medsurg exam 1

1/3 americans

living w chronic stress

Hans selye

stress theorist; began early research on stress in 1940 at McGill; studied stressors to animals -- formulated stress as a response which turned into GAS theory

GAS theory (general adaptation syndrome)

describes the process your body goes through when you are exposed to any kind of stress, positive or negative

stress definition

a response of the body to any demand made on it

stressors

anything that induces stress - physical or emotional, pleasant, or unpleasant

examples of stressors (physiologic)

skin burn, chronic pain, hypothermia, infectious disease, excessive noise, starvation

examples of stressors (emotional/psychologic)

dx of cancer, marital probs, failing an exam, grief, winning lottery

3 stages of gas theory

alarm, resistance, exhaustion

alarm phase

in response to

activation of ___ “fight or flight”

stage of resistance determined by

physical state of person, number of stressors they have, coping abilities; goal is adaptation

stage of exhaustion

all energy for ____ is exhausted; may seen return of alarm phase, can be fatal

holmes, rahe, and masuda

stress as a stimulus

richard lazarus

stress as a transaction

mediators of stress

hardiness, sense of coherence, resilience, hassles vs uplifts (attitude/optimism)

hardiness

pt has clear sense of personal goals and values; has strong tendency toward interaction with an env; sense of meaningfulness is important; internal rather than external locus of ctrl

sense of coherence

seen as more powerful than hardiness - refers to how person sees the world and their place in it

SOC terms

comprehensibility, manageability, meaningfulness

comprehensibility

the sense that internal and external stimuli are ordered and make sense

manageability

that there are resources available as needed

meaningfulness

sense that demands that one faces are worthy of taking on

resilience

ones is resourceful, flexible, and a good problem-solver

hassles vs uplifts (attitude)

balance of the two within one’s life and how the stressors are viewed

attitude

positive = can mean quicker recovery

pessimism can = poorer health

link bt stress and illness

positive relationship bt stress and infection

latent viruses

aids

breast cancer incidence and recurrence

heart disease

accidents and suicide

immune system

acute and chronic stress can cause immunosuppression

immunosuppression from stress bc

decreasing # and function of natural killer cells

decreasing lymphocyte proliferation

altering production of cytokines

decreasing phagocytosis

theories?

not as important as how you will recognize stress in your pt at the bedside and how you’ll manage that stress

assist pt to handle stress by

relaxation, imagery, medication, therapeutic touch, 4x4 breathing techniques, prayer + spiritual encouragement

relaxation

opposite of fight or flight

imagery

seeing the fight (ex: cancer patients)

therapeutic touch

systematic manipulation of soft tissue to reduce tension

hematology

study of blood and blood forming tissues, including the blood cells, bone marrow, spleen, and lymph system

bone marrow

soft center of bones, home of stem cells; located in sternum, ribs, scapulae, clavicle, pelvis, flat cranial bones end of long bones

yellow matter

sponge that helps protect bone

red marrow

stem cells stimulate from; gives us white & red cells & platelets

3 types of blood cells

erythrocytes (RBCs), leukocytes (WBCs), thrombocytes (platelets)

complete blood count (CBC)

erythrocytes; males: 4.3-5.7 million/ul; females: 3.8-5.1

hemolysis

destruction of damaged/abnormal RBCs

2 reasons for decreased RBCS

age or immunocompromised

hemoglobin

combo of heme (iron) and globin (protein); binds with oxygen and carbon dioxide and represents oxygen carrying capacity of RBCs; low in anemia and hemodilution

HGB levels women

11\.7-16 g/dL

HGB levels men

13\.2-17.3 g/dL

hematocrit

measured as %; percentage of RBCs in relationship to total blood volume; best representative of blood volume loss

HCT levels women

35-47%

HCT levels men

39-50%

when HCT goes down (in hydrated pts)

RBCs go down

in dehydrated pts HCT

elevates with normal RBCs

mean corpuscular volume (MCV)

measure of average volume or size of single RBC and is used in classifying anemias; NORMAL: 80-100 fL

mean corpuscular hemoglobin (MCH)

measure of average amount (weight) of hemoglobin within an RBC; NORM: 27-34 pg

mean corpuscular hemoglobin concentration (MCHC)

measure of average concentration or percentage of hemoglobin within a single RBC; NORM: 32-36%

WBC levels

5,000-10,000 ul

neutropenia (or leukopenia)

WBC

platelets levels

normal: 150,000-400,000

critical values:

platelets clotting

activated by interstitial collagen, aggregate and form a plug, vascular response + plug + clotting factors = fibrin clot

spleen

filters out old RBCs and takes hemoglobin and hemolysis and catabolizes the iron; contains lots of lymphocytes and monocytes; sequesters 30% of platelets

effects of aging

stem cells drop after age 30 & again after 65; hemoglobin drops after middle age; WBC increase less w infection

assess

hx, meds, surgeries, family hx, nutrional hx, signs of bleeding, exercise level, reproductive pattern, lab values

erythrocytes sedimentation rate (ESR)

rate at which RBCs setting in saline over specified perioid (1hr); nonspecific measure of inflammatory conditions

