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77 terms

Med Surg Exam 4 study guide

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Innate (natural) immunity
Present at birth; not dependent on a specific immune response or previous contact with an infectious agent
Active Acquired immunity
Develops after birth as a result of the body's natural immune responses to antigens
Passive acquired immunity
temporary immunity, An injection of immune globulin or antiserum (made from human or animal blood) containing antibodies to a specific pathogen e.g. snakebite, rabies or exposure to hepatitis. Can also occur in an infant through ingestion of colostrum or receiving antibodies via the placenta. Antibodies that pass from mother to Baby
Autoimmune Diseases
Immune system reacts against and destroys its own tissues. T1DM, Rheumatoid arthritis, SLE, Graves Disease (body attacks itself)
1st line of defense
Skin and mucous membranes
2nd line of defense
phagocytosis and inflammation system
Cortisol
produced by adrenal cortex. Inflammatory response substance that releases histamine, stabilize lysosomal membranes and prevents influx of leukocytes. IMPEDES THE INFLAMMATORY RESPONSE. Hormone secreted by the Adrenal gland
inflammatory process
* Dilation of capillary beds increase blood flow and cause warmth and redness
* Increased permeability when fluid leaks out causing swelling
* Chemical Mediators with the release of prostaglandins, histamine and leukotrienes cause rash, pain and classic signs of inflammation
Bacteria
one celled microorganisms (not all cause disease)
Virus
small microorganisms that cause significant disease in humans, dependent on a host to reproduce. Have no cell wall. Cause significant disease in humans, most common is the Cold Virus (no effective vaccine for cold because to many strains
and constantly mutation).
Fungi
vegetable like organisms that exist by feeding on organic matter... Cause Athletes Foot and ringworm, candidiasis.
Rickettsiae:
come from rats and squirrels and transmitted to humans by fleas, and ticks, cause Rocky Mountain spotted fever, Typhus and Lyme Disease
Helminths
worms, parasites found in soil and water transmitted from hand and mouth: tapeworms, hookworms and pinworms
Protozoa
large group of one-celled organisms. Cause Malaria, dysnetery, giardiasis, sleeping sickness. Often spread by food or Water
Hand Washing
most effective and basic method of preventing cross-contamination. Running water, soap and friction for at least 15 sec
immunization and good hygiene
Prevention of Viral Infections
four signs of inflammation
heat, swelling, redness, & pain
common routes of infection
with helminths
worms, parasites found in soil and water transmitted from hand and mouth: tapeworms, hookworms and pinworms
fecal/ oral or through the skin
Community Acquired Infection
caused by day 2 day contact with the public. HIV, STD's, hep A, Salmonella and Strep. Contracted outside the healthcare facility
Hospital Acquired Infection
antibiotic resistant microorganisms, are more virulent: VRE and MRSA, UTI and pneumonia are most common nosocomial infections CDC has steps to prevent
adverse effect of antibiotic therapy
Candidiasis and yeast infections can occur when antibiotics destroy the normal flora
Common sites of nosocomial infections
wounds and procedure sites
Changes in a CBC count that indicate infection
increased WBC (shift to the left, WBC are above 60%)
S/S of Systemic Lupus Erythematosus.
butterfly rash Arthralgia: joint pain
Myalgia : muscle pain fever, anorexia, nausea, fatigue,*swelling of th kidneys, heart, and/ or lungs, resulting organ failure
Diagnostic test for SLE
ANA (antinuclear antibody), protien in urine, and elevated Sed Rate
Pt teaching for Decadron
Take with meals to prevent upset stomach because they inhibit prostaglandins (protect the stomach)
Drug should not be stopped abruptly because the body will not be producing steroids on there own and they will go into steriod crisis
Decadron
drug used to prevent rejection of transplanted organs
Stomatitis mouth care
* good oral care - no salt water or alcohol based mouthwash, use soft tooth brush
* NO lemon glycerine swabs
* use toothettes
Greatest risk factor for HIV Pt
Infection. We must prevent infection
Direct Contact
transfer of microorganisms directly. (STD's)
Indirect Contact
when pathogens are spread through droplets expelled during a sneeze or a cough or inanimate objects
Common Vehicle
through water, food, blood, or air currents contaminated with pathogens (Legionella)
Vectors
transported by a living organism such as a fly or mosquito
Fomites
any item that has been touched or cross-contaminated by the host, such as bed linen, side rails or hygiene items
Causative Agent
microorganisms that are present in sufficient number and virulence to damage human tissue
Reservoir
Human or animal tissue in which microorganisms can pool & multiply.
Portal of Exit
route by which the infectious agent leaves one host and travels to another. Nose and mouth are common portals
Mode of Transfer
mode in which a microorganism is transported to a host.
