Final review for med surg!!!!

tumor-specific antigen

unique protein on cell surface of tumors; measurement helps to track the extent of cancer as malignant cells mature and become less differentiated

Breathing exercises

used for PTs with chronic lung disease; diaphragmatic and pursed lip breathing increases effectiveness of breathing and helps reduce panic when dyspnea occurs

Huff coughing

used in PTs who have weak cough and airways that collasp easily (COPD)

How are tubes measure

using the French scale. Indicated by a number followed by the F. Each number on the French scale equals about 0.33mm. Larger number equals larger diameter

Autogenic drainage

variation on deep breathing and coughing; used for PT with thick secretions that are difficult to raise (cystic fibrous, severe COPD)

Ectopic

ectopic hormones are secreted from sites other than the gland where they would normally be found

Electrolyte excretion

is mainly through urine, fees, and sweat May also be influenced by hormones and medications Could be due to abnormal losses or fluid imbalances

rhonchi:

low-pitched wheezing or snoring sound associated with partial airway obstruction, heard on the chest auscultation.

Melanin

-color of skin is determined by this pigment -manufactured by the melanocytes located in the epidermis

Hard keratin

-protective function -fingernails/ toenails

harvesting the clients own tissue has several disadvantages.

1) it compounds the client's pain because it creates a new wound. 2) the donor site has the potential for scarring and atypical pigment changes. 3) there is a potential for donor site infection . 4) there is a delay in wound closure while waiting for the donor site to heal and be reharvested 5) delay caused by waiting for harvest sites to heal increases costs and challenge the client's ability to cope with a prolonged hospitalization. -it may be impossible to harvest sufficient skin to totally close a full-thickness burn wound that is greaer than 60 TBSA. regardless of the source of the skin graft, it is imperative to limit movement for some time to prevent disrupting the graft.

impaired ventilation is associated with a burn involving the upper airway and result from

1) swelling of the airway 2) inhalation of carbon monoxide 3) acute respiratory failure, may or all of which are manifested within the first 12-24 hours after the burn injury. -difficulty breathing, stridor, tachypnea, edema of the face or neck, -bronchoscopy may be performed to assess the internal airway. -warm, humidified O2 is administered, and an endotracheal tube should be available for insertion. -if full-thickness burn around in neck area, eschar, may compress the neck and pull it into flexion, making a tracheostomy the perferred technique for maintaining patent airway.

Heat: Cell damage

1) the temp of the heat source, 2) duration of contact, 3) the thickness of the tissue exposed to the heat source. The location of the burn also is significant. -burns in the perineal area at increased risk for infection from organisms in stool. -Burns of the face, neck and chest have the potential to impair ventilation. -burns involving the hand or major joints eventually can affect dexerity and mobility.

Mantoux skin test for TB

1.0 mL of PPD (purified protein derivative) intradermally; 25-27 gauge syringe, 5/8 inch needle; needle as close to possible to a parallel position with needle bevel facing up.

Sodium

135-145 mEq/L Primary ECF cation (90%) Regulates osmotic forces Neuromuscular irritability, acid base balance(sodium bicarbonate and sodium phosphate), and cellular chemical reactions and membrane transport.

hypoxemia:

: decrease in arterial oxygen tension in the blood.

Normal HCo3 Bicarb

22-26

Normal Bicarbonate level (HCO3)

22-26 mEq/L

Normal osmolality

290 mOsm

Cancer treatments

3 basic methods- surgery, radiation therapy & chemotherapy. there are other methods for selected cancers (stem cell transplants, bone marrow transplants, immunotherapy, gene therapy)

Advance the tube _______ inches every time client swallow s

3-5

Maintain sitting position ____ minutes after feeding

30

Pediculosis lifespan

30 days

After insertion of NG tube position client at minimum of:

30 degrees

orthopnea:

: inability to breathe easily except in an upright position.

ventilation:

: movement of air in and out of the airways.

the lung is made up of about how many alveoli?

300 million, which constitutes a total suface area of about 50 to 100 square meters.

fluid requirement for adults per day

30mL water/kg or 1mL /kcal

Normal CO2

35-45

Partial pressure of carbon dioxide(PaCO2)

35-45

Epidermis is constantly shed and replaced w/ epithelial cells from the dermis every day. The epidermis is totally replaced approximately every ______.

35-45 days

Hang no more than _____ hours worth of formula

4 hours

cause of glaucoma

4 types - open-angle or chronic glaucoma - angle-closure or acute glaucoma - congenital glaucoma - secondary glaucoma

Gastric decompression usual pressure

40 to 60mm/hg

Simple mask

5-10 L/min; delivers 40-60% O2 concentration

Total body weight in women

50%

Normal loss of hair

50-100 hair/day

Total body weight in men

60%

Normal PH

7.35-7.45

pH normal range

7.35-7.45

Measure / record volume of drainage every

8 hours

Calcium

8.5-10.5 mg/dl important ECF cation 99% is located in the bone as hydroxyapatite with balance controlled by parathyroid hormone and calcitonin Necessary for structure on bones and teeth, blood clotting, hormone secretion and cell receptor function, nerve membranes

Tube feedings are approximately _______% water

80

Normal O2 Sat

80-100

apheresis

process of separating blood into its components

Rosaccea

A chronic skin disorder that manifests in a variety of ways, is generally characterized by a rosy appearance.

Integrate inhibitors

A class of drugs that prevent the incorporation of viral DNA into the host cells DNA

C

A client at the clinic has just been diagnosed with iron deficiency anemia. What would you recommend the client consume to promote the absorption of iron? A. Vitamin E B. Meat, egg yolks, oysters, and C. shellfish D. Rich sources of vitamin C Sources of vitamin B12

A

A client comes to the walk-in clinic complaining of weakness and fatigue. While assessing this client, you find evidence of petechiae and ecchymoses. You note that the spleen appears enlarged. What would you suspect is wrong with this client? A. Aplastic anemia B. Pernicious anemia C. Iron deficiency anemia D. Agranulocytosis

C

A client diagnosed with Polycythemia vera has come into the clinic because they have developed a night-time cough, fatigue, and shortness of breath. What complication would you suspect in this client? A. Stroke B. Tissue infarction C. Congestive heart failure D. Pulmonary embolus

B

A client is admitted to the Emergency Department after a major motor vehicle accident. The client has lost a lot of blood and requires an emergency transfusion. What type of blood is compatible with all blood types? A. AB B.O C. ABO D. B

A

A client is admitted to the Emergency Department with significant blood loss. The physician orders 2 units of packed red blood cells to be transfused immediately. Which blood groups would be compatible with his O Rh-positive blood group? A. O Rh-positive or O Rh-negative B.Only O Rh-positive C. Only O Rh-negative D. AB Rh-positive or Rh-negative

capsid

A double layer of lipid material surrounding the incomplete HIV

Onychomycosis

A fungal dermatophyte infection of the fingernails or toenails.

Carbuncle

A furuncle from which pus drains.

Dermatitis

A general term that refers to an inflammation of the skin.

Advance Directives

A general term used to describe documents that give instructions about future medical care and treatments and who should make them in the event the person is unable to communicate.

Adaptive Grief

A healthy response. Grief that assists the person in accepting the reality of death. It may be associated with grieving before a death actually occurs or when the realty that death is inevitable is known.

Dermabrasion

A method of removing surface layers of scarred skin. Useful in lessening scars such as the pitting from severe acne.

Bronchophony:

Abnormal increase in clarity of transmitted voice sounds heard when auscultating the lungs.

Adventitious

Abnormal or extra; often refers to extra breath sounds ie wheezes and crackles.

Cancer

Abnormal unrelated cell growth

Prevention strategies for HIV is reduced or eliminated by adhering to the following

Abstain from sexual intercourse, have mutually monogamous sex with uninfected partner. Avoid casual sex with multiple partners. Use a condom that contains nonoxynol-9 during sexual intercourse. Abstain from using IV drugs, especially methaphetamine. Use a new needle and syringe each time I need drugs are injected. Refrain from donating blood if engaged in high-risk behaviors. If receiving blood do autologous blood (self donate).

Exudate

Accumulated fluid in a cavity; oozing of pus or serum, often the result of inflammation

C

Albumin is a protein in the plasma portion of the blood. Under normal conditions albumin cannot pass through the wall of a capillary. What significance is this for the vascular compartment? A. Helps push oxygen into the tissues of the body. B. Retains leukocytes in the vascular compartment. C. Helps retain fluid in the vascular compartment. D. Absorbs carbon dioxide from the tissues for transport to the lungs.

Listening

An active process required in the development of empathy toward another's feelings.

Enzyme-linked immunosorbent assay ELISA TEST

And initial HIV screening test, is positive when there are sufficient HIV antibodies, it also is positive when there are antibodies from other infectious diseases. The test is repeated if results are positive. If results of a second ELISA TEST are positive then use WESTERN BLOT

retinal imaging

produce a high res image of almost entire retina without having to dilate the pupils

Tinea pedis

Athlete's foot

Why would bolus be used

Because it mimics the body's natural filling/ emptying of the stomach

Comedone

Blackheads

Bone marrow suppression

Bone marrow suppression means there is decreased blood cell counts, which places the client at risk for bleeding, anemia, infection, and fatigue

Reverse transcriptase inhibitor's

By binding to viral DNA, NRTIs abort the terminal completion of genetic copying

7 warning signs of Cancer

CAUTION

Lumen

Channel

If elderly client receiving full strength formula concentration:

Check capillary blood levels Q4h for a 48 hour period until clients result WNL

Scabicides

Chemicals that destroy mites, such as lindane, permethrin cream, & crotamiton cream or lotion. May take 2-3 weeks for itching to go away.

Thermal Burns - Protein coagulation

Chemicals: Liquefy tissue; Loosen cell attachment

Anions

Chloride, Bicarb

Dumping syndrome

Cluster of symptoms from rapid deposition of calorie dense nourishment into small intestine.

Treatment for Hypovolemia

Correct the underlying cause replace both water and electrolytes normal saline lactaids ringers blood

Skin Substitutes

Cover wound; Promote healing Direct interaction with body tissues Applied soon after skin is healed and débrided

Partially hydrolyzed formulas

Criticare HN, Optimental, Vivonex T.E.N.

Enteral nutrition info

Delivered by installing formula through tube. NG can be used but most likely liquid formula administered Nasointestinal or transabdominal tubes.

Acid base imbalance

Determine the underlying cause either respiratory or metabolic

Crytosporidiosis

Develop serious diarrhea as a result of infection with a Protozan. The organism is spread by the fecal oral route from contaminated water, food, or human or animal waste. Those infected can lose from 10 to 20 L of fluid per day. Lost of fluid leads to dehydration and electrolyte imbalance. Diarrhea is accompanied by anorexia nausea and vomiting, weight is difficult to maintain

Drug cross resistance

Diminish drug response to similar HIV drugs are common.

Sump tubes

Double lumen ng tube used almost exclusively to remove fluid and gas from stomach

Reverse transcriptase inhibitor's

Drugs that interfere with the virus's ability to make a genetic blueprint

Manifestions of Hypovolemia

Dry mouth low skin turgor lightheadedness, dizziness, syncope low blood pressure, tachycardia, collapsed veins oliguria low RBC and platelet Weight loss -One liter of saline weighs 1kg. A person who losses 1 kg in 24 hours has excreted 1L of fluid or lost it through an abnormal route. *may be a deficit even without weight loss due to third spacing(ascites, intestinal obstruction)

Hypervolemia

ECF volume excess(isotonic) no change in osmolality excess of water and sodium

Advantages Nasointestinal

Easy insertion, comfortable, only slightly dilates esophageal sphincter, reduced aspiration danger, can remain for 4 weeks or longer

Nits

Eggs

Electrolyte

Electrolytes are ionized salts dissolved in water Most clinically important are sodium Potassium calcium magnesium phosphate chloride

Hypermagnesemia

Elevated magnesium amounts in ECF

Fluid intake

Entry of fluid into the body by any route

How often are large diameter tubes removed and changed

Every 2-4 weeks for adults

Carcinogens

Factors that contribute to the development of cancer

Continuous feeding information

Feeding pump used to regulate instillation. Delivered directly into small intestine. This reduces risk of vomiting and aspiration. Continuos feeding creates some inconvenience: pump must go where client goes.

Intracellular fluid

Fluid inside the cells (2/3 of total body water), rich in K+ and magnesium ions, organic and inorganic phosphates, and proteins. - Relatively low in sodium and chloride ions.

Causing of obstruction

Formulas with large molecule nutrients, refeeding partially digested gastric residual, admin formula less than 50mL /h, instilling crushed or hydrophilic meds into tube .

Types of transabdominal tubes

Gastronomy (gtube) and jejunestomy tube(j-tube)

A

Globulins are proteins contained in plasma. What is their primary function? A. Immunologic agents B. Destruction of invading organisms C. Precursors to clot formation D. Transport of oxygen to the tissues

What are the physical manifestations of approaching death in regards to the Urinary System?

Gradual decrease in urinary output. Incontinent of urine. Unable to urinate.

Intermittent feeding

Gradual instillation of liquid nourishment four to six times a day. Administered over 30-60 minutes. Usual volume 250-400mL per administration.

What are the physical manifestations of approaching death in regards to the Musculoskeletal System?

Gradual loss of ability to move. Sagging of jaw, resulting from loss of facial muscle tone. Difficulty speaking. Swallowing can become more difficult. Difficulty maintaining body posture and alignment. Loss of gag reflex. Jerking seen in patients on large amounts of opioids.

Hypertonic

HIGHER osmolality (3% saline)

Hyperchloremia

High amount of chloride Excessive sodium chloride intake

Hyperphosphatemia

High amounts of phosphate from renal failure

Promoting patency

Ice chips and occasional sips of water to NPO client. This helps dilute gastric secretions. Use sparingly: water is hypotonic, draws electrolytes into gastric fluid. Too much fluid could deplete serum electroytes.

If tube displaced above esophageal sphincter nursing interventions

If measured mark not at tip if nose, remove tape, advance tube, check placement , resecure

Hypocalcemia causes

Inadequate ingestion or intestinal absorption low albumin(moves calcium around) hypoparathyroidism hypomagnesemia chronic kidney disease osteoblastic metastases acute pancreatitis( not allowed to absorbed) sepsis, severe burns Vitamin D helps absorbed

Hypernatremia causes

Inappropriate administration of hypertonic IVFs, Cushing's disease(over release of aldosterone) diabetes insipidus watery diarrhea

What are the physical manifestations of approaching death in regards to the Cardiovascular System?

Increased heart rate; later slowing and weakening of pulse. Irregular rhythm, decrease in blood pressure, delayed absorption of drugs administered intramuscular or subcutaneously.

Opportunistic infection

Infections that usually do not occur in individuals with healthy immune system

Continuous feeding

Instillation if liquid nourishment without interruption. Administered approximately 1.5mL/minute.

Bolus feeding

Instillation of liquid nourishment in less than 30 min. Four-six times a day usually about 250-400 mL per administration.

Truvada Preexposure prophylaxis (PrEP)

Is a prevention pill Taken daily, it lowers and HIV negative person who is at risk of acquiring the virus by 90%

Acquired immunodeficiency syndrome (AIDS)

Is an infectious and eventually Fatal disorder that profoundly weakens the immune system

Formula considerations

Know type of tube, access site, type of formula. Factors : client weight, nutritional status, concurrent med conditions, projected length of therapy.

Preintubation assessment

LOC, weight, bowel sounds, abdominal distention, integrity of nasal/oral mucosa, cough/gag/swallow reflex (ability), nausea/ vomiting present MAIN GOAL: determine which nostril is best to use & length to be inserted

Hypotonic

LOWER osmolality (1/2 normal saline)

What may be beneficial for older adults who experience Malabsorption syndrome (ex: glucose intolerance)

Lactose-free tube feeding formula

Antifungals

Lamisil and Sporanox

Hypocalcemia

Low amounts of calcium in the ECF

Hypophosphatemia

Low amounts of phosphate malabsorption problems, GI tract problems, diarrhea, excessive antacids

Advantages NG tube

Low obstruction, accommodates crushed meds, facilitates bolus or intermittent, easy checking distal placement and residual

Why use a large volume 50ml syringe to Aspirate stomach contents

Larger syringe creates less negative pressure and provides enough fluid to test pH.

burn injury s/s

Light pink to black skin color-depending on depth of burn Edema; Blistering; Pain-except those affected by full thickness burn Compromised breathing; Symptoms of hypovolemic shock; In electric woundds, there usually are Entrance and exit wounds

Homeostasis

Maintain stable internal environment

Squamous Cell Carcinoma

Mets through blood, lymph

Hyperkalemia clinical manifestation and treatments

Mild attacks- increased neuromuscular irritability, tingling of lips and fingers, restlessness, intestinal cramping, and diarrhea severe attacks- muscle weakness, loss of muscle tone, and flaccid paralysis, cardiac dysrhythmias, respiratory arrest Treatment- D50 plus insulin(transient therapy for urgent hyperkalemia) sodium bicarbonate-potassium moves into the cell IV calcium Kaexalate- causes potassium to be excreted in the toll diuretics

Drugs for alopecia

Minoxidil/Rogaine and finasteride/Propecia

What excludes a certain nostril from tube insertion

Nasal polyps, deviated septum, narrow nasal passage

Signs of obstruction

Nausea, vomiting, abdominal distention

Gavage

Nourishment

Use of Nasointestinal tubes

Nourishment Removal of gas and liquid contents from small intestine(decompression tubes)

Enteral nutrition

Nourishment provided through stomach or small intestine rather than oral

Clearing an obstruction

Nurse consults physician. Occasionally possible to clear with meat tenderizer or pancreatic enzymes. Both require medical order.

Fluid absorption

Occurs mainly through the GI tract abnormal: could also occur through prolonged submersion of water or through the lungs in near drowning

Risk factors for patients with HIV and AIDS

Older adults are more suspectible to fluid and electrolyte in balance is, malnutrition, skin alterations, and wasting syndrome than younger adults

Gerontologic long term use tube feedings

Older adults with dementia or other chronic declining conditions involves many ethical considerations. Refusal to eat May be see by elderly as an attempt at suicide.

Risk factors for patients with HIV and AIDS

Older women experience vaginal dryness's and thinning of vaginal walls increasing their suspect ability to HIV infection

Shingles medical management

Oral acyclovir (Zovirax) when taken within 48 hours of the appearance of symptoms, reduces their severity and prevents the development of additional lesions.

What are different ethical and legal issues regarding end of life?

Organ and tissue donations, advance directives (e.g., medical power of attorney, living wills), and resuscitation.

