Exam 2 Flashcards
Perfusion
refers to the flow of blood through arteries and capillaries, delivering nutrients and oxygen to cells.
Central Perfusion
Force of blood movement is generated by cardiac output
Requires adequate cardiac function, blood pressure and blood volume
Cardiac output (CO)
CO = Stroke Volume x Heart Rate
Stroke volume
volume of blood ejected from the left ventricle with each heartbeat
HR= Beats/min
After-load reflects the amount of resistance the ventricles have to contract against - also known as SVR( systemic vascular resistance)
- influence by diameter of blood vessels and blood volume*
An increase in after-load results in a decrease of stroke volume
Peripheral Tissue or Local Perfusion
Volume of blood that flows to target Tissues
pressure generated from each myocardial contraction supplies blood to peripheral vascular system
Valve in each vein keeps blood flowing in direction toward hear
Athrosclerosis
- Is fatty substances within the walls of the arteries
- starts when waxy cholesterol (atheromas) becomes deposited on the intima of the major arteries
Atheromas interfere with the absorption of nutrients by the endothelial cells that compose the vessel lining and obstruct blood flow
- can lead to angina, myocardial infarction, stroke or sudden cardiac arrest
- Associated manifestations related to area of impaired ciculation
Arteriosclerosis
is a thickening and loss of elasticity and hardening of the arterial wall
Impaired central perfusion
Occurs when cardiac output is inadequate
- reduced cardiac output results in a reduction of oxygenated blood reaching the body tissues ( systemic)
- if severe, associated with shock
- if untreated, leads to ischemia, cell injury and cell death
Perfusion Risk Factors
Modifiable:
- abdominal obesity
- high blood pressure
- diabetes
- high cholesterol
- psychosocial factors
- SMOKING
non-modifiable:
- ethnicity
- age
- gender
- family history
Assessment
-baselines history
problem-focused history
- pain
- dyspnea
- edema
- dizziness ( altered mental status)
- extremity changes ( temp, skin, color etc.)
Common diagnostic tests for heart
- doppler studies ( ankle-brachial index; ABI)
- Electrocardiogram ( ECG)
-Cardiac Stress test
(exercise or pharmacological test)
- Radiographic studies
(chest x-ray, ultrasound, arteriogram; cardiac Catheterization)
Laboratory Tests
- creatine phospho kinase (CPK)(measure of muscle breakdown)
- natriuretic peptides ( BrainNP, AtrialNP) - congestive heart failure?
- troponin (test for MI, measure of muscle breakdown)
- homocysteine- predicts the risk of coronary artery disease if level go up so does risk for plaque and clot formation ( protein in b12 metabolism?)
- c-reactive protein ( reflective of endothelial inflammation)
- serum lipids ( fat in blood)
- platelets (measure of coagulation)
Tests for Coagulability
- prothrombin time (PT)- extrinsic
- Partialthromboplastin time (PTT)- intrinsic
- international normalized Ratio (INR) (end hemostasis)
Troponin
Complex of three regulatory proteins integral for muscle contraction
Troponin I-used for myocardial damage
- Released after myocardial injury
- Levels are usually so low, cannot be detected
- The higher the troponin, the greater the damage
- Start to rise within hours after infarct (most within 6 hours after attack)
- If levels are normal within 12 hours - infarction unlikely
- Levels detectable for 10-14 days
- Levels drawn upon arrival to ER and repeated twice within a 12-16 hour window
C-reactive protein
- Reflective of endothelial inflammation
- Treatment to lower levels include: aspirin, smoking cessation, exercise, lipid lowering agents, Omega-3,
Homocystein
- Amino acid result breakdown of dietary protein
- When levels are elevated, blood clotting may increase and the vascular endothelium may be damaged
- Treat with folic acid/B vitamin complex (supplements/diet)
SERUM LIPIDS **
Triglycerides ( <150 mg/dl )
HDL ( 40-60 mg/dl) GOOOD
LDL ( <100) BADDDD
TC (<200) total cholesterol
Risk Factors= smoking , low HDL, family history of premature CHD and age
Electrocardiogram (EKG)
PQRST wave forms to asses cardiac function
-deviations form normal sinus rhythm can indicate heart abnormalities
Holter monitoring
- Recording of ECG rhythm for 24-48 hours to assess arrhythmias
- Normal patient activity during recording
- Recorder stores information
- Information analyzed
- Patient needs to keep diary of activities/any symptoms
- No bath or shower during monitoring
- Skin irritation may develop from electrodes
Echocardiogram
Ultrasound of heart structures, size, blood flow and ejection fraction
Ejection fraction
Percentage of blood volume that is ejected during systole
Normal : >55%
provides information about the left ventricle function
Trans-esophageal Echocardiography (TEE)
- Provides more precise information about the heart
- Flexible endoscope with an ultrasound transducer
- Used in inpatient and outpatient
- Contraindicated in patient with esophageal disorders
- Require conscious sedation
Exercise Stress Test
- Involves walking on treadmill
- ECG & BP recording included before during and after exercise
- Patient instructed to report any chest pain, SOB etc. immediately during procedure
- Wear comfortable shoes
- Light meal or NPO 2 hours prior
- No caffeine
- Avoid smoking prior to the test
- Some medications may be held
Stress Echo
