exam 2 study guide Flashcards
prodromal stage of hepatitis ( PREICTERIC)
- Begins 2 weeks after exposure
clinical manifestations of prodromal stage of hepatitis
- HIGHLY INFECTIOUS
- N/V
- anorexia
- diarrhea
- weight loss
- Fatigue, fever, flu like symptoms ends in ENDS IN JAUNDICE
ICTERIC ( JAUNDICE) phase of hepatitis
- illness, JAUNDICE IS PRESENT
- Begins 1 week after prodromal phase and lasts up to 6 weeks
clinical manifestations of ICTERIC PHASE
- Actual illness, JAUNDICE IS PRESENT
- fatigue
- RUQ pain
- dark urine
- clay colored stools
- yellow sclera
- pruritus
RECOVERY phase of hepatitis (POSTICTERIC)
Can last 2-12 weeks
- Jaundice resolves
- symptoms diminish
- liver function return to normal
Management of hepatitis
REST! REST! REST!
- based on the type they have
- Nursing intervention for all patients with hepatitis: ACTIVITY RESTRICTION, REST AND NUTRITION
- VACCINE: hep A and B = prevention
- NO VACCINE FOR HEP C
- Blood and body fluid precautions—any body fluid needs to be treated as infectious
- antiemetics for nausea
- Corticosteroidd becuase hepatitis can cause inflammation
- Low fat/low sugar/low protein/high fiber/high calorie diet
HEPATITIS B AT RISK POPULATION
- Men who have sex with men
- Household contact of chronically infected = you are dealing with people with chronic illness, touching body fluids
- hemodialysis patients
- Health care and public safety workers
- Transplant recipients
CAN BE TRANSMITTED PARENTALLY DURING BIRTH AND PERCUTANEOULSY
Hepatitis C: HEALTH HISTORY
- Sexual behavior—high risk sexual behavior
- Drug abuse, especially IV
- Occupation exposure
- Dialysis
- Peritoneal exposure—dialysis
- One peritoneal (peritoneum) and one via blood (hemodialysis)—dialysis
- Blood transfusions before 1992
Hepatitis A: Heath teaching
FOCUS ON TRANSMISSION
- THROUGH FOOD: poor preparation, poor sanitary conditions, contaminated food and water
TRANSMITTED: ORAL FECAL ROUTE
- you can get other hepaittis if you have 1- they are not transmitted the same way
- Educate on hand-washing, food preparation, avoiding restaurants
what is cirrhosis
- A chronic liver disease characterized by WIDESPREAD DESTRUCTION OF HEPATIC CELLS REPLACED BY FIBROUS CELLS (SCARING)
- hepatitis can lead to cirrhosis but it doesnt have to
CIRRHOSIS IS MORE SEVERE
early and late cirrhosis
early cirrhosis = liver enlarged, firm and hard
late cirrhosis: shrinks in size
Medications for cirrhosis
Lactulose/CHEPHULAC: PO, NG tube, rectally
- Helps you go to bathroom through diarrhea/bowel movements
Lower ammonia levels
Assess hydration and electrolyte imbalance—> ASSESS NEURO STATUS
- Aldactone/spironolactone: diuretic (K-sparing0
- Maalox/mylanta: coats the stomach
- Questran/cholestyrimine
- Antivirals: if hepatitis is the cause
- Beta blockers for portal hypertension
- Coltrasine (USED FOR GOUT): not given to all patients with cirrhosis—but can help regenerate the liver
• Used for gout - STEROIDS
- Vasopressants for esophageal varices—to help avoid varices from bleeding
Hepatic Encephalopathy: (Hepatic Coma)
ALTERED MENTAL STATUS, FECTOR HEPATICUS, APRAXIA
- liver is unable to covert ammonia (CNS toxin) into glutamine leading to INCREASED SERUM AND CEREBRAL AMMONIA LEVEL
Prodromal stage of hepatic encephalopathy
- Subtle changes-
- FORGETFULLNESS
- DISORIENTED
- CANNOT SLEEP
- SLIGHT TREMOR
- DIMINISHED AFFECT
- SLURRED SPEECH
Impending stage of hepatic encephalopathy
- Tremor progresses into asterixis (hallmark of hepatic coma)
- lethargy
- wandering behavior
- apraxia = loss of ability to carry out learned movements)
Stuporous stage of hepatic encephalopathy
- Hyperventilation
- stunned
- confused
- slow to react
- difficult to arouse but when aroused can be abusive and combative
Comatose stage of hepatic encephalopathy
- Hyperactive reflexes
- positive Babinski sign
- fector hepaticus, coma
Lab values of CAD ACS
cardiac enzymes = troponin
- Ck-MB
- Myoglobin
Modifiable risk factors of CAD AND ACS
- elevated serum lipids
- HTN
- smoking
- obesity
- physical inactivity, - DM
- Diet
Diet for cardiac patients
–↓ Saturated fats and cholesterol
- ↑ Complex carbohydrates and fiber
- ↓ Red meat, egg yolks, whole milk
- ↑ Omega-3 fatty acids.
