MDC 1 FINAL EXAM (Spring 2023)

MDC 1 FINAL EXAM (Spring 2023) - Temp/warmth - Low/High CBC - Increased HR - Low BP - Increased respiratory rate - Redness Infection S/S - Rotate patient every 2 hours - Reposition - Padding - PROM - Barrier cream - Keep dry - Move using a lifting device Nursing interventions to decrease risk of pressure injuries CD4 will be lower not less than 200 CD8 will be normal HIV labs CD4 will be less than 200 CD8 will be increased. AIDS labs - Prevents the virus from multiplying, which reduces the amount of HIV in the body. This gives the immune system a chance to produce more CD4 cells. Antiretroviral drugs No pain associated. Cloudy/blurry vision Cataracts - Pain associated. Increased intraocular pressure. Nerve fibers will become damaged and is permanent. Glaucoma - PQRST - Therapeutic communication - Nonverbal signs: grimacing, holding pain site, restless - Vital signs: Everything is elevated/increased Pain assessment Diet for wound healing Proteins - A chronic, progressive, systemic, inflammatory autoimmune disease process that primarily affects the synovial joints; one of the most common connective tissue diseases and the most destructive to the joints RA - Bilateral pain. - Lab: elevated sed rate - Diagnostic test: Go in with a needle and aspirate synovial fluid to look at WBC to see if it's cloudy. RA - If they have a positive ----- -----it does not mean they have RA. Can indicate autoimmune disorders. RF measures the presence of unusual antibodies of the immunoglobulins G (IgG) and M (IgM) types that develop in a number of connective tissue diseases RF - Pale/blue discoloration of the nailbeds. Hands are cold. Raynaud's Phenomenon Painful vasospasms of arteries and arterioles in extremities, especially digits; causes red-white-blue skin color changes on exposure to cold or stress; cause unknown, occurs more in women, and may be autoimmune because it is associated with many rheumatic diseases Raynaud's phenomenon - Contractures, stiffness, osteoporosis, Sjogren syndrome, carpal tunnel, pain, fibromyalgia, swan neck of fingers, infections Complications of RA black, thick, can't get off Eschar - yellow and stringy. Can get off Slough Stage ? : - red and doesn't blanch Stage 1 Stage ? : Shallow and open. Can appear as a blister Stage 2 Stage ? : Deep and goes to the subcutaneous tissue and does not show bone, muscle, or tendon Stage 3 Stage ? : Does show bone, muscle, or tendon Stage 4 Stage ? : Can't see underneath necrotic tissue Unstageable Fractures: - Open fracture - Fixation device High risk for infection Cast: Hot spots may indicate Compartment syndrome condition in which increased tissue pressure in a confined anatomic space causes decreased blood flow to the area, leading to hypoxia and pain. Compartment syndrome Too much edema. Fasciotomy can treat ________ Compartment syndrome - 104 or above. Ice packs underneath the armpit or groin area, take off extra clothing Hyperthermia 96.5 or below. Get extra blankets Hypothermia The wound separates but does not go through the visceral layer Dehiscence - Does go through the visceral layer and organs are hanging out. Saline soak, gauze, or towels Evisceration Abnormal connection between two organs Fistula - S/S of scleroderma CREST syndrome - Calcium deposits, Raynauds, Esophageal dysmotility, Sclerodactyly, and Telangiectasia CREST syndrome - Butterfly rash - Risk for infection with flare ups - Wash your hands to prevent infection - Fatigue - Joint pain - Fever Lupus S/S - Primary defense of infection is skin Response to infection: fever Defenses against infection - Steroid ointment, avoid the sun, alcohol wipes (do not use) Psoriasis - Washing hands, PPE (gown and gloves), antibacterial soap, washing hands between dressing changes Avoid spread of MRSA - Body is susceptible to it. Weakened immune system and it destroys WBC's that fight them AIDs - Pale, cool, cap refill greater than 3 seconds, purple/blue nailbeds Inadequate perfusion Medication to decrease inflammation NSAIDs - Face the client and talk slowly and clearly Communication with hearing impaired clients First phase of wound healing Hemostasis Inflammatory phase. Typically lasts 3-5 days Second phase of wound healing - Proliferation phase. Healthy tissue starts regenerating Third stage of wound healing - Maturation phase. The scar forms.