1
Q
What is Rheumatoid Arthritis? (RA)
A
a chronic, systemic autoimmune disease that affects free moving joints (affects the synovium) causing inflammation and pain
- more common in woman
- bilateral joints affected
2
Q
What are early signs of RA
A
Joint inflammation
morning stiffness
anorexia
low-grade persistent fever
parasthesia
3
Q
What is a hallmark sign of RA
A
Morning stiffness
4
Q
What are late signs of RA
A
subcutaneous Nodules at joints
pericarditis
Deformations
fibrotic lung disease
osteoporosis
anemia (due to low erythropoietin levels)
Sjogrens syndrome
5
Q
what is sjogren’s syndrome and what disease does it go to?
A
Complication of RA
Sjögren’s targets moisture-producing glands, causing dry eyes/mouth, though both can cause joint pain.
6
Q
stages of RA
A
- synovial
- panus forms (forms nodules)
- ankelosis fussion (deformation)
7
Q
What are the 7 S’s of RA
A
- Morning stiffness
- Soft feeling joints (parasthesia)
- symmetrical
- swelling
- stages
- systemic
7.synovium
8
Q
A patient comes in with RA and elevated WBC. What as the nurse do you want to expect the patient is exhibiting
A
an exacerbation
9
Q
True or false + ANA is a definitive lab marker for RA
A
False - + ANA indicates that antibodies are being produced due to an immune response. This is not definitive for RA because in other diseases its also positive. like lupus
10
Q
Portal HTN can cause what two complications
A
Esophageal varacies
Acsities
11
Q
define acsities
A
built up fluid in the abdomen due to portal hypertension.
12
Q
What is the GOAL of RA
A
Decrease inflammation/pain and maintain independence.
13
Q
applying heat treats what
A
stiffness
14
Q
applying cold treats what
A
inflammation
15
Q
Are live vaccines allowed in RA?
A
no
16
Q
Normal erythropoietin levels
A
2.6-18
17
Q
A nurse will give folic acid and iron to this patient
(name the disease process)
A
Rheumatoid arthritis
18
Q
Methotrexate
A
class: DMARDs
blocks the chemicals that cause inflammation by releasing adenosine. (adenosine slows the heart)
immunosuppressive agent. (for RA and LUPUS)
- Nephro and hepatic toxicity! (monitor liver enzymes ALT,AST) (can cause lupus nephritis)
- causes increased risk for infection!
- take folic acid to prevent side effects
- oral ulcers
- NO alcohol/ No pregnancy (terotegenic)
- long term can cause bone marrow suppression.
19
Q
A patient with RA will be expected to receive these meds (list class)
A
NSAIDs (risk for GI bleeding)
Cox 2 enxyme blockers - ex. celebrex - impedes production of prostaglandins which decreases perception to pain.
DMARDs - ex. methotrexate
Steroids (know side effects)
Biological DMARDs
Leflunomide - avoid alcohol and pregnancy, liver enzymes.
Hydroxychoroquine - slow acting, educate eye exam
azathioprine and cyclophosphamide -immunosuppresive agents
20
Q
Hydroxychoroquine
A
antimalarial drug - DMARD for RA
slow acting
- irreversible retina damage
- skin rash or photosensitivity
educate importance of eye exam q6-12 months.
21
Q
Define Lupus
A
A chronic autoimmune disease that results in chronic inflammation and destruction of healthy tissue.Can effect any organ!
The body fails to clean up the dead stuff in the body - so this builds up and then the body thinks its a pathogen and kills it.
3 types (Discoid, systemic, med-induced)
22
Q
List the 3 types of lupus
A
Discolid- most common, skin issues
Systemic - organ failures/issues
med-induced - caused by three meds (reversible)
1. hydralazine
2. Procanamide
3. Isoniazid
23
Q
List some symptoms of Discoid lupus.
A
“skin issues”
Coin like lesions when exposed to sunlight
Alopecia - hair loss
mouth ulcers
Butterfly rash over nose * hallmark
fatigue
24
Q
WHat are some triggers for lupus flare ups
A
Illness
pregnancy
exposure to sunlight
major surgery
medication
allergies
25
What is Raynaud's phenomenon in LUPUS
Arteriolar vasospasm in response to cold/stress usually fingers and toes. color shift white to blue to red.
vasoconstricts everything
26
Nursing care in Lupus is focused on what?
