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256 Cards in this Set
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What are the risk factors for HIV/AIDS |
Unprotected Sex Drug users (sharing needles) Healthcare workers (needle sticks) Fetus is mother has HIV Blood transfusion 1978-1985 Exposure to infected clients blood via open wounds or mucous membranes. *carries a lower risk than does a needle stick* *Kissing, hugging, inanimate objects does not increase risk for infection.* |
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Early HIV signs and symptoms? |
Viral replication reached a steady rate
Chronic vague symptoms persist (fatigue, fever, HA, night sweats) Persistent generalized lymphadenopathy CD4 Count is normal 500-1500 |
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Intermediate HIV signs and symptoms? |
CD4 T cell count between 200-500 cells and increased viral load Exacerbation of symptoms Localized infections Increased lymphadenopathy and neurologic manifestations. Experience localized infections: candida, hairy oral leukoplakia, shingles, oral or genital herpes lesions, Kaposi's sarcoma |
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Late HIV signs and symptoms? |
CD4 T cell count less than 200 cells and viral load increases Diagnosis of AIDS is made when the HIV pt develops at least one of the following disease processes. CD4 T Cell count less than 200 AIDS dementia complex Wasting syndrome caused by HIV Opportunistic Cancer: kaposi's sarcoma Opportunistic Infection: fungal, bacterial or protozoal infection. |
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Types of opportunistic diseases? |
Coccidioides jiroveci pneumonia TB Fungal infections: histoplasmosis (pneumonia meningitis), coccidiodomycosis (pneumonia) Kaposi's sarcoma Candidiasis Viral infections: CMV, herpes simplex with chronic ulcers or bronchitis, esophagitis, or pneumonitis. |
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Tests used to confirm HIV |
ELISA test Rapid Test: orasrue, accucheck Whole blood tests: HIV antigen test Western Blot test: ultimate confirmation, done after a (+) ELISA test. |
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What is AIDS? |
Acquired immunodeficiency syndrome is a condition resulting from severe impairment of the immune system ability to respond to invading pathogens. AIDS ultimately affects all body systems. Occurs as a result of being infected with the human immunodefeciency virus. |
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What nursing interventions do you want to do for AIDS/HIV? |
Anti viral and AntiRetroviral therapy ASAP Protect pt from opportunistic infections. Neutropenic isolation later stages. Instruct pt to protect themselves and others. Maintain standard precautions Provide psychosocial, financial, or occupational support. Immunizations, flu shot Teach about sex protection (ABC) Abstinence, Be faithful, Condoms. |
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What are some potential Complications of HIV/AIDS |
Opportunistic infections because of low WBC
Pneumonia Meningitis Flu Cancer Depression Isolation |
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What is Lupus (SLE)? |
Multisystem inflammatory autoimmune disorder; the disease affects multiple organs. SLE is characterized by a diffuse production of autoantibodies that attack and cause damage to body organs and tissues. |
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What are some of the Risk factors for SLE? |
More common in women 20-40 yrs Familial tendencies May be triggered by by environmental stimulus (emotional stress, physical fatigue), infections, and medications. Sun exposure most common |
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What are the dermatologic manifestations associated with SLE? |
Alopecia (inflamed red rash) Butterfly rash Discoid lesions |
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What are the cardiopulmonary system manifestations associated with SLE? |
Pericarditis Pleural effusion Raynauds Phenomenon |
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What are the urinary system manifestations associated with SLE? |
Glomerulonephritis |
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What are the musculoskeletal system manifestations associated with SLE? |
Arthritis Myositis Synovitis |
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What are the CNS symptoms associated with SLE? |
Stroke Seizures Peripheral neuropathy psychosis organic brain syndrome |
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What are the hematopoietic system manifestations associated with SLE? |
Anemia Leukopenia Thrombocytopenia splenomegaly (enlarged spleen) |
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What are the GI system manifestations associated with SLE? |
Abdominal pain NVD Dysphagia |
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What are the reproductive system manifestations associated with SLE? |
Menstrual Abnormalities. |
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Other manifestations associated with SLE? |
Fever: is the classic sign of a flare or exacerbation. Fatigue Anorexia Vasculitis |
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Lab tests done to help diagnose SLE? |
RF antinuclear antibody Erythrocyte sedimentation rate Serum protein electrophoresis serum complement A false positive VDRL syphilis test is common with lupus. CBC: shows pancytopenia |
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Meds used to treat SLE? |
Nonsteroidal anti inflammatory medications Corticosteroids for exacerbations polyarthritis Immunosuppressants Aspirin, ibuprofen |
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Nursing interventions for preventing SLE? |
Good nutrition, low cholesterol diet avoid exposure to infections Teach about skin problems Teach about personal hygiene, prevent UTI Make sure pt knows how to take meds Avoid exposure to sunlight, wear sunscreen Contact physician before any immunization procedures. |
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Nursing interventions to maintain adequate tissue perfusion for a pt with SLE? |
Assess for indications of impaired peripheral perfusion, numbness, tingling and weakness of hands and feet. Prevent injury to extremities, esp fingers. Carefully evaluate fluid status with regard to cardiac. status, fluid retention, and weight gain. |
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Nursing interventions to help maintain renal function for a pt with SLE? |
Monitor for peripheral edema, hypertension, hematuria and decreased output. Monitor BUN, and creatinine levels Monitor for UTIs Assess for peripheral edema and excess fluid volume |
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Nursing interventions to help assist the client to maintain psychologic equilibrium with SLE. |
Observe for behavioral changes that may indicate central nervous system involvement: HA, inappropriate speech, difficulty concentrating. Encourage client to participate in support groups and to seek counseling to deal with stress. |
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Potential complications associated with SLE? |
Serositis Pneumonitis Myocarditis Nephritis
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What is RA? |
Rheumatoid arthritis is a chronic, systemic autoimmune disease that affects all areas of the body; inflammatory responses occur in all connective tissue. Early symptoms include inflammation of the synovial joints. |
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Risk factors associated with RA? |
