MED SURG 3 FINAL

Septic shock is caused by?

Widespread infection

How can you reduce septic shock incidence

strict infection control practices

Septic Shock s/s

- tachypnea
- tachycardia
- hypoxia, hypocarbia
- cool, clammy skin
- MENTAL STATUS CHANGE
- pallor and cyanosis
- skin mottling
- SEVERELY low bp with narrowed pulse pressure
- High temp then it becomes low
- seizures
- decreased cardiac output
- decreased urine output

Septic Shock Labs

- elevated bilirubin levels
- decrease platelet
- elevated lactate
- elevated inflammatory markers (WBC, plasma, C-rp, procalcitonin)

What should be completed within 3 hours of patient presentation/symptoms in septic shock?

- Obtain blood culture prior to admin of antibiotics
- Administer prescribed broad spectrum antibiotics

For septic shock, when do you initiate aggressive fluid resuscitation?

in patients with hypotension or elevated serum lactate (>4 mmol/L) → minimum initial fluid bolus of 30 mL/kg using crystalloid solutions

Since septic shock is most commonly caused by gram-negative bacteria, Joint Commission’s National Patient Safety Goals recommends the administration of

IV antibiotics that are effective against gram-negative bacteria within 1 hr of a septic shock diagnosis

What should be completed as soon as possible or within the first 6 hours of patient presentation/symptoms for septic shock

Begin vasopressor agents if hypotension is not improved (MAP < 65 mm Hg) after initial fluid resuscitation (norepinephrine)

For septic shock, if hypotension persists after initial fluid administration (MAP

Measure CVP (goal 8–12 mm Hg)
• Measure ScO2 (goal > 70%)
• Bedside cardiovascular ultrasound

What vasopressors are given for septic shock

Epinephrine, phenylephrine, vasopressin

When do you give broad spectrum antibiotics for septic shock

Admin should occur within 3 hours of admission to ED or within 1 hour of inpatient admission

Complication of septic shock

DIC -> creates hypoxia and anaerobic metabolism -> hemorrhage risk
Pt can develop diffuse petechiae and ecchymoses

What is the most common health care-associated infection in the US

Catheter Associated Urinary Tract Infection

What causes CAUTI

Escherichia coli

What does untreated UTIs lead to?

pyelonephritis, urosepsis -> can lead to septic shock and death

How do you prevent CAUTI

- strict aseptic technique during insertion
- frequently inspecting urine color, odor, and consistency
- performing daily perineal care with soap and water
- maintaining a closed system
- Following the manufacturer’s instructions when using the catheter port to obtain urine
specimens

CAUTI s/s

- low back or abdominal pain
- tenderness over the bladder area
- nausea
- urinary frequency and urgency
- feeling of incomplete bladder emptying or retention of urine
- perineal itching
- hematuria
- pyuria
- fever
- vomiting
- voiding in small amounts
- nocturia
- uretheral discharge
- cloudy or foul smelling urine

CAUTI older adult s/s

-Confusion
- Incontinence
- Loss of appetite
- Nocturia and dysuria
- Hypotension, tachycardia, tachypnea, and fever (indications of urosepsis)

CAUTI + lab

- urinarylsis, urine culture and sensitivity
- bacteria, sediment, wbc, rbc are present
- positive leukocyte esterase and nitrates (68-88%)

Collect catherized urine specimens using

sterile technique

What labs are looked at if urosepsis is suspected

wbc and differential

What antibiotics are used to treat CAUTI

- Fluoroquinolones
- Nitrofurantoin
- Trimethoprim
- Sulfonamides

Advise clients taking fluoroquinolones or sulfonamides that

- sun-sensitivity is increased and sunburn is a risk for even dark-skinned individuals
- medications can precipitate in the renal tubules, so advise client to take these medications with a full glass of water and to increase fluid intake
- take with food
- take whole count
- monitor and report watery diarrhea -> pseudomembranous colitis

Nitrofurantoin

an antibacterial medication where therapeutic levels are achieved in the urine only

Phenazopyridine

bladder analgesic used to treat UTIs
- Medication will turn urine orange
- Will not treat the infection, but it will help relieve bladder discomfort

CAUTI education

- shower, not bathe
- clean and wipe front to back
- drink at least 3L
- no coffee, teas, colas, alcohol, and other fluids that are urinary tract irritants
- void every 2-3 hrs during the day and completely empty the bladder

Parkinson's disease

Slowly progressing neurologic movement disorder that eventually leads to disability

What are the 4 main findings of Parkinson's

- tremor at rest
- muscle rigidity
- bradykinesia
- postural instability

What causes Parkinson's to happen

Low dopamine (movement)
High acetylcholine (Secretions)

dopamine

produces inhibitory effects on the muscles

acetylcholine

produces excitatory effects on the muscles

Stage 1 PD

Unilateral shaking or tremor of one limb

Stage II PD

Bilateral limb involvement occurs, making walking and balance difficult; mask-like face; slow, shuffling gait

