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- Mr. Davidson is a 24-year old boxer. He had a boxing game and received with a nose injury. Due to heavy nosebleed, he was transferred to ER. Health Assessment and Physical Exam: Diagnostic Test: Deviated septum is observed. X-ray is done to confirm the diagnosis.
- Patient is alert and oriented. He didn't lose his consciousness. The patient reports severe nose pain. No other symptoms.
- Nursing Care:
- What should be your highest priority when you plan the care of this patient? o Vent airway, BCs
- Which position should you assist the patient to and why? o Up right position, head slightly forward
- How do you differentiate between anterior nasal bleeding and posterior nasal bleeding? o Posterior: secondary to hypertension, older people, coughing, more dangerous, back of throat o Anterior: stops spontaneously, not life threatening, able to see
- What are some of the nursing interventions that can help control the bleeding of this patient? Provide rationale. o High fowlers, pinch nose, head tilt forward, acetaminophen, nasal sponges, nasal packing, medication for pain, Tylenol (no NSAIDS)
- What is the appropriate way to apply pressure to stop the epistaxis? How and for how long? o Pinch nose against septum 10-15 mins, up right, lean forward, ice
- Would you insert gauze into the bleeding nostril in this case? Why? o NO because patient has a fx. If stops in 10-15 mins then no gauze
- Considering the bleeding, what medications would be contraindicated? o NSAIDS, (aleve, advil, ibuprofen) anticoagulants (warfarin, heparin, Lovenox)
Heparin-IV, SC Lab: aPPT Need: sulfate
o Finish antibiotic in entirety o Bactrim is for MRSA or staph infection During the rhinoplasty, packing is inserted and left for few days. What teaching should you provide regarding the packing? o No nose blowing, swimming, heavy lifting, strenuous activity # 2: Allergic Rhinitis Mrs. Jones is a 32-year old who has a history of persistent allergic rhinitis.
- What is the difference between intermittent and persistent allergic rhinitis? o Intermittent- >4 days a week or 4 months per year o Persistent-symptoms present more than four days a week and for more than four weeks per year
- What seasons of the year do allergies flare up? Why? o Spring and fall
- What immunoglobulin rises when Mrs. Jones exposes to allergens? o IgE
- What are the major chemical mediators that are released during exposure to allergens? What are the major changes these mediators cause? How do these changes explain the symptoms of sneezing, itching, and congestion? o Prostaglandins, leukotrienes, histamines Release mediators, Nursing Care:
- The best and most important step management of allergic rhinitis is to avoid allergens. Teach the patient how to identify allergens. (Table 26-4)
- Mrs. Jones says "I want something to cure this allergy". How should you respond? o We can manage symptoms, but not cure allergies
- Identify the connection between the chemical mediators that result from the allergic reaction and the commonly prescribed medications. o Histamine- antihistamines (counteract histamines released)
- What is the indication, mechanism of action, desired outcome, side-effects, and adverse effects of 1stgeneration antihistamines? What is the major advantage of 2nd-generation antihistamines compared with 1st-generation antihistamine? Mention one 1st-generation antihistamine agent and 2ndgenerationantihistamine agent. 1 st^ gen- Benadryl (diamahydramine) Side effect: drowsiness –crosses blood brain barrier, sedation effect on brain Nursing consideration: no driving 2 nd^ Gen- Zyrtec, Claritin, allegra Pros: non-sedative, Con: not as strong as 1st
- How can the patient manages the dry mouth/mucosa results from antihistamines? o Ice chips, hydration
- Flunisolide spray, an intranasal corticosteroid, is prescribed for Mrs. Jones. For the best results, when should Mrs. Jones start using Flunisolide? o Couple weeks before allergy season o Take every day, no prn
- Mrs. Jones says "I should take Flunisolide when I need"? How should you responds? o False, need a few weeks to kick in
- Mrs. Jones says "Flunisolide relieves symptoms within minutes". How should you respond? o no
- Mrs. Jones asks "I usually get a sinus infection once a year, should I continue flunisolide if I get a sinus infection or quit?" How should you responds? o Keep taking
- In October, Mrs. Jones' symptoms become worse and Singulair (monteLUKAST), a leukotriene receptor antagonist inhibitor was added. Before Mrs. Jones can start using Singulair, what should the prescriber check first? o Liver function- AST and ALT labs
- It is safe for Mrs. Jones to use Singulair, what time of the day should she take it?
