Med Surg 3 Final
AVPU
Alert, Verbal, Pain, Unresponsive
A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first? a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.
B
A nurse cares for a client with a fractured fibula. Which assessment should alert the nurse to take immediate action? a. Pain of 4 on a scale of 0 to 10 b. Numbness in the extremity c. Swollen extremity at the injury site d. Feeling cold while lying in bed
B
A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first? a. A 22-year-old with a painful and swollen right wrist b. A 45-year-old reporting chest pain and diaphoresis c. A 60-year-old reporting difficulty swallowing and nausea d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101 F
B
On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1 F (40.1 C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and re-assess in 15 minutes
B: the client demonstrates a heat stroke
what is the normal T-cell count in a healthy adult
800-1000
An emergency department nurse cares for a client who sustained a crush injury to the right lower leg. The client reports numbness and tingling in the affected leg. Which action should the nurse take first? a. Assess the pedal pulses. b. Apply oxygen by nasal cannula. c. Increase the IV flow rate. d. Loosen the traction.
A symptoms represent warning signs of acute compartment syndrome
antibody-antigen tests for HIV/AIDs
ELISA (done first, than a confirmatory western is done. has window period) Western Blot (done after ELISA is positive)
A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposis sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly
D
A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? a. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowlers position. d. Gather appropriate equipment and prepare for an emergency airway
D
A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath
D
Clinical manifestations of hypoglycemia
Glucose less than 50-70 symptoms cease with administration of glucose neuroglycopenic manifestations autonomic NS and catecholamine manifestations
is an altered mental status more common in DKA or HHS
HHS also more common in older adults
medication common for pre-exposure prophylaxis for HIV
HIV-specific anti-retroviral drugs (truvada)
normalize serum glucose for hyperglycemic crisis
IV regular insulin (short acting)
Disaster Triage Tag System
Red: Emergent Yellow: Can wait short time for care Green: Non-urgent or "walking wounded" Black: Expected to die/are dead
lymphedema
abnormal accumulation of protein fluid in subcutaneous tissue reports sensation of heaviness, aching, fatigue, numbness, tingling, and or swelling in affected arm or upper chest at risk for infection
post-transplantation complications: graft rejection
activation of immune response against a transplanted tissue or organ hyperacute, acute, chornic
A of primary survey
airway/cervical spine
black tag
allowed to die or not be treated until others received care massive head trauma, extensive full-thickness body burns, high cervical spinal cord injury requiring mechanical ventilation
Mammography
annual screening at age 45 >55 may switch to every 2 years
stage unknown HIV classification
confirmed HIV infection but no info regarding CD4+ T-cell counts, illnesses
who cannot be on the transplant medical team
donors attending physician
Three-tiered triage system
emergent (life threatening) urgent (needs quick tx, but not immediately life threatening) nonurgent (could wait several hours if needed)
characteristics of HHS
blood sugar over 600 absence of ketones comatose or stuporous pH > 7.3
B of primary survey
breathing (whether or not ventilatory efforts are effective) listen to breath sounds and evaluate chest expansion, respiratory effort, and any evidence of chest wall trauma or physical abnormalities
E of primary survey
exposure want to prevent heat loss, collect evidence, removing clothing
fat embolus syndrome
fat globules are released from the yellow bone marrow into bloodstream within 12-48 hours after an injury or other illness globules clog small vessels that supply vitals organs and impair organ perfusion
management of hyperglycemia crisis
fluid resuscitation correcting electrolyte imbalances clear ketones & correct acidosis normalize serum glucose closely monitor patient's status id precipitating cause prevent further complications
Red tag
immediate threats to life such as airway obstruction or shock
post-transplantation complications: immunosuppressant-related complications
infection (fever, tachypnea, fatigue, tachycardia, pain) malignancy (h.pylori-gastric, epstein-barr- non hodgkins, PTLD, lymphoma)
