Exam 4 Flashcards
more NON differentiated cells = (characteristic of the canceR)
more aggressive cancer
problems r/t cancer can be caused by (3)
- cancer itself
- treatment
- both
management / goals for cancer:
- cure
- control
- minimize SE of treatment
main nursing priorities r/t cancer + related concerns
BM suppression….
- neutropenia –>infection
- anemia –> fatigue/oxygenation
- thrombocytopenia –> bleeding
severe neutropenia is defined as what?
ANC <1000 cells
most infections r/t neutropenia are what type?
opportunistic (suppressed immune system)
name some ways to prevent infections with neutropenic patients
handwashing, educate patients to be their own advocates, no fresh flowers or raw foods, avoid sick people, monitor VS (fever!), no cat litter
how do we treat patients if develop opportunistic infections r/t cancer? (general pharm)
KNOW
anti infectives
re: neutropenia and cancer, what changes should be reported to provider? (4)
- changes in skin + mucous membranes
- fever
- cough
- s+s of infection at central line
when should neutropenic precautions be started?
ANC <1000 w/fever
OR
ANC <500
name some elements of neutropenic precautions
no fresh flowers or raw foods no shared supplies private room + no sick visitors no stagnant water no indwelling catheters wear masks regular hygiene ASSESS often!
what are nurse-led protocols re: ABX with neutropenic patients?
ABX stewardship: get cultures, monitor for s+s of infection, get the right ABX on board + quickly!!
<50,000 platelets =
<20,000 platelets =
50k = prolonged bleeding
20k = spontaneous
what complication are we most concerned with re: platelets <20,000? + what specific assessment should occur?
spontaneous bleeding –> hemorrhagic stroke
FREQUENT NEURO CHECKS
what should you be assessing for if patient has thrombocytopenia?
bleeding:
- petichiae
- prolonged bleeding
- large flank bruise (sign of internal bleeding)
- blood in urine or stool
- tachycardia
- hypotension
what interventions should be introduced for patients with thrombocytopenia? (4)
- neuro assessments
- fall precautions
- bleeding precautions
- platelet administration
what should be avoided in patient with thrombocytopenia?
anything that could cause injury + bleeding: rectal tubes, rectal meds, unnecessary tube inserts
name some elements of bleeding precautions (7)
- limit venipunctures + IM injections
- lift sheet
- electric razor
- soft toothbrush, no floss
- ABD girth measurement
- no nose blowing
- assess IV sites
what interventions should be implemented for fatigue r/t anemia / cancer? (3)
- find exercise that feels good (can even be a walk to the bathroom)
- treat underlying cause if possible
- energy conservation + manage activities
why does chemo have such an effect on the GI cells?
chemo attacks rapidly dividing cells and GI cells fall into this category
what interventions should be implemented for cachexia? (2)
- protein + CHO - rich foods
2. small, frequent meals
interventions for mucositis + stomatitis r/t chemo or cancer
- cryotherapy
- mouth rinses (bicarbonate / magic mouthwash)
- soft toothbrush + no floss
- non-irritating cleansers
- hygiene
- ASSESS often!
N/V r/t cancer + therapy, what types can you have?
acute, anticipatory, breakthrough
motor + sensory deficits seen with cancer are related to what?
possible bone mets + compressed nerves
motor + sensory deficits r/t cancer put a person at risk for what? what interventions should we implement?
pain, injuries + falls
–> fall precautions, assess ability, offer assistance
peripheral nerve fxn r/t cancer puts a person at risk for what? what interventions should we implement?
pain, injuries, loss of balance + falls
–> fall precautions, assess for sensation + wounds
reduced oxygenation r/t anemia with cancer can lead to what? what interventions should we implement?
hypoxia + poor tissue perfusion
–> raise HOB + administer O2
interventions for pain r/t cancer should be _______
MULTIMODAL + patient specific <3
interventions for hair loss r/t cancer + chemo
protect scalp, wear hat, keep warm, address psychosocial aspect <3
“chemo brain” / cognitive changes can be from what?
