NSG 233 HESI FINAL STUDY MATERIAL
Spinal cord injury assessments:
Loss of motor and sensory function below level of injury
Spinal shock
Postural hypotension
Alteration in thermoregulation
Circulatory problems/edema
Rate: Depends
Rhythm: Irregular
P-wave: None
PR interval: None
QRS: Wide and bizarre
Cause: stimulants, sepsis, stress
S/S: skipped beat, pounding, quickening, pulse deficit, possible hypotension
Interventions: Treat cause, digoxin (discontinue/adjust), correct electrolytes,
drugs (procainamide, lidocaine, amiodarone)
PVCs (Premature ventricular contractions)
HIV CD4 count pathology: HIV replicates inside the body by hijacking or
taking over & killing the;CD4+ cells;(T helper cells). These cells are vital in
fighting off infections & diseases. Since HIV cannot reproduce on its own, it
attaches itself to these T-helper cells & fuses together with it becoming one.
HIV is a retrovirus which carry their genetic material in the form of RNA
rather than DNA.
Stage 1: HIV primary infection -;Dramatic drops of CD4;counts
Stage 2: AIDS -;CD4 count drops below 200
Carbon monoxide poisoning: O2 is replaced by CO which binds easily to Hgb,
resulting in severe hypoxia leading to death
Cause: Inhaled car toxins, stoves/fuel burning like wood (poor ventilated
areas)
S/S: vague, headache, dizziness, dyspnea, nausea, pulse ox not accurate
(false reading of high spO2)
Intervention: 100% O2 non-rebreather mask, flow rate 15 L/min
, Lead poisoning:
Patho: Toxic levels of lead build up in the blood stream; children <6 y/o at
most risk
Risk factors: lead-based paint in houses before 1970s, drinking from lead
pipes
S/S:;Neurocognitive impairment;- mild (hyperactive, impulsive), moderate
(learning disabilities, vision/hearing), severe (seizures, death),;anemia,
weight loss, sluggishness, fatigue
Education: follow-up blood tests for lead level, home inspection for lead
source, wash child's hands often (before meals)
Treatment:;Chelated therapy (activated charcoal, EDTA injection)
AIDS dementia:
AKA HIV encephalopathy;
A clinical syndrome characterized by a progressive decline in cognitive,
behavioral, and motor functions (i.e.;a;change in writing)
Heat stroke:
Prolonged exposure to the sun or a high environmental temperature
overwhelms the body's heat-loss mechanisms.;
S/S: giddiness, excessive thirst, and nausea,;increased heart rate
(HR), tachypnea, hypotension&
Interventions: Lie flat with legs elevated, cooling blankets, cool bath,
ice to groin/neck/axillae
Alcoholic - CAGE
CAGE - Cut, Annoyed, Guilty, Eye-opener
C - If client has thought about cutting down on drinking (C in CAGE)
A - Have people annoyed you by criticizing your drinking?
G - Have you ever felt bad or guilty about your drinking?
E - Have you ever had a drink first thing in the morning to steady your
nerves or get rid of a hangover (eye-opener)?
Alcoholic first assessment:
Psychosocial assessments: escape from problems, cover up depression
& anxiety, goal of counseling is to identify triggers
Withdrawal S/S: 24 hrs (anxiety, insomnia, palpitations), 48 hrs
(seizures, unstable VS), 48-72 hrs (delirium tremens, hand tremors,
sweating, hallucinations, increased VS, agitated, restless, seizures)
Teaching: accountability, coping, self-help/motivation
Interventions: monitor blood glucose, benzos, barbiturates, seizure
precautions
Hemorrhage - shock
Spinal cord injury assessments:
Loss of motor and sensory function below level of injury
Spinal shock
Postural hypotension
Alteration in thermoregulation
Circulatory problems/edema
Rate: Depends
Rhythm: Irregular
P-wave: None
PR interval: None
QRS: Wide and bizarre
Cause: stimulants, sepsis, stress
S/S: skipped beat, pounding, quickening, pulse deficit, possible hypotension
Interventions: Treat cause, digoxin (discontinue/adjust), correct electrolytes,
drugs (procainamide, lidocaine, amiodarone)
PVCs (Premature ventricular contractions)
HIV CD4 count pathology: HIV replicates inside the body by hijacking or
taking over & killing the;CD4+ cells;(T helper cells). These cells are vital in
fighting off infections & diseases. Since HIV cannot reproduce on its own, it
attaches itself to these T-helper cells & fuses together with it becoming one.
HIV is a retrovirus which carry their genetic material in the form of RNA
rather than DNA.
Stage 1: HIV primary infection -;Dramatic drops of CD4;counts
Stage 2: AIDS -;CD4 count drops below 200
Carbon monoxide poisoning: O2 is replaced by CO which binds easily to Hgb,
resulting in severe hypoxia leading to death
Cause: Inhaled car toxins, stoves/fuel burning like wood (poor ventilated
areas)
S/S: vague, headache, dizziness, dyspnea, nausea, pulse ox not accurate
(false reading of high spO2)
Intervention: 100% O2 non-rebreather mask, flow rate 15 L/min
, Lead poisoning:
Patho: Toxic levels of lead build up in the blood stream; children <6 y/o at
most risk
Risk factors: lead-based paint in houses before 1970s, drinking from lead
pipes
S/S:;Neurocognitive impairment;- mild (hyperactive, impulsive), moderate
(learning disabilities, vision/hearing), severe (seizures, death),;anemia,
weight loss, sluggishness, fatigue
Education: follow-up blood tests for lead level, home inspection for lead
source, wash child's hands often (before meals)
Treatment:;Chelated therapy (activated charcoal, EDTA injection)
AIDS dementia:
AKA HIV encephalopathy;
A clinical syndrome characterized by a progressive decline in cognitive,
behavioral, and motor functions (i.e.;a;change in writing)
Heat stroke:
Prolonged exposure to the sun or a high environmental temperature
overwhelms the body's heat-loss mechanisms.;
S/S: giddiness, excessive thirst, and nausea,;increased heart rate
(HR), tachypnea, hypotension&
Interventions: Lie flat with legs elevated, cooling blankets, cool bath,
ice to groin/neck/axillae
Alcoholic - CAGE
CAGE - Cut, Annoyed, Guilty, Eye-opener
C - If client has thought about cutting down on drinking (C in CAGE)
A - Have people annoyed you by criticizing your drinking?
G - Have you ever felt bad or guilty about your drinking?
E - Have you ever had a drink first thing in the morning to steady your
nerves or get rid of a hangover (eye-opener)?
Alcoholic first assessment:
Psychosocial assessments: escape from problems, cover up depression
& anxiety, goal of counseling is to identify triggers
Withdrawal S/S: 24 hrs (anxiety, insomnia, palpitations), 48 hrs
(seizures, unstable VS), 48-72 hrs (delirium tremens, hand tremors,
sweating, hallucinations, increased VS, agitated, restless, seizures)
Teaching: accountability, coping, self-help/motivation
Interventions: monitor blood glucose, benzos, barbiturates, seizure
precautions
Hemorrhage - shock
