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NURS 2356 MDC FINAL EXAM PAPER Questions and Correct Answers. Graded A+ MDC Final Exam Review

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NURS 2356 MDC FINAL EXAM PAPER Questions and Correct Answers. Graded A+ MDC Final Exam Review 1. Appropriate nursing actions: Nicole a) When a client falls • 1st priority – chec... k on patient for any injuries Before that, guide the patient to the floor. b) Positioning to reduce injury for bony prominences • Place pillows under areas and elevate • Changes position for 2hrs Elevate calves to protect heels c) Reducing shear injury (med surg pg 447) • Avoid pulling and sliding patient against bed • Keep head of bed at a slight elevation • Make sure sheets and blankets have ripples in them that rub against the patient’s skin • Use others to assist to protect from shearing. d) Reduce urinary tract infection • Proper cleaning of Perineum – front to back e) Reducing pressure ulcers- factors that are contributors (med surg pg 448) Preventing Pressure Injuries Positioning • Pad contact surfaces with foam, silicone gel, air pads, or other materials with pressure-redistribution properties. • Do not keep the head of the bed elevated above 30 degrees to prevent shearing. • Use a lift sheet to move a patient in the bed. Avoid dragging or sliding him or her. • When positioning a patient on his or her side, position at a 30-degree tilt. • Re-position an immobile patient at a frequency consistent with assessed needs. • Do not place a rubber ring or donut under the patient's sacral area. • When moving an immobile patient from a bed to another surface, use a designated slide board well lubricated with talc or use a mechanical lift. • Place pillows or foam wedges between two bony surfaces. • Keep the patient's skin directly off plastic surfaces. • Keep the patient's heels off the bed surface using bed pillow under ankles or a heel-suspension device. Nutrition • Ensure a fluid intake between 2000 and 3000 mL/day. • Help the patient maintain an adequate intake of protein and calories. Skin Care • Perform a daily inspection of the patient's entire skin • Document and report any manifestations of skin infection. • Use moisturizers daily on dry skin and apply when skin is damp • Keep moisture from prolonged contact with skin: • Dry areas where two skin surfaces touch, such as the axillae and under the breasts. • Place absorbent pads under areas where perspiration collects. • Use moisture barriers on skin areas where wound drainage or incontinence occurs. • Do not massage bony prominences. • Humidify the room. Skin Cleaning • Clean the skin as soon as possible after soiling occurs and at routine intervals. • Use a mild, heavily fatted soap or gentle commercial cleanser for incontinence. • Use tepid rather than hot water. • In the perineal area, use a disposable cleaning cloth that contains a skin-barrier agent. • While cleaning, use the minimum scrubbing force necessary to remove soil. • Gently pat rather than rub the skin dry. • Do not use powders or talc directly on the perineum. • After cleaning, apply a commercial skin barrier to areas in frequent contact with urine or feces. f) For vital signs out of range (i.e low oxygen saturation) (module 1 slide 56-59) • Normal body temperature 96.4 to 99.5 (depending on the site) • Respiration Rate – 12 to20 breaths per minute • BP – 120/80 and below; anything higher is abnormal • Pulse-Oximetry (saturation) – 94 to 100% • Pulse – 60 to 100 BPM g) Appropriate measures in taking an oral temperature (module 1 slides55) h) Vital signs that can indicate post-surgical pain? • Elevated Heart Rate • Breathing rate can be elevated • Elevated BP 2. Describe the following: Nicole a) Complications of amputations and type of pain (module 1 slide 10) Possibility of phantom pain b) Autonomy for a client requiring oral care (funds book pg 594-595) • Brush the teeth twice a day. • Use a soft toothbrush. • Moisturize oral mucosa and lips every 2 to 4 hours. • Use a chlorhexidine gluconate (0.12%) rinse twice a day during the perioperative period for patients who undergo cardiac surgery (adult patients). • Use mouthwash inside the mouth twice a day for adult patients who are on a ventilator. • Give the patients the oral supplies c) Fire safety measures and priorities (module 3 slides 12 &22) o Fires  Home fires are the major cause of death and injuries  Older adults & children < 5y/o have the highest risk.  