AH exam 2
Endocrine Hormones released by the anterior pituitary? Posterior pituitary?
Anterior Growth hormone (GH)---> located in ALL body cells. They promote protein anabolism (building up); lipid mobilization; and catabolism (breaking down). TSH-------> Stimulates T3 and T4------>metabolism of all cells ACTH------> located in the adrenal cortex. Stimulates secretion of corticosteriods FSH and LH----> reproductive hormones; prolactin MSH-----> melanin for our skin Posterior: ADH oxytosin
Type 1 hypersensitivity reactions Is this reaction a B or T cell response? Which antibody is primarily found in this response? What chemicals are released during this type of response? (4) hint : H_______, L_________, S________, and E________.
B cell response. IgE attaches to mast cells AND basophils. They release histamine, leukotrienes, serotonin and Eosinophils.
Drug Therapy: Leukotrienantagonists Function:
Blocks leukotrienes----major mediator involved in the allergic inflammatory process.
A nurse is caring for a client who has unilateral adrenal tumor, which of the following would be a priority to assess for immediately after postop?:
Blood pressure
Which of the following may occur with inadequate water intake, excess water loss or, rarely, sodium gain? a) Hyperkalemia b) Hyponatremia c) Hypernatremia d) Hypokalemia
C, hypernatremia
If a client that is scheduled for a skin test informs the nurse that they have been taking glucocorticoids to help control allergy symptoms, which of the following actions should the nurse take?:
Cancel the test until the client is off the medications
Cushing syndrome Causes? Symptoms?
Caused by -Excess of corticosteroids -Latrogenic administration of exogenous corticosteroids -ACTH-secreting pituitary adenoma -Adrenal tumors -Ectopic ACTH production by tumors S/S -Truncal/generalized obesity -"Moon face" -Purplish/blue or red striae -Hirsutism -Menstrual disorders -Hypertension -Hypokalemia -Excess glucocorticoids Weight gain from accumulation of adipose tissue Hyperglycemia related to glucose intolerance and ↑ gluconeogenesis Muscle wasting → weakness Loss of bone matrix → osteoporosis and back pain -Mineralocorticoid excess → hypertension -Adrenal androgen excess → Severe acne Virilization in women Feminization in men
A nurse is caring for a client who has a wound on the left arm, the nurse notes purulent drainage and odor when changing the dressing. Which of the follow actions should the nurse take first?:
Check the clients complete blood count
nurse is performing an assessment on a patient abdominal incision and observes the intrusion of intestines from the incision. Which of the following actions should the nurse take first?:
Cover the wound with sterile moistened towels
A nurse is assessing the abdomen of a client an notes fragile skin, purple/blue striae across the abdomen the nurse recognized that this is a manifestation of which of the following?:
Cushing's
A nurse is assessing a client for fluid status and notices that the clients skin stays wrinkled for 3 to 4 seconds after pinching. Which of the following actions should the nurse take?:
Document the finding as normal
Expected wound infection: Lab(s) to check? what types of drainage would the nurse expect to see?
Expected wound infection: -Check CBC -Check drainage for purulent, foul smell
Pressure ulcer unstageable:
Full thickness tissue loss with depth completely obscured by slough or eschar in the wound bed, depth of the wound cannot be determined
Why is documentation super important regarding wound stages?
Gives us a baseline to go off of----is the wound getting better or worse?
Sequence of hormone release starting from the Hypothalamus? Use thyroid hormone for sequence****
Hypothalamus-----TRH-----Anterior Pituitary----TSH----Thyroid---T3 and T4 Hypothalamus controls pituitary secretions!!!
he nurse is assessing a client diagnosed with Addison's disease, which of the following statements by the client is consistent with the disease?
I have a tendency to crave salty food
Innate immunity What types of cells travel to the site? True/False: cytokines are present for this type of immunity?
Immunity that is present before exposure and effective from birth. Responds to a broad range of pathogens. Consists of neutrophils, and monocytes ----> to macrophages TRUE! Also present for adaptive immunity
A nurse is providing care for a patient who is experiencing a type one hypersensitivity reaction. Which of the following would be the best action for the nurse to take?:
Implement emergency treatment for anaphylaxis
Macrophages are located in the _____________ They migrate to the inflammed/injured site ____________hours after neutrophils. Macrophages are involved in activation of the ________________response. Macrophages produce _____________and _____________hormone that suppress inflammation and initiate healing.
Located in the tissue 24 hours after neutrophils Adaptive immune response cytokines and growth factors
A nurse is preforming a skin assessment on a client who is newly admitted to the unit, a nurse notes an area on the clients heel that is dry with intact black skin covering the area, which of the following actions should the nurse take?:
Measure the area and note any drainage
Cushing syndrome: Drug therapy focuses on what class of drugs?
Medications focus on DECREASING corticosteroids ▪Gradually discontinue prednisone ▪Decrease dose (taper) ▪Convert to an alternate-day regimen
Hypothyroid Complications
Myxedema coma ▪Impaired consciousness ▪Precipitated by infection, drugs, cold, trauma ▪Subnormal temperature, hypotension, hypoventilation ▪Cardiovascular collapse ▪Treat with IV thyroid hormone
Most common way nurses are exposed to HIV?