- Same as exercise stress, but Includes echo ultrasound before and immediately after walking
- Pt. needs to get back on table as soon as exercises ceases so post exercise images can be obtained
Nuclear Stress Test
- injection of radioactive isotopes
- uptake is measured by a scan
- provides info regarding contractility, perfusion, and cell injury
- patient lays on back with arms extended overhead for 20 minutes, newer scans have seats
- involves exercise on treadmill or medications to simulate activity for patients with ambulation issues
- scans are repeated before and after exercise for comparison of images
Cardiac Catherization
Right-sided: Vein
Left-sided: Artery
- Views heart, chambers, O2 status and chamber pressures
- Involves insertion of a catheter and injection of contrast media and possible placement of stent
- Coronary angiogram – dye injected into coronary arteries to evaluate condition/blood flow
Pre-op Cath
Check for Allergies- shellfish
- pre-medicate
- baseline pulse assessment
- NPO 6-16 hrs prior
During Cardiac Cath
pt may be awake
- feeling warmth sensation
- maybe asked to cough as dye is passed
-may feel fluttering sensation
Post-care Cardiac Cath
CV assessment
- cath site care/pressure dressing
- observe for complications
- fluids
- flat ( if possible) bed rest 2-6 hrs
Primary Prevention
- Smoking and nicotine cessation
- Diet
- Exercise
- Weight control
- Monitor BP, Cholesterol levels, -Blood glucose
Secondary Prevention
- identify high risk patients
- blood pressure screen
- lipid screening
Collaborative Care
- Nutrition: heart healthy diet
- Activity/Exercise
- Smoking Cessation
Pharmacotherapy
- Vasodilators
- Vasopressors
- Diuretics
- Antidysrhythmics
- Cardioglycosides
- Anticoagulants
- Antiplatelets
- Thrombolytics
- Lipid Lowering Agents
Altered Peripheral (Tissue)Perfusion: Arterial Disorders
- Issue: poor perfusion and oxygenation
- Atherosclerosis is the leading cause in majority of cases
- Causes narrowing of the lumen, obstruction by thrombosis, plaque ulceration, aneurysm, rupture
Manifestations of Arterial Disorders
-Intermittent Claudication
-Thin, shiny, taut skin
-Loss of hair on the lower legs
-Diminished or absent pulses
-Skin changes related to color or temperature
“Dependent rubor”
“Elevation pallor”
-Ulcers (usually on toes or near toes, +pain, neurologic deficits present)
-Pain at rest
-Occurs in the foot or toes
-Aggravated by limb elevation
Nursing assistance
- Position affected part below heart level
- If edema is present, position slightly elevated but not above the heart
- Walking (Isotonic) exercises to promote circulation and development of collateral circulation
Carotid Artery Disease
-Risk of stroke
Manifestation: depends on size of obstruction
Diagnostic: Carotid duplex ultrasound, MRI, CT ( with contrast)
Carotid Endarterectomy (CEA) -opening the carotid artery and removing the obstructing plaque
Nursing care- monitor vitals, neuro status, pulses and bleeding
Peripheral Arterial Bypass
Operation with autogenous Vein to carry blood around the lesion or occlusion
Nursing care:
-important to asses for occlusion ( pulses, temp, cap refill, etc.)
-report of pain ( type of pain)
- bedrest for 18-24 hours
- check BP
- Notify surgeon immediately of abnormal findings
Reynauds
extreme sensitivity to Cold, aggravated by nicotine, emotion, chilling
- limited to hands and feet
- treatment and education related to preventing vasoconstriction
Thromboangiitis Obliterans or Buerger’s Disease
- non-arthrosclerotic
- recurrent inflammatory vaso-occlusive disorder resulting in microscopic occlusion (thrombi) of distal vessels of upper and lower extremeties
- caused by history of tobacco/marijuana use
Venous Disorders: venous thromboembolism (VTE)
Spectrum of pathology from DVT to PE
-watch for signs of pulmonary embolism
Virchow’s Triad
- Venous stasis
- Damage of endothelium
- Hypercoagulability of blood
-Pain, warmth, redness, and edema
Venous Thrombosis
formation of a thrombus in association with inflammation of the vein
superficial vein thrombosis(SVT)
- formation of thrombus in superficial vein
- generally benign
Deep Vein Thrombosis(DVT)
- formation of thrombosis in deep vein
- most commonly iliac and femoral veins involved
Venous Insufficiency disorders
Characteristics
- Results of prolonged venous hypertension that stretches the vein and damages the valves
- Difficulty eliminating waste
- Builds up in the tissues resulting in stasis, ulcers, edema, cellulitis, brownish “brawny” appearance
- Prominence of superficial veins
-Ulcers
Usually ankle area, +pulses, no claudication, no neurologic deficits
Venous insufficiency disorders
care and patient teaching
- Avoid sitting/standing for long periods
- Avoid trauma to limbs
- Elevate legs above level of heart to reduce edema
- Compression therapy
- Proper nutrition
- Exercise
- Collaborate with Wound Care specialist
Varicose veins
- VNUS procedure
- Laser
- Adhesive
Hypertension
sustained elevation of BP
Normal - <120/<80
systolic/diastolic
Pre-hypertension
120-139/ 80-89
Blood pressure
Force exerted by blood against walls of blood vessels
BP= CO x SVR
SVR- arteries’ resistance to blood flow
systolic
force of blood on arterial wall as heart contracts
Diastolic
Force as the heart relaxes to allow blood to flow into the heart
Primary Hypertension ( essential or idiopathic)
-95 % of all HTN
-usually >60 y.o.