- Few months after using Singulair, Mrs. Jones calls and reports that her eyes are "turning yellow". What should you tell her? o Stop med, liver damage
- Due to some life events, Mrs. Jones develops depression. Phenelzine (Nardil), an monoamine oxidase inhibitor (MAOI), was prescribed for her. How will Nardil affect the allergy medications of Mrs. Jones?
o Interacts with other medications, stop allergy med
- Mrs. Jones tells you that her mother-in-law has developed nasal congestion and she is going to get her Sudafed (pseudoephedrine) over-the-counter (OTC). Sudafed would be contraindicated if the patient has what medical conditions? o Table 26-2: Heart issues, hypertension,
- Phenylephrine (Neo-Synephrine), an alpha-1 adrenergic agonist topical decongestant, is prescribed to use PRN. What cautions regarding the use of this decongestant should you include in the teaching plan? o Do not take more than 3 times daily, able to get rebound congestion
- Mrs. Jones tells you that her pulmonologist mentioned to her a therapy called "immunotherapy" and ask you to tell her more about. o Intro allergen to body slowly so get get used to allergen (desensitize) o Allergy shots
- Provide patients with education based on table 27-1.
- KNOW!!! Antihistamines, singulair, corticosteroids, decongestants o Know typical med, generic and brand name, nursing consid, side effects, who cant use
3: Acute Viral Rhinitis (Common Cold)
- Mr. Richards has developed a common cold. He tells you that last week he worked 7 days in a row 14 hours a day. He asks you if there was a connection between working "to much" and getting the cold. What should your response be? o Yes, stress increases chances of getting sick
- What are the latent viruses? and where do they live? o Dormant, live inside body
- Mr. Richards says "I'm going to see my doctor to get an antibiotic", what do you think? o No, virus are not effective
- What does Mr. Richards need to treat the symptoms of his cold? o Rest, fluids, decongestants
- Five days later, Mr. Richards informs you that his symptoms got worse and now he has fever of 104.
o Viral: no green discharge, low grade fever
4: Influenza (flu)
You are participating in setting up a "Flu Clinic" to vaccinate the local community. The following patients are present and you need to decide who should receive the inactivated vaccine and who should receive live attenuated vaccine Live: nasal spray age 2- Inactivated: shot, older people, immunocompromised
- A 65 years old with COPD. Dead
- A 9 months old. dead
- A 71 years old who lives in a nursing home. Dead
- A 45 years old who is diagnosed with AIDS. dead
- A 26 years old nursing students who is healthy. either
- A 27 years old who is 30 weeks pregnant. dead
- How will you administer the inactivated vaccine? What route? Location? What's the volume of the vaccine? o Intramuscular, deltoid, 0.5ml
- The mother of the 9 months old is requesting that her child receive the vaccine via nasal spray because it is less painful. How should you respond? o No, patient is too young and not immunity mature
- The 65 years old says "the vaccine will make me infecious so I have to avoid people for 2-3 days". How should you respond? o Dead virus is not infectious
- During physical exam of a patient with the flu, it is expected to hear crackles on asuculation. True/False. o Crackles- pneumonia
- What is the most common complication of influenza? What are the signs and symptoms that indicate poor prognosis (=flu becomes pneumonia)?
o Pneumonia, better and then worse, cough, fever, crackles, sputum purulent, SOB, dyspnea
- Susan is a 19-year old freshman student presents to APU health center complaining of "scratcy throat". Through examination, acute pharyngitis is suspected.
o o Most pharagytis are virus!
o Surgical- remove tumor,
o Chemo- use meds to kill cancer, IV or PO, need special certification to give chemo, controversial o Radiation- high dose X-ray to kill cancer cells, skin reaction (red and sensitive), special skin care needed, intense sun screen, dehydration What is brachytherapy? What are some of the cautions?
