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,Hos does HIV attack the body? It attacks the immune system by destroying T-lymphocytes The virus also rapidly
self=replicates
What is so important about T-lymphocytes? T cells help immune system + recognize and fight pathogens
What is another name for T-Lymphocytes? CD4 cells
Why is the CD4 count important? The lower the CD4 count the more damage the virus has done to the body.
What is a normal cd4 count? 500-1500 cells/mm3
What is the normal CD4 count in a client with HIV? Anything at or above 500. Client is considered in good health. If below 500 HIV
has progressed to AIDS.
If a client's CD4 count is below 200, client is at risk for Opportunistic Infections
what?
List some opportunistic Infections -Oral pharyngeal canididal infection (mouth fungus)
-Kaposi's sarcoma (skin cancer)
-Pneumocystis pneumonia
-Cytomegalovirus (blindness)
-Meningitis
What is the goal of HIV medications? To interfere with the virus replicating
The most important medication for HIV/ AIDS is? Zidovudine (AZT, Retrovir)
Which isolation precautions are used with HIV? Universal precautions, patients do not have to tell you they have HIV, treat
everyone as if they are INFECTED!
How do the precautions change with AIDS? If the client has a low CD4 count and is at risk for opportunistic infection
implement private room, reverse isolation, RN wears gown, goggles, and mask
when in direct contact with blood or body fluids.
What are teaching points for parents who have a child clean up body fluid/blood with a 10:1 water/bleach ratio
with HIV get all immunizations except MMR, Varicella and oral poliovirus(live vaccines)
High Calorie High protein diet
gloves when changing diapers.
What is the definition of ACUTE RENAL FAILURE?(ARF) Sudden loss of kidney function to excrete toxins and regulate fluids/electrolytes
What are some possible causes of ARF? Infection, obstruction, shock
What are the three phases of ARF Oliguric, diuretic, recovery
During the Oliguric phase what will you see? This phase lasts one to two weeks.
Low urine output <400
hyperkalemia, hypertension, elevated BUN/creatinine
fluid overload
, What other two electrolytes will be elevated in the Sodium and potassium
oliguric phase of ARF?
The diuretic phase is second in ARF what will you see? Urine output slowly returns, hypokalemia, hypotension, BUN/creatinine decreases
but still elevated.
What does recovery phase mean? Kidneys are recovering through a slow process, urine vl & BUN is normal
What are nursing interventions? ARF Daily weights strict I and O treat the causes of renal failure and diuretics
What is the best diet for a client with ARF? High carb & low protein
Clients allergic to latex may also be allergic to which bananas, kiwi, chestnuts
foods?
What standard hospital equipment contains latex? Blood pressure cuffs, gloves, stethoscopes, tourniquets, band aids, and indwelling
catheters
What allergy is contraindicated for IV contrast dye? iodine/shellfish allergy
What are the major complications of having an Infections, skin breakdown, phantom limb pain, joint contractures
amputation performed?
what is the positioning for post op care? AKA (above the Elevate first 24 hours, then prone position twice daily to prevent hip flexion
knee) amputation
What is the positioning for post op care BKA(below the elevate foot of bed first 24 hours, then prone position twice daily to prevent hip
knee) amputation flexion
What should you encourage with an amputation? Expressing feelings about lost limb
Pain felt in an area that has been amputated Pain felt in an area that has been amputated
True or False? An aneurysm is a dilation formed at a weak True
point on the wall of an artery
What are the symptoms of aneurysms inside the body? most aneurysms inside the body have NO symptoms
what sound would be heard on auscultation of an blowing bruit
aneurysm
what are some of the risk factors of an aneurysm arteriosclerosis, infection (syphilis), smoking, HTN
What is the treatment for an aneurysm? Surgery-depends on size, strict blood pressure control with medications
What are the signs of a ruptured aneurysm? Severe pain, nausea, vomiting, tachycardia, decreased level of conscious,
hypotension