-unknown cause
-examine contributing factors
( smoking, diet, stress, exercise)
Secondary HTN
- 5 % of all cases
- elevated BP with specific cause that can be identified and corrected
- suspected in persons <20 or >50 with sudden onset
Isolated systolic Hypertension
SBP >140 with average DBP <90
- increases with aging
- DBP decreases with aging after 55 years
- related to arteriosclerosis, valve disease
Hypertension Diagnostic criteria
Patients with sustain BP higher that 140/90 are considered to have hypertension and are candidates for drug therapy
diagnosis is based on elevated readings at least 3 times over a period of a week or more
HTN EMERGENCY
develops over hours to days
BP 220/120
evidence of acute target organ damage (encephalopathy, ICH/SAH, MI, renal failure, retinopathy)
HTN Urgency
Develops over days/weeks
-BP severely elevated but no evidence of target organ damage
-can be due to non-compliance of medications, Crack Cocaine use, tumor of adrenal medulla
HTN Presentation
Asymptomatic in itself
However:
presents as effects on target organs as
- CAD (coronary artery disease)
- CVA
- PVD ( peripheral vascular disease)
- Retinal damage
- renal failure
- TIA ( Transient ischemic attack), stroke
- heart failure
- LVH -left ventricular hypertrophy
HTN Diagnostic testing
Check BP in both arms- then use arm with highest reading
- follow up for high BP is to take it twice, 5 minutes apart
- BP evaluation should be assessed carefully before initiating RX-correct technique
ABPM( ambulatory bp monitoring- r/o “white coat syndrome”
Taking a BP
feet flat on the floor legs uncrossed support back empty bladder support arm at heart level BP cuff on bare arm no talking
Collaborative Care for HTN
-Dash Diet ( See table 31-6)
Medications ( see table 31-5)
-encourage compliance
Side effect mgmt. :
Gum & hard candy for dry mouth
Slow position changes for orthostatic hypotension
Discussion R/T sexual dysfunction
Schedule diuretics to avoid nocturia
Heart Failure
Abnormal clinical syndrome involving impaired cardiac pumping and/or filling which leads to lower-than normal cardiac output
CO= HR x SV
- dominant feature: Increased intravascular volume
- manifestations depend on extent of failure and which ventricle is affected
Systolic Failure
inability of heart to pump blood effectively
- hallmark= decrease in Left Ventricle ejection fraction = decreased Cardiac output
Diastolic failure
inability of ventricles to relax and fill during diastole= stiff ventricles= decrease CO
-normale ejection fraction
Mixed failure
Dysfunction in both systolic and diastolic
Heart Failure: Left and Right sided Failure
the left and right ventricles can fail separately
left ventricle usually fails first
Acute decompensated heart Failure ( ADHF)
manifest as acute pulmonary edema
-increase in pulmonary venous pressure caused by decreased efficiency of the LV= pulmonary engorgement
LIFE THREATENING
SXS of Left Sided heart Failure
- paroxysmal nocturnal dyspnea
- elevated pulmonary capillary wedge pressure
- pulmonary congestion ( crackles, cough, wheezes, blood-tinged sputum, tachypnea)
- restlessness
- confusion
- orthopnea
- tachycardia
- exertional dyspnea
- fatigue
- cyanosis
sxs of R sided heart failure
- fatigue
- increase peripheral venous pressure
- ascites
- enlarged liver and spleen
- may be secondary to chronic pulmonary problems
- distended jugular veins
- anorexia and complaints of GI distress
- weight gain
- dependent edema
** R side makes you [R]etain water***
Management of Heart Failure
Diet - Sodium restriction, DASH diet
Fluid management – weigh daily
1kg = 1 liter of fluid
Weight gain: Call Provider
3 lbs. over 2 days
up to 5 lbs. over 1 week
Possible fluid restriction –(ice chips, hard candy to deal with thirst)
Activity - energy-efficient behavior and rest
Medications (table 30-8)
- Diuretics
- ACE or ARB’s
- Beta Blockers
- Inotropic Drugs
Education for Heart Failure
FACES:
[F]atigue [A]ctivity limitations [C]ongestion/Cough [E]dema [S]hortness of Breath
Coronary Artery Disease
chronic illness that can’t be cured and won’t disappear
-need basic lifestyle changs to promote recovery or health
Stable Angina
chest pain
temporary and reversible
Acute coronary Syndrome (Unstable angina)
not immediately reversible
Myocardial Infarction
Severe ischemia with cell damage
Pain:
-Severe, immobilizing chest pain not relieved by rest, position change, or nitrate administration
- Heaviness, pressure, tightness, burning, constriction, crushing
