Immunology & Inflammation: Lupus, Arthritis, CREST, Osteoarthritis, Skin Protection, Exams of Nursing

Download Immunology & Inflammation: Lupus, Arthritis, CREST, Osteoarthritis, Skin Protection and more Exams Nursing in PDF only on Docsity! NUR2356: Multidimensional Care I / MDC 1 Exam 1 MDC1 Final exam TOTAL questions- #150= 300 points Module 10 -#30 1. Scleroderma a. AKA systemic sclerosis b. Rare autoimmune connective tissue disorder c. Abnormal thickening of the skin d. Secondary Raynaud’s phenomenon can occur 2. Lupus a. 2 classifications: i. Discoid (affects the skin) ii. Systemic (causes major body organs to fail) (has remission and exacerbations, causes direct damage and causes vasculitis which deprives organ of blood and oxygen) (Butterfly rash across the nose, nephritis, pericarditis, Raynaud’s phenomenon) b. Lupus nephritis is the leading cause of death for lupus because of the damage done to the kidneys 3. Rheumatoid arthritis a. Autoimmune inflammatory systemic disease of the synovial joints. CD4+ helper cells stimulate release of cytokine release, stimulates neutrophils to break down cartilage. Steroids 4. CREST Syndrome a. Multisystem connective tissue disorder b. Calcinosis c. Raynaud’s phenomenon d. Esophageal dysfunction e. Sclerodactyly (thickening and tightening of skin of fingers and hands) f. Telangiectasia (dilation of capillaries, red marks on surface on skin) 5. Reynaud’s a. Think of Elsa from Frozen (cold hands and feet); can’t get a pulse Ox because fingers are too cold b. Risk factors for primary Reynaud’s: sex, age, climate, family history c. Secondary Reynaud’s: happens as a result of another illness 6. Osteoarthritis a. Most common type of arthritis in the U.S. b. Results in bone rubbing against bone in the joint space causing joint pain and stiffness leading to decreased mobility and muscle atrophy c. Risk Factors: aging, genetic factor, obesity, trauma, occupation d. Treatments: NSAIDS, acetaminophen, other analgesics 7. Gout a. Systemic disease where urate crystals deposit in the joints and other body tissues b. Primary: inborn errors of purine metabolism with the end product uric acid c. Secondary gout hyperurcemia caused by another disease or factor d. Risk Factors: obesity, cardiovascular disease, alcohol, chronic kidney failure, starvation/dieting, trauma e. Education: avoid organ (red meats) or shellfish, limit alcohol intake, limit aspirins, and diuretics, remind pt to increase fluid intake f. Treatments: NSAIDs, corticosteroids, main medication= colchicine 8. Fibromyalgia a. Chronic Pain Syndrome b. Widespread musculoskeletal pain w fatigue, sleep, memory and mood issues c. Cause is unknown d. Risk dactors: sex (more prevalent in women than men), family history, more likely to develop if you have osteoarthritis, lupus, RH a. Non-pharmacological b. Pharmacological 5. Priority care a. Wound assessment b. Prevent ulcers from developing into further stages 6. Pressure injury stages (1-4, Unstageable) a. Stage 1: skin intact, area usually over bony prominence, does not blanch with external pressure, observable pressure-related alterations of intact skin b. Stage 2: skin not intact, partial-thickness skin loss of epidermis or dermis, ulcer is superficial, may appear as abrasion, blister, or shallow crater, bruising is not present c. Stage 3: full-thickness skin loss, subcutaneous tissue and underlying fascia may be damaged or necrotic, bone/tendon/muscle not exposed, may have undermining tunneling d. Stage 4: full-thickness skin loss with exposed or palpable muscle, tendon, or bone, undermining and tunneling common with sinus tracts possible, slough and eschar often present e. Unstageable: full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed 7. Post-Surgical complications a. Dehiscence: when the wound comes open b. Evisceration: when the body part comes out (put patient in low fowlers position with knees flexed) 8. Normal skin findings a. Pinkish color (consistent with ethnicity) 9. Pressure injury prevention interventions a. Turn patient every 2 hours b. Encourage patient to turn themselves every 15 mins 10. Nutrition for skin healing a. Protein b. Vitamin A and C c. Zinc d. Fluids 11. Drainage color (sanguineous, serous-sanguineous, purulent, etc.) a. Serous = clear b. Sanguineous = bloody c. Serosanguineous = clearish and bloody d. Purulent = yellowish/green 12. Exudate assessment a. Assessing the drainage (color, consistency, and odor) 13. Cellulitis and what interventions to do a. Cellulitis is a skin infection b. You want to mark it with a pen around the infection so you can monitor if it continues to grow 14. High risk for pressure injury and skin breakdown a. Elderly patients, bed-bound patients, post-op patients 15. Elderly skin changes a. Stretchy, thin, elastic like, age spots 16. Braden Scale a. Used to assess pressure wounds b. Mild risk: 15-18, High: 10-12, Severe: <9 c. Categories are: (each category is out of 4; 4 being rarely, 1 being always) i. Sensory/perception ii. Moisture iii. Activity iv. Mobility v. Nutrition