VN 22 Test 10 Flashcards
- Nursing considerations for stem cell clients
• Avoid invasive procedures
• Avoid fresh fruits/fresh plants
• Limit number of visitors
• Monitor temp q4h (minimum)
- Adverse effects of radiation therapy
• Desquamation: Shedding of the skin: use once soft wash clot. Nothing rough
• Alopecia
• Erythema
• Stomatitis
• Xerostomia
• Anorexia
• Nausea
• Cystitis
• Pneumonitis
• Fatigue
- Precautions when administering radiation therapy
Radiation Safety:
• Time- plan ahead by having everything needed when entering client room
• Distance- stand at the greatest distance away from site of internal radiation
• Shielding- Wear lead apron if close contact and prolonged are needed
- Docusate sodium K,H,K
• Use for constipation
• AE: diarrhea
• Take full glass of water
• Contraindication with bowel obstruction
• Don’t take within 1 hour of other drugs, antacids, or milk
• Not for long term use; 1 week max
- Client education for chemotherapy, radiation
• Small frequent meals
• Increase fluids intake: 2500-3000mL/day
• Report excessive weight loss, change in LOC, paresthesia
- Endometrial cancer manifestations (Timby pg 732)
• Bleeding is the earliest sign
• Last symptoms for pain, pressure on the bladder or bowel
- TNM
• T= indicates size of tumor
• N= involvement of regional lymph nodes: N0-N3
• M= metastasis M0 or M1, M2 or M3
• Higher the grade the less differentiated
• Higher the number the larger the tumor or more lymph nodes involved
• Carcinoma in situ: abnormal cells present but have not spread to surrounding tissue
- Nursing considerations for xerostomia, stomatitis
• Stomatitis: irration inside the mouth, they can have mouth sores
Metalic taste
o Sugar free gum
• Xerostomia: dryness of the mouth
o Dietary modification; stay away from spicy foods, fatty foods
- Risks of cancer
• Age
• Tobacco use
• Exposure to radiation and/or chemical
• Some viruses and bacteria
• Hormones
• Family history of cancer/genetics
• Alcohol use
• Poor diet, lack of physical activity, or being overweight
• Altered immunity
- Cancer prevention
• Healthy lifestyle: diet~fruits and vegetables, follic acid, and Omega 3
• Awareness of warning signs and factors of cancer development
• Cancer screening programs
• Periodic physical examination
• Emphasize and teach self-examinations; breasts, skin, testicles
• Avoid risk factors
• Genetic testing
- Warning signs of cancer
• C: change in bowel/bladder habits
• A: a non-healing sore
• U: unusual bleeding
• T: thickening lump
• I: indigestion
• O: obvious change in size or wart/mole
• N: nagging cough
Additional: headaches, weight loss, chronic pain, fatigue, low-grade fever, and infection
Tamoxifen
o Use for Breast Cancer
o Risk of PE/DVT and endometrial CA (heavy vaginal bleed)
o SE: hot flashes
Doxorubicin
o Two red: heart failure/discoloration of urine/sweat/tears
o Monitor cardiac function
Vincristine
o (Ballerina) likes bone so no BM suppression, but peripheral neuropathy and phlebitis
Interferon alpha 2b: immunotherapy-enhances immune sx
o Flu like sx and history of depression
Filgastim (Neupogen) and Epoetin (Procrit)
o Filgrastim stimulate neutrophil-wait 24 hours after chemo
o Epoetin increase RBC
- Difference between strain and sprain
• Strain: injury to a muscle when stretched or pulled, very often after overuse
• Sprain: injuries to ligaments surrounding a joint, moved beyond their typical ROM-like twisting
RICE
• R= rest (if joint is weight bearing, use canes, crutches, or other walking devices)
• I= ice (ice pack or cold compression)
• C= compression (Bandages to encourage proper healing)
• E= elevation (above or at same level as heart)
- Nursing considerations with open fractures (complications)
• Fat and pulmonary embolism- priority/manifestation
o This could decrease oxygen with manifestation: change in LOC; SOB; chest pain; anxiety
• Compartment syndrome
• Delayed bone healing
• Infection-reddish, warm to the touch, fever: monitor vitals
• Avascular necrosis: assess neurovascular status
• Use ABCs as nurse approach. Assess for decrease oxygen, check capillary refill for neuro status
- Compartment syndrome manifestations
• Increased pressure in area
• Nerve pain
• Ischemia : Pt. Night have cool skin, Palored skin, Altered sensation in toes, No pulse at affected site
• Unrelenting pain
- Risks for fractures
• Post-menopausal
• Bone infections or tumors
• Diabetes
• History of steroid use
• Poor or inadequate nutrition
• Osteoporosis
• History of smokers
• Caucasian ethnicity
• Small framed individuals
- Prosthesis care
• Prosthesis is placed immediately after amputation to promote post-op ambulation
o Do not alter prosthesis
o Change dressings daily
o Inspect for skin breakdown using mirror
o Compression tape wrapping in figure-8 pattern
• At risk for hip deformation-encourage prone position 20-30 minutes a day
• Include active and passive ROM exercises
• Asses for infection
- Post op care for ortho surgery
• Vitals and capillary check every 2-4 hours
• Ambulation with assistance after day 1
o If antiembolic stockings: remove and assess every 8 hours for skin integrity
• Reduce risk for excessive bleeding : Assess wounds
• Help reduce pain and inflammation
• Prevent postoperative complications: Fluid increase, Good pin care
• New sterile applicator for each site; asses and report abnormal s/s
- Foods high in calcium
• Collard greens
• Broccoli
• Kale
• Canned Fisk
• Diary products like milk and cheese
Nursing Management: preventative measures
• Calcium intake increase add vitamin D
- Diagnostic labs for bone disorders
• DEXA scan is the key diagnostic test
- Pin care for traction
• Monitor pins for lossening
• Monitor for s/s infection; increase drainage, redness or swelling, tenting at the pin site
• When cleaning the pins; you want to use a new cotton tip swab to clean each pin. DO NOT REUSE
• If crusting at the pin site, you don’t want to remove that: it help prevent bacteria
Fractured or Dislocated hip Manifestations
• Severe pain
• Shortening; External rotation of leg
• Blood loss
• Extensive bruising
• Edema
• Contained bleeding
- Emergency procedure for traumatic amputation
• Wrap in sterile gauze or clean cloth (soaked in saline if available)
• Put in plastic bag
• Avoid contact with water or ice directly
- Medical treatment of phantom limb syndrome (ATI pg.577)
• Anticonvulsant medication (Gabapentin)
- Positioning precautions: hip replacement
• Have legs abducted with pillows or abductor cushion and extended avoiding position internal or external rotation of the affected hip. Avoid addiction and flexion beyond 90 degrees which can dislocate by prosthetic femoral head
• Sit in an elevated chair or on a seat raised by pillows, so that the flexion remains less than 90 degrees
• Do not cross legs
• Do not turn client on affect side
- Ruptured Achilles Tendon Nursing management
• Prevention: warm up/warm down
• Educate: brace to be worn 6-8 weeks
- Manifestations of dislocations
- “popping sound”
- sudden instability
- pain
- altered structural shape
- limited ROM
