Exam 2 Flashcards
What is public health surveillance, an aspect of emergency and trauma nursing?
-reporting frequent symptoms of patients that have similar histories
Example of an ER nurse using public health surveillance ?
-multiple patients have sx of gastroenteritis and ate at the same restaurant –> ER nurse reports this to the community
Why does disaster preparedness matter for a nurse working in the ER?
-contains policies and procedures so nurses know how to respond
-determines how many patients they can accept
What is a critical access hospital?
-small community hospital with 24/7 emergency areas
Requirements to be considered a critical access hospital?
-25 beds or less
- >35 miles from another hospital
-24/7 emergency area
How do inter professional specialty teams work in emergency and trauma nursing
-respond to specific patient scenarios
-ex : STEMI team, rapid response team, code team
What is the environment like in the emergency department?
-fast-paced
-challenging
-stimulating
Why is it important for nurses to continuously monitor patients in the ED?
patient acuteness changes very rapidly
What are a few of the most common reasons patients seek care in the ED?
-abdominal pain
-breathing difficulties
-CP
-fever
-Head ache
-injuries (common in older adults due to falls)
-pain (the most common sx)
who are vulnerable populations seen as patients in the ED
-homeless/ poor
-mental illness pts
-substance abuse concerns
-older adults
What are reasons why a person experiencing homelessness may come to the ED?
-cannot be refused
-no insurance
-shelter and food
What is important to remember as a nurse in the ED when a patient is homeless?
-help them find resources in the community
-do not bring bias
Examples of members of the inter professional team we encounter in the ED?
-SANE nurses
-Psychiatric crisis nurse team
-ER physicians
-ED techs
-physician specialties (cardiologist, neurologist)
-NPs, PAs, Residents
Communication in emergency settings uses the _____ method
SBAR
-situation
-background
-assessment
-recommendation
Why is the SBAR method an efficient way to communicate?
-offers precise communication
-reduces confusion
-reduces med errors
Most medication errors are a result of?
poor communication
How to identify patients in the emergency room to maintain their safety?
-use ID bracelet
-use two identifiers (name and DOB)
If an identity is unknown or privacy is to be protected, what is used to identify patients in the ER?
-special identification systems
What is a very common injury for patients in the ED?
-skin breakdown, falls, errors, misidentifications
How to prevent injury to patients in the ED
-keep rails up on stretcher
-orient to call light
-have someone at the bedside for confused patients
-minimize risk of skin breakdown
-perform frequent skin assessments
How to prevent adverse events/ errors in the ED?
-get thorough patient and family hx
-check pt for med alert bracelet or necklace
-search belongings for weapons or drugs
How to prevent injury to staff working in the ED?
-use standard precautions
-anticipate hostile or violent behavior
-have a plan for violence
-contact security
Core competencies of the ED RN include?
-multitasking
-critical thinking
-priority setting
-adaptability
-time management
-documentation
-assessment
What kind of system is used to triage patients in the ED?
-3 tier system
Triage is based on patients from _____ to _____ acuity
highest -> lowest
What are the components of the 3 tier system used in triage
-emergent / life threatening
-urgent /quickly (not life threatening)
-non urgent (can wait w/o fear of deterioration)
Why may triage in the ED be frustrating to some patients
-it is not a first come first serve system like they are used to
Ex of triaging: PNA in older adult
urgent
Ex of triaging: pt has a rash
non urgent
Ex of triaging: pt has abd pain
urgent
Ex of triage: pt has abd pain, BP of 85/60, and HR 140
emergent
Example of triage: sx of stroke
emergent
Example of triage: simple fracture
nonurgent
What is disposition in the ED?
-where they will go after
-med-surg, surgery, ICU, SNF, rehab
Who is involved in the decision making of disposition for a patient
-case management
-nurses, physicians
-patient and family
Trauma centers are graded by what levels?
1 - 4
Explain a level 1 trauma center
-urban area
-large teaching hospital
-full spectrum of trauma services and specialties
-includes peds
-research is required
Explain a level 2 trauma center
-community based
-cares for most injuries
-transfers if needed
Explain a level III trauma center
-community based
-stabilizes major injuries but usually transfers
Describe a level IV trauma center
-rural and remote communities
-basic trauma stabilization and ACLS
-arranges transfers
What is the primary survey?
a very quick focused initial assessment
components of the primary survey
A - airway and cervical spine
B - breathing
C - circulation
D - neuro status
E - exposure
(exposure of body such as removing clothes, exposure to chemicals, extreme cold or heat, environment)
For massive uncontrolled bleeding, the primary survey changes to
CABDE
A spinal cord injury at C2 can lead to
airway and breathing difficulties
When addressing airway and cervical spine, which one is done first
-airway still before cervical spine
ex: clear airway then apply c-collar
What does the secondary survey consist of?
