NURS 115 Final Exam Study Guide/NURS 115 Final Exam Study Guide/NURS 115 Final Exam Study Guide/NURS 115 Final Exam Study Guide/NURS 115 Final Exam Study Guide/NURS 115 Final Exam Study Guide
Immunity
• Sign and symptoms rash, fever, fatigue, lymphadenopathy, night sweats,
of AIDS: headache, and opportunistic infections.
• CD4 count: Less than 200 cells per microliter
• Viral loads: very high; over 100,000
Neuro system
•
Blood-brain permits passage of essential substances from blood
barrier: while excluding the transfer of unwanted material
o
highly lipid substances transfer alcohol, antibiotics, nicotine,
easily: and cocaine
o water soluble substances are excluded from transfer to the brain to prevent
swelling
o large molecules such as peptides and proteins are excluded because they
pull fluid into the brain and cause swelling.
•
Requirements 15% CO, 20% O2, and glucose is a major fuel source,
for Brain: but the brain has no where to store it and must rely on
supporting glial cells- hold neurons together and supply
glucose to the brain.
•
Increased since the brain is surrounded by the skull it has NO
ICP: room to expand or swell.
o Increased ICP leads to decomposition of the brain tissues. 10% blood,
80% brain tissue and 10% CSF. An inc. in ONE of these components, leads to a
dec. in the other TWO.
o
Causes- injury (concussion, head trauma, or inflammation),
disease factors (inc. production of CSF), or
chemical (pain meds or tumor).
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NURS 115 Final Exam Study Guide
Treatment- identify and correct the cause, limit PT actions and
ADLs that cause Valsalva maneuvers, internal ICP
monitoring, monitor LOC, personality, restlessness,
arousal, wakefulness, cognition, and ask for Person,
Place, Time, and Task.
•
CVA or sudden impairment of cerebral circulation, affects one or
Stroke: more blood vessels that supply the brain, and interrupts or
diminishes O2 supply causing serious damage or necrosis
to the brain tissue.
o
Causes- thrombosis, embolism, or hemorrhage.
Diagnosis- take history, evaluation of coexisting diseases,
neurological exams (MRI, MRA, CT, or Doppler
studies), FAST= Face (asymmetry), Arms (ability to
raise BOTH arms), Speech (slurred or salad speech
or cannot speak at all), and Time (if thrombosis or
embolism, can give TPA 3-4 hours after symptoms
started).
Treatment- anticoagulation therapy: immediate or long term,
surgical intervention, drugs that limit the calcium
cascade (calcium aids in clotting), long term ACE
inhibitors (to prevent vasoconstriction),
rehabilitation, dec. controllable risk factors, might
give NTG (promotes vasodilation), prevent
vasoconstriction, water and sodium retention, and
prevent an inc. in BP, PT, occupational therapy, and
speech therapy, rebuild lost functions, stop
smoking, drinking caffeine and dec. sodium intake.
•
Afferent neurons: (sensory) carry information TO the CNS.
•
Efferent (motor) carry information AWAY from the CNS and
neurons: toward efferent organs.
•
Somatic controls voluntary functions of extremities with skeletal
System: muscles and inner lining of pleura cavities (muscles, gut,
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NURS 115 Final Exam Study Guide
bladder, and uterus).
•
Autonomic controls the involuntary functions of the SNS (fight
System: or flight) and PNS.
•
Autonomic acute episode of exaggerated sympathetic responses,
Dysreflexia: occur w/ T6 or above injuries, CNS control of spinal
reflexes is lost, and usually occurs 6 months after
injury.
o
Signs- vasospasms, initially pallor, mild to severe
hypertension (acute), goose flesh w/ piloreceptor
response, bradycardia produced by baroreflex-
mediated vagal response, baroreflex-mediated
vasodilation w/ flushed moist skin, diaphoretic,
headache, and pale below injury. PNS is not
receiving message. Body cannot feel where pain is.
Complete or almost complete severance of the
spinal cord. Cannot get BP to dec.
Causes- painful stimuli: visceral distension (full bladder or
bowel), pain receptors (ingrown toenail, dressing
change), visceral contraction (ejaculation, bladder
spasms, uterine contractions).
Treatment- remove/correct cause, monitor BP, place in upright
position (orthostatic hypotension), remove
peripheral support hose (promotes venous pooling
and dec. BP) and drugs to block the autonomic
response, and check Foley catheter for kinks.
Inflammatory response & Infection
Sunday, December 9, 2018
6:06 PM
• Inflammatory response:
o
Acute- • vascular: immediate
vasoconstriction followed by vasodilation w/
release of chemical mediators
• cellular: movement of
phagocytic WBCs into injured area
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