- Substernal, retrosternal, epigastric
- More common in AM
- Atypical in women, elderly
- No pain if cardiac neuropathy (diabetes)
Other SXS:
Nausea/Vomiting
Fever
-Catecholamine release – SNS Stimulation
Cardiovascular Manifestations: Initially, ↑ HR and BP, then ↓ BP (secondary to ↓ in CO) crackles, JVD
Types of Angina
Chronic Stable Angina Pectoris Silent Ischemia Nocturnal Angina and Angina Decubitus Prinzmetal’s Angina Microvascular Angina Unstable Angina (falls under the umbrella of Acute Coronary Syndrome ACS)
Chronic Stable Angina TX
ABCDEF
[A]ntiplatelets/Anticoagulants/Anti-anginals/ACE-I/ARB [B]eta adrenergic blocker/blood pressure [C]igarette smoking/CCB/Cholesterol [D]iet/Diabetes [E]xercise/Education [F]lu vaccination
Altered central perfusion
Initial interventions 12-lead ECG Blood Studies Semi-fowler’s position IV access
IMMIDIATE Treatment for and MI
M-O-N-A
Morphine
Oxygen
Nitroglycerin (SL)
ASA (chewable) or plavix
Infective ( Bacterial ) Endocarditis
In a healthy heart, the constant blood flow does not allow any bacteria to stay and colonize
-If an individual has a defect of the inner lining, or heart valve – then any microorganism in the blood stream has a risk of developing endocarditis
Infective endocarditis (IE) is an infection of the valves and endothelial surface of the heart caused by direct invasion by bacteria or other organisms and leading to deformity of the valve leaflets
SXS:
-General manifestations (chills, fever, malaise, fatigue, anorexia)
- Micro-embolization in various organs
- Arthralgias, abdominal pain, back pain (pain caused by obstruction of blood flow to tissues needing oxygen and nutrients)
- Vascular Signs (Osler’s nodes, Janeway’s lesions, Roth’s spots)
- Can lead to heart failure
TREATMENT:
-Eradicate the invading organism
-4 to 6 weeks of IV antibiotics
-Possible surgical valve
replacement
- Adequate rest
- Home care – IV antibiotics, monitor temp, etc.
- Prompt treatment of minor symptoms ( fatigue, chills, etc.)
- Prophylactic Antibiotics to prevent IE and good oral hygiene
Pericarditis
Inflammation of the pericardial sac
Causes:
infection
noninfectious
autoimmune
SXS:
-restriction of heart motion and pain with breathing
-Chest pain: worse when lying flat and with deep inspiration
( sharp, stabbing)
-Dyspnea
-Pericardial friction rub
Complications: Pleural Effusion (increased fluid within pericardial sac)
Cardiac Tamponade:
compression of the heart by accumulation of fluid in the pericardial sac
sxs: JVD, muffled or distant heart sounds, low BP
Treatment for Pericarditis
- Treat underlying problem
- Bed rest
- Increase HOB 45 degrees
Drug Therapy: Anti-inflammatory agents, Antibiotics
-Manage Pain and Anxiety
-Pericardiocentesis (guided by echocardi0gram)
Cardiac Rehab
Three Phases
- Acute illness to discharge from hospital
- promote rest and limited mobility
- monitor HR ad BP with activities - Begins after discharge and continues through convalescence at home
- long term maintenance program
Cardiac Rehab
Three Phases
- Acute illness to discharge from hospital
- promote rest and limited mobility
- monitor HR ad BP with activities - Begins after discharge and continues through convalescence at home
- long term maintenance program
Recovery takes time:
- Resuming physical activity is slow and gradual
- Accept choices of patient: “what must be cut back”, “what should be cut back” and “what will be cut back”
Teaching – consider… Family learning needs Timing and family Emotional stage of family (grieving, shock, etc.) Anticipatory guidance
Physical Activity:
Levels are measured through MET (metabolic equivalents units)
1 MET is the amount of oxygen needed by the body at rest (3.5 ml of Oxygen per kilogram per minute)
Activity is gradual increased as tolerated
By discharge goal for patient able - tolerate at least 3 MET
Benefits of Physical Exercise
Increases CO Decreases blood lipids Decreases BP Increases blood flow through the coronary arteries Increases muscle mass and flexibility Assists in weight loss Improves the psychological state
Isometric ( static) exercises
- should be limited
- increases HR and BP Rapidly
- lifting, carrying, pushing heavy objects
- involves straining muscles against other muscles
Isotonic ( dynamic) exercises
- Walking, jogging, bike riding
- Puts a safe steady load on the heart
- Improves circulation to many organs
Cardiac Rehab and Sexual Activity
initiating and discussing this topic with patients.
