Exam 3: Integumentary, Endocrine, Management, Respiratory, and Immune
Acute Respiratory Distress Syndrome Treatment
- Bedrest - Intubation and ventilation - Anesthetic to ease insertion of trach tube (propofol) - Neuromuscular blocking agents (pancuronium, vecuronium) - Diuretic to decrease excess fluids in lungs (furosemide, bumetanide) - H2 blocker or proton pump inhibitor to decrease gastric acid (ranitidine, omeprazole) - Anticoagulants (heparin) - Analgesic (morphine) - Steroids to decrease inflammatory response (hydrocortisone, methylprednisolone) - Exogenous surfactant (beractant) - Antibiotics
Cor Pulmonale Treatment
- Bedrest - O2 therapy - Calcium channel blockers for vasodilation (diltiazem, nifedipine, nicardipine, amlodipine) - ACE inhibitors (captopril, enalapril) - Anticoagulants to reduce risk of clots (heparin) - Diuretics to remove excess fluid (furosemide, bumetanide) - Cardiac glycosides (digoxin) - Reduce sodium in diet to reduce fluid retention - Reduce fluid intake to reduce fluid retention
Emphysema: Treatment
- Beta2-agonists for bronchodilator (terbutaline, albuterol, levalbuterol) - Long-acting bronchodilators (formoterol, salmeterol) - Anticholinergics for bronchial smooth muscle relaxation (ipratropium, tiotropium inhaler) - Methylxanthines to dilate bronchi (aminophylline, theophylline) - Steroids to decrease inflammation in airway (hydrocortisone, methylprednisolone, prednisone) - Antacids, H2 blockers, or proton pump inhibitors to decrease acid in stomach (aluminum hydroxide, ranitidine, pantoprazole) - Expectorants to loosen secretions (guaifenesin) - Diuretics to decrease fluid retention (furosemide, bumetanide) - Vaccines to prevent resp. infections - Antibiotics - O2 therapy - Administer fluids
Type II: Cytotoxic and Cytolytic Reactions
- Binding of antibody to cell surface damages host cell (ex blood) - Ex. Hemolytic transfusion reactions
Transmission Fluids of HIV
- Blood - Breastmilk - Sexual fluids
Pulmonary Emblous
- Blood flow is obstructed in lungs caused by blood clot, air or fat embolism stuck in an artery - As blood supply diminishes alveoli collapse causing atelectasis - Can be fatal in 10-20% of cases
Moderate Reaction
- Bronchoconstriction - Dyspnea with wheezing - Systemic
Dermatological Manifestations Associated w/ Lupus
- Butterfly rash over cheeks and bridge of nose (50% of pts) - Alopecia can occur in patches all over the body - Photosensitivity (50% of pts, can occur at times w/ fluorescent lights) - Discoid Lupus, raised rash on face, scalp, ears, chest or arms
Reasons for Tracheotomy
- Bypass upper airway obstruction - Facilitate removal of secretions - Long-term mechanical ventilation - Permit oral intake and speech in patient who requires long-term mechanical ventilation
Maintaining Health Treatment Plans
- CBC to identify anemia, thrombocytopenia, leukopenia, and developing infections (Q6-12 months) - Mantoux test - Pap smear (2x year for 1st year then annually) - Screening for STI and Hep A, B, and C - Tests to determine previous exposure - CD4+ and viral load testing - Psychosocial assessments (Social support, assistance w/ ADLs, employment status, financial expenses)
Transmission of HIV
- Can be pass if infected fluid gets into someone elses blood - IV drugs or needles - Blood transfusions - Infected mother
Types of Fungal Infections Associated w/ HIV
- Candida Albicans - Cryptococcosis (Meningitis) - Histoplasmosis (Respiratory infection)
Dendritic Cell
- Capture antigens and bring them back to the lymph nodes
Pet allergen in skin secretions and saliva
- Cat
Pet Allergies
- Cats & dogs are most common - Tiny particles float in the air for prolonged periods of time and stick to whatever they contact - Clothing can be a major source of allergen
Nasal Obstruction
- Caused by polyp or deviated septum - Usually treated w/ minor surgery
Severe Acute Respiratory Syndrome (SARS)
- Caused by previously unknown type of coronavirus - Symptoms more severe in immunocompromised pts - No vaccine or cure - Most common outbreak was in China in 2002 but SARS hasn't been seen since 2004 - Pt can develop pneumonia in severe cases
A client has been started on a long-term therapy with Rifampin (Rifadin). The nurse should provide which information to the client about the medication?
- Causes ORANGE discoloration of sweat, tears, urine, and feces.
Gastrointestinal Autoimmune Diseases
- Celiac disease - Ulcerative colitis - Pernicious anemia - Crohn's disease
Infections Caused by Staphylococcus aureus
- Cellulitis - Atopic dermatitis - Necrotizing fasciitis - Impetigo - Folliculitis - Meningitis - Osteomyelitis - Sepsis
Infections Caused by Streptococcus pyogenes
- Cellulitis - Strep throat - Rheumatic fever - Necrotizing fasciitis - Glomerulonephritis
Pleurisy: Symptoms
- Chest pain that worsens when you breathe, cough or sneeze - Shortness of breath/restrictive breathing - Cough - Fever
Atelectasis Nursing Interventions
- Chest physio - May need bronchodilator - Encourage deep breathing and coughing, frequent turning and incentive spirometry
Chest Tube Complications
- Chest tube malposition - Re-expansion pulmonary edema - Vasovagal response w/ symptomatic hypotension - Infection at skin site - Pneumonia - Shoulder disuse
Emphysema
- Chronic inflammation which reduces flexibility of the walls of the alveoli, resulting in over-distended alveolar walls - Air trapping occurs in lungs, impeding gas exchange - Smoking is common cause
Systemic Lupus Erythematosus
- Chronic inflammatory disease where immune system attacks own tissues and organs - Can affects systems including your joints, skin, kidneys, blood cells, brain, heart and lungs - Results from interaction of genes, hormones, environment, and immune system
Asthma
- Chronic inflammatory disorder of the airway or constriction of the bronchial smooth muscles (bronchospasm)
Causes of Chronic Obstructive Pulmonary Disease
- Cigarette smoking - Occupational chemicals and dusts - Infection - Heredity - Aging
Lung Cancer Risk Factors
- Cigarette smoking & secondhand smoke - Environmental exposure - Genetics - Dietary factors
Allergic Assessment: Throat/Neck
- Clearing - Swollen lips or tongue - Red throat - Palpable neck lymph nodes
Acute Viral Rhinitis
- Common cold or acute coryza - Caused by viruses that invade the upper respiratory tract; spread by airborne droplet sprays emitted while breathing, talking, sneezing, or coughing or by direct hand contact
Negative Feedback in Endocrine System
- Common for one hormone to control the secretion of another - Often, the last hormone in a pathway turns off the secretion from first hormone - Promotes homeostasis of the endocrine system
Peritonsillar Abscess
- Complication of acute pharyngitis or acute tonsillitis when bacterial infection invades one or both tonsils - Tonsils may enlarge sufficiently to threaten airway patency - Patient experiences a high fever, leukocytosis, and chills
Causes of Pleural Effusion
- Congestive heart failure - Pneumonia - Liver disease (cirrhosis) - End-stage renal disease - Nephrotic syndrome - Cancer - Pulmonary embolism - Lupus and other autoimmune conditions
Allergic Assessment: Eyes
- Conjunctivitis - Rubbing - Excessive blinking - Dark circles under eyes
Sweat Test
- Considered gold standard for diagnosing cystic fibrosis - Measures concentration of salt in pt's sweat - Greater than 60mmol/L = positive result
Lungs
- Contained within pleural sac in thoracic cavity which operates on negative pressure
Uses of Hypothalamus & Pituitary Glands
- Control many other glands - Secrete hormones that release other hormones & profoundly effect the body
Cor Pulmonale Symptoms
- Cyanosis - Fatigue - Wheezing - Dyspnea - Productive cough - Peripheral edema - Distended neck veins - Weight gain
Types of Viral Infections Associated w/ HIV
- Cytomegalovirus (CMV) (effects eye, respiratory and GI tracts) - Herpes Simplex Virus (Perirectal, oral and genital areas) - Varicella-Zoster Virus
Treatment of Autoimmune Diseases
- Cytophersesis (Cells separated and removed) - Plasmaphersesis (Removal of plasma containing diseased components and replaced w/ saline or albumin - Exercise regularly - Rest - Vitamin supplements - Immunosuppressants - Blood transfusions
Goals of Treatment
- Decrease inflammation - Suppress overactive immune system - Prevent symptom flares - Minimize complications r/t disease or treatment
Categories of Acute Respiratory Failure
- Decreased respiratory drive (Drug induced) - Dysfunction of the chest wall (Neurological disorders) - Dysfunction of lung parenchyma (Pleural effusion, pulmonary edema)
Arterial Blood Gases
- Determines pt's ventilation, tissue oxygenation, & acid-base status - Assess for normal values • pH 7.35-7.45 • PaO2 80-100 mmHg • PaCO2 35-45 mmHg • HCO3 22-26 mEq/L
Endocrine Autoimmune Disease
- Diabetes type 1 - Hashimotos disease - Hypo/ hyperthyroidism - Addison disease
B-Lymphocytes
- Differentiates into plasma cells when activated and produce antibodies (Immunoglobulin)
Lifestyle Modifications w/ Lupus
- Difficulty in completing ADLs, caring for children, maintaining household - Inability to maintain full or part time employment - Decreased social activities - Lack of energy or ambition - Irritability - Impaired concentration - Insomnia - Suicidal thoughts
Allergic Assessment: Ears
- Diminished hearing - Recurrent ear infections - Immobile or scarred tympanic membranes
Symptoms of Chronic Nasal Congestion
- Dry, irritated sore throat - Snoring @ night - Mouth breathing - Orthodontic disturbances - Frontal headaches/ sinusitis - Chronic cough - Otitis media/possible hearing loss - Altered smell and/or taste - Sleep disturbance, with or without daytime fatigue - Asthma exacerbation
Symptoms of Emphysema
- Dyspnea - Barrel chest - Use of accessory muscles - Weight loss - Seated position is most comfortable
Chronic Obstructive Pulmonary Disease Symptoms
- Dyspnea - Wheezing - SOB - Cyanosis of lips - Lack of energy - Cough - Weight loss - Frequent resp. infections - Use of accessory muscles
Cor Pulmonale
- Enlargement of right ventricle secondary to diseases of the lung, thorax, or pulmonary circulation - Obstruction of airflow occurs caused by COPD
Examples of Beta-Adrenergic Agonists
- Epinephrine (Adrenalin, Bronkaid, Primatene) - Formoterol Fumarate (Foradil) - Isoproterenol (Isuprel, Medihaler-Iso) -Metaproterenol Sulfate (Alupent, Metaprel) - Salbutamol (PMS-Salbutamol) - Salmeterol (Serevent)
Cystic Fibrosis Symptoms
- Exacerbations of ↑ cough - Weight loss - ↑ Sputum - ↓ In pulmonary function
Tracheostomy Care
- Explain purpose before procedure. - Inform patient and family of inability to speak while inflated cuff is used. - Tubes contain a faceplate or flange - Rest on neck between clavicles and outer cannula - During insertion, obturator is placed inside outer cannula, with rounded tip protruding from end to ease insertion - After insertion, obturator must be immediately removed to allow airflow. - Keep obturator near bedside in case of decannulation. - Some tubes have a removable inner cannula for easier cleaning.
Nursing Assessment for Lupus: Systemic
- Fever - Fatigue - Anorexia - Vasculitis
Early Symptoms of HIV
- Fever - Fatigue - Swollen lymph nodes — often one of the first signs of HIV infection - Diarrhea - Weight loss - Oral yeast infection (thrush) - Shingles (herpes zoster)
Symptoms of Severe Acute Respiratory Syndrome
- Fever (>38C) - Dry cough - Shortness of breath - Chills - Headache - Muscle aches - Sore throat - Diarrhea
Type III: Immune-Complex Reactions
- Fever rash purpura lymphadenopathy, splenomegaly - Onset 2-4 weeks penicillin cause - Ex. Serum sickness
Influenza: Symptoms
- Fever/chills - Headache - Nonproductive cough - Fatigue - Muscle aches - Sore throat - Watery, nasal drainage
Pulmonary Edema
- Fluid builds up in the lungs r/t ineffective pumping of blood by the heart as a result of left-sided heart failure or volume overload - Pt experiences hypoxia caused by decreased oxygenation of blood
Health Care Transmitted HIV
- HIV PPE protocol - Prophylactic meds 2H after exposure - Antiretroviral meds x4 weeks - 0.3% needle stick injuries - 0.09% mucocutaneous
Blunt Trauma
- Hard blow to the chest, often causing fractured ribs - Can also cause hypoxemia, hypovolemia, and cardiac failure
SLE Ambulatory Care
- Health Teaching - Eliminating or Minimizing Exposure to Precipitating Factors -Lupus -Pregnancy
Malignancies
- Hodgkin's and Non-Hodgkin's lymphoma - Invasive cervical cancer - Kaposi's sarcoma
Types of Organ Rejection
- Hyperacute - Acute - Chronic
Severe Reaction
- Hypoperfusion (decreased blood flow through an organ) - Hypotension - Onset - 5 minutes to hours
Acute Respiratory Distress Syndrome Symptoms
- Hypoxemia - Dyspnea - Pulmonary edema - Anxiety - Crackles - Wheezing - Restlessness - Cyanosis - Use of accessory mescles
Allergic Rhinitis: Treatment
- Identify and avoid triggers of allergic reactions - Drug therapy: Nasal sprays, leukotriene receptor antagonists (LTRAs), antihistamines, and decongestants to manage symptoms - Intranasal corticosteroid and cromolyn sprays (decrease inflammation locally) - Provide instructions on proper use of nasal inhalers (they can cause rebound effect from prolonged use). - Immunotherapy ("allergy injections") may be used if drugs are not tolerated or are ineffective.
Type I: IgE Mediated Reaction
- Immediate - Release of inflammatory mediators 4-6 h of drug exposure - Ex. Anaphylaxis and allergic rhino conjunctivitis
Autoimmunity
- Immune responses of an organism against its own healthy cells and tissues - A disease resulting from abnormal immune system - Diseases occur in clusters
Prevention of Organ Rejection
- Immunosuppressant therepy for life
Cigarette Smoking: Effects on Respiratory Tract
- Increased production of mucus - Hyperplasia of mucous glands - Lost or decreased ciliary activity
Other Problems w/ Organ Rejection
- Infection - Damages organ
Pneumonia
- Infection of lungs which leads to inflammation of the lower airways & increased mucus product - Commonly caused by staphylococcus aureus & streptococcus pneumoniae microorganisms - Commonly acquired nosocomial infection - Aspiration pneumonia - breathing bacteria into lungs
Pulmonary Tuberculosis (TB)
- Infectious respiratory disease affecting the lung parenchyma which spreads via droplet transmission - Found worldwide & can be fatal - Droplets of the bacteria Mycobacterium tuberculosis can be spread through talking, sneezing, or coughing - Once inhaled the infection settles into the lungs but can infection any organ in the body - Well defined lesions develop on the lungs that contain the mycobacterium, necrosis changes occur inside - Reactivation of the virus can occur after treatment
Nursing Assessment for Lupus: Integumentary System
- Inflamed red rash - Discoid lesions
Allergic Rhinitis
- Inflammation of the mucous membranes of the nose - Involves reactions in the nasal mucosa from repeated allergen exposures which causes hypersensitivity - Can be seasonal or year round - Common allergens include; pollen from weeds, trees, grass and mould spores
Acute Pharyngitis
- Inflammation of the pharyngeal walls - May include tonsils, palate, and uvula - Can be caused by a viral (most common), bacterial ("strep throat") swollen uvula & white spots, or fungal yeast infection (candidasis) - Usually uncomplicated but can be life-threatening is it causes airway obstruction - Assess C&S
Pleurisy
- Inflammation of the pleurae, which impairs their lubricating function and causes pain when breathing. - Caused by pneumonia and other diseases of the chest or abdomen
Respiratory Viruses
- Influenza viruses - Parainfluenza viruses - Respiratory syncytial viruses - Rhinoviruses - Adenoviruses - Echoviruses, coxsackie viruses, herpes viruses
Penetrating Trauma
- Injury penetrates chest wall - Most common is gunshot & stab wounds
Acute Respiratory Failure (ARF)
- Insufficient ventilation causes inadequate exchange of oxygen and carbon dioxide - Body is unable to maintain enough oxygen or get rid of enough carbon dioxide - CNS depression r/t trauma or medication or disease can like to ARF
Infection
- Invasion of the body by a pathogen - Localized or systemic
T-Helper and T-Suppressor
- Involved in regulation of cell-mediated immunity, if balance is off results in autoimmune disorders - Also called CD4 helper cells
Chronic Obstructive Pulmonary Disease Pathophysiological Changes
- Irreversible airflow limitations during forced exhalation due to loss of elastic recoil - Airflow obstruction due to mucus hypersecretion, mucosal edema, and bronchospasm - Mucus hypersecretion - Dysfunction of cilia - Hyperinflation of lungs - Gas exchange abnormalities
Rhinitis
- Irritation & inflammation of the mucus membranes of the nose - Caused by environmental factors, infectious agents, change in temperature - Causes nasal discharge & congestion, perhaps itchiness & headache as well - Antihistamines, oral decongestants, intranasal corticosteroids, ophthalmic medications to treat
Causes of Pleurisy
- Irritation of the pleura r/t: - A viral infection, such as the flu (influenza) - A bacterial infection, such as pneumonia - A fungal infection - Rheumatoid disease, such as rheumatoid arthritis - Certain medications - Lung cancer near the pleural surface
Managing a Nosebleed
- Keep the patient quiet. - Place the patient in a sitting position, leaning forward, or if not possible, in a reclining position with head and shoulders elevated. - Apply direct pressure by pinching the entire soft lower portion of the nose for 10 to 15 minutes. - Apply ice compresses to the forehead and have the patient suck on ice (Causes vasoconstriction in nose) - Apply digital pressure if bleeding continues. - Obtain medical assistance if bleeding does not stop.
Types of Transplants
- Kidney - Pancreas - Liver - Heart - Lung - Intestine - Limbs - Bone Marrow - Bones - Eyes - Stomach
Natural Killer Cells
- Large lymphocytes involved in recognition and killing of virus infected cells , role in surveillance
Infections Caused by Streptococcus pneumoniae
- Leading cause of pneumonia - Can also cause otitis media, sinusitis, and meningitis
Advantages of Tracheostomy
- Less risk of long-term damage to airway - Increased comfort - Patient can eat - Increased mobility because tube is more secure
Signs & Symptoms of Hypothyroidism
- Lethargy - Apathy - Memory impairment - Emotional changes - Slow speech - Deep coarse voice - Edema of eyelids & face - Thick dry skin - Cold intolerance (Discomfort) - Slow pulse - Constipation - Weight gain - Abnormal menses
Airways
- Lined w/ mucus membranes to add moisture to inhaled air - Also helps to trap foreign particles; dust, pollen, or bacteria - Cilia, small hair-like projections help to move mucus w/ foreign material upward to be coughed out
Goals of Antithyroid Drug Therapy
- Lower activity of thyroid gland
Acute Respiratory Distress Syndrome (ARDS)
- Lungs stiffen as a result of a build up of fluids in the lungs - Fluid builds up in the tissue of the lungs (interstitium) and the alveoli - Damage to surfactant within alveoli leads to alveolar collapse, further impairing gas exchange - Attempts to repair alveolar damage may lead to fibrosis within the lungs - Most commonly caused by shock, sepsis, or as a result of trauma or inhalation injury
Renal Problems Associated w/ Lupus
- Lupus nephritis affects 50% of pts - Kidney involvement, usually silent until damage occurs
Lymph Nodes
- Lymphatic channels and large blood vessels -Thoaric cavity -Abdominal cavity -Groin -Armpit -Neck
Laryngectomy Interventions
- Maintaining a patent airway - Position in Fowler's or semi-fowler's - Deep breath & coughing - Regular cleaning of laryngectomy tube - Promoting adequate nutrition - May be NPO for 10-14 days > TPN or enteral feeds - Good mouthcare, decreased taste & smell - Promoting alternative communication methods - Will need call bell @ all times - May use talking board or pen & paper
Influenza Virus A
- Major epidemic - H1N1
Pregnancy & Lupus
- Major stressor - Can cause exacerbation (during/after) - Risk of miscarriage, stillbirth/premature birth - Pregnancy not recommended if renal, cardiac or CNS involvement present
Factors that Largely Impact Course of HIV/AIDS Disease
- Malnutrition - Age - Substance abouse - Gender - Pregnancy - Infections - Socioeconomic status - Personal experience w/ doctors and healthcare professionals - Education
Tuberculosis: Nursing Interventions
- Malnutrition - Side effects of medications - Multi drug resistance (Frequent appointments to monitor/prevent this) - Spread of TB (Monitor pt to prevent spread of infection)
Lung Cancer Nursing Interventions
- Manage dyspnea, fatigue, nausea, vomiting - Maintain airway patency (remove secretions, deep breathing & coughing, suctioning, chest physiotherapy) - Reduce fatigue caused by poor nutrition, insomnia, pain, discomfort, hypoxemia, anxiety, depression - Provide psychological support
Vital Capacity
- Max amount of air exhaled after max inspiration
Airway Obstruction
- May be complete or partial - Complete obstruction is a medical emergency. - Partial obstruction may occur as a result of aspiration of food or a foreign body; laryngeal edema following extubation; laryngeal or tracheal stenosis; CNS depression; or allergic reactions.
Compliance
- Measure of ease of expansion of lungs - Product of elasticity of the lungs and elastic recoil of chest wall - When compliance is decreased the lungs are more difficult to inflate - Examples include increased fluid (pulmonary edema, ARDS, pneumonia), less elasticity w/ lung tissue (pulmonary fibrosis, sarcoidosis), and restriction of lung movement (pleural effusion) - Compliance increases with damage to alveolar walls and loss of tissue elasticity like in COPD
Inspiratory Force
- Measure of pressure needed to inhale
Tuberculosis: Treatment
- Medications for 6-12 months - Canadian protocol is; #1 - Isoniazid & rifampin & pyrazinamide, #2- Isoniazid, rifampin
Antithyroid Drugs
- Medications used to treat cause of hyperthyroidism - Blocks formation of thyroid hormone
T-Lymphocytes
- Migrate from bone marrow to the thymus - Responsible for immunity against intracellular viruses, tumor cells and fungi
Mild Reactions
- Mild Bronchoconstriction
Influenza Virus B
- Milder disease - Common flu
Prevention of Pulmonary Embolisms
- Mobility - Anti-coagulant therapy - Intermittent leg compression therapy
Assessment of Thyroid Replacement Therapy
- Monitor decreasing symptoms r/t hypo/hyperthyroidism - Monitor T3, T4, TSH levels - Monitor client for signs of decreased compliance with therapeutic regimen
Nursing Interventions w/ Organ Transplant
- Monitor for risk of infection - Many side effects (Fever/Chills, nausea, vomiting, loss of appetite, fatigue) - Ensure therapy regimen compliance
Fractured Ribs
- Most common type of chest injury resulting from trauma - Ribs 5-10 are commonly fractured r/t lack of protection
Beta-Adrenergic Agonists
- Most effective drugs for relieving acute bronchospasms - Relaxes bronchial smooth muscle to cause bronchodilation, lower airway resistance and make breathing easier - Inhalation is much faster acting than oral therapy
Basic Functions of Resp. System
- Movement of air in & out of lungs - Exchange of O2 & CO2 - Helping maintain acid-base balance
Ventilation
- Moves air in (inspiration) and out (expiration) of the lungs - Air flows through nose & pasess into nasopharynx, pharynx, larynx, trachea, and bronchi
Central Nervous System Autoimmune Diseases
- Multiple sclerosis - Gillian-Barre's syndrome
Chest Drainage Interventions
- Must have a seal around entry & all tubes. - To prevent backflow should not raise above chest level - Ensure tubing is not kinked or twisted - May be attached to gravity drainage or wall suction - Always milk tubing toward the drainage system - Encourage DB & C
Immune System Surveillance
- Mutations arise in body but normally recognized as foreign cells and destroyed
Muscular Autoimmune Diseases
- Myasthenia gravis
Drug Therapy to Treat Lupus
- NSAIDs - Antimalarial drugs - Steroid-sparing drugs - Corticosteroids - Immunosuppressive drugs
Thyroid Drugs
- Natural thyroid hormone replacement - Treats low thyroid activity - Dose highly individualized, requires careful periodic adjustment
Examples of Mast-Cell Stabilizers
- Nedocromil (Tilade) - Cromolyn (Intal, Intal Inhaler, Gastrocrom)
Nursing Assessment of Pt w/ HIV
- Neuro check - Skin integrity - Respiratory status - GI system - Nutritional status - Illness history - Medical history plan - Infections - STI's - Risk behavior (needles) - Fluid/electrolyte imbalance
Nervous System Problems Associated w/ Lupus
- Neuropsychiatric problems are prevalent - Can cause seizures and psychosis - Headaches are also common
Oxyhemoglobin
- Oxygen + Hemoglobin
Diffusion
- Oxygen and CO2 move through alveolar capillary membrane through this - Movement from area of higher concentration to area of lower concentration - Continues until equilibrium is reached
Desmopressisn AE
-Water intoxication -Coma -Thromboembolitic disorder -Hyponatremia -Headache -Convulsions -Abdominal pain -Cramping -HTN
Treatment of SIADH
-Water restriction 800 to 1000 -Loop diuretics -INCREASED Salt and Potassium -Demeclocycline DECREASES Renal Tube Responsiveness to ADH
Contact Dermatitis Nursing Interventions
-Wear long sleeves and long pants on outings in the woods -Remove offending plants in the yard -Vinyl gloves (not rubber or latex) -Wash clothing well with soap and water -If contact occurs wash vigorously within ten minutes of contact -Oatmeal baths -Wash lesions daily -Avoid hot showers -Avoid occlusion of lesion
Signs and symptoms of asthma exacerbation
-Wheezing -Dyspnea -Chest tightness -Cough (at night or in morning) -Respiratory alkalosis -PEAK EXPIRATORY FLOW LESS THAN 50% OF NORMAL VALUES -Tachypnea -Tachycardia -Pulse paradoxus (systolic pressure drops 10mmHG)
Assessment Finding That Would Indicate a Worsening State
-Wheezing goes away (obstruction)
WHEN is insulin replacement STARTED?
-When 1 Liter of fluid is administered -The patient has urinated -The potassium is GREATER than 3.3
When is HIV treatment recommended?
