what types of imaging tests are used to diagnose cancer?
bone scans and PET scans (combined with CAT scan)
what is a bone scan?
inject the person with radioactive dye, have them come back in 3 hours and look for the presence of active metabolism in the bone. will be done if suspected metastasis in bone (e.g. lung, breast, prostate)
how does a PET scan work for diagnosing cancer?
PET= positron emission tomography. inject or inhale radioactive tracer, then have a CAT scan. Tumors are hypermetabolic (fast-growing) so will take up more of the tracer.
When is a PET scan helpful?
When you suspect a tumor, but have not been able to find the primary site.
what is a biopsy?
look at a sample of the tissue itself and grade it
how are tumors graded?
ranges from normal, well-differentiated tissue to undifferentiated tissue that doesn't look at all like the parent tissue
what is tumor testing?
test characteristics of the tumor itself. example is testing breast cancer cells for the estrogen receptor. if it's positive (ER+), that means that the tumor grows in response to estrogen, and that the patient should receive tamoxifen (anti-estrogen drug)
anti-estrogen drug given to women with breast cancer who test positive for estrogen receptor (tumor grows in response to estrogen)
what is the procedure for a prostate biopsy?
local anesthetic, transrectal ultrasound with a small needle that pops through the skin. patient must stop NSAIDs 7-14 days before bc don't want bleeding, need to do an enema the night before or morning of, take an AB before and up to 24h post-op to prevent infection. Counsel that you may have a little blood in urine, semen, stool if more than a little bleeding, come in
what are tumor markers?
substances that the tumor secretes when it's active. they are currently not used for screening purposes.
what is the ovarian cancer tumor marker?
what is the pancreatic cancer tumor marker?
What is the colon and biliary cancer tumor marker?
What is the prostate cancer tumor marker, and what is it used for?
PSA. This is currently used for testing, but the use is being questioned. Stands for prostate specific antigen. The normal values for PSA are very small, and increase every decade of life. If PSA greater than or = 4ng/mL, need biopsy. Important to look at velocity (rate of change of PSA markers), need to have 3 levels to compare. helpful in young men.
how will psa markers affect treatment?
the baseline of these markers is used to determine if the treatment is affective. if tx is effective, expect the markers to decrease. if markers increase, need to do more testing or possibly change tx.
What are the classifications of tumor staging?
T, N, M. The results of the T, N, and M puts the person in a certain stage of cancer.
What does the T tumor staging classification stand for?
T is graded from 0 to 4, stands for the size of the tumor. The higher the number, the bigger the tissue as well as the depth of perfusion of the tissue. Pathology is not always certain for treatment.
What does the N tumor staging classification stand for?
N is graded from 0 to 3, it involves the identification of tumor in the lymph nodes. It deals with both the number of lymph nodes that have the tumor as well as the location of the lymph nodes (and their proximity to the primary site).
What does the M tumor staging classification stand for?
M is graded 0 or 1. It means that the tumor has or has not metastasized.
what is performance status?
general, overall health status of a person's life. this predicts how well the person will respond to treatment.
what psychiatric assessments should be performed immediately on a cancer patient?
depression and anxiety screens should happen right away, because both can be effectively treated.
What are the 3 usual treatment for cancer?
surgery as 1st step, then chemo and radiation
what is radiosensitivity?
if the tumor is highly radiosensitive, it can be cured by radiation alone. it's based on the fact that radiation will damage the DNA of a cell that is rapidly dividing.
what happens if a tumor is radioinsensitive?
means that you can try radiation, but it may not help. example is melanoma, which has to be taken out surgically (best if caught early).
what can make radiation more effective?
the tumor can become more sensitive to radiation if chemotherapy is administered first, or if the patient is given hyperbaric oxygen.
what is radiosensitivity in a tissue?
various parts of the body can tolerate varied amounts of radiation. our bodies as a whole can only take so much.
what are the 2 types of radiation treatment?
external- outside your body, pointed at the exact same location at every treatment. internal (brachytherapy)- high dose of radiation that goes directly into the tumor, or area that the tumor used to exist in to try to knock out all remaining cells that could exist. final, last, high dose that's direct.
what is fractional dose?
a type of external radiation where they calculate the total amount of radiation that they want to give you and divide it up into smaller doses. pt frequently receives radiation 5 days a week for 6 or 7 weeks.
what is split field radiation?
a type of external radiation where the person gets part of the radiation from the front, and part from the back.
what is sealed source radiation
type of internal radiation where the radiation is contained in a pellet, bead or wire that's put directly into the tissues. person's body secretions are not considered radioactive. temporary (time predetermined, eg. cervical cancer-tube and applicator into cervix) or permanent (prostate cancer: in area above prostate, emits low levels of radioactivity outward, will remain in place).
what is an unsealed source of radiation?
type of internal radiation where radiation is circulating through the blood stream. take PO (outpt) or IV (inpt). eg. treatment for thyroid cancer. secretions are considered radioactive, so need to limit time with people, stay in a lead-lined room, 1 month free of intimate contact.
what is important to remember as a nurse caring for a pt with internal radiation?
time and distance. spend as little time as possible with the patient, and remain as far away as possible. nurses are limited to 30 mins a shift, so need to tag-team with other RNs and pt must be independent. No children, no pregnant women. Don't stand in general line of source of radiation (reverse squares).
