Cancer

- a disease process that begins when an abnormal cell is transformed by the genetic mutation of cellular DNA. - an umbrella term for a group of disorder in which certain cells grow and multiply uncontrollably, eventually forming tissue masses called tumors. Risk Factor Assessment 1. Internal risk factors - age - gender - race - genetic factors - immunologic factors - psychological factors - tobacco use 2. External Factors - chemical carcinogens - radiation - viruses - diet - alcohol use - chemotherapeutic drugs Etiology 1. Viruses and Bacteria 1.1 Herpes simplex virus type II 1.2 Cytomegalovirus 1.3 Human papillomavirus are associated with dysplasia and cancer of the cervix. 1.4 The Hep B virus is implicated in cancer of the liver; 1.5 The Human T-cell lymphatic virus may be a cause of some lymphocytic leukemias and lymphomas; 1.6 The HIV is associated with Kaposis Sarcoma 1.7 The bacterium helicobacter pylori has been associated with an increased incidence of gastric malignancy, perhaps secondary to gastric cells. 2. Physical Agents 2.1 Exposure to sunlight or radiation. 2.2 Chronic irritation or inflammation 2.3 Tobacco use 3. Chemical Agents 3.1 About 75% of all cancer are thought to be related to the environment.

3.2 Tobacco smoke, though to be the single most lethal chemical carcinogen, accounts for at least 30% of cancer deaths. 3.3 Smoking is strongly associated with cancer of the lungs, head and neck, esophagus, pancreas, cervix and bladder. 3.4 Tobacco may also act synergistically with other substances such as alcohol, asbestos, uranium and viruses to promote cancer development. 3.5 E.g: Asbestos, Benzene, Betel nut and Lime, Cadmium, Wood dust, Pesticides and Formaldehydes. 4. Genetic and Familial Factors 4.1 Almost every cancer type has been shown to run in families 4.2 Due to Genetics, Shared environment, Cultural/Lifestyle, Chance alone. 4.3 Cancer Associated with Familial Inheritance includes: 4.3.1 Retinoblastomas 4.3.2 Nephroblastomas 4.3.3 Pheochromocytomas 4.3.4 Malignant neurofibromatosis 4.3.5 Breast, ovarian, endometrial, colorectal, stomach, prostate and lung cancer. 4.4 Conditions Associated with a Genetic Predisposition 4.4.1 Inherited Cancer - Breast Cancer 5. Dietary Factors 5.1 Dietary factors are thought to be related to 35% of all environmental cancer. 5.2 Dietary substances associated with an increased cancer risk includes : 5.2.1 Fats (animal fats) 5.2.2 Alcohol 5.2.3 Salt-cured/smoked meats 5.2.4 Foods containing nitrates and nitrites 5.2.5 High caloric dietary intake 5.2.6 Red meat 5.3 Food Substances that Appear to Reduce Cancer Risk Includes: 5.3.1 High Fiber foods

5.3.2 Cruciferous vegetables (Cabbage, broccoli, cauliflower, Brussels, sprouts) 5.3.3 Carotenoids (Carrots, tomatoes, spinach, apricots, peaches, dark-green and deep yellow vegetables) 5.4 Obesity is associated with endometrial cancer and possible post-menopausal breast cancer. 5.5 Obesity may also increase the risk for cancer of the colon, kidney and gallbladder. 6. Hormonal Agents 6.1 Tumor growth may be promoted by disturbances in hormonal balance either by the bodys own (endogenous) hormone production or by administering of exogenous hormones. 6.2 Cancer of the breast, prostate and uterus are thought to depend on endogenous hormonal levels of growth. 6.3 Diethylstilbestrol (DES)(HormoneEstrogen-decrease vaginal atrophy) has long been recognized as a cause of vaginal carcinomas. 6.4 Oral contraceptives and prolonged estrogen replacement therapy are associated with increased incidence of hapatocellular, endometrial, and breast cancer, whereas they appear to decrease the risk for ovarian and endometrial cancer. 6.5 The combination of estrogen and progesterone appears safest in decreasing the risk for endometrial cancer. 6.6 Increase numbers of pregnancies are associated with a decreasing incidence of breast, endometrial and ovarian cancer. Warning Signs of Cancer Change in bladder and bowel habits A sore that does not heal Unusual bleeding Thickening/lump in the breast or elsewhere Indigestion

Obvious change in wart/mole Nagging cough Unexplained anemia Sudden unexpected weight loss Cancer Assessment Consideration Colorectal Cancer - Ask the client whether bowel habits have changed over the past year (e.g. in consistency, frequency or color) - Is there an obvious blood in the stool. - Test at least one stool specimen for occult blood during the clients hospitalization. - Encourage client to have a baseline colonoscopy. (a must for diagnosis) Bladder Cancer - Ask the client about the presence of: - pain on urination - blood in the urine - cloudy urine - increased frequency/urgency Prostate Cancer - Ask the client about: - hesitancy - change in the size of the urine stream - pain in the back/legs - history of UTI Skin Cancer - Examine skin areas for moles/warts - Ask the client about changes in moles (e.g. color, edges, or sensation) Leukemia - Observe skin for color, petechiae, or ecchymosis. - Ask the client about: - fatigue - bruising - bleeding tendency - history of infection or illnesses - night sweats - unexpected fevers Lung Cancer - Observe the skin and mucous membranes for color. - How many words can the client say between breaths?

- Ask the client about: - cough - hoarseness - smoking history - exposure to inhalation irritants - shortness of breath - activity intolerance - frothy/bloody sputum - pain in the arms/chest - difficulty swallowing ****DIAGNOSTIC TEST FOR CANCER Pathophysiology of the Malignant Process Cancer begins when an abnormal cell is transformed by the genetic mutation of the cellular DNA This abnormal cell forms a clone and begins to proliferate abnormally. The cells acquire invasive characteristics and changes occur in surrounding tissues. The cells infiltrate these tissues and gain access to lymph and blood vessels; which carry the cells to other areas of the body called Metastasis. Note: The abnormal cells have invasive characteristics and infiltrate other tissues and this phenomenon is metastasis. Differences between Malignant and Benign Cells Cellular growth characteristics The method and rate of growth Ability to metastasize or spread General effects Destruction of tissue Ability to cause death Benign Malignant Have continuous/ inappropriate cell growth. Show specific morphology. Perform specific differentiated functions. Adhere tightly together. Are nonmigratory Have rapid/continuous cell division. Show anaplastic morphology. Lose some or all differentiated functions. Adhere loosely together. Able to migrate. Grow by invasion.

Does not spread by metastasis. Does not usually cause tissue damage unless its location interfering with blood flow. Does not usually cause death unless its location interferes with vital functioning.

Metastasize to other areas of the body. Often causes extensive damage as the tumor grows. Usually causes death unless growth can be controlled.

Malignant Process 1. Cell Proliferation - uncontrolled growth with the ability to metastasize and destroy tissues and cause death. 2. Cell Characteristics - presence of tumor-specific antigens, altered shape, structure and metabolism. 3. Metastasis - the dissemination/spread of malignant cells from the primary tumor to distant sites through: - Lymphatic spread- lymphatic circulation - Hematogenous spread- blood stream - Angiogenesis- induce growth of new capillaries 4. Carcinogenesis - also called malignant transformation - process of transforming normal cells to malignant cells - thought to be at least a three-step cellular process - Initiation - Promotion - Progression Detection and Prevention of Cancer Primary - Concerned with decreasing cancer risk in healthy people. - Avoid known carcinogen or potential carcinogen. - Lifestyle and dietary changes to decrease cancer risk. - Modification of associated factors. - Removal of at risk tissues.

- Chemoprevention - Public and patient education. Secondary - Involves detection and screening to achieve early diagnosis and Intervention - Identification of patients at high cancer risk. - Cancer screening - Monthly self-breast exam - Yearly mammography for women older than 40 - Self-testicular exam - Colonoscopy at age 50 then every 10 years - Pap Smear test - Yearly fecal occult blood in adults of all ages - Yearly prostate specific antigen (PSA) test and digital rectal exam (DRE) for men over age 50 - Public and patient education Diagnosis of Cancer Tumor Staging and Grading Grading- determines the size of the tumor and the existence of metastasis. - refers to the class of the tumor cells. - grading systems seek to define the type of tissue from which the tumor originated and the degree to which the tumor cells retain the functional and hystologic characteristics of the tissue of origin. - samples of cells to be used to establish the grade of a tumor may be obtained through cytology (examinations of cells from tissue scrapings, body fluids, secretion, or washings), biopsy or surgical excision. TNM- frequently used system T- extent of the primary tumor N- lymph node involvement M- extent of metastasis - Primary Tumor (T) Tx- primary tumor cannot be assessed

T- no evidence of primary tumor Tis- carcinoma in situ T,T,T,T- increase size and/or local extent of primary tumor. - Distant Metastasis (M) Mx- distant metastasis cannot be assessed M- no distant metastasis M- distant metastasis - Regional Lymph Nodes (N) Nx- regional lymph node cannot be assessed N- No regional lymph node metastasis N,N,N- increase involvement of regional lymph nodes Management of Cancer Treatment options offered to cancer patients should be based on realistic and achievable goals for each specific type of cancer. The range of possible treatment goals may include: - Cure- complete eradication of malignant disease. - Control- prolonged survival and containment of cancer cell growth. - Palliation- relief of symptoms associated with disease 1. Surgery - Surgical removal of the entire cancer remains the ideal and most frequently used treatment. - Diagnostic Surgery is the definitive method of identifying the cellular characteristics that influence all treatment decisions. - Surgery may be the primary method of treatment, or it may be prophylactic, palliative or reconstructive. Diagnostic Surgery 1. Biopsy - usually performed to obtain a tissue sample for an analysis of cell suspected to be malignant. - Common Methods 1.1 Excisional Method 1.2 Incisional Method 1.3 Needle Method

2. Prophylactic - removing non-vital tissues/organs prone to cancer. - Consider: -Family history and genetic predisposition - Presence/absence of symptoms - Risks and Benefits - Ability to detect cancer at early stage - Patients acceptance of post op outcome 3. Palliative - relieve complications: - Ulcerations - Obstructions - Hemorrhage - Pain - Malignant effusions - Ascitis 4. Reconstructive - may follow curative/radical surgery - to improve function/obtain a more desirable cosmetic effect. - Nursing Management - Provide education and emotional support. - Communicate frequently with physician and other health care team members. - After the surgery, assess the patients response to the surgery and monitor for possible complications. -Infection - Bleeding - Thrombophlebitis - Fluid and Electrolyte Imbalance - Organ Dysfunction - Provide comfort - Teaching - Wound care - Activity - Nutrition - Medication information 2. Radiation Therapy - Used to interrupt cellular growth . - May be used to cure the cancer, as in Hodgkins disease, testicular seminomas, thyroid carcinomas, localized cancers of the head and neck, and cancers of the uterine cervix. - May be used to control malignant disease.

