CCI- Exam #1 Study Guide

What is anemia?

A deficiency in:

• Number of erythrocytes (RBCs)

• Quantity or quality of hemoglobin (Hgb)

• Volume of packed RBCs (hematocrit)

How is anemia diagnosed?

- Complete blood count (CBC)

- Reticulocyte count

- Peripheral blood smear

What are the functions of RBCs?

- Transport oxygen (O2) from lungs to systemic tissues

- Carry carbon dioxide from tissues to lungs

How is anemia classified?

- Morphology: Cellular characteristics and RBC size and color

- Etiology: Cause and clinical condition causing anemia

Anemia is caused by?

- The body’s response to tissue hypoxia

- Manifestations vary based on how fast anemia has evolved, its severity, and any coexisting disease

- Hgb levels are often used to determine the severity of anemia

What are the normal hemoglobin levels for males?

14-18 g/dl

What are the normal hemoglobin levels for females?

12-16 g/dL

What is a low level of hemoglobin?

<6

What is a high level of hemoglobin?

>20

What are the manifestations of anemia?

• Fatigue/Weakness, Dyspnea, Dizziness, Palpitations:

- Heart & Lungs trying to provide adequate O2 to tissues

- Cardiac output maintained by increasing the heart rate and stroke volume

• Pallor:

- Decreased Hgb

- Decreased blood flow to the skin

What are the nursing interventions for anemia?

- Alternate rest and activity

- Prioritize activities

- Accommodate energy levels

- Maximize O2 supply for vital functions

- Aid to minimize risk of injury from falls

- Monitor cardiorespiratory response(tachycardia and hypotension)

- Evaluate nutritional needs

What is iron-deficiency anemia?

- Most common nutritional disorder in the world

- Most susceptible:

- Very young

- Poor diet

- Women in reproductive years

What are sources of iron?

- Grains

- Red meat(leafy greens)

- Shellfish

- Egg yolks

- Cooked spinach

- Leafy greens

- Green peas

- Broccoli

- Brussel sprouts

- Poultry

- Dried fruits

- Legumes

What is the etiology of iron-deficiency anemia?

• Inadequate dietary intake:

- Normally dietary intake is enough

• Need more with menstruation and pregnancy

• Malabsorption:

- Iron absorption occurs in the duodenum

- Diseases or surgery that alter, destroy, or remove absorption surface of this area of intestine cause anemia

• Blood loss:

- Major cause of iron deficiency in adults

- Chronic blood loss most commonly through GI and GU systems

- Bleeding often not apparent

- May take time to identify

- Postmenopausal bleeding, chronic kidney disease, and dialysis may contribute.

What are the clinical manifestations of iron-deficiency anemia?

- General manifestations of anemia (dyspnea, fatigue, pallor, palpitations, dizziness)

- Pallor is most common

-Glossitis (inflammation of tongue) is second

- Cheilitis (inflammation of lips) is also found

How is iron-deficiency anemia diagnosed?

• Laboratory findings: - Hgb, Hct, MCV, MCH, MCHC, reticulocytes, ferritin (stores), serum iron, TIBC, bilirubin, platelets

- Stool occult blood test: GI bleed

- Endoscopy and colonoscopy

- Bone marrow biopsy: Used as a last resorts and tests if the iron stores are functioning appropriately

What is the treatment for iron-deficiency anemia?

• Treat underlying problems causing loss, reduced intake or poor absorption of iron

- *Replace iron

- Nutritional therapy

- Oral iron supplements

- Transfusion of packed RBC

What are the factors to consider with oral iron?

- Best absorbed in an acidic environment on an empty stomach with a source of vitamin C.

- Undiluted liquid iron may stain teeth: Should be diluted and drank through a straw

What are the side effects of oral iron?

- Heartburn

- Constipation

- May have black tarry stool(harmless)

What is a cobalamin deficiency(vitamin B12)?

- Most commonly caused by pernicious anemia

- Caused by absence or loss of intrinsic factor (IF)

What is the intrinsic factor?

• Protein secreted by parietal cells of gastric mucosa

- IT is required for cobalamin absorption in the distal ileum

What can also cause a cobalamin deficiency?

