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
