Module 3 (434)

medical management of aortic dissection (including DC instructions)

-First priority: limited progression of dissection by lowering systemic arterial pressure and reducing cardiac contractility (BP 100-120/50-80 and HR 50-70) via IV blood pressure meds and eventually PO beta blockers -monitor IV, oxygen, neuro, I&O, pain -DC: extensive medication teaching, HTN meds, worsening symptoms, self monitor HR and BP, follow up with CT or MRI to monitor

secondary prevention measures for aneurysm

-HTN and cholesterol screening, US screening for anuerysm

Complications of radiation therapy in breast cancer

Recurrence (1) Local: Skin, chest wall (2) Regional : Lymph nodes (3) Distant (really any area of body) (a) Skeletal (b) Spinal Cord (c) Brain (d) Lungs (e) Liver (f) Bone Marrow b) Nursing Lymphedema: Accumulation of lymph in soft tissue d/t lymph node sampling procedure or radiation therapy à axillary nodes cannot return lymph fluid to the central circulation, the fluid accumulates in the arm, hand, or breast, causing obstructive pressure on the veins and venous return i) From lymph node sampling or radiation therapy ii) Symptoms: heaviness, impaired ROM, numbness, paresthesia of fingers iii) Treatment: massage (called manual lymph drainage can encourage lymph fluid out of arm or leg and compression (wrapping limb encourages lymph fluid to flow back to trunk of body and should be tightest around fingers/toes)

Ethics definition

addresses questions such as the following: How should I behave? What actions should I perform? What kind of person should I be? What are my obligations to myself and to fellow humans? Ethical judgments are concerned with values. The goal of an ethical judgment is to choose that action or state of affairs that is good or right in the circumstances.

first line of treatment for postmenopausal osteoporosis

alendronate (70mg/week) of risendronate (25mg/wk or 150mg/month) also consider zoledronate (5mg q12months) to decrease risk of adverse GI effects and to increase adherence

Cerebral blood flow (CBF)

amount of blood in mL passing through 100g of brain in one min that is monitored and influenced by autoregulation

Tumors can be classified by

anatomic site, histology (severity) or extent of disease (staging; extent and spread)

Health effects associated with air pollution

asthma, CVD (HTN), cancer, immunological effects and reproductive effects (birth defects/infant death and neuro problems)

Autoregulation

automatic adjustment in diameter of the cerebral blood vessels by the brain to maintain a constant blood flow during changes in arterial blood pressure; its purpose is to provide for brains metabolic needs and maintain cerebral perfusion pressures

extend of disease classification of tumor (staging AND extend & spread)

based on anatomic extend of disease rather than on cell appearance staging: (a) 0: Cancer in situ (b) I: Tumor limited to tissue of origin; localized tumor growth (c) II: Limited local spread (d) III: Extensive local and regional spread (e) IV: Metastasis extend and spread (TMF): (a) TNM staging cannot be applied to all malignancies (like leukemia) (b) Anatomic extent of disease is based on 3 parameters: (i) Tumor size and invasiveness (T) (ii) Spread to lymph nodes (N) (iii) Metastasis (M) (c) The higher the M number, the more extensive the metastasis. (d) T1, T2 ect. Description of primary tumor based on size and/or invastion into nearby structures, the higher the T number, the larger the tumor and/or the more it has grown into the nearby tissues. (e) The higher the N number, the more extensive the lymph node involvement.

Aneurysms

diseased portion of the artery where the walls become dilated and thin causing a bulge of growth 1.5-2x normal size (which is about an inch)

Greenhouse gases

doesnt cause much direct harm to humans: i) Nitrous Oxide: Various management practices on agricultural soils can lead to increased availability of nitrogen in the soil and result in emissions ; laughing gas ii) Methane: Livestock, especially ruminants such as cattle, produce methane ( CH4) as part of their normal digestive processes.

Radon

naturally ocurring radioactive element in earth's crust and can seep into basements and into groundwater -2nd leading cause of lung cancer in US (second only to smoking)

Symptom management in cancer treatment

treatment for cancer associated with multiple complex complications, adverse effects, and side effects -multiple nursing interventions are geared toward managing complications and symptoms -pain management

tests for EVALI

-Bronchoalveolar lavage (BAL) fluid samples -blood (CBC, liver, ESR, CRP) -urine -lung xray (bacterial pneumonia) -lung biopsy -aerosol emission testing

i) Bisphosphonates: Alendronate, Risedronate, Ibandronate, zoledronic acid

(1) ibandronate and zoledronic acid available for IV administration for persons who cannot tolerate oral administration or poor adherence to taking oral (2) Bind strongly to bone minerals at sites of active remodeling and slow down bone resorption by inhibiting the activity of osteoclasts (3) Oral bisphosphonates are poorly absorbed in the GI tract (less than 3%)à Must be taken with water and on an empty stomach

