Exam 2 Flashcards
Role of hypothalamus
Release and stimulate hormones
No direct effect on the body
Releasing hormones
Adrenocortiocotropic hormone
Thyroid stimulating hormone
What releases parathormone (parathyroid hormone)
Parathyroid gland
What does parathormone do
Pulls calcium out of bones to increase serum calcium
Decreases phosphorus levels
What is the effect of hyperfunction of parathyroid
Hypercalcemia
What is the effect of hypofunction of the parathyroid
Hypocalcemia
Hyperparathyroidism
Increase in serum calcium
Bones turn to swiss cheese
Hyperparathyroidism risk factors
2-4x more in women, 60-70 yrs old
Hyperparathyroidism s/sx
Apathy, fatigue, muscle weakness
Loss of appetite
Constipation
Hypertension, cardiac dysrhythmias
Hyperparathyroidism complications
Osteoporosis
Skeletal pain and pathologic fractures
Kidney stones
How to dx hyperparathyroidism
Elevated calcium and increase parathormone levels
Pathologic bone changes on x-ray
Treatment for hyperparathyroidism
Laparoscopic removal of parathyroid gland
- For asymptomatic pts under 50, unlikely to follow up, calcium over 11, high urine calcium, or low bone density
Medications for hyperparathyroid
Calcitonin and corticosteroids
- Reduces serum calcium and increases calcium deposit in bones
Education/management of hyperparathyroidism
Hydration - 2+L/day
Encourage mobility (bone density)
Maintain dietary intake of calcium
Stool softeners
What to monitor post-op parathyroidectomy
Monitor Chvostek and Trousseau’s sign
- Looking for rebound hypocalcemia
Serious complication of hyperparathyroid
Hypercalcemic crisis
Hypercalcemic crisis s/sx
Neurologic, cardiovascular, and kidney symptoms
- Can be life threatening
Hypercalcemia crisis or hyperparathyroid tx
Rapid rehydration with large volumes of IV isotonic saline fluids
Calcitonin + corticosteroids to reduce serum calcium by increasing calcium deposition in bone
Causes for hypoparathyroid
Abnormal parathyroid development
Destruction of parathyroid gland (surgical or autoimmune)
Vit D deficiency
Hypoparathyroid s/sx
Tetany, numbness, tingling in extremities, stiffness of hands and feet
Bronchospasm, laryngeal spasm, carpopedal spasm
Anxiety, irritability, depression, delirium
ECG changes
Tx goal for hypoparathyroid
Increase serum calcium to 9-10 mg/dL
Tx for hypoparathyroid
Calcium gluconate IV - acute episodes
Pentobarbital - decreases neuromuscular irritability and tetany
Vitamin D
Hypoparathyroidism nursing education/considerations
Maintain cardiac monitoring
Monitor respiratory status
Quiet environment, soft lights
High calcium, low phosphorus diet
What hormones do the thyroid gland secrete
T3 and T4
What does T3 and T4 do
Regulates metabolism
Controls cell growth
Regulates basal metabolic rate, oxygen consumption, and glucose consumption
What stimulates hormones release from the thyroid
Pituitary gland releases thyroid stimulating hormone
What does TSH (thyroid stimulating hormone) do
Releases T3
Synthesis of T4 in liver
What do thyroid hormones require to be made
Iodine is needed for synthesis
Purpose of T3
Regulates metabolism
Purpose of T4
Steady state metabolism
Organ function, BMR, cholesterol, thermoregulation
Goiter
Enlarged thyroid
Caused by low iodine
What can a goiter lead to
Hypo or hyperthyroidism
Dx tests for thyroid
Primary screening of TSH
Serum T3/T4
Thyroid antibodies
Iodine uptake test
Thyroid biopsy
Thyroid scan
What leads to thyroid hyposecretion
Elevated TSH + decreased T3/T4
What leads to thyroid hypersecretion
Decreased TSH + increased T3/T4
Thyroiditis
Inflammation of thyroid gland
What is the effect of thyroiditis on thyroid hormones
Increased TSH and decreased T3/T4
Decreased function of thyroid gland
Is hypo or hyperthyroidism more common
95% of cases are d/t primary thyroid dysfunction
Cretinism
Congenital hypothyroid
Hasimotos Thyroiditis
Immune system (autoimmune) attacks thyroid
Leads to hypothyroidism
Most common population for Hashimotos Thyroiditis
Women 40-70
Hypothyroid s/sx
Extreme fatigue
Hair loss, brittle nails, dry skin
Numbness of fingers
Weight gain
Personality changes
What V/S changes can happen with severe hypothyroidism
Decreased pulse
Temperature changes
Myxedema coma s/sx
Depression, lethargy, somnolence, coma, hypoventilation, CO2 retention, hypoglycemia, bradycardia, hypothermia
Hypothyroidism tx
Synthroid - replaces thyroid hormones (long term)
Synthroid AE
Cardiac side effects
What medication is used for hypothyroidism crisis
IV T3/T4
What to monitor after synthroid administration (nursing consideration)
Monitor for angina and dysrhythmias
Common nursing dx for hypothyroidism
Activity intolerance - decreased metabolic activity
Impaired memory - reorient
Constipation - mobility, fluids, stool softeners
How long do patients have to take hypothyroidism medications
Lifelong (education)
Nursing considerations for myxedema coma
Maintain stable body temperature
Monitor gastric motility
Skin integrity
Reduced metabolism = hypoventilation
- Pulmonary toilet
Causes of hyperthyroidism
Graves disease (75% of cases)
Pituitary tumor - increases TSH
Too much thyroid hormone replacement
Hashimoto’s Thyroiditis
Thyrotoxicosis
Hypermetabolism d/t thyroid stimulation
S/sx of hyperthyroidism
Increase metabolic activity
- Tachycardia, HTN, tachypnea, hyperthermia, palpitations, bounding pulses
- Diarrhea, weight loss with increased appetite
- Irritability and mood swings, nervousness, twitching, insomnia
- Amenorrhea
- Thinned hair and skin with flushed appearance
Exopthalmos
Protruding eyes
Common in Grave’s disease or hyperthyroidism
Hyperthyroidism manifestations
Goiter - do not palpate
Pulse/thrill over thyroid
Decreased TSH, increased T4
Elevated iodine
Hyperthyroidism tx
Antithyroids - block hormone synthesis (Propylthiouracil [PTU] and methemazole)
Radioactive iodine - through straw
Beta blockers for tachycardia
Bedrest for acute hyperthyroid episodes
Radioactive iodine therapy
Tx of choice for nonpregnant pts
Removes sections of thyroid to decrease function
Takes up to 3 months for full effect
Hyperthyroidism surgical tx
Throidectomy
Requires long term thyroid hormone replacement
Hyperthyroidism nursing management
Increase calories
Extra fluids
Daily weight and calorie count
Ineffective coping - hypermetabolism puts pts on edge
- Low stress environment, dim lights, soft noises
Ice packs, cool room (hyperthermia r/t hypermetabolism)
