Nur 138 Exam 1 Flashcards
(193 cards)
1
Q
What is the normal immune response?
A
It’s how the body defends against pathogens, such as bacteria, viruses, fungi, and other foreign invaders.
2
Q
Innate Immune Response
A
Physical & chemical barriers –> the skin and mucous membranes, and chemical barriers like stomach acid and enzymes prevent pathogens from entering the body.
Phagocytosis –> phagocytes ( neutrophils and macrophages) engulf and digest pathogens.
Inflammation –> when tissue is damaged or there’s an infection, the body responds with inflammation.
Complement system –> a group of proteins that help antibodies and phagocytes clear pathogens more effectively.
3
Q
Adaptive Immune Response
A
Antigen recognition –> T cells and B cells recognize specific antigens through receptors. B cells produce antibodies that can neutralize pathogens. T cells kill them.
Clonal expansion –> once an immune cell recognizes an antigen, it undergoes clonal expansion, producing a large number of identical cells.
Memory Cells –> these “remember” the pathogen providing LT protection.
Cell-mediated immunity –> T cells play a crucial role in cell-mediated immunity. They can directly kill infected cells.
4
Q
Lifespan Immunity
A
baby –> protected for 2 months by the mom if breastfeeding, then decreases rapidly.
Toddler / kid –> immunity builds
Adult = strong immunity, slight decrease in pregnancy
older adult = decreases with age
5
Q
Active immunity
A
long lasting, often lifelong and takes several weeks to develop
6
Q
Passive immunity
A
immediate protection, but lasts only weeks or months
7
Q
IgM
A
Primary Immunity
Found 48-72 hrs after an antigen enters the body.
Produces the antibody activity against rheumatoid factors, gram-negative organisms, and the ABO blood group.
Does not pass through the placental barrier.
8
Q
IgG
A
Major immunoglobulin (what is passed between Mom and Baby)
the IgG response is longer and stronger than that of other immunoglobulins.
9
Q
IgA
A
Protects mucous membranes, therefore protects respiratory, GI & GU tracts, tears, and saliva.
Those having IgA deficiency are prone to autoimmune disease.
10
Q
IgD
A
Role unknown
11
Q
IgE
A
increases during allergic reactions, anaphylaxis
12
Q
Diagnostic Tests for hypersensitivity
A
WBC with differential
Radioallergosorbent test (RAST)
Blood type and cross match
Indirect and direct Coombs test
Immune complex assays
Complement assays
Skin testing
13
Q
Independent nursing actions for a client with a compromised immune system
A
Assure proper nutrition
Adequate exercise
Sleep
Stress Reduction & Mgmt
14
Q
What is a Central Venous Cather?
A
A catheter that is inserted into a large vein that is really close to the heart
(inferior & Superior Vena Cava). Usually insert at the subclavian or internal jugular.
Can be done in the femoral, but not usually because of the high risk of infection.
15
Q
Why use a CVC?
A
To give meds that are highly irritating (the volume of blood in the big veins then dilutes the irritating meds)
Multiple meds
High volume
Patient is hemodynamically unstable - so need lots of fluids at a high pressure.
Nutrition / TPN
Temporary hemodialysis
16
Q
Care for a CVC
A
10mL flushes to maintain patency
Push / Pull method for blood return. Do NOT use this for blood cultures due to false positives.
Clean, Dry, Intact dressing
chlorhexadine wipes
Pressure caps
17
Q
Inflammatory Response
A
- Recognize that there’s a pathogen.
- release inflammatory mediators, such as cytokines/chemokines / histamines.
- Vasodilation - blood vessels widen and increase blood flow, which leads to the major S&S of inflammation: Redness, Heat, Swelling, Pain, Loss of function.
- Neutrophils & phagocytes rush to the scene
- Phagocytosis : the neutrophils and phagocytes eat the pathogens.
- Resolution and tissue repair
- Adaptive immune Response: B cells produce antibodies to neutralize pathogens; T cells coordinate the immune response and kill infected cells.
- Resolution & return to homeostasis.
18
Q
Identify assessment findings indicative of a systemic reaction to inflammation
A
Fever
Tachycardia (increased HR)
Tachypnea (rapid breathing)
Hypotension
Altered mental status
Leukocytosis (elevated WBCs)
Increased RR
Oliguria or Anuria
19
Q
Nursing care of a client with anaphylactic shock
A
Maintain airway and breathing
Place patient in Fowler / High Fowler
Assess respiratory status / O2 per NC
Administer epinephrine
Establish IV access
Monitor vital signs
Reassess frequently
20
Q
Chain of Infection
A
o Starts with an Infectious agent…..
o Finds a reservoir (such as a human body) where the pathogen lives and multiples.
Could be a body of water or another living creature
o Then the virus leaves the reservoir through a portal of exit
think of respiratory fluids and the flu
o Then there’s the mode of transmission – which is how the pathogen gets to the portal of entry (how it gets from one place to the other).
Direct, indirect, or airbone
o Next, it has to enter the body through a portal of entry
mouth, nose, eyes, throat, genitalia
o And then the virus looks for a host to spread the pathogen.
21
Q
Stages of infection
A
o Incubation period = time from when the pathogen first gets into the body until when it makes it’s presence known.
If there’s a long incubation period, you might be contagious before you even know you’re sick
Active replication, no symptoms
o Prodromal Stage = when you start to feel sick
Nonspecific symptoms
o Illness phase = actual symptoms related to the infection (when you’re sick!)
Pathogens proliferate
Note that very old / alcoholics may respond with hypothermia
o Convalescence stage= when you are getting better. It could take a very long time.
22
Q
Risk Factors for Infection
A
Medical therapies such as radiation treatments, diagnostic procedures
Diseases that lower the body’s defenses such as COPd, PVD, Burns, Diabetes, Immune System Diseases
Age and heredity
Newborns have immature immune systems, are protected by IgGs from the mom, and begin to develop their own immune system at 1-3 months of age.
23
Q
Nursing Actions that decrease risk of infections
A
Use sterile technique when appropriate
Effective hand hygiene
Critical thinking, agency policy
Invasive procedures and equipment should be used only when absolutely necessary.
24
Q
Common methods of infection transmission in adults
A
Direct contact
indirect contact
Respiratory droplets
Airborne transmission
Fecal-oral transmission
vector-borne transmission
Sexual transmission
Bloodborne transmission
vertical transmission (mother to baby)
Zoonotic transmission (animals to humans)
Food & waterborne
25
Common methods of infection transmission in pediatrics?
Same as adult, but add in:
School & daycare settings
Playdates & social interactions
26
what are contact precautions and some diseases that need it?
Used for diseases that can be spread through direct or indirect contact (surfaces).
