Canvas Exam 2

What are nursing interventions post mastectomy from breast cancer

1. Elevate affected arm using a pillow for about a week because we are worried about lymphedema

2. no blood pressures or IVs on that side

3. wear loose fitted clothing

Who is at risk and what are s/sx for breast cancer

1. Family history and BRCA

2. Painless breast lump

3. Skin changes Dimpling or peau d'orange appearance.

4. Redness or thickening.

5. Nipple changes Retraction.

What does CAUTION stand for related to cancer?

C - change in bowel or bladder habits

A - a sore that doesn't heal

U - unusual bleeding or dicharge

T - thickening skin or lump

I - Indigestion or difficulty swallowing

O - obvious change in a mole

N - nagging cough or hoarseness

Danger signs in lesions for skin cancer

A→ Asymmetrical: if you folded the mole in half, the two halves would not match

B → Border irregularity: uneven, scalloped, jagged, or notched borders

C → Color: multiple colors

D → Diameter changes: Increases > ¼ inch (the size of a pencil eraser)

E → Evolution: Changes in size, shape, color, elevation, crusting, itching, etc.

Who is most at risk for developing cancer?

older adults d/t decreased immune response and reduced cellular repair

What are the key diagnostics for cancer?

1. biopsy is definitive

2. CBC trends identify treatment compications

3. Tumors markers are used to monitor response, not diagnose

Why is tamoxifen prescribed for breast cancer treatment? What are side effects?

1. blocks estrogen receptors → stops tumor growth

2. causes nausea and hot flashes

If someone has a mole and it gets bigger or has any changes, what should they do?

seek help, go see the doctor!

What cancer do we think of being highly metastatic?

multiple myeloma

When someone has cancer, they typically have low neutrophils/WBC count, what are they at risk for?

respiratory infections → pneumonia!

Sepsis → fever, tachy, hypotensive

What are common s/sx of bowel/colon cancer?

1. rectal bleeding

2. fatigue and weightloss

3. change in bowel habits

4. may have family history

5. biopsy is definitive- may start with colonoscopy

When should someone with a family history of colon cancer get a colonoscopy

40 rather than 50

What tumor markers are we monitoring in bowel/colon cancer?

1. CEA (carcinoembryonic antigen)

What diet is recommended for colorectal cancer

high fiber diet

What might the nurse anticipate being given in preparation for a tumor removal located in the GI tract?

give an antibiotic that can reduce the number of bacteria in the GI tract before surgery

If someone gets a barium enema, what should we think about doing afterwards?

fluids and/or laxatives to flush it out

what is the one thing we need to know when comparing Colostomy and Ileostomy?

Ileostomy higher up and requires more fluids

how should stomas appear?

1. Pink to red "beefy"

2. Moist, shiny

3. A pale, dusky, or purple stoma is an emergency

What determines whether a colostomy is reversible vs. irreversible?

if there is sphincter damage or fistula's in intestines it can NOT be reversed

What are we concerned about with a colostomy and ileostomy?

1. fluid status!

2. high protein diet right after placement

3. Return of bowel function → passing flatus is the first sign bowel function has returned.

4. use skin barrier products and avoid harsh soaps

Chemo causes thrombocytopenia and anemia. What labs should be closely monitored?

1. bleeding → ↓ platelets and ↓ H/H

2. sepsis → watch for Increased temps

3. WBCs →

What is the first sign of sepsis?

tachycardia and RR. Maybe a low-grade fever.

What is prioritization for cancer patients?

focus on perfusion

→ anemia d/t bone marrow suppression

→ chemo suppresses bone marrow

→ low RBC reduces oxygen delivery

→ fatigue, pallow, tachycardia

Which cells divide the fastest?

hair and mucousa

Due to mucosa cells quickly dividing, what should we implement in cancer patients?

1. Barrier cream for bum

2. saline mouth rinses

Prostate cancer: what do we need to know?