The organ system being affected
27
what is lupus nephritis
what is the treatment
renal failure in lupus - can also be caused by methotrexate
- foamy or frothy urine**
- elevated BUN and creatnine
- GFR, CRP, ANA and ESR
take immunospressants and steroids as prescribed
28
What is the FLARE nemonic for catching a lupus flare up early.
Fatigue
Low grade fever
Achy joints
Rashes
Edema
29
what 3 medications cause med - induced lupus
1. procanamide
2.hydralazine
3.isoniazid
30
your patient with lupus comes in complaining of chest pain and SOB - what doe you as the nurse want to assume is happening and your priority assessment
Pericarditis! a complication of lupus
cardiac is priority.
31
What is ESR and CRP - what do they indicate
Erythrocyte sedimentation rate (15-30) - elevated = inflammation
C-reactive protein (less then 1.0) - elevated = inflammation.
32
What does pancytopenia
all the blood levels are low! can be found in lupus
33
Treatment for lupus is focused on what?
as the nurse what is one specific teaching point you want to educate patients on
controlling and reducing exacerbations
do not use makeup to cover up the rash! (simple lotions are encouraged) - no hyleronic acid
dry skin = itching = infection risk = a trigger!!
34
What medications are expected to be given to a lupus patient
NSAIDs
Corticosteroids
Cortisol cream for skin
Antimalarial agents (hydroxychlorequin)
Methotrexate** - nephro and hepatic toxic! (also for RA)
Azathioprine
long term = bone marrow suppression and risk for infection - methotrexate
35
for a person who has a suppressed immune system are live vaccines contraindicated or are they encouraged
Contraindicated! they are at risk for infection
36
Define Sickle Cell Anemia
a genetic disorder of hemoglobin (hgb connects to RBC to carry o2) O2 becomes low - this causes the change in structure of RBC - they become spoon like. (sickled)
the difference in shape causes vassooclusive crisis and pain due to hypoxia and blockage.
*Oxygenation problem !!! you are getting them in but they are not able to get to the cells .
37
what are the 4 types of Sickle cell anemia
1. Vaso-oclussive (most common) - obstruction due to hemolized shape of RBC
2. Aplastic - bone marrow stops producing RBC
3. Sequestration - sudden pooling of RBC in spleen - leads to hypovolemic shock and cardiovascular failure.
4. Hemolytic crisis - Increased RBC hemolysis, decreased hgb, and jaundice (due to RBC breaking down too fast)
38
what is a key symptom of hypovolemic shock
widening pulse pressures in BP due to vasoconstriction shunting to core.
39
What is the most common cause of hospitalizations and death in relation to Sickle cell anemia
Acute chest syndrome
40
What is Acute chest syndrome
perfusion to the heart is being disrupted and diminished due to hemolyzed RBC.
* the symptoms resemble pneumonia - Resp infection, low O2. they lead to each other.
41
list some complications of Sickle cell anemia
#1 acute chest syndrome - heart failure
Fat emboli
resp infections
stroke risk increase
Pripapism - prolonged erection
pulmonary HTN
pneumonia
enlarged spleen and liver - high volumes of blood.
42
List some symptoms of Sickle cell anemia
pain - beleive them!!
hypoxia
anemia
SOB
Inflitrates on x-ray (mimics pneumonia!)
low hgb, low RBC, high WBC
jaundice
tachycardia
growth delays
43
What is the GOAL in treating Sickle cell anemia
preventing crisis and complications
44
What is Desferamone in Sickle cell anemia given for?
For iron chalading - patients with SCA often get a lot of iron infusions. a adverse affect to this is that iron can start to clump together like geletan. this med helps break it apart to pass.
45
A patient with Sickle cell crisis comes in, what is your first priority as a nurse
what is the second priority?
Oxygenation!!
hydration
PO- 200 ml/hr
IV- 250 ml/hr. (educate client at home to drink 3-4 L a day)
46
What is Hydroxurea and what is it used for?
