spray to reduce allergens in the nasal passages B High-efficiency particulate air (HEPA) purifiers and vacuum cleaner filters may also be used to reduce allergens in the environment. It is impossible to avoid exposure to all environmental allergens, so pharmacologic therapy or immunotherapy is needed.

Clinical Manifestations allergic rhinitis

Symptoms include sneezing, rhinorrhea, nasal itching, conjunctivitis, and nasal obstruction. Postnasal drip, cough, itching of the eyes, and fatigue. If symptoms are severe, allergic rhinitis may interfere with sleep, leisure, school, work, and overall quality of life. It commonly associated with chronic sinusitis, atopic dermatitis (eczema), and asthma. Infraorbital edema and dilation of peripheral vessels (due to histamine) can cause darkening under the eyes, "allergic shiners." A horizontal nasal crease can develop from constant rubbing of the nose; "allergic salute." The nasal mucosa can exhibit a grayish hue. Clear rhinorrhea, tonsillar hyperplasia, and postnasal rhinorrhea may be visible on examination of the throat. Tympanic membranes can be retracted or serous fluid may accumulate in the middle ear. Some patients can suffer oral allergy syndrome (OAS) with itching and irritation of the hard and soft palate. Allergic rhinitis and sinusitis can trigger migraine headache in some patients.

Self-Administration of Epinephrine

The nurse instructs the patient to: 1.After removing the autoinjector from its carrying tube, grasp the unit with the orange tip (injecting end) pointing downward. Form a fist around the unit with the orange tip down; with your other hand, remove the blue safety release cap. 2.Hold the black tip near outer thigh. Swing and jab firmly into the outer thigh until a click is heard with the device perpendicular (90-degree angle) to the thigh. Do NOT inject into buttocks. 3. Hold firmly against the thigh for approximately 10 seconds. Remove the unit from the thigh, and gently massage the injection area for 10 seconds. Call 911 and seek immediate medical attention. Carefully place the used autoinjector unit, needle-end first, into the device storage tube without bending the needle. Screw on the storage tube completely, and take it with you to the hospital emergency room.

Correct response: fexofenadine Explanation: Fexofenadine, an antihistamine, is used to treat allergic rhinitis. Pseudoephedrine and oxymetazoline are over-the-counter decongestants, and budesonide is a corticosteroid. They are not useful in treating allergic rhinitis.

The nurse is working with a client with allergic rhinitis. What medication does the nurse anticipate will be prescribed to treat the allergic rhinitis?

Correct response: Symptoms are localized to the area of exposure, usually the back of the hands. Explanation: Clinical manifestations of a delayed hypersensitivity reaction are localized to the area of exposure. Clinical manifestations of an irritant contact dermatitis can be eliminated by changing glove brands or using powder-free gloves. With an irritant contact dermatitis, avoid use of hand lotion before donning gloves; this may worsen symptoms, as lotions may leach latex proteins from the gloves. When clinical manifestations occur within minutes after exposure to latex, which is described as a latex allergy, an immediate hypersensitivity (type I) allergic reaction has occurred.

The nurse is working with a colleague who has a delayed hypersensitivity (type IV) allergic reaction to latex. Which statement describes the clinical manifestations of this reaction? a. Symptoms are localized to the area of exposure, usually the back of the hands. b. Symptoms can be eliminated by changing glove brands. c. Symptoms worsen when hand lotion is applied before donning latex gloves. d. Symptoms occur within minutes after exposure to latex.

Histamine, prostaglandins, and inflammatory leukotrienes Smooth muscle spasm, bronchospasm, mucosal edema and inflammation, and increased capillary permeability result. Symptoms of anaphylaxis are sudden in onset and progress in severity over minutes to hours

What are potent vasoactive mediators that are implicated in the vascular permeability changes, flushing, urticaria (hives), angioedema, hypotension, and bronchoconstriction that characterize anaphylaxis?

Correct response: Serum-specific IgE test Explanation: The serum-specific IgE test, formerly known as RAST, is a radioimmunoassay that measures allergen-specific IgE. It indicates the quantity of allergen necessary to evoke an allergic reaction. Provocative testing involves the direct administration of the suspected allergen to the sensitive tissue such as the conjunctiva. The scratch test does not indicate the quantity of allergen.

Which test indicates the quantity of allergen necessary to evoke an allergic reaction?

antibody

a protein substance developed by B cells in response to and interacting with a specific antigen

Second-generation (nonsedating H1-receptor antagonists)

antihistamines that DO NOT CROSS the blood-brain barrier to the same extent as first-generation antihistamines. They mainly bind to peripheral rather than central nervous system H1 receptors, causing less sedation. Examples of these OTC medications are loratadine, cetirizine, and fexofenadine.

Antihistamine nasal sprays azelastine and olopatadine

are available by prescription. They not only reduce inflammation and decrease nasal congestion, but also have rapid onset of action and can be used "on demand"

H1 receptors

are found predominantly on bronchiolar and vascular smooth muscle cells

Secondary mediators

are inactive precursors that are formed or released in response to primary mediators

Immunoglobulins of the IgE class

are involved in allergic disorders and some parasitic infections IgE-producing cells are located in the respiratory and intestinal mucosa

T helper cells

are specific types of T lymphocytes that assist B cells in the immune response

T helper cells

are specific types of T lymphocytes that assist B cells in the immune response. T cells secrete substances that direct the flow of cell activity and stimulate macrophages. Macrophages present the antigens to the T cells and initiate the immune response. They also digest antigens and assist in removing cells and other debris

Type I (Anaphylactic) Reactions

characterized by vasodilation, increased capillary permeability, smooth muscle contraction, and eosinophilia. Systemic reactions may involve laryngeal stridor, angioedema, hypotension, and bronchial, GI, or uterine spasm; local reactions are characterized by hives. EX: extrinsic asthma, allergic rhinitis, systemic anaphylactic and reactions to insect stings

Leukotrienes (derived from arachidonic acid and activated by mast cell degranulation) C, D, and E or slow-reacting substance of anaphylaxis

chemical mediators that initiate the inflammatory response. It cause leukotrienes cause smooth muscle contraction, increased vascular permeability, bronchial constriction, mucus secretion in the airways, and the typical wheal-and-flare reactions of the skin. Compared with histamine, leukotrienes are 100 to 1000 times more potent in causing bronchospasm.

Atopic diseases

consist of asthma, allergic rhinitis, and atopic dermatitis. All share a common pathogenesis, mediated by IgE, and are frequently present together in the same individual and in families

Skin testing

most accurate confirmation of allergy and entails the intradermal injection or superficial application (epicutaneous) of solutions at several sites. When there is doubt about the validity of the skin tests, a serum-specific IgE test or a provocative challenge test may be performed

corticosteroid nasal sprays

most effective pharmacotherapy for allergic rhinitis. These anti-inflammatory agents work directly on the nasal mucosa but take a few hours to work. The patient should understand that maximal therapeutic effectiveness of these agents can take 1 to 2 weeks.

anaphylaxis

most severe hypersensitivity reaction and unanticipated allergic reaction often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases.

T cells, or T lymphocytes

participate in cellular immunity (also called cell-mediated immunity), a type of adaptive immunity.. T cells secrete substances that direct the flow of cell activity and stimulate macrophages. Macrophages present the antigens to the T cells and initiate the immune response. They also digest antigens and assist in removing cells and other debris

Primary Mediators Preformed and Found in Mast Cells or Basophils Prostaglandins (chemically derived from arachidonic acid; require synthesis by cells)

produce smooth muscle contraction as well as vasodilation and increased capillary permeability. They sensitize pain receptors and increase the pain associated with inflammation. In addition, prostaglandins induce inflammation and enhance the effects of mediators of inflammatory response. Local manifestations include erythema, heat, and edema D and F series → bronchoconstriction E series → bronchodilation D, E, and F series → vasodilation

B cells, or B lymphocytes

programmed to produce one specific antibody which generate plasma cells, at the site of antibody production. The plasma cells secrete antibodies for the purpose of destroying and removing the antigens. B cells participate in humoral immunity (also called antibody-mediated immunity), which is one kind of adaptive immunity

histamine

released by mast cells, is a primary chemical mediator of hypersensitivity that acts within about 15 minutes after antigen contact its release causes sweating, sneezing, shortness of breath, and nasal congestion.

Histamine

released by mast cells, plays an important role in the immune response. First chemical mediator to be released in immune and inflammatory responses. It is synthesized and stored in high concentrations in body tissues exposed to environmental substances. It's effects peak 5 to 10 minutes after antigen contact and include the following: erythema; localized edema in the form of wheals; pruritus; contraction of bronchial smooth muscle, resulting in wheezing and bronchospasm; dilation of small venules and constriction of larger vessels; and increased secretion of gastric and mucosal cells, resulting in diarrhea. The action results from stimulation of histamine-1 (H1) and histamine-2 (H2) receptors.

Immunoglobulins immunoglobulins can be found in the lymph nodes, tonsils, appendix, and Peyer patches of the intestinal tract or circulating in the blood and lymph

response to an immunogenic stimulus constitute a group of serum proteins

Type II, or cytotoxic hypersensitivity

antibodies are directed against antigens on cells or basement membranes of tissues. This reaction can lead to cell lysis and tissue damage. Type II hypersensitivity reactions are associated with several disorders. The best example is a hemolytic transfusion reaction. For example, if a person with type A blood is mistakenly given type B blood, anti-B antibodies are triggered in the recipient that attack the infused type B blood cells and cause hemolysis **Cytotoxic hypersensitivity occurs when the body mistakenly identifies a part of the body as foreign, as in myasthenia gravis, where the body mistakenly identifies normal nerve endings as foreign.

Diphenhydramine, hydroxyzine, and chlorpheniramine

antihistamine, a medication that displays an affinity for H1 receptors and a common first-generation antihistamine available in over-the-counter (OTC) medications. Histamine 1 receptors can effectively relieve symptoms of hay fever, vasomotor rhinitis, urticaria (hives), and mild asthma. However, first-generation antihistamines cross the blood-brain barrier and cause significant sedation which impairs cognitive function and psychomotor performance.

Corticosteroids and antihistamines, including over-the-counter allergy medications

suppress skin test reactivity and should be stopped 48 to 96 hours before testing, depending on the duration of their activity. False-positive results may occur because of improper preparation or administration of allergen solutions.

3+ reaction

wheal (9 to 15 mm), slight pseudopodia possible with associated erythema;

1+ reaction

wheal present (5 to 8 mm) with associated erythema

Negative reaction

wheal soft with minimal erythema

Diagnosis of seasonal allergic rhinitis

Blood or laboratory testing is usually unnecessary. Diagnostic testing can be done with immediate hypersensitivity skin testing (skin prick testing). In sensitive patients, testing with select diagnostic solutions of tree, grass, or weed pollen, mold, house dust mites, and animal allergens results in a wheal-and-flare reaction at the skin test site within 20 minutes. IgE immunoassay can provide similar information to skin prick test. Nasal cytology can be performed to differentiate rhinitis due to allergy from that due to infection, although it is relatively nonspecific and insensitive.

Common Causes of Anaphylaxis

Foods: Peanuts, tree nuts (e.g., walnuts, pecans, cashews, almonds), shellfish (e.g., shrimp, lobster, crab), fish, milk, eggs, soy, wheat

Common Causes of Anaphylaxis

Insect Stings: Bees, wasps, hornets, yellow jackets, ants (including fire ants)

Xerostomia

(dryness of the mouth) is a frequent sequela of oral cancer, particularly when the salivary glands have been exposed to radiation or major surgery. It is also seen in patients who are receiving psychopharmacologic agents, taking multiple medications, or using drugs recreationally; in patients who have rheumatic diseases, eating disorders or HIV infection; and in patients who cannot close the mouth and, as a result, breathe through the mouth instead of the nose.

Extracapsular fractures

(extending from the base of the femoral neck to the area just distal to the lesser trochanter) are fractures of the trochanteric, intertrochanteric, and subtrochanteric region

allergic rhinitis

(hay fever, seasonal allergic rhinitis) is the most common form of respiratory allergy, which is mediated by an immediate (type I hypersensitivity) immunologic reaction. induced by airborne pollens or molds

sciatica

(i.e., pain radiating from an inflamed sciatic nerve); presence of this symptom suggests nerve root involvement **The patient's gait, spinal mobility, reflexes, leg length, leg motor strength, and sensory perception may be affected

Parotitis

(inflammation of the parotid gland) is the most common inflammatory condition of the salivary glands. Inflammation of the parotid may be due to mumps (epidemic parotitis), a communicable disease caused by viral infection and most commonly affecting unvaccinated children. People who are older, acutely ill, or debilitated with decreased salivary flow from general dehydration or medications are at high risk for bacterial parotitis. Anticholinergic medications inhibit saliva production. Patient feels pain in the ear, and swollen glands interfere with swallowing. The swelling increases rapidly, and the overlying skin soon becomes red and shiny.

Sialadenitis

(inflammation of the salivary glands) may be caused by dehydration, radiation therapy, stress, malnutrition, salivary gland calculi (stones; sialolithiasis), or improper oral hygiene. The inflammation is commonly associated with infection by S. aureus, which requires antibiotic therapy. In hospitalized or institutionalized patients, the infecting organism may be methicillin-resistant S. aureus (MRSA). Symptoms include pain, swelling, and purulent discharge. Massage, hydration, warm compresses, and sialagogues (substances that trigger saliva flow like hard candy or lemon juice) frequently cure the problem.

Syme amputation

(modified ankle disarticulation amputation) performed most frequently for extensive foot trauma and aims to produce a durable residual limb that can withstand full weight bearing

rehabilitation team

(patient, nurse, primary provider, social worker, physical therapist, occupational therapist, psychologist, prosthetist, vocational rehabilitation worker) helps the patient achieve the highest possible level of function and participation in life activities

Desquamation

(shedding of the epidermis) is a reaction to radiation therapy that can lead to a break in skin integrity and subsequent infection. Signs of wound infection (redness, swelling, drainage, tenderness) are reported to the primary provider

In an upper extremity injury:

- arm may be bandaged to the chest, or an injured forearm may be placed in a sling. -neurovascular status distal to the injury should be assessed both before and after splinting to determine the adequacy of peripheral tissue perfusion and nerve function

Clinical Manifestations of duodenal ulcer

-50% to 80% of patients awake with pain during the night -pain most commonly occurs 2 to 3 hours after meals -more likely to express relief of pain after eating or after taking an antacid than patients with gastric ulcer -pyrosis, vomiting, constipation or diarrhea, and bleeding. These symptoms are often accompanied by sour eructation (burping), which is common when the patient's stomach is empty.

Clinical Manifestations of achalasia

-Difficulty swallowing. -Primary symptom is dysphagia -**Food sticking sensation. -Food regurgitation. -Chest pain and pyrosis (heartburn). -Pulmonary complications due to aspiration. (The food just sits there) - symptoms mirror those of GERD, and patients are often misdiagnosed and treated for GERD

Treating the patient with gastric outlet obstruction,

-FIRST consideration is to insert an NG tube to decompress the stomach. Confirmation that obstruction is the cause of the discomfort is accomplished by assessing the amount of fluid aspirated from the NG tube. A residual of more than 400 mL suggests obstruction. Usually, an upper GI study or endoscopy is performed to confirm gastric outlet obstruction. Decompression of the stomach and management of extracellular fluid volume and electrolyte balances may improve the patient's condition and avert the need for surgical intervention. Balloon dilation of the pylorus via endoscopy may be beneficial.

Management for a hiatal hernia

-Frequent, small feedings that can pass easily through the esophagus (food high in fiber). -The pt is advised not to recline for 1 hour after eating, to prevent reflux or movement of the hernia -elevate the head of the bed on 4- to 8-inch (10- to 20-cm) blocks to prevent the hernia from sliding upward. -nurse monitors for postoperative belching, vomiting, gagging, abdominal distention, and epigastric chest pain, which may indicate the need for surgical revision; these should be reported immediately to the primary provider

Management of achalasia

-Injection of botulinum toxin into quadrants of the esophagus via endoscopy (inhibits the contraction of smooth muscle). However, risk of submucosal fibrosis, botulinum toxin is ONLY used in patients who cannot receive other definitive treatments May be treated conservatively by pneumatic dilation to stretch the narrowed area of the esophagus. Pneumatic dilation has a high success rate; however, typically two dilations are required and the long-term results are variable . Perforation is a potential complication. The procedure can be painful; therefore, moderate sedation in the form of an analgesic or tranquilizer, or both, is given for the treatment.

