AH 2, test 3 Flashcards

Bone marrow
Terms Definitions
Bone Marrow is a ______ forming organ.
blood. By 18, blood production is limited to the ends of the long bones. This is where we find Stem Cells which mature & become our blood cells.
How many RBCs is it normal for a person to have? What is another name for RBCs? What is their norm lifespan? If there is problems in the ________ there is problems with RBCs.
4-6 million. Erythrocytes. 120 days. kidneys.
How many WBCs is it normal for a person to have? What is another name for WBCs? Why are WBCs critical?
5,000-10,000. leukocytes. inflammation & immunity.
How many platelets is it normal for a person to have? How do platelets function & what is the importance of platelet aggregation?
150,000-400,000 is normal platelets. Platelets form platelet plugs which prevent from bleeding out. platelets clump together to form platelet plugs necessary for coagulation (blood forming clots).
A low platelet count is called _____________.
Thrombocytopenia. Platelet counts under 50,000 put a patient at risk of severe bleeding and platelet counts under 20,000 may cause spontaneous and fatal intracranial bleeding.
A high platelet count is called ___________.
thrombocytosis. Patients who have a high platelet count may have an increased risk of forming a thrombus. Importantly, a high platelet count may also place a patient at risk for a bleeding episode. When the platelet count is high, some of the platelets may be abnormal forms that do not function correctly to assist in the coagulation process.
What is the function of the spleen? If the spleen is taken we have problems with ____________.
The spleen destroys RBCs, stores platelets, and filters antigens. Spleen taken out? problems with Immunity.
What is the function of the Liver?
Liver is the Production site for prothrombin and clotting factors. If there is liver disorders, you may very well be at risk for bleeding.
Heparin & Lovenox are given for what? What categories are they examples of?
ANTICOAGULANTS. Heparin is for the treatment of DVT after have one. (remember pt w/ DVT on Heparin drip). Lovenox is for prevention of DVT. (Pt on long term bedrest is getting Lovenox injections to prevent DVT formation.
Coumadin is a __________ __ antagonist. What does it do?
Vitamin K - helps clot. Coumadin is a vitamin K ANTAGONIST (means it opposes the clot formation).
If your patient is on Coumadin, do you want them eating a diet high in Vitamin K? What should they avoid?
No, it would be working opposite of the meds. Vitamin K is in dark, leafy greens (Kale, spinach, broccoli, brussel sprouts, peas) and will increase blood clotting.
Streptase is a ___________.
fibrinolytic.
Fibrinolytics, like Streptase, are given when?
When they actually have a clot (DVT) & we need to treat it.
What is the most imp info to know when a pt arrives with a DVT is...
when was the onset of symptoms. This is b/c there is only a window of when the fibronolytic (Streptase) can be used. Usually 4 hrs or less.
Aspirin & Plavix are examples of ___________ ____________.
platelet inhibitors
What is a normal RBC amt for a Complete Blood Count (CBC)?
4.2-6.1
Decreased RBCs (less than 4.2) indicates...
possible anemia or hemorrhage
Increased RBCs (more than 6.1) indicates...
chronic hypoxia or polycythemia vera
What is a normal WBC in a complete blood count (CBC)?
5,000-10,000
Increased levels of WBCs (more than 10,000) are associated with...
infection, inflammation, autoimmune disorders, and leukemia.
Decreased levels of WBCs (less than 5,000) are associated with...
prolonged infection or bone marrow suppression
What is a normal Hemoglobin for a CBC?
12-18 g/dL
What is a normal Hematocrit for a CBC?
35-52%
Increased & decreased levels of Hgb & Hct indicate what?
Same as when RBC is high or low. If high=anemia or hemorrhage. If low=chronic hypoxia or polycythemia vera.
The Prothrombin time (PT) measures how long blood takes to clot. A normal PT is...
11-12.5 seconds
PT is monitored for patients taking...
Sodium Warfarin (COUMADIN!)
The partial thromboplastin time (PTT) assesses the clotting cascade. PTT is prolonged whenever there is hemophilia DIC (disseminated intravascular coagulation). _________ therapy is monitored by PTT. Desired therapeutic ranges for anticoagulation are _
Heparin. 1.5-2.0 times normal value.
Facilities are using PT test less often b/c of differences between one lab to the next. To reduce PT errors, the ___ is used to assess clotting time.
INR (International Normalized Ratio)
The INR measures the same process as PT (how long it takes blood to clot), but in a slightly different way - by establishing a normal mean or standard for the PT. A normal INR ranges from: __-__. However, the goal for someone on Warfarin (Coumain) is __
0.7-1.8 , 2.0-3.0
What are some RBC disorders? What do the first 4 have in common & what does that mean?
Iron Deficiency Anemia, Vitamin B12 deficiency anemia, Folic acid deficiency anemia, aplastic anemia and polycythemia vera (PV) are all RBC disorders. -- First 4 are ANEMIAs, this means reduction in RBC, Hgb, Hct. Anemia is NOT USUALLY THE DISEASE, but symptom of another problem. We will treat the anemia, but need to fin out what the underlying problem is. Anemia is usually a sign that something else is wrong.
Anemia is a reduction in what?
RBCs, amount of Hgb or amount of Hct.
Is anemia a specific disease?
Anemia is NOT a specific disease, rather it is a manifestation of an abnormal condition.
Anemia can result from what?
dietary problems, genetic disorders, bone marrow disease, or excessive bleeding. GI bleeding is the most common reason for anemia in adults.
In iron deficiency anemia, serum iron values are less than ___ g/L.
12
An adequate diet supplies about ___-___ mg of iron per day.
10-15
Iron deficiency anemia is a common type of anemia that can result from:
blood loss (GI bleed or heavy menstruation), inadequate iron intake (too little in diet or too little absorption) or rapid metabolic activity (pregnancy). Iron deficiency is more common in women.
What is the management for iron deficiency anemia?
EVALUATE FOR BLEEDING (find out why they're iron deficient), want them to eat food sources with iron & take iron supplements. Know that YOU CAN GIVE IRON AS an INTRAMUSCULAR INJECTION ALSO!
What are foods high in iron?
Iron is in green leafy vegetables & meat (Liver, red meat, organ meats). many vegetarians may not have enough iron. Iron is also in kidney beans, whole-wheat breads and cereals, carrots, egg yolks and raisins.
Can you give iron as an IM injection?
Yes
Vitamin B12 deficiency inhibits ______ ______ transport reducing DNA synthesis of precursor cells. These precursor cells then undergo improper DNA synthesis and the cells ________ in size.
folic acid. The cells INCREASE in size. This type of anemia is called megaloblasic (macrocytic) anemia b/c of the LARGE SIZE of these abnormal cells.
What causes Vit B12 deficiency?
1. POOR INTAKE (vegetarian diets and ones lacking dairy products) 2. POOR ABSORPTION OF VIT B12 (small bowel resection of tapeworm) 3. FAILURE OF ABSORPTION (pernicious anemia)
What symptoms present when people have Vit B12 deficiency anemia?
1. GLOSSITIS (big, beefy, red, tongue) 2. FATIGUE 3. PARESTHESIAS (b/c vit B12 is needed for normal nerve function, pts often have abnormal tingling sensations in hands & feet)
What is the management for Vit B12 deficiency anemia?
INCREASE VIT B12 INTAKE (food sources, oral supplements and injections (done for pernicious anemia)).
What food sources are high in vit B12?
liver, organ meats, dried beans, nuts, green leafy vegetables, citrus fruit, brewer's yeast.
Folic Acid deficiency anemia is very similar to Vit B12 deficiency, but WITHOUT...
nervous system involvement. So they're very similar, but folic acid is not going to have the paresthesias (tingling).
What are causes for folic acid deficiency?
3 main causes are: poor nutrition, malabsorption (Crohn's disease is an ex of malabsorption) and drugs (anticonvulsants). folic acid deficiency can also cause megaloblastic anemia like vit B12 anemia does.
Prevention of folic acid deficiency anemia is aimed at identifying high-risk clients, like who?
women who are pregnant. Want to encourage a diet high in folic acid & vit B12 (promote foods like liver, organ meats, eggs, cabbage, broccoli & brussel sprouts for folic acid).
Aplastic anemia is a deficiency of circulating RBCs because of...
bone marrow failure
Aplastic anemia often occurs with...
leukopenia (reduced WBCs), thrombocytopenia (reduced platelets).
These 3 problems often occur together (aplastic anemia, leukopenia, thrombocytopenia) b/c the damaged bone marrow loses the ability to produce any of these cells. ___________ (a deficiency of all 3 cell types) is common in aplastic anemia.
PANCYTOPENIA
In about 50% of cases the cause of aplastic anemia is ...
UNKNOWN
How is aplastic anemia treated?
BLOOD TRANSFUSIONS are mainstay of treatment for aplastic anemia. IMMUNOSUPPRESSIVE THERAPY helps those w/ anemia similar to autoimmune diseases. SPLENECTOMY (removal of the spleen) is done for people w/ enlarged spleens that is destroying RBCs or suppressing their development. BONE MARROW TRANSPLANTS replace defective stem cells and can cure the disorder. cost, availability and complications limit this treatment of aplastic anemia.
Polycythemia Vera is _______ of the blood.
cancer
PV is characterized by a sustained ________ in the # of RBCs.
increase
What is PV blood like?
It's Hyperviscous blood (hematocrit of more than 55%). Book said it is a disease w/ a sustained increase in blood Hgb levels to 18 g/dL, a RBC count of 6 million/mm3, or a Hct of 55% or greater.
PV has extreme hypercellularity, this means increases in..
RBCs (more than 6 million), WBCs (more than 10,000) and platelets (more than 400,000)
In PV, the # of cells in the blood is greatly increased and the cells are not completely normal, cell life spans are shorter. The shorter life spans and increased cell production cause a rapid turnover of circulating blood cells. This rapid turnover inc
sludging. Sludging blood is a manifestation of Polycythemia Vera.
Other manifestations & key features of Polycythemia Vera are...
HYPERTENSION, Flushed appearance, distended veins, intense itching, enlarged spleen, infarctions of the heart (MI's), Strokes, Bleeding. These people are just RED and they're often hot too b/c of too many RBCs.
How is Polycythemia Vera managed?
repeated Phlebotomies (2-5x/week) to get rid of all the excess blood, Increase hydration (drink 3 L/day) to dilute blood and reduce clot formation. Take Anticoagulants, wear support stockings, elevate feet (all to promote venous return and help prevent clot formation).
PV patients are on bleeding precautions, so What other precautions are recommended for PV patients?
avoid tight or constrictive clothing, wear gloves, contact physician at first sign of infection, take anticoagulants as prescribed, wear support hose or stockings while you are awake and up, elevate your feet whenever you're seated, exercise slowly and only on the advice of your physician, stop activity at the first sign of chest pain, use an electric shaver, use a soft-bristled tooth brush and do NOT floss teeth.
How do you know the management for PV is working?
Perhaps they're not so hypertensive, maybe their JVD has gone down, maybe they have had a lot of strokes and they're having less strokes.
What is Leukemia?
an uncontrolled production of immature WBCs in the bone marrow
How are leukemias classified?
Either as acute or chronic. Then by cell type. Lymphocytic comes from the lymphoid pathway. Myelogenous comes from the myeloid pathyway.
What are the 3 adult leukemias we discuss?
Acute Myelogenous (AML), Chronic Myelogenous (CML) and Chronic Lymphocytic (CLL).
What is the most common form of adult leukemia?
Acute Myelogenous (AML)
What is the age of onset for AML? Who does it affect most, men or women? What is the prognosis for this diagnosis? What can improve diagnosis?
15-39 years (very young), affects BOTH men & women, POOR PROGNOSIS, best prognosis is with bone marrow transplant.
Chronic Myelogenous Leukemia (CML) usually has an age of onset of over __ years. CML usually affects men or women?
over 50, men
Is Chronic Lymphocytic leukemia common? What is the age of onset? What gender & race is is most common in? Is there a genetic predisposition?
CLL is the RAREST TYPE, usually onset over 50 years-old, WHITE MEN, possible genetic predisposition.
The definitive test for leukemia is done by...
bone marrow aspiration.
What are the nursing diagnosis related to leukemia?
1. Risk for Infection 2. Risk for Injury 3. Fatigue
Leukemia patients are at high risk for infection! What precautions should nurses always take with these patients?