- Surgery or chronic diseases of the GI tract: Gastric bypass

- Excess alcohol or hot tea ingestion

- Smoking

- Long-term users of H2 histamine receptor blockers and proton pump inhibitors

- Strict vegetarians

What are the clinical manifestations of cobalamin deficiency?

- General manifestations of anemia develop slowly due to tissue hypoxia

- GI problems: Sore, red, beefy and shiny tongue, anorexia, nausea, vomiting, and abdominal pain

- Neuromuscular problems: Due to damage to myelin

- Weakness, paresthesias of feet and hands, decreased vibratory and position senses, ataxia, muscle weakness, and impaired thought processes.

How is cobalamin deficiency diagnosed?

- Macrocytic RBCs have abnormal shapes and fragile cell membranes

- Serum cobalamin levels are low: Less than 200pg/mL

- Normal serum folate levels and low cobalamin levels suggest megaloblastic anemia is due to cobalamin deficiency

- Upper GI endoscopy with biopsy of gastric mucosa to rule out gastric cancer

What is the treatment for cobalamin deficiency?

- Parenteral administration of cobalamin is the treatment of choice(B12 injections for the rest of life if no intrinsic factor)

- Patients will die in 1 to 3 years without treatment

- Anemia can be reversed with ongoing treatment but long-standing neuromuscular complications may not be reversible

What are the common causes of folic acid deficiency?

- Dietary deficiency

- Malabsorption syndromes

- Drugs

- Increased requirement

- Alcohol use and anorexia

- Loss during hemodialysis

What is a folic acid deficiency?

- Serum folate level is low

- Serum cobalamin level is normal

What are the normal levels for serum folate?

Normal is 5 to 25 ng/mL (11 to 57 nmol/L)

What are the normal levels for serum cobalamin?

Greater than 300pg/mL

What is the treatment for folic acid deficiency?

- Treated with replacement therapy

- Usual dose is 1 mg/day by mouth

- Encourage patient to eat foods with large amounts of folic acid

What are rich folic acid foods?

- Broccoli

- Pinto beans

- Bananas

- Tomatoes

- Soybeans

What is thrombocytopenia?

- Low platelet count <150,000

What are the function of thrombocytes/platelets?

- Involves the vascular endothelium, platelets, and coagulation factors

- Function together to stop hemorrhage and repair vascular injury

- Disruption of any component may result in bleeding or thrombotic disorders

What are the clinical manifestations of thrombocytopenia?

- Patients are often asymptomatic

- Most common symptom is mucosal or cutaneous bleeding

- Petechiae: Microhemorrhages

- Purpura: Bruise from numerous petechiae

- Ecchymoses: Larger lesions from hemorrhage

- Hemorrhage may be insidious or acute

- Internal bleeding may manifest as weakness, fainting, dizziness, tachycardia, abdominal pain, or hypotension

- Cerebral hemorrhage may be fatal

How is thrombocytopenia diagnosed?

- Decreased Platelet count< 150,000/μL

- Prolonged bleeding < 50,000/μL

- Spontaneous bleeding < 20,000/μL

- Clinical examination

- Lab parameter comparisons

What is a normal platelet level?

150,000-400,000/mm3

What is a normal WBC count?

5,000-10,000

What is a normal hematocrit level in males?

40%-52%

What is a normal hematocrit level in females?

37-47%

What is low for hematocrit levels?

<15

What is high for hematocrit levels

>60

What is treatment for thrombocytopenia?

- Discourage the use of OTC medications, especially aspirin products and NSAID's

- Prevent or control hemorrhage

- Soft-bristle toothbrush

- Electric razor

- Avoid IM injections

- If subcutaneous injection is unavoidable, use small-gauge needles and apply direct pressure or ice packs after

- Watch for bleeding that can be difficult to detect

- Neurological

What is neutropenia?

- Low neutrophil count

- Defined as an absolute neutrophil count (ANC) less than 1000 cells/uL

- Patients are at risk for infection

What is the normal range for neutrophils?

2500 to 8000 cells/uL

Those who are at risk for infection are those with an ANC of?

- ANC= 1500-2000 not significant

- ANC=1000-1500 minimal risk

- ANC=500-1000 moderate risk

- ANC=<500 severe risk

What is the formula to find the ANC?

