final new info (blood, musculoskeletal, skin, cancer, EOL) Flashcards
(103 cards)
1
Q
hematology - assessment - history
A
age related, clotting factors, drug use (bone marrow suppression meds, drugs causing hemolysis, drugs disrupting platelet action), nutrition status (diet, intake, protein rich/low protein, high fat, foods rich in vit K, iron deficient, alcohol), genetics/family hx (blood/clotting do, hemophilia, sickle cell, excessing bleeding/bruising)
2
Q
hematology age related changes
A
↓ blood volume, ↓ plasma proteins (diet, liver malfunction), ↓ RBC/WBC produced, ↓ lymphocytes/antibodies to fight infection/immune response.
thick discolored nail beds, loss of hair, skin moisture and skin color changes in older adults w/ dryness, loss of turgor, pigment loss, yellowing of skin
3
Q
hematology - assessment - current health problems (questions to ask)
A
bruising, bleeding, menstrual flow, exertional dyspnea, palpitations, weight loss, tinnitus, vertigo, sore tongue, fatigue! (anemia), trends of past month/months
4
Q
hematology - assessment - physical
A
skin (nail beds, gums, conjunctiva, petechiae, ecchymosis, areas of poor circulation), head/neck (tongue, oral mucosa, sclera, lymph nodes), respiratory (rate, depth, fatigue w/ speaking - anemia = reduce tissue oxygen levels causing SOB and respiratory changes), CNS (CN, vit B12 deficiency, cognitive function, neuro checks), cardiovascular (weak pulses, thready, JVD, edema, BP), renal (hematuria, urine color, CKD → anemia), musculoskeletal (sternal/rib tenderness - leukemia, swelling or joint pain), abdominal (enlarged spleen and liver, chronic GI bleeding ulcer or poly)
5
Q
hematology - assessment - diagnostic
A
XR (multiple myeloma or sickle cell: abnormal bone destruction), bone marrow aspiration and biopsy (invasive procedure, cells/fluids suctioned from the bone marrow w/ large bore needle - iliac crest or sternum, local anesthetic, sterile, post pressure
6
Q
hematology - assessment - labs
A
CBC w/ RBC, reticulocyte count (bone marrow function), platelet (thrombocytopenia), bleeding and coagulation (clotting - PT, INR, PTT).
7
Q
RBC
A
4.2-6.1
8
Q
increased RBC/HGB/HCT
A
possible chronic hypoxia or polycythemia vera
9
Q
decreased RBC/HGB/HCT
A
possible anemia or hemorrhage
10
Q
HGB
A
12-18
11
Q
HCT
A
37-52%
12
Q
WBC
A
5,000-10,000
13
Q
platelet
A
150,000-400,000
14
Q
increased WBC
A
associated w/ infection, inflammation, autoimmune disorders, leukemia
15
Q
decreased WBC
A
prolonged infection or bone marrow suppression
16
Q
increased platelet
A
polycythemia vera or malignancy
17
Q
decreased platelet
A
bone marrow suppression, autoimmune disease, hyperplenism
18
Q
INR
A
0.8-1.1
19
Q
increased INR
A
longer clotting time - thin blood (desirable for therapy w/ warfarin)
20
Q
decreased INR
A
hyper coagulation and increased risk for VTE
21
Q
PT
A
11-12.5 sec or 85-100%
22
Q
increased PT
A
indicates possible deficiency of clotting factors V and VII
23
Q
decreased PT
A
may indicate vitamin K excess
24
Q
Sickle Cell Disease (SCD)
A
Genetic disorder in which a mutation in the gene causes chronic anemia, pain, disability, organ damage, infection risk due to poor perfusion. Autosomal recessive genetic d/o.
Risk factors = african american.
Assessment = Hx (long standing diagnosis and unaware of sickle cell trait w/ no symptoms until acute illness. Events leading up to symptoms - 24 hr prior including food, exposure, stress, injury - energy level, SOB w/ exertion), psychosocial (behavior/cognitive changes d/t poor perfusion), physical (pain, high risk for HF/pulmonary HTN/pneumonia, murmurs, S3, JVD, ↑ HR, hypotension, pallor, cyanosis, jaundice, severe abdominal pain, spleen and liver ischemia, CKD, proteinuria, joint pain, leg/arm pain, fever, seizure, stroke).
Labs = hemoglobin S on electrophoresis (80-100%), RBC, ↓ Hct, ↑ reticulocyte, ↑ bilirubin, EBC (chronic inflammation, hypoxia, ischemia).
Diagnostic = XR joints, US, PET, MRI, ECG, ECHO.
Priorities = pain d/t poor perfusion, joint destruction w/ low oxygen levels, high risk for infection/sepsis/MODS.
Interventions = O2, pain, hydration, HOB 30 degrees or less, extremities extended (venous return), drugs (endari which increases RBC & decreases sickling rates - crizanlizumab which helps platelets and RBC adherence), 3-4L fluid daily.
25
Sickle cell crisis / Vaso-occlusive crises
Sudden onset of periodic episodes of extensive RB sickling. Occurs w/ body’s response to hypoxemia. Damage causes tissue hypoxia, anoxia, ischemia, cell death. Organ infaracts and scarring occur (spleen, liver, kidney, brain, joints, bones, retina). Risk factors = high altitudes, cold water/weather, heavy physical labor. Symptoms = pain in back, knees, legs, arm, stomach, chest, throbbing, sharp, stabbing. Emergency = fever, SOB, chest pain.
