NUR 211

What will you see with lupus?

Dermatological (butterfly rash) Butterfly rash (malar) less than 50% of clients Musculoskeletal (swan neck deformity)

Facts about RA

Diagnosis is a combination of History and physical Joint involvement Duration of symptoms Lab results

What is addiction?

A primary, chronic, neurobiologic disease manifested by behaviors involving problems with control over substance abuse There are non-substance addictions also 4 C's of Addiction Compulsion Craving Consequences Control Compulsion- overwhelming urges to use Craving- a physical need, hunger Consequences - uses in spite of negative consequences Control- loss of control over use

Multiple antibiotics necessary for TB

1 Antibiotic: Mutation rate 1 in 100 million (108) Bacterial load exceeds this in active disease. Mutation rate for two abx is 1016 To avoid resistance

What is HIV like in the US?

1 million people currently live with it 50,000 new cases annually Deaths from HIV reduced over time due to better treatment and advances in medicine "Generally" HIV is more common in those: Poverty Drug use- IV drug use Lack of access to health care- not able to get regular screenings About 25% of people living with HIV are over age 50- face comorbidities, lack of condom use, may have had blood transfusion or organ transplant before 1985 screenings, other influences? Takes awhile to learn that you have it, not testing for it a lot, not a lot of education about reducing exposure, not using condoms in nursing homes

Statistics for TB

100 immunocompetent people sufficiently exposed 30 of them develop latent TB 3 of them develop active TB later in life 3% of the population that is sufficiently exposed TB is not highly infectious Transmission requires close, frequent, or prolonged exposure Cannot be spread by Touching, sharing food utensils, kissing or physical

Hypersensitivity

4 types ranging from I-IV Type I - IgE Type II - IgG or IgM Type III - antigen/antibody complex Type IV - sensitized T cells Not necessarily about the substance but more about how your body reacts to it

Compartment syndrome

46 anatomical compartments in the body, 36 in extremities This is an emergency Requires surgical intervention if no improvement Compartment pressures can be monitored Sudden decrease in blood flow to the tissues Can lead to necrosis, loss of limb Keep extremity at level of heart, not above Too much pressure in a certain area of the tissue and its affecting circulation Pain, pallor, pulselessness, parasthesia, and paralysis (5 P's) Fasciotomy- excision of the fascia Pulselessness is a late sign Cross-sections of anatomic compartments. A. Compartments of the left lower leg. B. Compartments of the left forearm. From Chapman, M. W., Szabo, R. M., & Marder, R. A. (2000). Chapman's orthopaedic surgery (3rd ed., pp. 395-396). Philadelphia: Lippincott Williams & Wilkins.

Interpreting responses to TB skin test

> 15 mm induration Considered high risk for ANYONE > 10 mm induration Considered high risk if: Immigrated to US < 5 years ago, IV drug users, residents or workers in institutions, Mycobacteriology lab personnel, people with chronic conditions (but not immunocompromised) > 5 mm induration HIV-infected people, recent contact with a person with active TB disease, those with fibrotic lesions on Chest X-ray, organ transplants, those taking > 15 mg prednisone daily for more than a month This is a table right from the book. This is more for clinical knowledge. Can have a false negative if you are immunosuppressed, if you've been infected in the last 8-10 weeks or if its just been present for a really long time or if you have had a recent vaccination False positives can be if you have a different type of TB besides the mycrobacterium, some other countries use a vaccine so that will cause a false positive if someone had the vaccine

Alcohol abuse

A CNS depressant Affects Gaba receptors Leads to relaxation and decreased inhibition Intoxication: Slurred speech Impaired coordination and attention Judgement altered Unsteady gait Memory impacted Blackouts can occur Hypoglycemia can mimic alcohol intoxication

Gaba receptors and alcohol

A chronic alcohol user will require a higher dose of medications that act on Gaba receptors due to tolerance Examples: Benzodiazepines, barbiturates, propofol

What is a fracture?

A complete or incomplete disruption of the continuity of the bone Structures near the bone fracture are impacted Soft tissue Bleeding into joints and muscles Rupture tendons Nerve and blood vessel damage Organs damaged by punctures Can be classified by location, type, and description of the fracture Can be open or closed

Acting out

A defense mechanism Common with children and adolescents A way to deal with emotional conflict or stressors Trying to compensate for feeling powerlessness

Denial of substance abuse

A defense mechanism May deny any substance abuse or might minimize the problem Thorough screening and assessment needed to identify individuals with substance abuse

4 main types of leukemia

Acute Myeloid Leukemia (AML) Acute Lymphocytic Leukemia (ALL) Chronic Myeloid Leukemia (CML) Chronic Lymphocytic Leukemia (CLL) Acute means quickly and are the blast cells (baby cells, immature cells) Chronic is over time (mature cells)

Stroke in children and adolescence- treatment

ABC's Treatment of underlying medical condition Control seizures Diazepam (0.25-0.5 mg/kg) Phenobarbital (5-6mg/kg) Maintain ICP Dexamethasone Mannitol Post Surgical care Arterial aneurysm Seizures-compromise respirations, increase ICP Anticoagulants provide no benefit for those with vascular occlusions and are contraindicated in Bleeds.

Nursing assessment for stroke

ABCs Airway Blood pressure HR Neurological Altered LOC Seizures NIHSS Speech or visual disturbances Headache N & V History Time of onset Single most important point in the history is to find out time of onset Airway-decreased LOC or absent gag reflex Hypoxia and hypercarbia can make worse B/P elevates as a protective measure-administer medications Maintain fluid and electrolyte balance Highest priority is decreasing morbidity and mortality Goals of stroke prevention Health promotion for the well individual Education and management of modifiable risk factors to prevent stroke. How do you decrease morbidity and mortality from stroke? Maintain and improve cerebral perfusion First 3 hours after a stroke you are at risk for rebleeding ICH-chance of rebleeding will occur within the first 48 hours.

Herniated disk

AKA ruptured disk Nucleus protrudes through the annulus, placing pressure on the spinal nerve Continued pressure Noted on MRI - preferred diagnostic tool Neurological exam Most commonly occur in the cervical and lumbar disks

History of stroke

AKA: Brain Attack Recognized over 2,400 years ago by Hippocrates Called apoplexy which means "struck down by violence" in Greek 1996, not too long ago, a revolution in care was introduced to the stroke patients with thrombolytic therapy.

Lab results for lupus

ANA present in 95% of people with SLE? A person who has ANA might not have SLE Anti-smith (Sm) antibodies in 30-40% and is considered diagnostic? If a person has Sm antibodies, they have SLE LE cell prep can be positive in other rheumatic diseases Labs are used to monitor disease progression after diagnosis (CBC) Have to meet 4 of the 11 criteria to be diagnosed because it is hard to diagnose, look at history, manifestation and lots of other things

Cocaine effects

Immediate euphoria Mental alertness Paranoia Extreme happiness and energy Can cause bizarre, violent behavior Constricted blood vessels Dilated pupils Nausea Increased body temp Increased BP and HR Tremors Cardiac arrhythmias, MI, Seizures, and strokes

Symptom development for HIV

Fever Swollen lymph glands Sore throat Headache Malaise Nausea Muscle and joint pain Diarrhea More "unique" ones Diffuse rash with seroconversion? Seroconversion is when HIV antibodies develop Aseptic meningitis Peripheral neuropathy Facial palsy Guillain-Barre Symptoms that may develop in the first 2-4 weeks of HIV

Clinical manifestations in osteoporosis

First thing a person might "feel" Back pain First sign could be an actual fracture Most common areas affected Spine Hip Wrist

Extra-articular manifestations of RA

Flexion contractures and hand deformities cause diminished grasp strength These clients can develop cataracts and lose their vision Immobility, pain, vision loss, inability to perform basic tasks Self-care deficits, and they may develop depression

Immediate care for fractures

Immobilization Joints proximal and distal also immobilized Assess neurovascular status Before and after splinting Open fractures Cover with sterile dressing Remove clothing form area Pain management

What about labs or x-rays for osteoporosis?

Labs Only if there is a fracture Then alkaline phosphatase may be elevated X-ray can but Must have 25-40% of calcium in the bone lost before we notice a change on an x-ray Overall BMD with QUS and DEXA better

Diagnostics related to substance abuse

Labs: Serum and urine drug screens Liver function tests abnormal Screening tests: CAGE CRAFFT Michigan Alcohol Screening Test Drug Abuse Screening Test DSM-5 criteria CAGE for alcohol dependence CRAFFT- for adolescents and young adults Also tools used for measuring withdrawal symptoms

What happens in the brain with substance abuse

Flooded with dopamine Leading to a feeling of "high" that is pleasurable Brain adjust to increased dopamine levels with continued use This reduces the amount of pleasurable "high" felt Tolerance developed Can then get less pleasure from other experiences that were once enjoyed like food and social interaction Long-term changes: Alter learning, judgement, behavior, memory, decision-making, stress

Opioid abuse treatment

Abstinence Naltrexone (Vivitrol, ReVia) Blocks opiates, reduces cravings, can be given as a monthly injection Methadone (Dolophine) Opioid effects but doesn't cause cravings Does not have the "high" of heroin Psychosocial support is also important Buprenorphine/naloxone (Suboxone) Has a "ceiling" effect to limit the addictive nature Provides opioid analgesia effects Can cause sedation

Pernicious anemia (main cause of cobalamin deficiency)

Acid is needed to secrete intrinsic factor (IF) Autoimmune process against parietal cells or IF Or atrophy of gastric mucosa which disrupts parietal cells What else do parietal cells release? Hydrochloric acid which helps secrete the intrinsic factor People who are taking proton pump inhibitors can have decreased intrinsic factors due to these issues Parietal cells release hydrochloric acid. Acid is needed to secrete IF. Autoimmune processes attack BOTH intrinsic factor and the parietal cells. It reduces the intrinsic factor causing the reduction in vitamin B12 or cobalamin production in two ways. Usually later in life 60 most common age for diagnosis Scandinavian, North European, African American Higher incidence of gastric cancer It usually starts in the late forties but is not diagnoses until 60. There are 3 groups the text talks about having a higher incidence of it. These individuals have a higher incidence or potential for gastric cancer if they have gastritis-related pernicious anemia. Best thing for this person is screening.

Nursing interventions for OA

Activity management Pain management- not going to give opioids because it is a chronic problem Medication administration Educate on proper body mechanics to avoid stress on certain areas Braces, orthotic devices, walking aids Rest and protection Educate Avoid immobilization of the joint for more than a week

Definition of types of leukemia

Acute Abrupt onset, within a few weeks Immature cells (undifferentiated cells or blasts) Chronic Evolves over months or years Mature leukocytes Children are more likely to have acute (but it can happen in adults) Chronic are usually older adults (can be treated like a chronic illness sometimes and can be managed with oral chemo) but chronic can shift over into acute

Acute myeloid leukemia (AML)

Acute Uncontrolled proliferation of Myeloblasts ¼ of all leukemias 80% of leukemias in adults 2nd most common leukemia in children Remember the myelo in the name and the myeloblasts. May also use the term myelogenous. Most common of the myeloid leukemias. Prognosis varies, 5 year survival rate decreases with age. 50% survival rate in children. Defect is all myeloid cells: monocytes granulocytes erythrocytes platelets Due to replacement of normal hematopoietic cells by myeloblasts Clinical manifestations: Fever and infection Fatigue Dyspnea with exertion Pallor, petechia, ecchymosis, bleeding Pain From liver or spleen because it is filtering that collection of cells Bone pain (bone marrow) Gingival hyperplasia Mild hepatosplenomegaly (1/3) Sternal tenderness May not have have an infection, but still have a fever Diagnostic Findings WBC low or high - number of normal cells is decreased Red blood cell, hemoglobin, hematocrit, platelets all low (bleeding risk) LDH high Hypercellular bone marrow with myeloblasts WBC are decreased usually so increased risk for infection

Assessment for fibromyalgia

Historically, fibromyalgia was misdiagnosed Symptoms can be subjective Thorough pain history and assessment 9 sets of tender points, must have 11 out of 18 for a diagnosis of fibromyalgia

Cardiopulmonary changes in anemia

Acute cases (Hgb < 6) Low hemoglobin Tachycardia (to try and compensate for the volume loss) Hypotension (due to decreased volume) Chronic more serious (Hgb < 6 ) Prolonged myocardial oxygen deficit MI, ascites, peripheral edema, systemic congestion Anemia again is a deficit of erythrocytes, hemoglobin. What does hemoglobin carry? Yes, it carries oxygen. If you do not have enough oxygen the body tells this to the heart and the heart says I will just pump faster to get what oxygen I do have around faster, aka tachycardia. Sustained tachycardia leads to hypotension If someone has other comorbidities or has sustained anemia or low blood count this stresses the heart. That is not an all inclusive list of the complications from chronic anemia, just a few. Consider a person with a blockage of one of their coronary arteries. The heart supplies its own blood. The person gets anemic, has been for days. The heart has taken this limited oxygen due to lowered hemoglobin and is beating fast and trying to compensate. It is working hard with a narrowed artery, the reduced blood flow causes tissues to go without oxygen, you get ischemia, it spreads. If you have something going on that breaks down RBCS like mentioned before it can cause liver failure. Ascites results from that. What if someone already has a bad heart with an EF of 20%? The pump doesn't work but the body is making the pump work bad, whether it be tricuspid regurgitation or a stenotic valve, the blood will not flow as well or will back up you can get congestion of the heart or pulmonary system. What does congestion mean when I use it in those terms? Right fluid back up or build up. I don't mean a runny nose.

Causes of back pain

Acute lumbosacral strain Instability in the lumbosacral area Osteoarthritis of the lumbosacral vertebrae Degenerative disc disease Herniation of an intervertebral disc Previous trauma to back Cancer or infection in the spine

Client education for lupus

Adhere to therapy Avoiding exacerbating factors Keeping follow-up appointments Anticoagulant administration and precautions Blood glucose monitoring Risk before, during, and after pregnancy Support groups No cure, chronic systemic condition

Activity management for OA

Aerobic conditioning Range-of-motion exercises Resistance training..what muscle for the knee? Quadriceps for knee OA What if they are obese? Education on weight-loss methods With braces you don't want to immobilize the joint for more than a week because the joint will not want to move again and the muscles with atrophy

RA Joint damage progression

Affects bone density (makes it less dense) and breaks down bones

Bradykinesia related to parkinson's

Affects loss of involuntary or automatic movements secondary to? Physical and chemical alternation of basal ganglia Stooped posture Masked face or deadpan Dysphonia Drooling of saliva Dysphagia Shuffling gait Festination Postural instability Inability to stop themselves from going forward (propulsion) or backward (retropulsion) Assessed by pull test One of the more crippling aspects of Parkinson's

Non-modifiable risk factors for stroke

Age Gender Ethnicity History of prior stroke Heredity/Genetics Stroke: Age-Inc with age-doubles with each year after 55y/o...2/3 of all stroke occur after age 65 y/o Sex-more common in men than women Ethnicity-African-Americans higher risk (HTN, obesity, DM) Family history-increases risk as well as previous TIA Previous stroke-5-14% of those who have had a stroke will have another stroke within 1 year. 1/3 reoccur within 2 years.

Factors that influence bone healing

Age >40 Smoker Diabetes Rhuematoid arthritis Infection Corticosteroids NSAIDS (avoid ibuprofen) Malignancies Bone loss Inadequate immobilization Weight bearing before approval Table 42-2 in Med surg. Text, p. 1193 The older you get the longer it is going to take to heal Smoking and diabetes affects circulation and increases risk of infection Ibuprofen is bad because we need to avoid because it decreases inflammation and we want some inflammation to help heal

Induction therapy for leukemia

Aggressive Hits tissues, blood and bone marrow Targets leukemic cells 70% remission in most.... But? What about leukemic cells? Remain but are undetected Induction- rapid induction of complete remission, lasts 3-4 weeks Decreases neutrophil count Complications Neutropenia Reduction in neutrophils (the closer that is to 0 the less immunity they have) Thrombycytopenia Reduction in platelets Anemia Reduction in erythrocytes Chemotherapy agents (AML specific) Cytarabine Antitumor antibiotic: Anthracycline Daunorubicin Idarubicin mitoxantrone Usually done inpatient

How is TB spread/transmitted?

Airborne Particles are 1 to 5 mcm and can stay suspended in the air where they can be inhaled by others Droplets produced by: Breathing Talking Singing Sneezing Coughing Grows slowly, sensitive to UV light and heat Has to be inhaled, will not get it just from touching a surface

Assessment/Nursing intervention for TB

Airway, respiratory status Monitoring vital signs, especially temperature Assessing nutritional status Identify resources and educate clients Monitoring liver and kidney function with INH therapy Liver enzymes BUN Creatinine

Substances commonly abused

Alcohol Beer, Wine, Liquor Sedatives, hypnotics, anxiolytics Barbituates, benzodiazepines Cannabis (THC/Marijuana) Smoked, edibles, extracts Hallucinogens Mushrooms, LSD, Peyote Inhalants Solvents, aerosols, gases Stimulants Methamphetamine Cocaine, Crack Ecstasy, Molly (also has hallucinogenic effects) Steroids Anabolic and androgenic Tobacco/Nicotine Smokeless, cigarettes, vaping Opioids Prescription Injectable, Inhaled, transdermal

Risks or related factors

Alcohol or drug abuse History of violent behavior Cognitive impairment Certain psychiatric or medical diagnoses Experiencing pain Angered about current situation/ blame health personnel Social and financial risk factors

Treatment for alcohol abuse

Alcoholic's Anonymous (AA) 12 Step Program Self-help group Usually have a "sponsor" Individual counseling Family counseling and support

Examples of common biphosphonates

Alendronate once a week oral tablet Ibandronate and Risedronate once per month oral tablet Zoledronic acid once yearly IV infusion Salmon calcitonin IM, subcutaneous or intranasal

Antibody test and western blot test for HIV

Antibody tests with blood- which may not be present early because the body has not had time to develop them yet Detect HIV-antibodies in the blood Can be done rapid with results returned in a day Can be done with a home test kit Needs follow up with a confirmatory test Western blot Confirms diagnosis of HIV Immuno-fluorescence assay (IFA) also is a confirmatory test for HIV EIA (enzyme immunoassay) ELISA (enzyme-linked immunosorbent assay) Western Blot- used for confirmation Still contagious even if they do not have a positive antibody test

Treatment for post-stroke

Anticoagulants (blood thinner) Delay the clotting of blood Make it difficult for further clots to develop Keep clots from enlarging Heparin Coumadin (Warfarin) Antiplatelet Keeps blood clots from forming ASA, persantine,plavix Heparin-monitor PTT Warfarin-monitor PT- INR-International Normalized ration Therapeutic range is 2-3X normal Lovenox-monitor platelets should be greater than 100,000.

VTE/DVT and PE

Anticoagulants given prophylactically Monitor bleeding Educate on anticoagulant administration and what to watch for at home Less mobility after injury/surgery SCD's Get patient up when possible PE Assess respiratory function Need anticoagulant teaching if that is what they're going home on, also education

Opioid withdrawal

Anxiety Restlessness Aching back and legs Cravings N/V/D Dysphoria Rhinorrhea Sweating, Fever Yawning Insomnia Uncomfortable but not life-threatening Clinical Opiate Withdrawal Scale (COWS) Clonidine and ondansetron (Zofran) given to reduce withdrawal symptoms

Who gets low back pain

Anyone, 80% of adults have had it at least once Second only to headache as common pain complaint For working adults back pain is number 1 reason for lost time at work Occupations that increase risks?

Other causes of cobalamin deficiencies

Anything that disrupts distal ileum or parietal cell function Any surgery that affects colon Histamine 2 receptor blockers? Block acid production Proton Pump Inhibitors? Again block acid production Alcoholism Diet Vegetarian, Vegan The distal ileum is the place of absorption for B12.. Just remember, stomach surgery in general can disrupt absorption of things. Alcoholism is never good for any absorption. Vegetarians and Vegans at higher risk, need supplementation.

Clinical manifestations of stroke- communications

Aphasia Dysarthria Receptive Aphasia Global Aphasia Apraxia Aphasia-inability to express oneself or to understand language. Patient may experience aphasia when a stroke damages the dominant hemisphere of the brain. The left hemisphere is dominant for language skills in right-handed persons and in most left-handed persons. Aphasia occurs when a stroke damages the dominant hemisphere of the brain. Wernicke's area-receptive aphasia, neither sounds or meaning of speech is understood. Broca's Area-expressive aphasia, trouble expressing speech, may also involve writing Dysarthria-difficulty in speaking caused by the paralysis of the muscles Impairments may involve Pronunciation Articulation Phonation Receptive aphasia-difficulty understanding language Global (mixed) aphasia-both (all communication and receptive function are lost) Apraxia-inability to perform a previous action-makes verbal substitutions for desired syllables or words

Withdrawal from alcohol

Appear in 4-12 hours Coarse hand tremors Sweating Elevated HR, BP Nausea/Vomiting Insomnia Delirium tremens (DT's) Can be life-threatening Severe- can have hallucinations, seizures, or delirium Peaks on day 2, usually over in 5 days but can take up to 2 weeks Clients need medical supervision for detox, may need hospital admission for severe symptoms Give benzodiazepines, tapered dose schedule May need antiemetic IV fluid replacement Vitamin supplements- thiamine, folic acid, multivitamin

Chronic Lymphocytic Leukemia (CLL)

Are granulocytes and lymphocytes the same? No Granulocytes innate immune response Lymphocytes - adaptive immune response Mature lymphocytes B cell usually End points? Lymph node enlargement AKA Lymphadenopathy Bone marrow, liver and spleen affected, similar to what? CML (liver and spleen) This is the most common leukemia in older adults. Average age is 72. Usually involves proliferation of B lymphocyte cells. Most people survive over 20 years. Fevers, night sweats, weight loss (B symptoms) Unintentional weight loss Similar to CML Impaired T- cell function Tumor progression, secondary malignancies Infections (bacterial and viral) Splenomegaly, hepatomegaly Lymphadenopathy is unique What could this press on? Nerves Nerves causing pain and paralysis Diagnostics: Beta-2 macroglobulin - prognosis FISH (Fluorescence in situ hybridization) - guides prognosis and therapy Increase in lymphocytes WBC > 100,000 microliters As disease progresses mild anemia and thrombocytopenia Platelets normal or decrease as it progresses Idiopathic thrombocytopenic purpura (ITP) The longer you have the leukemia the more the abnormal cells are going to increase

What about health care workers for TB?