active surveillance of prostate cancer

"watchful waiting" via -(1) Life expectancy is <10yrs (2) Low-grade, low-stage tumor (3) Serious coexisting medical conditions

i) Selective Estrogen Receptor Modulators (SERMs): Raloxifene

(1) Act as estrogen agonists in the bone and estrogen antagonists in the breast and uterine tissue (2) Potential to prevent osteoporosis without increased risk for breast or uterine cancer (3) Increase BMD in the spine and femoral neck and lowers risk of vertebral fractures (4) Common adverse effects: hot flashes and mild cramping Serious adverse effects: 2x increased risk for thrombus (DVT, PE, VTE)

managing osteoporosis with calcium and vitamin D

(1) Calcium is poorly absorbed without adequate levels of vitamin D, so we recommend daily D dose (a) Vitamin D levels should be rechecked every 3 months after starting vitamin D supplementation via Serum 25- hydroxyvitamin D levels à normal range of 29-32 ng/mL (b) 800-1000 units for postmenopausal women (c) 1000 units for long-term care (d) 2000 units daily can be protective of fall prevention (2) Ideally dietary sources: Milk, cheese, yogurt, custard, ice cream, raisins, tofu, salmon or sardines, broccoli, other dark green vegetables, calcium-fortified orange juice and cereals (3) Calcium supplementations: calcium carbonate (better with food), calcium citrate (with or without food) (a) Can interfere with absorption of zinc, iron, atenolol, salicylates, propranolol, tetracyclines, and bisphosphonates (b) Do NOT recommend if poor renal status or hx of kidney stones (4) Calcium à constipation so need to institute measures to promote bowel function (discuss fluid intake and fiber intake) ii) Daily Calcium intake (1) Total intake

Acute management goals of TB

(1) Prevent spread of infection (2) Respiratory function (chest tube, monitor) (3) Nutrition (enteral nutrition?) (4) Activity (5) Medication adherence and side effects: several months; monitor liver function (6) Resolution of illness: course of meds completed, sputum negative, no symptoms and not contagious

calcitonin treatment

(1) Shown to increase bone density in the spine and to reduce vertebral fractures (2) & can have an analgesic effect in acute compression fractures, in Paget's disease of the bone or in bone pain due to metastatic disease (3) Administration (a) Subcutaneous (50-100units 3-5x per week) or nasal spray (one squirt in one nostril

extraarticular manifestations

(can affect almost every organ) i) Rheumatoid Nodules: (1) Rheumatoid nodules develop in about half the patients with RA.17 Rheumatoid nodules appear subcutaneously as firm, nontender, granuloma-type masses. They are often located on bony areas exposed to pressure, such as the fingers and elbows. Nodules at the base of the spine and back of the head are common in older adults. Treatment is usually not needed. However, these nodules can break down, similar to pressure ulcers. Cataracts and vision loss can result from scleral nodules. Nodular myositis and muscle fiber degeneration can cause pain similar to that of vascular insufficiency. In later disease, nodules in the heart and lungs can cause pleurisy, pleural effusion, pericarditis, pericardial effusion, and cardiomyopathy. ii) Cataracts and vision loss iii) Muscle fiber degeneration = pain (similar to vascular insufficiency) iv) Nodules in heart and lungs = pleurisy, pleural effusion, pericarditis, pericardial effusion, cardiomyopathy v) Sjogren's Syndrome- diminished lacrimal or salivary secretions (1) Sjögren's syndrome(SHOW-grins) can occur by itself or in conjunction with other arthritic disorders, such as RA and SLE. Affected patients have diminished lacrimal and salivary gland secretion, leading to a dry mouth; burning, itchy eyes with decreased tearing; and photosensitivity vi) Felty Syndrome - enlarged spleen and low WBC = risk of infection (1) Felty syndrome is rare but can occur in patients with long-standing RA. It is characterized by an enlarged spleen and low white blood cell (WBC) count. Patients with Felty syndrome are at increased risk of infection and lymphoma. (2) Flexion contractures and hand deformities cause diminished grasp strength and affect the patient's ability to perform self-care tasks. Depression also may occur. However, it is unclear if the patient becomes depressed from struggling with chronic pain and disability, or if depression is part of the autoimmune disease process.18 vii) Hand deformities, decreased grasp strength viii) Depression

Acute THC toxicity

(most toxic for those less than 12) -lethargy, hypotonia, hypoventilation, tachycardia, ataxia, mydriasis (dilated pupils)

Diagnosing a concussion

(one of more of the following:) i) Symptoms: somatic (e.g. headache) cognitive (e.g. feeling in a fog), and/or emotional ii) symptoms (e.g. lability) iii) Physical signs (e.g. LOC, amnesia, neurological deficit) iv) Balance impairment (e.g. gait unsteadiness) v) Behavioral changes (e.g. irritability) vi) Cognitive impairment (e.g. slowed reaction times) vii) Sleep or wake disturbances (e.g. somnolence, drowsiness)

