Adult II- Exam 2

What labs are monitored with anemia?

-RBC: 4.7-6.1

-HCT: 37-51

-HBG: 12.6-17.4

-bilirubin (because there is a breakdown of HBG)

-MCV

-MCH

-MCHC

-iron

-B12

-folic acid

-stool guaiac tests (ex. blood loss in stool)

What are the different types of anemia?

-Iron-deficiency (microcytic hypochromic- most common)

-Megaloblastic (large, abnormal RBC): cobalamin B12 deficiency and folic acid deficiency

Megoblastic Anemia is characterized as....

Macrocytic Normochromic

-high MCV

-normal MCHC

S/S of anemia for elderly

pallor, ataxia, confusion, and fatigue

Causes/Labs from Iron-Deficiency Anemia

-most common cause: GI bleed

-other causes: lack of iron in diet, lack of iron absorption, blood loss (ex. hemodialysis)

-labs that decrease: RBC, H/H, MCV, + MCHC

-labs that stay normal: B12 + folate

Tx for Iron-Deficiency Anemia

-treat the cause (ex. blood loss)

-blood transfusions

-iron supplements (give with orange juice because vitamin C enhances iron absorption if they cannot tolerate taking it on an empty stomach!!!!!)

-eat foods high in iron: legumes, liver, muscle meat, dried fruit, dark/leafy veggies, beans, eggs, whole grains

-obtain a bilirubin level if the patient has jaundice

Side effects of iron supplements

-heartburn

-constipation (prevention: make sure to increase fiber intake + stool softener!!!)

-diarrhea

When is parenteral iron necessary?

When there is malabsorption with oral route, oral iron intolerance, need a higher dose, and poor patient compliance with oral

Causes of Cobalamin (B12) deficiency

-MOST COMMON CAUSE is pernicious anemia: gastric mucosa is not secreting intrinsic factor that helps absorb vitamin B12

Other causes

-alcoholism

-long term use of PPIs or Histamine receptor blockers

-vegetarians d/t not eating enough foods with B12

With B12 deficiency anemia, what is the tx?

-foods high in b12 for vegetarian induced B12 deficiency: meats, liver, eggs, milk, dairy, and fish

-parenteral, SQ, or intranasal Cobalamin for other causes

Folic Acid Deficiency S/S vs. Cobalamin Deficiency S/S

Cobalamin:

-GI: sore tongue, anorexia, nausea, abdominal pain!!

-Neuromuscular: paresthesia!!, decreased vibratory and position senses, ataxia, muscle weakness, and impaired thinking

-other: confusion!!

Folic Acid:

-GI: sore tongue, anorexia, nausea, abdominal pain!!

-Neuromuscular: paresthesia!!, decreased vibratory and position senses, ataxia, muscle weakness

-NO NEURO S/S!!

What foods are high in folic acid?

green leafy veggies, liver, meat, fish, legumes, whole grains, orange juice, peanuts, and avocados

Sickle cell is a genetic autosomal --- disorder

receive (Hbg S)

-both parents need to be a carrier

-the RBC are misshaped and weak

S/S of sickle cell anemia

-asymptomatic except during sickling episodes

-pain from tissue hypoxia and damage!!

-pallor of mucous membranes!!

-jaundice from hemolysis!!

What can trigger sickling episodes? How do we prevent the episodes?

-Triggers: infection (most common), stress/emotional distress, high altitudes, surgery, blood loss, and dehydration

-Prevent: vaccinations, avoid high altitudes, stay hydrated!, treat infections promptly

Nursing management with sickle cell crisis

-pain management (PCA)!

-Oxygen!

-Fluids and electrolytes!

-watch for respiratory failure

-rest

-folic acid for RBC production

-Hydrea (antisickling agent)

*Iron will not help

*narcotics and 02 is only used in the hospital

Define Thrombocytopenia

Plts less than 150,000/µL (KNOW!)

-leads to spontaneous bleeding from minor trauma

-can be inherited or acquired (ex. cancer or viral infections)

-always need to monitor the platelets because they are at risk for a hemorrhage

S/S of Thrombocytopenia

-mostly asymptomatic

-decreased BP, increased HR, decreased UO, decreased LOC, cyanosis, and blood in the stool

-petechiae: mucosal or cutaneous bleeding

-prolonged bleeding with routine procedures like IV/IM injections when plts are less than 50,000

-risk for hemorrhage when plts are less that 20,000

***if there is a change in consciousness, CALL THE DOCTOR ASAP!

Define: Immune Thrombocytopenia Purpura

-most common acquired thrombocytopenia

-syndrome of abnormal destruction of plts

-autoimmune disease

Tx with ITP

-no aspirin

-corticosteroids to increase the lifespan of plts

-splenectomy

-plts transfusion when less than 10,000, actively bleeding, or prophylactically for a planned procedure

What are the different types of leukemia?

