Exam 3 Flashcards
pubic area has lots of?
lymph nodes
reproductive cancers sexual assessment
menstruation, long term exposure to estrogen (early menarche and late menopause)
pregnancies
exposure to meds
chronic illness
family and genetics
STDs, surgeries, procedures
how to ask patient about relationships
ask about meaningful ones instead of asking about labels (single, married, etc.)
colposcopy
area behind (retro) cervix
loop electrosurgical excision (LEEP)
looks like a horseshoe on a stem, electrified
endometrial biopsy
lining of uterus=endouterine
uterine cancer
dilation and curettage
scrapes and suctions endometrial layer
done for miscarriage and heavy menstrual cycles
laparoscopy (pelvic peritoneoscopy)
small incision on abdomen and putting in laparascope
hysteroscopy
same as laparoscopy but with uterus
HPV
most common STD among young people
gardasil vaccine for it! Given to people 11+
treatment of genital warts
HPV and cervical cancer
risk factor!
associated with cervical dysplasia and cervical cancer
annual pap smears (maybe more if extensive)
many strains (6 predispose to cancer)
4 S&S of premenstrual syndrome
HA, bloating, pain, mood changes
primary dysmenorrhea
occurs when you get your first period
severe cramps during period not from any secondary medical condition
amenorrhea causes
low body fat (estrogen in body fat)
low estrogen
Metrorrhagia
Bleeding between periods
symptoms of female cancers
no early symptoms
depends on location
vaginal discharge, pain, bleeding, systemic symptoms (weight loss and anemia)
cervical cancer cell types
Squamous cell carcinoma or adenocarcinoma
up to date HPV vaccine
-teens with 3 or more doses
-teens with 2 doses when the first HPV vaccine dose was initiated prior to age 15 years and there was at least five months minus four days between the first and second dose
risk factors for cervical cancer
early sexual activity (before 18)
multiple partners
sex with uncircumcised males
sexual contact with males whose partners had cervical cancer
early childbearing (12-13)
HIV infection, exposure to HPV
smoking
family history
nutritional deficiencies (folate and vit c)
cervical cancer S&S
few to no symptoms besides thin, water vaginal discharge
Irregular bleeding, pain or bleeding after sex, dark, foul- smelling discharge, leg or rectal pain with advanced disease
diagnosis of cervical cancer
abnormal pap smear
D&C to further stage disease
biopsy CIN III or carcinoma in situ
invasive cancer
cervical cancer treatment
Precursor or Pre-invasive lesions found and followed by colposcopy → cryotherapy, LEEP, conization
Invasive Cancer: based on stage lesion, host factors
hysterectomy, B/L pelvic lymphadenectomy, pelvic exenteration, radical trachelectomy
brachytherapy
ovarian cancer risks
increased risk in 40s peaks in 80s
pregnancy and OCP decrease risk because of interrupted estrogen
correlation between breast and ovarian ca
difficult to detect (no early screening, transvaginal ultrasound used for high risk)
family hx
obesity
ovarian cancer S&S
vague
Late signs, no early ones or screening
Abdominal bloating
Increased abdominal girth (ascites)
Pelvic pressure
Back pain
Constipation
Urinary urgency
Indigestion
Pelvic and/or leg pain
Flatulence/bloating
ovarian cancer diagnosis
pelvic imaging
management of ovarian cancer
Surgery: tumor debulking or removal for staging
Pre-op: barium enema, c/scope, UGI series, CT scan, CXR to r/o mets
Staging: TNM stage I-IV
Borderline tumor: removal of affected ovary
Chemo
Generally spreads to peritoneum
complications of advanced ovarian cancer and treatment
Pleural effusion and ascites
IVF
I&O
TPN
Comfort measures
Thoracentesis to remove fluid from chest area
endometrial (uterine) cancer risk factors
more common in white ppl than black (but black ppl die more)
age >55
obesity
unopposed estrogen therapy (without progesterone)
nulliparity (never pregnant)
truncal obesity
late menopause
use of tamoxifen (chemo for breast cx)
S&S of uterine cancer
irregular bleeding
postmenopausal bleed
vaginal cancer
rare and takes years to develop
vaginal cancer risk factors
previous cervical/vaginal/vulvar cancers, in utero exposure to DES (diethyl sylvesterone, given to women with repeated miscarriages, daughters of these women developed cervical and vaginal cancer), previous radiation therapy, history of HPV, or pessary use
vaginal cancer S&S
patients often report no symptoms
May report slight bleeding after intercourse, spontaneous bleeding, vaginal discharge, pain, and urinary or rectal symptoms
treatment of vaginal cancer
local excision, topical chemotherapy, or laser therapy
vulva cancer
Encourage regular pelvic exams, Pap smears, and self- examination for early diagnosis
risk factors of vulva cancer
smoking, HPV infection, HIV, immunosuppressant therapy
vulva cancer S&S
Long-standing pruritus and soreness
May present as a chronic dermatitis, or a lump, ulcer, or mass
Bleeding, foul-smelling discharge, and pain are late signs
diagnosis and management of vulva cancer
Endometrial bx for postmenopausal bleed
Sonogram
Total abdominal hysterectomy or total abdominal hysterectomy and bilateral salpingo oophorectomy (uterus and ovaries, respectively)
Brachytherapy
Chemo
fibroids (myomas)
benign growth of muscle tissue
ages 25-40
Common reason for hysterectomy secondary to menorrhagia
genetic predisposition!!
