Adult I final review

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Adult I final review
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Adult I final review
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  1. Contusion
    Strain
    Sprain
    • • CONTUSION– bleeding into soft tissue with skin intact
    • – S/S ecchymosis/bruise, pain, edema (hematoma)

    • • STRAIN– ‘muscle pull’ or tear - muscle that is forced pasts its elasticity
    • – S/S gradual soreness or sudden pain with isometric contraction of muscle, edema,stiffness, limited motion, swelling, bruising

    • • SPRAIN– ligament injury (joints) - may be partially or completely torn -
    • – S/S ecchymosis, painful joint with motion,edema, loss of functional ability, feeling a "pop" or tear
  2. Treatment for Soft Tissue Injuries (RICE)
    • R e s t (immobilizers, sling, splint)
    • - - limit weight bearing for 48 hours - use crutch/ cane on uninjured side so you can lean away and relieve weight on injured leg

    • I c e x 48 hrs. then heat (avoid rebound)
    • - 20 minutes at a time
    • - 4 to 8 times a day

    • C o m p r e s s i o n (ace wrap)
    • - - loosen if experience numbness or cyanosis

    • E l e v a t i o n (above heart level)
    • - - rest on pillow above level of heart

    • initial tx of tissue trauma - 24 to 48 hours
    • ice vasoconstricts and limits ability to swell
    • Heat promotes circulation

    • ANALGESICS/NSAID’s
    • PHYSICAL THERAPY - preventative
    • SURGERY - if severe sprain of ligament
  3. JOINT DISLOCATION
    Dislocation=end of bone out of socket/loss of articulation

    Subluxation=partial dislocation

    • • S/S of DISLOCATION:
    • – Pain
    • – Deformity
    • – Limited motion

    • • TREATMENT:
    • – Reduction via manual traction (Reducing = putting back in place)
    • – RICE and analgesics
    • • Rest-Ice/Immobilization
    • -compression, elevation

    – Neuro checks (pulses, movement, sensation)- esp with casts, binders - to maintain circulation
  4. Rebound phenominon with hot and cold
    heat - max vasodilation at 20-30 minutes - tx should be stopped becuase moving beyond that time will result in vasoconstriciton and tissue congestion

    Cold -vasoconstrction until skin gets to 60 degrees - then vessels vaso dilate to promote circulation
  5. Tx for sprains
    • ankle sprains -immobilized with casts or splints - no limit on weight bearing
    • knee - immobilizer
    • arm - sling

    • Surgery if severe
    • PT for rehab

    • Time - 3 to 6 weeks for minor sprain
    • - 8 to 12 months for severe sprain before return to full activities
  6. Preventative measure for strains & sprains
    • Avoid exercising or playing sports when tired or in pain
    • .Maintain a healthy, well-balanced diet to keep muscles strong.
    • Maintain a healthy weight.
    • Practice safety measures to help prevent falls.
    • Wear shoes that fit properly.
    • Replace athletic shoes as soon as the tread wears out or the heel wears down on one side.
    • Do stretching exercises daily.
    • Be in proper physical condition to play a sport.
    • Warm up and stretch before participating in any sport or exercise.
    • Wear protective equipment when playing.
    • Run on even surfaces.
  7. BONE FRACTURES
    = break in continuity of bone;

    • TYPES:
    • • Closed/simple
    • • Open/compound - need tetanus shot
    • • Avulsed - tendon & muscles pulled off bone - difficult to fix
    • • Comminuted - lots of pieces - risk for emboli
    • Complete - entire width of the bone
    • • Incomplete - partial width - also called greenstick
    • • Stable/nondisplaced - bones maintain anatomic alignment
    • • Unstable/displaced - bones move out of correct anatomic alignment
    • Pathological - secondary to disease
  8. Open Fractures
    S & S
    • -(If open, check Tetanus status)
    • • Disruption or break in the continuity of the structure of bone

    • • FX Signs & Symptoms:
    • – Deformity -cardinal sign
    • – Swelling
    • – Pain
    • – Numbness/nerve damage
    • – Ecchymosis/bruising
    • – Crepitus
  9. 5 P's of Neuro Assessment
    • Pain
    • Pulselessness - distal to break
    • Pallor
    • Paralysis - inability to move
    • Paresthesia - burning, tingling, prickling, itching
  10. 3 Phases FX Healing (6-16 wks)
    1. Inflammatory – blood flow ↑, WBC’s & collagen to site

    • 2. Reparative – osteoblasts form new bone,osteoclasts remove old bone, Calcium deposits in collagen
    • a. Fibrocartilaginous callus formation 48 hrs.
    • b. Bone callus formation (2-3 mos.)

