CHA 1 Exam 2

all units in one

pros and cons of pain

Pro: it’s a warning signal something is going on

Con: it hurts and can be debilitating, affecting quality of life.

Nociception: transduction - transmission - perception - modulation

transduction: conversion of stimuli to electrical signals

transmission: movement of signals to the brain

perception: recognition of pain

modulation: modification of the pain experience

best way to see how much pain a patient is in:

their subjective response and self report of their tolerance. With appropriate pain scale for the situation.

Acute Pain

sudden onset, last less than 3 months, cause identifiable, decreases over time, stimulates SNS (fight or flight) (tachy, HTN, diaphoretic), responds well to treatment.

chronic pain

pain lasting longer than 3 months, often without identifiable cause, persistent and can worsen over time, may lead to psychological effects such as depression or anxiety, and often requires long-term management.

classifying pain: nociceptive—— somatic vs. visceral

nociceptive pain refers to pain from actual or potential tissue damage. Somatic pain originates from skin (subcutaneous tissue, sharp, burning, prickly), muscles, bone or joints, while visceral pain is from internal organs (pancreatitis, IBD, inflammation, ischemia, inflammation).

classifying pain: neuropathic

neuropathic pain is caused by damage to peripheral nerves or structures in CNS, leading to abnormal pain signaling. It is often described as shooting, burning, or numbing, and can be sudden, intense, short, or lingering. Ex: phantom limb, diabetic neuropathy, MS

referred pain

pain perceived at a location other than the site of the painful stimulus or injury, often due to shared nerve pathways. For example, shoulder pain may result from a heart attack or right shoulder pain could be gall stones

radiating pain

pain that travels away and spreads from original location. It is commonly associated with conditions such as herniated discs or nerve compression.

analgesics (oxycodone)

short quick acting opioid

0-10 pain scale

best if used for self assess of people A+Ox3, verbal, and >8yrs old.

Wong Baker FACES pain scale

best if used for patients cognitively impaired and age <8 yrs old. Visual objective data gathered

FLACC pain scale

best if used for nonverbal adults, ages 2 months - 7 yrs old, and cognitively impaired. behavior based scale of objective data (face, legs, activity, cry, console 0-2)

NIPS pain scale

best if used for children from birth to 1 year. behavior based scale (0-2) useful in neonates. Facial expression, cry, breathing, arms, legs, alertness. Want to be 0

RASS: Richmond agitation and sedation score

when to use?

used when giving opioids or CNS depressants (not verbal response use scale!) or when completing any sedation procedure. Objective and useful in evaluating effectiveness of treatment, and shouldn’t be below -2 The scale ranges from -5 (unarousable) to +4 (combative).

non-opioids. Used? Pro? Con? Examples?

used for mild to moderate pain

available OTC, no dependence/tolerance

side effects

NSAIDS, acetaminophen, aspirin, ibuprofen, ketorolac

Opioids: Used? Pro? Con? Example?

used for moderate to severe pain

highly effective

side effects- constipation, N/V

morphine, hydrocodone, methadone

Adjuvant: use? pro? con? example?

alone or with other analgesic

best for neuropathic pain

side effects- CNS analgesic affects, extended time to work

antiseizure (pregabalin), antidepressants (SNRI)

PCA: continuos/basal dose

set dose every hour

PCA: loading dose

one-time dose on initiation

PCA: bolus/demand dose

patient controlled bolus to manage pain

medications that block nerve impulses, providing pain relief in a specific area without affecting consciousness.

• lidocaine patch

• EMLA 

• lidocaine/prilocaine

• bupivacaine 

local anesthetics

medications used for pain relief that are not classified as opioids, such as acetaminophen and NSAIDs- ketorolac, ibuprofen, diclofenac (also topical)  

nonopiods

medications that are used to manage moderate to severe pain and work by binding to opioid receptors in the brain and spinal cord. morphine

• hydrocodone

• hydromorphone

• oxymorphone

• fentanyl 

• oxycodone

• codeine

• buprenorphine

• tramadol (dual action mixed analgesic) 

opioids

medications that enhance the effects of primary pain relievers, such as antidepressants and anticonvulsants. They may also alleviate pain through different mechanisms.

• local anesthetics

• muscle relaxants

• anticonvulsants: gabapentin, pregabalin

• antidepressants: (SNRI) amitriptyline, venlafaxine, duloxetine 

adjuvants (co-analgesics)

medications that counteract the effects of opioids, typically used in cases of overdose.

