Adult 2

Finals Study Guide

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Unit I - Basic Principles, Fluid and Electrolytes, Intravascular Devices -13 questions 1. Be able to discuss the primary ideas concerning holistic health 2. Be familiar with the ideas of ethics and moral values 3. Know how to calculate an IV drip a. mLs to be infused X gtlli = Time in hours 60 min 4. Describe the functions, indications, and precautions of Colloids & Crystalloids a. Crystalloids - solutions that contain small molecules and are able to pass through semipermeable membranes (flow readily from vascular to interstitial space and cells)

-----

-

-

-h---=~~;:ately_th"""""-,,smolality-'l£1bat_o[ECE,_ond
1. 2. 3. 4.

th=-_

-i

Given to expand ECF volume Use with caution in pt's with CHF and HTN Have no net effect on cellular dynamics Examples: a. Normal Saline (0.9% NaCI) - only solution you can hang with blood, does not provide free water b. Ringers Solution - replaces K, Na, CI, Ca; does not have lactate, does not provide free water c. Lactated Ringers (LR) - Similar to human blood, no free water, no calories, used for lower GI tract loss (diarrhea), and bum victims d. Dextrose 5% in water (D5W) - (170 cal) i. Does not contain any other electrolytes 11. Provides free water iii. 2/3 goes into cell, 1/3 stays in ECF iv. Used for treatment ofhypernatremia ii. Hypotonic - Osmolality is lower than that of serum plasma 1. Given to reverse dehydration. Water pulled out of vessels and into cells. ! vascular volume , 2. Causes cells to swell and possibly burst 3. Provid~'-free water for cells and for excretion of body wastes 4. Used to treat hypernatremia 5. Excessive use can lead to intravascular fluid depletion, !BP, cellular edema and cell damage 6. Contraindicated in acute brain injury pts (cerebral cells are sensitive to free water) 7. Examples: a. 0.45% NaCI (112 NS) b. 0.225% NaCI (1/4 NS) c. D5W - isotonic in bag, hypotonic in body d. Dextrose 5% and 0.225% NaCI (D5 V4 NS) e. Dextrose 5% and 0.45% NaCI (D5 Y2 NS)

l
I

!

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Finals Study Guide

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Ill.

--'-'"'-~--""'--'~--

------------------------

Hypertonic - solutions have a higher osmolality than normal plasma 1. Causes water to be pulled from cells into the vessels 2. Used to treat specific problems and administered in carefully controlled, limited doses to avoid vascular volume overload and cell dehydration 3. Fluids must be given via an infusion pump or IV push 4. May irritate the veins 5. Once fluid is pulled into vascular space, diuretics may be given for renal excretion of the excess. 6. Examples: a. 3% NS (same as sea water) .......------ - ·-15:-Flulds -with-lO%urmoreDextrose('fPN}------------c.

-----------------f
II

5.

Hypertonic in bag -? (after metabolism) 1. D5LR -? LR ii. D5 Yz NS -? Yz NS iii. D5 Y4 NS -? Y4 NS b. Colloids - solutions that contain high molecular weight (proteins or starch) that do not cross the capillary semi-permeable membrane, and remain in the intravascular space for several days 1. Osmotic diuretics, such as Mannitol pull fluid from third spaces, tissues, and cells into vessels to be eliminated by the kidneys. ii. Can be isotonic or hypertonic iii. Contraindicated in anemic or dehydrated patients iv. Used cautiously in pts with cardiac or pulmonary problems or in clinical situations where there is increased capillary leakage (sepsis, burns, trauma) v. Examples: 1. Albumin - most common 2. Intralipids 10% - fats that aid in caloric intake 3. Intralipids 20% - fats that aid in caloric intake 4. Hetastarch (Hespan) 5. Dextrari - 10% Dextran in 5% or NS - plasma expander for trauma 6. Plasma Protein Fraction (PPF) 7. 8% Amino Acids c. Compared to Crystalloid Solutions, Colloids i. Remain in the vascular space longer than crystalloids ii. More likely to cause circulatory overload iii. Are more expensive than crystalloids iv. May cause febrile reactions Understand the indications and management of venous access devices a. Types i. Peripheral ii. Midline iii. Central 1. Types

I

Adult 2

Finals Study Guide

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a. b.

c.

Non-Tunneled - subclavian, jugular - 16-18 gauge - Single, Double, triple lumen central catheter Peripherally Inserted Central Catheter (PICC) and Power PICC i. AC space, 3-12 months ii. No BP or Venopuncture Tunneled Central Catheter I. Hickman ii. Brobiac
,I

~--

--~ -- ~--~

iii. Groshong iv. Permacath --- -- --- --- ---(l;---IiiiplatifeaYorts=Ponacath--------------2. 3.

. ----

--------.--

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Placement of these devices must be confirmed by X-ray before use! Management of Central Venous Access Devices a. Prevention of Infection i. Assess pt's underlying condition ii. Personal hygiene iii. Use of aseptic technique iv. Skin and port cleansing v. Type ofinfusate vi. Type of catheter vii. Type of dressing viii. Non-tunneled catheter - site changed q 4 weeks, dressing changed first 24 hours then q week h. Maintaining a closed N system i. Accidental disconnection poses risk of air embolism, hemorrhage, and t potential for infection ii. Make sure caps/ports are securely closed iii. On all devices, clamps on the lines need to be closed when caps are being changed IV. All devices (except power PICe) need to have the clamps closed on the lines when it is not in use c. Maintaining a patent device i. Make sure devise is properly flushed per protocol ii. Use correct lumen 1. Distal lumen - (16 G) - blood, viscous fluid 2. Middle lumen - (18 G) - PN 3. Proximal lumen - (18 G) - drawing or giving blood, or administering other medications iii. Occlusion can result ifN fluids are turned offfor prolonged period oftime* or if device is not flushed (*1 min for standard N fluids,S min for TPN) iv. Unblocking a CV AD - use gentle pressure and suction only. Never use force as this may rupture the catheter.

I

I I I
I

I,

Adult 2

Finals Study Guide

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Tape off clogged port so that others will not use it and notify Dr. Document fmdings d. Preventing damage to the device 1. Use 10 mL or larger syringes for all accessing ii. Know the manufactures guidelines for your pt's device iii. Follow hospital guidelines for accessing blood draws, flushes, and dressing changes iv. When PICC or Central catheter is removed, inspect and document appearance of catheter (catheter intact) b. Length of use depends on need ·-------------------------------------l.--SnOrt~feffir=-t.:2weeks-.:::.:-Peripheral-1. Site monitored and flushed every shift 2. Blood infusion through 20 gauge or larger 3. Usually site is changed q 3-4 days 4. Better to use arm veins than hand ii. Midterm - 1-8 weeks m. Long term - > 2 months Discuss the use and precautions of parenteral nutrition therapy a. Parenteral nutrition - used to supply the body with nutrients when oral intake is not possible or not adequate enough i. Indications 1. 10% deficit in pre-illness weight 2. Inability to take oral food or fluids at all due to illness or within 7 days post-op 3. Hypercatabolic illnesses (fever, infection, bums, sepsis) = need for more calories 4. Patient is not interested in or is unwilling to ingest adequate nutrients (anorexia nervosa, elderly) 5. Types: a. TPN i. Central line (higher glucose amount) n. 25-50% dextrose lll. Needs lipids to hang with it b. PPN i. Peripheral ii. 10% or less dextrose iii. Supplement (5-7 days) iv. May need lipids to hang with it c. Total Nutritional Additive (TNA) i. Dextrose, amino acids, and lipids d. Intralipids/lipids - fats; sometimes mixed in, sometimes not i. Can be given in peripheral line n. 1-3 weeks in. 30% of calories comes from lipids

6.

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Finals Study Guide

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iv. Check for frothiness, separation, or oily appearance

v.
ii. Need to know 1. PN bags/bottles should be checked once per shift against Dr's orders for exp date, and for clarity 2. Tubing on PN solutions is changed q 24 hours 3. MUST use filter tubing for TPN, PPN, and INA 4. Insulin may be added to TPN, PPN, or INA (occasionally) 5. TPN or PPN that is separate from the lipids are connected via 'Y' tubing. Lipids can be run separately through a peripheral vein since they are IfPN comes in glass bottle, use vent tubing Monitor 1&0, labs, weight, and accuchecks (critical in PN pts) Lipids that are separate should NOT be given through filtered tubing Don't let other solutions mix with the PN, ask pharmacy if questions arise. iii. Complications 1. Pneumothorax 2. Air embolism 3. Clotted catheter line 4. Catheter displacement and contamination 5. Sepsis 6. Hyperglycemia 7. Fluid Overload 8. Rebound hypoglycemia
Unit 2 - Cardiovascular Conditions - 20 questions

6. 7. 8. 9.