what Erikson stage are older adults in?
ego-integrity vs. despair (want a life that's meaningful)
what are major challenges with treating older adults?
they frequently have many comorbidities, greater risk of nosocomial infections, non-specific presentation of illness, don't show same signs of infection
where is highest concentration of older adults?
in the SW US and Florida, and in Italy and Japan
what is the average life expectancy in the US after age 65?
men- 20 years women- 24 years
what is the gender breakdown of older adults?
more male babies are born, but females are more prevalent at older ages.
what is the goal for caring for older adults?
to add life to years, to keep people walking, eating, and being independent. they can frequently articulate their own goals that we can work with.
what illnesses are more common to women?
hypertension and arthritis
what illnesses are more common to men?
heart disease, stroke, cancer, diabetes
what is the fastest growing cause of death?
what is life expectancy and freq cause of death for Alzheimer's patients?
highest cause of death after 75, average life expectancy post dx: 10 years, frequent cause of death is aspiration pneumonia and falls (30-50% of pts die within 1 year post-fall).
what is the most important thing to thing about when dealing with elderly?
function! also, team approach, holistic care
what are nursing emergencies when dealing with elderly patients?
new onset urinary incontinence and delirium
what is delirium
acute mental status change, need to figure out the cause in order to fix it and the longer it goes on, the harder it is to reverse
what are some considerations for obtaining an accurate health hx in elderly?
underreporting sx (don't want to be a burden), a lot of past hx, ask the most vital question 1st (they may get sick of you), consider the environment, consider the comfort of the patient, they may normalize symptoms
who has the highest risk for osteoporosis?
White and Asian females
who has the highest risk for suicide
white males (more successful, many men over 75)
who has the highest risk for hypertension and diabetes mellitus?
African American females, Hispanic females
who has the highest risk for tobacco abuse, stroke, cirrhosis, prostate cancer?
African American males, Hispanic males
who has the highest risk for diabetes mellitus (whole group)?
what is the biggest predictor of a fall?
a previous fall within 3 months
what are some areas to consider in treating older adults?
exposure to pesticides, high-stress jobs, immunizations up-to-date, spirituality, ADLs, safe sex practices, driving habits, economic status, mental and cognitive status, risk for polypharmacy, need to treat based on functional age
how do assess cognitive function of older adult?
folstein mini-mental status examination
how do you assess function of older adult?
activities of daily living; instrumental activities of daily living; gait and balance scales
how do you assess mood of older adult?
geriatric depression scale
what is medicare?
covers 98% of elderly, federal health insurance program, run by CMS. Part A is hospital insurance, Part B=doctors, Part D= drug benefit. Does not cover non-skilled care in nursing home or assisted living facility
what is the "Donut hole"?
After $2400 and before $5451, drugs are not covered (per year), so they don't take them or share them.
how aggressive should tx be for elderly?
downhill trajectory, the pt should have palliative care. if they're doing ok, should have aggressive treatment
what are intrinsic changes?
processes that occur within the body and do not result from external factors
what are progressive changes?
processes, not events
what are deleterious changes?
processes that are negative and decrease the person's ability to survive
what are some physical changes that occur with aging?
they begin at the cellular levels, cells become fewer and less are functional, graying hair, loss of SQ fat, loss of stature, lower oral temp, reduction in lean body mass (fat goes to abdomen), bone mass decreases, body fat doubles, extracellular fluid remains constant
what is frailty?
have to do everything for the person, they have no adaptive abilities
what is relative health?
if person has relative health, they have a wide zone of adaptation, can survive if things happen
what are some cardiovascular sx to consider with elderly?
postural hypertension (due to HTN meds affecting baro-receptors) increases risk of fall, risk of MI and stroke
what should you consider while examining an older adult?
get attention, assess hearing and LOC by saying "how are you," give time to respond, use 2ndary source if necessary, keep it simple, demonstrate physical skills, consider environmental factors
what are advance directives?
make sure proxy knows what the person wants, know if DNR, DNI, DNH, palliative care, hospice, comfort measures
what is "so what" to lab result?
make sure that the lab has a purpose for the person, don't treat the labs, make sure that the patient is doing better after the treatment, figure out if the result of the lab would help you treat the patient differently, risk vs. benefit
what are considerations for medication with elderly
polypharmacy, start low and go slow, keep regimen simple, provide written instructions and a phone number to call if they have questions.
how is drug absorption affected in elderly?
increased gastric pH, decreased motility, slower absorption and delayed onset, greater bioavailability of drugs with high hepatic extraction (due to decreased liver function)
how is drug distribution affected in elderly?
decreased total body fluid, increased body fat, decreased lean muscle mass, decreased serum albumin-->smaller older adult more sensitive to dose, lipophilic drugs have increased 1/2 life, hydrophilic drugs have increased peak concentrations
how is drug metabolism affected in elderly?
decreased renal and liver blood flow, increased/decreased effect of toxicity of drugs metabolized
how is drug excretion affected in elderly?
decrease liver and renal blood flow and rental tubule secretory function-->increased effect and toxicity of renally eliminated drugs and those metabolized in the liver
what are the "geriatric giants?"
mobility, bowel-bladder continence, mental status, self-care, safety, social support
what is a homologous transfusion?
you don't know the donor, must do blood typing
what is an autologous transfusion?
