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1329 Final BP
| Question | Answer |
|---|---|
| Pressure Ulcers occur when | Capillary blood flow to an area is reduced. |
| Capillary Refill | Part of Nail Assessment, Checked with fingernail bed, Color should return in <3 Seconds. |
| Small pigmented spot on the skin with a clearly-defined edge, brought on by age... | Lentigines |
| Atopic Dermatitis or Eczema | The acute stage is characterized by red, oozing, crusty rash and intense pruritis. |
| Treatment for Atopic Dermatitis | Topical corticosteroids provide the best control of inflammation. |
| Most pts. with Atopic Dermatitis have | personal or family history of asthma, hay fever, eczema, or food allgeries. |
| Older persons who have had increased sun exposure may develop skin lesions and should be taught careful self-examination. Small, brown, pigmented, benign lesions, known as | liver spots or senile lentigines, form on the hands and forearms of older people. |
| Tight, Shiny, skin suggests | fluid retention |
| First Signs of Systemic Infection | fever, shaking chills, overall weakness, and joint aches |
| Ointments, creams and lotions prescribed for dermatologic disorders must be applied exactly as the physician directs. Remind the client that, | unless they rapply the drug exactly as ordered, it may not be of therapeutic value. If the client uses and excessive amount, he or she is wasting the drug. |
| Medications used to relieve itching | Topical lotions, such as calamine, or systemic drugs, such as diphenhydramine (Benadryl) or cyproheptadine (Periactin) |
| Medications used to restore lubrication | Moisturizing creams with lanolin |
| Medications used for severe cases of Allergic dermatitis | wet dressings with astringent solutions such as Burow's solution (aluminum acetate). Or Corticosteroids are taken orally or applied topically. |
| Rule of Nines | Used to estimate the percentage of total body surface area affected by a burn injury. |
| Rule of Nines: Hands | 1% Each |
| Rule of Nines: Front of arm, back of arm | 4.5% Each (including hands) |
| Rule of Nines: Chest & Back | 18% Each |
| Rule of Nines: Head & Back of head | 4.5% Each |
| Rule of Nines: Front of legs, back of legs | 9% Each (with feet) |
| Rule of Nines: Feet | 1% Each |
| Suspect inhalation injury if the burn pt. has: | facial burns or singed nasal hairs, redness and swelling of the pharynx, hoarsenss, restlessness, cough/dyspnea/sooty sputum, Decreased O2 Saturation, Stridor |
| 3 Tiers of Medical Treatment of Burns | 1st aid/emergent care, acute care, wound management |
| The emergent stage begins | with the injury and ends when fluid shifts have stabilized |
| Goal of 1st aid is to prevent | further injury |
| Medical treatment of burn victim in the emergent stage | Assess the airway/breathing/circulation, NG tube and urinary catheter usually inserted, IV Fluid therapy is essential during first few days of treatment. |
| Medical treatment of burn victim in the acute care stage. | Burn and other injuries are assessed, Watch for impaired ventilation 12-24hrs, Analgesics, fluid resuscitation |
| Medical treatment of burn victim acute care goals | Restore intravascular volume, Prevent tissue and cellular ischemia, maintain vital organ function |
| Medical treatment of burn victim wound care goal | promote healing, prevent infection, control heat loss, retain functions, minimize disfigurement |
| Medical treatment of burn victim wound care | Clothing removed, hair around area of burn is shaved, ruptured blisters removed, topical antimicrobial meds are applied |
| Open Method of Wound Management | Isolation, Room warm and humidified, Eschar removed to allow underlying skin to grow, Epithelization, Increased risk for infection |
| Closed Method (preferred) of Wound Management | Burns covered with nonadherent and absorbent dressings and covered with occlusive dressings, Sterile Technique during dressing changes |
| Pediculosis | Head lice! Found in any hairy area of the body, Head is most common, Crawling and direct contact is the method of transport. Not an indicator of hygiene, wash all clothing/linen, vacuum carpets and furniture |
| S/S Pediculosis | Itching, Nits/eggs on hair shafts |
| Treatment of Pediculosis | Pediculicide Shampoo: Rid, Nix Quell. Contraindiciated in Pregnancy, <2years old, Open Wounds. Fine tooth comb. 'Poos not used prophylactically. |
| Accutane | Used to treat acne, oral admin of isotretinoin, Dosage is determined by weight, Warn clients not to increase dosage if acne becomes worse or doesn't work. DO NOT TAKE WHEN PREGNANT! |
| Scabicides | Used to treat Scabies, Chemicals that destroy mites, such as lindane, premethrin cream, and crotamiton cream or lotion. Applied from the neck down in a thin layer and left on for 8-12 hrs. then removed by washing. |
| Furuncle | or boil is an infection caused by staphaureus and is inflamed skin and subcutaneous tissue with deep, inflamed nodules. |
| Skin pales because the number of cells that produce | melanin decreases |
| Decreased what production causes gray hair | melanin |
| Melanin | pigment that determines color of skin, made by melanocytes in the epidermis, controlled by the pituitary gland, absorbs UV radiation when exposed. |
