**Combo of all sets**
Cells that have rough surfaces and are particularly susceptible to phagocytic functioning
"Non-self" cells
Cells that are smooth and covered with smooth protein
"Self" cells
phagocytosis
"cell eating" (ex: white blood cells and amoeba)
Do Not Resuscitate (DNR) also called
"no code"
hypercalcemia
"stones, moans & groans" increase in thirst and urine output anorexia N &V
**Kidneys
(SLOW BUT COMPLETE) hold or release H+ and Hco3
immunoglobulins (Ig)
(antibodies) Y shaped with two recognition segments and one effector segment
hypernatremia
(much less common) fluid retention, lethargy or weakness that can progress to seizures coma and death
Adaptive immunity
(specific immunity) aquired ability to recognize and destroy a pathogen or its products. Requires exposure of the immune system to the pathogen
Beneficence
- "Doing good" is in the best interest of the client. -benefits the patient
Nurse role in ethics: Intermediary
- A consensus on what constitutes intermediate care is needed(care pt needs is provided)
Pyelonephritis
- An inflammation of one or both kidneys - causes dark urine because WBC has bacteria, proteinuria, and casts.
Autonomy
- Client's right to self-determine, choose their care, informed consent
dehydration
- Dehydration occurs when a person loses more fluids than he/she takes in - Lab tests: HCT, Hbg - deceased pulse - increase HR - weak pulse, fatique -Addison's/ DM increase UO
Hyperkalemia
- High blood potassium - causes Cardiac Arrest K+ >5.5 mEq/L
Rules of infection/inflammation
- Infection w/Inflammation - Inflammation not always with infection
Nurse role in ethics: Moral distress
- Nurse is aware of the right and moral action but is unable to carry outaction
Cold and Hot Therapy
- The use of cold is recommended to reduce swelling and pain. - Later, the use of heat is recommended to increase circulation to the area; providing increased nutrients and oxygen to promote healing.
Eosinophils
- defense against parasites & other microorganisms - role in IgE mediated allergic reactions ((redness))
Fidelity
- to keep one's promises to the client about care that was offered. -Faithfulness to obligation, duty, or commitment.
Ph below ____ depresses the ___ and decreases _____
-7.35 -CNS -cell activity
Rheumatoid arthritis
-A form of arthritus in which an autoimmune response leads to inflammation of connective tissue, particularly the membranes that line the joints, resulting in overall stiffness, inflammation, aching, deformed joints, and a serious loss of mobility. -Most common in women and can occur at any age.
Crohn's Disease
-A type of inflammatory bowel disease that may affect any part of the gastrointestinal tract from mouth to anus, causing a wide variety of symptoms. -causes abdominal pain, diarrhea (which may be bloody if inflammation is at its worst), vomiting (can be continuous), or weight loss, but may also cause complications outside the gastrointestinal tract such as skin rashes, arthritis, inflammation of the eye, tiredness, and lack of concentration.
Remember, an ABG reflects the:
-Ability of the lungs to exchange O2 and Co2 (Respiratory Function) -Effectiveness of the kidneys to balance the retention and elimination of HCO3-
Mantoux Test
-Administered by means of an intradermal needle and syringe. Exposure and infected with TB; Access for reaction in 48-72 hours; induration of 10mm or more is positive (+) unless HIV then 5mm induration
Kussmaul breathing
-Air hunger, or the rapid, deep, and labored breathing -Patients with acidosis -Kussmaul breathing is seen with the acidosis of diabetes mellitus that is seriously out of control.
Tuberculosis
-An infectious disease that may affect almost all tissues of the body, especially the lungs -Acid fast, transmitted via droplet nuclei, difficult to eradicate. -s/s: fatigue, weight loss, anorexia, night sweats, productive cough with purulent sputum.
pharmacological interventions for urinary incontinence
-Antibiotics ■ Gentamicin (Garamycin) and cephalexin (Keflex) are given if an infection is present to treat bacteria. (give w/ food) -Tricyclic antidepressants ■ Nortriptyline (Pamelor) contains anticholinergic effects that can relieve urinary incontinence. (can cause orthostatic hypotension) -Urinary antispasmodics or anticholinergic agents ■ Oxybutynin (Ditropan) and dicyclomine (Bentyl) are used to decrease urgency and help alleviate pain with a neurogenic or overactive bladder. -Phenazopyridine (Pyridium) ■ This is a bladder analgesic used to treat urinary tract infections.
Patients at greatest risk for Acid base imbalances include:
-Burn patients -extreme ages (very young & the very old) -Pre-existing disease -chronic illness
How do you assess pain across the lifespan?
-By the subjective data from what the patient tells you their pain is -Assess location, severity associated features, attempted treatments/medications, related illnesses, impact on daily activities
Clots (Detecting DVT)
-Calf pain, tenderness, warmth, redness, and swelling. Measure leg to determine swelling. -Complications could be PE, CVA, MI.
Causes of Hypercalcemia
-Cancer causes uncontrolled release of calcium from the bones -hyperparathyroidism -Immobility -Excessive vitamin D or calcium intake -milk-alkali syndrome associated with increase CA++ and antiacid intake
Primary Buffer systems include:
-Carbonic Acid: HCO3- System -Lungs -Kidneys -Hemoglobin system -Plasma protein system
Effects of hypokalemia include
-Cardiac dysrhythmias (ECG changes) -Fatigue and Muscle weaknesses -Paresthesias (Pins and needles feelings) -decreased appetite and nausea
Respiratory Alkalosis
-Decreased pCO2 (due to hyperventilation) pain, fever, anxiety, hypoxia -Respiratory Alkalosis = [HYPERVENTILATION] rapid & deep respirations Symptoms: anxiety, light-headedness, headache, mental status change, muscle twitching
Effects of Hypercalcemia
-Depressed neuromuscular activity: Muscle weakness and loss of muscle tone; Lethargy, stupor; Anorexia and Nausea -Altered Kidney and Heart function -Altered bone density
Effects of Hyperkalemia
-ECG changes.... Generally wider complexes -Muscle weakness -Fatigue, Nausea and paresthesia
Causes of Hypocalcemia
-Hypoparathyroidism -Malabsorption -Deficient serum albumin -increased serum PH
Secondary prevention
-Identifying a health problem and its intervention -Screenings / Monitoring
Age related changes to Immune System - B & T cells, GI system and Urinary System
-Impaired function of B & T lymphocytes failure to recognize self from non self -GI System - decreased gastric secretions and motility, altered nutritional intake an example less protein. example would be gastroenteritis and diarrhea -Urinary System such as kidney function , hematuria, protein proteinuria, enlargement of prostate gland, neurogenic bladder, altered genitourinary tract flora. Examples more UTIs
What is inflammation?
-Inflammation is part of infection -Not the same as infection; difference is growth of pathogens
Calcium is absorbed in the ______ only under ______, which is activated in the ______
-Intestines -Vitamin D -Kidneys
Hypophosphatemia
-Loss of appetite, anxiety, bone pain, stiffness, fatigue, irritability -correct underlying cause and administer oral replacements with vitamin D
Hypokalemia
-Low blood potassium level - causes arrhythmias K+ <3.5 mEq/mL
Post-Op Goals
-Pain and Infection Control, Lungs (cough and deep breathing, IS) -Encourage mobility to decrease clots.
Immunity & Age
-Post thymectomy = all sorts of immune problems in future - Young & Old: incomplete immune function -Young: don't have developed immune system yet -Elderly: delayed onset of immune response
Immunodeficiency
-Primary Immunodeficiency- Genetic Defect. -Secondary Immunodeficiency- Secondary to something else (HIV, Corticosteroids, Chemo/Radiation, Diabetes, Organ Transplant Anti-Rejection Medications).
Causes of Hyperkalemia
-Renal failure -use of potassium sparing diuretics -leakage of ICF into the ECF as in burns
Breathe is ____ from ____ with diabetic acidosis
-Sweet -Keytones
Patients with renal disease prevents activation of ____ causing it to reduce the bodies ability to absorb ____
-Vitamin D -Calcium
Hypernatremia effects include:
-Weakness -Agitation -Edema -Increased thirst -Decreased urine output
Fluid overload
-a condition in which the body cannot eliminate the fluid consumed -when they get lasix, produces bigger output of urine.
SLE [systemic lupus erythematosus]
-chronic autoimmune inflammatory disease of collagen of the skin, of joints and of internal organs -Inflammation of almost any body part, chronic, multisystem inflammatory disorder that occurs when the body produces antibodies against its own cells. (malar rash)
Cause of Hypokalemia
-diarrhea -diuretic medications -hormone imbalances -decrease dietary intake -diabetic ketoacidosis treated with insulin
Causes of Hypernatremia include:
-increase in sodium intake -large loss of water
Elderly & Falls
-large age group for safety risk -Doing a falls assessment does NOTHING to prevent falls **When we implement interventions based on findings that we reduce the risk of falls**
Treatment for infections
-palliative therapy - via NSAIDS and NON-ASPIRIN ANTI-PYRETICS (b/c bleeding don't want to use aspirin) -corticosteroids if airway obstruction due to lymphadenopathy is a concern
SECONDARY LYMPHOID TISSUE
-the spleen, lymph nodes, and epithelial lymphoid tissues. -They are strategically placed in the body so that invading pathogens will encounter them as early as possible, allowing the immune -system to be activated before extensive damage can be done.
Severe effects of Hypokalemia
-weak shallow respiration's -Renal failure
What is a barium swallow and how should the pt prepare for the procedure?
A fluoroscopic visualization of the esophagus following the ingestion of barium sulfate. NPO at midnight, laxative the night before & enema the morning of
What is an upper GI study and how should the pt prepare for the procedure?
A fluoroscopic visualization of the stomach and small bowel following the ingestion of barium sulfate. No smoking 24 hr prior (increases gastric juices)
Antigen
A foreigner to the body - something that the body does not recognize.
Neutrophils cont.
A granulocyte that is phagocytic which surround and destroy bacteria.
What is a renal biopsy and how should the pt prepare for the procedure?
A needle biopsy via ultrasonic guided imagery to obtain samples of the renal cortex. NPO 4-6 hr prior. Bed rest required
What is a barium enema and how should the pt prepare for the procedure?
A rectal infusion of barium sulfate which studies the lower intestinal tract. Bowel prep necessary
What is an immunogen?
A substance capable of inducing an immune response
Neutrophils
A type of white blood cell that engulfs invading microbes and contributes to the nonspecific defenses of the body against disease. Actively involved in bacterial infections -most abundant 40-70% -1st responder -dies and turns to pus
Serious Complications of Oral Birth Control Pills (ACHES)
A- Abdominal Pain C - Chest Pain H - Headache E - Eye Problems S - Severe Leg Pain
Who needs dialysis? (Check the vowels: AEIOU)
A- Acid-Base Problems E- Electrolyte Problems I- Intoxications O- Overload of fluids U - Uremic Symptoms
Assessment Tests for Fetal Well-Being (ALONE)
A- Amniocentesis L- L/S Ratio O - Oxytocin Test N - Non-Stress Test E - Estriol Level
Symptoms of Leukemia (ANT)
A- Anemia N- Neutropenia T- Thrombocytopenia
Parkinson's Medications: "Ali Loves Boxing Matches"
A-Amantadine L- Levodopa B- Bromocriptine M-MAO inhibitors
Management of ASTHMA
A-drenergics (Albuterol) S-teroids T-heophylline H-ydration (IV) M-ask (Oxygen) A-ntibiotics
Emergency Trauma Assessment (ABCDEFGHI)
A-irway B-reathing C-irculation D-isability E-xamine F-ahrenheit G-et Vitals H-ead to Toe Assessment I-ntervention
Epiglottitis (AIR RAID)
A-irway Closed I-ncreased Pulse R-estlessness R-etractions A-nxiety Increased I-nspiratory Stridor D-rooling
Osteoporosis Risk Factors (ACCESS)
A-lcohol Use C-orticosteroid Use C-alcium low E-strogen low S-moking S-edentary lifestyle/s ACCESS leads to OSTEOPOROSIS
Trauma Surgery (AMPLE) after initial assessment
A-llergies M-edications P-ast Medical History L-ast Meal E-vents Surrounding Injury
Eating Disorder: ANOREXIA
A-menorrhea delayed N-o organic factors accounts for weight loss O-bviously thin but feels FAT R-efusal to maintain normal body weight E-pigastric discomfort is common X-symptoms (peculiar symptoms) I-ntense fears of gaining weight A-lways thinking of foods
5 A's to Alzheimer Diagnosis
A-mnesia A-nomia A-praxia A-gnosia A-phasia
Steps in the Nursing Process ADPIE (A Delicious PIE)
A-ssessment D- iagnosis P-lanning I-mplementation E-valuaton
Use the ABCD rule to assess a mole's malignant potential:
A: Asymmetry--Is the mole irregular in shape? B: Border--Is the border irregular, notched, or poorly defined? C: Color--Does the color vary (for example, between shades of brown, red, white, blue, or black)? D: Diameter--Is the diameter more than 6 mm?
Remember that here in the USA you D drive on the right side of the road. O= optical A= auditory
AD - right ear AS - left ear AU - both ears OD - right eye OS - left eye OU - both eyes
Innate immunity (immunity that is inherent within a species and develops regardless of exposure)
AKA natural immunity, is present at birth and functions similarly regardless of the pathogen, earning it the designation nonspecific.
Reviews and revises Code of Ethics
ANA
Osteoporosis
Abnormal loss of bony tissue resulting in fragile porous bones; lack of calcium "weak bones" -Risk Factors: age, sex, family hx, body frame, hormone levels, diet -Treat with weight bearing exercises, Ca+ & Vit D Supplements (maintain), No smoking/ETOH, Fosamax, Ca/Vit D Supplements.
Edema
Accumulation of an excessive amount of fluids in cells, tissues, or serous cavities; usually results in a swelling of the tissues.
Water also helps regulate ____and ____
Acid/Base Balance Electrolyte Balance
Body may be more inclined to be ____ due to cell metabolism that produces CO2
Acidic
The greater the concentration of H+, The more ____ the body fluids and the ____ the Ph
Acidic Lower
Ph of 0 is considered highly _____, having a ___ number of Hydrogen Ions
Acidic, Large
What does malignant hyperthermia lead to?
Acidosis High temp Dysrhythmias
Acidosis- ↑ Acid, ↓ Base Alkalosis- ↓ acid, ↑ base
Acidosis- ↑ Acid, ↓ Base Alkalosis- ↓ acid, ↑ base
Release hydrogen ions when dissolved in water
Acids
____ refers to immunity that is not present at birth and develops either as a result of exposure or through an external source, such as colostrum or injection of immunoglobulin.
Acquired Immunity
Immunity that is gained after birth either actively or passively
Acquired immunity
In the adaptive immunity response this occurs
Activated effector CD4+ Th cells, CD8+ CTLs, and antibody molecules leave the lymph node and enter the circulation to be transported to the site of infection within peripheral tissues.
____ is acquired through an immunization such as the varicella vaccine
Active Immunity
Develops after the introduction of a foreign antigen, resulting in the formation of antibodies or sensitized T lymphocytes (i.e. immunizations)
Active acquired immunity
Acquired immunity can either be ____ or ____
Active or Passive
Consequences of Exaggerated Immune Response
Acute hypersensitive reaction & Chronic body-wide system disease
Diagnostic criteria of ARDS
Acute onset Ratio (PaCO2/FiO2) <200 Diffuse infiltration Swan-Ganz wedge pressure (PAWP) <18mm Hg
Inflammation can be ____ or ____, and also ____/____
Acute or Chronic Repairs/Restores
Adaptive Immunity commences when innate immunity fails
Adaptive immunity commences when an immature dendritic cell ingests pathogen within the infected peripheral tissue. The dendritic cell then migrates to the draining lymph node where they present antigenic pathogen peptide in a manner that stimulates resting naïve T cells to proliferate and differentiate into effector and memory CD4+ T helper (Th) cells and CD8+ cytotoxic T cells (a.k.a. cytotoxic T lymphocytes, CTLs). Some effector CD4+Th cells provide, in turn, the help required for antigen-activated B cells to differentiate into antibody producing plasma cells.
Atrial Arrhythmias: ABCDE
Adenosine/amiodorone or anticoagulate (if Afib/Flutter has been present >48h) Beta blockers Calcium channel blockers Digoxin Electrocardiovert (if <48h)
Identity vs Role Confusion
Adolescent, 12 to 18
Cushing's Disease "too much Cush (cortisol)"
Adrenal cortex hypersecretion, persistent hyperglycemia, protein loss, water and salt retention, moon face, buffalo hump, bird legs
Unintended harm by an act of commission or omission rather than as a result of disease process
Adverse event
Cytokines
Affects the WAY other cells ACT (Cyto- "cell" and -kinein "move")
Factors affecting skin integrity include
Age Mobility Status Nutrition and Hydration Sensational level Impaired Circulation Medications Moisture Fever Infection Lifestyle
What are risk factors for a suppressed immune system?
Age (very young, elderly) Non-immunized state Environmental factors (pollutants, poor nutrition, heavy metals, poor hand hygiene, etc) Chronic illnesses Medical treatments Genetics (allergies, type 1 diabetes, fibromyalgia, MS, asthma) High-risk behaviors and substance abuse Pregnancy
Anesthesia
Agent that produces states such as loss of consciousness, analgesia, relaxation, and loss of reflexes.
____ occurs when air is introduced into an I.V. line Characterized by respiratory distress, chest pain, dyspnea, hypotension, and a weak rapid pulse
Air Embolism
Post op interventions for hypoxemia
Airway maintenance Monitor O2 sats Semi-fowlers O2 therapy, breathing exercises Mobilization asap
Examples of plasma proteins are:
Albumin Fibrin Globulin
____ determines the amount of reabsorption of sodium and water in the kidneys (Renin-Angiotensin-Alsosterone System or RAAS)
Aldosterone Hormone
The Body's cellular activity requires a slightly _____ medium
Alkaline
The lower the concentration of H+, The more ____ the body fluids and the ____ the Ph
Alkaline Higher
Alkalosis and Acidosis
Alkalosis - has a 'k' - Kicking the pH up Acidosis - has a 'd' - Dropping the pH down
All WBCs or leukocytes except for:
All the leukocytes except the lymphocytes are considered part of the innate immune system.
Acid-base balance: is expected in _____ Requires _____ physiologic functioning Indication of _____
All well Individuals Normal Homeostasis
Clinical findings for exaggerated immune functioning are:
Allergic Response Autoimmune Disorders
Individuals who have a "hyper" immune response range from:
Allergic reactions Cytotoxic reactions Autoimmune reactions
Clinical findings of exaggerated immune system:
Allergic response (mild-severe) Autoimmune disorders
Exaggerated Immune Functioning symptoms are:
Allergic symptoms Pain Fatigue Fever
Symptoms of exaggerated immune system:
Allergic symptoms Pain Fatigue Fever
Nursing process and safety: assessment
Allergies before a procedure, morse fall scale, older adult, home safety, violence, pain (location, level, radiation), Mercury inhalation
Other diagnostic tests for immune function and Disease specific testing includes:
Allergy testing Genetic testing Rheumatoid factor Western Blot Test TORCH Antibody Panel Organ function tests
Conditions in which immune responses are either suppressed or exaggerated
Altered Immunity
Why does fever occur in inflammation?
Alveolar macrophages get upset and release endogenous pyrogens to fight off the "bad bugs". Bugs usually prefer our normal body temp; heat can kill some bugs.
Exercise therapy to promote mobility
Ambulation, joint mobility, stretching, balance
For ventricular arrhythmias: AL
Amiodorone Lidocaine
Hypervolemia
An abnormal increase in blood volume or, strictly speaking, an abnormal increase in the volume of blood plasma. S&S: bounding increased pulse / increased BP / distended neck and hand veins / dysrhthmias/ Weight gain
Septic Shock
An acute infection, usually systemic, that overwhelms the body (toxic shock symdrome). Poisonous substances accumulate in bloodstream and blood pressure decreases, impairing blood flow to cells, tissues, and organs.
Explanation of an antibody which has two segments.
An antibody itself is a molecule composed of two segments, a recognition/binding segment and an effector segment. The recognizing segment binds to the antigen and the effector activates other parts of the immune system. Thus antibodies may neutralize threats directly by physically binding to them and keeping them from damage. At the same time, antibodies recruit other components of the immune system to attack and destroy the threat.
Sedation
An arousable state in which an individual is unaware of sensory stimuli. Depression of the central nervous system.
Inflammation
An irritation of a tissue caused by infection or injury. Inflammation is characterized by four cardinal symptoms; redness, swelling, heat, and pain.
Post op lab assessment
Analysis of electrolytes CBC ("left-shift"-bandemia) Specimens for C&S ABGs Urine and renal lab tests Other (serum amylase, blood glucose)
Complications of local or regional anesthesia
Anaphylaxis Incorrect delivery technique Systemic absorption Overdose Local complications
Diagnostic test done to detect DVT or PE
Angiogram
A client has been admitted for dehydration after fasting for five days. For which acid- base imbalance would the nurse assess this client? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
Answer 1
A client is admitted with severe diarrhea. Arterial blood gas ( ABG) results are pH 7.33; PaCO 2 42; HCO 3 - 20. The nurse concludes this client has which acid- base imbalance? 1. Uncompensated metabolic acidosis 2. Compensated respiratory acidosis 3. Compensated metabolic acidosis 4. Uncompensated respiratory acidosis
Answer 1
A client with end stage renal disease is experiencing hypermagnesemia. The nurse explains that which treatment will decrease the magnesium level most effectively? 1. Dialysis 2. Diuretics 3. Fluid restriction 4. High- volume IV fluids
Answer 1
A client with suspected severe acute respiratory syndrome ( SARS) arrives at the emergency department. Which physician order should the nurse implement first? 1. Airborne and contact precautions 2. IV D 5 NS at 100 mL/ hr 3. Nasopharyngeal culture for reverse- transcription polymerase chain reaction 4. Sputum for enzyme immunoassay testing
Answer 1
A client with tuberculosis asks the nurse if visitors will need to wear masks. What response by the nurse is most accurate? 1. " Everyone who enters your room must wear a mask to protect themselves from tuberculosis." 2. " Masks would not be necessary for visitors who have had tuberculosis before." 3. " It is less important for your family to wear masks, since they live in close contact with you." 4. " Only visitors who are at risk for tuberculosis need to wear a mask."
