NUR 265 EXAM 4
1. Lupus: Hallmark sign: butterfly rash on face
2. Lupus: Indication of flare: Fever and fatigue
*also assess BUN function
*c reactive protein remains normal
3. Lupus: Interventions: -Falls precautions
-treat pain with tylenol and NSAIDS (monitor kidney function)
-AVOID SUNLIGHT
-REPORT FLARE IMMEDIATELY
-clean skin with mild soap and pat dry and apply lotion
4. Lupus: medical management: -hydroxychloroquine(anti-malarial) decreases
absorption of UV light
5. Scleroderma: inflammatory, autoimmune connective tissue disease
6. Scleroderma: Hallmark Sign: Hard, leather-like edematous skin
Late: esophageal dysmotility
7. Scleroderma: Assess: Swallow safety--esophageal dysmotility (ASPIRATION) O2
circulation
skin
8. Scleroderma: Interventions: aspiration precautions (keep HOB at 60 degrees during
meals and after) skin protection measures
small frequent meals--avoid caffeine and alcohol
-avoid spices, caffeine and pepper
, .
9. fibromyalgia: S/sx: extreme fatigure GI symptoms dysuria blurred vision
forgetfulness
10. fibromyalgia: Assess: pain level
extreme
fatigue GI
symptoms
11.Fibromyal
gia:
Interventions
: NSAIDS
Nuerontin (gabapentin)
Lyrica (pregabalin)
SNRI and tricyclic antidepressants (amitriptyline)
promote sleep and low impact exercise (stretching, walking, swimming, rowing, water
exercise)
12. Lyme Disease: Hallmark sign: stage 1: "bulls eye rash" and flu-like symptoms
Stage 2: facial paralysis, carditis, meningitis
13. Lyme Disease: Assess: Skin
history of tick bites
14. Lyme Disease: Interventions: prevention!
Insect repellant with DEET
early stage--doxycycline
antibiotics ORAL late stage--Iv
antibiotics (ceftriaxone) avoid
tall grass
, .
wear light colored
clothing have pets wear
tick collars
15. Allergic Reaction Priority: STOP THE INFUSION/ELIMINATE the trigger, then STOP
the immune response
Give Epi
maintain
airway
16. Latex allergy: risks: -frequent use of latex condoms
-healthcare workers
-allergy to avocados, bananas, and some nuts
17. Anaphylactic shock: AIRWAY--give epi IV or IM STAT and intubate if needed
BREATHING--apply O2; mechanically ventilate
CIRCULATION--monitor for distributive shock; give fluids
18. Epinephrine Auto-injector teaching: always carry 2 devices
inject by "stabbing" into top of thigh with pants on
(AVOID pockets) call 911 immediately--patient still
needs to be monitored keep epi in cool dark place.
19 Immunocompromised Patient: -Do not drink anything that has been sitting out
-take temp at least once per day
-clean toothbrush once weekly in diswasher or bleach solution
-do not eat raw foods; salad, cottage cheese
-do not scoop litter boxes
-no plants or soil exposure
-antibacterial soap
1. Lupus: Hallmark sign: butterfly rash on face
2. Lupus: Indication of flare: Fever and fatigue
*also assess BUN function
*c reactive protein remains normal
3. Lupus: Interventions: -Falls precautions
-treat pain with tylenol and NSAIDS (monitor kidney function)
-AVOID SUNLIGHT
-REPORT FLARE IMMEDIATELY
-clean skin with mild soap and pat dry and apply lotion
4. Lupus: medical management: -hydroxychloroquine(anti-malarial) decreases
absorption of UV light
5. Scleroderma: inflammatory, autoimmune connective tissue disease
6. Scleroderma: Hallmark Sign: Hard, leather-like edematous skin
Late: esophageal dysmotility
7. Scleroderma: Assess: Swallow safety--esophageal dysmotility (ASPIRATION) O2
circulation
skin
8. Scleroderma: Interventions: aspiration precautions (keep HOB at 60 degrees during
meals and after) skin protection measures
small frequent meals--avoid caffeine and alcohol
-avoid spices, caffeine and pepper
, .
9. fibromyalgia: S/sx: extreme fatigure GI symptoms dysuria blurred vision
forgetfulness
10. fibromyalgia: Assess: pain level
extreme
fatigue GI
symptoms
11.Fibromyal
gia:
Interventions
: NSAIDS
Nuerontin (gabapentin)
Lyrica (pregabalin)
SNRI and tricyclic antidepressants (amitriptyline)
promote sleep and low impact exercise (stretching, walking, swimming, rowing, water
exercise)
12. Lyme Disease: Hallmark sign: stage 1: "bulls eye rash" and flu-like symptoms
Stage 2: facial paralysis, carditis, meningitis
13. Lyme Disease: Assess: Skin
history of tick bites
14. Lyme Disease: Interventions: prevention!
Insect repellant with DEET
early stage--doxycycline
antibiotics ORAL late stage--Iv
antibiotics (ceftriaxone) avoid
tall grass
, .
wear light colored
clothing have pets wear
tick collars
15. Allergic Reaction Priority: STOP THE INFUSION/ELIMINATE the trigger, then STOP
the immune response
Give Epi
maintain
airway
16. Latex allergy: risks: -frequent use of latex condoms
-healthcare workers
-allergy to avocados, bananas, and some nuts
17. Anaphylactic shock: AIRWAY--give epi IV or IM STAT and intubate if needed
BREATHING--apply O2; mechanically ventilate
CIRCULATION--monitor for distributive shock; give fluids
18. Epinephrine Auto-injector teaching: always carry 2 devices
inject by "stabbing" into top of thigh with pants on
(AVOID pockets) call 911 immediately--patient still
needs to be monitored keep epi in cool dark place.
19 Immunocompromised Patient: -Do not drink anything that has been sitting out
-take temp at least once per day
-clean toothbrush once weekly in diswasher or bleach solution
-do not eat raw foods; salad, cottage cheese
-do not scoop litter boxes
-no plants or soil exposure
-antibacterial soap
