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NSG 211 Final Study Guide
Health Care Concepts II (NSG 211)
Germanna Community College
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NSG 211 Final Study Guide Inflammation, Immunity, Violence, Sensory Perception foundational information: 5 Cardinal Symptoms: Warmth Redness Swelling Pain Decreased function Stages: Stage I change in blood vessels, histamine secretion, serotonin, and kinins that constrict the small veins and dilate arterioles. Increased blood flow and delivery of nutrients to injured tissues. Stage II (cell neutrophilia and pus (dead necrotic tissue, and fluids) Stage (tissue repair and trigger new blood vessel and growth of scar tissue Inflammatory Exudate: clear, watery i. Skin blisters, pericarditis increased fibrinogen i. Adhesions following surgery cloudy mucus i. Runny cold discharge i. Abscesses, boils, cellulitis, infectious presence of i. Hematomas Normal WBC Differential: Total Types of Immunity: what you are born with, acts immediately against all antigens Ex. Skin, stomach acid, mucous membranes, phagocytic cells Acquired production of antibodies against specific antigens Active o from infection o vaccinations Passive o maternal antibodies o monoclonal antibodies efficient immune function between ages of then slowly declines with Anaphylaxis Type I: rapid, IgE attaches to mast cells and basophils causing a release of histamines Causes: Contrast media (Iodine) Insect Foods Latex Signs and Symptoms: Within minutes to hours of initial contact with allergen Feeling of apprehension, weakness, impending doom Swollen face, urticaria, pruritus, flushing Respiratory dyspnea, bronchospasm, wheezes, stridor, hypoxia, cyanosis, dec. PER Hypotension, LOC, vasodilation, dec. DTR abd. Pain, cramping, incontinence Diagnostics: Inc. IgE serum study Skin allergen specific IgE Oral food challenge test Interventions: Administer Epinephrine High flow O2 assess airway patency, RR, HR, O2 sat, peripheral pulses, cap refill, LOC Infuse any other infusion Have intubation kit and code cart at bedside HOB legs Administer albuterol, antihistamines, steroids Stay with patient to decrease anxiety Place tourniquet proximal to the insect sting Epinephrine Medication: Vasopressor 1st line for anaphylaxis Repeat min until resolve Give IM 90 degrees in outer thigh, hold in place for 10 sec. No need for skin of clothing Side tachycardia, palpitations, dizziness Children with killed virus vaccines only, low salt low protein diet, delayed puberty, dec. bone mass, atherosclerosis HIV AIDS Chronic or impaired immunity, worldwide epidemic Transmissed through bodily fluids Risk Factors: Unprotected sex Needle users Blood products Mother to ba Stages: Early stage Fever, headache, fatigue, wt. loss, skin rash, cramping, enlarged lymph nodes Asymptomatic increased viral load and transmissions, decreased CD4 Chronic diarrhea, wt. appetite, nail changes, night sweats, confusion, cold sores CD4 loss of immune system Opportunistic CMV, HSV, malaria, TB, pneumonia (pneumocystis), candidiasis, sarcoma from opportunistic infection secondary to Labs: Enzyme linked immunosorbent assay (ELISA) Western blot assay take 2 weeks to 6 mo. For antibodies to show on lab work CBC, CMP, blood cultures, syphilis testing Hep A, B, C Tb, CD4, Viral load Chest for opportunistic infections Drug therapy (ART) Tenofovir, Abavavir Protease Atazanavir, Ritonavir Pt. Teaching: precautions Do not donate blood, share needles, razors, toothbrushes, or tweezers No piercings, tattoos Smoking, drinking, drug cessation Brush and floss everyday Stay away from sick people and large crowds Do not drink untreated water, avoid foods, safe food prep Clean with disinfectant then 1:10 bleach Increase protein, calories, fluids per day Avoid cleaning litter boxes Organ Transplant Types: Autologous bone marrow harvest, peripheral stem cell, umbilical cord blood Syngeneic bone marrow harvest, peripheral stem cell Allogenic bone marrow harvest, peripheral stem cell, umbilical cord blood Rejections: NK cells and cytotoxic attack the transplanted organ leading to rejection begins immediately, blood clots form in new organ, rejection organ is removed 1 week to 3 mo. After transplant, vasculitis, necrosis, lysis of organ o Impaired organ and biopsy to determine function o Increased drug management can save organ inflammation and scarring, smooth muscles overgrow and occlude vessels o Permanent fibrotic changes, no cure Pt. Teaching: Strict medication regimen Monitor for infection Avoid large crowds and ill people Lifestyle exercise and nutrition high protein and fiber, low fat and sodium Lifelong immunosuppressants Cox 1 and Cox 2 inhibitors watch for GI bleeding and kidney dysfunction Inflammatory Bowel Disease disease and Ulcerative colitis Causes inflammation and ulcers Unknown immune system Flare ups and remissions Increased risk of colon cancer Avoid high fiber, fatty, spicy, dairy foods Consume low fiber, high protein, increase hydration Disease: Affects entire GI mouth to anus in scattered fashion Most common in terminal start of colon, RLQ Cobble stone appearance Affects entire mucosal lining No cure Surgery