Exam 3 Flashcards

Question

Ulcerative Colitis: Drug Therapy Aminosalicylates (5-ASA) -- Sulfasalazine Action Patient education (3)

Answer 1

Action: metabolized by intestinal bacteria into 5-ASA which provides antiinflammatory effects and sulfapyridine Patient education * Take folic acid supplement b-c Sulfasalazine reduces its absorption * Thiazide diuretic may be contraindicated * Avoid if sulfa allergy

Answer 2

Use: antiinflammatory during acute flares Side effects of long-term use: hyperglycemia, osteoporosis, PUD, increased infection risk, adrenal insufficiency

Answer 3

Action: synergistic effect w/ steroids via igG monoclonal antibody to reduce activity of tumor necrosis factor (TNF) to decrease inflammation Side effects: immunosuppression (pt should report any s/s of infection and avoid large crowds)

Answer 4

- Use: symptomatic management w/ caution b-c can have opposite effect - Side effect: toxic megacolon (massive dilation of colon and colonic ileus leading to gangrene and peritonitis)

Answer 5

- If severe, NPO and then TPN if severely ill and malnourished - If less severe, drink elemental formulas (have components which reduce bowel stimulation) Avoid - caffeine and alcohol (may cause diarrhea and cramping) - raw veggies and high fiber (can cause GI symptoms) - lactose containing foods (poorly tolerated) - GI stimulants ( carbonated beverages, pepper, nuts, corn, dried fruits, smoking)

Answer 6

Acute - Abscesses in ulcers (pockets of infection) - Peritonitis - Bowel Perforation (stool goes in abdominal cavity) - Bowel Obstructions due to edema, hyperemia, and mucosal thickening - Toxic megacolon (massive dilation of colon leads to colonic ileus) - GI Bleeds Long-term - Malabsorption leads to anemia and malnutrition - Pernicious anemia (B12 deficiency) - Colorectal Cancer (if > 10 yrs of UC)

Answer 7

- Hematochezia (bright red stools) -- lower GI bleed - Melena (black, tarry, or dark red sticky stools) - Upper GI Bleed (Dark blood) - shock (low hct/hgb, low BP, high HR, weak pulses) - dizziness, confusion, syncope - vertigo

Answer 8

- Erosion of the mucosa of the stomach, esophagus or duodenum due to H. pylori neutralizing stomach acidity then exposing epithelium to gastric acid Transmission - via oral-oral OR fecal-oral route (water, food, saliva)

Answer 9

- sudden sharp mid-epigastric pain spreads over abdomen (often radiates to right shoulder - peritonitis (infection w/ tender, rigid, boardlike abdomen AND rebound tenderness)- fetal position for relief - Shock manifestations (hypotension, tachycardia, dizziness, confusion)

Answer 10

- Dyspepsia (sharp, burning or gnawing pain at epigastric or back; heartburn, NV) - GI bleedings (melena and hematemesis) - Sensation of abdominal pressure or fullness or hunger - Weight loss - pernicious anemia (r/t decreased intrinsic factor) Failure to rescue - Perforation - hemorrhage - pyloric obstruction (s/s metabolic alkalosis, NV due to stasis and gastric dilation)

Answer 11

Action: increase pH of gastric contents Precautions - CKD and CHF increase chance of toxicity w/ magnesium hydroxide Side effects - diarrhea w/ magnesium - constipation w/ aluminum Nursing Care - give 1-2 hrs after meals and at bedtime - give other drugs 2 hrs before or after

Answer 12

Use: PUD, heartburn, Action: decrease gastric acid secretions via blocking H2 receptors in stomach Nursing Care - give w/ or w/o food - give at bedtime

Answer 13

Action: decreases production of gastric acid Side effects (long term): fractures, pneumonia, C. diff Nursing Care - give 30 minutes before meals unless rabeprazole (for duodenal ulcers so give prior to morning meal) - do not give IV PPIs w/ other drugs - taper to prevent rebound activation w/ withdrawal

Answer 14

- Clarithromycin (monitor BUN) - Amoxicillin (monitor for NVD) - Tetracycline (take w/o meals; avoid dairy products and sunlight) - metronidazole (monitor for Nausea; avoid alcohol b-c disulfiram-like reaction

Answer 15

- high viral load (>200) leads to infections - low T cell/CD4 count (<800) and poor functioning T-cells leads to opportunistic infections, leukopenia, lymphocytopenia

Answer 16

Cause - Seen when CD4+ T-cell count rises, and immunity normalizes then becomes exaggerated - Result of T-cell recognizing opportunistic infections (esp TB) and sounding alarm about them s/s: inflammatory reaction (high fever, chills, maybe worsened disease) Treatment: short-term therapy w/ corticosteroids (Ideally treat Opportunistic infections prior to starting cART)

Answer 17

Therapeutic Effect - controls viral replication to reduce viral load in 4 weeks and increases T-cell count - U=U (undetectable viral load (< 200 for > 6 months) = untransmittable via sex) Preparation - genosure resistance paneling (determine hypersensitivity to drugs to determine what to use

