Adult II Exam 2

what is anemia?

a decrease in the oxygen-carrying ability of the blood (low Hgb/RBCs)

what are the general s/s of anemia?

-pallor (low hgb levels and decreased BF to skin)

-jaundice (r/t Hgb breakdown → increased bilirubin concentration)

-fatigue, weakness

-pruritus (increased serum and skin bile concentrations)

-inc HR/palpitations, low blood viscosity → murmurs/bruits

-SOB

-HA, dizziness

-mild anemia (10-12)→ palpitations, dyspnea, and mild fatigue (due to underlying disease or compensatory response to exercise)

-moderate anemia (6-10) → increase in cardiopulmonary sx, may have them at rest and with activity

-severe anemia (<6) → involves multiple body systems

which lab tests are monitored and associated with anemia?

-hemoglobin (low)

-hematocrit (low) → volume of cells in 100 mL of blood

-MCV (size of RBCs) + MCHC (coloring of RBCs)

-reticulocytes (high) → immature RBCs

-serum B12/folate (low) → nutrients required for DNA synthesis/RBC development

-iron labs → TIBC (high), ferritin (low), serum iron (low)

-stool guaiac test → blood in stool

what is iron-deficiency anemia? what are the causes? what are the s/s?

-lack of iron → impaired RBC synthesis

-causes: blood loss**, lack of intake, malabsorption, hemolysis, pregnancy, GI/GU blood loss, hemodialysis

-s/s: general s/s of anemia + brittle nails, swollen tongue, cracked corners of mouth

how is iron-deficiency anemia treated?

-iron supplements (ferrous sulfate): take with vitamin C to increase absorption, black stools expected, may cause constipation/diarrhea/heartburn (take w/ stool softener)

-increased dietary intake: liver, muscle meats, fish, legumes, eggs, some dried fruits (raisins, apricots, peaches, prunes), dark green/leafy veggie, whole grains, enriched bread and cereals, baked potatoes

• Parenteral Iron

  • Indications: malabsorption, oral iron intolerance, need for iron beyond parenteral limits, poor patient adherence

what is cobalamin deficiency anemia? what are the causes? what are the s/s?

-lack of cobalamin (vitamin B12) → impaired RBC synthesis (macrocytic)

-causes: no intrinsic factor for B12 absorption (pernicious anemia), decreased intrinsic factor (alcoholism, medications, GI surgeries, old age), lack of dietary intake (vegans/vegetarians), smoking, long-term use of h2blockers/ppi’s

-s/s: general symptoms of anemia, neurologic symptoms (numbness/tingling, ataxia, confusion), abdominal pain

how is cobalamin deficiency anemia treated?

-B12 injections (usually for life)

-increase dietary intake: red meats, liver, eggs, enriched grain products, milk and dairy foods, fish

what is sickle cell disease?

-genetic, autosomal recessive disorder

-causes RBCs to lose round, concave shape and instead become sickle-shaped

-genetic mutation: normal hemoglobin (HbA) replaced by abnormal sickle cell hemoglobin (HbS)

what are the clinical manifestations/complications of sickle cell disease?

-pain → tissue hypoxia and damage

-pale mucous membranes

-jaundice → hemolysis of sickled RBCs

-complications → organ hypoxia, infection

what is a sickle cell episode vs. sickle cell crisis?

-episodes: triggered by low oxygenation (infection, stress, high altitude, blood loss, dehydration); sickling is initially reversible with re-oxygenation

-crisis: severe, painful, acute exacerbation of sickling leads to vaso-occlusive crisis; severe capillary hypoxia and eventual tissue necrosis, life threatening shock

how is a sickling episode/crisis treated?

-oxygen therapy

-IVF and electrolyte replacement

-blood transfusion

-close monitoring for respiratory failure

-pain management: PCA, heat packs (vasodilate), pain medication (continuous and breakthrough, patients often have developed tolerance to pain meds)

-elevate extremities → increase blood flow

-promote rest

-DVT prophylaxis

what things would a nurse teach a sickle cell patient about crisis prevention?

