Adult Health Exam 3

Patho:

Genetic disorder of hemoglobin (HgbS) distorting RBC shape (sickle) in response to decreased O2

Hgb cannot carry oxygen well

Vaso-occlusive events

• Sickle cells are sticky, fragile, clump together, occlude blood vessels

  • This leads to anoxia, ischemic infarctions, end-organ damage

CM:

Pain

Severity varies, and periodic crises

Precipitating Conditions:

• Hypoxia states, High altitudes, Dehydration, Venous stasis, Physical/emotional stress, Anesthesia, Infections, Low/High environment or body temps

Complications:

• Retinopathy

• Cerebral infarcts or stroke

• Cardiomegaly → CHF

• Pulmonary infarctions → pneumonia

• Cholelithiasis

• Splenomegaly → splenic atrophy

• Renal infarcts → hematuria

• Infarcts of extremities

• Bone marrow hyperplasia

• Aseptic bone necrosis → osteomyelitis

• Lower extremity ulcers

Nursing Interventions:

Pain management

Oxygen

Hydration

Body positioning (bending = clumping/constriction)

Check circulation of peripheral extremeties

Assess signs of central claudication

• Chest pain, decor LOC, PE?

Keep Pt warm

Admin IVF or PO fluids

Prevent infection

Blood transfusion

Hydroxyurea (reduces sickling)

Teaching:

• To prevent crisis

  • Stay hydrated

  • Avoid low oxygenation

  • Avoid inf/illness

• Drug management

  • Birth control with hydroxyurea

• Emotional support

• Supportive care

Nursing Diagnosis:

Acute pain (lack of perfusion)

Ineffective peripheral tissue perfusion

Deficient fluid volume

Activity intolerance

Risk for decreased cardiac tissue perf

Risk for infection

Risk for ineffective cerebral tissue perf

Patho:

Loss of cellular regulation; proliferation of RBCs, WBCs, and platelets

Blood is hyperviscous

• Poor oxygenation of tissues; cell destruction

• RBC > 16.5

• Hgb > 18

• Hct > 55%

• High K, High uric acid

CM:

HTN

HAs

Dizziness

Purple/gray color

Itching

Dyspnea

Complications: bc thick blood

• Angina

• Claudication

• Thromboses

• Infarctions

• MI

• Intracranial bleeds/CVA

Diagnosis:

Treatment:

Repeated Apheresis 2-5 times/week

Medications

• Hydroxyurea

• Anticoagulants

Nursing Interventions:

Prevent clots

Hydration (3 L/day)

Stop smoking

Promote venous return

Elevate feet

Avoid tight clothing

Support hose

Thrombocytopenia precautions

Use electric razor, soft toothbrush

Neutropenic precautions

Contact Dr at first sign of inf or occlusion

Exercise slowly

• Stop activity at first sign of chest pain or dizziness

Interdisciplinary

• Anticoags

• Chemo

Nursing Diagnosis:

Ineffective protection

Risk for bleeding

Risk ineffective tissue perfusion

Patho:

Precancerous state – 30% develop acute leukemia

Abnormal cell formation in bone marrow; destroyed by body after release; decrease in all blood cell types (pancytopenia)

Risk Factors:

• > 65

• Exposure to chemicals (pesticides, benzene)

• Tobacco smoke

• Chemotherapy/radiation

Diagnosis:

Cytogenetic testing

Peripheral blood smears

Treatment:

Supportive care

Blood/platelet transfusions; Epogen (Procrit) injections

Allogeneic hematopoietic stem cell transplant only curative treatment

Immunomodulatory agents

Patho:

Local bleeding - petechiae

Easier to control than clotting factor disorders

Reasons:

Normal platelets = 150k-400k/mm3

• Decreased production

  • CAs and Tx

  • Aplastic anemia

  • Toxins

  • Meds

  • Alcohol

• Increased destruction

  • Autoimmune

  • Infections; meds; spleen disorder; CAs

• Increased consumption

  • Disseminating intravascular coagulation (DIC)

Thrombocytopenia:

• 40k-80k = Risk for bleeding with mild trauma

• <20k = Risk for spontaneous bleeding

• <5k = Risk for fatal bleeding in CNS or GI

  • Acute confusion!!