Monitor for dysrhythmias d/t hypermetabolism - beta blockers, stress free environment, avoid stimulants/caffeine
Hyperthyroidism patient education
Avoid stimulants
High carb, high calorie, high protein diet
Cool room and loose clothes
Eye care - drops, lubricants, steroid drops
Long term hormone replacement after thyroidectomy
Thyroid storm
Acute episode of excessive thyroid production
Increase metabolism leads to diarrhea, weight loss, altered mental status
Thyroid storm dx
Fever >38.5
Tachy >130
Thyroid storm tx
IV glucose
Humidified O2
Iodine infusion
Beta blockers - for tachycardia and hypertension
What is the main concern for thyroid storm
Increased BP and tachycardia can lead to heart damage
Thyroid cancer
Malignancies on thyroid lead to increased secretion of thyroid hormones
Thyroid cancer common population
75% of cases are women, ⅔ are under age of 55
Thyroid cancer dx
Signs of hyperthyroidism
Hard, fixed, palpable lesions on thyroid
Biopsy confirms diagnosis
Thyroid cancer tx
Thyroidectomy and neck dissection
Radiation if possible
Thyroidectomy indications
Pregnancy
Pts with goiter
Thyroid med allergy
What procedure is done alongside thyroidectomy
Neck dissection - removal of lymph nodes from neck
Pre-op thyroidectomy nursing considerations
Reduce stress/anxiety to avoid thyroid storm
Decrease caffeine, stimulants
High carb, high protein diet
Vitamin supplements
Post op thyroidectomy nursing considerations
Monitor airway
Monitor for hemorrhage
Monitor voice changes
Supplement thyroid hormone
Monitor for hypocalcemia
What is normal for thyroid hormone levels post thryoidectomy
A surge of thyroid hormone can temporarily occur
Complications of thyroidectomy
Hemorrhage and hematoma
Edema in airway
Changes in calcium metabolism d/t manipulation of parathyroid
DM is the leading cause of
Adult blindness
End-stage renal disease
Lower limb amputations (nontraumatic)
DM is a major contributing factor of
Heart disease
Stroke
HTN
High cholesterol
What factors may cause DM
Genetic
Autoimmune
Environmental
Virus
Where is insulin produced
Beta cells in islet of Langerhans
Daily amount of insulin secreted by adult
40-50 U
Insulin function
Promote glucose transport from bloodstream across cell membrane to the cytoplasm of the cell
Where is excess glucose stored
Liver and muscle cells store glucose as glycogen
What does increased insulin do
Inhibits gluconeogenesis
Enhances fat deposition
Increases protein synthesis
What does decreased insulin do
Release glucose from liver
Release protein from muscle
Release fat from adipose tissue
What hormones are couterregulatory (opposite effect) to insulin
Glucagon
Epinephrine
Growth hormone
Cortisol
T2DM risk factors
Overweight/obese
Advanced age
Family hx
T2DM pathophysiology
Pancreas produces some endogenous insulin, but not enough produced
Body does not use insulin efficiently
T1DM pathophysiology
Absence of endogenous insulin d/t body developing antibodies against insulin and/or pancreatic beta cells
Metabolic syndrome
Increases the risk for T2DM
- Increased glucose levels
- Abdominal obesity
- High BP
- High level of triglycerides
- Decreased levels of HDLs
3 of 5 components = metabolic syndrome
Normal impaired glucose tolerance range for prediabetes
140-199 mg/dL
Normal fasting glucose for prediabetes
100-125 mg/dL
When does gestational diabetes resolve
6 wks postpartum
Gestational diabetes risks
Increased risk for C section and perinatal/neonatal complications
When is gestational diabetes dx during pregnancy
24-28 wks
What does gestational diabetes put you at risk for later in life
63% change of getting T2DM within 16 years
Other types of DM
Injury/destructino of beta cell function in pancreas
Medical conditions/drugs
- Resolves when underlying condition is treated
Symptoms of T1DM
Polyuria
Polydipsia
Polyphagia
Weight loss
Weakness
Fatigue
Ketoacidosis
Symptoms of T2DM
Nonspecific symptoms:
Fatigue
Recurrent infection
Recurrent vaginal yeast or candida infection
Prolonged wound healing
Visual problems
Rapid acting insulin
lispro (Humalog)
aspart (Novolog)
glulisine (Apidra)
Short acting insulins
Regular (Humulin R, Novolin R)
Intermediate acting
NPH (Humulin N, Novolin N)
Long acting
glargine (Lantus)
detemir (Levemir)
1-2x/day
Do not mix with other insulin
Inhaled insulin
Afrezza
When to use bolus of insulin
Rapid acting or short acting before meals
When to give basal dose of insulin
Intermediate or long-acting insulin 1-2x/day
Insulin storage
Extreme temps make insulin less effective
Can be left at room temp for 4 wks
Refrigerate extra unopened insulin
Avoid direct sunlight
Why is insulin given SQ
IM injection can cause hypoglycemia
Why can insulin not be given PO
Inactivated by gastric fluid
Regular insulin route
Can be given IV
How often to change insulin pump
Every 2-3 days
How often to check BG throughout day with insulin pump
4-8x/day
Nursing considerations for insulin pumps
Infection risk at insertion site
Risk for DKA
Costs
Being attached to a device
AE of insulin
Hypoglycemia
Allergic reactions
Lipodystrophy - loss of fatty tissue, atrophy
Hypertropy of SQ tissue - overuse of site
Somogyi effect
High dose of insulin causes glucose to drop at night
Counterregulatory hormones cause rebound hyperglycemia
Dawn phenomenon
Morning hyperglycemia
May be due to release of counterregulatory hormones in predawn hours (growth hormone and cortisol)
Afrezza
Rapid acting inhaled insulin
Used in combo with long-acting insulin
AE of Afrezza
Hypoglycemia
Cough
Throat pain
Irritation
Contraindications for Afrezza
Tx of DKA
Smokers
Asthma/COPD - risk of bronchospasm
Metformin uses
Most effective 1st line tx for T2DM
Used for prevention of T2DM
Metformin (glucophage) routes
Immediate release
Extended release
Liquid
Metformin (glucophage) MOA
Reduces glucose production by liver
- Enhances insulin sensitivity
- Improves glucose transport
- May cause weight loss
Metformin (glucophage) alerts
Withhold for surgery/radiologic procedure
Metformin (glucophage) contraindications
Renal, liver, cardiac disease; lactic acidosis
Iodine based contrast medium can cause AKI
Excessive alcohol intake
Metformin (glucophage) nursing considerations/education
Take with good to minimize GI side effects
Sulfonylureas MOA
Increases insulin production from pancreas
Sulfonylureas SE
Hypoglycemia
Sulfonylureas examples
Glipizide (Glucotrol)
Glyburide (Glynase)
Glimepiride (Amaryl)
Meglitinides MOA