    3. Remodeling – new bone formed

    Wolff’s law – bone develops & remodels self to resist stresses placed on it
  11. FRACTURE TREATMENTS
    Closed reduction/external fixation•

    • Open reduction & internal fixation (ORIF,pins, screws, nails, etc.)
    • - open=surgical
    • - closed - external fixation

    • Cast – immobilize

    • • Traction - immobilize first 24 to 48 hours to decrease swelling and get bloodthinners out of system if necessary (heparin, coumadin) -
    • – pulling force maintains alignment
    • – Manual
    • – Straight/skin
    • – Skeletal
    • – Balanced suspension

    • • Electric bone stimulation
    • • NSAID’s & narcotics (PCA) 24 – 48 hrs.
  12. Compartment Syndrome
    • • Fluid trapped in enclosed space with decreased blood flow within 1st 48 hrs.
    • • Fascia is a closed compartment (or a cast)
    • • Swelling causes decreased circ. to muscles,tendons & nerves
    • • S/S: Pain, normal to decreased pulses,cyanosis, tingling, reduced capillary refill
    • • Myoglobins (proteins) too big for kidney to excrete causing fluid shifts & renal failure
    • • Treat by removing cast/bivalving or surgical fasciotomy to relieve pressure
    • - - windows on casts for wounds- don't throw away
  13. FAT EMBOLISM
    • • Fat Embolism- few hrs. – 1 wk. Post-injury
    • – occurs with fractures of long bones or pelvis or in hip replacements
    • – Fat globules lodge in pulmonary or peripheral circulation

    • S&S:
    • •Neuro: confusion, decreased LOC
    • • Pulm. edema, tachypnea, & dyspnea
    • • Petechia rash on chest, axilla, upperarms

    • Treat: Intubate & mechanical ventilation
    • Corticosteroids
  14. Hip Fractures and Care
    Intracapsular fracture - at the head or neck of the femur - no covereved in periosteum - no good blood supply

    Extracapsular fracture - fracture at trochanter regions - periosteum - good blood supply

    Tx: traction to reduce muscle spams - surgery within 24 hours - ORIF -with prostetics if blood supply has been interrupted

    • Nursing Tx:
    • -maintain skin integrity
    • -prevent infection
    • -alleviate pain
    • -maintain circulation to the injured extremity
    • -increase mobility
  15. DVT in fractures
    -can become pulmonary emboli

    • S & S
    • -can be asymptomatic
    • - swelling, pain, tenderness, or cramping of the affected extremity

    • Prevention:
    • early immobilzation of the fracture
    • early ambulation
    • prophylacitc anticoagulation
    • TED hose
    • SCD's
  16. Casts - complications and how to assess
    • -perform freuqent neuro checks - circulation to distal extremity
    • -palpate the cast for "hot spots" - may indicate infection
    • -report pain, changes in neuro status, hot spots, or drainage
    • -do not palpate while drying - 1 hr for fiberglass - 24 hours for plaster - palapting will cause dents that can cause pressure ulcers

    • Tx:
    • -dont put anything in the cast
    • -keep clean and dry
    • -use dryer on low if gets wet (fiberglass only)
    • -blow air into cast for itching
  17. Fractures - nursing Dx
    • Acute Pain
    • Risk for Peripheral Neurovascular Dysfunction
    • Risk for infection
    • Impaired Physical Mobility
  18. AMPUTATION
    Disarticulation
    • Partial or total removal of extremity due to interruption of blood flow
    • • From acute trauma or chronic process
    • • Levels of amputation:
    • – Forequarter (shoulder)
    • – Hemipelvectomy (top pelvis)
    • – Above or below elbow
    • – Above or below knee
    • – Syme’s (foot at ankle)

    • Types:
    • – Open/guillotine esp. if infection so can drain
    • – Closed with flap of skin covering wound

    Disarticulation - amputation - removed at joint

    gangrene - organism with toxic gas - try to amputate above gangrene
  19. CARE OF CLIENTS WITH AMPUTATIONS
    Safety - primary concern- bed rails if able - they forget limb is gone and try to get out of bed

    • • Prevent joint contractures
    • – avoid hip flexion, elevate extremity BKA(below knee amputation)
    • – prone with hip extended 30 min 3-4/dayAKA (above knee amputation)
    • – avoid semi-fowlers, esp. above knee - causes pressure

    • • Discuss phantom limb pain
    • • Analgesics, antibiotics, glucocorticoids
    • • Evaluate healing (air & massage)
    • • Compression dressing (distal to prox.)
  20. Carpal Tunnel Syndrome
    Compression of Median Nerve

    • Phalen’s sign (numbness of thumb, index finger & half of middle finger when dorso-flexhands x 60 sec.)
    • • Tinel’s sign (tapping over medial nerve causes burning or tingling)
    • • S/S: Numbness/tingling/pain at night, inability to grasp or hold objects

    • • Treatment:
    • – Rest
    • – NSAIDS
    • – Splints (immobilize)
    • – Surgery (resect carpal ligament)
  21. BURSITIS
    Inflammation of Bursae that line synovial membranes between tendons & bones (most often in shoulder, hip,knee or elbow)

    • S/S: Pain on flexing or extending joint with red, hot, edematous bursa

    • • Interventions:
    • – Bracing to immobilize the area
    • – Xylocaine & cortisone injection
    • – Acupuncture
    • – Electrical stimulation (TENS)
    • – Cold/ice
  22. Osteoporosis
    Risk Facotrs
    • = loss of bone mass
    • • Active bone growth til age 30 then declines til death