Most common causes of fires:  Cooking fires  Smoking  Heating Equipment  Home oxygen administration equipment: 75% of home fires involves oxygen, smoking materials are the ignition source  Remove the client from the area o RACE  Rescue – remove patient from danger  Alarm – pull the alarm  Contain - close doors  Extinguish fire (if possible) o PASS  Pull the pin  Aim at the base of the fire  Squeeze the handles  Sweep back and forth d) Infant safety- education for new moms in keeping babies safe. • Don’t Sleep with baby • Car seat faces backwards for 2 years • Baby should sleep in their back • Do not use microwave to heat formula • Do not sleep with mom and dad e) Client orientation to a new room may include what specifics • Ensure they can use call light before you leave • Show them where their personal items are and place them near to them • Show them where all the furniture is at and walk them around it. • Also show them where the bathroom is and how to get to it f) Delegation to an unlicensed assistive personnel (UAP) o Anytime there is concern over a finding from an unlicensed person – assess the patient yourself to confirm the concern o Things that can be delegated to unlicensed personnel  Vital signs on a non-critical patient  Moving/ambulating a patient  Bedside glucose monitoring  Bathing and documenting tasks 3. Describe the following: Casey a) Benefits of bathing for a client Cleans the body, stimulates circulation, provides relaxation, and enhance healing. b) Caring for a patient with dementia, specific nursing interventions promote patient orientation, use simple communication, decrease anxiety, keep the patient safe, and pro- vide continuity of care. (fund book, p. 787). As for assistance with procedures such as indwelling catheters or IV insertions. c) Normal temperatures of clients of all ages (infants, adults, elderly) Infant 97.7- 99.5, Adults 96.4 to 99.5, Elderly 96.8 average (due to loss of subcutaneous fat) d) Main causes of accidental poisoning • Young Children exposure is mainly due to improper storage of household chemicals, medicines, vitamins & cosmetics • Older children and adolescents cause is due to suicide attempt, accidental experiment with recreational or prescription drugs. • Adults poisoning occurs by misuse or abuse or prescription drugs, especially narcotics, tranquilizers and antidepressants ( module 3 , slide 8) e) Main purpose of incident report To give the health care facility and the healthcare professionals the opportunity to address the issue and prevent the occurrence of future incidents. f) Interventions for a patient with a DVT • Patient education • Leg exercises • Early ambulation • Adequate hydration • Graduated compression stockings • Intermittent pneumatic compression, such as sequential compression devices (SCDs) • Venous plexus foot pump • Anticoagulant therapy ( med surg p. 744) g) Different types of nurse/client relationships • Pre-interaction: The student nurse gathers information about the client before having a personal interaction, looking at the client’s medical record to begin data collection. • Orientation: The student nurse introduces themselves, explains their role in the relationship, determines the name the client wishes to be addressed by, and establishes trust and rapport. • Working: Active part of the relationship. The student nurse communicates caring and compassion to the client, encourages the client to express concerns and feelings openly and honestly in an environment, and shows mutual respect and understanding. The professional relationship is competent, courteous, and confidential. • Termination: This marks the end of the relationship, whether at the end of the shift or at discharge. The student nurse summarizes all of the work done during the relationship. This is a good way to end the shift. 4. Communication: Casey what are important aspects in communication? a) Christian Scientist beliefs in the ED Will most likely only encounter these patients following an accident because they do follow Western Medicine as first choice to promote health. Most adults are not likely to accept a blood transfusion. ( funds p. 332) b) Asian cultures and space People stand farther apart and touch less c) Jehovah’s Witness and blood transfusions View accepting blood transfusions or blood products as morally wrong. ( funds p. 332). However, it is vital for the nurse to educate o the client on the reasons why the blood transfusion is needed. d) Hindu clients and bathing Hindus prefer to wash in free-flowing water (e.g., a shower instead of a tub bath). If a shower is not avail- able, provide a jug of water for the person to use in the bath. Women are modest and usually prefer to be treated by female medical staff (funds p. 333) e) Catholics and last rights- who does the nurse communicate to? A Roman Catholic who is seriously ill might wish to receive the sacrament of anointing the sick. This sacrament, once known as the last rites, can be repeated if the person recovers and then be- comes ill at a later time. Only a priest can hear the sacrament of reconciliation (confession), during which God, through the agency of the priest, grants forgiveness for past sins. (funds p. 332) f) Describe empathetic statements • Desire to understand