Increases insulin production from pancreas
What is the benefit of Meglitinides having a rapid onset
Decreases risk of hypoglycemia
Meglitinide pt education
Take 30 minutes to just before each meal to mimic normal response to eating
Do not take if skip a meal
Meglitinide examples
Repaglinide (Prandin)
Nateglinide (Starlix)
α-Glucosidase Inhibitors MOA
“Starch blockers”
Slow down absorption of carbohydrate in small intestine
α-Glucosidase Inhibitors patient education
Take with first bite of each meal
α-Glucosidase Inhibitors nursing consideration/education
Check 2 hour postprandial glucose to determine effectiveness
α-Glucosidase Inhibitors examples
Acarbose (Precose)
Miglitol (Glyset)
Thiazolidinediones MOA
Improve insulin sensitivity, transport, and utilization at target tissues
Thiazolidinediones examples
Pioglitazone (Actos)
Rosiglitazone (Avandia)
Thiazolidinediones uses
Most effective in those with insulin resistance
Rarely used because of adverse effects
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors MOA
Block reabsorption of glucose by kidney
Increase urinary glucose excretion
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors examples
Canagliflozin (Invokana)
Dapagliflozin (Farxiga)
Empagliflozin (Jardiance)
What lifestyle modification can improve insulin sensitivity in T2DM
Wt loss of 5-7%
How to monitor effectiveness of therapy for T2DM
Blood glucose levels
A1C
Lipids
BP
Effect of alcohol on insulin/DM
Inhibits gluconeogenesis by liver
- Severe hypoglycemia
- Eat carbs when drinking
Recommended alcohol intake for DM
1 drink/day for women
2 drink/day for men
Risk during exercise (DM)
Hypoglycemia
When to delay activity for T1DM
If glucose is below 250 and ketones present in urine
When to self-test blood glucose
Before meals
Two hours after first bite
When hypoglycemia is suspected
Every 4 hours during illness
Before and after exercise
How often should diabetics check BG during illness
Every 4 hours
When and how often should diabetics check for ketones during illness
If glucose is over 240 check ketones every 3-4 hours
When should diabetic call HCP
If two consecutive BG are over 400 or if they have mod-high urine ketone levels
What is the risk for T1DM during illness
DKA d/t increased BG levels
What is the risk for all diabetic pts during illness
Risk of infection
Reduced healing
Nursing consideration for unconscious diabetic pt
Frequently monitor BG
Monitor for hypoglycemia: sweating, tachycardia, tremors
What condition may require pancreatic transplant
T1DM with ESRD and kidney transplant
Criteria for pancreas transplant
If no renal failure:
- Hx of acute/severe metabolic complications
- Incapacitating clinical/emotional problems with exogenous insulin
- Failure of insulin management
Islet cell transplantation
Donor islet cells infused into portal vein to liver
Effect of stress on glucose
Increases glucose secondary to counterregulatory hormones
Hypoglycemia Manifestations
Blood glucose < 70 mg/dL
Cold, clammy skin
Numbness fingers, toes, mouth
Tachycardia
Emotional changes
Headache
Nervousness, tremors
Faintness, dizziness
Unsteady gait, slurred speech
Hunger
Vision changes
Seizures, coma
Hypoglycemia causes
Alcohol intake without food
Too little food
Too much diabetes meds
Too much exercise without food
Diabetes med or food at wrong time
Loss of weight without med adjustment
Use of -adrenergic blockers interfering with symptoms
Hypoglycemia at home tx
Eat or drink 15 g of rapid-acting carbohydrates
Wait 15 minutes, check glucose
If less than 70 mg/dL, eat or drink another 15 grams of carbohydrates
If stable and meal more than 1 hour away or involved inn activity; give carbohydrate and protein
When hypoglycemic pt should call HCP/EMS
If glucose remains low after 2-3 times
Tx for acute care or unresponsive hypoglycemic pt
IV D50
IM glucagon
Hyperglycemia Manifestations
Elevated blood glucose
Increased urination
Increased appetite followed by lack of appetite
Weakness, fatigue
Blurred vision
Headache
Glycosuria
Nausea and vomiting
Abdominal cramps
Progression to DKA or HHS
Mood swings
Hyperglycemia causes
Illness, infection
Corticosteroids
Too much food
Too little or no diabetes meds
Inactivity
Emotional or physical stress
Poor absorption of insulin
Diabetic Ketoacidosis (DKA) cause
Profound deficiency of insulin
Most likely population for DKA
T1DM
DKA Precipitating factors
Illness
Infection
Inadequate insulin dosage
Undiagnosed type 1 diabetes
Lack of education, understanding, or resources
Neglect
DKA pathophysiology
Body burns fat as fuel
By-product of fat metabolism—acidic ketones alter pH (metabolic acidosis)
Ketones excreted in urine along with electrolytes
Impairs protein synthesis, causes protein degradation resulting in nitrogen loss from tissues
DKA complications
Hypovolemia followed by shock may cause renal failure, causing retention of ketones and glucose and further acidosis
Dehydration, electrolyte imbalance, and acidosis causes coma and if not treated, death
DKA manifestations
Dehydration
- Poor skin turgor
- Dry mucous membranes
- Tachycardia
- Orthostatic hypotension
DKA early signs
Lethargy and weakness
DKA manifestations as it progresses
Skin dry and loose; eyes soft and sunken
Abdominal pain, anorexia, nausea/vomiting
Kussmaul respirations
Sweet, fruity breath odor (acetone)
Blood glucose level of greater than or equal to 250 mg/dL
Blood pH lower than 7.30
Serum bicarbonate level less than 16 mEq/L
Moderate to high ketone levels in urine or serum
DKA tx
Replace potassium before starting insulin (insulin drives K into cells = hypokalemia)
IV regular insulin to correct hyperglycemia and ketosis
Long term complications of diabetes
Stroke
Retinopathy, cataracts, glaucoma, blindness
HTN
Dermopathy
CAD
Gastroparesis
Atherosclerosis
Islet cell loss
Nephropathy
Erectile dysfunction
Neurogenic bladder
Peripheral neuropathy
Peripheral vascular atherosclerosis
Gangrene
Infections
Angiopathy
Chronic complication of DM
Damage to blood vessels secondary to chronic hyperglycemia
Leading cause of diabetes-related death
Two categories of angiopathy
Macrovascular
Microvascular
Annual exams for diabetics
Retinopathy
Nephropathy
Neuropathy (comprehensive foot exam)
Cardiovascular risk factor assessment
As needed or every visit to HCP exams for diabetics
Foot and lower extremity exam
Exercise stress testing
Daily exam for diabetic pts
Self foot exam
Leading cause of end-stage renal disease in U.S.