Answer 18

* Do not stop taking drugs or change therapy once viral load decreases b-c drugs are not a cure * Must take drugs correctly 90% of time (9 out of 10 doses on time and correct) - Do not miss, delay, or take lower than prescribed dose * Drug resistance r/t missed doses causing new resistant viral particles (Once resistant to a drug, that drug no longer able to be used b-c resistant virus is archived indefinitely in body) * many drugs cause liver toxicity (report to HCP any jaundice, NV, abdominal pain) * If pregnant, check w/ HCP because some drugs cause birth defects but other drugs can help reduce transmission to baby

Answer 19

- persistent fever - sore throat - rash - night sweats, chills - diarrhea - weight loss - fatigue - headache, muscle aches - lymphadenopathy

Answer 20

Initial Exposure Primary HIV (acute): flu-like symptoms within 4 weeks; antibodies in 1-6 months Asymptomatic HIV (seropositive): infectious but no evidence except positive HIV antibody test Symptomatic HIV: can be 10 yrs after initial exposure AIDS: diagnosis made if T-cell count is ever < 200 OR less than 14% OR opportunistic infection (diagnosis remains forever)

Answer 21

ELISA 1st generation (1980s): IgG 2nd generation (1991): IgG 3rd generation (1992): IgM & IgG Note * 1st-3rd gen need western blot after if positive b-c can indicate influenza as well * takes 3 months for antibodies to appear after antigen * takes 14-21 days for antibody to be detected and then 7 days for western blot to confirm

Answer 22

Process - Detects ANTIGEN & ANTIBODY via antigen/antibody immunoassay - If positive, use antibody differentiation immunoassay - If antibody differentiation immunoassay is negative or indeterminate, use nucleic acid test to determine if acute HIV infection (RNA present) Timing - detects HIV-IgM and IgG antibodies (positive in 21 days) - detects presence of p24 antigen (HIV capsid protein which is positive in 14 days)

Answer 23

- Parenteral (needle sharing; contaminated equipment w/ blood) - Perinatal (vertical; from placenta due to contact w/ maternal blood and body fluids or breast milk) - sexual (genital, oral or anal b-c exposure to mucous membranes) - esp. anal or male-to-female

Answer 24

- one time screening for all adults b/w 15-65 - annual screening for adults at high risk for HIV (man/man sex, nonmonogamus, parenteral drug users, relationships w/one HIV positive and one HIV negative partner; anyone diagnosed with STIs in the past 6 months) - prenatal screening for pregnant people

Answer 25

* If drug user, clean used needle w/ bleach for 30-60 seconds OR partake in needle-exchange program * Abstinence or mutually monogamous sex w/ noninfected partner * Wear dental dam * Use Water based lube w/ condom * Latex gloves for finger or hand contact w/ vagina or rectum

Answer 26

Indication: use of HIV Antiretroviral drugs by HIV-uninfected adult to prevent infection Routine - once daily w/ prescription - Protection starts after 7 days of consistent dosing (can miss one and be okay; if miss > 2, need to wait 7 days for protection again) Concern: Black box warning for severe acute exacerbation of hep B Testing * Blood and urine testing plus liver and kidney function (test kidney q3 months) * other STI tests, hepatitis test * 4th gen HIV antigen/antibody testing to ensure HIV negative b-c not for HIV positive

Answer 27

* Standard Precautions (gloves for body fluids) * If sharps related; first wash wound for 1 full minute then contact employee health * If you perform exposure-prone procedures, know your HIV antibody status.

Answer 28

Indication: occupational exposure (sharps, body fluids of HIV positive pt w/ blood, broken skin or mucus membranes of HCP), nonoccupational exposure (consensual sexual exposure w/ person of unknown HIV status OR sexual assault) Routine - 3 drug regimen within 2-36 hrs of exposure for 28 days OR until HIV status negative - no prescription needed Testing - Periodic HIV testing at 1, 3, and 6 months - CBC, electrolytes, creatinine tests done 2 weeks after starting cART

Answer 29

Neurological (HIV-associated neurocognitive disorder (HAND) and HIV-associated dementia complex (HADC) * s/s cognitive, motor, and behavioral impairments (confusion to dementia) * peripheral neuropathy (paresthesia and burning sensations, reduced sensory perception, pain, gait changes) * myopathy (leg weakness, ataxia, and muscle pain) * increased ICP (pupil size or reactivity change

Answer 30

Cardiovascular: Disordered fat metabolism (elevated triglycerides and cholesterol) and diabetes increase risk for hypertension and atherosclerosis Skin changes * dry, itchy, irritated skin * folliculitis, eczema, psoriasis possible * petechiae or bleeding gums if low platelets Kidney changes (minor glomerular injury to AKI to CKD or HIV-associated nephropathy (HIVAN)

Answer 31

AIDS wasting syndrome (s/s diarrhea, malabsorption, anorexia, oral and esophageal lesions) Gonadal dysfunction (Low testosterone in men and Irregular menses in women) Body shape changes * Lipodystrophy w/ old cART (s/s buffalo hump, large belly fat) * Lipoatrophy (s/s wasted arms, face, legs; sunken cheeks) Adrenal insufficiency – life-threatening (s/s fatigue, weight loss, NV, low BP, electrolyte disturbance) Diabetes

