Galen College of Nursing
Nur265 Advanced Medsurg
Exam 4 (Unit 9 Ch 18, 17, 27, 32, 53, 63, 62 Unit 10 Ch 19, 20, 8 Unit11/12 Ch 10, 11, 12)
Medical Surgical Nursing: Ignatavicius, Workman, Rebar, Heimgarterner 10th edition
Prof Angoma
-Anaphylactic shock=(type 1) severe allergic reaction (hypotension and broncho constriction) effects ABC +hives; histamine released
S/S- Hives, Dyspnea, low BP, red edema, angioedema, erthymia, bronchospasm, stridor, Cyanosis, wheezing,
Treatment- epinephrine (vasopressor) ( epi-pen ) no skin prep; outer thigh hold for 10secs (repeat every 5-15mins if S/S
not going away ; give til S/S go away,
Epinephrine expected Side effects = tachycardia, palpitations, Dizzy
Meds: Epinephrine, Diphenhydramine, albuterol, steroids
Teaching- inject outer thigh 90 degree angle, hold 10 secs, go to hospital (epi wears off 10-15 secs) store at dark room @
room temp
Risk factors = may also be allergic to kiwi, banana, pineapple, tropical fruits, grape, avocado, potatoes, hazelnuts, water
chestnuts, spina bifida, peanut=====Latex allergy related to peanut and Bannas allergy
Page 351 Emergency Care for pt w/ anaphylaxis= immediately assess resp status, airway, o2 stat of pats who show symptoms of
allergic reaction; call rapid response, have intubation and trach equipment ready; apply O2 using high flow, non rebreather mask @
90% -100%; immediately discontinue IV drug of pt having anaphylactic reaction to that drug. Do not remove IV ; remove IV tubing
and hang normal saline; prepare epinephrine IM . Repeat drug as needed every 5-15mins until pt responds; keep HOB elevated 10
degrees if hypotension is present; if BP is normal HOB 45 degrees or higher to improve ventilation; raise feet and legs; stay with
patient; reassure patient that appropriate interventions are being instituted.
1. S/S of anaphylaxis
a. Widespread hives, hypoxia, angioedema, bronchospasm, stridor, cyanosis, wheezing, hypotension
2. Pt receives new medication within 5 mins pt develops swelling of eyes, anxious SOB, and dizzy. Priority nursing action
a. Respiratory assessment
3. Pt received IV med and reports feeling anxious, SOB, Dizzy and wheezing expected nursing interventions
a. Assess RR, O2 with non-rebreather, IM epinephrine, get crash cart, intubation tray available
____________________________________________________________________________________________________________
Lyme disease= infection caused by spirochete Borrelia Burgdorferi.“ pt went camping”
Cause- Spirochete Borrelia Burgdorferi; TICK BITE
S/S - Bulls eye aka erythema migrans , pain, stiffness in muscles and joints pain, flu like symptoms;
Report to HCP =neck stiffness = brain involvement
Treatment- antibiotics immediately
Meds- doxycycline, amoxicillin, erythromycin ( if allergy to penicillin)
Teaching- Avoid woods, wear insect repellant w/deet, wear long sleeves, long pants; avoid darker clothing, wear lighter (can
see ticks better)remove tick w/ tweezer + use antiseptic, wait 4-6weeks for dorf testing; shower after going into the woods;
If neck stiffness = REPORT
Page 360= Prevention & early detection of Lyme disease= Avoid wooded area, avoid thick underbrush areas ( especially in spring
and summer; walk incenter of trail; avoid dark clothing; light colored spots ticks easier, use insect repellant on skin and clothes; wear
long sleeve tops, tuck shirt into pants; tuck pants into socks; wear closed toe shoes/ boots, hats/ cap; bathe immediately after going
into woods; inspect body for ticks; check pets for ticks; gently remove ticks w/ tweezer or finger covered w/ tissue or glove. Dispose
of tick into toilet. DO NOT burn tick off. After removal clean tick area w/ alcohol, antiseptic ( alcohol); wait 4-6weeks after being
bitten to test for Lyme disease ( testing before is not reliable); REPORT S/S of rash or influenza like illness to HCP immediately
_______________________________________________________________________________________________
HIV- NO cure; HIV cells take over T cells ( which fight infection); dormant weeks/months;
Transmission- Sexual= bodily fluid, semen, vag secretions, prenatal (breast milk),Parenteral;blood, needles
Viral load Labs- Viral load (highest first 2-4weeks of transmission);