Are we at a serious risk? No, but still be safe Follow the airborne precautions 70% of immunocompetent adults infected with TB kill it themselves 30% contain a dormant version Of those 30%, 10% or less develop TB months or years later. Remember: TB requires prolonged exposure, a brief interaction or even an assessment period should not be enough for an immunocompetent person to get it.

Causes of chronic low back pain

Arthritis Spinal stenosis Degenerative Disk Disease Osteoporosis Prior injury Chronic strain Multiple pregnancies Relaxin, ligaments are stretched Obesity Bending Stooping Congenital abnormalities of the spine scoliosis

Do individuals with sickle cell have pain?

As a result of decreased circulation Most common areas..? Joints But can occur anywhere May have chronic skin ulcers, issues with spleen and liver, may have abdominal pain, also risk of CVA, paralysis and death Usually have a PCA and are getting high doses of pain meds and their body can build up a tolerance to these high doses which can cause issues

Tumor lysis syndrome (TLS) related to leukemia

As the leukemic cell is destroyed, release of: Intracellular fluids and electrolytes which can cause cardiac issues with an increase in potassium, phosphate and uric acid can also increase risk of kidney stones, seizures, confusion and muscle cramps also symptoms

What organs do you think are most affected by sickle cell?

Asplenia...what is this? Spleen does not function as well and because the spleen helps with immune function and fighting infection so they have increased risk of infection Also issues with liver function Increased risk of? Infection Children need prophylactic antibiotics until the age of 5 (usually they take it daily)...and what else? Immunizations (pneumonia vaccines, both of them.) Do not give these kids LIVE vaccines (like MMR and rubella)

Nursing care for fractures

Assess - observe, inspect, palpate Immobilize the affected limb Ice to reduce swelling first 8 hours Elevate above level of heart Neurovascular checks - 5 P's Pain control Education Prevention

Immediate postoperative period for hip fractures

Assess extremity for neurovascular impairment Color Temperature Cap refill Distal pulses Edema Sensation Motor function Pain Basics for any surgery Vital signs I and O Incentive spirometer Deep breathing and coughing Prevent pneumonia Administer pain medications Repositioning Observe for signs or infection? Constipation is an issue Exercise DVT prophylaxis Watch closely first 24-48 hours for complications

Windshield survey

Assessing the community health by driving around and looking at the community What are you looking for? Collect data Assess, Diagnose, Plan, Implement, Evaluate Policy making helps determine health through how much money goes to services to help with medical costs, rules about what health providers can and cant do. Also social factors determine health Genetics also plays a role in health

Nursing management for lupus

Assessment Treat pain Assist with mobility Education and support Review home medications Address financial concerns Nutritional needs Fatigue

Recovery phase assaultive phase

Assist the client in relaxation and/or sleep Discuss how the situation could have been handled differently with the client Staff debriefing Encourage client to discuss feelings

Ataxia, bowel and bladder problems

Ataxia Beta blockers Anticonvulsants (Neurontin) Benzodiazepines Bowel and Bladder Anticholinergics Alpha-adrenergic blockers Vitamin C (increases acidity in urine to decrease bacterial growth) Antibiotics

Review complications of immobility

Atelectasis Pneumonia/ Sepsis DVT/VTE Pulmonary Embolism Bowel and Bladder complications Muscle atrophy More complications with older population or those with comorbidities At risk for kidney stones

AML and maintenance (Not tested) for leukemia

Attached article discusses AML and discusses various modes of therapy Maintenance AML is curable without using maintenance so its not used routinely Studies have shown mixed results when using maintenance therapy with AML

Listen (for sickle cell)

Auscultation Heart Murmur Rate...elevated in? Pain, infection Lungs Diminished breath sounds Rhonchi..crackles...

What exactly happens with SLE (Systemic lupus erythematosus)

Autoantibodies against: DNA, erythrocytes, coagulation proteins, lymphocytes, platelets, and other proteins Host cells are destroyed These autoantibodies form complexes with the protein and deposit in the basement membrane of capillaries in various organs Complement is activated Inflammation B and T cells activated Process is similar to Rheumatoid Arthritis Similar process to with is going on with rheumatoid arthritis

Anemia of chronic disease

Autoimmune or infectious disease HIV, hepatitis, malaria Chronic inflammation Rheumatoid arthritis Chronic diseases such as kidney failure, CHF, etc... Underproduction of RBCs and shortened lifespan of RBC Usually normocytic and normochromic erythrocytes HIV, hepatitis, malaria are infectious diseases or autoimmune conditions listed. Renal failure is a chronic condition listed earlier that interrupts erythropoietin production. This condition relates to underproduction of RBCS but also a shortened lifespan of the RBC. Treat underlying condition - do not benefit form increase iron

What happens in an individual with MS?

Autoimmune process where T cells attack the central nervous system T-cells cross the blood-brain barrier Inflammation occurs Leads to demyelination of axons As the myelin is attacked Eventually the axon itself gets damaged Eventually scar tissue and sclerotic plaques form in the white matter of the CNS The nervous system gets damaged, which at first might manifest as weakness in the client. Once the axon gets damaged the nerve function is lost permanently. Damage is irreversible Characterized by three processes: chronic inflammation, demyelination, and gliosis? in the CNS Gliosis is scarring

Complication of corticosteroid chemotherapy for leukemia

Avascular necrosis- necrosis due to decrease in blood flow Increased susceptibility to infections Potassium depletion You do not want to suddenly stop steroids because it will cause an adrenal crisis, also it will increase your glucose

Prevention of exacerbations for lupus

Avoid Sun Exposure to infections Any autoimmune disease impairs the immune system Add in steroids and its an increased risk Stress Drying soaps, powders, household chemicals SLE has lots of skin issues, these exacerbate them DO Conserve energy Pace activities Wear sunscreen Regular medical and laboratory follow-up

Cardiovascular concerns for stroke

BP control Watch out for orthostatic hypotension What is hypotension for stroke? VTE prevention Mobility Rom exercises SCDS, TED hose Measure calf and thigh daily Pulmonary congestion Adventitious lung sounds What kind? Crackles or rhonchi IV titration Relates to BP control Discussed previously We discussed BP control and some of the medications they might be on to reduce it. The body is strange it gets used to a position. If someone has had a stroke and has been bedridden for a few days the body is used to that. What happens when you stand up sometimes after sitting for awhile? See spots, or get dizzy. The same can happen more pronounced to a stroke victim. The first time ambulating they can get hypotension. Generally you do not want BP to change more than 20 or 30% absolutely from baseline. For instance BP 180 systolic. You do not want it to change more than 36-54 points systolic, this is too much for this person. Hypotension even if its "normal" for other people can cause neurological problems or deficits. VTE: paralyzed extremities do not move. VTE happen more often in things that do not move. This is especially true for stroke victims. SCUDS used frequently for prevention. TED hose. Crackles or Rhonchi can indicate pulmonary problems, easy there isn't any patient who developing those lung sounds is considered okay.

Nursing management for DT's

Benzodiazepine administration Phenobarbital for seizures Maintain airway Seizure precautions Limit stimuli Antiemetics IV fluids Monitor for hypoglycemia

Treatment for aplastic anemia

Best case Stem cell transplant Requires a HLA-matched individual Risk for graft versus host with this (which is the body fighting the new cells and then the transplant will not take) The gold standard is a stem cell transplant if possible since the problem is in the marrow. However not all HLA's are created equal and some go on "supportive therapy" or the Right side of the slide. They draw it straight out of the donor bone marrow and then it is given to the patient intravenously

Pharmacology specifics for osteoporosis

Biphosphonates Fosamax, Actonel, Boniva, Reclast Inhibit osteoclasts...what did these do again? Side effects common to these: Anorexia and weight loss Gastritis Increases risk for esophageal ulcers To prevent those side effects Take with a full glass of water Take 30 minutes before food or other medications Remain upright for at least 30 minutes after taking Reclast is a yearly IV injection Do not take Ca and vit D supplements at the same time of day as biphosphenates Risk for esophageal and gastric ulcers Dentist needs to be aware of this drug because of risk of osteonecrosis of the jaw

Post-operative considerations for the bladder for low back pain

Bladder emptying may be impaired by several factors Activity restriction Opioids Anesthesia If possible, standing or ambulating to bathroom for urination is encouraged Possible intermittent catheterization may be needed

What exactly happens with leukemia?

Blood cell progression The longer Leukemia sets in Normal blood cells.. Decrease WBCs... Increase though they are what? Immature, unable to perform function Organ involvement WBCs have to go somewhere Splenomegaly Hepatomegaly What is a serious complication of massive buildup of white blood cells? leukostasis Leukemia in general is a progression. Infection is the most common cause of death with leukemia

What is a stroke?

Blood flow to the brain is interrupted by a blocked or burst blood vessel. Impairs functions such as: Movement Sensation Emotions Severity depends on location and extent of brain affected STROKE is a MEDICAL EMERGENCY!!!

Avascular necrosis (AVN)

Blood supply to the bone is lost Can occur form a fracture or: Radiation Sickle cell anemia High-dose corticosteroids Rheumatoid arthritis Management: NSAIDS Exercises Limit weight bearing May need a total joint replacement (hip and knee)

Thalassemia treatment

Blood transfusion Hgb < 10 Exchange transfusion? Remove blood all blood, replace with donated blood Iron chelation agents? Deferasirox Deferiprone Deferoxamine A stem cell transplant is the only cure for thalassemia, but it has complications that make it not worth the risk. These are the mainstays of symptom management. Chelation agents have really improved lifespan What is a chelation? It binds to iron and removes it because they may have too much iron in their body because the hemolysis is causing more iron than normal to be released in the body You can give blood since this is a lack of normal hemoglobin, or you can take out their blood, and donate more blood. When do you think you might do a blood transfusion instead of an exchange transfusion? look at your hemoglobin number, if its low then blood, if its normal > 10 then you will do exchange

Clinical manifestations for parkinson's

Bradykinesia Slow movement Rigidity Increased resistance to passive movement when limbs are put through range of motion Tremors at rest Can disappear with purposeful movement and while asleep "pill-rolling" movement Gait disturbance Issues that impact movement and mobility Difficulty initiating movement (standing from sitting, turning over) Posture and gait issues

Brain stent

Brain stent is used to treat blockages in cerebral blood flow. A, A balloon catheter is used to implant the stent into an artery of the brain. B, The balloon catheter is moved to the blocked area of the artery and then is inflated. The stent expands because of inflation of the balloon. C, The balloon is deflated and withdrawn, leaving the stent permanently in place holding the artery open and improving the flow of blood.

Dopamine receptor agonists related to parkinson's

Bromocriptine, pergolide, ropinirole, pramipexole, rotigotine Directly stimulate dopamine receptors Used in early PD only by some providers as first line treatment before sinemet

Life threatening S/S of anaphylaxis

Bronchospasm and edema Bronchoconstriction Dysrhythmias Vessel dilation Increased capillary permeability - 35% volume shift in 10 minutes What does that mean? High risk for hypotension, and organ dysfunction without treatment.

Drug therapy for HIV

CCR5 Coreceptor Antagonist Blocks the receptor site on the cell membrane that the virus needs to enter the cell Maraviroc (Selzentry)

Someone has confirmed HIV now what tests?

CD4 T cell count Determines immune function and status Normal 800-1200 cells/uL Viral load (quantitative RNA assay) Assesses disease progression Reported just as a "real number" (e.g. 1000 copies / uL) Undetectable means viral load is lower than test but does NOT mean cured. If you have an undetectable viral load you are not considered contagious (that does not mean you should take risks) and this is the goal of treatment Babies are given a bath immediately after birth with HIV positive mom, multiple modes of transmission through pregnancy and birth so really important to get to an undetectable viral load

Withdrawal assessment for substance abuse

CIWA- clinical institute withdrawal assessment for alcohol Box 19.2 in Videbeck text Used to measure withdrawal and adjust benzodiazepines as needed Score <8 mild withdrawal 8-15 moderate withdrawal >15 severe withdrawal Assess: Tremors Sweating N/V Agitation Tactile disturbances Auditory and visual disturbances H/a Orientation and clouding sensorium

Sedatives/ Hypnotics/ and anxiolytics

CNS depressants Similar symptoms of intoxication as alcohol Barbiturates and benzodiazepines most commonly abused Nonbarbiturate hypnotics and anxiolytics are also in this category Assessment: Drowsiness Slurred speech Lack of coordination, unsteady gait Labile mood Stupor and even coma can occur

Diagnostics for stroke

CT/MRI Primary diagnostic test used after a stroke Used to distinguish between ischemic or hemorrhagic stroke. Cardiac Imaging Highest cause of embolic stroke is heart disease. Lumbar Puncture CT may not show a SAH if there is bleeding into the spine Cerebral angiography Definitive study to identify source of SAH. CT scan-single most important test-distinguishes between an ischemic and hemorrhagic stroke-also determines size and location of a stroke Doppler Ultrasound: evaluates the flow of blood through the carotid arteries and will give the degree of occlusion in the artery. Evaluates the flow of blood through carotid arteries which provides information about the degree of occlusion in an artery Transcranial Doppler (TCD) Ultrasonography non-invasive which measures the velocity of the blood flow into the cerebral arteries Ideal for detecting micro emboli, vasospasm, SAH CT Angiography Visualization of the vascular lesions and blockages

Treatment varies and the main goal is prevention for osteoporosis

Calcium goals Premenopausal women (or men of any age) 1000 mg/day Postmenopausal women with estrogen 1000 mg/day Postmenopausal women without estrogen 1500 mg/day Calcium supplementation education (Pill form) Need to take divided doses no more than 500 mg with any individual dose Take with food Different formulations have different amounts, read label carefully

Inhibitors (related to acetylcholine)

Called anticholinergics Trihexyphenidyl, benzotropine Decrease acetylcholine to lessen the amount of dopamine needed to maintain the balance Benadryl can be used for tremors due to its anticholinergic properties

Barbiturate overdose

Can cause coma, respiratory arrest, cardiac failure, and death Can mimic alcohol overdose Usually need to be treated in ICU Gastric lavage (if within one hour of ingestion) Repeated doses of activated charcoal may be needed High risk of addiction to these Examples of theses drugs: Butabarbital, pentobarbital, phenobarbital, secobarbital Airway, monitor for shock, IV fluids, may need hemodialysis

With anaphylaxis what comes first?

Check the airway, maintain the airway Then? Apply oxygen if needed, start an IV, check full set of vitals Then? If hypotensive, fluids and epinephrine.. Complications? What if they are on a beta-blocker? Administer glucagon Ongoing monitoring after? Airway, vitals, cardiac rhythm (especially after epinephrine)

Thalassemia client education

Can you take ascorbic acid? Yes, but only with chelation..why? What would it do by itself? Increase iron absorption by itself Zinc? Chelation can lower this, supplement their zinc Splenectomy? Spleen filters bad blood cells, can enlarge and require removal It is recommended to take vitamin C with chelation because it helps excrete iron in the urine. However if it is not taken concurrently you should not because as discussed it promotes absorption of iron. Do not give iron Chelation therapy can lower zinc so supplementation may be needed Hemoglobin of 10 Splenectomy may be given why? Remember bad blood cells filtered here, spleen cant keep up gets larger functions worse, may need to remove it

Cannabis abuse

Cannabis sativa- hemp plant The resin of this plant gives the psychoactive effects Can be inhaled by smoking or ingested Most commonly used illicit drug in US Has been legalized in some states Can have second-hand smoke effects Acts in < 1minutes from inhalation Peak 20-30 minutes, lasts 2-3 hours Slower action when ingested Impacts brain development long-term Breathing problems similar to tobacco smokers (cough, increased mucous, higher risk of infection) No reported deaths from overdose

Long-term effects of alcohol use

Cardiac myopathy Wernicke's encephalopathy Korsakoff's psychosis Pancreatitis Esophagitis Hepatitis Cirrhosis Leukopenia Thrombocytopenia Ascites Box 19.1 in Videbeck text

Systemic manifestations of lupus

Cardiopulmonary Pericarditis Myocarditis Hypertension Arrhythmias Pleural effusions Infiltrations Renal Nephritis Increase serum creatinine Can lead to hypertension Kidneys are impacted a lot with this, some patients end up getting kidney transplants Hematologic Anemia Mild leukopenia Thrombocytopenia Bleed too much or clot too much Antiphospholipid syndrome Nervous Seizures in up to 15% Headaches Cognitive dysfunction Disorientation, memory deficits Psychiatric disorders Depression, mood disorders, anxiety, psychosis

Carotid endarterectomy

Carotid endarterectomy is performed to prevent impending cerebral infarction. A, A tube is inserted above and below the blockage to reroute the blood flow. B, Atherosclerotic plaque in the common carotid artery is removed. C, Once the artery is stitched closed, the tube can be removed. A surgeon may also perform the technique without rerouting the blood flow.

Type 3 (Immune-complex reactions)

Causes Antigens bind to immunoglobulins Can be viral, bacterial, fungal Immune complexes deposit in tissue, activate immune response and damage tissue or area Examples Lupus Rheumatoid Arthritis Nephritis Auto-immune issues Causing permanent organ damage in the body potentially

Iron-deficiency anemia

Causes Pregnancy Menstruation Surgery Surgery Where is iron stored? Duodenum Malabsorption Biggest cause is blood loss Most common types of bleeds? GI Bleed Smelliest bleed... Kidneys make what? Erythropoietin The first type of anemia is a deficit of iron. The book gives some facts such as it affects postmenopausal women and men, related to poor diet. Iron enters the body, the body metabolizes and stores or uses it as needed. Anything that disrupts that would cause that. So when you have a loss of blood your hemoglobin goes down, and then your body uses the iron stores to make more red blood cells so we do not always give someone iron who has had a big blood loss If someone does not take enough iron in their diet that's an obvious cause. If someone has a gastric surgery that removes a portion of the stomach (specifically the duodenum which is where iron is stored) that was involved in absorption of it, that would do it. If someone is bleeding they may lose iron such as menopause. The kidneys make erythropoietin. This stimulates the production of red blood cells. If you have problems with your kidneys this slows down. Renal patients usually have a lower hemoglobin. Concave "spooning" appearance of the fingernaills

Pathophysiology of sickle cell

Cells sickle, begin to clump together and form a stoppage but it is different from a clot but can function like a clot in stopping blood flow to certain areas Blood becomes viscous Prevents blood flow to tissues (especially smaller tissues) Two types of vessels affected most? Venules and capillaries Triggering events Stress Traumatic event Infection Fever Acidosis Physical exertion Excessive cold exposure Hypoxia is a big one because low oxygen causes more sickling which causes lower oxygen which causes more sickling Etc....

Type 4 (delayed hypersensitivity)

Cellular hypersensitivity- mediated by sensitized T cells Causes Poison ivy Latex Contact dermatitis Graft-versus-host Hashimoto's thyroiditis Sarcoidosis Time line 24-72 hours to take effect

Family history for parkinson's

Certain genes are linked to PD. Further, certain genes are linked to the onset of PD. Most common gene is LRRK2 A-synuclein (SNCA) Both of those are associated with the traditional age related PD Parkin (PARK2), DJ-1, and PINK1 Associated with a younger onset age of PD PINK-1 associated with youngest onset PD

Spinal column

Cervical 1-7 Thoracic 1-12 Lumbar 1-5 Sacral 1-5 Coccyyx

Joints commonly affected by OA

Cervical vertebrae Lower lumbar vertebrae Hip Metacarpophalangeal Distal interphalangeal Proximal interphalangeal Knee Metatarsals Weight-bearing joints- hips, knees, cervical, lumbar Proximal interphalangeal (PIP) - Bouchard's nodes Distal interphalangeal (DIP) - Heberden's nodes

What is parkinson's disease?

Chronic Progressive Neurodegenerative disorder characterized by bradykinesia, rigidity, tremors at rest, and gait disturbance

Iron deficiency anemia S/S

Chronic Pallor Glossitis -swelling of tongue that looks smooth Chelitis - Swollen lips, cracks in corners of mouth Paresthesia- pins and needles feeling Brittle and ridged nails Pallor-most common Glossitis- swollen tongue, smooth appearance, soreness Chelitis-swollen lips

SLE and psychosocial toll

Chronic condition Can decrease mobility Financial concerns and stress Support groups and resources are important

MS and etiology

Chronic, progressive, degenerative disorder of the CNS Autoimmune Onset usually between 20-50 years of age, peak at age 30 More common in women Environmental risks With genetic link that activates onset Family link noted One must be genetically susceptible to develop MS Some have chronic progressive deterioration Others have remissions and exacerbations Life expectancy not greatly affected People who live further from the equator have a higher instance of MS

What is rheumatoid arthritis?

