adults 2 exam 1

Discuss the concepts of stigma.

Public

- Dangerous, incompetent, to blame, unpredictable

Self

- Lowered self esteem and self efficacy

Structural

- Intended or unintended loss of opportunity

Describe the significance of communication and the therapeutic relationship to psychiatric nursing practice.

use therapeutic use of self

(self awareness, empathy, and therapeutic communication)

Components of the mental status assessment

Appearance

Behavior

Motor activity

Speech

Mood

Affect

Thought process

Thought content

Perceptions

Cognitions

Insight

Judgment

Escalation scale of anger

Trigger

agitation/acceleration

Peak

Deescalation

Post crisis depletion

Risks for aggression

Inability to communicate needs

Physical needs or conditions

Personal space enlarged - invaded by staff

Demands exceed the ability of the patient

Altered thinking

Inability to process stimuli

Sensory impairment

History of rage and violent episodes

Most important risk factor

Impulsivity

Suspiciousness

Unwillingness to follow rules

Fear

Behaviors that deescalate situations

Therapeutic milieu

Physical environment

Program and structure

Staff presence

Situational awareness

Use of therapeutic self

Empathy

Presence

Apply the nursing process in managing aggression or violence in patients

We do not manage behavior - we seek to identify and be proactive

Recognize the prevalence and incidence of cancer in the United States.

40% of people will be diagnosed with cancer in their life

Cancer is the second most common cause of death

What are the 4 most common cancer sites in men in the US

Prostate

Lung and bronchus

Colorectal

Urinary bladder

What are the 4 most common cancer sites in women in the US

Breast

Lung and bronchus

Colorectal

Corpus and uterus, NOS

What cancer is responsible for the most deaths in the US

Lung and bronchus

Identify the nurse's role in detecting and preventing cancer.

Approx 40% of cancer cases in US are associated with modifiable risk factors

Educate patients on modifiable risk factors such as obesity, tobacco, alcohol, UV light, diet, cancer causing pathogens, and physical activity

Describe the pathophysiology of cancer (proto-oncogenes)

Proto-oncogenes: code for proteins that stimulate the cell cycle and promote cell growth and reproduction

Genes that normally help cells grow and divide to make new cells

Can mutate and become permanently activated → causing cells to grow out of control and become cancer cells

The mutated version is called an oncogene

Describe the pathophysiology of cancer (tumor suppressor genes)

Slow down cell division, repair DNA mistakes and tells cells when to die

When they are inactivated cell division can get out of control → cancer

EX: BRCA1 and BRCA2

People who inherit harmful variants of these genes have increased risks of breast and ovarian cancer

Differentiate the three phases of cancer development.

1. Initiation

Mutation in a cells DNA

2. Promotion

Reversible stage of cancer development

Changes in gene expression

3. Progression

Irreversible stage

Malignant growth

Main sites of metastasis

Brain and cerebrospinal fluid

Lung

Liver

Adrenals

Bone

Carcinoma:

Malignant cancer of epithelial tissue origin

Sarcoma

Connective tissue (bone, tendons, cartilage, muscle, fat)

Myeloma

Plasma cells of bone marrow

Leukemia

Cancers of bone marrow origin

Lymphoma

Lymphatic system

Grade

How different it looks from the cell it comes from

Grade 1 - well differentiated

Grade 2 - moderately differentiated

Grade 3 - poorly differentiated

Grade 4 - undifferentiated

Describe the immune system's role in recognizing and destroying tumor cells.

recognizing abnormal proteins on their surface as "non-self" antigens, which triggers a response from specialized immune cells like T cells and natural killer (NK) cells to target and eliminate the cancerous cells

Stages of cancer

Stage 0: abnormal cells that could grow into cancer but have not been spread

Stage 1: cancer is present but has not spread

Stage 2 and 3: cancer is present and has spread into nearby tissue

Stage 4: cancer has spread to distant tissue

TMN

T: tumor size and extent of tumor invasion into the tissue

N: number of nearby nodes that have cancer

M: metastasis or whether the cancer has spread to distant tissues and or organs

Explain the use of surgery in cancer treatment.

Removes the tumor

Explain the use of chemotherapy in cancer treatment.