26
Acute chest syndrome (SCD)
life threatening condition caused by fat embolism from sickled cells and respiratory infection. S/S = cough, SOB, fever, infiltrate, respiratory failure, MODS
27
Anemia
reduction in the # of RBC, Hgb, Hct.
Causes = diet, genetic d/o, bone marrow disease, excessive bleeding, GI bleeding.
S/S = pallor, cool skin, brittle nails, rapid HR, murmurs, orthostatic hypotn, exertional SOB, low O2 statBCP, methotrexate, anticonvulsants.
Eat a diet high in folic acid and vit B12), aplastic (caused by exposure to radiation, chemicals, or virus - hep b, CMV, epstein barr.
Intervent = blood transfusion, immunosuppression, splenectomy, stem cell transplant).
28
Polycythemia Vera (PV)
are chronic myeloproliferative neoplasm. A type of leukemia blood cancer. Bone marrow makes too many RBCs. Excess cells thicken your blood (hyperviscous), which decreases blood flow causing blood clots. Malignant disease.
Cause = unknown.
Hallmark signs = massive production of RBC, excessive leukocyte production, excessive production of platelets.
S/S = flushed skin, cyanotic, itching, HTN, thrombus risk, hypoxia, poor perfusion, SOB, high risk for organ failure (heart, spleen, kidneys).
Interventions = apheresis (whole blood withdrawn, removal of some components and return plasma to patient - hydration anticoagulants, aspirin, hydroxyurea).
29
Preleukemia & Leukemia
blood cancer that results from a loss of normal cellular regulation, leading to uncontrolled production of immature WBCs (blast cells) in the bone marrow. THe loss of cellular regulation causes cells to change or malignant. Stem cells (immature cells) are extensive. Risk factors = ionizing radiation, viral infection, chemical or drug exposure, immunity factors. Cause = genetic/environmental; unknown. Treatment = stem cell transplant (HSCT)(early) or supportive care (blood or platelet transfusion). Assessment = Hx (risk factors, occupation, infection - leukopenia, clotting, bleeding issues). S/S = exxymoses, petechiae, pallor, fatigue, headache, fever, seizures, coma, tachycardia, palpitations, SOB, murmurs, coughing, abnormal bleeding, weight loss, enlarged spleen & liver, occult blood in stool, haematuria, bone pain, joint swelling, anxious, feer, coping. Labs/diagnostic = CBC, Coags, bone marrow biopsy, genetic testing, XR. Priorities = infection risk. Drug therapy = AML (induction, consolidation), CML (imatinib mesylate first line, interferon alfa), CLL (chemotherapy, monoclonal antibody therapy, stem cell transplantation.
30
types of anemia
sickle cell (genetic), G6PD (genetic), iron-deficient (common - caused by chronic alcoholism, diet, malabsorption syndromes, pregnancy. Increase oral intake of iron from food such as red meat, egg yolks, kidney beans, green leafy vegs), vitamin B12 (caused by diet, gastrectomy, pernicious anemia, malabsorption, small bowel resection. Increase foods in vit B12 - animal protein, fish, eggs, nuts, dairy, leafy greens), folic acid (caused by diet, drug therapy - BCP, methotrexate, anticonvulsants. Eat a diet high in folic acid and vit B12), aplastic (caused by exposure to radiation, chemicals, or virus - hep b, CMV, epstein barr. Intervent = blood transfusion, immunosuppression, splenectomy, stem cell transplant).
31
Hematopoietic stem cell transplantation (HSCT)
standard treatment for pts w/ acute leukemia. Interventions = bleeding risk at harvest site, pain management, apheresis procedure (withdrawing blood, filter, return - hypocalcemia, hypotn). Side effects = fever, HTN (benadryl, antihtn, diuretics), infection and poor clotting, failure to engraft, graft vs host disease, sinusoidal obstructive syndrome.
32
Malignant lymphomas
cancers of the lymphoid cells and tissue w/ abnormal overgrowth of lymphocytes. Growth in solid tumors in lymphoid tissues especially in lymph nodes and spleen. Interventions = aggressive therapy, external radiation, chemotherapy (extensive), CAR-T cell therapy (enhances own immune system - cytokine storm 5-7 days after infusion resolves in 2wks - fatigue, fever, low BP, confusion, N/V). Nursing management = infection risk, anemia, N/V, skin issues, infertility, clos monitoring of infusion related reactions.
33
Hodgkin lymphoma (HL)
teens and adults > 50yo. Singly lymph node and spreads. Cause = unknown, but viral infections (EBV, hyman T cell virus, HIV, exposure chemicals).
34
Non-Hodgkin lymphoma (NHL)
any age. Spreads through the lymphatic system. Cause = unknown but higher in organ transplants, HIV, immunosuppressant therapy, H.pylori, EBV, chemical exposure. NHL is a group of disorders where classification is based on histology, genetics, cytometry. Common types = B-cell lymphoma (aggressive, large masses, symptoms), and T-cell.
35
Multiple Myeloma (MM)
EBC cancer of mature B-lymphocytes called plasma cells that secrete antibodies. Cancer cells produce excessive antibodies (gamma globulins) & myeloma cells produce excessive cytokines that increase cancer cell growth/destroy bone. Starts in bone marrow. Anemia, infection risk, bleeding. Risk factors/onset = >65yr old, african americans, men. Cause = unknown. Complications = risks for AKI, CKD, HF, dysrhythmias, DCT, pulmonary HTN, pleural effusions. S/S = asymptomatic early, ↑ serum protein, fatigue, anemia, bone pain, fractures (no injury), infections, easy bruising. Interventions = pain management, chemotherapy, stem cells, steroids, immunomodulating drugs
36
Thrombocytopenia Purpura
estructive reduction of circulating platelets after normal platelet production. 3 types (see pic) S/S = bruising, purpura (red, purple petechia rash), anemia. Interventions = high risk for poor clotting and excessive bleeding, platelet transfusion, safety to avoid injury, Drugs (anticoagulants, direct thrombin inhibitor, corticosteroids, ASA), surgical (splenectomy).