can be in endometrium or muscle layers
S&S of fibroids
May have no symptoms, or may produce abnormal vaginal bleeding, pain, backache, bloating, constipation, urinary problems constipation, menorrhagia, metrorrhagia. May also interfere with fertility (can get pregnant but have early/late miscarriage bc of cramping from myoma)
management of fibroids
Watch and wait, surgical options, medical options
Myomectomy
Hysterectomy
Laparoscopic myolysis
Laparoscopic cryomyolysis
Uterine artery embolization (UAE)
May do fibroid, hysterectomy, laparoscopy and burn/freeze muscle layer
More common is uterine artery embolization (embolize or ablate uterine artery so feeding of blood to myoma stops)
Magnetic resonance-guided focused u/s surgery
Meds: gonadotropin-releasing hormone, mifepristone
endometriosis
Benign lesion(s) that proliferate the uterine lining and can grow anywhere in pelvic cavity like diaphragm and intestines
Associated with chronic pelvic pain and infertility
Familial predisposition
Ectopic tissue bleeds into cavity with no outlet causing adhesions and pain
S&S of endometriosis
Dysmenorrhea, dyspareunia (pain r/t discourse), pelvic discomfort, dyschezia (need to poop but never feel empty), infertility, depression
diagnosis of endometriosis
menstrual pattern, limited uterine mobility and fixed tender nodules on bi-annual exam
Laparoscopic exam to stage disease
Stage I-IV
management of endometriosis
Based on desire for pregnancy and extent of disease
Symptom mgmt.: NSAIDs, OCP
Hormonal therapy: androgens (male hormones), GnRH-agonists
Surgical mgmt.: laparoscopic fulguration, endocoagulation, electrocoagulation, TAH, TAH/BSO
Nsg: Need to address psychological impact of inability to conceive, symptom mgmt
May need to remove some organs if serious
hysterectomy
removal of uterus to treat cancer, dysfunctional bleeding, endometriosis, nonmalignant growths, pain, pelvic relaxation, prolapse, and previous injury
total or radical
laparoscopic, vaginal, or abdominal
potential complications of hysterectomy
hemorrhage
DVT
bladder dysfunction
Mastitis and diagnosis
inflammation of breast tissue, often diagnosed instead of breast cancer
Start with ultrasound, then mammogram to avoid radiation
risk factors for breast cx
Female gender
Age
Personal and family history including genetic mutations
Hormonal factors (longer exposure to estrogen)
Exposure to radiation
History of benign breast disease
Obesity
High-fat diet (controversial)
Alcohol intake
Fibrositis? breast (dense tissue)
most commonly affected genes in hereditary breast and ovarian cancer
breast cancer 1 (BRCA1) and breast cancer 2 (BRCA2) genes
Make you more likely to have female cancers
BRCA1 and BRCA2 genes
Normally protect you from certain cancers
Mutations prevent them from working properly, making you more likely to have these cancers
NOT EVERYONE WITH THE GENE WILL HAVE CANCER
guidelines for early detection of breast cancer
women in 20-30s: breast exam q3y, then annually after 40
Mammogram annually once 40
Women with risk factors may have early, more frequent detection along with ultrasound and MRI
once 20, teach BSE
Do BSE lying or standing (same every time)
Breast self exam
best 5-7 days after first day of menses or once monthly for postmenopausal women
Breasts more edematous and sensitive during menses
part of the exam may be done in shower with soapy hands to glide over breast
note importance of underarm and the area under it
breast disorders
Breast pain
Cysts
Fibroadenomas
Benign proliferative breast disease
Atypical hyperplasia
Lobular carcinoma in situ
lobular carcinoma in situ**
in lobules (milk ducts!!)
MRI on patient with ICD
Rep from ICD company has to come in for the procedure so they can recalibrate the ICD or pacemaker (if it’s MRI compatible)
percutaneous breast biopsy
fine-needle aspiration, core biopsies (fluid=cystic=benign)
surgical biopsies for breast
excision, incision, wire needle localization
lumpectomy, modified radical mastectomy and sentinel node biopsy
lumpectomy: tumor and some surrounding area
modified radical mastectomy: take off breast lymph nodes adjacent to breast
sentinel node biopsy: if one node is neg, ur good, if one is pos, look at the others
cervix and bladder vascularity
VERY VASCULAR
what to do if breast surgery pt hemorrhaging
Apply pressure if hemorrhaging to immediately stop flow, patient is coming back with drains
Should be serosanguinous at some point, less and less drainage
(Internet says serosanguinous at 6w)
when to alert surgeon after breast surgery
Blood after serosanguinous drainage
Fever
Pus
Keep a log of drainage
Hematoma if she feels pressure!!!
Pain that is getting worse
Another drain to release blood
concerns with modified radical mastectomy
Lymphedema since we are removing axillary lymph nodes
how to avoid lymphedema after breast surgery
Pressure dressing on right arm
Exercises to prevent lymphedema
Impossible to get rid of!
Keep arms at least at breast level or elevated
Very dramatic, LOTS of fluid
FOREVER, not just during recovery
silicone implants after mastectomy
Putting fluid every month
Sometimes abdominal muscle used for breast reconstruction
Sometimes latissimus dorsi muscle
All painful
hormonal therapy for breast cancer
Estrogen and progesterone receptor assay
-Moms genetic coding is checked and meds are given for specific type of cancer
Selective estrogen receptor modulators (SERMs)— tamoxifen
Aromatase inhibitors—anastrozole, letrozole, exemestane
what type of therapy if lymph nodes involved in breast cx
radiation
what to do if family member says patient wants meds
HEAR IT FROM THE PATIENT
potential complications of breast surgery
lymphedema
hematoma/seroma (serous fluid) formation
infection
area is throbbing and burning
random intractable pain
hand and arm care after breast surgery
potential for lymphedema formation after ALND
follow prevention guidelines for life
PT to avoid contractures
no BP, injections, or blood draws to affected arm
exercise 3x/day for 20 mins
mild analgesic or warm shower before exercise
initial limitation of lifting (5-10 pounds)
heavier than half milk gallon=2 arms
when is drain removed after breast surgery
after <30mL output in 24 hours (usually 7-10 days)
normal WBC count and why is it important
4,500-11,000
if patient is neutropenic, can’t do chemo
Normal PaCO2
35-45 mmHg
Normal HC03
22-26 mEq/L
Normal PaO2
80-100 mmHg
Base excess/deficit
+/- 2 mEq/L
resp acidosis
low pH
PaCO2 >42
due to inadequate exertion of CO2 (pons/brainstem controls breathing, drugs, CNS trauma, COPD, PNA)
chronic resp acidosis, body may compensate and be asymptomatic
symptoms of resp acidosis
suddenly increased pulse, respiratory rate, and BP
mental changes
feeling of fullness in head
resp alkalosis
high pH
PaCO2 <35
always from hyperventilation
manifestations of resp alkalosis
lightheadedness
inability to concentrate
numbness and tingling
sometimes loss of consciousness
metabolic acidosis
low pH
HCO3 <22
caused by diabetes, shock, and renal failure
metabolic alkalosis
high pH
HCO3 >26
sodium bicarb overdose, prolonged vomiting, NG drainage
larynx
voice box!
