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224 Cards in this Set
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When a patients is given morphine what do we as nurses need to watch for?
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Morphine is a respiratory depressant so keep an eye on Respiration's. It should be given with a stool softener as it causes constipation. Pt. should have plenty of H20, fruits, veggies, fiber when applicable. Because it is a depressant it can cause urinary retention, so a bladder scan may be needed. Also watch for nausea and vomiting. Morphine is a common med. used w/ surgery.
Classification: Opioid Analgesic MONITOR: BP, Pulse, and Respiration's before and throughout therapy. Assess for fall risk. |
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Valium
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Also depresses the CNS, producing skeletal muscle relaxation. Monitor BP, Pulse, Respirations. Decreases anxiety.
Valium is Teterogenic to baby. Contraindicated. (Mild sedative) Classification: Diazepam |
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Versed
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Preoperative sedation/ anxiolysis/amnesia. As with all of these drugs monitor BP, pulse, and Respiration's continuously. Oxygen and resuscitative equipment should be right there.
Classification: Benzodiazepine |
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What are the 3 phases of the perioperative period?
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Pre-operative (begins when the decision to have surgery is made and ends with the transfer of the pt. onto the O.R. table.)
Intra-operative (begins when the patients is transferred onto the O.R. table and ends with admission to the PACU) (Post-Anesthesia Care Unit) Post-operative (begins with admission to the PACU and ends with a follow up evaluation in the clinical setting or at home.) |
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What are some of the risk factors for Surgical complications? What would the nurse be assessing for pre-operatively?
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Risk factors are higher in younger and older patient's, these patients are more prone to infection.
Does the patient have any respiration, renal, liver, or cardiac disorders? Is the pt. allergic to latex? Has the pt. been on any steroids in the last year? Is the pt. taking any herbal treatments, street drugs, or any other meds. (Aspirin?) not given by this hospital? Is there a family history of malignant hyperthermia. Does the pt. have any loose teeth, dentures, or dental problems? Is the pt. a Jehovah's witness and will not accept a blood transfusion? Does the pt. have contact lenses in? Database is established for vital signs. Physical exam Nutritional/ Fluid Status Endocrine function (Monitor blood glucose) Psychosocial Factors (Is pt. ready/comfortable with surgery?) Hypovolemia Weight Extremes (Obesity, Emaciation) Pregnancy All done on pre-op assessment and signed by the R.N. |
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What is important when giving PREOP Teaching?
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1.)Initiate asap. (preferable before hospitalization for an elective surgery.
2.)What to expect postoperatively; e.g. ventilator? 3.)Incentive spirometer; splinting. Used mainly in thoracic & abdominal incisions; involves folding hands over incision while coughing to mobilize secretions) 4.) Pain Control: let them know there are plenty of medications available to help w/ pain. 5.)Let the pt. know how important it will be to have early ambulation following surgery, because it improves circulation, prevents venous stasis, and promotes optimal respiratory function. **Following surgery if pt. is in pain and meds are not due for another hour, call the Dr. don't wait! Remember guided imagery, music therapy, optimistic thoughts , distraction and other techniques to avoid pain. |
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When a patient is in pain it hinders the healing process, causing what to happen?
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The sympathetic nervous system takes over causing stress; leading to coagulation and increase in blood glucose.
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What lab work is important prior to surgery?
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CBC (checks for infection (WBC) and hemoglobin/hematorcit levels.
Urinalysis to ensure proper kidney function |
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What are some of the causes of preoperative anxiety and what are some nursing interventions to alleviate these fears?
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General fears:
fear of the unknown loss of control loss of love from significant other threat to sexuality Specific Fears: -diagnosis of malignancy anesthesia dying pain disfigurement permanent limitations **As a nurse it is important to help the pt. to address these fears, listen well, and provide information to help alleviate these concerns. Pre-op Teaching can also help to eliminate some of these concerns. |
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What are some legal and ethical considerations related to informed consent?
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Informed Consents is mandatory is the following circumstances:
*Invasive procedures, such as surgical incision, a biopsy, a cytoscopy, or paracentesis. **Procedures requiring sedation and or/anesthesia **A non surgical procedure, such as an arteriography, that carries more than a slight risk to the patient **Procedures involving radiation The pt. signs the consent if of legal age and mentally capable. Otherwise permission is obtained from a surrogate, who is a responsible family member, or legal guardian. Consent is obtained by a PHYSICIAN, and pt. signature is WITNESSED by the R.N. or other professional staff member. It needs to be in writing and contain the following information: Explanation of procedure and its risks. Benefits and alternatives, An offer to answer questions about the procedure, Instructions that the pt. can withdraw consent. If pt. does not speak English consent must be written and verbal in the pt.'s language. |
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Remember, when assessing pt.'s pre-operatively to:
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find out their pregnancy status!
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What are some nursing considerations when the pt. is given anesthesia??
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Nursing considerations when the pt. is given anesthesia:
Can decrease B.P. Not for hypovolemic pt.s Can cause a headache Blocks the autonomic nerves |
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What are pre-operative nursing measures that decrease the risk of post. op complications?
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Pt. teaching:
Diaphragmatic breathing/ Coughing/ Leg Exercises/Foot exercises/ Mobility Provide Psychosocial interventions: Assist the pt. to identify coping strategies that he or she has used previously to decrease fear. Help the pt. determine the source of fears. Let the pt. know that family and friends will be there following surgery. Let the pt. know what to expect following surgery. Maintain pt. safety Managing nutrition and fluids (Depends on the age of the pt. and the type of food eaten.) Preparing the skin (Decrease bacteria w/out injuring the skin) Hair is not removed unless it interferes with operation. It would then be removed with clippers in the O.R. Enemas are usually only given in abdominal or pelvic surgery/ |
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Describe the interdisciplinary approach to the care of the pt. during surgery:
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The surgical team consists of :
Patient Circulating Nurse: (R.N.)(Not sterile) Coordinates and documents care in the O.R. Prepares skin for surgery, pt. positioning, monitors temp. lighting, supplies, safe equipment, monitors for aseptic techniques and calls for a "Time out" in which every member of the surgical team verifies the pt.'s name, procedure, and surgical site before beginning the surgery. Scrub Role:R.N. L.P.N. or surgical technologist who scrubs and dons sterile attire, prepares surgical equip. and supplies and provides them during procedure. The scrub person and circulator count all needles, sponges, and instruments. All sponges need to be visable on X-ray and counts need to take place once before and twice at the end. Surgeon: Heads the team First Assist: (R.N.) Right hand to surgeon, handles tissue, helper. Anesthesiologist or anesthetist: |
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Principles of Surgical Asepsis:
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All surgical supplies, instruments, needles, sutures, dressings, gloves, covers, and solutions that may come in contact with the surgical wound or exposed tissue must be sterilized before use. Only personnel who have scrubbed, gloved, and gowned touch sterilized objects. Non-scrubbed personnel cannot touch anything sterile.