Osteoporosis and exercise

(walking is a weight-bearing exercise) Goals: v) Older adults should be encouraged to start out slowly and gradually increase both the number of days as well as time walked each day vi) Persons with an osteoporotic fracture should be referred to PT for postural exercises, alternative modalities for pain reduction and suggested changes in body mechanics to prevent future fractures vii) Adherence to exercise is important viii) Exercise is also important in fall prevention

Common diagnostic tests for cancer

)Common diagnostic tests a) Radiographic tests: x-rays, magnetic resonance imaging (MRI), computed tomography (CT), radioisotope scans, ultrasound, diagnostic mammography b) Direct visualization: colonoscopy, endoscopy c) Laboratory tests: complete blood count, chemistry panel, genetic or tumor marker tests d) Pathology: examination of cells and tissues for a diagnosis of malignancy, tissue type, grade tumor

Ethics and core functions of population-centered nursing

*assessment, policy development, and assurance* a) assessment: i) Competency related to knowledge development, analysis, and dissemination (1) Are the persons assigned to develop community knowledge adequately prepared to collect data on groups and populations? ii) Virtue ethics or moral character (1) Do the persons selected to develop, assess, and disseminate community knowledge possess integrity? iii) "Do no harm" (1) Is disseminating appropriate information about groups and populations morally necessary and sufficient? b) policy development: i) Achieve the public good (Rooted in citizenship) ii) Service to others over self (a necessary condition) (1) Serve rather than steer (2) Serve citizens, not customers (3) Value citizenship and public service above entrepreneurship iii) What is ethical is also good policy. c) Two ethical tenets of assurance: i) All persons should receive essential personal health services. ii) Providers of public health services are competent and available.

pharmacologic interventions for RA

*cornerstone of treatment* -DMARDs, BRMs, TNFI -other: antibiotics, immunosuppressants, gold preparations, corticosteroids, joint injections, NSAIDs and salucylates

How long does it take between the initial genetic alteration and the actual clinical evidence of cancer?

-1-40yrs -(1) Before the cancer becomes clinically evident is associated with the mitotic rate of tissue of origin and environmental factors (2) For disease to become clinically evident, the cells much reach "critical mass" or a tumor that is 1cm with 1 billion cells (detectable by palpation) (3) 0.5cm is the smallest that can be detected via MRI

Signs of increased ICP in children/adolescents/adults

-AMS (earliest sign) -irritability, restlessness, drowsiness, indifference, decrease in physical activity, inability to follow commands, memory loss, confusion -headache -vomiting -change in pupils or vision

diagnostic evaluation of osteoprosis

-BMD study of spine and hip that is reported as a Z or T score -Z score if premenopausal -T score used for postmenopausal -osteopenia will be more than 1 SD and less than 2.5 -osteoporosis will be more than 2.5 SD -severe osteoporosis more than 2.5SD with hx of fx

Bypass complications

-MI: atherosclerosis most likely to be in other parts as well -reocculsion d/t graft failure or stenosis in another area -systemic thrombosis (clot in graft) -hematoma or hemorrhage (blood thinners increase risk) -compartment syndrome (pressure builds in muscles preventing blood flow to nerve and muscles causing death of cells and renal failure as myoglobin is released uncontrollably due to damaged muscle cells -wound infection or graft infection (most serious as it threatens both limb and the life)

Treatment of EVALI

-Oxygen -Stabilize vital signs -bronchoalveolar lavage -severe: steroids, transplants -avg 5-7days

Reducing ICP

-Oxygenate patient (vent) -Manage cerebral edema via MANNITOL (1. expand plasma by reducing HCT and blood viscosity to increase CBF2. Osmotic effect will move blood from tissues to blood vessels lowering the ICP dt less total brain fluid ) *monitor for F/E imbalances* or HYPERTONIC SALINE (to move water out of swollen brain cells and into vessels; need to monitor BP and serum sodium levels) -Reduce metabolic demands (via seizure precautions/prophylaxis, cooling blankets/ice packs, antipyretics, avoid shaking/shivering, control fever, pain and agitation -Barbiturates such as pentobarbital to decrease cerebral metabolism and cause a decrease ICP/cerebral edema

Monitoring ICP

-Ventriculostomy (catheter into brain to drain CSF via closed system) -Position ventriculostomy level with the tragus of the patient's ear -When moving head up or down or changing positions, clamp the ventriculostomy and RELEVEL when the patient is at a new set position

