Exam 5 Flashcards
What is Cirrhosis?
Cirrhosis is extensive scarring of the liver, usually caused by a chronic reaction to hepatic inflammation and necrosis.
Complications depend on the amount of damage sustained by the liver.
In compensated cirrhosis, the liver has significant scarring but performs essential functions without causing significant symptoms.
Complications of Cirrhosis
- Portal hypertension
- Ascites
- Bleeding esophageal varices
- Coagulation defects
- Jaundice (Table 61-1)
- Portal-systemic encephalopathy with hepatic coma (Table 61-2)
- Hepatorenal syndrome
- Spontaneous bacterial peritonitis
Known causes of liver disease include?
Alcohol (Laennec’s cirrhosis) Viral hepatitis Autoimmune hepatitis Steatohepatitis Drugs and toxins Biliary disease Metabolic /genetic causes Cardiovascular disease
In early stages, signs of liver disease include?
- Fatigue
- Significant change in weight
- GI symptoms
- Abdominal pain and liver *tenderness
- Pruritus
Abdominal assessment in liver disease
Massive ascites (measure abdominal girth)
Umbilicus protrusion
Caput medusae (dilated abdominal veins)
Hepatomegaly (liver enlargement)
Labs to assess in liver disease
- Aminotransferase (AST,ALT)serum levels and lactate dehydrogenase (LDH) may be elevated.
- Alkaline phosphatase levels may increase.
- Total serum bilirubin and urobilinogen levels may rise.
- Total serum protein and albumin levels decrease.
Other lab findings in liver disease
- Prothrombin time is prolonged; platelet count is low.
- Hemoglobin and hematocrit values and white blood cell count are decreased.
- Ammonia levels are elevated.
- Serum creatinine level is possibly elevated.
Nursing diagnosis for liver disease
- Excess fluid volume
- Risk for imbalanced nutrition
- Ineffective breathing pattern
- Chronic pain
- Risk for infection
- Ineffective coping
- Sexual dysfunction
- Disturbed body image
What is the most common nursing diagnosis for liver disease?
Excess fluid volume
Interventions for liver disease
Interventions:
Nutrition therapy consists of low sodium diet, limited fluid intake, vitamin supplements.
Drug therapy includes a diuretic, electrolyte replacement.
Paracentesis is the insertion of a trocar catheter into the abdomen to remove and drain ascitic fluid from the peritoneal cavity.
Observe for possibility of impending shock.
Comfort measures for liver disease
For dyspnea, elevate the head of the bed at least 30 degrees, or as high as the patient wishes to help minimize shortness of breath.
Patient is encouraged to sit in a chair.
Weigh patient in standing position, because supine position can aggravate dyspnea.
Surgical interventions for liver disease
Peritoneovenous shunt
Portocaval shunt
Transjugular intrahepatic portosystemic shunt (TIP) –nonsurgical
Potential for hemorrhage for liver disease
Screen for esophageal varices
Drug therapy–nonselective beta blocker to decrease heart rate/pressure gradient
Managing hemorrhage
- Blood transfusions
- Esophagogastric balloon tamponade
- Vasoactive therapy (Octreotide)
- Endoscopic procedures: *Endoscopic variceal ligation (EVL-banding) & Endoscopic sclerotherapy (EST)
- Transjugular intrahepatic portal-systemic shunt (TIP)
Potential for Portal-Systemic Encephalopathy
Interventions include:
- Ammonia & toxic metabolic by-products can not be converted by liver to less toxic form
- Need to reduce ammonia levels
- Nutrition therapy: moderate protein/fat & simple carbohydrates
*Monitor bleeding: intestinal bacteria metabolize blood cells that increase ammonia
*Drug therapy:
Lactulose
Neomycin sulfate
Metronidazole
*Check for asterixis (liver flap) &fector hepaticus
What is Hepatitis?
*Inflammation of the liver
Viral hepatitis
*Most common cause (Hepatitis A,B,C,D,E) Other possible causes Drugs (alcohol) Chemicals Autoimmune liver disease Bacteria (rarely)
(Cytomegalovirus Epstein-Barr virus Herpes virus Coxsackievirus Rubella virus)
Hepatitis A
- 61,000 cases of hepatitis A occur annually in the United States
- Rates declined 89% since vaccine available in 1995
- 1.4 million cases of hepatitis A occur annually worldwide
- Nearly universal during childhood in developing countries
Hepatitis A virus
Hepatitis A virus (HAV)
Transmitted fecal–oral route, oral-anal sexual activity, parenteral (rarely)
Frequently occurs in small outbreaks
Found in feces 2 or more weeks before the onset of symptoms and up to 1 week after the onset of jaundice
Present in blood briefly
No chronic carrier state
Hepatitis A causes
Similar to that of a typical viral syndrome; often goes unrecognized
- Spread via the fecal-oral route by oral ingestion of fecal contaminants
- Contaminated water, shellfish from contaminated water, food contaminated by handlers infected with hepatitis A
- Also spread by oral-anal sexual activity
- Incubation period for hepatitis A is 15 to 50 days.
- Disease is usually not life threatening.
- Disease may be more severe in individuals older than 40 years.
- Many people who have hepatitis A do not know it; symptoms are similar to a GI illness.
Hepatitis B
- Nearly 400 million people chronically infected with hepatitis B
- 50% to 75% active viral replication
- 73,000 new cases of hepatitis B annually in United States
- 1.4 million Americans chronically infected
- Incidence of new infections decreased due to HBV vaccine
How is Hep B transmitted?
- Transmitted when infected blood or other body fluids enter the body of a person who is not immune to the virus
- Spread is via unprotected sexual intercourse with an infected partner, sharing needles (IV drug use), accidental needle sticks, blood transfusions (before 1992), hemodialysis, perinatal, maternal-fetal route.
Symptoms of Hep B
Symptoms occur in 25 to 180 days after exposure; symptoms include anorexia, nausea and vomiting, fever, fatigue, right upper quadrant pain, dark urine, light stool, joint pain, and jaundice.
Hep C
- 170 million people are infected with the hepatitis C virus (HCV)
- 30,000 new cases diagnosed annually
8,000 to 10,000 people in the U.S. die each year from complications of end-stage liver disease secondary to HCV
*Approximately 30% to 40% of HIV-infected patients also have HCV
What are some risk factors for Hep C?
Risk factors IV drug use Hemodialysis Blood products Occupational exposure High-risk sexual behavior Perinatal transmission is rare
More information on Hep C
- Acute symptoms of infection is not common, up to 10% of patients with HCV cannot identify a source
- Most remain asymptomatic for months and years until liver impairment causes them to seek medical care
- Most do not clear the virus and are chronically infected
- Leading cause in U.S., after alcohol, for cirrhosis
- Leading indicator for liver transplant in the U.S.; most transplanted livers become reinfected
- Additional data needed regarding risk of body piercings, tattooing, and intranasal drug use in transmission of HCV
Hep D
- Transmitted primarily by parenteral routes
- Incubation period 14 to 56 days
- Requires the helper function of HBV to replicate
- Cannot survive on its own
Hep E
- Present in endemic areas where waterborne epidemics occur and in travelers to those areas—most common mode of transmission is drinking contaminated water
- Occurs primarily in developing countries
- Transmitted via fecal-oral route
- Resembles hepatitis A
- Incubation period 15 to 64 days
Hep E symptoms
- Abdominal pain
- Changes in skin or eye color
- Arthralgia (joint pain)
- Myalgia (muscle pain)
- Diarrhea/constipation
- Fever
- Lethargy
- Malaise
- Nausea/vomiting
- Pruritus
Lab assessment for hepatitis
Hepatitis A, B, C—acute elevations in level of liver enzymes
Levels of ALT and AST may rise
Alkaline phosphatase level normal or elevated
Serum total bilirubin levels elevated
Hepatitis A—HAV antibodies in blood
Hepatitis B—Hepatitis B antigen-antibody & detectable viral count (HBsAg & anti-HBc IgM)
People vaccinated against HBV have a positive HBsAb as immunity against the disease
Preventing Hep A
*Proper handwashing, especially after handle shellfish
*Avoid contaminated food or water
*Receive immune globulin 14 days after expose
*Receive the HAV vaccine before traveling to
areas where common (Mexico, Caribbean)
*Receive vaccine if living enclosed with others (Havrix and Vaqta—inactive hepatitis A virus)
Hep B prevention
Vaccine—Engerix-B, Recombivax-HB
Immunizations for
People who have unprotected sex with more that one partner
Men sex with men
People with chronic liver disease
People exposed to blood or body fluids
Which statements about immunodeficiency are true?
- It may be acquired or congenital
- It occurs when a person’s body cannot recognize antigens
- It may cause very reactions from mild, localize health problems to total immune system failure
Which immune function abnormalities are a result of HIV infection?
- CD4 plus sell depletion
2. Lymphocytopenia
Which groups are experiencing increased numbers of HIV infections?
- Men having sex with other men
- IV drug users
- women having sex with men
- African-Americans
- Hispanics
Which descriptions are characteristic of a non-progresser?
- ?Has been infected for 10 years
- is asymptomatic
- is immunocompetent
Which statements about the transmission of HIV are true?
- Those with recent HIV infection and high viral load are very infectious
- Those with end-stage HIV and no drug therapy are very infectious
Which conditions may be the first signs of HIV and women?
- Vaginal candidiasis
- Cervical neoplasia
- Pelvic inflammatory disease
Which statements regarding HIV and AIDS among older adults are true?