Meticulous cleaning of the OR takes place in between cases. Air is also filtered. Gowns are considered sterile in the front from the chest to the level of the sterile field. The sleeves are considered sterile from two inches above the elbow to the cuff. Sterile areas must be kept in view during any movement, and a 1ft. distance must be maintained during any movement to prevent contamination. |
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Types of Anesthesia and Sedation:
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General: Not arousable, cannot ventilate on own . Touch is good while going under and waking up. Monitor Respration's as anesthesia slows breathing.
Regional: Does NOT compromise respiratory. Epidural, Spinal, and Local Blocks. Headache is a common side effect. Moderate Sedation: Pt. can still breathe on own, conscious sedation, loss of hearing. Local Anesthesia: Anesthesia is injected into tissues at the incision site. |
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Why is it important to know if a pt. is on antihypertensives, diuretics, digoxin, potassium chloride, or insulin injection prior to surgery?
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Diuretics can cause excessive respiratory depression due to electrolyte imbalance.
Need more info. |
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What are some Intraoperative Complications?
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Nausea and Vomiting: Cannot always be avoided (After surgery turn pt. to side if suspected)
Anaphylaxis: Nurse's must be aware of type and agent used to prevent this life-threatening reaction. Hypoxia: Must monitor oxygen levels at all times. Hypothermia: Metabolic acidosis (to much Co2) Low body-temp. Re-warm pt. gradually. Higher risk: infants and elderly Malignant Hyperthermia: rare, life-threatening condition, triggered by exposure to most anesthetic agents inducing a drastic and uncontrolled increase in skeletal muscle oxidated metabolism that can overwhelm the body's capacity to supply oxygen, remove Co2 and regulate temp, leading to circulatory collapse and death if untreated. |
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What are the symptoms of malignant HYPERthermia?
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Tachycardia (H.R. greater than 150)
Rigid muscles Rise in temp. is a later sign!! STOP ANESTHESIA! |
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What are the Surgical Positions?
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Dorsal Recumbent. Flat on back (Most common position)
Trendelenburg: Upper body is slightly lowered High risk of aspirations Used in Pelvic and abdominal surgeries. Lithotomy: used for all perineal, rectal, and vaginal. Most susceptible to DVT. Sims or Lateral: Off to one side. Used for renal surgery. Beware of Bony prominences. |
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Normal levels:
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Potassium: 3.5-5.0
Sodium 135-145 Creatinine: .6-1.2 (kidney function) |
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Nursing Process:
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Maintenance of Safety:
Aseptic Environment Manage human resources Patient transfer/positioning/grounding (O.R. is at high risk for electrical fires Physiologic Monitoring Fluidloss/gain (How much fluid was given during surgery, how much output. Vital sign monitoring Psychological Support: Emotional support Touch |
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Post Anesthesia Care:
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PHASE 1 PACU: immediate recovery phase where intensive nursing care is provided
PHASE 2 PACU: less frequent observation required |
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PACU ASSESSMENT:
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1.) AIRWAY!!!!! prevent hypoxia (reduced oxygenation in the blood)
Cardiovascular stability (Regular rhythm, any tachycardia, bradycardia, and is cap. refill less than 3 sec.? Pain and Anxiety Nausea and Vomiting Mental status (if low on oxygen, mental status changes) WATCH PULSE OX. WATCH FOR DROP IN B.P. If systollic is less than 90mmHg report immediate. Compare pre-op B.P. to post op B.P. A previously stable B.P. that has a downward trend of 5mmHg should be reported. Watch color, and rate of respirations! Minimum of 30 mL of urine |
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PACU discharge
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Stable Vital signs
Orientation Pulmonary Function Pulse oximetry Urine output Nausea and vomiting under control Minimal pain Aldrete score between 8-10 |
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Nursing Interventions:
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Preventing Respiratory Complications (incentive spirometer, deep breathing)
Relieving pain (dilated pupils, sweating, increased B.P. are all symptoms) Encouraging activity (If they cannot walk now, what time would they like to take a walk at?) Promoting wound healing (diet) Maintaining normal body temp. Maintaining G.I. function (Have you had any bowel movements or gas?) Nutrition Resumption of urinary function Move pt. at least every 2 hours! |
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Post Op. Assessment:
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Respiratory: Atelectasis, Pneumonia. Pulmonary embolism, Aspiration (assess Depth, Rate, Sound),
Neurologic: Delirium, Stroke? Keep patient in a well-lit room, close to nurse's station. Urinary: Acute urine retention,UTI? Pt. should urinate w/in 8 hours of surgery Functional: Weakness, fatigue,Functional decline Wounds: Infection, Dehiscence, Evisceration, Delayed healing, Hemorrhage, Hematoma (clot in wound, swelling?) Cardiovascular" Shock, DVT (Thrombophlebetis) Use Anti-embolism stockings. Prophylactic treatment of heparin can also help to prevent DVT's. Gastrointestinal: Constipation, Paralytic ileus, Bowel obstruction. Plenty of fiber, H20, etc. If the pt. is having shallow breaths is there another cause, such as drsg. too tight, obesity? SAFETY: 3 side rails up, bed in LOW position. |
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If there is swelling at an incision line or excessive drainage what might this be?
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DEHISCENCE
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If this incision is opening and there is evidence of bowel through the incision what is this?
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EVISCERATION
Step 1: Stay w/ pt. Saline on drsg. Low-fowler's position Call Dr. Stat. surgery. |
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DVT
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Symptoms:
pain in calf, swelling, heat To Prevent: Ted Hose, SCD's, walking, hydration. DVT would not show on Pedal Pulse, it would be unaffected. |
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Types of Drains following surgery:
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PENROSE Drains:Not expecting a lot of drainage fluid should be getting less and less.
Jackson Pratt: More drainage, empty when container is 1/2 full, wear gloves Hemovac: Most drainage |
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Variables that affect wound healing:
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Surgical wound healing occurs in 3 phases. First intention, Second intention, and third-intention wound healing Ongoing assessment of the surgical site involves inspection for approximation of wound edges, integrity of sutures or staples, redness, discoloration, warmth, swelling, unusual tenderness or drainage. Adequate nutrition, cleanliness, rest, and position determine how quickly a wound heals.
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Describe shock and the underlying pathophysiology:
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Shock is a condition in which widespread perfusion to the cells is inadequate to deliver
oxygen and nutrients to vital organs or support cellular function. Nutshell: A decrease in blood flow to body tissues causes cellular dysfunction leading to eventual organ failure. Impaired tissue perfusion is the end result |
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What must be present in order to have adequate blood flow to the tissues?
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Sufficient blood volume
Adequate cardiac pump Effective vascular and circulatory system |
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Define Hypovolemic shock:
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A decrease in intravascular fluid results in decreased venous return of blood to the heart and subsequent decreased ventricular filling. Decreased ventricular filling results in decreased stroke volume and decreased cardiac output. Cardiac output drops, BP drops, and tissues can no longer be adequately perfused.