risk factors for larynx cancer
carcinogens like tobacco products
ETOH
occupational
men > women
advanced age >60
chronic laryngitis
vocal straining
laryngeal cancer carcinogens
tobacco
Combined effects of alcohol and tobacco
Asbestos
Secondhand smoke
Paint fumes
Wood, Cement dust
Chemicals
Tar products
Mustard gas
Leather and metals
7 other factors in laryngeal cancer
Nutritional deficiencies (vitamins)
History of alcohol abuse
Genetic predisposition
Age 65 +
Men > women
More prevalent in African Americans and Caucasians
Weakened immune system
clinical manifestations of laryngeal cancer**
Hoarseness (lower voice) of more than 2 weeks’ duration occurs
ACE inhibitors (-prils) cause cough and polyps in throat (not cancer but check!
persistent cough or sore throat
lump in neck
later symptoms of laryngeal cancer**
Dysphagia
Dyspnea
Unilateral nasal obstruction or discharge
Persistent hoarseness
Persistent ulceration and foul breath (late symptoms)
Cervical lymphadenopathy
Unintentional weight loss
General debilitated state
Pain radiating to the ear may occur with metastasis
diagnostic procedures for laryngeal cancer
FNA biopsy
barium swallow
-fluoroscopy, drink barium liquid
-can cause constipation, drink lots of fluids after test so they have a proper BM (some white in poop)
Endoscopy
CT or MRI scan
Positron emission tomography (PET) scan
Direct laryngoscopy
OXYGEN MUST BE HUMIDIFIED POST-OP
CAN’T SPEAK AFTER SURGERY
staging of cancer
TNM system
T- size and invasion
N-node involvement
M-metastasis
where does laryngeal cancer often spread
lungs
radiation therapy for larynx
tries to preserve laryngeal function
relearn how to talk
speech therapist
treatment of laryngeal cancer
radiation
Chemotherapy (5FU, cisplatin)
Surgery
Vocal cord stripping (razor shaves vocal chords)
Cordectomy
Laser surgery
Partial laryngectomy
Supraglottic laryngectomy
Hemilaryngectomy
Total laryngectomy
postop management after laryngeal surgery
assessment and diagnosis
airway clearance (SEMI FOWLERS)
education
relieve anxiety (maybe meds)
postop interventions for laryngeal surgery
maintain patent airway
promote alternate communication
promote body image (family reactions)
how to maintain patent airway after laryngeal surgery
-fowler or semi fowler
-observe for restlessness, labored breathing, apprehension, tachy (low O2)
-assess lung sounds
-avoid opioids (toradol instead bc anti inflammatory)
-turn, cough, deep breaths
-suction
-careful w suture lines
-early ambulation to avoid atelectasis, PNA, and venous thromboemboli
-pulse ox
Promoting alternative communication methods after laryngeal surgery
Establish an effective means of communication
Understand and anticipate postoperative needs by working with patient, speech therapist, and family
Encourage the use of alternative communication methods
esophageal speech
therapist may teach patient to swallow air and send it back up through the mouth
hydration and nutrition after laryngeal surgery
no eating or drinking 7 days post op
swallow study before oral intake
once feeding started, keep suction at bedside for self suctioning
avoid sweets
frequent oral care (every few hours)
observe weight, skin turgor, VS, and lab data
complications of laryngeal surgery
Respiratory distress (hypoxia, airway obstruction)
Tracheal edema
Hemorrhage
Infection and wound breakdown
Aspiration
Tracheostomal stenosis (stoma getting fibrous with scar tissue so opening isn’t as patent)
how to prevent aspiration after laryngeal surgery
keep HOB elevated
check gastric residual when giving tube feedings
swallowing maneuvers
thickened liquids
how to prevent resp distress after laryngeal surgery
observe for restlessness, agitation, confusion, tachypnea, decreased O2, or cyanosis
reposition to ensure open airway
be prepared to give O2 or mechanical ventilation
how to prevent hemorrhage after laryngeal surgery
observe for bleeding from drains
rupture of carotid very dangerous, apply pressure and yell for help
vitals, cold clammy skin, decreased resp
how to prevent infection after laryngeal surgery
observe for change in drainage, erythema, increased WBC, lethargy, weakness
wound cultures, isolation, sepsis, abx, IV fluids
wound breakdown, fistula development with high risk of carotid rupture
tracheal stenosis risk factors after laryngeal surgery
Excessive traction on the tracheostomy tube by the connecting tubing, and persistent high tracheostomy cuff pressure
oral cancer risk factors
tobacco
alcohol
men > women
>40
african american
manifestations of oral cancer
anywhere but lips, lateral tongue, and floor of mouth are most common
dentists find this!