-When CD4 count is between 350 to 500
Excessive body heat
-When bodys temp is elevated cells need more oxygen, especially cells under pressure which are already oxygen deficienet
Desmopressin admin alerts
-When given IV for DI, it is given undiluted over 1 minute -AFTER IV FLUIDS MUST BE RESTRICTED AND CAREFULLY MONITORED TO PREVENT WATER INTOXICATION -Tolerance can develop if given more frequently than every 48 hours or by IV
Effects of Second-Hand Smoke
- ↓ Pulmonary function - ↑ Risk of lung cancer - ↑ Respiratory symptoms
The nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's Disease. Which statement by the student indicates an accurate understanding of this disorder?
-"Cushing's disease results from an INCREASED PITUITARY secretion of adrenocorticotropic hormone."
The community health nurse visits a client at home. Prednisone, 10mg PO DAILY, has been prescribed and the nurse teaches about the medication. Which statement by the client indicates a need for FURTHER teaching?
-"I can take my Aspirin or antihistamine if I need it." -(NO OTC meds without physician approval)
The nurse is caring for a client with a diagnosis of Influenza who first began to experience symptoms yesterday. Antiviral Therapy is prescribed and the nurse provides instructions to the client about the therapy. Which statement by the client indicates an understanding of the instructions?
-"I must take the medication exactly as prescribed."
The home health nurse visits a client with a diagnosis of Type 1 DM. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed in 24 hours. Which additional statement by the client indicates a need for FURTHER teaching?
-"I need to stop my insulin."
The nurse is providing discharge instructions to a client who has Cushing's Syndrome. Which client statement indicates that instructions related to DIETARY management are understood?
-"I should eat foods that have A LOT of POTASSIUM in them." -(encourage PROTEIN and POTASSIUM!)
The nurse provides instructions to a client newly diagnosed with Type 1 DM. The nurse recognizes accurate understanding of measures to prevent DKA when the client makes what statement?
-"I will notify my HCP is my blood glucose level is higher than 250 mg/dL"
Rule of nines for adults legs
-18% EACH -9% anterior -9% posterior
Rule of nines for adults back and chest
-18% each
WHEN do newborns have their Thyroid tested?
-2 to 6 DAYS AFTER birth -Too HIGH right away
Venturi Mask
-24% to 55% O2 -Flow rate: 4-10 L/min -Gauge at end of the mask that allows mixing of room air with O2 flow
Nasal Cannula
-24-44% low oxygen concentration -Flow rate: 1-6 L/min
How is vasopressin administered
-3 to 4 times per day -IM, IV, intransal
What should serum potassium levels be KEPT at?
-3.5-5
Simple Mask
-35% to 60% oxygen -Flow rate: 5-8 L/min -O2 delivery affected by: RR, inspiratory flow, adequacy of mask to fit
Serum glucose levels should NOT be lowered MORE THAN
-50 to 75 mg/dl per hour to prevent cerebral edema -Which could lead to coma and seizures
HIV/AIDS Symptoms
-50% of T helper cells destryoed -Can be asymptomatic for 2-15 years -Fatigue -Diarrhea -Weightloss -Neurological changes -Immune deregulation -Hormone imbalance -Metabolic disturbances -Leisions in brain, fingers, spinal cord, peripheral nerves
What should the PaO2 level be KEPT at for someone with ACUTE respiratory failure?
-60 to 70
Non-rebreathing Mask
-60-100% O2 -Flow rate: 10-15 L/min -Valves at exhalation ports -Oxygen reservoir bag with a valve to prevent exhaled air from entering the reservoir -Reservoir has to be 2/3 full
Demeclocycline
-600 to 1200 mg PO -Divided doses twice a day -MAY NOT BE EFFECTIVE FOR TWO WEEKS -Nephrotoxicity and Risk for Infection
Oxygen Hood
-80% to 90% O2 INFANTS ONLY -Allows easy access to chest and lower body
Rule of nines for adults face
-9% -4.5% anterior -4.5% posterior
Rule of nine for infants arms
-9% EACH -4.5% anterior -4.5% posterior
Rule of nines for adults arms
-9% EACH -4.5% anterior -4.5% posterior
The nruse is caring for a client hospitalized with an ACUTE exacerbation of COPD. Which findings would the nurse EXPECT to note on assessment of this client?
-A HYPERinflated chest noted on the chest X-Ray - Decreased O2 saturation with MILD exercise
Cushing's Syndrome
-A METABOLIC Disorder -Resulting from the CHRONIC and EXCESSIVE production of CORTISOL by the ADRENAL CORTEX or by Administration of Glucocorticoids in LARGE Doses for SEVERAL WEEKS or LONGER -(Exogenous or Iartrogenic).
Cushing's Disease
-A METABOLIC Disorder -Characterized by Abnormally INCREASED Secretion (Endogenous) of CORTISOL -Caused by INCREASED Amounts of ADRENOcorticotropic Hormone (ACTH) Secreted by the PITUITARY Gland.
What is Asthma?
-A chronic inflammatory airway disorder
The nurse is performing an assessment on a client with Pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder?
-A heart rate that is 90 BPM and IRREGULAR
What type of virus is HIV?
-A retro virus -In the form of RNA
Chvostek's Sign
-A sign of HYPOcalcemia -A SPASM of the FACIAL Muscles Elicited by TAPPING the FACIAL NERVE just anterior to the EAR.
Influenza Virus
-A, B, & C -Birds are common reservoir -Negative sense single stranded RNA -Hemaglutininin:aids in attachment -Neuraminidase:breaks down mucous -Named according to H and N spikes
Diabetes Results
-ABOVE 200 -Fasting Plasma Glucose= GREATER than 126 -2 Hour Plasma= OVER 200 -PRESENCE of Ketones -A1C GREATER than 6.5
Desmopressin T/P
-ADH replacement -Vasopressin analong
When is a TB client no longer considered INFECTIOUS?
-AFTER THREE sputum cultures are NEGATIVE
Togavirus (Rubella) Teratogenic
-Ability to stop mitosis
GI and Thyroid Storm
-Accelerate protein and fat degradation -Abdominal pain -Nausea -Jaundice
Examples of Mucolytics
-Acetylcysteine (Mucomyst, Mucomyst-10, Acetadote)
Examples of Anticholinergics
-Aclidinium (long-acting- Tudorza Pressair) -Ipratropium (short-acting- Atrovent) -Tiotropium (long-acting- Spiriva)
Acne Neonatum
-Acne in babies -Appears at 2 to 4 weeks -Usually goes away in 4 to 6 months -Could last up to 2 to 3 years
What does hypersecretion of growth hormone cause?
-Acromegaly -Abnormal growth of the hands, feet, and face -Ocetrotide (Sandostatin)
Assault
-Act that results in a persons genuine fear
The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for TB. Which instructions should the nurse INCLUDE on the list?
-Activities should be resumed gradually. -A sputum culture is needed every 2-4 weeks once medication therapy is initiated. -Respiratory isolation is NOT necessary because family members have already been exposed. -Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.
When is parenteral anticoagulation used?
-Acute PE with thrombolytic therapy in massive PE
Arbovirus Symptoms
-Acute fever and rash -Establish in brain, swelling -Coma -Paralysis -Loss of coordination -Memory deficits
What is Bronchiolitis?
-Acute inflammatory process of the bronchioles and small bronchi
SLE Acute Intervention
-Acute intervention -Severity of Symptoms -Response to Therapy -Intake and Output -Observe for Signs of: -Bleeding, such as: -Pallor -Skin Bruising -Petechiae -Tarry Stools
Varizella-Zoster Virus Treatment
-Acyclovir -There is also a vaccine
What is done when the blood glucose reaches 200 in DKA?
-Add 5% DEXTROSE to the fluid to assist in the resolution of Ketosis
Hyposecretion of the adrenal cortex
-Addisons disease -Corticosteroids
The nurse is caring for a client admitted to the ED with DKA. In the ACUTE phase, the nurse plans for which PRIORITY intervention?
-Administer SHORT-duration insulin IV.
A client with HYPERthyroidism has been given Methimazole (Tapazole). Which nursing considerations are associated with this medication?
-Administer WITH FOOD. -Assess the client for unexplained BRUSING or BLEEDING. -Instruct the client to report side/adverse effects such as: -Sore Throat -Fever -Headaches.
Zidovudine (Retrovir, AZT) administration alerts
-Administer on an empty stomach (water only) -Avoid administering with fruit juice -Category C
Levothyroxine (Levothroid, Synthroid) admin. alerts
-Administer the same time every day -Administer in the morning to decrease potential for insomnia
Propylthiouracil admin. alerts
-Administer with meals -Lab work and blood values done periodically
Hydrocortisone T/P
-Adrenal Hormone -Corticosteroid
Symoptoms of cushing syndrome
-Adrenal atrophy -Osteoporosis -HTN -Delayed wound healing -moon face -buffalo hump -Acne -Obesity -Peptic ulcers -Psychologically dependent on the drug
Lupus
-Affects more females then males -Affects more African Americans then Caucasians -Fever -Malaise -Weightloss -Anorexia -Butterfly shaped rash across the bridge of the nose and cheeks -Discoid Rash -Polycyclic leisions
When is child NOT contagious and can return to school?
-After 24 hours of antibiotics -Throw away tooth brush to avoid reinfection
Propylthiouracil AE
-Agranulocytosis -Bradycardia -Hepatotoxicity -Rash -Transient leukopenia -SYMPTOMS OF HYPOTHYROIDISM
What is Pneumothorax
-Air in the pleural space -Usually causes from traumatic force or occurance
Objective Physical Findings During the Emergent Phase of Burn Injury
-Airway & Breathing (upper burns) and circulation -Pain (Lower burns) -Tachycardia -Amount of fluid coming out of the body -Mouth and nose and in sputum (inhalation) -Hoarse voice -Notice and document circumferential burns
Glimepride (Amaryl) is prescribed for a client with DM. The nurse instructs the client to AVOID consuming which FOOD while taking this medication?
-Alcohol
Standard Precautions
-All health care workers use standard precautions whether or not they have HIV -Hand washing -Gloves
What two regions make up the pitutary gland?
-Anterior (adenohypophysis) -Posterior (neurohypophysis)
EIA
-Antibodies are detected against HIV
What drug can induce HYPOthyroidism
-Antidysrythmic Amiodarone (Cordarone)
What is Contact Dermatitis?
-Antigentic substance exposure -Allergy to nickel, cobalt, or plants
Thyroid Storm Supportive Care
-Antipyretic -COOLING blankets -Ice packs -O2 -HIGH calorie -HIGH protein
Hereditary risk factors of PE
-Antithrombin deficiency -Protein C deficiency -Protein S deficiency -Factor V Leiden -Activated Protein C resistance -Dysfibrinogenemia -Plasminogen deficiency
Hyper-resonance could mean
-Asthma
Palpation of Cystic Fibrosis
-Asymmetric chest excursion (bc of atecletasis) -Tactile fremitus -Tenderness over liver
Silver Sulfadiazine (Silvadene)
-Bactericidal -FOR BURNS -Apply two times a day -Cover with occlusive dressing -DON'T USE IN CHILDREN WITH SULFA ALLERGY -DON'T use on face or a child younger than two months -May cause transient neutropenia
What are Antibiotics (systemic) used for?
-Bactericidal or bacteriostatic -Acne vulgaris -Extensive impetigo -Cellulitis -Scalded skin syndrome
Promoting skin integrity
-Balance b/w rest and mobility -Turn pt every 2 hours -Apply lotion, ointment, and dressings to affected skin
Examples of Glucocorticoids
-Beclomethasone (Beclovent, Apo- Beclomethasone) -Budesonide (GEN-Budesonide) -Fluticasone (Flovent) -Methylprednisolone (Medrol, Methylprednisolone Sodium Succinate) -Prednisone (Apo-, Novo-prednisone) ** -Triamcinolone (Nasacort, Nasacort)
Hemopoiesis
-Begins early in embryonic membrane -Red bone marrow
Influenza Flu
-Begins in the UPPER respiratory tract -1 to 4 day incubation period
Justice
-Being treated fairly
Beneficence
-Benefit or promote the goods of others -Act in clients interest
What is used for ANTAGONISM of Peripheral Effects of Thyroid Hormone
-Beta blocker -propanolol (Inderal) - Lowers heart rate -HIGH dose glucocorticoids
Mast-Cell Stabilizers
-Block MAST cells from releasing histamines & other chemical mediators -Prevens Bronchoconstriction -SAFE drugs for PREVENTING asthma -Ineffective for ACUTE Bronchospasms -LESS EFFECTIVE than INHALED Glucocorticoids
Anticholinergics
-Block parasympathetic nervous system for bronchodilator effect -Occassionally used as alternative to beta-agonists in asthma therapy -First line of treatment for COPD (Chronic obstructive pulmonary disease)
Kaposi's Sacroma Virus HSV-8 Transmission
-Blood -Sex
Hepatitis B & C Transmission
-Blood Transfusion -Drug use -Tattoing, body piercing -Sexual
WHEN can patients be transitioned to SubQ insulin
-Blood glucose less than 200 -pH greater than 7.3 -Bicarb greater than 15 -Calculated anion gap is 12 or less
What is intrapulmonary shunting
-Blood returns to the left side of the heart without participating in gas exchange
What are patients with Myxedema UNABLE to maintain?
-Body HEAT -DECREASED Metabolic Rate
What are fluid resuscitation requirements?
-Body weight in kg -The % of TBSA burned -Patients age - 4mL x wt (kg) x TBSA (%)
Growth Hormone Deficiency Lab Tests
-Bone Age -CT or MRI -Pituitary Function Test
Growth Hormone Deficiency Results
-Bone age shows TWO or MORE deviations BELOW normal -CT or MRI rule out tumors or structural abnormalities -Peak GH levels BELOW 7 to 10 in TWO tests
What does asthma do to the airways?
-Bronchoconstriction -Airway edema -Mucus plugging -Airway remodling
What happens in status asthmaticus?
-Bronchoconstriction does not respond to bronchodilators -Hypercapneia -Hypoxia -Respiratory acidosis
A Cromolyn Sodium Inhaler is prescribed for a client with Allergic Asthma. The nurse provides instructions regarding the side and adverse effects of this medication and should tell the client that which UNDESIRABLE effect is associated with this medication?
-Bronchospasm
Eschar
-Brown or black necrotic tissue
What stage is AFTER the Cleavage Phase?
-Budding
Complications with EBV
-Burkitt Lymphoma -Tumor of connective tissue jaw -Nasopharyngeal Carcinoma -Malignancy of epithelial cells -Seen more in underdeveloped countries
What does HIV use to ENTER T cells?
-CCR5 or Chemokine Receptors
Stage 2
-CD4 T cells are 200 to 499
What type of cells does HIV target?
-CD4 cells on T lymphocytes
If there is NOT water in the WATER SEA chamber then the AIR can do what?
-COLLAPSE the lung
Diabetes Insipidus Lab Tests
-CT,MRI,Ultra sound of skull and kidneys -Urinalysis -Specific Gravity -Urine Osmolarity -Sodium -Fluid Deprivation Test
How are Proviruses spread when they are LATENT?
-Can be stimulated by activation such as another infection
HPV Prevention
-Can detect early with pap smear -Incurable; treatments to maintain
Thyroid storm
-Can lead to death -Severe HYPERthyroidism -Antithyroid drug used -Treated with supported methods
Friction
-Can remove superficial layers of the skin -Sheets rubbing against the patient
What can happen when administering HYPERtonic saline / correcting Serum Sodium too quickly?
-Can result in Central Pontine Myelinolysis -LEAD TO PERMANENT BRAIN DAMAGE OR DEATH
Cardiac and Myxedema
-Cardiac function depressed -DECREASED BP -Stroke volume -Contractility -Cardiac Putput -May develop PERICARDIAL EFFUSION
Therapeutic Management of Cystic Fibrosis
-Chest physiotherapy -Postural drainage -Physical exercise -Increased calorie high protein diet -Lung transplant -Pancreatic enzymes given with food to maintain nutrition
Pneumothorax Nursing Management
-Chest tube -Monitor respiratory status and effort -100% oxygen for a few hours -Chest tube is occlusive -Keep tube free of kinks -Keep drainage unit below level of patient. -Do NOT milk tube -Do NOT clamp tube, unless ordered or in emergency -If tube comes dislodged from: -Adults chest: put in sterile water or clamp with Kelly Clamp, perform respiratory assessment, and notify the MD -Child's chest: put a Vaseline occlusive dressing, perform a respiratory assessment, and notify the MD
Who is more likely to get Influenza?
-Children in day care or school -Diabetics -Heart or lung disease -Renal disease -Immune deficiency -Children receiving chemo
Systemic Lupus Erythematosus
-Chronic -Multi-System Inflammatory Disease -Associated with ABNORMALITITES of Immune System -Results from interactions among: -Genetic -Hormonal -Environmental -Immunological factors -SLE affects 17,000 Canadians -10 times more likely in WOMEN -Affects the following: -Skin -Joints -Serous membranes -Renal system -Hematological system -Neurological system
What happens AFTER Viral Set Point is reached?
-Chronic Stage persists in which the body cannot fight it off
What is Seborrhea
-Chronic inflammation may occur on the skin or scalp -Also known as cradle cap -Could be on eyes, ears, nose or diaper area
Psorasis
-Chronic inflammatory skin disease
Hepatitis C affects
-Chronic liver disease -Liver cancer
Secondary Lymphoid Organs
-Circulatory -Spleen -Lymph nodes
To INVOLUNTARILY commit someone there MUST be
-Clear Probable Cause -Convincing Evidence
What stage is AFTER Translation?
-Cleavage
Herpes SV-1 Transmission
-Close contact; usually to the face
What is the stage AFTER Attachment?
-Coating
A client has begun therapy with Theophylline (Theo-24). The nurse should plan to teach the client to LIMIT the INTAKE of which items while taking this medication?
-Coffee -Cola -Chocolate -(No caffeine!)
What is Empyema?
-Collection of PUS in the PLEURAL cavity
SLE Evaluation
-Completion of PRIORITY activities -Communication of having MORE energy -Expression of SATISFACTION with pain relief measures -Performance of Activities of Daily Living WITHOUT pain -Limitation of DIRECT exposure to sun and use of sunscreen -NO OPEN skin lesions -Expression of SATISFACTION with activity level -PACING of activities to match level of tolerance -Expression of CONFIDENCE in ability to MANAGE SLE over time and in home environment
How do you prevent PEs?
-Compression stockings -Intermittent pneumatic compression devices -Mobilization regimen -Avoid using pillows under knees -Assess extremities on a regular basis
Ways to prevent the spread of HIV
-Condoms (LATEX ONLY) -One partner -Abstinence -Clean needles for drug use -Dont ingest urine or semen -Dont share needles, toothbrushes, sex toys, razors
Togavirus (Rubella) Diagnosis
-Confirmed by serologic studies
Mucolytics
-Control EXCESS mucus production -Helps to LOOSEN THICK BRONCHIAL secretions -(Easier to cough up)
Expectorants
-Control excess mucus production -INCREASE BRONCHIAL Secretions -(THINS Mucus Out so it can be coughed up)
A client with DM demonstrated acute anxiety when first admitted to the hospital for treatment of HYPERglycemia. What is the MOST APPROPRIATE intervention to DECREASE the client's anxiety?
-Convey empathy, trust, and respect towards the client.
How do you CONTRACT Legionnaire's Disease
-Cooling Tower Water -Warm Stagnant Water -Whirl Pool Spas -Showers
What hormone does the adrenal cortex secrete?
-Corticosteroids
What Glucocorticoids are secreted from the adrenal cortex
-Cortisol -Corticosterone -Cortisone
If the water in the WATER SEAL chamber spills what will you have the client do when water is put back in?
-Cough and Deep Dreathe
What if there is CONTINUOUS bubbling in the WATER SEAL chamber?
-Could be an AIR LEAK -Call HCP -ONLY CLAMP for a FEW SECONDS with provider's ORDERS -NEVER LEAVE patient if you CLAMP tube
Active acquired immunity
-Could be from natural exposure -Or from a vaccine
Involuntary Outpatient Commitment
-Court ordered -History of repeated decompensation -Likelihood that without treatment the patient will deteriorate -Severe persistent mental illness -Could become homeless, incarcerated, violent, suicidal -Treatment plan likely to be effective
Rhales
-Crackling -Alveoli become filled with fluid
What does hypersecretion of the adrenal cortex cause?
-Cushings syndrome -Antiadrenal drugs
Isotretinoin (Accutane)
-Cystic or severe acne that is resistant to treatment with oral antibiotics -PREGNANCY TESTS -Monitor for SUICIDE
Diagnostic tests for PE
-D-Dimer -V/Q perfusion -Pulse ox -ABG(hypoxemia or hypocapnia) -ECG (tachypnea) -Chest x-ray (rules other things out)
CBC
-DECREASED RBCs
Skeletal Muscle and Myxedema
-DECREASED tendon reflexes -Sluggish -Awkward movements
LOW pressure alarm
-DISCONNECTION or LEAK in the ventilator -The client STOPS SPONTANEOUS breathing
What is the stage AFTER Uncoating?
-DNA Synthesis
Where do most pulmonary embolisms originate from?
-DVTs of the lower extremities
Antitussives
-Dampen Cough Reflex -Raise Cough Threshold in CNS -(REDUCE Activity of Cough Reflex in BRAIN) -May be OPIOD or NON-OPIOD
When is oral anticoagulation used?
-Day 1 -Continue until INR is in therapeutic range for at least two days
What are antibiotics (topical) used for
-Decrease skin colonization with bacteria -Acne -Impetigo -Folliculitis
Diabetes Insipidus Plasma Volume
-Decreased
Diabetes Insipidus Urine Osmolality
-Decreased -Less than 100 mOsm
Benzoyl peroxide
-Decreases colonization of acne
A client with a diagnosis of DKA is being treated in the ED. Which findings would the nurse EXPECT to NOT as confirming this diagnosis?
-Deep, rapid breathing -Elevated blood glucose level -Low plasma bicarbonate level
Interferons
-Defense against viral infections -Non-specific immunity -Induced in early stages of viral infections
Ischemia
-Deficincy in the blood supply to the tissue -Cause of pressure ulcers -Tissue dies as a result of the compression of the bed and bony skeleton
Metered Dose Inhaler (MDI)
-Delivered Measured Dose of Drug -Most Commonly Used -Pt TIMES BREATHS with PUFFS of Inhaler
The home health care nurse is visiting a client who was recently diagnosed with Type 2 DM. The client is prescribed Repaglinide (Prandin) and Metformin (Glucophage) and asks the nurse to explain these medications. The nurse should provide which instructions to the client?
-Diarrhea may occur SECONDARY to the METFORMIN. -The Repaglinide is NOT taken if a MEAL IS SKIPPED. -The Repaglinide is taken 30 min BEFORE EATING. -A SIMPLE sugar food item is carried and used to treat MILD HYPOglycemia episodes.
Disadvantages of Aerosol Therapy
-Difficult to Measure Precise Dose -(Usually ONLY 10-50% of Drug is Placed) -Instructions May Be Too Complicated for Some Clients -Side Effects Occur if Client SWALLOWS PILLS or Doesn't RINSE Mouth AFTER Inhalation
The nurse has given a client taking Ethambutol (Myambutol) information about the medication. The nurse determines that the client understands the instructions if the client states he or she will IMMEDIATELY report which finding?
-Difficulty in discriminating the color RED from GREEN.
Benefits of Edema and Chemotaxis
-Dilutes toxic substances -Fibrin clot can trap and prevent spread -Phagocytosis
How is RSV contracted?
-Direct contact with respiratory secretions or particles on objects contaminated with the virus
What is used for patients who have heparin induced thrombocytopenia?
-Direct thrombin inhibitors -Argatroban or lepirudin
Epestein Barr Virus Transmission
-Direct, oral contact and contamination -By mid-life 90-95% of people are infected -Affects college age population -Immune deficiency is more susceptible
Stage 3
-Disability benefits housing and food stamps
Desmopressin OD
-Diuretics -Water restrictions
Nonmalficence
-Do no harm to client intentionally or unintentionally
Levothyroxine black box warning
-Dont use for weightloss or obesity
Herpes Viruses
-Double Stranded _Enveloped -All members show latency and cause recurrent infection -Common and serious opportunists among AIDS patients
Hepatitis B
-Double stranded DNA -Can cause life long infection (cirrohis)
Blood composition
-Draw blood -Centrifuge into blood sample - Plasma(55% of whole blood) - Buffy Coat(<1% leukocytes)-Erthrocytes (45% whole blood)
Propylthiouracil (PTU) T/P
-Drug for HYPERthyroidism -Antithyroid drug
Desmopressin actions
-Drug for diabetes insipidus -Acts on kidneys to reabsorb water -Oral route is preferred -Can be given intransal or parenteral -Duration of 20 hours -Causes contractions of the vascular system, uterus, and GI -Used for the management of bleeding in patients with hemophillia A -When taken before bed time it lowers the production of urine made at night, which decreases bed wetting
Levothyroxine (Levothroid, Synthroid) actions
-Drug of choice for patients with low thyroid -Weight loss, improved tolerance to temperature, increased activity, increased pulse rate -When taken orally it takes 1 to 3 weeks to reach therapeutic effects -Patients with cardiac disease are increased at 4 to 6 week intervals to avoid dysrhytmias -TSH checked regulararly.. too much =adminsiter T4
SLE Care
-Drug therapy: -NSAIDs -Antimalarial Drugs -Steroid-Sparing Drugs -Corticosteroids -Immunosuppressive Drugs
Goals Behind Treatment of Asthma
-Drugs Used to Stop ACUTE Bronchospasms in Progress & REDUCE FREQUENCY of Asthma Attacks - Different Medications are Needed to Achieve EACH GOAL -Client with Asthma can Present with ACUTE or CHRONIC Symptoms
Hepatitis B Maternal-fetal Transmission
-During delievery
Hepatitis C Maternal-fetal Transmission
-During pregnancy or delievery
What are the hallmark signs of COPD
-Dyspnea -Chronic cough -Sputum production -Barrel chest -Pursed lip breathing -Use of accessory muscles -Wheezing -Crackles -Diminished breath sounds -Chest tightness
What is the patient monitored for on Desmopressin?
