NCLEX: Physiological Integrity

NCLEX Physiological Integrity

51 cards   |   Total Attempts: 189
  

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Cards In This Set

Front Back
Anaphylaxis - Assessment
- Hives, rash
- ↑ BP, ↑ HR, ↑ RR
- "Panicked" feeling
Liver Impairment - Assessment
- Fever, Malaise
- N & V
- Jaundice, ↑ Bilirubin
- Light stools, dark urine
- Abd pain
- ↑ AST, ↑ ALT
Renal Impairment - Assessment
- ↑ BUN, ↑ Creatinine
- ↓ Hct
- Altered lytes
- Fatigue, Edema
- Irritability
CNS Impairment - Assessment
- Confusion, delirium
- Insomnia
- Drowsiness
- Hallucinations
Anticholinergic Effects - Assessment
- Dry mouth
- Altered taste perception
- Dysphagia
- Heartburn
- Urinary retention
- Impotence
- Blurred vision
- Nasal congestion
Cholinergic CRISIS
S L U D
[S]alivation
[L]acrimation (eye tears)
[U]rination
[D]efecation
Parkinson-like Effects - Assessment
- Akinesia (impaired body movement)
- Tremors
- Drooling
- Gait changes
- Rigidity
- Akathisia (extreme restlessness)
- Dyskinesia (spasms)
Stomatitis - Assessment
- Swollen gums (gingivitis)
- Swollen, red tongue (glossitis)
- Difficulty swallowing
- Bad breath
- Pain in mouth and throat
Guillain-Barre Syndrome
Begins in lower extremities and ascends bilaterally:

- weakness
- ataxis (lack of coordination; wobbling)
- bilateral paresthesia

Progressing to paralysis
Tetanus
= Lockjaw
- spasms of facial muscles
- jaw stiffness
- irritability
- diaphoresis
Glomerulonephritis
= Antigen-Antibody Complex (in Glomeruli) from recent strep infection

Causes:
- Inflammation
- ↓ Glomerular Filtration Rate (GFR)
- Proteinuria
- Hematuria
- Oliguria (↓ urine output)
- Dysuria (painful urination)

S&S:
- Headache,
- ↑ BP
- Facial /Periorbital Edema
- Lethargic
- Low grade Fever
- Weight gain (edema)
Renal Compensation in SHOCK
1. ↑ ADH = Fluid retention (Thou Shalt not pee!)

2. Think Big "Al" = Aldosterone = Na & Fluid retention

3. ↑ BP = Angio-tension II > Angiotension = Vasoconstriction = ↑ BP
Transfusion Reactions - Allergic
- Facial Flusing
- Hives / Rash
- ↑ anxiety
- Wheezing Dippnea
- ↓ BP
Transfusion Reactions - Hemolytic
- Hemoglobulinuria
- Chest pain
- Low back pain ***
- Apprehension
- Chills
- Fever
- Tachy
- ↓ BP
- ↑ RR
Immune System Response
Antigen (Foreign) invades body causing antigenic response.

Antibody (army) attacks antigen