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Atelectasis -
The collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide
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pernicious anemia
- The abscence of a glycoprotien intrinsic factor secreted by the gastric mucosa
- an autoimmune dsease in which antibodies in the parietal walls of the stomach prevent the production of intrinsic factor
- intrinsic factor is essential for absorption of vit B12
- if not treated can cause death
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causes of atelectasis
- occlusion of air to a portion of the lungs
- common post operative complication
- results from aspiration of a foreign body
- can lead to stasis anemia
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Hemophilia Treatment
- a hereditary coagulation disorder, is characterized by a disturbance of the clotting factors
- transfusions and administration of factor VIII or IX may be prophalactic or used to stop hemmorrhage
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polycythemia meds
- mylosuppressive agents - myleran
- hydroxyurea - hydrea
- melphalan - Alkeran
- and radioactive phosphorus are often given to inhibit bone marrow activity
- Allopurinol - may reduce the number of acute gouty attacks.
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neutropenic percautions
- standard precaution
- isolation techniques - reverse isolation - airborne, droplet and contact percautions
- Gowning, gloving, sterilization, or disinfection of materials brought into the area and other details of housekeeping vary withthe reason for the isolation and the usual practices of the hospital
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heparin vs. warfarin
- heparin - blocks conversion of prothrombin to thrombin and fibrinogen to fibrin - immediate action
- prophalaxisis and treatment of thrombosis and embolism
- anticoagulation for vascular cardiac surgery
- prevention of clotting antidote - protamine sulfate
- Warfarin
- blocks prothombin synthesis - delayed action 2-5 days - prophylaxsis and treatment of thrombosis and embolism
- A-fib w/ embolization adjunction
- treatment of coronary occlusion antidote - vit. k
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schilling test
- 24 hour urine test - measures the absorption of radioactive Vit. B12 before and after the parental injection of the intrinic factor
- normal findings are between 8% to 40%
- used to diagnosis pernicious anemia
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Hodgkin's signs and symptoms
- Enlargement of the cervical, axillary, or ninguinal lymph nodes is the initial development
- most common location is a medialstinal node mass
- anorexia, weight loss, fever, night sweats, malaise, extreme pruritis
- night sweats, weight loss, and fever are refered to as "B" symptoms, are associated with a worse prognosis
- Anemia and leukocytosis follow, with development of respiratory tract infections
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angioplasty / stent insertion
- angioplasty - technique widens the narrowing in a coronary artery without open heart surgery.
- flouroscopy is used to guide a catheter from the femoral or brachial artery to the coronary arteries to be treated
- inflation of a balloon in the catheter is achieved once it is positioned, thus reducing the constriction to improve blood flow
- Stent Placement - are used to treat abrupt or threatened vessle closure following angioplasty
- are expandable, meshlike structures designed to maintain vessel patency by resisting vasoconstriction
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Theophylline
- aka: accurbron, bronkodyl, Theo-Dur
- Bronchodilator
- Side effects - anxiety, restlessness, insomnia, headache, seizures, tachycardia, cardiac dysrhythmias, nausea, epigastric pain, hematemesis, GERD, tachypnea
- Nursing implications: DO NOT CRUSH sustained-release preparations; contents of pellet-containing capsules may be sprinkled over food; avoid caffeine; metabolism is affected by other medications (erythromycin, ciprofloxzcin, cimetidine, riframpin);
- monitor serum concentrations
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CABG
Coronary Artery Bypass Graft
- grafts are done, depending on the areas of occlusion so blood flow is restored to the occluded areas
- grafts are taken from sections of saphenous viens in the legs (5-10 years), or the internal mammary artery (last more than 15 years)
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Myocardial Infarction
- an occlusion of a major coronary artery or one of it's branches with subsequent necrosis of myocardium caused by atherosclerosis or an embolus or thrombosis
- occlusion leads to tissue ischemia - myocardial ischemia lasting more than 355-45 min will produce cellular damage and necrosis
- cell death brings in inflammation and enzymes are released from the dead cardiac cells
- pain is the formost symptom, crushing-an oppressive, heavy objects sitting on the chest
- pain radiates down to left arm and to the neck, jaws, teeth, and epigastric area
- occurs in conjunction with intense emotin, during exertion, or at rest
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PMI
- Also called the apex beat - is the furthermost point outwards (laterally) and downwards (inferiorly) from the sternum at which the cardiac impulse can be felt.
- The cardiac impulse is the result of the heart rotating, moving forward and striking against the chest wall during systole.
- It is also known as the "apical impulse".
