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NURS 120 FINAL STUDY GUIDE
DIFFERENT TYPES OF ANEMIA
Hypovolemic anemia manifestations:
- Weakness
- Stupor; irritability
- Pale, cool, moist skin
- Hypotension
- Tachycardia (rapid, weak, thready pulse)
- Hypoxia (restlessness, dyspnea)
- Hypothermia
- Pain How does hypovolemic anemia occur?
- Abnormally low circulating blood volume due to blood loss. It can occur as a result of surgery or trauma. Nursing Interventions:
- Control bleeding
- Treat shock → O2 elevate lower extremities, keep warm
- Replace fluid → blood transfusion, plasma, dextran, NS (normal saline) or LR (lactated ringer’s)
- Monitor vital signs
- Put patient in a Trendelenburg position when they are going into shock o Modified Trendelenburg would be to lay them down on the floor and lift their legs up Iron deficiency anemia manifestations:
- Pallor
- Fatigue; weakness
- Dyspnea
- Angina
- Glossitis → burning tongue
- Headache
- Paresthesia Groups at risk for iron deficiency anemia :
- Premenopausal and pregnant women
- Lower-class socioeconomic background
- Older adults & individuals experiencing chronic blood loss Nursing Interventions:
- Check occult blood
- Ferrous sulfate 900 mg daily
- Oral or injection (Z track)
- Take with OJ for better absorption
- Monitor the stool if it’s black normal side effect
- Diet high in iron
- Oxygen-sparing activity ***FERROUS SULFATE TABLETS SHOULD BE TAKEN BETWEEN MEALS TO HELP ABSORB THE MEDICATION MORE EFFICIENTLY!! Which foods are high in iron?
- Beans & lentils -** Tofu - Dark leafy greens - Cashew - Whole-grain and enriched breads - Lean beef - Oysters - Chicken - Turkey *VITAMIN C ENHANCES THE BODY’S ABSORPTION OF IRON !! Pernicious anemia manifestations:
- Extreme weakness
- Dyspnea
- Fever
- Hypoxia
- Fatigue
- Weight loss
- Jaundice
- Pallor
- GI complaints
- Dysphagia
- Sore, burning tongue smooth & erythematous
- Neurological symptoms o Tingling of the hands and feet o Disorientation o Personality changes, behavior problems o Partial or total paralysis What is pernicious anemia?
- Absence of the intrinsic factor it is essential for the absorption of vitamin B12 (cyanobalmin) What is the Schilling’s Test?
- It is done to determine whether a person is able to absorb Vitamin B12 from the GI tract. If the radioactive B12 injection is not absorbed, then the patient is given the diagnosis of pernicious anemia.
APLASTIC ANEMIA manifestations:
- Pancytopenic low wbc, rbc, & platelets - Repeated infections w/ high fevers - Fatigue, weakness, malaise - Dyspnea - Palpitations - Bleeding tendencies Nursing Interventions for APLASTIC ANEMIA:
- Identify & remove cause
- Platelet transfusion for severe thrombocytopenia
- Splenectomy for hypersplenism
- Steroids and androgens
- Antithymocyte globulin
- Bone marrow transplant
- HIGH RISK FOR INFECTIONS What is Anemia?
- Disorder characterized by RBC & hemoglobin & hematocrit levels below normal range. → Primarily diagnosed with a CBC What causes anemia?
- Blood loss
- Impaired production of RBCs
- Increased destruction of RBCs
- Nutritional deficiencies Symptoms of Anemia: - Yellowing of the eyes - Palesness, coldness, yellowing of the skin - Dyspnea - Weakness - Black, tarry stool - Fatigue,headache, dizziness, **fainting
- Hypotension,** systolic murmur
- Palpitations, tachycardia - Chest pain, angina, heart attack - Spleen enlargement - Vertigo, anorexia, disorientation - Dyspepsia - Insomnia Later signs: Chest pain, MI, cardiac dilation, death. Nursing Management: - Oxygenation - Blood transfusions - Epoetin alfa and vitamin supplements **BLOOD TRANSFUSION DURING ANEMIA:
- How often should the nurse check the pt’s vital signs?** o Every 15 mins after the start of the transfusion, then every 1 hr during the transfusion process BLOOD TRANSFUSION PROCEDURE:
- Check vital signs before transfusion
- Insert an IV with a 19- gauge needle
- Prime the blood tubing with 0.9% NaCl to reduce risk of hemolysis
- Check the expiration date of the blood product with a 2 nd^ nurse
- Transfuse the blood product within 4 hrs after removing it from refrigeration INTRACRANIAL PRESSURE, HEADACHES, & SEIZURES EMBOLIC STROKE: - Occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema. - Occurs rapidly, sudden onset - Rheumatic heart disease is a cause of embolic stroke in young to middled aged adults - Patient usually conscious although they may have a headache - Men are more likely to have them than women What causes ICP?
