just a few tips for nursing 4 that seems to help:
Isabel Romena-
-powerpoint presentations are directly from the book, DIRECTLY, but it is a good idea to read over them anyway, particularly the NP
>not all information from the ppt will be tested
-listen during lecture, paying special attention to scenarios she brings up, many of these show up on the test
>"So your neighbor complains to you about symptoms she has been experiencing..."
>"What would you do if a patient is exhibiting these symptoms..."
>there are also personal experiences she brings up to incorporate into lecture
-do the study guides
-read the chapters, but not the whole thing, there is too much! instead take the questions from the study guide and read the section corresponding to it.
>ie: the study guide question is asking about types of fractures, read that entire section because small details show up on the tests at times
>if you cannot read, read the related charts at minimum
-know your diagnostic tests and labs, not necessarily the ranges, but diagnostic tests/labs which can diagnose a patient's problem or determine if a treatment is working effectively
-know your "at risk" patients for each disease studied
-and no...the Lewis study worksheets were not THAT helpful
Caralee Bromme-
-a majority of test questions come from the lecture
-points which are emphasized during lecture are generally tested
-know your diagnostic tests and ranges for labs
-answer the study guide questions from the lecture first, particulary the NP questions
-understand pathology of the disease process
-make certain you understand the concept of fluids and electrolytes
*continue to perfect your testing skills using ATI practice tests, test banks, and the program in the nursing computer lab...
Don't forget to take care of yourself!!!
Showing posts with label N004. Show all posts
Showing posts with label N004. Show all posts
Wednesday, March 11, 2009
Monday, March 9, 2009
Exam #6: Ch. 62-65 (Musculoskeletal System)
KEEP ON TRUCKIN...FINAL FOR N004!!!
1. Explain the effects of aging on the MS system.
-joint and muscle discomfort
-loss of bone density
-decreased tendon flexibility and muscle strength
-vertebral disc compression causing loss of height
2. Explain the different diagnostic tests of the musculoskeletal system and related nursing care.
*standard x-ray: determines bone density
-avoid unnecessary exposure and ensure patient is not pregnant
*diskogram: contrast dye x-ray to determine intevertebral disk abnormalities
-assess for allergy
*CT scan: identifies soft tissue and bony abnormalities and musculoskeletal trauma
-painless, assess for allergy
*myelogram: sensitive test able to pick up nerve impingement and subtle lesions and injuries
-risk for spinal headache which should resolve in 1-2 days with rest and fluids
*MRI: used to diagnose avascular necrosis, disk disease, tumors, osteomyelitis, ligament tears, and cartilage tears
-check for contraindications such as metal on clothing or metal implants like pacemakers
*DEXA: diagnose metabolic bone disease and monitor treatment progress
-painless
*QUS: measures bone density, elasticity, and strength of patella and calcaneous with ultrasound
-painless
*bone scan: radioisotope injection uptake by bone is monitored
-explain procedure
*arthroscopy: visualization of joint structure and contents using an arthroscope
-performed with strict asepsis, cover wound with sterile dressing
*mineral metabolism/serologic studies: studies of minerals and antibodies in the body
-obtain blood samples and observe for bleeding/hematoma
*arthrocentesis: puncture into joint capsule to obtain synovial fluid
-apply compression dressing and observe for leakage; send samples for examination
*electromyogram (EMG): evaluation of skeletal muscle contraction by insertion of small needles
-avoid stimulants and inform patient of discomfort with needle insertion
*duplex venous doppler: ultrasound to detect blood flow abnormalities
-painless
*thermography: infrared detection of heat radiation on skin surface
-painless
*plethysmography: records variations of volume and pressure of blood through tissues
-painless
*somatosensory evoked potential (SSEP): similar to EMG with electrodes placed to the skin
-no needles involved
Ch. 63-Nursing Management: Musculoskeletal Trauma and Orthopedic Surgery
1. Identify patients at risk for musculoskeletal injury.
-young, elderly, women, occupations with high risks, history of injury
2. Explain the assessment findings and interventions for acute soft tissue injury.
*assessment
-edema
-ecchymosis/contusion
-pain/tenderness
-decreased sensation
-decreased pulse, coolness, and cap refill of >2 seconds
-decreased movement
-pallor
-shortening or rotation of extremity
-inability to bear weight if injury to lower extremity
-limited function if injury to upper extremity
-muscle spasms
*interventions
-ensure ABCs
-assess neurovascular status of affected limb
-RICE
-anticipate x-rays
-pain relief
-give tetanus or diptheria prophylaxis if skin integrity is broken
-give antibiotic prohylaxis for open fractures
-monitor neurovascular status
-monitor for compartment syndrome
-monitor for infection/sepsis
3. Explain the different stages of fracture healing and nursing implications.
-fracture hematoma: semisolid clots of blood surrounding ends of fragments 72 hours after injury
-granulation tissue: hematoma converts to granulation tissue which is the basis of new bone formation 3-14 days after injury
-callus formation: cartilage, osteoblasts, calcium, and phosphorus woven about the fracture parts and can be verified by x-ray 2 weeks after injury
>assist with ADLs if necessary
-ossification: ossification of callus prevents movement of fracture 3 weeks to 6 months after injury
>cast may be removed and limited mobility is allowed
-consolidation: distance between fracture eventually closes
>x-ray determines radiologic union of fracture
-remodeling: excess bone tissue is resorbed and bone gradually returns to preinjury shape and strength
>introduce exercise, then weight bearing activities
4. Describe the different fracture reduction techniques.
-closed reduction: non-surgical, manual realignment of bone fragments, followed by immobilization of alignment until healing occurs
>skin/skeletal traction
-open reduction: invasive correction of bone alignment using pins and wires
-traction: pulling and counteraction forces (weights) applied to affected part to prevent or reduce muscle spasm, immobilize affected part, reduce fracture or dislocation, and treat pathological joint condition
5. Use the NP to provide care to a patient with mandibular wiring, post-hip replacement, and post-lower limb amputation.
*mandibular wiring
-maintain patent airway, oral hygiene, communication, and nutrition
-position with wire side up
-keep wire cutters at bedside in case of respiratory or cardiac emergency
-keep tracheostomy tray at bedside
-frequently rinse mouth
-use communication boards
-provide appetizing liquid choices for diet
-check for GI functioning
-address concerns with body image
*post-hip replacement
-general nursing care of post-operative patient
-assess for CSMPT
-use pillows for log rolling
-avoid extreme flexion or rotation at hip until soft tissue has healed
-avoid turning on affected side
-keep abductor pillow between legs
-apply CPM as ordered
-teach patient on correct positioning and risky activities
*post-lower limb amputation
-general post-operative nursing care
-monitor VS and dressing
-sterile technique dressing changes
-avoid prolonged sitting or pillow under extremity to avoid contractures
-correct bandaging to foster correct shape
-ROM exercises
6. List and explain the problems/outcomes of fractures and related nursing care.
-muscle atrophy: decreased muscle mass following a period of disuse or loss of nerve innervation
>implement passive exercises within the confines of mobilization device to prevent muscle atrophy
-contracture: flexion and fixation of joint caused by shortened muscles, loss of skin elasticity, and atrophy
>progressive stretching, passive ROM exercises, repositioning, and correct body alignment
-footdrop: shortened Achilles tendon caused by disuse
>apply foam boots and other preventative measures
-pain: associated with injury
>correct any underlying problems such as repositioning the patient or loosening dressings before medicating
-muscle spasms: involuntary muscle contracture which could lead to pain
>thermotherapy, especially heat
7. List and explain the complications resulting from fractures.
-infection: open fractures are vulnerable to contamination with bacteria
-compartment syndrome: compromised tissue integrity and confined myofascial space cause increased compartment pressure
>causes pressure pain, may cause loss of function if not addressed
-venous thrombosis: lower extremity thrombus formation is common with injury and can travel up after periods of immobility
-fat embolism syndrome: free fat droplets are released from injured bone or at the time of trauma and can cause an embolism
8. Use the NP to provide care to a patient with these complications.
*infection
-assess for signs and symptoms of infection
-implement aggressive surgical debridement
-administer antibiotics
-maintain clean technique when dealing with wound
*compartment syndrome
-recognize signs and symptoms of compartment syndrome
-extremity should not be elevated above heart level
-ice should not be used
-loosen or remove bandages, bivalve casts, or reduce traction weight
-surgical fasciotomy my be necessary
*venous thrombosis
-TED hose/SCDs
-ROM exercises
-administer anticoagulant drugs as ordered
*fat embolism syndrome
-CDB
-immobilize long bone fractures
-manage symptoms with fluid replacement and maintain airway/breathing
Ch. 64-Nursing Management: Musculoskeletal Problems
1. Explain the pathophysiology of osteomyelitis and osteoporosis.
-osteomyelitis: severe infection of bone, bone marrow, and surrounding soft tissue causing increased pressure and vascular compromise of periosteum
-osteoporosis: bone resorption is greater than bone deposition causing weakened bone prone to fractures, both spontaneous and secondary to minor trauma
2. Use the NP to provide care for a patient with osteoporosis and osteomyelitis.
**osteoporosis
*assessment
-subjective: age, family history, genetics, early menopause, sedentary lifestyle, anorexia, oophorectomy, history of smoking, alcohol use
-objective: weight/height, low calcium intake, low testosterone levels
-dx: serum calcium, bone mineral densitometry, x-ray
*diagnoses
-risk for injury
*planning
-nutritional therapy
-calcium supplementation
-exercise
-prevention of fractures
-drug therapy: estrogen replacement and increase bone resorption
*implementation
-diet high in calcium or supplement calcium/vitamin D
-weight bearing exercises
-quit smoking and decrease alcohol consumption
-estrogen therapy
**osteomyelitis
*assessment
-subjective: bone trauma, infection, bone surgery, IV drug abuse, chills, weight loss, weakness, muscle spasms, local tenderness, irritability, withdrawal, anger
-objective: restlessness, night sweats, edema, diaphoresis, restricted movement, wound drainage
-dx: bone or soft tissue biopsy, CBC, ESR, bone scan, CT, MRI
*diagnoses
-acute pain
-ineffective therapeutic regimen management
-impaired physical mobility
*planning
-pain and fever control
-no secondary complications
-follow treatment plan
-maintain positive outlook
*implementation
-immobilization to decrease pain
-drug therapy
-relaxation techniques
-drainage dressing changes in sterile technique
-repositioning for patients on bedrest
-monitor for adverse side effects of drug therapy
3. Use the NP to provide care after spinal surgery.
-maintain proper body alignment: log roll, use pillows or wedges, one or more staff members to move
-pain control
-fluid replacement
-assess for CSF drainage
-monitor neurological signs
-monitor GI/GU system for functionality
-patient teaching: avoid long periods of standing or sitting, mentally think through an activity to avoid injury and pain
Ch. 65-Nursing Management: Arthritis and Connective Tissue Diseases
1. Explain the pathophysiology of osteoarthritis, rheumatoid arthritis, gout and SLE.
*osteoarthritis: damage to cartilage triggers metabolic response
-body attempts to repair weakened cartilage leading to fissuring and erosion at joint surfaces
-pain caused by bone contact after cartilage is destroyed
*rheumatoid arthritis: pannus, or high vascular granulation tissue, forms within joint covering and eroding cartilage
-inflammatory cytokine production also contributes to destruction of cartilage -causes tendon and ligament scarring and shortening
*gout: marked by hyperuricemia; deposits of sodium urate crystals cause sudden swelling and pain in articular, periarticular, and subcutaneous tissues
*SLE: production of antibodies against nucleic acids, particularly directed against the make-up of the cell nucleus
-can deposit basement membrane of capillaries in a variety of locations in the body triggering an aggressive inflammatory response by the complement system
2. Use the NP to provide care to client with osteoarthritis, rheumatoid arthritis, gout and SLE.
**osteoarthritis
*assessment
-subjective: type, location, severity, frequency, and duration of joint pain; effects on ADLs, pain relief measures
-objective: tenderness, swelling, ROM, crepitation, and comparison of affected joints -dx: CT, MRI, x-ray, and synovial fluid analysis
*diagnoses
-acute and chronic pain
-insomnia
-impaired physical mobility
-self-care deficit
-imbalance nutrition: more than body requirements
-chronic low self-esteem
*planning
-maintain/improve joint function with periods of rest and activity
-provide joint protection measures to improve activity tolerance
-optimize ADLs
-manage pain using drug therapy and non-pharmacologic strategies
*implementation
-drug therapy
-heat/ice packs
-relaxation techniques
-highly individualized depending on patient’s progression of disease
**rheumatoid arthritis
*assessment
-subjective: infection, joint surgery, medications, family history, anorexia, weight loss, swelling or weakness of joints, numbness and tingling to hands and feet, pain and aching of joints with activity
-objective: fever, peripheral edema, skin ulcers, shiny/taut skin over joints, symmetric pallor and cyanosis of fingers (Raynaud’s phenomenon), chronic bronchitis, Felty syndrome, joint deformity
-dx: positive rheumatoid factor, synovial fluid analysis
*diagnoses
-chronic pain
-impaired physical mobility
-disturbed body image
-ineffective therapeutic regimen management
-self-care deficit (total)
*planning
-pain relief
-minimize loss of affected joint functioning
-plan and carry out therapeutic regimen
-maintain positive self-image
-maximize self-care
*implementation
-drug therapy
-heat/ice packs
-relaxation techniques
-highly individualized depending on patient’s progression of disease
**gout
*assessment
-subjective: trauma, surgery, sepsis
-objective: dusky, cyanotic joints, extremely tender joints, inflammation of big toe, low grade fever, tophaceous deposits
-dx: elevated uric acid levels
*diagnoses
-acute pain
-activity intolerance
-self care deficit
-disturbed body image
*planning
-avoid unnecessary pain
-joint immobilization
-heat/cold application
*implementation
-drug therapy
-patient education: avoid overindulgence and excessive caloric intake of foods containing purines and other precipitating factors
**SLE
*assessment
-subjective: depression, withdrawal, irregular menstrual periods, visual disturbances, headache, diarrhea, dyspnea, fatigue, weight loss, dysphasia, frequent infections, photosensitivity with rash
-objective: proteinuria, arthritis, facial weakness, hallucinations, disorientation, dysrhythmias, symmetric pallor and cyanosis of fingers, murmurs, decreased breath sounds, alopecia, butterfly rash, leg ulcers, fever, edema
-dx: presence of assorted antibodies in the body (anti-Smith and anti-DNA)
*diagnoses
-fatigue
-acute pain
-impaired skin integrity
-deficient knowledge
*planning
-pain relief
-comply with therapeutic regimen
-awareness of activities which could cause exacerbation
-optimal functioning and self-image
*implementation
-individualized periods of activity and rest
-drug therapy and relaxation techniques
-monitor skin for breakdown
-educate on signs and symptoms of exacerbations
3. Explain the mode of action and resulting nursing care of the different drug categories used in the management of these conditions.
*osteoarthritis:
-acetaminophen: for mild to moderate joint pain
>should not exceed 4 grams daily
-topical creams: works to stop transmission of pain impulses
-NSAIDS: for moderate to severe pain, working by blocking prostaglandins
>risk for bleeding with warfarin and GI side effects
-antibiotics: decreases loss of cartilage with OA of the knee
>monitor treatment effectiveness
-hyaluronic acid (HA): supplements substances found in normal joint fluid and articular cartilage
*rheumatoid arthritis:
-disease-modifying antirheumatic drugs (DMARDS): lessen permanent effects of RA >potential for bone marrow intoxication and hepatotoxicity
-NSAIDS: anti-inflammatory effects
>may be used when patient is intolerant of high aspirin doses
-biologic/targeted drug therapies: slows disease progression
>follow schedule of injections; anakinra and abatacept should not be used in combination with TNF inhibitors
-corticosteroids: temporarily relieves pain and inflammation symptoms experienced during flare-ups
>can be used until DMARDS effects can be seen, but should not be a long-term therapy
*gout:
-colchicine: anti-inflammatory with no analgesic effect
>monitor effectiveness as it may add to evidence to diagnose gout
-NSAIDS: pain management
>used in combination with colchicine
-allopurinols: blocks production of uric acid
>patients who cannot tolerate side effects can be switched to oxypurinol
-selective xanthine oxidase inhibitor: reduces serum uric acid
*SLE
-NSAIDS: pain management
>monitor GI effects
-antimalarial agents: used in combination with NSAIDS to treat fatigue, and moderate skin/joint problems
>monitor for retinopathy; may be switched to anti-leprosy drugs if not tolerated -corticosteroids: used sparingly to control polyarthritis exacerbations
>monitor for toxicity and side effects
Sunday, February 22, 2009
Exam #4: Ch. 17, 48-50 (Endocrine System)
Ch. 17-Fluid and Electrolytes
1. Review calcium regulation.
-present in the body as free or ionized, bound to proteins like albumin, and complexed with phosphate, citrate, or carbonate
-serum calcium levels reflect all three forms
*plasma acidosis: decreases albumin bound calcium, thus increasing ionized calcium
*plasma alkalosis: increases albumin bound calcium, thus decreasing ionized calcium
*calcium balance controlled by parathyroid hormone (PTH), calcitonin, and vitamin D
-PTH: produced by parathyroid gland and stimulated by low serum calcium
>increases movement of calcium out of bones, GI absorption of calcium, and renal tubule reabsorption of calcium
-calcitonin: produced by thyroid gland and stimulated by high serum calcium
>opposes PTH action—decreases GI absorption, increases calcium deposition into bone, and promote renal excretion
-vitamin D: formed through UV rays in precursors found in skin or diet
>aids in absorption of calcium in GI
2. Identify clients at risk for calcium imbalance.
*hypercalcemia
-hyperparathyroidism
-malignancies: cause bone destruction from tumor invasion or secrete a parathyroid-like protein to stimulate calcium release from bones
-vitamin D overdose
-prolonged immobility: bone mineral loss and increased plasma calcium concentration
-rarely occurs from increased calcium intake
*hypocalcemia
-removal or injury of parathyroid gland
-acute pancreatitis: causes lipolysis which produces fatty acids that combine with calcium ions