(Low intravascular blood volume) |
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All types of shock have certain physiologic responses:
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hypoperfusion of tissues
hyper metabolism activation of the inflammatory response |
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Steps of shock:
First symptom: Tachycardia H.R. is attempting to keep up. |
Initial physiologic insult (could be car accident, surgery, dehydration, vomiting, sweating, etc)
Decrease in cardiac output and tissue perfusion Sympathetic nervous system (Fight or Flight) Endocrine Response Renin angiotensin activation (Kidney's secrete renin to increase blood flow.) Vasoconstriction and activation of antidiuretic hormone increases PRELOAD. Vascular compliance, blood volume, and cardiac output. |
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M.A.P
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Mean arterial pressure : Should be above 65mmHg-70mmHg (Shows blood volume, do not rely on machines for numbers)
Anotherwords: MAP>65=Perfusion |
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Pulse Pressure:
S=120 D=80 P.P= 40 S=110 D=90 P.P.=20 If the pulse pressure decreases what does this indicate? |
Stroke volume is decreasing
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Stages of shock:
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Compensatory (phase 1)
Progressive (phase 2) Irreversible (phase 3) |
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What is happening in the compensatory phase of shock?
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SNS (sympathetic nervous system, "fight or flight" kicks in causing vasoconstriction, increased HR, and increased heart contractility. Epinephrine and norepinephrine are released
BP and CARDIAC output are still maintained within normal limits Body shunts blood from skin, kidneys, and GI tract, which results in cool, clammy skin, hypoactive bowel sounds, and decreased urine output. Perfusion of tissues is inadequate, lactic acid builds up. Lack of oxygen leads to acidosis due to anaerobic metabolism. Respiratory rate increases due to acidosis and may cause a compensatory respiratory alkalosis. Confusion may occur. |
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Is a Drop in BP an early or a late symptom in the compensatory phase?
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LATE, the body will still be trying to maintain BP. A Drop is a late sign in shock. Do not wait for this sign.
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Over all what is the nurse monitoring for in tissue perfusion?
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Changes in LOC, vital signs, urinary output, cool clammy skin, and lab values. (Base deficit, and ABG's (lactic acid levels)
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What is happening in the progressive state of shock?
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Mechanisms that regulate BP can no longer compensate.
Decrease in BP and MAP All organs suffer from hypo perfusion Vasoconstriction continues, further compromising cellular perfusion. Mental status further deteriorates as a result of decreased cerebral perfusion and hypoxia. Lungs begin to fail, decreased pulmonary blood flow causes further hypoxia, and CO2 levels INCREASE, alveoli collapse and pulmonary edema occur. Inadequate perfusion to the heart leads to dysrhythmias and ischemia. (loss of blood flow to organ) As MAP falls below 70, GFR cannot be maintained. Acute renal failure may occur. Liver function, GI function, and hematologic function are all affected. DIC (disseminated intravascular coagulation) may occur as a cause of shock. (Widespread intravascular coagulation) BP starts to fail! |
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Irreversible Stage of Shock
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Organ damage severe
BP remains low Renal and liver functions fail Anaerobic metabolism worsens acidosis. Multiple organ dysfunction progresses to complete organ failure. The judgment that shock is irreversible is made only in retrospect. |
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During Hypovolemic shcok the pt. is experiencing External fluid loss or Internal fluid shifts. List some of both:
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External fluid loss:
Hemorrhage (Loss of RBC's)(Need blood cell replacement Trauma Diuretics Loss of GI fluid (caused by aspirin) Diabetes Insipidus Vomiting (Loss of potassium, Electrolyte replacement therapy needed) Diarrhea (Loss of potassium) NG suction (K+ Loss) Internal fluid shifts: Hemorrhage Burns Ascites (3rd spacing-Interstitial) Peritonitis (fluid in lungs) Dehydration Internal bleeding caused by organ rupture or anticoagulant therapy |
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Management in all types and phase of shock includes:
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Support of respiratory system w/ supplemental oxygen and/or mechanical ventilation.
Fluid replacement to restore intravascular volume. Vasoactive medications to restore vasomotor (vascular) tone and improve cardiac function. Nutritional support to address the metabolic requirements that are often dramatically increased in shock. |
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Relative Hypovolemic Shock:
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The fluid has not left the body but has shifted from the IVS to another space that is unavailable for circulation.
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In the progressive phase what position would we need to put the pt. in?
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Modified Trendelenburg position. The legs are elevated to promote return of venous blood. (Not used in compensatory phase, as the body is still compensating.)
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Types of Fluid Replacement:
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Crystalloids: 0.9% saline, lactated Ringer's(widely available) hypertonic sollutions(3% saline, draws fluid)
Colloids: albumin (human based) dextran(rapidly expands plasma volume, may interfere with platelet aggregation. BLOOD:componenets for hypovolemic shock. (always a solo line) |
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What are some complications of fluid replacement?
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fluid overload and pulmonary edema.
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If fluid fails to reverse hypovolemic shock, what can be given?
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Vasoactive medications that can prevent cardiac failure.
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When a pt. is on vasoactive medications what is a nursing priority?
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Vital signs every 10-15 minutes. Given through a central line.
Vasoactive meds. support hemodynamic status by stimulating the SNS. |
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What is the essential focus of nursing care in regards to shock?
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Primary prevention
Hypovolemic shock can be prevented in some instances by closely monitoring patients who are at risk for fluid deficits and assisting w/ fluid replacement before intravascular volume is depleted. Nursing considerations: 1.)Safe administration of prescribed fluids and meds. 2.)Documenting administration and effects. 3.)Monitor for complications and side effects of treatment and report promptly. |
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What are the results of hypovolemic shock?
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1.)Decreased venous return
2.)Decreased stroke volume 3.)Decreased CO 4.)Circulatory insufficiancy 5.)Inadequate tissue perfusion |
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Potential causes of hypovolemic shock:
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Burns
Vomiting/Diarrhea Trauma Surgery Hemorrhage |
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There are many types of rheumatic diseases/disorders. What is most affected by R.D?
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skeletal muscles, bones, cartilage, ligaments, tendons, & joints. They can affect both men & women.
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What is the onset of Rheumatic diseases?
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acute or insidious
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Rhematic disorders can have both remission or exacerbation. What is the classification?
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Monoarticular (affects a single joint)or Polyarticular.(affects multiple joints
RX: Simple or Complex |
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What types of assessment and diagnostic tests are used?
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General Health History: physical and complete assessment. onset of symptoms, family history, patients perception of problem, gait, musculoskeletal size and structure, gross deformities and abnormalities in movement. symmetry, size, etc.