1. Hypertension - Describe treatment and nursing care a. Treatmenti. Goals 1. BP for nondiabetics <140/90, for diabetic <130/80 2. Free of sIs 3. Prevent complications ii. Lifestyle goals - t in weight, alcohol use, smoking (or quit), sodium intake, and t exercise b. Antihypertensive Drugs i, Diuretics - t excretion of sodium and water 1. Loop Diuretic - Lasix (furosemide) 2. Thiazides - Hydrodiuril (hydrochlorothiazide) 3. Potassium-sparing - Amilloride (Midamor), triamterene (Dyrenium) ii. Aldosterone receptor blockers - competitive inhibitors of aldosterone binding 1. Aldactone (spironolactone)

Adult 2

Finals Study Guide

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iii. Beta-Adrenergic blockers - blocks the sympathetic nervous system especially the sympathetic to the heart, producing a slower HR and lowered BP - usually end in

-0101
1. Inderal (Propanolol)

2. Metoprolol (Lopressor)
iv. Cental Alpha2-agonists and other centrally acting drugs 1. Catapres (Clonidine) 2. Aldomet (methyldopa) - displaces norepinephrine from storage sites v. Vasodilators - acts directly on smooth muscle of blood vessel 1. Apresoline (hydralazine) -- --- - ~ - ~~ -- ~~~~~-2:-Nitrogl.Ycenne-(NitrobT(nV~Tfiailr----------------~-~-_ ~ vi. Angiotensin-converting enzyme (ACE) Inhibitors - inhibit conversion of angiogensin I to angiotensin II, and lower peripheral resistance (usually end inpril) 1. Lisinopril (prinivil, zestril) 2. Capoten (captopril) vii. Calcium Antagonists - (Calcium channel blockers) - inhibit calcium ion influx 1. Cardizem (diltiazem hydrochloride) - also slows velocity of conduction of cardiac impulse 2. Procardia (nifedipine) - also has vasodilation on coronary and peripheral arteriole, and! cardiac word and energy consumption, t delivery of 02 to myocardium Nursing care - Assessment i. Healthhx ii. Risk factors - in weight, alcohol use, smoking (or quit), sodium intake, and t exercise 111. . Signs/Symptoms - dizziness, headache, nosebleeds, problem focusing eyes, t pulse pressure iv. Complications (uncontrolled/untreated) 3. Blindness 1. ! life expectancy 4. Kidney failure 5. Stroke 2. Heart attack and relate the causative factors to: Hypertension - high blood pressure (above 140/90) i. Systolic - 140-159 mmHg OR ii. Diastolic - 90-99 mmHg Primary (Essential) - denotes high blood pressure from an unidentified cause (r/t increased peripheral resistance) 1. 90-95% have primary hypertension ii. Contributing factors 5. Atherosclerosis 1. Obesity 6. Familyhx 2. Smoking 3. Stress 7. t age 8. Race(AA) 4. Arteriosclerosis

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.... -...-"-

--- --

c.

2. Define
a.

b.

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Finals Study Guide

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------

9. Diet t in salt, and saturated fats iii. Pathophysiology 1. Sympathetic nervous system - stimulated rlt stress, anxiety, t release of norepinephrine (vasoconstrictor) 2. Adrenal glands - stimulated to secrete epinephrine (vasoconstrictor) a. .i blood flow to kidney ~ retains water ~ t blood pressure iv. Signs and symptoms 1. Usually asymptomatic 2. Overtime, can lead to damage to: a. Eyes c. Kidneys ..--------------------... -----K-Uearr······------······-···-----... -----------------..--o;Jtt'am----c. Secondary Hypertension - high blood pressure from an identified cause such as renal disease i. 5-10% have secondary hypertension ii. Causes 1. Renal abnormalities a. Narrowing of the renal arteries b. Renal parenchymal disease c. Pylenephritis d. Glomular nephritis e. Renal artery embolism 2. Metabolic and Endocrine disorders a. Diabetes 3. CNS disorders a. t intracranial pressure b. Brain tumors 4. Pregnancy 5. Hyperaldosteronism (mineralcorticoid hypertension) 6. Certain medications a. Oral contraceptives 7. Coarctation of the aorta - malformed aorta 8. Pheochromocytoma - benign tumor of adrenal gland a. Effect on blood pressure - t aldosterone ~ body retains sodium and water ~ t CO ~ t BP 9. Chronic ingestion of black licorice Malignant Hypertension - (Accelerated) 1. Systolic pressure - ~ mmHg ii. Diastolic pressure - > 120 mmHg iii. Can lead to 1. Swelling of optic nerve 2. Acute hypertensive retinopathy 3. Nephrosclerosis 4. Encephalopathy Hypertensive Crisis -life threatening condition

-----------------+
I I
.l

d.

e.

Adult 2

Finals Study Guide

PageS

--------------------

i. Hypertensive emergency - a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage ii. Hypertensive urgency - a situation in which blood pressure is severely elevated but there is no evidence of target organ damage iii. Signs and symptoms 6.NauseaIV omiting 1.CHF 2. CNS dysfunction 7. Seizures 8. Intracranial 3.Headache 4. Confusion hemorrhage 5.Lethargic 9.Coma ---------------iv~-Tfeafifient=-Goal=tot(jwer13P_in-l-hour;otherwise-permarrentorgarr-dinnage -----------------and death may occur 1. Nitroprusside (vasodilator) - IV 2. Diuretics - !fluids Coranary Artery Disease a. Coronary Artery Disease (CAD) - diseases affecting blood vessels of the heart, such as: coronary atherosclerosis, coronary atherosclerosis, angina, and myocardial infarction. i. Arteriosclerosis - diffuse process involving the accumulation of lipids, calcium, blood components, carbohydrates, and fibrous tissue on the intimal layer of a large or medium-sized artery (hardening and loss of elasticity) ii. Atherosclerosis - abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and lumen (fatty streaks leading to irregular thickening and plaque formation) iii. Angina Pectoris - chest pain brought about by cardiac ischemia iv. Causative factors 1. Genetics 3. Diabetes 2. Obesity 4. Hypertension 5. Oral contraceptives 6. Sedentary lifestyle (! HDL) 7. Diet (t in saturated fats and sugar) 8. Hyperlipidemia (cholesterol >200) 9. Cigarette smoking (2x more likely of CAD, t stickiness of platelets) 10. Emotional stress (t cholesterol, t acceleration of blood coagulation)

3.

v. SIS
1. Chest pain 2. Arrhythmias 3. Aneurisms 4. Infarction 5. Sudden death Treatment 1. Diet - t fiber 2. Medications - statins (Lipitor), (Zetia) 3. Exercise 4. Smoking cessation

vi.

-!absorption

of fat

Adult 2

Finals Study Guide 5. Surgical intervention (Angioplasty, Stent, Bypass) 6. For Angina a. Nitroglycerine - coronary vasodilator b. Beta-adrenergic blockers - Inderal c. Calcium channel blockers - Cardizem d. Surgical interventions 1. PTCA ii. Stents

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4.

