I Primi Secoli di Roma e le Guerre Puniche

Section C - Punch

VHS Study Guide Psychology WEEK 1: Psychology as a Science The goal of this week is to distinguish between "Pop Psychology" (myths) and "Empirical Science" (facts). 1. The Philosophical Roots & "Big Names" Wilhelm Wundt: Established the first psychology lab (1879). He used Structuralism, trying to map the "structure" of the mind through Introspection (having subjects report every tiny sensation they felt). Sigmund Freud: Founded Psychoanalysis. He believed behavior is driven by the Unconscious mind and childhood traumas. He used dream analysis and "free association." Behaviorism (Watson & Skinner): They rejected Freud. They argued psychology must be an Empirical Science, meaning we only study what we can see and measure. Watson: Famous for the "Little Albert" study (fear conditioning). Skinner: Focused on how rewards/punishments shape behavior (Operant Conditioning). Ivan Pavlov: A physiologist who discovered Classical Conditioning (associating a neutral stimulus, like a bell, with a natural reflex, like drooling). Maslow’s Hierarchy of Needs: A Humanist theory. It’s a pyramid starting with basic survival (food/water) and moving up to Self-actualization (reaching your full potential). 2. The "Brain Traps" (Critical Thinking & Myths) Word-of-Mouth: We believe things just because we’ve heard them a lot (e.g., "We only use 10% of our brain"—FALSE). Desire for Easy Answers: People prefer a "quick fix" (like a 5-minute cure for anxiety) over complex scientific reality. Selective Perception: We only notice things that confirm our existing beliefs. Post Hoc, Ergo Propter Hoc: "After this, therefore because of this." The logical error of assuming that because Event B followed Event A, Event A must have caused it. Inferring Causation from Correlation: The most common exam trap. Just because two variables move together (like heat and crime), it doesn't mean one causes the other. Reasoning by Representativeness: Stereotyping. Thinking a person "looks like" a certain role, so they must be that role (the "Finance Bro" vest example). WEEK 2: Scientific Inquiry and Research This is the "How-To" of psychology. You need to know the difference between just watching people and running a real experiment. 1. Research Methods Naturalistic Observation: Watching subjects in their natural habitat without interfering. High "real world" accuracy, but you have zero control. Case Study (Clinical): An intensive, detailed look at one unique individual (e.g., a person with a rare brain injury). Great for detail, but you can't apply the results to everyone. Archival Research: Looking at old records, newspapers, or medical files to find patterns. Longitudinal vs. Cross-Sectional: Longitudinal: Following the same group of people for 20+ years. (Expensive, but shows true change). Cross-Sectional: Comparing different ages at the same time (e.g., testing 10-year-olds and 50-year-olds today). 2. The Experimental Design (The "Gold Standard") Inductive vs. Deductive: Inductive: Starting with observations $\rightarrow$ forming a theory (Bottom-up). Deductive: Starting with a theory $\rightarrow$ testing it with an experiment (Top-down). Independent Variable (IV): The variable the researcher manipulates (The "Cause"). Dependent Variable (DV): The variable being measured (The "Effect"). Control vs. Experimental Group: The experimental group gets the "treatment"; the control group gets a placebo or nothing. Random Assignment: Every participant has an equal chance of being in either group. This prevents Bias. Single-Blind vs. Double-Blind: Single: Participants don't know which group they are in. Double: Neither the participants nor the researchers know. This prevents the researcher from accidentally giving "cues." WEEK 3: Biology and Behavior The "Hardware" section. How the physical brain creates the "Pink Slime" experience. 1. The Nervous System Map Central (CNS): Brain and Spinal Cord. Peripheral (PNS): Everything else. Somatic: Voluntary movements (walking). Autonomic: Involuntary (heartbeat). Sympathetic: "Fight or Flight" (Eyes dilate, heart speeds up, digestion stops). Parasympathetic: "Rest and Digest" (Calms the body down). 2. The Neuron (The Building Block) Dendrites: Receive messages. Soma (Cell Body): Process info. Axon: Sends the electrical signal. Myelin Sheath: Fatty tissue that speeds up the signal. Synapse: The tiny gap between neurons where chemicals travel. Neurotransmitters: Agonist: A chemical that mimics a neurotransmitter (enhances the effect). Antagonist: A chemical that blocks a neurotransmitter. 3. Brain Tools & Anatomy EEG: Measures electrical brain waves (good for sleep studies). MRI vs. fMRI: MRI shows structure (a picture); fMRI shows function (where blood is flowing). PET Scan: Uses radioactive "tracer" sugar to see which parts of the brain are active. The Endocrine System: Uses Hormones (slow-acting chemicals) released into the bloodstream by Glands (like the Adrenal or Pituitary). 4. The "Hidden" Biological Details (Week 3) Refractory Period: After a neuron fires, it needs a tiny "recharge" break before it can fire again. Think of it like a camera flash or a toilet flushing—you can't do it twice in a split second. Broca’s Area vs. Wernicke’s Area: * Broca’s: Controls Speech Production (Frontal Lobe). If damaged, you know what you want to say but can't get the words out. Wernicke’s: Controls Language Comprehension (Temporal Lobe). If damaged, you can speak, but it's "word salad"—it makes no sense. WEEK 4: Consciousness Consciousness is your awareness of yourself and your environment. It’s not an "on/off" switch; it’s a spectrum. 1. Processing Levels Conscious Processing: Tasks that require focused attention (e.g., learning a new TikTok dance or solving a math problem). Automatic Processing: Tasks we do "without thinking" once they are learned (e.g., walking or an experienced driver steering a car). 2. Altered States Hypnosis: A state of extreme self-suggestion where a person is highly open to direction. Meditation: A practice of focused attention to achieve mental clarity and emotional calm. Daydreaming: A shift in attention away from the current task toward internal thoughts and "mental movies." 3. Psychoactive Drugs (The "Drug Cabinet") Depressants (Alcohol, Barbiturates): Slow down the Central Nervous System (CNS). They decrease heart rate and reaction time. Stimulants (Caffeine, Nicotine, Cocaine, ADHD meds): Speed up the CNS. They increase heart rate and energy. Opiates (Heroin, Morphine, Vicodin): Specifically target pain receptors. They mimic Endorphins to stop pain and create euphoria. Hallucinogens (LSD, Marijuana, Psilocybin): Distort perceptions and evoke sensory images in the absence of sensory input. WEEK 5: Sleep and Dreams Sleep is a biological necessity, not a luxury. Your brain is incredibly active during this "downtime." 1. Stages of Sleep (The Cycle) Stage 1 (NREM-1): Light sleep. You might experience "hypnagogic sensations" (feeling like you are falling). Stage 2 (NREM-2): Deep relaxation. Characterized by Sleep Spindles (bursts of rapid brain activity). Stage 3 & 4 (NREM-3): Deepest sleep. This is when the body repairs itself. If you wake up here, you’ll feel very groggy. REM (Rapid Eye Movement): The "Dream Stage." Your brain waves look like you are awake, but your motor cortex is blocked—meaning your body is paralyzed so you don't act out your dreams. 2. Dream Theories (Why do we dream?) Freud’s Wish Fulfillment: Dreams are a "safety valve" for unacceptable feelings. Manifest Content: The actual storyline of the dream (e.g., being chased by a giant Pink Slime). Latent Content: The hidden psychological meaning (e.g., you are running away from your final exam stress). Activation-Synthesis: The brain's attempt to make sense of random neural static. The brain "synthesizes" a story from random "activation." Information Processing: Dreams help us sort out the day's events and consolidate memories. Threat Simulation Theory: Dreaming allows us to "practice" surviving dangerous situations in a safe environment. WEEK 6: Thinking and Processing This is about "Cognition"—how we use our "Pink Slime" to solve problems and make decisions. 1. Building Blocks of Thought Concepts: Mental groupings of similar objects (e.g., the concept of "Dogs"). Prototype: The best example of a category. (If I say "Bird," you probably think of a Robin, not a Penguin. The Robin is your prototype). Schemata (Schema): A mental framework that helps us organize and interpret information (e.g., your "School Schema" includes desks, teachers, and bells). 2. Problem-Solving Tactics Trial-and-Error: Trying random solutions until one works. (Slow and inefficient). Algorithms: A step-by-step, logical rule that guarantees a solution. (e.g., a math formula or checking every single aisle in a store to find milk). Heuristics: A mental shortcut or "rule of thumb." It's faster than an algorithm but can lead to errors. (e.g., looking at the signs above the aisles to find the milk). 