    • • Risk Factors:
    • – Female > male
    • – Caucasian or Asian
    • – Small Stature
    • – Anorexia
    • – Low estrogen
    • • Post Menopausal
    • • No estrogen replacement/HRT
    • – Low activity/exercise
    • – Smoker - decreases O2 to bone
    • – Hx of fracture as adult
    • – Oral steroids> 3mo
    • – > than 2 drinks/day
  23. Osteoporosis Signs &Symptoms
    • \Silent disease as bone loss withou tsymptoms
    • • Decrease height from vertebral collapse
    • • “Dowager hump” kyphosis and lordosis with flexed knees & hip
    • • Low back pain
    • • Fractures of forearm, spine or hip
  24. Bone Density Tests
    • Quantitative Computed Tomography (QCT)
    • Dual Energy X-ray Absorption (DEXA)
    • – Measures bone density in lumbar spine & hip
    • – Highly accurate
    • – Normal 1.0 SD below peak bone mass
    • – Osteopenia-1.0to –2.5 SD
    • – Osteoporosis >-2.5 SD
    • • Ultrasound of heel of foot (screenings)
    • • AST (Alkaline phosphatase) & Calcium
    • – Elevated when fracture(s) present
    • • Serum Bone Gla-protein
    • – An indicator of bone turn-over (osteoclasts)
    • – More effective to evaluate treatment
  25. Osteoporosis Treatments
    • Nutritional Therapy
    • – (Foods high in calcium)
    • • Drug Therapy:
    • – Fosamax, Actonel(biphosphonates)
    • - - • (AM dose, 8oz water, no food/drink for 30minutes - should not lay down after take it - damages esophagus)
    • – Estrogen- keeps calcium in bone
    • – Evista - Mimics estrogen –keeps calcium in bone– Calcitonin hormone increases bone formation (nasal yeta llergic responses)

    • Calcium:1200-1500mg/d with Vit. D:
    • 1000 mg/day 19-50
    • 1200 mg/day 51-64
    • 1500 mg/ day >65

    • • Calcium Carbonate
    • – Constipation
    • – Before meals so absorb

    • • CA Gluconate
    • – Metabolic Alkalosis

    • • CA Citrate with meals so less side effects
    • • Sodium Fluoride

    • Wt. Bearing Exercises - such as walking to slow degeneration
  26. OSTEOARTHRITIS
    • =Progressive loss of joint cartilage mainly in weight-bearing joints (cartilage turns yel.-gray/brown & bone spurs/”joint mice”)
    • -Also called DJD - Degenerative Joint Disease
    • -Wear & Tear disorder vs. RA which is autoimmune
    • RISK FACTORS
    • • Female hands v. male hips
    • • Genetics
    • • Obesity/inactivity
    • • Mechanical joint stress (repetitive)
    • • Trauma/sports
    • • Hormone disorders
    • • Age > 40 yrs.
  27. Osteoarthritis (DJD) Treatments
    • Analgesics (ASA, Tylenol, NSAID esp. Cox-2inhibitors like Celebrex, Mobic)
    • • Capsaicin cream for joint pain & Topical NSAID's
    • - -keep away from eyes, nose, mouth, and open skin
    • - - use 3-4 times a days and D/C is irritation occurs
    • - - up to 2 weeks of regular use may be needed for full effect

    • • Intra-articular corticosteroid injections q 4-6mons. - may hasten cartialge breakdown if used more frequently
    • Hyaluronan - hyluronic acid HA - injection in knee- 3 to 5 weekly injections - lasts up to 6 mo
    • • Moist heat
    • • Surgery – total joint replacement (hip, knee)
    • - arthroplasty - joint replacement
    • • Bioelectromagnetic therapy
    • • Supplements (glucosamine, chrondroitin,zinc, copper, selenium, manganese)
  28. RHEUMATOID ARTHRITIS
    • Chronic, systemic, autoimmune inflammatory disease of the connective tissue
    • Involves cartilage& synovial membranes

    • Signs/Symptoms:
    • • Joint pain
    • • Joint morning stiffness > 1 hr.
    • • Swelling, warmth
    • • Reduced mobility
    • • Fatigue
    • • Begins with small joints (boggy, spongelike swollen inflamed)
    • • Joint deformities
  29. Rheumatoid Arthritis Diagnosis
    • Elevated rheumatoid factor (antibodies IgG)
    • • Elevated ESR (erythrocyte sedimentation rate)
    • • Cloudy synovial fluid with increased protein & WBC’s
    • • CBC to identify anemia
    • • Antibodies to cyclic citrullinated peptide(CCP-early stage)- provides more specific marker for RA but may only be present in 50% of patients in early stages
    • • X-ray with joint space narrowing (late stage)
  30. RA nursing Dx:
    • Chronic Pain
    • Fatigue
    • Ineffective Role Performance R/T disability
    • Distrubed Body Image
  31. Rheumatoid / Osteoarthritis
    • RA
    • • Young/middle aged 20-40
    • • Female > male
    • • Systemic manifestations
    • • Usually bilateral
    • • Hand & feet deformities
    • • Inflammatory (red, hot swollen boggy joints)
    • • Stiffness on arising > 1hr. & prolonged activity
    • • Anemia common
    • • ESR elevated