-comprehensive head to toe
-tubes, lines, diagnostics
-treatments, dressings
Heat-related illnesses usually occur in temperatures and humidity greater than
> 95 degrees f
80% humid
Sx of heat exhaustion include
-faint or dizzy
-excessive sweating
-cool, pale, clammy skin
-rapid, weak pulse
-muscle cramps
Why do we get muscle cramps with heat exhaustion
electrolyte imbalances
Interventions for heat exhaustion include
-get in cool water (shower, lake)
-get to a cool, air conditioned place
-cool fluids
-cold compresses to face, neck, groin, underarms, etc
Is heat stroke considered a medical emergency
yes
Manifestations of heat stroke include
-throbbing headache
-no sweating
-red, hot, dry skin
-rapid, strong pulse
-unconsciousness
Is it important to call 911 for heat stroke?
YES
What internal body temperature is considered heat stroke
> 104
Why do we use cool IV fluids for those with heat stroke
decrease internal body temp
What kind of thermometer should we use for those with heat stroke
rectal bc it is most accurat
Why should we reduce shivering in patients with heat stroke
shivering raises BMR and increases use of energy and stress on the body
What can we give to reduce shivering in clients with heat stroke>
Benzes or muscle relaxers
Cooling guidelines for heat stroke include
use interventions until internal temp 102, then slowly back off measures
Can cooling blankets be used for heat stroke>
yes
Who is at increased risk of heat related injuries
old age, children, construction workers, people experiencing homelessness, those that are dehydrated
Prevention is key in reducing the occurrence of
cold related injuries (hypothermia or frostbite)
Clothing recommendations to prevent cold weather injuries
-use synthetic fabric and fleece thermal layers
-use wool clothing
-do NOT wear cotton
why should clients out in the cold not wear cotton
-cotton holds water
Using thick wool socks are important to preventing cold related injuries, but what is one aspect we should consider
too many layers can decrease circulation
Other education we should provide to prevent cold related injuries
carry cold weather supplies at all times
carry extra clothes, food, and water
Mild hypothermia temp ranges
90-95 degrees F
Moderate hypothermia temp ranges
82.4-90
Severe hypothermia temp rages
< 82.4
risk factors for cold related injuries include
-low BMI
-circulatory disorders
-hypothyroidism
-being submerged in water
-children and older adults
-homelessess
-alcohol and other substances
Pre-hospital interventions for hypothermia
-remove wet clothes
-blanket
-warm fluids
Hospital interventions for hypothermia
-bear hugger
-warming blankets
Should we re-warm the periphery or core first in hypothermia
core!
What is after-drop>
When extremities get warmed before the core
Why is after-drop important to prevent?
warming the periphery first sends cold blood back to the core and vital organs
Interventions to warm the core of the body include
-warm IV fluids
-warmed oxygen
-dialysis (warm blood)
-cardio-pulmonary bypass machines
Can someone be pronounced dead before they are completely re-warmed?
NO
-cannot effectively evaluate neurologic status until they are re-warmed
What is the definition of frost bite?
inadequate insulation from cold leading to freezing tissue
Frostbites is graded on a ____ to ____ scale
1 to 4
Grade 1 frostbite characteristics
red, swollen
Grade 2 frostbite characteristics
blisters filled with white fluid
Grade 3 frostbite characteristics
-red-brown, dark colored fluid
-nonblancheable
-may require debridement
Grade 4 frostbite characteristics
-necrosis
-infection and gangrene
-amputation
Pre-hospital treatment of frostbiteq
-get out of cold
-place hands in armpits, between groin
-get blankets
Hospital treatment of frostbite
-water bath
-pain control
-elevate extremities (prevent edema)
-tetanus immunization
What is a water bath treatment for frost bite?