| Hot or wet soaks are used to localize the infection and provide symptomatic relif. Antibiotics are used in some instances, especially if fever is present. | Furuncle Treatments |
| Never pick or squeeze - drainage is infectious. Follow strict aseptic technique when applying dressing | Furuncle Nursing Management |
| Psoriasis is a | chronic, noninfections inflammatory disorder of the skin that affects both men and women. |
| Genetic predisposition is likely but the cause is unknown | Psoriasis |
| Psoriasis is triggered by | systemic infection, injury to the skin, vaccination, or injection. |
| In psoriasis, skin cells called keratinocytes | behave as if there is a need to repair a . The cells of the epidermis profilerate faster than normal-so fast, that the upper layer of cells cannot be shed fast enough. |
| Excessive cells accumulate and form elevated, scaly lesions called | plaque. |
| Psoriasis is characterized by patches of | erythema (redness) covered with silvery scales, usually on the extensor surfaces of the elbows, knees, trunk, and scalp. |
| Psoriasis has no cure. Symptomatic treatment to control the scaling and itching includes | topical agents such as coal tar extract, corticosteroids, or anthralin. Topical corticosteroids, topical retinoids, and analogs of vitamin D have proved beneficial. |
| Photochemotherapy | a combination of UV light therapy and photosensitizing psoralen drug such as metoxsalen, also has been used for severe, disabling psoriasis. |
| Dermatitis | is a general term that refers to an inflammation of the skin. It is a common sign of many skin disorders accompanied by a red rash. May be localized or generalized. Cause must be diagnosed and definitively treated. Common types: Allergic/Irritant. |
| Pruritus | associated symptom of dermatitis, aka itching. May be localized or generalized. |
| Allergic dermatitis | sensitive to one or more substances such as drugs, fibers, cosmetics, plants, and dyes |
| Primary irritant dermatitis | localized reaction that occurs when the skin comes into contact with a strong chemical such as solvent or detergent. |
| In clients with allergies, sensitized mast cells in the skin release | histamine, causing a red rash, itching and localized swelling. |
| The skin response to dermatitis is characterized by | dilation of the blood vessles, causing redness and swelling, and sometimes by blister formation (vesiculation) and oozing. Itching. |
| Diagnosis of dermatitis | visual examination |
| Assessment of burns | skin color changes, edema/blistering, pain/discomfort, hypovolemic shock, hypotension, tachycardia, tachypnea, oliguria, anuria. |
| Partial thickness burn (1st degree) | Epidermis and Part of Dermis - Painful with pink or red edema, bust subsides quickly, no scarring. |
| Superficial partial thickness burn (2nd degree) | Epidermis and dermis, hair follicles intact - Mottled pink to red, painful, blistered or exuding fluid, blanches with pressure. |
| Deep partial thickness burn (2nd degree) | Deeper layer of the dermis with damage to sweat and sebaceous glands - Variable color from patchy red to white, wet or waxy dry, does not blanch with pressure, sensitive to pressure only. |
| Full thickness burn (3rd degree) | Epidermis, dermis, subq - Red white, tan, brown, or black; leathery covering (eschar); painless |
| Full thickness (4th degree) | Epidermis, dermis, subq; mayt include fat, fascia, muscle and bone - Black; depressed; pauinless; scarring |
| Vitamin D | Synthesized when skin is exposed to UV, Can be used to treat psoriasis, |
| Rosacea | Chronic vasodilation of blood vessels, causes hypertrophy of dermal tissue and sebaceous glands causing papules and pustules. |
| S/S of Rosacea | Intermittent blushing, papules, pustules, facial swelling, rhinophyma rosy appearance, skin across bridge of nose thick and distorted, may have blood shot eyes if vascular structures involved. |
| Medical Mgmt of Rosacea | Oral antibiotics to decrease inflammation, topical medications, pulse light/laser treatment to remove thickened skin |
| Assessment of rosacea | Frequent flushing across face |
| Rosacea is triggered by | Hot beverages, spicy foods, exposure to environmental elements |
| Herpes Zoster or Shingles | Caused by the same organism that causes chicken pox. For those who have had Chicken pox, the virus remains latent in cranial or spinal nerve routes until the infection is activated in the form of shingles. |
| S/S of Shingles | The first symptoms are pain, itching and heightened sensitivity along a nerve pathway, followed by formation of vesicles in the area. Unilateral. |
| THe infection is contagious to people who have not had previous exposure to Shingles or chicken pox so the patient must be put in | contact isolation. |
| Pressure Sore Stage 1 | Redness - fails to resume normal color or blanch when pressure is relieved |
| Pressure Sore Stage 2 | Blistering or skin tear |
| Pressure Sore Stage 3 | Shallow crater with drainage |
| Pressure Sore Stage 4 | Deep ulcerated tissue, exposed muscle and bone; sepsis-most traumatic and life-threatening! |
| Common areas for Pressure sores | coccyx, sacrum and hips, back of head, shoulder blades, heels, elbows, ears |