sore that doesn’t heal
white or reddish patch inside mouth
loose teeth
growth or lump inside mouth
mouth pain
ear pain
pain or difficulty swallowing
management of oral cancer
Surgical resection
Radiation therapy
Chemotherapy
Targeted Therapy
Immunotherapy
assessment of a patient with a radical neck dissection
knowledge and risks of complications
postop monitoring of airway, breathing, pain, bleeding, etc
complications of oral cancer surgery
hemorrhage
chyle fistula (opening from one area of tissue to another, chyle is like purulent drainage but white instead of yellow, not an infection)
Assessing the graft after oral surgery
examine both sites and check for same things (infection, hematoma, etc)
maintaining airway after oral surgery
Frequent assessment
Place in Fowler’s position
Encourage coughing and deep breathing
If patient has a tracheostomy provide tracheostomy care as required
how to prevent imbalanced nutrition after oral surgery
Assess nutritional state preoperatively and intervene early to prevent nutritional problems
Encourage high-density, high-quality intake
Diet may need to be modified to liquid diet, or to soft, pureed, and liquid foods
Consider patient preferences and cultural considerations in food selection
Provide oral care before and after eating
Nasogastric or gastrostomy feedings may be required
lung cancer patho
inhaled carcinogens cause changes of DNA in cells which cause malignant growths
risk factors of lung cancer
tobacco
pack per year history (#cigs/day x yrs/smoked)
environmental and occupational factors
genetics
clinical manifestations of lung cancer
Asymptomatically until late
Cough 65% or change in chronic cough (from dry to productive 25%)
Dyspnea (early symptom)
Hemoptysis (also seen in TB and pleural effusion)
Recurring fever, weakness, anorexia, wt loss
CP, hoarseness, dysphagia, pleural effusion
Mets → lymph node, bone, brain, liver
treatment of lung cancer
Surgery- surgical resection
Radiation- usually palliative or in conjunction with other modalities
Chemotherapy: palliative or in conjunction
Palliative care: radiation, chemo, pain control
two major categories of lung cancer
small cell
non-small cell (more common)
most small cell cancers arise in major bronchi (upper resp) and spread along bronchial wall
preop studies of lung cancer
Provides a baseline for comparison during the postoperative period and detect additional abnormalities
May include a bronchoscopic examination
Chest x-ray, magnetic resonance imaging, electrocardiogram (ECG)
Nutritional assessment
Determination of blood urea nitrogen and serum creatinine levels
Determination of glucose tolerance or blood glucose level
Serum electrolytes and protein levels
Blood volume determinations
Complete blood cell count
postoperative management after lung surgery
Vital signs checked frequently
Oxygen
Careful positioning
Medication for pain
Mechanical ventilation (sedate these pts, they try to fight the ventilator)
Chest drainage
pneumonectomy
The removal of an entire lung (pneumonectomy) is performed chiefly for cancer when the lesion cannot be removed by a less extensive procedure
lobectomy
limited to one area of a lung, is more common for bronchogenic carcinoma, giant emphysematous blebs or bullae, benign tumors, metastatic malignant tumors, bronchiectasis, and fungal infections
segmentectomy (segmental resection)
when lesions are located in only one segment of the lung
wedge resection
performed without regard to the location of the intersegmental planes
pleural effusion
secondary to HF, TB, PNA, pulmonary infection
presents with fever, chills, pleuritic pain, dyspnea
decreased or absent breath sounds, decreased fremitus, and dull, flat sound on percussion
may have tracheal deviation away from affected side
pleural effusion treatment
chest x-ray, chest CT, and thoracentesis
treat underlying cause
chest drainage
for spontaneous and traumatic pneumothorax
used postop to re-expand lung and remove excess air and fluid
traditional and dry suction water seal or just dry suction
used for prevention of cardiopulmonary complications
3 things a chest drainage system has
suction source
collection chamber
mechanism to prevent air from reentering chest w inhalation
goals for chest tube drainage
have patient sit on edge of the bed over the table so they have expansion
NEGATIVE PRESSURE IN LUNGS
Walk ASAP
non-invasive positive pressure ventilation
nasal masks, oral or nasal devices
eliminates need for intubation or trach
CPAP
BiPAP
4 BiPAP indications
Respiratory arrest
Serious dysrhythmias
Cognitive impairment
Head/facial trauma
potential short term complications of mechanical ventilation (8)
Tube dislodgement
Accidental decannulation
Bleeding
Pneumothorax
Air embolism
Aspiration
Subcutaneous or mediastinal emphysema
Recurrent laryngeal nerve damage
potential long term complications of mechanical ventilation (8)
Airway occlusion
Infection
Rupture of the innominate artery
Dysphagia
Tracheoesophageal fistula
Tracheal dilation
Tracheal ischemia and necrosis
Tracheal stenosis after tube removal
preventing complications of mechanical ventilation
Administer adequate warmed humidity
Maintain cuff pressure at appropriate level (average: 20 to 25 mm hg)
Suction as needed per assessment findings
Maintain skin integrity
Semi-fowlers or fowlers position
Auscultate lung sounds
Monitor for signs and symptoms of infection
Administer prescribed oxygen and monitor oxygen saturation
Monitor for cyanosis (lips, fingertips)
Maintain adequate hydration of the patient
Use sterile/aseptic technique when suctioning and performing tracheostomy care
interventions for enhancing gas exchange
cautious use of analgesics without suppressing resp drive
repositioning
fluid balance!
interventions for effective airway clearance
assess lung sounds q2-4h
suctioning
chest PT
positioning
humidification of airway
administer meds
pneumothorax
occurs when the parietal or visceral pleura is breached
basically there’s positive pressure instead of negative or neutral
tension pneumothorax
occurs when air is in the pleural space from a lacerated lung or wound in the chest wall
may be a complication of other types of pneumothorax
pain is sudden and pleuritic
minimal resp distress and slight chest discomfort and tachypnea with small simple or uncomplicated pneumo
S&S of breast cancer
Swelling of all or part of a breast
Nipple retraction
Nipple discharge breast or nipple pain
Swollen lymph nodes under the arm or near the collar bone
Nipple or breast skin that is red, dry, flaking, etc
dense breast tissue
tissue close together, hard to read, areas of calcifications may be there, biopsied to check if it’s cancer or calcifications
most common site for breast cancer
upper outer quadrant
monitoring and care of chest tubes
nurse is responsible for making resp and thoracic assessments
VS to reflect effectiveness of therapy or impending complications
know appropriate interventions if condition changes
equipment for chest tube
sterile gloves
PPE (gown, gloves, goggles, face shield)
sterile drainage collection unit
sterile water
suction source
connection tubing
sterile 4x4 drain dressings
sterile 4x4 or 2x2 gauze pads
3-4’’ elastic tape
1’’ adhesive tape
2 rubber tipped clamps for each chest tube
optional: sterile petroleum gauze, sterile nonadherent gauze, sterile transparent dressing
implementation in chest tube
review doctors orders
confirm w 2 identifiers
explain procedure
hand hygiene
maintain sterile technique
what to do for all drainage systems
note character, consistency, and amount of drainage
mark drainage level w time and date every shift or more
