Acute Exam 2

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Iggy Chapters 18, 21, 27, 28, 36, and 40

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60 Terms

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Polycythemia
A compensatory increase increase in red blood cells and iron in the chronically hypoxic patient

\-patient has hyperviscous blood

\-Condition can be temporary (because of other conditions) or chronic.
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Why might a person be polycythemic
If they are chronically hypoxic, COPD
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Normal Platelet Count
150000-400000
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Implications for abnormal platelet count
Increased (thrombocythemia)= polycythemia vera or malignancy

\-patients are at greater risks for thrombi forming

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Decreased (thrombocytopenia)= bone marrow suppression, autoimmune disease, hypersplenism

\-patients are at a greater risk for bleeding
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Changes that occur to the immune system in the older adult
\-Decrease in blood volume

\-lower levels of plasma proteins (transport of hormones, vitamins, etc)

\-bone marrow ages leading to fewer blood cells, antibody levels and responses are lower and slower, hemoglobin levels fall
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Warfarin therapy and patient teaching
\-decreases the bodys ability to form clots by blocking the formation of vitamin k clotting factors

\-very important to know the blood levels so they will be monitored frequently

\-based off of results may lead to dose being adjusted.

\-Never increase or decrease dose unless told to by your doctor

\-Excessive bleeding is a side effect

\-Avoid drinking alcohol on this or drink in moderation

\-do not eat excessive amounts of food high in vitamin k because it can lower the effectiveness of the warfarin (leafy greens)
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Function of the Spleen
Help balance blood production with destruction and assists with immunity

\-Destroys old or imperfect RBCs

\-Breaks down the hemoglobin released from these destroyed cells for recycling

\-stores platelets, RBCs, and WBCs

\-filters antigens

\-major site of antibody production
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Implications for someone who has had a splenectomy
\-at an increased risk for infection and sepsis due to reduced immune function

\-doctor may recommend that you take preventative antibiotics or get certain vaccinations
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Bone Marrow biopsy (nurse’s role and teaching)
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Anemia clinical manifestations
Reduction in the number of RBCs, amount of Hgb, or Hct

\-Women Hgb
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Sickle cell disease
AR genetic disorder where a mutation in the gene for the beta chains of hemoglobin causes chronic hemolytic anemia, pain, disability, organ damage, increased risk for infection, and early death as a result of poor blood perfusion

\-HbS is sensitive to low oxygen so they fold even more, distorting the cells into sickle shapes

\-these clump together and block blood flow and perfusion
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Priority interventions for sickle cell crisis

1. Pain

\-PCA with opioids

\-oral pain medications

\-hydration by oral or IV route (hypotonic fluids)

\-keeping the room warm

\-Using distraction and relaxation techniques

\-positioning with support for painful areas

\-aromatherapy

\-therapeutic touch

\-warm soaks or compresses
2. Potential for infection, sepsis, multiple organ dysfunction syndrome, and death

\-thorough handwashing

\-monitor CBC with differential WBC count

\-inspect the mouth for lesions

\-inspect lung sounds

\-inspect urine for odor and cloudiness and ask about UTI symptoms

\-oral antibiotics

\-take vitals signs every 4 hours to assess for fever

\-encourage vaccinations

\-remove restrictive clothing

\-instruct patient to acoid keeping jips and knees flexed

\-oxygen therapy (nebulized)

\-blood transfusion

\-HSCT
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Pernicious anemia
Anemia that results from failure to absorb vitamin B12

\-caused by a deficiency of intrinsic factor which is needed for intestinal absorption of B12

\-Without adequate vit. B-12 there are fewer red blood cells carrying oxygen throughout the body

\-type of autoimmune disorder

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Symptoms

\-pallor

\-jaundice

\-glossitis (smooth, beefy-red tongue)

\-fatigue

\-weight loss

\-paresthesia
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Treatment of pernicious anemia
Patients are given vitamin B12 injections weekly at first and then monthly for the rest of their lives

\-oral, nasal sprays, or sublingual methods of B 12 intake may be used after the deficiency has been corrected by injections
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What causes a sickle cell crisis episode
\-hypoxia

\-dehydration

\-infection

\-venous stasis

\-pregnancy

\-alcohol consumption

\-high altitudes

\-low or high environmental or body temperatures

\-acidosis

\-strenuous exercise

\-emotional stress

\-nicotine use

\-anesthesia
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Polycythemia vera
Chronic myeloproliferative neoplasm (MPN) where there is a loss of cellular regulation with excessive expansion of of specific groups of abnormal myeloid cells with decreased function

\-more than 90% of people with PV have a mutation of the JAK2 kinase gene

\-treated with blood thinners

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Cancer of the RBC with 3 major hall marks

\-massive production of RBCs

\-excessive leukocyte production

\-excessive production of platelets

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\
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Polycythemia vera manifestations
Levels

\-Men Hgb >18

\-Women Hgb >16.5

\-RBC count of 6 million

\-Hct >55%

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Signs and symptoms

\-dark, purpple, or cyanotic, flushed appearance in face

\-distended veins

\-poor perfusion

\-hypertension

\-vascular stasis and occlusions leads to hypoxia, anoxia, infarction, and necrosis