1. PSA → prostate-specific antigen for trends

2. biopsy is definitive

What are the effects of raditation therapy in prostate cancer?

1. hematuria

2. cystitis

3. thrombocytopenia

What is patient teaching following a prostatectomy?

1. no lifting over 10-15lbs fofr 6-weeks

2. monitor urine output or signs of infection

What are priority nursing interventions regarding radiation?

1. Risk for Skin breakdown and Infection

2. loose fitted clothing

3. avoid lotions, deodorants, unless prescribed

4. don't remove the markings

Who should NOT be around radiation treatment?

1. pregnant women

2. children

What is tumor lysis syndrome?

massive destruction of cells leading to hyperkalemia → often seen during chemotherapy

What might labs look like in tumor lysis syndrome?

1. Hyperkalemia → cardiac monitor, hyperkalemia protocol

2. Hyperphosphatemia → sevelamir

3. Hypocalcemia → tetany, Chivosteks and Trousseaus

4. Hyperuricemia → allopurinol

What is the tx for tumor lysis syndrome

1. aggressive IV fluids → at least 150ml/hr

2. polystyrene sulfonate for high K

3. cardiac monitoring → peaked T and ST elevation

What is vena cava syndrome?

1. tumor pressing on the vena cava blocking blood return to heart

2. causes periorbital edema, JVD, hoarseness

3. associated with lung and mediastinal tumors

Priority nursing interventions for vena cava syndrome

1. Elevate head of bed immediately

2. ABCs

3. if airway or nuero status is worsening call PCP

If a cancer patient is feeling down and not supported, what can we refer them to?

cancer support groups

Which cancers commonly lead to bone cancer?

breast and prostate

If a cancer patient develops bone cancer, what are we worried about?

1. calcium loss from the bones

2. Hypocalcemia - tetany, chvosteks and trosseaus

3. Hypercalcemia -Constipation, lethargy, alot of weakness

4. risk for fractures and falls

What do we need to know about bone marrow aspiration?

1. bleeding at the site

2. apply pressure afterward

4. assess for pain and infection

What can alert a provider that a patient might have cancer

unexplained weightloss

Your patient with breast cancer is complaining of bad back pain and radicular symptoms (pain, numbness, tingling, or weakness that radiates along the path of a spinal nerve root). What might you suspect is going on?

metastasis has spread to bone cancer

If a cancer patient reports that they are not getting relief with their prescribed hydrocodone or oxycotin dose, what can we anticipate will happen?

it is common to increase their dose

Nuetropenic precautions are implemented when WBCs are

1. Avoid fresh fruits/veggies, no fresh flowers

2. teach visitors good hand hygiene → infection prevention

3. daily temperature monitoring

What acid base imbalance may occur from the vomiting from chemo?

metabolic alkalosis

What is nadir and how does it relate to cancer?

1. Lowest blood counts occur 7 to 14 days after chemo.

2. This is peak infection risk → lung infections → monitor for sepsis

3. teach patient infection precautions

Leukocytes are found in the bone marrow, what is done in cancer to get a level?

Any cancer or chemo question involving WBCs (luekocytosis), RBCs (anemia), or platelets links back to bone marrow suppression.

biopsy - bone marrow aspiration

What is a lobectomy?

removal of one lobe of the lung d/t lung cancer

What are priority nursing interventions post lobectomy?

1. TCDB → Q2hrs while awake to mobilizes secretions

2. IS → 10x/hr while awake to prevent alveolar collapse

3. lying on operative side to allow the remaining lung tissue to expand

4. splinting the incision

5. early ambulation → increase ventilation and perfusion to decrease risk of PNA/DVT

What are red flags following a lobectomy that may suggest a pneumothorax?

1. suddent dyspnea

2. tracheal deviation

3. absent breath sounds on one side

4. subQ emphysema → rice crispy sounds

QRS in EKG

ventricular depolarization

P wave in EKG

atrial depolarization

PR interval represents what

SA to AV node

Tell me what this EKG is?

