exam 3 Flashcards

Question

gout

Answer 1

Monosodium urate crystals deposit in joints; Tophi swollen and inflamed joints, masses of uric acid (tophi), uric acid crystals Manifestations: Acute pain, redness, swelling, warmth of affected joint Triggers: Alcohol, trauma, diet, medications, stress, illness food to avoid: fatty fish, shell fish, red meat, eggs, caffeine, white flour, yeast, alcohol, leafy green veggies, cake, pastries, sugars Testing: polarized light microcopy pf synovial fluid, Serum uric Acid level ``` Treatment Xanthine oxidase inhibitor (Allopurinol) Uricosuric agents (Probenecide) NSAIDs Colchicine ``` ``` Nursing Care: Rest joint Apply ice Avoid aspirin, stress, ETOH, trauma, food high in purines Drink plenty of fluids ```

Answer 2

Manifestations Chronic pain, Diffuse musculoskeletal achiness, Morning stiffness, Fatigue, Sleep disturbances, Functional impairment, Weight gain, Mood disturbances, Chemical sensitivity, dysmenorrhea, ``` Dx by manifestations Widespread pain index (WPI) & symptom severity score Symptoms present for at least 3 months No other disorder to explain the pain ``` ``` Treatment NSAIDs TCA (Amitriptyline, Nortriptyline) Muscle relaxants (Cyclobenzaprine) AEDs (Gabapentin, Pregabalin) Antidepressants ``` Nursing Care Exercise Cognitive therapy Medication regimen

Answer 3

Treatment Goals Cure- complete eradication of malignant disease Control- prolonged survival and containment of cancer cell growth Palliation- relief of symptoms associated with the disease and improvement of quality of life Treatment Approaches Surgery- diagnostic surgery (biopsy), treatment, prophylactic surgery, palliative surgery, reconstructive surgery Radiation Chemotherapy Preop care: Emotional support. Education (consistent information) RN is patient advocate & liaison Post-op care: Complications (dehiscence, fluid/electrolyte imbalances, organ dysfunction) Wound care, pain management, activity, nutrition & medication teaching Surgery combined w/radiation & chemotherapy post-op complications: Infection & impaired wound healing & development of VTE Altered pulmonary & renal function Discharge: Community resources (American Cancer Society)

Answer 4

Treatment Goals Cure- Thyroid carcinomas, cancers of the cervix Control- reduce tumor size to facilitate surgical resection Prophylactically- prevent spread of the primary cancer to a distance area Palliative- relieve the symptoms of metastatic disease Administration Teletherapy- external-beam radiation e.g. EBRT (GammaKnife) Brachytherapy- internal radiation implantation (vagina, abdomen, pleura, breast, prostate)- LDR (low dose), HDR (high dose) ``` Toxicity Early, systemic, late effects Altered skin integrity Alterations in oral mucosa Affect QOL, overall health ``` Side Effects- localized Alopecia, Erythema, Desquamation, Potentially Ulceration, Hyperpigmentation Stomatitis, Xerostomia, change in or loss of taste Mucositis, anorexia, nausea, vomiting, and diarrhea Anemia, Leukopenia, Thrombocytopenia ``` Radiation precautions- Time, Distance, & Shielding private room w/notice on door staff wear dosimeter badges no pregnant staff members assigned no children or pregnant visitors limit visits to 30 min. daily stay 6 feet away If internal implant dislodged: Pick up w/metal forceps. Place in lead-lined container Contact radiation safety officer & go to occupational health ``` Protect skin and oral mucosa Avoid ointment, lotion, powder on treated area Gently cleanse with mild soap using fingertips instead of washcloth Do not remove temporary skin markings Electric razors only Avoid constrictive clothing Avoid sun exposure, health lamps, head pads, ice packs Gentle oral hygiene

Answer 5

Technique for administration Administered in the hospitals, outpatient center, or home setting Right atrial silastic catheters, Implanted venous access device or PICC Prevention of extravasation Hypersensitivity reactions- Type I Discontinue medication immediately Initiate emergency procedures Aspirate any remaining drug from the extravasation site Toxicity Gastrointestinal system, Hematopoietic system, Renal system, Cardiopulmonary system, Reproductive system, Neurologic system, cognitive impairment, and Fatigue ``` management: Assessing Fluid and Electrolyte Balance Assessing Cognitive Status Modifying Risks for Infection and Bleeding Preventing Nausea and Vomiting Managing Cognitive Changes Managing Fatigue Protecting Caregivers ```