Use extreme care during all nursing procedures to protect leukemia patients from infection. (USE ASEPTIC/STERILE TECHNIQUE) Observe strict procedures when performing dressing changes or accessing a central venous catheter. Maintain strict aseptic technique in the care of these catheters at all times. Use FREQUENT HANDWASHING. Neutropenic precautions.
What are neutropenic precautions for leukemia patients?
This is just a reminder to do good handwashing and keep people away that could increase the patient’s risk of infection. If they have to go somewhere (like radiology) then they can wear a mask to give them some protection from all the bugs floating around the medical world. If they are neutropenic at home—they need to avoid crowds and don’t eat off the salad bar! You no longer need to place them in "reverse isolation" and cover yourself or their visitors with masks, gowns, gloves...
Why is it so important to continually assess leukemia patients for the presence of infection? Why is it so difficult?
Infection signs are usually not obvious in patients with leukopenia (reduced WBCs) in leukemia. The development of fever and the formation of pus both depend of the presence of WBCs. The client with leukopenia may have a severe infection without pus and with a relatively low fever.
What are the 3 phases of drug therapy for acute leukemias?
Induction, Consolidation, Maintenance
During the "Induction" phase, Chemotherapy is done for leukemia. what happens here?
Starts with the diagnosis. Goal is to WIPE OUT THEIR LEUKEMIA, get rid of any sign of it. Goal is RAPID, COMPLETE REMISSION.
What is the major side effect of chemo during the induction phase?
Bone marrow suppression. Other sd effects are nausea, vomiting, diarrhea, hair loss, mouth sores.
When does the 2nd phase, Consolidation, start?
Once they show signs of remission that they don't have it. When consolidation starts the point is to try to cure them.
How is the "trying to cure"/consolidation phase done?
Chemotherapy again, but a different dose or combo of previous treatment. It starts with remission. The goal is to cure. Can be a single dose or repeated doses of chemo.
The 3rd phase is the Maintenance phase and is indicated for what types of leukemia?
ALL (acute lymphocytic anemia) and APL (a type of AML - acute myelogenous leukemia). The goal here is TO MAINTAIN REMISSION. They're often given it orally for 2-5 years.
_____ __________ Transplants are standard treatment for acute leukemias.
Bone Marrow
What are the 3 different kinds of bone marrow transplants? Remember, they are classified by the source of the stem cells...
1. AUTOLOGOUS (pt's own cells) 2. SYNGENEIC (identical sibling's cells) 3. ALLOGENEIC (matched HLA donor, could be a sibling or unrelated)
What are the 5 phases of a Bone Marrow Transplant, what happens in each?
1. OBTAINING STEM CELLS (done by aspiration at the iliac crest usually, peripheral stem cell pheresis or umbilical cord). 2. CONDITIONING (5-10 days of chemo/radiation is done before transplant, we wipe them out. we wait 2 days after chemo conditioning to get chemo out b/c it would kill the transplant itself) 3. TRANSPLANTATION (atleast 2 days after conditioning, infused via central catheter or PICC line) 4. ENGRAFTMENT (when we hope donor cells take to the pt. We hope to see a rise in pt's WBC, RBC and platelets (means they're taking up the donor cells). 5. POST-TRANSPLANTATION RECOVERY (going to be on long term therapy b/c of transplant, risk for infection and bleeding, risk for GVHD)
What is GVHD?
Graft vs. Host Disease. The donated cells recognize the recipient's cells, tissues and organs as FOREIGN and ATTACK them. So, the implant is attacking the host. 15% who develop GVHD die of its complications.
What is an early sign of GVHD?
patients start peeling
Which is the better Hodgkin's (Hodgkins or non-Hodgkins)?
Hodgkin's is better
Hodgkins occurs at what age?
mid to late 20's; don't see it again until over 50 yrs old.
Hodgkins is characterized by the _____________ cell.
Reed-Sternberg
How does Hodgkin's manifest?
Pt's will get a large, painless lymph node in the neck.
What are the survival rates for Hodgkins?
It is one of the most curable cancers, use radiation & chemo
What age group does Non-Hodgkins Lymphoma hit usually?
usually happens to people over 50 years old
Non-Hodgkin's Lymphoma is characterized by....
enlarged lymph nodes that are painless - so they often do not come in for awhile
What is the prognosis for Non-Hodgkin's lymphomas?
Prognosis is not good. Cures are rare. There are 12 subtypes of Non-Hodgkins lymphoma. Radiation & chemo are used.
How common is "Multiple Myeloma"? What age group is effected?
It is very, very uncommon cancer & effects less than 1%. People over 50 years old.
Multiple Myeloma is a ___ cancer than involves a more mature lymphocyte than either leukemia or lymphoma.
WBC
In Multiple Myeloma, there is an excess production of... What effect does this have?
antibodies and cytokines. The excess antibodies and cytokines increases the cancer cell growth rate and destroys the bone... CAUSING FRACTURES!
We are going to look at 2 platelet disorders: Idiopathic Thrombocytopenia Purpura (ITP) and Thrombotic Thrombocytopenia Purpura (TTP). What is the problem with ITP?
There is not enough platelets in circulation (though the body is producing them normally)
ITP is considered an ___________ disease and effects _________ age 20-40.
autoimmune disease b/c clients are producing an antibody directed against the surface of their own platelets (an antiplatelet antibody)... coating the platelet & making them more likely to be destroyed by macrophages, women
In ITP the decreased # of circulating platelets causes decreased ________ ____________.
blood clotting.
What treatment is used for ITP?
IMMUNOSUPPRESSANTS (like Corticosteroids, try to inhibit immune system production of antiplatelet autoantibodies), PLATELET TRANSFUSIONS and SPLENECTOMY (b/c the spleen has lots of macrophages that destroys lots of platelets).
Why is TTP a platelet disorder?
TTP is RARE, but the platelets clump in small vessels leaving too few platelets in circulation. The client has inappropriate clotting, yet the blood fails to clot when trauma occurs.
What happens b/c of TTP & platelet clumping?
Tissues become ischemic
Treatment for TTP involves...
preventing platelet clumping and stopping the autoimmune process. Treatment is plasma pheresis and the infusion of fresh frozen plasma. Also drugs that inhibit platelet clumping like aspirin also may be helpful.
What happens during septic shock?
large amounts of toxins and endotoxins produced by bacteria are released into the blood, causing a whole-body inflammatory reaction.
What are common organisms that cause septic shock?
Pseudomonas, E. Coli (gram negative) and Staph and Strep (gram positive).
If septic shock is suspected, we take urine & blood cultures when the patient has a spiked fever. If _________ comes up positive, we get scared.
blood
Manifestations of the 1st phase are unique to septic shock and often opposite from those seen with all other types of shock. What happens in phase 1 of septic shock?
It's called the warm shock phase. Cardiac output actually increases in the first phases and BP is increased. This phase is HYPERDYNAMIC and is also called the high output phase.
Septic shock does not resemble other types of shock (manifestations in the first phase are often opposite of those seen with other types of shock), so it's very difficult to assess b/c their VS seem ok. However, the chance for recovery is good when the c
Increased cardiac output with normal to elevated BP. Warm, flushed skin. Pink oral mucous membranes.
The second phase of septic shock has a sudden onset and a rapid downhill course. If septic shock progresses to the 2nd phase, chances for recovery are poor. What are the signs during the phase 2 of septic shock?
Phase 2 is caled the hypodynamic or low-output phase. The client is hypovolemic in this phase. Cardiac output, BP and pulse pressure decrease dramatically. These are the normal s/s of hypovolemic shock. The HR increases though b/c it is trying to compensate. They will have skin pallor.
As septic shock progresses, DIC may occur. What is that?
Disseminated Intravascular Coagulation. The inflammation & endotoxins trigger what is called COMPLEMENT ACTIVATION. This is clots forming and hemorrhaging/bleeding at the same time. There is a huge # of small clots using clotting factors & fibrinogen faster than can be produced by the liver. This makes clients more succeptible to hemorrhage. This reduction of clotting factors and fibrinogen mark the beginning of the 2nd phase of septic shock, the hypodynamic phase.
The key to managing septic shock is by early detection. How's this done?
Change in VS from baseline. Know their baseline & trends! Changes in WBC count. Look at daily CBC for changes in WBCs! "left shift" is decreasing segmented neutrophil level with increasing band neutrophil. Treat the infection with antibiotics, start w/a broad spectrum until we get results back. After culture comes back, give more specific meds. During phase 2: need to give fluids & vasopressors. Want to correct the conditions causing shock and prevent complications (like ARDS).
We want to assess all clients at risk for shock for a change in....
affect, reduced cognition, altered LOC, and increased anxiety.
Assess the immunocompromised client every shift for ...
infection. always check their skin integrity well.
Immediately assess VS of client who have change in LOC, increased thirst or anxiety. Assess for changes in _____ rate and quality rather than blood pressure as an indicator of shock.
pulse
Give _________ to any client in shock.
oxygen
Assess hourly __________ ________ for adequacy of treatment for hypovolemic shock.
urine output
What drug therapy is necessary in hyopvolemic shock?
ANTIBIOTICS! (must treat the underlying infection) ANTICOAGULANTS (clotting happening in DIC) CLOTTING FACTORS & BLOOD PRODUCTS (hemorrhage happening in DIC)
The nurse recognizes that the trigger for erythropoiesis is: a) iron b) hematocrit c) tissue oxygenation d) hemoglobin
tissue oxygenation
The nurse understands that hemostasis (blood clotting) starts with...
platelet aggregation
The nurse recognizes that complete hemostasis occurs with: a) suppression of intrinsic factor b) inactivation of vit K c) fibrin clot formation d) platelet agglutination
c) fibrin clot formation
The nurse implements anticoagulant therapy in order to: a) dissolve blood clots b) decrease the inflammatory process c) prevent formation of new clots d) reduce platelet production
c) prevent formation of new clots
In preparing a client being discharged on Warfarin (Coumadin) the nurse includes which of the following directives? a) use NSAIDs for pain b) increase intake of green leafy vegetables c) avoid taking gingko bilboa d) aspirin may be taken once daily
c) avoid taking gingko biloba
After a bone marrow aspiration, the nurse questions which post procedure order? a) administer aspirin for pain b) apply ice packs to the puncture site c) administer acetaminophen for discomfort d) maintain sandbag on puncture site until bleeding stops
a) administer aspirin for pain
In providing dietary teaching to a client with vit B12 deficiency, the nurse encourages the client to increase intake of: a) dairy products B) grains c) starchy veggies d) eggs
a) dairy products
In monitoring a client receiving epoetin, the nurse correlates which finding to be a sd effect of the med?
muscle aches
In providing care to the client with aplastic anemia, the nurse understands that this disorder is caused by: a) impaired oxygen to RBCs b) destruction of RBCs by toxins c) decreased bone marrow production of RBCs d) inadequate production of RBCs d/t lac
c) decreased bone marrow production of RBCs
The nurse recognizes that leukemia is caused by: a) decreased production of thrombocytes b) overproduction of immature WBCs c) decreased release of mature WBCs from bone marrow d) elevated # of circulating leukocytes
b) overproduction of immature WBCs
In developing a staff inservice about leukemias, the nurse includes which of the following risk factors? (pick all that apply) a) ionizing radiation b) down syndrome c) premature birth d) multiple blood transfusions e) chemical exposure f) bone marro
a) ionizing radiation b) down syndrome e) chemical exposure
The nurse correlates which clinical manifestations to the client in the hyperdynamic phase of septic shock? a) increased CO b) increased urine output c) decreased BP d) decreased HR
increased cardiac output
Is rheumatoid arthritis acute or chronic? Why does it occur? Where does it primarily effect?
RA is a CHRONIC, progressive, SYSTEMIC (effects entire body), INFLAMMATORY, AUTOIMMUNE process that affects CONNECTIVE tissue, primarily SYNOVIAL TISSUE.
RA is 2.5x higher in women or men?
women
In RA, AUTOANTIBODIES called ___________ factors are formed that form immune complexes that attack healthy tissue (mainly synovium).
rheumatoid
3 processes cause the cartilage damage in clients with RA...
1) Neutrophils and other cells break down joint cartilage 2) Cytokines (IL-1 & TNF alpha) cause chondrocytes to attack 3) Synovium digests cartilage, releasing inflammatory substances.
What are the early symptoms of RA?