MRSA, C Diff, Scabies, Multidrug-resistant organisms (MRDOs).
Use gloves & gown when entering the patient's room, ensure hand hygiene, dedicate patient care equipment, follow cleaning protocols.
27
what are some droplet precautions and common diseases?
Used for diseases transmitted via respiratory droplets when the patient coughs, sneezes, talks, or breathes.
Flu, Pertussis, mumps, COVID-19
Wear a mask, maintain 3 ft of separation, proper hand hygiene, patient has to wear a mask if leaving the room.
28
What are airborne precautions and common diseases?
Used for diseases that can be transmitted through tiny airborne particles that remain suspended in the air for an extended period.
TB, measles, chicken pox, disseminated herpes zoster
N95, airborne isolation room (negative pressure), limit movement of patient and use an N95 if have to transport.
29
what is a protective environment and the diseases that might need it?
Used for patients with compromised immune systems, such as those who have undergone bone marrow transplants or organ transplants. Or who have cancer. The goal is to protect the patient from environmental pathogens.
Maintain strict hand hygiene, use sterile techniques when handling invasive devices, limit visitors and ensure that visitors follow infection control measures.
30
Infection in pregnant women
Rubella, Cytomegalovirus, parvovirus, chicken pox infections may cause birth defects.
HIV, Group B Strep, Cytomegalovirus, listeriosis infections can be transmitted to the newborn.
Precautions include antiviral treatment for HIV, antibiotics for Group B Strep, good hygiene, avoiding contaminated foods.
31
Infection in older adults
immune system reacts more slowly and may not exhibit classic manifestations of infection.
Thymus gland atrophies (T cells decline), antibody responses decline, reduced resistance to antigens.
Medications, dehydration, poor nutrition, mental status, chronic illnesses, activity level, and hospitalizations also increase risk of infections.
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Nursing Assessment for Infection
Take the client's history
Assess the degree of risk for infection through observation and interview.
Physical assessment - local infection = warm, redness, swelling, pain, loss of function.
Systemic infection = fever, increased pulse, fatigue, loss of appetite, enlarged/tender lymph nodes.
Assessing for infection is important to catch it quickly. Particularly for patients with IVs, indwelling catheters, surgical wounds.
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Diagnostic Tests for Infection
WBC Count & differential
Direct antigen detection methods
Antibiotic peak, trough levels
Radiologic examination of chest/abdomen/ urinary system
Lumbar puncture
Ultrasonic examination (echocardiogram or renal US)
cultures and urinalysis.
34
Nursing Independent Interventions for Infection
Goals of care are to identify the organ system involved, identify the causative agent, and achieve a cure by the least toxic, least expensive, and most effective means.
Therapy should be tailored to the patient's needs
Prevent transmission of infection.
Promote the psychosocial needs of patients in isolation due to sensory deprivation and decreased self-esteem.
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How to Promote psychosocial needs of patients in isolation
* Assess the individual’s need for stimulation.
* Initiate measures to help meet the need for stimulation, including regular
communication with the patient and diversionary activities.
* Explain the infection and the associated procedures to help patients, their families,
and caregivers understand and accept the situation.
* Demonstrate warm, accepting behavior. Avoid conveying to the patient any sense of
annoyance about the precautions or any feelings of revulsion about the infection.
* Do not use stricter precautions than are indicated by the diagnosis or the patient’s
condition.
36
Care of an infected surgical site
1. Overall assessment, vital signs, signs of systemic infection (WBC, fever)
2. culture and lab tests --> obtain wound cultures as ordered and perform lab tests such as CBC and inflammatory markers (C-reactive protein and ESR) to assess severity of the infection and the body's response.
3. Wound irrigation and debridement --> removes debris and infectious material and even possibly have to remove necrotic tissue and infected material.
4. Wound dressings - clean, dry, and intact! antimicrobial dressing or silver-containing dressings for infected wounds.
5. Antibiotic therapy as ordered.
6. pain management
7. education re wound care and completing the full course of antibiotics
8. Assure appropriation nutrition and hydration
37
post-op care
1. monitor VS, pain, level of consciousness, and surgical site for bleeding/infection / other complications.
2. Follow orders for wound care, ensuring proper hand hygiene and sterile technique.
3. Encourage early mobility and ambulation as appropriate.
4. manage pain thru meds and non pharma methods.
5. Fluids and nutrition
6. Respiratory care - encourage deep breathing exercises and coughing.
7. Med management
8. Diet & Bowels --> start with a clear liquid diet and progress as tolerated. Monitor BMs and provide stool softeners/laxatives as ordered.
9. Education & communication.
38
Post op discharge instructions
1. provide clear instructions on how to care for the surgical wound.
2. review meds and how to take them.
3. pain mgmt techniques
4. Activity / mobility recommendations.
5. Diet and nutrition
6. Hygiene and wound care -- keep site clean and dry, how to bathe/shower.
7. follow up appointments are scheduled.
8. Assure the patient can identify complications like infection, bleeding, adverse reaction to meds and can seek help.
39
Immunizations in infancy and early childhood (birth - 6yo)
Hep B
DTaP
Hib (flu)
PCV13 (pneumococcal conjugate)
Polio (IPV)
RV (Rotavirus)
MMR
Varicella
Hep A
Flu annually
40
Immunizations in late childhood and adolescence (7-18 years)
Tdap booster
HPV
Meningococcal
Flu annually
COVID
41
Immunizations in Adulthood (19+)
Tdap booster if not received
Flu annually
Shingles for 50+
Hep A & B if needed
MMR if not already vaccinated/immune
COVID
42
Immunizations in 65+
Flu
Pneumococcal
Shingles
COVID
43
Passive Immunity in Vaccines
Hepatitis B Immunoglobulin (HBIG) is a passive immunity vaccine given right after exposure to prevent infection of Hep B (i.e. after a needle stick.)
Rabies Immunoglobulin (RIG) is used to provide immediate immunity to individuals who have been exposed to rabies.
Passive immunity involves the transfer of pre-made antibodies.
44
Active immunity in vaccines
MMR (weakened form)
Flu (part of the virus)
Active immunity stimulates the immune system to produce it's own antibodies to protect against those antigens.
45
strategies for AIDS prevention
education about safe sex, consequences of high risk sexual behaviors, drug use, autologous transfusion, informing medical personnel of diagnosis.
46
Post-exposure Prophylaxis for HIV
Post-exposutre prophylaxis (PEP) is for those who have been exposed, like healthcare workers with a needle stick. Must begin within 72 hrs of exposure. Includes 2-3 antiretroviral therapy (ART) meds for 28 days. Follow up testing is required.
47
Pre-Exposure Prophylaxis for HIV
Pre-exposure prophylaxis (PrEP) can reduce risk in HIV-negative individuals at risk of becoming infected with HIV.