Nephropathy d/t diabetes
- 20% to 40% of people with diabetes have it
Nephropathy risk factors
Hypertension
Genetics
Smoking
Chronic hyperglycemia
Monitoring for nephropathy
Annual screening for albuminuria and albumin-to-creatinine ratio
Drugs for albuminuria from nephropathy
ACE inhibitors
or
Angiotensin II receptor antagonists
When to screen T2 diabetic for neuropathy
At time of diagnosis
When to screen T1 diabetic for neuropathy
5 years after diagnosis
Distal symmetric polyneuropathy
Most common form
Both hands or feet are affected
Paresthesias
tingling, burning, itching
“walking on pillows” or numb feet
Sensory Neuropathy
Manage BG
Drugs:
Topical creams
TCA’s
SSRI’s and NRI’s
Antiseizure meds
pregabalin (Lyrica)
Autonomic neuropathy complications
Bowel incontinence
Urinary retention - neurogenic bladder
Gastroparesis - N/V, anorexia, GERD
CV - postural hypotension, resting tachycardia, painless MI
ED, decreased libido, vaginal infections
Urinary retention/neurogenic bladder d/t diabetes tx
Credé’s maneuver - manual pressure to abd
Cholinergic agonists
Self-catheterization
Thrombocytopenia common nursing dx
Risk for bleeding
Causes of thrombocytopenia
Blood disorders - dyscrasias
Chemotherapy
Manifestations at different platelet levels
Symptoms present when under 50,000
Under 20,000 = spontaneous bleed
Under 5,000 = CNS/GI bleed
Thrombocytopenia nursing interventions
Platelet transfusion
Reduce blood loss - needles, gums, invasive procedures
Fall precautions
Thrombocytopenia complications
Hemorrhagic stroke
Shock
GI Bleed
Joint bleeds
Hemophila patho
Deficiency in a coagulation factor
Von Willebrand patho
Disorder of coagulation proteins
Hemophila & Von Willebrand assessment findings
Prolonged bleeds after:
Dental procedures
Minor trauma
Nosebleed
GI ulcers
SubQ hematomas
How to dx Hemophila & Von Willebrand
Deficient clotting factors on coagulation studies
Causes of Hemophila & Von Willebrand
Genetic link
Hemophila & Von Willebrand tx
Prevent bleeding
Genetic counseling
DDAVP - Desmopressin
Antifibrolynics
Hemophila & Von Willebrand pt education
Bleeds monitored for 72 hours
Notify surgeon before procedures
Prophylactic coagulation factor replacement
Immobilize bleeding joints
Disseminated Intravascular Coagulation patho
Not a disease but a sign of an underlying disorder
Increase in clotting combined with an increase in bleeding
Disseminated Intravascular Coagulation causes
Sepsis
Trauma
Shock
Cancer
Abruptio placentae
Toxins
Allergic reactions
Disseminated Intravascular Coagulation assessment findings
Bruising, hemoptysis, tachycardia & hypotension, bloody stools, hematuria
Manifestations of clotting - DIC
Tissue necrosis
Diminished pulses
Pulmonary embolism
Abdominal pain, diminished bowel sounds
DIC nursing interventions
Continuous cardiac monitor
Two large bore IV
Continuous O2 and BP monitoring
Platelet transfusion - for severe blleds
Cryoprecipitate or FFP
Heparin
Myeloid cells become
Granulocytes: Neutrophils, Eosinophils, Basophils
RBC
Platelets
Lymphoid cells become
Agranulocytes:
Lymphocytes - T cells, B cells, and Monocytes
Natural killer cell
Leukemia patho
Abnormal growth of WBC’s
Normal during infections, abnormal if no infection is present
What does leukemia cause
Leukocytosis
Lymphoma
Neoplasms of lymphoid tissue, usually derived from B lymphocyte
Multiple myeloma
Malignancy of plasma cell
Leukemia cause
Many causes
Disease traced back to one type of stem cell
Types of leukemias
Acute myeloid leukemia
Chronic myeloid leukemia
Acute lymphocytic leukemia
Chronic lymphocytic leukemia
Acute leukemia is more common for
Children and young adults
- More fatal
Chronic leukemia is more common for
25-60
Dx for leukemia
CT scan - shows enlarged lymph nodes
PET scan - metabolic activity
Abnormal WBC symptoms
Frequent, severe infections
Leukocytes under 15,000
Enlarged liver and spleen
Symptoms of reduced RBC and/or platelets
Weakness, pallor, weight loss
Fatigue, lethargy, hypoxia
Bruising and hemorrhage
General s/sx of WBC imbalance in later stages
CNS changes
Renal failure
Leukemia dx
Bone marrow biopsy
Blood smears
CBC diff showing leukocytosis
Acute Lymphocytic Leukemia complication
Severe neurological symptoms
Chronic Myelogeous Leukemia
Occurs in stages:
Chronic stage can be controlled with meds
Blastic phase - acute drop in all cell counts
Cause of Chronic Myelogeous Leukemia
Philadelphia chromosome
Chronic Lymphocytic Leukemia s/sx
Can be asymptomatic
Lymph nodes enlarged
Chronic fatigue
Liver/spleen enlargement
B symptoms: fevers, drenching sweats (especially at night), and unintentional weight loss
Leukocyte tx options
Chemotherapy
Total body radiation
Stem cell transplant
Palliative
Induction therapy
Hard core chemo that destroys all abnormal leukemia cells
Similar to stem cell transplant
- Focus on neutropenia, thrombocytopenia and anemia
What to expect after induction chemotherapy
Intensification
Consolidation
Maintenance low doses to maintain leukemia-free cells
Cause of stomatitis and oral irritation
Gingival hyperplasia and chemo
- Frequent oral care
- Monitor for bleeding
When to implement neutropenic precautions
ANC (absolute neutrophil count) under 1,000
Neutropenic precautions
“Reverse isolation” keep pt from outside
No raw meats, fresh fruit, plants, vegetables
Avoid crowds
Handwashing
Minimize invasive devices - foleys
Avoid vaccinations and recently vaccinated people