Peripheral Vascular Disease (PVD) AKA Peripheral Artery Disease (PAD) - t circulation leads to tissue ischemia and pain a. Types i. Buergers (Thromboangiitis Obliterans) ii. Raynauds iii. Deep Vein Thrombosis (DVT) b. Risk factors viii. t stress i. t age 11. Males ix. Sedentary life style iii. +familyhx x. CVA xi. MI IV. Smoking v. DM xii. Arteriosclerosis xiii. Atherosclerosis VI. Obesity vii. Hx of Hypertension c. SIS i. Pain ii. Lower extremities 5. t (or absent) perjpheral pulses I.Cool, pale extremities 6.Dry, scaly, shiny (with 2.RubralRuddy when edema) skin dependent 7.Hair loss 3. t cap refill 4. Mottled iii. Ulceration/Sores iv. Edema d. Treatment i. Control underlying conditions (HTN, obesity) 11. Lifestyle changes 4. Exercise 1. Diet 5. Adequate fluids 2. Smoking iii. 3. t stress Surgery 1. Bypass - for pain 2. Angioplasty/stent

~~~:.-~cates~~__j

II

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Finals Study Guide

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3. Thomboectomy - removal of clot (DVT) 4. IVC filter (DVT - Greenfield filter in inferior vena cava)
iv. Other 1. TED hose 2. SCDs 3. Early ambulation Medications i. Anticoagulants - for DVTs - pts should not be taking NSAIDs or ASA

e.

1. co:ad!~

~~:::::

Prothrombin Time)

I'

.-~~;:a~~~~~-.-~

b. c. 2. Heparin a. IV or Sub q b. PIT (Partial Thromboplastin Time) i. Normal range 30-45 seconds ii. Therapeutic range - 1 ~ - 2 times the norm iii. 100 or above = spontaneous bleeding (hemorrhage) c. Antidote - Protamine sulfate 3. Thrombolytics - Streptokinase (clot buster)

norm) iii. > 30 seconds = spontaneous bleeding (hemorrhage) Antidote - Vitamin K International National Ratio (INR) - Therapeutic range 2.0-3.0

4.

SIS

5.

d. Excessive bleeding a.Bleeding e.Bleeding gums b.Woundnot f. Easily bruised healing c. Nose bleeds 11. Antiplatelet aggregate (Trental, Plavix) iii. Vasodilators f. Nursing care. Myocardial Infarction a. Pathophysiology - death of myocardial tissue due to interruption of the blood supply i. Plaque breaks off ii. Bleeding causes dislodgement of plaque 111. Blood clot develops b. SIS i. Severe crushing, or vice-like pain, often radiating to the jaw, arms or back 11. Weakness iii. Hypotension and tachycardia (or bradycardia) iv. NN v. Pallor; cool, clammy skin vi. High anxiety c. Diagnostic tests

Adu1t2

Finals Study Guide i. EKG - i ST wave or abnormal Q wave ii. Troponin T - proteins found in striated muscle 111. CK and CKMB - i 4-6 hours, stay i for 5-7 days IV. LDH v. Sed rate - i in tissue damage VI. WBC count - i with severe stress d .. Medical Treatment " ,,:,,';y.> i. ICU or CCU e. ""Medications i. Antiarrhythmias (Lidocaine)

Page 11

ii. Cardiac monitoring

·----.-.--------.------------~--ti~~-Oxygeti:-·-i·:;:"~~------~------- ...------------.-.------

···-------------1-·-····-·-·-·-··--····--

6.

iii. Mprphfiie Sulfate (chest pain) iv. Anti6o:gulants and/or Thrombolytics (t thrombus formation) v. Vasodilators f. Nursing Care Congestive Heart Failure - impairment of myocardial contractility leads to ! cardiac output

a. SIS i. Left sided
4. Orthopnea 1. Shortness of S.Cough breath 2. Edema 6. Restlessness/Anxiety 3. Fatigue 7.Weight gain 8. Paroxysmal nocturnal dyspnea - wake up gasping ii. Right sided 4. Anorexia & Nausea 1. Edema (sacral) 5. Nocturia 2. Weight gain 6. Weakness 3. Ascites 7. Liver enlargement (Hepatomegaly) b. Medical Treatment 1. !cardiac workload 11. Strengthen myocardial contractility - medication iii. Eliminate excess fluids - medication, !Na diet, !fluids iv. Detect and relieve underlying cause Medications 1. Digoxin1.. "How it works i force of contraction, i cardiac output, i circulation and . tissue perfusion, i renal blood flow, ! edema 2. Typical side effects -! appetite, slight nausea, altered taste (0.9-2.0) 3. Toxicity - nausea/vomiting, visual disturbances, arrhythmias, confusion
i

c.

d.

Diuretics iii. ACE Inhibitors - ! preload, ! afterload resistance -7 leads to perfusion (Captopril (Capoten)) Nursing Care i. Check Digoxin levels
11.

i CO, i tissue

Adult 2

Finals Study Guide 1. Assess VS 2. Assess for SIS of toxicity 3. Patient teaching - checking pulse, SIS to report, OTC drugs

Page 12

Pulmonary Edema a. Pathophysiology - fluid moves out of the vascular space, enters Interstitial lung tissue, moves into the Alveolar spaces and fmally into the Bronchi b. SIS i. Stage 1- Initial (Interstitial) 3. t respiratory rate 1.SOB on exertion 4. Cough 2.Noctumal dyspnea -----------------------------------------5:Restlessness1Anxiety---ii. Stage 2 - Advanced (Alveolar) 1. t respiratory ratelSOB 2. Use of accessory muscles 3. Adventitious lung sounds 4. Blood tinged sputum (pink frothy sputum)

7.

iii.

5. Cyanosis 6. Diaphoresis 7. Arrhythmiasl t BP 8. Confusion Stage 3 - Acute (Bronchial) I.Wheezing 2.Metabolic acidosis

c.

3.tLOC Medical Treatment i. Oxygen ii. Fluid restrictions iii. Low sodium diet iv. Positioning - high fowlers v. 1&0 - check output hourly vi. Acute stage 1. Cardiac monitoring 2. Hemodynamic monitoring 3. Assessment of ABGs 4. Assessment of hourly urine output 5. Capillary blood pressure Medications i. Diuretics - t fluid overload ii. Digitalis - t contractility of heart iii. Bronchodilators Nursing Care

4.t breath sounds 5. Shock 6.lf not reversed = death

d.

e.

Unit 3 - Respiratory System - 12 questions 1. Be able to describe the diagnostic respiratory tests listed in the syllabus

Adult 2 a.

Finals Study Guide

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----------------------

Bronchoscopy - direct inspection of the trachea and bronchi through a flexible fiber-optic or rigid bronchoscope i. Purpose - allows doctor to determine the location and extent of the pathologic processes, assess respectability of a tumor, diagnose bleeding sites, collect tissue or sputum specimens, and remove foreign bodies, mucous plugs, or excessive secretions ii. Nursing Actions 1. Pre-test a. Tell pt that hell receive a sedative, such as diazepam (Valium), midazolam (Versed), or meperidine (Demerol) --------------- ------b:--Explallrthanh-e-doctorwHlintroduce-the-bronchoscopetube-----------------through the patient's nose or mouth into the airway. Then, he'll flush small amounts of anesthetic through the tube to suppress coughing and gagging. Post-test a. Report bloody mucous, dyspnea, wheezing, or chest pain to the practitioner immediately. A chest X-ray will be taken after the procedure and the patient may receive an aerosolized bronchodilator treatment b. Monitor for subcutaneous crepitus around the pt's face and neck, which may indicate tracheal or bronchial perforation c. Watch for breathing problems from laryngeal edema or laryngospasm; call the practitioner immediately if you note labored breathing d. Observe the pt for signs of hypoxia, pneumothorax, bronchospasm, or bleeding e. Keep resuscitative equipment and a tracheostomy tray available during the procedure and for 24 hours afterward

2.

b.

Chest X ..rayi. Purpose - can show location and size of lesions and identify structural abnormalities that influence ventilation and diffusion (can help visualize pneumothorax, fibrosis, atelectasis, and infiltrates) ii. Nursing Actions 1. _ Pre-test a. Tell the pt that he must wear a gown without snaps and must remove alljewelry from his neck and chest, but doesn't have to remove pants, socks, and shoes. b. If the test is performed in the radiology dept, tell the pt that he'll sit or stand in front of the machine. If it's performed at the bedside, someone will help him to a sitting position and a cold, hard film plate will be placed behind his back. He'll be asked to take a deep breath and to hold it for a few seconds while the Xray is taken. He should remain still for those few seconds

Adult 2

Finals Study Guide c.

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c.

."~-'------.~-.-.~-.--.--- ~-.---.-~ ... ....------ ~-.,~--"- '-~-"~"~--'-"-'--'--~""'--"'''~'-·-----·'·-aroun(ttlrt?neelile-insertion-site-wi-}l-be--shaved~--.-.-,-.--.-----.b.

Reassure the pt that the amount of radiation exposure is minimal. Explain that facility personnel will leave the area when the tech takes the X-ray because they're not potentially exposed to radiation many times each day. Thoracentesis - AKA Pleural aspiration i. Purpose - used to obtained a sample of pleural fluid for analysis, relieve lung compression and (occasionally) obtain a lung tissue biopsy specimen ii. Nursing Actions 1. Pre-test a. Tell the pt that his vital signs will be taken and then the area

.. --.-----.-.---" ... ---,------

d.

Explain that the Dr. will clean the needle insertion site with a cold antiseptic solution, then inject a local anesthetic. Tell the pt that he may feel a burning sensation as the doctor injects the anesthetic 2. During procedure a. Explain to him that after his skin is numb, the Dr. will insert the needle. He'll feel pressure during needle insertion and withdrawal. He'll need to remain still during the test to avoid the risk of lung injury. He should try to relax and breathe normally during the test and shouldn't cough, breathe deeply, or move. b. Emphasize that pt should tell Dr. ifhe experiences dyspnea, palpitations, wheezing, dizziness, , weakness, or diaphoresis; these symptoms may indicate respiratory distress. 3. Post-testa. After withdrawing the needle, the Dr. will apply slight pressure to the site and then an adhesive bandage. b. Tell the pt to report fluid or blood leakage from the needle insertion site as sis of respiratory distress. Pulmonary function studies i. Types 1. Tidal volume (V T) - amount of air inhaled or exhaled during normal breathing 2. Minute volume (MY)'_ amount of air breathed per minute 3. Inspiratory reserve volume (lRV) - amount of air inhaled after normal inspiration 4. Forced vital capacity (FVC) - amount of air that can be exhaled after maximum inspiration 5. Forced expiratory capacity (FEe) - bolume of air exhaled in the first (FEVl), second (FEV2), and third (FEV3) FVC maneuver ii. Purpose1. Can measure either volume or capacity. 2. Test aid in diagnosis in pts with suspected respiratory dysfunction. 3. Evaluate ventilatory function through spirometric measurements