- Older adults to participate in high-risk behaviors are susceptible to HIV infection
- Cognitive deficits associated with the disease may appear earlier and older adults with HIV
What is the most important means of preventing HIV spreader transmission?
Education
HIV can be transmitted by which routes?
Sexual, parenteral, perinatal
Hi reactivated anti-retro viral therapy causes what a fact?
Decrease of the viral load
The patient is an IV drug user who regularly shares needles and syringe is with friends. What information does the nurse provide to decrease the patient’s risk of HIV through shared needles and syringe after each use
Phil and then flush the syringe with Clearwater, then fill the syringe with bleach, shake approximately 30 to 60 seconds, and rinse with Clearwater
Which practices are recommended by the CDC to prevent sexual transmission of HIV?
Use of the latex or polyurethane condom for genital an anal intercourse and or use of a late text barrier for genital an anal intercourse
Which opportunistic infections can be observed in AIDS?
- Protozoan
- viral
- bacterial
- fungal
A patient with new mall cytosis Jarabec idiot and ammonia usually presents with which symptoms?
- Dyspnea, tachypnea, persistent dry cough, and fever
2. fatigue, and weight loss
The patient presenting with toxoplasmosis may have which signs and symptoms?
- Speech difficulty
- visual changes
- impaired gait
- mental status change
Cryptosporidium else this is a form of intestinal infection in which diarrhea can amount to a loss of how many liters of fluid per day?
15 to 20
Where can candidiasis occur in the body?
Mouth esophagus and vagina
True or false
Cryptococcosis is a type of meningitis
True
True or false
Histoplasmosis is a localized respiratory infection
False, histoplasmosis progresses to a widespread infection
Where in the body can cytomegalovirus present with symptoms
- The eyes, causing visual impairment
2. respiratory tract causing pneumonitis 3.gastrointestinal tract, causing colitis
How does the herpes simplex virus manifest itself in patients with HIV and AIDS?
- A chronic ulceration after vesicles rupture
- Vesicles located in the perry rectal, oral, and genital areas
- Numbness and tingling occurring before the vesicle forms
Shingles results from vera Cella zoster virus leaving the nerve ganglia and entering the body by which route?
Body fluids and other tissue areas
Lymphoma is associated with AIDS include which types?
- Non-Hodgkin’s B cell
- immunoblastic
- Hodgkin’s
- Burketts
- primary brain
Which treatments are intended to boost the man system?
- Hematopoietic growth factors
- lymphocyte transfusion
- administration of interleukin 2
- infusion of lymphokines
Which conditions cause severe pain and HIV disease and AIDS?
- Enlarged organs
- peripheral neuropathy
- Rumors
What methods are agents are used to treat Kaposi’s sarcoma?
Radiotherapy, chemotherapy, cryotherapy
Which actions are useful in helping orient a patient?
- Repeating person, place, and time
- Using clocks and calendars
3 having familiar items present
The nurse assesses the patient diagnosed with advanced it’s for malnutrition. Which findings that the nurse most likely assess?
- Pain
- Anorexia
- Diarrhea
- Vomiting
Corticosteroids perform which actions?
- Block the movement of neutrophils and monocytes through cell membranes
- reduce the number of circulating T cells, resulting in suppress cell mediated immunity and
- decrease intercranial pressure
True or false
The person with HIV infection can transmit the virus others at all stages of disease
True
True or false
Lesions resulting from Kaposi’s sarcoma are painful and have Prielin drainage
False
True or false
It’s dementia complex is caused by infection of the cells in the central nervous system by HIV
True
True or falsepatients with HIV you should know that his CD4 count slower, clinical manifestations decrease
False, clinical manifestations increase
True or false
The viral load test measures the pressure of HIV genetic material in the patient’s blood and helps with monitoring the disease progression
True
True or false
Antiviral drug therapy kills the virus before it is able to replicate
False, it only inhibits the virus not kill
True or false
HIV is more easily transmitted from infected female to uninfected mail them from infected mail to uninfected female
False, HIV is more easily transmitted from infected mail to uninfected female that infected female to uninfected mail
Which methods are items are means of transmitting HIV?
Sexual intercourse
breastmilk
The nurses teaching a patient about preventing HIV infection through sexual contact. Which statement made by the patient indicates effective teaching?
Mutually monogamous sex with and not infected partner will best prevent HIV infection
Patient diagnosed with HIV is receiving medications to reduce the viral load and improve CD for lymphocyte count. Which terms accurately describe this HIV-AIDS drug regimen?
HAART therapy
A client asked the nurse should I tell my partner I just found out I’m HIV-positive? What is the nurses most appropriate response?
You’re having difficulty deciding what to say
A client who abused IV drugs with sadness with the HIV virus several years ago. The nurse explained that the diagnostic criteria for acquired immunodeficiency syndrome has been met with the client does what?
Has a CD4 plus T lymphocytes level of less than 200 cells
A nurses caring for a client who is HIV-positive. For which complication associated with this diagnosis is it most important for the nurse to teach prevention strategies?
Infection
Mother with a diagnosis of AIDS states that she has been caring for her baby even though that she is not been feeling well. What important information to the nurse determine
If the baby is breast-feeding
A nurses caring for a client with diagnosis of AIDS. The IV infiltrates and Macy restarted. What is necessary to protect the nurse when are you starting the IV?
Gloves and hand hygiene
A nurse is planning to provide discharge teaching teaching to the family of a client with AIDS. Which statement should the nurse include in the teaching plan?
Wash use dishes in hot soapy water
During an AIDS education class for client states that Celine works great when I use condoms. Which conclusion of the clients knowledge economy is can the nurse draw from the statement?
Ignorance related to correct condom use
The client also has a nursing diagnosis of decreased cardiac output related to decreased plasma volume. Which assessment findings support this nursing diagnosis?
Flatten neck veins when the client is in the supine position
The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN being supervised by the nurse?
Reminding the client to avoid commercial mouthwashes
encouraging mouth rinsing with warm saline observing the lips, tongue, mucous membranes
providing mouth care every two hours with the client is awake
The healthcare provider is written on these orders for a client with a diagnosis of excess fluid volume. The clients morning assessment reveals bounding peripheral pulses waking up 2 pounds, putting ankle edema, moist crackles bilaterally. Which order takes priority at this time?
Administer forosemide or Lasix 40 mg IV push
You’ve been floated to the telemetry unit for the day. The monitor watch your informs you of the clients develop problem that you waves. Which lab value should you check Amilee?
Potassium
Clients potassium level is 6.7. Which intervention should you delegate to the first year nursing student when you’re supervising?
Administer sodium polystyrene sulfonate 15 g Orlean
A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion. For which electrolyte abnormality would you be sure to monitor?
Hyponatremia
The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to you, a newly graduated RN. Which action can you delegate to the UAP?
Providing oral care every 3 to 4 hours
The client has a history of hypothyroidism. Which skin condition should the nurse expect when performing a physical assessment?
Dry skin
A nurses caring for a client was experiencing in under production thyroxine. Which client response is associated with an under production of the Roxy or T4?
Myxedema
It is the severest form of hypothyroidism
Propylthiouracil or PTU is prescribed for a client diagnosed with hyperthyroidism. The client asked the nurse why do I have to take this medication if I’m going to get the atomic cocktail? The nurse explains that the medication is being prescribed because it decreases the?
Production of thyroid hormones
A nurses caring for a client with an underactive thyroid gland. Which responses should the nurse expect the client to exhibit as a result of decreased level of triode I thyronine T3 and T4?
Weight gain and cold intolerance
Which clinical findings should the nurse expect when assessing a client with hyperthyroidism?
Diarrhea and weight-loss
Nurses caring for a client after radioactive iodine is administered for Graves’ disease. What information about the clients condition after the therapy should the nurse consider when providing care?
Mildly radioactive but should be treated with her team safety precautions
The client is scheduled to have a thyroidectomy. Which medication does the nurse anticipate the healthcare provider will prescribe to decrease the size of vascularity of the thyroid gland before surgery?
Potassium iodide
Nurse is assessing a client for possible laryngeal nerve injury following a thyroidectomy. Which action should the nurse implement on an hourly basis?
Ask the client to speak
A nurse is caring for a newly admitted client with a diagnosis of graves disease. And preparing a teaching plan, the nurse anticipate switched I will be ordered for this client?
High calorie diet
A claim with hyperthyroidism asked the nurse about the test that will be ordered. Which diagnostic test of the nurse include in a discussion with this client?
TSH assay a and T3
A nurse in the post anesthesia care unit is caring for a client who just had a thyroidectomy for which client response is most important for the nurse to monitor?
Signs of respiratory obstruction
A nurses caring for a client who just had a thyroidectomy. For it’s Clara sponsor the nurse assessed the client one concern about an accidental remover of the parathyroid glands are in surgery?
Tetany
I’m taking the blood pressure of a client who had a thyroidectomy, the nurse identifies the claim is pale and have spasms of the hand. The nurse notified the healthcare provider. What should the nurse expect the healthcare provider to prescribe?
Calcium
What should a nurse do immediately when a client returns from the postanesthesia care unit filing a subtotal thyroidectomy?
Place a tracheostomy set at the bedside
On the first postoperative day finally thyroidectomy a client tolerates a full fluid diet. This is changed to a soft diet on the second postoperative day. The client reports having a sore throat and swollen. What should the nurse do for us?
Administer analgesics as prescribed before meals
A nurse is assessing a client with a diagnosis of hypothyroidism. Which clinical manifestations to the nurse expect when assessing a client?