4-6 weeks before the procedure you donations of your own blood begin, pt takes iron, last donation of blood made 72 hours before surgery.
what is directed donor transfusion?
person donates blood specifically for another, designated person. it's not safer. person can check a box saying "do not use this blood" if don't want questions raised.
what is blood salvage?
uses a cell saver in the OR or ER, your blood is mixed with saline, spun out and given back to you (so you get your own blood back), good for people who are nervous about transfusions. working on artificial blood production, too.
what is normal hematocrit count?
females: 35-45% males: 40-50%
what is normal hemoglobin count?
female: 12-14 g male: 13-17 g
what are the hemoglobin values for an anemia scale?
moderate anemia: 8-10 g severe anemia: 6-8 g life-threatening: less than 6 g
what would you do for someone who lost a lot of blood, hgb is down to 7?
have them lie flat, don't take a lot of blood from them for tests, give them an IV of iron, administer epoiten alpha (stimulates production of RBC)
what is FFP?
fresh, frozen plasma
what are the risks involved with transfusion?
transmission of disease (takes 2 weeks to screen for HIV), bacteria control (has to be regulated at a certain temperature, and can only hang blood for certain amount of time- usually 4 hours and within 30 mins of receiving), febrile, hemolysis (typing issue), overload
what is the reason for giving someone PRBC?
increases the O2 carrying capacity, and replace blood loss. if this is not needed just give the person fluids.
what is included in consent for a transfusion?
there needs to be an MD order, and consent which is usually surgical. consent can last the whole hospitalization, unless the diagnosis changes.
what is involved in type and cross checking of blood?
take the blood of the patient and mix it with the donor blood to see reaction. Coombs test is performed, and you want no reaction and no agglutination. this should be done in advance bc takes about 45 minutes.
how do you set up a blood transfusion?
blood tubing has a filter which removes clots and debris, always run normal saline with transfusion, blood must have a dedicated line that only blood goes through it until completed.
what is the RN procedure for obtaining blood?
first sign it out. when you get it from the blood bank, you need to compare 2 IDs on the blood and the patient, verify the type and the unit number, you have to have another RN with you and you must be at the patient's bedside. both RNs must sign.
what is the timeframe for transfusion?
blood must be hung within 30 minutes of receiving in, and it must run between 0-4 hours. need to regulate the blood so that it gets in within specified time frame.
what do you monitor during a transfusion?
at baseline, do full VS. stay in the patient's room for the 1st 15 minutes, at 15 mins take temperature and others if needed. then, take VS q hour. At completion, take another full set of VS.
what sx indicate transfusion reaction?
temperature increase of 2 degrees or more, if they are itchy or having any pain
what is the rate for transfusing PRBC?
250-375 mL over 1-4 hours, unless there's an emergency
what are the expected lab results 2-4 hours after PRBC transfusion?
Hematocrit increases 3% per unit of PRBC; hemoglobin increases 1 gm per unit PRBC
what is the general reason for transfusing platelets?
to control or prevent bleeding
what would be a patient look like when you would need to transfuse PRBC?
give it if they are actively bleeding, have less than 25% hematocrit, less than 8g hgb, and are symptomatic (tachycardia, fatigue, pallor, dyspnea, increased RR, drop in O2 sat, decreased BP)
at what platelet count would you transfuse platelets?
you don't give them routinely. do if it the platelet count is less than 50,000 and the person is actively bleeding. must transfuse if platelet count is lower than 20,000 regardless of bleeding status
what is the rate that you transfuse platelets?
usually give between 5.10 units of platelets over 15-30 minutes
what lab results 2-4 hours post-platelet transfusion are expected?
platelet count increases 5000-10,000 for each unit of platelets
why would you give FFP (fresh, frozen plasma)
to provide clotting factors
what data would suggest that you need to give FFP?
INR greater than 1.5 PT greater than 15 PTT greater than 45
what is the rate for FFP infusion?
250 mL for 30-60 minutes
what is the expected lab result for FFP infusion
INR less than 1.5; decrease in PTT and PT
what is the reason for administering cryoprecipitate?
fibrinogen deficiency, hemophilia A, hemophilia B
when would you administer cryoprecipitate?
when fibrinogen is less than 100 mg/dL
what is the rate for cryoprecipitate infusion?
IVP over 3 minutes
what is normal platelet count?
what is normal PTT?
21 - 35 seconds
what is normal PT?
11 - 13 seconds
what is a normal RBC count?
what is a normal WBC count?
what is the first reaction if a transfusion reaction is suspected?
stop the blood transfusion
what are the signs of a febrile, non-hemolytic reaction?
fever, chills, flushing, headache
what is the usual response/treatment for a febrile reaction?
stop blood if temperature is increase 2 degrees from baseline. Call the MD. Give tylenol or benadryl 30 minutes before a subsequent transfusion.
what are sx of a mild allergic reaction to a transfusion?
itching, uticaria, flushing
what is the treatment for a mild allergic reaction?
stop blood, call MD. benadryl 30 prior to subsequent transfusion.
what are sx of a hemolytic reaction?
classic triad: fever or chills, flank (low back) pain, reddish/dark urine (hemoglobinuria. Also: anxiety, HA, increased RR, increased HR, severe hypotension, chest pain.
slow rate or stop transfusion, call MD. position with HOB increased. O2 at 2-4 LNP, lasix IVP
what are sx of sepsis?