Joint pain, low-grade fever, fatigue & weakness, paresthesias
What are the late symptoms of RA?
joint deformities, pain and morning stiffness, osteoporosis, anemia/fatigue, wt loss (only a couple lbs), nodules (only occur in 50% of pts), vasculitis, pericarditis, fibrotic lung disease. It is often 2-5 yrs later when these people are diagnosed b/c symptoms are vague + come & go. Fibrotic lung disease is the number one killer of patients with Rheumatoid arthritis.
What is gel phenomenon?
morning stiffness that lasts between 45 minutes and several hours after awakening.
Joint involvement in RA is usually...
bilateral and symmetrical. One hot, swollen, painful joint is considered infection unless proven otherwise and requires immediate treatment.
What kind of lab tests are done for RA?
Rheumatoid factor is in 80-85% of pts. The ESR (erythrocyte sedimentation rate) & CRP when it is elevated can confirm inflammation anywhere in the body. ANA (screens out other diseases), NEW (anti-CPP), CBC w/ differential, X-ray, MRI or joint ultrasound. ALL OF THESE TESTS TOGETHER GIVE A COMPLETE PICTURE. WHOLE PANEL TELLS WHAT THE PT COMES UP WITH AND STOPS FALSE POSITIVES.
You may be asked to assist with aspiration of fluid from a joint in a pt with RA. What should be done?
Remember to pre medicate the patient with pain meds. The Dr. may inject local or may not. Support the patient during the procedure and watch for bleeding, swelling and pain afterwards. You may instruct the patient to use ice packs. Usually use a large gauge needle and a 20 or 30 ml syringe. The Dr. may order for the aspirate to be sent to the lab for culture and sensitivity and examination of the cells. Antibiotic treatment may need to be long term (6 to 8 weeks) due to poor penetration of drugs into the joint. Going to need a central line probably.
What is a pannus?
In RA, the synovium becomes thickened, hyperemic (congested with blood), fluid accumulates and a PANNUS forms. This pannus, or membrane of grannulation tissue takes up space and erodes bone... taking over the normal surface of the cartilage.
What are the biggest worries for RA patients?
Chronic pain and fear of disability are problems for these patients, along with changes in body image.
Many meds for RA are very toxic and are not given lightly. Treatment for RA may include:
ANALGESICS: BIOLOGICS: TNF inhibitors, Selective B-cell inhibitor, interleukin 1 inhibitor, selective costimulation modulator. DISEASE MODIFIERS:IMMUNOSUPPRESSANTS & STEROIDS: they are NOT going to react to infection, no redness, swelling or fever until it’s too late)GOLD THERAPY:
What non pharm methods are used for RA?
ADEQUATE REST COMBINED WITH MILD EXERCISE (gotta keep people moving) PROPER POSITIONING, ICE & HEAT APPLICATION, ASSISTIVE DEVICES, PLASMAPHERESIS (take plasma out and remove all the antibodies), ALTERNATIVE THERAPIES (if it works, great).
What is Systemic Lupus Erythematosus?
Chronic, progressive, inflammatory connective tissue disorder. (just like RA)
how does Systemic Lupus disease course go? Is the onset acute or insidious? Where does the disease come from?
Lupus has spontaneous remissions with flare ups. Onset: can be acute or insidious (slow)Lupus is an Autoimmune disease that can affect the entire body.
it is the ________ antibodies (ANAs) that affect the DNA within the cells of people with lupus.
Antinuclear
How are the organs damaged in Lupus?
Organs are damaged by inflammation and vasculitis which leads to hypoxia and tissue death.
Does lupus affect men or women more?
Lupus affects women between the ages of 15 and 40. Lupus affects women 8-10x more than men.
What is the leading cause of death for lupus patients?
lupus nephritis. The killing of kidneys is the #1 cause of death in these patients.
Lupus needs 4 out of 11 of the following for diagnosis. Malar rash-butterfly rashDiscoid rashPhotosensativityOral or nasal ulcersArthritis: 2 or more peripheral jointsPleuritis or pericarditis Renal disorder/nephritisNeurological disorder-seizuresHistolo
90% of people will show up with some type of arthritis. Excessive protein in the urine and/or cellular casts Hemolytic anemia or leukopenia, WBCs below 4,000 or lymphopenia (low lymphocytes) or thrombocytopenia (low platelets). proof of Immunologic  Disorder, may also be abdominal pain, fever fatigue, anorexia, pleural effusions. may have Raynaud's phenomenon, More than 50% will have some lymph node enlargement.
Some of the lab tests are the same as you will see for many of the autoimmune diseases, including ...
ANA, ESR, Rheumatoid factor, CBC with diff, serum protein electrophoresis, CRP and immunoglobulins.
What treatment is used for Lupus?
Aggressive treatment to bring about remission. Topical cortisone (helps skin lesions fade) and Retinol Plaquenil (hydroxychloroquine) is an antimalarial med helps w/ fatigue, skin & joint disease.Chronic steroid therapyNSAIDSImmunosuppressive drugs in severe cases ie. Methotrexate, Imuran and cyclosporine
What is Discoid Lupus?
Less commonAffects only the skinEspecially evident where skin is exposed to the sun or ultraviolet light. Diagnosed on biopsy.10% of patients develop systemic form.
For patients with both discoid and systemic lupus the skin lesions can be very embarrassing and bring about social isolation. Depression and frustration is common. As the book says the patient may look normal at times and people expect them to do normal
Fatigue management, stress management and support. (If they get too tired or stressed, it will bring on a flare)
What is scleroderma?
Progressive systemic sclerosis (also called scleroderma) is an autoimmune disease that results in damage & hardening of the skin, blood vessels, lungs, heart, kidneys and GI tract. Overall, it is a progressive, chronic scarring of the soft connective tissue disease. Every tissue in body becomes thickened & stiffened, decreases peoples functionality.
Scleroderma can pop up in any area of the body. There is a lot of heart and lung disease, but ________ involvement is the leading cause of death with scleroderma.
renal. Scleroderma causes renal failure. While, Lupus causes nephritis.
Scleroderma is characterized by:
inflammation, fibrosis, and sclerosis of the skin and vital organs, and collagen deposits.
Who does scleroderma affect most?
Occurs in women 3-4x more than men. Onset is usually between 30-50 yrs old.
What do you think happens to the lungs and blood vessels as the scleroderma disease progresses?
HTN as blood vessels harden & can’t react to things. These people typically get limb ulcers, their skin is pale, tight, shiny, moddled and gets poor blood supply.
What are the manifestations of Scleroderma?
Arthralgia (joint pain)Skin-itching, shiny, tight.Raynauds.Pulmonary fibrosis and hypertension.Renal failure.Esophageal ulcers and strictures.SOB on exertion (also at rest) & a nonproductive cough occursPalpations occur for no reason, sudden heart race.Weakness occurs in 80% of patients.Happens to people when they’re most active (in their 40s- 50s)… then really need help from people & they get depressed.Get interstitial lung disease & it can cause organs to fail
What do lab studies for scleroderma look like?
Increased ESRThrombocytopenia (draw CBC)HypergammaglobulinemiaHemolytic anemiaIncreased creatine phosphokinase levels in patients with muscle involvementIncreased urea and creatinine levels in patient with kidney involvementCan lead to abnormal bleeding, bruisingOther x-rays and scans are done depending on the symptoms and the system affected. The patient may need an EGD or pulmonary function test or further kidney function tests. EKG and echocardiograms may be done to assess the heart function. This is not just a skin disease. That’s just what we see.
What kind of treatment is done for scleroderma?
Skin protection (wear gloves) and treatment of ulcers.Symptomatic treatment: H2 blockers, ACE inhibitors etc. Immune modulating drugs as in lupus. Emotional support and physical care. Problems swallowingHave problems with dehydration & malnutrition.Stress & smoking can make this disease much worse. They do not respond well to immune modifying drugs that help with RA. (Steroids & Methatrexone will not help)
What is gout?
Deposition of needle like uric acid crystals in connective tissue that leads to inflammation and pain. Purine is a breakdown product of protein metabolism. Which is further broken down into uric acid. When uric acid level overwhelm the kidneys ability to excrete it then uric acid blood levels increase.
Why was gout called the disease of Kings?
because in the past it was associated with the wealthy who could afford to eat lots of protein, were overweight and drank alcohol. People were looked upon as self indulgent, rich and lazy. These were actually just the people eating small boned stuff, getting the protein that couldn't be broken down.
Why do people get primary gout?
It is an inborn X-linked trait error of purine metabolism
What is a podagra?
extreme pain in the big toe, typical of gout. Approximately 75% of first attacks occur at the big toe. People cannot even tolerate the sheet touching their foot.
What is gouty arthritis? remember, this is classified as a form of arthritis. Lead exposure can also lead to gout. Some other agent that can cause secondary gout are salycilates and niacin. What is the difference between primary gout & secondary gout in
Primary gout: is an in born errorSecondary gout: hyperuricemia cause by another disease or medication such as renal insufficiency, diuretics, cyclosporine, and chemotherapeutic agents
What foods are high in purines? Contribute to the label 'disease of kings'
Foods high in purines: organ meats, gravies, shellfish, fish with bones (sardines), salmon, and some peas and beans. Alcohol interferes with the removal of uric acid from the body.
what is TOPHI?
Tophi is deposits of uric acid crystals under the skin (likes to gather on the ear)
What are the stages of gout?
1. Asymptomatic hyperuricemic phase (no symptoms, disease not found unless uric acid blood level is taken which is extremely rare)2. Acute phase3. Intercritical phase (phase between attacks)4. Chronic tophaceus gout (Lots of attacks, body is just not eliminating uric acid)
How long does an acute phase/gout attack last? what is elevated?
3-5 days. ESR & white count are elevated.
What happens during the Intercritical (or Intercurrent) phase?
Nothing, it is the asymptomatic period between attacks. It may be months or years.
What happens in the Chronic tophaceous gout phase?
after repeated bouts uric acid tophi form there is repeated attacks. (DO NOT TOUCH THESE PEOPLES FOOT in the last stage)
During the Chronic stage these patients are also more at risk for having ___________________________.
uric acid kidney stones, about 20% of these patients will develop kidney stones.
How is gout treated during an acute attack?
Acute attack: Pain relief! NSAIDS or moreColchicine: works w/in 12 hrs. Take 4-7 days. Do not start or stop Allopurinol during an attack b/c it causes the uric acid to move in & out of cells. If they are not on it, don’t start it. Give them the Colchicine. Once attack is over, you’ll start on allopurinol.
How is gout treated if it is chronic?
Chronic treatment: Allopurinol (Zyloprim) or ProbenecidIncrease fluid intakeAvoid alcohol and NSAIDSDietary restrictions are controversial.
What is the Type of arthritis with an abrupt onset in adults over the age of 50. Usually older. Pain in hip & shoulder area. They’ll say, “I can’t comb my hair. Can’t get arm above shoulder level.”Stiffness, weakness and aching in shoulders
Polymyalgia rheumatica
What meds help Polymyalgia rheumatica?
NSAIDs do not help. Low doses of prednisone will help w/ in a few days, 10-15 mg/day (then taper off). Some are on Prednisone for up to 3 years if single dose doesn't help though.
Why is it so important to really listen to person with Polymyalgia rheumatica disease if they have headache or vision changes?
We worry about this disease b/c about 10-20% develop permanent blindness. If they have headache, they’ve gotta get huge dose of steroid for a month.
What is Temporal Arteritis?
A type of vasculitis, usually of the vessels of the head. About 20% of people with polymyalgia rheumatica will develop what is called temporal arteritis.
What will pts with Temporal Arteritis complain of?
These patients may complain that it hurt to touch their head or to comb their hair. They may also complain of pain in their jaw or when chewing. They may complain of general flu-like symptoms.
It is an important part of patient education for patient with polymyalgia rheumatica to report... What is the greatest risk for pt's with this disorder?
any new headache, blurred or double vision. If blood vessels to the eye are affected this can result in sudden permanent blindness. They will also get high doses of corticosteroids like Prednisone.
What is Ankylosing Spondylitis?
Type of arthritis of the spine and sacroiliac joints. Permanent spinal deformity. Can affect the eyes, lungs and heart valvesCauses... Stiffness, lack of mobility and deformity
What kind of drugs are patients with Ankylosing Spondylitis, so what is the nurse really taking care to watch for?
Going to be getting immunosuppressant drugs, going to be watching for sd effects.