Dry skin and brittle hair
Level thyroxine 0.125 mg by mouth is prescribed for a client with hypothyroidism. The only tablets available contain 25 µg per tablet how many tablets should the nurse administered?
5 tablets
The client is diagnosed with hyperthyroidism is in experiencing exophthalmia. Which meds or should the nurse include one teaching the client how to manage the discomfort associated with XFL man?
- Use tinted glasses
- elevate the head of the bed 45°
- tape Eyelids shut at night if they do not close
For which client response to the nurse monitor when assessing for complications of hyperparathyroidism?
Bone pain
Nurses caring for a client who is admitted to the hospital with a diagnosis of primary hyperparathyroidism. Which action should be included in this clients plan of care?
Ensuring a large fluid intake
Client lab values demonstrating increased serum calcium level, and further diagnostic tests reveal hyperparathyroidism. For what clinical manifestations to the nurse assesses client?
Correct dysrhythmias and hypoactive bowel sounds
A nurses caring for a client newly admitted with a diagnosis of pheochromocytoma. Which clinical findings as a nurse expect when assessing this client?
Headache, palpitations, diaphoresis
Preparation of the client for a subtotal thyroidectomy may include that ministration of potassium iodide solution. The client refuses to take the medication. What explanation to the nurse give us the wife medication should be taken?
It will reduce the risk of hemorrhage during surgery
The nurse is interviewing a patient who is newly admitted to the unit with a diagnosis of anemia which assessment findings does the nurse expect?
Dyspnea on exertion orthostatic hypotension intolerance to cold temperatures club like appearance of the nails pallor of the ears headache
All OF THEM
Patient with sickle cell crisis is admitted to the hospital. Which questions does the nurse asked the patient to elicit information about the cause of the current crisis?
Ask the patient about recent airplane travel determine the patient’s perceived energy level using a scale from 0 to 10
review all activities and events during the past 24 hours
ask the patient about the ability to climb stairs ask the patient about symptoms of infection
ALL OF THEM
Patient is scheduled to undergo lab testing to diagnose sickle cell anemia. For which diagnostic test of the nurse provide patient teaching?
- White blood cell count
- hemoglobin S
- red blood cell count
The student nurses caring for a patient with sickle cell crisis which action by the student warrants intervention by the supervising nurse?
Keeping the patient’s room cold
A patient with vitamin B12 deficiency anemia is being discharged home with primary care responsibility being assume by the family. The patient and family about dietary modifications to manage this condition. Which statement by the family indicates additional teaching as needed about dietary modification?
Dairy products will be omitted from the diet citrus fruits will be omitted from the diet
green leafy vegetables will be omitted from the diet
Which statement is true about the pattern of inheritance for sickle cell disease?
If a patient with sickle cell disease has children each child one here at one of the two abnormal gene or wheels and at least have the sickle cell trait
The nurses caring for a patient in sickle cell crisis which I already interventions for this patient?
Pain management and assessing oxygen saturation
The nurses aide is providing care to a patient in sickle cell crisis. Which action by the nurses aide requires intervention by the supervising nurse?
Obtaining the patient’s blood pressure with an external cuff
A patient admitted for sickle cell crisis is being discharged home. Which statement by the patient indicates the need for food further postoperative discharge instruction?
I will visit my friends in Denver
When reviewing the procedure for administering I am medications by the track method which statement by the student nurse indicates that further instruction is needed?
I will use the ventral gluteal site for the injection
A patient with polycythemia vera is being cared for by a nurses aide. Which action by the nurses aide requires intervention by the supervising nurse?
Assisting the patient to flosses teeth
A patient with a low white blood cell count is being discharged home in what situations with the patient be instructed by the nurse to contact his or her healthcare provider?
For temperature greater than 100° if a persistent cough develops with or without sputum is plus or foul-smelling drainage develops from any open skin area or normal body opening if a boil or abscess develops for year and it is cloudy or foul-smelling or if burning on urination is experienced
ALL OF THEM
Which food should a patient with low white blood cell count the encourage to eat?
A well-done steak
The nurses caring for a patient with acute leukemia which characteristics is the nurse assessed the patient for?
- Hematuria
- Orthostatic hypotension
- bone pain
- joint swelling
- fatigue
Which factors are associated with an increased risk for lymphoma?
- Autoimmune disease and immunosuppressive disorders
- chronic infection from helical backed or pylori
- Epstein-Barr virus infection
- inherited genes damage
- pesticides and insecticides
Which disorder make the patients at high risk for the development of infection?
Sickle cell crisis
Which medication place is a patient at risk for infection?
Steroids
The nurse is caring for a patient with thrombocytopenia which order does the nurse question?
Edminister enema
A patient undergoing bone marrow or stem cell transplant patient reports severe fatigue to assist the patient with energy management, what does the nurse encourage the patient to do?
- Verbalize feelings about limitations
- monitor nutritional intake to ensure adequate energy resources
- limit the number of visitors as appropriate
- plan activities for. When the patient has the most energy
- monitor overall response to self-care activities
The Homecare nurses is it a patient who had at Sam’s cell transplant. Which observation by the nurse requires immediate action?
The patients grandson is visiting after receiving in MMR vaccine
The patient has been taught how to care for his central venous catheter at home with statements by the patient indicate that further instruction is necessary?
I will flush the catheter with heparin three times a day
I will change the Luer lock On each catheter daily
The nurse instructed patient at risk for bleeding about techniques to manage this condition which statement by the patient indicates that the teaching have been successful?
- I will take a stool softener to prevent straining during about movement
- I won’t take aspirin or aspirin containing products
- I won’t participate in any contact sports
- I will report a headache that is not responsive to acetaminophen
- I will avoid bending over at the waist
The new registered nurse is giving a blood transfusion to a patient which statement by the new nurse indicates the need for action by the supervising nurse?
I’ll be sure to complete the red blood cell transfusion is within six hours of removal from refrigeration
The new registered nurse is identifying a patient for blood transfusion which action by the new nurse wants intervention but supervising nurse?
Uses the patient’s room number is a form of identification
A patient receiving a stem cell transplant from an identical twin is receiving which type of transplant?
Syngeneic
A patient with hemophilia VIII will most likely receive which components of blood for management of the disease
Cryiprecipitate
Patients with sickle cell disease are more susceptible to infection specifically streptococcus pneumonia and hemophilia’s influenza A which actions help prevent infection?
1. Consistent good handwashing technique 2 yearly flu vaccination 3. twice daily oral penicillin 4. monitoring CBC 5. assessment of vital signs at least every four hours
The nurses caring for a patient who is donated bone marrow. In addition to having the aspiration safe monitored the nurse would anticipate the need for which interventions?
- Fluid for hydration
- pain management
- possible RBC infusion
- anabiotic therapy
- assessment for complications of anesthesia
When caring for a patient after bone marrow stem cell transplant Tatian, when does the nurse expect engraftment to occur?
12 to 28 days after infusion
A patient is at high risk for the development of venoocclusive disease what assessments does the nurse performed for early detection of this disorder?
Jaundice
Hepatomegaly
right upper abdominal pain
ascites
Hodgkin’s lymphoma
Pain in lymph nodes brought on are made worse with ingestion of alcohol
one of the more treatable type of cancer fevers, drenching night sweats, and unexplained weight loss
of viral infections and exposure to chemical agents
read stern big cells
Enlarged painless lymph nodes
more common in teens
Non-Hodgkin’s lymphoma
- Over 60 subtypes
2. associated with autoimmune disorders
Alogenic
From a sibling or HLA match
Syngeneic
From an Identical twin
Autologous
From own stem cells
Well being interviewed for admission a patient tells the nurse that he has Christmas disease. What does the nurse document?
Hemophilia B
Which characteristics described patients who have hemophilia?
- Bleeding for a long period of time
2. exhibit abnormal bleeding a response from
What size of an IV needle is best for administering a blood transfusion and
20 gauge needle
A patient is receiving a blood transfusion. Which solution does the nurse administered with the blood?
Normal saline
A nursing student has to registered nurse why D5W is contra indicated when transfusing blood. How does the nurse respond?
It causes hemolysis of blood cells
Patient is receiving a blood transfusion through a single lumen peripherally inserted central catheter the patient has two peripheral IVs one is And the other has D5 45 and running at a rate of 50 mL an hour what infusion is acceptable to add to the blood products?
Normal saline
The nurse realizes that he will let it reactions to blood transfusions occur most often within the first how many milliliters of the infusion?
50 mL
Which type of medication is used for patients receiving a platelet transfusion as a pre-medication to prevent a reaction?
Benadryl and Tylenol
Patient has been receiving frequent blood transfusions soon after this transfusion has begun the patient develops a fever and report a racing heart does not report any pain. The nurse notes that the patient is also hypotensive clinical manifestations may be the cause of which type of transfusion reaction?
- Hemolytic
- bacterial
- febrile
A client expresses concern about being exposed to radiation therapy because it can cause cancer. Which of the nerds emphasize one informing the client by exposure to radiation?
Only a small part of the body is a radiated
A client who is to receive radiation therapy for cancer says to the nurse my family said I will get a radiation burn. What is the nurses best response?
I look like skin reaction usually occurs
I nurse is caring for a client who had an insertion of radium for cancer of the cervix. For what radium action should the nurse assess the client?
Pain
Read inserted into the vagina have a client is now been removed. What safety precaution to the nurse employee when assisting with the radium remove all?
