NUR 2480 FINAL EXAM REVIEW

Final Exam. Sickle Cell Anemia Inheritance by: African decent & Hispanic Triggers: Dehydration/Cold weather/Infection/ Low oxygen Treatment: HOPV (Hydration/Oxygen/Pain killers/Vasodilator) No Meperidine Warmth, avoid cold Ischemia: Increase lactic acid. 50- Vaso-occlusive sickle cell crisis - Treatment, safety, side effects, risks, complications Crisis Management: Use the acronym HOP when prioritizing care for vaso-occlusive crisis: − Hydration − Oxygen − Pain Management Nursing Interventions: − Monitor Oxygenation status − Monitor hydration; calculate fluid requirements and ensure intake exceeds minimum. − Apply warm compresses to painful joints, avoid cold compresses. Monitor and measure size of the spleen, bed rest to conserve energy SLE systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. Like RA, it is characterized by spontaneous remissions and exacerbations (“flare-ups”), and the onset may be acute or insidious (slow). The condition is potentially fatal, but most patients with SLE live many years after diagnosis and lead productive lives. Patient Education for SLE Instruct patients to avoid prolonged exposure to sunlight and other forms of ultraviolet lighting, including certain types of fluorescent light. Remind them to wear long sleeves and a large-brimmed hat when outdoors. Patients should use sun-blocking agents with a sun protection factor (SPF) of 30 or higher on exposed skin surfaces. Medication for SLE 1. Choline magnesium trisalicylate 2. NSAIDs- Acetaminophen (Tylenol) or NSAIDs may be used to treat joint and muscle pain and inflammation 3. Hydroxychloroquine- Hydroxychloroquine decreases the absorption of ultraviolet light by the skin and therefore decreases the risk for skin lesions. Teach patients to have frequent eye examinations (before starting the drug and every 6 months thereafter) if they are receiving hydroxychloroquine. 4. Corticosteroids- topical cortisone preparations help reduce inflammation and promote fading of the skin lesions. When patients are taking steroids and/or immunosuppressants, stress the importance of avoiding large crowds and people who are ill. NI for SLEwhat are Nursing Implementation for Systemic Lupus Erythematosus? 1. Encourage maintenance of activity 2. Pace activities 3. Hot packs for joint pain/stiffness 4. Raynaud's: warmth and protect from injury 5. Support self image 6. Adequate rest 7. Avoid infectious people Isolation Precautions Severe Acute Respiratory Syndrome (SARS) – Interventions, Isolation Respiratory illness caused by a coronavirus, called SARS-associated coronavirus. The syndrome begins with a fever, an overall feeling of discomfort, body aches, and mild respiratory symptoms. Prevention: − Avoid contact with those suspected of having SARS − Avoid travel to countries where an outbreak of SARS exists. − Avoid close contact with crowds in areas where SARS exists − Frequent hand washing if in an area where SARS exists. - Standard, Contact and Airborne Precautions/N-95 pressure room. - **SARS (severe acute resp syndrome) airborne + contact (just like varicella) Airborne barrier protection- standard precautions; private pressure, negative pressure airflow of at least 6-12 air exchanges per hour via HEPA filtration; mask or respiratory protection device Droplet precautions-droplet larger than 5 microns; being within 3 feet of patient; diphtheria (pharyngeal); rubella; streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children; pertussis; mumps; mycoplasma pneumonia; meningococcal pneumonia or sepsis; pneumonia plague Droplet barrier protection- standard precautions; private room or cohort patient; refer to facility policy for cohorting patients; mask or respirator is required; refer to facility policy Contact precaution- direct patient or environmental contact; colonization or infection with multidrug-resistant organisms, such as VRE and MRSA, Clostridium difficile, or respiratory syncytial virus; draining wounds if secretions are not contained; scabies contact barrier precautions- standard precautions; private room or cohort patients; refer to the facility policy for cohorting patients, gloves, gowns Protective precautions- allogeneic hematopoietic stem cell transplantation Delegation and Management of care/ Priority Delegation Description -Delegation is assigning a specific nursing task to an individual who has the education, skill, and experience to perform that task. -Outcomes are achieved through the sharing of activities with others who have the experience to carry out these tasks. -The nurse practice act and any practice limitations (e.g., agency policies and procedures) define which aspects of care may be delegated and which must be performed by the registered nurse. -Even though a task may be delegated to someone else, the nurse who delegates maintains