-Dyspnea -HTN -Weight gain -Hyponatremia -Headache -Drowsiness
Diagnostic Tests for HIV
-EIA/ELSA (not definitive diagnostic) -Western blot (when ELSA is positive) -Viral load -CD4/CD8 -Oraquick
Psychosocial Considerations for a patient with HIV/AIDS
-Find out their usual level of social interaction to provide a baseline -Encourage them to express their feelings -Provide info on how to protect themselves and others -Encouraged to stay in contact with family and friends -Local or national AIDS support groups -Continue usual activity as much as possible -Consultations with mental health counselors -Education about HIV
Variola Virus - Small Pox
-First disease to be eliminated by vaccination
Staphlycoccal Scalded Skin Syndrome
-Flattish bullae that rupture within hours -Red weeping surface on face groin neck and axillary -Antibioitcs -IV -Fluid management
Interferons most common side effects
-Flu like symptoms -Fatigue -Headache -Anorexia -Diarrhea
Treatment of MILD SIADH
-Fluid intake restricted to 800 to 1000 mL a day -Liberal Protein and Sodium intake
BEFORE you start insulin therapy you need to make sure...
-Fluid replacement is underway -Potassium is greater than 3.3
Diabetic Ketoacidosis (DKA) Signs and Symptoms
-Flushed dry skin -Dry mucous membranes -Decrease skin turgor -Tachycardia -Hypotension -Kussmaul's respirations -Acetone breath -Altered LOC -Visual disturbance -Polydipsia -Nausea and vomiting -Anorexia -Abdominal pain
Retinoids (topical)
-For severe acne -Dryness, burning -USE SPF 15 SUNSCREEN
Antihistamines
-For: -Hypersensitivity -Atopic dermatitis -Contact dermatitis -May give three or four times daily -SEDATION EFFECTS
Lymphatic Fluid
-Formed by blood plasma moving out of blood vessels into ECF and into lymphatic capillaries
How to prevent the common cold
-Frequent hand washing -Healthy diet -Adequate rest -Avoid second hand smoke -Avoid large crowds in the winter
Shearing Force
-Friction and pressure -Caused from patient sitting up in bed -Body slides downward which moves pressure to the sacral bone and deep tissue
When do other sinuses come in?
-Front and sphenoid develop at 6 to 8 years
Stage 3
-Full thickness skin loss -Extends into the dermis and subcutaneous tissues -Necrosis -Slough may be present -Does not go through underlying fascia -Subcutaneous tissue may be visible -Undermining and tunneling may or may not be present.
Unstageable
-Full-Thickness loss -Wound bed is covered by slough and/or eschar -Unknown true depth -Stage of wound cannot be determined until debridement -Covered in slough -Could be a stage III or IV
Stage 4
-Full-Thinkness skin loss is present -Necrosis with damage to muscle, bone, tendon or joint capsule -Slough or eschar may be present -Osteomylitis and sepsis can occur -Undermining and tunneling may be develop
Candidiasis
-Fungal infection -Creamy white patches in the oral cavity -Can progress into the esophagus and stomach -Difficult and painful swallowing pain behind the breast bone -Not always from HIV
Antifungals (topical)
-Fungicidal used to treat -Tinea -Candidal diaper rash -apply a thin layer
WHEN should infection be SUSPECTED in Myxedema Coma?
-GREATER than 98.6 F Temperature
HPV Vaccine
-Gardaisl -ages 9-26
Nortons Pressue Area Risk Assessment For Scale
-General physical condition -Mental state -Activity -Mobility -Incontinence
HSV-2
-Genital and anal lesions -Painful sores -Severe in immuocompromised - Outbreaks can be caused by stress - More susceptible to HIV
If susceptible to RSV and under age of two
-Get Palivizumab(Synagis) shot -Given once a month for the RSV season -IM injection
Hydrocortisone admin. alerts
-Give at the same time every day -GIVE WITH FOOD -DC GRADUALLY
Zanamavir (Relenza)
-Give within 48 hours of treatment to shorten influenza symptoms from 7 days to 5 days
What does the Anterior Pituitary (Adenohypophysis) do?
-Glandular tissue that secretes -ACTH -TSH -Growth hormone -Prolactin -LH
What is given for patients with HYPOadrenalism and HYPOthyroidism?
-Glucocorticoid administration -Hydrocortisone 100 mg -Followed by 50 to 100 every 6 to 8 hours for 7 to 10 days
Serum Sodium level in Dibetes Insipidus
-Greater than 145
Thymus
-Grows until puberty -Then shrink -T cell maturation
What horomone does the pituitary gland secrete
-Growth hormone -ADH
What is somatotropin?
-Growth hormone -Can cause short stature -If severe it can cause dwarfisim
Avian Influenza A Virus
-H5N1 -Direct contact -Infected poultry or contaminated surfaces
What do people in the BEGINNING stages of HIV test negative for?
-HIV -Even though their viral load is VERY HIGH
What happens in the Cleavage Phase?
-HIV enzyme protease cuts the Polyprotein Chain into individual proteins that make up the new virus
What is Viral Set Point
-HIV is equal with the immune response -THE HIGHER the Viral Set Point, the POORER the PROGNOSIS
Cardiac and Thyroid Storm
-HYPERDYNAMIC HEART -HIGH output HF -Cardiovascular collapse -Palpitations -TACHYCARDIA -Widened pulse pressure -S3 -Systolic murmur
Percussion of Cystic Fibrosis
-HYPEResonnacne -Dullness over abdomen (enlarged liver or mass)
How to help SEVERE HYPOnatremia? (LESS than 120)
-HYPERtonic saline -With or without loop diuretic
A client is taking Humulin NPH insulin and REGULAR insulin EVERY MORNING. The nurse should provide which instructions to the client?
-HYPOglycemia may be experienced BEFORE DINNERTIME. -The insulin should be administered at ROOM temp.
What suggests Nephrogenic DI?
-HYPOkalemia -HYPERcalcemia
Hallmark Sign of SIADH
-HYPOnatremia -HYPO-osmolality -Concentrated urine
Addison's Disease
-HYPOsecretion of ADRENAL CORTEX Hormones (glucocorticoids and minerlcorticoids) from the adrenal gland -Resulting in DEFICIENCY of the CORTICOIDS and MINERALALCORTICOID Hormones -FATAL if UNTREATED.
Signs of HYPOvolemia
-HYPOtension -Decreased skin turgor -Dry mucous membranes -Tachycardia -Weight loss -Low RIGHT ATRIAL and PULMONARY ARTERY occlusion pressure
HHS Urine
-HYPOtonic
How to correct HYPERnatremia
-HYPOtonic solution of DEXTROSE in water
Respiratory and Thyroid Storm
-HYPOventilation -CO2 RETENTION -Respiratory Acidosis -Respiratory failure
Respiratory and Myxedema
-HYPOventilation -Respiratory muscle weakness -CO2 RETENTION -May develop PLEURAL EFFUSION or UPPER AIRWAY EDEMA
What is the most common cause of HYPOthyroidism
-Hashimoto thyroiditis
SLE Goals
-Have SATISFACTORY pain management -Adhere to Therapeutic Regimen to achieve MAXIMUM symptom management -Demonstrate AWARENESS of and AVOID activities that cause disease EXACERBATION -Maintain OPTIMAL role function and a POSITIVE self-image
How to REMOVE the chest tube
-Have the client take a DEEP BREATHE -Valsalva (bare down) -Place an OCCLUSIVE PETROLEUM dressing over the site
Side effects of Desmopressin
-Headache -Nausea -Mild abdominal cramps
Congenital Rubella Syndrome
-Hearing Loss -Neurological problems -Ophthalmic problems
Protective devices
-Heel protector -Alternating pressure mattress -Water bed -Static low air loss bed-press
Ocular Herpes HSV-1
-Herpetic Keratitis -Ulceration of cornea -Can lead to blindness
Variola Virus symptoms
-High fever (flu like) -Skin rash -Can lead to death
What is Cushings Syndrome
-High levels of corticosteroids are present in the blood over a prolonged period
What is Stridor?
-High pitched -Audible INSPIRATORY noise -Sign of UPPER airway obstruction -"Stride to inspire up"
Wheezing
-High pitched -Usually occurs on EXPIRATION -Results from obstruction of the bronchioles -If clears with coughing it is secretions in the lower trachea -"WhEEzing is to ExpirE"
Preferred tool for detecting PE
-High resolution multi detector CT angiography -Shows direct visualization of the large emboli in the main and lobar pulmonary arteries -D-Dimer
Paramyxovirus Mumps
-Highly contagious -Upper and lower respiratory tract -Spreads to lymphs - MMR vaccine
What is Urticaria
-Hives -May go away in a few days or take 6-8 weeks
What is the parkland formula?
-How much LR to give in the first 24 hours -4mL x wt (kg) x TBSA (%) = Volume (mL) -Half is given in the FIRST 8 hours -Ex) 2,400mL/2 = 1,200 for FIRST 8 hours - Remaining volume divided into HALF again for second and third 8 hours - Ex) 1,200 (remaining)/2 = 600 mL Second & 3rd 8 Hours (16 hours total)
Discharge teaching for asthma
-How to implement environmental controls -Understand diff. in meds that control or relieve symptoms -Properly use inhaler devices -Written action plan is made
Cyanosis is a result of
-Hypoxia -Usually presents first around the MOUTH
Prednisone is prescribed for a client with DM who is taking Humulin NPH insulin daily. Which prescription change does the nurse anticipate during therapy with Prednisone?
-INCREASE in the amount of daily NPH insulin
HYPERpituitarism Lab Tests
-INCREASED level of Insulin-Like Growth Factor -FAILURE to suppress Serum GH AFTER Oral Glucose Challenge Test -Bone Scan determines whether the Epiphyseal Plates are CLOSED -MRI to detect any TUMORS
Precocious Puberty Lab Tests
-IV GnRH -If: LH, FSH, estrogen or testosterone come back at ADULT LEVELSthe test is POSITIVE -CT,MRI, skull radiography shows any signs of TUMORE or CYSTS present in the abdomen, pelvic area, or testes
A client is brought to the ED in an unresponsive state and a diagnosis of HYPERglycemia HYOERosmolar Nonketotic Syndrome (HHNS) is made. The nurse would IMMEDIATELY prepare to initiate which anticipated health care provider's prescription?
-IV of Normal Saline
Causes of pressure ulcers
-Immobility -Inadequate nutrition -Fecal and Urinary Incontinence -Decreased mental status -Diminished sensation -Excessive body heat -Advanced age -Chronic Medical condition
When is a person INVOLUNTARILY committed?
-In an emergency situation (dangerous to self or others) -For observation and treatment of a mentally ill patient -When someone is unable to take care of basic patient needs (gravely disabled)
OraQuick
-In home HIV test
Contraindication of somatotropin?
-In patients are the epiphyses have closed
The nurse is preparing a plan of care for a client with DM who has HYPERglycemia. The nurse places the HIGHEST PRIORITY on which client problem?
-Inadequate Fluid Volume
Effects of glucocorticoids:
-Increase blood glucose -Increase breakdown of proteins and lipids -Supress inflammatory and immune response -Increase sensitivity of vascular smooth muscle to norepinephrine and angiotensin 2 -Promotes bronchodilation
Pyrogens
-Increase body temp -Increase heat production -Vasoconstriction
Pulmonary System and SIADH
-Increase respiratory rate -Dyspnea -Adventitious lung sounds -Frothy pink sputum
Diabetes Insipidus Serum Sodium
-Increased
Diabetes Insipidus Serum Osmolality
-Increased -Greater than 295
HIGH pressure alarm
-Increased SECRETIONS -Wheezing or Bronchospasm -Endotracheal Tube is DISPLACED -Vent Tube is OBSTRUCTED -Client cough GAGS or BITES the ET Tube -Client is ANXIOUS and FIGHTING the ventilator
Nursing Management of Chronic Lung Disease
-Increased caloric formula -Fluid restrictions/diuretics -Echocardiograms
What is the CD4 count?
-Indicator of immune function -Strongest predictor in subsequent disease progression
Autonomy
-Individuals are capable of making independent choices for themselves
Benefit of Pyrogens
-Inhibit multiplication of microorganism -Increase immune reaction of host
Stages of Swelling
-Injury -Rubor (redness) -Calor (heat) -Tumor (swelling) -Dolor (pain)
Pressure Ulcer
-Injury to skin and/or underlying tissue usually over a bony prominence as a result of force alone or in combination with movement -Multiple stages or un-stagable (worst)
Lines of defense against infection
-Intact skin -Mucous membranes -Cilia of the respiratory tract (coughing and sneezing) -Sweat, tears, sebaceous substances, acidic gastric secretions, saliva
What stage is AFTER DNA Synthesis?
-Integration
Propylthiouracil actions
-Interferes with the synthesis of T3 and T4 -Prevents the conversion of T3 and T4 in the target tissues -Action may be delayed for days to up to 6 to 12 weeks -Weight gain, reduction in anxiety, less insomnia,slower pulse -Administered several times per day
Zidovudine (Retrovir, AZT) drug-drug
-Interferon alfa -Aspirin -Methadone -Valproic acid -Dont use with Saint Johns Wort
Piconavirus Target
-Intestinal epithelial - Motor neurons
Symptoms of HYPOthyroidism
-Intolerance to cold -Weakness -Muscle cramps -Dry skin -Slurred speech -Weight gain -Bradycardia
Symptoms of HYPERthroidism
-Intolerance to heat -Weight loss -Tachycardia -Increased body metabolism
If a client REFUSES medications...
-Involuntary commitment -Legal competency hearing -Client discharge
Wasting Syndrome
-Involuntary weight loss of lean and fat mass -Anorexia, diarrhea, malabsorption, and lack of nutrition -Increase protein metabolism leads to muscle and protein break down
What is essential for the synthesis of T4 and T3?
-Iodine -Found in salt
Blockage of Thyroid Hormone
-Iodine agents -SSKI or Lugols -Given 1 to 2 hours AFTER anti-thyroid drugs
Suspected Deep-Tissue Injury
-Ischemic subcutaneous tissue injury -Under intact skin -Appears purple or maroon colored -May be painful, firm, or boggy
What does vasopressin do?
-It enhances water reabsorption
When a client threatens to harm self or others
-It is the duty of the nurse to tell the other health care team members and document
What does the hypothalamus do?
-It secretes releasing hormones that travel through the blood vessels to the pituitary gland -These hormones speicfy what horomone is to be released by the pituitary gland -Temperature Regulation
Congenital Cytomegalovirus
-Jaundice -Loss of hearing -Enlarged liver or spleen -Ocular inflammation
RA signs and symptoms
-Joint pain -MORNING stiffness lasting longer than an hour -Swelling -Warmth -Errythema -Lack of function -Spongy or boggy tissue -Symptoms are bilateral and symmetric -Deformities in the hand are common -Fever -Weight loss -Fatigue -Anemia -Lymph node enlargement -Raynauds syndrome (blanching or cyanosis in fingernails)
Grave PROGNOSIS for patients with what TEMPERATURE?
-LESS than 88.6 F
Sodium
-LEss than 130
What should a patient with a high risk for PE receive?
-LMWH
Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Lab Tests
-LOW Serum Sodium -LOW Serum Osmolality -DECREASED: -Urea -Creatinine -Uric Acid -Albumin -Specific Gravity GREATER than 1.030 -ELEVATED Sodium Osmolality
Poxvirus
-Largest genome -Double stranded DNA -Specificity: Epidermal and subcutaneous connective tissue
The nurse is caring for a post-op parathyroidectomy client. Which client complaint would indicate that a life-threatening complication may be developing, requiring notification of the HCP IMMEDIATELY?
-Laryngeal Stridor
Herpes Simplex Virus 2
-Lesions on genitalia - Sexually Transmitted
Herpes Simplex Virus 1
-Lesions on the face or mouth -Usually occurs in childhood
HHS Bicarbonate
-Less than 15
Bicarbonate DKA
-Less than 20
HHS pH
-Less than 7.3
pH DKA
-Less than 7.3
Agranulocytes
-Leukocytes -specific immune respone (T and B cells) -large spherical nucleus -Monocytes -give rise to macrophages and dendritic cells -kidney shaped nucleus
What medications are used to TREAT Myxedema Coma
-Levothyroxine sodium 200 to 500 mcg IV loading dose -Then 50 mcg/day IV -Liothyronine Sodium 25 mcg IV every 8 hours for 24 to 48 hours -Then 12.5 mcg every 8 hours
Partial Re-breathing Mask Nursing Interventions
-Liter flow must be set at 10 to 12 L/min to prevent rebreathing of CO2 -Reservoir bag does not completely empty when child inspires if set correctly
Oxygen Hood Nursing Interventions
-Liter flow must be set at 10 to 15 L/min -Need to remove infant for feeding -SHOULD be humidified
What is given to patients with an Iodine Allergy to BLOCK Thyroid Hormone?
-Lithium Carbonate
A client with TB is being started on Anti-TB Therapy with Isoniazid. Before giving the client the FIRST dose, the nurse should ensure that which BASELINE STUDY have been completed?
-Liver Enzyme Levels
Zafirlukast (Accolate) is prescribed for a client with Bronchial Asthma. Which laboratory test does the nurse EXPECT to be prescribed BEFORE the administration of this medication?
-Liver Function Tests
Hepatitis B affects
-Liver failure -Liver Cancer -Possibly fatal
GI Manifestations
-Loss of appetite -Nausea -Vomitting -Oral and Esophageal candidiasis -Chronic diarrhea
HYPOproteinemia
-Low protein the blood -Can lead to edema -Edema decreases skins elasticity making it more prone to edema
Lymphatic Organs and Tissues
-Lymph nodes -Tonsils -Thymus: T-lymphocytes -Sleepn: cleanses blood - MALT/ GALT
Complement
-Lyse microorganism -Enhance phagocytosis by opsonization -Intensifies antibody and inflammatory response
First Line Non Specific Chemical Defenses
-Lysozyme -Lactic acid & electrolytes:sweat -Hydrochloric acid -Skins slightly acidic pH -Digestive juices and bile -Vagina: acidic pH -Semen: antimicrobial chemicals
Mycobacterium Avium Complex
-MAC -Infection in people with AIDs -Usually causes respiratory infection but is also found in the GI tract, lymph nodes, and bone marrow
Endogenous Pyrogens
-Macrophages -Interleukins -Tissue necrosis factor
A client is admitted to the ED and a diagnosis of Myxedema Coma is made. Which action would the nurse prepare to carry out INITIALLY?
-Maintain a Patent Airway
Provide nutrition
-Make sure the client has an adequate intake of: -calories -protein -iron -vitamins -Monitor weight regularly
Leukocytes
-Make up less than 1% of total blood volume -Larger and shorter lived than RBCs -Moves through tissues by chemotaxis and ameboid motion -WBC count over 11,000
What is surgical embolectomy?
-Manual removal of the thrombus from the pulmonary artery
How can PE be classified?
-Massive -Submassive -Nonmassive
When is thrombolytic therapy used?
-Massive PE -Hypotension -Reduced right ventricular function
What types of sinuses are newborns born with?
-Maxillary -Ethmoid
Acute Respiratory Failure Treatment
- Oxygen therapy - Bronchodilators to enhance airflow (albuterol, levalbuterol, metaproterenol, terbutaline) - Anticholinergics to treat bronchospasms (ipratropium) - Intubation to maintain patent airway - Anesthetic to ease intubation (propofol) - Neuromuscular blocking agent to ease mechanical ventilation (pancuronium, vecuronium, atracurium) - Steroids to decrease inflammatory response (hydrocortisone, methylprednisolone, prednisone) - Anticoagulants to reduce risk of clots (heparin, warfarin) - Analgesic for discomfort and to decrease myocardial oxygen demand (morphine) - Histamine2 blockers or proton pump inhibitors to reduce chances of ulcers (ranitidine, pantoprazole) - Antibiotics to treat infection
Types of Lung Surgeries
- Partial laryngectomy - Supraglottic laryngectomy (voice sparing, temp. trach) - Hemilaryngectomy - Total laryngectomy
Nursing Assessment for Lupus: Cardiovascular System
- Pericarditis (Tachy, chest pain, cardiac ischemia) - Raynaud's disease (15%, pain, red, blue and white fingers r/t vasoconstriction)
Nursing Assessment for Lupus: Respiratory System
- Pleural effusions and pneumonia (50%)
Pneumonia: Complications
- Pleurisy - Shock - Respiratory failure - Atelectasis - Pleural effusion - Lung abcess - Superinfection - Confusion
Types of Protozoa Infections Associated w/ HIV
- Pneumocystis Carinii Pneumonia (PCP) - Toxoplasmosis encephalitis - Cryptosporidiosis
Complications of Penetrating Trauma
- Pneumothorax (air in between pleural layers) - Hemothorax (blood in between pleural layers) - Lung contusion - Cardiac tamponade (compression of heart r/t fluid around pericardial sac)
Nursing Assessment for Lupus: Musculoskeletal System
- Polyarthritis (knees, small joints/similar to RA without deformity) - Myositis (Inflammation of muscles) - Avascular necrosis (Usually 5 years after treatment w/ steroids) - Muscle atrophy from disuse/invasion of skeletal muscle from immune complexes
Atelectasis
- Portion of lung doesnt expand completely, decreases lung capacity to exchange gases which decreases blood oxygenation - Obstruction caused by fluid, mucus plug or tumor can cause collapsed lung - Common postoperatively r/t pain pain, immobility, lack of deep breathing & anesthesia
Total Laryngectomy
- Pre-operatively cl needs to be aware what can be expected post-op - Lose use of voice - Will have permanent tracheostomy - Excessive mucus production - Dysphagia - Lose some independence
Symptoms of Smoke Inhalation
- Presence of soot around mouth and nose and in sputum (carbonaceous sputum) -Tachycardia -Stridor -Wheezing -Hoarseness -Hypoexmia -Facial burns -Difficulty swallowing -Singed nasal hairs -Intercostal/suprasternal retractions
Lymphocytes
- Produced in bone marrow and differentiate into B and T lymphocytes 1) B-lymphocytes 2) T-lymphocytes 3) T-cytotoxic cell 4) T-helper and T-suppressor 5) Natural killer cells 6) Dendritic cell
Influenza: Treatment
- Proper hand washing - Influenza vaccine - Antipyretics - Antivirals
Immune System Defense
- Protects against invasions by micro-organisms and prevents development of infection by attacking foreign antigens & pathogens
Pulmonary Angiography
- Radioactive dye inserted into patients vein and allows an image of the circulatory system to be taken - Determines condition of blood flow to lungs
Pharyngitis: Symptoms
- Range from "scratchy throat" to severe pain - Appearance not always diagnostic; cultures or rapid strep antigen test needed
Signs & Symptoms of Hyperthyroidism
- Rapid pulse - Palpitations - Excessive perspiration - Heat intolerance (Discomfort) - Nervousness - Irritability - Weight loss
Allergic Assessment: Integumentary
- Rash - Urticaria - Wheel and flare - Papules - Dryness - Scaliness - Scratching - Irritation - Vesicles - Bullae
Pulmonary Embolism Nursing Interventions
- Reduce risk of PE - Reduce risk of thrombus formation - Assess for thrombus/embolus presence - Monitor anticoagulant therapy - Managing pain - Manage O2 therapy - Relieving anxiety - Teaching client self-care
Prevention of Antibiotic Resistant Organisms
- Refuse prescription requests for antibiotics unless indicated - Ensure pt takes antibiotic therapy as prescribed - Dispose of leftover antibiotics - Follow infection control procedures as recommended - Ensure hand hygiene is performed before contact, before procedures, after fluid exposure and after contact
Thoracentesis
- Removal of fluid from pleural sac to drain fluid or identify contents of fluid - Pt lays on unaffected side, local anesthetic is used and needle is inserted to drain fluid into syringe
Treatment of Allergic Reactions
- Remove causative agent - O2 to establish and maintain airway - Keep patient warm - Place patient in recumbent position and elevate his/her legs - Maintain blood pressure w/ fluids, volume expanders, vasopressors - Medications (Epinephrine, Diphenhydramine, Histamine blockers) - Monitor vitals, respiratory effort, oxygen saturation, LOC, cardiac rhythm
Pneumonia: Nursing Interventions
- Remove secretions - Encourage fluid intake of 2 to 3 L/day - Humidify the air - Deep breathing & coughing exercises Q1h while awake - Use incentive spirometry Q1h while awake - Chest physio as deemed appropriate by physiotherapist - O2 therapy as needed. - Pulse oximetry should be obtained several times per day & PRN
Chest Tube Removal
- Removed when lungs are re-expanded & fluid drainage has ceased - Suction is discontinued - Gravity drainage
Chronic Obstructive Pulmonary Disease (COPD)
- Respiratory disorder caused largely by smoking and characterized by progressive, partially reversible airflow obstruction - Pt's affect often display signs of chronic bronchitis and emphysema
Total Laryngectomy: Complications
- Respiratory distress, hemorrhage - Infection, wound breakdown
Chemoreceptors
- Respond to changes in fluids around them -Respond when changes in CO2 & O2 occur - Low O2 = Breathe more
Mechanical Receptors
- Responds to abnormal changes in lungs - Stimulated by irritants like smoke, dust, or pollen - Muscle stretching occurs
Mononuculear Phagocytes
- Responsible for capturing, processing, presenting antigen to lymphocytes
Restrictive Respiratory Disorders
- Restriction in lung volume caused by decrease compliance of the lungs or chest wall - Extrapulmonary disorders involve the central nervous system, neuromuscular system, and chest wall - Intrapulmonary disorders involve the pleura or the lung tissue - Excessive fluid may accumulate because the body does not handle fluid properly (such as in congestive heart failure, or kidney and liver disease) - The fluid in pleural effusions also may result from inflammation, such as in pneumonia, autoimmune disease, and many other conditions
Heart Autoimmune Diseases
- Rheumatic fever
Sleep Apnea
- Risk factors include obesity & cigarette smoking - Can tax heart & lungs and causes high B/P - Treatment includes medications & CPAP machine
Barrel Chest
- Rounded/Bulging chest - Commonly found in pt w/ Osteoarthritis which can stiffen the joints where the ribs attach to the spine - Also found in pt w/ emphysema
Discoid Lupus
- Scaly, raised rash that appears on face, scalp, ears, chest or arms - If untreated it can leave permanent scars - Involvement in hair roots on scalp and can lead to permanent damage prevents future hair growth
Type IV: Delayed Hypersensitivity Reactions
- Sensitized to drug or preservative - Ex. Contact dermatitis from poison ivy or nickel allergy
Deviated Septum
- Septum displaces to one side and can partially occlude the nostril
Human Immunodeficiency Virus (HIV)
- Sexually transmitted infection, can also be spread by contact with infected blood or from mother to child during pregnancy or breastfeeding - Interferes with your body's ability to fight organisms that cause disease - No cure, but meds to slow progression
Pneumothorax Symptoms
- Sharp chest pain - Dyspnea - Absent breath - Subcutaneous emphysema - Tachycardia - Tachypnea
Pleural Effusion: Symptoms
- Shortness of breath - Chest pain, especially when breathing in deeply (pleurisy, or pleuritic pain) - Fever - Cough
Mucosal Ulcers Associated w/ Lupus
- Small sores in mucous lining of the mouth and nose - Occurs most often on the roof of the mouth - Usually painless - Nose ulcers are usually painless but they may cause nosebleeds
HIV to AIDs Progression Symptoms
- Soaking night sweats - Recurring fever - Chronic diarrhea - Persistent white spots or unusual lesions on your tongue or in your mouth - Persistent, unexplained fatigue - Weight loss - Skin rashes or bumps
Vesicular sounds
- Soft, blowing, or rustling sounds normally heard throughout most of the lung fields - Normally heard throughout inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration.