| Vesicle | Elevated, round, filled with serum (blister) |
| Papule | Elevated, obvious raised border, solid (wart) |
| Split-thickness graft | Epidermis and thin layer of dermis harvested from donor site, buttocks or thighs most common sites |
| Full thickness graft | Epidermis, dermis and subq tissue harvested, closer to normal skin |
| Slit graft | Harvested tissue stretched to cover larger area |
| Skin biopsy: Scrape | scraping the lesion parallel with the skin with a scalpel or razor blade |
| Skin biopsy: Surgical Excision | Excising the lesion partially or entirely with scissors or a scalpel. |
| Skin Biopsy: Punch | Using the punching instrument to remove a cylindrical core of tissue. |
| Skin Biopsy | to identify malignant, premalignant, and nonmalignant skin lesions as well as chronic skin disorders such as leprosy. After injecting a local anesthetic a physician obtains the skin sample in one of 3 ways! |
| Checking peripheral circulation during musculoskeletal assessment | distal pulses should be present and strong, capillary refill <3seconds, Skin color similar to color in other body areas, Skin temperature warm, Local edema should be absent. |
| The most commmon adverse effects of NSAIDS are related to the | gastrointestinal tract: nausea, vomiting, diarrhea, and constipation. GI bleeding, which in some cases is severe has been reported with the use of these drugs. Stress to your pt to take the medication with food. |
| arthography | a radiographic examination of a joint, usually the knee or shoulder. |
| The physician first injects a local anesthetic and then inserts a needl into the joint space. Fluoroscopy may be used to verify correct placement of the needle. The synovial fluid is then aspirated and sent to the laboratory for analysis. | Arthogram |
| If the client has had an invasive joint exam the nurse inspects the area for | swelling and bleeding or serous drainage. He or she changes or reinforces dressings as needed. Notify of severe pain. |
| Decreased serum calcium may indicate | osteomalacia (rickets), osteoperosis, and bone tumors |
| Primary Osteoporosis | Age related loss of bone mass without apparent underlying medical causes |
| Secondary Osteoporosis | loss of bone to factors such as hyperthyroidism, long term steroids, or heparin. |
| Until adolescence, bone formation exceeds | bone absorption. Process remains about equal through the twenties. |
| By age 30, bone absorption surpasses | bone formation. Net result is loss of bone mass, which makes the pt more susceptible to fractures. |
| Osteoporosis Risk Factors | Greatest risk are elderly women with small frames, white, fair skinned, and blonde or red hair. |
| S/S Osteoporosis | Back pain from fractures, fractures, loss of height due to vertebral compression, kyphosis or lordosis, poorly fitting dentures |
| Assessment findings of Osteoporosis | Freq. complaints of lumbosacral pain, thoracic back pain or both / may be the result of tiny compression fractures in the vertebrae / Pathologic fractures in the long bones. |
| Diagnostic Findings of Osteoporosis | DEXA - measures bone mineral density of the spine and hip. Quantative ultrasound - measures heel density and provides baseline info for dx osteoporosis and predicting risk of fx. |
| Medical Treatment of Osteoporosis | Calcium supplements, estrogen, Vit D (calcium absorption), Fosamax (inhibit bone reabsorption w/o retarding mineralization), Regular exercise (weight bearing) |
| Spinal compression fractures treated with | percutaneous vertebroplasty - a needle is inserted into the vertebra and a special type of cement is injected - minimally invasive - minimized risk - short recovery |
| Kyphosis | humpback |
| lordosis | swayback |
| Gout | painful metabolic disorder involving an inflammatory reaction in the joints, usually affects the feet (especially the great toe), hands, elbows, and knees. Characterized by the deposition of urate crystals in joints. |
| Gout is more prevalent among men in their | 40s and 50s |
| Kidney stones develop in about | 20% of pts with gout. |
| Gout occurs from one or more of the following | hyperuricemia, severe dieting or starvation, excessive ingestion of purines (organ meats, shellfish, sardines), heredity, abnormal purine metabolism, |
| S/S of Gout | Blood uric acid level is elevated, abrupt onset usually at night, severe crushing pain to one joint, hypersensitive to touch and cannot bear even the bed sheets, skin turns red and joint swells. |
| Pts with advouced gout may have tophi, or deposits of | sodium urate crystals under the skin. Attack may last 1-2 weeks, repeated episodes in the same joint may deform the joint |
| Dx of Gout | History and physical exam, elevated uric acid level in blood and urine, x-rays, urate crystals in the synovial fluid, salt of uric acid, crystallizes in body tissue and deposited in soft and bony tissues. |
| Medical treatment of gout | Colhicine for initial attacks and to stop impending attacks. Allopurinol, probenecid, indomethacin, and sulfinapyrazone for asymptomatic periods. Decrease purines, high protein, high carbs, increase urate excretion, low fat (fats retard urate excretion) |