Ankylosing Spondylitis usually happens to who?
adolescent and young males and isn’t treated right away because it is usually attributed to some other cause of back pain or stiffness, but Early diagnosis and treatment can delay severity.
Spondylarthropathies share a common genetic marker, it is _________.
HLA-B27
How is Ankylosing Spondylitis treated?
Treat with anti-inflammatory drugs, physical therapy and heat applications.Disease-modifying drugs such as methotrexate and biological response modifiersReally difficult to heal & could result in amputation. This is a lifelong problem. Patients need to be encourged to continue with a lifelong habits of exercise and treatment to avoid severe and permanent deformity as is seen above.
What is Systemic necrotizing vasculitis?
Autoimmune disease of inflammation of the vessel walls leading to thickening, scarring and necrosis.
Necrotizing vasculitis is rare. It may occur in rheumatoid arthritis and is commonly seen with systemic lupus erythematosus, polyarteritis nodosa, and progressive systemic sclerosis. It is very rare in children. What vessels does Systemic necrotizing vas
May affect any vessel of the body. Treated with steroids and other immune suppressant drugs.
What is Fibromyalgia?
Has to do with how track in brain handles pain. Fibromyalgia is a common condition characterized by long-term, body-wide pain and tender points in joints, muscles, tendons, and other soft tissues. Fibromyalgia has also been linked to fatigue, morning stiffness, sleep problems, headaches, numbness in hands and feet, depression, and anxiety. For many years these patients were seen as faking or were referred to psychologists.
What are the hallmarks for fibromyalgia?
sleep disturbance, depression & headaches
What are the triggers for fibromyalgia? what makes it worse?
Pain worsens in response to stress, increased activity, illness or weather conditions. Physical/emotional trauma is a trigger for this. Pain worsens in response to stress, increased activity, illness or weather conditions. Commonly occurs with people who have other diseases like RA, lupus..
How is fibromyalgia diagnosed?
Diagnosis of fibromyalgia requires a history of a least three months of widespread pain, and pain and tenderness in at least 11 of 18 tender-point sites, A full physical work up is done to rule out other diseases.
What causes fibromyalgia?
While the underlying cause or causes of FM still remain a mystery. . Most researchers agree that FM is a disorder of central processing with neuroendocrine/neurotransmitter dysregulation. pt's have abnormal pain d/t abnormal sensory processing in the central nervous system. Evidence shows it may be caused by increased levels of substance P, low blood flow to brain
What are some things we can do for fibromyalgia?
Look for other causes that we can do something about (RA, lupus) and get a good sleep routine (gets messed up in hospitals)
Treatment for fibromyalgia is:
Good sleep hygiene and medications (Avoid alcohol and stimulants, establish a regular sleep pattern), Anti-depressants: SSRI’s help. Takes about 5 yrs to be diagnosed usually. NSAIDs & steroids don’t really help.Physical therapy, pain relief and muscle relaxants. Counseling for depression and stress reduction.
There is a new test for fibromyalgia, it is looking for The APA (Anti-Polymer Antibody) Assay detects _____________________ in human serum. It can identify about ½ to ¾ of the patients who have fibromyalgia.
IgG anti-polymer antibodies
Caroline is being tested for a connective tissue disease. What lab test signifies an abnormal result? a) negative rheumatoid factor b) an alpha1 globulin of 0.8 g/dL c) a negative LE preparation d) a beta globulin of 0.8 g/dL
b) an alpha1 globulin of 0.8 g/dL
Sophia is teaching a class on systemic lupus & progressive systemic sclerosis. Which statement, if made by a class participant, demonstrates the need for further teaching? a) both diseases can cause fatigue, fever and anorexia. b) both diseases can cau
d) both diseases can cause renal failure
Michelle has just been diagnosed with progressive systemic sclerosis. Which nursing intervention should be initiated first? a) ascertain a foot cradle b) initiate small, frequent meals c) encourage smoking cessation d) teach the client to use mild so
b) initiate small, frequent meals
Jim is a 40 year-old man who presents to the ER with an acute gout attack in his right knee. which treatment option would be indicated at this time? a) encourage the client to maintain a fluid restriction b) encourage the client to avoid excessive al
a) encourage the client to maintain a fluid restriction
Mary Ellen is a 57 yo diabetic with fibromyalgia. her physical findings are diarrhea, heartburn, IBS, tender joints, abd pain, & orthostatic hypotension. Which treatment option would not be indicated for this client? a) high impact exercising b) physi
a) high impact exercising
Type I: Rapid Hypersensitivity Reactions result from have an increased production of ____ antibodies
IgE
AnaphylaxisAllergic asthmaAllergic rhinitisEnvironmental allergens such as latex, iodine, bees, foods and drugs. .... are examples of what type of hypersensitivity rxn?
Type I - rapid hypersensitivity rxns. They are the MOST COMMON reaction.
In type I hypersensitivity rxns, the acute inflammation that happens is b/c of....
the release of histamine and other vasoactive amines from mast cells and basophils.
For type I sensitivity rxns... you get activation of basophils, eosinophils and mast cells. On a CBC with differential you will see an increase in ___________.
eosinophils
Type I: Rapid Hypersensitivity Reactions, how do the allergens get to the host?
Allergens may be inhaled, ingested, injected or contacted
In Type I: Rapid Hypersensitivity Reactions, reactions involve what body parts?
Reactions may involve skin, eyes, nasopharynx, bronchopulmonary, or gastrointestinal systems.
How long does it take Type I: Rapid Hypersensitivity Reactions to react? can these reactions be life threatening?
Reactions usually occur within 15 to 30 minutes, but may be delayed up to 10 to 12 hours. Yes, type 1 hypersensitivity rxns range from irritating to life threatening.
During an anaphylactic reaction, it is dramatic and life-threatening: rapid, systemic and multi-organ involvement. There are feelings of impending doom, weakness, anxiety, or apprehension. Erythema (redness), hives with raised skin wheals or angioedema
There is Hypotension, dysrythmias, cardiac arrest. There is capillary leakage and hypotension. They will have a weak rapid pulse. As the process progresses the client may become light headed, increasingly anxious and confused. Most deaths occur due to respiratory and cardiac failure.
How is anaphylaxis treated?
OBTAIN AN AIRWAY! &/or do CPR, EPINENPHRINE (1:1000) 0.3 to 0.5 ml sub-q may repeat q 15 min, ANTIHISTAMINES: diphenhydramine (BENADRYL) 25 to 100 mg IV, IM or PO, PREDNISONE (corticosteroid to reduce inflammation), give Oxygen, albuterol, Theophylline (bronchodilator), Vasopressors as needed (such as dopamine are sued to counter act hypotension.)
People who have known anaphylaxis should carry what?
epinephrine or Epi pen, People who have known severe allergies should carry one of these with them at all times and WEAR A MED ALERT bracelet. I have also seen people given H2 inhibitors in the ER. An Epi pin is a rescue device, to bring you to the hospital (really just buys some time).
What are some common anaphylactic allergens?
*Antibiotics: Penicillin, cephalosporins, tetracycline, sulfonamides, amphotericin B etc.*Adrenocorticotropic hormone, insulinAllergen extracts, muscle relaxants, vaccines, local anesthetics (lidocaine)Whole blood or blood productsRadiocontrast medium (iodine)OpiatesFood: shellfish, eggs, nuts, grainsPollensInsects and animals: bees, venom
What is the best thing you can do to avoid type I allergic rxns?
Best thing you can do is recognize your allergy, get tested & avoid it!This can be difficult, especially with food allergies. You really have to read the labels. Nut allergies are on the increase in children.
Allergic Rhinitis is triggered mostly by _________.
airborne allergens.
In Type I Hypersensitivity rxns, the antigen specific IgE is formed after first exposure to allergen. What happens when the person is reexposed?
Upon re-exposure the allergen binds to two adjacent IgE molecules on the surface of a basophil or mast cell causing them to degranulate or release vasoactive amines (carries histamine & causes vasodilation).
THe releases of histamine in type I hypersensitivity rxns will cause: “Histamine causes capillary leak, nasal and conjunctival mucous secretion, and itching, often with redness.”Continuing response due to inflammation from infiltration of white blood
Nasal drainage causes throat irritation by “post nasal drip”. Itchy watery eyes, nose blowing and stuffiness are what you see. Ears may feel full and the person feel “foggy”.
Are type I hypersensitivity rxns life threatening?
Not usually life threatening, but can complicate other respiratory diseases like asthma.
When the Dr is taking a history to determine about allergic rhinitis, what might he ask?
We want to know when things started and are they seasonal or year round, Has anything specific been identified as an allergen previously, What have they tried in the past and how did it work, Comorbid conditions such as asthma or COPD, You want to know how this is impacting their life, In looking at people with allergies you may see them have what is called allergic shiners or dark circles around the eyes… part of the allergic process.
What are some common allergen causes?
dust mites and cockroaches. All parts of a cockroach including their feces can be an allergen. Other allergens can be molds, dust or pollen. Animals and pets.
About __% of people with allergies have one parent with them.
50
Type I Allergy testing, scratch test - does what?
Small amount of different allergens are placed on the skin and then tiny scratches are made through them. You then wait and watch for a reaction. Results in 15-20 min. Have emergency resuscitation equipment available. This is different from the patch testing we will cover in a few minutes. This may not identify all allergens, but may give a clue to categories. The severity of the reaction is determined by the size of the wheal.
5 days prior to a scratch test, the patients should..
Discontinue antihistamines and steroids for 5 days prior to testing. Give these pt’s antihistamine creams & oral antihistamines to calm the back AFTER scratch tests.One of their major draw backs is drowsiness and dry mouth.
Type I Allergy Testing, labs you will see ___________ rise. Norm is 1-2%, rise to 12% in allergic rxn.
eosinophils
If pt has Chronic sinusitis? ________ to look at fluid levels in sinuses.
CT scan
How are Type I allergies treated?
1. Environmental control/allergen avoidance. (Take shower after being outside, Use air conditioning, Remove drapes, rugs, clean mold, Wear respirator mask on the job, when mowing) 2. Take Medications-more info coming 3. Immunosuppressant Therapy (allergy shots also called DESENSITIZATION THERAPY)Improvement may not been seen for up to 12 monthsIf it helps continue over 3 to 5 years.
How do the Immunosuppresant Therapy (Allergy shots "densitization therapy") work for allergies?
It appears to work by competition by increasing the IgG and binding the allergen with out activating the IgE (increases IgG & decreases the IgE). It work about 80% of the time with certain allergens. A very dilute injection solution of a known allergen is given. A 0.05 ml dose is given weekly until the client is receiving a 0.5 ml dose and then the client is started on the next strongest dilution. Injections given weekly the first year, every other week the second year, every 3 to 4 weeks for the 3rd year and after up to 5 years.
What are the Type I allergy meds given?
1. First generation antihistamines: Diphenhydramine, Chlorpheniramine 2. Second generation antihistamines: Non-sedation, compete for H1, Loratadine, Fexofenadine 3. Decongestants 4. Nasal Corticosteroids: Flonase, Nasonex5. Leukotriene Antagonists: Singulair6. Nasal Cromolyn: Mast cell stabilizer: Nasalcrom (cromolyn also in eye drop form) 7. Nasal Antihistamines: Astalin
What significant sd effects can the first generations meds like Diphenhydramine (Benadryl) & Chlorpheniramine have?
They may cause significant drowsiness and dry mouth. Chrlortimaton potentiates the effects of alcohol. ** Avoid benadryl, when worried about the vasoconstriction, in patients with glaucoma and urinary retention. There is a lot of alternative meds used with this. Second generation antihistamines are less drying and sedating. They are all the ones you see advertised: Claritin, Allegra, Zyrtec.
Another Type I allergy is Latex allergy. It is caused by cumulative exposure. The use of Universal Precautions has increased the # of latex allergies. There are many natural latex used in many products in and out of the hospital. We want to ask about
Avacado, Banana, Kiwi, Chestnuts. These foods have a similar protein structure to natural rubber latex & so the immune system may react to them too.
Type II: Cytotoxic Reactions... what happens here?
Foreign antigen attaches to self cells. Special auto-antibodies attack self cells, bind and form immune complexes.Self cell destroyed along with attached antigen
What are some examples of Type II: cytotoxic reactions?
thrombocytopenic purpura (skin rxn), hemolytic transfusion reactions (given the wrong blood type), drug-induced hemolytic anemia (RBs burst & are deformed), Goodpasture’s.