Expert consensus-based recommendations for pin site care include the following (Walker, 2018):

-Pins located in areas with soft tissue are at greatest risk for infection. -After the first 48 to 72 hours following skeletal pin placement, pin site care should be performed daily or weekly. -Chlorhexidine 2 mg/mL solution is the most effective cleansing solution. If chlorhexidine is contraindicated (due to known hypersensitivity or skin reaction), saline solution should be used for cleansing. -Strict hand hygiene before and after skeletal pin site care should always take place.

the extent of damage to the teeth may be related to the following:

-Presence of dental plaque, which is a gluey, gelatinlike substance that adheres to the teeth -Length of time acids are in contact with the teeth -Strength of acids and the ability of the saliva to neutralize them -Susceptibility of the teeth to decay

The following drugs may cause a pseudoallergic drug reaction:

-Radiocontrast agents -Opioids (e.g., morphine and meperidine) -NSAIDs (e.g., ibuprofen) and aspirin -Vancomycin -Local anesthetic agents (e.g., lidocaine, benzocaine) -Chemotherapeutic agents (e.g., platinum-based drugs

The nurse performs the following procedures to monitor and prevent skin breakdown: Buck's extension traction

-Removes the foam boots to inspect the skin, the ankle, and the Achilles tendon at least twice daily. A second person is needed to support the extremity during the inspection and skin care. -Palpates the area of the traction tapes daily to detect underlying tenderness. -Provides frequent repositioning to alleviate pressure and discomfort, because the patient who must remain in a supine position is at increased risk for development of a pressure injury. -Uses advanced static mattresses or overlays rather than standard hospital foam or alternating-air/low-air-loss mattresses to reduce the risk of pressure injury formation

Ulcer healing Proton pump inhibitors Esomeprazole 40 mg daily Lansoprazole 30 mg daily Omeprazole 20 mg daily Pantoprazole 40 mg daily Rabeprazole 20 mg daily

-Should be used for 4-8 wks for complete peptic ulcer healing; patients who are at high risk require a maintenance dose for 1 yr **For patients with ZES, hypersecretion of gastrin stimulates the release of gastric acid (HCl)

When caring for the patient in traction, the nurse should follow these additional principles:

-Traction must be continuous to be effective in reducing and immobilizing fractures. -Skeletal traction is never interrupted. -Weights are not removed unless intermittent traction is prescribed. -Any factor that might reduce the effective pull or alter its resultant line of pull must be eliminated. -The patient must be in good body alignment in the center of the bed when traction is applied. -Ropes must be unobstructed. -Weights must hang freely and not rest on the bed or floor. -Knots in the rope or the footplate must not touch the pulley or the foot of the bed.

Primary Mediators Preformed and Found in Mast Cells or Basophils Histamine (preformed in mast cells)

-Vasodilation -Smooth muscle contraction -increased vascular permeability -increased mucus secretions

Dietary Modification for peptic ulcer

-avoid oversecretion of acid and hypermotility in the GI tract. - avoid extremes of temperature in food and beverages and overstimulation from the consumption of alcohol, coffee (including decaffeinated coffee, which also stimulates acid secretion), and other caffeinated beverages. -neutralize acid by eating three regular meals a day. -Small, frequent feedings are not necessary as long as an antacid or an H2 blocker is taken. -Diet compatibility becomes an individual matter: The patient eats foods that are tolerated and avoids those that produce pain

Immediately after injury:

-body part must be immobilized before the patient is moved -Adequate splinting is essential - Joints proximal and distal to the fracture must be immobilized -Immobilization of the long bones of the lower extremities may be accomplished by bandaging the legs together, with the unaffected extremity serving as a splint for the injured one.

Early manifestations of dumping syndrome

-occur 15 to 30 minutes after eating -Signs and symptoms include vertigo (feeling of spinning), tachycardia, syncope, sweating, pallor, palpitations, borborygmi (loud, hyperactive bowel sounds) diarrhea, nausea, and the desire to lie down.

Management of all three spastic disorders

-smooth muscle relaxants such as calcium channel blockers and nitrates may be used to reduce the pressure and amplitude of contractions. - Proton pump inhibitors (PPIs) may also be indicated, especially if symptoms of GERD are present. - Small, frequent feedings and a soft diet are usually recommended to decrease the esophageal pressure and irritation that lead to spasm. -If conservative therapies do not provide relief, Heller myotomy or POEM may be tried

Clinical Manifestations of peptic ulcer disease

-some pts has no signs or symptoms. These silent peptic ulcers most commonly occur in older adults and those taking aspirin and other NSAIDs. - dull, gnawing pain or a burning sensation in the mid epigastrium or the back. - pain most commonly occurs immediately after eating, -0% to 40% of patients wake up with pain during the night -pyrosis, vomiting, constipation or diarrhea, and bleeding. These symptoms are often accompanied by sour eructation (burping), which is common when the patient's stomach is empty.

Ilizarov fixation

-specialized type of external fixator consisting of numerous wires that penetrate the limb and are attached to a circular metal frame -used to correct angulation and rotational defects, to treat nonunion (failure of bone fragments to heal), and to lengthen limbs -The device gently pulls apart the cortex of the bone and stimulates new growth through daily adjustment of the telescoping rods

Late manifestations of dumping syndrome

2-3 hours postprandial and include hypoglycemic symptoms such as pale, cool skin with anxiety, shakiness, irritability, and hunger; these symptoms are causes by excessive release of insulin in response to a rapid rise in blood glucose due to high-CHO bolus entering jejunum.

Shoulder spica cast

A body jacket that encloses the trunk, shoulder, and elbow.

parenteral form

A careful history of any sensitivity to suspected antigens must be obtained before administering any medication, particularly in, ___________ _____ because this route is associated with the most severe anaphylaxis.

Correct response: urticaria Explanation: Urticaria presents with itching, swelling, redness, and wheals of superficial skin layers. Dermatitis medicamentosa presents with sudden generalized bright red rash, itching, fever, malaise, headache, arthralgias. Contact dermatitis presents with itching, burning, redness, rash on contact with substance. Angioedema presents with itching, swelling, redness of deeper tissues and mucous membranes.

A client presents with itching, swelling, redness, and wheals of superficial skin layers. What is the most likely type of allergy this client is displaying?

Correct response: L4, L5, and S1 Explanation: The lower lumbar disks, L4-L5 and L5-S1, are subject to the greatest mechanical stress and the greatest degenerative changes. Disk protrusion (herniated nucleus pulposus) or facet joint changes can cause pressure on nerve roots as they leave the spinal canal, which results in pain that radiates along the nerve.

A client visits an orthopedic specialist because of pain beginning in the low back and radiating behind the right thigh and down below the right knee. The doctor suspects a diagnosis of sciatica. The nurse knows that the origin of the pain is between which intervertebral disks?

Correct response: Open nerve release Explanation: Evidence-based treatment of acute carpal tunnel syndrome includes the application of splints to prevent hyperextension and prolonged flexion of the wrist. Should this treatment fail, open nerve release is a common surgical management option. A variety of treatments may be tried by the client, however, they may fail to improve the condition. These treatments include laser therapy, ultrasound therapy, and the injection of substances such as lidocaine. Though these can be used, surgery to release nerves is the best option.

A client with carpal tunnel syndrome has had limited improvement with the use of a wrist splint. The nurse knows that which procedure will show the greatest improvement in treatment for this client?

depressed fracture

A fracture in which fragments are driven inward (seen frequently in fractures of skull and facial bones)

stress fracture

A fracture that results from repeated loading of bone and muscle

subluxation

A partial or incomplete dislocation of a joint.

Correct response: Supine, with the knees slightly flexed and the head of the bed elevated 30 degrees Explanation: A medium to firm, not sagging mattress (a bed board may be used) is recommended; there is no evidence to support the use of a firm mattress. Lumbar flexion is increased by elevating the head and thorax 30 degrees by using pillows or a foam wedge and slightly flexing the knees supported on a pillow. Alternatively, the patient can assume a lateral position with knees and hips flexed (curled position) with a pillow between the knees and legs and a pillow supporting the head.

A patient is having low back pain. What position can the nurse suggest to relieve this discomfort?

median nerve

A patient presents with a deformed wrist, pain, swelling, weakness, and limited finger ROM, and possibly reports of "tingling" in the affected hand. Tingling sensation may indicate injury to what nerve?

Antibiotic Metronidazole

A synthetic antibacterial and antiprotozoal agent that assists with eradicating H. pylori bacteria in the gastric mucosa when given with other antibiotics and proton pump inhibitors •Should be **GIVEN with meals to decrease GI upset; may cause anorexia and metallic taste •Patient should avoid alcohol; increases blood-thinning effects of warfarin

internal fixation, casts, or splints

After skeletal traction is discontinued, what are then used to immobilize and support the healing bone?

a bladder scan should be performed to determine the volume of urine; intermittent catheterization may be indicated

After surgery, If the patient does not void within 6 hours of catheter removal and/or is expressing symptoms of urinary retention (e.g., abdominal fullness, discomfort)

every 1 to 2 hours for the first 24 hours is essential to monitor the function of the nerves and the perfusion of the tissues To control the anticipated edema, the foot should be elevated on several pillows when the patient is sitting or lying. Support of the entire limb under the knee is preferable. Ice packs applied intermittently to the surgical area during the first 24 to 48 hours may be prescribed to control edema and provide some pain relief

After surgery, how often should the nurse do a neurovascular assessment of the exposed toes?

Walking boot

Also called an air or walking cast; protects and supports the foot, ankle or lower leg by controlling alignment and reducing movement; also supports the user's weight while walking.

Assessment and Diagnostic Findings of Barrett esophagus

An EGD provides screening in patients with multiple risk factors. This usually reveals an esophageal lining that is pink rather than pale white. Biopsies are performed, and BE is diagnosed when the squamous mucosa of the esophagus is replaced by columnar epithelium (columnar metaplasia) at least 1 cm above the gastric folds, and that area resembles that of the stomach or intestines (intestinal metaplasia) as evidenced by the presence of goblet cells.

Anatomic Area Clavicle fracture

Assessment Findings -Holds arm closely to body -Unable to raise affected arm above head -Can feel movement of both ends of clavicle

Herpetic gingivostomatitis

Burning sensation with the appearance of small vesicles 24-48 h later; vesicles may rupture, forming sore, shallow ulcers covered with a gray membrane Herpes simplex viral infection Occurs most frequently in people who are immunosuppressed; may occur in other infectious processes such as streptococcal pneumonia, meningococcal meningitis, and malaria Saline or 2-3% hydrogen peroxide irrigations

CHAPTER 37 Management of Patients with Musculoskeletal Trauma

CHAPTER 37 Management of Patients with Musculoskeletal Trauma

CHAPTER 39 Management of Patients with Oral and Esophageal Disorders

CHAPTER 39 Management of Patients with Oral and Esophageal Disorders

CHAPTER 40 Management of Patients with Gastric and Duodenal Disorders (p. 1266-1277)

CHAPTER 40 Management of Patients with Gastric and Duodenal Disorders (p. 1266-1277)

Sialolithiasis, or salivary calculi (stones)

Calculi within the salivary gland itself may cause no symptoms unless infection arises; however, a calculus that obstructs the gland's duct causes swelling and sudden, local, and often colicky pain, which is abruptly relieved by a gush of saliva. On physical assessment, the gland is swollen and quite tender, the stone itself may be palpable, and may be visualized by ultrasound, noncontrast computed tomography (CT), or sialendoscopy.

external retention bolster the area beneath the gastric tube

Candida may appear in warm moist areas of the body; what is the most common area on the gastric tube for it to develop?

Ch 36 Management of Patients with Musculoskeletal Disorders (pages 1113-1122)

Ch 36 Management of Patients with Musculoskeletal Disorders (pages 1113-1122)

Polymeric formulas

Commercially prepared formulas for tube feedings that contain intact proteins, carbohydrates, and fats that require digestion

Volkmann ischemic contracture

Contracture of the fingers and wrist occurs as the result of obstructed arterial blood flow to the forearm and hand. The patient is unable to extend the fingers, describes abnormal sensation (e.g., unrelenting pain, pain on passive stretch), and exhibits signs of diminished circulation to the hand. Irreversible damage develops within a few hours if action is not taken.

Prostaglandin E1 Analogue Sucralfate

Creates a viscous substance in the presence of gastric acid that forms a protective barrier, binding to the surface of the ulcer, and prevents digestion by pepsin •Should be taken without food but with water 1 h prior to meals •Other medications should be taken 2 h before or after this medication •Many drug-drug interactions (e.g., digoxin, phenytoin, warfarin) •May cause constipation or nausea

H2 Receptor Antagonists Famotidine

Decreases amount of HCl produced by stomach by blocking action of histamine on histamine receptors of parietal cells in the stomach •Best choice for patient who is critically ill because it is known to have the least risk of drug-drug interactions; does not alter liver metabolism •Prolonged half-life in patients with renal insufficiency •Short-term relief for GERD

H2 Receptor Antagonists Cimetidine

Decreases amount of HCl produced by stomach by blocking action of histamine on histamine receptors of parietal cells in the stomach •Least expensive of H2 receptor antagonists •May cause confusion, agitation, or coma in older adults or those with renal or hepatic insufficiency •Long-term use may cause diarrhea, dizziness, and gynecomastia •Many drug-drug interactions (e.g., amiodarone, amitriptyline, benzodiazepines, metoprolol, nifedipine, phenytoin, warfarin)

H2 Receptor Antagonists Nizatidine

Decreases amount of HCl produced by stomach by blocking action of histamine on histamine receptors of parietal cells in the stomach •Used for treatment of ulcers and GERD •Prolonged half-life in patients with renal insufficiency •May cause headache, dizziness, diarrhea, nausea/vomiting, GI upset, and urticaria

Proton Pump Inhibitors of Gastric Acid Lansoprazole

Decreases gastric acid secretion by slowing the H+, K+, ATPase pump on the surface of the parietal cells of the stomach. •A delayed-release capsule that is to be swallowed whole and taken before meals

Proton Pump Inhibitors of Gastric Acid Omeprazole

Decreases gastric acid secretion by slowing the H+, K+, ATPase pump on the surface of the parietal cells of the stomach. •A delayed-release capsule that is to be swallowed whole and taken before meals •May cause diarrhea, nausea, constipation, abdominal pain, vomiting, headache, or dizziness

Proton Pump Inhibitors of Gastric Acid Pantoprazole

Decreases gastric acid secretion by slowing the H+, K+, ATPase pump on the surface of the parietal cells of the stomach. •A delayed-release tablet that is to be swallowed whole and taken before meals •May cause diarrhea and hyperglycemia, headache, abdominal pain, and abnormal liver function tests

Proton Pump Inhibitors of Gastric Acid Rabeprazole

Decreases gastric acid secretion by slowing the H+, K+, ATPase pump on the surface of the parietal cells of the stomach. •A delayed-release tablet that is to be swallowed whole and taken without regard to meals; however, if used for duodenal ulcers give after meals and when used for H. pylori treatment, give with food. •May cause abdominal pain, diarrhea, nausea, and headache •Drug-drug interactions with digoxin, iron, and warfarin

Proton Pump Inhibitors of Gastric Acid Esomeprazole

Decreases gastric acid secretion by slowing the H+,K+-ATPase pump on the surface of the parietal cells of the stomach •Used mainly for treatment of duodenal ulcer disease and H. pylori infection •A delayed-release capsule that is to be swallowed whole and taken before meals

Proximal (parietal cell) gastric vagotomy without drainage

Denervates acid-secreting parietal cells but preserves vagal innervation to the gastric antrum and pylorus

deformity

Displacement, angulation, or rotation of the fragments in a fracture of the arm or leg causes a ___________ that is detectable when the limb is compared with the uninjured extremity

epinephrine or alcohol, or cauterizing the site, or clipping the ulcer, all in efforts to stop the bleedin

During endoscopic interventions, what may be injected to stop the bleeding?

H. pylori infection Alternate therapy with clarithromycin 500 mg bid, amoxicillin 1 g bid, metronidazole 500 mg bid, plus PPI for 10-14 days

Efficacy of therapy is approximately 85% qid dosing may decrease adherence to the regimen

H. pylori infection Quadruple therapy with bismuth subsalicylate 525 mg qid, plus tetracycline 500 mg qid, plus metronidazole 500 mg bid, plus a PPI daily for 10-14 days

Efficacy of therapy is approximately 85% qid dosing may decrease adherence to the regimen

Body cast

Encircles the trunk.

Hip spica cast

Encloses the trunk and a lower extremity. A double hip spica cast includes both legs.

Antibiotic Clarithromycin

Exerts bactericidal effects to eradicate H. pylori bacteria in the gastric mucosa •May cause GI upset, headache, altered taste •Many drug-drug interactions (e.g., colchicine, lovastatin, warfarin); interacts with **grapefruit juice

Antibiotic Tetracycline

Exerts bacteriostatic effects to eradicate H. pylori bacteria in the gastric mucosa •May cause photosensitivity reaction; advise patient to use **sunscreen •May cause GI upset •Must be used with caution in patients with renal or hepatic impairment •Milk or dairy products may reduce effectiveness

Short arm cast

Extends from below the elbow to the palmar crease, secured around the base of the thumb. If the thumb is included, it is known as a thumb spica or gauntlet cast.

Short leg cast

Extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position.

Long arm cast

Extends from the axillary fold to the proximal palmar crease. The elbow usually is immobilized at a right angle.

Long leg cast

Extends from the junction of the upper and middle third of the thigh to the base of the toes. The knee may be slightly flexed.

gastrostomy or jejunostomy tubes are preferred for administration of medications or nutrition.

For tube feedings longer than 4 weeks, what tube feedings are preferred?

Humerus Shaft Fracture

Fractures of the midshaft of the humerus are most frequently caused by either a direct blow or trauma that results in a transverse, oblique, or comminuted fracture, or an indirect twisting force that results in a spiral fracture.

pain, pallor, pulselessness, paresthesia, and paralysis

Frequent assessment of neurovascular function after a fracture is essential and focuses on the "five Ps":

Necrotizing gingivitis (trench mouth)

Gray-white pseudomembranous ulcerations affecting the edges of the gums, mucosa of the mouth, tonsils, and pharynx; halitosis; painful, bleeding gums; swallowing and talking are painful Progressive, painful bacterial infection Related to poor oral hygiene, lack of access to dental care, inadequate rest, overwork, emotional stress, smoking, and poor nutrition Irrigate with 2-3% hydrogen peroxide or normal saline solution.

vacuum-assisted closures (VACs)

Heavily contaminated wounds are left unsutured and treated with ______________________ to facilitate wound drainage. Wound irrigation and débridement may be repeated, removing infected and devitalized tissue and increasing vascularity in the region

It begins with a small hole, usually in a fissure or in an area that is hard to clean. Decay extends into the dentin. Because dentin is not as hard as enamel, decay progresses more rapidly and in time, reaches the pulp of the tooth. Older adults are subject to decay from drug-induced or age-related oral drynes

How does dental decay develop?

producing movement of synovial fluid into the articular cartilage.