-Acute myelogenous leukemia (AML)- there is an excessive amount of immature WBC; 5 year survival is at 25%

-Chronic lymphocytic leukemia (CLL)- cancer of the blood and bone marrow d/t B lymphocytes

What is AML (ex. population affected, patho, and s/s)?

-common in older adults

-there is myeloblast proliferation --> blast cells overcrowd the bone marrow

-WBC do not differentiate past the blast stage --> do not function normally

-there is hyperplasia of the bone marrow and spleen

-s/s: are at risk for infection and abnormal bleeding

What are the nursing responsibilities when caring for a Pt with AML?

In the hospital

-manage drugs and treatment side effects

-monitor labs

-educate about their disease process/ drugs/ treatment

-help them manage stress

At home

-monitor for s/s of disease control and relapse

-teach about follow-up care and when to seek medical attention

-need PT, immunizations, vocational retraining, and teach about the reproductive concerns that may occur

Tx with leukemia

-what to attain remission

-chemotherapy (will shut down the bone marrow)

-corticosteroids

-radiation therapy (targeted or total body)

-hematopoietic stem cell transplant (IV infusion of stem cells from bone marrow or umbilical cord)

-THERE ARE MANY COMPLICATIONS WITH BONE MARROW TRANSPLANTS!!

What is CLL?

-most common leukemia in adults

-two types: aggressive and indolent form

-there is a humoral immunity deficiency (ex. antibodies to not function properly --> weaker immune system)

-there is proliferation of functionally inactive but long-liver, mature-appearing lymphocytes

Complications with CLL

-complications are rare from the early stages; often asymptomatic

-complications develop as the disease advances

-lymph nodes enlarge and cause pain

-there is paralysis from the pressure

-spenomegaly, hepatomegaly, weakness, fatigue, nights sweats, and fever

-aggressive CLL leads to anemia, thrombocytopenia, infection, and invasion of other organisms

The nurse is caring for a patient who is to receive a transfusion of two units of packed red blood cells. After obtaining the first unit from the blood bank, the nurse would ask which health team member in the nurses' station to assist in checking the unit before administration?

a.Unit secretary

b.Another registered nurse

c.A physician's assistant

d.An unlicensed assistive personnel (UAP)

B

Which patient is most likely to experience anemia related to an increased destruction of red blood cells?

a.A 59-year-old man whose alcoholism has precipitated folic acid deficiency

b.A 30-year-old woman with a history of "heavy periods" accompanied by anemia

c.A 23-year-old African American man who has a diagnosis of sickle cell disease

d.A 60-year-old woman whose diet has precipitated cobalamin deficiency

C

A 36-year-old mother of two children has anemia related to inadequate intake of essential nutrients. Which intervention would be appropriate for the nurse to include in the plan of care for this woman?

a.Plan for 30 minutes of rest before and after every meal.

b.Encourage foods high in protein, iron, vitamin C, and folate.

c.Instruct the patient to select soft, bland, and nonacidic foods.

d.Give the patient a list of medications that inhibit iron absorption.

B

The nurse instructs an African American man who has sickle cell disease about symptom management and prevention of sickle cell crisis. The nurse determinesfurther teaching is necessary if the patient makes which statement?

a."When I take a vacation, I should not go to the mountains."

b."I should avoid contact with anyone who has a respiratory infection."

c. "I may experience severe pain during a crisis and need narcotic analgesics."

d."When my vision is blurred, I will close my eyes and rest for an hour."

D

A 64-year-old man with leukemia admitted for severe hypovolemia after prolonged diarrhea has a platelet count of 43,000/µL. It is most important for the nurse to take which action?

a. Administer prescribed enoxaparin (Lovenox).

b. Insert two 18-gauge IV catheters.

c. Monitor the patient's temperature every 2 hours.

d. Check stools for presence of frank or occult blood.

D

What is cancer?

-uncontrolled and unregulated cell growth

-failure of immune system to recognize what is abnormal

Describe the difference between benign and malignant tumors

-benign cancer spreads to adjacent tissues and organs

-malignant cancer will spread to distant tissues and organs

When is radiation therapy used? Goals?

-Used with lower stages of cancer because it only has effect on the tissues within the treatment field

-Directed at specific tissue to shrink or destroy cancer cells, less systemic effects

-Can use with other treatments

Goals

-prevent further spread (prophylaxis)

-limit tumor growth (control the disease)

What are the two types radiation therapy?