Test = Elisa test- (tests for antibodies for HIV); Western Blot, immunoassay screening, Viral load test ; Perinatal breast feeding
,vag birth ( C-section recommended)
a.-w/ Elisa test false neg = low antibodies (window); False positive= mothers, iv drug users, hx malaria
b. Western blot more accurate= confirmation test
1
, c. Viral load test= Maintenace test during treatment (if high most infectious)
Labs- CD4 normal=800-1000 ; CD4 over 200 = HIV (CD4 below 200= AIDS) and viral load, normal Tcells=800-1000
Early S/S - flu like systems, muscles aches, fever, night sweats (TB), rash, sore throat, chills
Education- Prevention= Abstinence, Be faithful, Condoms, Do NOT share needles; if pt does not adhere to regimen drug
resistance can occur; NO live vaccines ;
Meds- HAART therapy= highly active anti-retroviral therapy (stop virus from replicating DOES NOT kill virus); vitamins,
minerals
AIDS- viral disease caused by HIV destroys T cells ; increases suitability to infection; Chronic
Dx= + for HIV, Elisa test; western blot
Labs= CD4 below 200
S/S= weight loss, fever, anorexia, opportunistic infection, viral infection (herpes), Kaposi sarcoma
1. Pt with Aids presents with chest pain, SOB, productive cough, reports night sweats. Airborne precaution have been initiated . What is nursing intervention
a. assesses for fever, weight loss, anorexia, opportunistic infection
2. Pt with HIV oral care to delegate to AP
A. Offer oral rinses of Na bicarb w/ normal saline several times a day; soft toothbrush, drink plenty of fluids; if oral pain avoid alcohol based
mouth wash, inspect mouth every 8hrs
3.Priority Nursing Dx-
a. ineffective breathing pattern related to opportunistic infection
Page 336 Patient education prevent infection= When WBC are low>>>>avoid crowds, large gatherings, do NOT share personal
items toothpaste, toothpaste, wash clothes, deodorant sticks; bathe daily with antimicrobial soap; if bath not possible wash
armpits , groin , genitals and anal area 2x a day with antimicrobial soap; clean toothbrush weekly thru dishwasher, or rinse in
laundry bleach (then rinse out with warm water); wash hands w/ antimicrobial soap before eating and drinking, after touching pet,
shaking hands; wash hands after outings and after using restroom; avoid eating undercooked meat, fish , eggs; wash dishes between
use w/ hot sudsy water or dishwasher; Do NOT change litter if possible; if unavoidable use gloves and wash hands immediately;
Avoid reptiles as pets( turtles, snakes); Do not feed pets raw or undercooked meats; Take all rx meds; do NOT dig in garden or work
with houseplants; void travel to area with poor sanitation or primitive health cares facilities. take temp once a day and whenever
not feeling well.
Report any signs of infection to Dr> temp greater than 100; persistent cough w/ or without sputum; put or foul-smelling drainage
from any open skin area or normal body opening; presence of boils or abscesses; urine that is cloudy, foul smelling or burning during
urination
Page 337 Care of Patient w/ reduced immunity= place patient in private room whenever possible; use good handwashing technique
or alcohol based hand rubs before touching pt or any of their belongings. Ensure pt room & bathroom are cleaned at least once each
day. Do not use supplies from common areas ( disposable gloves for their room only, individually wrapped food); limit personnel
entering room; monitor VS temp every 4hrs; inspect mouth and skin ( anal area); for fissures, abscesses every 8hrs; inspect open
areas IV sites every 4hrs for signs of infection; change wound dressing gauze everyday; obtain specimen of all suspicious areas for
culture and notify PCP; help pt perform coughing and deep breathing exercises; keep frequently used equipment in room for use
with this pt only ( bp cuff, stethoscope, thermometer); limit visitors to healthy adults; use strict aseptic technique for all invasive
procedures. do not drink standing water (any amt of hours), no live vaccines
-Antiviral drugs DO NOT KILL virus; it does control viral replication; PT must take drugs correctly 90% of the time making sure that 9
out of 10 doses are taking on time and correctly.