PaCO2 =

Partial pressure of arterial carbon dioxide.

Psoriasis characterized by:

Patches of erythema, covered with silvery scales, usually on the extensor surfaces of the elbows, knees, trunk, and scalp.

What are the goals for grief resolution?

Patient expression of feelings related to grief, acknowledgment of the impending loss, and demonstrations of behaviors that reflect progress in grief resolution.

Diagnostic Findings

Physical inspection Radiographs- to identify secondary injuries such as fractures, or compromised lung function in inhalation injuries.

3 buffer systems

Plasma respiratory renal

Tamponade

Pressure

Integrase inhibitors

Prevent the incorporation of viral DNA into the host cells DNA by blocking the activity of the Integrase enzyme

AIDS vaccines

Preventative vaccines for HIV negative people and therapeutic vaccines for HIV-positive people to improve their immune system

Electrolyte Distribution

Primarily influenced by hormones like -epinephrine -insulin -parathyroid hormone -medications -may be rapid

Cell Membrane

Primary barreier to the movement of solutes in the body Pores allow water and small water soluble substances to pass; lipid soluble substances pass directly through the membrane Larger proteins can not pass through

Goals of Palliative Care:

Provide relief from symptoms, including pain. Regard dying as a normal process. Affirm life and neither hasten nor postpone death. Support holistic patient care and enhance quality of life. Offer support to patients to live as actively as possible until death. Offer support to family during patients illness and in their own bereavement.

Bereavement Program

Provide support and to assist survivors int he transition to a life without the deceased person.

Radiation Therapy Treatment/Purpose

Radiation therapy is used to treat malignant skin lesions.

Why would the nurse tell the patient to take a deep breath and hold it just before removing NG tube

Reduces risk for aspiration

Gerontologic considerations diminished gag reflex

Reduction in # of laryngeal nerve endings. Neurological disorders such as dementia and stoke and repeated insertion/removal of dentures

Overfilling stomach can cause

Reflux, regurgitation, vomiting , aspiration, pneumonia

Gastric reflux

Reverse flow if gastric contents

Inside the capsid are three important enzymes

Reverse transcriptase, integrase, and protease- and strands of RNA

Deviated septum

S&S: chronically stuffy nose or discomfort from blocked sinus drainage, some PTs have nosebleeds and headaches. Tx: nasal decongestants, antihistamines, or intranasal cortisone sprays to relieve inflammation- sometimes nasoseptoplasty can be done.

HIV may be present in

Saliva, tears, conjunctival secretions

Advantages jejunestomy

Same as gastronomy / reduced potential for reflux/aspiration

Isotonic

Same osmolality( normal saline)

Clearing an obstructed feeding tube guidelines

Select a syringe at least 50mL Wash hands Gloves Aspirate as much as possible from feeding tube Instill 5mL of selected solution Clamp tube and wait 15 minutes Aspirate or flush tube with water

What are the Martocchio Stages of Grieving?

Shock and disbelief, yearning and protest, anguish, disorganization and despair, identification of bereavement, and reorganization and restoration.

Levin tube

Single lumen nasogastric tube with many uses. Ex: decompression

The most common type of cancer in the US.

Skin cancer

Skin cancer can involve what types of cells in the epidermis?

Squamous cells- flat/scaly Basal cells- round Melanocytes- cells that contain color pigments.

Interventions with bowel obstruction (complete/partial)

Surgery, intestinal decompression

Effects of edema

Swelling- pale or red in color Pitting- Presence of excess interstitial fluid, moves aside when pressure is applied, pit remains when finger is removed Increased body weight- with generalized edema Functional impairment-restricts range of movement,reduced vital compact,impaired diastole(decreased preload) Pain- edema exerts pressure on nerves locally, headaches with cerebral edema, stretching of capsules in organs(viceral) Impaired arterial circulation- Ischema leading to tissue breakdown Dental practice- difficult to take accurate impressions, dentures do not fit well Edema in skin- Susceptible to tissue breakdown from pressure

C

The clinic nurse is caring for a client diagnosed with leucopenia. What does the nurse know this client has? A. Too many erythrocytes B. A decrease in granulocytes C. A general reduction in all white blood cells D. A general reduction in neutrophils and basophils

A

The clinic nurse is preparing a client for diagnostic testing. What would the nurse include in the education of this client? A. Tasks are necessary to participate in the test. B. Anesthetic will be applied. C. Consent needs to be signed. D. They will need someone to drive them home.

Shingles is contagious until?

The crusts from ruptured lesions have dried and fallen off the skin. They also can recur.

Who takes Truvada

The drug is targeted for those cases in which one sexual partner is HIV-positive and the other is HIV negative, also couples wishing to conceive a child.

Gastric tubes tend to dilate

The esophageal sphincter (cardiac valve)

Tracheotomy

a surgical opening in the neck into the trachea

A

The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. Why? A. Trauma and microabrasions may contribute to anemia. B. Fragile tissues and altered clotting mechanisms may result in hemorrhage. C. The client is at risk for spontaneous and uncontrolled bleeding. D. The client is at risk for infection from microorganisms.

D

The nurse is caring for a client who is taking medications that depress the hematopoietic system. What signs of leucopenia would the nurse assess this client for? A. Unusual or easy bleeding B. Oozing from injection sites C. Dark, tarry stoolS D. Fever and sore throat

B

The nurse is caring for a client with a lymphatic system disorder. What physical assessment is a priority for the nurse to perform? A. Examine the color and quantity of urine. B. Inspect the tonsils for size and appearance. C. Frequently examine and record blood pressure. D. Examine for any signs of physical injury.

right lung has how many lobes?

Three.

If NG tubes remain in place too long

Throat and nose discomfort may happen.

Pulmonary value functions

Tidal volume 400-600 mL at rest Residual volume 1000-1500 mL Functional residual capacity 2300 mL Inspiratory reserve 2000-3000 mL Expiratory reserve 1000-1500 mL Forced vital capacity 3000-5000 mL Forced expiratory volume in 1 second 65-85% of Peak expiratory flow rate 450 L/min

If tube diameter is too large or pressure is prolonged

Tissue irritation or break down may occur

Why does nurse measure gastric residual

To determine whether rate or volume of feeding exceeds clients physiologic capacity.

Hypomagnesemia

To little magnesium amounts in blood

Nasointestinal tubes

Tube inserted through nose for distal placement below stomach. One than gastric tubes allowing for placement into small bowel.

Orogastric intubation

Tube inserted through the mouth into the stomach

Nasogastric intubation

Tube inserted through the nose into the stomach

When an obstruction cannot be cleared?

Tube removed and another inserted rather than compromise nutrition

Purpose of orogastric tube

Used in emergencies to remove toxic substances that have been ingested. Diameter of tube is large enough to remove pill fragments and stomach debris. Example is Ewald tube

Cyclic feeding information

Used to wean clients from tube feedings while continuing to maintain adequate nutrition. Given late evening hours and sleep. During day clients eat some food orally. Oral intake increase then tube feeding decreases.

Highly attractive antiretroviral therapy (HAART) has several benefits

Using different mechanisms, The combination of drugs suppresses replication of the virus

Highly attractive antiretroviral therapy (HAART) has several benefits

Using two or more drugs simultaneously reduces the chance that the virus will develop resistance of cross-resistance

TB hospital room

Venting to the outside, six air exchanges per hour, UV light, and negative pressure to surrounding areas

Gastric residual

Volume of liquid within stomach

Hyponatremia causes

Vomitting and diarrhea diuretic use inappropriate administration of hypotonic IVFs SIADH

Bedside ultrasonography can be used to assess placement of

Weighed tip feeding tubes

D

What factor in plasma can be transformed from a liquid to a solid? A. Globulins B. Albumin C. Leukocytes D. Fibrinogen

ELISA & Western bolt

Written consent must be obtained before tests are performed. The results of the test require strict confidentiality.

Progression of radiopaque tip through GI tract monitored by

X-ray

melanoma

a type of cancer that develops from the pigment-containing cells known as melanocytes. Melanomas typically occur in the skin but may rarely occur in the mouth,

Clients at risk for pressure Ulcers benefit from formulas with extra:

Zinc, protein, other nutrients

Pneumothorax

abnormal presence of air in the pleural cavity resulting in the collapse of the lung (spontaneous, traumatic, open/ closed, tension, or hemothrax are different types of pneumothorax)

tachypnea:

abnormally rapid respirations.

Tachypnea

abnormally rapid respiratory rate

otitis media

acute inflammation or infection in the middle ear

INH (isoniazid)

antitubercular therapy (TB); liver enzymes evaluated for baseline and during first 3 months of therapy; common side effect peripheral neuritis

cataract corrective eye glasses

aphakic eye: eye without the lens inside (surgically removed) - the corrective lens for the aphakic eye causes the pt to see objects 1/3 larger than normal - distort peripheral vision - pt has to turn head to see objects that are not in the center of vision - dark coat is applied to eyeglasses so that only the aphakic eye is used (with the corrective lens)

Local (topical) anesthetics

are applied to relieve minor skin pain and itching. Antiseptics are used to reduce bacteria on the skin.

chemical agents that are carcinogens

believed to account for 75% of all cancers. Tobacco smoke & nicotine, chewing tobacco. Prolonged exposure to asbestos and coal dust, pesticides, formaldehydes, wood dust, polyvinyl chloride, chromium compounds, tars Organs most affected by chemical agents are: liver, kidneys & lungs (because they are involved with biotransformation & excretion of chemicals)

Pulmonary perfusion:

blood flow through the pulmonary vasculature.

Hemothorax

blood in the pleural space; may be associated with trauma, TB, and pneumonia

skin substitutes

can be applied all over the burn wound as soon as the skin is cleaned and debrided instead of having to wait until enough skin is available for grafting purposes.

sarcomas

cancers originating from connective tissue, such as bone or muscle

Treatment for Hypervolemia

correct the underlying cause remove sodium and water without producing abnormal electrolyte changes -diuretics (worry about k+) -fluid restriction

Hemoptysis

coughing up of blood from the respiratory tract

Pleurodesis

creation of adhesions between the parietal and visceral pleura to treat recurrent pneumothorax

neutropenia

decreased neutrophils

Vesicle

elevated, round skin lesion filled with fluid (i.e. blister)

whisper test

examiner stand 1-2 feet away and covers untested ear and whispers in the tested ear (few phrases) and ask client to repeat back

Fluid shift, electrolyte deficits, and loss of ectracellular proteins such as albumin from the burn wound affect

fluid and electrolyte status. -anemia develops-heat destroys erythrocytes -the client experiences hemocontration when the plasma components of blood is lost or trapped. - the sluggish flow of blood cells through blood vessels results in indequate nutrition to healthy body cells and organs

secondary glaucoma

following: - administration of meds such as steroids - ophthalmic infections - as a result of systemic disease or ocular trauma

Apocrine glands

found around the nipples, in the anogenital region, in the eyelids (Moll's glands), in the mammary glands of the breast, and in the external ear canals.

unassisted healing

healing without the use of a skin substitute or skin graft, results in the proliferation of granulation tissue. -Granulation tissue contains fibroblast, which creates hypertrophic scars that contract and pull the edges of the wound together, causing an uneven appearance in the healed tissue and contractures.

a superficial partial-thickness burn

heals within 14 days, with possibly some pigmentary changes but no scarring; it requires no surgical intervention

Vesicular breath sounds

heard over peripheral lung fields where the air enters the alveoli

Bronchovesicular breath sounds

heard over the major bronchi

Bronchial breath sounds

heard over trachea and larynx

Chest Xray

helps diagnose a variety of pulmonary disorders

xenograft or heterograft

is obtained from animals, pigs or cows. -are used temporary cover large areas, they are rejected in days to weeks and must be removed and replaces at that time.

Zone of Hyperemia

is the area of least injury, where the epidermis and dermis are only minimally damaged. because of early appearance of the burn injury can change, the estimate of burn depth may be revised in the first 24-72 hours.

Deep breathing and couging

keeps airways clear of secretions; have PT take 2-3 deep breaths, after 3rd inhalation tell PT to hold breath for a few seconds then cough forcefully; good hydration is helpful

keratitis and corneal ulcer

keratitis : inflammation of the cornea corneal ulcer: erosion in the corneal tissue

Hypomagnesemia causes

malnutrition malabsorption alcoholism renal dysfunction hypercalcemia (competes with calcium in the kidney) loop diuretics diabetic ketoacidosis, hyperthyroidism, hyperaldosteronism

NI when Pt's skin blanches w/ pressure relief

massaging bony areas if the client's skin blanches with pressure relief helps to improve the circulation to the area

mechanical ventilation

may be necessary to maintain normal blood gases and prevent repiratory failure. -victims of carbon monoxide poisoning may require hyperbaric O2 tx- administration of 100% O2 at 3times greater than atmospheric pressure in a specially designed chamber-- to increase the binding of O2 rather than Carbon monoxide to hemoglobin molecules.

Myalgia

muscle pain or tenderness

Oxygen therapy

ordered by Dr when PT unable to maintain oxygenation; O2 sat less than 90%

environmental factors that are carcinogens

prolonged exposure to sunlight, radiation & pollutants. electromagnetic fields from microwaves, power lines, cell phones are possible carcinogens (conflicting study results)

Status asthmaticus

prolonged period of unrelieved asthma symptoms; place PT in high Fowler's position 1st

Parathyroid hormone

releases calcium from bone

the most common causes of thermal burns in older aduls are

scalding and home fires; secondary to smoking, alcohol ingestion, or flammable substances that ignite materials.

retinal detachment

sensory layer becomes separated from the pigmented layer of the retina

metastasis

spreading of cancer cells to adjacent tissues, from lymph vessels into the tissues adjacent to lymphatic vessels, by transport from blood or lymph systems, or by diffusion within a body cavity. metastasis is one of cancer's most discouraging characteristecs.

dyspnea:

subjective experience that describes difficulty breathing; shortness of breath.

Pulmonary Embolism symptoms

sudden chest pain, dyspnea, increased respiratory rate, also may have cough, tachycardia, fever, diaphoresis, anxiety, & possible syncope

Influenze (flu)

sudden onset of symptoms, fever may exceed 101F, headache, muscle aches, usually dry cough, chest pain, fatigue, chills (sometimes runny nose or sore throat) Complications: pneumonia Tx: rest and fluids, antiviral agents in some cases

A cough that worsens when the patient is supine:

suggests postnasal drip (rhinosinusitis).

Nasoseptoplasty

surgical correction of the nasal septum

sebum

the oily secretion of the sebaceous glands

Coughing at night may indicate: . .

the onset of left-sided heart failure or bronchial asthma.

Helps to assess skin for moisture

the palm of hand

Hypercapnia

the presence of more than the normal amount of carbon dioxide in the blood tissues resulting from an increase of carbon dioxide in the inspired air or a decrease in elimination (COPD)

how many different type of alveloar cells are there?

three types.

left lung has how many lobes?

two.

OA may be at higher risk for burn injuries if concurrent change in

vision, hearing, or touch have developed. Reduced mobility may influence ability to provide self-care or home maintenance. Risk in the home environment such as adequate fire protection and safe heating systems. -additional risk for burns may include peripheral neuropathy. careful assessment and teaching must include setting water temp no higher than 110.

astigmatism

visual distortion caused by an irregularly shaped cornea

tidal volume:

volume of air inspired and expired with each breath during normal breathing.

TB symptoms

weight loss, anorexia, fatigue, lethargy, night sweats, low grade fever, cough with blood tinged sputum

ultrasonography

when pathologic changes such as opaque lens, cloudy cornea, or bloody vitreous makes hard to look directly at posterior of eye - looks at contents in eye using sound waves - anesthetic drops are used and probe is place don cornea - helpful for detecting eye lesions and measure intraocular lens implant before extracting a cataract

Cryosurgery Purpose

• Liquid nitrogen circulates through a probe that is touched to the skin / inserted to the center of the lesion • After application of extreme cold, the area thaws and becomes gelatin-like in appearance • A scab forms at the site • Healing takes approximately 4 to 6 weeks

Heat is lost in the following 4 ways:

• Radiation • Conduction • Evaporation • Convection

Corticosteroids

• applied topically / administered systemically to relieve inflammatory and allergic symptoms • Scabicides / pediculicides are used in the treatment of infestations with the scabies mite and lice

subjective vertigo

- person feels motion but the surrounding environment is stationary

objective vertigo

- person is stationary and environment is moving - things moving around oneself

Why does odor occur with perspiration?

