Med Surge 3 Final
Help!
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| Central nervous system | Brain and Spinal cord
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| Peripheral nervous system | Peripheral nerves and Cranial nerves
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| Autonomic nervous system | Sympathetic (adrenergic) and Parasympathetic (cholinergic)
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| Frontal lobe | socialization, expressive speech (Broca's area)
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| Parietal lobe | Sensory interpretation, Proprioception, and Body image
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| Temporal lobe | Receptive language (Wernicke’s area)
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| Hippocampus | Memory - deep in the temporal lobe
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| Occipital lobe | Interpretation of vision
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| Brainstem | Vital life center
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| Cerebellum | "little brain" (Coordination, Fine motor movement, and Balance)
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| Vertebral column | 33 vertebrae
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| First pair of spinal nerves | leaves the cord above C1
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| Sympathetic nervous system | Fight of flight (Dilated pupils) - general rule: speed up except GI tract
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| Parasympathetic nervous system | general rule: slow down except GI tract
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| CN 1 | Olfactory (S)
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| CN 2 | Optic (S)
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| CN 3 | Oculomotor (M)
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| CN 4 | Trochlear (M)
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| CN 5 | Trigeminal (B)
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| CN 6 | Abducens (M)
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| CN 7 | Facial (B)
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| CN 8 | Acoustic (S)
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| CN 9 | Glossopharyngeal (B)
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| CN 10 | Vagus (B)
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| CN 11 | Spinal accessory (M)
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| CN 12 | Hypoglossal (M)
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| CN 3, 4, and 6 | Tested together for eye movement
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| Miotic | constricted pupils
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| Mydriatic | dilated pupils
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| Altered LOC | A decrease in response to surroundings
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| A&Ox4 | person, place, time, situation
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| CSF in the brain | 75 mL
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| 3 things that work to keep balance | water, blood, and CSF
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| Epidural hematoma | between the skull and dura
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| Subdural hematoma | acute, subacute, or chronic (NOT acute, life-threatening arterial bleeds)
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| ICP normal range | 10-20
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| The earliest sign of serious impairment of brain circulation related to ICP | throbbing headache
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| Mannitol | osmotic diuretic (pulls fluid from different places, VERY important to get electrolytes); it does not cross an intact blood brain barrier
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| CPP | Central Perfusion Pressure (needs to be >70 to have adequate O2)
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| CBF | Cerebral blood flow
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| CBV | Cerebral blood volume (75 mL at all times)
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| CPP | MAP-ICP (70 or > = good CBF; <50 = Irreversible brain damage)
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| IICP | Increased myocardial contractility
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| Herniation | the most common, compression of brain tissue
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| Cushing's reflex/response/triad | Increased BP, Decreased HR, Decreased RR
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| Widening pulse pressure | assessment finding of IICP
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| Most serious complication of IICP | brain herniation
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| IICP Diagnoses | History and physical, CT (if contrast is used force fluids after), and Lumbar Puncture
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| Relieve IICP | avoid trendelenberg position
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| Reduce metabolic demand of IICP | avoid shivering (it increases ICP)
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| Generalized seizures | whole brain
Convulsive = Tonic (rigid muscle contraction - brief, sudden contraction), Tonic/Clonic (alternating contraction and relaxation) - most common
Nonconvulsive = rigid and stiff (dead in the bed)
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| Epilepsy | reocurring seizures
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| EEG | electrical activity with or without stimulus that encompasses the whole head
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| CT for seizures | ordered with an EEG to confirm diagnosis of seizures
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| Dilantin (Phenytoin) | Treatment effect not immediate because it needs to get a therapeutic level - ALWAYS give Dilantin in NS - Stop tube feedings and hour before and after giving Dilantin and tube rinsed/flushed with water after
SE = gingival hyperplasia
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| Celebrex (Fosphenytoin) | Short term management
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| Dilantin and Celebrex therapeutic level | 10-20
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| New admit for seizures | most important plan of care is to place a sign above the bed
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| Post-ictal phase of a seizure | let them rest, without rest they will seize again
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| HA categories | Stress/tension, HTN, and vascular
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| Most effective way to diagnose a functional headache | get a thorough history
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| Migraine auras | Sensory - pain is NOT an aura
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| Migraine triggers | Stress, Caffeine, foods high in tyramine and nitrates, smoke, and bright lights. Avoid smoking, aged cheese, and red wine.
