Final Exam Flashcards
3 pacemakers of the heart
SA node (60-100)
AV node (40-60)
purkinje fibers (20-40)
afib S&S
dizziness, palpitations, syncope, dyspnea, fatigue
management for afib
Manage obesity, HTN, obstructive sleep apnea, diabetes, smoking, alcohol, caffeine, surgery
meds for afib
anticoags (watch plt count)
BB (better than digitalis, not for pts in HF or hx bronchospasm)
Ca+ channel blockers (verapamil/diltiazem, good for pts w asthma, COPD, HTN, and HF)
digitalis (w BB)
amiodarone (converts rate and rhythm, ibutilide)
rhythm control for symptoms
procedures for afib
radiofrequency ablation
maze with cryoablation
Transesophageal echocardiogram for atrial thrombus
cardioversion (not for pts with clot)
catheter ablation
electrical cardioversion things to know
patient is NPO for 6 hours pre-procedure, IV access needed, anterior and posterior pads placed patient sedated with IV midazolam & propofol. Synchronized electrical shocks delivered. Observe for burns, alleviate discomfort
pharmacologic cardioversion
Using antiarrhythmics (amiodarone, sotalol, flecainide) for patient who developed afib within the past 7 days. Monitor HR, BP, K+, perform EKG to assess for QT prolongation. Contraindicated in digitalis toxicity, multifocal atrial tachycardia and sub-optimal anticoagulation
what anticoag to use in patients with mechanical heart valves
warfarin!! But watch vitamin K and do frequent INR draws
procedure for pts who can’t handle long term anticoags
left atrial appendage obliteration for stroke prevention as this is the main site for thrombus formation
target INR
2-3
complications of afib
clots causing CVA, MI, or cognitive decline (from micro emboli)
hypoperfusion from < CO (heart failure)
findings of angina
May be described as tightness, choking, or a heavy sensation
Frequently retrosternal (behind sternum, deep pain) and may radiate to neck, jaw, shoulders, back or arms (usually left)
Anxiety frequently accompanies the pain
Other symptoms may occur: dyspnea or shortness of breath, dizziness, nausea, and vomiting
unstable angina
characterized by increased frequency and severity and is not relieved by rest and NTG.
No longer managed with NTG, pain still exists
priorities for treating angina
no activity (semi-fowler)
VS, resp distress, pain
ECG
meds (NTG)
2L oxygen
pt teaching for angina
avoid extreme temps
avoid OTC meds that > HR or BP
no nic or fat
high fiber
maintain normal BP and glucose
NTG bottle
dark, keep away from kids and sunlight
unstable angina vs STEMI vs NSTEMI
Unstable angina, coronary ischemia but no acute MI
STEMI: acute MI, damage to myocardium
NSTEMI: elevated biomarkers, no ECG evidence of MI, less damage
manifestations of MI
Chest pain: Occurs suddenly and continues despite rest and medication
SOB; C/O indigestion; nausea; anxiety; cool, pale skin; increased HR, RR
ECG changes: Elevation in the ST segment in two contiguous leads is a key diagnostic indicator for MI
Lab studies: cardiac enzymes, troponin, creatine kinase (muscle damage), myoglobin
MONA and VOMIT
morphine, oxygen, nitrates, aspirin
vitals, oxygen, monitor, IV, time (if few hrs, give clot busters)
S&S of MI in women
Sweating: Similar to stress sweat, rather than sweating from exercise
SOB: Typically trouble breathing for no reason
Fatigue: Extreme tiredness
Chest pain or discomfort: The pain can be anywhere in the chest, not just the left side
Pain in the arms, back, neck, or jaw
Pain can be gradual or sudden
Nausea
Flu-like symptoms, including nausea, may occur a few days before a heart attack
Stomach pain: Can range in intensity from heartburn-like pain to severe abdominal pressure
emergency procedure for MI
CABG
hypertrophic and dilated heart
cardiomyopathy
right sided HF
Viscera (near abdominal area, ASCITES) and peripheral congestion
JVD
Dependent edema
Hepatomegaly
Ascites
Weight gain
Left sided HF
Pulmonary congestion, crackles
S3 or ventricular gallop (happens with HTN, right after S2, S4 is right before S1)
Dyspnea on exertion (DOE)
Activity level before you feel out of breath
Diet
How many pillows
Low O2 sat
Dry, nonproductive cough initially
Ace inhibitors, arbs taken instead
Oliguria
systolic HF
blood can’t pump
Impaired contractile function (like scar tissue from MI)
Increased afterload
Cardiomyopathy (hypertrophic & dilated)
Mechanical abnormalities (valve disease)
Decreased left ventricular ejection fraction (EF)
when to get heart transplant
EF: 5-10%
diastolic HF
Impaired ability of the ventricles to relax and fill during diastole, resulting in decreased stroke volume and CO