3. The Biases (Why we make mistakes) Confirmation Bias: Searching for information that supports our preconceptions and ignoring everything else. Hindsight Bias: After an event occurs, believing we "knew it all along." Anchoring Bias: Getting "stuck" on the very first piece of information offered. (e.g., if a shirt is "on sale" for $50 down from $100, you think $50 is a deal, even if the shirt is only worth $10). Availability Heuristic: Estimating the likelihood of events based on how easily they come to mind. (e.g., being afraid of a plane crash because you saw one on the news, even though car crashes are more common). Mental Set: The tendency to approach a problem in one particular way, often a way that has worked in the past but may not work now. WEEK 7: Memory Memory is the persistence of learning over time. 1. The Three Stages of Memory Encoding: Getting information into our brain. Semantic Encoding: Encoding the meaning of words (Deepest processing). Visual Encoding: Encoding images. Acoustic Encoding: Encoding sounds. Storage: Retaining that information. Retrieval: Getting the information back out. 2. Types of Storage Short-Term Memory (STM): Holds about 7 items (plus or minus 2) for about 20 seconds. Long-Term Memory (LTM): Unlimited capacity and can last a lifetime. Explicit (Declarative): Facts and experiences (Semantic = facts; Episodic = your life stories). Implicit (Procedural): Skills (like riding a bike or typing). 3. Memory Sins & Failures Schacter’s Seven Sins: Includes Transience (fading over time), Absent-mindedness (forgetting your keys), and Persistence (unwanted memories that won't go away). Amnesia: Anterograde: You can't form new memories. Retrograde: You can't remember the past. 4. Enhancement Techniques Chunking: Organizing items into familiar, manageable units. Spaced Repetition: Studying small amounts over a long time rather than cramming. Mnemonic Devices: Memory aids like "PEMDAS" for math. 5. The "Subtle" Memory Sins (Week 7) The Serial Position Effect: You are most likely to remember the beginning of a list (Primacy Effect) and the end of a list (Recency Effect), but you’ll probably forget the middle. Pro-Tip: This is why you should study the "middle" weeks (Week 4, 5, 6) extra hard! Misinformation Effect: This is why eyewitness testimony is shaky. If someone asks, "How fast was the car going when it smashed into the pole?" you will remember the car going faster than if they said "hit." WEEK 8: Lifespan Development Developmental psychology examines how we change physically, cognitively, and socially from "womb to tomb." 1. Cognitive Development (Jean Piaget) Piaget believed children think differently than adults and move through four stages: Sensorimotor (0–2 years): Exploring the world through senses. Key milestone: Object Permanence (realizing things still exist even if you can't see them). Preoperational (2–7 years): Symbolic thought (make-believe) but lacks logic. Key trait: Egocentrism (thinking everyone sees the world exactly as they do). Concrete Operational (7–11 years): Logical thinking about physical objects. Key milestone: Conservation (understanding that volume stays the same even if the shape of the glass changes). Formal Operational (12+ years): Abstract reasoning and hypothetical "what if" thinking. 2. Psychosocial Development (Erik Erikson) Erikson focused on "crises" we face at each age. Trust vs. Mistrust (Infancy): Is the world safe? Identity vs. Role Confusion (Adolescence): "Who am I?" (This is the most common exam question). Integrity vs. Despair (Late Adulthood): Looking back on life with satisfaction or regret. 3. Moral Development (Lawrence Kohlberg) Pre-conventional: Doing the right thing to avoid punishment or get a reward. Conventional: Doing the right thing because it's the law or to fit in. Post-conventional: Doing the right thing based on universal ethical principles (even if it breaks the law). 4. Parenting Styles Authoritative: High warmth, high rules. (The "Goldilocks" style—best outcomes). Authoritarian: Low warmth, high rules. ("Because I said so!"). Permissive: High warmth, low rules. (More like a friend than a parent). Uninvolved: Low warmth, low rules. (Neglectful). WEEK 9: Learning Learning is a relatively permanent change in behavior due to experience. 1. Classical Conditioning (Ivan Pavlov) Learning by association (connecting two stimuli). Unconditioned Stimulus (UCS): The natural trigger (Food). Unconditioned Response (UCR): The natural reflex (Drooling for food). Neutral Stimulus (NS): A trigger that means nothing yet (A Bell). Conditioned Stimulus (CS): The bell after it has been paired with food. Conditioned Response (CR): Drooling for the bell alone. 2. Operant Conditioning (B.F. Skinner) Learning by consequences (Rewards and Punishments). Positive Reinforcement: Adding something good to increase behavior (A gold star for working). Negative Reinforcement: Removing something bad to increase behavior (The car stops beeping when you buckle your seatbelt). Positive Punishment: Adding something bad to stop behavior (A speeding ticket). Negative Punishment: Taking away something good to stop behavior (Taking away your phone). 3. Observational Learning (Albert Bandura) Learning by watching others. Famous study: The Bobo Doll Experiment, where kids imitated adults punching a doll. 4. The "Fine Print" of Learning (Week 9) Spontaneous Recovery: After a behavior has been "extinct" (gone away) for a while, it suddenly reappears out of nowhere. (Like Pavlov's dog suddenly drooling at a bell weeks after he stopped). Generalization vs. Discrimination: Generalization: Fearing all dogs because one bit you. Discrimination: Only fearing the specific dog that bit you. WEEK 10: Social Influences This is the study of how the "situation" and "group" overpower the individual. 1. The Stanford Prison Experiment (Zimbardo) Demonstrated the power of Social Roles and Scripts. Ordinary students became abusive "guards" or submissive "prisoners" simply because of the role they were assigned. 2. Influence & Conformity Normative Social Influence: Conforming to fit in and be liked (Dressing like your friends). Informational Social Influence: Conforming because you think the group has more info than you (Following the crowd in a new city). Obedience (Milgram): Following orders from an authority figure, even if it hurts someone else. 3. Group Dynamics Social Loafing: Working less hard in a group than when alone (The "Billy" effect). Deindividuation: Losing self-awareness and self-restraint in a large crowd or behind an anonymous screen. Group Polarization: When group discussion leads to more extreme opinions. Bystander Effect: People are less likely to help if others are around due to a Diffusion of Responsibility. 4. Thinking Patterns Fundamental Attribution Error: Blaming someone's personality for their behavior while ignoring the situation. Cognitive Dissonance: The "icky" feeling when our actions don't match our beliefs (e.g., you hate lying, but you just lied to your mom). We usually change our beliefs to match our actions to feel better. 5. Social Psych "Secret" Terms (Week 10) Self-Serving Bias: When we succeed, we take the credit ("I'm a genius"). When we fail, we blame the situation ("The test was unfair"). Foot-in-the-Door vs. Door-in-the-Face: Foot-in-the-Door: Ask for something tiny first, then the big thing. Door-in-the-Face: Ask for something HUGE (get rejected), then ask for the smaller thing you actually wanted. They are more likely to say yes because it feels like a "compromise." WEEK 11: Multiculturalism & Diversity This is the study of how culture, identity, and group values shape our behavior and how we interact with others. 1. Cultural Values Individualism: Cultures that value personal independence and "Me" goals (e.g., USA). Success is based on personal achievement. Collectivism: Cultures that value group harmony and "We" goals (e.g., Latin America, Asia). Success is based on doing what is best for the family or community. 2. Acculturation (How we adapt to new cultures) Integration: The "Best of Both Worlds." Keeping your original culture while participating in the new one. Assimilation: Giving up your original identity to fully "blend in" with the new culture. Separation: Keeping your original culture and avoiding the new one. Marginalization: Feeling like you don't belong to either culture (The "lonely" state). 3. Metaphors for Society The Melting Pot: The old idea that everyone should blend together and lose their differences to become one "American" identity. The Salad Bowl: The newer idea where cultures live together but stay distinct. You can see the "tomatoes" and the "lettuce"—everyone keeps their unique flavor. 4. Social Barriers Microaggressions: Small, daily slights or "backhanded compliments" toward marginalized groups (e.g., "You’re so articulate for someone from your neighborhood"). Prejudice vs. Discrimination: Prejudice is the thought/feeling (pre-judging), while Discrimination is the action (treating someone differently). WEEK 12: Stress & Health This is the study of how our brain's "appraisal" of the world affects our physical and mental health. 1. The Appraisal Process (Lazarus) Primary Appraisal: Judging if a stressor is a Threat (harmful) or a Challenge (potential for growth). Secondary Appraisal: Evaluating your tools. "Do I have the resources to handle this?" If yes, stress stays low. If no, panic sets in. 2. The Body’s Response (Selye’s GAS) General Adaptation Syndrome (GAS): The three stages of how your body reacts to stress: Alarm: Fight-or-Flight. Heart races, adrenaline hits. Resistance: Staying on "high alert" to cope. This is where you grind through the week. Exhaustion: Your battery dies. Your immune system crashes, and you get sick (The Cohen Cold Study). 3. Types of Stress Eustress: "Good stress." The kind that motivates you to finish a project or perform well in a game. Distress: "Bad stress." Chronic pressure that leads to burnout, fatigue, and health problems. 4. Coping Strategies Problem-Focused Coping: Attacking the problem directly. (Example: Time-Blocking your homework so it isn't overwhelming). Emotion-Focused Coping: Managing the feelings. (Example: Going to the Gym or meditating to stop feeling anxious). 