N432 Exam 3

acute myeloid leukemia

uncontrolled proliferation of myeloblasts, hyperplasia of bone marrow + spleen, bleeding

acute lymphocytic leukemia

immature, small lymphocytes proliferate in bone marrow, cns manifestations

chronic myeloid leukemia

increased mature neoplastic granulocytes in bone marrow, infiltrate liver + spleen, Philadelphia chromosome

chronic lymphocytic leukemia

b cell involvement, lymphadenopathy body wide, pain, paralysis from pressure, caused by enlarged lymph nodes

leukostasis

life-threatening complication, thickened blood blocks circulatory pathways

stages of chemo

induction

post induction/ post remission

maintenance

leukemia tx

chemo therapy

corticosteroids

radiation

biologic/ targeted therapies

leukemia sx

fever, lymphadenopathy, lethargy, pallor, jaundice, petechiae, ecchymosis, tachy, systolic murmurs, oral lesions, bleeding, hepatomegaly, splenomegaly, confusion, seizures, muscle wasting, bone/ joint pain

leukemia nursing interventions

neutropenic precautions

bleeding precautions

improve nutrition, low microbial, mucositis care

Hodgkins lymphoma

abnormal, giant, multi-nucleated cells (reed-Sternberg cells in lymph nodes)

Hodgkins lymphoma risk factors

epstein-barr virus infection, genetic predisposition, occupational toxins

Non-hodgkins lymphoma

heterogenous group of malignant neoplasms, inherited immunodeficiency, immunosuppressive meds, received chemo/ radiation

Hodgkins lymphoma dx

increase in single location, cervical lymph, spreads along adjacent lymphatic, infiltrates, liver, spleen, lungs, begins above diaphragm, lymph node biopsy, bone marrow exam, radiologic evaluation

Non-hodgkins dx

MRI, detect extranodal sites, lymph node biopsy, indolent (low grade), aggressive (high grade)

hodgkins sx

increased cervical, axillary, inguinal lymph nodes, movable, painless, mediastinal node mass, weight loss, night sweats

hodgkins mgmt

chemo, radiation, intense chemo/ HSCT, better prognosis

non-hodgkins tx

chemo-radiation, monoclonal antibodies (-imab, sx pancytopenia), phototherapy

multiple myeloma

plasma cells in bone marrow become malignant, collect inside, destroying bone

multiple myeloma sx

bone breakdown, pain, osteoporosis, fractures, hypercalcemia, increased serum protein, renal damage/ failure, increased serum viscosity, anemia, fatigue, bleeding, infection

multiple myeloma tx

chemo, corticosteroids, radiation, biphosphonates

multiple myeloma key fx

CRAB- calcium increase, renal dysfunction, anemia, bone lesions/pain

multiple myeloma mgmt

Nsaids, opioids, proper body mechanics, hydration, infection control, monitor renal

shock

poor tissue perfusion, lack of O2, anaerobic metabolism, organ failure, cellular injury, death

hypovolemic shock

d/t external blood loss, internal bleeding, fluid loss

cardiogenic shock

MI, valvular dysfunction, HF

distributive shock

anaphylaxis, sepsis, brain injury, spinal, neuro anesthesia

obstructive shock

PE, tamponade, valvular disease, tension pneumo

stages of shock

initial- hypoxia, hypoperfusion, compensatory- neural, endocrine, chemical, progressive- shunting blood to vital organs, refractory- cell death, MODS, irreversible

systems response- compensatory

constriction, increased NA/ water reabsorption, shunting of blood away from organs, hyperglycemia, resp. alkalosis, oliguria, decreased bowel sounds, cool/ moist skin

systems response- progressive

extensive shunting of blood away from organs, failure of Na/ K pump, lethargy/coma, dysrhythmias, anuria, absent bowel sounds, met. acidosis, cold extremities

systems response- refractory

insufficient anaerobic metabolism, tissue hypoxia, coma, hypotension, met/ resp. acidosis, hep/ renal failure, tissue ischemia/ necrosis

shock assessment

CNS, CV, resp., renal, GI

shock- hemodynamic + lab monitoring

central venous catheter/ central line, arterial line, pulmonary artery catheter, ABGs, lactate >2, electrolytes, renal studies, LFTs, glucose