====================================================================
Page 332 Optimistic infections=
A. PJP aka Pnuemocytis Jirovec pneumonia S/S- SOB, dyspnea, tachypnea, dry persistent cough, low grade fever, dry non –
productive cough, fatigue, breath sounds w/ crackles, weightless
Teach- rest, drink plenty of fluids
Nurse =NO mask needed for these symptoms
1. Client w/ Aids dx PJP nursing interventions
A. Room door closed at all times, high carb, high protein diet, stay hydrated 2-3L daily, no mask needed on nurse
2. Expected S/S of PJP
A. SOB, tachypnea, dry non productive cough, fever. No mask needed for pt or nurse..
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2
Nur265 Advanced Medsurg
Exam 4 (Unit 9 Ch 18, 17, 27, 32, 53, 63, 62 Unit 10 Ch 19, 20, 8 Unit11/12 Ch 10, 11, 12)
Medical Surgical Nursing: Ignatavicius, Workman, Rebar, Heimgarterner 10th edition
Prof Angoma
-Anaphylactic shock=(type 1) severe allergic reaction (hypotension and broncho constriction) effects ABC +hives; histamine released
S/S- Hives, Dyspnea, low BP, red edema, angioedema, erthymia, bronchospasm, stridor, Cyanosis, wheezing,
Treatment- epinephrine (vasopressor) ( epi-pen ) no skin prep; outer thigh hold for 10secs (repeat every 5-15mins if S/S
not going away ; give til S/S go away,
Epinephrine expected Side effects = tachycardia, palpitations, Dizzy
Meds: Epinephrine, Diphenhydramine, albuterol, steroids
Teaching- inject outer thigh 90 degree angle, hold 10 secs, go to hospital (epi wears off 10-15 secs) store at dark room @
room temp
Risk factors = may also be allergic to kiwi, banana, pineapple, tropical fruits, grape, avocado, potatoes, hazelnuts, water
chestnuts, spina bifida, peanut=====Latex allergy related to peanut and Bannas allergy
Page 351 Emergency Care for pt w/ anaphylaxis= immediately assess resp status, airway, o2 stat of pats who show symptoms of
allergic reaction; call rapid response, have intubation and trach equipment ready; apply O2 using high flow, non rebreather mask @
90% -100%; immediately discontinue IV drug of pt having anaphylactic reaction to that drug. Do not remove IV ; remove IV tubing
and hang normal saline; prepare epinephrine IM . Repeat drug as needed every 5-15mins until pt responds; keep HOB elevated 10
degrees if hypotension is present; if BP is normal HOB 45 degrees or higher to improve ventilation; raise feet and legs; stay with
patient; reassure patient that appropriate interventions are being instituted.
1. S/S of anaphylaxis
a. Widespread hives, hypoxia, angioedema, bronchospasm, stridor, cyanosis, wheezing, hypotension
2. Pt receives new medication within 5 mins pt develops swelling of eyes, anxious SOB, and dizzy. Priority nursing action
a. Respiratory assessment
3. Pt received IV med and reports feeling anxious, SOB, Dizzy and wheezing expected nursing interventions
a. Assess RR, O2 with non-rebreather, IM epinephrine, get crash cart, intubation tray available
____________________________________________________________________________________________________________
Lyme disease= infection caused by spirochete Borrelia Burgdorferi.“ pt went camping”
Cause- Spirochete Borrelia Burgdorferi; TICK BITE
S/S - Bulls eye aka erythema migrans , pain, stiffness in muscles and joints pain, flu like symptoms;
Report to HCP =neck stiffness = brain involvement
Treatment- antibiotics immediately
Meds- doxycycline, amoxicillin, erythromycin ( if allergy to penicillin)
Teaching- Avoid woods, wear insect repellant w/deet, wear long sleeves, long pants; avoid darker clothing, wear lighter (can
see ticks better)remove tick w/ tweezer + use antiseptic, wait 4-6weeks for dorf testing; shower after going into the woods;
If neck stiffness = REPORT
Page 360= Prevention & early detection of Lyme disease= Avoid wooded area, avoid thick underbrush areas ( especially in spring
and summer; walk incenter of trail; avoid dark clothing; light colored spots ticks easier, use insect repellant on skin and clothes; wear
long sleeve tops, tuck shirt into pants; tuck pants into socks; wear closed toe shoes/ boots, hats/ cap; bathe immediately after going
into woods; inspect body for ticks; check pets for ticks; gently remove ticks w/ tweezer or finger covered w/ tissue or glove. Dispose
of tick into toilet. DO NOT burn tick off. After removal clean tick area w/ alcohol, antiseptic ( alcohol); wait 4-6weeks after being
bitten to test for Lyme disease ( testing before is not reliable); REPORT S/S of rash or influenza like illness to HCP immediately
_______________________________________________________________________________________________
HIV- NO cure; HIV cells take over T cells ( which fight infection); dormant weeks/months;
Transmission- Sexual= bodily fluid, semen, vag secretions, prenatal (breast milk),Parenteral;blood, needles
Viral load Labs- Viral load (highest first 2-4weeks of transmission);