Five primary groups of chemotherapy drugs

Classified according to chemical structure and mechanism of action

Primarily works by disrupting the cell cycle in rapidly dividing cells

Cancer cells and normal tissues like bone marrow mucous membranes GI tract skin and hair follicles are often rapidly dividing

Explain the use of radiation therapy in cancer treatment.

Use of high energy radiation to damage the cancer cells DNA and destroy its ability to grow and divide

Used for both the curative and palliative treatment of cancer

Explain the use of endocrine therapy in cancer treatment.

Used to treat hormone-sensitive breast and prostate cancers. Examples:

Selective estrogen receptor modulators like tamoxifen interfere with estrogen's ability to stimulate the growth of estrogen receptor-positive breast cancer cells.

Androgen suppression therapy slows the growth of prostate cancer cells that rely on testosterone to grow.

Hormone therapy is used along with other cancer treatments.

Explain the use of immunotherapy in cancer treatment.

A cancer treatment that boosts the body's immune system to help find and destroy cancer cells

Less side effects

Immune checkpoint inhibitors

Pembrolizumab

T cell transfer therapy

Car T therapy for leukemia and lymphoma

Explain the use of targeted therapy in cancer treatment

Drugs designed to destroy cancer cells by focusing on a specific protein or mutation in the cancer cell that is allowing it to grow and multiply.

Distinguish between external beam radiation and brachytherapy.

- External beam

Linear accelerator used to deliver photon external beam radiation therapy

First session is a simulation session to map out exactly where the radiation needs to be delivered

- Internal beam (brachytherapy)

Insertion of radioactive materials directly int or near the tumor

Sources are sealed in seeds wires or capsules

Used for treatment of cervical breast prostate and head and neck cancer

Intracavitary brachytherapy for cervical cancer

Describe the effects of chemotherapy and radiation on normal tissue.

Can destroy all types of healthy blood cells and harm the bodys production of new ones

Describe the interprofessional management of patients receiving chemotherapy

PPE for chemo

Two pairs of tested gloves - change every 30 min

Disposable polyethylene coated gowns with solid front long sleeves and a tight closed elastic cuff

Fit tested N 95 mask with face shield or eye protection

Superior vena cava syndrome info

What: condition where the flow of blood through the SVC, a large vein that carries blood from the head, neck, arms, and chest into the heart, is obstructed

s/s: Swelling of the face, neck, arms, and upper chest, Veins becoming prominent in the upper body, Shortness of breath, Cough, Chest pain

Cause: blood clots and cancer

Diagnosis: CT or xray

Treatment: usually addressing the cancer or stent placement

spinal cord compression info

What: occurs when the spinal cord is squeezed or put under pressure

s/s: Pain in the back, neck, or legs, numbness, difficulty walking

Cause: trauma or tumor

Diagnosis: CT, MRI, X-ray

Treatment: medication, surgery, steroids

Hypercalcemia info

What: condition where there is an abnormally high level of calcium in the blood

s/s: fatigue, bone pain, kidney stones, NVC

Causes: cancer, meds, kidney disease, parathyroid disorders

Diagnosis: through blood test

Treatment: meds, surgery, chemo

tumor lysis syndrome info

What: a life-threatening medical emergency that occurs when large numbers of cancer cells rapidly die and release their contents into the bloodstream

s/s: muscle weakness and cramps, seizures, confusion, NV

Causes: chemo or radiation, meds

Diagnosis: blood tests, urine analysis

Treatment: hydration, meds, dialysis

neutropenic fever info

What: a fever (body temperature above 38.3°C or 101°F) that occurs in individuals with a low white blood cell count, specifically a low neutrophil count.

s/s: fever, chills, body aches NV

Causes: chemo, bone marrow disorders

Diagnosis: physical exam and blood test

Treatment: IV fluids, antipyretic meds

State the American Cancer Association's guidelines for breast cancer screening.

Women at average risk: age 40-44

Women at high risk: age 30

Every year for 40-54

54+ can choose to do every other

Identify modifiable risk factors that place a patient at high for breast cancer.