and be sensitive to feelings, beliefs and situation. o As the nurse, adaptation to different style, tone, vocabulary and behavior is important to create the best approach for each patients’ situation. • Place your-self in the patient situation. Think about “how would I want to be treated if it was me? This will help you: o Appreciate everyone uniqueness o Understand the needs (module 2, slide 13) g) Describe therapeutic communication • Client-centered communication directed to achieve the patients’ goal. • Has 5 key characteristics • Key skills to establish a therapeutic relationship, express interest, concern, caring perception, provide and obtain healthcare information (module 2, slide 12) h) How can communication be improved with a client wearing hearing aids? • Position yourself directly in front of the patient. • Ensure that you are not sitting or standing in front of a bright light or window, which can interfere with the patient's ability to see your lips move. • Make sure that the room is well lighted. • Get the patient's attention before you begin to speak. • Move closer to the better-hearing ear. • Speak clearly and slowly. • Do not shout (shouting often makes understanding more difficult). • Keep hands and other objects away from your mouth when talking to the patient. • Have conversations in a quiet room with minimal distractions. • Have the patient repeat your statements, not just indicate assent. • Rephrase sentences and repeat information to aid understanding. • Use appropriate hand motions. • Write messages on paper if the patient is able to read. (med surg p.999) • Remove distractions like turning off the television. i) Non-compliant clients- what are best responses by the nurse? Find out the reason why. Provide education. Document. j) How can a nurse best meet psychosocial needs for a client? • involve clients in daily care • Provide stimuli such as newspapers, TV, magazines • Assist with grooming and hygiene such as shaving and makeup • Involve the client in planning of daily routine • Maintain orientation to time such as a clock, and calendar 5. Immobility/mobility: Janett What exercises can improve mobility? Range of motion (Passive & Active) Weight baring exercise (page 208) Describe different types of passive range of motion exercises. (flexion, extension, abduction, adduction, circumduction, internal/external rotation, opposition) (page 506) Explain why certain medications place clients at risk for pressure ulcers. Some medications alter the blood flow. This causes less blood to go to pressure areas. May lead to necrosis. (page 81) What are the benefits of exercise? Bone reformation and growth, Cardiovascular health promotion, Promotes balance and stability, Reduce stress and increase energy levels, Improves pulmonary circulation, skeletal development, skin tone, Reduces systemic inflammation (page 187) What are the negative effects of immobility? Osteoarthritis, Rheumatoid Arthritis, Loss of muscle strength, Impaired balance, Altered join mobility, Decreased stability, Osteoporosis, Depression, isolation, anxiety, and mood change, Can cause decreased peristalsis, DVT(page 830) Interventions to reduce the risk of contractures Gently straighten out contracted extremity, fingers, Mobility-encouraging interventions such as passive ROM, and rotation. Flexion and extension exercises, These interventions should be performed about every 2hrs and as needed if the contractures are present (page 843) What are the effects of immobility on the respiratory system? Pulmonary embolisms, pneumonia. Decreased depth of respirations, decreased ability to cough, atelectasis (page 831) 6. Diseases that contribute to immobility: Janett Assessment of osteoarthritis. progressive deterioration & loss of cartilage & bone in one or more joints (crepitus), history (of join pain, pain management, history of joint injury, weight history, family history, affecting of the ADL’s), atrophy of skeletal muscle from disuse, limp, lab assessment (erythrocyte sedimentation rate, c-reactive protein) (page 306) Non-pharmacological interventions for rheumatoid arthritis. Adequate rest, proper positioning, heat/cold therapy, hypnosis, imagery, music therapy, adequate nutrition, gradual weight loss (page 323) Education of a client using a walker from a lying/sitting position. Feet firmly on the floor, one hand on the chair the other on the walker. Stand up slowly. (page 845) Education on reducing risk of osteoporosis. Prevent obesity, proper nutrition, avoid injuries, weight baring exercises, active live style, avoid staying (siting or laying) in one stop for too long, participate in ADLs (page 212). Know why these interventions are important. 