Heart failure with normal (preserved) EF
Problem filling, not getting blood out
Result of left ventricular hypertrophy from hypertension, MI, valve disease, or cardiomyopathy
mixed HF
Seen in disease states such as dilated cardiomyopathy (DCM)
Poor EFs (<35%)
High pulmonary pressures
Biventricular failure
Both ventricles may be dilated and have poor filling and emptying capacity
compensatory mechanism for HF
adrenal glands
catecholamines
nor and epi
compensatory mechanisms for HF
SNS
neurohormonal responses
ventricular remodeling
dilation
hypertrophy
SNS in HF
released epi and norepi
increased HR, contractility, peripheral vasoconstriction
helps then harms
neurohormonal responses in HF
kidneys release renin and initiate RAAS
ADH secretion
endothelin released
proinflammatory cytokines (CRP and homocysteine, seen in MI and HF)
what lab value indicates HF
BMP
ventricular remodeling
Results from SNS activation and neurohormonal responses
Hypertrophy of ventricular myocytes
Ventricles larger but less effective in pumping
Can cause life-threatening dysrhythmias and sudden cardiac death
Might get implantable defibrillator in case this happens
dilation in HF
enlargement of chambers
initially effective then CO decreases
hypertrophy in HF
increased cardiac wall thickness
effective at first then leads to poor contractility, increased O2 needs, poor circulation, and v-dysrhythmias
FACES in chronic HF
fatigue
activity intolerance
chest congestion/cough
edema
SOB
Paroxysmal nocturnal dyspnea
SOB that wakes the pt up
anasarca
entire body has pitting edema, fluid comes from pores, soaking bed, end stage
very uncomfy, give morphine
weight gain in ADHF
> 3lbs in 2 days
meds for HF
ACE inhibitors (vasodilation, diuresis, watch for hypotension, hyperkalemia, bad renal, cough)
angiotensin II (alternative to ace)
Hydralazine and isosorbide dinitrate (alternative to ace)
BB (careful w asthma)
diuretics (watch electrolytes)
digitalis (watch for toxicity esp with hypokalemia)
IV milrinone (hypotension) and dobutamine
gerontologic considerations for HF
May present with atypical signs and symptoms such as fatigue, weakness, and somnolence
Decreased renal function can make older patients resistant to diuretics and more sensitive to changes in volume
Administration of diuretics to older men requires nursing surveillance for bladder distention caused by urethral obstruction from an enlarged prostate gland
activity for HF patient
30-45 mins daily
2 hrs after eating
avoid extreme temps
manifestations of pulmonary edema
restlessness, anxiety, dyspnea, cool and clammy skin, cyanosis, weak and rapid pulse, cough, lung congestion (moist, noisy respirations), increased sputum production (sputum may be frothy and blood tinged), decreased LOC
meds for cardiogenic shock
diuretics
positive inotrope (+ contractility)
vasopressors
circulatory assist devices
intra-aortic balloon pump (temporary, does work for the heart)
mani of cardiac tamponade
ill-defined chest pain or fullness, pulsus paradoxus, engorged neck veins, labile or low BP, shortness of breath
Cardinal signs of cardiac tamponade: falling systolic BP, narrowing pulse pressure, rising venous pressure, distant heart sounds
treatments for cardiac tamponade
Pericardiocentesis: Puncture of the pericardial sac to aspirate pericardial fluid
Pericardiotomy: Under general anesthesia, a portion of the pericardium is excised to permit the exudative pericardial fluid to drain into the lymphatic system
endocarditis
from unresolved strep-A
incompetent valves
treatment for endocarditis
spironolactone (can cause gynecomastia/big boobs)
use eplerenone instead
empagliflozin
Classes I-IV of HF
I: No limitation
II: Slight limitation, rest is good but lots of activity causes fatigue
III: Less activity causes fatigue but rest is good
IV: Fatigue even at rest
manifestations of ischemic stroke
Symptoms depend on the location and size of the affected area
Numbness or weakness of face, arm, or leg, especially on one side
Confusion or change in mental status
Trouble speaking or understanding speech
Difficulty in walking, dizziness, or loss of balance or coordination
Sudden, severe headache
Perceptual disturbances
hemiplegia
one side paralysis
hemiparesis
one side weakness
hemianopsia
only seeing on one side
agnosia
not recognizing objects
care of patient after stroke
primarily supportive
Bed rest with sedation
Oxygen
Treatment of vasospasm, increased ICP, hypertension, potential seizures, and prevention of further bleeding
Deliberate CALM care!!