shock mgmt

head to toe assessment, nonbreather mask, prepare intubation, labs, vasopressors+ IV fluids

cardiogenic shock mgmt

12-lead ECG, cardiac enzymes, fluids, vasopressors, NTG/ nitroprusside, diuretics w/ caution

obstructive shock mgmt

PE- anticoagulants, thrombolytics, suction thrombectomy, pulmonary thrombectomy, cardiac tamponade- pericardiocentesis, pneumothorax- needle thoracostomy, vasopressors

dsitributive shock mgmt- neurogenic

vasopressors/ atropine, tx underlying condition, raise HBO slowly (reduce orthostatic hypotension), SCDs

dsitributive shock mgmt- anaphylactic

IM epi, remove trigger, urticaria/ angioedema, antihistamines, corticosteroids, inhaled bronchodilators

dsitributive shock mgmt- septic

blood cultures, urine, sputum, wound cultures, handwashing, oral care, “1hr bundle of care”, crystalloid fluids, vasopressors

sepsis+ septic shock

lead to DIC + MODS

UTI

caused by E.coli, fungal, parasitic

upper UTI

pylonephritis

lower UTI

cystitis (bladder), urethritis (urethra)

pyelonephritis

parenchyma, pelvis, ureters, flank pain, tender enlarged kidney, systemic

lower UTI sx

dysuria, urgency, subrapubic pain, bladder spasms, hematuria, cloudy, foul-smelling

lower UTI dx

dipstick urinalysis

upper UTI

CT, US, intravenous pyelogram,

UTI mgmt

antibitoics, bactrim, antifungals, urine analgesic (phenazopyridine), fluoroquinolones (hepatotoxicity), hydration, avoid bladder irritants, local heat, pt teaching

acute pyelonephritis

inflammation of renal parenchyma (collecting system), bacteria cause, starts as lower UTI, vesicoureteral reflux (backward movement of urine), renal medulla to cortex

acute pyelonephritis sx

flank, back pain, tender costovertebral angle, malaise, urinary burning, urgency, frequency, nocturia

acute pyelonephritis dx

urinalysis, WBC (shift to left), US, CT, urography

pyelonephritis mgmt

parenteral antibiotics, antipyretics, urinary analgesics, relapse- 6 week course, urine culture, imaging, hydration, monitor cystitis

glomerulonephritis

inflammation of glomerular capillaries, lead to nephrotic syndrome

acute glomerulonephritis

triggered by immune mechanism

acute glomerulonephritis sx

proteinuria, hematuria, rust-colored urine (d/t increased permeability, hematuria), casts, edema, periorbital, ascites, abd/flank pain, increased BUN/ creatinine

acute glomerulonephritis mgmt

dietary- limit sodium/ fluids, protein, antibiotics, corticosteroids, immunosuppressants

chronic glomerulonephritis

cause- repeated ep. acute glomerulonephritis, hypertensive nephrosclerosis, hyperlipidemia,

chronic glomerulonephritis

urine- fixed specific gravity, casts, proteinuria, serum- hypoalbuminemia

chronic glomerulonephritis mgmt

ACEis, ARBs, corticosteroids, plasmaphersis, limit Na/ K, protein, diuretics

Nephrotic syndrome

damages glomerular membrane, increases permeability to plasma proteins, hypoalbuminemia, edema

Nephrotic syndrome mgmt

diet- decrease salt, fat, cholesterol, add fruits/ veggies, protein/ fluid intake depends, prednisone, cyclophosphamide, cyclosporine, diuretics, ACEis/ ARbs, albumin + diuretics (repeat)

PKD

autosomal dominant, autosomal recessive

PKD sx

abd/ flank pain, nocturia/ hematuria, increased abd. girth, enlarged kidney (constipation d/t pressure)

PKD dx

ULTRASOUND (kidney cysts), family hx, genetic testing

PKD mgmt

NO CURE, antihypertensives, diuretics, bowel mgmt, low sodium, fluid monitoring, prevent infection (cystis)

