Altered Immunity

Question 1

What are the 5 cardinal signs of inflammation

Answer 1

warmth, redness, swelling, pain, and decreased function

Question 2

The stage of inflammation is the vascular response were histamine, serotonin, and kinins constrict small veins and dilate arterioles which care redness and warmth bringing nutrients to the sight of injury. What increases in this stage

Answer 2

This is stage one of inflammation. Capillary permeability in this phase causing fluid to leak into the tissues resulting in swelling. The bone marrow produces more WBC in this phase.

Question 3

This stage is when the number of neutrophils increase and attack and kill bacteria. what occurs in the is stage when the bone marrow is unable to keep up with the neutrophil production?

Answer 3

This is stage two, the bone marrow will begin production immature ineffective neutrophils

Question 4

The final stage of would healing, stage three is?

Answer 4

Tissue repair and replacement.

Question 5

This type of hypersensitivity response is the immediate release of mediators histamine form the reaction of igE. What are some examples of this reaction?

Answer 5

This is type one hypersensitivity reaction is commonly seen in hay fever (rhino-sinusitis), allergic asthma, anaphylaxis, and angioedema

Question 6

A patient has had an allergy to shrimp was exposed and began to have itching, watering eyes and rhinorrhea. What type of reaction is the patient likely having?

Answer 6

The patient is experiencing a type one hypersensitvity reaction from an allergen

Question 7

A patient presents to the ER wiht swelling in the nose,, eyes, lips and face. What is the patent experiencing and what is the primary concern

Answer 7

The is experiencing angioedema cause my deep tissue igE mediated release of proteins and involves all layers of the skin. The primary concern is airway obstruction. The nurse will need to reverse the edema before intubation is needed by administering epinepherine, corticosteriods, diphendrydramina.

Question 8

What are the top three priorities for a patient with angioedema

Answer 8

The primary concern is airway obstruction, gas exchange, and anxiety

Question 9

A patient with angioedema is experiencing stridor and the patient cannot swallow what is the main intervention.

Answer 9

The patient will need an emergency intubation, tracheostomy is larygeal edema is present (6in)

Question 10

This is the most life threatening reaction of the type one and can be fatal if delayed epinepherine is not administered

Answer 10

Anaphylaxis

Question 11

A patient present to the ER with generalized itching and hives, erythema and angioedema after some time the patient appears to have increasing respiratory distress, crackles, wheezing and stridor. What is the patient experiencing and what is the priority when caring for this patient

Answer 11

The patient is experiencing anaphylaxis reaction. The priority is gas exchange. The airway needs to be opened.

Question 12

The nurse is caring for a patient and administered a new a drug to a patient. The patient is having s/s of anaphylaxis. What are the steps of interventions for this patient.

Answer 12

If the patient is having stridor and cannot swallow the nurse will need to maintain gas exchange by keeping the airway open. Stop the drug and change the IV tubing with NS running open, lastly the nurse needs to administer Epi IM or IV.

Question 13

What is the priority intervention for a patient experiencing anaphylaxis reaction with no signs of stridor and can swallow.

Answer 13

The first intervention the nurse will do is administer epinephrine then corticosteroids and Benadryl later for management.

Question 14

This complication is commonly associated with Ace inhibitors and NSAIDS. what is important teaching for a patient taking these medications.

Answer 14

Angioedema. Teach the patient to report swelling in the eyes, lips, nose, throat, and a persistent dry cough.

Question 15

The patient who is on the surgery table receiving a kidney transplant has clotting in the new organ which causes ischemic necrosis inflammation and phagocytosis of the organ. what type of reaction occurred, what is the solution, and how did this occur.

Answer 15

This is a hyperacute reaction that occurred immediately due to antigen-antibody complexed formed in the blood vessels of the transplanted organ to which the recipient had antibodies against. This rejected organ is then removed.

Question 16

The patient that received a kidney transplant began to show signs of organ failure of the organ donated 1 week to 3 mon. after the transplant surgery. What is the reaction. what occurred, what is the treatment.

Answer 16

The patient is experiencing an acute reaction where the recipient cells inflammatory process started and caused lysis of the organ cells. The patient will get drug management to limit the pt immune response and save the organ.

Question 17

What is a chronic transplant rejection, what occurs and waht is the trratment

Answer 17

This is due to chronic inflammation and scarring of the organ which reduced the function. This process occurs over time as smooth muscles of arteries overgrow and occlude the vessels. This process will occur to all transplanted organs eventually, so the final treatment is retransplantation.

Question 18

The nurse is care for a patient that appears to have a medication history of caclcineurin, corticostrerios, antiprogliferative agents, and prograf. What will the nurse need to do immdiately.

Answer 18

The nurse will need to call the provider and notify them of the medications.

Question 19

What teaching is important for a patient that is at risk of transplant rejection?