cancer itself, brain mets, treatment or both
goals of radiation
cure, control + palliate
minimize destruction of normal tissue
exposure vs dose?
exposure: amt delivered
dose: amt absorbed
differences between teletherapy + brachytherapy? what are the 2 types of brachytherapy?
teletherapy: external
brachytherapy: internal
what are the 2 types of brachytherapy? + describe them
sealed: only patients emit radiation (not body fluids)
unsealed: bodily fluids are radioactive + patient
precautions for patients w/brachytherapy? (5)
- private room w/sign
- lead apron + limited time inside
- visitors 6 feet away + limited time (30 mins)
- no pregnant caregivers
- keep all linens in room until discharge
SE of teletherapy (remember, it’s localized) (6)
- hair loss @ site
- erythema
- inflammation
- fatigue
- secondary malignancies
- CV disease
what are the 3 categories for breast cancer?
- noninvasive
- invasive
- metastasis
describe ductal carcinoma in SITU
early noninvasive –> can become invasive if untreated
describe lobal carcinoma in SITU (4 things) + what is treatment?
- begins in lobules
- not true cancer
- cannot spread
- increases chance of developing breast cancer later
tx: OBSERVATION
describe infiltrating ductal carcinoma
INVASIVE: starts in ducts –> epithelial cells lining the ducts –> grows into tissue
re: infiltrating ductal carcinoma, fibrosis, dimpling + peau d’orange indicates what?
late disease
inflammatory breast cancer
INVASIVE, highly aggressive + usually diagnosed later in disease
no palpable lump + might not show up on mammogram
s+s of inflammatory breast cancer (3)
swelling, pain, redness
triple negative breast cancer
HIGHLY AGGRESSIVE
lacks typical receptors (locks), so medication (keys) to treat cancer will have no effect
triple negative breast cancer is common with what populations? (3)
BRCA positive + pre-menopausal females + black women
risk factors for breast cancer
gender, age, genetics, breast density, early menstruation, hormone replacement therapy, ETOH, obesity, oral contraceptives, null parity
re: screening for breast cancer, what are protocols for normal risk + high risk?
normal risk: annual mammogram from 40-45 yrs old
high risk: annual mammogram + annual MRI + clinical breast exams
what is a diagnostic mammogram? what is screening mammogram?
diagnostic: mammogram + ultrasound (if someone has lump)
screening: mammogram only
what s+s (r/t skin) might you see with more progressed breast cancer
- peau d’orange
- nipple changes (retractions)
- ulceration
describe these surgery options for breast cancer:
lumpectomy partial mastectomy total mastectomy radical mastectomy neoadjuvant
lumpectomy: lump removal
partial mastectomy: remove part of breast tissue
total mastectomy: all breast tissue removed
radical mastectomy: all breast tissue + lymph node removed
neoadjuvant: chemo before surgery to reduce lump size
postop care after surgery for breast cancer
- no BP readings or venipuncture on affected side
- VS q15
- monitor drains
- educate patient on what to report (s+s of infection
- semi fowlers
when can patient start arm exercises post surgery for breast cancer? what can they do?
one week –> start active ROM
- squeeze ball
- arm raises
- elbow extension
if they have pain? STOP!
home care for patient after having surgery for breast cancer
- no commercial lotion
- no deodorant
- monitor for lymphedema + report
how can we prevent lymphedema?
don’t take BP on affected side, even if it’s been years!!
s+s of lymphedema (5) + what should you do?
- heaviness
- aching
- numbness
- swelling
- tingling
CONTACT PROVIDER ASAP
what is nurse role for chemo?