watch for fever and high bp (ischemic stroke and > ICP)
check glucose (high is bad) don’t give dextrose
HOB 30
mani of hemorrhagic stroke
Similar to ischemic stroke
Severe headache
Early and sudden changes in LOC
Vomiting
Bleeding
assessment during acute phase of stroke
LOC and neuro assessment
GCS
pupil
I&Os
BP
bleeding
O2
nursing care after acute phase of stroke
Mental status
Sensation/perception
Motor control
Swallowing ability
Nutritional and hydration status
Skin integrity
Activity tolerance
Bowel and bladder function
Get men ready to pee again once they’re stable enough to stand
how often to turn patient after stroke
q2h
prom or arom 4-5x/day
diet for post CVA
Chin tuck or swallowing method
Use of thickened liquids or pureed diet
Ice chips bad!!
how often to do neuro assessment post CVA
q2-4h
aneurysm precautions
Absolute bed rest with HOB 30 degrees
Avoid all activity that may increase ICP or BP; Valsalva maneuver, acute flexion or rotation of neck or head
Stool softener and mild laxatives so they don’t bear down
Non-stimulating, non-stressful environment; dim lighting, no reading, no TV, no radio
Visitors are restricted
early identification of aneurysm rupture
Call RRT (neuro)
Initiating stroke algorithm
Ensure labs are sent prior to CT scan
CBC, BMP, coags, T&S
nursing interventions to maintain airway
HOB >30
suction and O2 assessment
modified massey bedside swallow test
complete with time and date (cva and tia)
within 24h of new tia/cva
can’t just document +/- gag
when in doubt, NPO
right sided stroke
Left paralysis
Spatial difficulties
Impulsive behavior
Poor judgment
Time blindness
left stroke
Right paralysis
difficulty knowing left and right
slow cautious movements
impaired cognition
dep and anxiety
decorticate
Plantar flexed (feet point OUTWARD)
Legs internally rotated
Arms flexed and adducted (towards midline)
Hands flexed
BETTER PROGNOSIS
decerebrate
Plantar flexed (feet point OUTWARD)
Arms adducted (toward midline), extended, pronated, and hands flexed outward
GCS-eye
4 Spontaneous
3 Loud voice
2 Pain
1 None
GCS-verbal
5 Normal conversation
4 Disoriented conversation
3 Non coherent
2 No words, only sounds
1 None
GCS-motor
- Normal
- Localized to pain
- Withdraws to pain
- Flexion
- Extension
- None
CN1 and test
olfactory
smell stuff
CN2 and test
optic
snellen
wiggle fingers and move hand medially, ask when pt sees it
ishihara for color blindness
pt looks at you while you wiggle fingers in each quadrant
pupil reflex
fundoscope
CN3 and test
oculomotor
6 cardinal points in H
PERRLA
CN4 and test
trochlear
6 cardinal points in H
PERRLA
CN5 and test
trigeminal
dull sharp
corneal reflex with cotton, pt should blink
resist jaw against hand
jaw jerk should cause protrusion
CN6 and test
abducens
6 cardinal points in H
PERRLA
CN7 and test
facial
raise eyebrows
close eyes tight
puff cheeks and show teeth
taste
CN8 and test
vestibulocochlear/acoustic
rinne (forehead > ear)
weber (ear=ear)
CN9 and test
glossopharyngeal
swallow/gag reflex
phonation
taste
CN10 and test
vagus
swallow/gag reflex
phonation
taste
CN11 and test
spinal accessory
shrug against resistance
CN12 and test
hypoglossal
stick out tongue, is it straight
obtunded
Difficult to arouse, needs constant stimulation to follow a simple command
stupor
Arouses to vigorous, continuous stimulation (can’t follow a simple command)
severe impairment to brain circulation
may become comatose
akinetic mutism
unresponsiveness, no movement or sound, sometimes opens eyes
PVS
sleep-wake! no cognitive function
locked in syndrome
Inability to move or respond except for eye movements due to a lesion affecting the pons (according to Chicago Med, some pts can move eyes up and down but not side to side)
cushing’s triad
Increased SBP w widening pulse pressure
Bradycardia
Bradypnea
seen in herniation syndrome
normal ICP
1-15
early mani of increased ICP
Changes in LOC
Any change in condition
Restlessness, confusion, increased drowsiness, increased respiratory effort, purposeless movements (loss of spontaneous movement), hemianopsia, lost taste for sweet and salty, pulse and pulse pressure changes