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Types of Burn injury
- Superficial - first degree - flash flame, ultraviolet light (sunburn)- dry no vesicles, minimal or no edema - blanches with fingertip pressure- increased erythema - painful
- Partial thickness - 2nd degree - contact w/hot liquids or solids, flash flame to clothing, direst flame, chemicals and ultraviolet light - large moist vesicles that increase in size - mottled with dull, white, tan, pink, or cherry red areas - very painful
- Full thickness - 3rd degree- same as 2nd degree but also electrical contact - dry white leathery eschar, charred vessles visible under eschar, thin-walled vesicles that do not increase in size may be present - white, charred, dark tan, black, red - little or no pain, hair easily pulls out
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Types of Lesions
- Macule - freckles papule - wart
- patch - vitiligo, port wine stains plaque- psoriasis
- wheal - insect bites, urticaria nodule - lipomas
- tumor - lipoma, hemangioma vesicle - herpes zoster
- Bulla - blister pustule - acne, impetigo
- cyst - sebaceous cyst Telangiectasia - rosacea
- scale - flacking of skin atrophy - aged skin, striae
- lichenification - chronic dermatitis
- keloid - irregular shaped, elevated, progressively enlarging scar
- scar - healed wound or surgical incision
- excoriation - abrasion of scratch, scabies
- fissure-athlete's foot, cracks at the corner of the mouth
- erosion - rupture of varicella or bulla
- ulcer - pressure sore crust - scab
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Wood's Light
- causes hairs infected by a fungus to become brilliantly fluorescent
- supports the diagnosis of all fungal infections of the skin
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Acne Meds
- Benzoyl peroxide -clearasil
- vitamin A acids, antibiotics, and sulfur-zinc lotions
- systemic antibiotics - such as tetracycline
- isotretinoin - accutane - a form of vit A - do not get pregnant!!
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Phototherapy care
Photochemotherapy
- Light used as treatment
- Photochemotherapy - involves the use of a drug enhanced by exposure to light - PUVA
- this therapy combines methoxsalen (Oxsoralen), which is given orally, and the concurrent use of ultraviolet light A (UVA)
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Psoriasis
- Non-infectious skin disorder; it is a hereditary, chronic proliferative disease involving the epidermis and can occur at any age.
- the skin cells divide much more rapidly than normal
- severe scaling results from the rapid cell division
- normal sloughing and generation of new cells, is 28 days, with psoriasis the time may decrease to 7 days
- lesions appear as raised, silvery scaling plaques.
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Psoriasis
Medical Management
- Aimed at slowing the proliferation of epithelial layers of skin
- Topical steroids and keytolitic agents are used in occlusive wet dressing to decrease inflammation
- can also use photochemotherapy
- methotrexate and vitamin D reduce epidermal proliferationin some cases
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Blackheads
Also called comedo, a wide opening on the skin surface filled with skin debris and sebum, and bacteria
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Boils Management
- also called a furuncle
- management aimed at preventing the spread of infection
- Pt are isolated - wound and secretion precautions
- Surgical treatment may include draining the lesion and applying topical antibiotics
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Erikson's Developemental tasks
- Infancy: TRUST VS. MISTRUST
- Toddler: AUTONOMY VS. SHAME & DOUBT
- Preschool: INITIATIVE VS. GUILT
- School age: INDUSTRY VS. INFERIORITY
- Adolescence: IDENTITY VS ROLE CONFUSION
- Middle adult: GENERATIVITY VS. STAGNATION
- Late adult: EGO INTEGRITY VS. DESPAIR
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Cast Care
- Handle wet casts gently and support it with the flat of the hand or on pillows to avoid indetions that cause pressure on the skin and lead to skin impairment
- set cast dryer on warm, never hot
- elevate cast 24-48 hrs. to reduce edema
- cast syndrome can occur after application of a spica - involves acute obstruction of the duodenum- if nausea occurs , place pt in prone position to relieve pressure
- pt often complain of pruritis, provide distraction and or antihistamine
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Fracture First Aid
Pulselessness, paresthesia, paralysis or paresis, polar temperature, pallor, puffiness (edema), pain
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Bed Trapeze
- Skin Traction
- Sponge rubber, moleskin, and elastic bandage with adherent or plastic materials attached to the skin below the site of the fracture, pull exerted on the limb
- Buck's Traction - frequently used to maintain the reduction of a hip fx before surgery, treat muscle
- Russell's Traction - similar to Buck's traction. However, a knee sling supports the affected leg
- Bryan's Traction - used in pediatrics, under 40 lbs. 1-3 yr. olds - both legs are elevated in soft traction with buttocks off of bed slightly, traction is facilitated be the weight of the child's torso. legs @ 90 degrees. check senstion of feet, toe motion, circulation.