ARTHROCENTESIS:going into joint space, fluid should be clear, straw or amber colored and scant. X-Ray (MRI, no metal, jewelry, pacemakers, tattoos, some patches,) CT scans:w/ or w/out dye Lots of radiation Tissue biopsies Blood tests |
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Know these blood tests: (On exam)
Creatinine |
Levels should be ( .6-1.2 ) An increase may indicate renal damage, this will tell if the rhuematic disease has attacked the kidney's yet.
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Know these blood tests: (On exam)
ERTHROCYTE SEDIMENTATION RATE (ESR) |
This test looks at how fast the RBC's settle; which represents inflammation activity . This test shoes the progression of the disease.
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Complete Blood Count
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Hematocrit, RBC, WBC
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URIC ACID
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elevated levels of uric acid w/ gout
(2.5-8) |
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Rheumatic Factor
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Negative or Positive
Determines presence of abnormal antibodies in connective tissue. |
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Antinuclear antibody (ANA)
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Negative or Positive
Are you making antibodies? |
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C-reactive protein
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Shows presence of glycoprotein due to inflammatory process
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Compliment levels
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The only test when positive, the levels go down.
Shows inflammation |
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What are some ways to medically manage Rheumatic disorders?
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Pharmacologic Therapy: Salicylates, NSAID's, anti-inflammatories, antirheumatic drugs. These all help to manage pain, but have a delayed response.
Nonpharmacologic Therapy: ice: brings down inflammation, max. time 20 minutes. assistive and supportive devices: canes, crutches, walkers, splints, cervical collars, metatarsal bar, foot pads. Exercise and Activity: improove joint mobility and overall function. Alternative Therapies: muscle relaxation techniques, imagery, self-hypnosis, and distraction. Weight reduction to relieve stress on painful joints. |
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Nursing Management with Rheumatic Disorders:
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FATIGUE is a major symptom and does not go away w/ sleep.
1.)Relieve pain and discomfort 2.)Decreasing fatigue/promoting restful sleep....In pt.'s w/ acute pain, sleep time is reduced. 3.)Increasing mobility/facilitating self care. 4.)Improving body image and coping 5.)Education 6.)Monitoring and managing potential complications |
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Diffuse Connective Tissue Diseases:
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Rheumatoid Arthritis
SYSTEMIC lupus Erythematosus Scleroderma |
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Rheumatoid Arthritis:
(Occurs mostly in women, it can be genetic, and long-term exposure to an antigen can lead to R.A.) |
How to Diagnose R.A. (4 0f the 7)
*Morning stiffness greater than one hour. *Arthritis of more than 3 joint areas. *Arthritis of hand joints *Symmetric arthritis *Rhematoid nodules *Positive Rheumatoid Factor *Radiographic changes |
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What is the pathophysiology of R.A.?
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The Synovial Joint ( area most commonly affected) Inflammation is eroding both the bone and the cartilage.
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What does it mean to say that R.A. is localized?
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1 joint is affected.
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What does it mean to say that R.A. is multi-system or systemic?
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All involve some degree of inflammation and degeneration.
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In inflammatory Rheumatic disorders the primary process is inflammation caused by the immune response. Degeneration occurs as what?
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A secondary process, resulting from the effect of pannus (proliferation of newly formed synovial tissue infiltrated with inflammatory cells)
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If R.A. goes systemic what can be the affects?
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# 1 assessment priority:
PERICARDITIS:inflammation around the heart. fever weight loss anemia lymph node enlargement rheumatoid nodules: non-tender movable; indicates rapid progression of disease. arterisis neuropathy scleritis (eye) splenomegaly SJOGREN'S SYNDROME: dry eye and mucous membranes RAYNAUD'S: cold induced, burning hands and feet, vasospasm digital blanching. (Pt.'s w/ Raynaud's should NOT smoke.) |
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What will show in the assessment and diagnosis of Rheumatoid Arthritis?
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Rheumatoid nodules
Symmetrical stiff, tender, swollen joints Weight loss, fatigue Elevated ESR (Sed Rate or Erythrocyte sedimentation rate) Rheumatoid Factor Positive in 80 percent or 3/4 of patients. RBC and C4 complement decreased. Positive C-reactive protein and ANA. Synovial fluid : cloudy, milky, or dark yellow. Usually found in hands and feet, swan-neck deformities. **Baseline of x-Rays should be established to monitor the progression of R.A. |
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When a pt. is diagnosed with R.A. what is most important?
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Aggressive and early treatment, best w/ in 3 months. There is a 2yr. window of symptom control from the onset.
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Can a person with R.A. take live vaccines?
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No.
Live=MMR, Varicella, and Flu |
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DMARDs should be given w/ in first 2 years of diagnosis.
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Antimalarials: monitor eyes
Gold Penicillin Immunosupressors:Methotexate, Cytoxan:if symptoms are aggressive, watch for infections and educate pt. NSAID's, ASA, Cox-2 inhibitors Corticosteroids Antidepressants Biologic response modifiers:new early treatments. |
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How would you check for pericarditis? (Can take place with R.A. or Lupus)
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If a patient complains of chest pain, stop and Listen apically, or to the left of the sternum third intercostal. A grading or scratching sound might indicate inflammation.
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SYSTEMIC Lupus Erythematosus (SLE)
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Differences from R.A. in particular are the CNS,(subtle changes in behavior patterns or cognitive ability. Renal, Butterfly shaped rash across the bridge of the nose, and oral ulcers.
Aslo: Insidious or acute Musculoskeletal system and synovitis |
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SLE Assessment /Diagnosic Findings
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History and Physical Exam
Blood tests: anemia due to less platelets thrombocytopenia: means less platelets, bleeding. No razors and soft toothbrushes recommended. Leukocytosis: increase in WBC's due to inflammation leukopenia: abnormally low WBC's ANA: Positive Positive lupus antibodies Serum Compliment decreased in both R.A. and Lupus BUN, Creatinine, UA L |
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SLE (LUPUS Diagnosis likely if 4 of 11)
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1.)Butterfly rash
2.)Discoid skin rash (deep scars) 3.)Photosensitivty (sunlight or ultraviolet) Educate SPF 60 and wide-brimmed hats Mucous Membrane Ulcers Arthritis of 2 or more joints Pleuritis OR Pericarditis Kidney abnormaility Brain irritation CBC abnormalities Positive ANA Immunologic disorder antibodies |
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If a pt. is on steroids, what should we monitor?
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Bone density
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What needs to be managed in SLE or Lupus?
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Preventing loss of organ function
Decrease acute exacerbations Prevent complications of therapy Medications: DMARD's, corticosteroids, antimalarials, NSAID's, Immunosuppressive agents Fatigue Pain Impaired Skin Integrity Deficient Knowledge Nutrition |
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What is most important to educate Lupus pt.'s on from a nursing standpoint?
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Avoid sunlight or wear protective clothing.