Answer 6

The preoperative phase begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room (OR) bed. The intraoperative phase begins when the patient is transferred onto the OR bed and ends with admission to the PACU. Intraoperative nursing responsibilities involve acting as scrub nurse, circulating nurse, or registered nurse first assistant. The postoperative phase begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home. Surgical interventions can be describe based on purpose: Facilitating a diagnosis (a diagnostic procedure such as biopsy, exploratory laparotomy, or laparoscopy) Curative (e.g., excision of a tumor or an inflamed appendix), or repair (e.g., multiple wound repair). Reconstructive or cosmetic (such as mammoplasty or a facelift) Palliative (to relieve pain or correct a problem—such as debulking a tumor to achieve comfort, or removal of a dysfunctional gallbladder). Rehabilitative (e.g., total joint replacement surgery to correct crippling pain or progression of degenerative osteoarthritis.) Surgery can also be classified based upon the degree of urgency involved: emergent, urgent, required, elective, and optional preop: Preop assessment Patient demographics and health history (including medication profile) Consent (page 422, Chart 17-2) Diagnostic (CT, MRI, X-rays, ECG, etc.) Laboratory tests (CBC, BMP, PT, PTT, UA, etc.) Education– the patient is educated not only on expectations of the procedure and outcomes, but also on the post operative plan of care. How will the paient prepare for the procedure, What will the patient need before/during/after, what medications can they expect to take, what will follow up look like, what activities will they be doing, what sort of support should they plan to have, etc. postop: Nursing management of the post operative patient (Page 463-464, Chart 19-4). During the first 24 hours after surgery, nursing care of the hospitalized patient on the medical-surgical unit involves continuing to help the patient recover from the effects of anesthesia, frequently assessing the patient’s physiologic status, monitoring for complications, managing pain, and implementing measures designed to achieve the long-range goals of independence with self-care, successful management of the therapeutic regimen, discharge to home, and full recovery. In the initial hours after admission to the clinical unit, adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, nausea and vomiting, neurologic status, and spontaneous voiding are primary concerns.

Answer 7

The hazards of surgery for older adults are proportional to the number and severity of comorbidities and the nature and duration of the operative procedure. Older adult patients have less physiologic reserve (i.e., the ability of an organ to return to normal after a disturbance in its equilibrium) than younger patients. Cardiac reserves are lower, renal and hepatic functions are depressed, and gastrointestinal activity is likely to be reduced. See Table 11-1 for additional age-related changes. Respiratory and cardiac complications are the leading causes of postoperative morbidity and mortality in older adults.

Answer 8

Risk for ineffective airway clearance related to depressed respiratory function, pain, and bed rest Acute pain related to surgical incision Decreased cardiac output related to shock or hemorrhage Risk for activity intolerance related to generalized weakness secondary to surgery Impaired skin integrity related to surgical incision and drains Ineffective thermoregulation related to surgical environment and anesthetic agents Risk for imbalanced nutrition, less than body requirements related to decreased intake and increased need for nutrients secondary to surgery Risk for constipation related to effects of medications, surgery, dietary change, and immobility Risk for urinary retention related to anesthetic agents Risk for injury related to surgical procedure/positioning or anesthetic agents Anxiety related to surgical procedure Deficient knowledge related to wound care, dietary restrictions, activity recommendations, medications, follow-up care, or signs and symptoms of complications in preparation for discharge

Answer 9

Surgical asepsis prevents the contamination of surgical wounds. The patient’s natural skin flora or a previously existing infection may cause postoperative wound infection. Rigorous adherence to the principles of surgical asepsis by OR personnel is basic to preventing surgical site infections. All surgical supplies, instruments, needles, sutures, dressings, gloves, covers, and solutions that may come in contact with the surgical wound or exposed tissues must be sterilized before use. Traditionally, the surgeon, surgical assistants, and nurses prepared themselves by scrubbing their hands and arms with antiseptic soap and water; however, this practice is being challenged by research investigating the optimal length of time to scrub and the best preparation to use. Surgical team members wear long-sleeved, sterile gowns and gloves. Head and hair are covered with a cap, and a mask is worn over the nose and mouth to minimize the possibility that bacteria from the upper respiratory tract will enter the wound. During surgery, only personnel who have scrubbed, gloved, and gowned touch sterilized objects. Nonscrubbed personnel refrain from touching or contaminating anything sterile. An area of the patient’s skin larger than that requiring exposure during the surgery is meticulously cleansed, and an antiseptic solution is applied. If hair removal needs to take place and this was unable to be performed before the patient arrived in the OR suite, this is done immediately before the procedure with electric clippers (not shaved) to minimize the risk of infection. The remainder of the patient’s body is covered with sterile drapes. All practitioners involved in the intraoperative phase have a responsibility to provide and maintain a safe environment. basic principles: All materials in contact with the surgical wound or used within the sterile field must be sterile. Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile; contact with unsterile objects at any point renders a sterile area contaminated. Gowns of the surgical team are considered sterile in front from the chest to the level of the sterile field. The sleeves are also considered sterile from 2 in above the elbow to the stockinette cuff. Sterile drapes are used to create a sterile field (see Fig. 18-2). Only the top surface of a draped table is considered sterile. During draping of a table or patient, the sterile drape is held well above the surface to be covered and is positioned from front to back. Items are dispensed to a sterile field by methods that preserve the sterility of the items and the integrity of the sterile field. After a sterile package is opened, the edges are considered unsterile. Sterile supplies, including solutions, are delivered to a sterile field or handed to a scrubbed person in such a way that the sterility of the object or fluid remains intact. The movements of the surgical team are from sterile to sterile areas and from unsterile to unsterile areas. Scrubbed people and sterile items contact only sterile areas; circulating nurses and unsterile items contact only unsterile areas. Sterile areas must be kept in view during movement around the area. At least a 1-ft distance from the sterile field must be maintained to prevent inadvertent contamination. Whenever a sterile barrier is breached, the area must be considered contaminated. A tear or puncture of the drape permitting access to an unsterile surface underneath renders the area unsterile. Such a drape must be replaced. Every sterile field is constantly monitored and maintained. Items of doubtful sterility are considered unsterile. Sterile fields are prepared as close as possible to the time of use. Proper draping exposes only the surgical site, which decreases the risk of infection. The routine administration of hyperoxia (high levels of oxygen) is not recommended to reduce surgical site infections Environmental Controls Floors and horizontal surfaces are cleaned between cases with detergent, soap, and water or a detergent-germicide. Sterilized equipment is inspected regularly to ensure optimal operation and performance. All equipment that comes into direct contact with the patient must be sterile. Sterilized linens, drapes, and solutions are used. Instruments are cleaned and sterilized in a unit near the OR. Individually wrapped sterile items are used when additional individual items are needed. Airborne bacteria are a concern. To decrease the amount of bacteria in the air, standard OR ventilation provides 15 air exchanges per hour, at least 3 of which are fresh air A room temperature of 20°C to 24°C (68°F to 73°F), humidity between 30% and 60%, and positive pressure relative to adjacent areas are maintained. Staff members shed skin scales, resulting in about 1000 bacteria-carrying particles (or colony-forming units [CFUs]) per cubic foot per minute. With the standard air exchanges, air counts of bacteria are reduced to 50 to 150 CFUs per cubic foot per minute. Systems with high-efficiency particulate air (HEPA) filters are needed to remove particles larger than 0.3 μm. Unnecessary personnel and physical movement may be restricted to minimize bacteria in the air and achieve an OR infection rate no greater than 3% to 5% in clean, infection-prone surgery. Even using all precautions, wound contamination may inadvertently occur. Constant surveillance and conscientious technique in carrying out aseptic practices are necessary to reduce the risk of contamination and infection.