o Non-modifiable risk factors of CAD ACS
- Age
- Gender
- Ethnicity
- Family history
- Genetic predisposition
treatment of CAD and AC
- 12-lead ECG
- Upright position
- Oxygen – keep O2 sat > 93%
- V access, Nitroglycerin (SubLingual)
- ASA (chewable)
- Statins
- Morphine
• Stable angina intervention
- Medications
- Oxygen
- Reduce and control risk factors
o Medications for CAD
- Nitroglycerin
- Beta-adrenergic blocking agents
- Calcium channel blocking agents
- Antiplatelet and anticoagulant medication
- Aspirin
- Clopidogrel and Heparin
- Lipid lowering drugs
- Sodium current inhibitor
what does ACS branches off to
unstable angina and Non-ST segment elevation MI or ST –segment elevation MI
Unstable Angina and NSTEMI/STEMI
treatment of NSTEMI
reperfusion therapy
treatment choice for confirmed STEMI
- Emergent Percutaneous Coronary Intervention (PCI)
- Goal: 90 minutes from door to catheter laboratory and Balloon angioplasty + stent(s)
Thrombolytic therapy (STEMI)
- Only for patients with a STEMI
- Agencies that do not have cardiac catheterization resources
- Given IV within 30 minutes of arrival to the ED
- Patient selection critical
Any patients admit to cardiac unit with chest pain must be
attach to the cardiac monitor first
• Any dysrhythmias on the monitor…
check the patient first and assess them for the cause
• If patient not much responsive, what do you check for
- check for pulse
- always check the nearest pulse to the heart—that is the CAROTID ARTERY
who’s sicker, unstable angina and stable angina who are both complaining of chest pain
the unstable angina is more sicker
The 6 P’s to Neurovascular Assessment
Pain, pallor, pulse, Paresthesia(numbness and tingling)
- paralysis
- poiklothermic(affected extremity is cold to touch)
STEMI—cath lab-baloon angioplasty
after procedure, keep for FEMORAL ARTERY
—keep leg straight, distal pulses, site for bleeding
Morphine indications for CAD ACS
- reduce myocardium o2 demand
- relieve pain
- reduce anxiety
Simvaststin CAD ACS
- do not miss a dose
- muscle pain side effect
- monitor liver function test
o Nitroglycerine CAD ACS
- vasodilation and reduce pre load
- call ems if no relieve in pain after taking S/L nitro
what is HEART FAILURE
A clinical syndrome resulting from structural or functional cardiac disorders that impair the ability of the ventricles to fill or eject blood
• Clinical manifestations of LEFT heart failure
- Pulmonary congestion, crackles
- S3 or “ventricular gallop”
- Dyspnea on exertion (DOE)
- Low O2 sat
- Dry, nonproductive cough initially
- Oliguria
• Clinical manifestations of RIGHT heart failure
- Viscera and peripheral congestion
- Jugular venous distention (JVD)
- Dependent edema
- Hepatomegaly
- Ascites
- Weight gain
o Priority interventions OF HEART FAILURE
Medications
Diet: low-sodium diet and FLUID RESTRICTION.
