Nsg 321 Final Exam Study Guide

NSG 321 FINAL EXAM STUDY GUIDE ORGAN DONATION AND TRANSPLANTATION REJECTION • Tissue typing o Recipient receives transplant from an ABO compatible doron o Do NOT need to have same Rh factor o Human leukocyte antigen (HLA) typing on donors and recipients • Teach signs and symptoms of infection and when to contact HCP • Hyperacute Rejection o Antibody mediated (humoral) o Minutes to hours after transplant • Acute rejection o Days to months after transplant o New incisional pain o Monitor BUN, Creatinine (Will be high) ▪ Normal BUN 8-23 ▪ Normal Creatinine 0.51-0.95 • Chronic Rejection o Months-years after transplant o Irreversible • Avoiding rejection o Immunosuppressants for life o Initially wear a mask in public, avoid crowds o Monitor for increased pain o Report temps greater than 99.5 • Graft Vs. Host Disease (GVHD) o Donor T-cells attach and destroy recipients’ cells o 7-30 days after transplant o Pruritis, shredding skin, liver disease, diarrhea, abdominal pain, GI bleed MEDICATIONS • Teach patient about lifelong need for immunosuppressants • Goal of immunosuppressant drugs o Suppress immune response without wiping out immune system o Lifelong balance between rejection and infection • Medications used to prevent rejection o These medications inhibit T-cell production and prevent response from the body that causes organ rejection ▪ Corticosteroids (initially but not for long term use) ▪ Calcineurin inhibitors ▪ Cytotoxic drugs ▪ Monoclonal antibodies ▪ Polyclonal antibodies o Doses of drugs are reduced over time, will have to monitor T-cells o Immunosuppressants increase risk for malignancies ▪ Teach patient to keep appointments and get regular screenings o Corticosteroid related complications ▪ Increase blood sugars ▪ Aseptic necrosis of hips, knees, joints ▪ Peptic ulcer disease ▪ Cataracts DISASTER PREPAREDNESS AND EMERGENCY/TRAUMA SYSTEMS PRIMARY SURVEY VS. SECONDARY SURVEY WITH TRAUMA PATIENTS Primary Survey: ABCDEF Secondary Survey A: Alertness and Airway B: Breathing C: Circulation D: Disability E: Exposure and Environment F: Facilitate adjuncts and Family History and Head to toe Head, Neck, and Face Chest Abdomen and Flanks Pelvis and Perineum Extremities Inspect Posterior Surfaces • Primary Survey o Focuses on airway, breathing, circulation, disability, exposure, facilitation of adjuncts, and family o If uncontrolled external hemorrhage is noted, format may be reprioritized with CABC for hemorrhage o Primary survey aids to identify life-threatening conditions so appropriate interventions can be started • Secondary Survey o Begins after addressing each step of the primary survey and starting lifesaving interventions o Brief, systematic process that aims to identify ALL injuries- not just life-threatening injuries PRIORITIES OF CARE WITH TRAUMA PATIENT • Mass triage o Move: those who can walk, move to green are o Assess: assess the remaining who did not move o Sort: (red [immediate], yellow [delayed], green [minimal], black [expectant]) • Triage o All victims have equal importance (this includes women and children) o Only TWO interventions allowed during triage: ▪ Open and clear airway ▪ Direct pressure to external hemorrhage o Should be no more than 30 seconds/patient • Triage Evaluation: RPM o Respiratory: Check airway and Breathing o Pulses: Check circulation and bleeding o Mental Status: Check mental status • The “Golden Hour” o Critical trauma patients have only 60 minutes from time of injury to reach definitive surgical care or the odds of successful recovery diminish drastically. MASS CASULTY CATEGORIES • Mass casualty incident o Man-made or natural o Overwhelms a community’s ability to respond with existing resources o Require assistance from resources outside of the affected community (American Red