-prevent infection: vaccination, masks, avoidance, treat infections promptly

-stay hydrated

-avoid high altitudes

-receive prompt medical attention if an episode arises

-pain management

-medications: chelation therapy (helps remove excess iron), folic acid (inc RBC production), hydrea (antisickling agent)

what is thrombocytopenia?

-reduction of platelets (< 150,000)

-results in abnormal hemostasis (prolonged or spontaneous bleeding)

-primarily an acquired disorder (heparin, aspirin, malignancy)

what are the the possible complications a patient with thrombocytopenia might have?

-prolonged bleeding, especially when platelets are < 50,000

-hemorrhage risk (external or internal) when PLTs < 20,000

What is immune Thrombocytopenia Purpura?

• most common acquired thrombocyotpenia

• syndrome of abnormal destruction of platelets by spleen

• primarily an autoimmune disease

  • live with platelets <100,000)=

what things would a nurse teach a patient with thrombocytopenia?

-avoid SQ/IM injections; if injection is necessary, apply pressure or ice packs

-teach s/s of bleeding so pt receives prompt treatment: mucosal or cutaneous bleeding, petechiae/purpura

-teach self-care measures to reduce risks for bleeding

-teach medication risks: cancer chemotherapy drugs, heparin, OTC meds that can cause blood thinning ( aspirin, NSAIDS, placid, Coumadin)

-limit alcohol

-splenectomy → indicate if pts do not respond to other txs

-platelet transfusion → <10,000 or prophylactically for planned procedure

-corticosteroids → increase lifespan of platelets

-platelet transfusion <10,000

-avoid contact sports

what is CLL? what is the disease process? what are the s/s?

-chronic lymphocytic leukemia

-most common leukemia in adults

-slowly progressive disease in which there is a proliferation of functionally inactive but long-lived, mature-appearing lymphocytes (infiltrate BM, spleen, liver)

-s/s: weakness, fatigue, weight loss, fever/night sweats, swollen lymph nodes

what are possible complications of CLL?

-immunosuppression

-lymph node enlargement & pain

-paralysis from pressure

-bone marrow suppression

what is CML? what are the s/s?

-chronic myelogenous leukemia → overproduction of mature and immature WBCs → bone marrow suppression

-s/s: fatigue, pallor, unexplained weight loss, abnormal bleeding

what is AML?

-acute myelogenous leukemia

-proliferation of immature WBCs (myeloblasts)

-s/s very similar to CML

what are the nursing responsibilities when caring for a patient with AML?

-disease management: bone marrow suppression from overcrowding of cancerous cells → anemia, thrombocytopenia, dec WBCs, infiltration into other organs (spleen, liver, lymph nodes, etc.)'

-Bone pain

-Meningeal irritation

-Oral lesions

-monitor labs: hematology, WBCs

-Dx: blood counts, bone biopsy

-manage side effects of drugs/treatment

-support psychosocial needs: patient education, stress management, reproductive concerns

-Chemotherapy

• Other therapies

  • Corticosteroids

  • Radiation therapy - targeted or total body

  • Hematopoietic stem cell transplant

what is the difference between benign and malignant tumors?

benign:

-tumor that is not cancerous and does not spread to other areas of the body

-slow, progressive growth

-rare recurrence

-typically good prognosis

malignant:

-tumor containing cancerous cells that spreads to other areas of the body

-undifferentiated, abnormal structure

-accelerated growth

-infiltrates/invades other tissues

-higher rate of recurrence

-prognosis depends on success of treatment

what is staging & grading of cancer?

-grading: classifies tumors by cellular changes (severity)

-staging: TNM (tumor size/invasiveness, nodular involvement (spread to regional lymph nodes), metastases)

what is the goal of chemotherapy?

-eliminate or reduce the number of malignant cells present in the primary tumor and metastatic tumor site(s); destroy rapidly growing/dividing cells

what is extravasation? what should the nurse do if this occurs?