Routine screenings due to the risk of multiple organ systems. Nutrition is very important due to the increased risk of cardiovascualr disease. There is an Increased Risk of Systemmic involvement. |
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What is happening to the body of a pt. with Scleroderma?
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HARD-SKIN
The body is producing the wrong type of collagen. It is rare, the cause is unknown, and there is a poor prognosis. Remission/Exacerbations |
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What are some of the specific's to Scleroderma?
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The skin is insoluable collagen, taut, shiny, skin.
Raynaud's (vasospasm in hands and feet, burning, cold induced, pt. should NOT smoke.) Mask-like face (wrinkles go away) Internal sclerosing of the heart, esophagus, lungs, intestines, and kidney's. CREST syndrome |
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What is CREST syndrome?
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Calcinosis: calcium deposits
Raynaud's: cold and stress induced vasospasms Esophageal hardening and dysfunction Sclerodactyly: scleroderma of digits (contractures in fingers) Telangectasia- capillary dilation (seen in alcoholics) |
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What are the diagnostic findings of Scleroderma?
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Skin biopsy: cellular changes
Echo-LV changes; cardiac effusion Esophageal studies-decreased motility Blood Tests: ANA Treatment is based on organ involvement and supportive. It depends on how many organs are affected. |
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What is Fibromyalgia?
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A common syndrome, the etiology is unknown. Could be Viral, Lyme, nonrestorative sleep. It is a metabollic and endocrine disorder associated with Rheumatic disorders.
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What are some of the general symptoms associated with fibromyalgia?
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Chronic fatigue, generalized muscle aching & stiffness; abnormal pain perception; 9 PAIR OF TENDER POINTS.
RX symptoms and supportive care: NSAIDs, tricyclic antidepressants for sleep, SSRI and anticonvulsants. |
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Nursing Process of Fibromyalgia:
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Validation helps the pt. to cope.
Also statisitcs show that the nurse offering therapeutic communication can help the pt. significantly. Fibromyalgia is CHRONIC. |
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What is osteoarthritis?
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It is a degenerative joint disease. The only one that we are studying that is not systemmic. The cartilage erodes so the body produces more bone which compounds the problem.
It is a localized inflammation without an increased SED rate and CBC's would still be the same. |
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What is the pathophysiology of osteoarthritis?
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It affects the articular cartilage, subchondral bone, and synovium.
NOT SYSTEMMIC. It is also Idiopathic (no prior event or disease) Begins at age 30 and peaks between the 5th and 6th decades. |
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What are the risk factors of osteoarthritis?
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AGE: Increasing age directly relates to the degenerative process, microfractures are common.
Obesity Previous joint damage Repetitive use (tennis player's) Anatomic deformity (congenital born with one leg longer than the other Genetic susceptibility |
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What is the best way to help osteoarthritis?
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loose weight
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What would we see when assesing a pt. with osteoarthritis?
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Tender stiff usually less than a half hour in the morning, and decreases with movement.
Enlarged joint: Heberden's nodes: bony enlargement of distal interphalangeal joint Bouchard's nodes:proximal Inflammation: localized not systemmic Narrowing of joint space (progressive loss of joint cartilage that appears on X-ray as a narrowing of joint space. Osteophyte development: cartilage is attempting to regenerate. |
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Inflammation when present in osteoarthritis is what?
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Not the destructive type seen in the connective tissue disorders such as R.A.
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Management of osteoarthritis:
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NO DMARDS
Pain: acetaminophen, NSAID, COX-2 inhibitors Joint Function Mobility Surgical Adult pt.'s no more than 4 g. per day of acetaminophen. |
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What is the gout?
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Genetic defect in purine metabolism resulting in hyperuricemia.
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What can cause gout?
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Foods high in purines such as organ meats and shellfish. Also starvation
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What is hyperuricemia?
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Crystal deposits in toes, hands, and ears.
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What can trigger gout?
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stress, trauma, alcohol
DX: microscopy of synovial fluid Acute & Chronic |
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What is immunity?
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The body's specific protective response to invading foreign agent or organism.
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What are the main components of the immune system?
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Differential WBC
Central and Peripheral Lymphoid Organs Barriers |
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What is the differential WBC composed of and where are they produced?
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WBC's (produced in bone marrow)
Granulocytes: Neutrophils:first cells to arrive at site,where inflammation occurs. usually indicative of a bacterial infection. Eosinphils:increase during stress and allergic reactions. Basophils Agranulocytes: Monocytes: phagocytic cells. Lymphocytes: *B cells: mature in bone marrow and then enter circulation *T cells: move from bone marrow to the thymus |
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What do cytotoxic cells do?
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Kill the cells
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What do helper cells do?
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Support antibody production
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Immune disorders (excess or deficiency) The body is producing "too much" or "too little" responses to specific agents.
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Autoimmunity: attack of self
Hypersensitivity: exxagerated response to antigen, ex. allergic reaction to bee sting. |
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HIV is an example of what type of immune deficienciy?
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Secondary
They are bron healthy and are now fighting a daily battle. |
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What is the main phagocyte or infection fighter?
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neutrophils
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The Central and Peripheral Lymphoid Organs are what?
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Lymphnodes: can palpate for infection
Spleen: Important for immune function, if the pt. no longer has a spleen, say due to a car accident, they are more compromised. |
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What are the barriers?
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intact skin, chemical barriers, and acidic gastric secretions or enzymes in tears or saliva
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Natural immunity
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Barriers
WBC's A non specific response to any foreign invader. Inherited and involves the immune response. |
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What is acquired immunity?
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Specific response against a foreign antigen as a result of a prior exposure to an antigen. Vaccination.
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What are some of the variables that affect immune function?
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Age and Gender
Nutrition: May be due to alcoholism Presence of conditions and disorders: cancer/neoplasm, chronic illness, autoimmune disorders (lupus, R.A.) Allergies History of Infection and immunization Genetic factors Lifestyle Medicatioons Psychoneuroimmunologic factors: ex. family support, depression, stress. Burns |
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What do we need to do to evaluate immune function?
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Get a Health history (Listen)
Family History: anyone who has had lupus or R.A. in the family? Evaluate for variable impacting the system? Are you having a lot of colds, infections, etc? Systems Review: Any heart problems, breathing difficulties, etc.? Medication Review: Palpation of the lymphnodes, examinin the skin, mucous membranes, gastrointestinal, musculoskeleta, genitourinary, cardiovascular, and neurosensory systems. |
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What are the tests to evaluate Immune Function?
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WBC count and differential (31 indicator of immunity)
Bone marrow biopsy (done in sternum and hips in adults) Complement component tests: one of the few test results that will decrease indicating a positive reading. Hypersensitivity tests Specific antigen- antibody tests HIV infection tests. |
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What is the structure of HIV?
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It is a retrovirus, it carries its genetic material in the form of RNA, rather than DNA. Infection starts when HIV enters the host CD4 (T) cell(It can not live w/ out a host cell) Which is the CD4 helper cell.