And stir that long for steps are available for moving the radium
A nurse is checking the Predium of a client with a radium implant for cervical cancer observe the packing protruding from the vagina. When is the next notify the healthcare provider to remove it immediately?
Radioactive packaging will enjoy a healthy tissue
A nurse is caring for a client who has a radium implant for cancer of the cervix. What is the priority nursing action?
Restrict visitors to a 10 minute say
The client was treated with the reading implant for cancer of the cervix. What information is important for the nurse to teach the client when giving discharge instructions?
Return for follow-up care
Postmenopausal women who has cancer of the breast besides Avalon back to me followed by chemotherapy. After receiving chemotherapy for several weeks, she says to the nurse at the clinic I don’t feel well. The nurse reviewed the chemotherapy medication for client is receiving and check the lab values obtained the clients vital signs. Based on this information what does the nurse include in this clients priority need?
Preventing infection
The client with upper G.I. bleeding developed mild anemia. What should the nurse expect to be prescribed for this client?
Iron salts
The client has a low hemoglobin level, which is attributed to nutritional deficiency, and the nurse provides dietary teaching. Which food choices by the client indicates that the nurses instructions are effective?
Raisins and spinach
The client is admitted with a higher than expected red blood cell count. What physiological alteration is the nurse expect will result from this clinical finding?
Increase blood viscosity
A transfusion of packed red blood cells in order for a client with anemia. List the following actions in order in which they should be performed by the nurse
- Ensure that the client signed a consent form
- Determine clients vital signs
- Compare the number on the blood product and lab record
- Donna pair of clean gloves
- Run the transfusion slowly
A client of the bone marrow aspiration perform. After the procedure what is the first nursing action?
Briefly apply pressure over the aspiration side
The client is diagnosed with Hodgkin’s disease. Which lymph node does the nurse expect to be affected first?
Cervical
What group of clients to the nurse anticipate to have the highest incidence of non-Hodgkin lymphoma
Older adults
Nurses teaching a client with Hodgkin’s disease about response to whole body radiation which clinical indicator increase to the nurse include?
Susceptibility to infection
Acclimate started on a continuous infusion of heparin. Which finding does the nurse used to conclude that the interventionist therapeutic?
APTT is 2 times he control value
A client is receiving Coumadin. The nurse explained the need for careful regulation of dietary intake of vitamin K. What physiological processes vitamin K promote that this makes this instruction essential?
Prothrombin formation by the liver
A nurses caring for a client with a diagnosis of policies in the vera. The client asked why do I have an increased tendency to develop blood clots? Which effect of the policy theme yeah vera explain increases the risk of these thrombosis?
Increase blood viscosity
A female client has a low hemoglobin level, which is attributed to an iron deficiency which food should the nurse recommended client increase in their diet?
Spinach, beef liver, and baked beans
The client is receiving epoetin for the treatment of anemia associated with chronic renal failure. Which client statement indicates the nurse that further teaching about this medication is necessary?
I really that important to take this medication because it will cure my
Wrong because epoetin one creates a sense of well-being but I will not cure the underlying medical problem
You are reviewing the complete blood count for a patient who is abatement a minute for knee arthroscopic knee. Which value is the most important to report to the physician before surgery?
White blood cell count of 16,000
You are providing orientation for a new RN who is preparing to administer pack red blood cells to a patient my blood loss during surgery. Which action by the new RN requires that you intervene immediately?
Priming the transfusion that using 5% dextrose and lactated ringer solution
A 32-year-old patient with sickle cell anemia is admitted to the hospital during a sickle cell crisis which action prescribed by the healthcare provider will you implement first?
I minister 100% oxygen using a non-rebreather mask
These activities are included in the care plan for 70-year-old patient admitted to the hospital with anemia caused by possible gastrointestinal bleeding. Which activity can you delegate to an experienced UAP?
Obtaining stool samples first fecal blood test slides
As a charge nurse you’re making the daily assignments on the MedSurg unit. Which patient is best assigned to a float nurse who has come from the post anesthesia care unit?
52-year-old patient with chronic gastrointestinal bleeding was returned to the unit after a colonoscopy
You’re making a room assignment for newly arrived patient was lab test results indicate Pancytopenia. Which patient with be the best roommate for this new patient?
Patient with digoxin toxicity
A 67-year-old who is receiving chemotherapy for lung cancer is admitted to the hospital with thrombocytopenia. Which statement made by the patient when you are obtaining the admission history is most of most concern?
I take one aspirin every morning because of my history of angina
After a car accident, patient with a medical alert bracelet indicating hemophilia A is admitted to the emergency department. Which action prescribed by the healthcare provider will you implement first?
Transfuse factor VII concentrate
As a home health nurse, you are obtaining an admission history for a patient who has the van thrombosis and is taking Coumadin 2 mg daily. Which statement by the patient is the best indicator that additional teaching about Coumadin may be needed?
I have started to eat more healthy food like green salads and fruit
A patient is admitted to the intensive care unit with disseminated intravascular quite elation associated with the gram-negative infection. Which assessment information has the most immediate implications for the patient’s care?
The patient’s oxygen saturation is 87%
A 22-year-old was stage one Hodgkin’s disease is admitted to the oncology unit for radiation therapy. During the initial assessment the patient tells you sometimes I’m afraid of dying. Which response is most appropriate at this time
Tell me a little bit more about your fear of dying
You received a change of shift report about the following patients. Which one were you with us first?
69-year-old with chemotherapy induced neutropenia with an oral temperature hundred and one
A patient in a long-term care facility who have chronic lymphocytic leukemia has a nursing diagnosis of activity intolerance related to weakness and anemia. Which nursing action will you delegate to the UAP?
Checking the patient’s blood pressure and pulse rate after ambulation
A transfusion of packed red blood cells has been abusing for five minutes with the patient becomes flesh to And says I’m having chills please give me a blanket. Which action should you take first?
Stop the transfusion
A group of patients is assigned to an RN LPN team. The OPN should be assigned to provide patient care and administer medications to which patient?
36-year-old with chronic kidney failure who will need a subcutaneous injection of Procrit
You obtain the following dad about a patient admitted with multiple myeloma. Which information has the most immediate implications for the patient’s care?
The patient reports new onset leg numbness
The nurse in the outpatient clinic is assessing a 22-year-old required a splenectomy after recent motor vehicle accident. Which information obtained during assessment will be of most immediate concern to the nurse?
The oil temp is 100°
A patient my graft versus host disease after bone marrow transplant patient is being cared for in the medical unit. Which nursing activities best delegated to the travel RN?
Infusing 5% dextrose and 0.45% saline at 125 mL an hour into the patient
You’re the charges on an oncology unit want to patient was an absolute neutrophil count to 300 and submitted with staff member should you decide to provide care for this patient, under the supervision of an experience oncology RN?
LPN with two years of experience on the oncology unit
You’re transferring a patient with newly diagnosed chronic myeloid leukemia to an LTC facility. Which information is most important to communicate to the LTC charge nurse before transferring the patient?
The patients chemotherapy has resulted in neutropenia
A patient with acute Milo Janice leukemia is receiving induction phase chemotherapy. Which assessment finding requires the most rapid action?
Serum potassium level of 7.8
Patient has been receiving cyclosporine following an organ transplantation is experiencing the following symptoms. Which one is of most concern?
Nontender lump in the right groin
Patient with Hodgkin’s on Phoma is receiving radiation therapy to the groin area has skin redness and tenderness in the area being irradiated which nursing activities should you delegate to be UAP caring for the patient?
Cleansing the skin over the area daily with a mild soap
After you receive the change of shift report, which patiently with us first?
20-year-old with possible acute Milo leukemia I was just arrived on the medical unit
Autoimmune thrombolytic purpura
- Also called idiopathic
- Antibodies directed against own platelets
- Women age 20-40
- pre-existing autoimmune condition
- Immunosuppressive therapy to reduce intensity
- Corticosteroids and azathioprine
Thrombotic thrombocytopenia purpura
- Platelets clump
- Plasmopheresis
- Inappropriate aggregation of platlets
True or false
Cirrhosis is extensive, irreversible scarring of the liver usually caused by chronic reaction to hepatic inflammation and necrosis
True
True or false
Most common cause for cirrhosis in the United States are alcoholic liver disease and hepatitis C
True
True or false
Laennecs cirrhosis is caused by viral hepatitis and exposure to drugs or chemicals
False this type of cirrosis is caused by alcohol abuse
True or false
Ascites the accumulation of free fluid within the peritoneal cavity caused by increased hydrostatic pressure from portal hypertension
True
True or false
Massive ascites may cause renal vasoconstriction triggering the angiotension system resulting in sodium and water loss
False massive ascites may cause renal vasoconstriction, Trigal triggering the running angiotensin system resulting in sodium and water retention
True or false
Esophageal varies occurs when fragile thin walled esophageal beans become distended from increased pressure
True
True or false
Melena is the term that refers to black tarry stool
True
Patients with cirrhosis are susceptible to bleeding and easy bruising because they’re lacking and factors II, VII, IX , X
True
True or false
Hepatorenal syndrome is often the cause of death in patients with cirrhosis
True
True or false
cirrhosis has a rapid onset was severe and specific early manifestations
False
When admitting the patient was cirrhosis, the nurse assesses for which conditions as possible complications of the disease
- Ascites
- bleeding esophageal variances
- Hepatorenal renal syndrome
- Coagulation defects
- portal hypertensive gastropathy
Patient with roses are susceptible to bleeding and easy bruising because there is a decrease in the production of bile in the liver preventing them which vitamin?