Gender: women possible connection between female reproductive hormones Age: peak during 20-45 yrs of age) Genetic link |
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Early signs & symptoms of RA? |
Joint Pain Systemic Generalized weakness Anorexia (weight loss of 1-2lbs) Persistent low grade fever. |
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Late signs and symptoms of RA? |
Joint Deformities and moderate to severe pain and morning stiffness.(lasts 45min) Decreased ROM Systemic Osteoporosis, severe fatiuge, anemia, weight loss, SC nodules, peripheral neuropathy, vasculitis, pericarditis, fibrotic lung disease, sjogrens syndrome, renal disease, feltys syndrome. TMJ: painful to chew, bakers cysts |
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Labs done to diagnose RA? |
Rheumatoid factor Antinuclear antibody (ANA) Only (+) later on Anti- SS-A Serum complement esp C3 and C4 Elevated ESR helps confirm CRP: inflammation |
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Diagnostic tests done for RA? |
Athrocentesis: aspiration of a sample of synovial fluid to relieve pressure and analyze for inflammatory cells and immune complexes. Xray CT Bone scan |
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Medical interventions done for RA? |
Synovectomy: remove inflammed synovium may be needed for joints like the knee or elbow. Total join arthroplasty |
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Medications for RA? |
NSAIDS Aspirin Immunosuppressant -methotrexate |
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Interventions for RA? |
Hot shower Splinting Joint protection Daily exercise PT&OT Stress management Wax dip Promote self management |
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Potential complications of RA? |
Nodules develop in the lungs. Inflammation of blood vessels, organs become ischemic Foot drop and paresthesia Dry mouth and eyes Enlarged liver and spleen Tendon rupture Respiratory issues Pleurisy, pneumonitis, Diffuse interstitial fibrosis, Pulmonary hypertension |
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What is a brain tumor |
Can be malignant or benign, both are life threatening. A tumor expands, invades, infiltrates, compresses and displaces normal brain tissue which leads to other problems. Cerebral edema, ICP, Neurologic deficits, hyrocephalus, pituitary dysfunction. Can be found in the brain, meninges, and skull. |
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Causes of brain tumor? |
Cause is unknown for sure but could be: Hx of head trauma Genetic Exposure to carinogenic chemicals Certain Viruses |
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Signs and symptoms of Brain tumor |
HA Vomiting unrelated to food intake Changes in visual activity, diplopia Hemiparesis or hemiplegia Hypokinesia Hyperesthesia, paresthesia Seizures Aphasia Changes in personality or behavior Hearing loss Facial pain and weakness Dysphasia Nystagmus Hoarseness Ataxia and dysarthria |
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Medical interventions done for a brain tumor? |
Chemotherapy Chemotherapeutic drugs Immunotherapy Radiation Surgery (craniotomy) stereotactic radiosurgery drugs for pain |
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What diagnostic tests can be done for a Brain Tumor to help diagnose? |
CT MRI EEG Brain Scan PETR (Positron Emission Tomography) |
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What nursing interventions can be done to monitor changes in ICP after craniotomy? |
Obtain VS and perform Neuro checks and cranial nerve assessments as necessary. Maintain pulmonary function and hygiene. Anticipate use of anticonvulsants and antiemetics. Discourage coughing Carefully evaluate LOC Evaluate dressing. Maintain Semi-Fowlers position Maintain fluid regulation (I&O monitor) Evaluate Neuro status in response to fluid balance and diuretics. Evaluate changes in Temp Provide pain relief avoid narcotic analgesics Maintain seizure precautions |
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What are the early, intermediate and late signs of increasing intracranial pressure? |
Early: restless, irritable, lethargic. Intermediate: Unequal pupil response, projectile vomiting, vital signs changes. Late: Decreased LOC, decreased reflexes, hypoventilation, dilated pupils, posturing.
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Labs to monitor for a pt with a Brain Tumor? R/t cerebral salt wasting? |
Electrolyte imbalance |
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What are some potential complications r/t the brain tumor? |
Overgrowth of tumor = DEATH After Surgery: ICP, hematomas, hemorrhage, fluid and electrolyte imbalance, hydrocephalus, respiratory complications, wound infection, meningitis, seizures. |
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What is a TIA? |
Transient ischemic event: less than 24 hrs with symptoms, temporary loss of blood supply, warning sign. (silent stroke) Resolves within 30-60 mins |
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What is a CVA? |
Cerebral Vascular Accident: deficit that lasts longer than 24hrs, long term damage caused by extended loss of blood supply. |
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What is a hemorrhagic stroke? |
blood vessel supplying the brain ruptures and seeps into surrounding tissues, poor prognosis because happens so quickly. |
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What is a ischemic stroke? |
clot has blocked blood flow to an area of the brain. (thrombolytic or embolic) |
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Risk factors for a stroke? |
Advancing age Sex (happens to women more often) Race HTN Heart Disease Smoking Oral Contraceptives Diabetes Dysrhythmias Hypercholesterolemia |
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Signs and symptoms of a TIA? |
Visual deficits: blurred vision, diplopia, blindness of one eye, tunnel vision. Transient hemiparesis, gait problems Slurred speech, confusion. Transient numbness of an extremity |
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Signs and symptoms of a stroke? (complete stroke, ischemic/hemorrhagic) |
Hemiplegia: loss of voluntary movement Aphasia: defect in language Acalculia: difficulty w/ math May be unaware of the affected side Cranial nerve Impairment Incontinent initially Agnosia: disturbance in sensory, unable to recognize familiar objects. Cognitive impairment of memory, judgement, proprioception. Hypotonia (flaccidity) Visual defects Apraxia Increased ICP |
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Imaging done for a stroke? |
CT scan: hemorrhagic stroke seen right away! MRI: ischemic area seen within 2 hours |
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Specific Medication for Ischemic stroke? |
Thrombolitics (tPA): clot buster, very specific time frame between symptoms and tx to recover brain tissue. (for ischemic not hemorrhagic) |
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What general drugs are used for a stroke? |
Antiplatelet agents: prevent further stroke Anticoagulants: usually IV <36 hrs depending on stroke type. Antiseizure: depends on area if the stroke caused seizure. HTN med: usually an underlying problem Temp management: increased temp takes energy the brain needs, decrease temp |
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Surgery for a TIA? |
Carotid Endarterectomy |
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Other surgeries for strokes? |
Craniotomy for evacuation of hematoma. Extracranial intracranial bypass for mild strokes. |