- Trauma, hydrocephalus, tumors, stroke, etc.
- Ex: a person who fell has a high risk of developing intracranial bleeding. *OCCURS SUDDENLY AND PROGRESSES RAPIDLY!!
- Avoid administration of morphine sulfate to prevent the occurrence of hypoxia
- Maintain body temperature
- Prevent shivering (shivering = increased ICP)
- Decrease environmental stimuli
- Monitor electrolyte levels and acid-base balance
- Monitor I&O - Limit fluid intake to 1200 ml/day
- Instruct client to avoid straining activities, such as coughing & sneezing
- NO LUMBAR PUNCTURE TESTS!! SUCTIONING IS CONTRAINDICATED!! MEDICATIONS FOR ICP - Corticosteroids DEXAMETHASONE for brain tumors, bacterial meningitis - Osmotic diuretic MANNITOL 25% reduces ICP o Given IV o S/E: HF, pulmonary edema, renal failure, dehydration, electrolyte imbalances (Na, K), phlebitis. - Anticonvulsants Phenytoin (DILANTIN) given for seizure. - Hypertonic saline reduces swelling and improves cerebral blood flow - Histamine CIMETIDINE or PPI PANTOPRAZOLE to prevent GI ulcers & bleeding Why is Mannitol given as a medication for patients with ICP?
- Decreases ICP by reducing the hematocrit and blood viscosity which then increases the CBF and O2 delivery.
- Mannitol creates a vascular osmotic gradient fluid moves from the tissues into the blood vessels reducing ICP b/c of the decrease in the total brain fluid content. CEREBRAL ANEURYSM MANIFESTATIONS:
- Headache and pain
- restlessness
- Irritability
- Decreased LOC
- Visual changes
- Tinnitus
- Hemiparesis
- Nuchal rigidity inability to flex the neck forward
- Seizures later signs NURSING INTERVENTIONS FOR CEREBRAL ANEURYSM:
- Maintain a patent airway
- Administer O2 as prescribed
- Avoid taking rectal temperature
- Maintain normothermia
- Maintain a darkened room
- Maintain fluid restrictions
- Semi-fowler’s position SEIZURE NURSING INTERVENTIONS
- Loosen restrictive clothing
- Place pillow under the head
- Turn them on the side to allow secretions to drain while maintaining the airway
- Move away objects
- If the person is standing or sitting, place them on the floor and protect the head and body
- Make sure there’s an IV access for a patient with a history of seizure, can’t give oral meds since it could lead to aspirations.
- Padded side rails, rails up, suction at bedside
- Adequate rest
- Good nutrition
- Avoid alcohol and OTC meds
- Avoid activities that requires alertness
- Good oral hygiene
- Medic alert tag What should the nurse asses during a seizure?
- Description (tonic, clonic, location, etc)
- Length
- Frequency
- Degree of impairment
- Description of aura afterwards MUSCULOSKELETAL VENOUS THROMBO EMBOLISM - DO NOT massage patient’s legs VTE MANIFESTATIONS: - Swelling/ edema - Erythema - Weak pulses - Pain - Tenderness
- Decreased mental status - Petechia on the neck, anterior chest wall, axilla, buccal membrane, and conjunctiva of the eye. *FES MAY BE RAPID AND ACUTE! IT CAN LEAD TO DEATH IF S/S AREN’T RECOGNIZED EARLY ON. DEEP VEIN THROMBOSIS ASSESSMENT: - Red - Edematous - Painful **ORIF ASSESSMENT:
- Color, temperature, sensation RESPIRATORY How much O2 can a nurse use as PRN oxygen for the patient without a DR’s order? -** Up to 4 liters DIFFERENT KINDS OF RESPIRATORY DISEASES:
- Pneumonia
- TB
- Asthma
- COPD Chronic bronchitis, Emphysema
- Atelectasis collapsing of the lungs PNEUMONIA:
- Inflammatory process of the bronchioles and the alveolar spaces due to infection or aspiration o Signs & symptoms: ▪ Productive cough ▪ Fever ▪ Chills ▪ Tachycardia ▪ Dyspnea ▪ Pleural pain ▪ Malaise ▪ Respiratory distress ▪ Mental status changes ▪ Decreased breath sounds in affected area rhonchi in airways
o Productive cough yellow, blood streaked, rusty sputum = infection *CONFUSION IS A SIGNIFICANT MANIFESTATION IN OLDER ADULTS WITH PNEUMONIA. PNEUMONIA NURSING INTERVENTIONS:
- Administer O
- Monitor respiratory status
- Monitor for labored respirations, cyanosis, cold and clammy skin
- Encourage deep breathing, coughing, and use incentive spirometer