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4. Determine the cause of dyspnea 5. Assess the effectiveness ofmeds, such as bronchodilators and steroids 6. Determine whether a respiratory abnormality stems from an obstructive
or restrictive disease process 7. Evaluate the extent of dysfunction iii. Nursing Actions 1, Pre-test Explain that he may receive an aerosolized broncodilator. He may need to receive the bronchodilator more than once to evaluate the drug's effectiveness. ··---~-~-----------~------o.--Emf5haslz<nlratthe-testwiU-proceeu-quicklyifihel>tfollows .... .------~-----~ directions, tries hard, and keeps a tight seal around the mouthpiece or tube to ensure accurate results Instruct the pt to loosen tight clothing so he can breathe freely. Tell him he must not smoke or eat a large meal for 4 hours before test. May be advised to withhold bronchodilators and other respiratory treatments before the test. If the pt receives a bronchodilator during the test, don't give another dose for 4 hours. (Anxiety can affect the test's accuracy, so analgesics and bronchodilators may produce misleading results) a.

~-~--~-------~---~--

c.

d.

e.

f.

Incentive Spirometry 1. Purpose - Encourages the pt to take deep breaths to maximize vital capacity and to prevent atelectasis. ii. Nursing Actions 1. Pre-test - Explain to pt that he has to be in an upright position PPDIMantoux tests i. Purpose - determines presence ofMyobacerium tuberculosis which causes the infectious disease tuberculosis (TB) 11. Nursing Actions 1. Pre-test - Explain to pt that they must return in 48-72 hours to obtain results

2.

Post-test a. Induration of 10 mm or greater in diameter indicates a positive skin test b. Induration of 5 mm is considered a positive test for immunocompromised pts. c. A positive PPD indicates either exposure to TB or presence of the inactive disease. It does not confirm present active disease d. If pt received a BeG vaccine within the past 10 years, it may produce a false-positive result. These pts must get a chest X-ray to evaluate the presence of an active TB infection

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Finals Study Guide e. f. g.

Page 16

h. g.

Chest X-ray may be ordered to detect active lesions in lungs Sputum culture and smear A positive acid-fast test suggests an active infection. TB precautions should be followed until the dx is confirmed or ruled out. The dx is confirmed by a positive culture for M. tuberculosis

Sputum care 1. Purpose - helps diagnose respiratory disease, determine the cause of respiratory infection, identify abnormal lung cells, and manage lung disease . .ii. Nursing Actions a.

2. 3.

Encourage pt to increase fluid intake the night before sputum collection to aid expectoration b. To prevent foreign particles from contaminating the specimen, instruct the pt not to eat, brush his teeth, or use a mouthwash before expectorating. He may rinse his mouth with water. c. When the pt is ready to expectorate, instruct him to take 3 deep breaths and force a deep cough d. Before sending the specimen to the lab, make sure it's sputum, not saliva. Know the normal ranges for ABGs. Be able to identify respiratory acidosis and alkalosis as well as metabolic acidosis and alkalosis Know the symptoms, medical treatment and nursing care for the respiratory disorders listed in syllabus a. Bronchitis - COPD i. SIS 1. The presence of productive cough and sputum production for at least a combined total of 3 months in each of 2 consecutive years 2. History of frequent respiratory infections 3. Common to have a history of cigarette smoking or pollution exposure ii. Treatment 1. Bronchodilators 2. Postural drainage and percussion 3. Increase fluids (2-3 L/24 hours) - PO or IV 4. Give corticoid steroids if client fails to respond b. Emphysema - a disease of the airways characterized by destruction of the walls of overdistended alveoli -leads to permanent distention of airspaces (COPD) i. SIS 1. Work of breathing is increased because there is decreased functional lung tissue to exchange oxygen and carbon dioxide 2. Progressive dyspnea on exertion 3. Often thin client 4. Often leans forward with arms on knees to breathe 5. Anterior/posterior chest diameter enlarged (barrel chest)

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6. Uses accessory muscles n. Treatment
1. Bronchodilators 2. Steroids 3. Oxygen 4. Exercise (mild) and pursed lip breathing Asthma - chronic inflammatory process involving constricted small air passages, disorder of bronchial airways characterized by episodes of bronchospasm , i. SIS .. ------.. ..---- .....--- ... -.--.---....

c.

1. Dyspnea ...------ .. ...--.- ...--- .. -------.-- .. -2~·. asanlarmg;plitsed'ltp15reatlring"..· .N
n.

iii.

3. Expiratory wheezing Diagnosis 1. Clinical manifestations 2. Pulmonary fup.ction tests (spirometry) Therapeutic management 1. Antiinflammatories - corticosteroids (Asmacort, Flovent) 2. Bronchodilators (advair, Theophylline) 3. Leukotriene modifiers (Singulair) 4. Low dose oxygen 5. Hydration 6. Conserve energy 7. No additional triggers in pt's room

-I
t-

r··

d.

Tuberculosis 1. SIS and Diagnosis 7. Low grade 1. Positive TB test fever 2. Hx of exposure 8. Chest pain 3. Cough 9. Crackles 4. Fatigue 10. Sputum culture 5. Anorexia 11. Chest X-ray 6. Wt loss 12. ELISA test ii. Therapeutic management - must be taken 4-12 months, Therapeutic results may be seen 2-3 weeks after beginning therapy, pt is then non-infections 1. Meds - must be taken a. Isonozid (INR) b. Rifamapin (RIP) c. Streptomycin (SM) d. Pyrazinamide (PZA) 2. Rest 3. If in hospital- negative airflow room, under droplet precautions Lung abscesses - collection of pus within lung tissue (Empyema- pus pocket in lung); i. S/S1. In early stages resembles pneumonia

e.

Adult 2

Finals Study Guide

Page 18

~---"~~'-"-"---"-~~""~'~-"-"'-'~---."~~---,--,--.-~.-,-. ----~"- ... .... . --..-----13~--·-CracltleS]fiay'-·o·cc1lt-asabsc~ss-drains-11.

2. Undiagnosed and untreated ~ lung necrosis 3. Most common site is posterior upper lobe of right lung 4. Pts most at risk: Impaired cough reflexes (CVA, Seizures, drug and ETOH abusers, esophageal problems, NG tube) 5. Fever 7. Pleuritic pain 6. Chills 8. Cough 9. Copious sputum (foul or bloody) 10. t breath sounds 11. Dullness to percussion 12. Friction rub over affected area
- ---.-_--- ..

_--- ..

__

.---.--.--.-_.----_-.-.--.-------"

- ...

"----------""------.--

... ~.-- ..--."-.- ... ----.-

~.-----.-

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f.

Diagnosis 1. Chest X-ray 2. CTscan 3. Sputum culture iii. Therapeutic management 1. Antibiotics 2. Bronchoscopy 3. Postural drainage - elevate head of bed 4. Frequent mouth care 5. High calorie, high protein diet 6. Education -'-sit up while eating, knowing their swallowing precautions Pleurisy/pleural effusion i. Pleurisy - Sharp pain felt suddenly with deep inspiration and coughing, usually felt on lower lobes or on one side of the stomach ii. Pleural effusion - accumulation of fluid in pleural spaces iii. Causes 1. CHF - does not usually have pleurisy 2. LiverlRenal failure 3. Infections - viral, bacterial, TB 4. Lupus, arthritis, cancer 5. Trauma 6. Lymphatic obstruction iv. PE SIS 1. Dependent on amount of fluid present and degree of lung compression 2. Dry, non-productive cough 3. Percussion dull 4. Pleurisy (pain) v. Therapeutic management1. Thorecentisis and Video assistant thoracentesis (VATs) 2. Fibrothorax 3. Obliteration of pleural space 4. Medications a. Bronchodilators

I

Adult 2

Finals Study Guide b. Antihistamines c. Expectorants d. Cough suppressants e. Antifungals f. Corticosteroids g. Antibiotics

Page 19

Unit 4 - Neurological Disorders -11 questions

1. Describe key aspects of the neurological assessment and diagnostic tools utilized
. ~_'_ <;omJ>_a,r~_~_4_~_QJ!1!_astM!!I!iI>_l~~~1_~2~_i~~~)(i!!~~n_~_~~_M)'~s!~_eniag!avj_s_(~~_f~i!!CIT ~~~___ treatment and drugs used for each) • Multiple Sclerosis o Etiology (cause), theories - unknown, possibly autoimmune, possibly due to stress o Pathophysiology - Demyelination in the CNS in the cerebrum(mainly), spinal cord, cerebellum, brainstem, optic nerves (one of the first signs) • Inflammation • Edema • Sclerotic plaques • Axons remain intact in early stages but are destroyed in later stages Incidence • Age -20-40 years old • Gender - Females • Other - Caucasians, i in colder regions, i in parents who have lost a child Diagnostic tests • Rule out other diseases • Hx - sis of neurological dysfunction • • • Motor - fatigue, weakness, muscle spasms, double vision Sensory - numbness, tingly, patchy blindness Cerebellum - ataxia (impaired coordination), impaired balance ..

----+l

o

o

o

• Intellect usually intact • CSF - Immunoglobulin G (IgG), i lymphocytes, • CAT scan - to RIO vascular issues • MRI - detection of sclerotic plaques History and assessment of signs/symptoms .• • • • • • • • • • • History and other medical dx SIS Disease progression Treatment & response Client/family knowledge Cognitive abilities Neurological assessment - test cranial nerves PerfonnanceofADLs Sensory deficits Bowel and bladder function Sexual function

i monocytes

Adult 2

Finals Study Guide

Page 20

o

Interventions • Medical- Rx • Adrenocorticotrophic • hormone (ACTH)

Corticosteroids o Methylprednisolone o Prednisone Immunosuppressive therapy o Azathioprine (Imuran) o Cyclophosphamide (Cytoxan) o Avonex - weekly - t flare-ups ---.-~Allergic reactioii=seiZUfes;lWBC;TRBC~rplalerets--• Side effects - depression anorexia, hair loss, n/v Antivirals - beta interferon (Interferon) Antispasmodics - help with bladder tone o Baclofen o Diazepam (Valium) o Oxybutynin (Ditropan)

--------------

• •

Surgical • Myelotomy - surgical severing of nerve fibers in spinal cord • Rhizotomy - resection of nerve root Bee sting therapy Physical therapy - maintain/improve

t pain, t spasticity

Other • • •

strength, ROM (below waist)

Occupational therapy - above the waist, modifications in home

o

• Nerve block - for patients with very spastic muscles Psychosocial effects - depression common • • Counseling Medication for depression

o o