Answer 10

The creation of a surgical wound disrupts the integrity of the skin, bypassing the body’s primary defense and protection against infection. Exposure of deep body tissues to pathogens in the environment places the patient at risk for infection of the surgical site, and a potentially life-threatening complication such as infection can increase the length of hospital stay, costs of care, and risk of further complications. Multiple factors place the patient at potential risk for infection. Type of the wound Surgical wounds are classified according to the degree of contamination. (Table 19-5 defines the classification of surgical wounds) Patient-related factors include age, nutritional status, diabetes, smoking, obesity, remote infections, endogenous mucosal microorganisms, altered immune response, length of preoperative stay, and severity of illness Factors related to the surgical procedure include the method of preoperative skin preparation, surgical attire of the team, method of sterile draping, duration of surgery, antimicrobial prophylaxis, aseptic technique, factors related to surgical technique, drains or foreign material, OR ventilation, length of procedure, and exogenous microorganisms. Other risk factors for wound sepsis include wound contamination, foreign body, faulty suturing technique, devitalized tissue, hematoma, debilitation, dehydration, malnutrition, anemia, obesity, shock, duration of surgical procedure, and associated disorders (e.g., diabetes) Efforts to prevent wound infection are directed at reducing risks. Postoperative care of the wound centers on: assessing the wound preventing contamination infection before wound edges have sealed enhancing healing Wound infection may not be evident until at least postoperative day 5. Most patients are discharged before that time, and more than half of wound infections are diagnosed after discharge, highlighting the importance of patient education regarding wound care S/S of wound infection Increased pulse rate Elevated temperature Elevated white blood cell count Wound swelling, warmth, tenderness, or discharge/drainage Increased incisional pain. Local signs may be absent if the infection is deep. Management Intensive medical and nursing care is essential if the patient is to survive. When a wound infection is diagnosed in a surgical incision, the surgeon may remove one or more sutures or staples and, using aseptic precautions, separate the wound edges with a pair of blunt scissors or a hemostat. Once the incision is opened, a drain is inserted. If the infection is deep, an incision and drainage procedure may be necessary. Antimicrobial therapy and a wound care regimen are also initiated. Wound Dehiscence and Evisceration are serious surgical complications (see Fig. 19-6). Wound dehiscence (disruption of surgical incision or wound) Evisceration (protrusion of wound contents) Dehiscence and evisceration are especially serious when they involve abdominal incisions or wounds. These complications result from sutures giving way, from infection, or, more frequently, from marked distention or strenuous cough. They may also occur because of increasing age, anemia, poor nutritional status, obesity, malignancy, diabetes, the use of steroids, and other factors in patients undergoing abdominal surgery. When the wound edges separate slowly, the intestines may protrude gradually or not at all, and the earliest sign may be a gush of bloody (serosanguineous) peritoneal fluid from the wound. When a wound ruptures suddenly, coils of intestine may push out of the abdomen. The patient may report that “something gave way.” The evisceration causes pain and may be associated with vomiting. p. 474