37
musculoskeletal - changes w/ aging
osteopenia, osteoporosis (severe osteopenia leads to kyphosis), synovial joint cartilage becomes less elastic and compressible (osteoarthritis), muscular atrophy
38
musculoskeletal - older adult considerations
safety tips to prevent falls, reinforce need to exercise, prevent pressure on bony prominences, teach proper body mechanics, assess need for ambulatory devices, provide moist heat for pain, assist w/ ADLs&ambulation, don't rush.
39
musculoskeletal - health promotion
vitamin D, calcium supplements, weight bearing activities, smoking cessation, minimal ETOH, assess risky lifestyle behaviors
40
serum calcium
9-10.5
41
increased calcium
metastatic cancers of the bone, Paget disease, bone fractures in the healing stage
42
decreased calcium
osteoporosis, osteomalacia
43
serum phosphate
3-4.5
44
increased phosphate
bone fractures in the healing stage, bone tumors
45
decreased phosphate
osteomalacia
46
alkaline phosphate
30-120
47
increased phosphate
metastatic cancers of the bone or liver, pagers disease, osteomalacia
48
CK-MM
30-170
49
increased CK-MM
muscle trauma, muscular dystrophy, effects of electromyography
50
AST
0-35
51
increased AST
skeletal muscle trauma, muscular dystrophy
52
osteoporosis
chronic disease of cellular regulation. Bone loss occurs in vertebral bodies of spine, femoral neck in hip, distal radius of arm. Health promotion = peak bone mass achieved by 30 yo in most women, building strong bone as a young person may be the best defense against osteoporosis in later adulthood, limit carbonated beverages. Assess fear of falling. Labs = serum Ca, total D2 plus D3 (25-80 ng/mL), osteocalcin, BSAP. Imaging = xray, DXR (t-score +1/-1 is normal; < -1 indicates low bone mass. < -2.5 = osteoporosis). Interventions = nutrition (same as those for preventing, 1000-1200 Ca, Vit D, avoid ETOH/caffeine - promotion of a single nutrient won't prevent or treat osteoporosis), lifestyle changes (exercise, tobacco), drug therapy (indicated w/ t score or >50yo w/ hip or vertebral fracture - oral bisphosphonates which is first line after Ca & vit D can be oral or IV and contraindicated for those unable to stay upright for 30-60 min or esophageal disorders or CKD, estrogen agonists/antagonists, RANKL).
Primary: Risk factors = women after menopause (low levels of estrogen associated w/ ↑ in bone resorption), genetic, lifestyle, environment, excessive caffeine, no sunlight, euro-caucasion or asian, rheumatoid arthritis, hx of low-trauma fracture, thin women, smoking, ETOH, steroid therapy.
Secondary: Causes = DM, hyperthyroidism, hyperparathyroidism, rheumatoid arthritis, prolonged immobilization, bone cancer, cirrhosis, HIV, corticosteroid, antiepileptic, barbiturates, ethanol, high levels of thyroid hormone, cytotoxic agents, immunosuppressants, loop diuretics, aluminum-based antacids
53
osteomyelitis
bone infection caused by bacteria, viruses, parasites, or fungi. Stimulates inflammatory response in bone tissue. Inflammation produces ↑ vascular leak and edema (inv surrounding soft tissue). Vessels in area become thrombosed and release exudate into bony tissue (ischemia follows and results in necrotic bone). Assessment = bone pain that is constant/localized/ pulsating sensation (worse w/ mvmnt), fever > 101, swelling around affected area, erythema/heat, tenderness, ↑ WBC/ESR, + blood cultures. Interventions = acute (4-6wk of antimicrobial therapy IV vanco or oral linezolid if MRSA), chronic (IV drug therapy for >3mo, contact precautions if copious wound drainage, wound care, pain management), surgical (incision and drainage, wound debridement, bone graft - elevate extremity, assess pain/mvmnt/sensation/warmth/temp/pulses/cap refill, amputation if all treatments fail)
54
bone tumors
Assessment = pain (mild to severe - direct tumor invasion into soft tissue, compressed peripheral nerves or fragility fracture), observe and palpate affected area, swelling, muscle atrophy or spasm, marked disability and impaired mobility, psychosocial assessment. Labs = ↑ Ca d/t massive bone destruction, ↑ ESR d/t secondary tissue inflammation. Interventions = pain, chemo, radiation, drugs for specific metastatic cancers, bisphosphonates for bone mets from breast/lung/prostate, RANKL inhibitors, microwave ablation, surgical (tumor removed or reduced, wide or radical resection to salvage affected limb, large bone defects may require total joint replacement w/ prosthetics/custom metallic implants/ allografts, cast managements, non-weight bearing, assistance w/ ADLs).
Benign: often asymptomatic and often discovered w/ routine xrays. Chondrogenic, osteogenic, fibrogenic.
Malignant: primary occur btwen 10-30yo, secondary originate in other tissues and metastasize to bone.