Pupillary changes and impaired ocular movements
Weakness in one extremity or one side
Headache: constant, increasing in intensity, or aggravated by movement or straining
late mani of increased ICP
Respiratory and vasomotor changes
VS: major changes
Cushing triad: bradycardia/pnea, HTN
Projectile vomiting
Further deterioration of LOC
Going from stupor to coma
Hemiplegia, decortication, decerebration, or flaccidity
Respiratory pattern alterations including cheyne-stokes breathing and arrest
Loss of brainstem reflexes: pupil, gag, corneal, and swallowing
brain tumor mani
depends on location and size
Localized or generalized neurologic symptoms
Symptoms of increased ICP
Headache
Vomiting
Visual disturbances
Seizures
hormonal if pituitary
loss of hearing, tinnitus, and vertigo if acoustic
planning for radical neck dissection
absence of infection
viability of graft
nutrition and fluids
laryngeal cancer early S&S
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 and pain and burning in the throat
A lump may be felt in the 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
S&S of resp alkalosis
lightheadedness, inability to concentrate, numbness and tingling, sometimes loss of consciousness
S&S of resp acidosis
may be asymptomatic
Symptoms may be suddenly increased pulse, respiratory rate and BP, mental changes, feeling of fullness in head
what type of pressure do we want in lungs
negative!
internal beam radiation
implant that is right next to tumor, less systemic side effects
brachytherapy
seeds, don’t be near pregnant women and be cautious with immune system threat
external radiation
Can be scary bc mimics pulmonary cancer S&S
fatigue bc of bone marrow suppression
risk factors for breast ca
longer exposure to estrogen
obesity
high fat diet
alc
fibrositis (dense tissue)
breast cancer screening
20-30s, breast exam q3y
annual after age 40
annual mammo at 40
fine needle aspiration biopsy for breast cancer
fluid=cyst=benign
hormonal therapy for breast ca
Estrogen and progesterone receptor assay (Moms genetic coding is checked and meds are given for specific type of cancer)
SERMs (tamoxifen/causes uterine)
aromatase inhibitors (anastrozole, letrozole, exemestane)
physical therapy after mastectomy
exercise 3x/day for 20 mins
do not lift over 5-10 lbs
when to remove drains after mastectomy
<30ml drainage in 24 hrs for 2 days
usually 7-10 days
palliative surgery
DEBULKING
radiation, chemo, pain control
specific gravity
1.010-1.025
serum creatinine
0.6-1.2
BUN
7-18
8-20 for >60
3 way bladder irrigation
Urine should be a little pinkish first day, should NOT look cranberry color. If clots are there, they should be small enough to pass
Irrigating bladder wall, VERY vascular so minimize bleeding
mani of cirrhosis
Jaundice is late manifestation
Portal hypertension, ascites, and varices (a varicose vein, outpouching of the vein, can rupture)
Hepatic encephalopathy or coma
Nutritional deficiencies
hepatocellular jaundice
May appear mildly or severely ill
Lack of appetite, nausea, weight loss
Malaise, fatigue, weakness
Headache chills and fever if infectious in origin (like hepatitis)
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)
treatment of ascites
Low-sodium diet
Diuretics (often a combination of diff classes)
Bed rest
Paracentesis
Administration of salt-poor albumin
Transjugular intrahepatic portosystemic shunt (TIPS) to continually remove fluid
hepatic encephalopathy
A life-threatening complication of liver disease. May result from the accumulation of ammonia and other toxic metabolites in the blood
assessments with hepatic encephalopathy
LOC q15-30 minutes
seizures
fetor hepaticus (shit breath)
f&e and ammonia
asterixis
medical management of hepatic encephalopathy
Lactulose to reduce serum ammonia levels
IV glucose to minimize protein catabolism
Protein restriction
Reduction of ammonia from GI tract by gastric suction, enemas, oral antibiotics (not eating, they have an NG tube, meds go IV, not NG)
Discontinue sedatives analgesics and tranquilizers
Monitor for and promptly treat complications and infections