Needle stick
Drug therapy for Hyperthyroidism
Not considered curative ▪Antithyroid drugs ▪Beta Blockers ▪Iodine ▪Propylthiouracil (PTU) and methimazole (Tapazole) Inhibit synthesis of thyroid hormone Improvement in 1 to 2 weeks Good results in 4 to 8 weeks
A nurse notes that a client's potassium level is 6.0, which of the following actions should the nurse take?:
Notify the health care provider
Cancer and obesity linkage?
Obesity leads to excessive levels of proinflammatory cytokines, sex hormones, lipid metabolites, and altered adipokines. The altered adipose tissue becomes a source of various extracellular matrix proteins, cancer stem cells, and cancer-associated adipokines. Collectively these alterations contribute to tumor initiation, growth, and recurrence. The systemic metabolic changes of obesity—hyperinsulinemia and hyperglycemia—can further contribute to a tumor-permissive environment.
Fluid and Electrolytes Osmolality measures
Osmolality measures the number of milliosmoles per kilogram of water, or the concentration of molecules per weight of water. Osmolality is the preferred measure to evaluate the concentration of plasma, urine, and body fluids
emerging infectious diseases are commonly defined as:
Outbreaks of previously unknown diseases Known diseases that are rapidly increasing in incidence or geographic range in the last 2 decades Persistence of infectious diseases that cannot be controlled. Emerging diseases include HIV infections, SARS, Lyme disease, Escherichia coli (E. coli), hantavirus, dengue fever, West Nile virus, and the Zika virus. Reemerging diseases include malaria, tuberculosis, cholera, pertussis, influenza, pneumococcal disease, and gonorrhea.
A 61-year-old female is admitted with pneumonia with total serum calcium level of 13.3 (normal is 8 to 10.) the nurse is will anticipate the need to teach the patient about testing what blood levels?:
Parathyroid
Pressure ulcer stage 2:
Partial-thickness skin erosion with loss of epidermis or also the dermis - Superficial/shallow ulcer looks shallow like an abrasion or open blister with a red-pink wound bed - presented w/o slough -May be serosanguinous (blood and serous fluid)
After received daily shift report, which patient should the nurse assess first?:
Patient with serum magnesium of 1.1 who has tremors and hyperactive reflexes
A nurse is concerned that a client's external wound is at risk for dehiscence. Which of the following interventions would help prevent this complication?:
Placing a pillow over the incision when they need to cough or sneeze
Hydrogels
Re-hydrates wound tissue, good for debridement; requires a secondary dressing **good for dry wounds **Good for wound with minimal drainage **Good for necrotic wounds
Wound Assessment
Record findings in a "clock" format -Measure wound in cm -note undermining ---applicator will form a "lip" around the wound -Note Tunneling -Record consistency, color, odor and amount of drainage!! (serous, serosanguinous, sanguenous, purulent)
A nurse is caring for a client with the following arterial blood gases: pH is 7.48, CO2 is 30 and HCO3 is 23. The nurse should recognize that the client has which of the following?:
Respiratory Alkalosis
Type 1 hypersensitivity reactions Allergic rhinitis areas affected? s/s?
Seasonal = pollen from trees, weeds, or grasses Perennials = dust, molds, animal dander Areas affected: eyes/conjunctiva, and mucosa of respiratory tract S/S: nasal discharge. sneezing, lacrimation (watery eyes), mucosal swelling with airway obstruction and pruritis( itching) around eyes, ears, nose and mouth.
Addison's Disease is an insufficient production of.............? S/S
Specifically, the adrenal glands produce insufficient amounts of the hormone cortisol (glucocorticoid) and sometimes aldosterone (mineralcorticoid). Not evident until 90% of adrenal cortex is destroyed ▪Insidious onset ▪Progressive weakness ▪Fatigue ▪Weight loss Anorexia ▪Orthostatic hypotension ▪Hyponatremia and salt craving ▪Hyperkalemia ▪Nausea and vomiting ▪Diarrhea ▪Irritability, depression ***Hyper-pigmentation
Most severe infections will be _________cell deficiencies
T-cell deficiencies
A nurse is assessing a new admit client for risk of hyperphosphatemia you should ask the client about which of the following when obtaining the medical history?:
Thyroid surgery
Wounds why check CBC?:
To see if WBC's are elevated which indicates wound infection
A nurse is teaching a client about an incision that needs the heal by secondary intention, which of the following pieced of information should the nurse include in the teaching?:
Unfortunately, this type of healing will most likely leave a large scar
Inflammation What happens during the Vascular response of inflammation? What happens during the Cellular response to inflammation?
V: cell injury occurs------> release of histamine and prostaglandins----->produces local vasodilation and increases capillary permeability (responsible for redness and heat at injury and surrounding area)---------------->local edema (contains albumin) C: chemotaxis occurs---> leukocytes migrate to site of injury: Neutrophils---> first on site. Bone marrow releases more WBCs---are PHAGOCYTES as well Monocytes----appear 3-7 days after onset of inflammation-----> form macrophages to undergo PHAGOCYTOSIS. Macrophages also clean the site; happens before healing can occur. Lymphocytes---> immune response (humoral and cell-mediated immunity)
Vitamins that aid in wound healing?
