COMMON CLINICAL MANIFESTATIONS IN THE HEMATOLOGIC SYSTEM?

Clinical manifestations
Fever - Persons with neutropenia or immunosuppression may be unable to mount the inflammatory response of fever, redness, and pus formation.

Fatigue/Malaise - Anemia is characterized by pallor, weakness, and lightheadedness; severe anemia manifests with chronic fatigue, exertion dyspnea, HA, or vertigo.

Bleeding – Assess for bleeding disorders.

CBC TESTS FOR HEMATOLOGIC DISORDERS?=KNOW THESE!!!

Complete blood count
Red blood cell count – 11.7 – 17.4 g/dL
Hemoglobin level – 12 – 18 g/dL
Hematocrit level – 35 – 52%
Reticulocyte count – 0.5 – 1.5% (of RBCs)
Red blood cell indices
MCV – 84 – 96
MCH – 28 – 33
MCHC – 0.5 – 1.5%

DIAGNOSTIC TESTS FOR CLOTTING FACTORS IN HEMATOLOGIC DISORDERS?=KNOW THESE!!!

Clotting Factors
Platelet count – 150,000 – 450,000
aPTT – 20 – 39 seconds
PT – 9.5 – 12 seconds
Bleeding time – 1.5 – 9.5 minutes

DIAGNOSTIC WBC TESTS AND #'S FOR HEMATOLOGIC DISORDERS?

White blood cell count – 4,500 – 11,000
White blood cell differential
Neutrophils 45 – 73%=THE MOST ABUNDANT
Eosinophils – 0 – 4%=ALLERGIC REACTIONS
Basophils – 0 – 1%=HISTAMINE release
Lymphocytes – 20 – 40%=
Monocytes – 2 – 8%=remove debris and bacteria

Antiglobulin tests-to detect antigen-antibodies
Bone marrow aspiration and biopsy-where rbc’s are manufactured

NEUTROPHIL ROLES?

ESSENTIAL IN PREVENTING OR LIMITING BACTERIAL INFECTION VIA PHAGOCYTOSIS

MONOCYTE ROLES?

ENTERS TISSUE AS MACROPHAGE; HIGHLY PHAGOCYTIC, ESPECIALLY AGAINST FUNGUS; IMMUNE SURVEILLANCE

EOSINOPHIL ROLES?

INVOLVED IN ALLERGIC RXNS (NEUTRALIZES HISTAMINE); DIGESTS FOREIGN PROTEINS

BASOPHIL ROLES?

CONTAINS HISTAMINE; INTEGRAL PART OF HYPERSENSITIVITY RXNS

LYMPHOCYTE ROLES?

INTEGRAL COMPONENT OF IMMUNE SYSTEM

T LYMPHOCYTE ROLE?

RESPONSIBLE FOR CELL-MEDIATED IMMUNITY; RECOGNIZES MATERIAL AS "FOREIGN" (SURVEILLANCE SYSTEM)

B LYMPHOCYTE ROLE?

RESPONSIBLE FOR HUMORAL IMMUNITY; MANY MATURE INTO PLASMA CELLS TO FORM ANTIBODIES

PLASMA CELL ROLE?

SECRETES IMMUNOGLOBULIN (Ig,ANTIBODY); MOST MATURE FORM OF B LYMPHOCYTE

RBC (ERYTHROCYTE) ROLE?

CARRIES HEMOGLOBIN TO PROVIDE OXYGEN TO TISSUES; AVERAGE LIFESPAN IS 120 DAYS

PLATELET (THROMBOCYTE) ROLE?

FRAGMENT OF MEGAKARYOCYTE; PROVIDES BASIS FOR COAGULATION TO OCCUR; MAINTAINS HEMOSTATIS; AVERAGE LIFESPAN IS 10 DAYS

WBC (LEUKOCYTE) ROLE?

FIGHTS INFECTION

Which of the following manifestations may be seen in clients with immunodeficiencies?

A. Diarrhea
B. Weight gain
C. Lightheadedness
D. Rash

A. DIARRHEA

Clients with immunodeficiencies have a hx of recurrent infections, and may have a history of delayed wound healing.

You are caring for a client who recently had part of the duodenum removed. Which of the following may occur as a result of this procedure?

A. Increased risk of contracting infections
B. Decreased absorption of vitamin B12
C. Iron deficiency anemia
D. Decreased absorption of amino acids

C. IRON DEFICIENCY ANEMIA

Surgical removal of duodenal tissue can decrease iron absorption and produce iron deficiency anemia

You are caring for a client who has taken a high dose of corticosteroids for months. Which of the following manifestations indicates that this client has an infection?

A. The client complains of generalized feelings of fatigue and malaise.
B. The client has a fever.
C. The client has a decreased WBC count.
D. The infection is widespread before being detected.

D. THE INFECTION IS WIDESPREAD BEFORE BEING DETECTED

Treatment with corticosteroids Can mask fever and other manifestations until an infection is serious and widespread

LEUKOPENIA

A DECREASED NUMBER OF CIRCULATING LEUKOCYTES=USUALLY BELOW 5000/mm3

CBC

COMPLETE BLOOD COUNT=IDENTIFIES THE TOTAL NUMBER OF BLOOD CELLS (LEUKOCYTES, ERYTHROCYTES, AND PLATELETS) AS WELL AS THE HEMOGLOBIN, HEMATOCRIT (PERCENTAGE OF BLOOD VOLUME CONSISTING OF ERYTHROCYTES), AND RBC INDICES.

PERIPHERAL BLOOD SMEAR

A DROP OF BLOOD IS SPREAD ON A GLASS SLIDE, STAINED, AND EXAMINED UNDER A MICROSCOPE. THE SHAPE AND SIZE OF THE ERYTHROCYTES AND PLATELETS, AS WELL AS THE ACTUAL APPEARANCE OF THE LEUKOCYTES, PROVIDE USEFUL INFORMATION IN IDENTIFYING HEMATOLOGIC CONDITIONS.

BLOOD FOR THE CBC IS TYPICALLY OBTAINED BY VENIPUNCTURE.

BONE MARROW ASPIRATION AND BIOPSY

ARE CRUCIAL TESTS WHEN ADDITIONAL INFORMATION IS NEEDED TO ASSESS HOW A PERSON'S BLOOD CELLS ARE BEING FORMED AND TO ASSES THE QUANTITY AND QUALITY OF EACH TYPE OF CELL PRODUCED WITHIN THE MARROW.

THESE TESTS ARE ALSO USED TO DOCUMENT INFECTION OR TUMOR WITHIN THE MARROW.

BONE MARROW IN ADULTS IS USUALLY ASPIRATED FROM THE ILIAC CREST AND OCCASIONALLY FROM THE STERNUM.

BIOPSY SAMPLES ARE TAKEN FROM THE POSTERIOR ILIAC CREST; OCCASIONALLY, AN ANTERIOR APPROACH IS REQUIRED. A MARROW BIOPSY SHOWS THE ARCHITECTURE OF THE BONE MARROW AS WELL AS ITS DEGREE OF CELLULARITY.

A 5ML SAMPLE OF BLOOD AND MARROW IS ASPIRATED=KNOW!!!

ANEMIA and S&S=KNOW!!

A CONDITION IN WHICH THE HEMOGLOBIN CONCENTRATION IS LOWER THAN NORMAL; IT REFLECTS THE PRESENCE OF FEWER THAN THE NORMAL NUMBER OF ERYTHROCYTES WITHIN THE CIRCULATION. AS A RESULT, THE AMOUNT OF O2 DELIVERED TO BODY TISSUES IS ALSO DIMINISHED. ANEMIA IS NOT A SPECIFIC DISEASE STATE BUT A SIGN OF AN UNDERLYING DISORDER. IT IS BY FAR THE MOST COMMON HEMATOLOGIC CONDITION!!!=KNOW!!!

S&S:
PALLOR
LIGHT-HEADEDNESS
ORTHOSTATIC HYPOTENSION
EXERTIONAL DYSPNEA
VERTIGO
MORE RAPID HEART RATE IN ANEMIA, OR REDUCED BP DUE TO HYPOTENSION, DYSRHYTHMMIAS,

IRON DEFICIENCY ANEMIA

DECREASED RETICULOCYTES OR ERYTHROCYTE PRODUCTION, IRON, FERRITIN, IRON SATURATION, MCV; INCREASED TIBC

MEGALOBLASTIC ANEMIAS

B12 deficiency (pernicious anemia)*
Folic acid deficiency-malabsorption; alcholism; oral contraceptives; growth spurts; pregnancy

NORMAL VALUES FOR:
A. PLATELETS
B. WBCs
C. RBCs
D. HEMATOCRIT

ANSWER:
A.150,000-300,000 PLATELETS/uL
B.5,000-10,000 WBCS/uL
C.4.5-5.5 MILLION RBCs/ul
D.45%

ANTIPLATELET DRUGS MOST COMMONLY CAUSE HYPERSENSITIVITY REACTION?

ANAPHYLAXIS=THE MOST COMMMON IS BRONCHOSPASM WITH ASTHMA LIKE SYMPTOMS

A client is in the emergency department with a suspected fracture of the right hip. Which assessment findings would the nurse expect?

Select all that apply:
1. The right leg is longer than the left leg.
2. The right leg is shorter than the left leg.
3. The right leg is abducted.
4. The right leg is adducted.
5. The right leg is externally rotated.
6. The right leg is internally rotated.

ANSWER:
2. The right leg is shorter than the left leg.
4. The right leg is adducted.
5. The right leg is externally rotated.

WHICH IMMUNOGLOBUIN IS SPECIFIC TO AN ALLERGIC RESPONSE?

IgE
IgB
IgE
IgG

ANSWER: IgE IS INVOLVED WITH AN ALLERGIC RXN.

You need to draw blood from a client who is HIV positive. Which of the following precautions should you follow when performing this procedure?

A. Wear a gown, clean gloves, and a mask.
B. Wear a mask and sterile gloves.
C. Wash hands and don sterile gloves.
D. Wash hands and don clean gloves.

D.Wash hands and don clean gloves.

S.R. is HIV positive and shares an apartment with friends who do not have HIV. Which of the following activities could spread HIV?

A. Using the same toilet as S.R.
B. Eating a meal prepared by S.R.
C. Using S.R.’s razor
D. Wearing S.R.’s hat

C. Using S.R.’s razor

A phlebotomist was exposed to HIV via an accidental needle-stick from an HIV-positive client. The initial enzyme immunoassay result was negative. The phlebotomist is in the employee health department for the 6-week follow-up enzyme immunoassay test; those results were also negative. The phlebotomist asks the nurse what these findings mean. Which of the following represents the best response from the nurse to the phlebotomist?

A. “You have not been infected with HIV.”
B. “We still really don’t know your HIV status; you will need to be retested again in 6 weeks.”
C. “You probably don’t have HIV, but you still need to return for more follow-up testing.”
D. “You probably don’t have HIV. We will know for sure when you are retested in 3 months.”