    • Osteoarthritis DJD
    • • Usually > 40 years
    • • Female (hands) = male(hip)
    • • Local joint manifestations
    • • One or more joints-unilat.
    • • Hand nodes (Heberden orBouchard’s )
    • • Noninflammatory (bony,hard, cool enlarged joint)
    • • Stiffness with inactivity
    • • Uncommon for anemia
    • • Normal ESR usually
  32. OSTEOMYELITIS
    • =infection of bone
    • • 3 Mechanisms:
    • – Blood borne (hematogenous)
    • – Contiguous soft tissues
    • – Vascular insufficiency

    • Esp. staph aureus (70-80%)

    S/S: fever/chills, malaise, swelling redness & warmth,lymphadenopathy (acute v. chronic)

    • Dx:
    • MRI & CT scan - identify abscesses, sinus tracts, and bone changes
    • Ultransound - detect subperisteal fluid collections, abscesses, and periosteal thickeneing and elevation
    • ESR & WBC elevated
    • Blood and tissue cultures - C & S

    • TX: IV antibiotics, surgical debride, hyperbaric oxygentherapy, high cal. high protein diet
  33. SYSTEMIC LUPUS ERYTHEMATOSUS
    • • Chronic multisystem inflammatory disease of connective tissue
    • • Antibodies agains town DNA form immune complexes that are deposited in connective tissues,blood vessels, lymph & organs
    • Problems
    • • Dermatologic
    • • Musculoskeletal
    • • Cardiopulmonary
    • • Renal
    • • Infection
    • • Central nervous system
    • • Hematologic
    • • Ocular
  34. LUPUS
    Signs & Symptoms
    • • Facial Rash “Butterfly rash”
    • • Joint pain (arthralgia)
    • • Fever
    • • Malaise
    • • Anorexia/weight loss
    • • Alopecia
    • • Infection
    • Renal insufficiency (50%)
    • - proteinuria
    • • Pulmonary – pleurisy, effusions, lupusp neumonitis
    • • Ocular – photophobia, retinal vasculitis
    • • CNS – organic brain syndrome, seizures
    • • CV – endo/pericarditis, Raynaud’s
    • • Hematologic -
    • – Anemia
    • – Leukopenia
    • – Thrombocytopenia
  35. Lupus Nursing DX
    • Impaired Skin Integity
    • Ineffective Protection
    • Readiness for Enhanced Self Health Management
    • Impaired Body Image R/T butterfly rash
  36. MUSCULOSKELETAL NURSING DIAGNOSES
    • • Acute or Chronic Pain RT Fx or arthritis
    • • Impaired Physical Mobility RT traction
    • • Risk for Injury: Periph. Neurovascular
    • • Risk for Infection RT osteomyelitis
    • • Risk for Ineffective Tissue Perfusion
    • • Hyperthermia RT Osteomyelitis
    • • Disturbed Body Image RT Rheumatoid Arthritis
    • • Risk for Dysfunctional Grieving RT Amputation
    • • Knowledge Deficit RT Health Seeking Behaviors
    • • Fatigue RT fibromyalgia
    • • Imbalanced Nutrition, less than required for calcium RT osteoporosis
    • • Risk for Impaired Skin Integrity RT traction
    • • Self-care Deficit RT ADL & osteoarthritis
    • • Ineffective Role Performance RT traction
    • • Ineffective Protection RT immunosuppression
    • • Decisional Conflict RT bone cancer
    • • Impaired Health Maintenance RT lupus
  37. Malignant Hyperthermia
    •  S/S:
    • -fever (105-111)
    • * Acidosis (resp. & met.)
    • Muscle rigidity
    • * Warm, mottled skin
    • Tachycardia
    • * Arrhythmia/CV collapse

    • Treatment
    • * Lower body temp. (hyperthermia blanket, cool fluids)
    • * Monitor urine output
    • * Monitor VS
    • * Treat arrhythmias
  38. Atelectasis Postop
    S & S
    Nursing Interventions
    Incomplete expansion or collapse of lung tissue resulting in inadequate ventilation and retention of pulmonary secretions

    • S & S
    • dyspnea
    • diminished breath sounds over the affected area
    • anxiety
    • restlessness
    • crackles
    • cyanosis

    • Nursing interventions:
    • elevate HOB
    • administer 02 as prescribed
    • turn cough and deep breathing. Q2 hours
    • ambulate
    • incentive spirometry
    • analgesics as prescribed
    • promote hydration
    • supportive measures to patient and family
  39. postop pain control
    • relaxation
    • music
    • distraction
    • imagery
    • massage
    • heat or cold
    • tens units for incisional pain
    • acupuncture
    • acupressure
    • therapeutic touch

    Opiate drugs - remember PO doses are not equal to IV doses

    • Assess and document pain at scheduled intervals to determine degree of pain control
    • observe per drug side effects
    • assess the need to change doses and are frequency of medication
  40. postop urinary retention and interventions
    urinary retention may occur due to recumbent position, effects of anesthesia and narcotic, inactivity, altered fluid balance, nervous tension, or surgical manipulation in the pelvic area