Vit A: accelerates epithelization Vit C: collegen synthesis and new capillary formation Vit D: facilitates calcium absorption Vit B: co-enzymes
A nurse is talking to a client at a public health clinic, the client asks, "the doctor said that my CD4+ is 450, is that good?" Which of the following responses should the nurse make?:
Your count is a bit low and you susceptible to infection
A patient is receiving IV KCL for low potassium levels. What should the nurse be assessing for every hour during the infusion a) Phlebitis and infiltration of the IV site b) Trousseau sign c) Seizure activity d) Sluggish deep tendon reflexes
a)
a) Eosinophil and Mast cell function? b) In part of degranulation, mast cells release _____________, which causes vasoconstriction.
a) E: Helps defend against parasitic infections They move to inflamed areas, trapping substances, killing cells, anti-parasitic and bactericidal activity, participating in immediate allergic reactions, and modulating inflammatory responses. M: Located in the tissues and contain HISTAMINE. These cells are located within the tissue near blood vessels (skin, GI, respiratory tract). When activated, they are released by via degranulation and synthesis. They also release leukotrienes (later stages) b) release of contents of mast cells--histamine. Causes vasoconstriction of large blood vessels, elevated temp, dilation of post capillary venules Synthesis- new production and release of mediators in response to a stimulus.
T Lymphocytes a) T cells are produced in ______ _______; transfers or moves to the __________. b) T cells make up _____ to _______% of circulating lymphocytes, and are primarily responsible for ____________ to viruses, bacteria, and fungi.
a) Bone marrow; Thymus b) 70-80%, immunity
Diseases associated with hypernatremia include which of the following? Select all that apply a) Cushing syndrome b) Diabetes insipidus c) SIADH d) Primary hyperaldosteronism e) Uncontrolled diabetes mellitus
a, b, d, and e
Hyponatremia With Decreased ECF Volume can cause which of the following signs and symptoms? Select all that apply. a) Twitching b) Irritability c) Postural hypotension d) Intense thirst e) Dry mucous membranes
b, d, e
Which of the following alterations in cardiac rhythm may you see in a patient with hyperkalemia? (Select all that apply) a) ST segment elevation b) Widened QRS complex c) Peaked P Waves d) ST segment depression e) Peaked T waves
b, d, e
Sodium, the main cation of Extracellular (ECF), plays a major role in maintaining the concentration and volume of ECF and influencing which of the following between the ECF and Intracellular (IICF)? a) Sugar balance b) Potassium balance c) Water distribution d) Sodium balance
c---water balance
Type 1 hypersensitivity reactions Atopic dermatitis (eczema)
chronic inherited disorder with exacerbation and remissions ---inflammation
RA (rheumatoid arthritis)
chronic, systemic inflammatory disease of joints and surrounding connective tissue. AFFECTS THE SYNOVIAL FLUID --Develops over weeks to months --Morning stiffness lasts 1 hour to all day --Pain improves with joint use --Joint effusions are common --Typically affects small joints first --Fever, fatigue, and loss of energy may occur
Type 1 hypersensitivity reactions Urticaria (Hives) Occurs due to _____________ release What do hives look like? S/S?
cutaneous reaction against systemic allergens S/S: wheals (fluid filled, red, raised)---histamine release
The Adrenal Medulla produces what 2 hormones? What are they classified as? What is their function?
epinephrine and norepinephrine (catecholamines) These hormones are increased when the body is responding to stress. They can enhance and prolong the effects of the sympathetic nervous system (increase HR, BP, RR, decrease gastric secretions).
Hyperthyroidism Causes? Labs will show ______________TSH secretion, with _____________T3 and T4 levels S/S?
excessive activity of the thyroid gland, high metabolism. Stimulates the sympathetic nervous system 1. graves disease (most common autoimmune condition), toxic nodular goiter, thyroiditis, excessive iodine intake, pituitary tumors, and thyroid cancer 2. Low TSH sectretion and elevated T3 and T4 3. -goiter -exopthalmos (protruding eyeballs resulting from fluid buildup and fat deposits), dry eyes -heat intolerance, diaphoresis -increased HR and BP (increase in SNS) -diarrhea (increased GI motility), increased appetite and thirst -weight loss -soft silky hair (d/t increased blood flow) -personality changes (anxiety, restless, irritable, insomnia)
Evisceration of wound:
extrusion of viscera outside the body, especially through a surgical incision
Neutrophils Function and presence?
first at site of injury/inflammation (6-12 hours) . They ingest bacteria, dead cells, and cellular debris
Hydrocolloids
flat dressing that forms a gel on the wound surface supports debridement and prevents secondary infections **Good for wounds with light to moderate drainage
How do antigens travel and interact with the immune cells in your body? (Monocytes)
monocytes capture, process and presents the antigen to lymphocytes----presents it to T or B lymphocytes and macrophages within the lymph nodes, which generates an immune response.
A nurse is obtaining an admission history for a patient with Guillain-Barre Syndrome, which of the following should the nurse expect to find in the patient's history?: I
nfluenza virus 3 weeks ago
Why is Vitamin D important?
(provided by the sun and food) helps aid in calcium and phosphorus absorption by food---which is important for bone development!!
Nursing Assessment: HIV What types of questions would you ask your patient? What medications interact with ART therapy?
+ get a good health history!!!!! (number of partners, exposure to needles, syringes, blood, secretions, people with the virus/contaminants). + Recently transmitted STI or previous exposure? +Medications taken ((OTC meds interact with anti-viral therapy!!! Note if pt takes Aspirin, GERD meds, prilosec)) +more recent infections or problems with fatigue, weight loss
Type 1 hypersensitivity reactions What types of conditions occur d/t type 1 reactions? Cause?