Surgery for Colorectal Cancer

-a) resecting tumor, exploring abdomen for spread, removing lymph nodes, restoring bowel continuity and preventing complications i) Surgical Resection of colon (1) Anastomosis of remaining bowel ii) Colostomy (1) Sigmoid colostomy—most common iii) Polypectomy iv) Determined by stage (1) Stage I: Laparoscopic (especially in L colon) (2) Stage II: Resection & re-anastomosis, chemotherapy (3) Stage III: Surgery & Chemo (a) Radiation and chemo may be done before surgery to shrink tumors (4) Stage IV: Palliative (a) Radiation and Chemo to prevent spread and provide pain relief

Histology classification of tumor (grading severity)

-appearance of cells and degree of differentiation (how closely do they resemble tissue of origin?) 4 grades: (a) Grade I: Cells differ slightly from normal cells (mild dysplasia) and are well differentiated (low grade) (b) Grade II: Cells are more abnormal (moderate dysplasia) and moderately differentiated (intermittent grade) (c) Grade III: Cells are very abnormal and poorly differentiated (d) Grade IV: Cells are immature and primitive and undifferentiated (i) Cell of origin is difficult to determine (e) Grade X: grades cannot be assessed

Hydrocephalus

-associated with myelomeningocele =imbalance between production and absorption of CSF -Treat by shunting via ventroperitoneal shunt that passess sub into peritoneal cavity

What populations are at risk for having airway constriction/inflammation from ground-ozone?

-children -elderly -those with lung disease (asthma) -active outdoor people such as workers or runners -those with vitamin A deficits *Vit A decreases effects of oxidative stress and increases immune system -those with vitamin C & E deficits (make sure they are meeting daily requirements)

LATE signs of increased ICP

-decreased LOC -projectile vomiting -decreased motor response (hemiparesis/hemiplegia) -decerebrate or decorticate posturing -decreased sensory response to painful stimuli -alterations in pupil size and reactivity Cheyne-Stokes respirations

Risk factors for TB

-from a country with a high incidence of TB (not born in US): Asian, Black or African American, and Hispanics/Latino -diabetes -ETOH -HIV -noninjectable drugs -homeless -correctional settings

assessing prostate cancer

-health history, risk factors, urinary elimination patterns, hematuria, and physical assessing for distention, urinary flow, and retention

care management of ADHF

-high fowlers -oxygen -noninvasive positive pressure ventilation (CPAP) -inaortic balloon pump -endotracheal intubation -vital signs, OU q1 until stable, ECG, Pulse ox, intraerial BP, drugs, cardioversion (for a fib) or ultrafiltration

criteria for diagnosis of EVALI

-hx of vapping -CXRAY--> presence of substance denser than air in lungs -absence of lung infection or other diagnosis that can explain symptoms

Signs of increased ICP in infants

-irritability -increasing head circumference OCF -bulging fontanels -widening suture lines -"sunset" eyes -poor feeding -distended scalp veins -high pitched cry

health effects that may present after an exposure to a pollutant

-irritation of eyes/nose/throat -headaches -dizziness -fatigue -N&V -other may present later such as respiratory disease, heart disease and cancer

Managing the Patient with increased ICP

-maintain airway (limit suctioning as it can increase ICP) -elevate HOB to 30 degrees to avoid hip flexion which could increase the intra-abdominal pressure and increase ICP and also avoid neck flexion which could cause venous obstruction and contribute to elevated ICP -preventing vomiting (NG tube) -Nutrition: needs GLUCOSE as increased ICP causes hypermetabolism

Breast Cancer

-malignant tumor that has developed from cells in breast -begins in lobules (milk producing glands) or ducts -can begin in stromal tissues but less common (fatty CT) second most common cancer in women and leading cause of cancer-related death in women

Causes of increased skull volume

-mass, cerebreal edema, need to treat underlying cause via neurosurgery or drugs that will decrease edema (Mannitol or hypertonic saline)

Nursing Assessments related to ICP

-mental status -GCS (eye, verbal and motor) -PERRLA (Doll's eyes that do NOT turn with movement of head--> increased ICP) -cranial nerves -motor strength and response -vital signs

Heart failure general symptoms

-most common symptoms is SOB -weight gain such as 2-5lb in 1-4 days -new or increased LE swelling -abdominal symptoms (nausea, pain, distension) -unexplained cough -functional decline and or lethargy

EVALI (who, sx, and what is it characterized by)

-mostly young men -sx: cough, SOB, chest pain, N&V, AB pain, diarrhea, fever/chills, and weight loss -characterized by pneumonitis (inflammation of lungs) due to wbc or accumulation of oils

What plays a role in the development of breast cancers?

