Exam 1 Flashcards
Which population group is more likely to be diagnosed with fibromyalgia syndrome?
Women between 30 and 50 years of age
The nurse is assessing a patient who has undergone a total knee arthroplasty for which continuous nerve block was used. The nurse notes the patient is anxious, vital signs are BP 92/58, HR 62, RR 12, and SpO2 89%. What is the priority nursing intervention?
Notify Rapid Response Team— nerve block became systemic and is affecting multiple areas
During a health history assessment, a patient with RA, chronic HTN, and recent CVA states she is taking 2 fish oil capsules daily as an RA supplement. What additional questions should the nurse ask?
Are you taking anticoagulants Have you found fish oil to be helpful What other supplements do you currently take How long have you been taking fish oil Have you notified your physician? --- fish oil is a natural blood thinner
The nurse understands which of the following is a risk factor associated with the development of MS in women?
Smoking
Which couple has the highest risk for sexual transmission of HIV without the use of a condom or dental dam?
An infected male performing vaginal intercourse with an uninfected female
— due to large surface area of mucous membranes in the vagina
During a health assessment of a healthy 22 yr old college student, she tells the nurse that she is sexually active and protects herself from HIV and STIs by using oral contraceptives. What is the nurse’s best action?
Inform the student that oral contraceptives protect against pregnancy but not STIs
A 30 year old man with HIV is admitted to the acute care unit. Which assessment findings does the nurse recognize that may indicate that the patient currently has AIDS?
Kaposi’s sarcoma
Wasting syndrome
Esophageal candidiasis
The patient is very weak. During this admission he has experienced anorexia, painful swallowing, severe diarrhea, and occasional vomiting. Frequent mouth care is to be delegated to the CNA? What instructions should the nurse give the CNA?
Use PPE- standard precautions
Soft bristle toothbrush
Educate/expect mouth sores
frequent mouth cares– frequent rinses with sodium bicarbonate and water or NS, no alcohol mouth rinse
After 8 days, the patient is being discharged home, where he lives with his mother and father. The nurse is completing discharge instructions for him and his family. What infection control teaching should the nurse provide to the patient and family?
Do not share needles/razors/toothbrush/etc.
Proper precautions
Soiled linens wash in hot water and bleach
bleach and water to disinfect.
S/Sx of worsening conditions and CNS changes
As the nurse is talking to the patient, the patient comments that he doesn’t know why he must live with such a horrible disease, and states that he knows he will die soon. What is the appropriate nursing response?
Provide education about living with the disease, support groups and community resources…
Assess why he is fearing death/disease…
True or false: genetic testing has no benefit in the treatment plan of a patient with HIV.
False…. Used to determine appropriate medications and how they work on the body… Genetic testing is key!
A patient tells the nurse that she has recently engaged in unprotected sex. The nurse recognizes that which symptoms may be consistent with acute infection, following infection with HIV?
Fever Chills HA Night sweats Muscle aches
A patient is fearful that he has been infected with HIV. The nurse recognizes which as the first symptom associated with possible HIV infection?
Fever, night sweats, muscle aches
The nurse is caring for an older adult patient at risk of shock. What is an early sign of shock in this patient?
Restlessness — a change in LOC occurs first
The nurse is caring for a patient with sepsis. At the beginning of the shift, the patient is in a hypo dynamic state. Several hours later, the patient’s BP is elevated and pulse is bounding. How does the nurse interpret this change?
Worsening of the condition rather than improvement—- Severe sepsis is the calm before the storm, a hyper dynamic state.
The nurse is caring for a patient in septic shock. The nurse notes that the rate and depth of respirations is markedly increased. The nurse interprets this as a possible manifestation of the respiratory system compensating for which condition?
metabolic acidosis—- resp compensation for metabolic changes causing metabolic acidosis with resp alkalosis.
A patient receives dopamine 20mcg/min IV for treatment of shock. What does the nurse assess for while administering this drug?
Chest pain and hypertension
When administering norepinephrine (Levophed), what does the nurse monitor for in the patient?
Extravasation
HA
chest pain
HTN
A 59 yr old male is 3 days post-op after a colon resection. The nurse has delegated to the CNA to take his morning VS. At 8:00 am the CNA reports the patient’s oral temp as 101.6. What is the nurse’s priority action?
Go assess the patient.
Infection or inflammation, or atelectasis
Upon assessment, the nurse notes that the patient is flushed and slightly diaphoresis. He appears lethargic but responds to simple questions. His VS are now BP90/40, HR 134, RR 26 and deep, and his temp has risen to 102.8. Lungs are clear throughout. His abdominal wound has a dressing that is moist with a moderate amount of purulent drainage. What is the nurse’s interpretation of this data?
