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KSU Nursing Adult Health Exam 3
Terms in this set (121)
GI Nursing Baseline Assessment
Ask about pain, recent history of N/V, stool (consistency, how often), nutritional assessment last 72 hours, daily postprandial (after eating) patterns, and lifestyle habits. Focused review of systems + pain (TIP). Ask about dyspepsia, flatulence, bloating, change in bowel habits, bleeding, anemia, and weight loss or gain.
First line diagnostic tests for GI problems.
Serum lab tests: CBC, serum antibodies against H. Pylori antigen, C-reactive protein and ESR (markers for inflammation). Histology samples, and stool sample test for blood (guaiac or hemocult II), but contraindicated if hemorrhoid bleeding present.
Abdominal CT scan with Contrast
For diverticulitis, perforation, fecal infection detection, bowel wall thickening and mesenteric edema, and pelvis fistulas and abscesses.
Reveals free gas and fluid levels within the peritoneal space and intestinal collapse or blockage with associated megacolon.
Visual examination of the colon. Uses light sedation (propofol), a colon cleansing program, check vitals/AMS from sedation. S/S of perforation. NPO prior to procedure.
To visualize upper GI system. Light sedation (midazolam), gag reflex, encourage deep breathing and coughing, and monitor for bleeding. NPO prior to procedure.
A hollowed out area that forms in the mucosa of the stomach, opening to the duodenum, or in esophagus. 30 out of 100 hospitalized. Imbalance between the protective mucosal and the destructive factors. Erosion of mucous membrane with possible complications. Acute gastritis.
Milder form, inflammation of mucosa with non-erosive properties.
Peptic ulcer cause
NSAIDS (most common medication), smoking, gram negative bacteria H. Pylori, Familial tendency - type O blood and autoimmune disorders. Stress-related - surgeries, trauma. Zollinger-Ellison Syndrome (excess gastrin release due to malignancy).
Peptic Ulcers by H. Pylori
Most common reason for peptic ulcer, can live for years in stomach. NSAID use with H.Pylori increase further risk. Linked to food and water, person to person through emesis contact. Develops into chronic gastritis. Clinical manifestations: Asymptomatic and symptomatic. Pts. complain of dull gnawing pain or burning (pyrosis) in mid-epigastric or back and flatulence.
Gastric Pain (Related to peptic ulcers)
Occurs 30-60 minutes postprandial (after eating) with associated pain.
Duodenal Pain (Related to peptic ulcers)
Pain occurs 2-3 hours postprandial, pain may be relieved with food or antacid. Pain common at night.
Nursing Interventions for H.Pylori /Peptic Ulcers
Nursing Diagnosis: Acute pain related to increased gastric acid on damaged tissue, anxiety, and imbalanced nutritional status. Expected patient outcomes: Managing the ulcer with compliance to medication. Reducing associated pain and maintaining appropriate nutrition. Absence of complications: life threatening and minor (fractures, malabsorption of B12 + Vitamin D).
Complication from an ulcer. Mild hemorrhage produces black tarry stool (melena), can cause syncope/dizziness, hypotension with tachycardia/tachypnea, and hematemesis. Prolonged bleeding (>50% total blood loss), diffuse abdominal discomfort, and dysphagia.
Vomiting blood. 2000-3000 mL induces vomiting. The brighter red the more dangerous. Coffee grounds appearance.
Nursing Interventions for GI Hemorrhage
NG placement for evaluation, blood replacement, prepare for endoscopy and cauterization if needed, and monitor for hemorrhagic shock.
Perforation of ulcer
Emergent, most critical crisis (surgery). Erosion of the ulcer through the serosa into adjacent organs causing: severe sudden epigastric and back pain that intensifies. Can have referred pain to the right shoulder and phrenic nerve irritation in diaphragm. Tender rigid abdomen upon palpation. Hypotension - tachycardia - vomiting.
Acute inflammation and accumulation of fluid/air/pus into the abdominal cavity. Secondary causes: related to bacterial/fungal infection due to GI perforation - organ leakage (post-op), small/large bowel disorders, ruptured diverticuli, and peptic ulcer. Other causes: trauma, primary spontaneous due to dialysis/ascites, and reproductive organs.