-Primary tumors of prostate, breast, kidney, thyroid, and lung are bone-seeking cancers - vertebrae, pelvis, femur, ribs; tumor cells carried to bone through blood stream.
- Osteosarcoma: most common. Distal femur, large, acute pain, swelling
-Ewing sarcoma: men more than women, most malignant. May have fever, fatigue, pallor, anemia
-Chondrosarcoma: dull pain and swelling for long period - pelvis and proximal femur
-Fibrosarcome: gradual w/o specific symptoms. Local tenderness, w/ or w/o palpable mass, long bones of lower extremities.
55
Osteoarthritis (OA/DJD)
most common and major cause of impaired mobility, persistent pain, and disability. Progressive deterioration and loss of articular (joint) cartilage and bone in one or more joints. Risk factors = primary (aging, genetics), secondary (joint injury, obesity, excessive use, other joint diseases), comorbidities (gout, DM). Health promotion = nutrition, avoid injuries, work breaks, active/healthy lifestyle. Assessment = nature and location of joint pain, occupation, hx of injuries, obesity, inspect joints (bony hypertrophy/overgrowth and osteophytes, heberden/bouchard nodes), assess mobility, ability to perform ADLs. Labs/Diagnostic = aspirated joint fluid can show urate crystals, ESR, C-reactive protein, xr, MRI. Priority = pain, decreased mobility. Interventions = acetaminophen (may upset stomach), COX-2 inhibitor (avoid w/ HTN, kidney disease, CVD), tramadol (ultram - pain), topical drugs (lidocaine, topical salicylates - voltaren, topical NSAIDs - diclofenac), weight loss, rest, exercise (low impact - swimming, aerobic, active exercise rather than active-assist or passive), joint positioning, heat/cold applications, glucosamine, chondroitin, medical marijuana, surgical (TJA, RHA, joint coach, preoperative rehabilitation).
56
Total Hip arthroplasty
anterior (exposed w/o detaching the muscles. Won't dislocate easily as posterior) vs posterior (incision behind head of femur - more complications d/t muscle detachment). Post surgery = hip precautions, monitor for s/s of hip dislocation (intense, sudden pain, agitation, affected leg rotation, leg shortening), neurovascular assessment, older adult care (use abduction pillow - posterior), float heels, change in mental status = infection, deep breathe, transfer to chair asap, manage pain, reorient frequently). Complications = VTE (DVT/PE), implement PAC (Pharmacology heparin or factor Xa inhibitors; Ambulation and exercise TID; Compression devices - on pt for 19 hrs/day to prevent clot), manage pain (peripheral nerve block - don't get out of bed), cryotherapy, music therapy.
57
Posterior THA precautions
no adduction, keep legs apart at all times, do not cross legs, do not sit on low or soft seats, avoid recliners/rocking chairs/low stools, don't bend forward at hips past 100 degrees, do not prop or lift leg up past 100 degrees, dressing (step in shoes, reacher), do not twist leg inward.
58
Anterior THA precautions
don’t step backwards w/ surgical leg, no hup extension, do not allow leg to externally rotate, don't cross legs, use a pillow between legs when rolling, sleep on surgical side when side lying (can cause hip to roll over or rotate).
59
Total Knee Arthroplasty (TKA)
unilateral procedure, sometimes bilateral. Indicated for moderate to severe arthritis. Preoperative rehabilitation = weight training, weight loss, smoking cessation (delays healing process), joint coach (learns exercises w/ pt), pain management. Precautions = leg in neutral position, avoid internal/external rotation, don't place a pillow under the knee, don't hyperextend knee
60
Rheumatoid Arthritis (RA)
chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. Disease can affect any or all parts of the body while affecting many joints. Permanent joint damage may be avoided if RA is diagnosed early. Early & aggressive treatment to suppress synovitis may lead to remission. Characterized by natural remissions and exacerbations (flare-ups). Risk factors = euro-americans, women. Labs = rheumatoid factor, anti-CCP antibodies, ESR, C-reactive protein, antinuclear antibody (ANA), high sensitivity c-reactive protein (hsCRP), CBC, RBC, WBC.. Must rule out other conditions in order to diagnose. Diagnostic = XR, CT, arthrocentesis, bone scan, joint scan, MRI, nerve conduction study, pulmonary function test. S/S = early (joint inflammation, low-grade fever, fatigue, weakness, anorexia, paresthesias), late (deformities - swan neck or ulnar deviation, mod-severe pain, morning stiffness 30-60 min, osteoporosis, severe fatigue, subcutaneous nodules, vasculitis, sjogren syndrome). Priorities = chronic inflammation and persistent pain, decreased mobility, decreased self-esteem. Interventions = NSAIDs, famotidine, biological modifiers (enbrel/humira/rituxan), methotrexate, glucocorticoids (infection risk/immune response), rest, positioning, paraffin wax dips, safety bars, hot showers, hypnosis, acupuncture, imager, music, stress management, nutrition, weight management.
61
Rheumatoid vasculitis
complication of RA: arterial involvement can cause ischemia in major organs. Ischemic skin lesions that appear in groups as small, brownish spots, most commonly around the nail beds. Increased lesions indicate increased vasculitis. Large lesions can lead to ulceration. Peripheral neuropathy associated w/ decreased circulation - can cause foot drop and paresthesia.
62
Sjogren Syndrome
complication of RA: dry eyes (keratoconjunctivitis sicca - KCS, or sicca syndrome), dry mouth (xerostomia), dry vagina.