portal HTN
Obstructed blood flow through the liver results in increased pressure throughout the portal venous system (everything is backing up, like a reflux)
results of portal HTN
Ascites (abdominal fluid buildup, usually peritoneal, puts pressure on diaphragm which causes SOB)
Esophageal varices (when these rupture, pt vomits bright red BADDD smelling blood)
pancreatic (pancreatitis) cancer treatment
Use of analgesics
Nasogastric suction to relieve nausea and distention
Frequent oral care
Bed rest
Measures to promote comfort and relieve anxiety
common bile duct obstruction complications
chronic pancreatitis
type 1 diabetes
Fluid and electrolyte disturbances
Necrosis of the pancreas
Shock
Multiple organ dysfunction syndrome
DIC
jaundice
pruritus
RUQ pain
anorexia
fever, fatigue
If left untreated, infections, sepsis, and liver disease
complications of pancreatitis
Fluid and electrolyte disturbances
Necrosis of the pancreas
Shock
Multiple organ dysfunction syndrome
DIC
SIADH fluid restriction
<800ml/day
S&S of SIADH
Weight gain without edema, weakness, anorexia, N/V, personality changes, seizures, oliguria, decreased reflexes, coma, hyponatremia
treatment of SIADH
Treat underlying malignancy & correct the sodium- water imbalance (fluid restriction, oral salt tablets or isotonic [0.9]) saline and IV administration of 3% sodium chloride solution.
Furosemide (Lasix) may also be a helpful treatment in the initial phases.
Demeclocycline (Declomycin) may be needed on an ongoing basis
Monitor sodium level
diabetes insipidus
decreased ADH
Excessive urine output
Decreased urine osmolality
Serum hyperosmolality
Give IV fluids, electrolyte replacement and desmopressin (synthetic vasopressin)
Hypopituitary
addison’s disease
adrenocortical insufficiency
adrenal suppression
addison’s disease S&S
Muscle weakness, anorexia, GI symptoms, fatigue, dark pigmentation of skin and mucosa, hypotension, low blood glucose, low serum sodium, high serum potassium, apathy, emotional lability, confusion
diagnostic tests for addison’s
adrenocortical hormone levels, ACTH levels, ACTH stimulation test
low sodium, high potassium
bronze skin
assessments for addison’s
Note any illness or stressors that may precipitate problems
Fluid and electrolyte status
VS and orthostatic blood pressures
Note signs and symptoms related to adrenocortical insufficiency: weight changes, muscle weakness, fatigue
interventions for addison’s
monitor for signs and symptoms of fluid volume deficit; encourage fluids and foods; select foods high in sodium; administer hormone replacement as prescribed
Activity intolerance; avoid stress and activity until stable, perform all activities for patient when in crisis; maintain a quiet, non stressful environment; measures to reduce anxiety
cushings
Excessive adrenocortical activity or corticosteroid medications
mani of cushings
Hyperglycemia; central-type obesity with “buffalo hump;” heavy trunk and thin extremities; fragile, thin skin; ecchymosis; striae; weakness; lassitude; sleep disturbances; osteoporosis; muscle wasting; hypertension; “moon-face”; acne; infection; slow healing; virilization in women; loss of libido; mood changes; increased serum sodium; decreased serum potassium
**tests for cushing’s
ACTH stimulation test and dexamethasone suppression
assessment for cushings
Activity level and ability to carry out self-care
Skin assessment
Changes in physical appearance and patient responses to these changes
Mental function
Emotional status
Medications
addisonian crisis
complication of addison’s
too much too little
Profound fatigue
Dehydration
Vascular collapse (low BP)
Renal shutdown
Decreased sodium, increased potassium
planning for cushings
decreased risk of injury, decreased risk of infection, increased ability to carry out self-care activities, improved skin integrity, improved body image, improved mental function, and absence of complications
corticosteroid therapy
Suppress inflammation and autoimmune response, control allergic reactions, and reduce transplant rejection
long half life, same time per day TAPER!