Vitamin K
Which lab value as the usual I didn’t indication of Hepatic encephalopathy
Elevated ammonia level
Which elevated lab test results indicate the hepatic cell destruction?
- Serum aspartame aminotransferase
- Serum alanine aminotransferase
- Lactate dehydrogenase
- Serum total bilirubin
- Urine urobilinogen
- INR
ALL OF THEM
The patient is scheduled for a procedure to place a stent in the biliary tract. For which procedure does the nurse provide patient teaching?
Endoscopic retrograde cholangiopancreatography
When caring for a patient with cirrhosis who has Puritius The nurse delegates which task to the UAP?
Use of lotion to soothe the skin
The nurses teaching a patient with cirrhosis about nutrition therapy. Which statement by the patient indicates teaching has been effective?
I will read the sodium content labels on all food and beverages
I’m preparing a person for Perry centesis what does the nurse do?
Ask the patient to void before the procedure obtain the patient’s heart rate
assess the patient’s respiratory rate
obtain the patient’s blood pressure
Patient will undergo an abdominal paracentesis. Which factor provides an additional safety measure?
The procedure is performed using ultrasound
The student nurses caring for a patient with cirrhosis. Which action by the student nurse causes a supervising nurse to intervene?
Uses a straight edge razor to shave the patient
The nurse who is assessing a patient with portosystemic and slept a lot but the find that the patient has better hepaticus, positive events he signed, and seizures but no Asterix. The nurse identifies the patient is being which stage of portosystemic encephalopathy?
Stage IV comatose
True or false
All patients with the roses should be screened for esophageal varies by endoscopicy to detect them early before they bleed
True
True or false
Bleeding esophageal varies our medical emergencies
True
True or false
Nonselective beta blocker engage in such as Inderal is usually prescribed to prevent esophageal varies from bleeding
True
True or false
IV octreotide is the mainstay for acute hemorrhage dude esophageal berries in the United States
True
True or false
It’s off of gastric balloon tamponade is really used today because it is difficult to use, uncomfortable for the patient, and prone to dangerous complications
True
The nurses teaching a patient with psoriasis about lactulose therapy. Which statement by the patient indicates the teaching is been effective?
This therapy will promote the removal of ammonia in my stool
How is mycifeadin in used to treat patients with cirrhosis
It destroys the normal flora of the bowel, diminishing protein breakdown and decreasing the rate of ammonia production
True or false
Hepatitis D is the leading cause of cirrhosis and liver failure in the United States
False , hepatitis C is
True or false
Appetite is a spread via the fecal oral route
True
True or false
Hepatitis B can be transmitted by unprotected sexual intercourse with an infected partner
True
True or false
Hepatitis carries have chronic obvious signs of hepatitis B
False no signs
True or false
Hepatitis C is transmitted by casual contact or intimate household contact
False not transmitted through that type of contact
True or false
Hepatitis D only occurs with hepatitis B to cause viral replication
True
True or false
Hepatitis is transmitted via the fecal oral route
True
When teaching a group of adult patients measures for preventing hepatitis A what information does the nurse include?
- Perform proper handwashing especially after handling shellfish
- Receive immune globulin within 14 days of expose the virus
- Receive the HAV vaccine before traveling to Mexico or the Caribbean
- Receive the vaccine of living in a college dorm
- Receive the vaccine if working in a long-term care facility
Which people are in need for immunization against hepatitis B?
- People have unprotected sex with more than one partner
- men want sex with men
- people with any chronic liver disease 4. firefighters
- police officers
True or false
Needlesticks are the major source of hep B transmission in healthcare worker
True
True or false
The hepatitis B vaccine is administered in a series of two injections
False it’s administered in a series of three injections
True or false
Hepatitis B vaccine also prevents hepatitis E
False only hepatitis B
True or false
It’s a healthcare worker is exposed to hepatitis a, immunoglobulin should be administered immediately
True
True or false
All cases of hepatitis should be reported to the health department
True
True or false
A person who has a history of being infected with hepatitis C me never donate blood, body organs, or other body tissue
True
True or false
A person with viral hepatitis can no longer transmit the disease once the jaundice this is resolved
False they can continue to transmit the disease
True or false
Patient with hepatitis should eat small frequent meals with a high carb, moderate fat, and moderate protein content
True
True or false
People of been vaccinated against HPV have a positive HB a B because they also have immunity to the disease
True
Which lab test results indicate permanent immunity to have a?
Immunoglobulin G antibodies
Which antiviral drugs are given to patients with hep B virus?
- Lamivudine
- Entecavir
- Telbivudiene
- Pegylated interferon alpha 2b
Which conditions place of patients at high risk for the development of fatty liver?
Diabetes
mellitus obesity
elevated lipid profile
alcohol abuse
In performing an assessment on a patient with liver trauma, what is the nurse expect to find?
Positive kerhs sign
Guarding of the abdomen
Abdominal distention
True or false
Liver cancer is most often seen in regions of Asia and the Mediterranean
True
True or false
Risk factors for the development of liver cancer include use of anabolic steroids, androgens, or estrogens
True
True or false
Alpha fetiprotein is a tumor market for cancers of the liver
True
True or false
Chemotherapy is the treatment of choice for cancer of the liver
False selective internal radiation is the treatment of choice for cancer of the liver
True or false
Liver transplantation maybe use for the patient with the primary liver tumor
True
True or false
Patients with advanced cardiac disease are not considered candidates for liver transplantation
True
True or false
The success of all transportation has greatly improved since the introduction of cyclosporine in immunosuppressive drugs
True
True or false
Transplant rejection is treated aggressively with immunosuppressive medications
True
True or false
Clinical manifestations of organ rejection may include tachycardia, fever, right upper quadrant or flank pain, decreased bile pigments volume, and increasing Johnese
True
What is thyrotoxicosis?
The manifestations of hyperthyroidism.
Negative feedback system of the brain in regards to hyper and hypothyroidism
The hypothalamus gets info from what is in the blood, if body needs more t4 or T3 is needed then sets out thyroid release of hormone to anterior pituitary. The pituitary then sets out a thyroid stimulating hormone which goes to the thyroid gland. It tells it to produce more or less of T4 or T3 depending on condition of body
HIV and the immune response
HIV disrupts this process by directly infecting the helper T-cells. Your initial immune response does get rid of a great deal of HIV, but some of it manages to survive and infect these important cells. Once the infected helper T-cells are activated, they work to create new viruses instead of doing the job they are supposed to do in your immune system. In addition, many helper T-cells are destroyed in the HIV replication process.
Normal T3 levels
Serum T3(Triiodothyronine):70-205 ng/dL or 1.2-3.4 SI unit
Normal T4 levels
Serum T4 (Thyroxine): 4-12 mcg/dL or 51-254 SI units
Normal TSH levels
TSH (Thyroid Stimulating Hormone): 0.3-5.0 uU/mL or
0.3-5.0 SI units
What is anemia?
Reduction in either the number of red blood cells, the amount of hemoglobin, or the hematocrit Clinical sign (not a specific disease); a manifestation of several abnormal conditions
What is sickle cell disease?
Genetic disorder resulting in chronic anemia, pain, disability, organ damage, increased risk for infection, and early death
Sickle cell disease state and sickle cell trait
Carrier will have one hemogobin A and one hemogobin S
Sickle cell path
Main problem of the disorder is formation of abnormal hemoglobin chains
HBS: decreased oxygenation
Sickle cells are sticky and start clumping up together which causes a vasocclusive disorders
Hypoxia, anesthesia dehydration, venoustasis, alcohol ad drugs, high altitudes, temp changes all cause sickling
Sickle cell manifestations
Cardiovascular: risk high-output HF,fatigue
Skin: pallor, cyanosis, jaundice, sores
Abdominal changes: spleen, liver enlarge
Renal and urinary: damaged nephrons
Musculoskeletal: necrotic degeneration;
reduced ROM; pain
CNS: seizures, stroke, gait, coordination
Psychosocial: Behavioral from hypoxia,
Lifestyle changes
Sickle cell lab assessment
Hemoglobin S (HbS) SC trait-40% HbS;
SC disease 80-100%HbS
Number of RBCs with permanent sickling
SC trait-5-50%; SC disease 90%+
Hematocrit-low
Reticulocyte count-high
Total bilirubin-high
Total white blood cells-high
Imaging assessment-bone changes;
joint necrosis and destrucion
What is the most common problem in sickle cell disease?
Pain is the most common problem:
Drug therapy—48 hours of IV analgesics;
avoid PRN and IM meds
Number 1 treatment of sickle cell
IV solution at high rates because they are very suspectible to dehydrations: number #1 treatment
Then treat pain, morphine PCA
Crisis will decline after 5-7 days then morphine can go to PRN
Sickle cell and sepsis
Highly suspectible to sepsis: practice infection control: educate
Drug therapy—prophylactic therapy (Pcn BID),
flu & pneumonia vaccine
Sickle cell interventions
Hydration: hypotonic solution to flush those sickle cells and prevent clumping
Hydration, pain management and oxygenate (hydration is number one) ON TEST
Preventing sickle cell crisis
Patient and family ed. Chart 42-3, p. 898
Drink 3-4 liters liquid daily
Avoid alcoholic beverages & tobacco
Call at first sign of illness or infection
Flu shot yearly & ask pneumonia vaccine
Avoid extremes of hot and cold
Wear sock & gloves on cold days
Avoid high altitudes (planes, Denver)
Tell health providers you have Sickle Cell
Avoid strenuous exercise; do mild exercise
Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency Anemia
Most common type of inherited hemolytic anemia
Effect of exposure to some drugs, benzene and other toxins
Screening for this deficiency necessary before donating blood, because cells deficient in G6PD can be hazardous
Hydration
Osmotic diuretics
Transfusions
Immunohemolytic Anemia
Immune system attacks person’s own RBC
Warm antibody anemia—IgG antibody+++
Cold antibody anemia—IbM 86 F (30 C)
Management—steriods, splenectomony, immunosuppressive therapy
Iron Deficiency Anemia (Microcytic)
This common type of anemia can result from blood loss, poor intestinal absorption, or inadequate diet.