Abd. Infection, symptomatic
Twenty minutes later, the nurse calls the physician to report the abnormal findings. The provider orders:
Blood cultures x2; 5 minutes apart.
Over the next hour, the patient continues to decline with a decreased LOC and a temp of 103.8, BP 80/40, HR 134, RR 34. the nurse calls teh provider to report these findings and obtain orders to transfer the pt to the ICU. When preparing the transfer, the nurse notes that the O2 sat is 87% on RA. What is the priority nurse action?
Apply oxygen at 2-3 L/min per NC.
Within 30 minutes of transfer to the ICU, his condition continues to deteriorate. His SaO2 continues to fall, RR 36, and the IU nurse notes blood oozing around the catheter sites. A foley cath is placed, and his urine output is minimal. What is the nurse’s interpretation of these findings?
DIC with septic shock
A 37 yr old is admitted with a severely abscessed tooth. BP 90/42, HR 136, RR 28, SpO2 90%, temp 38.7. The nurse suspects the pt has developed sepsis. what is the priority nursing intervention?
Initiate IV fluid resuscitation. — to increase BP and perfusion.
When assessing a patient for shock, the nurse knows that which symptom is the earliest manifestations of shock?
increased HR—- decreased BP, your chasing your tail.
Which clinical manifestations does the nurse recognize that indicates worsening in the condition of a patient in the refractory phase of shock?
Bleeding, oozing from the IV sites —- DIC indicates loss of clotting factor, need full system support.
What is the purpose of inflammation and immunity?
Provide protection by neutralizing, eliminating, or destroying organisms that invade the body. critical to maintain health and prevent disease.
What is the immune system influenced by?
Nervous, endocrine, and GI systems
What is bone marrow?
Source of all blood cells, includes most of immune system cells.
What are stem cells?
Immature, undifferentiated cells in the bone marrow
Erythrocytes:
RBCs, stem cells exposed to erythropoietin (growth factor)
Leukocytes are:
WBCs; immunity cells
defense actions: recognition, destruction, production of antibodies, complement activation, production of cytokines
How is the human body protected by immunity?
Inflammation
Antibody mediated immunity (AMI)
Cell mediated immunity (CMI)
What is infection?
Response to injury and invasion
Usually accompanied by inflammation, but inflammation can occur WITHOUT infection.
Neutrophils:
Mature neutrophils are 55-70% of WBC aka “segs”
Immature neutrophils aka “bands”, 12-14 days to mature
Function of neutrophils: protect against invaders via phagocytosis; mature neutrophils only cell capable of phagocytosis
What is a left shift?
Decrease in mature neutrophils aka “segs” and increase in “bands”
Caused by sepsis; bone marrow cannot produce enough mature WBCs to keep up with infection.
What are macrophages?
Function: immediate inflammatory response and stimulates longer-lasting immunity (AMI and CMI) via
PHAGOCYTOSIS.
Macrophage tissue locations:
Alveolar macrophages --- lungs Histocytes--- connective tissues Microglial cells--- brain Kupffer cells--- liver Peritoneal macrophages--- peritoneum Osteoclasts--- bone Synovial type A cells--- Joints Mesangial cells--- kidney
Stem cell maturation cycle:
Committed stem cell Myeloblast Promyelocyte Metamyelocyte Band neutrophils Mature segmented neutrophils
Basophil function:
Act on blood vessel walls and smooth muscles via vasoactive amines, general inflammation and allergy hypersensitivity
Heparin: decrease blood and protein clotting
Histamine: constricts small vessels, decrease blood flow
Kinins: dilate arterioles and increase capillary permeability
CAUSING: blood leakage into interstitial spaces
Eosinophils function:
Active against infestations of parasitic larvae and limit inflammatory reactions; vasoactive chemicals
–enzymes degrade other vasoactive chemicals
What is the Sequence of Inflammatory Response:
Stage 1: vascular changes= redness and warmth, swelling and pain.
Stage 2: cellular exudate= increase WBCs and pus formation
NSAIDs stop inflammation cascade
Stage 3: tissue repair and replacement
Cell Mediated Immunity function:
Protect body by ability to differentiate self from non-self.
T-lymphocytes and natural killer cells
Transplant rejection:
Cytotoxic T-cells and natural killer cells destroy foreign cells
Hyper acute Rejection:
Begins immediately on transplant, AMI response
Antigen/antibody complexes form in vessels, activating compliment= triggers clotting cascade
=ischemic necrosis and massive cell destruction
occurs mostly in kidneys
Reaction occurs in minutes and cannot be stopped
Organ removed.