• Support groups • Speech therapy • Dietary consult • Bowel and bladder training Potential complications Prognosis - Goals • Maximize neuromuscular function • Maintain independence • Optimize psychosocial well being of client and family • Prevent complications/injury Discharge Planning • Home care • Knowledge assessment and instructions • • Self care levelCommunity resources -

o

Adult 2

Finals Study Guide

Page 21

• Rehabilitation • Long-term care Myasthenia Gravis o Etiology (cause), theories - Autoimmune neurological disease affecting transmission of

o

neurological impulses Pathophysiology - Antibodies are produced against acetylcholine receptors, decreasing receptor sites. Prevents acetylcholine molecules from attaching

• Loss in muscle strength • Thymic rumors in 15% of clients • Viral infection may lead to acute attack (trigger) ----------·-------------------------.----SO%-of-clientslfavt:radisorder-ofthe-thymus-glamr----------_··-o • 70-90%t in acetylcholine receptor sites Incidence • Women 15-35 yearsold

-----------------------.---

o

• Men >40 • Other - increased with familial pattern Diagnostic tests • Eye test - eye lids will droop • EMG - electromylography test - measure muscle contractions by changes in electrical nodes = t response of hand with repetition • Tensilon test - IV injection of anticholinesterase stimulates muscle, stops breakdown of acetylcholine = improved muscle contraction • • (Be sure to have Atropine at bedside during test) Serum test for antibodies -looks for antibodies to acetylcholine

o

• CAR scan of thymus - look for abnormalities History and assessment of signs/symptoms • Assess respiratory function • Assess swallowing reflex • Fatigue in skeletal muscles • • • Eyes/eyelids Chewing/swallo wing Speaking/breath ing • Neck, shoulders, and hips

o

• No sensory loss • Normal reflexes • Rare to have muscle atrophy Interventions • Medical • Anticholinesterase - inhibits enzyme that breaks down acetylcholine, and

i amount
o o o

of sites Mestinon - short acting Prostigmin -long acting Side effects

Adult 2

Finals Study Guide

Page 22

• [sweating • i saliva • hypotension
• • Corticosteroids - prednisone o Imuran Irinnunosuppressants o Cytoxa n • Surgical- thymectomy • Other - plasma exchange - removes antibodies in plasma Potential complications • Impairment of swallowing and breathing • • • • • Can lead to aspiration/choking Respiratory insufficiency/failure Respiratory infection

• • • •

Cramping n/v diarrhea bradycardia

o

• Respiratory distress Quadraplegia Crisis - from stress heat, infection, labor, surgery, not taking meds • • Maintain gas exchange Mechanical ventilation

Parkinson's Diseaseo Etiology (cause), theories o Pathophysiology * Deterioration and loss of dopamine producing neurons • Decreased cerebral blood flow • • o Incidence • Age - >50 years • Other - No genetic link, rare in African Americans Diagnostic tests • Hx and clinical features • MRI • Response to anti-Parkinson medication History and assessment of signs/symptoms • Motor dysfunction • • • • Rigidity Bradykinesia - total akinesia Tremors Loss of postural reflexes Increased prevalence of dementia Coexistence of Alzheimers

o

• EEG • CAT scan

o

Adult 2

Finals Study Guide a. Shuffling gait b. Festination gait • Decreased cognitive function (memory impairment) • Impaired function of facial muscles
I

Page 23

o
-_.. .._---_._-_ .....
-

• Elimination abnormalities • Depression and/or anxiety • Dementia (40%) Interventions • Medical • Dopaminergic - LevodopaiCarbidopa ,-_._------,"_._ __ _ _._ ··-.···Anficlioleijergi~(to relieve-tremorsr::::.
.. ...- .. ..

--"-.- .... --,.-~....-...-,~"'--..------"' .."-

amme-·-~-·-· ~-- - ..• MAOIs

-.-- ..- ~

--.--..

• • •

Antihistamines (to relieve tremors and rigidity) - Benadryl Antiviral agents Antidepressants • Pallidotomy

• Surgical • Subthalamotom y • Other • • • Diet low in protein during the day Exercise & physical/occupational/speech

therapy

3. Differentiate between bacterial and viral meningitis
Meningitis o Etiology (cause), theories o Pathophysiology • Viral • • Incidence - end of summer/early fall Caused a. b. c. d. e. by Enteroviruses - 90% of cases Herpes Polio virus Mumps Hepatitis

o o

• Bacterial Incidence - Age -15-24 years old Diagnostic tests • Lumbar puncture (CSF)



o

L glucose
tWBC

• t protein
History and assessment of signs/symptoms • Feels like flu • Fever/chills • SEVERE headache

·NN
• Confusion/lethargy • Stiff neck

Adu1t2

Finals Study Guide • Photophobia • Skin rash (petechiae) - more with bacterial Interventions • Medical • • • • Antibiotics Anticonvulsants Corticosteroids - ! swelling Sedatives and analgesics

Page 24

• Seizures
I

o

I

I
I-

___ ~

~

• Antipyretics ~ __}l?!~ntia~~mplications • Seizures • Hearing loss • Vascular complications • Blindness • DIC • Learning diabilities • Sepsis o Prognosis - Excellent in viral cases, Poor in bacterial cases • Aspiration Pneumonia b. Risk factors • Anything that interferes with normal lung drainage - cancer, smoking, COPD • Immunosuppressed pts • Improperly cleaned • Smoking equipment • Prolonged immobility • NPO status • Depressed cough • ETOH intoxication • Advanced age • Antibiotic therapy

..-..---- ----- ·-----·-ParaIysls·· --

-- ---~~---------~
[I

I

Unit 5 - Gastrointestinal System - 11 questions 1. Be able to explain the diagnostic GI tests listed in the sullabus a. Esophagogastroduodenoscopy (EGD)1. Client prep 1. NPO 12 hours before test 2. Twilight sleep - conscious sedation (Demerol, Versed) 3. Local anesthetic 4. Atropine - to ! secretions 5. Position on left side - this! laryngeal spasms, ! chance of vagal stimulation ii. Procedure 1. Lubricate gastroscope with KY jelly iii. Post procedure - NPO until gag reflex returns 1. Monitor for a. sIs of perforation - Hemorrhage, Pain, GI bleed b. Distress (t HR, t temp), c. New dysphagia 2. Prevent Aspiration b. Colonoscopy - direct visual inspection of entire colon i: Client prep

Adult 2

Finals Study Guide 1. Clear liquid diet 1-2 days before test 2. "Go-Lytely", fleets phospho soda, Magnesium Citrate a. Bowel is cleaned when stool is brown, very watery ii. Procedure 1. Client on left side - this i laryngeal spasms, i chance of vagal stimulation 2. Twilight sleep - conscious sedation (N Versed) 3. Possible complications iii. Post procedure 1. Bedrest initially

Page 25

-~- -- - ~-----~~----~ -- ------~- --~ - - -~---- "·2~~·'-·Observe"·fOf···S/s-of-pelforation·-----·-

a. Rectal bleeding b. Abdominal pain c. t temp d. Cardiac dysrhythmias e. Vasovagal stimulation c. Magnetic Resonance Imaging (MRJ) - non-invasive, magnetic fields not radiation, cannot use if client has a pacemaker, performed with or without contrast i. NPO 6 hours before procedure ii. Disadvantages/Contraindications - decreased kidney function iii. Ativan, Xanex for people with clostrophobia iv. Solimedrol, Benadryl for allergic reaction to contrast v. Nursing Responsibilities for MRIs 1. Remove metal objects 2. Sedation, if ordered 3. Check for allergies, especially iodine 4. Instruct pt on procedure d. Computerized Tomography (CT) scan - combines use of X-rays with computers to produce cross sectional images (slices) may be done with or without contrast i. Painless ii. Disadvantages e. MRCPI Endoscopic Retrograde Cholangiopancreatrophy (ERCP) - A dye is injected into the bile and pancreatic ducts using a flexible, video endoscope. Then x-rays are taken to outline the bile ducts and pancreas. NPO 8 hours before test i. Gallstones, which are trapped in the main bile duct ii. lockage ofthe bile duct iii. Yellow jaundice, which turns the skin yellow and the urine dark iv. Undiagnosed upper-abdominal pain v. 2. Cancer of the bile ducts or pancreas Pancreatitis (inflammation of the pancreas) Know the GI disorders listed in the syllabus a. Esophageal Disorders i. Achalasia - difficulty swallowing liquids & solids; usually congenital anomaly

Adult 2

Finals Study Guide 1. Common in people over 40

Page 26

2.

SIS
a. Difficulty swallowing b. Possible regurgitation c. Chest pain d. Heart burn e. Indigestion Diagnosis a. UpperGI b. Manometry - esophageal pressure measured

3.

11.

a. Symptomatic b. Calcium channel blockers - Cardizem (relaxes muscles) c. Esophageal dilation - balloon dilates blockage Hiatal Hernia - stomach protrudes up into the chest through the diaphragm 1. . Common in people over 50

2.

SIS

a. Heartburn b. Dysphagia c. Nocturnal heartburn 3. Dx-EGD 4. Treatment a. Small frequent meals b. Elevate HOB c. Sit up for 1 hour after eating d. Avoid spicy meals e. Surgery (Lap Nissen) iii. Esophagitis - inflammation of esophagus (from GERD)

1. SIS
a. Sudden or gradual onset b. Heartburn c. Dysphagia d. Acid reflux 2. Dx: with hx & symptoms or scope 3. Treatment - antacids a. Reglan b. Nexium c. Protonix iv. Esophageal varices - dilated veins in lower esophagus 1. SIS - usually asymptomatic until massive hemorrhage - vomiting blood 2. Diagnosis a. H&P - related to alcoholism and fatty liver b. Endoscopy Treatment

3.

Adult 2

Finals Study Guide a. Control bleeding - balloon tamponade b. Maintain airway c. Medsi. Vasoconstrictors (Vasopressin) 11. IV fluids iii. Blood products iv. Transjugular

Page 27

b. GI disorders i. Gastroenteritis - inflammation of stomach and intestinal tract (bacterial/viral) 1. SIS b. Nausea c. Vomiting d. Diarrhea 2. Tx - same as dysentery ii. Dysentery - ameobic (traveler's diarrhea) or basillary 1. SIS a. Frequent diarrhea b. Bloody diarrhea c. Cramping 2. Treatment a. Rest GI tract (diet) b. Replace fluids c. Antidiarrheals - Immodium d. Antibiotics 3. Nursing Management a. Comfort measures b. Assess abdomen and diarrhea c. Administer meds iii. Peptic Ulcer Disease - a break in the continuity of esophageal, gastric, or duodenal mucosa 1. Predisposing factors a. H. pylori b. Stress c. Alcohol d. Caffeine e. Smoking f. Steroids g. Familyhx h. NSAIDs (ASA, Ibuprofen) 2. SIS a. Gastric ulcer i. Pain - caused by food relieved by vomiting ii. Poor appetite

Adult 2

Finals Study Guide

Page 28

b.

iii. t weight iv. Belching v. NN VI. Feeling tired/weak vii. Bleeding - Hematemesis Peptic ulcer i. Pain - occurs when stomach is empty, often at night, ii, Normal appetite
~~~~ ,11