-obesity, overweight, ETOH, sedentary lifetsyle, radiation to chest, poor diet -estrogen/progesterone increases risk by (after D/Cing it returns to baseline within 2 years) -estrogen only increases risk after 10 years of therapy -autosomal dominant *BRCA 1 and 2* and other additional genes

Clinical manifestations of colorectal cancer

-often asymptomatic -pain from bone metastatic is often initial manifestation -urinary manifestations often similar to those of BPH such as urgency, frequency, hesitancy, dysuria, nycturia

care management of chronic HF

-oxygen, drugs, cardiac resynchronization therapy -LVAD -heart transplant -rest-activity periods -dietitians consult -PT or OT consult -cardiac rehab -home health -palliative and end of life care

Prostate Cancer

1) Abnormal growth of prostate tissue a) Curable when diagnosed early b) If confined to prostate at diagnosis: c) 5-year survival rate 100% d) If spread regionally: 5-year survival rate approximately 95 e) Most common in men and second leading cause of cancer death in men f) Pathology and etiology i) Exact etiology unknown, but androgens believed to have role ii) Almost all are adenocarcinomas iii) Develop in peripheral zones of prostate gland iv) May compress urethra v) Metastasis by lymph, venous channels common vi) Most common cancer type vii) Second-leading cause of death among men in North America viii) Primarily a disease of older men (1) Incidence increases with age (2) Majority diagnosed over age 65

Radiation therapy

1) Energy used to damage and kill cancer cells that is delivered to specifically targeted tissue area a) Multiple forms of delivery b) Multiple side effects require symptom management c) Most at risk are patients treated with alkylating agents and high-dose radiation i) May be progressive ii) Generally permanent d) Secondary cancers such as Leukemia, angiosarcoma, skin cancer

Rational vs assisted suicide

1) Rational Suicide: A situation in which a competent adult makes a reasoned decision to die by suicide while he or she is cognitively intact and relatively free from pain. 2) Assisted suicide: individual who has decided to end his or her life does so with the aid of another person. Legal in New Mexico, Oregon, Vermont, Washington

a)Normal ICP

1. Volume in skull made up of brain tissue, blood, cerebrospinal fluid (CSF) 2. Hydrostatic force measured in the brain CSF compartment 3. Volume remains constant

Increased ICP Complications

1. compression of brainstem causes an upset in the process of the hypothalamus/pituitary--> SIADH--> high levels of ADHD in body cause retention of water--> hyponatremia and hypo-osmolity--> LOW URINE OUTPUT, INCREASED BODY WEIGHT, AND SYMPTOMS OF HYPONATREMIA (cramping/pain/weakness) 2. Diabetes insipidus (d/t deficiency of production or secretion of ADH or a decreased renal response to ADH-->INCREASED URINE OUTPUT AND PLASMA OMSOLALITY --> fluid/electrolyte imbalances 3. Herniation (brain tissue forcibly shifts downward due to increased ICP that forces the shift from an area of high pressure to an area of less pressure (spinal column) (spinal column = vaccuum)

Compensatory mechanisms for HF (3)

1. neurohormonal response a) renin-angiotensin-aldosterone system (RAAS) maintains homeostasis to promote sodium/fluid retention to increase BP (but overtime, it actually causes symptoms of HF) b) sympathetic nervous system activated in response to decreased SV/CO--> release of catecholamines--. vasoconstriction--> increased HR (chronotropic) and myocardial contractility (inotropy) *overtime, this increases workload, preload (volume), and oxygen 2. ventricular dilation: heart enlarges to increase volume of blood (Frank-Starling law: increased contraction leads to increase CO and dilation occurs as an adaptive mechanism to cope with increasing blood volume *overtime, elastic elements become overstretched and cannot contract effectively 3. Ventricular hypertrophy: increased muscle mass and wall thickness in response to overwork and strain (occurs slowly for muscles to thicken) *overtime, muscle has poor contractility, requires more oxygen, and has poor coronary circulation, prone to dysrhythmias

Complications of HF (5)

1. pleural effusion d/t excess accumulation in pleural cavity from increasing pressure in pleural capillaries --> dyspnea, cough, chest pain 2. dysrhythmias (d/t enlargement of heart which changes electrical pathways), afib promotes thrombus formation within the atria--> stroke 3. left ventricular thrombus: enlarged LV and decreased CO combine to increase the risk of thrombus formation in LV which can decrease contractility/CO/perfusion --> stroke 4. Hepatomegaly: RF causes liver to become congested with venous blood--> liver cells die--> fibrosis --> cirrhosis 5. renal failure: decreased CO that accompanies chronic HF results in decreased perfusion to the kidneys and can lead to renal insufficiency or failure

TAA incidence and symptoms

6-10/100,000, 20% generic, men and women equally, more common with increasing age sx: depend on the location -compression of adj structures: chest pain, SOB, cough, hoarseness, dysphagia -ascending aorta: aortic regurgitation and HF -superior vena cava: edema of the face, neck and arms

normal EF

50-70% borderline 41-49% reduced <40%

Vaping Facts

500 or 900% increase? e cigs heat liquid and produce an aerosol that you can inhale into lungs

Concussion: features and definition

= complex pathological process affecting brain and influenced by traumatic biochemical forces i) May be caused by direct blow to the head, face, neck, or elsewhere on the body with an "impulsive" force transmitted to head ii) Rapid onset of short lived impairment of neurological function that resolves spontaneously iii) Neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than structural injury iv) Graded set of clinical syndromes that may or may not involve a loss of consciousness v) The clinical signs and symptoms cannot be explained by drug, alcohol, medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction etc.), or other comorbidities (e.g. psychological factors or coexisting medical conditions etc.)