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| Preventative migraine medications | taken every day - Inderal (beta blockers)
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| Sumatriptan (Imitrex) | Abortive drug - take it to stop the entire migraine. Can only take twice a day and it has to have an hour in between doses
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| Antiemetics for headaches | Zofran when they are nauseous, once they have vomited they need phenergan (must be diluted in at least 10 mL NS and given slowly - at least over 5 minutes)
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| Patient with the "worst headache of their life" | tell them to go to the ED immediately
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| Malignancies | May be primary, secondary, or rapid growing
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| Gliomas | arise from neuroglia
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| Meningioma | arise from the meninges
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| Neuromas | arise from nerves
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| Pituitary Adenomas | Responsible for hormone release (Prolactin, HGH, ACTH)
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| Angiomas | Speculated that at least 40% of cerebral hemorrhage in people under 40 is related to angiomas
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| Grade 1 Tumor | The tumor grows slowly, has cells that look similar to normal cells, and rarely spreads. May be removed surgically. Most likely a menengioma
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| Grade 2 Tumor | The tumor grows slowly, but may spread into nearby tissue and may become a higher grade tumor. Most likely a glioma
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| Grade 3 Tumor | The tumor grows quickly, is likely to spread into nearby tissue and the tumor cells look very different from normal cells.
Most likely an oligdendroglia
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| Grade 4 Tumor | Grows very aggressively
Has cells that look very different from normal cells, and is difficult to treat successfully.
Most likely an oligdendroglia
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| Embolic stroke | most serious because it is acute. Usually results in atrial fibrillation.
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| TIA | <24 hr in duration. One sided weakness (no bilateral paresthesias)
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| Left brain CVA | o Right hemiplegia
Expressive, receptive, or global aphasia
Cognitive impairment
Slow cautious behavior
Right visual field defects
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| Right brain CVA | Left hemiplegia
Spatial-perceptual issues
Hemi-neglect (Denial – neglect of the affected side (don’t realize that it is even still there))
Distractibility
Poor judgment
Left visual field defects
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| Patient who is right handed and experiences a left sided stroke | right hemiparesis and speech is affected
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| Anterior Cerebral Artery | Supplies the medial surface of the frontal lobe and the parietal lobes
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| Vertebral arteries | Supply cerebellum, brainstem, spinal cord, medial and inferior aspects of temporal lobes. And the occipital lobes
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| Middle Cerebral Artery | Artery that supplies the largest area of the cerebrum
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| Hemorrhagic CVA | primarily caused by uncontrolled HTN
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| CT with Contrast | Force fluids after and creatinine levels need to be checked
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| Dysphagia | Feed on UNAFFECTED side, HOB up, and thickened liquids
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| Verbal deficits after CVA | allow pt sufficient time - DON'T finish sentences for the pt
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| Walking aids after CVA | When transferring patient from a chair to a wheelchair, do not have them lean forward and keep their good leg straight
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| Contusion | Usually results in decreased LOC
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| Dextrose 5% | becomes hypotonic when in the body but may be identified as isotonic
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| Hypertonic Solutions | D5/0.45 NS and D5/0.9 NS
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| Isotonic Solutions | 0.9% NS and LR
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| Spinal Cord Injuries | Concussion
Contusion
Laceration
Transection
Shearing of vessels
Hemorrhage
Edema
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| Patient admitted from the ED following a MVC on a backboard with a c-collar and is alert and oriented | talk to the trauma doctor, obtain a written order to remove the backboard after his c-spine has been cleared and leave the collar in place
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| Spinal Shock | Flaccid paralysis, loss of reflexes below injury, hypotension, lasts less than 48 hours, temporary loss of motor and sensory function, temporary loss of reflexes and autonomic function
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| Autonomic Dysreflexia | Drives BP dangerously high (300/160), severe HA and blurred vision
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| MS | Progressive demyelinating disease of the CNS (progressive increasing weakness)
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| MS Tremor | Intentional (Not resting)
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| Guillain Barre | Number 1 concern = airway (check pulse ox and pulmonary function - peak flow)
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| Guillain Barre Diagnosis | Serial peak flow rates - essential to evaluate ascending progression that involves the phrenic nerve
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| Guillain Barre Management | Ventilatory/intubation/trach and IV immunioglobulin (must be hung at the same time every time)
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| Trigeminal Neuralgia | Painful twitch
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| Trigeminal Neuralgia Medication | Antiseizure medicaitons - Tegretol (Carbamazepine)
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| Trigeminal Neuralgia Goal | prevent pain
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| Bells palsy | more common in younger patients
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| Parkinson's | Insufficient amounts of dopamine in the basil ganglia
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| Parkinson's cardinal findings | Tremor at rest, Muscle rigidity, Bradykenesia, Shuffling gait
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| Parkinson's Mask like expression | priority is the ability to chew and swallow
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| Parkinson's Medication toxicity | acute confusion
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| Parkinson's Medication | Sinemet – Ldopa often given in combination with Carbidopa,
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| Parkinson's walking education | Teach pt to stop periodically when walking to prevent falling from propulsive gait – reduces the risk of falling
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| Myasthenia Gravis | Easily fatigability, diplopia, ptosis (weak eye closure)
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| MG Diagnosis | Tensilon Test
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| Anticholinesterase drugs | give before meals to give the best chance of preventing aspiration – if breakfast is at 8:30, it needs to be given at least by 8. This medication must be given on time every time.