- monitor central line
- manage symptoms
- give chemo
name some effects of chemotherapy? (4)
KNOW
- myelosuppression –> low WBCs, RBCs, platelets KNOW
- fatigue
- GI effects
- nerve + motor involvement
Hormonal therapy for cancer can only be used for which type of cancer
w/hormone receptors
NOT triple-negative - wouldn’t be effective
what is colorectal cancer?
cancer of large bowel: large intestine + rectum
where are most colorectal cancers found? + what type are most of them?
rectosigmoid region
most are adenocarcinoma (starting in mucous producing cells)
precancerous cells of colorectal cancer =
polyps
visualized on colonoscopy
metastasis of colorectal cancer can happen via which 3 routes?
- blood
- lymph
- through intestinal wall to surrounding organs
what is “seeding” r/t colorectal cancer surgery?
cancer cells that are dropped into new places, spreading cancer
what are some complications of colorectal cancer? (5)
- obstruction
- perforation
- fistula
- abscess
- bleeding
re: colorectal cancer, where are obstructions most common?
transverse + descending colon
what are s+s of obstruction? (3)
- gas pains
- cramping
- incomplete evacuation
what are s+s of partial bowel obstruction? (3)
- PAIN
- visible peristalsis
- tinkling/high pitched bowel sounds
what are s+s of complete bowel obstruction? (2)
- PAIN
2. absent bowel sounds
what are risk factors for colorectal cancer? (8)
- ULCERATIVE COLITIS
- age
- genetics
- ETOH + smoking
- sedentary lifestyle
- high fat diet + low fiber
- Crohn’s disease
- obesity
what is gold standard for screening for colorectal cancer?
colonoscopy
what is the “con” to fecal occult blood test?
positive? need colonoscopy
negative? can’t rule out cancer
= VERY LIMITED
screening recommendations for colorectal cancer:
- average
- high risk
- close relative or strong hx
average: colonoscopy 45 years
high risk: colonoscopy before 45 years
close relative or strong hx: genetic testing
most common s+s of colorectal cancer (3)
+ name some others…
- changes in stool
- changes in bowel habits
- bleeding
fatigue, weight loss, pain, distention, fullness, palpable mass
re: CRC, mahogany blood =
further up in colon
re: CRC, bright red blood =
+ most likely which location
lower in colon
probably rectosigmoid
what is our BEST tool to diagnose CRC? why?
colonoscopy - can visualize entire colon
what lab tends to be low with CRC?
H+H
normal per Messer 11-17 Hgb
surgical intervention options for CRC (2)
- colon resection
2. colectomy
what is colostomy?
piece of colon diverted through ABD wall to bypass part of colon –> stoma formed
ileoanal pullthrough =
entire colon removed + j pouch formed
name some components of wound management after surgery for CRC (4)
- monitor for s+s of infection
- manage drains
- pain management (incl. phantom pain)
- comfort (physical + psychosocial)
postoperative care after surgery for CRC (3) think orders
- NG tube
- NPO
- colostomy care w/WOCN
assessment findings for stoma ◡̈
- beefy red
- budding + protruding from skin 3/4”
- intact peristomal skin
after colostomy, what should drainage look like and progress towards?
start: sanguineous –> serosanguineous –> “working” in 2-3 days (stool)
what would excoriated skin around stoma indicate?
wafer not cut properly + skin exposed to stool
how should wafer be cut for stoma?
1/8-1/16 larger than stoma
stool findings if colostomy formed in:
- ascending colon:
- transverse colon:
- descending colon:
-ileostomy:
ascending colon: liquid
transverse colon: pasty
descending colon: solid
ileostomy: liquid
what is most common upper GI disorder?