- Allergic rhinitis - causes: pollen, dust, dander, molds, grass, weeds. - atopic dermatitis (eczema) - Urticaria -Angioedema -Anaphalaxis
Celiac disease (aka: celiac sprue, gluten-sensitive enteropathy) is an:
- An immune reaction to eating gluten, a protein found in wheat, barley, and rye. - If you have celiac disease, eating gluten triggers an immune response in your small intestine. - Over time, this reaction damages your small intestine's lining and prevents it from absorbing some nutrients (malabsorption). - The intestinal damage often causes diarrhea, fatigue, weight loss, bloating and anemia
A nurse is assessing a client's genetic risk for endocrine disorders. The nurse should ask the client if any relatives have a history of which of the following endocrine disorders? (select all that apply):
- Cushing's - Graves - Diabetes - Hashimotos
Pressure ulcer stage 3:
- Full-thickness pressure ulcer extending into the subcutaneous tissue - resembling a crater - May see subcutaneous fat but not muscle, bone, or tendon. - may show slough (stringy matter attached to wound bed) or eschar (black or brown necrotic tissue). -may include undermining or tunneling
Pressure ulcer stage 4:
- Full-thickness pressure ulcer involves all skin layers and extends into supporting tissue. - Exposes muscle, tendon, or bone - may show slough (stringy matter attached to wound bed) or eschar (black or brown necrotic tissue).
Primary intention healing? Primary intention wound healing example? Dressings we can use?
- Healing from side/side. Fills with blood from cut vessels--->blood clot forms. Acute inflammation -Wound that is Intact with sutures or staples. Paper-cut - dry sterile dressing; remove when draining stops. Medicated sprays can be used to clean site. Can also use transparent films or adhesives (they are permeable to oxygen)---then are covered with a sterile dressing
A nurse is planning care for a patient who is newly diagnosis with early chronic human immunodeficiency virus (HIV) which of the following prescribed prophylaxis immunizations should the nurse include in the plan of care? (Three)
- Hepatitis B Vaccine (both viruses share the same routes of transmission; semen, blood, or other body fluids) - Pneumococcal vaccine - Influenza Vaccine
Wound healing diet:
- High protein - low carbohydrates - low fats
A nurse is talking to a patient with HIV with an undetectable viral load. Which of the following statements would require more teaching by the nurse? (3)
- I am so happy that my partner is no longer at risk for getting the virus - Now that I am undetectable, I can begin using over the counter antacids - I look forward to being able to stop taking my HIV medications
A nurse is teaching a client who is receiving immunotherapy for severe allergies, which of the follow information should the nurse include in the patient teaching?
- Immediately report any itching, sneezing or dizziness after receiving the dose -After you receive the dose you will need to be observed for 20 to 30 minutes -You should try to avoid whatever causes your allergies as much as possible
Guillain-Barre syndrome is a:
- Rare disorder in which your body's immune system attacks your nerves. - Weakness and tingling in your extremities are usually the first symptoms. - These sensations can quickly spread, eventually paralyzing your whole body - Prone to the influenza virus
A nurse is planning an education conference about autoimmune disease. Which of the following diseases should the nurse plan on talking about?
- Rheumatoid Arthritis -Systemic Lupus -MS - Graves -celiac
The nurse is preforming a key diagnostic assessment for a client who is suspected for having an endocrine disorder. Which of the following lab tests should be included? (select all that apply):
- Thyroid Stimulating Hormone - Glycosylated Hemoglobin - Thyroxine (T4) - Serum Osmolality
Dehiscence of wound is: Dehiscence risk factors
- a surgical complication in which a wound ruptures along a surgical incision. Dehiscence risk factors:: - age - collagen disorder - diabetes - obesity--decreased blood supply to adipose tissue - poor knotting or grabbing of stitches - trauma to the wound after surgery
Risks of acquiring hyperthyroidism? (3)
- cigarette smoking - genetic factors -goiter
Antimicrobials
- good for partial and full thickness wounds - can be used over surgical incisions - can be used around trachs
Wound evisceration requires:
- immediate attention. - The surgeon must be notified. - Using sterile technique, cover the wound site with gauze or a sterile towel moistened in sterile saline. - Take measures to prevent shock.
A patient came into the ER with complaints of redness, heat and pain in her leg after she fell and badly scrapped her knee. The nurse knows that this is part of the inflammatory response. What additional findings may we see in a patient with local inflammation?
- swelling -loss of function (d/t swelling and pain) ****may or may not see a fever with local inflammation
Severe cases of anaphalaxis can result in hypovolemic shock; why or how does this occur?
--can occur d/t loss of intravascular fluid that moves to the interstitial space ---> secondary to increased capillary permeability ---->sympathetic nervous system tries to compensate for the fluid shift---can cause cell damage and even death
What is the role of cytokines?
-Act as messengers between cell types (T-cells, B-cells, monocytes, macrophages) -Can be pro-inflammatory or anti inflammatory - promotes wound healing -promotes phagocytoosis -promotes Hematopoesis--- of through which the body manufactures new blood cells
Drug Therapy: Corticosteroids What EENT condition can corticosteriods treat? Distributed via____________?