-take extremity and place in water > 99 degrees
considerations for water bath treatment
-it is extremely painful! premedicate
-do not hit the sides of the container
Poisonous snakes in North America include
rattlesnakes, copperheads, cottonmouths, coral snakes
red on yellow
kills a fellow
red on black
venom lacks
Prevention of snake bite
-dont touch
-wear long pants
-do not grab mouth after decapitation
Main risk from snake bites include
-losing the airway
(snake venom can cause loss of airway)
Pre-hospital interventions from snake bite
-remain very calm
-remove jewelry due to swelling
-immobilize at the level of the heart
-do NOT use ice
Why do we not use ice for a snake bite
Ice decreases blood flow
Can we use a tourniquet in a snake bite
no
Should clients try and suck the venom out of snake bites
no
Hospital interventions for snake bites
-intubation supplies
-IV start
-anti-venom administered
-fluids
-pain meds
-EKG
-tele
What can we do to monitor the site of snake bite
-mark the site to note any changes
Arthropods that can bite or sting humans include
spiders, scorpions, bees, wasps
Spiders that produce toxic reactions include
-brown recluse
-black widows
How to prevent bites from spiders
-do NOT stick hands in dark places
-spray your home
-long sleeve clothes and boots
Prehospital interventions for spider bites
-cold compress and ice
- do NOT apply heat
- elevate limb
Hospital interventions for spider bites
-tetanus shot
-epinephrine
-circle site
-airway, oxygen, EKG, etc
Where do most lightning strikes occur
Florida (due to golf)
Adverse effects of lightning strikes include
-heart stopping
-dysrhythmias
-burns
-falling
-spinal cord injuries
-neuro status changes
Hospital interventions for lightning strike
-apply tele
-obtain EKG
-intubation supplies
-tetanus shot
-neuro assessment
the O2 percent at sea level is
21 % and decreases as you get higher in altitude
Altitude related illnesses risk occur at this elevation
2500+
Increased altitude = _____ barometric pressure
decreased (which means less oxygen)
What MUST be done to help prevent altitude related illnesses
acclimate to the changes in O2 slowly
What are HAD and AMS
-high-altitude disease
-acute mountain sickness
-can occur as altitude related illnesses
what is HACE
-high altitude cerebral edema
manifestations of HACE
-neuro changes
-loss of balance
-tremors
-confusion
-increased ICP
-headaches
-etc
treatment for HACE
dexamethasone
what is HAPE
high altitude pulmonary edema
manifestations of HAPE
-resp changes
-SOB, cough, dyspnea, etc
Treatment of HAPE
slidenafil
ALL altitude related illnesses will cause
Manifestations of hypoxia
What medication can be given to reduce the risk of altitude related illnesses
acetazolamide
When should acetazolamide be taken>
-24 h prior to ascent and the next two days into trip
How does acetazolamide work
Induces metabolic acidosis –> increases RR –> increases O2 saturation
Prehospital treatment of altitude related illnesses
go back down
O2
Hospital treatment of altitude related illenss
-give O2
-treat symptoms
The leading cause of accidental deaths in the US is
drowning
Prevention of drownign
-do not swim alone
-check the depth of water
-teach swimming
-no drinking or drugs
-fences around pool
-signage
-etc
Why is it important to check the depth of water
people dive in shallow water –> cervical spine injury –> drown
What is key to assess in drowning situations
quantity and makeup of the water
Do fresh and salt water produce relatively the same effects?
yes
One key thing to note about salt water drowning?
-pulls water from other tissues into the lungs
therefore increases risk for hypovolemia
Why are clients that drowned at increase risk of PNA
contaminates in the water may cause infection
Pre-hospital interventions for drowning
-spine stabilization
-maintaining airway
-performing CPR
Hospital interventions for drowning
-CPR
-defibrillation
-NGT
-tele, EKG
-abx right away
Why do we insert NGT for clients who have drowned
-water can also accumulate in stomach, esophagus, intestines, etc
-helps decrease vomiting
Internal disasters occur
in the hospital (such as flooding or fire)
External disasters occur
outside (tornadoes, flooding)
When is something classified as a disaster
illness or injury exceeds resources available
START triage vs normal triage
-start triage includes class IV
Class I of START triage
-emergent
-immediate threat to life
-red tag
Class II of START triage
-urgent or class II
-major injuries sustained
-yellow tag
Class III of START triage
-nonurgent
-minor injuries
-green tag
What is the meaning of walking wounded?