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Nursing interventions for a stroke? |
Teaching: about risks associated with a TIA Reposition (side lying w/ HOB elevated) Assess for symptoms of hypoxia Assess for signs of ICP, treat ICP Eval swallow studies, nutrition! High fowler while eating Hygiene PT/OT Passive ROM on affected and Active ROM on unaffected side. Watch response to diuretics: |
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Possible complications r/t a stroke? |
Weakness Uncoordinated Language/ Communication deficits |
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What is Encephalitis? |
Severe inflammation of the brain parenchyma: usually viral, but can also be due to bacteria, fungi, and other organisms. |
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What causes encephalitis? Risk factors? |
If patient has meningitis the patient has a higher risk of developing encephalitis |
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What are the signs and symptoms of encephalitis? |
Sudden onset of F, HA and vomiting Changes in mental status Motor dysfunction (dysphagia) Focal (Neuro deficits) Photophobia (light sensitivity) and phonophobia (noise sensitivity) Fatigue Symptoms of increased ICP (decreased LOC) Facial paralysis, seizures, ataxiastiff neck and back |
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Diagnostics done for encephalitis? |
Examination of CSF: looking for offending organism. Polymerase chain reaction test may be used to detect viral DNA or RNA in CSF. EEG for seizures Blood test for west nile virus CT: looking for ICP (w/out contrast) |
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Medications given to the patient with encephalitis? |
Anticonvulsants Glucosteroids Mannitol Sedatives Acetaminophen Abx: only for bacterial |
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Nursing interventions for encephalitis? |
Follow ABC Take VS and Neuro check q2-4hr Cranial nerve check, 3,4,6,7,8 Vascular assessment Decrease environmental stimuli Give drugs and IV fluids Record I&O to prevent overload Monitor labs Position carefully to prevent ulcers Maintain transmission based precautions Monitor for and prevent: Increased ICP, vascular dysfunction, fluid and electrolyte imbalance, seizures, shock. |
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Possible complications r/t encephalitis? |
Increased ICP Vascular dysfunction Fluid and electrolyte imbalance Seizure Shock |
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What is meningitis? |
Inflammation or infection of meninges that surround the brain and spinal cord. Can be bacterial or viral, bacterial is more serious. |
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What are the risk factors for meningitis? |
Not vaccinated Come in contact with bacteria/virus *Meningococcal meningtitis contagious and transmitted by droplets. |
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Signs and symptoms of Meningitis? |
Decreased LOC Disoriented to person, place, and year Pupil reaction and eye movements: photophobia, nystagmus, abnormal eye movements Motor Response: hemiparesis, hemiplegia, and decreased muscle tone (later) Cranial nerve dysfunction: 3, 4, 6, 7, 8 Memory/ personality changes Severe HA Generalized muscle aches and pain NV F and chills Tachycardia Red macular rash |
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Diagnostics done for meningitis? |
(+) Brudzinkis and Kernigs signs Lumbar puncture of CSF analysis: cloudy Xray: for infectionCT/MRI: to identify increased ICP Blood culture CBC |
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Meds for the pt with meningitis? |
ABX Antiviral Anticonvulsants Steroids |
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Nursing interventions for the pt with meningitis? |
Quite room Careful diet Keep fever down Keep comfortable Provide abx Respiratory Isolation (droplet precaution) Perform a complete vascular assessment q4hrs to detect early vascular compromise from septic emboli. Monitor Neuro status |
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Possible complications r/t meningitis? |
Brain damage Hearing loss Learning disabilities |
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What is multiple sclerosis? |
Chronic autoimmune disease that affects the myelin sheath and conduction pathway of the CNS. Inflammatory response that results in diffuse random or patchy areas of plaque in the white matter of the CNS. There are periods of remission and exacerbation. |
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Risk factors for MS? |
Possible causes: Viral, environment (colder climates), hereditary. More common in women. |
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Signs and symptoms of MS? |
Muscle weakness and spasms Fatigue Intention tremors Dysmetria (inability to direct or limit movement) Numbness or tingling sensations Hypalgesia (decrease sensitivity to pain) Ataxia (Decrease motor coordination) Dysarthria (slurred speech) Dysphagia Diplopia (double vision) Nystagmus (involuntary eye movement) Scotomas (changes in peripheral vision) Decreased visual and hearing acruity Tinnitus and vertigo Bowel and bladder dysfunction Alterations in sexual function Cognitive changes (memory loss, impaired judgement, decreased ability to solve problems or perform calculations) |
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What diagnostic tests are done to help diagnose MS? |
No single diagnostic test but a collective of results from various tests are usually conclusive: Abnormal CSF fluid (elevated protein & WBC) CSF electrophoresis shows increase in myelin basic protein and increased IgG bands. CT scan may show increased density in white matter and MS plaques MRI shows presence of plaques |
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What drugs is a MS patient on to help with symptoms? |
Interferon beta Glatiramer acetate Natalizumab DECADRON |
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Nursing interventions for MS? |
Safety! Prevent falls Plan care around rest periods Teach to exercise PT/OT Teach to avoid stress, extreme temp, humidity, people with infections. If patient has eye problem, teach to wear an eye patch that is alternated between eyes. Teach about bladder and bowel care (self catherization, indwelling catheter) |
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Potential complications r/t MS? |
Pt weak and easily fatigued Falls Eye problems Self esteem and body image Stress |
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What is myasthenia gravis? |
Is an acquired autoimmune disease characterized by fatigue and weakness primarily in muscles innervated by the cranial nerves as well as in skeletal and respiratory muscles. |
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Risk factors for Myasthenia gravis? |
Autoimmune Hereditary Overgrowth of the Thymus gland Hyperthyroidism |
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What are the signs and symptoms of Myasthenia gravis? |
Progressive muscle weakness that usually improves with rest. Poor posture Ocular palsies Ptosis Weak or incomplete eye closure Diplopia Respiratory compromise Loss of bowel and bladder control Fatigue Muscle achiness Paresthesias Decreased sense of smell and taste. Facial |
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What labs are done for Myasthenia gravis? |
Acetycholine receptor antibodies: positive antibody test confirms diagnosis, but negative finding does not rule out the disease. |
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What other diagnostic tests are done for myasthenia gravis?