Peritonitis Assessment postoperatively
Vital signs altered - abdominal distention: febrile, diffuse pain changing into constant and localized, nausea/vomiting, rebound tenderness with decreased bowel sound (paralytic ileus), hypovolemia, AMS and collapse, septicemia! Renal and diabetic patients may have altered symptoms, such as producing less urine output.
Nursing interventions peritonitis
NG decompression ordered, fluid and electrolytes, isotonic solutions, vitals, monitor lung expansion, oxygen therapy, and bowel sounds. Admission to ICU and administration of antibiotics. Place HOB at 30 degrees. May or may not have bowel sounds, should be hypoactive.
Gastric outlet obstruction
Distal stenosis. Related to edema and scarring of ulcerated tissue. N/V, constipation, and anorexia. Epigastric fullness noted, NG insertion required for decompression: >400 ml residual suctioned fluid indicates obstruction and possible surgery. Possible gastrojejunostomy diversion or vagotomy.
Rare disease arising from the pancreas. Symptomology is different: high levels of gasrin emitted. Several gastrinomas found in gastric triangle, resistnat to standard medical therapy, and pyrosis diarrhea. Steatorrhea - fat in the stools.
H. Pylori (Pharmacological management)
Combination treatment regimen. 10-14 days, rest, and antibiotics and proton pump inhibitors.
Metronidazole (Flagyl) + Clarithromycin
Amoxicillin (Amoxil) + Clarithromycin
Lansoprazole (Prevacid) + Omeprazole (Prilosec)
Triple or quadruple therapy adds Bismuth salt (Pepto-bismol). Healing ulcers require PPI's, and H2 blockers. Prophylactic therapy for NSAID ulcers require PPI's and misoprostol.
H. Pylori/ulcer (Client-centered care)
Education: Compliance, smoking cessation, OCT NSAID and ASA restrictions. Dietary modification: Avoid extremes in food temperature and overconsumption, alcohol, coffee, and tea's. Eat 3 small meals per day, eat foods that are tolerated. Nutrition consultation.
Foods to avoid for ulcers
Meals with a high fat content.
Citrus fruits and juices.
Coffee and tea — either caffeinated or decaffeinated.
Irritable Bowel Syndrome (IBS)
A group of chronic maladies that include inflammation or ulceration (or simultaneous involvement) of the bowel.
Subacute and chronic inflammatory state, incurable. Transmural - can be across the entire GI system (mouth to anus) - granulomas. Bacterial invasion creating overactive state, most common in RLQ, edematous thickening of mucosa with skip lesions (cobblestone appearance). Bleeding is mild, tenderness/spasm, steatorrhea, malnutrition/malabsorption, and and anorexia.
Chronic, selective area of colon-mucosal ulcers usually in rectal, lower colon region. Chronicity leads to fibrosis (mass) of lumen - thickening of bowel. Mucosal edema, perianal involvement. Complication: High of incidence of fistuals (enterocutaneous), possible colon cancer risk.
Ulcerative colitis S/S
10-20 diarrhea stools per day - inflammed bowel lumen with shortening of colon. Mucus and pus in stool. Rectal tenesmus, anorexia/fatigue. Vomiting/dehydration, LLQ pain/rebound tenderness RLQ. Malabsorption tendencies. Will not have fat in stool in ulcerative colitis, iron supplement would be good.
Nursing goal of therapy for IBD
Nutrition and weight gain - Parenteral nutrition for up to 2 weeks, weight gain achieved (0.5 kg/1.1 lbs DAILY during parenteral feedings)
Blood glucose monitored q 6 hours during parenteral feedings, low residue high protein diet, small feedings (once established). Cold foods, liquids and smoking stimulate peristalsis.
Monitor I & O's
Fluid intake, skin turgor/breakdown. Use barrier cream.
Patterns of what aggravates it before or after meals
Interventions: BOWEL REST
Digestive tract inability to absorb one or more major vitamin, mineral, or nutrient. Vitamins affected: A (vision),D (calcium and bones),E ( nerves),K (coagulation), + B12 (nerves). Minerals affected: Iron and calcium. Nutrients affected: carbohydrates, fats, and proteins. Conditions associated: bowel disorders with ostomy, celiac disease, chronic bacterial overgrowth (giardia), pancreatitis, gastric bypass, and short gut syndrome.
Malabsorption syndrome Symptomology
Paresthesia, steatorrhea (gold standard test for malabsorption), glucose intolerance, diarrhea, anemia-bruising, weight loss, vitamin B12 deficiency, flatulence, chronic diarrhea, and vision changes (night blindness).