- Can be used prophylactically to prevent leukemic infiltration to the brain/spinal cord. External Radiation - x-rays can be used to destroy cancerous cells at the skin surface or deeper in the body. - The higher the energy, the deeper the penetration into the body. - Gamma Rays - deliver this radiation dose beneath the skin. - Particle-beam Radiation Therapy - treat hypoxic, radiation resistant tumors. - also known as high linear energy transfer radiation, damages target tissue. Internal Radiation - Brachytherapy - Delivers a high dose of radiation to a localized area. - Implanted by means of needles, seeds, beads/ catheters into cavities (vagina, abdomen, pleural/intestinal compartments (breast)) - Can be orally as with the isotope 1131 used to treat thyroid carcinomas - Intracavity Radioisotopes - frequently used to treat gynecologic cancers. - radioisotopes are inserted into specially positioned applicators after their placement are verified by x-ray. - Observe for: - Patients are maintained on bed rest and log rolled to prevent displacement of the intracavitary delivery device. - An indwelling urinary catheter is inserted to ensure that the bladder remains empty. - Low-residue diets and anti diarrheal agents, such as diphenoxylate (Lomotil) are provided to prevent bowel movement

during therapy, to prevent the radioisotopes from being displaced. - Interstitial Implants - Used in treating such malignancies as prostate, pancreatic or breast cancer may be temporary/permanent, depending on the radioisotope used. - Because patients receiving internal radiation emit radiation while the implant is on place, contacts with the health care team are guided by the following: Principles Of: -Time - Distance - Shielding to minimize exposure of personnel to radiation. - Safety Precautions: - Assign the person to a private room. - Post appropriate notices about radiation safety precautions. - Have staff members wear dosimeter badges. - Make sure that pregnant staff members are not assigned to these patients care. - Prohibit visits by children/pregnant visitors. - Limit visits from others to 30 minutes daily. - See to it that visitors maintain a 6 foot distance from the radiation source. - Radiation Dosage - Depends on: - Sensitivity of the target tissues to radiation. - Tumor size - Side Effects: - Toxicity - Localized to the region being irradiated. 1. Altered skin integrity is a common effect and

can include alopecia(hair loss), erythema, and shedding of skin(disquamation). 2. Alterations in oral mucosa secondary to radiation therapy includes: - Stomatitis - Xerostomia(dryness of the mouth) - Changes and loss of taste and - Decreased salivation - The entire gastrointestinal mucosa may be involved and esophageal irritation with chest pain and dysphagia may result. - Anorexia, nausea, vomiting, and diarrhea may occur if the stomach/colon is the irritated field. 3. Bone marrow cells proliferate rapidly and if bone marrow-producing sites are included in the radiation field, anemia, leucopenia (decreased WBC) and thrombocytopenia (decreased platelets) may result. 4. Chronic anemia may occur. Research continues to develop radio protective agents that can protect normal tissue from radiation damage. 5. Certain systemic side effects are also commonly expected by patients receiving radiation therapy. - Fatigue - Malaise - Anorexia - Nursing Care 1. Protect the skin and oral mucosa - Assess the patients skin, nutritional status and general feeling of well being. - The skin is protected from irritation and the patient is instructed to avoid using ointments, lotions or powders on the area. - Gentle oral hygiene is essential.

- Offer reassurance by explaining that these symptoms are a result of the treatment and do not represent deterioration/progression of the disease. 2. Protect the caregiver - When the patient has a radioactive implant in place, nurses and other healthcare providers need to protect themselves as well as the patient from the effects of radiation. 3. Chemotherapy - Antineoplastic agents are used in an attempt to destroy tumor cells by interfering with cellular functions and reproduction. - May be combined with surgery/radiation therapy/both to: - Decrease tumor size pre op - Destroy any remaining tumor cells post op - Treat some forms of leukemia. - Goals - Cure - Control - Palliation - Phases of Cell Cycle

- Chemo agents are also classified according to various chemical groups, each with a different mechanism of action. - These includes the alkylating agents, nitrosureas, antimetabolites, antitumor antibiotics, plant alkaloids, hormonal agents and miscellaneous agents. - Administration of Chemo Agents - Topical - IM - Oral - Subq - IV - Arterial - Intracavity - Intrathecal - Route depends on

- Type of agent - Required dose - Type, location and extent of tumor being treated - Dosage - Based primarily on patients total body surface area, previous response to chemotherapy/radiation therapy and major organ function. )))))))))))DRUG CLASSIFICATION AND EXAMPLE - Special Problems 1. Extravasation - Vesicants are those agents that if deposited into the subcutaneous tissue causes tissue necrosis and damage to underlying tendons, nerves and blood vessels. (e.g. Vesicants) 2. Toxicity - Associated with chemotherapy can be acute/chronic. - Cells with rapid growth rates (e.g. epithelium, bone marrow, hair follicles, sperm) are very susceptible to damage and various body system may be affected as well. 2.1 Gastrointestinal System - Nausea and vomiting - Medications that decrease nausea and vomiting -Serotonin blockers block serotonin receptors of GI track. -e.g. ondansetron granisetron dolasetron 2.2 Hematopoietic System - Most chemotherapy agents cause myelosuppression(depression of bone marrow functions), resulting in decreased production of blood cells(anemia) and platelets (thrombocytopenia) and increase the risk for infection and bleeding. 2.3 Renal System - Chemotherapy agents can damage the

kidneys because of their direct effects during excretion and the accumulation of end products after cell lysis. - Cisplatin, methotrexate and mitemycin are particularly toxic to the kidneys. - Rapid tumor cell lysis after chemo results in increasing urinary excretion of uric acid which can cause renal damage. - Intracellular contents are released into the circulation, resulting in excessive levels of potassium and phosphates and hypokalemia. - Nursing Responsibilities - Monitor - BUN - Serum creatnine - Creatnine clearance - Serum electrolyte levels - Provision of adequate hydration, alkalinization of the urine to prevent formation of uric acid crystals and the use of allopurinol are frequent indicated to prevent these side effects. (CHON= 6.6-7.9) 2.4 Cardiopulmonary System - Antitumor antibiotics (daunorubicin and doxorubicin) are known to cause irreversible cumulative cardiac toxicities, especially when total dosage reaches 550mg/m. - Bleomycin carmustine(BCNU) and busulfan are known for their cumulative toxic effects on lung function. - Pulmonary fibrosis can be a long term effect of prolonged dosage. 2.5 Reproductive System - Testicular and ovarian function can be menopause/ sterility.

affected resulting in possible - Normal ovulation, early permanent sterility may result. - In men temporary/permanent, azoospermia (absence of spermatozoa) may develop. 2.6 Neuro System - Repeated dosage - Peripheral neuropathies - Loss of deep tendon reflex - Paralytic ileus - Hearing loss 2.7 Miscellaneous - Fatigue is a distressing side effect for most patients that greatly affects quality of life. - Nursing Management 1. Assess Fluid and Electrolyte Status - Anorexia, nausea, vomiting, altered taste and diarrhea put the patient at risk for nutritional, fluid and electrolyte disturbances. 2. Modify Risks for Infection and Bleeding - Suppression of the bone marrow and IS is an expected consequence of chemotherapy. - Infection- increased vs; redness 3. Administer Chemotherapy - The patient is observed closely during its administer because of the risk and consequences of extravasation particularly of vesicant agents, which may produce necrosis if deposited in the subcutaneous tissues. 4. Implement Safeguards - Nurses involved in handling chemotherapeutic agents may be exposed to low doses of the drugs by direct contact, inhalation and ingestion. - Urinalysis of personnel repeatedly exposed to cytotoxic agents demonstrate mutagenic act.

- Nausea and vomiting, dizziness, alopecia and nasal mucosal ulcerations have been reported in health care personnel who have handled chemotherapeutic agents. 4. Bone Marrow Transplantation - Used for hematologic cancer that affects the marrow of solid tumors, which are treated with a chemotherapy dosage that ablates the bone marrow. - Types Based on the Source of donor cells - Allogeneic- others - Autologous- patient itself - Syngeneic- identical twin - Nursing Management 1. Implement Pre-transplantation Care - All patients must undergo extensive pretransplantation evaluations. - Nutritional assessment, extensive physical examination and organ function tests and psychological evaluation. - Blood work includes assessing past antigen exposure. - The patients social support system and financial and insurance resources are also evaluated. - Informed consent and patient teaching about the procedure and pre-transplantation and postransplantation care are vital. 2. Provide Care during Treatment - Skilled nursing care is required during the treatment phase when high dose chemotherapy (conditioning regimen) and total body irradiation are administered. - Closely monitor Nursing Process for Patients with Cancer Assessment - Infection - Pain - Bleeding - Fatigue - Skin problems - Psychosocial status - Nutritional concerns - Body image - Hair loss

Nursing Interventions 1. Manage Stomatitis * An inflammatory response of the oral tissues commonly develops within 5-14 days after the patient receives certain chemotherapeutic agents such as doxorubicin and 5% fluorouracil, and BRMs, such as 1L-2 and IFN. - Good oral hygiene that includes brushing, flossing and rinsing is necessary to minimize the rise for oral complications associated with cancer therapies. - Soft-bristled toothbrushes and non-abrasive toothpaste To prevent/reduce trauma to the oral mucosa. - Oral swabs with sponge like applicators may be used in place of a toothbrush for painful oral tissues. - Oral rinses with saline solution/ tap water may be necessary for patients who cannot tolerate a toothbrush. - Products that irritate oral tissues/impair healing such as alcohol-based mouth rinses are avoided. - Foods that are difficult to chew/ are hot or spicy are avoided to minimize further trauma. - The patients lips are lubricated to keep from becoming dry and cracked. - Topical anti-inflammatory and anesthetic agents may be prescribed to promote healing and minimize discomfort. - Products that coat/protect oral mucosa are used to promote comfort and prevent further trauma. - The patient who experience severe pain and discomfort with stomatitis require systemic analgesics. - Adequate fluid and food intake is encouraged. - In some instances, parenteral hydration and nutrition are needed. - Topical/systemic antifungal/ and antibiotic medicines are prescribed to treat local or systemic infection.