--> Truvada is taken once a day and blocks infection pathways.
--> Descovy is approved for some adults and adolescents.
--> 99% effective when combined with other prevention methods.
48
Modes of transmission for HIV/AIDS
Sexual contact (found in body fluids)
infected needle sharing
Transfusions of infected blood before 1985
49
HIV Viral Load
5,000-10,000 copies / mL indicate need for treatment.
If the viral load gets undetectable (20-50 copies / mL), that would indicate the person is effectively managing the virus with ART or they don't have HIV.
Measures the amount of actively replicating HIV
Correlated with disease progression and/or response to antiretroviral therapy
50
CD4 Cell Counts for AIDS
CD4 cell counts monitor disease progression and guide therapy. Monitor every 3-6 months for people with HIV.
AIDS = CD4<200 mm3 + presence of opportunistic infection / immunodeficiency
or
AIDS = CD4 lymphocytes <14%
Normal range is 500-1,500 per mL of blood.
51
WBC normal range
4,500-10,000
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CBC - Hemoglobin
Normal: 12-18
Risky: 8-11- report to the HCP!
Below 7 "sends your patient to heaven" Patient needs immediate transfusion or will die of shock.
One unit of PRBCs will increase Hgb by 1
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CBC - Hematocrit
36-48% for adult females
38-52% for adult males
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CBC - platelet count
150K-450K per uL of blood
Anything less than 50,000 is risky / deadly!! This typically results from cancer
Platelets are not clotting factors! Note the difference.
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CBC - RBC
4.5M - 6M cells / uL for adult females
4.5M - 5.5M cells / uL for adult males
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HIV Diagnosis
ELISA test first for the antigen test, then confirmed by the Western Blot test.
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HIV/ AIDS - Pregnant women and Newborns
Infants can acquire HIV by vertical transmission from the mother, transplacentally, or during delivery.
Pregnancy isn't thought to accelerate progression of HIV / AIDS in asymptomatic women.
Most HIV meds are safe to take during pregnancy.
Prophylactic ART treatment during birth
Can be transmitted during breastfeeding
Without treatment, 25-30% of infants born to HIV positive mothers are infected perinatally. With treatment, only 5% are infected.
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HIV Care for Pregnant Women
Consult with OB and ID specialist
Vaccinations for pneumonia, flu, Hep B (if not already vaccinated)
Get a CBC every trimester and do regular serologic checks
Continue the HIV treatment regiment --> infected mothers should receive oral AZT after the 1st trimester and IV AZT during labor
Recommended a scheduled C section at 38 weeks, prior to rupture of membranes.
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Newborns of women with HIV
Prevent spread of HIV from mother to newborn
All infants get prophylactic AZT and prophylaxis against PJP, continuing to 12 months.
60
HIV / AIDS in infants and children
Usually asymptomatic at birth, but S&S show up within 2-3 months of birth.
Opportunistic infections are sooner for children infected prenatally than those infected thru blood transfusion.
Mortality is high due to opportunistic diseases such as gram-negative sepsis and problems associated with prematurity (low birth weight, failure to thrive)
61
HIV / AIDS - S&S in infants & Children
Most have nonspecific findings at first, and specific findings appear within 2 years of infection.
Enlarged spleen, liver, swollen glands
Recurrent respiratory infections, rhinorrhea
Recurrent diarrhea and weight loss
UTI
Persistent, recurrent oral candidiasis
Loss of achieved milestones
All immunizations should be received as soon as they reach the age, although the CD4 and viral count may play a role in when. Live vaccines like MMR and varicella can produce a stronger immune response, which can be a concern if the child is immunocompromised. Inactivated vaccines like Hep
A, Hep B, polio, and flu are fine.
Need annual TB tests
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HIV / AIDS - Diagnosis in Infants & Children
Early identification is essential!!
ELIA, Western blot tests are inappropriate before 18 months of age. HIV DNA polymerace chain reaction (PCR) and HIV RNA assays are preferred.
Perform the first PCR within 48 hours of birth.
Infants with known perinatal HIV exposure should receive virologic diagnostic testing at ages:
14-21 days
1-2 months
4-6 months
63
HIV/AIDS in adolescents
largest % of HIV-infected pediatric group
43% are undiagnosed
Most are infected through risky sexual behavior, although some are survivors of perinatal or infant infection (these need a different clinical course than those recently infected).
Challenging to treat adolescents due to compliance and the developmental stage.
64
HIV/AIDS in older adults
adults>50 make up 50% of the people living with diagnosed HIV/AIDs
They might practice unsafe sex and don't know to get tested. Aren't often educated.
S&S might be overlooked as part of the aging process or are masked by chronic diseases.
At greater risk for drug interactions with ART meds.
65
Type II Hypersensitivity
Cytotoxic / Tissue specific.
Involves direct antibody-mediated reactions against host antigens. It occurs when the immune system produces antibodies (IgG or IgM) against self-antigens or antigens on the surface of host cells.
The antibodies / auto-antibodies form immune complexes that can activate the complement system, leading to cell destruction and tissue damage.
Examples: rheumatoid arthritis, autoimmune hemolytic anemia.
66
Type III Hypersensitivity
Immune complex mediated.
Involves immune complex-mediated reactions. It occurs when immune complexes consisting of antibodies (IgG or IgM) and antigens become deposited in tissues throughout the body.
In secondary hypersensitivity, the immune complexes circulate in the bloodstream and become trapped in various organs and tissues. This can trigger an inflammatory response, leading to tissue damage and symptoms.
Examples: Systemic Lupus Erythematosus (SLE), rheumatoid arthritis
67
Type I Hypersensitivity
Allergy or Atopy
Mediated by IgE antibodies specific for antigens that are normally non-pathogenic.
Mast cell or basophil are the primary cellular components.
PCN (penicillin) and cephalosporin allergies are Type I, as some people develop IgE antibodies specific to PCN. Upon subsequent exposure, IgE binds to the drug causing release of histamine and other inflammatory mediators / mast cells. This immune response leads to the rapid onset of symptoms, which can range from mild to life threatening.
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Type IV Hypersensitivity
Type IV HS is a delayed / variable process. It occurs when effector T cells, macrophages and other leukocytes induce delayed inflammatory tissue damage.
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Mild hypersensitivity responses
rhinitis
Water / itchy eyes
Scratchy throat
Lasts hours to a few days
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Moderate hypersensitivity responses
difficulty breathing & congestion
Loss of smell, taste, appetite
SKin reactions: urticaria, atopic and contact dermatitis
Food allergies: urticaria and GI symptoms
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Severe hypersensitivity reactions
may lead to respiratory distress, death
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Nursing response to a latex allergy
Assess for allergy & document it. Make sure the patient has a wristband to identify it.