-those that can walk after mass casualty are a green tag
Class IV of START triage
-expectant
-allowed to die
-black tag
tagging during a mass casualty event should take how long
less than one minute per person
A person who is bleeding can die from blood loss within
5 minutes
How to stop the bleed
- apply pressure with both hands
- apply pressure with dressing or clothing
- apply tourniquet
Where should a tourniquet be applied
2-3 inches closer to the torso than the bleed
Who is the Hospital Incident Commander
-physician or administrator in charge of implementing and leading disaster plan
Who is the Medical Command Physician
-physician who decided the number, acuity, and resource needs of patients
Who is the triage officer
-physician or nurse who rapidly evaluates each patient to determine priority treatment
Who is the Community Relations or Public Information Officer
-the liaison between HCF and outside media
What should be done after a disaster occurrence?
-hospital staff debriefing
-addresses needs of HCP
During the debriefing period following a disaster, what is important to remember
the psychosocial and response of survivors
-meaning HCP
How are burns classified
-by the degree of burns
-by the degree of thickness
What skin layer is a superficial first degree burn
only top of epidermis
Characteristics of superficial first degree burns
-red, dry, pain
-no edema, blisters, eschar
How quickly do superficial first degree burns heal
1 week
What skin layer is a superficial partial thickness second degree burn
epidermis and into dermis
Characteristics of a superficial partial thickness burn
-moist red, blanches
-mild-mod edema
-pain worse
-blistering occurs
How long does a superficial partial thickness burn take to heal
2 weeks
What skin layer is a deep partial thickness second degree burn
entire epidermis and deep into dermis
Characteristics of a deep partial thickness burn
-less moist, less blanching, less painful
-moderate edema
-blistering rare
-soft/dry eschar
Healing of a deep partial thickness burn
-2-6 weeks
-possible skin graft
-scarring, contraction, and issues re-epithelializing occur
What layer is a full thickness 3rd degree burn
entire dermis and into subcutaneous fat
Characteristics of a full thickness burn
-dry, black/brown/yellow/white
-may be red
-severe edema
-no pain
-no blisters
Healing process of a full thickness burn
-hard eschar
-skin is non elastic
-will take weeks to months
-skin grafts needed
-contraction and scar deposition
What layers are a deep full thickness 4th degree burn
damage to bone, muscle, tendon
Characteristics of a deep full thickness burn
-black
-severe edema
-no pain or blisters
-hard eschar
healing process of deep full thickness burn
weeks - months
grafting may not work
What is the Rule of 9’s?
used to calculate TBSA burned
Examples of dry heat burns
-open flames
-explosions
-flash burns
Examples of moist heat burns
-scalding injuries
-water, steam, hot liquids, thermal burns to lungs
Examples of contact burns
-hot metal
-hot tar
-hot grease
-touching hot surface
Examples of chemical burns
-anything involving chemical
-could be occupational
-could occur at home
The longer a chemical is on the skin can cause
more severe burns
What is important to remember about chemical burn
may cause systemic effects
What are examples of electrical burns
-from an outlet
-from lightning strike
How do electrical burns occur?
the current of the electricity generates heat
What is a key consideration for electrical burns
-may see clear entry and exit wounds
-wound may be small
-internal damage can be MUCH greater
Examples of radiation burns
-cancer treatments
-industrial exposure
-sun exposure
-x-rays
Water heaters at home should be set less than ___ to prevent burns
140 degrees
Fire places should be cleaned ____ to prevent fires
annually
where should co2 and smoke detectors be placed
-every bedroom
-each hallway
-in kitchen
-in stairways
-entrances of home
How long is the emergent (resuscitation) phase of burn treatment
time of injury up to 48 hours
What interventions are done during the resuscitation phase of burn treatmen
-based on severity of burns
-airway and circulation
-help regulate body temp
-pain relief and emotional support
How long is the acute (healing phase) of burn treatment
begins 36-48 h after injury and lasts until burn injury is complete
What interventions are done during the acute healing phase of burn treatment
-prevent fluid shifting
-promote rest
-respiratory, wound care, and nutrition begin to play a role
How long is the Rehabilitative (restorative) phase of burn treatmet
-begins at time of admission through highest level of function
(longest phase)
What interventions are implemented during the rehabilitative phase of burn treatmetn
-psychosocial funcitoning
-preventing scarring
-preventing contractures
-help to resume activities
Why should we know the patient’s Ht and Wt before the burn injury
-help determine how much fluid resuscitation is needed
-helps know how much edema is present
Should clients with burns receive the tetanus shot
yes
Other things we need to know to treat burn injuries?