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Left vs. Right sided Heart Failure
- Left sided - dyspnea, PND, Orthopena, cough, frothy, blood tinged sputum, pulmonary crackles
- Right Sided - distended jugular veins, anorexia, nausea, abd distention, hepatomegaly (enlarged liver), RUQ pain,, cirrhosis, ascites (fluid in peritoneal cavity), edema in ankles, feet, sacrum, splenomegaly, Splenomegaly, increased central venous pressure
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Buerger's Disease
- Occlusive vascular condition in which the small and medium sized arteries become inflamed and thrombotic.
- Assessment - inflammation of vessel walls, pain w/ exercise affecting the arch of the foot, pain may occur at rest, frequent, persistent, skin is cold, pale, ulcers and gangrene, sensitivity to cold is an outstanding clinical manifestation.
- Diagnostic Tests - none specific, based on onset, hx of tobacco use, clinic symptoms
- Medical management - prevent disease progression, smoking cessation, promote exercise, amputation of gangrenous fingers and toes, sympathectomy to relieve vasopasm
- Nursing Interventions - provide well-fitting shoes and socks, meticulous extremity care, cessation from smoking
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Burn Priority Care
- Stop the burning process, remove clothing and shoes, provide an open airway, control bleeding
- Priority Nursing Interventions - control pain, support the patient's psychological well-being, IV opioids in small frequent doses, truthful explanations and listening
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Maslow's Hierarchy of Needs
- Self Actualization
- Esteem
- Love & Belonging
- Safety
- Physiological
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Angina Pectoris
signs/symptoms
- spasmodic, cramp-like, choking feeling
- hypoxia or ischemia - chest pain - NO DAMAGE!
- 5 E's that cause chest pain - exercise, exertion, emotions, excessive smoking, excessive, eating, exposure to cold
- Assessment -
dyspnea, SOB, diaphoresis, patient complain of chest tightness, or left arm or back
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Evisceration
- Protrusion of viscera through the disrupted wound
- Need to cover in moist sterile gauze then inform the charge nurse, and physician
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Laryngitis risk factors
- inhalation of irritating fumes
- singers
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Colostomy Bag Change
- 1. Standard percautions
- 2. gather supplies
- 3. remove old bag
- 4. provide ostomy care - cleans skin with warm water and pat dry
- 5. measure stoma - note color and viability of stoma
- 6. apply protective skin barrier about 1/8 inch from stoma
- 7. apply protective wafer with flange
- 8. gently attach pouch to flange by compressing the two together
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Guaiac Test
- also known as occult blood testing
- stool collected is examined for presence of bacteria, ova and parasites
- at least 3 stool specimens are collected for 2 successive days
- obtain stool sample before barium examination
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Hypovplemic Shock
- Hypovolemic stage- 1st 48 hours - capillaries dilate, increased capillary permability - EDEMA - HYPERKALEMIA - HYPOVALEMIA - LOWERED BP - BLISTERING, CARDIAC ARREEST - ACUTE RENAL FAILURE
- plasma to interstitial fluid shifting
- Burns also increase possible renal function deficiency due to lack of blood flow
- shock = lack of oxygen (hypoxia)
- normal potassium 3.5-5.0
- 2nd Stage - DIURETIC STAGE - 48-72 HOURS
- interstitial to plasma, blood volume increases, increase urine output, low level potassium due to urine output
- risk of Hypokalemia, and Congestive Heart Failure
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NGT Decompression
Nasojejunal tube in inserted and connected to wall suction to decompress the intestine of gas/fluids
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Gastric Residual Measurement
150ml of residual fluid or more indicates delayed gastric emptying
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Liver biopsy prep/lab test
- Diagnose pathologic liver conditions
- pt lies supine with the right arm over the head
- pt should be instructed to exhale fully and not breath while needle is inserted
- Nursing Intervention - obtain signed consent, ensure that PT, INR, platelet, clotting or bleeding time has been ordered, observe for pneumothorax keep pt on the right side for 2 hours
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Heparin lab tests
- Order PT, PTT
- normal PT - 10-14 seconds
- PTT - 60-70 seconds
- Goal - 1.5 to 2.5 times the control value
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Stoma Assessment
assess color, size, should be pink and moist
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Post-op Care, splinting, DBAC
Deep Breathing, coughing to promote gas exchange, splinting abdomen with pillow when coughing, change position every 2 hours
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GERD risk factors
- Is a backward flow of stomach acid up into the esophagus
- causes burning pressure behind the sternum, attributed to the inappropriate relaxation of the lower esophageal sphincter in response to an unknown cause
- most common after meals
- Diagnostic test - 24 hour pH monitoring to record reflux episodes, bernstein test, barium swallow w/fluroscopy
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Pyrosis
Heartburn - pain described as substernal or retrosternal, occurs 20 minutes - 2 hours after meals
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Diverticulosis
- the presence of pouch-like herniation's through the muscular layer of the colon
- diverticulitis is inflammation of one or more diverticula (give low fiber/low residue diet during attack)
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Psychosocial issues re: colostomy surgery
Body image issues regarding colostomy
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Laryngitis Management
- Medical Management - Bacterial - antibiotics
- analgesics, antipyretics for comfort
- antitussives
- throat lozenges for comfort
- Nursing Interventions - warm or cool mist inhalation via vaporizer
- encourage to rest the voice
- provide other means of communication, anticipate needs
- instruct pt to finish entire meds
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Oxydenation in COPD
- Low flow rate 1-2L by nasal cannula to aviod depletion of hypoxic drive
- Hypoxic drive - is when the pt is used to functioning on higher cO2 levels.