fever, tachycardia, hypotension, chills
what is response to sepsis?
stop blood, call MD, NS IV, cultures, antibiotics
what is ECF, and what are main components?
extracellular fluid, plasma in the interstitial space, most common cation is Na, most common anion is Cl. fx: transport of nutrients and oxygen through blood stream (cleaned up by lymph)
what is ICF, and what are main components?
intracellular fluid (in cells). most common cation is K, most common anion is Phosphate. majority of water is intracellular.
what is diffusion?
movement of solids across a semi-permeable membrane
what is osmosis?
movement of fluids across a semi-permeable membrane
what factors affect body water concentration?
fat (contain little water, decrease H20 with more fat) age (decreased with age) gender (females have lower water bc more fat)
how does age affect body water concentration?
normal water content for adult is 50-60%, for older adult it's 45-55%, making them more at risk for deficits and dehydration.
what is transcellular space?
CSF, pleural fluid, synovial fluid, GI tract, peritoneal fluid spaces.
what is facilitated diffusion?
protein carriers bind to a specific solute (ion) and transport substances across the membrane (either way)
what is hydrostatic pressure?
the pressure that is exerted when a liquid is at rest (pushes water out of the cells)
what is oncotic pressure?
pulls fluid into the cells
what happens to a solution with a high solute concentration?
there is a high osmotic pressure, which draws fluid in
what happens to a solution with low solute concentration?
there is a low osmotic pressure, so water moves out
what is osmolarity?
the number of particles in a liter of solution. osmolarity increases with dehydration and decreases with hydration.
what is normal urine serum osmolarity?
what are the 3 movements of body fluid?
hypertonic: pulls fluid from a cell isotonic: expands fluid volume without causing a fluid shift hypotonic: allows fluids to move into cells
what is a water deficit?
40% of water is normally in the cell, this gets pulled out when there is a deficit
what techniques can nurses use for fluid shifts?
measure intake and output; assess for skin turgor, capillary refill, sunken eyes, dehydration; edema in ankles and stomach; crackles in lungs; decreased BP, increase HR, daily weights
what is hypothalamic regulation?
- in water deficit, hypothalamus stimulates thirst and secretion of ADH for reabsorption of H2O by kidneys. - in water excess, hypothalamus suppresses the secretion of ADH and allows the excretion of water by the kidneys
what is pituitary regulation?
hypothalamus controls posterior pituitary which releases ADH. Problems: - syndrome of inappropriate anti-diuretic hormone (SIADH): a disorder where ADH is abnormally secreted causing water retention - diabetes insipidus: reduction in the release or action of ADH
what is adrenal cortical regulation?
regulated by adrenal hormones: glucocorticoids; mineralcorticoids
what is renal regulation?
kidneys are the primary organ in F/E balance. kidneys hold on to Na and get rid of K. selectively reabsorb electrolytes through the urine. renal tubules control the action of ADH and aldosterone.
what is cardiac regulation?
atrial natriuretic factor (ANF): released by the cardiac atria in response to increased atrial pressure
GI tract accounts for majority of fluid intake (2000-3000mL/day), small amount is excreted in feces, diarrhea and vomiting are big problems for dehydration
what is insensible water loss?
invisible water loss through vaporization out the lungs and skin. serves to maintain body temperature, lose approximately 900mL/day (more with athletes)
what is the role of sodium (Na)?
maintains ECF volume and concentration, determines ECF osmolality. Generates nerve impulses important for muscle contraction. excreted through urine, sweat, and feces.
what is hypernatremia?
an increase in Na, causing water to shift out of the cells and into the ECF. causes cellular dehydration, increased pressure, fluid retention, and makes heart work harder. occurs with H2O loss. Prevented by thirst reflex.
how do you treat hypernatremia?
treat the underlying cause. if NPO, give IV D5 or hypotonic saline. administer diuretics, decrease Na gradually (or else there will be cerebral edema)
what is hyponatremia
low sodium caused by water excess or loss of sodium-containing fluids. could be caused by N/V/D, NG tube, sweating. Na range from 128-130.
what are clinical sx of hyponatremia?
confusion (r/o stroke), nausea, vomiting, seizures, coma
what is the treatment for hyponatremia?
if caused by excess H2O, fluid restriction is needed. if seizures occur, small amount of hypertonic solution given.
what is normal range of Na?
135 - 145
what causes ECF volume imbalances?
hypovolemia: loss of fluids resulting in plasma-to-interstitial fluid shift hypervolemia: excessive intake of fluids resulting in interstitial to plasma shift
what is the treatment for hypovolemia?
give isotonic IV solutions or blood to replace the volume that's lost.
what is the treatment for hypervolemia?
use of diuretics, fluid restriction, Na restriction
what is K, where is it stored, where does it come from, what does it do?
1) major intracellular fluid ion 2) needed for transmission and conduction of nerve impulses, maintenance of cardiac rhythms, skeletal muscle contractions, acid-base balance 3) critical action of membrane potential 4) found in fruits and veggies, salt substitutes, medications, stored blood
how do you administer K
NEVER IVP. can give bag of diluted K on a pump, or in KCl, but nevermore than 10mEq/hr
what causes hyperkalemia?
1) increased retention of K due to renal failure or potassium-sparing diuretic 2) increased intake of K 3) mobilization of ICF from tissue destruction or acidosis
what are the clinical manifestations of hyperkalemia?