Small Bowel Intestinal Obstructions
Blockage of a portion of the intestine. Decrease in venous and capillary pressure, increase in intestinal lumen pressure proximal to obstructions = edema, congestion, necrosis, and rupture or peritonitis. Fluid and gas accumulate. 1. Colicky pain 2. Pass blood or mucus 3. Vomiting of stomach contents - bile-fecal matter "reverse propulsion" - can cause aspiration 4. Dehydration 5. Hypovolemic shock/septic shock requires immediate surgery.
Nursing interventions for small bowel obstruction
NG for 3 days (per provider),
Bowel rest, Monitor for risk of aspiration due to vomiting feces, Lab values.
Prepare mentally for surgery if decompensation fails (therapeutic communication)
Large bowel obstruction
Confirm diagnostically - diverticulitis/carcinomas. Clinical symptoms - progresses slowly. Dehydration, constipation (with diarrhea), weight loss and iron deficiency, megacolon visible outwardly, and stragnulation of bowel-necrosis. Nursing interventions - monitor for compromise, maintain IV fluids. Prepare for surgical resection if needed (anastomosis)
Supportive measures (for postoperative fecal diversions, colostomy/ileostomy)
Support patient independence and body image. Utilize community and hospital resources (bilingual patients and videos), adhere to bowel management program per disorder. Nutrition adherence for ileostomies - increase fluid intake for ileostomy by 30%, be cautious with high fiber foods, advise client on slow release medication. Do not walk into room with mask on, do not make comments about size, have patient use the mirror to observe you changing the pouch. Encourage patient to investigate their stoma. Observe and listen for cues of anxiety or depression. Support groups - online and in community. Intimacy issues.
Disorder of the anorectum, at lower sacrum in gluteal cleft, adolescence and early adult, "in grown hairs", can be congential. Medical prescription: abscess/surgical debridement, secondary tract into muscle (fistula), antibiotics/sitz baths/wound care. Prevent constipation.
Obesity - obtaining surgical candidacy
1) Patient with BMI >30 kg must adhere to a "lifestyle modification" program that is provider prescribed and engages in behavioral interventions initially.
12-26 high intensity counseling sessions that include: Dietary restrictions and planning by nutritionist, 500 to 1000 calorie decrease within 6 months
150minutes moderate intensity/75 minutes vigorous
Strength training biweekly
2nd part for obtaining surgical candidacy. Provider prescribed - pharmacologic medications to treat obesity if unsuccessful at obtaining loss of weight through diet (<10%). Xenical- prevents digestion of fats, may cause diarrhea, flatulence, and decreased vitamin and food absorption. Lorcaserin - stimulates serotonin. Antidepressants - decreases depression in obese patients unable to lose weight.
Surgical candidacy requirements (Obesity)
Body mass index (BMI) ≥40 kg/m2 without excessive surgical risk OR
BMI ≥30 kg/m2 with one or more obesity-associated comorbid conditions (e.g., coronary artery disease, type 2 diabetes, obstructive sleep apnea, hypertension, asthma, debilitating arthritis, or impaired quality of life) AND/OR
Failure of previous nonsurgical attempts at weight loss, including nonprofessional programs AND
Expectation that patient will adhere to postoperative care, follow-up visits, and recommended medical management, including the use of dietary supplements
Nursing managment of Bariatric surgery
Pre-op preparation guidelines. 48 hours dietary restriction - clear liquid diet. Lab tests and result verification. Post-op: Clear liquids 24-48 hours, maximizes weight loss over time. Immediate post-op oral intake: liquids (small volume), 30 ml q 15 minutes. Sugar free drinks. Stop if fullness or nausea occur. Bowel function - monitor for bowel sounds in each quadrant. Initiate feedings if positive bowel sounds (per order). Education for discharge: Progressive diet necessary for maximized weight loss and prevention of mild side effects.
Greater with open abdominal surgery. Signs and symptoms: nonspecific, fever, pain, tachycardia, leukocytosis.
Dumping syndrome - postprandial plus drinking fluids with meals. Vasomotor reaction (pallor, headache, diaphoresis, tachycardia), 10-90 minutes after eating. Reactive hypoglycemia (High BG-high insulin release). Lie down after eating, anorexia may become an outcome.
