Exam 4: cancer, HIV, ICU, shock Flashcards
Where does BPH develop? What causes the clinical manifestations?
inner portion of the prostate. Enlargement of the prostate compresses the urethra leading to symptoms.
Differentiate between the obstructive symptoms of BPH and the irritative symptoms?
obstructive= caused by prostate enlargement= decr. in the force of urinary stream, difficulty initiating voiding, intermittency, dribbling at the end of voiding
Irritative- due to urinary retention= frequency, urgency, dysuria, bladder pain, nocturia, incontinence
What are possible complications of BPH?
- Acute urinary retention= sudden onset of painful inability to urinate
- treatment= catheterize to empty bladder- UTI- from residual urine
- calculi may form from alkalization of residual urine
- UTI- from residual urine
Understand the diagnostic tests for BPH.
- History and physical
- DRE- can palpate the prostate
- PSA- to rule out prostate cancer
- TRUS- trans rectal ultrasound— indicated for pt with abnormal DRE and elevated PSA
— accurately assess the size of the prostate and differentiates BPH from prostate cancer - urinalysis- culture for possible infection
Describe the pharmacological treatment for BPH? Include specific examples of drugs used.
- 5 alpha reductase inhibitors- reduce the size of the prostate gland: Proscar (finasteride)= decreases PSA levels
— increased risk of orthostatic hypotension with ED drugs
Avodart (dutasteride) - Alpha adranergic recpetor blockers- promote smooth muscle relaxation in prostate —> increases urine flow through urethra= Cardura (doxazosin) & Hytrin (terazosin)
Briefly describe TURP and possible complications.
removal of prostate tissue and cauterization
- gold standard for BPH
- bladder irrigation carries out debris
- bleeding is a complication
What are the pre and post op assessments and goals for TURP?
pre: assess clotting factors; restore urinary drainage; treat UTI- increase fluids, CBI, understand the procedure and post care
post: clots are normal for first 24-36 hr, hematuria, restore urinary control- may have dribbling, complete bladder emptying; may go home with catheter (can be removed 2-4 days), avoid heavy lifting, driving and sexual activity resumed after follow up with physician
Describe continuous bladder irrigation and associated complications.
NS for 24 hr after TURP
regulate flow with roller clamp
irrigation should be room temp
maintain colorless or light pink drainage return
tape cath to leg to provide gentle traction— balloon at end of cath is pulled down into prostatic tissue removal area to put pressure on area and maintain hemostasis
removes clotted blood form bladder
complications= hemorrhage (look for large amounts of bright red blood)
bladder spasms- use oxybutynin (Ditropan)
if inflow> outflow check cath for patency, kinks, or clots
Risk factors for prostate cancer.
age >50, ethnicity- highest in AA, family hx, possible high-fat diet
Differentiate between early and late symptoms of prostate cancer.
usually as symptomatic in early stages:
dysuria, hesitancy, dribbling, frequency, urgency, hematuria, nocturia, retention, inability to urinate
late signs= pain in lumbosacral area that radiates to hips or legs, when coupled with urinary symptoms
Where does prostate cancer typically metastasize to?
pelvic lymph nodes, bladder, lungs, liver, bones
What tests are used to diagnose prostate cancer?
PSA- elevated levels indicate prostate pathology (not necessarily cancer); also used to monitor success of treatment (decr after successful treatment)
DRE- hard, nodular and asymmetric
Biopsy of prostate tissue is necessary to confirm diagnosis- done using TRUS
Briefly describe the treatments used for prostate cancer. Include some side effects.
- watch and wait: men that have a life expectancy <10 yrs, presence of significant co-morbidity, low-grade, low-stage tumor
- Radical prostatectomy: entire gland, seminal vesicles, and part of the bladder neck are removed; retroperineal lymph node dissection usually done; most effective for long-term survival; major complications= ED, UI, hemorrhage, DVT/PE
- Nerve-sparing surgical procedure: spares nerves responsible for erection; only indicated for cancer confined to the prostate; no guarantee it will be maintained
- Radiation therapy:
A. External beam- most widely used outpatient procedure; side effects= skin irritation, GI probs, ED, fatigue, bone marrow suppression
B. Brachytherapy= implantation of radioactive seed into prostate gland— spares surrounding tissue
Differentiate between cure, control, and palliation, in terms of treatment for cancer.
cure= treatment is offered that is expected to have the greatest chance of disease eradication and may involve local therapy (surgery or radiation) alone or in combination with or without periods of adjunctive systemic therapy (chemotherapy) control= for cancers that can’t be completely eradicated but are responsive to anticancer therapies and can be maintained for long periods with therapy palliative= relief or control of symptoms and the maintenance of a satisfactory quality of life are the primary goals rather than cure or control of the disease process
List 4 major complications of chemotherapy.
