Semester 2 Flashcards
Innate immune response
-Present at birth
-First line of defense
Active immune response
Foreign substance or infection
(🐔pox)
Passive Immune response
Received from mother
Type 1 reaction
-IgE mediated
-anaphylaxis reaction
Type 1 RN interventions
-Hx of allergies?
-Allergy test
-Epipen 💉
-Daily antihistamines 💊
-Educate: lifestyle, diet, and employment changes
Type 2 immune response
-Cytotoxic
-blood transfer
-RH incompatibility
RN interventions
-🛑 infusion
-📞 physician
-Change IV tubing
-Recheck crossmatch records
-Monitor fluids/electrolyte balance
-Eval serum calcium levels
-Treat symptoms as presented
Type 3 immune response
-Immune complex
-Tissue damage
-could be systemic/local/delayed/immediate
Type 4 immune response
-Delayed
-Cell mediated
-Contact dermatitis
-Transplant rejection🫀
Type 3 & 4 RN interventions
-Identify & remove allergen
-Assess & manage symptoms
-Monitor increases
-Monitor VS
-🦠infection control protocols
-Promote nutrition & mobility🏃🏽♀️
-Skin/wound assessment
-Monitor WBC & Platelets
-Educate pt & Family
-importance of wearing an allergy bracelet
Immunocompromised RN interventions/education
-Mask
-Gown
-Gloves
-LIMIT invasive lines
-LIMIT visitors (especially ill)
-single pt items
-No raw/uncooked veggies🥦 🥕
-no buffets
-Boiled/filtered water
-use dishwasher
-DONT SHARE ANYTHING
Clinical manifestations of systemic anaphylactic reaction
-Edema
-Itching
-Increase mucus
-Vascular permeability
-Decrease BP
-Dyspnea
Emergency management of anaphylactic reaction
-Epipen
- establish/maintain patent airway
-High flow O2😤
-Maintain BP
-Continuous monitoring/assessing🩺
-teaching prevention and Epipen
HIV prevention
-Use Protection
-Needle exchange programs
-PrEP use
-HIV transmission
-fetal/infant risk
-Testing
-avoid sex while on drugs and etoh
-Limit partners/practice abstinence
How can HIV be transmitted
-Blood
-semen
-breast milk
-Vaginal secretions
When is a fetus or infant at risk when the mother is HIV+
-vaginal birth
-breast feeding
HIV nursing interventions
-Hand hygiene
-cautious use of foley/venipuncture
-Monitor signs of infections at IV site, urine, lungs and mouth
HIV education
Adequate nutrition 🍱
Avoid people with infections 🦠
Decrease stress 🤕
Decrease smoking/drinking etoh 🍹
Maximize quality of life
Adhere to med regimen 💊
RN interventions for inflammation
Remove foreign material
Establish an environment for healing
R.I.C.E.
Describe inflammatory process
Sepsis diagnostic criteria
○ AMS
○ Temp>100.9
○ HR>90bpm
○ Hyperglycemia>140
○ Hypothermia<97
○ SBP<100 mmhg
○ Significant edema
○ Tachypnea>22
Sepsis nursing care
○ Antibiotics
○ Antipyretic
○ Fluids
○ Monitor sugars
Continuous monitoring
Influenza s/s
-Fever
-Aches
-Chills
-Tiredness
-Sudden onset
Influenza Nursing management
-Symptom relief
-Rest
-Hydration
-Antipyretics
-Antivirals Analgesics