B. “We still really don’t know your HIV status; you will need to be retested again in 6 weeks.”

Which of the following is the leading cause of death in clients with systemic sclerosis (SSc)?

A. Renal crisis
B. Biliary cirrhosis
C. Pulmonary arterial hypertension
D. Esophageal sclerosis

C. Pulmonary arterial hypertension

Which factor has most likely contributed to the increased prevalence of systemic lupus erythematosus (SLE) over the past 40 years?

A. Environmental pollution
B. Increased number of young African-American females
C. Increased number of new medications that may cause SLE
D. Increased testing and awareness of SLE

D. Increased testing and awareness of SLE

Which of the following statements is true concerning depression in clients with rheumatoid arthritis (RA)?

A. The relationship between depression and pain may be influenced by clients’ beliefs about their abilities to control their pain.
B. Depressed clients with RA may have decreased levels of pain and functional impairment.
C. Depressed clients with RA use health care services less often than those who are not depressed.
D. Depression is viewed as an acceptable strategy for coping with RA.

A. The relationship between depression and pain may be influenced by clients’ beliefs about their abilities to control their pain.

A nurse is providing education to a Mrs. N., a 57-year-old client with newly diagnosed rheumatoid arthritis (RA). Mrs. N. asks which exercises would be appropriate for her to follow. The nurse notes the patient is having pain at level 6 with joint swelling. What would be the nurse’s best response?

A. “It is more important for you to get plenty of rest at this time.”
B. “Performing isometric exercises will be the most beneficial to you at this time.”
C. “Because you have decreased strength, passive range-of-motion [PROM] exercises will be the most beneficial at this time.”
D. “Although your joint pain is not yet controlled, you may continue to ride your bike and swim.”

B. “Performing isometric exercises will be the most beneficial to you at this time.”

Which of the following upper extremity joints are commonly affected in clients with rheumatoid arthritis (RA) (List all that apply)?

A. Wrists
B. Metacarpophalangeal (MCP) joints
C. Proximal interphalangeal (PIP) joints
D. Distal interphalangeal (DIP) joints

B. Metacarpophalangeal (MCP) joints
C. Proximal interphalangeal (PIP) joints
D. Distal interphalangeal (DIP) joints

A nurse on your unit has a latex allergy. To which of the following foods would she be likely to have a reaction?

A. Kiwi
B. Orange
C. Peach
D. Cantaloupe

A. Kiwi

Which of the following food allergies is most likely to be outgrown?

A. Peanuts
B. Tree nuts
C. Eggs
D. Shellfish

C. Eggs

Which of the following are factors that influence the likelihood of developing an allergy (list all that apply):

A. Age at the time of exposure to the allergen
B. The type of allergen
C. The month of a person’s birth
D. The body mass index of a person

A. Age at the time of exposure to the allergen
B. The type of allergen

Which percentage of the population have allergies?

A. 10% to 20%
B. 20% to 30%
C. 30% to 40%
D. 40% to 50%

B. 20% to 30%

Disseminated intravascular coagulation (DIC) is characterized by which of the following clinical manifestations?

A. Prolonged PT and PTT
B. Platelet count >100,000/mm3
C. Elevated fibrinogen
D. Bradycardia

A. Prolonged PT and PTT

Which of the following populations would be at risk for developing anemia? (list all that apply)

A. Alcoholic people
B. Pregnant women
C. Older adults
D. Middle-aged women

A. Alcoholic people
B. Pregnant women
C. Older adults

Mrs. M., 73 years old, was recently diagnosed with anemia. During your assessment of this client, you might expect to find the following manifestations of anemia (list all that apply):

A. Angina
B. High energy levels
C. Ataxia=DEFECTIVE MUSCULAR COORDINATION
D. Confusion

A. Angina
C. Ataxia=DEFECTIVE MUSCULAR COORDINATION
D. Confusion

You are caring for a client who has taken a high dose of corticosteroids for months. Which of the following manifestations indicates that this client has an infection?

A. The client complains of generalized feelings of fatigue and malaise.
B. The client has a fever.
C. The client has a decreased WBC count.
D. The infection is widespread before being detected.

D. The infection is widespread before being detected.

You are caring for a client who recently had part of the duodenum removed. Which of the following may occur as a result of this procedure?

A. Increased risk of contracting infections
B. Decreased absorption of vitamin B12
C. Iron deficiency anemia
D. Decreased absorption of amino acids

C. Iron deficiency anemia

Which of the following manifestations may be seen in clients with immunodeficiencies?

A. Diarrhea
B. Weight gain
C. Lightheadedness
D. Rash

A. Diarrhea

Neoplasia

is an abnormality of cell growth and multiplication characterized by

At cellular level
Excessive cellular proliferation
Uncoordinated growth
Tissue infiltration

At molecular level
Disorder of growth regulatory genes
Develops in a multistep fashion

Damage occurs when cancer uses nutrients and oxygen healthy tissue needs or interferes with normal function.

Origin of Neoplasia – two types

Monoclonal
Initial change affects a single cell
Field origin
Carcinogen (substance or “other” that causes changes in cells ability to divide/reproduce into exact copy) acts on large number of cells producing field of potentially cancerous cells

Multiple Hits and Multiple Factors OF CARCINOGENESIS?

Some feel to cause cancer it requires 2 hits
1st event – initiation
Carcinogen = initiator
2nd event – promotion
Agent = promoter
Change in the DNA which is transmitted to new cells when it divides (ie. clone)

Lag period
Time between exposure (first hit) and development of clinically apparent cancer
Altered cell shows no abnormality during lag period

Oncogenes and Tumor Suppressor Genes

Tumor suppressor genes?

- “Self destruct button” built into DNA that causes death of cell if mutation of DNA
Cancer occurs when this does not work

Viral Hypothesis

RNA Retrovirus – inserts gene into RNA to produce cancer
DNA virus - act by blocking suppressor gene
Examples – HPV, EBV,HBV

Epigenetic Hypothesis

Cancer is due to adult stem cell that for unknown reason change into cancer cell

Failure of Immune Surveillance Hypothesis

Neoplastic changes frequently occur in cells
Altered DNA result in production of cancerous cell
Immune response (cytotoxic) reacts to cancer cell as if foreign protein (just like bacteria or virus)
Cancer occurs when neoplastic cells escape recognition and destruction thus becoming clinical cancers

Agents Known or Believed Agent in Causing Neoplasia

Chemical Oncogensis
Radiation Oncogenesis
Viral Oncogenesis
Nutritional Oncogenesis
Hormonal Oncogenesis
Genetic Oncogenesis

Carcinogens?

substances known to cause cancer or produces an increase in incidence of cancer in animals or humans
Cause of most cancers is unknown
Most cancers are probably multifactorial in origin
Known carcinogenic agents constitute a small percentage of cases
Unidentified ‘environmental’ agents probably play a role in 95% of cancers

Mode of carcinogenesis

Inducing changes in DNA – deletion, breakage, cross-linkage
Synergistic action with viruses
Promoter for other carcinogens
Difficulties in identifying carcinogen
Numerous industrial, agricultural, household chemicals present in low levels
Exposed to large number of chemicals in a lifetime
Long lag phase

Radiation Oncogenesis

Types of oncogenic radiation
Ultraviolet
X-ray
Radioisotopes
Nuclear Fallout
Mode of oncogenesis
Direct effect on DNA
Activation of other causes (example weakened immune system)

UV Radiation

Solar UV radiation associated with skin cancers – squamous CA, basal cell CA, malignant melanoma
Fair-skinned and elderly are susceptible
UV light is believed to induce cross-linkages between DNA molecules and CA occurs when repair mechanisms are not efficient

X-ray radiation

Earlier use of X-rays caused skin cancer, leukemia and papillary thyroid CA
Radiotherapy causes raditation-induced malignancy 10-30 yrs later – usually sarcomas
Diagnostic X-rays are considered to have no increased risk except in abdominal x-rays which increase incidence of leukemia in the fetus

Radioisotopes

Osteosarcoma common among factory workers who use radium-containing paints
Radioactive mineral mining in Europe and USA associated with lung cancer
Thorium increases risk of liver cancer – hepatocellular, angiosarcoma, cholangiocarcinoma
Radioactive iodine – increased risk of cancer 15-25 years later

Viral Oncogenesis
Types?

Oncogenic RNA Viruses
Oncogenic DNA Viruses

Nutritional Oncogenesis

Little evidence linking cancer to diet except for known chemical carcinogens
Some associations
Low-fiber diet and colonic CA
Fatty diet with breast ca
Betel leaves with oral ca

Protective agents – ?antioxidant effect, awaiting confirmation
Beta-carotene
Vitamin C, E
Selenium

Hormonal Oncogenesis
Types?

Induction of Neoplasms by Hormones
Dependence of Neoplasms on Hormones
Hormones inducing Neoplasms
Estrogen – breast ca
Diethylstilbestrol (DES) – vaginal and uterine ca

Hormonal Dependence of Neoplasms?

Neoplasm not caused by hormones but depend on hormones for optimal growth
Neoplastic cells possess receptors for binding hormone
Loss of hormonal stimulation slow but does not halt growth
Examples
Prostate CA
Breast CA
Thyroid CA

Genetic Oncogenesis (Role of Inheritance)

Some forms of cancer seem to run in families
Some genes have been identified placing individual at greater risk (but not certain will have cancer)
Breast cancer
Retinoblastoma
Wilm’s tumor
Neurofibromatosis (type 1 von Recklinghausen’s disease)
Multiple endocrine adenomatosis (MEN)
Familial polyposis coli
Nevoid basal cell carcinoma syndrome

PATHOGENESIS OF CANCER?

Pathogenesis of cancer is complex
it is a genetic disease- either acquired genetic abnormality or inherited genetic abnormality
It arises when several mutations accumulate within genome

Added insults from the environmental exposures to carcinogens : chemicals, radiation, viruses
Growth autonomy from activation of growth factors or by suppression of tumour suppressor genes

CHARACTERISTICS OF CANCER CELLS?

Have rapid or continuous cell division
Do not respond to signals for apoptosis
Show anaplastic morphology
Have a large nuclear-cytoplasmic ratio
Lose some or all differentiated functions
Adhere loosely together
Able to migrate
Grow by invasion
Not contact inhibited
Different than usual 23 pairs of chromosomes

Metastasis occurs through a progression of steps?

Extension into surrounding tissues
Bloodborne metastasis
Blood vessel penetration
Release of tumor cells
Invasion
Local seeding
Lymphatic spread

CANCER CLASSIFICATION

Cancer grading and staging help standardize diagnosis and treatment prognosis.
Grading on the basis of cell appearance and activity compares the cancer cell with its normal parent tissue.
Staging classifies clinical aspects of the cancer and determines exact location and degree of metastasis at diagnosis.