Oral hygiene, avoid dental procedures
Cause of fatigue and activity intolerance in neutropenic precaution
Anemia, chronic infections, and chemotherapy
- Iron supplements
Pharmacological tx for chemotherapy/neutropenia
Filgrastim - for decreased ANC
Erythropoietin - for decreased RBC
Prophylactic antibiotics and antifungal
Most common type of lymphoma
Non-Hodgkin’s
Hodgkin’s lymphoma
Rare malignancy, high cure rate
Reed-Sternberg cells: abnormal cells found in lymph nodes (B-cell origin)
Cause of Hodgkin’s lymphoma
Virus
Hodgkin’s lymphoma manifestations
Painless lymph node enlargement
Pruritus
B symptoms: fever, night sweats, weight loss
Pain on ETOH ingestion
Nursing management and tx of Hodgkin’s lymphoma
ABVD regimen of chemo
Radiation therapy for localized lymph node disease
Secondary malignancies common
Address fertility issues
Non-Hodgkin’s lymphoma patho
Lymphoid tissues become infiltrated with malignant cells
Spread is unpredictable and localized disease is rare
Can originate outside of lymph nodes
Non-Hodgkin’s common population
Increases with age
Average age is 66 years old
Non-Hodgkin’s s/sx
Symptoms may depend on where lymph node masses spread
- Hepatomegaly
- Splenomegaly
- Renal failure
Non-Hodgkin’s dx
Bone marrow biopsy
Lumbar puncture
Organ biopsy
Non-Hodgkin tumor responses to tx
More aggressive tumors are more likely to respond to tx
T cells lymphomas are more difficult to tx
Non-Hodgkin’s tx
Manage symptoms
- Pain, bleeding, infection
- Monitor for bowel perforations
- Care for radiation sites
Multiple Myeloma patho
Plasma cells destroy the bone marrow
These create monoclonal B-cells that cannot fight infection
Cytokines engage in abnormal bone destruction
Multiple Myeloma s/sx
Bone pain in pelvis, spine and ribs
Osteoporosis and fractures related to bone destruction
- Hypercalcemia
Hyperviscosity syndrome
Multiple Myeloma dx
M proteins in blood
Bence-Jones proteins in urine
Decreased bone density on imaging
Multiple Myeloma tx
Corticosteroids, chemo, immune therapy and targeted therapy
Multiple Myeloma nursing interventions
Treatment for bone density:
- Ambulation and weight bearing exercise
- Monitoring for complications of hypercalcemia
- Hydration to improve renal function
Target UOP
Pain management: Peripheral neuropathy
High dose chemotherapy followed by HSCT
Essential thrombocytopenia patho
AKA primary thrombocythermia
Stem cell disorder within the bone marrow
Essential thrombocytopenia cause
Unknown
Essential thrombocytopenia population
Affects women more than men
Median age 65 to 70 years old
Essential thrombocytopenia symptoms
Vascular occlusion
Headaches
Enlarged spleen
Hemorrhage
Essential thrombocytopenia nursing consideration
Risk for developing thrombosis or hemorrhage
Primary Myelofibrosis patho
Chronic myeloproliferative disorder within the stem cell
Primary Myelofibrosis population
Disease of older adults 65 to 70 years; survival rate 2 to 10 years
Primary Myelofibrosis symptoms
Enlarged spleen
Fatigue
Pruritus
Bone pain
Weight loss
Infection
Bleeding
Cachexia
Pancytopenia common
Primary Myelofibrosis tx
Decrease symptoms and splenomegaly
Improve blood count
Splenectomy for significant problems
Types of genes (r/t cancer)
Protooncognes: Normal cell genes, important regulators in cell process, promotes growth
Tumor suppressor genes: Prevent tumor formation
Onco-genes
Mutants of protoncognes that create malignant cells
How are these genes changed during cancer
Onco-genes are turned ON
Tumor suppressor genes are turned OFF
CAUTION warning signs of cancer
Change in bowel and bladder habits
A sore that does not heal
Unusual bleeding or discharge
Thickening or lump in tissue
Indigestion or difficulty swallowing
Obvious change in wart or mole
Nagging cough or hoarseness
Breast cancer screening guidelines
Begin screening when you choose
Yearly mammograms by age 45
Every other year mammograms at 55
Colon cancer screening guidelines
Over 50
African American - greater risk
Family hx
Prostate cancer dx
PSA - Prostate specific antigen
Protein produced by the prostate gland
Increased = prostate cancer/condition
Prostate biopsy
Types of biopsy
Fine needle
Surgical
Endoscopic
TNM classification
Tumor size
Lymph node status
Metastasis
Radiation uses
Isolated tumors
Reduction in tumor size
Instill radiation in body cavities
Types of radiation
Electromagnetic
Particulate
High energy x-ray
Different uses for low and high energy beams (radiation)
Low energy beams for external or superficial tumors
High energy beam for internal tumors
External radiation pt teaching
Irritation at radiation 1-24 hours after treatment
- Frequent skin assessment
Unscented, mild soaps
- No lotion/deodorant
Avoid sunlight, temperature extremes
Avoid rough washcloths and tape
Brachytherapy
Radiation “seeds” are implanted at the cancer site
Sealed sources of radiation placed near the tumor
Unsealed radiation
Type of internal radiation
Ingested or instilled in body cavity
ALARA
As low as reasonably achievable
- Reduce radiation
Radiation nursing considerations/safety
Stay in room for no longer than 30 mins
Door closed
Visitors 6 ft
Private room
Disposable trays
Keep linen in room
Radiation warning sign
Avoid pregnant nurses
Dosimeters can be worn with lead apron
Implanted brachytherapy seed nursing consideration
Bedrest while implant in place
Ensure location of implant
Body fluids are not radioactive