RNA virus, fecal-oral transmission. Low mortality rate - generally self-limiting. Vaccine available. More common in low-income countries.
Double stranded DNA virus, parenterally and sexually transmitted - blood and body fluids. Cannot be spread through casual contact. Not spread through contaminated food. Acute hepatitis B leads to hepatic failure. 5% of individuals develop chronic hepatitis B infection. Chronic puts at risk for cancer and cirrhosis. Vaccine for it, but no cure.
Single strand RNA virus. Primarily transmitted through parenteral exposure. No vaccine, sexual transmission is rare. Responsible for most cases of posttransfusion hepatitis. But less than 5% of hepatitis C cases are from transfusion. Fulminant illness uncommon (unlike Hepatitis B), up to 80% of cases develop chronic infection, 20% of those chronically infected progress to cirrhosis.
Early symptoms vague and non specific, such as fatigue and vague abdominal symptoms (indigestion, gas, RUQ pain). Symptoms of advanced liver disease/cirrhosis - jaundice, peripheral edema and ascites, skin changes (palmar erythema, spider nevi, etc), peripheral neuropathies, hematologic findings, endocrine disturbances - build up of aldosterone.
AST: 10-40 units/ml
ALT: 9-40 untis/ml
PT: 12-16 seconds
Nursing role in liver biopsy
Prior to sending a patient for biopsy: Assess vital signs, confirm and review coagulation studies, compatible donor blood is available.
Post: Right side-lying position. Pillow placed under the right costal margin. VS per orders. Assess S&S of bleeding and monitor for S&S of infection.
Resistance to hepatic blood flow increases pressure in portal venous system. Resistance caused by fibrotic changes in liver. Portal hypertension = portal pressures > 12 mmHg. Consequences of portal hypertension r/t to increased hydrostatic pressure of capillary systems feeding into portal system.
Ascites and peripheral edema - Third spacing of fluid r/t increased portal pressure, decreased intravascular oncotic pressure, elevated aldosterone.
Esophageal and rectal varices - fragile collateral veins susceptible to rupture
Hepatic Encephalopathy - mental dysfunction caused by increased ammonia levels in blood.
Nursing management ascites
Think ABCs, sodium restriction (fluid restriction not usually indicated unless ascites severe), diuretic therapy, fluid removal (paracentesis), and albumin infusion.
Paracentesis (Nursing role)
Confirm consent form has been signed, review labs-especially clotting factors, have patient void before procedure, position patient in sitting or high fowler's position. Monitor vitals during procedure, post-procedure, assess puncture site for bleeding. Monitor for S&S of infection. Education regarding physical activity restriction.
Esophageal varices (Pharmacologic management)
Beta-blockers - reduces portal and collateral blood flow. Primary and secondary prophylaxis, may be combined with nitroglycerin. Octreotide-Constricts splanchnic arterioles.
Vasopressin - constricts splanchnic arterioles. Nursing considerations: monitor for complications (high risk). May need nitroglycerin to counter side effects.
Endoscopic Procedures for E.V.
Sclerotherapy - injection of sclerosing agent into variceal lumen. Induces thrombosis and fibrosis; results in varix obliteration.
Band ligation - elastic band used to obliterate varix via strangulation.
Management of Acute Variceal Hemorrhage
Protect airway, insure IV access, monitor hemodynamic status, transfer to ICU, fluid/blood transfusions, balloon tamponade therapy.
Care considerations: Monitor airway, prevent aspiration, balloon management, emergency equipment at bedside (suction equipment, scissors), prevent skin breakdown patient education.
Decline in neurological status due to liver disease - R/T build up of toxins normally metabolized by liver, ammonia the major contributor to H.E. Initially, subtle changes in mentation - may be intially overlooked. Early signs: restlessness, insomnia, tremors, changes in computational skills, changes in fine motor function. Hyperreflexia eventually develops as HE progresses. Late signs: stupor, confusion, coma, hyporeflexia.
Management of Hepatic Encephalopathy
Think ABCs, frequent neuro checks - LOC, reflexes, cognition, motor function, EEG. Patient status may change rapidly, imperative that small changes be identified. Assess for risk factors for HE. Goal: reduce ammonia formation - lactulose, neomycin, moderate protein intake-vegetable sources better than animal, identify and treat contributing factors.
