3/23 Flashcards
Which of the following should the nurse recognize as a risk factor for sickle cell disease?
A. fluid overload
B. low attitude
C. hypoxia
D. hypernatremia
Answer: C
Rationale: main reason look at cells sickling is hypoxia - anything that causes lack of O2 to cells - takes round fluffy slippery RBC and makes it turn into a C-shaped and these clump together and have abnormal oxygen carrying capacity - is a form of anemia
High altitude is a risk - lower partial pressure of O2 - get dizzy/fall down
Dehydration - allows cells to clump together more - lot what do is administer fluids on top of pain medication
Hyponatremia - lack of fluid retention in the body
Pain medication requested every 2 hours - give it to them - lack of pain medication could cause these people to not want to breathe; incredibly painful; can cause outlook on life as rosy as see; chronic disease process that has lots of things that trigger it
Pregnancy is a trigger for it
Hydroyxurea for female population not big deal but looking at high fetal issues - pregnancy with use of this drug is a no-no
RBCs like to clump together - MI, stroke/CVA, PE; do like to go is into microcirculation - see hands and feet with dead tissue (necrosis) - so imp give packed RBCs to these clients - increased ability to carry O2
What is the primary nurse diagnosis for a client who suffers from thrombocytopenia?
A. risk for injury
B. risk for bleeding
C. risk for aspiration
D. risk for altered tissue perfusion
Answer: B
Rationale: Risk for injury - unless an injury occurs not at risk but once injured - risk increases
Risk for aspiration - mostly if neuro injury occurs
Risk for altered tissue perfusion - more thrombocytosis
Neutropenic precautions and bleeding precautions and attach lab values to them - at risk for infection or bleeding due to primary disease process or treatment of disease (chemo, radiation, hydroxyurea - in chemo drug)
Is the risk for bleeding an appropriate nursing diagnosis for a patient being treated for Primary Polycythemia Vera?
True
False
Answer: true
Rationale: BEING TREATED - looks at apheresis (bleed them off, drain them off) and anticoagulants - once on that - become risk for bleeding
Typed and crossed blood and have blood ready in blood bag
Have an order
How nurse proceeds
Make sure right person
Consent - understands risks and benefits
Full set of VS - high temp - no transfusion
Place IV
Set up blood tubing using only NS and blood filter
Take pt information and go to blood bank - check blood off together
Look at blood - have 30 minutes to set up transfusion from time get blood
Double check blood band and ID band - hook up blood and ID band
Tell them let know if feel SOB or chest pain
Start blood between 40-50 mL/hr as start
Stay with pt for 15 min then get set VS
If tolerating increase rate as tolerated: healthy - 125-150 mL/hr; 300 mL in bag of blood
Have HF - slowing down to longest time to possibly can and watch closely and question physician about need for lasix in between
1 unit blood has 4 hrs to go in
Close eye on pt after 15 minutes
VS qhr at min
Pt shows sign reaction
Can develop antibodies against blood transfusion
Give other medications during blood transfusions - give regular meds; start another line if on another drip; not give new during blood transfusion
Transfusion of blood products:
Stop the blood - flush with separate flush and cap off blood; not throw away tubing; anaphylactic rxn - epi pen, antihistamines, proton pump, benadryl, corticosteroids - eye on pt - allergic rxn can come back quickly; after stabilized pt, talk to physician and lab
Next may try another unit blood - if continual issue - premedicate heavily before give unit of blood
Pt shows sign reaction
Get rigors - shaking
Lot people do - delay transfusion - have antibodies that stop norm blood product and have look at antibodies - take hrs to days to get blood
More blood transfusions more likely to develop antibodies
Can develop antibodies against blood transfusion
What is the difference between Hodgkin’s and Non-Hodgkin’s lymphoma?
A. only Non-Hodgkin’s involves lymph nodes
B. they are both incurable
C. both have spread to organs by time of diagnosis
D. only Hodgkin’s starts in one lymph node
Answer: D
Rationale: by time non is diagnosed will have multiple lymph node involvement and spread to organs
Both involve lymph nodes
Hodgkin’s = curable
Non = not curable = treated like a chronic disease
Which of the following best describes leukemia?
A. under production of normal WBC’s
B. overproduction of abnormal RBC’s
C. overproduction of abnormal WBC’s
D. under production of normal WBC’s
Answer: C
Rationale: over producing WBC’s - high risk for infection - seggs (mature cells; normal WBCs) and bands (immature cells) on complete blood count with differential
Not have well-trained seggs - have bands - have too many WBC’s and overproduction of WBC’s - not effective at fighting infection
Under production of normal WBC’s - leukopenia
Overproduction of abnormal RBC’s - polycythemias
Under production of normal RBC’s - polycythemias - break down into primary (occur within BM) and secondary (EX: COPD pt; overproduce - to get more Hgb to carry more O2)
Coomb’s test - looking for antibodies that attack RBC - might make anemia happen
Epogen for kidney - for chronic disease
Person of color - see pallor within skin - look conjunctiva (is the red part of the eye that pull down underneath eyelid) of eyes for pallor
BM biopsy - role as generalist nurse:
Anemias
Consent form
Positioning
Admin of meds
Assessment of site
Assess for bleeding
BM biopsy - role as generalist nurse:
In general: top priority: lack of O2 - put O2 on is priority - hopefully help some cells reform because that what caused because that what caused some C cell shape originally; C cell caused pain and destruction
Position: no bending - blood vessels kink and clot forms; fetal position = bad
Clots can form anywhere - penis (priapism - massive amount of swelling); clots cause disruption of fluid volume moving around body any place
Pt with this and want keep them warm - do not put anything on them that has own heat - anything that has heat requires physician order; use body heat
Sickle cell disease
Out exercising - develop chest pain - stop exercising, call 911, get help; not know why happening - causing damage to heart/lungs
Want a low iron diet but also want a heart diet to help protect the heart
Cardiomyopathy could be an issue if this went on for extended period; HTN - could cause hypertrophy - big muscle little filling space
PPV
Putting on steroids - put them on neutropenic - wiped out immune sys which have do with autoimmune
Platelet count 7500 - now find confused pt that previously A&Ox4 - potentially blew vessel in brain
ITP
Easily treated
Give back factors
Lab values - PT (linked with INR - know what labs mean and which most concerning to you), INR (normalized ratio of PT - linked with PT - treatment related for bioprostethetic valves - about 3; higher than that is alarming), PTT
Often get norm transfusion factor VIII through lives
Ice the joints
Hemophilia
Treatment: heavy - induction (in hospital) - wipe them out completely - STRICT PRECAUTIONS - no flowers, fresh fruit or veggies
Move into consolidation - stem cell transplant
Maintenance - maintained on chronic disease platform
Leukemia