-multiple blood transfusions: citrate used as anticoagulant binds to calcium
-low calcium diet or decreased absorption from laxative abuse or other syndromes
3. Recognize the signs and symptoms of hypercalcemia and hypocalcemia.
*hypercalcemia
-reduced excitability of muscles and nerves: decrease in memory, confusion, disorientation, fatigue, muscle weakness, constipation, cardiac dysrhythmias, and renal calculi
*hypocalcemia
-increased excitability of muscles and nerves: tetany, manifested by Chvostek’s sign and Trousseau’s sign, laryngeal stridor, dysphasia, numbness and tingling around the mouth or in extremities, and ventricular tachycardia from decreased cardiac contractility
4. Use the NP to provide care to a client with a calcium imbalance.
*assessment
-subjective: ALOC, confusion, memory loss, fatigue, muscle weakness, numbness and tingling around mouth and extremities
-objective: disorientation, constipation, cardiac dysrhythmias, renal calculi, tetany, dysphasia, laryngeal stridor
-dx: serum calcium levels, ionized calcium levels
*diagnoses
-risk for injury
**planning/implementation
*hypercalcemia
-promote excretion of calcium in urine: loop diuretics, hydrate with isotonic saline solutions, 3000-4000 ml fluid intake (also to decrease kidney stone formation)
-lower serum calcium levels: synthetic calcitonin, low calcium diet
-enhance bone mineralization: mobilization with weight-bearing activity
-Aredia: hypercalcemia associated with malignancy; inhibits osteoclast action which breaks down bone and releases calcium as a result
-Mithracin: cytotoxic antibiotic; inhibits bone resorption to lower serum calcium levels
*hypocalcemia: treat the underlying cause
-oral or IV calcium, but not IM
-high calcium diet with vitamin D supplements or calcium supplements for low tolerance of dairy products
-treat pain and anxiety to prevent respiratory alkalosis induced hypocalcemia
Ch. 48-Nursing Assessment: Endocrine System
1. Review the normal regulation of hormonal secretion.
-stimulate or inhibit hormone synthesis or secretion using:
*simple feedback: based on blood levels of a particular substance
-negative feedback: increase or decrease of secretion depending
>calcium regulation: low serum calcium stimulates PTH to increase calcium levels, once achieved the increased calcium levels inhibit further PTH release
-positive feedback: increases target organ action beyond normal
>pressure receptors in the vagina during birth stimulate more oxytocin secretion to make stronger uterine contractions
*complex feedback: hormone stimulation or inhibition involving multiple glands
*nervous system control: hormone secretion directly affected by nervous system actvity like pain, emotion, sexual excitement, and stress
*physiologic rhythms: secretions by rhythms originating in the brain structure like the circadian rhythm related to sleep-wake or dark-light cycles
2. Review the actions of the different hormones and their sources.
**hypothalamus: secretes releasing and inhibiting hormones to the anterior pituitary gland to stimulate or inhibit release of hormones
*releasing hormone:
-corticotropin-releasing hormone (CRH)
-thyrotropin-releasing hormone (TRH)
-growth hormone-releasing factor or somatotropin-releasing hormone
-gonadotropin-releasing hormone (GnRH)
-prolactin-releasing hormone
*inhibiting hormone
-somatostatin: inhibits growth hormone release
-prolactin-inhibiting hormone
**anterior pituitary
*tropic hormone: precursor hormones with control the secretion of hormones by other glands
>thyroid stimulating hormone (TSH), adrenocortiocotropic hormone (ACTH), follicle stimulating hormone (FSH), and luteinizing hormone
*growth hormone: affects growth and development of skeletal muscle and long bones
*prolactin: stimulates breast development for lactation after childbirth
**posterior pituitary: hormones actually produced in hypothalamus, but stored here until release is triggered
*antidiuretic hormone (ADH): regulates fluid volume by stimulating reabsorption of water in renal tubules, making concentrated urine; also a potent vasoconstrictor
*oxytocin: stimulates ejection of milk into mammary glands and contraction of uterine smooth muscle
**thyroid gland: regulated by TSH from anterior pituitary
*thyroxine (T4) and triiodothyronine (T3): affect metabolic rate, caloric requirements, oxygen consumption, carbohydrate and lipid metabolism, growth and development, brain functions, and other nervous system activities
*calcitonin: lowers serum calcium levels by inhibiting calcium resorption from bone, increasing calcium storage in bones, and increasing kidney excretion of calcium and phosphorus
**parathyroid glands
*parathyroid hormone (PTH): regulate blood level of calcium
-stimulates bone resorption and inhibits bone formation
-increases calcuim reabsorption and phosphate excretion
-stimulates conversion of vitamin D in most active form to enhance intestinal absorption of calcium
**adrenal glands
*adrenal medulla
-catecholamines: stress response neurotransmitters
*adrenal cortex: any hormones secreted are referred to as corticosteroids except androgens
-cortisol: glucocorticoid; regulates blood glucose concentration by stimulating hepatic conversion of amino acids to glucose; necessary to maintain life
>antiinflammatory action, maintains vascular integrity and fluid volume
-aldosterone: mineralocorticoid; maintain extracellular fluid volume by promoting reabsorption of sodium and excretion of potassium and hydrogen ions
-adrenal androgens: stimulates pubic and axillary hair growth and sexual drive in females in the form of estrogen
>negligible amounts in men
**pancreas (islets of Langerhans)
*glucagon: increases blood glucose through stimulation of glycogenolysis, gluconeogenesis, and ketogenesis
*insulin: facilitates glucose transport into cell membrane
3. Effects of the sympathetic and parasympathetic system.
-insulin secreted by both systems
Ch. 49-Nursing Management: Diabetes Mellitus
1. Differentiate the pathophysiology of the different types of DM.
-Type 1 DM: destruction of islets by immune system, therefore there is a little to no insulin production
-Type 2 DM: pancreas can produce insulin, but is insufficient and/or poorly utilized by the body
-Gestational: high blood glucose during pregnancy and high risk of developing type 2 diabetes
-Pre-Diabetic: not enough to be diagnosed, but high risk of type 2 diabetes if not treated
>Fasting glucose and OGTT higher than normal
-Secondary Diabetes: result of another medical condition or treatment which causes high glucose levels
2. Differentiate normal, pre-diabetic, and diabetic blood-glucose levels.
-normal: 70-120 mg/dl
-pre-diabetic: >100 -<126>140-<200 mg/dl casual
-diabetic: >126 mg/dl when fasting or >200 mg/dl casual
3. Use the NP to provide care to a pre-diabetic patient and a diabetic patient.
*assessment
-subjective: obesity, family history, history of viral infections, surgery, or medical conditions, thirst, hunger, poor healing
-objective: Kussmaul respirations (rapid, deep breathing with fruity odor), weight loss
-dx: Hb A1c, FSBG, IGT, IFG
*diagnoses
-ineffective theraupeutic regimen management
-risk for injury
-risk for infection
-powerlessness
-imbalanced nutrition: more than body requirements
*planning
-active patient participation
-few or no episodes of acute hyperglycemic emergencies or hypoglycemia
-maintain blood glucose within normal range
-prevent/delay chronic conditions
-maintain ADLs with minimal stress
*implementation
-identify those at risk
-teach how to monitor blood glucose regularly
-teach insulin therapy
-emphasize personal hygiene and foot care
-medical alert bracelet and ID
4. Know the action of the oral hypoglycemic agents.
*not insulin, works to improve mechanisms which insulin and glucose are produced and used
*three main actions: increases insulin production from pancreas, decreases glucose production from liver, and/or improves insulin use by body
-sulfonylureas (Glucotrol, Amaryl): increases insulin production from pancreas
-meglitinides (Prandin, Starlix): increases insulin production from pancreas
-biguanides (Glucophage): decreases glucose production from liver, improves insulin use by body
-alpha-glucosidase inhibitors (Precose): slows absorption of carbohydrates in small intestine
-thiazolidinediones (Actos, Avandia): greatly improves insulin use by body
5. Know the onset, peak action, and duration of the different types of insulin.
*rapid-acting (Humalog, Novolog, Apidra, Exubera): peaks 60-90 minutes
-onset: 15 minutes
-duration: 3-4 hours
*short-acting (regular): peaks 2-3 hours
-onset: 30-60 minutes
-duration: 3-6 hours
*intermediate-acting (NPH): peaks 4-10 hours
-onset: 2-4 hours
-duration: 10-16 hours
*long-acting (Lantus, Levemir): no peak
-onset: 1-2 hours
-duration: 24+ hours
6. Explain the information needed to teach a diabetic patient about exercise and the management of their diabetes.
-teach patient it is essential to diabetes management because it increases insulin receptor sites, lowers blood glucose, and contributes to weight loss
-individualized exercise plan: done after medical clearance with a gradual progression
-monitor blood glucose before, during, and after
-exercise after meals with small carbohydrate snacks every 30 minutes
7. Explain the pathophysiology of DKA, HHS, hypoglycemia and hyperglycemia.
*DKA: profound deficiency of insulin causes breakdown of fat with ketones as a byproduct
-lowers pH causing metabolic acidosis
-ketones are excreted in the urine and electrolytes become depleted
*HHS: inadequate hydration paired with polyuria cause blood glucose to be >400 mg/dl and high serum osmolality
*hypoglycemia: too much insulin in proportion to glucose in the blood
*hyperglycemia: too much glucose in proportion to insulin in the blood
8. Use the NP to provide care for a patient with DKA, HHS, and hypoglycemia
**DKA
*assessment:
-subjective: type 1 diabetes, illness or infection, poor self management, neglect, lethargy, weakness, nausea, vomiting
-objective: inadequate insulin dosage, dehydration, abdominal pain, Kausmall respirations (rapid, deep rhythm), fruity smelling breath
-dx: blood glucose >300 mg/dl, ABG pH <7.3,>add D5 to prevent hypoglycemia when blood glucose levels approach 250 mg/dl
>replace potassium
>sodium bicarbonate, if pH <7>400 mg/dl, increased serum osmolality, and little to no ketone bodies in blood or urine (unlike DKA because of circulating insulin)
*diagnoses:
-risk for injury
*planning (like DKA):
-maintain patent airway
-correct fluid/electrolyte imbalance, more than DKA
-insulin therapy (after fluids have begun)
*implementation:
-administer oxygen
-1/2 NS or NS to restore urine output and blood pressure
>add D5 to prevent hypoglycemia when blood glucose levels approach 250 mg/dl
>replace potassium
>sodium bicarbonate, if pH <7>70 mg/dl, investigate further; begin treatment if <70 mg/dl
--alert patients should be given 15-20 g of a simple carbohydrate like orange juice
--avoid fatty foods as they decrease absorption of sugar
--continue to monitor BG and give scheduled snacks
-if after 2-3 doses of simple carbohydrates do not work or the patient is not alert
--administer 1 mg of glucagon IM or SQ
--give complex carbohydrate after recovery
--20-30 ml D50 IVP in acute care setting
9. List and explain the chronic complications resulting from diabetes.
*microvascular angiopathy: thickening of capillary and arteriole vessel membranes particularly in the eyes, kidneys and skin
-retinopathy:
--proliferative: most severe; occlusion of small blood vessels involving retina and vitreous
--non-proliferative: most common; partial occlusion of small blood vessels in retina
-neuropathy: damage of vessels which supply blood to glomeruli of kidneys; nerve damage caused by metabolic complications of diabetes
--sensory: abnormal sensation of hands and/or feet bilaterally
--autonomic: can affect nearly all body systems
-integumentary problems: infection and necrosis caused by a combination of loss of nerve sensation and poor blood circulation
10. Use the NP to provide care to a patient specific to each of these complications.
*angiopathy:
*retinopathy: treat early with annual dilated eye exams
-photocoagulation
-cryotherapy
-vitrectomy
*neuropathy: tight glucose control, BP management, yearly screening of microalbuminuria in urine and serum creatinine, drug therapy
*integumentary problems: treat infections quickly and vigorously
Ch. 50-Nursing Management: Endocrine Problems (incomplete)
2. Differentiate between the signs and symptoms of Addison's disease and Cushing's disease.
-Addison's disease: lack of corticosteroids; progressive weakness, fatigue, weight loss, skin hyperpigmentation, anorexia, confusion
-Cushing's disease: excess corticosteroids; weight gain (moon face, trunk weight, water retention), secondary diabetes, purple-red straie, slow wound healing,
1. Review calcium regulation.
-present in the body as free or ionized, bound to proteins like albumin, and complexed with phosphate, citrate, or carbonate
-serum calcium levels reflect all three forms
*plasma acidosis: decreases albumin bound calcium, thus increasing ionized calcium
*plasma alkalosis: increases albumin bound calcium, thus decreasing ionized calcium
*calcium balance controlled by parathyroid hormone (PTH), calcitonin, and vitamin D
-PTH: produced by parathyroid gland and stimulated by low serum calcium
>increases movement of calcium out of bones, GI absorption of calcium, and renal tubule reabsorption of calcium
-calcitonin: produced by thyroid gland and stimulated by high serum calcium
>opposes PTH action—decreases GI absorption, increases calcium deposition into bone, and promote renal excretion
-vitamin D: formed through UV rays in precursors found in skin or diet
>aids in absorption of calcium in GI
2. Identify clients at risk for calcium imbalance.
*hypercalcemia
-hyperparathyroidism
-malignancies: cause bone destruction from tumor invasion or secrete a parathyroid-like protein to stimulate calcium release from bones
-vitamin D overdose
-prolonged immobility: bone mineral loss and increased plasma calcium concentration
-rarely occurs from increased calcium intake
*hypocalcemia
-removal or injury of parathyroid gland
-acute pancreatitis: causes lipolysis which produces fatty acids that combine with calcium ions
-multiple blood transfusions: citrate used as anticoagulant binds to calcium
-low calcium diet or decreased absorption from laxative abuse or other syndromes
3. Recognize the signs and symptoms of hypercalcemia and hypocalcemia.
*hypercalcemia
-reduced excitability of muscles and nerves: decrease in memory, confusion, disorientation, fatigue, muscle weakness, constipation, cardiac dysrhythmias, and renal calculi
*hypocalcemia
-increased excitability of muscles and nerves: tetany, manifested by Chvostek’s sign and Trousseau’s sign, laryngeal stridor, dysphasia, numbness and tingling around the mouth or in extremities, and ventricular tachycardia from decreased cardiac contractility
4. Use the NP to provide care to a client with a calcium imbalance.
*assessment
-subjective: ALOC, confusion, memory loss, fatigue, muscle weakness, numbness and tingling around mouth and extremities
-objective: disorientation, constipation, cardiac dysrhythmias, renal calculi, tetany, dysphasia, laryngeal stridor
-dx: serum calcium levels, ionized calcium levels
*diagnoses
-risk for injury
**planning/implementation
*hypercalcemia
-promote excretion of calcium in urine: loop diuretics, hydrate with isotonic saline solutions, 3000-4000 ml fluid intake (also to decrease kidney stone formation)
-lower serum calcium levels: synthetic calcitonin, low calcium diet
-enhance bone mineralization: mobilization with weight-bearing activity
-Aredia: hypercalcemia associated with malignancy; inhibits osteoclast action which breaks down bone and releases calcium as a result
-Mithracin: cytotoxic antibiotic; inhibits bone resorption to lower serum calcium levels
*hypocalcemia: treat the underlying cause
-oral or IV calcium, but not IM
-high calcium diet with vitamin D supplements or calcium supplements for low tolerance of dairy products
-treat pain and anxiety to prevent respiratory alkalosis induced hypocalcemia
Ch. 48-Nursing Assessment: Endocrine System
1. Review the normal regulation of hormonal secretion.
-stimulate or inhibit hormone synthesis or secretion using:
*simple feedback: based on blood levels of a particular substance
-negative feedback: increase or decrease of secretion depending
>calcium regulation: low serum calcium stimulates PTH to increase calcium levels, once achieved the increased calcium levels inhibit further PTH release
-positive feedback: increases target organ action beyond normal
>pressure receptors in the vagina during birth stimulate more oxytocin secretion to make stronger uterine contractions
*complex feedback: hormone stimulation or inhibition involving multiple glands
*nervous system control: hormone secretion directly affected by nervous system actvity like pain, emotion, sexual excitement, and stress
*physiologic rhythms: secretions by rhythms originating in the brain structure like the circadian rhythm related to sleep-wake or dark-light cycles
2. Review the actions of the different hormones and their sources.
**hypothalamus: secretes releasing and inhibiting hormones to the anterior pituitary gland to stimulate or inhibit release of hormones
*releasing hormone:
-corticotropin-releasing hormone (CRH)
-thyrotropin-releasing hormone (TRH)
-growth hormone-releasing factor or somatotropin-releasing hormone
-gonadotropin-releasing hormone (GnRH)
-prolactin-releasing hormone
*inhibiting hormone
-somatostatin: inhibits growth hormone release
-prolactin-inhibiting hormone
**anterior pituitary
*tropic hormone: precursor hormones with control the secretion of hormones by other glands
>thyroid stimulating hormone (TSH), adrenocortiocotropic hormone (ACTH), follicle stimulating hormone (FSH), and luteinizing hormone
*growth hormone: affects growth and development of skeletal muscle and long bones
*prolactin: stimulates breast development for lactation after childbirth
**posterior pituitary: hormones actually produced in hypothalamus, but stored here until release is triggered
*antidiuretic hormone (ADH): regulates fluid volume by stimulating reabsorption of water in renal tubules, making concentrated urine; also a potent vasoconstrictor
*oxytocin: stimulates ejection of milk into mammary glands and contraction of uterine smooth muscle
**thyroid gland: regulated by TSH from anterior pituitary
*thyroxine (T4) and triiodothyronine (T3): affect metabolic rate, caloric requirements, oxygen consumption, carbohydrate and lipid metabolism, growth and development, brain functions, and other nervous system activities
*calcitonin: lowers serum calcium levels by inhibiting calcium resorption from bone, increasing calcium storage in bones, and increasing kidney excretion of calcium and phosphorus
**parathyroid glands
*parathyroid hormone (PTH): regulate blood level of calcium
-stimulates bone resorption and inhibits bone formation
-increases calcuim reabsorption and phosphate excretion
-stimulates conversion of vitamin D in most active form to enhance intestinal absorption of calcium
**adrenal glands
*adrenal medulla
-catecholamines: stress response neurotransmitters
*adrenal cortex: any hormones secreted are referred to as corticosteroids except androgens
-cortisol: glucocorticoid; regulates blood glucose concentration by stimulating hepatic conversion of amino acids to glucose; necessary to maintain life
>antiinflammatory action, maintains vascular integrity and fluid volume
-aldosterone: mineralocorticoid; maintain extracellular fluid volume by promoting reabsorption of sodium and excretion of potassium and hydrogen ions
-adrenal androgens: stimulates pubic and axillary hair growth and sexual drive in females in the form of estrogen
>negligible amounts in men
**pancreas (islets of Langerhans)
*glucagon: increases blood glucose through stimulation of glycogenolysis, gluconeogenesis, and ketogenesis