-the leakage of chemotherapy drugs into the skin and surrounding tissue

-administration preferred through CVAD (implanted port)

-chemo is very toxic, causes skin break down and possible necrosis; swelling is first sign

-nurse management: immediately discontinue the infusion, cooling/diluting/elevating the site, extravasation kits on the unit (contain antidotes and flushes)

what is the goal of radiation?

causes cell death:

-kill or reduce tumor

-control: limit tumor growth, control symptoms

-provide comfort/palliation in metastatic disease

-prophylaxis: prevent further spread

what is brachytherapy? what are the nursing precautions for a patient undergoing bradytherapy?

-internal radiation

-radioactive seeds are implanted directly into the tumor/involved tissues or in close proximity adjacent to the tumor; may be permanent or temporary

-nursing precautions: ALARA principles (as low as reasonably achievable; avoiding exposure to radiation); limit time near radioactive source, increase distance between you and radioactive source, shield yourself from the source using a barrier (TDS); wear film badge (measures level of exposure)

what are the common side effects of chemotherapy & radiation?

-bone marrow suppression/hematologic: anemia, thrombocytopenia, infections

-fatigue

-GI effects: nausea, diarrhea, mouth sores; intenstinal mucosa is one of the most sensitive tissues

-pulmonary: toxicity and irreversible tissue damage

-cardiovascular: cardiotoxicity, HF

-skin effects: desquamation, rashes, skin redness, hair loss

-NS and cognitive: peripheral neuropathy, CNS edema, "chemo brain" (fogginess, forgetfulness)

-genitourinary: reproductive dysfunction, nephrotoxicity

what would be the patient teachings for someone who is neutropenic?

-monitor for s/s of infection

-prevent infections: avoid fresh flowers, cannot clean up after dog/cat, cannot have raw veggies/fruit/seafood/eggs, cannot drink well water; all nurses/visitors must wear masks in the room; hand hygiene

-meds to increase the WBCs may be scheduled prior to chemo (Neupogen - filgrastim; Neulasta - pegfilgrastim)

-a neutropenic emergency includes fever > 100.4 & neutrophil count < 500; call provider

-chemotherapy may be stopped until neutrophils levels rise again

what is superior vena cava syndrome? what are the s/s? what is the treatment?

-obstruction of the SVC by tumor or thrombosis

-commonly seen with lung cancers, breast tumors, and non-hodgkin's lymphoma

-s/s: facial/upper extremity edema, distended neck veins, HA, seizures

-tx: emergent radiation

what is spinal cord compression? what are the s/s? what is the treatment?

-compression of the spinal cord r/t malignant tumor in the epidural space

-commonly seen with breast, lung, prostate, GI, and renal tumors

-s/s: sudden intense back pain, new loss of bladder or bowel function

-tx: radiation and corticosteroids

what are the metabolic oncologic emergencies? what are the s/s and treatments of each?

SIADH (excessive ADH secretion; lung cancer)

-s/s: weight gain without edema, weakness, anorexia, N/V, severe hyponatremia

-tx: fluid restriction, hypertonic NS, lasix

hypercalcemia (metastatic bone cancer)

-s/s: depression, fatigue, muscle weakness, elevated serum Ca2+ levels

-tx: hydration (IVF) and diuretics, calcitonin

what is cardiac tamponade? what are the s/s? what is the treatment?

-fluid accumulation in the pericardial sac (pericardial effusion) + constriction of the pericardium or pericarditis (d/t radiation)

-s/s: heavy chest, dyspnea, tachycardia, cough

-tx: emergent fluid removal (pericardiocentesis)

what are the priority nursing interventions when caring for cancer patients?