Methods of chemo administration
Intra-arterial
Intraperitoneal
Intrathecal - bypasses blood brain barrier
Intravesical bladder chemo
Chemo side effects
Hair, skin and nails
GI mucosa
Bone marrow cells: RBC, WBC, Platelets
- D/t destruction of all rapidly growing cells
Anaphylaxis, extravasation
Organ toxicity
Stomatitis nursing interventions
Frequent oral care
Soft bristled toothbrush
Baking soda + saline after meals
Avoid acidic or spicy food
Avoid extremes in temperature
Chemo nutrition considerations
Small, frequent meals - high protein, high calorie
Cachexia: muscle wasting
Monitor wt and nutrition labs - albumin, prealbumin
Monitor I&O’s for dehydration
Chemo skin potential reactions
Erythema: redness of affected area
Wet desquamation: Exposure of underlying dermis
Hand-foot syndrome: redness/swelling
Extravasation: Many chemos are irritants or vesicants
Nursing considerations/interventions for extravasation (during chemo)
Use central lines for chemo
Extravasation kit at bedside - warm/cold compress, antidote meds
Stop infusion and notify HCP for pain, redness, swelling
SE of chemo/radiation
- Bone marrow suppression
Neutropenia
Thrombocytopenia
Anemia
Priority intervention for chemo/radiation
Infection
All blood cell types can be transfused except for
WBC
What level indicates neutropenia
ANC (absolute neutrophil count) under 1500mm3
Certain infection when ANC under 100mm3
What lab shows need for neutropenia isolation
WBC under 1000
Neutropenia tx
Depends on cause:
Remove offending meds
Tx bone marrow cancer
Hospital admission with cultures and CXR for suspected infection
Platelet labs levels and what they indicate
Below 150,000 = thrombocytopenia
Below 50,000 = increased risk of bleeding
Below 20,000 = spontaneous bleed
When is the typical onset of anemia after chemo
3-4 months after chemo is started
Anemia tx
erythropoetin (EPO) to stimulate RBC growth
RBC transfusion - last resort
Fatigue tx (chemo)
Treat anemia
Correct electrolyte imbalances
Cluster care
Establish a sleep/wake cycle
Maintain light daily activity as tolerated
Late effects of chemotherapy
- months or years after
In liver, kidneys, bone, heart muscle
Cataracts
Cardiac toxicity
Osteoporosis
Secondary malignancies
Immunotherapy for cancer (prototypes)
Interleuken-2 (IL2)
Rifuximab
Types of immunotherapy
Cytokines
Vaccines
Monoclonal antibodies (drugs ending in –mab)
Immunotherapy SE’s
Flu-like symptoms
- Tylenol or IV Demerol
Infusion related symptoms
Fever
Chills
Urticaria
Muscosal congestion
N/D
What is the tx for cancer that fails to respond to chemo
Hematopoietic stem cell transplant or
Bone marrow transplant
Myelosuppression
Performed on transplant recipients
Eliminates existing stem cells - similar effect as chemo
Graft-vs-Host Disease
Major cause of morbidity and mortality in the allogeneic transplant population
Donor lymphocytes initiate immune response against the recipient’s tissues (skin, gastrointestinal tract, liver) during the beginning of engraftment
Preventions of graft-vs-host disease
Immunosuppressant drugs - such as cyclosporine
Acute vs chronic graft-vs-host disease
Acute: within 100 days
Chronic: after 100 days
Superior vena cava syndrome
Obstruction of superior vena cava. Common causes are lung cancer, non-Hodgkin lymphoma
Hypoproliferative anemia
Abnormal RBC’s are produced then destroyed
Hemolytic anemia
Destruction of RBC’s
RBC’s appear normal
Increase in byproducts of RBC breakdown - bilirubin
Increase in immature RBC’s
Iron deficiency anemia patho
Inadequate dietary iron
Inadequate iron absorption
Blood loss
RBC destruction
Iron deficiency anemia specific assessment
Pallor
Inflammation of the tongue
Inflammation of the lips
Burning of tongue
Paresthesias
Iron deficiency anemia dx
Hgb, Hct, RBC below normal
Serum iron
Serum ferritin
RBC smears
Stool exam
Iron deficiency anemia causes
History of GI bleeds, heavy menses, peptic ulcers iron loss
What foods are good/bad for anemia
ETOH - blocks iron absorption
Red meat, leafy greens - good sources of iron
Iron deficiency anemia tx
Iron supplementation
Iron pill + calcium + stool softener
IM or IV iron
Thalassemia patho
Abnormal hemoglobin production causes decreased O2 delivery
Abnormal cells are destroyed in spleen
Thalassemia specific assessment
Pallor, deficits in growth and development
Jaundice
Bone marrow hyperplasia
Thalassemia dx
Small, pale RBCs
Hgb < 10 = transfusion
Bone marrow biopsy
Thalassemia cause
Genetic link – Mediterranean, north African, southeast Asian
Thalassemia tx
Frequent blood transfusion
Chelation therapy for iron overload
Monitor for DVT, s/s heart failure
Splenectomy
Megaloblastic Anemia patho
Lack of B vitamins leads to abnormally large RBCs that are destroyed in circulation
Megaloblastic Anemia specific patho
Sore, red, beefy tongue
Nausea and vomiting, abd pain
Paresthesias
Neuro changes
Pernicious = potentially fatal
Megaloblastic Anemia dx
Large RBCs on smear
Folate levels
Anti-IF antibodies
Megaloblastic Anemia causes
Dietary intake of folate
Scandinavian or African American
Family history
GI s/s and food diary
Megaloblastic Anemia tx
Pernicious anemia: IM B12 injections 2x week
B vitamin supplementation for inadequate dietary intake
Chronic anemia patho
Chronic infection, inflammation, disease leads to decreased RBC production
Chronic anemia specific assessment
Presence of 1 or more chronic diseases
Chronic anemia dx