2. Maintain Tissue Integrity - Some of the most frequently encountered disturbances of tissue integrity in additional to stomatitis includes: - Skin and tissue reactions to radiation therapy - Alopecia- starts 2-3 weeks after 1st chemotherapy. - Metastatic skin lesions - Rubbing and use of hot/cold water, soaps, powders, lotions and cosmetics are avoided. - Avoid tissue injury by wearing loose fitting clothes and avoiding clothes that constrict, irritate/rub the affected area. - Moisture and vapor-permeable dressings such as hydrocolloids and hydrogels, are helpful in promoting healing and reducing pain. - Aseptic wound care to minimize the risk for infection and sepsis. - Topical antibiotics, such as 1% silver sulfadiazine cream (silvadene), may be prescribed for use on areas of moist desquamation (painful, red, moist skin). 3. Assist Patients to Cope with Alopecia - Provide information about alopecia. - Support patient and family in coping with disturbing Effects of therapy. - Patients are encouraged to acquire a wig/hairpiece before hair loss. - Use of attractive scarves and hats may make the patient less conspicuous. 4. Manage Malignant Skin Lesions - Careful assessment and cleansing the skin. - Decreased superficial bacteria. - Control bleeding - Decrease odor - Protect the skin from pain and further trauma. 5. Promote Nutrition - Nutritional Problems - Anorexia - Malabsorption- tumors produce hormone/enzymes like gastrin that irritates the abdomen.

- Cachexia- inadequate intake with increased metabolic demand. 6. Relieve Pain - Identify sources of pain - Analgesics are administered based on the patients level of pain. 1. Non Opioid Analgesics - acetaminophen - mild 2. Weak Opioid Analgesics - codeine - moderate 3. Strong Opioid Analgesics - morphine - severe - Adjuvant Medications - Antiemetics - Antidepressants - Anxiolytics - Antiseizures - Stimulants - Local Anesthetics - Radiopharmaceutical (painful bone tumors) - Corticosteroids 7. Decrease Fatigue 8. Improve Body Image and Self-esteem 9. Assist in the grieving process - Loss of health - Normal sensations - Body image - Social interaction - Sexuality - Intimacy 10. Monitor and Manage Potential Complications - Infection - Septic shock - Bleeding and Hemorrhage ************ONCOLOGIC EMERGENCIES Supportive Care and Rehabilitation for Cancer Patients Cancer Rehabilitation - Objectives - Psychological support upon diagnosis - Optimal physical functioning after treatment - Vocational counseling when indicated - Optimal social functioning (ultimate goal) - In its broadest sense, the goal of cancer rehabilitation is to enable patients to achieve as normal and full life as possible in light of the effects of the disease and its

treatment. - Members of Rehabilitation Team - Physician- the one closest to the patient. - either the oncologist or the primary physician. - Support Team - Oncology Nurse - Psychologist/other Health professional - Physiatrist - Physical Therapist - Occupational Therapist - Social Worker - Home Care Nurse - Clergy - Lay Volunteers - Interventions 1. Preventive Interventions - Lessen the impact of anticipated disability through patient training and education. - e.g. Teaching a woman about to undergo mastectomy the exercises she will need to perform post-op to prevent swelling and loss of arm function. 2. Restorative Procedures - Aim to restore,as closely as possible, the patients state before the treatment. - e.g. Breast reconstruction following mastectomy. 3. Supportive Intervention - May be provided for the patient who has a disabling condition as a result of the cancer and its treatment. - e.g. Teaching esophageal speech to a patient who has had a total laryngectomy. 4. Palliative Intervention - Provide comfort, assistance in every functioning and emotional support in those cases where cancer is advanced and recovery is not expected. - Nurses Role 1. Pre-op teaching that includes discussion about changes to expect in care of stoma and communication alternatives.

2. Focuses with general care issues such as post op complications caused by prolonged bed rest and immobility. 3. Ongoing assessment of a patients coping skills, use of defensive mechanisms and compare patterns with family and significant others. 4. To participate in group effort to improve the patients quality of life. 5. Activities as resource speaker or referral source. 6. In educational groups, the nurse is often the teacher, organizer and evaluator. 7. Identifies and coordinates services available in the community. - Supportive Services - Are those that assists the patients and families in dealing with the many emotional, physical, and practical problems that follow the diagnosis and treatment of cancer. - Home care - Hospice care - Postural Care Acute Leukemia - Malignant proliferation of white blood cell precursors (blasts) in bone marrow or lymph tissue and their accumulation in peripheral blood, bone marrow, and body tissues. - Types 1. Acute Lymphoblastic (lymphocytic) Leukemia (ALL) - Abnormal growth of lymphocyte precursors (lymphoblast). 2. Acute Myeloblastic (myelogenous) Leukemia (AML) - Myeloid precursors (myeloblast) rapidly accumulate 3. Acute Monoblastic (monocytic) Leukemia - Schillings type - Marked increase in monocyte precursors (monoblasts). - Pathophysiology

Immature, non functioning WBCs appear to accumulate 1st in the tissue where they originated (lymphocytes in lymph tissues ad granulocytes in bone marrow). These immature WBCs then spill into the blood stream Infiltrate other tissues Organ malfunction from encroachment/hemorrhage - Lab exams and Results: - CBC- decreased hemoglobin (anemia) - decreased platelets (Thrombocytopenia) - decreased neutrophils (neutropenia) - Bone Marrow Aspirations - shows proliferation of immature WBCs and confirms the diagnosis. - A slew of immature WBCs, plus anemia, thrombocytopenia, and neutropenia (definitively suggest leukemia). - Treatment - Systemic Chemotherapy - Other Treatments - Antibiotics - Antivirals - Antifungals - RBC Transfusion - Bone Marrow Transplant for some - Nursing Interventions 1. Control Infection 2. Monitor vital signs every 2-4 hours. 3. Watch for bleeding 4. Watch for signs and symptoms of meningeal leukemia 5. Take steps to prevent hyperuricemia. 6. Control mouth ulcers 7. Check the rectal area daily for induration, swelling, erythema, skin discoloration and drainage. 8. Minimize stress 9. Provide psychological support 10. Evaluate patient Breast Cancer - Risk Factors 1. Gender- more than 90% of breast cancer occur in women 2. Age- Risk increases after 50 3. Personal history of the diseases (15% in women)

4. Family history of the disease (women who have 1st degree relatives with breast cancer have 23 fold increased risk) - Secondary Risk Factors - Never having given birth - Giving birth to a 1st child after 30 - Prolonged hormonal stimulation (menarche before age 12 and menopause after 50) - Atypical hyperplasia on a previous breast biopsy. - Spread Pattern - Breast cancer spreads via the lymphatic system and bloodstream through the right side of the heart to the lungs, and eventually to other breast, chest wall, liver, bone and brain. - Lab Results 1. Detection of a breast lump/tumor on BSE, clinical breast exam/mammography suggested breast cancer. 2. Diagnosis hinges on biopsy and pathologic evaluation of the suspicious tissue. 3. The staging workshop may include CXR as well as liver and bone scans. - Management - Chemotherapy - Radiation Therapy - Surgery Cervical Cancer - 3rd most common cancer of the female reproductive system (after uterine and ovarian cancer) - May be pre/invasive - With early detection and treatment - Lab Exams and Results 1. Papanicolaou (Pap) can detect cervical cancer before symptoms arise. 2. Colposcopy- can reveal the presence and extent of preclinical lesions. 3. Biopsy and histologic exam - Management - Preinvasive lesions may warrant total - excisional biopsy - kryosurgery - laser destruction of the tumor - conization - Invasive squamous Cancer - Radical hysterectomy - Radiation therapy (internal/external)

- Nursing Management - Provide comprehensive patient teaching. - Provide emotional and psychological support. - If patient is to receive internal radiation, remember the safety precautions- time, distance and shielding. - Check vital signs every 4 hours. - Watch for skin reactions, vaginal bleeding, abdominal discomfort and evidence of dehydration. Cancer of the Uterus - Endometrium - Cancer of the uterine endometrium (fundus/corpus) has increased incidence, partly because people are living - Risk Factors: 1. Cumulative exposure to estrogen is considered the major risk factor. This exposure occurs with the use of estrogen replacement therapy without the use of progestin. 2. Early menarche 3. Late menopause 4. Never having children 5. Others: infertility; diabetes; HTN; gallbladder disease; obesity; Tamoxifen may also cause proliferation of the uterine lining, women receiving this med for treatment/prevention of breast cancer are monitored by their oncologist. - Assessment and Diagnostic Findings 1. All women should be encouraged to have annual check Ups including a gynecologic exam. 2. Any woman who is experiencing irregular bleeding should be evaluated promptly. 3. If a menopausal/premenopausal woman experience bleeding, an endometrial aspiration/biopsy is performed to rule out hyperplasia, a possible precursor. - Medical Management -Total hysterectomy - Bilateral Salpingoophorectomy - Node Sampling - Depending on the stage, the therapeutic approach is

individualized and is based on: - Stage - Type - Differentiation - Degree of invasion - Node involvement - Whole pelvis radiotherapy is used if there is any spread beyond the uterus. Colorectal Cancer - Risk Factors - Breast and gynecologic cancer - Inherited tendency toward colon polyps - High fat diet - Signs and Symptoms -Malaise and Fatigue - Later Signs and Symptoms - Laboratory Exam and Results 1. Tumor biopsy- verify colorectal cancer 2. Direct Rectal Exam (DRE)- can be used to detect suspicious\ rectal and perineal lesions. 3. Fecal Occult Blood Test (FOBT)- detects blood in the stool- a warning sign of rectal cancer. - Management 1. Surgery- most effective 2. Chemotherapy- as adjuvant therapy for patients with metastasis, residual disease/ recurrent inoperable tumors 3. Radiation - Nursing Intervention - Evaluate the patient - He should verbalize an understanding of the treatment regimen including ostomy care and long term follow-up. Hodgkins Disease - May involve a virus - Pathophysiology - Enlargement of lymph nodes, spleen and other lymphoid tissues results from proliferation of lymphocytes, histiocytes. - Sign and Symptoms - Early - Late