-symptom management: antiemetics (especially on chemo days), pain medication/relief, energy conservation/light exercise (walking), skin care

-safety: neutropenic precautions, PPE for chemo administration

-monitor weight, small/frequent meals high in protein/calories, inc fluid intake

-monitor ECG, pay attention to sx of HF

-monitor neuro status

-monitor kidney function, avoid nephrotoxic drugs

what is an HLA screen?

human leukocyte antigens:

-determines tissue type

-HLA system is responsible for rejection of genetically unlike tissues

-HLAs of donor have to be matched to HLAs of recipient

what is a PRA screen?

panel of reactive antibodies:

-determines whether prospective crossmatch is needed

-high/positive PRA: indicates there are a lot of cytotoxic antibodies and the patient will most likely reject the new organ

-low/negative PRA: indicates a crossmatch will most likely be successful

what are the three types of organ rejection and what characterizes each?

hyperacute

-occurs in OR/first 24 hours

-blood vessels rapidly destroyed r/t antibodies (high PRA)

-no treatment

-organ must be retrieved

-patient death

acute

-occurs in first 6 months after transplant

-T-lymphocytes attack the organ

-usually reversible via high doses of immunosuppressive medications

chronic

-occurs over the lifespan of the transplanted organ

-fibrosis, scarring of the organ, irreversible damage/organ failure

-poor prognosis

-either need another transplant or they die from organ failure

what are the s/s of organ rejection?

-fever

-malaise

-body aches

-pain at transplant site

-signs of the transplanted organ failing

what is the action of calcineurin inhibitors? which are commonly used? what are potential side effects?

-suppress activation of cytotoxic T-cells

-cyclosporine, tacrolimus (Prograf)

-SE: nephrotoxicity (monitor BUN/creatinine), hypertension

what is the action of cytotoxic (antiproliferative) drugs? which are commonly used? what are common side effects?

-inhibit T and B cell proliferation

-sirolimus (rapamycin), azathioprine (imurman), mycophenolate mofetil (cellcept)

-SE: GI toxicity (N/V, diarrhea)

what is the action of corticosteroids (for immunosuppression)? which are commonly used?

-impair antigen recognition

-prednisone, methylprednisolone

-not used long-term; tapered off

what is the action of monoclonal antibodies? which are commonly used?

-decrease immunoreactivity by inhibiting t-cell proliferation

-received 2 hours prior to transplant

-Basiliximab, muromonab-CD3

what are common long-term problems associated with organ transplant?

-hypertension

-renal insufficiency

-hyperlipidemia

-diabetes

-osteoporosis

-malignancy**: skin cancer, post-transplant lymphoproliferative disease, other tumors

-CV disease**

-infection**

-transplant patients require frequent follow ups for signs of infection/rejection

what is ICP? what is the normal value?

-measure of the total pressure exerted by the three components within the skull (brain tissue, blood, and CSF)

-5-15 mmHg

-a sustained ICP > 20 mmHg is considered above the upper limit and is abnormal

what is CPP? what is the normal value?

-the pressure needed to ensure blood flow to the brain.

-normal: 60-100 mmHg (MAP-ICP)

-CPP < 50 indicates ischemia and possible death

what is Cushing's triad?

vital sign changes related to increased ICP:

1) inc SBP and widening pulse pressure

2) decreased HR

3) irregular respirations

how do nurses assess for increased ICP? (clinical manifestations?)

-earliest sign is decreased LOC

-Cushing's triad

-ocular signs (cranial nerve III, brainstem reflexes)

-dilation of the pupils

-decline in motor function

-headache (often improves when sitting up)

-vomiting (projectile)

-posturing signs: decorticate (cortex of brain not communicating; fists clenched, arms flexed inward); decerebrate (midbrain/brain stem injury: arms extended down, fists faced away)

how is ICP measured/monitored?

-ventriculostomy → specialized catheter is inserted & coupled to external transducer

-device can also drain CSF to reduce pressure

what is the nursing care/treatment for increased ICP?