7. Osteomyelitis(infection of the bone. Can be acute or chronic): Angela interventions in reducing infection: a) Proper dental care b) Maintaining clean & intact skin c) Proper hand hygiene d) Not leaving catheters in long tern e) Understanding who is at risk f) Using proper standard and contact precautions g) Reduce caffeine and stop smoking (Module 5 PPT; slide 49) Open fractures- interventions in reducing infection • Hand washing or strict infection control • Dressing changes with aseptic technique • Monitor vital signs especially temperature & HR • Administer broad spectrum antibiotics if ordered (Clindamycin & Gentamycin) • If irrigating open wound may be used using an antibiotic solution (Module 6 PPT; slide 23) • For chronic infections – adherence to antibiotic regimen Priorities in discharge instructions for osteomyelitis • 4-6 weeks of antibiotic therapy for acute osteomyelitis • May require wound irrigation & medicated beads that are directly in contact with the wound • May be in contact isolation precautions if area is draining copious amounts of drainage • Hyperbaric oxygen therapy (Module 5 PPT; slide 50) 8. Describe the following: Angela How does a nurse perform a neurovascular assessment? If negative findings occur, what should the nurse do next? Assessment of the extremities to evaluate sensory & motor function (neuro) & peripheral circulation (vascular). Components: (bilateral comparison) pulses, capillary refill, skin color, temperature, sensation, & motor function (movement). Pain & edema are also assessed. (5 P’s: Pain, Pulse, Pallor, Paresthesia, & Paralysis) A doppler is used to determine blood flow. (Module 5 PPT; slide 15) Negative findings: a. Assess BAC & provide as needed b. Expose the area of injury to assure accurate assessment c. Control any bleeding. Apply direct pressure to bleeding site or pressure artery above the fracture d. To prevent shock, position patient in a supine e. Splint the injury Manage pain with an opioid medication (Module 6 PPT; slide 15) What is the normal aging process for bones? It undergoes a continuous process of formation & resorption, or destruction, at equal rates until the age of 35 years. In later years, bone resorption increases, decreasing bone mass & predisposing patients to injury, especially older women.Osteopenia, less synovial joint cartilage, muscle atrophy(Medical-Surgical Nursing e-textbook; pg. 1005) What types of clients are at greatest risk for a DVT? • Decreased mobility or immobility • Older adults (40 years or older) • Family history or history of DVT, VTE, PE varicose veins, or edema • Oral contraceptives use • Smoking • Decreased cardiac output • Hip fracture or total hip or total knee surgery • Obesity • Cancer • Spinal cord injury • Heart disease (Medical-Surgical Nursing e-textbook; pg. 244, 1034) Prolonged bedrest can result in what types of physical issues? • Atrophy/muscle discomfort • pressure wounds/skin breakdown • immunosuppression (pneumonia) • DVT/damage to superficial nerves & blood vessels • Contractures Appropriate interventions of a client who is confused and at risk for falling. • Place client in a room close to the nurse’s station • Place client with a sitter • Orient client to room & surroundings & do not reposition furniture • Keep bed in lowest position • Remove rugs & keep floors clutter free • Use proper fitting non-skid footwear • Keep top 2 bed rails up; maximum 3 bed rails total • Keep call light within reach • Ensure proper lighting for patient to see at night 9. Orthopedics: Alicia a) Appropriate interventions for a patient with a cast with a negative assessment. • Teach patient and family to smell area for mustiness/unpleasant odor; teach to never put anything inside cast (hanger, pencil). Circulation: teach patient to assess for circulation at least daily, including the ability to move the area distal to the extremity, note numbness, increased pain. Pg. 1039 b) Halo traction and problems with infection. What are priority steps? • Follow hospital policy for pin site care which may specify use of solutions such as saline, and Vaseline dressings. Monitor vital signs for indications of possible infection, fever, purulent drainage from pin site. Send cultures prior to the start of an antibiotic. c) What are complications of hip surgery? • Blood clots, infection d) Describe stages of bone healing. • Stage 1: 24-72 hours after injury hematoma formation • Stage 2: 3 days-2 weeks granulation tissue invades hematoma forming fibrocartilage. • Stage 3: 3-6 weeks callus formation • Stage 4: 3-8 weeks callus is gradually reabsorbed and transformed into bone • Stage 5: 4-6 weeks to a year consolidation and remodeling of bone to continue to meet mechanical demands. Pg. 1032 e) Explain the purpose of traction • Application of a pulling force apart of the body to provide reduction alignment, rest, and is last resort to decrease muscle spasm and prevent/connect deformity and tissue damage. Pg. 1040 f) What is compartment syndrome? • Limb threatening complication caused by severe neurovascular impairment manifested by increasing alterations in levels of comfort (pain even after analgesics are given) and paresthesia (painful tingling and numbness). g) Education for an elderly client at risk for falls at home • Physical activity/exercise, weight bearing for bone strength • Home mods: handrails, slip-proof rugs, adequate lighting, avoid scatter rugs, slippery floors, clutter, encourage use of visual, hearing, ambulatory assistive devices. 