GERD
what is GERD?
reflux of stomach contents into esophagus –> inflammation –> hyperemia
GERD can be caused by what? (3)
- excessive relaxation of LES
- increased ABD pressure
- reduced stomach emptying
re: GERD, reduced stomach emptying can be caused by what?
gastric neuropathy from DM
risk factors for GERD (7)
- ETOH + smoking
- spicy foods
- large portions
- pregnancy
- lying down after eating
- obesity
- tubes (NG tube)
complications of GERD
- Barrett’s epithelium (precancerous cells - cells changed to protect from acidic stomach contents in esophagus)
- PNA
- dental decay
- cardiac disease
s+s of GERD (5)
- indigestion (20 min - 2 hrs after eating)
- pain
- regurgitation + water brash
- heartburn
- morning hoarseness
what is definitive way we diagnose GERD? but how do we usually diagnose GERD?
pH exam
don’t usually need this; we usually diagnose based on symptoms – if we treat and it works? assume GERD
interventions for GERD (9)
*Emily’s fav card ◡̈ *
- small, frequent meals
- sit upright after eating for 1 hour
- avoid irritating foods + spicy foods
- don’t eat before bedtime
- sleep on right side
- weight loss
- sleep apnea eval
- ETOH + smoking cessation
- meds to reduce acid (usually PPIs)
why would someone get nissen fundoplication surgery?
unrelenting GERD not improving with meds; to create a tighter LES
peptic ulcer + what is common cause?
mucosal lesion of stomach or duodenum
common cause: H. pylori
gastric ulcers are often caused by what?
DELAYED stomach emptying (food sitting in stomach too long –> causes lesions)
gastric ulcer pain is often felt where?
upper epigastrium and left
how long after eating would manifestations of a gastric ulcer be felt?
30-60 mins
if bleeding was present with gastric ulcers, what would you see?
hematemesis
duodenal ulcers are often caused by what?
INCREASED stomach emptying
duodenal ulcer pain is often felt where?
below epigastrium and right
how long after eating would manifestations of a duodenal ulcer be felt?
1.5-3 hrs after eating
if bleeding was present with duodenal ulcers, what would you see?
melena (blood in stool)
stress ulcers are often caused by what? (7) + what medical scenarios? (4)
H. pylori*, NSAIDs, corticosteroids, ETOH, smoking, caffeine, stress
+ often after medical crisis or trauma (burns, head injury, sepsis, NPO)
s+s of stress ulcer
- indigestion
- sharp, burning pain
- fullness
- tenderness
- hyperactive bowel sounds EARLY
- hypoactive bowel sounds LATE
- N/V
what assessment is very important with stress ulcers? why?
VS - can give us cues about bleeding happening in the body
what is diagnostic for PUD?
what is diagnostic for H. pylori?
KNOW
PUD: EGD
H. pylori: urea breath test
interventions for PUD
reduce pain + complications + meds
re: PUD treatment, what is triple therapy? what is quadruple therapy?
triple: PPI + 2 ABX
quadruple: triple + Pepto-Bismol
what nutrition interventions should be implemented with PUD? (3)
BRAT diet (banana, rice, applesauce, toast)
no irritating foods
no bedtime snacks
what is a major complication of PUD?
hemorrhage
hematemesis: upper bleed
melena: dark, tarry stool
things to monitor for with hemorrhage r/t PUD? (4)
- VS (tachycardia + BP trending down) KNOW
- hemoccult test
- H+H
- s+s of bleeding
management of hemorrhage rt PUD (4)
KNOW
- AIRWAY PROTECTION –> position on their side if vomiting KNOW
- O2
- fluids (volume replacement)
- prepare patient for EGD
- IV PPI
if patient is unstable with hemorrhage r/t PUD, what should you do?
KNOW
anticipate blood products + fluids…. GET IV!!!!
what could happen with perforation as complication of PUD?
GI contents leak into peritoneal cavity
s+s of perforation (2)
- sudden, sharp mid epigastric pain –> radiates through ABD
- tender, rigid, boardlike abdomen with rebound tenderness = peritonitis
gastritis
inflammation of mucosal lining of stomach
acute gastritis is usually _______
self-limiting (several days)
most common cause of acute gastritis
NSAIDs
acute gastritis symptoms usually occur when? what are they? (6)
AFTER MEALS
pain, cramping, indigestion, anorexia, N/V, bleeding
interventions for acute gastritis (2)
SUPPORT:
- fluids
- BRAT diet (banana, rice, applesauce, toast)
chronic gastritis
patchy, diffuse inflammation –> stomach wall things and atrophies
what is common cause of chronic gastritis?