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How is HIV transmitted?
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Through bodily fluids through hetero or homo sexual acts with an HIV infected person. People who received blood transfusions, children born to mothers with HIV, breast-fed infants, and health care workers exposed to needle stick injury by an infected patient. Deep open mouth kissing, tatoos.
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Clinical manifestations:
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can be mild abnormalities in immune response w/ out overt signs and symptoms to profound immunosupression, life-threatening infection, malignancy, and tissue damage.
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HIV cannot spread through?
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air or water
mosquitos saliva alone sweat |
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Clinal manifestations cont.
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Respiratory: SOB, dyspnea (labored breathing) Pneumonia is the most common opportunistic infection in AIDS pt. fever
GI: loss of appetite, N/V, diarrhea, wasting syndrome, oral candidiasis Fatigue Cancers: Most common in people w/ AIDS. Kaposi's sarcoma is most common malignant tumor growth . B-cell lymphoma 2nd most common and cervical cancer: pay attention to a yeast infection that doesn't go away. Neuro: Distal Sensory Polyneuropath (DSPN) Encephalopathy : AIDS dementia complex. CMV renitis Depression Herpes simplex or Zoster |
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What is cancer indicative of?
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Usually is a sign of a pt. transitioning from HIV to AIDS.
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Stages of HIV disease:
What is primary infection? |
The period of infection with HIV to the development of HIV specific antibodies. Initially there is a window period in which a person can test neg. even though they are pos. Highly contagious characterized by high levels of viral replication.
Symptoms can be none to flu-like. Most people will develop detectable antibodies within 2-8 weeks; avg. 25 days. |
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HIV asymptomatic:
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After the viral set point is reached, HIV + people enter into a chronic stage in which the immune system cannot eliminate the virus. Can go w/ out symptoms for 8-10 years.
More than 500 CD4 T lymphocytes, so body has sufficient immune response to defend against pathogens. |
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HIV symptomatic
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CD4 T cells gradually fall and symptoms begin to show.
Pt |
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AIDS
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CD4 T cell levels drop below 200 cells/mm, significantly imparing the immune system.
Opportunistic infections/Opportunisitc cancer Wasting syndrome Dementia |
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What are some of the most common HIV-related opportunisitc infections?
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Tuberculosis, Pneumonia, septicaemia (blood poisoning) Toxoplasmosis (pt.'s w/ HIV should not have a cat) Fungal diseases, candidiasis, Fungal & Viral diseases...Herpes, Kaposi's sarcoma, lymphoma.
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Treatment (HAART)
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Highly Active Anti-Retroviral Treatment.
Adherance is mandatory and at least 3 of the drugs must be taken at one time. |
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Nursing Carse:
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Fatigue:
Diarrhea: Monitor I & O's, weight , education about caloric intake. Imbalanced Nutrition: Risk for Infection: No cat, No rare meat, etc. Social Isolation: Support groups Impaired Skin Integrity: tell pt. to avoid scratching, to use nondrying or nonabrasive soaps, skin moisturizers, keep bed linen free of wrinkles, wear white cotton socks and shoes, sitz bath, Activity Intolerance: monitor ability to ambulate and perform daily activities, teach energy conservation strategies. Deficient knowledge: Educate Anticipatory grieving: Disturbed thought processes: |
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How the virus spreads:
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Infectious agent (virus)
need a reservoir (place to live) could be people, equipment or H20. Then the virus must have: a portal of exit: through excretions, secretions, skin, and droplets. (Hand hygeine can help stop the spread) Means of transmission: Direct contact, Ingestion, or Airborne (A mask would stop) Next, a portal of entry through: mucous membrane, GI or GU tract, respiratory tract, broken skin: And now we need a susceptible host preferably someone who is immunocompromised such as the elderly, someone w/ diabetes, a burn, or follwoing surgery. |
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Transmission based precautions:
What are Airborne precautions? |
Hospitalized pt.'s should be in negative pressure room w/ the door closed; health care workers should wear an N-95 respirator mask at all times when in the room.
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What are droplet precautions?
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Wear a face mask but door may remain open; transmission is limited to close contact.
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What are contact precautions?
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Use of barriers to prevent transmission; emphasize cautious technique as organism is easily transmitted by contact between the health care worker and the pt.
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What is Clostridium Difficile? (C.diff)
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A bacterial organism that has a distict odor, and must have at least 3 watery stools. If the stool is formed don't send it to the lab.
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How are these G.I. bugs trasmitted?
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The portal of entry (oral ingestion)
A disruption of normal acidity Increased number of organisims Antimicrobial agents Immune dysfunction C.Diff can live on surfaces for months! |
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Indications for work-up for Clostridium difficle:
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3 or more episodes of watery stool w/ a 24 hr. period OR
pt. w/ a history of C. diff is admitted w/ diarrhea, Get order for: stool for Clostridium difficile toxin Test diarrhea stools only |
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What are the symptoms of C. Diff?
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Watery diarrhea
Fever Loss of appetite Contact isolation nausea abdominal pain |
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The facts:
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C. diff spores can live outside the human body for months.
Even after washing them, spores can be found on virtually every hospital surface, including bedrails, telephones, call buttons, and toilets. Spores can even cling to skin. Infections can be spread person to person on the hands of health care providers and visitors. Alcohol will not kill. Must use soap and water. |
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C.Diff prevention:
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Hand Hygeine:soap and H20
PPE: gowns and gloves upon entry into pt.'s room Isolation: use contact precautions for pt.'s w/ a history of C.Diff, pt.'s admitted w/ diarrhea or if a C.Diff test is oredred. Environmental: a bleach-based product, for daily cleaning of bed, bedrails, furniture, bedside commode, bathrooms, and any high touch surfaces. Equipment: dedicated pt. care items wherever possible. |
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The OTHER ABC's
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Activate Surveillance of high risk pt.'s
Barrier Precautions Compulsive Hand Hygiene Disinfection/Environmental Cleaning |
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Assessment of C. Diff
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Hydration status:
thirst oral mucosa sunken eyes weak pulse (like in hypovolemia) loss of skin turgor. Measure liquid stool only Measure I & O's; weight Accurate history |
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Nursing Process: Diagnosis
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Deficient fluid volume r/t fluid loss from diarrhea
Deficient knowledge r/t infection transmission to others |
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Nursing process: Outcome criteria:
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Maintenace of fluid and electrolyte balance
Increased knowledge about the disease, risk of transmission Absence of complications |
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Nursing process: Interventions
What would you give in a case of mild dehydration? |
50 ml of oral rehydration solution per 1kg of weight over a 4-hr. interval
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How much in a case of moderate dehydration?
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100ml/kg over 4 hours
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How much in severe dehydration?
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IV replacement
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How much loss in hypovolemia?
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A liter per hour.
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If a pt. has a UTI and is taking antibiotics, what is likely to happen?
