exam 3 Flashcards
1
Q
Changes in elderly that increase risk for infection?
A
Respiratory changes
Genitourinary changes
Gastrointestinal changes
Skin and subcutaneous tissue changes
Immune changes
Other factors
2
Q
pediatric considerations that increase risk for infection?
A
Age < 1 month
Serious injury
(e.g., major trauma, burns, or penetrating wounds)
Chronic debilitating medical condition
Host immunosuppression
Large surgical incisions
Indwelling vascular catheters
Urinary tract abnormalities with frequent infection
3
Q
airborne precautions for …
A
chicken pox, TB, measles, COVID
4
Q
droplet precautions for ….
A
pneumonia, strep, flu
5
Q
contact precautions for …
A
MRSA, VRE, Noro
6
Q
prevention for nosocomial infections
A
Prevention is key!
Meticulous handwashing
Minimize invasive procedures
Strict medical and surgical asepsis
Oral care
Critical thinking, Agency policies
Hand hygiene for clients, nurse and family
Resources- WHO, CDC
7
Q
What is sepsis and septic shock?
A
A life-threatening organ dysfunction cause by a dysregulation of the host body’s response to infection; Sepsis is an unregulated, uncontrolled, intravascular inflammation
8
Q
what happens in septic immune response to infection?
A
mismatch of proinflammatory and anti-inflammatory mediators followed by leakage of inflammatory mediators into blood causing a systemic response
9
Q
stages of sepsis
A
precipating event - vasodilation - activation of inflammatory response - maldistribution of intravascular volume - decreased venous return - decreased CO - decreased tissue perfusion
10
Q
criteria for SIRS (systemic inflammatory response syndrome)
A
Temperature >38.3 or <36
Tachycardia
Tachypnea
WBC >12,000 or <4000 or > 10% immature cells
Must have 2 criteria present
to be identified with SIRS
not specific to sepsis
11
Q
SIRS caused by ….?
A
ischemia, trauma, infection
12
Q
What does SOFA score stand for?
A
sequential organ failure score
13
Q
QSOFA criteria?
A
hypotension (systolic bp less than 100), altered mental status, tachypnea (RR above 22)
14
Q
what is QSOFA?
A
quick sequential organ failure assessment- quick patient screening without labs
15
Q
what is MEWS score?
A
modified early warning system
16
Q
what is observed for MEWS?
A
RR, HR, systolic BP, conscious level (UPVA), temp, hourly urine for 2 hours
17
Q
what is PEWS?
A
pediatric early warning signs
18
Q
sepsis diagnosis criteria?
A
Suspected or known infection
Meeting MEWS or qSofa criteria
Increase of 2 or more on the SOFA scale
19
Q
presentation of initial stage of sepsis?
A
Warm flushed skin
Bounding pulse
Normal blood pressure
Fever
Normal to decreased urinary output
20
Q
tx of initial stages of sepsis?
A
Identify and treat underlying cause
Antibiotic administration
Fever control
Maintain hydration
Prevent progression to severe sepsis
21
Q
early (warm) sepsis presentation?
A
B/P: normal to hypotension
↑ pulse
Rapid & deep respirations
Warm, flushed skin
Alert, oriented, anxious
Normal UOP
↑temp, chills, N/V/D
Weakness
22
Q
late (cold) sepsis presentation
A
Hypotension
Tachycardia, arrhythmias
Rapid, shallow resp
Dyspnea
Pale, cool skin
Edematous
Lethargic to comatose
Oliguria to anuria
Norm to decreased temp
23
Q
severe sepsis criteria?
A
Suspected or known infection
Sepsis induced organ dysfunction (increase of 2 or more points on SOFA criteria) or tissue hypoxia
24
Q
severe sepsis presentation
A
Warm flushed skin (core)
Pale cool skin (periphery)
Fever
Bounding pulse, tachycardia
Hypotension
Elevated respiratory rate
Decreased urinary output, elevated creatinine
Nausea, vomiting, diarrhea, slow GI motility
Altered mental status
Increased bilirubin
Increased lactic acid level
Increased procalcitonin
25
severe sepsis tx?