Cross/FEMA) • Natural Disasters o Hurricane, tornado, earthquake, tsunami, famine, flooding, landslide • Man-made Disasters o Intentional (Riots, train derailment, terrorism) o Biological Agents ▪ Anthrax (Treated with antibiotics; Vaccine available) ▪ Smallpox (Vaccine available) ▪ Botulism ▪ Plague (antibiotics) ▪ Hemorrhagic fever o Chemical ▪ Sarin (toxic nerve gas; Paralyzes respiratory muscles) • Antidote: atropine and pralidoxime chloride ▪ Phosgene, Mustard gas o Radiologic/Nuclear ▪ Dirty bombs (radioactive material/explosives) • Radiation causes illness to survivors • Measures to decontaminate radiation • Four levels of triage o GREEN: ▪ Walking wounded ▪ Minor injuries ▪ Can provide some selfcare o YELLOW: ▪ Delayed- stable but serious ▪ Status not likely to deteriorate over several hours ▪ In practice questions- patient usually able to talk/lucid o RED: ▪ Critical but savable ▪ Life threatening but treatable injuries ▪ Requires rapid medical attention o BLACK: ▪ Deceased or expected to die ▪ No CPR- comfort measures only CANCER Chemo and radiation treatments/Care for side effects and complications • Chemotherapy → Use of cytotoxic drugs to destroy cancer cells ▪ Combinations of drugs are better than the use of a single drug ▪ Usually given 3-6 months but with metastasis, can be given for life ▪ IV most common → Central venous access (CVAD) “port” may be placed to help avoid multiple venipunctures ▪ Effects of Chemo on normal tissue: o Cannot distinguish between normal or cancer cells → Especially rapidly proliferating cells ▪ Skin cells ▪ Mucosal cells ▪ Cells in GI tract ▪ Hair cells ▪ Drugs can post occupational risk to healthcare worpers who do not follow safe handling guidelines ▪ Some risk of handling body fluids and excretions of people receiving chemotherapy for up to 48 hours o Flush toilet twice o Remove excretions from immediate area ▪ Chemotherapy Bone Marrow Suppression o Risk for infection, hemorrhage, fatigue o Monitor CBC (neutrophil, platelet, RBCs) o Lowest blood cell counts usually seen between 7 and 10 days after starts of treatment (nadir= peak of tx) ▪ Chemotherapy Neutropenia (see below) ▪ Chemotherapy Thrombocytopenia o Low platelet count o Normal 150,000-400,000 o 50,000 severe bleeding risk o Interventions for Thrombocytopenia: ▪ Monitor for bleeding and hemorrhage ▪ Avoid invasive procedures ▪ Teach patients to avoid activities that place them at risk for bleeding ▪ Treat w/ blood transfusions ▪ Chemotherapy Anemia o 3-4 months after the start of treatment o Administer RBC growth factors & Iron supplements ▪ Darbepoetin (Aranesp) & Epoetin (Procrit) ▪ Chemotherapy Fatigue o May persist long after treatment has ended o Caused by anemia, lack of sleep, accumulation of toxic substances, etc) o Encourage rest (but not total immobile) ▪ Chemotherapy Gastrointestinal Side Effects o Nausea/Vomiting ▪ Administer antiemetics 1 hour BEFORE chemotherapy • Metoclopramide (Reglan), Prochlorperazine (Compazine), Serotonin antagonist (Zofran) ▪ Eating a light meal of nonirritating food may be helpful (Crackers, jello, ginger ale, etc.) ▪ Assess for dehydration and metabolic alkalosis o Diarrhea ▪ Low fiber diet: Avoid fresh fruits, veggies, seeds, nuts ▪ Avoid fried, fatty, highly seasoned, or gas producing foods ▪ Antidiarrheals: • Bismuth Sub. (Pepto bismol) • Loperamide (Immodium) • Diphenoxylate with atropine (Lomotil) • Octreotide acetate (Sandostatin) ▪ Encourage fluids & Maintain a poop log o Mucositis ▪ Irritation, inflammation, ulceration of the mucosa (from mouth to anus) ▪ Interventions for Mucositis: • Keep oral cavity clean, moist, free of debris →Frequent oral rinses with saline or salt solution • Avoid irritants: Tobacco, alcohol, spicy foods, acidic foods, extremes in temp • Topical anesthetics for pain: Viscous