63
Fractures:
a break or disruption in the continuity of a bone. Health promotion = osteoporosis screening, fall prevention, home safety assessment, dangers of substance use and driving, preventing overuse injuries, helmets, airbags, seatbelts, dangerous activities. Assessment = pain, cause, other organs, substance use, occupation, all body systems first for life-threatening complications, respiratory status, changes in bone alignment, tissue integrity, palpate for subcutaneous emphysema, circulation, motion, sensation. Labs/Diagnostic = H&H (bleeding), erythrocyte sedimentation rate increased in inflammatory response, WBC (infection), XR, CT, MRI. Priorities = pain, soft tissue damage, muscle spasm, edema, mobility, neurovascular compromise, infection. Interventions = pain, ABCs, cardiac monitoring for pts > 50 yrs, bone reduction, immobilization, splints, cast (should be able to insert finger between cast and skin. Ice for first 24-48 hrs to reduce swelling. See image), traction (application of a pulling force to a part of body to provide bone reduction as a last resort to decrease muscle spasm. Two types - skin traction use of velcro/buck boot for hup and proximal femur fractures & skeletal traction is screws surgically inserted into bone for realignment), PT, meds (opioids, nonopioids, NSAIDs, muscle relaxants, prevent constipation), surgery (see image), neurovascular compromise monitoring (pain, pressure, paralysis, paresthesia, pallor, pulselessness), prevent infection (dressing change, wound irrigations, abxs, monitor inflammation/drainage, negative pressure wound therapy)
64
types of fractures
Complete: a break across the entire width of the bone, dividing it into two distinct sections
Displaced: bone alignment is altered or disrupted
Incomplete: fracture does not divide the bone into two portions bc the break is through only part of the bone
Open (compound): skin surface over the broken bone is disrupted, causing and external wound
Simple: does not extend through the skin. No visible wound
Fragility: occurs after minimal trauma to a bone weakened by disease.
65
Hip fractures:
most common injury in older adults. High mortality d/t multiple complications r/t surgery, depression, decreased mobility. Risk factor = osteoporosis! Surgical management = FICB, ORIF, buck traction b4 surgery to decrease pain, fall preventions, manage delirium (acute, fluctuations confusional state - alteration of mental status that results in inability to focus and confusion. Fast onset. Last hours to less than 1 mo. Causes = surgery, infection, drugs. Usually reversive. Manage by removing or treating the cause), early and frequent mobility, VTE prevention.
66
Femur Fracture
surgically repaired w/ ORIF w/ plates, nails, rods, or compression screw. External fixation may be used. Healing time is > 6mo. Nonsurgical treatment may be skeletal traction, full leg brace/cast.
Tib-fib fracture: closed reduction w/ casting, internal fixation, and external fixation
67
Ankle fracture:
ORIF w/ screws or nails placed into tibia and a comparison plate w/ multiple screws keeps fibula in alignment. Restricted weight bearing
68
Acute complications of fractures
VTE (DVT, PE - most common complication of LE surgery or trauma), infection (superficial skin infection to deep wound abscesses, osteomyelitis r/t open fracture), acute compartment syndrome (limb-threatening condition), fat embolism syndrome (life-threatening condition)
69
Acute compartment syndrome (ACS)
increased pressure within 1 or more compartments (that contain muscle, blood vessels and nerves). Pain is much greater than expected for the nature of injury. Acute severe pain w/ passive motion. Perfusion to the area is reduced. Ischemia. Sensory perception deficits or paresthesia first symptoms. Pallor, weak pulses, palpably tense, cyanosis, tingling, numbness, paresis, necrosis. Causes = pressure from external source (tight, bulky dressings, cast), pressure from internal source (blood/fluid accumulation), could also be from severe burns, extensive insect or snake bites, massive infiltration of IV fluids. Treatment = fasciotomy.
70
Fat embolism syndrome (FES)
rare & defined by fat globules are released from yellow bone marrow into the bloodstream within 12-48 hrs after fracture. Globules clog small blood vessels that supply vital organs, specifically lungs. First S/S = hypoxemia, dyspnea, tachypnea - headache, lethargy, agitation, confusion, decreased LOC, seizures, vision changes, red-brown petechiae may appear over neck/upperarms/chest (last sign to develop).
71
Chronic complications of fractures
delayed bone healing, decreased perfusion and death of bone tissue (avascular necrosis - most commonly w/ hip fractures or displacement of bone, Surgical repair d/t hardware interfering w/ circulation, long term corticosteroid use), delayed union (fracture that does not heal w/in 6 mo of injury), complex regional pain syndrome (severe, persistent pain. Treat w/ PT w/ different stimuli).