How does motion promote healing of injured joints?

by elevating the head and thorax 30 degrees by using pillows or a foam wedge and slightly flexing the knees supported on a pillow. **the patient can assume a lateral position with knees and hips flexed (curled position) with a pillow between the knees and legs and a pillow supporting the head. Prone position should be avoided because it accentuates lordosis.

How is Lumbar flexion increased ?

Initiating medications like antacids, H2 blockers, or proton pump inhibitors

How is chronic gastritis managed?

by assessing color, temperature, capillary refill time, edema, and pulses. Cyanotic nail beds suggest venous congestion. Pallor or dusky and cold digits, prolonged capillary refill time, and diminished pulses suggest impaired arterial perfusion. Edema may obscure the function of arterial pulsation, and Doppler ultrasonography may be used to verify a pulse. Pulselessness is a late sign.

How is peripheral circulation evaluated ?

Only by the palms so that indentations in the cast may be prevented; indentations can result in areas of pressure on the skin. If elevation is requested to reduce swelling, a cloth-covered pillow is preferred to one covered in plastic, which could retain heat and prevent drying. A wet plaster cast feels damp, appears dull and gray, sounds dull on percussion, and smells musty. The cast is dry when it feels hard and firm, has a white and shiny appearance, is resonant to percussion, and odorless.

How should the wet plaster cast be handled?

by rotating the gastric tube (not done with jejunostomy tubes) daily and moving the tube inward 2 to 10 cm at least once a week

How to prevent buried bumper syndrome, a severe, but rare complication?

avascular necrosis (AVN)

If a dislocation or subluxation is not reduced immediately, ____________ __________ (AVN) may develop. AVN of bone is caused by ischemia, which leads to necrosis or death of the bone cells. Signs and symptoms of a traumatic dislocation include acute pain, change in or awkward positioning of the joint, and decreased ROM. Bilateral assessment will usually make apparent the abnormality in the affected joint. X-rays are usually taken to confirm the diagnosis and reveal any associated fracture

zinc oxide-based protectants

If gastric contents leak and irritate the skin at the stoma site what protection base could be used?

to the medial collateral ligament.

If the knee is struck laterally, where may the damage occur?

a solution of 10% dextrose and water is infused to prevent hypoglycemia. The nurse would then order the next parenteral nutrition bag from the pharmacy.

If the parenteral nutrition solution runs or running out, what should the nurse do?

Fracture tibia/fibula

If the peroneal nerve is assessed; if damaged, the patient cannot dorsiflex the great toe and has diminished sensation in the first web space, so what is damaged?

Atopy

IgE-mediated diseases, such as allergic rhinitis, that have a genetic component which is a genetic predisposition to mount an IgE response to inhaled or ingested innocuous proteins.

actual shortening

In fractures of long bones, there is actual ____________of the extremity because of the compression of the fractured bone. Sometimes, muscle spasms can cause the distal and proximal site of the fracture to overlap, causing the extremity to shorten

some serous drainage, skin warmth, and mild redness at the pin sites are expected; these are expected to subside after 72 hours. The nurse monitors the neurovascular status of the extremity every 2 to 4 hours and promptly reports changes to the primary provider. Because the pins are inserted externally, particular attention is focused on the pin sites for signs of inflammation and infection. The goal is to avoid osteomyelitis. The nurse assesses each pin site at least every 8 to 12 hours for redness, swelling, pain around the pin sites, warmth, and purulent drainage, because these are the most common indicators of pin site infections

In the first 48 to 72 hours postinsertion, what is expected at the pin sites of external fixator?

about 5 cm (2 inches) to compensate for the change in weight distribution.

In wheelchairs designed for patients who have had amputations, how far is the rear axle set back?

PCL

Injury occurs when the foot is firmly planted and the leg sustains direct force, either forward or backward. If it is backward force places force on the ___. If the patient exhibits significant swelling of the joint within 2 hours after the injury, the ACL or PCL may be torn

ACL

Injury occurs when the foot is firmly planted and the leg sustains direct force, either forward or backward. If the force is forward, the ____suffers the impact from the force. If the patient exhibits significant swelling of the joint within 2 hours after the injury, the ACL or PCL may be torn

Actinic cheilitis

Irritation of lips associated with scaling, crusting, fissure; white hyperkeratosis (overgrowth of horny layer of epidermis) Considered a premalignant squamous cell skin cancer causes: Exposure to sun; more common in fair-skinned people and in those whose occupations involve sun exposure, such as farmers. Chronic inflammatory lesion that may lead to squamous cell cancer of the lip

Rebound hypoglycemia

Low blood sugar resulting from abrupt cessation of total parenteral nutrition solutions signs and symptoms: weakness, faintness, sweating, shakiness, feeling cold, confusion, and increased heart rate

Anatomic Area Clavicle fracture

Mechanism of Injury Fall on shoulder or outstretched arm Direct blow to the clavicle

Stomatitis

Mild erythema and edema; severe forms include painful ulcerations, bleeding, and secondary infection Inflammation of the mucous lining of the mouth Associated with chemotherapy; radiation therapy; severe drug allergy; myelosuppression (bone marrow depression)

tendonitis

Muscle tendon sheaths also become inflamed with repetitive stretching

Nursing management for low back pain

On physical examination, the nurse assesses the spinal curve, any leg length discrepancy, and pelvic crest and shoulder symmetry. The nurse palpates the paraspinal muscles and notes spasm and tenderness. When the patient is in a prone position, the paraspinal muscles relax and any deformity caused by spasm can subside.

radiculopathy

Pain radiating down the leg (i.e., pain radiating from a diseased spinal nerve root

either H2 blockers or proton pump inhibitors, and cytoprotective agents (e.g., misoprostol, sucralfate) because of the increased risk of upper GI tract hemorrhage

Patients at high risk for stress ulcers (e.g., patients who are mechanically ventilated for more than 48 hours) may be treated prophylactically with what medications ?

superior mesenteric artery syndrome, also known as cast syndrome

Patients immobilized in large casts may develop ___________ ____________ _____________ __________________, also known as ____ ________, a rare condition characterized by compression of the third portion of the duodenum between the aorta and superior mesenteric artery

Doses are tapered when discontinuing this medication to avoid adrenal insufficiency. The patient should be cautioned about side effects, which include fluid retention, weight gain, hypertension, gastric irritation, glucose intolerance, osteoporosis, immunosuppression, and adrenal suppression.

Patients who receive high-dose or long-term corticosteroid therapy must be cautioned not to stop taking the medication suddenly, why?

sling

Postoperatively, the shoulder is immobilized with a _____, a supportive arm bandage, for 4 to 6 weeks; length of time of immobilization depends on the severity of injury

Prophylactic therapy for NSAID ulcers Peptic ulcer healing doses of PPIs (above) Misoprostol 100-200 mcg qid

Prevents recurrent ulceration in approximately 80-90% of patients; qid dosing may decrease adherence to the regimen Pregnancy category X (i.e., should not be taken by a pregnant woman as it can soften the cervix and result in miscarriage or premature labor.)

Clinical Manifestations of GERD

Pyrosis (heartburn, specifically more commonly described as a burning sensation in the esophagus that is noncardiac in nature) and regurgitation are the hallmark symptoms, but patients may also experience dyspepsia (indigestion), dysphagia or odynophagia, hypersalivation, and esophagitis. Can result in dental erosion, ulcerations in the pharynx and esophagus, laryngeal damage, esophageal strictures, adenocarcinoma, and pulmonary complications

Lichen planus

Radiating white, lacelike striations on the tongue and buccal mucosa; often association with painful ulcerations and erythema Apply topical corticosteroids such as fluocinolone acetonide gel. Avoid foods that irritate. Administer corticosteroids systemically or intralesionally as prescribed. Instruct the patient of need for follow-up if condition is chronic.

Erythroplakia

Red, velvety, asymptomatic patch on the oral mucous membrane; most commonly located on the mouth floor, the ventral aspect of the tongue, and the soft palate

Chancre

Reddened circumscribed lesion that ulcerates and becomes crusted sign of syphilis

Billroth II (gastrojejunostomy)

Removal of lower portion (antrum) of stomach with anastomosis to jejunum. Dotted lines show portion removed (antrectomy). A duodenal stump remains and is oversewn.

Antrectomy Billroth I (gastroduodenostomy)

Removal of the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus. The remaining segment is anastomosed to the duodenum. May be performed in conjunction with a truncal vagotomy.

4-8 laterally, where they are thin and have less overlying musculature.

Rib fractures occur most often in which ribs?

Truncal vagotomy

Severs the right and left vagus nerves as they enter the stomach at the distal part of the esophagus; most commonly used to decrease acid secretions.

Selective vagotomy

Severs vagal innervation to the stomach but maintains innervation to the rest of the abdominal organs.

Aphthous stomatitis (canker sore)

Shallow ulcer with a white or yellow center and typically a well-defined red border; seen on the inner side of the lip and cheek or on the tongue; it begins with a burning or tingling sensation and slight swelling; painful; usually lasts 7-10 days (minor) and heals without a scar Use over-the-counter benzocaine as indicated

Ulcer healing H2 receptor antagonist Cimetidine 400 mg bid or 800 mg at bedtime Famotidine 20 mg bid or 40 mg at bedtime Nizatidine 150 mg bid or 300 mg at bedtime

Should be used for 6-8 wks for complete peptic ulcer healing; patients who are at high risk require a maintenance dose for 1 yr

c. Take opioid analgesics as prescribed. e. Take beta blockers as prescribed Explanation: Opioid analgesics may be effective in relieving phantom pain while beta blockers may relieve dull, burning discomfort. Heat, immobility, and elevation are not noted to relieve this form of pain.

Six weeks after an above-the-knee amputation (AKA), a client returns to the outpatient office for a routine postoperative checkup. During the nurse's assessment, the client reports pain in the missing limb. Which action(s) will the nurse inform the client to perform to reduce the discomfort? Select all that apply. a. Apply intermittent hot compresses to the area of the amputation. b. Avoid activity until the pain subsides. c. Take opioid analgesics as prescribed. d. Elevate the level of the amputation site. e. Take beta blockers as prescribed

Clinical manifestation of chronic gastritis

Some have no symptoms; may complain of fatigue, pyrosis (a burning sensation in the stomach and esophagus that moves up to the mouth; heartburn) after eating, belching, a sour taste in the mouth, halitosis, early satiety, anorexia, or nausea and vomiting. Some pts may have only mild epigastric discomfort or report intolerance to spicy or fatty foods or slight pain that is relieved by eatin

Anatomic Area Clavicle fracture

Sports Activity -Football -Rugby -Hockey -Wrestling -Gymnastics Acute management -Sling or shoulder immobilizer -Ice -NSAIDs

Antidiarrheal Bismuth subsalicylate

Suppresses H. pylori bacteria in the gastric mucosa and assists with healing of mucosal ulcers •Given concurrently with antibiotics to eradicate H. pylori infection •Should be taken on empty stomach •May darken the bowel movements

Prostaglandin E1 Analogue Misoprostol

Synthetic prostaglandin; protects the gastric mucosa from agents that cause ulcers; also increases mucus production and bicarbonate levels •Used to prevent ulceration in patients using NSAIDs •Administer with food •May cause diarrhea and cramping (including uterine cramping) •Used mainly for the treatment of duodenal ulcers •Pregnancy category X (i.e., should not be taken by a pregnant woman as it can soften the cervix and result in miscarriage or premature labor.)

medial epicondyle of the humerus and the ulnar styloid

The main pressure sites on the upper extremity are located at what part of the body?

Quality and Safety Nursing Alert!!!

The nurse AVOIDS using the affected extremity for blood pressure measurements and venipuncture in the patient with CRPS.

Correct response: "I will leave the dressing on until I follow up with my doctor as scheduled." Explanation: The first dressing is changed by the surgeon at a scheduled follow-up appointment.

The nurse is educating a client on home care following removal of a ganglion cyst from the right wrist. Which statement by the client demonstrates that the nurse's teaching has been effective?

Correct response: mucosal Explanation: Mucosal exposure can occur from the use of latex condoms, catheters, airways, and nipples. Parenteral exposure can occur from IV lines or hemodialysis equipment. Cutaneous exposure involves the wearing of latex gloves.

The nurse is teaching a client about latex allergies. What route of exposure from latex products occurs from use of latex condoms?

a. "The early stage of oral cancer is characteristically asymptomatic." b. "A lesion, lump, or other abnormality may be present on the lips or mouth."

The nurse is teaching a client with a family history of oral cancer about the early stage of the disease. Which statement(s) should the nurse include in the teaching? Select all that apply a. "The early stage of oral cancer is characteristically asymptomatic." b. "A lesion, lump, or other abnormality may be present on the lips or mouth." c. "Difficulty eating or tasting food may occur." d. "Pain and numbness are typically present." e. "Persistent hoarseness is a hallmark sign."

acute tenderness, swelling, paravertebral muscle spasm, and change in the normal curves or in the gap between spinous processes

The patient with a spinal fracture presents with what abnormalities?

rhinitis medicamentosa

The use of drops and sprays should be limited to a few days to avoid rebound congestion, which is also referred to as what?

Nasal decongestant sprays include phenylephrine, oxymetazoline, and naphazoline.

These agents vasoconstrict blood vessels in the nasal mucosa by blocking alpha-adrenergic receptors After using these agents for 3 to 7 days, reduced sensitivity of alpha-adrenergic receptors develops which can cause worsening nasal congestion.

Correct response: "Avoid coffee and alcoholic beverages." Explanation: To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren't gastric irritants.

To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?

Nicotine stomatitis (smoker's patch)

Two stages—begins as a red stomatitis; over time, the tongue and mouth become covered with a creamy, thick, white mucous membrane, which may slough, leaving a beefy red base

10 to 15 minutes to complete.

Typically a bolus tube feeding of 300 to 500 mL requires about how long to complete?

sugar tong splint

U-shaped splint that looks like tongs used for sugar cubes.) The splint is placed around the medial and lateral arm to the elbow and up to the top of the shoulder. The splint supports the arm in 90 degrees of flexion at the elbow; a sling or collar and cuff support the forearm. The weight of the hanging arm and splints put traction on the fracture site.

Orthopedic shoe inserts

Used for unequal leg length

Antibiotics and radiocontrast agents

What agents cause the most serious anaphylactic reactionsz?

•Cognitive-behavioral therapy (e.g., biofeedback) •exercise regimens •spinal manipulation •physical therapy •acupuncture •massage •yoga

What are all effective nonpharmacologic interventions for treating chronic low back pain?

Subtle personality changes, restlessness, irritability, or confusion

What are indications for immediate arterial blood gas studies in a patient who has sustained a fracture?

hematemesis, tachycardia, and hypotension

What are indicators of hemorrhagic gastritis?

Wound irrigation using a sterile isotonic saline solution and débridement (removal of tissues and foreign material) wound is cultured, and bone grafting may be performed to fill in areas of bone defects. The fracture is carefully reduced and stabilized by external fixation, and the wound is usually left open.

What are initiated in the operating room as soon as possible with an open fracture?

osteomyelitis (i.e., infection of the bone), tetanus, and gas gangrene Intravenous (IV) antibiotics are given upon the patient's arrival in the hospital along with intramuscular (IM) tetanus toxoid as indicated.

What are patient at risk for with an open fracture?

dumping syndrome and gastritis

What are the adverse effects of have a vagotomy?

Proton pump inhibitors

What are the strongest inhibitors of acid secretions?

Gastritis and hemorrhage from peptic ulcer

What are the two most common causes of upper GI tract bleeding?

pulmonary and include hypoxia, tachypnea, and dyspnea accompanied by tachycardia, substernal chest pain, low-grade fever, crackles, and additional manifestations of respiratory failure. Petechial rash may develop 2 to 3 days after the onset of symptoms

What are the typical first manifestations of Fat Embolism Syndrome?

lubrication, protection against harmful bacteria, and digestion

What are three main functions of saliva?

Hemorrhage and shock Bleeding arises mainly from the laceration of veins and arteries by bone fragments and possibly from a torn iliac artery. The peripheral pulses, especially the dorsalis pedis pulses of both lower extremities, are palpated; absence of a pulse may indicate a tear in the iliac artery or one of its branches. Abdominal CT may be performed to detect intra-abdominal hemorrhage. Excessive movement of the pelvis should be avoided, and the patient is handled gently so that bony fragments are not displaced, which may exacerbate bleeding and shock. Fluid replacement and analgesics are administered as needed. Exploratory laparotomy may be performed to further visualize the peritoneum.

What are two of the most serious consequences that can occur with pelvic fracture?

acute periapical abscess infection of the dental pulp extends through the apical foramen of the tooth to form an abscess around the apex.

What arises from an infection, usually secondary to dental caries?

the leg is shortened, adducted, and externally rotated

What assessment findings will you find with fractures of the femoral neck?

Hashimoto thyroiditis, Addison disease, and Graves' disease

What autoimmune disorders are associated with the development of chronic gastritis?

People with blood type O are more susceptible to the development of peptic ulcers than are those with blood type A, B, or AB

What blood type is more susceptible to the development of peptic ulcers ?

moleskin can be used over any rough area of the cast that may rub against the patient's skin

What can be used over any rough area of the case that can prevent skin breakdown?

mediastinal sepsis which may be accompanied by pneumothorax and subcutaneous emphysema

What can occur with Boerhaave syndrome?

manometry a process in which peristalsis, contraction amplitudes, and esophageal pressure is measured by a radiologist or gastroenterologist

What confirms the diagnoses of achalasia?

ambulatory pH monitoring Ambulatory pH monitoring involves transnasal catheter placement or endoscopic wireless capsule placement for approximately 24 hours.

