Physiological Integrity Flashcards
Myasthenia Gravis
Myasthenia gravis is a chronic autoimmune disorder characterized by progressive muscle weakening and chronic fatigue. Clients become weaker throughout the day, contributing to the potential for complications. Stress reduction techniques are important since stress can contribute to a myasthenic crisis, a severe respiratory emergency. Daily tasks, including ADL’s, should be completed early in the day when the client has the most energy. Medications for MG, including neostigmine and pyridostigmine, must be taken on time and prior to meals.
Myasthenia gravis is an autoimmune disease associated with antibodies to the acetylcholine receptors. The main symptom is weakness in the voluntary skeletal muscles, which are muscles under your control. The failure of muscles to contract normally occurs because they can’t respond to nerve impulses. Without proper transmission of the impulse, a blocked communication occurs between nerve and muscle and weakness results. It is associated with painless weakness or muscle fatigue, worsening after exertion and deteriorating during stress, infection, or trauma.
Tendon reflexes are normal. Clinical manifestations include: Fluctuating weakness, usually proximal and worse as the day progresses; Ocular symptoms include ptosis, diplopia and blurred vision worse on driving, watching television, and reading; Bulbar weakness resulting in difficulty chewing, swallowing, talking, inadequate clearance of secretions and maintenance of upper airway; A slack jaw and a nasal voice can also be seen; An expressionless Myasthenic Facies (Snarl); Proximal limb muscle weakness - neck flexors usually weaker than neck extensors. Deltoid, triceps, extensors of fingers and wrist and ankle dorsiflexors are often weaker than other limb muscles; Respiratory muscle weakness with often absent gag reflex; Exhaustion and Ventilatory Failure (i.e. Myasthenic Crisis) leading to Coma.
Option 2: Good choice! Stress can quickly contribute to an exacerbation of this disease process, referred to as a myasthenic crisis. The homecare nurse suggests that the client include consistent stress reduction techniques, such as biofeedback or guided imagery, into daily activities because these techniques help MG clients improve their daily functioning ability.
Option 3: Important action for the client! Remember that clients with myasthenia gravis experience increasing weakness as the day progresses. Therefore, all ADL’s or chores should be scheduled early in the day while the client is strongest. When these clients do not rest frequently, they place themselves at risk for a myasthenia crisis, which could put the airway at risk!
Option 4: Medication timing is important for all clients but particularly critical for the myasthenia client. Standard MG medications, including pyridostigmine bromide (Mestinon) and neostigmine (Prostigmin), are anticholinesterase drugs designed to increase acetylcholine for neuromuscular function. However, the action of these medications usually lasts just 6 hours, so taking the meds on time is crucial for this client. Additionally, meds work better when taken with food.
The parents of a child admitted with rheumatic fever (RF) ask why the child has been placed on bedrest. The nurse explains that bedrest serves what primary purpose for the client?
Rheumatic fever is a secondary, infectious process that occurs several weeks after an unresolved streptococcal infection, such as strep throat. The Group A beta-hemolytic strep can cause inflammation in the myocardium or epicardium, ultimately affecting the valves of the heart, particularly the mitral valve. The resulting thickening and fibrosis leads to cardiac stenosis which could lead to heart failure. During this illness, decreasing the workload on the heart is vital to help prevent cardiac complications.
Treatment includes corticosteroids, anti-inflammatory drugs, antibiotics and bedrest. Knowing the possible complications of this illness, what do you think should be the nurse’s main focus? The parents are concerned about treatment and prognosis, providing the perfect opportunity for the nurse to initiate teaching.
Although clients experience multiple hot, red, swollen joints, referred to as polyarthritis, there is no permanent damage to joints once the illness is resolved. Some clients can develop involuntary movements referred to as chorea, but this involves the central nervous system and not the joints.
A client presents to the after-hours clinic with reports of pain that occurs with walking but generally subsides with rest. The nurse’s assessment reveals coolness and decreased pulses in lower extremities bilaterally. What condition would the nurse recognize these symptoms being most indicative of?