Urinary tract calculi (nephrolithiasis)

white, male, outside worker/ summer, dehydrated, genetic/ climate/ lifestyle

nephrolithiasis s/s

asymptomatic, severe pain d/t obstruction, cool/ moist skin, flank pain, testicular, labial, groin pain, UTI sx, dysuria,

nephrolithiasis dx

non-contrast CT/ KUB, US, IVP, UA, 24hr urine

nephrolithiasis mgmt

pain-opioids, obstruction- tamsulosin/ terazosin, prevent further stones, surgery, pt teaching, struvute stones-antibiotics, acetohyeloxamic acid, surgery removal

indications for surgery (stones)

too large to pass, w/ bacteriuria, causing impaired renal function, pain/ nausea, paralytic ileus

AKI

prerenal causes: decreased renal blood flow (dehydration, HF, decreased CO), decreased GFR to oliguria, intrarenal causes- acute tubular necrosis, damage to kidney tissue, ischemia, nephrotoxins, REVERSIBLE, postrenal cause- BPH, prosate cancer, calculi, trauma

AKI oliguric phase

urinary changes < 400ml/day, casts, RBCs, WBCs, fixed urine SG 1.010, distended neck veins, bounding pulse, edema, HTN, stupor (neuro sx), met. acidosis, kaussmaul resp., sodium excretion, Hyperkalemia, leukocytosis, increased BUN/ creatinine

AKI diuertic phase

daily OU 1-3L, or 5L<, hyponatremia, hypokalemia, dehydration

AKI dx

serum creatinine increased kidney function loss > 50%, urinalysis, kidney US, renal scan, CT scan, avoid contrast dyes d/t nephrotoxicity

AKI mgmt

eliminate cause, manage sx, prevent complications, increase fluids, loop diuretics, osmotic diuretic, tx hyperkalemia- insulin + sodium bicarb, calcium carbonate, sodium polystyrene sulfonate

indications for RRT (AKI)

volume overload, increased potassium level, met. acidosis, bun increased, change in LOC, pericarditis, pericardial effusion, cardiac tamponade

AKI nutrition

decreased, sodium, adequate CHO, increase fat, enteral nutrition

dialysis

move fluid and molecules across semi-permeable membrane, tx drug overdose, GFR< 15, uremia not cured

ESKD tx with dialysis bc:

lack of donated organs, some pts unsiuitable for transplant

diffusion

solutes move from greater to less concentration

osmosis

fluid moves to area of more solutes from area of fewer solutes

ultrafiltration

water/ fluid removal, osmotic gradient exists across membrane

peritoneal dialysis cycles

inflow, dwell, drain

peritoneal dialysis complications

peritonits, hernias, lower back pain (increased abd. pressure), bleeding, atelectasis, pneumonia, bronchitis, protein loss

Hemodialysis: Dialyzers and Procedure, complications

hypotension, muscle cramps, blood loss, hepatitis

cheyne strokes

cycles of hyperventilation + apnea

central neurogenic hyperventilation

sustained, regular rapid/ deep breathing

apneustic breathing

prolonged inspiratory phase/ pauses alternating expiratory pauses

cluster breathing

clusters of breaths follow each other w/ irregular pauses between

ataxic breathing

completely irregular, deep breaths/ shallow, irrgular pauses, slow rate

normal ICP

5-15mm Hg

elevated ICP

>20mm Hg

ocular sx

unilateral pupil dilation, sluggish reaction, inability to move eye upward, eyelid ptosis

cranial nerve sx

diplopia, blurred vision, EOM changes, papillledema

adequate oxygenation

PaO2> 100mm Hg, PaCO2 35-45 mmHg

increased ICP tx

osmotic diuretic, hypertonic saline, antiseizure meds, antipyretics, sedatives, anagesics, barbiturates, increase glucose, eneteral/ parenteral nutrition, isotonic saline

Increased ICP mgmt

patent airway, HOB 30 degrees, suctioning, minimize abd. distention, prevnet hip flexion, extreme neck flexion, turn slowly, avoid coughing, straining, valsalva, pain/ anxiety meds, monitor- DI/ SIADH, protection from self-injury

scalp lacerations

external head trauma, highly vascular, profuse bleeding, blood loss, inection, fractures, infections, hematoma, tissue damage

basilar skull fracture

raccon eyes and battles sign

diffuse/ generalized TBI- concussion

retrograse amnesia, short duration, lethargy, headache, shortened attention spam