-maintenance of a patent airway**→ adequate oxygenation, ABGs, possible ventilation (to keep PaO2 at 100 mmHg)

-drug therapy (next card)

-nutritional therapy: patient is in hypermetabolic and hypercatabolic state; increased need for glucose, want to keep patient normovolemic

-frequent neurological assessments (Glasgow Coma Scale, cranial nerves, pupil evaluation, motor and sensory testing)

-positioning: increase head of bed (dec pressure/improve venous return), maintain good body alignment, turn q 2 hours

what are the drugs used to treat increased ICP?

-Mannitol (osmotic diuretic): reduces fluid volume

-hypertonic saline (3%): reduces edema by pulling fluid out of brain cells

-corticosteroids (dexamethasone/decadron): decrease inflammation

-barbiturates ("-barbital"): reduces cerebral metabolic demands and cerebral blood volume, sedates them/keeps them calm

-acetaminophen: fever reducer

-anti-seizure drugs: high ICP irritates brain and increases seizure risk

-stool softeners: prevent constipation to reduce abdominal pressure

what is the Glasgow Coma Scale (GCS)?

-assessment tool measuring degree of impaired consciousness

-used in primary evaluation of traumatic brain injury

-looks at eye opening response, verbal response, and motor response

-the higher the score, the better (15 max)

what do Battle's sign, raccoon eyes, and halo sign indicate?

location of skull fracture alters the presentation of manifestations:

-Battle's sign: fracture to the temporal, parietal, or basilar region

-raccoon eyes: basilar or facial fracture

-halo sign: rhinorrhea/otorrhea produces ring of white/yellow around it → indicates drainage is CSF

what is an epidural hematoma?

-bleeding between the dura and inner surface of the skull

-neurologic emergency

-usually arterial origin, resulting in very rapid bleeds

-classic signs: immediate loss of consciousness followed by lucid intervals; HA, nausea, vomiting; rapid deterioration

what is a subdural hematoma?

-bleeding between the dura and arachnoid layers

-usually venous in origin; slower appearance, develop mass large enough to produce symptoms

-elderly (medications, falls, veins more prone to injury) and alcoholics at increased risk

what is diffuse axonal injury? what is the result? what is the tx?

-twisting, shearing, rotational forces cause injury/tearing of axons and death of the neuron

-presence of petechiae (microhemorrhages) throughout the brain

-usually causes coma; disrupts normal brain communication and chemical processes → severe impairments

-tx: alleviate swelling/edema, control high ICP

what abnormal findings confirm meningitis?

-meningeal signs: Kernig's (lifting knee induces severe back pain), Brudzinski's (lifting head off pillow causes flexion of hip and knees)

-key signs: fever, severe headache, nausea, vomiting, photophobia and nuchal rigidity

-signs related to inflammation of the meninges

what test is performed for suspected meningitis?

-when patient presents with manifestations suggestive of bacterial meningitis → CT scan and a blood culture should be done

-diagnosis is usually verified by performing a lumbar puncture with analysis of the CSF (most definitive; cloudy, bloody, proteins, WBCs present; unable to perform if ICP is elevated)

what is the nursing care for patients with meningitis?

acute interventions:

-IV antibiotics (AFTER culture; bacterial meningitis)

-pain relief: positioning, analgesics (codeine)

-Tylenol to reduce fever

-photophobia: dark environment

-seizure precautions

-droplet precautions (airborne spread; private room, surgical mask)

-IVF

health promotion:

-vaccinations

-treatment of respiratory and ear infections

what is the nursing care for patients with encephalitis?

-symptomatic and supportive care; initial stages often require intensive care

-antivirals (herpes simplex virus), antibiotics

-fluids

-prevention: mosquito control, vaccinations

what are the risk factors for stroke:

non-modifiable

-age

-gender

-race/ethnicity

-heredity/family history

modifiable

-HTN (single most important modifiable risk factor)

-heart disease

-diabetes mellitus

-smoking

-obesity

-sleep apnea

-physical inactivity

-drug/alcohol abuse

-poor diet

what is an ischemic stroke and what are the types?