| Nursing care for Gout pt. | elevate affected extremity, administer rx meds, may also use a bed cradle, sift urine for stones, 24hr urine exams |
| CPM Therapy | Helps reduce pain and inflammation, Prevent postoperative complications. |
| Short term fracture complications | shock, fat embolism, deep vein thrombosis, compartment syndrome, shock |
| Fat Embolism is a condition in which fat globules are | released from the marrow of the broken bone into the blood stream. They lodge in capillaries of the lung and obstruct blood flow. Fat particles break down into fatty acids, which inflame the pulmonary blood vessel leading to pulmonary edema |
| Fat embolisms are most commonly associated with | long bone fractures, multiple fractures, and severe trauma. Occurs 24-48 hours after inury. |
| An older pt with a hip fracture is at highest risk for | fat embolisms. |
| The first sign of fat embolism is | respiratory distress followed by: tachycardia, tachypnea, fever, confusion and decreased LOC. |
| Treatment of Fat embolism | bedrest, gentle handling, oxygen, ventilatory support and fluid restrictions and diuretics for pulmonary edema. |
| Complications of Fat embolism | pulomoary embolism, sudden and severe CP and SOB, stroke, weakness, slurred speech, and confusion, MI, severe CP, hypotension, irregular pulse, confusion. |
| Prevention of Deep Vein Thrombosis | Anti-embolism stockings, compression devices and early ambulation |
| Bone formation facilitators | calcium, phosphorus, estrogen, testosterone, calcitonin, vitamins ACD, Growth hormone, exercise, insulin |
| Bone formation retardants (bad) | estrogen/androgen deficiency, vitamin deficiency, starvation, diabetes, steroids, inactivity/immobility, heparin, excess parathyroid hormone |
| Cast Care p 972 | |
| After hip surgery the nurse implements measures to prevent | skin breakdown, wound infection, pneumonia, constipation, urinary retention, muscle atrophy, and contractures. |
| The client after hip surgery usually has a wound drain in place for | 1-2 days after surgery. The nurse monitors the drainage and administers antibiotics as prescribed. |
| The nurse must show the client how to use the overhead trapeze safely for | independent movement and activity. Place abductor piollow between legs when turning the client from side to side. |
| Benign bone tumors usually result from | misplaced or overgrown clusters of normal bone or cartilage cells that cause the structure to enlarge and impair function. Grow slowly and don't metastasize. Bone structure weakened |
| S/S Benign Bone Tumors | pain or discomfort that increases with weight bearing and deformed bone with swelling over the affected area. |
| Treatment of Benign bone tumors | surgery if bone is deformed, growing tumor, or if pain interferes with ADLs and mobility. May reoccur. Goal is to treat pain and prevent fractures. |
| Malignant Bone tumors are abnormal | osteoblastor myeloblasts that exhibit rapid and uncontrolled growth. |
| Primary Malignant bone tumors include | osteosarcoma, Ewing's sarcoma, chondrosarcoma, and fibrosarcoma. |
| Malignant Bone tumors are usually found around the | knee in the distal femur or proximal fibula with a few found int he proximal humerus. As the tumor expands it lifts the periosteum. |
| S/S of Malignant bone tumors | Pathological fracture, persistent pain, swelling and difficulty moving the involved extremity, limp or abnormal gait, by the time the client experiences symptoms, the tumor usually has spread. |
| Medical treatment of malignant bone tumor | surgical removal by amputation or wide local resection, radiation and chemo, amputation. |
| ESR and C-reactive protein | determine if the disorder is inflammatory or noninflammatory. |
| Elevated serum uric acid level | may indicate gout |
| Traction | Exerts a pulling force on a fractured extremity to provide alignment of the broken bone fragments. Decreases muscle spasms. Aids with pain relief. |
| Skin Traction | applied directly to the skin. Uses weights of 5-10 lbs. Includes Bucks traction: used in hip and knee fractures / Russells traction: elevates knee / head halter traction / pelvic traction |
| Skeletal traction | provides a strong steady pull and can be used for long periods of time. Types: Gardner-wells, crutchfield, Vinketongs, and halo vest. |
| Important skeltal traction points | weights must hang freely, maintain good body alignment, use padding, assess affected extremity for temp, pain, sensation, cap refill, pulses. Assess pin sites for redness, drainage, odor. |
| Colle's Fracture | Break in the distal radius, Usually when an outstretched hand is used to break a fall. |
| Osteomyelitis | infection in the bone, limited blood supply, inflammation of an dpressure on the tissue and formation of new bone around devitalized bone tissue make this a difficult and challenging condition to treat. |
| Staphylococcus aureus causes 70-80% of | bone infections. |
| Acute osteomyelitis results from | bacteria reaching the bone through the blood stream. |
| Acute localized osteomyelitis occurs when bone is | contaminated directly by trauma, such as penetrating wounds or compound fractures. |
| S/S of Osteomyelitis | high fever, chills, rapid pulse, tenderness, pain, redness swelling, drainage from wounds, exposed bone |