How are Type II: cytotoxic reactions treated?
Remove offending drug or blood product, plasmapherisis to remove antibodies
If someone is having a hemolytic transfusion reaction (when someone is being given the wrong type of blood) what is the first thing you do?
Blood reaction? First thing you do is… stop giving them the blood.
Type III: Immune Complex Reactions. This Immune complex reaction is an aggregation of antigens, ___ and ____ antibodies.
IgG and IgM
Type III: Immune Complex Rxns, form in the blood as clump and are deposited in small blood vessels, skin, joints and kidneys. Complexes trigger the whole inflammatory reactions cascade. Reactions occur in hours to days.
A lot of the diseases we have discussed previously have symptoms that result from immune complexes.Some of these are Rheumatoid arthritis, Lupus, vasculitis, nephritis, arthritis, and sub acute bacterial endocarditis. The problem is when: the body starts to recognize itself as something that shouldn’t be there. Could be your body or foreign subject too.
What is the Type III: Immune Complex Rxn - Serum Sickness?
Reaction to receiving certain serums and drugs. Certain anti serums, given to avoid infections, most common causes today are penicillin and other antibiotics. It is less common now that vaccines don’t contain animal proteins. Symptoms: Fever, joint pain, rashes, lymphadenopathy, hypotension and shock. sickness is self limiting – soon as you stop what’s causing it. Treat inflammatory process & it goes away. Not going to concentrate on this much, type 1 & 4 is what we really conc on.
Type IV: Delayed Hypersensitivity Reaction, Previously sensitized ______________ cells respond.
T-lymphocyte, T CELL not antigen mediated.
Type IV: Delayed Hypersensitivity Reaction.... Takes several hours for the immune respond cascade to complete and reveal symptoms. Local collection of lymphocytes and macrophages leads to edema, induration, ischemia and tissue damage. What is the most co
it is poison ivy. Can happen in 12-24 hrs or even days to respond.
What meds help & what meds do not help Type IV: Delayed Hypersensitivity Reactions?
Antihistamines DO NOT work in Type 4 hypersensitivity reactions. Benadryl cream is NOT going to help poison ivy. STEROID CRMS ARE GOING TO HELP.
Type IV: Delayed Hypersensitivity Reaction is used in TUBERCULOSIS tests (also called PPD or Mantoux test). What happens here?
We know that over the next 2-3 days that this is going to show up. We utilize knowing this is going to happen.Previously exposed T cells (immune cells) respond to an antigen by releasing chemical mediators and triggering macrophages (WBCs) to destroy the antigen. The area of induration (palpable, raised, hardened area) around the site of injection is the reaction to tuberculin.
Type IV: Delayed Hypersensitivity Reactions are usually self-limiting. We treat them symptomactically. Does Benadryl help? What meds help?
Benadryl does NOT help Type Iv reactions. Benadryl doesn’t tend to help because the reaction is not histamine mediated. Corticosteroids help (remember to taper off).
To help identify what someone may have a reaction to, patch testing is done for Type IV. What is this?
Patch testing: Test chemical are applied to intact skin under occlusive patches. Keep area dry. Patches are removed after 48 hrs. and again in 3 to 5 days. Take them off in 48 hrs & again in 3-5 days. As many as 60 different allergens can be tested at one time. You want to clean and shave the area. If the patches start to come off don’t try and put them back on as you can mix up antigen. The patient should avoid showering, swimming and heavy exercise that causes sweating.
Does IgE mediate the Type IV sensitivity reactions?
No, it is not IgE & so desensitization will not work. It is IgG & IgM
In Type V: Stimulatory Reactions, the Humoral antibody inappropriately activates a receptor site. We have receptor sites on diff organs. The target organ or tissue is continually “turned on” as in Grave’s disease (autoimmune disease, body going aft
remove enough tissue to allow normal response and/or use immunosuppressant drugs.
What is HIV?
Human Immunodeficiency Virus, First recognized in 1981, A retrovirus composed of a small outer envelope and an inner core of genetic material (RNA) and 3 enzymes necessary for reproduction: reverse transcriptase, integrase and protease. Impairs cellular immunity by hijacking helper T4 lymphocytes (CD4 cells)
Can HIV reproduce on its own?
HIV cannot reproduce on its own, but must attach to and invade other cells to reproduce.
46% of cases in the US are among men having sex with men, but __________________ are the fastest growing group of HIV infected people.
heterosexual women. Women make up nearly one-third of new HIV infections. In the US the largest group remain men having sex with men followed by IV drug users.
HIV is actually very fragile & cannot survive for long outside the body. (survival time depends on the size of the liquid droplet) Isolated from all types of body fluids. The 4 main fluids for HIV transmission are: blood, semen, vaginal fluid & breast
1. Unprotected vaginal or anal sexual contact with an infected person. (Small tears in the anus for vagina provide a portal of entry) 2. Inoculation with infected blood or blood products.3. Pregnancy, delivery or breastfeeding.
Primary symptoms of flu or mononucleosis occur within 2-4 weeksSymptoms last a few days to weeks. There is a “Window” period between exposure and seroconversion. Explain what that is?
This is the time between infectino & when you seroconvert. In the "window period" you can spread the virus, but tests show you are negative. HIV seroconversion (converting from HIV negative to HIV positive), and usually occurs within 3 months of exposure, but on rare occasions may occur up to a year after exposure. Here virus antibodies can be detected in the blood.
Following the acute episode of illness with HIV, there may be no symptoms for years or the next decade. Can HIV be transmitted at all stages?
Yes, HIV infection can be transmitted at all stages of the disease. Acute HIV infection can, but does not always, progress to early symptomatic HIV infection and to advanced HIV disease (AIDS).
The Classification system for HIV/AIDS is A, B, C and 1, 2, 3. Categories A, B and C depends on symptoms and the presence of different opportunistic infections or conditions. A, B, C combines with and 1, 2, 3 depends on CD4 cell count. What are the rang
1= count > 500/µL2=count of 200-499/µL3=count
What risks do HC personnel have working w/ HIV infected patients?
Transmission very low if Standard Precautions are followed. Risk of infection from a needle stick is less that 1%.If hit w/ a needle stick, PEP or post exposure prophylaxis should be stared asap w/ 2-3 different types of anti retroviral therapy and continued for four weeks. Health care workers should have serological testing done at the time of exposure and at 6 weeks, 3 months and 6 months after exposure
1 test for HIV is -- ELISA (Enzyme-linked immunosorbent assay): Determines the presence of antibodies. A positive result is always repeated. Highly sensitive and specific. ELISA is the most widely used test in the diagnosis of HIV. The ELISA is inexpens
A positive result is always repeated. The test is Highly sensitive and specific. If a second test is positive then another, different test is done. A patient may have been tested at a time when the antibodies were low.
Will ELISA detect HIV antibodies if the person is in the window period?
NO, ELISA will not detect antibodies if the client is in what is called the “window period”. That is the time between infection and the development of antibodies. The person is still able to infect others, but if they have the test done just once and it is during this period they will think they don’t have HIV and may go on infecting others.
Western Blot is another test for HIV, it is more expensive & takes more time. When is it used?
It is used in conjunction w/ ELISA. The Western Blot is used as a confirmatory test. It identifies antibodies of individual viral components to four specific HIV antigens.
There is Home Testing available for HIV. What are the benefits?
Sample can be sent in anonymously and results are given a number. Oral and blood kit. If positive further serum testing is needed.
What is Viral Load Testing used for?
measures RNA and viral protein levels. Show the level of viral load and are used in monitoring progression and treatment effectiveness. Specificity of 100%.
Care for Immunocompromised Clients focuses on what? Since the beginning of multidrug therapy in 1996, life expectancy for HIV+ people is about __ years.
Suppression of viral load and prevention of opportunistic infections. 24
Antiretroviral Therapy: HAART, was introduced in 1996. What are the goals of this therapy?
1. To suppress & maintain the viral load at non-detectable levels for as long as possible.2. Restore and preserve immune function.3. Improve quality of life.4. Reduce HIV associated morbidity and mortality.
Does Antiretroviral Therapy kill the virus? What happens if th client does not comply w/ their medications?
It is vitally important to remember that antiretroviral therapy only INHIBITS VIRAL REPLICATION and does NOT kill the virus. Interruption of the med routine promoted viral replication and drug resistance. Replication can begin within hours of missing a dose.
WHAT DO YOU THINK ARE SOME OF THE CHALLENGES WITH DRUG REGIMENS WITH CLIENTS WHO CONTINUE TO BE IV DRUG ABUSERS?
The cost of medications makes up 70% of the cost of HIV treatment. Drawbacks not only include the expense but side effects, food and timing requirements and the number of pills daily. The regimen is lifelong and can be a burden.
HOW DO Nucleoside Analog Reverse Transcriptase Inhibitors work?
Blocks the conversion of viral RNA to viral DNA by suppressing the production of reverse transcriptase.
What are some examples of Nucleoside Analog Reverse Transcriptase Inhibitors?
zidovudine (Retrovir, AZT), didanosine (ddI, Videx), zalcitabine (ddC, HIVID), lamivudine (Epivir), stavudine (d4T, Zerit), tenofovir (Viread), emtricitabine (Emtriva), and abacavir (Ziagen)
How do Non-Nucleoside Analog Reverse Transcriptase Inhibitors work?
Inhibits the synthesis of reverse transcriptase.
What are some examples of Non-Nucleoside Analog Reverse Transcriptase Inhibitors? What is a common reaction?
nevirapine (Viramune), delavirdine (Rescriptor) and efavirenz (Sustiva). Allergic reaction occur in about 17% of patients within first 6-8 weeks of therapy.
How do Protease Inhibitors work?
Blocks the HIV protease enzyme thus preventing breakdown of large chains of proteins into small “loadable” chains. The small bits of information or viral particles cannot be loaded into the new viral “capsules”.
What are examples of Protease Inhibitors?
ritonavir (Norvir), indinavir (Crixivan), saquinavir (Invirase, nelfinavir (Viracept), amprenavir (Agenerase), lopinavir (Kaletra, atazanavir (Reyataz) and fosamprenavir (Lexiva).
Lipodystrophy is a common sd effect in protease inhibitosrs? As a nurse you know this means..
change in your body figure and may have impaired glucose tolerance and lipid metabolism disorder. If you develop hypercholesterolemia and hyperglycemia, or the loss of fat from your arms, legs and face while your trunk gains fat after several months to several years from the start of taking the drugs, please consult your doctor. Patients need to be instructed to DRINK AT LEAST 1.5 liters of fluid a day while taking these meds.
How do Fusion (or Entry) Inhibitors work?
Blocks the ability of gp41 to fuse with the host cell so that genetic material cannot be passed. Must be used in combination with other antiretroviral drugs.
How are Fusion (or Entry) Inhibitors given?
Sub-Q twice a day
How is immune enhancement managed for HIV pts?
Vitamins and antioxidant supplementsComplementary and alternative therapies. Be sure to get an accurate record of all herbal and other treatments because of therapy interactions. We try and keep all other diseases under good management and watch for drug interactions.
Opportunistic infection are the leading cause of death in HIV patients. What is Pneumocystis jiroveci?
PCP or pneumocytic pneumonia, it is the most common AIDS defining condition. It is a fungus that does not usually affect healthy people.
How would HIV pt's w/ Pneumocystis jiroveci present?
Only 50 % of patients present with the classic fever, exertional dyspnea & nonproductive cough.Dyspnea, tachypnea, cyanosis, initial uncompensated respiratory alkalosis
Tuberculosis is another opportunistic infection that is very dangerous for HIV/AIDs patients. What is TB again? What meds are given to treat it?
TB is a BACTERIAL infection usually of the lung, but it can spread to other organs. Incomplete treatment leads to drug resistant strains. Treat with RIFAMPIN and ISONIAZID.
Treatment for Rifampin & ISONIAZID should be expected for a minimum of 6 months. What are some of these meds sd effects?
Limited to minor cough and mild fever, if apparent Fatigue-This and weight loss are already problems for many people with HIV/AIDS, Unintentional weight loss Coughing up blood, Fever and night sweats, Phlegm-producing cough
Another opportunistic infection for HIV patients, it is a cancerous tumor of connective tissue-the most common AIDS related malignancy. The patient will present with Bluish red or purple skin lesions and is diagnosed by biopsy. What is this?
