Violence, Environments, Musculoskeletal

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  1. How do you ID a person who has been a subject of violence
    • Ask....
    • Have you been kicked, hit, punched or hurt by someone in the past year?
    • Do you feel safe in your current relationship?
    • Is there a partner from a previous relationship who makes you feel unsafe now?
  2. What do you do if a person is the subject of violence?
    • immediate care of the injury
    • reassure
    • determine immediate threat
    • treat medical problems
    • document
  3. What is the safety plan for a person whos the subject of violence
    • isolate them from the abuser
    • develop an alternate destination
    • provide referral phone number/agencies
    • respect difficulty to leave the partner
  4. Children and abuse....
    • they will be withdrawn
    • they will have multiple bruises all with different stages of healing

    talk to charge nurse and fill out a abuse report, which is anonymous and inform social worker/CPS
  5. Heat cramps
    • felt in large muscles
    • occurs after exercise or heavy labor
    • pain is brief, but intense
    • nausea
    • tachy
    • pallor
    • weak
    • diaphoresis
  6. Heat exhaustion
    occurs when an individual engages in a strenuous activity in hot, humid weather or in sedentary individuals

    • fatigue
    • lightheaded
    • n/v/d
    • feelings of impending doom
    • tachycardia/tachypnea
    • hypotension
    • elevated body temp
    • dilated pupils
    • mild confusion
    • profuse diaphoresis
  7. Heat stroke
    most serious, and as a medical emergency.  Results from failure of hypothalamic thermoregulatory processes

    • increased sweating
    • vasodilation
    • increased RR
    • depletion of F&E
    • Temp >104
    • altered mentation
    • ABSENCE of perspiration
    • circulatory collapse
  8. What is the skin like for a person with heat stroke?
    • hot
    • dry
    • ashen
  9. Interventions for heat related emergencies
    • Manage/maintain ABC's
    • High flow O2 with non rebreather or BVM
    • IV access and fluids
    • Cool patient
    • ECG
    • Obtain blood for electrolytes and CBC
    • Insert urinary catheter
    • Elevate feet
  10. Ongoing monitoring for a person with heat related emergencies
    • Monitor ABC's
    • VS
    • LOC
    • cardiac rhythm
    • O2 sats
    • Electrolytes
    • UO
  11. 2 problems that can occur from heat related emergencies and how do I monitor for them?
    Myoglobinuria....urine sample (rhabdomylisis)

    DIC....clotting studies (PT,PTT)
  12. Additional heatstroke interventions
    • Initiate rapid cooling measures
    • remove patients clothes
    • place wet sheets over patient and place fan in front of patient
    • immerse in ice water bath
    • administer cool IV fluids or lavage with cool fluids
  13. How do you help a patient who has hyperthermia not shiver when we are cooling them down?
    administer Thorazine
  14. What is a sign that a person has rhabdomyolysis?
    tea colored urine
  15. How do you get rhabdomyolysis?  Treatment?
    • working out too hard causing extreme fatigue
    • hypotension
    • increased CPK
    • renal failure
    • lactic acid

    insert foley and start aggressive fluid resuscitation
  16. S/S of hypothermia
    • decreased temp
    • shivering
    • hypoventilation
    • hypotension
    • altered LOC
    • areflexia
    • pale, cyanotic skin
    • blue, white frozen extremities
    • dysrhythmias
    • fixed dilated pupils
  17. Mild, moderate and profound hypothermia temps
    • mild 93.2-96.8
    • moderate 86-93.1
    • profound <86
  18. Dysrhythmias seen with hypothermia
    • brady
    • a fib
    • v fib
    • asystole
  19. Interventions for hypothermia
    • ABC's
    • High flow O2
    • Anticipate intubation
    • Rewarm patient
    • Anticipate need for hemodialysis or cardiopulmonary bypass
    • Establish IV access w/ 2 large bore catheters
    • Keep patients head covered with warm, dry towels or stocking cap to limit loss of heat
    • Treat patient gently to avoid increased cardiac irritability
  20. How do  you warm a patient and why?
    warm central trunk first when they have profound hypothermia to limit rewarming shock
  21. When rewarming a person stop at....why?
    • 95 degrees
    • warming places the patient at risk for after drop, a further drop in the core temperature. 