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Repetitive nerve stimulation Electomyography Tensilon testing: used to differentiate cholinergic crisis from myasthenic crisis. HAVE CRASH CART WHEN DOING TENSILON CT or Chest xray to look at thymus |
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Signs and symptoms for Cholinergic crisis? |
NVD Abdominal Cramps Blurred vision Pallor Facial Muscle Twitching Pupillary miosis Hypotension |
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Signs and symptoms of Myasthenic Crisis? |
Increased Pulse and respiration Rise in BP Anoxia Cyanosis Bowel and bladder incontinence Decreased Urine output Absence of cough and swallow reflex. |
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Surgery done for myasthenia gravis? |
Thymectomy: performed early in disease, those who have surgery within 2 years of the onset of teh disease show most improvement. |
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Nursing interventions for Myasthenia gravis? |
Plasmapheresis Teach factors in exacerbation such as avoiding: Overheating, crowds, overeating, erratci changes in sleeping habits, emotional extremes Assess respiratory w/ decreased muscle strength Give O2 Check cough reflex- suctioning Assess muscle strength before and after activity Assist w/ ambulation Work with Dietitian, r/t decrease food intake r/r weak muscles. PT, OT Provide rest periods. |
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Possible complications of Myasthenia Gravis? |
Aspiration Pneumonia Respiratory Distress Nutrition Deficiency Pneumothorax or hemothorax for the pt having a thymectomy. Exacerbation |
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What is parkinsons diease? |
Degenerative changes of basal ganglia. Disruption of dopaminergic (calming) neurons. Loss of balance between dopamine and acetylcholine. |
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What are the risk factors for parkinsons? |
Onset occurs after age 60 More common in males |
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What are the motor symptoms of parkinsons? |
Bradykinesia (Slow movement) Muscular rigidity Akinesia Tremors Pill-rolling Masklike facies Difficulty chewing and swallowing Uncontrolled drooling, especially at night Fatigue Difficulty getting into and out of bed Reduced arm swinging on one side of the body when walking. Micrographia or handwriting gets smaller. |
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Non motor symptoms of parkinsons? |
Cognitive dysfunction Dementia Psychosis Hallucination Mood disorders depression anxiety apathy sleep disturbances Autonomic dysfunction Pain and sensory disturbances |
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What diagnostic tests are done for parkinsons? |
CT, MRI, CSF, SPECT, PET
Based on clinical finding after other neurologic diseases are eliminated as possibilities. |
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Types of drugs used for parkinsons? |
Dopamine agonists anticholinergics |
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Surgical management for parkinsons? |
Stereotactic pallidotomy Thalamotomy Deep brain stimulation Fetal tissue transplantation |
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What nursing interventions do we want to do for the patient with parkinsons? |
PT, OT, Speech therapy High risk for falls, keep them safe Activity keep them up and moving Focus on nutrition and elimination Assess for depression and anxiety Treat insomnia or sleepiness Provide high calorie nutrition thats easy to chew |
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Stage 1 parkinsons: Initial stage |
Unilateral limb involvement Minimal weakness Hand and arm trembling |
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Stage 2 parkinson: Mild stage |
Bilateral limb involvement Masklike facies Slow, shuffling gait |
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Stage 3 parkinsons: Moderate disease |
Postural instability Increased gait disturbances |
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Stage 4 parkinsons: Severe disability |
Alkinesia Rigidity |
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Stage 5 parkinsons |
Complete ADL dependence |
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Risk factors for seizures? |
Increased ICP Metabolic alterations Infections |
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Chronic, recurrent, epilepsy risk factors? |
Brain injury at birth Brain tumors trauma vascular disease Genetic factors idiopathic |
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Seizure precautions? |
Monitor clients compliance with taking antiseizure medications as prescribed. Make environment safe by removing potentially unsafe objects. Keep suction, bab valve mask resuscitator, and airway equipment at bedside. Pad side rails to prevent injury during seizures |
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Nursing interventions for seizures? |
Remain with pt who is having seizure, note the time the seizure began and how long it lasted. Do not attempt to force anything into the clients mouth Protect the client from injury Loosen any constrictive clothing Do not restrain client during seizure activity; allow seizure movements to occur, but protect pt from injury. Evaluate respiratory status; if vomiting occurs, be prepared to suction the client to clear the airway and prevent aspiration. Maintain calm atmosphere and provide for privacy after seizure activity. Reorient client |
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What is a tonic-clonic seizure? |
Lasts 2-5 mins, begins with tonic (causes stiffening or rigidity of the muscles in arms and legs and immediate loss of consciousness) and then clonic (rhythmic jerking of all extremities) Patient may bite tongue and may become incontinent. Fatigue, acute confusion and lethargy up to an hr after seizure. |
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What is a tonic seizure? |
Abrupt increase in muscle tone, loss of consciousness, and autonomic changes from 30 seconds to several minutes. |
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What is an absence seizure? |
Brief (seconds) loss of consciousness and blank staring as though the person is daydreaming. Patients eyes may flutter Automatisms (involuntary behaviors, such as lip smacking and picking at clothes) Pt returns to baseline right after seizure |
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What is a myoclonic seizure? |
Brief jerking or stiffening of the extremities. Occurs singly or in groups Only a few seconds Symmetric or asymmetric |
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What is atonic seizure? |
Sudden loss of muscle tone
Lasts for seconds, followed by postictal (after a seizure) confusion Most resistant seizure to drug therapy. |
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Tonic clonic, tonic, clonic, absence, myoclonic, and atonic seizures are categorized as what types of seizures? |
Generalized seizures. |
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Complex partial seizures (psychomotor or temporal lobe seizures) |
Loss of consciousness/blackout for 1-3 mins Pt is unaware of the environment, may wander at start of the seizure, and have amnesia after the seizure. Temporal lob is most involved Most common among older adults and difficult to diagnose. |
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Simple partial seizure |
Pt remains conscious throughout the episode Often reports aura before the seizure takes place During: pt may have one sided extremity movement, have unusual sensations or have autonomic symptoms. (changes in heart rate, skin flushing, epigastric discomfort) |
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Diagnostic testing for seizures |
EEG CT MRI PET Lab studies to identify metabolic or other disorders, ABG, general labs |
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Treatment for secondary seizures? |
Remove underlying condition |
