Digiulio M., Keogh J. Medical-Surgical Nursing Demystified
Подождите немного. Документ загружается.
169
CHAPTER 3 Immune System
•
After the procedure:
•
Explain when the test results will be available to the patient.
•
Assess the site of the venipuncture to confirm adequate clotting.
Western Blot Tests
WHY IS IT GIVEN?
This test looks for the presence of HIV-related viral proteins in the patient’s blood
to confirm if the patient is HIV-positive.
HOW DOES THE TEST WORK?
A small amount of blood is taken and examined for the presence of HIV viral
proteins.
WHAT TO DO?
•
Before the procedure:
•
Obtain written informed consent due to legalities.
•
Explain the purpose of the test and how the test result is interpreted.
•
After the procedure:
•
Explain when the test results will be available to the patient.
•
Make sure that the site of the venipuncture isn’t bleeding to ensure ade-
quate clotting.
Culture and Sensitivity of Sputum
WHY IS IT GIVEN?
Sputum from the patient is cultured to find which, if any, bacteria is contained in
the sputum and determine which antibiotic will be effective.
170
Medical-Surgical Nursing Demystified
HOW DOES THE TEST WORK?
Sputum is collected from the patient either from a deep cough or from suctioning
and sent to the lab where samples are smeared on petri dishes and incubated for
48 to 72 hours to grow the bacteria. Samples of the bacteria are stained and exam-
ined under a microscope to identify the bacteria. Once identified, known antibiotics
are administered to the bacteria in the petri dish to determine which antibiotic kills
the bacteria.
WHAT TO DO?
•
Before the test:
•
Determine which, if any, antibiotic the patient is taking.
•
Use a sterile specimen container to avoid contamination.
•
Collect sputum only and not saliva as the mouth contains many bacteria.
•
During the test:
•
Deep coughs are necessary to generate sputum.
•
After the test:
•
Continue taking the prescribed antibiotic.
Lymphangiography
WHY IS IT GIVEN?
This test produces a radiographic image of the lymphatic system to determine if
there are any abnormalities, such as edema of the legs, Hodgkin’s disease, lym-
phoma, lymphadenopathy, and lymphatic metastases. The results are useful in the
staging of lymphoma and Hodgkin’s disease and to determine the efficacy of
treatment.
HOW DOES THE TEST WORK?
A radiopaque dye is injected via catheter into the lymphatic system and then the
patient is x-rayed. The dye remains present for up to one year so repeat testing can
be done.
171
CHAPTER 3 Immune System
WHAT TO DO?
•
Before the test:
•
The patient must sign an informed consent due to the invasive nature of
the test.
•
Make sure that the patient is not allergic to seafood, iodine, or contrast dye.
•
Check renal function (BUN, creatinine) as the kidneys are responsible
for processing the dye.
•
During the test:
•
Check for allergic reaction to the dye such as skin rash, itching, shortness
of breath, and swelling.
•
After the test:
•
Administer fluids to aid in elimination of the dye.
•
Monitor peripheral pulses to ensure adequate circulation in the feet.
•
Examine injection site for complications such as infection, bleeding, and
edema.
•
Urine, stool, and skin might have a blue color from the dye.
Quiz
1. A cell whose functions include ingesting foreign or invading cells is a (an):
(a) T-cell.
(b) B-cell.
(c) Macrophage.
(d) Erythrocyte.
2. A confirmatory lab test for HIV includes:
(a) Western Blot.
(b) Low WBC.
(c) Comprehensive metabolic panel.
(d) Enzyme-linked immunosorbent assay (ELISA).
172
Medical-Surgical Nursing Demystified
3. When assessing a patient for anaphylaxis, you would be alert for:
(a) Chest pain and indigestion.
(b) Hives and dyspnea.
(c) Hypertension and blurred vision.
(d) Headache and photophobia.
4. Patients with rheumatoid arthritis typically have pain:
(a) With activity.
(b) Upon awakening.
(c) Late in the evening.
(d) All day without remission.
5. The joints most commonly involved with rheumatoid arthritis include:
(a) Symmetrical involvement of major joints.
(b) Small joints of hands and feet.
(c) Spine, from the sacrum upward to cervical.
(d) Slightly movable joints of the axial skeleton.
6. The primary mode of treatment for ankylosing spondylitis is:
(a) Relaxed posture for comfort.
(b) Strict bedrest.
(c) Physical therapy.
(d) Respiratory therapy.
7. In your patient with a CD4 count <200, the most important nursing
assessment would include:
(a) Bowel movements.
(b) Urinary output.
(c) Fever.
(d) Blood pressure.
8. The best treatment for mononucleosis is:
(a) Antibiotics.
(b) Physical therapy.
(c) Nonsteroidal anti-inflammatories (NSAIDs).
(d) Rest and fluids.
173
CHAPTER 3 Immune System
9. During exacerbations of Systemic Lupus Erythematosus, patients are
often treated with:
(a) Antiemetics.