• Ex: Idiopathic thrombocytopenic purpura

Thrombocytosis:

• >600k

• Risk for clotting

• Ex: Thrombotic thrombocytopenic purpura

Idiopathic Thrombocytopenic Purpura (ITP):

Autoimmune disorder

Pts make Abs against own platelets; macrophages destroy

• Viral infections thought to trigger

• Most common women 20-40

Diagnosis: serial low platelets & Bone marrow Bx

Treatment:

• Immunosuppressive drugs (prednisone)

• Platelets transfusion

• Splenectomy (last resort)

  • Stored platelets → swelling and could rupture

Thrombotic Thrombocytopenic Purpura (TTP):

Autoimmune disorder

Platelets clump together abnormally in capillaries and too few available in circulation

• Inappropriate clotting but also fails to clot when trauma occurs

Tissue becomes ischemic → may lead to kidney failure, MI, CVA

• Untreated fatal in 3 months

Treatment:

• Plasmapheresis

• FFP to provide platelet aggregation inhibitors

• Platelet inhibitor drugs

Patho:

Occurs deeper in the body

• Joint spaces, SQ

• Deep bleeds are diffic to control and often restarts

Disorders:

• Hemophilia

• HIT

Hemophilia:

Genetic disorder

• X linked recessive trait

• Women carrier (50% chance of passing gene to offspring)

Type A

• Factor VIII deficiency

• More common

Type B

• Factor IX deficiency

CM:

• Abnormal bleeding to any trauma, specifically joints

• Bleed longer than normal

• Problem forming stable fibrin clot

Joint problems from repeated episodes of bleeding is most common complication

Hemophilia Diagnosis:

Prolonged PTT

Nursing Interventions:

Minimize trauma and other causes of bleeding

• Thrombocytopenia precautions

• Risk assessment: protect pt from injuries

Assess for s/s of bleeding

Interdisciplinary

• Prepare to admin platelet transfusions for platelet < 10k

• Replace missing factor with infusion of synthetic factors

• Educate pt and family on risk for bleeding

Patho:

Acute - sudden onset abnormal blood cells

Chronic - abnormal cells replicate slowly

Classifications:

• Lymphocytic

• Myelogenous

Types:

• Acute lymphocytic leukemia (ALL)

  • Common in young children

• Acute myelogenous leukemia (AML)

  • Most common in adults

• Chronic lymphocytic leukemia (CLL)

  • Most common chronic adult leukemia

• Chronic myelogenous leukemia (CML)

  • Asymptomatic for yrs before entering a fast growth phase

Risk Factors:

• Prior exposure to chemo or radiation

• Bone marrow hypoplasia

• Genetic factors (Downs)

• Immune deficiency

• Virus

CM:

Fever

Night sweats

Easy bleeding and bruising

Purplish patches or spots on skin

Freq infections

Fatigue

Loss of appetite

Weight loss

Swelling

Easy SOB

Spleen and/or liver enlargement

Musc weakness

Bone/joint pain or tenderness

Treatment:

Induction Therapy

• Intense chemotherapy started as soon as diagnosis confirmed

• Hospitalized 2-3 weeks in protective isolation

• AE

  • Severe bone marrow supp

  • Alopecia

  • N/v

  • Stomatitis

  • Organ toxicity

Consolidation Therapy

• Repeat drugs or bone marrow transplant

Maintenance Therapy

• Months and years to maintain remission

Diagnosis:

CBC

• Abnormal WBC: high blast cells poorer prognosis

• Low H&H and platelets

Bone Marrow Bx - Definitive test

• Provides info about blood cells and production

• Nursing:

  • Teach what to expect

  • Position

  • Sedative provided

  • Local anesthetic injected

• After:

  • Control bleeding

  • Inspect site q2h

  • Pain control

Chromosome analysis

Other x-rays, CT, MRI

Patho:

CA of lymphocytes

Two main types:

• Hodgkin's lymphoma (HL)

  • Teens and adults 50-60s

• Non-Hodgkin’s lymphoma (NHL)

  • All other lymphomas

  • Older adult men

• Many subtypes

Hodgkins:

Starts in single lymph node in neck, underarm, or chest

Proceeds in orderly fashion to next

Risk Factors:

• Viral infections

• Chemical exposure

Fatigue, anorexia, SOB

“B” symptoms: sweats, fever, itching, weight loss

Pain in node areas after alcohol intake

Treatment

• External radiation and chemo

• Curable

Non-Hodgkins:

Lymphadenopathy in multiple sites

Spread to other organs at diagnosis

Risk Factors:

• Autoimmune disease and immunosuppr disorders

• Viruses (HIV, EBV)

• Chemicals

Treatment:

• Chemotherapy/monoclonal Abs; Radiation

• Chronic disease/not curable

Patho:

Overgrowth of plasma cells (PC)

PC overproduce gamma globulin (gammopathy)

• Excess Abs in blood clog vessels of kidney and other organs

Produce excess cytokines

• Incr CA growth rate and destroy bone

CM:

Early

• Fatigue

• Anemia

• Easy bruising

• Bone pain

• Infections

Late

• Bone fractures

• Kidney dysfunction

• HTN

• Rare: Hypercalcemia, Hyperviscosity syndrome

Leads to progressive bone destruction, bleeding, kidney failure, immunosuppression, and death

Diagnosis:

Serum electrophoresis

• Detects monoclonal immunoglobulin

Bone marrow

• > 10% infiltrated plasma cells

Xray

• Osteolytic bone lesions

Treatment:

Chemotherapy agents

Bone marrow transplant

INCURABLE

Nursing Interventions:

Care of immunocompromised

Pain control

Nursing Diagnosis:

Febrile Transfusion Reaction:

Occurs most often in pt with anti-WBC Abs, which develop after multiple transfusions

Chills

Tachycardia

Fever

Hypotension

Tachypnea

Giving leukocyte reduced blood, WBC filters, or single-donor reduces risk

Hemolytic Transfusion Reaction:

Caused by blood type or Rh incompatibility

Fever

Chills

DIC and circulatory collapse

Other sx:

Apprehension/sense impending doom

HA

Chest pain

Low back pain

Tachycardia

Tachypnea

Hypotension

Hemoglobinuria

Allergic Transfusion Reaction:

Most commonly seen in pts with other allergies

Urticaria

Itching

Bronchospasm

Anaphylaxis

Onset usually during or 24 hours after

Bacterial Transfusion Reaction:

Contaminated blood products (esp gram neg organisms)

Tachycardia

Hypotension

Fever

Chills

Shock

Rapid onset

Transfusion-related Acute Lung Injury (TRALI):

Most commonly when donor blood contains Abs against recipient's neutrophil Ags

Dyspnea

Hypoxia

Rapid onset - within 6 hours

Early detection key to survival

Most pts need intubation

Transfusion-associated Circulatory Overload (TACO):

Occurs when transfused too quickly

HTN

Bounding pulse

Distended jugular veins

Dyspnea

Restlessness

Confusion

Monitor I&O, infusing blood products more slowly, giving diuretics

Transfusion-associated Graft-vs-Host Disease:

Most commonly in immunosuppressed pt

Thrombocytopenia

Anorexia

N/v

Chronic hepatitis

Weight loss

Recurrent infection

Sx usually within 1-2 weeks

Acute Pain Transfusion Reaction:

Severe chest pain

Back pain

Joint pain

HTN

Anxiety

Redness of the head and neck

During or shortly after transfusion

Diabetes Insipidus:

Deficiency of ADH

• Excessive urination; manifestations of dehydration

Cause

• Lifelong: Genetics

• Not always permanent: Trauma (incl brain surgery), Tumors, Renal problem

Manifestations

• Excessive thirst, urination (250 mL or more/hr, dilute/light color)

Treatment

• ID cause

• Replace vasopressin (desmopressin nasal spray)

Nursing (BOTH):

• Close monitoring I&O

• Daily weight

• Blood chemistries, electrolytes

• Monitor neurological status

Syndrome of Inappropriate ADH:

Excess ADH

Water retained, delusional hyponatremia

• Sodium Is Always Down (136-145 mEq/mL)

• Hyponatremia = confusion or altered mental status

Cause

• CA, Respiratory infections, CNS disorders, Drugs

Manifestations

• Neuro impairment

Treat

• Treat cause

• Fluid restriction

• Diuretics

• Hypertonic saline (SLOWLY)

• Safe environment - confusion

• Freq neuro assess (q4hr)