If mild—symptoms of weakness and pallor.
Evaluate adult patients for abnormal bleeding, especially from the GI tract.
Treatment—increasing oral intake of iron from food sources, oral iron supplements, or IM iron solutions.
2/3 of iron is contained in hgb, 1/3 in bone marrow
Spinach, kale, red meat high in iron (need to take iron supp with meals)
Pernicious Anemia
Anemia resulting from failure to absorb vitamin B12 caused by a deficiency of intrinsic factor
Treatment:
Vit B 12 injections,
Cyanocobalamin (CaloMist)
Aplastic Anemia
Deficiency of circulating RBCs because of failure of the bone marrow to produce these cells
Injury to the pluripotent stem cell
Pancytopenia common
Nursing: Assess bone marrow failure, poor oxygenation
Treatment:
Blood transfusions,Immunosuppressive therapy,Splenectomy
Anemia: decreased white blood cell and thrombocytopenia
Can get allogenic stem cell transplant
Polycythemia Vera
Polycythemia vera is a chronic myeloproliferative disorder characterized by increased red blood cell mass (RCM), or erythrocytosis
The resultant hyperviscosity of the blood predisposes such patients to thrombosis
Polycythemia Vera cont..
Disease with a sustained increase in blood Hgb levels to 18g; RBC count of 6million; or a Hct of 55% or greater
Patients may present with complaints of pruritus after bathing, burning pains in the distal extremities (erythromelalgia), gastrointestinal disturbances, or nonspecific complaints such as weakness, headaches, or dizziness.
Pruritus results from increased histamine levels released from increased basophils and mast cells and can be exacerbated by a warm bath or shower.
This occurs in up to 40% of patients.
Other patients are diagnosed after an incidental finding of an elevated hemoglobin and/or hematocrit level on a complete blood count.
Headache, dizziness, vertigo, tinnitus, visual disturbances, angina pectoris, or intermittent claudications
Polycythemia Vera—Cancer of the RBCs
Disease with a sustained increase in blood hemoglobin (18 g/dL)or hematocrit (55%+) Massive production of red blood cells Excessive leukocyte production Excessive production of platelets Blood poor O2, thick blood moves slow-HTN, vascular stasis-thrombosis Treatment: Phlebotomy Hydration Anticoagulants
What is leukemia?
Cancer with uncontrolled production of immature white blood cell in bone marrow
Classified by cell type:
Lymphocytic or lymphoblastic
Myelocytic or myelogenous
Etiology of leukemia
Etiology: basic is damage to genes controlling cell growth
Myloid displatic syndrome (know)
The myelodysplastic syndromes (also known as MDS or myelodysplasia) are hematological (i.e., blood-related) medical conditions with ineffective production (or “dysplasia”) of all blood cells.[1]
Patients with MDS can develop severe anemia and require blood transfusions. In some cases, the disease worsens and the patient develops cytopenias (low blood counts) caused by progressive bone marrow failure.
The outlook in MDS depends on the type and severity. Many people live normal lifespans with MDS. Often, people are asymptomatic and are unaware they even have MDS until it shows up in a routine blood test.
Key features of acute leukemia
Cardiovascular—heart rate inc.; B/P dec.
Respirations—dyspnea on exertion
Skin—pallor & cool result of reduced tissue perfusion. Petechiae.
Intestinal—bleeding gums, weight loss, nausea, anorexia, constipation
CNS-cranial nerve disturbance, headaches, papilledema, seizures, coma
Miscellaneous—bone & joint tender, lymph nodes enlarged, fatigue
Leukemia lab values
Decreased hemoglobin and hematocrit levels
Low platelet count
Abnormal white blood cell count; may be low, normal, or elevated but is usually quite high
Bone marrow aspiration and biopsy
Blood-clotting times
Chromosome analysis
Imaging assessment
Leukemia :major cause of death
Infection is a major cause of death and sepsis is a common complication (ON TEST)
Chronic leukemia treatment
Chronic leukemia get bone marrow transplant and chemo
Bone marrow transplant
Allogeneic : sibling or matched unrelated donor (stem cells from bone marrow or umbilical cord)
Autologous: self-donation (own stem cells before high-dose chemo therapy)
Syngeneic : patients’s HLA identical twin
True or false
Less than 10,000 wbc doctors order transfusion
True
What is hodgkins lymphoma
Cancer that starts in a single lymph node or a single chain of nodes
Marker—Reed-Sternberg cell
Large, painless lymph node, usually in the neck, spreads from one to next node in orderly fashion
Becomes painful when alcohol ingested; fever, drenching night sweats, and unexplained weight loss
Hodgkins lymphoma interventions
One of the most treatable types of cancer
External radiation—Stage I and II
Chemotherapy—more extensive disease
Combination radiation and chemotherapy
Nursing: focuses on manage side effects (pancytopenia, N/V, skin, constipation, diarrhea, long term follow-up)
Chronic infection from h.pylori
Non-hodgkins lymphoma
All lymphoid cancers that do not have the Reed-Sternberg cell
More than 12 types of non-Hodgkin’s lymphoma
Staging similar for Hodgkin’s lymphoma
Treatment varies
Nursing care similar to Hodgkin’s Lymph
Multiple myeloma
White blood cell cancer that involves a more mature lymphocyte called a plasma cell—over growth of B-lymphocyte plasma cells in bone marrow overproduce anti-bodies. Result fewer RBC, WBC, platelets
Assessment: fatigue, anemia, bone pain, infections, fractures, renal dysfunction
Interventions: Chemo, Autologous stem cell transplant, Analgesics, Alternative pain
Multiple myeloma lab values
CBC: blood counts all over the place
Decreased albumin increased calcium
Medications that alter hematologic function
RBC: Erythropoetin stimulating agents: arensep, epogen, proctir
WBC: filgrastin,
Platlets: by transfusion
Don’t give ibuphron, nsaid, coumadin, heparin with low platletes
What is hemophilia?
Hemophilla: hereitary bleeding disorder, clotting deficentcy
Hemophilia A: deficiency factor 8
Hemophilia B: christmas disease, deficiency factor of 9
Labs: prolonged PTT, normal PT #1 problem degenerating joint function from chronic bleeding into joints (hips and knees)
Acute chest syndrome :)
WHEN YOU ARRIVE at Nia Robinson’s room in response to the call bell, you find her in visible distress and complaining of chest pain and shortness of breath. Her vital signs are BP, 146/88 mm Hg; pulse, 104; temperature, 100o F (37.8o C); respirations, 30; and SpO2, 91% on room air.
Ms. Robinson, a 25-year-old African-American woman with a history of sickle-cell disease, was admitted to your unit earli- er today with a diagnosis of vaso-occlusive crisis. This is her second admission this month. She’s receiving I.V. fluids and morphine. On morning assessment, she was resting comfort- ably in bed and her vital signs were BP, 132/86 mm Hg; pulse, 78; temperature, 98.2o F (36.8o C); respirations, 20; and SpO2 of 98% on room air.
Suspecting acute chest syndrome (ACS), a potentially life- threatening complication of sickle-cell disease, you activate the rapid response team and administer supplemental oxy- gen at 2 L/minute via nasal cannula. After the rapid response team assesses Ms. Robinson and reviews her medical record,
42 | Nursing2009 | June
www.nursing2009.com
EYE OF SCIENCE/PHOTO RESEARCHERS, INC.
syndrome
www.nursing2009.com June | Nursing2009 | 43
a stat chest X-ray is ordered with arte- rial blood gas (ABG) analysis, com- plete blood cell (CBC) count, blood cultures, and chemistry panel.