(b) Antineoplastics.
(c) Corticosteroids.
(d) Antibiotics.
10. Which of the following would have the highest priority in septic shock?
(a) Monitoring temperature.
(b) Monitoring ABC (airway, breathing, circulation).
(c) Monitoring pupillary reaction.
(d) Monitoring ANA and RF levels.
This page intentionally left blank
Hematologic System
CHAPTER 4
Marrow
Red Blood Cells
White Blood Cells
Platelets
Lymphocyte
Monocyte
Eosinophil
Basophil
Neurophil
Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use.
176
Medical-Surgical Nursing Demystified
Learning Objectives
Key Terms
Clotting factors
Ecchymosis
Epistaxis
Hematocrit
Hemoglobin
Hemolysis
Leukopenia
Lymphocytes
Macrophages
Microemboli
Petechiae
Prothrombin
PT
PTT
Purpura
Stem cells
Thrombocytopenia
Anemia
Aplastic anemia (Pancytopenia)
Iron deficiency anemia
Pernicious anemia
Disseminated intravascular
coagulation (DIC)
Hemophilia
Leukemia
Multiple myeloma
Polycythemia vera
Sickle cell anemia
Deep vein thrombosis (DVT)
Idiopathic thrombocytopenic
purpura (ITP)
1
2
3
3
4
7
8
9
5
6
10
11
12
How the Hematologic System Works
The hematologic system refers to the blood and blood-forming organs. The forma-
tion of red blood cells, white blood cells, and platelets begins in the bone marrow.
Stem cells are produced in the bone marrow. Initially, these cells are not differen-
tiated and may become red blood cells (RBCs), white blood cells (WBCs), or
platelets. In the next stage of development, the stem cell becomes committed to a
particular precursor cell, to become either a myeloid or lymphoid type of cell and
will differentiate into a particular cell type when in the presence of a specific
growth factor.
The spleen is found in the left upper quadrant of the abdomen. The spleen fil-
ters whole blood. It removes old and imperfect white blood cells, lymphocytes and
macrophages, and RBCs. The spleen also breaks down hemoglobin and stores of
RBCs and platelets.
177
CHAPTER 4 Hematologic System
The liver is found in the right upper quadrant of the abdomen and is the main
production site for many of the clotting factors, including prothrombin. Normal
liver function is important for vitamin K production in the intestinal tract. Vitamin
K is necessary for clotting factors VII, IX, X, and prothrombin.
Just the Facts
Anemia
WHAT WENT WRONG?
A low hemoglobin or red blood cell (RBC) count results in decreased oxygen-
carrying capability of the blood. This may be due to blood loss, damage to the red
blood cells due to altered hemoglobin or destruction (hemolysis), nutritional defi-
ciency (iron, vitamin B
12
, folic acid), lack of RBC production, or bone marrow
failure. Some patients have a family history of anemia due to genetic transmission,
such as thalassemia or sickle cell.
PROGNOSIS
Anemia is a symptom of something else happening. The cause of the anemia needs
to be determined in order to correct the anemia and its symptoms.
HALLMARK SIGNS AND SYMPTOMS
•
Fatigue due to hypoxia from less oxygen being available to the tissues of
the body
•
Weakness due to hypoxia
•
Pallor due to less oxygen being available to the surface tissues
•
Tachycardia as the body attempts to compensate for less available oxygen by
beating more rapidly to increase blood supply
•
Systolic murmur due to increased turbulence of blood flow
•
Dyspnea or shortness of breath due to hypoxia as body attempts to get more
oxygen
•
Angina as the myocardium is not getting enough oxygen
1
178
Medical-Surgical Nursing Demystified
•
Headache due to hypoxia
•
Lightheadedness due to hypoxia
•
Bone pain due to increased erythropoiesis as body attempts to correct anemia
•
Jaundice in hemolytic anemia due to increased levels of bilirubin as red blood
cells break down
INTERPRETING TEST RESULTS
•
Hemoglobin level low.
•
Hematocrit level low.
•
RBC count low.
•
MCV (mean corpuscular volume) shows size of cell—normal (normocytic),
microcytic (low), or macrocytic (high).
•
MCH (mean corpuscular hemoglobin) shows color of cell—normal (nor-
mochromic), hypochromic (low).
•
RDW (red cell distribution width) elevated—shows the variation of the cell
sizes; there is greater variation in cell size when body is attempting to com-
pensate for anemia.
•
Reticulocyte count elevated when RBC cell production is increased to com-
pensate for the anemia.
TREATMENT
Correction of the underlying cause is necessary. Treatment may include dietary
modifications and supplementations. See specific anemias below.
NURSING DIAGNOSIS
•
Fatigue
•
Activity intolerance
NURSING INTERVENTION
•
Check vital signs for changes.
•
Monitor CBC—hemoglobin, RBC, MCV, MCH, RDW.