*insulin: facilitates glucose transport into cell membrane
3. Effects of the sympathetic and parasympathetic system.
-insulin secreted by both systems
Ch. 49-Nursing Management: Diabetes Mellitus
1. Differentiate the pathophysiology of the different types of DM.
-Type 1 DM: destruction of islets by immune system, therefore there is a little to no insulin production
-Type 2 DM: pancreas can produce insulin, but is insufficient and/or poorly utilized by the body
-Gestational: high blood glucose during pregnancy and high risk of developing type 2 diabetes
-Pre-Diabetic: not enough to be diagnosed, but high risk of type 2 diabetes if not treated
>Fasting glucose and OGTT higher than normal
-Secondary Diabetes: result of another medical condition or treatment which causes high glucose levels
2. Differentiate normal, pre-diabetic, and diabetic blood-glucose levels.
-normal: 70-120 mg/dl
-pre-diabetic: >100 -<126>140-<200 mg/dl casual
-diabetic: >126 mg/dl when fasting or >200 mg/dl casual
3. Use the NP to provide care to a pre-diabetic patient and a diabetic patient.
*assessment
-subjective: obesity, family history, history of viral infections, surgery, or medical conditions, thirst, hunger, poor healing
-objective: Kussmaul respirations (rapid, deep breathing with fruity odor), weight loss
-dx: Hb A1c, FSBG, IGT, IFG
*diagnoses
-ineffective theraupeutic regimen management
-risk for injury
-risk for infection
-powerlessness
-imbalanced nutrition: more than body requirements
*planning
-active patient participation
-few or no episodes of acute hyperglycemic emergencies or hypoglycemia
-maintain blood glucose within normal range
-prevent/delay chronic conditions
-maintain ADLs with minimal stress
*implementation
-identify those at risk
-teach how to monitor blood glucose regularly
-teach insulin therapy
-emphasize personal hygiene and foot care
-medical alert bracelet and ID
4. Know the action of the oral hypoglycemic agents.
*not insulin, works to improve mechanisms which insulin and glucose are produced and used
*three main actions: increases insulin production from pancreas, decreases glucose production from liver, and/or improves insulin use by body
-sulfonylureas (Glucotrol, Amaryl): increases insulin production from pancreas
-meglitinides (Prandin, Starlix): increases insulin production from pancreas
-biguanides (Glucophage): decreases glucose production from liver, improves insulin use by body
-alpha-glucosidase inhibitors (Precose): slows absorption of carbohydrates in small intestine
-thiazolidinediones (Actos, Avandia): greatly improves insulin use by body
5. Know the onset, peak action, and duration of the different types of insulin.
*rapid-acting (Humalog, Novolog, Apidra, Exubera): peaks 60-90 minutes
-onset: 15 minutes
-duration: 3-4 hours
*short-acting (regular): peaks 2-3 hours
-onset: 30-60 minutes
-duration: 3-6 hours
*intermediate-acting (NPH): peaks 4-10 hours
-onset: 2-4 hours
-duration: 10-16 hours
*long-acting (Lantus, Levemir): no peak
-onset: 1-2 hours
-duration: 24+ hours
6. Explain the information needed to teach a diabetic patient about exercise and the management of their diabetes.
-teach patient it is essential to diabetes management because it increases insulin receptor sites, lowers blood glucose, and contributes to weight loss
-individualized exercise plan: done after medical clearance with a gradual progression
-monitor blood glucose before, during, and after
-exercise after meals with small carbohydrate snacks every 30 minutes
7. Explain the pathophysiology of DKA, HHS, hypoglycemia and hyperglycemia.
*DKA: profound deficiency of insulin causes breakdown of fat with ketones as a byproduct
-lowers pH causing metabolic acidosis
-ketones are excreted in the urine and electrolytes become depleted
*HHS: inadequate hydration paired with polyuria cause blood glucose to be >400 mg/dl and high serum osmolality
*hypoglycemia: too much insulin in proportion to glucose in the blood
*hyperglycemia: too much glucose in proportion to insulin in the blood
8. Use the NP to provide care for a patient with DKA, HHS, and hypoglycemia
**DKA
*assessment:
-subjective: type 1 diabetes, illness or infection, poor self management, neglect, lethargy, weakness, nausea, vomiting
-objective: inadequate insulin dosage, dehydration, abdominal pain, Kausmall respirations (rapid, deep rhythm), fruity smelling breath
-dx: blood glucose >300 mg/dl, ABG pH <7.3,>add D5 to prevent hypoglycemia when blood glucose levels approach 250 mg/dl
>replace potassium
>sodium bicarbonate, if pH <7>400 mg/dl, increased serum osmolality, and little to no ketone bodies in blood or urine (unlike DKA because of circulating insulin)
*diagnoses:
-risk for injury
*planning (like DKA):
-maintain patent airway
-correct fluid/electrolyte imbalance, more than DKA
-insulin therapy (after fluids have begun)
*implementation:
-administer oxygen
-1/2 NS or NS to restore urine output and blood pressure
>add D5 to prevent hypoglycemia when blood glucose levels approach 250 mg/dl
>replace potassium
>sodium bicarbonate, if pH <7>70 mg/dl, investigate further; begin treatment if <70 mg/dl
--alert patients should be given 15-20 g of a simple carbohydrate like orange juice
--avoid fatty foods as they decrease absorption of sugar
--continue to monitor BG and give scheduled snacks
-if after 2-3 doses of simple carbohydrates do not work or the patient is not alert
--administer 1 mg of glucagon IM or SQ
--give complex carbohydrate after recovery
--20-30 ml D50 IVP in acute care setting
9. List and explain the chronic complications resulting from diabetes.
*microvascular angiopathy: thickening of capillary and arteriole vessel membranes particularly in the eyes, kidneys and skin
-retinopathy:
--proliferative: most severe; occlusion of small blood vessels involving retina and vitreous
--non-proliferative: most common; partial occlusion of small blood vessels in retina
-neuropathy: damage of vessels which supply blood to glomeruli of kidneys; nerve damage caused by metabolic complications of diabetes
--sensory: abnormal sensation of hands and/or feet bilaterally
--autonomic: can affect nearly all body systems
-integumentary problems: infection and necrosis caused by a combination of loss of nerve sensation and poor blood circulation
10. Use the NP to provide care to a patient specific to each of these complications.
*angiopathy:
*retinopathy: treat early with annual dilated eye exams
-photocoagulation
-cryotherapy
-vitrectomy
*neuropathy: tight glucose control, BP management, yearly screening of microalbuminuria in urine and serum creatinine, drug therapy
*integumentary problems: treat infections quickly and vigorously
Ch. 50-Nursing Management: Endocrine Problems (incomplete)
2. Differentiate between the signs and symptoms of Addison's disease and Cushing's disease.
-Addison's disease: lack of corticosteroids; progressive weakness, fatigue, weight loss, skin hyperpigmentation, anorexia, confusion
-Cushing's disease: excess corticosteroids; weight gain (moon face, trunk weight, water retention), secondary diabetes, purple-red straie, slow wound healing,
Wednesday, February 4, 2009
Exam #3: Ch. 56-60 (Neurological System)
Ch. 56-Nursing Assessment: Nervous System
1. Review the functions of the cerebral lobes.
*frontal: higher cognitive function, memory retention, voluntary motor movement, voluntary eye movement, expressive speech
*temporal: receptive speech, integration of somatic, visual, and auditory data
*parietal: sensory cortex, control and interpret spatial information
*occipital: sight processing
2. Describe the effects of aging on the nervous system.
*CNS
-loss of neurons in certain areas of brainstem, cerebellum, and cerebral cortex
>enlargement of ventricles
>decreased brain weight
>decreased blood flow
>decreased CSF production
-glycosylated hemoglobin (Hb A1C): risk factor for accelerated cerebral atrophy
*PNS
-changes to anterior horn cells, peripheral nerves, and target organ muscle
-deteriorated myelin sheath, therefore decreased nerve conduction
-decreased neuromuscular activity
>slower BP response to position change and body temperature
*additional relevent changes
-decreased memory, vision, hearing, taste, smell, vibration/position sense, muscle strength, and reaction time
>decreased dietary intake
>increased perceptual confusion
>fall/fracture risk
3. Differentiate the effects of the sympathetic and parasympathetic nervous system.
*both are part of the autonomic nervous system which governs involuntary functions of cardiac muscle, smooth (involuntary) muscle, and glands
-sympathetic nervous system (T1-L2): “fight or flight” response
>release of norepinepherine and acetylcholine
>occurs throughout body
>imagine what the body would do if a bear was attacking you
-parasympathetic nervous system (S2-S4): conserves and restores energy stores of the body
>releases acetylcholine
>acts in localized and discrete regions of the body
>imagine what the body would do after thanksgiving dinner
4. Explain common neurological assessment abnormalities.
*mental status
-ALOC: unable to speak, obey commands, or open eyes appropriately with verbal or painful stimulus
-anosognosia: unable to recognize bodily defect or disease
*speech
-aphasia: loss of language faculty
-dysphasia: difficulty with use of language
-dysarthria: lack of coordination in articulating speech
*eyes
-aniscoria: unequal pupil size
-diplopia: double vision
-homonymous hemianopsia: loss of vision in one eye
*cranial nerves
-dysphasia: difficulty swallowing
-ophthalmoplegia: paralysis of eye muscles
-papilledema: “choked disc”; swelling of optic nerve head
*motor system
-apraxia: inability to perform learned movements
-ataxia: lack of coordination in movement
-dyskinesia: fragmentary movements due to impairment of power
-hemiplegia: one-sided paralysis
-nystagmus: jerking of eyes while tracking objects
-opisthotonus: arching of back with head retraction
*sensory system
-analgesia: loss of pain sensation
-anesthesia: absence of sensation
>hyperesthesia/hypoesthesia: increase/decreased in sensation
-astereognosis: inability to recognize object form by touch
*reflexes
-Babinski’s sign: upgoing toes with plantar stimulation
-Brudzinski’s sign: neck lesion results in neck pain and reflex flexion of hip and knee
-Kernig’s sign: reflex contraction and pain when in supine position and hips are flexed 90 degrees
*spinal cord
-bladder dysfunction
>atonic: no muscle tone/contractility
>hypotonic: decreased muscle tone/contractility
>hypertonic: increased muscle tone, but decreased capacity
-paraplegia: paralysis of lower extremities
-quadriplegia: paralysis of all extremities
5. Explain different types of diagnostic studies of the neurological system and appropriate nursing responsibilities.
*cerebral angiography: catheter inserted into femoral artery, when vascular lesions or tumors are suspected, then x-rayed
-observe for bleeding
-apply pressure dressing and ice to promote hemostasis and prevent swelling
*electroencephalography (EEG): monitors electrical activity of surface cortical neurons of the brain
-withhold stimulants
-inform patient it is similar to an ECG, no pain involved
*electromyography (EMG): records electrical activity associated with innervation of skeletal muscles
-inform patient of slight discomfort with needle insertion
*lumbar puncture (LP): CSF aspiration at L3-L4 or L4-L5 interspace to assess CNS disease
-monitor neurologic system and vital signs
-encourage fluids
-label specimen
-maintain strict asepsis
-patient should be flat lying after procedure
-assure there is no tumor which could be herniated with procedure
*computed tomography scan (CT): computer assisted x-ray on several thin cross sections of body parts
-elicit allergies to contrast media
-remain calm during procedure and explain scanner
-non-invasive if no dye is used
*magnetic resonance imaging (MRI): imaging using magnetic energy with greater contrast than CT scan
-screen body for metal parts
-be aware of contraindications
-the patient will need to lie still for about an hour
-administer sedatives if necessary
*myelography: detects spinal lesions by x-ray of spinal cord and vertebral column with contrast media
-pre-procedure sedation
-empty bladder
-table will move during test
-patient should lie flat for a few hours after procedure
-encourage fluids
-monitor neurological system and vital signs
-headache and n/v may occur
*positron emission tomography (PET): assess cell death or damage by using radioactive material to measure metabolic activity
-explain procedure and that there will be 2 IV lines required
-no sedatives or tranquilizers involved
-empty bladder pre-procedure
-different activities may need to be performed during test
-glucose monitoring is necessary due to injected venous scan material
*carotid duplex studies: combined ultrasound and doppler technology to evaluate stenosis of carotid and vertebral arteries
-explain procedure to patient
Ch. 57-Nursing Management: Acute Intracranial Problems
1. Explain factors that affect intracranial pressure and cerebral blood flow.
*ICP
-arterial pressure, venous pressure, intraabdominal/intrathoracic pressure, posture, temperature, and ABGs, particularly CO2
*CBF
-carbon dioxide, oxygen, hydrogen ion
>low CO2: relaxes smooth muscle, dilates cerebral vessels, decreased cerebrovascular resistance, and increased CBF
>high CO2: constricts cerebral vessels, increased cerebrovascular resistance, increases CBF, and increased O2 tension
>low O2 tension: causes lactic acid which leads to vasodilation and the accumulation of hydrogen ions
--acidosis: autoregulation is lost and CBF would then be directly influenced by systemic BP, hypoxia, and catecholamines
2. Use the NP to provide are to a patient with IICP.
*assessment
-subjective: obtain from family/friend familiar with patient
-objective: LOC, deviations from normal bodily functions, neurological assessment
-dx: CT or MRI
*diagnoses
-ineffective tissue perfusion (cerebral)
-decreased intracranial adaptive capacity
-risk for disuse syndrome
*planning
-maintain patent airway
-have ICP within normal limits
-demonstrate normal fluid and electrolyte balance
-no complications secondatry to immobility or decreased LOC
*implementation
-suction airway
-reposition from side to side
-elevate HOB
-NG tube for gastric distention unless contraindicated
-decrease environmental stimuli and hazards
-assess ABGs, F&E, and pain
-minimize actions which promote ICP
3. Use the NP to provide care for a patient with an acute head injury.
*assessment
-subjective: how injury was inflicted, anticoagulant usage, use of alcohol or drugs, risky behaviors, headache, mood changes, impaired judgement, fear, denial, anger, agression
-objective: ALOC, type of laceration and bruising, patency of airway, fluid leakage, Cushing’s triad, vomiting, incontinence, uninhibitied sexual expression, pupil dysfunction, neurological function, muscle strength
-dx: CT, MRI, PET
*diagnoses
-ineffective tissue perfusion (cerebral)
-hyperthermia
-acute pain (headache)
-impaired physical mobility
-anxiety
-potential complication: increased ICP
*planning
-adequate cerebral oxygenation and perfusion
-remain normothermic
-control pain and discomfort
-free from infection
-maximal cognitive, motor, and sensory function
*implementation
-protective gear education
-safe driving education
-explain need for frequent neurological checks
-check for CSF leaks
-care for the immobile patient
-surgery consent from family if needed
4. Explain the types of head injuries and related complications.
*scalp lacerations
-external head trauma
-excessive blood loss
-risk for infection
*skull fractures
-linear, depressed, simple, comminuted, compound
>intracranial infection, hematoma, meningeal, and brain tissue damage
*minor head trauma
-concussion: sudden transient mechanical head injury
>repeated minor head trauma could lead to a more progressive, serious problem
*major head trauma
-contusion: bruising of brain tissue
-laceration: bleeding of brain tissue
>brain hemorrhage
*epidural hematoma
-bleeding between dura and inner brain surface
*subdural hematoma
-bleeding between dura mater and arachnoid layer
*intracerebral hematoma
-bleeding within the brain
5. Explain the indications for and types of cranial surgery
*stereotactic
-uses precision apparatus to drill Burr hole
-removes small brain tumors and abscesses, drains hematomas, ablative procedures for extrapyramidal diseases, and repair of arteriovenous malformations
-reduces surrounding tissue damage
-also ionizing radiation procedure
*craniotomy
-removal of brain part by sawing Burr hole
6. Use the NP to provide care to a patient post-cranial surgery
*assessment
-subjective: how injury was inflicted, anticoagulant usage, use of alcohol or drugs, risky behaviors, headache, mood changes, impaired judgement, fear, denial, anger, agression
-objective: ALOC, type of laceration and bruising, patency of airway, fluid leakage, Cushing’s triad, vomiting, incontinence, uninhibitied sexual expression, pupil dysfunction, neurological function, muscle strength
-dx: CT, MRI, PET
*diagnoses
-ineffective tissue perfusion (cerebral)