Answer 32

Kaposi’s sarcoma * r/t coinfection of HIV and human herpesvirus 8 * S/s: small, purplish-brown, raised lesions on skin and mucous membranes (mouth, throat, intestinal tract, lungs, lymph nodes) that are not painful or itchy * Nursing care: assess #, size, location, if intact Non-Hodgkin’s or Hodgkin’s lymphoma * s/s: swollen lymph nodes, weight loss, fever, night sweats Invasive cervical carcinoma and anal cancer * r/t HPV leading to cervical and anal dysplasia * Prevention: Cervical Pap testing q6 months or anal Pap test Lung cancer GI cancer

Answer 33

Process - Measures actual amount of HIV viral RNA particles in 1 mL of blood to measure therapy effectiveness - positive within 10 days of exposure - takes 14 hrs for test to process Results * Uninfected adult: no viral load * Positive load: as little as 20 particles/mL or > 1 million particles/mL * Higher the load, higher risk of transmission Concern: some immune systems may suppress viral replication and cause false low; so 4th gen testing needed alongside viral load testing

Answer 34

Toxoplasma gondii (Toxoplasmosis encephalitis) * Transmission: contact w/ cat feces or ingestion of infected undercooked meat * S/s: subtle changes in mental status (confusion, speech), neurologic deficits (vision, seizures, gait), headaches, fever Cryptosporidium (cyptosoporidiosis) ¬ - protozoal * Intestinal infection w/ mild diarrhea to severe wasting (> 5 lb unplanned weight loss w/ electrolyte imbalance)

Answer 35

Cytomegalovirus - S/s: nonspecific (fever, malaise, weight loss, fatigue, swollen lymph nodes) - For eye, impaired vision to blindness - For GI, diarrhea, abdominal bloating and discomfort, and weight loss; adrenalitis, hepatitis, disseminated infection - For CNS, encephalitis - For respiratory, pneumonitis Herpes simplex virus * s/s: more widespread, longer duration, numbness or tingling 24 hrs prior to blisters in oral, perirectal, or genital area * blisters rupture; fever, headache, pain, enlarged lymph nodes, malaise Varicella-zoster virus (shingles) * Seen in adults who had chickenpox previously * S/s: chickenpox w/ rash and fever; pain and burning along nerve tract; headache; low fever; blisters w/ or w/o crusting

Answer 36

Mycobacterium avium complex (MAC) * Systemic infection of respiratory or GI tract * s/s: fever, physical weakness, weight loss, malaise, swollen lymph glands or organ disease Mycobacterium tuberculosis (Tuberculosis) * Usually extrapulmonary disease sites * s/s: cough, dyspnea, chest pain, fever, chills, night sweats, weight loss, anorexia * Note: If T cell < 200 may not have positive PPD test (anergy) so need blood analysis w/ NAAT (automated nucleic acid amplification test) – results in 2 hrs Pneumonia * 2 or more bacterial pneumonia cases in 12 months is diagnostic for AIDS progression * s/s chest pain, productive cough, fever, dyspnea

Answer 37

Pneumocystis jivorevi pneumonia (PCP) – fungal * s/s: SOB, tachypnea, persistent dry cough, persistent low-grade fever, fatigue, weight loss, breath sounds (crackles) Candida albicans - Stomatitis or esophagitis (funny tasting food, mouth pain, difficulty swallowing, pain behind sternum) - cottage cheese-like yellowish white plaques and inflammation - vaginal (severe pruritus, perineal irritation; thick, white vaginal discharge) Cryptococcus neoformans (Cryptococcosis) * Debilitating meningitis * s/s: fever, headache, blurred vision, NV, neck stiffness, confusion, seizures, malaise Histoplasma capsulatum (Histoplasmosis) * s/s: dyspnea, fever, cough, weight loss TO enlarged lymph nodes, spleen, liver

Answer 38

* Place the patient in a private room whenever possible. * clean bathroom at least once each day. * Limit the number of personnel entering the patient’s room. * Monitor vital signs, including temperature, every 4 hours. * Inspect the patient’s mouth and skin and mucous membranes (including the anal area) for the presence of fissures and abscesses; lungs sounds at least every 8 hours. * Inspect open areas such as IV sites every 4 hours for signs of infection and assess w/ strict aseptic technique * Change gauze-containing wound dressings daily. * Help the patient perform coughing and deep-breathing exercises. * Keep frequently used equipment in the room for use with this patient only (e.g., blood pressure cuff, stethoscope, thermometer). * Limit visitors to healthy adults.

Answer 39

* Temperature > 100° F (37.8° C) * Persistent cough (with or without sputum) * Pus or foul-smelling drainage from any open skin area or normal body opening * Presence of a boil or abscess * Urine that is cloudy or foul smelling or that burns on urination

Answer 40

* Avoid crowds and other large gatherings of people. * Do not share personal articles such as toothbrushes, toothpaste, washcloths, or deodorant sticks. * If possible, bathe daily, using an antimicrobial soap. If total bathing is not possible, wash the armpits, groin, genitals, and anal area twice a day with an antimicrobial soap. * Clean your toothbrush at least weekly by either running it through the dishwasher or rinsing it in liquid laundry bleach (and then rinsing out the bleach with hot running water) * Wash your hands w/ antimicrobial soap before you eat or drink, after touching a pet, after shaking hands with anyone, as soon as you come home from any outing, and after using the toilet. * Avoid eating or touching undercooked meat, fish, and eggs. * Wash dishes between use with hot, sudsy water or use a dishwasher. * Do not change pet litter boxes or play in gardens. If unavoidable, use gloves and wash hands immediately. * Avoid turtles and reptiles as pets. * Take your temperature at least once a day and whenever you do not feel well. * Avoid travel to areas with poor sanitation or primitive health care facilities