Answer 11

First-Intention Healing Wounds made aseptically with a minimum of tissue destruction that are properly closed heal with little tissue reaction by first intention (primary union). When wounds heal by first-intention healing, granulation tissue is not visible and scar formation is minimal. Often covered with a dry sterile dressing. If a cyanoacrylate tissue adhesive (LiquiBand) has been used to close the incision without sutures, a dressing is contraindicated. Second-Intention Healing Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been approximated. When an abscess is incised, it collapses partly, but the dead and dying cells forming its walls are still being released into the cavity. For this reason, a drainage tube or gauze packing is inserted into the abscess pocket to allow drainage to escape easily. Gradually, the necrotic material disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue. The cells surrounding the capillaries change their round shape to become long, thin, and intertwined to form a scar (cicatrix). Healing is complete when skin cells (epithelium) grow over these granulations. This method of repair is referred to as healing by granulation, and it takes place whenever pus is formed or when loss of tissue has occurred for any reason. When the postoperative wound is to be allowed to heal by secondary intention, it is usually packed with saline-moistened sterile dressings and covered with a dry sterile dressing. Third-Intention Healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are re-sutured later, thus bringing together two opposing granulation surfaces. This results in a deeper and wider scar. These wounds are also packed postoperatively with moist gauze and covered with a dry sterile dressing

Answer 12

Fluid and electrolyte balance is a necessary component for life in the maintenance of homeostasis. If unable to take PO/no other route available, fluids are administered by IV (intravenous access). Goals include: Provide water, electrolytes, and nutrients to meet daily requirements To replace water and correct electrolyte deficits To administer medications and blood products

Answer 13

Isotonic Fluids Use: hydration or fluid loss Alert: Do not use in clients with HTN, cardiac disease, or renal disease (may cause Fluid Volume Excess, HTN, Hypernatremia) NS (0.9% normal saline), of note this is the only fluid that can be used when administering blood products LR (Lactated Ringers) Contains NA,K, CA++, & CL D5W (is considered both isotonic and hypotonic- at base is isotonic but in effect is hypotonic because the glucose is rapidly metabolized and the water has a hypotonic effect-must be carefully used and monitored. Hypotonic Fluids Use: treat intracellular dehydration, such as diabetic ketoacidosis & hypernatremia. Use in clients with HTN, cardiac disease, or renal disease (may cause Fluid Volume Deficient, decrease BP) 1/2NS (0.45% sodium chloride) Hypertonic Fluids Use: For severe hyponatremia, edema, burns, or ascites Alert: may cause intravascular fluid volume overload and pulmonary edema Monitor closely in ICU setting for 3% NS D50 (50% dextrose in water), D10W (Dextrose 10% in water) 3% saline ``` Isotonic Solutions “Stay where I put it!” HypOtonic Solutions “Go Out of the vessel (into cells)” HypErtonic Solutions “Enter the vessel” ```

Answer 14

Systemic Fluid overload S/S: moist crackles, cough, restlessness, distended neck veins, edema, weight gain, dyspnea, rapid/shallow respirations, increased blood pressure, increased central venous pressure. Treatment: stopping infusion or decreasing the rate, monitoring vital signs frequently, assessing breath sounds, placing the patient in a high fowlers position, notifying the provider Air Embolism most often associated with central venous catheters and related to the size/rate of embolus S/S: palpitations, dyspnea, continued coughing, jugular venous distention, wheezing, cyanosis, hypotension, weak/rapid pulse, altered mental status; and/or chest, shoulder, or low back pain. Treatment: Immediately clamping the cannula (replacing a leaking or open infusion system), placing the patient on their left side in the Trendelenburg position, assessing vital signs and breath sounds, and administering oxygen. Infection S/S: abrupt temperature elevation after initiation of the IV solution, backache, headache, increased pulse and/or respirations, nausea and vomiting, diarrhea, chills and shaking, and general malaise. Additionally, erythema, edema, induration or drainage at the insertion site. Treatment: Varies significantly based on the severity from local involvement to sepsis. Focus on prevention. Careful hand hygiene Strict aseptic technique Firmly anchoring the cannula Examine the catheter for cracks, leaks, or cloudiness Inspect IV site with assessments and use Disinfect injection/access ports Removing the IV at the first sign of local inflammation, contamination, or complication Replace peripheral IV cannula per policy Follow policy regarding replacement of solution bags, tubings, medication sets Local Complications Infiltration Unintentional administration of a nonvesicant solution into surrounding tissue Occurs when the IV cannula dislodges or perforates the wall of the vein Characterized by edema around insertion site, leakage of fluids from the insertion site, discomfort or coolness in the area of infiltration, and decrease in flow rate. Interventions: stop the infusion, discontinue the IV catheter, apply sterile dressing, elevated the extremity, a warm or cool compress may be applied to the site depending on what was infiltrated. Extravasation Similar, to infiltration- unintentional vesicant solution into the surrounding tissue Phlebitis Inflammation of a vein Can be related to chemical, mechanical, or bacterial causes, often more than 1 cause. Interventions: discontinue the IV, restart IV in another location using aseptic technique and the appropriate sized cannula for the vein, anchor the cannula well, assess/monitor frequently; apply a warm moist compress to the site. Thrombophlebitis Presence of a clot plus inflammation in the vein. Characterized by localized pain, redness, warmth, and swelling around the insertion site or along the path of the vein; immobility of the extremity r/t discomfort and swelling, sluggish flow rate, fever, malaise, and leukocytosis. Interventions: Discontinue infusion, apply cold compress first then followed by warm compress, elevated extremity, restart IV in opposite extremity. If concerned for thrombophlebitis- IV line should NOT be flushed. The catheter should be cultured the area cleaned with alcohol. Hematoma When blood leaks into the tissues surrounding the IV site Characterized by ecchymosis, immediate swelling at the site, and leakage of blood at the insertion site. Interventions-remove the needle or cannula, apply light pressure with dry dressing, ice may be applied for the first 24hours to avoid extension of hematoma, elevated the extremity, frequent neurovascular monitoring Clotting and Obstruction Characterized decreased flow rate, blood backing into the tubing. Interventions-discontinue IV and restart in a new location, main focus is related to prevention.