What diagnostic testing is used for the diagnoses of GERD or a PPI trial which is gold standard?

ligament damage and possible instability of the knee joint.

What does knee effusion suggests ?

fiberglass or plaster of Paris, as these are materials that can be molded

What does the most common casting materials consist of ?f

stridor (coarse, high-pitched sound on inspiration) by listening frequently over the trachea with a stethoscope. This finding must be reported immediately because it indicates obstruction of the airway.

What does the nurse assess for immediately postoperative period after neck dissesction?

The nurse monitors for potential superior mesenteric artery syndrome, noting bowel sounds every 4 to 8 hours, and reports abdominal discomfort and distention, nausea, and vomiting to the primary provider.

What does the nurse monitors the patient in a large body cast for?

Antimicrobial drugs (amoxicillin), antimalarials, and calcium channel blockers

What drugs are the most frequently reported triggers of AGEP?

sodium, potassium, chloride

What electrolyte levels are assessed every 24 hours to detect any imbalance with gastritis?

Gastrostomy is preferred over nasogastric or orogastric feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely. Placement involves creation of a stoma, an artificially created opening, that houses the tube.

What feeding tube is preferred in a patient who is comatose?

Because these fractures cause pain with respiratory effort, the patient tends to decrease respiratory excursions and refrains from coughing. As a result, tracheobronchial secretions are not mobilized, aeration of the lung is diminished, and a predisposition to atelectasis and pneumonia results.

What happens because of rib fracture ?

Hemorrhage may occur which can result in frank bleeding or the formation of a hematoma. The following measures are indicated:

What happens if a carotid artery rupture as a result of necrosis of the graft or damage to the artery itself from tumor or infection?

synovial membrane secretes additional synovial fluid due to the irritation, and the knee becomes very edematous. Initial conservative management includes rest and immobilization of the knee, ice to the knee for 15 minutes every 4 to 6 hours, the use of crutches for support, anti-inflammatory agents, analgesic agents, and modification of activities to avoid those that cause the symptoms. Diagnosis is confirmed through MRI or arthroscopy

What happens when a meniscus is torn?

weakness at the shoulder that can cause shoulder drop, which is a forward curvature of the shoulder.

What happens when a patient has an excision of the sternocleidomastoid muscle and spinal accessory nerve?

Negative-pressure wound therapy using a vacuum dressing

What has been shown to be effective to remove fluids and decrease times to primary closure?

radical neck dissection

What involves removal of all cervical lymph nodes from the mandible to the clavicle and removal of the sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve on one side of the neck?

muscle spasm

What is a common symptom of low back pain?

Paralysis (no movement)

What is a late finding after prolonged ischemia and is associated with neurovascular injury?

the mucosa become gangrenous or perforate

What is a more severe form of acute gastritis which is caused by the ingestion of strong acid or alkali?

Boerhaave syndrome

What is a spontaneous rupture of the esophagus after forceful vomiting (may occur after eating a large meal), is characterized by retrosternal pain, dysphagia, infection, fever, and severe hypotension?

octreotide

What is a synthetic analogue of the natural hormone somatostatin, that works primarily by inhibiting the release of gastrointestinal hormones that regulate digestion and absorption, thereby reducing lymph flow and decreasing the chyle flow?

Glucagon

What is administered before removing a foreign body because it relaxes the smooth muscle of the esophagus, thereby facilitating insertion of the endoscope?

Edema

What is controlled by elevating the injured extremity and applying ice as prescribed?

erosive form of acute gastritis

What is most often caused by local irritants such as aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen); corticosteroids; alcohol consumption; and gastric radiation therapy?

Erosion of a circumscribed area of mucosa

What is the cause of peptic ulcer?

Dysphagia

What is the most common symptom of esophageal disease, which may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute odynophagia (pain on swallowing)? Often, the patient can indicate that the problem is located in the upper, middle, or lower third of the esophagus

skin and skeletal manual traction is only used briefly under healthcare provider direction

What is the most common traction?

Zenker diverticulum (ZD) caused by a dysfunctional sphincter that fails to open, which leads to increased pressure that forces the mucosa and submucosa to herniate through the esophageal musculature (called a pulsion diverticulum). It is usually seen in people older than 60 years of age.

What is the most common type of diverticulum?

boxer's fracture occurs when a closed fist bangs against a hard surface, fracturing the neck of the fifth finger. Falls and occupational injuries (e.g., machinery injuries, crushes) are the most common cause of phalangeal injury in adults

What is the most common type of metacarpal fracture in adults?

Volkmann ischemia contracture (an acute compartment syndrome), which results from antecubital swelling or damage to the brachial artery and leads to contracture (shortening) of the forearm muscles. This more commonly occurs in children than in adults and will result in a "clawlike" appearance to the hand and wrist. The nurse needs to monitor the patient regularly for compromised neurovascular status with the "5 Ps"; marked swelling and induration of the forearm are other signs

What is the most serious complication of a supracondylar fracture of the humerus?

Helicobacter pylori (H. pylori) which is most often caused by an infection with a spiral-shaped gram-negative bacterium?

What is the nonerosive form of acute gastritis?

approximately 300 mOsm/kg

What is the osmolality of normal body fluids (i.e., concentration) ?

functional bracing contoured thermoplastic sleeve is secured in place with interlocking fabric (Velcro) closures around the upper arm, immobilizing the reduced fracture. As swelling decreases, the sleeve is tightened, and uniform pressure and stability are applied to the fracture. The forearm is supported with a collar and cuff sling. Allows active use of muscles, shoulder and elbow motion, and good approximation of fracture fragments. Pendulum shoulder exercises are performed as prescribed to provide active movement of the shoulder, thereby preventing a "frozen shoulder." Isometric exercises may be prescribed to prevent muscle atrophy. The callus that develops is substantial, and the sleeve can be discontinued in about 8 weeks. Complications that are seen with humeral shaft fractures include neurovascular compromise and nonunion because of decreased blood supply in that area.

What is the preferred definitive treatment for a humerus shaft fracture?

Upper endoscopy because it allows direct visualization of inflammatory changes, ulcers, and lesions?

What is the preferred diagnostic procedure FOR GASTEIC ULCERS?

The nasal route

What is the preferred route for passing a tube when the client's nose is intact and free from injury also when healthcare provider of a client with oral cancer has ordered the placement of a GI tube to provide nutrition and to deliver medications?

footdrop (the inability to maintain the foot in a normally flexed position). Consequently, the patient drags the foot when ambulating.

What is the term called when there is an injury to the peroneal nerve as a result of pressure?

selective neck dissection

What is the treatment usually used in oral cavity cancer for patients who are infected with HPV?

malunion fracture

What kind of fracture occurs most commonly in fractures of the hand (or fingers)?

A medium to firm, nonsagging mattress (a bed board may be used) **there is no evidence to support the use of a firm mattress

What mattress is recommended for low back pain ?

Erosive gastritis

What may cause bleeding, which may manifest as blood in vomit or as melena (black, tarry stools; indicative of occult blood in stools) or hematochezia (bright red, bloody stools) ?

barium swallow

What may determine the exact nature and location of a diverticulum?

Immediate postoperative bleeding A large tourniquet should be in plain sight at the patient's bedside so that if severe bleeding occurs, it can be applied to the residual limb to control the hemorrhage. The nurse immediately notifies the surgeon in the event of excessive bleeding.

What may develop slowly or may take the form of massive hemorrhage resulting from a loosened suture?

Changing the patient's position or placing a light sandbag on the residual limb to counteract the muscle spasm

What may improve the patient's level of comfort with an amputation?

motor weakness

What may occur as a late sign of nerve ischemia?

1. preoperative epidural analgesia (preemptive analgesia) 2. Perioperatively, the patient may be managed with acetaminophen, NSAIDs, anticonvulsants (gabapentin), opioids, and NMDA receptor antagonists (ketamine infusion 3. Epidural and perineural catheter analgesia may be used during and immediately after the operation

What may reduce the incidence and severity of phantom limb pain over the long term?

Esophageal manometry

What measures the motility and internal pressure of the esophagus, which remains the standard test for irregular and high-amplitude spasms?

The use of NSAIDs Damage to the mucosal barrier also results in decreased resistance to bacteria, and thus infection from H. pylori bacteria may occur

What medication inhibits prostaglandin synthesis, which is associated with a disruption of the normally protective mucosal barrier?

Octreotide

What medication is used to treat Zollinger-Ellison syndrome (ZES) which suppresses gastrin levels?

The use of NSAIDs, such as ibuprofen and aspirin

What medication represents a major risk factor for peptic ulcers?

Misoprostol The nurse should be aware of this risk when caring for women of childbearing age.

What medication should not be taken by a pregnant woman as it can soften the cervix and result in miscarriage or premature labor.?

•Tricyclic antidepressants (e.g., amitriptyline) •dual-action serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine) •atypical anticonvulsant medications (e.g., gabapentin, which is prescribed for pain from radiculopathy)

What medications are used effectively in chronic low back pain?

The use of corticosteroids, anticoagulants, vasoconstrictors, or vasodilators

What medications may influence management and prolong or delay wound healing?

Dorsiflexion

What movement exacerbates signs and symptoms of a ganglion?

Patients with duodenal ulcers pain most commonly occurs 2 to 3 hours after meals

What pts secrete more acid than normal?

patients with gastric ulcers When the mucosal barrier is impaired, even normal or decreased levels of HCl may result in the formation of peptic ulcers.

What pts secrete normal or decreased levels of acid?

Avascular necrosis

What refers to the death of the bone from insufficient blood supply, typically manifested by complaints of increased pain and decreased function?

proton pump inhibitor, antibiotics, and sometimes bismuth salts

What select drug combinations can treat H. pylori ?

Thick cream moisturizers and emollients that contain glycerol or urea

What should be used as these will keep the skin hydrated?

medical identification such as a bracelet or necklace

What should people who are predisposed to anaphylaxis wear, which identifies allergies to medications, food, and other substances?

Stridor is the presence of coarse, high-pitched sounds on inspiration. The nurse would auscultate frequently over the trachea. This finding must be immediately reported because it indicates airway obstruction.

What should the nurse immediately report with radical neck dissection?

Manometric studies

What studies may be performed for patients with epiphrenic diverticula to rule out a motor disorder?

esophagomyotomy, called a Heller myotomy involves cutting the esophageal muscle fibers. A complete lower esophageal sphincter myotomy is usually performed laparoscopically, with or without a fundoplication (antireflux procedure that minimizes the incidence of GERD).

What surgery can treat achalasia?

Zollinger-Ellison syndrome (ZES)

What suspected when a patient has several peptic ulcers or an ulcer that is resistant to standard medical therapy?

aseptic technique along with general strategies such as cleansing each pin site separately to avoid cross contamination with nonshedding material (e.g., gauze, cotton-tip swab) and using chlorhexidine 2 mg/mL solution once weekly. Chlorhexidine can be an allergen, however. Therefore, the patient should be monitored for manifestations of an allergic reaction, which may include pruritus and/or contact dermatitis at the pin site, or, rarely in severe cases, angioedema and even anaphylactic shock. Pin sites should be cleaned and dressed as prescribed unless there is copious drainage, the dressing becomes wet, or infection is suspected, in which case cleaning and dressing may be more frequent. If signs of an allergic reaction or infection are present or if the pins or clamps seem loose, the nurse notifies the primary provider.

What technique is advised during pin insertion?

Radiologically inserted gastrostomy tube (RIG) The RIG is internally sutured and held in place by an internal balloon that is inflated with a small amount of water

What tube can be placed fluoroscopically by a skilled provider when an endoscope cannot be passed through a strictured or obstructed esophagus.

radiologically inserted gastrostomy tube (RIG) The RIG is internally sutured and held in place by an internal balloon that is inflated with a small amount of water

What tube can be placed fluoroscopically by a skilled provider when an endoscope cannot be passed through a strictured or obstructed esophagus?

streptococcal bacteria.

What type of bacteria is contained in thrombus aspirate and arterial blood taken from patients who had an ischemic stroke?

Stress ulcers Stress ulcers are believed to be a result of ischemia to gastric mucosa and alterations in the mucosa barrier. When the patient recovers, the lesions are reversed. This pattern is typical of stress ulceration.

What ulcers are most common in patients following significant burn injuries, traumatic brain injury, or who require mechanical ventilation?

bacteria, specifically gram-negative bacteria More recently, it was confirmed that these bacteria cause an inflammatory response that initiates an increase in inflammatory markers such as C-reactive protein, white blood cells, and fibrinogen. These markers are associated with an increased risk of cardiovascular disease.

What were the culprits that link periodontal disease to other systemic diseases, specifically coronary artery disease, including myocardial infarction and stroke?

when they are placed in the prone position; however, if they are also receiving enteral nutrition, they are at greater risk for aspiration in this position. These patients should be placed in reverse Trendelenburg, with their heads elevated 10 to 25 degrees, to minimize this risk

When does patients with severe COVID-19 pneumonia who are intubated and mechanically ventilated experience an improvement in their respiratory status?

the formula hang time in the bag at room temperature should never exceed what the formula manufacturer recommends, which is usually no more than 4 to 8 hours

When doing open system tube feeding, how do you avoid bacterial contamination?

the nurse notifies the healthcare provider. The nurse does NOT discard the aspirate because the client has partially digested this fluid. AFTER discussing with the healthcare provider, the nurse may stop the continuous feeding for some time or decrease the rate of infusion, but stopping the tube feeding is not an independent nursing action.

When excessive residual volume (more than 200 mL) of a nasogastric feeding occurs twice, what should the nurse do?

a 20-mL or larger syringe is used because the pressure generated by smaller syringes could rupture the tube

When small-bore feeding tubes for continuous infusion are irrigated after administration of medications, what size syringe is used?

Crepitus

When the extremity is gently palpated, a crumbling sensation, called __________, can be felt or may be heard. It is caused by the rubbing of the bone fragments against each other.

to the lateral collateral ligament.

When the knee is struck medially, where may damage occur?

oxidation of hemoglobin to methemoglobin

When vomited blood is bright red, or it have a dark coffee grounds appearance, what does that mean?

duodenum than in the stomach

Where are peptic ulcers more likely to occur?

stomach, duodenum, or proximal jejunum and help preserve GI integrity by preserving normal intestinal and hepatic metabolism

Where are tube feedings delivered?

lips, sides of the tongue, or floor of the mouth.

Where can cancer be found in the oral cavity?

cervical, thoracic, or abdominal portion of the esophagus

Where could esophageal perforation occur?

in the lesser curvature of the stomach, near the pylorus.

Where does chronic gastric ulcers tend to occur ?

gastroduodenal mucosa this tissue cannot withstand the digestive action of gastric acid (HCl) and pepsin. The erosion is caused by the increased concentration or activity of acid-pepsin or by decreased resistance of the normally protective mucosal barrier. A damaged mucosa cannot secrete enough mucus to act as a barrier against normal digestive juices. Exposure of the mucosa to gastric acid (HCl), pepsin, and other irritating agents (e.g., NSAIDs or H. pylori) leads to inflammation, injury, and subsequent erosion of the mucosa.

Where does peptic ulcers occur mainly?

Tibial fracture

Which fracture has an Increased risk for compartment syndrome and nonunion fracture?

Oral hairy leukoplakia

White patches with rough hairlike projections; typically found on lateral border of the tongue Epstein-Barr virus-induced lesion Related to smoking and the use of tobacco Associated with HIV infection

Leukoplakia

White patches; may be hyperkeratotic; usually in buccal mucosa; typically painless Fewer than 2% are malignant, but may progress to cancer (premalignant) Common among tobacco users

primary provider

Who reduces a fracture as soon as possible to prevent loss of elasticity from the tissues through infiltration by edema or hemorrhage.?

because caffeine is a central nervous system stimulant that increases gastric activity and pepsin secretion

Why does the nurse discourages the intake of caffeinated beverages with gastritis?

Smoking decreases the secretion of bicarbonate from the pancreas into the duodenum, resulting in increased acidity of the duodenum. Continued smoking is also associated with delayed healing of peptic ulcers. Therefore, the patient is encouraged to stop smoking.

Why is smoking cessation important for healing of peptic ulcers?

because of diminished production of intrinsic factor by the stomach's parietal cells due to atrophy, which may lead to pernicious anemia.

Why might pts with chronic gastritis may not be able to absorb vitamin b12?

It may adversely affect their absorption. In addition, to avoid nutrient and drug interactions, medications should not be mixed with the feeding formulas

Why should administering medications through postpyloric enteric tubes may be avoided?

Myofascial pain

a discomfort in the muscles controlling jaw function and in neck and shoulder muscles

Internal derangement of the joint

a dislocated jaw, a displaced disc, or an injured condyle

avulsion fracture

a fracture in which a fragment of bone has been pulled away by a tendon and its attachment

Traction

a pulling force exerted on a limb in a distal direction in an effort to return the bone or joint to normal alignment -reduces fracture, lessens muscle spasms, relieves pain, correct deformities promote rest, and allows for exercise.

Teachings about dislocation precautions

a. AVOID extremes of internal rotation, adduction, and 90-degree flexion of affected hip for at least 4-6wks after procedure b. prevent adduction: use an abduction pillow, AVOID crossing the legs, AVOID twisting to reach for objects behind, avoid driving a car, and AVOID taking tub baths for at least 4-6wks c. modifies equipment to AVOID 90-degree hip flexion (raised toilet seats, platform under chair, use of reachers, long-handled shoehorns, and sock pullers.