Sexual dysfunction after MI is common and that dysfunction usually disappears after several attempts
Chest pain can occur during intercourse
Medications for erectile dysfunction are avoid when patient taking Nitrates
Can generally be resumed about 1 week after an uncomplicated MI
The energy expended during sexual activity is similar to walking briskly up two flights of stairs
Avoid sex after a full meal
Positioning is a matter of individual choice
Provide pamphlets on sexual activity after an MI
Alleles
Responsible for variation in traits- each individual has two ‘versions’ of these factors (genes)
Law of Dominance
when two plants express different forms ( alleles) of the trait are crossed, only one form can be expressed
Recessive will be masked
Dominant will be expressed
Genotype
is the combination of alleles
Phenotype
the physical characteristics that are expressed
Homozygous
alleles are the same
ex ( TT)
heterozygous
alleles differ
Ex (Tt)
hemizygous
only one copy ( genes on the X chromosome in males)
Dominant inheritence
trait or disorder is express in the heterozygote (Dd)
Recessive Inheritence
trait is expressed in the homozygote (dd)
Autosomal intheritence
trait expressed on genes on chromosome 1-22
X-linked (sex linked)
trait is expressed genes on the X ( or Y) chromosomes
Autosomal dominant
- Carried on the autosome
- male to male transmission CAN occur
- each off spring has a 50% chance of inheriting the mutant allele
- does not skip generations, off spring can pass on only the recessive gene
- occurs equally in males and females
Examples: Huntington's disease Familial Hypercholesterolemia Marfan syndrome polydactyl
Autosomal Recessive
- 25% chance of having the disease
- 50% chance of being a carrier ( inherited one allele)
- must have both alleles from disease ( one from each parent)
- males and females affected
- affected males and females can transmit the gene, unless it causes death before reproductive age
- trait can skip generations
- parent of an affected individual are heterozygous or have the disease
Examples:
cystic fibrosis
phenylketonuria
sickle cell disease
Sex linked
- Genes carried on X chromosome are X linked
- Genes carried on Y chromosome are Y linked
Y-linked traits are rare because the chromosome has few genes and many have counterparts on the X chromosome
Y-linked are passed male to male
X-linked recessive
- females are carriers ( 50% chance of transmitting dominant mutant gene to offspring)
- Mutant allele is on the X chromosome
- expressed more severely in males ( has no other allele to balance it)
- high rate of miscarriages in males due to early lethality in males
- affected males had a mother who IS a carrier
- an unaffected females with an affected brother has 50% chance of being a carrier
- affected female has an affected father and and affected/carrier mother
Examples:
Hemophilia
muscular dystrophy
Menkes Disease
X-linked Dominant
- expressed in females in one copy
- much more sever in effects in males
- HIGH rate of miscarriages
- no male-male transmission
- sons can only be effected by mothers
- daughters can be effected from either parent
Examples:
incontinentia pigmenti
hypertrichosis
Mitochondrial DNA (Exeptions to Mendel Law)
mitochondria are structures inside the cell that convert energy form food into the form that the cell can use.
- most DNA is packaged in chromosomes within the nucleus, mitochondria also have a small amount of their own DNA
Alterations in mitochondrial DNA has been linked to many cancers ( leukemia, breast, etc.)
Transmitted via the maternal gene ONLY
-affected males do NOT pass the gene
Examples:
leigh syndrome ( shows up in infancy/childhood; usually fatal)
Lebers hereditary optic neuropathy- rapid central visin loss, tremors in teens and young adults
Common mtDNA related disorders include: migraines, thyroid disease, diabetes, heart failure, pancytopenia
Multiple Alleles
Exceptions to mendels laws:
- More than two alleles (normally a person has two alleles for any autosomal gene)
- different allele combination can produce different variation in phenotype
ex: different types of CF, PKU, eye color
Penetrence
When someone with a particular genotype do no have associated Phenotype
expressivity
a genotype is associated with a phenotype of varying intensity ( polydactyly)
Incomplete dominance
the heterozygous phenotype is intermediate b/w either homozygote
Ex. Flower (snapdragon)
with red (dominant) crosses
with a white (recessive)
results in pink flowers
co-dominance
Different alleles are both expressed in a heterozygote
- blood typing (ABO)
- a child’s blood types doesn’t have to match parents
Lethal allele
deadly
- usually causes death before and individual can reproduce
- usually results in spontaneous abortion or miscarriages
Chromosomal disorders
occur as a results of structural rearrangement within or between chromosomes
-arrangement is ‘balanced’ if chromosome set appears to contain all the correct material but arranged in unusual way
unbalance when there is additional or missing chromosome material such as depletion or duplication of a chromosome
- when normal balance is disturbed, mental or physical development is altered
- person who carries a rearrangement does not have any disabilities
Deletion
loss of a portion of the chromosome
22q11.2 deletion syndrome (syndrome with heart defects, immune problems, cleft palate, low calcium)
Ring Chromosome
- A circular structure that occurs when a chromosome breaks in two places and its broken ends fuse together
- Variety of conditions depending on chromosome involved
inversion
- Breaks in a single chromosome
- Piece reinserted
- Balanced - May not see any visible changes
Some noticeable anomalies include polydactyly, club foot, cardiac and GI conditions
Examples of Chromosomal disorders
-Down syndrome (Trisomy 21)
sxs range from mild to severe; increased risk of thyroid disease, leukemia, sleep apnea and dementia
- Turner Syndrome (X0) (females sexually undeveloped)
- Klienefelter syndrome (XXY)(males sexually undeveloped, large hands and feet, may develop breast tissue)
- Trisomy 18(Edward’s Syndrome) mental and physical disabilities,
Multifactorial conditions
- Many birth defects as well as adult diseases have a multifactorial cause.