- two much oxygen will make them hypoxic
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PPD
- Mantoux tuberculin Skin test
- must be read within 48-72 hours
- measure and record induration - 5mm or more is considered positive
- do not measure the errythema
- skin test - chest x-ray - AFB sputum smear - presumptive diagnosis - culture test comes back in 6-8 weeks
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Suction Procedure
- Suction for 10-15 seconds with 1-2 mins. between sunctioning
- suction pressure 150mm hg
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TB Isolation
- Hospitalized pt remain in respiratory isolation during their hospital stay
- after treatment for 2 weeks not considered contagious
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Pink Pufer
pink puffer cuz the reddish complexion and the pt. hyperventilates .....these pts have less hypoxemia compared to chronic bronchitis ( blue bloaters) ....and so in emphysema u will have no carbon dioxide rentention
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Chronic Bronchitis
Blue Bloaters
blue bloaters is when pts . will be cyanotic hence blue colour of lip and skin ...cuz its chronic bronchitis and they will have co2 retention and more severe hypoxemia .....
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Chronic Bronchitis Complication
Infection, bronchospasm, hypoxia, hypercapnia, impaired gas exchange
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Emphysema Assessment
- characterized by changes in the alveolar walls and capillaries
- Bronchi and alveoli inflame because of chronic irritation air becomes trapped (bleb/Bullae) ->alveolar distention -> alveoli rupture
- leads to cor pulmonale (RV failure) due to hypertrophy of the right ventricle, weight loss, pink puffer
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Cor pulmonale
- an abnormal cardiac condition characterized by hypertrophy of the right ventricle of the heart as a result of hypertension of the pulmonary circulation
- results in edema in the lower extremities and in the sacral and perineal area, distended neck veins, and enlargement of the liver with ascites
- Late compliction of emphysema!!
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Pharyngitis Culture
Throat culture: two throat swabs are obtained sa a culture can be performed if the rapid strep screen test is negative
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Chest Tube
- Purpose is to remove air and fluid in the pleural space
- Pneumothorax (gunshots, stab wound)
- Effusion (HF, lung cancer)
- Chest tubes re-establish negative pressure
- closest to the pt is the drainage container
- middle is water seal (air goes in) - tidaling should be present in this chamber - No continuous bubbling(indicative of air leak)
- 3rd is suction control chamber; the higher the water the higher the sunction to the patient - continuous bubbling
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Chest Tube Management
- Ensure the patency of the chest tube system
- Proper system functioning; ensuring that the water in the water-seal chamber fluctuates
- absence of fluctuation - means there is a leak
- if tube is disconnected from the chest - cover the chest
- disconnected from the bottle-reconnect, place in glass of sterile water, clamp for a short time
- ALWAYS HAVE HEMOSTATS OR CLAMP!!!
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ABG analysis
- if pH is low it is acidosis -if high it is alkalosis
- if CO2 is low it is alkolosis - if high acidosis
- if HCO3 is low acidosis - if high alkalosis
- uncompinsated - pH is abnormal and PCO2 is abnormal and HCO3 is normal or pH is abnormal and PCO2 is normal and HCO3 is abnormal
- P. Compensated - pH is abnormal, PCO2 is abnormal (opposite), HCO3 is abnormal (opposite)
- F. Compensated - pH is normal, pCO2 is abnormal (opposite), HCO3 is abnormal (opposite)
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