\-gout and hyperkalemia are caused by increased cell debris

\-bleeding problems
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Autoimmune Thrombocytopenia Idiopathic Purpura (ITP) manifestations
\-idiopathic

\-think it has a viral component

\-production is normal but destroyed and platelet count low

\-See manifestations in skin and membranes first such as color, bruising, and petechiae

\-treatment = find and treat the underlying cause 

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Hemophilia A vs Hemophilia B
Hemophilia a = deficiency in factor 8 (more common)

Hemophilia b = factor 9 deficiency (christmas disease)

\n
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Nurse’s Responsibility before blood transfusion
\-Assess lab values

\-verify the HCP prescription for type of product, dose, and duration of transfusion

\-establish or use venous access with 19 gauge needle or catheter

\-transfuse blood products soon after receiving them from blood bank

\-verify the patient by name number and blood compatibility and note expiration time with another nurse
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Nurse’s Responsibility During Blood Transfusion
\-Administer the blood product using the appropriate filtered tubing to remove aggregates and possible contaminants

\-infuse blood products with IV normal saline

\-stay with the patient for the first 15-30 minutes to assess for reactions

\-infuse the blood product at the prescribed rate

\-monitor vital signs often
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Nurse’s Responsibility After Blood Transfusion
\-when complete discontinue the infusion and dispose the bag and tubing according to agency and blood bank policies

\-document all aspects of the transfusion
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Vital signs with Blood transfusion (nurse roll)
\-Prevention or early recognition of transfusion reactions

\-assess vital signs 15 minutes after transfusion begins

\-if vital signs are good then increase rate to 1 unit in 2 hours

\-take vital signs every hour
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Febrile transfusion reactions
Most often occurs in patients with anti-WBC antibodies (occurs with multiple transfusions, WNC transfusions, and platelet transfusions)

\-chills

\-tachycardia

\-fever

\-hypotension

\-tachypnea

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Hemolytic transfusion reactions
Caused by blood type or Rh incompatibility with either immediate onset of after transfusion

\-mild (fever and chills)

\-life threatening (disseminated intravascular coagulation and circulatory collapse)

\-apprehension

\-headache

\-chest pain

\-low back pain

\-tachycardia

\-tachypnea

\-hypotension

\-hemoglobinuria

\-sense of impending doom
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Allergic transfusion reactions
Seen in patients with other allergies and may occur during or up to 24 hours after

\-urticaria

\-itching

\-bronchospasm

\-anaphylaxis
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Bacterial transfusion reactions
Occurs from infusion of contaminated blood products (especially gram negative) and rapid onset

\-tachycardia

\-hypotension

\-fever

\-chills

\-shock
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Transfusion-related acute lung injury (TRALI)
Life threatening event that occurs when donor blood contains antibodies against the recipient’s neutrophil antigens, HLA, or both

\-dyspnea and hypoxia with rapid onset withing 6 hours of transfusion
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Transfusion-associated circulatory overload (TACO)
Occurs when a blood product is infused too quickly, especially in the older adult, most common with whole blood transfusions

\-hypertension

\-bounding pulse

\-distended jugular veins

\-dyspnea

\-restlessness

\-confusion
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Transfusion-associated graft-versus-host disease (TA-GVHD)
Rare but life threatening problem that occurs most in immunosuppressed patients, donor T-cell lymphocytes attack host tissues, with onset occurring within 1 to 2 weeks

\-thrombocytopenia

\-anorexia

\-nausea

\-vomiting

\-chronic hepatitis

\-weight loss

\-recurrent infection
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Acute pain transfusion reaction
Rare event with unknown cause that occurs shortly after or during transfusion

\-severe chest pain

\-back pain

\-joint pain

\-hypertension

\-anxiety

\-redness of the head or neck
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Drugs given that have major immunosuppressive effects
\-steroids

\-some antiviral

\-some antibiotics

\-most autoimmune drugs
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Thrombocytopenia
Low platelet count, may cause decreased clotting
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Implications for patients with Thrombocytopenia
\-increased risk for bleeding

\-think of patient safety

\-ex. fall risk
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Infection prevention and control
\-Hand hygiene

\-disinfection and sterilization

\-standard precautions

\-transmission based precautions

\-staff and patient placement and cohorting
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MDROs
\-Multi-drug resistant organism infections: caused by the overprescription of antibiotics and prescribing higher doses for longer periods of time

\-Most common = Methicillin-resistant Staphylococcus aureus, Vancomycin-resistant Enterococcus and Carbapenum-resistant Enterococcus
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MRSA
Methicillin-resistant Staphylococcus aureus

\-type of staph aureus that is difficult to treat because of the resistance to certain antibiotics

\-In the community it was first seen with athlete by sharing things such as towels and personal items in locker rooms. Use contact precautions - pt should have a single room or both pts have mrsa
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C Diff
\-Associated with antibiotic use, especially in older adults

\-C.diff is spread through indirect contact with inanimate objects such as medical equipment

\-its toxins can cause colon dysfunction, diarrhea, and even cell death from sepsis