primary survey
initial assessment of trauma patient A, B, C, D, E
correcting electrolyte imbalances for hyperglycemia crisis
insulin causes decreases in K, so monitor and maintain above 3.3
laboratory assessment for HIV/AIDs
lymphocyte count viral load testing antibody-antigen tests
yellow tag
major injuries such as open fracture with distal pulse and large wounds that need treatment within 30 mins to 2 hours burns spine injuries eye injuries stable abdominal injuries
viral load testing for HIV/AIDS
measure presence of HIV's RNA or viral proteins in patient blood indicate level of viral burden useful in monitoring disease progression and treatment effectiveness after 10 days of infection (can be processed in as little as 24 hours)
green tag
minor injuries that can be managed in a delayed fashion (more than 2 hours) closed fractures, sprains, strains, abrasions, contusions walking wounded
Kaposi Sarcoma
most common AIDs-related malignancy related to co-infection with human herpes virus-8 small, purplish brown, raised lesions on skin and mucous membranes that are usually not painful or itchy
Emergency management of electrical burns
§ At scene, separate patient from electrical current § Smother any flames present § Initiate cardiopulmonary resuscitation § Obtain ECG (electrocardiogram)
neuroglycopenic manifestations of hypoglycemia
§ Diminished cognitive abilities and altered balance and coordination § Changes in mental status § Emotional lability § h/a, dizziness § thickened, slurred speech § numbness, drowsiness, convulsions, coma
heat stroke interventions at scene
§ Ensure patent airway § Remove from hot environment § Remove patient clothing § Pour or spray cold water on patient body and scalp § Fan the patient § Place ice in cloth or bag and position packs on scalp, groin, behind neck, armpits § Contact emergency medical services to transport the patient to ED
labs for breast cancer
o After diagnosis o Pathologic study of lymph nodes (help detect metastases) o Elevated liver enzyme levels (possible liver) o Increased serum calcium and alkaline phosphatase (bone)
human leukocyte antigen
proteins that are found on most cells in body, unique per person (family) way for immune system to tell which cells belong to your body and which ones do not tissue typing is ID of HLA of both donor and transplant and evaluates degree to which two sets are HLA matches (better chance for success)
last sign to develop for fat embolus syndrome
red/brown petechia that appears over chest, neck, or upper arms macular, measles-like rash
emergent tier examples
respiratory distress chest pain with diaphoresis stroke active hemorrhage unstable vital signs
urgent tier examples
severe abdominal pain renal colic displaced or multiple fractures complex or multiple soft tissue injuries new onset respiratory infections, especially pneumonia in older adults lacerations not associated with hemorrhage temperature greater than 101F (38.3C)
HIV transmission routes
sexual: genital, anal, oral parenteral: sharing of needles or equipment perinatal: from placenta, contact with maternal blood and body fluids during birth or breast milk
breast self-exam
should start doing them once menses start inspect breasts 1 week after menstrual period pick a day each month if after menopause
multiple casualty
2-99 people can be treated using local hospital resources, can be managed
normal potassium levels
3.5-5.0 mEq/L
mass casualty
>100 people cannot be managed from just single hospital, needs help
. An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a. Apply oxygen and continuous pulse oximetry. b. Provide small quantities of ice chips and sips of water. c. Request a prescription for an antitussive medication. d. Ask the respiratory therapist to provide humidified air
A
A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states Whew! I was really worried about that result. What action by the nurse is most important? a. Assess the clients sexual activity and patterns. b. Express happiness over the test result. c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months
A ELISA can be falsely negative
A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The clients vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first? a. Administer oxygen via nasal cannula. b. Re-position to a high-Fowlers position. c. Increase the intravenous flow rate. d. Assess response to pain medications
A high risk for fat embolism and has some manifestations
A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with stage 1 HIV disease are not infectious to others.
