EXAM 4 CHRONIC

Braden scale

Assess risk for pressure injury:

• sensory perception

• moisture (ex. due to incontinence)

• activity/mobility

• nutrition

• friction/shear

Score: 6-23

• <18 → at risk MUST implement preventative measures

Psoriasis

Immune disorder causing chronic inflamm of skin

• skin cell produc. > shedding → epidermal thickness

Signs: occur anywhere → elbows, knees, palms, soles, scalp

• thick, raised red patches w/ silvery flaking scales

• painful & itchy

Lab: based on signs

• elevated CRP & ESR (serum inflamm markers)

Tx: no cure

• topicals/ointments (corticosteroid, retinoids), uv light therapy (kills cells), methotrexate

Care:

• pt are better in warmer climate → uv kills cells

Skin cancer

Cause: uv radiation

Types:

• (#1) basal cell carcinoma → usually tx b/c localized

• melanoma → harder to tx

Labs: changes in skin (size, color, sensation)

Tx: chemo, radiation

Care:

• limit sun exposure (spf 30, hats/long sleeve)

• monthly self exams

Burn injuries types

1) Superficial (sunburn)

• affect only epidermal

• signs: mild erythema/hypersensitivity

• tx: resolves in 24-72 hrs (no meds necess.)

2) superficial partial thickness

• affect epidermis & superficial

• signs: very painful b/c exposed nerve endings, wet weeping pink blisters, cap refill normal

• tx: heals in 1-2 wks

3) deep partial thickness

• affect epidermis & extend into deeper portions

• signs: appear waxy (no weepy blister), pink/cherry red, vary pain, NO cap refill

4) full thickness

• affect epidermis, dermis, subcut tissue, maybe muscle/bone

• destroy hair follicles, sweat gland, nerve ending → poor temp control & no pain

• tx: skin graft

Burn injuries

Risk: pt age & medical hx

Effects: burn shock & fluid/electrolyte imbalance secondary to massive fluid shifts

• fluids/electro leak out of intravascular space into interstitial b/c increased cap perm.

• initial: hyerK

• late: hypoK & hypoN

Burn injury stages

1) emergent

• goal: resolve immediate life threat → baseline eval, airway, fluids, prevent hypothermia, initiate wound care

• care: 100% humidified o2, place large bore iv cath (fluid resus), warming measures (ex. blanket)

2) immediate (after resus & stabilize 48-72hr later)

• goal: wound healing & closure, optimal nut., prevent infection & pain

• care: assess labs (protein, wbc, albumin), wound care, nut. (maybe feeding tube)

3) rehab (may last for years)

• goal: rehab & pyschological support

• care: community resources, teach pt how to apply pressure garment (prevents hypertrophic scarring)

  • pt w/ burn may lack sweat gland & skin graft is sensitive to light

  • increased metabolic rate & caloric need post burn

HIV

Virus that attacks body’s immune system

• targets CD4+ lymphocytes → integrate rna into host cell dna through reverse transcriptase

Cause: STI (#1), blood, breast milk

• fluid MUST come in contact w/ mucous membrane/injected into bloodstream

Lab: annual screening

• viral load & cd4 count to establish baseline

Tx: no cure → proper managment

• antiretroviral therapy (ART)

• w/o proper tx → AIDS develops

Care:

• avoid food that irritate bowel (raw fruit/veg, carbonated)

• may need enteral/parenteral nut.

• avoid high risk (use condom, reduce partners, no share needles)

• hygiene → hand wash, avoid crowds

Stages of HIV

Stage 1: acute

• develop 2-4 post exposure → very contagious

• hiv rapidly spread → increase viral load → body can still control the virus → CD4 return to normal levels (500 cells/mm3)

• signs: temporary flu like symp (fever, chills)

Stage 2: chronic

• prolonged → last several decades w/ tx or a decade w/o

• low CD4 → 200-499

• sign: asymp but STILL contagious

  • nonspecific sign → resp. tract infection, enlarged lymph

Stage 3: aids

• CD4: <200 = aids

HIV tx

Antiretroviral therapy (ART)

• interfere w/ ability of hiv to reproduc. & suppress virus

• use: confirmed case, pre/post exposure prophylaxis

• uses multiple agents & adherence is required

  • atleast 95% adherence for tx to be effective

  • eval renal & hepatic

Pneumonia

Inflamm of lung parenchyma from infection

Signs: pleuritic chest pain, cough, fever

Lab: chest x-ray

• elevated wbc, crp, positive sputum

• starts as resp. alka → later: resp. acid

Tx:

• bronchodilator: albuterol or combivent → open airway

• antibiotic → broad then specific

Care:

• SaO2 >92%

• position: good lung down, hob 30

TB

Resp. infection caused by mycobacterium tuberculosis

• spread via aerosolized droplet (NOT direct contact) → airborne precaut.