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| Myasthenia Crisis | Sudden exacerbation of symptoms (ventilatory distress, increased muscle weakness, difficulty swallowing and talking), Tensilon test = pt improves, Give anticholinesterase medications
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| Cholinergic Crisis | Sudden exacerbation of symptoms (abd cramping, diaphoresis, ventilatory distress, increased muscle weakness), Tensilon test = pt worsens, Give atropine antidote IV
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| MG Medication administration | administer medications 30 - 60 minutes BEFORE meals to help with chewing and swallowing
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| Orthopedic overuse | Keyboarding and Other repetitive joint actions
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| Bursitis | Inflammation of the fluid filled sacs that prevent friction between bones in joints
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| Tendonitis | Inflammation of the tendon sheaths and the synovial membrane
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| Bursitis and tendonitis treatment | prolonged rest, intermittent ice and heat, NSAIDs
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| Carpel Tunnel Syndrome | Irritation and Inflammation of the medial nerve
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| Carpel Tunnel Treatment | Rest in neutral position
Cockup splints (especially at hs)- Wrists in neutral position
NSAIDS
Surgery if risk of permanent nerve damage or extreme pain
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| Ganglion Cyst | "Bible bumps" - forms at the dorsum of the wrist usually resulting from chronic overuse irritation. Tx = stop activity and possible surgery
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| Epicondylitis (tennis elbow) | Pain radiates to dorsal, extensor surface of the forearm, NSAIDS and rest = treatment of choice
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| Effects of Chronic Immobility | Pneumonia, DVT, pressure ulcers
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| Immobility | Can produce degenerative changes. Caused by nonuse, lack of exercise, pain, weakened muscles, joint contractures (takes 24-48 hrs to develop), prolonged bed rest, and incorrect positioning in bed
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| Preventing immobility | MOVE! (PT and OT can help), correct full turning, isometric exercises, ROM
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| Deep Tissue Injury | Blue to deep bruising that you cannot tell whether the skin has been eradicated or not (patient’s who have fallen and laid in the same position for a period of time). Unable to be staged (usually found to be greater than a 4th stage pressure ulcer)
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| Rehab of immobility | begins the instant nurses begin working with someone who has an immobility issue. Move what can be moved and do it often
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| Joint Strains | Injury to a muscle or muscle and tendon
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| Strain Treatment | Rest with moderate movement
NSAIDS
Analgesics
Apply ice and elevate
Ace bandage
No heat in the first 24 hours
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| Joint Sprains | Twisting injury to ligaments. Usually involves stretching and tearing of ligaments
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| Dislocation or subluxation of joints | Pain with movement. Both require reduction and may require conscious sedation
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| Rotator Cuff Tear | Tear in 1 or more of the SITs muscles, + drop test, Tender AC joint, unable to perform over the head activities, MRI needed, NSAIDS and possible surgery
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| Torn Ligaments | Tear = higher risk in girls, causes knee instability issue, pain and loss of functions, rest, NSAIDs, and surgery.
Prevention = 4 point knee muscle exercises
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| Meniscal Tears | 2 crescent shaped cartilage discs attached to head of the tibia, allows knee to bed without pain, knee may "give away", loose cartilage may become trapped preventing extension, Rest NSAIDs and surgery
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| Osgood-Schlatter disease | Painful swelling of the bump on the upper part of the shinbone, just below the knee (tibial tubercle).
Thought to be caused by small injuries due to repeated overuse before the area has finished growing. Affects boys more than girls
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| Ruptured Achilles | May occur suddenly, common in runners especially those that don't warm up. Sharp pain with inability to plantar flex, surgical repair and a cast (long term immobility of joint). Will never get back to 100%
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| Fractures | Open or closed, complete or imcomplete, simple or compound, stable or unstable
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| Most dangerous fracture | Open compound (r/t infection)
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| Oblique fx | 45 degree angle
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| Spiral fx | curves up or down the bone
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| Greenstick fx | broken on one side - bone looks bent. Incomplete stable fracture
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| FX treatment (medication) | NSAIDs/ Prostaglandins, morphine, possible surgery
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| Prostaglandins | produced with the help of an enzyme called cyclooxygenase (AKA as Cox).
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| FX treatment (ortho) | Splints to avoid joint movement, crutches to avoid weight bearing, canes to limit weight bearing
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| FX ER management | RICE, if open - cover with sterile dressing, stop bleeding, check pulses, splint
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| Traction for fx | helps maintain alignment and reduce muscle spasms
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| Pt in traction reports severe pain from muscle spasms | Check body alignment
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| Bucks Traction | Decrease spasm, hip fractures
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| Russell's traction | Buck;s with a double pulley and knee sling
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| Bryant's traction | for children with a fractured femur
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| Pelvic traction | helps with muscle spasm (back and pelvic fx)
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| Skeletal traction | pins/external fixation
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| Electrical stimulation | used in fx that are not healing appropriately, can be internal or external
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| Pin care | sterile supplies but clean procedure. Site can be covered with a 4x4 but is not needed if the area is dry
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| Casting | rigid immobilization device applied after swelling as past peak point (usually 72 hrs)
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| Plaster Cast | 48 hrs to dry and must be kept dry
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| Fiberglass cast | 1 hr to dry and may blow dry if it gets wet (no more than 10 min on low heat)
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| Nursing priorities in cast care | Distal vascular checks (swelling), distal neuro checks (sensation and motion), checking for hot spots indicating infection or possible cast compression
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| Rib fractures | Biggest issue is pain and the ability to deep breathe. No use of restrictive devices, pillow used for splinting with coughing
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| Flail chest | nonsymmetrical chest with breathing. Highly unstable chest wall that interferes with ability to ventilate. may require ventilator and PEEP.