blister pack to taper
immunosuppression
increased glucose
personality in kids
SNS
Pupils dilate
Bronchodilation
Increased HR
Smaller blood vessels constrict
Relaxed GI
Relaxed bladder and uterus
PNS
Constricted pupils
Constricted bronchioles and increased secretions
Decreased HR
Dilated blood vessels
Increased peristalsis and secretions
Contracted bladder
Increased salivation
treatment for hyperthyroidism
treatment of choice is removal
modified or radical neck dissection, possible radioactive iodine to minimize mets
seeds to shrink tumor before surgery
caffeine and thyroid
avoid caffeine
thyroid storm!
preop education for thyroid surgery
dietary guidance
no caffeine and stimulants
explain tests and procedures
head + neck support
look for shoulder drop to make sure we didn’t cut into sternocleidomastoid muscle
postop management for thyroid surgery
Monitor respirations; potential airway impairment
Monitor for potential bleeding and hematoma formation; check posterior dressing
Assess pain and provide pain relief measures
Semi-Fowler position, support head and neck
Assess voice, discourage talking
Potential hypocalcemia related to injury or removal of parathyroid glands
parathormone regulates what 2 electrolytes and how
calcium and phosphorus
increases serum Ca and decreases ph
hyperparathyroidism
may have no symptoms
apathy, fatigue, muscle weakness, nausea, vomiting, constipation, hypertension, and cardiac dysrhythmias may occur
mimics depression
hypercalcemic crisis**
neuro, cardio, and renal symptoms
life threatening
rapid isotonic rehydration
calcitonin and corticosteroids given
3 causes of hypoparathyroid
Abnormal parathyroid development
Destruction of the parathyroid glands (surgical removal or autoimmune response)
Vitamin D deficiency
clinical mani of hypoparathyroid
Tetany, numbness, tingling in extremities, stiffness of hands and feet, bronchospasm, laryngeal spasm, carpopedal spasm, anxiety, irritability, depression, delirium, ECG changes
Carpopedal spasm = chvostek trousseau
chvostek and trousseau
chvostek: sharp tap in front of parotid and ear, spasm of mouth, nose, and eye
trousseau: BP cuff for 3 mins, gay italian hand
management of hypoparathyroid
increase calcium to 9-10
calcium gluconate
pentobarbital to decrease muscular irritability
parathormone
low stim environment
high calcium, low phosphorus
vit d
medical management of pituitary tumors
Stereotactic radiation (external beam)
bromocriptine/octreotide (inhibits GH and octreotide shrinks tumor)
surgical management of pituitary tumor
Hypophysectomy (removal of pituitary gland, also for cushing’s and palliation for bone pain)
Irradiation
Cryosurgery
Menstruation stops
Infertility after total or near-total ablation of pituitary
Replacement therapy with corticosteroids and thyroid hormone
adrenal crisis S&S
low cortisol
dizziness, weakness, sweating, abd pain, N/V, LOC, rapid weak pulse, rapid RR, pallor
CLL
Malignant clone of B lymphocyte (T lymphocyte CLL is rare) *Most of leukemic cells of CLL are mature, (may have escaped/resisted apoptosis)
men > 60
2-14 year survival
diagnosis and mani of CLL
Normal or ↓erythrocytes and platelet
Early: ↑lymphocyte count
Lymphadenopathy- Swollen painful nodes;
Enlarged liver and spleen
Later stage: Thrombocytopenia
Auto-immune complications can occur at any stage.
B symptoms: Night sweats, unintentional wt loss; infections
medical management of CLL
early: no treatment, monitor
late: begin!
chemo, monoclonal antibody therapy, IVIG, HSCT
hodgkin’s lab findings
Reed Sternberg cell or be of viral etiology.