Alcohol use

Hormone use

Heavy smoking

Physical inactivity

Weight gain/obesity

Identify non modifiable risk factors that place a patient at high for breast cancer.

older than 50

Family history

Genetics

Female

Early menarch or late menopause

BRCA1 and BRCA 2

Prophylactic oophorectomy and mastectomy

Describe the pathophysiology of invasive breast cancer

Invasive ductal carcinoma

- Accounts for 80% of invasive breast cancer

- Cancer begins in breast ducts and can invade surrounding tissue sentinel or distant lymph nodes and distant organs

- Medullary carcinoma, tubular carcinoma, colloid carcinoma, papillary carcinoma and metaplastic carcinoma

Invasive lobular carcinoma

- starts in the lobules of the breast

Describe the pathophysiology of noninvasive breast cancer

Cancer within the ducts of the breast that has not invaded local tissue or spread to other organs

Includes ductal carcinoma in situ or pure pagets disease

Typically treated with lumpectomy with or without radiation therapy, total mastectomy with or without SLNB, and hormone therapy

Can progress to an invasive cancer if left untreated

Explain how to perform a nursing assessment of a breast mass.

a visual inspection of the breasts for any abnormalities, followed by systematic palpation of each breast quadrant to identify the location, size, consistency, and mobility of any palpable masses, while also noting skin changes, nipple discharge, and axillary lymph node involvement

Signs of breast cancer

Changes in skin texture

Nipple discharge

Dimpling

Lymph node changes

Breast or nipple pain

Retracted or inverted nipple

Changes in skin color

Swelling

Changes in breast size

Identify the diagnostic studies used to diagnose breast cancer.

Mammography, breast ultrasound, breast MRI, CT scan

Describe the interprofessional care of the patient with breast cancer, including surgery, radiation, and drug therapy.

- Lumpectomy - removing the tumor along with a margin of normal surrounding tissue

- mastectomy - Removal of the entire breast. Can include removal of axillary lymph nodes

- Radiation can be used in the adjuvant or palliative setting

- Chemotherapy hormone therapy or targeted therapy can be used in the adjuvant metastatic or palliative setting

Prioritize evidence-based nursing care for patients undergoing a mastectomy.

Managing pain, VS, body image issues, emotional healing

Describe the nurse's role in preventing, detecting, and managing treatment-associated lymphedema.

Teaching patient not to leave the affected extremity in a dependent position for long periods of time

Encourage light exercise and active ROM with the extremity

No BP readings, venipunctures or injections on the affected extremity

Avoid any potential trauma to the extremity including lacerations burns constriction or blunt force

Breast cancer lymphedema

an accumulation of lymph in soft tissue as a result of defective lymph drainage and obstructive pressure on the local venous system

Can occur after lymph node removal or radiation to lymph nodes

Identify modifiable risk factors for prostate cancer.

Obesity

Diet high in red and processed meat

High fat diet

Chemical pesticide exposure

Identify nonmodifiable risk factors for prostate cancer.

Age

Ethnicity

Family history

Recall the American Cancer Association's recommendations for screening for prostate cancer.

Men at average risk: age 50

Men at high risk: age 45

Men at higher risk: age 40

Average: PSA test - below 2.5 ng/mL every 2 years

High: PSA above 2.5 ng/ml every year

Describe the pathophysiology of prostate cancer

Typically slow growing: androgen dependent

Spread occurs by 3 routes

- Direct extension: invasion of cancer into the seminal vesicles, urethral mucosa, bladder wall, and external sphincter

- Lymphatic spread: migration of cancer cells to regional lymph nodes

- Bloodstream spread: cause for metastatic disease to the axial skeleton

clinical manifestations of prostate cancer.

- In early stages asymptomatic

- Initially symptoms may mimic BPH

- In later stages lumbosacral pain that radiates to the hips and legs is noted along with urinary obstructive symptoms/complications

- Sacral and lumbar spine metastasis can cause severe pain and spinal cord compression (oncologic emergency)

Describe the tests to diagnose and stage prostate cancer.

Annual PSA testing and DRE

When to start screening is dependent on age and other risk factors

Biopsy of the prostate must be done to confirm prostate cancer and is usually conducted via transrectal ultrasound

Describe the interprofessional care of the patient with prostate cancer, including active surveillance, surgery (radical prostatectomy and nerve-sparing procedure), radiation, hormone therapy, and chemotherapy.