These symptoms are indicative of arterial insufficiency as there is pain with walking that is relieved by rest. This pain is known as intermittent claudication. In addition, the pulses are decreased or may be absent with arterial insufficiency and the extremities are cool to touch. Other s/s include: paleness of extremity when elevated or possible redness when lowered, loss of hair on affected extremity, and thick nails.
Which assessment finding in a client 5 hours post open cholecystectomy would require the nurse to notify the surgeon?
- Absent bowel sounds.
- Jackson Pratt drain has 90 mL of blood.
- Urinary output of 180 mL since return from surgery.
- Client report of abdominal pain of 8/1
An open cholecystectomy will usually result in the placement of a drain. The drainage should be green (bile). Blood is a problem and needs immediate intervention.
The client has been diagnosed with cutaneous anthrax in a cut on the right hand. What measure should be implemented by the nurse to prevent further spread of the disease?
Cutaneous anthrax is not spread person-to-person. However, it can be spread to others in rare events if the wound is draining. Standard precautions should protect the individual.
A client exhibits positive Kernig’s and Brudzinski’s Signs, Photophobia, Nuchal Rigidity and severe headaches. This is indicative of?
Meningitis.
Brudzinski’s sign is the involuntary lifting of the legs when the neck is passively flexed (head is lifted off the examining surface). Kernig’s sign is positive when the thigh is bent at the hip and knee at 90 degree angles and attempts to extend the knee are painful, resulting in resistance. Both of these signs are thought to indicate meningeal irritation. These seem to be caused when the motor roots become irritated as they pass through inflamed meninges, and the roots are brought under tension. Photophobia (sensitivity to bright light), severe, unrelenting headache, and nuchal rigidity (stiff neck) are all believed to be due to irritation of the meninges
The nurse should assess for what signs of toxicity in a child who is admitted with salicylate overdose?
Nausea and vomiting are the most common toxic effects. This can be caused by CNS toxicity or by direct damage to the gastric mucosa. Salicylates can be neurotoxic, and this is manifested by ringing in the ears. Ototoxicity can also lead to hearing loss. Diaphoresis results in the early phase of toxicity. Serious dehydration can result from insensible losses due to hyperventilation and fever, as well as active losses due to vomiting.
The first phase of salicylate toxicity is characterized by hyperventilation due to stimulation of the respiratory center in the brain. This is a key feature of salicylate toxicity.
A client is admitted to the hospital reporting chills, fatigue and left lower leg pain for nearly a week. During initial assessment, the nurse notes wide-spread swelling and redness of left ankle in addition to a fever of 103.5° F (39.72° C). Which admission order should the nurse implement first?
Osteomyelitis is a serious inflammation of bone tissue caused when bacteria or fungus has entered the body through an open wound, an infected prosthetic, or even animal bite. Symptoms include fever, chills, nausea, and fatigue with decreased mobility in the affected extremity. The client can quickly become septic as the illness spreads through the system. Bedrest along with massive doses of antibiotics are necessary to prevent the spread of the infection, resulting in possible bone death or even amputation.
A client is admitted to the emergency department with digoxin toxicity. Nursing assessment reveals cool skin, a slow, weak pulse, and a BP of 86/44. What initial action should the nurse take based on the assessment and cardiac rhythm strip?
This client is exhibiting symptomatic bradycardia, specifically 3rd degree heart block. Transcutaneous pacing is the treatment of choice.
Digoxin Toxicity: Symptoms Confusion Irregular pulse Loss of appetite Nausea, vomiting, diarrhea Fast heartbeat Vision changes (unusual), including blind spots, blurred vision, changes in how colors look, or seeing spots Decreased consciousness Decreased urine output Difficulty breathing when lying down Excessive nighttime urination Overall swelling
Complications may include:
Irregular heart rhythms, which may be deadly
Heart failure
A client arrives to the after hours clinic with reports of palpitations and skipping heart beats. The nurse notes the client to be alert and oriented with a BP of 124/76, HR irregular at 95 beats per minute, respirations at 18 breaths per minute, and is afebrile. Cardiac monitoring is initiated. Based on this data, what questions should the nurse ask the client?
