complex final Flashcards
Pneumonia clinical manifestations
-Productive cough, pleuritic pain
-crackles and wheezes
-fever
-SOB
-O2 sat. less than 90%
Pneumonia nursing interventions
-collect sputum culture
-auscultate lung sounds
-monitor ABG’s
-suction as needed
-breathing treatments
-oxygen as needed
Pneumonia education
-Use incentive spirometer 10x Q1-2hrs
-Drink 2-3L fluid per day
-cough and deep breathe
Tuberculosis clinical manifestations
-cough lasting longer than 3 weeks
-purulent or bloody sputum
-weight loss
-night sweats
-lethargy
Airborne precautions
-N95 mask
-Gown
-Gloves
-Negative pressure room
-if client has to leave they need to wear a surgical mask
TB meds
RIPE orange
-Rifampin- orange secretions
-Isoniazid
-Pyrazinamide
-Ethambutol
What therapy for TB patients?
-heated and humidified oxygen therapy
What if pH less than 7.35 and HCO3 less than 22?
Metabolic Acidosis
What if pH less than 7.35 and PaCO2 greater than 45?
Respiratory Acidosis
What if pH greater than 7.45 and HCO3 greater than 26?
Metabolic Alkalosis
What if pH greater than 7.45 and PaCO2 less than 35?
Respiratory Alkalosis
Asthma clinical manifestations
-Dyspnea
-chest tightness, barrel chest
-anxiety or stress
-coughing, wheezing, mucus production
Asthma nursing interventions
-silent chest (no sounds)- very bad
-Raise HOB (high fowlers)
-administer Oxygen as prescribed
-monitor cardiac rate and rhythm during an acute attack
-monitor RR and rhythm
-incorporate rest into ADLs
-administer meds as prescribed
COPD clinical manifestations
-dyspnea
-productive cough
-crackles and wheezes
-rapid and shallow respirations
-use of accessory muscles, barrel chest
-enlarged neck muscles
-clubbing of fingers and toes
-pallor and cyanosis
COPD nursing care
-high fowlers
-encourage coughing to remove secretions
-2 to 4 L/min nasal cannula of oxygen
-monitor weight
-exercise walking for 20 min 3x a week
-drink 2-3L fluid a day
COPD meds
-Chronic Medications Save Lives
C- corticosteroids
M- methylxanthines and Mucolytics
S- short acting bronchodilators
L- long acting bronchodilators
Corticosteroids
-Fluticasone and Prednisone
-decrease airway inflammation
-can cause increased risk for infection, hyperglycemia, easy bruising
-rinse mouth after inhalational use
-don’t discontinue med suddenly
what medication is a Methylxanthine?
Theophylline
Mucolytic agents
-thin secretions
-acetylcysteine and dornase alfa are nebulizer treatments
-Guaifenesin is an oral agent
Short acting bronchodilators
-provide rapid relief
-albuterol
-can cause tachycardia and tremors
Long acting bronchodilators
-Ipratropium (anticholinergic)
-suck on hard candy
-palpations can occur
Complications of COPD
-respiratory infections
-Right sided HF (cor pulmonale)
HIV clinical manifestations
-Similar to flu
-night sweats, headache, sore throat, weakness, fatigue, chills, rash
HIV diagnostics
-enzyme linked immunosorbent assay test (ELISA)
- if positive, will be confirmed with a positive Western Blot test
-then if both positive= HIV
-Then viral load test done next
-also drug resistance and liver testing, Brain or lung MRI or CT scan
HIV nursing care
-Assess risk factors (sexual practices, IV drug use)
-monitor I&O’s, weight loss, nutritional intake, electrolytes
HIV education
-avoid crowds, cleaning litter boxes, RAW food
-conduct frequent CD4+ and Viral load counts
-no live vaccines
-clean needles with bleach
SLE findings
-Alopecia
-Fatigue/malaise/weakness
-blurred vision
-pleuritic pain
-anorexia/weight loss
-depression
-joint pain, swelling, tenderness
SLE physical assessment findings
-erythematous “butterfly” rash