1) skeletal muscles are weak or paralyzed (including the heart) 2) vtach-->vfib-->asystole 3) cardiac depolarization is impaired 4) abdominal cramping or diarrhea
what is nursing management of hyperkalemia?
1) eliminate PO or IV K+ 2) increase the elimination of K+ (diuretics, dialysis) 3) IV sodium bicarb to for K from the ECF to the ICF 4) administer IV calcium gluconate to reverse effects of elevated ECF
what is the normal range of K?
3.5 to 5
what are the causes of hypokalemia?
increased loss of potassium due to: 1. aldosterone 2. loop diuretics 3. GI losses 4. associated with Mg+ 5. movement into the cells
what does an EKG of a person with hypokalemia look like?
P wave- slightly peaked PR interval- slightly prolonged ST- depression T wave- shallow U wave- prominent
what does an EKG of a person with hyperkalemia look like?
P wave- flat and wide R wave- decreased amplitude QRS- widened T wave- tall and peaked
what are the clinical manifestations of hypokalemia?
1. ventricular arrythmias 2. decreased GI motility 3. increased digoxin toxicity 4. muscle weakness and paralysis 5. muscle cell break breakdown (myoglobin in plasma and urine)
what is nursing management for hypokalemia?
replacement PO or IV (NOT PUSH) of K, no more than 10-20 meq/hr - NEVER GIVE K to renal failure patient who is on dialysis
what does calcium do in the body?
calcium is absorbed from food, has inverse relationship with phosphorus, stored in the bones, transmits nerve impulses (including the heart), blood clotting, formation of teeth and bones, muscle contractions
what causes hypercalcemia (4)?
1. hyperparathyroidism 2. malignancy (tumor secretes hormones to keep all Ca) 3. vitamin D deficiency 4. prolonged immobilization
what are clinical manifestations of hypercalcemia?
promote excretion of calcium using: 1. loop diuretics 2. isotonic saline infusion (for hydration) 3. synthetic calcitonin 4. mobilization (to stop calcium from leaving the bone)
what are the causes of hypocalcemia (5)?
1. decreased production of parathyroid hormone 2. acute pancreatitis 3. multiple drug transfusions 4. alkalosis 5. decreased Ca intake
what are clinical manifestations of hypocalcemia?
1. Trousseau's sign (twitching hand with BP cuff) 2. Chvostek's sign (twitching eye/face when touch) 3. dysphagia 4. numbness 5. tingling around the mouth 6. laryngeal stridor
what is nursing management for hypocalcemia?
treat the cause of it, less invasive treatments are better, PO or IV Ca supplements
what does phosphate do in the body?
1. essential for muscle, RBC, and nervous system function 2. acid-base balance, ATP production, cellular use of glucose 3. kidneys are major route of phosphate excretion
what are the causes of hyperphosphatemia?
1. acute or chronic renal failure 2. chemotherapy 3. excessive injestion of milk or laxatives containing phosphate 4. large intakes of vitamin D
what are the clinical manifestations of hyperphosphatemia?
1. hypocalcemia 2. tetany 3. calcium phosphate precipitates in the skin, soft tissue, cornea, viscera and blood vessels
what is nursing management for hyperphosphatemia?
1. identify and treat the underlying cause 2. limit intake of phosphorous in food 3. hydration and treatment of hypocalcemic conditions 4. administer sevelamer (medication that binds to phospate to decrease levels)
what causes hypophosphatemia?
1) malnurishment 2) alcohol withdrawal 3) use of phosphate-binding antacids 4) with inefficient parenteral nutrition
what are the clinical manifestations of hypophosphatemia?
1) maintenance- when PO intake is not adequate 2) replacement- when losses have occured 3) need to be cautious of electrolyte imbalances 4) as a last effort, but depends on the disease process
what happens if you administer an IV of hypotonic solution?
fluid goes into the cell, which causes the cell to swell and potentially burst. this can pose a risk, especially in neuro.
what happens if you administer an IV of isotonic solution?
no shift change, but volume is expanded. ECF=ICF
what happens if you administer an IV of hypertonic solution?
fluid moves out of the cell, so the cell shrinks. the ECF becomes dehydrated.
why would you administer D5W (an isotonic solution)?
1) provides 170 kcal/L 2) free water will move into the ICF causing an increase in renal solute excretion 3) prevents ketosis 4) supports edema formation 5) decrease chance of IVF overload 6) compatible with medications
what is normal saline?
isotonic, 0 calorie solution. 30% is intravascular, 70% is extravascular. Important for immediate fluid response. Does not change the ICF. Used in conjunction with blood products (always hang together)
what is Lactated Ringer's (LR)
similar to plasma, has less NaCl than NS. Contains K, Ca, PO4, and electrolytes. Expands the ECF, intravascular. Do not want to free flow it in, or can administer too much K.
what is D51/2W?
HYPERTONIC solution, which is a common maintenance fluid. May contain KCl. Provides calories. Moves into ICF. Compatible with medications.
what is D10W?