Safety concerns: Patient is at risk for falls. Needs bed alarm, frequent toileting, area around bed clear.
Chronic mangement of cirrhosis
Goal - stop or slow disease progression. Nutritional management: high calorie, low sodium, low fat, moderate protein diet. Strict protein restriction should usually be avoided in most cases. Vitamin and mineral supplements. Complimentary suplements (ex: milk thistle) Abstinence from alcohol. Avoid hepatotoxic medications (acetaminophen). Adequate rest
Psychosocial considerations (Liver disease)
Altered body image, lowered self-esteem r/t alcohol induced disease. Psychological issues: e.g. depression, anxiety, hopelessness. Lack of social support or complicated family processes-mainly with alcohol-induced cirrhosis.
Gerentologic considerations (Liver disease)
Incidence of liver disease increases with age, decrease in liver volume - drug metabolism decreased. Decrease in regenerative capacity of liver. Polypharmacy increases chances of heaptic injury. Aging of baby boomers -relevance - lifetime health behaviors - obesity, chronic alcohol use, etc.
Inflammation of the pancreas. Common causes-chronic alcohol use and cholelithiasis. Acute vs Chronic: Acute can be life threatening, usually reversible.
Progression of Acute pancreatitis
Acute inflammation of pancreas - necrosis of pancreas - digestion of vascular walls - thrombus and hemorrhage - death.
Abdominal Pain - Comes on when recumbent, deep piercing (knife-like), continuous, twisting. LUQ or mid-epigastrium radiating to back, patient may flex spine to get relief. Aggravated by eating and alcohol. Unrelieved by vomiting, aggravated by supine position or walking. Relieved by sitting up and leaning forward. It is severe, with sudden onset.
Clinical manifestations (Acute pancreatitis)
Bowel sounds decreased or absent, low-grade fever, leukocytosis. Hypotension, tachycardia, cyanosis, dyspnea - pulmonary complications. Jaundice, abnormal lung sounds - crackles, diminished sounds. Discoloration of abdominal wall - Turner's or Cullen's signs. Signs of shock!
Diagnostic tests (Pancreatitis)
Serum amylase (25-125 U/L), increases >200 for 24-72 hours starts to rise 2-6 hr after onset of pain. Peaks @ 24 hr, returns to normal @72 hours. Serum lipase (3-19 U/dl), rises later than amylase (48 hr), returns to normal within 8-14 days. WBC's, glucose, and lipids increase, and calcium decreases.
Acute pancreatitis complications
Pulmonary - related to release of noxious cytokines that damage surfactant and lung parenchyma.
Cardiovascular - related to fluid loss, myocardial depression.
Electrolyte imbalance - hypocalemia (s/s - twitching, spastic, tingling fingers or numbness of lips).
Goals of care (pancreatitis)
Relief of pain, prevention or alleviation of shock, support respiratory function, decrease of pancreatic secretions, and maintain fluid/electrolyte balance.
Nursing Care (pancreatitis)
Pain management - IV narcotics, antispasmodic agents, position: sitting up and leaning forward, side-lying fetal position. Prevention of shock-hemodynamic stability. Prevent shock - hemodynamic stability - careful monitoring/trending of vital signs. Administer fluids, blood, volume expanders per orders. Suppress pancreatic enzymes, support respiratory function, correction and maintenance of fluid/electrolyte balance. Antibiotics, promote rest, and monitor for S/S of Peritonitis.
Continuous, prolonged inflammatory, and fibrosing process of the pancreas. Becomes destroyed as it is replaced by fibrotic tissue. Progressive loss of pancreatic functions. May follow bouts of acute pancreatitis or can occur in absence of any history of acute condition. Major causes: chronic alcohol use, biliary disease (gallstones etc.), malnutrition - from eat disorders (younger, often female).
Clinical manifestations (chronic pancreatitis)
Abdominal pain (located in the same area as in AP), heavy, gnawing feeling; burning and cramp-like. Malabsorption with weight loss, constipation, mild jaundice with dark urine, steatorrhea-fatty, foul smelling stool. Frothy urine/stool. Diabetes mellitus.
Goals of treatment (chronic pancreatitis)
Prevent acute exacerbations, pain relief, control of pancreatic exocrine and endocrine insufficiency - pancreatic enzyme replacement; bile salts, acid-neutralizing and acid-inhibiting drugs. Low fat, high-carb diet (recognize and address effects of malabsorption) and avoid crash diets and binging. Surgery - indicated when biliary disease is present or if obstruction or pseudocyst develops. Divert bile flow or relieve ductal obstruction.