Gigantism:

GH hypersecretion before puberty

Usually pituitary tumor

Sweating, HA, Vision impairment, Weakness, Insomnia, Delayed puberty

Dwarfism:

GH hyposecretion

Suppl GH can be administered for some types

Acromegaly:

GH hypersecretion after puberty

Pituitary adenoma

Slow changes over time

• Enlarged tongue, lips, nose, hands, feet, facial bone growth

• Organ enlargement

Skeletal changes cannot be reversed

Patho:

Decrease ACTH and adrenocortical steroids from adrenal cortex

Cause

• Autoimmune

• Meds: corticosteroids (abrupt dc, long-term use)

Low on 3 S’s

• Salt, sugar, steroids

CM:

Hyperpigmentation (incl gums)

Fatigue

Weakness

Anorexia

Weight loss

Confusion

Emotional lability

Hypoglycemia

Blood vol depletion

Hyperkalemia & hyponatremia

• Hyponatremia = confusion

• Hyperkalemia = dysrhythmias

Diagnosis:

Early morning plasma cortisol provocation tests

• Injection of ACTH admin, blood drawn 60 later

  • Measure cortisol (excreted in reaction to ACTH)

• Performed to differentiate primary from secondary adrenal insufficiency

  • Primary: direct effect on kidneys, etc

  • Secondary: pituitary tumor affecting ACTH, etc

• Primary = greater increase in plasma ACTH and lower than normal cortisol concentration

Fasting blood glucose, electrolytes, BUN

Treatment:

Restore blood vol and prevent shock

• First line = crystalloid fluids (NS, LR)

Replace hormones (hydrocortisone, dexamethasone)

Treat hyponatremia and hyperkalemia

• SLOWLY

• Hyperkalemia: insulin then D50W or kayexalate or loop diuretics (be careful about decr blood vol)

Treat hypoglycemia

• Monitor careful, esp if using insulin to treat hyperkalemia

Administer fluids, Monitor I&O

Monitor VS

• Will have low BP and high HR

Vasopressors for hypotension

Determine cause

Nursing Interventions:

Monitor VS q1-4h

Assess dysrhythmias or postural hypoTN

Daily weight

Promote fluid balance

• Monitor for fluid deficit

• Accurate I&O

Monitor lab values

• Renal function, BUN/Cr, Electrolytes

Give cortisol and aldost replacement

Acute Adrenal Crisis: Life threatening

Sudden loss of cortisol and aldosterone

Typically occurs after stressful event

• Surgery, trauma, severe infection

Clinical Manifs

• Shunting blood away from GI tract

  • Vomiting

  • Abdominal pain

• Low glucose and Na

• High K

• Severe hypotension

  • Loss blood vol because lack aldosterone - fluid and Na not being retained

• Hypovolemic shock

Patho:

Adrenocortical Excess

Cause:

• Pheochromocytoma (pituitary tumor)

High on 3 S’s

• Salt, sugar, steroids

CM:

Acne

Muscle wasting, Weakness

Fragile skin

Moon face

Buffalo hump

Enlarged trunk

Virilization:

• Hirsutism

• Male pattern baldness

• Clitoral hypertrophy

• Breast shrinkage

• Menses cease

• Voice deepens

• Loss of libido

Retention of Na and water: HTN and HF

Hyperglycemia

Diagnosis:

Three tests (2 must be abnormal for Dx)

• Serum cortisol

• Urinary cortisol (24hr collection)

  • ALL urine (miss void = start over)

  • Container kept on ice

• Low dose dexamethasone suppression test

Treatment:

Surgery

• If cause is pituitary tumor or primary adrenal hypertrophy

• Adrenal insufficiency 12-48 hrs post-op

  • Support with hydrocortisone

Drug therapy: Adrenal enzyme inhibitors

• Used to suppress ACTH if tumor cannot be removed

  • Mitotane

Radiation is an option, but takes long to see effects

Nursing Interventions:

Decrease risk for injury

Decrease risk of infection

Prep pt for surgery

Encourage rest and activity

Promote skin integrity

Improve body image

Improve coping

Monitor for potential complications

Promote home and community care

Nursing Diagnosis:

Patho:

Primary Aldosteronism

CM:

Profound decline in serum K levels (Hypokalemia) and hydrogen ions (Alkalosis) with increase in serum bicarb

HTN common universal sign

Muscle weakness

Cramping

Fatigue

Excessive urine volume

Polyuria

Serum concentration - Polydipsia

Treatment & Nursing:

Surgical removal of adrenal tumor

Treat HTN with spironolactone

• K sparing

• Monitor serum K and Cr for 4-6 wks during drug therapy

Nursing

• Post-op care

• Assist with collaborative care

Patho:

Inflammation, fibrosis, lymphocytic infiltration

Types:

• Acute - infection

• Subacute - granulomatous

• Chronic - Hashimoto’s disease (most common)

CM:

Neck pain

Swelling

Dysphagia

Treatment:

Patho:

Thyrotoxicosis

Excess thyroid hormones

Women > men

Graves Disease (most common type)

• Caused by abnormal stimulation by immunoglobulins (autoimmune)

Other types

• Formation of nodules from iodine deficiency (toxic multinodular goiter)

• Viral infection of the thyroid gland (thyroiditis)

• Excessive pituitary secretion of TSH (secondary hyperthyroidism)

Thyroid Storm

• Worsening of hyperthyroid s/s

• Rare complication of hyperthyroidism; Can be fatal

• Develop HF, circulatory collapse, high fever

  • Seizure risk

CM: Fast forward metabolic processes

Nervousness

Apprehensive

Cannot sit still

Tremors

Excess perspiration

Poor heat tolerance

High HR

• At least 120 at rest

Flushed, moist skin

Increase appetite

Weight loss

Weakness

Amenorrhea

Exophthalmos

• Typically permanent

Thyroid enlargement

Bruit over thyroid arteries

Diagnosis:

TSH low

T3 & T4 elevated

Radioactive Iodine Uptake

• Measures rate of iodine uptake by thyroid

• Hyperthyroid exhibit high uptake; hypothyroid low

Fine-needle Aspirate Bx

• Tissue sample to detect CA

Thyroid scan

• Radionuclide injected and test determines “Hot” areas of increased activity and “Cold” areas of decreased activity (CA)

• Entire body may be scanned to determine metastatic thyroid disease

Treatment:

Antithyroid medications

• Methimazole

Plasmapheresis or dialysis to remove excessive T3 & T4

Ablation (burn or cauterize) or removal of gland

Cardiac monitoring - dysrhythmias

Oxygen to treat dyspnea and possible HF

Beta blockers to decrease sympathetic activity sx

Acetaminophen to reduce temperature

Nursing Interventions:

Monitor VS

• Special attn on temp and HR elevations

Provide calm and quiet environ to decr anx

Maintain cool room

Provide eye care (exophthalmos)

• Admin artificial tears to reduce dryness

• Elev HOB at night

Corticosteroids to reduce inflam

• Taper when dc

Collab with dietician

• Hypermetabolic state, Caloric intake must be increased to 4000-5000 cal/day

• Encourage 6 meals/day

Teach pt and family need for antithyroid medication

Encourage follow-up with HCP

Provide info about online resources

Treat photophobia with dark glasses

• exophthalmos

Ablation/Removal:

Radioactive Iodine Therapy (I-131)

• Most common tx

• Remission with high dose 80%

If I-131 not successful= Surgical removal of the thyroid

Total thyroidectomy/Ablation will ness lifelong thyroid hormone replacement

Radioactive Iodine Therapy:

Ablative dose I-131 administered

Causes acute release of thyr hormone

• Induce thyroid storm

Observe for thyroid storm (thyrotoxic crisis)

• Fever 101.3 or greater

• HR > 130 bpm

• Effects on organs: Abd pain, Diarrhea, Edema, Chest pain, Dyspnea, Delirium, Psychosis

Management

• Cooling blanket

• Hydrocortisone (shock and adrenal insuf)

• Methimazole (impede formation of thyroid hormone)

• Iodine decrease T4 output

• Support cardiac, resp, renal systems

Precautions

• Wear gloves and shoe gloves

• Wear dosimetry badge - monitor nurse exposure to radiation

• Minimize time spent with the pt

• Remain at least 3 ft away when possible

• Contaminated linens must be collected

• Pt must remain in room at all times

• Pt must use disposable utensils

• No minors or pregnant visitors allowed

• Radiation Safety must release the room before another pt admitted

Post-Op

• Observe for potential complications

  • Hemorrhage

  • Respiratory distress

    • Thyroid near airway

  • Hypocalcemia and tetany (parathyroid)