- Result from gene variations and environmental influences that work together
- Conditions cluster in families but do not demonstrate the characteristic pattern of inheritance seen with single gene disorders
Examples:
- Neural Tube Disorders (Spina Bifida) – taking folic acid has decreased the incidents
- Congenital Heart Defects
- Diabetes
- Heart Disease
CBC
Complete Blood Panel
- Red blood cells ( 4.1 - 5.3 ), which carry oxygen
- White blood cells ( 4500-11,000), which fight infection
- Hemoglobin (Men- 13.2 - 17.3) (females 11.7- 15.5), the oxygen-carrying protein in red blood cells
- Hematocrit (male: 43-49%) (females: 38-44%), the proportion of red blood cells to the fluid component, or plasma, in your blood
- Platelets ( 150,000- 450,000), which help with blood clotting
ESR
Erythocyte sedimentation Rates “sed rate”
-reflects inflammation or infection
< 30mm
Bleeding TIme
3-8 minutes
temporary clot
Clotting studies
PT - 11- 12.5 seconds -extrinsic
PTT - 40 secs -Intrinsic
INR - 1 sec
Hematological Diagnostic studies
Radiological Studies:
CT
MRI
Biopsies(only definitive cancer diagnostic tool):
bone marrow
lymph node
Bone Marrow aspiration/biopsy
patient prep
anxiety/pain med
education - what to expect/feel
position- prone or side lying
Procedure :
last 5-10 minutes
sedation ( local or monitored anesthesia care, MAC)
Sterile procedure
Post care:
- Prevent bleeding- put patient on side for 30 -60 minutes (to maintain pressure)
- check for infection
- pain relief soreness for 3-4 days
- wear bandage for 24 hours- report any soaking, reinforce, do not remove for 24 hours
- no tub baths or shower for 24 hours
- avoid contact sports
Aplastic Anemia
develops when damage occurs to your bone marrow, slowing or shutting down the production of new blood cells
Manifestations- Similar to anemia
( pancytopenia) : decrease RBCs, Decrease WBCs, Decrease platelets )
EVERYTHING IS LOW
Collaborative mgmt: Prevent complications
- hypoxia
- infection
- hemorrhage
Nursing Care
- neuro assessment
- good hand washing
- oral care
- screen visitors for infection/exposure to illness
- avoid invasive procedures
- prevent problems with immobility
- protective isolation
- bleed precautions
- Increase fluid & fiber intake
- increase head of the bed
- no fresh flowers or fruit
- avoid over inflation of BP cuff
- may need an arterial line
Polycythemia
Primary polycythemia/polycythemia vera
-Chronic myeloproliferative disorder arising from chromosomal mutation in stem cell
↑RBC ↑ WBC ↑ platelets (cells are often impaired)
↑ blood viscosity ↑ blood volume, congestion of organs/tissues with blood
-Hypercoagulopathies = predisposed to clotting
Secondary polycythemia (CAUSED by Hypoxia)
Hypoxia stimulates erythropoietin in kidneys
↑ RBC production
Complications
Stroke (secondary to thrombosis)
SXS: headache dizziness angina intermittent claudification general pruritus (increase in RBCs prompt the immune sxs to release histamine= itchiness) flushing of face left upper abdominal pain/fullness
WDYD:
- Hydration therapy
- aspirin if Primary
- Small frequent meals
- Avoid iron supplements
- Avoid tight-fitting clothing
- Avoid citrus with meals- (because citrus ↑absorption of iron)
- Reduce blood volume and viscosity ( hydration, severe, transfuse blood out)
- Anti-platelets (ASA)
- Reduce bone marrow activity with myelosuppressant agents
- Ambulate to decrease thrombus formation
- Avoid extreme temp changes ( because of vaso-dilation/constriction )
Throbocytopenia
Low platelets <150,000
He GONNA DIE: < 20,000 platelets -pt at risk for spontaneous bleed ( inside or out)
WDYD: -assess vitals ( worrisome vitals = HR: initial increases (Tachycardia) RR: increased BP: decreased mental status change cold, pale skin
- monitor for signs of bleeding
- Health promotion- ID bands for pt.s at risk
- monitor labs
- patent teaching
Neutropenia
-Normal leukocyte (WBC) count: 4,500-11,000/µL
Diagnostic tests:
- ANC ( Absolute Neutrophil Count)- determined by multiplying the total WBC count by % of neutrophils
ANC < 1000/µL = neutropenia – at risk for bacterial infection
ANC 500-1000/µL – moderate risk for bacterial infection
ANC < 500/µL – severe risk for bacterial infection
- Peripheral blood smear
- assesses for immature cells - bone marrow aspiration and biopsy
WHAT IS NEUTROPENIA
- Neutrophils are one type of WBC – primary phagocytic cell
- Reduction in the number of neutrophils
- Clinical consequence which occurs with a variety of conditions/diseases
Most common cause = iatrogenic
Widespread use of chemotherapy/immunotherapy in treatment of malignancies & autoimmune diseases
Classic signs of infection/inflammation (redness, heat, swelling) may not occur
WDYD:
- Patient teaching
- Alert for minor complaints that may indicate infection
-Sore throat, diarrhea, low grade fever, etc.