Create a latex-free environment (latex free products only!) & make sure others know about the allergy. Double check all equipment / meds for latex.
Educate the patient about sources of latex and what to do if they are accidentally exposed.
Monitor for exposure and signs of an allergic reaction - hives, itching, swelling, SOB, wheezing, anaphylaxis.
If exposed, maintain an open airway, administer epinephrine if indicated, and prepare for potential respiratory support.
73
Type I Hypersensitivity examples in kids and appropriate nursing care
Hay fever, asthma, food allergies, anaphylaxis
Identify the triggers and educate on avoidance.
Administer antihistamines, bronchodilators, or epinephrine per provider's orders.
Monitor respiratory status, BP, HR, and O2 sat
Provide emotional support and reassurance
Provide education about epinephrine and discuss an allergy action plan.
74
Type II Hypersensitivity examples in kids and appropriate nursing care.
Hemolytic disease of the newborn (Rh or ABO incompatibility), drug-induced hemolytic anemia
Monitor newborn for signs of hemolysis, such as jaundice or anemia, and provide appropriate treatment if needed.
Administer RhoGAM to Rh (-) pregnant women
Ensure blood type compatibility for transfusions and meds.
Educate & provide emotional support.
75
Type III Hypersensitivity examples in kids and appropriate nursing care.
Rheumatoid Arthritis, Systemic Lupus Erythematosus (SLE), glomerulonephritis
Monitor for S&S of immune complex-mediated diseases such as joint pain, skin rashes, proteinuria, and edema.
Administer meds for autoimmune diseases.
Promote skin and joint care to reduce discomfort.
Educate about disease management - med adherence and symptom monitoring, and emotional support.
76
Type IV Hypersensitivity in kids and appropriate nursing care.
Contact dermatitis (poison ivy, nickel allergy), tuberculin skin test reactions.
Identify and remove the causative agent if known.
Provide topic or oral corticosteroids as prescribed to manage skin reaction.
Instruct on allergen avoidance and proper hygiene.
Monitor for secondary bacterial infections if skin integrity is compromised.
77
Use and Care of EpiPen
EpiPen should only be used in severe allergic reactions that include difficulty breathing, swelling of the face or throat, hives, a rapid/weak pulse, confusion or loss of consciousness.
Jab the EpiPen into the thigh at a 90degree angle. Keep in place for 10s to allow the meds to be injected. Then call 911.
Store at room temp and keep with you.
Educate others about the need and where it is.
Make sure it isn't expired (don't use an expired one)
Practice if possible!
78
Risk Factors for Hypersensitivity Reactions
Incidence and intensity increase with previous exposure
Age, sex, concurrent illnesses, previous reactions to related substances
Family member with allergy
Development, severity factors
79
Systemic Hypersensitivity Response
Occurs when an allergen triggers a widespread and profound immune response throughout the body.
Symptoms are not confined to a specific site and can affect multiple organ systems.
S&S include:
skin reactions (hives or urticaria)
Respiratory symptoms (wheezing, coughing, SOB)
GI symptoms (nausea, vomiting, diarrhea)
Cardiovascular symptoms (rapid HR, decreased BP)
CNS symptoms (confusion and anxiety)
they can range from mild to severe (anaphylaxis)
80
Localized Hypersensitivity Response
Local/focal allergic reaction triggers an immune response that is confined to a specific area or organ of the body.
S&S are confined to the specific site of contact:
Allergic contact dermititis (skin rash and itching) due to exposure to an allergenic substance like poison ivy or nickel.
Allergic rhinitis (hay fever) with symptoms such as sneesing, runny nose, and itchy eyes often triggered by airborne allergens like pollen.
Generally less severe than systemic reactions, but still might need treatment with antihistamines or corticosteroids.
81
Blood administration process
Confirm the correct patient, blood, etc by comparing all the information.
Assure informed consent
Baseline vital signs
Insert a dedicated IV for the transfusion
Inspect the blood bag and verify again for compatability and correct patient/blood
Warm blood if needed
Prime the tubing with normal saline
Initiate transfusion at a slow rate (2-5 mL/min) for the first 15 minutes while closely monitoring the patient for any signs of a transfusion reaction.
Monitor the patient's vital signs and observe for transfusion reactions such as fever, chills, rash, SOB, or hypotension.
Adjust the transfusion rate to the patient's tolerance.
Complete within 4 hours.
Afterwards, monitor for at least 30 minutes for delayed reactions, document, and educate the patient about reporting adverse reactions.
82
What is TB
a bacterial infection in the lungs that is spread via airborne route
Once inhaled, it spreads to the blood and lymph streams. The upper lobes of the lung are most impacted and it implants in the alveoli.
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Clinical manifestations of TB
Blood tinged cough (hemoptysis)
night sweats
Weight loss
Fever
dyspnea and SOB
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Precautions for TB
Airborne precautions
"On Air with MTV" = MTV is Measles, TB, and Varicella
N95 mask for staff, negative pressure room, door closed, and the patient wears a surgical mask for transport.
85
Positive TB Test
Induration greater than 15 mm on the Tuberculin Skin Test (TST)
But since this doesn't mean they're in active form, you then do a chest x-ray or sputum cultures.
Sputum cultures are taken until there are 3 negative cultures on 3 different days.
86
TB Medication Purpose
Medication is used to prevent the spread and reduce symptoms.
Prophylaxis is available:
Isoniazid 300mg/day for 6-12 months
Bacille Calmette-Geurin (BC) vaccine
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Active TB Medication Regiment
Combination of 4 oral meds for 2 months
>> isoniazid (inhibits TB growth)
>>Rifampin (kills the bacteria),
>>Pyrazinamide (kills dormant TB bacteria),
>>Ethambutol (helps prevent the development of drug resistance)
Followed by 4-7 months of
>>isoniazid and rifampin
the duration may be extended if there are underlying immunocompromised diseases present.
Take on an empty stomach and monitor the liver due to hepatotoxicity.
88
Nursing actions to promote oxygenation in a TB patient
>Med Management (monitor for side effects and hepatotoxicity)
> Respiratory isolation to prevent the spread of disease to others
> assessment of RR, effort, lung sounds, respiratory distress and O2 levels
> Positioning - upright or semifowlers, change positions to prevent atelectasis and promote ventilation
> nutrition and hydration
>Airway clearance - effective coughing and deep breathing exercises. chest physiotherapy if indicated.
89
What is rheumatoid arthritis (RA)
RA is a chronic autoimmune disorder that primarily affects the joints. The immune system mistakenly attacks the synovium, which is the lining of the membranes surrounding the joints. Often, RA affects joints on both sides of the body symmetrically.