Home/Ambulatory Care (chronic pancreatitis)
Focus is on chronic care and health promotion. Dietary control - no alcohol, avoid caffeine, low fat, high carbohydrate diet, avoid crash diets and binging, smoking cessation. Control diabetes, taking pancreatic enzymes correctly. Patient and family teaching r/t disease progression.
Well differentiated, tumor does not infiltrate surrounding tissue, growth is slow, and does not spread. Does not cause generalized effects, just localized effects. Does no usually cause tissue damage or death unless location interferes with vital function.
Undifferentiated, invades and infiltrates, rate of growth is variable, spreads to other areas of the body-metastasizes. Can cause anemia, weakness, systemic inflammation, weight loss. Can cause extensive tissue damage and eventually causes death unless growth can be controlled.
Process of transforming normal cells into cancer cells. Every phase of this process is affected by multiple gene mutations.
Family History for oncology disorders
History of cancer on maternal or paternal sides, 3 generations - parent, sibling, or child. Clusters of cancer that occur at young ages. Multiple cancers in one individual or two or more close relatives with the same cancer.
Factors inducing carcinogenesis
Viruses: HPV, HepB, Epstein Barr.
Bacteria: H. plylori
Physical agents: sunlight, radiation, tobacco, asbestos.
Hazardous chemicals (alter DNA structure): tobacco smoke, passive smoke, cigars, pipes, chewing tobacco. Workplace chemicals and asbestos.
Lifestyle factors: diet (long term ingestion of carcinogens), such as fats, alcohol, salt cured or smoked meats, nitrate containing foods, red and processed meats. Obesity, and insufficient physical activity.
Diagnosis of cancer
Determine: presence of cancer and extent (type/grade/metastasis), evaluate the function of involved and uninvolved systems and organs. Multiple tests and time of high anxiety. Determining presence/type of malignancy.
Staging a tumor
Size of tumor, local invasion, lymph node involvement, and distant mets. It is done prior to treatment, provides baseline data, and treatment options and prognosis are based on staging.
Further local spread, also usually includes spread to the nearest lymph nodes.
Usually indicates more extensive lymph node involvement
Always indicates distant spread.
Tumor, Nodes, and Metastasis: TNM
T- extent of primary tumor (how large)
N - absence or presence and extent of regional lymph node involvement
M - Absence or presence of distant Mets
Determine the type of tumor the tissue originated from. Differentiation does the tumor cells retain the function and histologic characteristics of the tissue of origin -differentiation. Grade 1 is well differentiated and resembles the tissue of origin. Grade 4 is poorly differentiated and more aggressive, less responsive to treatment.
Purposes: cure, control cancer when tumor cannot be removed, reduce tumor size before surgery, prevent local recurrence, prevent metastasis, and palliation. Replicating cells are most vulnerable, body cells that are undergoing frequent cell division most sensitive (bone marrow, lymphatic tissue, epithelium of the GI tract, hair follicles, ovaries and testes). It is a localized treatment, only tissue within treatment field affected. Acute toxicities - 2 weeks. Normal cells within treatment area are damaged. Altered skin integrity is most common (radiation dermatitis)
Radiation therapy side effects
Radiation dermatitis can become so severe treatment may need to be interrupted. It is erythema, like a sunburn, may have a permanent skin color change at site. Can also have wet dequamation -dermis of the skin exposed, skin oozing serous fluid. Ulceration can also occur. Treatment interruption or cessation. At stomach or colon - anorexia, nausea, vomiting, diarrhea. Thoracic radiation - Esophageal irritation, chest pain, and dysphagia.
Radiation therapy nursing management
Skin care during radiation - Avoid use of: soaps with fragrance/perfume, powders, lotions, ointments unless prescribed, aluminum-based deodorant. Use only lukewarm water to bathe the area, no soap. Avoid rubbing or scratching, use only an electric razor, do not apply ice or heating pad (extreme temps), avoid sun exposure and tight clothing. Wet desquamation - susceptible to infection, do not disrupt blisters, avoid frequent washing report blistering, only use prescribed creams, non-adhesive dressing, may need a WOCN.