Answer 1
A client's arterial blood gas ( ABG) results are pH 7.36; PaCO 2 50; HCO 3 - 28. What do these results indicate to the nurse? 1. Compensated respiratory acidosis 2. Compensated metabolic acidosis 3. Uncompensated metabolic acidosis 4. Uncompensated respiratory acidosis
Answer 1
The client has a percutaneous jugular central venous line that is capped and used for intermittent infusions. After administering the medication, the best method to maintain patency is to do which of the following? 1. Flush the line first with 3- 5 mL of normal saline, then with 1- 3 mL of heparinized normal saline. 2. Flush the line with 3- 5 mL of normal saline. 3. Flush the line with 3- 5 mL of heparinized normal saline. 4. Flush the line first with 3- 5 mL of heparin, then with 1- 3 mL of normal saline.
Answer 1
The family of a client with hypercalcemia states that the client is " not acting like himself." The nurse focuses assessment on which manifestation? 1. Personality change 2. Anxiety 3. Seizure activity 4. Carpal spasms
Answer 1
The home health nurse is monitoring a client who performs self- care of a central line. The nurse observes the client doing all of the following activities. Which activity indicates the need for further education? 1. Flushing the central line with a 3 mL syringe 2. Cleaning the needleless injection cap with alcohol before accessing 3. Using sterile gloves to change the central line dressing 4. Wearing a mask while changing the central line dressing
Answer 1
The nurse assigned to the respiratory care unit is working with four clients who have pneumonia. The nurse should assign the only remaining private room on the nursing unit to the client infected with which organism? 1. Penicillin- resistant Streptococcus pneumoniae pneumonia 2. Pseudomonas aeruginosa pneumonia 3. Pneumocystis carinii pneumonia 4. Legionella pneumophila pneumonia
Answer 1
The nurse is caring for a pediatric client with acquired immunodeficiency syndrome ( AIDS). Which activity by the nurse should be reported to the employee health department as an exposure for the nurse? 1. While flushing out the used bedpan, fluid splashes in the nurse's eyes. 2. The nurse does not wear a mask while in the client's room. 3. During the bath, the nurse removes gloves when giving a backrub on intact skin. 4. The nurse is stabbed with a sterile syringe to be used to draw up the client's medications.
Answer 1
The nurse is caring for several clients with central venous catheters. While changing the tubing on the central lines, the nurse would not need to instruct the client to perform Valsalva maneuver when the client has which catheter? 1. Groshong 2. Single- lumen 3. Percutaneous 4. Accessed subcutaneous venous port
Answer 1
The nurse teaches a client that which factor might increase risk of developing an exacerbation of systemic lupus erythematosus ( SLE)? 1. Pregnancy 2. Hypotension 3. Fever 4. GI upset
Answer 1
The nurse would assess for which electrolyte imbalance as a common finding in a client with AIDS? 1. Hyponatremia 2. Hypernatremia 3. Hyperkalemia 4. Hypocalcemia
Answer 1
The nurse would suspect that a client who frequently uses which medication is at risk for developing metabolic alkalosis? 1. Calcium carbonate ( Tums) 2. Ibuprofen ( Motrin) 3. Acetylsalicylic acid ( aspirin) 4. Acetaminophen ( Tylenol)
Answer 1
The nurse writing a care plan determines that which nursing diagnosis is a priority early in the care of a client with scleroderma? 1. Impaired Skin Integrity 2. Disturbed Body Image 3. Activity Intolerance 4. Hopelessness
Answer 1
The pediatric nurse would suspect severe combined immunodeficiency disorder ( SCID) when which child is admitted to the hospital nursing unit? 1. A 2- month- old with thrush and low white blood cell counts 2. A 2- year- old with history of recent repeated infections 3. A newborn with positive TORCH titer 4. A newborn admitted with positive ELISA test
Answer 1
What instruction should the nurse include in an education program to prevent dehydration for a high school hiking club that is planning a 12- mile hike in early summer? 1. Take water and commercial sports drinks to sip often along the way. 2. Drink large amounts of water, at least 16 ounces every hour, while hiking. 3. Take salt tablets every 3- 4 hours, and drink plenty of water while in the heat. 4. Stop every 4 hours along the way, and drink a few ounces of water while resting.
Answer 1
Which finding in a client's history would alert the nurse to assess for signs of hypophosphatemia? 1. Alcohol abuse 2. The oliguric phase of acute tubular necrosis 3. Short- term gastric suction 4. Occasional use of aluminum- containing antacids
Answer 1
Which medication reported by a client during a nursing history could be associated with the development of hypocalcemia? 1. Phenytoin ( Dilantin) 2. Calcium carbonate ( TUMS) 3. Calcitriol 4. Hydrochlorothiazide ( HydroDIURIL)
Answer 1
While assessing a client's intravenous ( IV) line, the nurse notes that the area is swollen, cool, pale, and causes the client discomfort. What complication should the nurse document? 1. Infiltration 2. Phlebitis 3. Infection 4. Air embolism
Answer 1
The nurse is restarting an IV line on a client known to have hepatitis B. Which precautions should the nurse use to protect against exposure? Select all that apply. 1. Handwashing 2. Gloves 3. Mask 4. Face shield 5. Gown
Answer 1, 2
The nurse would take which actions to comply with principles of medical asepsis? Select all that apply. 1. Wash hands before and after assisting client with personal hygiene. 2. Wear gown and gloves when working with client on contact precautions. 3. Re- cap needle after administering insulin. 4. Insert needle into rubber port of a previously used multidose vial without swabbing it with alcohol. 5. Use surgical facemask while working with client who has tuberculosis.
Answer 1, 2
The nurse is caring for a client with hepatitis A. Which client statements indicate that teaching conducted by the nurse about disease transmission was effective? Select all that apply. 1. " We must avoid kissing." 2. " We can use the same bath towels." 3. " We must avoid eating with the same utensils." 4. " We must wear masks." 5. " No special precautions are needed."
Answer 1, 3
A client is admitted to the hospital with a diagnosis of respiratory acidosis secondary to overdose of barbiturates. Which assessment would the nurse anticipate? Select all that apply. 1. Slow, shallow respirations 2. Tetany symptoms 3. Increased deep tendon reflexes 4. Palpitations 5. Headache
Answer 1, 5
Medication instruction for the client with rheumatoid arthritis ( RA) should include which teaching points? Select all that apply. 1. Injection of gold salts requires monitoring for anaphylactic reactions every half- hour. 2. Treatment with sulfasalazine requires fluid restriction to avoid nausea and vomiting. 3. Acetaminophen may be used to decrease inflammation associated with RA. 4. Penicillamine may be safely used during pregnancy. 5. Nonsteroidal anti- inflammatory drugs ( NSAIDs) and aspirin may be used interchangeably to decrease inflammation.
Answer 1, 5
The nurse assesses the client with rheumatoid arthritis for which characteristic joint changes? Select all that apply. 1. Swan- neck deformity 2. Heberden's and Bouchard's nodes 3. Tophi 4. Charcot's joints 5. Ulnar deviation
Answer 1, 5
The nurse is caring for a client who has sustained partial and full thickness burns over 30% of his body 18 hours ago. The nurse assesses for which fluid and electrolyte imbalances at this time? Select all that apply. 1. Hyperkalemia 2. Hypokalemia 3. Hypervolemia 4. Hypercalcemia 5. Hypovolemia
Answer 1, 5
A 10- month- old infant is admitted to the emergency department with a 102° F rectal temperature and a history of vomiting and diarrhea for 48 hours. For what signs should the nurse look related to this client's likely fluid imbalance? 1. Bulging fontanels, tearless cry, and low urine output 2. Sunken eyes, lethargy, and dry, furrowed tongue 3. Weight loss, dilute urine, and peripheral edema 4. Dry skin, thready pulse, and neck vein distention
Answer 2
A 12- year- old boy is diagnosed with early human immunodeficiency virus ( HIV) infection secondary to factor transfusions for hemophilia. The family is very concerned about their ability to manage his care, risk of infection to family members, and whether the child should remain in the home. Which action by the nurse will best promote family coping at this time? 1. Explain to the family that the infection cannot be spread by casual contact. 2. Demonstrate positive acceptance of the child with each contact. 3. Explain that prophylactic drugs will prevent the virus from spreading. 4. Show the family how to wash their hands properly.
Answer 2
A client admitted to the hospital with a 30- pound weight gain over the past month has a fat pad at the back of the neck and moon facies. Admission laboratory results indicate decreased serum potassium and magnesium, and elevated serum chloride and sodium levels. The nurse interprets that which disorder is most consistent with these electrolyte abnormalities? 1. Addison's disease 2. Cushing's syndrome 3. Burns 4. Syndrome of inappropriate ADH ( SIADH)
Answer 2
A client diagnosed with scleroderma reports painful fingers that change colors ( pale to red) when washing dishes. Which suggestion by the nurse might help the client with this symptom? 1. Increase the water temperature. 2. Use gloves during dishwashing. 3. Start physical therapy to increase blood flow to the hands. 4. Take over- the- counter H 2 receptor antagonist medications.
Answer 2
A client is admitted to the hospital after vomiting for three days. Which arterial blood gas ( ABG) result would the nurse expect? 1. pH 7.30; PaCO 2 50; HCO 3 - 27 2. pH 7.47; PaCO 2 43; HCO 3 - 28 3. pH 7.34; PaCO 2 50; HCO 3 - 28 4. pH 7.48; PaCO 2 30; HCO 3 - 23
Answer 2
A client is admitted to the hospital with sudden onset of severe abdominal pain. Which arterial blood gas ( ABG) value would the nurse expect to see with this client? 1. PaCO 2 48 2. HCO 3 - 18 3. pH 7.32 4. SaO 2 90
Answer 2
A client is admitted with a diagnosis of renal failure. Which arterial blood gas ( ABG) result would the nurse expect to see with this client? 1. pH 7.49; PaCO 2 36; HCO 3 - 30 2. pH 7.30; PaCO 2 35; HCO 3 - 18 3. pH 7.31; PaCO 2 50; HCO 3 - 23 4. pH 7.43; PaCO 2 48; HCO 3 - 30
Answer 2
A client is to start taking prednisone for treatment of rheumatoid arthritis ( RA). Which client statement indicates that medication teaching was successful? 1. " I will take the medication on an empty stomach to maximize absorption." 2. " I will take the specific dose ordered at the same time every day." 3. " I will not have to limit my sodium intake." 4. " I will not have to adjust my insulin regimen."
Answer 2
A home health nurse is making a visit to an older adult client with a history of heart failure ( HF). The client was prescribed diuretics twice a day and a low- sodium diet. The nurse should be most concerned about which current laboratory result? 1. Sodium 145 mEq/ L 2. Chloride 90 mEq/ L 3. K + 4.2 mEq/ L 4. HCO 3 27 mEq/ L
Answer 2
A male client who has acquired immunodeficiency syndrome ( AIDS) asks why oral progesterone ( Megace) is being prescribed for treatment. What is the nurse's best response? 1. " Megace is used to treat the nausea associated with this infection." 2. " Megace is used as an appetite stimulant to boost nutritional support." 3. " Megace provides symptomatic relief of constipation." 4. " Megace is used as an antineoplastic agent for palliative treatment."
Answer 2
The nurse assessing a client for signs of hypocalcemia would conclude that this electrolyte imbalance exists after noting which finding? 1. Negative Chvostek's sign 2. Positive Trousseau's sign 3. Positive Kernig's sign 4. Hypoactive bowel sounds
Answer 2
The nurse concludes that a history of which condition places a client at risk for possible hypokalemia? 1. Chronic obstructive pulmonary disease (COPD) 2. Cirrhosis 3. Addison's disease 4. Chronic renal failure (CRF)
Answer 2
The nurse determines that a client with a nasogastric tube on low suction for five days is at risk for developing which acid- base imbalance? 1. Respiratory acidosis 2. Metabolic alkalosis 3. Metabolic acidosis 4. Respiratory alkalosis
Answer 2
The nurse is inserting an intravenous ( IV) line into a cli-ent. After piercing the skin and entering the vein, what manifestation should cause the nurse to refrain from advancing the catheter? 1. Blood backflow into the IV catheter 2. Mild resistance with advancement 3. No reports of client discomfort 4. IV catheter was inserted bevel side up
Answer 2
The nurse is preparing to start a peripheral intravenous ( IV) line in a client. The client's record indicates a latex allergy. What action should be taken by the nurse? 1. Utilize a new tourniquet for this client. 2. Use a blood pressure cuff to distend the vein. 3. Avoid putting povidone iodine on the skin. 4. Initiate a latex- free alternative therapy.
Answer 2
The nurse looks for results of which laboratory measure-ment that provides a reliable indicator of lymphocyte sta-tus in a client with HIV infection? 1. B lymphocytes 2. T- helper cells ( CD 4 ) 3. Natural killer cells ( NK) 4. T- cytotoxic cells
Answer 2
The nurse would take which action to protect the client from infection at the portal of entry? 1. Place sputum specimen in a biohazard bag for transport to the lab. 2. Empty Jackson- Pratt drain using sterile technique. 3. Dispose of soiled gloves in waste container. 4. Wash hands after providing client care.
Answer 2
Which assessment finding by the nurse warrants further investigation to determine if the client has rheumatoid arthritis ( RA)? 1. Negative family history 2. Reports of prolonged morning stiffness lasting for 1 hour 3. Occasional use of NSAIDs for aches and pains 4. Reports of pain with movement
Answer 2
Which precaution would the nurse implement when admitting a client with herpes zoster to the nursing unit? 1. Airborne precautions 2. Contact precautions 3. Droplet precautions 4. Neutropenic precautions
Answer 2
Which suggestion by the nurse would be most helpful to a human immunodeficiency virus ( HIV) positive client who has altered taste perception? 1. Drink plenty of salty broths and other fluids to stimulate taste buds. 2. Try zinc supplementation to improve taste perception. 3. Increase intake of meat to at least one serving per day. 4. Avoid using plastic eating utensils.
Answer 2
The nurse would assess for which signs and symptoms in a client who has metabolic acidosis? Select all that apply. 1. Weight gain 2. Rapid, deep respirations 3. Drowsiness 4. Decreased respiratory rate and depth 5. Melena
Answer 2, 3
The nurse is preparing to leave the room of a client on transmission- based precautions. Place in the correct order the steps the nurse would follow to remove personal protective equipment and perform hand hygiene. 1. Remove gown. 2. Remove gloves. 3. Remove mask. 4. Remove eye protection. 5. Wash hands.
Answer 2, 3, 1, 4, 5
The nurse is leaving the room of a client who has methicillin- resistant Staphylococcus aureus ( MRSA) microorganisms in a wound and the urine. Place the following personal protective equipment in order of removal. 1. Eye protection 2. Gloves 3. Mask 4. Gown
Answer 2, 3, 4, 1
The nurse is admitting a client who has metabolic alkalosis. The nurse plans to assess for manifestations of which electrolyte imbalance? Select all that apply. 1. Hypernatremia 2. Hypochloremia 3. Hypermagnesemia 4. Hypocalcemia 5. Hypokalemia
Answer 2, 4, 5
The nurse concludes that which sign reliably indicates that ascites fluid is being effectively mobilized in response to therapy? Select all that apply. 1. Weight gain of 1 pound in 24 hours 2. Increase in urine output 3. Drop in blood pressure 4. Hand veins fill slowly 5. Abdominal girth has decreased by 1 inch in 24 hours
Answer 2, 5
Which assessment of an adult client is a reliable indicator that therapy for Fluid Volume Excess is achieving the desired outcome? Select all that apply. 1. Full, bounding peripheral pulses 2. Flat neck veins with the head of the bed elevated 3. Hand vein emptying longer than 20 seconds 4. S 3 heart sound clearly audible on auscultation 5. Lungs sounds are clear
Answer 2, 5
Which statement by the client indicates that discharge teaching for respiratory alkalosis is understood? 1. " I will not take so many antacids anymore." 2. " I will take a stress management class." 3. " I will not take my furosemide ( Lasix) without taking my potassium supplement." 4. " I will tell the doctor the next time I have diarrhea for so long." 5. " I am more aware of how my breathing changes when I get nervous."
Answer 2, 5
Which actions by the nurse comply with core principles of surgical asepsis? Select all that apply. 1. Wash hands before and after client care. 2. Keep sterile field in view at all times. 3. Wear personal protective equipment. 4. Add contents to sterile field holding package 6 inches above field. 5. Consider outer 1.5 inches of sterile field as contaminated.
Answer 2,4
The client is receiving 5% dextrose and 0.45% sodium chloride intravenously and is complaining of pain at the IV site. The nurse assesses the site and notes erythema and edema. What is the appropriate action for the nurse to take? Select all that apply. 1. Slow the infusion to a keep- open rate. 2. Discontinue the IV and apply a warm compress to the IV site. 3. Apply antibiotic ointment to the IV site. 4. Gently pull back on the IV catheter to attempt repositioning. 5. Relocate the IV site and document the event.
Answer 2,5
A 5- year- old child is brought into the clinic after being stung by an insect. The child appears to be going into anaphylactic shock. Which nursing action is of highest priority? 1. Assess urinary output to determine renal perfusion 2. Apply cold, wet compresses to the site 3. Position the child's head to maintain an open airway 4. Establish intravenous access for medication delivery
Answer 3
A client is admitted to the hospital with an acid- base imbalance. Arterial blood gas ( ABG) results are pH 7.33; PaCO 2 49; HCO 3 - 28. How would the nurse interpret these results? 1. Uncompensated respiratory acidosis 2. Metabolic alkalosis, uncompensated 3. Partially compensated respiratory acidosis 4. Partially compensated metabolic acidosis
Answer 3
A client is admitted to the hospital. Arterial blood gas ( ABG) results are pH 7.50; PaCO 2 40; HCO 3 - 29. Which question should the nurse ask the client to help determine an etiology for these results? 1. " Have you had diarrhea lately?" 2. " Do you have a history of COPD?" 3. " How long have you had nausea and vomiting?" 4. " Do you smoke?"
Answer 3
A client presents with dyspnea, pruritis, and localized swelling of the forearm after being stung by a bee. What is the priority nursing intervention? 1. Remove the stinger from the client's arm 2. Keep the client warm with soft blankets 3. Check the tongue for swelling and listen for stridor 4. Place client in the Trendelenburg position
Answer 3
A client will undergo scratch tests for allergies. In teaching the client about the planned tests, the nurse should include which statement? 1. " This test allows us to rule out one or two specific antigens." 2. " The scratch test is the most sensitive allergy test." 3. " Results can be obtained in 30 minutes." 4. " It involves drawing a small amount of blood for testing."
Answer 3
A client with hypocalcemia is taking supplemental vita-min D. When the client asks the purpose of this therapy, what explanation should the nurse give? 1. It directly opposes calcitonin. 2. It prevents renal disease in clients with hypocalcemia. 3. Calcium is absorbed in the intestines only under the influence of activated vitamin D. 4. The only way to obtain vitamin D is with oral supplementation.
Answer 3
A client's arterial blood gas ( ABG) results are pH 7.48; PaCO 2 30; HCO 3 - 23. How will the nurse interpret these results? 1. Compensated respiratory alkalosis 2. Uncompensated metabolic alkalosis 3. Uncompensated respiratory alkalosis 4. Compensated metabolic alkalosis
Answer 3
In establishing a plan of care to manage pain for a client with rheumatoid arthritis ( RA), what intervention would the nurse use to increase the client's mobility? 1. Have the client work through pain by continuing exercise in order to establish endurance. 2. Have the client use pain medication only when pain is present. 3. Teach the client that both heat and cold applications may help to relieve pain. 4. Teach the client to flex muscle groups when pain is felt in an extremity.
Answer 3
The client has a tunneled Groshong catheter for intermittent medication administration. After administering the medication, the nurse prepares to do which of the following? 1. Clamp the catheter after medication administration. 2. Flush the catheter with heparin at scheduled times. 3. Flush the catheter with saline after medication administration. 4. Initiate a Valsalva maneuver when disconnecting medication tubing.
Answer 3
The client is receiving 5% dextrose in 0.45% sodium chloride. The physician has ordered the client receive one unit of packed cells. Prior to hanging the blood, the nurse will prime the blood tubing with which solution? 1. 5% dextrose 2. Lactated Ringer's 3. 0.9% sodium chloride 4. 5% dextrose in 0.45% sodium chloride
Answer 3
The client is to receive the intravenous medication vancomycin ( Vancocin). To prevent adverse reactions from rapid infusion, by what method should the nurse plan to administer this drug? 1. Using gravity 2. With a regulator 3. Electronic infusion pump 4. Elastomeric pump
Answer 3
The following arterial blood gas ( ABG) results are on the client's chart: pH 7.50; PaCO 2 36; HCO 3 - 30. How will the nurse interpret this report? 1. Partially compensated metabolic alkalosis 2. Compensated respiratory alkalosis 3. Uncompensated metabolic alkalosis 4. Uncompensated respiratory alkalosis
Answer 3
The nurse concludes that a client does not have an increased magnesium level based on which finding? 1. Hypotension 2. Bradycardia 3. Supraventricular tachycardia ( SVT) 4. Flushing and sweating
Answer 3
The nurse is assisting a client who has methicillin- resistant Staphylococcus aureus in collecting a clean- catch urine specimen. Which protective equipment is unnecessary? 1. N95 particulate respirator 2. Gown 3. Eye protection 4. Sterile gloves
Answer 3
The nurse is caring for a client who has a sodium level of 149 mEq/ L. The nurse concludes that it is important to administer which of the following to this client? 1. Cough suppressant to treat symptomatic cough 2. 3 percent saline solution 3. Water 4. Lactulose ( Chronulac)
Answer 3
What information will the nurse include when explaining therapeutic measures to a client taking methotrexate ( Rheumatrex) for rheumatoid arthritis ( RA)? 1. Relief of symptoms will be assessed for within 1 week of starting medication. 2. Fluids should be restricted to prevent possible edema formation. 3. Drug doses will be adjusted for optimum effect at lowest dose once relief has been established. 4. Six months of therapy will be adequate to stop the disease process from progressing.