- Change client’s position frequently and ambulate to mobilize secretions
- Encourage fluids up to 3L/day to thin secretions
- Prevent the spread of infection by handwashing and proper disposal of secretions
- Monitor pulse oximetry
- Provide chest physiotherapy ATELECTASIS: - Collapse of alveoli, common in post-surgical patients and those who are confined to a bed or wheelchair. ATELECTASIS NURSING INTERVENTIONS: 1. Encourage coughing and deep breathing, incentive spirometer 2. Early ambulation 3. Medicate and splint as needed TUBERCULOSIS: - Airborne, inhalation of tubercle bacillus (mycobacterium tuberculosis), usually involves the upper lobe of the lungs but can also AFFECT ANY ORGANS brain, kidneys, and bones. At risk for TB: 1. Low socioeconomic class 2. Homeless 3. Recent immigrants 4. Nursing home residents 5. Alcoholics 6. IV drug users 7. Immunosuppressed 8. Prisoners 9. Healthcare workers 10. Asians have the highest TB rate of any ethnic group in the US CLINICAL MANIFESTATIONS OF TB:
- Rifampin : hepatotoxicity, orange secretions, GI upset. Decreases effectiveness of oral contraceptives.
- Isoniazid : hepatotoxicity, neuropathy.
- Pyrazinamide : hepatotoxicity, joint pain.
- Ethambutol: hepatotoxicity, changes in vision. *Most clients have negative sputum cultures after 3 months of compliance with medication therapy. ROLE OF ABGs: - maintain a steady balance between acid and bases to achieve homeostasis. - Health problems lead to imbalance: ▪ Diabetes mellitus ▪ Vomiting and diarrhea ▪ Respiratory conditions **Respiratory affects CO 2 & Metabolic affects HCO3- NORMAL ABG values:
- pH: 7.35-7.
- PaCO2: 35-45 mmHg
- HCO3: 22-28 mEq /L
- PaO2: 80-100 mmHg
- O2 saturation: 95-100%**
Respiratory Acidosis:
- Asthma -Hypoventilation - Atelectasis -Pneumonia - Head trauma -Pulmonary Edema - Bronchitis - COPD - Bronchiectasis - Emphysema - CNS depressants -Neuromuscular disease Respiratory Alkalosis: - Fever - Hyperventilation - Hypoxia - Pain - PULMONARY EMBOLISM - Severe anxiety & hysteria - Overventilation by mechanical ventilators Metabolic Acidosis: - DM/ DKA - Methanol/ Salicylate OVERDOSE - High fat diet - Malnutrition - Renal failure - Severe diarrhea - Rhabdomyolysis - Alcoholic ketoacidosis Metabolic Alkalosis: - Diuretics - Vomiting - GI suctioning - Steroid therapy - Hypokalemia - Sodium bicarbonate intake (TUMS!!!) Lobectomy surgical removal of 1 lobe of the lung for tumors confined to a single lobe. THORACOTOMY opening into the thoracic cavity, assessment of the airway !! Different types of Shocks
- Teach client to avoid factors that can cause esophageal irritation such as peppermint, chocolate, coffee, fried or fatty foods, carbonated beverages, alcoholic beverages, and smoking. - Eat a low-fat, high-fiber diet and to avoid eating and drinking 2 hrs before bedtime and wearing tight clothes - Elevate the HOB on 6-8inches. - SLEEP ON THE RIGHT-SIDE LYING POSITION IT HELPS WITH NIGHTTIME REFLUX. - Eat small MEALS. - Sit UPRIGHT x 2hrs after meals and elevate the head of bed on blocks - Avoid using anticholinergics = delays stomach emptying; avoid NSAIDs GERD MANIFESTATIONS: 1. Heartburn, epigastric pain 2. Dyspepsia 3. Nausea, regurgitation of gastric contents 4. Pain and dysphagia 5. Hypersalivation 6. Hoarseness abnormal voice changes IRRITABLE BOWEL SYNDROME DIET:
- Increase high protein, calories
- Decrease low fiber, caffeine, alcohol
- Small frequent meals
- Dietary supplements ULCERATIVE COLITIS: - Leads to pernicious anemia because the intestinal mucosal doesn’t absorb vitamin B - Instruct clients to avoid gas forming foods, milk products, and foods such as whole-wheat grains, nuts, raw fruits & vegetables, pepper, alcohol, and caffeine products. - CHRONIC BLOOD LOSS *client with a peptic ulcer disease taking sucralfate tablets should take it 1 hr BEFORE meals!!! It is a mucosal protectant and should be taken on an EMPTY STOMACH for maximum effectiveness. CYSTITIS UTI an inflammation of the bladder from an infection, obstruction of the urethra, or other irritants. - Most common cause of it is E.COLI, Enterobacter, and pseudomonas. - More common in WOMEN shorter urethra and close to the rectum - Sexually active women and pregnant women are vulnerable to cystitis