H. pylori (burrows –> activate activates toxins –> inflammation)
what can chronic gastritis cause if not treated? what would this lead to?
pernicious anemia
(parietal cell fxn decreases –> less acid + less intrinsic factor)
= B12 injections needed!!
intervention for chronic gastritis
remove cause + PPI
prevention of chronic gastritis
- diet (healthy foods + avoid irritating / spicy foods - caffeine, spicy, chocolate)
- exercise
- smoking cessation
- limit ASA + NSAIDs
some patient education for UC + CD
- medication adherence: continue even through remissions
- food journal + BM journal
- how to get adequate nutrition
- check perineal area while maintaining dignity (Explain why you’re doing what you’re doing)
what is tenesmus?
urge to defecate
what is ulcerative colitis?
inflammation of rectum + sigmoid colon (starts at “end” and can move up the colon to involve all of it)
with ulcerative colitis, the intestinal mucosa is _______, _______ + ______.
(adjectives)
hyperemic, edematous + narrowed
re: UC, edema of the colon can cause ________, which can lead to ___________ (complication)
edema can cause THICKENING/NARROWING, which can lead to OBSTRUCTION
what is the main difference re: stool in Ulcerative Colitis + Crohn’s Disease?
UC stool: diarrhea w/blood or pus
CD: steatorrhea (fatty stool)
what is the main difference re: stool in Ulcerative Colitis + Crohn’s Disease?
UC stool: diarrhea w/blood or pus
CD: steatorrhea (fatty diarrhea)
what is toxic megacolon?
dilation of colon + ileus…. BIG ASS COLON on xray
what are the main (2) complications of UC?
- malabsorption
2. GI bleed
1/3 of all deaths r/t ulcerative colitis are from what?
development of colorectal cancer
what psychosocial aspect of both UC + CD are very important to look for and care for?
anxiety + depression
strong correlation
what psychosocial aspect of both UC + CD are very important to look for and care for?
anxiety + depression
strong correlation
with both UC + CD, we can have manifestations involving nearly any organ system. what is this called? what are some systems affected?
extraintestinal symptoms
liver, lungs, kidney, eye, skin + joints
re: ulcerative colitis and nutrition, what would be something to assess with patient?
nutrition history: food diary + triggers
weight loss
re: ulcerative colitis, what aspects of bowel elimination should we be assessing?
color, characteristic, frequency, pain, pattern, blood
what medication class can cause an exacerbation of ulcerative colitis?
NSAIDs
GI!!
why is it especially important to assess bowel elimination patterns with patients with UC or CD?
we can prepare them for BM + set them up for success!!
re: UC, fever + tachycardia could be sign of worsening complication…. what complication might this be?
dehydration / F+E imbalances
re: UC/CD and extraintestinal complications, what are some very important assessment pieces? (Harrell repeated this multiple times)
skin assessment + oral mucosa assessment
re: UC + CD, what might labs look like: H+H: WBC: CRP + ESR: electrolytes: albumin:
H+H: low (r/t bleeding) WBC: high (r/t inflammation + infection) CRP+ ESR: high (r/t inflammation) electrolytes: low (malabsorption + diarrhea) albumin: low (loss of protein in stool)
what is gold standard for diagnosing Ulcerative Colitis + Crohn’s disease?
MRI - can visualize bowel, bowel wall + surrounding organs
if you’ve had ulcerative colitis for > 10 years, how often should you get a colonoscopy?
TEST QUESTION
annually ◡̈
with ulcerative colitis management, what are goals? (3)
- relieve symptoms
- decrease inflammation
- intestinal healing
re: nutrition therapy + UC and CD, is diet a major factor in the inflammatory process?