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--.----'------.------"-_---,.. .._------"'--------,-----.~"'---... --,-""-,.--.--.-.-.--..

-------.-~-.--1I

v. Bleeding - melena (bloody stool) vi. More common in elderly

3. Treatment
a. Proton pump inhibitors 1. Omeprazole - Prilosec 11. Lansoprazole - Prevacid iii. Esomeprazole - Nexium iv. Pantoprazole - Protonix v. Rabeprazole - Aciphex Antacids i. Maalox ii. Mylanta iii. TUMS Surgery 1. Vagotomy - eliminates acid secreting stimulus to gastric cells (cutting off of vagus nerve) 11. Vagotomy & Pyelorplasty - cutting of right and left vagus nerves and widening the existing exit of the stomach at the pyloris 111. Subtotal Gastrectomy - removes acid secreting portions of the stomach (distal portion removed, remaining portion sutured to duodenum)

b.

c.

4.

Complications· a. Hemorrhage i. Ranges from minimal - presence of blood in stool to massive vomiting of bright red blood or coffee ground emesis ii. Interventions 1. Treat hypovolemic shock - ! BP, t HR, t RR, temp 2. Prevent dehydration, electrolyte imbalance 3. Stop bleeding 4. NG tube - suction - Miller, Canter

t

Adult 2 b.

Finals Study Guide

Page 29

Perforation i. Surgical emergency ii. Occurs more often with duodenal ulcers iii. Gastrectomy - resection of bowel iv. Diverticulosis - outpouching of mucosa that protrudes through weak portion of esophagus/lntestines 1. SIS - usually none, possibly LLQ pain alternating with diarrhea a. b. c. Difficulty swallowing Eructation Regurgitation

v.

a. Barium swallow b. EGD c. Colonoscopy 3. Treatment - medication, high fiber diet to produce soft, regular BM Diverticulitis - InflammationlInfection of the outpouches in GI wall 1. SIS a. Cramping pain LLQ, radiating to the back b. t flatus, bloating, abdominal distention c. Nausea/Anorexia, weakness d. Low grade fever may be present e. Obstruction causes constipation alternating with diarrhea f. Rupture occurs with 20% g. Shock - t HR, ! BP 2. Treatment a. Low fiberlResidue diet until pain subsides b. Acute attach - bed rest, NG tubes, analgesics (no ASA) c. Surgery Peritonitis - fecal matter enters the abdominal cavity and causes inflammation of peritoneum, serous linings 1. Resultof a. Ulcer b. Bowel perforation c. Appendicitis d. Trauma e. Inflammation of other organs 2. Causes inflammation and paralytic ileus

vi.

3. SIS
a. b. c. d. e. f. High fever Chills Pain Distended abdomen Rigid muscle

NN

Adult 2

Finals Study Guide g. Tachycardia 4. Diagnosis a. Barium enema b. colonscopy 5. Treatmenta. Surgery - Laparotomy (cleans out gut, wall of ruptured abscesses) b. Fluids and electrolyte replacement c. Large doses of antibiotics d. Analgesics f. Possible colostomy if needed 6. Complications a. Sepsis leading to death b. Intestinal obstruction c. Wound dehiscence and evisceration , d. Abscess formation e. Future adhesions c. Anorectal Disorders 1. Fistulas - tiny, tubular tunnels that extend into anal canal 1. Usually from trauma, infection 2. Pus or consistent stool leakage 3. Treatment - surgical ii. Fissures- tear or ulceration of anal canal 1. Result of excessive tissue stretching from hard stools 2. Treatment a. Cleansing b. Correct constipation c. Surgical excision d. Keep stools soft e. Exercise f. Sitz baths iii. Hemorrhoids 1. Perianal varicose veins (external or internal) 2. Causes a. Constipation b. Pregnancy c. Sedentary lifestyle 3. SIS a. Pain b. Itching c. Bleeding 4. Diagnosis a. External- visual exam

Page 30

Adult 2

Finals Study Guide

Page 31

b. Internal- digital palpation, proctoscopy 5. Treatment a. Medical- treat constipation, relieve pain b. Surgical- sclerotherapy, rubber band, cryo, laser c. NSG - keep area clean with TUCKs, wash after stools, sitz bath TID 12 hours after surgery 6. Complication a. Bleeding - anemia b. Thombis c. Strangulation ------7:- ·Posf.:;op-Coffipl1catioll~~ --------~- -.----~------~-~---~-~~...-----~---~--~-----i. a. Hemorrhage b. Urinary retention c. Pain d. Irregularity 3. Describe the transmission routes of Hepatitis A, B, C, D; and E a. Hepatitis A - Least serious virus of hep virus, never becomes chronic i. Clinical presentations 3. Anorexia 1. Jaundice 4. Diarrhea 2. Fatigue ii. Routes of transmission 1. Contaminated food and water 2. Blood exposure (rare) iii. Risk factors 1. Unprotected sex 2. International travelers 3. Native American reservations 4. Poor sanitation and crowding iv. Treatment - None specific h. Hepatitis B -lethal in 1% of pts, 5-10% become carriers, 15-25% chronic HBV will die prematurely. i. Clinical presentations 6.Mild fever 1.Nausea/vomiting 7. i in liver enzymes 2.Loss of appetite 8.Dark urine (Tea 3.Abdominal pain colored) 4.Fatigue 9.Light stool 5.Maybe jaundiced ii. Routes of transmission - contaminated body fluids iii. Risk factors 1. IV drug users 2. Sexually active persons 3. Infants born to infected mothers .4. Hemodialysis pts iv. Markers ofHBV - Prothrombin level is best indicator of prognosis

i

i

I

Adult 2

Finals Study Guide

Page 32

.---..

~ ~-~
..

..-"-~,- ...--- "-

-~ .."-----,-.-,--~-"-.-~-..-

-~-~--~~-~C~--PrevenfioIi--~----------------------~-----------~---~---~-~-------

1. Surface antigen a. HBsAg - pt is infected with the virus b. Anti-Hlss (surface antibody) - pt is immune (from natural infection or vaccine) c. Anti-Hbc (core antibody) -pt has been in contact with HBV and maylmay not still be infected d. IgM anti-Hlsc - signifies recent (w/in 6 mo) infection with HBV. Pt will usually not be a carrier e. IgG anti-HBc - signifies a past infection with HBV v. Treatment-

a. Hep B vaccine b. Screening of pregnant women c. Tx of infants born to infected mothers d. Screening of blood, organ, and tissue donors 2. interferon 3. Liver transplant c. Hepatitis C 1. Clinical presentations 1. Jaundice 4. Stomach ache 2. Anorexia 5. Abdominal pain 3. Fatigue 6. NN ii. Routes of transmission - Blood and bodily fluids iii. Risk factors _;. 1. N drug users 2. Organ transplant recepients 3. Hemodialysis 4. Multiple sex partners 5. 40% have no identifiable risk factors iv. Treatment 1. Interferon and Ribaviron 2. Liver transplants v. Prognosis - i risk for liver cancer and cirrhosis, liver damage may occur for years before sIs occur d. Hepatitis D 1. Clinical presentations - 75% chance fliver cancer or cirrhosis for those with HBV-HDV ii. Routes of transmission - defective RNA virus that requires presence ofHBV in order to replicate iii. Treatment - once HBV exists there is no immunization for HDV e. Hepatitis E i. Routes of transmission - fecal-oral contamination ii. Treatment - Prevention - good hand washing, clean water supplies

Adult 2

Finals Study Guide

Page 33

f.

iii. Risk factors - developing countries, areas experiencing a disaster (hurricane, floods, etc) Hepatitis Gi. Routes of transmission - results from bloodboume transmission ii. Risk Factors - transfusion recipients and IV drug users are highest risk iii. Prognosis - chronic hepatitis develops in > 90% of those infected iv. Tx - no immunizations available

Unit 6 - Endocrine System -7 questions (2 on DM - very basic)

.__.

.____ _L_. . ._..

Hyp~t:tl!Y!Qi<i.i~l!l_______. .. __ .... ___._... _.. _. ....______. .____. ._ ..__.. __. ... ._ il. Pathophysiology- overproduction of T3 & T4 i. Graves disease - autoimmune ii. Cancer 1. Exposure to radiation 2. Dx by biopsy 3. Treated with surgical removal b. SIS - Thyrotoxicosis VI. Exopthalmos i. Hyperactivity & t appetite VH. irritability Weight loss ii, Chronic fatigue and viii. IX. tBP weakness x. Osteoporosis iii. Heat intolerance xi. CHF IV. t cardiac rate v. Warm moist skin c. Treatment i. Medication 1. Propylthiouracil (PTV) 2. Methimazole (Tapazole) 3. Iodines - usually prior to surgery 4. Inderal (beta blocker) - helps control symptoms (palpitations, tremors, muscle weakness, diaphoresis) ii. Radioactive iodine - destroys thyroid tissue iii. Thyroidectomy - removal of 5/6 of thyroid, or completely in cases of cancer 1. Maintain a patent airway 2. Prevent strain on suture line 3. Complications a. Respiratory distress b. Hemorrhage c. Laryngeal nerve injury d. Thyroid storm e. Infection f. Hypocalcemia - due to damage of parathyroid gland d. Nursing Care Hypothyroidism

2.

Adult 2 a.

Finals Study Guide

Page 34

Pathophysiology - underproduction ofT3 (triiodothyronine), T4(thyroxine) i. Primary hypothyroidism - Hashimoto thyroiditis unknown cause, autoimmune ii. Secondary - caused by pituitary disorder, pregnancy, or congenital

b.

SIS
1.

._ -- ..-

Fatigue ii. Hypothermia lll. t respirations iv. t mental acuitylirritability v. Dry skin, brittle nails, hair loss vi. Numbness & tingling of extremities ··-----·------·-·--vii:-Mensft1larirregularities-(neavier-fiow}----..... c. viii. Constipation Treatment i. Replacement therapy 1. Levothyroxine (Synthroid) 2. Thyroglobulin (Proloid) ii. Check T3 & T4 annually after age 30 Nursing i. ii. iii.