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| Complications of fx | Hemorrhage, infection, mal/non/dys alignment, compartment syndrome, DVT, gangrene, fat emboli,
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| Compartment syndrome | Muscle pressure builds up too much and the blood supply is impeded and the muscles do not get adequate oxygen
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| Forearm Compartments | 2
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| Thigh Compartments | 3
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| Lower leg compartments | 4
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| Compartment Syndrome s/s | deep, throbbing, unrelenting PAIN
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| Volkman’s Contracture | Contractured wrist and fingers of affected hand – secondary to impaired arterial blood flow
Unable to extend fingers
Diminished color, temperature, and pulsations distally
Permanent damage in hours if arterial circulation not restored
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| Amputations | Surgical removal of all or part of a limb.
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| Diabetic foot amputation | Partial sims - best type of amputation to get because the patient can still walk (with a stump sock on)
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| Stump Care | Elevate, ACE, Clean and DRY surgical wound, encourage movement of affected limb, monitor drainage pain and infection, stump sock after dressing comes off. Goal is to keep the limb health for fitting of prosthesis.
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| Disorders of the back | Pain or discomfort associated with the actual vertebral column, the nerves emanating from within the vertebral column, and, or the muscles articulating with the vertebral column.
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| Low back pain | L4-5 and L5-S1
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| Low cervical region pain | C2-5 is most common
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| Back strain | twisting, bending, and lifting
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| Acute sharp pain | muscular
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| burning and sharp pain | nerve involvement
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| dull and aching pain | chronic issue
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| Sciatica or radiculopathy | pain that radiates down one or both legs
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| Back pain management | Focused on history and physical. Pt is treated symptomatically for up to 4 weeks (rest and relaxation, analgesics, stress reduction, muscle relaxants), no heavy lifting, NSAIDs, Medrol dose pack for anti-inflammatory, heat and cold therapy
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| Back pain may be self limited | 40% remit in one week
60 -80 % remit in 3 weeks
90 % remit in two months
May be chronic (up to 3 mo)
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| Degenerative Disk Disease | May be injured by trauma and/ or wear and tear disorders that cause the nucleus pulposus to herniated through the annulus
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| Degeneration and/or herniation of intervertebral discs | Discs become more fibrous with age because of wear and tear
L4 to S1 most common sites
Cervical vertebrae the 2nd most common site
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| Back pain diagnosis | MRI = diagnostic tool of choice, myelogram, EMG possibility
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| Medical Management: Cervical Neck | Non-operative, rest, cervical collar, pain management, possible traction
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| Discectomy | Removal of the disc. May be donw with spinal fusion
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| Laminectomy | Removal of boney processes that allows the visualization of the nerves and the removal of pathology
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| Hemilaminectomy | Removal of the lamina and part of the vertebral arch
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| Foraminotomy | Increasing the space in the intervertebral foramen to allow more space for the nerve
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| Nursing Management: Neck | Cervical Discectomy and fusion, neck collar, bedrest, immobility of neck, pillow under shoulders and head, log rolling, routine dressing care (do not change)
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| Bone Cancer | Malignancy within bone structure. Metatstatic is most common. CT, MRI, labs - Hypercalcemia is commonly found because of bone breakdown.
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| Hypercalcemia | weakness, incoordination, anorexia, n/v, short QT and ST, bradycardia, LOC changes
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| Osteoarthritis/DJD | Chronic, progressive degeneration of the hands and weight bearing joints such as the knee, hip, and lumbar vertebrae.