| Dx of Osteomyelitis | Elevated WBCs, ESR, Postive blood cultures, xrays show irrgeular bone decalcification, bone necrosis, elevation of the periosteum and new bone formation. Bone scans and MRI are useful. |
| Medical Management of Osteomyelitis | Immobilization with cast or immobilize to decrease pain and prevent fracture. Application of warm saline soaks to promote circulation. I.D. causative organism for antibiotic therapy. IV Antibiotics=3-6weeks Oral Antibiotics up to 3months. bone grafts. |
| Nursing MGMT of osteomy elitis. | Pt education about dx and care, protect skin from breakdown, administer medications and antibiotics, meticulous diabetic care of extermities. |
| What is Retinal Detachment | A seperation of the sensory layer of the eyeball from the pigmented layer. |
| How does Retinal detachment happen | A separation of the sensory layer of the eyeball from the pigmented layer. A tear in the retina allows fluid to collect between the sensory and the pigmented layers. This separation deprives the sensory layers of nutrients and oxygen. Vision lost! |
| Retinal detachment...Retinal tears may occur | spontaneously or as a result of trauma. Pts may report seeing flashes of light or floaters, or blind spots. Vision may be cloudy. |
| Retinal detachment some pts say it seems as if a | curtain has come down on or across the line of vision. vision may be lost completely. Painless. |
| Surgical Repair of Retinal detachment | Laser reattachment: lasers used to surgically repair tears, as the area heals scar tissue forms that seals the tear. Cryosurgery: uses cold to cause the scar tissue to form in sclera, choroid and retina. |
| Retinopexy | Gas is injected into the eye to apply pressure to the tear. Client has to recline 16hrs before surgery, 8 hours 3x's a week after surgery. |
| Scleral buckling is often done along with | laser treatment or cryosurgery. Silicone band that is secured around the eyeball under the sclera bringing the layers of tissue back together by pressing from the outside. The band is left in place permanently. |
| Tonometry | measures intraoccular pressure. Normal readings are 10-21mm Hg. Applanation Tonometry provides greatest accuracy. Indentation method may be used because it is smaller/portable. Either method requires topical anesthesia. |
| Cataracts | When the lens becomes opaque so that it is no longer transparent. Vision decreased R/T decreased light getting into retina. |
| Cataracts may be | congenital, traumatic or degenerative, may also be secondary to eye diseases, DM, HTN, |
| Cataracts can be R/T | DM, UV rays, Radiation, Steroids |
| Assess for S/S of Cataracts | Halos around lights, difficulty reading, distortion of objects, cloudy lens upon inspection |
| Medical treatment of cataracts | surgery - intracapsular extraction (lens removed, extracapsular extraction (posterior capsule left), phocoemulsification (US used to break up lens and remove) |
| Complications with cataract surgery may include | leakage of the vitrous humor, hemorrhage into the eye and opening of the incision, Intraocular lenses are placed in the eye following cataract surgery. |
| After Cataract surgery asses for | pain and nausea, the pt is likely to have a patch and shield over the operation eye.Vision will be blurred for ~1 week. |
| Nursing Mgmt for cataract surgery | verbal and written discharge instructions, assess for and try to prevent: N/V, coughing, sneezing, avoid lying client on operative side, assess: pain in eye or near brow, |
| S/E of chilinergics (miotics)(pilocar, miostat) used to increase aqueous fluid outflow by contracting the ciliary muscle and causing miosis and opening of trabecular meshwork a/w glaucoma | periorbital pain, blurry vision, difficulty seeing in the dark. |
| S/E of adrenergic agonists (propine) used to reduce production of aqueous humor and increase outflow a/w glaucoma | eye redness and burning, can have systemic effects, including palpitations, elevated blood pressure, tremor, headaches and anxiety. |
| S/E of Beta-Adrenergic Blockers (betoptic, timoptic) used to decrease aqueous humor production and decrease intraocular pressure a/w glaucoma | Can have systemic effects, including bradycardia, exacerbation of pulmonary disease, and hypotension: common ocular side effects are burning/stinging, discomfort, dry eyes, and eyelid erythema |
| S/E of Alpha-adrenergic agonists (iopidine, alpagan) used to decrease aqueous humor production a/w glaucoma | Eye redness, dry mouth, and nasal passages |
| S/E of Carbonic Anhydrase Inhibitors (diamox, neptazane, trusopt) used to decrease aqueous humor production a/w glaucoma | oral meds a/w serious side effects, including anaphylactic reactions, electrolyte loss, depression, lethargy, GI upset, impotence and weight loss; topical form: allergy |
| S/E of Prostaglandia Analogs (xalatan) used to increase uvescleral outflow a/w glaucoma | Darkening of the iris, conjunctival redness, possible rash. |
| To reduce the consequences of spontaneous rupture of the eardrum, subsequent scarring, and hearing loss, the physician performs a | myringotomy or tympanotomy, an incisional opening of the tympanic membrane. The incised opening facilitates drainage of the purulent material, eases the pressure, and relieves the throbbing pain. The incision heals readily with little scarring. |
