NUR2356; Multidimensional Care I Final Exam Spring Infection signs and symptoms (ANS- fever, BP drops, high respiratory rate, fast heart rate, altered mental status
if wound gets infected it may be red and hot
Hyperthermia temperature (ANS- Above 99.5
antipyretics, ice packs under armpits, take off layers of clothing
Hypothermia temperature (ANS- Below 96.4 F
blankets
Normal body temperature (ANS- 98.6 F or 37 C
nursing interventions to decrease risk of pressure injury: positioning
(ANS- pad - pad hard surfaces with pressure redistribution properties
do not elevate - do not elevate head of bed greater than 30 degrees
suspend - suspend heels off the bed surface
nursing interventions to decrease risk of pressure injury: nutrition
(ANS- encourage protein intake at each meal serve protein shakes between meals
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nursing interventions to decrease risk of pressure injury: skin care
(ANS- complete a daily skin inspection moisture dry skin with lotion do not massage bony prominences
nursing interventions to decrease risk of pressure injury: skin cleaning
(ANS- clean - clean skin asap after soiling occurs
pat - pat skin dry
use - use tepid rather than hot water
Dosage and Calc Basic Conversions (ANS-
- tsp = 5 mL
- tbsp = 15 mL
- oz = 30 mL
- cup = 8 oz
- kg = 2.2 lbs
- L = 1 kg
- kg = 1000g
- g = 1000 mg
- mg = 1000 mcg
16 oz = 1 lb
98.6 F = 37 C
- cup = 0.5 pint
- pint = 480 mL
Signs and Symptoms of HIV/AIDS (ANS- Wasting Syndrome - skinny and lost a lot of weight in a short period of time skin lesions malaise 2 / 4
fever anorexia flu like symptoms night sweats non-hodgskins lymphoma risk Kaposi's Sarcoma - skin lesions that occur primarily in individuals with a compromised immune system
HIV: CD4 and CD8
(ANS- CD4 is decreased CD8 is normal
AIDS: CD4 and CD8
(ANS- CD4 is decreased CD8 is increased
CD4 count less than 200 equals
(ANS- AIDS
Antiretroviral drugs - combination drug therapy (ANS- HIV patients on it for life It stops the virus from replicating
already have HIV and exposed again (ANS- progression to AIDS is faster
HIV/AIDS Labs (ANS- CD4 and CD8 counts HIV Viral Load testing - highest after infection
Other Assessments -pulmonary function test -liver spleen scans 3 / 4
-chest x-ray
Priority of HIV patient is to (ANS- prevent infection
Prevent Infection Compromised Immunity (ANS- avoid crowds bathe daily with antimicrobial soap wash hands thoroughly avoid raw fruits and vegetables avoid working in the garden or with houseplants
monitor for signs and symptoms of infection -increase temperature -purulent drainage -foul smelling drainage -cloudy urine
Prevent Infection when Hospitalized Compromised Immunity (ANS- -private room -clean patient room and bathroom daily -vital signs every 4 hours -change gauze dressings daily -encourage cough and deep breathing exercises -strict aseptic technique for invasive procedures -no fresh flowers or potted plants in room -avoid undercooked meat
Steroids (ANS- increase blood sugar delay bone healing mask infection
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