Stage III PD

Physical movements slow down significantly, affecting walking more; postural instability

Stage IV PD

Tremors can decrease but akinesia and rigidity make day-to-day tasks difficult

Stage V PD

Client unable to stand or walk, is dependent for all care, and might exhibit dementia

All of PD s/s

• Resting tremor
• Pill Rolling
• Bradykinesia (slow movements)with rigidity
• Postural and gait disturbances (shuffling gait)
• Expressionless, fixed gaze, masklike
• Autonomic: sweating, drooling, slurred speech, flushing,
orthostatic hypotension, gastric and urinary retention
• Dysphagia
• Psychiatric changes: depression, anxiety, dementia, delirium,
hallucinations

How do you diagnose parkinsons

Diagnosis is made based on manifestations, their progression, and by ruling out other disease

What drugs control PD symptoms and maintain functional independence

BALSA
- bromocriptine, Amantadine, Levodopa, Selegline, Benztropine

Bromocriptine

Dopamine Agonist
- may be used in conjunction with a dopaminergic (ex: levodopa) for better results
- monitor for orthostatic hypotension, dyskinesias, and hallucinations

Amantadine

Antiviral, antiparkinsonian, anticholinergic
- it increases dopamine
- Monitor for discoloration of the skin that subsides when amantadine is discontinued
- pt might experience anxiety, confusion, and anticholinergic effects
- side effects: tremor, rigidity, bradykinesia

Dopaminergics

Levodopa - increases dopamine levels (leaves more in the brain)
- may be combined with carbidopa to decrease metabolism of levodopa (conserves)
- monitor for the wearing off phenomenon and dyskinesias (indicates the need to adjust the dosage or time of admin or the need for a medication holiday)

Carbidopa + Levodopa education

- slow onset 2-6 weeks to become effective
- slow position changes
- red, brown urine/sweat/salivia (NORMAL)
- NO HIGH PROTEIN MEALS

Selegline

MAO-B inhibitor
prevents the breakdown of dopamine
Reduce the wearing off phenomenon when given with levodopa
Severe reactions can occur when these medications are administered with sympathomimetics,
meperidine, and fluoxetine
Avoid foods high in tyramine, which can cause hypertensive crisis

Benztropine

anticholinergic
treats tremors and rigidity NOT bradykinesia

Which antihistamines can be used to control PD s/s

- diphenhydramine hydrochloride (benadryl)
- orphenadrine citrate (banflex)
- phenindamine hydrochloride (neo-synephrine)

Parkinsons nutrition

Semisolid food with thick liquids
encourage high fiber diet due to constipation
Monitor swallowing, HOB UP or SIT UP
Suction at bedside
Monitor weight weekly
PEG tube may be necessary to maintain nutrition
supplemental feedings increase caloric intake

Parkinsons + Improving mobility

- daily exercise (walking, riding a stationary bicycle, swimming, and gardening) helps maintain joint mobility
- stretching and ROM exercises promote joint flexibility
- postural exercises (counters tendency of the head and neck to be drawn forward and down)
- warm baths and massage
- walk erect, watch horizon, use a wide based gait
- frequent rest periods
- proper shoes
- use of assistive devices

Parkinsons + enhancing self care activities

- adaptive or assistive devices (hospital bed at home, over bed frame with a trapeze, rope tied to the food of the bed)

Parkinsons + bowel elimination

avoid laxatives
follow a regular time pattern, increase fluid intake, eat foods with moderate fiber content
raised toilet seat

Uterine cancer

cancer of the endometrium -> originating in the lining of the uterus
most women are diagnosed after menopause

Types of Uterine Cancer

type 1 (estrogen dependent, low grade, favorable prognosis)
type 2 (estrogen independent, high grade)

Older adults and african american women are at higher risk for

type 2 uterine cancer

s/s of uterine cancer

- Irregular and/or postmenopausal bleeding
- Low-back, abdominal, or low pelvic pain

If a menopausal woman experiences bleeding, what should be done to rule to hyperplasia

endometrial aspiration

hyperplasia

possible precursor of endometrial cancer

Transvaginal ultrasound

used to measure the thickness of endometrium

women who are postmenopausal should have a

very thin endometrium due to low levels of estrogen
a thicker lining warrants further investigation

What tumor markers are elevated in uterine cancer

Alpha-fetoprotein (AFP) is elevated
Cancer antigen-125 (CA-125) is positive

What is the standard treatment for uterine cancer

Total hysterectomy with bilateral salpingectomy/ oophorectomy

Progestin therapy

used frequently for uterine cancer
be prepared for such side effects as nausea, depression,
rash, or mild fluid retention