helps quality of bowel resection, colectomy abscess, fistulas, fissures, malnourishment, strictures Signs and Symptoms: o Diarrhea o Abd. Pain RLQ o Mouth ulcers o Anal fissures o Weight loss Ulcerative Colitis: Affects only large intestine and rectum Starts in rectum and migrates in continuous fashion Affects only inner lining (mucosa and submucosa) Cure with colectomy and ileostomy Managed with meds and diets toxic megacolon, bowel rupture, loss of form to haustra pipe wt. loss and dehydration, anemia from bleeding ulcers, inflamed joints, eyes, skin, and liver Signs and Symptoms: o BM o Severe diarrhea with blood, mucus, pus o Rectal bleeding o Low of wt., low o Cramping o Electrolyte imbalance o Elevated temp. Medications for Both and UC: 5 sulfasalazine prednisone Azathioprine (Imuran) Adalimumab (Humira) Imodium because of increased risk of GI bleeding and ulcers Diet Low fiber Low residue High protein High calorie Vitamins and iron Skinned and cooked fruits and vegetables, white rice AVOIDo Fatty foods o dairy o Raw vegetables and fruit o Nuts o Popcorn o Whole grain o Cereals o Spicy foods Gastro Esophageal Reflux Disease (GERD) Chronic condition where stomach content flows back into the esophagus due to lower esophageal sphincter Esophageal line erodes causes inflammation and esophagitis Risk Factors: Pregnancy Obesity, overeating Hiatal hernia Delayed gastric emptying Smoking Foods calcium channel blockers, sedatives, antihistamines Signs and Symptoms: Heartburn Epigastric pain Regurgitation Dry cough Nausea Dysphagia infections Assessment: Frequency and quality of pain Respiration and voice changes Chronic cough Med history Dec. O2 sat, inc. RR, abnormal lung signs of aspiration Mothers diet if ba has GERD Low Socioeconomic status Pregnancy Risk factors for being a perpetrator: Alcohol and substance abuse Mental hx of depression, personality disorders Past exposure to violence Decreased academic achievement Younger age, delinquent behaviors at youth unemployment a red flag is social isolation History: May be incomplete or inconsistent with injuries observed Victims may be afraid to provide events Victims may not be able to recollect events Examination: Range from obvious to severe Old or new injuries Be alert to unusual patterns of cuts, bruises, burns, and fractures Take note of injuries not typically seen in the context of day to day living Collaborative Care: Treat the underlying injuries Report suspected interpersonal it is a legal requirement as a nurse if they meet the standards Refer victim to a safe house Provide emotional support Consider collaborative practice social work, counseling, chaplain Decrease stigma talk with patient in a private area alone Common chronic disease processes of victims: Increased cortisol levels (stress) Ischemic heart disease Bowel difficulty swallowing to IBS Fibromyalgia PTSD Depression, suicide flags: Headaches Back pain Chest pain GI problems, choking sensation Facial fractures Forensic nurse educated to obtain patient histories, collect forensic evidence, and offer counseling and follow up care for victims of rape, child abuse, and domestic violence They recognize evidence of abuse and when to intervene on the behalf Sexual assault nurse examiners or sexual assault forensic examiners Special barriers for not seeking care: Cultural religious beliefs that restrain the survivor from leaving the abusive relationship or involving outsiders. Strong loyalty binds to race, culture and family. Distrust of law enforcement, criminal justice system, and social services. Lack of service providers that look like the survivor or share common experiences. Lack of culturally and linguistically appropriate services. Lack of trust based on history of racism and classism in the United States and U. Territories. Fear experiences will reflect on or confirm the stereotypes placed on their ethnicity. Assumptions of providers based on ethnicity. Attitudes and stereotypes about the prevalence of domestic violence and sexual assault in communities of color. Legal status in the U. of the survivor the batterer. Oppression, including is intensified at the intersections of race, gender, gender identity, sexual orientation, ability, legal status, age and socioeconomic status. Child Abuse Number one injury in infants and death: traumatic brain injury Second leading cause: abdominal injury leading to internal bleeding Other commonalities: o Burns from scalding water o Burns with stocking or circular pattern o Shaken ba syndrome Learning disabilities, blindness, seizure, paralysis Risk Factors: Parental predisposition towards maltreatment (previous hx of abuse) Stress within the home Parental substance abuse Lack of knowledge of child unrealistic expectations of inadequate parenting skills Low poor impulse control Parental or child disabilities Child Behavioral Indicators of abuse: Complains of soreness or moves uncomfortably Wary of adult contacts Has sleep problems or nightmares Bizarre or unusual sexual behavior or knowledge Seems threatened or afraid of physical contact Receives unexplained money or gifts Sudden noticeable changes in behavior Abuses alcohol or drugs May set fires, eating