Answer 41

- Brief interruption in cerebral blood flow which when artery is blocked for short period of time; Time - Symptoms resolve within 30-60 minutes but may last up to Implications - no permanent deficits w/ TIA vs permanent deficits w/ stroke - management for TIA is the same as for stroke b/c initial symptoms are the same as stroke - TIA is a warning sign for stroke

Answer 42

* Age greater than or equal to 60 (risk increases with age) * BP > or equal to 140/90 mm Hg (either systolic or diastolic or both) * Clinical TIA features which increase stroke risk (unilateral weakness; carotid artery stenosis > 70%; new onset a-fib * Duration of symptoms (longer the TIA symptoms (> 4 minutes), greater the risk of stroke)

Answer 43

- Interruption of perfusion to any part of the brain leading to permanent disabilities from infarction (inability of brain to get oxygen and glucose or dispose of CO2 and lactic acid) Types - ischemic strokes: due to occlusion or blockage of cerebral or carotid artery (Thrombotic (by clot) or emboli (dislodged clot)) - hemorrhage (ruptured vessel causes intracerebral, subarachnoid or subdural bleeding))

Answer 44

Thrombotic - Location: atherosclerosis of carotid and cerebral arteries esp bifurcation of carotid - Onset: slow and gradual w/ gradual progression of deficits Embolic - Location: clot breaks off and travels to cerebral arteries esp. due to a-fib - onset: sudden w/ immediate neurologic deficits

Answer 45

Vasospasms - causes constriction of cerebral artery leading to decreased blood flow at distal areas - can lead to subsequent strokes or seizure activity due to ischemia to cerebral tissue - within 4-14 days after stroke occurrence

Answer 46

- cocaine (spasms of cerebral artery) - HTN - aneurysm (abnormal blister or ballooning of an artery causing excessive pressure and weakening of wall causing vulnerability to bleeding) - congenital arteriovenous malformation (angled collection of malformed, thin-walled, dilated vessels w/o capillary network which may rupture and cause bleeding in subarachnoid space) - Head trauma - Increased ICP

Answer 47

- a-fib r/t decreased perfusion causing clot - other Heart conditions (MI, prosthetic heart valve, heart valve disease, endocarditis, atherosclerosis, hyperlipidemia) - Diabetes mellitus - Hypercoagulability - Smoking - Heavy alcohol use - Oral contraceptives - Obesity - High fat diet

Answer 48

- Cerebral angiography (arteriography) - Imaging: CT, MRI - Coagulation Studies: Prothrombin time/ international ration (PT/INR); Promboplastin (PTT)

Answer 49

Implication - high risk drugs that can cause bleeding included IC hemorrhage - aspirin (325 mg enteric coated) given within 24-48 hours of onset of stroke

Answer 50

Implication - relaxes smooth muscles of vessel walls - given to reduce incidence and severity of vasospasm rather than for HTN

Answer 51

- for AVM/Aneurysm, Surgical resection, Clip, or Coil - for Clot Removal, Embolectomy

Answer 52

- informed consent needed - given within 45 min of ED arrival - nurse monitor vitals before, during, and after admin (esp. BP) - q10-15 min during; q30 for 6 hrs after; q1h for 24 hr - If BP > 185/110 mm Hg, give IV antihypertensive (labetolol) before and throughout alteplase admin to maintain BP < 185/110 mm HG - avoid other invasive tubes (NG or catheters) until pt stable to prevent bleeding - 24 hrs - discontinue if NV, severe headache or severe HTN

Answer 53

Time - give within 3 hrs of initial stroke symptoms to reduce severity of neurological deficits in ED - can be given in 4.5 hrs sometimes Risks - bleeding esp IC hemorrhage

Answer 54

* Age older than 80 years * Anticoagulation therapy regardless of INR * Imaging evidence of ischemic injury w/ > 1/3 of the brain tissue supplied by the middle cerebral artery * Baseline NIHSS score > 25 * History of both stroke and diabetes * Evidence of active bleeding

Answer 55

Facial Drooping Arm Weakness Speech Difficulty Time to call 911

Answer 56

- seen within 10 minutes in ED for stroke like symptoms (hx should not delay treatment) - glasgow and NIHSS assessments done routinely for patients admitted w/ stroke - Rule out pathophysiological causes (hypoxia and hypoglycemia)

Answer 57

- confusion (trouble speaking or understanding others) - numbness or weakness of the face, arm - trouble seeing in one or both eyes - dizziness, trouble walking, or loss of balance or coordination - severe headache with no known cause (esp. aneurysm r/t) - embolic stroke: new-onset heart murmur, dysrhythmias, HTN - hemorrhage subarachnoid: NV, photophobia, stiff neck, CN deficits

Answer 58

- Unilateral neglect or inattention r/t hemianopsia - Lack of proprioception/body sense (unable to distinguish left/right or up/down) - problems w/ depth and distance perception - Disoriented to time and place - Personality changes (impulsivity and poor judgment)