Answer 3
Which client medication should the nurse review first for its potential interaction in a client admitted to the hospital in a state of alkalosis? 1. Warfarin ( Coumadin) 2. Metformin ( Glucophage) 3. Digoxin ( Lanoxin) 4. Ibuprofen ( Motrin)
Answer 3
Which concurrent electrolyte imbalance should the nurse anticipate while caring for a client with hyperphosphatemia? 1. Potassium 2.8 mEq/ L 2. Sodium 131 mEq/ L 3. Calcium 6.8 mEq/ L 4. Magnesium 3.4 mEq/ L
Answer 3
Which postoperative client would be at risk for develop-ing a sodium imbalance? 1. A client who has just had a tonsillectomy 2. A client who has a primary cesarean section for failure to progress in labor 3. A client who has a transurethral resection of the prostate ( TURP) 4. A client who has a right knee arthroscopy
Answer 3
Which suggestion would the nurse give to a client with human immunodeficiency virus ( HIV) infection to best alleviate nausea? 1. Drink liquids with meals. 2. Eat high- fat foods. 3. Eat small, frequent meals. 4. Lie down after eating.
Answer 3
A child who must undergo skin testing for allergies takes an antihistamine to control symptoms. The nurse explains that the client must discontinue use of the antihistamine for _____ days before the skin testing to avoid false negative results. Provide a numerical answer.
Answer 3 days
A client is admitted to the hospital with respiratory acidosis. The nurse considers that which condition could be an etiology for this state? Select all that apply. 1. Severe diarrhea for several days 2. Diabetic ketoacidosis 3. Obesity 4. Diuretics 5. Sedative overdose
Answer 3, 5
The family of a home infusion client calls the home health nurse one night to report that the electronic infusion pump is alarming. What should the nurse anticipate as the cause of the infusion pump alarming? Select all that apply. 1. The client's pulse and blood pressure are falling. 2. The client is experiencing a reaction to the medication. 3. The prescribed infusion is complete. 4. There is an incompatibility with the medications. 5. An occlusion has interrupted the infusion.
Answer 3, 5
The nurse includes in the plan of care to periodically monitor which item for a client who is at risk for developing hypocalcemia? Select all that apply. 1. Blood urea nitrogen (BUN) and creatinine levels 2. Constipation 3. Serum albumin level 4. Fluid overload related to intravenous saline therapy 5. Serum magnesium level
Answer 3, 5
The nurse would review a client's electrolyte levels to detect a possible increase in magnesium if the client had which condition? Select all that apply. 1. Cushing's syndrome 2. Diabetes 3. Addison's disease 4. Splenomegaly 5. Dehydration
Answer 3, 5
A client asks, " How did I get scarlet fever?" What would be the nurse's best response? 1. " Scarlet fever is transmitted through sexual intercourse." 2. " You can get scarlet fever if you share contaminated needles or get a blood transfusion." 3. " Most people get it by eating contaminated food." 4. " You inhaled infected droplets in the air."
Answer 4
A client is admitted to the hospital with atelectasis and reports of chest pain. For which acid- base imbalance would the nurse assess this client? 1. Respiratory alkalosis 2. Metabolic acidosis 3. Metabolic alkalosis 4. Respiratory acidosis
Answer 4
A client is admitted to the hospital with numerous epi-sodes of muscle weakness and twitching. Arterial blood gas ( ABG) results are pH 7.44; PaCO 2 49; HCO 3 - 30. How would the nurse interpret these findings? 1. Uncompensated metabolic acidosis 2. Compensated respiratory alkalosis 3. Uncompensated respiratory alkalosis 4. Compensated metabolic alkalosis
Answer 4
A client with vancomycin- intermediate- resistant Staphylococcus aureus ( VISA) is admitted to the nursing unit. What type of precautions should the nurse institute? 1. Standard precautions 2. Neutropenic precautions 3. Droplet precautions 4. Contact precautions
Answer 4
An infant is admitted to the pediatric unit with a diagnosis of sepsis. The nurse is completing a nursing assessment. What would be the priority nursing assessment for this infant? 1. Skin Integrity 2. Temperature 3. Jaundice 4. Respiratory Function
Answer 4
The community health nurse is assigned to a client who recently was discharged from the hospital with resolving hypernatremia. During the initial assessment interview, what information would be of critical importance in determining a plan of care for this client? 1. The client lives on the second floor of an apartment building that has an elevator. 2. The client needs to walk 100 feet each day to reach the mailbox for the apartment building. 3. The client performs self- monitoring of blood glucose once a day. 4. The client uses Alka- Seltzer on a frequent basis for gastrointestinal complaints.
Answer 4
The nurse is caring for a client who has a sodium level of 128 mEq/ L. As part of the care, the nurse will restrict which item for this client? 1. Sports drinks, such as Gatorade 2. Eggs and cheese products 3. Salt on the diet tray 4. Water
Answer 4
The nurse is caring for a client with a Hickman central line. While changing the central line dressing, the nurse notes that the injection cap ( e. g., heplock adapter) is of the slip lock variety instead of a luer lock device. The nurse recognizes that this adapter puts the client at risk for which complication? 1. Sepsis 2. Occlusion 3. Phlebitis 4. Air embolism
Answer 4
The nurse is preparing to irrigate a wound infected with vancomycin- resistant enterococci. What personal protective equipment ( PPE) would the nurse wear? 1. Gloves, gown, and particulate respirator 2. Gloves and surgical mask 3. Gloves, eye protection, and shoe covers 4. Gloves, gown, eye protection, and surgical mask
Answer 4
The nurse reviews the laboratory test results for a client with preeclampsia, expecting to find which value? 1. Sodium 148 mEq/ L 2. Sodium 125 mEq/ L 3. Magnesium 3.1 mEq/ L 4. Magnesium 1.2 mEq/ L
Answer 4
The nurse who is providing care to a group of clients concludes that the client with which health problem exhibits a type III immune- complex- mediated hypersensitivity reaction? 1. Transfusion reaction 2. Goodpasture's syndrome 3. Transplant rejection 4. Systemic lupus erythematosus
Answer 4
The nurse would anticipate which finding in a client with an immunologic disorder associated with a human leukocyte antigen ( HLA)? 1. Acute course 2. Frequent effects on reproductive capacity 3. Genetic determination 4. Chronic and possibly subacute course
Answer 4
The nurse would expect to institute transmission- based precautions for a client with which infection? 1. Pneumonia caused by Pseudomonas aeruginosa 2. Pneumocystis carinii pneumonia 3. A sacral wound contaminated by Escherichia coli 4. A draining leg wound with methicillin- resistant Staphylococcus aureus
Answer 4
The nurse would implement which of the following as a requirement of care specific to the client who has tuberculosis? 1. Disposal of needles and syringes in a rigid, puncture- proof container 2. Handwashing after removing contaminated gloves 3. Wearing a gown if splashing is possible 4. A private room with negative air flow
Answer 4
The nurse's forearm becomes splattered with blood while inserting an intravenous catheter. What action should the nurse take? 1. Wash blood away with isopropyl alcohol. 2. Wipe blood away with a tissue. 3. Flush forearm with hot water, letting water flow from elbow toward fingers. 4. Wash forearm with soap and water.
Answer 4
The physician is going to order a hypotonic intravenous solution for a client with cellular dehydration. The nurse would expect which fluid to be administered? 1. 0.9% normal saline 2. 5% dextrose in normal saline 3. Lactated Ringer's solution 4. 0.45% sodium chloride
Answer 4
The white blood cell ( WBC) count of a client with systemic lupus erythematosus ( SLE) shows a shift to the left. Which nursing diagnosis reflects the highest priority for this client? 1. Ineffective Health Maintenance 2. Impaired Skin Integrity 3. Ineffective Individual Coping 4. Ineffective Protection
Answer 4
To enhance meeting the psychosocial needs of a client on transmission- based precautions, the nurse should place highest priority on which of the following? 1. Letting the client sleep to build up stamina 2. Maintaining strict precautions when entering and leaving the room so that the client feels he or she is getting the best care 3. Providing client care within a limited time frame to maintain isolation and keep client safe 4. Providing the client with diversional activities to enhance sensory input
Answer 4
Which health care provider order for potassium chloride ( KCl) should the nurse question regarding a client with severe hypokalemia? 1. Infuse 1000 mL normal saline with 20 mEq KCl IV over 8 hours. 2. Give KCl 20 mEq PO daily after meals. 3. Infuse 1000 mL normal saline with 40 mEq KCl IV at 200 mL/ hour. 4. Give 20 mEq KCl IV over 10 minutes.
Answer 4
Which treatment option does the nurse anticipate will be most appropriate for a client with a potassium level of 3.5 mEq/ L? 1. Give sodium polystyrene sulfate ( Kayexalate) per rectum. 2. Use salt substitutes in the diet. 3. Administer oral potassium chloride ( KCl). 4. Continue to monitor and offer foods high in potassium.
Answer 4
The nurse is preparing to enter the room of a client with pneumonia caused by penicillin- resistant Streptococcus pneumoniae ( PRSP). The client has a tracheostomy and requires suctioning. Put the following personal protective equipment in order of donning. 1. Eye protection 2. Gloves 3. Mask 4. Gown
Answer 4, 3, 1, 2
The nurse would perform which action when washing hands as part of medical asepsis before caring for a client in an outpatient clinic? Select all that apply. 1. Wash hands with the hands held higher than the elbows. 2. Adjust temperature of water to the hottest possible. 3. Scrub hands and nails with a scrub brush for 5 minutes. 4. Use a clean paper towel to turn water off. 5. Rub vigorously using firm circular motions.
Answer 4,5
The nurse is inserting a peripheral intravenous ( IV) line. Place the following steps in order to perform this procedure correctly. 1. Apply a tourniquet above insertion site. 2. Insert catheter at 5- 15 degree angle through skin. 3. Select a vein and cleanse the skin. 4. Attach tubing primed with IV solution. 5. Gather the appropriate equipment.
Answer 5,3,1,2,4
The nurse would report to the charge nurse that an assigned client has hyperkalemia after noting that the serum potassium level drawn that morning was greater than how many mEq/ L? Provide a numerical answer. ____ mEq/ L
Answer 5.1
____ is released by the right atrium
Atrial Natriuretic Peptide or ANP
IgE- the Trigger to inflammation!!
Attaches to Mast Cells and BASOphils, Diagnostic: RAST to test for IgE
Primary prevention
Attempts to prevent the onset of the disorder (i.e., vaccinations).
Chemokines
Attract other leukocytes to the area to battle the invaders in a process called CHEMOTAXIS
A person's right to choose and ability to act on that choice
Autonomy
Prevention of MVA injuries
Avoid distractions in car, use DD, use seat belts, proper age-dependent restraints for children
Granulocytes mnemonic
B - E - N Basophils - kills fungus, Eosinophils - kills parasites, activated during allergic reactions, Neutrophils - phagocytic, neutropenia
____ are activated, resulting in the production of antibody
B Lymphocytes
B cell- mediated immunity
B cell immunity a.k.a.Humoral or Antibody Mediated Immunity defend against Extracellular pathogens
What are the lymphoid progenitor cells?
B lymphocytes, mature T lymphocytes, and natural killer cells
BRAT Diet (for severe dehydration)
B- Banana R- Rice A- Apple T- Toasted Bread
Outcome of Alcoholism: BAD
B- Brain Damage A- Alcoholic Hallucinosis D- Death
Nine-point Postpartum Assessment... BUBBLEHER
B- Breasts U- Uterus B- Bladder B- Bowel function L- Lochia E- Episiotomy H- Homan's sign E- Emotional Status R- Respiratory System
ADLs (Activity of Daily Living) BATTED
B-athing A-mbulation T-oileting T-ransfers E-ating D-ressing
Eating Disorder: BULIMIA
B-inge eating U-nder strict dieting L-acks control over-eating I-nduced vomiting M-inimum of to binge eating episodes I-ncrease/Persistent concern of body size/shape A-buse of diuretics & laxatives
Post-Partum Assessment (BUBBLE)
B-reasts U-terus B-owels B-ladder L-ochia E-pisiotomy/lateration/C-section incision
Memory Trick:Need to remember which kind of beta blocker has which action?
B1 Blocks the heart (you have only one heart) B2 Blocks the lungs (you have two lungs)
To remember which blood types are compatible, visualize the letter "O" as an orb representing the universe, because type O blood is the universal donor blood. Patients with any blood type can receive it. But O also means "odd man out": Patients with type O blood can receive only type O blood. Think BEEP to remember the signs of minor bleeding:
B: Bleeding gums E: Ecchymoses (bruises) E: Epistaxis (nosebleed) P: Petechiae (tiny purplish spots)
Diarrhea diet
BRAT (bananas, rice, apple sauce, toast)
Blood test that tells us about renal function
BUN & creatinine
Safety hazards for healthcare workers
Back injury, needle stick injury, radiation injury, workplace violence,
____ releases endotoxins or exotoxins, which damage the cells of the host and initiate an inflammatory response
Bacteria
Neutrophils will be elevated in the body when
Bacteria is present in the body
An excess in band cells released by the bone marrow into the blood. It signifies infection (sepsis) or inflammation
Bandemia
Bind with hydrogen ions in solution
Bases
Ph of 14 is considered highly ____, having a ___ number of Hydrogen Ions
Basic, Low
Prevention of take-home toxins
Be aware of workplace preventative measures, remove work clothing, shower if appropriate, use gloves
Should your face mask be put on before or after scrubbing?
Before
Conveying Ability
Being With
Share Feelings
Being With
Perioperative Concerns School Age
Being different from peers
Justice
Being fair to all and giving equal treatment, including distributing benefits, risks, and costs equally. "Equal treatment"
Do not burden
Being with
Death occurs with Ph below ___ & above ____
Below 6.8 & Above 7.8
pH levels that can cause death:
Below 6.9 or over 7.8
The duty to do or promote good
Beneficence
When is impaired wound healing most commonly seen?
Between 5th and 10th days after surgery
The body only produces enough ______ that it needs
Bicarbonate
What is HCO3
Bicarbonate A salt containing the anion HCO3-, which is the most important buffer in the blood, it is regulated by the kidney,
Anions include:
Bicarbonate 22-26 meq/L Chloride 96-108 meq/L Phosphate 2.5-4.5 mg/dL Hydrogen ion 0-14
Trust vs Mistrust
Birth to 1 year
Complications of thrombolytic therapy: The 3 B's
Bleeding Brady's (dysrhythmias) Bloodclots (d/t excessive thrombin)
Inflammation steps
1. Vasodilation - widens the area, opening up the blood vessel, increases blood flow to the area, send more soldiers to fight. Makes the area look red, warm, this stage does not last too long. 2. Swelling - Better permeability happens in the cells allowing the WBC's to go into the tissue to fight the infection, increased vascular permeability - swelling increased fluids to the area. 3. Form a blood clot around the area - which contains the infection in the area decreasing circulation - keeps the WBC's in place to fight.
Normal Urine specific gravity is
1.010 to 1.025
What is the normal range for magnesium?
1.5-2.5
Mg
1.6-2.6
5 stages of the star model
1.Discovery 2. Summary 3. Translation 4. Integration 5. Evaluation
How to treat carbon monoxide poisoning
100% humidified oxygen
Systolic BP pre-HTN
120-139
Na+
135-145
What is the normal range for sodium?
135-145
Sodium
135-145 meq/L
highest uninsured rate - age group
19-29
Recommended fluid intake
2,700 mL/day women, 3,500 mL/day men
Monocytes make up only
2-9% of the WBC's in the circulation and are formed in the bone marrow and move throughout the circulatory system and are carried to various tissues in the body where they become mature macrophages and carry out phagocytic activity.
1 L of water equals how many lbs?
2.2 lbs
Apply ice for ____ minutes every ____ hours
20 to 30 2-4 hours
Normal osmolarity
280-300 mmol/kg
** Determining type of Acid/Base Imbalance STEP 1- Look at the clients Ph If < 7.35, diagnosis is ____ If > 7.45, diagnosis is ____ STEP 2- Look at the PACO2 and HCO3 together Determine which is within normal range Respiratory= PACO2 is _____ Metabolic= HCOs is _____ STEP 3- Combine Step 1 & 2 to identify the diagnosis
<7.35, Acidosis >7.45, Alkalosis Respiratory= PACO2 is <35 or >45 Metabolic= HCO3 is <22 or >26
Diastolic Optimal BP Range
<80
Inactivated
= dead virus
Attenuated
= live virus
Diastolic BP HTN
> 90
Systolic BP HTN
>140
Crohns disease
A chronic inflammatory bowel disease that affects the lining of the digestive tract.
Infection
A condition that occurs when pathogens enter the body, multiply, and cause harm A white blood cell (WBC) count of 18,000
Goal of transcultural nursing
Culturally congruent care
Chemical components of the immune response
Cytokines- They act Chemokines- They work through chemotaxis - Complement System-
5 D's of Behavioral Problems of Alcoholism
D- Denial D- Dependency D- Demanding D- Destructive D- Domineering
Major Symptoms of a Manic Attack (DIG FAST)
D- Distractibility I - Indiscretion G - Grandiosity F- Flight of Ideas A- Activity Increase S- Sleep Deficit T - Talkative
Hypertension Nursing Care (DIURETIC)
D-aily Weight I- ntake and Output (I & O) U- rine Output R-esponse of BP E-lectrolytes T-ake Pulses I-schemic Episodes (TIA) C-omplications: 4C's
Common Causes of Transient Incontinence (DIAPPERS)
D-elirium I-nfection A-trophic Urethra P-harmaceuticals P-sychologic E-xcess Urine Output R-estricted Mobility S-tool Impaction
Examples of Hypertonic Solutions include:
D5 1/2 NS D5 1/4 NS D5NS 3% NaCl 5% NaCl 10% dextrose 50% dextrose
Diagnostic test done that measures bone density
DEXA
What is the most important intervention when evaluating the hydration of your patient?
Daily weights
Wound care includes:
Debridement Irrigation (Cleansing agent determined by EBP)
Surgery regarding spinal stenosis
Decompression laminectomy relieves the pressure within the spinal canal and reduces pain
too much hydrogen ions in the blood causes PH to
Decrease
Hypovolemia
Decreased circulatory blood volume resulting from extracellular fluid losses. [Na+ deficit]
Risks for older adults undergoing surgery
Decreased- cardiac output, peripheral circulation; vital capacity, blood oxygenation; blood flow to kidneys, glomerular filtration rate Increased- BP, risk for skin damage/ infection, sensory deficits, deformities r/t osteoporosis/arthritis
Thirst sensation ____ with age
Decreases
With the release of ADH the production of urine ____ and water reabsorption in the kidney tubules ____
Decreases Increases
Osteoarthritis "OA"
Degeneration of the articular cartilage & bones begin to rub together causing pain, swelling, stiffness & deformity -Risk Factors: >55, woman, obesity, genetics -Treat with exercise (ROM), leech therapy, cartilage implant, joint replacement, Celebrex (Cox2 inhibitor), steroid injection
____ equals poor skin turgor
Dehydration
____ occurs when the body's fluid intake is not sufficient to meet the body's needs
Dehydration
Use Isotonic fluids for:
Dehydration, hypovolemia (bleeding, etc)
Other signs for fluid volume DEFICIT:
Delayed capillary refill > 3 seconds Dry skin and mucous membranes Cracked lips Poor turgor +1 to +4 seconds Sunken eyes Flat neck veins
What should be removed from pt before surgery?
Dentures Prosthetic devices Hearing aids Contact lenses Fingernail polish Artificial nails Pierced jewelry
Other signs for fluid volume EXCESS:
Dependent Edema Distended neck veins Cool pale skin
How to treat poisoning
Depends on type of poison ingested; antidotes, charcoal, etc
Treatment for edema includes:
Diuretics, fluid restriction, dialysis, etc.
Diverticulitis
Diverticulm pouch in large intestine ruptures and infection sets in
Neuromusculoskeletal status for fluid volume DEFICIT:
Dizzy Faint Confused Weak Tired
Anticipate
Doing for
Comfort
Doing for
Analyzing Arterial Blood gas results: In ACIDOSIS, Ph is _____ In ALKALOSIS, Ph is _____ The respiratory function indicator is ____ The metabolic function indicator is ___
Down (Below 7.35) Up (Above 7.45) PCO2 HCO3
Prevention of vector-borne pathogens
Drain standing water, insect repellents, protect skin contact with insects, wipe out breeding areas
Examples of insensible fluid loss include:
Draining wound Burn Fistula?
Hyperkalemia
Drink, Urine retention, *cardiac arrest
Pinpoint pupils: Drugs, drops & nearly dead
Drugs: opiates Drops: meds for glaucoma Nearly dead: damage in the pons area of the brainstem
The common side effects of dehydration are:
Dry mucous membrane Decreased skin turgor Decreased BP Weak pulse Fatigue Dizziness Weakness Flat neck and hand veins Increased Hematocrit
What are the signs/symptoms of dehydration?
Dry skin, mucous membranes Nonelastic skin turgor Decreased urine output Hypotension Tachycardia Rise in temp
**If the Ph INCREASES the Kidneys ____ bicarbonate & _____ hydrogen ions
Dump bicarbonate & retain hydrogen Ions
If the innate immune response is unsuccessful in eliminating an invading pathogen, a more versatile and specific adaptive immune response is initiated.
During this response, resting, naïve T and B cells in the lymph node become stimulated by antigen to proliferate and differentiate into both effector and memory T cells and B cells. Effector cells function immediately to rid the body of the infecting pathogen. In contrast, memory cells do not take part in the ongoing fight against a primary (i.e. first) infection. Rather, they form the basis of immune memory as they remain circulating after the infection is cleared, ready to respond immediately should an attempt at a secondary, re-infection take place.
Neutrophils
EARLY inflammatory response of the body
Bicarbonate system is primarily in _____ and is used when assessing a clients ______
ECF, acid base status
ESR or sed rate
ESR is used as a marker of tissue inflammation and is highly sensitive, but nonspecific. Elevated ESR is caused by acute inflammation phase reactants binding to red blood cells. Measures how fast or how slow RBCs settle from plasma in the blood.