-Allergic rhinitis -nasal sprays
Anaphalaxis: Nursing interventions (detailed) (think medications, airway, BP, and monitoring)
-Ensure patent airway if suspected obstruction -Remove stinger if present -Establish IV access MEDS -Epinephrine 1mg/mL (IV) 0.3-0.5mg (IM). Can repeat very 5-15 min -High flow o2 (8-10L/min) via face mask -Neubulized albuterol if epinephrine doesn't work -Benydrl for hives/itching (ANTIHISTAMINE) -Corticosteroids IV Hypotension management: -place is recumbent position and elevate legs (get blood going to the heart) -IV NS bolus of 1-2L -Maintain BP with fluids, volume expanders, or vasopressors (dopamine) Monitoring - vitals, RR, o2 saturation, LOC, cardiac rhythm, and urine output -If there is severe respiratory distress, intubation
Pressure ulcer stage 1
-Intact skin with non-blanchable redness of a localized area, usually over a bony prominence - skin is not broken but is red or discolored - skin can be warm or cool
Most common symptomatic infections associated with HIV?
-Thrush (oral candidiasis) painful GIVE NYSTATIN -Shingles/herpes - Persistent vaginal candidiasis infections -Bacterial infections
A nurse is caring for a client who has a dry wound on the left leg which of the following would be appropriate for the nurse to apply?
-Transparent Film -Hydrogels
Dressings Transparent films: Function and types of wounds?
-allows for wound visualization - minimal absorption - can draw in moisture; increases risk for infection ***Good for dry wounds ***Good for uninfected wounds ***good for minimal drainage wounds
s/s we will see in systemic inflammation?
-fever-(body increases hypothalmic set point; shivering is a result of this---epinephrine is released from adrenal medulla to increase metabolic rate -nausea, anorexia -malaise - increase HR and RR
Type 1 hypersensitivity reactions Angioedema ----occurs due to excessive histamine release which increases capillary permeability Areas included? Symptoms that occur?
-localized cutaneous lesion but in deeper layers -Include areas such as: eyelids, lips, tongue, larynx, hands, feet, GI tract and genitalia. -swelling begins in the face and spreads downward -Dilation and engorgement of the capillaries is secondary to the release of histamine causes diffuse swelling (lesions can burn, sting or itch)
Type 4: Delayed Hypersensitivity----TB -Which organ is effected with TB? -How does TB react with our cells?
-lungs - Material that is released from the tubercle bacillus reacts with our bodies T-cells, which initiates a cell mediated immune response. As a result, the response caused extensive necrosis of the lung
What does hematocrit measure? What condition (skin) can cause an increased hematocrit?
-measures the proportion of red blood cells in your blood -Burns can increase hematocrit levels due to fluid and protein leaking out of the vascular compartments
The nurse is caring for a 76-year-old patient who had a total knee replacement 1 hour ago. Which of the following pieces of information should indicate to the nurse that the patient has a high RISK for developing a pressure ulcer? (select all that apply):
-the clients age - Inability to move due to surgery - Client is alert and oriented x1 - Client is received IV pain meds
Drug Therapy: Mast cells What condition is treated with mast cells? Effective medication for this condition? How is the medication distributed/available?
-txs allergic rhinitis -Cromolyn--stabilizing agent that inhibits the release of histamine, leukotrienes, and other mast cell agents. -available via an inhalant neubulizer solution OR nasal spray
Tertiary Intention What happens when a wound heals by tertiary intention? Dressings?
1. (delayed primary intention) -Healing occurs with delayed suturing d/t contamination OR when primary wound becomes infected. -Wound is left open and allowed to granulate -larger and deeper scar formation (bigger than primary and secondary intention) 2. Contaminated wounds need to be cleaned (debride) before healing can occur. Absorptive dressings can be used to excess exudate AND allow for the wound surface to stay clean. These dressing pull drainage from wound surface when dressing is removed.
Type 4: Delayed Hypersensitivity 1. How long does it take until this response occurs? 2. Which cells are attracted to the site? (3-4) 3. Examples of reactions?
1. -Referred to as the cell-mediated response---usually protective but can still cause some tissue damage 24-48 hours until reaction occurs 2. T-cells, monocytes, and macrophages cytokines attract macrophages to the area. ---->The macrophages released are responsible for tissue destruction 3. Types: -Contact dermatitis(POISON IVY) CD4 cell type reaction -Diabetes Type 1 -Hashimoto's -MS (T cells destroy myelin fibers around the nerves) CD4 -Rheumatoid arthritis -TB hypersensitivity to bacterial, viral, or fungal infections. Also transplant rejections
Secondary intention healing: Secondary intention wound healing example: Dressings and treatments we can use?
1. Secondary intention healing: - Healing from inside/outside via GRANULATION TISSUE -Inflammation may be GREATER than in primary -irregular wound margins, edges cannot be approximated or brought together -may need debrding before healing can occur - Usually leaves a noticeable scar 2. Secondary intention wound healing example: - pressure ulcers -trauma 3. - wounds that are granulating and re-epithelializing should be kept slightly moist until wound heals. Do not want to let the wound dry out. ***Careful with antibacterials and antimicrobials because they can damage newly formed tissue
Adrenal Cortex Explain the function of Glucocorticoids and Mineralcorticoids. Why is it critical that this gland works properly? Both are considered to be____________________hormones
1. glucocorticoids - cortisol, hydrocortisone ***Anti-inflammatory, increases in response to stress. PROTECTS body from stress. Increases blood glucose due to release during stress response ***Helps to maintain vascular integrity and fluid volume d/t mineralcorticoid receptors. Inhibits glucose release in a fasting state. Also inhibits protein synthesis Mineralcorticoids Aldosterone regulates sodium and water balance. Also involved in the excretion of potassium. 2. Steroid hormones
Hypothyroidism 1. Causes: ____________deficiency, ____________of thyroid gland, over__________for hypothyroidism, and drugs. 2. S/S? 3. Labs TSH is____________-and T3 and T4 are _________________?