- perspiration- includes secretions from both eccrine and apocrine glands- is odorless -odor develops when perspiration mixes with bacteria on the skin

motion sickness

- physiologic vertigo meds: - dimenhydrinate (Dramamine) or meclizine hydrochloride (Antivert) - scopolamine patches are used to block the histamine response

nurse management of conjunctivitis

- remain at home, and away from people - separate towels linens and other personal items - wash hands with soap and water before and after - use new tissue every time there is a wipe of eye - discard eye makeup items and do not use new makeup until conjunctivitis is clear - if discharge becomes thick or yellowish, return to doc

structures of the eye intraocular

- sclera: white of the eye, tough connective tissue that protects - uvea: middle layer vascular coat of the eye includes the chorid and the iris - pupil: an opening that dilates and constricts - cilary body: composed of cilary process and cilary muscles - cilary process: produces aqueous humor (nutrient ricch liquid that nourishes eye structures). flows from the posterior chamber to the anterior chamber, then drains into the canal of schlemm - cilary muscle: helps change the shape of lens when adjusting to near or far vision - anterior chamber: behind the cornea, is filled with the aqueous humor and provides nourishment to the cornea - lens: lies behind the pupil and iris - posterior chamber: small space behind the lens - vitreous humor: thick gelatinous material that maintains the spherical shape of the eyeball, and placement of retina - retina: inner most layer of the eye that is composed of pigmented outer layer and inner neuro sensory layer

ocular therapeutic system

- small thin film that contains eye meds - replaced weekly, it continues to release meds and eliminates the need for frequent eye drop instillation

nurse management of retina detachment

- sometimes positioned on their side of the affected eye (left eye tear, lay on left side) - do not move pt for several days after surgery - head may be immobilized, do not move or turn pt without orders. . for IOP - use clean cloth rinsed in very warm water as a gentle compress over the affected eye for mild discomfort . for after buckle surgery - can sit up for meals and ambulate to bathroom as well as sitting for periods of time - do not lie on back - do not fly for 2 weeks - patch eye for at least 3 weeks - for laying down: lie on stomach with pillows under chest and head. position head at an angle with eye gaze towards the mattress. - maintain work restrictions for at least a month

symptoms of hearing loss

- speech deterioration: slurring or dropping ends of words - fatigue: results of straining to hear - indifference: related to depression, isolation, or disinterest - social withdrawal: afraid to participate in social activities - insecurity: lac of self confidence - indecision and procrastination: fear of making mistakes - suspiciousness: fear that people are talking about him or her because of inability to hear the whole conversation - false pride: attempts to hide hearing loss - loneliness and unhappiness: boredom, isolation, and fear - tendency to dominate the conversation: able to control the conversation

med and surg management of eye trauma

- surgery if internal eye structures are damaged - blunt trauma are hospitalized - eyelid laceration: inject of local anesthetic and then sutures are used

cause of macular degeneration

- tends to be age related degeneration - #1 cause of blindness . dry - the outer layers of the retina break down over long period of time - small yellowish deposits (drusen) are seen under retina - when it forms within the macular, the client sees blurred vision . three stages of dry macular degeneration 1) early dry AMD: have small or very few drusen, and vision may not be impacted 2) intermediate dry AMD: number of frusen are either increased or there are a few large drusen; may have a blurred spot in their vision and need more light to do task that require close vision such as reading 3) advanced dry AMD: addition to drusen, there is a breakdown of light-sensitive cells supporting tissue in the macula

cause of keratitis and corneal ulcer

- trauma and infection - secondary infection common when epithelium is damage -

tuning fork tests

- tuning fork: instrument that produces sound the same range as human speech - used to identify conductive or sensorineural hearing loss . - conductive hearing loss: interferences in the transmission of sound waves to the inner ear - sensorineural hearing loss: is the result of nerve impairment

electronystagmography

- used with the caloric stimulation - probe is used to measure the velocity of the eye movement attached superiority, inferiority, and laterally about the eye

food for eyes

- vitamin c and e and beta carotene to prevent or delay cataract - 5-9 servings of colorful fruits

nursing management for cataract surgery

- wear protective eye shield for 24 hr day and night and sleep and naps - sunglasses for 1 week - eye drops for 1 week - blurring vision for days to weeks - eye discharge - redness and scratchy sensation for few days - notify doc if new floaters or increased redness, flashing lights, or change in vision - healing takes place in 8 weeks

test for eye trauma

- x-ray or ct confirms an orbital fracture dye identifies minute foreign body or abrasion to the cornea - slit lamp exam for visualize structures in the anterior and posterior segments

thickness of the nail varies from

-0.3 to 0.65 mm -nails thicken when there is a fungal infection and poor circulation

Methods to determine distal placement of NG tube

-Aspiration (should be clear, brownish/yellow, or green) -Auscultation of abdomen( instill 10ml of air. Hear swooshing sound. Belching indicates tip still in esophagus) -Test pH of aspirated fluid (first two steps are presumptive pH is confirmation. Most accurate secondary to X-Ray)

Pressure Sore

-Commonly occur on the skin over the coccyx and sacrum, hips, heels, elbows, shoulder blades, ears, and back of head

Electrolyte homeostasis

-Concentration of an electrolyte in plasma is different from its concentration in the cell -For body function, electrolyte concentration must be normal in both the plasma and in the cells -Control of electrolyte levels are dynamic :If intake of specific electrolyte increases, excretion of that electrolyte may increase to normalize plasma levels :If electrolyte intake decreases, electrolytes may be redistributed into the plasma to maintain normal plasma levels

Causes of dehydration

-Decreased fluid intake -increased fluid output -fluid shift between compartments

Total body water

-Decreases with age -more body fat means less % of body water

Manifestations of Hypervolemia

-Edema pitting -pulmonary congestion -circulatory overload( bounding pulses, jugular vein distention, elevated blood pressure - weight gain

Hypovolemia

-Extracellular volume deficit (isotonic) -No change in osmolality -Depletion of water and sodium

Antiseborrheic agents

-Meds applied directly to the scalp ot incorporated into the shampooing products -Used to control dandruff

Functions of body fluid

-Surrounds and permeates the cells -Lubricant and solvent for metabolic chemical reaction -Transports oxygen, nutrients, chemical messengers and waste products to their destination - Important in regulating body temperature

Levin tube information

-Usual adult size 14-18F -Single lumen -42-50 inches -multiple drain openings purposes: lavage, Gavage, decompression, diagnostics

Body fluid abnormalities can occur by?

-Volume, concentration, electrolyte composition -result of pathological conditions

Managing a gastronomy guidelines

-Wash hands -Gloves -Assess/replace gauze over new gastronomy if moist, slight bleeding or serous drainage from wound is normal for a few weeks post op. -Remove and d/c dressing after first 24h unless physician orders diff -Inspect skin around tube daily -Ensure sutures are intact -Report redness/tissue maceration -Apply skin barrier if skin appears irritated -Press down on skin at base of tube. If they have a PEG, compress arms of external bumper together and lift about 1 inch. -clean skin with half strength hydrogen peroxide or 0.9% saline. After 1 week soap and water is sufficient. -rotate direction of external bumper 90 degrees or other external retaining devices at least once daily -slide external bumper so it is flush with the skin -avoid placing any type of dressing under arms of external bumper -replace water in balloon weekly using luer-tip (not-luer-lok) syringe -tape g tube to abdomen or secure it with abdominal binder or commercial tube stabilizer. -make sure no kinks /stretched skin -insert foley 2-5in within opening and inflate balloon to retain it. - use g-tube similar to how Ng tube used for feedings

Why can densely saturated moist air result in heat stroke?

-When the temperature / humidity outside the body rise, radiation, evaporation, and convection are ineffective - alternative method by which heat is transferred under these conditions is by conduction -This is why exposure to warm temperatures and densely saturated moist air can raise the body temperature and result in heat stroke

Stage II Pressure Ulcer

-area reddened -accompanied by blistering -shallow break in skin -sometimes diescribed as a skin tear -Impairment of the skin leads to microbial colonization / infection of the wound

extent of burn injury

-besides determining the burn depth and zones, the severity of a burn also is determined "Rule of Nines"- i Percentage of TBSA Burned Client's Palm: 1% of TBSA

Causes of Hypervolemia

-chronic renal failure, acute glomerulonephritis -excess fluid intake -congestive heart failure -liver failure, cirrhosis -hormone imbalances (cushing, hyperaldosteronism)

autograft

-client's own skin, which is transplanted from one part of the body to another. -autograft from an identical twin can become permanent part of the client's own skin. - besides actually harvesting and grafting the skin from an unburned area, autologous, epithelial keratinocytes (skin cells) are cultured. - To do so, a postage stamp-sized specimen of the client's epidermis is removed. - keritonocytes are isolated from the specimen, they are then cultured in a flask for 2-3 weeks -the sheet of cultured epithelial cells is then transferred to the burn area -the cultured cells promote rapid healing without the potential for rejection

Sebaceous glands

-connected ot each hair follicle -secrete an oily substance called sebum

Providing adequate hydration

Identify amount of water on label of formula. Add amount to total volume of flush and compare with recommended amount. Significant deficit- revise plan of care, increase either volume (preference) or frequency of flushing tube. If fluid is excessive nurse monitor client urine output and lung sounds.

What are the physical manifestations of approaching death in regards to the Respiratory System?

Increased respiratory rate. Cheyne-Strokes respirations. Inability to cough or clear secretions resulting in grunting, gurgling or noisy congested breathing (Death Rattle). Irregular breathing, gradually slowing down to terminal gasps (guppy breathing).

Drug resistance

Ineffective response to a prescribed drug because of the survival and replication of exceptionally Virulent mutations and noncompliance with drug therapy regimens

Burn Injury Wound Management

Infection prevention measures; Debris removal- HCP wear powder free gloves- may cause complicated healing. -the body hair around the perimeter of the burn is shaved, because hair is a source of bacterial wound contamination. -eye ointment or irrigation remove dirt -blisters are ruptured removed with scissors.

Bronchitis

Inflammation of the mucous membrane of the bronchial airways; may be viral or bacterial

Onychocryptosis

Ingrown toenails.

P24 antigen test and polymerase chain reaction Test

Measure viral loads for HIV. They are used to guide drug therapy and follow the progression of the disease. Viral load test and T4 cell counts may be performed every 2 to 3 months once it is determined that a person is HIV-positive

Fluid regulation

Mechanisms that promote fluid intake and output -thirst -renin-angiotension-aldosterone system(RAAS) -anti diuretic hormone( ADH) -Diuretics Tonicity - isotonic/ Isoosmolar -Hypotonic/Hypoosmolar -Hypertonic/ hyperoosmolar

Stylet

Metal guide wire helps straighten and support tube during insertion

How often are pediatric clients tubes changed

More frequently than others. Tissue is more fragile, greater potential for infection

What are the physical manifestations of approaching death in regards to the Integumentary System?

Mottling of hands, feet, arms and legs. Cold, clammy skin. Cyanosis of nose, nail beds and knees. Wax like skin when very near death.

Hypocalcemia clinical manifestation and treatment

Muscle cramps, hyperactive reflexes, hyperactive bowel sounds, paresthesias, Tetni (Chvostek and trousseau signs) delayed heart conduction *Remember increased neuromuscular excitability Treatment- Various medications (supplements) correct underlying conditions/deficiencies

What is recommended with Truvada

Must be tested for HIV every month, continue using condoms, and limit their sexual partners.

Disadvantage gastronomy

Must wait 24hr to use after initial placement May leak/cause breakdown Increased risk for infection Requires skin care at tube site Can migrate/ dislodge if not secured Gastric overfill/Aspiration possible

HIV 1

Mutates easily and frequently, producing multiple strands that are identified by letters from A through O. HIV-1 is more prevailant in the United States and in the rest of the world.

Tube measurement

NEX First mark- nose to earlobe (indicates distance to nasal pharynx above gag reflex) Second mark- where tube reaches xiphoid process(indicates depth to reach stomach)

Insertion of nasointestinal tube measurement

NEX+9.

Keofed

Nasointestinal tube used for feeding. Small diameter, flexible polyurethene or silicone. Narrow/soft. Allows them to remain in same nostril 4 weeks or longer. Reduce potential for reflux b/c deliver nutrition beyond stomach

Clients who neglect to take Antiretroviral drugs as prescribed

Neglect to take Every dose, at its designated time, with or without food as directed, causes risk development of drug resistance.

Hyponatremia clinical manifestions and treatments

Nerologic symptoms, lethargy, confusion Hypovolemia signs and symptoms treatment treat the underlying cause, salt tablets, hypertonic solutions free water restrictions <800 mL/day

Hypernatremia treatment and clinical manifestations

Nerologic symptoms- cellular shrinking If due to sodium gain think fluid overload if due to net water loss think of hypovolemia Treatment Treat underlying condition sodium restriction in sodium gain volume repletion, generally with hypotonic solutions if due to hypervolemia

Surgical Management: Skin Grafting

Purpose: Lessen infection Minimize fluid loss by evaporation diminish pain promote regeneration of tissue. Hasten recovery Reduce scarring Prevent loss of function Keratinocytes regenerate epidermis Used for deep partial-thickness and full-thickness burns Unassisted Healing: Granulation tissue; Contractures; Chronic open wounds

Removal of NG tubes

RNs duty. When condition improves, tube becomes hopelessly obstructed, or according to standards for integrity or oral mucosa. Some physicians prescribe a trial period where tube is clamped and client allowed to consume oral fluids. If no symptoms occur - good indication client no longer needs tube. If symptoms develop, reinsertion isn't necessary bc tube is already in place.

Renal buffer system

Reacts in hours to days

Respiratory buffer system

Reacts in minutes

Plasma buffer system

Reacts in seconds

Hypokalemia

Related to reduced intake of potassium, increased entry of potassium, increased loss of potassium

Hypernatremia

Related to sodium gain or net water loss

Hyponatremia

Related to sodium loss, inadequate sodium intake, and dilution of the body sodium level regulated by aldosterone

Surgical Excision Purpose

Removal of a benign or malignant growth.

Intestinal decompression

Removal of gas and intestinal contents

Decrompression

Removing gas and liquid contents from stomach or bowel

Lavage

Removing substances from stomach typically poison

Hypermagnesemia causes

Renal failure magnesium containing antacids

Disadvantages Nasointestinal

Requires x ray to verify placement, easily obstructed, best for continuos feeding

Gastric residual standards

Residual should be no more than 100mL or no more than 20% of previous hours tube feeding. If it is high, feeding stopped and residual checked Q30min until WNL.

D

The Family Nurse Practitioner is conducting a physical assessment on a client with suspected Hodgkin's lymphoma. What could unilateral enlargement of an extremity indicate? A. Peripheral edematous involvement of the extremity B. An ineffective lymphatic system C. Splenic enlargement D. Obstruction of lymphatic circulation

D

The Oncology Advanced Practice Nurse (APN) is assessing a client with leukemia. How would the Oncology APN assess for enlargement and tenderness over the liver and spleen? A. By reviewing laboratory test results B. By calculating the absolute neutrophil count C. By looking for evidence of bruising D. By palpating the abdomen

A

The Pediatric Nurse Practitioner is doing a physical examination of a client with sickle cell anemia. Why would the nurse practitioner auscultate the lungs and heart? A. To detect the abnormal sounds suggestive of acute chest syndrome and heart failure B. To detect the evidence of infection such as fever and tachycardia C. To detect the evidence of dehydration that might have triggered a sickle cell crisis D. To detect the motor strength and stroke-related signs and symptoms

What are signs of Adaptive Grief?

The ability to see some good resulting from the death and positive memories of the deceased person.

Highly attractive antiretroviral therapy (HAART) has several benefits

The drug lower the viral load more quickly - sometimes to undetectable levels. Doing so ultimately slows the rate of disease progression, prevents opportunistic infections and in turn, lengthening survival

D

Your client was admitted to the Emergency Department after an accident with a chain saw. The client is exhibiting signs and symptoms of acute hypovolemic anemia from severe blood loss. What signs and symptoms would you assess for? A. Malabsorption disorders B. Postural hypotension C. Fatigue D. Reduced urine output

Zones of burn injury

Zone of Coagulation Zone of Stasis Zone of Hyperemia

lipoma

a benign tumor composed of adipose tissue. It is the most common benign form of soft tissue tumor. Lipomas are soft to the touch, usually movable, and are generally painless.

Diagnosis of chronic skin disorders such as Hansen's disease (leprosy):

a biopsy of skin tissue to identify malignant, premalignant, and nonmalignant skin lesions

burn injuries

a burn is a traumatic injury to the skin and underlying tissues. Heat; Chemicals; Electricity cause burn injuries -Burns cause by electricity are characteristically the most severe because they are deep. -electricity moving through the body follows an undetermined course from entrance to exit, causing major damage in its path.

Warning signs of cancer

a change in bowel habits or bladder function sores that do not heal unusual bleeding or discharge thickening of lump in the breast or other body parts persistent indigestion or difficulty swallowing a change in a wart or a mole a persistent nagging cough or hoarseness

Crepitus

a crackling/grating sound or sensation; fractured bone ends or joints rubbing together; also air bubbles under the skin that produce a crackling sound or crinkly feeling.

Tracheostomy

a surgical opening in the neck into the trachea to provide an airway when the trachea is obstructed; more permanent, usually has tube inserted into the opening to maintain patency

caloric stimulation test

assesses vestibular reflexes of inner ear that controls balance - temperature controlled water or air is instilled into the external meatus of each ear separately - fluid alters the temp of the temporal bone and creates convection currents in the fluid of the inner ear that stimulate movement of the head - nystagmus (quivering movement of the eye) is normal

ophthalmic technician

assistants who are certified by the joint commission on allied health personnel in ophthalmology to assist in selected eye test and procedures

presbyopia

associated with aging and results in difficulty with near vision - holds materials at a distance to see it more clear

Common causes of cough include:

asthma, gastrointestinal reflux disease, infection, aspiration, and side effects of medications, such as angiotensin-convert- ing enzyme (ACE) inhibitors...To help determine the cause of the cough, the nurse inquires about the onset and time of coughing.

middle ear

air filled cavity in the temporal bone - contains the eustachian tube: extends from floor to pharynx (lined with mucous membrane) - three small bone: malleus, incus, stapes (stretch from tympanic membrane to oval window, not round window) - stapes vibrate the fluid in the inner ear

slit graft

also called a lace or an expansile graft. is used when the area available as a donor site is limited, as in clients with extensive burns. -the skin is removed from the donor site and passed through an instrument that slits it, thus, a smaller peice of skin is stretched to cover a larger area.

A cough of recent onset is usually from:

an acute infection...

Bleb

an irregularly shaped elevation of the skin, such as a blister; may also occur in lung tissue

vision specialist ocuplastic specialist

an ophthalmologist with advanced training in plastic and reconstructive surgery of the eye and surrounding structures

Induration

area of hardened tissue

Coughing after food intake may indicate:

aspiration of material into the tracheobronchial tree..

corneal light reflex test

asses alignment of eye - examiner holds penlight 12 inch away from pt face - pt stares straight ahead - reflection f light should be same spot on each eye - if uneven, then it can be from muscle weakness or paralysis

a nurse stops to give first aid to a burn victim running from a home that is on fire. The nurse rolls the victim on the ground to smother the flames. The chest and the neck of the victim are burned. What is the next priority for the nurse?

monitor the victim for respiratory distress

open-angle or chronic glaucoma

most common form - onset is slow - pt may not notice for years . - when structures in the drainage system degenerate and the exit channels for queous fluid is blocked - IOP rises and cause: a) edema b) atrophy of nerve endings c) develops painless d) changes occur slowly

Hypercalcemia clinical manifestations and treatment

muscle weakness, decreased reflexes, tingling, intestinal cramping, hypoactive bowel sounds, consitpation, cardiac arrest, lethargy * Decreased neuromuscular excitability Treatment hydration( prevent kidney stones) calcitonin, bisphosphanates

sign of poor circulation/fungal infection

nails thicken

myopia

nearsightedness - people with elongated eyeballs

neoplasms

new growths of abnormal tissue, also called tumors

emmetropia

normal vision - light rays are bent to focus images precisely on the retina

med management for refractive errors

not all can wear glasses (people have trouble with them) - people with history of eye infections, low tear production, severe allergic reactions

accommodation

on the posterior side, the lens can change shape - muscle relax and lens flatten to see far - muscle contract and lens round to see near - near point: closest object a person can see

Laryngectomee

one who has undergone a laryngectomy, which is surgical removal of part or all of the larynx.

superficial partial thickness

second degree epidermis and dermis; hair follicles intact classified as either superficial or deep partial thickness, depending on how the much the dermis is damaged. mottled pink to red, painful, blistered, or exudating fluid, blanches with pressure

Deep partial thickness

second degree deeper layer of the dermis with damage to sweat and sebaceous glands variable color from patchy red to white, wet or waxy dry, does not blanch with pressure, sensitive to pressure only. takes more than 3 weeks to heal, may need debridement, is subject to hypertrophic scarring, and may be require skin graft.