10. Sensory: Claudia a) Orientation to a new room for a blind client (Exam 2 Review) i. Use clock wise or compass direction. ii. Ask the patient if describing the layout would help iii. Speak to patient in normal tone and normal voice b) Education for the reason that glaucoma is irreversible. i. Continued retinal hypoxia as result of glaucoma results in necrosis of photoreceptors and nerve fibers leading to permanent nerve damage. Meaning these nerves cannot be repaired and the damage that has been done is nonreversible. Additionally, extensive loss of photoreceptors and nerve fibers can result in permanent blindness. c) Education for a client with Meniere’s disease (pg. 995 med surg. Book) a. Meniere’s disease the excess endolymphatic fluid that distorts the entire b. Encourage patient to stop smoking because of blood-vessel constricting effect c. Teach patient to move head slowly to prevent worsening of vertigo d. Encourage nutritional and lifestyle changes (stop smoking), such as reducing sodium intake to help reduce excess retention of endolymphatic fluid, adhere to medications. d) Glaucoma (open and closed angle) which test determines the difference? i. Gonioscopy is used when IOP is high and can determine whether a patient has open or close angled glaucoma. A special lens eliminates the corneal curve and allows for visualization of where the iris meets the cornea. The procedure is painless. Or ultrasonic imaging. e) Describe symptoms of bilateral cataracts. (Module 7 Outline) a. Blurred/clouded vision b. Double vision c. Decreased color perception d. Problems with ADLs e. Decreased visual acuity, recent in prescription change f. Difficulty with night vision and sensitivity to light/glare g. Rate and development of cataracts vary in each eye h. May think glasses are smudged. i. Halos around objects f) Eye drops contain beta blockers (Timolol-used to treat glaucoma) What precautions need to be taken by the nurse when administering these drops? (pg. 978 of med surg. book) a. Nurse must monitor glucose levels and vital signs. If blood pressure or HR too low , hold medication. b. Additional side effects include hives, difficulty breathing, swelling of the face, lips, tongue, and/or throat. c. Nurse must assess airway and breathing and for signs of swelling of the face, lips, tongue and/or the throat. d. Ask whether the patient has moderate to severe asthma or COPD. If these drugs are absorbed systemically, they constrict the pulmonary smooth muscle and narrow airways. e. Warn the patients with diabetes to check their blood glucose levels more often with this medication. Induces hypoglycemia and can mask symptoms of hypoglycemia f. Teach patients who also take oral beta-blockers to check their pulse at least 2x daily and to notify a provider if their pulse is consistently below 58 beats/min. Timolol can cause an unsafe drop in pulse and BP. g) Explain myopia. (pg. 980 of med surg. Book) i. Myopia is a type of refractive error; Aka nearsightedness. The eye over refracts the light and bent images fall in front of, not on the retina causing far away objects to appear blurry. h) What is normal intra-ocular eye pressure (IOP)? 12-22mmHg i) What are medical terms to describe ringing in the ears? Tinnitus 11. Wounds: Yvette a) Be able to describe different types of incisions/wounds. Look at the terms primary, secondary, and tertiary intention • Surgical incisions • Burns • Lacerations • Pressure ulcers • Abrasions. b) Know appropriate nursing interventions. • Physical Assessment- Noticing signs and symptoms • Wound Care Assessment-Record the location and size of wound measuring length, width, and • Depth. • Change synthetic dressings when exudate cause the adhesive seal to break and leakage to occur. • Assessing for infection and inflammation- monitor for signs of infection (cellulitis, progressive increase in ulcer size and depth, change in exudate, signs of bacteria (fever, elevated WBC count). • Reducing mechanical forces- Obtain pressure reduction devices. Protects against the mechanical forces of pressure, sheer, friction. • Interpreting Lab values- Evaluate WBCs, prealbumin, and total protein levels. • Pain- medicate the client with pain medication for deep wounds such as tunneling. c) Client education for cellulitis • Take prescribed antibiotic until gone • Keep the infected area clean • Raise the infected area above the level of heart