STAGE 0=CARCINOMA IN SITU

STAGE 1=Higher numbers indicate more extensive disease: Larger tumor size and/or spread of the cancer beyond the organ in which it first developed to nearby lymph nodes and/or organs adjacent to the location of the primary tumor.

STAGE 2=The cancer has spread to another organ(s).

CANCER PREVENTION?

Avoidance of known or potential carcinogens
Modification of associated factors
Removal of “at-risk” tissues
Chemoprevention
Screening programs
Gene therapy

NURSING ASSESSMENTS FOR CANCER SCREENING?

Colorectal - CHANGE in bowel habits, blood, ? testing for occult, ? baseline colonoscopy, intake of red/smoked/fatty meats, intake of bran/roughage

Bladder – pain, blood, cloudy, urgency, frequency

Prostate – hesitancy, stream size, pain in back of legs, hx UTI

Skin – moles/warts new or 

Leukemia – petechiae-tiny bruises, ecchymosis-larger bruises, fatigue, bleeding tendency, infections, night sweats, unexplained fever

Lung – skin color, breathlessness with talking, cough, hoarseness, smoking hx, environmental irritant hx, lack of activity tolerance, SOB, sputum frothy/blood, pain in arms or chest, difficulty swallowing

DIAGNOSTICS FOR SCREENING CANCER?

Imaging – view of tumor
Pathology – evaluating cancer at cellular level
Lab – evaluating what cancer is doing to healthy tissue; preventing healthy tissue from functioning correctly
Example – increased calcium levels due to bone cancer “digesting” bone releasing calcium into blood

FUNCTIONS OF THE MUSCULOSKELETAL SYSTEM?

Protection of vital organs
Mobility and movement
Facilitate return of blood to the heart
Production of blood cells (hematopoiesis)
Reservoir for immature blood cells
Reservoir for vital minerals

Osteoblasts

Function in bone formation

Osteocytes

Mature bone cells that function in bone maintenance
Located in the lacunae

Osteoclasts

Multinuclear cells function in destroying, resorbing, and remodeling bone
Located in Howship’s lacunae

A.Osteogenesis:
B.Ossification:

a.process of bone formation

b.the process of formation of the bone matrix and deposition of minerals

What is atrophy?

A.Shrinkage-like decrease in the size of the muscle.
B.Fluid-filled sac found in connective tissue.
C.Rhythmic contraction of muscle.
D.Grating or crackling sound or sensation.

A. Atrophy is shrinkage-like decrease in the size of the muscle. Bursa is a fluid-filled sac found in connective tissue. Clonus is rhythmic contraction of muscle. Crepitus is a grating or crackling sound or sensation.

Rheumatoid Arthritis?

—Ulnar Deviation and “Swan-Neck” Deformity

Neurovascular assessment?

Pain
PULSE
Pallor
PARESTHESIA
PARALYSIS
Temperature
Capillary refill
Paresthesia
Mobility of affected joints
Peripheral nerves

DIAGNOSTIC TESTS FOR MUSCULOSKELETAL?

X-rays
Computed tomography
MRI
Arthrography
Bone densitometry
Bone scan
Arthroscopy
Arthrocentesis
Electromyography
Biopsy
Laboratory studies

Which statement is correct about magnetic resonance imaging? (list all that apply)

A.Credit cards with magnetic strips may be erased.

B.Nonremovable cochlear implant devices can become inoperable.

C.Transdermal patches that have a thin layer of aluminized back must be covered with gauze.

D.Jewelry and hair clips must be removed before the MRI is performed.

A.Credit cards with magnetic strips may be erased.

B.Nonremovable cochlear implant devices can become inoperable.

D.Jewelry and hair clips must be removed before the MRI is performed.

True statements are credit cards with magnetic strips may be erased. Nonremovable cochlear implant devices can become inoperable. Jewelry and hair clips must be removed before the MRI is performed.
Transdermal patches that have a thin layer of aluminized back must be covered with gauze is false. Transdermal patches that have a thin layer of aluminized back must be removed before the MRI is performed because they can cause burns.

FRACTURED BONE HEALING PROCESS?

Stage 1 -Hematoma and inflammation
Stage 2 - Angiogenesis and cartilage formation
Stage 3 –
Cartilage calcification
Cartilage removal
Bone formation
Remodeling

1.IMPACT
2.INDUCTION
3.INFLAMMATION
4.SOFT CALLUS
5.OSSIFICATION
6.REMODELING

COLLABORATIVE PROBLEMS WITH HEALING PROCESS OF BONES?

Compartment syndrome=REDNESS,COOLER TEMP, PALENESS
Pressure ulcer
Disuse syndrome
Delayed union or nonunion of fracture(s)

STRAINS OF MUSCLES?

Excessive stretching of a muscle or tendon when it is weak or unstable
Muscle damage can be in the form of tearing (part or all) of the muscle fibers and the tendons attached to the muscle. The tearing of the muscle can also damage small blood vessels, causing local bleeding (bruising) and pain (caused by irritation of the nerve endings in the area).

S&S OF STRAINED MUSCLES?

Swelling, bruising or redness, or open cuts as a consequence of the injury
Pain at rest
Pain in relation to that muscle is used
Weakness of the muscle or tendons
Inability to use the muscle at all

SPRAINS OF MUSCLES?

Excessive stretching of a ligament
Diagnostics – rule out fracture
Usual signs and symptoms
Pain, swelling, bruising, instability, and loss of the ability to move and use the joint; signs and symptoms can vary in intensity, depending on the severity of the sprain. Some patients will report a pop or tearing sensation when the injury happens

SPRAIN CLASSIFICATION?

Grade I or mild sprain is caused by overstretching or slight tearing of the ligaments with no joint instability

Grade II or moderate sprain is caused by further, but still incomplete, tearing of the ligament and is characterized by bruising, moderate pain, and swelling. A person with a moderate sprain usually has more difficulty putting weight on the affected joint and experiences some loss of function.

Grade III or severe sprain completely tear or rupture a ligament. Pain, swelling, and bruising are usually severe, and the patient is unable to put weight on the joint.

OSTEOPOROSIS AND OSTEOPENIA?

Affects approximately 40 million people over the age of 50 in the United States.
Normal homeostatic bone turnover is altered and the rate of bone resorption is greater than the rate of bone formation, resulting in loss of total bone mass.
Bone becomes porous, brittle, and fragile, and break easily under stress
Frequently result in compression fractures of the spine, fractures of the neck or intertrochanteric region of the femur, and Colles’ fractures of the wrist
Osteopenia is a milder form of the disorder; may progress to Osteoporosis if left untreated

NUCLEAR SCANS

BONE SCANS ARE DONE WHEN A CLIENT'S ENTIRE SKELETAL SYSTEM IS TO BE EVALUATED

A RADIONUCLIDE TEST INVOLVES RADIOACTIVE MATERIAL INJECTED 2-3 HR BEFORE SCANNING.

BONE SCANS CAN MOST COMMONLY DETECT HAIRLINE BONE FRACTURES. THEY DETECT TUMORS, FRACTURES, AND DISEASES OF THE BONE (OSTEOMYELITIS, OSTEOPOROSIS, VERTEBRAL COMPRESSION FRACTURES)

GALLIUM AND THALLIUM SCANS ARE MORE SENSITIVE TO DETECTING BONE PROBLEMS THAN A BONE SCAN.

THE RADIOISOTOPE MIGRATES TO TISSUES OF THE BRAIN, LIVER, AND BREAST AND IS USED TO DETECT DISEASE OF THESE ORGANS ALSO. RADIONUCLIDE IS INJECTED 4-6HR BEFORE SCANNING. THE SCAN TAKES 30-60 MIN AND MAY REQUIRE SEDATION IN ORDER FOR THE CLIENT TO LAY STILL DURING THAT TIME. REPEAT SCANNING OCCURS AT 24,48, AND 72HRS.

DUAL X-RAY ABSORPTIOMETRY (DXA)

DXA SCANS ARE DONE TO ESTIMATE THE DENSITY OF A CLIENT'S BONE MASS-USUALLY IN THE HIP OR SPINE-AND THE PRESENCE/EXTENT OF OSTEOPOROSIS

ELECTROMYOGRAPHY AND NERVE CONDUCTION STUDIES

EMG AND NERVE CONDUCTION STUDIES ARE DONE TO DETERMINE THE PRESENCE AND CAUSE OF MUSCLE WEAKNESS.

EMG=THIN NEEDLES ARE PLACED IN THE MUSCLE UNDER STUDY AND ATTACHED TO AN ELECTRODE, WHICH IS ATTACHED TO AN OSSILLOSCOPE. ELECTRICAL ACTIVITY IS RECORDED DURING A MUSCLE CONTRACTION

WHEN EMG AND NERVE STUDIES ARE DONE. THE NERVE CONDUCTION IS COMPLETED FIRST.

NERVE CONDUCTION STUDY?

FLAT ELECTRODES ARE TAPED ON THE SKIN.
LOW ELECTRICAL CURRENTS ARE SENT THROUGH THE ELECTRODES AND MUSCLE RESPONSE TO THE STIMULUS IS RECORDED

INDICATIONS:
NEUROMUSCULAR DISORDERS
MOTOR NEURON DISEASE (AMYOTROPHIC LATERAL SCLEROSIS, MYASTHENIA GRAVIS, GUILLAIN BARRE)
PERIPHERAL NERVE DISORDERS (CARPAL TUNNEL)

ARTHROSCOPY?

IS DONE TO VISUALIZE THE INTERNAL STRUCTURES OF A JOINT, MOST COMMONLY THE KNEE OR SHOULDER JOINTS.

CAN'T BE DONE IF INFECTION IS PRESENT IN THE JOINT OR IF THE CLIENT IS UNABLE TO BEND THE JOINT AT LEAST 40 DEGREES.

NUMBER AND PLACEMENT OF INCISIONS DEPEND ON THE AREA OF THE JOINT NEEDING TO BE VISUALIZED AND THE EXTENT OF TH NEEDED REPAIR.

GALLIUM SCAN

INVOLVES A RADIOISOTOPE CALLED RADIONUCLIDE THAT IS INJECTED INTO THE CLIENT 4-6HR BEFORE THE SCAN TO VIEW THE CLIENT'S BONES. THE RADIONUCLIDE ALSO MIGRATES TO THE TISSUES OF THE BRAIN,LIVER, AND BREAST AND IS USED TO DETECT DISEASE OF THESE ORGANS.

INDICATIONS:
DETECT FRACTURES, OSTEOPOROSIS, BONE LESIONS, OSTEOMYELITIS, AND ARTHRITIS

ARTHROPLASTY

REFERS TO THE SURGICAL REMOVAL OF A DISEASED JOINT DUE TO OSTEOARTHRITIS, OSTEONECROSIS, RHEUMATOID ARTHRITIS, TRAUMA, OR CONGENITAL ANOMALIES, AND REPLACING IT WITH PROSTHETICS OR ARTIFICIAL COMPONENTS MADE OF METAL AND/OR PLASTIC.