Cerebral Perfusion Pressure

= pressure needed to ensure blood flow to the brain -normal 60-100mmHg -if under 50-ischemia/neuron death -if under 30-ischemia and incompatible with death

Chemotherapy

=1) Pharmacological agents used to prevent cancer cells from multiplying, invading, or metastasizing a) Provides systemic treatment b) Usually administered by nurses who are certified in providing chemotherapy c) Multiple side effects require symptom management d) Preparation and handling of chemotherapy agents i) May pose an occupational hazard ii) Drugs may be absorbed through (1) Skin (2) Inhalation during preparation, transportation, and administration iii) Only properly trained personnel should handle cancer drugs e) Side effects i) Fatigue ii) Alopecia iii) Nausea and vomiting iv) Mucositis v) Skin changes vi) Myelosuppression (neutropenia, anemia, and thrombocytopenia)

Interstitial lung disease

=inflammation or scarring of lungs resulting from long-term exposure to harmful substances or autoimmune disorders symptoms: asymptomatic in early illness, progressively worsening dyspnea on exertion, and persistent cough

Diagnostic tests for ICP

CT, MRI, EEG, CSF assessment or lumbar puncture, ICP monitoring

Diagnosing ADHF vs Chronic HF

ADHF: measurement of LV function, hemodynamic monitoring, endomyocardial biopsy in select patients CHRONIC HF: cardiopulmonary exercise stress test, 6 min walk test, sleep studies in select patients

Risk factors for Prostate Cancer

Age: more common in older men ii) Race: African-American men at highest risk (1) Rates 60% higher than rates in Whites iii) Geography: most common in North America, northwestern Europe, Australia, and on Caribbean islands iv) Genetic and hereditary factors: father or brother, BRCA 1 or BRCA 2, or Lynch Syndrome (hereditary non, polyp colorectal cancer) v) Environment: firefighters and agent orange vi) Dietary factors (1) High in animal fat (red) (2) High fat dairy (3) Low vegetables and fruits

MAP

BP at which vital organs are perfused; calculated using SBP and DBP (normal 70-110) if below 68, blood shunts to brain and kidneys and if below 65, blood hunts to heart

Respect for autonomy in ethics

Based on human dignity and respect for individuals, autonomy requires that individuals be permitted to choose those actions and goals that fulfill their life plans unless those choices result in harm to another.

DMARDs in treatment of RA

Because irreversible joint changes can occur as early as the first year of RA, HCPs aggressively prescribe disease-modifying antirheumatic drugs (DMARDs). These drugs may slow disease progression and decrease risk of joint erosion and deformity. The choice of drug is based on disease activity; the patient's functional level; and lifestyle considerations, such as the wish to become pregnant.

What is biomonitoring

CDC testing of human fluids and tissues for presence of toxic chemicals -found in tissues and umbilical cord

What act regulates the air pollution from point and non-point sources?

Clean Air Act

Distributive justice

Distributive justice requires that there be a fair distribution of the benefits and burdens in society based on the needs and contributions of its members. This principle requires that, consistent with the dignity and worth of its members and within the limits imposed by its resources, a society must determine a minimal level of goods and services to be available to its members.

Diagnostics and symptoms of aortic dissection

Diagnostic: HH, PE, ECG to rule out MI, TEE (transesophageal echocardiogram), CT scan *gold standard* Symptoms: -tearing chest or back pain (most common) -N&V, diaphoresis, tachycardia, tachypnea, dyspnea, dizziness, neuro changes

Nonmaleficence

Do no harm. It is impossible to avoid harm entirely, but this principle requires that we act according to standards of due care, always seeking to produce the least amount of harm possible.

early HF symptoms (FACES)

Fatigue, Activity limitation, Congestion/Cough, Edema, SOB

diagnostics of PAD

Health history, PE, Ankle-brachial index (greater than 1.4 noncompressible, 1-1.40 normal, .91-.99 borderline, .9 or less abnormal Doppler studies and angiogram

What enhances the reaction that produces ground ozone?