HYPERTONIC. Provides 340 kcal/L. Expands the ECF. Hang it if you're waiting for TPN from pharmacy. Provides free water with no electrolytes.
what causes acute side effects of external radiation?
inflammation and irritation
what causes long-term side effects of external radiation?
scarring, replacing normal tissue with scar tissue, or destruction of tissue
what are the most common general side effects of external radiation?
fatigue (cumulative) and radiation dermatitis (redness- week 2, itching, dryness, scaling-week 3-5 of skin), change in taste (metallic)
what are the common SE of radiation to the head/scalp, and what are the tx?
hair loss-->tx: will grow back (no tx) cerebral edema-->steroids
what are the common SE of radiation to the oral cavity/neck?
mucositis (pain, increases risk of oral candidiasis); permanent xerostomia, tooth decay, changes in taste of food, hypothyroid, hearing loss
what are the tx for SE of oral cavity/neck radiation?
viscous xylocaine, eat soft/slushy foods, artificial saliva, flouride treatments, no alcohol-based mouthwash, intake of high calorie, high protein foods to reduce weight loss
what are SE of lung radiation, and what are the tx?
1. change in bowel or bladder fx 2. sores that do not heal 3. unusual bleeding or discharge 4. thickening or lump in breast or elsewhere 5. indigestion or difficulty swallowing 6. recent change in wart/mole 7. cough or hoarseness
neutropenia*, thrombocytopenia, anemia (all-->bone marrow does not produce neutrophils, platelets or RBC)
what is the ANC and how do you calculate it?
Absolute neutrophil count ANC= Total WBC x (% of neutrophils + % bands)
what is the normal range for phosphorous?
what is the normal range for calcium?
lab values for neutropenia toxicity scale
normal= 3000-7000 cells/mm3 mild neutropenia= low normal- 1500 moderate= 1500-1000 severe= 500-1000 life-threatening= less than 500
what special precautions would someone with an ANC of 3000-7000 need for chemo?
they can get chemo because in the normal range. should practice hand hygiene, and get the flu and pneumococcal vaccines, and stay away from people with active illnesses
what special precautions would someone with an ANC of 1000 get?
person is still an outpt. they need to avoid anything invasive (e.g. no tampons, wear gloves), use hand hygiene and deep breathing exercises. start on neucogen (G-CSF: Granulocyte colony stimulating factor), low-microbial diet, if they get a fever, ADMIT. may have bone pain
what special precautions would someone with an ANC of less than 500 get?
life threatening, usually have a fever too. pt would be in private, positive pressure room (air forced out). on broad spectrum antibiotic. BIGGEST WORRY: PERSON WILL BECOME SEPTIC. discharge when ANC greater than 1000. NO CHEMO.
what is nadir?
the low-point of WBC count (and RBC). this is when pt is at highest risk for infection. calculate it.
what is a normal platelet count?
at what platelet count would you start to worry about thrombocytopenia, and why?
50,000, big worry is BLEEDING AND MENTAL STATUS CHANGE (pt shouldn't use anticoagulants, razors, etc.) need to watch patient to assess for bleeding (bruising), mental status-bleeding in the brain
what would you do for a pt with 20,000 or less platelets?
they are on high alert, would transfuse them immediately. transfusion should increase platelet count by 5-10,000 per unit infused. worried that they may spontaneously bleed.
how do you treat anemia?
administer epoitin-alpha (epogin or procrit) which stimulates bone marrow to produce RBC (hgb must be less than 10g/dL). give this SC, QOD, at same time as iron
what are some sx of anemia?
shortness of breath, fatigue, tachycardia, pale, not energetic
when would you transfuse an anemic patient?
if they're symptomatic, actively bleeding, or if their hematocrit falls below 25 (hgb below 8)
what are the causes and types of N/V from chemo?
chemo is noxious and interacts with NK-1 receptors in brain which triggers N/V. types: acute- develops within 48 hours and delayed- extends beyond 48 hours to next treatmnet, and anticipatory (before chemo actually admin)
what drugs can be used to combat N/V
serotonin-receptor blockers: Zofran dopamine-receptor blockers: Lorazopam NK-1 receptor blockers: appartant * mostly give these drugs in combination
what are the sx of mucositis, and how do you assess it?
caused by rapidly dividing epithelial cells in the mouth, lots of redness, pain, difficulty swallowing, inflammation. look with flashlight in mouth for sores, redness, lesions; voice quality, pain, herpes
how do you prevent mucositis?
good oral hygiene and having the patient keep ice chips in their mouth while receiving chemotherapy.
what are tx for mucositis?
magic mouth: combination of benadryl, kaopectate, and viscous lidacaine which numbs the mouth so the pt can eat (no taste though)
what are risks from diarrhea and how would you treat it?
risk of dehydration, replace fluid and electrolytes and administer immodium (loperamine)
how do you recognize and treat spinal cord compression?
early dx is critical or else may be irreversible. highest risk pt are those with mets to the spinal cord. sx: back pain, motor weakness, paresthesias in legs, bladder and bowel issues (incontinence, renention, CONSTIPATION). tx: immediate neuro eval (xray, MRI), immediate radiation or decompression, administer decadron
how would you recognize and treat increased intracranial pressure?
cause: space occupying lesion, brain mets, hemmorhage, abscess (usually from lung, breast and melanoma cancers). tx: MRI, decadron, radiation therapy for 1-2 weeks
how would you recognize and treat pericardial effusion?
can lead to cardiac tamponade. highest risk: lung, breast cancer. sx: chest pain, pain on inspiration, CHF. tx: tap and drain accumulated fluid, monitor for fluid reaccumulation
what is hypercalcemia (cancer)?