-reynaud’s
-anemia
-lymphadenopathy
-fever
ulcerative colitis expected findings
-left lower quadrant pain
-rectal bleeding
-diarrhea: up to 15-20 liquid stools per day
Crohn’s disease expected findings
-Right lower quadrant pain
-anorexia and weight loss
-diarrhea: 5 loose stools per day
UC/Crohn’s nutrition
-High protein and calorie
-Low fiber
-vitamins and b12 injections
C and C findings
-sharp pain in right upper quadrant (often radiates to right shoulder)
-rebound tenderness (blumberg’s sign)
-Dyspepsia and eructation
-jaundice
C and C education
-low fat diet
-no gas forming foods (beans, cabbage, cauliflower, broccoli)
-regular exercise
C and C meds
-analgesics
-bile acid
Genital herpes manifestations
-Pain
-small red bumps
-blisters
-ulcers
-scabs
Genital herpes meds
-antivirals like acyclovir
Chlamydia manifestations
-females are often asymptomatic
-painful urination
-lower abdominal pain
-vaginal discharge
-penile discharge
-painful sexual intercourse
Chlamydia meds
-azithromycin and doxycyclin
-2x a day for 7 days
-no sex for 7 days, recheck in 3 months
Chlamydia complications
-other STI’s
-pelvic inflammatory disease
-infertility
-infection in newborns
Gonorrhea manifestations
-dysuria
-painful urination
-discharge from penis
-pain or swelling in testicles
-targets male urethra and female cervix
-infertility
-infections can spread to joints
-infants can have blindness
-vaginal bleeding
gonorrhea meds
antibiotics
BPH manifestations
-voiding difficulties
-incontinence
-intra-abdominal pressure increased
-infections
-Hematuria
BPH diagnostics
-Digital rectal exam (DRE)
-lab work (urinalysis, prostate-specific antigen test)
-cytoscopy
-transrectal ultrasound
hypertensive crisis
-headache
-chest pain
-SOB
-dizziness
-blurry vision
hypertension meds
-Thiazide diuretics
-Ace inhibitors (Pril’s)
-ARB’s (sartans)
-calcium channel blockers (dipine’s)
-Beta blockers (olol’s)
hypertension education
-limit sodium, alcohol, caffeine
-smoking cessation
-exercise
-measure and keep records of BP at home
right sided HF symptoms
SWELLING
S- swelling of leg, hands, liver
W- weight gain
E- edemal pitting
L- large neck vein
L- lethargic
I- irregular heart rhythm
N- nocturia
G- girth of abdominal size
Left sided HF symptoms
DROWNING
D- dyspnea
R- rales (crackles)
O- orthopnea
W- weakness
N- nocturnal proximal dyspnea
I- increased HR
N- nagging cough
G- gaining weight (2-3lbs/day, 5lbs/week)
HF diagnostics
-BNP
-Echocardiogram
-Chest x-ray
-ultrasound
HF nutrition
-limit fluid to 2L/day
-limit sodium to 2-3g/day
-increase protein
HF teaching
-raise HOB
-Aerobic exercises
-daily weight
-compliance with meds
PAD risk factors
-hypertension
-diabetes
-smoking
-obesity
-hyperlipidemia
-females
-age over 65
-elevated C-reactive protein
-hyperhomocysteinemia
PAD teaching
-stop and rest if pain while walking
-avoid restrictive clothing and crossing of legs
-maintain warm environment and wear socks
-dangle legs to alleviate pain
DVT manifestations
-leg pain
-redness and inflammation and edema
-unilateral swelling
DVT diagnostic
D Dimer
DVT teaching
-don’t massage legs
-compression socks
DVT meds
Anticoagulants
A fib
can’t tell where P wave is
(all look different, can’t tell which one is the P wave)
A flutter
too many P waves
hyperthyroidism manifestations
-tachycardia
-restlessness, irritability, nervousness
-decreased attention span
-heat intolerance
-weight loss, diarrhea
-menstrual problems
-sweaty
-goiter
hypothyroidism manifestations
-bradycardia
-fatigue, lethargy
-intolerance to cold
-weight gain, constipation
-depression
-dry, flaky skin