Answer 15

Peripheral devices PIV- For short-term access (up to 96 hours) Midline- Rarely used because of growing popularity of PICCs; When access is needed for longer than 1 month or when vesicant medications are involved Central devices PICC- For medium-term access (up to 6 months) and especially for antibiotics, TPN, chemotherapy, transfusions, and frequent blood sampling Non-Tunneled central catheter- For short-term access when PIV is not suitable, and especially for resuscitation and central venous pressure monitoring; When access is required for more than a few days (use a tunneled catheter instead) Tunneled central catheter- For frequent long-term access, and especially for TPN, transfusions, and frequent blood sampling Can be used when PICC line is contraindicated or not possible; When access of shorter duration is required (consider an implantable port if access is to be less frequent) Implantable port- For infrequent access on a long-term basis or when lifestyle concerns make one of the other options less appealing; When venous access is regularly required (frequent needle pokes would be uncomfortable for the patient)

Answer 16

``` TPN Nutritional Content carbohydrates proteins fats vitamins minerals and electrolytes Who makes TPN- a pharmacist with special training to make the solution according to your lab results, weight, health conditions, and other factors. Can be done at hospital or at home. Goal- Correct or prevent malnutrition Reasons- digestive systems either can't absorb or can't tolerate food eaten by mouth ``` An interdisciplinary nutrition team, if available, should monitor patients. Weight, CBC, electrolytes, and BUN should be monitored often (eg, daily for inpatients). Plasma glucose should be monitored every 6 h until patients and glucose levels become stable. Fluid intake and output should be monitored continuously. When patients become stable, blood tests can be done much less often. Liver function tests should be done. Plasma proteins (eg, serum albumin, possibly transthyretin or retinol-binding protein), prothrombin time, plasma and urine osmolality, and calcium, magnesium, and phosphate should be measured twice/wk. Changes in transthyretin and retinol-binding protein reflect overall clinical status rather than nutritional status alone. If possible, blood tests should not be done during glucose infusion. Full nutritional assessment (including BMI calculation and anthropometric measurements) should be repeated at 2-wk intervals ``` Complications Catheter infection Pneumothorax Air embolism Clotted catheter Hyper (Hypo) glycemia Blood clots Fluid overload Mineral imbalances ``` Benefits Return to a healthy weight Nutritional repletion while resting the bowel Get better condition before surgery Nutritional support after surgery to aid in healing For children nutrition is extremely important for growth and development. TPN can help. Indications Insufficient oral or enteral intake Impaired ability to ingest or absorb food orally or enterally Patient unwilling or unable to ingest adequate nutrients Prolonged pre- or post-operative nutritional needs Cancer Crohn’s disease Ischemic bowel disease GI surgery Bowel obstruction Temporary depletion Small bowel can’t absorb nutrients well The patient needs to “rest” the bowel in order to help it heal Severe weight loss Short bowel syndrome Prolonged diarrhea Get a patient in better health in preparation for surgery ``` Nursing management Central venous access devices Monitor blood glucose q 6 h Monitor I & O, weight, CBC, electrolytes, BUN, liver function, prothrombin time Prevent infection Monitor S/S of complications ```

Answer 17

``` Type Site Date Size Patency Condition of the site ```

Answer 18

Encompasses a large group of disorders with many different causes, manifestations, treatments, and prognoses. Second leading cause of death in the U.S. Causes Genetics and familial factors Life style factors Environmental exposures (physical and chemical agents Viruses and bacteria Hormonal agents Prevention Primary-Focuses risk reduction, immunizations Secondary-Focuses on screening and early detection Tertiary-Focuses on monitoring for and preventing recurrence of the primary cancer as well as secondary malignancies. Diagnosis- Based on physiologic and functional changes Determine presence/extent of disease Identify possible metastatic disease Evaluate function of body systems Tissue sample for confirmation, staging and grading ``` Staging- Determines Size Existence of local invasion Lymph node involvement Metastasis ``` Grading- Pathologic classification of tumor cells Type of cells and characteristics Grade I- IV ``` Goals of care Medical Management- surgery, chemo, radiation Nursing role- Education Symptom management Comfort Advocate Monitoring and prevention of complications Nursing diagnosis (Chart 15-7) Complications Infection Typical s/s may be absent r/t decreased circulating WBCs and diminished local inflammatory response. Fever may be the only sign. Septic Shock Life threatening complication Bleeding and Thrombocytopenia Decrease in circulating platelets often related to bone marrow suppression after some types of chemo/radiation ```