For sickle cell anemia - suppresses bone marrow function
stimulates production of fetal hemoglobin. used to reduce sickling episodes by producing new (normal shaped hgb)
Complications
- Toxicity
- Infection risk
- leukemia
47
As the nurse what are some interventions for a patient with sickle cell anemia AFTER your priorities are done (O2, Hydration)
also list some education points
- pain management - opioids - believe them!!
- remove constrictive clothing
- extremities extended for blood flow ** promote perfusion
- keep room warm
- Neuromuscular checks every hour! **
- educate - they need to learn to self manage
- educate 3-4 L of water a day
- avoid smoking
- avoid strenuous activities (mild activity 3-4x a week)
- recognize S/S of crisis.
48
UNDERSTAND THE GLASCOW COMA SCALE
highest score = 15
lowest score = 3
a T is given for a patient who is intubated - highest T = 11T, lowest = 3T
49
What are primary injuries to TBI
* Diffuse axonal injury
the initial cause of injury!
*** Diffuse axonal injury - severe widespread injury that causes nerve pathway to knot up. this leads patient into sympathetic storm (all vitals go up)
50
normal ICP
0-15
51
Normal CPP
70-100 - the net driving force of the brain
52
What are examples of Secondary injuries for TBI - why are these so dangerous?
They are the leading cause of death over the primary injury
- Cerebral edema - GIVE MANNITOL
- Ischemia
- Hypercapnia (> 40-45)
- menigitis
- Biochemical changes
- epilepsy
53
What is mannitol and why is it given
Osmotic Diuretic given for Cerebral edema in TBI
draws the fluids out of the brain.
high salt levels causes fluid in brain to shift, moves it to be excreted in urine.
- may cause hyponatremia and hypovolemia - any fluids above 150 ml/hr you are going to question!!!
54
According to the GCS - a patient presenting with POSTURING could be a warning sign of what complication
Sympathetic Storm
- increased HR and T ** they go hyperthermic
patient looses all ability to control temp.
constant fight or flight
55
Define Cushing Triad and what disease is it associated with - seeing these three symptoms what does the nurse immediately want to think
what is a intervention/ procedure
TBI - BRAIN HERNIATION!!!
Cushings triad =
1. decreasing HR
2. low BP with Widening pulse pressures**
3. Increased RR
and rising CPP
Craniectomy!
56
What is the priority nursing intervention for someone with a TBI
Reduce ICP (0-15)
57
What is the treatment GOAL for someone with TBI
Promote independence and adapt to new deficit.
58
How to calculate MAP
ex: 128/74 BP
Systolic + 2
times by Diastolic
all divided by 3
128+2 x 74 =276
divided by 3 = 92 MAP
59
Calculate the CPP with the following
ICP = 4
MAP = 92
CPP = MAP -ICP
92-4=88 CPP
60
Define Basilar Skull Fracture - list S/S
fracture at the base of the skull. Blood vessels and cranial nerves affected
** Battle signs:
- Raccoon eyes (bruising around eyes)
- Halo effect : CSF fluid leaking out ears and nose.
61
What is an early indicator a patient with TBI is having a complication
change in LOC
62
What does an ICP lower then 50 indicate
irreversible damage
63
As the nurse what interventions are you going to do for a patient with TBI
- decrease Stimulation! - educate family to not touch and keep talking to a minimum
- quiet environment / no lights in room
- Bed rest
- Elimination - bowel and bladder programs
- diet and nutrition- swallowing techniques / tube feeding
64
Define Stoke - talk through the general information
- right sided and left sided
- 3 types
When blood to the brain gets interrupted for some reason. brain cells die due to low perfusion.
- 3rd leading cause of death
- right sided stroke = left sided complications
- Left sided stroke (dominant hemisphere) = right sided complications.
3 kinds
1.TIA - Transient Ischema Attack - a *warning sign of impending stroke!! (temporary symptoms) no damage to Brian tissue, wont show up on CT
2. Ischemic (most common) *Blockage
3. Hemorrhagic *brain bleed
65
A patient comes in with a stoke alert - as the nurse what are your immediate interventions in order.
1.BGL finger check
2. IV insertion
3. CT to determine kind of stroke
4.