-how it ocured
-source of injury
-current meds taken or other conditions
-other injuries sustained
-allergies
Black around a persons nose, face, neck may indicate
inhalation injury
How can heat from burns affect the airway
causes lining of bronchi to slough off –> airway swells –> gas exchange worsens
Wheezing heard on auscultation of lung sounds after burns may indicat
-partial obstruction
-need for intubation
The cardiac assessment following burns should include
-addressing fluid shifts
-BP and hypovolemia
-tachycardia presence
-cardiac output
-increasing IV fluids if needed
The skin assessment following a burn should include
-calculation of TBSA
-determining depth of burns
-determining risk of infection
The inflammatory response following a burn can do what
suppress the immune system’s ability to fight off infection
What can hypovolemia due to the gi tract
decrease blood flow –> decrease peristalsis –> increase risk of paralytic ileus
Other than bowel sounds, nurses should perform a gastrointestinal assessment following burns to evaluate
-presence of gi distention which can be caused by increased intestinal secretions and gases
What is a curlings ulcer?
peptic ulcer commonly found in patients with burn
How to prevent curlings ulcer in patients with burn
-put them on prophylactic medications
-PPI or histamine blockers
Burns can increase the release of these hormones?
- catecholamines (epi and norepinephrine)
- ADH
- aldosterone
- cortisol
Diet for patients following a burn includes
-increased need for proteins, fat, calories
Can intubation be performed prophylactically in patients with burns?
yes
-may be done to reduce airway swelling
What is important to remember before performing a dressing change on a burn wound
-extremely panful
-premedicate at least 30 minutes before
Infection control for patient with burns interventions
-tetanus
-prophylactic abx
Wound healing for patients with burns interventions
-compression garments
Compression garments can be used to prevent
contractures and hypertrophic scars
What formula is used to calculate burn resuscitation needs?
parkland formula
What fluids are used for burn resuscitation
-crystalloid fluids
-LR or NS (LR more common)
what is the parkland formula?
4ml x kg x TBSA (rule of 9’s)
What is the actual leading cause of death from fires?
CO2 poisoning
Why is CO2 poisoning so common
-released during combustion
-tasteless, odorless, and colorless making it undetectable
How does CO2 poisoning affect the body
-binds to hemoglobin in replace of oxygen
-knocks out oxygen carrying capacity
Patients skin color with CO2 poisoning will be
cherry-red
Manifestations of CO2 poisoning
-headache
-breathlessness
-drowsiness
-AMS
-death
During co2 poisoning, BP will _____ and HR will _____
decrease ; increase
Antibiotics for wound management of burns may be given
topical, IV, or PO
Dressings for wound management of burns are typically managed by
wound care nurse
Handwashing for wound management of burns is so important because
reduces risk of infection
What is the primary concern in initial management of burns
fluid resuscitation
What is the most common cause of death in burn patients in the first 24 hours
hypovolemic shock
What is the importance of escharotomy in burn patients
to relieve pressure and improve circulation
Which of the following is a priority in the acute phase of burn treatment?
fluid resuscitation
What is so important to remember about electrical burns
-risk of dysrhythmias very high
What is the role of silver in burn wound management
infection prevention
Can burns cause compartment syndrome?
Yes
-remember 6 P’s
what is the purpose of skin graft in burn treatment
-skin closure
What is the recommend nutritional guidelines for burn patients
-high protein, high calorie
What is the needed urine output for fluid resuscitation to be considered successful?
0.5-1ml / kg / h
Psychological issues than can appear in patients following burns include
-PTSD
-anxiety
-depression
All types of shock lead to issues with
perfusion and oxygenation
What is hypovolemic shock
when there is inadequate volume of fluid in the body
causes of hypovolemic shock include
-bleeding, DHD, vomiting, diuresis, burns, diarrhea
What is cardiogenic shock
-when heart fails to pump, leading to decreased cardiac output
Causes of cardiogenic shock include
-filling problem
-contraction problem
-conduction problem
-structural problem
What can cause filling problems in patients that may lead to cardiogenic schock
-diastolic heart failure (pre-load affected because not enough stretch on heart)
What can cause contraction problems in patients that may lead to cardiogenic shock
-systolic heart failure
-cardiomyopathy
What can cause conduction problems in patents that may lead to cardiogenic shcok
-v-tach, v-fib, a-fib, bradycardias
What are structural problems in the heart that my lead to cardiogenic shock in patients
-valvular disease
What is obstructive shock?