Chronic, systemic autoimmune disease Involves inflammation of connective tissue in synovial tissue Peaks between age 30-50 Type III hypersensitivity Affects bilateral joints Synovial tissue lubricates the joint which can cause issues if it is inflamed

Reduction for fractures

Closed Manual manipulation and traction to bring back into alignment Requires sedation/anesthesia Held in place with a splint or cast X-ray confirms alignment achieved May need traction until surgery Open Aligned surgically Internal fixation Pins, wires, screws, plates, nails, and rods External fixation May need traction that is either weighted or un-weighted to keep things in alignment

What do we look for (inspection) for sickle cell

Color...jaundiced...what complication? Splenic sequestration with liver involvement Temperature...why? Spleen issues lead to infection Blood pressure Decreased from anemia Or Increased if they have damage to the kidneys due to blockages which can cause irreversible damage If sickled cells clump around kidneys can cause renal failure and increased BP

Impulse control

Common in children, this is a normal part of development Impulse control should develop over time Positive interactions and having responsibility for actions helps this develop

Gerontologic considerations for anemia

Common in older adults Chronic disease Nutritional deficiencies More often in males S/S go unrecognized or mistaken for normal aging changes 1/3 have no known cause May have decreased mobility Increased depression Increased delirium Could have decreased mobility More prevalent as age increases Do not respond to anemia as well as younger individuals Occurs more drastically in males than females 1/3 have nutritional type of anemia 1/3 r/t renal insufficiency or chronic inflammation (because erthyroproetin is made in the kidneys) 1/3 unexplained Chronic diseases such as renal failure can cause this

Types of remission for leukemia

Complete remission No trace in physical exam, bone marrow, or peripheral blood Minimal residual disease Detected by molecular testing only Molecular remission All molecular studies are negative for residual leukemia Partial remission Still in the bone marrow Lots of different testing is done to determine someone's level of remission The more times they have it come back, the harder it is to go back into remission

Barriers to TB treatment

Complicated drug regimen Here, take these 4 medications for 8 weeks without missing a dose, don't drink anymore alcohol, and don't be surprised by orange bodily fluids... Then take these 2 for 18 additional weeks with the same instructions... What do you think? Access to healthcare Long time to sustain treatment Poor socioeconomic status Comorbid conditions Plenty of reasons....anything that was a risk factor for getting TB is also a contributor to not being compliant

Stroke in children and adolescence- underlying systemic diseases

Congenital Heart Disease Cyanotic type congenital heart disorder Purulent Venous Thrombosis Infection of the mastoids, paranasal sinuses, scalp, face Trauma Head trauma most frequent Damage to the carotid artery (neck or intraoral trauma) Sickle Cell Anemia ICH Initial task is to determine any underlying medical condition-will prevent further progression or complications Second question-Is it a SAH-if so, suspect aneurysm CT scanning and LP-presence of RBCs. Complete a CBC-sickle cell U/A-renal function-HTN Angiography-vascular pathways

Iron-deficient-anemia in children

Consider safety risks Fatigue Impaired mobility Dietary assessment based on age Children have a lower blood volume, cannot tolerate blood loss at same rate as an adult Lead poisoning could be a cause Elevated levels of lead interferes with the biosynthesis of hemoglobin Assess risks for lead exposure and educate parents Too much milk can be a cause

Normal nerve cell

Nucleus and cell body surrounded by dendrites Dendrites receive messages Axon surrounded by the myelin sheath and nodes of Ranvier Myelin sheath aids in conduction Signal sent to the synapses, then on to the next nerve cell

Nursing management of coping and loss with stroke

Coping Effects patient & family Emotionally Socially Financially Social Services or Case Manager involvement Discharged to Rehabilitation Facility, SNF, HH, or outpatient therapy Family has had no time to prepare There are lots of ways in which a stroke victim may feel a sense of loss. Some people go from fully independent lives to being completely dependent. They can lose their job, they can lose their role as the breadwinner or provider. Losing one side of the body to function can really be hard on someone. There are many elements of loss with a stroke it is important to keep this in mind when taking care of them.

Disease-modifying antirheymatic drugs (DMARDs)

Cornerstone of RA treatment Examples: Methotrexate (monitor CBC and liver function panel, avoid in pregnancy) Sulfasalazine Hydroxychloroquine (antimalarial) Leflunomide (avoid in pregnancy) Tofacitinib We try to slow down the damage Some of these drugs are not good for people with comorbidities like liver issues and pregnancy Also biologic and targeted therapies Some of these are immunosuppressant's but then they are more likely to get an infection

Chronic skin ulcers for sickle cell

Nursing Interventions Monitor skin Protect areas from trauma Prevent infection

Interprofessional collaboration for OA

Occupational Therapy Physical Therapy

Other medications that may be seen for RA

Corticosteroids Symptom control Risk of complications...? Osteoporosis, increased infection risk NSAIDS Anti-inflammatory properties Analgesic properties Antipyretic NSAIDS have a bleeding risk We want to try and not use opioids for chronic issues if we can May also need antidepressants which can also help re-establish sleep patterns

Opioid intoxication/overdose

Create a sense of euphoria and well-being Desensitize physiologic and psychologic pain Apathy Lethargic and listless, psychomotor retardation or agitation Impaired judgement Constricted pupils Slurred speech, impaired attention and memory Severe: Coma Respiratory depression Cardiac arrest Hypotension N/V Death Use can also cause constipation Airway, respiratory and cardiovascular function, narcan administration, cardiac monitoring

Clinical manifestations of fractures

Crepitus (snap-crackle-pop) Shortening of extremity Pain Edema, Ecchymosis Deformity Loss of function- limp or unable to bear weight

What about stem cell transplant for sickle cell?

Curative for some but... Not done generally Negative factors Donor matches difficult to find Expensive Risk of graft versus host

Medications that metabolize faster with nicotine

Cyclobenzaprine (Flexeril) Naproxen (Aleve) Propranolol (Inderal) Verapamil (Calan) Warfarin (Coumadin) Need higher doses of these meds because they metabolize faster

Aplastic anemia

Decrease in ALL blood cell types, unique because it includes WBCs (immunity) and platelets (clotting) as well Hypocellular bone marrow Two causes Congenital or acquired Most causes are idiopathic The last anemia in this section is aplastic anemia. This one is unique because it is a decrease in all blood cell factors. It is generally looped into two categories, congenital which is chromosome alterations or acquired. It is due to a hypocellular bone marrow. Bone marrow is where cells are created so a hypocellular one would explain less cells being produced. Idiopathic- no apparent cause

Deconditioning related to parkinson's

Decreased mobility Orthostatic hypotension Skin integrity compromised Infection risk increased

Surgical therapy for parkinson's

Deep brain stimulation Electrode in thalamus, globus pallidus or subthalmic nucleus Connect to a generator in left upper chest Delivers current to brain, which can be modified or even removed to control symptoms

What is anemia?

Deficiency in number of erythrocytes (most anemias except aplastic) Less erythrocytes means a decrease in the amount of oxygen reaching tissues Hemoglobin, hematocrit, red blood cells (we look at these to see what kind of anemia they have) It is not a specific disease Manifestation of pathologic process- can cause oxygenation issues, perfusion issues, ect. Anemia is a manifestation of a pathologic process. Clients can have certain types of anemias that will be on their list of medical conditions. However the term "anemia" by itself is not a condition. For instance someone can have iron deficiency anemia etc. It just means there is a change in the red blood cells You look at the red blood cell parameters exclusively

Diagnostics aplastic anemia

Definitive...bone marrow biopsy Shows hypocellular with increased yellow marrow Less definitive but useful Morphology Elevated iron, elevated total iron-binding capacity Bone marrow biopsy is useful for all anemias, but it is the gold standard for aplastic anemia

Etiology of parkinson's disease

Degeneration of dopamine producing neurons in substantia nigra of the midbrain Lower amount of dopamine Acetylcholine and dopamine are two neurotransmitters Acetylcholine causes involuntary movements These neurotransmitters function in a balance to maintain normal extrapyramidal motor system (or EPS) Posture, support and voluntary motion As dopamine lowers the neurons of the substantia nigra get damaged Once 80% of them are lost, the above mentioned traits decline and more involuntary movements occur Acetylcholine is excitatory and dopamine is inhibitory

Clinical manifestations of HIV

Dependent on the stage of the disease

Clinical manifestations of parkinson's: not related to movement

Depression Anxiety Apathy Fatigue Dementia -75% Loss of sense of smell Pain Constipation Impotence Short-term memory impairment Sleep problems Excessive sweating

How do we test for osteoporosis?

Diagnostics Bone Mineral Density (BMD) scans which has two types Quantitative Ultrasound (QUS) Dual-energy X-ray absorptiometry (DEXA) DXA results are reported as T scores. They reference a person's bone density to the "average person's bone density" They measure the number of standard deviations away from normal. T score less than -2.5 diagnostic for osteoporosis T score between -1.0 and -2.5 is defined as osteopenia (pre osteoporosis) May get screened earlier if they have a history of fractures and family history of osteoporosis

Degenerative disk disease

Disk is a cartilaginous plate that creates a cushion between the vertebrae Nucleus pulposus Aging Develop radiating cracks in annulus, weakens DDD- capsule pushes back into the spinal canal Produces pain, sensitive to touch in affected area

DIC

Disseminated Intravascular Coagulation Results in widespread hemorrhage Blood not able to clot Support IV fluids Oxygenation Monitor VS closely Transfusions (massive transfusions)

Education to prevent low back pain

Do If you have to stand, place foot on a step or stool during prolonged periods Recommend 15 minutes of exercise in morning and evening with stretching Carry light items close to the body Dont Do not lean forward without bending knees Do not lift anything above the elbow Do not continue exercise if having severe pain without contacting your physician

Communication post-stroke, how can I help?

Do not attempt to complete their sentences. Consistent routine and repetition Communication board Speak slowly One step instructions rather than multiple step instructions Remember to talk to the patient, even if they can't talk back Reduce extraneous noises Patient may be unable to write their thoughts if they have expressive communication. Do not give a pencil and expect they can write what they want. With expressive aphasia, you cannot help the client by giving them a pencil and pad to write it down. They cannot produce language. The best way to assist the client is to allow them time to answer and initiate speech, don't rush.

Why do some people become addicted and others do not?

Does giving someone narcotics during an acute medical situation lead to addiction? There are many theories on addiction: biological, environmental, developmental influences The rat park experiment- watch video Rat Park Experiment

Stimulant abuse

Drugs that stimulate the central nervous system Clinically used to treat ADHD (amphetamine) "Uppers", used to be popular for weight loss or to stay awake Cocaine (Blow, coke, crack, rock, snow) Methamphetamines (meth, crank, crystal, speed, chalk) Can be swallowed, inhaled, snorted, or smoked Cocaine can be rubbed into the gums "Bath salts" are a human made stimulant Can overdose on stimulants, leading to death Cocaine and heroin together = speedball Maintain airway Treat for hyperthermia, seizure precautions, cardiac monitoring, may need to evacuate stomach if cocaine was ingested to smuggle ("mule"), activated charcoal

Late clinical manifestations of parkinson's

Dysphagia Deconditioning Akinesia Dementia

Nutrition education for parkinson's

Dysphagia and bradykinesia can be present making it difficult to eat safely Foods should be: Easily chewed Roughage and fruit to prevent constipation Cut into bite-sized Kept warm 6 smaller meals may be better Vitamin B6 and protein impairs levodopa absorption. Limit these until later in the day

Pharmacology for OA

Early on Acetaminophen and Capsaicin Antibiotics Doxycycline Minocycline Used with mild OA But studies have shown mixed results on their effectiveness...but you still may see it NSAIDS Watch for bleeding Need to take regularly for desired effect (aka routine not PRN) Examples? Ibuprofen Salicylates Same education as NSAIDS Examples? Acetylsalicylic acid...ASA...aspirin!

As a nurse what am I concerned with for osteoporosis?

Educating patients about: Risk factors Prevention Treatment Comfort (if they sustain fractures) Use of devices (TLSO) Pre-op and post-op for surgical interventions If you are not up moving around then your digestion slows down and then you can become constipated Increased risk of DVTs if not moving around

Nursing acute care for stroke

Ensure Airway Decreased LOC or absent gag reflex Intubation or ventilation Administer oxygen Notify stroke team Obtain V/S Maintain B/P Complete Neuro checks Maintain fluid and electrolyte balance Obtain IV access with NS Obtain CT scan immediately Management of increased ICP Prevent hyperthermia Monitor for seizures Perform baseline labs Position head midline Elevate HOB if no s/s shock or injury Anticipate thrombolytic therapy for ischemic stroke Hypoxia and hypercarbia can make worse B/P elevates as a protective measure-administer medications-Lopressor or Cardene Hydration may compromise perfusion-want to prevent cerebral edema Increased ICP occurs more frequently with hemorrhagic strokes but can occur with ischemic strokes-elevate the HOB, head and neck alignment, avoid hip flexion Increased temperature increases cerebral metabolism Seizures occur in 5-7% of the patients in the first 24 hrs Give Dilantin and Kepra

Pressure measurements for muscles/tissues

Ensure that there is one finger amount of space between skin and cast Loosen dressing or open cast Prepare for fasciotomy Doppler can be used to check pulses Assess (frequently) Circulation Motion Sensation Color The Wick catheter is inserted into a muscle compartment and continuously monitors compartment pressure. From Chapman, M. W., Szabo, R. M., & Marder, R. A. (2000). Chapman's orthopaedic surgery (3rd ed., p. 401). Philadelphia: Lippincott Williams & Wilkins.

Risk factors for substance abuse

Environmental Peer pressure Low socio-economic status Unemployment Dysfunctional family dynamics Substance accessibility Criminal involvement Cultural and social influences Genetic Family history Male Gender History of depression or anxiety Psychological diagnosis Certain genetic traits that increase predisposition

Anaphylaxis treatment

Epinephrine Activates. . . alpha 1 - vasoconstriction beta 1 - force and rate of contraction beta 2 - bronchodilation Use epi pen ASAP and then you can call the dr. It is a neurotransmitter than can be given IV, SQ and endotracheal (in rare cases) Increases HR and BP and can cause possible arrhythmias as well so monitor for cardiac issues with telley leads Assess respiratory status before and after Assess O2 stats Always make sure it is the correct dose (if it is their epi pen then it is the right dose for them) Oxygen IV Telemetry Maintain patent airway Fluid resuscitation Antihistamines - H1 and H2 Corticosteroids If they are on a beta-blocker then they need to be given glucagon ASAP to counteract it so the epinephrine will work most effectively

Treatment for chronic low back pain

Everything from acute low back pain Antidepressants Pain and sleep Duloxetine (Cymbalta) Gabapentin (Neurontin) Helps walking, improves leg symptoms Neuropathic pain Heat and cold Epidural corticosteroids Alternative therapies Acupuncture, yoga Implanted pump Surgery if pain is refractory to treatment TENS device (transcutaneous electrical nerve stimulation)

Type 1 (IGE Mediated)

Examples Asthma Allergic rhinitis Bee sting reactions Systemic anaphylactic reaction Causes Pollen, food, drugs, dust, etc. Factors in body that are involved Histamine, Mast cells Leukotrienes Prostaglandins Immediate response Also prostaglandins being released that starts the inflammation process in the body Mast cells release histamines that cause edema, pruritus (itching), bronchospasm, dilates the Venules but dilates the larger vessels so we give anti-histamines to people for that

Type 2 (Cytotoxic and Cytolytic reactions)

Examples Transfusion reaction Goodpasture syndrome Immune Thrombocytopenic purpura Graves disease Myasthenia Gravis Pernicious anemia Causes Cell surface of RBCs Cell basement membrane The cell surface of the RBCs are being impacted at the cell basement membrane Can lead to cells and tissues being damaged which is irreversible

Risk factors for developing back pain

Excess body weight Lack of muscle tone Poor posture Smoking Prolonged periods of sitting Pregnancy Prior compression fractures Family history Jobs that require heavy lifting Anatomical abnormalities- scoliosis

What will these clients show?

External rotation -more with extracapsular Muscle spasm Shortening of affected extremity Severe pain near fracture site Displaced femoral neck fractures can disrupt blood supply to the femoral head Avascular necrosis of the femoral head Interruption of blood supply to the bone causes this AVN

Precautions for anemias

Fall Risk Bleeding risk Client may be confused

Safety concerns for MS

Falls Ataxia, and vision impairment Swallowing difficulties Assessing home environment

What causes false negatives or false positives for skin test for TB

False negatives: Immunosuppression Recent infection within 8-10 weeks of exposure Tuberculosis present for multiple years Recent vaccination from measles or chickenpox or other live virus False positives: Previous bacillus Calmette-Guerin (BCG) vaccine Used in other countries as a vaccine to TB Unreliable results Not used in US Tuberculosis from bacteria other than mycobacterium tuberculosis

Codependence related to substance abuse

Family and friends have dysfunctional behaviors due to being in a relationship with a substance abuser May have excessive anxiety and worry, resistant to change May exhibit enabling Helping perpetuate the abuse Making excuses Family members become at risk for substance abuse At risk for low self-esteem and inability to trust if a child of a substance abuser Education and support for the family and friends is important to treatment

What clinical manifestations would a client with RA demonstrate?

Fatigue Anorexia Weight loss Stiffness After periods of inactivity such as morning or rest periods Morning stiffness longer than 1 hour Joints affected Small joints of hands and feet Joint characteristics Hot, swollen, tender Ultimately, limited range of motion with painful movement Eventually it erodes the bone Symmetric usually Can also have nerve compression Joints may feel spongy because it is degrading in that area

Nursing management for MS

Fatigue Pain Spasticity Promoting mobility Reduce contractures Bowel and bladder issues Nutrition Swallowing function Cognitive function Coping Sexual function

Acute Chest syndrome (related to sickle cell)

Fever Respiratory distress New infiltrates on Chest x-ray which could be caused by infarction, infection, other issues Causes: Atypical infections Pulmonary fat embolism Pulmonary infarction Pulmonary thromboembolus Sepsis due to infection Gall stones Also affects visual acuity

What else could go wrong besides blood pressure with a stroke?

Fluid and electrolytes Fine balance Too much fluid...what happens? Cerebral swelling, HTN Too little fluid...what happens? Hypotension, worsening perfusion ADH (Elimination) Antidiuretic Hormone If this increases, water is retained What happens to sodium? Decreased due to dilution Why do we care? Hyponatremia Too much fluid can cause cerebral swelling, HTN, problems that you don't want Too little has the reverse, you can have hypotension, and stress an already stressed body to perfuse and already damaged area. Sodium would become lower due to what? Dilution Hyponatremia can cause cerebral edema. Swelling of the brain on an already compromised ischemic or infarcted area is bad bad bad. It would be the equivalent of taking someone with a heart attack and asking them to bench press their max at the same time.

what do we do once we give the drugs for leukemia

Follow-up concerns Immunizations Pneumonia vaccine Influenza vaccine How often? Pneumonia every 5 years Flu annually Psychosocial support- isolation, financial concerns, in children they are going to school and interacting with other kids No live vaccines (varicella, MMR)

Folic acid foods

Foods high in Folic Acid Green leafy vegetables Liver, meat, fish Legumes, peanuts Whole grains Orange juice Taken from the table and placed into your powerpoint for convenience

What about HIV and nursing?

For healthcare workers the primary method is through accidental needle stick On average 3-4 out of 1000 or 0.3% or 0.4% chance of contracting HIV from a needle stick However that risk is dependent upon... How deep the needle stick is How big the needle is, if it is hollow bore Phase of HIV in the patient Things that impact needlestick HIV transmission is how big the needle is (more risk for larger bore), phase the patient is in, and how deep the needle goes in Just because you are exposed does not mean you are going to contract HIV Right after needlestick you immediately wash hands with soap and water and then tell your supervisor and nursing instructor

Triggering factors for MS

For those that are susceptible, there are believed to be several triggering events that could cause an exacerbation Infection (URI, UTI) Trauma Immunization Childbirth (pregnancy through 3 months postpartum) Stress Climate change Heat Not everyone has triggers, but it is important to find out what they are for each client

Foraminotomy

Foraminotomy- removal of intervertebral foramen to increase space for the exiting spinal nerve

How does calcium relate to osteoporosis?

Formal definition: chronic progressive metabolic bone disease characterized by low bone mass. In other words, bone loses calcium and becomes easier to fracture or break Decrease in the strength of the bone, become porous and fragile Most common bone disease What is osteopenia? Low bone mineral density, precursor to osteoporosis Your text states 1:2 caucasian women and 1:5 men will have fracture related to this

Impact of stroke

Fourth cause of death in the United States. Leading cause of long term disability. 795,000 people in the US suffer from stroke every year. On average, someone suffers from a stroke every 40 seconds. We are located in the "stroke belt" 4th leading cause behind heart disease, cancer and lower respiratory diseases-295,000 deaths annually Cost is $34 billion dollars in 2008.

What is a hip fracture?