Most common disorder of joints
Causes chronic join pain especially with early movement
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| Rheumatoid Arthritis | A connective tissue disorder
Inflammatory based arthritis
Autoimmune response occurs in the synovial fluid
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| Osteoarthritis Risk Factors | Over 40, obesity, wear and tear, trauma, congenital, inflammatory, poor posture, prolonged steroid use
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| Osteoarthritis Goals | Prevent disease or halt progression, maintain joint mobility, prevent deformity, reduce pain
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| Osteoarthritis joint pain | deep aching pain, especially upon wakening, limited ROM, improves with movement, related to temperature. Joint stiffness usually lasts less than 30 minutes
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| Rheumatoid Arthritis Joint pain | swelling, warmth, erythema, bilateral and symmetric. Joint stiffness > 30 minutes
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| Heberden’s Nodes | hard nodules or boney swellings around the distal interphangeal joints - late stages of OA
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| Bouchard’s Nodes | Similar to Heberden’s but develop around the proximal interphangeal joint
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| OA and RA diagnosis | X-rays, lab tests (inflammatory indicators: ANA, ESR, CRP)
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| OA and RA prevention | maintain normal weight, physical activity, minimal wear and tear
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| OA Management | No cure - goal is to stop progresion. Pain management: tylenol, NSAIDs
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| Cox 1 | Ibuprofen, Advil
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| Cox 2 Inhibitors | Celbrex
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| Joint replacement | Need for joint replacement commonly associated with mobility, pain and/or stability issues secondary to Osteoprosis, OA, RA, Fx, trauma
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| Hip replacement | Removal of the head of the femur followed by placement of a prosthetic implant of the head of the femur and/or socket
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| Knee Replacement | Replacement of knee joint with femoral (distal) component and tibial component
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| Complications of joint replacement | infection, hemorrhage
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| Hip Dislocation Prevention: Posterior Surgical Approach | worry more about dislocation. NO internal rotation, do not adduct hip past midline, do not sit on low chairs, lean forward, or put on shoes without extension equipment
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| Hip Dislocation Prevention: Anterior Surgical Approach | Greater chance for them to have hemorrhage because of vessel location. No external rotation, do not flex hip greater than 90 degrees, don't sit on low chairs or lean forward while sitting. Do not raise knee higher than hip, don't pivot on involved leg
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| Hemorrhage r/t joint replacement | Joint replacements commonly lose a lot of blood - Surgeons will often have patients donate their own prior to surgery: Autologous - Can only donate 2 units within a 59 day period. Monitor VS, drainage, and H & H
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| Neurovascular Compromise | Assess color, temperature, and movement. Monitor for swelling and/or deep throbbing unrelenting pain, pain with movement
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| DVT | Assess for pain, swelling, temperature changes. TEDS - remove no more than 1 hour tid. SCDs
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| Time line for complications | Wrong Move (disslocation) - anytime
Wind (pneumonia) - 48 hrs
Water (UTI/Bladder)- 48 to 72 hrs
Wound (Infection)- 72 to 96 hrs
Walk (DVT)- 72 to 120 hrs
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| Osteoporosis | A metabolic, age related bone disorder in which bone demineralization causes decreased bone density, bone loss, decreased bone mass, and bone weakening
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| Primary Osteoporosis | More in women
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| Secondary Osteoporosis | More in men r/t steroids and smokers
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| Osteoporosis Goals | prevention of bone loss, deformity and complications, and fractures
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| Osteoporosis Assessment | loss of height, low back pain, kyphosis, pathologic fractures (wrist, hip, vertebral)
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| Osteoporosis Prevention | Adequate calcium, vitamin d, and protein, weight bearing exercise, avoid ETOH, caffeine, and smoking, HRT
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| Osteoporosis Diagnosis | Decrease in serial height, DEXA scan, spot scans, labs (Ca, Vit D3, Ph, alkaline phosphatase)
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| Osteoporosis Management | Encourage regular weight bearing exercises (walking, biking, low impact aerobics)
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| Bishosphonates | inhibit osteoclast function thus suppressing bone loss. Fosamax, Boniva, Calcitonin, Reclast, selective estrogen receptor modulators, parathyroid hormone agonist, biophosphate. Medications can be given daily
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| Fosamax | once a week, sitting or standing up 30 min
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| Boniva | Once a month, sitting or standing up 30 min
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| Calcitonin | Daily nasal sprain then IM/SQ
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| Reclast | IV once a year
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| Selective estrogen receptor modulators | Evista
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| Parathyroid Hormone Agonist | Forteo
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| The nurse is reviewing a prescription for a pt receiving drug therapy for the prevention of osteoporosis and the Pt has HTN | the nurse should question a prescription for hormone replacement therapy
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| Systemic Lupus Erythematosus | An auto immune disorder that results in an exaggerated production of autoantibodies. Characterized by exacerbations and remissions
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|
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| SLE symptoms | vague symptoms: x-rays to rule out arthritis, labs and endocrine studies r/t weight loss, weakness….play the rule out game to properly diagnose
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| SLE skin | Butterfly rash across the face, papules, erythema, purpura, sensitivity to sunlight
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| SLE Diagnosis | history and physical. Blood tests revealing anemia, thrombocytopenia, leukocytosis or leukeopenia, positive ANA (antinuclear antibodies), urine to see if there is any hematuria
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| SLE treatment | no cure - supportive treatment. NSAIDs and Corticosteroids (single most important medication - need to check BS, they mask infection), immunosuppressive agents (reserved for the most seriously ill patients)
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| Vagnintis | vaginal discharge, may be watery or thick, cottage cheese appearance, itching redness, and irritation
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|
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| Gardnerella vaginalis | Fish like odor, plated or glitter cells
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|
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| Oral Candidiasis | oral lesions. redness, pain, common after inhaled steroid use and chemo. Give nystatin
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| The nurse is performing an oral assessment on a pt and notes white-plaque-like lesions on the tongue, palate, pharynx, and buccal mucosa. When patches are wiped away the underlying surfaces are red and sore. What disorder does the nurse suspect? | candida albicans
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| HIV | a retrovirus that invades certain lymphatic cells such as helper T cells or CD4 cells (cell wall receptor cells) and macrophages and leads to their destruction and ultimately loss of effective immune functioning.