lidocaine o Anorexia ▪ Peaks around 4 weeks of treatment ▪ Interventions for Anorexia: • Monitor weight & dehydration • Encourage small frequent meals of ↑ protein, ↑ calorie foods • Nutritional supplements (ensure) • Monitor albumin and prealbumin • Megace for appetite stimulation Radiation Therapy and Side Effects • High energy beams that break up chemical bond in DNA, resulting in cell death • Total body radiation in preparation for bone marrow transplantation (or stem cell transplant) • Brachytherapy: *Internal radiation* using radioactive pellets inserted into the body via a catheter • Organ or field specific such as liver or spleen • Usually coupled with chemotherapy ▪ Radiation Therapy Skin Care o Skin in radiation field requires special attention→ Locals, occurs where radiation was o Erythema develops 1-24 hours after treatment DO NOT RUB o Goal: Prevent infection and facilitate wound healing o Do not use heating pads, ice packs, hot water bottles, constricting garments, harsh chemicals, deodorants o Lubricate dry skin with non-irritating lotion that has no metal, no alcohol, no perfume or additives o Calendula ointment and topical hyaluronic acid cream and aloe vera gel are recommended o Wet Desquamation of Tissues (Skin sloughing) → Weeping of serious fluid is seen ▪ Keep tissue clean with normal saline compresses or modified Burrow’s solution soaks ▪ Protect skin with moisture vapor permeable dressings or Vaseline petrolatum gauze Neutropenia (nursing care) • Reduction in neutrophils • Absolute neutrophil count 1,000 • Severe neutropenia 500 o Requires isolation o Body can no longer fight infection → Reduction in WBCs o Serious risk for infection and sepsis • Interventions for Neutropenia: o Screen visitors for infectious disease o Good hand hygiene for everyone o Avoid uncooked meats, seafood, eggs, unwashed fruits and veggies o No fresh flowers in room o Avoid large crowds o Monitor temperature and signs of infection (Report temps 100.4) o Provide WBC growth factors: (filgrastim [Neupogen], Pegfilgrastim [Neulasta] ENDOCRINE DKA: s/s, immediate interventions, medications, hypoglycemia • DKA Signs and Symptoms o Associated with Type 1 Diabetes o Precipitating Factors ▪ Illness, infection, inadequate insulin dosage, poor diabetes management, neglect o Clinical Manifestations of DKA ▪ Dehydration • Poor skin turgor • Dry mucous membranes • Tachycardia • Orthostatic Hypotension • Hypovolemic shock ▪ Lethargy and weakness ▪ Skin dry and loose ▪ eyes soft and sunken ▪ Abdominal pain/ anorexia/nausea/vomiting ▪ Kussmauls respirations ▪ Sweet, fruity breath ▪ Blood Glucose 250 ▪ Blood pH 7.3 (Acidosis) ▪ Serum Bicarbonate 16 ▪ KETONES in urine • DKA Immediate interventions and Medications o Possibly treated at home but hospitalized if severe fluid/electrolyte imbalance o First AIRWAY → Administer O2 o Establish IV access for fluid resuscitation ▪ 0.45% or 0.9% NaCl ▪ ADD 5% or 10% Dextrose when blood sugar approaches 250 to prevent hypoglycemia ▪ Continuous regular IV insulin Drop 0.1 U/kg/hr • This is a high alert med, comes from pharmacy, and will need a second RN and frequent assessment • Insulin also causes potassium to shift out of the circulation and into the cells which causes HYPOkalcemia o Potassium replacements as needed ▪ Use caution with rehydration → can cause cerebran edema if done too quickly • Hypoglycemia o Too much insulin and not enough glucose o Sometimes no symptoms until glucose is critically low o Blood glucose 70 o Manifestations of Hypoglycemia: ▪ Hangry ▪ Shakiness ▪ Palpitations ▪ Diaphoresis ▪ Anxiety ▪ Hunger ▪ Pallor (cool and clammy) • Can present like they’re drunk ▪ Difficulty speaking ▪ Visual disturbances ▪ Stupor ▪ Confusion ▪ Coma ▪ Death ▪ Polyuria/Polydipsia • Hypoglycemia Causes: o Too much insulin o