Pulmonary Function studies

series of tests done to determine lung volume, capacity, and flow rates-- help diagnose and monitor restrictive or obstructive lung disease

cause of otitis media

serous otitis media: collection of pathogen free fluid behind the tympanic membrane - results form respi allergy that spread from the eustachian tube to middle ear - streptococcus pneumoniae and haemonphilus influenzae - rupture from pressure can occur and cause scar tissue on eardrum - mastoiditis or labryinthitis can happen

cilia:

short hairs that provide constant whipping motiion that serves to propel mucus and foreign substances away form thelung toward the larynx.

slit lamp exam

slit lamp: binocular microscope that magnifies the surfaces of the eye - beam of light narrowed to a slit is directed at the cornea - used to identify disorders such as corneal abrasions, iritis, conjuctivitis and cataracts

Viral rhinitis (common cold)

slow onset of symptoms, no or low grade fever, cough, slight fatigue, runny nose, sore throat, (sometimes headache or muscle aches) Tx: rest and fluids

phacoemulsification

small incision cataract surgery - small portion of anterior cap is removed and a probe is inserted with ultrasound waves - suction out the particles - pts are able to return in a short period of time

Signs of heat or smoke inhalation injury

soar throat singed nasal hairs, eyebrows, eyelashes. Hoarseness -carbon in sputum -soot around mouth and nose -SOB -Stridor

crackles:

soft, high pitched, discontiuous popping sounds during inspiration caused by delayed reopening of the airways.

Bronchospasm

spasm of the bronchial smooth muscle resulting in narrowing of the airways; associated with asthma and bronchitis

vision specialist optometrist

specialist who earns a doctor of optometry (OD) after undergraduate and graduate education optometrists test vision, examine eyes, prescribe corrective lenses and contact lenses, and in some states treat eye disease with prescribing meds

vision specialist optician

specialist who makes eyeglass or contact lenses based on prescriptions from ophthalmologists and optometrists also ensures that lenses fit properly

Thoracotomy

surgical incision into the chest wall

Thoracentesis

surgical puncture of the thoracic cavity, usually using a needle, to remove fluids from pleural space

Lobectomy

surgical removal of a lobe of any organ or gland

gene therapy

technique for fighting cancer that involves replacing altered genes with normal genes, inhibiting defective genes, or introducing substances that destroy defective genes or cancer cells.

chemotherapy

technique that uses antineoplastic (anti-cancer) agents to treat cancer cells locally and systemically

Apnea

temporary absence of breathing

cover-uncover test

test assesses extraocular muscle function - examiner ask client to cover one eye with opaque card while staring straight ahead at an object - examiner examines uncovered eye and then removes the card and examines that eye for a moment - the uncovered eye should remain fixed - if there is movement, it can indicate a deviation in alignment and muscle weakness

Compliance

the ability of the lungs to distend

Retraction

the act of drawing back, or condition of being drawn back; intercostal retractions particularly prominent in Pts with difficulty in breathing

Cryosurgery Treatment

the application of extreme cold to destroy tissue.

Zone of Stasis

the area of immediate burn injury -blood vessels are damaged, but the tissues has the potential to survive. -if circulations is secondarily impaired, however, injured tissues in the zone of stasis can convert to a zone of coagulation

Stage IV cancer

the cancer has invaded or metastasized to other organs of the body.

the release of histamine as a consequence of the stress response increases gastric acidity

the client with a burn is prone to developing gastric ulcers.

split-thickness

the epidermis and a thin layer of dermis are harvested from the client's skin. -vary in thickness, size, and shape. -Usually obtained from the buttocks or thighs. -have more successful outcomes than other types, however, appearance is less than desireable, they are less elastic, and hair does not grow from their surface.

full thickness

third and fourth degree -epidermis, dermis, subcutaneous tissue -may be fat , fascia, muscle, and bone, ligament, tendons. -red, white, tan, brown, or black; lethergy covering (eschar) painless -black, depressed, painless, scarring. - the tissue appears charred or lifeless. if not debrided, this type of burn injury leads to sepsis, extensive scarring, and contractures, -skin graft is necessary because the skin cells no longer are alive to regenerate.

Hypochloremia

to little amounts of chloride usually associated with alkalosis early stages of vomitting- loss of hydrochloric acid

rinne test

tuning for is struck - placed on the mastoid process behind ear - held there until client cant hear fork - immediately after that, the still vibrating fork is held besides hear until client no longer hears the fork - normal: air conduction (besides ear) is twice as long as bone conduction (mastoid)

weber test

tuning fork is struck and placed in center of forehead or middle of skull - sound is heard in both ears equally

antineoplastic

type of drug used to treat cancer that works by interfering with cellular function & reproduction

malignant

type of tumor that is invasive and capable of spreading (cancerous)

benign

type of tumor that is not invasive or spreading/non-cancerous; benign tumors usually do not cause death

Osmol

unit of osmotic pressure

canthus

upper and lower eyelids are folds of skin that meet at an angle - outer (lateral) angle - inner (medial) angle - asians: have epicanthal fold, which is a fold of skin that covers the inner canthus - children with down syndrome have a line that slants upward and outward

immunotherapy

use of biologic response modifiers to stimulate the body's natural immune system to restrict and destroy cancer cells

Venturi mask

used for PT who requires precise % of O2 (chronic lung disease with CO2 retention)

Partial rebreather mask

uses a reservoir to capture some exhaled gas for rebreathing; delivers oxygen concentrations of 50% or more

Bronchoscopy

uses flexible endoscope to examine larynx, trachea, and bronchial tree; used for visualization or to obtain specimen or remove obstruction; PT breathes thru nose; NPO 6-8 hours, signed consent, atropine to dry secretions, anesthetic spray- post procedure: monitor VS, watch for signs of laryngeal edema, sputum may be blood tinged, NPO until gag reflex returns

otoscopic exam

using an otoscope, inspecting the external acoustic canal and tympanic membrane

Bacterial respiratory infection

usually slow onset of symptoms, fever may exceed 101F, cough- dry or productive, chest pain, fatigue (sometimes headache, muscle aches, runny nose, sore throat) Complications: pneumonia Tx: antibiotics

Low pressure alarm sounds on ventilator and you are unable to determine cause

ventilate PT manually with a resuscilation bag

fremitus:

vibrations of speech felf as tremors of the chest wall during palpitation.

surge management for glaucoma

when compliance is poor or meds no longer is effective, or when surgery is needed to preserve vision, drainage system is made - procedures : a) LASER or SURGICAL IRIDOTOMY: - holes are burned into iris to increase areas for drain. - if does not work then surgical is used in which a section of the iris is removed by peripheral or sector - peripheral: small section of iris is removed at outer margin of iris - sector: (keyhole) larger segment of iris is removed in the direction of the pupil b) LASER TRABECULOPLASTY: - alternative to surgical iridotomy - laser beam is directed at trabecular network, which lies near the canal of schlemm to create openings for drainage c) CORNEAL TREPHINE: - same as a trabeculoplasty but makes a small hole at the junction of the cornea and sclera to provide an outlet for aqueous fluid

myoglobin and hemoglobin are tranported to the kidneys

where they may cause tubular necrosis and acute renal failure.

Zone of Coagulation

which is at the center of the injury , is the area where the injury is most severe and usually deepest.

Electrical burns and lightening also produce heat

which is greatest at the point of entry to and exit from the body. -because deep tissues cool more slowly than those at surface, it is difficult initially to determine the extent of internal damage.

whispered pectoriloquy:

whispered sounds heard loudly and clearly upon thoracic auscultation.

In the ED, it is determined that a burn victim has deep-partial- and full-thickness burns over 35% of the upper body. During the nursing assessment of the burn injury, what characteristics will the nurse use to identify the initial appearance of the Full-thickness burn?

white and leathery

Pulmonary Angiography

xray exam of pulmonary vessels after IV administration of radiopaque dye into pulmonary artery; diagnoses PE and other vessel disorders; NPO 4-8 hours, signed consent form, check for allergies, medications for comfort- post procedure: bed flat for 3-8 hours, monitor VS, observe for bleeding, sandbag, encourage fluids

Nonrebreather mask

has one or both side ventsd closed to limit mixing of room air with O2; vents open to allow expiration but remain closed on inspiration; reservoir bag has valve to store O2; 70%-100% oxygen concentrations; useful in emergency situations

Dehydration diagnosis

history and physical examination lab analysis -blood concentrations of electrolytes bicarbs blood urea nitrogen creatine specific gravity

s/s of otitis media

history of respi infection or seasonal allergies - tenderness behind ear indicates mastoiditis - eardrum looks red and bulging - nausea due to pressure or vomiting and dizziness - drainage reveals specific infectious microorganisms when tested - WBC is elevated

Types of Autografts

human skin from the client with a burn is harvested under general anesthesia. Either a split thickness or full-thickness graft is removed. Split-thickness; Full-thickness; Slit Disadvantages; Pressure garments; Sunscreen

Hypostatic

hypostatic pneumonia occurs from congestion in the lungs associated with lack of activity

COPD (Chronic Obstructive Pulmonary Disease)

hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory muscles of respiration, prolonged

Nasal samples

identify flu or other respiratory viruses

full-thickness graft

includes epidermis, dermis, and some subcutaneous -is used when the burn area is fairly small and involves that hands, face, or neck -are more compareable in appearance to normal skin and can tolerate more stress once they become permanently attached to the burn wound.

a treatment plan for a burn victim includes using the open method of burn wound management, what is the most appropriate for the nurse to monitor when caring for a client being treated by the open method?

infection

muscles of eye

inferior rectus: up and down medial lateral rectus: move eyes toward and away from nose and temple superior and inferior oblique: move to left and right

conjunctivitis

inflammation of the conjunctiva - pink eye - hemorrhage of the subconjunctival blood vessels

Laryngitis

inflammation of the larynx

blepharitis

inflammation of the lid margins

stomatitis

inflammation of the mouth

Pharyngitis

inflammation of the mucous membranes and lymph tissues of the pharynx, usually caused by infection

Rhinitis

inflammation of the nasal mucosa, usually associated with congestion, itching, sneezing, and nasal discharge

Sinustis

inflammation of the sinuses; may be due to viral or bacterial infection, or to allergies

vesicants

intravenous medications that cause tissue necrosis if they infiltrate

rules of nine

is a quick initial method of estimating how much of the client's skin surface is involved.

med and surge management of keratitis and corneal ulcer

keratitis: - topical anesthetic - mydriatics (meds that dilate the pupil) local and systemic antibiotics - dark glasses for photophobia corneal ulcer: - earl stage only (treatment is same as keratitis) - one scar tissue is formed, only treatment is corneal transplant (keratoplasty)

Hypoxia

lack of oxygen; O2 sat below 90%

structures of the eye extraocular

lacrimal glands: - found beneath the body orbital ridge - tears (water, sodium chloride, lysozyme [antibacterial enzyme]) lacrimal caruncle: small reddish elevation on the conjunctiva located at the inner canthus lacrimal apparatus: lacrimal glands, punctum, lacrimal canals, lacrimal sac, nasolacrimal ducts conjunvtiva: a sensitive transparent mucous membrane that extends from the lid margins and meets the cornea cornea: transparent like structure that covers the most anterior portion of the eyeball limbus: outer most edge of the iris

Bulla

large blister or skin lesion filled with fluid; may occur in lung tissue

extravasation

leaking of an intravenously administered drug into surrounding tissues

cataracts

lens of eye becomes opaque

s/s of blepharitis

lid margins are inflamed - patchy flakes cling to eyelash and lids - drainage is present (purulent) - diagnose: exam the scales microscopically (not necessary)

refraction

light rays bend and change speed

What can cause the skin to look yellow?

liver and kidney disease as well as destruction of RBCs

compliance:

measure of the force required to expand or inflate the lungs....Factors that determine lung compliance are the surface tension of the alveoli, the connective tissue and water content of the lungs, and the compliance of the thoracic cavity. Compliance is determined by examining the volume-pres- sure relationship in the lungs and the thorax. Compliance is normal (1 L/cm H2O) if the lungs and thorax easily stretch and distend when pressure is applied.

Oxygen saturation (pulse ox, O2 sat or SPo2)

measures arterial oxygenation and the % of hemoglobin that is saturated with oxygen

tonometry

measures intraocular pressure (IOP) - use a tonometer to indent or flatten (applanate) - normal IOP is 10-21 mm Hg - High reading is high IOP - low reading is low IOP - applanation tonometer is more accurate - use anesthesia before test . noncontact tonometer: - less accurate - blows a puff of air against the cornea - no anesthetic is used

Respiratory center of brain

medulla oblongata and pons

Why are emollients, ointments, powders, and lotions used on the skin?

May be combined with other agents to soothe, protect, and soften the skin.

Older adults at risk for fluid and electrolyte imbalance and as a result:

May develop hyperglycemia when tube feeding administered

Abnormal lung sounds

coarse/ fine crackles, wheezes, stidor, pleural friction rib, diminished, absent

Atelectasis

collasped or airless condition of the lung or portion of the lung, caused by obstruction or hypoventilation

Photochemotherapy Treatment

combination of psoralen methoxsalen and type A ultraviolet light

Sign of iron deficiency anemia

concave-shaped nails, referred to as spooning

alopecia

condition that affects the hair follicles & results in partial or total hair loss

wheezes:

continuous musical sounds associated with airway narrowing or partial obstrucion.

Sputum culture and sensitivity test

culture identifies pathogens present in sputum; sensitivity determines which antibiotics will be effective

What medications are used to treat infectious disorders?

- Antibiotic, antifungal, and antiviral agents - applied topically or administered systemically

Body fluid

- It is the largest single component of he body - Flows in arteries, veins, and lymph vessels -Have 3 compartments that is secreted into

3 specialized compartments for body fluid

- Joints -Cerebral ventricle -Intestinal lumen

test for macular degeneration

- dye is pooling in the blister area - amsler grid is used to determined if client has changes in central vision. lines can be wavy or disappear

IV analgesics are administered for pain - often severe

- Morphine sulfate- drug of choice. dose as high as 50mg/hr necessary for adults who are severely burned. -naloxane ( narcan) administered for respiratory depression. -tetanus immunizations also adminstered.

nursing management of keratitis and corneal ulcer

- advise clients that wear contacts to temporarily stop wearing them

cause of cataracts

- aging process - congenitally acquired - injury to lens - secondary to other eye diseases - high incident in diabetes or family history - prolong to rays, radiation, or drugs (steroids)

med management of blepharitis

- antibiotic ointment - cleaning eyelids once or twice daily - frequent wash of face and hair of oil

med management of conjunctivitis

- antibiotic or antiviral ointment or drops - antihistamines and decongestants if allergen cause - warm soak or sterile saline for irrigation

cause of conjunctivitis

- bacteria, viral, or rickettsial infection - allergic reactions, trauma from chem, or foreign bodies in the eye also cause it - neisseria gonorrhea and chlamydia trachomatis also leads to blindness

macular degeneration

- breakdown of or damage to the macular - the point on the retina where light rays converge for the most acute visual perception

s/s of eye trauma

- can be painful or gritty - if fracture: diplopia (double) or asymmetrical - rust ring is seen in retained foreign bodies that contain iron

s/s of cataract

- early symptoms: seeing halo around light - other symptoms: change in color vision, glaring of objects in bright light, distortion of objects, blurred vision, double vision in one eye - white or gray spot is visible behind the pupil

jaeger chart and rosenbaum pocket vision screener

- evaluates near vision - contains numbers, words, letters in various print sizes - examiner tells pt to cover one eye and read the smallest print 14 inch away.

test for keratitis and corneal ulcer

- flashlight illumination, slit-lamp exam, fluoresce drops or strips provide evidence of scar

snellen eye chart

- for visual acuity: ability to see FAR images clearly - examiner ask client to cover one eye and identify letters of decreasing size. (large to small) - ##/##: first number represent client and second number represent everyone - if client cant see the largest letter, examiner will raise finger to count - if client fails to count fingers, then examiner will distinguish of light to dark test - can also be computerized test

Nursing responsibilities NG tubes

(RN) - insertion /removal LVN- maintaining patency, (unobstructed), implement prescribed use.

med management of impacted cerumen

- half strength peroxide, warm glycerin, or mineral oil - commercial agents: carbamide peroxide (Debrox) and triethanolamine (Cerumenex) - cerumen spoon or curette is used

congenital glaucoma

- happens early in life - family related

surge management of cataract

- cant be treated medically, only surgery - outpatient settings with topical and intraocular anesthesia - pts are awake and can converse during procedure - for pt who have both cataracts, surgery is done one at a time with weeks to months apart from each other - many procedures exist: a) phacoemulsification b) extracapsular extraction - after surgery vision is restored with 3 different methods: a) intraocular lens implant b) corrective eyeglasses c) contact lens

endophthalmitis

- condition in which all three layers of the eye and the vitreous are inflamed - removal of eye may be necessary - penetrating trauma can cause it

Dermatophytoses

(tinea) Are superficial fungal infections. Examples: ringworm, athlete's foot, jock itch.

instructions after surgery of eye

- do not bend or stoop or do anything that will increase IOP - do not immerse the eyes in water - do not engage in activity that could cause dust or particles to lodge in the eye - do not eat anything that is hard due to excessive facial movement to prevent tearing

nurse management of cerumen

- do not use cotton swabs or toothpicks - irrigate syringe directed toward the roof not the eardrum

blindness best corrected visual acuity (BCVA)

- driving test: one eye at least 20/40 - low vision: BVCA of 20/70 - 20/200 - blindness (visually impaired): BVCA of 20/200 or less - no light perception: BCVA 20/400

cause of retinal detachment

- hole or tear in the retina caused by stretching or degenerative changes - can be from trauma - tumors, hemorrhage in front of or behind retina, or loss of fluid - sometimes its unknown - usually common after 40 . three types have been identified: 1) rhegmatogenous: fluid moves under the retina through a tear and separates it from the pigmented layer. this is the most common 2) tractional: tension or a pulling force causes scar tissue to form on the retina's surface and eventually the retina separates from the pigmented layer 3) exudative: fluid moves under the retina secondary to inflammatory disorders or injury to the eye; there are no tears in the retina, macular degeneration or uveitis

cause of blepharitis

- hyper secretion from sebaceous glands - this type happens with dandruff of the scalp or seborrheic dermatitis found about the ears and eyebrows - some can be both

Allograft or homograft

- is a biological source of skin similar to that of the client. -it can be obtained from another a cadaver, from human donor cells such as stem cells from umbilical cord blood, or infrequently from amniotic membranes. -cadaver skin tissues are screened for HIV and hepatitis. -transCyte- temporary skin graft that contain human neonatal fibroblast cells that are cultured aseptically and incorporated within a nylon mesh membrane.