-87% of all strokes

-results from inadequate blood flow to the brain from partial or complete occlusion of an artery (plaques, clots)

-types: thrombotic (more common, r/t atherosclerosis of cerebral arteries) and embolic (ex: A-fib, MI), TIA (transient ischemic attack; mini-stroke, can be warning sign that larger thrombotic stroke is to come)

-symptoms are often rapid and severe

what is a hemorrhagic stroke?

-a stroke caused by bleeding into the brain tissue itself or into the subarachnoid space/ventricles (intracerebral or subarachnoid hemorrhage)

-can be torn artery or rupture of cerebral aneurysm

-main risk factor is HTN

-symptoms often have sudden onset, with progression over minutes to hours because of ongoing bleeding; "worst HA of life," altered LOC, vomiting, seizures

what are the clinical manifestations of stroke?

-motor/sensory changes: impaired mobility, respiratory function, swallowing and speech, gag reflex, and self-care abilities

-communication: aphasia, dysphasia, dysarthria

-personality/affect: difficulty controlling emotions, memory and judgement impaired

-intellectual function

-spatial-perceptual alterations

-bowel/bladder elimination

what does the acronym BEFAST stand for?

signs of stroke:

-balance: watch for sudden loss of balance

-eyes: check for vision loss

-face: look for an uneven smile

-arm: check if one arm is weak

-speech: listen for slurred speech

-time: call 911 right away

which diagnostics are used to confirm stroke?

MRI, non-contrast CT scan** (immediate; time = brain); indicate the size and location of the lesion and can differentiate between ischemic and hemorrhagic stroke

what are the preventive therapy measures for stroke?

-management of modifiable risk factors: healthy diet, weight control, regular exercise, no smoking, preventing or controlling hypertension, limiting alcohol consumption, and routine health assessments

-preventing clot formation: antiplatelet drugs, warfarin

-surgical interventions: carotid endarterectomy (plaque removal in carotids), stents

what is included in the emergency assessment of stroke?

-past medical history, current medications, family history

-neuro exam: altered LOC, motor/sensory/reflexes, weakness/numbness/paralysis, severe HA, unequal pupils, vertigo, seizures

-speech, swallow, or visual disturbances

-BP/HR/respiratory changes

-bladder incontinence, constipation

-nausea and vomiting

what deficits would likely be seen with a right-sided stroke?

-problems in spatial-perceptual orientation: agnosia (inability to interpret sensations and recognize things), apraxia (unable to perform tasks or movements when asked), unilateral neglect (difficulties in attending to stimuli in the left perceptual hemifield)

-left hemiplegia

-impaired judgement, impulsive

-impaired time concepts

-rapid performance, short attention span, impatient

-deny/minimize problems

what deficits would likely be seen with a left-sided stroke?

-right hemiplegia

-impaired speech/language (receptive/expressive aphasia)

-slow performance, cautious

-aware of deficits: depression, anxiety

-impaired comprehension related to language/math

-respond best to non-verbal (visual) cues

what are the emergency treatments for ischemic strokes?

-managing the airway, breathing, and circulation

-elevated BP is common immediately after a stroke; may be protective response to maintain cerebral perfusion

-baseline neurologic assessment; monitor closely for inc neurologic deficits/ICP

-careful fluid and electrolyte balance: maintain hydration to promote perfusion

-single most important point in the patient's history is the time of onset (determines eligibility for tPA)

-surgical interventions: endovascular clot retrieval

what medications are used for acute care of ischemic strokes?

-aspirin within 24-48 hours of stroke (reduces platelet aggregation)

-platelet inhibitors (Plavix) and anticoagulants (Heparin, Warfarin)

-tPA: clot buster; must be administered within 3 - 4.5 hours of the onset of clinical signs

what are the emergency treatments for hemorrhagic strokes?

-goals for managing airway, breathing, circulation, and intracranial pressure are the same as for ischemic stroke

-surgical: resection, clipping/coiling of aneurysm, evacuation of hematomas

-seizure prophylaxis

-drug therapy to manage HTN (beta blockers) and reduce incidence of cerebral vasospasms (calcium-channel blockers

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