Early stage cancers may be cured with surgical resection however surgery may also be offered to help relieve symptoms

Radical prostatectomy involves removal of the entire prostate gland, seminal vesicles and part of the bladder neck as well as dissection of pelvic lymph nodes

Adverse outcomes include erectile dysfunction and urinary incontinence

Radiation therapy

External beam can be used to treat cancer confined to the prostate and or surrounding tissues; comparable rates of cure with radical prostatectomy

Brachytherapy involves placing radioactive seed implants into the prostate gland; helps spare surrounding tissue the adverse effects of radiation. It is best used for early stage cancer

Chemotherapy and hormone therapy can also be used to treat and palliate late stage cancer

Define anemia

Decrease in the amount of oxygen delivered to the body tissues

A reduction in one or more of the major red blood cell measurements

- RBC count

- Hemoglobin

- Hematocrit

Mild anemia clinical manifestation

Hgb 10-12 g/dL

Mild fatigue

Dyspnea with exertion

May report no symptoms

Heart palpitations with excretion

May report heavy menstrual bleeding or blood in stool

Moderate anemia clinical manifestation

Hbg 7-10 g/dL

Moderate fatigue

Dizziness

Heart palpitations

May report heavy menstrual bleeding or blood in stool

Worsening dyspnea with exertion

Severe anemia clinical manifestations

Hgb < 7

Glossitis

Headache

Lightheadedness or fainting

Reduced ability to concentrate

Severe fatigue

Pallor

Jaundice

Cold intolerance

Dyspnea at rest

Tachycardia

Chest pain if person has CAD

Glossitis

Smooth beefy red and enlarged tongue

Koilonychia

Spoon nails

Recognize nursing diagnoses for the person with anemia.

- Ineffective tissue perfusion R/T inadequate oxygen at the tissue level

- Activity intolerance R/T impaired oxygen transport

- Fatigue R/T decreased oxygen supply to the body

Can lead to self care deficit R/T weakness

- Risk for injury R/T dizziness and falls

- Imbalanced Nutrition: Less Than Body Requirements R/T inadequate intake of essential nutrients for erythropoiesis

- Readiness for Enhanced Knowledge R/T insufficient knowledge of condition, dietary requirements, and drug therapy

Diagnostic tests for anemia

Bone marrow exam - usually at posterior iliac crest

Complete blood count CBC

RBC count description and components

The number of circulating RBC per 1 microliter of blood

Hgb

Hct

Reticulocyte count

Hgb description

Measures the grams of hemoglobin per deciliter of blood

Hct description

Measures the volume of packed RBCs per unit of blood expressed as a percentage

Reticulocyte count

Measures the percentage of immature RBCs

Mean corpuscular volume MCV

Average size of circulating RBC

Mean corpuscular hemoglobin MCH

Reflect the weight of the Hbg per RBC

Mean corpuscular hemoglobin concentration MCHC

Measures the average concentration of hemoglobin in the RBCs

Iron deficiency pathophys and clinical manifestations

An anemia resulting from decreased dietary intake of iron, reduced absorption of iron or blood loss

Normal clinical manifestations

Iron deficiency anemia diagnostic findings

Hemoglobin - decreased

Hematocrit - decreased

Mean corpuscular volume - low (microcytic)

Mean corpuscular hemoglobin - low (hypochromic)

Serum iron - decreased

Serum ferritin (amount of iron stored in the body) - decreased

Iron deficiency anemia treatment

Increasing iron in diet (heme in animal products and non heme in plant based)

Oral iron supplements - take lower doses once every other day, best absorbed in an acidic environment. - bad for absorption: antacids, calcium, dietary fiber, tea, coffee, eggs

Parenteral iron - if severe or unable to absorb oral iron

Anemia of chronic illness pathophys and clinical manifestations

Very common anemia found in people with certain long term medical conditions that involve inflammation

Anemia is usually mild to moderate

Anemia of chronic illness diagnostic findings

Hgb levels moderately low (>8)

Low serum iron

Ferritin level is normal or elevated

TIBC normal

C reactive protein CRP is often high

Anemia of a chronic illness treatment

Monitor patient

Decreased serum iron may be protective - prevents nourishment of bacteria and cancer cells