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| AIDS | a wasting syndrome resulting from HIV infections that is characterized by immune system failure
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|
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| B cells | offer humoral (Body fluid/blood) immunity and are antibody producing
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|
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| T cells | offer cellular immunity and directly attack viruses and other invaders
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|
||||
| Stem cells from bone marrow | migrate to the thymus where they are converted to T cells
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|
||||
| Helper Ts | react to antigens and activate the immune system; T cells secrete cytokines that attract and activate B cells
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|
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| seroconversion | Once the HIV infection occurs and despite the virus being inactive antibodies are formed against it. Go from HIV (+) to (-)
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|
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| Classification/Stages of HIV/AIDS | Once the patient reaches a particular level or category he/she stays in that category
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|
||||
| Primary Infection (Acute HIV infection) | The point from infection to the development of antibodies to HIV
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| viral set point | the balance between HIV and the body’s response to it. The higher the viral set point the poorer the prognosis.
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|
||||
| HIV Asymptomatic (CDC Category A) | Virus present but in low enough levels that it does not cause sx except for persistent lymphadnopathy. Focus on maintaining health and good defense responses.
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|
||||
| HIV Symptomatic (CDC Category B) | Symptoms begin to arise (treat the symptoms). Immunocompromised, fever, diarrhea, hairy leukoplakia, thrombocytopenic purpura
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|
||||
| AIDS (CDC Category C) | Virus infection is now considered full blown AIDS. Symptoms expand and entitlements begin
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|
||||
| HIV/AIDS diagnosis | Often not diagnosed until viral load is high and symptoms are advanced. Requires several screenings.
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|
||||
| Ora Quick Rapid HIV-1 test | Uses less than a drop of blood is much more rapid, which allows for earlier intervention and education. Tests the progression of HIV into AIDS
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|
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| HAART (combination therapy) | a regimen consisting of two antiretroviral agents inhibitors plus a protease inhibitor OR two protease inhibitors and one antiretroviral agent (2 and 1). Antivirals and Protease inhibitors
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|
||||
| HIV/AIDS nursing management | Supportive approach by body systems symptoms and stage. Emotional support, education, and social stigma and confidentiality.
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|
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| Snellen Alphabet/Chart | Numerator = the distance between the patient and the chart
Denominator = the distance from which a person with normal vision could read the lettering
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|
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| Low Vision – Blindness | a general term describing visual impairment that requires patients to use devices and strategies (magnifying glass) in addition of corrective lenses to perform visually based tasks
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|
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| Best Corrected Visual Acuity (BCVA) | 20/70 - 20/200
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|
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| 20/80 to 20/100 | still be able to read at near normal levels with optic aids
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|
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| 20/200 t0 20/400 | may be able to read slowly with optical aids
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|
||||
| loss of visual light perception | BCVA that does not exceed 20/200 in the best eye and a widest visual field diameter of 20 degrees or less
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|
||||
| Blindness causes | diabetic retinopathy, macular degeneration, glaucoma, cataracts, aging
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|
||||
| Blindness management | Visual aides for magnification and vision enhancement, orientation to and frequent scanning of environment, using a clock for placement
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|
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| Impaired vision | decreased ability to see objects clearly. refractory or nonrefractory
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|
||||
| Refractory: Hyperopia | Inability to see NEAR objects clearly because of a failure to accommodate - Light focuses in front of retina. Most common (Far sighted)
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|
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| Refractory: Myopia | Inability to see DISTANT objects clearly because of a failure to accommodate - Light focuses behind the retina. Most common in children (Near sighted)
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|
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| Refractory: Presbyopia | Natural loss of accommodation caused by changes in lens accommodation (usually hyperopic in nature)- Poor near vision, Almost 100% of 60 year old require glasses
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|
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| Refractory: Astigmatism | Curvature issues in the lens or other part of the optic apparatus that results in a refractive error- Easily corrected
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|
||||
| Refractory: Anisometria | Different refractory errors in each eye. May be congenital or acquired.