Because it can lead to respiratory failure, ACS is the leading cause of death among patients with sickle-cell disease.1 Sickle-cell disease affects about 80,000 Americans
What is vas occlusive crisis
In a vaso- occlusive crisis, low oxygen tension causes the abnormal red blood cells (RBCs) to lose their round, pliable shape and become deformed, rigid, and sickle-shaped. The abnormally shaped and inflexible sickled RBCs can adhere to each other and also to the vascular endothelium, compromis- ing circulation and leading to pain, edema, fever, tissue ischemia, and
infarction. A crisis can be triggered by exposure to cold, excessive physical exertion, late pregnancy, infection, dehydration, and emotional or mental stress. In some cases, the cause of the crisis is unknown.3
Hyperthyroidism lab values
T3, T4 higher
TSH decreased
Hypothyrodism lab values
T3, T4 lower
TSH increased
Causes of hyperthyroidism
Graves disease;
Toxic multinodular goiter;
Excess thyroid replacement hormone
Causes of hypothyroidism
Hashimoto thyroiditis;
Cretenism(Infant); iodine def
Excess hyperthyroid med (PTU);
Lithum inhibits thyroid hormone radiation; Pituitary or_hypothalamic disorder
Symptoms of hyperthyroidism
Enlarged thyroid gland
VS: inc HR, inc B/P, inc temp, inc resp rate ; increased cardiac output; increased metabolism
Graves disease-exophtahlamos with lid lag; pretibial myxedema
Symptoms of hypothyroidism
Myxedema features( non-pitting edema –eyes, hands, feet, tongue thick, husky deep voice)
Impaired growth in child
Depression; tired; fatigue; cold
Libido dec; infertility; impotence
Blood cholesterol levels in hyperthyrodism
Decreased
Blood cholesterol levels in hyporthyrodism
Increased
Treatments of hyperthyroidism
Radioactive Iodine; surgery____
Anti-thyroid: (Tapazole) methi-mazole,(PTU)prophylthiouracil ;
Beta blockers to ↓ HR ; Iodine_
↑ calories, proteins, carbs___
Treatments of hypothyroidism
Levothyroxin; Synthroid (for life)
Hyperparathyroid lab values
Calcium high
Phosphate low
Hypoparathyroid
Calcium low
Phosphate high
Causes of hyperparathyroid
Parathyroid adenoma or carcinoma; neck trauma; radiation; Vit D deficiency;
Benign tumor in one gland
Causes of hypoparathyroid
Iatrogenic: removal of all parathyroid with thyroidectomy or intentional surgically removal
Idiopathic :autoimmune
Hypomagnesemia as in alcoholics & pt w malabsorption, chronic kidney & malnutrition causes ↓ PTH secretion
General features hyperparathyroid
↑PTH act on kidney causing ↑kidney reabsorption of Ca++ & excretion of PO4;
Reduced bone density as ↑PTH =↓osteoblastic &↑ osteoclastic
production=osteoporosis,fractures
↑PTH=renal calculi & deposits of Ca++ in soft tissue of kidney
GI=N/V, epigastric pain; fatigue;
Ca++ >12 mg/dL psychosis, confusion, coma, death
General features hypoparathyroid
Tingling & numbness mouth & hand.
Trousseau’s sign (BP cuff 3 min)= flexion at wrist
Chvostak’ sign (touch cheek)=ipsilateral (same side) facial contraction
Muscle cramps hand, feet, seizures; Mental changes; bands or pits encircle teeth
Treatment for hyperparathyroidism
Hydration with IV saline;
diuretics (Lasix);
Surgery-parathyroidectomy (support neck to elevate head, observe resp distress, ER trach kit, ck serum Ca++ immed after surgery & q 4 hr; ck Trousseas’s & Chvostek’s signs);
Prevent fractures; fall prevention, use of lift sheets; ck cardiac; I&O;
Treatment for hypoparathyroidism
IV 10% Calcium Chloride or Calcium gluconate for acute & severe ↓Ca++.
IV calcitriol for acute Vit D def
IV 50% Magnesium sulfate for
hypomagnesemia
Diet changes in hypoparathryodism
High calcium, but avoid dairy as dairy has phosphates
Medications for hyperparathyrodism
Lasix to↑ kidney excretion ofCa++
Calcitonin ↓ release if skeletal Ca++ & ↑ kidney excretion if Ca++
Calcium chelators bind Ca++ reducing free Ca++: Mithramycin, Penicillamine (Cuprimine, Pendramine)
Medications for hypoparathyrodism
Vitamin D (Ergocalciferol) & Calcium long term
What are the top 3 most common causes of cirrhosis?
- Hep C
- Alcoholism
- Biliary obstruction
What is portal hypertension?
It’s when the backup of blood flow causes increased pressure on the portal veins, this leads to ascites which then leads to bleeding esophageal varices because the veins of been dilated and stretch causing them to thin which means they can burst or develop holes lead into bleeding
Clinical manifestations of late stage cirrhosis
Jaundice Dry skin Petechiae Spider Angie's Warm red palms
What is fector hepaticus
Fruity bad breath
What are two signs of hypocalcemia ?
- Chvostek sign
2. Trousseaus sign
What is chvosteks sign
Elicit action: Tapping on the face at a point just anterior to the ear and just below the zygomatic bone
Positive response: twitching of the ipsilateral facial muscles, suggestive of neuromuscular excitability caused by hypocalcemia
What is trousseaus sign?
Elicitation: inflating a blood pressure cuff above systolic blood pressure for several minutes
Positive response: muscular contraction including flexion of the wrist and marred metacarpal joints, hyper extension of the fingers and flexion of the thumb of the palm, suggestive of neuromuscular excitability caused by hypocalcemia
What is ast test?
Aspartate aminotransferase test measures the amount of this enzyme in the blood. Low levels of AST are normally found in the blood. One body tissue organ organ such as the heart or liver is the third damage additional AST is released into the bloodstream. The higher the AST the higher the damage
Normal ast levels
- 14-20 u/l (0.23-0.33) males
2. 10-36 u/l ( 0.17-0.60)
What is the alt test?
The alanine aminotransferase rest is used to detect liver injury. Hi levels of AL T mean that there is injury somewhere. Normal range between 7-56
Hepatic renal syndrome
Ammonia, creatine, Billy Ruben are all going to be elevated
What type of fluids do you give before a paracentesis
You give albumin and IV fluids before and after a paracentesis
What kind of medication do you give for your cirrhosis patient with a diagnosis of excess fluid volume
Give diuretics, potassium sparing diuretics AKA spironolactone or furosemide
What is the normal amount of fluid to be drained from a pleurex
A pleurex drain to be placed to remove excess fluid, normal amount drained is 4 liters
Potential for hemorrhage
- Screen for esophageal varies
- Drug therapy: nonselective beta blocker to decrease heart rate/pressure gradient
Selective beta blocker the agent is propanol, you don’t want to use atenolol or Metropolol
GI bleed: put on antibiotic
Bacterial med: sipro, floxacin, cephtiaxon
Management of hemorrhage
Make sure the patient is sitting up for balloon tamponade, suction and watch for aspiration
What is terlipressin?
It is used as a vasoactive drug in the management of low blood pressure. It has been found to be effective when norepinephrine does not help. Indications for use include hepatic renal syndrome and esophageal varices.
Octrotide and somatostatin
Octreotide: decreases portal venous outflow
Somatostatin: it inhibits the secretions of growth hormone, insulin and gastrin
Drug therapy for portal systemic encephalopathy
1: Lactulose
2: neomycin sulfate
3. Metronidazole
Asterisk
Shivering hands
Neomycin
Antibiotic
Long term drug therapy for portal systemic encephalopathy
Rifaximim
What is hepatitis?
Inflammation of the liver
What is the leading indicator for a liver transplant in the US?
Hepatitis C most transplanted livers become reinfected
What hepatitis has a vaccine for?
There is a vaccine for hepatitis B
Energix-B and recombivax HB
True or false acetaminophen is very bad to take if you have liver damage
True
Carrier of sickle cell disease
Carrier will have one hemoglobin a and one hemoglobin S
Sickle cell disease
HBS: decreased oxygenation
Sickle cells are sticky and start clumping up together which causes a vasocclusive disorders
Hypoxia, anesthesia dehydration, venoustasis, alcohol ad drugs, high altitudes, temp changes all cause sickling
Sickle cell interventions
Highly suspectible to sepsis: practice infection control: educate
Interventions include:
Prevention of infection–strict asepsis
Early detection strategies—assess, monitor CBC, WBC, inspect mouth, lungs sounds, vs, urine color
Drug therapy—prophylactic therapy (Pcn BID),
flu & pneumonia vaccine
Sickle cell cont
Hydration: hypotonic solution to flush those sickle cells and prevent clumping
Hydration, pain management and oxygenate (hydration is number one) ON TEST
Iron deficiency
Sentences and phrases
2/3 of iron is contained in hgb, 1/3 in bone marrow
Spinach, kale, red meat high in iron (need to take iron supp with meals)
Vitamin B12 defciency
Lack of vitamin B12 causes improper DNA synthesis of RBCs.
Poor intake of foods containing vitamin B12 —vegetarian diet or lack dairy
.
Tx: Foods-animal protein, eggs, dairy
Symptoms: Pallor ,jaundice, fatigue, weight loss, glossitis
Calcintonin, phosphorus, vit D
Calcitonin: Released from thyroid in response to high levels of serum calcium Inhibits release of calcium from bone Phosphorus: Inversely related to calcium Increases as Ca+ decreases Vitamin D: Promotes calcium absorption through the intestines, Ca+ resorption from the bone, and kidney reabsorption of Ca+
Aplastic anemia
Deficiency of circulating RBCs because of failure of the bone marrow to produce these cells
Injury to the pluripotent stem cell
Pancytopenia common
Nursing: Assess bone marrow failure, poor oxygenation
Treatment:
Blood transfusions,Immunosuppressive therapy,Splenectomy
Anemia: decreased white blood cell and thrombocytopenia
Can get allogenic stem cell transplant
What is Polycythemia vera?
Polycythemia vera is a chronic myeloproliferative disorder characterized by increased red blood cell mass (RCM), or erythrocytosis
The resultant hyperviscosity of the blood predisposes such patients to thrombosis
Polycythemia vera
Polycythemia vera is a chronic myeloproliferative disorder characterized by increased red blood cell mass (RCM), or erythrocytosis
The resultant hyperviscosity of the blood predisposes such patients to thrombosis
Disease with a sustained increase in blood Hgb levels to 18g; RBC count of 6million; or a Hct of 55% or greater
Patients may present with complaints of pruritus after bathing, burning pains in the distal extremities (erythromelalgia), gastrointestinal disturbances, or nonspecific complaints such as weakness, headaches, or dizziness.