Decreased RBC production with no other distinct cause of anemia
Iron levels normal
IF present
B vitamin levels normal (same as aplastic anemia)
Chronic anemia causes
1-2 month history of disease
Kidney disease
Chronic anemia tx
Correct underlying disorder
Anemia d/t renal disease patho
Decreased erythropoietin production
EPO stimulates RBC production
Aplastic Anemia patho
Bone marrow disorder causes decreased production of all cells
Aplastic Anemia specific assessment
Presence of 1 or more chronic diseases
Aplastic Anemia causes
Frequent bleeding
Frequent infection
Underlying disorders
Aplastic Anemia dx
Decreased RBC production with no other distinct cause of anemia
Iron levels normal
IF present
B vitamin levels normal (same as chronic anemia)
Aplastic Anemia tx
Correct underlyingdisorder
Bone marrow transplant
Anemia d/t acute blood loss patho
Trauma, surgery, esophageal varices causes acute anemia
Anemia d/t acute blood loss specific assessment
Sudden blood loss of 30% of Hgb can cause s/s of shock
Anemia d/t acute blood loss causes
Recent bleed
Anemia d/t acute blood loss tx
PIV x2 and resuscitation fluids
Blood transfusion
Correct underlying bleed
Albumin or Dextran
Platelet or plasma transfusion
Continuous cardiac monitor and frequent VS
Anemia d/t chronic blood loss patho
Slow GI bleed, menstrual bleeding, similar to iron deficient
Meds, ETOH
Anemia d/t chronic blood loss specific assessment
Gradual blood loss of up to 50% blood volume may only cause mild s/s
Anemia d/t chronic blood loss dx
S/s specific diagnostic tests
Anemia d/t chronic blood loss tx
Identify and treat cause of bleed
May lead to iron deficient anemia
Where does RBC breakdown happen
Spleen and liver
What does an excess of RBC’s cause
Hepatomegaly
Splenomegaly
Sickle Cell Disease cause
Genetic - primarily affects African descent
Abnormal genes make RBCs that “sickle” when O2 concentrations get low
Sickle cell crisis
Severe clots and reduced circulations leads to tissue death
Things that affect sickled cells
Infection
High altitude
Heavy exercise
Stress
Surgery
Dehydration
Sickle cell disease s/sx
Chest pain, tachycardia
Pulmonary embolism, tachypnea - supplement with O2
Enlarged liver, gallstones
Damaged kidney - increased BUN/creat, decreased UOP
Grey skin, jaundice
Sickle cell disease dx
(+) Hgb-S
Sickled cells on smear
Chronic anemia
Bone and joint deformities
Primary concern for sickle cell disease
Respiratory failure
Hospital interventions during acute sickle cell disease episodes
IV abx
Continuous O2 - lung assessments
Rest
Anticoagulants
IV fluids - hydration
Monitor renal labs
Folic acid supplements
Sickle cell disease complications
Avascular necrosis – death of femoral head
Venous stasis ulcers
Iron overload
Changes in vision
Priapism
Sickle cell disease tx
Stem cell transplant
Hydroxyurea promotes normal Hgb growth
Acquired Hemolytic Anemia patho
Destruction of RBC from outside factors
Acquired Hemolytic Anemia tx
Immunosuppression
Folate replacement
Remove cause if possible
Acquired Hemolytic Anemia dx
Elevated bilirubin and decreased RBC
Acquired Hemolytic Anemia specific assessment
Jaundice
Acquired Hemolytic Anemia causes
Dialysis
Radiation
Poisoning
Heart valves - ask about hx
Antibodies
Hemachromatosis patho
Iron overload
Can be secondary to blood transfusion
*likely don’t need to know this condition, skip over
Hemachromatosis specific assessment
Fatigue, joint pain, weight loss, cirrhosis
Bronze skin
Hemachromatosis dx
Iron levels > 6g and up to 50g
Hemachromatosis causes
Genetic link
History of anemic disorders with transfusion
Hemachromatosis tx
Therapeutic phlebotomy
Chelating agents
Polycythemia patho
Excess RBC production leads to sludgy blood
Secondary – excess RBC production d/t chronic hypoxia
Polycythemia specific assessment
Headache, dizziness, tinntus, vision changes
Itching and flushing
Chest pain and heart failure
DVT formation
Polycythemia dx
Elevated RBC and Hgb
Microcytosis
Low EPO levels
Polycythemia tx
Phlebotomy to target Hct < 45-42
Hydration
Polycythemia causes
Genetic link
History of anemic disorders with transfusion
Where are blood cells formed
Bone marrow
Where does the breakdown of RBC’s occur
Spleen and liver
Where are immune cells formed
Lymph system
RBC’s are also called
Erythrocytes
What controls RBC production
Erythropoietin
Released by kidneys
Normal hct
35-50%
Normal hgb
11-17
Normal RBC
4.5-5.7
Normal MCV
80-100
Mean corpuscular volume
- Size of RBC
Types of lymphocytes
B cells
T cells
Natural killer (NK)
Normal neutrophil count
4,500 - 7,000
Low = risk of infection
Normal platelet count
150,000 - 400,000
Normal aPTT
25-35 sec
Normal PT
11-16 sec
Normal INR
Below 1.1
2-3 in anticoagulated pts (warfarin)
What level of Hgb diagnosis each severity of anemia
Mild anemia = Hgb 10-11
Moderate anemia = Hgb 7-10
Severe anemia = Hbg under 7 (transfusion)
What does adrenal medulla release
Catecholamines - dopamine, norepinephrine, and epinephrine (adrenaline)
Sympathetic NS stimulation
What does the adrenal cortex release
Steroid hormones - Glucocorticoids, mineralocorticoids, progestins, androgens, and estrogens
What do glucocorticoids/corticosteroids do
Inhibit inflammation
Controls metabolism and stress response
What does too little glucocorticoids/corticosteroids do
Causes an inability to respond to stress
What does too much glucocorticoids/corticosteroids do
Suppress the immune response