Identify and treat underlying cause
Antibiotic administration
Fluid resuscitation
Fever control
Prevent progression to septic Shock
26
septic shock criteria?
Suspected or known infection
*Sepsis induced organ dysfunction or tissue hypoxia
*Hypotension despite adequate fluid resuscitation
Subset of sepsis causing increased mortality due to abnormalities in circulation and cellular function
27
septic shock presentation
Critically ill
Hypotensive
Tachycardia
Altered level of consciousness
Respiratory distress or failure
Minimal to no urine output
Hypoactive bowel sounds
28
septic shock tx?
Antibiotic administration
Adequate fluid resuscitation
Vasopressor medications
Prevent progression to MODS
29
lab tests for sepsis?
CBC
Chemistries
LFTs
Lactate
Procalcitonin
Coagulation studies
CSF
Cultures- blood, urine, sputum
30
radiology testing for sepsis?
CXR, CT, US
31
lactic acid levels
<2 mmol/L Normal
2-4 mmol/L Lactic acidosis
>4 mmol/L Sever Lactic Acidosis
32
cause of lactic acid elevation?
Poor tissue perfusion
Cells begin anaerobic metabolism for energy
Anaerobic metabolism produces byproduct of lactic acid
33
effects and tx of high lactate levels?
Anaerobic metabolism
Makes cells swell
Causes membrane permeability
Lactate ½ life about 20 minutes
Consistently elevated lactate equals continue anaerobic metabolism
Lactic acid level > 4.0
27% increased mortality rate
Fluid resuscitation to improve perfusion
Vasopressor medications
Hypotension despite fluid resuscitation to improve perfusion
34
what is procalcitonin?
A protein produced by many cells in the body
Increased production in the presence of bacterial infections
½ life is about 28-30 hours
-cells release procal when exposed to bacterial toxins, used to determine the level of inflammation and degree of bacterial infection
35
interpretation of procal levels?
Normal 0.15ng/ml
0.15-2ng/ml
Localized mild to moderate bacterial infection
Noninfectious SIR
Untreated end-stage renal failure
>2ng/ml
Bacterial sepsis
Severe localized bacterial infection
Severe noninfectious inflammatory stimuli
36
Sepsis tx
Glycemic control
Nutrition
DVT prophylaxis
Temperature control
Fluid resuscitation
Medications
Vasopressor medications
Antibiotics
Insulin therapy keep blood sugar <180
Initiation of enteral feedings tolerated
Heparin or Lovenox
Tylenol or Motrin
IV fluids
30ml/kg adult
40ml/kg pediatric > 1 year
Up to 60ml/kg pediatric
37
What is the sepsis 6?
take 3 (blood cultures, blood tests including lactate, measure urine output), give 3 (O2 to keep sats >92, IV fluids, IV antibiotics as per local guidelines)
38
alpha 1 adrenergic receptors
Located in the vasculature
Global vasoconstriction
Increase BP
Strong Alpha 1 stimulation causes end organ damage due to decreased blood supply r/t vasoconstriction
39
beta 1 adrenergic receptors
Located in the heart
+ inotropic,
Increased heart rate (cardio stimulant)
Increase CO
Increase blood flow
40
beta 2 adrenergic receptors
Located in lungs and blood vessels
Vasodilation
Smooth muscle relaxant
Decrease blood pressure
41
what is norepinephrine (levophed)?
vasopressor- first line pressor for sepsis; start if hypotension remains despite fluids
1st for Adult septic shock
Alpha 1 Stimulation
Mild stimulation
Beta 1 & Beta 2 receptors
Global vasoconstriction
Minimal increase in CO
42
what is high dose dopamine?
vasopressor;
1st line pediatric septic shock
Beta 1 stimulation
Alpha 1 receptors (some)
Minimal Beta 2 receptors
Increased HR
+ Inotropic effect
Some vasoconstriction
43
what is epinephrine?
vasopressor;
1st or 2nd pediatric septic shock
Strong Alpha 1 & Beta 1 stimulation
Minimal Beta 2 stimulation
Global vasoconstriction
Increased HR,
+ Inotropic effects
may see increase in lactic acid
44
what is vasopressin (ADH)?