72
Amputations:
lective or traumatic. R/t complications of PVD w/ DM as underlying cause. Considered when limb salvage procedure fails to restore circulation to lower extremity. Complications = hemorrhage leading to hypovolemic shock, infection, phantom limb pain, neuroma, flexion contractures. Health promotion: DM (A1C < 7), smoking cessation, healthy, precautions, avoid speeding & driving while intoxicated. Assessment = neurovascular status, skin color, temp, sensation, pulses in both affected and unaffected extremities, psychosocial (grief, motivation for rehabilitation, family). Diagnostic = assessed for viability of the limb based on blood flow - ABI (divide ankle systolic pressure by brachial systolic pressure - normal is 0.9 +), doppler ultrasonography, laser doppler flowmetry, transcutaneous oxygen pressure. Priorities = decreased tissue perfusion, pain, decreased mobility, decreased self-esteem. Interventions = emergency/traumatic (assess airway/breathing, apply direct pressure, elevate extremity above heart to decrease bleeding, do not remove dressing to prevent dislodging clot, put amputated part in watertight sealed plastic bag in ice water), elective (monitor for sufficient tissue perfusion and no hemorrhage, skin flap should be pink and not discolored, area warm but not hot, assess proximal pulse), manage pain (calcitonin, propranolol, gabapentin, baclofen, antidepressants, massage, heat, TENS, mirror therapy, ultrasound therapy), promote mobility (PT/OT, ROM exercise, trapeze, 2hr turns, firm mattress, lay prone Q3-4 hr for 20-30 min, stretching and contract gluteal muscles, referral, use shape and shrink devices to prepare limb for prosthesis), promote self esteem
73
Pressure Injuries
loss of tissue integrity caused when skin and underlying soft tissue are compressed between a bony prominence and external surface. Can occur on any body surface. HOB should not be > 30 degrees. Assessment = hx, contributing factors (bedrest, immobility, incontinence, DM, PVD, malnutrition, decreased sensory perception, cognitive problems), inspect entire body, wound assessment, stages, document (location, size, color, extent of tissue involvement, cell types in wound base and margin, exudate, condition of surrounding tissue, presence of foreign bodies, length, width, depth, ‘clock’), psychosocial (body image, social services, refer). Labs = wound culturing, tissue culture. Diagnostic = arterial blood flow studies if arterial occlusion is suspected, duplex ultrasound imaging, blood tests for nutritional deficiencies. Priorities = tissue integrity (dressings, PT, drugs, nutrition, adjunctive therapy), infection (monitor s/s, report changes, maintain safe environment).
74
stage 1 pressure injury
intact skin w/ localized are of non-blancahble erythema. May be preceded by changes in sensation, temperature, or firmness. Color changes are NOT purple or maroon.
75
stage 2 pressure injury
partial thickness loss of skin w/ exposed dermis. Wound bed is viable, pink or red, and moist. May look like intact or ruptured serum-filled blister.
76
stage 3 pressure injury
full thickness skin loss w/ adipose (fat) visible in the ulcer. Granulation tissue and rolled wound edges are often present. Slough and/or eschar may be present. Undermining and tunneling may be present. SubQ tissues may be damaged or necrotic
77
stage 4 pressure injury
full thickness skin loss w/ exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone. May have slough or eschar. Rolled edges, undermining, or tunneling may be present
78
unstageable or suspected deep tissue injury
covered w/ eschar or unable to see how deep the wound may be
79
Skin Irritations
pruritus (ie detergent chemical that irritates skin. Address dry skin, seep nails short, antihistamine may be prescribed), urticaria (ie drugs, temperature extremes, foods, infection, diseases, cancer, insect bites. Remove triggering substance, antihistamine)
80
Inflammatory skin d/o
eczema, contact dermatitis (makeup, poison ivy, etc), atopic dermatitis, drug eruption. Treatment = identify causative agent and then avoid it, steroid therapy, antihistamines, comfort measures.
81
Psoriasis
chronic autoimmune d/o. Exacerbations and remissions. Scaled lesions w/ underlying dermal inflammation from epidermal cell growth abnormality. Can be triggered by environmental factors, stress, skin injuries, medications, infections. Assessment = hx (family, flares, precipitating factors, treatments that have helped in past), physical (plaque, guttate, inverse, pustular, erythrodermic). Interventions = topical, light therapy, systemic therapy, emotional support.
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Common skin infections
bacterial (cutaneous anthrax, folliculitis, furuncles, carbuncles, cellulitis, MRSA), viral (herpes simple - contact precautions until lesions are crusted over, herpes zoster - shingles contact precautions sometimes airborne precautions from longs), fungal (tinea, candidiasis). Promotion = avoidance of offending organisms, practice of good hygiene, vaccination. Assessment = hx, physical (s/s of specific d/o, labs). Interventions = drug, avoid spread, skin care.
83
phases of wound healing
1. inflammatory
2. proliferative
3. maturation
4. re-epithelialization
84
Burns
range in severity from minor sunburns to life-threatening trauma. Changes = anatomic, functional, psychosocial. Burn classification is based on the depth of destruction. Degree of burn = degree of thickness. Phases = emergent (resuscitation- onsite and continuous for 24-48hrs), acute (healing - 36-42 hrs after injury when fluid shift resolves ), rehabilitative (restorative - until wound closure is complete. ABCs priority, nutrition, wound care. Until the patient reaches highest level of function - may take a while). Assessment = Hx (circumstances surrounding injury, age, weight, height, full health history, allergies, meds, immunizations, other injuries that took place at time of burn), physical (respiratory - black carbon particles in nose, mouth, sputum, lung sounds, skin - extend and depth). Labs = drug & ETOH screen. Diagnostic = ophthalmic evaluation. Interventions = airway maintenance, pain control, infection control, wound healing, intubation supplies at the ready at bedside
Uncomplicated burn: chemical, electrical, radiation, smoke-related (inhalation - immediate intubation, no O2 therapy, thermal
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Skin cancer:
Risk factors = actinic keratoses (sun-damaged skin), squamous cell carcinoma (chronic skin damage), basal cell carcinoma (genetic predisposition, UV exposure), melanomas (genetic predisposition, UV exposure, chemical carcinogens, precursor lesions - highly metastatic, survival is based on early diagnosis and treatment). Health promotion = avoid or reduce exposure to sun or tanning beds, sunscreen, wear hats & opaque clothing, sunglasses, monthly skin checks, report skin changes, ABCDE guide for melanoma (asymmetry, border, color, diameter, evolving). Assessment = family hx of cancer, past surgery for removal of skin growths, recent changes in moles/birthmark/wart/scar, demographic information, occupational and recreational activities. Interventions = nonsurg (topical therapies, targeted therapy, immunotherapy, radiation - palliative), surg (cryosurgery, curettage and electrodesiccation, excision, mohs surgery, wide excision)
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Life-threatening skin disorders
Life-threatening skin disorders: d/o typically triggered by a drug. Classified by a percentage of body surface affected. Treatment involves discontinuation of the drug and supportive care
Stevens-Johnson syndrome - allopurinol (gout)
Toxic epidermal necrolysis
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Factors causing cancer
80% environmental. Chemical (tobacco, preventable source of cancer, lungs, airways, pancreatic, oral, laryngeal, bladder, cervical), physical (radiation, chronic irritation, viral). Advancing age is the single most important risk factor for cancer. Immunity decreases and external exposures accumulate. Dietary = cancer-promoting effects in some foods, additives, prepared. Avoid excessive fat, nitrates, red meat, and alcohol. Eat more bran, veggies, foods high in Vit A/C.