What do mineralcorticoids do
AKA aldosterone
Regulates Na, K, and water
What does too much mineralcorticoids do
Increased Na, increased BV, decreased K
What does too little mineralcorticoids do
Decreased Na, decreased BV, increased K
Pheochromocytoma
Benign tumor in the adrenal medulla
Pheochromocytoma s/sx
5H:
Hypertension
Headache
Hyperhidrosis
Hypermetabolism
Hyperglycemia
Pheochromocytoma dx
Elevated urine and plasma catelcholamines
- Measured with 24 hr urine collection
Clonidine suppression test
Pheochromocytoma nursing interventions
Bed rest
Raise HOB
Pheochromocytoma med tx and what to monitor for after administering
Alpha and beta blockers
- Monitor for orthostasis, nasal drainage, fatigue
Pheochromocytoma surgical tx
Removal of adrenal glands
Adrenalectomy nursing considerations
Pre-op: Hydration to control HTN
Calcium channel blockers to supplement Beta-blockers
10-14 days of BP control before adrenalectomy
What is the endocrine process that stimulates the adrenal glands
Hypothalamus secretes corticotropin-releasing hormone (CRH)
CRH stimualtes the pituitary gland to release adrenocorticotropic hormone (ACTH)
ACTH stimulates adrenal glands to release hormones
Addison’s Disease
Decrease in glucocorticoid production - inability to generate stress response
Decrease in aldosterone - dehydration
Addison’s Disease s/sx
Low glucocorticoids
- Decreased BG
- Fatigue, muscle weakness, depression
- Frequent infections
Low mineralcorticoids
- Decreased Na, dehydration
- Orthostatic hypotension
- Weak pulses
- Weight loss
Bronze mucous membranes
Addison’s Disease dx
ACTH stimulation test
→ACTH given IV, then blood is drawn to see if cortisol levels increase
-Decreased Na, increased K
-Increased BUN
Addison’s Disease tx
Lifelong hormone therapy
-Hydrocortisone is drug of choice
- “stress dosing”
Avoid high-stress activities
Addison’s Disease risk factors
Adrenal tumor, hemorrhage, tuberculosis
Long term corticosteroid use
Critically ill
Adrenal/renal hemorrhage
(anything that damages the adrenal gland)
Secondary Addison’s Disease cause
Damage to the pituitary gland causes decreased ACTH
Addison’s Disease diet
High sodium
Low potassium
Increase fluids
Adrenal Crisis patho
An acute drop in hormone production
Adrenal Crisis causes
Stressor during Addison’s disease
-Critical illness
Adrenal Crisis s/sx
Severe fatigue and weakness
Decrease in BP leading to shock
Hypoglycemia
Adrenal Crisis tx
IV dextrose and hydrocortisone replacement
Adrenal Crisis nursing interventions
V/S
Strict I/O’s
Daily wt
Prevent stress
Adrenal Gland Removal postop meds
Continuous corticosteroid replacement with solumedrol or prednisone
- Avoids rebound Addison’s disease
Cushing’s Disease patho
Excessive steroid hormone activity
-Increase in gluco- and mineral-corticoids
Cushing’s Disease causes
Adrenal hyperplasia
Excessive steroid administration
Pituitary tumor
Cushing’s Disease s/sx
Central obesity, “buffalo hump”, thin extremities
Fragile, thin skin, ecchymosis, striae
Weakness, personality/mood changes
Osteoporosis, muscle wasting, HTN
Moon-face, acne, infection, slow healing
Virilization in women, loss of libido
Increased Na, decreased K
Cushing’s Disease dx
Serum and urine cortisols, dexamethasone (decadron) suppression test
-Decadron test given overnight to measure cortisol release
-Urine cortisol is 24 h collection
Cushing’s Disease tx
Pituitary removal or adrenalectomy
Cushing’s Disease nursing interventions
Monitor VS, daily weight, blood glucose
Close monitoring for early signs and symptoms of infection
Emotional support for body changes
Cushing’s post-op tx
Supplemental steroid hormones
Monitor for rebound Addisonian crisis - extreme hypovolemia leading to shock
Organs that pituitary gland stimulates
Adrenal glands
Thyroid gland
Ovaries/Testes
Bone and soft tissues
Anterior pituitary hormones
Adrenocorticotrophic hormone (ACTH)
Thyroid-stimulating hormone (TSH)
Luteinising hormone (LH)
Follicle-stimulating hormone (FSH)
Prolactin (PRL)
Growth hormone (GH)
Melanocyte-stimulating hormone (MSH)
Posterior pituitary hormones
Vasopressin - antidiuretic hormone (ADH)
Oxytocin
Panhypopituitarism
Decrease in all hormones of the pituitary gland, including all releasing and stimulating hormones
What is the difference between anterior and posterior pituitary gland disorders
Anterior: Chronic, long term management
Posterior: Acute, hospitalization
Acromegaly
Oversecretion of GH from anterior pituitary
Dwarfism
Decrease in GH
Diabetes insipidus dx
Plasm and urine specific gravities
Fluid deprivation test: water held for 8-12 hours
- DI will have large urine volumes
Diabetes insipidus tx
Correct fluid imbalance
Long term: DDVAP - synthetic ADH, nasal spray
SIADH (Syndrome of inappropriate ADH)
Unable to dilute urine
Concentrated urine, diluted blood, third spacing
SIADH causes
Medications
Head injury
Brain surgery
Tumor
SIADH s/sx
Fluid retention, hyponatremia, concentrated urine
Weight gain, severe edema, pulmonary edema
Severe hyponatremia
Under 120
Neuro symptoms - seizures
N/V, cramps, muscle twitching
Pituitary tumor dx
CT
MRI
Serum hormone levels
Pituitary tumor tx
(Transsphenoidal) Hypophysectomy: removal of tumor through nasal passage
Hormone replacement
(Transsphenoidal) Hypophysectomy nursing considerations
Used for either hypo or hyper pituitarism
Removal of gland always leads to panhypopituitarism
- Lifelong hormone replacement