Hot sunny days create more ground-level ozone and can be spread during windy days

Monro-Kellie

If volume of any of these changes, another component will need to compensate to avoid increased ICP--> Brain tissue: Distend dura or compress; Blood: Vasoconstriction or vasodilation; CSF: Absorption, production, or displacement into subarachnoid space

progress of PAD if left untreated

LE claudication, progresses to pain with rest, tissue necrosis/gangrene, dependent rubor or pallor on elevation of affected extremity,, loss of pulse with cold to the touch extremity (critical limb ischemia)

Types of HF

LEFT SIDED HF: most common, results from either inability of LV to empty during systole OR inability to fill during diastole *left sided can be classified as systolic, diastolic, or mixed 1. systolic failure (HFrEF): results from an inability of the heart to pump blood (decreased EF less than 45%) which causes the LV to become dilated and hypertrophied--> low SV and CO which cause increase in end diastolic volumes and pressures--> pulmonary congestion and edema as it backs up into lungs 2. diastolic failure (HFpEF): inability of ventricles to relax and fill during diastole due to stiff ventricles (d/t HTN)--> decreased filling ventricles/SV/CO--> pulmonary congestion 3. MIXED: seen in dilated cardiomyopathy (DCM) where poor systolic function is further compromised by a dilated LV that is unable to relax--> poor EF <35%, high pulmonary pressures, biventricular failure (both ventricles are dilated and have poor filling and emptying capacity RIGHT SIDED: when RV fails to pump effectively, fluid backs up into venous system causing peripheral edema, ab ascites, hepatomegaly, JVD -most common cause is Left sided HF

left sided vs right sided heart failure clinical manifestations

LEFT: -fatigue, activity intolerance, dizziness, syncope, dyspnea, orthopnea, cyanosis, crackles, wheezes, S3 gallop RIGHT: -edema in feet/legs/sacrum, anorexia, nausea, RUQ pain, distended neck veins (JVD)

crepitus indicates...

OA

fatigue, fever, organ involvement are NOT present

OA

main differences between OA and RA

OA: a) Slow progressing b) Noninflammatory c) Impacts synovial joints d) 27 million affected and rising e) Gradual loss of articular cartilage with formation of bony outgrowths f) NOT a normal part of aging process but age is a risk factor g) Cartilage Destruction begins: 20-30yrs, majority before age 40. h) Symptoms start: 50-60yrs i) Women more than men RA: a) Chronic & Systemic b) Exact Cause: Unknown c) Autoimmune disease (widely accepted theory) d) Inflammation of connective tissue e) Impacts synovial joints f) Periods of remission and exacerbation g) Peak: age 30-50yrs h) Affects women at a rate of three times more than men

What are the changes in the ozone and how does that affect us?

Ozone is made of 3 O2 atoms and man-made chemicals create holes in the ozone later--> letting down harmful UV rays Ground ozone is created not released from chemical reactions between oxides of nitrogen and volatile organic chemicals --> muscles in the airway constrict --> inflammation and constriction traps alveoli causing SOB, asthma, emphysema, chronic bronchitis, coughing, sore/scratchy throat, wheezing, increased infection, COPS, damage to lungs

Types of osteoporosis

Primary (Type I): Occurs in women between the age of 51-75, related to estrogen deficiency seen with menopause Secondary (Type II): Often the result of underlying disease such as osteomalacia, hyperthyroidism, hyperparathyroidism, multiple myeloma, men i) Occurs in persons older than 60 years & affects both men (hypogonadism) and women ii) Medications: glucocorticoids, phenytoin and alproic acid (anticonvulsants), thyroid hormones à honeycomb structure

initiation vs promotion

Promoters are REVERSIBLE (and are dietary fat, obesity, smoking, ETOH, etc that act against body tissues) some carcinogens such as smoking can both initiate and promote cancer

anorexia, weight loss and anemia seen in this type of chronic inflammation

RA

exacerbations occur with physical and emotional stress

RA

Replication vs Proliferation vs differentiation

Replication: activated when cells degenerate or die Proliferation: reproduction of new cells through cell growth and cell division Differentiation: acquisition of a specific cell function, a normal process by which a less specialized cell becomes a more specialized cell type

Consequentialism

The decision is based on outcomes or consequences. The right action is the one that produces greatest amount of good or least amount of harm in a given situation.

Egalitarianism

The view that everyone is entitled to equal rights and equal treatment in society

Staging breast cancer

Tumor size, Nodal involvement, and Metastasis

Who regulates the air, water and soil pollutants and pesticides?

US EPA

Utilitarianism

a well-known consequentialist theory that appeals exclusively to outcomes or consequences in determining which choice to make.