Common symptoms include joint pain, swelling, and stiffness. It can lead to systemic symptoms such as fatigue, fever, and weight loss.
Without treatment, it can lead to join damage and deformities.
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Risk factors for RA
combo of genetic, environmental, and hormonal factors.
Obesity and occupational exposures.
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Diagnosis of RA
Diagnostic tests include CBC, rheumatoid factors, CCP, ESR, CRP, x-rays of affected joints.
Note that RA factors don't say how widespread it is, just that it's present.
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Appropriate activities for children with RA
Anything non-contact like yoga or swimming
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non-pharma pain management for a client with RA
Rest and exercise
PT & OT
Heat / Cold
Orthotic and assistive devices
nutrition and lifestyle
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Signs & Symptoms of TB
Chronic cough (dry to bloody sputum)
Fever
Night Sweats
Fatigue
Loss of appetite and weight loss
Chest Pain
SOB
Swollen lymph nodes
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nursing care of TB
Isolation / Airborne precautions.
Medication management --> make sure all meds are taken as prescribed bc otherwise they won't work.
nutrition
Education re transmission, medication regimen, proper respiratory hygiene, and cough etiquette.
Monitor for adverse side effects such as hepatotoxicity and GI disturbances.
contact tracing
Prevention Education
Nursing care for TB not only manages the disease but provides support, education, and promotes adherence to med treatment to prevent the spread of TB.
96
ulcerative Colitis S&S
"UC Blood"
"uLcerative Pain" == pain is in the left lower quadrant
5-30 mucousy stools a day
BMs will decrease the pain
focused in the large intestine and rectum
Mucosa layer is the most affected.
Continuous ulcers
Anemia
no cure unless rectum & colon removed.
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Crohn's S&S
diarrhea, less likely to be bloody
cRohn's pain is in the Right lower quadrant
"Gums to Bums"
Entire bowel wall is affected, which leads to fistulas.
skip lesions/patches = looks like cobblestones
Infections like peritonitis, abcesses, and sepsis.
98
S&S of both Crohn's and Ulcerative Colitis
No difference across the sexes
15-30 most frequent for onset
hereditary
loss of electrolytes
increased colorectal cancer risk
hypoalbuminemia / anemia
weight loss
malnutrition / dehydration
Acute cases: NPO
99
Nursing activities for Crohn's and UC
Monitor fluid / electrolyte balance as this can impact cardiovascular system
Monitor Daily weight
WBC / CBC
Stoma Care: should look red and beefy
Nutrition support
Pain Management
Education & emotional support
Monitor for complications such as fistulas, abscesses, strictures, or bowel obstructions.
100
What would you expect of lab results following chemotherapy?
Decreased platelet count
Decreased WBC
Decreased RBC
101
Breast Cancer S&S
lump or mass
change in breast size or shape
Skin changes (redness, resembles an orange peel, dimpling, or puckering)
Nipple changes like inversion, discharge, crusty/scaly rash
Breast pain
Swelling in breast or underarm
unexplained weight loss
change in breast sensation (tingling or numbness)
102
Cancer Care Nursing goals
Goals are that the patient will
Maintain a WBC <10000
Make informed treatment decisions
Express feelings regarding diagnosis, treatment, and prognosis
Receive appropriate support from family and significant others
103
Cancer Care nursing care
VS, I/O, daily weights
Prevent infection - avoid deoderants, talcum powder until incision is healed
encourage good nutrition
Promote optimal circulation
>ROM in affected arm
> lymphedema massage and elastic compression bandage
> use non-surgical side for BP, starting IVs
> elevate arm higher than shoulder but do not abduct
Promote healthy body image
Provide emotional support
Administer meds (anti-nausa, pain) as appropriate
104
Estrogen Replacement Therapy (ERT) relationship to Breast cancer
ERT is associated with an increased risk of Breast Cancer, particularly when used in LT (greater than 5 years) or certain combinations --> estrogen alone seems lower risk than estrogen+progestin.
Risks are thought to be higher when ERT is started closer to menopause/after menopause as opposed to starting ERT earlier in life.
But there should be individual risk assessment done.
105
Etiology for lung cancer
Smoking is the main cause
Develops as damaged bronchial epithelial cells mutate, become neoplastic.
Genetic changes -->
> inherited: genetic abnormality on chromosome 6
> acquired: develop over lifetime, mostly from exposure to cancer-causing chemicals
Alterations of tumor suppression genes seen in some types
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Risk Factors for Lung Cancer
smoking is the strongest risk factor.
Exposure to ionizing radiation, inhaled irritants
Radon exposure
Risk increases with age
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superior vena cava syndrome
obstruction of blood flow in someone who has lung cancer results in edema of the face and arms
108
Diagnostic Tests for Lung Cancer
Chest X-ray
Sputum specimen
Bronchoscopy
Computed Tomography (CT)
Cytologic examination, biopsy
CBC, liver function, serum electrolytes
Tuberculin test
Pulmonary function test, arterial blood gases
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Clinical Manifestations of Lung Cancer
COUGH is the earliest sign of lung cancer. Begins as non-productive and progresses to productive. Wheezing, pain, and blood-tinged sputum are later signs of the disease.
Initial symptoms are often attributed to smoking or chronic bronchitis.
Systemic paraneoplastic manifestations include weight loss, anorexia, fatigue, weakness, bone pain, clubbing.
endocrine, neuromuscular, cardiovascular, and hematologic symptoms
110
Symptoms of metastasis in lung cancer
Brain = confusion, impaired gait & balance, headache, personality changes.
Bone = pain, pathologic fractures, spinal cord progression.
Blood = thrombocytopenia, anemia is marrow is invaded.
Liver = jaundice, anorexia, upper right quadrant pain.
111
Nursing care of a client with lung cancer
Nursing care is related to respiratory status, the cancer itself, possible metastases, and the treatment plan.
Goals are related to maintaining O2 levels, normal RR (12-20), deny dyspnea, maintain HR WNL, report tolerable pain.
Assess and document respiratory status at least every 4 hrs
Supplemental O2, suctioning
Chest physiotherapy
Continuous ECG if indicated
Elevate HOB to 60 defrees
Turn / reposition; cough and deep breathe
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colostomy
connects colon (large intestine) to the abdominal wall (stoma)
Temporary or reversible
Stool may be semi-formed to solid depending on the location of the colostomy
Conditions that may require ostomy – infection, inflammation, diverticulitis, Crohn’s, ulcerative colitis, blocked bowel, familial adenomatous polyposis, serious bowel injury
Flatter to the skin, as opposed to an ileostomy
typically located in the left iliac fosta
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ileostomy
small bowel / intenstine is brought out into the skin.