Amputation

a. Teach client how to care for residual limb: with focus on infection control and molding of the stump; wash daily using warm water and bacteriostatic soap, rinse and gently pat dry thoroughly, expose to air for at least 20 minutes after washing; AVOID use of lotions, alcohol, powder, or oils UNLESS prescribed by healthcare provider; change limb sock daily, wash sock using mild soap and dry flat, and discard sock that is in poor condition; molding of stump through proper bandaging enables easier fitting of prosthetic b. Instruct client to lie prone for 30 minutes 3-4 times/day (if client is able and if part of standard care) and AVOID elevating or sitting with residual limb on pillows to prevent flexion. c. Tell client that pain may persist in amputated extremity (phantom limb pain) and that this is normal and real; the discomfort will be treated with analgesics or other interventions.

skin or straight traction (using tape, boots, splints)

a. assists in reduction of a fracture (DOES NOT primarily achieve reduction) and helps decrease muscle spasms. b. generally used for short-term treatment (48-72 hours) and is applied directly to skin. c. weights range from 5-10 lbs. d. most common type is Buck's traction.

client-centered nursing care for low back pain

a. goal of treatment is to improve symptoms a slow progression of degenerative process b. bedrest on a FIRM mattress (and possibly bed boards) may be initially prescribed c. teach and assist to use a sleeping position consistent with principles of body mechanics (side-lying or supine with KNEES and HIPS flexed). d. heat and cold therapy may be used as adjuncts for pain relief e. physical therapy consultation will provide a plan for resuming activities and lower-back strengthening exercises. f. include client and family in the plan g. provide emotional support

Skeletal traction (using pins, or wires inserted into bones)

a. indicated for long-term use. b. used to align injured bones and joints or to treat joint contractures and congenital hip dysplasia. c. weights range from 5-45lbs and amounts of weight may be adjusted initially until full fracture reduction is achieved by x-ray results.

Client education: post procedure after arthroscopy

a. take analgesics for comfort and limit activity as directed b. observe site for hematoma or bleeding c. How to perform neurovascular assessment (temperature, color, refill, movement, and sensation) on affected extremity d. signs and symptoms of infection to report: elevated temperature, warmth at injection site, purulent discharge, and redness.

client education post procedural for arthrogram

a. temporary discoloration of skin and urine is normal after injection or dye; increase fluid to eliminate contrast. b. How to perform neurovascular assessment on affected extremity.

Balanced suspension (traction that is hanging support to immobilize body part in a desired position)

a. used with skeletal traction to improve mobility while maintaining alignment of fraction. b. body part is suspended using splints, ropes, and weights. c. client able to perform activities such as toileting and personal hygiene; bed linen can be changed without disturbing traction alignment.

Secondary Mediators Inactive Precursors Formed or Released in Response to Primary Mediators Bradykinin (derived from precursor kininogen)

ability to cause increased vascular permeability, vasodilation, hypotension, and contraction of many types of smooth muscle, such as the bronchi. Increased permeability of the capillaries results in edema. Bradykinin stimulates nerve cell fibers and produces pain. Smooth muscle contraction, increased vascular permeability, stimulates pain receptors, increased mucus production

Clinical examination of Achilles tendon

ability to plantar flex is decreased and to dorsiflex is improved. Nonoperative modalities include cast immobilization for 2 to 8 weeks. After immobilization with the cast, a boot and functional brace with a heel lift is worn with increasing weight-bearing status. The total rehabilitation is approximately 6 weeks

Below-knee amputation (BKA)

above-knee amputation (AKA) because of the importance of the knee joint and the energy requirements for walking

Severe systemic reactions

abrupt onset with the same signs and symptoms described previously. These symptoms progress rapidly to bronchospasm, laryngeal edema, severe dyspnea, cyanosis, and hypotension. Dysphagia (difficulty swallowing), abdominal cramping, vomiting, diarrhea, and seizures can also occur. Cardiac arrest and coma may follow. Severe reactions are also referred to as anaphylactic shock

menisci

act as shock absorbers in the knee. Normally, little twisting movement is permitted in the knee joint. Forceful twisting of the knee or repetitive squatting and impact may result in either tearing or detachment of the cartilage from its attachment to the head of the tibia. The peripheral third of the menisci have a small amount of blood flow, which allows that portion to heal if torn.

Type IV reactions

activated T cells, which take time to develop. Type IV reactions usually take at least 48 to 72 hours and sometimes days to weeks to develop following exposure to the drug. There reactions can vary from a nonurticarial, maculopapular rash (drug fever) to Stevens-Johnson syndrome and toxic epidermal necrolysis, or drug rash with eosinophilia and systemic symptoms, or DRESS/DiHS.

side effects of oral corticosteroid therapy

adrenal suppression, fluid retention, weight gain, glucose intolerance, hypertension, and gastric irritation.

Primary Mediators Preformed and Found in Mast Cells or Basophils Eosinophil chemotactic factor of anaphylaxis (preformed in mast cells)

affects the movement of eosinophils (granular leukocytes) to the site of allergens. It is preformed in the mast cells and is released from disrupted mast cells. Attracts eosinophils.

Pathophysiology Allergic rhinitis

allergen-specific IgE-mediated immunologic response. Sensitization most commonly begins by inhalation of antigen. IgE antibodies are stimulated and bind to mast cells in the respiratory mucosa, basophils in the peripheral blood, and eosinophils in the nasal and respiratory mucosa. Eosinophilia in the tissues is the key characteristic of allergic rhinitis. When IgE antibodies bind to mast cells there is histamine release. Histamine is the major mediator of allergic reactions in the nasal mucosa. Inflammation, tissue edema, vasodilation, and increased capillary permeability occur

Angioedema The regions most often involved in angioedema are the lips, eyelids, cheeks, hands, feet, genitalia, and tongue; the mucous membranes of the larynx, bronchi, and gastrointestinal tract may also be affected, particularly in the hereditary type.

allergic reaction that involves the infiltration of fluid in subcutaneous tissue and mucous membranes resulting in diffuse swelling. It is manifested by nonpruritic, brawny, widespread, nonpitting edema.

Frey syndrome

also known as auriculotemporal syndrome, involves facial sweating and flushing in the general location of the (removed) parotid gland that occurs while eating. May be successfully treated with botulinum toxin type A injections.

RICE method

an acronym that refers to rest, ice, compression, and elevation. Rest prevents additional injury and promotes healing. Intermittent application of cold or ice packs during the first 24 to 72 hours after injury produces vasoconstriction, which decreases bleeding, edema, and discomfort. Cold packs should NOT be in place for longer than 20 minutes at a time, and care must be taken to avoid skin and tissue damage from excessive cold. Elastic compression bandage controls bleeding, reduces edema, and provides support for the injured tissues. Elevation at or just above the level of the heart controls the swelling. If the sprain or strain is the most severe grade or degree, immobilization by a splint, brace, or cast may be necessary so that the joint will not lose its stability no

Systemic Manifestations Of chronic gastritis

anemia and fatigue

splints

applied to immobilization

Type I reflex sympathetic dystrophy

applies to patients with CRPS without evidence of peripheral nerve injury

Lumbar support belts

are NOT recommended to treat acute low back pain but may be marginally effective devices for preventing low back pain in occupational health settings

Leukotrines, bradykinin, and serotonin

are all secondary chemical mediators

VTE, including DVT and PE

are associated with reduced skeletal muscle contractions and bed rest Patients with fractures of the lower extremities and pelvis are at high risk for VTE

Allergic reactions to foods, latex, certain drugs, or insect stings

are common examples of mast cell-mediated angioedema.

Alpha-adrenergic agonist ophthalmic drops, such as tetrahydrozoline

are commonly used for allergic conjunctivitis as they vasoconstrict the blood vessels of the eye.

bursae

are fluid-filled sacs that prevent friction between joint structures during joint activity and are painful when inflamed

Primary mediators

are found in mast cells or basophils

Intracapsular fractures

are fractures of the femoral head and neck. Higher rate of nonunion or malunion and femoral neck fractures may damage the vascular system that supplies blood to the head and the neck of the femur, and the bone may become ischemic.

Nasal decongestants

are helpful when used just before air travel in patients who have difficulties with middle ear or sinus equilibration with flying or in patients who have problems with altitude changes

Opioid medications

are indicated only short term (1 to 2 weeks) for acute moderate to severe cases of low back pain, except in older adults, those with kidney disease, or those who must AVOID chronic NSAID exposure because of its adverse gastric effect.

Bursitis and tendonitis

are inflammatory conditions that commonly occur in the shoulder

Type III reactions

are mediated by antigen-antibody complexes that deposit on basement membranes and usually present as serum sickness, vasculitis, or drug fever. Signs and symptoms take 1 or more weeks to develop after drug exposure, since significant quantities of antibody are needed to generate symptoms related to antigen-antibody complexes. These are uncommon reactions but are seen with antitoxins for rabies, botulism, and venoms, tetanus, hepatitis, and diphtheria vaccines

Adverse effects of corticosteroid nasal sprays

are mild and include drying of the nasal mucosa and burning and itching sensations caused by the vehicle used to administer the medication

Systemic corticosteroids and acetaminophen

are not effective in fully alleviating acute low back pain

Oral adrenergic agents

are not first-line agents in allergy and have potential for cardiovascular and neurological adverse effects

Acute traumatic dislocations

are orthopedic emergencies because the associated joint structures, blood supply, and nerves are displaced and may be entrapped with extensive pressure on them

Deaths from malignancies of the head and neck

are primarily attributable to regional metastasis to the cervical lymph nodes in the neck and extra capsular spread, which is a specific characteristic of regional metastasis where the malignant tumor in the lymph node extends into the surrounding connective tissue.

lower lumbar discs, L4-5 and L5-S1

are subject to the greatest mechanical stress and the greatest degenerative changes

Anticonvulsant agents (e.g., lamotrigine, phenytoin, phenobarbital) and allopurinol

are the most frequently reported causes of drug rash with eosinophilia and systemic symptoms (DRESS)

Displaced femoral neck fractures

are treated as emergencies, with reduction and internal fixation performed within 24 hours after fracture. *BLOOD SUPPLY IS INTERRUPTED *RISK OF AVASCULAR NECROSIS IS HIGH DUE TO LOSS OF BLOOD SUPPLY *A FULL HIP PROSTHESIS IS ONLY OPTION OF REPAIR

Standard polymeric formulas

are undigested and require that the patient has relatively normal digestive function and absorptive capacity

H2 blockers and proton pump inhibitors that reduce gastric acid secretion

are used to treat ulcers NOT associated with H. pylori infection.

malignancies of the oral cavity

are usually squamous cell carcinomas

Gastric outlet obstruction

area distal to the pyloric sphincter becomes scarred and stenosed from spasm or edema or from scar tissue that forms when an ulcer alternately heals and breaks down. The patient may have nausea and vomiting, constipation, epigastric fullness, anorexia, and, later, weight loss.

dislocation of a joint

articular surfaces of the distal and proximal bones that form the joint are no longer in anatomic alignment

Dupuytren disease

associated with arthritis, diabetes, gout, cigarette smoking, and alcoholism patient may experience dull and aching discomfort, morning numbness, and stiffness in the affected fingers. This condition starts in one hand, but eventually both are affected

intravenous fat emulsion

attached to a Y connector close to the infusion site. The fat emulsion is administered simultaneously with the parenteral nutrition admixture

Gastroesophageal reflux disease (GERD)

backflow of gastric or duodenal contents into the esophagus that causes troublesome symptoms and/or mucosal injury to the esophagus. Excessive reflux may occur because of an incompetent lower esophageal sphincter, pyloric stenosis, hiatal hernia, or a motility disorder. The incidence of GERD seems to increase with aging and is seen in patients with irritable bowel syndrome and obstructive airway disorder exacerbations (e.g., asthma, COPD, cystic fibrosis), peptic ulcer disease, and angina. GERD is associated with tobacco use, coffee drinking, alcohol consumption, and gastric infection with Helicobacter pylori.

sialadenitis

bacterial or viral infection of the salivary glands

Antibiotic Amoxicillin

bactericidal antibiotic that assists with eradicating H. pylori bacteria in the gastric mucosa •May cause abdominal pain and diarrhea •Should NOT be used in patients allergic to penicillin

Fracture healing,

based upon clinical assessment and x-ray findings, takes about 10 to 14 weeks; it takes about 6 to 9 months until full function is restored

Heterotopic ossification

benign bone growth in an atypical location, such as in the soft tissue. Heterotopic ossification that is categorized as traumatic myositis ossificans usually develops in response to soft tissue trauma (e.g., contusion, sprain). It is characterized by pain and joint stiffness that causes decreased ROM. It typically occurs in young males after musculoskeletal sports injuries. If significant ROM dysfunction persists, surgery may be indicated to remove the bone growth and restore function.

Soft corns

between the toes and are kept soft by moisture. Treatment consists of drying the affected spaces and separating the affected toes with lamb's wool or gauze. A wider shoe and toe box may be helpful

Leukotriene receptor antagonists (LTRAs), such as zafirlukast and montelukast

block the synthesis or action of leukotrienes and prevent the signs and symptoms associated with acute asthma. ***Leukotriene receptor antagonists are for long-term use, and patients should be advised to take their medication daily

Large-bore (larger than 12-Fr) nasogastric (NG) tubes

can be uncomfortable and their usefulness for tube feedings is limited; however, they may be used for administration of short-term feedings

Alpha-adrenergic agonist (also called sympathomimetic) medications, such as pseudoephedrine

can be used as decongestants in allergies. These agents activate alpha-adrenergic receptor sites on the smooth muscle causing vasoconstriction of the nasal mucosal blood vessels, reducing local blood flow, fluid exudation, and mucosal edema

First-generation antihistamines

can have anticholinergic effects such as dry mouth, blurry vision, urinary hesitancy, and confusion. Due to their anticholinergic effects, first-generation antihistamines should be avoided in older adults.

Early manifestations of impingement syndrome

characterized by edema from hemorrhage of these structures, pain, shoulder tenderness, limited movement, muscle spasm, and eventual disuse atrophy. The process may progress to a partial or complete rotator cuff tear

Gustilo-Anderson

classifies the severity into three categories based on the extent of soft-tissue injury and the size of the corresponding skin wounds

ganglion

collection of neurologic gelatinous material near the tendon sheaths and joints—appears as a round, firm swelling locally tender and may cause an aching pain. When a tendon sheath is involved, weakness of the finger occurs

ganglion

collection of neurologic gelatinous material near the tendon sheaths and joints—appears as a round, firm, cystic swelling, usually on the dorsum of the wrist. It frequently occurs in women younger than 50 years. The swelling is locally tender and may cause an aching pain. When a tendon sheath is involved, weakness of the finger occurs. Treatment may include aspiration, corticosteroid injection, or surgical excision. After treatment, a compression dressing and immobilization splint are used.

Fractures of the distal radius (Colles fracture)

common and are usually the result of a fall on an open, outstretched hand, with the wrist in extension

Cushing ulcer

common in patients with a traumatic head injury, stroke, brain tumor, or following intracranial surgery. Thought to be caused by increased intracranial pressure, which results in overstimulation of the vagal nerve and an increased secretion of gastric acid (HCl). Typically deep, single ulcerations and have increased risk of perforation.

Open reduction internal fixation (ORIF)

common orthopedic surgical procedure used to treat severe fractures.

Clinical Manifestations of sliding hernia

commonly associated with GERD; may have pyrosis, regurgitation, and dysphagia, but many patients are asymptomatic. The patient may present with vague symptoms of intermittent epigastric pain or fullness after eating. Large hiatal hernias may lead to intolerance to food, nausea, and vomiting. Hemorrhage, obstruction, volvulus (bowel obstruction caused by a twist in the intestines and supporting mesentery), and strangulation can occur with any type of hernia but are more common with paraesophageal hernia

Ewing sarcoma

commonly on the mandible; initial symptoms include swelling, pain, paresthesia, and dental displacement Cancer (most often the primary site) that is often initially mistaken for dental infection. Median age at onset is 14 yrs old

Patients with peripheral vascular disease and arteriosclerosis

complain of burning and itching feet, resulting in scratching and skin breakdown. Foot deformities may occur with Rheumatoid arthritis (RA)

fracture

complete or incomplete disruption in the continuity of bone structure and is defined according to its type and extent and occur when the bone is subjected to stress greater than it can absorb. May be caused by direct blows, crushing forces, sudden twisting motions, and extreme muscle contractions. When the bone is broken, adjacent structures are also affected, which may result in soft tissue edema, hemorrhage into the muscles and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels. Body organs may be injured by the force that caused the fracture or by fracture fragments.

Grade III sprain

complete tear or rupture of the ligament which may also cause an avulsion of the bone. Symptoms include severe pain, edema, tenderness, ecchymosis, and abnormal joint motion.

Complex Regional Pain Syndrome (CRPS)

complex and rare disorder characterized by regional pain in a limb that is disproportionate; it typically begins following a fracture, soft tissue injury, or surgery. Dysfunctional peripheral and central nervous system responses that mount an excessive response to the precipitating event (e.g., fracture, surgery) are thought to be the cause of the pain. Women are affected more often than men, and the average age of diagnosis is 40 years .