adjunct med to vasopressor- use when hypotension persists despite fluids and pressors
Used with norepinephrine (Hence the BFF)
Not commonly used alone
Increased SVR and BP
Increases retention of water
Vasoconstriction
Synthetic ADH
45
when do you start antibiotics for sepsis?
within 1-3hrs of identification
46
Sepsis complications
Acute Kidney Injury
Hyperglycemia
GI complications
Disseminated Intervascular Coagulation
Acute Respiratory Distress Syndrome
Multi Organ Dysfunction Syndrome
47
what is MODS?
Alteration in organ function requiring medical treatment to continue organ function
Organ damage occurs at cellular level
PREVENTION of tissue hypo-perfusion important
Supporting organ function only treatment
High mortality associated
48
sx of mild systemic anaphylactic reaction?
Peripheral tingling
Warmth
Possible full feeling in mouth or throat
Nasal congestion
Periorbital swelling
Begins within 2 hours of exposure
49
sx of moderate systemic anaphylactic reaction?
Nasal congestion
Periorbital swelling
Flushing
Warmth
Anxiety
Itching
Possible bronchospasm
Possible airway swelling
Begins within 2 hours of exposure
50
first med given for anaphylaxis?
epinephrine
51
second med given for anaphylaxis?
diphenhydramine - benadryl
52
how long does epi last?
30-45 minutes
53
what is the dosing for epipen and epipen jr?
0.3mg adult; 0.15mg JR
54
What are the 3rd and 4th meds given for anaphylaxis?
histamine 2 blockers, methylprednisone (solumedrol)
55
nursing interventions for anaphylaxis?
meds (epi, benadryl, histamin 2 blockers, solumedrol), duoneb, monitor ABCs, monitor vitals, support pt and family, education for pt and family, MONITOR pt for rebound sx
56
pathophys of malignant cells?
rapid cell division, no useful funtion, adhere loosely, able to migrate, grow by invasion
57
what are factors that are associated with the development of cancer?
environmental exposure
genetic predisposition
immune function
58
risk factors for developing cancer?
Heredity
*Age
*Gender
*Poverty
*Stress
* Diet
*Occupation
* Infection
*Tobacco use
*Alcohol
*Obesity
59
what is CAUTION? (cancer)
– Changes in bowel/bladder habits
– A sore that does not heal
– Unusual bleeding/discharge
– Thickening or lump in the breast/elsewhere
– Indigestion
– Obvious change in wart or mole
– Nagging cough or hoarseness
60
primary prevention for Ca
Dietary habits to
reduce cancer risk
Weight control
Tobacco use
Alcohol use
Sun exposure
61
secondary prevention for Ca
ACS recommendations for early detection in
asymptomatic people:
* Sigmoidoscopy
* Fecal occult
* Digital rectal exam
* Prostate, testicular
* Pap smear
* Mammography
* Breast exam
62
What are the types of biopsies?
* Removal of tissue for pathologic review for definitive
diagnosis
* Needle
* Incisional
* Excisional
* Results identified, classified and graded
63
what is Tumor TNM classification staging?
* T The extent of the primary tumor
* N The absence or presence and extent of
regional lymph node metastasis
* M The absence or presence of distant
metastasis
* The use of numerical subsets of the TNM
components indicates the progressive
extent of the malignant disease.
64
things to know about primary tumor (T) in TNM
* Tx Primary tumor cannot be assessed
* T0 No evidence of primary tumor
* Tis Carcinoma in situ
* T1, T2, T3, T4 Increasing size and/or local
extent of the primary tumor
65
things to know about regional lymph nodes (N) in TNM staging?
* Nx Regional lymph nodes cannot be
assessed
* N0 No regional lymph node metastasis
* N1, N2, N3 Increasing involvement of
regional lymph nodes
66
things to know about distant metastasis (M) in TNM staging?
