NEW 2022 STUDY GUIDE EXAM FOR ADULT HEALTH NCLEX

NEW 2022 STUDY GUIDE EXAM FOR ADULT HEALTH NCLEX

stages of pressure ulcers - 4 stages

pressure ulcer stage 1 - nonblanchable erythema of intact skin

pressure ulcer stage 2 - - partial thickness (some skin loss or blistering) open blister, shallow, red/pink color

pressure ulcer stage 3 - full thickness skin loss, possible visible fat, but no bone or muscle showing

pressure ulcer stage 4 - - muscle damage and exposure and tendon exposure

unstagable ulcer - ulcer covered with slough or eschar (necrotic tissue) in the base

serous drainage - clear, watery plasma normal process of healing

serosanguineous drainage - pale, red, watery: mixture of clear and red fluid

normal process of healing

sanguineous drainage - bloody drainage uncommon in wounds

hemorrhage - excessive or profuse bleeding uncommon

purulent drainage - yellow, gray, or green drainage due to infection in the wound

superficial burns - damage the epidermis pink/red with no blisters; heals in 3-6 days

superficial partial thickness burn - damage to the dermis; pink/red with blisters and edema; heals in 10-21 days

deep partial thickness burn - deeper into the dermis, red skin with what dry areas+ no blisters due to dead tissue; heals in 3-6 weeks

full thickness burn - destruction of epidermis and dermis, waxy white deep red and brown/black dry and hard skin health takes weeks or months

deep thickness burn - injury extends into muscles, bone, tendon skin is black and hard healing involves skin grafting

nursing care for burns - priority 1.) airway patency, suction, et tube, mechanical ventilation 2.) o2 3.) vs 4.) iv fluid replacement (prevent hypovolemic shock) 5.) keep warm 6.) npo 7.) assess for infection

psoiasis - silverly plaques on reddened skin

autoimmune 1.) avoid triggers 2.)corticosteroids 3.) phototherapy 4.) medication (methotrexate-anti-rheumatic) 5.) avoid alcohol

hypoglycemia - below 70

cold and clammy need some candy irritable, pale, weak, and diaphoretic

hyperglycemic - above 110 polyphagia, polyuria, polydipsia, blurred vision, fruity breath, hot and dry

addisons disease - decrease in cortisol

lethary, fatigue, muscle weakness, weight loss, impotence, hypoglycemia, hypotension, hyponatremia, hyperkalemia, hyperpigmentation (jfk) of skin

what do steroids do too glucose? - increase steroids increases glucose

addisonian crisis - caused by stress, infection, trauma, surgery can lead to extreme hyponatremia, hyperkalemia, hypoglycemia, seizure, coma, death

priority 5's 1.) salt replacement 2.) sugar (dextrose) 3.) steroid 4.) support physiological function 5.) search for cause

cushing's disease - increase in cortisol

muscle weakness and wasting, moon face (swollen face), truncal obesity, hirsutism (masculine feature in feminine), hyperglycemia, hypernatremia, hypokalemia, hypertension, fragile skin

retains water due to high sodium: daily weights!

hypothyroidism - high tsh low t3 and t4

everything slow lethargy, fatigue, weakness, cold intolerance, weight gain, dry skin, bradycardia, constipation, edema (myxedema- puffiness), goiter,

hypotension, hyponatremia, hypoglycemia, hypothermia (due to cold intolerance), edema, respiratory failure, coma

levothyroxine: treatment of choice for lifetime

myexedema coma - persistent hypothyroidism and shows decreases in mental status and brain function

creatinism - congenital hypothyroidism

hyperthyroidism (grave's disease) - increased in thyroid hormone (autoimmune)

irritability, fine tremors, heat intolerance, weight loss, smooth skin, palpitations, diarrhea, exophthalmos, hypertension, goiter

thyroid storm - due to uncontrolled hypertension

fever, tachycardia, htn, agitation + tremors, confusion, seizures, delirium, coma

hypoparathyroidism - decrease in parathyroid hormone-not pulling enough calcium out of the bone

hypocalcemia, hyperphosphatemia, tingling, muscle cramps, positive trousseau's and chvostek's

treat with calcium gluconate iv, and vitamin d for enhancing calcium

what helps calcium absorption? - vitamin d

hyperparathyroidism - increase production of pth-pulling too much calcium out of the bone

hypercalcemia, hypophosphatemia, fatigue, bone weakness, bone deformities, anorexia, n/v, weight loss, hypertension

calcitonin is given to decrease calcium release and increase calcium absorption

di - increase fluid excretion-pee out all that you have

dehydration, low specific gravity (diluted urine), fatigue, postural hypotension hypernatremia

monitor electrolytes maintain fluid intake monitor i&o, weight, specific gravity *given desmopressin*

siadh - decrease in fluid excretion-fluid is being held in the body

hyponatremia-dilutional effect fluid overload, change in loc, weight gain, hypertension, tachycardia

1.) monitor loc 2.) monitor i&o, weight, 3.) restrict fluid 4.) diuretics 5.) seizure precautions

dka - increase glucose 250 glucose ketones in urine type 1 diabetes only confusion fruity breath increased thirst due to dehydration of cells hyperkalemia-potassium is coming out of cells kussmauls respirations due to metabolic acidosis

hyperglycemic hyperosmolar nonketotic syndrome (hhns) - increase blood glucose gradual onset due to poor fluid intake altered mental status, increased thirst, urination, lethargy, coma, no ketones in urine

dawn phenomenon - early morning insulin levels are too low which causes hyperglycemia when they wake up. this is thought to be due to growth hormone increases at night. check bs 2-4 am and see if it is high. this usually cause increase in insulin needs!