Symptoms of Hypoxia (RAT BED)
Early Hypoxia: R-estlessness A-nxiety T-achycardia/ Tachypnea Late Hypoxia: B-radycardia E-xtreme Restlessness D-yspnea
Secondary Prevention
Early diagnosis and prompt treatment
____ is an excess accumulation of fluid in the interstitial space aka third spacing
Edema
high Eosinophils means
Either a parasite or allergies
____ do not change with aging process
Electrolytes
_____ are elements or compounds that when broken down they turn into ions and are able to conduct electricity
Electrolytes
________ includes past medical history, family history, genetic history, current medications, immunizations received, allergies, lifestyle behaviors, occupation, and social environment
Elements of History
Diagnostics for gout
Elevated uric acid; leukocytosis, elevated ESR; X-ray/ MRI
Inform/Explain
Enabling
____ is found among a particular group of people and/or in a localized area
Endemic Infection
____ is spread over a large region affecting many people
Epidemic Infection
____ is the study of patterns, causes, and effects of health and disease
Epidemiology
Drug of choice to stop an allergic reaction
Epinephrine - Epi pen.
Plate that permits growth after birth, allowing the long bones of the body to extend and a person to grow as he or she reaches maturity.
Epiphyseal plate
The study or examination of morality through a variety of different approaches
Ethics
What are the risk factors for an exaggerated immune response?
Gender, race, ethnicity Genetics Environmental or medication exposure
____ is an excessive accumulation of fluid in the interstitial space throughout the body as a result of a condition such as cardiac, renal, or liver failure
Generalized Edema
Signs and symptoms of osteomalacia
Generalized skeletal pain and pain in the hips, ribs, and feet; waddling gait
Active Immunity continued.
Give the body a toxin - like a vaccine and the body develops an immunity to it. The body develops anti-bodies against it. Your body works for this immunity.
Metabolic disorder that leads to increased uric acid levels
Gout
Five physiological processes that occur in bone
Growth, modeling, remodeling, blood-bone exchange, repair/healing
How to prevent scalds and burns
Guard rails by fireplace, turning pot handles, care with candles, sunscreen, care when warming food in microwave
Other Lymphoid tissues include
Gut associated Lymphoid Tissue - the tonsils, adenoids, Peyer's patches in the small intestine, and the appendix. GALT - Gut Associated Lymphoid Tissue BALT - Bronchial Associated Lymphoid Tissue MALT- Mucosal Associated Lymphoid Tissue, these are extra protections from antigens.
Plasma protein system
H+ vary in proteins
Right-Sided Heart Failure (HEAD)
H- Hepatomegaly E- Edema (Bipedal) A- Ascites D- Distended Neck Vein
Severe Pre-Eclampsia (HELLP)
H- emolysis E- levated L- iver function tests L- ow P- latelet count
Inflammation (HIPER)
H-eat I-nduration P-ain E-dema R-edness
Mast cells release which chemical?
HISTAMINES, if you stabilize mast cells in allergies you can control allergies. Chromaline sodium a medication is a mast cell stabilizer.
Everyone knows to make the ABCD (airway breathing circulation and neurologic disability) assessment first. Then as soon as possible, further assessment/intervention is done, which includes:
His (health history) Head (head to toe assessment) Is (insert monitoring devices -- caths, ECG, arterial lines) So (splints for fractures) Wide (wound care) Olivia (other interventions)
Assessment before surgery
History Knowledge and understanding Age Allergies Drugs and substance abuse Current medications Medical history (family) Prior surgical procedures and anesthesia reactions Blood donation Discharge planning (support system)
Water is critical for ____
Homeostasis
The source of an infection can be ____ versus ____ or ____ versus ____
Hospital acquired vs. Community acquired Primary infection vs. Secondary infection
___ is present on the surface of a cell membrane and made up of proteins
Human Leukocyte Antigen
Interventions for metabolic acidosis
Hydration Drug therapy (insulin to treat DKA, antidiarrheals, bicarbonate)
Primary prevention of elimination complications
Hydration High fiber Regularly toileting Regular exercise Avoid environmental contamination
To compensate for acid base imbalances ____ shifts between _____ & _____
Hydrogen Extracellular & Intracellular
Acid contains a _____
Hydrogen Ion (H+)
"Water-pushing pressure"- force that pushes water outward from a confined space through a membrane. Amount of water in any body fluid space determines pressure
Hydrostatic pressure
Bases contains ____
Hydroxyl Compounds (OH-)
____ is an increase of blood flow to different tissues of the body
Hyperemia
Chronic illnesses like Hyperglycemia which depress the immune system.
Hyperglycemia is also a big one - associated with increased infections. primarily because of neuropathy and arterial insufficiency.
What are the signs/symptoms of overhydration?
Hypertension Bounding pulse Pale, cool skin Edema/ascites Crackles
____ have a higher osmolality and water is pulled out of the cell
Hypertonic Solutions
Corrects fluid, electrolyte, and acid-base imbalances by moving water out of body's cells intomosis and he the bloodstream. Ex: parenteral nutrition
Hypertonic infusate
How does the respiratory system maintain pH?
Hyperventilation or hypoventilation: used to regulate carbonic acid by eliminating or retaining CO2
Basophils are increased in
Hypo-thyroidism and Decreased in hyper-thyroidism. Basophils UP with hypothyroid, DOWN with hyper-thyroid
The 4 H's that invalidate a neuro exam:
Hypotension Hpoxia Hypoglycemia Hypothermia*
____ stimulates or depresses desire to drink
Hypothalmus
Complications of cardiopulmonary bypass (CPB): The 3 H's
Hypothermia (to decrease O2 consumption)...Effects SVR (vasoconstriction) and causes myocardial depression (decreases contractility) Hemodilution (to improve macrocirculation)...fluid shifting (third-spacing), e-lyte imbalances (K+, Mg+ & Ca++ often need replacing!) Heparinzation (to prevent clots in circuit)...monitor aPTT.
____ have a lower osmolality and water is pulled into the cell
Hypotonic Solutions
Moves water into the cells and expands them
Hypotonic infusate
Hyponatremia effects include:
Hypovolemia and decrease BP (fluid shifting into cells)
Drugs for Bradycardia & low BP (IDEA)
I - Isoproterenol D - Dopamine E - Epinephrine A - Atropine Sulfate
Post op fluid, electrolyte, and acid base balance assessment
I&OS Hydration status IV fluids Vomitus Urine Wound drainage NG tube drainage Acid base balance
Steps of Risk Management
Identify possible risks, analyze them, act to reduce, evaluate
Protects entrance to the body; found in high concentrations in the body fluids (tears, saliva, secretions of the resp and GI tracts)
IgA
Found within the cell membrane of B lymphocytes
IgD
Responsible for allergy symptoms and increased in the presence of parasitic worms; normally found in trace amounts
IgE
Primary immunoglobulin; may enter tissue spaces, selectively crosses the placenta, coats antigen for more effective and efficient presentation for an immune response: binds to macrophages and neutrophils for increased phagocytosis
IgG
Remains in the blood and efficiently kills bacteria; largest of the immunoglobulins; first antibody produced with an initial immune response
IgM
Antibody
Immune function of B cell - Proteins produced by plasma cells that recognize and bind to a specific antigen
_____ is the normal physiologic response to microorganims and protiens as well as conditions associated with an inadequate or excessive immune respone
Immunity
Primary prevention to protect immune system
Immunizations Avoid high-risk behaviors Adequate nutrition Exercise Infection control measures
Primary Preventions include:
Immunizations Avoiding high-risk behaviors Adequate nutrition Exercise Infection control measures
Age Related Changes to Immune System - Pulmonary System - respiratory, Integumentary System - skin
Impaired Cilia reaction because of repeat exposure to toxins environmental, reduced cough reflex. examples more respiratory infections or impaired clearance of secretions. -Skin- Thinning of skin, loss of elasticity, loss of adipose tissue. skin breakdown or infection.
____ negatively affects tissue metabolism
Impaired Circulation
Age Related Changes to Immune System - Circulatory System - Neurologic function
Impaired microcirculation for circulatory examples: stasis and pressure ulcers Decreased sensation and slowing of reflexes for Neurologic causes increased risk for injury like falls, burns, abrasions
Hyponatremia effects include:
Impaired nerve function: -Fatigue -Muscle cramps -Abdominal cramps with nausea and vomiting
Minor risk factors for osteoporosis
Impaired vision, estrogen deficiency at an early age < 45, dementia, poor health or frailty, recent falls, low calcium intake, low physical activity, alcohol in amounts > 2 drinks per day
____ impedes healing
Infection
____ is characterized by fever, chills, erythema, or drainage at the IV site
Infection
____ is the invasion and multiplication of microorganisms in body tissue, which may be unapparent or the result of local cellular injury caused by competitive metabolism, toxins, intracellular replication, or antigen-antibody response
Infection
____ potentially affects all individuals, regardless of the age, gender, race, and socioeconomic status
Infection
The two major problems that result from a suppressed immune response are: 1. 2.
Infection Cancer
Chain of infection
Infectious agent, reservoir, portal of exit, means of transmission, portal of entry and susceptible host.
____ is leakage of fluids into the surrounding tissue, resulting in edema, blanching, and coolness around the site
Infiltration
Intravenous Complications include:
Infiltration Phlebitis Infection Air Embolism
Local complications of IV therapy
Infiltration Phlebitis and post-infusion phlebitis Thrombosis Thrombophlebitis Ecchymosis and hematoma Site infection Venous spasm Nerve damage
____ can effect all individuals, regardless of age, gender, race, and socioeconomic status
Inflammation
____ is an immunologic defense against tissue injury, infection, or allergy
Inflammation
Inflammation is
Inflammation is an INNATE immune process that is crucial in combating infection. The hallmarks of an inflammatory response are redness, heat, swelling, and pain. BASOPHILS ARE elevated during inflammatory diseases like Crohn's disease/
The phases of wound healing include:
Inflammatory Proliferative Remodeling
____ is the restitution of normal, functioning cells after injury and/or fibrous repair when restitution of functioning cells is impossible
Inflammatory Response
Excess fat cells cause
Inflammatory response
What happens to muscle through aging?
Lean muscle mass decreases, atrophy from disuse can lead to muscle wasting, muscle contraction time decreases, fatigue is often increased and endurance decreased, ligaments and tendons lose elasticity and resiliency, loss of flexibility and ROM
IgE
Least common, present in allergic reactions and parasitic infections
Postoperative
Leaves OR to PACU-stays until they are stable. Post-Op lasts until complete recovery.
In the elderly fat cells contain ____ water than muscle cells
Less
Factors affecting mobility and activity
Lifespan, nutrition, lifestyle, stress, external environment, disease
Individual factors affecting safety
Lifestyle, cognition, balance, hair, mobility, ability to communicate, visual acuity, emotional health, safety awareness
Mast Cells
Live in the skin and connective tissues. when activated they release things... such as Histamines come from mast cells. Histamines causes allergies. sneezing, coughing, redness in local areas. By stabilizing those mast cells you can control allergies. Mast cell stabilizers are given to control allergies.
Inflammation can be
Local - paper cut OR Systemic - sepsis - all over inflammation - secretes TNF - tumor necrosis factor - once released it happens all over the body leading to DIC - Disseminated Intravascular Coagulation. Clotting all over the body. and bleeding because using all the clotting factors.
Consequences of an excessive or ineffective inflammatory response include:
Local tissue damage from compression Development of chronic inflammation Systemic pathology (atherosclerosis, chronic renal disease, and neurologic disorders)
Acute hypersensitive reactions can have either ____ or ____ effects
Localized (redness, swelling) or Systemic (fever, BP)
____ occurs as a result of traumatic injury from an accident, surgery, local inflammatory process, or burn
Localized Edema
Signs and symptoms of osteomyelitis
Localized pain, non bearing weight on extremity can have pseudo paralysis, signs of sepsis
The location of an infection can be ____, ____, or ____
Localized, Disseminated (spread throughout an organ or the body), or Systemic
Classification of infection
Location (local or systemic), Primary, Secondary, Exogeneous (someone else), Endogeneous (within body), - Acute, chronic, latent [duration]
Infections are categorized based on ____, ____, and ____
Location, Duration, and Source
Antidiarrheal meds
Lomotil and immodium
Which areas are most affected in patients with Paget's disease
Long bones, pelvis, lumbar vertebrae, and skull
Treatment for osteomyelitis
Long term pharmacological treatment 4-6 weeks of IV antibiotic therapy
4 Major Goals of Healthy People 2020
Longer lives, health equality, good health environments, and quality of life across all life stages
What are the developmental factors affecting safety for older adults?
Loss of muscle strength, joint mobility; slowing reflexes; sensory losses
Diluted urine has a ____ specific gravity
Lower
Immune organ that is responsible for storage and WBC formation
Lymph glands
Natural Killer [NK] cells
Lymphocyte that recognizes and destroys foreign cells - responsible for immune surveillance and detection, subsequent destruction of abnormal tissue cells by releasing cytotoxins.
The HYPERKALEMIA "Machine" - Causes of Increased Serum K+
M - Medications - ACE inhibitors, NSAIDS A - Acidosis - Metabolic and respiratory C - Cellular destruction - Burns, traumatic injury H - Hypoaldosteronism, hemolysis I - Intake - Excesssive N - Nephrons, renal failure E - Excretion - Impaired
MURDER Signs and Symptoms of Increased Serum K+
M - Muscle weakness U - Urine, oliguria, anuria R- Respiratory distress D - Decreased cardiac contractility E - ECG changes R - Reflexes, hyperreflexia, or areflexia (flaccid)
Immediate treatment of MI, think MONA:
M Morphine sulfate O Oxygen N Nitroglycerin A ASA
Management of Myocardial Infarction (MONATAS)
M- Morphine O- Oxygen N- Nitrates (Nitroglycerin) A- Aspirin (ASA) T- Thormbolytics A- Anti-Coagulants S- Stool Softeners
Immediate Treatment of a Myocardial Infarction Client (MONA)
M- Morphine O- Oxygen N- Nitroglycerine A- ASA
Pulmonary Edema (MAD DOG)
M-Morphine A-Aminophylline D- Digitalis D-Diuretics (Lasix) O- Oxygen G- ases (Blood Gases ABG's)
Learning the Systems of the Body? MR DICE RUNS
M= Muscle R= Respiratory D=Digestive I= Integumentary C= Circulatory E= Endocrine R= Reproductive U= Urinary N= Nervous S= Skeletal
Live virus vaccine
MMR, varicella, nasal spray version of flu vaccine, oral polio vaccine, rotavirus
IgG
MOST common Ig or most abundant >75% of immunoglobulins will be IgG
Best diagnostic tool for spinal stenoiss
MRI
Radiographic tests for inflammation include:
MRI, CAT scan, pet scan, colonoscopy
Safety hazards in the community
MVA, community-acquired pathogens, pollution, electrical storms
Magnesium containing Meds
Maalox, MOM
DEMENTIA
Make sure they don't have problems with: D-rug and alcohol E-yes and ears M-etabolic and endocrine disorders E-motional disorders N-eurologic disorders T-umors and trauma I-nfection A-rteriovascular disease
An acute, life threatening complication that may be genetic. It begins with skeletal muscle exposed to specific agent. It increases the metabolism and calcium levels in muscle cells
Malignant hyperthermia
Complications from general anesthesia
Malignant hyperthermia Overdose Unrecognized hypo ventilation Problems with specific anesthetic agents Intubation problems
Nursing interventions for urinary incontinence
Prevent skin breakdown Teach lifestyle modifications Implement bladder training Encourage kegels Anti-incontinent devices Promote independent urination Pharmaceutical interventions Pt teaching for enuresis
Managing fecal impaction
Prevention Determine presence Enema- oil softens; tap or fleet remove and cleanse Disimpaction Prevent reoccurrence by establishing bowel program
Type of immunodeficiency that occurs as a result of improperly developed cells or an absence of cells required to execute immune responses (genetic, rare)
Primary
Disorders in which part of the body's immune system is missing or does not function properly are known as
Primary Immunodeficiency
____ & ____ are ways to clinically manage your immune system
Primary Prevention & Screening
Water is the ____ in all body fluids
Primary compound
Which level of prevention includes immunization?
Primary prevention
Water is the ____ in the body
Primary solvent
To move your body without causing injury
Principles of body mechanics
What is a colonoscopy and how should the pt prepare for the procedure?
Procedure that allows visualization of the inner lining of the large intestine via a thin flexible tube. NPO 6 hrs prior. Bowel cleansing is necessary
Proliferation of WBCs
Proliferation is the other concept necessary to understand white blood cells. Although lymphocytes originate in the bone marrow from stem cells, they are also able to reproduce within lymph tissue. When activated, lymphocytes will proliferate (reproduce) first and then differentiate into their final functioning form. this allows the lymphocytes that are the first responders to reproduce quickly to fight things off.
Health Care Safety
Promoting Safety- PPE, Time out, Never Events, Fall Prevention, Standard Precautions, Hand Hygiene.
How should you use proper body mechanics?
Proper alignment, wide base of support, avoid bending and twisting, squat to lift, keep objects close when lifting, raise beds, push vs lift, get help
Prevention of pollution
Proper disposal and recycle of solid wastes, environmentally safe products, car pool/public transport, ear plugs
Prevention of food-borne pathogens
Proper storage, cleaning, and cooking of foods; clean cooking surfaces; attention to folk remedies
IgG - Most abundant of all of them
Protects Viral and bacterial and protects newborns. only one that Can cross placenta.
What are the 3 protective functions of an optimal immune system?
Protects the body from invasion of microorganisms and other antigens Removes dead or damaged tissues and cells Recognizes and removes cell mutations that have demonstrated abnormal cell growth and development
Someone with a wound should have food high in:
Protein and Vitamin C
Treatment
Psychosocial assessment- stages of grief (DABDA), biopsy, surgical resection, radiation and chemo
Informed Consent
Pt signs, Nurse signs as witness to Pt signature, MD obtains the informed consent by talking about risks/benefits/alternatives. Any problems or questions, the pt is referred back to MD without signing the consent.
PERRLA
Pupils Equally Round and Reactive to Light and Accomodation
Bleeding Precautions (RANDI)
R- Razor Electric/ Blades A- Aspirin N- No needles (esp. in small gauge) D- Do decrease in needle sticks) I - Injury (Protect from)
Evalution of Episiotomy Healing (REEDA)
R- Redness E- Edema E - Ecchymosis D - Discharge, Drainage A - Approximation
Nursing Care for Sprains and Strains (RICE)
R- Rest I - Ice C - Compression E- Elevation
Situations requiring Crisis Situation: RAPE
R- Ruthless A- Abusive P- Personal E- Experience
Gluten Free Diet (ROW)
R- Rye O- Oats W- Wheat
Acid-Base (ROME)
R-espiratory O-pposite M-etabolic E-qual
Primary testing used for immune system
RBC & WBC count with differential Fluorescent antinuclear antibody CRP ESR
CBC values
RBC 4.0-6.0 million cells/mcL, WBC 3,500 to 10,500 cells/mcL, Hgb 12.0-17.0 grams/L, Hct 35-50 percent, PLT 150,000 to 450,000/mcL
Common diagnostic test for immune function are:
RBC Count WBC Count with differential Fluorescent antinuclear antibody C-reactive protein (CRP) Erythrocyte sedimentation rate (ESR)
sprains and strains
RICE [Rest, Ice, Compress, Elevate]
Carbonic Acid: HCO3 system is
Ratio of 20 parts HCO3- to 1 part Carbonic acid Written as (20:1) or (1:20)
**If the Ph DECREASES the Kidneys ______ & ______ more Bicarbonate
Reabsorb & Regenerate
Critical in maintaining normal body fluid pH
Buffers
"CATS" of "HYPOCALCEMIA"
C - Convulsions A- Arrhythmias T - Tetany S - Spasms and stridor
Assistive devices -- Canes:
C Cane O Opposite A Affected L Leg
Canes and Walkers (COAL)
C- Cane O- Opposite A- Affected L- Leg
Tracheal Esophageal Fistula (3 C's)
C- Choking C- Coughing C - Cyanosis
4 C's of Hypertension (Complications)
C- Coronary Artery Disease C- Coronary Rheumatic Fever C- Congestive Heart Failure C- Cardio Vascular Accident
Left-Sided Heart Failure (CHOP)
C- Cough H- Hemoptysis O- Orthopnea P- Pulmonary Congestion (crackles/ rales)
CANCER'S Early Warning Signs CAUTION UP
C-hange in bowel or bladder A- lesion that does not heal U-nusual bleeding or discharge T-hickening or lump in breast or elsewhere I-ndigestion or difficulty swallowing O-bvious changes in wart or mole N-agging cough or persisten hoarseness U-nexplained weight loss P-ernicious Anemia
Warning Signs of a Child Abuse/ Neglect: CHILD ABUSE
C-hild's excessive knowledge on sex & abusive words H-air growth in various lengths I-nconsistent stories from the child & parent/s L-ow self-esteem D-epression A-pathy, no emotion B-ruised U-nusual injuries S-erious injuries E-vidence of old injuries not reported
Cleft Lip - Post Op Care (CLEFT LIP)
C-hoking L-ie on back E-valuate Airway F-eed Slowly T-eaching L-arger nipple opening I-ncidence incerase in males P-revent crust formation and aspiration
CANCER Interventions
C-omfort A-ltered Body Image N-utrition C-hemotherapy E-valuate response to meds R-espite for caretakers
Energy Decreased (CAPS)
C-oncentration decreased A-ppetite P-sychomotor function decreased S-uicidal Ideations
When asking assessment questions, remember the American Cancer Society's mnemonic device CAUTION:
C: Change in bowel or bladder habits A: A sore that doesn't heal U: Unusual bleeding or discharge T: Thickening or lump I: Indigestion or difficulty swallowing O: Obvious changes in a wart or mole N: Nagging cough or hoarseness.
Laboratory tests for infection include:
CBC with WBC diff, Culture and Sensitivity, CRP, ESR, Serologic
Laboratory tests for inflammation include:
CBC, WBC with diff, CRP, ESR, Serologic (tests to detect specific antibodies or viruses)
Bone cancer diagnostics
CT scan
Nursing interventions for osteoporosis
Ca and vit d, meds (biophosphonates calcitonin, selective estrogen receptor modulators, parathyroid hormone), exercise
How to prevent poisoning
Cabinet locks, store poison high, keep poison control telephone number available
Labs for osteoporosis
Calcium, magnesium, phosphate, vit d, parathyroid hormone (secondary)
Laboratory tests related to musculoskeletal disorders
Calcium, phosphorus, CK/CPK, CRP/ESR, H/H, uric acid, WBCs
Recognition of the invader in the body occurs from
Recognition is initiated when specific pattern recognition receptors, including the well-defined Toll-like receptors (TLRs) on the surface and within the cytoplasm of macrophages, neutrophils and dendritic cells, are triggered by microbe-specific motifs known as pathogen-associated molecular patterns (PAMPs). PAMPs are, in effect, repeating units of danger signals which are common components of specific groups of pathogens.