| For at least one week following catarct surgery the pt must avoid: | engaging in strenous activity and heavy lifting, bending and stooping, immersing eyes in water, any activity that potentially could cause dust or other particles to lodge in the eye. |
| Advise clients who have had cataract surgery to eat | soft, easily chewed foods until healing is complete to avoid tearing from excessive facial movements. |
| Parts of the nurses assessment of the pt with eye issues | clients description of vision changes and visual or eye discomfort, use of glasses or contacts, use of rx and nonrx eye meds, previous eye trauma, opthalmic and med diseases, and surgery, family history of inherited eye issues (glaucoma), Allergy history |
| Nursing interventions for hearing impaired | speaking clearly in alow tone of normal volume during frequent reorientations and teaching related to assistve hearing devices. The client's ability to care for the assistive device will influence selection of a hearing aid from various styles available. |
| Rinne's Test | the tuning fork is struck, placed on the mastoid process behind the ear- held there until the client can no longer hear sound- Immediately after that, the still-vibrating tuning fork is held beside the hear, and again says when sound isno longer heard. |
| Normally during the rinne Test, air conduction beside the ear measures | twice as long as by bone conduction through the mastoid. |
| Otitis Media | An infection of the middle ear, usually develops after: respiratory infections or allergic reactions, |
| In Otitis Media, fluid accumulates in the middle ear, causing painful pressure on the | tympanic membrane. |
| ototoxicity | damage to the ear or eighth cranial nerve caused by specific chemicals, including some drugs. |
| S/S ototoxicity | tinnitus and hearing loss |
| Common Ototoxic drugs: | salicylates (aspirins), aminoglycoside antibiotics, loop diuretics, quinidine, quinine |
| Keratitis | inflammation or infection or both of the cornea |
| Keratitis does not produce noticeable | drainage but it causes considerable pain. |
| Keratitis can be cause by | trauma to the cornea |
| Keratoplasty | the only treatment for corneal opacity is removal of the scarred cornea and replacement with a healthy cornea. |
| Otalgia | Pain in the ear |
| Pilocarpine (Pilocar) is a Cholinergic (Miotic) Used to treat glaucoma | Increase aqueous fluid outflow by contracting the ciliary muscle and causing miosis (constriction of the pupil) and opening of trabecular meshwork. S/E: Periorbital pain, blurry vision, difficulty seeing in the dark Nursing: diminished vision in dim light |
| Impacted Cerumen Removal | 1 or 2 drops of 1/2 strength hydrogen peroxide, warm glycerin or mineral oil or may be softened with commercial agents. Wax is then removed with a cerumen spoon or by irrigation. |
| Foreign Objects in the ear - the client will: | c/o pain, decrease in hearing, feeling movement or hear buzzing |
| Assessment of ears for foreign objects shows: | Foreign object, swelling and redness in auditory canal |
| Treatment of foreign objects in ears | mineral oil, forceps |
| Nursing mgmt of foreign objects in ears | instruct client to: clean ears with face towels, nothing to be placed in ear canal, protection ears from flying insects. |
| Meniere's disease is a disorder of the | labyrinth. Usually occuring in Middle-aged adults. |
| The cause of Meniere's is unknown but symptoms are related to an accumulation of | fluid in the inner ear. |
| Classic symptoms of Meniere's Disease | hearing loss, tinnitus and vertigo. The hearing loss is unilateral. |
| S/S upon assessment of Meniere's disease | vertigo, tinnitus, hearing loss, nystagmus, "ora", HA, fullness in affected ear, attacks may last from minutes to weeks. |
| Diagnostics of Meniere's Disease | Medical Hx and Physical exam, caloric stimulation test, CT scan/MRI, Audiometry |
| Treatment of Meniere's DIsease | Decreasing fluid production in inner ear, facilitating drainage from inner ear, treating symptoms, Low Sodium diet, cessation of smoking, antihistamines, BR during attacks. |
| Drug therapy for Meniere's disease | Meclizine (antivert), Diazepam (valium), Promethazine (phenergan), Diuretics |
| Nursing mgmt for meniere's disease | Assess: Medical Hx S/S:Hearing Deficit Provide: Medications as ordered, BR, assist with ADL's upon attacks. Educate on: medical regimen, low sodium diet, hearing aid |
| Glaucoma is the second leading cause of | blindess in the US |
| Normally aqueous humor enters and leaves the anterior chamber so that intraocular pressure is | maintained between 10 and 21 mm Hg |
| Glaucoma occurs most often caused by some | interference with the outflow and production of aqueous humor. The exact cause is unknown. |
| Excess pressure damages the back portion of the eye and impairs | blood flow to the optic nerve. Increased IOP. |
| Glaucoma causes peripheral vision to be lost first. The field of vision gradually | narrows until the pt has tunnel vision. Complete blindness eventually occurs. |