Answer 59

- deficits in analytical skills - speech deficits (Aphasia (receptive, expressive or mixed), Dysarthria) - Apraxia (slow, cautious, hesitant behavior style) - personality changes (lacks initiative and anxious)

Answer 60

- decreases of 2 or more points on Glasgow coma scale - posturing (flaccid or extension) - pinpoint, dilated or nonreactive pupils - sudden changes in mental status (earliest sign of change in neurological status)

Answer 61

Spontaneous (4) To sound (3) To pain (2) None (1)

Answer 62

Obeys commands - 6 Localizes pain - 5 Normal flexion (withdrawal) - 4 Abnormal flexion (decorticate) - 3 Extension (decerebrate) - 2 None - 1

Answer 63

Oriented (5) Confused conversation (4) Inappropriate words (3) Incomprehensible sounds (2) None (1)

Answer 64

- facial drooping - expressive/Broca's aphasia- understands spoken and written words, but unable to speak or write (can read) - receptive/Wernicke's - unable to understand spoken or written word; can talk but no logical meaning - dysarthria (slurred speech r/t muscle weakness or paralysis)

Answer 65

- Present one thought in a complete sentence - give one-step command - Face client and speak slowly NOT loudly - Repeat names of objects used on routine basis - Avoid yes/no questions b-c - patients may give automatic but incorrect responses to yes/no question - Use alt communication (flash cards, computer, picture or communication board) - do not rush patient when speaking

Answer 66

- right hemisphere = hemplegia to left side of body - left hemisphere = hemiplegia to right side of body - decreased blood flow to brainstem = total paralysis (quadriparesis) - Weakness (facial droop, arm or leg drift, hand grasp) - Ataxia (lack of muscle control and coordination affecting gait, balance, and ability to walk)

Answer 67

- VTE protocol (SCDs, position changes, ambulation) - assess patient's ability to perform ADL in home-setting - be aware of patient's extremities (do not pull) - position arm on pillow to prevent shoulder dislocation/subluxation - instruct all staff working with patient about any deficits in mobility to prevent harm to patient (no pulling affected extremity)

Answer 68

- Maintain NPO until SLP screen - Assess for gag reflex w/ small liquid - Assess mouth for increased drooping/drooling - Position patient upright before feeding/eating - Check diet orders (soft, mechanical soft thickened liquids) b-c thin cause more coughing) - Place food in back of mouth to prevent trapping in cheek - Monitor for s/s of aspiration (coughing, dyspnea, crackles) - stop feeding if patient coughs

Answer 69

Sensation - Numbness (Decreased sensation) - Unilateral Neglect (unaware of affected side) - vertigo Visual (r/t brainstem damage) - Ptosis (eyelid drooping) - Hemianopsia (blindness in half of visual field) - Nystagmus - tunnel vision - diplopia (double vision) - blurred

Answer 70

Visual - If pt has diplopia (double vision), patch over affected eye and change q2-4 hrs - place objects in visual field including yourself - If hemianopsia, patient should turn head back and forth to scan full visual range - patient should dress affected side first Memory - Establish structured, repetitious, and consistent routine - If memory problems, orient pt to month, year, day of week, and circumstances surrounding hospitalization

Answer 71

- Increased restlessness, irritability, and confusion - Headache - Projectile NV - Systolic BP >180 mm Hg /Diastolic BP > 110 mm Hg (OR sudden increase in BP - Change in speech pattern, dysarthria, aphasia - Sensorimotor changes (CN dysfunction, Ataxia) - Seizures (usually within first 24 hours after stroke)

Answer 72

Earliest sign - Decreased LOC-- earliest indicator Late signs - Pupillary changes: dilated and nonreactive pupils (“blown pupils”) or constricted and nonreactive pupils (very late sign) - Cushing triad (very late sign): Severe HTN, Widened pulse pressure, Bradycardia - Abnormal posturing (very late sign): Decerebrate or Decorticate

Answer 73

- Elevate HOB to 30 degrees - Maintain head and body in midline position (hip or neck flexion = increased ICP_ - Avoid clustering activities - Maintain quiet environment - Decrease light esp if photophobia - give oxygen if hypoxic esp prior to suctioning - Monitor LOC, BP, heart rhythm, O2, glucose, temp and notify HCP of sig. changes

Answer 74

- VTE prophylaxis - Discharge with antithrombotic therapy - Discharge with anticoagulation therapy for atrial fibrillation/flutter - Antithrombotic therapy re-evaluated by end of hospital day 2 - Discharge on statin medication - Stroke education provided and documented - Assessment for rehabilitation based on individual needs and functional status

Answer 75

- stay with patient and remain calm - prevent aspiration and keep airway clear (side-lying) - Make note of seizure (date, time, duration; characteristics) - call for another RN to get the antiepileptic drugs - Do not force anything into the patient’s mouth. - Remove any objects or restrictive clothes that might injure the patient. - Suction oral secretions if possible without force. - Do not restrain or try to stop the patient’s movement; guide movements if necessary.