- Nodular infiltration of the spleen, liver and bones. - Enlarged retroperitoneal lymph nodes. - Laboratory Examinations and Results 1. Lymph nodes reveals abnormal histologic proliferation, nodular fibrosis, necrosis and ReedSternberg cells. 2. Blood Tests- show mild to severe normocytic anemia; normochromic anemia. 3. Serum alkaline phosphatase levels may be elevated indicating liver/bone involvement. - Management - Chemotherapy - Radiation - Both Lung Cancer - Histologic Headings - Small cell (oat cell) carcinoma (cancer of the wall of a majore bronchus, having round/elongated cells) - Large cells (anaplastic) carcinoma (a bronchogenic tumor with undifferentiated large cells). - Adenocarcinoma (involves cells that line the lungs walls). - Prognosis - Generally poor - Etiology - Tobacco smoking- 90% - Others: - Genetics - Exposure to carcinogenic industrial/air pollutants (asbestos, uranium, arsenic, nickel, iron oxides). - Signs and Symptoms - Late stage response findings with small cell and squamous Cancer: - Smokers cough - Hoarseness - Laboratory Examination Results - Others: liver function test - Management - Combination of : - Surgery - Radiation - Chemotherapy Malignant Melanoma - Uncommon

- Most lethal skin cancer - Risks - Family Tendency - A history of melanoma/dysplastic nevi - Excessive sun exposure - History of severe sunburns - Fair skin - When any skin lesions/nerves - enlarges - changes color - becomes inflamed/sore - itches - ulcerates - bleeds - changes texture - pigment recession - Laboratory Examinations and Results D. Chest X-ray= aid staging E. Blood Studies anemia; ESR - Management - Wide surgical resection - Chemotherapy - Radiation Therapy Prostate Cancer - Second leading - 50years increases risk - Important - to detect prostate cancer early, all males over 40 should undergo DRE and prostate-specific antigen. - Risks - Age over 40 - High saturated fats - Hormonal factors - Signs and Symptoms - Hematuria - Laboratory Examinations 1. PSA- detect cancer 2. Transrectal prostatic ultrasonography can detect a mass. 3. Biopsy- confirms diagnosis 4. Serum acid phosphatase levels are elevated in 2/3 of patients with metastasized prostate cancer. 5. Increased alkaline phospatase levels. - Management - Radiation - Prostatectomy - Orchiectomy to decrease androgen production - Cryoablation - Hormone therapy with synthetic estrogen - chemotherapy - Nursing Interventions

- If in continence/impotence follows treatment, the patient and significant others must be informed. Heart Failure - Sometimes referred to as pump failure. - Often referred to as Congestive Heart Failure. - Is often referred to as congestive heart failure (CHF). - The inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen ad nutrients. - Types 1. Left-sided Heart Failure - Two ventricles; Two pumping systems. - Most failures begins with failures of the left ventricle and progresses to failure of both ventricles. - Formerly referred to as CHF - Typical Causes: - HTN- blood viscosity (Thinckened) - CAD - Valvular disease involving the mitral/aortic valve. - It could be acute/chronic, mild-severe. - It is further divided into subtypes: - Systolic heart failure - Diastolic heart failure * Systolic Heart Failure (Systolic Ventricular Dysfunction) - Results when the heart is unable to contract forcefully enough during systole to eject adequate amounts of blood into the circulation. - Result- preload (amount of myocardial stretch) increase with contractility, and afterload (myocardial resistance) increase as a result of increasing peripheral resistance (e.g. HTN). - The ejection fraction (the percent of blood ejected from the heart during systole) drops from a normal of 50%70% to less than 40% - As the ejection fraction decreases, tissue perfusion diminishes and blood accumulating in the pulmonary vessels.

- Manifestations - Symptoms of inadequate tissue perfusion - Pulmonary and Systemic Congestion * Diastolic Heart Failure (Diastolic Ventricular Dysfunction) - Occurs when the left ventricle is unable to relax adequately during diastole. - inadequate relaxation/ stiffening prevents the ventricle from filling the sufficient blood to ensure an adequate cardiac output, however, the ejection fraction may remain near normal. 2. Right-sided Heart Failure - It may be caused by: - left ventricular failure - right ventricular myocardial infarction - pulmonary hypertension - Increase volume and pressure develop in the systemic veins, and systemic venous congestion develops with peripheral edema. 3. High Output Failure - can occur when cardiac output remains normal/above normal. - it is caused by: - increased metabolic needs/hyperkinetic conditions such as septicemia, fever. - Clinical Manifestations - Right-sided Failure - Right ventricle cannot eject sufficient amounts of blood and blood backs up in the venous system. - Peripheral edema - Hepatomegaly - Ascites- measure abdominal girth; daily weight - Anorexia - Nausea - Weakness - Weight gain - Left-sided Failure(High back rest) - Left ventricle cannot pump blood effectively to the systemic circulation. - Pulmonary venous pressures increases, resulting in pulmonary congestion with - dyspnea - cough - crackles

- impaired oxygen exchange - Pulmonary Venous Congestion - dyspnea -cough -pulmonary crackles and lower than normal oxygen saturation levels. - an extra heart sound, s3, may be detected on auscultation. -dyspnea or shortness of breath, may be precipitated by minimal to moderate act (dyspnea on exertion (DOE)) -dyspnea also can occur at rest - the patient may report orthopnea, difficulty in breathin when lying flat. - They may need pillows to position themselves up in bed, or they may sit in a chair and even sleep sitting up. - Some patients have sudden attacks of orthopnea at night, a condition known as PHD. - Classification of Heart Failure - New York Hospital Association (NYHA) -classification I, II, III, IV - AHA - stages A,B,C,D

- Pathophysiology

-Etiology - coronary artery disease is found in 60% of patients with heart failure. - Cardiomyopathy- disease of the myocardium - Hypertension- systemic/pulmonary hypertension - valvular disorder ****Primary Focus in CAD: compliance to medications - Medical Management - eliminate/reduce etiologic/contributory factors - decrease the workload of the heart by decreasing afterload and pre-load. - optimize all therapeutic regimens - prevent exacerbations of heart failure - medications are routinely prescribed for heart failure. - Managing the patient with Heart Failure includes

- Providing general counseling and education about sodium restriction - monitoring daily weights and other signs of fluid retention - reencouraging avoidance of excessive fluid intake, alcohol and smoking. - Medications 1. Angiotensin-Converting Enzymes Inhibitors - ACE inhibitors (ACE Is) have a pivotal role in the management of HF due to systlic dysfunction. - Relieve s/s and decrese mortality and morbidity (when used to treat a smptomatic) by inhibiting neurohormonal activation. - Vasodilation and diurhetics. - Diuresis- decrease secretion of aldosterone (hormone that causes kidneys to retain Na) - Promotes Na secretion - Block conversion of Angiotensin 1- Angiotensin II - side effects: Hyperkalemia, Hypotension and renal dysfunction. 2. Angiotensin-Receptor Blockers - have similar hemodynamic effect as ACE Is - lowers BP - lowers systemic vascular resistance - block the effects of angiotensin I at the angiotensin II receptor. - side effects: Hyperkalemia, Hypotension and renal dysfunction. 3. Hydralazine and Isosorbide Dinitrate - Combination of hydralazine (Apresoline) and Isosorbide dinitrate (Dilatrate- SR, Isordil, Sorbitrate) may be another alternative for patients who cannot take ACE Is. - Nitrates- causes venous dilation 4. Beta blockers - Beta blockers with ACE Is decreases mortality and morbidity in NYHA class II/III HF patients and decrease cytotoxic effects from the constant stimulation of the SNS. - Side Effects: Exacerbation of HF - to avoid: titrate doses - Most frequent side effects: - dizziness; hypotension; bradycardia

5. Diuretics - Increase urine production and remove excess extracellular fluid from body. - most common: - thiazide- increase K and bicarbonate excretion - loop- inhibit Na and Chloride reabsorption in the ascending loop of Henle. - Potassium- sparing diuretics - inhibits reabsorption in the late distal tubule and collecting duct. * Important: - serum creatnine and potassium levels are monitored frequently (e.g: within the first week and then with four weeks when this medicine is first administered.) * Side Effects of Diuretics: - Electrolyte imbalances - symptomatic hypotension (especially with overdiuresis) - Hyperuricemia (causing gout) - Ototoxicity 6. Digitalis - digoxin (Lanoxin)- the most commonly prescribed from of digitalis for patients with HF. - increase force of myocardial contraction and slows conduction through the AV node. - improves contractility, increase left ventricular output. - enhance diuresis. 7. Calcium Channel Blockers - First generation- contraindicated with systolic dsfunction; may be used in patients with diastlic dysfunction. - Amlodipine, felodipine, dihydropyridine - Vasodilation * Nursing Alert: - Decrease risk for hypokalemia -dried apricots -figs -beets -orange/tomato juice -peaches -prunes -potatoes raisins -spinach -squash - watermelon - oral potassium supplement may also be prescribed. Nursing Management:

Assessment -Health history - Sleep and activity - Knowledge and coping - Physical Exam - mental status - lung sounds: crackles and wheezes - heart sounds: S3 - Fluid status/signs of fluid overload. - daily weight and I&O - Assess response to medications -I. Activity Intolerance - bed rest for acute exacerbation - encourage regular physical activity; 3045minutes daily - exercise training - pacing of activities - wait two hours after eating before doing physical activity. - modify activities to conserve energy. - Avoid activities in extremely hot, cold/humid weather. - Modify activities to conserve energy - Positioning; elevation of HOB to facilitate breathing and rest, support of arms. -II. Fluid Volume Excess -Assessment for symptoms of fluid overload. - Daily weight - I and O - Diuretic therapy; timing of medications - Fluid intake; fluid restriciton - Maintainance of sodium restriction. -III. Patient Teaching - medications - Diet: low-sodium diet and fluid restriction. - Monitoring for signs of excess fluid, hypotension, and symptoms of disease exacerbation, including daily weight. - Exercise and activity program. - Stress management. - Prevention of Infection - Know how and when to contact health care provider. - Include family in teaching Myocardial Infarction - Occurs when mycocardial tissue is abruptly and severely depreived with oxygen. - When the blood flow is acutely reduced by 80%-90% ischemia develops. - Ischemia can lead to injury and necrosis (infarction) of

myocardial tissue if blood flow is not restored. - Most Mis are athe result of - Atherosclerosis of a coronary artery. - Rupture of the plaque - Subsequent thrombosis - Occlusion of blood flow. - Other factors: - Coronary artery spasm - Platelet aggregation - Emboli from mural thrombi (thrombi lining the walls of the heart chambers) Process of Infarction - Infarction is a dynamic process htat does not occur instantly; rather, it evolves over period of several hours. Classification of MI by Location - the clients response to an MI also depends on which coronary artery/arteries were obstructed and which with the left ventricle wall was damaged. - Anterior; lateral;septal;inferior;posterior Etiology and Genetic Risk - Atherosclerosis is the primary factor in the development of CAD. Men: 65.8 y/o Women: 70.5 y/o Clinical Manifestations - Chest pain that occurs suddnely and continues despite rest and medication is the preenting symptom in most patients with an MI. - Patients may also be anxious and restless - Cool, pale, moist skin - HR and RR may be faster than normal. - In many cases, the s/s of MI cannot be distinguished from those of unstable angina. KEY FEATURES OF ANGINA AND MI Diagnosis Presenting symptoms ECG Lab results Prognosis depends on Severity of coronary artery obstruction Extent of myocardial damage ECG Should be obtained within 10 minutes from the time patient reports pain. Location evaluation and resoution of an MI can be identified and monitored. Classic ECG changes T-wave inversion