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
hodgkin’s S&S
related to compression of organs involved ie: Compression of trachea cough; pleural effusion; abdominal pain; Pruritus; Herpes Zoster
Severe pain on ingestion of alcohol; anemia; B symptoms; normal or slightly decreased platelet count; decrease skin sensitivity test
lab findings of tumor lysis
HYPERuricemia
HYPERphosphatemia
HYPERkalemia
HYPOcalcemia
S&S of tumor lysis
N/D, muscle cramps, confusion, weakness, seizures
resp mani at EOL
cheyne stokes
accessory muscles
irregular and slowing down
can’t cough or clear secretions
death rattle is fluid from lungs building up
hearing and touch mani at EOL
hearing is the last sense to go
decreased sensation to hot and cold
decreased perception of pain and touch
taste, smell, and sight mani at EOL
blurred vision
no blinking
eyelids half open
decreased taste and smell
skin mani at EOL
mottling
cold, clammy
cyanosis of nose, nails, knees
wax like skin when close to death (looks wet)
urinary mani at EOL
decrease in output
incontinent
unable to urinate
GI mani at EOL
slow GI tract and possible cessation
accumulation of gas
distension and nausea
incontinent
BM before or at time of death
musculoskeletal mani at EOL
loss of ability to move
trouble holding body posture and alignment
loss of facial muscle tone (sagging jaw, difficulty speaking, no gag reflex, go from normal to puree to NPO)
cardio mani at EOL
tachy then slow, weak pulse
irregular
decreased BP
delayed absorption of IM or SQ
HIV
Targets CD4+ lymphocytes AKA T-cells
T-cells and B-cells work together
HIV integrates its RNA into host cell DNA through reverse transcriptase, reshaping the host’s immune system
3 infection stages of HIV
stage 1: CD4+ 500
Stage 2: CD4+ 200-499
Stage 3 (AIDS): CD4+ <200, T-lymphocytes >14%
B-cell lymphoma
non-hodgkins
non-hodgkin’s lymphoma
b-lymphocyte
average age 50-60
diagnosis of non-hodgkins
CT
PET
Bone marrow biopsy
CNS fluid analysis
S&S of non-hodgkins
multiple lymph nodes!
B symptoms (33%)
Less aggressive forms can wax and wane
Asymptomatic in early stage.
Lymphadenopathy in stage 3-4.
Lymph masses can compromise organ functions e.g. respiratory, spleen CNS; urinary
treatment for non-hodgkins
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
kaposi sarcoma
Oncologic manifestation of HIV
a malignancy of endothelial cells that line the blood vessels
chronic, benign
kaposi sarcoma mani
dark reddish-purple lesions of the skin, oral cavity, gi tract, and lungs
kaposi sarcoma risk factors
older men mediterranean or jewish
endemic (african) ks: eastern half of africa, men, resembles classic
iatrogenic/organ transplant-associated ks: organ transplant patients and immunosuppressants
occurs with AIDS, aggressive
AIDS defining illnesses
HIV encephalopathy, pneumocystis, recurrent PNA
complications of AIDS
Opportunistic (secondary) infections
Most common are fungal
Impaired breathing or respiratory failure
Wasting syndrome and f&e imbalance
Electrolyte imbalance kills most ppl, same w chemo
Adverse effects of medications
4 causes of blindness
macular degeneration
glaucoma
cataracts
diabetic retinopathy
glaucoma
Disturbance of the functional or structural integrity of the optic nerve. This is characterized by increased fluid secretion or decreased fluid drainage which increases intraocular pressure and can cause atrophy of the optic nerve and deterioration of vision
open angle glaucoma
more common
aqueous humor secretion decreased bc of blockage in schlemm
increased pressure in eye
S&S of open angle glaucoma
headache
mild pain
loss of peripheral vision
halos around lights
IOP 22-23
treatment of open angle glaucoma
cholinergics (carbachol, echothiophate, pilocarpine)
adrenergic agonists (Apraclonidine, brimonidine tartrate, dipivefrin)
BB
Carbonic anhydrase inhibitors (-lamide)
prostaglandin analogs (-prost)
surgery for open angle glaucoma
Laser trabeculectomy
Iridotomy
Placement of shunts to allow fluid to circulate better
closed angle glaucoma
There is a closure of the angle of the iris and the sclera which causes a sudden and dramatic rise in intraocular pressure
This is an emergent situation
S&S of closed angle glaucoma
Severe pain
Blurred vision, decreased vision, loss of vision
Pupils that do not respond to light
Light sensitivity
Halos around lights are seen
IOP greater than 30 mm Hg
treatment of closed angle glaucoma
osmotics (mannitol or glycerin)
cholinergics
adrenergic agonist
BB
carbonic anhydrase inhibitors (-lamide)
prostaglandin analogs (-prost)
surgery for closed angle glaucoma
Laser trabeculectomy
Iridotomy
