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Nursing 2 final exam review
Examples of passive immunity: Breast milk colostrum from mother to child, and placenta. Delegations, priority… on our own. HIV – When CD4 count is less than 200 AIDS is diagnosed, and high risk of developing serious illness. When PT CD4 drops below 200 or below 500 with opportunistic infection. Treatment beings with counts drop below 500. When there is fever, night sweats, severe cough and this client CD4+cellcount is low, he or she may have anergy, or the inability to mount an immune response to TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if is present. Next the nurse notifies the provider about the low CD4+ count and requests alterative testing for TB. Client with pneumocystic carrini, should pace activities and allow for adequate rest. Opportunistic disease for HIV. toxoplasma gondii: use standard precaution consistently. (2) pneumonitis carinii or Jiroveci – lab value CD4+ less than 200, low platelet and low sodium. (3) HIV wasting syndrome. Treatment for type 1 allergies- anaphylactic reaction is (select all that apply ) – EpiPen, and stay with the person always. When on IV antihistamine patient should not get up without help because it causes drowsiness. After a patient has been stabilized after anaphylactic reaction and still wheezing give albuterol. Establish/maintain airway!! Raise feet and legs – tundenbug position Prevent spread of allergen, 0.3mL epinephrine IM, intubation kit – tracheostomy. Recumbent position, elevate legs, warm patient, support respirations with O2,BP maintained with IV fluids , Benadryl, steroid. Indication of albuterol: used for wheezing as a bronchodilator. DKA S/S: DYHYDRATION, KAUSSMAUL BREATH, ABDOMINAL PAIN, FRUITY BREATH .Hyperglycemia, Tachycardia, Orthostatic Hypotension, Ketones In The Urine, An Increased Rate And Depth Of Respiration. Illness, Undiagnosed And Untreated And Decreased Insulin. ABGs for DKA Metabolic Acidosis. Labs: glucose greater than 300 -600, PH less than 7.35, HNO3 15, PCO 28, PO2 98, BUN more than 30, Creatine more than 1.5. Ketones in urine.
Other Causes – PT Error, Intentional Skipping Of Insulin. Type 1 Diabetes. DKA with Kussmaul respiration give IV insulin. A glass of wine is okay with meals and counted as two fat exchanges. Medical Management of DKA: Rehydrate with normal saline then .45% NaCl D5 .45NS, restore electrolytes, ECGs, hourly blood sugars, IV insulin, avoid bicarb (it affects K). Types of hypersensitivity reactions – Type 1 (anaphylactic -Hypersensitivity – immediate reaction). Through contact, inhalation, ingestion, or injection of allergen. Allergic reaction mediated by IgE antibodies, release of histamine from cells, causing local or systemic reaction. Examples: Anaphylaxis, hay fever, atopic eczema, drug allergy, latex allergy! Type 2 (Blood transfusions – Hypersensitivity – Cytotoxic reaction)– Antibody is directed against an individual’s own cells or foreign body, can be life threatening. Blood transfusions, myasthenia gravis, autoimmune hemolytic anemia, good pasture syndrome. EAR DROP TEACHING : Warm bottle of drops between hands before administration (rolling), store in room temperature.do not expose to light, remove cerumen, do not use cotton tip swab. massage the ear for absorption. Pull up &back for adult, and down and back for children. BACTERIAL CONJUCTIVITIES TEACHING : Hand washing, keep hands away from eyes, do not share wash cloth or towels, replace eye cosmetics and do not share, do not wear contact lens until resolve, avoid rubbing eyes, instill eye drops/ointment correctly without touching tip of container with eye or eyelashes. Two different bottles of the same medication to avoid cross contamination. NURSING INTERVENTION FOR MENIERE’S DISEASE: tell patient to be on low sodium diet. Stop smoking, avoid caffeine. Client needs to be in bed with side rails up due to vertigo. Avoid sudden position change, will need help out of bed. Monitor fluid intake and output. Menu will be broiled chicken breast, and green herbal tea with meals. Medications are Chlorpromazine, hydrochloride (Thorazine), Diphenhydramine (Benadryl) and Meclizine(Antivert). TIMOLOL TEACHING FOR GLAUCOMA : do not administer when pulse/HR is less than