ST- segmental elevation Development of an abnormal Q wave. ECHOCARDIOGRAM Laboratory Tests Creatnine Kinae and its Isoenzumes. Medical Mangement -Goal - minimize myocardaial damage - preserve myocardial function - prevent comlicaitons * Achieved by reperfusing the area with the E use of thrombolytic medicines or Percutaneous Transluminal Coronary Angioplasty (PTCA) * Minimizing Myocardial Damage - reduce myocardial oxygen demand and - increase oxygen supply with medicines - oxygen administration, and bed rest. Pharmacologic Management 1. Thrombolytics - Intravenous - Direct administration into the coronary artery in the Cardiac catheterization laboratory. - Purpose: - dissolve and lyse the thrombus allowing reperfusion - Door-to-needle time - administer within 30 minutes - Agent used often: Streptokinase (1st) - risk for allergic reaction - vasculitis has occurred up ot 9 days after administration 2. Analgesics - Acute MI= Morphine Sulfate= IV = decrease pain and anxiety = decrease pre-load = relaxes bronchides to enhance oxygen 3. ACE Is - decrease mortality and prevent heart failure - before administering, patient should be: - hypotensive -hyponatremic - hypovolemic - hyperkalemic - monitor closely: - BP - Potassium - Serum Na - Urine Output - Creatnine levels - Emergen Percutaneous Coronary Intervention(PCI)

- Patient with acute MI may be reffered immediately to E PCI. - Door-to-balloon - less than 60 minutes -Cardiac Rehabilitation - after MI patient is free of symptoms - education - individual and group support - physical activities Phases: I. Diagnosis of atherosclerosis - admitted - low level activities and initial education for the patient and family. II. Discharge - 4-6 weeks but may last up to 6months III. Maintain cardiovascular stability and long term condition. Nursing Process Goal - Relief of pain/ischemic sign and symptoms - Prevention of further myocardial damage - Absence of response dysfunction - Decrease anxiety - Adhere to self-care program Nursing Interventions - Relieve pain and other signs and symptoms of ischemia - Improve respiratory funtion - scrupulous attention to fluid volume status prevents overloading the heart and lungs -Promote adequate tissue perfusion - Reduce Anxiety - Monitor and manage potential complications Metabolic Emergencies Diabetic Ketoacidis (DKA) - Caused by an absence or markedly inadequate amount of insulin. - This deficit in available insulin results in disorder in the metabolism of carbohydrate, protein and fat. - The three main clinical featurs - Hyperglycemia - Dehydration and Electrolyte loss - Acidosis PATHO Causes: - decrease/missed dose of insulin - illness/infection - undiagnosed and untreated diabetes - DKA may be the initial manifestation of diabetes. - An insulin deficit may result from an insuficient dosage of

insuline prescription/from insulin dosage may be made by patients who are ill and who assume that if they are eating less/ if they are monitoring, they must decrease their insuline doses. - Because illness, especially infection, may cause increase blood glucose levels, patients do not need to decrease their insulin doses to compensate for decrease food intake when ill and may even need to increase the insulin dose. -Other potential causes of decreased insulin - patient error in drawing up or injecting insulin - intentional skipping of doses. - equipment problems - Illness and infection are associated with insulin resistance. Assessment and Diagnostic Finding - Blood glucose levels may vary from 300800mg/dL (16.644.4mmoL/L) - some patients may have severe acidosis with modestly elevated blood glucose levels whereas others may have no evidence of DKA despite blood glucose levels of 400500mg/dL (22.2-27.7mmoL/L) - Evidence of ketoacidosis is reflected in low serum bicarbonate (0-15mEz/L) and low pH (6.8-7.3) values - a low PCO2 level (10-30mHg) reflects Acute Respiratory Failure - Sudden and life threatening deterioration of the gass exchange function of the lung. - A fall in arterial oxygen tension (PaO2) to greater than 50mmHg (hypoxemia) and a rise in arterial carbon dioxide tension (PaCO2) to greater than 50mmHg(hypercapnia), with an arterial pH of les than 7.35. - The ventilation or perfusion mechanisms in the lung are impaired. Respiratory system mechanisms leading to ARF includes: Alveolar hypoventilation Diffusion abnormality Ventilation- perfusion mismatching

Pathophysiology - Causes 1. Decrease respiratory drive - may occur with - severe brain injury - large lesions of the brain stem (multiple sclerosis) - use of sedative medications, and - metabolic disorder such as hypothyroidism. 2. Dysfunction of the chest wall - These includes: - musculoskeletal disorder (muscular dystrophy, polymositis) - neuromuscular junction disorder (myasthemia gravis poliomyelitis) - some peripheral nerve disorder, and - spinal cord disorder (amyotrophic lateral sclerosis, Guillain-Barres syndrome and cervical spinal cord injury) 3. Dysfuntion of lung parenchyma - Pleural effusion - Pleural effusion - Hemothorax - Pneumothorax - Upper airway obstruction are conditions that interfere the ventilation by preventing expansion of the lung. 4. Others: - Pneumonia - status asthmaticus - loabr atelectasis - pulmonary embolism - pulmonary edema A mismatch of ventialation to perfusion is the usual cause of respiratory failure after major abdominal, cardiac, or thoracic surgery. Clinical Manifestations - Impaired oxygenation and may include: restlessness, fatigue, headache, dyspnea, air hunger, tachycardia and increased bp. - As the hypoxemia progresses: - confusion - lethargy - tachycardia - tachypnea - central cyanosis - daiphoresis - respiratory arrest

Medical Management: - Objectives - to correct underlying cause - restore adequate gas exchange in the lung. - intubation - mechanical ventilation may be required to maintain adequate ventilation and oxygenation while the underlying cause is corrected. Nursing Management - Assit with intubation - Maintains mechanical ventilation - Assesses the patients respiratory staus by monitoring the patients level of response. - Arterial blood gases - Pulse oximetry - Vital signs - Assess the respiratory system - Come up with strategies to prevent complications (e.g., turning schedule), in mouth care, skin care, ROM. - Assess the patients understanding of the management strategies. Acute Renal Failure - Results when the kidneys cannot remove the bodys metabolic wastes or perform their regulatory functions. - The substances normally eliminated in the urine accumulate in the body fluids as a result of impaired renal excretion, leading to a disruption in endocrine and metabolic functions as well as fluid, electrolyte, and acidbase distrubances. - Reanl failure is a systematic disease and is a final common pathway of many different kidney and urinary tract disease. Acute Renal Failure is reversible syndreom that results in decreased glomerular filtration rate (GFR) and oliguria Chronic Renal Failure is progressive; irreversible deterioration of renal function results in azotemia. Pathophisiology - Acute Renal failure is a sudden and almost complete loss of kidney function (decrease GFR) over a period of hours to days. - ARF manifests with oliguria, anuria, or normal urine

volume. - Oliguria (less than 400mL/day of urine) is the most common clinical situation seen in ARF; - Anuria (less than 50mL/day of urine) - Normal urine output. Cathegories I.Parenal (hypoperfusion of kidney) conditions occur as a result of impaired blood flow that leads to hypoperfusion of the kidney and a drop in the GFR. - Common clinical situations are volumedepletion states (hemorrhage or GI losses), - Impaired cardiac performance (MI, HF/cardiogenic shock), and - Vasodilation (sepsis/anaphylaxis) II.Intrarenal (actual damage to kidney tissue)causes of ARF are the result of actual parenchymal damage to the glomeruli or kidney tubules. - Conditions such as: - burns - crush injuries - infections - nephrotoxic agents, may lead to Acute tubular necrosis and cessation of renal function. - Sever transfusion reactions - Medications may also predispose patient to intrarenal damage, especially nonsteroidal antiinflamatory drugs and ACE Is III. Postrenal (obstruction to urine flow) causes of ARF are usually the result of an obstruction somewhere distal to the kidney. - Pressure rises in the kidney tubules. Causes: - Hypovolemia - Hypotention - Decrease CO and HF - Obstruction of the kidney/ lower urinary tract. - Obstruction of renal arteries/veins. Four Clinical Phases of ARF 1. Initiation- begins with the initial insult and ends when oliguria develops. 2. Oliguria- accompanied by a rise in the serum concentration of substances usually excreted by

the kidneys (urea, creatnine, uric acid, organic acids and intracellular cations (K and Mg)). - In this phase uremic symptoms first appear and life threatening conditions such as hyperkalemia develops. 3. Diuresis- the patient experience gradually increasing urine output, which signals that GFR has started to recover laboratory values stop rising and eventually decreases. 4. Recovery- signals the improvement ofrenal function and may take 3-12months. Laboratory values return to normal. Clinical Manifestations - Appear critically ill and lethargic - With persistent N&V and diarrhea. - Skin and mucous membranes are dry from dehydration. - Breath may have the odor of urine (uremic fetor). - CNS S&S includes: - drowsiness, headache, muscle twitching and seizures. Assessment and Diagnostic Findings: I. Changes in urine - urine output varies (scanty to normal volume) - Hematuria - Low specific gravity (1.010/less, compared to normal value of 1.015-1.025). II. Change in kidney contour III. Increased BUN and Creatnine levels (Azotemia) IV. Hyperkalemia - With a decline in the GFR, the patient cannot excrete potassium normally. - Hyperkalemia may lead to dysrhtythmias and cardiac arrest. V. Metabolic Acidosis VI. Calcium and Phosphorus abnormality - there may be an increase in serum phosphate concentrations. - Serum calcium levels may be low in response to

decreased absorption of calcium from the intestne and as a compensatory mechanism for the elevated serum phosphate levels. VII. Anemia - Inevitably accompanies ARF due to decreased erythropoietin production, uremic GI lesions, reduced RBC lifespan, and blood loss, usually from the GI tract. Medical Management - Objectives of Treatment of ARF: - to restore normal chemical balance. - to prevent complications until repair of renal tissue and restoration of renal function can take place. - Overall Medical Management: - maintaining fluid balance. - avoiding fluid excesses,/ - possibly performing dialysis (hemodialysis; peritoneal dialysis) - maintainance of fluid balance. Assessment of the Patient with Renal Failure: I. Excess Fluid Volume - Assess for s/s of fluid volume excess; keep accurate I&O and daily weight records. - limit fluid to prescribed amounts. - identify sources of fluid - Explain to patient and family the rationale for restricion. - Assist patient in coping with the fluid restriction. II. Imbalance Nutrition - Assess nutritional staus, weight changes and laboratory data. - Assess patient nutritional patterns and histroy ; note food preferences. - Provide food freferences within restricitons. - Encourage high-quality nutritional foods while maintaining nutritional restrictions. - Assess and modify intake related to factors that contribute to altered nutritional intake,eg., stomatitis/anorexia. III. Risk for Situational Low Self Esteem - Assess patient and family responses to illness and treatment. - Assess relationships and coping patterns.