LASIK

- laser called a femtosecond laser or a surgical blade to create a thin corneal flap that is folded back - cool-beam laser resculpts the cornea - sutures are not required for the flap that is folded back - eye drops and ointments are used for healing . complications: - wrinkles in the flap - debris under the flap - displaced flap - infection or inflammation of the flap

surgical management of retinal detachment

- laser surgery, cryopexy, diathermy, retinopexy, and scleral buckling . - laser: (photocoagulation) making small burns around the tear to attach the retina back in place - cryopexy: (freezing) involves the application of a supercooled probe to the tear, assisting the retina to reattach - diathermy: uses electric current to heat the tissue around the tear - retinopexy: (pneumatic) less invasive for large tears. after the above method is used, a gas bubble is injected to push the retina against the sclera. pt has to position face down for 7-10 days. - scleral bucking: (indenting of the surface of the eye) use a band to attach the outside of eyeball to push the wall of eye against the detached retina. vitreous is removed and replaced with gas. the methods above are used as well to weld the retina back in place

angle closure or acute glaucoma

- less common - onset is very sudden - immediate recognition and treatment are required to prevent blindness . - when people have an anatomically narrow angle at the junction where the iris meets the cornea - movement of fluid is impaired because increased pressure in the posterior chamber produces a forward bowing of the iris, which narrows the approach to the canal of schlemm - can be from mydriatic drug, by pupil dilation in dark, or lens enlarges with age and bulges forward - this type is an emergency and any delay will result in partial or total loss of vision

extracapsular extraction

- longer incision is made and the lens is extracted in one piece

nurse management of otitis media

- myringotomy: discharge from ear is bloody and purulent - wipe with DRY sterile cotton applicator or insert a loose cotton

Why do nails have a pink semitransparent appearance?

- nails have an abundant capillary blood supply -resulting in their pink semitransparent appearance

med and surge management of otitis media

- needle aspirate - antibiotics - myringotomy or tympanotomy: incisonal opening of the tympanic membrane - mastoidectomy is performed to remove diseased tissue (although rare if treated early)

nurse management of glaucoma

- never administer mydriatics (drugs that dilate) - anticholinergic properties should be consulted with doc (atropine sulfate)

med and surge management of dry macular degeneration

- no cure or treatment - vitamin and mineral formula: Vitamin C, E, A (beta-carotene) zinc oxide, and cupric oxide (copper) to reduce risk of advanced AMD and severe vision loss. clients that are healthy do not benefit - diet: AMD clients eat 2-3 servings o cold water fish/week and daily servings of leafy green vegetables and fruits

test for cataract

- ophthalmoscopic and slit-lamp examine, lense appears in varying stages of opacity - tonometery determines whether the cataract is increasing the IOP

s/s of keratitis and corneal ulcer

- pain or sensation that a foreign body is present - blinking increase discomfort - photo-phobia, blurred vision, tearing, purulent discharge and redness

Blood samples are drawn- fluid resuscitation with

-crystalloid and colloids solutions begin according to the severity of the burn injury - fluid replacement regimen is calculated from the time the they burn injury occurred. - the goals of fluid resuscitation is restoration of intravascular vol, prevention of tissue and cellular ischemia, and amintenance of vital organ function. -successful fluid resuscitation is gauged by a urinary output of 0.3-0.5 mL/kg/hr via indwelling catheter. -a low dose infusion of dopamine (Intropin) may be necessary to ensure renal perfusion.

Why are older adults more vulnerable to heat?

-decline in the number of eccrine glands /decreased cutaneous vascularity -->causes a decrease in spontaneous sweating with age -this makes older persons more vulnerable to heat

Dehydration clinical manifestations

-decreased level of consciousness -prolonged cap refill time -dry mucous membranes -decreased or absent tears -change in vital signs -depressed fontanel for neonates/ infant -Decreased or absent urine output

Medical Management

-depends on the initial first aid provided and the subsequent tx in the hosp. or burn center. Potential life-threatening complications: Inhalation injury; Hypovolemic shock; Infection Major burns: Transport to regional burn center

Keratolytics are used ti treat warts, corns, and calluses:

-dissolve thickened, cornified skin -action causes the treated area to soften and swell, facilitating removal

Client preparation NG tube insertion

-explain diameter or tube smaller than most food that they swallow -explain procedure/give instructions how they can assist w/ insertion -provide them with a means of control. -establish a signal (raising hand) to indicate a need for a pause during insertion

After the burn

-fluid from the body move toward the burned area, which accounts for edema at the burn site. -fluid is then trapped in this area and rendered unavailable for the use by the body, leading the intravascular fluid deficit. -fluid is also lost from the burned area, often in extremely large amt, in the forms of water vapor and seepage. -decreased BP follow, -if physiologic changes are not immediately recognized and corrected, irreversible shock is likely. -these changes happen so rapidly, and the client's status may change from hour to hour, requiring that the client's burns receive intensive care by skilled personnel.

Why is skin considered protective?

-forms a protective barrier between the outside world / underlying organs / structures of the body -prevents microorganisms /foreign substances from reaching the structures below the epidermis -prevents structures below the surface of the skin from losing water

Maxter tube

-intestinal decompression (Nasointestinal) -size usually 18F -100in -double lumen -tungsten weighted -graduated marks Q 10in(25cm)

Subcutaneous tissue

-layer of skin attached to the muscle and bone -composed primarily of connective tissue and fat cells

consequence of skin impairment

-leads to the microbial colonization and infection of the wound

to reduce conditions under which pressure sores are likely to form

-moisturizing skin cleansar -Pad bony areas -Turn/position

Hair does not cover these sites:

-palms, soles, dorsum of the fingers, lips, penis, labia, nipples

American Burn Association Referral criteria

-parital or full thickness burn greater than 10% TBSA -burns that involve the face, hands, feet, genitalia, perineum, and major joints. -full-thickness burns in any age group -electrical burns, including lightening injury -chemical burns -inhalation burns -burn injury with a preexisting medical disorder that could complicate management, prolong recovery, or affect mortality -burns accompanied by trauma in which the burn injury poses the greatest risk for morbidity and mortality -burned children in hospitals without qualified personnels or equipment for the care of children -burn injury for those who will require social, emotional, or rehabilitative intervention,

Antihistamines

-prescribed when allergy is a factor in causing a skin disorder -relieve itching and shorten duration of allergic reaction

skin has four major functions:

-protection -temperature regulation -sensory processing -chemical synthesis

Stage I Pressure Ulcer

-redness of the skin -fails to resume normal color, blanch when pressured is relieved

Fungal culture

-requires incubation at room temp for 2-3 weeks

Stage III Pressure Ulcer

-shallow crater extends tot he sub Q -accompanied by serous drainage form plasma / purulent drainage caused by infection -relatively painless

Sources for Skin Grafts-

-temporary or permanent. -manufactured synthetically, obtained from a biologic source, or a combination of the two. Autograft: Client's own skin Allograft: Human skin from cadaver Heterograft: Animal skin

Evaporation

-the loss of moisture or water. Water on the surface of the body is warmed. As the moisture vaporizes, the body is cooled. Evaporation occurs unnoticed (insensible loss) and when there is obvious perspiration.

Convection

-the transfer of heat by means of currents of liquids or gases in which warm air molecules move away from the body. An example of convection is a cool breeze that blows across the body surface.

Conduction

-the transfer of heat through contact. An example of conductive heat loss is placing a cool cloth on warm skin.

Radiation

-the transfer of surface heat in the environment. An example of radiant heat loss is the escape of heat from the surface of warm skin into cooler air.

Stage IV Pressure Ulcer

-traumatic life-threatening -deeply ulcerated -exposing muscle/bone -dead tissue -produces rank odor -local infection spreads - causing potentially fatal condition referred to as sepsis

glaucoma

group of eye disorder caused by an imbalance between the production and drainage of aqueous fluid - IOP rise due to obstructed drainage system in the anterior chamber - optic nerve damage can occur - no cure for glaucoma but can be controlled

patient teaching - use of a pressure garment

-wear the pressure garment at least 23 hours each day. -follow the manufacturer's instructions for donning and removing the pressure garment -contact the physician or PT if the garment causes discomfort or does not seem to fit properly. - ensure that holes or nonfunctioning zippers are repaired immediately or as soon as possible -hand-wash the pressure garments daily with mild laundry detergent -rinse the garment thoroughly to remove detergent residue, salt water, or chlorinated water from a swimming pool -squeeze and roll the garment in a towel to remove as much moisture as possible; do not dry the garment in the sun or in a clothes dryer -massage any moisturizer, lotions, cream, and petroleum-based ointment completely into the skin because these can cause deterioration of the garment

skin substitute and skin grafts

-when a wound dressing alone is no longer appropriate for covering large areas of burned tissues, use of -skin substitutes- a temporary covering -skin grafting- transferring the client's own skin to another area, becomes advantageous. -either or both techniques are used when skin layers responsible for regeneration have been destroyed. -Large burns may not be able to granulate fully, resulting in chronic open wounds and delayed healing.

(V/Q) imbal- ance causes shunting of blood, resulting in hypoxia (low level of cellular oxygen). Shunting appears to be the main cause of hypoxia after thoracic or abdominal surgery and most types of respiratory failure. Severe hypoxia results when the amount of shunting exceeds 20%. Supplemental .oxygen may elimi- . nate hypoxia, depending on the type of (V/Q) imbalance.

...

PaO2 =

...

The most common causes are: • Pulmonary infection • Carcinoma of the lung • Abnormalities of the heart or blood vessels • Pulmonary artery or vein abnormalities • Pulmonary embolus and infarction The nurse must determine the source of the bleeding, as the term hemoptysis is reserved for blood coming from the respiratory tract. Sources of bleeding include the gums, naso- pharynx, lungs, or stomach. The nurse may be the only wit- ness to the episode, and when documenting the bleeding epi- sode, the following points should be considered: • Bloody sputum from the nose or the nasopharynx is usu- ally preceded by considerable sniffing, with blood pos- sibly appearing in the nose. • Blood from the lung is usually bright red, frothy, and mixed with sputum. Initial symptoms include a tickling sensation in the throat, a salty taste, a burning or bub- bling sensation in the chest, and perhaps chest pain, in which case the patient tends to splint the bleeding side. This blood has an alkaline pH (greater than 7). • Blood from the stomach is vomited rather than expec- torated, may be mixed with food, and is usually much darker and often referred to as "coffee ground emesis." This blood has an acid pH (less than 7).

...

sputum is often indicative of its cause. A profuse amount of purulent sputum (thick and yellow, green, or rust colored) or a change in color of the sputum is a com- mon sign of a bacterial infection. Thin, mucoid sputum fre- quently results from viral bronchitis. A gradual increase of sputum over time may occur with chronic bronchitis or bron- chiectasis. Pink-tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath point to the presence of a lung abscess, bron- chiectasis, or an infection caused by fusospirochetal or other anaerobic organisms

...

Most formulas provide ______ kcal/mL

0.5-2.0

Procedure to remove Nasointestinal decompression tubes

1. Disconnect from suction source 2. Remove tape from face and withdraw tube 6-10 in at 10 min intervals 3. When last 18 in remains, tube pulled gently from nose 4. Provide nasal and oral hygiene measures 5. Cannot be removed nasally if distal end passes ileocecal valve between small and large intestines. Proximal end is cut and tube gradually removed manually or by peristalsis.

Antibiotic drugs for Tx of TB

1st line: Isoniazid, Rifampin, Ethambutol, Pyrazinamide (usually fewest side effects; can be toxic to liver and nervous system) 2nd line: Rifabutin, Rifapentine, Para-aminosalicylic acid, Strepomycin, Levofloxacin, Ethionamide, Amikacin and others (more toxic and reserved for cases that do not respond to first line) drugs usually taken for 6-9 months or up to 2 years for MDR-TB

Closed Method- wound is covered

: Current, preferred method because it creates a microbial barrier, reduces heat loss through evaporation, and provides moist environment that facilitates healing. Use of dressings: Nonadherent; Absorbent; Occlusive, semiocclusive; Dressing changes change wound dressing frequently enough to maintain antimicrobial effectiveness, check for infection, and monitor for healing process, = done Q8hours to once a week. -necessary for wound changes when wound is infected and when there is significant saturation with wound exudate.

Surgical Management: Debridement

?Removal of necrotic tissue -the procedure is potentially painful and warrants premedication with an analgesic. Four ways: Naturally-nonliving tissues sloughs away from uninjured tissue. Mechanically-- when dead tissues adheres to dressings or is detached during cleansing Enzymes--through the application of topical enzymes to the burn wound. Surgery-- with the use of forceps and scissors during dressing changes or wound cleansing. Disadvantage: Bleeding because burn victims already have secondary problems with healing, because of low RBCs . Covering of healthy tissue: Skin graft; Temporary skin substitute; Cultured skin

stridor:

harsh high-pitched sound heard on inspiration, usually without the need of a stethescope, secondary to upper airway obstruction.

B

A client with a diagnosis of pernicious anemia comes to the clinic complaining of numbness and tingling in their arms and legs. What do these symptoms indicate? A. Loss of vibratory and position senses B. Neurologic involvement C. Severity of the disease D. Insufficient intake of dietary nutrients

C

A client with a diagnosis of thrombocytopenia has been admitted to your unit for IV corticosteroid treatment. As the nurse caring for this client, you would expect the physician's orders to include which of the following? A. A sleeping medication B. Small frequent meals throughout the day C. A tapering course of solumedrol at discharge D. An order for oxycodone for steroid induced headaches

Protease inhibitor

A drug that inhibits the ability of virus particles to leave the host cell

Scabies

A fairly common infectious skin disease. Caused by infestation with tiny itch mites. Skin-to-skin contact. Can't survive off the body for more than 2 days.

What is one way for creating an environment for the patient and his/her family members?

A family conference.

Living Will

A lay term used frequently to describe any number of documents that give instructions about future medical care and the treatments or the wish to be allowed to die without heroic or extraordinary measures should the patient be unable to communicate for self.

Pneumocystis pneumonia

A nonproductive cough and shortness of breath. Can cause respiratory failure

Grief

A normal reaction to loss and adapting to change. Dynamic and includes both psychological and physiologic responses to a loss.

A

A nurse caring for a client who has hemophilia is getting ready to take the client's vital signs. What should the nurse do before taking a blood pressure? A. Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints. B. Ask if taking a blood pressure has ever produced pain in the upper arm. C. Ask if taking a blood pressure has ever caused bruising in the hand and wrist. D. Ask if taking a blood pressure has ever produced the need for medication.

Chyene-Strokes Respirations

A pattern of breathing characterized by alternating periods of apnea and deep rapid breathing. Usually seen as a person is near death.

Podiatrist

A person trained to care for feet.

Western bolt test

A positive result on Western boat confirms the diagnosis, however False - positive and false - negative results on both test are possible.

Dermatome

A skin area supplied by the nerve.

Shingles/ Herpes Zoster

A skin discorder that develops years after an infection with varicella. Frequently in middle-aged to older adults or people immunocompromised.

ABC

A student nurse, learning about the hematopoietic system would include what in their studies? Select all that apply. A. Bone marrow B. Blood C. Plasma D. Plasma granulocytes E. Protein inhibitors

Kaposi's sarcoma

A type of connective tissue cancer common among those with AIDS

Directive to Physicians

A written document specifying the patients wish to be allowed to die without heroic or extraordinary measures.

Do Not Resuscitate (DNR)

A written physicians order instructing health care providers not to attempt CPR, often requested by family; must be signed by a physician to be valid.

A

Erythrocytes, or red blood cells, carry oxygen throughout the body. The number of erythrocytes actually varies with age, gender, and altitude. What is the normal range for erythrocytes in the adult body? A. 3.6 and 5.4 million/mm3 B. 5.6 and 8.4 million/mm3 C. 7.2 and 9.3 million/mm3 D. 8.2 and 10.7 million/mm3

Progression of HIV infection

Manifestation occurs within 2 to 4 weeks of infection. Symptoms are similar to those of influenza and can include a rash and sore throat. Decreased CD4 cells in increased CD8 cells

Dehydration

Alerterations in fluid and electrolytes balances -sodium imbalances -negative fluid balances

Extracellular fluid

All body fluid outside of the cells (1/3) of total body water - Vascular compartment -interstitial compartment Dense connective tissue and bones

What are the psychosocial manifestations of approaching death?

Altered decision making, anxiety about unfinished business, decreased socialization, fear of loneliness, fear of meaninglessness of ones life, fear of pain, helplessness, life review, peacefulness, restlessness, saying goodbyes, unusual communication, vision-like experiences, withdrawal.

D

An 81-year-old male with acute lymphoblastic leukemia is terminal. The family asks you why the prognosis is so poor for this client. What would be your best response? A. "Your family member is old and just can't fight any more." B. "This disease has been going on for a long time." C. "Leukemia is cancer of the blood and cancer is hard to beat." D. "Your family member doesn't have enough blood cells of all kinds."

Pediculosis

An infestation with lice. Crawling brown insects, size of sesame seed. Feed on human blood. Nits cemented to hair shaft. Direct contact transmission.

Acne vulgaris

An inflammatory disorder that affects the sebaceous glands and hair follicles. Tends to coincide with puberty.

Granuloma

An inflammatory nodular lesion, may form as a result of a cellular attack waged against the particles in the tattoo pigment, which the body senses as foreign.

Keloids

An overgrowth of scar tissue.

Nasal inspection

Ask client to blow nasal debris into tissue. Inspect size, shape, patency of each nostril. Occlude one nostril at a time and exhale.

Acute Care:

Assess extent of burn injury, additional trauma Interventions: Ventilation; Fluid resuscitation Endotracheal tube; Bronchoscopy Mechanical ventilation; Tracheostomy; Hyperbaric oxygen treatment IV analgesics; Tetanus immunization

Restoring patency

Assess tube frequently monitoring volume and characteristics of drainage. Observe for signs of obstruction. Inspect equipment to identify possible cause. Sometimes NG tube needs irrigating. Need a medical order to do this.

Medical Power of Attorney

At term used by some states to describe a document used for listing the person or persons to make health care decisions should a patient become unable to make informed decisions for self.

Alopecia Areata

Autoimmune disorder characterized by patchy areas of hair loss about the size of a coin. Antibodies attack and destroy the hair follicle.

What are the Rando Stages of Grieving?