Answer 19

Skin Epidermis Outermost layer-forms a protective layer that can repel pathogens and prevent excessive fluid loss Contains melanin-gives skin and hair its color Contains Merkel cells- not fully understood but sensory? Contains Langerhans cells-cutaneous immune reactions Dermis Largest portion of the skin, provides strength and structure Contains blood and lymph vessels, nerves, sweat and sebaceous glands, and hair roots Subcutaneous Inner most layer, primarily adipose and connective tissue- which provides cushion between skin layers and the muscles and bones Protects vascular and nerve structures Promotes mobility Insulates- important in thermoregulation ``` Functions of skin Protection Sensation Fluid Balance Temperature regulation Vitamin production (Vit D) Immune response ``` Hair Present over entire body except soles and palms Serves different functions based on location Filters debris (eye lashes) Provides insulation (thermoregulation) Nails Protection

Answer 20

Cherry angiomas (bright red “moles”) Diminished hair, especially on scalp and pubic area Dyschromias (color variations) Solar lentigo (liver spots) Melasma (dark discoloration of the skin) Lentigines (freckles) Neurodermatitis (itchy spots) Seborrheic keratoses (crusty brown “stuck-on” patches) Spider angiomas (see Fig. 49-3) Telangiectasias (red marks on skin caused by stretching of the superficial blood vessels) Wrinkles Xerosis (dryness) Xanthelasma (yellowish waxy deposits on upper and lower eyelids)

Answer 21

Primary Lesions MACULE, PATCH Flat, nonpalpable skin color change (color may be brown, white, tan, purple, red) Macule: <1 cm; circumscribed border Patch: >1 cm; may have irregular border Freckles, flat moles, petechia, rubella, vitiligo, port wine stains, ecchymosis PAPULE, PLAQUE Elevated, palpable, solid mass with a circumscribed border Plaque may be coalesced papules with flat top Papule: <0.5 cm Plaque: >0.5 cm Papules: Elevated nevi, warts, lichen planus Plaques: Psoriasis, actinic keratosis NODULE, TUMOR Elevated, palpable, solid mass that extends deeper into the dermis than a papule Nodule: 0.5–2 cm; circumscribed Tumor: >1–2 cm; tumors do not always have sharp borders Nodules: Lipoma, squamous cell carcinoma, poorly absorbed injection, dermatofibroma Tumors: Larger lipoma, carcinoma VESICLE, BULLA Circumscribed, elevated, palpable mass containing serous fluid Vesicle: <0.5 cm Bulla: >0.5 cm Vesicles: Herpes simplex/zoster, varicella, poison ivy, second-degree burn (blister) Bulla: Pemphigus, contact dermatitis, large burn blisters, poison ivy, bullous impetigo WHEAL Elevated mass with transient borders; often irregular; size and color vary Caused by movement of serous fluid into the dermis; does not contain free fluid in a cavity (e.g., as a vesicle does) Urticaria (hives), insect bites PUSTULE Pus-filled vesicle or bulla Acne, impetigo, furuncles, carbuncles CYST Encapsulated fluid-filled or semisolid mass in the subcutaneous tissue or dermis Sebaceous cyst, epidermoid cysts Secondary Lesions EROSION Loss of superficial epidermis that does not extend to dermis; depressed, moist area Ruptured vesicles, scratch marks ULCER Skin loss extending past epidermis; necrotic tissue loss; bleeding and scarring possible Stasis ulcer of venous insufficiency, pressure ulcer FISSURE Linear crack in the skin that may extend to dermis Chapped lips or hands, tinea pedis SCALES Flakes secondary to desquamated, dead epithelium that may adhere to skin surface; color varies (silvery, white); texture varies (thick, fine) Dandruff, psoriasis, dry skin, pityriasis rosea CRUST Dried residue of serum, blood, or pus on skin surface Large, adherent crust is a scab Residue left after vesicle rupture: impetigo, herpes, eczema ``` SCAR (CICATRIX) Skin mark left after healing of a wound or lesion; represents replacement by connective tissue of the injured tissue Young scars: Red or purple Mature scars: White or glistening Healed wound or surgical incision ``` KELOID Hypertrophied scar tissue secondary to excessive collagen formation during healing; elevated, irregular, red Greater incidence among African Americans Keloid of ear piercing or surgical incision ATROPHY Thin, dry, transparent appearance of epidermis; loss of surface markings; secondary to loss of collagen and elastin; underlying vessels may be visible Aged skin, arterial insufficiency LICHENIFICATION Thickening and roughening of the skin or accentuated skin markings that may be secondary to repeated rubbing, irritation, scratching

Answer 22

Vary in size, shape, cause Type and appearance Primary lesions Initial lesions Characteristic of disease Secondary lesions Results from changes in primary lesions; scratching, trauma, infections, wound healing ``` document: Color Redness, heat, pain, swelling Size and location Patterns of eruptions Distribution of lesions ```

Answer 23

Itching- creams help Allergic- Benadryl, antihistamines Metabolic- Rash Gotta know what is causing this Keep nails short and clean