--.------.--

----------

d.

Care Pt teaching - report cardiac sis Medication interactions Myxedema Coma - severe t of hormones (thyroid)

3.

Hyperparathyroidism a. Pathophysiology - t parathyroid hormone leads to t calcium 1. Adenoma (benign tumor) ii. Adenocarcinoma iii. Secondary hyperparathyroidism 1. Conditions that cause t calcium levels 2. Stimulate glandular growth b.

I

SIS
Kidney stone (polydipsia, polyuria) .Osteoporosis ii. iii. Renal insufficiency iv. Pyelonephritis v. Nausea vi. Constipation Diagnostic tests 1. Sulkowitch test ii. Skeletal X-rays iii. EKG Treatment i. Estrogen ii. Mild exercise iii. Bedboards
1.

~ Ulcers Weakness ix. t mental acuity x. Depression and/or irritability xi. Cardiac arrhythmias

vii. viii.

Ir:

xii.

i Ca, t Phosphorus

c.

iv. Ultrasound v. MRl vi. Biopsy

d.

Adult 2

Final Study Guide

Page 35

Corset or brace v. Increased fluids (flush out kidneys) vi. Tumor excision - adenoma vii. Total parathyroidectomy - adenocarcinoma 1. Look for a. Tetany b. Dyspnea c. Voice change d. Hemorrhage e. Nursing Care -----------------~----4:___nypoparathyroi<lisnr--------- - - -----IV.

--- - -- ------ - --- -

-- ---------- ----

a.

Pathophysiology - inadequate PTH leads to t calcium, t phosphorous 1. From kidneys, intestines (t adsorption), skeleton (leaves blood, goes into bones) ii. Trauma - surgery on thyroid iii. Atrophy of parathyroid gland Numbness and tingling of extremities ii. Tetany 1. Carpopedal spasm - painful muscle spasm of fingers 2. Trousseau's sign - BP cuff pumped up to 200 - hand spasm 3. Chvosteks sign - tap on facial muscle, lip twitches iii. Spontaneous tonic contractures iv. Laryngospasm andlor bronchospasm (effects breathing) v. Premature gray hair and alopecia vi. Enamel defects of teeth vii. Cataract development Treatment i. Calcium gluconate or calcium chloride ii. Parathyroid extract iii. Diet high in calcium and vitamin D Nursing Care 1. Goal: Prevent tetany ii. Assess response to treatment iii. Teach sIs to report, diet and medications
1.

_J

I I

b. SIS

c.

d.

Unit 7- Urinary disorders -13 questions 1. Be familiar with diagnostic tests of the GU system a. Urinalysis i. Color 11. Odor iii. pH (4.6 - 8.0) 1. Increased (alkaline) a. Citris fruit b. Metabolic and respiratory alkalosis

Adult 2

Final Study Guide

Page 36

--------------------

c. Vegetarian diets d. Bacteria 2. Decreased (acidic) a. High protein diet b. Ingestion of certain fruits (cranberries) c. Metabolic and respiratory acidosis iv. Specific gravity (1.010 - 1.040) 1. Increase - dehydrated; increase in ADH (elderly) 2. Decrease - over hydration; ADH deficiency (surgery pts, renal disease) b. Glycosuria ---------------t---D:rugs-tbaraffe~neaning1. False positive a. Ascorbi cacid b. Penicill in c. Keflin 2. False negative a. Aspirin d. e. Tetracy cline Aldome t

b.

Pyridiu m

c.

d.

Ii. Clinical significance 1. Severe stress 3. Preeclampsia 2. Kidney disease 4. Exercise KUB (Kidneys, Ureters, Bladder) - flat plate radiographic X-ray of kidneys, ureters and bladder i. Contraindicated in pts that are pregnant 11. Possible fmdings 1. Stones 4. Renal 2. Ascities Hematomas 3. Organomegaly 5. Intestinal Obstruction 6. Calcified areas in urinary or vascular system IVP (Intravenous Pyelorogram) - demonstrates ability of kidneys to excrete dye i. Contraindicated in pts with allergy to iodine and shellfish 11. Purposes - to detect structural defects or tumors iii. Pretest Nursing Care 1. Light evening meal 2. Creatinine clearance & BUN - measure kidney function (kidneys able to excrete dye?) 3. Nursing Instructions iv. Posttest Nursing Care 1. Increase fluids to 2000-3000 mL for the next 24 hours 2. Observe for sIs of difficulty voiding/allergic reaction

Adult 2 e.

Final Study Guide

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-----------------------------------f.

Cystoscopy - examines the interior of the bladder for inflammation, stones, tumors, etc. via small scope (also acts like a "roto-rooter" to break up stones, etc) 1. Pretest Nursing care 1. If general anesthesia is used instruct pt to TCDB 2. Assess for bleeding/dysuria - irritation from procedure. 3. Assess for urinary retention - from swelling 4. Cholinergic drugs stimulate bladder contraction (Ditropan) 5. Assess for possible infection - dysuria, i temp, i HR, concentrated urine, t WBCs 6. Assess for bladder spasms .-..·.-----a::--Treatedwith-Detrol;-or-Beltadonna-&OpiumsuppositOty(B&e---suppository) BUN (Blood Urea Nitrogen) - measures amount of urea nitrogen in the blood 1. Normal values (8-25 mg/dL) 1.

i BUN
a. b. c. d. DiseasedlDamaged kidneys Anything that causes poor renal perfusion or renal dysfunction High protein diet Dehydration

g.

tBUN a. Over hydration b. Increased ADH c. Pregnancy Blood Creatinine - end product of creatine metabolism 1. Range l. Males - 0.6-l.2 mg/dL 2. Females-0.5-I.l mg/dL ii. Increased levels l. Trauma (MY A) 2. Degenerative muscle disease 3. CHF 4. Dehydration 5. Renal disease and failure 12. Medication a. Many antibiotics b. NSAIDs c. Anti-hypertensives iii. Decreased Levels 1. With t age 2. Poor protein intake

2.

6.

7.
8.

9.
10. 11.

Hyperthyroidis m Shock Polio Renal calculi High protein diet Giantism

3.

Severe liver disease

Adult 2

Final Study Guide Muscular dystrophy 7. Medications a. Lisinop ril b. Ibuprof en iv. Chronic renal insufficiency 0.5-3.0 mg/dL) v. Chronic renal failure (> 3.0 mg/dL) h. Urinary Cultures ----------I--I--wBCs=usuallycaiisoot5)'lniectiofc---4.

Page 38 5. 6. Pregnancy Small stature c. d. Dopami ne Citrates

.

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ii. More common in older women due to incomplete emptying ofbladderlurinary stasis iii. Pretest Nursing Care 1. Clean peri area with towelette (Females wipe front to back) 2. Urinate into toilet 3. Stop the urine flow and urinate directly into a specimen cup 4. Finish rest of void into toilet iv. Reference values - must have a colony count of > 100,000 to state that an infection is present. v. Interfering factors 1. Antibiotic therapy beforespecimen collection (false negative) 2. Improper specimen collection methods which result in contamination (false positive) 3. Overgrowth of bacteria and false positive a. Specimen storage for longer than 30 minutes at room temperature . b. Specimen storage for 24 hours in the refrigerator 2. Explain and describe the formation of renal calculi a. SIS i. Sudden severe flank pain ii. Dysuria iii. Hematuria iv. NauseaIV omiting v. Urinary frequency alternating with retention Vl. Low grade fever vii. WBCs and RBCs in urinalysis b. Causes i. Family history 11. Diet high in calcium, protein iii. Dehydration iv. UTIs v. Immobilization vi. Gout

Adult 2

Final Study Guide vii. Over 65 years old c. Nursing Care i. Monitor VS 11. 1&0 iii. Control NN (phenergan, Zofran) iv. Increase fluid intake (2-3 Liters) v. Strain urine - send to stone to lab for analysis vi. Warm baths/warm pad to flank area V11. Analgesics (morphine, Demerol) 'd. Renal Stones

Page 39

.-.--~.-.---.. ..'---'~-"--'--~-""-"--"-"--'~"-----"-"~-'~-"""--'-'-i~-~'"Composition-~-'----'---" , -------"-.,...----.,----.--.--- -_'-----------.-",-.----.----.----_--.--'--..----.-.-.----.--.----.-------.1. Calcium Phosphate - most common (80-90%) a. Medications used to eliminate stones - Calcibind, Urocit-K 2. Oxylate a. Medications used to eliminate stones - Questran b. Diet - restrict peanuts, strawberries, cranberries, chocolate, and spinach 3. Struvite (mixure) - Staghom (related to infection) 4. Uric acid a. Medications used to eliminate stones - Zyloprim, Sodium bicarbonate e. Surgical Management i. Ureteroscopy - Visualizing the stone by inserting a ureteroscope and the inserting a laser or ultrasound device to fragment and remove the stones ii. Extracorporeal Shockwave Lithotripsy (ESWL) - shockwaves that are created outside the body travel through the skin and body tissues until they hit the denser stones. 1. Stones break down into sand-like particles and are easily passed through the urinary tract in the urine 2. Short recovery time 3. Done on out patient basis iii. Percutaneous Nephrolithotomy - tiny incision made in pt's back and tunnel created directly into the kidney 1. Surgeon removes stone with nephroscope 2. Some type of energy probe (ultrasonic or electohydraulic) may be used to break down the stone into small pieces 3. Hospitalized for several days 4. May have small tube (nephrostomy) left in kidney during healing process Describe pyelonephritis and the nursing care associated with it a. Common Causes i. Usually secondary to urtereovesical reflux ii. Infections to bladder iii. Use of a catheter to drain urine from the bladder IV. Use of a cystoscope to examine the bladder and urethra

3.

Adult 2

Final Study Guide v.
VI.