Wheezes (2 Kinds)
- Sonorous: sounds like snoring - Silibant: high pitched
Broncho-Vesicular sounds
- Sounds are heard in the posterior chest between the scapulae and in the center part of the anterior chest. - Softer than bronchial sounds, but have a tubular quality. Bronchovesicular sounds are about equal during inspiration and expiration; differences in pitch and intensity are often more easily detected during expiration.
Third Line of Defense
- Specific host defenses that must be developed uniquely for each microbe -Long term and usually has a memory
Sputum Culture
- Sputum collected from pt in sterile container and sent to lab to assess for bacteria involved - Takes 72 hours to complete testing process
Diagnostic Testing for Lung Cancer
- Staging - Screening for lung cancer - Chest x-ray - Sputum for cytology - Bronchoscopy w/ biopsy - CT scan - Fine needle aspiration
COPD: Effects of Nicotine
- Stimulates sympathetic nervous system - Increases HR - Causes peripheral vasoconstriction - Increases BP and cardiac workload - ↓ Amount of functional hemoglobin - ↑ Platelet aggregation - Compounds problems in CAD
Tracheostomy
- Stoma that results from tracheotomy
Tracheostomy Care Continued
- Suctioning the airway to remove secretions - Cleaning around stoma - Changing ties - Providing inner cannula care - Tube with inflated cuff is used for risk of aspiration or in mechanical ventilation. - Inflate cuff with minimum volume required to create an airway seal. - When patient can protect against aspiration and does not require mechanical ventilation, a cuffless tube is used.
Pulmonary Edema Treatment
- Supplemental oxygen - Morphine, lowers atrial pressure and decreases myocardial oxygen demand - Diuretics to remove excess fluid (furosemide, bumetanide, meolazone) - Cardiac glycosides to increase contractions of heart (digoxin) - Cardiac inotropes to strengthen the heart (dobutamine, inamrinone, milrinone) - Nitrates to decrease B/P (isosorbide dinitrate)
Viral Rhinitis: Treatment
- Supportive therapy such as rest, fluids, proper diet, antipyretics, and analgesics
Lung Cancer Treatment
- Surgery performed when cancer is slow growing and hasn't metastasized - Radiation therapy - Chemotherapy - Antiemetics - O2 therapy - Analgesics
Tracheotomy
- Surgical incision into the trachea to establish an airway
Long Term Improvements after O2 Therapy
- Survival - Exercise capacity - Cognitive performance - Sleep in hypoxemic patients
Airway Obstruction: Symptoms
- Symptoms: Stridor; use of accessory muscles; suprasternal and intercostal retractions; wheezing; restlessness; tachycardia; cyanosis
Diagnostic Tests for TB
- TB skin test - Chest x-ray - Sputum culture
Cardiopulmonary Problems Associated w/ Lupus
- Tachypnea and cough, suggestive of restrictive lung disease - Pleuritis and pericarditis - Pleuritis can cause increased pain w/ breathing in - Pts have less pain when sitting or standing - Hypertension and hypercholesterolemia - Pt at risk for coagulation problems (antiphospholipid syndrome)
Pulmonary Function Test
- Test done to assess lung's ability to move air - Monitor for changes from normal functions - Use of incentive spirometer to calculate tidal volume & vital capacity
Diagnostics for HIV
- Testing blood and saliva for HIV antibodies - CD4 cell count - Virus load to assess amount of viral impact - Drug resistance
Fibrosis
- Thickening & scarring of connective tissue, usually resulting from injury
Goals of Thyroid Replacement Therapy
- Thyroid levels are normal - Hypothyroid symptoms are decreased - Free from significant adverse effects of drug therapy - Pt verbalizes understanding of hypothyroidism and need for lifelong therapy
Pleurisy: Treatment
- Treat underlying condition - Commonly antibiotics
Pleural Effusion: Treatment
- Treatment usually involves treating underlying cause - Antibiotics for pneumonia - Diuretics for CHF - For infected or inflamed pleura, drainage may be necessary to alleviate symptoms
Complications of HIV
- Tuberculosis - Cytomegalovirus - Candidiasis - Meningitis - Toxoplasmosis - Cryptosporidiosis - Kaposi's sarcoma (Tumor of blood vessel walls) - Lymphomas (WBC) - Wasting syndrome - Neurological complications - Kidney disease
Propylthiouracil (Propyl-Thyracil)
- Type of Drug: antithyroid drug - Mechanism of action: to interfere with synthesis of T3 and T4 in thyroid gland Also prevents conversion of T4 to T3 in target tissues - Primary use: treats hyperthyroidism - Adverse effects: symptoms of hypothyroidism --Rash and transient leucopenia most common side effects --Small percentage of clients experience agranulocytosis --Drug interactions
Beclomethasone (Beclovent, Apo-Beclomethasone)
- Type of Drug: glucocorticoid - Mechanism of action: acts by reducing inflammation - Primary use: to decrease frequency of asthma attacks, also for allergic rhinitis. Should not be used to terminate asthma attacks in progress - Adverse effects: hoarseness, oropharyngeal candidiasis
Chest X-Ray
- Used to assess size and position of heart and lungs - Looking at lung density and assessing for abnormal accumulation of fluid in lungs
Bronchoscopy
- Used to view bronchial tree and to remove foreign obstructions, obtain tissues for biopsy, or for suctioning fluid - Bronchoscope inserted into pt's mouth and down trachea and bronchial tree.
Pulmonary Embolus Risk Factors
- Venous stasis - Hypercoagulability - Heart disease - Trauma - Post-op or Post-partum - Diabetes Mellitus - COPD - Obesity or pregnancy - BCPs or history of DVT/PE
Influenza
- Viral infection affecting respiratory tract which spreads through droplets - Infection can settle in upper or lower respiratory tract and causes damage to the upper layers of cells - Can lead to pneumonia - In mild cases symptoms can dissipate within 7 days
Pleuras of Lungs
- Visceral Pleura- Close to lungs - Parietal Pleura - Close to chest wall - Pleural space between the two layers containing small amount of fluid to prevent friction w/ chest movement on inspiration & expiration
Virus Diagnosis
- Visualization by Electron microscope - Cell culture (cytopathic effects, hemagglutination, immunofluorescence) - Detection of viral antigens (ELISA) - Rise in antibody titre
Common Symptoms of Allergic Rhinitis
- Watery nasal drainage - Nasal congestion - Repetitive sneezing - Itchy eyes, nose, ears, and throat - Nose rubbing
Systemic Symptoms of Allergic Rhinitis
- Weakness - Fatigue - Discomfort or uneasiness - Irritability - Difficulty focusing - Decreased appetite
Goals of Hypothyroid Drug Therapy
- Weight loss - Improved tolerance to environmental temp - Increased activity - Increased pulse
Asthma Symptoms
- Wheezing - Dyspnea - Tachypnea - Use of accessory muscles - Bronchoconstriction/Tight in chest - Cough - Tachycardia
Allergic Assessment: Lungs/Respiratory
- Wheezing - Thick sputum - Laryngeal stridor
Open Pneumothorax
- When air gets into the pleural space from an injury to the chest - This can happen with stab wounds, like from a knife. It can also happen after a gunshot injury - Injury is most dangerous if wound sucks in air and doesn't let it back out
Pneumonia: Risk Factors
- Young & old - both groups are susceptible to both viral & bacterial pneumonia - Recent surgery or invasive treatment - Immunocompromised - Chronic illnesses ex. COPD, AIDs - Conditions that promote mucus production & bronchial obstruction - Cigarette smoking - Conditions that prevent the expectoration of mucus -fractured ribs - Depressed cough reflex - Elderly, alcohol or drug intoxication
Pt @ home 10 days after burn of L hand and arm, partial thickness burn what are priorities
- assessment - health teaching - assessing for infection - fever, pus, smell - pain : medication working, ADL, Sleep - wound healing: protein + Vit C ( componant of making collogen) - increased calories - hungry - nausea - stress ulcer
Examples of Thyroid Agents
- levothyroxine (Levothyroxine, Synthroid) - liothyronine (Cytomel) - thyroid (Thyroid, Thyrodinum)
Antithyroid Agents
- potassium iodide & iodine (Lugol's solution, Thyro-Block) - propylthiouracil (Propyl-Thyracil) - radioactive iodide (Iodotope)
Guidelines for restraints
-May be initiated without a doctors order -Cannot wait longer than one hour to get an order -Must be reissued every 4 hours for adults -In person re-evaluation every 8 hours -Physician must conduct an in person evaluation after 24 hours of initiating restraints -Clients must be observed every 10 to 15 minutes: circulation, respiration, nutrition, hydration, elimination -Cant false imprison voluntary committed people -If so court needs to see if they're incompetent and need to be involuntarily committed
Promote usual bowel patterns
-Measure quantity and volume of stool -Small frequent meals to prevent abdominal distention -Antidiarrheal meds on a regular basis
When is informed consent NOT needed?
-Mentally incompetent -Refusing endagers the life of another -Client cannot exercise own judgement -Children
The nurse is caring for a client who is 2 days post-op following an abdominal hysterectomy. The client has a history of DM and has been receiving REGULAR glucose insulin according to capillary blood glucose testing 4 times a day. A CARB-controlled diet is prescribed, but the client is complaining of nausea and not eating. On entering the client's room, the nurse finds the client confused and diaphoretic. Which action is MOST APPROPRIATE at this time?
-Obtain a capillary blood glucose level and perform a FOCUSED assessment.
Massive PE symptoms
-Occludes 50% or more pulmonary vasculature or lobar arteries -Syncope -Hypotension -Extreme hypoxemia -Cardiac arrest
B-Cell Lymphoma
-Occur in the brain, bone marrow, and GI tract -Treatment is less successful because of severe heamtologic toxicity and complications of opportunistic infections
PRR
-Of the innate immune system -Pathogen recognition receptor
The nurse provides instructions to a client who is taking Lvothyroxine (Synthroid).The nurse should tell the client to TAKE the medication at WHICH TIME?
-On an EMPTY stomach
HPV Warts
-On genital -Tiny and flat - Affect cervix, cause malignancies
Treatment of intrapulmonary shunting
-Opening the alveoli and improving ventilation
Norovirus Transmission
-Oral ingestion:contaminated food or water -50% of all the outbreaks of nonbacterial gastroenteritis in the US -Camps, schools, nursing homes
Wasting Syndrome care
-Oranges and bananas -Cheese and soups (Sodium) -3L or more per day -IV fluids
Occupational exposure
-Organic and inorganic dust -Chemical agents -Fumes
AE of Levothyroxine seen in women
-Osteoporosis -Menstrual irregularities
Tinea Versicolor
-Oval-like scaly lesions on UPPER back and chest and arm -More common in WARM weather
RA resources
-PT and OT -Home aides -Meals on wheels -Local Arthritis Foundation
Zidovudine(Retrovir, AZT) adverse effects
-Pancreatitis -Bone marrow supression -Lactic acidosis -Neurotoxicity -Anemia -Low RBC and WBCs
Non-bullous Impetigo
-Papules professing to vessicles -Honey colored exudate when the vesicles rupture -Treat topically with Mupirocin ointment -Remove crust with cool compress two times a day
What type of cells does the thyroid gland have?
-Parafollicular -Follicular
Diminished sensation
-Paralysis, stroke, or other neurologic diseases -body cant recognize hot, cold, tingling, trauma -body cant recognize and providing healing for a wound
Piconavirus Symptoms
-Paralytic poliomylettis -Nausea -Constipation -Stiffness
Hydrocortisone sodium succinate route
-Parenteral
The nurse is preparing to give a bed bath to an immobilized client with TB. The nurse should wear which item when performing this care?
-Particulate Respirator -Gown -Gloves.
Passive acquired immunity
-Passed from mother to baby in utero, breast feeding -Immunoglobulin injections
Tinea capitis
-Patches of scaling skin on the scalp -Hair loss -No school or day care for a week after treatment
PAMP
-Pathogen Associated Molecular Patterns that are recognized by cells of the innate immune system
Symptoms of Asthma
-Patient may appear pink or cyanotic -May have a barrel chest -Wheezing or coarseness -Hyperressonance -Cough mainly at night -Chest tightness -Frothy sputum -Dyspnea with exercise
Influenza vaccine
-Patients in long term care facilities, with chronic cardiopulmonary disease, children age 5 and younger, pregnant women, adults 65 and older -Immunity is achieved 2 weeks after and lasts several months -Given to children two doses one month apart IM live attenuated
Who gets IV fluid resuscitation?
-Patients with burns over 20% of their body
A client has been taking Isoniazid for 1.5 months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?
-Peripheral Neuritis
Pallor is a result of
-Peripheral vasoconstriction
Complications of Group A Strep
-Peritonsillar -Retropharyngeal abcess -Acute rheumatic fever -Acute glomerulonephritis
Stage 3 HIV Infection
-Person has full blown AIDS -Is eligible for disability, food stamps, housing
Stage 2 HIV Infection
-Person is considered to have AIDS -CD4 count drops below 200 cells
Immune function is affected by
-Physical and emotional status -Diet -Medications -Stress of illness, trauma, or surgery -Allergies -History of infections -Genetics -Lifestyle
Dry Powder Inhaler (DPI)
-Pill Placed INSIDE Device & Button Gently Presses to Pop HOLE in Pill -Patient INHALES Powdered Drug -Device activated by INHALATION -(Medication CAN'T Escape)
What is the endocrine system made up of?
-Pineal gland -Hypothalamus -Pituitary gland -Parathyroid gland -Thyroid -Thymus -Adrenal glands -Pancreas -Ovary
What is the MOST COMMON life threatening infection of AIDS?
-Pneumocystis Pneumonia
What is a Chest Tube used for?
-Pneumothorax (External) -Empymea
Tympany could mean
-Pneumothorax (external)
HIV/AIDS
-Pneuomina -Sarcoma -Loss of immune function -Level of virus in blood -Level of T cells in blood
After several diagnostic tests, a client is diagnosed with DI. The nurse performs an assessment on the client, knowing that which symptom is MOST indicative of this disorder?
-Polydipsia
The nurse is monitoring a client newly diagnosed with DM for signs of complications. Which sign would indicate HYPERglycemia?
-Polyuria
The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for PRIMARY HYPERparathryoidism. Which client complaint would be characteristic of this disorder?
-Polyuria (HYPERcalcemia causes diuresis)
Ineffective Airway Clearance
-Position with airway open -Sniffing position if supine -Humidify O2 or room air -Suction (particularly prior to bottle feeding) -NPO if tachypneic -Encourage coughing -Chest physiotherapy
A client who is HIV POSITIVE has had a Tuberculin Skin Test (TST). The nurse notes a 7mm induration at the site of the test and interprets the results as which finding?
-Positive -HIV patients are considered positive for TB if result is > 5mm induration)
How is COPD diagnosed?
-Postbronchodilator spirometry
Where is ADH secreted from
-Posterior pituitary
What electrolyte imbalance is GREATEST in HHS?
-Potassium
What needs replacement during insulin administration?
-Potassium -Phosphate -Chloride -Magnesium
What test IDENTIFIES Fungal Disorders?
-Potassium Hydroxide KOH prep
Examples of Expectorants
-Potassium Iodide (Pima, ThyroShield) -Guaifenesin (Mucinex, Benylin, Guaifenex LA) -Carbocysteine (Availnex)
Glucocorticoids
-Potent Anti-inflammatory drugs -Suppresses AIRWAY INFLAMMATION -Drugs of choice for LONG-TERM PREVENTION of ASTHMA -Oral drugs used for SHORT-TERM THERAPY of SEVERE, ACUTE ASTHMA
A client with DM visits a health care clinic. The client's DM previously had been well controlled with Glyburide (DiaBeta) daily, but recently Fasting Blood Glucose level has been 180-200 mg/dL. Which medication, if added to the client's regmind, may have contributed to the HYPERglycemia?
-Prednisone -(Steroid = HYPERglycemia)
Methimazole (Tapazole)
-Preffered drug for the treatment of thyroid storm -Long half life
What do glucocorticoids do
-Prepare the body for long term stress -Affect the metabolism of every cell
Alternating pressure mattress
-Pressure alternately increases and decreases
Lopinavir (Kaletra) mode of action
-Prevent the final maturation of the HIV virons -Serum levels of lopinavir increase by 100 fold
Addisons disease
-Primary adrenocortical insufficiency -Deficient in mineralcorticosteroids and glucocorticosteroids -Autoimmune destruction of both adrenal glands
Stage 1 of HIV
-Primary infection -CD4 T cell count drops to 500 to 1,500 cells
Common cause of cushings syndrome
-Prolonged use of corticosteroids
SLE Health Oromotion
-Promote EARLY diagnosis and treatment
Two primary drugs for HYPERthyroidism
-Propylthiouracil -Tapazole
Inhibit Thyroid Hormone
-Propylthiouracil (blocks T3 and T4 conversion) -Tapazole (long half life, high potency)
Preventing pressure ulcers
-Provide nutrition -Maintain skin hygiene -Avoid skin trauma -Provide supportive devices
What is Histoplasmosis?
-Pulmonary Fungal Infection -Transmission occurs by INHALATION of SPORES in contaminated SOIL
What is the "gold standard" for detecting PE?
-Pulmonary angiogram -Invasive procedure consisting of catheterization of the right side of the heart with contrast medium injected through the catheter into the pulmonary vascular system
Improve Airway Clearence
-Pulmonary therapy (coughing & deep breathing) every 2 hours -Position in semi fowlers or fowlers position -Drink 3L of fluid
Active low air loss
-Pulsates from side to side stimulating capillary blood flow
Diagnostic Tests for RSV
-Pulse oximetry -Chest radiograph(HYPERINFLATION/ATELECTASIS) -Blood gases(CO2 RETENTION/HYPOXEMIA) -Nasal Pharyngeal washings (ELISA)
Diagnostic Tests for Asthma
-Pulse oximetry -Chest radiograph(HYPERINFLATION) -Blood gases (CO2 RETENTION/HYPOXEMIA) -PFT -PEFR (DECREASED) -Allergy testing
Leukotriene Modifiers
-REDUCE Inflammatory Components of Asthma -Primarily used for PREVENTION of Asthma Attacks -(When persistent asthma isn't controlled by other drugs)
What happens in DNA Synthesis?
-RNA is turned into DNA through Reverse Transcriptase -DNA carries the instructions for viral replication
What accounts for the MAJORITY of Bronchiolitis?
-RSV -Happens in winter to spring -Occurs most in infants or toddlers
Hypothyroid Lab Tests
-Radioimmunological assay -Measures levels of T4 -If level is LOW -Repeat the test -Thyroid Scan -Serum T3 -Radioiodine Uptake -Thyroid Bound Globulin -Ultrasonography
Nursing Interventions for RSV
-Raise the head of the bed -Isolation -Contact -Gown & Gloves -Handwashing -Wash hands -Suctioning -Frequent assessment
SLE Manifestations/Complications
-Ranges from a relatively mild disorder to rapidly progressive, affecting many body systems -Most commonly affects the SKIN and MUSCLES, lining of lungs, heart, nervous tissue, and kidneys -Dermatological Manifestations -Musculoskeletal Problems -Cardiopulmonary Problems -Renal Problems -Nervous System Problems -Hematological Problems -Infection
How can the diagnosis of Influenza be confirmed?
-Rapid assay test
Diagnosis of Pharyngitis
-Rapid throat swab -Throat culture if rapid comes back negative
Medication for Cystic Fibrosis
-Recombinant Human DNase -Choice of antibiotic is determined by sputum culture
Bullous Impetigo
-Red macules and bullous eruptions -Good hygiene -Cephalosporins
Folliculitis
-Red raised hair follicles -WARM compresses with soap and water several times a day -Topical Mucpirocin
Influenza vaccine nursing considerations
-Redness and discomfort at site of injection -Fever -Minor aches -Arthralgias
Acquired risk factors for PE
-Reduced mobility -Advanced age -Cancer -Acute Medical illness -Major surgery -Trauma -Spinal cord injury -Pregnancy and postpartum -Polycythemia vera -Antiphospholipid antibody syndrome -Oral contraceptives -Hormone replacement therapy -Heparins -Chemo -Obesity -Central venous catheterization -Immobilizer or cast
Immobility
-Reduction in the amount of control of body movements -ex: paralysis, extreme weakness, pain
MOST PROMINENT clinical features of Thyroid Storm
-SEVERE FEVER -Marked TACHYCARDIA -Heart failure -Tremors -Delirium -Stupor -Coma
HSV-2 Latency
-Sacral ganglia
What do follicur cells do?
-Secrete T4 (thyroxine) -and T3 (triiodothryronine)
What is Paradoxical Breathing?
-See-saw breathing -Chest falls on inspiration -Normally rises -Chest rises on expiration -Normally falls
Mycobacterium Avium Complex (MAC) treatment
-Seek treatment if CD4 is LESS THAN 50
Diabetes Lab Tests
-Self Monitoring Blood Glucose -Fasting Plasma Glucose -2 Hour Plasma Glucose -Urine or Serum Ketone Testing -Hemoglobin A1C
Postexposure prophylaxis Health Care Providers
-Shot of gammaglobulin -Counseling
Nursing Implications of a Chest Tube
-Should tube became dislodged from container: -Chest tube must be: -Tube placed in Sterile water -Clamped immediately using Kelly Clamps to avoid further air entry into the chest cavity
Stage 1
-Skin intact -Area red & does not black with external pressure -Potential ulceration -May be painful, firm, soft, warmer, or cooler
Reactive Hyperemia
-Skin is bright red and flush -Extra blood flows to the area to make up for the previous impeded blood flow
Stage 2
-Skin is not intact -Abrasion, blister, shallow crater -Some skin may be damaged beyond repair -Partial Thickness skin loss of dermis -Shallow open ulcer with red-pink wound bed -OR- as intact or open/ruptured serum-filled blister
Picornavirus (Polio)
-Small single stranded RNA
What does hyposecretion of growth hormone cause?
-Small stature -Somatotropin (genotropin) -Cretinism
MILD SIADH
-Sodium 125 to 135
What is NOT beneficial to help acidosis?
-Sodium Bicarbonate
Hydrocortisone AE
-Sodium and fluid retention -Cushings syndrome -Insomnia, anxiety, headache, vertigo, confusion, and depression -Peptic ulcers
SEVERE SIADH
-Sodium less than 110
How is Nephrogenic DI controlled?
-Sodium restriction -Thiazide diuretic
Neurological and Myxedema
-Somnolence -Delirium -Seizures -Coma -Paranoia -Delusions
Acquired (adaptive) immunity
-Specific -Not present at birth -Develops after exposure to an antigen -Could be active or passive
What is the basal metabolic rate?
-Speed at which cells perform their functions
How does pneumothorax occur
-Spontaneously -Surgery -Trauma -CPR
The nurse performs an admission assessment on a client with a diagnosis of TB. The nurse should check the results of which diagnostic test that will CONFIRM this diagnosis?
-Sputum Culture
Lupus teaching
-Stay out of sunlight/UV light -Wear sunscreen and clothing
What does somatotropin do?
-Stimulates growth and metabolism in every part of the body
Urticaria Nursing Management
-Stop antibiotics -Administer antihistamines, steroids, and ani-itching medications -Check respiratory and airway -Assess what they ate, drank, changes in environment, recent infection,unusual stress
Platelets
-Stop bleeding -Inflammation & Clotting
Symptoms of a cold
-Stuffy/runny nose -Nasal discharge watery and thin then may become thicker and discolored -Child may be hoarse and complain of a sore throat -Cough produces little sputum -Fever, fatigue, watery eyes, appetite loss -Symptoms worse the first few days than decrease
What TYPE of insulin do patients with MILD DKA receive?
-SubQ of RAPID acting insulin on a titration scale -Blood sugars checked every 6 to 8 hours
What TYPE of HIV is MOST COMMON?
-Subtype B HIV-1
Trivalent Inactivated Influenza Vaccine
-Suitable for any eligible person age 6 months and older -Not capable of causing disease -Given by Intramuscular (IM) injection
Treatment for PE to maintain ABCs
-Supplemental O2 -Positioning the patient with the good lung in the dependent position -Analgesics
First Line of Defense
-Surface protection composed of anatomical and physiological barriers that keep microbes from penetrating sterile body compartments
Aerosol Therapy
-Suspension of DROPLETS or PARTICLES into a GAS -Onset of action is ALMOST IMMEDIATE -For IMMEDIATE relief of BRONCHOSPASMS & to LOOSEN THICK mucus secretions -Side effects are reduced, however systemic effects still occur
Diagnostic Tests for Cystic Fibrosis
-Sweat chloride test: Over 60 mEq/L -Pulse oximetry: Decreased -Chest radiograph: -Hyperinflation -Wall thickening -Atelectasis -Infiltration -PFT: Decreased
What is SIADH?
-Syndrome of Inappropriate Antidiuretic Hormone -Too much ADH -Retaining water -Concentrated urine
Hydrocortisone actions
-Synthetic corticosteroid -Treats inflammation, allergies etc -Intra-atricular injections given to decrease inflammation in the joints -AVAILABLE IN SIX DIFFERENT SALTS
What is vasopressin?
-Synthetic drug that has structural identity with that of human ADH
Treatment for acute exacerbation
-Systemic corticosteroids -Oxygen supplementation(partial or complete nonrebreathing mask) -IV fluids -Magnesium sulfate (induce smooth muscle relaxation)
HYPERthyroid Lab Tests
-T3 and T4 are ELEVATED -TSH is LOW (Suppressed)
Thermoregulation Thyroid Storm
-TEMP REGULATION IS LOST -May be as high as 106 -Warm moist skin
Pneumocystis Pneumonia Treatment
-TMP-SMZ (TREATMENT OF CHOICE) -Corticosteroids -THERAPY IS 21 DAYS
The FIRST sign of respiratory illness in infants is
-Tachypnea
A client has a prescription to take Guaifenesin (Mucinex). The nurse determines that the client understands the proper administration of this medication if the client states that he or she will perform which action?
-Take the tablet with a FULL glass of water
The nurse performs a physical assessment on a client with Type 2 DM. Findings include a fasting blood glucose level of 120 mg/dL, temperature of 101 F, pulse of 88, respirations of 22, and BP of 100/72. Which finding would be of MOST CONCERN to the nurse?