\-spores are killed with bleach
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Airborne Precautions
\-used for things such as tb that stay in the air longer than droplet

\-includes the use of negative-airflow room and staff would clean hand and wear n-95 mask
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Contact Precautions
MDROs, gloves and gown
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Droplet Precautions
\-used for flu pts (spread through coughs and sneezes)

\-gloves, mask, and goggles -?
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Standard Precautions
Hand hygiene

\-after touching blood, body fluids, secretions, excretions, and contaminated items

\-immediately after removing gloves

\-between patient contacts

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PPE

\-Gloves= for touching blood, body fluids, secretions, excretions, contaminated items; touching mucous membranes and non intact skin

\-Gown= during activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions are anticipated

\-Mask/eye protection= during activities likely to generate splashes of blood, body fluids, secretions, especially suctioning and endotracheal intubation

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Soiled patient care equipment

\-wear gloves if visibly contaminated, perform hand hygiene, and handle in a manner that prevents transfer of microorganisms

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Environmental control

\-routine care, cleaning, and disinfection of environmental surfaces

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Textiles and Laundry

\-handle in a manner that prevents transfer of microorganisms

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Needles and other sharps

\-do not recap, bend, break, or hand manipulate used needles, place in sharps container

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Patient resuscitation

\-use mouthpiece, resuscitation bag, and other devices to prevent contact with mouth and oral secretions

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Patient Placement

\-prioritize for single-patient room if patient is at increased risk for transmission or increased risk for acquiring infection
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TB
\-Airborne

\-if someone is found to have tb they are legally mandated to be treated because of how highly communicable it is

\-People can be infected with TB without symptoms

\-someone only becomes contagious when they begin to have manifestations of symptoms

\-Most prominent symptom is the cough mucopurulent sputum, blood streaks
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TB treatment
\-Combination drug therapy with strict adherence: Isoniazid, Rifampin, Pyrazinamide, Ethambutol.

\-Negative sputum means no longer infectious
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Pandemic flu
\-Mostly prevalent among animals and birds but virus can mutate and become infectious to humans (H1N1 - swine flu)

\-An influenza is a global outbreak of a new influenza A virus

\-Pandemics happen when new influenza A viruses emerge which are able to infect people easily and spread from person to person in an efficient and sustained way.
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Pneumonia
\-Excess fluid in lungs resulting from inflammatory process

\-generally around the alveoli so limited gas exchange (causes high resp rate, hypoxemic, and can cause dehydration)

\-inflammation is caused by infectious organisms or inhalation of irritants

\-Community acquired and nosocomial

\-Educate pts esp older ones and promote them to get a vaccine

\-often seen in pts with chronic respiratory process.

\-Empiema - puss accumulating in pleaural space, describe it by lobes and describe consolidation

\-Lung sounds over consolidated area may be incredibly diminished or not heard at all; may hear crackles from fluid - may here adventitious sounds where there shouldnt be
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Bronchoscopy
what and why
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Patient teaching regarding bronchoscopy
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Allergy Clinic
\-test for what you are allergic to
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Normal WBC count
5000-10000
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Microbiota transplant
\-When a person who lacks normal healthy flora has a transplant of normal flora from a donor through a fecal transplant through their lower gi tract

\-need to stop taking any antibiotics for 2 to 3 days before the procedure

\-You may need to follow a liquid diet

\- may be asked to take laxatives the night before the procedure

\-need to prepare for a colonoscopy the night before FMT
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Type 1 Hypersensitivity Reaction
Rapid hypersensitivity reaction

\-also known as atopic allergy

\-most common type

\-Cause by the overproduction of the igE immunoglobulin 
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Type 2 Hypersensitivity Reaction
Cytotoxic reaction

\-Body makes special autoantibodies directed against self cells that have some form of foreign protein attached to them
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Type 3 Hypersensitivity Reaction
Immune complex reaction

\-excess antigens cause immune complexes to form in the blood

\-Circulating complexes lodge in small blood vessels

\-Usual sites:  Kidneys, skin, joints

\-Deposited complexes trigger inflammation, resulting in tissue or vessel damage
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Type 4 Hypersensitivity Reaction
Delayed hypersensitivity reaction

\-reaction cell is t-cells

\-Local collection of lymphocytes and macrophages causes edema, induration, ischemia, tissue damage at site
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Angioedema
\-Deep tissue problem involving the build up of fluid

\-most often involving the lips, face tongue, larynx and neck

\-Cause – exposure to any ingested drug or chemical.
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Angioedema treatment
Treated with antihistimines and oral steroids
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Anaphylaxis
\-life threatening form of reaction

\-Occurs rapidly and systemically

\-Episodes vary in intensity and can be fatal
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Anaphylaxis treatment
Anaphylaxis requires an injection of epinephrine and a follow-up trip to an emergency room.
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Epi Pen and Patient Teaching
\-device used to administer epinephrine used for emergency treatment of an acute allergic reaction

\-Teach how they should only be injected into the middle of your upper thigh

\-When administering it push it into thigh until it click and then hold firmly in place for 3 seconds

\-then massage the injection area for 10 seconds