ESR normal range

less than 30 mm/hr - usually women higher than men

serum iron lab test

iron + proteins; 50-175 mcg/dl

TIBC

proteins available to bind to iron; 250-425 mcg/dl

Ferritin

major iron storage protein; 10-250 mcg/dl

transferrin

largest protein that binds w iron (190-380 mcg/dl)

serum iron goes up

TIBC down

Serum iron up

ferritin up (& vice versa)

prothrombin time (PT)

assessment of clotting times for factors I, II, V, VII, X

normal PT

11-16 seconds; above normal associated w vit. K deficiency or therapeutic coumadin dose

activated partial thromboplastin time (PTT)

assessment of clotting times for factors I, II, V, VIII, IX, X, XI, and XII

normal PTT

25-35 sec; therapeutic 60-70 sec

international normalized ratio

standard method of reporting PT; normal: 0.5

hemophilia

men get; hereditary bleeding disorder due to deficient clotting factors; A type - classic, factor VIII (80%), B type - christmas disease, factor IX

von willebrand disease

involves congenitally acquired deficiency of coagulation protein

medical mgmt of hemophilia

primary means of tx: replace clotting factor;

given during crisis and before procedures; assess for blood born infections, thrombosis; minor bleeds, tx for 72 hr, surgeries for 10-14 days; DDAVP may be used for mild type A and some von willeb. subtypes

hemophilia joint bleed mgmt

rest joint, pack in ice, analgesics without aspirin, mobilize as soon as bleeding under ctrl without weight bearing (ROM)

hemophilia nurs mgmt

genetic counsel referral, only female carriers, stop acute bleeds, assess for intracranial bleeds & airway obstruction from hemorrhage into neck and pharynx

anemia

deficiency of # of erythrocytes, the quantity of HGB, and/or volume of packed RBCs (HCT)

anemia compensation

shift oxygen from tissues to blood; shunt blood from tissues that dont need as much; increase cardiac output, HR, and stroke volume; increase # of RBCs produced

iron deficiency

most common type; caused by inadequate diet, poor absorption, GI bleed, menstruation

iron deficiency s/s

pallor, glossitis, burning of tongue, chelitis, headache, paresthesia

tx for iron deficiency

treat underlying cause and iron replacement; may be given PO (give in acidic env like orange juice), IM (using Z-track method), or IV

thalassemia etiology

genetics, mediterranean and equatorial regions of asian, middle easter, and african cultures

thalassemia

inadequate production of HGB

s/s of thalassemia

pale, thickening of cranium & maxillary cavity, hyperplasia of bone marrow, growth retardation and ultimately death

tx for thalassemia

palliative transfusions and IV desferal/ferriprox; goal to keep Hgb bt 9-10 & prevent buildup of iron

cobalamin deficiency (pernicious anemia)

insufficient amt of intrinsic factor; can be d/t gi surgery, crohns, chronic alcoholism

s/s pernicious anemia

paraesthesia, ataxia, weakness, confusion or dementia

normal b12 levels

190-950 pg/mL

folic acid deficiency causes

Poor diets

Malabsorption disorders

Oral contraception

Patients on anti-seizure drugs

__Alcohol__ abuse / anorexia

Hemodialysis patients

anemia of chronic disease causes

inflammatory, autoimmune, infectious, and malignant disease; treat underlying disease

aplastic anemia

life threatening stem cell disorder resulting in pancytopenia

aplastic anemia etiology

Congenital or Acquired (through Cancer treatment, infections tx, pregnancy, idiopathic)

aplastic anemia sequelae

risk for infection, fatigue and dyspnea, cardiovas and cerebral vascular response, thrombocytopenia

sickle cell anemia

family of __genetic__ disorders caused by the abnormal properties conveyed to RBC by mutated sickle cell hemoglobin; affects african americas, mediterranean, caribbean, s and central america, arabian or east indian

incidence of sickle cell

1 in 375 births; incurable and often fatal by middle age;

´If both parents have the trait, ___25__% chance that each pregnancy will result in a child with sickle cell

´If only one parent has the trait, then __50%__ of children will have one trait

prsentation of sickle cell

much like chronic anemia until crisis (v__ascular occlusion__ leading to pain and tissue death.  Lasts days to weeks.  Often without known cause, may result in shock)

mgmt of sickle cell

\-Teamwork is essential

\-Lifestyle: avoid high altitudes, __hydrate__ well, treat infections promptly, Pneumovax and H flu __vaccines__

\-Treat the areas of tissue necrosis – ex. Chronic leg ulcers

\-Large doses of continuous narcotics to control pain during crisis

\-\`Stem Cell Transplant

stems cells form new cells

when cells are damaged/die; when body needs mroe (like WBCs)

all tissue

has stem cells

initiation phase

inherited mutation; when host exposed to carcinogen, may be environmental, physical, or biological; sets cellular change into motion

promotion phase

presence of agent creates correct env for dev; reversible