less than 14 mg/dl, interferes with renal absorption of Na and H2O leading to polyuria and dehydration. usually occurs secondary to bone mets.
what are sx of hypercalcemia, and who is most at risk?
risk: lung, prostate and breast cancer sx: "abdominal moans"- N/V/constipation, anorexia then "psychic groans"- lethargy, decreased concentration, decreased self-care, cardiac issues
what is tx for hypercalcemia?
hydration of 2-3 liters per day (preventative), high volume NaCl with lasix, biophosponates, calcitonin, mithromycin
what is the first-line tx for breast cancer?
breast conservation therapy including lumpectomy (+ radiation)
what is a lumpectomy?
surgery to remove the margin until just cancer-free cells are present in the tissue. it's an outpatient procedure.
what is a simple mastectomy?
take out all of the breast tissue, but none of the surrounding muscle. usually a 1-day procedure. does not remove lymph nodes
what is a modified radical mastectomy?
a mastectomy with a sentinel node biopsy or an axillary lymph node biopsy. remove breast tissue and get either one of those.
what is a sentinel node biopsy?
a sentinel node drains the majority of lymph from the breast. inject a dye into the lymph node and see which takes up the majority of the dye (these are the nodes that you would remove). low risk of lymphadema. good for assessing in the cancer has spread to the lymph system.
what is a lymph node dissection?
removes a sample of the lymph nodes (axillary and surrounding). good for determining if cancer is in lymph nodes, and how extensive spread is. risk for lymphadema.
why is it best to do reconstruction at the time of mastectomy?
tissue is pliable, there is an easily recognizable blood supply. if not then, must wait 3-6 months until chemo/radiation are finished.
what are implants?
can be either saline or silicone. 1-2 hour procedure. put in a tissue expander at the time of mastectomy, inject saline to stretch the skin to prepare it for the implant; can be a little painful, create nipple, tattoo areoli. quick and least traumatizing to body.
what is a TRAM reconstruction?
transverse rectus abdominal muscle flap. reconstrusts breast from tissue and muscle from abdomen. gold standard procedure. gains and loses weight with person. 4-5 hours per breast. risk for hernia.
what is a DIEP graft?
deep inferior epigastric perforator graft- reconstruct breast tissue using fat from abdomen. person will have 2 drains in abdomen and breast.
what are the post-op concerns for TRAM or DIEP?
make sure tissue is viable, assess blood supply q2-4 hours (measure O2 sat), concerned if it drops 20% in an hour-->need to go back to OR. what sutures, capillary refill, color (not good if purple). keep room hot, good vasodilation, keep pt hydrated, give aspirin.
how do you tx pain following mastectomy?
epidural or PCA, switched quickly to oral meds when tolerating fluids. elevate the arm on pillows to prevent swelling. if they have numbness of inner arm, will not go away.
how do you tx wound healing post-mastectomy?
check for evidence of bleeding or hematoma. JP drains will yield sanguinous or serosanguinous exudate. pt will go home with drains-->teaching to empty and measure drains. surgeon will remove when drainage is less than 30cc/24 hours. heep HOB at 45 deg and knees bent 45 deg
what is the risk of lymphadema?
collection of fluid resulting in 2 cm difference in limb girth or 200 mL volume difference. interventions: assess for swelling, pulses, color, sensation and motion. elevate arm. no procedures on that side. no heavy lifting, use compression wraps. arm exercises (PT)
what is normal WBC count? (how many T-cells too)?
WBC: 4000-10,000 t-cells: 500-1000 (low, less AB production, more prone to infection)
what are the 3 things that happen when HIV infects a t-cell?
1) the cell becomes damaged, so it can't properly do it's job 2) when the cell divides, it produces infected daughter cells 3) every time it's stimulated, it will release HIV into the blood stream which will infect other t-cells.
how does the HIV virus attack cells, and how do you test for it?
attacks t-cells by binding to the CCR5 co-receptor (if defective, immune). test for the P24 capsule, though there is a window of ~2 weeks after you are exposed and before P24 shows up in the blood stream.
what is the HIV process?
exposure to virus-->acute retroviral syndrome (fatigue, sore throat, aching muscles, fever, swollen lymph nodes)-->relative health-->seroconversion (when can test for AIDS) or early HIV-->early AIDS
what is the criteria for AIDS?
CD4 count of less than 200, and an opportunistic infection.
what is pneumocystis carinii pneumonia?
fungus that affects lungs, risk when CD4<100. tx: prophylaxis with TMP-SMX (bacrtim) double strength daily when CD4<200 or lifelong following infection.
what are sx of PCP?
fever, progressive dyspnea, non-productive cough, chest pain. more sx with exertion. increased RR, increased HR, rales, hypoxemia.
how do you dx PCP?
chest xray, bronchoscopy for sputum specimen.
what is tx for PCP?
21 days IV Bactrim or pentamidine (2nd choice)
what are the key elements of PEP (Post-exposure prophylaxis)?
start PEP drug regiment ASAP including 2 NRTI drugs or 1 NRTI and 1 NtRTI. consultation and counseling. baseline HIV testing, then repeat 6 weeks, 12 weeks, 6 months. antiretroviral drugs taken for 4 weeks. reduce risks: needle sharing, anal intercourse. effective within 72 hours.
what are the steps for normal wound healing?