to keep swelling down. • Apply clean bandage as advised • Take temperature once a day • Wash your hands often to prevent spreading the infection • Advise how to apply cool compress for discomfort alternating with warm and moist compress. d) Appropriate diet for a client with a healing wound • Well-balanced diet, emphasizing protein, • Vegetables, fruits, whole grains and vitamins. Increase caloric intake. e) Priority actions with wound assessment pg. 456 • Identify reason for impaired skin integrity. • Assess the wound: location, size, color, extent of tissue involvement, wound base and margins, exudate, condition of surrounding tissue. • Presence of foreign body. • pain level • Nutritional status f) Be able to stage wounds (I, II, III, IV)Please review notes • Hemostasis- clothing • Inflammatory Phase- Cleaning • Proliferative phase- granulation • Maturation phase- scar g) Understand causes for pressure ulcers. Explain how aging can play a part of a compromised state. • Loss of tissue integrity caused by compression of skin between bony prominences and external • Surface. Pressure results in decreased tissue perfusion, hypoxemia, tissue ischemia and cellular • Death. a) Aging can play a part by decrease in skin integrity: decreased dermal flow, dermal thickness, b) Lack of proper diet, malnutrition, and dehydration – not enough nutrients and essential vitamins and minerals. c) Immobility 12. Infection: Andrea a) Define different types of infection: nosocomial or opportunistic (Med-surg pg. 338) • Nosocomial-hospital-acquired infection • Opportunistic- caused by organisms that are present as part of the body's microbiome and usually are kept in check by normal IMMUNITY b) Articulate typical assessment findings for a client with an infection. (Fundamentals pg. 529) • Observe the patient’s general appearance: Does he seem fatigued? Is he diaphoretic? Is he wrapped in blankets or complaining of feeling chilled? Does the patient appear well nourished? Are the mucous membranes dry? Does the skin have normal elasticity (turgor)? Physical assessment includes a thorough examination of the skin. Look for signs of local infection evidenced by pain, redness, swelling, and warmth. Note the presence or absence of any rashes, along with any breaks or reddened areas of the skin. Patients with poor peripheral circulation often have various skin discolorations, rather than signs of inflammation, when experiencing an infection. Swollen lymph nodes indicate the possible presence of an infection in the area that drains into the nodes. Elevated temperature and pulse rate are classic signs of an infection. c) Appropriate nursing interventions for a client with a lowered immunity. (Fundamentals pg. 530) • Reduce exposure to pathogens through the use of aseptic technique • Maintain skin integrity and support natural defenses against infection. • Reduce stress. • Promote immune function through collaborative care. • Provide supportive measures to decrease the length of time that invasive devices, such as intravenous lines and urinary catheters, are needed by a patient • For clients who have had surgery and general anesthesia or who are at risk for pneumonia, promote coughing and deep breathing on a regular basis. • For clients being mechanically ventilated, provide special oral care designed to prevent ventilator-associated pneumonia. • For older adults, especially those who or frail or in a debilitated state and those living in a group residence, encourage immunizations that can help them to acquire immunity from some communicable diseases, such as influenza. • For clients who have breaks in the skin or incision sites, provide regular assessment for infection status and follow appropriate medical or surgical asepsis guidelines. • For all clients at risk for infection, provide care that is based on principles of medical asepsis d) Explain the differences between acquired, adaptive, innate, and specific immunity (Med-surg pg. 298) • Acquired- antibody-mediated immunity, acquired by infection (active) or by the transfer of antibody or lymphocytes from an immune donor (passive) • Adaptive- a person's body learns to make as an adaptive response to invasion by organisms or foreign proteins, occurs either naturally or artificially through lymphocyte responses and can be either active or passive. • Innate-nonspecific defense mechanisms that come into play immediately or within hours of an antigen's appearance in the body, already present in the body • Specific- acquired during the organism's lifetime and involves the activation of white blood cells (B and T lymphocytes), which distinguish and react to foreign substances. B lymphocytes (or B cells) operate by producing antibodies, proteins that neutralize foreign molecules e) Be explain the meaning of “highly virulent” Virulence: power of the agent to cause a disease f) Appropriate