-decreased intracranial adaptive capacity
-risk for disuse syndrome
*planning
-return to normal consciousness
-control pain and discomfort
-maximize neuromuscular functioning
-rehabilitate to maximal ability
*implementation
-therapeutic communication
-explain procedure
-prevent ICP
-suction airway
-reposition from side to side
-elevate HOB
-NG tube for gastric distention unless contraindicated
-decrease environmental stimuli and hazards
-assess ABGs, F&E, and pain
-minimize actions which promote ICP
7. Use the NP to provide care to a patient with bacterial meningitis.
*assessment
-subjective: how injury was inflicted, anticoagulant usage, use of alcohol or drugs, risky behaviors, headache, mood changes, impaired judgement, fear, denial, anger, agression
-objective: ALOC, type of laceration and bruising, patency of airway, fluid leakage, Cushing’s triad, vomiting, incontinence, uninhibitied sexual expression, pupil dysfunction, neurological function, muscle strength
-dx: CT, MRI, PET
*diagnoses
-decreased intracranial adaptive capacity
-disturbed sensory perception
-acute pain
-hyperthermia
*planning
-maximize return of neurologic function
-resolve infection
-control pain and discomfort
*implementation
-darken room and cool towel for photophobia
-manage fever
-assess for dehydration
-respiratory isolation
-therapeutic communication
Ch. 58-Nursing Management: Stroke
1. Differentiate the pathophysiology of each type of stroke.
*anatomy of cerebral circulation
-internal carotid arteries: anterior circulation
-vertebral arteries: posterior circulation
*regulation of cerebral blood flow
-cerebral autoregulation: changes to vessel diameter to compensate for systemic BP changes
-systemic BP, CO, and blood viscosity all affect brain blood flow
-collateral circulation: compensation for decreased cerebral blood flow
-ICP
*artherosclerosis: hardening and thickening of arteries can lead to thrombus formation and contribute to emboli
*ischemic stroke: inadequate blood flow to brain from partial or complete artery occlusion
-thromobotic stroke: injury to vessel wall and blood clot fomration
>narrowing of vessel by plaque
-embolic stroke: clot blocks blood flow
*hemorrhagic stroke: bleeding into brain tissue itself or into subarachnoid space or ventricles
-intracerebral hemorrhage: bleeding within the brain by a ruptured vessel
>hypertension
-subarachnoid hemorrhage: bleeding into CSF-filled space between arachnoid and pia mater on brain surface
2. Using a system’s approach, identify the complications resulting from an acute stroke.
*motor function
-impairment of mobility, respiration, swallowing/speech, gag reflex, and ADLS
*communication
-aphasia, dysphasia, dysarthria
*affect
-uncontrolled exaggerated emotional responses related to loss of functions
*intellectual function
-impaired memory and judgement
>right brain stroke: impulsive decisions and memory problems related to language
>left brain stroke: cautious decisions
-difficulty making generalizations; difficulty learning
*spatial-perceptual alterations
-right side stroke: decreased perception of self and illness, decreased sensory input form affected side, decreased object recognition by sight, touch, sound and decreased ability to carry out learned sequential movements on demand
*elimination
-initial and temporary
>secondary result
3. Use the NP to provide care to a patient with stroke.
*assessment
-subjective: description of current illness, hisotyr of similar symptoms, current medications, risk factors such as HTN and family history
-objective: LOC, cognition, motor ability, cranial nerve function, deep tendon reflexes (all should be monitored continuously)
-dx: non-contrast CT scan for confirmation and cause
*diagnoses
-ineffective tissue perfusion (cerebral)
-ineffective airway clearance
-impaired physical mobility
-impaired verbal communication
-unilateral neglect
-impaired urinary elimination
-impaired swallowing
-situational low self esteem
*planning
-maintain or improve LOC
-attain maximum physical functioning
-maximum self-care abilities and skills
-stable body functions
-maximal communication skills
-adequate nutrition
-avoid further complications
-effective coping
*implementation
-focused prevention on risk factors
-respiratory patency and function
>positioning, suctioning, oxygenation, gag reflex
-monitor neurological signs
-monitor cardiac rhythm and vital signs
-monitor IV and I&O
-monitor lung sounds and heart sounds
-ROM exercises
-observe lower extremity edema
>TEDs and SCDs
-elevation to avoid dependent edema
-hygiene care
-bladder training or foley care
-mouth care
-therapeutic communication
-monitor possible changes to senses and perceptions
-familial support
-patient education regarding home care
Ch. 59-Nursing Management: Chronic Neurologic Problems
1. Explain the pathophysiology and types of seizures
*abnormal neurons spontaneously fire
*generalized seizures: involve both sides of the brain
-tonic-clonic: loss of consciousness, stiffening of body, then subsequent jerking
-typical absence seizure: staring spell may be resulting from hyperventilation or flashing lights
>children
-atypical absence seizures: staring spells accompanied by peculiar behavior or confusion
*partial seizures: begin at one side of brain and can evolve to both
-simple partial seizure: no loss of consciousness and short lasting
-complex partial seizures: ALOC, longer than one minute, involves emotional, behavioral, cognitive, and affective function followed by confusion
2. Use the NP to provide care to the patient with seizure disorder, multiple sclerosis, myasthenia gravis and Parkinson’s disease
**seizure disorder
*assessment
-subjective: history of seizures, current compliance with medications, family history of seizures, changes before seizure, anxiety, depression, changes in sexual drive
-objective: bitten tongue, soft tissue damage, abnormal RR or breath sounds, HTN, tachycardia, bradycardia, GI/GU incontinence, type of seizure, weakness, paralysis
-dx: toxiclology screen, serum levels, LP
*diagnoses
-ineffective breathing pattern
-risk for injury
-ineffective coping
-ineffective therapeutic regimen management
*planning
-free of injury during seizure
-optimal mental/physical health while taking anti-seizure drugs
-satisfactory psychosocial functioning
*implementation
-identify precipitating events
-promote safety measures
-good general health habits
-record details of seizure
-maintain airway and safety
-therapeutic communication
-medic alert bracelet
**multiple sclerosis
*assessment
-subjective: past infections or vaccines, use/compliance to current medications, family history, malaise, weight-loss, dysphagia, decreased GI/GU function, generalized muscle weakness, numbness, tingling, muscle spasms, blurred/lost vision, anger, depression, euphoria
-objective: apathy, inattentiveness, pressure ulcers, scanning speech, impaired hearing, muscular weakness
-dx: CSF analysis, MRI
*diagnoses
-impaired physical mobility
-sexual dysfunction
-impaired urinary elimination pattern
-interrupted family processes
*planning
-maximal neuromuscular function
-independent ADLs
-optimal psycho-social well-being
-adjust to illness
-decrease precipitating factors
*implementation
-therapeutic communication
-prevent complications of immobility
-bladder training/ foley care
-maintain strong immune system
**Parkinson’s Disease
*assessment
-subjective: CNS trauma, encephalitis, fatigue, dysphasia, weight loss, decreased GI/GU function, excessive sweating, loss of dexterity, difficulty initiating movements, muscle soreness and cramping, mood swings, hallucinations
-objective: blank face, slow monotonous speech, infrequent blinking, ankle edema, postural hypotension, drooling, tremor, poor coordination, rigieity, stooped posture, shuffling gait
*diagnoses
-impaired physical mobility
-impaired verbal communication
-deficient diversional activity
-imbalanced nutrition: less than body requirements
*planning
-maximal neurological function
-maintain ADLS as long as possible
*implementation
-physical exercise
-well balanced diet
-encourage independence
-avoid secondary complications
**myasthenia gravis
*assessment
-subjective: fatigue level, affected body parts, severity, coping abilities
-objective: RR and depth, SpO2, and muscle strength
-dx: ABGs, pulmonary function tests
*diagnoses
-ineffective breathing pattern
-ineffective airway clearance
-impaired verbal communication
-imbalanced nutrition: less than body requirements
-disturbed sensory perception (visual)
-activity intolerance
-disturbed body image
*planning
-return of muscle endurance
-manage fatigue
-avoid secondary complications
-maintain quality of life
*implementation
-adequate ventilation
-drug therapy and monitor side effects (drug-drug interactions)
-daily planning
-balanced diet
Ch. 60-Nursing Management: Alzheimer’s Disease and Dementia
1. Explain the pathophysiology of dementia and Alzheimer’s disease
*dementia: neurodegeneration and vascular disorders
*Alzheimer’s Disease: plaque of the brain, abnormal protein threads inside nerve cells and loss of neuron connections
2. Use the NP to provide care for a patient with dementia and Alzheimer’s Disease.
*assessment
-subjective: repeated head trauma, family history, malnutrition, incontinence, poor personal hygiene, disturbed sleep pattern, impaired coping, forgetfulness
-objective: disheveled appearance, loss of recent memory, disorientation, agitation, confusion, inability to do simple tasks
-dx: diagnoses by exclusion
*diagnoses
-disturbed thought process
-self-care deficit
-risk for injury
-wandering
*planning
-maintain functional ability as long as possible
-safe environment and minimal injuries
-meet personal care needs
-maintain dignity
*implementation
-assess for depression and suicide ideation
-work with caregiver to monitor ongoing changes
-consistency to reduce anxiety or disruptive behavior
3. Explain the general categories of drug therapy for Alzheimer’s Disease.
*drugs for…
-decreased memory and cognition: block cholinesterase to improve functional abilities
-depression: improve cognitive ability
-behavioral problems: atypical anti-psychotics with uncertain side effects
-sleep disturbances
4. List general nursing care instructions for the caregiver.
-provide a safe environment
-stop potentially dangerous behavior early
-reinforce routine and continue communication
-monitor diet
-reduce stress triggers
-know when caring for the patient is too much
1. Review the functions of the cerebral lobes.
*frontal: higher cognitive function, memory retention, voluntary motor movement, voluntary eye movement, expressive speech
*temporal: receptive speech, integration of somatic, visual, and auditory data
*parietal: sensory cortex, control and interpret spatial information
*occipital: sight processing
2. Describe the effects of aging on the nervous system.
*CNS
-loss of neurons in certain areas of brainstem, cerebellum, and cerebral cortex
>enlargement of ventricles
>decreased brain weight
>decreased blood flow
>decreased CSF production
-glycosylated hemoglobin (Hb A1C): risk factor for accelerated cerebral atrophy
*PNS
-changes to anterior horn cells, peripheral nerves, and target organ muscle
-deteriorated myelin sheath, therefore decreased nerve conduction
-decreased neuromuscular activity
>slower BP response to position change and body temperature
*additional relevent changes
-decreased memory, vision, hearing, taste, smell, vibration/position sense, muscle strength, and reaction time
>decreased dietary intake
>increased perceptual confusion
>fall/fracture risk
3. Differentiate the effects of the sympathetic and parasympathetic nervous system.
*both are part of the autonomic nervous system which governs involuntary functions of cardiac muscle, smooth (involuntary) muscle, and glands
-sympathetic nervous system (T1-L2): “fight or flight” response
>release of norepinepherine and acetylcholine
>occurs throughout body
>imagine what the body would do if a bear was attacking you
-parasympathetic nervous system (S2-S4): conserves and restores energy stores of the body
>releases acetylcholine
>acts in localized and discrete regions of the body
>imagine what the body would do after thanksgiving dinner
4. Explain common neurological assessment abnormalities.
*mental status
-ALOC: unable to speak, obey commands, or open eyes appropriately with verbal or painful stimulus
-anosognosia: unable to recognize bodily defect or disease
*speech
-aphasia: loss of language faculty
-dysphasia: difficulty with use of language
-dysarthria: lack of coordination in articulating speech
*eyes
-aniscoria: unequal pupil size
-diplopia: double vision
-homonymous hemianopsia: loss of vision in one eye
*cranial nerves
-dysphasia: difficulty swallowing
-ophthalmoplegia: paralysis of eye muscles
-papilledema: “choked disc”; swelling of optic nerve head
*motor system
-apraxia: inability to perform learned movements
-ataxia: lack of coordination in movement
-dyskinesia: fragmentary movements due to impairment of power
-hemiplegia: one-sided paralysis
-nystagmus: jerking of eyes while tracking objects
-opisthotonus: arching of back with head retraction
*sensory system
-analgesia: loss of pain sensation
-anesthesia: absence of sensation
>hyperesthesia/hypoesthesia: increase/decreased in sensation
-astereognosis: inability to recognize object form by touch
*reflexes
-Babinski’s sign: upgoing toes with plantar stimulation
-Brudzinski’s sign: neck lesion results in neck pain and reflex flexion of hip and knee
-Kernig’s sign: reflex contraction and pain when in supine position and hips are flexed 90 degrees
*spinal cord
-bladder dysfunction
>atonic: no muscle tone/contractility
>hypotonic: decreased muscle tone/contractility
>hypertonic: increased muscle tone, but decreased capacity
-paraplegia: paralysis of lower extremities
-quadriplegia: paralysis of all extremities
5. Explain different types of diagnostic studies of the neurological system and appropriate nursing responsibilities.
*cerebral angiography: catheter inserted into femoral artery, when vascular lesions or tumors are suspected, then x-rayed
-observe for bleeding
-apply pressure dressing and ice to promote hemostasis and prevent swelling
*electroencephalography (EEG): monitors electrical activity of surface cortical neurons of the brain
-withhold stimulants
-inform patient it is similar to an ECG, no pain involved
*electromyography (EMG): records electrical activity associated with innervation of skeletal muscles
-inform patient of slight discomfort with needle insertion
*lumbar puncture (LP): CSF aspiration at L3-L4 or L4-L5 interspace to assess CNS disease
-monitor neurologic system and vital signs
-encourage fluids
-label specimen
-maintain strict asepsis
-patient should be flat lying after procedure
-assure there is no tumor which could be herniated with procedure
*computed tomography scan (CT): computer assisted x-ray on several thin cross sections of body parts
-elicit allergies to contrast media
-remain calm during procedure and explain scanner
-non-invasive if no dye is used
*magnetic resonance imaging (MRI): imaging using magnetic energy with greater contrast than CT scan
-screen body for metal parts
-be aware of contraindications
-the patient will need to lie still for about an hour
-administer sedatives if necessary
*myelography: detects spinal lesions by x-ray of spinal cord and vertebral column with contrast media
-pre-procedure sedation
-empty bladder
-table will move during test
-patient should lie flat for a few hours after procedure
-encourage fluids
-monitor neurological system and vital signs
-headache and n/v may occur
*positron emission tomography (PET): assess cell death or damage by using radioactive material to measure metabolic activity
-explain procedure and that there will be 2 IV lines required
-no sedatives or tranquilizers involved
-empty bladder pre-procedure
-different activities may need to be performed during test
-glucose monitoring is necessary due to injected venous scan material
*carotid duplex studies: combined ultrasound and doppler technology to evaluate stenosis of carotid and vertebral arteries
-explain procedure to patient
Ch. 57-Nursing Management: Acute Intracranial Problems
1. Explain factors that affect intracranial pressure and cerebral blood flow.
*ICP
-arterial pressure, venous pressure, intraabdominal/intrathoracic pressure, posture, temperature, and ABGs, particularly CO2
*CBF
-carbon dioxide, oxygen, hydrogen ion
>low CO2: relaxes smooth muscle, dilates cerebral vessels, decreased cerebrovascular resistance, and increased CBF
>high CO2: constricts cerebral vessels, increased cerebrovascular resistance, increases CBF, and increased O2 tension
>low O2 tension: causes lactic acid which leads to vasodilation and the accumulation of hydrogen ions
--acidosis: autoregulation is lost and CBF would then be directly influenced by systemic BP, hypoxia, and catecholamines
2. Use the NP to provide are to a patient with IICP.
*assessment
-subjective: obtain from family/friend familiar with patient
-objective: LOC, deviations from normal bodily functions, neurological assessment
-dx: CT or MRI
*diagnoses
-ineffective tissue perfusion (cerebral)
-decreased intracranial adaptive capacity
-risk for disuse syndrome
*planning
-maintain patent airway
-have ICP within normal limits
-demonstrate normal fluid and electrolyte balance
-no complications secondatry to immobility or decreased LOC
*implementation
-suction airway
-reposition from side to side
-elevate HOB
-NG tube for gastric distention unless contraindicated
-decrease environmental stimuli and hazards
-assess ABGs, F&E, and pain
-minimize actions which promote ICP
3. Use the NP to provide care for a patient with an acute head injury.
*assessment
-subjective: how injury was inflicted, anticoagulant usage, use of alcohol or drugs, risky behaviors, headache, mood changes, impaired judgement, fear, denial, anger, agression
-objective: ALOC, type of laceration and bruising, patency of airway, fluid leakage, Cushing’s triad, vomiting, incontinence, uninhibitied sexual expression, pupil dysfunction, neurological function, muscle strength
-dx: CT, MRI, PET
*diagnoses
-ineffective tissue perfusion (cerebral)
-hyperthermia
-acute pain (headache)
-impaired physical mobility
-anxiety
-potential complication: increased ICP
*planning
-adequate cerebral oxygenation and perfusion
-remain normothermic
-control pain and discomfort
-free from infection
-maximal cognitive, motor, and sensory function
*implementation
-protective gear education
-safe driving education
-explain need for frequent neurological checks
-check for CSF leaks
-care for the immobile patient
-surgery consent from family if needed
4. Explain the types of head injuries and related complications.
*scalp lacerations
-external head trauma
-excessive blood loss
-risk for infection
*skull fractures
-linear, depressed, simple, comminuted, compound
>intracranial infection, hematoma, meningeal, and brain tissue damage
*minor head trauma
-concussion: sudden transient mechanical head injury
>repeated minor head trauma could lead to a more progressive, serious problem
*major head trauma
-contusion: bruising of brain tissue
-laceration: bleeding of brain tissue
>brain hemorrhage
*epidural hematoma
-bleeding between dura and inner brain surface
*subdural hematoma
-bleeding between dura mater and arachnoid layer
*intracerebral hematoma
-bleeding within the brain
5. Explain the indications for and types of cranial surgery
*stereotactic
-uses precision apparatus to drill Burr hole
-removes small brain tumors and abscesses, drains hematomas, ablative procedures for extrapyramidal diseases, and repair of arteriovenous malformations
-reduces surrounding tissue damage
-also ionizing radiation procedure
*craniotomy
-removal of brain part by sawing Burr hole
6. Use the NP to provide care to a patient post-cranial surgery
*assessment
-subjective: how injury was inflicted, anticoagulant usage, use of alcohol or drugs, risky behaviors, headache, mood changes, impaired judgement, fear, denial, anger, agression
-objective: ALOC, type of laceration and bruising, patency of airway, fluid leakage, Cushing’s triad, vomiting, incontinence, uninhibitied sexual expression, pupil dysfunction, neurological function, muscle strength
-dx: CT, MRI, PET
*diagnoses
-ineffective tissue perfusion (cerebral)