5. Stress "Secret" Terms Cortisol: The primary stress hormone. Great for emergencies, but too much of it "eats" your memory and weakens your heart. Psychoneuroimmunology: The fancy word for the study of how your brain (stress) talks to your immune system. WEEK 13: Mental Wellness & The Science of Happiness The goal of this week is to identify the psychological frameworks and empirical studies that explain how humans build resilience and long-term well-being. 1. The Three Dimensions of Happiness (Module 14.5) According to the textbook, happiness is an enduring state consisting of joy and contentment. It is built through three "lives": The Pleasant Life: Attaining and savoring daily pleasures that add joy to the moment (e.g., the aroma of coffee or the feeling of sunshine). The Good Life: Identifying your unique skills and using them to enrich your life. This is where you find the state of Flow—being so "in the zone" that you lose track of time. The Meaningful Life: Using your talents and efforts in the service of the greater good or to help others, which provides a deeper sense of fulfillment than pleasure alone. 2. The Four Pillars of Well-Being (Wellness Studies) Based on Dr. Richard Davidson’s research, well-being is a "trainable skill" rather than a fixed trait. It is built on: Awareness: Noticing what your mind is doing in the present moment (meta-awareness). Connection: Cultivating kindness and healthy social relationships, which are the #1 predictor of long-term health. Insight: Having curiosity about how your own mind works and not believing every negative thought as a "fact." Purpose: Having a clear sense of direction or a "life compass" that guides your daily actions. 3. Empirical Evidence: The Creswell et al. Study (2014) This study provided scientific proof that mental training has biological effects: The Setup: An experimental design where students were randomly assigned to either a mindfulness group or an analytic control group. The Independent Variable: Brief 3-day mindfulness meditation training (25 mins/day). The Dependent Variable: Biological stress markers (Cortisol levels) and self-reported stress. The Result: The mindfulness group showed significantly lower cortisol levels, proving that meditation fosters biological resilience to stress. 4. Scientifically Proven Benefits of Gratitude Research shows that gratitude is a powerful "reset" for the nervous system: Physical: Improved sleep quality and duration; fewer reported aches and pains. Psychological: Reduces "toxic" emotions (envy, resentment) and increases mental strength. Studies of 9/11 survivors showed gratitude was a major factor in preventing PTSD. Social: Encourages "pro-social" behavior, making people more likely to form and maintain new relationships. 5. Mindfulness vs. Meditation (The State vs. The Practice) It is critical to distinguish between these two often-confused terms: Mindfulness: A state of being. It is the quality of being fully present, aware of where we are and what we’re doing, without being overly reactive or overwhelmed. Meditation: The formal practice or "mental gym" used to train the brain. It is the intentional time set aside to practice techniques that eventually lead to a consistent state of mindfulness. 6. Key Terminology & Cognitive Traps Affective Forecasting: The human tendency to overestimate how much future events (both good and bad) will affect our long-term happiness. We assume milestones like "perfect grades" will provide permanent joy, but they usually don't. Optimism & Resilience: Optimism is the general tendency to expect good outcomes. It is the "engine" of resilience—the ability to "bounce back" from major life stressors (like those listed on the SRRS). Problem-Focused vs. Emotion-Focused Coping: * Problem-Focused: Dealing with the stressor directly (e.g., studying for the test). Emotion-Focused: Managing the feelings associated with the stressor (e.g., taking a nap or exercising)

NUR 204: EXAM 1 COMPLETE STUDY GUIDE SECTION 1: CANCER PATHOPHYSIOLOGY & EPIDEMIOLOGY Cellular Characteristics • Cancer is uncontrolled cell growth caused by genetic damage. • Apoptosis: The body's natural ability to destroy abnormal or cancerous cells. Malignant cells fail to undergo apoptosis. • Angiogenesis: Malignant cells can create their own blood supply for nourishment, making them very difficult to eliminate. • Progression to Malignancy: Hyperplasia (rapid increase in normal cells) → Dysplasia (abnormal cells) → Carcinoma in situ (localized cancerous cells) → Malignancy. Tumor Types & Staging • Primary vs. Secondary: The primary tumor is where the cancer originated. Secondary tumors are the sites of metastasis (e.g., lung cancer that spreads to the liver means the liver contains secondary tumors). • TNM Staging System: o T = Tumor size. o N = Lymph Node involvement. o M = Metastasis (Spread). • Number Staging (0-4): Stage 0 (In situ, abnormal cells haven't spread) to Stage IV (Distant metastasis, spread to distant body parts). Risk Factors & Prevention (Live Lecture Focus) • Modifiable vs. Non-modifiable: Age, genetics (BRCA mutations), and gender are non-modifiable. Smoking, alcohol, obesity, and sedentary lifestyle are modifiable. • Environmental Factors: o Physical: UV light (tanning beds), radiation. o Chemical: Tobacco, alcohol, workplace pesticides/cleaners. o Biological: Viral infections (HPV causes cervical cancer, Hep B/C causes liver cancer), poor diet. • Nurse's Role in Community Screenings: Skin cancer screenings are highly effective for community health fairs because they are non-invasive. Screening Guidelines • Breast: Mammograms starting at age 40 (earlier if high risk). • Colorectal: Colonoscopy every 10 years starting at age 45. • Prostate: PSA blood screening at age 50. • Tumor Markers: PSA (Prostate) and BRCA1/BRCA2 (Breast). SECTION 2: IMPACT OF CANCER & NURSING CARE Physiological Impacts • Pain: Very common, affecting up to 80% of advanced cancer patients. • Infection/Neutropenia: Dangerously low white blood cells. Live Lecture Note: Any spike in temperature (even a low-grade fever like 100.4°F) is a massive red flag for impending sepsis and must be addressed immediately. • GI Issues: Nausea, vomiting, and mucositis (painful mouth inflammation). For mucositis: avoid spicy/acidic foods and use lidocaine rinses. Cognitive & Psychosocial Impacts • Delirium (HIGH YIELD): Acute, sudden confusion. Live Lecture Note: Delirium is reversible. The nurse must treat the underlying cause. Interventions include reorienting the patient, clustering care, avoiding interruptions, and simulating day/night to regulate circadian rhythms (lights on during the day, off at night). • Financial & Psychosocial: Cancer treatments are grueling and expensive, leading to lost employment and depression. Nurses should facilitate early referrals to social workers and case managers. Nursing Safety & Medication Administration • Extravasation Safety: Vesicant chemotherapy drugs can severely damage tissue if they leak outside the vein. Live Lecture Note: If chemo is given via a peripheral IV, the nurse MUST check for blood return every single hour to prevent extravasation. If extravasation occurs: stop the infusion immediately. • Chemotherapy PPE: The nurse must wear proper PPE (e.g., double gloves, chemo gown, face protection) and dispose of chemo materials in designated hazardous waste bins (e.g., yellow bins). • Neutropenic Precautions (Reverse Isolation): Protecting the highly vulnerable patient from the nurse/visitors. Includes strict hand hygiene, no sick visitors, and avoiding crowds. SECTION 3: ONCOLOGIC EMERGENCIES • Spinal Cord Compression: Early signs include back pain, muscle weakness, loss of sensation, and bowel/bladder incontinence. • Brain Metastasis/Increased ICP: Personality changes, seizures, altered speech/balance. • Hypercalcemia: Confusion, severe muscle weakness, arrhythmias, and ECG changes. • Superior Vena Cava (SVC) Syndrome: Tumor compresses the SVC causing facial/neck edema and dyspnea. • Tumor Lysis Syndrome (TLS): Rapid cell death causes severe electrolyte imbalances (hyperkalemia, hyperuricemia). • SIADH: Tumor triggers excessive antidiuretic hormone (ADH), leading to massive water retention, dilutional hyponatremia, and confusion. SECTION 4: SELECTED CANCERS Lymphedema What is it? A frequent cancer treatment complication where fluid builds up in an extremity (typically on one side), causing severe swelling. • Signs & Symptoms: Swelling, a feeling of heaviness, decreased range of motion, and tightness in the skin. • Common complication of: Breast cancer treatments, specifically resulting from lymph node dissection/removal, radiation therapy, or chemotherapy. • Nursing Priorities & Treatment: o Elevate the affected arm above heart level. o Use compression sleeves as prescribed. o Encourage range-of-motion exercises to prevent stiffness. o ABSOLUTE SAFETY RULE: NO blood pressures, NO IVs, and NO blood draws on the affected arm. • Breast Cancer: o Live Lecture Note: Ductal breast cancer is the most common type (originating in the milk ducts). o Signs: Hard mass, nipple retraction, "orange peel" skin (peau d'orange). o Hormone Receptors: If the tumor is estrogen-receptor positive, treatment must avoid estrogen as it will feed the tumor. o Lymphedema Care: Swelling in the arm due to lymph node removal. Rule: No blood pressures, IVs, or blood draws on the affected arm. Elevate the arm and use compression. • Lung Cancer: o Live Lecture Note: Often asymptomatic in the early stages, leading to late diagnosis. o Signs: Chronic cough, hemoptysis (rust-colored/bloody sputum), dyspnea. High risk for brain metastasis. • Colorectal Cancer: o Live Lecture Note: A hallmark sign is "ribbon-like" or pencil-thin stool, caused by