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Treatment for primary seizures? |
Drug therapy (antiepileptic and anticonvulsants) Teach scheduled lab appointments for blood therapeutic/toxic levels. Antiepileptic drugs must not be stopped, even if seizures have stopped. Balanced diet, proper rest and rest reduction techniques for prevention. |
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Surgery management of seizures? |
VNS (vagal nerve stimulation) for simple or complex partial seizures. Craniotomy Partial corpus callosotomy |
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What does status mean, for status epilepticus? |
Status means that nothing is working! Everything you have done for medical intervention is still not working. |
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What is a complete spinal cord injury? |
Spinal cord has been severed or damaged. |
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What is incomplete spinal cord injury? |
Some function/ movement below the level of the injury |
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What is hypeflexion injury? |
Head is forcefully accelerated forward |
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What is hyperextension injury? |
head suddenly accelerated and then decelerated. |
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What is axial loading/vertical compression injury? |
Diving accidents, hard landing on butt/feet. |
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What is excessive head rotation injury? |
Turning head beyond normal range. |
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Risk factors for spinal cord injury? |
Traum Falls Acts of violence Tumors Dare devil |
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Signs and symptoms of spinal cord injury? |
Injury at C3 through C5 will cause respiratory compromise. Depending on degree of injury, the degree of paralysis and amount of sensory loss below the level of injury will vary. Spinal shock: generally occurs within 72 hrs and may last for several weeks, flaccid paralysis, loss of sensation and absence of reflexes, bowel and bladder dysfunction. Hypotension and bradycardia Autonomic dysreflexia in clients with injuries at T6 or higher. Severe hypertension, bradycardia. Complaints of HA, flushing and diaphoresis above level of injury. |
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Diagnostics for spinal cord injury? |
CT MRI Stabilize and immobilize |
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Medications for a spinal cord injury? |
Methylpredisolone (solu-medrol) decrease inflammation. Dextran: increase capillary blood flow within spinal cord Atropine sulfate: treat bradycardia Muscle relaxants |
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Surgical interventions for spinal cord injury? |
Remove penetrating objects Decompressive laminectomy: remove laminae to increase cord expansion Cervical Fusion |
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Nursing interventions for spinal cord injury? |
Assess vitals, LOC Hygiene Community resources Maintain proper body alignment pain control Stabilize and immobilize patient. |
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Potential complications r/t spinal cord injury? |
Loss of motor function Sensation reflex activity Bowel/bladder control (hydroneprhosis, renal failure, kidney stones) Difficulty breathing Paralysis Pressure ulcer Contractractures DVT or PE Orthostatic hypotension autonomic dysreflexia |
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What is Amyotrophic lateral sclerosis? (ALS) |
Also known as Lou Gehrigs disease, is a rapidly progressive, invariable fatal degeneration of nerves controlling voluntary muscles. (degenerative) |
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Signs and symptoms of early ALS? |
weakness of hands and arms
Tongue atrophy Facial twitching Speech is nasal sounding Dysarthria Dysphagia Fatigue while talking |
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Later S&S of ALS? |
Progressive weakness Muscle spasticity Paralysis affecting the ability to talk, swallow and breathe. 90% die within 3-5 years |
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Diagnostics for ALS? |
Electromyography and nerve condition studies Muscle biopsy |
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Treatment for ALS?
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Riluzole (Rilutek) prolongs life by a few months; protects motor neurons Supportive care |
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Nursing interventions for ALS? |
Promote independence in ADLs Conserve energy; space activities Avoid extremities of hot and cold. Use of appliances to prolong independence in ambulation and ADLs. Small frequent feedings Sit upright when eating Keep suction equipment easily available during meals. At risk for aspiration Encourage family and client to talk about losses and the difficult choices they face. Advance directive |
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What is PID? |
Pelvic inflammatory disease is an infectious condition of the pelvic cavity that involves the fallopian tubes, the ovaries and or the peritoneum |
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What are the risks/ causes for PID? |
<26 yrs old
Multiple sex partners IUD Smoking Hx of PID Chlamydial or gonococcal infection Bacterial vaginosis Hx of STDs |
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Signs and symptoms of PID? |
Lower abd pain Irregular vag bleeding (spotting or bleeding between periods) Dysuria Increase or change in vag discharge Dyspareunia Malaise F Chills Yellow/green cervical discharge Reddened friable cervix (bleeds easily) |
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Labs done for PID? |
Specimens from cervix, urethra, rectum collected and tested for N. gonorrhoea or C. trachomatis. Increase in WBC, ESR, CRP HCG: find out if preggo |
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Interventions for PID? |
Abx therapy heat application for comfort surgical excision of abscess analgesics antipyretics |
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Possible complications r/t PID |
sterility caused by adhesions and strictures within the fallopian tubes. Ectopic pregnancy Pelvic abscess or generalized peritonitis septic shock |
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Risk factors for ovarian cysts? |
Functional ovarian cysts can occur in a woman of any age but are rare after menopause. Other cysts and tumors of the ovaries are not r/t the menstrual cycle but arise from ovarian tissue. |
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Diagnostics for ovarian cysts? |
Pelvic exam Transvaginal Ultrasound MRI CT Laparoscopic Biopsy |
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S&S of ovarian cysts? |
Discomfort for prolonged period. |
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Surgery for ovarian cysts? |
Laparoscopic surgery |
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Complications of ovarian cysts? |
Cancer |
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What is testicular torsion? |
Twisting of the testes and spermatic cord |
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S&S of testicular torsion? |
Acute onset Pain Swollen red testis |
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Treatment for testicular torsion? |
Surgery to remove torsion/twisting of testes. *EMERGENCY SURGERY* Blood flow to testes is compromised! |
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What is erectile dysfunction? (ED) |
Inability to achieve or maintain an erection for sexual intercourse. |
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Causes of ED? |
Inflammation of the prostate, urethra or seminal vesicles. Surgical Procedures such as prostatectomy Pelvis fractures Lumbosacral injuries Vascular disease, including Hypertension Chronic neurologic conditions: parkinsons, MS Endocrine disorders, DM, thyroid disorders Smoking and alcohol consumption Antihypertensives Poor overall health that prevents sexual intercourse. |