caused by obstruction of cardiovascular system
Causes of obstructive shock
-cardiac tamponade
-tension pneumothorax
-PE
What is distributive shock
when blood volume is redistributed to interstitial tissues
Causes of distributive shock include
-sepsis
-anaphylaxis
-spinal cord injuries –> neurogenic shock
How does sepsis cause distributive shock
vessels dilate –> vessels leak into tissues –> intravascular space depletes
How does anaphylaxis cause distributive shock
histamine is released –> bronchospasm and vasodilation occur
What is the treatment for anaphylactic shock
epinephrine
(epi vasoconstricts and bronchodilates)
How does a spinal cord injury lead to neurogenic shock
- vessels not getting sympathetic stimulation –> tone decreases and vessels dilate
heart not getting sympathetic stimulation –> HR and CO decrease
Why is neurogenic shock special
it also affects the heart so we have no compensatory mechanism
Neurogenic shock is the ONLY shock where we give what medication?
atropine
What are the four stages of shock?
- initiation
- compensatory
- progressive
- refractory
What is happening during the initiation phase of shock?
- Hypoperfusion
- Baseline MAP decreased by <10 mmhm
- BP decreases by 10 pts
- HR barely increases
What does MAP tell us
how well organs are being perfused
Why is the initiation phase of shock often missed
changes are not large enough to promote concern
What occurs during the compensatory phase of shock?
-compensatory mechanisms begin to work
What are the compensatory mechanisms we will see during the compensatory phase of shock?
- increased HR
- increased blood sugar
- reabsorption of sodium and water
- hyperventilation
Why do we see increase in HR and contractility during the compensatory stage of shcok
-trying to increase CO to increase perfusion and oxygenation to tissues
What is the only type of shock where we will not see an increase in HR as a compensatory mechanism
neurogenic
Why does blood sugar increase during the compensatory stage of shock
-body is under stress which triggers the release of cortisol
Why is increased blood sugar bad during septic shock
-gives bacteria something to feed on –> can make the sepsis worse and harder to treat
Why do the kidneys reabsorb sodium and water during the compensatory stage of shock
increase volume of circulating blood and help retain fluid
What hormones are used to help kidneys reabsorb water and sodium
-aldosterone
-antidiuretic hormone
During the compensatory stage of shock, we will begin to notice urine output
decrease (due to kidneys)
Why does a patient hyperventilate during the compensatory stage of shock
help receive more oxygen
T or F: patients during the compensatory phase may begin to look better?
yes
what happens during the progressive stage of shock?
-compensatory mechanisms begin to fail
-MAP decreases by >20 mmHg
During the progressive stage of shock, the HR may be very high but the BP will
be very low (compensatory mechanism failing)
During the progressive stage of shock, the patient may be hyperventilating still, but our O2 saturation will be
continuously droppign
A map of less than ____ indicates poor perfusion
65
T or F: weak pulses and skin color changes can occur during the progressive stage of shock
yes
What happens during the refractory period of shock>
-become unresponsive to therapy
-MODS (organ failure)
Cardiac symptoms of shock include
-tachycardia (not neurogenic)
-decreased BP
-pale and cool skin
-decreased cap refill
-diminished pulses
Respiratory symptoms of shock include
-hyperventilation
-cyanosis
-decreased oxygenation
Renal symptoms of shock include
-decreased urinary outpt
Skin changes seen during shock include
-pale, cyanotic
-cool to touch
-mottled
Gastrointestinal changes during shock
blood is shunted away to vital organs
-hypoactive bowel sounds
-constipation
Why is lactate increased during shock
cells do not have enough oxygen –> anaerobic metabolism begins
the higher the lactate, the ____ the hypoxia
worse
the ABG of a client with shock will show
respiratory acidosis
A caveat to the ABG in a patient with shock
-O2 may be increased during compensatory stage
What lab evaluating cardiac muscle damage may be elevated during shock?