66
What are some modifiable risk factors for a patient at risk for stoke/
HTN
AFIB
Hyperlipidemia
Diabetes
Smoking
Obesity
Alcohol use
Heart valve disease
67
Will the symptoms of a stroke in general be unilateral or bilateral -
what are some symptoms the patient may present with?
Unilateral **
- Facial droop/drooling
- slurred speech
- Homonymous Hemianopia - vision loss on same side of impairment.
Apraxia - inability to use a object correctly
Agnosia - neglect to one side of body
V, dizzy, Headache
68
Homonymous Hemianopia in a stroke patient
vision loss on same side of impairment. (both eyes can't see to the left)
69
Apraxia
Inability to use a object correctly in stroke patient
70
Agnosia
Neglect to one side of the body in stroke pt.
71
What is TPA and what is it used for?
Trans Plasminogen activator "alteplase"
used for strokes
a thrombolytic used in ischemic strokes to bust clots and obstruction.
parameters
1. immediate CT - to determine kind of stroke
2. NIHSS
3. Door to needle < 60 min! time critical
- HX of bleeding ulcers>
- BP
- surgery
- age
-medications
contraindicated : HEMORRHAGIC STROKE!!!
72
a specific symptom of a hemorrhagic stroke would be?
" I have the WORST HEADACHE EVER"
73
What is the treatment GOAL for a patient with a stroke
SAFETY - nurse teach adaptive techniques.
74
TRUE or FALSE a patient post- stroke should be started on finger foods
what is the patient at risk for after a stroke
FALSE - NPO until swallow test is done.
patient is at high risk for aspiration!!
75
What technique for safety do you want to educate your stroke patient
Scanning technique
76
What are the 3* GOALS for a Spinal Cord injury pt
1. Prevent complications
2. progression of neuro deficits
3. prevent secondary injury
77
C4 and above controls what on the spinal cord
if someone injured their spinal cord at C4 or above what might they need?
Respiratory drive. ** monitor respiratory.
a ventilator.
78
Define Spinal Shock
A sudden, temporary, depression of reflex activity below the level of injury - can last up to 48 hrs
- increased BP, HR and CO - then it all tanks!
- flaccid paralysis *
- fecal incontinence
- urinary retention
meds:
- vasopressors
- inotropes
79
Define Autonomic Dysreflexia
sudden uncontrolled autonomic reflex (patient looses body fluids)
can occur up to a year after injury.
- increase in BP with drop of HR
- triggered by stimuli!! - distended bladder = #1
in order of priority -
- #1 elevate HOB
- #2 BP meds - Hydralazine!!
- #3 remove trigger
80
What are some triggers for autonomic dysreflexia
#1 bladder retention
wrinkled sheets
pressure on skin
tight clothing
sexual activity
pregnancy - patient can get pregnant but must be educated/ counseling
81
True or false a patient with autonomic dysrflexia can not get pregnant
False - they CAN get pregnant but must be educated and go through counseling - will not be a normal pregnancy.
82
List some complications for a patient with Spinal Cord injury
- Spinal shock
- Autonomic Dysreflexia **
- Venous Thromboembolism (IVC filter, SCDs, and anticoags.)
- Long term osteoporosis (educate increased calcium and biophosphonates in diet)
83
Define Cerebral Palsy
A group of disorders that affects a persons ability to move- permanent life long condition.
- most common in childhood
- most common kind is spastic (tight muscles)
- but* does not affect lifespan
84
What is the #1 risk factor for Cerebral palsy
genetics (AFP in the womb)
normal AFP is less then 10-15
85
What is the definitive sign for cerebral palsy
developmental delays in children
- sitting
- rolling
- crawling
- walking
86
List some symptoms of Cerebral palsy
#1 developmental delays
Gowers sign
tight/contracted muscles
abnormal gait
weakness or loss of movement.
spastic movements of tongue
87
at what age is cerebral palsy normally seen?
in 2 years and after at least 3 months of age
88
What is the nurses highest concern for a patient with cerebral palsy
Safety!