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Diagnositc tests for ED? |
Hormone testing: testosterone and gonadotropins (LH) (FSH) Duplex doppler Nocturnal penile tumescence test |
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Interventions for ED? |
Meds: sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) Self administered intracavernous injections of papaverine or prostaglandin E. Testosterone therapy Counseling Penile implants Vascular reconstructive surgery |
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What is benign prostatic hyperplasia? (BPH) |
Hypertrophy: enlargement of prostate gland tissue. |
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Risk factors for BPH and Prostate cancer? |
Age >50yrs Prostatic carcinoma |
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S&S of BPH? |
Bladder outlet obstruction -urinary hesitancy, frequency, urgency, dribbling -Nocturia, hematuria, urinary retention, sensation of incomplete emptying of bladder -Urinary retention may cause overflow urinary incontinence and dribbling after voiding. Acute retention may cause hydroureter and pressure in kidney. Increase UTI incidences |
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What labs do we do for BPH and Prostate cancer? |
CBC
BUN PSA Culture and sensitivity of prostatic fluid |
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Diagnostic imaging for BPH and Prostate cancer? |
Transabdominal Ultrasound Transrectal Ultrasound Tissue biopsy Bone scan CT MRI |
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Medical interventions for BPH and prostate cancer? |
BPH: 5a Reductase Inhibitors and alpha-adrenergic blockers to shrink prostatic tissue. Watchful waiting when there are mild symptoms; may include decreasing caffeine intake, avoiding decongestants and anticholinergics, and restricting fluid intake. Prostate Cancer:Radiation, hormonal therapy, and chemotherapy for malignancy |
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Surgeries done for BPH and Prostate cancer? |
BPH: TURP, TUIP Prostate cancer: Prostatectomy, TUMT, Brachytherapy, hormone therapy, cryotherapy |
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Care of pt after TURP (TransUrethral Resection of the Prostate) |
Continuous or intermittent bladder irrigation w/ NS Close observation of drainage system: increased bladder distention causes pain and bleeding. Maintain catheter patency Bladder spasms Pain control: analgesics and decrease activity first 24 hrs Avoid straining with BMs. Increase Fiber and laxatives. |
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Possible complications r/t TURP |
Hemorrhage: bleeding should gradually decrease Urinary incontinence- kegel exercises INfections: increase fluids Prevent DVT SEquential compression stockings Discourage sitting for prolonged periods. |
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Goals for the pt with BPH and prostate cancer? |
Prevent UTI and provide education. Maintain closed irrigation after surgery in the client who has undergone TURP or suprapubic prostatectomy. Provide postoperative care Provide postoperative care for a client after radical open prostatectomy. |
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Risk factors/ etiology for syphilis? |
Incubation period is 10-90 days, with an avg of 20-30 days. Transmission is by direct contact with the primary chancre lesion; contact with body secretions, or transplacental transmission to the fetus. Highly infection during the primary stage. Blood contains the spirochete during the secondary stage; usually noninfectious after 1 year during the latent stage; noninfectious in the late tertiary stage. |
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S&S of syphilis during primary stage? |
Chancre: small, hard, painless lesion found on the penis, vulva, lips, vagina, or rectum. Usually heals spontaneously w/in 2-3 weeks w/ or w/out tx. HIGHLY CONTAGIOUS DURING THIS STAGE Will progress w/out tx. |
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S&S of syphilis during secondary stage? |
Usually begins anywhere from 2 weeks to 6 months after the chancre has healed. May be asymptomatic or may have maculopapular rash on the palms of the hands and soles of the feet, sore throat, HA, gray mucous patches in mouth. Symptoms disappear w/in 2-6 weeks |
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S&S of syphilis during the latent stage? |
Absence of clinical symptoms Results of serologic tests for syphilis remain + Transmission can occur through blood contact Majority of clients remain in this stage w/out further symptoms. |
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S&S of syphilis in tertiary stage? |
Gummas may develop in skin, bone, liver Causes Neurologic problems from mild personality changes to tremors and major psychoses. |
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Diagnostic tests for syphilis |
RPR (rapid plasma reagin test) VDRL: if + then fluorescent treponemal antibody absorption test or the microhemagglutination assay for T. palladium is done to confirm. |
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Tx for syphilis? |
Penicillin G IM (Single dose) May use tetracycline or doxycycline if allergic to penicillin. |
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Risk factors/ etiology for chlamydia? |
Incubation period:1-3 weeks |
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S&S for men with chlamydia? |
Urethritis, epidiymitis, proctitis Primary reservoir is the male urethra. Both men and women are asymptomatic and often do not seek medical attention until a complication arises. |
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S&S for women with chlamydia? |
Mucopurulent cervicitis, salpingitis, vaginitis Primary reservoir is the cervix Both men and women are asymptomatic and often do not seek medical attention until a complication arises. |
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Diagnostic tests for chlamydia? |
Nucleic acid amplification test (NAAT) Direct fluorescent antibody (DFA) test Enzyme immunoassay (EIA) |
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Tx for chlamydia? |
Single dose of zithromax No sex for 7 days Treat partner also! |
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Nursing interventions for chlamydia? |
Urge client to have sexual partner treated. Emphasize the importance of LT drug therapy because of the pathogens unique life cycle, which makes it difficult to eliminate Use of condoms with all sexual contacts Avoid sex for 7 days after tx and |
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Potential complications of chlamydia? |
PID Ectopic pregnancy Infertility in women |
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Risk factors/etiology for gonorrhea? |
Incubation period is 3-7 days Contagious as long as organism is present. |
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S&S of gonorrhea in men? |
Urethritis, epididymitis, dysuria, and purulent urethral discharge. Increased evidence of asymptomatic disease or a chronic carrier state in males. |
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S&S of gonorrhea in women |
Initial urethritis or cervicitis that is often mild enough to remain undetected by client. Vulvovaginitis, vaginal discharge, dysuria. |
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Diagnostics for gonorrhea? |
Positive gram stain smear of discharge or secretions. Positive culture |
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Treatment for gonorrhea? |
Single dose of rocephin |
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Nursing interventions for gonorrhea? |
Prophylactic abx tx to the eye in all newborns to prevent opthalmia neonatorum. Encourage follow up cultures in 4-7 days after tx and again at 6 months. Teach importance of abstinence from sexual intercourse until cultures are neg. Urge client to inform sexual partner so that he or she can be treated for infection. Importance of taking the full course of abx. |