Fracture of upper third of the femur Fractures in the capital, subcapital or femoral neck region often due to osteoporosis - intracapsular region Fractures in the extracapsular region are often due to trauma or a fall

Concerns for abuse for fractures

Fractures occur in children less than 2 years of age, usually caused by another person Newborn fractures should lead to concern except those caused from birth trauma Spiral femur fractures Rib fractures- from squeezing Humerus fractures

Risk calculation for osteoporosis

Frax tool

Benzodiazepine overdose

Gastric lavage(if within one hour of ingestion) Activated charcoal May need dialysis if symptoms are severe enough Can cause seizures, coma, circulatory collapse, death Flumazenil (Romazicon)- reversal of sedative effects of benzo's Examples of these drugs: Alprazolam, chlrodiazepoxide, clonazepam, diazepam, lorazepam, tempazapam Seizure precautions, may need intubation, cardiac monitoring

Who is more likely to get rheumatoid arthritis

Gender difference? Women more likely than men Genetic link HLA-DR4 and HLA-DR1 Comparison of twins found identical twins had it more than fraternal twins Smokers May be a link to sex hormones as well since it is more commonly found in women

Positioning for parkinson's

Goal is to prevent dependent edema Ottoman can be used to keep legs elevated Each proximal joint lower than the more distal joint Hand higher than elbow, elbow higher than shoulder

Bleeding- loss of blood

Going to have lower BP, increased HR Fluids (to increase volume) Oxygen (due to decreased hemoglobin) Monitor for hypotension Ready for possible transfusion If anemia is a result of active bleeding, sudden drop in hemoglobin, or is critically low then the patient needs close monitoring, notify HCP, be ready to act Prioritize actions!

What is leukemia?

Group of malignant disorders An unregulated increase of leukocytes, leaving less room for normal cell production which can cause lab values to be kind of all over the place Affects bone marrow because that is where these cells are made, lymph and spleen because they start to build up there Buildup of dysfunctional cells Cellular regulation has gone wrong for some reason and that turns on this change Does not matter what kind of leukemia you have, eventually all healthy cells are going to be crowded out by leukocytes

Who is at increased risk for TB?

Homeless Substance abusers Poor Weakened immune system HIV, infection, cancer, corticosteroid use Limited access to healthcare Foreign-born people In US highest rate are those of Asian descent Working in institutions Prisons, shelters, hospitals, long-term care facilities People who live closely together are more at risk Taking corticosteroids

Pediatric HIV concerns

HIV encephalopathy - may cause developmental milestones to be missed Microcephaly Motor deficits Loss of previous developmental functions Infants- receive zidovudine for 6 weeks if mother HIV+ Adolescents- Sexual education important for prevention Safe needle practices Treatment compliance Vaccinations- do not give live vaccines to people who are immunocompromised (like varicella and MMR) We treat the mom during labor and treat the infant for 6 weeks because we don't actually know if the baby will get it for awhile

Possible precipitating factors for fibromyalgia

HIV infection Lyme disease Emotional or physical trauma Steroid withdrawal Flu-like viral illnesses

Tremors related to parkinson's

Handwriting trails off toward ends of words - micrographia More prominent at rest Aggravated by stress or concentration

Assessment/interview questions with HIV?

Have you had a blood transfusion before or used clotting factors? Was this before 1985? This is when they started testing blood for HIV Have you ever shared drug-using equipment with another person? Have you had unprotected sexual encounters? Have you ever had a sexually transmitted infection?

Diagnostics for MS

Health history, assessment, and some tests can aid Cerebral spinal fluid (CSF) electrophoresis MRI might see plaques in brain May see atrophy of spinal cord Diagnosis requires 3 criteria Lesions in two places in CNS MS symptom or episodes occurring twice 1 month or more apart Rule out all other diagnoses

Community nursing focus

Health promotion and maintenance Prevention Slowing disease progression Improve quality of life Health promotion: exercise, nutrition, vaccines, smoking cessation, preventative medicine We should educate people as early as possible

Substance abuse statistics

Healthcare costs annually for: Tobacco $168 billion (2010) Alcohol $27 billion (2010) Illicit drugs $11 billion (2007) Prescription opioids $26 billion (2013) North Carolina has 4 of the top 25 cities with highest incidence of opioid abuse In 2013 in the US, 66.2% of students reported having at least one drink of alcohol, 18.6% report having a drink before age 13

Long term impact of substance abuse on the body

Heart and lung disease Hypertension Infections Sepsis - can lead to endocarditis HIV/AIDs Hepatitis Nutritional Malnourished GI disturbances Poor dental health Pulmonary emboli Thrombophlebitis Gangrene Increase of "risky behaviors" Unintended pregnancy STI's Accidents/ Trauma Depression, Anxiety, Psychosis, Suicidal Ideation

Heat and cold for RA treatment

Heat No longer than 20 minutes at a time Do not use heat-producing cream such as capsaicin with heating devices Cold Between 10-15 minutes application at a time Both are beneficial to help relieve stiffness, pain, and muscle spasms

Client education for MS, set goals

Help client identify their personal triggers and how to avoid them If client immobile, prevent complications from this...? Respiratory infections, UTIs, pressure ulcers, DVTs Educate on exercise and rest periods Bladder education May need to teach self-catheterization Bowel problems Include more roughage in diet Psychosocial adjustments When someone is awaiting a possible diagnosis of MS, there is a lot of anxiety This is a progressive chronic disease without a cure, depression is common

HSCT for leukemia

Hematopoietic stem cell transplantation Must have a suitable match (based on more than just your blood type) Risk of graft-versus-host disease Patient undergoes aggressive chemo and maybe radiation first because we need to take away their entire immune system The donated stem cells are infused intravenously to restart the blood cell production process (healthy cells) Be the match.org Transplant is not always a "cure". The new cells may not make the new healthy cells needed. This is graft failure. Also, a relapse may still occur.

Antiretroviral therapy adverse effects

Hepatotoxicity- if they have other liver issues then they may not be able to take their meds as well Osteopenia- bone density issues Nephrotoxicity- people who already have kidney issues may have issues with their meds Increased risk of cardiovascular disease and MI Fat redistribution- sunken in cheeks and fat accumulating in abdomen, breasts and in buffalo hump Facial wasting Fat accumulation Abdomen, Breasts, dorsocervial region (buffalo hump)

Thalassemia

Hereditary Hypochromia (decrease in hemoglobin content of the erythrocyte) Extreme microcytosis - smaller than normal erythrocytes Hemolysis Hemolytic (there is a hemolysis going on)

Anemia severity

Hgb levels used to determine severity Mild (Hgb 10-12 g/dl) Moderate (Hgb 6-10 g/dl) Severe (Hgb <6 g/dl) Caused by body's response to hypoxia HGB levels are used to determine severity of anemia Severity of symptoms depends on sudden or gradual onset, is this a chronic problem? Individuals with comorbidities more symptomatic

Cannabis intoxication

High feeling Lowered inhibitions Relaxed Increased appetite Impaired motor coordination Inappropriate laughter Distorted perception of time May have anxiety, social withdrawal, or dysphoria Physical assessment: Bloodshot eyes (conjunctival injection) Dry mouth Hypotension Tachycardia Delusions and psychosis can occur

Health care workers

High rates of abuse for controlled substances for these occupations Easy access Also higher rates of alcoholism Duty to report co-workers, suspicious behavior Protect your login and password information Watch others actually waste meds if you are the witness Signs of abuse: Frequent absenteeism Excessive waste of meds Clients reporting ineffective pain relief Unexplained absences from the unit

For the client that has a hip fracture and repair, what are they looking at?

Hospital stay 3-4 days A type of rehab facility for a few weeks after that Return to home possibly with home health Use of assisted devices Principles important at any of those places Pain management Monitor for infection Prevent DVT..how? Anticoagulants Monitor for signs of bleeding Exercises to restore strength Weight bearing activity resumes when..? Depends on the stability of the fracture

How is HIV not spread?

Hugging Dry kissing Shaking hands Sharing eating utensils Using toilet seats Tears Saliva Urine Emesis Sputum Feces Sweat Respiratory droplets Enteric routes All you need are universal precautions

What is HIV?

Human Immunodeficiency Virus Retrovirus? Replicate backwards aka go from RNA to DNA Reduces effectiveness of the immune system AKA immunosuppression It makes the immune system not work as well which opens up the body to infections that you would not normally get, which are called opportunistic infections What impacts immunity? Stress, fatigue, lack of sleep, poor nutrition

Other treatment options for OA

Hyaluronic acid (HA) Found in normal joint fluid and articular cartilage Can be given by injection Pain relief for up to 6 months

Pharmacological treatment for sickle cell

Hydroxyurea FDA approved Safe in children Increase fetal hemoglobin to replace the sickle cells with regular cells Mechanism Increases fetal hemoglobin Increases hydration Decreases adhesion of cells Essentially... It replaces sickled cells with normal cells Less sickled cells are formed.

Prevention of TB

Hygiene education Avoid prolonged and close contact with individuals with TB when traveling to other countries Prophylactic treatment for individuals at risk for TB with INH therapy Example: Someone living with a person infected with TB

Modifiable risk factors for stroke

Hypertension Diabetes Heart Diseases Cigarette smoking High RBC count High blood cholesterol & lipids Lack of exercise Obesity Excessive alcohol use Drug abuse Sleep apnea Poor Diet BCP in combination with smoking HTN-single most important modifiable risk factor-Risk can be decreased up to 50% with tx of HTN Heart disease-Atrial fibrillation most important treatable cardiac risk (20% of all strokes) Diabetes-5X greater risk than the general population Smoking-doubles the risk Alcohol-depends on the amt consumed-Females >1 drink a day, Males>2 drinks a day Obesity-specifically abdominal girth Physical activity-benefits can occur with light to moderate activity Diet-high in sat fat and low in fruits and veggies increase the risk BCP-high levels of hormones with smoking increases the risks. Other risks: Migraine H/As, inflammatory conditions, hyperhomocystinemia, sickle cell anemia Some herbal meds such as Gingko and Garlic can also increase the risk Childbirth Menopause Pregnancy History of Migraines

Classifications of anemia

Hypoproliferative Defect in the production process of erythrocytes (not enough of them for what we need) Iron, B12, Folic Acid, not having enough erthyroproetin Hemolytic Destruction Sickle cell, enphalicemia Loss Bleeding (can be obvious or hidden)

Complications with fractures

Hypovolemic Shock- especially with pelvic breaks and multiple breaks Fat embolism syndrome (FES) Compartment syndrome DVT/VTE Avascular necrosis PE Delayed union/malunion Infections DIC (disseminated intravascular coagulation) with this you use up all your clotting factors and so your blood does not clot anymore and you can reverse this with the right blood products hopefully Eight-month-old ring finger malunion in a 19-year-old female patient. From Strickland, J. W., & Graham, T. J. (2005). Master techniques in orthopaedic surgery: The hand (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.

Why does oxygen matter for sickle cell?

Hypoxia increases sickling Sickling leads to further hypoxia Not a preferable cycle to be in! What can you give to fix this? Oxygen But only if pulse ox < 92% What happens if hypoxia is prolonged? Can lead to a sickle cell-crisis Then oxygen does not help and other interventions take priority

Types of hemorrhagic stroke

ICH-Intracerebral Hemorrhage Bleeding into the brain caused by a rupture of a vessel Accounts for 10% of all strokes Poor prognosis Most common cause? Hypertension Sudden onset Neurological deficits SAH-Subarachnoid Hemorrhage Intracranial bleeding into the cerebrospinal fluid Poor prognosis Most common cause? Rupture of a cerebral aneurysm Significant cognitive deficits Complications-rebleeding ICH: 50% of deaths within first 48 hrs Causes: (most common in patients with HTN and atherosclerosis) Vascular malformation (AVM-most common cause of strokes in young people) Coagulation disorders Anticoagulant and thrombotic drugs Trauma Brain tumors Ruptured aneurysms SAH: 40% die with first episode Causes: (most common cause is a hemorrhage from a AVM, intracranial aneurysm, trauma, or hypertension) Trauma Illicit drug use This type of stroke is considered the number 1 culprit if someone reports having the "worst headache of their life". This, like intracerebral hemorrhage also has a poor prognosis. Sometimes the body will temporarily manage the bleed but then it will re-bleed. It is important to get any stroke patient to the proper intervention needed (will discuss soon I promise) The text mentions vasospasms. Metabolites such as endothelin are kept in normal tissue and released when appropriate. However with a bleed, brain tissue gets ischemic and necrotic. This releases the metabolites uncontrolled out. Vasospasm = constantly contracting and narrowing of the cerebral vessels. When you already have a perfusion problem, narrowing arteries more does not help, it only hurts.

National patient safety goals with HIV

Identifying the patient correctly before administering medications Hand washing to prevent infection

Nursing assessment after spinal surgery for low back pain

If dressing present check for CSF Clear or slightly yellow Report severe headache immediately Both could mean CSF leakage Monitor peripheral neurologic signs after surgery Should be same as before surgery If client had paresthesia before surgery it should not be expected to disappear after surgery, it takes time sometimes weeks to months Every 2-4 hours for first 48 hours (neuro checks)

Treatment options for acute low back pain

If mild NSAIDs, Acetaminophen, Cyclobenzaprine If severe Opioids Most lower back pain will resolve within 2 weeks Opioids should only be used for short term Muscle relaxers like cyclobenzaprine (flexeril)- contracted muscles can cause the spine to be pulled out of alignment

Treatment- disease modifying for MS

Immunomodulating and immunosuppression therapy Interferon- flu-like symptoms and liver damage Copaxone -subcutaneous, daily Novantrone- Iv every 3 months IV Methylprednisolone- used with acute relapse Anti-inflammatory effect Followed by oral prednisone taper Increased risk of infection with immunosuppression

Substance abuse in older adults

Impairment at lower levels for adults over age 65 due to changes in metabolism and kidney function Increased possibility of comorbidities Increased risk of interactions with prescribed medications Increase of chronic illnesses that cause pain Stress, isolation, grief, and depression increase risks

Lab review for anemia

Important Labs to Know Hemoglobin? 13-17 g/dL Male 12-16 g/dL Female Hematocrit? 35-50% Male 35-47% Female Simple trick? Hemoglobin x 3 should roughly equate to hematocrit Simple trick is that hematocrit should be roughly triple hemoglobin. If you can remember the normal hemoglobin then you should be good with hematocrit. Depending upon your area you will work, some doctors will focus on one or the other. Large majority will focus on hemoglobin, but some older physicians will ask for hematocrit..I have no idea why either. You usually don't call a doctor for a patient with a low blood count then ask why they prefer hematocrit over hemoglobin etc. Hydration status can falsely affect your hemoglobin level (dehydrated makes it look higher, over hydrated makes it seem lower)

Inhalants

Includes anesthetics, nitrates, organic solvents "Huffing" Gasoline, paint thinner, spray paint White out, glue, markers, hair spray Cleaners Nitrous oxide, laughing gas Can cause overdose, death Mostly alters CNS: Slurred speech Dizziness, lack of coordination euphoria May have hallucinations or delusions Long-term: Damage liver/kidney Hearing loss Delayed development Brain damage Mostly commonplace items Nitrates- misuse of Rx for chest pain Spray chemicals in a paper bag then inhale fumes Treat symptoms Can become addicted

Goals of nursing with HIV

Increase adherence with drug regimen Adopt healthy lifestyle changes to prevent transmission Protect others from HIV Explore spiritual issues Maintain and develop healthy and supportive relationships Maintain activities and productivity Cope with symptoms caused by HIV and treatment Come to terms with disease and prognosis

Quality of life for fibromyalgia

Increase physical activity Self-management education classes Support groups Nurture physical, mental, emotional, and spiritual health

Sedative withdrawal

Increased HR, BP, Temp, RR Hand tremor Insomnia, anxiety, Nausea, Seizures Hallucinations These drugs should be tapered off when detoxing to avoid coma or death Should not stop taking abruptly!!

Nutritional concerns for leukemia

Increased metabolism from the disease process Stomatitis, mouth pain Nausea Side effect of chemo, antibiotics, pain meds Nutritional supplements Need increased calories Antiemetics Oral anesthetics to help with pain but then we want to watch for swallowing issues Stomatitis- inflammation of the oral tissues, can occur with chemo and radiation

Effects of nicotine use

Increased: Arousal and alertness HR, BP Cardiac output Vasoconstriction Gastric motility Decreased: Appetite

How long does HIV take to progress?

Individualized Depends on each person's immune system The process described before is without receiving any treatment In a immunocompetent individual without treatment 8-10 years to notice symptoms 10 or more years to be immunocompromised

Other treatment for RA

Individualized exercise plans are pivotal Therapeutic exercise programs by PT to maximize flexibility and strength of joints Gentle ROM Aquatic exercises ROM helps prevent contractors, stiffness and increases blood flow Aquatic exercise can be very helpful because it decreases the stress on the joints

Stages of chemotherapy for leukemia

Induction Therapy Postinduction (Intensification) or Postremission Therapy Maintenance Therapy CNS prophylaxis (children or people with ALL)

What is TB?

Infectious disease caused by... Mycobacterium tuberculosis Grows slowly, sensitive to heat and UV light Affects Primarily lungs Can spread through lymphatics to anywhere in the body Kidneys, epiphyses of bone, cerebral cortex, adrenal glands to name a few Bacterial infection People with compromised immune systems are more likely to get TB

AML Gum changes

Infiltration of leukemic cells into gingival areas Gingival hyperplasia

Corticosteroid therapy for OA

Injected into joint (intraarticular) Strict aseptic technique needed Normal to feel pain worsen after injection, avoid overuse at this time Pain relief can last from weeks to months Examples? Methylprednisolone Triamcinolone Injected into vein (systemic) Uses in severe cases Limit use Taper when stopping May be used if symptoms are present despite other anti-inflammatory medications Examples? Hydrocortisone Methylprednisolone Dexamethasone Triamcinolone Over time this disease is going to get worse, especially if you don't modify things because this is a chronic issue

What do we do to improve compliance with TB treatment

Institute what they call direct observed therapy (DOT) Doses of both phases usually doubled and have to be observed to ensure compliance In addition, teaching, counseling, reminder systems, incentives or rewards are also effective

Nursing goals and interventions for parkinson's

Keep them moving Understand medication regimen and take as prescribed Follow nutritional guidelines Understand the toll this takes on the psyche and how to deal with depression and anxiety Caregiver education Exercise to prevent muscle atrophy Safety Fall-free environment Proper shoes Elevated toilet seats

Clinical manifestations (integumentary) for anemia

Integumentary (Hgb < 6) pallor Reduced blood flow to skin Jaundice...why? Liver involvement when anemia involves a process that causes hemolysis which releases things that cause the jaundice Pruritus Buildup of bile salt in skin and serum The symptoms you see are dependent on whether they lost a lot of blood quickly or over time where there body could compensate some If you have a patient that looks like this, they are well past treatment. Obviously one sign from lowered blood would be pallor. Jaundice, you usually don't think of jaundice with a lowered blood count, but think about why the blood count could be low. Some blood counts or hemoglobin specifically reduce from pathologic processes that cause hemolysis. Red blood cell waste products increase bilirubin levels reflecting upon what organ? Liver. With jaundice where is the best place to see it? Sclera of eyes and mucous membranes Pruritus is due to a buildup of bile salt in the skin and serum. Remember the CAUSE of anemia causes the lowered blood count.

Post-induction therapy for leukemia

Intensification (postinduction): when remission was not achieved with induction Immediately after induction High-dose, may include new agents Consolidation (postremission): when remission is achieved with induction After remission achieved Agents determined case by case May be continuation of induction agents May be more intensive Purpose? reduce those remaining undetected leukemic cells

Nicotine addiction/withdrawal

Irritability Decreased focus Trouble sleeping Increased appetite Irritability Varenicline (Chantix) Oral med used to decrease cravings and withdrawal symptoms Take with food and full glass of water Can cause suicidal thoughts, vivid dreams, insomnia, and depression No nicotine in this medication

Cannabis withdrawal

Irritability Muscle aches Sweating Anxiety Difficulty sleeping Decreased appetite

Supportive measures for leukemia

Is aggressive treatment an option or appropriate? Brief use of hydroxyurea to control the increase of blast cells in AML Blood transfusions- to treat hemoglobin and anemia Antibiotics Comfort care Pain Nausea

Two types of stroke

Ischemic Inadequate blood flow to the part of the brain that results in the death of brain cells. Thrombotic Embolic Hemorrhagic Caused by burst or leaking blood vessels in the brain. Strokes can be divided into two categories: Ischemic and Hemorrhagic. Ischemic occurs in 87% of the stroke cases Hemorrhagic occurs in 13% of the stroke cases Ischemic-begins with development of fatty deposits lining the blood vessel wall Cerebral arteries most common cause. The plaque deposits cause the lining to thin and weaken, and create a hole in the vessel lining. They then begin to clump together and form a fibrin clot which may stay or break off and become an embolus. See table 67-1 for the comparisons of stroke on pg. 1973

Major types of stroke

Ischemic strokes are either thrombotic or embolic in nature. Thrombus is a clot that forms and does not move. Embolus is a clot that moves. Hemorrhagic, a vessel bleeds out into the brain. Ischemic strokes-TIAs are often precursors to this type of stroke. Thrombotic is the bodies response to injury to the blood vessel. The blood vessel gets injured, the clotting process begins and a clot is formed. This clot ends up narrowing the artery and causes reduced blood flow leading to infarction. These form easier where plaque is...plaque is what? Cholesterol. The arteries are already narrow in high cholesterol individuals that have plaque buildup so the clot doesn't have to be as big to occlude the artery. These individuals may notice symptoms that have progressed over time. As the blockage gets larger the symptoms get worse. It is usually not rapid or sudden unlike embolic strokes.

Treatment for TB

Isoniazid (INH) Rifampin (Rifadin) Rifapentine (Priftin) Rifabutin (Mycobutin) Pyrazinamide Ethambutol (Mayambutol)

How does the virus spread?

