NURS 366 exam 3 study guide

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normal changes in the integumentary system due to aging

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normal changes in the integumentary system due to aging

-skin injuries and infection become more common
-the sensitivity of the immune system is reduced
-muscles become weaker and bone strength decreased
-sensitivity to sun exposure increases
-the skin becomes dry and often scaly
-hair thins and changes color
-sagging and wrinkling occur
-the ability to lose heat decreases
-skin repairs process slowly

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2

skin injuries and infection become more common with age due to

epidermis thins as stem cell activity declines

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3

the sensitivity of the immune system is reduced with aging due to

the amount of macrophages residing in the skin decreasing

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muscles become weaker and bone strength decreases with age due to

reduced calcium and phosphate absorption from declined vitamin D3 production

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5

sensitivity to sun exposure increases with age due to

less melanin production from decreased melanocyte activity (pale skin)

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6

skin becomes dry and scaly with age because

glandular activity declining reducing oil and sweat production

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7

hair thins and changes color with age because

follicles stop functioning or produce thinner finer hairs

decreased melanocyte activity creates gray or white hair

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8

sagging and wrinkling of the skin occurs with age due to

dermis becomes thinner and the elastic fiber network decreases in size

the skin becomes weaker and less resilient

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9

the ability to lose heat decreases with age because

blood supply to the dermis is reduced

sweat glands become less active

combination makes older clients less able to lose heat

overexertion and overexposure to high temperatures can be dangerous

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10

skin repair in older adults

takes 6-8 weeks when compared to 3-4 weeks for younger adults

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11

pruritus s/s

itching

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eczema s/s

-red to brownish gray colored patches
-itching, which may be severe especially at night
-small, raised, bumps which may leak fluid and crust over when scratched
-thickened, cracked, or scaly skin
-raw sensitive skin from scratching

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dermatitis s/s

-swelling
-red
-itchy
-lesions

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psoriasis vulgaris s/s

-bright red areas of raised patches (plaques) on the skin, often covered with loose silvery scales
-localized or general
-itchy

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acne vulgaris s/s

-blackheads
-whiteheads
-pustules
-on the face, neck, upper back

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skin tear s/s

-acute traumatic wounds
-not pressure ulcers
-separation of epidermis and dermis

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stage I pressure ulcer

reddened area
nonblanchable

pressure ulcer is starting to develop

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stage II pressure ulcer

-skin blisters
-forms open sore
-may be red and irritated

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stage III pressure ulcer

breakdown looks like a crater

damage to the tissue below the skin

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stage IV pressure ulcer

deep damage to the muscle and bone and sometimes tendons and joints

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sunburn s/s

UV rays exceed what can be blocked by melanin resulting in a burn on the skin

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cellulitis s/s

-heat
-tenderness
-edematous
-erythema
-chills
-fever
-malaise

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shingles s/s

-grouped vesicles
-unilateral on trunk, face, and lumbosacral areas
-burning
-mild to severe during outbreak
-neuralgia preceding outbreak

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causative agent for pallor (skin color)

anemia

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causative agent for cyanosis (skin color)

respiratory issues

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causative agent for jaundice (skin color)

liver issues

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compartment syndrome (orthopedic treatment complication)

increased pressure in a limited anatomical space (splint, cast, crush injury, edema)

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fat emboli (orthopedic treatment complication)

catecholamines mobilize fatty acids from adipose tissue

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Discuss the care of patient's in traction regarding mobility and skin care

-assess skin throughout
-weights keep hanging free
-maintain ropers over midline
-maintain patient alignment

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30

normal anatomy and physiology of the musculoskeletal system

206 bones, tendons, ligaments, cartilage

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musculoskeletal system functions

-support
-movement
-protection
-blood cell production
-calcium and phosphorous storage

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bone remodeling

resorption
reversal
formation
resting

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resorption (bone remodeling)

osteoclasts remake bone mineral and metric, creating an erosion cavity (3-4 weeks)

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reversal (bone remodeling)

mononuclear cells prepare bone surface for new osteoblasts to begin building bone

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formation (bone remodeling)

osteoblasts synthesize a matrix to replace resorbed bone with new bone (3-4 months)

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resting (bone remodeling)

a prolonged resting period until a new remodeling cycle begins

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normal changes of the musculoskeletal system with aging

-decreased muscle mass, size and muscles look smaller
-decreased muscle tone
-decreased amount of elastic tissue
-slower muscle response
-decrease in elasticity of tendons and ligaments
-decreased range of motion (stiffness)
-decreased joint mobility
-osteoporosis: thinning and softening of the bone

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knee replacement pre-op education

-weight bearing within 24 hours of surgery
-elevate leg when sitting
-s/s of infection, PE, atelectasis, urinary retention, skin breakdown, constipation, pain, DVT
-weight bearing restrictions, isometric exercises, need for early ambulation, pneumatic compression (SCD)
-drains
-heparin, lovenox, aspirin
-labs: CBC, coagulation, CXR, EKG, UA

