ADULT & ELDER II – Exam 2 Review.

ADULT & ELDER III TEST #2 REVIEW PRESSURE ULCERS & WOUND CARE ▪ Wound Types: o Acute • Surgical • Trauma o Chronic • Vascular ulcers • Pressure ulcers • Diabetic foot ulcers ▪ Pressure Ulcer Staging: o Stage ...

ADULT & ELDER III TEST #2 REVIEW PRESSURE ULCERS & WOUND CARE ▪ Wound Types: o Acute • Surgical • Trauma o Chronic • Vascular ulcers • Pressure ulcers • Diabetic foot ulcers ▪ Pressure Ulcer Staging: o Stage 1non-blanchable redness, skin intact o Stage 2blisters, partial thickness o Stage 3full thickness, subcutaneous fat may be visible o Stage 4full thickness, bone, tendon or muscle exposed, slough or eschar present o Unstageablefull thickness, depth unknown, completed obscured by slough and/or eschar o Deep Tissue Injurypurple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear o Location: • Where is it anatomically located? o Measurements: • Length x width x depth • Greatest length (head to toe) • Greatest width (side to side) • Depthuse cotton tipped applicator, note/mark depth & hold against ruler o Wound Characteristics: • Describe by % of type of tissue • Granulation ➢ Red ➢ Cobblestone appearance ➢ Filing-in appearance • Necrotic ➢ Slough o Eschar • Undermining ➢ Separation of tissue from the surface under the edge of the wound ➢ Describe by clock face • Tunneling o Wound Drainage & Odor: • Exudate ➢ Scant, light, moderate, heavy, copious ➢ Clear ➢ Sanguineous (red, thin, watery) ➢ Serosanguineous (thin, watery, clear-pink) ➢ Purulent (sign of infection, green/yellow) • Odor ➢ Most wounds have an odor ➢ Clean well prior to assessing odor o Periwound • Protection is important! • Assess color, texture, temperature, & skin integrity o Infection • All wounds are contaminated, but not necessarily infected • Contamination on wound surface • Colonization • Infection invades soft tissueleads to systemic response • Look for inflammation, pus, increased/different exudate, fever, pain, & delirium • Sterile technique during dressing changes ▪ Other factors that contribute to wound healing o Nutrition/hydration (especially protein) o Circulation (pressure relief, oxygenation, no smoking) o Edema o Glucose control o Delayed wound healingadvanced age, type-2 diabetes, smoking, etc. ▪ Nursing management: o Prevention! • Minimize friction, sheer, & pressure • Incontinence • Nutrition • Education o Relieve pain • Use appropriate pain scale • Try to alleviate pressure where the pressure ulcer is • Administer pain before debridement or dressing change • Encourage communication when uncomfortable o Proper positioning • Turn & reposition (regardless of support surface) • Avoid positioning on bony prominences with existing non- blanchable erythema • Don’t keep on bedpan too long • 30 degree titled side-lying position • Moving and shifting in chair • Do not use donut-shaped devices • Should not use these devices to elevate heels: ➢ Synthetics sheepskin pads ➢ Cutout, ring, or donut-type devices ➢ IV fluid bags ➢ Water-filled gloves ➢ Use specialized cushioned boots o Proper nutrition • Assess ability to swallow • Ask patient food preferences • Ensure a high protein diet (supplements like Ensure or Boost) • Education of patient and family/caregiver • Hydration • Consult with registered dietitian • 30-35 kcalories/kg body weight with 1.25-1.5 grams protein/kg of body weight • Consider enteral or parenteral nutrition when oral intake is inadequate • Older adults we really want BMI above 21 even though normal is 18.5-25…older adults are very frail o Relieve pressure • Support surfaces o Enhanced pressure redistribution, shear reduction, & microclimate control such as air-loss or air fluidized mattress for those with Stage 3, 4, or unstageable pressure ulcers o Foam mattressesstage 1 or 2 o Fill in dead space if wound is deep o Protect skin from incontinence o Protect periwound skin o DO NOT USE WET to DRY Dressings o Clean wound with saline or “wound cleaner” o Debridement • Wound will not heal with presence of necrotic tissue • Necrotic tissue increases bioburden • Firm, dry, stable eschar should not be debrided from heels • Autolytic, enzymatic, sharp, & biological ▪ Dressing Selection: o Manage drainage while maintaining a moist wound healing environment o Dressing Types: 1) Firms 2) Hydrogel • Doesn’t have a lot of drainage, but has lots of granulation tissue that you want to protect while healing 3) Hydrocolloids • Shallow stage 3, non-infected, most common 4) Alginates • Heavy exudate 5) Foams • Lots of exudate, stage 2/shallow stage 3 6) Gauze • Pressure ulcers that have been cleaned/debrided 7) Silicone • To prevent periwound tissue injury when area is fragile 8) Silver-Impregnanted • Very infected…silver helps kill 9) Honey-Impregnanted • Stage2/3…promote wound healing 10) Cadexomer Iodine • Those that have lots of exudate • Be careful…relates to thyroid • A lot of people are allergic to iodine • Be cautious in those with impaired renal function 11) Collagen Matrix • Stage 3 or 4 to help heal o Specialty Dressings • Antimicrobial dressings o Vacuum-assisted wound treatments (NWPT) o No recommended in: ▪ Inadequately debrided ▪ Necrotic, or malignant wounds ▪ Where vital organs are exposed ▪ Wounds with no exudate ▪ Individuals with untreated coagulopathy, osteomyelitis or local/systemic clinical infection ▪ Actively bleeding wounds ▪ Wounds in close proximity to major blood vessels o Hyperbaric oxygen treatment RESPIRATORY ALTERATIONS ▪ Decrease in # of alveoli as we age ▪ Alteration in shape of alveoliincreases AP diameter ▪ Decreased elastic recoil due to stiffening of elastin & collagen connective tissue ▪ Chest wall stiffness ▪ Arteriosclerosis ▪ Loss of muscle tone ▪ Increase in thoracic rigidity ▪ Change to spine (ie: kyphosis)compresses thoracic cage, can’t expand to breathe as well ▪ Factors that lead to lung problems: o Age o Exposure to pollutants o Cigarette smoking4-5 years of not smoking will bring lungs back to almost normal o Comorbidities ASTHMA: ▪ Reversible airflow obstruction & wheezing ▪ Want to consider older adults change in sensitivity of beta-adrenergic receptors o Bronchoconstriction/dilation o Beta 2 receptor agonists may not be beneficial ▪ More common in women ▪ Type 1 hypersensitivity reaction o IgE triggers histamine release from mast cells ▪ Onset in early life (often childhood) ▪ Symptoms may vary day to day ▪ Symptoms may worsen at night/early morning ▪ Family history of asthma ▪ Allergy, rhinitis and/or eczema also present ▪ Clinical manifestations: o Audible wheezeinitially on expiration…if getting worse will hear on inspiration o Increased RR o Increased coughif getting worse sputum would come up (white/thick)… possibly blood if coughing hard enough o Use of accessory musclesto produce more space for oxygen or to expel air o Retractionstrying to breathe air in…making negative space o “Barrel chest” from air trapping o Long breathing cyclequick intake, but long to get air out o Cyanosis o Hypoxemia ▪ Diagnostic tests o ABGs • Decreased O2 • Decreased CO2 level early & increase laterpoor gas exchange • pH: 7.35-7.45 • CO2: 35-45 • HCO3: 22-26 • O2: 80-100 • Respiratory Acidosis: elevated pCO2 due to ventilation depression • Respiratory Alkalosis: depression of pCO2 due to alveolar hyperventilation • Metabolic Acidosis: depression of HCO3 or an increase in non- carbonic acids • Metabolic Alkalosis: elevated HCO3 due to excessive loss of metabolic acids o Allergic asthma will have elevated serum eosinophil count & IgE levels o Sputum with eosinophils & mucus plugs with shed epithelial cellsfrom coughing o Pulmonary Function Tests • Forced vital capacity (FVC) • Forced expiratory volume in the first second (FEV1) • Peak expiratory flow rate (PEFR) ▪ Management o Patient education important! o Peak flow meter should be used twice a day daily o Want to rinse mouth after steroidsprone to thrush ▪ Treatment o Anti-inflammatory agents: • Corticosteroids • Leukotriene antagonists • Immunodulators o Rescue • Short-acting beta 2 agonists ➢ Salbutamol • Anti-cholinergic ➢ Atrovent o Preventive • Inhaled corticosteroids ➢ Fluticasone • Long-acting beta 2 agonists (LABA)give first…this will open up airway so steroids are more effective ➢ Salmeterol • Leukotriene receptor antagonist (LTRA) ➢ Singulair (pill) o Other • Theophylline ➢ Less effective & less well tolerated than long acting bronchodilators ➢ Can reduces exacerbations • Cromolyn • Omalimuzab • Stabilize mast cells, which stop release of histamines o Administration • Metered dose inhaler (MDI) • Dry powder inhaler (DPI) • Autohalergoes in with breath o Exercise (ie: swimming) & activitypromotes ventilation & perfusion o Oxygen therapy ▪ Status Asthmaticus o Severe, life-threatening, acute episode of airway obstruction o If not reversed patient may develop pneumothorax and cardiac or respiratory arrest o Clinical manifestations (that asthma attack worsening) • Cyanosis • Inspiratory wheezing • Altered LOC • Use of accessory muscles • Check ABGs or O2 saturation o Treatment • IV fluids • Potent systemic bronchodilator • Steroids • Epinephrine • Oxygen COPD: ▪ Bronchospasm & dyspnea ▪ Tissue damage is not reversible & increases in severity…eventually respiratory failure ▪ Leading cause of morbidity & mortality worldwide ▪ Associated with significant economic burden ▪ Onset in mid-life ▪ Symptoms slowly progress ▪ Long smoking history ▪ Risk factors: o Cigarette smoking • Smoking cessation! ➢ ASK ➢ ADVISE ➢ ASSESS ➢ ASSIST ➢ ARRANGE o Alpha 1 antitrypsin (AAT) deficiency • Helps breakdown enzymes around alveoli • If not working they will breakdown alveoli = emphysema at younger age with no PMH of smoking o Air pollution o Gender o Age o Respiratory infections o Socioeconomic status o Asthma/bronchial hyperreactivity o Chronic bronchitis ▪ Emphysema o Loss of lung elasticity o Hyperinflation of the lung o Dyspnea o Increased RR o Decreased expiratory phase = can’t get as much air in = decreased expiratory even more…and so on o Air trappingdue to loss of elastic recoil in alveolar walls, overstretching, & enlargement of the alveoli into bullae, & collapse of small airways (bronchioles) o Clinical manifestations • “Pink Puffer” • Pursed lip breathingexhale slowly, help expand to get air out that’s “deep down” • Dyspnea • Hyperessonance on chest percussiondue to air trapping • Orthopnea • Barrel chest • Prolonged expiratory time • Speaks in short, jerky sentences • Anxious • Use of accessory muscles • Thin appearance • Tripod positioning ▪ Chronic Bronchitis o Inflammation of the bronchi & bronchioles caused by chronic exposure to irritants, especially tobacco smoke o Inflammation, vasodilation, congestion, mucosal edema, & bronchospasm o Affects only the airways NOT the alveoli o Production of large amount of thick mucus o Hard to get rid of air on way out due to blockage o Clinical manifestations • “Blue Bloater” • Cyanotic • Recurrent cough & sputum production • Hypoxia • Hypercapnea • Respiratory acidosis • Increased hemoglobin (secondary polycythemia) • Increased RR • Dyspnea or exertion • Increased incidence in heavy cigarette smokers • Digital clubbing • Cardiac enlargement • Use of accessory muscles • Leads to right-sided heart failure ▪ Complications o Hypoxemia o Acidosis o Respiratory infections o Lung cancer o Diabetes o Osteoporosis o Cardiac failure, especially cor pulmonale (hypertrophy/right-sided heart failure) • Air trapping = taking up more space = more resistance = more pressure = right ventricle working harder to pump blood o Cardiac dysrhythmias • Hypertrophy of heartincreases distance electrical conduction has to travel o Ventilation failure (not getting air in/out) o Oxygenation failure (not getting O2 to blood) o Or Combination o Anxiety & depression ▪ Diagnostic tests o Dyspnea assessment tool o ABGs o Sputum samples (culture & sensitivity, infection?) o CBC (hemoglobin/hematocrit) o Serum electrolyte levels (dilutional hyponatremia) o Serum AAT levels (Alpha 1 Antitrypsin deficiency?) o Chest x-ray o Pulmonary function test o Spirometry: required to establish diagnosis • Should be performed after administration of dose of short-acting inhaled bronchodilator to minimize variability • FEV1/FVC < 0.70 confirms airflow limitation • 2 or more incidences that FEV1 < 50% OR 1 + hospitalizations for COPD exacerbations = HIGH RISK ▪ Treatment o Pulmonary rehab • Incentive spirometer 10x/hour • Chest physiotherapy • Hydrationif not fluid overloaded • Exercise o Beta-adrenergic agents o Cholinergic antagonists o Methyxanthines o Corticosteroids o Mucolyticsto get mucus out o Want to stop Robitussin or any other cough suppressants…stop cough, which will prevent them from removing secretions o Lung transplantationfor end-stage • Large midline incision or a transverse anterior thoracotomy ▪ Management o Ineffective breathing • Breathing techniques • Positioning to help alleviate dyspnea or drainage • Energy conservationnot doing too much at one time ➢ Encourage patient to pace activities ➢ Do not rush through morning activities ➢ Gradually increase activities o Ineffective airway clearance • Possible suctioning • Controlled coughing • Chest physiotherapy with postural drainage • Hydration via beverage & humidifier • Flutter-valve mucus clearance devices • Tracheostomy o Risk for imbalance nutrition • Often in a hyper-metabolic stateneed more calories • Prevent protein-calorie malnutrition through dietary consultation • Monitor weight, skin condition, & serum pre-albumin levels • Dyspnea management • Food selection to prevent weight loss o Prevent anxietythis can worsen symptoms o Risk for pneumonia & other respiratory infections • Avoid large crowds • Pneumonia vaccine • Yearly influenza vaccine LUNG CANCER: ▪ Leading cause of cancer deaths ▪ Poor long-term survival because of late-stage diagnosis ▪ Bronchogenic carcinomas ▪ Staged to assess size & extent of disease ▪ Warning signs o Hoarseness o Change in respiratory pattern o Persistent cough o Blood in sputum o Chest pain/tightness o Shoulder pain o Recurrent pneumonias o Dyspnea o Wheezing o Weight loss o Possible JVD & edema in upper extremities ▪ Management o Can be curative (if caught early) to increase survival time, and/or palliative o Chemotherapy o Targeted therapy (to de-bulk, then do in & remove it) o Radiation therapy (to de-bulk, then do in & remove it) o Photodynamic therapy o Wedge resection o Lobectomy o Pneumonectomy o Postoperative care • Chest tube placement (except for pneumonectomy) ➢ Sterile technique ➢ Place drainage system below level of patient ➢ Look for kinks ➢ Tidaling ➢ Vaseline dressing • Pain management • Respiratory management (mechanical ventilation) ▪ Interventionsto maintain quality of life, ADLs, IADLs o Oxygen therapy o Drug therapy o Radiation therapy o Thoracentesis (remove fluid from pleural space) o Pleurodesis (injection to “close off” pleural space so fluid can’t get it) o Dyspnea management o Pain management o Hospice care (~6 months) SLEEP APNEA: ▪ Breathing disruption during sleep that lasts at least 10 seconds & occurs a minimum of 5 times an hour ▪ Results in upper airway obstruction by the soft palate or tongue ▪ Risk factors o Obesity o Large uvulasometimes they will laser off the uvula o Short neck o Smoking o Enlarged tonsils/adenoids o Oropharyngeal edema • Can be from ACE inhibitorsstop drug ▪ Clinical manifestations o Heavy snoring o Excessive daytime sleepiness o Inability to concentrate o Irritability o Headaches o Personality changes MECHANICAL VENTILATION: ▪ Modes of ventilation o BiPAP • 2 levels of positive airway pressure via nasal or oral mask, nasal pillow, or mouthpiece • Higher level of pressure during inspiration augments spontaneous breathskeep soft palate & tongue away from back of throat • Lower level of pressure during exhalation o CPAP • Delivers a set positive airway pressure continuously during each cycle of inhalation & exhalation • Keeps alveoli open during inhalation & prevent collapse during exhalation o Assist-control (A/C) • Set tidal volume & rate (how fast they will breathe, but can initiate breaths) • All breaths (assisted or controlled) are delivered with the same set pressure/flow rate • Used in initiating mechanical ventilation and/or when patient at high risk for respiratory arrest • If start breathing on own, probably not the best because they can be overventilated o Synchronized intermittent mandatory ventilation (SIMV) • Preset tidal volume & rate • Allows spontaneous breaths • Starting to “wean” patient off ventilator • Breaths synchronized with patient’s effort o Pressure support (PS) • Positive pressure