- Teach Mr. Ghali about supraglottic swallow.
- Discuss the post-op diet progression for Mr. Ghail (from NPO- IV- liquid-pureed!). o Go from Npo to IV (TPN[need central line, total parenteral nutrition], PPN [need peripheral IV, peripheral parental nutrition]) to clear liquid to full liquid to puree food to mechanical soft to regular diet ABG Exercise:
- pH 7.31, PaO2 80 mmHg, PaCO2 55 mmHg, HCO3 24 mEq. Respiratory acidosis
- pH 7.30, PaO2 85 mmHg, PaCO2 40 mmHg, HCO3 18 mEq. Metabolic acidosis
- pH 7.53, PaO2 90 mmHg, PaCO2 29 mmHg, HCO3 25 mEq. Respiratory alkalosis
- pH 7.50, PaO2 82 mmHg, PaCO2 37 mmHg, HCO3 30 mEq. Metabolic Alkalosis Memorize Normal: pH 7.35-7.45, PCO 2 35-45 mmHg (respiratory compensation), HCO 3 22-26 mEq/ml (renal system) metabolic *Memorize CBC (Complete Blood Count): Normal: WBC- 4000-11000, Hemoglobin Male 13-18 Female 1215, Hct Men 38-50, female 35-45, platelets 150- PT, INR (Normal 0.8-1.2, no coumodin)- monitered when on coumodin PT(11-14) PTT (125-135) *Memorize BMP- chem 7, Na (135-145), K(3.5-5), Cl (101-111), CO 2 (20-29), BUN (7-20) (renal, increase with exercise or high protein diet), SrCr (renal, not interfered by diet/exercise) (0.8-1.2), Glu (70-110) CMP: comprehensive metabolic panel (chem 12) X-ray- radiation, fx CT- radiation, computerized tomography, is basically a 3D x-ray, contrast v no contrast (renal impairment no IV contrast), MRI – no radiation, sound waves, no metals (pacemaker, transplant) Lower Respiratory Tuberculosis Case Study Nursing Science: Physiological Integrity Case Study: History Mr. B is a 38 year old homeless male consults presents to ED c/o cough , sputum production and mild
1. What can you identify in this patient's history that put him at high risk for this present illness? - Cough - Sputum production - Mild hemoptysis - Unexplained weight loss - Comes from an at risk population - homeless 2. Based on the clinical presentation, the MD suspects tuberculosis (TB). Assuming the diagnosis is accurate, what microorganism causes TB? How did Mr. B get infected with TB (think from the route of acquiring causing microorganism)? - Organism - Mycobacterium tuberculosis - Route of Infection - TB is released as droplet nuclei into the air from an infected person when they cough, sneeze, sing, or speak. These nuclei are inhaled by others who then become infected. 3. Based on the history of Mr. B, it is very likely that he was exposed to TB many years ago but until recently became active. What are the difference between active and inactive TB? Why Mr.B's inactive TB became active? - Active TB - Positive TB test with symptoms present. Highly infectious. - Inactive TB - Positive TB test indicating that an individual has the bacteria in their system, but no symptoms are present. 5-10% of those with a positive TB test will go on to develop the disease at some point in their life. Not infectious. - Reinfection can occur when the patient becomes immunocompromised. Mr. B's Physical Exam Findings On exam, Mr. B appeared to be chronically ill and wasted. Cavernous breath sounds are heard over the right apex. 4. The MD suspects TB and orders a series of tests. Place the interventions in the order that they should be performed. 1. Perform a PPD intradermal skin test 2. Have a CXR performed 3. Institute airborne precautions 4. Obtain sputum culture **5. Notify the Department of Health
- After the PPD skin test. The result of Mr. B will be considered positive if, after 48-72 hours, he** developsan induration that measures over mm? What is the rationale? Think from different patient populations. - Mr. B is homeless and therefore categorized in the “at risk” population. In addition, based on the history he provided, he is suspected to be immunocompromised. Those who are immunocompromised have developed a decreased response to tuberculin, so smaller indurations are
graded as positive. Therefore, if the induration measures over 5mm , Mr. B tests positive for the PPD test.