| African Americans are at increased risk for | Glaucoma |
| Vision may be restored if glaucoma is | treated early, otherwise vision loss is peromanent. |
| Open angle glaucoma, also called chronic glaucoma Results from | some alteration that prevents the normal passage of aqueous humor through the trabecular meshwork. |
| Pts. with open angle glaucoma complain of | tired eyes or discomfort, occasional blurred vision and halos around lights. Another clue is frequent changes of eyeglass Rx. Decrease in Peripheral vision. |
| Angle-closure Glaucoma, also called acute glaucoma is caused by | the flow of the aqueous humor is blocked through the pupil, causing the iris to push forward and blocking the trabecular meshwork. Rapid rise in IOP. Considered a medical Emergency. Vision can be lost in 1-2 days. |
| Angle-closure glaucoma causes sudden acute pain and | nausea/vomiting, HA on affected side, Red conjunctiva, "cloudy cornea" |
| Glaucoma is treated by | drugs are used to immediately lower the pressure followed by suregery to prevent recurrence. Medications used may have systemic effects. |
| MYDRIATICS ARE | CONTRAINDICATED IN GLAUCOMA |
| Surgical Intervention for glaucoma may be recommended when | drugs do not reduce pressure adequately. |
| Trabeculoplasty. | the use of laser to create multiple holes in the trabecular meshwork. |
| laser iridectomy | holes burned into iris to make exit pathways |
| surgical iridectomy | part of the iris is surgically removed. Done if laser iridectomy is unsuccessful. |
| Corneal trephine | small holes produced at junction of cornea and sclera for drainage. |
| Nursing Mgmt of Glaucoma pts | Hx of diagnosis, family hx, medical compliance, pain, drug therapy, decreased sensory stimulation, quiet room, dim lights |
| Preventing activities that increase intraocular pressure: | laughing, sneezing, N/V, straining, lifting >5 pounds. |
| Blepharitis | inflammation of the hair follicles along the eyelid margin. |
| Symptoms of Blepharitis | itching, burning, photophobia, scales or crusts may be seen on the eye lid margins. This should be cleaned with baby shampoo and water. |
| Blepharitis can lead to | hordeolum or chalazion. |
| Blepharitis is treated with a | topical antibiotic. |
| Surgical iridectomy | part of the iris is surgically removed. Done if laser iridectomy is unsuccessful. |
| Many pharmacologic agents affect the hematopoietic system, causing a decrease in various blood components. Closely monitor clients taking medications that depress the hematopoietic system, particularly | thrombocytes and leukocytes, for signs of leukopenia (fever, sore, throat, chills) and thrombocytopenia (unusual or easy bleeding, oozing from injection sites, bleeding gums, dark, tarry stools). |
| Schilling Test | 24 Hour Urine Test. Identifies deficiencies of intrinsic factor in the gastric mucosa (needed for the absorption of Vitamin B12). Used to diagnose pernicious anemia. |
| The Schilling Test may pose a problem in older adults if proper collection of the 24-hour specimen is not possible as a result of | cognitive problems or urinary incontinence, the scholling test is rarely orderd to detect B12 deficiencies for older adults bc the cause of pernicious anemia in the older pop is usually gastric hypoacididty. |
| Liver | regulates blood glucose levels. Regulates blood levels of amino acids based on tissue needs for protein sythesis. Forms lipoproteins for transport of lipids in blood to other tissues. |
| Spleen | Stores about 500 mL of blood that can be released in emergencies. Destroys worn out RBC. Removes bacteria by phagocytosis. |
| Erythrocytes (RBC) | 3.6-5.4 million / infants have more than adults / women have fewer than men |
| hemoglobin | an iron containing pigment attached to eryhtocytes. Normal count: 12-17.4 g/dL |
| Erythrocytes circulate in the blood for about | 120 days after which the spleen removes them; the liver removes severely damaged eryhthrocytes. |
| Leukocytes (WBC) | perform various protective functions such as engulfing invading microorganisms and cellular debris, and manufacturing antibodies. Normal count 5k-10k mm |
| Neutrophils | are a major component of the inflammatory response and defense against bacterial infection. protect the body by phagocytosis. 60-70% of Total WBCs / Range: 3000-7000 |
| Basophils | active in allergic contact dermatitis and some delayed hypersensitivity with phagocytosis. 1-4% of Total WBC / Range:50-400 |
| Eosinophils | phagocytize foreign material. Their numbers increase in allergies, some dermatolgic disorders and parasitic infections.5-1% of total wbc / range: 25-100 |
| Lymphocytes | WBCs with immune functions. 20-40% of total wbc / range: 1000-4000 |
| Monocytes | phagocytize large-sized debris, help combat severe infections and contribute to the immune response. 2-6% of total wbc / range: 100-600 |
| Type O blood can be given to | A, B, AB, or O |
| People with Rh positive blood can receive | Rh positive or Rh Negative blood |
| Those with Rh Negative blood can never receive | Rh Positive blood regardless of blood type |
| B Lymphocytes | provide humoral immunity by producing antibodies against foreign antigens |