It is transmitted through bodily fluids such as blood, semen, vaginal secretions or breast milk Via sexual intercourse, exposure to HIV infected blood, transmission during pregnancy, at delivery, or breastfeeding For delivery if HIV is untreated it is a 25% chance of passing the infection. However, with treatment the risk is less than 2%. Other factors Length of contact- you are more likely to contract HIV if you have longer contact Host immune status- if you are immunocompromised you are when you come in contact with HIV Concentration of virus that makes contact- how much virus your body is exposed to and the phase of the infected person And to a lesser extent the "phase" of HIV (though it can transmit in all phases) Vertical contraction- Pregnancy, delivery Horizontal- drug use, sexual contact

Clinical manifestations of OA

Joint discomfort Difficulty sleeping Crepitus Systemic manifestations? None, this is one distinction between this and RA Pain before weather change..? Not 100% proven, but popular theory Barometric pressure differences Joints are like a balloon and the outside pressure keeps them from expanding Before bad weather barometric pressure drops allowing them to expand Joints become painful the more stiff they are In the morning joints are usually stiff for about 30 minutes... Anyone remember what it was with RA? 1 hour, this is another distinguishing factor They start hurting because they are not up moving, even ROM can help increase comfort

Nurse responsibility for assaultive behavior

Know your self Do not pass judgement Don't avoid a client's anger because you are uncomfortable Self-awareness o ow you deal with your own anger Avoiding can lead to escalation

Sinement for parkinson's

Levadopa and carbidopa used in early stages of PD (called Sinemet Levadopa is chemical precursor to dopamine, converts to dopamine in basal ganglia Carbidopa inhibits an enzyme that breaks down levodopa Together they increase dopamine and prevent it from being broken down, synergistic effect Patient education Monitor for signs of dyskinesia? Impaired involuntary movement Improvement may take weeks to months to appear Notify doctor of any uncontrolled movements, mental changes, difficulty urinating, severe nausea, or palpitations

Exercise therapy for parkinsons

Limits consequences of immobility Physical therapy can design specialized exercise routines to target specific muscles Especially those with speaking and swallowing

Treatment for assaultive behaviors

Lithium - bipolar, conduct disorders Carbamazepine -dementia, psychosis, personality disorders Valproate -dementia, psychosis, personality disorders Benzodiazepines - reduce irritability Haloperidol (Haldol)- used in combination with lorazepam to decrease agitation and psychotic symptoms Seclusion and restraints - not long term, may be needed in a crisis, last resort

Foods that are high in iron

Liver and muscle meats Eggs Dried Fruits Legumes Dark green leafy vegetables Whole-grain and enriched bread and cereals Potatoes

Epidemiology

Look at statistical information regarding the spread of disease, number of people affected, evaluate prevention programs CDC MMWR link Incidence - number of new cases per 1,000 people Prevalence - number of existing cases at a specific time per 1,000 people Mortality Rate - number of deaths from a specific cause per 1,000 people Morbidity - incidence of a specific disease

Treatment for iron-deficient anemia

Look at the cause, then treat it if you can.. Fix a bleed if there is one If they don't eat right... Foods high in iron If they had blood loss.. Give some blood If their diet is fine but their iron is low... Iron supplementation You treat the cause first and foremost. You can provide diet teaching if that's the only problem. Or if they are not eating right then they made need some help, they may need some ferrous sulfate or iron. If they are bleeding then we should give them some blood. Prioritize actions based on severity of symptoms!! In critical situations with a low hemoglobin your treatment will first correct the low hemoglobin then focus on the cause. For instance if you have someone come in for a bleed in their lower GI system. While a colonoscopy to stop the bleed is the "cure", they may die if they do not temporarily increase their hemoglobin so blood would come first.

Maintenance therapy for leukemia

Lower doses of same drugs Every 3-4 weeks for an undefined amount of time (prolonged) Goal? Same as before, reduce leukemic cells Exception? AML Get rid of any residual cells, length of time is 2-3 years Low dose, daily, weekly, or intermittent

Stem Cell classification

Lymphoid (immunity) B lymphocytes Helps form antibodies T-lymphocytes -recognize "foreign" material Myeloid Monocytes Granulocytes Neutrophils, basophils, eosinophils Erythrocytes Platelets Monocyte- macrophage Neutrophil - prevent and limit bacterial infection Basophil - contains histamine Eosinophils -neutralize histamine, digests foreign products Erythrocytes- carry hemoglobin, oxygenation of tissues Platelets - coagulation

National patient safety goals

Make sure that the correct patient gets the correct blood when they get a blood transfusion. Get important test results to the right staff person on time.

Nursing management for fibromyalgia

Many patients need emotional and/or psychological support to deal with pain Educate on ways to manage symptoms like pain and fatigue Reassurance that fibromyalgia is an actual diagnosis, not made up Educate on exercise and sleep regulation Educate on techniques to reduce stress

Chronic Myeloid Leukemia (CML)

Mature neoplastic granulocytes Endpoint what organs? Liver and spleen Chronic (Stable) phase Transformation phase- where things start changing Blastic (acute) phase Philadelphia chromosome 90-95% of clients ( a little more diagnostic) Chronic tells us it's a mature cell that proliferates. Good prognosis in chronic phase but can transform into acute phase Cellular changes but we can deal with it Early on, no symptoms Unique ones Massive splenomegaly , tenderness Increase in sweating Shortness of breath Confusion Malaise Anorexia Weight loss Treatment can make this a chronic illness and not a terminal illness Diagnostics High platelet beginning, low later Increased neutrophils Due to granulocyte proliferation Normal lymphocytes Low leukocyte alkaline phosphatase Is Philadelphia chromosome diagnostic? No, it is 90-95% but not diagnostic It is used as a reliable detector of relapse, but NOT diagnostic of CML It is also present in ALL

Giving alcohol to patients

May be allowed by some facilities for individuals with a history of chronic use Must be closely supervised, have to watch them drink it Client could "save it for later" so that they can have multiple drinks at one time

Delayed union, malunion and non-union

May need an electric bone stimulator or ultrasound stimulation Autograft (from the patient for their own use) Allograft (tissue from a donor) Bone graft substitutes Need pain management Education Support Reinforce weight-bearing activities allowed or not allowed May not be healing the way it needs to, may not be in alignment

What is available for the consumer?

Media - Television, radio, commercials, billboards Literacy -education materials must be at a 5th grade reading level Immunizations Buncombe County Immunization Rates What is out in the community for the consumer to learn and know regarding health? How do you identify what is available and what is needed?

If stem cell transplant is not an option for aplastic anemia

Medications Antithymyocyte globulin Cyclosporine Cyclophosphamide Corticosteroids which will increase the platelets some Blood transfusions Their iron isn't a problem so what else? Iron chelation agents discussed before These agents mostly immunosuppress and prevent inflammation. These patients can also get blood transfusions. Remember they already had a high iron content. Their problem is not iron but cellular products, so you will need to administer iron chelating agents. However, in terms of testing focus on these treatments. No fresh flowers, make sure they are really washing fresh fruits and veggies to avoid infection

Therapy for muscle spasticity related to MS

Medications: Baclofen, dantrolene, Tizanidine, cyclobenzaprine Benzodiazepines Surgical options (for disabling spasms and/or contractures) If having tremors may use deep brain stimulation Nerve Blocks For spasticity may use intrathecal? Baclofen delivered by a pump These clients can have a lot of trouble with mobility with weakness, paralysis, spasticity and tremors Exercise, especially water therapy helps Helps train muscles to compensate for each other to improve movement Improves daily function on "good" days, does not prevent exacerbations

Neurologic manifestations of anemia

Moderate (Hgb between 6-10) Roaring in the ears Severe signs (hgb < 6) Headache Confusion Fatigue Changes in LOC Ataxia? Lack of muscle coordination Patients with low hemoglobin are at an increased risk of falls

Prevention of OA

Modify or decrease risk factors Weight loss Exercise Treat injuries to decrease amount of damage to joints

Once a client with OA goes home...

Modify the environment

Nursing management for leukemia

Monitor for bleeding and infection Educate client and family Ask about varicella immunization or h/o illness Assess lungs, lymph nodes Pain management Atraumatic care for pediatric patients EMLA cream for lab and IV sticks

Inhibitors (dopamine related) for parkinson's

Monoamine oxidase-B inhibitors (MAO-B) MAO-B is an enzyme that breaks down dopamine. If you block MAO-B, you increase dopamine Catechol-O-methyltransferase (COMT) COMT breaks down levodopa Block this, you have more levodopa This is only used in conjunction with levodopa or analogs (sinemet)

Risk factors for fibromyalgia

More common in females Family history Obesity History of a repetitive injury Lupus or rheumatoid arthritis

Opioids related to substance abuse

Morphine Meperidine Codeine Hydromorphone Oxycodone Methadone Hydrocodone Heroine Fentanyl Carfentanyl Carfentanyl- 100x potency of fentanyl, 5,000x as potent as heroin, and 10,000x as potent as morphine Often sold as heroin, cheaper than heroin, intended for large animal use

Osteoarthritis (OA)

Most common form of joint disease AKA -Degenerative Joint Disease (DJD) Noninflammatory disorder of the joints Not systemic Breakdown in the articular cartilage The body responds to this damage- new tissue formed Osteophytes- a bone spur Osteophyte- bone spurs, grow into joint space, limits range of motion and causes more damage Someone can have osteoarthritis and rheumatoid arthritis Starts in 30's, peaks at around 60's Note the decrease in the joint space created by the osteophytes Bone on bone can cause a snap-crackle-pop kind of noise Can get a bone cyst as well

Acute lymphocytic leukemia (ALL)

Most common in who? Children Median age 13 Immature small lymphocyte proliferation or lymphoblasts This is the most common Leukemia in children. Classified based on the type of cells involved - T cell, B cell, early pre-B cell, or early pre-T cell Clinical manifestations: Leukocyte count high or low High number of immature leukocytes Central Nervous system often affected Meningeal involvement Pain Bone Liver and spleen Leukemic cells infiltrate organs more with this leukemia Neurological manifestations Common due to meningeal irritation Lethargy, elevated intracranial pressure, cranial nerve dysfunction Hypercellular bone marrow with lymphoblasts X-ray findings Transverse lines of rarefaction at the ends of the metaphysis of long bones. Growth plate CSF Can detect lymphoblasts in this Spinal tap needed to get this CSF (do not put invasive procedure specimens in the tube system) Philadelphia chromosome 20-25% of patients (not diagnostic) Translocation of chromosome 22 and 9 which interferes with normal cellular regulation Interferes with normal cell cycle aka increases cellular proliferation (nonspecific)

Clinical manifestations for stroke- motor function

Most obvious effect of stroke Include impairment of Mobility Respiratory function Swallowing and speech Gag reflex Self-care abilities Symptoms are caused by the destruction of motor neurons in the pyramidal pathway (nerve fibers from the brain that pass through the spinal cord to the motor cells). Characteristic motor deficits Loss of skilled voluntary movement Impairment of integration of movements Alterations in muscle tone Alterations in reflexes Hemiparesis v/s Hemiparalgia An initial period of flaccidity May last from days to several weeks Related to nerve damage Spasticity of the muscles follows the flaccid stage. Related to interruptions in upper motor neuron influence What is hemiparesis? Weakness in one side of the body or a part of it. What is hemiplegia? Paralysis in one side of the body or a part of it. Because the pyramidal pathway crosses at the level of the medulla, a lesion on one side of the brain affects motor function on the opposite side of the body (contralateral). Spasticity later on is what causes the contractions.

Clinical manifestations of stroke- elimination

Most problems with urinary and bowel elimination occur initially and are temporary. When a stroke affects one hemisphere of the brain, the prognosis for normal bladder function is excellent. Initially, the patient may experience frequency, urgency, and incontinence. Although motor control of the bowel is usually not a problem, patients are frequently constipated. Constipation is associated with immobility, weak abdominal muscles, dehydration, and diminished response to the defecation reflex.

Opioid antagonist- naloxone (Narcan)

Reverses all signs of overdose toxicity Bind to the opioid receptors, blocking them Administered IV, IM, Subcutaneous, and intranasal May also be given via ET tube Can cause seizures, HTN, V-fib, or V-tach Duration of opioid may outlast naloxone so client can relapse into respiratory depression

Clinical manifestations of MS

Motor Fatigue Weakness or paralysis of limbs, trunk or head Diplopia Muscle spasticity Coordination difficulty Sensory Paresthesia, numbness, tingling Blurred vision, vertigo, tinnitus, neuropathic pain Total blindness is a possibility Cerebellar Nystagmus, ataxia, dysarthria, dysphagia Lhermitte's sign Electric shock radiating down spine or into limbs when flexing neck Frontal and Parietal lobe Cognition Psychosocial Dementia is rare Dementia is rare with MS Biggest issue is fatigue and weakness Other areas affected depend on where the plaques form in the CNS Bowel Bladder Sexual function What about in pregnancy? Gets better during pregnancy, hormones thought to improve the immune process What about post-partum? Exacerbation of the disease due to hormones decreasing Stress and fatigue

Systemic lupus erythematosus (SLE)

Multisystem inflammatory autoimmune disease Affects skin, joints, kidneys, heart, lungs Chronic condition with unpredictable exacerbations and remissions Discoid lupus is just on the skin Can have medication-induced lupus that can go away

Movement and skin concerns with stroke

Musculoskeletal (mobility) Prevent Contractures Muscle atrophy Positioning (joints) Each joint higher than proximal Prevents dependent edema Integumentary Loss of sensation to areas Massage? No causes damage, there is not a blood flow problem Turn? On the affected side up to 30 minutes, do not neglect the weakened side when turning Some of you who are CNAs already or even some in clinical who aren't have probably seen someone with contractures. Their hands will be closed permanently their arms all contracted or legs. They are difficult to turn. What is worse once you try to straighten out the contracture this is painful for the person even though their position looks painful already. This is a big concern for stroke patients with paralyzed extremities in rehab. As the positioning point describes you want to position them to avoid developing dependent edema in the joints. Do not massage, this can cause further damage Incontinence may or may not happen it usually corrects itself. Turning bedridden patients is important. You can turn them on their paralyzed side but limit it to 30 minutes, do not avoid it.

Airborne precautions for TB

Must be initiated as soon as possible if TB suspected Negative pressure room, door has to stay closed Private room only Healthcare worker must wear a respirator while in the client's room NIOSH (National Institute or Occupational Safety and Health )approved N95 respirator or power, air-purifying respirator (PAPR)

How do we diagnose SLE?

Must meet 4 of the 11 criteria A person is classified as having SLE if four or more of the criteria are present, serially or simultaneously, during any interval of observation. Chart 38-5 in text page 1099 Look at history, physical exam, and blood tests (ANA, CBC)

What is to blame for leukemia?

Mutation of DNA of certain cells Oncogenes can be turned on by things like a virus or chemical exposure Viruses may also activate certain genes Environmental influences What hospital worker? Radiologists, x-ray etc Chemicals Chernobyl..what was this? Nuclear reactor aka radiation Anything that changes cellular regulation

Neurologic symptoms of stroke

NIH Stroke Scale (NIHSS) Mental status Pupil responses ? Not a reliable way to tell, some have dilation, some have constriction Extremity movement and strength Out of the options listed on the left, which do you think you might notice changes in first? Slurred speech or change in speech pattern and changes in weakness in extremities would be the first changes. Pupils do not always have a change with strokes. There is not a "reliable" pupil to stroke pattern to learn. NIH (National Institute of Health)stroke scale is something you take a class for to work at a facility because it is worded funny. Scale 0(normal)-42(severe). See T able 67-4. Integrates neurological components LOC Speech and language Vision Motor Sensory Can predict outcomes

National patient safety goals for TB

NPSG.07.03.01: Use proven guidelines to prevent infections that are difficult to treat. NPSG.01.01.01: Use at least two ways to identify patients. For example, use the patient's name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.

Treatment for lupus: symptom based

NSAIDS Belimubab (Benlysta) Decreases the antibodies, impacts progression Antimalarial Hydroxychloroquine and chloroquine Corticosteroids May be topical for skin lesions Anticoagulants Warfarin Immunosuppressant For more severe cases Examples: methotrexate, cyclophosphamide, azathioprine Avoid sun, educate on sun block, hat, coverage If you are on an immunosuppressant or corticosteroids then they are at risk for infection A lot of immunosuppressant's are contraindicated in pregnancy Corticosteroids also decrease bone density so increased risk for osteoporosis and fractures Also have to taper corticosteroids

Pharmacology for low back pain

NSAIDS Tylenol Narcotics Muscle relaxers Corticosteroids What about non-pharmacological interventions?

Pain management for sickle cell

Narcotics at first Addiction? NSAIDS and acetaminophen once pain becomes less severe Nonpharmacologic interventions? Patient controlled analgesia (PCA) Pregnancy is a huge trigger for sickle cell Are going to need narcotics when they are in a crisis or a PCA

Spinal stenosis

Narrowing of spinal canal, for our purposes around the lumbar region Compresses spinal cord, causing pain Certain positions make it worse Standing or walking Pain starts in lower back, radiates to sacral area and leg May have numbness, tingling weakness and heaviness in legs One way to tell if someone has this is if pain eases up with sitting or bending forward

Surgical interventions for low back pain

Needed if progression in loss of function, sphincter control, radicular pain Not responding to conservative management Microdiskectomy Laminectomy Hemilaminectomy Partial laminectomy Diskectomy with fusion Foraminotomy

Diagnostics for sickle cell

Newborn Screening Required by law in all 50 states Sickledex or sickle cell prep Tells if there is sickle cell Does not distinguish between trait or anemia Hemoglobin electrophoresis Definitive diagnosis but usually we know right after birth with the newborn screening Sickle cell anemia has lowered hematocrit and sickled cells noted on smear. Diagnosis is confirmed by hgb electrophoresis.

Screening for alcohol abuse

Simple screening Instrument for alcohol and other drugs (SSI-AOD) Box 19.5 CAGE

Nicotine replacement therapy

Nicotine gum, transdermal patches, and lozenges Do not use while smoking! Certain health conditions? Should consult healthcare provider before using Asthma, heart disease, HTN, DM, stomach ulcers, liver disease, kidney disease, overactive thyroid Side effects: Mild headache Increased heart rate Increased appetite Nausea Dizziness Hiccups Abnormal Dreams

Nicotine abuse

Nicotine is found in the tobacco plant and can be addictive Smoke, Chew, Sniff, Vape Nicotine stimulates the adrenal glands releasing epinephrine Increases levels of dopamine in the brain causing pleasure Increases: BP Heart rate Respirations Other chemicals in with nicotine that can lead to Cancer Chronic bronchitis Emphysema Cataracts Pneumonia Secondhand and third-hand exposure possible Overdose uncommon but is possible Children exposed to second hand smoke- increased risk of SIDS, ear infections, asthma, lung infections Little known about effects of vaping and e-cigs, chemical exposure in lungs occurs, nickel and chromium exposure from heating coils in the device

My TB test is red, am I in trouble?

No Measured by induration, not redness Record in millimeters

Who is at greater risk to develop osteoporosis?

Non-modifiable Risk Factors Female gender Caucasian or Asian Advancing Age Postmenopausal Family history of Osteoporosis Use of corticosteroids, heparin, anti-epileptics, thyroid hormone Low testosterone in men Modifiable Risk Factors Cigarette smoking Greater than 2 drinks per day of alcohol Diet low in calcium or vitamin D Sedentary lifestyle- lack of weight bearing activity Depo-Provera is a big one in decreasing bone density Peak bone mass is 18-25 SSRIs Proton-pump inhibitors

Risk factors for parkinson's

Non-modifiable risks Increases with age, but there is not a true cutoff, any age can get it Men get it more than women 3:2 ratio Family link noted 20% of those with PD have a positive family history Modifiable risks Chemicals Carbon monoxide, manganese, meperidine Medications Metoclopramide, reserpine, methyldopa, lithium, haloperidol, chlorpromazine Amphetamines, methamphetamines Medical conditions Hydrocephalus, multiple sclerosis, encephalitis, infections, stroke, tumor, Huntington's disease, trauma

If someone has had a stroke and their BP is very high...

Normal protective response by the body Higher pressure needed to perfuse damaged area But too high is bad and there is a "different high" value for different circumstances Which type of stroke do you think a higher BP is good for? Ischemic Blood pressure will be higher or SHOULD be higher in someone who has had a stroke. Strokes with low blood pressure are very dangerous and you better do something quick for that (will discuss that shortly) Ischemic strokes support a higher blood pressure. With hemorrhagic strokes you are bleeding so it has a lower "high' accepted value. Anytime there is bleeding, higher blood pressure usually is bad. This matters post-operatively with carotid patients etc..

Anger

Normal response A strong emotional response to an actual or perceived provocation Body has a physical response, fight or flight Can be helpful in resolving conflict Can be expressed inappropriately or suppressed Can lead to hostility or aggression

What happens in the body to cause osteoporosis?

Normally Osteoblast and osteoclast activity are balanced Calcium going from bone to serum and back is "equal" Otherwise known as remodeling Osteoporosis Osteoclast activity exceeds that of osteoblast Another way to say it, bone resorption exceeds bone deposition

What is sickle-cell?