-decreased intracranial adaptive capacity
-risk for disuse syndrome
*planning
-return to normal consciousness
-control pain and discomfort
-maximize neuromuscular functioning
-rehabilitate to maximal ability
*implementation
-therapeutic communication
-explain procedure
-prevent ICP
-suction airway
-reposition from side to side
-elevate HOB
-NG tube for gastric distention unless contraindicated
-decrease environmental stimuli and hazards
-assess ABGs, F&E, and pain
-minimize actions which promote ICP
7. Use the NP to provide care to a patient with bacterial meningitis.
*assessment
-subjective: how injury was inflicted, anticoagulant usage, use of alcohol or drugs, risky behaviors, headache, mood changes, impaired judgement, fear, denial, anger, agression
-objective: ALOC, type of laceration and bruising, patency of airway, fluid leakage, Cushing’s triad, vomiting, incontinence, uninhibitied sexual expression, pupil dysfunction, neurological function, muscle strength
-dx: CT, MRI, PET
*diagnoses
-decreased intracranial adaptive capacity
-disturbed sensory perception
-acute pain
-hyperthermia
*planning
-maximize return of neurologic function
-resolve infection
-control pain and discomfort
*implementation
-darken room and cool towel for photophobia
-manage fever
-assess for dehydration
-respiratory isolation
-therapeutic communication
Ch. 58-Nursing Management: Stroke
1. Differentiate the pathophysiology of each type of stroke.
*anatomy of cerebral circulation
-internal carotid arteries: anterior circulation
-vertebral arteries: posterior circulation
*regulation of cerebral blood flow
-cerebral autoregulation: changes to vessel diameter to compensate for systemic BP changes
-systemic BP, CO, and blood viscosity all affect brain blood flow
-collateral circulation: compensation for decreased cerebral blood flow
-ICP
*artherosclerosis: hardening and thickening of arteries can lead to thrombus formation and contribute to emboli
*ischemic stroke: inadequate blood flow to brain from partial or complete artery occlusion
-thromobotic stroke: injury to vessel wall and blood clot fomration
>narrowing of vessel by plaque
-embolic stroke: clot blocks blood flow
*hemorrhagic stroke: bleeding into brain tissue itself or into subarachnoid space or ventricles
-intracerebral hemorrhage: bleeding within the brain by a ruptured vessel
>hypertension
-subarachnoid hemorrhage: bleeding into CSF-filled space between arachnoid and pia mater on brain surface
2. Using a system’s approach, identify the complications resulting from an acute stroke.
*motor function
-impairment of mobility, respiration, swallowing/speech, gag reflex, and ADLS
*communication
-aphasia, dysphasia, dysarthria
*affect
-uncontrolled exaggerated emotional responses related to loss of functions
*intellectual function
-impaired memory and judgement
>right brain stroke: impulsive decisions and memory problems related to language
>left brain stroke: cautious decisions
-difficulty making generalizations; difficulty learning
*spatial-perceptual alterations
-right side stroke: decreased perception of self and illness, decreased sensory input form affected side, decreased object recognition by sight, touch, sound and decreased ability to carry out learned sequential movements on demand
*elimination
-initial and temporary
>secondary result
3. Use the NP to provide care to a patient with stroke.
*assessment
-subjective: description of current illness, hisotyr of similar symptoms, current medications, risk factors such as HTN and family history
-objective: LOC, cognition, motor ability, cranial nerve function, deep tendon reflexes (all should be monitored continuously)
-dx: non-contrast CT scan for confirmation and cause
*diagnoses
-ineffective tissue perfusion (cerebral)
-ineffective airway clearance
-impaired physical mobility
-impaired verbal communication
-unilateral neglect
-impaired urinary elimination
-impaired swallowing
-situational low self esteem
*planning
-maintain or improve LOC
-attain maximum physical functioning
-maximum self-care abilities and skills
-stable body functions
-maximal communication skills
-adequate nutrition
-avoid further complications
-effective coping
*implementation
-focused prevention on risk factors
-respiratory patency and function
>positioning, suctioning, oxygenation, gag reflex
-monitor neurological signs
-monitor cardiac rhythm and vital signs
-monitor IV and I&O
-monitor lung sounds and heart sounds
-ROM exercises
-observe lower extremity edema
>TEDs and SCDs
-elevation to avoid dependent edema
-hygiene care
-bladder training or foley care
-mouth care
-therapeutic communication
-monitor possible changes to senses and perceptions
-familial support
-patient education regarding home care
Ch. 59-Nursing Management: Chronic Neurologic Problems
1. Explain the pathophysiology and types of seizures
*abnormal neurons spontaneously fire
*generalized seizures: involve both sides of the brain
-tonic-clonic: loss of consciousness, stiffening of body, then subsequent jerking
-typical absence seizure: staring spell may be resulting from hyperventilation or flashing lights
>children
-atypical absence seizures: staring spells accompanied by peculiar behavior or confusion
*partial seizures: begin at one side of brain and can evolve to both
-simple partial seizure: no loss of consciousness and short lasting
-complex partial seizures: ALOC, longer than one minute, involves emotional, behavioral, cognitive, and affective function followed by confusion
2. Use the NP to provide care to the patient with seizure disorder, multiple sclerosis, myasthenia gravis and Parkinson’s disease
**seizure disorder
*assessment
-subjective: history of seizures, current compliance with medications, family history of seizures, changes before seizure, anxiety, depression, changes in sexual drive
-objective: bitten tongue, soft tissue damage, abnormal RR or breath sounds, HTN, tachycardia, bradycardia, GI/GU incontinence, type of seizure, weakness, paralysis
-dx: toxiclology screen, serum levels, LP
*diagnoses
-ineffective breathing pattern
-risk for injury
-ineffective coping
-ineffective therapeutic regimen management
*planning
-free of injury during seizure
-optimal mental/physical health while taking anti-seizure drugs
-satisfactory psychosocial functioning
*implementation
-identify precipitating events
-promote safety measures
-good general health habits
-record details of seizure
-maintain airway and safety
-therapeutic communication
-medic alert bracelet
**multiple sclerosis
*assessment
-subjective: past infections or vaccines, use/compliance to current medications, family history, malaise, weight-loss, dysphagia, decreased GI/GU function, generalized muscle weakness, numbness, tingling, muscle spasms, blurred/lost vision, anger, depression, euphoria
-objective: apathy, inattentiveness, pressure ulcers, scanning speech, impaired hearing, muscular weakness
-dx: CSF analysis, MRI
*diagnoses
-impaired physical mobility
-sexual dysfunction
-impaired urinary elimination pattern
-interrupted family processes
*planning
-maximal neuromuscular function
-independent ADLs
-optimal psycho-social well-being
-adjust to illness
-decrease precipitating factors
*implementation
-therapeutic communication
-prevent complications of immobility
-bladder training/ foley care
-maintain strong immune system
**Parkinson’s Disease
*assessment
-subjective: CNS trauma, encephalitis, fatigue, dysphasia, weight loss, decreased GI/GU function, excessive sweating, loss of dexterity, difficulty initiating movements, muscle soreness and cramping, mood swings, hallucinations
-objective: blank face, slow monotonous speech, infrequent blinking, ankle edema, postural hypotension, drooling, tremor, poor coordination, rigieity, stooped posture, shuffling gait
*diagnoses
-impaired physical mobility
-impaired verbal communication
-deficient diversional activity
-imbalanced nutrition: less than body requirements
*planning
-maximal neurological function
-maintain ADLS as long as possible
*implementation
-physical exercise
-well balanced diet
-encourage independence
-avoid secondary complications
**myasthenia gravis
*assessment
-subjective: fatigue level, affected body parts, severity, coping abilities
-objective: RR and depth, SpO2, and muscle strength
-dx: ABGs, pulmonary function tests
*diagnoses
-ineffective breathing pattern
-ineffective airway clearance
-impaired verbal communication
-imbalanced nutrition: less than body requirements
-disturbed sensory perception (visual)
-activity intolerance
-disturbed body image
*planning
-return of muscle endurance
-manage fatigue
-avoid secondary complications
-maintain quality of life
*implementation
-adequate ventilation
-drug therapy and monitor side effects (drug-drug interactions)
-daily planning
-balanced diet
Ch. 60-Nursing Management: Alzheimer’s Disease and Dementia
1. Explain the pathophysiology of dementia and Alzheimer’s disease
*dementia: neurodegeneration and vascular disorders
*Alzheimer’s Disease: plaque of the brain, abnormal protein threads inside nerve cells and loss of neuron connections
2. Use the NP to provide care for a patient with dementia and Alzheimer’s Disease.
*assessment
-subjective: repeated head trauma, family history, malnutrition, incontinence, poor personal hygiene, disturbed sleep pattern, impaired coping, forgetfulness
-objective: disheveled appearance, loss of recent memory, disorientation, agitation, confusion, inability to do simple tasks
-dx: diagnoses by exclusion
*diagnoses
-disturbed thought process
-self-care deficit
-risk for injury
-wandering
*planning
-maintain functional ability as long as possible
-safe environment and minimal injuries
-meet personal care needs
-maintain dignity
*implementation
-assess for depression and suicide ideation
-work with caregiver to monitor ongoing changes
-consistency to reduce anxiety or disruptive behavior
3. Explain the general categories of drug therapy for Alzheimer’s Disease.
*drugs for…
-decreased memory and cognition: block cholinesterase to improve functional abilities
-depression: improve cognitive ability
-behavioral problems: atypical anti-psychotics with uncertain side effects
-sleep disturbances
4. List general nursing care instructions for the caregiver.
-provide a safe environment
-stop potentially dangerous behavior early
-reinforce routine and continue communication
-monitor diet
-reduce stress triggers
-know when caring for the patient is too much
Sunday, February 1, 2009
Exam #2-Ch. 17, 26-19 (Respiratory System)
Ch. 17-Fluid, Electrolytes and Acid-Base Imbalances
1. Know the normal ABG value.
*pH: 7.35-7.45
-high: alkalosis
-low: acidic
*PaCO2 (respiratory): 35-45 mm Hg
-high: acidic
-low: alkalosis
*HCO3 (metabolic): 22-26 mEq/L
-high: alkalosis
-low: acidic
*What is the overall pH?
*Is it respiratory or metabolic?
*Is there compensation?
-zero compensation
-partial compensation
-total compensation
2. Review the processes of acid-base regulation.
*buffer system
-fastest acting, primary system
-change strong acids into weaker acids or neutralize acid
*respiratory system
-excrete by-products of cellular metabolism, CO2 and water
*renal system
-reabsorb and conserve bicarbonate
-eliminate excess H ions
3. Recognize clients at risk for acid-base imbalances.
-patients with diabetes mellitus, chronic obstructive pulmonary disease, kidney disease, vomiting, diarrhea, older patients, or patients with serious illnesses
4. Use the NP to provide nursing care to a client with an acid-base imbalance.
*assessment
-subjective: past medical history, medications, diet, lifestyle, health perception, tingling, numbness, n/v/d, light-headedness
-objective: irregular breathing, low BP, irregular heartrate, confusion, lethargy
-dx: serum electrolyte values, ABGs, serum glucose, BUN, creatinine
*diagnoses
-ineffective breathing pattern
-risk for injury
-acid/base imbalance
*planning
-replacement of electrolyte and oral/intravenous fluids
*implementation
-treat underlying cause
5. Given lab values, identify the acid-base imbalance and the resulting nursing care.
*respiratory acidosis, hypoventilation
-7.3, 50, 30
-deep breath
*respiratory alkalosis, hyperventilation
-7.5, 30, 20
-deep breath
*metabolic acidosis, severe diarrhea
-7.3, 30, 20
-Lactated Ringer’s
*metabolic alkalosis, severe vomiting or excess gastric suctioning
-7.5, 50, 30
-anti-enemics, monitor suctioning
Ch. 26-Nursing Assessment of the Respiratory System
1. Review the factors that control respiration.
*chemoreceptors: responds to change of chemical composition of the fluid surrounding it
-central, peripheral
-changes respiratory rate
*mechanical receptors: stimulated by physiologic factors like irritants, muscle stretching, and alveolar wall distortion
-located in lungs, upper airways, chest walls, and diaphragm
2. Explain the pulmonary changes associated with aging. (Table 26-4)
*alterations in:
-structure: decreased elasticity and compliance
-defense mechanisms: less forceful cough, less functional cilia, and dry mucous membranes
-respiratory control: decreased response to changes in blood gases
3. Explain the different diagnostic tests. (Table 26-11)
*blood studies: assesses Hb, Hct, and ABGs
*oximetry: assesses oxygen saturation
*sputum studies: tests infecting microorganism
*skin tests: tests for allergic responses
*radiologic studies: screens lungs for lesions, areas of inadequate airflow, and evaluates change
*endoscopic examinations: uses scopes to inspect the lungs and collect specimen
*lung biopsy: obtain tissue, cells, or secretions for evaluation
*thoracentesis: locally anesthesized, fluid collected from pleural space
*pulmonary function tests: measure lung volumes and air-flow to diangose pulmonary disease, monitor disease progression, and evaluate disability /response to bronchodilators
*exercise testing: determines exercise capacity for disability evaluation
4. Use the NP to provide care to the patient pre- and post- thoracentesis/ bronchoscopy. (Table 26-11)
*thoracentesis:
-explain and obtain signed permission for procedure
-position patient upright with elbows on overbed table with feet supported
-instruct patient not to cough or talk during procedure
-observe signs of hypoxia and pneumothorax
-monitor lung sounds in all fields after procedure
-encourage deep breathing for lung expansion
-send specimen to lab
*bronchoscopy
-NPO 6-12 hours prior
-obtain signed permission
-administer ordered sedative before procedure
-continue NPO status until gag reflex returns after procedure
-monitor laryngeal gag reflex
-monitor recovery from sedative
-monitor for hemorrhage and pneumothorax
-blood tinged mucus is not abnormal
Ch. 27- Nursing Management: Upper Respiratory Problems
1. Use the NP in care of a client with influenza and OSA
**Influenza
*assessment
-subjective: abrupt onset of symptoms (cough, fever, myalgia), headache, sore throat, weakness, patient health history
-objective: dyspnea, crackles, purulent sputum
-dx: influenza in the community
*diagnoses
-risk for infection
-ineffective airway clearance
-ineffective breathing
*planning
-symptom relief
-prevention of secondary infection
*implemenation
-drug therapy: antivirals to relieve symptoms and prevent spread
*evaluation
-does the patient have difficulty in breathing?
-is the patient free of secondary infection?
**OSA
*assessment
-subjective: frequent awakenings at night, insomnia, daytime sleepiness, witnessed apneic episodes, snoring, morning headaches, personality changes, irritability, inability to concentrate, impaired memory…
-objective: hypertension, dysrhythmias
-dx: polysomnography (more than 10 episodes of oxygen desaturation of below 90%)
*diagnoses
-ineffective breathing
-disturbed sleep pattern
*planning
-patient will understand methods to treat mild-severe OSA
*implementation
-avoid sedatives and alcohol 3-4 hours before sleep
-referral to weight loss programs for OSA r/t excessive weight
-oral appliance to prevent airflow obstruction
-CPAP, BiPAP, or uvulopalatoplasty
-monitor SpO2, HR, BP...
*evaluation
-does the patient demonstrate understanding of the treatment methods?
Ch. 28-Nursing Management: Lower Respiratory Problems
1. Explain the pathophysiology of pneumonia, HAP, CAP, tuberculosis, pulmonary edema, pulmonary hypertension, cor pulmonale, lung cancer, pulmonary embolus, and atelectasis.
-pneumonia: congestion (fluid fills alveoli), red hepatization (dilation of capillaries, making the lung appear red and granular), gray hepatization (decreased blood flow and consolidation of affected part of lung), resolution (exudate lysed by macrophages and gas-exchange returns to normal)
-HAP: same as above, acquired in hospital
-CAP: same as above, acquired in community
-tuberculosis: active bacteria that multiply and cause clinically active disease
-pulmonary edema: increased hydrostatic pressure or decreased colloidal oncotic pressure pulls fluids into interstitial space
-pulmonary hypertension: deficient release of vasodilators to pulmonary epithelium causing increased pulmonary pressure
-cor pulmonale: enlargement of right ventricle secondary to diseases of the lung, thorax, or pulmonary circulation
-lung cancer: hypersecretion of mucus, desquamation of cells, cancerous cells of upper lobes
-pulmonary embolus: thrombus, fat or air embolus, or tumor tissue blocking pulmonary arteries obstructing perfusion
-atelectasis: collapsed, airless alveoli commonly caused by airway obstruction from retained exudate and secretions observed in post-operative patients
2. Identify clinical situations and patient populations at risk for developing the listed pulmonary conditions.
-pneumonia: decreased defense mechanisms-age, air pollution, ALOC, immune suppression, prolonged immobility, chronic diseases, debilitating illiness, inhalation of noxious substances, tube feeding, malnutrition, smoking, upper respiratory tract infection, intubation…
-HAP: VAP and HCAP
-CAP: smokers
-tuberculosis: immunocompromised, exposure to infected individuals
-pulmonary edema: most commom cause is left-sided HF
-pulmonary hypertension: use of Fen-Phen, more women than men
-cor pulmonale: patients with disease of lung, thorax, or pulmonary circulation
-lung cancer: smokers or exposure to second-hand smoke
-pulmonary embolus: post-surgery or childbirth-immobilization, stroke, history of DVT, and malignancy
-atelectasis: post-operative patients
3. Use the NP to care for clients with pneumonia, HAP, CAP, pulmonary edema, pulmonary hypertension, cor pulmonale, lung cancer, pulmonary embolus, and atelectasis.