COPD is another chronic disease that impairs the immune system
Recurrent infections occur because of increased secretions and decreased cilia activity.
The spleen contains ____ & ____
Red pulp & White pulp
____ and ____ are the cause of increased blood flow to injured area in response to chemicals released by mast cell degranulation
Redness and Heat
Addison's Disease "Add some more cortisol"
Reduced secretion of hormones of the ADRENAL cortex, characterized by low blood pressure, dehydration, muscle weakness, and mental lethargy.
Nursing response to wound healing
Reducing risk of infection Wound care
Primary prevention for inflammation includes:
Reducing risk of injury or infection Good Hygiene Proper use of safety equipment Proper storage and prep of food
Immunizations and infections
Can decrease risk through vaccines, some have almost been eliminated like small pox or polio.
Primary prevention of musculoskeletal disorders
Regular physical activity, protect against injury, optimal nutrition, fall prevention measures
For remembering the coronary arteries and which side they are on: I have a RIGHT to CAMP if you LEFT off the AC
Right = Right C=oronary A=Artery M=Marginal Artery P=Posterior Interventricular Artery Left=Left A=Anterior Interventricular Artery C=Circumflex Artery
Nursing process related to safety: diagnosis
Risk for falls, risk for injury, knowledge deficit
Type of immunodeficiency where there is a loss of immune functioning as a result of an illness or treatment (i.e. cancer, HIV)
Secondary
Diseases that occur when the immune system is compromised are known as
Secondary Immunodeficiency
Labs for osteomyelitis
Sed rate and WBC will be elevated
Drugs for preop preparation
Sedatives- hydroxyzine (Vistaril) Hypnotics- lorazepam (Ativan) Anxiolytics- midazolam (Versed) Opioid analgesics- morphine Anticholinergic agents- atropine H2 histamine blockers- ranitidine (Zantac)
Prevention of injury during electrical storm
Seek lowest spot possible, seek shelter in large building away from water, do not use metal objects
Highest Level on Maslows
Self-Actualization
Unexpected occurrence involving death or serious injury
Sentinel or never event
Considerations for pediatrics undergoing surgery
Separation anxiety Developmental concerns Anesthesia risks
____ occurs when an infection enters the blood stream, can be life-threatening
Sepsis
Consequence of uncontrolled infection include:
Septic Shock Multisystem Failure Death
An example of suppressed immune function are:
Shingles & a Cold Sore
Phases of Adjustment after Major Change of Body Image
Shock, Withdrawal, Acknowledgment, Acceptance, Rehabilitation
Side effects of steroids. The 5 S's.
Sick- easier to get sick Sad-causes depression Sex-increases libido Salt-retains more and causes weight gain Sugar-raises blood sugar
Signs and symptoms for osteoporosis
Silent disease, decrease in height, kyphosis, fractures
Sjögren's syndrome
Sjogren syndrome is an autoimmune disorder in which the glands that produce tears and saliva are destroyed. This causes dry mouth and dry eyes. The condition may affect other parts of the body, including the kidneys and lungs. If female dry vaginal area. Need to protect these areas : eyes with eye drops, mouth - assess for open sores or pus, prevent the sores keep mouth moist. hard candy, good oral hygiene with water and alcohol free mouthwash. Vaginal area- use lubrication
Water is lost through ____, ____, ____, ____, and ____
Skin Lungs Perspiration Inspiration Urine
Involuntary release of urine or feces can lead to:
Skin breakdown, changes in daily activities, & changes in social relationships
Causes of falls in the home
Slippery floors, stairs, tubs, low seated toilets, high beds
How to prevent fires
Smoke alarms, caution with cigarettes, fire extinguisher, no candles unattended, safety with holiday lights, care with electrical cords
Medications can cause a suppressed immune system
So everyone can be at risk for immune suppression due to medications, nutritional status.
What are the major electrolytes?
Sodium Potassium Calcium Magnesium Chloride Phosphate Bicarbonate
3 major electrolytes are:
Sodium (NA+) Potassium (K+) Calcium (CA++)
Cations include:
Sodium 135-145 meq/L Potassium 3.5-5.1 meq/L Calcium 8-11 mg/L Magnesium 1.4-2.1 mg/dL
Kidneys excrete ____ and ____
Sodium and water
Four main buffers include:
Sodium- Bicarbonate system Phosphate system Hemoglobin system Protein System
Diagnostic test done that detects time from stimulation to response
Somatosensory evoked potentials
K+ sparing Diuretics
Sparing= Aldactone.
Lab test that helps evaluate your body's water balance and urine concentration
Specific gravity
Degeneration of the spine that causes narrowing of the spinal canal secondary to bony overgrowth
Spinal stenosis *most common area lumbar
Immune organ that filters blood and distributes T and B cells
Spleen
Secondary organs involved with immune response: 1. 2. 3.
Spleen Lymph Nodes Epithelial Lymphoid Tissue
The Uniform Determination Act
Standards: irreversible cessation of the circulatory and respiratory functions, or functions of entire brain including the brain stem
Intraoperative
Starts in the OR (at the door)
_____ 1. Tissue injury and the release of chemical mediators 2. Vasodilation and increased blood flow 3. Swelling and retraction of activated endothelial cells 4. Increased vascular permeability and leakage of small plasma proteins 5. "Walling off" 6. Movement of immune cells to the site of injury 7. Exudate of glucose and oxygen to the site needing repair 8. Release of chemical repair factors from activated endothelial cells
Steps in an acute inflammatory response
Surgical Considerations to prevent infection
Sterile technique (asepsis), positive air flow, skin prep, hand-washing, controlled temperature & humidity
Complementary Drugs for inflammation include:
Steroids (ex. prednisone) NSAID's (ex. Ibuprofen Aspirin, Celebrex) Antipyretic (ex. Tylenol, Aspirin, Ibuprofen) Analgesic (ex. Tylenol, Morphine, Ibuprofen) Antihistamines (ex. fexofenadine aka Allegra, diphenhydramine aka Benadryl)
Managing a bowel diversion
Stoma assessment and care Peristomal skin assessment Monitor amount and type of effluent Attentive to psychosocial needs Pt teaching for home care
____ weakens our immune system, putting us at greater risk for illness and delays the healing process
Stress
Stress incontinence
Stress incontinence occurs when your bladder leaks urine during physical activity or exertion. It may happen when you cough, lift something heavy, or exercise. It is the most common type of bladder control problem in younger and middle-age women
What are the functions of the bone
Support the structure of the body, provide form, enable movement, protections to vital organs, store minerals, blood production
What is a cystoscopy and how should the pt prepare for the procedure?
Surgical procedure that allows visualization via a self-contained visual lens system. NPO 4-8 hr prior
____ result of leaking plasma and leukocytes into injured area
Swelling
effects of anticholinergics:
Can't see Can't pee Can't spit Can't --defecate
Assistive Devices (ambulation) Basics
Canes/Stairs; Up with the strong, down with the weak/bad leg Crutches: Crutch then foot going down stairs, Foot then crutches going up stairs.
What are developmental factors affecting safety for infants/toddlers?
Cannot recognize danger, tactile exploration of environment, totally dependent
Mneumonic device for remembering questions to ask emergency room admits:
Car? (circumstances of event) Please (precipitating events) Listen (location of event) To This: (Time of event) Watch (when symptoms appeared) Underage (unconsciousness after injury?) Alcoholics (arrival time in ER) Heading (hospital admits previously?) Home (previous history/health status) And (allergies) Maybe (medications) Flattening (fears for safety) My (meal, time of last) Poodle (period, time of last menstrual) Dog (primary doctor, name and location of) Tonight (tetanus, date of last immunization)
How to prevention carbon monoxide poisoning
Carbon monoxide detector
S/S of hyponatremia
Symptoms of dehydration, BP LOW, pulse rate increased, weak palpable pulses.
Hyperphosphatemia
Symptoms: blurred vision or conjunctivitis, irregular heart rate (most likely K+ related) -Causes: DKA, renal failure
Hypophosphatemia
Symptoms: loss of appetite, anxiety, bone pain, fragile bones Causes: Alcoholism
Diagnostics for osteoarthritis
Synovial aspirations, X-ray, MRI
TDCI (These Drugs Can Interact)
T - Theophyline D - Dilantin C - Coumadin I - losone (Erythromycin)
____ are activated, resulting in phagocytosis
T Lymphocytes
T cell-mediated Immunity
T cell mediated Immunity a.k.a.Cell Mediated Immunity, provides protection against intracellular pathogens
Care of Client in Traction (TRACTION)
T- Temperature (Extremity, Infection) R - Ropes hang freely A - Alignment C - Circulation Check (5 P's) T- Type & Location of fracture I - Increase fluide intake O - Overhead trapeze N - No weights on bed or floor
Cyanotic Defects: 4 T's
T- Tetralogy of Fallot T- Truncus Arteriosus T- Transportation of the Great Vessels T- Tricuspid Atresia
Cells associated with immune response
T-Cells & B Cells
Hypoglycemia (TIRED) - an abnormal decrease of blood in the sugar
T-achycardia I-rritability R-estless E-xcessive Hunger D-iaphoresis/ Depression
Complications of Trauma Client (TRAUMATIC)
T-issue Perfusion Problems R-espiratory Problems A-nxiety U-nstable Clotting Factors M-alnutrition A-ltered Body Image T-hromboembolism I-nfection C-oping Problems
Blood Flow Through the Cardiac Valves (Tissue Paper My Assets)
T-ricuspid P-ulmonic M-itrial A-ortic
To remember the four causes of cell injury, think of how the injury tipped (or TIPD) the scale of homeostasis:
T: Toxin or other lethal (cytotoxic) substance I: Infection P: Physical insult or injury D: Deficit, or lack of water, oxygen, or nutrients.
Signs of septic shock
TADDLE -Tachycardia, Altered LOC, Decreased BP, Delayed cap refill, Light colored (pallor), Extremities are cold
DIfference between TJC and ANA
TJC- patient/workplace safety, ANA- education
S&S of malignant hyperthermia
Tachycardia Skin mottling Cyanosis Myoglobinuria Rise in end tidal carbon dioxide Elevated temp
Veracity
Telling the truth, not hiding anything (respect for autonomy)
IgD - required to mature B cells
Tells B cells where to go and what to do.
Post op neuro assessment
Cerebral functioning Motor and sensory assessment after epidural or spinal anesthesia
Post op renal/urinary system
Check for urine retention Consider other sources of output (sweat, vomitus, etc) Report urine output <30 ml/hr
Electrolyte
Chemically, electrolytes are substances that become ions in solution and acquire the capacity to conduct electricity. Electrolytes are present in the human body, and the balance of the electrolytes in our bodies is essential for normal function of our cells and our organs.
Imaging assessment and others preop
Chest X-ray ECG
When development of values begins
Childhood
Who is at high risk for suffocation/asphyxiation
Children 0-4 years old
Populations at greatest risk for bowel and urinary elimination are
Children, pregnant women and older adults
Populations at greatest risk for problems with bowel and urinary elimination are:
Children, pregnant women, older adults
Hemoglobin system
Chloride Shift
Systemic complications of IV therapy
Circulatory overload Speed shock Allergic reaction Catheter embolism
Interventions to reduce infection risk with IVs
Clean needleless system connections before use with antimicrobial for 30 seconds Do not tape connections between tubing sets Use evidence-based hand hygiene guidelines
An interpretation or conclusion about a pts needs, concerns, or health problems, and/or the decision to take action, use or modify standard approaches, or improvise new ones as deemed appropriate by the pts response
Clinical judgement
Functional incontinence
The inability to make it to the bathroom to urinate. Functional incontinence is related to physical, cognitive, or social impairment.
Urge incontinence
The inability to stop urine flow long enough to reach the bathroom. Urge incontinence is related to an overactive detrusor muscle with increased bladder pressure (diabetes, stroke, or Alzheimer's disease). It is also sometimes an early sign of bladder cancer.
Macrophage
The macrophage is the key initial player in an innate response, functioning both to eliminate the pathogen and to recruit other innate inflammatory cells.
the main function of lymphocytes is
The main functional characteristic of lymphocytes is the ability to mount specific immune responses against virtually any foreign antigen.
The only function of B cells in the immune system is to
The only immune function of the B cell is to release antibodies which are proteins produced by plasma cells that recognize and bind to a specific antigen) when activated. Unlike T cells, which venture out of the lymph nodes when activated, plasma cells stay in the lymph nodes, secreting antibodies to be delivered to the systemic circulation.
The six families of WBCs or leukocytes are:
There are six families of leukocytes that have distinct roles in the body's defense. These are the monocyte in blood-macrophages in tissue, which are phagocytic, dendritic cells star shaped cells migrate to skin, airway, and lymph nodes surround and kill phagocytic, mast cells live near skin and connective tissue release substances-like HISTAMINES, granulocytes, lymphocytes, and NK cells.
NKC's Natural Killer Cells
They detect and attack abnormal cells, cells that are infected with disease, or cancer cells.
Even though leukocytes originate in the bone marrow along with RBCs
They spend little time in the blood, they live in lymph tissue and organ tissue in the body. Leukocytes use blood mainly as a transport system to travel to areas of the body where they are needed.
Intradermal skin testing - more advance allergen testing
Think of a TB test. This can also be done for allergy testing if the scratch test does not work, put the allergen right under the skin to see if there is a reaction, redness, induration - raised reaction on the skin.
What is the #1 mechanism of how osmosis helps maintain homeostasis?
Thirst mechanism
GI for fluid volume DEFICIT:
Thirsty Dry tongue Nausea and Vomiting Weight loss
Non-Maleficence
This is the obligation to minimize or prevent harm. -"Do no harm"
Individual risk factors for inflammation include:
Those with: autoimmune disorders allergies compromised immunity chronic diseases
Immune organ that is responsible for the formation of T cells
Thymus
When assessing a wound you want to note:
Time Site Drainage color, smell, amount Wound size, depth, and length
What are common screening tools for mobility
Timed get up and go, performance oriented mobility assessment
Trousseau's sign medical sign observed in patients with low calcium.
To elicit the sign, a blood pressure cuff is placed around the arm and inflated to a pressure greater than the systolic blood pressure and held in place for 3 minutes. This will occlude the brachial artery. In the absence of blood flow, the patient's hypocalcemia and subsequent neuromuscular irritability will induce spasm of the muscles of the hand and forearm. The wrist and metacarpophalangeal joints flex, the DIP and PIP joints extend, and the fingers adduct.
Autonomy vs Shame
Toddler: 1-2 years
Common Types of Surgery for children
Tonsillectomy, appendectomy, adenoidectomy most common. Common Types of Surgery for Young Adults: Appendectomy, gallbladder, trauma, and orthopedic repairs. **Will not be tested on plastic surgery.**
Immune organ that is responsible for distinguishing invaders for destruction
Tonsils/adenoids
Electrolyte imbalance:
Too little or too much of any electrolyte is called _______ and will affect most body systems.
Specific gravity decreases
Too little solute, increased solvent, over hydration, renal failure or impending renal failure, low sodium levels, Diabetes Insipidus. Urine will be almost clear in color
TORCH stands for
Toxoplasmosis Others Rubella Cytomegalovirus Herpes Simplex
IgE mediated or atopic "allergic" immune response
Type I (seasonal allergic rhinitis, systemic anaphylactic reactions)
Tissue specific or cytotoxic immune response
Type II ( autoimmune thrombocytopenic purpura, Graves disease, autoimmune hemolytic anemia)
Immune complex-mediated immune response
Type III (Systemic lupus erythematosus)
Cell-mediated or delayed hypersensitivity immune response
Type IV (Contact sensitivity to poison ivy and metals )
Treatment of CHF, think UNLOAD FAST:
U sit Upright N Nitro L Lasix O Oxygen A Aminophylline D Digoxin F Fluids- decrease A Afterload - decrease S Sodium - decrease T Tests: dig level, ABG, K+
Treating CHF (UNLOAD FAST)
U-pright Position N-itrates (in low dose) L-asix O-xygen A-minophylline D-igoxin F-luids (decrease) A-fterload (decrease) S-odium restriction T-est (Dig level, ABGs, K level)
Who creates statutory law?
US Congress
When should the morse falls score sheet be used
Upon admission, ongoing as condition changes
Lab assessment preop
Urinalysis Blood type & cross match CBC or hemoglobin level and hct Clotting studies (PT, INR, aPTT) Electrolyte levels Serum creatinine level Pregnancy test
Overactive Bladder
Urinary retention associated with bladder over-distention and frequent loss of small amounts of urine.(BPH or spinal cord injury).
Specific gravity increase =
Urine will look dark yellow with higher SG. Signs; dehydration, decrease solvent & increased solute, SIADH
Chloride (Cl-) Abnormalities:
Usually occurs with sodium (Na+) abnormalities
Primary prevention against an infection includes ____ and ____
Vaccinations and Hygiene
fetal accelerations and decelerations!!! Just remember VEAL CHOP
Variable Cord compression Early Head compression Accelerations OK Late Placental insufficiency
Believe that food should be served as close to its natural state as possible
The Japanese
first adopted legislation regarding DNR
The New York Law
Events at Sites of Inflammation - vasodilation
Vasodilation -increases blood flow to the infected area - It is responsible for the heat and redness that occurs at sites of inflammation. Increases in local heat can inhibit some pathogens.
Common wounds are:
Venous ulcers Pressure ulcers Diabetic foot ulcers
The duty to tell the truth
Veracity
The populations at risk for severe or ineffective inflammatory response are:
Very old Very young Uninsured
The population at greatest risk for infection are:
Very old Very young Uninsured Residents of geographic areas where an infection is prevalent
____ is the severity of a disease or degree of the infection
Virulence
Treatment for osteomalacia
Vit d and ca
With edema you need to monitor:
Vital Signs Weight intake and output Oxygen saturation
For patients with fluid volume abnormalities you need to monitor:
Vital signs Neuro-musculo-skeletal Function Respiratory Function GI Function Renal Function
Post op CV assessment
Vitals Heart sounds Cardiac monitoring Peripheral vascular assessment (VTE)
Causes of dehydration include:
Vomiting Diarrhea Excessive sweating Insufficient fluid intake Inappropriate use of diuretics Gastric suctioning Hemorrhage Irrigation Medications
Canes and Walkers (WWAL) Wandering Wilma's Always Late
W- Walker W- With A- Affected L - Leg
Findings of a Bulimia client: WASHED
W-eight loss of 15% of original body weight A-menorrhea S-ocial withdrawal H-istory of high activity & achievement E-lectrolyte Imbalance D-epression/ Distorted Body Image
Leukocytes
WBC, originate from the bone marrow. spend most of their time in storage, in lymphoid tissues, or dispersed throughout the host tissues.
Signs of inflammation
Warmth, redness, pain, swelling
Preventing Infection after exposure:
Wash area, report to employee health or similar, get IGg
K+ wasting Diuretics
Wasting= Furosemide (lasix), thiazides
Prevention of suffocation/asphyxiation
Watch for small/removable parts, cut food into tiny pieces, pay attention to mobiles, strings, cords, and plastic bags, apply barrier to pool, know Heimlich maneuver
____ is a major component of the body
Water
GI for fluid volume EXCESS:
Weight gain Ascites: accumulation of fluid in the peritoneal cavity
____ is especially susceptible to decreased fluid volume
The brain
Bone Marrow makes
The cells that the body needs. Ex: allergy season it will make Eosinophils for allergies or WBC's for infection, or RBC if you are bleeding.
IgM- Think first responder
The first Ig that is made by newborns.
Radiographic tests for infection include:
X-Ray, MRI, cat scan, pet scan and indium scans
Diagnostics for osteoporosis
X-ray, DEXA
Prevention of mercury poisoning
Yearly facility training, following facility policy
Can general anesthesia be reversed?
Yes, by turning med off or using a reverse agent
Intimacy vs Isolation
Young Adult, 19 to 40. affiliation, love, ability to form intimate relationships
Foods containing Bi carbonate include
Zero foods
B lymphocytes
[Mature in bone marrow or thymus] complete their differentiation process and become plasma cells, releasing ANTIBODIES
T lymphocytes
[Mature in thymus] (aka T-cells) cells that mature in the thymus and exist in four varieties, one of which kills antigen-bearing cells
Makes the determination of legal competency
a judge
Orthopnea
a person must sit or stand to breathe well, abnormal condition
The increase of the number of immature neutrophils in the body's circulation is called
a shift to the left
Perfusion
ability of cardiovascular system to pump/return oxygenated/deoxygenated blood
Descisional Capacity
ability to make right choices for oneself as they relate to medical care
Hypovolemia
abnormally low circulating blood volume
Biot's Respirations
abnormally shallow for 2 or 3 breaths then irregular period of apnea
When elevating elevate ____ the heart
above
Apnea
absence of respirations for a period of time, eventually respiratory arrest
Deep, rapid breathing compensates for
acidosis because of blowing off & getting rid of excess hydrogen
The chemical components of the immune system
act as cytokines, chemokines, opsonins, and effectors.
Fidelity
act in ways that are loyal
Inspiration
active, stimulated by chemical receptors in aorta
Action
actively engaged in strategies to change behavior
Health Promotion
activities such as routine exercise and good nutrition
Active Strategies of Health Promotion
activities that depend on the patients motivation to adopt a health program
The duration of an infection can be ____ or ____
acute or chronic
Maturation
adapts, shows competence in new situations
Nebulization
adding moisture to inspired air by adding water droplets
Most collective cultures give higher priority to
age and gender
Fidelity
agreement to keep promises by following through by action
Taking to many antacids causes an altered ____ & _____
altered excrition & an altered buffer
Hypoventilation
alveolar ventilation cannot eliminate enough CO2, respiratory rate low
Most common form of dementia
alzheimers
Stroke Volume
amount of blood ejected by ventricles with each contraction
Cardiac Output
amount of blood ejected from left ventricle each minute
Respiratory Acidosis is Characterized by
an increase in Carbon Dioxide in the blood
Clinical Judgment is
an interpretation or conclusion about a pt's needs, concerns or health problems, and/or the decision to take action
Anergy test - like a PPD test injected into the skin
an intradermal test to look for T cell immunodeficiency.