Iron supplements could be harmful

Megaloblastic anemia caused by vitamin B12 deficiency pathophys

Anemia characterized by the presence of very large RBC

Nutritional deficiency - veg or vegan

Age related loss of gastric acid production or pernicious anemia

Heavy alcohol consumption

Chronic gastritis and H pylori

Gastrectomy or gastric bypass surgery

Crohn's disease, celiac disease or metformin

Long term use of antacids, proton pump inhibitors and H2 receptor blockers

Megaloblastic anemia caused by vitamin B12 deficiency clinical manifestations

S/S of anemia

Glossitis

GI problems

Neurological problems - muscle weakness, numbness in hands and feet

Can result in ataxia memory loss disorientation and dementia

Megaloblastic anemia caused by folic acid deficiency lab findings and manifestations

Hgb/Hct are low

• RBCs are macrocytic

• Ferritin is normal

• Folate levels low

Similar to B12 but no neurologic problems

Large RBC

Megaloblastic anemia caused by foci acid collaborative interventions

Folic acid supplement

Better diet

Megaloblastic anemia caused by vitamin B12 treatment

Increase dietary intake of red meats liver eggs and B12 fortified foods

Supplements

Parenteral vitamin B for those who can't absorb from oral route

Aplastic anemia pathophys and definition

Blood condition where the bone marrow fails to produce blood cells in sufficient numbers

Most often caused by an autoimmune disorder

Radiation and chemo

Can be idiopathic

Ferrous sulfate indications, major side effects, nursing admin and patient teaching

Anemia caused by low iron

Nausea, constipation, diarrhea, black poop, stomach pain

Take with vitamin C

Take smaller doses every other day to avoid discomfort

Iron dextran indications, major side effects, nursing admin and patient teaching

Anemia caused by low iron in individuals who can't absorb oral iron

Dizziness, risk for allergic reaction

May require a testing dose

Tell provider if you are feeling unwell after receiving this

Oral cyanocobalamin (B12) indications, major side effects, nursing admin and patient teaching

Megaloblastic anemia due to B12 deficiency

Diarrhea, dizziness, nausea

Encourage foods rich in vitamin B12

Intramuscular B12 indications, major side effects, nursing admin and patient teaching

Megaloblastic anemia due to B12 deficiency in individuals who can't absorb it

Allergic reactions, diarrhea, nausea

Causes of chronic blood loss anemia

GI tract

Menstruation

Can be frank or occult

Blood loss anemia interventions

Administer O2

PRBC transfusion

Platelets FFP clotting factor replacements if indicated

Recovery phase: iron supplements

Blood loss anemia lab findings

Early

- Can be normal

36-48 hours after

- Hgb hct and RBC count decreases

- MCV MCH will be normal

- Reticulocyte count may increase

In 3-4 weeks

- Hgb hct and RBC count will return to normal if sufficient iron is available

- Without sufficient iron, Hgb & Hct rise will be slower and MCV and MCH will drop

Acquired RBC destruction anemia what causes it and description

Hemolytic anemia is characterized by the premature destruction of RBCS

Immune mediated - Autoimmune hemolytic anemia

Blood transfusion reaction

Infection that destroys RBCs like malaria

Inherited RBC destruction anemia causes

Hereditary

Sickle cell disease

Thalassemia

Hereditary spherocytosis

Clinical manifestations of anemias caused by hemolysis

Jaundice

Increased serum bilirubin levels

Dark urine

Enlarged spleen and liver

Care for an individual experiencing vaso occlusive sickle cell crisis

Obtain VS and O2 saturations

Admin O2

Admin fluids

Initial continuous opioid infusion

Obtain BCB to see if PRBC transfusion is needed

Antibiotics for fever or acute chest syndrome

Heparin is used to prevent DVT and pulmonary embolism

Interprofessional care to prevent sickle cell crisis

Routine health management with a hematologist

Immunizations

Seek prompt treatment for fever or any sign of infection

Avoid dehydration cold temps and high altitudes

Pathophys of hemochromatosis and description

An iron overload disorder

Primary

- A hereditary disorder characterized by excessive intestinal absorption of dietary iron

Secondary

- Occurs as the consequence of chronic blood transfusions

Clinical manifestations of hemochromatosis

Fatigue joint pain bronze skin stomach pain heart palpitations DM

Liver cirrhosis

High TIBC

Care of hemochromatosis

Dietary mod

Routine therapeutic phlebotomy

Chelation therapy to bond excess iron