Kaposi’s Sarcoma (usually from an interaction between a weakened immune system and the human herpesvirus-8). People who have kidney transplants are also at risk for Kaposi's sarcoma.
This opportunistic infection is A VERY painful, blistering rash along one dermatome but can involve more in HIV. Reactivation linked to aging, stress & immunocompromise. What is this? How is it treated?
Herpes Zoster: Shingles. Occurs only in people who have had chicken pox. Treat with anti-virals (Acyclovir), steroids and pain medication.
Another Opportunistic Infection is Herpes Simplex. Patients may have a burning or tingling sensation along with a fever and lymph node enlargement. What is the difference between Type I & Type II?
Virus type I- Lips and faceVirus type II- sexually transmitted.Remember, that any infections problem the patient might have had can become fulminant as the immune system fails. Symptoms include genital ulcers or sores. can continue into a brain infection. A finger infection, called herpetic whitlow, is another form of herpes infection (affects HC workers exposed to oral secretions). antiviral meds used: Acyclovir
What opportunistic infection is white “cheesy” lesions in the mouth or reddened areas of skin? How is it treated?
Candidiasis:Yeast infection with Candida albicans.Treat with antifungal creams, mouth rinses and medications. (Swallowing can be difficult & painful, nutrition can become a problem) Stronger antifungals such as Diflucan and amphoteracin B have their own toxicity.
What is the opportunistic infection that is a fungal infection & the lungs are the entry point? Most patients will have a flu-like syndrome and pulmonary (lung) complaints related to underlying pneumonia or other lung involvement Up to 10% of patients ma
Histoplasmosis (grows on mold in soil, high conc in bird/bat droppings. high exposure in midwest)
What opportunistic infection is an infection with an intracellular protozoan parasite? Cats are the definitive host of the parasite. What happens?
Toxoplasmosis. Brain lesions! they are associated with fever, headache, confusion, seizures, and abnormal neurological findings.
What is the severe demyelinating disease of the central nervous system? It is caused by JC virus (JCV) Mostly white matter is demyelinated. MRI picks it up better than a CT scan.
Leukoencephalopathy. Although CD4+ T-cells are usually below 100/µl at manifestation of disease, it is the most common neurological prob after toxoplasmosis.
A common problem in HIV/AIDs is ___________ Syndrome. This occurs due to a combination of diarrhea, malabsorption, anorexia and oral esophageal lesions.
Wasting
__________ complex: Occurs in about 70% of AIDS patients. Results from infections of cells in the CNS or side effects of drugs.
Dementia
What recommendations are made for HIV pt's for prophylaxis & to prevent opportunistic infections?
Pneumoccocal vaccine (penumonia vaccine), Annual flu vaccine, Hepatitis A and B vaccines, Varicella Zoster if no history of exposure to chk pox, Tuberculosis testing at least annually.
Health maintenance recommendations for HIV/AIDs patients includes:
Stress should be kept to a minimum. Avoid exposure to people with acute infectious illnesses. Get adequate exercise, but don't wear yourself out. Maintain a nutritious diet with adequate caloric intake. Avoid settings and situations that could lead to depression. Maintain positive social contacts, hobbies, interests, and pets. Practice safer sex. The disease is highly infectious in the first month after infection. It is also important that these patients get support
The nurse recognizes which of the following as a cause of primary immunodeficiency? a) viral infection b) contact w/ a toxin c) genetic mutation d) corticosteroid therapy
c) genetic mutation
The immunocompromised client w/ which of the following disorders poses the greatest risk to the HC personnel caring for them? a) pneumocystitis carinii pneumonia b) candida albicans infection c) histoplasmosis d) tuberculosis
d) TB
What is required for the diagnosis of AIDs?
a CD4+ count of less than 200 cells/mm3
In preparing a teaching plan about HIV transmission, the nurse includes which of the following as possible transmission routes? Mosquito bites, anal intercourse, blood products, toileting facilities, oral sex, eating utensils... pick as many as you think
anal intercourse, blood products, oral sex
WHich of the following statements by the immunocompromised client about reducing their risk of infection indicates that teaching was effective? a) raw fish is a good source of protein for me b) I should not eat any raw vegetables c) eating protein is im
c) eating protein is imp to my health (to reduce infection)
The nurse prioritizes which intervention in the care of a client with severe protein-calorie malnutrition? a) treat the infection b) correct electrolyte imablances c) increase protein intake d) encourage fat intake
a) treat the infection
THe nurse correlates which clinical finding to the administration of cytotoxic agents? a) hypoalbuminuria b) thrombocytosis c) iron deficiency d) leukopenia
d) leukopenia
Is cancer the #1 killer in US?
Actually it is #2. #1 is heart disease.
What do cancer cells look like?
Cell division is rapid or continuous, their Appearance is Anaplastic (cells are less differentiated), the Nucleus is large. Migratory and invasive. May or may not have 23 Chromosomes. Loosely adherent.
_____________ is cancer development.
carcinogenesis
____________ Cells move from the primary location.
metastasis
What is "staging"?
Staging classifies cellular aspects of cancer cells. Talks about differentiation from the original tissue.
What is "grading"? What is TNM?
Grading is how far has it spread. TNM: tumor, node, metastasis.
The 7 warning signs of cancer are in the acronym CAUTION, what does each letter stand for?
C=Changes in bowel or bladder habitsA=sore that does not healU=unusual bleeding or dischargeT=thickening or lump in the breast or elsewhere. I=Indigestion or difficulty swallowing.O=Obvious change in wart or mole. N=Nagging cough or hoarseness.
Male cancer type that is the highest is...
prostate. followed by lung & colorectal. Lung causes a higher death rate than prostate though.
female cancer type that is the highest is...
Breast. followed by lung & colorectal. Again, lung causes a higher death rate than breast too.
What are the 4 major types of Lung cancer?
1. Small cell carcinoma (oat cell)2. Adenocarcinoma3. Squamous cell(non-small cell)4. Large cell
What are the lung cancer risk factors?
Tobacco smoking, Asbestos, Cancer-causing agents in workplace, Miners, Exposure to chemicals, Marijuana, Recurring inflammation
__% of lung cancers are found in the early stages. many are diagnosed incidentally. What are the common sites for lung cancer to metastasize to?
15%. BrainBoneLiverLymph nodesPancreas
What are the S & S of lung cancer?
No symptoms earlyCough that does not go awayChest pain; Worse with deep breathingHoarsenessBloody or rust-colored sputumShortness of breathFever of unknown originRecurring infection (bronchitis or pneumonia)
How is lung cancer diagnosed?
History & physicalSputum cytologyChest x-rayCT scan/MRINeedle biopsyBronchoscopyMediastinoscopy
What medical treatments are done for lung cancer? What about surgical treatments?
Medical: Chemotherapy and radiation. Surgical: Pulmonary resection lobectomy, Pneumonectomy, Laser surgery
Nursing care for a patient with lung cancer, post-op is...
O2 therapy, Positioning: Semi-fowlers or Side to side, Assessment: Respiratory rate, quality, O2 sat, Assessment of Respiratory is obviously important. Look at Blood gases, Breath sounds, Chest tube placement, drainage, drainage system function, Use of incentive spirometer
More nursing mgmt for post-op lung cancer treatments is Pain Mgmt & Wound Care. What pain mgmt is given?
Analgesics (PCA, Epidural, Oral), Wound splinting, Stabilizing chest tubes with activity
Most colorectal cancer is __________________. Where is colorectal cancer usually found?
adenocarcinomas. Most tumors found in distal portion of large bowel, from the sigmoid colon to anus (approximately 1/2 of all cancers occur in the sigmoid or rectum area - end of the large intestines)
Patients w/ cancer in the sigmoid/rectum will have s/s of...
blood in stool, changes in bowel habits & rectal discomfort. (In other areas it is common to have Pain, Anemia, Obstruction)
Risk factors for colorectal cancer includes:
Family history &Personal history of: Colorectal CA, Intestinal polyps, Chronic IBS, Aging, Diet primarily from animal sources and Physical inactivity
Early detection of colorectal cancer is done with...
Digital rectal examFecal occult blood testSigmoidoscopyColonoscopyBarium enema with air contrast
Colorectal CA diagnosis is done with...
Sigmoidoscopy and/or colonoscopyBarium enema with air contrastRectal ultrasoundCT scan MRIBiopsy
What nursing responsibilities are necessary for a Colonsocopy?
Prep-cleansing of bowel, Conscious sedation, No driving for 24 hours
What nursing responsibilities are for a Barium Enema?
Prep- cleansing of bowelPost care (remove barium)constipation (laxative)
Big S &S of Colorectal Cancer are...
Change in bowel habits, Feeling need to have BM that is not relieved by doing so, Rectal bleeding or blood in stool, Cramping or steady abdominal pain, Decreased appetite, Weakness & fatigue, Jaundice
Beginning at age 50, both men & women should do 1 of the 3 following to detect colorectal cancer...
1. Yearly fecal occult blood + flexible signmoidoscopy every 5 years or2. Colonoscopy every 10 years or3. Double contrast barium enema every 5-10 years
Surgery is the main treatment for colorectal cancer. What will be done? Also, chemo & radiation are used.
Surgically, a segmental resection is done. A colostomy may be needed (either temporary or permanent).
Post-op ostomy care involves...
stoma color & drainage, skin care
Wound care post-op for a perineal wound (where the rectum is removed) will heal how?
wound will heal by secondary intention. This occurs in open wounds. When the wound edges are not approximated and it heals with formation of granulation tissue
What is the difference between a colostomy, sigmoid colostomy and a ileostomy?
colostomy is anywhere in the intestine prior to the sigmoid, sigmoid colostomy is in the sigmoid (right before rectum) and ileostomy is for urine.
90& of pancreatic cancer is..
duct cell adenocarcinoma
are most pancreatic cancer in the pancreatic head or the tail? What is the prognosis like for pancreatic cancer?
75% is in the pancreatic head. 25% is in the tail. Prognosis is poor.
What are the S & S of pancreatic cancer?
JAUNDICE, CLAY COLORED STOOLS, DARK URINEAbdominal painDigestive problemsGallbladder enlargementWeight loss (late)
How is pancreatic cancer diagnosed?
H & P, CT scan or MRI, UltrasoundENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP), Liver function tests, Biopsy
What are the risk factors for pancreatic cancer?
Age, gender & race: Over 50, male, Cigarette smoking, Diet: High fat, meats, low in fiber, Chronic pancreatitis, Family history, Currently no tests are available for early detection. CA 19-9 tumor marker is elevated in late stage.
If your pt is about to get an ERCP, what is the nursing job?
NPOConscious sedationSimilar to EGDPost careAssess for increased abdominal painSigns of peritonitisJaundice
What are the surgeries done for pancreatic cancer that are "potentially curative"?
Distal or total pancreatectomy (part or all of pancreas removed)Whipple procedure (the head of the pancreas, a portion of the bile duct, the gallbladder and the duodenum is removed)
What is another "palliative care" option for pancreatic cancer?
Stent or surgery to relieve blockage of common bile duct
Chemotherapy is also used for the treatment of pancreatic cancer. What medications are used?
Gemcitabine or fluorouracil (5-FU)
WHat Nursing Care is needed after procedures for pancreatic cancer?
PAIN CARE (give Analgesics - IV or EpiduralWOUND CARE (Assess wound, Assess drainage, amount and colorTEACHING (based on extent of surgery... Diet, activity, wound healing, pain management)
What nursing care is necessary for a pt with pancreatic cancer, that is not going to undergo surgery?
PAIN IS HUGE (it is difficult to manage. Give OpioidsPO, transdermal. Celiac plexus block - procedure to block nerves w/ anesthetic injections from pancreas)Give ANTIEMETICS, ASSESS NUTRITION (Anorexia, Indigestion, Weight loss)
Bladder Cancer is most commonly___________ growths in bladder urothelium, it may infiltrate into the bladder wall.
papillomatous growths
Bladder cancer is most frequently a neoplasm in the urinary tract. What does that mean?
A tumor that develops anywhere along the urinary tract. The urinary tract includes the kidneys, urethra and ureters.
What are the risk factors for bladder cancer?