- Tell patients to AVOID bladder irritants carbonated drinks INTERSTITIAL CYSTITIS chronic pain, felt in suprapubic area - NOT a bacterial infection - NEGATIVE urine culture - Doesn’t respond to antibiotics - More common in women - Referred to as bladder pain syndrome UTI MANIFESTATIONS: - Urgency, frequency, burning on urination - Nocturia - Abdominal discomfort - Cloudy/blood tinged urine - Malodorous urine - Confusion often first sign in elderly clients RISK FACTORS: - Hygiene - Tube- catheters - Obstructions in flow from kidneys - Dehydration inadequate flow to kidneys - Disease states NURSING INTERVENTIONS FOR UTI: - Antibiotics; urinary antiseptics/ analgesics - Encourage fluids cranberry juice acidifies urine / 8-10 glasses of H 2 O - Provide/ perform good perineal care - Avoid douches, bubble baths, powders, sprays - Urinate after sexual intercourse - Wipe from FRONT to BACK **UTI MEDICATIONS:
- Ciprofloxacin ** may be taken with or without food - S/E: tendon rupture (tendonitis) - Pyridium can decrease burning feeling of a UTI - S/E: orange/red discoloration of urine during treatment CARDIOVASCULAR
- Lasts less than 15 minutes - Relieved with rest or nitroglycerin - Intermittent chest pains that occurs over a long period with the same pattern of onset, duration, and intensity. STABLE ANGINA MANIFESTATIONS: - pain - dyspnea - anxiety - diaphoresis - nausea HYPERTENSION RISK FACTORS: - aging - family history - RACE NONMODIFIABLE FACTOR OF HTN!!!! - Obesity - Smoking - Stress - Excessive alcohol - Hyperlipidemia - Increased intake of salt or caffeine HYPERTENSION MANIFESTATIONS: - Headache - Epistaxis - Blurred vision - Dizziness - Angina - Diaphoresis BLOOD TRANSFUSION REACTIONS: - Infiltration - Redness & warmth on site - Dyspnea (SOB) - Anaphylactic shock - Wheezing - Generalized urticaria allergic transfusion reaction! Normal BP: SBP <120 DBP < Prehypertension: 120- 139 DBP 80- 89 Stage 1 HTN: 140- 159 DBP 90- 99
Stage 2 HTN: >160 DBP: > DIABETES Type 1 (insulin dependent) autoimmune disorder that affects the pancreas ability to produce insulin. Little or no insulin produced so cells are unable to produce glucose for energy.
- Risk factors: genetic predisposition, family history, age, exposure to viruses.
- Manifestations: polyuria, polydipsia, polyphagia, altered mentation, Kussmaul respirations (rapid breathing), recurrent infections, weakness, fatigue, slow healing wounds, weight loss. - Diet: o Count elements of intake in order to balance insulin needs o Carbohydrates, proteins, fats ▪ Lean meats, veggies, fruits, whole grains, low fat dairy o Several small meals and snacks daily
- Test BG before, during, and after exercise. Type 2 (insulin resistant) progressive condition due to increasing inability of cells to respond to insulin & decreased production of insulin by beta cells. Linked to obesity, sedentary lifestyle, and heredity.
- Risk factor: OBESITY is #1 factor
- Sedentary lifestyle, poor diet (high calorie/ high fat), age, ethnicity, genetic.
- Manifestations: polyuria, polydipsia, recurrent infections, visual changes, fatigue.
- Medications METFORMIN (Glucophage), NEPHROTOXIC , used to control blood sugar levels for type 2 DM. o S/E: GI upset, metallic taste, diarrhea, lose weight, N/V , lactic acidosis, & B12 deficiency. o Take with meal, take B12 supplement if indicated. o DO NOT use alcohol
- Medications GLIPIZIDE (glucotrol), increases insulin release from pancreas, used to control BG levels in type 2 DM. o S/E: HYPOGLYCEMIA, photosensitivity, GI upset o Take 30 mins BEFORE a meal. o DO NOT use alcohol o Wear sunscreen
- Give insulin 30 mins BEFORE eating !!! Diabetes Insipidus pituitary disorder - Causes dehydration because they are peeing a lot.