Neutropenic fever (>100.4°F) and ANC < 500/µL is a medical emergency
- Blood cultures and antibiotics
- Strict hand-washing
- Private room (Laminar air flow rooms if needed)
- Avoidance of fresh fruits and vegetables (or may wash before eating)
Neutropenic Precautions
- strict hand washing
- private room with closed room- negative air
- FULL precautions - gown and gloves
- no fresh fruit o flowers
- no visitors
Leukemia
Accumulation of dysfunctional (immature) cells due to loss of regulation in cell division
Pathophysiology:
- No single causative agent
- Combination of genetic and environmental influences
- Associated with
- Chemical agents
- Chemotherapeutic agents
- Viruses
- Radiation
- Immunologic deficiencies
SXS:
-Clinical manifestations are varied but usually related to bone marrow failure
- Overcrowding by abnormal cells
- Inadequate production of normal marrow elements
- Anemia
- Thrombocytopenia
- ↓ Number and function of mature WBCs
Nursing diagnoses:
related to anemia, thrombocytopenia, neutropenia
Nursing care:
acute intervention
-administer medications and monitor side effects (chemo, anti-emetics)
Ambulatory home care
-refer patients and family to survivor networks
Lymphomas
Hodgkins disease (H is better):
A malignant condition caused by proliferation of abnormal, giant, multi-nucleated cells (Reed-Sternberg cells) located in the lymph nodes
SXS
- enlarged cervical, axillary or inguinal nodes
- fever
- fatigue
- night sweats
- weight loss
- chills
Non-hodgkins disease:
A malignant neoplasms of the immune system (B & T cells)
SXS:
-painless lymph node enlargement with s/s dependent on area of disease
Diagnostic/staging studies for Lymphoma
- nodes biopsies ( only definitive diagnosis)
- staged 1-
size
matastasize
level of organ involvement
Treatment:
- localized radiation
- combination chemotherapy with local radiation
- high dose combo therapy with radiation
- surgery
- stem-cell replacement: depends on the aggressiveness of the disease
Multiple Myelomas
- Neoplastic plasma cells infiltrate bone marrow and destroy bone
- Neoplastic cells produce excess amount of immunoglobulins (myeloma protein) and cytokines which play a role in bone destruction
Cause unknown:
-possible radiation, chemical exposure as well as viral or genetic influence
SXS: -Skeletal pain is most common Symptoms develop slowly -Fatigue -Easy bruising -Bone degeneration/Fractures -hypercalcemia
WDYD:
- Maintain adequate hydration( to flush out calcium)
- Move patient carefully
- Ambulation as tolerated ( to put calcium back in bone)
- Pain management
Teach patient and family about remissions and exacerbations, and need for hospitalization during acute episodes
TX:
- Chemotherapy
- Immunotherapy
- Corticosteroids
- Biophosphanates (medicine that prevents the loss of bone density)
- Stem cell transplantation
Cellular regulation
all functions carried out within a cell to maintain homeostasis, including its responses to extracellular signals ( such as hormones, cytokines and neurotransmitters) and the way each cell produces an intracellular response
Signs of Cancer
CAUTION
[C]hange in bowel habits
[A] sore that wont heal
[U]nusual bleeding or discharge
[T]hickening or a lump in breast
or elsewhere
[I]ndigestion or difficulty
swallowing
[O] bvious change in mole or wart
[N]agging cough or hoarsness
Cancer risks
Prevention is KEY!
Modifiable:
- alcohol
- tobacco
- diet
- sun exposure
- infectious disease
- chemicals
- radiation
- Vaccinations
Non-Modifiable:
- age
- sex
- race
- family medical history
Types of Tumors
Benign tumors:
- non cancerous
- can often be removed
- usually do not reoccur
- cells do not spread outside of the tumor
example: lipoma
Malignant Tumor:
- cancerous
- can invade other areas- matastasize
examples:
- carcinoma ( skin and tissues lining internal organs)
- sarcoma ( bone, connective tissue or supportive tissue)
- leukemia ( starts in blood)
- lymphoma and myeloma (immune system)
- CNS ( brain and spinal cord)
Malignant Melanoma
ABCD
[A] assymetry
[B] borders
[C] color
[D] Diameter more that 6mm
E- elevated
E-evolving
F - firmness
Radiation
-Destroys cancer cells
Types:
- external (teletherapy)
delivery of radiation from a source placed at some distance from target
-internal ( Brachytherapy)
involves placement of specially prepared radioisotopes directly into or near the tumor itself or close proximity
(interstitial seeds)
Radiation safety precautions
Sealed-source Internal Radioactive Implants
- Patients require private room & bath
- Rooms at ends of halls
- Rooms with lead-shielded walls
- Sign on door: “Caution: Radioactive Material”
- Turn patient away from door and keep door closed as much as possible
- Nurse wears dosimeter film badge
- No pregnant staff or children less than 16
- visitors remain 6 feet away and max 30 min/day
Leaded shields at doorway to wear; lead container and pair of long-handled forceps in case implant comes out of place
Ensure proper handling of bed linens/clothing
Call radiation therapist & radiation officer immediately to retrieve and secure source
Radiation and skin
- Don’t wash treatment area until instructed to do so
- Wash treated skin gently with mild soap, rinse well, pat dry
- Use warm or cool water
- Use hands for bathing in place of washcloths
- Don’t remove tattoo marks
- Avoid powders, lotions, creams, alcohol, & deodorants on treated skin
- Loose-fitting clothing to avoid friction over treatment field
- No tape/dressings on site
- No direct sunlight, chlorinated swimming pools, or temperature extremes
Chemotherapy
- Can cure disease
- Increases mean survival time
- Decreases the risk for specific life-threatening complications
- Combination therapy usually more successful than the use of a single medication
Chemotherapy can be an irritant or a vesicant!!!!