Placement of shunts to allow fluid to circulate better
same as open angle
administering eye drops
antiseptic technique
sit upright or lay down with chin up
-dropper held 1-2cm above conjunctival sac
-don’t drop onto cornea
-gentle pressure on tear duct to prevent systemic absorption
-wait 5 min if multiple
-ointments should go inner to outer corner
administering ear drops
aseptic technique
room temp
sit upright or lie on side
straighten ear canal by pulling UP AND OUT for adults and BACK for children <3
dropper 1cm above canal
apply gentle pressure to tragus unless too painful
no cotton inside ear, just outermost part of canal
stay in side-lying for 2-3 mins
meniere’s disease
A chronic disorder of the inner ear involving sensorineural hearing loss, severe vertigo and tinnitus
meniere’s and aspirin
no aspirin
meds for meniere’s
antihistamines
tranquilizers
antiemetic
diuretic
gentamycin
2 surgeries for meniere’s
Endolymphatic sac decompression: shunting. Basically a drain, first-line, safe, effective, and quick
Vestibular nerve sectioning: preserves hearing if done that way. Cutting the nerves stops auditory input
brief stay
basal cell carcinoma
appears on sun exposed hands,face, neck, scalp
small waxy nodule
may appear shiny, flat, gray, yellow
rarely metastasizes
reoccurrence common
surgery of basal cell carcinoma
surgical incision
mohs micrographic surgery
electrosurgery
cryosurgery
alternatives to surgery for basal cell carcinoma
radiation, photodynamic, topical chemotherapeutic creams
malignant melanoma
cancerous neoplasm present in dermis and epidermis
manifests as a change in nevus or a new growth on the skin
color is dark, red, blue colored or a mix, irregular shape
itching, rapid growth, ulceration, bleeding
treatment of malignant melanoma
surgical excision, chemotherapy
what to ask about with malignant melanoma
pruritus, tenderness, pain, changes in moles, or new pigmented lesions
squamous cell carcinoma
arises from epidermis, sun damaged skin
less aggressive than melanoma, can cause death
may metastasize by blood or lymph
rough, thickened, scaly tumor
may be asymptomatic or bleed
border is wide, more infiltrated, more inflammatory
psoriatic plaques complications
infection and psoriatic arthritis
what aggravates psoriasis
stress, trauma, seasonal and hormonal changes
treatment of psoriasis
baths to remove scales and medications
remove scales with soft brush
emollient creams after
maintain routine
pharmacologic therapy
topical
phototherapy
ASSESS NAIL AND SCALP
CABG complications
Bleeding
Clots
Infection
PNA
Breathing issues
Pancreatitis
Kidney failure
Abnormal heart rhythms
Graft failure
Death
Post-op gallbladder care
low fowlers
fluids and NG suction for distention
soft diet when bowel sounds return
avoid turning
splint affected side
shallow breaths
analgesics to help pt turn, cough, and deep breathe
ambulate
treatment of adrenal crisis
IV glucose, fluids, electrolytes (sodium), missing steroid hormones, and vasopressors
S&S of thrombocytopenia come from (4)
enlarged spleen, vascular occlusion, headaches, and hemorrhage
leukemia S&S
From inadequate production of normal blood cells
Neutropenia (fever and infection)
Anemia (pallor, fatigue, weakness, dyspnea on exertion, dizziness)
Thrombocytopenia (ecchymoses, petechiae, nosebleeds, gingival bleeding
S&S from enlarged liver or spleen
Hyperplasia of gums and bone pain from expansion of marrow
HIV encephalopathy early mani
Memory deficits, HA, difficulty concentrating, confusion, psychomotor slowing, apathy, and ataxia
HIV encephalopathy late mani
global cognitive impairments, delay in verbal responses, vacant stare, spastic paraparesis, hyperreflexia, psychosis, hyperreflexia, tremor, incontinence, seizures, mutism, and death
herpes virus presentation
Blisters, painful and can take 2-4w to heal, or asymptomatic
Itching and pain on infected area, red and edematous
May begin with macules and papules and progress to vesicles and ulcers
Labia is usually primary site
Men is usually foreskin, glans penis, or shaft
Inguinal lymphadenopathy (groin lymph nodes), minor temp, malaise, HA, myalgia (muscle aches), dysuria
herpes virus treatment
No cure
Relieve symptoms
Prevent spread of infection, make pt comfy, decrease health risks, counseling
Oral antivirals (acyclovir, valacyclovir, famciclovir) can suppress symptoms and shorten course of infection
Antispasmodics and saline compress
tamponade nursing actions
IV fluids for hypotension
chest x-ray or ECG
prep pt for pericardiocentesis
monitor hemodynamic pressures
monitor heart rhythm, changes indicate improper needle position
monitor for dyspnea and give O2 prn