A, B, C, D
Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 or less than 14% b. Infection with Pneumocystis jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) d. Presence of HIV wasting syndrome e. Taking antiretroviral medications
A, B, D
A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.) a. Edema Increased capillary permeability b. Pallor Increased blood blow to the area c. Unequal pulses Increased production of lactic acid d. Cyanosis Anaerobic metabolism e. Tingling A release of histamine
A, C, D
. Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen
A, C, D, F
A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.) a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag
A, D
5. An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Administer oxygen via mask or nasal cannula. b. Administer ibuprofen, an antipyretic medication. c. Apply cooling techniques until core body temperature is less than 101 F. d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. e. Obtain baseline serum electrolytes and cardiac enzymes.
A, D, E not C because you cool to 102F
3. An emergency room nurse is caring for a trauma client. Which interventions should the nurse perform during the primary survey? (Select all that apply.) a. Foley catheterization b. Needle decompression c. Initiating IV fluids d. Splinting open fractures e. Endotracheal intubation f. Removing wet clothing g. Laceration repair
B, C, E, F
characteristics of DKA
Blood glucose over 250 ketosis metabolic acidosis osmotic diuresis kussmaul breathing
A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds
C
A nurse is triaging clients in the emergency department. Which client should be considered urgent? a. A 20-year-old female with a chest stab wound and tachycardia b. A 45-year-old homeless man with a skin rash and sore throat c. A 75-year-old female with a cough and a temperature of 102 F d. A 50-year-old male with new-onset confusion and slurred speech
C
A nurse is triaging clients in the emergency department. Which client should the nurse classify as nonurgent? a. A 44-year-old with chest pain and diaphoresis b. A 50-year-old with chest trauma and absent breath sounds c. A 62-year-old with a simple fracture of the left arm d. A 79-year-old with a temperature of 104 F
C
An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first? a. A 30-year-old distraught mother holding her crying child b. A 65-year-old conscious male with a head laceration c. A 26-year-old male who has pale, cool, clammy skin d. A 48-year-old with a simple fracture of the lower leg
C: patient is in shock
stage 2 HIV classification
CD4+ T-cell count between 200-499 (no AIDs illness)
stage 1 HIV classification
CD4+ T-cell count greater than 500 (no AIDs illness)
Stage 3 HIV classification
CD4+ T-cell count less than 200, or those with higher CD4+ T-cell who also has AIDs defining illness
C of primary survey
Circulation adequacy of HR, BP, overall perfusion large bore catheter access
fluid resuscitation for hyperglycemic crisis
NPO normal saline, regular insulin change fluids to dextrose when drops at or below 200 blood sugar
lymphocyte count for HIV/AIDS
WBC < 3500 (normal 5000-10000) low CD4+ T-cells lymphopenia
graft vs host disease
complication that develops in allogenic HSCT patients Donor T cells see recipient's tissue as non-self and attack
Stage 0 of HIV classification
develops first positive HIV test result within 6 months after a negative HIV test result (changing in stage does no occur till 6 months has elapsed since stage 0 designation)
differences between HIV & AIDs
diagnosis of AIDs require that the adult be HIV positive and have either CD4+ T-cell count less than 200 or less than 14% or an opportunistic infection
What is the CD4+ T-cell
directs immunity and regulates activity of all immune system cells
D of primary survey
disability rapid baseline of neurologic status AVPU GCS
kussmaul breathing
elevated respiratory rate and depth
What can a cardiac death donate
heart valves, corneas, eyes, sapheonous veins, skin bones
Post-op information to teach patient after breast cancer surgery