| T Lymphocytes | provide cellular immunity and interact with foreign cells and release a substance called lymphokine, which enhances the actions of phagocytic cells. |
| Platelets (thrombocytes) | last 7.5 days, they are manufactured in the red bone marrow. Circulate in the blood and contribute to hemostasis. Helps in clot formation. Count: 150,000-350,000 mm |
| Plasma is the | liquid or serum portion of the blood: consists of 90% water and 10% proteins |
| Albumin is formed in the liver is the most abundant protein in | plasma. Cannot pass though a capillary wall. helps maintain the osmotic pressure that retins fluidin the vascular compartment. |
| Globulins are divided into three groups | alpha, beta, and gamma |
| gamma globulins are also called | immunoglobulins |
| Globulins function primarily as immunologic agents; they prevent or | modify some types of infectious diseases. Like albumin they help maintain osmotic pressure |
| Fibrinogen plays a key role in forming | blood clots. It can be transformed from a liquid to fibrin a solid that controls bleeding |
| Physical exam includes inspection of the skin with particular attention to | color (normal, extreme redness, pallor) temperature, and ecchymosis or other lesions. |
| A rapid pulse rate can indicate | reduced erythrocytes or inadequate hemoglobin levels |
| The nurse palpates the lymph nodes in the neck for tenderness or swelling and notes the | size, location, and characteristics of symptomatic lymph nodes. He or she examines the skin adjace to the node for redness, streaking, and swelling. |
| In relation to the hematopoietic and lymphatic systems, it is important to establish if the client: | experiences prolonged bleeding, has unexplained blood loss, rectal bleeding, nosebleeds, bleeding gums, or vomiting blood, feels fatigued , becomes dizzy or faints, bruises easily, is easily chilled, has frequent infections, |
| In relation to the hematopoietic and lymphatic systems, it is important to establish if the client (continued): | feels discomfort in the axilla, groin or neck. has difficulty swallowing with localized throat tenderness. has had surgery with lymph node removal or splenectomy, is undergoing treatment for cancer, or has renal failure |
| Leucopenia | decreased number of leukocytes. |
| Lymphatic system includes the | thymus gland, spleen, and a network of lymphatic vessels, lymph nodes and lymph |
| The system of lymphatics circulates interstitial fluid and carries it to the veins. Along the pathway, the lymphatic system filters and destroys | pathogens and removes other potentially harmful substances. |
| Bone marrow is the soft tissue that fills spaces in the interior of the long bones and spongy bones of the skeleton, manufactures | blood cells. The two types of bone marrow are red and yellow. |
| Red marrow is primarily found in the | ribs, sternum, skull, clavicles, vertebrae, proximal ends of the long bones, and iliac crest. |
| Red marrow manufactures | blood cells and hemoglobin |
| Yellow marrow consists primarily of | fat cells and connective tissue. It does not participate in the manufacture of blood cells; however it can form blood cells under conditions involving intense stimulation. |
| Anemia | is a term that refers to a deficiency of either erythrocytes or hemoglobin. |
| Most anemias result from | blood loss, inadequate or abnormal erythrocyte production, or destruction of normally formed RBCs |
| Hypovolemic anemia | caused by a loss of blood volume which results in fewer blood cells. |
| iron deficiency anemia | develops when iron is insufficient to produce hemoglobin. Examples include when heme cannot be recycled because of blood loss, dietary intake of iron is insufficient, absorption of iron is inadequate and needing excess iron |
| To correct iron deficiency anemia, 200 mg of | ferrous sulfate is given three times per day 1 hour before meals, therapeutic response is monitored throughout periodic hemoglobimn and hematocrit counts. If the client canot swallow tabs, liquid iron preps are available. |
| Heme iron is found in animal foods such as | beef, pork, lamb, egg yolks, oysters, and the dark meat of poultry. It is well absorbed, and its rate of absorption is influenced only by need. Adding 3 serivings of lean meats per week helps. |
| Sickle cell anemia is so named because erythrocytes become | sickle or crescent shaped when oxygen supply in the blood is inadequate. Common genetic disorder found primarily in african americans and mediterraneans. |
| hemolytic anemia | refers to the consequence of a widely diverse group of conditions, some aquired, some hereditary, some idiopathic, in which there is chronic premature destruction of erythrocytes. |
| Iron injection via Ztrack technique: Fill with prescribed amout of med, draw up an additional 2 mL of air, attach a needle that is 1.5 - 2 inches long. Don Gloves. POsition client on the abdomen or side depending on which injection | site you use. Use the side of your hand, pull the tissue laterally about 1 inch until it is taught. Swab with alcohol. Insert needle at 90 degree angle. while still holding tissue. Aspirate. Instill. Wait 10 sec. withdraw. release tissue. apply pressure. |
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