Those at greatest risk for transplant rejection:
- received organ with different ABO comparability
- multiple transfusion
- multiple pregnancies
- previous transplant
Acute rejection:
Occurs within 1 week to 3 months after transplant
Antibody mediated= vasculitis
Cell mediated= cytotoxic T cells and natural killers start inflammatory response and lysis of organ
Dx: lab tests and organ biopsy
Does NOT automatically mean organ loss; drug management may decrease damage
Chronic rejection:
Takes place over time; smooth muscles of blood vessels overgrow and occlude vessels.
- donated tissue replaced with scar tissue
- organ function decreased
- longstanding, occurs continuously in response to chronic ischemia
NO cure, medication management
If damage stops organ from functioning properly, only option is organ transplant.
Maintenance therapy for transplant rejection:
Continuous immunosuppressants
- calcineurin inhibitor
- corticosteroids
- anti proliferative agents
** life long therapy cause increased r/f bacterial or fungal infection and cancer
Rescue therapy for transplantation rejection:
Monoclonal and polyclonal antibodies
Corticosteroids:
Prednisone and prednisolone:
Broadly inhibit cytokines, generalized immunosuppression
S.E.: HTN, hyperlipidemia, osteoporosis, wt gain, Cushing’s appearance, opportunistic infections, glaucoma, GI ulcer, increased BS.
Calcineurin Inhibitors:
Cyclosporine (Tacrolimus)
Stops production of IL2, prevents lymphocyte activation in transplant rejection
S.E.: nephrotoxic, HTN, tremor, CAD, hirsutism, gingival hyperplasia, increased r/f infection, malignancies, hyperuricemia, hepatotoxicity, increased K, decreased Mg, increased BS.
Antiproliferatives:
Azathioprine, Mycophenolate, Sirolimus
Inhibits DNA synthesis, prevents cell devision
S.E.: bone marrow suppression, thrombocytopenia, anemia, pancreatitis, hepatotoxic, malignancy, leukopenia, N/V, acne, increased r/f infection, increased cholesterol, Increased BS, GI upset.
Rheumatoid Arthritis:
Connective tissue disease, chronic progressive systemic
- primarily affects synovial joints; more likely in WHITE -rheumatoid factors attack healthy tissue= inflammation
- remissions and exacerbations
- permanent joint damage may be avoid if Dx early, Monroe common in winter months
- affects joints bilaterally, osteoporosis is unilateral
Key features:
Early- joint inflammation, low grade fever, paresthesia, fatigue/weakness, anorexia, wt loss (2-3lb)
Late- joint deformities, osteoporosis, moderate to severe pain, morning stiffness, severe fatigue, anemia (decrease H&H and RBC), increased wt loss, SubQ nodules, peripheral neuropathy, vasculitis, pericarditis, fibrotic lung disease, Sjogern’s syndrome, kidney disease, Felty’s syndrome (decreased WBCs), muscle atrophy, Caplan’s syndrome, decreased ROM, increased WBC’s = inflammation
RA: complications
Respiratory: Pleurisy, PNA, interstitial fibrosis, pulmonary HTN
Cardiac: pericarditis, myocarditis
Eyes: iritis, scleritis
RA: Sjogren’s Syndrome:
Dry eyes, mouth, vagina
RA: Felty’s syndrome:
Enlarged liver and spleen and leukopenia
RA: Caplan’s Syndrome:
rheumatoid nodules in lungs
RA: Labs and Dx:
Positive rheumatoid factor Positive ANA Increased CRP and ESR Decreased serum compliment C3 and C4 SPEP: decreased albumin and increased alpha globulin
Dx: XR, CT, MRI
arthrocentesis- leg bore needle, aspirated synovial fluid
**bed rest for 24 HR, Tylenol for pain
RA: Tx:
Synovectomy: remove synovium
Joint arthroplasty: total joint replacement
Meds:
DMARDS: methotrexate, Plaquinel, Arava
*plaquinel retinal damage-eye exam q6 months
* Arava- antidote cholestyramine (Questran)
BRMs: Enbral, Remicade, Humira, Orencia, Rituxan, Xeljanz**
**black box warning-opportunistic infections, TB, lymphoma, cancers
NSAIDs: decrease pain and inflammation, give Rantidine to decrease GI upset, Celebrex (COX2 inhibitor)
Glucocorticoids: steroids; prednisone (co: pulse therapy)
Others: Imuran and cytoxan (chemo meds) for immunosuppression
Plasmapheresis: in combo pulse therapy.
AVOID narcotics