a tumor pressing in the rectum and narrowing the passageway. Other signs: rectal bleeding, changes in bowel habits, anemia. • Pancreatic Cancer (HIGH MORTALITY): o Live Lecture Note: High mortality because early symptoms are incredibly vague; usually caught too late. o Whipple Procedure: Surgery that removes the head of the pancreas but leaves a portion behind so the patient retains some insulin secretion. Nursing Priority: You must strictly monitor for manifestations of diabetes (hypo/hyperglycemia) because pancreatic function is deeply impaired. • Skin Cancer: o Types: Basal cell (slow-growing, sun-exposed areas), Squamous cell (more serious), Melanoma (most deadly, highly metastatic). o Melanoma ABCDEs: Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolving. • Brain Tumors: o Live Lecture Note: Primary brain tumors are typically benign. Malignant brain tumors have usually metastasized from somewhere else. SECTION 5: INFLAMMATION & IMMUNITY BASICS • Acute vs. Chronic Inflammation: Acute is short-term and protective (redness, heat, swelling, pain). Chronic is prolonged, causing tissue damage. Exam Tip: Chronic inflammation heavily increases the risk for cardiovascular disease. • Infection vs. Inflammation: Inflammation does not always mean infection (e.g., sprains, allergies). Systemic infection signs include fever, tachycardia, and confusion. Rule: Always draw a blood culture before starting antibiotics. SECTION 6: AUTOIMMUNE & INFLAMMATORY DISORDERS Detailed Osteoarthritis (OA) (Live Lecture Focus) • Pathophysiology: OA is a degenerative joint disease causing progressive cartilage breakdown. It is characterized by the friction of "bone on bone" as cartilage degenerates, which leads to the formation of bone spurs and bone cysts (fluid-filled cavities). • Key Distinction: There is NO systemic inflammation; OA is localized to the affected joints. • Risk Factors: Natural wear and tear of aging, trauma, joint overuse (e.g., repetitive work or sports), obesity, genetics, and a sedentary lifestyle. • Complications: Because OA causes a lack of mobility and a sedentary lifestyle, patients are at a highly increased risk for cardiovascular disease, diabetes, and obesity. Patients over 65 should also be screened for iron overload (hemochromatosis), which can accelerate the progression of OA. Patients are also at high risk for depression and anxiety due to loss of independence and chronic pain. • Signs & Symptoms: Joint pain, stiffness, crepitus (cracking of the joints), muscle atrophy, and limited range of motion. • Treatment: o Non-surgical first: Physical therapy, exercise (specifically swimming/water exercises to take pressure off the joints), and weight loss. o Medications: Acetaminophen (monitor for liver toxicity), NSAIDs like ibuprofen/naproxen (monitor for kidney toxicity), and cortisone injections into the joint. o Surgical: Joint replacement (e.g., hip or knee). Nursing Priority: Ambulate the patient right away after surgery to prevent complications. Detailed Rheumatoid Arthritis (RA) (Live Lecture Focus) • Pathophysiology: A chronic autoimmune disease where the body's immune system mistakenly attacks the synovial tissue and fluid in the joints. • Risk Factors: Increased age (highest onset in the 60s), genetics, females (especially those who have never given birth), obesity, smoking, and high stress. o Trigger mechanism: Someone with a genetic susceptibility who experiences an external trigger (like an infection or trauma) can kickstart the autoimmune reaction. • Signs & Symptoms: Symmetric joint swelling and pain (usually in the hands and feet), morning stiffness lasting longer than 1 hour, fever, malaise, and weakness. Patients experience flare-ups (severe symptoms) and remissions (no symptoms). • Rheumatoid Nodules: The most common visible manifestation of RA. These are detachable, movable subcutaneous knots or swellings of varying sizes, typically found in the fingers/hands. • Diagnostics: Elevated ESR and C-reactive protein (CRP) indicate inflammation. Positive Rheumatoid Factor (RF) and ANA (anti-nuclear antibody) blood tests. • Medications & Safety: o Treated with DMARDs (Disease-Modifying Antirheumatic Drugs). o Priority: DMARDs suppress the immune system, putting the patient at a severe risk for infection. o Hydroxychloroquine teaching: Long-term use can cause retinal damage and glaucoma leading to blindness; patients MUST see an optometrist regularly for eye exams. Systemic Lupus Erythematosus (SLE): • Multisystem autoimmune disease attacking self-tissues. • Symptoms: Butterfly rash on the face, photosensitivity, joint pain. • Complications: Cardiovascular disease (pericarditis) and kidney failure (lupus nephritis). • Triggers: Teach patients to avoid UV light/sun exposure, severe stress, exhaustion, and infections to prevent flare-ups. Peritonitis (LIFE THREATENING): • Inflammation of the peritoneum (abdomen). • Symptoms: Rigid, board-like abdomen, rebound tenderness. • Complication: Septic shock and death. SECTION 7: HIV / AIDS & HYPERSENSITIVITY HIV/AIDS: • A retrovirus that specifically targets and destroys CD4 T-cells. • Transmission Phase: The virus is most highly infectious during the initial phase when the viral load is the highest. • Opportunistic Infections: When CD4 drops < 200 (AIDS), the patient is at extreme risk for deadly infections like Tuberculosis, Pneumocystis pneumonia (PCP), and Kaposi sarcoma. • PrEP (Pre-Exposure Prophylaxis): Reduces risk of contracting HIV but does NOT replace safe sex practices (condoms). Risk Factors & At-Risk Populations: o Individuals with multiple sexual partners without protection, and those who share IV drug needles. o Substance use (drugs/alcohol) is a major risk factor because it lowers inhibitions, leading to unprotected sex. o Incarcerated populations or those in closed settings (due to sharing needles, self-tattooing, and sexual violence). o Pregnant or lactating women (due to the risk of perinatal transmission). Phases of HIV Progression: 1. Acute Infection Phase: Occurs 2 to 4 weeks after exposure. The risk of transmission is at its absolute highest because the viral load in the blood is massive. Patients exhibit flu-like symptoms (fever, malaise, fatigue). 2. Chronic Infection Phase: Patients are often asymptomatic, meaning they may not even realize they are infected. They can still transmit the virus if their viral load is high enough. This stage can last for a decade or longer. 3. AIDS: If left untreated, HIV progresses to AIDS. Diagnosis is confirmed when the CD4 T-cell count falls below 200. Immune system damage is severe, creating a very high risk for fatality and opportunistic infections (such as Tuberculosis, Kaposi sarcoma, and fungal infections). • PrEP vs. PEP (Crucial Difference): o PrEP (Pre-Exposure Prophylaxis): Medication taken prophylactically to prevent the transmission of HIV to an HIV-negative person. It does NOT replace safe sex practices (condoms must still be used). o PEP (Post-Exposure Prophylaxis): Medication taken after accidental exposure (e.g., a broken condom, a needle stick injury, or sexual assault). It MUST be taken within 72 hours of exposure to be effective. It is taken daily for 28 days and is not meant for regular, ongoing use. Anaphylaxis: • Severe allergic reaction triggering massive histamine release. • Patho: Causes increased capillary permeability, where blood vessels leak fluid into the tissues, leading to profound hypotension and airway edema. • Priority Treatment: Epinephrine IM. • High-Risk Factor: Patients taking Beta-blockers or Alpha-adrenergic blockers are at a high risk of death because these medications reduce the effectiveness of epinephrine, preventing the reversal of the shock. SECTION 8: INFECTIONS & SAFETY PROTOCOLS Meningitis (SAFETY RULE): • Diagnosed via Lumbar Puncture (testing CSF). • Live Lecture Safety Rule: If the patient shows signs of Increased Intracranial Pressure (ICP) (like severe headache, altered mental status), a CT scan of the head MUST be performed BEFORE a lumbar puncture. Performing a lumbar puncture when ICP is high can cause fatal brain herniation. • Risk Groups: College dorm students, unvaccinated individuals. Lumbar Puncture (Live Lecture Safety Rules) • Purpose: To draw out and test the cerebrospinal fluid (CSF) specifically to screen for and confirm a diagnosis of meningitis. • Position: The patient should be laying on their side with their knees pulled to their chest (fetal position) to help open up the spinal column for needle insertion. • Contraindication & Safety Priority: A lumbar puncture is completely contraindicated if the patient has Increased Intracranial Pressure (ICP). o Rule: A CT scan of the head MUST be performed BEFORE a lumbar puncture to rule out increased ICP. Performing a lumbar puncture on a patient with increased ICP can cause fatal brain herniation Sinusitis: • Inflammation of the sinuses causing facial pressure ("like you got punched in the face"), congestion, and post-nasal drip. • Live Lecture Rule: Treat with hydration, nasal irrigation, and steam. AVOID over-the-counter antihistamines and decongestants because they cause rebound inflammation (making symptoms worse when they wear off). Influenza: • FACTS Mnemonic: Fever, Aches, Chills, Tiredness, Sudden onset. High risk for secondary pneumonia in older adults and pregnant women. SECTION 9: MEDICATIONS HIGHLIGHTED IN LIVE LECTURE 1 Your instructor specifically highlighted these medications and their nursing implications during the recorded lectures: 1. Analgesics & Anti-inflammatories • Opioids (Cancer Pain): A major side effect is delayed gastric emptying and severe constipation. Intervention: Administer stool softeners, encourage hydration and mobility. Monitor for decreased respirations and drowsiness (which creates a fall risk). • Acetaminophen (Tylenol): Used for mild OA pain. Warning: Hepatotoxic (toxic to the liver) if too much is given. • Ibuprofen/Naproxen (NSAIDs): Used for OA/RA inflammation. Warning: Nephrotoxic (toxic to the kidneys) and can cause GI bleeding. • Corticosteroids (Cortisone): Can be injected directly into joints for OA inflammation. 