TOTAL JOINT ARTHROPLASTY=TOTAL JOINT REPLACEMENT-INVOLVES REPLACEMENT OF ALL COMPONENTS OF AN ARTICULATING JOINT.

DOS AFTER ARTHROPLASTY:
USE ELEVATED SEATING/RAISED TOILET SET
USE STRAIGHT CHAIRS WITH ARMS
USE AN ABDUCTION PILLOW, OR A PILLOW, IF PRESCRIBED, BETWEEN THE CLIENT'S LEGS WHILE IN BED (AND WITH TURNING, IF RESTLESS, OR IS IN AN ALTERED MENTAL STATE)
EXTERNALLY ROTATE A CLIENT'S TOES

DONTS:
AVOID FLEXION OF HIP GREATER THAN 90 DEGREES
AVOID LOW CHAIRS
DO NOT CROSS A CLIENT'S LEGS
DO NOT INTERNALLY ROTATE A CLIENT'S TOES.

TOTAL KNEE ARTHROPLASTY

REPLACEMENT OF THE DISTAL FEMORAL COMPONENT, THE TIBIA PLATE, AND THE PATELLAR BUTTON. TOTAL KNEE ARTHROPLASTY IS A SURGICAL OPTION WHEN CONSERVATIVE MEASURES FAIL.

UNICONDYLAR KNEE REPLACEMENTS?

ARE DONE WHEN A CLIENT'S JOINT MAY BE DISEASED IN ONE COMPARTMENT OF THE JOINT.

TOTAL HIP ARTHROPLASTY

INVOLVES THE REPLACEMENT OF THE ACETABULAR CUP, THE FEMORAL HEAD, AND THE FEMORAL STEM.

DVT MAY DEVELOP AND RESULT IN PULMONARY EMBOLISM.

HEMIARTHROLASTY

REFERS TO HALF OF A JOINT REPLACEMENT. FRACTURES OF THE FEMORAL NECK CAN BE TREATED ONLY WITH REPLACEMENT OF THE FEMORAL COMPONENT.

DISARTICULATION

DESCRIBES AN AMPUTATION PERFORMED THROUGH A JOINT

SYME AMPUTATION

REMOVAL OF FOOT WITH ANKLE SAVED

LOWER EXTREMITY AMPUTATIONS

ARE USUALLY DONE DUE TO PVD AS A RESULT OF ARTERIOSCLEROSIS

SALVAGE OF THE KNEE WITH A BELOW THE KNEE AMPUTATION ALSO IMPROVES FUNCTION OVER AN ABOVE THE KNEE AMPUTATION.

THE HIGHER THE LEVEL OF AMPUTATION THE GREATER THE AMOUNT OF EFFORT THAT WILL BE REQUIRED TO USE A PROSTHESIS

ANGIOGRAPHY

ALLOWS VISUALIZATION OF PERIPHERAL VASCULATURE AND AREAS OF IMPAIRED CIRCULATION

DOPPLER LASER AND ULTRASONOGRAPHY STUDIES

MEASURE SPEED OF BLOOD FLOW IN AN EXTREMITY

TRANSCUTANEOUS OXYGEN PRESSURE (TcPO2)

MEASURES OXYGEN PRESSURES IN AN EXTREMITY TO INDICATE BLOOD FLOW IN THE EXTREMITY, WHICH IS A RELIABLE INDICATOR FOR HEALING.

ANKLE-BRACHIAL INDEX

MEASURES DIFFERENCE BETWEEN ANKLE AND BRACHIAL SYSTOLIC PRESSURES.

CLOSED AMPUTATION

THIS IS THE MOST COMMON TECHNIQUE USED. SKIN FLAP IS SUTURED OVER END OF RESIDUAL LIMB, CLOSING SITE.

OPEN AMPUTATION

THIS TECHNIQUE IS USED WHEN AN ACTIVE INFECTION IS PRESENT. SKIN FLAB IS NOT SUTURED OVER END OF RESIDUAL LIMB ALLOWING FOR DRAINAGE OF INFECTION. SKIN FLAP IS CLOSED AT A LATER DATE.

OSEOPENIA

THE PRECURSOR TO OSTEOPOROSIS, REFERS TO LOW BONE MINERAL DENSITY RELATIVE TO THE PTS AGE AND SEX

BONE MINERAL DENSITY PEAKS BETWEEN THE AGES OF 18-30

OSTEOPOROSIS RISK FACTORS?

FEMALE GENDER, FAMILY HX, AND THIN, LEAN BODY BUILD ARE PRECURSORS TO LOW BONE DENSITY

IF THE CLIENT IS OVER AGE 60, IS A FEMALE WHO HAS POSTMENOPAUSAL ESTROGEN DEFICIENCY, HAS LOW LEVELS OF CALCITONIN, OR IS MALE WITH LOW TESTOSTERONE, INCREASED BONE LOSS MAY OCCUR.

HX OF LOW CALCIUM INTAKE WITH SUBOPTIMAL LEVELS OF VITAMIN D DECREASES BONE FORMATION.

HX OF SMOKING AND HIGH ALCOHOL INTAKE

SECONDARY OSTEOPOROSIS RESULTS FROM?

HYPERPARATHYROIDISM
LONG-TERM CORTICOSTEROID USE (ASTHMA, SLE)
LONG-TERM ANTICONVULSANT MEDICATION USE
LONG TERM LACK OF WEIGH-BEARING (SPINAL CORD INJURY)

pQUS=PERIPHERAL QUANTITATIVE ULTRASOUND

AN ULTRASOUND, USUALLY OF THE HEEL, TIBIA, AND PATELLA. USED TO DETERMINE OSTEOPOROSIS

QCT=QUANTITATIVE CT

IS USED TO MEASURE BONE DENSITY ESPECIALLY IN THE VERTEBRAL COLUMN.

VERTEBROPLASTY OR KYPHOPLASTY?

ARE MINIMALLY INVASIVE PROCEDURES PERFORMED BY A RADIOLOGIST. BONE CEMENT IS INJECTED INTO THE FRACTURED SPACE OF THE VERTEBRAL COLUMN WITH OR W/O BALLOON INFLATION. BALLOON INFLATION OF THE FRACTURE IS TO CONTAIN THE CEMENT AND ADD HEIGHT TO THE FRACTURED VERTEBRA.

MILD SEDATION IS USED
CLIENT LIES SUPINE FOR 1-2 HR FOLLOWING PROCEDURE
MONITOR VS FOR SOB AND THE PUNCTURE SITE FOR BLEEDING
COMPLETE A NEUROLOGICAL ASSESSMENT
APPLY COLD THERAPY THE INJECTION SITE

FRACTURE

A BREAK IN A BONE SECONDARY TO TRAUMA OR A PATHOLOGICAL CONDITION.
FRACTURES CAUSED BY TRAUMA ARE THE MOST COMMON TYPE OF BONE FRACTURE.

PATHOLOGICAL FRACTURES MAY BE CAUSED BY METASTATIC CANCER, OSTEOPOROSIS, OR PAGET'S DISEASE

CLOSED, OR SIMPLE FRACTURE

DOES NOT BREAK THROUGH THE SKIN SURFACE

HAS ONE FRACTURE LINE, WHILE A COMMINUTED FRACTURE HAS MULTIPLE FRACTURES

OPEN, OR COMPOUND FRACTURE

DISRUPTS THE SKIN INTEGRITY, CAUSING AN OPEN WOUND AND TISSUE INJURY WITH A RISK OF INFECTION

OPEN FRACTURES ARE GRADED BASED UPON THE EXTENT OF TISSUE INJURY?

GRADE I=MINIMAL SKIN DAMAGE

GRADE II=DAMAGE INCLUDE SKIN AND MUSCLE CONTUSIONS BUT W/O EXTENSIVE SOFT TISSUE INJURY.

GRADE III=DAMAGE IS EXCESSIVE TO SKIN, MUSCLES, NERVES, AND BLOOD VESSELS

COMPLETE FRACTURE

GOES THROUGH THE ENTIRE BONE, DIVIDING IT INTO 2 DISTINCT PARTS.

AN INCOMPLETE FRACTURE GOES THROUGH PART OF THE BONE

DISPLACED FRACTURE

HAS BONE FRAGMENTS THAT ARE NOT IN ALIGNMENT, AND A NON-DISPLACED FRACTURE HAS BONE FRAGMENTS THAT REMAIN IN ALIGNMENT.

FATIGUE (STRESS) FRACTURE

RESULTS WHEN EXCESS STRAIN OCCURS FROM RECREATIONAL AND ATHLETIC ACTIVITIES.

COMPRESSION FRACTURE

OCCURS FROM A LOADING FORCE PRESSING ON CALLUS BONE. THIS CONDITION IS COMMON IN THE OLDER ADULT CLIENT WHO HAS OSTEOPOROSIS.

COMMINUTED FRACTURE

BONE IS FRAGMENTED

OBLIQUE FRACTURE

FRACTURE OCCURS AT OBLIQUE ANGLE AND ACROSS BONE

SPIRAL FRACTURE

FRACTURE OCCURS FROM TWISTING MOTION (COMMON WITH PHYSICAL ABUSE)

IMPACTED FRACTURE

FRACTURED BONE IS WEDGED INSIDE OPPOSITE FRACTURED FRAGMENT

GREENSTICK FRACTURE

FRACTURE OCCURS ON ONE SIDE (CORTEX) BUT DOES NOT EXTEND COMPLETELY THROUGH THE BONE (MOST OFTEN IN CHILDREN)

TYPES OF IMMOBILIZATION DEVICES

CASTS
SPLINTS/IMMOBILIZERS
TRACTION
EXTERNAL FIXATION
INTERNAL FIXATION

CLOSED REDUCTION

IS WHEN A PULLING FORCE (TRACTION) IS APPLIED MANUALLY TO REALIGN THE DISPLACED FRACTURED BONE FRAGMENTS. ONCE THE FRACTURE IS REDUCED, IMMOBILIZATION IS USED TO ALLOW THE BONE TO HEAL

OPEN REDUCTION

IS WHEN A SURGICAL INCISION IS MADE AND THE BONE IS MANUALLY ALIGNED AND KEPT IN PLACE WITH PLATES AND SCREWS. THIS IS KNOWN AS AN OPEN REDUCTION AND INTERNAL FIXATION (ORIF) PROCEDURE

CASTS

ARE MORE EFFECTIVE THAN SPLINTS OR IMMOBILIZERS B/C THEY CAN'T BE REMOVED BY THE CLIENT.