Foods to avoid- cold cuts, Broths and stocks, canned foods
Foods to avoid HEART FAILURE
- cold cuts
- Broths and stocks
- canned foods
PATIENT TEACHINGS HEART FAILURE
- Monitoring for signs of excess fluid, hypotension, and symptoms of disease exacerbation, including daily weight
- Exercise and activity program
- Stress management
- Prevention of infection
- Know how and when to contact health care provider
- Include family in education
• Drugs FOR HEART FAILURE
o Angiotensin-converting enzyme (ACE) inhibitors: vasodilation; diuresis; decreases afterload; monitor for hypotension, hyperkalemia, and altered renal function; cough
o Angiotensin II receptor blockers: prescribed as an alternative to ACE inhibitors; work similarly
o Hydralazine and isosorbide dinitrate: alternative to ACE inhibitors
o Beta-blockers: prescribed in addition to ACE inhibitors; may be several weeks before effects seen; use with caution in patients with asthma
o Diuretics: decreases fluid volume, monitor serum electrolytes Side effect of Lasix—low potassium, so must be on k supplement—potatoes, orange juice, banana
o Digitalis: improves contractility, monitor for digitalis toxicity especially if patient is hypokalemic
o IV medications: indicated for hospitalized patients admitted for acute decompensated HF
o Milrinone: decreases preload and afterload; causes hypotension and increased risk of dysrhythmias
o Dobutamine: used for patients with left ventricular dysfunctio
Digitalis
improves contractility, monitor for digitalis toxicity especially if patient is hypokalemic
Milrinone
decreases preload and afterload; causes hypotension and increased risk of dysrhythmias
Dobutamine
used for patients with left ventricular dysfunction
nursing diagnosis for heart failure
- if cannot do ADLS = activity intolerance related to fatigue
- If cannot breath = fluid overload
Any Heart Failure
Lasix/other name is furosemide
- oxygen should result in less dysnpea and increase output
o Who to see first heart failure
- If patient health detroiating, O2 sat dropping
Sinus tachycardia what to assess
Assess the patient for possible causes
Vtach on monitor
- pt unresponsive
- check pulse-carotid
• Supra ventricular tachycardia
if symptomatic—vagal stimulation
• If non symptomatic = observe and monitor the rhythm
• Atrial Fibrillation
irregular pulse with high rate
• Which patient to see first dysrythmia
pulseless rhythms
- Ventricular fibrillation
- Asystole
- Ventricular tachycardia with no pulse
- Pulseless electrical activity( PEA)
what hepatitis can ANTIVIRALS CAN BE USED
- peg interferon and ribavirin
MOST OFTEN USED FOR HEPATITIS C
- FOR HEPATITIS B ONLY IF IT IS SEVERE
• Esophageal varices
- These are enlarged veins in the esophagus, and they are at greater risk for rupturing—patient can bleed out
Balloon tamponade ( Sengstaken-blakemore tube ) Esophageal varices
- Exert pressure at the bleeding site
- Used for 24 hours
Clinical manifestations OF HEPATITIS
o Increased AST and ALT (liver function)
o Jaundice
o Pruritus
o RUQ tenderness
o Anorexia
o fatty stools/steatorrhea
o dark urine
o pleural effusion (build up of fluid in up of fluid in belly
o asterixis (flapping tremor)
o Hallucinations
o bleeding and bruising tendencies
o spider Angiomas—blood vessels that look like spider webs (often on trunk, can be on face), TPI (purple spots on body)
o ascites
o fetor hepaticus (rotten egg smell in breath, or fruity—smell is a result of breakdown of ammonia and other toxins)
o gallstones
o esophageal varices—engorgement of veins
o decreased albumim
o increased ammonia—>can lead to hepatic encephalopathy from high ammonia level
o Elevated bilirubin
o prolonged pTT
o portal hypertension
Thrombocytopenia lab values
Normal platelet count ranges from 150,000 to 450,000 platelets per microliter of blood