1. External: teletherapy

2. Internal: bradytherapy

Bradytherapy

-action/how it works

-precautions for nurses

Will cause cell death by emitting radioactive activity by using seeds

Precautions

-T: time (ex. clump cares to spend as little time in the room as possible)

-D: distance (ex. be far away)

-S: shielding (ex. PPE)

-wear a film badge (measures exposure to radiation for the day)

What are the side effects of radiation therapy?

Localized S/S

-fatigue

-skin reactions

-infection

-hair loss if it is in that area

-burns with sun exposure

-localized skin burns with bradytherapy

What is chemotherapy?

-systemic administration of drug that destroys everything in it's path

-attacks all rapidly proliferated cells

For chemotherapy, what PPE is required for nurses?

-special gloves, gowns, and goggles

-diluted laminar airflow hood

Which sites are acceptable for IV infusion of chemotherapy?

-muse be a well running IV site

-prefer: central lines

-try to avoid infusions in the arm to prevent infiltration

What is extravasation? S/S?

-leakage of agents into tissues around IV site

-common with IVs in the arm

-S/S: pain or no pain, swelling!, redness, presence of vesicles in the skin

A nurse checked in on her patient who was receiving chemotherapy. She noticed some swelling around the infusion site. What is the priority in this situation?

STOP THE IV INFUSION

-swelling is the first sign of extravasation

What are the side effects of chemotherapy?

Systemic S/S

-bone marrow suppression

-fatigue (d/t anemia, dehydration, infection, or anxiety)

-GI effects (stomatitis, mucositis, esophagitis, N/V!, anorexia, diarrhea, or constipation)

-skin reactions (ex. desquamation- skin peels off and alopecia)

-pulmonary and cardiovascular effects (ex. dry hacking cough, fever, dyspnea, and decreased EF)

-nervous system and cognitive effects (ex. chemo brain: foggy and memory issues)

-GU: incontinence and prone to UTIs d/t lowered immune system

-others: infection, bleeding, hair loss, and mouth sores

Bone marrow suppression leads to ...

neutropenia

With neutropenia, what should the nurse monitor? What occurs when neutrophils are low?

-WBC (especially neutrophil count)

-if they are LOW, chemotherapy may be delayed until they RISE!!

What medications are used with neutropenia? Route and action?

SQ: filgrastim or pegfilgrastim

-pt will return 24 hours after their chemotherapy for these medications

-results in increased WBC production

What would you teach a neutropenic patient?

-CALL THE PROVIDER if you have a low grade fever (ex. 100.4 F), the pt will most likely need to come in to be checked out!!

-no fresh flower, fruit, or vegetables

-all visitors and nurses must wear masks in the room

-wash your hands

-cook meats through

-no seafood

What constitutes a neutropenic emergency?

-temp greater than or equal to 100.4 F

-neutrophil count < 500

With N/V that results from chemotherapy, how is it managed?

-ANTIEMETICS 30-60 minutes before administering chemotherapy!

-eat/drink when no nausea is present

-small, frequent meals

-fluids between meals

What is the treatment for anorexia, diarrhea, or constipation due to chemotherapy?

-anorexia: small high protein and high calorie meals; eat lemon to enhance taste/flavor of food

-diarrhea: anti-diarrheas unless an infection is present; low fiber diet; drink 3 L of fluid a day

-constipation: stool softeners, high fiber diet, and fluids

How does chemotherapy affect the nervous system? Tx?

a. Increased ICP can occur

-corticosteroids

b. Peripheral Neuropathy

-neurotonin to decrease the pain

Since the GI system is affected with chemotherapy, what does the nurse need to monitor/avoid?

-monitor BUN/Creat

-avoid nephrotoxic drugs: NSAIDs (ex. Aspirin), gentamyacin, and vancomycin

What are the complications with cancer?

-infection with the primary cause of death! The patient must call the MD if the temp is greater than 100.5 F

-malnutrition (ex. monitor albumin)

-altered sense of tase

With a stem cell transplant, what should the nurse frequently monitor?

-temperature, plts, and WBC

-the patient is at high risk for infection

What are the different types of oncological emergencies?

Obstructive

-Superior vena cava syndrome

-Spinal cord compression

Metabolic

-Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

-Hypercalcemia

Intrafiltrative

-Cardiac Tamponade

Superior Vena Cava Syndrome

-describe

-s/s (KNOW THEM!)

-cancers associated with this condition

-tx

-there is an obstruction by a tumor or thrombosis

-s/s: facial edema, upper extremity edema, SOB, cough distended neck veins, HA, and seizure

-common from lung cancer, breast tumors, and non-hodgkin's lymphoma

-tx: radiation

Spinal Cord Compression

-describe

-s/s (KNOW THEM!)

