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 <65 mm Hg) or initial lactate was ≥4 mmol/L → reassess intravascular volume status and tissue perfusion using two of the following assessment parameters
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 estrogena 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