    • Assess for distention. If patient has not voided and 7-8 hours after surgeryor if frequent small voids
    • bladder scanner
    • monitor I & O
    • IV fluids as prescribed
    • oral intake of 2500 to 3000 mL if permitted
    • straight Or indwelling catheter If ordered
    • positioning and privacy when patient uses bedpan
    • assisting to bedside commode or bathroom
    • measured amount of warm water over the perineal area
  41. general anesthesia risk factors
    patients with respiratory or circulatory diseases such as emphysema or CHF are at greater risk for complications

    patients with renal or hepatic diseases cannot metabolize and eliminate anesthetic safely

    inhalation agents should be avoided in patients with a history of malignant hyperthermia because they trigger MH
  42. SEVEN SIGNS OF CANCER
    • • C Change in bowel or bladder
    • • A A lesion that does not heal
    • • U Unusual discharge from any orifice
    • • T Thickening lump in breast or elsewhere
    • • I Indigestion or difficulty swallowing/dysphagia
    • • O Obvious change in a wart or mole
    • • N Nagging cough or persistent hoarseness

    • GENERAL SIGNS AND SYMPTOMS OFC ANCER
    • • Pain in later stages
    • • Fatigue
    • • Cachexia - wasting syndrome
    • • Anemia
    • • Infection/leukopeniaWBC’s < 4,000 (Normal 5,000-10,000)
    • • Bleeding/thrombocytopenia Platelets < 150,000 (Normal 150,000-400,000 uL)
  43. graft versus host disease
    • bone marrow transplant or stem cell transplant
    • immune cells of the donated bone marrow identified the recipients body tissue as foreign

    • S & S
    • skin rashes, progressing to desquamation (loss of skin)
    • diarrhea
    • G.I. bleeding
    • liver damage
    • maculopapular rash that begin the palms and soles of the feet and make standard the entire body

    Treated with antibiotics and steroids and immunosuppressive drugs
  44. superior vena cava syndrome
    cancer complication

    • -most common cause is small cell or squamous cell lung cancers
    • obstruction of the venous system causes venous pressure, venous stasis, and engorgement of the veinsbetter drained by the superior vena cava

    • S & S
    • facial, periorbital, and arm edema
    • respiratory distress, dyspnea, cyanosis, tachypnea, altered LOC

    • Interventions:
    • monitor vital signs
    • administer corticosteroids
    • provide respiratory support with oxygen and prepare for tracheostomy
    • provide a safe environment, including seizure precautions
  45. cancer complications
    pericardial effusions and neoplastic cardiac tamponade - access of fluid that compresses the heart, restricts heart movement, and resulting cardiac tamponade

    • interventions:
    • administer oxygen
    • insert IV catheter
    • monitor vital signs
    • prepare vasopressor drugs
    • get crash cart
    • reassure the patient

    Superior vena cava syndrome

    Sepsis and septic shock

    Final cord compression

    Obstruct daily uropathy - obstruction of bladder neck or ureters

    Hypercalcemia

    Hyperuricemia

    Tumor lysis syndrome - combination of 2 or more metabolic abnormalties - hyperuricemia, hyperphosphatemia, hyperkalemia, hypocalcemia
  46. benign versus malignant neoplasms
    • benign
    • localized growths
    • solid mass
    • well defined borders
    • contact inhibition
    • slow growth
    • encapsulated
    • easily removed
    • does not recur

    • Malignant
    • invasive
    • non-cohesive - irregular shape
    • no contact inhibition
    • invades and destroy surrounding tissue
    • rapid growth
    • metastases to distant sites
    • not always easy to remove
    • can recur
  47. BSE breast self exam
    • lie on back- spreads breast tissue over chest wall
    • use finger pad of middle fingers
    • use overlapping dime sized circular motions
    • 3 different levels of pressure to feel all tissue
    • use up-and-down pattern between ribs and collarbone
    • standard front of mirrorwith hands on hips
    • look for changes in size, shape contour or dumpling
    • examine underarm while sitting or standing with arms lightly raised
  48. testicular self exam
    • examine and warm shower or bath, or just after
    • Hands and scrotum should be soapy
    • roll each testicle between and fingers
    • -if you feel hard lumps or one is substantially larger than the other. Contact your physician
  49. RED BLOOD CELL COUNT
    • • Number of erythrocytes 3.5 - 5.5 mm3
    • • Contain hemoglobin Hgb 12-18
    • • Hematocrit (Hct) - volume, expressed as 36-50 (3 times Hgb)
    • WBC count - 5000 to 10,000
  50. A N E M I A - Signs / Symptoms
    • Weakness
    • • Fatigue/malaise
    • • Dyspnea on exertion
    • • Tachypnea
    • • Pallor
    • • Tachycardia
    • • Palpitations
    • • Systolic murmur
    • • Night cramps
    • • Chest pain/angina due to increased cardiac workload
    • • Bone pain due to increased erythropoietin
    • • Headache, dizzinessor dim vision due to cerebral hypoxia
    • • Heart failure with vent. hypertrophy