Fiberglass Casts

composed of polyurethane resins that have the versatility of plaster but are lighter in weight, stronger, water resistant, and more durable than plaster. Facilitate radiographic imaging better than plaster and have the benefit of reaching full rigidity within 30 minutes of application. Because they tend to be more difficult to contour and mold, commonly used for simple fractures of the upper and lower extremities. They consist of an open-weave, nonabsorbent fabric that requires tepid water for activation. Heat is given off (an exothermic reaction) while the cast is applied. The heat given off during this reaction can be uncomfortable, and the nurse should prepare the patient for the sensation of increasing warmth so that the patient does not become alarmed. Can cause thermal injury like plaster casts, but the risk is less

Dumping syndrome

concentrated solution of high osmolality entering the stomach is taken in quickly or in large amounts, the small intestines expand and water moves rapidly into the intestinal lumen from fluid surrounding the organs and the vascular compartment. patient may have feelings of fullness, nausea, cramping, dizziness, diaphoresis, and osmotic diarrhea. This can lead to dehydration, hypotension, and tachycardia

Chemically defined or predigested formulas

contain easier-to-absorb nutrients

arthrogram

contrast media or air is injected into joint cavity to allow for visualization of joint structures; client moves joint through a series of movements while a series of x-rays are take; assess for allergy to contrast media preprocedure.

anticonvulsants

control stabbing and cramping pain

Type III, or immune complex hypersensitivity,

damaging inflammatory reaction caused by the insoluble immune complexes formed by antigens that bind to antibodies. They are deposited in tissues or vascular ends are too large to be cleared from the circulation by phagocytic actiothelium and trigger inflammation at different sites throughout the body. An example of this kind of hypersensitivity reaction occurs in rheumatoid arthritis. An unknown antigen triggers antibody formation, which then forms immune complexes that are deposited in the joints. Many autoimmune disorders are type III hypersensitivity reactions. In autoimmune reactions, such as systemic lupus erythematosus, patients form autoantibodies that form immune complexes that deposit in the lungs, skin, and kidney

disuse syndrome

deterioration of body systems as a result of prescribed or unavoidable musculoskeletal inactivity. To prevent this, the nurse instructs the patient to tense or contract muscles (e.g., isometric muscle contraction) without moving the underlying bone. Isometric exercises, such as instructing the patient with a leg or arm cast to splint or brace to "push down" the knee or to "make a fist," respectively, helps reduce muscle atrophy and maintain strength. Muscle setting exercises (e.g., quadriceps and gluteal setting exercises) are important in maintaining muscles essential for walking. Isometric exercises should be performed hourly while the patient is awake.

hematoma

develops from bleeding at the site of impact, leaving a characteristic "black and blue" appearance

chemical peritonitis

develops within a few hours of perforation and is followed by bacterial peritonitis, the perforation must be closed as quickly as possible and the abdominal cavity lavaged of stomach or intestinal contents. In some patients, it may be safe and advisable to perform surgery to treat the ulcer disease in addition to suturing the perforation.

provocative testing

direct administration of the suspected allergen to the sensitive tissue, such as the conjunctiva, nasal or bronchial mucosa, or gastrointestinal tract (by ingestion of the allergen), with observation of target organ response. This type of testing is helpful in identifying clinically significant allergens in patients who have a large number of positive tests. Major disadvantages of this type of testing are the limitation of one antigen per session and the risk of producing severe symptoms, particularly bronchospasm, in patients with asthma

gastroesophageal reflux disease (GERD):

disorder marked by backflow of gastric or duodenal contents into the esophagus that causes troublesome symptoms and mucosal injury to the esophagus

Pilon fractures

distal fractures of the tibia that extend into the joint

baboon syndrome

distinctive drug eruption that typically develops within a few hours to days of drug exposure and presents with demarcated, V-shaped erythema in the gluteal/perianal or inguinal/perigenital areas, often with involvement of at least one other flexural area, such as the axillae, elbows, or knees. Aminopenicillins are a common trigger of SDRIFE

PROVIDING WOUND CARE after radical neck surgery

drainage tubes are connected to a portable suction device (e.g., Jackson-Pratt), and the container is emptied periodically. Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours. Excessive drainage may be indicative of a chyle fistula or hemorrhage. dressings are reinforced as needed and are observed for evidence of hemorrhage and constriction, which impair respiration and perfusion of the graft. A graft, if present, is assessed for color and temperature and for the presence of a pulse, if applicable, to determine viability. The graft should be pale pink and warm to the touch.

Clinical Manifestations of pharyngoesophageal pulsion diverticulum

dysphagia, fullness in the neck, belching, regurgitation of undigested food, and gurgling noises after eating. The diverticulum, or pouch, becomes filled with food or liquid. When the patient assumes a recumbent position, undigested food is regurgitated, and coughing may be caused by irritation of the trachea or aspiration. Halitosis (foul odor from the oral cavity) and a sour taste in the mouth are also common because of the decomposition of food retained in the diverticulum. Although less acute, dysphagia is the primary symptom in the other types of diverticulum.

Management of GERD

educating the pt to avoid situations that decrease lower esophageal sphincter pressure or cause esophageal irritation. Lifestyle modifications include tobacco cessation, limiting alcohol, weight loss, elevating the head of the bed, avoiding eating before bed, and altering the diet.

Anticonvulsant agents (e.g., gabapentin) and antidepressant agents (e.g., amitriptyline)

effective in treating neuropathic pain.

Perforation

erosion of the ulcer through the gastric serosa (thin membrane covering the outer surface of the stomach) into the peritoneal cavity without warning. It is an abdominal emergency and requires immediate surgery. Occurs more commonly with duodenal ulcers than it does with gastric ulcers; however, in both cases, it is a very serious complication that can result in sepsis or multiorgan failure.

Penetration

erosion of the ulcer through the gastric serosa into adjacent structures such as the pancreas, biliary tract, or gastrohepatic omentum (membranous fold of the peritoneum). Symptoms of penetration include back and epigastric pain not relieved by medications that were effective in the past. Like perforation, penetration usually requires surgical intervention

peptic ulcer

excavation (hollowed-out area) that forms in the mucosa of the stomach, in the pylorus (the opening between the stomach and duodenum), in the duodenum (the first portion of the small intestine, between the stomach and the jejunum), or in the esophagus. Erosion of a circumscribed area of mucosa is the cause. This erosion may extend as deeply as the muscle layers or through the muscle to the peritoneum (thin membrane that lines the inside of the wall of the abdomen.

Clinical Manifestations of esophageal perforation

excruciating retrosternal pain followed by dysphagia. Infection, fever, leukocytosis, and severe hypotension .

Fat embolism syndrome (FES)

fat emboli enter circulation following orthopedic trauma, especially long bone (e.g., femur) and pelvic fractures, more frequent in closed fractures than in open fractures). At the time of fracture, fat globules may diffuse from the marrow into the vascular compartment. The fat globules (e.g., emboli) may occlude the small blood vessels that supply the lungs, brain, kidneys, and other organs. The onset of symptoms is rapid, typically within 24 to 72 hours of injury, but may occur up to a week after injury, the occurs more frequently in males than in females, with its highest incidence in those between the ages of 10 and 40 years.

Hammer toe

flexion deformity of the interphalangeal joint, which may involve several toes. Tight socks or shoes may push an overlying toe back into the line of the other toes. The toes usually are pulled upward, forcing the metatarsal joints (ball of the foot) downward. Corns develop on top of the toes, and tender calluses develop under the metatarsal area. Treatment: wearing open-toed sandals (unless the patient has diabetes) or shoes that conform to the shape of the foot with a round toe box, carrying out manipulative exercises, and protecting the protruding joints with pads. Osteotomy (surgical cutting of the bone) may be used to correct a resulting deformity. Orthotics may help prevent hammer toe in people with high arches. Attention is required for patients with diabetes who may develop friction points, causing wounds.

Moderate systemic reactions

flushing, warmth, anxiety, and itching in addition to any of the milder symptoms. More serious reactions include bronchospasm and edema of the airways or larynx with dyspnea, cough, and wheezing. The onset of symptoms is the same as for a mild reaction

Pes cavus (clawfoot)

foot with an abnormally high arch and a fixed equines deformity of the forefoot. The shortening of the foot and increased pressure produce calluses on the metatarsal area and on the dorsum of the foot. Exercises are prescribed to manipulate the forefoot into dorsiflexion and relax the toes. Orthotic devices alleviate pain and can protect the foot. In severe cases, arthrodesis (fusion) is performed to reshape and stabilize the foot.

Salivary calculi

formed mainly from calcium phosphate. If located within the gland, the calculi are irregular and vary in diameter from 1 to 35 mm. Sialendoscopy is considered the standard in the treatment of sialothiasis, but gland-preserving incisional approaches alone may also be used for palpable stones 6 mm or larger. Lithotripsy, a procedure that uses shock waves to disintegrate the stone, may be used instead of surgical extraction for parotid stones and smaller submandibular stones.

halitosis

foul odor from the oral cavity; in laypersons' terms, "bad breath"

impacted fracture

fracture in which bone fragments are pushed into each other

pathologic fracture

fracture that occurs through an area of diseased bone (e.g., osteoporosis, bone cyst, Paget disease, bony metastasis, tumor)

Periprosthetic fractures

fractures to the regions surrounding prosthetics joints which are increasing due to the growing number patients having previously had total joint replacements

Onychocryptosis (ingrown toenail)

free edge of a nail plate penetrates the surrounding skin. A secondary infection or granulation tissue may develop. This painful condition is caused by improper self-treatment, external pressure (tight shoes or stockings), internal pressure (deformed toes, growth under the nail), trauma, or infection. Trimming the nails properly (clipping them straight across and filing the corners consistent with the contour of the toe) can prevent this problem. Active treatment consists of washing the foot twice a day and relieving the pain by decreasing the pressure of the nail plate on the surrounding soft tissue. Warm, wet soaks help drain an infection.

Trauma

frequent cause of musculoskeletal injury

Arthrodesis

fusion of a joint (most often the wrist or knee) for stabilization and pain relief.

With decreased physical activity

gastrointestinal motility decreases, and intestinal gases accumulate. Physiologic manifestations include abdominal distention and discomfort, nausea, and bilious vomiting, which can lead to food aversion, poor intake, malnourishment, and weight loss

Fluoridation of public water supplies

has been found to decrease dental caries

comminuted fracture

has more than two fragments

Delayed union

healing does NOT occur within the expected timeframe for the location and type of fracture. May be associated with distraction (pulling apart) of bone fragments, systemic or local infection, poor nutrition, or comorbidity (e.g., diabetes, autoimmune disease). The healing time is prolonged, but the fracture eventually heals

corn

hyperkeratosis (overgrowth of a horny layer of epidermis) produced by internal pressure (the underlying bone is prominent because of a congenital or acquired abnormality, commonly arthritis) or external pressure (ill-fitting shoes). The fifth toe is most frequently involved. •treated by a podiatrist by soaking and scraping off the horny layer, by application of a protective shield or pad, or by surgical modification of the underlying offending osseous structure. •Early intervention is required for patients with diabetes.

classic triad of clinical manifestations of FES includes

hypoxemia, neurologic compromise, petechial rash

client education preprocedural for arthrogram

if injected contrast dye is used, inform client that once dye is injected there may be a feeling of warmth, nausea, headache, salty taste in mouth, itching, hives, and rash throughout body.

Impingement syndrome

impaired movement of the rotator cuff of the shoulder which usually occurs from repetitive overhead movement of the arm or from acute trauma resulting in irritation and eventual inflammation of the rotator cuff tendons or the subacromial bursa as they grate against the coracoacromial arch.

nonunion fracture

incomplete healing of a fracture and results from failure of the ends of a fractured bone to unite

The immobility of lower extremity surgery

increases the risk of venous thromboembolism (VTE) development

Nasoduodenal or nasojejunal feeding

indicated when the esophagus and stomach need to be bypassed or when the patient is at risk for aspiration (i.e., inhalation of fluids or foods into the trachea and bronchial tree).

jejunostomy tube tubes either have an internal balloon or dacron cuff, or are sutured externally to secure them. Unlike the gastrostomy tubes, jejunostomy tubes should not be rotated and only last between 6 to 9 months. The small intestine can also be accessed by placing a jejunal extension tube through an existing gastrostomy tube and manipulating it through the pylorus into the small intestine endoscopically, fluoroscopically, or during a surgical procedure this is referred to as a gastrojejunostomy tube.

indicated when the gastric route is not accessible, or to decrease aspiration risk when the stomach is not functioning adequately to process and empty food and fluids

enteric route

infers that the intestines are receiving nutrients.

Plantar fasciitis

inflammation of the foot-supporting fascia, presents as an acute onset of heel pain experienced with the first steps in the morning. The pain is localized to the anterior medial aspect of the heel and diminishes with gentle stretching of the foot and Achilles tendon.

Novel treatments under investigation for complex regional pain syndrome include

infusions of immunoglobulin (IVIG) and ketamine and the use of hyperbaric oxygen

Severe MCL injuries

initially treated with non-weight-bearing status with progression to weight bearing as tolerated in a hinged-brace for a lengthy timeframe; the healing process may take 8 to 12 weeks

Arteriography with embolization or Transcatheter Arterial Embolization (TAE)

interventional radiologic procedure in which a catheter is placed percutaneously (through the skin) into an artery (e.g., femoral or brachial artery) and is advanced under use of fluoroscopy to the site of the bleeding peptic ulcer. An embolic agent is then delivered via the catheter, which selectively occludes blood flow to the bleeding vessel(s), and thus stops bleeding of the peptic ulcer. Common embolic agents used include metallic coils (a small metal device) and ethylene vinyl alcohol copolymer

second-degree strain

involves moderate stretching and/or partial tearing of the muscle or tendon. Signs and symptoms include acute pain during the precipitating event, followed by tenderness at the site with increased pain with passive ROM (PROM), edema, significant muscle spasm, and ecchymosis.

Epicondylitis

is a chronic, painful condition that is caused by excessive, repetitive extension, flexion, pronation, and supination motions of the forearm

Type I fracture characteristics

is a clean wound less than 1 cm long and simple fracture pattern

Disc degeneration

is a common cause of back pain.

Hallux valgus (bunion)

is a deformity in which the great toe deviates laterally. There is a marked prominence of the medial aspect of the first metatarsophalangeal joint. There is also osseous enlargement (exostosis) of the medial side of the first metatarsal head, over which a bursa may form (secondary to pressure and inflammation). Acute bursitis symptoms include a reddened area, edema, and tenderness. Factors contributing to bunion formation include heredity, ill-fitting shoes, osteoarthritis, and the gradual lengthening and widening of the foot associated with aging. Treatment depends on the patient's age, the degree of deformity, and the severity of symptoms. In uncomplicated cases, wearing a shoe that conforms to the shape of the foot, or that is molded to the foot to prevent pressure on the protruding portions, may be the only treatment needed. Corticosteroid injections control acute inflammation. In advanced cases, surgical removal of the exostosis and toe realignment may be required to improve function, appearance, and symptoms. If surgery is required in an athlete, at least 3 months of rest is required before returning to play

Allergic contact dermatitis

is a delayed (type 4) hypersensitivity reaction to exogenous contact antigens that involves activation of T cells

gastrostomy

is a procedure in which an opening is created into the stomach either for the purpose of administering nutrition, fluids, and medications via a feeding tube, or for gastric decompression in patients with gastroparesis, gastroesophageal reflux disease, or intestinal obstruction. Preferred over a nasally inserted tube to deliver enteral nutrition support longer than 4 to 6 weeks

rotator cuff tear

is a rip in a tendon that connects one of the rotator muscles to the humeral head. it stabilizes the humeral head and keeps the arm in the shoulder socket. It is composed of four muscles that come together as tendons (supraspinatus, infraspinatus, teres minor, and subscapularis) that cover the head of the humerus, helping to raise and rotate the arm. Clients with a rotator cuff tear experience pain with movement and limited mobility of the shoulder and arm. They especially have difficulty with activities that involve stretching their arm above their head. Many clients find that the pain is worse at night and that they are unable to sleep on the affected side.

contusion

is a soft tissue injury produced by blunt force, such as a blow, kick, or fall, causing small blood vessels to rupture and bleed into soft tissues (ecchymosis or bruising). Local symptoms include pain, swelling, and discoloration. It can limit joint range of motion (ROM) near the injury, and the injured muscle may feel weak and stiff. Most resolve in 1 to 2 weeks.

Esophageal perforation

is a surgical emergency. It may result from iatrogenic causes, such as endoscopy or intraoperative injury, or from spontaneous perforation associated with forceful vomiting or severe straining, foreign-body ingestion, trauma, and malignancy. A delay of more than 24 hours is associated with higher mortality (20%) when compared to rapid recognition and treatment (7.4%).

Morton neuroma (plantar digital neuroma, neurofibroma)

is a swelling near the third (lateral) branch of the median plantar nerve. Microscopically, digital artery changes cause an ischemia within the third intermetatarsal (web) space. The result is a throbbing, burning pain in the foot that is usually relieved with rest and massage. Conservative treatment consists of inserting innersoles and metatarsal pads designed to spread the metatarsal heads and balance the foot posture. Local injections of a corticosteroid and a local anesthetic may provide relief. If these fail, surgical excision of the neuroma is necessary. Pain relief and loss of sensation are immediate and permanent with surgery. The risk of falls is increased because of the loss of all sensation.

Achalasia

is absent or ineffective peristalsis of the distal esophagus accompanied by failure of the esophageal sphincter to relax in response to swallowing. Narrowing of the esophagus just above the stomach results in a gradually increasing dilation of the esophagus in the upper chest. Can result in the aspiration of gastric contents.

Peptic ulcer disease

is also associated with Zollinger-Ellison syndrome (ZES).

Tooth decay

is an erosive process that begins with the action of bacteria on fermentable carbohydrates in the mouth, which produces acids that dissolve tooth enamel.

