Med Surg Ch. 19 & 20.
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. What would you like to do?
Janet is caring for Mr. Brown who had a kidney infection transplant 8 days ago. Mr. Brown has been doing very well but this afternoon he is very quiet and refuses to eat his lunch. What would be the best action for Janet to take?
Spend extra time with him & allow him to verbalize his feelings
What will be an action that nurse Mary would take in caring for Mr. Jones who has Ankylosing Spondylitis?
Activity every two hours
How will nurse Nima know the tx for pernicious anemia has been successful?
Increase in vitamin b12 and a decrease in the number of enlarged RBC's
Which outcome should receive priority in caring for an AIDS pt?
Remain free of infection
T or F: HIV is not considered a chronic disease with treatment?
False: HIV is chronic
T or F: HIV can enter the body through breaks in the scalp
In monitoring Mr. Key who has aids, nurse tara will expect to identify:
What test should nurse Cathy review to monitor response to antiretroviral therapy
T or F: Phagocytes are increased when the disease is in the active stages
False: phagocyes are minimal, this is when opportunistic infections are present
In collecting data for Jena with suspected exposure to HIV, the nurse Kathy should be most concerned with..?
Fever, rash, and joint pain
Nurse Alex will explain to his pt that the purpose of medication that the pt is taking is to..
Inhibit enzymes to interfere with viral production
In preparing a care plan for a pt with HIV, the nurses goal is to:
Keep virus from replicating
Which manifestation should the nurse advise the pt with aids to report immediately
T or F: A greater risk for infection in a pt with HIV/AIDs is due to a weak immune system and parenteral therapy
Signs and Symptoms of Pernicious Anemia (Vitmain B12 deficiency)
Increased weakness, loss of appetite, glossitis (inflammation or infection of the tongue) and pallor. Irritability, confusion, and numbness or tingling of the extremity occurs because the nervous system is affected.
Type I sensitivity reaction, commonly known as hives
Signs and Symptoms of Anaphylaxis
- -Smooth muscle spasms occurs
- -Bronchial narrowing
- -Creating stridor
- -Laryngeal edema
Neurological changes include apprehension, dowsiness, profound restlessness, headache, and possible seizures. Change in mental status also occurs.
Common triggers of anaphylactic reaction. Includes bees, wasps, hornets, fire ants, and snakes
System reaction that produces life-threatening changes in circulation and in the bronchioles. A severe allergic reaction to an allergen.
A type III hypersensitivity immune reaction in which antigen-antibody complexes form and lodge in small vessels, which leads to inflammation, tissue damage, and necrosis. Usually occurs after pt takes penicillin or sulfonamide.
Antihistamines / Benadryl
Type of medication given to control severe allergic reaction with symptoms of itching
When recovering from an allergic reaction, what would you teach a pt to do to prevent another allergic reaction from occuring?
- -Assess pts knowledge of allergic reaction
- -Teach pt to wear a medical alert that includes identifying allergies
- -Acquire a prescription for an epi pen
When teaching a pt about a dust allergy, what would be in the teaching plan about modifying the environment?
- -Avoid antigen
- -Wear a mask
- -Have heating/cooling duct cleaned
- -Cover heat registers with filters
- -Frequent vacuuming & dusting
When the immune system no longer recognizes the body’s normal cells as self
What can cause or influence an autoimmune disorder?
- -Viral infections
- -Cross Reactive Antibodies
Signs and Symptoms of Transplant Rejection
- -Sudden onset of low back / chest pain
- -Fever increased more than 1.8 degrees F.
What do you do before you adminster a blood transfusion?
- -Two nurses double check specific data
- -At bedside, check a recheck pts name, ID blood, and blood type on bag
- -Vital signs before transfusion
- -Monitor pt and vital signs for 15 minutes after transfusion
What are therapetuic measures for serum sickness?
- -Treatment is focused on symptoms
- -Antipyrectics = fever
- -Analgesics = Arthralgia
- -Antihistamines and epinephrine = urticarial and angioedema
- -If symptoms persist, corticosteroids may be ordered
It is a form of urticara and has the same pathophysiology and etiology EXCEPT it affects the submuscosal and subcutaneous tissues rather than the skin. Much deeper and more wide spread.