Answer 24

Caused by Varicella Assessment Careful H & P ``` Diagnoses Impaired Comfort Acute Pain Risk for Infection Social Isolation-zoster virus ``` Plan Relieve pain Reduce/avoid complications ``` Interventions Medications – antivirals, analgesics, corticosteroids Dressings as needed Proper hand hygiene Evaluation ``` Stress and illness can bring this on Hallmark: pain along dermatome followed by an eruption of an itchy rash , one sided Can be spread to other people Contact precautions Can go blind in the eye if it is in that area Can get this more than once Lasts a few weeks Start antivirals ASAP Analgesics and corticosteroids Dressing over it to keep from scratching and shedding virus

Answer 25

Type 1- (cold sore or fever blister) Highly contagious (razors, towels, dishes) Incubation 2-12 days Activated sunlight, wind, cold, flu/infections, stress, heavy alcohol use 50-80% of the population by 30 years old Type 2 Vesicular and ulcerative lesions *genital and anal area* Early symptoms: burning, itching, increased sensitivity or tingling sensation-may occur several days prior to appearance of lesions Lesions progress to vesicles, then yellow crusts, then healing skin Antivirals-acyclovir and valacyclovir

Answer 26

H & P Diagnoses Impaired comfort Impaired Skin Integrity Anxiety Plan Identify cause Soothe/heal skin Prevent infection Interventions Medications – barrier creams, topical corticosteroids Evaluation

Answer 27

H & P Diagnoses Impaired Skin Integrity Disturbed Body Image Impaired Comfort Plan Slow the rapid turnover of epidermis Interventions Stress management Regular skin care routine Medications – topical (corticosteroids and non-steroidals), phototherapy, systemic (cytotoxic, biologic agents) Evaluation Skin care most important Warm baths, gently exfoliate off epidermal cells, apply immolates and hydrate skin Prevent exacerbations UVB phototherapy

Answer 28

Benign vs Malignant ``` Skin cancer prevention: Minimize sun exposure Use sunscreen Avoid tanning beds/booths Check skin regularly ``` ``` A - asymmetry B - border uneven C - color D - Diameter E - evolving ```

Answer 29

H & P Biopsy Diagnoses Fear Acute pain Readiness for enhanced Self-Health Management Plan Surgical excision ``` Interventions Medications Stage II-III = high-dose interferon Stage III-IV = monoclonal antibodies, chemotherapy Pain management Psychological support ``` Evaluation Education on prevention Hats, sunglasses, appropriate clothing, sun screen Cancer Chronic sun exposure Dark red, blue, irregular border, itchy, rapid growth, can ulcerate and bleed Chemo cream

Answer 30

``` Health History Common symptoms Pain Altered sensation Gerontologic consideration Past health, Social & Family history ``` ``` Physical Assessment: Posture Scoliosis Kyphosis Lordosis ``` Gait- Smoothness and Rhythm Bone Integrity- Deformities and Alignment Joint Function- Range-of-motion, Deformity, Stability, tenderness, & Nodular formation skin- edema, temp, color ``` neuromuscular status 5 ps pain pulse pallor paresthesia paralysis ```

Answer 31

Bone Gradual progressive loss of bone mass Bones fragile and prone to fracture Muscles Diminish in size Loss of strength and flexibility Joints Progressive cartilage deterioration Stiffness, reduced flexibility and pain Ligaments Lax ligaments Weakness

Answer 32

Imaging Procedure- X-ray, Computed tomography (CT), Magnetic resonance imaging (MRI), Arthrography Bone Densitometry- Bone Mineral Density (BMD)- determined by Dual-energy x-ray absorptiometry (DXA, DEXA) Bone Scan- metastatic and primary bone tumor Arthroscopy Other- Arthrocentesis, Electromyography, Biopsy FRAX - fracture risk assessment tool a tool that predicts a patient’s 10-year risk of fracturing a hip or other major bone, which includes the spine, forearm, or shoulder nursing management: Prepare the Patient (Before and after)- Position, Allergies Education- Procedure, S/S of infection Monitor and Document- Neurovascular status Administer Analgesic Agent

Answer 33

Indications Joint pain Joint disease Preparation Assess for contraindications Allergies ``` Nursing Implications Compression bandage Rest joint 12 hours after Mild analgesia, ice Clicking/cracking nose normal for 24-48 hours after ``` done in OR only looking into joints

Answer 34

Indications Bone Mineral Density (BMD) Predicts risk of fracture Preparation Assess for contraindications Nursing Implications Not much low BD = easily fractured

Answer 35

``` Indications Bone tumor (primary and metastatic) Osteomyelitis Degenerative bone disease ``` Preparation Assess for contraindications Assess for allergies Nursing Implications Flushing, warm feeling Drink fluids

Answer 36

Indications Diagnosing joint disorders Treat tears Preparation NPO Nursing Implications Ice, compression, elevation Neurovascular assessment Pain management

Answer 37

Indications Examine synovial fluid Remove fluid Preparation Hair removal Nursing Implications Ice 24-48 hours after