1. ▪Iodine deficiency ▪Atrophy of the gland ▪Over treatment for hyperthyroidism ▪Drugs 2. Cardiovascular ▪Angina, CHF, MI, anemia, iron/folate deficient Respiratory ▪SOB, low tolerance Neuro ▪Fatigue, lethargy, slowed speech, mood changes GI ▪Decreased appetite, nausea, vomiting, wt gain, constipation Integument ▪Poor turgor, thick and brittle nails, dry skin, generalized edema, pallor MS ▪Slow to move, muscle aches and pain 3. TSH is HIGH and T3 and T4 are LOW
T Lymphocytes : TYPES 1. What are Cytotoxic T-cells? --->CD4 or CD8? 2. What are Helper T cells? ----->CD4 or CD8? 3. What is the role of Cell-mediated immunity? Cells included (4 types)? 4. Role of T-Dendritic cells in Cell-mediated immunity?
1. - (CD8) release cytotoxic substances to destroy the pathogen. Some of these cells do not attack the foreign body, but instead retain the 'memory' of the antigen. This process results in a faster and more POTENT immune response if a secondary infection occurs 2. -Helper T cells (CD4) regulate CELL MEDIATED IMMUNITY and HUMORAL (B cell) response -They also produce different types of cytokines 3. includes T cells (also dendritic), B cells, macrophages, and NK cells The purpose of this type of immunity is to monitor/surveillance for malignant cell changes 4. IMPORTANT for this response!! ACTIVATES immune response -These cells line the nose, lungs, stomach and intestine -Function to capture antigens at sites of contact w/ the external environment and transports the antigen until it reaches a T cell specifically for the antigen
Type 1 hypersensitivity reactions Anaphalaxis 1. Causes? 2. Initial S/S (3 initial) Can lead to ________ 3. What types of drugs, foods, and insects can cause an anaphalactic reaction?
1. -occurs when mediators are released systemically antibiotics, blood, insect stings 2. -Initial s/s: edema and itching at the site, erythemia can lead to SHOCK Shock s/s: -Rapid, weak pulse -SOB -Tachycardia -Hypotension -Dilated pupils -Cyanosis -Seizures ALSO, n/v, impending doom, abdominal pain, diarrhea.. 3. Drugs: Aspirin, Cephalosporins, chemo drugs, insulin, local anesthetics, NSAIDs, penicillin, sulfonamides, tetracycline Food: eggs, milk, nuts, peanuts, shellfish, chocolate, strawberries Insects: wasps, hornets, yellow jackets, bumble-bees, ants.
Allergic disorders: Assessment Most important subjective data? objective data? (body systems---EENT)
1. Past health history--recurrent respiratory problems, seasonal exacerbations, medications taken, reactions present.? 2. Eyes: lacrimation, rubbing, dark circles under eyes Ears: decreased hearing, recurrent ear infections, scarred TM Nose: nasal polyps, itchy nose, boggy mucus membranes, sniffling, repeated sneezing, swollen nasal passages, recurrent--unexpected nose bleeds. Throat: Continual clearing of the throat, swollen lips, swollen tongue, red throat, palpate neck lymph nodes Respiratory: Wheezing, stridor, thick sputnum
B lymphocytes: 1. Differentiate into____________cells. ____________cell produce antibodies. 2. Describe what each immunoglobulin does in relation to the immune response: -IgG -IgA -IgE -IgD -IgM 3. Which immunoglobulins are involved in the secondary response to a pathogen?
1. plasma cells (both) 2. IgG: most abundant (PRIMARY RESPONSE) and accounts for most of the protection against infections. Can cross placenta. Also plays a role in SECONDARY response IgA: Primarily in body secretions (Tears, Sweat, Saliva) and in breast milk IgE: Located within the PLASMA and INTERSTITIAL fluid - Mediator of many allergic-type responses. Fixes to mast cells and basophils. -Assists against parasitic infections IgD: found in PLASMA. -Present themselves on the lymphocyte surface. -Helps in differentiation of B-lymphocytes IgM: Found in the PLASMA FIRST antibody produced in the primary (INNATE)immune response to an antigen. -Synthesized early in neonatal life. -Apart of forming antibodies to ABO blood antigens. 3. IgG and Memory B cells
Drug Therapy: Sympathomimetric/Decongestant Drugs 1. Name 2 types of decongestant drugs 2. Epinephrine's role in an immune response? 3. How does epinephrine act on cells, particularly one type of cell? 4. How can the nurse administer epinephrine?
1. sudafed, Afrin 2. produced in the adrenal medulla of the kidney; stimulates alpha and beta adrenergic receptors. Alpha: vasoconstriction of peripheral blood vessels Beta: relaxes bronchial smooth muscle 3. Acts directly on Mast Cells to PREVENT them from further degranulation of tissue 4. -IV or IM
Name the 6 mediators in the inflammatory response?