CBC with differential measures
and differentiates WBCs and their amount via a percentage in the blood.
Some collaborative interventions for infection include:
antimicrobial therapy rest and comfort measures proper nutrition fluids disinfection of physical environment
What is an antigen?
any molecule that can bind with a specific antibody. A foreign substance, such as a microorganism, which triggers the immune response
_____ is @ risk for abnormal levels
anybody
Adaptive immune responses
are considered either humoral-mediated or cell-mediated.
B Cells
are created in Bone marrow. B for bone
Dendritic cells
are essential in inducing and maintaining tolerance to BY PRODUCTS OF antigens, keeping the immune system from reacting to the body's antigens
Monocytes (Macrophages aka EATERs)
are leukocytes found in relatively small quantities in the blood, because most of them are either in the tissues or stored in the bone marrow. Fully differentiated stage is called a macrophage
T Cells
are matured in the Thymus gland.they travel to the thymus for maturity. T for thymus.
Basophils
are the final and most inscrutable granulocyte - appear effective against FUNGUS - role in inflammation
Pulse Oximetry
arterial oxygen saturation
Events at Sites of Inflammation - Chemotaxis
as neutrophils, monocytes and, sometimes, other white blood cells follow a chemokine gradient and move (extravasate) from small vessels into the infected tissue. One of the key functions of inflammation is to bring effector molecules and cells to the site of infection.
Medications causing metabolic acidosis:
aspirin
examples of intentional torts
assault, battery, false imprisonment
Postop nursing activities include
assessing for physical adaption following anesthesia and surgical intervention, assisting in orienting client back to consciousness, providing continuity of information between nursing units about client progress and adaption following procedure
Futilis
associated w/ the goal of medical intervention, to improve the pts prognosis, comfort , well being and general state of health
Wheezing
asthma, acute bronchitis, or pneumonia, narrowed airway, high-velocity
Required Request Laws
at the time of admission, a qualified health care provider must ask each patient over 18 if they are an organ donor
P wave
atrial contraction
Ethical Decision making models: Patient preferences
autonomy
Nonmaleficence
avoiding harm or hurt
Intraop phase begins and ends
begins when client is transferred to operating table and ends with admission to postop/ PACU unit
Justice
being fair
Ethical Decision making models: Medical indications
beneficence and non-maleficence; pt will benefit from medical and nursing care and harm will be avoided.
Ethical Decision making models: Quality of life
beneficence and non-maleficent and autonomy
Postop phase begins and ends when
bgins with client admission to PACU and ends with a f/u evaluation in a clinical setting or at home.
Myocardial Ischemia
blood supply to myocardium insufficient, angina pectoris and MI, cellular death after 20 minutes
When people hyperventilate, CO2 decreases, have patient
breathe into a paper bag Random Notes from IDK: Establish airway Alot of Tums- Education
Asthma
can be initiated by allergies or triggered by them.
Renal failure increases what?
can cause an increase of electrolytes.
Hyperkalemia
cardiac arrest
Benner and Wrubel
caring creates possibility
Hemoglobin
carries the majority of O2 to tissues
Darling vs Charleston Community Memorial Hospital
cast w/ insufficient padding, nurses didn't tell supervisor that physician ignored patients complaints, nurses were also held liable
Anemia
cause of pale conjunctivae in eyes
Chronic illnesses or comorbidities can
change immune system status. Chronic renal disease cause lower levels of erythropoietin and fewer numbers of all blood cells including leukocytes, it also changes the function of the WBCs because of blood PH and build up of waste toxins.
hypomagnesemia
changes in personality (irritability) hypoactive reflexes nystagmus- eyeball twitching + Chvostek, Trousseau, and Babinski sign
Development
changes in skill and capacity to function
Surfactant
chemical produced in lungs, maintains surface tension, keeps alveoli from collapsing
Active immunity
chicken pox example, the body is exposed to it and then the body produces immunity
Statutory law is either
civil or criminal
Tort
civil wrong made against a person or property
Injury occured
client has suffered physical, emotional or financial injuries
Exotoxin
comes from lysed gram negative bacteria (dead bacteria), causes weak immune response; fever, diarrhea, vomitting
other terms for utilitarian system
consequentialism and teleology
Contemplation
considering a change within the next 6 months
knowledge transformation
conversion of research findings from primary research result through a series of stages and forms to have an impact on health outcomes by way of EBP
Bouvia vs Superior Court Case
courts upheld the right to refuse medical treatment
Active immunization
creates memory B cells, which will quickly produce antibodies if the body is later infected with the pathogen.
Felony
crime of serious nature, penalty or imprisonment for less than 1 year
Leninger
cultural caring behaviors
With hyponatremia call doctor for
decrease in LOC (level of conscious)
Hypotonic IV fluid:
decrease intravascular volume and will incresase intracellar volume
Cheyne-Stroke's respirations
decreased blood flow or injury to brainstem, apnea and hyperventilation
Cyanosis
decreased cardiac output, hypoxia, inspect fingertips and nail beds
Left Sided Heart Failure
decreased functioning of the left ventricle
Pursed-Lip Breathing
deep inspiration then prolonged expiration through pursed lips
Advance Directives
deff: person making specific decisions about future health care treatments in advance of illness. (living will, durable power of attorney, surrogate decision maker, verbal advance directives)
Metabolic Acidosis is caused by
deficit in Bicarbonate Ions (HCO3+) or an excess in Hydrogen Ions (H+)
Nursing Practice Acts
describe and define the legal boundaries of nursing practive within each state
Factors effecting bowel elimination
developmental age, nutrition/hydration, meds, procedures, prego, patho conditions,
IgM
develops about 72-96 hours after infection, lasts about 28 days. IgM develops FIRST.
Dysrhythmias
deviation from the normal sinus heart rhythm
Nasal Cannula
device used for precise oxygen delivery
Bronchoscopy
diagnostic test, for bloody sputum
You need a ____ to apply ice
doctors order
Perform skillfully
doing for
preserve dignity
doing for
protect
doing for
high or low potassium causes ______
dysrhythmia
Treatment for Auto Immune Diseases
eat a balanced and healthy diet exercise regularly get plenty of rest take vitamin supplements take hormone replacement, if necessary get blood transfusions, if blood is affected take anti-inflammatory medication, if joints are affected take pain medication take immunosuppressive medication get physical therapy decrease stress limit sun exposure
Electrocardiogram (ECG, EKG)
electrical activity of myocardium, graphic record
The Spires vs Hospital Corporation of America
emphasizes the potential seriousness of short staffing
Support/ allow
enabling
focus
enabling
generate alternatives
enabling
valdate and give feedback
enabling
Phagocytic or a phagocyte
engulfs and absorbs waste material, harmful microorganisms and other foreign bodies in the bloodstream and tissues.
Most important aspect for a SN to learn in relation to knowing the client
establishing a relationship
closely related to feminist ethics
ethics of care
Bragdon vs Abbott
even asymptomatic HIV constitues a disability, aka someone who is HIV positive without AIDS
Passive Immunity
example is Anti-venom - does not last it goes away
Metabolic Alkalosis is caused by an
excess of Bicarbonate or a loss of acids
Diffusion
exchange of gases in alveoli and capillaries of tissues
Endotoxin
excreted by living bacteria from cell wall, causes strong immune response. -Bad, highly toxic, fatal
Retracting Breathing- uses _____ to breathe
extra muscles, seen with diabetic acidosis
Enabling
facilitating the other's passage through life transitions (birth, death)
Justice
fairness
Hyponatremia
fatigue, muscle spasm, h/a, irritability
Cultural Pain
feeling a patient has after a health care worker disregards a patients way of life
Primary Prevention
first contact in a given episode of illness that leads to a decision regarding a course of action to prevent worsening
The Oregon Death with Dignity Act of 1994
first statue to permit physician assisted suicide, terminal disease
Secondary Prevention
focus is on early diagnosis and rapid start of treatment
Teleology and Utilitarion : EthicalTheory
focus on what will happen or consequences of an action
Tetiary prevention
focuses on stopping disease progression & returning the individual to pre-illness state, or learn to live with disease
Mental Health Parity Act
forbids health plans from placing lifetime or annual limits on mental health coverage
IgA - THINK secretions
found in saliva, tears, colostrum, bronchial secretions, prostate and vagina.
Liberty
free and independent from enforcement
Basophils
fungus
Ventilation
gases are moved into and out of the lungs
Dementia
generalized impairment of intellectual functioning
Euthanasia
good and easy death
Dementia is
gradual, progressive, and irreversible
Hypercapnia
greater than normal amounts of CO2 in the blood
The Community Health Accreditation Program
has guidelines for staffing ratios
Hypokalemia:
heart rhythm disturbances, which mimic MI (no enzyme changes)
Hypomagnesium
heaviness of the limbs, extreme fatigue, decreased DTRs (deep tendon reflex) potentially can lead to respiratory arrest
The intestines have natural flora which
help to invade and kill off some types of bacteria.
Spleen
helps filter the blood. Without a spleen a patient is at a higher risk of infection. Teach hand hygiene, and stay away from sick people.
Wellness
higher level of functioning, achieving optimum balance between internal and external environments
Northwest cultures are more ______ than western
holistic
Futile
hopeless or severs no useful purpose
Examples of tertiary prevention
hospice and rehabilitation
Central Cyanosis
hyoxemia, inspect skin
Preop nursing activities include
identification, assessment, identifying actual or potential health problems and beginning of postop education
Uniform Anatomical Gift Act
if you're at least 18, you have the right to make an organ donation
Angina Pectoris
imbalance between myocardial O2 supply and demand, chest pain
Acquired immunity
immunity that is not present at birth and develops either as a result of exposure or through an external source, such as colostrum or injection of immunoglobulin.
Individual risk factors for infection include:
immunodeficiency chronic disease crowded or unsanitary living conditions contaminated water/air improper food storage or prep breaks in their skin lack of proper nutrition smokers medications (steroids) multiple sex partners stress
Right Sided Heart Failure
impaired functioning of right ventricle, pulmonary disease or long-term left sided failure
Cultural Awareness
in depth self-examination of ones own background, recognizing biases and prejudices
Hypoxia
inadequate oxygen for tissue at the cellular level
Occurrence Report
incident reports, risk management
Isotonic fluids
include NS 0.9% NaCl and LR
Kussmaul's Respirations
increase in both rate and depth of respirations
What does steroids do to electrolyte balance?
increase sodium levels (sodium retention) and excrete potassium (K+)
Terminal Disease
incurable, irreversible disease, will produce death within 6 months
example of common law
informed consent
Nurse role in ethics: Consumer awarness
informed consent signed
Potassium lives_____ the blood
inside
Battery
intentional touching without consent, actually giving an injection to a patient that did not consent
Risk Factor
internal/external variable that makes someone more vulnerable to illness or unhealthy event
Sodium Normal(more neurologic)
is 135 to 145
Another name for WBC's
is Leukocytes.
Trousseau's signs
is a carpal spasm induced by inflating a blood pressure cuff above the systolic pressure for a few minutes. hypocalcemia, hypoparathyroidism
Ulcerative Colitis
is a chronic disease of the large intestine, also known as the colon, in which the lining of the colon becomes inflamed and develops tiny open sores, or ulcers, that produce pus and mucous.
Glomerulonephritis
is a group of diseases that injure the part of the kidney that filters blood. S/S puffiness of your face, brown urine, urinating less than usual. strep throat can cause
pyelonephritis (kidney infection)
is a potentially serious kidney infection caused by bactira that can spread to the blood and cause renal failure
The inflammatory process
is a protective mechanism for the body. It is the body's immediate reaction to repair any damage in the body.
Humoral-mediated immunity
is the adaptive immunity pathway -B-cells (antibodies) -The production of antibody molecules in response to an antigen.
Veracity
is the principle of truth telling
hypophosphatemia
joint stiffness impaired tissue perfusion tremors, paresthesia confusion
Intimacy vs Isolation Task
learn to make personal commitment to another as spouse or parent
Crackles
left sided heart failure (related to)
A Health Care Proxy or Durable Power of Attorney
legal document, designates someone to make health care decisions when the patient is no longer able to do so themselves
Standards of Care
legal requirements for nursing practice that describe minimum acceptable nursing care
With poor nutrition comes ____ when talking about skin integrity
less regeneration
Misdemeanor
less serious crime, penalty or fine for less than 1 year
Bradypnea
less than 12 breaths per minute but regular
Advance Directives include
living wills, health care proxies, and durable powers of attorney
Antigen Tests - Ag
look for specific antigens
Deontology does NOT
look to consequences of actions to determine right or wrong
hypermagnesemia
loose bowels confusion, lethargy hypotension hyperactive reflexes
Rhonchi
loud, low-pitched rumbling, indicates suctioning
Hypoxemia
low O2 level in the blood, arterial blood O2 level less than 60 mm Hg
Hyperventilation
lungs remove CO2 faster than it is produced by cellular metabolism, rate and depth of respiration increases
Isotonic IV fluids:
maintain vascular volume, or if run fast will increase vascular volume
"go the distance"
maintaining belief
maintain a hope-filled attitude
maintaining belief
offer realistic optimism
maintaining belief
First step in resolving an ethical dilemma
making a clear statement
Preparation
making small changes in preparation for a change in the next month
Physical Growth
measurable, quanitative
Hypercalcemia
moans, stones, & groans, Kidney stones, depression, abd pain
Six families of leukocytes that have distinct roles inthe body's defense
monocyte-macrophages, dendritic cells, mast cells, granulocytes, lymphocytes, and NK cells.
Deontology Theory: Ethical Theory
moral duty and obligation concerned with the action rather than the outcome of the action. (is an approach to Ethics that focuses on the rightness or wrongness of actions themselves, as opposed to the rightness or wrongness of the consequences of those actions)
hypocalcemia
muscle cramps
Hypermagnesemia
muscle weakness, jerky movements, coordination issues loss
Myocardial Infarction (MI)
necrosis of cardiac muscle, obstruction in coronary artery
Elective
needed but condition is not immediately life threatening: surgery will improve clients life
Malpractice
negligence by a professional; professional failure to carry our or perform duties that result in injury to another
Sodium
nerve pulse transmission Priority nurse assessment: neurological
Hyponatremia monitor
neuro muscular system
Innate Immunity is ____
nonspecific
Potassium (K+) (looking at cardiac things)
normal is 3.5 to 5.5
Pre-contemplation
not intending to make changes within the next 6 months
Acquired immunity
not present at birth and develops as a result of exposure to something or through an external source such as colostrum or vaccine. The body gets exposure to immunoglobulin which helps it fight off something.
hypocalcemia
numbness and tingling muscle cramps hyperactive reflexes Trousseau's sign (hand) Chvostek's sign (cheek)
Breech of duty
nurse fails to complete this duty; this can include acts on commission (activities nurse did) and omission (activities nurse failed to do)
Due Process
nurse must be notified of charges against them, right to hearing, state board must follow before revoking/suspending license
Ethics of care: Ethical Theory
nurses care for those in need. ( a theory about what makes actions morally right or wrong.)
Swanson
nurturing, caring is not unique to nursing
Events at Sites of Inflammation - Increased permeability
of capillaries promotes the movement of fluid and plasma proteins into the interstitium (space between tissue cells), and results in local swelling or edema. Pain is the result of both swelling, which stimulates free nerve endings, and certain plasma proteins. These initial inflammatory events occur within seconds to minutes of infection.
Passive Euthanaisa
omission of an action, allowing death to occur ex. DNR pt
Radwin
oncology patients
Assisted suicide
one person assisting another to end their life
Slander
one speaks falsely about another
Growth and Development
orderly, predictable processes that begin at conception and continue until death
Plasma protein regulates the body's ____
osmotic pressure
emphasis of consequentialism
outcome (consequence) of action
Sodium lives _____ the cells
outside
Eosinophils
parasites & allergic reaction
Expiration
passive, depends on elastic recoil of lungs, little to no muscle work
Passive Strategies of Health Promotion
patient is recipient of actions by health care professionals
Neutropenia
patients have Low Neutrophils and are at very high risk for sepsis or a systemic infection
Hematocrit
percentage of red blood cells in the blood
Emergant
performed immediately to save a clients life, limb or organ
Chronic Illness
persists over a long time
Illness
physical, emotional, intellectual, social, developmental, or spiritual functioning is impaired
Assualt
places a person in apprehension of a harmful contact without consent
Autopsy
postmortem exam
Examples of physiological risk factors
pregnancy or being overweight
Introp nursing activities include
preparing client of introduction to anesthesia, maintaining homeostasis and asepsis throughout procedure, assisting surgeon and team as needed.
Must be ruled out whenever dementia is suspected
presence of delirium
Hypernatremia
primarily a neurological symptoms, fluid follows sodium: hypernatremia= edema, intravascular fluid excess, hypervolemia, INCREASED BP, bounding pulse
Morals
private, personal standards of right and wrong
Informed consent
process by which a pt receives info about a specific procedure or therapy(Elements: completeness, clarity, comprehension, voluntariness, and competence
Humidification
process of adding water to gas, oxygen therapy, greater than 4 L/min
EBP in nursing
process of moving research into practice
EBP (evidence based practice)
process through which scientific evidence is identified, appraised and applied in health care inteventions
The National Organ Transplant Act of 1984
prohibits the purchase of sale of organs
Chloride Low
prolonged vomiting, diarrhea, weakness, respiratory distress
Healthy People 2020
promotes a society in which all people live long, healthy lives
Civil Laws
protect the rights of individuals within our society, provide for fair and equal treatment when civil wrongs occur
Autonomy
protects patients independence, including patient in all aspects of care
Passive immunization
provides an infusion of antibodies that gives the body a reprieve to allow the body's own immune system a chance to activate.
Good Samaritan Laws
providing emergency assistance at an accident scene
Clients right include
pt bill of rights, informed consent form, privileged communication, advance directives, organ/tissue donation
Neutrophils are mature cells
ready for action when they leave the bone marrow unless there is sustained inflammatory response. In a sustained inflammatory response, the neutrophils are rapidly depleted and dispersed into the blood stream by the bone marrow.
Treatment for Inflammation
reduce blood flow, reduce swelling, and block the actions of the chemical mediators with anti-inflammatory drugs, steroids.
Humoral-mediated immunity
refers to immunity that is mediated by B lymphocytes, plasma cells, and antibodies.
Cell-mediated immunity
refers to immunity that is mediated by T lymphocytes.
Regulatory Law or Administrative Law
reflects decisions made by administrative bodies such as State Boards of Nursing
Tertiary Prevention
rehabilitation
Most older adults
remain functionally independent
example of regulatory law
requirement to report incompetent or unethical nursing conduct to the State Board of Nursing
The Patient Self-Determination Act
requires health care institutions to provide written info to patients about their rights to make decisions
hypochloremia
respiratory distress *occurs with Na abnormalities
Common Law
results form judicial decisions made in courts when individual legal cases are decided
Hyperphosphatemia
results from renal failure, DKA, regular heart rate, muscle weakness, N/V >4.5 mg/dL
**Lungs
retain Co2 or Blow off carbonic acid via rate and depth of respiratory rate (QUICK)
Rights based: Ethical Theory
rights are provided to everyone
Wellness Strategy
risk-factor modification, health promotion, or any program that attempts to change unhealthy lifestyle behaviors
inpatient
same day admission
Outpatient
same day surgury
Generativity vs Stagnation Task
satisfaction through productive career family, and interests
Secondary prevention includes
screenings plus treatments
IgA
second most common (external secretions / tears, saliva) provides passive immunity for breastfed infants / found in all mucous membrane secretions.
Autonomy
self rule, free from controlling interference and limitation from others
Causes of hyponatremia
severe vomiting, diarrhea, sweating diuretic medications combined with a low salt diet hormone imbalances renal failure excessive water intake
Dyspnea
shortness of breath
Differentiation
simple to complex development of activities and functions
First line of defense
skin, ph level of the skin makes it not a nice place for things to live, perspiration contains salt which kills some pathogens. Sebaceous glands secrete sebum that helps to trap invaders and actually inhibits some types of bacteria. Cilia in the lungs sweeps up stuff from the respiratory system to dispose of it. Mucous or phlegm is also a first line of defense. Eyes protected by eyelashes. Saliva as well.
Vesicular Sounds
soft, breezy, and low-pitched
Active Euthanaisa
someone other than pt performs action to end pt life. ex lethal injection
Acquired immunity is also called ____
specific
Immunizations are NOT health promtion they are
specific protection
Delirium
state of acute confusion
hypothalamus
stimulate or depress the desire for a person to drink A neural structure lying below the thalamus; directs eating, drinking, body temperature; helps govern the endocrine system via the pituitary gland, and is linked to emotion
Monocytes
sustain the inflammation
Maintenance
sustained change over time, begins 6 months after action and continues indefinitely
Acute Illness
symptoms of short duration, severe, affect functioning of patient in all dimensions
Beneficence
taking positive actions to help others
Mast cells
tend to live near the skin and connective of small blood vessels and contain granules with stored chemicals. When activated, they release substances within the granules (degranulate) that affect vascular permeability, particularly HISTAMINE.
Ethocentrism
tendency to hold one's own way of life as superior to that of others
glomerular filtration rate
test used to check how well the kidneys are working
Benefience
the action that is done for the benefit of others
When neutrophils are rapidly depleted from bone marrow
the body will put out immature cells called bands.
An infection can trigger
the body's immune response.
When the body needs to destroy foreign bodies
the bone marrow rapidly pours out stored neutrophils and the level of them in the blood rises very rapidly
QRS
the electrical impulse traveled through the ventricles, 0.06-0.1 second
Makes the determination of decisional capacity
the family
difference between utilitarianism and deontonlogy
the focus on outcomes
one-caring
the individual who provides care
feminist ethics
the nature of relationships
Normal Sinus Rhythm
the normal sequence on the ECG
What is compared to what in a malpractice lawsuit?
the nurse's actual conduct is compared to nursing standards of care
Although not all the details are known, it appears that the specific combination of pattern recognition receptors triggered on innate immune cells by an invading microbe will determine:
the particular type of innate immune response that occurs and, with time, the specific type of adaptive immune response that will mounted against the pathogen.