Connects the last part of the small intestine (ileum) to the abdominal wall (stoma)
Most often necessary for IBD (Crohn’s and ulcerative colitis)
Output contains stool and digestive enzymes
Stool is usually liquid or soft
Temporary or reversible
More liquidy - fluid is usually re-absorbed in the large intestine.
Right iliac fossa
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Gastrostomy
artificial connection to the stomach so that the patient can feed.
"PEG" tube
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Urostomy
typically have a spout and are located in the right iliac fossa
Avoid the urine touching the skin, as that would cause irritation
116
End colostomy
created after the removal of a section of bowel, where the end part of the proximal portion of the bowel is brought to the skin.
Feces drain into the bag
The end part of the bowel is sutured and left in the body. These two parts can be reunited.
Permanent after an abdomino-perineal resection because the rectum and anus are removed.
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End ileostomy
permanent after a panrpoctocolectomy, which is a removal of the entire large intestine, rectum, and anus.
done due to IBD
118
Role of nutrition in healing
Nutrition provides the body with essential components required for tissue repair, immune function, inflammation control, and overall recovery.
> protein is needed for building and repairing tissues.
> Vit A,C,D,E, and Zinc are essential for immune function
>omega 3 fatty acids are anti-inflammatory
> Vit C and Zinc are crucial for collagen formation and proper wound healing.
> Nutrition is needed for energy, GI health, etc.
> Calcium and Vit D are important for bone health
119
What should a healthy stoma look like?
red, beefy
120
Prostate Cancer Risk Factors
Age is the biggest risk factor
then race (African American men
Diet high in dairy foods and processed meat
Obesity
investigating others:
> genetic / hereditary factors
> vasectomy
> excessive supplemental Vit A
121
Strategies to prevent skin cancer
sunscreen
Avoid tanning beds
Monitor Nevi for changes as they can become malignant.
122
ABCDE of Skin Cancer
A = asymmetry
B = border
C = color
D = diameter
E = evolution
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Hyperplasia
increase in the number of cells in a tissue or organ, resulting in the enlargement of that tissue.
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Metaplasia
reversible change in which one type of adult cell is replaced by another adult cell.
this can be in response to chronic irritation or stress- for example, transformation of normal columnar epithelial cells of the respiratory tract into squamous epithelial cells in response to smoking.
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Dysplasia
abnormal growth, development, or maturation of cells.
Considered a pre-cancerous condition, as it represents disorganized/atypical growth pattern.
126
Anaplasia
complete lack of differentiation in cells and subsequent loss of normal cellular characteristics and functions.
A hallmark of highly aggressive and undifferentiated cancer cells.
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Early warning signs of cancer (CAUTION)
"CAUTION"
C = change in bowel or bladder habits.
A = a sore that does not heal
U = unusual bleeding or discharge
T = thickening or lump in the breast or elsewhere
I = indigestion or difficulty swallowing
O = obvious change in wart or mole
N = nagging cough or hoarseness
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Diagnostic tests for cancer.
CT / MRI
Endoscopy
tissue biopsies (very important!)
Cell cytology
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Early Breast Cancer Screening Protocol
Breast Self Exams
Clinical Breast Exams
mammography, annually starting at age 40 or 45
Breast MRI for high risk
Genetic Counseling & Testing for BCRA1 or BCRA2
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Normal Collaboration for Leukemia
Treatment focuses on achieving remission or cure.
> cure is more often achieved in children.
Multidisciplinary approach:
> diagnosis & staging; bone marrow aspiration and biopsy, cytogenetic and molecular studies.
> chemotherapy either orally, IV, or intrathecal injections. Induction, consolidation, and maintenance therapy.
> Targeted therapies
>stem cell transplantation
> radiation therapy to target the spleen or CNS; often used in conjunction with chemo
> Supportive care
> Clinical trials
> Psychosocial Support
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Leukocytosis lab values
above 10000
132
Leukopenia lab values
less than 4000
Low WBC when the normal game is 5000- 10,000
133
thrombocytopenia
<150,000
134
Pancytopenia
Hemoglobin<12 in women and <13 in men
Platelets <150,000
Leukocytes <4000 or
Absolute neutrophil <1800
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anemia
hemoglobin <13 in a man and <12 in a woman
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neutropenia
insufficient numbers of neutrophils (low WBC)
= higher risk of infection
Implement neutropenic protection at the hospital. Put on protective gear to prevent exposure to the patient.
Carefully monitor temp, restrict visitors who are ill, cook all food, no fresh plants or flowers, keep dedicated equipment in the patient's room.
Filgrastin is a medication that helps boost the neutrophil count.
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neutropenia patient teaching
Report any temp >100 to the doctor
Avoid crowds and sick people
Avoid yard work/gardening
Don't change the cat littler box
wash dishes in hot water or in the dishwasher. Also wash their toothbrush!
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Anemia
Decreased RBC counts
Epoietin alpha increases RBC count
Ferrous Sulfate is an iron supplement and is a key component of RBCs
Encourage the patient to increase their intake of foods high in iron, folate, and B12.
Take extra rest periods - anemia can make you feel very fatigued.
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Risk factors for breast cancer
Gender (female)
Age (>50)
Family history
Genetics - BRCA1 and BRCA2
Personal history of breast cancer / non-cancerous breast diseases
Hormone Replacement Therapy - particularly estrogin & progestin combined
Exposure to estrogen in menopause / not having children
Obesity
Alcohol and tobacco use
140
Risk factors for Colon Cancer
Age (>50)
Family history of colon cancer, Lynch syndrome, or familial adenomatous polyposis (FAP)
Personal history of IBD, polyps, cancer
Diet in red / processed meats and low in fiber, fruits, and vegetables
Physical inactivity
Obesity
Smoking
Alcohol consumption
141
Risks for Prostate Cancer
age (men>50)
Family history / close relative with prostate cancer
Race / ethnicity - African American men
Genetics
Diet in red / processed meats and low in fiber, fruits, and vegetables
Obesity
Smoking
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Risk Factors for Lung Cancer
Smoking is the leading cause of lung causer, and it has a dose response.
Secondhand smoke
radon gas
Occupational exposure
Air pollution
Family history
Radiation Therapy - previous treatment to the chest
Lung diseases like COPD
143
Cancer treatment factors for adults
~60% of cancers occur in older adults
Older adults don't respond to cancer treatment the same way that younger adults do.
They have higher risks because of additional chronic conditions
Older adults aren't always screened -- screening for specific cancers is for adults who have a life expectancy >10 years
144
What is radiation therapy?
A medical treatment that uses high-energy radiation to target and destroy cancer cells or shrink tumors.
External administration = external beam radiation
Internal administration = brachytherapy
Often used in conjunction with chemo or surgery. It can shrink a tumor prior to surgery.