1. Histamine 2. Serotonin ( stimulates smooth muscle contraction 3. Kinins 4. Cytokines 5. prostaglandins (pro-inflammatory, potent vasodilators, contribute to increased blood flow and edema formation 6. Luekotrienes (constricts smooth muscle of the bronchi, which can lead to airway edema)
How do monocytes plan a role in the immune and inflammatory response? What organs are they present in? (3 organs) Are monocytes located in the blood or the body tissue?
1. In the inflammatory response, monocytes migrate to the site of injury. They are the PRECURSORS to macrophages. Located in the brain, lungs, liver--- 2. located in the blood.
Patient teaching for use of radioactive iodine therapy (hyperthyroidism):
1. May gargle with salt and baking soda 2. Avoid being close to pregnant women 3. Wash laundry separately from other family members
Use of corticosteroids with allergy testing:
1. Needs to be discontinued prior to any allergy testing 2. Will show false positives
Risk factors for developing pressure wounds (post op)
1. Not alert and oriented x's 3 2. Receiving post op IV pain meds 3. Immobile 4. Age of client
Patient teaching for immunotherapy treatment with allergies:
1. Report any sneezing, itching, dizziness 2. You will need to be observed in the office for 20-30 minutes after the injection 3. Avoid what causes allergic reactions
Types of autoimmune diseases? 1. Systemic 2. Blood 3. CNS/brain 4. Muscle 5. Heart 6. Endocrine 7. Kidney 8. GI 9. Neuro
1. Rheumatoid arthritis, Systemic lupus, sclerdoma 2. Hemolytic anemia, Lupus erythem. 3. MS, Gillian Barre syndrome 4. Myasthenia Gravis, Fibromyalgia 5. Rheumatoid fever 6. Thyroiditis, Hashimotos, Graves disease, Addison's, Hypothyroidism, Type 1 diabetes 7. Goodpasture syndrome, glomerulonephritis 8. Celiac disease, IBD, Crohns, Ulcerative colitis 9. peripheral neuropathy, Diabetic neuropathy
People at risk for pressure ulcer development?
1. advanced age 2. anemia 3. contractors 4.diabetes 5. elevated body temp 6. friction 7.immobility 8. impaired circulation 9. incontinence 10. low diastolic BP 11. mental deterioration 12. neurologic disorders 13. obesity 14.pain 15. prolonged surgery 16. vascular disease
Drug Therapy: Antihistamines 1. Best drug for ___________and _________. 2. Can also treat_______and ____________. 3. What is their MOA? 4. When should a pt take them? 5. T/F: Antihistamines prevent brochoconstriction
1. allergic rhinitis and urticaria (Hives) 2. edema and puritis (itching) 3. Blocks H1 receptor 4. take as soon as allergy s/s appear. For AR, take at peak pollen seasons 5. False
Main goals of HIV drug therapy?
1. decrease viral load 2. Maintain or increase CD4 counts 3. Prevent opportunistic infections and s/s of HIV 4. delay disease progression 5. Monitor and maintain ART therapy ----STRICT TIME SCHEDULES 6. Prevent further transmission of IV----good/safe sex practices; encourage testing, communicate with partner(s). Avoid IV drug use!!!!!
1. Adaptive Immunity is defined as: ? 2. Consists of __________ and ____________ lymphocytes. 3. Where are B and T cells produced? 4. Important components of BOTH cells?
1. long term protection of infectious organisms 2. B and T cells 3. B cells: Bone marrow; T cells: Thymus 4. Humoral (B-cells) = immunoglobulins/antibodies bind to bacteria and viruses T cells kill target cell and stimulate other leukocytes BOTH PRODUCE MEMORY CELLS
Histamine 1. H1? 2. H2? 3. Are prostaglandins painful?
1. pro-inflammatory---blood vessel dilation, increased capillary permeability, bronchoconstriction 2. anti-inflammatory ----induces stomach acid secretion , vasodilation 3. YES, very irritating to skin
How would a nurse manage a pt who has anaphalaxis? 1. recognize s/s of _________ 2. maintain ____________ 3. use ___________to manage the spread of the reaction 4. Admin appropriate ___________ 5. tx for ______________
1. recognize s/s of anaphalaxis 2. maintain airway 3. use tourniquet to manage the spread of the reaction 4. Admin appropriate drugs 5. tx for shock
1. HIV is a _________________that causes immune suppression. 2. What is the timeline for HIV? Describe the s/s you may see associated with each phase. 3. Diagnostic criteria for HIV and AIDs?