Pruritus results from increased histamine levels released from increased basophils and mast cells and can be exacerbated by a warm bath or shower.
This occurs in up to 40% of patients.
Other patients are diagnosed after an incidental finding of an elevated hemoglobin and/or hematocrit level on a complete blood count.
Headache, dizziness, vertigo, tinnitus, visual disturbances, angina pectoris, or intermittent claudications
Complications
Shorter life span of cells causes rapid turnover and increases amount of cellular debris in the blood, increases ‘sludginess’, venous stasis, blood vessel occlusion
Hyperkalemia
Uric acid
Interdisciplinary care
Repeated phlebotomy
Patients with hematocrit values of less than 70% may be bled twice a week to reduce the hematocrit to the range of 40%.
Patients with severe plethora who have altered mentation or associated vascular compromise can be bled more vigorously, with daily removal of 500 mL of whole blood
Elderly patients with some cardiovascular compromise or cerebral vascular complications should have the volume replaced with saline solution after each procedure to avoid postural hypotension
Patients treated with phlebotomy alone benefit from low rates of malignancy but experience more thrombosis events during the first few years of treatment.
Patients treated with myelosuppressive agents and supplemental phlebotomy avoid this early thrombotic risk but in turn have significant rates of malignant transformation after about six years of therapy
Polycethmia vera labs
Disease with a sustained increase in blood hemoglobin (18 g/dL)or hematocrit (55%+
Leukemia and death
Infection is a major cause of death & sepsis is a common complication
Mulitple myeloma labs
Decreased albumin increased calcium
Hematology meds
RBC: Erythropoetin stimulating agents: arensep, epogen, proctir
WBC: filgrastin,
Platlets: by transfusion
Don’t give ibuphron, nsaid, coumadin, heparin with low platletes
Hemophillia
Hemophilla: hereitary bleeding disorder, clotting deficentcy
Hemophilia A: deficiency factor 8
Hemophilia B: christmas disease, deficiency factor of 9
Labs: prolonged PTT, normal PT #1 problem degenerating joint function from chronic bleeding into joints (hips and knees)
Serum T4 (Thyroxine) lab values
4-12 mcg/dL or 51-254 SI units
TSH (Thyroid Stimulating Hormone) lab values
- 3-5.0 uU/mL or
0. 3-5.0 SI units
Thyroid regulation
Negative feedback system
Hypothalamus secretesThyrotropin Releasing Hormone (TRH)
Anterior pituitary secretes Thyroid Stimulating Hormone (TSH)
Thyroid gland secretes T3, T4
T3,T4 blood level relates need back to hypothalamus to ↑ or ↓ TRH
Hormones of the thyroid
Tyrosine + Iodine = thyroid hormone
T4 - Thyroxine (normal 4-12 mcg/dL)
80-90% of thyroid hormone; weaker than T3
T3 – Triiodothyronine (normal 70-205 ng/dL)
10-20% of thyroid hormone; stronger and more biologically active than T4
Function: Control cellular metabolic activity and the rate at which cells “do business”
TSH –Thyroid Stimulating Hormone
(normal levels in adult 0.4 to 4.5 miu/L)
Hyperthyrodism
Thyroid hormones affect metabolism in all body organs
“Hypermetabolism and increased sympathetic nervous system activity
Negative nitrogen balance from increased protein synthesis and degradation
Catabolism overtakes anabolism
Cellular resistance to glucose → hyperglycemia
Increased fat metabolism
Increased appetite
Weight loss
Chronic nutritional deficiency
Causes of hyperthyroidism
Graves Disease
Most common & also called “toxic diffuse goiter
Autoimmune condition
Often associated with a family history
Onset of symptoms is gradual—exophthalmos, pretibial myxedema, goiter
Toxic Multi-nodular goiter
Milder symptoms than Graves Disease; no exophthalmos & pretibial myxedema
Exogenous Hyperthyroidsim
Excessive use of thyroid replacement hormones
Lab values in hyperthyroidism
Decreased TSH levels(normal 0.4-4.5 miu/L)
Increased T3 levels (normal 70-205 ng/dL)
Increased T4 levels (normal 4-12 mcg/dL)
Thyroid scan–Measure RAI uptake
Ultrasonography
Electrocardiogram (EKG)
Tachy
A-fib, dysrhythmias
Changes in P & T waves
Thyroid storm
Thyroid Storm – excessive thyroid hormone release Life-threatening Manifestations develop quickly Dramatic increase in metabolic rate Fever Tachycardia Systolic hypertension GI manifestations Abd pain n/v Diarrhea Anxiousness Tremors Increased restlessness Confusion Psychosis Seizure Coma Mortality rate of 25% Maintain airway patency Provide adequate ventilation Reduce fever Stabilize BP
THyroid storm cont..
Severe hyperthyroidism – abrupt onset
Extremely high fever, extreme tachycardia, altered mental state, elevated SBP
Life threatening – fatal if untreated
Usually precipitated by a stressor
Treatment: decrease temp and heart rate
NO ASPIRIN!!! ASA has greater affinity to thyroid binding sites and will worsen hyperthyroidism
Hypothyroidsm
Definition: Lack of sufficient thyroid hormone Types: Primary Hypothyroidism: due to a problem with the thyroid itself Decreased thyroid tissue Decreased thyroid hormone Secondary– due to pituitary disorder Tumor, infection, infarct Hypothalamic defects
Myxedema coma
Low metabolic rate affects tissues & organs
Metabolites glycosaminaoglycans (proteins & sugars) build inside of cell>increase mucus & water >cellular edema>changes in organ texture
Non-pitting edema forms everywhere
Physiologic function decreased
Myxedema coma—life threatening
Mydexema cont..
Most extreme stage of hypothyroidism Precipitated by a “trigger event” Rare but often fatal Seizures, hypothermia, bradycardia Treatment: Maintain airway Fluids IV hormone replacement Frequent VS & hourly temp checks Myxedema coma High mortality rate Decreased metabolism causes heart muscle to become flabby Decreased cardiac output Decreased perfusion to brain and all vital organs Worsens the already slowed cellular metabolism, leads to tissue and organ failure
“Trigger Events” Acute illness Hypothermia Untreated hypothyroidism Surgery Sedatives/sedation
Lab values in hypothyroidism
Elevated TSH (will be low only in secondary hypothyroidism)
Low T3 and T4
Diagnosis is based almost solely on measuring the circulating thyroid hormone in the blood
Thyroditis
Acute: Bacterial infection Subacute: Viral infection Chronic: Hashimoto’s Disease Autoimmune disorder--thyroid destroyed Triggered by bacterial or viral infection Thyroid hormones low; TSH increased Thyroid hormone replacement
Ca++ (serum calcium): lab values
Ca++ (serum calcium): 8.2 (9.0) to 10.2 (10.5) mg/dL or 2.25-2.75 SI units
PO4 (serum phosphate): lab values
PO4 (serum phosphate): 2.5 (3.0) to 4.5 mg/dL or 0.97 to1.45 SI units
Serum parathyroid hormone lab values
Serum parathyroid hormone: C-terminal 50-330 pg/mL
Parathyroid gland
Parathyroid Hormone (PTH) Hormone that regulates calcium and phosphorus metabolism Negative feedback system regulates its’ release Draws Ca+ from bones, increases absorption from kidneys and intestines Increases phosphate excretion through kidneys
Calcintonin, phosphorus, vit D
Calcitonin: Released from thyroid in response to high levels of serum calcium Inhibits release of calcium from bone Phosphorus: Inversely related to calcium Increases as Ca+ decreases Vitamin D: Promotes calcium absorption through the intestines, Ca+ resorption from the bone, and kidney reabsorption of Ca+
Causes of hypercalcemia
Causes: Hyperparathyroidism - most common Benign tumor in one gland Cancer – second most common cause Multiple fractures or prolonged immobilization Hypophosphatemia Abuse of certain medications Antacids with Ca+, excessive Vit D, lithium, thiazide diuretics
Hyperparathyroidsm
Parathyroid hormone (PTH) acts on kidney & increases kidney reabsorption of calcium and increases phosphate excretion.
Result: Hypercalcemia (serum Ca+ above 10.5 mg/dL )
Hypophosphatemia (serum PO4 below 3.0 mg/dL)
High PTH increases bone resorption (loss of calcium from bone) by decreasing osteoblastic (build up) activity and increasing osteoclastic (bone destruction) activity== reduction of bone density, hypercalcemia and calcium deposits in tissue
Labs of hyperparathyroidism
Elevated PTH (normal C-terminal 50-330 pg/ml)
Elevated serum calcium (normal 9.0-10.5 mg/dL)
Decreased serum phosphate (normal 4.64- 5.28 mg/dL)
X-rays
Calcium deposits; Bone lesions; fractures
CT scan
Kidney stones
Hypercalcemia
Wait for atrophied glands to resume function
Be alert for hypocalcemic crisis
Monitor calcium levels immediately following surgery & q4h
Trousseau’s
Palmar flexion spasm
Chvostek’s
Tap facial nerve to elicit facial twitching of one side of mouth, nose, cheek
Signs of hypocalcemia
Tetany - most characteristic finding Anxiety, irritability, confusion, delirium Decreased cardiac output, hypotension Muscle cramps in extremities Tingling of fingers/toes or around mouth Fractures Bands or pits around teeth Positive Chvostek’s (touch cheek) and Trousseau’s sign ( BP cuff inflate 1-4 min)