PPE for MRSA (Fundamentals pg. 1628) • Gloves and gown g) Proper education for reducing the spread of chicken pox. (Med-surg pg. 418) • Private room required with monitored negative airflow (with appropriate number of air exchanges and air discharge to outside or through HEPA filter); keep door(s) closed • Special respiratory protection: • Wear PAPR for known or suspected TB • Susceptible people not to enter room of patient with known or suspected measles or varicella unless immune caregivers are not available • Susceptible people who must enter room must wear PAPR or N95 HEPA filter* • Transport: patient to leave room only for essential clinical reasons, wearing surgical mask • Wiping any objects or surfaces with a sterilizing solution and making sure that any infected clothing or bedding is washed regularly • Vaccination 13. Connective Tissue Disorders: Mindy Explain the typical assessment findings of scleroderma/lupus p.329 Physical assessment: • Alopecia • Mouth ulcers • Polyarthritis • Hardened skin- scleroderma Symptoms and signs: • Inflamed red rash across the nose (butterfly rash) • Nephritis • Pericarditis • Raynaud’s phenomenon • Pleural effusions • Pneumonia • Abdominal pain • Join inflammation • Fever • Fatigue • Anorexia • Weight loss • Generalized weakness Lab assessment • Same as for RA • Other test • Anti-SS-a • Anti-SS-b • Anti-smith • Anti-DNA and extractable nuclear antigens • CBC Psychosocial assessment • Altered body image • Decreased activity-social isolation • Assess support system Education for a client who has scleroderma receiving an organ transplant should take what precautions? P.328 • Teach patients that the drug increases their risk for serious infections. • Teach them not to receive live vaccines for 30 days before treatment. • Do not receive live flowers, do not visit ill people, wear a mask when visiting others Nursing education for a client with lupus experiencing Raynaud’s phenomenon. P.329, 330 Raynaud's phenomenon occurs in various degrees in most patients with Systemic sclerosis (SSc). On exposure to cold or emotional stress, the small arterioles in the digits of both hands and feet rapidly constrict, which causes decreased blood flow. Education for client with lupus: • Remind unlicensed nursing personnel to use a bed cradle and foot board to keep bed covers away from the skin in severe cases. • Adjust the room temperature to prevent chilling, which can precipitate digit vasospasm. • The patient who can tolerate touching the affected areas can wear gloves and socks to increase warmth. • Because cigarette smoking and extreme emotional stress can also cause symptoms to recur, teach the patient to avoid or minimize these factors as much as possible. Nursing interventions for a client with fibromyalgia, p.333 • Recognize that patients with fibromyalgia syndrome (FMS) are often frustrated because they have not been diagnosed or have been misdiagnosed. Therefore, inform them about the National Fibromyalgia Association for additional information and patient and family support. • Teach the patient that these drugs can cause drowsiness and sleepiness and that alcohol should be avoided while taking them. • Promote comfort with help of NSAID and physical therapy • Encourage at home low impact exercise such as walking, swimming, rowing, biking, and water exercise. Help establish regular sleep patterns. Client education at home for Rheumatoid arthritis, p.324 • Balance activity with rest. • Take one or two naps each day. • Pace yourself; do not plan too much for one day. • Set priorities. Determine which activities are most important and do them first. • Delegate responsibilities and tasks to your family and friends. • Plan ahead to prevent last-minute rushing and stress. • Learn your own activity tolerance and do not exceed it. • Use of assistive devices such as grab bars. Elevate lab values for Rheumatoid arthritis, p.320 • Rheumatoid factor: Positive or increase indicative of possible RA or other CTD; may also be elevated in leukemia, liver disease, and kidney disease • ANA: Elevations common in SLE, SSc, RA, and other inflammatory CTDs (5% of healthy adults have positive ANA results) • Erythrocyte sedimentation rate (ESR): Increased in inflammatory diseases such as RA, SLE, PMR, temporal arteritis; also elevated in patients with bacterial infections or severe anemias • Alpha1 globulin: (>0.3 g/dL; >3 g/L) Increased level possible in RA What is CREST syndrome? P.328 Cutaneous form of systemic scleroderma. Patients with the limited form of the disease often have the CREST syndrome: • Calcinosis (calcium deposits) • Raynaud's phenomenon (first symptom that occurs) • Esophageal dysmotility • Sclerodactyly (scleroderma of the digits) • Telangiectasia (spider-like hemangiomas) – bilateral carpal tunnel [Show More]

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