Normally people have Hgb-AA Glutamic acid Affected individuals have Hgb-SS Switches glutamic acid for Valine Cell has shortened life span Translation: hemoglobin is abnormal, therefore it doesn't function as well Autosomal Recessive Disorder 25% chance of children obtaining What would individuals with Hgb-AS be? Carriers (Sickle Cell Trait) Incidence African Americans Mediterranean, Caribbean, South America, Central America, Arabia, East India Hemolytic anemia It is designated as hemoglobin AA which means it is normal hemoglobin and contains glutamic acid If glutamic acid is replaced by Valine, it is changes to Hgb SS If someone has AS it means they are a carrier but will not have the active disease. Autosomal Recessive Disorder: If both parents are carriers, a child has a 25% chance of getting sickle cell and 50% to be a carrier Genetic, cells are more likely to be misshaped which causes them to get stuck and also decreases their oxygen carrying capacity

Is there a cure for MS

Not at this time Medications (there are a lot of them) are focused at battling symptoms or slowing progression down. The focus of treatment is on enhancing mobility Treatment is individualized, based on the client's symptoms Each person is unique so treatment is not uniform in terms of medications. **Life expectancy- 5-7 years shorter than normal Preventing damage and progression is the goal

Methamphetamine and cocaine withdrawal

Not life-threatening Marked dysphoria Depression Sleep disturbances Fatigue Cravings Psychosis Slowed thinking Unpleasant dreams Brain reward video for Methamphetamine

Knee joint for OA

Note the areas with color change Damaged cartilage Which knee's joint has a smooth surface?

What is "nursing"s responsibility when discharging a TB patient

Notify the public health department Public health nurses follow-up to check for medication adherence and may possibly be the ones administering the DOT

Types of Drug therapies for HIV

Nucleotide Reverse Transcriptase Inhibitors (NRTI's) Compete with the nucleosides in the cell that the virus needs to reproduce Ziagen, Videx, Emtriva, Epivir, Retrovir (AZT), Viread, Zerit XR Non-Nucleotide Reverse Transcriptase Inhibitors (NNRTI's) Bind to the HIV reverse transcriptase, blocking the RNA and DNA dependent polymerase activities Prevent the virus form taking over the cell's DNA and reproduce Rescritptor, Sustiva, Intelence, Viramune, Edurant Review your pharmacology text for these drugs and the side effects AZT is used in pregnancy to prevent maternal transmission of the disease Just need to know how they work and know the common side effects and which stage in the cell life cycle that it works on Protease Inhibitors Blocks protease activity in the HIV virus, keeping the virus immature It is unable to fuse and inject itself into the cell Reyataz, Prezista, Lexiva, Crixivan, Kaletra, Viracept, Norvir, Forovase, and Aptovus Fusion Inhibitors Prevents the virus form fusing to the cell membrane, thus it cannot enter the cell Fuzeon Integrase Strand Transfer Inhibitor Inhibit Integrase, which is an enzyme needed for the virus to replicate Trivicay, Isentress

How does hemorrhagic stroke occur?

Occurs when a weakened blood vessel ruptures 20% of all strokes Causes: Aneurysms: Ballooning of a weakened region of a blood vessel. Arteriovenous Malformations (AVMs): Cluster of abnormal blood vessels. Hypertension Starts pg. 1988 80% of all hemorrhagic strokes are caused by hypertension. Talk about a water hose for an example

What is an assaultive behavior?

Of, relating to, or tending toward assault Assault A violent physical or verbal attack

Substance abuse in the adolescent

Often abuse starts before age 20 Poor academic performance and low-self-esteem are risk factors Also at risk if peer group abuses substances Should perform universal screening Brain development continues into twenties Can interrupt with meeting developmental milestones and cognitive development Less impulse control More influenced by peer group at this age

Who do hip fractures happen to?

Old age is the main cause of hip fractures Weaker quadriceps muscles Slowed reflexes Decreased bone tensile strength Conditions increase risk of falls Women are more likely than men to get hip fractures..why? Osteoporosis 90% of these fractures result from falls

Exceptions to the common manifestations of TB

Older people Change in cognitive status may be only symptom Weight loss Fever Other organs Kidneys Dysuria, hematuria Bone Joint pain Brain Headaches, vomiting, lymphadenopathy

Latent TB drug therapy

Only one drug usually needed Depending upon compliance issues or medical history CDC Latent TB treatment Isoniazid for 9 months daily orally Combination of isoniazid and rifapentine orally for 3 months for those not presumed to have drug resistant strain If resistant to isoniazid then four month therapy with rifampin

What is PEP?

PEP Post-exposure prophylaxis (should be started within 72 hours of possible exposure)

Chronic low back pain

Pain that lasts more than 3 months Progressive

Feel (for sickle cell)

Palpation Hands and Feet swollen (bilaterally) Emergency: infarction of metacarpals and metatarsals Organs enlarged Liver and spleen Which comes first? Spleen To help with pain we can try reposition, dim lights, distraction and then try pharmacologic issues Blocked blood flow is causing the pain so we try to help that by pushing fluids and we MAY use oxygen (though for test and NCLEX we will not put oxygen unless they have an Sp)2 stat that requires it Also to help with blockages we may want to do movement, incentive spirometer, scuds, also HEAT

How does the body regulate calcium?

Parathyroid Hormone (PTH) Stimulates osteoclast activity.. Otherwise known as bone resorption? (consumes) Makes serum calcium increase Calcium in the bones decreases Opposite end of the spectrum Osteoblasts..? (build) Makes serum calcium decrease Calcium in the bones increases Metabolic process going on where you are breaking down bone faster than you are building it

Straight leg test for low back pain

Patient lays flat on back and attempts to raise a leg keeping it in a straight position, pain radiates into the leg as the sciatic nerve is stretched

Nursing care for visual deficits homonymous hemianopia related to stroke

Patients are taught to scan with their vision to visualize everything

Medication therapy: "on/off" periods can occur 3-5 years after medication therapy started

Periods where PD symptoms return despite medication Sometimes clients report hypomobility Inability to rise from chair, speak or walk Apomorphine treats hypomobility same effect as dopamine Associated with nausea Clients taking apomorphine cannot take ondansetron. Ondansetron is a serotonin receptor antagonist The combination of apomorphine and serotonin receptor antagonist leads to hypotension and syncope

Health risks associated with nicotine

Peripheral artery disease Atherosclerosis Delayed/impaired wound healing Peptic ulcer disease GERD For Women: Increased menstrual bleeding Dysmenorrhea Early menopause Infertility Smokeless tobacco: Less risk of lung disease Still have systemic effects such as cardiovascular disease Risk of cancer of mouth, cheek, tongue, and gingiva (increased by 50%)

Hemorrhagic stroke

Pharmacological Blood Pressure Management Keep Bp < what again? < 160 systolic Anticoagulation? Make bleed worse, no Surgical Evacuation Clipping Coiling BP < 160 for hemorrhagic stroke No anticoagulation. They are bleeding, you don't want them to bleed more. To be clear you usually do not see fresh frozen plasma, or platelets or reversal agents given either. The only exception to that would be if someone had a specific overdose, but even then that is case specific. Reversal of a lot of anticoagulants is often expensive (10s of thousands of dollars) Evacuation: you go in and remove the pooled blood Clipping, coiling are for aneurysms which are pockets of blood where a vessel has weakened or broken. Clipping is literally clipping off the broken part. Coiling puts a bunch of coils in the aneurysm to prevent blood flow so it doesn't rupture. Again the specifics of these aren't so much important as knowing the general options.

Treatment for RA

Pharmacology Physical therapy Occupational therapy Lots of education

Whats the easy way to prevent a stroke

Pharmacology Aspirin - 81-325 mg/day Warfarin (Coumadin) Enoxaparin sodium (Lovenox ) Clopidogrel (Plavix) Dipyridamole (Aggrenox) Dabigatrian (Pradaxa) Rivaroxaban (Xarelto) Antihypertensive medications Labetalol Statin medications Zocor If someone has already had a TIA, then they will be prescribed medication in addition to the preventive measures discussed last slide. Which medication might you see someone take that hasn't had a TIA yet? Lot of people take 81 mg aspirin daily even without a history. Some physicians recommend it for those with family histories, or with risk factors such as obesity, HTN, etc.. What about if you see 325 mg? Safe to assume they have had SOMETHING in the past to warrant this dose If someone has afib like discussed before they should be taking their blood thinner for that whether it be Xarelto, Coumadin, Eliquis, Pradaxa etc. Warfarin-dose adjusted based on the INR (international normalized ratio) of 2-3. Will need routine labs. Lots of side effects of Coumadin, biggest is risk for bleeding. More have been placed on Lovenox SQ due to routine labs and risk factors. With warfarin, need to avoid eating large doses of green leafy veg vegetables. Platelet inhibiting medications: ASA, Aggrenox, Plavix Antihypertensive: These are the two medications you will see commonly used. Cardene will be a drip and will be infused. Facilities have protocols in place that will tell you exactly what to do. Labetalol can be a drip but much more likely will be a push. You may see a PRN depending upon the type of stroke that says administer. The doses scale starting with 10 mg IV, 20 mg IV, 40 mg IV, 80 mg IV every 10 minutes as long as HTN persists. Labetalol is a beta-blocker. It has alpha and beta blocking properties in a roughly 1:7 ratio for IV. It would be important to watch for bradycardia with this. Labetalol is popular on Mission Neuro and I see that a lot for post-stroke BP control.

Specific types of fractures

Plastic or bowing Buckle Greenstick Complete Pathologic Spiral Compression Page 1725 in Ricci text table 44.8 shows you the types of fractures, also p. 1190 in med surg. text

The longer the virus persists with HIV...

Point is reached where the immune system cannot function to prevent "everyday" infections Otherwise known as opportunistic infections Opportunistic infections and disease are the primary cause of death from HIV, not the HIV itself

Substance abuse treatment complications

Polysubstance abuse Dual diagnosis Stigma of substance abuse and treatment centers Mistrust of healthcare workers

What is PrEP?

Pre-exposure Prophlaxis Truvada Taken daily to reduce infection risk Must be taken consistently to improve effectiveness For individuals at high risk for HIV infection Greater protection if PrEP used in conjunction with condoms (latex condoms specifically) Max protection takes about 20 days of taking the med to really work well

Special considerations in the older population for MS

Presence of other chronic health conditions Medications for other conditions might interfere with those for MS Age related changes change how medications are absorbed and metabolized Osteoporosis Risks? Decreased mobility, decreased weight bearing Corticosteroid use Costs associated with medications and care May be on a fixed income Risk for social isolation Increased depression and suicidal ideation

Environment for assaultive behaviors

Prevention Activities to minimize boredom Allow for interaction and expression Providing a schedule and structure can reduce anxiety Physical activity Once triggered Quiet area Decrease stimulation Adjust temperature

Best way to treat all strokes?

Prevention Diet and exercise No smoking Limit alcohol Diabetes or Heart Disease Ensure what? Compliance Prevention of stroke is the best thing just like with any other health condition. These tips should look run of the mill and just like those for heart disease or diabetes. These health conditions are interrelated. If they have DM or Heart Disease you want to ask what they take, if they take it like they are supposed to. Remember what is the biggest cause of Embolic Strokes? Undiagnosed or Untreated HTN is the biggest culprit in "out of nowhere strokes". It is much more likely (50x more likely) for a person to have undiagnosed HTN versus afib. Afib without going into detail makes a person feel funny and it scares them and they go to the doctor. HTN oftentimes has no side effects unless it gets extreme. DASH diet (used to think low salt diet)-but stands for Dietary approaches to stop hypertension. Fruits, vegetables, low fat dairy products, and low animal protein. Best thing is community screening to help identify those at risk and provide education. B/P, risk factors, Doppler studies and so forth.

Stages of HIV

Primary (Stage 1)- can have a negative test during this time but can be very contagious at this time Stage 2: 200-499 Stage 3: below 200 Know the table 37-1 Primary - stage 1, can have negative antibody test but highly contagious Stage 2- when CD4 count 200-499 Stage 3 - CD4 below 200 (AIDS) Cannot lower classification once client progresses to a new level (so once they are stage 2 they will never be stage 1 again and so on)

Health Prevention

Primary - health promotion and prevention Secondary -health maintenance, screening Tertiary - minimizing disease progression, improve quality of life

Diagnostics for leukemia

Primary diagnostics Peripheral blood evaluation Bone marrow evaluation Other studies to examine spread LP (lumbar puncture or spinal tap) CT (to determine other organ involvement)

Classification of TB (By clinical manifestations)

Primary infection (has active disease): Bad cough greater than 3 weeks Coughing up blood, hemoptysis Weakness, weight loss, poor appetite Fever, chills, night sweats Chest pain Latent TB infection (not active): Cannot transmit bacteria to others 5-10% will develop active TB Important to begin treatment No symptoms

Megaloblastic anemia

Problem with intrinsic factor production Two types: Cobalamin Deficiency (Vitamin B 12) Pernicious anemia Other causes Folic Acid Deficiency Megaloblastic anemia is a problem with DNA synthesis and is primarily these two types Vitamin B 12 deficiency may be from inadequate diet intake, disruption in GI absorption, or intrinsic factor Problems with intrinsic factor is pernicious anemia.

Safety interventions for parkinson's

Proper footwear Velcro Non-slip Avoid: Throw rugs Excess furniture Anything that could increase a stumbling risk

What was that you said about penicillin with sickle cell?

Prophylactic Penicillin Penicillin V Potassium Prevents pneumoccal infection If allergic to Penicillin, you can give Erythromycin How long..until what age Age five Pneumonia prevention why not just get vaccine? Get two pneumonia vaccines (7 valent and the 23 valent) How often do they get this? Annually after age 2 Begin flu vaccine annually after 6 months of age Infection prevention is important. These children will be on a specific immunization/antibiotic regimen.

Infection prevention for sickle cell

Prophylactic antibiotics At risk for infection due to spleen involvement

Complications after hip replacements

Prosthesis dislocation Sudden severe pain Lump in buttock Limb shortening External rotation Requires open or closed reduction depending upon situation Infection risk post-op Maintain skin integrity Bowel and bladder Keep client NPO for intended surgery Prevent aspiration risk due to use of general anesthesia

Clinical manifestations of anaphylaxis

Pruritus Smooth muscle contraction Swelling- tissues, especially the larynx Bronchial Spasms Angioedema Hypotension Increased mucus secretion Abdominal pain - GI spasms, vomiting Dilated pupils

What can nurses do for themselves and for clients with back pain

Raise bed height to appropriate level Bend at the knees Request assistance to move clients unless lift is available Good posture when sitting Flat shoes, or shoes with low heels Maintain healthy weight What about sleep? Avoid prone Supine or side-lying with hips flexed Stop smoking

Other drugs for osteoporosis

Raloxifene Similar to estrogen Does not cause problems with breast or uterus like estrogen May actually decrease breast cancer risk But linked to leg cramps, hot flashes, and increased risk of blood clots

Stroke in children and adolescence

Rare Often severe Result Major motor deficits Convulsive disorder Fatal Diagnosis Age Underlying medical condition Clinical pattern of stroke CT scan will demonstrate cerebral hematoma LP to differentiate ischemia from SAH (not detected on CT scan) AVM Acute Hemiplegia of Childhood Sudden onset of hemiparesis with ICH May or may not be accompanied by a single seizure Occlusive vascular disease at the base of the brain Narrowing of the internal carotid artery Intracranial Hemorrhage Sudden Accompanied by a H/A, somnolence, nuchal rigidity Confirmed by CT or LP AV malformations most common cause of SAH Aneurysms ICH Presence of rbcs in CSF is diagnostic

Surgical treatment for OA

Reasons for surgical intervention: Unrelieved pain Unable to perform self-care Loss of joint function Under age of 55 they recommend arthroscopic to remove cartilage that has broken off to allow more joint space Over 55 may require actual joint replacement People who have had an injury may need a joint replacement at a younger age

Hemorrhagic stroke complications

Rebleed Can happen, people can keep bleeding How would you tell? Worsening neurological status Vasospasm Metabolites released Cause contraction of blood vessels Nimodipine If you are monitoring the patient and their neurological status worsens it could indicate they are re-bleeding. What other signs and symptoms might they exhibit? Headache, pupil changes, vomiting... Vasospasms. Whenever tissue dies in the body the cells release all kinds of metabolites. In some instances these cause hypotension, in others they cause hypertension or vasoconstriction. In the cerebral arteries these can cause vasoconstriction. Damaged areas of the brain being vasoconstricted = bad. Nimodipine is listed as an option for preventing this. Calcium causes muscle contraction. If you block the calcium you block contraction, prevents vasospasms. At least that is the believed method, the true mechanism isn't really known.

What is the focus from the nursing perspective for RA

Reduce inflammation Pain management Maintain joint function Prevent joint deformity Nutrition Mobility Surgery

Clinical manifestations of stroke- cognitive impairment and psychological effects

Reduced learning capacity Memory Depression Emotional Liability Patients who suffer a stroke may have difficulty controlling their emotions. Emotional responses may be exaggerated or unpredictable. Learning Decreased attention span, decreased comprehension, forgetfulness, and lack of motivation Depression and feelings associated with changes in body image and loss of function can make this worse. Patients may also be frustrated by mobility and communication problems. An example of unpredictable affect is as follows. A well-respected lawyer has returned home from the hospital following a stroke. During meals with his family, he becomes frustrated and begins to cry because of difficulty getting food into his mouth and chewing, something that he was able to do easily before his stroke.

CNS Prophylaxis for leukemia

Reduces the risk of CNS disease Given periodically in all stages of treatment based on what is going on

Treatment/surgery for fractures

Reduction (open or closed)- getting things back in alignment. If its closed it may be done with sedation, if its open then it probably needs surgery Immobilization (external or internal) Splints, casts, external fixators Elevate/ Ice Assess neurovascular status Circulation Motion Sensation Exercises to decrease muscle atrophy Surgeon determines weight bearing status Techniques of internal fixation. A. Plate and six screws for a transverse or short oblique fracture. B. Screws for a long oblique or spiral fracture. C. Screws for a long butterfly fragment. D. Plate and six screws for a short butterfly fragment. E. Medullary nail for a segmental fracture. Surgeon determines weight-bearing ability

Activities to help with fatigue for fibromyalgia

Regular exercise- start out easy and gradually add activities Set a regular sleep pattern Avoid daytime napping Limit Caffeine intake Set aside time each day for relaxation (deep breathing and/or meditation)

Nursing management for rehabilitation related to stroke

Rehabilitation Care Receives 3 hours of therapy a day between two therapy disciplines Physiatrist Nurse certified in rehabilitation approach ARN definition of rehabilitation: The goal of rehabilitation nursing is to assist individuals with disabilities and chronic illness in the restoration, maintenance, and promotion of optimal health. The rehabilitation nurse is skilled at treating alterations in functional ability and lifestyle resulting from injury, disability, and chronic illness. Association of Rehabilitation Nursing

Patterns of MS

Relapsing-Remitting 85% of people have this pattern Clear relapse of symptoms with full recovery and some deficit on recovery Moat will progress to secondary-progressive eventually Primary-Progressive Worsening neurologic function from beginning No relapse, no recovery 15% Secondary-Progressive Begins in relapsing-remitting stage and develops after 10 years Begins a progression like stage New treatments can slow progression Progressive-Relapsing 5% Begins in progressive mode With relapses where function gets worse faster "recovery" periods are where the neurologic function goes back to the slow progressive decline

Surgical options for RA

Relieves severe pain For severely deformed joints Synovectomy Removal of joint lining Arthroplasty Joint replacement Not usually an option unless there is severe pain or deformity

Extra considerations when caring for RA clients

Remember their joint stiffness is around periods of rest Usually need daytime rest and substantial sleep...how long? 8-10 hours a night Firm mattress or bed board to maintain alignment to avoid flexion Use positions of extension rather than flexion..why? Decreases joint contracture risk No pillows under knees Small flat pillow under head and shoulders

Folic Acid Deficiency

Required for DNA synthesis Needed to make RBC Clinical manifestations similar to vitamin B12 deficiency except for neurological ones Causes Diet, malabsorption, alcohol Treatment is supplementation and diet This slide is everything you need to know about folic acid deficiency The only difference between folic acid and pernicious anemia via nursing assessment would be the absence of neurological signs The causes are similar to others with problems with the stomach, not enough intake, alcohol etc. To be clear hemodialysis lowers everything so a renal patient could have a problem with this too Here are a list of foods for you that are high in folic acid

Postcrisis phase of assaultive behavior

Restraint and seclusion discontinued Do not lecture the client regarding behavior Discuss behavior in a clam manner Allow client to regain control and reintegrate into activities

Hemolytic transfusion reaction (Type 2 continued)

Result of ABO-incompatible blood transfusion Antibodies attack donated blood causing clumping (agglutination) This clumping can block vessels What do you do if you suspect a blood transfusion reaction? Stop the blood! Notify the physician Send it back to blood bank Blood transfusion reactions are caused where the antibodies attack the new RBCs and cause clumping which blocks blood vessels Normal saline is the only thing you can run with blood so you stop the blood, run NS and monitor closely but all the blood and tubing needs to be saved and goes to the lab to be tested again (this is all if there is a reaction to the blood) but we pre-medicate with Benadryl and Tylenol to prepare

Pain management for fibromyalgia

Review pain management from the text (Med-surg Nursing pp.213-220) Fibromyalgia is a chronic pain that persists throughout the client's life once it develops Review how pain affects the body Review assessment of pain How does the pain effect quality of life? Location, onset, duration, quality, aggravating and relieving factors Identifying pain goals with the client

Diagnostics for RA

Rheumatoid factor (RF) Positive in 80% of RA patients (not definitive) Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) Measures of active inflammation which might also indicate something else is going on Antinuclear antibody (ANA) Seen in "some" patients Antibodies to cyclic citrullinated peptide (anti-CCP) more specific than RF Assessment, history, and labs must be considered

In severe RA you may see extra-articular manifestations

Rheumatoid nodules 20-30% of those with RA Sjögren's syndrome 10-15% of those with RA which is dry eyes and gums These are more likely to occur in those with higher levels of rheumatoid factor (RF) Also Raynauds syndrome (cold hands and feet and discoloration)

Nutritional support for RA

Rheumatoid side of things Pain, limited movement Can interfere with shopping or preparation of food Occupational therapy can modify home or make assistive devices to aid movement to accomplish these tasks Corticosteroid side of things Increase hunger, increasing weight gain but that usually adjusts down after therapy is over Weight will adjust back to baseline within a few months after cessation of therapy May need to eat smaller, frequent meals and want to increase protein, calcium, vitamin D, also supplements because they may not be hungry

Specific information on TB Treatment

Rifampin, Rifabutin and rifapentine can cause discoloration of urine, sweat, and tears..what color? Orange Can stain clothes or contacts Medications that increase metabolism of the anti tuberculosis medications and therefore decrease their effectiveness when taking rifampin or rifabutin Quinidine, metoprolol, propranolol, corticosteroids, oral contraceptives, oral anticoagulants, oral antidiabetic agents, digoxin, theophylline, methadone, phenytoin, verapamil, cyclosporine, or ketoconazole

Rigidity related to parkinson's

Rigidity Cogwheel rigidity? Jerky quality Intermittent catches in the movement of a cogwheel When joint moved passively Jerky movement Sustained muscle contraction Slowed movement

Pathophysiology of OA

Risk Factors? Injury Repetitive motions Genetics Inflammation from other disease processes Usually starts in 30's and peaks in the 50's and 60's Medications -corticosteroids, indomethacin Weight is also a risk factor because it causes more wear and tear on the joints Being female puts you at higher risk Increased age puts you at higher risk Career can have increased risks due to repetitive motions

Diagnostic criteria for anemia

Rule out megaloblastic anemias: Normal cobalamin Normal folic acid Rule out iron deficiency anemia Increased serum ferritin Increased iron stores in macrophages To difference it from iron deficiency anemia you check ferritin and iron stores To check it versus pernicious anemia check cobalamin To check it versus folic acid deficiency check it against folic acid Essentially this is a diagnosis of exclusion. You will have a patient presenting with the signs and symptoms of anemia, but not specific ones such as the beefy red tongue or neurological manifestations. Someone comes in pale, fatigued, tachycardic with low hemoglobin on the initial CBC. After that you would check these if you suspect anemia. Obviously if the person had chronic conditions like HIV or kidney disease it would help with an "opinion" but these tests are more definitive.

