Tiff Test 3 COPY 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
s/s of SIADH
Increase ADH: water retention Fluid overload (edema, weight gain) HTN Hypovolemia Seizures Tachycardia Hyponatremia (increase of water in body but sodium stays the same so sodium is diluted) Confusion - edema of brain Anorexia- so full of water they do not want to eat Low UO: high specific gravity
management of SIADH
Daily weights, strict IO’s, safety Fluid restriction Meds: Loop diuretics- watch out for hypokalemia because they like to deplete K+ levels so check potassium levels. Hypertonic iv 3% NS declomycin
adrenal cortex:
Adrenal cortex: sex hormones
Releases corticosteroids and sex hormones
Steroid hormones: aldosterone and cortisol
Aldosterone: mineralocorticoid, regulates BP via RAAS, retention of Na+ and secretes K+
Cortisol: glucocorticoid, stress hormone, regulates BG, breakdown fats, carbs, and proteins, helps body deal with stress ex: illness, external stress, increases BP
Addisons
Decrease secretion of cortisol and aldosterone-
Autoimmune disorder- attacking the cortex due to cancer, TB, or trauma
S/S of addisons:
Low “steroid” hormones Sodium and sugar levels will be very low, salt cravings Tired and weak Electrolyte imbalance (K+ and Ca+) Reproductive changes lOw BO Increased pigmentation (hyperpigmentation of the skin) Diarrhea and nausea, depression
Management of addisons
Monitor for hypoglycemia and hyperkalemia
HRT
Report stress/illness
Can not abruptly stop medication
Medic alert bracelet
Diet high in protein, carbs, and normal Na+
Avoid stress, illness, and strenuous exercise
Watch out for addisonian/adrenal crisis 5 s’s Sudden pain in stomach, back, and legs Syncope Shock Super low bp Severe vomiting, diarrhea, and h/a Tx for addisonian crisis Iv cortisol Iv fluid
Thyroid Secretions:
T3 and T4 = Thyroid Hormone Control of metabolism Exert effects on HR and contractility Affect RR and drive Act as insulin antagonists Increase RBC production Calcitonin = helps regulate serum calcium and phosphorus levels
Calcitonin
Thyroid control Ca and phosphorus levels in blood
Calcitonin decreases serum Ca and phosphorus levels by reducing bone resorption (breakdown)
Serum calcium levels control calcitonin section
Low serum CA, suppress calcitonin
High serum CA, increase secretion
Actions opposite of parathyroid hormone
Thyroid Storm:
s/s:
increases metabolic rate
key manifestations: fever, tachycardia, HTN
anxious, chest pain, n/v, diarrhea
so hyperstimulated can cause dysrhythmias
Management of thyroid storm:
Airway Antithyroid drugs Blood pressure drugs Reduce fever Monitor cardiac, vital signs Prevent vascular collapse Glucocorticoids (Hydrocortisone) to treat/prevent shock
Parathyroids:
4 small glands
Embedded posterior thyroid
Easily removed by accident in thyroid surgery
Secrete Parathyroid hormone (PTH)
Regulate calcium and phosphorus by acting on bone, kidneys and GI tract
Parathyroid Hormone (PTH)
-Kidneys
PTH activates vitamin D, increases absorption of CA and phosphorus
Kidney tubules reabsorb CA and put into serum
Bone
Main storage site of CA
PTH increases bone resorption (from bone to blood), thus increasing serum CA
Serum CA levels determine PTH secretion
PTH secretion decreases when CA levels are high
PTH increases when CA levels are low
Work with calcitonin to maintain balance
Inverse relationship with phosphorus
Hyperparathyroidism
Common cause benign tumor of parathyroid Manifestations: High serum Ca+ and hypophosphatemia Cardiac dysrhythmias GI problems Muscle weakness Pathological fractures Skeletal pain Emotional changes Kidney stones r/t output of Ca and Phos
Nonsurgical and Surgical interventions for hyperparathyroidism
furosemide- increase ca+ excretion
Prevent injury/safety: because of loss of ca+ and bones are fragile
calcitonin has opposite effect of parathyroid, also can give other drugs that help or block hypercalcemia and block PTH
Hypoparathyroidism
S/Sx: High phosphorus Low Calcium S/S of tetany Tremor and Spasms Changes in mental status Cardiac dysrhythmias
Low Ca with hypoparathyroidism
Trousseau’s sign: carpal spasms with BP cuff 3 minutes
Chvostek’s sign: Tap facial nerve (in front of ear) to produce facial spasms
AKI INTERVENTIONS
Prevention, perfusion, nephrotoxic medications
Monitor intake and output. first indicator there is problem
Monitor vital signs and MAP (CVP, art line)
Daily weights
Labs: trends
Promote fluid balance.
Assess for manifestations of volume excess, pulm edema, electrolyte imbalance
Nutrition therapy
RRT
Drug therapy:
Includes diuretics to increase UOP
Rid body of excess fluid and electrolytes
Fluid challenges to promote kidney perfusion
pre renal kidney failure
Most common type: hypovolemic shock and heart failure
Reduced perfusion:Results from decreased blood flow to kidney and consequent ischemia of nephrons
Keep MAP > 65mmHg
Restoration of renal blood flow and GFR can rapidly reverse prerenal AKI
LABORATORY ASSESSMENT of AKI
Serum creatinine
BUN
BUN to serum creatinine ratio: BUN divided by creatine - increased ration increased fluid volume deficit, decreased fluid volume excess
Creatinine clearance: looks at how well creatinine is cleared from kidneys- look at this with meds
Blood osmolarity: concentration of blood, good indicator of hydration (normal range: 285-295)
GFR:
ABGs: change in terms of metabolic acidosis and the kidneys inability to produce and secrete bicarb
Electrolytes
Urinalysis: observing urine looking for quantity, specific gravity, pH, color, ketones
post av fistula assessment
don't bend arm don’t use arm do not take iv, sticks on side do not take bp make sure they have distal pulses don't carry heavy objects avoid tight clothing don’t sleep on it
Patient Considerations on HD
Restricted d/t keeping appt 3-4x/week Restricted fluids Restricted diet Anemia Major sleep disturbances Hypotension Muscle cramping H/A, nausea, vomiting r/t cerebral fluid shifts
Continuous Renal Replacement Therapy
Used for patients too unstable with hypotension for traditional hemodialysis: in ICU settings
Does not cause rapid fluid shifts
Requires access to circulation
Specialized training for nurses to perform
Blood passes through a hemofilter that contains semipermeable membrane
lab for hyperparathyroidism
High serum Ca+
hypophosphatemia
Complications: of PD
Complications: Peritonitis is most common Serious Cloudy dialysate Abdominal pain Rebound tenderness Antibiotics Flushes to abdomen Unresolved = cath removal = hemodialysis After approx 1 month, can replace cath Strict sterile technique is necessary