Irritant contact dermatitis

is an inflammatory response of the skin to direct chemical damage that releases mediators predominantly from epidermal cells

strain

is an injury to a muscle or tendon from overuse, overstretching, or excessive stress; it is commonly known as a muscle pull. Often occur in tendons of the foot, leg (e.g., hamstring), and back.

sprain

is an injury to the ligaments and tendons that surround a joint. It is caused by a twisting motion or hyperextension (forcible) of a joint

Laryngeal preservation

is associated with better speech and verbal communication, but swallowing and aspiration issues remain common functional deficits with total glossectomy and free flap reconstruction

Most low back pain

is caused by one of many musculoskeletal problems, including acute lumbosacral strain, unstable lumbosacral ligaments and weak muscles, intervertebral disc problems, and unequal leg length

carpal tunnel syndrome

is commonly caused by repetitive hand and wrist movements, it is also associated with rheumatoid arthritis (RA), diabetes, acromegaly, hyperthyroidism, or trauma

Lateral epicondylitis (e.g., tennis elbow)

is frequently identified in someone who repeatedly extends the wrist with supination of the forearm. Patients complain of pain and tenderness over the lateral epicondyle and in the proximal wrist extensor muscles

Curling ulcer

is frequently observed after extensive burn injuries and often involves the antrum of the stomach or the duodenum.

Chlorhexidine

is generally NOT recommended for the prevention of oral mucositis OM, specifically not for patients undergoing head and neck radiotherapy

Grade II sprain

is more severe and involves partial tearing of the ligament. Manifestations include increased pain with motion, edema, tenderness, joint instability, ecchymosis, and partial loss of normal joint function.

Shoulder dysfunction

is most common in radical neck dissection and often requires extensive physical rehabilitation.

closed fracture (simple fracture)

is one that does not cause a break in the skin

Grade I sprain

is stretching or slight tearing in some fibers of the ligament and mild, localized hematoma formation. Manifestations include mild pain, edema, and local tenderness

malunion fracture

is the healing of a fractured bone in a malaligned (deformed) position. the patient complains of persistent discomfort and abnormal movement at the fracture site

Chronic sialadenitis

is typically due to decreased salivary flow and may be treated with sialendscopy, an endoscopic procedure that allows for direct visualization of Stensen duct (diagnostic) and instillation of antibiotics, corticosteroids, or irrigation (treatment), particularly in adolescents with recurrent parotitis. Surgical drainage or excision of the gland and its duct are considered in cases of sialadenitis that are recurrent or refractory to antibiotics.

Streptococcus mitis

is typically found in the mouth. Although a preliminary study, there is evidence that these oral bacteria may contribute to the progression of cardiovascular thrombotic events

Symptoms of acute contact dermatitis include

itching, burning, erythema, skin lesions (vesicles and bullae), and oozing

Type II fracture characteristics

larger wound with minimal soft tissue damage and no flaps or avulsions.

plaster cast

less costly and achieve a better mold than fiberglass casts; however, they are heavy, not water resistant, and can take up to 24 to 72 hours to dry post application. The exothermic reaction during cast application has the potential to cause serious burns. Extra care should be taken when these types of casts are applied to older adults because their skin is more temperature sensitive than average adult skin. During the cast application process, clean, room temperature water should be used. Minimal layers of padding should be used. In addition, the cast should NOT be covered while it is drying because the heat generated by the chemical reaction cannot escape.

Barrett Esophagus

lining of the esophageal mucosa is altered. Association with family history of BE or esophageal adenocarcinoma (EAC), GERD, smoking, and obesity. Only known precursor to EAC, one of the fastest rising cancers in Western populations.

Pes planus (flatfoot

longitudinal arch of the foot is diminished. It may be caused by congenital abnormalities or associated with bone or ligament injury, excessive weight, muscle fatigue, poorly fitting shoes, or arthritis. Signs and symptoms include a burning sensation, fatigue, clumsy gait, edema, and pain. Exercises to strengthen the muscles and to improve posture and walking habits are helpful. Foot orthoses can give the foot additional support

Type III achalasia

lower esophageal sphincter obstruction with esophageal spasms

Chyle leak

lymphatic leak in the thoracic duct

Acute compartment syndrome

managed by maintaining the extremity at heart level (NOT above heart level) and removing constrictive dressings by opening and bivalving the cast or opening the splint, if one or the other is present.

Dumping syndrome

manifested by hypotension, diarrhea, tachycardia, and diaphoresis. The client often reports a feeling of fullness, nausea, and vomiting. Because of the rapid movement of water to the stomach and intestines, bowel sounds would most likely be increased.

Gastritis

may be acute, lasting several hours to a few days, or chronic, resulting from repeated exposure to irritating agents or recurring episodes of acute gastritis.

Cyclic infusions

may be appropriate for patients who are being weaned from tube feedings to an oral diet, for patients who cannot eat enough and need supplements, and for patients at home who need daytime hours free from the pump. -infused feeding is given by an enteral feeding pump over 8 to 18 hours -Elevate the head of the bed to 45 degrees.

Arthroscopic examination

may be carried out to visualize the extent of joint damage as well as to obtain a sample of synovial fluid.

Tinel sign

may be elicited in patients with carpal tunnel syndrome by percussing lightly over the median nerve, located on the inner aspect of the wrist. **If the patient reports tingling, numbness, and pain, the test for Tinel sign is considered positive

Arthrography with MRI or computed tomography (CT) scan

may be more sensitive for certain tears but is usually reserved for cases when a labral injury is suspected

gastric resection or a gastrojejunostomy(anastomosis of jejunum to stomach to detour around the pylorus)

may be necessary to treat gastric outlet obstruction, also called pyloric obstruction, a narrowing of the pyloric orifice, which cannot be relieved by medical management.

Contoured splints of plaster or pliable thermoplastic materials.

may be used for conditions that do not require rigid immobilization, for those in which swelling may be anticipated, and for those that require special skin care

Local injection of corticosteroids

may be used for symptom management, but because of its degenerative effects on tendons, this treatment is traditionally reserved for patients with severe pain who do not respond to first-line treatment methods

Doppler ultrasound device

may be used to locate the pulse at the graft site and to assess tissue perfusion. Depending on the extent of the surgery, the patient may require a temporary or permanent tracheostomy after surgery

clavicular strap, also called a figure-eight bandage

may be used to pull the shoulders back, reducing and immobilizing the fracture. The nurse monitors the circulation and nerve function of the affected arm and compares it with the unaffected arm to determine variations, which may indicate disturbances in neurovascular status. The majority of clavicle fractures occur in the middle third of the clavicle; clinical union (healing) takes 6 to 12 weeks in adults. A sling may be used to support the arm and relieve pain. The patient may be permitted to use the arm for light activities as pain allows

X-ray of the spine:

may demonstrate a fracture, dislocation, infection, osteoarthritis, or scoliosis

stress-related gastritis or ulcer

may develop in acute illnesses, especially when the patient has had major traumatic injuries, burns, severe infection, lack of perfusion to the stomach lining, or major surgery.

Bone scan and blood studies:

may disclose infections, tumors, and bone marrow abnormalities

patient with Zollinger-Ellison syndrome ZES

may experience epigastric pain, pyrosis, diarrhea, and steatorrhea (fatty stools). Patients with ZES associated with MEN-1 syndrome may have coexisting pituitary or parathyroid tumors. ZES-associated MEN-1 syndrome is diagnosed with hyperparathyroidism; therefore, patients may exhibit signs of hypercalcemia for several years before MEN-1 is diagnosed.

tricyclic antidepressants

may not only alleviate phantom limb pain but may also be prescribed to improve mood and coping ability

Loose bodies ("joint mice")

may occur in a joint space as a result of articular cartilage wear and bone erosion. These fragments can interfere with joint movement ("locking the joint"). Loose bodies are removed by arthroscopic surgery if they cause pain or mobility issues.

beta-blockers

may relieve dull, burning discomfort

Obesity, postural problems, structural problems, and overstretching of the spinal supports

may result in back pain

Acute compartment syndrome

may take up to 48 hours for symptoms to present, it typically has a rapid progression of symptoms and signs over a few hours after the initial injury or fracture repair

A first-degree strain

mild stretching of the muscle or tendon with NO loss of ROM. Signs and symptoms may include the gradual onset of palpation-induced tenderness and mild muscle spasm.

effusion into the knee joint

most common complication into the knee joint, which produces pain

Type III fracture characteristics (A, B, and C subtypes)

most severe, highly contaminated, and has extensive soft tissue damage; it involves vascular injury or traumatic amputation.

neurovascular status

neurologic (motor and sensory) and vascular function of the injured extremity, is monitored at frequent intervals (e.g., every 15 minutes for the first 1 to 2 hours after injury) and then at lesser intervals (e.g., every 30 minutes) until stable. Decreases in sensation or motion and increases in pain level should be documented and reported to the patient's primary provider immediately to prevent acute compartment syndrome

Assessment Before surgery

nurse must evaluate the neurovascular and functional status of the limb through history and physical assessment. traumatic amputation, the nurse assesses the function and condition of the residual limb. The nurse also assesses the circulatory status and function of the unaffected limb. If infection or gangrene develops, the patient may have associated enlarged lymph nodes, fever, and purulent drainage. The nurse evaluates the patient's nutritional status and develops a postoperative plan for nutritional care in consultation with a dietitian or metabolic nutrition support team. A diet with adequate protein and vitamins is essential to promote wound healing. Additional calories may be necessary due to the energy required for transfers and ADLs when using a prosthesis

Esophageal ulcers

occur as a result of the backward flow of HCl from the stomach into the esophagus (gastroesophageal reflux disease [GERD]

systemic reaction

occur within about 30 minutes after exposure and involve cardiovascular, respiratory, gastrointestinal, and integumentary organ systems.

Intramural diverticulosis

occurrence of numerous small diverticula associated with a stricture in the upper esophagus

chronic periodontal abscess

occurs from a slowly progressive infectious process. In contrast to the acute form, a fully formed abscess may occur without the patient's knowledge. The infection eventually leads to a "blind dental abscess," which is actually a periapical granuloma. It may enlarge to as much as 1 cm in diameter. It is often discovered on x-ray images and is treated by extraction or root canal therapy, often with apicoectomy (excision of the apex of the tooth root).

transverse fracture

occurs straight across the bone

paraesophageal hernia

occurs when all or part of the stomach pushes through the diaphragm beside the esophagus. Are further classified as types II, III, or IV, depending on the extent of herniation. Type IV has the greatest herniation, with other intra-abdominal viscera such as the colon, omentum, or small bowel present in the hernia sac that is displaced through the hiatus along with the stomach.

Sliding, or type I, hiatal hernia

occurs when the upper stomach and the gastroesophageal junction are displaced upward and slide in and out of the thorax. Between 90% and 95% of patients with esophageal hiatal hernia have a sliding hernia.

greenstick fracture

one in which the bone is bent and only partially broken

open fracture (compound or complex)

one in which the skin or mucous membrane wound extends to the fractured bone. Are often classified using a modified system by Gustilo-Anderson which classifies the severity into three categories based on the extent of soft-tissue injury and the size of the corresponding skin wounds

hiatal hernia

opening in the diaphragm through which the esophagus passes becomes enlarged, and part of the upper stomach moves up into the lower portion of the thorax. Occurs more often in women than in men.

Carpal tunnel syndrome

pain or burning in one or both hands, which may radiate to the forearm and shoulder in severe cases. The pain tends to be more prominent at night and early in the morning. Shaking the hands may reduce the pain by promoting movement of edematous fluid from the carpal canal. Sensation may be lost or reduced in the thumb, index, middle, and a portion of the ring finger. The client may be unable to flex the index and middle fingers to make a fist. Flexion of the wrist usually causes immediate pain and numbness; entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a thickened flexor tendon sheath, skeletal encroachment, edema, or a soft tissue mass Women going through menopause or who are taking estrogen or birth control pills have the highest risk

oral mucositis (OM)

painful inflammatory, typically ulcerative condition that is also referred to as stomatitis. Using saline or sodium bicarbonate rinses increases oral clearance, promotes oral hygiene, and promotes patient comfort. The nurse facilitates the patient rinsing or irrigating with a solution of ½ to 1 teaspoon of baking soda (or ¼-teaspoon salt) in 8 oz of warm water.

odynophagia

painful swallowing

saddle anesthesia

paresthesias in the perineal, inner thigh, or buttock region that may be asymmetrical

B cells

participate in humoral immunity (also called antibody-mediated immunity), which is one kind of adaptive immunity

Type II (Causalgia)

patients with nerve injury

Charcot-Marie-Tooth disease

peripheral neuromuscular disease associated with a familial degenerative disorder), diabetes, and progressive neurologic disorders are common causes of pes cavus (claw foot)

Myelogram:

permits visualization of segments of the spinal cord that may have herniated or may be compressed (infrequently performed; indicated when MRI scan is contraindicated

Magnetic resonance imaging (MRI) scan:

permits visualization of the nature and location of spinal pathology

cauda equina syndrome

potential cause of low back pain, which results from compression of the cauda equina, the bundle of spinal nerves that arise from the lower portion of the spinal cord the patient will have signs and symptoms that include severe or progressive neurologic deficit, recent bowel or bladder dysfunction, and saddle anesthesia which is characterized by paresthesias in the perineal, inner thigh, or buttock region that may be asymmetrical

Application of a splint (i.e., a process called splinting)

practical and common and is the preferred method of fracture immobilization in the acute care setting and for the initial treatment of fractures that eventually require casting. Often used for simple and stable fractures, sprains, tendon injuries, and other soft tissue injuries.

Clinical Manifestations of oral cancers

produce few or no symptoms in the early stages. Later, the most frequent symptom is a painless sore or lesion that bleeds easily and does not heal. May also present as a red or white patch (leukoplakia) in the mouth or throat. A typical lesion is a painless indurated (hardened) ulcer with raised edges. Depending on the location (tonsil, base of the tongue, soft palate, or pharyngeal wall), the patient may report tenderness, difficulty in chewing, swallowing, or speaking, coughing of blood-tinged sputum, trismus (limited jaw range of motion), weight loss, a neck mass, or enlarged cervical lymph nodes

Neutrophil factor

produces allergic skin reactions, asthma, and hay fever

countertraction

pulling force exerted in opposite direction to prevent client from sliding to end of bed (Trendelenburg), and elevating head of bed with cervical traction

Symptoms of GERD

pyrosis (burning sensation in the esophagus), dyspepsia (indigestion), regurgitation, dysphagia or odynophagia (pain on swallowing), hypersalivation, and esophagitis.

Clinical Manifestations of acute gastritis

rapid onset of symptoms, such as epigastric pain or discomfort, dyspepsia (indigestion; upper abdominal discomfort associated with eating), anorexia, hiccups, or nausea and vomiting, which can last from a few hours to a few days.

Zollinger-Ellison syndrome (ZES).

rare condition in which benign or malignant tumors form in the pancreas and duodenum that secrete excessive amounts of the hormone gastrin. The excessive amount of gastrin results in extreme gastric hyperacidity and severe peptic ulcer disease. 25% to 30% of cases are linked to an inherited, genetic condition called multiple endocrine neoplasia, type 1 (MEN-1)

Acute generalized exanthematous pustulosis (AGEP)

rare type of reaction characterized by superficial pustules, usually appearing within 24 hours after the administration of the culprit drug.

Electromyogram (EMG) or myogram

records and evaluates electrical activity of muscles during contraction; used to differentiate between muscle dysfunction and nerve dysfunction; used to evaluate spinal nerve root disorders (radiculopathies)

jackhammer esophagus

referred to as hypercontractile esophagus, spasms occur on more than 20% of swallows at a very high amplitude, duration, and length.

Delivering Enteral Nutrition

refers to infusing nutritional formula feedings through a tube directly into the GI tract.

Medial epicondylitis (e.g., golfer's elbow)

repetitive wrist flexion and pronation of the forearm. Extreme tenderness occurs at the medial epicondyle and in the proximal wrist flexor muscles

Lithotripsy

requires no anesthesia, sedation, or analgesia. Side effects can include local hemorrhage and swelling. Gland removal may be necessary if symptoms and calculi recur repeatedly.

peroneal nerve injury

resulting from pressure at the head of the fibula

Hypovolemic or traumatic shock

results from hemorrhage is more frequently noted in trauma patients with pelvic fractures and in patients with a displaced or open femoral fracture in which the femoral artery is torn by bone fragments. Treatment for shock consists of stabilizing the fracture to prevent further hemorrhage, restoring blood volume and circulation, relieving the patient's pain, providing proper immobilization, and protecting the patient from further injury and other complications

Dupuytren contracture/disease

results in a slowly progressive contracture (i.e., an abnormal shortening) of the palmar fascia that causes flexion of the fourth, fifth, and, sometimes, middle finger, rendering these fingers more or less useless patient may experience dull and aching discomfort, morning numbness, and stiffness in the affected fingers. This condition starts in one hand, but eventually both are affected

Degenerative joint disease

rheumatoid arthritis or osteoarthritis in the jaw joint

cast

rigid external immobilizing device that is molded to the contours of the body. Must fit the shape of the injured limb correctly to provide the best support possible. Used to immobilize a reduced fracture, to correct or prevent a deformity (e.g., clubfoot, hip displacement), apply uniform pressure to underlying soft tissue, or support and stabilize weakened joints. Permit mobilization of the patient while restricting movement of the affected body part.

Chronic contact dermatitis symptoms can include

scaling, lichenification, thickening of the skin, and pigmentary changes.