Answer 76

Major side effects - liver dysfunction - leukopenia - gingival hyperplasia and damage (need frequent oral care) - osteoporosis (esp. postmenopausal Monitoring - CBC, BMPs, liver enzymes, and blood levels of drugs regularly (tolerance develops w/ age)

Answer 77

- ask HCP before taking any drugs (Oral contraceptives, OTC drugs) - wear medical identification bracelet, necklace, ID card - Avoid alcohol and excessive fatigue. - Avoid warfarin and phenytoin - Avoid grapefruit juice b-c can increase chance of drug toxicity

Answer 78

- Oxygen/suctioning w/ airway at bedside - IV access for PRN AEDs (diazepam, lorazepam, phenytoin) - Never insert tongue blade into patient’s mouth (b-c can lead to chipped teeth and aspiration of fragments

Answer 79

- prolonged seizure lasting longer than 5 minutes OR repeated seizures over 30 minutes (can lead to death if > 10 minutes) Treatment - Oxygen - airway - large bore catheter IV for NS (only fluid compatible w/ phenyotin) - IV push lorazepam or diazepam - IV phenytoin and fosphenytoin to prevent further seizures or cardia arrests - rapid response team, provider notified and put in ICU

Answer 80

Stress -> CRH (from hypothalamus) -> ACTH (pituitary gland) -> cortisol (adrenal gland) -> Immune system function, metabolism Low blood volume -> Angiotensin II -> Aldosterone (Adrenal gland) -> Na and water reabsorption, K reabsorption

Answer 81

Neuromuscular - Profound fatigue/weakness - joint/muscle pain Gastrointestinal - Weight loss/anorexia - decreased gastric acid production - NVD, constipation - salt craving (dehydration) Skin - Bronze pigmentation - decreased hair, axillary, body (r/t loss of androgens) - vitiligo (primary autoimmune) r/t destruction of melanocyte Cardiovascular - Vascular collapse - anemia - hypotension

Answer 82

- cortisol (decreased) - ACTH (varies- may be decreased or normal) - hypoglycemia (sweating, headaches, tachycardia, tremors) - hyponatremia - hyperkalemia (dysrhythmias w/ irregular HR) - hypovolemia - hypercalcemia - Kidney: decreased GFR, high BUN

Answer 83

- take w/ meals to avoid gastric irritation. - increase dose when ill or stressed - Divided doses given (2/3 in morning and 1/3 at 6pm to mimic normal release of hormone) - Do not confuse prednisone w/ prednisolone which is more potent - may need sodium restriction - Weigh yourself daily and keep a record to show your primary HCP - wear your medical alert bracelet or necklace.

Answer 84

Hormone Replacement - Start rapid infusion of NS or D5NS - corticosteroids (cortisone, hydrocortisone, prednisone) bolus then continuous - H2 histamine blocker (e.g., cimetidine) IV for ulcer prevention. Hyperkalemia Management - Administer insulin in units equal to the same number of mg of extra dextrose in NS IV to shift potassium into cells. - Give potassium binding and excreting resin. - Give loop or thiazide diuretics. - Avoid potassium-sparing diuretics, as prescribed. - Monitor for hyperkalemia (slow heart rate; heart block; tall, peaked T waves; fibrillation; asystole). Hypoglycemia Management - Administer IV glucose - Prepare to administer glucagon as needed and prescribed - Monitor blood glucose level hourly

Answer 85

GI - Increased appetite - GI distress r/t increased acid Integumentary - Bruises and Petechiae (r/t fragile capillaries) - Reddish-purple striae r/t destruction effect on collagen - Thin or translucent skin - acne - Hirsutism (increased body and facial hair) or male-pattern baldness Cardiovascular - HTN - dependent edema

Answer 86

Musculoskeletal - Bone density loss (osteoporosis; decreased height and vertebral collapse) - Muscle atrophy (thin extremities) - aseptic necrosis of femur Immune - Increased risk for infection (reduced WBC, macrophage activity, antibody synthesis) - poor wound healing - reduced inflammatory chemicals (histamines) and cytokines (less reaction)

Answer 87

Reproductive - For males, gynecomastia - For females, oligomenorrhea, clitoral hypertrophy Psychosocial - Personality changes - CNS irritability General - Thin arms r/t increased tissue breakdown - Weight Gain r/t increased total body fat (dependent edema) - Truncal Obesity - Moon Face - Buffalo Hump

Answer 88

- cortisol (increased) - ACTH (excess if pituitary) - hypervolemia (bounding pulse, JVD, crackles, peripheral edema, reduced urine output, urine specific gravity < 1.005, Pulmonary edema, HF) - hypernatremia - hyperglycemia

Answer 89

- High calorie diet, high protein - Increased amount of calcium and vitamin D (for bone density) (Ex. Milk, cheese, yogurt, green leafy and root vegetables) - Avoid caffeine and alcohol which increase GI ulcer risk and reduce bone density. - Avoid smoking, fasting, NSAIDs, salicylates b-c cause gastric irritation.

Answer 90

* Monitor for hypervolemia q2h * Fluid and Na restriction (usually no added salt) * Monitor I & O, weight (1 lb. of weight after first ½ lb. = 50 mL of retained water) * Weight at same time w/ same clothes each day prior to breakfast

Answer 91

Steroidogenesis inhibitors - Action: interfere w/ ACTH production or adrenal hormone synthesis for temp relief Mifepristone - Indication: pts w/ increased ACTH production, type 2 DM, and no response to other drugs - Action: synthetic steroid that blocks glucocorticoid receptors - Contraindicated in pregnancy b-c blocks progesterone receptors. Pasireotide - Indication: pts w/ hypercortisolism r/t pituitary adenoma - Action: subQ admin which binds to somatostatin receptors on adenoma to inhibit tumor production of corticotropin -> decreases cortisol production in adrenal gland

Answer 92

- Correct f/e balance and hyperglycemia - Cardiac monitoring r/t potassium imbalance - To prevent falls, raise top side rails, encourage pt to ask for assistance when getting out of bed. - High-calorie high protein diet - Glucocorticoids given before and throughout surgery to prevent adrenal crisis.