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Possible complications of gonorrhea? |
In men: prostatitis, urethral stricture, urethritis, and sterility. In women: PID, bartholins abscess, ectopic pregnancy, infertility |
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What is Menorrhagia? |
Excessive vaginal bleeding. Single episode of heavy bleeding may indicate a spontaneous abortion. May be associated with IUD |
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Causes of Menorrhagia? |
Hypothyroidism, uterine fibroids, hormone imbalance. |
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Nursing interventions for menorrhagia? |
Help determine most likely cause of problem. Report excessive bleeding, abd pain, fever. |
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TX for menorrhagia? |
Dilation and curettage for diagnostic purposes in older women. Endometrial ablation Removal of fibroids. |
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What is endometriosis? |
Presence of endometrial tissue outside of the uterus. The tissue responds to hormonal stimulation by bleeding into areas within the pelvis, causing pain and adhesions. |
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Causes pf endometriosis? |
Theory is that the endometrial tissue migrates directly through the fallopian tubes during menses. The tissue then implants on pelvic structures or distant organs such as lungs or heart. |
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S&S of endometriosis? |
Pain peaks before menstrual flow. Located Lower Abd Dyspareunia (painful sex) Painful defecation Low back ache Infertility ND |
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Diagnostic tests for endometriosis? |
Pelvic exam: reveals pelvic tenderness, tender nodules, limited movement of uterus. CA-125 is + in women w/ endometriosis Transvaginal US |
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Surgical management of endometriosis? |
Laparoscopic removal of endometrial implants and adhesions in a same day surgical setting. *temporary postoperative pain from CO2 can occur in the shoulders and chest. Hysterrectomy: for women close to menopause |
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Nursing interventions for endometriosis? |
Oral contraceptives Continuous low level heat Relaxation techniques such as: yoga, massage, biofeedback. Calcium and Mg+ may also relieve muscle cramps. |
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Possible complications r/t endometriosis? |
Infertility Adhesions Bowel obstruction |
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Causes of genital warts? |
HPV Highly contagious, yet most do not have symptoms. Transmission is through sexual contact with a person who has a lesion. |
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S&S of genital warts. |
(Small, large, flat) Warts: penis, urethra, perianal area, anal canal, vulva, cervix, vaginal canal, oral Lesions are raised, skin toned, damp, cauliflower like growth. If wart like lesion bleeds easily, appears infected, is atypical, or persists, a biopsy of the lesion is performed to r/o cancer. |
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Tx for genital warts? |
Chemical or laser ablation Podophyllin, applied topically once or twice a week for small external warts. |
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Nursing interventions for genital warts? |
Education regarding transmission Vaccination against HPV with gardasil or cervarix may reduce or prevent genital warts. |
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Complications r/t genital warts? |
Cervial and or vulvar cancer in women. Rectal and or penile cancer in men (Also oral cancer) |
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What is hepatitis B? |
Widespread inflammation of the liver tissue. Highest concentrations in blood; lower concentrations in semen, vaginal secretions and wound exudates. |
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S&S of hepatitis B |
May be asymptomatic Fever Fatigue Loss of appetite NV Abd pain Dark urine Clay colored bowel movements Joint pain Jaundice |
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Prevention for hep b? |
Hep b vaccine |
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Complications of Hep b? |
Chronic liver disease and or liver failure. |
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What is genital herpes? |
Is an acute, recurring, incurable viral disease. It is the most common STD in the US. |
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Causes of genital herpes? |
Caused by herpes simplex virus type 1 or 2. transmission is by direct contact with skin or mucous membranes of an infected person. Incubation period: 2-20 days avg period being 1 week. |
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S&S of genital herpes? |
Initial sensation of tingling and itching before appearance of the lesion; may also include local inflammation, lyphadenopathy, F, HA, myalgia, and malaise. Multiple small vesicles appear on the penis, scrotum, perineum, vagina and cervix. |
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Diagnostics for genital herpes. |
Tissue culture that identifies herpes type 2 virus Virus culture Serologic blood tests for antibodies for HSV2 both IgG and IgA. |
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Nursing interventions for genital herpes? |
Teach importance of genital hygiene and avoidance of unprotected sex. Teach good hygiene practices. Open lesions can spread the virus through contact with the fluid from the lesion. Latex condoms should always be used to prevent exposure. Sex should be avoided when lesions are present. |
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Complications r/t genital herpes? |
Increased incidence of cervical cancer in women Lesions or positive viral culture in pregnant women should be monitored closely. CEsarean delivery may be necessary to prevent exposure to the infant during passage through the birth canal blindness, encephalitis, aseptic meningitis |
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Risk factors and etiology of testicular cancer |
Rare Most common cancer in men ages 15-35 More common in pts who have had cryptorchidism (undescended) and infections. |
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S&S of testicular cancer? |
Swollen testes, and Painless lump found on testicular exam. oligospermia azoospermia |
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Diagnostics for testicular cancer? |
Alpha fetoprotein (AFP) Beta human chorionic gonadotropin (hCG) Lactate dehydrogenase (LDH) Testosterone Ultrasound CT Lymphangiography MRI |
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Medical tx for testicular cancer? |
Postoperative irradiation to the lymphatic drainage pathways. Multiple chemotherapy meds Orchiectomy (removal of testicle) Retroperitoneal lymph node dissection is performed. |
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Interventions for testicular cancer? |
Teach testicular self examination Talk about sperm banking Emotional care Pre and post op care |
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Risk factors for breast cancer? |
Older women >50 yrs Genetics/ hereditary Early mearche before 12 yrs of age Late menopause after 50 yrs Hx of previous breast cancer No pregnancies First birth after age 30 |
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S&S of breast cancer? |
Asymmetry of the breasts Skin dimpling, flattening, nipple diviation Skin coloring and thickening, large pores (orange peel appearance) Changes: retraction of the nipple; discharge from the nipple. Mass is painless, nontender, hard, irregular in shape, and nonmobile. Majority of malignant lesions are found in the upper outer quadrant of the breast. |
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Diagnostics for breast cancer |
Mammography Digital mammography US MRI Breast biopsy: only definitive way to diagnose Lymph node dissection |