- Nutrition:
A. Malnutrion- protein and calorie malnutrition characterized by fat and muscle depletion
suggested foods: whole milk, milk shake, yogurt, eggs, eggnog, chesse (cottage, American, cheddar), pork, chicken, fish
suggest nutritional supplementation after 5% weight loss
monitor albumin and prealbumin
B. altered taste- cancer cells stimulate substances that release bitter taste - Infection- primary cause of death in cancer patients: GU, lungs, mouth, rectum, peritoneal cavity, and blood
result of ulceration and necrosis
compression of vital organs
neutropenia - Oncological emergencies:
identify risk factors for developing lung cancer.
Total exposure to tobacco smoke is number one risk factor.
- inhaled carcinogens: asbestos, radon, nickel, iron, air pollution, etc.
carcinogens in cigarette smoke directly damage DNA
common manifestations of lung cancer.
initially silent, pneumonitis: fever, chills, cough, persistent cough with sputum, chest pain, dyspnea, wheezes
Briefly explain tumor lysis syndrome. Characterizations, and hallmark signs.
characterized by rapid release of intracellular components in response to chemo
potassium, phosphate, DNA & RNA components, released and metabolized to uric acid by the liver
increase serum phosphate= decreased calcium
—> leads to acute renal failure
***hallmark signs= hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia
How would you be able to identify complications of continuous bladder irrigation?
- hemorrhage (look for large amounts of bright red blood)
- bladder spasms- use oxybutynin (Ditropan)
- if inflow> outflow check cath for patency, kinks, or clots
Differentiate between benign and malignant tumors?
benign= encapsulated, differentiated, no metastasis, slightly vascular malignant= rarely encapsulated, poorly differentiated, possible metastasis and recurrence, infiltrative and expansive, abnormal cell characteristics unlike parent cells
What are potential risks of administering chemo drugs IV?
venous access difficulties
infection
infiltration/extravasation
Which cancers have a screening test and what are the recommendations for each?
Breast cancer= mammogram
Prostate cancer= PSA
Colon cancer= colonoscopy
cervical cancer= pap smear
Explain debulking.
used when a tumor cannot be completely removed (if it is attached to a vital organ)
as much is removed as possible before chemo or radiation therapy
Touch on each of the systems that chemo therapy effects and the problems it causes. Identify nursing management of these problems
GI: n/v/d= antiemetics prophylactically, antidiarrheals prn; high-protein high cal foods low fiber, >3L fluids
Hepatotoxicity: monitor liver function tests
Hematologic: anemia= H&H, iron supplements and Erythropoeitin
leukopenia= WBC count, report increase temp.
thrombocytopenia= observe for signs of bleeding (platelets< 20,000)
Integumentary: alopecia= suggest wigs, scarves, discuss self-image
skin changes-use lotions and avoid sun
GI: hemorrhagic cystitis= incr. fluids
reproductive dysfunction, nephrotoxicity= monitor BUN and serum creat., admin allopurinol and sodium bicarb
IICP
peripheral neuropathy= anti seizure meds (gabapentin)
Pneumonitis, pericarditis, myocarditis, cardiotoxicity, hyperuricemia, fatigue (encourage mod exericse as tolerated)
What is AIDS?
CD4 cell count<200
opportunistic infection
When should post exposure to HIV prophylaxis be initiated?
ASAP, within 72 hours of exposure
consists of 2-3 antiretroviral meds taken for 28 days
Who should receive an HIV vaccine?
HPV vaccinated, at risk populations, age groups, everyone
Breast cancer risk factors
female> 50 w/ family hx, modifiable risk factors, full-term pregnancy after 30
Define shock
characterized by decreased tissue perfusion and impaired cellular circulation.
What are the classifications of shock?
low blood flow= cardiogenic & hypovolemic
maldistibution of blood flow= neurogenic shock, anaphylactic shock, or septic shock
List some of the precipitating causes of cardiogenic shock.