Aspiration and falls
89
What is the GOAL for cerebral palsy
Maintain independence
90
List the medications for Cerebral Palsy
Baclofen - muscle relaxer (may cause severe fatigue) reduces hyper-excitability.
Botox (slows synapse transmission)
anticonvulsants
91
What are the main roles of the LIVER
PEOPLE DRINK SO MUCH
P- Produce (Albumin, bile and coagulation factors)
D- Detox (first pass phenomenon) Kuppfer cells - the Bouncer!
S- Storage (Stores excess glucose as glycogen for energy)*
- also stores vitamins and iron.
M-Metabolize (ammonia to urea)
92
What is normal Albumin range and what does it do in the body?
3.5-5.5
transports "drugs" and fluids in the body.attracts fluid from the vascular space, and binds to calcium.
complication of low albumin or liver failure
- toxicity of drugs
- hypocalcemia
- hypovolemia
93
Why is bile important??
"THE BUS"
gets rid of old RBC in the body - excretes it as bilirubin.
build up of bilirubin = jaundice.
and transports cholesterol - build up can clog arteries- MI.
breaks down steroids as well
94
What is the first pass phenomenon in the liver mean?
This is the liver's Detoxing job. it acts as a bouncer
first pass for alcohol and pathogens.
they enter through the portal vein and hepatic artery.
with the help of Kuppfer* cells - the toxins are pulled out
in liver failure
- drug toxicity is very high risk!! body is not processing.
you have to be VERY careful when giving medications.
95
What are Kuppfer cells
they are the liver's detoxing agents in the first pass phenomenon. they block pathogens from entering the body.
96
Complications of Liver failure
- hyperbilirubinemia
- Hypo/Hyper glycemic events.
- drug toxicity
- hepatic encephalopathy (high ammonia levels!)
97
True or false - 20% of blood flows through your liver & it is the only organ in the body that can reproduce itself (unless in cirrhosis)
TRUE
25% of O2 is used by the liver as well
98
Define Hepatic encephalopathy
build up of toxic ammonia levels in the body.
S/S * change in mental status #1
- astrixis - flapping tremor of the hands - late sign
- motor disturbances
- feter hepaticus ** musty smelling breath = portal HTN
99
What is the main medication given for hepatic encephalopathy
Lactulose - laxative - major diarrhea
improve in mental status
decrease in ammonia levels
100
What are clotting factors and ranges!
Pt - 11-13
Ptt - 25-35
INR - 0.8-1.2
101
Complications associated with liver failure - clotting complications.
Esophageal varacies - ulcers in the esophagus. and due to high pressure in portal vein - they will violently throw up blood.
bleeding!
itching (peritus) leads to scratching - bleeding! and increased risk for skin integrity break and infection.
102
What are the VOP interventions associated with the Liver coagulation complications
V-vasopressin
O- Octeriotide
P - propanolol
+ o2
fluids and blood products
103
A patient with High bilirubin levels is at risk for?
what is a normal bilirubin range
GALLSTONES
normal (0.1- 1.2)
bilirubin is 20-25 mmhg/dl = damage to brainstem.
104
Define Cirrhosis
Scaring of the liver
- nodules are felt
- ascites - third spacing located in the abdomen.
105
What are the two main electrolytes to monitor for a liver failure patient (list ranges)
Sodium and Potassium
Sodium - 135-145
Potassium - 3.0-5.3
106
For a patient on fluid restrictions- what is the general conversion the nurse will do to determine how much they can have?
urine output yesterday + 500ml = amount they can have today
107
True or false Tylenol, methotrexate and ibuprofen are hepatic toxic
TRUE
- note on Tylenol it is only toxic if the patient has alcohol onboard. taking it at the same time.
108
what procedure is done to treat acsities
- post procedure what does the nurse expect to see.
pericentesis
pulling out with a needle.
*educate to empty bladder prior to procedure.
post
- orthostatic hypotension. educate pt!
109
What foods to avoid in liver failure
avoid alcohol, high-sodium foods (bacon, canned soup), raw shellfish, processed foods, and high-sugar items
110
A patient coming back from a pericentesis for ascities build up - what is the major complication the nurse needs to look out for?
Hypovolemic shock!
- but don't just overload them with fluids!
4th Semester Nursing
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