    • •koilonychias - Brittle spoon-shaped nails
    • • Cheilosis/cracks around mouth corners
    • • Smooth, sore tongue (glossitis)
    • • Pica (unusual cravings for starch, clay,etc.)
  51. B12 Deficiency Anemia
    • – B12 is needed to mature RBC's (macrocytic)
    • – Enough not consumed in strict vegetarian diet:
    • • Meat/fish (salt water)
    • • Eggs
    • • Dairy (milk & cheese)

    • – Not absorbed by gastric mucosa due to lack of intrinsic factor (pernicious anemia) or other reasons (malabsorption)
    • – Schilling test to detect if B12 malabsorption v. lack of intrinsic factor
  52. Signs/Symptoms of B12Anemia
    • • Pallor or slight jaundice
    • • Sore, beefy red tongue
    • • Diarrhea
    • • Paresthesias & decreased proprioception

    • • Treatment:
    • • Increase diet B12 (muscle meats, fish, eggs,dairy)
    • • Oral B12 (Kaybovite) if absorption not problem (Pernicious anemia)
    • • B12 injections for rest of life if absorption problem (hydroxycobalamin or cyanocobalamin)
  53. SICKLE CELL ANEMIA
    • • Genetic defect (HbS gene)- when the HBS cell is deoxygenated it crystallizes into rodlike structures
    • -when normal oxygen tension is restored cells resume their normal shape
    • -repeated episodes. weaken RBC cell membrane so RBC life span is greatly reduced

    • • Episodes can be triggered by:
    • • Infection,
    • • High altitudes (hypoxia)
    • • Stress/acidosis
    • • Surgery/blood loss/anesthesia
    • • Excess exercise

    • • Pain is caused by ischemia from the sickled cells clumping and decreasing circulation to organs
    • • Can affect all organs (esp. spleen & kidney)
  54. SICKLE CELL DISEASE•
    Sickle cell trait=inherit gene from 1 parent; 40% HbS hemoglobin; asymptomatic unless severe hypoxia

    • Sickle cell disease=inherit gene from both parents so at risk for sickle cell crisis

    • Sickle cell crisis= severe episode of fever & intense pain with thrombi & ischemia (4-6 days)

    • Sequestration crises= blood pooling in liver & spleen esp. in children with sickle cell

    • DX: Sickle cell test & hemoglobin electrophoresis

    • Sickle Cell Symptoms:
    • • Pallor
    • • Fatigue
    • • Jaundice
    • • Irritability
    • • Enlarged liver/spleen
    • • Swollen joints
    • • Priapism
    • • Abd. pain/infarct
    • • Stroke from thrombi

    • • Supportive Care:
    • • Rest
    • • O2 supplemental
    • • Analgesics for pain
    • • Hydration
    • • Folic acid
    • • Hydroxyurea
    • • Blood transfusions
    • • Genetic counseling
  55. BloodTypes/Compatibilities
    • BloodTypes/Compatibilities
    • • A: A antigens, B antibodies
    • – Compatible A & O; incompatible B & AB

    • • B: B antigens, A antibodies
    • – Compatible B & O; incompatible A & AB

    • • AB: A & B antigens, no antibodies
    • – Compatible A, B, AB, & O; no incompatibilities as universal recipient

    • • O: no antigens, A & B antibodies
    • – Compatible O as universal donor; incompatible A, B, & AB• Rh positive with D antigen; Rh negative no antigen
  56. BLOOD ADMINISTRATION
    • • check Dr’s order & pt. consent
    • • check labels - 2 Nurses
    • • Pt arm band
    • • MAR
    • • Label on blood
    • • baseline vitals & q 5 min x 3 then q 30 min til 1 hr post
    • • #18 gauge needle
    • • normal saline only
    • • set with filter
    • • severe reactions first 15minutes
    • • change tubing/filter if giving multiple units
    • • return bag to blood bank
  57. Blood Reactions
    • - Febrile (1st 15 min.)Sensitivity of client’s antibodies to donor’s WBC’s
    • • Fever
    • • Chills
    • • Warm flushed skin
    • • Headache
    • • Anxiety
    • • Muscle pain

    • -Hypersensitive(during or after transfusion)
    • Mild Allergic• Sensitivity of client’s antibodies todonor’s plasma proteins (IgA)
    • • Itching
    • • Flushing
    • • Urticaria/wheals
    • • Bronchial wheezing

    • • Severe Allergic(Anaphylactic)• Antibody – Antigen Reaction
    • • Dyspnea
    • • Chest pain
    • • Circulatory collapse
    • • Cardiac arrest

    • Acute Hemolytic -ABO incompatibility between client & donor - Discontinue Blood
    • • Chills
    • • Fever
    • • Headache
    • • Backache
    • • Dyspnea
    • • Tachypnea
    • • Cyanosis
    • • Chest pain
    • • Tachycardia
    • • Hypotension
  58. Interventions for Blood Transfusion Reactions
    • • Stop the Blood ( tubing & KVO with .9NS IV)
    • • Call MD
    • • Monitor Vitals, I & O
    • • Give Antipyretics, antihistamines as ordered
    • • Treat shock if present
    • • Recheck crossmatch