-Troponin (due to inadequate oxygenation of heart muscle)
(this is very common in cardiogenic)
T or F? hematocrit and hemoglobin levels will be different based on which type of shock is occurring?
true
Shock caused by hemorrhage will have increased or decrease H&H
deceased
Shock caused by DHD will have increased or decreased H&H
increased
Everyone with shock should receive what interventions?
-fluids (blood, vasopressors, etc)
-O2 (via NC or ventilator)
Hob positioning is very dependent on the patient because?
-HOB down promotes perfusion
-HOB down also increases WOB
(some patients may not be able to tolerate it, BUT if MAP is very low –> head dow)
Glucose levels should be monitored how often during shock
q 15 min
what is the only kind of insulin that can be given IV
regular
What is a central venous pressure line?
-measures the volume of blood in the heart
-great for patients with shock
What are vasoconstrictors patients with shock may be given?
Norepinephrine
Phenylephrine
Important nursing consideration for levofed/norepinephrine
-it is such an extreme vasoconstrictor pts can lose their fingers and toes due to decreased peripheral circulation
What are inotropic agents that can be given during shock (mostly cardiogenic)
-dobutamine
-milrinone
What are agents that enhance myocardial perfusion and given during shock?
-nitroprusside
-nitroglucerin
What is HIV
human immunodeficiency virus
What are T cells?
cells in our immune system
What are CD4 cells?
-a type of T cell
-AKA T-helper cells
CD4 cell function
-invite more immune cells to come help fight infection
How does HIV affect CD4 cells
-invades T cells and destroys CD4 cells
-injects own genetic material into cells to create more
What are the three stages of HIV
1: acute infection
2: clinical latency
3: AIDS
What occurs during the first stage of HIV
-CD4 cells destroyed
-virus replicating rapidly
What symptoms may occur during the first month of HIV infection?
Flu like symptoms
-bodyaches, fever, sweating, muscle aches, sore throat, rash, fever, etc
Why is HIV often not detected during the acute infection stage?
Flu- like symptoms are often missed as HIV
Can HIV be detected during the acute phase of infection?
No, because body has not had enough time to produce anti-bodies
-traditional HIV tests assess for antibodies
What occurs during the clinical latency stage of HIV infection?
-body begins making antibodies
-flu like symptoms go away
-may be completely sx free
How long can the clinical latency phase of HIV last
-decades even without tx
What occurs during the AIDS stage of HIV infection
-HIV virus overwhelms the immune system again
-Immune system destroyed
-AIDS defining illnesses can occur
A CD4 count of less than ___ is indicative of an AIDS diagnosis?
200
Can a patient with HIV and a CD4 count greater than 200 be diagnosed with AIDS
yes, IF they have an AIDS-defining illness
-any patient with an AIDS defining illness will be considered as having AIDS
What are AIDS-defining illnesses?
illnesses that would normally be able to fight off
-including certain types of cancers
Is transmission possible in all stages of HIV- AIDS
yes
What are examples of AIDS defining illnesses?
-cytomegalovirus retinitis (with loss of vision)
-pneumocystitis Jiroveci pneumonia
-chronic intestinal cryptospoirdiosis
-HIV - related encephalopathy
-tuberculosis
-invasive cervical cancer
can HIV be transmitted to the fetus during pregnancy>
yes
Women with HIV who are pregnant are at higher risk of
-premature delivery
-LBW
-transmission of virus
How does HIV transmit from mom to baby
-placenta
-breasat milk
Most cases of HIV are
- men who have sex with men
- either gender IVDA
How many new cases of HIV are discovered annually?
40,000 with 25 % being women
Is there a cure for HIV and AIDS
no
What are the most common transmission of HIV?
-sexual
-parenteral (sharing needles)
-needlesticks (occupational_
-perinatal
Can HIV spread via casual contact or insects?
no
What fluids can spread HIV?
-blood
-semen
-vaginal fluid
-breastmilk
-amniotic cluid
-urine
-feces
-CSF
How should we handle all patients to reduce the risk of spreading blood borne pathogens
use standard precautions for everyone
-gloves, handwashing, goggles, etc
How to prevent transmission of HIV parenterally?
use standard precautions, educate on IV drugs, needle exchange programs
We should educate IVDA to not do these things to limit their risk of HIV
-share needles
-reuse needles
Prevention of perinatal transmission include
education on risk of transmisson
Occupational prevention of HIV transmission includes
-reducing needlesticks
-use safety devices
-do not recap needles
-follow procedures
T or F: HIV is more easily transmitted from infected male to unaffected female than vice versa
True! due to vaginal mucosa membranes, it is easier for vagina to enter body
T or F: HIV can spread through anal intercourse
true (due to risk of tearing mucous membranes)
Safe sex practices include?