    This can induce hypotension and cardiac dysrhythmias
  22. Inteventions for submersion injuries....drownings
    • ABC
    • assume cervical spine injury/stabilize
    • provide 100% O2 via non rebreather mask or BVM
    • Anticipate need for intubation
    • Establish IV access w/ 2 lg bore catheters for fluid resuscitation/warming
    • assess for other injuries
    • remove wet clothes and cover w/ warm blankets
    • obtain temp and rewarm as needed
    • obtain c spine and chest x rays
    • insert gastric tube
  23. Ongoing monitoring for a person who almost drowned
    • ABC
    • Temp
    • s/s of acute respiratory failure
    • monitor for neurologic changes
  24. What doesn't cartilage have?
    vascular blood
  25. Sprains/Ligament Injury
    injury which occurs when a joint exceeds its normal limit...ankle, knee or shoulder
  26. Mild sprain/ligament injury
    produces slight pain and swelling

  27. Moderate sprain/ligament injury
    pain, tenderness, swelling, and inability to use the limb for more than a short time

    RICE with weight bearing crutches
  28. Severe sprain/ligament injury
    tearing of the ligaments resulting in pain, tenderness, swelling, discoloration and inability to use the limb

    RICE with NON weight bearing crutches
  29. Rules of RICE
    Rest, Ice, Compression, Elevation

    20 min/day...4x/week
  30. Strains
    weakening or overstretching of a muscle where it attaches to the tendon
  31. Strains....mild, moderate and sever.

    How do you treat it?
    mild-local pain with tenderness and light muscle spasm

    moderate-local pain with tenderness, swelling, discoloration and inability to use the limb for long prolonged periods

    severe-local pain with tenderness, swelling, discoloration and may offer hx of "snapping noise" at time of incident

    RICE with same rules with crutches for each
  32. Dislocations
    occurs when joint exceeds its ROM and the joint surfaces are no longer articulating....will have severe swelling and possible vein/artery damage
  33. Symptoms of dislocation
    • weak distal pulses and sensations
    • skin color changes and increased moisture
    • increased capillary refill
  34. How do you treat a dislocation
    • splint in the position found or a position of comfort
    • apply cold compress
    • pre and post relocation x ray
    • stabilization for 6 weeks
  35. How do you stabilize a dislocation
    • cast
    • sling
  36. If a person has neurovascular compromise from a dislocation what happens?
    need surgery's an emergency
  37. General considerations for a person with a dislocation
    • they are caused by force, check for other injuries
    • immobilize joints inferior/superior to area of injury
    • dislocations are very painful...give analgesia
    • keep patient NPO for possible surgery
    • fx may occur in conjunction with dislocations...get x rays
  38. Which do you do first?  Cast/Splint and why?
    splint first....cause prevents compartment syndrome
  39. fractures
    disruption or break in the integrity of the bone
  40. Simple vs. Compound fx
    • simple-bone is broken but skin is in tact
    • compound-bone is protruding, has punctured the skin and returned beneath the surface, or a foreign body has penetrated the skin and bone causing fx
  41. Green stick fx
    occurs when a bone bends and cracks, instead of breaking completely in to separate pieces
  42. spiral fx
    bone is twisted apart....

    aka torsion fx
  43. Clinical manifestations of a fracture
    • edema/swelling
    • pain/tenderness
    • muscle spasm
    • deformity....or not
    • ecchymosis
    • loss of fxn
    • crepitation
  44. Collaborative care for a fx
    • anatomic realignment of bone fragments (reduction)
    • Immobilization with splint then cast
    • Restoration to normal or near normal fxn
  45. 5 P's with a fx
    • pain
    • pointed tenderness
    • pulses distal to injury
    • paresthesias-tingly
    • paralysis
  46. Why do we need to take baseline VS with a fx?
    cuz bones have a blood supply and the patient can become shocky from a fx
  47. Calcaneus fx =
    spinal compression fx
  48. Spine/pelvic fx=
    paralytic ileus
  49. Spinal injury =
    kidney injury
  50. Rib fx=
    lung/spleen,liver injuries
  51. Pelvic fx=
    genitourinary/gastrointestinal injury
  52. Patellar fx=
    fx of dislocated hip or femur
  53. A complication of a fx is decreased neurovascular status...what does that look like?
    • decreased distal pulses
    • decreased distal skin temp
    • cyanosis
    • decreased distal sensation
    • shock
  54. After you splint....teach the patient to.....
    • elevate the injury above the level of the heart
    • cold compresses
    • analgesia as needed
  55. Complications of a fx
    • shock
    • infection
    • fat embolism
    • compartment syndrome
    • venous thrombosis
  56. What do I check on a patient after I splint them and before they go home?
  57. General considerations for fractures....
    • neurovascular compromise is a serious emergency
    • all injuries are fx until proven otherwise
    • baseline VS are never know
    • all clothing is removed to do a complete assessment
    • keep pt NPO cuz possible surgery
  58. What helps manage pain for a person with a fx....then what if they are still in pain?
    • immobilization
    • cold compress
    • elevation