Avoidance, Confrontation and Accommodation.

Alopecia

Baldness. The condition affects the hair follicles and results in partial or total hair loss.

Interventions to stop smoking

Behavior modification, counseling, setting a quit date, nicotine replacement, drug therapy (Zyban, Chantix), Acupuncture, Hypnosis

To maintain tube patency :

Best to flush tubes with 30-60 mL water immediately before and after feeding or meds, every 4 hours if client continuously fed, and after refeeding residual. Cranberry juice and carbonated beverages may be used.

Vesiculation

Blister formation

Transmission of HIV

Body fluids through which HIV is transmitted: blood, semen, vaginal secretions, breastmilk, infected equipment used for body piercing, Tattoo, and dental

Furuncle

Boil.

4 ways to administer tube feedings

Bolus, intermittent, continuous, cyclic

D

Both the liver and the spleen have a role in erythrocyte metabolism. How would this role best be described? A.The spleen helps in creating mature erythrocytes. B.The liver generates erythropoietin which regulates the rate of erythrocyte production. C.The spleen stores the iron component of hemoglobin from erythrocytes and returns it to the red marrow. D.The spleen removes erythrocytes after 120 days, and the liver removes severely damaged erythrocytes.

Respiratory blood lab tests

CBC- measurement of RBC and hemoglobin; eleveated WBC indicate infection ABG-determine the effectiveness of gas exchange

HIV targets

CD4, Lymphocytes also known as T cells

Cytomegalovirus

CMV can infect the choroid and retinal layers of the eye leading to blindness

cachexia

Cachexia or wasting syndrome is loss of weight, muscle atrophy, fatigue, weakness, and significant loss of appetite in someone who is not actively trying to lose weight. The formal definition of cachexia is the loss of body mass that cannot be reversed nutritionally

Calcitonin

Calcium goes into the bone

Altered fluid balances

Can be extracellular saline imbalances or imbalances of body fluid(water) concentration, or both Integrally related to sodium in ECF which may be normal low or elevated Hypovolemia Hypervolemia

common complications for electrical burn victims

Cardiac dysrhythmias and Central nervous system

Anion Gap

Cations - Anions

Hypoosmotic

Caused by SIADH(pituitary is secreting to much) or ingestion of a large volume of water. Causes hyponatremia, can lead to death due to CNS disturbances

Human immunodeficiency virus (HIV)

Causes AIDS. People can remain well, sometimes up to 10 years or longer, despite being infected with HIV, before the initial infection develops into AIDS

Hypokalemia clinical manifestations and treatment

Causes a decrease in neuromuscular excitability skeletal muscle weakness, smooth muscle atony, decreased GI motility, paresthesias, glucose intolerance, and cardiac dysrhythmias Severe: shallow respirations, polyuria Treatment: IV or oral potassium change diuretic or supplemental daily with potassium

Pityrosporum ovale

Causes dandruff.

Collection data for HIV and AIDS

Chills, rash Anorexia, nausea, weight loss Weakness and fatigue Headache and sore throat Night sweats

Bronchiectasis

Chronic dilation of the bronchus or bronchi; usually associated with secondary infection and excessive sputum production

Psoriasis

Chronic, noninfectious inflammatory disorder of the skin that affects both men/women. Periods of emotional stress, hormonal cycles, infection, and seasonal changes appear to aggravate the condition.

Depth of Burn Injury

Color Skin Characteristics Sensation in Burn Area Classification Superficial Partial thickness Full thickness

HIV infection turns into AIDS

Markedly decreased T4 cell count from a normal level of 800 to 1200 The development of certain cancers and opportunistic sections

Highly attractive antiretroviral therapy (HAART) has several benefits

Combination of drugs increases the numbers of healthy helper T cells lymphocytes because it protects many from becoming infected

Highly attractive antiretroviral therapy (HAART) has several benefits

Combination therapy diminishes the rate of of viral mutations and prolongs drug effectiveness

Examples high calorie formula

Comply, nutren 1.5, nutren 2.0, deliver 2.0

Near the end of life how can a patients communication oftentimes be identified as?

Confused, disoriented, or garbled.

Dermis

Consists of connective tissue and contains elastic fibers, blood vessels, sensory and motor nerves, sweat and sebaceous glands, and hair follicles

Cyclic feedings

Continuous installation of liquid nourishment for 8-12 hours. Followed by 6-12 hours pause.

Causes of Hypovolemia

Decreased intake -Nausea, anorexia -Inability to drink or obtain water/ fluids Increased loss -trauma involving hemorrhaging or burns -high urine output(polyuria, diuretics, dialysis) -High GI output(diarrhea, vomiting, suction) -Fluid shift( third spacing, shock, diaphoresis)

What are the Kubler-Ross Stages of Grieving?

Denial, Anger/Bargaining, Depression and Acceptance.

Hypokalemia causes

Dietary deficiency, alcoholism, malnutrition diabetic use, diarrhea, prolonged vomitting insulin administration( cause k+ to move into the cell cushing's( high levels of aldosterone leads to increases k+ in the urine)

Causes of gastronomy leaks

Disconnection between feeding delivery tube and G tube Clamped G tube during infusion Mismatching size of G tube and stoma Increased abdominal pressure from formula accumulation, retching, sneezing, coughing Under inflation of balloon beneath skin Less than optimal stoma or stomal location

Malignant Melanoma

Distant mets, poor prognosis

Why is bolus least desirable

Distends the stomach rapidly causing gastric discomfort and increased risk of reflux. Clients who are unconscious or have delayed gastric emptying at greater risk for regurgitation, vomiting, aspiration.

Symptoms dumping syndrome

Dizziness, sweating, nausea, vomiting. Caused by fluid shifts from circ blood to intestine and low BGL r/t surge of insulin.

Pathophysiology of initial burn

Effect of inflammatory process- affect layers of the tissues below the initial surface injury. ex, protease enzymes and chemical oxidants are proteolytics, causing additional injury to healing tissues and deactivatation of tissue growth factor. -neutrophils-phagocytize debris, consume available O2 at the wound sit- contribute to tissue hypoxia. -injured capillaries thrombose, causing localized ischemia and tissue necrosis. -bacterial colonization, mechanical trauma, and even topically applied antimicrobial agents can cause further damage viable tissue.

What are essential communication components in end of life care?

Empathy and active listening.

Health promotion and disease prevention for AIDS and HIV

Encourage the client to maintain up-to-date immunizations, including yearly seasonal influenza and pneumococcal polysaccharide vaccine (PPSV)

Respiratory patterns

Eupnea- normal respiratory rate and rhythm Hyperventilation- deeper respirations; normal rate Tachpnea- increased resp. rate Bradypnea- slow but regular respirations Apnea-absence of breathing may be periodic Cheyne-Stokes- resp. that gradually become faster and deeper then normal, then slower, alternates with periods of apnea Kussmaul's-faster deeper respirations without pauses

How often are smaller diameter flexible tubes removed and changed

Every 4weeks-3months depending on policy

Edema

Excess fluid in the interstitial compartment may be a manifestation of excess ECF volume May also arise from other mechanisms -Increased capillary hydrostatic pressure -increased interstitial fluid osmotic pressure -blockage of lymphatic drainage

Seborrheic dermatitis

Excess secretions. Red areas covered by yellowish, greasy appearing scales.

Open Method- wound is left uncovered

Exposes burned areas to air; Used only for areas where it is difficult to apply dressings (face, perineum) Isolation- HCP and visitors wear sterile gowns and mask -clients skin is sensitive to draft and temp changes- bed cradles or sheets are placed over client's - room is kept warm and humidified. Escharotomy- an incision into the eschar-done to relieve pressire on the affected area.

nutritional considerations

Extensive burns increase metabolism by as much as 100% -calorie needs may increase to 4000-5000 calories/day -protein needs are typically 2.0-2.5g/kg esp if burns are >10 TBSA . -calorie and protein needs increase if complications develop, and they lessen as wound healing progresses. -fluid needs increases significantly. with damages cells and skin, the body not only loses fluids but also struggles to retain fluids. Strict I&O records, wt loss is the result of fluid loss, wt daily, sufficient fluid added to reflect the fluids lost in wt change. Enteral and parenteral nutritional support -used with extreme precaution because of the increased risks for infection and sepsis. Vitamins and minerals; C, B-complex, iron, zinc -selenium and and copper have been shown to promote healing and decrease the risk of infection in burn clients.

Third spacing

Fluid shifts out of the blood into a body cavity or tissue and can NO LONGER reenter the vascular compartment

Why would a physician order a potassium hydroxide test?

For fungal infections that do not fluoresce the physician may take a scraping of the skin and perform a potassium hydroxide test

How does silence aide in communication with dying clients and their family?

Frequently related to the overwhelming feelings experienced at the end of life. Can also allow time to gather thoughts. Listening sends a message of acceptance and comfort. Also considerate patients ethnic, cultural and religious backgrounds.

Why Are GI tubes used

Gavage, lavage, decompression, sampling secretions for diagnostic testing, admin oral meds when patients can't swallow, control gastric bleeding (tamponade)

Intermittent feedings information

Generally given by gravity drip. Gradual filling of stomach at slower rate reduces bloated feeling w bolus. Thorough flushing after each feeding. Tube feeding administration sets replaced every 24 hours.

Androgenetic Alopecia

Genetically acquired condition; many refer to it as male pattern baldness.

Abnormal results of Papanicolaou Test

Genital warts, pelvic inflammatory disease, and persistent vaginitis mate correlate with HIV infection

HIV

Gradually impairs the ability of infected T4cells to recognize foreign antigens and stimulate Bcell lymphocytes. While massive numbers of viral particles are being released

When HIV encounters a helper T cell

HIVs binding protein with the T cell receptor and connects the HIV virus to the Tcell

Wood's light

Hand held device that ID's certain fungal infections that fluoresce under long-wave ultraviolet light

ADC

Has to do with dementia Normal concentrations of glutamate enhance memory and Learning, too much glutamate is lethal to brain cells

Distal sensory polyneuropathy DSP

Has to do with sensory Which is characterized by abnormal sensations such as burning and numbness in the feet and later in the hands

Furunculosis

Having multiple furuncles or boils.

Palliative Care

Health care aimed at symptom management rather than curative treatment for diseases that no longer respond to treatment.

What are the physical manifestations of approaching death in regards to Sensory Systems?

Hearing usually the last sense to disappear. Decreased sensation and decreased perception of pain and touch. Decreased taste and smell with disease progression. Blurring of vision, sinking and glazing of eyes, blink reflex absent, eyelids remain half open.

Adjunct drug therapy

Hydroxyure (Hydrea) which is usually used to treat cancer. When combined with antiretroviral drugs, hydroxyure interferes with viral replication, increasing anti-HIV effects

Hypomagnesemia clinical manifestations and treatments

Hyperactive reflexes, tetany, convulsions, tachycardia, hypertension, arrhythmias *increases neuromuscular excitability Treatments IV magnesium replacement/ orally

Hypercalcemia causes

Hyperparathyroidism(releasing to much from bones) malignancy hypophoshatemia (opposite from calcium) thyrotoxicosis hypervitaminosis D(high activated vit D) pheochromocytoma (adrenal gland) medications Immobility

intraocular lens implant

IOL - inserting of an IOL behind the iris at the time of cataract surgery - most common method - ultrasonography is used before surgery to determine the size and prescription of the IOL - can be made as a monofocal or multifocal lens - reduce the need for glasses . cloudy vision can be experience after surgery - membrane can become cloudy - to correct this, laser is used to clear the membrane . other complications: - infection - loss of vitreous - intraocular hemorrhage - retinal detachment - displacement of the IOL implant

Burn Injury Medical Management

Initial First Aid: First priority: Prevent further injury; Observe for respiratory difficulty for people who have been burned around the face or neck or who may have inhaled smoke, chemicals, steam, or flames. -inhalations can damage or severely irritate the mucous membranes lining the respiratory passages, resulting in edema in the resp tract. -secretions of mucus may be excessive-make breathing difficult. -O2 is administered, and begin IV fluid therapy

Checking tube placement Nasointestinal

Initially with xray. Electromagnetic system eventually will become more widely used. Other techniques are less reliable. Auscultation may be inconclusive because air escapes from distal tip is less pronounced as a result of small diameter of the tube. Also aspiration of stomach contents from small diameter tubes is not possible because negative pressure causes tube to collapse. Requires frequent checking.

Benefits/risks of tube feedings

Installing into stomach uses body's natural reservoir for food. Also reduces potential for enteritis bc chemicals in stomach tend to destroy microorganisms. Gastric feeding- increases potential for gastric reflux bc of volume and temporary retention within stomach. Placement of tubes within intestine reduces risk for gastric reflux(doesn't eliminate risk). Dumping syndrome- intestinally placed

Health promotion and disease prevention for AIDS and HIV

Instruct client how the virus is transmitted and ways to prevent infection such as the use of condoms, abstinence, and avoid sharing needles.

Nursing interventions for Hypovolemia

Intake and output, daily weights safely(fall precautions, change in near status) skin and mucous membrane care

Electrolyte homeostasis sub categories

Intake, absorption, distribution, excretion

Four sub process of fluid homeostasis

Intake,absorption, distribution, excretion

HIV

Integragtes RNA into host cell DNA through reverse transcriptase, reshaping the host's immune system

Protease inhibitor's

Interfere with the maturation of viral copies

Magnesium

Intracellular cation Plasma concentration 1.5 to 2.5 mEq/L acts as a cofactor in intracellular enzymatic reactions increases neuromuscular excitability

Placement of a tube into a body structure

Intubation

What are interventions focusing on meeting personal needs that will assist in alleviating stress?

Involvement in hobbies or other interests, scheduling time for yourself, maintaining a peer support system, and developing a support system beyond the workplace are beneficial. Professional assistance groups, informed discussion sessions and flexible time schedules as well.

Electrolyte Absorption

Is essential for electrolte to be used metabolically depends on -concentrations -binding proteins -Ph of intestine -medications

HIV-2

Is less transmittable, and the interval between initial infection with HIV-2 and development of AIDS is longer. Western Africa is the primary site of infection with HIV-2

The goal of Antiretroviral Therapy

Is to keep CD4 cell count above 350mm and bring the viral load to a virtually unexpected level. This level is no more than 500 or 50 copies, depending on the sensitivity of the selected viral load test

Candidiasis

Is yeast infection caused by the Candida albicans Microorganisms. May develop in the oral, Pharyngeal, esophageal, or vaginal cavities or in folds of the skin. Often called the thrush when located in the mouth. Inspection of the mouth, throat or vagina reveals areas of white plaque that may bleed when mobilized with a cotton tipped swab

Over hydration

Isoomotic hyperosmotic hypotonic

Tonicity

Isotonic hypertonic hypotonic

Antiretroviral drug therapy

It is critical of the clients with HIV comply with regular appointments for Laboratory blood test. Drugs are prescribed based on the clients CD4 Tcell and viral load counts, potential compliance, medication side effect profiles, and drug interactions

Photochemotherapy Purpose

It is one method used to treat psoriasis, a chronic skin condition

Medical management for HIV and AIDS

It is usually recommended that the clients infected with HIV receive pneumococcal, hepatitis B, and yearly influenza vaccines

Pruritus

Itching

Fiber containing formulas

Jevity, compleat, ultracal

Interstitial Compartment

Located between cells Extracellular -Rich in sodium, chloride, and bicarbonate ions -relatively low in k+, magnesium, and phosphate ions

Vascular Compartment

Located in blood vessels Extracellular -rich in protien

Dandruff

Loose, scaly material of dead, keratinized epithelium shed from the scalp in pt who may or may not have serborrheic dermatitis.

Why is thermoregulation altered in the older adult?

Loss of subcutaneous fat impacts this process

B

Macrophages attack and destroy foreign substances to the body. Where does this action occur? A. At the site of trauma B.In the lymph node C. In the vascular system D. In the thymus

Chloride

Major extracellular anion (negatively charged) Plasma concentration is 96-106 mEq/L levels are related to sodium levels can shift in response to acid bace imbalances

Potassium

Major intracellular cation 3.5-5.0 mEl/L blood volume essential for transmission and conduction of nerve impulses, normal cardiac rhythm, and skeletal and smooth muscle contractions Changes in PH affect K+ balances Hydrogen ions accumulate in the ICF during states of acidosis. K+ shifts out to maintain a balance of cations across the membrane acidosis- K+ moves out of the cell alkinosis-K+ moves into the cell

Serious burns

Neuroendocrine changes within the first 24 hours ACTH and ADH are released in response to stress and hyvolemia. =when adrenal cortex is stimulated, it released glucocorticoids, which cause hyperglycemia, and aldosterone, a mineralocorticoid, which cause Na retention. Na retention leads to edema as a result of flui shift and oliguria. -The client eventually enters a hypermetabolic state that requires increased oxygen and nutrition to compensate for the accelerated tissue catabolism

Shampoos used to treat pediculosis

Nix or RID

Gastronomy advantages

No nasal tube, easily concealed, long term use, infrequent tube replacement, can teach self care

Are products like boost, carnation, ensure for tube feedings?

No. They are primarily intended as supplements

Death Rattle

Noisy, wet sounding respiration's, due to the mouth breathing and accumulation of mucus in the airways.

7 major parts of the upper respiratory tract:

Nose, paranasal sinuses, pharynx, tonsils, adenoids, larynx, trachea.

Epistaxis

Nosebleed; nasal hemorrhage

Electrolyte Intake

Occurs normally through food and fluid intake but also oral medications, iv r blood infusions, body tubes

Fluid excretion

Occurs primary through the urinary tract(2.5L) could also occur through bowels, lungs, skin

Fluid distribution

Occurs through the vasculature -transfer to and between other compartments as a result of pressure and concentration gradients

Decompensation

Occurs when -causative problem becomes more severe -additional problems occur -compensation mechanisms are exceeded or fail * requires intervention to maintain homeostasis life threatening

Examples standard isotonic formula

Osmolite,isocal, nutren1.0,

Osmolarity

Osmotic pull per liter of solution

Medical management for HIV and AIDS

Our treat it with antiretroviral drugs, adjunct drug therapy to boost the immune system response and supportive care during opportunistic infections.

Hyperosmotic

Over administration of IV or oral hypertonic solution. Fluid shifts into the vasculature, causing increased plasma volume and decreased ICF. Can cause hypertensive crisis

Isomotic

Over hydration either rally or via IV with isotonic solution, can lead to edema

Alkalosis

PH >7.45 Systemic decrease in H+ concentration

Fully compensated

PH is normal Both Co2 and Bicarb are out of range

Partially compensated

PH is out of range Both Bicarb and Co2 are out of range

PEG tube

Percutaneous endoscopic gastronomy tube. Transabdominal tube inserted under endoscopic guidance. Anchored with internal and external crossbars called bumpers.