Ethics of care places the nurse as
the patient's advocate
Afterload
the work the heart must overcome to eject blood from the left ventricle
Physiological Changes with Aging
there is generally a decline with advanced age
The truth about older adults
they stay active and involved in their community
hyperphosphatemia
tingling in extremities paresthesias muscle weakness N & V
Chvostek's sign
tingling of the lips twitching of the extemities/face
Assimilation
to become absorbed into another culture and adopt its characteristics
Watson's Caring Theory
transcultural
Watson
transpersonal caring, spiritual, inner healing
Chvostek's signs
twitching of the lip at the corner of the mouth or spasm of all facial muscles depending on the severity of hypocalcemia
nurses who function from an ethic of care are sensitive to
unequal relationships, abuse of power
Negligence
unintentional failure to act as responsible person in a similar circumstances would act that results in injury to another
False Imprisonment
unjustified restraint
Pallor
unnatural paleness or absence of color in the skin
Non-maleficent
use ability, judgement, and skill to help others and to cause no harm
How does leukocytes get around?
use blood mainly as a transport system to travel to areas of the body where they are needed
utilitarian system of ethics
value of something is determined by its usefulness
Peripheral Cyanosis
vasoconstriction, diminish blood flow, inspect skin
Preload
volume of blood in ventricles at end of diastole, then ventricular contraction
Illness Behavior
ways in which people monitor their bodies, define/interpret their symptoms, take action, and use the health system
Hypernatremia
weight gain thirst (Fluid retention, bounding pulse) increased urine output
Hyponatremia
weight loss muscle cramps and weakness headache lethargy
Emergency Medical Treatment and Active Labor Act
when a patient comes to the ER or hospital, an appropriate medical screening must occur within that hospital and patient must be stable before discharge
Preop begins & ends when
when pt is scheduled for surgery an ends at time of transfer to surgical suit
Diastole
when the ventricles fill with blood
Neutrophils and monocytes carry out phagocytosis
which is destroy foreign bodies in the body. they surround and digest foreign invaders in the body. Think of an amoeba
Roe vs Wade
woman has a right to an abortion
Libel
written defamation of character
To rule in or rule out allergies
you get allergy testing. Skin test for allergy testing. Scratch test scratch the area with a little bit of the allergen - if there is a reaction then there is probably an allergy. Stop any antihistamines or steroids if the patient is going through allergy testing - their body will not react because of the medications. Stop at least a week before the procedure. Make sure emergency equipment is Available!! If they have a BAD reaction you need to have it available to treat them.
Breast self examination (i made a song out of this)
♫ ♪ ♪ ♫1 little 2, little 3 little fingers Do BSE 7 days after menses Press nipple once check for discharge Call your doctor I'm sure you will do it more...♫ ♪ ♪ ♫
Prostate Problems are no... FUN
F- Frequency U- Urgency N- Nocturia
Systolic Optimal BP Range
90-119
Cl-
95-105
Symptoms of Hypoxia (in Pediatrics) - FINES
F-eeding difficulty I-nspiratory Stridor N-ares Flares E-xpiratory Grunting S-ternal Retractions
patients with hyponatremia @ risk for
Fall precautions Seizure precautions
Prevention of falls in the health care facility
Fall risk assessment, environmental safety, clean, dry floors, client education
Movement of fluid through cell or blood vessel membrane because of differences in water volume pressing against confining walls
Filtration
Prevention of firearm injuries
Firearm safety education for parents and children, proper locked storage, keep ammunition separate
Passive Immunity continued
Anti venom - The body will neutralize the venom but no long term effects. you will need the anti venom again. The immunity passes through the body.
____ controls the amount of fluid leaving the body in the urine
Anti-diuretic Hormone or ADH
Safety hazards in the healthcare facility
Falls, equipment-related accidents, fires/electrical hazards, restraints, side rails, mercury poisoning, biological hazards
What are the developmental factors affecting safety for adolescents?
False confidence feel indestructible, risk-taking behaviors, most lack adult judgement
External Variables influencing Health Beliefs
Family Practices Socioeconomic Factors, Cultural Background
Assessment for Paget's disease
Family history, pain, bowing of the legs, enlarged skull, warm skin over affected areas
General guidelines for immobilized patient
Frequent turning, positioning, alignment; skin assessment and skin care; ROM; deep breathing; weight bearing if possible; measures to optimize elimination; nutrition
Solutions: Isotonic, Hypotonic, Hypertonic
Isotonic - "Same as I" - the solution used will be the same as normal body fluid composition. Fluids remain inside intravascular space. Hypotonic - "Hypo, hippo" - the solution pulls fluid from the intravascular space into the ICF - the cell "swells like a hippo".
____ are solutions where both sides of the permeable wall are equal
Isotonic Solutions
Water does not move into or out of body's cells; risk for fluid overload especially in older adults. Water does not move
Isotonic infusate
Traditional to eat eel on Christmas Eve
Italy
Assess Changes in Senile Dementia (JAMCO)
J- Judgment A- Affect M- Memory C- Cognition O- Orientation
first proposed teleology
John Stuart Mill
Signs and symptoms of osteoarthritis
Joint pain, inflammations, decreased ROM, crepitus, joint atrophy
Common Types of Surgery Elderly
Joint replacement, heart surgery (CABG), spinal surgery.
The obligation to be fair
Justice
Hyperkalemia Management (KIND)
K- Kayexalate (orally/ enema) I- Insulin N- Na HCO3 D- Diuretics (Furosemide & Thiazides)
____ and ____ problems may cause fluid retention
Kidney and Heart
How does the renal system maintain pH?
Kidney movement of bicarbonate. Takes longer but is long term
____ regulates water loss
Kidneys
**Major mechanisms to control Acid-Base balance include* The ____ excrete ammonia (NH3) in the form of Ammonium (NH4) in an effort to _____ Ph Buffers including ____ & ____ Excretion of ___ ______ are making constant chemical changes
Kidneys; Balance Hydrogen Ions -Bicarbonate-Base -Carbonic Acid- Carbon dioxide + Acid Co2 (Constantly produced by the cells) Hydrogen Ions
Avoid Assumptions
Knowing
Engage the self or both
Knowing
Seek cues
Knowing
Swanson's Five Processes of Caring
Knowing, Being With, Doing for, Enabling, Maintaining Belief
hyperchloremia
Kussmaul breathing intense thirst *occurs with Na abnormalities
Hyperchloremia
Kussmaul's breathing, intense thirst (r/t hypernatremia) Chloride levels >108 mEq/L. -Result of underlying condition, not just bc of increased chloride. -Diag: blood chem, ABGs. -Treatment: Diuretics to help eliminate Na+ will help eliminate chloride, bicarbonate (basic) neutralizes the acidosis if present.
Emergency Drugs to LEAN on
L- Lidocaine E - Epinephrine A- Atropine Sulfate N - Narcan
Diagnostic test done to detect defects around the spinal column
Myelogram
NSAID Drugs
N - Naproxen S - Salicylates A - Advil I - Ibuprofen D - Diclofenac S - Sulinclac
OB Non-Stress Test (NNN) 3 negatives in a row to interpret results of Non-Stress Test
N - Non-reactive N - Non- Stress is N - Not good
Health
NOT just absence of disease, state of complete physical, mental, and social well-being
Medications that cause immune system depression
NSAID, corticosteroids, cytotoxic agents, and anesthetics, can cause immune suppression in a variety of ways. Patients should also be asked if they have had an adverse event, such as leukopenia, in response to any medications.
Innate immunity
Is present in the body at birth also called natural immunity - non specific - Innate immune cells, unlike adaptive immune cells, do not show strict specificity in their recognition of pathogenic microbes. Instead, cells of the inmate immune system recognize and respond to broad classes of invading microbes. - Broad protection
Ethics
Is the study or examination of morality through a variety of different approaches (systematic study of right and wrong)
Risk factors for delayed wound healing include:
Ischemia Infection Repetitive injury Chemical mediators Poor nutrition Steroids Old age
Error of commission or omission that could have harmed a patient, but harm did not occur as a result of chance
Near miss
If a patient is suspected of infection or inflammation
Need to get the following: Vital sign - temperature, WBC's, CRP, Blood Sugar, Hemoglobin A1C if they have high blood sugar.
Anions are
Negative
Diagnostic testing done to look for nerve damage
Nerve conduction (electromyography)
Sodium
Neuro changes
Neutrophils
Neutrophils are the main cells seen early in a response to pathogens, and they are the principal cells that engulf and destroy invading micro-organisms. Neutrophils are short lived cells, and they do not re-enter the circulation. The pus that is associated with some types of bacterial infections is largely composed of dead and dying neutrophils.
Granulocytes
Neutrophils, Eosinophils, Basophils
The WBC's or leukocytes consist of several types of cells which are:
Neutrophils, monocytes and phagocytes. NMP
What are the myeloid progenitor cells?
Neutrophils, monocytes, eosinophils, basophils, and mast cells
Medications & Fall risks
Opioids, diuretics, anti-hypertensives (orthostatic hypotension), psychotropics, CNS depressants **Elderly have MUCH greater side-effects than "average" age people**
____ is an infection that occurs when your immunocompromised
Opportunistic
Temperature Regulation and Getting Accurate Temp
Oral Temp- Has the pt had anything hot/cold to drink in the last 15 minutes. Have pt hold under the tongue. Temporal scan is very accurate.
The movement of water only through a selectively permeable membrane.
Osmosis
Noninflammatory degenerative joint disease characterized by degeneration of cartilage, hyper trophy of bone at the margins, and changes in the synovial membrane
Osteoarthritis
Metabolic disease that causes poor and delayed mineralization of the bone cells in mature bones, main cause is vit d deficiency
Osteomalacia
Bone infection that can stem from a soft tissue infection or blood infection. Cellulitis develops in the bone marrow.
Osteomyelitis
What happens to bones through aging?
Osteopenia occurs- bone becomes weaker and thinner
Characterized by low bone mass, compromised bone strength, and an increase in the risk of fracture
Osteoporosis
3 P's of Diabetes Mellitus - Type 1 Signs & Symptoms
P- Polyuria (excessive urination) P- Polydypsia (excessive thirst) P- Polyphagia (excessive hunger)
Electrolytes - PISO
P- Potassium I- Inside S- Sodium O- Outside
3 P's of Blindness
P- Preventable P- Painless P- Permanent
6 P's of Dyspnea
P- Pulmonary Bronchial Constriction P- Possible Foreign Body P- Pulmonary Embolus P- Pneumothorax P- Pump Failure P- Pneumonia
5 P's of Circulatory Checks
P-Pain P-Paresthesia P-Paralysis P-Pulse P-Pallor (Paleness)
Promotion of Normal Elimination (POOPER SCOOP)
P-osition O-utput O-ffer Fluids P-rivacy E-xercise R-eport Results S-ize (Amount) C-onsistency O-ccult Blood O-dor P-eristalsis
Chronic bone disorder similar to arthritis. Increase in bone absorption, to compensate for this, bone formation increases along with bone remodeling. New bone is fragile, which leads to deformity and fx
Paget's disease
____ is a result of increase in fluid causing injury to the nerve endings in the specific injured area
Pain
Signs and symptoms of gout
Pain and edema in one joint (big toe), tophus, uric acid stones, impaired ROM
Nursing implementation for gout
Pain control, bed rest, heat, ice, elevation during acute attack; nutrition- diet low in purine; avoid alcoholic beverages, turkey, bacon; meds- NSAIDs, antigout meds (colchicine- for acute attacks, allopurinol and uloric- lower uric acid levels), corticosteroids, analgesics
Nursing interventions for Paget's disease
Pain management, limiting disability, prevent complications (neurological complications, bleeding, hypercalcemia) meds are same as osteoporosis
The 5 P's of circulation loss in a limb.
Pain, Pallor, Pulselessness, Parasthesia, Poikilothermia
Common symptoms associated with altered mobility
Pain, reduced joint movement, reduced sensation or loss of sensation, falls, fatigue, altered gait or imbalance, reduced functional ability
____ is an infection that is affecting people worldwide
Pandemic Infection
____ is inflammation to the lumen of a vein manifested by warmth, swelling, a red streak, and pain
Phlebitis
Lowest Level on Maslows
Physiologic
Maslow's Hierarchy of Human Needs
Physiologic, Safety, Love and Belonging, Self-Esteem, Self-Actualization
What are the developmental factors affecting safety for preschoolers?
Play extends to outdoors, more adventurous
Diuretics
Point is to rid body of excessive fluid. You would do this in cases of CHF, Pulmonary Edema, HTN, and Fluid Overload. -Post surgical edema is an expected finding, typically will not use a diuretic for this.
Safety hazards in the home
Poisoning, carbon monoxide poisoning, scalds and burns, fires, falls, firearm injuries, suffocation/asphyxiation, take-home toxins
Some possible interventions for edema include:
Positioning patient in semi-fowlers positions, Administer Diuretic if ordered, Monitor hematocrit and electrolyte levels if ordered, Monitor skin, Restrict fluids if ordered, Provide low sodium diet if ordered
Cations are
Positive
Post op GI assessment
Post op nausea/vomiting common (30%) Peristalsis delayed up to 24 hours Monitor for bowel sounds
ADH is released from the ____ in response to the cardiovascular system
Posterier Pituitary Gland
Stages of Health Behavior Change
Pre-contemplation, Contemplation, Preparation, Action, and Maintenance
Preoperative Goals
Pre-op starts at decision to have surgery.
Sepsis
Presence of pathological microorganisms or their toxins in the blood
Cultural Care PAR
Preservation, Accommodation, Repatterning
Nursing care for urinary catheter
Prevent UTI Prevent back flow Encourage fluids Perineal hygiene
Interventions for alkalosis
Prevent further losses of hydrogen, potassium, calcium, chloride ions Restore fluid balance Monitor changes, provide safety Modify or stop gastric suctioning, IV solutions with base, drugs that promote hydrogen ion excretion
The compliment system
Antibodies serve to both trigger a system of proteins, the compliment system, to directly lyse bacteria and other microbes, and to flag microbes in such a way that they are more readily targeted by macrophages for phagocytosis.
Perioperative Concerns Preschoolers
Fear of disfigurement
Dilated pupils: Fear, Fits & Fast Living
Fear: panic, extreme anxiety Fits: seizures Fast Living: cocaine, crack, phencyclidine (PCP)
Lab test done to evaluate fat absorption to tell how well the liver, gallbladder, pancreas, and intestines are working
Fecal fat
____ depletes moisture and increases metabolic rate
Fever
Generativity vs Stagnation
....
Integrity vs Despair Task
....
Intimacy vs Isolation
.....
Ph ranges from
0-14
Examples of Hypotonic Solutions include:
0.45% sodium chloride or 1/2 NS 0.225% sodium chloride or 1/4 NS
Normal Creatinine range
0.5-1.2
Examples of intravenous solutions to treat dehydration are:
0.9% Saline or NS 5% Dextrose in Water or D5W 5% Dextrose in 0.225% Saline or D5 1/4 NS Lactated Ringer or LR
Examples of Isotonic Solutions include:
0.9% Sodium Chloride or NS Lactated Ringers or LR 5% Dextrose in water or D5W
PICC Line Med Administration
1) Do medication check and figure which port if there is multiple ports (one for blood, one for medication). 2) Clean with ETOH for at least 20 seconds, then unclamp PICC line 3) Flush with NS (at least port you're using, sometimes it is both ports), then reclamp. 4) Hook up med ball and unclamp. 5) Reclamp line, unhook med, unclamp, flush and reclamp.
When compensatory Mechanisms fail, the following physiologic consequences occur: 1. _______, especially in the brain when CO2 crosses the blood brain barrier 2. Change in ______ resulting in cell dysfunction 3. Acidosis: Decrease the ______ 4. Alkalosis: Decreases the _____ and has other _____; May cause ____
1. Altered cell function 2. Intracellular enzyme activity 3. Level of consciousness (LOC) 4. Level of consciousness (LOC, Neurological manifestations, dysrhythmias
Steps for inflammation
3 major events: 1) vasodilation 2) increased permeability of capillaries 3) escaped of leukocytes from the capillaries
Initiative vs Guilt
3 to 6 years
Phos
3-4.5
Phosphorus
3.0 - 4.5 mg/dl -Required for energy production (ATP) and pH regulation, growth and repair of body cells and tissues, together with calcium provide structure & strength for bones.
What is the normal range for potassium?
3.5-5
K+
3.5-5.0
Potassium
3.5-5.1 meq/L
Diastolic BP Pre-HTN
80-89
The level of normal leukocytes in the body is
4,500 to 11,000 per mm3 according to the textbook.
What is the normal range for calcium?
4.5-5.5
Minimum urine amount needed to excrete toxic waste products
400-600 mL
Average urine output
50-75 ml/hr, Minimum is 30 ml/hr. 1500 is average output per 24 hrs. More urine is not necessarily a bad thing- could be SIADH, but not necessarily bad- depends on situation.
Neutrophils make up
56% of the total WBC's in the blood and are formed in bone marrow
Industry vs Inferiority ages
6 to 11 years
Optimal Heart Rate
60-100 BPM
Integrity vs Despair
65 and older. review life accomplishments, deal with loss and prepare for death
Neutral Ph is considered
7
Plasma protein makes up ____% of the blood
7
Normal BUN range
7-20 mg/dl
Normal Ph is maintained between
7.35-7.45
What is the normal range for pH?
7.35-7.45 (7.4 is neutral)
In the elderly intra cellular fluids decrease by about ____%
8
Calcium
8-11 mg/L
Ca+
8.5-10.5
A client has a continuously running peripheral infusion. The physician orders an antibiotic as a piggyback infusion four times per day. In order to administer the antibiotic, the nurse should do which of the following? Select all that apply. 1. Avoid compatibility issues by starting an additional IV access. 2. Start a new IV access to eliminate the problem of too much volume for one site. 3. Flush the IV line before and after infusion of an incompatible drug. 4. Check to see if the antibiotic is compatible with the continuous infusion. 5. Change the flow rate to facilitate the administration of the antibiotic.
Answer: 3,4, 5
Pharmacotherapy agents to help with the immune response are:
Antihistamine Sympathomimetic Mast Cell Stabilizer Anti-inflammatory Agents
We get symptomatic relief from:
Antipruritic Decongestant Analgesics
8 A's for Hepatotoxic Drugs (Check SGPT/SGOT)
Antituberculosis Anticonvulsant S - sodium Luminal G - gabapentin P - phenytoin T - tegretol Anticancer Aspirin Alcohol Antifamily (contraceptice pills) Acetaminophen Aflatoxins
Diagnostic test done that injects air-cartilage lesions
Arthrography
Diagnostic test that detects ligament laxity of the knee
Arthrometry
Diagnostic test done to diagnose and repair knee joints
Arthroscopy
Surgery for osteoarthritis
Arthroscopy, tibial osteotomy, and arthroplasty (joint replacement)
The pathophysiology of ARDS:
Assault on the respiratory system Respiratory distress Decreased lung compliance Severe respiratory failure
Managing diarrhea
Assess & monitor for fluid imbalance Monitor for skin integrity Dietary teaching (clear liquid, BRAT- bananas, rice, applesauce, toast) Antidiarrheal medication- not for acute diarrhea, lomotil & Imodium, pt education about OTC aids
Propofol for Sedation
Assess Respiratory System.
Knowing
Assess thoroughly
Look for these things with infection:
Fever Malaise Fatigue Chills
The duty to keep promises
Fidelity
Water regulates ____, ____, ____, and ____
Body Temp pH Fluid Pressures BP
Perioperative Concerns Adolescents
Body image
Prevention of safety hazards for healthcare workers
Body mechanics, sharps awareness/ proper disposal, radiation precautions, environmental awareness of personal safety
Metabolic Acidosis
Body retains too many H+ ions, or loses too many bicarb ions = pH will fall (acid). -Metabolic Acidosis = increased depth & rate (fast) of respiration Symptoms: Feel like poop, headache, n/v/d, hypotension, hyperkalemia
Primary organs involved with immune response: 1. 2.
Bone Marrow Thymus
PRIMARY LYMPHOID ORGANS
Bone Marrow & Thymus - Lymphocyte develope and mature
Immune organ where B cells are produced
Bone marrow
Primary Lymph organs are
Bone marrow and thymus - B cells are made by the bone marrow and the thymus matures them into killer T cells.
Diagnostic test done to detect bone density and metastasis
Bone scan/nuclear scan
Innate immune system
Born with it - mechanical factors (skin, mucous membranes, cilia, etc); lysozymes (enzymes that dissolve certain organisms); Inflammatory cells (PNMs, macrophages, mast cells, basophils); natural killer cells
Magnesium
Bowels
Hyponatremia effects include:
Brain swelling: -Confusion -Headache -Weakness -Seizures
Prevention of respiratory complications post op
Breathing exercises- deep (diaphragmatic) & expansion Incentive spirometer Coughing and splinting
The maintenance of acid-base balance is important to
Cell function
When pt is NPO, what conditions should drugs be taken for?
Cardiac disease Respiratory disease Seizures Htn
Salts contain both a ____ & an _____
Cation & Anion
Use hypotonic fluids for
Celluar dehydration (normal BP but concentrated urine or high HCT)
Knowing
Center on the one cared for
agglutination
Clumping of (foreign) cells; induced by cross-linking of antigen-antibody complexes.
Individuals are risk for fluid volume abnormalities are:
Cognitively impaired Very young Very old Those that can not communicate Those that can not get fluids
Atelectasis
Collapse of alveoli, prevents respiratory exchange (O2 and CO2)
These side effects occur during the ____: increased thirst rapid weight loss increased heart rate thready pulse postural hypotension vasoconstriction (pale cool skin) decreased urine output dark concentrated urine increased specific gravity decreased mental function confusion loss of consciousness
Compensatory Effect
Acid base imbalance: Develops as a _____ Never considered "Normal", but may be "Expected" if ___
Complication of another underlying condition a chronic condition is present
Pain Assessment: The 5 C's
Comprehensive assessment Consistent use of assessment tools Continuous reassessment Customized plan of care Collaborative approach
Perioperative Concerns Toddlers
Concerned with separation anxiety, control, wants comfort objects -blanket, stuffed animal
Altered Immunity - suppressed
Conditions where the immune response of the body is either suppressed or exaggerated. EX: suppressed responses to immunity are referred to as immunocompromised or immunodeficiency. HIV, AIDs chemotherapy, high dose steroid patients will have a suppressed immune system.