Page 40

Surgery on the urinary tract Prevention of efficient flow of urine from the bladder 1. Prostate enlargement 2. Kidney stones Chills Fever Pyuria (pus in urine) Flank pain Mental status changes (confusion) v. Dysuria vi. Frequency vii. Hematuria viii. Malaise

b.

SIS
i. ii. iii. iv. ix.

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......·-C:·-AculePyef6nepnntls·_····· __···_···_· __·__· ___·_· i. Diagnostic findings
1. Ultrasound CT scan 2. IVP rarely indicated (findings normal in 75% of cases) 3. Urine culture and sensitivity ii. Medical management - usually treated as outpatient if not severely dehydrated 111. Pharmacologic Therapy 1. 2 week course of antibiotics 2. Cipro, gentamicin most commonly used 3. Follow up urine culture 2 weeks after completion of antibiotic therapy d. Chronic Pyelonephritis 1. Clinical signs 1. Usually none until acute exacerbation occurs 2. Fatigue 5. Polyuria 3. Headache 6. Excessive thirst 4. Anorexia ii, Diagnostic finding 1. Creatinine clearance and BUN 2. Intravenousurogram iii. Complications 3. Hypertension 1. ESRF (causes 4. Kidney stones renal scarring) 2. Sepsis iv. Pharmacologic Therapy 1. Antibiotics after urine C&S 2. Careful monitoring of renal function v. Nursing Management 1. May require 3. Encourage hospitalization fluids 2. Monitor 1&0 4. Client teaching Identify the differences between Minimal Change Disease and Membranous Nephropathy a. Minimal Change Disease AKA Minimal Change Nephrotic Syndrome (MCNS) i. Affects children 2-6 years old and frequently seen in adults ii. Cause is unknown - believed to have an immunologic component

4.

Adult 2

Final Study Guide

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-~

-----~~-- --_

iii. Often preceded by a non-specific illness 4-8 days before (viral, allergic reaction, or recent immunization) IV. Pathophysiology - increased glomerular permeability to plasma protein - results in massive urinary protein loss v. Clinical Manifestations 1. Nephrotic syndrome a. Primary glomerular condition characterized by: i. Protein in the urine (> 3.5 g/day) ii. Decrease of protein (albumin) in the blood iii. Edema ~~ - -- --- - -------------------...... -- Iv.Higll serumc1io1esteroian:d:1ow<ie-nsitylipoproteinsDramatic weight gain 3. Abdominal pain 4. Diarrhea, loss of appetite 5. Decreased urine volume 6. Urine is dark and frothy 7. Fatigue, irritability 8. BP normal! May be low! 9. History - non-specific disease, immunization, allergic reaction, age of child 10. Needle biopsy a. Decreased immunoglobulins b. Increased platelets, Hgb, Hct due to hemoconcentration c. Fats may be present in urine VI. Treatment Goal - reduce excretion of urinary protein and maintain protein-free urine 1. Corticosteroid therapy and/or Immunosuppressant therapy 2. Albumin infusion if albumin is < 1.5, followed with diuretics (judicial use of diuretics) 3. ACE inhibitors 4. Antibiotics for any infections 5. Dietary changes vii. Nursing Care 1. Skin care 2. 1&0 3. Bed rest (turning to prevent skin breakdown) 4. Monitor weight and abdominal girth Membranous Nephropathy i. Kidney disorder resulting in disruption of kidney function because of inflammation of the glomerulus with thickening of the capillary wall of the basement membrane by immune complexes ii. One of the most common causes of Nephrotic syndrome iii. Can occur at any age, but seen more commonly after 40 iv. Causes 1. Idiopathic 2.

b.

Adult 2 2.

Final Study Guide Possibly related to a. Hepatitis B b. Malaria c. Malignant tumors d. Non-Hodgkin's lymphoma e. Syphilis f. Systemic lupus erythematosus (SLE) g. Exposure to certain substances/medications v. SIS - Nephrotic syndrome vi. Treatment ····_·· _ _ ·_·C···SimilarloMinimai-Cnange·Dislfase·--- .._._

Page 42

-

-.- .. _-_.-.-

__..- __.__

_

5.

2. Anti-hypertensives to control BP and help with dieresis - hypervolemic vii. Prognosis - 70-90% of pts have permanent kidney damage, 20% in ESRD Know the manifestations of Nephrotic syndrome a. Nephrotic syndrome -i. SIS - vary and in many cases there are no symptoms at all 1. Frothy urine 5.Nocturia 2. Weight gain 6.High BP 3. Poor appetite 7.Bx results of kidney 4. Hematuria n, Primary glomerular condition characterized by: 1. Protein in the urine (> 3.5 g/day) 2. Decrease of protein (albumin) in the blood 3. Edema 4. High serum cholesterol and low density lipoproteins

Unit·S - Integumentary - 13 questions 1. Describe aspects of skin assessment including variations for dark-skinned persons a. History - skin issues, family hx, current sis, allergies b. Physical- hygiene, odor, clean i. Color ii. Temperature - assess with back of the hand iii. Moisture IV. Texture - smooth, dry, scaly v. Turgor - elastic vi. Nailbeds - clubbing, infection, cap refill vii. Lesions - inspection, piercings, tattoos, bruises viii. Wounds - scrapes ix. Hair/scalp - patchy baldness (alopeciaj..dry, oily c. Dark Skinned Individuals i. Prerequisites - adequate lighting, close to pt, underlying conditions, clean skin, temperature and emotions affect skin color ii. Principle # 1: Edema masks color changes iii. Principle #2: Check less pigmented areas

Adu1t2

Final Study Guide

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-----2.

1. Palms 5. Inside of cheek 2. Feet 6. Sclera 3. Lips 7. Conjunctiva 4. Tongue iv. Petechiae & Ecchymosis v. Pallor - look at conjunctiva, earlobes, appear yellowlbrown or ashy gray VI. Erythema - redness (not always hot), may appear purplish vii. Rash - stretch skin to see clearly viii. Cyanosis - darkish gray, check conjunctiva, blanch skin (what color comes back)' IX. Jaundice - sclera, palms, palate, labs, tea colored urine, clay colored stools, t ·-------···-urmaryOTItput;-rBP;-rHR_-----------~-·--···-··-------------.. .--.-- ... ..... --.- -.--.-.-Give examples of charting observations of skin abnormalities using correct terminology a. Pruritis - itching from external stimulus (allergies) - corticosteroids, benedryl used b. Seborrhea - hyperactivity of sebaceous glands, oily skin - axillary, face, scalp c. Furuncle - (boil) inflammation of a hair follicle, can cause cellulitis (antibiotics used) d. Carbuncle - inflammation that is more deeply rooted, widely spread over the body e. Annular - ring shaped f. Circinate - circular g. Confluent ~ lesions run together h. Discrete - lesions are separate 1. Generalized - wide spread j. Universal - entire skin affected k. Linear - forms a line 1. . Multiform - more than one kind m. Excoriation AKA Erosion - moist superficial loss of skin/tissue n. Crusts -dried secretions (Impetigo) o. Scales - layers of dead skin p. Fissure - deep groove/crack q. Ulcer - stasis ulcer, pressure ulcer, sloughing of necrotic tissue r. Vascular lesions - bruising, petichiae, hematoma s. Primary lesions 1. Macule - spot, flat, less than 1 cm (freckle) ii. Patch - similar to macule, but more than 1 em in diameter iii. Papule - raised spot less than 1 em iv. Plaque - raised spot more than 1 ern v. Vesicle - raised with serous fluid, less than 1 em (blister) vi. Bulla - raised with serous fluid, more than 1 em vii. Pustule - filled with pus viii. Furuncle - raised pus filled vesicle or bulla ix. Wheal- larger raised patch, transitory edema, more flat topped (hives) Give 3 nursing diagnoses for skin disorders/conditions. For each of the diagnoses give a nursing intervention and the rationale a. Nursing dx i. Impaired skin integrity RlT disease process

.. .--.- ..-.------

3.

Adult 2
ll.

Final Study Guide Risk for infection RlT ... iii. Risk for impaired skin integrity RlT . iv. Alteration in comfort; itching RlT . v. Alteration in comfort, pain RlT ... vi. Anxiety RIT ... vii. Knowledge deficit RlT ... viii. Body image disturbance RlT ... b. Nursing care i. Inspect skin daily ii. Maintain cleanliness

Page 44

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v. Cool compresses if needed vi. Teach on disease processes and prevention 4. Describe 2 common medical treatments for skin disorders/conditions (baths, dressings) a. Dressings - provides protection (from scratching) and prevents infection b. Baths i. Zinc and copper - disinfect, deodorize ii, Tar - for itching, used for dandruff(T-Gel) iii. Colloid - oatmeal bath, soothing iv. Sodium Bicarb ~ soothing, t inflammation c. Topical applications - ointments (oil based prevent fluid loss), antibiotics, steroids, lotions (cools, protects dry skin) 5. For the major skin disorders/conditions discussed in class describe etiology, S/S,treatment, nursing care, and patient teaching. (on syllabus papers) a. Cellulitis - deep inflammation, generalized from staphylococcus usually in lower extremities i. SIS - generalized malaise, edema, redness, tenderness ii. Treated with systemic antibiotics (PO, IV), and elevated extremities b. Pemphigus Vulgaris i. Autoimmune disease ii. Most common in Jewish or Mediterranean populations iii. SIS 1. Blisters of the skin and mucous membranes a. Painful b. Rupture = serum leakage 2. Epidermal cells fail to adhere together iv. Diagnosis - made by biopsy of skin v. Complications vi. Treatment 1. Cortizone 2. Immunosuppressants - cydophophamide c. Herpes Zoster d. Skin Cancers

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II.

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I
"II

Adult 2

Final Study Guide

Page 45

e. Lupus Erythematosus

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