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knee replacement post-op education

-VS, LOC, TCDB, pain management, nutrition, prevention of infection
-watch for: constipation, urinary retention, venous stasis, CMS, respiratory complications, changes in skin integrity
-PT, PTT, INR, check for bleeding
-correct position of the operative extremity, neuromuscular checks, progressive ambulation

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home care for knee replacement

-1-3 days hospitalization then rehab
-rehab phase post-op is a year
-maximum strength and flexibility takes about 3 years to return
-anticoagulant use continues
-need for low impact exercises
-venous foot pumps and or pneumatic compression
-blood transfusions (autologous or homologous)
-weight bearing restrictions
-assistive devices: cane, crutches, walker

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patient education & home care for hip replacement

-do not bend hip more than 90 degrees
-do not cross legs when sitting
-do not bend body forward to pick up objects
-do not rotate leg when standing, keep leg straight, no pigeon feet
-possible high blood loss during surgery
-drains: hemovac, JP
-cell saver
-keep legs abducted: use of pillows
-HOB 45 degrees or less
-do not flex operative, bend, or scissor legs
-ambulate POD 1-2
-check CMS

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lumbar laminectomy and discharge needs

-gradually return to normal ADLs
-no heavy lifting for 4-6 weeks
-no bending, twisting or lifting
-no sitting for extended periods of time for 6 weeks including car rides
-instruct patient to take short walks to avoid fatigue
-change position frequently
-may resume sex in two weeks
-return to work dependent on occupation
-assure patient has assistance for ADLs, cleaning, and child care

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43

portal hypertension

the elevation of blood pressure within the portal venous system

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portal hypertension complications

-Right sided HF
-Anorexia
-Esophageal and gastric varices
-Periumbilical varices
-Ascites
-Uncontrolled bleeding
-Associated with cirrhosis
-When alcoholic liver disease is left untreated it can lead to cirrhosis, portal hypertension and liver failure

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45

causative factors of pancreatitis

alcohol, biliary sludge, trauma, post-ERCP, hypertrogliceridemia, biliary tract obstruction, hyperparathyroidism, steroids, cancer, mumps, smoking, nicotine

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pancreatitis pathophysiology

stimulant / irritant → enzymes activated in pancreas → autodigestion → severe inflammation and necrosis
-Enzymes and necrosis leaks into circulation→ shock, DIC, ARDS
-Enzymes leak into peritoneum; destruction and inflammation → severe pain, hemorrhage shock, peritonitis, sepsis

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liver lab tests

-Total protein
-Albumin
-AST/ALT (liver tissue): show inflammation and injury
-Alk Phos: seen in bile duct disorders
-Bilirubin
-Ammonia: changed into urea
-GGT (obstruction): needed for protein synthesis, most sensitive to hepatobiliary diseases
-Coagulation labs
-Ammonia
-ALP (obstruction)

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Cirrhosis AST/ALT ratio

>1

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Hepatitis AST/ALT ratio

<1

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hepatitis A labs

elevated ALT & AST

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hepatitis B labs

elevated ALT & AST

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hepatitis C labs

elevated ALT & AST

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cirrhosis labs

LFT elevated then normal

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primary biliary cirrhosis labs

elevated GGT and alk phos

+ ANA

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alcoholic cirrhosis labs

-elevated ALT & AST
-thrombocytopenia
-hypoglycemia
-elevated neutrophils

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alcoholic steatohepatitis labs (alcoholic liver disease)

Decreased neutrophils and phagocytes

Reduced NKs

Impaired cytotoxic T cells

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fibrosis labs
(alcoholic liver disease)

Decreased NKs

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alcoholic cirrhosis labs
(alcoholic liver disease)

Decreased NK
Decreased dendritic cells (DC)
Decreased B cells

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alcoholic liver disease labs

elevated ALT & AST

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fatty liver disease labs

-Increased LDLs
-Increased interleukin 6
-Increased CRP
-Hyperglycemia
-Hyperlipidemia
-Hyperinsulinemia

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In general levels of ALT and AST are ___ in liver impairment

elevated

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62

purpose of common medications utilized with liver impairment

???