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Side effects of radiation therapy
Skin changes -- red, dry, itchy, sensitive; so wear loose clothing and use gentle skincare products.
Fatigue
Nausea & vomiting
Hair loss
Difficulty swallowing if there is radiation to the throat or neck.
Changes in bowel habits - diarrhea or other GI symptoms
Urinary changes - the patient should be encouraged to stay hydrated.
Pain - usually at the treatment site.
146
Nursing care for Radiation Therapy
Prepare & educate the patient
Skin care - gentle cleaning & moisturizing
Fatigue management
Nutrition / hydration
Medication management
Pain Management
Emotional Support
Follow-up care
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Radiation safety requirements for brachytherapy
Take steps to protect yourself!
Keep the door closed to the patient’s room
Warning sign so that everyone understands that there’s internal radiation
Limit visitors to 30 minutes and they have to stay 6 feet away from the patient
Wear a lead apron and a docimeter film badge, which helps to track how much radiation exposure you’re getting.
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Schedule 1 drugs
No currently accepted medical use and a high potential for abuse
Heroin, ecstasy, methaqualone, peyote
149
Schedule 2 drugs
High potential for abuse, with use potentially leading to severe psychological or physical dependence
Vicodin, cocaine, methamphetamine, methadone, hydromorphone (dilaudid), meperidine (demerol), oxycodone / oxycontin, fentanyl, adderall, and ritalin
150
Schedule 3 drugs
Moderate to low potential for physical and psychological dependence. Abuse potential is less than Schedule 1 and Schedule 2, but more than Schedule 4
Tylenol with codeine, ketamine, anabolic steroids, testosterone
151
Schedule 4 drugs
Low potential for abuse and low risk of dependence
Xanax, Soma, Darvon, Darvocet, Valium, Ativan, Talwin, Ambien, Tramadol
152
Schedule 5 drugs
Lowest potential for abuse and containing limited quantities of certain narcotics.
Usually antidiarrheal, antitussive, and analgesics
Robitussin AC, Lomotil
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Pregnancy Cat A
Controlled studies show no risk or find no evidence of harm
(folic acid)
154
Pregnancy Cat B
Animal studies show no risks, but there are no controlled studies in pregnant women
acetaminophen and amoxicillin
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Pregnancy Cat C
Animal studies have shown risk to the fetus, or animal studies or studies in women are not available.
Albuterol, fluoxetine/ Prozac
156
Pregnancy Cat D
Positive evidence of potential fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk
Lithium, Tobramycin
157
Pregnancy Cat X
studies in animals or humans have demonstrated fetal abnormalities. Contraindicated in women who are or may become pregnant
Warfarin, nicotine, alcohol, accutane
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Corticosteroids
Corticosteroids, often known as steroids, are an anti-inflammatory medicine. They're a synthetic version of hormones, normally produced by the adrenal glands (2 small glands that sit on top of the kidneys).
Inhaled corticosteroids require meticulous oral care to prevent oral candidiasis.
Oral corticosteroids like prednisone have side effects patients should be educated about – weight gain, elevated blood glucose, increase infection risk, and insomnia are common
159
Bronchodilators
Bronchodilators are a type of medication that make breathing easier. They do this by relaxing the muscles in the lungs and widening the airways (bronchi). They're often used to treat long-term conditions where the airways may become narrow and inflamed.
Acute exacerbations of asthma are treated with "rescue inhalers" that have bronchodilators such as albuterol and ipratropium.
While SABAs are used to occasionally alleviate asthma symptoms quickly, LABAs are taken daily to help with asthma maintenance. Also, LABAs can only be used when combined with inhaled corticosteroids.
Side effects of these meds, particularly in kids, include hyperactivity.
160
NSAIDS
non-opioid analgesics
Used to treat inflammation, analgesics, fever reduction, dysmenorrhea, and inhibition of platelet aggregation (Aspirin)
NSAIDS block the COX enzymes thereby decreasing the production of prostaglandins. Prostaglandins are lipids made at sites of tissue damage/ infection that control inflammation, pain, fever, blood flow, the formation of clots, and the induction of labor.
Contraindicated in pregnancy. NSAID use during the third trimester may cause premature closure of the fetal ductus arteriosus, fetal renal impairment, inhibition of platelet aggregation, and may delay labour and birth.
161
NSAID Pharmacology
COX 1 blockage causes a decrease in platelet aggregation and kidney damage
Cox 2 blockage decreases inflammation, fever, and pain
Metabolized in the liver (CYP-450)
Excreted via the kidneys
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NSAID Adverse Drug Reactions
gastric upset, heartburn, nausea, and gastric ulcerations
Bleeding
Kidney dysfunction
Increased risk of CV event (heart/stroke)
Liver damage with frequent use
Salicylism (ASA toxicity) -- toxic condition marked by ringing in the ears, nausea, and vomiting.
Reye's syndrome in kids when given ASA for fever
thromboembolic event
163
Prednisone - type of med and uses
Prednisone is a corticosteroid/glucocorticosteroid.
It's a synthetic form of cortisol, which is produced by the adrenal glands.
Used for inflammatory conditions (Crohn's diseases & UC), severe allergic reactions (asthma & skin), autoimmune diseases (MS and myasthenia gravis) because it suppresses the immune system, reducing airway inflammation (asthma & COPD), and with organ transplants.
164
Side effects of Prednisone
Weight gain
Mood changes
Insomnia
Elevated BP
Increased risk of infections
Bone thinning (Osteoporosis)
GI issues - stomach ulcers
Elevated blood sugar
165
Prednisone client teaching
Take meds exactly as prescribed
Describe side effects
Tapering!! Prednisone should not be abruptly stopped.
Encourage balanced diet and lifestyle
infection precautions
166
Prednisone nursing considerations
Assessment: VS, weight, fluid balance, bone health, signs of infection, BP and blood sugar
Tapering!
Educate the patient about side effects, med adherence, tapering
Psychosocial support
Bone health: Calcium, Vit D, weight bearing exercises, fall prevention measures
167
EpiPen uses and type of med
EpiPens are used to treat anaphylaxis.
Common triggers include food allergies, insect bites/stings, meds, and latex
168
Side effects of EpiPen
Increased HR
Nervousness & tremors
Sweating
Headache
Nausea & vomiting
169
Client Teaching for EpiPen
How to recognize anaphylaxis
How to use it (into the thigh at a 90degree angle, push the button, hold for 10 secs)
When to use - only severe allergic reaction
Follow up with care!!!
Carry at all times
Expiration dates!!!
170
Nursing Considerations for EpiPen
Assessment: alergic history, knowledge of EpiPen, previous anaphylactic episodes
Teach how to use and that follow up care is needed, and to assure not expired.
Teach how to store (room temp, easily accessible)
Teach whole family and others who might have to administer.