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Labs done for breast cancer? |
Carnioembryonic antigen (CEA) Human chorionic gonadotropin (hCG) |
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Surgeries/TX for breast cancer |
Modified radical mastectomy: Removal of all breast tissue and axillary lymph nodes. Lumpectomy: breast is preserved Radical mastectomy: less common, removal of all breast tissue, pectoral muscles and axillary lymph nodes of surrounding tissue. Breast reconstruction: post radiation, or at time of mastectomy Radiation Hormonal therapy Chemotherapy |
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Nursing interventions for breast cancer |
Teaching: screening mammo should begin at 40. BSE, Help with emotional stress and anxiety. Provide emotional support. Tx symptoms of chemo and radiation such as antiemetics. Comfort, pain relief. |
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Post mastectomy care |
Elevate affected side with distal joint higher than proximal joint. No BP, injections or venipunctures on affected side. Watch for S&S of edema on affected arm. Lymphedema can occur any time after axillary node dissection. Flexion and extension exercises of the hand in recovery. Abduction and external rotation arm exercises after wound has healed. Assess dressing for drainage. Assess wound drain for amount and color Provide privacy when pt looks at incision. Chemotherapy, radiation therapy Monitor for complications: hemorrhage, hematoma, lymphededma, infection, postmastectomy pain syndrome. Psychological concerns: altered body image, altered sexuality, fear of disease outcome. |
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Risk factors for cervical cancer |
>30yrs old Multiple sex partners Early sexual activity Hx of STDs, HSV-2 Genital warts (HPV) Abnormal pap smears |
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S&S of cervical cancer |
Clients are asymptomatic until late in disease state. Thin and watery drainage that becomes dark and foul smelling as the disease progresses. Abnormal vaginal bleeding or discharge Low back pain Painful sexual intercourse |
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Diagnostics for cervical cancer |
Pap Smear. -initial pap at age 21 or after first sexual intercourse. -pap smears are continued after menopause and hysterectomy. -testing for HPV-type 16 & 18. Recent research shows that testing for HPV may be better than the pap test for screening for cervical cancer. -Cervical biopsy |
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Treatment/prevention for cervical cancer? |
-Gardasil vaccination -Radiation either internal or external -Surgical intervention -conization (cryosurgery) -Vaginal hysterectomy -Radical hysterectomy -Pelvic exoneration |
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Interventions for cervical cancer? |
-Teach warning signs of cancer -Importance of yearly pap smears -Encourage verbalization of feelings r/t the surgery and diagnosis of cancer. -After surgery, assess for complications, such as backache or decreased urine output because these symptoms can indicate accidental ligation of the ureter. -Early ambulation -Urinary retention may occur as a result of bladder atony and edema; explain to client the necessity for a urinary retention catheter. |
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Risk factors for ovarian cancer? |
Unknown Usually detected by chance not screening. |
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S&S of ovarian cancer? |
Often asymptomatic leading to late diagnosis and tx. most lethal gynecologic cancers. Palpable hard firm mass |
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Diagnostics for ovarian cancer |
US CT MRI Usually detected on pelvic exam Exploratory laparotomy CA125 tumor marker but not 100% reliable. |
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what is Metrorrhagia |
bleeding between menstrual periods
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Causes of metrorrhagia? |
hormonal imbalances PID cervical or uterine polyps or cancer Early evaluation for cancer is important |
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Post menopausal bleeding is caused by? |
Endometrial polyps hyperplasia uterine cancer *early evaluation for cancer is important* |
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Diagnostic studies for abnormal uterine bleeding? |
CBC Thyroid hormones HCG levels Pelvic US Hysteroscopy Endometrial biopsy |
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Tx for abnormal uterine bleeding? |
-Hormone therapy -Therapeutic dilation and curretage or scraping the uterine wall. -Endometrial ablation; destroying the endometrial layer of the uterus. -Hysterectomy |
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Cranial nerve 1 is called what? What does it do? |
Olfactory Sense of smell |
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Cranial nerve 2 |
Optic Vision: conducts information from retina. |
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Cranial nerve 3 |
Oculomotor Downward and outward movement of the eye. Pupillary constriction and accommodation. Muscle of the upper eyelid. |
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Cranial nerve 4 |
Trochlear Movement of the eye |
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Cranial nerve 5 |
Trigeminal Corneal reflex Sensory fibers of the face Motor nerves for chewing and swallowing |
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Cranial nerve 6 |
Aducens Inward movement of the eye |
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Cranial nerve 7 |
Facial Facial expression. Sense of taste on anterior tongue. Muscle of the eyelid. (ability to close eyelid) |
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Cranial nerve 8 |
Acoustic Reception of hearing and maintenance of equilibrium. |
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Cranial nerve 9 |
Glossopharyngeal Sense of taste on posterior tongue. Salivation. Swallowing or gag reflex. |
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Cranial nerve 10 |
Vagus nerve Assists in swallowing action. Motor fibers to larynx for speech. Innervation of organs in thorax and abdomen. Important in respiratory, cardiac, and circulatory reflexes. |
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Cranial nerve 11 |
Accessory Ability to rotate the head and raise the shoulder |
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Cranial nerve 12 |
hypoglossal Muscle of the tongue |
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Signs and symptoms of a Right hemisphere stroke? |
Paralyzed Left side: hemiplegia
Left sided neglect Spatial perceptual deficits Tends to deny or minimize problems Rapid performance, short attention span. Impulsive, safety problems Impaired judgement Impaired time concepts |
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Signs and symptoms of a Left hemisphere stroke/ |
Paralyzed right side: hemiplegia Impaired speech and language: aphasias Impaired right/left discrimination Slow performance, cautious Aware of deficits: depression, anxiety Impaired comprehension r/t language, math. |
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Key features of Autonomic dysreflexia? |
Sudden onset of severe, throbbing HA Severe, rapidly occurring hypertension Bradycardia Flushing above level of lesion. (face and chest) Pale extremities below level of lesion Nasal stuffiness Sweating N Blurred vision Piloerection Felling of apprehension |
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Interventions for autnomic dysreflexia? |
Sitting position (1st priority) Page/notify healthcare provider Loosen tight clothing on the pt. Assess for and treat the cause Check for bladder distention and catheterize immediately if indicated, check for kinks in catheter Check for fecal impaction, remove immediately Check room temp, make sure its not too cold Monitor BP q10-15 mins Give nitrates or hydralazine |