MI, cardiomyopathy, blunt cardiac injury, severe systemic or pulmonary hypertension,
lead to compromised CO, systolic dysfunction (pump failure), and diastolic dysfunction (filling failure)
Manifestations of shock.
tachycardia, hypotension, narrowed pulse pressure, increased myocardial O2 consumption (heart is working harder to perfuse)
What assessment findings warrant immediate intervention with a physician or other medical team member?
falling BP, anxiety, confusion, decreased renal perfusion and urine output
Define hypovolemic shock and list possible causes.
loss of intravascular fluid volume.
hemorrhage, GI loss (v/d), fistula drainage, DI, hyperglycemia, diureses
At what point does a person in hypovolemic shock require blood volume replacement?
> 30% loss or if patient doesn’t respond to 2-3 L of NS fluid resuscitation
Explain the term third spacing.
relative hypovolemia- results when fluid volume moves out of the vascular space into extravascular space (interstitial or intracavity space)
What is neurogenic shock?
hemodynamic phenomenon that can occur within 30 min of a spinal cord injury at the T5 vertebra or above and can last up to 6 weeks
Manifestations of neurogenic shock
results in massive vasodilation, leading to pooling of blood in extremities:
hypotension, bradycardia, temp dysregulation (resulting in heat loss), dry skin, poikilothermia (take on temp of the environment)
Describe anaphylactic shock.
acute, life-threatening hypersensitivity reaction: massive vasodilation, release of mediators, increase capillary permeability:
causes anxiety, confusion, dizziness, sense of impending doom, chest pain, incontinence, swelling of lips and tongue, wheezing stridor, reap. distress and circulatory failure
Define sepsis.
systemic inflammatory response to documented or suspected infection
severe sepsis= leads to organ dysfunction
What is septic shock?
presence of sepsis with hypotension despite fluid resuscitation and the presence of perfusion abnormalities
Manifestions of septic shock
increase coagulation and inflammation, decrease fibrinolysis–> formation of micro thrombi and obstruction of microvasculature:
tachypnea/hyperventilation, decr UO, altered neuro status, * resp failure
This type of shock develops when a physical obstruction to blood flow occurs with decreased CO
obstructive shock
What types of obstructions lead to shock and what symptoms will this cause?
restriction to diastolic idling of the right ventricle due compression (cardia tamponade, tension pneumo)
abdominal compartment syndrome
leads to decr CO, incr after load, variable left vent filling pressures
If the perfusion deficit isn’t corrected in a patient experiencing shock, what will happen next?
enters progressive stage of shock- begins when compensatory mechanisms fail= decr cellular perfusion and ice cap permeability (leakage of protein into interstitial space and increased interstitial edema)
Briefly describe the path involved in the progressive stage of shock and what symptoms it leads to.
fluids move into alveoli– edema, tachypnea, crackles
CO begind to fall– decr perfusion, hypotsn, tachycardia, ischemia
myocardial dysfunction results in dysrhythmias, ischemia, MI, complete deterioration in cardio system
mucosal barriers of GI system becomes ischemic= ulcers, bleeding
liver fails to metabolize drugs and waste= jaundice, elevated enzymes, DIC, bleeding
What can be continuously monitored in the ICU?
ECG BP O2 sat mechanical ventilation cardiac output ICP temp: foley cath, rectal probe
Identify the 3 reasons why patients will be admitted to the ICU.
- physiologically unstable, required advanced and sophisticated clinical judgements
- pt at risk for serious complications and require frequent assessments or invasive procedures
- require intensive and complicated nursing support related to the use of IV polypharmacy & advanced biotechnology
Give a few examples of patients that would be admitted to the ICU
those scheduled for an interventional cardiac procedure, awaiting a heart transplant, receiving polypharmacy IV drugs; if they require mechanical ventilation
common problems of critical care patients
usually immobile and at high risk for venous thromboembolism and skin problems; invasive devices predispose them to hospital-acquired infections
nutrition- hyper metabolic state from burns or sepsis, or serenely malnourished from chronic cardiac, pulmonary, or liver disease
anxiety
pain
sensory-perceptual problems- “ICU psychosis”
What values are commonly measured with hemodynamic monitoring?
measurement of pressure, flow, and oxygenation
values include systemic and pulmonary arterial pressures, CVP, PAWP, O2 sat, Hgb of arterial blood
Define preload
the volume within the ventricle at the end of diastole
Define afterload
the forces opposing ventricular ejection
Diagnostic studies for septic shock
thorough hx and physical exam Blood studies: elevated lactate, base deficit 12-lead ECG chest xray hemodynamic monitoring
Fluid resuscitation is indicated for what type of shock?
septic, hypovolemic, anaphylactic
What is the primary goal of drug therapy in the treatment of shock?
correction of decreased tissue perfusion- vasopressors to vasoconstrict and so everything pools to the vital organs
ex. dopamine, norepinephrine
What should all ICU patients undergoing intubation or receiving mechanical intubation have at the bedside?