2. Neurological & Emergency Medications • Mannitol: An osmotic diuretic used specifically to lower elevated Intracranial Pressure (ICP) in patients with brain tumors. • Phenytoin & Levetiracetam (Keppra): Anti-epileptic medications used to prevent seizures in patients with brain metastasis/tumors. • Epinephrine: The absolute first-line priority treatment for anaphylaxis. Works to constrict blood vessels and open the airway. • Hydroxychloroquine (DMARD): Used for RA and Lupus. Warning: Can cause retinal toxicity. Patients require regular eye exams (every 6 months) and must use photosensitivity precautions. SECTION 10: SAMPLE QUESTIONS & ANSWERS Q1: The client’s cancer is staged as T1, N2, M1 according to the TNM classification system. How would the nurse interpret this staging? A. One tumor that is nonresponsive to treatment with distant metastasis B. Leukemia indicated that is confined to the bone marrow C. A 2-cm tumor with one regional lymph node involved and no distant metastasis D. Small tumor with extension into two lymph nodes and one site of distant metastasis Answer: D. Rationale: T = small primary tumor, N = extension to regional lymph nodes, M = distant metastasis has occurred. Q2: The nurse is assessing an older client at a checkup visit. Which reported change would alert the nurse to the possibility of colon cancer? A. Pencil-thin stool B. Erectile dysfunction C. Reduced urine stream D. Persistent pain in the lower back and legs Answer: A. Rationale: Tumors growing in the colon/rectum compress the passageway, resulting in ribbon-like or pencil-thin stool. Q3: A nurse is performing a cancer screening assessment on several clients. Which of the following findings is a possible manifestation of cancer? (Select all that apply) A. Temperature 36° C (96.8° F) B. Sore that does not heal C. Difficulty swallowing D. Blood in the urine E. Rhinitis Answer: B, C, D. Rationale: Using the CAUTION mnemonic, signs include sores that do not heal, difficulty swallowing, and unusual bleeding/discharge. Q4: A nurse is caring for a client who has breast cancer. The client asks why the treatment plan contains a combination therapy of three different medications. Which of the following responses should the nurse make? (Select all that apply) A. “Combination chemotherapy decreases the risk of medication resistance.” B. “Combination chemotherapy attacks cancer cells at different stages of cell growth.” C. “Combination chemotherapy increases production of platelets.” D. “Combination chemotherapy stimulates the immune system.” Answer: A, B. Rationale: Using multiple chemo drugs reduces drug resistance and attacks the cell at various phases of the cell cycle. Q5: A nurse is caring for a burn client whose calculated 24-hour intravenous fluid requirements are determined to be 5000 mL. What is the total volume (mL) that the nurse should infuse after the first 8 hours of fluid resuscitation has infused? Answer: 2500 mL. Rationale: Standard burn fluid resuscitation protocols require half (50%) of the 24-hour total to be administered in the first 8 hours following the burn injury. Q6: The nurse is caring for a client who has a systemic infection. What is the best method to prevent infection transmission? A. Obtaining an immunization B. Implementing proper hand hygiene C. Wearing gloves D. Managing the client’s fever Answer: B. Rationale: Strict hand hygiene remains the most effective method for preventing the transmission of infectious organisms. Q7: The nurse is assessing a client with systemic lupus erythematosus (SLE). Which of the following laboratory findings should the nurse anticipate? (Select all that apply) A. Positive ANA titer B. Increased hemoglobin C. Pancytopenia D. Urine positive for protein and RBCs Answer: A, C, D. Rationale: SLE causes an autoimmune response (Positive ANA), bone marrow suppression (pancytopenia), and lupus nephritis, which damages the kidneys causing protein and blood to spill into the urine. Q8: A nurse is providing teaching to a client who is to receive a vaccination following a deep puncture wound to the foot. Which information would the nurse include? A. “You will need to receive this vaccination annually.” B. “Your passive immunity will be boosted by receiving this shot.” C. “I am administering this vaccination to help protect you against tetanus.” D. “This immunization requires three separate injections several weeks apart.” Answer: C. Rationale: Tetanus vaccination is indicated for deep puncture wounds. Q9: A nurse is assessing a client who is being treated with interferon alfa-2b for malignant melanoma. The nurse should identify that which of the following findings are adverse effects of this medication? (Select all that apply) A. Tinnitus B. Muscle aches C. Peripheral neuropathy D. Bone loss E. Depression Answer: B, C, E. Rationale: Interferon therapy causes significant flu-like symptoms (muscle aches, chills), peripheral neuropathy, and mood changes including severe depression. Q10: A nurse is reviewing the medical record of a client. Which of the following findings are risk factors for ovarian cancer? (Select all that apply) A. Previous history of endometriosis B. Family history of colon cancer C. First pregnancy at age 24 D. First period at age 14 E. Use of oral contraceptives for 10 years Answer: A, B. Rationale: Endometriosis and a family history of associated cancers (like colon or breast BRCA mutations) increase the risk for ovarian cancer. (Pregnancy and oral contraceptive use typically decrease the risk). Q11: The nurse is caring for a client whose white blood cell count is 6000/mm3. Which differential value would the nurse discuss with the health care provider? A. Eosinophils 700/mm3 (Reference range: 50–400/mm3) B. Monocytes 500/mm3 (Reference range: 100–800/mm3) C

NURS 348 — EXAM 4 STUDY GUIDE Hypertension Definition & Overview • Persistent elevation of BP ≥130/80 mmHg (systolic at/greater than 130 OR diastolic at/greater than 80) on at least 2 separate visits, 2+ weeks apart. • Primary (Essential): No identifiable cause, most common (90–95% of cases). • Secondary: Caused by another condition or adverse effects of medications. Etiology/Pathophysiology • ↑ Peripheral resistance and/or ↑ cardiac output → ↑ blood pressure → When blood vessels get narrower (increased resistance) or the heart pumps more forcefully (increased output), pressure inside the vessels rises “like squeezing a hose while water is running” → Over time, this high pressure damages the vessel walls and heart muscle, increasing the risk for atherosclerosis, heart attack (myocardial infarction), and stroke. • ↑ Increased peripheral resistance (arteriolar constriction) → ↑ afterload → left ventricular hypertrophy → heart failure → The heart pushes against more resistance (afterload), making the heart muscle thicker (hypertrophy). Over time, it becomes weaker and can lead to heart failure. • Kidneys retain sodium and water → ↑ circulating volume → The kidneys hold onto extra salt and water, adding more fluid to the blood. More fluid means higher pressure—like overfilling a water balloon. • Activation of renin–angiotensin–aldosterone system (RAAS) = vasoconstriction + fluid retention. RAAS is like the “blood pressure booster” → When this system turns on, blood vessels tighten and the kidneys save even more salt and water, both of which raise blood pressure. Risk Factors: • Primary: family history, ↑ sodium intake, Obesity (BMI >25), African-American ethnicity, smoking, hyperlipidemia, diabetes mellitus, and stress. • Secondary: kidney disease, Cushing’s, pregnancy, pheochromocytoma, medic (steroids, OCPs). Clinical Manifestations (S/S) • Often asymptomatic (“silent killer”)!!! • Headache, dizziness, fainting, vision changes • Retinal damage on exam (cotton wool spots, papilledema). • Note: if blood pressure reading is elevated then take in both arms; pt legs uncrossed, and arms above heart; correct cuff Diagnostics (Dx)/Labs • Multiple BP readings (both arms, sitting and standing) • ECG → Left-Ventricular hypertrophy. evaluates cardiac function. • Labs → ↑ BUN/creatinine (kidney disease), lipids, glucose, cortisol (Cushing’s) Nursing Care / Nursing Interventions • Monitor pt BP regularly and accurately, check both arms/correct cuff • Put on DASH diet (Dietary Approach to Stop Hypertension) Medications • ⭐️Diuretics (first-line): excess fluids, they need to remove; increase urine • Thiazides (hydrochlorothiazide) inhibits water & sodium reabsorption and increases potassium excretion • Side effects/SE: hypokalemia; monitor potassium(K⁺) levels • Loop (furosemide) decreases sodium reabsorption & increase potassium excretion– SE: hypokalemia; monitor potassium(K⁺) levels • Potassium-sparing (spironolactone) – SE: hyperkalemia; monitor potassium levels. EKG: peaked T waves • Also watch out for muscle weakness, irregular, pulse, and dehydration. • ⭐️Calcium channel blockers (verapamil, amlodipine, and diltiazem) Calcium channel blockers relax and widen blood vessels by preventing calcium from entering muscle cells, leading to lower blood pressure (vasodilation) • SE: constipation; take fiber for verapamil, and all can ↓HR • Avoid grapefruit juice ➡️ toxicity, hypotensive effects Calcium= contract • ⭐️ACE