Answer 38

``` Indications Muscle weakness, pain, disability Neuromuscular disorders Peripheral nerve disorders (carpal tunnel) ``` ``` Preparation Consent Assess for use of anticoagulants, skin infection Avoid lotions, creams day of test ``` Nursing Implications Warm compresses after

Answer 39

Providing patient education Pre-op assessment (nurse, dr, anesth.) eval. CV, respiratory, renal and liver function risk factors of DVT neurovascular status Mobility -(HIP PRECAUTIONS - post op total hip-can’t bend past 90 degrees, don’t internally rotate-wedge pillow b/w legs in hospital, don’t cross legs, raise toilet—all can predispose to dislocation of new hip) Positioning – post op knee-NEVER pillow under knee, Check Continuous passive motion device (CPM) settings, slightly elevate heels off bed Activities after surgery-PT Preventing infection

Answer 40

Blood loss management Reinfusion devices- collects blood that’s lost during surgery, filters out cells and debris and it can be reinfused back if Hgb is low; 200-500 ml of drainage in first 24 hours on reinfusion device – after 24 hours 50 ml every hours or less Monitor estimated blood loss (EBL) closely Adherence to sterile procedures Prevent infection Culture of joint during surgery May be helpful in identifying subsequent infections

Answer 41

``` Replacement of a severely damaged hip with an artificial joint Indication- OA acetabular dysplasia, RA, AVN, traumatic injury ``` ``` Nursing Interventions Preventing DVT Preventing infection Managing Pain Assessing for Hemorrhage Assessing neurovascular status (5 Ps) Pain Pallor Pulse Paresthesia Paralysis Promoting Ambulation ``` education: Keep the knees apart at all times. Put a pillow between the legs when sleeping. Never cross the legs when seated. Avoid bending forward when seated in a chair. Avoid bending forward to pick up an object on the floor. Use a high-seated chair and a raised toilet seat. Do not flex the hip to put on clothing such as pants, stockings, socks, or shoes. Positions to avoid after total hip replacement are shown in the illustrations. abduction, neutral rotation and flexion of less than 90 degrees

Answer 42

Replacement of a severely damaged knee with an artificial joint Indication Severe pain Functional disabilities ``` Nursing Interventions Preventing DVT Preventing infection Managing Pain Assessing for Hemorrhage Assessing neurovascular status (5 Ps) Pain Pallor Pulse Paresthesia Paralysis Promoting Ambulation ```

Answer 43

``` Assessment/Diagnostic Findings Acute vs. Chronic Radiculopathy? Sciatica? Gait, general observation, spinal mobility, reflexes, strength, sensation Neurologic testing Diagnostic Procedures (Chart 41-1) ``` Medical Management Analgesics (NSAIDS, muscle relaxant) Rest - avoid twisting, bending, lifting, reaching Change positions frequently – limit sitting to 20-50 min Thermal therapy Spinal manipulation Assessment H & P Diagnoses Acute Pain Impaired physical mobility Activity intolerance Plan Management of causes Pain management Improved mobility ``` Interventions Pharm and non-pharm pain management Body mechanics (Chart 41-2) Lumbar flexion (pillows between knees) Exercise program Weight reduction ``` Evaluation

Answer 44

``` Reduced bone mass Resorption > Formation => porous, brittle, fragile Deterioration of bone matrix Diminished bone architectural strength ``` biggest problem is fractures bone density test ``` high risk: slender female caucasian alcohol smoker steroid use Genetics Age Nutrition Physical Exercise Lifestyle Medication women after menopause ``` ``` ACCESS alcohol use corticosteroid use calcium low estrogen low smoking sedentary lifestyle ```

Answer 45

Pharmacologic Therapy- Calcium and Vitamin D Supplements and Bisphosphonates (alendronate, risedronate, ibandronate) Fracture Management- Surgically joint replacement, Open/Closed reduction with internal fixation (Osteoporotic compression fractures of vertebrae are managed conservatively) Prevention is the best action!

Answer 46

Inadequate Mineralization- The skeleton softens and weakens => Spinal Kyphosis/ Rickets and Bowed Legs soft bones due to calcium loss O shaped extremities patho: Vitamin D Deficiency Decrease Calcium Absorption/ Increased Calcium Loss Risk Factors- GI disorders, Liver and Kidney diseases, Hyperparathyroidism, Malnutrition Medical Management- Reduce discomfort and pain, Underlying cause correction

Answer 47

``` D Fatty fish - tuna, mackerel, and salmon Beef liver Cheese Egg yolks Foods fortified with vitamin D - some dairy products, orange juice, soy milk, and cereals ``` calcium Spinach, Kale, Okra, Collards Soybeans White beans Fish - sardines, salmon, perch, and rainbow trout Foods fortified with calcium - some orange juice, oatmeal, and breakfast cereal

Answer 48

infection to bone!! Hematogenous spread Trauma or surgical instrumentation ``` Assessment/Diagnostic Findings X-ray, bone scan, MRI Increased WBCs Elevated ESR Wound/blood culture ``` Management Pharm – antibiotics IV (3-6 weeks) Surgery – debridement Wound irrigations prevention Postpone elective orthopedics surgery if client has infection (UTI, URI, etc.) Surgical environment Prophylactic antibiotics Urinary catheters and drains only as needed; remove ASAP Aseptic wound care Assessment H & P Diagnoses Acute Pain Impaired physical mobility Plan Pain management Improved mobility Interventions Immobilization (keep infection localized) Analgesics Elevate extremity Activity restrictions so do ROM on joints above and below affected joint Evaluation