attempt suicide Guardian may be extremely protective, or show favoritism to that child babies only get bruises from external sources If bruised, the caregiver must have reasonable explanation If no more screening is necessary Most common areas: soft tissue, ears, neck, inner thigh, or trunk Screening tools: skeletal survey or imaging, CT, retinal exam, coagulation studies Always consider possible head injury in a vomiting, irritable, lethargic child Responding: Find a private place to talk without interruptions Sit near them, not behind a desk Ask before touching the child Reassure that they are not in trouble Keep your own feelings under control Use open ended questions Use the vocabulary Let the child know what you will do Support the sorry that happened to DO NOT o Press for details o Ask questions o Promise not to tell anyone o Ask leading or suggestive questions o Make angry or critical comments about the alleged perpetrator o Disclose information indiscriminately, keeping in mind the right to privacy o Make the child feel different or singled out Elder Abuse Vulnerable populations: Over 75 African American Women Disabled Widowed risk of cognitive decline, depression, and dementia The abuser is often a family member who becomes frustrated or distraught over the burden of caring for the older adult Common new role for adult children, usually women Results in fatigue, conflict, and strain caregiver fails to provide for an older basic needs such as food, clothing, medications, or assistance with ADLs. The caregiver refuses to let other people such as nursing assistants or home care nurses into the home also failure to provide healthcare dehydrated, malnourished, pressure sores, very poor living conditions, contractures, urine burns, excessive body odor, and listlessness Physical abuse is the use of physical force that results in bodily injury Common abdomen, buttocks, genital area, upper thighs, the Hitting, burning, pushing, slapping, kicking, shoving, biting, pinching, and molesting the patient is also seen as abusive Restraining or locking them in a room or not allowing them to go to the bathroom Financial abuse occurs when the older property or resources are mismanaged or this is more common than physical abuse Stealing SSN, forcing to withdrawal money, deceiving to get money Emotional abuse is the intentional use of threats, humiliation, intimidation, and isolation toward older adults. Psychological yelling, belittling, intimidation, threats, ridiculing their belief system, humiliation silent, afraid, ashamed Sexual blood on clothing, fear of being touched, pain when painful urination, bruising on breasts or genitals Carefully assess the patient for signs of abuse such as bruises in clusters or regular burns, commonly to the buttocks or the soles of the unusual hair or multiple injuries, especially fractures. If the older adult is too weak or has no other resources or support systems, he or she may not admit that abuse is occurring. Screening: Elder Abuse Suspicion Index Elder Assessment Instrument Indicators of Abuse Screen Questions to Elicit Elder Abuse Elder Abuse Screening Tool Caregiver Abuse Screen Brief Abuse Screen for the Elderly Vulnerability to Abuse Screening Scale Reporting: Evidence of mistreatment without sufficient clinical explanation Report an older adult of being abused or neglected A belief the health care professional that there is a high risk for or probable abuse, neglect, abandonment, or exploitation higher risk for engaging in health risk behaviors such as smoking, binge drinking, and HIV risk behaviors societal costs associated with medical services for injuries, mental health services, lost productivity from paid work, childcare, household chores, and criminal justice and child welfare costs Teach safe and healthy relationship skills learning programs for youth Healthy relationship programs for couples Engage Influential adults and peers Men and boys as allies in prevention stander empowerment and education programs Disrupt the developmental pathways toward partner violence Early childhood home visitation Preschool enrichment with family engagement Parenting skill and family relationship programs Treatment for children, youth, and families Create protective environments Improve school climate and safety Improve organizational policies and workplace climate Modify the physical and social environments of neighborhoods Strengthen economic supports for families Strengthen household financial security Strengthen supports Support survivors to increase safety and lessen harms services Housing programs First responder and civil legal protections approaches Treatment and support for survivors of IPV, including teen dating violence Rape Trauma Syndrome Physical symptoms: Shock, cold, faint, mentally confused, tremble, nausea and vomiting immediately after a rape Pregnancy periods, vaginal discharges, bladder infections, Bleeding and infections from tears or cuts in the vagina or rectum Soreness, bruising, grazes, cuts or other injuries Nausea or vomiting Throat irritations or soreness due to forced oral sex Tension headaches Pain in the lower back or stomach Sleep disturbances