Smoking, Occupational exposure, Race, Increasing age, Personal history of bladder CA, Birth defects involving bladder
Early detection of Bladder Cancer includes screening people at high risk...
urine cytologycystoscopyurinary tract radiographic imaging (x-rays)
Diagnosis of bladder cancer includes:
Urine culture: to rule out infection, Urine cytology: examine urine under microscope to look for cancerous or precancerous cells, Flow cytometry: measure amount of DNA in bladder cells. Is useful in determining recurrence of bladder cancer & predicting prognosis, Bladder tumor marker studies: BTA looks for porteins in urine which indicates presence of recurrent cancer cells and NMP22 measures the level of a protein from the nucleus of the bladder cancer cells.
Surgeries for bladder cancer treatment are:
Tumor excision(limited to mucosa), Tumor excision plus chemotherapy (use M-VAC and MCV), Cystectomy (involves radiation and chemotherapy)
What nursing care is needed with a Cystectomy/Ileal-Conduit?
Assess Urostomy (Color, Urine output, amt, color, Appliance placement and fit, Skin around ostomy) and Teaching (Appliance application, Skin care, Wound care)
Does prostate cancer grow fast or slow? What is the 5 yr survival rate if it does not spread beyond the prostate?
slow. 100%. It is related to male hormones, but exact mechanism unclear.
What are the risk factors for prostate cancer?
Age Race (African Americans highest)Family historyNationalityDiet (high in fat)Physical inactivity
Procedure for early detection of prostate cancer is a blood test to measure elevated Prostate-specific antigen (PSA) & Digital Rectal Exam (DRE) yearly, starting when?
45 if at high risk. Otherwise 50.
WHat are the S & S of prostate cancer?
There are NO symptoms (early), Frequency, reduction in streamHematuria (blood in urine), Pain in pelvis, spine, hips, or ribs
How is prostate cancer diagnosed?
PSA (prostate specific antigen) & DRE (digital rectal exam)Prostate biopsyTransrectal ultrasound
Treatments for prostate cancer include:
Surgery (Radical prostatectomy, Transurethral resection of prostate, Cryosurgery) Radiation, Hormone therapy, Expectant therapy, Chemotherapy (minimal effective)
What are sd effects of prostate cancer treatment?
Incontinence, Impotence, Reduced or absent sexual drive (orchiectomy & LHRH androgens), Hot flashes, breast tenderness & growth of breast tissue (LHRH androgens)
Testicular cancer is rare, but is most common in what age group?
males 15 - 35 years oldImpacts reproductive and psychologic status
How is testicular cancer identified?
Testicular self exams - early detection makes it one of the most curable solid cancers. There can be reproductive & psychological effects though.
The 2 types of testicular cancer are Seminomas andNon-Seminomas, which is more common?
Seminomas - most common
What is the BIG risk factor for developing testicular cancer?
Undescended Testicles (Cryptorchidism), have an 80% chance of developing Cancer.
What is an orchidectomy?
Surgery to remove one or both testicles
Nursing care following testicular cancer includes..
Teach sperm banking & Altered sexuality
_________ Cancer is the leading cause of death from reproductive malignancies.
Ovarian
About 25% of ovarian cancer is found in early stages. When it is localized, what is the prognosis for the next 5 years?
90% live for 5 years
What age is most common for ovarian cancer?
after menopause
What are the risk factors for ovarian cancer?
Use of Fertility drugs, not having kids (the greater the number of pregnancies, the lower the risk for developing ovarian cancer), Diet (obesity increases risk), Family history, past hx of Breast cancer, having kids, having your tubes tied or hysterectomy decreases risk)
What are the risk factors for endometrial cancer?
Early menarche (period before 12) or late menopause(after 52) (prolonged hormone levels play a big role) Reproductive history (no kids, infertility) Obesity; diet high in animal fatbeing treated with TAPMOXIFEN for breast cancer, estrogen replacement therapy (ERT) for treatment of effects of menopauseOther reproductive cancerOther: age, race, SES, family hx., pelvic radiation
What are the risk factors for gynecologic cancer?
Age, Black & Native American race, Prostitution, Low Socioeconomic status, Reproductive history of no children, Postpartum lacerations during birth
What helps early detection of gynecological cancer?
Seek prompt medical attention for symptoms!Routine pelvic & PAP exams starting at age 18 or when becomes sexually active (yearly)THERE ARE NO BLOOD TESTs or IMAGING STUDIES recommended
What are the S & S of gynecological cancer?
Unusual vaginal bleeding or discharge, Sore that does not healPain or pressure in pelvic area, Persistent change in bowel or bladder habits, Frequent indigestion or abdominal bloating, Thickening or lump that causes pain or can be felt
Is it difficult to obtain an early diagnosis of ovarian cancer? Why?
Yes, b/c signs are vague... GI discomfort, etc...
Surgery for gynecological cancers depends on...
surgery depends on location and how far cancer has spread.
What other treatments are options for ENDOMETRIAL cancer...
Hormone therapy & Internal radiation
What nursing care is involved for INTERNAL RADIATION in GYN cancer?
Brachytherapy (sing "seeds," small radioactive rods implanted directly into the tumour), Patient is radioactive during treatment - Time, Distance, Shielding
External Radiation for GYN Cancers involves..
Skin Care (wear loose cloths, avoid hot/cold temps, keep baths short, wear SPF, do not wear adhesive tape like bandaids on area) & Side effects results due to site and dose
By far, the most common type of breast cancer is: a) Infiltrating ductal carcinoma b) Medullary carcinoma c) Infiltrating lobular carcinoma
Infiltrating ductal carcinoma
_________ cancer is the 2nd leading cause of death in women
breast
What is BRCA1 and BRCA2?
Inherited mutated genes that mean you are at an increased risk for breast cancer. Women with an inherited BRCA1 or BRCA2 mutation have up to an 80% chance of developing breast cancer during their lifetime,
Non-modifiable risk factors for breast cancer include:
genderAgingGenetic Family/personal historyRace (white women more likely)Previous breast biopsy/irradiation
What are some lifestyle related risk factors for breast cancer?
Oral contraceptives (slightly increase risk for breast cancer), Not having children, Estrogen replacement therapy, Alcohol & smoking, Obesity & high fat diets
Early detection for breast cancer recommends...
Screening mammogram (ACS protocol: women over 40 should have a yearly mammogram, if at high risk do it earlier, more often), Breast self-examination (every month), Breast clinical physical examination
What are the S/S of breast cancer?
NonePainless mass or lumpNipple dischargeDimpling of skinChange in breast contour
How is breast cancer diagnosed?
Mammography (x-rays of breast)Breast ultrasoundDuctogram (dx's nipple discharge)Nipple discharge examinationBiopsy
Breast CA treatment options include:
Surgical options, Chemotherapy & radiation, Hormone therapy (Estrogen/Progesterone-receptor positive vs. negative tumors), Tamoxifen, Stem cell transplant, Breast Cancer Drugs (Evista, Fareston, Herceptin)
What are the different surgery options for breast cancer?
1. Modified Radical Masectomy (removal of breast & lymph nodes, but leaves chest muscle intact) 2. Radical Masectomy (breast, underlying chest muscle, and lymph nodes are removed), 3. Lumpectomy with node dissection (good for early stage breast cancer, it removes one tumor & some surrounding tissue)
What nursing care is done post-op breast cancer surgeries?
Yes, DO Exercise the operative arm, Elevate it above the heart, Pain is moderate only-oral analgesics. Teach home care for J-tube. Discuss body image & sexuality concerns.
What are pt's at risk for after breast cancer surgeries?
Lymphedema develops after breast surgery because there is an alteration in the pathway that drains the fluids involved in the immune system (The lymph nodes were removed) - causes excess fluid in arm (s) b/c it is not being filtered out.
What helps lymphedema?
Exercise and arm elevation, Physical therapy (Gentle massage & wearing compression sleeve)
After a breast cancer masectomy, what are some do's & don'ts?
1) Avoid blood pressure, injections, blood draw in affected arm 2) Prevent infection by wearing gloves and protecting hand and arm from trauma 3) Exercise arm and hand as directed
What are the goals for breast reconstruction?
Symmetry & Contour
What needs to be assessed post-op breast reconstruction?
Tissue perfusion. Do assessment of color, pulses, and sensation in extremities. Also, Pain and wound care are more extensive with reconstruction. Remember it was just oral analgesics following a masectomy.
What is a TRAM flap in a breast reconstruction?
The TRAM flap is the most popular technique for breast reconstruction with autologous tissue. "TRAM" is "transverse rectus abdominis myocutaneous." Skin, fat, and muscle will be moved from your tummy up to your chest, and used to create a breast mound. Most women have enough tissue in their tummy area to create a new breast. But if there is not enough tissue, a small implant can be placed to fill out the size of the new breast. Two methods are used to move your tissue from your tummy to your chest -- free flap and pedicle flap.
What are the 2 main types of Lymphomas?
Hodgkin lymphoma: 5 subtypes & Non-Hodgkin lymphomas: 30 subtypes
What are the S/S of lymphoma?
Enlarged lymph nodes. May start with a painless swelling in the neck, under arm or groin, Enlargement of the spleen may cause abdominal pain or discomfort, Fever, chills, weight loss, night sweats.
What health promotion/prevention is recommended to decrease all cancers?
Do not use tobacco in any formEat high proportion of plant foodsLimit amounts of meat, dairy, & other high fat foodsLimit intake of alcoholic beveragesMaintain ideal body weightBe physically active
In comparing benign & malignant tumors, the nurse recognizes that malignant tumors: a) originate from anther cell type b) invade other tissues c) grow by expansion d) always spread to other parts of the body
b) invade other tissues
In preparing a teaching plan about cancer associated w/ tobacco, the nurse includes which sites of cancer? a) skin b) breast c) liver d) thyroid
c) liver
The nurse recognizes that promotion of cancer cells correlates with: a) mutation of the DNA of a cell b) growth of cancer cells c) lengthened latency periods for cancer cells d) cancer cells breaking off the original tumor
b) growth of the cancer cells
In reviewing the chart for a client with recent diagnosis of cancer, the nurse recognizes that TNM correlates with: a) location of cancer b) stage of cancer c) size of cancer d) origin of cancer
b) stage of cancer
In comparing "low grade" and "high grade" cancer, the nurse understands that high grade cancer is characterized by:
poorly differentiated cells
The nurse recognizes that OA are at greater risk of cancer b/c of: a) increase in cell mutations b) inability to differentiate self from non self c) lowered metabolic rate d) decrease in immune system function
d) decrease in immune system function
The nurse recognizes that a client's risk for cancer development may be affected by genetic predisposition b/c: a) precursors of oncogenes are passed on genetically b) mutated cancer cells may be inherited c) suppressor genes may be overly functional d)
a) precursors of oncogenes are passed on genetically. (Oncogenes turn normal cells into abnormal cells)
The nurse recognizes that __________ is associated with 30% of cancers in america.
tobacco
______________: removal of growth not presently malignant such as polyp
Preventative: removal of growth not presently malignant such as polyp
Diagnostic is...
confirm diagnosis & identify specific cancer
___________ determinse extent of disease & amount of lymph node involvement
Staging
____________- considered primary treatment of cancer; removal of tumor when tumor appears to be localized & there is hope of taking out of cancerous tissue
Curative
___________ - performed as treatment of complications of advanced disease and is not intended to cure cancer. Debulking is a common term used to describe palliative procedures aimed at removing all visible tumor.
Palliative
an example of Supportive
vascular access devices
an example of Restorative..
Restorative - breast reconstruction after mastectomy or bone grafts or prosthetic bone or joint replacements
Brachytherapy is an example of internal radiation. What is brachytherapy?
Brachytherapy: radioactive pellets are about the size of a grain of rice; used in the treatment of prostate, lung, and uterine cancer, and thyroid.
Do all clients emit radiation for a period of time?
Yes (External is teletherapy & is focused from a source outside the body. Internal is brachtherapy and radioactive isotopes)
How does radiation work?
Radiation destroys the cell’s ability to reproduce by damaging cell’s DNA, Small doses over a set period of time. Rapidly dividing cells, such as cancer cells are more vulnerable to radiation than more slowly dividing cells. GI, integument, and myeloproliferative systems are at greatest risk for damage. Furthermore, normal cells have a greater ability than cancer cells to repair the DNA damage from radiation.
How is the radiation dose determined?
Intensity of exposure, Direction of exposure, Proximity of radiation source to cells
What is the "Inverse Square Law of Radiation Exposure?"