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63

cirrhosis nursing care

-Health promotion and prevention of risk factors: malnutrition, alcohol use, hepatitis, biliary obstruction, obesity, right sided HF
-Urge patients to abstain from alcohol
-Conserve muscle strength
Prevention of pneumonia and thromboembolic problems
-Modification of the activity rest schedule

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64

causes of hepatitis

-Viruses: A,B,C,D,E
-Autoimmune
-Other viruses: mono, CMV, Epstein-Barr, herpes, coxsackie, rubella
-Bacteria: salmonella
-Parasites: amoebiasis

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hepatitis A cause

fecal oral transmission

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hepatitis B cause

STD

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hepatitis C risk factors

IV drug abusers, high risk behavior, healthcare workers

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hepatitis treatments

-Prevention = #1
-Vaccination for A, B
-Serum antibody screening
-Symptom management: rest, nutrition, fluids, medications

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hepatitis medications

-direct acting antivirals
-supplementation
-antihistamines
-antiemetics

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cirrhosis medications

-diuretics
-beta blockers (carvedilol)
-silymarin

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alcoholic liver disease medications

corticosteroids for inflammation

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nonalcoholic fatty liver disease medications

-vitamin E
-antidiabetics
-statins
-antihypertensives

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GERD (adult)

-most common upper GI problem, C/O heartburn, epigastric pain, dyspepsia
-stomach acid refluxes into esophagus, stomach HCL and pepsin irritate and inflame

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GERD etiology

no single cause, foods, medications, hiatal hernia

ETOH chocolatemedications fatty foodpeppermint nicotine tea/coffee

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GERD treatments

-identify and eliminate cause
-stop eating 2 hours before bedtime
-lifestyle management
-medicationsL PPIs, H2 receptor blockers, antacids, pro kinetic therapy -endoscopic therapy -surgery

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GERD diagnosis

H&P exam
EDG barium swallow mobility studies

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hiatal hernia

-herniation of part of the stomach above the diaphragm
-most common upper GI problem
-found on x-ray
-acute paraesophageal hernia is a medical emergency

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sliding hiatal hernia

top of stomach slides through when patient is supine and slides back down when patient is upright

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paraesophageal or rolling hiatal hernia

the funds and greater curvature of the stomach roll up through and form a pocket

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80

hiatal hernia etiology

structural changes, weak diaphragm at esophageal opening, increased intraabdominal pressures, obesity, pregnancy, ascites, tumors, heavy lifting, physical exertions

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hiatal hernia s/s

similar to those of GERD

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hiatal hernia complications

GERD
esophagitis hemorrhage esophageal erosion esophageal stenosis
ulcerations aspiration into trachea

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hiatal hernia diagnosis

barium swallow EGD

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hiatal hernia treatment

-conservative treatment similar to GERD treatment
-avoid straining or lifting
-surgery: fundoplacations, mesh placements, herniorrhaphy, gastroplexy

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85

gastritis

-inflammation of gastric mucosa
-very common-acute or chronic
-the result of breakdown in gastric mucosa = inflammation

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gastritis etiology

drugs, diet, alcohol, microorganisms, environmental factors, diseases, disorders, procedures, stress

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gastritis s/s

anorexia n/v epigastric tenderness
fullness

some asymptomatic

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gastritis diagnosis

H&P
drug and ETOH use
occ CBC
EGD

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gastritis treatment

-eliminate cause
-supportive care
-NPO if n/v
-PRN: NG to monitor bleeding, lavage, and empty
-clear liquids
-medications: PPIs, H2RB, antibiotics if bacterial
-lifestyle changes

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gastric peptic ulcers

-burning or gas pressure in epigastrium, pain 1
-2 hours after eating
-common in women, H pylori is the cause of 80% of cases
-NSAID most common cause of non H pylori cases -less common than duodenal ulcers
-increased cancer risk -high recurrence
-management: stop NSAIDs, antibiotics for H pylori, WTOH and smoking cessation, eliminate coffee, medications (H2 or PPI)

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duodenal peptic ulcers

-burning, cramping, pressure like pain across midepigastrium and abdomen, back pain, pain 2-5 hours after meal midmorning or middle of night, pain relief with food and antacids
-most common peptic ulcer
-in men more than women -high recurrence
-management: similar to gastric, ETOH and smoking cessation, stop NSAIDs, H2 or PPI medications

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chronic PUD complications

hemorrhage
upper GI bleed

perforation (most lethal)

gastric outlet obstruction

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IBD

-common onset 15-30 years but can occur at any age
-difficult to diagnose, symptoms similar to other diseases/condition -no cure but remissions are possible
-thought to be autoimmune
-urban > rural and highest in white, and Jewish, genetic link

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ulcerative colitis involves only the

colon

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Crohn's disease can involve

the small intestine or colon

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Crohn's disease

a chronic relapsing disease that can occur segmentally in the smallbowel and colon

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crohn's s/s

-involves the entire thickness of wall, especially submucosa
-common in terminal ileum and colon but can occur anywhere
-not common in the rectum
-diarrhea usually without blood
-onset mid 30s or >60
-abdominal pain, cramping, diarrhea, rectal bleeding, fever, weight loss, malabsorption

relief during remission

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crohn's complications

-cancer (esp small bowel)
-perianal abscesses and fistulas
-perforation
-strictures

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ulcerative colitis s/s

-onset teens
-30s or over 60
-severe abdominal pain
-diarrhea
-fever
-rectal bleeding
-tenesmus
-pseudopolyps

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ulcerative colitis complications

-colorectal cancer
-c diff
-perforation
-toxoic megacolon

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