-Temperature
The nurse is caring for a client after HYPOphysectomy and notes clear nasal draining from the client's nostril. What INITIAL action should the nurse take?
-Test the drainage for glucose
False Imprisonment
-The deliberate and unauthorized confinement o f person within fixed limits by the use of verbal or physical means
Negligence
-The failure to exercise the standard of care that a reasonably prudent person would have exercised in a similar situation
Influenza
-The flu -Spread by inhalation, droplets, contact with fine particle aerosols
Informed Consent
-The protection of an individuals autonomy -Doctors can be charged with assault and battery for performing life sustaining treatments to a client who has not agreed to it
Adrenalectomy
-The surgical Removal of an ADRENAL Gland -LIFELONG Replacement of Glucocorticoids and Mineralcorticoids is necessary with a BILATERAL Adrenalectomy -TEMPORARY Replacement May Be Necessary For Up to 2 YEARS For a UNILATERAL Adrenalectomy.
Intentional tort
-The touching of another person without their consent
What happens in the Integration Stage?
-The viral DNA enters the CD4 T cell -It binds with the CD4 T cells DNA with integrase -This creates a permanent lifelong infection -HIV IS NOW PERMANENT
Antiviral drugs can reduce symptoms of Influenza if..
-They are started in the first 24 to 48 hours
What do these drugs do?
-They inhibit the incorporation of iodine atoms into T3 and T4
The infants epidermis is
-Thinner than the adults
What is the Virchow triad?
-Three main mechanisms that favor the development of VTE -Venous stasis (reduction in blood flow) -Altered coagulability of blood -Damage to vessel walls
How do newborns breathe when they cry?
-Through their mouths
Maceration
-Tissue softened by prolonged wetting and soaking
Irritants
-Tobacco smoke -Indoor/outdoor pollution -Perfumes -Cleaning agents -Sprays
Children tend to have enlarged
-Tonsillar and adenoidal tissue even without illness
Hydrocortisone acetate route
-Topical
Nebulizer
-VAPORIZES LIQUID Drug into FINE MIST -Uses Small Machine & FACE MASK
Volume replacement in Diabetes Insipidus
-Vital signs recorded every hour -Urine output recorded every hour -I and O -Fluid replacement
The HCP prescribes Exenatide (Byetta) for a client with type 1 DM who takes insulin. The nurse should plan to take which MOST APPROPRIATE intervention?
-WITHHOLD the medication and call the HCP, questioning the prescription for the client. -(This medication is used for Type 2 DM and NOT recommended for clients taking insulin)
What is Lymphatic Fluid made of?
-Water -Dissolved salts -2 to 5% proteins (antibodies and albumin) -WBCs, Cellular Debris, and Infectious Agents -NO RBCs
Fluid Replacement in DKA
-Water deficit 100 mL/kg -Normal saline is fluid of choice for initial fluid replacement
HHs Fluid Replacement
-Water deficit as high as 200 mL/kg
673. A nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles? 1. Mask 2. Gown 3. Gloves 4. Eye protection
1. Mask Rationale: Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure. The other options are not necessary.
655. An emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign, if noted in the client, would indicate the presence of a pneumothorax? 1. A low respiratory rate 2. Diminished breath sounds 3. The presence of a barrel chest 4. A sucking sound at the site of injury
2. Diminished breath sounds Rationale: The client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may present with tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. There may also be hyperresonance on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.
677. The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis? 1.Chest x-ray 2.Bronchoscopy 3.Sputum culture 4.Tuberculin skin test
3.Sputum culture Rationale: Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy
661. The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is most appropriate? 1.Continue to suction. 2.Notify the healthcare provider immediately. 3.Stop the procedure and reoxygenate the client. 4.Ensure that the suction is limited to 15 seconds
3.Stop the procedure and reoxygenate the client. Rationale: During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.
672. The nurse is giving discharge instructions to the client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation? 1. Fever 2. Fatigue 3. Weight loss 4. Shortness of breath
4. Shortness of breath Rationale: Shortness of breath is an early sign of exacerbation of pulmonary sarcoidosis. Others include chest pain, hemoptysis, and pneumothorax. Systemic signs and symptoms that occur later include weakness and fatigue, malaise, fever, and weight loss.
675. A nurse is instructioning a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position will the nurse instruct the client to assume? 1. Sitting up in bed 2. Side-lying in bed 3. Sitting in a recliner chair 4. Sitting on the side of the bed, leaning on an overbed table
4. Sitting on the side of the bed, leaning on an overbed table Rationale: Positions that will assist the client with breathing include sitting up and leaning on an overbed table, sitting up and resting with the elbows on the knees, or standing or leaning against the wall.
What helps DIFFERENTIATE SIADH?
-Urine sodium greater than 200
Sildenafil (Viagra) is prescribed to treat a client with ED. The nurse reviews the client's medical records and should question the prescription if which data is noted in the client's chart?
-Use of Nitroglycerin
Hepatitis B Treatment
-Vaccine
Rhabdiovirus Treatment
-Vaccine for dogs, cats, and humans
ADH can also be called..why
-Vasopressin -It can constrict blood vessels and raise BP
The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning to a MAXIMUM of which time period?
10 seconds
Partial thickness burn
Apperance: large thick walled blisters covering extensive areas Edema: molted red base; broken epidermia, wet, shiny weeping surface Sensation: painful, sensative cold Course: heals in 10-14 deep burn takes 21-28
3 Main Functions of Immune System
- Defense - Surveillance - Hemostasis
Pigeon Chest
- Deformed chest w/ projecting breastbone
Funnel Chest
- Deformed chest w/ sunken breastbone
Lung Cancer: Treatment
- Depends on extent of tumor - Usually surgery & radiation are the first steps - Sometimes micro laryngeal surgery can be performed in early stages - Chemotherapy is used if there is a recurrence
Influenza
-Viral infection -Sore throat, sneezing, coughing, chills -Airborne dropelts -Type A, B, and C type A is the worst
Other factors that influence asthma severity
-Viral respiratory infections -Rhinitis/sinusitis -GERD -Exercise -Sensitivity to NSAIDs -Topical and systemic beta blockers
Varizella-Zoster Virus (VZV)
-Virus spreads through bloodstream -Virus can enter neurons and remain latent -Chicken pox and shingles -Humans are the only natural host
Pneumonia: Symptoms
- Dypsnea - Fever/chills - Cough - Crackles - Colored sputum - Tachycardia - Tachypnea - Headache - Muscle & joint pain
Atelectasis: Symptoms
- Dyspnea - Anxiety - Tachypnea - Diaphoresis - Cyanosis - Hypoxemia
Pulmonary Embolism Symptoms
- Dyspnea - Tachycardia - Tachypnea - Chest pain - Hemoptysis - Crackles
Pulmonary Edema Symptoms
- Dyspnea - Tachypnea - Frothy bloody sputum r/t capillary permeability - Cyanosis - Cool, clammy skin - Restlessness r/t lack of oxygenation - Distended jugular vein r/t increase pressure in chest - Crackles, wheezing
Seborrhea Nursing Management
-Wash affected area with mild soap -Apply mineral oil then comb off crust 10 to 15 minutes later -Selenium sulfide shampoo can be used
Preventing RSV
-Wash hands
DI
decreased ADH causing an increase in urine output - not absorbing enough water, excreting too much
SIADH labs serum
decreased Na decreased K decreased osmolality
Addison's labs
decreased Na increased K decreased glucose increased calcium
hypothyroidism
decreased T3 T4 increased TSH increased cholesterol anemia
Acute Respiratory Failure Symptoms
- Dyspnea r/t lack of oxygen - Use of accessory muscles - Orthopnea - Fatigue r/t lack of oxygenation - Coughing r/t inflammation, bronchospasms - Hemoptysis r/t irritation of airways - Tachypnea - Diaphoresis - Cyanosis - Anxiety r/t air hunger and lack of oxygenation - Crackles - Wheezing r/t inflammation in airway
Sinusitis: Treatment
- Environmental control - Appropriate drug therapy - Increase fluid intake - Nasal cleaning techniques and irrigation - Persistent complaints may require endoscopic surgery
Kidney Autoimmune Diseases
- Glomerulonephritis - Goodpasture syndrome
TSH
-GREATER than 25
Neonatal Herpes- Encephalitis
-HSV-2 -Potentially fatal -Infeciton of the mouth,eyes, CNS
What is an acute PE?
-Occurs quickly -Either responds to treatment or death occurs
What is Myxedema Coma?
-The MOST EXTREME form of HYPOthyroidism -Life threatening
Battery
-Unconsented touching of another person
What does Influenza PRIMARILY infect?
-Upper respiratory epithelium -Can cause systemic effects
Pneumothorax Treatment
- Bedrest - O2 therapy - Chest tube - Analgesic
Diabetes Insipidus Signs and Symptoms
-Urine is pale and dilute -Polydipsia (very thirsty) -LOW Urine Osmolality (Uosm) -DECREASED Urine Specific Gravity -HIGH Serum Osmolality (SrOsm)
Chronic Obstructive Pulmonary Disease Complications
- Cor pulmonale - Acute exacerbations of COPD - Acute respiratory failure - Depression, anxiety, and panic
Lung Cancer: Symptoms
- Cough - Hemoptysis - Anorexia - Fatigue - Dyspnea - Chest pains
Crackles
- "Clicking, rattling, popping sounds" - Sound of air moving through fluids in lungs - Heard in pts w/ pneumonia, atelectasis, pulmonary fibrosis, acute bronchitis
HIV Encephalopathy
- 70% of AIDS pts will have CNS involvement - Effect is behavioural, cognitive, and motor dysfunction
Types of Antigens
1) Virus 2) Bacteria 3) Toxins 4) Mis-matched RBC's 5) Cancer
660. Thenurseispreparingtosuctionaclientviaatracheostomytube.Thenurseshouldplantolimitthesuctioningtimetoamaximumofwhichtimeperiod? 1. 1 minute 2. 5 seconds 3. 10 seconds 4. 30 seconds
3. 10 seconds Rationale: Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10seconds
659. The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client,should be reported immediately to the healthcare provider? 1.Dry cough 2.Hematuria 3.Bronchospasm 4.Blood-streaked sputum
3.Bronchospasm Rationale: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs/symptoms of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure
Dawn Phenomenon
A NOCTURNAL Release of GROWTH Hormone -May cause Blood Glucose Level Elevation BEFORE BREAKFAST in the Client with Diabetes Mellitus -Treatment Includes: -Administering an EVENING Dose of INTERMEDIATE-Acting Insulin at 10 P.M.
Pituitary hormone
ADH
GI manifestations
Abdominal pain dysphagia diarrhea nausea and vomiting
hematopoeitc system manifestations
Anemia Leukopenia Lymphadenopathy Splenomegaly Thrombocytopenia coaglopathy
Musculoskeletal manifestations
Arthritis myositis synovitits Poly arthritis - morning stiffness, pain and swelling - occurs in 90% typically 1st symptoms non errosive, but can cause deformaties
Emergent resuscitative phase
Begins with fluid loss and edema formation at time of burn *greatest threat is hypovolemic shock- BP decreases, HR increases, U/O decreased Continues until fluid mobilization and diuresis occurs ABCs are the priority Can last 48 hours to several days
classification of burns
Burn Depth Partial thickness - superficial Partial thickness - deep- takes first layer of dermis off Full thickness Extent of Body Surface Area Injured TBSA
Breathing
Breathing pattern, ABGs, O2 sat, supplemental oxygen airway obstruction - inhalation - secondary edema
EEvaluation of implementations
Completion of priority activities Communication of having more energy Expression of satisfaction with pain relief measures Performance of activities of daily living without pain Limitation of direct exposure to sun and use of sunscreen No open skin lesions Expression of satisfaction with activity level Pacing of activities to match level of tolerance Expression of confidence in ability to manage SLE over time and in home environment
A nurse teaches the emergency department staff about their roles during a disaster with mass casualties. Which primary responsibility should the nurse describe that is expected of all licensed and unlicensed health care staff? A. Notify local, state, and national authorities. B. Assist security personnel to patrol the area. C. Learn the hospital emergency response plan. D. Contact the American Red Cross for assistance.
C. Learn the hospital emergency response plan. All health care providers must be prepared for a mass casualty incident. The priority responsibility is to know the agency's emergency response plan.
A client is diagnosed with pheochromocytoma. The nurse understands that pheochromocytoma is a condition that has which characteristic?
Causes the release of excessive amounts of catecholamines
Oncogenic
Causing a development of tumors
A client has experience a PE. The nurse should assess for which symptoms, which is MOST commonly reported?
Chest pain that occurs SUDDENLY.
Burn Shock
Compensation with intense peripheral vasoconstriction for 1-2 hours BP- decrease HR- increase Urine output- decrease When compensatory mechanisms fail S&S of hypovolemic shock will appear with CO ↓ 30-50%
Hemoptysis
Coughing up blood
Teratogenic
Crosses the placenta
Adrenal gland disorders
Cushing's and Addison's
Pituitary gland disorders
Diabetes insipidus and SIADH
Dyspnea
Difficulty breathing
The Emergency Department nurse is assessing a client who sustained a blunt injury to the chest wall. Which finding would indicate the presence of a Pneumothorax in this client?
Diminished breath sounds
HPV Transmission
Direct contact
Pet allergen in skin, scales, and hair
Dog
A client with AIDS has Histoplasmosis. The nurse should assess the client for which EXPECTED finding?
Dyspnea
Treatment
Emergency Treatment Stop the burning ABCs *consider C-spine and internal injuries Conserve body heat- lose own body heat from fluid loss Minimize wound contamination- sterile sheets, bedding Remove jewelry/constricting garments Transport quickly Keep NPO - secondary may need surgery History of accident and medical history
Phases of burn management
Emergent (Resuscitative) Phase Acute Phase Rehabilitation Phase
cardiopulmonary manifestations
Endocarditis Myocarditis paricarditis pleural effusion pnuemonitis Raynauds dysrthymias secondary to fibrosis, restrictive lung disease
Oncogenic RNA viruses
Leukemia, Liver Cancer
nursing diagnosis
Fatigue Acute pain Impaired skin integrity Deficient knowledge
Fluid Resuscitation
First 24 hours Ringer's Lactate is used Eg. Parkland formula: 4ml/kg/%TBSA ½ of the calculated amount is given over the first 8 hours since injury The rest is given over the next 16 hours Eg. Pt. weighs 50 kg., has 50% TBSA burns. Injury was @ 0900h. And the IV was started at 1000h. Calculate the total volume for the 24 hours At what time should the first 5000 ml be finished? 1st 8 hours 0900-1700 4X50X50 =10,000ml -1/2 in first 8hr = 5,000ml - 7 hours left run @ 714 ml/hr - 1700-0900 16 hrs run @ 312 ml/hr
Autograft - permanent coverage
From patient- Cultured
urinary manifestations
Glomerulernephritis Hematuria Proteinuria
Adrenal hormones
Glucocorticoids Mineralocorticoids Androgens
SIADH assessment
HA anorexia muscle cramps weight gain increased HR personality changes n/v/d oliguria seizures, coma FVE
overall goals for SLE patient
Have satisfactory pain management Adhere to therapeutic regimen to achieve maximum symptom management Demonstrate awareness of and avoid activities that cause disease exacerbation Maintain optimal role function and a positive self-image
nursing implementation
Health promotion Promote early diagnosis and treatment Acute intervention Severity of symptoms; response to therapy; intake and output; observe for signs of bleeding, such as pallor, skin bruising, petechiae, tarry stools
Oncogenic DNA viruses
Hepatitis B, Kaposi Sarcoma, and HPV
Major complications
Hypertrophic scarring Occurs 2° to ↑ vascularity, ↑ fibroblasts, collagen deposits, edema Scar formation occurs over ~ 2 years Melanocytes do not regenerate well...in deep burns skin color usually does not return Contracture formation PT, OT, NUTRITION
A client is admitted to a hospital with a diagnosis of DKA. The initial blood glucose was 950. A continous IV of short-acting insulin is initiated, along with IV rehydration with NS. The serum glucose level is now 240. The nurse would NEXT prepare to administer which item?
IV fluids containing dextrose. (During DKA, blood sugar needs to stay 250-300 until pt is recovered from ketosis)
The nurse is assessing a client with multiple trauma who is at risk for developing ARDS. The nurse should assess for which EARLIEST sign of ARDS?
Increased Respiratory Rate
Synthetic & Biosynthetic grafting
Integra synthetic skin Alloderm product
Hypoxemia
Low O2 concentration in arterial blood
Hypoxia
Low O2 supply
Circulation after burn
MONITOR TISSUE PERFUSION CLOSELY Additional fluid: FFP, colloids once capillary permeability is restored By 48 hours capillaries begin to seal and fluid will return from third spaces to the vascular space→ watch for fluid volume overload
The nurse is taking the history of a client with Occupational Lung Disease (Silicosis). The nurse should assess whether the client WEARS which items during periods of EXPOSURE to Silica particles?
Mask
Circulation
Massive fluid shift from plasma to interstitium- interstitium exposed to air- wheep Sodium and protein move out of the vascular bed- lost serum Potassium increases due to damaged cells- K is intracellular end up in pt blood Wound allows evaporation to occur 4-15x normal rate → BURN SHOCK
nursing management for SLE
Nursing assessment Assess patient's physical, psychological, and sociocultural problems with long-term management of SLE Assess pain and fatigue daily Obtain subjective and objective data Educate and counsel on expected issues
thyroid storm interventions
OXYGEN as ordered maintain airway monitor cardiac status IV fluids Tylenol for fever - NO ASA (can increase thyroid hormones) prepare client for thyroidectomy cool sponge baths, ice packs, cooling blankets monitor temp - even for 1 degree increase PTU, antithyroid meds as ordered I&O, daily weights insulin to control hyperglycemia
myxedema coma interventions
OXYGENATE monitor cardiac status increase circulation with IV fluids warm blankets IV thyroid hormone as ordered supplemental glucose PRN I&O, daily weights check for underlying causes NO CNS DEPRESSANTS/sedatives
Zidovudine (Retrovir, AZT) onset peak duration
Onset: 1 to 2 hours Peak: 1 to 2 hours Duration: Unknown
Psychosocial implications
Pain Depression- milieu therapy Self-image Self-worth Risk for suicide Role in the family / at work Coping Distrust Getting on with life...
The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should EXPECT to note which finding?
Pain, especially with INSPIRATION.
A client with a chest injury has suffered FLAIL chest. The nurse assesses the client for which MOST distinctive sign of a flail chest?
Paradoxical Chest Movement
The nurse is discussing techniques of chest physiotherapy and postural drainage to a client having expectoration problems because of chronic thick, tenacious mucus production in the LOWER airway. The nurse explains that after the client is positioned for postural draining, the nurse will perform which action to help loosen secretions?
Percussion and vibration
Antimalarial drugs
Plaquenil TX: fatigue, moderate skin rashes, joint pain, nausea, loose stool slow acting maintenance to prevent flare ups
Types of Immunodeficiency
Primary or congenital - Present at birth Secondary or Acquired - result exposure, medical therapy and unknown causes AIDs
The nurse instructs a client to use the pursed-lip method of breathing and client asked the nurse about the purpose of it. The nurse responds, knowing that the PRIMARY reason is to promote which outcome?
Promote CO2 ELIMINATION
Range of Lupus
Ranges from a relatively mild disorder to rapidly progressive, affecting many body systems Most commonly affects the skin and muscles, lining of lungs, heart, nervous tissue, and kidneys
wound debridement
Removes devitalized and contaminated tissue Exposes granulation tissue Promotes healing and decreases infection although debrided wounds are at greater risk of infection Natural (dead tissue separates spontaneously) Mechanical (surgical scissors, wet-to-dry dressings, topical enzymes) Surgical (early and aggressive surgical wound closure has lowered incidence of septic shock)
A client has been admitted with chest trauma after an MVA and has undergone intubation. The nurse checks the client when the HIGH-PRESSURE alarm on the vent sounds and notes that the client has ABSENCE of breath sounds in the RIGHT upper lobe of the lung. The nurse IMMEDIATELY assess for other signs of which condition?
Right Pneumothorax
SLE affects the following
Skin (rashes) Joints (arthritis) Serous membranes Renal system Hematological system Neurological system
Immune system
Skin barrier is destroyed Decreased effectiveness of immune system 70% of those with burns die if they develop sepsis
Airway
Smoke Inhalation (check for soot on skin/clothes and carbonaceous sputum) Assess for respiratory distress, ↓pO2, altered LOC Treated with oxygen, bronchodilators CO poisoning Oxygen is displaced from HGB- CO2 higher afinity for HGB Cherry red lips and skin may not be present Treated with 100% oxygen, positioning, DB&C - bright red skin to much CO2 Airway Obstruction 2°edema, circumferential burns Pneumonia ARDS ( acute respiratory distress syndrome) (2-5 days post burn with 50% mortality)
Severity of burn determined by:
TBSA injured Burn depth Location of burns Age Concommitant(another injury on top of burn) injury Past health history
diagnostic studies
There is no specific test. SLE is diagnosed primarily on criteria relating to patient history, physical examination, and laboratory findings. Characterized by antinucular antibodies : anti-double-stranded DNA, Anti-smith -antibody Blood tests increased: CRP, ESR- inflammation must have 4 or more manifestations to be lupus
causes of burns
Thermal - heat Chemical- laundry detergent, alkaline burn worse then acid Electrical- lightning strike- coterizes bld flow
thyroid storm assessment
VS increased decreased CO - heart can't fill - risk for afib diaphoresis dehydration infection/stressor delirium vomiting abd pain
lupus nephritis
affects 50% -> proteinuria -> glomerular nephritis lead to end stage renal disease in the blood creatinine and BUN build up as waste products
Cushing's disease
hyperfunctioning of adrenal hormones
Addison's disease
hypofunctioning of adrenal hormones
immunosuppresive drugs
imuran - severe lupus nephritis cyclophosphamide
Cushing's labs
increased Na decreased K increased glucose decreased calcium
health teach about
minimizing precipatory factors : sun, avoid excessive fatigue and infections in and out caths to assess for proteinuria
DI interventions
monitor VS, LOC I&O, daily weights F&E replacement skin and oral care promote safety avoid caffeinated foods fiber and fruit juices for constipation
myxedema coma assessment
presence of stressor or infection VS severely decreased decreased CO cerebral hypoxia increased PaCO2 stupor
Cushing's interventions
prevent infection, handwashing monitor I&O, daily weights monitor VS and heart rhythm physical activity as tolerated turn q 2 prevent falls/fractures low Na, fat diet, increase K
a sun burn is what type of burn
primary - increases risk of melanoma
what infection typically can end someone with lupus life
pulmonary infection - penumonia
Allergy Disorder
• Results from hypersensitivity (excessive reaction to a stimulus) of the immune system to allergens. • 10-20% of population affected • Genetic link • Allergens include; food, animals, environment, and medication • Also includes transfusion reactions, transplant rejection
Central nervous system manifestations
stroke seizures periphreal neuropathy psychosis organic brain syndrome decrease in sensory motor function cognitive deficits- decreased memory, confusion, headaches and psychosis
poorly controlled hyperthyroidism
thyroid storm
The nurse had conducted discharge teaching with a client diagnosed with TB, who has been receiving medication for 1.5 weeks. The nurse determines that the client has understood the information if the client makes which statement?
"I should NOT be contagious after 2-3 weeks of medication therapy"
Eschar
(sloughing layer of necrotic tissue, collagen and protein exudate that coagulates into a hard crust) + edema →tight constricting band that prevents airway/chest expansion
Highly Active Antiretroviral Therapy (HAART)
- 3 drugs spanning 2 classes (Protease inhibitor and 2 NNRTIs) to reduce virus and delay progression of HIV to AIDS
Addisonian Crisis
- A life-threatening disorder caused by ADRENLA HORMONE INSUFFICIENCY -Precipitated by: -Infection -Trauma -Stress, -Surgery -DEATH Can Occur from: -Shock -Vascular Collapse -HYPERkalemia.