inhibitors (lisinopril, enalapril): prevents angiotensin II → vasodilation • SE: - hypotension; monitor BP and pulse HR -hyperkalemia; monitor potassium levels -erectile dysfunction -⭐️cough linked to angioedema (swollen tissue under the skin around lips, tongue, and glottis); report swelling & discontinue med • ⭐️ARBs (valsartan, losartan): for ACE-intolerant pts from cough/hyperkalemia. ARBs lower blood pressure by blocking angiotensin II from binding to its receptors, preventing vasoconstriction, and reducing fluid retention. • SE: angioedema, heart failure, hyperkalemia • Change position, slowly, report, angioedema, edema, and avoid foods that are high in potassium (bananas, potatoes, apricots, spinach, beans); monitor potassium levels • Aldosterone-receptor antagonists (eplerenone, spironolactone): blocks aldosterone action. • SE: kidney damage, hypertriglyceridemia, hyponatremia, and hyperkalemia; monitor kidney function, triglycerides, sodium, and potassium levels • Avoid Grapefruit juice and St. John’s wort, salt substitutes, and potassium rich foods • ⭐️Beta blockers (metoprolol, atenolol): blocks beta receptors (adrenaline/epinephrine) ➡️reduces heart rate, cardiac output, and blood pressure ↓HR, ↓CO; use cautiously in diabetics • SE: -⭐️erectile dysfunction, -Fatigue, weakness, depression -hypoglycemia • Monitor heart rate (hold if HR is less than 60) and do not suddenly stop taking med (cause rebound hypertension); and don’t give to pts with asthma, airway disease (cause bronchospasms) • Central Alpha-2 agonists (clonidine): calm the nerves that raise blood pressure, letting blood vessels, relax, and BP go down, ↓SNS tone • SE: sedation, orthostatic, hypotension, and sexual dysfunction/impotence • Monitor BP and pulse • Alpha-adrenergic blockers (prazosin, doxazosin): vasodilator= relaxed BP; give at night to avoid first-dose hypotension. Start with low dose. • SE: postural hypotension; make sure patient rises slowly and caution. • Monitor BP 2 hrs after initiation Complications • Hypertensive Crisis: usually when patients do not follow the medication regimen • BP >180/120 → organ damage (encephalopathy, renal failure) • S/S: severe headache, dizziness, blurred vision, confusion, epistaxis • Treat: IV antihypertensives (nitroprusside, nicardipine, labetalol); the goal is to lower BP gradually by 20-25% in first hour. Not less than 140/90. Monitor BP every 5-15 mins Patient Education • Adhere to medication regimen, don’t abruptly stop even when you feel better • Change positions slowly • Encourage DASH diet (low sodium, high fruits/veggies, low-fat dairy) ex: grilled salmon, brown rice, steamed broccoli, and low-fat milk • Avoid high-sodium foods. Consume less than 2.3 g/day • Monitor BP at home • Report signs or symptoms of electrolyte imbalances • Encourage Weight loss, exercise 3x weekly • Encourage Smoking cessation • Encourage Limit alcohol (≤2/day men, ≤1/day women) • Manage stress • Report persistent cough or swelling (ACE inhibitor red flag) Peripheral Venous Disorders(PVD) Patho: problems with veins where Deoxygenated blood can't get back to the heart Oxygenated blood pools in the extremities. The valves are preventing backflow. • Venous Thromboembolism (VTE): blood clot that starts in a vein. -Two types: deep vein thrombosis (DVT) and pulmonary embolism (PE) • Venous insufficiency: Improper functioning of the veins. Veins aren’t able to push back blood to the heart which results in swelling, venous stasis ulcers, or cellulitis. Blood can go down into the veins just fine but cannot come back up. a. VTE ex: Deep Vein Thrombosis (DVT) Pathophysiology • Thrombus (Blood clot) forms in deep veins (usually in legs) → can embolize (travel and block vessel) its way to lungs (PE). • Caused by Virchow’s triad: venous/blood flow stasis, endothelial injury, hypercoagulability. Risk Factors • Surgery (hip, knee, prostate) • Immobility • Heart failure • Pregnancy • Family hx • Oral contraceptives or hormone therapy • Cancer • COVID-19 (elevated D-dimer) • Central venous catheters Clinical Manifestations • Note that clients can be asymptomatic • Calf/groin pain (dull/achy), tenderness, warmth, edema • Unilateral swelling • Shallow, irregular shaped wounds • Too much blood, brown/yellow discoloration • Sudden SOB and sharp chest pain → suspect PE • Positioning: “Elevate Veins”, position up in “V” shape, above heart. Worsens: if dangling, sitting/dangling for long periods of time. Diagnostics • ⭐️Venous duplex ultrasonography = gold standard; it’s an ultrasound of Leg to see blood clot/blood flow through the vessel. • ⭐️D-dimer ↑ = clot breakdown evidence • Venogram/MRI if ultrasound inconclusive Nursing Interventions • Bed rest until anticoagulation started • Elevate leg slightly above heart (no knee gatch). Positioning: “EleVate Veins”, think V as veins are up, to keep the veins open. • Warm compresses • DO NOT massage leg • Compression stockings (after swelling ↓) • Encourage early ambulation when safe • SCDS Medications/Procedures (Anticoagulants) stops blood from clotting, another nurse must be with you • Unfractionated heparin (given IV): prevents clots and growth of existing clot; monitor platelets, and aPTT (how long it takes blood to clot) (1.5–2× normal). Must be given in facility. MUST MONITOR CLOSELY • Antidote: protamine sulfate • Low-molecular-weight heparin (Lovenox/enoxaparin): given SubQ, weight-based, prevention and treatment of DVT, given twice daily, can be used in home setting. Don’t need labs. Monitor for bleeding, and take bleeding precautions (Electric razor, soft toothbrush, environment safety) • Warfarin (Coumadin): oral, inhibits vitamin K clotting factors overlaps; combined with heparin 3–4 days until INR 2–3 (takes awhile to kick in; therapeutic affect) • Antidote: vitamin K • Avoid high vitamin K foods (green leafy veggies) • Monitor PT (range: 11-13.5 secs), INR (must know range: 2–3) • Factor Xa inhibitors (fondaparinux; SubQ) (rivaroxaban, apixaban; oral): Prevents development of Thromboses; transitional medication; initial labs are PT and PTT; not routinely • Direct thrombin inhibitors (dabigatran): directly prevents growth of thrombus Formation, given sub Q ; initiate initial lab values only for PT and APTT. • Antidote: idarucizumab • Thrombolytics (tPA): for massive DVT/PE, directly infused into clot, start within 24hrs- 5 days of clot formation; monitor for bleeding, neuro status, dizziness, headache. Take bleeding precautions, pt must use electric razor and, brush teeth with a soft toothbrush. • Inferior vena cava filter: prevents embolus from reaching lungs (PE), inserted in femoral vein; catches blood clot. Used when pt is unresponsive to other treatments. Monitor: bleeding, hematoma, infection, PE (dyspnea, chest pain, tachycardia). Nursing actions: assess circulation and encourage leg exercises/ambulation early, have patient not sit for too long Anticoagulant Therapy Nurse’s Role • Verify labs,;Double-check with another RN for IV heparin, Assess for bleeding (bruises, gums, stools) and Monitor vitals, mental status (signs of intracranial bleed) Reversal Agents • Heparin → protamine sulfate • Warfarin → vitamin K • Dabigatran → idarucizumab Patient Education • Avoid contact sports • Soft toothbrush, electric razor • Avoid sudden diet changes (vitamin K) Complications (anticoagulants) • ⭐️Pulmonary embolism: sudden dyspnea, chest pain, SOB, anxiety, tachypnea → emergency; sit, patient in high Fowlers, and administer oxygen and anticoagulants • ⭐️Ulcer formation(venous): often formed over the medial malleolus, chronic, hard to heal, can reoccur. Can lead to amputation/death. Neuropathic patients might not feel this. Nursing care: Dressing is left 3–7 days; wound vacuums, diet: high in zinc, protein, iron, and vitamins A and C, debride necrotic tissue so wound can heel. Patient Education(Anticoagulants) • Bleeding precautions (soft toothbrush, electric razor) • Report bruising or black stools • Avoid prolonged sitting/crossing legs • Wear compression stockings b. Venous insufficiency Pathophysiology • Valves and legs are damaged due to prolong venous HTN Our previous blood clot Risk factors: • Sitting/standing in one position for a long period of time • Obesity • Pregnancy • Thrombophlebitis Clinical manifestations: • Status dermatitis(brown discoloration along ankles) • Edema • Stasis ulcers around ankles Labs/DX • D-dimer ↑ = clot breakdown evidence, detects clot Nursing interventions: Elevate legs to increase venous return (20 mins, 4-5/day), position: legs above heart, “Elevate Veins”, Apply stockings, and monitor for cellulitis Patient education: avoid sitting/standing still for too long, change positions often, avoid crossing legs, tight clothing. Apply stockings before getting out of bed in the morning Peripheral Arterial Disease (PAD) : affects blood vessels that carry blood away from the heart; artery carries blood away from heart but has difficulty going down to extremities. Pathophysiology • Atherosclerosis in lower extremities → decreased blood flow to tissues. Risk Factors • Smoking, DM, hypertension, hyperlipidemia, obesity, age, sedentary lifestyle. Clinical Manifestations • Intermittent claudication: leg pain with exercise, relieved by rest; not enough oxygen makes the tissue suffer = pain; ischemia • Pain(sharp) that is only relieved when resting in dependent position • Cool, pale, cyanotic skin • Loss of hair on legs, thick toenails • Weak/absent pedal pulses; dorsalis pedis; Doppler(verify), +1 • Numbness, burning at night • No blood and no edema due to an adequate blood flow • Note: think “A” in PAD as Antarctica, where it’s cold! For cold, pale skin! Diagnostics • ⭐️ABI < 0.9 = PAD; ankle