- Always check HR before administration. It lowers HR & IOP. Check BG. EFFECTIVENESS OF HEALING FOR GLAUCOMA: Reduces IOP. PHOTOS DYNAMIC THERAPY FOR MACULAR DEGENERATION TEACHING: Verteporfin for photo dynamic therapy. Teaching is to avoid sun exposure or bright indoor light for 5 days postoperatively. How to perform Rhine test, equipment: *The Rinne test is normal if air conduction is twice as long as bone conduction. Rinne test: (air/bone)
NEUROGENIC SHOCK
It is a distributive shock above C6. Patient at greatest risk 24 hrs after injury. Hypotension, bradycardia, dry , warm skin, decreases oxygen, decreases urine output, diaphragmatic breathing if injury from C5. Intervention for neurogenic shock are: assess breathing, LOC, Monitor for abdominal pain. Assess bowel sounds, and ensure patent airways, insert or maintain IV cath. Give O2, NURSING INTERVENTION FOR HYPOKALEMIA:. Implement safety measures with a patient who has muscle weakness from hypokalemia, including the fall precautions. Be sure to have the patient wear a gait belt when ambulating with assistance. Respiratory monitoring is performed at least hourly for severe hypokalemia. Assess the clients respiratory rate, rhythm, and depth first. Obtain pulse and b/p. Get order for potassium replacement. NURSING INTERVENTION FOR SOMORGI EFFECTS Nocturnal hypoglycemia followed by rebound hyperglycemia : advice pt to check BG btw 2- 4am for hypoglycemia- if present use less insulin. Also Change time of insulin to right before bed. Give peanut butter sandwich before bed INDICATION AND MECHANISM OF GLIPIZIDE FOR DIABETES TYPE II: Glipizide, Glyburide (2nd^ gen Sulfonureas) – increase insulin production. PEAK, ONSET, DURATION OF NOVOLOG, HUMALIN, LANTUS. Fast Acting (Novalog/Humalog - Lispro): Peaks 30-90 min – Food intake must occur w/in 15 mins to prevent hypoglycemia Regular: Peak 2-4 hours – Best 30-45min prior to food intake. Long acting (lantus): No peak – lasts 24 hours. Type 1 diabetes. Pre-mixed dual peaks. Best for patients who have trouble mixing Non modifiable risk factor for diabetes can be born with type 1 of diabetes
- age -gender -family history/genetics -being over 55’sl modifiable risk factors for diabetes
knowledge deficit physical inactivity -high fat levels -obesisty-impared glucose tolerance -gestational diabetes -being over 45 and overweight sedimentary life style. METABOLIC SYNDROME IN DIABETES – TEACHING Metabolic Syndrome is considered a pre-diabetic state. Fasting blood glucose test greater than 100, and elevated blood pressure, abnormal cholesterol ASSESSMENT FOR CHECKING PLACEMENT OF PEG TUBE: TEACHING FOR BURGERS DISEASE Quit smoking COMPLICATIONS OF THROMBOEMBOLISM AND INTERVENTIONS Bleeding, blood clot. Use soft toothbrush, no razor for shaving, low green leafy vegetables. FOODS TO AVOID WITH COUMADIN Green leafy vegetable, Brussels, green tea. RAYNAUD’S PHENOMENON TEACHING avoiding exposure to cold, need to wear mittens or gloves in cold weather and when handling cold items or defrosting the freezer. avoidance of stress and cigarette smoking need to inspect skin frequently and to seek immediate care for evidence of skin breakdown or infection prescribed medication therapy, including vasodilators. S/S OF DIGOXIN TOXICITY 0.5-2. Confusion, irregular pulse, loss of appetite, nausea, vomiting, diarrhea, palpitations, vision changes, decreased consciousness, decreased urine output, difficulty breathing, overall swelling. if the value is more than 2ng/mL is toxic. S/S OF ACE INHIBITORS