vi. Friction/shear 17. Shearing and Friction a. Dragging patient against the bed when moving then (not lifting) (basically rug-burn) Module 7 -#10 1. Safety (fall prevention, fire, home care safety), 2. Communication, especially with impaired patients 3. Glaucoma (symptoms, signs, education, interventions,) a. Common in African Americans > 40 or all >60; Genetic, corneal thinness, abnormality of optic nerve, damage starts out peripheral and then extends b. Open angle: drainage goes out (90% of cases) foggy vision, mild eye aching, headache, halos around lights, losing peripheral vision c. Closed angle: drainage is blocked, rapid onset, less common d. Secondary glaucoma: related to another eye problem e. Associated glaucoma: related to another disease process f. Non-surgical  drug therapy g. Surgical management: laser trabeculoplasty, trabeculectomy 4. Cataracts (symptoms, signs, education, interventions, surgical interventions) a. Opacity of the lens of the eye that lies behind the iris; age related; makes it difficult to see retina, no pain or eye redness b. Risk factors: diabetes, hyperparathyroidism, down syndrome, chronic sunlight exposure, corticosteroids, phenothiazine derivatives, miotic agents c. Surgery will destroy opaque lens by phacoemulsification and suctioned out and replaced by a plastic lens 5. Tests for auditory; test for glaucoma, test for open or closed angle glaucoma a. Auditory: hearing test b. Glaucoma: tonometry c. Open angle glaucoma: gonioscopy (when the test shows it is wide and opened) d. Closed angle glaucoma: gonioscopy (when the test shows it is closed and blocked) Module 6 - #10 1. Assessment when a fall happens a. Check vital signs and neuro 2. Neurovascular assessment a. Pain b. Pulse c. Pallor (skin color) d. Parasthesia (can you feel this?) e. Paralysis (can you move this?) 3. Cast care a. Don’t stick anything inside them (to itch etc.) b. Inspect the cast regularly c. Keep dry; moisture weakens the plaster and damp padding next to the skin can cause irritation 4. Type of fractures a. Incomplete fracture: bone is not completely separated b. Complete fracture: bone is completely separated c. Transverse fracture: break is in a straight line across the bone d. Spiral fracture: the break spirals around the bone; common in a twisting injury e. Oblique fracture: diagonal break across the bone f. Compression fracture: the bone is crushed, causing the broken bone to be wider or flatter in appearance g. Comminuted fracture: the break is in three or more pieces and fragments are present at the fracture site h. Segmental fracture: the same bone is fractured in two places, so there is a “floating” segment of bone Module 5 - #10 1. Crepitus a. Crackling or grating sound caused by bones rubbing against each other; AKA creaky joints b. The production of crepitation in the lungs = rales 2. Osteoporosis a. Bone disease that occurs when the body loses too much bone, makes too little bone, or both. As a result bones become weak and break from a fall or, in serious cases, from sneezing or minor bumps 3. DVT a. When a blood clot (thrombus) forms in one or more of the deep veins in your body, usually in your legs. 4. Nursing assessment, interventions, evaluation; patient education a. Nursing assessment: the gathering of information about a patient’s physiological, psychological, sociological, and spiritual status b. Interventions: the implementation of the nursing care plan c. Evaluation: final step in the nursing process; the step the reviews everything that has been done and review if the desired outcome was reached or not, if not figure out a new care plan to reach the desired outcome d. Patient education: empowers patients to improve their health status; when patients are involved in their care they are more likely to engage in interventions that may increase their chances for positive outcomes Module 4- #10 1. Promotion of independence a. Emphasize partnership, use motivational interviewing, provide useful information, make it easy, address barriers 2. Benefits of activity a. Reduce the risk of a heart attack, manage weight, lowers blood cholesterol levels, lowers the risk of type 2 diabetes/some cancers, helps lower blood pressure, strengthens bones/muscles/joints, lowers risk of osteoporosis, lowers the risk of falls 3. Posture a. Places the spine in a neutral (resting) position; allows the bones to be aligned, reduces stress and fatigue & muscles, joints, and ligaments can work efficiently 4. Risk of immobility a. Decrease in depth of respiration, pooling of secretions in the airways, decrease ability to effectively cough, increases the workload of the heart, promotes venous stasis, risk of thrombus formation, drops the metabolic rate, decreased appetite, weight loss, bone loss from calcium reabsorption, external pressure leads to compressed capillaries in the skin, constipation, paralytic ileus, kidney stone formation, stagnant urine leading to increase UTIs, isolation, mood change, depression, anxiety Module 3- #5 1. Vital signs a. Temperature