171
Viagra - uses and type of med
Viagra is sildenafil citrate and is used to treat erectile dysfunction in men.
172
Viagra side effects
Headache (very common)
flushing
Indigestion
Nasal congestion
Dizziness
Vision changes (blurred vision, increased light sensitivity, blue-green tint)
Priapism = prolonged, painful erection. Seek medical attention!!
Hearing loss
173
Viagra client teaching
Dosage & timing: take s directed, usually 30 minutes before sex
Requires sexual arousal
Food interactions: heavy/high fat meals will delay onset
Avoid alcohol and grapefruit
Do not take more than what is prescribed!!
174
Viagra nursing considerations
Assess medical history - cardiovascular issues and meds can interact with viagra
Educate about dosage timing, food interactions, tell patient to stop using if hearing/vision loss and to seek help in the event of priapism
Acknowledge and support the psychosocial/emotional aspects of erectile dysfunction
175
Betablockers use and type of med
Beta Blockers target the beta-adrenergic receptors in the body and can be used for:
Hypertension -- reduce the force and rate of the heart's contraction
Cardiovascular conditions like angina (chest pain), arrhythmias (irregular heart rhythms), and CHF
Migraine prevention (propranolol)
Anxiety and performance anxiety
Glaucoma - as eye drops, can reduce intraocular pressure in open-angle glaucoma
176
Side effects of beta blockers
fatigue / weakness
Cold hands and feet
Slow heart rate (bradycardia)
dizziness / lightheadedness
Breathing difficulties -- can sometimes cause bronchoconstriction which is a problem for those with asthma or COPD
Depression / mood changes
Insomnia
Masking of hypoglycemia - beta blockers can mask the symptoms of low blood sugar in people with diabetes.
177
Client teaching with beta blockers
Med adherence
BP monitoring
Symptom recognition (too low BP, bronchoconstriction)
Orthostatic hypertention - so go from sitting to standing slowly
Diabetes management
178
Nursing considerations for beta blockers
Assess VS, BP, HR, and monitor for bradycardia, hypotention, and worsening heart conditions
Take meds on schedule
Educate patient about purpose, side effects, proper administration
Monitoring = monitor for adverse side effects particularly respiratory ones
Patient safety with orthostatic hypertension
Psychosocial support
179
Statins - use and med type
Statins lower cholesterol levels (lower LDLs) in the blood. Used for:
Hypercholesteremia (high LDL cholesterol - especially those at risk of CV disease)
Prevention of cardiovascular events
Diabetes management to lower their cardiovascular risk.
180
Statins side effects
Muscle pain and weakness
Liver enzyme elevation
GI symptoms (nausea, gas, diarrhea)
Increased blood sugar levels - which is a concern for those with diabetes.
Cognitive effects - memory loss or confusion
Rash or flushing
181
Statin Client Teaching
Med adherence
Diet & lifestyle
Muscle pain == report any unexplained muscle pain, weakness, or tenderness
Liver monitoring
Blood sugar monitoring
182
nursing considerations for statins
Assess the patient's lipid profile, medical history, and risk factors for CV disease
Monitor for muscle-related symptoms and liver enzyme elevations
Educate patient on med adherence, lifestyle modification, and potential side effects.
Lab monitoring
183
Rifampin uses and type of med
Rifampin is an antibiotic. Uses include:
TB : highly effective against the mycobacterium tuberculosis bacterium
Meningococcal infection prophylaxis
Leprosy
Endocarditis prophylaxis before dental or surgical procedures.
184
Side effects of Rifampin
GI disturbances like nausea, vomiting, diarrhea, and abdominal pain
Discoloration of body fluids (orange or reddish brown)
Hepatotoxicity = can lead to elevated liver enzymes or severe liver problems. Monitoring liver function is critical.
Flu-like symptoms
Skin rash
Hemolytic anemia (blood cells are destroyed faster than they can be produced.
185
Rifampin client teaching
medication adherence
Side effects
186
Rifampin nursing considerations
Assess med history, current meds, allergies
Monitor for side effects (GI, liver, skin reactions, flu symptoms)
Liver function monitoring
Infection control - prevent the spread of infections that require rifampin therapy
187
Genvoya uses and type of med
ART (antiretroviral therapy) used to treat HIV infection. Fixed-dose combo medication.
Controls HIV infection, prevents progression to AIDS, and reduces the risk of HIV transmission.
188
Side effects of Genvoya
Nausea
Diarrhea
Headache
Fatigue
Decreased bone mineral density over LT use, which can lead to fractures
Renal impairment
Metabolic changes - increases in cholesterol and triglyceride levels
Immune Reconstitution Inflammatory Syndrome (IRIS): as the immune system improves with treatment, patients may experience worsening of pre-existing infections or develop new symptoms related to underlying conditions.
189
Genvoya client teaching
Adherence: consistently and at the same time each day
Take with food!
Side effects
Protection against transmission: safe sex
Regular follow ups.
190
Genvoya nursing considerations
Assess medical history including HIV status and previous ART use
Med administration
Monitor for side effects, changes in kidney function, bone mineral density.
Assess viral load and CD4 count every 3-6 months to evaluate treatment efficacy
Labs: kidney function, bone density, and lipid profiles
191
Blood Transfusion Reactions - nursing Interventions
1. Slow or stop the infusion
2.Hang new tubing, then give normal saline to flush the tubing
3. report to the HCP
4. Assess VS and take a urine specimen to check for hemolyzed RBCs and high potassium (hyperkalemia).
If the potassium > 5.0, it's too high. Potassium pumps the heart, so we'll see Peaked T waves on the ECG
192
Blood transfusion reactions
1. Febrile reaction (mild allergic reaction) with flushing and itchiness. Typically give acetaminophen and benadryl prior to the infusion
2. Anaphylactic reaction - wheezing, hives - more serious!
3. Circulatory Overload -- Lung crackles, restlessness, dark urine, SOB & Dyspnea, jugular vein distention. This means too much fluid in the body! this causes a risk for HF. So, slow the infusion to 4 hours max and wait at least 2 hours between infusions.
HOPE
H = head of the bed is elevated
O = Oxygen
P = push Diuretics (like Furosemide)
E = End all IV fluids
4. Hemolytic reaction --> blood cells have lysed
S&S are hypotension, LOW BACK PAIN, fever, tachycardia (fast HR), and urine specimen to check for hemolyzed RBCs
193
steps of a transfusion
Confirm informed consent
2 RNs verify the blood order (name and blood type)
Vital signs every 15 minutes for the 1st hour
Prep: 18g IV Catheter and 2 tubings
1 blood tubing with filter
2nd is the normal saline only (no LR or dextrose)
Stay at the bedside for 15 minutes
After the infusion give normal saline