Surgical treatment (cancer)
1. Diagnostic surgery-biopsy (wide excision, local excision, needle biopsy, fine needle aspiration).
2. Primary treatment
3.Prophylactic surgery (preventive)
4. Reconstructive surgery
5. Palliative - pain or symptom management in advanced cancer.
Used to kill tumor cells by interfering with cellular functions and reproduction. Kills rapidly dividing cells. Better survival rates among patients who receive combination chemotherapy regimens. Can be given: IV, orally, intrathecal, intrabdominal. Only administered by a nurse prepared or certified to administer. Special precautions, requires two RNs to check and adminster. Chemo gear, handling, and disposal. Do not administer if not specially prepared.
Chemotherapy side effects Part 1
Nausea and vomiting is most common side effect- anticipatory, acute, delayed, and chronic. GI effects - 5-14 days, stomatitis (mouth), and mucositis (oral cavity and GI tract) - eat bland and moist foods (soft/pureed/chilled), use straw to bypass sores, keep lips moisturized, pain medications, topical anesthetic. Thrush in mouth. Must assess the mouth, good oral hygiene, sodium bicarb mouth (baking soda) and or NS rinses 4x/day. Avoid alcohol based mouthwashes, soft tooth brush, and maintain hydration.
Cancer fatigue is distressing. Rest helps, but does not make it go away. A little activity may be exhausting, interferes with family, work, recreation, and social life. Carefully plan activity/rest. Seek help and support.
Actual/potential losses, fear, symptoms, changes in family and social roles, financial issues, loss of control. Nurses are vital.
Occurs most commonly with cancer as a side effect of chemotherapy. Bone suppression.
Reduction in neutrophils and WBC. Monitor CBC with differential. Can be caused by chemotherapy and radiation. Drug therapy - hematopoietic growth factors: neupogen and neulasta. Monitor - high risk for infection. Protective measures: vital signs every 4 hours (fever can be the first sign of infection), monitor WBC and differential daily. Inspect all sites that may serve as entry ports for pathogens. Nurses are key - hand hygiene, private room, avoid rectal or vaginal procedures, patient-meticulous personal hygiene, encourage ambulation, no IM, and avoid insertion of urinary catheters.
2 or more of the following: Temp >100.4, HR>90, RR >90, WBC >12,000 or <4000. Septic shock: symptoms of sepsis plus hypotension and circulatory collapse, body is no longer compensating, can lead to death.
Platelets below 150,000/microliters. Protective measures - only electric razors, no IM injections, foley catheter insertion only if absolutely necessary, soft toothbrush, no direct pressure, avoid aspirin and NSAIDS. Monitor for S/S of bleeding, drop in H&H, VS changes. Assess for S/S of intracranial bleed - monitor level of consciousness and neuro checks.
Monitor VS, assess for dyspnea and S/S of hypovolemia. Monitor O2 stat. Administer IV fluids/packed RBCs per orders. Administer O2 to keep sat>92%.
Destruction of hair follicles by chemotherapy or radiation to head and neck. Hair loss usually temporary with chemotherapy. Usually permanent in response to radiation.
Women's risk: 12%. Increases with age, 5-10% hereditary (gene defects inherited from parent). Higher death rate in African American women, differences in socioeconomic status.
Breast cancer assessment
Redness, prominent venous pattern (can signal increased blood supply required by a tumor), edema and pitting of the skin. New nipple inversion. Should be evaluated: ulcerations, rashes, spontaneous discharge. Palpation- normal lymph nodes are not palpable. If mass detected-note location size, shape, consistency, border delineation, mobility. Malignant tumor - hard, poorly defined, non-tender. Cysts: commonly found in menstruating women, usually well defined, pre menstrual-cysts maybe tender.
Breast cancer diagnostic evaluation
Mammogram-may detect a breast tumor before it is clinically palpable (<1cm). Mammogram every year starting at age 45. Digital mammography (better for very dense breasts), 3D mammography- contrast mammography, radiopaque material into the breast. Ultrasounds, MRIs. Testing used to detect breast abnormality. Biopsy used to confirm diagnosis of breast cancer, figure out what type.