Types:

• latent → asymp. & NOT contagious

• active → abnormal chest x-ray/sputum

Signs: hemoptysis (coughing blood), weight loss, night sweat

Lab: tuberculin skin test (mantoux test) → assess induration (size/firm)

Tx: 3-9 months

• 2 phases: intensive → continuation

Asthma

Intermittent, reversible airway obstruction from inflamm → increase mucus, bronchospasm

Signs: wheezing, dyspnea, coughing, increased sputum/RR, tachy

Lab: spirometry, chest x-ray, abg

Tx: anti-inflamm (inhaled corticosteroid), bronchodilator

Care:

• maintain o2 >90%

• teach action plan, pursed lip, peak flow meter

Laryngeal cancer

Originate from squamous cells that line larynx/hypopharynx/ esophagus entry → slow develop

Risk: (#1) tabacco & alcohol

Signs: change in voice (lower, raspy, >2 wks), persistent sore throat, ear pain

Lab: laryngoscopy, barium swallow

Tx: radiation, chemo, surgery

Care: post op

• trach care/suction, pulmonary hygiene (deep breath), nut., emergency equip at bedside

Hypertension

BP that is above normal “silent killer”

Types:

• primary (#1) → multifactorial, chronic

• secondary → caused by underlying, acute

Signs: increase bp

• late → headache, chest pain, sob, vision change

Lab: >2 bp reading at SEPARATE times

Tx: slowly & cautious

• start w/ 1-2 med (LOW doses) → diuretic, beta block, ½ dose for older

HTN complications

Hypertensive crisis

• hypertensive urgency → bp very high but no sign of organ damage

• hypertensive emergency → bp >180/120 + possible damage

Coronary artery disease (CAD)

Obstruct/dysfunc of blood vessels that deliver o2 rich blood to heart muscles → ↓ perfusion of myocardial tissue

Cause: atherosclerosis (harden/narrow of arteries b/c plaque)

Risk: elevated serum lipids

• cholesterol >200, trig. >150

Sign: asymp until 40% block → angina

Lab: lipid profile

Tx: surgery (ex. stent)

• aspirin (stop aggregate)

• nitroglyercin (relief) → every 5 min x3

Care: bleeding precaut.

• diet: decrease saturated fat (meat, whole milk), increase complex carb (whole grain)

Peripheral artery disease (PAD)

Narrow/block of vessels that carry blood from heart to upper/lower extremities → deprive o2 → ischemia, necrosis

Cause: atherosclerosis

Signs: intermittent claudication (#1) → muscle pain b/c lactic acid buildup, foot pain worse w/ elevation, coolness, thin shiny skin

Lab: vascular assessment (palp, auscul, inspect), ABI

Tx: meds, angioplasty

Complications: nonhealing ulcers + gangrene → may need amputation

Venous thrombus

Blood clot in vein → potential to break off (thromboembolism)

Signs: Virchow’s triad

• stasis, endothelial injury, hyercoag.

Sign: swell, tender, redness, warmth

Lab: duplex ultrasound (confirm), D-dimer (+ test)

Tx: heparin or enoxa. (for active clot only) → transition to long term oral anticoag (warfarin (INR 2-3))

Care: watch out for bleed (bruise, petechiae, hematuria)

Venous insufficiency

Occurs when leg veins do not allow blood flow back to heart → blood flow backward & pools in leg

Sign: “heavy pain”, skin change (brown), varicose vein, venous stasis ulcer (ankles/calves)

• twisted, enlarged vein

Tx: surgery

• sclerotherapy, vein ligation & stripping

HF

Progressive disease characterized by myocardial cell dyfunc. & muscle weakening

Sign: fatigue, weight gain, tachy

• left side: sob, crackles, fatigue, cool/weak

• right: JVD, hepatomegaly, ascites, edema

Types:

• HFrEF → inability to pump forward “weak pump”

  • EF <45%

• HFpEF → unable to relax & fill “stiff, improper fill”

  • EF >45% but low CO

Lab: ecg

• troponin, BNP/NT-proBNP (released in response to high bp/fluid)

Tx: diuretic, ACE inhibitor (#1), beta block

Cancer

Uncontrolled growth of malignant cells that compromise normal cells

Risk: exposure to carcinogen → cellular mutation

Types:

• solid tumor → arise from specific organ (ex. lung)

• hematological → from cells (ex. leukemia)

Staging: TNM (tumor size, spread to lymph, metastasis)

Sign: CAUTION

Lab: biopsy

Tx: radiation, chemo, bone marrow transplant

End of life

Pt goals guide treatment

Signs: dyspnea, anorexia, delirium, depression

• late → gurgling, terminal bubbling

Care:

• suctioning, position (lateral w/ elevated head), antimuscinaric/anticholinergic to dry up secretions

Anemia

Reduction in o2 carrying capacity b/c less rbc or reduction in hemoglobin

Causes: blood loss, inadequate rbc produc, increased rbc destruct., deficiency

Types:

• iron defic. (#1) → insuff. hemoglobin to carry o2

  • sign: hypoxia, pallor, fatigue

  • lab: low serum ferritin, low H&H

  • tx: red meat, dark leafy, dried beans, fortified cereal/bread (take w/ vit C)

• vit b12 → need for func. of CNS, formation of rbc, dna reg.

  • sign: cns changes → spinal cord degen, altered mental

  • lab: b12 assay

  • tx: animal protein → meat, seafood, egg, dairy

• folic acid → need for formation of heme for rbc mature

  • sign: pallor, tachy, dizzy

  • lab: cbc

  • tx: fortification of cereal/grains → supplements for preg.

• sickle cell → cause hemoglobin to be sticky → block blood flow → hypoxic

  • sign: vassooclusion → pain swell

  • tx: o2 therapy, avoid cold

Polycythemia vera

Disorder of bone marrow → makes blood more viscous (thick) → slow circulation & o2 exchange

• increase in volume of rbc BUT still hypoxic

Cause: JAK2 gene

Sign: takes years for symp → sob, headache, risk for clot

Lab: routine blood test

Tx: therapeutic phlebotomy (remove blood)

Care:

• hydration (3L/day), elevate legs