Harrell says NO.
re: nutrition and UC + CD, what would be a recommendation to the patient to track their food tolerances and how it impacts eliminiation?
food journal
+
BM journal
very individualized
re: UC + CD and management, what’s one way we can relieve symptoms, decrease inflammation + promote healing?
bowel rest / NPO <3
name some potential food triggers for UC + CD (7)
- high fiber foods
- ETOH
- caffeine
- raw veggies
- carbonated drinks
- lactose
- nuts + corn
= foods that increase GI motility
what is the GOLD STANDARD for surgical treatment of ulcerative colitis? (just the name)
restorative proctocolectomy w/ ileostomy pouch anal anastomosis
(phew)
what happens with a restorative proctocolectomy w/ ileostomy pouch anal anastomosis?
2 step procedure:
- remove colon + most of rectum (leave anus and sphincter intact). create internal pouch (j pouch) and connect to anus –> temporary ileostomy so pouch can heal
- reverse the ileostomy 1-2 months later
what happens with a total proctocolectomy?
removal of colon, rectum + anus.
surgical closure of anus.
permanent ileostomy
re: UC + ileostomy, what characteristics will the output have when ostomy is new and before adaptation has taken place? (4 things)
- known as “effluent”
- sweet smell
- liquid green
- very caustic to skin
re: UC + ileostomy, if we see >2000mL in 24 hours, this is known as what? what’s our MAIN concern? what are some of our solutions? (4)
HIGH OUTPUT ILEOSTOMY
main concern: fluid loss + electrolyte imbalance
solutions:
- TPN until regulated
- benefiber to bulk up stool
- gatorade (replace electrolytes)
- opium tincture (slow things down)
re: UC and a new ileostomy, after time adaptation will occur. what is this? what will you see with the stool? (2)
small intestine adapt to take on functions of the colon –> stool volume decreases and becomes thicker / pasty –> stool is brown or yellow-green color
crohn’s disease is what?
chronic inflammation of small intestine, colon or both
“gum to bum”
= can affect ENTIRE GI tract
crohn’s disease most commonly affects what area of the GI tract?
terminal ileum
what is the hallmark sign of crohn’s disease?
cobblestone appearance of the bowel
crohn’s disease causes ______ + ________ which could lead to ________
causes EDEMA + NARROWING, which could lead to OBSTRUCTION
what risk increases with Crohn’s disease? (complication)
fistulas
what is the main difference re: pain in Ulcerative Colitis + Crohn’s Disease?
UC: rectum + abdominal
CD: abdominal (constant around umbilicus)
what manifestation is more common in Crohn’s (VS)?
FEVER
common when pt has fistula, abscess or severe inflammation
which sign/symptom is much more SIGNIFICANT in CD compared to UC?
weight loss
secondary to malabsorption
GI bleed more likely in Crohn’s or UC?
UC
colon cancer and small bowel cancer more likely in Crohn’s or UC?
UC
severe malabsorption + malnutrition more common in Crohn’s or UC?
Crohn’s
fistula formation more common in Crohn’s or UC?
Crohn’s
perirectal abscess more common in Crohn’s or UC?
Crohn’s
what would you hear re: bowel sounds in severe inflammation and/or obstruction?
decreased or absent
what would you hear re: bowel sounds over narrowing?
high pitched
what assessment is very important if abscess or fistula is present? (with UC or CD) + who should we consult?
skin assessment / perineal assessment
consult WOCN
neurological changes with UC or CD could indicate what complication?
electrolyte imbalances (Na)
re: CD, what would you expect labs for folic acid and vitamin B12 to look like?
decreased (r/t malabsorption)
re: fistula management with Crohn’s disease, how many calories are needed per day for wound healing?
3000 cal/day
if an abscess forms from CD, what would you expect to give as a nurse?
ABX!
