EXAM 4 REVIEW
1. Priority assessment/intervention for a patient who had an allergic reaction to a vaccine
Page 365 chart 20-3
Emergency care of the patient with anaphylaxis
Immediately assess the respiratory status, airway, and oxygen saturation of patients
who show any symptoms of an allergic reaction
Call the RRT
Ensure that intubation and tracheotomy equipment is ready
Apply oxygen using a high-flow, nonrebreather mask at 90% to 100%
Immediately discontinue the IV drug or infusing solution of a patient having an
anaphylactic reaction to that drug or solution. DO NOT discontinue the IV, but
change the IV tubing and hang NS
m
er as
If the patient doesn’t have an IV, start one immediately and run NS
Be prepared to administer epinephrine IV or IM
co
eH w
epinephrine 1:1000 concentration, 0.3 to 0.5 mL IV push or IM
Repeat drug administration as needed every 5 to 15 minutes until the patient
o.
responds
rs e
ou urc
Keep the HOB elevated about 10 degrees if hypotension is present; if BP is normal,
elevate the HOB to 45 degrees or higher to improve ventilation
Raise the feet and legs
o
Stay with the patient
aC s
Reassure the patient that the appropriate interventions are being instituted
vi y re
2. Typical signs and symptoms of an anaphylactic reaction
Page 364 chart 20-2
ed d
Anaphylaxis
ar stu
Clinical criteria 1: onset within minutes to hours of skin or mucous membrane
problems involving swollen lips, tongue, soft palate, uvula; widespread hives;
is
pruritis; or flushing along with any one of these new-onset symptoms:
respiratory distress or ineffectiveness
Th
dyspnea
bronchospasms
wheezes
sh
stridor
hypoxia
cyanosis
peak expiratory rate flow lower than the patient’s usual rate
hypotension or any indication of reduced perfusion resulting in organ
dysfunction
This study source was downloaded by 100000830883196 from CourseHero.com on 09-28-2021 17:47:38 GMT -05:00
https://www.coursehero.com/file/71360710/EXAM-4-REVIEWdocx/
, loss of consciousness
Incontinence
Hypotonia
Absent deep tendon reflexes
Clinical criteria 2: onset within minutes to hours of two or more of these symptoms
after a patient has been exposed to a potential allergen
skin or mucous membrane problems involving swollen lips, tongue, soft
palate, uvula; widespread hives’ pruritis; or flushing
respiratory distress or ineffectiveness as evidenced by any dyspnea,
bronchospasms, wheezes, stridor, hypoxia, cyanosis or peak expiratory
rate flow lower than the patient’s usual
hypotension or any indication of reduced perfusion resulting in hypotonia, or
absent deep tendon reflexes
Persistent GI problems such as NV, cramping, abdominal pain
m
er as
Clinical criteria 3: onset within minutes to hours of hypotension with systolic BP
co
eH w
lower than 90mm Hg or 30% lower than the patient’s baseline systolic pressure
o.
rs e
3. Precautions for an immunocompromised patient with meningitis
ou urc
4. HIV medication regimen and drug resistance are avoided by how much percent
compliance
o
90% compliance book answer
aC s
vi y re
5. Dietary concerns of a patient with HIV/AIDS
Page 354 Enhancing nutrition
ed d
Many patients with AIDS have difficulty maintaining their weight and nutrition status. This
ar stu
problem may be caused by fatigue, anorexia, nausea and vomiting, difficult or painful
swallowing, diarrhea, intestinal malabsorption, or wasting syndrome.