to augment inspiratory effort • Patient controls RR, flow rate, & tidal volume • Used for weaning off or in combination with other modes • Can have with A/C or SIMV (as an extra boost) • All breaths on own, but assists with breathing in • “Last step” ▪ Reasons for Ventilation o Improve gas exchange & decrease work of breathing o Doesn’t cure anything o Support patient until natural breathing can resume ▪ Ventilator Settings o RRwhen weaning off, will set lower so they breathe on their own o Tidal volume o Oxygen concentration o Flow ratehow fast in o Positive end-expiratory pressure (PEEP)to keep alveolar open & prevent lungs from collapsing o Pressure supportextra push when they breathe in ▪ Ventilator Alarms o High pressure • Secretions or mucus plug • Coughing, gagging, biting tube • Obstruction • Asynchrony (“fighting the ventilator”)may need to sedate, or it may indicate they are ready to be weaned off • Airway displaced or movedwant to auscultate • Pulmonary complications (ie: bronchospasm, pneumothorax, pneumonia) o Low pressure • Leak in circuit • Cuff leak • Loss of spontaneous breathing or decreased respiratory effort • If patient can talk to you with ET tubeLEAK ▪ Complications o Cardiac problems • May need to address fluid overload, electrolytes) o Lung problems (ie: barotrauma) o GI & nutritional issues (ie: ulcersmay need Nexium) o Infections o Ventilator dependence MUSCULOSKELETAL ALTERATIONS OSETOPOROSIS: ▪ Chronic metabolic disease in which bone loss causes decreased density & possible fractures ▪ Osteoblasts put stuff into bone, osteoclast take stuff out…more osteoclastic activity than osteoblastic activity ▪ Primary o Most common in postmenopausal women & men in 60-70 (especially those thin & frail) o Bone mineral density (BMD) decreases rapidly post-menopausal ▪ Secondary o From an associated medical condition • Hyperparathyroidismpulling Ca+ out of bone = bone weaker • Long-term drug therapy • Long-term immobility (may have MS or Parkinson’s) • Chronic drug use (ie: corticosteroids, heparin, anticonvulsants) ▪ Regional o When limb is immobilized (ie: related to fracture) o Can build bone back up usually, but we worry about age ▪ Risk factors: o Older age o Family history o Low body weight/thin build o Chronic low calcium & vitamin D intakeactivate Ca+ to move around body to get into bone o Estrogen/androgen deficiencyaffects bone density o Early menopause o Smokingaffects bone density o High alcohol intake (1 drink for women, 2 for men) o Lack of physical exercise/immobility o White, thin women are likely to develop osteoporosis at an earlier age ▪ Health Promotion/Illness Prevention!!! o Teaching should start with young women who begin to lose bone density after 30 years of age o Focus of osteoporosis prevention is to decrease modifiable risk factors o Ensure adequate nutrition • Vitamin D • Calcium • Make sure not getting too frailkeep good BMI o Avoid sedentary lifestyle o Continue program of weight-bearing exercises ▪ Physical assessment: o “Dowager’s hump”due to bone density loss, kyphosis o Loss of height o Complains of back painif spine is losing a lot of bone density, affect cartilage, possible compression of nerves o Fallophobiamay be sedentary due to fear of falling ▪ Diagnostic tests: o No definitive lab tests o Serum calcium, vitamin D, & phosphorus to rule out secondary osteoporosis & other metabolic bone diseases o Dual X-ray Absorptiometry* • To measure bone mineral density • Look at hip and spine • T Score ➢ More commonly used ➢ To help determine risk of fracture (fragility fracture) ❖ Might just be walking & fracture a hip ➢ < -2.5 = osteoporosis ❖ Times # by 10 to get % of bone loss (ie: -2.5 x 10 = 25% loss of bone density compared to that of a 30- year-old female) ➢ -1 to -2.5 = osteopenia ❖ Want to start treating in this stage to prevent osteoporosis ➢ < -1.5 & has risk factors = should start some kind of treatment ➢ < -2 should start treatment right away even without risk factors ➢ Compares score to that of a normal 30-year-old female • Z Score ➢ This compares the patient to someone of the same relative age & gender ➢ Not really used in diagnostic testing ▪ Interventions: o Nutritional therapy • Calcium & vitamin D • Protein, magnesium, vitamin K, & other minerals o Lifestyle changes • Muscle strengthening & weight-bearing exercises • Water aerobics are good too • Walking for 30 minutes 3-5 times/week • Avoid smoking o Drug therapy • Calcium & vitamin D (Os-Cal, Citracal) ➢ 1-1.5 grams in divided doses ➢ Vitamin D is in units • Estrogen Agonist/Antagonist (Raloxifine) ➢ Hormone therapy ➢ Normal for post-menopausal therapygreat risk for DVTs, especially if also smoking ➢ Watch for DVT & monitor LFTs • Bisphosphonates [Alendronate (Fosamax), Risedronate (Actonel), Ibandronate (Boniva)] ➢ Can affect lower esophageal sphicter ➢ Side effect: Esophagitis ➢ Take on empty stomach first thing in morning with full glass of water & stay upright/sitting for 30 minutes-1 hr. • Other agents ➢ Parathyroid hormone ➢ Calcitonin ➢ Fortero (Pen)subQ daily ❖ Possibly helps increase bone density, but definitely helps with further loss OSTEOARTHRITIS: ❖ Lots of education! ❖ Rotate site (deltoid, abdomen, thigh) ❖ Clean site ❖ Proper disposal ▪ Most common type of arthritis ▪ Joint pain & loss of function characterized by deterioration & loss of cartilage in the joints ▪ Development of osteophytes ▪ Less we use it, less mobility & function ▪ Most common in hips, knees, & ankles ▪ Bone hypertrophybony outgrowths ▪ Bone rubbing against bone = pain & inflammation ▪ Primary o Triggered by aging or genetics o Weight-bearing joints mostly affected (ie: knees) ▪ Secondary o Results from other musculoskeletal conditions such as rheumatoid arthritis (can lead to osteoarthritis), congenital anomalies, joint sepsis, obesity, smoking, & other metabolic conditions (ie: diabetes) ▪ Clinical manifestations: o Chronic joint pain & stiffness o Pain may be present at rest (getting worse) o Interruption of sleep patterns o Tenderness on palpation/ROM o Enlarged joint o Heberden’s (DISTAL) & Bouchard’s nodes (PROXIMAL) o Joint effusion o Atrophy o Loss of function ▪ Diagnostic tests: o Elevated ESR (Normal: 0-22 men/ 0-29 women) o Elevated C-reactive protein (Normal: < 1)lot of inflammation throughout body • The more joints affected, the higher the ESR & CRP will be o Better diagnostic tests: • X-raychanges in bone structure, bone spurs, hypertrophy • MRIwhat’s going on in joint, joint space, & blood flow to area • CT ▪ Nursing management: o Manage pain o Get them moving o Address secondary causes o Analgesics • Tylenol is the drug of choice* (keep under 4g/day to prevent overdose) ➢ Remember that other drugs may have Tylenol in them • Lidoderm 5%patch ➢ Follow instructions on how long to have it on ➢ Don’t use bare hands/be careful applying it ➢ Change location (don’t want to wear skin out) • NSAIDsworry about GI problems o Other • Cortisone injectionsinto joint space to decrease inflammation • Hyaluronate injectionssimilar to a compound in our joint spaces, help lubricate & move properly • Muscle relaxantshelpful especially with back spasms o Rest & positioning • Positioning depends on wear the pain is o Weight control o Hot or cold application • Heat may decrease muscle tension • Hot shower/baths • Cold to reduce swelling/inflammation • Depends on the patient & what works for them o Complementary/alternative therapies • Worry about drug interactions! • Chondroitin & glucosamine (for osteoarthritis), & turmeric (strong anti-inflammatory) • Acupuncture • Massage therapy • TENS (Transcutaneous electric nerve stimulation)get blood flowing & muscle moving o No therapy will halt progression o Current therapy directed at relief of pain & minimizing functional disabilityaddress ADLs, IADLs, pain, & mobility o Agents for pain relief • Topical agents • Systemic oral agents (acetaminophen, NSAIDs) • Intra-articular agents ➢ Corticosteroids for synovial inflammation ➢ Hyaluronic acid ▪ Surgical management: o Total Joint Arthroplasty (most commonhip or knee replacement) • Pre-Op ➢ Teaching what to expect post-op ➢ Medications (insulin , BP meds, Coumadin, Lovenox, aspirin, etc.) ➢ Pain management • Operative • Post-Op ➢ Prevention of discoloration ➢ Make sure placement stays ➢ Prevention of infection ❖ Prophylactic antibiotics ➢ Thromboembolic complications ➢ Assess for bleeding ➢ Management of anemia HIP FRACTURE: ▪ Most common injury in older adults ▪ High mortality rate ▪ Especially concerned with femoral neck fracturecould lead to avascular necrosis of the femoral head ▪ Clinical manifestations: o Injured leg shortened o Externally rotated o Extreme pain prevents movement ▪ Treatment: o Immobilize immediately to prevent further damage o Buck’s traction may be used before surgery • Little boot around lower leg (traction & weight) • Make sure weight is NOT on floor • DO NOT turn side to side • Trapeze can be used to help the patient move (sit upright more) • No pins • Assess skin • Look at circulation • May need to reposition o Surgery is treatment of choice • Open Reduction Internal Fixation (ORIF) ➢ Femoral neck fracture repairs = pins ➢ Intertrochanteric fracture repairs = bidirectional o Surgical procedure depends on • Type of injury • Condition of the person • Preexisting orthopedic conditions o With acute or chronic diseases the risk of surgery may be too greatmedical management may be preferred ▪ Nursing management: o ABCs! o Pain assessment o Skin assessment o Body alignmentabduction pillow o Ambulation • Provide analgesic before first time out of bed o Education to return home o Monitor for complications • Dislocation of the device • Avascular necrosis • Infection • Delayed healing • PEfrom DVT or fracture surgery, fat embolism or something else from rupturing the tissue, etc. • DVTdue to immobility • Compartment Syndrome ➢ Due to lack of perfusion ➢ Reduced circulation in an area due to edema ➢ Pain, pressure, paralysis, parathesia, pallor, pulselessness (use Doppler) ➢ Notify HCP! • Poor alignmentdislocation of the prosthesis • Infection • Skin alterations • Hazards of immobility *Side note: For NCLEX questions, pain is considered psychosocial, BUT chest pain is ABCs! HIP REPLACEMENT SURGERY: ▪ Precautions o DO NOT stand or sit for long periods o DO NOT flex hips more than 90 degrees o Abduction pillow o Avoid internal rotation ▪ Prevention of complications o Continuous Passive Movement (CPM) • Give pain medication before o Assess for neurovascular compromise o Manage pain o Progression of activityup & moving post-op day 2 o Promotion of self-careOT ADVANCED CARE PLANNING & END OF LIFE ▪ Barriers to Quality EOL Care: o Limited evidence base o Fear & discomfort about death o Lack of experience with death o Death denying culture o Uncertainty about communication ▪ Advanced Directives o An order to let the provider know what they want ahead of time in case a decision needs to be made o Progressive, ongoing discussion o Patient status & wishes often change with time o Should be about values, not documents o Durable Power of Attorney (Health Care Proxy) • A person who can speak for you when you cannot speak for yourself o Living Will • DNR (Do Not Resuscitate) • DNI (Do Not Intubate) • AND (Allow Natural Death) • DNH (Do Not Hospitalize) • Can decide about other things we may not think about such as artificial hydration & nutrition, dialysis, antibiotics, re- hospitalization, etc. ▪ MOLST (Medical Orders for Life Sustaining Treatment) ▪ FIVE WISHES (person you want to speak for you, who you want around you, etc.) ▪ Where people want to die, differs from where people actually do die o 50% Hospitals o 25% Nursing Homes o 25% Home ▪ Communication Skills: o Assessment first o Open-ended questions o Reflecting/Validating o Therapeutic use of silence ▪ Moral Uncertainty (just doesn’t feel right) o Uncertain if a problem exists, unsure about its nature, & unclear which values conflict ▪ Moral Dilemma (discomfort feeling that can be identified) o 2 or more ethical principles clash ▪ Moral distress (we can identify, but feel like we can’t do anything about it) o Emotion resulting from inability to act upon the right course of action ▪ Our values may not match the patient’s & that’s okay! ▪ Autonomy: the right to make your own choices ▪ Beneficence: doing good ▪ Nonmaleficence: do no harm ▪ Veracity: truthfulness ▪ Confidentiality ▪ Fidelity: doing what you promised the patient ▪ Justice: equality across all boundaries CAPACITY COMPETENCY Task specific Global Clinical determination Legal determination Waxes & wanes Global Patient must understand: 1. Nature of intervention 2. Risk/benefits 3. Alternatives ▪ Anytime you think patient doesn’t understandknow their capacity ▪ Ethics Committees o Advisory services designed to assist patients, families, & health professional in identifying, analyzing, & resolving ethical dilemmas o Interdisciplinary o Confidential o In most institutions anyone can call an ethics consultation ▪ Euthanasiaillegal everywhere, patient is “killed” ▪ Assisted Suicidehelp patient to kill themselves, legal in 5 states o Nurses should promote comfort & relieve suffering even if death hastened o Withholding/withdrawing can be ethically acceptable o Nurses should seek to understand request for assisted suicide o Nurses should create environment where patient can feel comfortable expressing their thoughts o Get help for pain & symptom management ▪ Many patients have an issue of control: fear of pain, uncontrolled symptoms, loss of dignity, being a burden ▪ Palliative Care o Focus on Quality of Life o Pain & symptom management (throughout treatment) o Aligning goals with treatment o Interdisciplinary team o Given at any point in illness along with active treatment o Almost anyone with a chronic illness can benefit from palliative care o It works...when people feel better they do more for themselves ▪ Hospice Care o Medicare benefit o Care provided in the last 6 months of life ▪ Care of an Actively Dying Patient: o Change in Rhythm of Care • More intensive care o Change in Goals of Care o Shift in Focus of Care • More about quality of life • Focus on existing or new symptoms • Initiation of new measures for comfort • Discontinuing non-essential treatment • Family needs may become more pronounced o Change in priorities • Life prolonging treatments • Vital signs • Diagnostic tests • Fluid & nutrition • Medications (re-evaluate) • Increased focus on family! o Nursing response • Validate • Normalize • Intervene o Signs of Pending Death • Cold, mottled, clammy skinbody shunting blood from extremities to brain & heart • Cyanosis • Changes in breathing pattern (Cheyne-Stokes) ➢ Periods of rapid respirations followed by apnea ➢ Oxygen ➢ Opioids ➢ Fan ➢ Family education ➢ Morphine (for respiratory distress or dyspnea) • Decreased LOC • “Death Rattle” ➢ Noisy secretionssaliva on voice box, sounds worse than it feels ➢ Raise HOB ➢ Positioning ➢ No deep suction ➢ Anticholinergic ➢ Glycopyrrolateto dry up secretions • Agitation ➢ Address causes (ie: pain, urine retention) ➢ Palliative sedation ➢ Anti-psychotics (Haldol or Ativan) • Some may die with eyes openloss of subcutaneous fat or blink reflex ➢ Eye drops to prevent dryness • Decreased PO intake ➢ Oral care at end of life is essential! ➢ Avoid IVs/hydration3rd spacing can occur where fluid in vessels leak into tissue = increased secretions, increased incontinence, edema, etc.-->substitute with other “caring” habits (ie: do hair, massage, oral care) o Emotional-Spiritual Symptoms • Withdrawal ➢ Some family members experience loss of intimacytell them its okay to touch them ➢ We believe hearing is the last to go…encourage family to speak to the patient even if he/she cannot respond • Letting go: Restlessness • Visions • Saying Goodbye o Cultural Competence ➢ Self-reflection…how do you view this issue? ➢ Identify & integrate knowledge of most common cultural groups in your practice o Cultural Humility ➢ Commitment to self-reflection & self-critique ➢ Developing mutually beneficial, respectful partnerships ➢ Is there anything about your culture/religion that would help me take care of the patient? o The Death Vigil • Family presence • Common fears ➢ Being alone with patient ➢ Time of death: how do you know death has occurred ➢ Missing the moment o When Death Occurs… • Cessation of integrated tissue & organ function manifested by lack of heartbeat, absence of respirations, or irreversible brain dysfunction • No pulse • No respirations • Fixed & dilated pupils • Relaxation of muscles & sphincters • Eyes may remain open, jaw may drop