WALKING CAST

A RUBBER WALKING PAD ON THE SOLE OF THE CAST ASSISTS THE CLIENT IN AMBULATING WHEN WEIGHT BEARING IS ALLOWED

SPICA CASTS

A PORTION OF THE TRUNK AND ONE OR TWO EXTREMITIES; TYPICALLY USED ON CHILDREN W/ CONGENITAL HIP DYSPLASIA

BODY CASTS

ENCIRCLE THE TRUNK OF THE BODY

PLASTER OR PARIS CASTS

ARE HEAVY, NOT WATER RESISTANT, AND CAN TAKE 24-72 HRS TO DRY

SYNTHETIC FIBERGLASS CASTS

ARE LIGHT, STRONGER, WATER RESISTANT, AND DRY VERY QUICKLY (30 MIN)

TRACTION

USES A PULLING FORCE TO PROMOTE AND MAINTAIN ALIGNMENT OF THE INJURED AREA.

GOALS:
PREVENT SOFT TISSUE INJURY
REALIGN OF BONE FRAGMENTS
DECREASE MUSCLE SPASMS AND PAIN
CORRECT OR PREVENT FURTHER DEFORMITIES

STRAIGHT OR RUNNING TRACTION

THE COUNTERTRACTION IS PROVIDED BY THE CLIENT'S BODY BY APPLYING A PULLING FORCE IN A STRAIGHT LINE. MOVEMENT OF THE CLIENT'S BODY CAN ALTER THE TRACTION PROVIDED

BALANCED SUSPENSION TRACTION

THE COUNTERTRACTION IS PRODUCED BY DEVICES SUCH AS SLINGS OR SPLINTS TO SUPPORT THE FRACTURED EXTREMITY OFF THE BED WHILE PULLING WITH ROPES AND WEIGHTS.

THE CLIENT'S BODY CAN BE MOVED W/O ALTERING THE TRACTION

MANUAL TRACTION

A PULLING FORCE IS APPLIED BY THE HANDS OF THE PROVIDER FOR TEMPORARY IMMOBILIZATION, USUALLY WITH SEDATION OR ANESTHESIA, IN CONJUNCTION WITH THE APPLICATION OF AN IMMOBILIZING DEVICE

SKIN TRACTION

PRIMARY PURPOSE IS TO DECREASE MUSCLE SPASMS AND IMMOBILIZE THE EXTREMITY PRIOR TO SURGERY. THE PULLING FORCE IS APPLIED BY WEIGHTS THAT ARE ATTACHED BY ROPE TO THE CLIENT'S SKIN WITH TAPE, STRAPS, BOOTS, OR CUFFS.

EXAMPLES=BRYANT'S TRACTION=USED FOR CONGENITAL HIP DISLOCATION IN CHILDREN

BUCK'S TRACTION=USED PREOPERATIVELY FOR HIP FRACTURES FOR IMMOBILIZATION IN ADULT CLIENTS

SKELETAL TRACTION

THE PULLING FORCE IS APPLIED DIRECTLY TO THE BONE BY WEIGHTS ATTACHED BY ROPE DIRECTLY TO A ROD/SCREW PLACED THROUGH THE BONE TO PROMOTE BONE ALIGNMENT

EXAMPLES:
SKELETAL TONGS (GARDNER-WELLS)
FEMORAL OR TIBIAL PINS (STEINMANN PIN).

WEIGHTS 15-30LB CAN BE APPLIED AS NEEDED

HALO TRACTION

SCREWS ARE PLACED THROUGH A HALO-TYPE BAR THAT ENCIRCLES THE HEAD INTO THE OUTER TABLE OF THE BONE OF THE SKULL. THIS HALO IS ATTACHED TO RODS THAT ARE SECURED TO A VEST WORN BY THE PT. ENSURE THAT THE WRENCH TO RELEASE THE RODS IS ATTACHED TO THE VEST WHEN USING HALO TRACTION IN THE EVENT CPR IS NECESSARY

EXTERNAL FIXATION=SURGICAL

INVOLVES FRACTURE IMMOBILIZATION USING PERCUTANEOUS PINS AND WIRES THAT ARE ATTACHED TO A RIGID EXTERNAL FRAME.

USED TO TREAT:
COMMINUTED FRACTURE OR NONUNION FRACTURES WITH EXTENSIVE SOFT TISSUE DAMAGE
LEG LENGTH DISCREPANCIES FROM CONGENITAL DEFECTS
BONE LOSS RELATED TO TUMORS OR OSTEOMYELITIS

OPEN REDUCTION AND INTERNAL FIXATION (ORIF)

OPEN REDUCTION REFERS TO VISUALIZATION OF A FRACTURE THROUGH AN INCISION IN THE SKIN, AND INTERNAL FIXATION WITH PLATES, SCREWS, PINS, RODS, AND PROSTHETICS AS NEEDED

COMPARTMENT SYNDROME

USUALLY AFFECTS EXTREMITIES AND OCCURS WHEN PRESSURE WITHIN ONE OR MORE OF THE MUSCLE COMPARTMENTS (AN AREA COVERED WITH AN ELASTIC TISSUE CALLED FASCIA) OF THE EXTREMITY COMPROMISES CIRCULATION, RESULTING IN AN ISCHEMIA EDEMA CYCLE.

CAPILLARIES DILATE IN AN ATTEMPT TO PULL OXYGEN INTO THE TISSUE. INCREASED CAPILLARY PERMEABILITY FROM THE RELEASE OF HISTAMINE LEADS TO EDEMA FROM PLASMA PROTEINS LEAKING INTO THE INTERSTITIAL FLUID SPACE.

INCREASED EDEMA CAUSES PRESSURE ON THE NERVE ENDINGS, RESULTING IN PAIN. BLOOD FLOW IS FURTHER REDUCED AND ISCHEMIA PERSISTS, RESULTING IN COMPROMISED NEUROVASCULAR STATUS.

ASSESS USING THE 5 P'S=PAIN, PARALYSIS, PARESTHESIA, PALLOR, AND PULSELESSNESS

NEUROMUSCULAR DAMAGE OCCURS WITHIN 4-6 HR.

FASCIOTOMY=SURGICAL TREATMENT FOR COMPARTMENT SYNDROME

A SURGICAL INCISION IS MADE THROUGH THE SUBCUTANEOUS TISSUE AND FASCIA OF THE AFFECTED COMPARTMENT TO RELIEVE THE PRESSURE AND RESTORE CIRCULATION

AFTER THE FASCIOTOMY, THE OPEN WOUNDS REQUIRE STERILE PACKINGS AND DRESSINGS UNTIL SECONDARY CLOSURE OCCURS. SKIN GRAFTS MAY BE NECESSARY

FAT EMBOLISM

ADULTS BETWEEN AGE 70-80 ARE AT THE GREATEST RISK

HIP AND PELVIS FRACTURES ARE MOST COMMON

OCCURS AFTER THE INJURY, USUALLY WITHIN 48HR FOLLOWING LONG BONE FRACTURES OR WITH TOTAL JOINT ARTHROPLASTY

FAT GLOBULES FROM THE BONE MARROW ARE RELEASED INTO THE VASCULATURE AND TRAVEL TO THE SMALL BLOOD VESSELS, INCLUDING THOSE IN THE LUNGS, RESULTING IN ACUTE RESPIRATORY INSUFFICIENCY AND ORGAN PERFUSION.

CLINICAL MANIFESTATIONS:
DYSPNEA, CHEST PAIN, DECREASED OXYGEN SATURATION
DECREASED MENTAL ACUITY RELATED TO LOW ARTERIAL OXYGEN LEVEL=EARLIEST SIGN
RESPIRATORY DISTRESS
TACHYCARDIA
TACHYPNEA
FEVER
CUTANEOUS PETECHIA=BRUISES ON NECK, CHEST, UPPER ARMS, AND ABDOMEN=FROM THE BLOCKAGE OF THE CAPILLARIES BY THE FAT GLOBULES. THIS IS A DISCRIMINATING FINDING FROM PULMONARY EMBOLISM AND IS A LATE SIGN

DVT

DEEP VEIN THROMBOSIS IS THE MOST COMMON COMPLICATION FOLLOWING TRAUMA, SURGERY, OR DISABILITY RELATED TO IMMOBILITY.

OSTEOMYELITIS

AN INFECTION OF THE BONE THAT BEGINS AS AN INFLAMMATION WITHIN THE BONE SECONDARY TO PENETRATION BY INFECTIOUS ORGANISMS FOLLOWING TRAUMA OR SURGERY

CLINICAL MANIFESTATIONS:
BONE PAIN THAT IS CONSTANT, PULSATING, LOCALIZED, AND WORSE WITH MOVEMENT
ERYTHEMA AND EDEMA AT THE SITE OF THE INFECTION
FEVER
LEUKOCYTOSIS AND POSSIBLE ELEVATED SEDIMENTATION RATE

DIAGNOSTICS:
BONE SCAN USING RADIOACTIVE MATERIAL
MRI
BACTERIAL CULTURES

AVASCULAR NECROSIS

RESULTS FROM THE CIRCULATORY COMPROMISE THAT OCCURS AFTER A FRACTURE. BLOOD FLOW IS DISRUPTED TO THE FRACTURE SITE AND THE RESULTING ISCHEMIA LEADS TO TISSUE (BONE) NECROSIS.

COMMONLY FOUND IN HIP FRACTURES OR IN FRACTURES WITH DISPLACEMENT OF A BONE.

MALUNION

FRACTURE HEALS INCORRECTLY

NONUNION

FRACTURE THAT NEVER HEALS.

ELECTRICAL BONE STIMULATION AND BONE GRAFTING CAN BE USED TO TREAT NONUNION

RA=RHEUMATOID ARTHRITIS

SYNOVIAL MEMBRANE INFLAMMATION RESULTING IN CARTILAGE DESTRUCTION AND BONE EROSION; INFLAMMATORY

SWELLING, REDNESS, WARMTH, PAIN AT REST OR AFTER IMMOBILITY (MORNING STIFFNESS)

ALL JOINTS AFFECTED
USUALLY UNDER WEIGHT
SWAN NECK AND BOUTONNIERE DEFORMITIES OF HANDS

SYSTEMIC INVOLVEMENT
SYMMETRICAL

DIAGNOSTIC TESTS:
XRAYS AND POSITIVE RHEUMATOID FACTOR

OSTEOARTHRITIS

CARTILAGE DESTRUCTION WITH BONE SPUR GROWTH AT JOINT ENDS; DEGENERATIVE

PAIN WITH ACTIVITY THAT IMPROVES AT REST
LOCALIZED INFLAMMATORY RESPONSE
USUALLY OVERWEIGHT
HEBERDEN'S AND BOUCHARD'S NODES
NO SYSTEMIC INVOLVEMENT
NOT SYMMETRICAL
XRAYS

OSTEOPHYTES

BONE SPURS IN OA AND RA

RESULTS IN NARROWED JOINT SPACES.
THE CHANGES WITHIN THE JOINT LEAD TO PAIN, IMMOBILITY, MUSCLE SPASMS AND POTENTIAL INFLAMMATION

HEBERDEN'S NODES ENLARGED AT DIP JOINTS
BOUCHARD'S NODES LOCATED AT PIP JOINTS

LAB TESTS FOR OA

ESR AND HIGH-SENSITIVITY C-REACTIVE PROTEIN MAY BE INCREASED SLIGHTLY RELATED TO SECONDARY SYNOVITIS.