Breast cancer risk factors
No single specific cause, combination-genetic, hormonal, possibly environmental. Female, increasing age, personal history of breast cancer. 80-90% have no familial history. Family Hx: First degree relative, and premenopausal when diagnosed. 5-10% hereditary, BRCA1 and BRCA2 (7 times more likely to get cancer with this mutation). Obesity, alcohol (2-5 drinks daily). Hormonal factors (early menarche), late menopause (after 55), no full term pregnancies, late age first full term pregnancy (after age 30). Long term use of hormone replacement therapy.
High risk breast cancer patients
Long term surveillance, chemo prevention, tamoxifen - puts women in menopause, can experience hot flashes - estrogen modulator, can treat breast cancer, may also prevent breast cancer in women at high risk of developing it.
Breast cancer prevention
Tamoxifen - hormone receptor-positive breast cancers need estrogen and/or progesterone to grow. Tamoxifen attaches to the hormone receptor in the cancer cell, blocking estrogen from attaching to the receptor. Slows or stops the growth of the tumor by preventing the cancer cells from getting the hormones they need to grow.
Removal of breast, no axillary nodes.
Modified radical mastectomy
Treat invasive breast cancer, removal of breast tissue and portion of axillary nodes.
Surgical management (breast cancer)
Breast conservative treatment + radiation therapy. Excise tumor while achieving acceptable cosmetic results. Lumpectomy, wide excision, partial mastectomy. If cancer invasive, axillary lymph node dissection.
Sentinel Lymph Node Biopsy
Status of lymph nodes is one of the most important prognostic factors. Sentinel node - the first node in lymphatics that receives drainage from the primary breast tumor. Dye injected/radioactive isotope into breast, travels to lymph nodes. Surgeon removes first (sentinel) node -- biopsy. + Axillary lymph node dissection (decreased arm and shoulder mobility, need range-of-motion exercises). - No node dissection.
Complications of ALND
Cellulitis, decreased arm mobility, lymphedema - chronic swelling due to interrupted lymphatic circulation, painful, arm weakness, tingling sensation. Collateral lymph, once develops chronic.
Nursing management of ALND
To prevent lymphedema, avoid: blood draws, IV insertion, BP, injections, use only use an electric razor to shave armpit, suntan lotion, insect repellent, avoid lifting objects >10lb. Trauma in skin.
Used to delay or prevent recurrence and spread. May also have surgery and XRT. + lymph nodes, and invasive tumor >1 cm.
Leading cause of cancer death among men and women in the U.S. 1 in 4 cancer deaths. More than colon, breast, and prostate cancers combined. 57% of patients disease has spread to regional lymph nodes and other sites by time of diagnosis. Overall 5 year survival 17%. Most common causes are cigarette and second hand smoke. 23x higher in males, 15x higher in females. Small cell -10-15% (very aggressive, grow quickly, spread rapidly). Non-small cell 85-90% - more treatable.
Lung cancer manifestations
Many times asymptomatic until late in course. Signs and symptoms depend on locations, size of tumor, degree of obstruction, existence of metastases. Most common symptom: cough or change in character of chronic cough. Symptoms: dyspnea, hemoptysis, chest or shoulder pain, pain from bone mets, anorexia and weight loss.
Radiation therapy (lung cancer)
Useful when neoplasm can't be resected. May be used to shrink a tumor so it is operable or relieve pressure on vital structures. Toxic to normal tissue within radiation field: esophagitis, pneumonitis, radiation lung fibrosis, pericarditis. Fatigue.
Colon and rectum third most common site of new cancers. Disease of western cultures, third leading cause of cancer deaths in the U.S. Incidence increases with age, mean age at diagnosis-70.
Colorectal risk factors
Older age, family history (20%), IBD, diet (high fat, high protein (red meat) diet with low fiber). High consumption alcohol, type 2 diabetes, male gender, African Americans. Cigarette smoking, obesity, Ashkenazi Jewish descent.
Colorectal cancer prevention
Early screening starting at age 50, fecal occult blood testing every year, flexible sigmoidoscopy every three years, colonoscopy every 10 years.
Colorectal cancer clinical manifestations
Depends on location of tumor and stage of disease. Most common presenting symptom is change in bowel habits. Second common is blood in or on stools, melena - black tarry stools. Symptoms colon cancer: unexplained anemia, anorexia, weight loss, fatigue, abdominal pain, cramping, constipation, and distension. Complications: complete bowel obstruction may develop, ulceration into surrounding blood vessels-hemorrhage. Perforation, abscess formation, peritonitis, sepsis, and shock.
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