accountability for the overall nursing care of the client. -Only the task, not the ultimate accountability, may be delegated to another. Remember the “five rights” of delegation: right task, right circumstances, right person, right direction or communication, right supervision or feedback. Review calculations- Desired Dose x vehicle/ dose on hand Tetralogy of Fallot- four cardiac defects: ventricular septal defect (VSD), right ventricular outflow tract obstruction (pulmonary stenosis), right ventricular hypertrophy, and dextroposition of the aorta, with overriding of the VSD. } Tetralogy of Fallot – Four defects that result in mixed blood flow: Pulmonary stenosis - Ventricular septal defect - Overriding aorta- Right ventricular hypertrophy } Signs and Symptoms:  Cyanosis, severe dyspnea, clubbing of the fingers, hyper-cyanotic spells, and acidosis  Murmur, polycythemia, and clot formation  Child frequently assuming a squatting position (decreases venous return)  Failure to thrive and growth retardation GTPAL • G -- Gravity • T – Term births • P – Preterm births • A – Abortions or miscarriages • L – Current living children Example: A woman is pregnant for the 4th time. She had 1 elective abortion in the first trimester, a daughter who was born at 40 weeks’ gestation, and a son who was born at 36 weeks’ gestation. She is gravida (G) 4, parity (number of births carried past 20 weeks) 2, and term (T) 1 (the daughter born at 40 weeks): preterm (P), 1 (the son born at 36 weeks); abortion (A), 1 (the abortion is counted in the gravidity, but is not included in the parity because it occurred before 20 weeks); living children (L), 2. Shock Syndrome signs and symptoms, NI What are the 3 main stages of shock?- Stage 1. COMPENSATION STAGE - the initial stage in which the body tries to compensate for loss of volume by raising the heart rate Stage 2. DECOMPENSATION STAGE - the body, working very hard is losing it's ability to compensate and supply oxygenated blood to vital organs - URGEN INTERVENTION REQUIRED Stage 3. IRRVERSIBLE STAGE - irreversible cellular damage from prolonged shock occurs Types of Shock?  Cardiogenic - failure of cardiac muscle to pump A group of complicated symptoms associated with severe left ventricular failure causing; - diminished tissue perfusion - impaired cellular metabolism, which result to poor cardiac output, hypoxic tissue injury, metabolic acidosis and multiple organ dysfunction  S & S of Cardiogenic shock- 1. vasocontriciton (sympathetic compensatory mechanism) 2. Tachycardia (HR weak, thread) 3. SBP 90 mmHG 4. pallor or cyanosis 5. tachypnea 6. clammy skin 7. decreased urine output 30ml/h 8. cerebral hyoperfusion manifested by agitation, disorientation 9. metabolic acidosis 10. symptoms of HF (distended neck veins) 11. peripheral edema  Managment and *N Care 1. airway management (O2) 2. strict I/O (insert foley cath.) 3. support BP (IV fluids) 4. decrease preload (lasix, dopamine, dobutamine) 5. provide safety measures (side rails up) 2. Hypovolemic - markedly decrease/loss of volume. characterized by rapid loss of circulating fluid volume, either blood or plasma causing inadequate perfusion to the vital organs Diagnostic Tests for Hypovolemic shock 1. CBC 2. electorlyte levels (K, Na, CL, HCO3, creatinine, glucose levels) 3. PT/PTT 4. ABG's 5. urinalysis especially on patient with trauma Symptoms of Hypovolemic shock 1. low bp 2. tachycardia 3. tachypnea 4. cool and clammy skin 5. changes in LOC Tx of Hypovolemic shock 1. AIRWAY MANAGEMENT - to maximize O2 delivery - assess airway; monitor depth and rate of respirations, assess breath sounds for pneumothorax, hemothorax, flail chest 2. control bleeding through surgical procedures 3. FLUID RESUSCITATION - 2 large bore needles must be inserted (gauge #16 or 18) - start isotonic IV fluid (RL and NS); initial bolus, 1-2 L given in adult and or 20 mL/kg in ped - if not responding to isotonic fluids, give blood transfusions or other crystalloids - synthetic colloids (hetastarch, pentastarch, dextran) have volume expanding properties as they remain in the intravascular space reducing the occurrence of interstitial edema - albumin and fresh frozen plasma are natural colloids Meds for Hypovolemic shock- Vasoconstrictors—Improve mean arterial pressure by increasing peripheral resistance, increasing venous return, and increasing myocardial contractility. Dopamine (Intropin, Revimine) Norepinephrine (Levophed) Phenylephrine HCl 4. POSITION - to improve circulation - Trendelenburg is no longer recommended for hypotensive pt. for it can lead to aspiration of oral secretions and it does not improve gas exchange - side lying position is beneficial especially with pregnant pt. 3. Anaphylactic - severe reaction to foreign protein resulting to profound vasodilation and severe bronchoconstriction Anaphylactic Shock