Description: Irregular and chaotic atrial activity with no distinct P waves.

Rate: Variable.

P Wave: Absent.

QRS Complex: Irregularly spaced.

a-fib → Apixaban and warfarin to prevent blood clots from blood pooling in the heart

What can digoxin cause if we are not careful when referring to the heart?

It can cause a heart block by slowing down AV node conduction too much or make a heart block worse

Tell me what this EKG is?

Description: Fast heart rate originating from the SA node.

Rate: Greater than 100 beats per minute.

P Wave: Present and normal.

QRS Complex: Narrow and consistent.

Sinus tachycardia

tell me what this EKG is?

Description: Slow heart rate due to the SA node firing at a slower rate.

Rate: Less than 60 beats per minute.

P Wave: Present and normal.

QRS Complex: Narrow and consistent.

Sinus brady

symptomatic brady = 1mg atropine q 3-5 for a max of 3mg

tell me what this EKG is?

Description: Regular heart rhythm originating from the sinoatrial (SA) node.

Rate: 60-100 beats per minute.

P Wave: Present and normal.

QRS Complex: Narrow and consistent.

normal sinus rhythm

tell me what this EKG is?

Description: Complete disassociation between atrial and ventricular rhythms.

Rate: Varies.

P Wave: Present, but not related to the QRS complexes.

QRS Complex: May be narrow or wide depending on the escape rhythm.

3rd Degree heart block - complete heart block

treat with dopamine/epi until pacer

Tell me what this EKG is?

Description: Intermittent failure of some atrial impulses to be conducted to the ventricles, with a constant PR interval.

Rate: Varies.

P Wave: Present, some are not followed by QRS.

QRS Complex: Dropped periodically.

Second-Degree Heart Block (Type II - Mobitz)

treat with dopamine/epi until pacer

EKG shows QRS greater than .12, compensatory pause, premature

PVC

Your patient is having a ton of PVCs and BP is dropping, what medication is given?

amiodorone → antiarrhythmic

Tell me what this EKG is?

Description: Prolonged PR interval

P Wave: Present and normal.

QRS Complex: Narrow.

1st Degree Heart Block

Tell me what this EKG is?

Description: Chaotic and ineffective electrical activity in the ventricles.

Rate: Rapid and irregular, no identifiable QRS complexes.

P Wave: Absent.

QRS Complex: None.

V Fib = D Fib

Know the treatment!

EKG shows lengthening p waves followed by dropped QRS

Mobitz 1 wenckenbach → watch and wait

tell me what this EKG is?

Description: Early beats originating from an ectopic focus in the atria.

Rate: Depends on the underlying rhythm.

P Wave: Premature P wave that looks different from normal.

QRS Complex: Narrow.

Premature atrial contraction

tell me what this EKG is?

Description: Rapid, regular atrial contractions with a "sawtooth" pattern.

Rate: Atrial rate 240-340 beats per minute.

P Wave: Sawtooth pattern called "F-waves."

QRS Complex: May be regular or irregular depending on AV conduction.

A Flutter

Know the treatments for stable vs. unstable

Tell me what this EKG is?

Description: Rapid heartbeat originating from the ventricles.

Rate: 100-250 beats per minute.

P Wave: Not present or dissociated.

QRS Complex: Wide and bizarre.

V Tach

know the treatments for stable vs. unstable

Priority post cardiac cath interventions

1. Bleeding at the site! → ↓ H/H

2. femoral → keep leg strait → distal pulses from the site

3. monitor for Cardiac Tamponade

4. keep patient flat

Patient teaching pre cardiac cath

you may feel a warmed flushed sensation and nausea

Cardiac catheterization uses contrast dye. What do we need to monitor

1. nephrotoxic → monitor urine output (Bun/Cr)

2. encourage fluids

Priority nursing interventions for open heart surgery → CABG, valve replacement or repair

1. ABCs

2. wean from ventilator

3. encourage IS once extubated

4. DVT → anticoagulation therapy

5. Strict I/Os

6. temporary pacer → monitor for a-fib

What do we need to know about chest tubes

1. remove air, blood, or fluid from pleural space

2. continuos bubbling = air leak

3. system below chest

4. never clamp unless ordered

5. sudden increase or bright red output call PCP

What is an escharotomy?