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|
||||
| Nonrefractory: Retinal disorders | degeneration, tears, detachments, hemorrhages
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|
||||
| Nonrefractory: Glaucoma | A group of ocular disorders characterized by increased intraocular pressure that if unresolved will result in damage to the optic nerve and microinfarction causing loss of visual field
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|
||||
| Glaucoma | May be open angle or closed angle - 3rd leading cause of blindness in the US
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|
||||
| Primary Open Angle Glaucoma (POAG) | Is a primary issue of angled tissue in the anterior chamber that results in resistant flow of the aqueous humor - Most common form
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|
||||
| Primary Angle Closure Glaucoma (closed angle) | Resistance/blocking of aqueous humor between the posterior surface of the iris and lens, which places pressure against the pupil close proximity to the pupil - Rare, constitutes a medical emergency
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|
||||
| Cataracts | A decrease in transparency of the lens that interferes with visual acuity, protein coagulations cause the formation of opaque areas in the lens
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|
||||
| Macular Degeneration | results in loss of central vision, usually in older adults - gradual onset
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|
||||
| Strabismus | deviation from symmetrical movement. AKA Tropias
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|
||||
| Esotrophic | crossed eyed
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|
||||
| Exotrophic | deviates outward
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|
||||
| Hypertrophic | deviates up
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|
||||
| Hypotrophic | deviates down
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|
||||
| Conjunctivitis | Acute injection or redness of the conjunctiva. May be viral (watery drainage), bacterial(muco-purulent drainage), allergic (watery drainage).
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|
||||
| Eye trauma | occurs as the result of blunt or penetration injury because of foreign bodies, chemicals, lacerations, blunt force trauma, traumatic enuculation, chronic eye dryness
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|
||||
| Presbyopia | Progressive decrease in near vision - may still have 20/20 vision, requires reading glasses, usually after age 40
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|
||||
| Open angle glaucoma s/s | silent in early stages, bilateral, mild to dull ache, halos around lights, blurred vision, loss of visual acuity is not corrected by glasses, headache
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|
||||
| Closed angle glaucoma s/s | ACUTE - rapid onset, unilateral pain, conjunctivitis, cloudy cornea, photophobia, blurred vision
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|
||||
| Cataracts s/s | decreased visual acuity, glare, distorted vision, altered color perception
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|
||||
| Retinal detachment s/s | flashing lights, veiling (most common), floaters
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|
||||
| Fluorescence tape and a Wood Lamp | ascertain abrasive trauma - Paper tape with orange dye that stains the abrasion green so it is easier to see
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|
||||
| Ear infections: external canal | otitis externa - more in swimmers
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|
||||
| Ear infections: inner ear | otitis media - more in kids
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|
||||
| External Otitis | Inflammation of the external canal. Pain and fullness, pain when lifting up the pinna, yellow/green foul smelling discharge, canal is red and edematous
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|
||||
| Cholesteatoma | In growth of skin, debris that leads to chronic infection of the mastoid bone and possible the inner ear
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|
||||
| Otitis Media | Acute infection of the inner ear. Complication of URI, sinusitis, tonsillitus, allergic rhinitis. Usually short term. Otalgia, fullenss, fever, hearing loss
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|
||||
| Meniere’s Disease | Abnormal fluid in the inner ear. May be vestibular or cochlear. Usually unilateral.
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|
||||
| Meniere’s Disease: Cochlear | sensoineural hearing loss, tinnitus
🗑
|
||||
| Meniere’s Disease: Vestibular | extreme vertigo, n/v
🗑
|
||||
| Meniere’s Disease Management | low Na diet, antihistamines, antiemetic, diuretics
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|
||||
| Vertigo | Eyes get very big when changing positions to try to stop themselves if they are spinning. Patient has to get used to it because there is no cure
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|
||||
| Hearing Loss | 3rd most common disorder above 65. Can be conductive or sensoinural.
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|
||||
| Conductive hearing loss | Loss of sound conduction from the external and middle ear to the inner ear
🗑
|
||||
| Sensoineural hearing loss | Hearing loss related to impaired function of the inner ear, primarily the cochlea and CN VIII
🗑
|
||||
| Weber test | Bone conduction to test for lateralization of sound.
