N213: Health Differences Across the Life Span 3

N213: Health Differences Across the Lifespan 3 Study Guide ©2017 Achieve Test Prep Page 135 of 204 Monitor vital signs frequently for signs of hypovolemic shock • Take measures to control bleeding prior to surgery • Give increased IV fluids • Prepare to give blood transfusions if needed • Give pain medications per MD order • Give antibiotics per MD order before and after surgery • Tetanus injection if needed; if patient cannot remember last vaccination or cannot speak give TD booster • Wrap body part and amputation site in moist gauze to preserve tissue • Thoroughly irrigate wound with normal saline to removecontamination • Fill complete amputations, place moist bulky dressing over stump; for partial amputations, re- align body part and wrap in moist rolled gauze • In post-op monitor stump for signs of infection: redness, swelling, drainage, andwarmth • Apply a pressure bandage to stump with elastic wrap over gauze • Continually assess pain levels and inquire about “phantom” pain (where patients will continue to feel pain in the lost extremity even if it isn’t thereanymore) • Teach patient stump care: clean with normal saline, wrap in rolled gauze, andwrapwith elastic wrap • Refer to physical therapy for rehabilitationprogram • Refer to community support groups Expected outcomes for traumatic amputations: • Patient remains free from infection • Verbalizes increased comfort • Circulation remains stable with no signs of hypovolemia • Vital signs remain stable • Dressings are clean, dry, and intact • Verbalizes knowledge of stump wound care, wrapping, and rehabilitation plan Intervertebral Disk Problems This disease begins with an abnormality in the structure of the spine. The vertebrae begin to narrow and put pressure on the disks that normally act to absorb shock. The annulus fibrosis (fibrous tissue) begins to tear and degrade. Any stress to the spine causes the disk to degenerate even more and eventually the gelatin like filling pushes through and herniates, or pushes out, the side in between the vertebrae. Nursing interventions for traumatic amputations: •