Further you are away, the decreased amt
THe different types of rays emitted during radiation are Gamma, Beta & Alpha. Which has the highest ability to penetrate?
Gamma - it is very light & travels at speed of light, consentrates and penetrates deeply into tissue. Beta is next & is heavier & does not penetrate tissues as well. Alpha is last & are very heavy and slow... lose ability to penetrate very fast.
One sd of effect of radiation is "the rapidly dividing cells are damaged much quicker." Who does this affect?
growing children at higher risk for complications. the younger the child, the more radiosensitive body organs. In children radiation can cause cognitive deficits and bone growth discrepancies in later life.
What tissues are most sensitive to external radiation?
Hematopoietic (blood cells)Epithelial (skin, mucus membrane and hair follicles)Gonadal or reproductive tissue.
What safety precautions are done for internal radiation safety?
They need a private room, have a caution “radio-active material” sign on door, wear a dosimeter badge at all times, pregnant nurses or children under 16 not allowed in room, minimize direct patient contact, maximize distance from implant site, pregnant nurses should not care for these clients, limit visitors to 1/2 hr each day, caregiver exposure is limited to 30 min's per 8 hr shift, Stand at client’s shoulder for cervical implants or at the foot of the bed for head and neck implants (client’s body will shield you), Foley catheter flush urine down toilet, meals no special care
What is done for radiation therapy patients linens? What happens if radioactive source dislodges?
Check linen for radiation implant before disposing. Save all dressings and bed linens until after the radioactive source is removed. After the source is removed, dispose of dressings and linens in the usual manner. other equip can be removed from the room at any time. (Hold in room until source is removed then dispose of all linen.)If becomes dislodged... Never touch w/ bare hands. Keep lead container in room with forceps in case implant dislodges from source.
Sd effects of radiation are: hematopoietic (anemia), skin (redness, dryness, itching, desquamation-shedding of skin), alopecia-hair loss, sterility in gonads, fatigue, altered taste from metabolites & long term tissue damage. What recommendations are mad
wash area gently daily with warm water or mild soap, use hand not washcloth, do not remove markings indicating where beam of radiation goes, dry using patting motions, do not use powders, ointments, lotions or creams, wear soft clothing, avoid belts, buckles, straps (anything tight), avoid sun exposure there (wear SPF & wear protective clothing), avoid heat exposure at site.
What is recommended to patients suffering from alopecia (hair loss)?
Use mild shampoos Use soft hair brushesUse low heat with dryerNo hair dyes or permanentsCut hair shortProtect the scalp (especially in sun)Use satin pillowcaseShould warn people that when hair comes back it is often a different color & texture.
How does chemotherapy work? Does it have a narrow therapeutic window?
Destroy cancer cells by cell destruction or interference with cell division. Yes, chemo has a big draw back of having a very narrow therapeutic window (not toxic enough vs. too toxic)
Does chemo also destroy the rapid growing cells?
Yes, chemo destroys rapidly growing cells (normal & abnormal)(b/c the amneoplastic agents cannot differntiate between cancer cells and healthy cells... these are often killed - like Hair folliclesmucous membrane (GI)hematopoieticreproductive (spermatocytes)
Chemotherapy is based on the patients _________.
weight, so it is important to get a current weight and not use a previous one.
How do hormonal agents for chemo work? drugs like corticosteroids, prednisone, androgens,estrogen,LHRH, tamoxifen-antiestrogen, antiandrogens-flutamide
interfere with protein synthesis and alter cell metabolism.
Chemo often uses Combined drug regimens for optimal cell cycle destruction and minimal SE. The drugs are cycled for a specific amt of time. We will use these drugs with different Nadirs. What are Nadirs?
Time after chemotherapy when the white blood cell or platelet count is lowestOccurs between 7-14 daysHelps to predict when client at greatest risk for infection & bleedingRecovery of WBC’s and platelets within 21-28 days
___________ stimulate specific immune system cells to identify and destroy cancer cells. big sd effect is you feel like you have the flu for a month. used w/ cancer & hep C.
Interleukins
__________ cell substances that enhance activity of natural killer cells in the body . used for renal or ovarian cancers.
Interferons.
______________ antibodies binds protein and prevents division of ca cells
Monoclonal
what is NADIR (key concept)?
when pts at highest risk & we plan accordingly for it. know time effect after therapy that we’re going to peak on sd effects for bone marrow, ski, GI tract. Platelets really low? Worry about bleedingWBCs? Worried about infectionNeutropenic precautions: protect pt from us. No fresh fruits, vegetables, no plants in room , no kid in room, everyone wears gloves, mask
Support given after chemotherapy is Biologic Response Modifiers. They are colony stimulating factors that induce a more rapid recovery of bone marrow after chemotherapy. There is Neupogen, Epogen, Neumega & Leukines. What do they promote?
Neupogen –promotes NeutrophilsEpogen-promotes ErythrocytesNeumega-promotes PlateletsLeukine -All granulocytes
Now often considered standard therapy. MANY types of cancer are treated for relapse with a second round of chemo. Explain...
Client may be subject to another round of chemotherapeutic drugs which may be more potent than first-round drugs & given Bone marrow transplantation (BMT)
Why do chemo patients have central lines?
Usually given through central line to avoid possible extravasation. Extravasation: Peripheral IV where drug leaked into tissues & causes necrosis. Why these people have central lines!
Nursing interventions for the big sd effect of fatigue in cancer are..
Plan activities around periods of restGet assistance with non-essential activitiesGet regular mild exerciseThey do recommend slow exercise, slow walks… At the onset of therapy many patients may underestimate the level of their fatigue and not plan accordingly. They may become depressed when they realize they can not continue with normal activities. teach to lower infection (avoid crowds & use good hand hygiene), avoid aspirin use, ensure adequate fluid intake
________________ is the term for "extreme body wasting/malnutrition"
Cachexia
_______________ is term for "Change in taste or appetite"
anorexia (Chemotherapy and Radiation may release metabolites that alter the taste of foods.)
Xerostomia or Stomatitis are...
sloughing down esophagus, Difficulty swallowing. There are all sorts of causes for malnutrition in cancer. They experience fatigue, muscle loss and difficulty eating. they are definitely "at risk for inadequate nutrition."
What are some nursing interventions to help w/ malnutrition in cancer?
Small frequent high caloric mealsAvoid offensive foods and food odorsEnteral and/or parenteral feedings may be orderedGet the dietitians involved earlyMonitor weight, lab work (albumin, total protein)Provide patient flexibility with food choices.Hospital food timing often does not work. Work with the physician to allow family and friends food that the patient may prefer. Be prepared that the patient and family may be disappointed that favorite foods do not taste the same.
What helps reduce N/V for cancer patients?
Administer antiemetics prophylacticlySmall, frequent mealsEat & drink slowlyEat foods cold or at room temperatureRemain in an upright position for 2 hrs after eatingEncourage patient to use nonpharmacologic means such as music, muscle relaxation, massage, acupuncture and guided imagery.
Cancer patients experience stomatits/mucositis which is Inflammation and ulceration of mucous membranes of the entire GI tract. It is very Painful and interfere with eating. Want to Inspect mouth frequently & do Frequent gentle mouth care. This is so im
1. Do not use alcohol containing mouthwashes & avoid flossing, 2. Frequent mouth rinses with either NS (1 tsp salt in a pint of water = NS) or sodium bicarb (1 tsp baking soda with 1/2 teaspoon salt in a quart of water). 3. Antifungals such as Nystatin (swish or swallow; swish & spit) on a regular basis for prophylaxis.
The major dose limiting side effect of chemo is BONE MARROW SUPPRESSION. What is happening, what is so low that is a problem?
Immunosuppression: Neutropenia (very low neutrophils... those are WBCs)
The really big risk of chemo causing low WBCs is the high risk of infection. What infections are these pt's at high risk for?
Puts the client at extreme risk of infection (nosocomial infections like MRSA, VRE, C. Diff & pneumonia are big worries). Most infections develop from an overgrowth of the client’s own normal flora. BE VERY METICULOUS TO PREVENT INFECTION!
Goal for an absolute neutrophil count is 1000 for cancer patients. Normal is 3500. The Absolute neutrophil count is WBCs x % of neutrophils. Basically letting us know how at risk for infection they are. What special care is done for pt's with neutrope
private rooms, good handwashing, do not use supplies from common areas for these pt's (own drinking straw, plastic silverware, own cup, gloves, bandages), limit HC going in/out, change wound dressing daily, obtain C & S for anything suspicious, assist in coughing & deep breathing, change IV tubing daily, keep thermometer, BP cuff in their room, limit visitors, no fresh flowers or plants, avoid catheters. If they go anywhere, wear a mask. cover wheelchair w/ blanket. Patient is in REVERSE ISOLATION - we're protecting pt from other people & illnesses.
The typical manifestations of infection are often absent because these clients are not able to produce an adequate inflammatory response to infection. ___________ is the single most important and often the only manifestation of infection in the neutrope
Fever. It should be treated as an emergency if found in a neutropenic client.
Thrombocytopenia is a reduction in platelets. Normal is 140,000. If less than 50,000 or 20,000 they're at high risk of bleeding out. What nursing precautions are necessary for thrombocytopenia?
No aspirin or antiplatelet aggregation meds until platelet count rises, Avoid IM injection and constricting devices, Watch for GI bleeds, unstoppable nose bleeds, want to avoid injuries, talk to about using electric razor instead of regular razor, blow nose gently. When we talk about slight traumas we can mean things like blood draws, IV insertion, flossing and brushing teeth, or a difficult bowel movement in someone with hemorrhoids.
If a pt with thrombocytopenia who has unstoppable nose bleed or GI bleed needs....
to receive platelets and whole blood.
The colony stimulating factor drug given to help with low platelets (thrombocytopenia) is..
Neumega (opelvekin).
S & S of anemia include..
fatigue, pallor, dyspnea, palpitations and/or angina, and alterations in mental status.
How do we help anemia?
1. Monitor Hb/Hct as ordered. 2. Provide well balance diet. 3. Give epoeitn/epogen/procrit? Don’t give sub-q! it can be given IV! 4. Iron supplements. What’s the problem with them? Cause constipation. Epoetin alfa (Epogen or Procrit) or Darbeposetin alfa (Aranesp) 5. Blood transfusions
What are the oncological emergencies?? huge worries...
Sepsis BIG worrySIADH (syndrome of inappropriate anti-diuretic hormone. Severe pleural effusion.Cardiac tamponade. Disseminated intravascular coagulation (DIC)Clots and hemorrhage70% die even with treatment
What is a big oncological emergency that happens when a tumor enters the spinal cord or the vertebrae collapse from tumor degradation? Leads to severe back pain and neural deficits. May result in permanent paralysis.
Spinal Cord Compression. May be treated with...SteroidsSurgeryBraces
Another oncological emergency that occurs in 75% of patients with lung cancer & the early symptoms: facial edema, visual changes, and headache.late: upper limb edema, dysphagia, dyspnea, cough and hoarseness. _______________ _________ __________ syndrome
Superior vena cava
What electrolyte imbalance is common in cancer patients d/t bone metastasis?
hypercalcemia, serum calcium > 11 mg. Early symptoms are: fatigue, nausea, vomiting, constipationLater sympoms are: severe muscle weakness, paralytic ileus, dehydration and EKG changes.Decreased mobility and dehydration make it worse.
________ ___________ syndrome is Destruction of large numbers tumor cells leads to release of intracellular content. Leads to hyperkalemia, hyperphosphatemia and hyperuricemia.How do we treat it?
Tumor Lysis Syndrome. Treat with hydration: At least 3 to 4 liters/day, allopurinol, phosphate binders.May require dialysis.
Your pt has Unexplained oral bleeding or bruising on the neck, swelling, trouble swallowing or breathing, retrosternal chest pain, mental status change. This is most common in head and neck cancer after radiation, surgery or infection. What happens is the
carotid artery rupture. Need to apply pressure until surgical repair. If patients have a palpable pulse on or near a tumor this is more common.
You are taking care of a cancer patient that is becoming tolerant and require levels of pain med that would knock us out, what do you do?
They are needed! Pain is UNDERTREATEDHELP YOUR PATIENT TO KEEP PAIN UNDER CONTROL!!!NEEDLESS SUFFERING DUE TO PREJUDICE AND FEAR OF DEPENDENCE. be a patient advocate and get that pain relieved!
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