    • Hemolytic Reactions:
    • • blood samples
    • • urine sample
    • • monitor fluid / lytes
    • • evaluate cause of reaction
  59. HIV transmission and blood transfusions
    • in the US, donated blood is screened for HIV antibodies and antigen's
    • very rare- 11 day window before blood seroconverts
    • 3 cases in 25,000,000
  60. LEUKEMIA CANCER OF THE WBC’S•
    • Usual number of white blood cells to red blood cells is reversed
    • .• Bone marrow is replaced by immature white blood cells.
    • • Infiltrates into liver, spleen, and lymph nodes.
    • • Begins with one malignant stem cell.
    • • Do not differentiate normally
    • • Do not function normally so immune system is compromised
  61. Acute Lymphocytic leukemia- (AML)
    • • 80% of acute leukemia’s in adults
    • • 66% with remission
    • • Decreased neutrophils result in severe infections
    • • Death results from hemorrhage or infection.
    • • Proliferation immature WBC’s (myeloblasts) and hyperplasia of bone marrow and spleen
    • neutropenia-recurrent severe infections
    • thrombocytopenia-bleeding, petechiae, purpura, ecchymoses, epistaxis (nose bleed), GI bleed

    • interventions
    • protective isolation
    • meticulous hand hygiene
    • assist patient with hygiene measures
    • restrict visitors with cold, flu, or infections
    • provide oral hygiene after every meal
    • monitor neutrophil level
  62. Allergic Rhinitus
    • S/S: nasal inflammation with coryza (perfuse nasal discharge)
    • Watery eyes, itching, sneezing Bronchospasm, stridor/wheezes

    TX: ****Management: Nasal decongestant sprays are not recommended more than 5 days due dependence and rebound effect - phenylephrine

    • Oral decongestants & antihistamines
    • Nasal corticosteroids (Flonase, Beconase,Rhinocort) Cromolyn – mast cell stabilizer/antihistamine
    • Allergen desensitization/allergy shots
  63. Epistaxis
    • Anterior -
    • Posterior - bleeding from terminal branchs of internal maxillary arteries

    • TX:
    • pressure on septumfor 5 to 10 min
    • ice packs on nose and forehead to cause vasoconstriction
    • sitting position to decrease blood flow to the head
    • leaning forward reduces swallowing the blood
    • spit out blood to reduce nausea and vomiting
    • vasoconstrictors
    • nasalpacking
    • -anterior 24 to 72 hours
    • -posterior to to 5 days
    • ballooncatheter
    • surgery
    • Both no sneezing,nose blowing, lifting
  64. ABG's
    • pH (7.35-7.45)
    • CO2 (35-45 mm Hg)
    • determine HCO3 (22-26) mmol/L
  65. NURSING INTERVENTIONS FOR PNEUMONIA
    • Push Fluids/monitor IV’s
    • Monitor VS esp. respirations
    • Provide humidified O2
    • Postural Drainage
    • Suction PRN
    • Encourage Rest
    • Administer Meds (antibiotics,bronchodilators)
    • High Fowlers to present aspiration
    • Check gag reflex
    • Do not overmedicate with Narcotics

    • Client Education
    • Teach prevention
    • Emphasize need to finish all meds
    • Adequate rest
    • Encourage vaccine
    • Deep breathing exercises(X 6 wk after Hosp. Discharge)Return to M.D. if fever, SOB,dyspnea, sleepiness, confusion
  66. TB precautions
    transmitted by droplet nuclei-airborne droplets produced when an infected person coughs, sneezes, speak, sings

    • Droplets can remain airborne for several hours
    • negative pressure room
    • HEPA filtered respirator

    isolation minimum of 2 weeks after starting TB drug therapy
  67. COPD NURSING INTERVENTIONS
    • Breathing exercises (abd., purse lip, or huffing)
    • Nutrition (low dairy & low Na, high protein, highfat with min. carbohydrates & freq. small meals)
    • Exercise program (6 min. walk for ADL)
    • Rest periods
    • Pulmonary hygiene/postural drainage
    • Encourage plan to stop smoking
    • LOW FLOW O2 - hypoxic drive (CO2 narcosis)

    Patients with COPD have raised CO2 levels and depend on a deficiency of oxygen (hypoxia) to stimulate respiration; This is termed Hypoxic Drive. This is in contrast to the normal person where the blood level of CO2 drives respiration. In these patients high dose oxygen can reduce respiration and cause respiratory depression. They will develop increased CO2 retention, respiratory acidosis and subsequently will require mechanical ventilation.
  68. respiratory distress and interventions for patients having difficulty breathing
    nonproductive cough, SOB, dyspnea, hypoxemia,

    •  O2 & ventilatory support for hypoxemia
    • Monitor resp. & breath sounds
    • Encourage fluids
    • Breathing exercises (pursed-lip & abd.breathing)
    • Chest physiotherapy/postural drainage
    • O2 – monitor O2 sat. & ABG’s
    • Keep calm (relaxation exercises)
    • Pt. education (triggers & how to control with medications)
    • ambu bag
  69. HTN risk factors
    • Onset Age 30-50
    • No known cause but Risk Factors are:

    Overactive renin angiotensin,aldosterone with Na & H2O retention

    • Diabetes Mellitus
    • -Increased fat & plaque in arteries
    • - Increased vascular resistance