- Encourage open discussion about changes and concerns. - Explore alternate ways of sexual expression. - Discuss role of giving and receiving lose, warmth, and affection. IV. Provide Skin Care - meticulous skin care. - massage bony prominences. - Turn the patient frequently - Bathe the patient with cool water are often comforting to prevent skin breakdown. V. Provision of Support - The patient and family need assistance, explanation and support during this time. - The purpose and rational of the treatments are explainte to the patient and family by the physician. - Repeated experience and clarification by the nurse may be needed. - Encourage family members to touch and talk to the patient. Hyperglycemic Hyperosmolar Nonketotic Syndrome - HHNS is a serious condition in which hyperosmolarity and hyperglycemia predominate, with alterations of sensorium. - Check LOC - Basic biochemical defect is lack of effective insulin (ie, insulin resistant) - Occurs most often in older people (50-70) with no known history of diabetes/with mild type 2 DM(non dependent). - Because of possible delays in therapy, hyperglycemia,dehydration, and hyperosmolarity may be more severe in HHNS. Clinical Manifestations - Hypotension - Profound dehydration - Tachycardia - Neurologic signs - alteration of sensorium - seizures - hemiparesis - Mortality 10-40% r/t underlying illness. Assessment and Diagnostic Findings - Laboratory Tests - blood glucose- FBS, CBG

- electrolytes - BUN - Complete blood count - Serum osmolality - Arterial blood gas analysis * The blood glucose level is usually 6001200mg/dL, and the osmolality exceeds 350mOsm/kg. Medical Management - fluid replacement - correction of electrolyte imbalances - insulin administration * Close monitoring of volume and electrolyte status is important for prevention with fluid overload, HF and cardiac dysrhythmias. Nursing Management - Close monitoring of vital signs - Fluid status - Laboratory values - Maintain safety and prevent injury - Fluid status and urine output are closely monitored. - The nurse must direct nursing care to the condition that may have precipitated the onset of HHNS. - Careful assessment of cardio muscular; pulmonary and renal function. Shock - Can be best be defined as a condition in which systemic blood pressure is inadequate to deliver oxygen and nutrients to support vital organs and cellular functions. - Lack of circulating blood volume - Cell death - Inadequate tissue perfusion Without Treatment - Inadequate blood flow to the tissue results in poor delivery of oxygen and nutrients to the cells. - Cellular starvation - Cell death - Organ dysfunction progressing to organ failure. - Eventual death. Classification 1. Hypovolemic 2. Cardiogenic 3. Septic 4. Neurogenic 5. Anaphylactic Stages I. Compensatory Stage - the BP remains within normal limits. - vasoconstriction, increased HR, and increased

contractility of the heart contribute to maintaining adequate CO. Clinical Manifestations - Increase HR - Cahnge in mental status such as confusion/combativeness, as well as arteriolar dilation - Patients skin is cold and clamy - Hypoactive bowel sound - Decreased urine output Medical Management: - Fluid replacement and medication therapy must be initiated to maintain an adequate BP and establish and maintain tissue perfusion. 1. Monitor Tissue Perfusion - observe for changes: - LOC - Vital signs (plus pulse pressure=30-40) - Urinary output - Skin - Laboratory Values 2. Reduce anxiety 3. Promote safety - monitoring potential threats to the patients safety. II. Progressive Stage - The mechanism that regulate BP can no longer compensate and BP and the MAP decrease (Mean Arterial Pressure) - All organs suffer from hypoperfusion. - Mental status further deteriorates. MAP= systolic + 2(diastolic)/3 Assessment and Diagnostic Findings 1. Respiratory Effects - Respirations are rapid and shallow - Crackles are heard over the lung fields. - Decreased pulmonary blood flow. 2. Cardiovascular Effects - Lack of adequate blood supply leads to dysrhythmias and ischemia. - The patient has a rapid heart rate. - The patient may complain of chest pain and even suffer a MI. - Cardiac enzymes level increase 3. Neurologic Effect - Confusion/a subtle change in behavior - Lethargy increase and the patient begins to lose consciousness. - The pupils dialte are only sluggishly reactive to light 4. Renal Effects - ARF can develop 5. Hepatic Effects

- Patient becomes more susceptible to infection and patient appears jaundiced. 6. GI Effects 7. Hematologic Effects - Disseminated intravascular coagulation (DIC) can occur either as a cause. Medical Management - use appropriate IV fluids and medications to restore tissue perfusion. - includes early enteral nutritional support Nursing Management: 1. Prevent Complications - Evaluate blood levels of medications - Observe invasive vascular lines for signs of infections. - Checking neurovascular state if arterial lines are inserted. - Invasive procedures and arterial and venous punctures are carried out using asseptic techniques. - Venous and arterial puntures and infusion sites are maintained. - Positioning and repositioning the patient to promote comfort, prevent pulmonary complications and maintaining skin integrity. 2. Promotes Posture and Comfort - Decrease the patients physical activity and fear/anxiety. - Nurses perform only essential nursing activities. - Nurses protects the patient from temperature extremes (excessice warmth/ shivering cold). - Patient should not be warmed too quickly. 3. Support family members. III. Irreversible - Organ damage is so severe that the patient does not respond to treatment and cant survive. - BP remains low. - Renal and liver functions fail Overall Management Strategies in Shock 1. Fluid Replacement - Avoid cardiovascular overloads - Pulmonary Edema - CVP line is inserted. 2. Vasoactive Medical Therapy - Increase the strength of myocardial contractility, regulate HR, decrease myocardial resistance and initiative vasoconstriction. Vasoactive Agents in Treatment of Shock - Sympathomimetics

- Improve contractility - Vasodilators - Vasocontrictor 3. Nutritional Support - 3,000 calories daily. Types: 1. Hypovolemic Shock - Pathophysiology - decrease blood volume - decrease venous return - decrease stroke volume - Fluid Replacement in shock - Crystalloids - Colloids - Redistribution of fluid - Modified trendelenburg Nursing Management - Administer blood and fluids safely 2. Cardiogenic Shock - The hearts ability to contract and to pump blood is impaired and supply of oxygen is inadequate for the heart and tissues. - Pathophysiology - decrease cardiac contractility - decrease stroke volume and CO - Pulmonary -Decrease systemic Decrease coronary Congestion tissue perfusion artery perfusion Clinical Manifestation - Angina pain - Dysrhythmias - Hemodynamic instability Medical Management - Correction of underlying causes - may require: - thrombolytic therapy - angioplasty -CABG - Oxygenation (2-6Lpm)90% - Pain control - Hemodynamic Therapy Pharmacologic Therapy - Vasoactive medicines - Sympathomimetic - Vasodilators - Antiarrhythmic - Fluid Therapy Nursing Management - Maintain oxygenation - I&O - Medications - Laboratory Results 3. Circulatory Shock - Septic Shock - Neurogenic shock- spinal - Anaphylactic shock

A. Septic Shock - most common - caused by widespread infection Pathophysiology - Precipitating event - Vasodilation - Inflamatory response - Decrease venous return - Decrease CO - Decrease tissue perfusion Risk Factors - Septic Shock - Immunosuppresion - Extremes of age (<1y/o and >65y/o) - Malnourishment - Chronic illness - Invasive procedures - Neurogenick shock - Spinal cord injury - Spinal anesthesia - Depressant action of medications - Glucose deficiency - Anaphylactic Shock - Penicillin Sensitivity - Transfusion reaction - Bee sting allergy - Latex sensitivity Medical Management 1. Pharmacologic Therapy - 3rd generation cephalosporin + an aminoglycoside may be prescribed initially 2. Nutritional Therapy Nursing Management - Assess high risk patients - Prevent infection (insertion sights, catheter) B. Neurogenic Shock - Vasodialtion occurs as a result of a loss of sympathetic tone. - Causes - Spinal cord injury - Spinal anesthesia/ nervous system damage - depressant action of medications Medical Management - Specific treatment depends on its cause - stabilization of a SCI - Instance of spinal anesthesia by positioning the patient - Hypoglycemia Nursing Management - elevate and maintain the HOB at 30 degrees - in suspected SCI carefully immobilizing the patient to prevent further damage to SC. - NI are directed toward supporting cardio and neuro functions.