Chest Tube
- A small incision is made in the chest wall, and a plastic tube is inserted into the pleural space - Attached to suction and are often kept in place for several days
Nursing Assessment for Lupus: GI & Urinary
- Abdominal pain - Assess for renal nephritis
Pleural Effusion
- Abnormal accumulation of fluids around the lungs - Fluid builds up between the two pleural layers
Sinusitis: Symptoms
- Acute: Significant pain, purulent nasal drainage, nasal obstruction, congestion, fever, malaise - Chronic: Facial pain, nasal congestion, increased drainage; severe pain and purulent drainage are often absent - Symptoms may mimic those seen with allergies - Difficult to diagnose because symptoms may be nonspecific; patient is rarely febrile
Treatment of Herpes simplex virus
- Acyclovir -Famciclovir -Valacyclovir -Topical medications
Lung Cancer Symptoms
- Cough - Hemoptysis - Anorexia - Fatigue - Dyspnea - Chest pains
Systemic Autoimmune Disease
- Lupus - Rheumatoid arthritis - Scleroderma
Allergic Rhinitis: Manifestations
- Nasal congestion; sneezing; watery, itchy eyes and nose; altered sense of smell; thin, watery nasal discharge - Nasal turbinates appear pale, boggy, and swollen - Chronic exposure to allergens: Headache, congestion, pressure, postnasal drip, nasal polyps - Patient may complain of cough, hoarseness, snoring, or recurrent need to clear the throat
Allergic Assessment: Nose
- Nasal polyps - Nasal voice - Nose twitching - Itchy nose - Rhinitis - Pale - Sniffling - Sneezing - Swollen nasal passages - Nosebleeds
What Happens during Organ Rejection
- Natural killer cells and cytotoxic cells destroys cells from other people or animals
Hypothyroid Drugs
- Natural synthetic thyroid agent used to treat hypothyroidism (Underactive thyroid)
Epistaxis
- Nosebleed - Occurs in all ages, especially in children (anterior bleeding), and older adults (posterior bleeding) - Causes trauma, foreign bodies, nasal spray abuse, drug use - Use of blood thinning agents causes pt predisposition (Aspirin, NSAID's)
Antiviral Meds for HIV
- Nucleoside reverse transcriptase inhibitors (NRTIs) - Non-nucleoside transcriptase inhibitors (NNRTIs) - Protease inhibitors - Nucleotide analogue reverse transcriptase inhibitors
Atelectasis: Treatment
- O2 Therapy - Mucolytics - Bronchodilators
Pneumonia: Treatment
- O2 therapy - Antipyretics - Antiinfectives - Corticosteroids - Analgesics - Bronchodilators - Increase fluid intake - Incentive spirometry
Pulmonary Embolism Treatment
- O2 therapy - Thrombolytics - Anticoagulants - Analgesics - Vena cava filter - Surgical removal of clot
Transplant
- Organ removed from one body and placed in the body of a recipient, to replace a damaged or missing organ -
Hyperthyroidism
- Overactive thyroid - Increase in T3 & T4 levels
Uses of O2 Therapy
- Reduce work of breathing - Maintain PaO2 - Reduce workload on the heart
Nursing Alerts for Beta-Adrenergic Agonists
- Shouldn't be used if pt has history of dysrhythmia or MI - Used limited in children younger than 6 years - NOT recommended for women who are breast feeding
Nursing Interventions for Lupus
- Skin protection (Avoid UV, SPF 50 - Mild soaps and cosmetics - Hair preservation (Mild shampoo, avoid harsh treatment) - Stress management (Acupuncture, massage, yoga, meditation) - Avoid fatigue, smoking, alcohol - Dietary changes (Omega-3, increase supplements, assess weight) - Monitor temp to prevent exacerbation - Monitor mood and affect
TB (Mantoux) Skin Test
- Skin test is an intradermal injection 10cm distal to the antecubital fossa - 48-72 hours later to be read - Reaction w/ erythema & induration indicates sensitivty to tuberculin - Induration > 10mm is significant - Induration > 5mm is significant in high risk pts
Levothyroxine (Levothyroxine)
- Type of Drug: hypothyroid drug - Mechanisms of action: same as those of thyroid hormone - Primary use: drug of choice for replacement therapy in clients with low thyroid function - Adverse effects: hyperthyroidism, palpitations, dysrhythmias --Anxiety, insomnia, weight loss, heat intolerance --Menstrual irregularities and osteoporosis in women --Drug interactions
Infections Caused by Pseudomonas aeruginosa
- UTIs - Atypical pneumonia - Infections in burns
Lung Cancer
- Uncontrolled cell growth in lung tissues leading to a tumor - Most preventable cancer - Can be primary or secondary - Staged I-IV
Lung Cancer
- Uncontrolled cell growth in lung tissues leading to tumor - Tobacco is #1 cause but is also caused by asbestos, mustard gas, wood dust, cement dust, tar products & metals - Diagnosed with laryngoscope & biopsy, CT & MRI can also be used
Hypothyroidism
- Underactive thyroid - Decrease in in T4 - Caused by acute or chronic inflammation - Severe hypothyroidism also known as myexedema
Clinical Manifestations of Anaphylaxis
- Urticaria (hives, large itchy red rash) - Localized Erythema (redness of skin and mucous membranes) - Rhinitis
Eye Autoimmune Diseases
- Uveitis
The nurse teaches a client about the effects of Diphenhydramine (Benadryl), which has been prescribed as a cough suppressant. The nurse determines that the client needs FURTHER instruction if the client makes which statement?
-"I will take the medication on an EMPTY stomach" -(Should be taken WITH FOOD to decrease gastric upset)
The nurse has just administered the FIRST dose of Omalizumab (Xolair) to a client. Which statement by the client would alert the nurse that the client may be experiencing a life-threatening effect?
-"My lips and tongue are SWOLLEN."
A client with type 1 DM calls the nurse to report recurrent episodes of HYPOglycemia with exercising. Which statement by the client indicates an INADEQUATE understanding of the PEAK action of NPH insulin and exercise?
-"The best time for me to exercise is mid-to late afternoon."
The nurse is interveiwing a client with Type 2 DM. Which statement by the client indicates an understanding of the treatment for this disorder?
-"The medications I'm taking help release the insulin I already make."
Rule of nine for adults perineal
-1%
Non-rebreathing Mask Nursing Interventions
-10 to 15 L/ minute to prevent rebreathing of CO2 -Reservoir bag does not completely empty if the flow rate is set correctly
What should you notify the physician of in a Chest Tube?
-100 mL or GREAYER of drainage in the FIRST hour
In Suspected Inhalation Injury What is the Recommended % of 02 and Mode of Delivery?
-100% HUMIDIFIED O2 by NON-Rebreathing facemask or endotracheal tube.
Symptoms of Influenza in infants
-103.1 fever or higher -Irritable -Cough -Coryza -Pharyngitis -Wheezing -Erythematous rash -Diarrhea
Rule of nine for child 1-8 legs
-14% EACH -7% anterior -7% posterior
Rule of nine for infants legs
-14% EACH -7% anterior -7% posterior
Rule of nine for child 1-8 face
-18% -9% anterior -9% posterior
Rule of nine for infant face
-18% -9% anterior -9% posterior
Rule of nine for infants chest and back
-18% -9% anterior -9% posterior
Mineralocorticoids
-95% is aldosterone -Promotes sodium absorption and potassium excretion
The community health nurse is conducting an education session with community members regarding symptoms associated with TB. Which is one of the FIRST manifestations associated with TB?
-A COUGH with the EXPECTORATION of mucoid sputum.
Second Line of Defense
-A cellular and chemical system that comes immediately into play if infectious agents make it past the surface defenses
When does grunting occur?
-Alveolar collapse -Atelectasis (internal) -Pneumonia -Pulmonary edema
Veracity
-Always be truthful
What is a pulmonary embolism?
-An embolus in the pulmonary vasculature
HHS Insulin Therapy
-An initial bolus of 0.1 unit/kg regular insulin given -Then continuous
Kaposi's Sarcoma Virus HSV-8
-Anigiogenic tumors (dark purple lesions) -Affects immunocompromised (AIDS)
Inhalant allergens
-Animals -House dust mites -Cockroaches -Indoor fungi -Outdoor allergens
Seborrhea Therapeutic Management
-Anti dandruff shampoo -Corticosteroid creams or lotions
Coal Tar Preparations
-Anti itching -Anti-inflammatory -For psoriasis and atopic dermatitis -Apply at bed time and wash off in the morning -May stain sheets
Corticosteroids (topical)
-Anti-Inflammatory effect in atopic dermatitis and certain kinds of contact dermatitis -DON'T USE HIGH POTENCY ON FACE OR GENITALS -DON'T cover with an occlusive dressing
Systemic corticosteroids
-Anti-inflammatory -Immunosuppressive action -SEVERE contact dermatitis -TAKE WITH FOOD
Treatment for Group A Strep Pharyngitis
-Antibiotics -Penicillin/Amoxicillin -If allergic to penicillin: macrolides and cephalosporins
What is ADH
-Antidiuretic hormone
Symptoms of RSV
-Apnea -Grunting -Wheezing -Air-hungry -Listless -Uninterested in feedings or surroundings -Tachypnea -Retractions -Accessory muscle use -Cough
West Nile Virus (Arbovirus)
-Appeared in 1990 -Most infected but didnt feel -Mosquito to human
Ineffective Breathing
-Assess -Use pulse oximetry -Position with airway open using pillows or padding if necessary -Administer oxygen as ordered -Allow for rest -Spirometry
Impaired gas exchange
-Assess O2 -Supplemental O2 -Suctioning, physiotherapy, coughing -Bronchodilators -Monitor mental status changes
Ineffective tissue perfusion
-Assess pulses -Elevate extremities -Assist with escharotomy and fasciotomy
Nursing Alerts for Anticholinergics
-Assess resp. rate BEFORE & AFTER FIRST dose -Monitor vitals (RR, P, O2 sat) -Monitor skin color, lung sounds and respiratory effort -(Use of accessory muscles when breathing)
Maintain Skin Hygiene
-Assess skin daily in the hospital and weekly in the home -When bathing use minimal force and do not use products that will dry out the skin -Use lotion after bathing
Impaired Skin Integrity
-Assess skin for warmth, redness, color, drainage -Use Norton or Braden scale for risk assessment -Position the child on the opposite side of the skin impairment to avoid further skin breakdown -Proper nutrition -Wound and Ostomy care
Tinea Pedis
-Athletes foot
Causes of intrapulmonary shunting
-Atrial or ventricular septal defect -Atelectasis -Pneumonia -Pulmonary edema
What is the FIRST step of the HIV life cycle?
-Attachement
Efavirenz (Sustiva)
-Avoid high fat meals -Take on an empty stomach -Take at bedtime to limit CNS effects -Sleep disorders, nightmares, dizziness, reduced ability to concentrate, delusions: stop after 3 to 4 weeks -Rash -Do not give to pregnant women -Do not drink alcohol -Do not take saint johns wort
Acne Neonatum Nursing Management
-Avoid picking or squeezing -Wash area with clear water -Avoid fragrance soap -Will go away on its own when babies hormones stabilize
Signs and Symptoms of COPD
-BARREL chest -Use of ACCESSORY muscles -Congestion and HYPERINFLATION on chest x-ray -ABG: RESPIRATORY ACIDOSIS and HYPOEXMIA
What is seen on a CHEST X-Ray of Respiratory Distress Syndrome?
-BILATERAL alveolar INFILTRATES
What is used for patients who have contraindications to thrombolytic therapy
-Catheter embolectomy or local intraembolic thrombolytic therapies
What does HYPO-osmolality cause?
-Causes a shift of water into brain cells leading to cerebral edema and ICP
Inadequate Nutrition
-Causes weight loss, muscle atrophy, loss of subcutaneous tissue -Reduce the amount of padding between the skin and bone
What can Rapid Fluid Administration in DKA lead to?
-Cerebral Edema
Preventing Diaper Candidasis
-Change diapers frequently -Wash area with soft cloth avoiding harsh soaps -Use fragrance free baby wipes -Allow child to go diaperless for a period of time -Blow dry rash set on warm for three to five minutes
What do hormones do?
-Chemical messangers released in response to a change in the bodys environment
How do you get air OUT of the chest?
-Chest Tube -Needle Aspiration -AKA: Needle Decompression
Signs of Pneumothorax
-Chest pain -Tachypnea -Nasal flaring -Grunting -Retractions -Tachycarida -Diminished breath sounds
What is asthma?
-Chronic inflammatory disorder of the airways
Inhalation
-Common Route for Pulmonary Drugs -RAPID and EFFICIENT -Rich Blood Supply -Allows for QUICK ABSORPTION and ONSET of action -Delivers Drugs DIRECTLY to SITE of Action -Drugs CAN leave patient with "HYPER/STIMULATED" feeling
What drug is used for Neurogenic DI?
-Desmopressin -Longer antidiuretic action
Western Blot
-Detects antibodies of HIV -CONFIRMS EIA
Examples of Antitussives
-Dextromethorphan (Benylin DM) -Benzonatate (Tessalon) -Dextromethorphan (Buckleys Mixture) -Dextromethorphan (Robitussin CoughGels Long- Acting) -Dextromethorphan (Vick's Dayquill, Vick's Formula 44, & Vick's Nature fusion cough) -Sucret's Cough Drops
Terbutaline is prescribed for a client with Bronchitis. The nurse understands that this medication should be used with CAUTION if which medical condition is present in the client?
-Diabetes Mellitus
Chronic Medical Conditions
-Diabetes and Heart disease cause poor perfusion and cause poor delayed healing
What does hyposecretion of ADH cause?
-Diabetes insipidus -Vasopressin, decompressin, and lypressisn
Chronic Lung Disease
-Diagnosed in infants who have experienced RDS -Require oxygen at 28 days old -Seen mostly in premature infants -Affects growth and development of lung structure -Number of normal alveoli is reduced
What is Acute Respiratory Distress Syndrome (ARDS)?
-Diffuse lung INJURY -Leads to EXTRAVASCULAR lung FLUID -Pulmonary Edema
Signs and symptoms of PE
-Dyspnea -Hemoptysis (coughing up blood) -Chest pain -Syncope -Chest wall tenderness -Chest pain aggravated by deep inspiration -Tachypnea -Decreased SpO2 -Cough -Crackles -Wheezing -S2 -A-fib -Adult onset asthma -Diaphoresis
Levothyroxine (levothroid, syntrhoid) AE
-Dysrhytmias -Palpations -HTN -Insomnia -Anxiety -Weight loss -Heat intolerance
A daily dose of Prednison is prescribed for a client. The nurse provides instructions to the client regarding administration of the medication and should instruct the client that which TIME is BEST to take the medication?
-EARLY MORNING -(BEFORE 9am to minimized adrenal insufficiency and mimic natural steroid release)
Polycystic Ovary Syndrome (PCSO) Lab Tests
-ELEVATED Insulin in correlation with glucose -ELEVATED levels of Free Testosterone -ELEVATED Androgenic Hormones
Static low air loss
-Each level of the bed can be inflated to a different level of firmness
Nutritional Status
-Eat foods that are easy to swallow -Avoid spicy, sticky, too hot/cold foods -Oral care before and after meals -Avoid foods fiber rich or lactose -Add eggs, butter, and fortified milk -High calorie nutritional foods puddings, powders, and milkshakes
What is Atopic Dermatitis?
-Eczema
Cardiovascular and SIADH
-Edema -INCREASED BP -ELEVATED Central Venous (CVP) and Pulmonary Artery Occlusion Pressure (PAOP)
Respiratory Support in DKA
-Elevate HOB -Patient may be intubated and on ventilation if severe
Goals Behind Treatment of Emphysema
-Emphysema is the TERMINAL Stage of COPD -Goals are to: -Treat Infections -Control Cough -Relieve Bronchospasms -Patient Might Receive: -Bronchodilators -Inhaled Glucocorticoids -Mucolytics -Expectorants -Oxygen -Antibiotics
Exogenous Pyrogens
-Endotoxins -Caccines
Paramyxovirus
-Enveloped -Negative sense RNA -Measels and Mumps
HIV
-Enveloped RNA virus -Reverse transcriptase: retrovirus -Binds to CD4 cells
Superficial Burns
-Epidermal injury -Heal without scarring in 4 to 5 days
Partial Thickness
-Epidermis and dermis -Heal within two weeks with minimal scarring
SLE Etiology
-Etiology is unknown -Most probable causes: -Autoimmune reactions directed against constituents of CELL NUCLEUS, DNA -Antibody response related to B- and T-cell HYPERACTIVITY
How often do you record Chest Tube drainage?
-Every HOUR in the FIRST 24 hours -Every 8 AFTER that
Goals Behind Treatment of Chronic Bronchitis
-Excess mucus is produced in the bronchial tree -May be caused by tobacco smoke or pollution -Condition of COPD -Expectorants & Mucolytics given for excess mucus and other type of Pulmonary Drug to promote BRONCHODIALATION -(Depends on CONDITION & SEVERITY)
How is Neurogenic DI controlled?
-Exogenous ADH preparations
Goals with patients at risk for skin integrity
-Explain to the client that they will be turned and how often -Position proper body alignment -Use speciality beds and mattresses as need -Document skin status every shift -Remove moisture -Apply protective barriers
What is the strongest stimuli for increased thyroid production?
-Exposure to cold
Psorasis Nursing Management
-Exposure to sun light -UV -Tar -Anti-inflammatory -Mineral oil and warm towels
Influenza Flu Symptoms
-Extreme fatigue -Headache -Chills -Dry cough -Body aches -Fever -Stuffy Nose
A client has been diagnosied with HYPERthyroidism. Which s/s may indicate THYROID STORM, a complication of this disorder?
-FEVER -Nausea -Tremors -Confusion
Piconavirus Transmission
-Fecal:Oral -Oral:Oral
The nurse is preparing a client with a new diagnosis of HYPOthyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which symptoms are associated with the diagnosis?
-Feeling Cold -Loss of Body Hair -Persistent Lethargy -Puffiness of the Face
Yellow Fever Virus (Arbovirus) Symptoms
-Fever -Bleeding -Muscle pain -Headache -Liver and Intestinal Hemorrhages -Nausea -Black vomit -Jaundice
West Nile Virus Symptoms (Arbovirus)
-Fever -Body ache -Rash -Eye pain -Fatigue -Mental numbness -Muscle jerking
Rhabdovirus Rabies Symptoms
-Fever -Dialtion of pupils -Tears -Salivation -Anxiety
Symptoms of Influenza in children
-Fever -Facial flushing -Chills -Headache -Myalgia -Malaise -Cough -Coryza (nasal discharge) -Ocular symptoms (photophobia, tearing, burning, and eye pain)
What do people with HIV exhibit signs of in the BEGINNIG of the infection?
-Fever -Fatigue -Rash
Second Line of Defense
-Fever -Phagocytosis -Inflammatory response -Pyrogens: exogenous and endogenous -Antimicrobial proteins: complement and interferons
What is Pneumocystis Pneumonia
-Fever -Chills -SOB -Dyspnea -Chest pain -Respiratory failure can develop in 2 to 3 days
Pharyngitis symptoms
-Fever -Sore throat -Difficulty swallowing -Headache -Abdominal pain -Petachiae on the palate -Strawberry appearance on tongue -RED RASH ON TRUNK OR ABDOMEN: -Scarlatiniform
Signs and symptoms of infection
-Fever chills -Enlarged lymph nodes -Skin and mucous membranes assessed for bleeding, inflammation, and discharge -Joints are assessed for tenderness, swelling, increased warmth, and limited ROM
Spleen
-Filters blood -Removes RBCs & pathogens
Auscultation of Cystic Fibrosis
-Fine or coarse crackles -Wheezing -Diminished breath sounds -Tachycardia -Gallop
Hepatitis A Transmission
-Food -Water -Fecal-oral route
Live Attenuated Influenza Vaccine
-Given Intranasally and is indicated for healthy persons between 2 to 49 yrs old -It can replicate and shed for a week -Should not be given to anyone who will be in contact with an immunosuppressed person
An external insulin pump is prescribed for a client with DM and the client asks the nurse about the functions of the pump. The nurse bases the response on which information about the pump?
-Gives a small continuous dose of short-duration insulin SubQ and the client can self administer a bolus with an additional dose from the pump BEFORE each meal.
What are corticosteroids made up of?
-Glucocorticosteroids -Mineralocorticosteroids
How to help HYPOglycemia in Myxedema Coma?
-Glucose is added to IV fluids
What happens in the Attachment Phase?
-Glycoproteins bind with the hosts uninfected CD4 cells and Chemokine Receptors -This results in fusion of the HIV and the CD4 and T-cell membrane
How are colds resolved?
-Go away after 7 to 10 days on their own
The nurse performs an admission assessment on a client who visits a health care clinic for the first time. The client tells the nurse that Propylthiouriacil (PTU) is taken daily. The nurse continues collecting data from the client, suspecting that the client has a HISTORY of which CONDITION?
-Grave's Disease -(PTU INHIBITIS Thyroid synthesis and is used to treat HYPERthyroidism aka Grave's Disease)
What does hypersecretion of thyroid cause?
-Graves disease -swelling of the neck and protrusion of the eyes -PTU -T3 & T4 High
Glucose DKA
-Greater than 250
HHS Glucose
-Greater than 250
Beta-Hydroxybutyrate
-Greater than 3.0 mg
HHS Osmolality
-Greater than 330
Osmolality DKA
-Greater than 330
Oxygen Tent
-High humidity -50% O2 concentration (varies due to environmental loss) -Flor rate: 8-12 L/min
Discharge teaching for Community acquired pneumonia
-Hydrate with 2 to 3 L per day -Change positions frequently -Cough and deep breathe -Incentive spirometer -Rest don't over exert -Small frequent meals -Get a flu shot
What are the characteristics of Asthma?
-Hyperresponsiveness -Airway edema -Mucus production -Some kids have persistent symptoms others have long periods of no signs and acute exacerbations
Early signs of hypoxemia
-Hypertension -Increased HR -Pallor -Cool, dry skin -Dyspnea -Tachypnea -Tachycardia -Dysrhythmias -Chest pain -Anxiety -RESTLESSNESS -CONFUSION -Fatigue -Combativeness/agitation
CD4/CD8
-Impaired Immune System
Decreased mental status
-Individuals with a reduced level of awareness -unconscious, heavily sedated, have dementia -cant recognize and respond to pain
Nursing Diagnosis for Respiratory Problems
-Ineffective airway clearance -Ineffective breathing patterns -Impaired gas exchange -Pain -Activity Intolerance
Risk factor of Myxedema Coma?
-Infection -Being out in the COLD
Epstein Barr Virus
-Infects lymphoid tissues and salivary glands
Cytomegalovirus pathogenesis
-Infects upper respiratory tract, then monocytes -Can circulate to spleen and lymph nodes -Spreads to salivary glands, kidney tubules, testes, and cervix
Pharyngitis
-Inflammation of the throat -Group A streptococci accounts for 15% to 25% of cases
When glucose values are LESS than 200
-Infusion rates set at 0.02 to 0.05 kg/hr -MAINTAIN BETWEEN 150 TO 200
What are asthma triggers?
-Inhalant allergens -Occupational exposure -Irritants -Other
Variola Virus pathogenesis
-Inhalation or skin contact -Viremia (virus in blood) -Heart, liver, kidney -Epithelium of dermis
Medication for acute exacerbation of asthma
-Inhaled rapid acting beta-agonist via NEBULIZER (PEF greater than 70, breaths less than 30) -Inhaled anticholinergics
Topical immune modulators
-Inhibit T lymphocyte action at skin level -Atopic dermatitis -Or for conditions resistant to topical steroids -AVOID SUN LIGHT -Burning, itching, flu like symptoms
Chest Tube
-Insertion of a drainage tube into the pleural cavity -Facilitates the removal of air or fluid -Allows for full lung expansion
The nurse is monitoring a client receiving Levothyroxine sodium (Synthroid) for HYPOthyroidism. Which findings indicate the presence of a SIDE EFFECT associated with this medication?
-Insomnia -Weight LOSS -MILD HEAT intolerance -(Too much med = HYPERthyroid symptoms)
What hormone do pancreatic islets secrete?
-Insulin -Can lead to diabetes mellitus -Treated by insulin and antidiabetic drugs
What is Diabetic Ketoacidosis (DKA)?
-Insulin deficiency resulting in cellular dehydration and acidosis -HYPERglycemia
What is HYPERosmolar HYPERglycemic state
-Insulin deficiency resulting in dehydration and HYPERosmolarity -Extremely high blood sugars
WHY does potassium need to be monitored BEFORE insulin administration?
-Insulin therapy will promote translocation of potassium into the Intracellular Space (ICF) resulting in a further decrease of potassium levels
Tinea Cruris
-Jock itch
Signs and Symptoms of Pleurisy?
-KNIFE-LIKE pain aggravated on DEEP breathing -PLUERAL FRICTION rub HEARD on auscultation -LIE on AFFECTED side -SPLINT chest
How is HYPOthermia helped in Myxedema Coma?
-Keep the room WARM -Passive warming blankets
Negative feedback
-Keeps body at homeostasis -When the PTH secretes calcium when serum calcium levels are low -High glucose, pancreases produces insulin until glucose levels return to normal
Preferred drug for cushings syndrome
-Ketoconazole (Nizoral) -Blocks synthesis of corticosteroids -Patients develop tolerance -DONT GIVE TO PREGNANT WOMEN
Antifungals (systemic)
-Kills fungus -Binds to human keratin making it resistant to fungus -For Tinea Capitis and severe widespread fungal infections -GIVE WITH FATTY FOODS
T3 Free
-LESS than 0.2
Platelets
-LESS than 150,000
T3 Resin Uptake
-LESS than 25%
T4
-LESS than 5 mcg
Glucose
-LESS than 50
pH
-LESS than 7.35
Advanced age
-Loss of body mass -Thinning epidermis -Decreased strenght and elasticity -Increased dryness -Diminished pain perception -Diminished venous and arterial flow
Excoriation
-Loss of superficial layers of the skin -caused by urea, gastric tube drainage, digestive enzymes in feces
What should a patient with a moderate risk for PE receive?
-Low dose un-fractionated heparin -Low Molecular Weight Heparin (LMWH) - Enoxaparin Sodium (Lovenox)
Lymphatic Vessels
-Lymph fluid
Treatment of Influenza
-Maintain hydration -Focus on symptomatic symptoms
Avoid Skin trauma
-Make sure bed is smooth, wrinkle free, and firm -Turn client frequently -For bed ridden clients do not elevate bed more than 30 degrees
Viral Load
-Measures HIV RNA in Plasma
Ineffective airway clearance for burns
-Monitor SpO2 every hour -Assess RR -Auscultate breath sounds q4h -Cough and deep breathe every hour awake -Turn every 2 hours -Elevate HOB -Schedule activities to avoid fatigue
Cytomegalovirus
-Mono -Can cross the placenta
Nursing Alerts for Glucocorticoids
-NOT recommended for PREGNANT or BREAST- FEEDING women -PRIMARY purpose to PREVENT resp. distress -DON'T use DURING ACUTE asthma attack
When receiving IV insulin patients should be..
-NPO
Medications that cause immunosuppression
-NSAIDs -Anesthetic agents -Antibiotics -Corticosteroids -Cytotoxic agents
RA Teaching
-NSAIDs to relieve symptoms -Relaxation techniques -Hot and cold therapies -Reconstructive surgery -Corticosteroids -Immunosuppressive agents -PT and OT
What is RATE on a ventilator?
-NUMBER of ventilator BREATHS per MINUTE
Respiratory system in newborns
-Nasal passages are narrower -Trachea and chest wall are more compliant -The bronchi and bronchioles are shorter and narrower -Larynx is more funnel shaped -Tongue is larger -Fewer aleveoli
Symptoms of Cystic Fibrosis
-Nasal polyps -Barrel chest -Clubbing -Protuberant abdomen thin extremities -Edema -Abdominal pain/difficulty passing stool -Poor weight gain -Bulky greasy stool
Two types of immunity
-Natural (innante) present at birth -Acquired (adaptive) after birth
GI System and SIADH
-Nausea -Vomiting -Anorexia -Muscle cramps -DECREASED bowl sounds
Lopinavir (Kaltera) adverse effects
-Nausea -Vomitting -Diarrhea -Hyperglycemia -Worsen diabetes mellitus -Pancreatitis -Lipodystrophy syndrome
If patient is INCOMPETENT to sign informed consent
-Nearest relative -Court to appoint a guardian or conservator -Hospital administrator
What is Bronchiolitis caused by?
-Nearly always by a viral pathogen
What does the Posterior Pituitary (Neurohypophysis) do?