Neuromusculoskeletal status for fluid volume EXCESS:
Confused Muscle weakness
Ethical Decision making models: Contextual features
Fidelity (loyalty) and Justice (fairness)
Phagocytosis - destroys pathogens in the infected area or tissue
Destruction of pathogens in the tissues occurs by phagocytosis
People with edema can be seen having:
Crackles Increased Respirations Increased Heart Rate Increased BP Edema Weight gain Neck and hand vein distention Decreased Hematocrit Confusion Functional Impairment Pain
neutropenia
Deficiency in neutrophils is called
Neutropenia is the
Deficiency in neutrophils, called neutropenia, can lead to overwhelming bacterial infection.
Respiratory Alkalosis Intervention:
Deficit of plasma CO2 (Carbonic Acid (H2Co3)) Involve the client using a re-breathing mask or breathing into a paper bag
Ask about ____ and ____ with those who may have an infection
Exposure & Pain
____ is discharge of blood serum or lymph from a vessel into tissue
Extravasation
____ is accumulated fluid in a cavity, and is seen in inflammation
Exudate
HYPERNATREMIA "You Are Fried"
F - Fever (low grade), flushed skin R - Restless (irritable) I - Increased fluid retention and increased BP E - Edema (peripheral and pitting) D - Decreased urinary output, dry mouth Can also use this one: SALT S = Skin flushed A = Agitation L = Low-grade fever T = Thirst
Exercise Guide for Diabetic Fitness (FIT)
F - Frequency (3x per week) I - Intensity (60-80% of Maximal Heart Rate) T- Time (Aerobic Activity)
side effects & adverse reactions to immunizations:
F- Fever I- Itching S- Stiffness H- Headache E- Edema R- Redness F- Fussy L- Localized Tenderness A- Appetite decrease G- General Aches Pains
What are the 3 potential outcomes for autoimmune disorder
Destruction of body tissue Abnormal organ growth Change in organ function
Chronic body-wide system diseases include:
Destruction of body tissue Abnormal organ growth Changes in organ function
Internal Variables influencing Health Beliefs
Developmental Stage, Intellectual Background, Perception Background, Emotional Factors, Spiritual Factors
The free movement of particles across a permeable membrane from an area of higher concentration to an area of lower concentration
Diffusion
____ leads to increased risk of pressure ulcers and skin breakdown
Diminished sensation
The effects of dehydration are ____
Direct
Electrolytes are active chemicals that dissociate into ions when _____ in _____
Dissolved in water
Signs and symptoms of cardiac tamponade (Beck's Triad): The Three D's
Distant heart sounds Distended jugular veins Decreased pulse pressure (think of a narrow pulse pressure as opposed to a wide one)
Respiratory Acidosis
Etiology may include airway obstruction (asthma, COPD), obstructive airway disease, thoracic trauma, narcotic/sedative overdosage, TPN, respiratory failure) *elderly decompensate faster -Respiratory Acidosis = [HYPOVENTALATION] Air hunger, respiratory rate & depth increases Symptoms: headache, dizziness/confusion, SOB, anxiety
Process through which scientific evidence is identified, appraised, and applied in health care interventions
Evidence- based practice
Altered Immunity - Exaggerated
Exaggerated immune response Ex: of exaggerated - allergies, you are not supposed to die because you have an allergy to penicillin. This is the bodies exaggerated immune response. Pollen is an allergen that makes you feel like crap, the body is triggering an exaggerated response. Auto immune diseases...Lupus, arthritis, some types of diabetes. These are auto immune responses the body has to itself. Hypersensitivity reaction that the body has. Treatment for auto immune diseases is immunosuppressants.
An allergy is an
Exaggerated immune response. Some allergies can be uncomfortable or a nuisance or some can kill you like anaphylactic shock.
Stress and Surgeries can also impact the immune system function
Example spleen removal, spleen filters the blood, organ transplants - the body will attack the foreign organ also because of immunosuppressants from medications. Stress because it depresses the immune system, body stress like running a marathon also depresses the immune system. Social isolation causes decreased immune system function.
What does Lasix do to electrolytes balance?
Excrete K+ and retain Na+
______ relieves stress
Exercise
Nursing implementation for osteoarthritis
Exercise pt, encourage weight loss, increase ca, vit d, phos, selenium, protein, iron; meds for pain control- Tylenol, NSAIDs, steroid shots, opioids
What are the three lines of defense?
First: Skin boundary surface (i.e. mucous membranes, enzymes, normal flora, complement proteins) Second: Activities of phagocytes, natural killer T lymphocytes, granulocytes, and macrophages Third: Antibodies derived from B lymphocytes and the T lymphocytes
What are the 3 systems that maintain pH?
First: buffers Second: respiratory system Third: Renal system
Types of bone
Flat, short, long, irregular
____ occurs when fluid intake or retention exceeds the body's needs
Fluid Excess Edema Fluid Overload Hypovolemia
Interventions for respiratory acidosis
Focus on improving ventilation and oxygenation Maintain patent airway Drug therapy (bronchodilators, anti-inflammatories, mucolytics) Oxygen therapy Pulmonary hygiene Ventilation support Prevention of complications
Examples of never events
Foreign objects left in patient after surgery, air embolism, administering the wrong type of blood, severe pressure ulcers, falls and trauma, infections associated with urinary catheters, infections associated with IVs, symptoms resulting from poorly controlled blood sugar levels, surgical site infections following certain elective procedures, DVT or PE following total knee and total hip replacement procedures
Rheumatoid Arthritis (will show up with inflammatory response)
Form of arthritis in which an autoimmune response leads to inflammation of connective tissue, particularly the membranes that line the joints, resulting in overall stiffness, inflammation, aching, deformed joints, and a serious loss of mobility.
____ screening for those with specific risk factors
HIV
Primary Prevention
Health Promotion
ABG shows how the Lungs and Kidneys are functioning but it does not say anything about the ____
Heart
Potassium
Heart Problems
Concentrated urine has a ____ specific gravity
Higher
Immunosuppression
Inability of the immune system to respond to an antigen. Occurs in response to disease or medications; may be intentional to prevent rejection of transplants or a side effect of some medications.
What do potassium levels do in pts with acidosis?
Increase (affects heart and kidney function)
Managing constipation
Increase high fiber foods Increase fluids Increase exercise Provide privacy Position pt Uninterrupted time Offer laxatives
When a patient id dehydrated the body compensates by releasing a ____ in an attempt to ____
Increase of ADH Increase volume or BP
Effects of Hypocalcemia
Increase the excitability of the nerves: -Muscle twitching (spasms) -Carpopedal spasm -Chvostek's sign -Trousseau's sign -Tetany: Life Threatening *Weak heart contractions, twitching in skeletal muscles
Causes of edema include:
Increased capillary hydrostatic pressure (BP) Obstruction on Lymphatic Circulation Increased capillary permeability Loss of plasma protein
Vital signs for fluid volume DEFICIT:
Increased heart rate Decreased BP Decreased CVP Hypoxia
Vital signs for fluid volume EXCESS:
Increased heart rate Increased BP Bounding pulse Increased CVP
Mobility status is a risk factor for skin integrity because:
Increased pressure, Shearing and Friction can lead to skin breakdown
Respiratory status for fluid volume DEFICIT:
Increased respiration
Respiratory status for fluid volume EXCESS:
Increased respiration Shallow breathing Crackles Diminished lung sounds
ESR [Erythrocyte Sedimentation Rate]
Increased with inflammation or infection
The immune system is generally divided into two large categories:
Innate & Acquired
____ also called natural immunity, is present at birth and functions similarly regardless of the pathogen
Innate Immunity
Inflammation is a form of
Innate immune response. We are born with it.
Immunity that is present at birth
Innate immunity
____ is loss of water through perspiration and expiration
Insensible fluid loss
Water is found both ____ and ____ of the cell
Inside and Outside
Musculoskeletal physical exam
Inspection: edema symmetry, deviation Palpation: crepitus, masses, texture Evaluation of passive and active ROM Neurovascular assessment: color, pulses, temp, sensation, movement (compare both sides) Muscle tone and muscle strength Gait Injuries: pain, deformity Homans' sign Sports injury
Third space between the cells
Interstitial
To find out food allergies
Introduce foods one at a time or restrict foods one at a time to figure it out. Eliminate them for a few days and then reintroduce the foods to see if there is a reaction.
Cell Mediated Immunity
Involves T-CELLS!!! Attack anything it doesn't recognize (Infected cells)
Veins cannot be used in pts with:
Mastectomy Axillary lymph node dissection Lymphedema Paralysis of upper extremities Dialysis graft of fistulas
Clinical findings for suppressed immune functioning are:
May appear poorly nourished or have wasting syndrome May have chronic wounds May have enlarged lymph nodes Presence of opportunistic infection
Clinical findings of suppressed immune functioning:
May appear poorly nourished or have wasting syndrome May have chronic wounds May have enlarged lymph nodes Presence of opportunistic infection
What are the developmental factors affecting safety for adults?
May be exposed to injury in the workplace, lifestyle choices impact health, some decline in strength and stamina, others maintain fitness
Protein Electrophoresis
Measures serum proteins like albumin and globulins like alpha-beta and gamma globulins. Also used to screen for tumor proteins
____ can cause dehydration due to fluid and electrolyte loss
Medications
Skeletal diseases
Metabolic bone disease (osteomalacia, Padgetts disease), osteomyelitis, tumors of musculoskeletal system, osteoporosis, spinal disorders (scoliosis)
Primary vs secondary tumors in bone cancer
Metastatic tumors are more commonly seen than primary tumors, produces pain
Generativity vs Self-Absorption and Stagnation ages
Middle Age, 40 to 65. production, care, ability to expand personal and social involvement
C-A-U-T-I-O-N
Mnemonic for Cancer screening - changes in health. -C- change in bowel or bladder habits. -A- area or a sore that does not heal. -U- unusual bleeding or discharge -T-Thickening or a lump in the breast, testicles or elsewhere. -I-Indigestion or difficulty swallowing -O- obvious or change in a wart or a mole -N- nagging cough or hoarseness
____ leads to maceration
Moisture
Collaborative care for immunodeficiency
Monitor immune function Nutrition Prevent opportunistic infections Monitor and treat opportunistic infections Drug therapy
Interventions for patients that are dehydrated include:
Monitor intake and output Daily weight Vital signs Check mucous membranes and skin turgor Test urine for specific gravity
Collaborative care for immunodeficiency include:
Monitoring immune function Proper Diet Prevent opportunistic infections Monitor and treat opportunistic infections Drug Therapy
More hydrogen ions= Less hydrogen ions=
More=Acid Less= Basic
What screening tool is used for fall assessment?
Morse falls score sheet
How do the buffers maintain pH?
Moves or release hydrogen ions
Calcium
Muscle Problems
Consequences of immobility
Muscle atrophy, joint dysfunction, atelectasis/pneumonia, venous stasis, increased coagulation, orthostatic hypotension, glucose intolerance, pressure ulcers, constipation, paralytic ileus, UTI, renal calculi, depression, sleep disturbances, disorientation
hypocalcemia
Muscle cramps, Confusion/forgetfulness, tingling in lips & fingers, hypoparathyroidism
In the elderly ____ tissue changes to ____ tissue
Muscle, Adipose
If a patient has inflammation does it mean that the patient has an infection?
No, not necessarily!! Inflammation is the body's response to injury such as tissue, joints injuries, allergens, infection etc. Rheumatoid Arthritis - they will have inflammation of the joints but do not have an infection in the joints.
Prevention of falls in the home
Non skid shoes, tidy clothes, proper lighting, grab bars/rails, no scatter rugs
What is a renal ultrasound and how should the patient prepare for procedure?
Noninvasive diagnostic exam that produce images to assess the size, shape, and location of the kidneys. No prep such as sedation or fasting. Nurse should make sure pt is educated about procedure
The twofold duty to do no harm and prevent harm; risk of harm not always clear; weigh risks and benefits
Nonmaleficence
Calcium:
Normal 8.5 to 10.5 [My bones became strong when I was about 8 to 10 (8.5-10.5) years old]
____ is the good bacteria that is normally found without causing disease, and helps fight infection
Normal Flora
Specific Gravity
Normal SG is 1.015-1.030.
Correct electrolyte imbalance
Normal functions nerve/muscles develops structure of body cells coordination of physical activities blood clotting
Magnesium
Normal is 1.6 to 2.6
Chloride
Normal is 95-105
Phosphorus
Normal levels are 3.0 to 4.5
IV solutions:
Normal serum osmolarity (adults) 270-300 mOsm/L Isotonic 270-300 mOsm/L Hypertonic fluids >300 mOsm/L Hypotonic fluids <270 mOsm/L
Nurse role in ethics: Patient advocacy
Nurse supports pt
Lab test done to determine a parasitic disease
O&P
Cranial Nerve Mnemonic 02
O- Oh O- Oh O- Oh T- To T- Touch A- And F - Feel A G - irl's V - agina S - So H- Heavenly
Cranial Nerve Mnemonic 03
O- On O -Old O- Obando T- Tower T- Top A- F- Filipino A - Army G - Guards V - Villages A - And H - Huts
Cranial Nerve Mnemonic 01
O-Lympic (Olfactory) O-Pium (Optic) O-Ccupies (Oculomotor) T-ROubled (Trochlear) T-RIathletes (Trigeminal) A-fter (Abducens) F-inishing (Facial) V-Egas (Vestibulocochlear) G-ambling (Glossopharyngeal) V-Acations (Vagus) S-till (Spinal Accessory) H-igh (Hypoglossal)
Trouble figuring out which eye is which?
OS is left eye OD is the right eye You can remember which one is the right eye (OD), because you can make the D into an R - You just have to draw to stick legs on the bottom of the D. Write it down on paper, you'll see what I mean (it's hard to show you when all I can do is type)
Pts at risk for DVT
Obese pt 40 or older Hist of cancer Decreased mobility/ immobile Spinal cord injury Smoking History of PE, VTE, varicose veins, edema Oral contraceptives Hist of decreased cardiac output Hip fracture, total hip/knee surgery
____ happens if lymph nodes are surgically removed, a tumor, or an infection
Obstruction of the Lymphatic Circulation
Lab test done that determines if there is blood in the stool
Occult blood
____ skin: less elastic, drier, reduced collagen, hyerperpigmentation, more prone to injury
Older
What age group is at risk for most electrolye imbalances
Older adults from age-related organ changes
Post op drug therapy to reduce nausea/ vomiting
Ondansetron (Zofran) Meclizine (Antivert, Dramamine)
____ is acquired through the transfer of antibodies, like a mother to her baby
Passive Immunity
Occurs by the introduction of performed antibodies either from an artificial or natural route (i.e. from mother to fetus)
Passively acquired immunity
Elements of a musculoskeletal assessment: history
Past medical history, family history, current medications, lifestyle behaviors, occupation, social environment, problem-based history
Post op respiratory system assessment
Patent airway, adequate gas exchange Note artificial airway if applicable Rate, pattern, depth Breath sounds Accessory muscle use Snoring and stridor Resp depression or hypoxemia
____ is an invader or infectious agent that causes disease or illness
Pathogen
Hypokalemia
Pee, Drink, dysrhythmias
Antibiotic agents used to treat infections are:
Penicillin (usually end in -cillin) Cephalosporin's (ex. ancef, rocephin) Fluroquinolones (ex. Cipro, Levofloxcin) Tetracycline's (ex. Erythromycin) Macrolides (ex. Zithromax) Aminoglycosides (ex. Tobramycin, Streptomycin) Antivirals (ex. Zovirax, Tamiflu) Antifungals (ex. fluconazole) Antiprotozoal (ex. metronidazole aka. Flagyl)
Risk factors for osteoporosis and related fractures
Personal history of fracture as an adult, history of fragility fracture in first- degree relative, low body weight <127 lbs, current smoking, use of oral corticosteroid therapy > 3 months
____ has the potential power of the hydrogen ion in a solution
Ph
The process of ingesting cellular material and involves the ability of phagocytes to be selective in recognizing cells that must be ingested and discarded
Phagocytosis
Collaborative Care for exaggerated immune response include:
Removal of exposure (if possible) Airway Support Pharmacotherapy Symptomatic relief
BUN and Creatinine increase indicate that there's an issue with
Renal system
Suppressed Immune Functioning symptoms are:
Report of frequent infections Report of poor wound healing Fatigue Malaise Weight loss *symptoms are based on severity
Symptoms of suppressed immune functioning:
Report of frequent interactions Poor wound healing Fatigue Weight loss Malaise
Urgent
Requires prompt attention within 24 hours
RICE stands for ____ and is most helpful after a sprain, strain, or trauma. It helps minimize swelling and most beneficial 24-48 hours after injury.
Rest Ice Compression Elevation
Tertiary Prevention
Restoration and rehabilitation
The goals for edema treatment are:
Restore Fluid Balance Correct Electrolyte imbalance Eliminate and/or Control the underlying cause of fluid overload
Goals for people who are dehydrated include:
Restoring fluid volume Replacing electrolytes Eliminate cause of fluid volume deficit
Metabolic Alkalosis
Results from vomiting, gastric suction, K wasting diuretics, increased renal excretion of acid. -Metabolic Alkalosis = Respiratory rate & depth decrease [slow breathing] Symptoms: Feel like poop, n/v/d, numbness & tingling in extremities, dysrhythmia
Paternalism
Revealing or withholding information for the best interest of the patient -ex/ not telling someone their diagnosis because you think its better for them (treat like child)
ROME is my best place to yell (Live Viruses)
Rubella, oral polio, measles, epidemic typhus, influenza, mumps, BCG (TB), plague, typhoid, yellow fever.
Cranial Nerve Mnemonics (Sensory, Motor or Both)
S - Some S - Says M- Marilyn M- Monroe B - But M- My B- Brother S- Says B- Bridget B - Bardot M- Mmm M- Mmm
Signs of a Cholinergic Crisis, think SLUD:
S Salivation L Lacrimation U Urination D Defication
S/S of Hyponatremia
S tupor/coma A norexia, N&V L ethargy T endon reflexes decreased L imp muscles (weakness) O rthostatic hypotension S eizures/headache S tomach cramping
Cranial Nerve Mnemonics 02 (Sensory, Motor or Both)
S- Some S- Say M - Marry M- Money B- But M- My B - Brother S- Says B- Bad B- Business M - Marry M - Money
Cholinergic Crisis (SLUD)
S-alivation L-acrimation U-rination D-efecation
IADLS (Instrumental Activities of Daily Living) SCUM
S-hopping C-ooking and Cleaning U-sing telephone or transportaiton M-anaging money and medications
Depression Assessment (SIG)
S-leep Disturbances I-nterest Decreased G-uilty Feelings
Lidocaine Toxicity (SAMS)
S-lurred Speech A-ltered Central Nervous System M-uscle Twitching S-eizures
Adrenal Gland Hormones (SSS)
S-ugar (Glucocorticoids) S-alt (Mineralcorticoids) S-ex (Androgens)
Heart sounds:
S3= Heart fail-ure (3 syllables) S4=Hy-per-ten-sion (4 syllables)
The most common infection screenings are:
STD and TB
Prevention of health care errors and the elimination or mitigation of patient injury caused by healthcare errors
Safety
Electrolytes are found in all body fluids as _____, _______, ______
Salts, Acids, and Bases
Malignant neoplasm of the MS system
Sarcoma
Lateral curvature of the spine most common in adolescence
Scoliosis
Where RBC's are destroyed if infected
The red pulp of the spleen
Body's first line of defense
The skin and mucous membranes lining, the respiratory, digestive, and genitourinary tracts.
Immunoglobulin Electrophoresis
The test that separates and measure the Immunoglobulins, measures them individually.
Assessment of the immune system
The very young and the very old have problems with the immune system. preemie babies have no immune system
Is responsible for immune response and preventing septicemia
The white pulp of the spleen
Water is the ____ for the body
Transportation System
Treatments for dehydration include:
Treating the underlying cause Supplemental fluid and electrolyte replacement
T/F alkalosis presents hypocalcemia and hypokalemia?
True
What are the developmental factors affecting safety for school-aged children?
Try new activities without practice, more time outside the home, stranger danger
Digestive system is another barrier to pathogens - first line of defense
With regard to the digestive system, saliva in the mouth forms the first chemical barrier. The pH of saliva, combined with several enzymes, make it an unattractive place to live. The hydrochloric acid and pepsin of the stomach form the next inhospitable atmosphere that invaders will encounter.
What questions do you ask to get an understanding of pain?
What makes it better/worse, does it interfere with daily function, how often, intermittent/constant, where is it located, is there a pattern, when did it begin, how would you rate it (pain scales), have you had this type of pain before, what have you tried to relieve it.
Barium swallow: What and Why
What: When taking the test, you drink a preparation containing Barium sulfate. Why: to determine the cause of painful swallowing, difficulty with swallowing, abdominal pain, bloodstained vomit, or unexplained weight loss.
Barium Enema: What and Why
What: enema tube with Barium sulfate is inserted Why: Detect or screen for colon cancer, ulcerative colitis, Crohn disease, cause of blood in stools, diarrhea, or very hard stools
Colonoscopy: What and Why
What: examiner evaluates inside colon with a flexible tube that has a camera. Why: if pt had bloody stool, abdominal pain, abnormality found, colon cancer, colitis
Cystoscopy: What and Why
What:is the use of a scope (cystoscope) to examine the bladder. (Can cause bladder spasms*) Why:Check for cancer of the bladder or urethra, evaluate urinary tract disorders, determine the cause of pain during urination
Self versus non-self
When the body recognizes itself or not itself. When the body recognizes that something is supposed to belong or does not belong.
Having difficulty distinguishing hypoplasia from hyperplasia?
When you see plasia in any word, think of "plastic." Plastic, in turn, means forming or developing. As for hypo and hyper, that's the easy part. Hypo means under, or below normal. Hyper means excessive, or above normal. Thus, hypoplasia means underdevelopment, and hyperplasia means overdevelopment.
Autoimmune disorders
Where the body attacks itself. Lupus, Rheumatoid Arthritis, MS, psoriasis - #1 treatment is immunosuppressants to suppress the bodies response to attacking itself.
When assessing the skin where an ice pack has been used if the skin is ____ that is bad and if it is ___ that is good
White Red
Perioperative Concerns Adults
Who will help
What are the national guidelines for osteoporosis screenings?
Women 65 and older and/or younger that have increased fracture risk