o Ambulation and regular diet are resumed by day after surgery o Avoid hunched-back position with arm flexed o Beginning exercises that do not stress incision started day after surgery o Incisional care o No lotions or ointments to area until healed completely o Loose fitting clothing until 6-8 weeks when healed o Active range of motion exercises begin 1 week after surgery or when sutures and drains removed
common precipitating factors of hypoglycemia
o Antidiabetic agents (sulfonylureas) o Insulin o Changes in medication regimen o Potentiating effects of medications (propranolol, alcohol) o Consumption of too little food o High activity levels o Hormonal deficiencies (cortisol, glucagon, epi) o Sepsis o Kidney, liver, or heart failure
General management of all types of burns
o Assess for airway patency o Administer oxygen as needed o Cover patient with a blanket o Keep patient on NPO status o Elevate extremities if no fractures are obvious o Obtain vitals o Initiate IV line and begin fluid replacement o Administer tetanus toxoid for prophylaxis o Perform a head-to-toe assessment
Avoid exposure to infection for HIV/AIDS
o Avoid crowds and other large gatherings of people who might be ill o Do not share personal toilet articles (toothbrush/paste, washcloths, deodorant) o Bathe daily, using antimicrobial soap o Clean toothbrush at least weekly by running it through dishwasher or rinsing in laundry bleach o Wash hands thoroughly with antimicrobial soup before eating or drinking, touching something o Avoid eating salads, raw fruit, vegetables, undercooked meat, fish, eggs, pepper, paprika o Wash dishes between use with hot, sudsy water or use dishwasher o Do not drink water, milk, juice or other cold liquids that have been standing over an hr o Do not reuse cups and glasses without washing o Do not change pet litter boxes ( or use gloves and wash hands immediately) o Avoid turtles and reptiles as pets o Do not feed pets raw or undercooked meets o Take temperature at least once a day or whenever not feeling well o Report any indications of infection (T > 100, cough, pus, smelling drainage, presence of boil or abscess, cloudy smelling urine) o Take all prescription drugs o Do not dig in garden or work with houseplants o Wear a condom o Avoid travel to areas of world with poor sanitation
post-op care and self-management after surgery for breast cancer
o Elevate arm on pillow for at least 30 minutes a day for 1st 6 months if lymph nodes removed (lymphedema) o Avoid using affected arm for measuring BP, giving injections, or drawing blood o Assess patient position to ensure that drainage tubes or collection device is not pulled or kinked o Head of bed elevated at least 30 degrees, with affected arm elevated on pillow while awake o Provide comfort measures
Fluids Resuscitation of Burn Patient
o Initiate and maintain at least 1 large bore IV in area of intact skin o Coordinate with physician to determine appropriate fluid type and total volume to be infused during first 24 hours postburn (4ml x kg x TBSA) o Administer one half of total volume within 1st 8 hours postburn and then remaining volume over next 16 hours o Assess IV access site, infusion rate, infused volume at least hourly o Monitor vitals hourly (BP, pulse, RR, breath sounds, voice quality, oxygen sat, CO2) o Assess urine output hourly (volume, color, specific gravity, character, protein) o Assess fluid overload (formation of dependent edema, engorged neck veins, rapid, thready pulse, presence of lung crackles or wheezes on auscultation) o Measure additional body fluid output hourly
clinical manifestations of fat embolus syndrome
o Low arterial oxygen (hypoxemia) o Dyspnea o tachypnea o SOB o Anxiety, agitation, confusion o Tachycardia o Headache o Lethargy o Decreased LOC o Seizures o Visual changes o petechia
imaging assessment for breast cancer
o Mammography o MRI: screen high-risk women and better examination of suspicious areas o Ultrasound: dense breasts, but not for routine screening o Tomosynthesis: newer, but uses three dimensional images
How do we determine an inhalation injury?