* Mx Distant metastasis cannot be assessed
* M0 No distant metastasis
* M1 Distant metastasis
67
GX grading
grade cannot be assessed (undetermined)
68
G1 grading
well differentiated (low grade)
69
G2 grading
moderately differentiated (intermediate grade)
70
G3 grading
poorly differentiated (high grade)
71
G4 grading
undifferentiated (high grade)
72
how does cancer metastasize?
bloodborne or lymphatic
73
diangostic tests and tumor markers?
CA 125- ovarian, breast
PSA- prostate specific antigen
ADH- brain
CEA- GI
alkaline phosphatase- bone, liver
AFP (alphafetoprotein)- liver, ovarian, testicular, pancreas
74
diagnostic tests and labs?
* CT scan
* Bone Scan
* PET scan
* Chest x-ray
* CBC with diff
* BMP
75
What happens with internal radiation?
implant placed into affected area and sealed in tubes, seeds, etc.
may be temporary or permanent
can be ingested, injected, or introduced to tumor via catheter
may transmit rays outside the body or excreted in body fluids
76
external radiation nursing care?
▪ Monitor for adverse effects: skin changes, ulcerations of
mucous membranes; nausea and vomiting, diarrhea, or
gastrointestinal bleeding.
▪ Assess lungs for rales
▪ Identify and record any medications that the client will be
taking during the radiation treatment.
▪ Monitor WBC’s and platelet count
77
patient and family teaching for radiation?
* * Wash the skin that is marked as the radiation site only
with plain water, no soap; do not apply deodorant, lotions,
medications, perfume, or talcum powder to the site during
the treatment period. Take care not to wash off the
treatment marks.
* * Do not rub, scratch, or scrub treated skin areas. If
necessary, use only an electric razor to shave the treated
area.
* * Apply neither heat nor cold (e.g., heating pad or ice
pack) to the treatment site.
* * Inspect the skin for damage or serious changes, and
report these to the radiologist or physician
* Wear loose, soft clothing over the treated area.
* Protect skin from sun exposure during treatment and for
at least 1 year after radiation therapy is discontinued.
Cover skin with protective clothing during treatment; once
radiation is discontinued, use sun-blocking agents with a
sun protection factor (SPF) of at least 15.
* External radiation poses no risk to other people for
radiation exposure, even with intimate physical contact.
* Be sure to get plenty of rest and eat a balanced diet.
78
common side effects with chemo?
Alopecia
* Nausea/vomiting
* Stomatitis
* Skin changes
* Hematopoietic effects: bone marrow suppression
79
education for oral chemo
Medication calendar
* Do not chew/cut or crush meds
* Watch for s/e:
* Hand-foot syndrome
* Nausea/vomiting
* Flu-like symptoms
* Skin rash
* Elevated temp
* Hair loss and nail changes
* Mouth sores -
80
chemo can cause ....?
* Bone Marrow Suppression
* Thrombocytopenia :< 100,000, severe <20,000
* Hold chemo if <7500
* Give thrombopoietin receptor agonist, transfuse platelets
* Leukopenia/Neutropenia: <1,000 some say <3500
* Give Neupogen (filgrastin)
* Reverse precautions
* Anemia: HCT (10-13)
* Give epoetin
81
what is nadir?
- the period after chemo during which blood counts
(particularly the WBC) are the lowest--generally 10-14 days after chemo *bone marrow suppression*
82
paraneoplastic syndrome tx
* Corticoid steroids
* Antipsychotics & benzodiazapines
* Opioids – oral, iv, systemic
* Megace
* Electrolyte replacement
* Epoeitin Alfa
* Tricyclic antidepressants
* Anticonvulsants
* Lidocaine patches
83
risk factors for breast cancer
* Family history of breast cancer
* BRAC1 & BRAC2
* Early menarche & late menopause
* Previous cancer of the breast, uterus, or ovaries
* Obesity, high-dose radiation exposure of chest
84
breast cancer manifestations
* Breast mass or thickening
* Unusual lump in the underarm or above the collarbone
* Persistent skin rash near the nipple area
* Flaking or eruption near the nipple
* Dimpling, pulling, or retraction in area of breast
* Nipple discharge
* Change in nipple position
* Burning, stinging or pricking sensation
* Peau d’orange
85
surgical tx for breast cancer
* Lumpectomy – excision of primary tumor & adjacent
breast tissue f/b radiation therapy
* Simple mastectomy- breast tissue & nipple are removed,
lymph nodes are left intact
* Modified radical mastectomy – breast tissue, nipple and
lymph nodes are removed, muscles are left intact
* Radical mastectomy – removal of entire affected breast,
underlying chest muscles, and lymph nodes under the
arms
* Breast reconstruction – may be performed at time of
mastectomy or any time after
86
non-surgical breast cancer tx
* Chemotherapy
* Radiation therapy
* NEW – intraoperative radiation therapy
* Hormonal use of medications (eg, tamoxifen)
87
risk factors for colon cancer
genetics and diet
88
manifestations of colon cancer?