- Elastic compression stock infection and elevating the foot of bed to minimize pooling of blood in legs. C. Anaphylactic Shock - Severe allergic reaction when a patient who has already produced antibodies to a foreign substance. Medical Management - Remove cause agent - Administer medications that restor vascular tone. - Providing E support of baisc life functions. - Epinephrin is given for vasoconstriction-DOC - Dipenhydramin- reverse effects of histamine Nursing Management - Assess/Identify allergies - How she react the last time she reacted to it. Multiple Organ Dysfunction Syndrome (MODS) - Progression of shock - Altered organ function that requires medical intervention to support continued organ function. - classified as primary/ secondary - Prevention is best. Management of Patients Burn Injury Classification 1. Superficial Partial Thickness- epidermis; sunburn 2. Deep Partial Thickness- second degree burn; scalds; epidermis, upper dermis. 3. Full Thickness- electric current; prolonged exposure to hot water; may need skin graftings. Classification by Extent of Injury 1. Minor Burn- TBSA - second degree burns; < 15% adults and <10% children. 2. Moderate, uncomplicated burn - third degree burn; do not include eyes,ears,joints 3. Major Burn - eyes, ears, joints - all second degree burn that exceeds 25% Zones of Burn Injuries: -Zone of Hyperemia- least damage -Zone of Stasis- compromised blood supply -Zone of Coagulation- cellular death Factors to consider in Determining Born Depth - how the injury occurred - causative agent - temperature of agent - duration of contact with the agent

- thickness of the skin. Method to Estimate Total Body Surface Area (TBSA) Burned - Rule of nnes- simplest/easiest - Lund and Browler method - Palm method (1% of TBSA) Effects of Major Burn Injury - fluid and electrolyte shifts (hypovolemia) - cardovascular effects (ECG) - pulmonary injection (Pulmonary Congestion) - Renal(Anuria, IFC, I&O) and GI alterations(no appetite;NGT- risk for aspiration..fowlers) - Immunologic Alterations (Infection) - Effect upon thermoregulation (tempterature) Phases of Burn Injury - Emergent/resuscitative phase - onset of injury to completion of fluid resiscitation - Acute/Intermediate phase -from beginning of diuresis to wound closure - Rehabilitation phase - from wound closure to return to optimal physical and psychososcial adjustment. Guidelines and Formulas for Fluid Replacement in Burn Patient 1. Consensus Formula - Lactated Ringers Solution (or other balanced saline solution) - 2-4mL x kg body/weight x % TBSA burned - Half to be given in first 8 hours remaining half to be given the next sixteen hours\ 2. Evans Formula - Colloids:1mL x kg body weight x % TBSA burned - Electrolytes: 3. Brooke Army Formula - Colloids: 0.5mL x kg body weight x % TBSA burned. - Electrolytes (Lactated Ringers Solution) 1.5mL x kg body weight x % TBSA burned - Glucose (5% in water): 2000mL for insensible loss 4. Parkland/Baxter Formula - Lactated Ringers Solution: 4mL x kg body weight x %TBSA burned. Patients with burns exceeding 20-25% should have an NGT for suction. 1. Emergent/ Resuscitative Phase - Catheter- bonano catheter/ suprapubic catheter - Address pain, IV meds only

- ECG- 3 leads 2. Acute/ Intermediate Phase - 48-72 hours after injury 3. Rehabilitation Phase - May need reconstructive surgery. Burn Wound Care 1. Wound Cleaning - Hydrotherapy (shower carts; individual showers; bed bath) - Water= 37 degrees celcius. 2. Use of Topical Agents - silver sulfadiazine 1% (silvadene) watersoluble cream - Matenide acetate 5% to 10%(sulfamyton) hydrophilic-based cream. - silver nitrate 0.5% aquaeous solution 3. Wound Depridement - natural debridement - mechanical debridement- forcep scissors - surgical debridement- deeper-facia;bone 4. Wound Dressing- impregnated with antimicrobial agents 5. Skin grafting Types of Skin Grafting(biologic dressing) - homografts/allographs- living or recently dead humans - heterografts- animals; pig - biosynthetics/ Synthetic dressing - Biobrane dressing- most common; indefinite shelf life 1. Pain Management: A. Analgesics - IV used during emergement and acute phases. - Morphine - Fentanyl - Sustained-release opioids, such as MS Contin/oxycodone (Ocy Contin) B. Nonpharmacologic Measures - music therapy 2. Nutritional Support - prefer jejunal feeding than NGT 3. Other Major Care Issues - Pulmonary Care - Psychological Support of patient and family - Patient and Family education - Restoration of function Collaborative Problems/Potential Complications - HF and pulmonary edema - Sepsis - ARF

- Cisceral Damage (electrical burns) Nursing Interventions - Restoring normal fluid balance - Preventing Infection - Maintaining adequate nutrition - Promoting skin integrity - Relieving pain and discomfort - Promoting physical mobility - Strengthening coping strategies - Monitoring and managing potential complications. Managemet of Patients with Poisoning Poison- any substance that when ingested, inhaled, absorved, appliedto the skin, or produced with in the body in relatively small aounts injures the body and its chemical action. Treatment Goals: - Removal/inactivate the poison before it is absorved. - Probide supportive care in maintaining vital organ system. - Administer specific antidotes. - Implement treatment to hasten the elimination of the poison. Ingested Poisons * Corrosive poison includes - Alkaline Products: -lye; drain cleaners; toilet bowl cleaners; bleach; Non phosphate detergents; oven cleaners; button batteries - Acid Products - toilet bowl cleaners; pool cleaners; metal cleaners; rust removers and battery acid Assessment of Patients with Ingested Poisons - use ABC - Monitor VS, LOC, ECG, UO - Assess laboratory specimens - Determine what, when and how much substance was ingested. - Assess s/s of poisoning and tissue damage - Asseses Health history - Determine age and weight. Management of Patient with Ingested Poisons - The patient who ingested a corrosive poison is given water/ milk for dilution - Gastric emptying procedures may be used as prescribed. - syrup of ipecac to induce vomiting in the alert patient.

- Gastric lavage for the obstunded patient. Gastric aspirate is saved and sent to the laboratory for testing (toxicology screens.) - Activated charcoal is administered if poison is one that is absorved by charcoal. - Cathartic, when appropriate. Measures to Remove the toxin/ decrease its absorption Use of emetics Gastric lavage Activated charcoal Cathartic when apporpriate Administration of specific antagonist as early as possible. May include: diuresis/dialysis - dimercaprol- mercury/heavy metal; arsenic. Management for patient with Carbon Monoxide - Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin, which does not transport oxygen Manifestations: CNS symptoms predominate Treatment Get to fresh air immediately CPR if necessary Administer 100% oxygen Monitor patient continuously Other S/S Headache Muscular weakness Palpitation Dizziness Confusion Which can rapidly progress to coma Skin color, which can range from pink/cherry-red to cyanotic and pale, is not a reliable sign.

Management Goals - to reverse cerebral and myocardial hypoxia and - to hasten elimination of carbon monoxide Whenever a patient inhales a poison Carry the patient to fresh air immediately; open all doors and windows. Loosen all tight clothing Initiate CPR if require; administer oxygen Prevent chilling; wrap patient in blankets

Keep patient as quiet as possible Do not give alcohol in any form

Management of Patients with Food Poisoning Food Poisoning - sudden illness due to the ingestion of contaminated food/drink. - food poisoning, such as botulism/fish poisoning, may result in respiratory paralysis and death. - Salmonylosis; e-coli; staphylococcus Management - ABCs and Supportive measures - Treatment fluid and electrolyte imbalances - control N&V - Provide clear liquid diet and progression of diet after N&V subside. - Measures to control N are also important to prevent vomiting. - An antiemetic medicine is administered parenterally - For mild nausea, the patient is encouraged to take sips of weak tea, carbonated drinks/ tap water. - After N&V subside, clear liquids are usually prescribed for 12-24 hours and the diet is gradually progressed to a low- residue, bland diet. Management for Skin Contamination Poisoning (Chemical burns) 1. Immediately flush the skin with running water from a shower, nose or faucet. - Lye/white phosphorus must be brushed off the skin dry. 2. Protect health care personnel from the substance. 3. Determine the substance 4. Some substance may require prolonged flushing/irrigatin. 5. Antimicrobial treatment, debridement, tetanus prophylaxis as prescribed is instituted. 6. The patient may require plastic surgery for further wound management. 7. Follow-up care includes re-exam of the area at 24hours, 72 hours and 7days.

concept that an E is whatever the patient/family considers it to be. *Qualifications of an E Nursing - has special training - education - experience - expertise in assessing and identifying health care problems in crisis situations. * Tasks of an E Nurse 1. Establish priorities 2. Monitors 3. Continuously assesses acutely ill and injured patients. 4. Supports and attends to families. 5. Supervises allied health personnel 6. Teaches patients and families within a time-limited, high pressured environment. * Focus of E Care 1. Preserve life 2. Prevemt deterioration before definitive treatment can be given.

FINALS
Emergency Nursing Scope and Practice of Emergency Nursing * Emergency Management: - traditionally refers to urgent and critical care needs. - however the ED has increasingly been used for non-urgent problems and E management has broaden to include the

3. Determine the patients ability to follow commands and evaluate motor skills and pupillary size. 4. Carry out a rapid initial and ongoing physical exam. 5. Start cardiac monitoring if appropriate. 6. Splint suspected fracture. 7. Protect and clean wounds and apply sterile dressing. 8. Identify allergies and medical history that is significant (DM; seizure). 9. Document vital signs; neuro status; I&O to guide decision making. * Special Considerations in E Nursing 1. Data collection 2. Information control 3. Make safety the first priority 4. Preplan to ensure security and a safe environment 5. Closesly observe patient and family members in the event that they respond to stress with physical violence. 6. Discharge planning. 7. Psychological support - patient focused - family focused - Relieve anxiety and provide a sense of security. - Allow family to stay with patient if possible, to alleviate anxiety.

- Provide explanations and informations. - Provide additional interventions depending upon the stage of crisis. 8. Documentation * Triage - To sort patients by heirarchy based on the severity of health problems and the immediacy with which these problems must be treated. - It is used to determine those patients in need of immediat treatment and those who can safely wait. * Three Main Categories of Triage 1. Emergent- life- threatening/ potentially life threatening injuries or illness requiring immediate treatment. 2. Immediate- non-acute, none-life threatening injury or illness. 3. Urgent- minor illness/injury needing first-aid level treatment. - can be referred to a primary physicains office/clinic. * Priorities in E Nursing 1. Establishing an airway 2. controlling hemorrhage 2.1 fluid replacement. 3. Controlling hypovolemic shock - shock condition in which there is loss of effective circulating blood volume. * Managemenbt 1. Ensure a patent airway and maintain effective breathing. 2. Restoration of the circulation of blood bolume which is accomplished by rapid fluid and blood replacement as ordered. 3. CVP line- to know the pressure in the right atrium - normal: 4-10cm H2O 2-7mm Hg - manometer- oxygen level of right atriem. 4. BT 5. IFC 6. on going nursing surveillance of which total patient is maintained. 7. BP, RR, HR, Skin temp, color, pulse oxy, neuro stat, CVP, ABGs, ECG, Hct, Hgb, etc.. 1? 2. Wounds- vary from tears to severe crushing injuries. * Management: - shave/clip hair around - clean with NSS/betadine/H2O2 - do not get deep into the wound without thorough rinsing.