Test = Elisa test- (tests for antibodies for HIV); Western Blot, immunoassay screening, Viral load test ; Perinatal breast feeding
,vag birth ( C-section recommended)
a.-w/ Elisa test false neg = low antibodies (window); False positive= mothers, iv drug users, hx malaria
b. Western blot more accurate= confirmation test
1
, c. Viral load test= Maintenace test during treatment (if high most infectious)
Labs- CD4 normal=800-1000 ; CD4 over 200 = HIV (CD4 below 200= AIDS) and viral load, normal Tcells=800-1000
Early S/S - flu like systems, muscles aches, fever, night sweats (TB), rash, sore throat, chills
Education- Prevention= Abstinence, Be faithful, Condoms, Do NOT share needles; if pt does not adhere to regimen drug
resistance can occur; NO live vaccines ;
Meds- HAART therapy= highly active anti-retroviral therapy (stop virus from replicating DOES NOT kill virus); vitamins,
minerals
AIDS- viral disease caused by HIV destroys T cells ; increases suitability to infection; Chronic
Dx= + for HIV, Elisa test; western blot
Labs= CD4 below 200
S/S= weight loss, fever, anorexia, opportunistic infection, viral infection (herpes), Kaposi sarcoma
1. Pt with Aids presents with chest pain, SOB, productive cough, reports night sweats. Airborne precaution have been initiated . What is nursing intervention
a. assesses for fever, weight loss, anorexia, opportunistic infection
2. Pt with HIV oral care to delegate to AP
A. Offer oral rinses of Na bicarb w/ normal saline several times a day; soft toothbrush, drink plenty of fluids; if oral pain avoid alcohol based
mouth wash, inspect mouth every 8hrs
3.Priority Nursing Dx-
a. ineffective breathing pattern related to opportunistic infection
Page 336 Patient education prevent infection= When WBC are low>>>>avoid crowds, large gatherings, do NOT share personal
items toothpaste, toothpaste, wash clothes, deodorant sticks; bathe daily with antimicrobial soap; if bath not possible wash
armpits , groin , genitals and anal area 2x a day with antimicrobial soap; clean toothbrush weekly thru dishwasher, or rinse in
laundry bleach (then rinse out with warm water); wash hands w/ antimicrobial soap before eating and drinking, after touching pet,
shaking hands; wash hands after outings and after using restroom; avoid eating undercooked meat, fish , eggs; wash dishes between
use w/ hot sudsy water or dishwasher; Do NOT change litter if possible; if unavoidable use gloves and wash hands immediately;
Avoid reptiles as pets( turtles, snakes); Do not feed pets raw or undercooked meats; Take all rx meds; do NOT dig in garden or work
with houseplants; void travel to area with poor sanitation or primitive health cares facilities. take temp once a day and whenever
not feeling well.
Report any signs of infection to Dr> temp greater than 100; persistent cough w/ or without sputum; put or foul-smelling drainage
from any open skin area or normal body opening; presence of boils or abscesses; urine that is cloudy, foul smelling or burning during
urination
Page 337 Care of Patient w/ reduced immunity= place patient in private room whenever possible; use good handwashing technique
or alcohol based hand rubs before touching pt or any of their belongings. Ensure pt room & bathroom are cleaned at least once each
day. Do not use supplies from common areas ( disposable gloves for their room only, individually wrapped food); limit personnel
entering room; monitor VS temp every 4hrs; inspect mouth and skin ( anal area); for fissures, abscesses every 8hrs; inspect open
areas IV sites every 4hrs for signs of infection; change wound dressing gauze everyday; obtain specimen of all suspicious areas for
culture and notify PCP; help pt perform coughing and deep breathing exercises; keep frequently used equipment in room for use
with this pt only ( bp cuff, stethoscope, thermometer); limit visitors to healthy adults; use strict aseptic technique for all invasive
procedures. do not drink standing water (any amt of hours), no live vaccines
-Antiviral drugs DO NOT KILL virus; it does control viral replication; PT must take drugs correctly 90% of the time making sure that 9
out of 10 doses are taking on time and correctly.
====================================================================
Page 332 Optimistic infections=
A. PJP aka Pnuemocytis Jirovec pneumonia S/S- SOB, dyspnea, tachypnea, dry persistent cough, low grade fever, dry non –
productive cough, fatigue, breath sounds w/ crackles, weightless
Teach- rest, drink plenty of fluids
Nurse =NO mask needed for these symptoms
1. Client w/ Aids dx PJP nursing interventions
A. Room door closed at all times, high carb, high protein diet, stay hydrated 2-3L daily, no mask needed on nurse
2. Expected S/S of PJP
A. SOB, tachypnea, dry non productive cough, fever. No mask needed for pt or nurse..
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2