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Cancer development process
process of normal to cancer cells. Carcinogenesis, oncogenesis, or malignant transformation
Initiation: widespread mets disease can develop from one cancer cell. Carcinogens = chemicals, physical agents, viruses
Promotion: enhanced growth
Progression: continued change of the cancer, malignant over time.
Primary tumor: original group of cancer cells. Organs (brain/lung) grow and invade function. Soft tissue expand wo damage (breast)
Secondary/Metastatic tumors: blood borne metastasis when tumor cell release into the blood (common). Lymphatic spread r/t lymph node and vessel transport.
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cancer - malignant tumor grading/staging
grading of tumors: grades X-4 - depends on the tumor cell differentiation
Staging of cancer: primary tumor = T (Tx-T4 - sizing)
Regional lymph nodes = N (Nx-N3 - lymph node involvement)
Distant metastasis = M (Mx-M1 - mets spread/distance)
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seven warning signs of cancer
CAUTIONS
C - changes in bowel or bladder habits
A - a sore throat that does not heal
U - unusual bleeding or discharge
T - thickening or lump in the breast or elsewhere
I - indigestion or difficulty swallowing
O - obvious change in a wart or mole
N - nagging cough or hoarseness
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Metastasis progression
tumor, node, metastasis (TNM) is used to describe anatomic extent of cancers. Tumor growth is assessed in doubling time & mitotic index (% of actively cell division inside the tumor). Smallest tumor detected is 1cm and 1 billion cells. Mitotic index < 10% = slow growing. Mitotic index >85% = fast growing.
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Age related & genetics in cancer risk
colorectal cancer (bowel habits, blood in stool, education about diet and prevention), lung (skin, dyspnea, cough), prostate (urine issues, stream), skin (moles, warts, prevention - sun), leukemia (skin, bleeding, bruising), bladder (blood in urine, frequency, pain). Genetic testing for cancer predisposition (small percentage have hereditary gene risk. Detailed family hx, tests provide information not diagnosis - risk only, positive for gene gives risk of developing cancer, but the cancer may never develop. Genetic testing important for all family members). Race risks (african american, hispanic/latino).
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Health promotion & prevention
Primary (strategies to prevent the actual occurrence of cancer, avoidance, modify risk factors, removal of risk factors, vaccination, chemoprevention), secondary (use of screening strategies to detect cancer early, regular routine screening, genetic test).
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Impact of cancer on physical function
impaired immunity and clotting (bone marrow dysfunction from disease or chemo), altered GI function (increased metabolic rate w/ weight loss/cachexia, obstruct or compressed tumors), altered peripheral nerve function (from disease or chemo #1 - chemo-induced peripheral neuropathy - numb, pain, ataxia), motor and sensory deficits (bone invasion, brain tumor, compress nerves, fracture risk, pain, mobility), altered respiratory and cardiac function (airway obstruction, hypoxia, pleural effusions, radiation & chemo affect cardiac function - CAD, pericarditis, HTN, loss of cardiac muscle mass, HF), cancer pain and QOL (chronic pain, improve quality, support)
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Management of cancer
purpose is to cure or control the disease while minimizing the side effects of therapy. Delayed rapid intervention can increase mortality. Type of cancer, tumor, grading, and staging have direct effects on outcomes. Nursing priorities = same medical interventions as all other surgical patients, psychosocial interventions, coordination w/ interprofessional team, physical rehabilitation. Surgery interventions = prophylactic (breast cancer), diagnostic (lesion removed for biopsy or tumor removed), curative (all cancer removed), control/debulking (partial tumor removal), palliative (symptom relief to improve QOL), reconstructive (function, appearance - bowel, skin, breast, scars).