Irritant: Damages intima of vein
Vesicant: Can cause severe local tissue breakdown and necrosis
Extravasation: fluid from IV leak into tissues
- Pain
- Swelling
- Redness
- Presence of vesicles on the skin
Requires antidote or chemo-protective agent; may require skin grafts for closure
Stop the infusion immediately!!!!!!
Route of Chemotherapy
Central line- most common
PICC ( peripherally inserted catheter) - tip resides in superior vena cava, placed in ante-cubital fossa; low complication rates and less expensive
-No BP/ blood draws from this extremity
Implantable port - jugular vein
Needle
Regional chemo:
- intraarterial
- intraperitoneal
- intrathecal
- intravesical bladder chemotherapy
Nursing/collaborative care
- monitor blood panel
- Monitor for weight loss (may also be indicative of depression)
- hair loss- whole body, not everyone looses it, when lost its called alopecia, may come back different texture
- Eat small, frequent, low fat meals
- Avoid spicy foods
- Take nutritional substances as prescribed
- Encourage 2 to 3 liters of fluid per day if not contraindicated
- Administer antiemetics prior to chemotherapy
- Continue daily activities however, rest in between
Side effects: -Coping with therapy -Bone marrow suppression -Fatigue -Skin reactions -Nausea and vomiting -Mucositis, Stomatitis, and Xerostomia ( dry mouth, mucosal lesions, lip ulcers) -Diarrhea -Anorexia -Thrombocytopenia -Neutropenia -peripheral neuropathy ( pins and needles feeling) - cognitive dysfunction -urethral cystitis increase fluids)
IV therapy
Check the site of IV!
Assessment – renal/cardiac function
Monitor patient status (Wt, I/O, lab studies)
Doctor’s orders - rate and solution
Patient Safety
- Be aware of “high alert” drugs (KCL)
- Smart pump
- Computerized physician order entry
Sterile principals of IV therapy
check expiration of tubing and fluids, check for beak in sterile technique
Flow rates via gravity w/out pump
IV piggy backs hung hire than straight gravity iv flow
Factors that influence Flow rate of gravity pump
- height of solution
- patency of cannula
- venous spasms
- size of cannula
- blood in tubing
- presence of local complications
Multi-lumen Catheter
can deliver two or more solutions at the same time via separate pathways
Central Lines
tunneling or non-tunneling
- X-Ray before starting fluids
- Sterile dressing change
- Observe site for S/S infection
- Observe for IV systemic complications
- Care depends on complication assessed
Implantable ports
-no part of catheter is visible
- venous system most common placement
- accessed with a needle through the skin
Indications for Central Venous Access Device ( CVAD)
-Medication Administration
-Nutrition
Blood samples/transfusions
-Conditions (renal failure, burns etc.)
Complications:
- Catheter Occlusion
- Embolism
- Infection
- Pneumothorax
- Catheter Migration
Intraosseous route
(IO route - into bone marrow)
- High infusion rates are possible
- Pain meds may be required
- Good for severely dehydrated or during cardio/resp. emergencies
- Proximal humerus, proximal and distal tibia
Nurse role in IV therapy
CHECK THE SITES
Local complications
- infiltration
- nerve damage
- infection
- phlebitis
- thrombophlebitis
- hematomas and ecchymosis
Systemic complications:
-Catheter related infection (pyrogenic or septic) - abrupt rise in temp, severe chillds, increaser HR and RR, headache
-circulatory overload
increased Bp, distended neck veins, SOB
WDYD: increase head of bead, decrease drip rate
Pneumothorax
SXS:
Decreased or absent breath sounds, respiratory distress, distended unilateral chest
WDYD
Air embolism
SXS:Chest pain, SOB, decrease BP, increase HR, cyanosis, anxiety, confusion
WDYD:
put pt in L lateral, modified trandelenburg ( just raise feet), to trap air in R atrium
Are these solutions hyper/hypo/isotonic
ISO:
0.9% NaCl (NS)
5% Dextrose in water (D5W)
Lactated Ringers (LR)
Hypotonic:
0.45% NaCl (1/2 NS)
0.33% NaCl
5% Dextrose and ¼ NS (D5 ¼)
Hypertonic: 3% NaCl 10% Dextrose in water (D10W) 5% Dextrose and ½ NS (D5 ½) 20% Dextrose in water (D20W) 5% Dextrose in lactated ringers (D5LR) Plasmalyte
PCA Pumps
- Enables the patient to self administer medication on prn. basis
- Programmed according to medical orders (dosage, time intervals between doses, and lock-out intervals)
- Can record the amount of medications received and the number of requests by the patient