* Blood in stool
* Anorexia, vomiting,
* Weight loss, malaise
* Anemia abnormal
stools
* Guarding or
abdominal distention
* Abdominal mass (late
sign)
* Ascending colon
tumor (diarrhea)
* Descending colon
tumor (constipation,
some diarrhea, or flat,
ribbon like stools)
* Rectal tumor
(alternating
constipation &
diarrhea)
89
colon cancer tx
* Hyperthermic intraperitoneal chemotherapy (HIPEC)
* Targeted therapy
* Immunotherapy
* Surgery
90
causes of lung cancer
* Cigarette smoking
* Exposure to
environmental
pollutants
* Exposure to
occupational pollutants
91
sx of lung cancer
* Cough, dyspnea,
hoarseness,
hemoptysis, chest
pain, anorexia, weight
loss
* Weakness
* FATIGUE FATIGUE
FATIGUE
92
lung cancer tx
* Radiation therapy for
palliation of
hemoptysis,
obstruction,
dysphagia & pain
* Chemo may be
prescribed for TX of
nonresectable tumors
or as adjuvant
therapy
* Laser therapy
* Thoracentesis &
pleurodesis
* Thoracotomy
* Lobectomy
93
causes of leukemias?
* Exposure to radiation, certain chemicals
* Retrovirus known as human T-lymphotropic virus
* Malignant production of WBC’s actual cause of disease
94
types of leukemias?
* Acute myelogenous leukemia (AML)
* Chronic myelogenous leukemia (CML)
* Acute lymphocytic leukemia (ALL)
* Chronic lymphocytic leukemia (CLL)
95
major effects of leukemias?
* Increased numbers of abnormal, immature leukocytes
* Accumulations of cells within lymph nodes, spleen and
other organs
* Eventual infiltration of malignant cells t/o organs of body
96
acute leukemia info
* Sudden, rapid growth of
immature blast or stem cells
* Rapid progression of
disease
* Short survival if not treated
97
chronic leukemia info
Gradual onset,
* Slower disease
progression
* Relatively longer survival
time
* CLL common in men over
50
* CML most common in
young & middle-aged
adults
* CML progresses to acute
form, death is common
98
s/s of leukemia?
* Fever
* Malaise
* Frequent or persistent infections
* Swollen lymph nodes
* Enlarged spleen
* Bone pain
* Weight loss
* Easy bleeding or thrombosis
99
what is graft v host diseases?
* Graft-versus-host disease (GVHD) is a complication that
can occur after a stem cell or bone marrow transplant
* Newly transplanted donor cells attack the transplant
recipient's body
* Treatment of chronic GVHD includes steroids and
antibiotics
100
risk factors for childhood leukemias?
Genetics
* Having a brother or sister with leukemia
* Environmental – chemicals - benzene
* Radiation & chemo exposure
101
long term side effects of tx with childhood cancers?
Abnormal pulmonary function
* Hearing loss
* Endocrine or reproductive dysfunction
* Cardiac conditions
* Neurocognitive impairment
* Liver & kidney dysfunction
* Abnormal blood cell counts
* Osteoporosis
* 18% of survivors will have a second malignancy during
adulthood
102
what is superior vena cava syndrome?
happens when the superior vena cava is partially blocked or compressed. Cancer is usually the main cause of SVCS.