Answer 93

- Monitor ICU for VS, central venous pressure, pulmonary wedge pressure, I & O, daily weights, serum electrolytes - Assess q15 for shock (hypotension, rapid, weak pulse, decreased urine output) - Lifelong glucocorticoid r/t bilateral adrenalectomy w/ glucocorticoid and mineralocorticoid - Two yrs of glucocorticoids if unilateral adrenalectomy to give remaining adrenal gland time to increase hormone production.

Answer 94

* Prevent skin breakdown (pressure-relieving devices, turn q2h, pad bony prominences) * assess pressure areas daily (coccyx, elbows, hips, heels) * Assess skin for redness, excoriation, breakdown, edema. * Keep skin clean, dry thoroughly after washing,moisturize * Use soft toothbrush and electric shaver. * Use tape sparingly and remove carefully.

Answer 95

Cause of GI bleeding * Cortisol inhibits production of thick, gel-like mucus that protects stomach lining. * Cortisol decreases blood flow to stomach. * Cortisol triggers release of excess hydrochloric acid Drugs * Antacids- buffer stomach acids (take around the clock not PRN) * H2 blockers (cimetidine, famotidine, nizatidine) – decreases secretion of hydrochloric acid. * PPIs (omeprazole, esomeprazole) – inhibit gastric proton pump to prevent formation of hydrochloric acid.

Answer 96

- Anyone w/ URI needs mask prior to entering pt.’s room. - Assess for s/s of infection (may be masked w/ only low-grade fever or urinary symptoms) - Monitor CBC w/ diff esp. neutrophils daily. - Inspect mouth every shift for lesions and mucosa breakdown. - Assess lungs for crackles, wheezes, reduced breath sounds q8h. - Perform pulmonary hygiene 2-4 hrs (deep breaths and incentive spirometer hourly when awake) - Take vitals q4h (a temp change of > 1F or 0.5C is significant)

Answer 97

Reproductive - Menstrual disturbances (amenorrhea, prolonged, anovulation) - impotence in men - decreased libido Cardiovascular - Bradycardia - dysrhythmias - enlarged heart - hypotension CNS - Decreased LOC (Slow intellectual functions, lethargy, somnolence) - Apathy (dull-blank expression); depression - hearing loss - paranoia

Answer 98

Pulmonary Symptoms - Hypoventilation - Pleural effusion - Dyspnea and decreased activity tolerance GI - Weight gain (decreased urine output) - Constipation - anorexia - abdominal distention Muscular - Muscle aches and weakness - Extreme fatigue - decreased DTRs - paresthesia (numbness and tingling)

Answer 99

Integumentary - Myxedema (Non-pitting edema of hands/feet; facial puffiness, periorbital edema) - Thick tongue and skin (slow speech and hoarseness) - Dry skin (coarse and scaly)- cool, pale, yellow - Hair loss (eyebrow hair loss) and receding hairline - Thick dry, brittle nails and hair - goiter (if TSH binds to thyroid cells) - poor wound healing Metabolic - Decreased metabolism - Cold intolerance (decreased body temp)

Answer 100

- Decreased T3 and T4 - Elevated TSH (may be decreased or normal in secondary hypothyroidism)

Answer 101

* Adverse effects of high dose: severe HTN, heart failure, MI Patient education * Report chest pain or chest discomfort immediately (* Start on lowest dose possible esp. if severe hypothyroidism to prevent cardiac problems) * Take levothyroxine exactly as prescribed. * Monitor for s/s of hyperthyroidism. * Take on empty stomach w/o food or drink for 30-60 mins

Answer 102

Improving Gas Exchange - Observe and record rate and depth of respirations, O2 sat, breath sounds - Apply oxygen if patient hypoxemic (ventilatory support if severe) - Avoid sedating b-c can worsen gas exchange. - If sedation needed, reduce dose b-c increased sensitivity to opioids and tranquilizers w/ hypothyroidism. Preventing Hypotension - Monitor BP, HR, rhythm, shock (hypotension, decreased urine output, change in mental status) - Give lifelong thyroid hormone replacement (levothyroxine)

Answer 103

- Hyponatremia - Hypotension -> shock - Hypothermia - Hypoglycemia - Respiratory failure (major cause of death) - Reduced LOC and cognition -> coma - flabby heart muscle and increased chamber size (decreased cardiac output)

Answer 104

- Maintain a patent airway, mental status changes, VS (BP and temp) hourly - Start treatment quickly according to symptoms vs wait for lab confirmation. - Cover the patient with warm blankets. Meds - Replace fluids with IV normal or hypertonic saline - Give levothyroxine sodium IV as prescribed (given via IV due to reduced GI motility and absorption) - Give glucose IV as prescribed. - Give corticosteroids as prescribed