is
Patients should:
Th
a) Select foods high in calories and protein
b) Maintain current weight or gaining weight
c) Drink at least 2-3 liters of fluids per day
sh
d) Maintain normal blood levels of ferritin, albumin, prealbumin and hemoglobin
Nutrition therapy includes monitor weight, I&O, and calorie count. Assess food preferences and
dietary cultural or religious practices. Collab with the dietician to teach the patient about the
need for a high-calorie and high-protein diet. Encourage him or her to avoid dietary fat, because
fat intolerance often occurs as a result of the disease and as a side effects of some antiretroviral
This study source was downloaded by 100000830883196 from CourseHero.com on 09-28-2021 17:47:38 GMT -05:00
https://www.coursehero.com/file/71360710/EXAM-4-REVIEWdocx/
1. Priority assessment/intervention for a patient who had an allergic reaction to a vaccine
Page 365 chart 20-3
Emergency care of the patient with anaphylaxis
Immediately assess the respiratory status, airway, and oxygen saturation of patients
who show any symptoms of an allergic reaction
Call the RRT
Ensure that intubation and tracheotomy equipment is ready
Apply oxygen using a high-flow, nonrebreather mask at 90% to 100%
Immediately discontinue the IV drug or infusing solution of a patient having an
anaphylactic reaction to that drug or solution. DO NOT discontinue the IV, but
change the IV tubing and hang NS
m
er as
If the patient doesn’t have an IV, start one immediately and run NS
Be prepared to administer epinephrine IV or IM
co
eH w
epinephrine 1:1000 concentration, 0.3 to 0.5 mL IV push or IM
Repeat drug administration as needed every 5 to 15 minutes until the patient
o.
responds
rs e
ou urc
Keep the HOB elevated about 10 degrees if hypotension is present; if BP is normal,
elevate the HOB to 45 degrees or higher to improve ventilation
Raise the feet and legs
o
Stay with the patient
aC s
Reassure the patient that the appropriate interventions are being instituted
vi y re
2. Typical signs and symptoms of an anaphylactic reaction
Page 364 chart 20-2
ed d
Anaphylaxis
ar stu
Clinical criteria 1: onset within minutes to hours of skin or mucous membrane
problems involving swollen lips, tongue, soft palate, uvula; widespread hives;
is
pruritis; or flushing along with any one of these new-onset symptoms:
respiratory distress or ineffectiveness
Th
dyspnea
bronchospasms
wheezes
sh
stridor
hypoxia
cyanosis
peak expiratory rate flow lower than the patient’s usual rate
hypotension or any indication of reduced perfusion resulting in organ
dysfunction
This study source was downloaded by 100000830883196 from CourseHero.com on 09-28-2021 17:47:38 GMT -05:00
https://www.coursehero.com/file/71360710/EXAM-4-REVIEWdocx/
, loss of consciousness
Incontinence
Hypotonia
Absent deep tendon reflexes
Clinical criteria 2: onset within minutes to hours of two or more of these symptoms
after a patient has been exposed to a potential allergen
skin or mucous membrane problems involving swollen lips, tongue, soft
palate, uvula; widespread hives’ pruritis; or flushing
respiratory distress or ineffectiveness as evidenced by any dyspnea,
bronchospasms, wheezes, stridor, hypoxia, cyanosis or peak expiratory
rate flow lower than the patient’s usual
hypotension or any indication of reduced perfusion resulting in hypotonia, or
absent deep tendon reflexes
Persistent GI problems such as NV, cramping, abdominal pain
m
er as
Clinical criteria 3: onset within minutes to hours of hypotension with systolic BP
co
eH w
lower than 90mm Hg or 30% lower than the patient’s baseline systolic pressure
o.
rs e
3. Precautions for an immunocompromised patient with meningitis
ou urc
4. HIV medication regimen and drug resistance are avoided by how much percent
compliance
o
90% compliance book answer
aC s
vi y re
5. Dietary concerns of a patient with HIV/AIDS
Page 354 Enhancing nutrition
ed d
Many patients with AIDS have difficulty maintaining their weight and nutrition status. This
ar stu
problem may be caused by fatigue, anorexia, nausea and vomiting, difficult or painful
swallowing, diarrhea, intestinal malabsorption, or wasting syndrome.
is
Patients should:
Th
a) Select foods high in calories and protein
b) Maintain current weight or gaining weight
c) Drink at least 2-3 liters of fluids per day
sh
d) Maintain normal blood levels of ferritin, albumin, prealbumin and hemoglobin
Nutrition therapy includes monitor weight, I&O, and calorie count. Assess food preferences and
dietary cultural or religious practices. Collab with the dietician to teach the patient about the
need for a high-calorie and high-protein diet. Encourage him or her to avoid dietary fat, because
fat intolerance often occurs as a result of the disease and as a side effects of some antiretroviral
This study source was downloaded by 100000830883196 from CourseHero.com on 09-28-2021 17:47:38 GMT -05:00
https://www.coursehero.com/file/71360710/EXAM-4-REVIEWdocx/