OA WITHOUT SYNOVITIS IS NOT AN INFLAMMATORY DISORDER.

RADIOGRAPHS AND MRI CAN DETERMINE STRUCTURAL CHANGES WITHIN THE JOINT (DECREASED JOINT SPACE, BONE SPURS)

CEREBRAL ANGIOGRAM

PROVIDES VISUALIZATION OF THE CEREBRAL BLOOD VESSELS

DIGITAL SUBTRACTION ANGIOGRAPHY "SUBTRACTS" THE BONES AND TISSUES FROM THE IMAGES, PROVIDING XRAYS WITH ONLY THE VESSELS PRESENT.

THE PROCEDURE DETECTS DEFECTS, NARROWING, OR OBSTRUCTION OF ARTERIES OR BLOOD VESSELS IN BRAIN.

PERFORMED IN RADIOLOGY DEPARTMENT. IODINE-BASED CONTRAST DYE IS INJECTED INTO AN ARTERY DURING THE PROCEDURE

INDICATIONS:
ASSESS THE BLOOD FLOW TO THE AND WITHIN THE BRAIN, IDENTIFY ANEURYSMS, AND DEFINE THE VASCULARITY OF TUMORS. IT MAY ALSO BE USED THERAPEUTICALLY TO INJECT MEDICATION THAT TREAT BLOOD CLOTS OR TO ADMINISTER CHEMOTHERAPY.

CEREBRAL CT SCAN

A CT SCAN PROVIDES CROSS SECTIONAL IMAGES OF THE CRANIAL CAVITY. A CONTRAST MEDIA MAY BE USED TO ENHANCE THE IMAGES

INDICATIONS:
A CT SCAN CAN BE USED TO IDENTIFY TUMORS AND INFARCTIONS, DETECT ABNORMALITIES, MONITOR RESPONSE TO TREATMENT, AND GUIDE NEEDLES USED FOR BIOPSIES.

EEG=ELECTROENCEPHALOGRAPHY

THIS NONINVASIVE PROCEDURE ASSESSES THE ELECTRICAL ACTIVITY OF THE BRAIN AND IS USED TO DETERMINE IF THERE ARE ABNORMALITIES IN BRAIN WAVE PATTERNS.

INDICATIONS:
PERFORMED TO IDENTIFY AND DETERMINE SEIZURE ACTIVITY, BUT THEY ARE ALSO USEFUL FOR DETECTING SLEEP DISORDERS AND BEHAVIORAL CHANGES.

PROCEDURE GENERALLY TAKES 1 HR
WITH THE CLIENT RESTING IN A CHAIR OR LYING IN BED, SMALL ELECTRODES ARE PLACED ON THE SCALP AND CONNECTED TO A BRAIN WAVE MACHINE OR COMPUTER.

ELECTRICAL SIGNALS PRODUCED BY THE BRAIN ARE RECORDED BY THE MACHINE OR COMPUTER IN THE FORM OF WAVY LINES. THIS DOCUMENTS BRAIN ACTIVITY.

NOTATIONS ARE MADE WHEN STIMULI ARE PRESENTED OR WHEN SLEEP OCCURS.

AN EEG PROVIDES INFO ABOUT THE ABILITY OF THE BRAIN TO FUNCTION AND HIGHLIGHTS AREAS OF ABNORMALITY.

GLASGOW COMA SCALE

THIS ASSESSMENT CONCENTRATES ON NEUROLOGIC FUNCTION AND IS USEFUL TO DETERMINE THE LOC AND MONITOR RESPONSE TO TREATMENT.

GCS SCORES ARE HELPFUL IN DETERMINING CHANGES IN LOC OF PTS WITH HEAD INJURIES, SPACE OCCUPYING LESIONS OR CEREBRAL INFARCTIONS, AND ENCEPHALITIS.

THE BEST POSSIBLE GCS SCORE IS 15. SCORE CORRELATES WITH THE DEGREE OR LEVEL OF COMA.

LESS THAN 8=ASSOCIATED WITH SEVERE HEAD INJURY AND COMA
9-12-INDICATE A MODERATE HEAD INJURY
GREATER THAN 13=REFLECT MINOR HEAD TRAUMA

ASSESSESS EYE OPENING, VERBAL RESPONSE, AND MOTOR RESPONSE

E+V+M=TOTAL GCS

INTRACRANIAL PRESSURE MONITORING=ICP

IS A DEVICE INSERTED INTO THE CRANIAL CAVITY THAT RECORDS PRESSURE AND IS CONNECTED TO A MONITOR THAT SHOWS A PICTURE OF THE PRESSURE WAVEFORMS.

MORE PRECISE THAN VAGUE CLINICAL MANIFESTATIONS

INDICATIONS:
ICP MONITORING IS USEFUL FOR EARLY IDENTIFICATION AND TREATMENT OF ICP. CLIENTS WHO ARE COMATOSE AND/OR HAVE GCS SCORES OF 8 ARE CANDIDATES FOR ICP MONITORING

INTRAVENTRICULAR CATHETER-ICP MONITORING SYSTEM

A FLUID-FILLED CATHETER IS INSERTED INTO THE ANTERIOR HORN OF THE LATERAL VENTRICLES (MOST OFTEN ON THE RIGHT SIDE) THROUGH A BURR HOLE. THE CATHETER IS CONNECTED TO A STERILE DRAINAGE SYSTEM WITH A THREE-WAY STOPCOCK THAT ALLOWS SIMULTANEOUS MONITORING OF PRESSURES BY A TRANSDUCER CONNECTED TO A BEDSIDE MONITOR AND DRAINAGE OF CSF.

EPIDURAL OR SUBDURAL SENSOR

A FIBER-OPTIC SENSOR IS INSERTED INTO THE EPIDURAL SPACE THROUGH A BURR HOLE. THE FIBER OPTIC DEVICE MEASURES CHANGES IN THE AMOUNT OF LIGHT REFLECTED FROM A PRESSURE SENSITIVE DIAPHRAGM IN THE CATHETER TIP. THIS METHOD IS NONINVASIVE B/C THE DEVICE DOES NOT PENETRATE THE DURA.

LUMBAR PUNCTURE=SPINAL TAP

THIS PROCEDURE IS USED TO DETECT THE PRESENCE OF CERTAIN DISEASES (MULTIPLE SCLEROSIS, SYPHILIS, MENINGITIS), INFECTION, AND MALIGNANCIES. CAN ALSO BE USED TO REDUCE CSF PRESSURE, INSTILL A CONTRAST MEDIUM OR AIR FOR DIAGNOSTIC TESTS, OR ADMINISTER MEDICATION OR CHEMOTHERAPY DIRECTLY TO SPINAL FLUID.

MRI

PROVIDES CROSS SECTIONAL IMAGES OF THE CRANIAL CAVITY. A CONTRAST MEDIA MAY BE USED TO ENHANCE THE IMAGES. UNLIKE CT SCANS, MRI IMAGES ARE OBTAINED USING MAGNETS, THIS MAKES THIS PROCEDURE SAFER FOR WOMEN WHO ARE PREGNANT.

MAY BE USED TO DETECT ABNORMALITIES, MONITOR RESPONSE TO TREATMENT, AND GUIDE NEEDLES USED FOR BIOPSIES.

MRIs ARE CAPABLE OF DISCRIMINATING SOFT TISSUE FROM TUMOR OR BONE. MORE EFFECTIVE AT DETERMINING TUMOR SIZE AND BLOOD VESSEL LOCATION.

PET AND SPECT SCANS

ARE NUCLEAR MEDICINE PROCEDURES THAT PRODUCE 3 DIMENSIONAL IMAGES OF THE HEAD. THESE IMAGES CAN BE STATIC (DEPICTING VESSELS) OR FUNCTIONAL (DEPICTING BRAIN ACTIVITY).

IS MOST USEFUL IN DETERMINING TUMOR ACTIVITY AND/OR RESPONSE TO TREATMENT. ALSO ABLE TO DETERMINE THE PRESENCE OF DEMENTIA, INDICATED BY THE INABILITY OF THE BRAIN TO RESPOND TO THE TRACER.

RADIOGRAPHY=XRAY

USES ELECTROMAGNETIC RADIATION TO CAPTURE IMAGES OF THE INTERNAL STRUCTURES OF AN INDIVIDUAL.

XRAYS OF THE SKULL AND SPINE CAN REVEAL FRACTURES, CURVATURES, BONE EROSION AND DISLOCATION, AND POSSIBLE SOFT TISSUE CALCIFICATION, ALL OF WHICH CAN DAMAGE THE NERVOUS SYSTEM.

XRAYS ARE OFTEN THE FIRST DIAGNOSTIC TOOL USED AFTER AN INJURY.

TRANSDUCTION

THE CONVERSION OF PAINFUL STIMULI TO AN ELECTRICAL IMPULSE THROUGH PERIPHERAL NERVE FIBERS (NOCICEPTORS)

TRANSMISSION

OCCURS AS THE ELECTRICAL IMPULSE TRAVELS ALONG THE NERVE FIBERS, WHERE NEUROTRANSMITTERS REGULATE IT.

PAIN TOLERANCE

THE AMOUNT OF PAIN A PERSON IS WILLING TO BEAR

PAIN THRESHOLD

THE POINT AT WHICH A PERSON FEELS PAIN

SUBSTANCES THAT INCREASE PAIN TRANSMISSION AND CAUSE AN INFLAMMATORY RESPONSE

SUBSTANCE P
PROSTAGLANDINS
BRADYKININ
HISTAMINE

SUBSTANCES THAT DECREASE PAIN TRANSMISSIONS AND PRODUCE ANALGESIA

SEROTONIN
ENDORPHINS

SALICYLISM

TINNITUS, VERTIGO, DECREASED HEARING ACUITY THAT OCCURS WHEN TAKING NONOPIODS THAT CONTAIN ACETAMINOPHEN

ACUTE PAIN

PROTECTIVE, TEMPORARY, USUALLY SELF-LIMITING, RESOLVES WITH TISSUE HEALING.