**pneumonia, HAP, CAP
*assessment
-subjective: chest pain, confusion, fatigue, headache, sore throat, nausea,
-objective: sudden onset of fever, shaking chills, SOB, productive cough, rust-colored sputum, crackles, bronchial breath sounds, vomiting, diarrhea
-dx: chest x-ray, CBC, blood stain, sputum test
*diagnoses
-impaired gas-exchange
-ineffective breathing pattern
-ineffective airway clearance
*planning
-clear breath sounds
-normal breathing patterns
-no signs of hypoxia
-normal chest x-ray
-no complications related to pneumonia
*implementation
-teaching: hygiene, rest, exercise, and good health habits
-position to minimize risk of aspiration, repositioning every 2 hours
-“good lung down”
-elevate HOB for tube feedings and VAP patients
-infection control
-CDB/IS
-medication routine
**tuberculosis
*assessment
-subjective: weight loss, fatigue, malaise, night sweats, anorexia
-objective: productive cough with white, frothy sputum, chest pain
-dx: chest x-ray, TB skin test, bacteriologic studies
*diagnoses
-ineffective breathing pattern
-imbalanced nutrition: less than body requirements
-noncompliance
-activity intolerance
-ineffective health maintenance
*planning
-comply with therapeutic regimen
-no recurrence of disease
-normal pulmonary function
-prevention of disease spread
*implementation
-isolation
-appropriate drug therapy
-stage disease
-teach patient to prevent spreading disease
-follow-up care
**lung cancer
*assessment
-subjective: exposure to airborne carcinogens, smoking history, frequent respiratory infections, persistent cough, chest pain, headache
-objective: fever, jaundice, edema of neck and face, clubbing, lung sounds (stridor, wheezing), unsteady gait
-dx: chest x-ray, sputum testing, bronchoscopy, MRI, PET, lung scan…
*diagnoses
-ineffective airway clearance
-ineffective health maintenance
-ineffective breathing pattern
*planning
-effective breathing pattern
-adequate airway clearance
-adequate oxygenation of tissues
-minimize pain
*implementation
-referral to quit smoking
-teach methods to reduce pain
-therapeutic communication, therapy
**pulmonary embolus
*assessment
-subjective: anxiety
-objective: rapid and weak pulse, low BP, hypoxemia, severe dyspea, pallor, dysrhythmia, ALOC, crackles, blood streaked sputum
-dx: ventilation-perfusion lung scan, D-dimer test
*diagnoses
-inadequate tissue perfusion
-inadequate cardiac output
-decreased level of comfort
*planning
-maximize breathing
-monitor VS
-limit progression and recurrence
*implementation
-position in semi-fowlers
-therapeutic communication
-teaching regarding long term anti-coagulation
**pulmonary hypertension
-treat underlying cause
**pulmonary edema
-monitor cardiac and respiratory function
-fluid therapy
**atelectasis: CDB, IS
**cor pulmonale:
-chronic management, resulting from COPD: continuous low-flow O2 during sleep, exercise, and small, frequent meals to feel better and be more active
4. Nursing care of a post lung/chest surgery patient. (Table 28-2)
-monitory respiration
-reposition
-oxygen therapy
-monitor bubbling and tidaling in water-seal chamber
-prevent air leaks and keep drainage container below chest
-pain management
-IS
Ch. 29-Nursing Management: Obstructive Pulmonary Disease
1. Recognize the clinical profile of a patient with COPD.
-exposure to noxious particles and gases: smoker, occupational chemical and dusts, urban air pollution
-prone to infection
-AAT deficiency: hereditary risk factor
-aging: change to lung structure, thoracic cage, and respiratory muscles
2. Explain the measure needed to teach patients to prevent COPD.
-quit or do not begin smoking
-avoid exposure to occupational and environmental pollutants
-IS: shows how much function has been lost, but can be regained
3. Explain the pathophysiology of asthma, emphysema and bronchitis.
-asthma: chronic inflammation causing acute airflow limitation, hyperresponsiveness occurs with exposure to allergens or irritants
-emphysema: abnormal permanently enlarged air spaces with destructed walls and no obvious fibrosis
-bronchitis: chronic productive cough for 3 months in each of the last 2 consecutive years with not other cause
4. Explain information needed to teach patients on the correct use of MDI’s and PDI’s.
-when it is appropriate to use
-does it need to be shaken?
-duration of inspiration
-cleaning and storage of inhaler
5. Use the NP to provide care to a client with asthma, emphysema and bronchitis
**asthma
*assessment
-subjective: past medical history, medications, family history, lifestyle, sleep pattern, stress
-objective: body positioning, sweating, eczema, cyanosis, wheezing, crackles, nasal drainage, use of accessory muscles, tachycardia, low SpO2
-dx: ABGs, allergy skins tests, peak expiratory flow rate
*diagnoses
-ineffective airway clearance
-inadequate gas exchange
-inadequate tissue perfusion
*planning
-maintain >80% of personal best PEFR or FEV1
-have minimal symptoms during day and night
-maintain acceptable activity levels
-have no or decrease incidence of asthma attacks
-have knowledge to carry out management
*implementation
-educate to identify personal triggers and how to avoid or reduce risk of attack
-educate on medications which can inhibit bronchodilation or immunity
-monitor lung sounds and cardiac functions for red flags
-deep breath
**emphysema and bronchitis
*assessment
-subjective: exposure to smoke or irritants, weight loss/gain, past medical history, family history, lifestyle, PND, headache, soreness, anxiety, constipation, gas, bloating
-objective: cyanosis, poor skin turgor, shallow breathing, tachycardia, ascites, barrel chest, accessory muscle use, wheezing, crackles
-dx: ABGs, chest x-ray, pulmonary function tests
*diagnoses
-ineffective airway clearance
-inadequate tissue perfusion
-ineffective breathing pattern
-disturbed sleep pattern
*planning
-prevent disease progression
-improve activity tolerance
-symptom relief
-no COPD related complications
-improve quatity of life
-ability to implement long-term treatment
*implementation
-breathing techniques
-monitor respiratory and cardiac function
-position techniques to maximize breathing
-oxygen therapy
6. Methods of oxygen administration and related nursing care. (Table 29-22)
-nasal cannula: pad ears to avoid pressure points
-simple face mask: clean, check for pressure points on ears, and keep at 5 L/min
-partial rebreathing mask: check for occlusion
-non-rebreathing mask: snug fit with the bag adequately inflated at inspiration and expiration
-oxygen-conserving cannula: check for pressure points on ears, for long-term use
-transtracheal catheter: not appropriate for patients with excessive mucus
-face tent: maintain aerosol at body temperature
-tracheostomy collar: clean to prevent aspiration and infection
-tracheostomy T-bar: should be removed when suctioning, and emptied as necessary
-venturi mask: check for occlusion
7. Explain the mode of action of the different drug categories used in the management of these conditions and resulting nursing care. (Table 29-7)
*anti-inflammatory agents: decreases inflammatory response
-administer in AM with milk
-discontinue gradually over time
-observe for epigastric distress
-long-term corticosteroid therapy should be paired with vitamin D and calcium
*mast cell stabilizers: inhibit release of mast cells to suppress other inflammatory cells
-educate patient on correct use
*anti-cholinergics: blocks bronchoconstriction
-may cause blurred vision if contact with eyes
-cautious use for narrow-angle glaucoma or prostatic enlargement patients
*leukotriene modifiers: reverse bronchospasms of acute asthma attacks
-monitor liver enzymes
-effects metabolism of erythromycin, warfarin, and theophylline
-take 1 hour before or 2 hours after meals
*B2-adrenergic agonists: prevent bronchoconstriction and increase mucociliary function
-cautious use patients with diabetes, hypertension, angina, or cardiac disorders
-overuse may cause rebound bronchospasm
*methylxanthines: bronchodilator
-monitor cardiac function
1. Know the normal ABG value.
*pH: 7.35-7.45
-high: alkalosis
-low: acidic
*PaCO2 (respiratory): 35-45 mm Hg
-high: acidic
-low: alkalosis
*HCO3 (metabolic): 22-26 mEq/L
-high: alkalosis
-low: acidic
*What is the overall pH?
*Is it respiratory or metabolic?
*Is there compensation?
-zero compensation
-partial compensation
-total compensation
2. Review the processes of acid-base regulation.
*buffer system
-fastest acting, primary system
-change strong acids into weaker acids or neutralize acid
*respiratory system
-excrete by-products of cellular metabolism, CO2 and water
*renal system
-reabsorb and conserve bicarbonate
-eliminate excess H ions
3. Recognize clients at risk for acid-base imbalances.
-patients with diabetes mellitus, chronic obstructive pulmonary disease, kidney disease, vomiting, diarrhea, older patients, or patients with serious illnesses
4. Use the NP to provide nursing care to a client with an acid-base imbalance.
*assessment
-subjective: past medical history, medications, diet, lifestyle, health perception, tingling, numbness, n/v/d, light-headedness
-objective: irregular breathing, low BP, irregular heartrate, confusion, lethargy
-dx: serum electrolyte values, ABGs, serum glucose, BUN, creatinine
*diagnoses
-ineffective breathing pattern
-risk for injury
-acid/base imbalance
*planning
-replacement of electrolyte and oral/intravenous fluids
*implementation
-treat underlying cause
5. Given lab values, identify the acid-base imbalance and the resulting nursing care.
*respiratory acidosis, hypoventilation
-7.3, 50, 30
-deep breath
*respiratory alkalosis, hyperventilation
-7.5, 30, 20
-deep breath
*metabolic acidosis, severe diarrhea
-7.3, 30, 20
-Lactated Ringer’s
*metabolic alkalosis, severe vomiting or excess gastric suctioning
-7.5, 50, 30
-anti-enemics, monitor suctioning
Ch. 26-Nursing Assessment of the Respiratory System
1. Review the factors that control respiration.
*chemoreceptors: responds to change of chemical composition of the fluid surrounding it
-central, peripheral
-changes respiratory rate
*mechanical receptors: stimulated by physiologic factors like irritants, muscle stretching, and alveolar wall distortion
-located in lungs, upper airways, chest walls, and diaphragm
2. Explain the pulmonary changes associated with aging. (Table 26-4)
*alterations in:
-structure: decreased elasticity and compliance
-defense mechanisms: less forceful cough, less functional cilia, and dry mucous membranes
-respiratory control: decreased response to changes in blood gases
3. Explain the different diagnostic tests. (Table 26-11)
*blood studies: assesses Hb, Hct, and ABGs
*oximetry: assesses oxygen saturation
*sputum studies: tests infecting microorganism
*skin tests: tests for allergic responses
*radiologic studies: screens lungs for lesions, areas of inadequate airflow, and evaluates change
*endoscopic examinations: uses scopes to inspect the lungs and collect specimen
*lung biopsy: obtain tissue, cells, or secretions for evaluation
*thoracentesis: locally anesthesized, fluid collected from pleural space
*pulmonary function tests: measure lung volumes and air-flow to diangose pulmonary disease, monitor disease progression, and evaluate disability /response to bronchodilators
*exercise testing: determines exercise capacity for disability evaluation
4. Use the NP to provide care to the patient pre- and post- thoracentesis/ bronchoscopy. (Table 26-11)
*thoracentesis:
-explain and obtain signed permission for procedure
-position patient upright with elbows on overbed table with feet supported
-instruct patient not to cough or talk during procedure
-observe signs of hypoxia and pneumothorax
-monitor lung sounds in all fields after procedure
-encourage deep breathing for lung expansion
-send specimen to lab
*bronchoscopy
-NPO 6-12 hours prior
-obtain signed permission
-administer ordered sedative before procedure
-continue NPO status until gag reflex returns after procedure
-monitor laryngeal gag reflex
-monitor recovery from sedative
-monitor for hemorrhage and pneumothorax
-blood tinged mucus is not abnormal
Ch. 27- Nursing Management: Upper Respiratory Problems
1. Use the NP in care of a client with influenza and OSA
**Influenza
*assessment
-subjective: abrupt onset of symptoms (cough, fever, myalgia), headache, sore throat, weakness, patient health history
-objective: dyspnea, crackles, purulent sputum
-dx: influenza in the community
*diagnoses
-risk for infection
-ineffective airway clearance
-ineffective breathing
*planning
-symptom relief
-prevention of secondary infection
*implemenation
-drug therapy: antivirals to relieve symptoms and prevent spread
*evaluation
-does the patient have difficulty in breathing?
-is the patient free of secondary infection?
**OSA
*assessment
-subjective: frequent awakenings at night, insomnia, daytime sleepiness, witnessed apneic episodes, snoring, morning headaches, personality changes, irritability, inability to concentrate, impaired memory…
-objective: hypertension, dysrhythmias
-dx: polysomnography (more than 10 episodes of oxygen desaturation of below 90%)
*diagnoses
-ineffective breathing
-disturbed sleep pattern
*planning
-patient will understand methods to treat mild-severe OSA
*implementation
-avoid sedatives and alcohol 3-4 hours before sleep
-referral to weight loss programs for OSA r/t excessive weight
-oral appliance to prevent airflow obstruction
-CPAP, BiPAP, or uvulopalatoplasty
-monitor SpO2, HR, BP...
*evaluation
-does the patient demonstrate understanding of the treatment methods?
Ch. 28-Nursing Management: Lower Respiratory Problems
1. Explain the pathophysiology of pneumonia, HAP, CAP, tuberculosis, pulmonary edema, pulmonary hypertension, cor pulmonale, lung cancer, pulmonary embolus, and atelectasis.
-pneumonia: congestion (fluid fills alveoli), red hepatization (dilation of capillaries, making the lung appear red and granular), gray hepatization (decreased blood flow and consolidation of affected part of lung), resolution (exudate lysed by macrophages and gas-exchange returns to normal)
-HAP: same as above, acquired in hospital
-CAP: same as above, acquired in community
-tuberculosis: active bacteria that multiply and cause clinically active disease
-pulmonary edema: increased hydrostatic pressure or decreased colloidal oncotic pressure pulls fluids into interstitial space
-pulmonary hypertension: deficient release of vasodilators to pulmonary epithelium causing increased pulmonary pressure
-cor pulmonale: enlargement of right ventricle secondary to diseases of the lung, thorax, or pulmonary circulation
-lung cancer: hypersecretion of mucus, desquamation of cells, cancerous cells of upper lobes
-pulmonary embolus: thrombus, fat or air embolus, or tumor tissue blocking pulmonary arteries obstructing perfusion
-atelectasis: collapsed, airless alveoli commonly caused by airway obstruction from retained exudate and secretions observed in post-operative patients
2. Identify clinical situations and patient populations at risk for developing the listed pulmonary conditions.
-pneumonia: decreased defense mechanisms-age, air pollution, ALOC, immune suppression, prolonged immobility, chronic diseases, debilitating illiness, inhalation of noxious substances, tube feeding, malnutrition, smoking, upper respiratory tract infection, intubation…
-HAP: VAP and HCAP
-CAP: smokers
-tuberculosis: immunocompromised, exposure to infected individuals
-pulmonary edema: most commom cause is left-sided HF
-pulmonary hypertension: use of Fen-Phen, more women than men
-cor pulmonale: patients with disease of lung, thorax, or pulmonary circulation
-lung cancer: smokers or exposure to second-hand smoke
-pulmonary embolus: post-surgery or childbirth-immobilization, stroke, history of DVT, and malignancy
-atelectasis: post-operative patients
3. Use the NP to care for clients with pneumonia, HAP, CAP, pulmonary edema, pulmonary hypertension, cor pulmonale, lung cancer, pulmonary embolus, and atelectasis.
**pneumonia, HAP, CAP
*assessment
-subjective: chest pain, confusion, fatigue, headache, sore throat, nausea,
-objective: sudden onset of fever, shaking chills, SOB, productive cough, rust-colored sputum, crackles, bronchial breath sounds, vomiting, diarrhea
-dx: chest x-ray, CBC, blood stain, sputum test
*diagnoses
-impaired gas-exchange
-ineffective breathing pattern
-ineffective airway clearance
*planning
-clear breath sounds
-normal breathing patterns
-no signs of hypoxia
-normal chest x-ray
-no complications related to pneumonia
*implementation
-teaching: hygiene, rest, exercise, and good health habits
-position to minimize risk of aspiration, repositioning every 2 hours
-“good lung down”
-elevate HOB for tube feedings and VAP patients
-infection control
-CDB/IS
-medication routine
**tuberculosis
*assessment
-subjective: weight loss, fatigue, malaise, night sweats, anorexia
-objective: productive cough with white, frothy sputum, chest pain
-dx: chest x-ray, TB skin test, bacteriologic studies
*diagnoses
-ineffective breathing pattern
-imbalanced nutrition: less than body requirements
-noncompliance
-activity intolerance
-ineffective health maintenance
*planning
-comply with therapeutic regimen
-no recurrence of disease
-normal pulmonary function
-prevention of disease spread
*implementation
-isolation
-appropriate drug therapy
-stage disease
-teach patient to prevent spreading disease
-follow-up care
**lung cancer
*assessment
-subjective: exposure to airborne carcinogens, smoking history, frequent respiratory infections, persistent cough, chest pain, headache
-objective: fever, jaundice, edema of neck and face, clubbing, lung sounds (stridor, wheezing), unsteady gait
-dx: chest x-ray, sputum testing, bronchoscopy, MRI, PET, lung scan…
*diagnoses
-ineffective airway clearance
-ineffective health maintenance
-ineffective breathing pattern
*planning
-effective breathing pattern
-adequate airway clearance
-adequate oxygenation of tissues
-minimize pain
*implementation
-referral to quit smoking
-teach methods to reduce pain
-therapeutic communication, therapy
**pulmonary embolus
*assessment
-subjective: anxiety
-objective: rapid and weak pulse, low BP, hypoxemia, severe dyspea, pallor, dysrhythmia, ALOC, crackles, blood streaked sputum
-dx: ventilation-perfusion lung scan, D-dimer test
*diagnoses
-inadequate tissue perfusion
-inadequate cardiac output
-decreased level of comfort
*planning
-maximize breathing
-monitor VS
-limit progression and recurrence
*implementation
-position in semi-fowlers
-therapeutic communication
-teaching regarding long term anti-coagulation
**pulmonary hypertension
-treat underlying cause
**pulmonary edema
-monitor cardiac and respiratory function
-fluid therapy
**atelectasis: CDB, IS
**cor pulmonale:
-chronic management, resulting from COPD: continuous low-flow O2 during sleep, exercise, and small, frequent meals to feel better and be more active
4. Nursing care of a post lung/chest surgery patient. (Table 28-2)
-monitory respiration
-reposition
-oxygen therapy
-monitor bubbling and tidaling in water-seal chamber
-prevent air leaks and keep drainage container below chest
-pain management
-IS
Ch. 29-Nursing Management: Obstructive Pulmonary Disease
1. Recognize the clinical profile of a patient with COPD.
-exposure to noxious particles and gases: smoker, occupational chemical and dusts, urban air pollution
-prone to infection
-AAT deficiency: hereditary risk factor
-aging: change to lung structure, thoracic cage, and respiratory muscles
2. Explain the measure needed to teach patients to prevent COPD.
-quit or do not begin smoking
-avoid exposure to occupational and environmental pollutants
-IS: shows how much function has been lost, but can be regained
3. Explain the pathophysiology of asthma, emphysema and bronchitis.
-asthma: chronic inflammation causing acute airflow limitation, hyperresponsiveness occurs with exposure to allergens or irritants
-emphysema: abnormal permanently enlarged air spaces with destructed walls and no obvious fibrosis
-bronchitis: chronic productive cough for 3 months in each of the last 2 consecutive years with not other cause
4. Explain information needed to teach patients on the correct use of MDI’s and PDI’s.
-when it is appropriate to use
-does it need to be shaken?
