Test 3 Flashcards
HIV attacks immune system by destroying __ and __
T cell, and CD4 cells
-Attacks the cell, takes over cell function, replicates
Priority Patient Problems for HIV
-Potential for infection: avoid exposure, drug therapy, education, private room, prevention
-Inadequate oxygenation: drug therapy, comfort, rest, support
-Pain: comfort measures, drug therapy, alternative therapy
Inadequate nutrition: nutrition, mouth care, drug therapy
-Diarrhea: minimize diarrhea, restore skin integrity
-Reduced skin integrity
-Confusion: reorientation, safety, support
-Reduced self-esteem: trust, acceptance, encourage self care
-Potential loss of social contact
Systemic Manifestations of Anemia
▪ Integumentary
-pallor, cool to touch, brittle nails, intolerance to cold
▪ Cardiovascular
-tachycardia at rest and increases with activity, orthostatic hypotension, murmurs or gallops (when severe)
▪ Respiratory
-dyspnea on exertion, decreased O2 sats
▪ Neurological
-increased fatigue, decreased LOC, headache
Sickle Cell Crisis Interventions
1 priority is managing pain
Managing pain:
- IV analgesics: Opiods - IV hydration - Hydroxyurea - Complimentary therapies
Preventing sepsis:
- role of the spleen: immunizations - antibiotics - assessments - lab data
Perfusion:
- Remove restrictive clothing - Keep room > 72 degrees F - Keep extremities extended - Oxygen - Transfusion
reduce condition that is causing the sickling
IV opioids is the best way to manage pain, PCA
IV hydration- normal saline
IV fluids will hopefully reduce the clumping of the sickle cells
most patients who come in are dehydrated in sickle cell crisis so blood is hypertonic so give NS or hypotonic solution. BP will tell how hydrated they are
Hydroxyurea - medication that can help with sickle cell crisis
oral, reduce number of sickling events
comfortable in bed, extremities extended: get blood flow back, restricted clothing: can encourage clot formation, do not move knees above bed, keep temp above 72: cold causes vasoconstriction, elevated HOB no more than 30 degrees
decreases immune function can lead to sepsis
spleen can not function with our immunity response- get flu vaccine and pneumococcal
o2 given during crisis
transfusion with RBC will dilute hemoglobin s levels and will provide RBC when pt is anemic
*teaching prevention of sickle cell crisis, and when to come in for treatment: early is better!
DI
Water metabolism problem caused by an ADH deficiency (either decrease in ADH synthesis or inability of kidneys to respond to ADH) Classifications Kidneys: Do not conserve fluid Do not reabsorb water Put out large amounts of dilute urine Risk for dehydration!
Assessment findings in DI
think about dehydration due to massive water loss
skin- dry, cracked, poor skin turgor
lab values- hypernatremia due to loss of water
GU-Increased UOP, dilute, low specific gravity
Cardio-Hypotension, tachy, weak pulses, hemoconcentation (risk for hypernatremia)
Neuro-Great thirst, Decreased LOC (with dehydration)
Management of DI:
I/Os, IVF, weights, urine specific gravity
Oral chlorpropamide
Desmopressin acetate
Early detection of dehydration and maintenance of adequate hydration
Lifelong vasopressin therapy with permanent condition
Teach patients to weigh themselves daily to identify weight gain
SIADH Assessment:
Decrease in serum sodium levels
CNS/LOC changes
Risk for seizure
Fluid volume overload/water retention:, UOP decrease, Bounding pulses, Risk for heart failure and pulmonary edema
SIADH Interventions
Fluid restriction Drug therapy: diuretics, hypertonic saline (3% saline IV), Vasopressin antagonists Monitor for fluid overload Monitor labs Safe environment Neurologic assessment
Posted care for hypophysectomy:
managing ICP and anything that will delay healing
Monitor neurologic response- change in LOC, vision, mental status, strength in extremities
Assess for post nasal drip- csf leak due to “digging around in brain” (clear drainage, positive for glucose, severe headache)
Elevate HOB- promote drainage to release any ICP
Assess nasal drainage- color, clarity, odor
Avoid coughing soon after surgery- can increase ICP
Assess for meningitis- sx in brain increases risk for meningitis. monitor temp, vitals, change in LOC, headache, neucoregidity
Hormone replacement- lifelong HRT
Avoid bending- decrease ICP
Avoid straining at stool- to decrease ICP
Avoid tooth brushing- can introduce foreign particles, and infection and can cause delay in healing in sx site
Numbness in the area of the incision
Decreased sense of smell
Vasopressin- at risk for DI
Monitor fluid balance- i/o’s, cardiovascular status
Mineralocorticoids:
Fluid and electrolyte balance
Regulated by RAS, K levels, ACTH
Aldosterone:
Regulates Na++ and K+
Promotes sodium and water reabsorption
Promotes potassium excretion
s/s of adrenal crisis:
5 S’s and 3 H’s
Super low BP (nothing will bring it up, no fluids or vasopressors)
Sudden pain in stomach, back, or pain
Syncope
Shock
Severe vomiting, diarrhea, headache
Hyponatremia (less than 135) vomiting and diarrhea
Hypoglycemia- cortisol increases BG and if body doesn’t have cortisol will have low BS
Hyperkalemia- greater than 5.1
Nursing management of adrenal crisis:
Priority is getting pt stable Administer cortisol STAT! Iv fluids Oral glucocorticoids or mineral (replace aldosterone) Monitor glucose, K+ and Na+ Prevent infection
ADH: antidiuretic hormone (vasopressin)
Regulates water in the body through water retention, constricts arterioles
Renal tubules retain water
Increase adh, kidneys to retain water
Decrease adh, kidneys will get rid of water
Hypothalamus produces adh -> signals to posterior pituitary to secrete and that is where it is stored.
SIADH: syndrome of inappropriate diuretic hormone - INCREASED adh
Adh is being produced somewhere other than hypothalamus ot its damaged Lung cancer is a major cause Damage to posterior pituitary Infections Medications- chlorpropamide