TACHYCARDIA, HTN, ANXIETY, DIAPHORESIS, MUSCLE TENSION

GRIMACING, MOANING, FLINCHING, GUARDING

CHRONIC PAIN

NOT PROTECTIVE, ONGOING OR RECURS FREQUENTLY, LASTS LONGER THAN 6 MONTHS, PERSISTS BEYOND TISSUE HEALING, CAN BE MALIGNANT OR NONMALIGNANT

PHYSIOLOGICAL RESPONSES:
NO CHANGE IN VS
DEPRESSION
FATIGUE
DECREASED LOC
DISABILITY

NOCICEPTIVE PAIN

ARISES FROM DAMAGE TO OR INFLAMMATION OF TISSUE OTHER THAN THAT OF THE PERIPHERAL AND CNS SYSTEMS, IS USUALLY THROBBING, ACHING, LOCALIZED; PAIN TYPICALLY RESPONDS TO OPIOIDS AND NONOPIOID MEDICATIONS

SOMATIC=IN BONES, JOINTS, MUSCLES, SKIN, OR CONNECTIVE TISSUES

VISCERAL=IN INTERNAL ORGANS SUCH AS THE STOMACH OR INTESTINES, CAN CAUSE REFERRED PAIN

CUTANEOUS=IN SKIN OR SUBCUTANEOUS TISSUE

NEUROPHATHIC PAIN

ARISES FROM ABNORMAL OR DAMAGED PAIN NERVES (PHANTOM LIMB PAIN, PAIN BELOW THE LEVEL OF A SPINAL CORD INJURY, DIABETIC NEUROPHATHY), USUALLY INTENSE, SHOOTING, BURNING, OR PINS AND NEEDLES

PHYSIOLOGICAL RESPONSES TO ADJUVANT MEDICATIONS:
ANTIDEPRESSANTS
ANTISPASMODIC AGENTS,
SKELETAL MUSCLE RELAXANTS

MULTIPLE SCLEROSIS=MS=AUTOIMMUNE DISORDER

A NEUROLOGICAL DISEASE THAT TYPICALLY RESULTS IN IMPAIRED AND WORSENING FUNCTION OF VOLUNTARY MUSCLES.

AFFECTS NERVE CELLS IN THE BRAIN AND SPINAL CORD.

DEVELOPMENT OF PLAQUE IN THE WHITE MATTER OF THE CNS. THIS PLAQUE DAMAGES THE MYELIN SHEATH AND INTERFERES WITH IMPULSE TRANSMISSION BETWEEN THE CNS AND THE BODY.

AMYOTROPHIC LATERAL SCLEROSIS=ALS

A NEUROLOGICAL DISEASE THAT TYPICALLY RESULTS IN IMPAIRED AND WORSENING FUNCTION OF VOLUNTARY MUSCLES.

IS A DISEASE OF THE UPPER AND LOWER MOTOR NEURONS CHARACTERIZED BY MUSCLE WEAKNESS PROGRESSING TO MUSCLE ATROPHY AND EVENTUALLY PARALYSIS AND DEATH.

ALS DOES NOT INVOLVE AUTONOMIC CHANGES, SENSORY ALTERATIONS, OR COGNITIVE CHANGES.

MYASTHENIA GRAVIS=MG=AUTOIMMUNE DISORDER

A NEUROLOGICAL DISEASE THAT TYPICALLY RESULTS IN IMPAIRED AND WORSENING FUNCTION OF VOLUNTARY MUSCLES.

MG AFFECTS THE NERUOMUSCULAR JUNCTION.

CHARACTERIZED BY ANTIBODY-MEDIATED LOSS OF ACETYLCHOLINE RECEPTORS AT THE NEUROMUSCULAR JUNCTION, INTERFERING WITH COMMUNICATION BETWEEN MOTOR NEURONS AND INNERVATED MUSCLES

AMNESIA

LOSS OF MEMORY

S&S OF ICP=INTRACRANIAL PRESSURE?

SEVERE HEADACHE
DETERIORATING LOC, RESTLESSNESS, IRRITABILITY
DILATED, PINPOINT, OR ASYMMETRIC PUPILS, SLOW TO REACT OR NONREACTIVE

ALTERATION IN BREATHING PATTERN (CHEYNE-STOKES RESPIRATIONS, CENTRAL NEUROGENIC HYPERVENTILATION, APNEA)

DETERIORATION IN MOTOR FUNCTION, ABNORMAL POSTURING (DECEREBRATE, DECORTICATE, OR FLACCIDITY)

CUSHING REFLEX, WHICH IS A LATE FINDING CHARACTERIZED BY SEVER HTN WITH A WIDENING PULSE PRESSURE (SYSTOLIC-DIASTLIC)AND BRADYCARDIA

CSF LEAKAGE FROM THE NOSE AND EARS ("HALO" SIGN=YELLOW STAIN SURROUNDED BY BLOOD ON A PAPER TOWEL; FLUID TESTS POSITIVE FOR GLUCOSE

SEIZURES

ASSESSMENTS FOR CLIENTS WITH HEAD INJURIES?

RESPIRATORY STATUS=PRIORITY ASSESSMENT=KNOW!!!
-THE BRAIN IS DEPENDENT UPON OXYGEN TO MAINTAIN FXN AND HAS LITTLE RESERVE AVAILABLE IF OXYGEN IS DEPRIVED. BRAIN FUNCTION BEGINS TO DIMINISH AFTER 3 MIN OF OXYGEN DEPRIVATION.

CHANGES IN LOC, USING GCS, WHICH PROVIDES THE EARLIEST INDICATION OF NEUROLOGICAL DETERIORATION

CRANIAL NERVE FUNCTION (EYE BLINK, GAG REFLEX, TONGUE AND SHOULDER MOVEMENT)

PUPILLARY CHANGES (PERRLA)

FINDINGS OF INFECTION (NUCHAL RIGIDITY OCCURS WITH MENINGITIS)

BILATERAL SENSORY AND MOTOR RESPONSES

ICP: 4 WAYS TO MONITOR
1. USE A THIN TUBE INSERTED INTO THE LATERAL VENTRICLE (INTRAVENTRICULAR)

2. USE A BOLT OR SCREW PLACED IN THE SUBARACHNOID AREA (SUBARACHNOID)

3. PLACE A SENSOR IN THE EPIDURAL SPACE (EPIDURAL)

4. PLACE A FIBEROPTIC TRANSDUCER-TIPPED CATHETER INTO THE SUBDURAL OR SUBARACHNOID SPACE, VENTRICLE, OR BRAIN TISSUE.

EXPECTED REFERENCE RANGE FOR ICP IS 10-15 mm HG

ICP MAY BE INCREASED BY WHAT?

HYPERCARBIA, WHICH LEADS TO CEREBRAL VASODILATION
ENDORTRACHEAL OR ORAL TRACHEAL SUCTIONING
COUGHING
BLOWING THE NOSE FORCEFULLY
EXTREME NECK OR HIP FLEXION/EXTENSION
MAINTAINING THE HOB AT AN ANGLE LESS THAN 30 DEGREES
INCREASING INTRA-ABDOMINAL PRESSURE (RESTRICTIVE CLOTHING, VALSALVA MANEUVER).

SECONDARY BRAIN INJURY CAUSES?

USUALLY RESULTS FROM CLIENT CONDITION FOLLOWING TRAUMA:

CAUSES INCLUDE:
HYPOTENSION
HYPOXIA
HYPERGLYCEMIA
HYPOGLYCEMIA
ACIDOSIS
HYPERCAPNIA

CRANIOTOMY?

THE REMOVAL OF NONVIABLE BRAIN TISSUE THAT ALLOWS FOR EXPANSION AND/OR REMOVAL OF EPIDURAL OR SUBDURAL HEMATOMAS. IT INVOLVES DRILLING A BURR HOLE OR CREATING A BONE FLAP TO PERMIT ACCESS TO THE AFFECTED AREA. TREATMENT OF INTRACRANIAL HEMORRHAGES REQUIRES SURGICAL EVACUATION.

NURSING ACTIONS:

FOR SUPRATENTORIAL SURGERY, MAINTAIN HOB AT LEAST 30 DEGREES WITH BODY POSITIONING TO PREVENT INCREASED ICP.

FOR INFRATENTORIAL CRANIOTOMY, KEEP CLIENT FLAT AND ON EITHER SIDE FOR 24-48 HR TO PREVENT PRESSURE ON NECK INCISION SITE.

HYPERVENTILATE THE MECHANICALLY VENTILATED CLIENT FOR 24-48 HR AS PRESCRIBED TO MAINTAIN PaC02 AROUND 35 mm Hg.

MONITOR WOUND DRESSING AND MARK DRAINAGE EVERY 1-2 HR. MONITOR AND MAINTAIN WOUND DRAIN, DOCUMENTING OUTPUT EVERY 8 HOUR.

BRAIN HERNIATION?

THE DOWNWARD SHIFT OF BRAIN TISSUE DUE TO CEREBRAL EDEMA.

THE MONRO-KELLIE DOCTRINE STATES THAT ANY ALTERATION IN THE VOLUME OF ONE OF THESE RESULTS IN A COMPROMISE IN THE OTHER COMPONENTS.

WHEN TRAUMA CREATES A SHIFT IN THESE COMPONENTS, AND THE OTHER COMPONENTS ARE UNABLE TO ACCOMMODATE, THE BRAIN SHIFTS FROM THE CRANIAL VAULT, OR HERNIATES.

HEMATOMA AND INTRACRANIAL HEMORRHAGE S&S?

SEVERE HA
RAPID DECLINE IN LOC
WORSENING NEUROLOGICAL FXN AND HERNIATION
CHANGES IN ICP

SURGERY IS REQUIRED TO REMOVE SUBDURAL AND EPIDURAL HEMATOMA.

INTRACRANIAL HEMORRHAGE IS TREATED WITH OSMOTIC DIURETICS.

CSW=CEREBRAL SALT WASTING?

PRIMARY CAUSE OF HYPONATREMIA FOLLOWING NEUROSURGERY.

CSW IS CAUSED BY EFFECTS OF ATRIAL NATRIURETIC FACTOR (ANF) LOCATED IN THE HYPOTHALAMUS.

INCREASED ANF PRODUCTION DECREASES SODIUM RETENTION IN THE KIDNEYS. ANF ALSO MAY PREVENT RENIN AND ALDOSTERONE RELEASE.

CSW CAUSES DECREASED SERUM OSMOLALITY AND HYPONATREMIA, HYPOVOLEMIA, COMPARED WITH INCREASED EXTRACELLULAR FLUID IN CLIENTS WITH SIADH

LUMBAR PUNCTURE?

CSF (ABOUT 150-200mL) bathes and protects the brain and spinal cord.

BY PLACING A NEEDLE IN THE SUBARACHNOID SPACE OF THE SPINAL COLUMN ONE CAN MEASURE THE PRESSURE OF THAT SPACE AND OBTAIN CSF FOR EXAMINATION AND DIAGNOSIS.

THIS TEST MAY BE PERFORMED TO OBTAIN CSF FOR EXAMINATION, TO MEASURE AND REDUCE CSF PRESSURE, AND TO ADMINISTER MEDICATIONS INTRATHECALLY (INTO THE SPINAL CANAL)

THE NEEDLE IS USUALLY INSERTED INTO THE SUBARACHNOID SPACE BETWEEN THE THIRD AND FOURTH OR FOURTH AND FIFTH LUMBAR VERTEBRAE. THE SPINAL CORD ENDS AT THE FIRST LUMBAR VERTEBRAE.