-swelling in face/tongue/hands/feet (myxedema)
-menstrual problems
Diabetes manifestations
SUGARR
S- slow wound healing
U- blUrry vision
G- glycosuria
A- acetone breath
R- rash on skin
R- repeated yeast infection (women)
hypoglycemia manifestations
“I’m cold and clammy give me some candy”
-sweaty, clammy, confused, light headed
-give fruit juice, hard candies, graham crackers
-if unconscious give IV D50
Hyperglycemia manifestations
3 P’s
Polyuria
Polydypsia (very thirsty)
Polyphagia (very hungry)
peripheral neuropathy for diabetics
check feet daily with mirror
osteoporosis health promo
-consume calcium, and vitamin D
-spend time outdoors
-weight bearing exercises
foods with calcium
-milk
-green leafy vegetables
-orange juice
-cereals
-read and white beans
-figs
foods with vitamin D
-most fish
-egg yolks
-cereal and fortified milk
osteoporosis care
-environment safety (clear walkways)
-limit caffeine, alcohol, carbonated beverages
Cataracts/ Glaucoma/ Macular Degeneration management of care
- Don’t do things that increase intraocular pressure:
- Bending over
- Sneezing
- Straining
Macular degeneration nutriton
High in antioxidants, vitamin E and B12
Cataract meds
Anticholinergics (atropine 1% ophthalmic solution)
Glaucoma meds
- Pilocarpine ophthalmic solution
- Beta blockers: Timolol (1st line)
Peripheral Neuropathy clinical manifestations
- Dependent of affected nerve
- Aching, shooting, burning pain
- Feelings of cold feet
Peripheral Neuropathy teaching
- Foot care
- Smoking cessation
- Avoid toxic chemicals
- Massage to improve circulation
- Stimulate nerve and reduce pain
- Avoidance of repetitive motion or prolonged pressure
- Guided imagery
- Relaxation techniques
MS clinical manifestations
- Fatigue
- Memory loss
- Decreased visual acuity
- Ataxia
- Nystagmus
- Bowel dysfunction
- Uhtoffs sign (temporary worsening of vision)
MS diagnostics
- Cerebrospinal fluid will have elevated protein level and increased WBC
- MRI: plaques of the brain and spine
MS management of care
- watch for back stiffness
- Monitor speech patterns and swallowing
- Increase fluids to decreased risk of UTI
- Communication board
- Eye patches for diplopia
- Energy conservation
MS meds
- Muscle relaxors
- Dantrolene
- Baclofen
- Diazepam
· Jaundice
· Muscle weakness
· Don’t stop abruptly - Immunomodulators
- Interferon beta
· Treat or prevent relapses - Anticonvulsants
- carbamazepine
parkinson’s diagnostics
No definitive diagnostic procedures
Parknison’s meds
Carbidopa Levidopa
-no protein
Parkinson’s Management of care
- Document weight weekly
- Semisolid foods and thickened liquids
- Keep a diet intake log
- Encourage fluids and document intake
- Small frequent meals
- Maintain mobility as long as possible
- Promote communication as long as possible
Osteoarthritis manifestations
-joint pain and stiffness
-pain with activity that improves with rest
-crepitus
-excess joint fluid
-finger joints enlarged
-limp gait
-back pain
Osteoarthritis management of care/ teaching
-NSAIDS prior to activity or as needed
-proper body mechanics like using two hands and bending in the knees not back
-assess if mobility aids needed
-high energy activities in morning
-heat for joint tenderness and stiffness
-cold for inflammation
Back pain diagnostics
- X ray
- CT
- MRI
- Electromyogram
- Arthogram
- Bone Scan
back pain meds
-NSAIDs
-mild opioids (tramadol)
-topical creams, sprays, and gels
-Ziconotide (for severe chronic back pain)
Stroke clinical manifestations
- Facial weakness
- Arm and leg weakness
- Speech problems (aphasia)
-writing problems (agraphia)