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Yeast infections
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If a pt. has bladder issues should they drink coffee or alcohol?
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No, because they are bladder irritants
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Where can urinary tract infections be located?
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Most common in women because of anatomy and intercourse.
UPPER: Pyelonephritis: means kidney infetion, the bladder infection coould have made its way up to the kidney. Lower: Cystitis, prostatitis, urethritis. |
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Signs and Symptoms of a UTI:
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CYSTITIS: in the bladder
Frequency Urgency Suprapubic Pain Dysuria: painful urination Hematuria: blood in urine Fever: not usually CONFUSION: BIG SYMPTOM in older adults, look for possible UTI's. PYELONEPHRITIS: Flank pain Dysuria Pain at Costovertebral Angle Same S&S as Cystitis |
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Diagnosis for UTI:
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GET A CULTURE!
Dipstick for leukocyte Estrace and Nitrates UA/ C&S Increased Rick in Older Adults |
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Treatment for UTI:
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Anti-Microbials
Increased Fluid Intake Do not ingnore the urge |
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Nursing Goals For UTI's:
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Symptomatic Relief
Teaching & Prevention: Showers better than baths Perineal cleansing "front to back" Voiding after intercourse Anti-Microbial Therapy No scented t.p. No perfumes , etc. to perineal Empty bladder regularly. Drink 8-10 glasses of fluid per day. Also pt.'s can get infections though immobility and blood infection. |
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How do we assess Urinary?
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Health History: Elderly Concerns(look at creatinine clearance)
Changes in voiding : how much, any blood, color, odor, clarity, frequency, urgency GU symptoms GI symptoms Anemia Physical Exam: Abdominal assessment Bladder Percussion if no bladder scan available |
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If a pt. just voided will they still have urine in the bladder?
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Yes, probably 100 ml.'s.
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Diasnostic Evaluation of Urinary
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Urinalysis and Urine Cultue: looking for bacteria
Specific gravity: 1.010-1.025 Microalbuminemia Renal Function Tests X-Ray and other imaging modalities Urological Endoscopic Procedures: viewing though urethra into bladder Biopsy of kidney Urodynamic tests PSA (Prostate specific antigen) |
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If a pt. had a specific gravity over 1.025 what would that indicate?
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Dehydration
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If a pt. had a specifc gravity under 1.010 what would that indicate?
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Overhydration
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What is the number one cause for pt.'s entering a skilled facility?
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Urinary Incontinence
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What are the ranges for creatinine?
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0.6-1.2
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What does normal urine consist of?
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Sodium, chloride, bicarbonate, potassium, urea, creatinine, and uric acid.
Glucose is not usually present unless the amount in the blood exceeds the amount that can be reabsorbed: pregnancy and DM Protein usually not in urine |
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What could blood in urine be indicative of?
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Cancer brought on by smoking. (no pain)
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Dysfunctional voiding Patterns:
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Anything that interferes with normal emptying of urine:
Urinary Retention: can be a lot or a little, risk of infection. Neurogenic bladder: nerve or spinal cord injury Urinary Incontinence: can have a bladder lift to repair caused by: stress, urge or overactive bladder, functional:Alzheimer's or overflow: person that retains urine and overflow's because of the retention. |
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How can we manage incontinence?
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Behavioral: limiting fluids is NOT a way to treat incontinence
Pharmacological: Diuretics should probably NOT be taken at night. Surgical Other: Avoid constipation; avoid bladder irritants,(coffee, alcohol) void every 2-3 hours |
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What is urinary retention?
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An inability to empty bladder completely after each void.
After 60 years of age may have 50-100 residual (if a young person has 100ml residual there is a problem) Post void residual greater than 100mL is diagnositic of urinary retention Untreated leads to infection and leakage To facilitate: privacy, proper positioning, treat infections/constipation, running water, men prefer to stand. |
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What are the complications and treatment for a neurogenic bladder?
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Complications: infection, stones, kidney damage, immobility
Treatment: liberal fluids, catheterizations, decreased calcium intake. |
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Catheterization
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Indwelling devices and infections
Suprapubic catheterization Bladder retraining Intermittent self-catheterization |
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What are some measures a nurse can do to decrease the chance of infection in a catheter?
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Perform perineal care at least daily with soap and water
Keep the bag below the level of the bladder Empty the bag at least every 6-8 hours. |
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Renal Calculi (Kidney Stones)
Sign/Symptoms |
Increased Incidence in Males
N&V Agonizing flank pain May radiate to: groin, testacles, abdominal area Sharp, sudden, severe pain (may be intermittent depending on stone movement. May or may not have hematuria or Dysuria Urinary Frequency |
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What are the Diagnostics used for Kidney Stones?
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Ultrasound (non-invasive, no radiation)
IVP Renal Stone Analysis KUB (X-RAY) Serum: Calcium Oxalate, Uric Acid |
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What are the risk factors for Kidney Stones?
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Infection
Urinary Stasis & Retention Immobility Dehydration Increased Uric Acid Increased Urinary Oxalate I |
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Treatment for kidney stones
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NSAID's and OPIODS
1.)Cytoscopy: going in and pulling in out. 2.)Extracorporeal shock wave lithotripsy :sedation, can expect bruising,strain urine as stone will be pulverized 3.)Percutaneous nephrolithotomy: used to treat larger stone, the stone is extracted. Encourage movement in pt.'s w/ stones |
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Who has increased risk for urinary tract cancers?
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aging, caucasions, and tobacco is the leading risk factor.
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Types of urinary diversions:
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Cutaneous urinary diversion: most common, pt. has a urinary bag. Ileal conduit, watch for skin integrity should be pink.
Continent Urinary Diversion: Indiana Pouch, man made bladder w/ catheter. Ureterosigmoidostome:HUGE risk for infection, ureters are hooked up to colon. |
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In managing a stoma:
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watch for infection, watch for output, urine should be mucousy following surgery.
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Problems r/t male urinary function (male urinary & reproductive systems are intertwined)
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assess external genitalia
ask about urinary & sexual dysfunctioning/changes ex.)Do you have trouble starting the stream? Increased urinary frequency Decreased force or stream "Double" or "triple" voiding Nocturia, dysuria, hematuria, and hematospermia Medications, drug, and alcohol use Conditions that may affect sexual function (diabetes, cardiac disease, and multiple sclerosis |
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Does a nurse palpate the prostate?
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No
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Diagnostic Tests
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Prostate Specific Antigen (PSA) all men over 50, family history,
Ultrasonography Prostate fluid or tissue analysis (done w/ a needle) |
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Conditions of the prostate (can just be an infection not always cancerous)
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Prostatitis: inflammation caused by an infectious agent
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Conditions of the Prostate:
BPH |
Benign Prostatic Hyperplasia (enlarged prostate)
BIG SIGN:urinary obstruction Slow and insidious Affects half of men over age 50 and 80% of men over age 80 Risk Factors: Smoking, Heavy alcohol, obesity, decreased activity, DM, heart disease, hormones, Western diet Manifestations are those of urinary obstruction, urinary retention, and UTI's. As men age the risk of UIT's increase. |
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Treatment for BPH
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If minor symptoms: watchful waiting.