o Patient who were injured in closed space o Intra-oral charcoal, especially on teeth and gums o Patients who were unconscious at time of injury o Patients with singed scalp hair, nasal hairs, eyelids, eyelashes o Coughing up carbonaceous sputum o Changes in voice such as hoarseness or brassy cough o Use of accessory muscles or stridor o Poor oxygenation or ventilation o Edema, erythema, ulceration of airway mucosa o Wheezing, bronchospasm o Extensive burns or burns on face
Care of hospitalized immunosuppressed patient (HIV/AIDS)
o Place patient in private room whenever possible o Use good handwashing technique or alcohol-based hand rubs before touching the patient or any of his or her belongings o Ensure that the patient's room and bathroom are cleaned at least once each day o Do not use supplies from common areas for neutropenic patients. For example, keep a dedicated box of disposable gloves in his or her room and do not share this box with any other patient. Provide single-use food products, individually wrapped gauze, and other individually wrapped items o Limit the number of personnel entering the patient's room o Monitor vital signs, including temperature, every 4 hours o Inspect the patient's mouth at least every 8 hours o Inspect the patient's skin and mucous membranes (especially the anal area) for the presence of fissures and abscesses at least every 8 hours o Inspect open areas such as IV sites every 4 hours for signs of infection o Change gauze-containing wound dressings daily o Obtain specimens of all suspicious areas for culture (as specified by the agency) and promptly notify the primary health care provider. o Help the patient perform coughing and deep-breathing exercises o Encourage activity at a level appropriate for the patient's current health status o Keep frequently used equipment in the room for use with this patient only (e.g., blood pressure cuff, stethoscope, thermometer) o Limit visitors to healthy adults o Use strict aseptic technique for all invasive procedures o Avoid the use of indwelling urinary catheters o Keep fresh flowers and potted plants out of the patient's room o Teach the patient to eat a low-bacteria diet (e.g., avoiding raw fruits and vegetables; undercooked meat, eggs, and fish; pepper and paprika as seasonings sprinkled on food right before eating).
Characteristics of heat stroke
o T > 104 degrees o Hypotension, tachycardia, tachypnea o Hot and dry skin o Mental status changes (acute confusion, bizarre behavior, anxiety, LOC, hallucinations, agitation, seizures, coma) o Electrolyte imbalances, (Na, K) o Decreased renal function (oliguria) o Coagulopathy (abnormal clotting) o Pulmonary edema (crackling)
Early signs of compartment syndrome
pain pressure paralysis paresthesia pallor pulselessness
metabolic acidosis
ph < 7.3 HCO3 <15 PaCO2 <35
how to we assess neurovascular status
skin color skin temp sensation cap refill pulses movement (numbness, tingling) can they move extremity pain (location, nature, frequency)
non-urgent tier examples
skin rash strains and sprains "colds" simple fractures
clear ketones and correct acidosis for hyperglycemic crisis
sodium bicard but may correct itself
what can a brain death donate
solid organs and tissues
heat stroke interventions at hospital
§ Give O by mask or nasal cannula, be prepared for endotracheal tube § Start at least one IV with large-bore needle or cannula § Administer normal saline as prescribed, using cooled solutions § Use cooling blanket § Do not give aspirin or any other antipyretics § Insert rectal probe to measure core body temperature continuously or use rectal thermometer to assess T every 15 minutes § Insert an indwelling urinary drainage catheter § Monitor vital signs frequently as clinically indicated § Obtain baseline lab tests as quickly as possible (serum electrolytes, cardiac enzymes, liver enzymes, CBC) § Assess arterial blood gases § Administer muscle relaxants if shivering § Measure urine output and specific gravity to determine fluids needs § Stop cooling interventions when core temp is at 102 § Obtain urinalysis and monitor urine output
emergency management of chemical burns
§ If dry chemicals are present on skin, do not wet them § Brush off any dry chemicals present on skin or clothing § Remove patients clothing § Ascertain type of chemical causing burn § Do not attempt to neutralize until it has been identified and agent is available
emergency management of flame burns
§ Smother flames § Remove smoldering clothing and all metal objects
autonomic NS manifestations of hypoglycemia
§ Tachycardia, palpitations § Hunger, sweating, anxiety § Tremors, nervousness, cold, clammy skin § Hyperventilation § Tingling in extremities § n/v