This rhythm strip is showing that the client has normal sinus rhythm with premature atrial contractions (PACs). Common causes of PACs include stress and excess caffeine intake from coffee, tea, colas, and over the counter medications that contain caffeine.
The son of an elderly diabetic client reports that his mother is frequently having low blood sugar. What should the nurse teach this family member about symptoms of hypoglycemia in the elderly?
Older clients are at risk for hypoglycemia unawareness. Blood sugar levels should be checked frequently. Some oral medications are more likely to cause hypoglycemia episodes. If the client has frequent episodes, perhaps a medication change is warranted. The elderly must maintain regular meal schedules and adequate food intake. This may present challenges for the elder who lives alone. If an elder develops unsteady gait, loss of concentration, and/or lightheadedness, the blood glucose levels should be checked. These symptoms are typical in a hypoglycemic episode
The nurse, caring for a client who has chronic renal failure, suspects that the client is experiencing anxiety. Which statements by the client would validate the nurse’s suspicion?
- “I do not think I can continue working.”
- “My husband has taken over the house cleaning and cooking.”
- “I fear I am dying.”
- “I have an “uneasy” feeling most of the time.”
- “Most of the time I feel very ‘down and blue’.
The inability to maintain employment is of concern to most clients who have been used to working. With a chronic illness, the client is unlikely to be able to return to work. Anxiety related to role strain is common. The client may not be able to perform the duties that she once did, thus causing others to have to assume their roles. Death is a possible outcome if transplant does not occur. Fear may be a later diagnosis as the client’s condition deteriorates. Clients with anxiety often report feeling uneasy or on edge.
A client on routine dialysis asks the nurse about the process of a family member donating a kidney. In what order should the nurse explain the steps for kidney organ donation?
First, the donor and recipient will undergo tissue typing and antibody screening; compatibility of tissues and cells of the donor and recipient have to be determined.
Second, the donor will undergo psychosocial examination and counseling. Once it has been confirmed that the donor and recipient are compatible, the donor will undergo a psychosocial examination to assess the organ donor’s motive for giving the organ and to ensure donor is making an informed decision. Pre-donation counseling for a nephrectomy is required.
Third, the recipient and donor will be assessed and treated for any infection. Both must be free of infection at the time of kidney transplantation so they will be assessed for any infections, including gingival gum disease and dental caries.
Fourth, the recipient will undergo hemodialysis. If a dialysis routine is established, then hemodialysis is performed the day before transplantation to optimize recipient’s physical status.
Fifth, the recipient will receive immunosuppressive agents. Lifelong immunosuppressive agents are prescribed to prevent rejection of the organ.
Fifth Disease
What is Fifth’s Disease? It is a mild rash illness caused by parvovirus B19. It is more common in children than adults. A person usually gets sick with fifth disease within 4 to 14 days after getting infected with parvovirus B19.
After several days, the client may get a red rash on the face called “slapped cheek” rash. This rash is the most recognized feature of fifth disease. Some people may get a second rash a few days later on their chest, back, buttocks, or arms and legs. The rash may be itchy, especially on the soles of the feet. The client may also have painful or swollen joints.
Following a hemorrhagic stroke, a client had a craniotomy with insertion of a ventriculostomy. Upon arrival in the ICU, the nurse’s initial readings indicate an increase in intracranial pressure (ICP). What is the nurse’s priority action?
- Correct: A ventriculostomy is a temporary drain placed in the brain to remove excess cerebral spinal fluid in order to decrease intracranial pressure. Because the client’s ICP readings are increasing, the nurse’s initial action is to try to reduce that pressure by hyperventilating the client with a bag valve mask, also called an Ambu bag or manual resuscitator. This lowers cerebral CO2 levels, causing vasoconstriction which temporarily decreasing blood flow and reducing pressure within the brain.