-duration of inspiration
-cleaning and storage of inhaler
5. Use the NP to provide care to a client with asthma, emphysema and bronchitis
**asthma
*assessment
-subjective: past medical history, medications, family history, lifestyle, sleep pattern, stress
-objective: body positioning, sweating, eczema, cyanosis, wheezing, crackles, nasal drainage, use of accessory muscles, tachycardia, low SpO2
-dx: ABGs, allergy skins tests, peak expiratory flow rate
*diagnoses
-ineffective airway clearance
-inadequate gas exchange
-inadequate tissue perfusion
*planning
-maintain >80% of personal best PEFR or FEV1
-have minimal symptoms during day and night
-maintain acceptable activity levels
-have no or decrease incidence of asthma attacks
-have knowledge to carry out management
*implementation
-educate to identify personal triggers and how to avoid or reduce risk of attack
-educate on medications which can inhibit bronchodilation or immunity
-monitor lung sounds and cardiac functions for red flags
-deep breath
**emphysema and bronchitis
*assessment
-subjective: exposure to smoke or irritants, weight loss/gain, past medical history, family history, lifestyle, PND, headache, soreness, anxiety, constipation, gas, bloating
-objective: cyanosis, poor skin turgor, shallow breathing, tachycardia, ascites, barrel chest, accessory muscle use, wheezing, crackles
-dx: ABGs, chest x-ray, pulmonary function tests
*diagnoses
-ineffective airway clearance
-inadequate tissue perfusion
-ineffective breathing pattern
-disturbed sleep pattern
*planning
-prevent disease progression
-improve activity tolerance
-symptom relief
-no COPD related complications
-improve quatity of life
-ability to implement long-term treatment
*implementation
-breathing techniques
-monitor respiratory and cardiac function
-position techniques to maximize breathing
-oxygen therapy
6. Methods of oxygen administration and related nursing care. (Table 29-22)
-nasal cannula: pad ears to avoid pressure points
-simple face mask: clean, check for pressure points on ears, and keep at 5 L/min
-partial rebreathing mask: check for occlusion
-non-rebreathing mask: snug fit with the bag adequately inflated at inspiration and expiration
-oxygen-conserving cannula: check for pressure points on ears, for long-term use
-transtracheal catheter: not appropriate for patients with excessive mucus
-face tent: maintain aerosol at body temperature
-tracheostomy collar: clean to prevent aspiration and infection
-tracheostomy T-bar: should be removed when suctioning, and emptied as necessary
-venturi mask: check for occlusion
7. Explain the mode of action of the different drug categories used in the management of these conditions and resulting nursing care. (Table 29-7)
*anti-inflammatory agents: decreases inflammatory response
-administer in AM with milk
-discontinue gradually over time
-observe for epigastric distress
-long-term corticosteroid therapy should be paired with vitamin D and calcium
*mast cell stabilizers: inhibit release of mast cells to suppress other inflammatory cells
-educate patient on correct use
*anti-cholinergics: blocks bronchoconstriction
-may cause blurred vision if contact with eyes
-cautious use for narrow-angle glaucoma or prostatic enlargement patients
*leukotriene modifiers: reverse bronchospasms of acute asthma attacks
-monitor liver enzymes
-effects metabolism of erythromycin, warfarin, and theophylline
-take 1 hour before or 2 hours after meals
*B2-adrenergic agonists: prevent bronchoconstriction and increase mucociliary function
-cautious use patients with diabetes, hypertension, angina, or cardiac disorders
-overuse may cause rebound bronchospasm
*methylxanthines: bronchodilator
-monitor cardiac function
Sunday, January 25, 2009
Exam #1, Ch. 13, 14, and 17 (Immune System)
Chapter 13 - Inflammation and Wound Healing
1. Explain the inflammatory response
**cellular injury
**vascular response: release of histamines, kinins, and prostaglandins increases blood flow to tissue causing edema and swelling, WBCs adhere to thickened blood
**cellular response: movement of WBCs for phagocytosis
**healing: by primary, secondary, and tertiary healing
2. Explain the cellular response, types of WBC’s and their normal values
**cellular response
-chemotaxis (migration of WBCs) to injury site, margination (movement of neutrophils and monocytes to capillary wall), and diapedesis (movement of neutrophils and monocytes throught capillary wall) to injury site for phagocytosis
-migration of lymphocytes, eosinophils, and basophils for more specialized role in response
-phagocytosis results in cellular exudate at injury site
**types of WBCs and normal values
-eosinophils: 3% of WBC count, associated with parasitic infections
-basophils: normally lacking in circulation, associated with allergic reactions from mild to severe
-lymphocytes (T and B cells): 20-40% of WBC count, elevated count indicates “shift to right”, viral infection
-granulocytes (neutrophils): 55-70% of WBC count, elevated count plus elevated bands indicate “shift to left”, bacterial infection
-agranulocytes (monocytes): 2-8% of WBC count, macrophage
3. List and explain the chemical mediators and their effects on homeostasis (Table 13-1)
*complement system: increases inflammatory response by enhancing phagocytosis, vascular permeability, chemotaxis, and cellular lysis
-kills bacterial cells
*prostaglandins and leukotrienes: causes vasodilation and stimulates chemotaxis, respectively
-allows increased local blood flow for immune response
*histamine: causes vasodilation and increased vascular permeability
-allows increased local blood flow for immune response
*serotonin: causes vasodilation and increased vascular permeability
-allows increased local blood flow for immune response
*kinins: contraction of smooth muscle and dilation of blood vessels to stimulate pain
-sends body message of injury
*cytokines: increase pulse, respiration, and metabolism to increase body temperature
-increases immune response
4. Use the NP to explain the nursing management of a patient with an inflammatory response.
**assessment
-subjective: pain, loss of function, diet, past medical history, age, lifestyle, medications, surgery, altered elimination pattern
-objective: swelling, redness, drainage, color, heat, fever, high BP and P, malaise, nausea, and anorexia
-dx: CBC, WBC, wound culture
**diagnoses:
-acute pain r/t inflammation process
-hyperthermia r/t inflammation process
-risk of FVD r/t increased metabolic rate
-risk for imbalanced nutrition: less than body requirements r/t decreased intake of essential nutrients
**planning:
-drug therapy: fever, inflammation, nutrients
-nutritional therapy: promote healing and nutrients/fluids to meet energy demands
**implementation:
-RICE: rest, ice/heat, compression/immobilization, elevation
-anti-pyretics for fevers greater than 104 degrees F
-anti-enemics for nausea
-vitamins to promote healing process
-continue observations of swelling and wound, if present
-adequate nutritional/fluid intake and output
**evaluation
-is the patient running a harmful, high-grade fever?
-is the patient in pain?
-is the patient nutritional needs getting met?
Chapter 14 - Genetics, Altered Immune Responses and Transplantation
1. Differentiate the different types of Immunity
*natural: immunity exists prior to contact with antigen
*passive: receives antigen, rather than synthesizing it
-artificial: injections from immune animal or human
-natural: mother to child
*active: invasion of foreign substances resulting in development of antibodies and lymphocytes
-artificial: immunization with antigen
-natural: getting over a flu
2. Differentiate between cell-mediated immunity from humoral immunity (Table 14-7)
*cell-mediated: involves T lymphocytes and macrophages which produce sensitize T cells and cytokines against fungus, intracellular viruses, and chronic infectious agents
*humoral: involves B lymphocytes which produce antigens against bacteria, extracellular viruses, and respiratory and GI pathogens
3. Explain the effects of aging on the immune system (pg. 224)
*decline in cell-mediated immunity specifically from decreased size and activity of thymus gland
4. Explain and differentiate between the different types of hypersensitivity reactions. Give examples of conditions under each type.
*Type 1 Reaction: allergens cause allergic reactions immediately causing smooth muscle contraction, increased vascular permeability, vasodilation, hypotension, increased mucus secretion and itching
-asthma
*Type 2 Reaction: destruction of erythrocytes, platelets, and leukocytes resulting in rapid tissue damage
-transfusion reaction
*Type 3 Reaction: local or systemic reactions on self-cells resulting in tissue damage
-rheumatoid arthritis
*Type 4 Reaction: a delayed allergic reaction which could cause itching, redness, and scaly skin
-contact dermatitis to poison ivy
5. Using the NP, explain the care of a patient with an allergic disorder.
*assessment
-subjective: past health history, medications, family history, diet, lifestyle, cramps, diarrhea, fatigue, cough, itching, burning, stinging, tightness of chest
-objective: rashes, wheals and flares, dryness, scratches, watery eyes, lung sounds, sputum, swelling, sneezing…
-dx: skin tests
*diagnoses
-ineffective airway clearance
-fatigue
-risk for infection
-ineffective tissure perfusion
-readiness to learn
-knowledge deficit
*planning
-reduce exposure to allergen
-treat symptoms
-immunotherapy, if necessary
*implementation:
**drug therapy/ immunotherapy:
-anti-histamine: swelling and itching
-sympathomimetics/decongestants: epinepherine for anaphylactic reactions and minor decongestants for allergic rhinitis
-corticosteroids: relieves allergic rhinitis
-anti-pruritic drugs: itch relief
-mast-cell stabilizers: asthma management
-leukotriene receptor antagonists: blocks leukotriene, a major inflammatory mediator
**patient education: administer epi-pen, self tourniquet, avoid allergen sources, sleep in air-conditioned room, hypoallergenic products, medic-alert bracelet
*evaluation:
-does the patient understand the information presented?
6. List and explain the cardinal principles in the therapeutic management of anaphlaxis. (pg. 230)
1. recognizing signs and symptoms of a reaction
2. maintaining a patent airway
3. using a tourniquet to prevent the spread of the allergen
4. drug administration
5. treatment for shock:
-patent airway
-remove substance, ie: bee sting
-Epinepherine 1:1000: 0.2-0.5 ml SQ, repeating 10-15 min
-Epinepherine 1:10,000: 0.5 ml, 5-10 min
-O2 per NRB on high flow
-recumbent elevate leg
-Benadryl IM/IV
-Histamine H2 blocker
-maintain BP
-corticosteroids
7. Describe the different mediators of the allergic response and resulting clinical outcomes. (Table 14-10)
*histamine: increases vascular permeability, constricts smooth muscle, and stimulates irritant receptors
-edema of airway, constriction of bronchial, swelling, itching, n/v/d, shock
*leukotrienes: contricts bronchial smooth muscle, increases vascular permeability
-bronichial constriction, enhanced histamine effect on smooth muscle
*prostaglandins: stimulates vastodilation and constricts smooth muscle
-wheal and flare reaction, hypotension, and bronchospasm
*platelet-activating factor: stimulates vasodilation and aggregates platelets
-increases pulmonary artery pressure and causes systemic hypotension
*kinins: stimulates slow, sustained smooth muscle contractions, increases vascular permeability, stimulates secretion of mucus, and pain receptors
-angioedema with painful swelling, bronchial constriction
*serotonin: increases vascular permeabiliyy and stimulates smooth muscle contraction
-mucosal edem and bronchial constriction
*anaphylatoxins: stimulates histamine release
8. Briefly explain autoimmunity and the different treatment methods and related nursing care.
**immune response against self
*corticosteroids: suppress immune response
*aphresis: term meaning “separate”, separation of a plasma component thought to be the cause of the disease
-watch for complications of hypotension and citrate (anticoagulant) toxicity
9. Differentiate primary from secondary immunodeficiency disorders and related nursing care.
*immunodeficiency involves deficiency of one or more: phagocytosis, humoral response, cell-mediated response, complement system, or combined humoral and cell-mediated response
-primary: caused by irregular or absent immune cells
-secondary: caused by immunosuppression by illness or treatment, primarily drug-induced
**drug therapy and patient education: avoid crowds, report symptoms of infection, avoid animals and plants, avoid sick people…
Chapter 17 – Fluid, Electrolytes, and Acid-Base Imbalances
1. Review fluid movement in capillaries. (pg. 318)
*capillary hydrostatic pressure: moves water out of capillaries
*intersitial oncotic pressure: moves water out of capillaries
*interstitial hydrostatic pressure: moves water into capillaries
*plasma oncotic pressure: moves water into capillaries
*capillary hydrostatic pressure vs. plasma oncotic pressure
-capillary hydrostatic pressure greater at arterial end-fluid moves out of capillary
plasma oncotic pressure greater at venous end-fluid draws back into capillary
**fluids get pulled by proteins, oncotic pressure is due to proteins
2. Explain the different types of crystalloids and their uses.
*hypotonic
-D5W: replaces water, does not expand ECF
*isotonic
-NaCl (.9% NS): for ECF deficits
-Lactated Ringers (LR): for ECF deficits resulting from bleedings and dehydration from loss of bile
*hypertonic
-Lactated Ringers with D5W: for ECF deficits
-D5.9NS: for ECF deficits with metabolic acidosis
-D5.45NS: maintainence fluid
-D5.2NS: maintainence fluid
*colloids
-albumin: increases oncotic pressure
-blood: increases oxygen carrying capacity
3. Give examples of patient conditions or situations with abnormal fluid dynamics and the pathophysiology.
-hyperglycemia
-hypernatremia
4. Use the NP to provide nursing care of a client with sodium imbalance and water imbalances.
**sodium imbalance
*assessment
-subjective: past medical history, medications, diet, elimination pattern, numbness, tingling, twitching, weakness of muscles
-objective: cold, clammy skin; flushed, dry skin; rapid, weak, thready pulse; hypotension; decreased LOC; restlessness; indifference; confusion and irritability
-dx: serum electrolytes and arterial/venous blood gases
*diagnoses
-risk for injury secondary to abnormal CNS function
*planning
-correct underlying cause and fluid/sodium imbalance
*implementation
-monitor neurological changes, ie: LOC, pupillary response, voluntary movement of extremities…
-monitor cardiovascular changes, ie: JVD, BP, pulse force
*evaluation
-is the underlying cause corrected?
**water imbalance
*assessment
-subjective: past medical history, medications, diet, elimination pattern, numbness, tingling, twitching, weakness of muscles
-objective: poor skin turgor; pitting edema; bounding pulse; rapid, weak, thready pulse; hypo/hypertension; SOB; moist crackles; indifference; restlessness; confusion and irritability; ALOC
-dx: serum electrolytes and arterial/venous blood gases
*diagnoses
-FVE/FVD
-impaired gas exchange
-decreased cardiac output
-risk for impaired skin integrity
-disturbed body image
*planning
-correct underlying cause of deficit/excess
-replace/remove fluids
*implementation
-input and output
-monitor cardiovascular changes, ie: JVD, BP, pulse force
-monitor respiratory changes, ie: SOB, cough, crackles, increased RR
-monitor neurological changes, ie: LOC, pupillary response, voluntary movement of extremities…
-daily weights
-skin care
-monitor IV fluids
*evaluation
-is underlying problem of the imbalance corrected?
1. Explain the inflammatory response
**cellular injury
**vascular response: release of histamines, kinins, and prostaglandins increases blood flow to tissue causing edema and swelling, WBCs adhere to thickened blood
**cellular response: movement of WBCs for phagocytosis
**healing: by primary, secondary, and tertiary healing
2. Explain the cellular response, types of WBC’s and their normal values
**cellular response
-chemotaxis (migration of WBCs) to injury site, margination (movement of neutrophils and monocytes to capillary wall), and diapedesis (movement of neutrophils and monocytes throught capillary wall) to injury site for phagocytosis
-migration of lymphocytes, eosinophils, and basophils for more specialized role in response
-phagocytosis results in cellular exudate at injury site
**types of WBCs and normal values
-eosinophils: 3% of WBC count, associated with parasitic infections
-basophils: normally lacking in circulation, associated with allergic reactions from mild to severe
-lymphocytes (T and B cells): 20-40% of WBC count, elevated count indicates “shift to right”, viral infection
-granulocytes (neutrophils): 55-70% of WBC count, elevated count plus elevated bands indicate “shift to left”, bacterial infection
-agranulocytes (monocytes): 2-8% of WBC count, macrophage
3. List and explain the chemical mediators and their effects on homeostasis (Table 13-1)
*complement system: increases inflammatory response by enhancing phagocytosis, vascular permeability, chemotaxis, and cellular lysis
-kills bacterial cells
*prostaglandins and leukotrienes: causes vasodilation and stimulates chemotaxis, respectively
-allows increased local blood flow for immune response
*histamine: causes vasodilation and increased vascular permeability
-allows increased local blood flow for immune response
*serotonin: causes vasodilation and increased vascular permeability
-allows increased local blood flow for immune response
*kinins: contraction of smooth muscle and dilation of blood vessels to stimulate pain
-sends body message of injury
*cytokines: increase pulse, respiration, and metabolism to increase body temperature
-increases immune response
4. Use the NP to explain the nursing management of a patient with an inflammatory response.
**assessment
-subjective: pain, loss of function, diet, past medical history, age, lifestyle, medications, surgery, altered elimination pattern
-objective: swelling, redness, drainage, color, heat, fever, high BP and P, malaise, nausea, and anorexia
-dx: CBC, WBC, wound culture
**diagnoses:
-acute pain r/t inflammation process
-hyperthermia r/t inflammation process
-risk of FVD r/t increased metabolic rate
-risk for imbalanced nutrition: less than body requirements r/t decreased intake of essential nutrients
**planning:
-drug therapy: fever, inflammation, nutrients
-nutritional therapy: promote healing and nutrients/fluids to meet energy demands
**implementation:
-RICE: rest, ice/heat, compression/immobilization, elevation
-anti-pyretics for fevers greater than 104 degrees F
-anti-enemics for nausea
-vitamins to promote healing process
-continue observations of swelling and wound, if present
-adequate nutritional/fluid intake and output
**evaluation
-is the patient running a harmful, high-grade fever?