Ambu bag attached to O2 and suction
How do you monitor for correct ET tube placement and how often should it be checked?
confirm the exit mark on the tube remains constant while at rest and during patient care, repositioning and transport
check at least every 2-4 hr.
What are the roles of the RN, LPN, and UAP in caring for a patient requiring mechanical ventilation?
RN= breath sounds and resp. effort, monitor vent settings, care of the ET tube, educate, monitor oxygen level LPN= suction trach or ET tube as directed, admin routine meds, admin enteral nutrition to stable pts UAP= VS, hygiene and skin care, position change, passive or assisted ROM, I&O
Emergency interventions for shock
assess ABGs stabilize cervical spine as appropriate high flow oxygen via non-rebreather anticipate intubation IV access w/ 2-large bore cats blood cultures (lactate, WBC) control bleeding vasopressor if hypotension persists with fluid resuscitation indwelling cath and NG
treatments for cardiogenic shock
diuretics to reduce preload
emergency revascularization
treatments for anaphylactic shock
epinephrine, diphenhydramine
maintain airway- nebulizer bronchodilators, ET intubation
aggressive fluid replacement because of vessel permeability
IV corticosteroids if hypotension persists 1-2hr
What is the drug of choice to increase cardiac output without increasing the blood pressure?
Nitroprusside/Nipride. It is given with a contractile agent
What are the first signs of HIV?
flu-like symptoms which go away
Diagnostic finding to confirm AIDS
CD4 T-cell count <200 or HIV+ opportunistic infection
What can sever sepsis lead to?
SIRS= systemic inflammatory response syndrome and MODS- multiple organ dysfunction syndrome
What cancer is a CT used to diagnose?
neurologic, pelvic, skeletal, abdominal, thoracic cancers
Which cancers is fluoroscopy used in diagnosing
skeletal, lung, gastrointestinal cancers
Promotion, the second stage in the development of cancer, is characterized by __
reversible proliferation of altered cells
Myelosuppression is __
__one of the most common effects of chemotherapy and, to a lesser extent, with radiation. It can result in life-threatening effects, including infection and hemorrhage.
What could increased levels of PSA indicate?
Prostate cancer
BPH
acute urinary retention
acute prostatitis
What 4 common alpha adrenergic blocker meds are used to treat BPH?
alfuzosin (Uroxatral)
terazosin (Hytrin)
doxazosin (Cardura)
tamsulosin
What are some facts about the 3 way system for bladder irrigation?
also called the Murphy drip, monitor I’s & O’s , watch for TUR syndrome, if 500 mL goes in, then 500 mL should come out - make sure not absorbing the fluid, blood clots normal first 24-36 hrs., bladder spasms, increase fluids to prevent UTI, give laxative - no straining with BM’s, excessive bleeding may need balloon on indwelling cath increased to compress the area of bleeding (uses sterile, antibiotic, isotonic irrigating solution)
Modified radical mastectomy
removal of breast and axillary nodes but preserves pectorals major muscle
may or may not have breast reconstruction
- selected over breast conserving when tumor is too large to excise with good margins and attain a reasonable cosmetic result
How does hormonal therapy help in the treatment of breast cancer?
estrogen promotes cancer cell growth so Tamoxifen (Nolvadex) is used to bock the source of production
What is Herceptin?
biological therapy for breast cancer- antibody-antigen affect
What are abnormal findings during CBI and how do you correct?
bloody with good outflow= increase flow
Red, dark cherry, clots, decreased urine output= stops fluids, flush catheter with 50cc, slowly increase fluids, and notify physician
List all the potential causes of elevated PSA
inflammation/infection (prostatitis), prostate cancer, BPH, ejaculation, urinary retention, catheter placement, biopsy
Discuss the importance of compliance with ART.