Pharmacologic: alpha-adrenergic blockers, 5-alpha reductase inhibitors, and antiandrogen agents Catheterization if unable to void, may need to be done by urologist Surgery |
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Prostate cancer
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difficulty and frequency or urination, urinary retention, decreased size and force of stream. Blood in urine or semen.
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Nursing Diagnosis for the pt. undergoing Prostateectomy:
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Anxiety/Sexual concerns
Acute pain postoperatively Acute pain postoperatively Deficient knowledge |
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Collaborative Problems/Potential Complications of Prostatectomy:
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Hemorrhage & shock
Infection DVT: if pt. is on levenox there will be more bleeding Catheter obstruction: nurse should keep from happening Sexual dysfunction |
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How do How do we plan the care of the pt. undergoing prostatectomy?
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Watch for hypernatremia
Major goal preoperatively: adequate preparation and reduction of anxiet and pain Major goals postoperatively: maintaenance of fluid volume balance, relief of pain and discomfort, ability to perform self care activities, and absence of complications |
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Relief of Pain:
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Monitor urinary drainage and keep catheter patent.
Assessment of pain: Bladder spasms cause feelings of pressure and fullness, urgency to void, and bleeding from the urethra around the catheter Medications and warm compresses or sitz baths relieve spasms Administer analgesics and antispasmodics as needed Encourgae pt. to walk but to avoid sitting for long periods PREVENT CONSTIPATION: very important, be sure to check for last bowel movements prior to any surgery. Irrigate catheter as prescribed. |
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3 way system for bladder irrigation
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The prostate is removed.
Very strict I + O's, subtract fluid entered from urine output If output is flowing too fast and is too clean slow the clamp. If there is red in the tube open the clamp for more fluids. The catheter drain stays closed for sterility |
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TURP
Transurethral Resection of the Prostate |
Continuous or Intermittent Bladder Irrigation
Close observation of drainage system , increased bladder distention pain & bleeding. Maintain catheter patency Bladder spasms Pain Control: Analgesics & decreased activity first 24 hours Avoid straining w/ BM's. Increase fiber & laxatives Complications: Hemorrhage bleeding should gradually decrease to light pin in 24 hours. Urinary incontinence-Kegal Exercises Infections: Increase fluids Prevent D.V.T.'s SCD's, low dose heparin, discourage sitting for long periods. |
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Which autoimmune disorders have Raynaud's?
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Rheumatoid Arthritis (R.A.)
Lupus Sleroderma |
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What is important teaching in pt.'s w/ Raynaud's?
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Do not smoke!!
Wear gloves in freezer.... (extremities hypersensitive to temp. change color, burning sensation |
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Which autoimmune disorders have Pericarditis?
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Rheumatoid Arthritis
Lupus |
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Which autoimmune disorder has Pleuritis?
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Lupus
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All of the disorders we have gone over are systemic, except which one?
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Osteoarthritis
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Where does the nurse listen for pericarditis?
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3rd intercostal space, left of sternum, to hear grating/scratching sound.
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Which disorder has Sjogen's syndrome?
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Rheumatoid Arthritis (dry eyes and dry mucous membranes)
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In which non systemic disorder will you see Herberden's Nodes and Bouchard's Nodes? PANUS
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Osteoarthritis
Heberden's nodes:bony enlargement of distal joint Bouchard's nodes: bony enlargement of proximal joint. |
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What is very important to the success of the treatment of Rheumatoid Arthritis?
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DMARD's w/in first 2 yrs of dx. (best if found in 1st months.)
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Which disorder can be prescribed antimalarial's?
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R.A.
(Plaquenel) Monitor eyes, watch for hallucinations, Lupus |
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Which disorder has a swan-neck deformity in the hands?
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R.A.
Boggy/Tissues and joints also!! |
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What will the synovial fluid look like in R.A.
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cloudy, dark yellow, or milky!
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Which lab results will decrease in our autoimmune disorders?
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RBC and CR complement are decreased in R.A.
C4 complement is also decreased in Lupus. |
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What is important for a nurse to know about immunosupressive agents?
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They shut down the immune system and are contraindicated with live vaccines.
Methotrexate, Cytoxan, DMARD's. They are all taken daily! |
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Your pt. has a butterfly rash, as well as a discoid rash, what do you think they might have?
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Lupus
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Your pt. has lupus, what is some important teaching for them to know?
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Photosensitivity (SPF 60)
Also, be aware of CNS changes, ex. personality, dementia.. |
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Your pt. has lupus, and you need to check labs to see if it has gone systemic. What might you check?
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BUN, Creatinine, UA.
To monitor renal status |
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Now, your pt. is experiencing Alopecia (hair loss) you think this could be due to.....
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Lupus
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Your pt. has symmetrical arthritis in both hands w/ morning stiffness greater than 1 hour. What might this be?
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R.A.
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Why might a pt. who has Lupus be diagnosed w/ impaired Skin Integrity?
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S&S Lupus:
skin lesions oral ulcers |
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Your pt. comes in with a mask-like face with taut, shiny skin. Which disorder comes to mind?
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Scleroderma
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What does CREST syndrome stand for?
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Calcinosis (calcium deposit)
Raynaud's (don't smoke) Esophageal hardening and dysfunction Telangectasia (capillary dilation) |
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What are 2 alternative therapies used to manage Scleroderma?
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Increased dosages of estrogen
Warm climates Provide support systems |
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What interventions are most important when managing scleroderma?
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Skin biopsy
Echo-cardiac effusion (watch the heart) Treatment is based on organ involvment. |
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Although the etiology of Fibromyalgia is unknown, what is it thinked it could be linked to?
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Lyme disease
non-restorative sleep Decreased blood supply to thalmus |
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While taking your pt.'s blood pressure you notice that he is in an unusual amount of pain. What could this be attributed to?
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Fibromyalgia
9 Symmetrical pressure points. |
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Pain is subjective. Support, validate, and help with coping. Which type of therapy given once a week for 45 minutes has been proven to help pt.'s with pain perception?
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"Talk therapy"
Fibromyalgia (common disease) antidepressants for sleep |
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A pt. reports tender, stiff joints when she wakes up in the morning for less than a half hour. What might this be?
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Osteoarthritis
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Your pt. was a professional football player, overweight, now 65, and was born with one leg longer than the other. What do you suspect?
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Osteoarthritis
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Your pt. was recently diagnosed with gout. You are planning his diet, what do you tell him?
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no foods high in purines, such as shellfish, organ meats, alcohol, or vegies.
Uric acid levels are increased. |