  • Laryngeal nerve damage

  • Thyroid storm or thyroid crisis

• Administer hormone replacement therapy (synthroid)

Patho:

95% is primary d/t low levels of thyroid hormones

• Women > men

• Autoimmune (Hashimoto’s), Thyroid surgery, Iodine deficiency, Tumors, Drugs

CM:

Early:

• Fatigue

• ℅ cold (subnormal temp)

• Low HR

• Weight gain with poor appetite

• Constipation

TSH high

T3 & T4 low

Compensatory Mechanism: Enlarged Thyroid

Goiter

Abnormal enlargement of thyroid

Hypothyroid

• Hypothalamus signals release of more TSH binds to thyroid cells and causes thyroid to enlarge in attempt to trigger release of T3 & T4

Hyperthyroid

• Too much thyroid hormone released

Rare in US - major cause in lack of iodine

Treatment:

Levothyroxine (synthroid)

Nursing Interventions:

Modify activity

• Risk of immobility problems

Monitor physical status

• VS and mental status

• Medication AE

Promote physical comfort

• Keep room warm

• No heating pads

• Nutrition

• Increase fluids

• ADLs

Enhance coping mechanisms

• May have extremes of emotion - need support and counseling

• Tend to be more depressed

Promote home and community based care

• Teach - Meds, Keep appts for lab and HCP, Self-care

Myxedema Crisis:

Can be fatal

Tissue and organ failure d/t decreased metabolism

Occurs with undiagnosed or poorly treated hypothyroidism

Clinical Manifs

• Mucinous Edema - mucus and water

  • Non-pitting edema forms everywhere (eyes, hands, feet, between shoulder blades, tongue)

• Hypothermia

• Increasing lethargy

• Stupor

• Loss of consciousness

• Depressed resp drive

• Cardiovascular collapse

• Coma, Shock, Death

• Very sensitive to sedating drugs!

Nursing Interventions:

• Ineffective breathing pattern

  • Observe and record rate and depth of respirations

  • Auscultate the lungs

  • Assess for resp distress

  • Assess the client receiving sedation for respiratory adequacy

• Decreased cardiac output

  • Monitor circulatory status

    • BP, HR, periph pulses

  • Signs of inadequate tissue oxygenation

    • Pulses, cap refill

  • Changes in mental status

  • Fluid status and HR

    • HR will be lower with hypothyroidism

  • Administer oxygen or mechanical ventilation, as appropriate

Papillary, Follicular, Medullary, and Anaplastic

Surgery Tx of choice: thyroidectomy

• Suppressive doses of thyroid hormone for 3 months after surgery

• Study performed after drugs are withdrawn

Genetic counseling

Patho:

Excessive secretion of PTH

• Causes increase calcium in blood, bone decalcification, and renal calculi

CM:

Fatigue

Muscle weakness

Constipation

Skeletal pain

HTN

Dysrhythmias

Peptic ulcers

Pancreatitis

Diagnosis:

Elevated Ca

Xray

Scans

Treatment:

Diuretics

Fluids

Mobility

Diet restriction (Ca rich food)

Meds:

• Phosphates

• Calcitonin (hormone replacement)

Surgery

Parathyroidectomy:

Parathyroidectomy preoperative care:

• Client stabilized; calcium levels normalized

• Studies: bleeding and clotting times, CBC

• Teaching: coughing, deep breathing exercises, neck support

Post-op Care

• Observe for respiratory distress

  • Keep emergency equip at bedside

• Hypocalcemia crisis can occur

  • Watch for sx of tetany or seizures

  • Trousseau's sign - wrist bends when BP cuff tightened

• Recurrent laryngeal nerve damage can occur

Patho:

Decreased PTH secretion

• Lack of hormone causes increased phosphate and decreased calcium

Common cause:

• Inadvertent removal of gland during removal of thyroid or radical neck surgery

Treatment:

Vorrecting hypocalcemia, vitamin D deficiency

Keep pt in quiet environment to decrease neurologic stimuli

• Free of bright lights, drafts