PEJ tube

Percutaneous endoscopic jejunestomy tube. Tube passed through a PEG tube into jejunum. Small in diameter so easily inserted into PEG tube.

Acidosis

Ph <7.35 Systemic increase in H+ concentration

Uncompensated

Ph is out of range only 1 bicarb or co2 is out of range the other is normal

Transabdominal tube management

Physician inserts G and j tubes but nurse must carefully monitor. G tubes may leak and cause skin breakdown.

Electrodesiccation Purpose

Plantar warts and skin tumors are examples of disorders treated by this method

Phosphate

Plasma concentraion is 2.5 to 4.5 mg/dL Bone and tooth mineralization important in metabolism ATP phosphate buffer system- acid base balance Integral part of the cell membrane- Phosolipid bilayer reciprocal relationship with serum calcium

When radiograph indicates intestinal tubing advanced beyond stomach:

Position client on right side 2 hours, back to fowlers 2 hours, left side 2 hours

Disadvantages NG tube

Possible damage to nasal and pharyngeal mucosa from friction/pressure Dilation of esophageal sphincter potentiating gastric reflux Aspiration potential, require frequent replacement for integrity of nasal tissue

What does postmortem care include?

Preparation or delegation of the body for immediate viewing by the family with considerations for cultural customs and in accord with state law and agency policies and procedures. Close the patients eyes, replace dentures, wash the body as needed (placing pads under the perineum to absorb urine and feces), and remove tubes and dressings. The body should be straightened, leaving the pillow to support the head to prevent pooling of blood and discoloration of the face. Allow privacy and as much time as the family needs with the deceased person.

Tube placement primary concern

Primary concern: comfort, preserve integrity of nasal tissue, locate tube in stomach not respiratory passages.

Prolonged Grief Disorder

Prolonged and intense mourning. Recurrent distressing emotions and intrusive thoughts related to the loss of a loved one, severe pangs of emotion, self-neglect, and denial of the loss for longer than 6 months.

Height protein formulas

Promote, isocal HN, ultracal HN plus

Hospice Care

Provides compassionate supportive care to patients and their families who are in their last stages of the dying.

NasoIntestinal decompression tube insertion

Same manner of insertion as NG tube. Peristalsis and weight of tungsten tip propels it past the stomach. Openings through distal end provide channels which intestinal contents are suctioned. Kept in place until intestinal lumen is patent or surgical treatment is instituted.

Hypotonic Dehydration

Serum electrolytes decreased Causes: addison disease, over use of diuretics, maratons or other long strenuous activities, where H2o is only intake Clinical manifestation: same as to little sodium Treatment: Hypertonic fluids

Hypertonic dehydration

Serum electrolytes increased Causes: extended fever, diabetes insipidus, diabetes, reduced fluid intake Clinical manifestations: same as to much sodium Treatment: Hypotonic Solutions

Isotonic dehydration

Serum electrolytes stay in normal range Causes: complete fasting, diarrhea; vomiting; burns; hemorrhage Clinical manifestation: dry mucous membranes, decreased urine output, dry skin, other symptoms of hypovolemia Treatment: administer normal saline or lactaid ringers or oral hydration

Antimicrobial Therapy

Silver sulfadiazine; Mafenide; Silver nitrate; Acticoat- a dressing that contains a thin, soluble film coat of silver and can remain on the burn for up to 5 days, which greatly reduces the pain associated with dressing changes. all drugs are applied using sterile technique.

Hypermagnesemia clinical manifestations and treatment

Skeletal muscle depression, muscle weakness, respiratory depression, and increased level of lethargy and drowsiness *decreased neuromuscular excitability Treatment Stop intake dialysis (kidney failure)

Monitors the outside environment - warning of danger - specialized nerve endings in the skin respond to pressure, pain, heta, and cold.

Skin and body hair

Rhinophyma

Skin condition of inflamed tissue that causes the nose to become permanently enlarged, red, nodular, and bulbous.

Basal Cell Carcinoma

Slow growing, commonly recurs, rarely mets

What are the physical manifestations of approaching death in regards to the Gastrointestinal System?

Slowing or cessation of GI function (may be enhanced by pain-relieving drugs). Accumulation of gas. Loss of sphincter control may produce incontinence. Bowel movement may occur before imminent death or at time of death.

Removal of Nasointestinal decompression tube speed

Slowly. Removal is in reverse direction through curves of intestine and valves of upper and lower end of stomach.

Which tubes preferred for providing continuous infusion of nourishment

Small diameter tubes. (Comfort)

Older adults tend to tolerate which type of feeding

Small, continuous feeding

Nasogastric tube information

Smaller in diameter than orogastric, larger and shorter than nasointestinal. Some have more than one lumen.

Respiratory Disease risk factors include:

Smoking (the single most important contributor to lung disease). Exposure to secondhand smoke . Personal or family history of lung disease. Genetic makeup . Exposure to allergens and environmental pollutants . Exposure to certain recreational and occupational hazards . Vitamin D deficiency . Obesity . Excessive exposure to acetaminophen prenatally and in the first 2 years of life.

primary extracellular cation

Sodium

Cations

Sodium, potassium, calcium, magnesium

Chronic asymptomatic infection of HIV

Stage can be prolonged and silent asymptomatic. Client can remain asymptomatic for 10 years. Over time The virus begins active replication using the host's genetic machinery. CD4 cells are destroyed. The viral load increases. Dramatic lost of immunity begins

Entry inhibitors

Stop HIV from getting inside a CD4 T cell by blocking call receptors on the cell surface

Gastric decompression info

Suction either continuous or intermittent. Continuous with unvented tube can cause adherence to stomach mucosa irritating and interfering with drainage. Intermittent suctioning and vented tub prevent/minimize those effects. Tube connected to wall outlet/portable machine. Tube clamped with ambulation/ after in stilling meds.

Intestinal decompression tube components

Suction lumen, vent lumen, openings for suction, radiopaque tungsten tip(weighted)

The use of G.I. tube's reduces or eliminates problems

Surgery or conditions affecting the G.I. tract. Peristalsis, vomiting, gas accumulation.

Ostomy

Surgically created opening that a tube may be inserted into

HIV vs T4cells

T4cells process is never as fast as replication of the virus. Eventually the T4cells become significantly depleted and immunodeficiency develops. The infected person ultimately dies from an opportunistic infection

cycloserine (Seromycin)

TB med; requires weekly serum drug levels to monitor for potential of neurotoxicity; level should be less than 30mg/mL; should be taken after meals- notify Dr if skin rash or early signs of CNS toxicity are noted; alcohol increases risk of seizures

Obstructive sleep apnea:

Temporary absence of breathing during sleep secondary to transient upper airway obstruction.

Apnea

Temporary cessation of breathing

Narrow tubes

Tend to curl with insertion bc of flexibility. Some supplied with stylet, weighted tip. Checking placement is difficult, obstructed more easily.

Empathy

The identification with and understanding of another's situation, feeling, and/or motives.

C

The instructor in the anatomy and physiology class is discussing the components of the blood. What would the instructor cite as the most abundant protein in plasma? A. Platelets B. Fibrinogen C. Albumin D. Globulins

B

The nurse is taking a health history on a new client with a suspected lymphatic or hematologic disorder. Why is it important for the nurse to inquire about any foreign travel this client may have done? A.To determine the varied sexual history of the client, if any. B.To determine the potential exposure to infectious agents. C. To determine if the client has had any blood transfusions D. To determine if the client adopted any specific dietary habits

D

The nurse, caring for a client in the emergency room with a severe nosebleed, becomes concerned when the client asks for a bedpan. The nurse documents the stool as loose, tarry, and black looking. The nurse suspects the client may have thrombocytopenia. What should be the nurse's priority action? A. Stop the nosebleed B. Put in an IV line C. Ask someone to clean the bedpan D. Notify the physician

A

The nursing instructor is discussing disorders of the hematopoietic system with the pre-nursing pathophysiology class. What disease would the instructor list with a primary characteristic of erythrocytosis? A. Polycythemia Vera B. Sickle Cell Disease C. Aplastic anemia D. Pernicious anemia

B

The nursing instructor is talking with their clinical group about coagulopathies. How should the instructor define coagulopathies? A. Coagulopathies are bleeding disorders that are characterized by abnormalities in the numbers and types of red blood cells in the body. B. Coagulopathies are bleeding disorders that involve platelets or clotting factors. C. Coagulopathies are bleeding disorders that are characterized by a deficiency of globulins in the plasma. D. Coagulopathies are bleeding disorders that involve the destruction of stem cells in the bone marrow.

C

The nursing instructor is teaching their clinical group about laboratory blood tests. What is the major function of erythrocytes? A. Act as mediators for the immune system B. Destroy invading organisms C. Transportation of O2 to the tissues and removal of CO2 from the tissues D. Oxygenation of the brain

The impetus to find alternative drug administration routes is related to the following

The oral route is associated with undesirable Gastrointestinal side effects

The impetus to find alternative drug administration routes is related to the following

The oral route requires numerous medications be taken simultaneously around the clock on a schedule that requires near perfect compliance

The impetus to find alternative drug administration routes is related to the following

The parenteral drugs require self injection which many people find objectionable

Bereavement

The period of time following the death of a loved one during which grief is experienced and mourning occurs.

B

The physician has ordered a Schilling test for an 82-year-old client you are caring for. You know that in some older adults the Schilling test poses a problem. Why would this be true? A.Older adults cannot be subjected to radioactive substances. B.Older adults are prone to cognitive problems or urinary incontinence. C.Older adults pose a risk of adverse reactions from nonradioactive B12. D.Older adults have a decreased resistance to infection.

Acne is related to what?

The rise in androgen hormone levels that occurs when secondary sex characteristics are developing.

Respiratory acidosis

Think co2 retention due to hypoventilation respiratory center depression, drug overdose head injury lung disease, COPD, pneumonia, respiratory failure airway obstruction Manifestations: Dizziness, lethargy, headache, convulsions, coma

Respiratory alkalosis

Think of excessive Co2 loss due to hyperventilation anxiety pain panic attacks head injury, brain stem tumors Manifestations: tingling sensations, confusion, tachypnea

Metabolic alkalosis

Think of excessive bicarbonate retention or loss of acid or chloride vomiting prolonged gastric suctioning medications(antacids) over-correction of acidotic states manifestations: numbness and tingling of fingers, toes, muscle cramps, tetney

Metabolic acidosis

Think of increased production of metabolic acids or loss of bicarbonates diabetic ketoacidosis lactic acidosis renal failure diarrhea Manifestations: headaches, hyperpnea, lethargy, confusion

AIDS

This stage can be life-threatening opportunistic infections. Is the end stage for HIV. Without treatment death can occur within 5years. People with AIDS have HIV, but not all people with HIV have AIDS.

HIV Replication

To enter a T cell lymphocyte the HIV must attach to the CD4 receptor and additional coreceptors on the surface of the cell

Hypercalcemia

To much calcium in the ECF

Gastronomy tube

Transabdominal tube located in stomach. Placed surgically/with an endoscope. Resembles long rubber catheter sutured to abdomen

Jejunestomy

Transabdominal tube that leads to jejunum of small intestine.

Hyperkalemia causes

Traumatic injuries/ burns/ destruction of cells renal failure hyperglycemia multiple blood transfusions metabolic acidosis( hydrogen will be pushed into the cell) medications(digoxin, ACE inhibitors, potassium sparring diaretics) aldosterone deficit (addisons) retain K+

Additional medical management includes

Treating anorexia, diarrhea, weight loss, and side effects of Antiretroviral medications

Is the following statement true or false? An infection within a burn wound can be life-threatening.

True. An infection within a burn wound can be life-threatening. Outcome of a burn injury depends on the initial first aid and subsequent acute treatment. Three complications of burns can be life-threatening: inhalation injury, hypovolemic shock, and infection.

Transabdominal tubes

Tubes placed through abdominal wall providing access to various parts of GI

If the drainage holes of tubes are adhering to gastric mucosal wall nursing interventions

Turn suction off momentarily. Reposition client .

C

Undifferentiated cells that migrate to the thymus gland develop into which of the following? A. A lymphocytes B. D lymphocytes C. T lymphocytes D. S lymphocytes

Risk factors for patients with HIV and AIDS

Unprotected sex, multiple sex partners, occupational exposure, blood transfusions, intervenous drug use with a contaminated needle

the blood pressure of a burn victim has stabilized. what is the next best means of assessing the client's response to the initial burn treatment?

Urinary output

HIV cannot be transmitted through

Urine, stool, vomit or sweat

Hyperkalemia

related to increased intake of potassium, shift of K+ for ICF to ECF, decreased renal excretion, insulin deficiency, or cell trauma

Inserting nasointestinal tube guidelines

Wash hands Gloves Activate lubricated bond Secure stylet in tube Insert tube to second mark (places tube in presumed stomach) Aspirate fluid using 50-mL syringe and test pH Loop tubing temporarily to cheek, if test for placement suggests it is in the stomach. Ambulate/position on right side at least 1 hour. (Allow tube to Move to pyloric valve) Secure tube at nose when third measure mark is at nasal tip Verify placement by x ray especially in unconscious/ lack of gag reflex Remove stylet using gentle traction Store stylet in clean wrapper at bedside NEVER reinsert stylet while tube in client. Measure/record length of tubing extended from nose

Assessing pH of aspirated fluid

Wash hands Gloves Aspirated small amount w/ clean syringe Drop sample on indicator strip Compare color test strip with guide on container *stomach fluid usually pH 1-3 very acidic. *pH5-6 indicates medications to decrease gastric acidity pH7 and up indicates tube is in respiratory tract

Checking gastric residual guidelines

Wash hands Gloves Stop infusion of tube feeding Aspirate fluid using 50mL syringe Continue aspirating until no all has been obtained Measure and record Reinstill fluid Postpone feeding if amounts exceed guidelines Check again Q30min Provide or resume feeding if WNL

Assessment of patient with tube feeding

Weight, I&O, bowel, lung sounds, temp, nasal and oral mucus membranes, breathing pattern, gastric complaints, status of distention, vomiting, bowel elimination patterns, skin condition at site, residual

A

What is hematopoiesis? A. The manufacture and development of blood cells B. The production of lymphatic fluid in the body C. The making of red blood cells and lymph D. The development of lymph in the bone marrow

D

What is the rationale for the classification of leukemia? A. Whether it attacks younger or older people B. Whether it is acute or chronic C. Which bone marrow it arises from, red, or yellow D. Which bone marrow stem cell line is dysfunctional

C

When assessing for signs and symptoms related to hematopoietic and lymphatic systems, what details should the nurse ask about further? A. A client who does not eat at night. B. A female client, age 50, yet childless. C. A client undergoing cancer treatment. D. A female client who has melanin-related skin problem

When are tube feedings used?

When clients have intact stomach or intestinal function but are unconscious, had extensive mouth surgery, difficulty swallowing, esophageal or gastric disorders

Clients who neglect to take Antiretroviral drugs as prescribed

When drug levels are not adequately maintained, viral replication and mutations increase.

Entry inhibitors

Which interfere with the ability of the virus to fuse with and enter the CD4 Cell

AIDS drug assistance program (ADAP)

Which is administered by the US department of health and human services

HIV Replication

Which means to reproduce more copies, HIV becomes a parasite of helper T cells. HIV alters the helper T cells genetic code to make more viral particles. The T cells nucleus follows the DNAs directions and forms long chains of viral particles enclosed within its membrane.

Acute retroviral syndrome, also called Acute HIV syndrome

Which often is mistaken for the flu or some other common illness. Some manifestations include fever, swollen and tender lymph nodes, pharyngitis, rash about the face, trunk, Palms, insoles. Muscle and joint pain. Headache, nausea and vomiting, and diarrhea. Enlargement of the liver and spleen, weight loss, your logic symptoms such as visual changes or cognitive and motor involvement

A

Which protein in plasma functions primarily as immunologic agents? A. Gamma globulins B. Albumin C. Fibrinogen D. Beta globulins

Nursing management---Assessment

Wound and how the burn injury has affected the Client's status Calculation and infusion—fluid replacement requirements Treatment of shock; -administer prescribed analgesics for Pain relief Wound care: Antimicrobials; Dressings; Monitoring for infection; Emotional support Client teaching: Exercise; adequate nurition intake , Pressure garments; Skin care measures

Preparing for home care:tube feedings

Written instructions: Places to obtain equipment/formula Amount and schedule for each feeding/flush using household measurements Guidelines for delaying feeding Special instructions : skin, nose, stomal care, frequency/type of products What to report: weight loss, reduced urination, weakness, diarrhea, nausea, vomiting, breathing difficulty Name and phone # of people to call with questions Date, time, place for continued follow up

B

You are assessing vital signs on a hemophiliac who has come to the clinic complaining of an upper respiratory infection. What is the suggested method to check the temperature for a client with hemophilia? A. Taking the temperature orally B. Taking the temperature tympanically C. Taking the temperature rectally D. Taking the temperature on the forehead

C

You are assisting your client with multiple myeloma to ambulate. What is the most important nursing diagnosis to help prevent fractures in this client? A. Increased mobility B. Adequate hydration C. Safety D. Adequate nutrition

C

You are caring for a 13-year-old diagnosed with sickle cell anemia. The client asks you what they can do to help prevent sickle cell crisis. What would be an appropriate answer to this client? A. Avoid any sports that tire you out. B. Drink at least 8 glasses of water every day. C. Avoid any activity that makes you short of breath. D.Stay on oxygen therapy 24/7.

B

You are caring for a client who has had prolonged treatment for osteoarthritis with Celecoxib. The client complains of fatigue, fever, chills, headache, and a vaginal infection. What would you suspect is wrong with this client? A. Multiple myeloma B. Agranulocytosis C. Leukopenia D. Leukemia

D

You are caring for a client who is undergoing bone marrow aspiration to determine their blood cell formation status. What nursing intervention should you provide to your client after the test? A. Administer oral radioactive vitamin B12 to the client. B. Administer a nonradioactive B12 injection. C. Collect urine for 24 to 48 hours after the client receives the nonradioactive B12. D. Support the client during a bone marrow aspiration and monitor the status.

B

You are caring for a client with multiple myeloma. Why would it be important to assess this client for fractures? A. Osteopathic tumors destroy bone causing fractures. B. Osteoclasts break down bone cells so pathologic fractures occur. C. Osteolytic activating factor weakens bones producing fractures. D. Osteosarcomas form producing pathologic fractures.