CSF PRESSURE WITH THE PT IN A LATERAL RECUMBENT POSITION IS NORMALLY 50-1800 mm h20.

THE CSF SHOULD BE CLEAR AND COLORLESS.
PINK, BLOOD-TINGED, OR GROSSLY BLOODY CSF=SUBARACHNOID HEMORRHAGE.

WHEN MORE THAN 20mL OF CSF IS REMOVED, THE PT IS POSITIONED SUPINE FOR SEVERAL HRS. KEEPING THE PT FLAT MAY REDUCE THE INCIDENCE OF HA.

NORMAL FINDINGS:
RBC: 0
WBC: ADULT=0-5 CELLS/uL
DIFFERENTIAL:
NEUTROPHILS: 0-6%
LYMPHOCYTES: 40-80%
MONOCYTES: 15-45%

PROTEIN: 15-45 mg/dL=up to 70 mg/dL in older adults and children)

GLUCOSE: 50-75 mg/dL or 60-70% of blood glucose level

CAUSES OF LEUKOCYTES IN CSF?

NEUTROPHILS: BACTERIAL MENINGITIS=KNOW!!!!, TUBERCULAR MENINGITIS, CEREBRAL ABSCESS, SUBARACHNOID BLEEDING, TUMOR

LYMPHOCYTES OR PLASMA CELLS: VIRAL, TUBERCULAR, FUNGAL, SYPHILITIC MENINGITIS, MS, GB SYNDROME

EOSINOPHILS: PARASITIC MENINGITIS, ALLERGIC RXN TO RADIOPAQUE DYES

MACROPHAGES: TUBERCULAR, FUNGAL MENINGITIS, HEMORRHAGE, BRAIN INFARCTION

MORE THAN 1 WBC PER 500 RBCs IS CONSIDERED PATHOLOGIC AND CAN INDICATE INFECTION SUCH AS MENINGITIS.

MOST COMMON CAUSES OF MENINGITIS?

HAEMOPHILUS INFLUENZAE (CHILDREN)

NEISSERIA OR STREPTOCOCCUS (ADULTS)

CEREBRAL ANGIORGRAPHY?

IS AN X-RAY STUDY OF THE CEREBRAL CIRCULATION WITH A CONTRAST AGENT INJECTED INTO A SELECTED ARTERY.

THIS TEST IS USED FOR INVESTIGATING VASCULAR DISEASE OR ANOMALIES, IT IS USED TO DETERMINE VESSEL PATENCY, IDENTIFY PRESENCE OF COLLATERAL CIRCULATION, AND PROVIDE DETAIL ON VASCULAR ANOMALIES THAT CAN BE USED IN PLANNING INTERVENTIONS.

YOU THREAD A CATHETER THROUGH THE FEMORAL ARTERY IN THE GROIN AND UP TO THE DESIRED VESSEL.

ALTERNATIVELY, DIRECT PUNCTURE OF THE CAROTID ARTERY OR RETROGRADE INJECTION OF A CONTRAST AGENT INTO THE BRACHIAL ARTERY MAY BE PERFORMED. XRAY IMAGES ARE OBTAINED AS THE CONTRAST AGENT FLOWS THROUGH THE VESSELS; THE CAROTID AND VERTEBRAL ARTERIAL SYSTEMS ARE VISUALIZED, AS WELL AS VENOUS DRAINAGE.

MYELOGRAPHY

A MYELOGRAM IS AN X-RAY OF THE SPINAL SUBARACHNOID SPACE TAKEN AFTER THE INJECTION OF A CONTRAST AGENT INTO THE SPINAL SUBARACHNOID SPACE THROUGH A LUMBAR PUNCTURE.

THIS SHOWS ANY DISTORTION OF THE SPINAL CORD OR SPINAL DURAL SAC CAUSED BY TUMORS, CYSTS, HERNIATED VERTEBRAL DISKS, OR OTHER LESIONS.

MYELOGRAPHY IS PERFORMED INFREQUENTLY TODAY BECAUSE OF THE SENSITIVITY OF CT AND MRI SCANNING.

S&S OF A TIA?

VISUAL DISTURBANCES, DIZZINESS, SLURRED SPEECH, AND A WEAK EXTREMITY.

THESE ARE WARNING SIGNS OF AN IMPENDING STROKE

LEFT HEMISPHERIC STROKE S&S?

THE LEFT CEREBRAL HEMISPHERE IS RESPONSIBLE FOR LANGUAGE, MATHEMATICS SKILLS, AND ANALYTIC THINKING.

S&S:
EXPRESSIVE AND RECEPTIVE APHASIA (INABILITY TO SPEAK AND UNDERSTAND LANGUAGE RESPECTIVELY)

AGNOSIA (UNABLE TO RECOGNIZE FAMILIAR OBJECTS)
ALEXIA=READING DIFFICULTY
AGRAPHIA=WRITING DIFFICULTY
RIGHT EXREMITY HEMIPLEGIA (PARALYSIS) OR HEMIARESIS (WEAKNESS)
SLOW, CAUTIOUS BEHAVIOR
DEPRESSION, ANGER, AND QUICK TO BECOME FRUSTRATED
VISUAL CHANGES, SUCH AS HEMIANOPSIA (LOSS OF VISUAL FIELD IN ONE OR BOTH EYES)

NEUROGENIC SHOCK?

ACCOMPANIES SPINAL TRAUMA, CAUSES A TOTAL LOSS OF ALL REFLEXIVE AND AUTONOMIC FXN BELOW THE LEVEL OF THE INJURY FOR A PERIOD OF SEVERAL DAYS TO WEEKS.

S&S:
BRADYCARDIA
HYPOTENSION
FLACCID PARLYSIS
LOSS OF REFLEX ACTIVITY BELOW LEVEL OF INJURY
PARALYTIC ILEUS=DUE TO LOSS OF AUTONOMIC FXN

TISSUE PERFUSION

NEUROGENIC SHOCK OCCURS AFTER A SCI AND CAN CAUSE TOTAL LOSS OF VOLUNTARY AND AUTONOMIC FXN FOR SEVERAL DAYS TO WEEKS.

S&S:
HYPOTENSION
DEPENDENT EDEMA
LOSS OF TEMPERATURE REGULATION

THROMBOPHLEBITITS?

SWELLING OF EXTREMITY, ABSENT/DECREASED PULSES, AND AREAS OF WARMTH AND/OR TENDERNESS

SPASTIC NEUROGENIC BLADDER FROM A SPINAL CORD INJURY?

PTS WHO HAVE UPPER MOTOR NEURON INJURIES WILL DEVELOP A SPASTIC BLADDER AFTER THE NEUROGENIC SHOCK RESOLVES.

BLADDER MANAGEMENT OPTIONS FOR MALES INCLUDE CONDOM CATHETERS AND STIMULATION OF THE MICTURITION REFLEX BY TUGGING ON THE PUBIC HAIR.

FEMALE PTS WILL NEED TO USE AN INDWELLING URINARY CATHETER DUT TO UNPREDICTABLY OF THE RELEASE OF URINE

FLACCID NEUROGENIC BLADDER?

PTS WHO HAVE LOWER MOTOR NEURON INJURIES WILL DEVELOP A FLACCID BLADDER. INTERVENTIONS FOR BOTH MALES AND FEMALES INCLUDE INTERMITTENT CATHETERIZATION AND CREDES METHOD (DOWNWARD PRESSURE PLACED ON THE BLADDER TO MANUALLY EXPRESS THE URINE)

NURSING CARE FOR SPINAL CORD INJURIES?

GI=AN ILEUS CAN DEVELOP IMMEDIATELY AFTER INJURY. MONITOR FOR BOWEL SOUNDS.

SKIN INTEGRITY=CHANGE POSITION OF CLIENT EVERY 2 HRS. AND EVERY ONE HOUR WHEN IN A WHEELCHAIR.

AUTONOMIC DYSREFLEXIA?

OCCURS SECONDARY TO THE STIMULATION OF THE SYMPATHETIC NERVOUS SYSTEM AND INADEQUATE COMPENSATORY RESPONSE BY THE PARASYMPATHETIC NERVOUS SYSTEM.

PTS WHO HAVE LESIONS BELOW T6 DO NOT EXPERIENCE DYSREFLEXIA BC THE PARASYMPATHETIC NERVOUS SYSTEM IS ABLE TO NEUTRALIZE THE SYMPATHETIC RESPONSE.

STIMULATION OF THE SYMPATHETIC NERVOUS SYSTEM CAUSES:
EXTREME HTN
SUDDEN SEVERE HA
PALLOR BELOW THE LEVEL OF THE SPINAL CORD'S LESION DERMATOME
BLURRED VISION
DIAPHORESIS
RESTLESSNESS
NAUSEA
PILOERECTION (GOOSE BUMPS)

STIMULATION OF THE PARASYMPATHETIC NERVOUS SYSTEM CAUSES:

BRADYCARDIA
FLUSHING ABOVE THE CORRESPONDING DERMATOME TO THE SPINAL CORD LESION (FLUSHED NECK AND FACE)
NASAL STUFFINESS

lymphangiography?

A diagnostic radiographic evaluation of lymphatic system filling after injection of a contrast medium into a lymphatic vessel of each foot or hand.

MAY CAUSE BLUISH URINE.

CUSHINGS TRIAD S&S FOR LATE SIGNS OF ICP?

RISING BP
BRADYCARDIA
WIDENING PULSE PRESSURE

LEUKOCYTOSIS

AN ELEVATION IN THE NUMBER OF WBCs. ALL TYPES OF WBCs OR ONLY ONE TYPE MAY BE INCREASED.

SPINAL SHOCK S&S?

ALL REFLEXES ARE ABSENT AND THE EXTREMITIES ARE FLACCID. SPINAL SHOCK OCCURS IMMEDIATELY AFTER A SPINAL CORD INJURY.

KAPOSI'S SARCOMA?

MALIGNANCY THAT INVOLVES THE EPITHELIAL LAYER OF BLOOD AND LYMPHATIC VESSELS

PERIPHERAL NEUROPATHY

DISORDER CHARACTERIZED BY SENSORY LOSS, PAIN, MUSCLE WEAKNESS, AND WASTING OF MUSCLES IN THE HANDS OR LEGS AND FEET.

PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY

OPPORTUNISTIC INFECTION THAT INFECTS BRAIN TISSUE AND CAUSES DAMAGE TO THE BRAIN AND SPINAL CORD

WASTING SYNDROME

INVOLUNTARY WEIGHT LOSS OF 10% OF BASELINE BODY WEIGHT WITH CHRONIC DIARRHEA OR CHRONIC WEAKNESS AND DOCUMENTED FEVER

ACUTE RETROVIRAL SYNDROME S&S

FEVER
LYMPHADENOPATHY
PHARYNGITITS
SKIN RASH
MYALGIAS/ARTHRALGIAS,