pressure compared to break your pressure; expected finding is 0.9–1.3; less than is PAD • ⭐️Arteriography for visualization of occlusion/decreased arterial flow with contrast injection on a x-ray. Monitor for bleeding, hemorrhage, marked, pedal pulses • Doppler studies → decreased flow in DM patients • ⭐️Exercise tolerance testing → decreased pressure in lower limbs, read the workload of the heart/circulation, and clarification during exercise. May use treadmill or meds (dipyridamole, adenosine). Finding of a BP/pulse waveform = arterial disease. Monitor vitals before, during, and after. Stop test if chest pain or symptoms are severe. Nursing Interventions • Encourage graded exercise until pain, rest, repeat • Avoid elevating legs above heart (impairs flow) • Avoid cold, caffeine, nicotine, tight clothing • Keep extremities warm (no heating pad), they can’t feel • Foot care: inspect daily, no bare feet, toenails straight Medications • Antiplatelets: (aspirin, clopidogrel) reduces blood viscosity and increases blood flow and extremities. Monitor: bleeding, abdominal pain, black, tarry stools. • Statins: (atorvastatin, simvastatin). Relieved manifestations like intermittent claudication. • Pentoxifylline: improves RBC flexibility (claudication). Monitor for bleeding, abdominal pain, black tarry stools. Procedures • Angioplasty (balloon/stent). Opens and helps, maintain the patency of the vessel, however, laser vaporizes atherosclerosis plaque. Monitor for bleeding, vital signs, pulses, cap Refill. As patients rest limbs are straight for 2-6 hrs before ambulation. Anticoagulant/Antiplatelet therapy given 1-3 months after. • Atherectomy rotation, device removes, arterial plaque. Monitor for bleeding and distal pulses. rest limbs are straight for 2-6 hrs. Anticoagulant/Antiplatelet therapy given 1-3 months after. • Arterial revascularization bypass surgery • Used for clients at risk for losing a limb, severe claudication, or limb pain at rest. It reroutes the circulation around the arterial occlusion. • Post-op: ⭐️ maintain adequate circulation in repaired artery, mark pedal/dorsalis pulses(compare both), monitor color/temp, pain, cap refill, blood pressure (HTN= risk for bleeding; Hypotension=clot risk). • Complications: for these notify provider first -graft occlusion: acute blockage of bypass graft within 24 hr(absent pulse, cold foot, increased pain) -compartment syndrome: tissue pressure restricting blood flow; causing ischemia (numbness, tingling, edema, worsening/passive pain) -infection: infection of site (warm, tenderness, elevated, WBC, purulent drainage, use sterile technique) Patient Education • Walk until pain → rest → walk more • Stop smoking • Avoid crossing legs • Diet low in cholesterol and fat Postoperative Care – Peripheral Bypass/Revascularization Priorities • Assess extremity: color, temperature, cap refill, sensation, pulses q15min ×1hr • Mark pedal pulses before surgery • Maintain adequate BP (avoid hypo or hypertension) • Do not flex hip/knee excessively • Encourage ambulation when ordered • Report sudden pain, loss of pulse, pale/cool extremity = graft occlusion Complications • Graft occlusion, Compartment syndrome, Wound infection Arterial vs. Venous Ulcers Feature Arterial Ulcer Venous Ulcer Location Toes, feet, lateral ankle Medial ankle Appearance Pale, dry, round “punched out”, no drainage Irregular, leaky/moist, brown discoloration Pain Severe, worse with elevation Achy, relieved with elevation Skin Cool, shiny Warm, thickened Treatment Improve arterial flow Compression therapy, elevate legs Valvular Heart Disease OVERVIEW Overview • Stenosis = narrowed opening/thickening and hardening • Regurgitation = backflow of blood • Causes: rheumatic fever, degenerative calcification, endocarditis Diagnostics • Chest X-ray → chamber enlargement • ⭐️ECG → hypertrophy • Echo → valve dysfunction • TEE → direct view of valves ⭐️ Medications overview • Diuretics [furosemide, hydrochlorothiazide, spironolactone]: reduce pulmonary congestion, by removing excessive extracellular fluid. Monitor: hypokalemia, eats foods high in potassium, and administer furosemide IV slowly over 1 – 2 minutes. • Afterload–reducing agents [Beta-blockers (-lol); calcium channel blockers (-dipine); ACE inhibitors (-pril); angiotensin–receptor blockers (-artan); vasodilators (hydralazine]): control heart rate, by lessening resistance to contraction. Monitor: hypotension. • Inotropic agents (digoxin): increases contractility, improves cardiac output. Hold medication if pulse rate (abnormal) is less than 60/min or greater than 100/min. Take medication same time every day, avoid combining with antacids (2hrs). Monitor: toxicity such as weakness, confusion, visual changes, low appetite. • Anticoagulants: reduces risk of thrombus. Monitor: stroke, PT, INR, bleeding/bruising. Procedures • Valvuloplasty (balloon dilation) • Valve replacement • Mechanical = lifelong anticoagulants • Tissue = replace every 7–10 years Patient Education • Prophylactic antibiotics before dental procedures • Good oral hygiene • Daily weights • Sodium restriction • Avoid caffeine/alcohol • Report HF signs (weight gain, edema, SOB) • Avoid alcohol, epinephrine, and ephedrine= can cause dysrhythmias THE 4 VALVULAR DISORDERS Mitral Stenosis Etiology/Pathophysiology: Narrowed mitral valve obstructs blood flow from left atrium (LA) → left ventricle (LV), increasing LA pressure and pulmonary congestion → right-sided heart failure. Often caused by rheumatic fever. Clinical Manifestations: Dyspnea on exertion, orthopnea, pitting edema, fatigue, palpitations, hemoptysis, apical diastolic murmur. Risk Factors: Rheumatic heart disease, aging, congenital malformations. Labs/Diagnostics: Echocardiogram (valve narrowing, pressure gradient), ECG (A-fib), chest X-ray (LA enlargement). Medications/Management: • Diuretics [furosemide, hydrochlorothiazide, spironolactone]: reduce pulmonary congestion, by removing excessive extracellular fluid. Monitor: hypokalemia, eats foods high in potassium, and administer furosemide IV slowly over 1 – 2 minutes. • Afterload–reducing agents [Beta-blockers (-lol); calcium channel blockers (-dipine): control heart rate, by lessening resistance to contraction. Monitor: hypotension. • Anticoagulants: reduces risk of thrombus; prevent emboli from A-fib. Monitor: stroke, PT, INR, bleeding/bruising. • Surgical: Balloon valvuloplasty or valve replacement. NCLEX Tip: Rheumatic fever is the most common cause. Mitral Insufficiency Etiology/Pathophysiology: Incomplete closure of mitral valve causes blood to leak back into LA during systole → LV dilation and hypertrophy. Clinical Manifestations: Fatigue, dyspnea, orthopnea, palpitations, holosystolic murmur at apex, pitting edema, S3 sounds Risk Factors: Mitral valve prolapse, rheumatic disease, MI, endocarditis. Labs/Diagnostics: Echocardiogram (regurgitant volume), ECG (A-fib), BNP (HF indicator). Medications/Management: • Beta-blockers (-lol); ACE inhibitors (-pril); ARBS/angiotensin–receptor blockers (-artan): reduce afterload /control heart rate, by lessening resistance to contraction. Monitor: hypotension. • Diuretics [furosemide, hydrochlorothiazide, spironolactone]: manage fluid overload. Monitor: hypokalemia, eats foods high in potassium, and administer furosemide IV slowly over 1 – 2 minutes. • Anticoagulants if A-fib present; reduces risk of thrombus; prevent emboli from A-fib. Monitor: stroke, PT, INR, bleeding/bruising. • Surgery for severe cases. NCLEX Tip: Afterload reduction decreases regurgitant flow. Aortic Stenosis Etiology/Pathophysiology: Narrowed aortic valve → obstructed LV outflow → ↑ LV pressure → hypertrophy → ↓ cardiac output. Clinical Manifestations: Triad: angina, syncope, dyspnea (heart failure); systolic murmur radiating to carotids. Risk Factors: Aging (calcification), congenital bicuspid valve, rheumatic fever. Labs/Diagnostics: Echocardiogram (valve area), ECG (LV hypertrophy), cardiac cath (pressure gradient). Medications/Management: • Avoid nitrates/vasodilators (can cause hypotension). • Use beta-blockers (-lol) cautiously. reduce afterload /control heart rate, by lessening resistance to contraction. Monitor: hypotension. • Surgical aortic valve replacement (definitive). NCLEX Tip: Do not aggressively lower preload; maintain perfusion. Aortic Insufficiency Etiology/Pathophysiology: Incomplete closure of aortic valve → backflow of blood into LV → volume overload → dilation and LV hypertrophy. Clinical Manifestations: Dyspnea, palpitations, fatigue, bounding (“water hammer”) pulse, wide pulse pressure, diastolic murmur. Risk Factors: Rheumatic fever, endocarditis, Marfan syndrome, trauma. Labs/Diagnostics: Echocardiogram (backflow volume), ECG (LV enlargement), chest X-ray (cardiomegaly). Medications/Management: • Calcium channel blockers (-dipine); ACE inhibitors (-pril); vasodilators (hydralazine]): reduce afterload /control heart rate, by lessening resistance to contraction. Monitor: hypotension. • Diuretics for volume management. • Surgical valve replacement when severe. NCLEX Tip: Bounding pulse and wide pulse pressure are hallmark findings. General Nursing & Exam Focus • Best diagnostic test: Echocardiogram (for all). • Monitor for A-fib in mitral disorders. • Valve replacement (mechanical): Lifelong anticoagulation. • Daily weights & fluid balance: Detect early HF. • Positioning: High-Fowler’s for dyspnea, low-sodium diet. Inflammatory Heart Disorders (Endocarditis, Pericarditis, Myocarditis, Rheumatic Carditis) Risk Factors • IV drug use, valve replacement, streptococcal infection, immunosuppression, lower socioeconomic status Pericarditis: inflammation of the pericardium (sac around