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Radiation therapy
uses high-energy radiation to kill cancer cells minimizing damage to healthy tissue. Short-long term effects. Exposure = amount of radiation. Series of treatments divided doses over a period of time. Greater destruction of cancer cells while reducing normal tissue damage. Nurse or care team limits exposure during care of the patient (lead, away, time of exposure). Methods = external beam (outside patient/specific markings, tattoo ink, mesh maks, precise delivery. For - head, neck, breast, lung, colon, prostate, brain, skin, esophageal), internal device/Brachytherapy (radioactive isotopes in solid form or within body fluids. Implanted radiation source - seeds, ribbons, capsules, ex iodine-131 for thyroid cancer, high dose vs low dose rate continuously, for = head, neck, breast, cervix, prostate, eye). Priorities of care = acute/long term effects (acute - brain, head, neck, breast, chest wall, abdomen, pelvis, eye; late - neuro, head/neck, lung, heart, breast/chest wall, abdomen/pelvis, soft tissue; local or systemic side effects), local (radiation dermatitis, site or external beam, red, rash, desquamation - skin peeling/shedding), systemic (fatigue, bone marrow suppression, immunity reduction). Note not all pts will have the same side effects even w/ identical treatments. Interventions = education (skin breakdown, high risk for infection, care of tattoo, tight clothing & friction, good hygiene, only lotions on area by MD, increase sunburn - limit exposure during radiation - photosensitive >1yr for burns, normal tissues sensitive to radiation (bone marrow, skin, hair, germ cells), fatigue, insomnia.
Radiation mask: safety w/ caring for pts with internal radiation devices. Private room w/ door closed w/ precaution sign. Dosimeter badge, visitors ½ hr per day, hazardous waste).
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Chemotherapy
used to kill cancer cells and disrupt cellular regulation. Used to shrink tumor before surgery/radiation. Use to kill remaining cancer cells following surgery/radiation. Chemo agents determined by tumor type, tumor markers, growth rate of cells & patient status. Chemotherapy pts at high risk for infection, immunosuppression, and complications of treatment. Regularly scheduled basis to maximize cancer cell kill and minimized damage to normal cells. Pt & family education to adhere to rigorous regimen. Chemotherapy is typically IV (CVAD), but can be CSF, intraperitoneal, intra vestibular, intraarterial, infused beads (inside tumor). Complications = topical risks to nurses/pharmacists in preparation (PPE, eye protection, double or chemo gloves, gown), Extravasation (infiltration - pain, infection, tissue loss), oral chemo (toxic in handling, education to home care for pts. Dispose of oral chemo drugs. Do not crush, split, break, chew), competency-trained chemo nurses. Side effects = bladder toxicity (hemorrhagic cystitis), cardiotoxicity (HF), loss of bone density, anemia, neutropenia (infection), thrombocytopenia (clotting and bleeding), N/V, alopecia, mucositis, anxiety, sleep issues, bowel issues, cognition changes, psychosocial issues, risk for infertility or sterility (pregnancy avoidance w/ reliable BC methods, female pts may not have a menstrual cycle but may ovulate, long term effects of infertility, referrals to sperm banking or fertility specialists), age related (greater risk for complications, physiologic changes w/ aging and comorbidities may not tolerate treatment and recovery is slow, focus = meds, function status, cardiac-pulmonary process). Priorities = infection risks from reduced immunity, neutropenia, bone marrow suppression (bacterial, fungal, viral), anemia, hypoxia, fatigue, risk of bleeding (clotting), important of neutropenia signs (fever > 100.4 must report to PCP). Education = handwashing, PPE< avoid crowds, bathe daily, wash foods, safety w/ preparing meals, report fever/infection symptoms/rash/skin changes/cough/urine issues/CVAD issues. Sepsis = life threatening oncology emergency.
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Oncologic emergencies
acute complications of cancer or cancer treatment. Nursing interventions = prevent & early interventions, monitor subtle changes, VS, lab trends
Sepsis/DIC - low WBC, immunity/infection risk. Early subtle signs. DIC from sepsis, clotting issues, fatal.
SIADH (lung cancer) - fluid balance, fluid restriction, hyponatremia
Spinal cord compression - tumor on spine/vertebral collapse (bone brittle), neuro assessment/early intervention
Hypercalcemia - multiple myeloma, bone metastasis. Severe = IV hydration, life threatening
Tumor lysis syndrome (NHL) - massive cancer cell destruction. Can cause AKI, High K+, high uric acid, high phosphate, life threatening.
Superior vena cava syndrome - compression/obstruction by tumor growth or clots. Mediastinal tumors, chest wall, lymph nodes. Early warning signs = facial edema, edema in arms/hands, SOB.
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Cancer prognosis & EBR
pts living longer w/ cancer, chronic disease vs death sentence, physical & psychosocial needs (long term effects), patient education and follow up protocols, routing imaging/blood work/trends, chemotherapy (cardiac and pulmonary toxicity), lymphedema (lymph nodes removed), nurses provide support ot acute and chronic cancer needs, EBR on cancer treatment, diagnosis, survival rates.
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End of Life - priority
cognition, perfusion, ethics
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advanced directive
document w/o legal consult. Process of advanced planning w/ documentation of self-determination discussing end of life care. Nurses advocate to pts requests, values, needs and goals. Durable POA-HC (medical decisions - not regarding DPOA-financials, appointed by pt to make medical decisions if pt lacks capacity to make own decisions). Living will/POLST (treatment wishes at end of life, CPR, artificial ventilation, artificial nutrition).
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Hospice
model for high quality compassionate care for people facing a life-limiting illness or injury. Outpatient, inpatient and home settings. Prognosis of < 6 mo to live. Team interprofessional focus, expert medical care, pain management, emotional/spiritual needs, family support
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palliative care
philosophy of care for ppl with life-threatening disease that helps pts and families identify their outcomes for care, decision making choices, and high quality care. Any stage of serious illness, improve quality of life/early access, team interprofessional focus toa address needs of patients. Nursing interventions = care, compassion, advocacy, therapeutic communication skills.