Eating disturbances Behavioral symptoms: Crying more than usual Difficulty concentrating Being restless, agitated, and unable to relax or feeling listless and unmotivated Not wanting to see anybody or socializing more than usual, so as to fill up every minute of the day Not wanting to be alone Stuttering or stammering Avoiding anything that reminds the survivor of the rape Suicide attempts and other behavior such as substance abuse or mutilation Being more easily frightened or startled than usual Being very alert and watchful Becoming easily upset small things Relationship problems, with family, friends, lovers and spouses Fear of sex, loss of interest in sex or loss of sexual pleasure Changes in lifestyle such as moving to a new house, changing jobs, not functioning at work or at school or changes to appearance Drop in school, occupational or work performance Increased substance abuse Increased washing or bathing Behaving as if the rape occur, trying to live life as it was before the rape, this is called denial Psychological symptoms: Increased fear and anxiety and guilt Helplessness, no longer feeling in control of your life Humiliation and shame Lowering of self esteem Feeling dirty or contaminated the rape Anger Feeling alone and that no one understands Losing hope in the future Emotional numbness Confusion Loss of memory Constantly thinking about the rape Having flashbacks to the rape, feeling like it is happening again Nightmares Depression Becoming suicidal Bullying kids per day skips school for fear of being bullied. When standers intervene, bullying stops within 10 seconds of the time. The 3 of Bullying 1. Bullier of youth admit to bullying 2. Bullied 1 in 3 students bullied at school 3. stander have witnessed bullying Scope of Sensory Perception changes in smell and taste for adults is a dry mouth o drugs that can cause dry mouth include antidepressants, chemotherapeutic agents, antihistamines, and antiepileptic drugs Touch (peripheral sensation loss acute and chronic neurologic problems such as stroke, traumatic brain injury, or spinal cord injury) o For many patients this sensory deficit is permanent Problems of sensory perception that occur in the adult population largely affect vision and hearing Common Risk Factors for Changes in Sensory Perception increased risk for decreased visual and hearing acuity with aging o presopia Hyperopia o myopia o prescusis (sensorineural type) o glaucoma o cataracts o macular degeneration diabetes mellitus and hypertension changes in or loss of vision o direct mechanical or chemical trauma, genetic risk, cranial nerve II (optic) damage, and drug therapy such as antihistamines and antihypertensives Hearing loss o caused direct physical trauma, cranial nerve (acoustic, or auditory) damage, occupational factors (e., consistent loud noises), genetic risk, and drugs that are ototoxic Examples of drugs that can cause ototoxicity are salicylates, diuretics, AEDs, and antibiotics, especially aminoglycosides. Assessment of Sensory Perception Use of eyeglasses or contacts Use of hearing aid or amplifier Assess vision acuity o reading a newspaper o Snellen chart: ages 5 and older Whisper test: stand feet away and cover each ear, stand on the side where the ear is covered o Tuning fork: Webber test Rhine test Interventions to Promote Sensory Perception and Prevent Changes in Sensory Perception Primary prevention o safety goggles o washing hands o proper contact care o sunglasses with UV protection o avoid tanning beds (can cause cataracts) o Erythromycin for infants and trimming their nails o Ear plugs or other ear protective devices can minimize the exposure to loud noises such as that caused machinery o A healthy lifestyle can help prevent the risk for diseases such as diabetes mellitus and hypertension, thus reducing the chance for decreased visual acuity from chronic disease secondary prevention o regular eye examinations (annually for older adults) and physical examinations to diagnose and manage any chronic diseases early Interventions for Patients with Changes in Sensory Perception drug therapy eye surgery hearing aids eyeglasses, contacts television, assistive listening devices, sign language guide dogs, braille Common Eye Definitions: far sighted near sighted deviation of eye due to poor muscle involuntary movement of the eye caused alcohol, MS, stroke) pupil constriction pupil dilation Arcus blue ring around eye o Seen with aging aging of the eye (40 yrs) right eye left eye bilateral Eye Care Teaching: Washing hands and gloving anytime if assessing eyes or getting medication Aseptic technique Examine good eye first Do not bring an ophthalmoscope near a eye who is confused No rubbing eyes Use of sunglasses with UV protection and eyeglasses Provide opportunities to express their concern Knock before you enter Orient their surroundings (ID the room) Never give a topical medication orally Yearly eye appts. for those with refractive issues or over 40 or diabetes Every year if normal Vision begins at 28 gestation
NSG 211 Final Study Guide
Course: Health Care Concepts II (NSG 211)
University: Germanna Community College
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