-abstinence
-monogamous
-condoms
all adults are recommended to be screened for HIV once between the ages of
18-65
Are all pregnant women screened for HIV?
yes
Should those that use injection drugs be tested annually?
yes
How often should those who have been to prison, those are sex workers, or those who have had sex in countries where HIV is prevalent be tested
annually
If a patient received a blood transfusion between the years 1978-1985, how often should they be screened for HIV
annually
What is pre-exposure prophylaxis (PREP)
-medication for those who are at high risk of contracting HIV to take and lower their risk
-does NOT replace safe sex practices
does PREP lower the risk of other STIs
no
What medications are the PREP regimen
-Truvada (tenofovir and emtricitabine)
-Discovy (emtricitabine and tenofovir)
Patient education for PREP
-take one tab daily
-Miss a day: you’re okay!
-Miss 2 days: must start over
If a patient misses their PREP dose, two days in a row, how long are they not protected from HIV?
7 days
PREP has a BBW for
hepatitis B
those on PREP need RFT’s how often
q 3 mos
What is Post-Exposure Prophylaxis (PEP)
Combination anti-retroviral therapy (cART) used after exposure to HIV to prevent contracting the infection
What are three possible exposure categories that may be eligible for PEP?
- occupational exposure
- non-occupational exposure
- sexual assault
PEP is a ____ drug regimen
3
PEP should be started within how many hours or it is not as effective?
-preferrably start within 2 h of exposure
-loses effectiveness after 36 hours
HIV testing following exposure, even while on PEP, should occur at
1 month
3 month
6 month
What is the initial testing for HIV
rapid antibody test
What labs are monitored in patients with HIV
-lymphocytes
-WBCs
-CD4 T cells
What is the ELISA test?
-antibody antigen test
-enzyme-linked immunosorbent assay tests a patient’s blood sample for antibodies
What is the Western blot?
-antibody-antigen test
-separates blood proteins and detects HIV antibodies
-used to confirm a positive ELISA
How accurate are combined ELISA and western blot tests
99.99%
What is the HIV IgG antibodies test
immunoglobulin G most common antibody in blood
-HIV is associated with elevated IgG antibodies
What are common respiratory infections seen in HIV
-pneumocystitis
-TB
What are common brain infections seen in HIV
-encephalitis
-meningitis
T or F: those with HIV are more at risk of intestinal infections
true
What fungal infections are those with HIV at higher risk of contracting
Candida
What other virus are those with HIV at risk of contracting
herpes
What malignancy is a complication of HIV
kaposi sarcoma
Psychosocial impacts of HIV include
-anxiety
-coping
-depression
-SI
What should we do to prevent infection in hospitalized HIV patients at with reduced immunity
-wash hands frequently
-private room
-clean frequently used equipment or get their own
-clean room and bathroom
What frequent assessments should we perform on hospitalized HIV patients at risk of infection
-IV site
-vitals sign monitoring
-mouth assessment
-skin assessment
-wound assessment
Do we need to limit visitors for patients with HIV at risk of decreased immunity
yes
How can we prevent pneumonia in patients with HIV
-turn, cough, deep breathe
-encourage activity
Do patients on cART require a lot of support
-yes; compliance to drugs is very burdensome and tiring
What are some downsides of cART to treat HIV
-very expensive
-multiple drugs daily
-lifelong
Patient teaching points for those with HIV taking cART
-specific food and timing requirements
-numerous side effects
What medication is used to treat oral candida
-fluconazole (diflucan)
Other nursing interventions for oral candida include
-ice chips
-frequent oral care
-antiemetics
Nutritional requirements for HIV patients
-increased calories and protein
Clients with HIV should avoid this dietary food
-fats
Why should clients with HIV avoid fats in food?
- HIV virus makes people fat intolerant
- cART regimen side effects also include fat intolerance
Nursing interventions to promote nutrition in those with HIV
-daily weights
-small frequent meals
-tube feedings/ TPN
Should a registered dietitian be consulted for patients with HIV
yes
Should patients with HIV used alcohol-based mouthwash?
NO