START HERE

START HERE

Prevention of anaphylaxis

Screening to identify allergen Avoid exposure Education Always assess a client's allergy status

Possible causes

Serotonin - inhibits aggressive behavior Dopamine and norepinephrine - increases associated with this behavior Structural Damage Limbic system Frontal lobe Temporal lobe

Low back pain

Several Categories to describe pain Localized Soreness, discomfort upon palpation Diffuse Larger area, from deeper tissue Radicular Irritation of a nerve root Example? Sciatica Referred Felt in lower back but from another source? Kidneys, ovaries, or abdomen, etc

Anaphylaxis

Severe allergic reaction Systemic response Emergency situation First exposure to allergen sensitizes individual Subsequent exposures lead to the anaphylactic reaction Symptoms dependent on the amount of allergy exposure, route of exposure, amount of mediator released

Other pre- and post-operative management for hip fractures

Severe muscle spasms may occur Teaching is often done in emergency department Exercise unaffected leg and both arms Use overhead trapeze bar and opposite side rail to change position

Workplace violence

Should be a zero tolerance policy regarding "Intimidating and disruptive behaviors" in the workplace according to The Joint Commision Lateral/ Horizontal Violence Violence against nurses video Patient attacking staff

Types of sickle cell disease

Sickle Cell Anemia Most severe Most common Homozygous for hemoglobin S (HgbS) Sickle Cell C Disease 2nd most common Sickle cell (HgbC) Sickle Cell Sickle cell (Hgb E) Sickle Cell Thalassemia Less severe and less common

Methampetamine effects

Similar to cocaine Highly addictive Brain damage related to frequent use Emotional and cognitive problems Infection risks Risky behaviors Extreme weight loss Dental problems- meth mouth Increase HR, BP, Temp, and respirations Irregular heart rhythm Increase activity Decreased appetite Violent behavior, paranoia, hallucinations Intense itching, picking at skin Can lead to stroke, MI, organ failure, hyperthermia

Clinical manifestations of lupus

Skin 80-90% have some cutaneous symptoms Malar (butterfly) rash Round, discoid lesions Oral ulcers Splinter hemorrhages Alopecia Musculoskeletal Increase risk of bone loss, fractures 90% of clients have joint symptoms Swelling Tenderness Pain Morning stiffness May also see Raymond's syndrome

Clinical assessment of lupus

Skin Pain- in joints Auscultate - pericardial friction rub, abnormal lung sounds Behavioral changes Presence of seizure activity, stroke Bruising, bleeding Kidney function- with urine output Vitals (particularly BP and RR) Mobility- may be at risk for DVTs if they cant get up Possible tachypnea or cough

Diagnostics of allergies

Skin test More accurate with food allergies than medication allergies No antihistamines or corticosteroids 48-96 hours prior to testing May have false positives RAST (Radioallergosorbent test)- measures allergen specific IGE More expensive Less risk to patient Provocative testing- direct exposure to tissue (mucosal, GI, nasal, conjunctiva) Skin test- intradermal creating a "bleb" or raised area, prick and scratch tests also; usually performed on the back Reaction based on the amount of erythema measured RAST- serum exposed to various allergens Have emergency equipment readily available in case testing causes systemic reaction First exposure sensitizes the patient so they may not have the reaction right away but will later

Advanced treatment for sickle cell

Someone comes in with this 'acute chest syndrome' or a 'stroke' Aka emergency situations Sickled cells can clump anywhere...brain, chest, etc Is there any way to reduce the number of sickled hemoglobin cells? Exchange Transfusion, may need many of these over their life Exchange transfusion is with a crisis, text says stroke or acute chest syndrome. This is a way to quickly remove the sickled hemoglobin and replace it with normal healthy hemoglobin. Please remember these are emergency situations. Pain while excruciating by itself is not an emergency and would not require an exchange transfusion

Clinical manifestations of stroke- spatial-perceptiual alterations

Spatial-perceptual problems may be divided into four categories. 1. Incorrect perception of self and illness 2. Erroneous perception of self in space 3. Inability to recognize an object by sight, touch, or hearing 4. Inability to carry out learned sequential movements on command A stroke on the right side of the brain is more likely to cause problems in spatial-perceptual orientation, although this can also occur with left-brain stroke as well.

Clinical manifestations aplastic anemia

Special precautions? Bleeding (education about razor safety, falls, gentle toothbrushinig with a soft-bristle toothbrush) Neutropenic What is unique? Since there is WBC involvement., susceptibility to infection Even low grade fevers are concerning risk for sepsis These patients might present with a low neutrophil count. What is it called when someone has a low neutrophil count? Neutropenia. When your body cannot fight infection, fever does not always accompany infection. Why do you think there is a blood drop? By reducing platelets they are also a bleeding risk. You need to have them on bleeding precautions.

Pathophysiology of back pain

Spinal column Vertebrae and intervertebral disks Facet joints, ligaments, and paravertebral muscles hold it all together With age, the cartilage of the disks becomes more dense Nerve roots may experience pressure from changes in the disks as they exit the spinal canal Pain can radiate along the nerve involved Most degeneration occurs in L4-5 and L5-S1 disk areas due to mechanical stress

Post-operative considerations (bowel) for low back pain

Spinal surgery can lead to paralytic ileus Monitor for abdominal distention, nausea, constipation How do we assess the abdomen? (3) Passing flatus Bowel sounds in all quadrants flat, soft abdomen What medications might we give? Docusate

Risk factors (pediatrics) for fractures

Sport Related injury Behaviors: Trampolines Climbing trees Monkey bars Osteogenesis Imperfecta- birth defect that causes brittle bones Rickets Renal osteodystrophy Obesity- puts stress on body Poor nutrition Growth plate impact

When am I officially clear of TB

Sputum cultures will be collected monthly Two consecutive negative sputum cultures are required to be clear But, the patient can go home with a positive culture as long as they are responding to the treatment and do not pose a risk to susceptible populations

Surgical options (If you can't get TPA) For stroke

Stent Retrievers Push wire through, deploy stent Blood flow increases, clot pushes, caught on stent Take out Mechanical Embolus Removal in Cerebral Ischemia (MERCI) Insert guidewire with corkscrew Burrow into clot, Balloon ahead of clot remove it You see the very scientific descriptions of the procedures. This would be hopefully how they are describes to patients or families. The general idea is to get rid of the clot or to widen the vessel. This is a picture of MERCI. The device goes ahead of the clot, it gets retracted to spiral around the clot. Then a balloon is inflated and pushed over to increase blood flow and make it easier to remove the clot without damaging the artery.

All those non chemotherapy treatments for leukemia

Steroids Radiation Total body? Preparation for bone marrow transplant Targeted fields Liver and spleen, etc Cranial Meningeal involvement - ALL Lymphoid blast cells (ALL) are sensitive to steroids- dexamethasone is the preferred corticosteroid. What do you need to know about steroid therapy? Total body radiation would be used before bone marrow transplant Fields would be if there was organ involvement Intrathecal methotrexate Where is that administered? Spinal Why? ALL, cranial involvement Hematopoietic Stem Cell Transplantation Can totally eliminate leukemic cells HLA-matched sibling Risks? Graft versus host disease Infection? Interstitial pneumonia Relapse? Specific to ALL, but can occur in all of them

STOP act in NC

Strengthen Opioid Misuse Prevention started January 1st, 2018 Impacts how opioids are prescribed Acute pain (5 day Rx) Post-operative pain control (7 day Rx) Must review a client's 12 month history through the NC Controlled Substance reporting System (NCCSRS)

Dual diagnosis of substance abuse

Substance abuse + a psychiatric illness Estimated that 50% of substance abusers have a mental health diagnosis Complicates treatment

Warning signs and symptoms of a stroke

Sudden weakness or numbness in the face, arm, or leg especially on one side of the body. Hemiparesis-weakness on one side Hemiplegia-paralysis on one side Sudden confusion Difficulty speaking or understanding Dysarthria-impairment of the lips, tongue, palate or pharynx Aphasia Dysphasia Changes in vision in one or both eyes Ptosis-droopy eyelid Sudden difficulty with ambulating, dizziness or loss of balance and coordination Ataxia-gait disturbance Sudden severe headache with no known cause

Exacerbating factors of lupus

Sun exposure Hormonal changes Pregnancy Menstruation Oral contraceptives Medications - anti-seizure medications

Hallucinogen treatment/ withdrawal

Supportive treatment Isolation, decreased stimuli May need physical restraints Treat BP, seizures if present Cooling devices May need respiratory support No withdrawal symptoms Cravings possible Supportive treatment Isolation, decreased stimuli May need physical restraints Treat BP, seizures if present Cooling devices May need respiratory support No withdrawal symptoms Cravings possible

Easy prevention didn't work, next steps for stroke prevention?

Surgical therapy Carotid Endarterectomy Transluminal Angioplasty Stenting Extracranial-Intracranial bypass Which is better? Surgical Pharmacological Lifestyle changes Depends upon the situation.... These are the four surgical options when preventing a stroke for those with a history of TIA. These types of surgeries can be seen in other vascular areas such as heart or legs for those with arterial problems. Angioplasty. Anytime you see angioplasty think balloon, balloon goes in to widen the vessel. Stent, they place a little stent in to keep the vessel open. Less invasive than a Carotid endarterectomy. Used for severe stenosis Bypass is just what it says, you take one vessel that is open, connect it to the top and bottom of the diseased vessel where the blockage is and cut out the diseased portion, its replacing the bad vessel with what you have. Carotid endarterectomy is just simply removing the plaque from the artery (more complicated but that's the general) Complications: Stroke cranial nerve injuries, infection, hematoma at the incision, and carotid artery disruption. If someone has the need (such as a blocked carotid) then truly the surgical approach is what would benefit them the most. If someone has afib or has had a TIA but does not have a blockage significant enough to work on, the medication. If someone doesn't have a history then the lifestyle changes. On your test keep that in mind when deciding what is the best option for patients.

Surgical treatment options for hip fractures

Surgical treatment has a few goals Early mobilization Decreases risk of major complications Surgery depends upon location and severity of fracture Hip compression screw Replacement of part of femur with prosthesis Total hip replacement (both femur and acetabulum) May just try stabilization if they are not a good candidate for hip surgery, depending on their age and comorbidities

When stroke prevention doesn't work, whats next?

Surprise...it depends Call...what? Code Stroke Make sure they are breathing and that they are alive Airway, Circulation Figure out what kind of stroke it is...how? Non-contrast CT, or MRI Clients with a stroke can range from very unstable to nothing apparently wrong except for the stroke itself. There is a code stroke team at most hospitals. If you were at a smaller hospital you may not. Code stroke team knows the ins and out of strokes that is their bread and butter. At mission this is what most nurses do and their participation ends at this step. Unlike basic life support here ABC is the order, airway, breathing, circulation. Airway means providing supplemental oxygen, using an assist device if necessary, or if they really have trouble then intubate. The first test to figure out what kind of stroke it is would be non-contrast CT or a MRI. And don't worry about the non-contrast for the test I won't ask a contrast CT question, but it literally is a CT without contrast that's how its ordered.

Joints with RA

Swelling, pain begins and then you get a warmth, redness and swelling of the joint

Treatment for fibromyalgia

Symptom focused NSAIDS Antidepressants (Tricyclic) Cognitive behavioral therapy SSRI's (Selective serotonin reuptake inhibitors) Alternative medicine therapies Accupuncture, massage, homeopathy, craniosacal therapy, myofascial therapy

Acute low back pain

Symptoms Pain that is typically less than 4 weeks in duration Develops 24 hours after event Event defined as heavy lifting, hyperflexion, overuse of back muscles, yardwork, sports injury, or sudden jolt like a car wreck Diagnostics Straight-leg raise MRI and CT only done if there is trauma or systemic disease such as cancer or an infectious process of the spine

Pulmonary hypertension for sickle cell

Symptoms usually do not show up until damage has already been done Elevated pulmonary artery pressures Pulse oximetry and lung sounds often normal until it is too late Often the cause of death for someone with Sickle cell anemia

The national osteoporosis foundation recommendation for osteoporosis treatment

T scores less than -2.5 receive treatment Or those between -1 and -2.5 for a T score that have risk factors (the word is plural so lets say at least two) Anyone who has had a prior history of a hip or vertebral fracture regardless of T score Calcium and vitamin D are used for treatment

Biologic and targeted therapies for RA

TNF inhibitors (represses inflammatory response) Etanercept Infliximab Adalimumab Certolizumab Golimumab IL-1 receptor antagonist Anakinra IL-6 receptor antagonist Tocilizumab T-cell blocker Abatacept B- cell blocker Rituximab

Escalation phase of assaultive behavior

Take control of the situation Calm but firm tone when talking Direct client to a "time out" to calm down Inform client that behavior is not acceptable Offer medications again if not taken yet May need to obtain assistance if client is not changing behavior Initially, staff there to assist should be present but allow for space

Iron supplementation

Take on empty stomach Liquid iron should be consumed with a straw and mouth should be rinsed after administering Eat foods high in vitamin C Iron supplementation will cause stools to appear darker in color May cause GI upset Iron absorption is decreased with food in the stomach Liquid Iron can cause staining of the teeth (stains them green) Vitamin C enhances iron absorption: citric fruits like oranges, tomatoes, strawberries, and broccoli) Constipation!

Drug therapy regimen for leukemia

Taking medication regularly increases the effectiveness. Combination Therapy? Decrease drug resistance Minimize drug toxicity Attack different stages of cell cycle Targeted Therapy Target specific proteins associated with cancer Potential for drug, food interactions that decrease effectiveness. (Tylenol- hepatomegaly, grapefruit and antacids- limit absorption)

General rehabilitation for stroke

Team approach Include family in rehab as much as possible Video Games Great way to include family Makes it enjoyable, rehab usually is painful and arduous Movement Mobility is very important to prevent what..? VTE..contractures...problems of immobility Rehab is painful and arduous as it says up there. Lots of clients can lose willpower or hope if they do not see results. Even with a great physical therapist, you still want involvement. Finding ways for family to get involved helps. Video games is mentioned in a little table and these can be fun, involve kids or family, and they can increase fine motor function.

Tender points of fibromyalgia

Tender points of fibromyalgia The patient with fibromyalgia syndrome may complain of specific areas of tenderness, which are shown in the illustrations below. Diagnostically, the patient must have tenderness on palpation of at least 11 of the sites along with a 3-month history of diffuse musculoskeletal pain.

Parathyroid recombinant for osteoporosis

Teriparatide Increases the action of osteoblasts...what does that mean? Administered subcutaneously once daily

Thalassemia clinical concerns

Thalassemia minor? No worries One abnormal thalassemia gene Aka heterozygous Autosomal recessive gene Thalassemia major? Uh oh 2 abnormal thalassemia genes Aka homozygous Develop in children by age 2 Growth and developmental delays Liver, spleen, bone marrow affected (because that is where cells are made) There are two designations. The minor is asymptomatic. Major has a lot of issues. You have a good amount of hemolysis which affects all organs. Hemolysis or damaged red blood cells damaged the liver as discussed previously. In addition, the spleen tries to filter these and the client develops splenomegaly. The bone marrow keeps making red blood cells, and as it does it gets overworked and causes bone marrow hyperplasia. The big problem is the iron that is released from red blood cells and it depositing various places in the body messing up organs

Mantoux test for TB

The Mantoux test for tuberculosis. A. Correct technique for inserting the needle involves depositing the purified protein derivative (PPD) subcutaneously with the needle bevel facing upward. B. The reaction to the Mantoux test usually consists of a wheal, a hivelike, firm welt. C. To determine the extent of the reaction, the wheal is measured using a commercially prepared gauge. Interpretation of the Mantoux test is discussed in the text.

What should be done with fluids for sickle cell?

The blood gets viscous so they need IV fluids in a crisis Adequate hydration is critical Promote hemodilution, lots of fluid Electrolytes are important to monitor What organ can be involved with this? Kidneys Transfuse if appropriate There can be hemolysis of cells if RBCs are infused What electrolyte might be an issue with this? Potassium Education on immunizations, prophylactic antibiotics Increased risk for infection in wintertime Gently palpate to see if liver and spleen are enlarged If they have bilateral swelling of the hands or feet you need to do something about that immediately and tell someone immediately Spleen before the liver

Crisis phase of assaultive behavior

The client has now become physically aggressive Must take control of the situation for safety reasons May require restraint and seclusion Must have an order from a physician ASAP if restraints are needed Follow protocols Usually 4-6 staff members needed to do this safely Medication

Salter-harris classifications

Type I Fracture is through the physis, widening it Type II Fracture is partially through the physis, extending into the metaphysis Type III Fracture is partially through the epiphysis, extending into the epiphysis Type IV Fracture is through the metaphysis, physis, and epiphysis Type V Crushing injury to the physis This classification for fractures describes the fracture location in regards to the growth plate.

Education about mobility right after surgery for hip fractures

The goal is to prevent dislocation Avoid more than 90 degrees of flexion Crossing of legs and ankles (aka adduction across the midline) Activities that can lead to dislocation: putting on shoes and socks, side-lying position incorrectly Avoid turning on the affected side until approved by surgeon Abductor pillow should be used when supine, or side lying for up to 6 weeks after surgery Use elevated toilet seats Inform dentist of prosthesis for prophylactic antibiotics

Pathophysiology of fibromyalgia

The pathways that moderate pain processing are abnormal and pain perceptions are amplified Genetic component suspected, exact cause is unknown Correlation with other conditions such as IBS, mood disorders, and chronic fatigue Diagnosis looks at where pain occurs (tender points) in conjunction with other symptoms: Fatigue Not feeling rested even after adequate sleep Cognitive symptoms

Nerve pathways

The process of demyelination. A, B. A normal nerve cell and axon with myelin. C, D. The slow disintegration of myelin, resulting in a disruption in axon function.

Drug therapy (Key client education points) for patients with HIV

The various medications work on different stages of the viral cell replication cycle One medication is often not effective and HIV develops resistance If dosing is not done properly HIV develops resistance Recommends 3 agents or more taken with consistent dosing for optimal effects When done this way, viral load is reduced by up to 99% Drug therapy is NOT a cure Goals of therapy are: Decrease viral load Maintain or increase CD4 T count Prevent opportunistic infections Delay disease progression Prevent HIV transmission Need to be compliant with drugs and take them consistently

What do the antibodies do related to rheumatoid arthritis?