Conductive loss will lateralize to the affected ear
Sensorineural loss will lateralize to the better ear
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|
||||
| Rinne test | Bone and air conduction timing test
Usually air conducts longer and louder than bone
Conductive loss BC ≥ AC
Sensorineural loss AC > BC
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|
||||
| Skin layers | Epidermis, Dermis, Subcutaneous layer
🗑
|
||||
| Skin assessment equipment | strong direct lighting, small centimeter ruler, penlight, gloves, special procedures: wood's light and magnifying glass
🗑
|
||||
| Koilonychia | anemia
🗑
|
||||
| Paronychia | inflammation of surrounding tissue
🗑
|
||||
| Leukonychia | related to trauma
🗑
|
||||
| Clubbing | COPD
🗑
|
||||
| ABCDE rule | Asymmetry, border, color, diameter, elevation
🗑
|
||||
| Macule | flat
🗑
|
||||
| Papule | raised <.5cm
🗑
|
||||
| plaque | cirrhosis
🗑
|
||||
| nodule | little bumps that feel hard
🗑
|
||||
| urticaria | hives
🗑
|
||||
| vesicle | <.5cm, small pox or chicken pox. raised and fluid filled
🗑
|
||||
| bulla | > .5cm. raised fluid filled lesion
🗑
|
||||
| pustule | raised lesion with puss in it
🗑
|
||||
| crust | impetigo
🗑
|
||||
| scale | cirrhosis
🗑
|
||||
| fissure | cracks
🗑
|
||||
| erosion | pressure ulcers
🗑
|
||||
| ulcer | stages 1-3 and unstagable
🗑
|
||||
| excoriation | children and older people who do not have their diaper changed
🗑
|
||||
| Primary lesions | macule, papule, patch, plaque, nodule, wheal, tumor, uticaria, vesicle, cyst, bulla, pustule
🗑
|
||||
| Secondary lesions | crust, scale, fissure, erosion, ulcer, excoriation, scar
🗑
|
||||
| Open Comedones | blackheads
🗑
|
||||
| Meningococcemia | Petechiae, purpura, ecchymoses
Child appears ill, hypotensive, and tachycardic
🗑
|
||||
| Rockey Mountain Spotted Fever | Maculopapular to petechial. Rash appears on the thenar eminence and flexor surfaces of the wrist and ankles. Palms and soles are usually affected
HA, myalgia
🗑
|
||||
| Stevens-Johnson Syndrome (SJS) | Vesicles to bullae. More shallow that SJS and TEN
Child appears less ill that with SJS and TEN Positive Nikolsky sign – skin reddens, fluid collects underneath, and the skin rubs off leaving a raw base
🗑
|
||||
| Malignant Skin Lesions | use ABCDE rules of examination
🗑
|
||||
| Beau’s line | Transverse furrow or groove across the nail that extends to the nail bed. Occurs with any trauma that temporarily impairs nail formation, such as acute illness, toxic reaction, or local trauma.
🗑
|
||||
| Habit-Tic Dystrophy | Depression down middle of nail or multiple horizontal ridges. Due to continuous picking of cuticle by another finger of same hand, which causes injury to nail base and nail matrix.
🗑
|
||||
| Burns | an alteration in skin integrity resulting in tissue loss or injury caused by heat, chemical, electrical or radiation
🗑
|
||||
| Dry heat | burn
🗑
|
||||
| moist heat | hot water
🗑
|
||||
| chemical burn | battery acid
🗑
|
||||
| electrical burn | a/c and d/c
🗑
|
||||
| radiation burn | gamma, beta
🗑
|
||||
| First-degree burn | superficial, involves only the epidermal layer, never blisters, heals spontaneously
🗑
|
||||
| Second-degree burn | dermal partial thickness, involves epidermal and dermal layers, pink moist and painful, gets blisters
🗑
|
||||
| Hand burns | bad due to loss of functionality
🗑
|
||||
| Third-degree burn | full thickness, nerve, muscle, and tendons, involves epidermal, dermal, subcutaneous layers and nerve endings. Formed eschar on skin
🗑
|
||||
| First-degree burn presentation | erythema, edema, painful, blanching
🗑
|
||||
| Second-degree burn presentation | very painful, ooxing, erythema, shiny, wet
🗑
|
||||
| Third-degree burn presentation | eschar, edema, white or charred, little or no pain
🗑
|
||||
| Immediate or Emergent Phase | Resuscitative stage lasts from the onset of injury through the successful fluid resuscitation – Stabilization. Determination whether to transport patient to a burn center - family travel is not considered
🗑
|
||||
| Estimation of Burn Size | Fluid amounts are calculated using the % of body burned. Rule of Nines - Divides teh TBSA into areas - best for adults and children over 10
🗑
|
||||
| Rule of Nines | face = 9%
arms (shoulder through fingers) = 9% each
front of body = 18%
back of body = 18%
legs (front and back) = 18% each
Perineum = 1% each
🗑
|
||||
| Consensus Formula | 2-4 mL x kg of body weight x % TBSA burned. Half is given in the first 8 hours then the next half given over 16 hours.
🗑
|
||||
| Acute or Intermediate Phase | begins 48-72 hours after a burn injury. continue to reassess respiratory and CV status, F&E, and nutritional status. Pharmacological therapy and wound management
🗑
|
||||
| Rehabilitative Phase | most costly and longest phase. Must be interdisiplinary.
🗑
|
||||
| Burns Blood Chemistry | Increased K, Decreased Na, total protein, and decreased albumin
🗑
|
||||
| Burn Hematoloty | Increased HGB and HCT, decreased fibinogen, platelets, and WBCs
🗑
|
||||
| Burns Assessment | Assess airway, breathing, and circulation, neck and face burns need to be intubated immediately, give O2, check for signs of shock, establish 2 large bore IVs (14 or 16), determine history of injury (AMPLE)
🗑
|
||||
| Transferring burn patient | do not apply creams, family travel is not considered, and a physician must call the burn center and speak to the physician to get the patient transferred
🗑
|
||||
| Nurse's role in transferring a burn patient | make sure paperwork is complete and goes with pt, and give the nurse receiving the pt a complete report.
🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
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You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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