-Nervous tissue that stores -ADH -Oxytocin
Atopic Dermatitis Nursing Interventions
-No hot baths -No fragerence soaps -Pat dry -Leave moist -Moisturize -Evening primrose oil -Chamomile -AVOID WOOL AND SYNTHETIC FABRICS -Avoid tight clothing and heat
If redness disappears
-No tissue damage has occured
Primary Infection
-None to Flu like symptoms -Virus = Immune response
Natural Immunity
-Nonspecific -Broad spectrum -First line of defense -Immediate (within 4 hour) -Delayed (withing 4 to 96 hours)
Diabetes Insipidus Urine Sodium
-Normal
SLE Nursing Assessment:
-Nursing assessment -Assess patient's: -Physical -Psychological -Sociocultural Problems -With long-term management of SLE -Assess PAIN and FATIGUE DAILY -Obtain subjective and objective data -Educate and counsel on expected issues -Nursing diagnoses: -Fatigue -Acute Pain -Impaired Skin Integrity -Deficient Knowledge
Flat or Dull sounds could mean
-Pneumonia
Who is most susceptible to RSV
-Premature -Chronic lung disease -Certain congenital heart diseases -Immunocompromised
The home care nurse visits a client recently diagnosed with DM who is taking Humulin NPH insulin DAILY. The client asks the nurse SHOW TO STORE unopened vials of insulin. The nurse should tell the client to take which action?
-Refrigerate the insulin
Risk for ineffective coping
-Reinforce information frequently -Interventions to reduce pain and fatigue -Consult social workers -Group support sessions
Anticipated Therapeutic Outcome of Escharotomy/Fasciotomy
-Relieve pressure -Restore circulation
When is Phosphate administration used with caution?
-Renal failure -Can have underlying HYPERphosphatemia
What is the GOAL of fluid replacement in DKA?
-Replace HALF of the fluid deficit in 8 hours -Replace the SECOND half of fluid deficit in the NEXT 16 hours
Why is hormone therapy used?
-Replacement therapy for patients unable to secrete enough of their own endogenous hormones -Used in cancer chemotherapy to shrink hormone sensitive tumors -Hormone antagonists block the actions of endogenous hormones
Zidovudine (Retrovir,AZT)
-Replaces the thymidine nuceloside creating a defective DNA strand -Can be used to treat HIV and postexposure health care workers to HIV -Resistant strains have been made
A client is to begin a 6-month course of therapy with Isoniazid. The nurse should plan to teach the client to take which action?
-Report Yellow Eyes or Skin IMMEDIATELY
What is Mycobacterium Avium Complex (MAC)?
-Respiratory -GI -Bone marrow -Lymph nodes
A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is PRIORITY for this client?
-Respiratory Distress
Varizella-Zoster Virus Transmission
-Respiratory droplets -Fluids from skin lesions and contact
Togavirus (Rubella) Transmission
-Respiratory route
Nursing interventions for DKA
-Respiratory support -Fluid replacement -Insulin -Replacement of electrolytes -Correction of acidosis
Paramyxovirus Measles
-Respiratory tract travels to the skin -Humans are the only reservoir -Koplick spots: oral leisions -Complications: pneumonia and encephalitis
BEST way to AVOID a lawsuit in psychiatry...
-Respond to the patient -Educate the patient -Complying with the standard of care -Supervising care -Adhering to the nursing process -Documentation -Follow up care
What is a chronic PE?
-Responds to treatment -Reoccurs -Small clots continue to develop and travel to the pulmonary vasculature bed after treatment
What is a Provirus?
-Resting nondiving CD4 cells
The nurse is preparing to administer a dose of Naloxone Hydrochloride (Narcan) IV to a client with an IV OPOID overdose. Which supportive medical equipment should the nurse plan to have at the client's bedside if needed?
-Resuscitation equipment
CMV in the Immunosuppressed
-Retinitis (occurs in AIDs patients) -Pneumonia -Colitis -Esophagitis -Encephalitis
Diagnostic testing for RA
-Rheumatoid Factor -Anti-CCP -ESR and CRP are elevated -RBC and C4 count is decreased -ANA test is positive -Arthrocentesis(synovial fluid is milky yellow cloudy -X Rays show bony erosions
Desmopressin AE Intransal
-Rhinitis -Epistaxis -Nasal congestion
What do patients with HHS need monitored during fluid replacement?
-Right Atrial Pressure -Pulmonary Artery Pressure
Tinea Corporis
-Ring worm
The nurse is instructing a client regarding intranasal Decompressin (DDAVP). The nurse should tell the client that which occurrence is a SIDE EFFECT of the medication?
-Runny Nose
How to correct Serum Sodium level
-SLOWLY -12 mEq within the FIRST 24 hours
Treatment of SEVERE SIADH
-SMALL amounts of HYPERtonic 3% saline
In what compartment is CONTINUOUS bubbling OKAY?
-SUCTION CONTROL chamber
Cytomegalovirus transmission
-Saliva -Urine -Breast milk -Blood -Semen -Vaginal secretions
The nurse has a prescription to give a client Salmeterol (Severent Diskus), two puffs, and Beclomethasone Dipropionate (Qvar) by metered dose inhaler. The nurse should administer the medication using which procedure?
-Salmeterol FIRST -Bronchodialator -THEN Beclomethasone -Steroid
Nursing treatment of Pharyngitis
-Salt water gargle - 8 oz of water and a half a table spoon of table salt -Analgesics -Throat lozenges/hard candy -Popsicles, ice chips, liquids
Braden Scale for Predicting Pressure Sore Risk
-Sensory perception -Moisture -Activity -Mobility -Nutrition -Friction -Shear
What happens if the Serum Sodium DECREASES to 120 in 48 hours?
-Serious neuro problems -Mortality as high as 50%
How to assess if treatment for DI is EFFECTIVE?
-Serum osmolality 275 to 295 -Stable weight and I and O -Serum sodium 135 to 145 -Return to baseline mentation
Somatotropin AE
-Severe respiratory impairments in patients with prader willi syndrome -Diabetes -Pancreatitis -Scoliosis of the spine -Papilledema -Intracranial tumor
HSV-2 Transmission
-Sexual contact
The nurse teaches the client with DM about differentiating between HYPOglycemia and Ketoacidosis. The client demonstrates an understanding of teaching by stating that a form of glucose should be taken if which symptoms develop?
-Shakiness -Palpitations -Lightheadedness
HHS Signs and Symptoms
-Shallow respirations -Absent deep tendon reflexes -Paresis -Positive babinski sign
Varizella-Zoster Virus Reactivation
-Shingles -Can get serious if cranial nerves are involved -Can lead to blindness -Can get chickenpox from a person who has shingles
Full thickness
-Significant damage -Epidermis, dermis, hypodermis -Extensive scarring -Significant time needed to heal
Rifabutin (Mycobutin) is prescribed for a client with ACTIVE MAC Disease and TB. For which SIDE/ADVERSE effects of the medication should the nurse monitor for?
-Signs of Hepatitis -Flu-like Syndrome -LOW Neutrophil Count -Ocular Pain or Blurred Vision
Partial Re-breathing Mask
-Simple facemask with oxygen reservoir bag -70% to 90% Oxygen -Flow rate: 6-15 L/min
Types of oxygen delivery systems
-Simple mask (35% - 60% O2) -Venturi mask (24% - 55% O2) -Nasal cannula (22% - 44% O2) -Oxygen tent (O2 % varies due to environment) -Oxygen hood (INFANTS ONLY: 80-90% O2) -Partial re-breathing mask (70-90% O2) -Non-rebreathing mask (60-100% O2)
Hepatitis A
-Single Stranded RNA -Hepatovirus: effects liver -Can spread quickly
Hepatitis C
-Single stranded RNA
Norovirus
-Single stranded RNA
Togavirus (Rubella)
-Single stranded RNA
The nurse is instructing a hospitalized client with a diagnosis of Ephysema about measures that will ENHANCE the effectiveness of breathing during dyspneic periods. Which POSITION should the nurse instruct the client to assume?
-Sitting on the SIDE of the bed and LEANING on an over-bed table. -(Tripod position)
First Line of Defense Physical Barriers
-Skin -Hair -Mucous Membranes
Atopic Dermatitis Therapeutic Management
-Skin hydration -Corticosteroids -Immune modulators -Antihistamines -Antibiotics
Signs and Symptoms of Acute Respiratory Distress Syndrome (ARDS)?
-Tachypnea (INCREASED Heart Rate) -Dyspnea (difficulty breathing) -DECREASED Breath Sounds -DETERIORATING ABG levels -Pulmonary INFILTRATES
Deep Partial-Thickness
-Take longer to heal -May scar -Resulting in nail hair and sebaceous gland function
Treatment for Asthma
-Take medicine even when not having exacerbations -Use medicine before work outs -Avoid known allergens -Take your PEFR daily -Stay away from cigarette smoke it makes it worse -Educate the child and boost their self esteem
What is ASSIST mode?
-The VENTILATOR takes over the WORK of BREATHING
Primary Lymphoid Organs
-Thymus -Bone Marrow
Levothyroxine (Levothroid, Synthroid) T/P
-Thyroid hormone -Thyroid hormone replacement
What does the Thyroid secrete?
-Thyroid hormone T3 and T4
How to help HYPOnatremia in Myxedema Coma?
-Thyroid replacement -Water restriction
Air fluidized/static bed
-Tiny silicone coated beads -Uniform support to body contours -Moisture from client soaks into beads and is kept away from the client keeping them dry -Head of bed cannot be elevated
What is the SEVERITY of the HYPERthyroid State determined by
-Tissue and organ responsiveness to the hormones
If redness does not disappear
-Tissue damage has occured
What stage is AFTER Integration?
-Transcription
What stage is AFTER Transcription
-Translation
Hepatitis B administration
-Transmitted through contaminated blood and body fluids -Can be from injected drugs, sexual partner with it, sex between men -Should recieve a vaccine if you are under age 60 with diabetes, HIV, chronic kidney disease, travel to countries where it is prevelant
Erthrocytes
-Transport oxygen
PRIMARY GOALS of SIADH?
-Treat the UNDERLYING cause -Eliminate excess water -INCREASE Serum Osmolality
The nurse provides medication instructions to a client who is taking Levothyroxine (Synthroid) and should tell the client to notify the healthcare provider is which problems occurs?
-Tremors -(HYPERthyroid symptoms: -Tachycardiac -Chest Pain -Tremors -Nervousness -Insomnia -HYPERthermia -HEAT Intolerance -Sweating)
The nurse is monitoring a client who was diagnosed with Type 1 DM and is being treated with NPH and REGULAR insulin. Which client complaint(s) would alert the nurse to the presence of a possible HYPOglycemia reaction?
-Tremors -Irritability -Nervousness
HSV-1 Latency
-Trigeminal ganglia
Ipratropium (Atrovent, Novo-Ipramide)
-Type of Drug: Anticholinergic -Mechanism of action: causes bronchodilation by blocking cholinergic receptors in bronchial smooth muscle -Primary Use: relief of ACUTE bronchospasm. -Sometimes combined with Beta-Agonists or Glucocorticoids. -Also prescribed for CHRONIC BRONCHITITS and for SYMPTOMATIC relief of NASAL CONGESTION -Adverse Effects: -Cough -Drying of Nasal Mucosa -Hoarseness -Bitter Taste
Dextromethorphan (PMS-Dextromethorphan)
-Type of Drug: Antitussive -Mechanism of Action: acts in the MEDULLA to DECREASE cough reflex -INCREASES and LOOSENS BRONCHIAL secretions - Primary Use: RELIEF of Cough - Adverse Effects: -Dizziness -Drowsiness -GI Upset
Salmeterol (Serevent)
-Type of Drug: Beta-Adrenergic agonist/bronchodilator -Mechanism of action: selectively binds to beta2- adrenergic receptors in bronchial smooth muscle to cause bronchodilation -Primary use: prevention of exercise-induced bronchospasm -Best suited for management of chronic asthma. -NOT indicated for termination of acute bronchospasm -Adverse effects: -Headaches -Nervousness -Restlessness -Tachycardia
Acute pain
-Type,location, quality -Administer meds as ordered -Medicate patient before bathing,dressing, and major procedures -Minimize open exposure of wounds -Distraction and relaxation techniques
WHY use caution when giving Vasopressors in Myxedema Coma?
-Unable to respond to them until they have adequate levels of Thyroid Hormones
Diabetes Insipidus Results
-Urine is dilute -Osmolarity LESS than 3,000 -Specific Gravity 1.005 -Sodium DECREASED -Serum Osmolarity GREATER than 300 -Serum Sodium ELEVATED -Normal -DECREASED Urine Output -INCREASED Specific Gravity -NO change in Sodium
What Physical Objective Finding Would Best Reflect Adequate Fluid Resuscitation During the Emergent Phase of Burn Injury?
-Urine output
What happens in the Uncoating Phase
-VIRAL CORE OF HIV EMPTIED INTO THE CD4 CELL -Protease -Integrase -Reverse transcriptase -Single strand of viral RNA
What is Pleurisy?
-VISCERAL and PARIETAL membranes RUB together during respiration and cause pain
The LOW-PRESSURE alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful, the nurse should take what INITIAL action?
-Ventilate the client MANUALLY.
An oxygen delivery system is prescribed for a client with COPD to deliver precised oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed?
-Venturi mask -(Most accurate for precise oxygen concentration) - 24%-55% ; 4-10 L/min
Diagnosis of Herpes Simplex Virus
-Vesicles and Exudate are typical diagnostic symptoms
How are colds spread?
-Viral particles spread through the air from person to person contact -Higher instance of colds in the winter
What is the common cold?
-Viral upper respiratory infection -Nasopharyngitis
The nurse is caring for a client with Pheochromocytoma who is scheduled for adrenalectomy. In the PRE-OP period, what should the nurse monitor as the PRIORITY?
-Vital Signs -(HYPERTENSION is the hallmark)
Why does intrapulmonary shunting exist?
-When lungs are inadequately ventilated but adequately perfused
What happens in the Transcription Phase?
-When the CD4 T cell is activated -Double stranded DNA forms mRNA -mRNA builds new viruses
WHEN is a person considered to HAVE AIDS?
-When the CD4T cells drop BELOW 200
WHEN can insulin infusion rate be DECREASED?
-When the blood sugar is 300
Why is ADH secreted
-When the hypothalamus senses that plasma volume has decreased -The osmolality of blood is too high
When do fluctuations in the Chest Tube stop?
-When the lung has re-expanded
WHEN does Phosphate replacement occur?
-When there is associated cardiac or respiratory dysfunction
The nurse is teaching a client how to mix REGULAR insulin and NPH insulin in the same syringe. Which action by the client indicates the need for FURTHER teaching?
-Withdraws NPH FIRST. -(AIR into NPH, Air into Regular, Draw REGULAR, Draw NPH) -"Nancy Regan, RN"
What does ADH do
-Works on collecting ducts to reabsorb water
What happens in the Translation Phase?
-mRNA creates polyproteins -Polyproteins contain the components needed in the construction of a new virus
671. A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding? 1. Dyspnea 2. Headache 3. Weight gain 4. Hypothermia
1. Dyspnea Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. There may be an enlargement of the client's lymph nodes, liver, and spleen as well.
510. The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? 1.Return of distal pulses 2.Brisk bleeding from the site 3.Decreasing edema formation 4.Formation of granulation tissue
1.Return of distal pulses Rationale:Escharotomiesareperformedtorelievethecompartmentsyndromethatcanoccurwhenedemaformsundernondistensibleescharinacircumferentialthird-degreeburn.Escharotomiesareperformedthroughavasculareschartosubcutaneousfat.Althoughbleedingmayoccurfromthesite,itisconsideredacomplicationratherthanananticipatedtherapeuticoutcome.Usually,directpressurewithabulkydressingandelevationcontrolthebleeding,butoccasionallyanarteryisdamagedandmayrequireligation.Escharotomydoesnotaffecttheformationofedema.Formationofgranulationtissueisnottheintentofanescharotomy
664. A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? 1.Right pneumothorax 2.Pulmonary embolism 3.Displaced endotracheal tube 4.Acute respiratory distress syndrome (ARDS)
1.Right pneumothorax Rationale: Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side.Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left mainstem bronchi
how many canadians does SLE effect
17,000 10 X times more likely in women - exacerbations from hormonal influences with menarrche, OCP, pregnancy and postpartum - typically occurs in reproductive years between ages 15-45 - may also have a genetic influence.
512.A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1.Restrict fluids. 2.Assess for airway patency. 3.Administer oxygen as prescribed. 4.Place a cooling blanket on the client. 5.Elevate extremities if no fractures are present. 6.Prepare to give oral pain medication as prescribed.
2, 3, 5 2.Assess for airway patency. 3.Administer oxygen as prescribed. 5.Elevate extremities if no fractures are present. Rationale:Theprimarygoalforaburninjuryistomaintainapatentairway,administerIVfluidstopreventhypovolemicshock,andpreservevitalorganfunctioning.Thereforethepriorityactionsaretoassessforairwaypatencyandmaintainapatentairway.Thenursethenpreparestoadministeroxygen.Oxygenisnecessarytoperfusevitaltissuesandorgans.AnIVlineshouldbeobtainedandfluidresuscitationstarted.Theextremitiesareelevatedtoassistinpreventingshock.TheclientiskeptwarmandplacedonNPOstatusbecauseofthealteredgastrointestinalfunctionthatoccursasaresultofaburninjury
674. An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed? 1.Face tent 2.Venturi mask 3.Aerosol mask 4.Tracheostomy collar
2.Venturi mask Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.
678. The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action? 1. Administer oxygen. 2. Check the client's vital signs. 3. Ventilate the client manually. 4. Start cardiopulmonary resuscitation (CPR).
3. Ventilate the client manually. Rationale: If an alarm is sounding at any time and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and a manual resuscitation device is used to support respirations until the problem can be corrected. Although oxygen is helpful, it will not provide ventilation to the client. Checking vital signs is not the initial action. There is no reason to begin CPR.
667. A nurse has conducted discharge teaching with a client diagnosed with tuberculosis, who has been receiving medication for 1½ weeks. The nurse determines that the client has understood the information if the client makes which statement? 1. "I need to continue medication therapy for 2 months." 2. "I can't shop at the mall for the next 6 months." 3. "I can return to work if a sputum culture comes back negative." 4. "I should not be contagious after 2 to 3 weeks of medication therapy."
4. "I should not be contagious after 2 to 3 weeks of medication therapy." Rationale: The client is continued on medication therapy for 6 to 12 months, depending on the situation. The client is generally considered to be not contagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds, until the medication is effective in preventing transmission. The client is allowed to return to employment when the results of three sputum cultures are negative.
657. A nurse instructs a client about pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to promote which outcome? 1. Promote oxygen intake. 2. Strengthen the diaphragm. 3. Strengthen the intercostal muscles. 4. Promote carbon dioxide elimination.
4. Promote carbon dioxide elimination. Rationale: Pursed lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure, which keeps air passages open during exhalation.
662. The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? 1.Slow deep respirations 2.Rapid deep respirations 3.Paradoxical respirations 4.Pain, especially with inspiration
4.Pain, especially with inspiration Rationale: Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest
The nurse is caring for a 46-year-old female patient during the first 12 hours after a thermal burn injury. She weighed 71 kg on admission to the burn unit. Which outcomes if observed by the nurse would indicate adequate fluid resuscitation? (select all that apply) A. Urine output is 80 mL/hour. B. Heart rate is 86 beats/minute. C. Urine specific gravity is 1.025. D. Mean arterial pressure is 54 mm Hg. E. Systolic blood pressure is 88 mm Hg.
A, B, C A. Urine output is 80 mL/hour. B. Heart rate is 86 beats/minute. C. Urine specific gravity is 1.025. Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be at least 0.5 to 1 mL/kg/hr. Cardiac factors include a mean arterial pressure (MAP) > 65 mm Hg, systolic blood pressure (BP) > 90 mm Hg, heart rate < 120 beats/minute. Normal range for urine specific gravity is 1.003 to 1.030.
The nurse provides information to a laboratory employee who was accidentally exposed to anthrax by inhalation. The nurse determines the teaching has been successful if the patient makes which statement? A. "An antibiotic will be prescribed for 2 months." B. "I will need to wear a mask for the next 2 weeks." C. "Anthrax can be spread by person-to-person contact." D. "Antibiotics are only indicated for an active infection."
A. "An antibiotic will be prescribed for 2 months." Postexposure prophylaxis includes a 60-day course of antibiotics. Ciprofloxacin (Cipro) is the treatment of choice. Antibiotics are indicated after exposure to inhaled anthrax. A mask is not needed. Anthrax is not spread by person-to-person contact; anthrax is spread by direct contact with the bacteria and its spores.
The nurse is providing emergent care for a 62-year-old man with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. Which action should the nurse take first? A. Administer 100% humidified oxygen. B. Teach the patient deep breathing exercises. C. Encourage the patient to express his feelings. D. Assist the patient to a high Fowler's position.
A. Administer 100% humidified oxygen. Carbon monoxide (CO) poisoning may occur in house fires. CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen. The other interventions are appropriate for inhalation injury but are not as urgent as oxygen administration.
The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the 70-year-old female patient 30 minutes before the scheduled dressing change? A. Morphine sulfate B. Sertraline (Zoloft) C. Zolpidem (Ambien) D. Enoxaparin (Lovenox)
A. Morphine sulfate Deep partial-thickness burns result in severe pain related to nerve injury. The nurse should plan to administer analgesics before the dressing change to promote patient comfort. Morphine is a common opioid used for pain control. Sedative/hypnotics and antidepressant agents also can be given with analgesics to control the anxiety, insomnia, and/or depression that patients may experience. Zolpidem promotes sleep. Sertraline is an antidepressant. Enoxaparin is an anticoagulant.
Temporary coverage grafting
Allograft (cadaver skin) Xenograft (biological dressing usually pigskin)
dermilogical manifestations
Alopecia Butterfly rash - anywhere on body where sun exposed Discoid errythema palmer erythema mucosal ulcers
full thickness burn
Apperance: deep, res, black white and brown Dry surface, edema, fat exposed, tissue disrupted Sensation: little pain, anesthetic course: 2-3 wks to heal requires removal of eschar and skin grafting
superficial burn
Apperance: mild to severe erythemia, skin blanches with pressure - skin dry -small, thin - walled blisters Sensation: painful, hyperesthetic, tingling, pain eased by cooling Course : discomfort last for about 48hrs
A 71-year-old woman arrives in the emergency department after ingesting 8 g of acetaminophen (Tylenol). Which question is most important for the nurse to ask? A. "Do you feel like you have a fever?" B. "What time did you take the medication?" C. "Have you tried to commit suicide before?" D. "Are you experiencing any abdominal pain?"
B. "What time did you take the medication?" Acetaminophen will bind to activated charcoal and pass through the gastrointestinal tract without being absorbed. Activated charcoal is most effective if administered within 1 hour of ingestion of acetaminophen and other select poisons.
The nurse is caring for a 34-year-old male patient who sustained a deep partial thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? A. Skin is hard with a dry, waxy white appearance. B. Skin is shiny and red with clear, fluid-filled blisters. C. Skin is red and blanches when slight pressure is applied. D. Skin is leathery with visible muscles, tendons, and bones.
B. Skin is shiny and red with clear, fluid-filled blisters. Deep partial thickness burns have fluid-filled vesicles that are red and shiny. They may appear wet (if vesicles have ruptured), and mild to moderate edema may be present. Superficial partial thickness burns are red and blanch with pressure vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard, and there may be involvement of muscles, tendons, and bones.
Acute phase of the burn
Begins with mobilization of fluid (= diuresis) and ends when burned area is completely covered or healed Highest risk of infection in this stage Can last 48 hours, weeks or months
Cancer and HPV
Block p53 tumor suppressor gene
Cyanosis
Blue discoloration r/t poor circulation or inadequate oxygenation of blood
The nurse is caring for a client AFTER a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported IMMEDIATELY to the HCP?
Bronchospasm
Which patient should the nurse prepare to transfer to a regional burn center? A. A 25-year-old pregnant patient with a carboxyhemoglobin level of 1.5% B. A 39-year-old patient with a partial-thickness burn to the right upper arm C. A 53-year-old patient with a chemical burn to the anterior chest and neck D. A 42-year-old patient who is scheduled for skin grafting of a burn wound
C. A 53-year-old patient with a chemical burn to the anterior chest and neck The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to handle this type of trauma (see Table 25-3). Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criterion for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center. A burn to the right upper arm is 4% TBSA.
Nutrition
Hypermetabolic state Caloric needs Protein requirement is high for healing If caloric needs are not met a state of negative nitrogen balance exists leading to Delayed healing Infection Wasting of body mass Death Oral or enteral feeds, TPN if GI tract not functional Transient ↑ blood sugar
Integument tx
Initial cleansing with tepid (cool/cold) N/S removes debris and removes surface bacteria Open method: topical antibiotic applied without a dressing Closed method: sterile dressing (wounds heal best in a moist environment) Flamazine (broad spectrum) Polysporin Tetanus toxoid
Addison's interventions
LIFELONG glucocorticoid therapy increased corticosteroid therapy during during times of stress EKG orthostatics fluid replacement high protein, high carb, normal Na, decrease K diet supplemental glucose PRN allow for several rest periods
mild, moderate and major burn TSBA
Minor burn <15% partial thickness/<2% full thickness Moderate burn 15-25% partial thickness/ < 10% full thickness Major burn > 25% partial thickness/ > 10% full thickness
EXTENT OF BODY SURFACE AREA INJURED
Rule of Nines - add 9 for each area of burn Lund and Browder- % of burn Palm Method Approx. 1-3% per "palm"
The nurse is giving discharge instructions to a client with Pulmonary Sarcoidosis. The nurse concludes that the client understands the information is the client indicates to report which EARLY sign of exacerbation?
Shortness of Breath
Orthopnea
Shortness of breath when laying down
Triangle Test
Step 1: is high risk fluid? Step 2: is direct transmission? Step 3: possible HIV If NO to step one then no need to continue
The nurse is suctioning a client via an ETT. During the suctioning procedure, the nurse notes on the monitor that the HR is decreasing. Which nursing intervention is MOST APPROPRIATE?
Stop the procedure and reoxygenate the client.
