Acute Exam 2

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

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.

Why might a person be polycythemic

If they are chronically hypoxic, COPD

Normal Platelet Count

150000-400000

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

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

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)

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

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

Bone Marrow biopsy (nurse’s role and teaching)

Anemia clinical manifestations

Reduction in the number of RBCs, amount of Hgb, or Hct

\-Women Hgb

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

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

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

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

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

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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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

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)

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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

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

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

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

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

Allergic transfusion reactions

Seen in patients with other allergies and may occur during or up to 24 hours after

\-urticaria

\-itching

\-bronchospasm

\-anaphylaxis

Bacterial transfusion reactions

Occurs from infusion of contaminated blood products (especially gram negative) and rapid onset

\-tachycardia

\-hypotension

\-fever

\-chills

\-shock

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

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

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

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

Drugs given that have major immunosuppressive effects

\-steroids

\-some antiviral

\-some antibiotics

\-most autoimmune drugs

Thrombocytopenia

Low platelet count, may cause decreased clotting

Implications for patients with Thrombocytopenia

\-increased risk for bleeding

\-think of patient safety

\-ex. fall risk

Infection prevention and control

\-Hand hygiene

\-disinfection and sterilization

\-standard precautions

\-transmission based precautions

\-staff and patient placement and cohorting

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

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

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

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

Contact Precautions

MDROs, gloves and gown

Droplet Precautions

\-used for flu pts (spread through coughs and sneezes)

\-gloves, mask, and goggles -?

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

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

TB treatment

\-Combination drug therapy with strict adherence: Isoniazid, Rifampin, Pyrazinamide, Ethambutol.

\-Negative sputum means no longer infectious

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.

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

Bronchoscopy

what and why

Patient teaching regarding bronchoscopy

Allergy Clinic

\-test for what you are allergic to

Normal WBC count

5000-10000

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

Type 1 Hypersensitivity Reaction

Rapid hypersensitivity reaction

\-also known as atopic allergy

\-most common type

\-Cause by the overproduction of the igE immunoglobulin 

Type 2 Hypersensitivity Reaction

Cytotoxic reaction

\-Body makes special autoantibodies directed against self cells that have some form of foreign protein attached to them

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

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

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.

Angioedema treatment

Treated with antihistimines and oral steroids

Anaphylaxis

\-life threatening form of reaction

\-Occurs rapidly and systemically

\-Episodes vary in intensity and can be fatal

Anaphylaxis treatment

Anaphylaxis requires an injection of epinephrine and a follow-up trip to an emergency room.

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