ANC=(% segments + bands) x WBC/100

What are causes of neutropenia?

- Autoimmune disorders: Lupus

- Hematologic disorders: Leukemia and Aplastic anemia

- Medications: Chemotherapy

- Infections: Viral (influenza, HIV)

What are the nursing interventions for neutropenia?

- Isolation precautions(reverse/neutropenic precautions)

- Strict hand hygiene

- Screen visitors

- No children

- Monitor for s/s of infection

- Fever > or = 100.4F

- Avoid uncooked foods

- No fresh flowers or plants

- Good oral hygiene

What is aplastic anemia?

Pancytopenia:

- Decrease in all blood cell types

- Red blood cells (RBCs)

- White blood cells (WBCs)

- Platelets (PLTs)

- Ranges from moderate to very severe

- Potentially fatal

What are the general manifestations of aplastic anemia?

- Fatigue, dyspnea, palpitations

- Neutropenia, anemia, thrombocytopenia

What is leukemia?

- A group of cancers affecting the blood and blood-forming tissues of: Bone marrow, lymph system, and spleen

- Occurs in all age groups(may be more prevalent in older and younger people)

- Accumulation of dysfunctional cells due to loss of regulation in cell division

- Fatal if untreated

What are the classifications of leukemia?

- Acute and chronic

- Based on cell maturity and the nature of disease onset

- Based on type of WBC:

- Acute lymphocytic leukemia (ALL)

- Acute myelogenous leukemia (AML)

- Chronic myelogenous leukemia (CML)

- Chronic lymphocytic leukemia (CLL

What is acute lymphocytic leukemia(ALL)?

- More common in children, but may happen in adults.

- Will have a fever when 1st come in.

- Clonal proliferation of neoplastic immature lymphoid cells.

- Lymphoblasts in the bone marrow or peripheral blood.

What are the s/s of Acute Lymphocytic Leukemia?

- Bleeding

- Infection

- Lymphadenopathy

- Fever

- Bone pain

What is Chronic Lymphocytic Leukemia(CLL)?

- Mainly affects older people(>65 years)

- Slower growing

- Most common one in the U.S.

- Clonal malignancy of B lymphocytes.

What are the s/s of Chronic Lymphocytic Leukemia(CLL)?

- Lymphadenopathy

- Hepatomegaly

- Splenomegaly

What is Acute Myelogenous Leukemia(AML)?

- Malignancy involving the myeloid line of precursor cells.

- > 20% blasts in bone marrow

- Typically affects adults greater than 65 years of age.

- Has an abrupt onset and cause serious infections and bleeding.

What are the s/s of Acute Myelogenous Leukemia?

- Leukostasis

- CNS symptoms

- Disseminated intravascular coagulation(DIC)

What is Chronic Myelogenous Leukemia(CML)?

- Caused by a reciprocal translocation

- A tyrosine kinase produced by the BCR-ABL gene is responsible for myeloid proliferation.

- Has a chronic stable phase followed by a more acute phase.

- Once transformed to acute or blasting phase, it has to be treated very aggresively.

- Due to a Philadelphia chromosome (genetic)

What are the s/s of Chronic Myelogenous Leukemia(CML)?

- Extreme tiredness

- Weight loss

- Fever

- Night sweats

- Pain

What are the clinical manifestations of leukemia?

- Inadequate marrow elements predispose patient to:

- Anemia

- Thrombocytopenia

- Neutropenia

What is the treatment for leukemia?

- Chemotherapy

- Immunotherapies

- Stem Cell transplants

A patient with acute myelogenous leukemia is starting chemotherapy. When teaching the patient about the induction stage of chemotherapy, what is an appropriate statement?

"You will be at increased risk for bleeding and infection."

What is lymphoma?

- Cancers originating in bone marrow and lymphatic structures

- Results in the proliferation of lymphocytes

- Comprise 4% to 5% of all cancers in United States

- Two major types:

- Hodgkin’s lymphoma(rare)

- Non-Hodgkin’s lymphoma (NHL)

What is Hodgkin's lymphoma?