Too little food o Delayed time of eating o Too much exercise • Symptoms can also occur when glucose levels drop too rapidly. The person can still have high glucose by the body shows symptoms of hypoglycemia due to rapid drop (ex. 300 to 180) • Treatment for Hypoglycemia: Rule of 15’s o Consume 15 g of a simple carbohydrate (ex. 4-6 oz of fruit juice) o Recheck glucose in 15 minutes o Repeat if glucose is still 70 o Avoid foods with fat (candy bars, whole milk) because they decrease the absorption of sugar o If glucose is still 70 after 3 times, call HCP o If blood glucose improves, then give a complex carbohydrate • Treatment for Hypoglycemia in Acute care o 50% dextrose 20 to 50 mL IV push or Glucagon 1mg IM or subcue (Turn patient to the side) HHS: s/s, immediate interventions • HHS Signs and Symptoms o Life threatening → Emergency situation → Associated with Type II diabetes o Precipitating factors: UTI, pneumonia, sepsis, acute illness, impaired thirst sensation • HHS Signs and Symptoms Continued: o NO KETONES o Polyuria and Polydipsia o Extreme dehydration o Because there is circulating insulin the blood sugar gets MUCH higher in HHS before its symptomatic o Blood Glucose 600 o SEVERE neurological manifestations from ↑ serum osmolality (dehydration → Blood gets thick) • HHS Immediate Interventions o Almost identical treatment for HHS as DKA except there is no kussmauls in HHS so go straight to IV fluid resuscitation o Establish IV access for fluid resuscitation ▪ 0.45% or 0.9% NaCl ▪ ADD 5% or 10% Dextrose when blood sugar approaches 250 to prevent hypoglycemia ▪ Continuous regular IV insulin Drop 0.1 U/kg/hr • This is a high alert med, comes from pharmacy, and will need a second RN and frequent assessment • Insulin also causes potassium to shift out of the circulation and into the cells which causes HYPOkalcemia o Potassium replacements as needed ▪ Use caution with rehydration → can cause cerebran edema if done too quickly o Correct underlying cause → Possible mismanagement problem o Assess renal status → severe dehydration can cause acute kidney injury o EKG for potassium changes o Level of consciousness because of neurological manifestations ▪ Fall precautions (low bed, side rails, etc) Differences between DKA and HHS Pheochromocytomia: post-op surgical care • Tumor in the adrenal medulla (middle) that excretes excess catecholamines (epinephrine and norepinephrine → Associated with the “fight or flight response”) • Excess catecholamines causes o severe hypertension o pounding headache o Tachycardia o Palpitations o Sweating o Abdominal/chest pain • Avoid palpating the abdomen of a patient with suspected pheochromocytoma, since it may cause the sudden release of catecholamines and severe hypertension. • Pheochromocytoma Pre-Op Care: o Primary treatment is surgical removal done laparoscopically o Treatment with α- and β-adrenergic receptor blockers is required preoperatively to control BP and prevent an intraoperative hypertensive crisis. • Pheochromocytoma Post–op Care: o Routine post-op surgical care o Emphasize the importance of follow-up and routine BP monitoring because hypertension may persist even when the tumor is removed. SIADH: s/s, causes • I like to think IADH for “Increased ADH” → Meaning TOO MUCH ADH • Fluid retentin • SIADH Signs and Symptoms o ↑ ADH o ↓ Urine output o ↑ Body weight o Thirst o Dyspnea on exertion o Fatigue o Muscle cramping o Irritability o Headache o HYPONATREMIA SYMPTOMS → Dilutional hyponatremia caused by fluid retention ▪ Vomiting ▪ Abdominal cramps ▪ Muscle twitching ▪ Cerebral edema ▪ Lethargy ▪ Confusion ▪ Seizures ▪ Coma ▪ Death ▪ Hypertonic saline can be used to treat extreme hyponatremia but it Is a high alert med and must come straight from pharmacy and get second RN → Can cause brain damage (demyelination) ▪ Risk for Seizures and falls → Implement precautions • SIADH Causes o Seen more in older adults o SMALL CELL LUNG CANCER ▪ Produces hormone similar to ADH ▪ Paraneoplastic syndrome o Self limiting with trauma or drugs o Chronic with tumors or metabolic diseases • SIADH Diagnostics o Measure urine and serum osmolality together → Blood will be lower than urine • Nursing Management of SIADH o Strict I & O o Vital signs o Monitor heart/lung for fluid overload o Daily weights o Observe for signs of HYPOnatremia → Headache, seizures, vomiting, decreased LOC o SEIZURE and FALL Precautions o Ice Chips and Sugarless gum for thirst o Supplement diet with sodium and potassium if using loop diuretics • Treatment of SIADH o Fix underlying cause o Avoid medications that stimulate ADH → Opioids, thiazides, antidepressants o Fluid restriction o Lasix (Furosemide) o Hypertonic IV fluids for hyponatremia (see above) DI: s/s, complications • I like to think D for “Decline” → Meaning DECLINE in ADH • Caused by Central (think issues with brain → Brain sugery, head injury, brain tumor, ETC) OR Nephrogenic (Kidneys- There is ADH in nephrogenic but the kidneys are unresponsive to it) • Diabetes Insipidus Signs and Symptoms o ↓ADH o EXTREME Polyuria (2-20 L/day) o Urine Low Specific gravity 1.005 because its ALL water no solutes o Low Serum osmolality o High serum osmolality (295) because of dehydration → Blood becomes thick with solutes o HYPERNATREMIA (145) o Patient drinks A LOT o Nocturia o Tired/Weak o Hypotension, tachycardia → Hypovolemic shock from severe dehydration o CNS Manifestations • Diabetes Insipidus Diagnostic Studies o Water deprivation test o Measurement of DDAVP levels after desmopressin is given • Diabetes Insipidus Nursing Management o Maintain fluid and electrolyte balance → TWO LARGE BORE IVs o Fluids (Oral and IV) o Monitor BP, HR o Monitor intake & Output/weight → Strick I&O and Daily Weights o Monitor specific gravity o Assess for dehydration o For central DI → Give DDAVP o For Nephrogenic DI → Kidneys will NOT react to DDAVP so NO DDAVP ▪ Low sodium diet ▪ Thiazide diuretics ▪ Indomethacin Pituitary: tumors • Hypophysectomy → Surgical removal of tumors of the pituitary gland o Transphenoidal approach o Requires LIFELONG hormone replacement o May use radiation to shrink tumor prior to surgery o Post-Op Hypophysectomy Care: ▪ Monitor for CSF leaks and Epistaxis (Nose bleeds) ▪ Avoid blowing nose, vigorous coughing, sneezing, straining when pooping for 48 hours after surgery ▪ Monitor “Moustache” dressing (Gauze under the nose) for any drainage • Check clear drainage with urine dipstick for protein or glucose • Call surgeon if you see drainage ▪ Frequent neuro checks ▪ Gentle mouth care ▪ NO TOOTH BRUSHING for 10 days → ewww ▪ Monitor for Diabetes Insipidus because of manipulation of the pituitary gland • Report urine output 200 mL/hr • Urine specific gravity 1.005 • Increased sodium levels o CSF Leak → Fluid leak positive for glucose or protein ▪ Increased risk for meningitis ▪ Persistent severe headache ▪ Treated with HOB elevated and bed rest ▪ Persistent leaks may be treated with spinal taps to remove pressure CARE TRANSITIONS AND END OF LIFE Hospice: services involved in hospice care, family presence, coping, pain management 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________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ______ ________________________________________________________________________ _____________ Legal and ethical decisions of patient and families at the end of life ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ___________________ Benefits and barriers of hospice care ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ___________________ Grief and bereavement: models and nursing role to facilitate