- More than 450,000 platelets is a condition called thrombocytosis; having less than 150,000 is known as thrombocytopenia
Heparin Induced Thrombocytopenia (HIT)
- Associated with increased use of heparin
- Life-threatening
- platelet count drops 50% from baseline
- venous thrombosis can also develop
- DVT and PE often results
o Two major responses to an immune-mediated response to heparin
- Platelet destruction and platelet count going below normal level after being on heparin or 5-10 days and Vascular endothelial injury
- o Discontinue any heparin infusion, sub cutaneous heparin, heparin flushes
Immune Thrombocytopenic Purpura (ITP)
Most common acquired thrombocytopenia, syndrome of abnormal destruction of circulating platelets, and primarily an autoimmune disease
Tretament: High doses of IV immunoglobulin (IVIG) and anti-Rho(D)
Platelet transfusions
Platelet transfusions are generally not recommended until the count is below 10,000/μL (10 × 109/L) unless the patient is actively bleeding
sign and symptoms of thrombocytopenia
Petechiae – micro hemorrhages
Purpura – bruise from numerous petechiae
Ecchymoses – larger lesions from hemorrhage
• Nursing considerations for thrombocytopenia
teaching risk factors
Use electric razor, soft brush, no clippers and trimmers that is electric, avoid injection if can, no regular razor, no contact sport—increase risk for bleeding,
drugs for patients with chronic ITP
- Romiplostim (Nplate) and eltrombopag (Promacta)
- Direct thrombin inhibitors
antifibrinolytic agent drugs used for severe bleeding
- Aminocaproic acid (Amicar) =
thromobocytopenia Precaution
- When the count drops below 20,000/μL (20 × 109/L), spontaneous, life-threatening hemorrhages (e.g., intracranial bleeding) can occur. Patient can become lethargic and difficult to arouse
• High risk behaviors for HIV
o Patient teaching for the adolescent and young adult populations is prevention of HIV transmission between sexual partners
• Transmission fo HIV
- through contact with certain body fluids
Blood, semen, vaginal secretions, and breast milk
• Diagnostic tests for HIV
HIV-specific antibodies and/or antigens
what is used to measure the presence of HIV vital genetic material in the blood
CD4 count (normal: 800 to 1200 cells/μL)
- A positive viral load test can measure as few as 40 particles/mL
- High viral loads can be greater than 80,000 HIV particles/mL
• Lab values of HIV
- Immune problems start when CD4+ T cell counts drop to less than 500 cells/μL
- Severe problems develop when less than 200 CD4+ T cells/μL
• Opportunistic Infections
Insufficient immune response allows for opportunistic diseases
• Complications of HIV
- If left untreated, a diagnosis of AIDS (Acquired immunodeficiency syndrome ) is made about 10 years after initial HIV infection.
- CD4+ T cells decline closer to 200 cells/μL. Symptoms become worse. HIV advances to a more active stage
• Symptomatic infection of HIV
Shingles, Persistent vaginal candidal infections, Oral or genital herpes, Bacterial infections
• Immune system severely compromised: Infections, Malignancies, Wasting and HIV-related cognitive changes
• When does one develop AIDS
CD4+ T-cell count of less than 200 cells/µL.
• What is needle exchange program
safer options to use injectable illegal drugs
Nursing interventions while caring for patient with HIV
help patient to vent their feelings and listen to them
• Meds teachings for HIV
o Most important factor- Patient’s ability to follow a complex medication regimen
o HAART – the effectiveness of antiretroviral therapy (ART) look at the viral load
o General side effects- Diarrhea, Peripheral neuropathy, Pain, Nausea/vomiting, Fatigue
o Patient teaching - not to miss any dose
• Who to assess first?—whose health is being compromised
General side effects of HIV meds
Diarrhea, Peripheral neuropathy, Pain, Nausea/vomiting, Fatigue
o Patient teaching - not to miss any dose