Brachytherapy

- delivered inside the body
- An applicator is placed in the vagina, then the radioactive isotope is placed in the applicator for
several minutes
- can occur 2-10 x / week, pt must remain in bed during the treatment
- Understand that there is no radioactivity between treatments and there are no restrictions on
interactions with others

External beam radiation therapy (EBRT)

delivered outside the body
Can be used in combination with surgery, brachytherapy, and/or chemotherapy
Often given for 4-6 weeks on an outpatient basis

Laparoscopy or a robot-assisted laparoscopic surgery

less invasive than abdominal surgery

Whole pelvis radiotherapy

may be used if there is any spread beyond the uterus

Breast Cancer

can be noninvasive (in situ) or invasive (most common)
common sites of metastasis are bone, lung, brain, and liver

Triple negative breast cancer

an aggressive form of cancer in which cells lack receptors for
estrogen, progesterone, and HER2

Breast feeding for a year or more decreases

breast cancer risk

Hormone replacement therapy and environmental estrogens have been linked to

breast cancer

breast cancer s/s

- breast change (appearance, texture, presence of lumps)
- breast pain or soreness
- skin changes (peau d'orange)
- dimpling
- breast tumors (usually small, irregularly shaped, firm, non-tender, and non-mobile)
- increased vascularity, erythema
- nipple discharge
- nipple retraction or ulceration
- enlarged lymph nodes

Male clients + breast cancer?

a mass around the areola that is hard and painless, nipple inversion, ulceration or swelling of the chest

When should clinical breast exam be conducted?

Every 3 years - ages 20-39
Yearly - OVER 40 yrs

When should breast self examination be conducted

monthly, on the same day every time

Biopsy

open or fine needle
definitive diagnosis of cancer cell type

Stereotactic biopsy

non-surgical needle biopsy for breast tissue in which affected tissue is visualized via client lying prone on special table with mammogram machine underneath

BRCA1 and BRCA2

presence of gene mutation increases breast cancer risk

HER2

presence of excess of this indicates the need for targeted therapy

Consider genetic testing for BRCA1 and BRCA2 if at risk

two first-degree relatives diagnosed with breast cancer prior to age 50 or family history of breast and ovarian cancer

Mammography, tomosynthesis (3D mammography)
MRI, ultrasound, CT scan, x-ray

visualization of the lesion

mammography is preferred over

x-ray

MRI and US provider better visualization of lesions for clients who have

dense breasts

nuclear imaging, breast specific gamma imaging

Scanning will display the uptake of the radioactive substance injected prior to the procedure

Positron emission mammography (PEM)

provides consistent images despite hormone
fluctuations

Hormone therapy

Most effective in cancer cells with estrogen or progesterone receptors

Ovarian ablation

Luteinizing releasing hormone (LH-RH) ex: leuprolide or goserelin
- inhibits estrogen synthesis
- use in PREMENOPAUSAL clients to stop or prevent the growth of breast tumors

Selective estrogen receptor modulators (SERMs): toremifene (tamoxifen and raloxifene)

Used in females who are at high risk for breast cancer or who have advanced breast cancer
• Suppress the growth of remaining cancer cells post-mastectomy or lumpectomy
• Tamoxifen has been found to increase the risk of endometrial cancer, DVT and
PE
• Raloxifene does not share these adverse effects

Chemotherapy and/or radiation can augment or replace a mastectomy, depending on several
factors

- client’s age
- hormone status related to menopause
- genetic predisposition
- staging of disease

Clients who undergo chemotherapy are usually given a combination of several medications

cyclophosphamide, doxorubicin, and fluorouracil

Radiation therapy is usually reserved for clients who had a

lumpectomy or breast-conserving
procedure

What is a priority concern due to radiation damage and generalized fatigue

skin care

What kind of therapy is most effective in breast cancer with HER2/neu gene

Target therapy

Trastuzumab, pertuzumab, and ado-trastuzumab emtansine

signal transduction inhibitors → inhibit proteins that are signals for cancer cells to grow

lumpectomy

breast conserving

modified radical mastectomy

lymph nodes removed

radical mastectomy

lymph nodes and muscle removed

Drainage tubes are usually left in for

1-3 weeks

Avoid placing the arm on the surgical side in a

dependent position
will interfere with wound healing

Perform early arm and hand exercises

squeezing a rubber ball, elbow flexion and extension, and hand-wall climbing to prevent lymphedema and to regain full range of motion

Genetic counseling for clients who test positive for the BRCA1/BRCA2 genetic mutation
includes recommendation

bilateral mastectomy and oophorectomy to prevent cancer occurrence

Sites of origin for most prostate cancer

posterior lobe
outer gland epithelium