• naloxone

• flumazenil

reversal agents

A medication used to stimulate the production of red blood cells, primarily in patients with anemia due to chronic kidney disease or chemotherapy.

epoetin alfa (Procrit or Epogen) 

A medication that stimulates the production of white blood cells, helping to prevent infections in patients undergoing chemotherapy or those with certain cancers.

filgrastim (Neupogen or Neulasta)

women: 3.8-5.1, 11.7-16, 35-47

men: 4.3-5.7, 13.2-17.3, 39-50

normal RBC, HGB, HCT levels

iron deficiency, cobalamin deficiency, folic acid deficiency, aplastic anemia, chronic disease

anemia’s caused by decreased RBC production

acute, chronic anemia

anemias caused by blood loss

infectious disease, hemolytic anemia, sickle cell disease

anemias caused by increased RBC production

mild anemia hgb 10-12 symptoms

palpitations, exertional dyspnea, fatigue, and weakness.

moderate anemia hgb 6-10 symptoms

bounding pulses, dyspnea, roaring in the ears, fatigue

severe anemia <6 symptoms

pallor, tachy, murmurs. angina, HF, MI, tachypnea, orthopnea, blurry vision, headache, vertigo, irritable, impaired thought process, anorexia, sensitive to cold, wt. loss, lethargy

can be caused by inadequate intake, malabsorption, blood loss, and hemolysis. Seen in pt. with glossitis, cheilitis, paresthesia. check diagnostics such as transferrin, ferritin.

iron deficiency anemia

iron replacement

replace with PO iron taken with vit. C to absorb, diet change including eggs, potatoes, IM insert can be painful, IV looks black and can cause hypotension, taking liquid use straw, black stool

Vitamin B12 cobalamin (low intake), pernicious anemia (lack intrinsic factor to absorb— needing a parenteral injection), folic acid deficient (N/V, tongue change, anorexia). seen with dyspepsia, red, beefy tongue, neuromuscular deficits.

Megaloblastic Anemias - large RBC - easily destroyed

seen with chronic inflammation, autoimmune disorders, infectious disease, chronic bleedings disorders, develops after 1-2 months. shown with general s/s of anemia. Important to differentiate- RBC isn’t being produced. correct cause if it’s renal, erythropoietin, give blood

anemia of chronic disease

cobalamin

oral B12

acute or chronic (hemorrhage), congenital (chromosome abnormal), acquired (autoimmune disorder). general s/s. can be acute or chronic. Low RBC, WBC, Plts.

aplastic anemia- pancytopenia

hemorrhage from trauma, surgery, abrupt hypovolemic shock, increased plasma volume. Seen in FVD: hypotension, tachycardia and tissue hypoxia: dyspnea, ischemic pain.

acute blood loss. Replace blood loss, identify source and stop the bleed, monitor pt. closely.

genetic and seen as newborn, can result from hypoxia, infection, stress, high altitudes, dehydration. Seen with high levels of pain (ischemic) and jaundice, hgb S present.

hemolytic anemia - sickle cell disease

treat sickle cell disease

fluid to lower risk of occlusion, oxygen, pain relief. minimize end organ damage in liver and spleen. give Hydroxurea to increase hgb production. educate to prevent (no high altitudes, up on vaccines, stay hydrated, good hygiene)

seen with hyperviscosity (thick blood) and FVE, HTN, prutitus’, emboli. two types: primary is increased RBC, WBC, and Plts, secondary is increased RBC (H/H).

polycythemia vera- primary (chronic with cell proliferation) or secondary (outside driven) solved by therapeutic phlebotomy, Hct <45%, suppressing bone marrow with corticosteroids

thrombocytopenia

plt <150,000. normal plt 150,000-400,000, PT/INR 11-16, PTT 25-35

destruction of platelets. atibodies that attach to platelets - spleen then destroys them. solved by IV steroids, plt stimulants, and IV immunoglobin, splenectomy

ITP- immune thrombocytopenic purpura

Accelerated clotting, consumption/reduction of plts, bleeding. clotting and bleeding happening at the same time. treat by removing cause such as sepsis, cancers, pregnancy. assess for clots and bleeds, balance benefit vs. risk.

DIC- disseminated intravascular coagulation (critical care! emergency) (organ fail possible)

immune mediated response to heparin 5-14 days after therapy, (lovanox and flush). Remove products from chart and document as allergy. use alternative options such as gatroban, coumadin only used if plt>150k. Plasmapheresis in severe clotting.