-cancers associated with this condition

-tx

-there is a malignant tumor in the epidural space in the spine

-s/s: BACK PAIN, change in bowel and bladder function

-common from breast, lung, prostate, GI, and renal tumors

-tx: radiation and corticosteroids

SIADH

-describe

-s/s

-cancers associated with this condition

-tx

-the body retains water instead of excreting it normally in urine

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

-Tx: oral fluid restriction + Lasix, while administering 3% NS to maintain perfusion

Hypercalcemia

-S/S

-cancer associated with this condition

-tx

-S/S: depression, fatigue, muscle weakness, and elevated calcium levels

-common with metastatic bone cancer

-tx: hydration and diuretics

Cardiac Tamponade

-describe

-s/s

-tx

-there is fluid accumulation in the pericardiac sac, constriction of the pericardium, or pericarditis from radiation

-s/s: heave chest, dyspnea, tachycardia, and cough

-THIS IS AN EMERGENCY, so fluid must be removed ASAP with a paracentesis

How will nurses manage pain for cancer patients?

-around the clock opioids!!

-other pain meds as needed

A patient came into the hospital brain dead, yet he is an organ donor. What is the first thing you would do?

Administer IVF

What is a PRA screen?

-Panel of reactive antibodies in the recipients blood

-determines whether prospective cross match is needed

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

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

What does HLA represent?

looks for tissue matching

Describe hyperacute rejection

-happens during the surgery or 24 hours after

-blood vessels are being rapidly destroyed d/t pre-existing antibodies

-due to high PRA levels (ex. cross match is incorrect)

-tx: remove the organ

Describe acute rejection

-happens within the first 6 months

-pt's lymphocytes attack the organ, OR other antibodies are developed and attack the organ

-tx: reversible with more immunosuppressants

Describe chronic rejection

-cause is unknown, or there were multiple acute rejections

-there is a lot of fibrosis and scarring around the new organ

-tx will be supportive cares

S/S with rejection

-fever (must come to the provider ASAP!)

-pain at the site of the transplant

-body aches

-nausea

-edema

What are the different types of immunosuppressive therapy?

-Calcineurin inhibitors (ex. cyclosporine + tacrolimus)

-Cytotoxic Agents (ex. Mycophenolate mofetil, Azathioprine, or Sirolimus)

-Corticosteroids

-Monoclonal Antibodies (will inhibit T cell proliferation; has flu-like symptoms for the first few days)

Calcineurin Inhibitors

-action

-side effects

-what to monitor

-they will suppress the activation of T cytotoxic lymphocytes

-side effects: nephrotoxicity and HRN

-monitor: BUN/Creat and BP

Cytotoxic Drugs

-action

-side effects/ how to treat them

-inhibits T and B cell proliferation

-side effects: GI toxicity such as N/V and diarrhea

-we do not want to take the patients off this medication, so we must treat the GI toxicity (ex. antiemetics)

Corticosteroids

-action

-risks

Impairs antigen recognition

-they are on them initially, but not long-term. Otherwise, they could develop Cushings

-need to taper off these meds

Immunosuppressants are taken --- a day

twice

Name the complications that can develop as a long-term effect of transplantation.

-HTN

-renal insufficiency d/t immunosuppressants

-hyperlipidemia

-diabetes

-osteoporosis

-malignancies: skin cancer, post-transplant lymphoproliferative disease, and other tumors

Normal ICP level

5-15

-if the patient is experiencing s/s of increased ICP, call the provider ASAP!

-if the level is above 15, you MUST contact the HCP ASAP!

-if the level is over 20 --> comatose

What are the three components that can increase ICP?

-CSF

-intravascular blood

-brain tissue

S/S of increased ICP

-change in LOC (earliest and most sensitive sign!!)

-VS (ex. Cushing's Triad)

-dilation of the eyes

-HA (worse in the morning or when they sit up)

-projectile vomiting without nausea

-motor function decreases (ex. cannot follow commands)

-decorticate position (hands turned in/pulled into the body)!!

-decerebrate position (extension in hands; hands are turned outward)!!

Decorticate and decerebrate positions are also seen with...

closed head injuries

What is Cushing's triad?

LATE SIGN

-there is increased SBP

-widening of PP (difference between SBP and DBP)

-decreased HR

-irregular respirations such as Chenye-Stokes (ex. cycles of hyperventilation with apnea and shallow breathing)!!!

How do nurses assess for increased intracranial pressure?