-is the patient in pain?
-is the patient nutritional needs getting met?
Chapter 14 - Genetics, Altered Immune Responses and Transplantation
1. Differentiate the different types of Immunity
*natural: immunity exists prior to contact with antigen
*passive: receives antigen, rather than synthesizing it
-artificial: injections from immune animal or human
-natural: mother to child
*active: invasion of foreign substances resulting in development of antibodies and lymphocytes
-artificial: immunization with antigen
-natural: getting over a flu
2. Differentiate between cell-mediated immunity from humoral immunity (Table 14-7)
*cell-mediated: involves T lymphocytes and macrophages which produce sensitize T cells and cytokines against fungus, intracellular viruses, and chronic infectious agents
*humoral: involves B lymphocytes which produce antigens against bacteria, extracellular viruses, and respiratory and GI pathogens
3. Explain the effects of aging on the immune system (pg. 224)
*decline in cell-mediated immunity specifically from decreased size and activity of thymus gland
4. Explain and differentiate between the different types of hypersensitivity reactions. Give examples of conditions under each type.
*Type 1 Reaction: allergens cause allergic reactions immediately causing smooth muscle contraction, increased vascular permeability, vasodilation, hypotension, increased mucus secretion and itching
-asthma
*Type 2 Reaction: destruction of erythrocytes, platelets, and leukocytes resulting in rapid tissue damage
-transfusion reaction
*Type 3 Reaction: local or systemic reactions on self-cells resulting in tissue damage
-rheumatoid arthritis
*Type 4 Reaction: a delayed allergic reaction which could cause itching, redness, and scaly skin
-contact dermatitis to poison ivy
5. Using the NP, explain the care of a patient with an allergic disorder.
*assessment
-subjective: past health history, medications, family history, diet, lifestyle, cramps, diarrhea, fatigue, cough, itching, burning, stinging, tightness of chest
-objective: rashes, wheals and flares, dryness, scratches, watery eyes, lung sounds, sputum, swelling, sneezing…
-dx: skin tests
*diagnoses
-ineffective airway clearance
-fatigue
-risk for infection
-ineffective tissure perfusion
-readiness to learn
-knowledge deficit
*planning
-reduce exposure to allergen
-treat symptoms
-immunotherapy, if necessary
*implementation:
**drug therapy/ immunotherapy:
-anti-histamine: swelling and itching
-sympathomimetics/decongestants: epinepherine for anaphylactic reactions and minor decongestants for allergic rhinitis
-corticosteroids: relieves allergic rhinitis
-anti-pruritic drugs: itch relief
-mast-cell stabilizers: asthma management
-leukotriene receptor antagonists: blocks leukotriene, a major inflammatory mediator
**patient education: administer epi-pen, self tourniquet, avoid allergen sources, sleep in air-conditioned room, hypoallergenic products, medic-alert bracelet
*evaluation:
-does the patient understand the information presented?
6. List and explain the cardinal principles in the therapeutic management of anaphlaxis. (pg. 230)
1. recognizing signs and symptoms of a reaction
2. maintaining a patent airway
3. using a tourniquet to prevent the spread of the allergen
4. drug administration
5. treatment for shock:
-patent airway
-remove substance, ie: bee sting
-Epinepherine 1:1000: 0.2-0.5 ml SQ, repeating 10-15 min
-Epinepherine 1:10,000: 0.5 ml, 5-10 min
-O2 per NRB on high flow
-recumbent elevate leg
-Benadryl IM/IV
-Histamine H2 blocker
-maintain BP
-corticosteroids
7. Describe the different mediators of the allergic response and resulting clinical outcomes. (Table 14-10)
*histamine: increases vascular permeability, constricts smooth muscle, and stimulates irritant receptors
-edema of airway, constriction of bronchial, swelling, itching, n/v/d, shock
*leukotrienes: contricts bronchial smooth muscle, increases vascular permeability
-bronichial constriction, enhanced histamine effect on smooth muscle
*prostaglandins: stimulates vastodilation and constricts smooth muscle
-wheal and flare reaction, hypotension, and bronchospasm
*platelet-activating factor: stimulates vasodilation and aggregates platelets
-increases pulmonary artery pressure and causes systemic hypotension
*kinins: stimulates slow, sustained smooth muscle contractions, increases vascular permeability, stimulates secretion of mucus, and pain receptors
-angioedema with painful swelling, bronchial constriction
*serotonin: increases vascular permeabiliyy and stimulates smooth muscle contraction
-mucosal edem and bronchial constriction
*anaphylatoxins: stimulates histamine release
8. Briefly explain autoimmunity and the different treatment methods and related nursing care.
**immune response against self
*corticosteroids: suppress immune response
*aphresis: term meaning “separate”, separation of a plasma component thought to be the cause of the disease
-watch for complications of hypotension and citrate (anticoagulant) toxicity
9. Differentiate primary from secondary immunodeficiency disorders and related nursing care.
*immunodeficiency involves deficiency of one or more: phagocytosis, humoral response, cell-mediated response, complement system, or combined humoral and cell-mediated response
-primary: caused by irregular or absent immune cells
-secondary: caused by immunosuppression by illness or treatment, primarily drug-induced
**drug therapy and patient education: avoid crowds, report symptoms of infection, avoid animals and plants, avoid sick people…
Chapter 17 – Fluid, Electrolytes, and Acid-Base Imbalances
1. Review fluid movement in capillaries. (pg. 318)
*capillary hydrostatic pressure: moves water out of capillaries
*intersitial oncotic pressure: moves water out of capillaries
*interstitial hydrostatic pressure: moves water into capillaries
*plasma oncotic pressure: moves water into capillaries
*capillary hydrostatic pressure vs. plasma oncotic pressure
-capillary hydrostatic pressure greater at arterial end-fluid moves out of capillary
plasma oncotic pressure greater at venous end-fluid draws back into capillary
**fluids get pulled by proteins, oncotic pressure is due to proteins
2. Explain the different types of crystalloids and their uses.
*hypotonic
-D5W: replaces water, does not expand ECF
*isotonic
-NaCl (.9% NS): for ECF deficits
-Lactated Ringers (LR): for ECF deficits resulting from bleedings and dehydration from loss of bile
*hypertonic
-Lactated Ringers with D5W: for ECF deficits
-D5.9NS: for ECF deficits with metabolic acidosis
-D5.45NS: maintainence fluid
-D5.2NS: maintainence fluid
*colloids
-albumin: increases oncotic pressure
-blood: increases oxygen carrying capacity
3. Give examples of patient conditions or situations with abnormal fluid dynamics and the pathophysiology.
-hyperglycemia
-hypernatremia
4. Use the NP to provide nursing care of a client with sodium imbalance and water imbalances.
**sodium imbalance
*assessment
-subjective: past medical history, medications, diet, elimination pattern, numbness, tingling, twitching, weakness of muscles
-objective: cold, clammy skin; flushed, dry skin; rapid, weak, thready pulse; hypotension; decreased LOC; restlessness; indifference; confusion and irritability
-dx: serum electrolytes and arterial/venous blood gases
*diagnoses
-risk for injury secondary to abnormal CNS function
*planning
-correct underlying cause and fluid/sodium imbalance
*implementation
-monitor neurological changes, ie: LOC, pupillary response, voluntary movement of extremities…
-monitor cardiovascular changes, ie: JVD, BP, pulse force
*evaluation
-is the underlying cause corrected?
**water imbalance
*assessment
-subjective: past medical history, medications, diet, elimination pattern, numbness, tingling, twitching, weakness of muscles
-objective: poor skin turgor; pitting edema; bounding pulse; rapid, weak, thready pulse; hypo/hypertension; SOB; moist crackles; indifference; restlessness; confusion and irritability; ALOC
-dx: serum electrolytes and arterial/venous blood gases
*diagnoses
-FVE/FVD
-impaired gas exchange
-decreased cardiac output
-risk for impaired skin integrity
-disturbed body image
*planning
-correct underlying cause of deficit/excess
-replace/remove fluids
*implementation
-input and output
-monitor cardiovascular changes, ie: JVD, BP, pulse force
-monitor respiratory changes, ie: SOB, cough, crackles, increased RR
-monitor neurological changes, ie: LOC, pupillary response, voluntary movement of extremities…
-daily weights
-skin care
-monitor IV fluids
*evaluation
-is underlying problem of the imbalance corrected?
Tuesday, January 20, 2009
Exam #1, Ch. 15 HIV
Chapter 15 – Infection and HIV Infection (Lecture and Ch. 15)
1. Explain the pathophysiology of HIV/AIDS. (Lewis Study Guide)
*virus binds to CD4 and chemokine receptors and enters cell
*virus splices itself into DNA of cell and reverse transcriptase assists to make viral DNA
*all replicated cells from that point on are infected
**greatly reduces the immunity
2. Use the NP to explain the nursing care of a patient with HIV/AIDS.
**assessment:
-subjective: lifestyle (high risk behavior), past medical history (STDs, family history, blood transfusions, clotting factors), flu-like symptoms (fatigue, nightsweats, fever), weight loss
-objective: thrush, oral hairy leukoplakia, localized infections, wasting syndrome, dementia, opportunistic diseases (AIDS diagnoses if one or more of the following criteria are met for a person with HIV: CD4 count under 200 cell per microliter, development of one opportunistic infection or cancer, wasting syndrome, or AIDS dementia)
-dx: EIA, WB, IFA, rapid tests, CD4 tests
**diagnoses:
-prevention stage: prevent or detect early HIV infection
-ongoing infection stage: promote health and disability and manage problems caused by infection
-dying stage: maximize quality of life and resolve end-of-life issues
**planning:
-keep viral load low
-maintain immune function: prevent opportunistic disease and new infections
-improve quality of life
-reduce disability: coping
**interventions:
-adhere to drug regimen
-promote healthy lifestyle: prevent transmission, have supportive relationships, maintain productive activity, explore spirituality
-cope with disease, symptoms, and treatments
**implementation:
-holistic and individualized approach
-health prevention promotion: safe lifestyle practices, appropriate medication for pregnant women
-therapeutic communication: coping with stress and social stigma
-antiviral therapy: are they ready?
>schedule fitting of lifestyle?
>lifestyle changes to promote healthy immunity
>side effects: depression, N/V/D, fatigue, pain, peripheral neuropathy
**evaluation:
-how is the patient adhering to the medication?
-does the patient understand the importance of lifestyle changes?
-is the patient abstain from high risk behaviors?
-is the patient coping?
3. Identify complications of HIV/AIDS and resulting nursing care.
*treat each patient in an individual and holistic approach
*opportunistic diseases: prevent infections and treat each disease and its side effects respectively
*coping: counseling and therapeutic communication
*transmission: patient education on high risk behavior and correlation with transmission to others
4. Explain diagnostic studies, criteria and collaborative care for patients with HIV/AIDS.
*Rapid tests: tests for antibodies yielding quick results, but need to be confirmed by WB and IFA if positive test
*EIA, WB, IFA: test for antigens
-risk assessment before the test and patient education after the test should be initiated
*collaborative care:
-get baseline and monitor CD4 and viral load of patient over a period of time
-prevent and detect opportunistic infections and complications of drug therapy
-maintain ongoing health assessement
-patient education regarding disease process and prevention
5. Explain the different opportunistic diseases associated with AIDS and general nursing management.
*pneumocystis jiroveci infection: pneumonia with dry, nonproductive cough
*herpes simplex 1 infection: cold sores of mouth and lips
-patient teaching: avoid kissing and oral sex
*kaposi sarcoma: hyperpigmented lesions of skin, lungs, and GI tract
*cytomegalovirus infection: retinitis, esophagitis, gastritis, colitis, stomatitis
-hydration for diarrhea, assess airway, daily weights
*varicella-zoster virus infection: shingles with maculopapular, pruritic rash
-medication for itching and redness
*candida albicans: yeast infection of mouth, esophogus, GI tract
6. Explain the indications for the initiation of antiretroviral therapy of the HIV patient.
*should be started when immune suppression is greatest to avoid burnout and nonadherence
*must be ready to initiate therapy to ensure better adherence to the regimen
*patient should understand the importance of taking medication on schedule and the side effects of the medication like pain, fatigue, N/V/D, depression and peripheral neuropathy
7. Explain the different drug categories of antiretroviral agents used in HIV infection. (Table 15-14)
*NNRTIs and NRTIs: inhibition of HIV to make a DNA copy in early replication
*NtRTIs: inhibit action of reverse transcriptase
*PIs: stops budding activity to occur on cell membrane
*Fusion or entry inhibitors: stops HIV from binding to cell receptors
1. Explain the pathophysiology of HIV/AIDS. (Lewis Study Guide)
*virus binds to CD4 and chemokine receptors and enters cell
*virus splices itself into DNA of cell and reverse transcriptase assists to make viral DNA
*all replicated cells from that point on are infected
**greatly reduces the immunity
2. Use the NP to explain the nursing care of a patient with HIV/AIDS.
**assessment:
-subjective: lifestyle (high risk behavior), past medical history (STDs, family history, blood transfusions, clotting factors), flu-like symptoms (fatigue, nightsweats, fever), weight loss
-objective: thrush, oral hairy leukoplakia, localized infections, wasting syndrome, dementia, opportunistic diseases (AIDS diagnoses if one or more of the following criteria are met for a person with HIV: CD4 count under 200 cell per microliter, development of one opportunistic infection or cancer, wasting syndrome, or AIDS dementia)
-dx: EIA, WB, IFA, rapid tests, CD4 tests
**diagnoses:
-prevention stage: prevent or detect early HIV infection
-ongoing infection stage: promote health and disability and manage problems caused by infection
-dying stage: maximize quality of life and resolve end-of-life issues
**planning:
-keep viral load low
-maintain immune function: prevent opportunistic disease and new infections
-improve quality of life
-reduce disability: coping
**interventions:
-adhere to drug regimen
-promote healthy lifestyle: prevent transmission, have supportive relationships, maintain productive activity, explore spirituality
-cope with disease, symptoms, and treatments
**implementation:
-holistic and individualized approach
-health prevention promotion: safe lifestyle practices, appropriate medication for pregnant women
-therapeutic communication: coping with stress and social stigma
-antiviral therapy: are they ready?
>schedule fitting of lifestyle?
>lifestyle changes to promote healthy immunity
>side effects: depression, N/V/D, fatigue, pain, peripheral neuropathy
**evaluation:
-how is the patient adhering to the medication?
-does the patient understand the importance of lifestyle changes?
-is the patient abstain from high risk behaviors?
-is the patient coping?
3. Identify complications of HIV/AIDS and resulting nursing care.
*treat each patient in an individual and holistic approach
*opportunistic diseases: prevent infections and treat each disease and its side effects respectively
*coping: counseling and therapeutic communication
*transmission: patient education on high risk behavior and correlation with transmission to others
4. Explain diagnostic studies, criteria and collaborative care for patients with HIV/AIDS.
*Rapid tests: tests for antibodies yielding quick results, but need to be confirmed by WB and IFA if positive test
*EIA, WB, IFA: test for antigens
-risk assessment before the test and patient education after the test should be initiated
*collaborative care:
-get baseline and monitor CD4 and viral load of patient over a period of time
-prevent and detect opportunistic infections and complications of drug therapy
-maintain ongoing health assessement
-patient education regarding disease process and prevention
5. Explain the different opportunistic diseases associated with AIDS and general nursing management.
*pneumocystis jiroveci infection: pneumonia with dry, nonproductive cough
*herpes simplex 1 infection: cold sores of mouth and lips
-patient teaching: avoid kissing and oral sex
*kaposi sarcoma: hyperpigmented lesions of skin, lungs, and GI tract
*cytomegalovirus infection: retinitis, esophagitis, gastritis, colitis, stomatitis
-hydration for diarrhea, assess airway, daily weights
*varicella-zoster virus infection: shingles with maculopapular, pruritic rash
-medication for itching and redness
*candida albicans: yeast infection of mouth, esophogus, GI tract
6. Explain the indications for the initiation of antiretroviral therapy of the HIV patient.
*should be started when immune suppression is greatest to avoid burnout and nonadherence
*must be ready to initiate therapy to ensure better adherence to the regimen
*patient should understand the importance of taking medication on schedule and the side effects of the medication like pain, fatigue, N/V/D, depression and peripheral neuropathy
7. Explain the different drug categories of antiretroviral agents used in HIV infection. (Table 15-14)
*NNRTIs and NRTIs: inhibition of HIV to make a DNA copy in early replication
*NtRTIs: inhibit action of reverse transcriptase
*PIs: stops budding activity to occur on cell membrane
*Fusion or entry inhibitors: stops HIV from binding to cell receptors
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