    reassess patient for other problems
  59. Why splint
    • prevent further damage to soft tissues
    • prevent damage to nerves, arteries and veins
    • decrease pain
  60. What is immobilized in a splint
    both proximal and distal areas to the suspected fx
  61. What do I document with a splint
    motor and sensory status before the splint was applied
  62. Function of a cast
    complete immobilization of the injury and surrounding distal and proximal areas
  63. Discharge instructions for a person with a cast
    • keep it dry
    • keep the injured limb elevated above the level of the heart for 24-48 hours
    • wiggle fingers 1x/hr
    • return immediately if foreign body is dropped in to cast
  64. S/S of a problem with the cast
    • cold/hot fingers
    • pale/dusky fingers
    • absence of feeling in fingers
    • foul odor from cast
    • unresolved pain
  65. Measuring for crutches/cane
    • measure with shoe they will be wearing
    • shoes should be tie/buckle with a 1"heel

  66. Proper fitting of crutches
    • arm piece is 2" from axilla
    • grips should be 6-8 inches to the side and from of the foot
    • elbow at 30 degree angle
    • *don't lean on armpits
  67. How do you use a cane?
    • cane is held next to the foot and the elbow should be at a 30degree angle
    • used for balance only...minimal support
  68. All soft tissue injuries
    need to have a tetanus shot if they haven't had one in the last 5-7 years (?)
  69. Abrasion and tx
    scraping of epithelia layer exposing dermal layer

    tx-scrub and irrigate, apply topical ointment and non adherent dressing
  70. Avulsion and tx
    full thickness skin loss in which a section of the skin is pulled away....deep, goes down to the dermis

    tx-scrub, irrigate and debride the wound, dress with bulky dressing
  71. Contusion and tx
    bruise in which the vessels are damaged, but the skin isn't disrupted

    tx-cold compress and analgesia....NO dressing
  72. Hematoma and tx
    escape of blood into subcutaneous space

    tx-depends on location
  73. Puncture and tx
    penetration of the skin by a pointed or sharp object....may appear innocent, but may have damaged underlying structures

    tx-soak in surgical soap solution BID for 2-4 days, antibiotics if infected and tetanus shot
  74. Abscess and tx
    localized collection of pus in subcutaneous skin

    tx-antibiotics, needle drainage, or I&D.  Will need daily wound care and packing if had I&D
  75. Laceration and tx
    an open wound or cut through the dermal layer...can be minor or major

    • tx-thorough cleaning with betadine, H2O or NS
    • Closure with steristrips, staples, sutures, dermabond
    • Dry sterile dressing
    • Tetanus shot
  76. What do I need to instruct the patient with a laceration
    • keep it clean and dry
    • may clean with water daily
    • assess for infection
  77. Rules for removal of stitches with a laceration
    • 3-5 days for face
    • 7-10 days for all others
  78. Impaling and tx
    sharp penetrating object causing a wound

    tx-don't remove, stabilize object if necessary
  79. Complications of musculoskeletal trauma
    • compartment syndrome
    • fat emboli
    • thromboembolitic complications
    • infection
    • avascular necrosis
    • delayed non-union
    • rhabdomyelisis
  80. How do you assess for compartment syndrome?
  81. How get a fat emboli, s/s and tx
    associated with long bone fx 24-48 hours after injury

    • respiratory distress
    • tachy

    tx-support ABC's
  82. Geriatric considerations with musculoskeletal issues
    • wound healing is delayed due to age and impaired nutrition
    • have chronic medical problems that can cause increased risk for complications
    • teach about poly pharmacy and side effects
    • mobility is a problem and increases risks for complications
    • vision may b impaired....making it hard to id complications and read instructions
    • $$ may make it hard to seek care promptly
  83. Neglect vs. abuse in the elderly?
    Neglect is more common
  84. When in the ED be aware of these things....
    • frequent flyers are usually women
    • many are drug seekers
    • 1/3 of all OD patients/suicide attempts are trying to escape abusive relationships
Card Set
Violence, Environments, Musculoskeletal
N176 exam 5
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