observe integrity of tubing q2-4h and pts condition
periodically check air vent (occlusion could cause tension pneumo)
coil tubing and secure to edge of bed (at level of patient)
avoid lifting drainage above patient’s chest
keep 2 clamps at bedside to clamp if system cracks or to help locate air leak
nursing alerts in chest tube
never clamp during OOB or transport (tension pneumo bc air can’t escape)
cough and deep breathe (splint)
RR and quality w auscultation
report breathing difficulty
when clots visible, assess pt then milk tubing in direction of drainage
check dressing at least every shift
check around site for crepitus or subq emphysema (air leaking into sq tissue)
change dressing when soiled
aROM or pROM for affected side
assess for pain and give meds
remind OOB pt to keep drainage below chest level and don’t D/C tubing (disrupts water seal)
troubleshoot when problems arise
DOCUMENT
additional steps for water-seal-wet suction system
check water-seal every shift
maintain proper level
check for fluctuations with respirations (2-4’’ is normal), momentarily d/c the system so the air vent is opened and observe for fluctuation
check for intermittent bubbling (normally when system is removing air, have pts take deep breath or cough, no bubbling means pleural space is sealed)
check water level (detach chamber and observe level when bubbling stops, add sterile water to bring level to 20cm or ordered level)
check for gentle bubbling showing proper suction level is reached (vigorous bubbling increases rate of water evap)
water-seal-dry suction system
check water-seal every shift
maintain proper level
check for fluctuations with respirations (2-4’’ is normal), momentarily d/c the system so the air vent is opened and observe for fluctuation
check for intermittent bubbling (normally when system is removing air, have pts take deep breath or cough, no bubbling means pleural space is sealed)
check that rotary dry suction control dial is turned to ordered suction (usually -20cm) and verify appropriate indicator
orange float may appear in an indicator window
other models indicate correct suction when the bellows reach calibrated triangular mark in suction monitor bellows window
always refer to manufacturer’s instructions
TPN what do we watch
glucose! Pt may go on insulin
leukemia
cancer in blood and bone marrow
rapid production of abnormal WBCs (one type) that can’t fight infection and impair ability of bone marrow to produce RBCs and PLTs
defect originates in stem cells (wannabe cells), myeloid or lymphoid
lymphoma
neoplasms from lymphoid cells
can involve lymphoid tissues of spleen, GI, liver, or bone marrow
classified according to level of differentiation and origin
hodgkins lymphoma
cause unknown, theory is immature lymphoid cell
reed sternberg cell, viral, or familial
spreads by contiguous extension into lymph nodes
unicentric (initiates in single node)
rare but common in men
peaks in early 20s and after 50
high cure rate
risk factors for hodgkins lymphoma
Pts receiving chronic immune-suppressive therapy (renal transplants); woodworkers & Military- exposure to agent orange
family hx
diagnosis of hodgkins lymphoma
bone marrow is + Reed Sternberg cell
Mediastinal mass on X-ray
Assess for B symptoms
PET scan; CT of chest, abd and/or pelvis
Lab: EST, Liver & Renal studies
Unilateral, painless enlargement of lymph node on neck.
S&S of hodgkins lymphoma
r/t compression of organs involved:
Compression of trachea
cough
pleural effusion
abdominal pain
Pruritus
Herpes Zoster
Severe pain on ingestion of alcohol
anemia
normal or slightly decreased platelet count
decrease skin sensitivity test.
Goal for hodgkin’s lymphoma
CURE
Treatment for hodgkin’s lymphoma
depends on stage
usually laparotomy and radiation
22-24 months of chemo followed by radiation
if it reoccurs, responds well to secondary chemo and radiation followed by autologous bone marrow or stem cell transplant
HSCT for advanced
Non-Hodgkins lymphoma
heterogenous group of cancers from neoplastic growth of lymphoid tissues
mostly B lymphocyte
unpredictable spread and multiple lymph node sites
risk factors for Non-Hodgkins lymphoma
50-60 (average 66)
increases with each decade of life
prognosis varies, highly complex
autoimmune, prior cancer, organ transplant, viral infection, pesticides
diagnosis of Non-Hodgkins lymphoma
CT, PET, bone marrow biopsy, CNS fluid analysis
S&s of Non-Hodgkins lymphoma
highly variable
lymphadenopathy in later stages
B symptoms
less aggressive forms can wax and wane
asymptomatic in early stage
4 systems affected by lymph masses
respiratory, spleen, CNS, urinary
treatment for Non-Hodgkins lymphoma
Bone marrow transplant & stem cell transplant may be considered for younger patients.
Chemo
Radiation: If the disease is not aggressive radiation alone may be needed.
Lifetime screening
interferon
multiple myeloma defect
malignancy of most mature B lymphocytes such as plasma cells w destruction of bone
disease cell produces non-functional immunoglobulin
angiogenesis!
incidence of multiple myeloma
age 65-70 years
male > female
black > white
prognosis of multiple myeloma
no cure
median survival time 3-5 years
infection is primary cause of death
diagnosis of multiple myeloma
lytic lesions and osteoporosis on x-ray
increased monoclonal protein in urine serum
M-protein serves as marker to monitor disease progression
elevated protein
bench jones protein
anemia or hypercalcemia
presence of plasma sheets
how to confirm multiple myeloma diagnosis
bone marrow biopsy
5 manifestations of multiple myeloma
bone pain (back and ribs)
pain w movement, rest helps, less pain when awakening and progresses more during the day
hypercalcemia (dehydration, constipation, altered MS, coma)
renal failure (anemia, decrease PLT and leukocytes)
infection (symptoms of anemia)
increased serum viscosity and risk for bleeding
osteoporosis and fractures
medical management of multiple myeloma (8)
chemo
corticosteroids (dexamethasone, thalidomide [birth defects, no limbs], velcade)
radiation to strengthen bone, relieve pain and reduce tumor size
vertebroplasty to treat vertebral fracture/compression
plasmapheresis to treat viscosity
bone marrow and stem cell transplant to extend remission
immunomodulatory drugs (IMiDs)
monoclonal antibodies
primary polycythemia defect
stem cell disorder within bone marrow, increase PLT (600k+)
size abnormal, occasionally increased erythro/leukocytes
rarely evolves into leukemia
incidence of primary polycythemia
65-70 years
women > men
prognosis of primary polycythemia
survival
diagnosis of primary polycythemia
r/o other disorders
CBC shows large and abnormal PLT with persistently high count (600k+)
Treatment of primary polycythemia
low dose ASA for younger pts
plateletpheresis
older pts: more aggressive treatment
chemo agent hydroxyurea for PLTs
interferon-alfa-2b TIW
when do complications occur for primary polycythemia
when PLT count reaches 1,500,000
idiopathic thrombocytopenic purpura (ITP) defect
autoimmune disorder
destruction of normal PLTs
antiPLT antibodies bind to PLTs
RES system ingests PLTs, body compensates by increasing PLTs
ITP can be induced how
sulfa drugs, viral infection, lupus, and pregnancy
incidence of ITP
common in children and young women
acute is mostly in children 1-4 weeks after viral illness
spontaneous remission within 6 months
diagnosis of ITP
chronic diagnosed by exclusion
plt <20,000
increased megakaryocytes in bone marrow
may have h.pylori
plts are young and functional. Adhere to themselves and endothelial tissue so spontaneous bleeding!