Stroke nursing interventions/ management of care
- Communication/ picture board
- HOB at least 30 degrees
- ROM
- Unilateral neglect
- Swallow test
GCS
Eyes:
- Spontaneous (4)
- To verbal (3)
- To pain (2)
- No response (1)
Verbal:
- Oriented (5)
- Confused (4)
- Inappropriate (3)
- Incomprehensible (2)
- No response (1)
Motor:
- Obeys (6)
- Localizes (5)
- Withdrawals (4)
- Flexion (3)
- Extension (2)
- No response (1)
Tonic- clonic seizure
- Starts with stiffening of muscles and loss of consciousness (tonic)
- 1-2 min of jerking of extremities (clonic)
- breathing can stop during tonic and become irregular during clonic
- Biting of cheek or tongue during clonic
- Incontinence
- Period of confusion following
Myoclonic seizure
- Brief jerking or stiffening of extremities, which can be symmetrical or asymmetrical
- Last for seconds
Atonic or akinetic seizure
- Few seconds in which muscle town is lost
- Followed by period of confusion
- Results in falling
complex partial seizure
-associated automatisms (behaviors client is unaware of like lip smacking or picking at clothes)
-loss of consciousness or blackout for several minutes
simple partial seizure
-consciousness is maintained
-unusual sensations like changes in HR and abnormal flushing
-unilateral abnormal extremity movements
Seizure nursing interventions
-seizure precautions
-turn patient to side
-loosen restrictive clothing
-vagal nerve stimulation (partial seizures)
Seizure meds
Phenytoin
-no oral contraceptives or warfarin
With aura (classic migraine)
- Awareness of findings for hours or days before: irritability, depression, food craving, gi effects
- Aura develops over min to hrs and include neurological findings
- 2ndstage: severe, incapacitating, throbbing headache lasting hrs
- 3rd: (4-72 hrs) dull headache
- Recovery: exercise worsens it
Without aura (common migraine)
- Pain is aggravated by physical activity
- Unilateral, pulsating pain
- One or more manifestations: photophobia, phonophobia, N/V
- Persist for 4-72 hrs (usually in the morning)
Atypical migraine
- Status migraine: Headache lasting longer than 72 hrs
- Migranious infraction: Neurological lasting more than 7 days
- Unclassified: does not fit other criteria
Cluster headaches
- Brief episodes of intense, unilateral, nonthrobbing pain lasting 30 min to 2 hr that can radiate to forehead, temple or cheek
- Occurs daily around same time
- Followed by period of remission for 9-12 months
-watery eyes with runny nose
-facial sweating
Anemia clinical manifestations
- Pallor
- Fatigue
- Numbness or tingling of extremities
- Nail bed deformities
- Smooth, sore, bright red tongue (pernicious)
Anemia diagnostics
- MCV: Size of RBC
- MCH: amount of hgb per RBC
- MCHC: hgb amount relative to the size of the cell
- Schilling test: measures B12 absorption with and without intrinsic factor
Anemia Meds
- Folic acid
- Vitamin B12
- Ferrous sulfate
- Epoetin alpha
Anemia nutriton
- Iron fortified cereals and breads
- Fish
- Poultry
- Dried peas and beans
- Green leafy vegetables
thrombocytopenia clinical manifestations
bleeding
-of gums
-nosebleeds
thrombocytopenia management of care
-safe environment
-use electric razor, soft toothbrush, avoid blowing nose vigorously, make sure dentures fit
Leukemia diagnostics
- CBC: high, low or normal WBC, decreased HCT&HGB
- Bone marrow biopsy
- Coagulation time: increased
Leukemia management of care
- Monitor for infection
- Hand hygiene
- Screen visitors carefully
- Private room
- No fresh or raw fruits or vegetables
- No fresh flowers or plants
Leukemia meds
- Filgrastim
- Chemo
- Bone marrow transplant