HIT- heparin induced thrombocytopenia

Bone marrow suppression, leukemia, chemotherapy, aplastic anemia, SSRI. Remove the cause of decreased production but consider benefit vs. risk. transfusion can be performed if needed 10,000 or less.

thrombocytopenia- decreased production of platelets

asymptomatic, bleeding in gums, IV site, hypotension, tachycardia, increased respiratory rate, skin can see petechiae or purpura. if plt less than 50k they can be symptomatic, less than 20k can be life threatening. Treat the cause, avoid meds that affect plt function (aspirin, lovanox), transfusion performed if platelet count less than 10,000.

thrombocytopenia assessment, diagnostics, and interventions

hemophilia A

A genetic disorder caused by a deficiency of coagulation factor VIII, leading to prolonged bleeding and difficulty in blood clotting.

hemophilia B

A genetic disorder caused by a deficiency of coagulation factor IX, which also results in prolonged bleeding and challenges in proper blood clotting.

Von Willebrand’s Disease

A genetic bleeding disorder caused by a deficiency or dysfunction of von Willebrand protein, leading to impaired platelet adhesion and prolonged bleeding, especially during surgical procedures or after injury.

assessment and interventions for hem. A, hem. B, VW disease

bleeding is seen, slow persistent, delayed bleed (rebleed), hematoma (neuro pinched nerve), hemarthrosis (enlargement in joint, immobilized solved with cold compress). Interventions may involve replacement therapy with the respective factor, use of desmopressin for von Willebrand’s, and recommendation of protective measures to prevent injuries (bleeding precautions)

leukopenia levels

neutropenia levels

WBC <3.5

neutrophils (ANC) <1

neutropenia assessment, diagnostics, and interventions

s/s of infection, fever above 100.4°F, risk for sepsis, ANC monitoring, blood smear: shift to the left (increase in bands, immature WBC) not good at fighting infections. interventions include antibiotic therapy, neutropenic precautions. Medications to stim. neutrophil production like neulasta, neupogen

acute leukemia

immature WBC, rapid progression, high blast count, often presents with fatigue, fever, and bleeding.

chronic leukemia

mature WBC, slow progression, lower blast count, may be asymptomatic for years.

myelogenous- myeloid stem cell leads to production of:

can be acute or chronic leukemia

RBC, WBC, Plt

lymphocytic- lymphocytic stem cells lead to production of:

can be acute or chronic leukemia

T cells, B cells, NK cells

hodgkin’s lymphoma

a type of cancer that originates from the lymphatic system, characterized by the presence of Reed-Sternberg cells. It typically presents with lymph node enlargement, fever, and night sweats. Chemo and radiation combo.

non-hodgkins lymphoma

a diverse group of blood cancers that include any lymphoma except Hodgkin's lymphoma impacting B, T, NK cells. Symptoms may include swollen lymph nodes, pancytopenia, and treatment often involves chemotherapy or radiation.

leukostasis

WBC > 100,000

leukemia chemotherapy treatment stages:

the phases of treatment including induction, postinduction, and maintenance aimed at eliminating leukemia cells.

chemotherapy is the mainstay to:

decrease drug resistance, minimize drug toxicity, and interrupt growth at multiple points in cell cycle.

local therapy using high-energy particles to destroy cells. interventions include prevent infection and healing wounds.

radiation

systemic treatment using drugs to kill cancer cells causes alopecia. Nursing interventions include: preventing infection, healing wounds, education, and emotional support

chemotherapy

obstructive oncology emergency: superior vena cava syndrome (SVCS)

A condition where obstruction of the superior vena cava occurs, leading to swelling and decreased blood flow to the head, neck, and upper body. seen with facial, periorbital edema, and JVD. It is often common in lung cancer, NH lymphoma, and breast cancer

obstructive oncology emergency: spinal cord compression

caused by presence of tumor in the epidural space of the spinal cord. seen with localized intense back pain, aggravated by Valsalva maneuver, motor weakness, sensory deficits, autonomic dysfunction. common in any metastatic cancer. Treat with radiation and corticosteroids and surgical decompression.

obstructive oncology emergency: third space syndrome

shifting of fluid from vascular space to interstitial space, may be from surgery, therapy, or septic shock (chemo, low albumin, malnutrition). Seen with HYPOTENSION, TACHYCARDIA, DECREASED UO, SOB (vascular fluid build up in the lungs). Treated with fluids (if hypotensive), colloids (albumin, FFP), or electrolyte replacement.

Tumor lysis syndrome (TLS)

massive cell destruction and rapid release of intracellular components into the bloodstream, leading to metabolic disturbances such as high uric acid, high K+, high phosphate, and low calcium. Treatment includes: hydration, preventing renal failure, allopurinol, and corrective electrolyte management.

Cardiac tamponade (chronic)

accumulation of fluid in the pericardial space, leading to decreased cardiac output and compression of the heart. Symptoms include hypotension, heavy chest feeling, jugular venous distension, decreased LOC, and distant heart sounds. Treatment often requires pericardiocentesis to remove excess fluid.