A

You are caring for a client with thalassemia who is being transfused. What your role during a transfusion? A. To closely monitor the rate of administration B. To administer vitamin B12 injections C. To instruct the client to rest immediately if chest pain develops D. To assess for enlargement and tenderness over the liver and spleen

D

You are caring for an 87-year-old female who has been admitted to your unit with anemia. What would you suspect? A. Excessive consumption of coffee or tea B. Elimination of iron by the body C. Decrease in the total body iron stores with age D. Blood loss from the gastrointestinal or genitourinary tract

B

You are caring for three clients who have the following blood count values: Client A has 24,500 white blood cells (WBCs), client B has 13.4 g/dL hemoglobin, and client C has a 250,000/mm3 platelet count. Which statement correctly describes the condition of each client? A.Client A has a normal WBC count, client B has a higher hemoglobin count than normal, and client C has a normal platelet count. B.Client A has a higher WBC count than normal, client B has a normal hemoglobin count, and client C has a normal platelet count. C.Client A has a higher WBC count than normal, client B has a normal hemoglobin count, and client C has a higher platelet count than normal. D.Client A has a normal WBC count than normal, client B has a normal hemoglobin count, and client C has a normal platelet count.

D

You are presenting an educational workshop for a local community group. You have been asked to speak about older adults and their health. What is the most important piece of information to include in this presentation? A. Older adults are more fragile than younger adults. B. Older adults get sicker than other people. C. Older adults take longer to heal than other people. D. Older adults are more susceptible to infections and malignancies.

ADE

You are studying the different forms of leukemia in your pathophysiology class. Which of the following would you be studying? Select all that apply. A. Chronic myelocytic B. Acute pernicious C. Chronic aplastic D. Acute lymphocytic E. Acute myelocytic

C

Your client has just been prescribed oral iron. Why would you advise this client to avoid taking their medication with coffee, tea, eggs, or milk? A. Grand mal seizures may result. B. Untoward reactions may occur. C. Absorption of iron will decrease. D. Coffee, tea, eggs, and milk interact with oral iron.

C

Your client is taking medications that depress the hematopoietic system. What signs should you closely monitor in this client? Your client is taking medications that depress the hematopoietic system. What signs should you closely monitor in this client? A)Signs of leukocytosis B)Signs of painful joints and discomfort C)Signs of leukopenia and thrombocytopenia D)Signs of hemolysis

Eccrine glands

release water and electrolytes, such as sodium and chloride, in the form of perspiration.

Tidaling

rise and fall; may refer to water in water-seal chamber of chest drainage system

egophony:

abnormal change in tone of voice that is heard when auscultating the lungs.

inhalation of hot air, smoke or toxic chemicals

accompanying injuries such as fractures, concurrent medical problems, and the client's are increases the mortality rate from burn injuries.

Pneumonia

acute inflammation and/or infection of the lungs when an infectious agent enters and multiples- common cause of death from infection; very young, adults over 65, immunocompromised most at risk; HAP, CAP Tx- broad spectrum antibiotics, after culture and sensitivity report narrow spectrum agents. Rest and fluids. Expectorants, bronchodilators, analgesics, nebulized mist, supplemental O2 (prevention vaccine to prevent Streptococcus pneumoniae) S&S- fever, shaking, chills, chest pain, dyspnea, fatigue, and productive cough. Sputum is purulent or rust colored/ blood tinged. Crackles and wheezes may be heard. Confusion and lethargy in older patients.

surgical management

additional treatment modalities to promote healing include debridement, applications of a skin substitute, or skin grafting.

a burn wound periodically is debrided using hydrotherapy. what nursing action is essential shortly before each debridement?

adminster a prescribed analgesic.

contact lens for cataract

advantages: - peripheral vision is not lost and objects appear their actual size disadvantage: - lens must be removed at night which is harder for older pt

Mucolytic

agent that liquefies sputum

Antitussive

agent that prevents or relieves cough

Expectorant

agent that promotes removal of pulmonary secretions

Exacerbation

aggravation of symptoms

Types of pneumonia

bacterial pneumonia , viral pneumonia(caused mostly by flu virus), fungal pneumonia , aspiration pneumonia, ventilator associated pneumonia, hypostatic pneumonia, chemical pneumonia

Cyanosis

bluish color of the skin, nail beds, and/or lips due to an insufficient amount of oxygen in the blood

s/s of dry macular degeneration

blurred vision - perception of color can be changed - bull's eye image appears when becomes irreparably damaged

benign paroxysmal positional vertigo (BPPV)

brief periods of severe vertigo when cleints ove their heads back and toward the affected ear - debris in the semicircular canals from trauma, infection, or other events - meclizine is used for 1-2 weeks

A cough in the morning with sputum pro- duction may indicate :

bronchitis.

Helps assess skin temperature

by placing the dorsum of the hand on the surface of the skin

CT scan

can show cancers, pneumonia, emphysema; obtains more info after abnormal chest xray; evaluate trauma and blood vessel abnormalities in chest; PT NPO before procedure, some receive contrast material, ask about allergies

carcinomas

cancers originating from epithelial cells

lymphomas

cancers originating from organs that fight infection

leukemias

cancers originating from organs that form blood

position test

cardinal positions - assess eye strength and cranial nerve function - ask pt to focus on an object that is 12 inches away and moves the object through six positions in a clockwise direction

ishihara polychromatic plates

cards with pattern of a number is embedded in a circle of colored dots

HIV is found in:

cervical cells, blood, inter body fluids

Paradoxical respiration

chest movement on respiration that is opposite of what is expected

the risk for acquiring a burn injury is highest among

children and adults older than 60 years of age.

amsler grid

clients with macular problems - made up of geometric grid of identical squares with a central fixation point - client looks at the center of the grid and reports if they see distortion of squares - if macular problems: squares are faded or wavy

can interfere with vitamin D synthesis

cloudy environments and air pollutants

Nail base and the skin greater than 160º angle indicates:

clubbing of nails suggests long-standing cardiopulmonary disease

hypoxia:

decrease in oxygen supply to the tissues and cells.

myelosuppression

decreased bone marrow function

thrombocytopenia

decreased platelet count

leukopenia

decreased white blood cell count

s/s of retinal detachment

definite gaps in their vision - blind spots - describe as curtain being drawn over their field of vision - see flash of light - sees cobwebs or moving particles - floaters - not painful - when the retina is inspected with an ophthalmoscope, the tissue appears gray int he detached area

Pt w/ Fx'd femur has Sx's of nausea, vomitting, diarrhea. What is the Pt at risk for?

dehydration is a risk factor for skin breakdown and pressure ulcers

Throat culture

determines presence of viral or bacterial pathogens

retinoscopy

determines the focusing power of each eye - use of a retinoscope and trial lenses - a handheld instrument that produce a line of light is focused in the eye - light appears distorted in the eye of clients with refractive errors - trial lenses of varying refractive powers are then placed in front of the eye until the light streak does not deviate in any direction

Cancer vaccines

development of cancer vaccines is relatively new. Vaccine currently approved in the U.S. is the HPV (human papillomavirus) vaccine, which may help prevent women from getting cervical cancer.

Atypical

deviating from normal

Dyspnea

difficult or labored breathing; shortness of breath

Dysphagia

difficulty in swallowing

Anergy

diminished ability of the immune system to react to an antigen

Bronchoscopy:

direct examination of the larynx, trachea, and bronchi using an endoscope.

brachytherapy

direct internal application of a high dose of radiation within a sealed source on or within a tumor

Emphysema

distention of interstitial tissue by gas or air; chronic pulmonary disease marked by terminal bronchiole and alveolar destruction and air trapping; "barrel chest"

anatomy of ears

divided into three: 1) outer 2) middle 3) inner (helps with balance)

audiometry

done by audiologist - measures hearing acuity precisely by decibels - sound is projected to one ear at a time - lowest sound normal individual can hear is 20dB - painful sound is heard at 120 dB

Respiratory excursion

downward movement of the diaphragm with inspiration

Bronchdilator

drug that expands the bronchial tubes by relaxing bronchial smooth muscle

ophthalmoscopy

examines the fundus (interior) of the eye - direct ophthalmoscopy: instrument that illuminates the internal surface of the eye and allows the examiner to see the lens, retina, and blood vessels, and disc under magnification - indirect ophthalmoscopy: use an instrument that produces a bright intense light. no magnification is involved

Polycythemia

excessive red cells in the blood

pulmonary diffusion:

exchange of gas molecules from areas of high concentration to low concentration.

Hemoptysis:

expectoration of blood from the respiratory tract.

Stimulates production of melanin

exposure to ultraviolet light temporarily stimulates the production of melanin to absorb harmful radiation

extrinsic factors that faciiltate a heat stroke

exposure to warm temperatures and densely saturated moist air may raise the body temperature and result in heat strok

hyperopia

farsightedness - people with shorter eyeballs

superficial

first degree pink or red edema, but subsides quickly; no scarring ex) sunburn epidermis and part of dermis - painful with pink and red edema, but subsides quickly, no scarring. -heals less then 5 days, usually spontaneously with symptomatic tx, infection, increased metabolism, and scarring do not occur,

retinal angiography

fluorescein angiography - used to detect vascular changes and blood flow through the retinal vessels - water soluble dye is injected into peripheral vein - special camera to photograph the appearance and distribution of the dye in the retinal arteries, capillaries,and veins at 1 sec intervals - dye cause skin to yellow slightly for 6-8 hr - urine is bright yellow but less noticeable 1-2 days . conditions that affect retinal circulation - DM - HTN - drug toxicity - tumors - AIDS

romberg test

for persons ability to sustain balance - eyes are closed and arms are out with feet together - any movement of arms, body swaying is not normal - additional testing is needed to confirm

4 paranasal sinuses:

frontal, ethmoid, sphenoid, maxillary.

respiration:

gas exchange between atmospheric air and the blood, and between the blood and the cells of the body.

s/s of glaucoma

open angle: - asymptomatic until later when a routine ophthalmologic exam - blurred vision - halos around lights - reduced peripheral vision - feeling of eye prescription needs to be changed . close angle: - symptomatic sudden - eye is rock hard - painful sightless - nausea and vomiting - conjunctiva is red - cornea is cloudy or steamy - attack is self limiting, but each attack is worse

Histoplasmosis

opportunistic fungal infection; begins as respiratory infection; S&S fever, dyspnea, cough and weight loss; may be enlargement of client's lymph nodes, liver and spleen.

outer ear

or auricle - pinna: fleshy external projection of the ear - external acoustic meatus: 1 inch canal that extends to the tympanic membrane - tympanic membrane: ear drums

inner ear

or labyrinth - cavities and canals that contains fluid - contains: a) cochlea: provides for hearing b) semicircular canals: promote balance c) vestibulocochlear nerve: cranial nerve VIII - organ of corti: located in the cochlea, are sound receptors that feels vibration of fluid from the stapes . vestibulocochlear nerve: the auditory or acoustic nerve, are made up by the cochlear nerve (8th cranial nerve) and the vestibular nerve. transmit info about motion. BOTH FOR BALANCE

Osmolality

osmotic pull exerted by all particles per kilogram of water

impacted cerumen

otalgia: pain in the ears

Metabolic alkalosis

pH and bicarbonate level elevated

Respiratory alkalosis

pH will be elevated and PCO2(carbon dioxide) level decreased

PACO2 =

partial pressure of alveolar carbon dioxide.

PAO2 =

partial pressure of alveolar oxygen.

PaO2 =

partial pressure of arterial oxygen.

PCO2 =

partial pressure of carbon dioxide.

P50 =

partial pressure of oxygen when the hemoglobin is 50% saturated.

PO2 =

partial pressure of oxygen.

Pv-CO2 =

partial pressure of venous carbon dioxide.

Pv-O2 =

partial pressure of venous oxygen.

Meds for Tx of scabies mite and lice

pediculicides are used in the treatment of infestations with the scabies mite and lice

Oxygen saturation:

percentage of hemoglobin that is bound to oxygen.

visual field examination

perimetry test - measures peripheral vision and detects gaps in visual field - pt looks straight ahead and focus on object - white object or light is placed on the side of the pt's vision - pt then indicates the point at which he or she sees the stimulus without directly looking at it

vision specialists ophthalmologist

physician or doctor of osteopathic medicine who specializes in the medical and surgical treatment of eye disease licensed to diagnose and treat eye disorders, prescribe medications, perform surgery, and prescribe corrective lenses or contacts

otolaryngologists

physician who specialize in the diagnosis and treatment of ear, nose, and throat disorder

Rhinoplasty

plastic surgery of the nose

physiologic dead space:

portion of tracheo bronchial tree that does not participate in gas exchange.

P =

pressure

once the skin graft heals

pressure garment made elasticized cloth or plastic are applied over the grafted area. -these garments smooth the grafted skin, reducing scarring amd the potential for wound contractures. - the client may need to wear a pressure garment for up to 2 years.

carcinogenesis

process of malignant transformation & altering of teh genetic structure of DNA within the cells.

Capnography

process of measuring a person's exhaled carbon dioxide; provides continuous measurement of the PTs ventilation status; used most often when PTs are intubated.

Fowler's position

promotes lung expansion; preferred position for eating and NG tube insertion

terms to look for in observation of eyes

ptosis: drooping upper eyelid proptosis: extended or protruded upper eyelid that delays closing or remains partially open nystagmus: uncontrolled oscillating movement of the eyeball

Empyema

pus in body cavity ; especially the pleural space

color vision testing

quantitative color blind test - different hues of disc are arranged in a continuum of gradually changing hues

Ventilation Perfusion Scan (lung scan or VQ scan)

radioactive substance is injected IV; scan views blood flow to lungs (perfusion) OR radioactive substance is inhaled showing how well O2 is distributed in lungs

Chest tube disconnection (closed chest tube drainage system)

reattach it to drainage system or submerge the end in a bottle of sterile water or saline to reestablish a water seal; if it become dislodged from insertion site, cover insertion site with sterile gauze

s/s of conjunctivitis

redness, excessive tearing. swelling, pain, burning or itching, purulent drainage - photophobia - starts in one eye and spreads to other by hand contact - herps simplex virus: lesions appear near the lid margins - severe case: lymph nodes near are enlarged . test - diagnosed by visual - or history of exposures to someone with symptoms

Treatment of dehydration

rehydration -oral -intravenous correction of electrolyte imbalances

Causes of Increased Airway Resistance

• Contraction of bronchial smooth muscle—as in asthma • Thickening of bronchial mucosa—as in chronic bronchitis • Obstruction of the airway—by mucus, a tumor, or a foreign body • Loss of lung elasticity—as in emphysema, which is characterized by connective tissue encircling the airways, thereby keeping them open during both inspiration and expiration

Electrodesiccation Treatment

• Electrosurgery- is the use of electrical energy converted to heat • Heat destroys the tissue

Hair assessment

• applies not only to the head • also to other locations such as the eyebrows, eyelashes, chest, arms, pubis, and legs • notes the color, texture, and distribution • keeping sex- and age-related variations in mind.

pressure sore occurs when...

• capillary blood flow to an area is reduced • when the skin over a bony prominence is compressed between the weight of the body / a supporting surface for a prolonged period

Laser Therapy Purpose

• energy of light vaporizes tissue and coagulates bleeding vessels

skin forms a chemical substance called 7-dehydrocholesterol

• facilitates the synthesis of vitamin D when the skin is exposed to sunlight • Vitamin D = formation of healthy bones and teeth • Dark-skinned people do not synthesize vitamin D as readily as light-skinned people • Cloudy environments and air pollutants that block sunlight also interfere with vitamin D synthesis • vitamin D is added to some food sources, such as milk

Laser Therapy Treatment

• light amplification by the stimulated emission of radiation • Lasers convert a solid, gas, or liquid substance into light

Surgical Excision Treatment

• necessary to remove a skin lesion • tissue may be excised conventionally or with a laser, cryosurgery, or electrodesiccation

Concavity of the nails

• referred to as spooning because of their characteristic appearance • sign of iron-deficiency anemia • Clubbing of the nails, evidenced by an angle greater than 160 degrees, suggests long-standing cardiopulmonary disease

The skin is composed of two layers:

• the epidermis, the outermost layer • the dermis, which lies below the epidermis • epidermis contains an outer layer of dead skin cells, the stratum corneum, that forms a tough protective protein called keratin.

Purpose of a therapeutic bath:

• various solutions, powders, and oils, but no soap, are added to water • client's entire body / only a part is submerged • used to relieve inflammation / itching and to aid in the removal of crusts and scales

Lifestyle changes important to some skin disorders include:

•Some skin disorders (psoriasis/herpes) grow worse when the person is tired / under emotional stress •rest and sleep are important •Diet - certain foods contribute to or aggravate skin disorders

Measures that reduce conditions under which pressure sores are likely to form include:

•Turning and repositioning the client frequently •Keeping client's skin clean and dry •Massaging bony prominences if the client's skin blanches with pressure relief •Using a moisturizing skin cleanser rather than soap •Applying pressure-relieving devices to the bed and chairs •Padding body areas that are subject to pressure and friction •Avoiding shearing, a physical force that separates layers of tissue in opposite directions, such as when a seated client slides downward •A nail assessment includes -observes the color of the nailbeds - Pink nailbeds suggest adequate oxygenation-however, the nails may be darker in clients other than Anglo-Americans •assess tissue perfusion, the nurse compresses the nailbeds, causing them to blanch, and then releases them.

A skin assessment and normal findings include:

•examine the skin on all areas of the body -as head-to-toe assessment / focused assessment •Good lighting • skin should be smooth, unbroken, of uniform color, warm, and resilient •It should feel neither wet nor unusually dry •Color deviations have several possible causes. •While examining may detect changes in its structure or integrity. •document the sites of any abnormalities •nurse assesses temperature by placing dorsum of the hand on the surface of the skin •can detect moisture with the palmar surface. •determine the quality of skin turgor •Tight, shiny skin suggests fluid retention •loose, dry skin may indicate dehydration •Poor nutrition can lead to changes in skin integrity and turgor

Application and purpose of a wet dressing:

•used to apply a solution to a skin lesion • have a cooling and soothing effect. •The nature of the skin lesion - open or intact -determines whether sterile technique is required •A dry dressing consisting of gauze or other porous material is first applied to the area •Cotton is not used because of its tendency to stick to wound surfaces. • dressing is then saturated with the prescribed liquid (Sterile NS). •Dressings can be TEMPORARILY anchored with nonallergenic tape or roller gauze •Some wet dressings are left in place until dry as a method of debridement, •When the dried gauze is removed, it usually contains bits of trapped debris in the gauze mesh. •Removing dead and dying tissue provides an environment that fosters and promotes regeneration of healthy tissue and closure of the wound