Portal of Entry
pathways into the host. Nose, mouth, open wounds, IV, catheters.
Suseptible Host
a person who can not fight a disease
Precautions for Immunosuppressed Patient
Private room, hand washing,
no fresh fruit and veges/ food must be thoughly cooked, no potted plants or fresh flowers
Nursing Dx for Lupus
Avoid the sun makes the rash worse, lots of rest for fatigue (schedule activities, balance btwn rest and activity)
Diagnostic test for Lupus
ANA (antinuclear antibody) positive may indicate disease, protein in urine, Sed Rate (elevated tells us inflammation)
Drugs used to treat Lupus
corticosteroids, antimalarial, NSAIDs
Causes of Neutropenia
Chemotherapy, autoimmune reaction, certain drugs, overwhelming infection
When to be aware of Pt allergies
Must be aware of a persons reaction when we are giving meds or when test are ordered because of Iodine (contrast media, shelfish)
Neutropenic Precautions
1) Hand washing (critical for all who come in contact with the patient)
2) Private room
3) Thoroughly cooked food, no raw fruits or vegetables
4) Equipment specific to that Pt's room
5) no flowers in standing water and no potted plants
6) Limit invasive procedures such as catheters and IV must be kept clean
7) Screen all visitors for illness
Complications of Bone Marrow Transplant
Infection Graft vs. Host Disease: T lymphocytes in the Transplanted bone marrow identify the Pt tissue as foreign and try to destroy the tissue
Patient teaching for SLE
* Know the names, dosage, schedule, and side effects of your drugs
* Avoid prolonged exposure to the sun and use sunscreen with SPF rating of > 15
* You can get additional information from the Lupus Foundation of America & American Lupus Society
Bacteria to avoid with immunocompromised Pt
E-coli from uncooked food
Pseudomonas auruginosa and Klebsiella
Cancer
abnormal growth of abnormal cells
Types of Cancer treatment
Surgery, Chemotherapy. Radiation, Biotherapy
alopecia
hair loss
carcinogen
cancer causing agent cigarettes, synthetic estrogens
biotherapy
Neupogin that stimulates the bone marrow to produce the blood cells and platelettes
antineoplastic
Chemical agent used to tx cancer : CHEMOTHERAPY
Benign
noncancerous tissue, can apply pressure and obstruct normal tissue
Malignant
Cancerous tissue
Fibroma
benign: fibrous connective tissue tumor
Lipoma
benign: fat tissue tumor
Leiomyomas
Benign: smooth muscle tissue tumor
Carcinoma
malignant: tissue of the skin, glands, lining of digestive, urinary tract
Sarcoma
Malignant: tissue of the bone, muscle other connective tissue
Melanoma
Malignant: pigment cells in the skin
Leukemia/ Lymphoma
Malignant: blood-forming tissue, lymphoid tissue, plasma cells and Bone marrow
Chemotherapy side effects
NVD, alopecia, bone marrow supression
Zofran
antiemetic cancer drug, Side effects are: constipation, diarrhea, headache
Reglan
antiemetic cancer drug. Side effects are: sedation, diarrhea, dizziness, EP symptoms
Leukemia complication
* Risk for Opportunistic Infections (infections from our own normal microbes)
* Bleeding (Thrombocytopenia) from low platelette counts
* Anemia causing fatigue, need to be taught energy saving techniques, allow periods of rest, coordinate care, limit visitors
* Dry mucous membranes/ Stomatitis
* Imbalanced nutrition from Tx and disease process : offer foods they like,
Radiation Precautions
1) patien in a private room that is lines with lead
2) Place sign on door indicating room is radiation area
3) Anyone who enters must take precautions. NO ONE under the age of 18 or pregnant women
4) Limit time in room and work as far from source as possible
5) Organize work efficiently. Care can be provided in a total of 30 minutes. Use portable lead shields.
6) Know that sealed sources can be dislodged accidentally. Check bedpans and linens for dislodged sources b4 disposal
DO NOT TOUCH AND SOURCE THAT COMES OUT OF THE PT's BODY WITH BARE HANDS
Antineoplastic Drug major side effects
The major systemic side effect of ANTINEOPLASTIC drugs are the same as those of radiation. Simultaneously irritate the lining of the digestive tract and stimulate the vomiting center of the brain.
Antineoplastic basic side effects
1) Bone marrow supression
2) Nausea and Vomiting
3) Alopecia
Antineoplastic Toxic effect
toxic on Heart, lungs, nerve tissue, kidneys and bladder
Adriamycin side effect
Toxic effects on the heart that may lead to heart failure, stomatitis (Cardiomyopathy)
Most common cancer in men
Prostate
Most common cancer in women
Breast
Body systems adversely affected by Chemotheray
Respiratory, Urinary, Skin, rapidly dividing cells of these systems are more sustible