1-3 days: fibrin and epithelial layers close the edges of wound, blood supply and nutrition return to wound 2-3 weeks: collagen fills up the wound, heals from the inside-->out 2 years: wound fully healed.
how do you assess a wound?
look at the wound if you can see it, or the dressing if you can't. look for: redness (around margins), increased warmth, swelling, pain/tenderness, type and amount of drainage, wound edge approximation (dehiscence or evisceration) cormobidities: healing in the past, obesity (inc. pressure)
what will dressing look like during healing process?
first will be sanguinous, then serosanguinous (orange)- if still present after 5 days, alert MD, the serous (yellow-clear)
how do you assess drains?
what type, where they’re coming from, type of drainage that’s going into drain record: drainage (type and amount), suction/patency (unobstructed), open vs. closed
what are comorbidities that make wound healing more difficult?
-how well they have healed in the past -obesity (very difficult to suture adipose tissue, may have retention sutures) -smokers: problem with getting O2 to the site. -immunocompromised pt: affects immune sx. -malnourished pt -constipation -chronic disease requiring steroid therapy -cough (stress on wound)
what factors cause ineffective wound healing?
edema (distention), stress at surgical site due to comorbidities
what are nonverbal signs of pain, and how does it affect wound healing?
grimacing, guarding, crying, moaning, increased temperature, change in LOC. won't get up and move which increases risk of DVT and atelectasis. (verbal- pain scale). need pt to cough, deep-breathe, incentive spirometer
what are the causes and common sites of pressure ulcers?
skin against bony prominences, improper oxygenation of tissues. common on sacrum, hips (trocanter), ankles (inside), heels...also occipital, scapula, shoulder points.
what are complications of pressure ulcers?
can turn septic, can attack kidneys, infection can travel to the bone (osteomyelitis), infectious arthritis, nosocomial infections
what are nursing actions to avoid pressure ulcers?
pull patient up carefully, avoid HOB being too high that patient slips down, keep HOB around 30 degrees, use specialty mattresses and beds, turn patients q2 hours, float heels, move bigger patients with a machine, use barrier creams
how do you assess a pressure ulcer?
look at (and document) location (use person's body as a clock to document location), size, color, amount of necrotic tissue, what the edges look like, granulated tissue?
what drugs would you use for someone who had MRSA?
vancyomycin and zyvox
how do you assess someone for infection?
spike a fever (except for older adults and immunocompromised patients), exudate (excessive), granulated or necrotic tissue, past med hx including diabetes (increase in sugar in blood, increase bacteria), systemic response (lymphadenopathy)
what would labs look like if someone had an infection?
increase WBC count or shift to the left (meaning more bands- immature neutrophils)--heads towards systemic problem if bone marrow becomes compromised.
when do you start an antibiotic for a wound infection?
AFTER YOU DO A WOUND CULTURE AND SENSITIVITY. usually do this in 3 different locations, 20 mins apart. after this, start broad spectrum AB. when labs come back, can start on narrow spectrum AB based on what bacteria it is, and what meds it's sensitive to.
what is the #1 risk for a fall?
history of a previous fall, especially if it was recent (also A&O low, unsteady gate, medications, especially beta blockers which cause orthostatic hypotension)
what are interventions for falls
HOB up or down, side rails up, call light clipped and within reach, location of the bathroom and obstacles to getting there, making sure there's enough light, bed alrms, bed in lowest and locked position
what is the process of shock
baroreceptors sense MAP and respond to a drop in pressure of 5-10mmHg. begin activating hormones of SNS which shunts blood to the brain, heart and liver. other organs begin functioning under anaerobic conditions (compensatory) which starts fluid shifts and lactic acid build up. pH drops, HR increases, tachycardia, MODS
how do you calculate MAP?
[systolic BP + (diastolic BP x 2 )] / 3
what is normal MAP range, and what does number tell you?
MAP range should be 70-100mmHg, the number tells you how well the tissues are being perfused with oxygen. goal is to keep it above 60.
what happens in the initial stage of shock?
1) may not be clinically apparent. 2) MAP decreases ~10mmHg 3) some tissues start being destroyed, so increase in lactic acid (anaerobic fx) 4) increased HR, RR, DBP, (SBP=)
what are the subjective measures of the compensatory stage of shock?
patient has extreme thirst due to increased Na, and they will complain of anxiety.
what are the objective measures of compensatory stage of shock?
what measures signify the progressive stage of shock?
1) MAP decreased by 20mmHg or more 2) compensatory mechanisms are failing--not enough O2 to organs 3) 5-20% decrease in O2 sat from baseline 4) pH decreases, lactic acid increases, K increases 5) thready pulses, decreased BP, cool extremities, pallor
what are sx of the refractory stage of shock?
1) peripheral vasoconstriction and decreased CO 2) fluid leaks out of vascular spaces, blood flow not maintained 3) cell destruction leading to death
what are the causes of hypovolemic shock?
ABSOLUTE: decrease circulating volume due to hemmorhage, trauma, GI loss RELATIVE: sequestration of fluid due to burns, cirrhosis, ruptured spleen - volume is inadequate to fill vascular space
what are the classifications of hypovolemic shock?
mild: 20% blood volume lost, vasoconstriction and shunting moderate: 20-40%, cellular destruction (kidneys, spleen, pancreas) severe: >40%, decrease perfusion to heart, confusion, decreased CO