manifestations of ITP
asymptomatic
easy bruising, heavy menses, petechiae on trunk or extremities
pts w simple bruising have less complications than wet purpura
wet purpura=greater risk for intracranial bleeding
complications of ITP
osteoporosis, proximal wasting, cataracts, dental caries
medical management of ITP
not initiated until plt <10k
goal is safe plt count (stop sulfa drugs)
immunosuppressant therapy like imuran or corticosteroids (prednisone and dexamethasone)
surgery splenectomy
monitor bone density (calcium + vit d)
Hemophilia A defect
genetic defect resulting in factor VIII defect or deficiency
incidence of Hemophilia A
rare
A is 3x more common than B
almost all males (females r carriers)
prognosis of Hemophilia A
25% of type A will develop inhibitor antibodies that diminish effectiveness of treatment
makes pt more susceptible to blood infections
diagnosis of Hemophilia A (when is it diagnosed)
diagnosed in childhood
6 manifestations of Hemophilia A**
spontaneous or traumatic hemorrhage (severity based on degree of deficiency)
bleeding occurs in joints, mucus membranes, intra and extra cranial
pain
ankylosis (joint stiffness due to fusion)
spontaneous hematoma can compress adjoining nerves
type A crippled from hemathrosis, less hopeful prognosis
medical management of Hemophilia A (7)
infusion of fresh frozen plasma
IV factor VIII and IX concentrates
amicar
DDVAP (desmopressin)
plasmapheresis
factor VIIa
immunosuppressant therapy
hemophilia B defect**
Factor IX defect or deficiency
hemophilia B incidence
12-15% of pts
prognosis of hemophilia B
50% develop inhibitor antibodies
diagnosis of hemophilia B
diagnosed in childhood
manifestations of hemophilia B
spontaneous or traumatic hemorrhage
bleeding in GI, joints, mucus membrane, intra and extra cranial
pain
ankylosis
spontaneous hematoma can compress adjoining nerves
Basically same as type A
medical management of hemophilia B
same as type A
infusion of fresh frozen plasma
IV factor VIII and IX concentrates
amicar, DDVAP (desmopressin), plasmapheresis, factor VIIa, immunosuppressants
DIC
not a disease but manifestation of underlying disorder
severity is variable but can be life threatening
altered homeostasis causes massive clotting in microcirculation
clotting factors consumed, bleeding occurs
symptoms r/t ischemia and bleeding
triggers of DIC
sepsis, trauma, shock, cancer, abrupto placenta, toxins, and allergic reactions
treatment for DIC
treat underlying cause and correct tissue ischemia
replace fluids and electrolytes, packed RBCs, maintain BP, replace coag factors
heparin!!
where does hematopoietic malignancy originate from
the hematopoietic stem cell, the myeloid, or the lymphoid stem cell
when do clonal stem cell disorders occur
When the control mechanism fails and the “indolent” slone cells evolve into more aggressive clone cells
leukemia
proliferation of a particular cell type
granulocytes, lymphocytes, sometimes erythro or megakaryocytes
S&S of leukemia
anemia, infection, bleeding (like petechiae)
weakness and fatigue
lab tests for leukemia
leukocyte count, ANC, hct, plt, creatinine and electrolytes
coag and LFTs
cultures
collaborative problems of leukemia
infection
bleeding/DIC (treat w heparin AND transfusions, also seen in post partum w preeclampisa)
renal dysfunction
TUMOR LYSIS SYNDROME
goals for leukemia
absence of complications and pain
nutrition
activity tolerance bc fatigue
self-care and coping
positive body image
understand disease and treatment
leukemia mucositis intervention
frequent, gentle oral hygiene
soft toothbrush or sponge-tipped applicators
rinse only with NS, NS with baking soda, or prescribed solutions
NO LEMON-GLYCERIN
perineal and rectal care (thin skin prone to breakdown)
oral hypoglycemics perineal considerations
care bc peeing glucose causes infection
leukemia nutritional interventions
oral care before and after meals
analgesics and antiemetics before meals
small, frequent feedings
soft foods mod in temp
low-microbial diet (greens r hard to break down)
nutritional supplements as support, NOT as a whole meal bc it suppresses appetite
leukemia comfort interventions
tylenol for fever and myalgias
cool water sponge
frequent bedding changes
gentle massage
relaxation techniques
balance activity and rest
leukemia fluid and electrolyte imbalance interventions
I&O
Daily weights
assess for dehydration and overload
lab studies including electrolytes, BUN, creatinine, and hct
replacement prn
Myelodysplastic syndromes (MDS)
Disorder of the myeloid stem cell
May be asymptomatic or present with fatigue or illness
Occurs in older adult: mean 65 to 70 years old
diagnosis of MDS
CBC or bone marrow biopsy (taken from hip or lumbar area
can be painful
sandwich method of good news, bad, then good
tell them what position to be in, local anesthetic before needle insertion, you’ll feel pressure
Nurse cleans area and puts pressure once needle removed
pt watched over next several hours
what to say before bone marrow biopsy
we’ll make you as comfy as possible
cure and treatments for MDS
Only cure: HCST
treatment: blood transfusion (may relieve dyspnea by providing RBCs), bone marrow– stimulating agents, immunosuppressive therapy in some, chelation therapy, and myeloid growth factors
3 examples of myeloproliferative neoplasms
Polycythemia vera (too many platelets)
Essential thrombocytopenia
Primary myelofibrosis
polycythemia vera
proliferative disorder of the myeloid stem cells
median age 60, survival 14-20 years
symptoms of polycythemia vera
ruddy complexion, splenomegaly, high blood pressure, generalized pruritus, and erythromelalgia (abnormal erythrocytes)
diagnosis of polycythemia vera
elevated hemoglobin or hematocrit and the presence of an acquired mutation in the JAK2 gene
risks of polycythemia vera
thrombosis complications (CVA, MI) and bleeding from dysfunctional platelets
treatment for polycythemia vera
phlebotomy (500mL 1-2x/week)
chemo to suppress bone marrow function
management of atherosclerosis
allopurinol to prevent gout (breaks down uric acid)
ASA for pain
plt aggregation inhibitors
interferon (painful injection)
essential thrombocytopenia and incidence
stem cell disorder in bone marrow
unknown cause
women > men
median age 65-70 years old
symptoms occur from what in essential thrombocytopenia
vascular occlusion, headaches, enlarged spleen, and hemorrhage
treatment of essential thrombocytopenia
based on risk for developing thrombosis or hemorrhage, and the presence of symptoms
primary myelofibrosis
Chronic myeloproliferative disorder within the stem cell
common in older adults 65-70
survival 2-14 years
symptoms of primary myelofibrosis
pancytopenia is common
enlarged spleen, fatigue, pruritus, bone pain, weight loss, infection, bleeding, and cachexia (weight loss, fragile, thin, sunken in, like a skeleton, WEIGHT LOSS IS IRREVERSIBLE, METABOLISM TOO HIGH)
Primary myelofibrosis treatment
based on reducing the burden of the disease and improving blood count.