- if indicated, the area is infiltrated with anesthesia before cleaning. - irrigate copiously with sterile NSS. 3. Traumas Priorities of Care of the Patient with Multiple Trauma - use a team approach - determine the extent of injuries and establish priorities of treatment. - assume cervical spine injury. - assign highest priority to injury intergering with vital physiological function. 4. Intra-abdominal Injuries 4.1 penetrating 4.2 blunt -Abdominal trauma can cause massive lifethreatening blood loss into the abdominal cavity. Assessment: - Obtain history - Perform abdominal assessment - Assess other body system for injuries that frequently accompany abdominal injuries. - Assess for referred pain that may indicate: - spleen- hemorrhage - liver - intraperitoneal injury -Perform the following: - laboratory studies - CT scan - abdominal ultrasound (FAST) - diagnostic peritoneal lavage - Assess stab wound via sonography. Manage Patients with Intra-abdominal Injuries - Continually monitor the patient - Immobilize cervical spine - Document all wounds - If viscera are protruding, cover with a sterile, moist saline dressing. - Hold oral fluids. - NGT to aspirate stomach contents. - Ensure airway, breathing and circulation. - Provide tetanus and anti-biotic prophylaxis. - Provide rapid transport to surgery if indicated. 5. Crushing Injuries Assessment: Observe for the following: - hypovolemic shock - paralysis of the body - erythema and blistering of the skin - damaged body part appearing swollen, tense and hard - renal dysfunction 6. Mlti/Multiple Injuries Nursing Responsibilities: - assess and monitor patient - ensure IV access

- Administer prescribed meds - Collect laboratory specimen - Document activites and patients response Priorities: - Establish airway and ventilation - Control hemorrhage - Prevent and treat hypovolemic shock. Monitor urine output. - Assess for head and neck injury. Maintain spine immobilization. -Evaluate for other injuries. -Spine traction 7. Fractures Management: -assessment for ABCs including pulse in extremities. - evaluate for neuro and abdominal injuries before the extremities are treated unless a pulse extremity is detected. 8. Management of Patients with Substance Abuse +Acute alcohol intoxication: a multisystem toxin. - Alcohol poisoning may result in death. - Maintain airway and observe for CNS depression and hypotension. - Rule out other potential causes of the behaviors before it is assumed the patient is intoxicated. - Use a nonjudgmental, calm manner5. - Patient may need sedationif noisy or belligerent. - Examine for withdrawal delirium, injuries and evidence of other disorders. 9. Family Violence, Abuse and Neglect Clinical Manifestations - may present with physical injuries/health problems such as - anxiety - insomnia - GI symptoms, that are r/t stress *In the ED, the most common physical injuries are: unexpected bruises; lacerations; abrasions; head injuries; fracture. Clinical Manifest of Neglect Malnutrition Dehydration Management: - Focused on the consequences of the abuse, violence/neglect and on prevetion of further injury. 10. Sexual Assault NR: Manner on how we treat our patient affect their psychological status. 11. Psychological E

- Overactive; underactive; violent;depressed;suicidal Management: - Maintain the safety of all persons and gain control of the situation. - Determine if the patient is at risk for injuring himself/others. - Maintain the persons self-esteem while providing care. - Determine if the person has a psychiatric history/is currently under care to contact the therapist. Crisis Intervention Goal: - Resolution of an immediate crisis. Focus: - Supportive - Restoration of the individual to his pre-crisis level of functioning/to a higher level of functioning. Terrorism, Mass Casualty and Disaster Nursing Priority 1- RED - Immediate: Injuries are life threatening but survivable with minimal intervention. Individuals in this group can progress rapidly to expectant if treatment is delayed. - Sucking chest wound, airway obstruction secondary to mechanical cause, shock, hemothorax, tension pneumothorax, asphyxia, unstable chest and abdominal wounds, incomplete amputation, open fracture of long bones, burn with. Priority 2- YELLOW - Delayed: injury are significant and require medical care, but can wait hours without threat to life/ limb individually in this group: receive treatment, only after immediate casualties are treated. - Stable abdominal wounds without evidence of significant hemorrhage; soft tissue injury, maxillofacial wounds without airwya compromise; cascular injury with adequate collateral circulation; genitourinary tract; most eye and CNS injuries. Priority 3- GREEN - Minimal: injury are minor and treatment can be delayed hours to days. Individuals in this group should be moved away from the main triage area. - Upper extremity fracture; minor burns, sprains, small lacerations without significant bleeding, behavioral disorder or psychological disturbances.

Priority 4- BLACK - Expectant- Injuries are extensive and chances of survival are unlikely even with definitive care. Persons in this group should be separated from other casualties but not abandoned. Comfort measures should be provided when possibe. - Unresponsive patients with penetrating head wounds high spinal cord injuries, wounds involving multiple anatomical sites and organs, second and third degree burns in excess of 60% of body surface area, seizures/vomiting within 24hours after radiation exposure, profound shock with multiple injuries, agona/respiratory, no pulse, no BP, pupils fixed and dilated. Categories of Protective Equipment: Level A: self contained breathing apparatus(SCBA) and vapor-tight chemicalresistant suit, glorus and boots. Level B: high level of repiratory protection (SCBA)but lesser skin and eye protectin; chemical resistant suit. Level C: air purified respirator, cover all with splash hood, and chemical resistant glorus and boots Level D: typical work uniform. ANTHRAX SARS Avian Flue Pathogenic strain of Bird Flu S/s - fever - headache - fatigue - sore throat - dry cough - runny nose/stuffy nose Types of Radiation Experience: External Contamination Incorporation Critical Insident Stress Management (CISM) Education Field Support Defusing Debriefing Demobilization Follow up components Post Traumatic Stress Disorder (PTSD) - A condition that generates waves of: - Anxiety - Anger - Aggression

- Depression - Suspicion - That threaten the persons sense of self and interfere with daily functioning - Some events that place a person at risk for PTSD: - Rape - Family violence - Torture - Terrorism - Fire - Earthquake - Military Combat - It has been postulated that people with PTSD lose the ability to control their response to stimuli. - The resulting excessive arousal can increase overall Body Metabolism and Trigger Emotional Reactivity - Manifestations: - Has difficulty sleeping - Has an exaggerated startle response - Is excessively vigilant Symptoms Can Occur Hours to Years After the Trauma is Experienced. - Acute- the experience of symptoms for less than 3month period. - Chronic- experence of symptoms longer than 3months - In the case of delayed PTSD, up to 6months may elapse between the trauma and manifestation of symptoms Nursing Implications It is important that nurses consider which of their patients are at risk for PTSD and be knowledgeable about the common symptoms associated with it. The sensitivity and caring of the nurse creates the interpersonal relationship necessary to work with patients who have PTSD. Essential components of Treatment for patient with PTSD 1. Establishing a trusting relationship 2. Addressing and working through thte trauma experience. 3. Providing education about the coping skills need for recovery and self- care. Intravenous Parenteral Therrapy Intravenous Therapy

- Insertion of a needle/catheter into the vein based on the physicians written prescription Goals: - To provide water, electrolytes and nutrients to meet daily requirement. - To replace water and correct electrolyte deficits. - To administer medicines and blood products. - To provide ready access for emergency med particularly in critically ill patients. Nursing Responsibilities in IV Therapy 1. Starting the infusion 2. Managing the flow rate 3. Monitoring for complications of IV therapy 4. Discontinuing the infusion Procedure for Starting IV Infusion 1. Prepare the equipment 2. Prepare the patient 3. Prepare the site 4. Perform the venipuncture 5. Document the procedure Veins of the Hand and Arm Hand sites: - Dorsal venous arch - Metacarpal vein - Digital vein Arm sites: - Cephalic vein - Accessory Cephalic Vein - Basilic Veins - Median Antebrachial. Documentation Document the following - Date and time of procedure - Type, length and gauge of the catheter inserted. - Number of attempts made - The exact location of each attempt and the final successful site. - Type of dressing applied - Patients response to the procedure - Condition of the IV site - The types of fluids and medicines used. - Patient teaching. Review: Fluids 1. Body fluids: Adults: 60% of the TBW (40% solids, fats, proteins, minerals, carbohydrates) 1. Main Compartments:

Intracellular- are within cell -40% Extracellular- interstitial- between and around the cell- 15% Intravascular- inside the blood vessels 5% Movement of Water and Electrolytes Diffusion- random movement of ions and molecules in all directions through a solution/gas. - spread is from area of greater to lesser concetration. Osmosis- water moves from less concentration to more concentration(.3 main types of IV) Active transport Filtration Types of IV Solutions: 1. Isotonic- fluids that are classified as isotonic have a total osmolality close to that of the ECF and do not cause rbc to shrink/swell. - Because these fluids expand the intravascular space, patients with hypertension and heart failure should be carefully monitored for signs of fluid overload. - e.g. D5W, PNSS,LRS 2. Hypotonic Fluids- ro replace cellular fluid, because it is hypotonic as compared with plasma. - to provide free water for excretion of body wastes. - used to treat hypernatremia and other hyperosmolar conditions. - can be helpful when cells are dehydrated such as those of a dialysis patient on diuretic therapy. - used for hyperglycemic patients as diabetic ketoacidosis in which high serum glucose levels draw fluids out of the cells into the vascular and interstitial compartments. - ex: half strength saline (0.45% NaCl) solution, with an osmolality of 154 mOsm/L, - Multiple-electrolyte solutions; D5NSS; a 18% NaCl -Excessive infusions of hypotonic solutions can lead to intravascular fluid depletion, decrease bp, cellular edema and cell damage. 3. Hypertonic- higher osmolality than serum. - Pull fluid and electrolytes from the intracellular nad interstitial space into the intravascular space and can help stabilize blood pressure, increase urine output and reduce edema. - eg: 9% NS; blood products and albumin. Complications 1. Thrombophlebitis Causes: Irritating solution and medicines.

Traumatized vein. and Symptoms Temperature Spikes Pain along the course of the vein. Possible discoloration of skin around of the injection site. d. IV leading at injection site. 2. Infiltration- the seepage of solution or medicines into surrounding tissue. Causes: Dislodged catheter Hyperactive patient Hubs/wings of needle not anchored properly IV insertion pushes needle bevel through posterior of vein. Needle placed in area of flexion Signsand Symptoms Swelling of affected area Coolness of skin around site Backflow of blood absent/ pinkish blood serum Slowing of infusion rate. 3. Mechanical Complications- Failure of the intravenous system to adequately deliver therapy at the prescribed rate. 4. Hematoma- swelling/mass of blood confined in the tissue caused by a break in the blood vessel. Causes: Damaged to vein during unsuccessful venipuncture attempt. Inadequate pressure after removal of cannula Inappropriate use tourniquet Signs and Symptoms Ecchymosis Swelling and discomfort at site. 5. Phlebitis- inflamation of vein Types 1. Mechanical 1. Chmeical 2. Bacteria 6. Venous Spasms Causes: Severe vein irritation Administration of cold fluids/blood. Very rapid flow rate 7. Extravasation- infiltration of vesicant medications 8. Tape burn. Signs a. b. c.