Clinical manifestations of Complex Regional Pain Syndrome (CRPS)

severe burning pain, local edema, hyperesthesia, stiffness, discoloration, vasomotor skin changes (e.g., fluctuating warm, red, dry and cold, sweaty, cyanotic), and trophic changes that may include glossy, shiny skin, and changes in hair and nail growth. This syndrome is frequently chronic, with extension of symptoms to adjacent areas of the body. Dysfunction of the affected limb may also be manifested in CRPS.

third-degree strain

severe muscle or tendon stretching with rupturing and complete tearing of the involved tissue. Signs and symptoms include immediate pain described as tearing, snapping, or burning, muscle spasm, ecchymosis, edema, and loss of function. An x-ray should be obtained to rule out bone injury, because an avulsion fracture (in which a bone fragment is pulled away from the bone by a tendon) may be associated with a third-degree strain. X-rays do not reveal injuries to soft tissue or muscles, tendons, or ligaments, but magnetic resonance imaging (MRI) and ultrasound can identify tendon injury.

continuous feeding

should be administered to a client who is at risk of diarrhea due to hypertonic feeding solutions

Current recommendations to treat xerostomia include

sipping water, using oral mucosal lubricants (saliva substitutes topically applied), incorporating the use of newer edible saliva substitutes such as oral moisturizing jelly (OMJ), and taking medications that stimulate saliva production. The hope is that providing oral moisture increases swallowing ability, and ultimately improves nutritional status for these patients.

Diffuse esophageal spasm (DES)

spasms are normal in amplitude but are premature/uncoordinated, move quickly, and occur at various places in the esophagus at once

Intranasal cromolyn sodium

spray that acts by stabilizing the mast cell membrane, thus reducing the release of histamine and other mediators of the allergic response

Complete protein antigens, such as animal dander, pollen, and horse serum,

stimulate a complete humoral response

Management of plantar fasciitis

stretching exercises, wearing shoes with support and cushioning to relieve pain, orthotic devices (e.g., heel cups, arch supports, night splints), and corticosteroid injections. Unresolved plantar fasciitis may progress to fascial tears at the heel and eventual development of heel spurs

Clinical Manifestations of Barrett esophagus

symptoms of GERD, notably frequent heartburn. The patient may also complain of symptoms related to peptic ulcers or esophageal stricture, or both.

Disseminated intravascular coagulation (DIC)

systemic disorder that results in widespread hemorrhage and microthrombosis with ischemia. Its causes are diverse and can include massive tissue trauma. Early manifestations include ecchymoses, unexpected bleeding after surgery and bleeding from the mucous membranes, venipuncture sites, and gastrointestinal and urinary tracts.

Oral alpha-adrenergic medications

systemic effect and are NOT recommended as first-line treatment of allergic rhinitis

Stress ulcer

term given to the acute mucosal ulceration of the duodenal or gastric area that occurs after physiologically stressful events, such as burns, shock, sepsis, and multiple organ dysfunction syndrome

Promoting Optimal Nutrition for acute gastritis

the nurse provides physical and emotional support and helps the patient manage the symptoms. The patient should take no foods or fluids by mouth—possibly for a few days—until the acute symptoms subside, thus allowing the gastric mucosa to heal. If IV therapy is necessary, fluid intake and output are monitored, along with serum electrolyte values. After the symptoms subside, the nurse may offer the patient ice chips followed by clear liquids. Introducing solid food as soon as possible may provide adequate oral nutrition, decrease the need for IV therapy, and minimize irritation to the gastric mucosa. As food is introduced, the nurse evaluates and reports any symptoms that suggest a repeat episode of gastritis.

callus

thickened area of the skin that has been exposed to persistent pressure or friction. Faulty foot mechanics usually precede the formation of a callus. Treatment: eliminating the underlying causes and having a painful callus treated by a podiatrist, keratolytic ointment may be applied, and a thin plastic cup worn over the heel if the callus is on this area. Felt padding with an adhesive backing is also used to prevent and relieve pressure. prevention: well-fitting socks and shoes. Orthotic devices can be made to remove the pressure from bony protuberances, or the protuberance may be excised

Acute compartment syndrome

time-sensitive surgical emergency, is characterized by the elevation of pressure within an anatomic compartment that is above normal perfusion pressure. Arises from an increase in compartment volume (e.g., from edema or bleeding), a decrease in compartment size (e.g., from a restrictive cast), or aspects of both. When the pressure within an affected compartment rises above normal, perfusion to the tissues is impaired, causing cell death, which may lead to tissue necrosis and permanent dysfunction

Achilles tendon

tough band of fibrous tissue that attaches the soleus and gastrocnemius (e.g., calf) muscles to the calcaneus (e.g., heel bone). traumatic rupture of this tendon occurs with the "pushing off" or unexpected dorsiflexion of the foot and ankle.

pyloroplasty

transecting nerves that stimulate acid secretion and opening the pylorus longitudinal incision is made into the pylorus and transversely sutured closed to enlarge the outlet and relax the muscle; usually accompanies truncal and selective vagotomies.

Small-bore (Dobhoff) tubes

typically inserted into the jejunum with a guidewire and manufactured for tube feedings, are better tolerated for up to 6 weeks; however, they require diligent monitoring and frequent flushing to remain patent

Closed delivery systems

use a prefilled, sterile container of about 1 L of formula that is spiked with enteral tubing and allows a typical hang time of 24 hours at room temperature. The closed delivery system must always use a pump to control formula rate in order to avoid dispensing a large formula volume in a short period of time. Closed systems lower the risk of infection from bacterial contamination

External fixator devices

used to manage fractures with large amounts of soft tissue damage. Complicated fractures of the humerus, forearm, femur, tibia, and pelvis are also managed with external skeletal fixators. They are also used to correct defects, treat nonunion, and lengthen limbs. The fixator provides skeletal stability for severe comminuted (crushed or splintered) fractures while permitting active treatment of extensive soft tissue damage

Braces (e.g., orthoses)

used to provide support, control movement, and prevent additional injury. They are custom-fitted to various parts of the body; thus, they tend to be indicated for longer-term use than splints. The orthotist adjusts the brace for fit, positioning, and motion so that movement is enhanced, any deformities are corrected, and discomfort is minimized.

Ultrasound:

useful in detecting tears in ligaments, muscles, tendons, and soft tissues in the back

Computed tomography (CT) scan:

useful in identifying underlying problems, such as obscure soft tissue lesions adjacent to the vertebral column and problems of vertebral discs

Epiphrenic diverticula

usually, larger diverticula in the lower esophagus just above the diaphragm. They may be related to the improper functioning of the lower esophageal sphincter or to motor disorders of the esophagus.

4+ reaction

wheal (12 mm+) with pseudopodia and diffuse erythema.

2+ reaction

wheal (7 to 10 mm) with associated erythema;

With an open fracture

wound is covered with a sterile dressing to achieve homeostasis as rapidly as possible at the injury site and to prevent contamination of deeper tissues . No attempt is made to reduce the fracture, even if one of the bone fragments is protruding through the wound. Splints are applied for immobilization

Assessment and Diagnostic Findings of achalasia

x-ray show esophageal dilation above the narrowing at the lower gastroesophageal sphincter, which is called a birds beak deformity, barium swallow, CT scan of chest, endoscopy,

Nursing Management of the Patient with an Immobilized Upper Extremity

~Frequent rest periods are necessary. ~To control swelling, the immobilized arm is elevated above heart level with a pillow. ~When the patient is lying down, the arm is elevated so that each joint is positioned higher than the preceding proximal joint (e.g., elbow higher than the shoulder, hand higher than the elbow). ~A sling may be used when the patient ambulates. To prevent pressure on the cervical spinal nerves, the sling should distribute the supported weight over a large area of the shoulders and trunk, not just the back of the neck. The nurse encourages the patient to remove the arm from the sling and elevate it frequently.

Nursing Management of the Patient with an Immobilized Lower Extremity

~patient's leg must be supported on pillows to the level of the heart to control swelling ~ Cold therapy or ice packs should be applied for 1 to 2 days. ~patient is taught to elevate the immobilized leg when seated. ~The patient should also assume a recumbent position several times a day with the immobilized leg elevated to promote venous return and control swelling. ~Gentle toe and ankle exercises that allow for isometric contraction of muscles beneath the cast. ~The nurse assesses circulation by observing the color, temperature, and capillary refill of the exposed toes. ~Nerve function is assessed by observing the patient's ability to move the toes and by asking about the sensations in the foot. ~numbness, tingling, and burning may indicate peroneal nerve injury resulting from pressure at the head of the fibula.

Strategies for Preventing Acute Low Back Pain Work Modifications

•Adjust height of chair using a footstool to position knees higher than hips •Adjust height of work area to avoid stress on back •Avoid bending, twisting, and lifting heavy objects •Avoid prolonged standing and repetitive tasks •Avoid work involving continuous vibrations •Use lumbar support in straight back chair with arm rests •When standing for any length of time, rest one foot on a small stool or box to relieve lumbar lordosis

The following agents are most commonly implicated in Stevens-Johnson syndrome and toxic epidermal necrolysis

•Allopurinol •Aromatic antiepileptic drugs and lamotrigine •Antibacterial sulfonamides (including sulfasalazine) •Nevirapine •Oxicam NSAIDss

Gastrointestinal Manifestations Acute Gastritis

•Anorexia •Epigastric pain (rapid onset) •Hematemesis •Hiccups •Melena or hematochezia •Nausea and vomiting

Many medications taken by older adults cause dry mouth, which is uncomfortable, impairs communication, and increases the risk of oral infection. These medications include the following:

•Antidepressant medications •Antihypertensive medications •Anti-inflammatory agents •Diuretic agents

For a patient to be considered for tube feeding at home, the patient should:

•Be medically stable and successfully tolerating at least 60% to 70% of the feeding regimen •Be capable of self-care or have a caregiver willing to assume the responsibility •Have access to supplies and interest in learning how to administer tube feedings at home

To ensure patency and to decrease the chance of bacterial growth, sludge build-up, or occlusion of the tube, at least 30 mL of water flush is recommended for adults receiving tube feedings in each of the following instances

•Before and after intermittent tube feeding •Before and after medication administration •After checking for gastric residuals (if required by policy) and gastric pH •Every 4 hours with continuous feedings •When the tube feeding is discontinued or interrupted

Chronic Gastritis Gastrointestinal Manifestations

•Belching •Early satiety •Intolerance of spicy or fatty foods •Nausea and vomiting •Pyrosis •Sour taste in mouth •Vague epigastric discomfort relieved by eating

The agents that most commonly exhibit Anaphylaxis include the following:

•Beta-lactam drugs (e.g., penicillins and cephalosporins) •Neuromuscular blocking agents (e.g., pancuronium) •Quinolones (e.g., ciprofloxacin) •Platinum-containing chemotherapeutic agents (e.g., carboplatin) •Foreign proteins such as monoclonal antibodies (e.g., rituximab)

Patients receiving gastric or enteric tube feedings can experience diarrhea or constipation. Possible causes of diarrhea include:

•Clostridium difficile (C. difficile) colitis: •Can result after antibiotic use alters normal intestinal flora and promotes the abnormal growth of this potentially dangerous microbe; C. difficile colitis occurs most commonly in patients who are hospitalized •Zinc deficiency: Zinc is lost with diarrhea, and zinc deficiency can then cause continued diarrhea •Concomitant lactose intolerance •Concomitant hyperthyroidism •Dumping syndrome: Formula is infused into the small intestine quickly or formula bypasses the stomach too readily into the small intestine and causes expansion of the intestinal wall. This leads to bloating, cramping, diarrhea, dizziness, diaphoresis, and weakness. Measures for managing the GI symptoms associated with dumping syndrome are presented in. •Contamination of the formula and feeding equipment with diarrhea-causing pathogens

Encouraging Exercise After Treatment for Wrist Fracture The nurse encourages active motion of the fingers and shoulder. The patient is instructed to perform the following exercises to reduce swelling and prevent stiffness:

•Hold the hand at the level of the heart. •Move the fingers from full extension to flexion. Hold and release. Repeat at least 10 times every hour when awake. •Use the hand in functional activities. •Actively exercise the shoulder and elbow, including complete range-of-motion exercises of both joints.

Patients receiving gastric or enteric tube feedings can experience diarrhea or constipation. Possible causes of diarrhea include:

•Intolerance to enteral nutrition, related to underlying disease •Malnutrition: A decrease in the intestinal absorptive area can cause diarrhea Medication therapy: •Elixir-based medications—often contain sorbitol, which can act as a cathartic •Magnesium—acts as a cathartic •Antibiotics—thought to alter normal intestinal flora, allowing pathogenic bacteria to flourish

Mouth Care

•Merely wiping the patient's mouth and teeth with a swab is INEFFECTIVE. • most effective method is mechanical cleansing (brushing). • If brushing is not possible, it is better to wipe the teeth with a gauze pad and then have the patient swish an antiseptic mouthwash several times before expectorating into an emesis basin. •A soft-bristled toothbrush is more effective than a sponge or foam stick. •Flossing should be performed daily. •To prevent drying, the lips may be coated with a water-soluble gel

Quadriceps Setting Exercise

•Position patient supine with leg extended. •Instruct patient to push knee back onto the mattress by contracting the anterior thigh muscles. •Encourage patient to hold the position for 5 to 10 seconds. •Let patient relax. •Have patient repeat the exercise 10 times each hour when awake.

Gluteal Setting Exercise

•Position patient supine with legs extended, if possible. •Instruct patient to contract the muscles of the buttocks. •Encourage patient to hold the contraction for 5 to 10 seconds. •Let the patient relax. •Have patient repeat the exercise 10 times each hour when awake.

Systemic Manifestations Of acute gastritis

•Possible signs of shock

Strategies for Preventing Acute Low Back Pain Body Mechanics

•Practice good posture •Avoid twisting, lifting above waist level, and reaching up for any length of time •Push objects rather than pull them •Keep load close to your body when lifting •Lift with the large leg muscles, not the back muscles •Squat while keeping the back straight when it is necessary to pick something up off the floor •Bend your knees and tighten abdominal muscles when lifting •Avoid overreaching or a forward flexion position •Use a wide base of support

Measures to Promote Shoulder Healing of Impingement Syndrome The nurse instructs the patient to:

•Rest the joint in a position that minimizes stress on the joint structures to prevent further damage and the development of adhesions. •Support the affected arm on pillows while sleeping to keep from turning onto the shoulder. •Gradually resume motion and use of the joint. Assistance with dressing and other activities of daily living may be needed. •Avoid working and lifting above shoulder level or pushing an object against a "locked" shoulder. •Perform the prescribed daily range-of-motion and strengthening exercises

Preventing Dumping Syndrome

•Slow the formula instillation rate to provide time for carbohydrates and electrolytes to be diluted. •Administer feedings at room temperature, because temperature extremes stimulate peristalsis. •Administer feeding by continuous drip (if tolerated) rather than by bolus, to prevent sudden distention of the intestine. •Advise the patient to remain in semi-Fowler position for 1 hour after the feeding; this position prolongs intestinal transit time by decreasing the effect of gravity. •Instill the minimal amount of water needed to flush the tubing before and after a feeding, because fluid given with a feeding increases intestinal transit time.

Signs and symptoms of perforation include the following:

•Sudden, severe upper abdominal pain (persisting and increasing in intensity) -pain may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm •Vomiting •Collapse (fainting) •Extremely tender and rigid (boardlike) abdomen •Hypotension and tachycardia, indicating shock

several precautionary steps must be observed before skin testing with allergens is performed:

•Testing is not performed during periods of bronchospasm. •Epicutaneous tests (scratch or prick tests) are performed before other testing methods, in an effort to minimize the risk of systemic reaction. •Emergency equipment must be readily available to treat anaphylaxis.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS Neck dissection

•Vital signs assessed (every 1 to 2 hours or every 15 minutes if the patient is critical). Once stabilized, assessment every 4 hours. Tachycardia, tachypnea, and hypotension may indicate hemorrhage and impending hypovolemic shock • AVOID the Valsalva maneuver to prevent stress on the graft and carotid artery. •Signs of impending rupture, such as high epigastric pain or discomfort, are reported. •Dressings and wound drainage are observed for excessive bleeding. •If hemorrhage occurs, assistance is summoned immediately. •Hemorrhage requires the continuous firm application of pressure to the bleeding site or major associated vessel. •The head of the patient's bed should be elevated at least 30 degrees to maintain airway patency and prevent aspiration. •A controlled, calm manner allays the patient's anxiety. •The surgeon is notified immediately, because a vascular or ligature tear requires surgical intervention.

Strategies for Preventing Acute Low Back Pain Prevention

•Weight reduction as needed •Stress reduction •Avoid high heels •Walk daily and gradually increase the distance and pace of walking •Avoid jumping and jarring activities •Stretch to enhance flexibility. Do strengthening exercises

The type of bone selected for grafting depends on function

•cortical bone- used for structural strength •cancellous bone-for osteogenesis •corticocancellous bone for strength and rapid incorporation

The proper posture

•the chest is up •the abdomen is tucked in (abdominal muscles contracted, giving a feeling of upward pull) •gluteal muscles contracted, (giving a downward pull) •shoulders are down and relaxed. ***Locking the knees when standing is avoided as well as bending forward for long periods.

safe and correct way to lift objects

•use strong quadriceps muscles of the thighs, with minimal use of weak back muscles •feet placed hip-width apart to provide a wide base of support •bend the knees •tighten the abdominal muscles •lift the object close to the body with a smooth motion, avoiding twisting and jarring motions. •avoid lifting more than one third of their ideal weight without help to prevent injury.

aminophylline and corticosteroids

In patients with episodes of bronchospasm or a history of bronchial asthma or chronic obstructive pulmonary disease, ______________ and __________________may also be given to improve airway patency and function

Common Causes of Anaphylaxis

Latex: Medical and nonmedical products containing latex

15 minutes Explanation: Maximum intensity is reached within about 15 minutes after antigen contact.

Maximum intensity of histamine occurs within which time frame following antigen contact?

Common Causes of Anaphylaxis

Other Pharmaceutical/Biologic Agents: Animal serums (tetanus antitoxin, snake venom antitoxin, rabies antitoxin), antigens used in skin testing