Answer 19

The patient will need to adhere to medications for the rest of their lives, notify all providers of medication esp if admitted to hospital. They are at increased risk for infection and cancer development and will need to avoid sick ppl, crowds, raw veggies, and perform strict hand washing.

Question 20

This is life threatening organ dysfunction caused by dyregulated host response to infection. What are the tree characteristics of this complication?

Answer 20

This is sepsis. The three main characteristics include excessive inflammation, excaggerated coagulation (blood clots), and supressed fibrinolysis (blood clots won’t break down).

Question 21

What is the patho behind sepsis?

Answer 21

Infection –> bacteria enters the bloodstream–> inflammatory mediators respond and cause massive system wide vasodilation–> increased capillary permiability –> fluid shifts out –> decreased bp, intravascular dehydration, widespread decreased perfusion. Increased platelet aggregation begins and clots form resulting in widespread ischemia r/t microvascular clotting–> clotting factors deplete (may cause DIC).

Question 22

What compensatory mechanisms are activated during sepsis?

Answer 22

Increase HR to compensate for vasodilation and intravascular dehydration (initial increase in CO
Peripheral vasoconstriction from decreased perfusion
Increase in oxygen consumption from tissues (decreased venous o2 sat)
Anaerobic metabolism which causes increased lactic acid production and leads to lactic acidosis

Question 23

A patient that has 3/5 WRATH criteris and no suspected evidence of infection most likely has what?

Answer 23

SIRS. Systemic inflammatory response syndrome.

Question 24

WHAt is WRATH criteria?

Answer 24

WBC alteration (> 12,000 or < 4,000)
Respirations (RR > 20)
Altered Mental Status
Temperature (> 100.5 or < 96.8)
Heart rate (HR > 90)

Question 25

A patient with and infection or suspected infection and meets SIRS criteria most like has what?

Answer 25

This patient has Sepsis. The infection must be suspected of confirmed in order to identify as Sepsis.

Question 26

What is the qSOFA scoring?

Answer 26

Systolic hypotension (<100mmhg)
Tachypnea (>22bpm)
GCS <=13 (altered mental status)
H.A.T.

Question 27

i. UTI
ii. Pneumonia
iii. Soft-tissue infection
iv. Gastroenteritis
v. Prosthetic device-associated infection
These are all associated with what?

Answer 27

These are common infections associated with Sepsis.

Question 28

Patient presents with diagnosis of pneumonia. The patient is AAO x 4. Temperature is 101.0 F, RR is 32, BP is 83/32 (49) heart rate is 105, WBC = 15,000.

Answer 28

SEPSIS

Question 29

Patient presents with foul smelling and cloudy urine. She is lethargic and only opens her eyes in response to physical stimulation. Her RR is 18, HR 101, temp 96.0, and BP is 90/35 (53).

Answer 29

SEPSIS

Question 30

How will the nurse caring for a patient with sepsis is experiencing septic shock .

Answer 30

The patient will have PERSISTENT hypotension despite adequate fluid resuscitatio AND the patient requires vasopressors to keep MAP >= 65
The patient has a lactic acis of >2mmol /L

Question 31

How will the nurse caring for a patient with septic shock that the patient is experiencing MODS.

Answer 31

The patient will have two or more organs failing. This patient is likely to die

Question 32

A nurse caring for a patient suspects sepsis what are the priority steps for the nurse to take using the one hour treatment bundle?

Answer 32

1. Measure lactate level
2. Obtain blood culture (BEFORE admin abx)
3. Administer broad-spectrum abx
4. Begin rapid admin of 30ml/kg of CRYSTALLOID (for hypotn or lactatate level of >4
5. Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP >= 65
6. Remeasure lactate level iif inital lactate was >2

Question 33

What are the hemodynamic goals of sepsis in the first 6 hrs?

Answer 33

1. CVP 8-12 mm Hg
2. MAP > 65 mm Hg
3. Urine Output > 0.5 mL/kg/hr
4. Scvo2 > 70%

Question 34

What is the first drug of choice for a patient with sepsis with an MAP of <65

Answer 34

Norepinepherine (levophed) is the #1

Then epinepherine or vasopression.

Question 35

What broad spectrum drugs will be administered during sepsis care.

Answer 35

Broad spectrum abx that cover both gram positive and gram negative for 7-10days.
The pt will get vancomycin for gram pos.
cafepime/zosyn for gram neg.

Question 36

What are the 2 most important labs caring for a patient with sepsis?

Answer 36

ABG and lactic acid (repeat within 3-4hrs)

Question 37

Sepsis Key Points!

Answer 37

1st Step: Prevention!
Early identification and notification of physician
IV fluids
Cultures before antibiotics
Vasopressor support if needed to maintain organ perfusion
Support failing organs