1. an incision made into the necrotic tissue resulting from a severe burn

2. fasciotomy due to compartment-like syndrome where swelling is restricting arterial flow

3. IV analgesia → morphine, fentanyl → monitor resp. status

How do we know an escharotomy has been successful?

1. chest → good lung expansion

2. leg → distal pulses

What is debridement?

Removal of foreign matter or necrotic tissue from a wound

if there is blood

Deep partial vs superficial burns

1. Deep partial → waxy white

2. superficial → red weepy moist

If someone has a burn covering the majority of their body, what are we thinking ASAP

1. Big fluid shifts → hypovolemic shock

2. Get an IV and Bolus LR

3. hyperkalemia d/t massive cellular destruction

What is the rule of 9s

Head and neck - 9%

Each arm - 9%

Each leg - 18%

Anterior trunk - 18%

Posterior trunk - 18%

Perineum - 1%

What is the Parkland formula?

1. 4 mL X kg X % of TBSB

2. Give half of total volume in first 8 hrs

3. Give remaining half over next 16 hrs

Burns cause what electrolyte imbalances?

hyperkalemia and hyponatremia

What is the best indicator of perfusion?

1. #1 urine output of >30mL/hr

2. #2 BP

What do we need to know following burns for wound and skin care

1. staph or strep G+ is most common

2. infection risk is high

3. sulfadiazine

Patient diet post burn

1. high protein and high calorie

2. Zinc supplementation

What are the nursing priorities post burns

1. sterile technique → sometimes germicidal wipes

2. monitor temp closely

3. decreased motility → Curlings "stress" ulcer → PPI -prazole

What do we need to know about graft care?

1. immobilize 4-5 days

2. do not disturb dressing

3. assess for signs of graft failure

What are the s/sx of hepatic encelopathy?

1. confusion

2. asterixis

3. decreased LOC

Hepatic encephalopathy tx

1. lactulose to decrease ammonia (collects ammonia in the gut to be pooped out)

2. reduce protein intake

the provider prescribes 90mL of lactulose. we know this is how many oz?

3 oz

30mL=1oz

Normal bilirubin

1

Patient teaching for a cirrhosis diet

Low sodium

Low fat

Moderate protein

High calorie

What is the diet for an advanced cirrhosis patient

low protein

Liver labs to know

ALT: 7 to 56

AST: 10 to 40

Bilirubin: 1

PT: 11 to 13.5 seconds

INR: 1

aPTT: 25 to 35 seconds

Albumin: 3.5 to 5.0

Total Protein: 6.0 to 8.3

Ammonia: 5 to 45

What are the most common causes of cirrhosis in order?

Hep C → fatty liver → alcoholism

Acites occurs d/t and how do we treat?

1. scar tissue blocks portal blood flow → portal hypertension → albumin production drops → fluid shifts into abdomen

2. give albumin to increase oncotic pressure

3. paracentesis → monitor for hypovolemia and tachycardia after this is done

What can we expect to be prescribed for portal hypertension

propanolol (non-selective BB)

How do we know if albumin is effective for ascites?

decreased abdominal girth

If a patient has developed significant ascites and finding it difficult to breath laying down what should the nurse do?

Sit the patient up to get the fluid off of the lungs

BEST place to look for jaundice with cirrhosis

sclera

Viral Hepatitis diet

high calorie and high carbs

What are the s/sx of hepatitis

1. flu like symptoms, loss of appetite, n/v

2. dark urine → clay colored stool