PO2- 80-90s CAUSES AND HOW TO TREAT HYPOKALEMIA – NEVER GIVE POTASSIUM WITH IV BOLUS OR PUSH. Lab value 3.5- 5 Causes: Thiazide diuretics, Flattened T-waves, U waves, paresthesia, orthostatic hypo, shallow resp. fall prevention. SPIROLACTONE- FOODS TO AVOID To avoid foods high in potassium such as: Potatoes, pork, banana, orange, tomatoes, avocado, strawberry, spinach, fish, mushroom, melons, cantaloupes. S/S OF HYPOVOLEMNIA weight loss decreased skin turgor, dry mucous membranes, decreased urine output, decreased BP ( less volume/less pressure ), tachycardia (weak & thready), increased RR, decreased CVP, vasoconstricted peripheral/ neck veins, cool extremities, increased urine specific gravity CORRECT USE OF LONG ACTING BETA ADRENEGIC MEDS FOR ASTHMA – TEACHING, EDUCATION. Inhibits the allergic process – an anti-inflammatory. NOT used for ACUTE attacks, used to PREVENT inflammation – must be taken even when feeling good. TX & TEACHING OF MIGRAINE Change positions slowly, take medication it every day, avoid food in tyramine- red wine, avoid msg. Imitrex -triptan. WHAT NOT TO GIVE WITH GLAUCOMA Do not give Atropine, epinephrine. EJECTION FRACTION - Poor perfusion if lower, look at the tissue, poor capillary refill SICKLE CELL CRISIS INTERVENTION Airway, hydration, pain medication. ARTERIAL INSUFFICENCY ASSESSMENT FINDINGS
CLINICAL MANIFESTATION OF ANEMIA:
Pale, Short of breath when doing activities but stop when at rest, fatigued, low Blood pressure, tachycardia. weakness, generalized malaise, skin pallor, SOB LAB RESULT TO BE MONITORED FOR BLOOD TRANFUSION Monitor potassium level if its more than 5 do not transfuse blood. SEIZURE: A tonic clonic seizure is Violent muscle contractions, loss of consciousness, rigid muscles. Lasts 2-3 minutes, occurs anytime of the day whether awake or not. Frequency is highly variable. medication for Tonic Clonic seizure is Ativan Status epilepticus is defined as either continuous seizures lasting greater than 5min or two. Occurs when abruptly stopping of antiepileptic drugs. It is a medical emergency, because it is often accompanied by respiratory distress brought on by hypoxia or anoxia. Morbidity and mortality for status epilepticus is 20%."
- Ativan, phenytoin (Dilantin), Phenobarbital (Luminal), Midazolam (Versed), Propofol (Diprivan), Fosphenytoin (Cerebyx)
- When an intravenous (IV) line is not available, intranasally administered benzodiazepines (midazolam) are a rapid and effective method to treat an acutely seizing patient Education: Take your medication every day. Phases: Prodromal – signs before seizure Aural – sensation/warning the pt remembers (odor, or flashing lights) Ictal – seizure Postictal – period immediately following. Safety positions: Left side – risk of aspiration, protect head INTERVENTION FOR PARKINSON’S DIEASES Bed Above 30 degrees, reinforce gait training, reinforce independent in care, monitor neurologic and respiratory status. MYESTENIA GRAVIS MANIFESTATIONS Dysphagia, drooping eye, profuse sweating. Muscle weakness, fatigue, resp.failure Monitor for choking, assess swallow and gag reflex. Monitor neuros and resp. status. They Can, not do the 6 cardinal signs or gaze, always have atropine ready due to secretions. APPENDICITIS ASSESSMENT: Right lower quadrant pain, RLQ Pain, Fever, McBurney’s point, rebound tenderness. Collaborative testing: Elevated WBC’s. CROHN’S DISEASSE TEACHING
Ethabutol TB regime ranges from 6-12 months Liver disease is contraindicated for meds. Such as hepatitis B. CHRONIC RENAL FAILURE – EKG FOR ARRYTHMIA – ABNORMAL ELECTROLYTE -HYPO OR HYPER?? – Hydrogen, hyperkalemia. DISORDERS FOR RESPIRATORY ACIDOSIS( SELECT ALL THAT APPLY QUESTION) Guilian -Barre, myasthenia gravis, spinal cord injury, pulmonary emboli, pulmonary edema, pneumonia, atelectasis, upper airway obstruction, chronic obstructive lung diseases, prolonged over breathing of CO2. GTUBE THAT CANT SWALLOW- HOW TO PREVENT ASPIRATIONS HOB up BMI Normal: Up to 25. Overweight: 25- 30 Obese: 31- 35 PRIORITY FOR SEIZURES Maintain patent airway Side lying. Orient client to environment. QUAD WITH DVT PREVENTION (SELECT ALL THAT APPLY) Lose weight, stay active. Avoid long periods of staying still. Ted sock, coumadin, anti-platelet – heparin. Passive range of motion. ANTIBIOTICS REACTIONS (SELECT ALL THAT APPLY) Maintain Patent airway Call rapid response oxygen ABDOMINAL AORTIC ANEURYSM TEACHING: Avoid palpating abdomen of a client with suspected AAA.
Assess distal pulses. Check urinary output.