heart) -RF: heart attack, lupus, rheumatoid arthriti -Clinical manifestations: Chest pain (relieved when leaning forward), coughing, Pericardial friction rub, fever, dysrhythmias, and SOB -Labs/DX: • High WBCs, EKG showing ST or T spiking, echocardiogram (inflamed heart) -Nursing care/Intervention: address pain/inflammation, and monitor for cardiac tamponade, position, patient upright, leaning forward, and monitor ECG - Medications: NSAIDs, corticosteroids, anti antibiotics for bacterial • Ibuprofen/NSAIDs for inflammation (pericarditis). Avoid if patient has peptic ulcer, monitor for G.I. bleeding, platelets, liver/kidney function. Must be taken with food, avoid alcohol. • Corticosteroids (prednisone) for autoimmune causes (pericarditis/myocarditis). Low-dose first, take with food, and patient must not stop abruptly. Monitor BP, glucose, electrolytes, wounds, infection, sudden weight gain. -Complication: cardiac tamponade → muffled heart sounds, paradoxical pulse, JVD, hypotension (Beck’s triad) Myocarditis: inflammation of the myocardium (heart muscle itself) -RF: viral (covid, Coxsackie), fungal, or bacterial infection; autoimmune disorder -Clinical Manifestations: Tachycardia, chest pain, murmur, friction rub, dysrhythmias, peripheral swelling, cardiomegaly. -Labs/Dx: ECG, echocardiogram, high troponin, CK – MB, ESR in CRP for inflammation/injury -Nursing Care/interventions: monitor for heart failure, and dysrhythmia’s, provide rest and activity restriction -Medication: • Amphotericin B for fungal infection (myocarditis/endocarditis). Monitor liver/kidney function for a G.I. upset. • Corticosteroids (prednisone) for autoimmune causes (pericarditis/myocarditis). Low-dose first, take with food, and patient must not stop abruptly. Monitor BP, glucose, electrolytes, wounds, infection, sudden weight gain. Endocarditis: bacterial infection that leaves inflammation of the endocardium (inner layer of the heart); bacterial or fungal Infection of endocardial tissues that leads to necrosis and embolization of growth -RF: congenital/valvular heart disease, prosthetic valve, IV drug use -Clinical Manifestations: janeway lesions, Fever, murmur, petechiae, splinter hemorrhages (red streaks under nail beds), Osler’s nodes -labs/dx: positive blood culture, echocardiogram -nursing interventions/care: administer IV antibiotics, antipyretics for fever, and anticoagulants, patient should use soft toothbrush, and prophylactic antibiotics before dental/invasive procedures -medication: • Penicillin for infection (rheumatic fever/endocarditis). Monitor for allergic reaction, kidney function/electrolytes. • Amphotericin B for fungal infection (myocarditis/endocarditis). Monitor liver/kidney function for a G.I. upset. Rheumatic Carditis/heart disease: infection of endocardium due to complication of rheumatic fever; GABHS triggers, rheumatic fever leading to inflammatory lesions in the heart -RF: children, Follows untreated strep infection -Clinical Manifestations: tachycardia, Fever, rash(trunk/extremities), joint pain, murmur, chest pain, muscle spasms, friction rub -Labs/Dx: throat culture (strep infection), positive ASO titer, echocardiogram -Nursing care/Interventions: administering antibiotics to stop strep infection, and promote rest, monitor for heart failure, and encourage life on prophylactic antibiotics. -Medications: antibiotics, valve replacement/repair • Penicillin for infection (rheumatic fever/endocarditis). Monitor for allergic reaction, kidney function/electrolytes. Nursing Interventions (Overview for Inflammatory disorders) • Monitor for tamponade & HF • Administer antibiotics (penicillin) • Pain relief (NSAIDs for pericarditis) • Bed rest • Emotional support • Auscultate heart sounds; murmur or friction rub • Collab with cardiologist and physical therapists Procedures (Overview for Inflammatory disorders) • Pericardiocentesis for fluid removal, then sent to laboratory; monitor for recurrence of cardiac tamponade. ( pericarditis.) • Valve surgery if damaged Complications (Overview for Inflammatory disorders) • Cardiac tamponade: medical emergency resulted from fluid accumulation in pericardial sac. S/S: dyspnea, dizziness, tightness in chest, restlessness. Administer IV fluids, notify the provider, obtain chest, x-ray or ECG Cardiac Diagnostics & Vascular Access (Ch. 28) Transesophageal Echocardiography (TEE) Provides clear heart images via probe in the esophagus to detect valve disease, thrombi, or heart failure. NPO 4–6 hr, monitor VS, ECG, and sedation; check gag reflex before eating post-procedure; keep HOB 45°. Stress Testing (Exercise or Pharmacologic) Assesses heart’s response to stress for angina, HF, MI, or dysrhythmia. NPO 2–4 hr, avoid caffeine/tobacco, wear comfortable clothes; stop test for chest pain, SOB, dizziness. Post: monitor ECG & BP until stable. Coronary Angiography (Cardiac Catheterization) Identifies coronary artery blockages using contrast dye via femoral, radial, or brachial artery. NPO 4–6 hr, assess renal function, allergies (iodine/shellfish), and hold metformin 48 hr before/after. Post: monitor VS and site for bleeding, hematoma, or thrombosis, keep limb straight, maintain bedrest. Complications: cardiac tamponade (↓BP, JVD, muffled heart sounds), embolism, hematoma, AKI—notify provider. Teach: report chest pain, bleeding, SOB, avoid lifting >10 lb, and take antiplatelets as prescribed if stent placed. Vascular Access Devices (VADs) Provide reliable central access for fluids, meds, TPN, or blood. Verify tip placement via x-ray before use. PICC: up to 12 mo use, insert in basilic/cephalic vein → SVC; no BP/venipuncture in that arm, keep dressing dry. Tunneled Catheter: long-term use, subcutaneous tunnel prevents infection; no dressing once healed. Implanted Port: long-term chemo access; access with Huber needle, flush with heparin after use. Complications: • Phlebitis: redness, pain, warmth—maintain sterile technique. • Occlusion: flush gently with 10 mL syringe; never force. • Mechanical issues: swelling or pain at port site = dislodgement → notify provider

🧴 1. SKIN ASSESSMENT – DETAILED NOTES 📄 ⭐ Purpose of Skin Assessment * Identify early signs of breakdown * Detect circulation or oxygenation issues * Prevent pressure injuries * Monitor healing or worsening conditions 🧠 What You Assess (Head-to-Toe Skin Check) 🔹 1. Temperature * Warm = normal * Cool = ↓ circulation * Hot = infection/inflammation 🔹 2. Color * Pallor → anemia / ↓ oxygen * Cyanosis → poor oxygenation (BLUE = BAD) * Redness → inflammation / pressure 🔹 3. Turgor * Pinch skin (usually chest or forehead) * Normal = snaps back quickly * Tented = dehydration 🔹 4. Moisture * Dry → dehydration * Diaphoretic → fever, stress * Excess moisture → breakdown risk 🔹 5. Integrity * Intact vs open areas * Look for: * wounds * tears * ulcers 🔹 6. Capillary Refill * Press nail bed * Normal = < 2 seconds * Delayed = poor perfusion 🔹 7. Edema * Swelling = fluid buildup * Check severity (pitting scale) 🚨 PRIORITY AREAS TO CHECK * Bony prominences (sacrum, heels, elbows) * Skin folds (obese patients) * Under devices (oxygen tubing, stockings) * Areas with ↓ sensation ⚠️ HIGH-YIELD FINDINGS * Non-blanchable redness = Stage 1 pressure injury * Cool, pale skin = ↓ perfusion * Moist skin = ↑ breakdown risk 🩹 2. SKIN TRAUMA & PRESSURE ULCERS – DETAILED NOTES 📄 ⭐ What is Skin Trauma? Damage to the body’s protective barrier ⚠️ Causes of Poor Wound Healing * Malnutrition * Poor blood flow * Infection * Smoking * Medications (steroids) * Age 🧬 Wound Healing Phases 1. Inflammatory * Redness, swelling * Body sends immune cells 2. Proliferative * New tissue forms * Wound starts closing 3. Maturation * Remodeling * Scar forms 👉 Know the ORDER!! 🔥 Types of Wound Healing * Primary intention → clean, closed (sutures) * Secondary intention → open wound heals slowly * Tertiary intention → delayed closure 🚨 PRESSURE INJURIES ⭐ Causes: * Pressure * Friction * Shearing ⭐ Risk Factors: * Immobility * Incontinence * Poor nutrition * ↓ mental status 🔴 STAGES (VERY TESTED) Stage 1: * Non-blanchable redness * Skin intact Stage 2: * Partial thickness * Blister / shallow wound Stage 3: * Full thickness * Fat visible Stage 4: * Muscle or bone exposed Unstageable: * Covered with slough/eschar Deep Tissue Injury: * Purple/maroon skin 🚑 INTERVENTIONS (PRIORITY CARE) * Turn every 2 hours * Keep skin clean and dry * Use barrier creams * Promote nutrition (protein!!!) * Assess skin daily ❌ DO NOT: * Massage reddened areas ⚠️ COMPLICATIONS * Infection * Dehiscence (wound opens) * Evisceration (organs out = emergency) 🧴 3. SKIN CONDITIONS – DETAILED NOTES 📄 ⭐ COMMON CONDITIONS 🔹 Dryness / Pruritus * Dry, itchy skin * Causes: * dehydration * irritants * allergies Treatment: * Moisturizers * Antihistamines * Steroids 🔹 Urticaria (Hives) * Raised, itchy welts * Blanch with pressure Treatment: * Antihistamines * Steroids * Epinephrine (severe) 🔥 Psoriasis (VERY TESTED) * Chronic autoimmune disorder Signs: * Silvery scales * Red plaques * Common areas: * elbows * knees * scalp Treatment: * Steroids * UV therapy * Biologic drugs 🔥 Cellulitis (IMPORTANT) * Bacterial infection Signs: * Red * Warm * Swollen * Painful Treatment: * Antibiotics * Elevate extremity 🔥 Shingles (VERY TESTED) * Reactivation of chickenpox Signs: * Painful vesicles * Burning/tingling Key Point: 👉 Contagious to people who never had chickenpox 🔥 Skin Cancer Types: * Basal cell * Squamous * Melanoma (most dangerous) ⭐ ABCDE RULE: * A = asymmetry * B = border * C = color * D = diameter * E = evolving 🧠 Nursing Diagnoses: * Impaired skin integrity * Risk for infection * Pain * Disturbed body image 🛌 4

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