- 90% reduction in viral load— drugs attack the replication from multiple angles
- resistance develops when taken alone or in inadequate doses
- interact with a lot of other med and OTCs- St. John’s wart, herbals
Pregnancy and HIV
women should receive optimal ART regardless of pregnancy status
Efaviranz (Sustiva) can cause fetal anomalies and should be avoided in pregnancy
What are the basic guidelines for ART?
- individualized based on risk for disease progression
- combination ART suppresses HIV replication and limits potential for replication
— use at least 3 effect ART drugs from two different - drug classes in optimum schedules and full doses
What is important in educating about prevention of HIV?
practice safe activities and risk-reducing activities
Seven warning signs of cancer
C-hange in bowel or bladder habits
A- sore that does not heal
U- nusual bleeding or discharge from any body orifiec
T- hickening or a lump in the great or elsewhere
I- ndigestion or difficulty in swallowing
O- bvious change in a wart or mole
N- agging cough or hoarseness
How can we as nurses educate the public about cancer prevention?
reduce modifiable risk factors reduce/avoid exposure to carcinogens eat balanced diet- decr. fat & preservatives exercise > 30min 5x wk adequate rest= 6-8 hr/day reg. health exam eliminate, reduce, change perception of stressors and cope effectively know 7 warning signs self-exams
what are tumor markers? identify the common ones
oncofetal antigens- an expression of the shift of cancer cells to more immature metabolic pathway
CEA- surfaces of CA cells derived from GI
PSA- prostate
AFP- produced by malignant liver cells and some testicular carcinomas
CA-125= ovarian
CA-19-9 pancreatic & gallbladder
CA 15-3 & 27-29= breast cancer
List opportunistic infections commonly associated with HIV
candida- thrush lymphoma- Hep B & C- jaundice, fatigue, n/v herpes pneumonia: fever, cough, weight loss
how does chemo effect normal cells?
chemo can’t selectively distinguish between normal cells and cancer cells so it destroys normal cells, mostly rapidly proliferating ones:
bone marrow, lining of the GI, hair skin and nails
How to manage pain in a cancer patient.
teach patients to keep a pain management diary
drug therapy includes anti-inflammatory drugs, opioids
Side effects of opiods in the cancer patient
appropriate to control the pain with the least amount of side effects
patient teaching should include addiction
Expected vs. unexpected side effects of chemo
expected= muscle aches, nausea, anorexia, elevated temp, hair loss unexpected= SOB, acute back pain, arrhythmia, severe bruising, edema, chest pain
What are ongoing assessments after intubation?
auscultate lungs bilaterally, observe for symmetrical chest movements, confirm placement with chest x-ray
routinely suction patient
provide oral care: gums should be moistened w/ saline or water swabs
meticulous skin care to prevent breakdown
reposition and retape tube every 24 hours
communicate with pt and reduce anxiety (morphine, lorazepam/Ativan, propofol
What is the purpose of PEEP on a ventilated patient?
positive pressure is applied to the airway during exhalation: normally airway pressure drops to zero on exhalation and is passive– PEEP has preset level of 3-20 cm H2O that pressure falls to.
Signs and symptoms of MODS
respiratory distress, decr renal perfusion, decr serum albumin and prealbumin, decr GI motility, acute neuro changes, myocardial dysfunction, DIC, changes in glucose metabolism
What is needed to diagnose HIV?
- highly sensitive enzyme immunoassay (EIA) to detect serum antibodies
- if blood EIA + repeat test
- if both + then perform confirming test= the western blot test (WB) immunoflourescence assay (IFA)
- if all three are positive the patient is HIV+
List postoperative complications
RESP.: pneumonia, atelactasis, pulm. embolism, hypoxemia, CIRC.: hypovolemia, hemorrhage, hypovolemic shock, thrombophlebitis, thrombus or embolus WOUND: infection, dehiscence, evisceration, PSYCH: postop depression GI: n/v, ileus, URINARY: retention, infection
which meds can potentiate the action of anesthetics?
antibiotics
list some drug categories that can affect a client in surgery
anticholinergics- incr potential confusion
anticoagulants-incr risk of hemorrhage
anticonvulsants- alter metabolism of anesthetics
antidepressants- lower bp
antidysrhythmics- reduce cardiac contractility
antihypertensives- can cause bradycardia, hypotension, and impaired circulation
corticosteroids- dosage may need to be upped for surgery due to stress
diuretics- potentiate electrolyte imbalances