Answer 105

Metabolism - Increased Metabolism - Heat intolerance (low grade fever) - Enlarged gland (goiter) Eyes - Exophthalmos (bulging, startled) - blurry or double vision r/t pressure on optic nerve - increased tears - photophobia - red conjunctiva - eyelid or globe retraction/lag -> corneal ulcers if dry Musculoskeletal - Muscle wasting r/t negative nitrogen balance from protein breakdown - Weight loss r/t increased fat metabolism - tremors - fatigue

Answer 106

Integumentary - Fine-straight, soft, silky hair - Pretibial myxedema (dry, waxy swelling of front surfaces of lower legs) - Finger clubbing - facial flushing and diaphoresis - goiter GI - diarrhea - enlarged spleen - increased appetite

Answer 107

Reproductive - Amenorrhea and decreased fertility - Breast enlargement - increased libido Cardiopulmonary - Increased systolic BP (r/t increased cardiac output, blood flow, stroke volume) - decreased diastolic so widened pulse pressure - Facial flushing - rapid, shallow respirations - chest pain (palpitations, dysrhythmias, tachycardia) Neurological - insomnia - decreased attention span - manic (emotional instability, restless, irritability

Answer 108

- Increased T3 and T4 - Decreased TSH (high in secondary hyperthyroidism) - Increased thyroid-stimulating immunoglobulins (TSIs) and Thyrotropin receptor antibodies (TRAbS)- Grave's - hyperglycemia (decreased glucose tolerance)

Answer 109

Action: decrease thyroid Hormone production via preventing iodide binding to thyroid gland Side effects * increased risk for infection * hypothyroidism ( weight gain, slow heart rate, and cold intolerance) * liver toxicity (darkening of the urine or a yellow appearance to the skin or whites of the eyes) -- Mainly PTU * birth defects - methimazole Notes - Delayed response b-c large amounts of stored thyroid hormones usually need to be released first. - higher dose needed for PTU

Answer 110

- Action: slows SNS down (no effect on thyroid hormone)- relieve diaphoresis, anxiety, tachycardia, palpitations

Answer 111

- Action: stops synthesis of thyroid hormone via stopping blood flow to thyroid gland Side effects - hypothyroidism - iodism (fever, rash, metallic taste, mouth sores, sore throat, GI distress) Notes - improvement in 2 weeks - give thioamide first to prevent initial rise in thyroid hormone production

Answer 112

* Measure apical pulse, BP, temp at least q4h. * Immediately report temp increase of 1 F or higher OR heart problems * Do not palpate goiter b-c can cause sudden release of excessive thyroid hormone and thyroid storm. * Quiet environment (rest, door closed, limit visitors, postpone nonessential care) * Reduce room temp b-c heat intolerance. * Ensure fresh pitcher of ice water. * Change bed linen whenever damp from diaphoresis. * Encourage patient to take cool sponge bath or shower several times a day.

Answer 113

- RAI destroys some of cells that produce thyroid hormone - contraindicated in pregnancy b-c crosses placenta - internal radiation precautions (flush 3x, separate toilet)

Answer 114

* Hemorrhage esp 24 hrs post-op serosanguineous drainage = normal * Respiratory distress (s/s laryngeal stridor) need suction, emergency trach, oxygen * Laryngeal nerve damage (s/s hoarseness and weak voice) * Thyroid storm * Parathyroid gland injury (hypocalcemia and tetany) - need rescue calcium gluconate or calcium chloride

Answer 115

- Increased neuromuscular excitability; tingling, muscle spasm (particularly in hands, feet, and facial muscles), convulsions, tetany - intestinal cramping - hyperactive bowel sounds - prolonged QT interval -> cardiac arrest

Answer 116

- Monitor labs b-c treatment can induce hypothyroidism - Thionamide to induce euthyroid prior to surgery. - Iodine preparations to decrease thyroid size and vascularity (reduces risk of hemorrhage and thyroid storm) - Control HTN, dysrhythmias, tachycardia - High-protein, high-carbohydrate diet for weeks or days prior

Answer 117

* Monitor for complications (Monitor VS q15 minutes until stable then q30 minutes) – most important action (Temp increase of 1 F (1.8C) = thyroid crisis) * Assess level of discomfort and give pain meds. * Use pillow or hands to support neck and head (avoid neck extension) * Place in semi-fowler * Deep breath every 30 min to 1 hr. * Lifelong thyroid hormone replacement if total thyroidectomy

Answer 118

- high fever - tachycardia - severe systolic hypertension - Other s/s: abdominal pain, NVD, anxious, tremors - Progressive s/s: restless, confused, psychosis, seizures, coma, death.

Answer 119

- Maintain a patent airway and adequate ventilation. - Monitor vital signs every 30 minutes. - Provide comfort measures, including a cooling blanket. Meds - Give nonsalicylate antipyretics as prescribed. - Correct dehydration with NS - Give oral antithyroid drugs as prescribed: methimazole or propylthiouracil. - Administer sodium iodide solution IV daily as prescribed. - Give propranolol IV as prescribed, slowly over 3 minutes. The patient should be connected to a cardiac monitor, and a central venous pressure catheter should be in place. - Give glucocorticoids as prescribed: hydrocortisone, prednisone, or dexamethasone.

Exam 3 Flashcards

(143 cards)