How is lupus an autoimmune disease
auto antibody produced and directed at self DNA of the cell. Antinucular antibodies attach to DNA and form immune complexes in the blood and deposit in the basement membranes of vessels and organs into capillaries, kidneys, heart, skin , brain and joints and sets off a inflammatory response
SLE
chronic multi system inflammatory disease - associated with abnormalities of the immune system - results from interactions among genetic, hormonal , environmental and immunological factors
ADH
controls serum osmolality and water balance by increasing permeability causing the kidneys to reabsorb water
Cushing's assessment
decreased WBC - increased risk of infection increased BP moon face, buffalo hump, enlarged trunk, thin extremities emotional instability fractures (osteoporosis) delayed healing hyperglycemia hirsutism bruises, petechiae, striae muscle wasting & weakness FVE - edema
DI labs urine
decreased specific gravity decreased osmolality decreased Na decreased K
Addison's assessment
fatigue nausea/vomiting/anorexia weight loss hypoglycemia orthostatic hypotension hyperpigmentation amenorrhea decreased BP FVD
lupus and pregancy
fertility issues due to medications still births IUGR
hypothyroidism interventions
frequent rest periods CTDBIS prevent DVT decrease cals, fat increase fluids, fiber include iodine in diet laxatives and stool softeners PRN extra clothing, blankets, keep room warm temp no external warming devices I&O, daily weights assist with ADLs lifelong tmt no CNS depressants
vasopressin test
if urine specific gravity increases = central cause of DI
hyperthyroidism interventions
increase cals, protein, vitamins monitor VS eye protection/lubrication small frequent meals avoid iodine rich foods quiet environment frequent rest periods I&O, daily weights sleep meds as ordered
SIADH
increased ADH causing a decrease in urine output - absorbing too much water, not excreting enough
SIADH labs urine
increased Na increased osmolality increased specific gravity
hyperthyroidism
increased T3 T4 decreased TSH
DI assessment
increased UO - up to 18L polydipsia - increased thirst increased HR decreased BP constipation high serum osmolality decreased urine specific gravity HA muscle weakness; fatigue FVD
DI labs serum
increased osmolality increased Na increased K
water deprivation test
increased plasma osmolality should reduce UO; if not positive for DI
hypothyroidism assessment
increased weight cold intolerance constipation joint & muscle pain thin, brittle hair/nails fatigue decreased VS decreased thought processes and speech swelling in hands and feet depression goiter
NSAIDS
inflammatory symptoms - ibuprophen, naproxin SE: ulcers, take with food to prevent GI bleed
hemolysis of RBC
initially Hct may be elevated (hemoconcentration); once fluid balance is restored anemia may be apparent Myoglobin in urine is released which can cause Rhabdomylosis and ATN ( acute tubular necrosis) (Acute renal failure)
What is the etiology of lupus
it is unknown most probable cause: Autoimmune reactions directed against constituents of cell nucleus, DNA Antibody response related to B- and T-cell hyperactivity
Reproductive manifestations
menstrual abnormalities
steroid sparing drugs
methotrexate
poorly controlled hypothyroidism
myxedema coma
more then 8% burn
need fluid replacement
corticosteroids
predinisone - for acute flare ups
Glucocorticoids; cortisol
regulate metabolism
Mineralocorticoids; aldosterone
regulate sodium absorption and potassium secretion
fasciotomy
remove pressure form eschar ( compartment syndrome) decrease pressure
SIADH interventions
restrict fluids - 500-1000cc/day I&O, daily weights decreased stimulation flush with NS to replace electrolytes seizure precautions
Other exacerbations for lupus
sun exposure genetics infection
DI diagnostics
water deprivation test vasopressin test
hyperthyroidism assessment
weight loss increased VS - S3 diarrhea hyperreflexia decreased attention span increased irritability warm, moist skin increased appetite insomnia abnormal menses facial flushing exophthalmos goiter
incidence of burns
~ 200,000 burns/year reported in Canada 5% require hospitalization In Ontario burns account for 1000 hospitalizations/year and 10,800 hospital days Mortality rate ~90% if >60 years of age, TBSA>40%, and inhalation injury
Anaphylaxis
• A systemic reaction to allergens • Most severe - Food (36%) - Medication (17%) - Insect bites (15%) - Blood transfusions - Vaccines
Passive Immunity
• Antibodies against a foreign invader (Strep throat) are in a person's body but weren't produced there (another animal/person) • Body recognizes as non-self and moves to destroy therefore immediate, short- term protection conferred
Active Immunity
• Antigens enter, body responds by making specific antibodies against the antigen • Can be natural or artificial
Active Immunity: Natural
• Causes disease and then immunity is conferred (e.g. Chicken pox) • Person won't become ill after 2nd exposure to the same antigen • Most effective and long-lasting
Passive Immunity: Artificial
• Deliberate injection with antibodies produced in another person/animal • Injected antibodies inactivate the antigen (e.g. flu shot, tetanus, anti-venom, polio shot)
Passive Immunity: Natural
• Mother to baby (placenta, colostrum and breast milk)
Active Immunity: Artificial
• When we want total avoidance of disease • Antigens introduced that have been processed (attenuated) to make them less likely to proliferate in the body • Antibodies against them formed • Re-exposure needed to maintain complete immunity
GI symptoms from acute phase
↓blood flow → ↓peristalsis → paralytic ileus Stress response → ↑ catecholamines → ↓ mucus and ↑ gastric acid = Curling's Ulcer (a form of stress ulcer with diffuse lesions) Assessment ______________ Treatment: NGT to suction (decompression), Zantac (Ranitidine)
Cystic Fibrosis
- Autosomal recessive, multisystem disease with altered function in exocrine glands of lungs, pancreas, sweat glands - Abnormally thick mucus can lead to chronic diffusive, obstructive pulmonary disorder -Occurs primarily in caucasians - First signs and symptoms usually occur in children - Median lifespan is more than 37 years
Most Common Infections
- Bacterial - Viral - Fungal - Protozoa
Oxygen Tent Nursing Interventions
-O2 levels drop when tent is opened -Change linens frequently b/c they become damp from humidity -Secure edges of tent by securing with blankets or tucking under the mattress -Mist may interfere with visualization inside tent
Hematological Problems Associated w/ Lupus
- Antibodies that attack one of blood cells - RBC can be attacked resulting in a large number of cells being destroyed and removed from the body in the spleen - Antibodies to platelets that may cause the platelet count to drop (thrombocytopenia) - Anemia, mild leukopenia - Coagulopathy involving excessive bleeding or blood clots
Treatment for HIV
- Antidepressant therapy - Antidiarrheal therapy - Nutritional therapy - Antivirals - Prevention/treatment of opportunistic infections
Musculoskeletal Manifestations Associated w/ Lupus
- Arthritic pain in joints of hands, wrists, elbows, knees and hips - Pain can migrate and can appear and disappear sporadically - Swan neck appearance of fingers r/t deformity - Ulnar deviation - Risk for bone loss and fractures
T-Cytotoxic Cells
- Attach the antigen on cell membrane to destroy the pathogen by releasing cytolytic substances
Pathophysiology of HIV
- Attaches to surface of specialized WBCs, CD4 t-lymphocytes - Membrane of virus and cell fuse and HIV particles release its antibodies into the cell - Replicates itself, HIV RNA converted to DNA, piece of protein of HIV orchastrates conversion - Newly converted HIV DNA enters cell and becomes part of cell, taking control of replication and make HIV protein particles called virions - Viral enzyme, protease works as "scissors" to break up chains of virions into new HIV RNA pieces - Viral copies bud from the cell that dies and then copies attack other CD4 cells to start the process over
Blood Autoimmune Disease
- Auto-immune hemolytic anemia - Immune thrombocytopenic purpura - Hemochromatosis
Liver Autoimmune Diseases
- Auto-immune hepatitis
Nursing Assessment for Lupus: Psychosocial
- Affect of disfigurement - Side effects of steroids (e.g. acne, striae, fat pads, weight gain)
Pneumothorax
- Air enters pleural sac surrounding lung, air takes up space of lung tissue and can lead to collapse
Closed Pneumothorax
- Air or gas gets in the pleural space without any outside wound - This sometimes happens when the lung is already injured somehow, like from diseases such as cancer or cystic fibrosis
Alevoli
- Air-filled sacs containing membranes coated w/ surfactant (Helps alveoli to expand evenly & prevents collapse) - CO2 & O2 are exchanged, higher concentration of gas moves to lower area of concentration - High CO2 in the blood moves into alveoli and is expired by lungs - High O2 in alveoli crosses membrane and attaches to hemoglobin and is distributed through the body
Triggers of Asthma Attacks
- Allergens - Exercise - Respiratory infections - GERD's ( Acid can be aspirated and cause bronchoconstriction) - Nose and sinus problems - Drugs and food additives - Emotional stress
Extrinsic Asthma
- Also known as atopic - Caused by allergens such as pollen, animal dander, mold, or dust - Often accompanied w/ allergic rhinitis and eczema
Intrinsic Asthma
- Also known as nonatopic - Caused by nonallergic factors such as a respiratory tract infection, exposure to cold air, changes in air humidity, or respiratory irritants
Tidal Volume
- Amount of air volume in lungs which is displaced between inhalation and exhalation - Approximately 500mL
Pulse Oximetry
- Amount of oxygen saturating hemoglobin molecules - Normal value = 95-100%
Manifestations of Tuberculosis
- Anorexia - Night sweats - Low grade fever - Productive cough w/ blood tinged sputum - Shortness of of breath - Malaise & Fatigue
Pharyngitis: Treatment
- Anti-infectives for bacterial, symptomatic for viral, anti-histamine for allergy - Infection control - Symptomatic relief - Prevention of secondary complications
Risk for hypothermia for burns
-Monitor rectal/core temp every hour -Monitor for shivering -For temps less than 98.6 institute rewarming measure
Examples of Leukotriene Modifiers
-Montelukast (Singulair) -Zafirlukast (Accolate)
HIV Asymptomatic
-More than 500 CD4 cells -Body has sufficient immune response to fight pathogens
Kaposi's Sarcoma
-Most common HIV malignancy -Most often seen among men who have sex with men -Can appear anywhere -Brown or purpleish -Flat or raised surrounded by ecchymoses and edema -Diagnosis confirmed by biopsy or lesions -Most common visceral sites are the lungs, lymph nodes, GI tract
Pneumocystic Carini Pneumonia (PCP)
-Most common life threatening infection -Fever, chills, shortness of breath, dyspnea, chest pain -If untreated could progress to pulmonary impairment or respiratory failure
Cold Sores HSV-1
-Most common recurrent HSV-1 infection
Arbovirus
-Most have RNA genome -Vector: Arthropods
What is the bodies response to HYPOnatremia and HYPO-osmolality
-Muscle WEAKNESS -Lethargy -Mental confusion -Difficulty concentrating -Restlessness -Headache -Seizures -Coma
Nasal Cannula Nursing Interventions
-Must be humidified -Can provide very low O2/minute -MAXIMUM RECOMMENDED IN CHILDREN IS 4L/min -Requires patent nasal passages
Venturi Mask Nursing Interventions
-Must fit snug -Set oxygen flow rate to desired percentage
Simple Mask Nursing Interventions
-Must maintain O2 flow rate at 6L/min to prevent rebreathing of CO2 -Mask must fit snuggly but not irritate the face
Somatotropin admin. alerts
-Must undergo regular assessment of glucose tolerance and thyroid function
What does hyposecretion of thyroid cause?
-Myexedema in adults (swelling, waxy skin) -Cretinism in children -Thyroid hormone, levothyroxine T4 -T3 & T4 Low
What to AVOID with Myxedema Coma?
-NARCOTICS -SEDATIVES -Respiratory Depression
SLE Diagnostic Tests
-NO specific test. -SLE is diagnosed PRIMARILY on CRITERIA relating to: -Patient History -Physical Examination -Laboratory Findings
Diaper Candidiasis
-NYASTIN cream
Rhabdovirus Rabies
-Negative sense single stranded RNA -Transmitted by bite -Incubation period 30-70 days
Granulocytes
-Neutrophils -most numerous -phagocytosis= killer of bacteria: multi-lobed -Eosinophils -active in worm and fungal infections: bi-lobed -Basophils -release histamine,inflammatory chemical
Leukocytes greatest to smallest
-Neutrophils -Leukocytes -Monocytes -Eosinphil -Basophils -"Never Let Monkeys Eat Bananas"
What happens in the Budding Phase?
-New proteins and viral RNA leave the infected CD4 T cell to start the process all over again
Congenital Adrenal HYPERplasia Lab Tests
-Newborn Metabolic Screening -Hormone Levels -Levels of ACTH -Bone scan -Advanced bone age and closure of Epiphyseal Plates in LONG bones
HPV
-No envelope -Double stranded -Most prevelant STD in the world -Different types cause genital and non genital warts -Can lead to cervial cancer or throat cancer
20. Which identifies accurate nursing documentation notations? Select all that apply. 1.The client slept through the night. 2.Abdominal wound dressing is dry and intact without drainage. 3.The client seemed angry when awakened for vital sign measurement. 4.The client appears to become anxious when it is time for respiratory treatments. 5.The client's left lower medial leg wound is 3cm in length without redness, drainage, oredema.
1, 2, 5 1.The client slept through the night. 2.Abdominal wound dressing is dry and intact without drainage. 5.The client's left lower medial leg wound is 3cm in length without redness, drainage, oredema. Rationale: Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable because it can be misunderstood. The use of vague terms, such as seemed or appears is not acceptable because these words suggest that the nurse is stating an opinion.
658. The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse will include on the list? Select all that apply. 1. Activities should be resumed gradually. 2. Avoid contact with other individuals, except family members, for at least 6 months. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members have already been exposed. 5. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. 6. When one sputum culture is negative, the client is no longer considered infectious and can usually return to his or her former employment.
1. Activities should be resumed gradually. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members have already been exposed. 5. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. Rationale: The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client is to follow the medication regimen exactly as prescribed and always to have a supply of the medication on hand. The client is advised of the side effects of the medication and ways of minimizing them to ensure compliance. The client is reassured that, after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. The client is also informed that activities should be resumed gradually and about the need for adequate nutrition and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection. The client and family are informed that respiratory isolation is not necessary, because family members have already been exposed. The client is instructed about thorough handwashing and to cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. The client is informed that a sputum culture is needed every 2 to 4 weeks once medication therapy is initiated and, when the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to his or her former employment.
24. The nurse calls the heath care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take? 1.Contact the nursing supervisor. 2.Administer the dose prescribed. 3.Hold the medication until the HCP can be contacted. 4.Administer the recommended dose until the HCP can be located
1.Contact the nursing supervisor. Rationale: If the HCP writes a prescription that requires clarification, the nurse's responsibility is to contact the HCP. If there is no resolution regarding the prescription because the HCP cannot be located or because the prescription remains as it was written after talking with the HCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until obtaining clarification
670. A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding? 1.Positive 2.Negative 3.Inconclusive 4.Need for repeat testing
1.Positive Rationale: The client with human immunodeficiency virus (HIV) infection is considered to have positive results on tuberculin skin testing with an area of induration larger than 5mm. The client without HIV is positive with an induration larger than 10mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor. Options 2, 3, and 4 are incorrect interpretations
15. The nurse has just assisted a client back to bed after a fall. The nurse and healthcare provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? 1.Reassess the client. 2.Conduct a staff meeting to describe the fall. 3.Document in the nurse's notes that an incident report was completed. 4.Contact the nursing supervisor to update information regarding the fall.
1.Reassess the client. Rationale: After a client's fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary
656. A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect to note on an assessment of this client? Select all that apply. 1. Hypocapnia 2. Dyspnea on exertion 3. Presence of a productive cough 4. Difficulty breathing while talking 5. Increased oxygen saturation with exercise 6. A shortened expiratory phase of respiration
2. Dyspnea on exertion 3. Presence of a productive cough Rationale: Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory muscles of respiration, The chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pilmonary function tests will demonstrate decreased vital capacity
668. The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which item when performing this care? 1.Surgical mask and gloves 2.Particulate respirator, gown, and gloves 3.Particulate respirator and protective eyewear 4.Surgical mask, gown, and protective eyewear
2.Particulate respirator, gown, and gloves Rationale: The nurse who is in contact with a client with tuberculosis should wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bed bath
666.The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions? 1.Palpation and clubbing 2.Percussion and vibration 3.Hyperoxygenation and suctioning 4.Administer a bronchodilator and monitor peak flow
2.Percussion and vibration Rationale: Chest physiotherapy of percussion and vibration helps loosen secretions in the smaller lower airways. Postural drainage positions the clients so that gravity can help mucus moving from smaller airways to larger ones to support expectoration of the mucus. Options 1, 3, and 4 are not actions that will loosen secretions
22. Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the seretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the UAP violated? 1.Libel 2.Slander 3.Assault 4.Negligence
2.Slander Rationale: Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group
516.The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? 1.Vital signs 2.Urine output 3.Mental status 4.Peripheral pulse
2.Urine output Rationale:Successfuloradequatefluidresuscitationintheclientissignaledbystablevitalsigns,adequateurineoutput,palpableperipheralpulses,andclearsensorium.However,themostreliableindicatorfordeterminingadequacyoffluidresuscitationistheurineoutput.Foranadult,thehourlyurinevolumeshouldbe30to50mL
509. An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 1.18% 2.24% 3.36% 4.48%
3.36% Rationale:Accordingtotheruleofnines,withtheinitialburn,theanteriorhalfoftheheadequals4.5%,theupperhalfoftheanteriortorsoequals9%,andthelowerhalfofbotharmsequals9%.Thesubsequentburnincludedtheposteriorhalfofhead,equaling4.5%,andtheupperhalfofposteriortorso,equaling9%.Thistotals36%
25. The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate nursing action? 1.Call the police. 2.Cut up the photograph and throw it away. 3.Call the nursing supervisor and report the incident. 4.Call the laboratory and ask for the individual's name who sent the photograph
3.Call the nursing supervisor and report the incident. Rationale: Ensuring a safe workplace is a responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a co-worker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 and 4 are inappropriate initial actions
17. The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1.Call security. 2.Call the police. 3.Call the nursing supervisor. 4.Lock the co-worker in the medication room until help is obtained.
3.Call the nursing supervisor. Rationale: Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and so this is not the appropriate action. Option 4 is an inappropriate and unsafe action
669. A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1.Hot ,flushed feeling 2.Sudden chills and fever 3.Chest pain that occurs suddenly 4.Dyspnea when deep breaths are taken
3.Chest pain that occurs suddenly Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis
518.The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? 1.Out-of-bed activities 2.Bathroom privileges 3.Immobilization of the affected leg 4.Placing the affected leg in a dependent position
3.Immobilization of the affected leg Rationale:Autograftsplacedoverjointsoronthelowerextremitiesaftersurgeryoftenareelevatedandimmobilizedfor3to7days.Thisperiodofimmobilizationallowstheautografttimetoadheretothewoundbed.Options1,2,and4areincorrect
511. A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50mmHg, a pulse rate of 110 beats/minute, and a urine output of 20mL over the past hour. The nurse reports the findings to the healthcare provider (HCP) and anticipates which prescription? 1.Transfusing 1 unit of packed red blood cells 2.Administering a diuretic to increase urine output 3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4.Changing the IV lactated Ringer's solution to one that contains dextrose in water
3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour Rationale:Fluidmanagementduringthefirst24hoursfollowingaburninjurygenerallyincludestheinfusionof(usually)lactatedRinger'ssolution.Fluidresuscitationisdeterminedbyurineoutputandhourlyurineoutputshouldbeatleast30mL/hour.Theclient'surineoutputisindicativeofinsufficientfluidresuscitation,whichplacestheclientatriskforinadequateperfusionofthebrain,heart,kidneys,andotherbodyorgans.ThereforetheHCPwouldprescribeanincreaseintheamountofIVlactatedRinger'ssolutionadministeredperhour.Bloodreplacementisnotusedforfluidtherapyforburninjuries.Administeringadiureticwouldnotcorrecttheproblembecauseitwouldnotreplaceneededfluid.Diureticspromotetheremovalofthecirculatingvolume,therebyfurthercompromisingtheinadequatetissueperfusion.Dextroseinwaterisanisotonicsolution,andanisotonicsolutionmaintainsfluidbalance.Thistypeofsolutionmaybeadministeredafterthefirst24hoursfollowingtheburninjury,dependingontheclient's psychological needs.
663. A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? 1.Cyanosis 2.Hypotension 3.Paradoxical chest movement 4.Dyspnea, especially on exhalation
3.Paradoxical chest movement Rationale: Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest
13. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the healthcare provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? 1.The client fell out of bed. 2.The client climbed over the side rails. 3.The client was found lying on the floor. 4.The client became restless and tried to get out of bed
3.The client was found lying on the floor. Rationale: The incident report should contain the client's name, age, and diagnosis. The report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse
14. A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1.Obtain a court order for the surgical procedure. 2.Ask the EMS team to sign the informed consent. 3.Transport the victim to the operating room for surgery. 4.Call the police to identify the client and locate the family.
3.Transport the victim to the operating room for surgery. Rationale: In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the best action
517. The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique? 1.Using sterile sheets and linens 2.Performing strict hand washing technique 3.Wearing gloves and a gown only when giving direct care to the client 4.Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron
3.Wearing gloves and a gown only when giving direct care to the client Rationale:Thoroughhandwashingshouldbedonebeforeandaftereachcontactwiththeburn-injuredclient.Sterilesheetsandlinensareusedbecauseoftheclient'shighriskforinfection.Protectivegarb,includinggloves,cap,masks,shoecovers,gowns,andplasticapron,needtobewornwhenintheclient'sroomandwhendirectlycaringfortheclient
23. An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? 1."Oh, really. I will discuss this situation with your son." 2."Let's talk about the ways you can manage your time to prevent this from happening." 3."Do you have any friends that can help you out until you resolve these important issues with your son?" 4."As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."
4."As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay." Rationale: The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with non medical personnel or the client's family or friends without the client's permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. Options 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client.
18.A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? 1."I will sign as a witness to your signature." 2."You will need to find a witness on your own." 3."Whoever is available at the time will sign as a witness for you." 4."I will call the nursing supervisor to seek assistance regarding your request."
4."I will call the nursing supervisor to seek assistance regarding your request." Rationale: Living wills, also known as natural death acts in some states, are required to be in writing and signed by the client. The client's signature must be witnessed by specified individuals or notarized. Laws and guidelines regarding living wills vary from state to state, and it is the responsibility of the nurse to know the laws. Many states prohibit any employee, including the nurse of a facility where the client is receiving care, from being a witness. Option 2 is non therapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor
515.A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? 1.100% oxygen via an aerosol mask 2.Oxygen via nasal cannula at 6L/minute 3.Oxygen via nasal cannula at 15L/minute 4.100% oxygen via a tight-fitting, non rebreather face mask
4.100% oxygen via a tight-fitting, non rebreather face mask Rationale:Ifaninhalationinjuryissuspected,administrationof100%oxygenviaatight-fittingnonrebreatherfacemaskisprescribeduntilcarboxyhemoglobinlevelsfall(usuallybelow15%).Ininhalationinjuries,theoropharynxisinspectedforevidenceoferythema,blisters,orulcerations.Theneedforendotrachealintubationalsoisassessed.Options1,2,and3areincorrectandwouldnotprovidethenecessaryoxygensupplyneededforadequatetissueperfusion.
676.The community health nurse is conducting an educational session with community members regarding the symptoms associated with tuberculosis. Which is one of the first manifestations associated with tuberculosis? 1.Dyspnea 2.Chest pain 3.A bloody, productive cough 4.A cough with the expectoration of mucoid sputum
4.A cough with the expectoration of mucoid sputum Rationale: One of the first pulmonary manifestations of tuberculosis is a slight cough with the expectoration of mucoid sputum. Options 1, 2, and 3 are late manifestations and signify cavitation and extensive lung involvement
19. The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which action to correct the error? 1.Documenting a late entry into the client's record 2.Trying to erase the error for space to write in the correct data 3.Using whiteout to delete the error to write in the correct data 4.Drawing one line through the error, initialing and dating, and then documenting the correct information
4.Drawing one line through the error, initialing and dating, and then documenting the correct information Rationale: If the nurse makes an error in narrative documentation in the client's record, the nurse should follow agency policies to correct the error. This includes drawing one line through the error, initialing and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation. Erasing data from the client's record and the use of whiteout are prohibited
513.The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? 1.Decreased heart rate 2.Increased urinary output 3.Increased blood pressure 4.Elevated hematocrit levels
4.Elevated hematocrit levels Rationale:Theresuscitation/emergentphasebeginsatthetimeofinjuryandendswiththerestorationofcapillarypermeability,usuallyat48to72hoursfollowingtheinjury.Duringtheresuscitation/emergentphase,thehematocritlevelincreasestoabovenormalbecauseofhemoconcentrationfromthelargefluidshifts.Hematocritlevelsof50%to55%areexpectedduringthefirst24hoursafterinjury,withreturntonormalby36hoursafterinjury.Initially,bloodisshuntedawayfromthekidneys,andrenalperfusionandglomerularfiltrationaredecreased,resultinginlowurineoutput.Pulseratesaretypicallyhigherthannormal,andthebloodpressureisdecreasedasaresultofthelargefluidshifts
16. The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which action first? 1.Call the hospital lawyer. 2.Refuse to float to the ICU. 3.Call the nursing supervisor. 4.Identify tasks that can be performed safely in the ICU
4.Identify tasks that can be performed safely in the ICU Rationale: Floating is an acceptable legal practice used by hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Calling the hospital lawyer is a premature action.
665. The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1.Bilateral wheezing 2.Inspiratory crackles 3.Intercosta lretractions 4.Increased respiratory rate
4.Increased respiratory rate Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles
21. A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this clients right? 1.Performing a procedure without consent 2.Threatening to give a client a medication 3.Telling the client that he or she cannot leave the hospital 4.Observing care provided to the client without the client's permission
4.Observing care provided to the client without the client's permission Rationale: Invasion of privacy occurs with unreasonable intrusion into an individual's private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment
A 47-year-old man who was lost in the mountains for 2 days is admitted to the emergency department with cold exposure and a core body temperature of 86.6o F (30.3o C). Which action is most appropriate for the nurse to take? A. Administer warmed IV fluids. B. Position patient under a radiant heat lamp. C. Place an air-filled warming blanket on the patient. D. Immerse the extremities in a water bath (102° to 108° F [38.9° to 42.2° C]).
A. Administer warmed IV fluids. A patient with a core body temperature of 86.6o F (30.3o C) has moderate hypothermia. Active core rewarming is used for moderate to severe hypothermia and includes administration of warmed IV fluids (109.4° F [43° C]). Patients with moderate to severe hypothermia should have the core warmed before the extremities to prevent after drop (or further drop in core temperature). This occurs when cold peripheral blood returns to the central circulation. Use passive or active external rewarming for mild hypothermia. Active external rewarming involves fluid-filled warming blankets or radiant heat lamps. Immersion of extremities in a water bath is indicated for frostbite.
A nurse is performing triage in the emergency department. Which patient should the nurse see first? A. 18-year-old patient with type 1 diabetes mellitus who has a 4-cm laceration on right leg B. 32-year-old patient with drug overdose who is unresponsive with a poor respiratory effort C. 56-year-old patient with substernal chest pain who is diaphoretic with shortness of breath D. 78-year-old patient with right hip fracture who is confused; blood pressure is 98/62 mm Hg
B. 32-year-old patient with drug overdose who is unresponsive with a poor respiratory effort The patient with a drug overdose is unstable and needs to be seen immediately. Patient with chest pain (possible myocardial infarction) should be seen second. Patient with hip fracture should be seen third. Patient with laceration is the most stable and should be seen last.