- RARE

- About 10% of lymphomas

- Contains Reed-Sternberg cells(owl-eyes appearance)

- Most frequent in 15-30 year olds

- More frequent in males than females

- Usually gradual onset

- Enlargement of cervical, axillary, or inguinal lymph nodes

- Second most common location is a mediastinal node mass

- Nodes are movable and nontender

- Not painful unless nodes exert pressure on adjacent nerves

- Will spread from node to node

What are the diagnostics for Hodgkin Lymphoma?

- Peripheral blood annulus

- Lymph node biopsy

- Bone marrow biopsy

What are the clinical manifestations of Hodgkin's Lymphoma?

- Painless lymphadenopathy

- Constitutional "B" symptoms

- Fever

- Night sweats

- Weight loss

- Pruritus

- Hepatosplenomegaly

What are the clinical manifestations of Non-Hodgkin's Lymphoma?

- Widespread disease usually present at the time of diagnosis(found when it has spread)

- About 75 types of Non-Hodgkin's

- Painless lymph node enlargement: Primary clinical manifestation

- Lymphadenopathy can wax and wane

- Other symptoms depending on where disease is present

- Resemble those used for Hodgkin’s lymphoma

How is Non-Hodgkin's Lymphoma diagnosed?

- Since NHL is more often extranodal(outside of the lymph nodes):

- MRI

- Lumbar puncture

- Bone marrow biopsy

- Barium enema or upper endoscopy

What is Multiple Myeloma?

- Condition in which cancerous plasma cells proliferate in bone marrow and destroy bone

- Involves excess production of plasma cells

- Normal plasma cells make immunoglobulins to protect the body

- In multiple myeloma, plasma cells make monoclonal antibodies that are ineffective and even harmful

What are the nursing interventions for Multiple Myeloma?

- Pain control

- Adequate hydration

- Prevent dehydration & M proteins from causing renal damage

- Maintain urine output of 1.5-2L/day

- Ambulation & weight bearing: To reabsorb calcium

What are the clinical manifestations of Multiple Myeloma?

- Skeletal pain is major manifestation: Pelvis, spine, and ribs

- Diffuse osteoporosis develops

- Osteolytic lesions seen in skull, vertebrae, long bones, ribs

- Compression of spinal cord, pathologic fractures

- Calcium loss from bones causes hypercalcemia: Leads to renal, GI, and neurologic manifestation

How is Multiple Myeloma diagnosed in the laboratory?

- M protein found in blood

- Pancytopenia

- Hypercalcemia

What is cancer?

- A group of diseases characterized by uncontrolled and unregulated growth of cells

- Occurs in people of all ages

- Most cases are diagnosed in those over age 55

What are the causes of cancer?

Multifactorial:

- Genes: Genetic links

- Environment: Viruses (HIV, HPV, EBV). chemicals (benzene, formaldehyde) and radiation (damages DNA)

- Dietary: Fatty foods and red meats

- Lifestyle: Sedentary, obesity, and unsafe sexual practices

What are tumors classified as?

- Benign: Non-cancerous

- Malignant: Cancerous

What are malignant tumors?

- Ability of malignant tumor cells to invade and metastasize is major difference between benign and malignant neoplasms

How is cancer classified?

Tumors can be classified by:

- Anatomic site

- Histology: Degree of differentiation of cells

- Extent of disease

What are the clinical staging classifications of cancer?

- 0: Cancer in situ

- I: Tumor limited to tissue of origin; localized tumor growth

- II: Limited local spread

- III: Extensive local and regional spread

- IV: Metastasis

What does the diagnostic plan for cancer include?

- Health history

- History of present illness

- Identification of risk factors(sedentary, obesity, etc)

- Physical examination

- Specific diagnostic studies

- Biopsy

What is a tissue biopsy?

- Involves histologic examination by a pathologist of a piece of tissue

- Tissue may be obtained by a needle or aspiration, incisional procedure, or an excisional procedure.

What is the gold standard for determining if it is cancer?

A tissue biopsy

What are the diagnostic studies used for cancer?

Typically used based on the site of cancer:

- Radiographic studies

- Radioisotope scans

- PET scan

- Tumor markers

- Genetic markers

How do you prevent cancer?