Therapeutic measures for angioedema
- -Teach the pt to avoid the antigen
- - Symptoms may be relieved with antihistamines and corticosteroids
Side Effects: Gastric distress, anorexia, vomiting, diarrhea, headache, muscle weakness, alopecia, blurred vision, irritability, dry, itchy skin, rash
Prescribed for: Tx of Systematic Lupus Erythematosus
Nursing treatments for Ankylosing Spondylitis
- -There is no cure
- -Give analgesic for pain within the doctor’s orders
- - Provide activities to reduce pain and stiffness
Which group is most vulnerable for systemic lupus erythematosus?
- -Young women of child bearing years
- -African American and Hispanic populations
- -First degree relatives of lupus pts
Whart is the cause of Hashimoto's Thyroiditis?
Autoantibodies for thyroid stimulating hormone form
Signs and Symptoms of Hashimoto's Thyroiditis
- Beginning Signs and Symptoms:
- - Restlessness, tremors, chest pain, increased appetite, diarrhea, moist skin, heat intolerance, and weight loss
- Later Signs and Symptoms:
- - Fatigue, bradycardia, hypotension, dyspnea, anorexia, constipation, dry skin, weight gain, sensitivity to cold, facial puffiness, and a slowing of mental processes
What are some nuring actions for Hashimoto's Thyroiditis
- -If pt has goiter, soft diet may be needed for comfort
- -Frequent rest periods
- -Antiembolic stockings
- -Daily weights
- -Monitor intake and outputs
A pt asks the nurse how an allergy can develop to a medication that has been taken before without problems. What would be the most appropriate response?
Viral illnesses and exposure to various chemicals and environmental substances can alter the immune system and its response to previously benign stimuli
A pt asks the nurse what ankylosing spondylitis is. What is the most appropriate response?
Chronic progressive inflammatory disease of large limb joints
What is a sign or symptom of pernicious anemia?
What care would the nurse provide for a pt under going a Schiling test for pernicious anemia?
Collect a 24 hour urine specimen
What interventions should the nurse anticipate will be included in the treatment plan for a pt with allergic rhinitis?
- -Avoiding the environmental stimuli
What data is collected when caring for a pt with contact dermatitis?
Appearance of skin lessions
A pt is admitted with an autoimmune disease and asks the nurse what autoimune means. What would the most appropriate response be?
Immunes cells are unable to distinguish between self and not self
The nurse would evaluate the pt as understanding modes of HIV transmission if the pt stated that the modes of HIV transmission included..
- -Unprotected sex with HIV-infected partner
- -Contact with infected blood products
The nurse is teaching a pt about HIV testing. List the HIV diagnostic tests in sequential order in which they are preformed.
- 1. Enzyme linked immunosorbent assay
- 2. Repeated ELISA
- 3. Western blot test
A pt who is newly diagnosed with HIV infection asks what to expect for future health status. The best response for the nurse to give is based on the understanding that HIV diseas and AIDS are characterized as..?
A chronically managed disease
What should a nurse include in the teaching plan to prevent HIV infection?
- - Abstain from sexual intercourse
- - Avoid injection drug use
- - Plan for autologous blood transfusion
- - Test for HIV at the time of labor
Which of the following should the pt with HIV be taught to do to decrease the risk of infections?
- -Wash hands before eating
- -Wash toothbrush
- -Report signs of infections
The nurse would recognize that the pt needs further reinforcement of knowledge if the pt state that one of the goals of antiretroviral therapy is which of the following:
A. Reduce the viral load
B. Decrease CD4+ T lymphocytes
C. Delay the progression of HIV disease
D. Improve survival rates
B. Decrease CD4+ T lymphocytes
HIV causes decreased CD4+ T lymphoctes, so the goal of antiretroviral therapy is to control the virus so CD4+T lymphocytes will increase
(this multiple choice question has been scrambled)
The nurse would recognize that the pt is having a reaction to delavirdine (rescriptor) if what occurred?
If the pt complained of a rash or headache, which are common side effects of delavirdine
A pt has an immune deficiency involving T lymphocytes. The nurse teaches the pt about need for frequent screenings for what?
A pt gets regular allergy shots but missed an appointment. When the pt comes next what should the nurse do?
Consult with the health care provider about giving a lower dose for this injection
A pregnant pt with a hx of nonsx HIV is seen at a clinic. What info will the nurse include when teaching the pt?
Most infants are not infected with the virus.
What would you like to do?
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