    • Overactive sympathetic nervous system
    • -causes vaso/ veno constriction

    • Obesity (central)
    • - Apple vs. Pear

    • Insulin Resistance
    • - Increases blood clots

    ↑ Alcohol Intake- 3 or more drinks/day

    Smoking- Nicotine vasoconstricts

    Stress- Vascular smooth muscle hypertrophy
  70. Dash Diet
    • Dietary Approaches to Stop Hypertension
    • Eat fruits and vegetables (up to 10 servings/ day)
    • Use low-fat dairy products
    • Reduce sodium intake
    • Reduce cholesterol, fat and saturated fat intake

    • Grains - 7 -8 servings / day
    • Meats/ Fish/ Poultry - 2 or less 3 oz servings/day
  71. ATHEROSCLEROSIS
    •  ATHEROSCLEROSIS -obstruction of arteries(atheromas or plaques)
    • Accumulation of lipids,calcium, blood components,carbohydrates and fibrous tissue
  72. Types of Angina
    • Stable angina - most common & predicatable - occurs
    • when the work of the heart is increased by physical exertion, exposure to cold, or by stress-relieved by rest and nitrates

    • Unstalble angina
    • - occurs with increasing frequency, severity, and duration - pain is unpredictable and occurs with decreasing levels of activity and may occur at rest -at risk for MI

    Prinzmetal's (variant) angina - atypical -occurs unpredictable (unrelated to activity) and occurs often at night-caused by coronary artery spasm with or without atherosclerotic lesion
  73. Drug Therapy for Angina
    Goal of treatment is to reduce oxygen demand and increase oxygen supply to myocardium

    Nitrates - Nitroglycerin - fast venous and arterial dialation

    • Beta Blockers -prophilaxis - first line to treat stable angina
    • propranolol
    • metoprolol
    • nadololatenolol
    • block EPI & NOR (cardiac stimulators) -reduce heart rate, contractility, and blood pressure

    • Ca Channel Blockers - slow acting - prophilixis
    • verapamil
    • dittiazem
    • nifedipine
    • act on cardiac muscle -coronary vasodialtors- lower BP, reduce contractility,
  74. Heparin & Coumadin
    • blood thinners - used for DVT
    • heparin prevents conversion of firbrinogen to firbrin
    • started first - IV - test with PTT
    • side effects - bleeding
    • antidote - protamine sulfate

    • warfarin (coumadin)
    • PO started - inhibits synthesis of Vit K dependnet clotting factors overlap of 4 to 5 days important
    • warfarin full anticoagulant effect is delayed and may actually promote clotting for the first few days of therapy-monitired with INR
    • -Side effects - bleeding
    • antidote - Vitamin K
    • While on coumadin therapy avaid food high in Vit K - green leafy vegetables (kale, spinach, parsley, etc)
  75. peripheral atherosclerosis vs. chronic venous insufficiency
    • ATHEROSCLEROSIS -PVD
    • Obstruction of arteries(atheromas or plaques)
    • Accumulation of lipids,calcium, blood components, carbohydrates and fibrous tissue

    • atheromas - lesions consisting of lipids, fibrous tissue, collagen, calcium, cellular debris
    • -can ulcerate or rupture and stimulate thrombosis

    -impairs blood supply to lower extremities - peripheral vascular disease

    Chronic Venous Insufficiency- inadequate venous return over a prolonged period of time

    • :Signs & Symptoms
    • Leg Ulcers
    • Eczema/dermatitis
    • Itching
    • Cyanosis
    • Stasis ulcers esp. ankle
    • Brown thin shiny skin
    • Edema worse when standing (dependent)
  76. Arterial vs. Venous Ulcers
    •  Arterial ulcers
    • on toes, feet, or shin
    • Pale on elevation &rubor on depend.
    • Skin cool with mild edema
    • Intermittent claudication with exercise
    • Decreased pulses

    • Venous ulcers
    • on anterior ankle
    • Pink with brown discoloration &cyanosis depend. Skin warm with lots of edema
    • Aching pain at rest
    • Normal pulses
  77. Varicose Veins
    Irregular tortuous veins - long periods of standing increases venous pressure which stretches the vessel wall

    • Incompetent valves - cause blood to pool - further stretching vessel walls
    • Usually in lower extrem.
    • Pain, swelling, fatigue
    • Stasis ulcers can occur
    • More common in: Women over 35 & pregnancy
    • -Whites > Afr. Americans
    • -who stand for work
    • -Pregnancy, BC Pill, HRT/ERT

    • Varicose Veins Signs &Symptoms:
    • Severe, aching leg pain/heaviness
    • Statis dermatitis (itching of extremity)
    • Warm to touch Thin, discolored skin above ankles
    • Visibly dilated, tortuous veins
    • Possible leg ulcers
  78. Orthopnea pathophysiologly & cardiac significance
    Orthopnea - difficulty breathing when supine

    R/T circulatory overload from increased water and sodium retention

    • Left sided heart failure
    • Manifestations:
    • Fatigue and activity intolerance
    • Dizziness and syncope
    • Dyspnea, SOB, Cough
    • Orthopnea
    • Inspiratory crackles and wheezes.
    • S3 gallop

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