Lifestyle habits to reduce risks:

- Avoid or reduce exposure to known or suspected carcinogens

- Cigarette smoke, excessive sun exposure, and vaping

- Limit alcohol use: 1 drink/day for women, 2 drinks/day for men

- Exercise regularly: 30 minutes x 5 days a week

- Maintain a healthy weight

- Get adequate rest

- Eliminate, reduce, or cope with stress

- Have a regular health examination

- Be familiar with your family history: Know your risk factors

What are the goals of cancer treatment?

Cure, maintain, or palliation

What is surgical therapy for cancer?

- The oldest form of cancer treatment

- Meets a variety of goals

- Trend is toward less radical surgeries

- Solid tumor is typically removed

What is chemotherapy for cancer?

Antineoplastic therapy:

- Use of chemicals given as a systemic therapy for cancer

- Mainstay for most solid tumors and hematologic cancers

- Can offer a cure, control, or palliative care

- Great tool, but kills good and bad cells.

- Will make people extremely sick!

What are the side effects of chemotherapy?

- Fatigue: Want patients to walk

- Hair loss: Wig

- Nausea/Vomiting: Ondansetron. 1 hour before chemo, round the clock (every 8 hours)

- Diarrhea: Antidiarrheals: (Unless contraindicated)Want to avoid roughage, fried & fatty foods

- Weight loss: High calorie & protein diet

- Mucositis: Rinse mouth, avoid alcohol products(Use lukewarm bottled water or normal saline)

What is immunotherapy for cancer?

- Life-saving drug

- Immunotherapy uses the immune system to fight cancer

- Boost or manipulate the immune system and create an environment not conducive for cancer cells to grow

- Helps the body attack cancer cells directly

What are the side effects of immunotherapy?

- Flulike symptoms: Monitor for fever(chills typically mean fever)

- Anorexia/weight loss

- Fatigue, malaise, weakness

- Headache

-Nausea/vomiting/diarrhea

- Photosensitivity

- The more symptoms you have, the more your body is fighting off the cancer.

What is external beam radiation?

- Radiation is used to treat a carefully defined area of the body

- Not a primary treatment for systemic disease

- May be used by itself or with chemotherapy or surgery

- To treat primary tumors

- For palliation of metastatic lesions

What are the side effects of external beam radiation?

- Depends on location treated

- Most common side effect is fatigue and skin reactions

What are the nursing interventions for external beam radiation?

- Outpatient Therapy

- Want to encourage walking

- Take care of the skin

- Use products such as aloe vera and Aquaphor

- Do NOT use perfumes, alcohol or dyes.

What is internal radiation therapy?

- Done within the hospital(inpatient)

- Implantation or insertion of radioactive materials into or close to tumor

- Minimal exposure to healthy tissue

- Commonly used in combination with external radiation

- Patient is emitting radioactivity

What are the nursing interventions for internal radiation therapy?

- Limit amount of time near patients being treated

- Organize care

- Use shielding

- Wear film badge to monitor exposure

What is Hematopoietic Stem Cell Transplantation(HSCT)?

- Bone marrow transplant (BMT)

- Peripheral stem cell transplantation (PSCT)

- Tumor cells are eradicated and bone marrow is rescued by infusing healthy cells

- Given IV at bedside

- Long hospital stay: Takes 2-4 weeks to start working

- Protected from exposure to infection

What are the side effects of Hematopoietic Stem Cell Transplantation?

Pancytopenia

What are the complications of Hematopoietic Stem Cell transplantation?

- Graft-versus-host disease (body attacks as foreign)

- Maculopapular rash palms & soles

- Diarrhea can be severe

- Infections(>100.4= fever)

- Want to monitor the skin and for infections

What is cancer pain?

- Pain is what the patient says it is!

- Undertreatment of pain causes:

Needless suffering, decreased quality of life and an increased burden on family caregivers

- Inadequate pain assessment is the single greatest barrier to effective cancer pain management

- Fear of addiction is unwarranted

- Numerous drug options for pain management:

- Nonpharmacologic interventions, including relaxation therapy and imagery, can be used effectively

What is cancer survivorship?

- A plan in place

- Cancer survivors continue to increase

- Aging and growth of the population

- Improvement in early detection and treatment

- Greater than 14.5 million in the United States

- Want every cancer patient to have a survivorship plan.