blood transfusions and erythroid agents for anemia
HSCT in younger ppl, reduces fibrosis of marrow
Splenectomy may be used to control significant problems
Polycythemia vera is a condition that places the
patient at a risk for increased infection (true or false)
False
Hodgkin lymphoma is characterized by highly
malignant cells that arise from a variety of tissues (true or false)
False
What should any older adult patient be evaluated for
whose chief complaint is back pain and who has an
elevated total protein level?
A. Anemia
B. Leukemia
C. Multiple myeloma
D. Non-Hodgkin lymphoma
C
where does the liver receive blood from
from the GI tract via the portal vein and hepatic artery
Liver function studies
Serum aminotransferases: AST, ALT, GGT, GGTP, LDH
Serum protein studies
Pigment studies: bilirubin stuff
Serum alkaline phosphatase
Serum ammonia** (causes big problems)
Cholesterol
causes of cirrhosis of the liver
Most common cause is malnutrition related to alcoholism
Infection
Anoxia
Metabolic disorders
Nutritional deficiencies
Hypersensitivity states (allergic reactions)
Hepatic dysfunction manifestations
jaundice is a late manifestation
portal HTN, ascites, varices (outpouching of the vein, can rupture)
hepatic encephalopathy or coma
nutritional deficiencies
types of jaundice
hemolytic
hepatocellular
obstructive
hereditary hyperbilirubinemia
hepatocellular and obstructive is usually from liver disease
S&S of hepatocellular jaundice
May appear mildly or severely ill
Lack of appetite (also from digoxin), nausea, weight loss
Malaise, fatigue, weakness
Headache chills and fever if infectious in origin (like hepatitis)
S&S of obstructive jaundice
Dark orange-brown urine and light clay-colored stools
Dyspepsia and intolerance of fats, impaired digestion
Pruritus (can also be a sign of hodgkin’s lymphoma)
portal HTN
obstructed blood flow through the liver results in increased pressure in portal venous system (everything is getting backed up)
results in ascites and esophageal varices
ascites and esophageal varices from portal HTN
ascites: abd fluid backup, usually peritoneal, causes SOB
esophageal varices: when these rupture, pts vomit bright red BADDDD smelling blood
causes of ascites in peritoneal cavity
-portal HTN resulting in increased capillary pressure and obstruction of venous flow
-vasodilation in splanchnic circulation (flow to major abd organs)
-changes in ability to metabolize aldosterone, causes fluid retention
-decreased synthesis of albumin, decreasing serum osmotic pressure
-movement of albumin into peritoneal cavity
assessment of ascites
abd girth and weight daily
striae, distended veins, and umbilical hernia
fluid in abd cavity by percussion (shifting dullness or fluid wave)
monitor for potential f&e balances
treatment of ascites
low sodium diet
diuretics (mixed classes)
bed rest
paracentesis
administration of salt-poor albumin
transjugular intrahepatic portosystemic shunt to continually remove fluid
hepatic encephalopathy and coma (cause and stages)
may result from accumulation of ammonia** and other toxic metabolites in blood
stages: change in LOC stage 1 (normal + lethargy) to 4 (comatose)
assessment of hepatic encephalopathy and coma
EEG
Changes in LOC, assess neurological status frequently (q15-30m)
Potential seizures
Fetor hepaticus (fecal smelling breath)
Monitor fluid, electrolyte, and ammonia levels
asterixis
flapping of hand
support hand at wrist, hand flaps as a reflex if ammonia is high
medical management of hepatic encephalopathy
eliminate cause
lactulose (diarrhea) to reduce ammonia
IV glucose to minimize protein catabolism
protein restriction
reduction of ammonia from GI by suction, enema, or abx (meds go IV, not NG)
d/c tranquilizers so we can watch LOC
monitor and treat complications and infections
bleeding of esophageal varices manifestations
first bleeding episode very mortal
hematemesis, melena, general deterioration, and shock (widening pulse pressure before overall BP drops, tachy at first then brady, call RRT and code hemorrhage)
how often should patients with cirrhosis undergo screening endoscopy
q2y
treatment of bleeding varices
treat shock
oxygen
IV f&e and volume expanders
blood
vasopressin, somatostatin, octreotide to decrease bleeding
nitro with vasopressin
BB propranolol and nadolol to decrease portal pressure
balloon Tamponade— Sengstaken–Blakemore Tube
4 ports, esophageal and gastric balloon and esophageal and gastric aspiration
endoscopic scleropathy
goes down like endoscopy
device that cauterizes blood vessels
esophageal banding
same with hemorrhoids
band goes around varices to seal them off
what to monitor in a patient with bleeding esophageal varices
emotional responses and cognitive status
hepatic encephalopathy resulting from blood breakdown in GI and delirium from alc withdrawal
tube care and GI suctioning nearby
oxygen
oral care
quiet calm environment
reduce anxiety
support pt and family
types of hepatitis
A: fecal/oral route
B: body fluids or IV drug use
C: blood and body fluids (transfusion or contact)
E
G and GB virus-C
Non viral: toxic and drug induced
Hep A
fecal/oral
poor hygiene, hand to mouth, close contact, food and fluids
incubation: 15-50 days
illness: 4-8w
low mortality
hep a manifestations
mild flu-like, low grade fever, anorexia, later jaundice and dark urine, indigestion and epigastric distress, enlargement of liver or spleen