-neuro exam (ex. ANO)

-monitor pupils

-Oculovestibular and Oculocephalic brainstem reflexes

-monitor changes in VS

-look at the body position

-Glasgow coma scale (worried if it is less than 8 --> worried about an abnormal CT scan)!

Complications with increased ICP?

-inadequate cerebral perfusion --> ischemia --> stroke

-brain herniation, so the brain presses down on the brain stem --> respiratory arrest

Tx for increased ICP

-first intervention: pulse ox and oxygen!!

-obtain ABGs

-Pa02 goal is 100

-may require mechanical ventilation

-increased need for glucose

-keep patient normovolemic with IV 0.9% NaCl

-medications

What medications are used with increased ICP?

Osmotic Therapy to reduce fluid volume

-mannitol (diuretic)!!!

-hypertonic saline or NS

Corticosteroids to reduce edema ("sone")

-monitor blood glucose because it will increase with steroids

-be aware of infections

H2 Blocker or PPI to prevent GI bleeds

Acetaminophen for the fever

Barbituates to decrease cerebral metabolism and prevent respiratory depression

Antiseizure drugs (increased ICP --> irritability --> seizures)

Stool Softeners

-straining with bowel movements increases ICP; want to prevent this

Sedatives/Pain medications

Why do use filtered tubing with Mannitol? How do we know when this medication is working?

-this medication can crystalize in the tube; therefore, special tubing is required. Always monitor for crystallization before administration

-the medication is working when there is decreased ICP!!!

What is important to avoid doing with patients who have increased ICP?

DO NOT

-cough and deep breathe

-suction

-allow the patient to become constipated

-allow the patient to be stressed (ex. administer benzos)

ICP nursing management in terms of body positioning

-HOB must be between 15-30 degrees

-avoid neck flexion, head rotation, and extreme hip flexion

-turn q 2 hours

-avoid sudden movement

-seizure precautions put into place (ex. side rails must be up and padded)

With scalp lacerations, what is the biggest major complication?

-Complication: infection

-the scalp is very vascular, so it may look like a lot of blood loss. However, infection is more worrisome

With skull fractures, the location will alter the presentation of the manifestations. Describe the differences between Battle's Sign and Raccoon Eyes

Battle's Sign

-location: temporal, parietal, basilar fractures

-most commonly seen at the base of the skull

-presented as bruising behind the ears

Raccoon Eyes

-location: basilar or facial fracture

-presented as bruising around the eyes

What is a Halo Sign?

Cerebrospinal fluid from nose/ear will form a clear "halo" around the blood on a cloth

What is the treatment for an arterial rupture/tear?

immediate craniotomy d/t the blood loss

What causes an epidural hematoma?

-when a skull fracture tears an underlying blood vessel

-car/bicycle accidents (prevent with helmets and seat belts)

Describe a subdural hematoma. Who is at risk?

-bleeding between the dura and arachnoid layers

-usually venous in origin

-pt will slowly develop a mass large enough to produce symptoms

-most commonly originated from the vein that drain the brain surface into the sagittal sinus

-risk: elderly and alcoholics (ex. both are likely to fall and tear a vessel)

Describe an epidural hematoma

-bleeding between the dura and the inner surface of the skull

-most likely involves an artery (can be venous; less blood present)

-apply pressure ASAP

What VS is most helpful to determine cerebral blood flow?

blood pressure!

How do we manage head injuries?

-manage ICP and edema (ex. glucocorticoids like dexamethasone, diuretics like mannitol, turn slowly, HOB elevated, barbiturates to decrease metabolic demand)

-neuro assessments (ex. s/s of increased ICP, CSF leaks from nose/ears, seizures)

-assess eyes (corneal reflex, periorbital edema, diplopia)

-treat hyperthermia

What abnormal findings confirm meningitis?

-Nuchal rigidity- stiff neck

-Kernig's sign- pain in the lower back and resistance to straightening the leg at the knee

-Brudzinski's sign- involuntary flexion of the hip and knees

What is meningitis?

Acute inflammation of meningeal tissue

-leads to increased CSF production and increased ICP

-can be bacterial or viral

What should a nurse do when she suspects her patient has meningitis?

-wear a mask and gloves

-instruct all other people who will be in the room to do the same (ex. CNA and visitors)

What test is performed for suspected meningitis?

Lumbar puncture

-be cautious because this test can also increase ICP

Nursing cares with meningitis

-promote vaccination (at 12 and before college)

-treat respiratory and ear infection

-IV antibiotics for bacterial

-tylenol for fever

-dark environment for photophobia

-seizure precautions because they are at risk

-droplet precautions (bacterial)

-prevention: caution with dorms or jails