1. retrovirus that uses our cells against us 2. a) acute infection (1-3 weeks; most infectious during this stage). PT can experience a fever, swollen lymph nodes, malaise, diarrhea, CD4 count drops TEMPORARILY. b) Asymptomatic- can last up to 8-9 years without showing symptoms c) Symptomatic infection- persistent fever, night sweats, chronic diarrhea, headaches, severe fatigue, CD4 counts start to tank. This may last 2-3 years d) Aids: high viral load---CD4 drops below 200 3. -CD4 counts drop below 200 cells - opportunistic infections occur (fungal, viral, bacterial) -Opportunistic cancer -Wasting syndrome
Magnesium Lab values: Phosphorus Lab values:
1.5-2.5 2.5-4.5
Normal pH range:
7.35-7.45 Normal HCO3 range: 22-26 Normal PCO2 range: 35-45 mmHg
The nurse is teaching a client who is scheduled to start radioactive iodine (RAI) therapy for hyperthyroidism. Which of the following information should the nurse include in the teaching? Select all that apply. A) "If your mouth becomes dry and irritated you may gargle with a mixture of salt and baking soda several times per day." B) "Effects from RAI may not be seen for up to 3 weeks." C) "You will need to avoid being close to any pregnant women while you are receiving the treatment." D) "Wash your laundry separate from others in your house to minimize their exposure to radiation." E) "You will not need to continue any antithyroid medication after you RAI is completed"
A, C, D
Endocrine Nursing assessment: What should a nurse observe when gathering objective data from a patient with a suspected endocrine disorder? Select all that apply a) skin, hair, nails b) head c) neck d) thorax e) abdomen f) extremities (size, shape, color) g) genital
ALL
A nurse is planning an education conference about fluid spacing, which of the follow should the nurse include as an example of third spacing?:
Abdominal Ascites
A nurse is preforming a physical assessment of a client who suspected of having an endocrine disorder. A nurse knows that hyperpigmentation on the client's knuckles, elbows and knees a nurse should recognize the finding as a manifestation of which of the following?:
Addison's
A nursing is caring for a client with severe allergies who is having skin testing. A few minutes after to intradermal injection of the allergen the patient reports having SOB, feeling anxious and dizziness. What would you do first?:
Administer prescribed epinephrine subcutaneously
The higher the concentration, the greater a solution's pull, or
osmotic pressure
Respiratory Alkalosis Values: Causes?
pH higher than 7.45 pCO2 lower than 35 HCO3 normal if uncompensated HCO3 lower than 22 if compensated respiratory alkalosis causes: - Hyperventilation - Mechanical ventilation
Metabolic Alkalosis Values: Causes?
pH higher than 7.45 pCO2 normal is uncompensated pCO2 higher than 45 if compensated HCO3 higher than 22 -Severe vomiting - Diarrhea -Excessive NG suctioning -Excess intake of antacids (TUMS) -Diuretic therapy (causing hypokalemia
Respiratory Acidosis Values: Causes?
pH lower than 7.35 pCO2 higher than 45 HCO3 higher than 22 Respiratory acidosis causes: - Hypoventilation - decreased stimuli (OD, anesthesia) - COPD - Pneumonia - Atelectasis
Metabolic Acidosis Values: Causes?
pH lower than 7.35 pCO2 normal if uncompensated pCO2 lower than 35 if compensated HCO3 lower than 22 -DKA - severe diarrhea - renal failure - shock
Calcitonin
regulates calcium and phosphorus serum levels; involves bone resorption of calcium to decrease blood calcium levels.
RICE explain the reason for each word
rest- helps body utilize nutrients and o2 appropriately ice/heat- vasoconstriction to the site and decreases swelling. Heat can be used after 24-48 hours to promote wound healing by increasing circulation and aid in removal of debris compression/Immobilization- counters vasodilation by preventing edema (ALWAYS assess peripheral pulses before and after application of compression devices to evaluate circulation. immobilization allows tissues to heal. elevation elevating above the heart decreases edema at the site by increasing venous and lymphatic return. Helps decrease pain associated with blood engorgement at site of injury DO NOT ELEVATE IF there is a decrease in arterial circulation
Drug therapy: Antipruitics 1. Can be applied topically IF the skin....? 2. Provides ____________relief
skin isn't broken Can provide itch relief
Checking serum calcium when what symptoms are present?:
tetany (tingling/numbness of digits)
What is negative pressure wound therapy? Type of lab values we need to monitor who has this treatment?
treats acute and chronic wounds---removes fluid, exudate, and debris through a vacuum. Has a vacuum pump, drainage tubing, a foam gauze wound dressing and an adhesive film MONITOR serum protein levels (albumin), and electrolytes d/t loss from wound.Also monitor PT and PTT
▪Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs? ▪A) Age ▪B) Symptoms ▪C) Lifestyle ▪D) Sexual orientation
▪A) Age
A patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse's priority action? ▪A) Provide high-flow oxygen ▪B) Assess the patient's airway ▪C) Administer antihistamines ▪D) Remove the stinger from the site.
▪B) Assess the patient's airway
▪The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take? ▪A) Instruct the patient to apply ice to the neck. ▪B) Explain to the patient that this is an expected finding. ▪C) Request that an antibiotic be prescribed for the patient. ▪D) Advise the patient that this indicates influenza infection.
▪B) Explain to the patient that this is an expected finding.
Addison's Disease- Collaborative Care
▪Correct underlying cause ▪Can happen secondary to additional underlying autoimmune diseases ▪Hormone therapy --Hydrocortisone Increase during periods of stress or crisis --Fludrocortisone ▪Increase dietary salt intake ▪Shock management
Hypothyroid- Drug Therapy
▪Levothyroxine (Synthroid) ---Start with low dose ▪Monitor for cardiovascular side effects (chest pain, dysrhythmias), weight loss, nervousness, tremors, insomnia ▪Increase dose in 4- to 6-week intervals as needed -take on empty stomach ( food can interfere with hormone levels) -Lifelong therapy
Which information about intradermal skin testing should the nurse teach to a patient with possible allergies? ▪a. "Do not eat anything the morning of your testing." ▪b. "Take Benadryl 50mg PO about an hour before the testing." ▪c. "Plan to wait in the clinic for 20 to 30 minutes after the testing." ▪d. "Reaction to the testing will take about 48 to 72 hours to occur."
▪c. "Plan to wait in the clinic for 20 to 30 minutes after the testing."