They mix with the abnormal IgG to form complexes These go to synovial membranes or joint spaces This activates "complement" Neutrophils, CD4 cells, monocytes, macrophages, synovial fibroblasts are all called into action Secrete interleukin-1, interleukin-6, and tumor necrosis factor This leads to a very inflamed space around this abnormal IgG complex, which is the problem with RA Antibodies mix and form complexes in the synovial areas which activates a compliment which cause the inflammation to begin which causes the immune system to attack the body which leads to it being very inflamed and breaks down the joint overall

Alcohol abuse treatments

Thiamine- treats or prevents Wernicke-Korsakoff syndrome This is brain disorder due to thiamine deficiency Cyanocobalamin (vitamin B12) and folic acid are needed for nutritional deficiency Acamprosate (Campral) - suppresses alcohol cravings Disulfiram (Antabuse) Client has adverse reactions if they drink alcohol while taking this Prescribed to help deter drinking Should read labels closely to avoid accidental alcohol consumption Reaction: flushing, headache, N/V, sweating, Products that contain alcohol: vanilla extract, mouthwash, cough syrups, perfume, lotions

Genetic inheritance of sickle cell

This demonstrates the gene inheritance pattern for parents that are carriers that have children Autosomal Recessive Genetic counseling for parents that are both carriers

Thalassemia concerns

Those who have had this for a long time (before 1992) 2017 - 1992 = 25 Not every 25 or older thalassemia just those that receive blood Commonly receive blood donations Screening did not start until 1992 At risk for Hepatitis C or HIV because they receive a lot of blood transfusions (before 1992 we did not test for Hepatitis C in the blood)

Is there a cause of lupus?

Thought that an environmental factor triggers onset Smoking UV light Sun Fluorescent lights Emotional stress Exposure to silica dust Physical stress Pregnancy Surgery Medications Sulfa drugs Penicillin Other antibiotics Infections Viral or bacterial

Mobility is a great preventative tool for osteoporosis

Walking 30 minutes a day, 3 times a week Any weight-bearing activity is helpful but walking is considered best Some activities can cause mechanical stress and increase risk of fracture (walking is good) Increased balance with more mobility Weight training, don't just only do pool stuff because weight-bearing is needed to build bone density

Ischemic strokes- two types

Thrombotic Injury to a blood vessel wall and formation of a blood clot Most common cause of stroke Develops slowly No change in LOC usually in first 24 hours While asleep or after sleep Occurs in men more than women Lacunar strokes are typically asymptomatic Embolic Embolus lodges and occludes the cerebral artery Second most common cause of stroke Sudden onset May have a H/A Immediate deficits While awake Most commonly at the bifurcations of blood vessels Large artery strokes are caused by atherosclerotic plaques that result in infarction (death) of tissue. Small artery thrombotic strokes are called lacunar strokes because of the cavity that is created after the death of the tissue. Cardiogenic embolic strokes are caused from afib. Cryptogenic strokes-no known cause

What makes a community healthy?

Time magazine link Buncombe County Unemployment Rate link Look at health indicators and health determinants Five influencers of health: Policy making Social factors Health services Individual behavior Biology and genetics

Definitions of substance abuse

Tolerance - needing more of a substance in order to achieve the desired effect Withdrawal -negative physical and psychological response when the substance is decreased or removed Intoxication - when use of a substance results in maladaptive behavior Detoxification - when a substance is safely withdrawn Blackout - individual functions but has no awareness or memory of behavior that occurred during that time Substance abuse disorder (SUD) - when recurrent use causes functional and clinical impairment that lead to health problems and difficulties at work, school, or home

Cobalamin deficiency clinical manifestations

Tongue Red beefy sore tongue with ridges GI upset Neuromuscular Reduced vibratory and position sense (which increases there risk of falls) Imagine a field sobriety test and failing it despite being sober The clinical manifestations from this are related to the absence of B12. The tongue will be sore, red, beefy and shiny. The client will present with anorexia, nausea, vomiting, stomach pain or just the general GI upset. They can have weakness, paresthesias, reduced vibratory and position senses, weakness, confusion, just all kinds of bad. Someone is not going to come to the ER for an upset stomach and the first thing you think is Cobalamin deficiency. If you do you will be wrong 99.9% of the time. However the red beefy sore tongue is unique, and the vibratory and position sense is unique.

Transient Ischemic Attack (TIA)

Transient episode Symptoms usually less than 1 hour Neurological deficit Carotid system Loss of vision in one eye, hemiparesis, inability to speak Vertebrobasilar Tinnitus, vertigo, blurred vision, diplopia, tinnitus, etc. Ischemia without infarction Progression 1/3 never have another TIA 1/3 have another TIA 1/3 progress to stroke (thrombotic usually) These signs and symptoms would ALL be warning signs of any type of stroke we will discuss today TIAs are like mini-strokes. You will see neurological symptoms like a stroke such as facial droop, weakness in the arms or legs on one side, or slurred speech. However, these usually resolve within an hour. Traditionally, TIAs were thought of as mini strokes that resolve within 24 hours. With a TIA, there isn't an infarction of the brain tissue but rather ischemia. This is why the symptoms reverse relatively fast compared to other types of strokes. Depending upon where the TIA is, will determine the symptoms. A TIA is still something to be worried about. 1/3 of these folks will go on fine, however 1/3 will have another TIA and 1/3 will progress to a full blown stroke.

Treatment with medication for parkinson's

Treatment with medication for PD is not curative Symptom management is the goal What were the neurotransmitters involved? Dopamine Acetylcholine Treatments work to alter those or their receptor sites You will either enhance dopamine or decrease acetylcholine

Triad associated with clinical symptoms of parkinson's

Tremors Rigidity Bradykinesia These three make a triad and need 2/3 for potential diagnosis Diagnosis dependent no these and health history Research being done regarding imaging for diagnostics

Aggressive cycle- five phases

Triggering - what initiates the response Escalation - response moving towards a loss of control Crisis - Loss of control by the client Recovery - Client regains physical and emotional control Postcrisis - Attempts reconciliation, returns to prior level of functioning Table 11.1 in Videbeck text

Diagnostics for TB

Tuberculin skin test (Mantoux test) Intradermal injection Check 48-72 hours after Can have false negative or positive results Interferon-y Release assays Detect interferon gamma released from T lymphocytes More expensive than skin test, but more reliable Requires a blood draw Chest X-ray Helpful in determining TB involvement, but NOT diagnosis of TB Sputum smear Detects acid-fast bacteria, not diagnostic but helpful Sputum culture Can take up to 8 weeks to grow Definitive diagnostic tool for TB detection

Alcohol abuse statistics

Twice as common in men than women Highest risk between ages 30-64 Binge drinking highest ages 18-25 (60% of people in US in this age group have reported this) By age 18, 60% of teens have had one drink

Thalassemia types

Two Categories: Alpha: reduced or absent alpha globulin chains Beta: reduced or absent beta globulin chains Primary problem: Decreased normal hemoglobin Secondary problem: Hemolysis Waste products of RBC destruction (iron) buildup in other organs (spleen and liver mainly) Who gets it? Mediterranean Sea, Asia, Middle East, Africa The severity of the problem depends on the degree at which the chains are affected Know that there is a decrease in hemoglobin because they are smaller and they break up easier as well All that stuff that is in the cell is then released in the body and so things like potassium can be higher (which can cause cardiac issues so you want to watch their potassium with this)

Active TB drug therapy

Two phases of treatment Initial phase- 8 weeks (usually taking 4 antibiotics daily) Continuation phase Initial usually consists of four drugs to treat active TB aggressively Initial phase.. 8 weeks a combination of the following 4 drugs Isoniazid (INH) Rifampin Ethambutol Pyrazinamide May not be used if liver disease or pregnancy included. In which case the initial therapy is just the prior 3 but is still for 8 weeks. Additionally, pyroxidine (vitamin B6) 50mg is given during the initial phase. For the continuation phase.. (additional 18 weeks) Isoniazid and rifampin Unless you cannot take pyrazinamide in initial phase then continuation phase lasts 31 additional weeks

Open fractures

Type I - clean wound, <1cm Type II- larger with tissue damage Type III- highly contaminated, extensive soft tissue damage Type III is the most severe and might require amputation Major risk for infection with open fractures, need surgical intervention

Types of MS

Types and courses of multiple sclerosis ( MS). 1. Relapsing-remitting (RR) MS is characterized by clearly acute attacks with full recovery or with sequelae and residual deficit upon recovery. Periods between disease relapses are characterized by lack of disease progression. 2. Primary progressive MS is characterized by disease showing progression of disability from onset, without plateaus and temporary minor improvements. 3. Secondary progressive MS begins with an initial RR course, followed by progression of variable rate, which may also include occasional relapses and minor remissions. 4. Progressiverelapsing MS shows progression from onset but with clear acute relapses with or without recovery. From Lublin, F. D., & Reingold, S. C. (1996). Defining the clinical course of multiple sclerosis: Results of an international survey. Neurology, 46(64), 907-911. Used with permission from Lippincott Williams & Wilkins.

Nursing considerations with surgical options for low back pain

Understand goals of surgery Restore movement Eliminate pain Maintain proper alignment of spine until it heals Have adequate staff when repositioning Opioids common 24-48 hours after, may use patient controlled analgesia (PCA) After client is encouraged to switch to PO opioids

Lewy Bodies

Unusual clumps of proteins found in the brain If these lewy bodies are found, it is a positive indicator of declining brain function Unsure of what causes these to form

Trigger phase of assaultive behavior

Use a calm, nonthreatening approach Relaxed body language Encourage expression of emotions and feelings verbally Show empathy Clear, concise, and simple statements Suggest a quiet area Offer medications Assist with relaxation techniques if client is willing

Delirium tremens related to substance abuse

Usually occurs 3 days into withdrawal Most severe form of withdrawal form alcohol Can lead to cardiovascular collapse and death Tremors, diaphoresis, tachycardia, anxiety, and seizures possible

Anything besides medications with HIV treatment

Vaccinations Hepatitis B Influenza Pneumococcal Goals To prevent opportunistic infections Hepatitis for instance damages liver which limits the antiretroviral therapy that can be used

Abuse of substances

Varied frequency of use of a substance, could be intermittent use May be legal or illegal Using a prescribed medication outside of the prescribed purpose or timeframe Does not always = addiction or dependence

Hostility

Verbal aggression May be expressed when a client feels powerless or threatened Can be real or imagined The intention is to intimidate or cause emotional harm This type of behavior can occur suddenly, may be unexpected Triggers can usually be identified

Procedures to help those that have had fractures already

Vertebroplasty Bone cement injected into the collapsed vertebra to stabilize it Does not correct deformity Kyphoplasty (for those with kyphosis or more severe deformity) Air bladder inserted into collapsed vertebra then inflated Regains vertebral body height Then inject bone cement

Pathophysiology review of HIV

Virus enters CD4 cells via gp120 Reverse transcriptase and the RNA makes the viral DNA Viral DNA and integrase incorporate the sequence into the cell's genetic structure Body responds as you would expect B cells make HIV-antibodies that work T cells mount their response against viral cells Invades the cell, takes over its DNA, creates more viral cells within that cell and then those go out and make more The body keeps creating CD4 cells to replace the CD4 T helper cells destroyed by the virus However, over time the body cannot replace as many that are being destroyed and the CD4 count begins to drop Normal CD4 T count is 800 to 1200 CD4 cells per microliter or (uL). Immune function persists with CD4 above 500 cells / uL Below this is when the immune system is "compromised" Note the normal CD4+ Count Primarily the cause of death of someone who has HIV or AIDS is infection Individualized, depends on their

Clinical manifestations of stroke- perceptual/sensory disturbances

Visual Homonymous hemianopsia Spatial-perceptual problems Impairment to touch Difficulty interpreting visual, tactile, and auditory stimuli Agnosias Homononymous hemianopsia-blindness in half the visual field-can be temporary or permeant. The affected side of vision corresponds with the paralyzed side of the body. So if they are paralyzed on the left side from a right sided stroke, they will lose vision in the left visual field. Spatial-perceptual problems may be divided into four categories. 1. Incorrect perception of self and illness 2. Erroneous perception of self in space 3. Inability to recognize an object by sight, touch, or hearing 4. Inability to carry out learned sequential movements on command Agnosia-difficulty recognizing previously familiar objects perceived by one of the senses (pencil or toothbrush)

Sunlight is good for osteoporosis

Vitamin D which is used in calcium absorption Being in the sun 20 minutes a day is usually enough to get daily requirements of Vitamin D Those who receive supplementation include: Postmenopausal women Elderly individuals Homebound individuals because they are unable to get outside Those with limited sun exposure

Alcohol overdose

Vomiting Loss of consciousness Respiratory depression Aspiration risks, pneumonia Hypotension that can lead to cardiovascular shock and death Treatment: Gastric lavage Possible dialysis Support respiratory and cardiovascular symptoms, usually need intensive monitoring

Community resources with HIV

WNC AIDS Project HIV Care WNC HIV/AIDs Bureau

Barriers and misconceptions for HIV

What are possible barriers to getting tested or seeking treatment? Fear of knowing HIV status, costs, transportation, social status What are some misconceptions regarding HIV and AIDs in the community? How its spread, what kind of people who get HIV, stigma

Interpersonal collaboration with HIV

What disciplines must work together for the care of these clients?

Cellular regulation

What is cellular regulation? It has a proper amount of time that it lives and then dies. Things go wrong when cells make too many or too few cells or do not die. What alters cellular regulation? Radiation, chemicals, cancer, genetics

Review the Concept of Immunity

What is immunity? the ability of an organism to resist a particular infection or toxin by the action of specific antibodies or sensitized white blood cells. Your body's way of protecting itself What is an allergy? a damaging immune response by the body to a substance, especially pollen, fur, a particular food, or dust, to which it has become hypersensitive. Antibody Meet the invader (antigen) Lymphocytes respond to release antibodies

Hallucinogen abuse

What is it? When reality and perception are distorted by a substance Visual hallucinations Examples: Mescaline (peyote) Psilocybin (found in some mushrooms) Lysergic acid diethylamide (LSD) Ecstasy, a "designer drug' PCP Dextromethorphan (DMX) Ketamine (Special K) Salvia Assessment: Increased HR, BP, and temp Sweating, palpitations, blurred vision Tremors, lack of coordination Anxiety, depression, paranoia, panic Dry mouth, nausea Dangerous behavior- ex. Thinking one can fly and jumping out a window Can be inhaled, swallowed, eaten, brewed in tea, snorted, injected, smoked, absorbed Long-term use can lead to speech problems, memory loss, anxiety, depression, suicidal ideation May also cause a persistent psychosis or flashbacks Flashbacks- transient reoccurrence of perceptual disturbances, can occur as late as 5 years after use

Education for client and family with sickle cell

What to do with fever Seek immediate attention Vaccinations, penicillin prophylaxis Fluids: encourage adequate intake Cold exposure: avoid Contact provider with: pain crisis, sickle cell crisis.. Long list, but all important

Nutrition post-stroke

What to feed them first? NPO until speech therapist evaluation ideally Ever heard of dysphagia? Difficulty swallowing Gag reflex could be absent Feeding specifics? Place food in UNAFFECTED side These patients have a high risk of dysphagia. This means difficulty swallowing. It can be due to an absent gag reflex. Equate absent gag reflex with aspiration which is bad, avoid that. Most patients are placed NPO until they are evaluated by speech for their first feeding. On neuro, the nurse does the initial quick swallow test and if there are issues, the patient is NPO until a Speech therapist can see them. If someone has been cleared by speech and they have a deficit feed them on unaffected side. Follow it with good oral hygiene. Even with perfect food placement food particles can get on the other side and just be left there. This can lead to aspiration or just development of infection.

Physical aggression

When an individual attacks another physically or destroys property Intent is to cause harm

Patient education with TB

When patients cough, cover nose and mouth with tissues then dispose the tissue Avoid public transportation Spend as much time outdoors rather than in confined spaces Sleep alone

My patient is going to get iron, what should I know?

When to take it 1 hour before meals because the stomach acid helps the iron absorb better However it may cause stomach upset so they may take it with meals, in which case they need to take a higher dose What is best with it Vitamin C..what is generic name? Ascorbic acid, enhances acidity, enhances absorption Complications? Constipation, and heartburn Iron is absorbed best on an empty stomach What does proximal duodenum tell you, just that you do not expect extended release or enteric coated tablets. Since you are not a pharmaceutical company that should not be an issue for you. Acidic environment means you want acid churning so 1 hour before a meal so that you have an empty stomach. You can also add something acidic to help. Vitamin C otherwise known as? Ascorbic acid will help its absorption. May start with one tab a day, then gradually increase dose to avoid GI problems Complications. Constipation is the biggest one. It is very common for people who get a prescription with iron to include some type of laxative with their prescription. Remember to educate on foods high in fiber.

Clinical manifestations of stroke

While treatment varies greatly, Clinical manifestations do not differ between ischemic and hemorrhagic strokes. The area of the brain damaged will dictate what is messed up. Table pg. 67-2 great list of deficits. Right-impulsive Left-slow and cautious Hemorrhagic-typically complain of headaches-"worst headache of my life"-more vomiting, early sudden change in LOC, possible focal seizures. May be pain or nuchal rigidity due to the meningeal irritation Affects many body functions ABCs Neurological Motor activity Elimination Intellectual function Spatial-perceptual alterations The neurologic manifestations do not significantly differ between ischemic and hemorrhagic stroke. The reason for this is that destruction of neural tissue is the basis for neurologic dysfunction caused by both types of stroke.

Dietary calcium intake

Whole milk Skim milk Yogurt Turnip greens Cottage cheese Ice cream Sardines Spinach

Mortality rate

number of deaths from a specific cause per 1,000 people

Fat embolism syndrome (FES)

With fracture of long bone or pelvic bones Prevention- Immediate immobilization Support in repositioning Fluid and electrolyte balances Fat emboli form, only 0.3% to 1.3% of cases have morbid complications Rapid onset of symptom (12-72 hours) Triad Hypoxemia Neurological compromise Petechial rash (more 48-72 hours later) Comes from the fat in the bone marrow May have tachycardia, SHOB

Gender differences for OA

Women After age 50, women are affected twice as often as men After age 55, OA in interphalangeal joints and thumb base is more common in women than in men After age 45, knee OA is more common in women than men Menopause can be an increase risk because it decreases estrogen levels Men Before age 50, men are affected more often than women After age 55, hip OA is more common in men than women Before age 45, knee OA is more common in men than women

Who is more likely to get SLE?

Women in their childbearing years 10 times more likely than men -ages 20 to 40 African Americans have highest incidence Also prevalent in Asian Americans, Hispanics and Native Americans

Further along once the CD4 count gets below 500 you may see...

Worsening of the above manifestations Most common is "thrush" or oropharyngeal candidiasis Others include: shingles, herpes, vaginal candida infections, Kaposi sarcoma, oral hairy leukoplakia

Diagnostics for fractures

X-ray CT or MRI

Diagnostics for OA

X-ray Staging and progression of the disease Blood work? Synovial fluid analysis: clear yellow with little or no sign of inflammation. Differentiates between other forms of arthritis. Bone scan CT scan MRI These three are useful for diagnosing in early stages of the disease due to their sensitivity (Bone scan, CT, MRI

Any other labs that may be altered with HIV?

Yes WBC Can be lowered Platelet Can be lowered Hemoglobin Can be lowered Liver function Can be impaired All of these changes could be due to HIV, opportunistic infections, or to the antiretroviral therapy to treat HIV. The cause for these can be hard to pinpoint. Could be a result of medications, could be opportunistic infections causing this or just HIV

Can TB relapse?

Yes, in about 5% of those with active disease Risk factors: Receiving immunosuppressive therapy Developing malignancy Multiple comorbidities Smoking associated with poor outcomes with TB

CAM therapy for OA

Yoga TENS unit- releases external electrical energy to distract pain signals Massage Accupuncture Accupressure Herbal and diet supplements Copper and Magnets What other CAM therapy's? How should you respond when a patient asks you about these?

Prevalence

number of existing cases at a specific time per 1,000 people

Incidence

number of new cases per 1,000 people

Melena

dark sticky feces containing partly digested blood. GI bleeds are a common cause of iron-deficiency anemia Iron gives the black tarry stools their color

Morbidity

incidence of a specific disease

TPA Administration for stroke

t-PA- dissolves the blood clot that is blocking perfusion Rapid diagnosis and initiation of t-PA within 3 hours improves the outcomes after 3 months IV or intra-arterial delivery Contraindications Complications Bleeding Hemorrhagic stroke If someone has a ischemic stroke they will receive tPA. I will never say tissue plasminogen activator again because tPA is so much easier. Please be familiar with this designation as it is what I will use on the test The most important thing to know with ANYONE with stroke symptoms is time from onset of symptoms. The time rules for you guys. IV - < 4.5 hours Intra Arterial < 6 hours I haven't ever seen an intra arterial. The patient goes to interventional radiology, they insert a guidewire through the femoral artery, go up to the blockage and they shoot tPA right at the clot to try to break it up. 3 hours and may be extended up to 4.5 hours in some stroke centers. T-PA 0.9mg/kg (max dose of 90mg)-2 IVS, 1 for tPA and one for fluids-do a bolus, then the remaining dose is given over an hour. Delays may make the patient ineligible because of revascularization of the necrotic tissue which causes cerebral edema and hemorrhage. Contraindications-see table 67-2 Previous History Any of these within 3 months GI bleed, stroke, head trauma Coagulation disorders (anything that makes someone bleed or more likely to bleed) Surgical History Within 14 days Major surgery Hospitals have stroke teams and even face time from some of the outlying hospitals to determine need for tPA.

Time is brain with a stroke

tPA can be administered within 3-4.5 hours of the onset of an ischemic stroke tPA (Tissue plasminogen activator) used to reestablish blood flow through the blocked artery to prevent cell death. Screening has to occur prior to administration to r/o hemorrhagic stroke Contraindicated if recent GI bleeding, stroke, or head trauma within the past 3 months or surgery within the past 14 days.