anti-HAV antibody after symptoms appear
had it before
management and prevention of hep a
good handwashing, safe water, proper sewage disposal
vaccine
immunoglobulin for contacts to provide passive immunity
bed rest during acute
nutritional support
Hep b
transmitted from blood to blood, saliva, semen, and vaginal excretions (sex and childbirth)
causes cirrhosis and liver cancer
incubation: 1-6 months
antigenic particles that elicit specific antibody markers during diff stages of disease
risk factors of hep b
exposure to blood and body fluids, health care workers, HD, MSM, IVDU, close contact, travel, multiple sex partners, hx of STD, blood tx
6 manifestations of hep b
mild flu-like
low grade fever
anorexia
later jaundice and dark urine
indigestion and epigastric distress
enlargement of liver or spleen
hep c
transmitted by blood and sexual contact (like needles)
most common blood-borne infection
causes 1/3 of liver cancer, most common reason for liver transplant
incubation period is variable
mild symptoms
chronic carrier state often occurs
risk factors of hep c
blood tx before 1992, health care worker, vertical tx, IVDU, multiple partner, HD, MSM, INCU
hemophilia and ITP pts bc of transfusions!
management of hep c
prevention
screening blood
prevent needle sticks
reduce spread of infection just like hep b
no alcohol and meds that affect liver
antivirals: interferon and ribavirin
standard of care triple therapy for hep c
interferon + ribavirin + Pl (incivek or vitrellis)
hep d (delta)
only ppl with hep b are at risk
blood and sexual contact
symptoms and treatment are similar to hep b but more likely to develop liver failure, chronic active hepatitis, and cirrhosis
hep E
fecal-oral route
incubation: 15-65 days
resembles hep a and is only abrupt, not chronic
3 types of hepatic cirrhosis
alcoholic
postnecrotic
biliary
manifestations of hepatic cirrhosis
Liver enlargement, portal obstruction and ascites, gastrointestinal varices, edema, vitamin deficiency and anemia, mental deterioration
assessments for liver cirrhosis
history
alcohol
diet and nutrition
toxins
mental status
ADLs
bleeding, fluid level changes, labs
collaborative problems with liver cirrhosis
Bleeding and hemorrhage
Hepatic encephalopathy
Fluid volume excess
activity intolerance for hepatic cirrhosis
rest and support
positioning
oxygen
planned mild exercise and rest
nutritional status
hazards of immobility
interventions for nutrition of hepatic cirrhosis pts
I&O
eat if no active bleeding
small frequent meals
pt preferences
supplemental vit and minerals (B if alc withdrawal)
water soluble forms of fat soluble vitamins if steatorrhea
high cal, low sodium for ascites
protein according to pt needs, restricted for encephalopathy
safety considerations for pt with hepatic cirrhosis
reduce scratching
prevent falls, trauma r/t bleeding
careful evaluation of injuries that can bleed
primary liver tumors
few
usually with hep b and c
hepatocellular carcinoma (HCC)
liver and metastatic cancer
frequent site of metastasis
manifestations of liver cancer
Pain, a dull continuous ache in RUQ, epigastrium, or back
Weight loss, loss of strength, anorexia, anemia may occur
Jaundice if bile ducts occluded, ascites if obstructed portal veins
nonsurgical management of liver cancer
cirrhosis increases risk of surgery
pts may not qualify for surgery bc of other issues such as cardiac issues or advanced cancer
radiation
chemo
percutaneous biliary drainage
surgical management of liver cancer
Treatment of choice for HCC if confined to one lobe and liver function is adequate
Liver has regenerative capacity
Types of surgery
Lobectomy
Cryosurgery
Liver transplant
acute pancreatitis
doesn’t lead to chronic
pancreatic duct becomes obstructed and enzymes back up into the pancreatic duct causing autodigestion (cells eat themselves) and inflammation of pancreas
chronic pancreatitis
progressive inflammatory disorder with destruction of the pancreas. Cells replaced by fibrous tissue and pancreatic pressure increases. Mechanical obstruction of pancreatic and common bile ducts and destruction of secreting cells of pancreas occur
often these pts develop type 1 diabetes
manifestations of acute pancreatitis
Severe abdominal pain
Patient appears acutely ill
Abdominal guarding
Nausea and vomiting
Fever, jaundice, confusion, and agitation may occur
Ecchymosis in the flank or umbilical area may occur
May develop respiratory distress, hypoxia, renal failure, hypovolemia, and shock
manifestations of chronic pancreatitis
Recurrent attacks of severe upper abdominal and back pain accompanied by vomiting
Stops when GI system rests
Weight loss
Steatorrhea
assessment of pt with pancreatitis
Focus on abdominal pain and discomfort
Fluid and electrolyte status
Medications
Alcohol use
GI assessment and nutritional status
Respiratory status
Emotional and psychological status of patient and family; anxiety and coping
collaborative problems of patient w pancreatitis
f&e imbalances
necrosis of pancreas
shock
multiple organ dysfunction
DIC
goals for pt with pancreatitis
pain relief
improved resp function
TPN
maintain skin integrity
prevent complications
relieving pancreatic pain
analgesics
NG suction for nausea and distention
frequent oral care
bed rest
promote comfort and relieve anxiety