Individual Risk Factors for Cancer

a) Age: not modifiable, 78% of new cancer diagnoses occur among those ages 55 years or older. b) Smoking/tobacco: at 30% of all cancer-related deaths and 87% of all lung cancer deaths can be attributed to smoking. c) Poor nutrition d) Excess weight e) Sedentary lifestyle f) Radiation: ionizing radiation includes medical radiation from tests used to both diagnose and treat (increased leukemia, breast and thyroid) also radon gas-lung cancer risks, ultraviolet radiation from the sun-skin cancers. g) Exposure to environmental carcinogens such as sunlight; pollutants in the air, soil, water, or food; or medical treatments such as medications or radiation h) Genetics: Only 5% of all cancers result from an inherited genetic alteration that is associated with an increased risk of developing certain types of cancer. i) Infectious agents-hep b, hep c, hpv h.pylori j) Carcinogens-pollutants in the air, water, soil food, asbestos, dioxin,

Indoor air pollutants (what are they and where are they found)

a) Asbestos: insulation, fireproofing, and other building materials. It has also been used in heat-resistant coverings, fabrics, and gloves, and friction products such as automobile brakes. particles can be released by the breakdown or demolition of building materials; they can be released by mining and shipbuilding. b) Formaldehyde: colorless, flammable; released into the air by burning fossil fuels such as wood, kerosene, or natural gas; from vehicle exhaust; and from smoking tobacco products. c) Radon: a radioactive, extremely toxic gas that is formed naturally from the decay of uranium or thorium in rocks and soil d) Secondhand smoke e) Lead f) PCBs: composed of over 200 chlorinated compounds. Production stopped in 1977; surface coatings, inks, adhesives, pesticides, old incinerators g) VOCs: VOCs are released from burning fuel such as gasoline, wood, coal, or natural gas. They are also released from many consumer products: h) Cigarettes, Solvents, Paints and thinners, Adhesives, Hobby and craft supplies, Dry cleaning fluids, Glues, Wood preservatives, Cleaners and disinfectants, Moth repellants, Air fresheners, Building materials and furnishings, Copy machines and printers i) Pesticides- When VOCs combine with nitrogen oxides in the air, they form smog. j) Carbon Monoxide: stoves, fireplaces k) Other: Bacteria, molds, and pollen, Building materials and furniture, Household products

signs of imminent death

a) Bodily functions slow down b) Nurses need to identify and recognize approach of death symptoms to keep family informed c) Determine if clergy is desired by the patient and/or family d) Manifestations: Decline in BP, Rapid, weak pulse, dyspnea and periods of apnea, slower or no pupil response to light, profuse perspiration, cold extremeties, bladder and bowel incompetence, pallor and mottling of skin, loss of hearing and vision.

Immunologic Survellience

a) Cancer cells display altered cell-surface antigens b) Antigens called tumor-associated antigens (TAAs) are regulated by the immune system using immunologic surveillance where the lymphocytes continuously check cell-surface antigens and detect and destroy cells with abnormal or altered antigenic determinants c) Involves cytotoxic T cells play a role in resisting tumor growth by killing tumor AND produce cytokines that stimulate T/NKB/macrophages), natural killer cells (NK; can directly lyse tumor cells without any prior sensitization; stimulated by y-interferon and Il-2à increased cytotoxic activity), macrophages, and B cells Monocytes and macrophages

Seven warning signs of cancer

a) Change in bowel or bladder habits b) A sore that does not heal c) Unusual bleeding or discharge from any body orifice d) Thickening or a lump in the breast or elsewhere e) Indigestion or difficulty in swallowing f) Obvious change in a wart or mole g) Nagging cough or hoarseness

Ethical Theories (4)

a) Ethics of Duty: Is the right thing to do. b) Ethics of Consequence: Is the greatest good for the greatest number. c) Ethics of Character: Is based on life experiences and a willingness to reflect on our actions. d) Ethics of Relationship: Is the nature and obligation inherent in human relationships. Nurses must have integrity, respect, courage and above all, advocate for the patient

How is EVALI similar to lipoid pneumonia?

a) Exogenous lipoid pneumonia is a rare disease caused by aspiration or inhalation of oily substances b) Non-infectious c) Lung assessment: fine crackles (small airways) d) Vitals: Increased RR & Decreased Pulse Ox

definitions of death

a) Final termination of life b) Cessation of all vital functions c) Act or fact of dying d) Brain death: determined by EEG e) Somatic death: determined by the absence of cardiac and pulmonary functions f) Molecular death: determined by cessation of cellular function

1) Cancer Public Health Concern (population statistics)

a) Higher in men than women b) Second most common cause of death in United States after heart disease c) Leading cause of death in people 40-79 years of age e) Annually about 589,400 Americans are expected to die as a result of cancer, which is more than 1600 people per day. f) If you refer to the chart in your Stanhope and Lancaster pg. 679 deaths caused by cancers. African American's have higher rates than Whites, Hispanics, Native Americans and Asian..

2 factors that affect the ethical-decision-making framework

a) Identify ethical issues and dilemmas b) Find meaningful context c) Obtain all relevant facts d) Reformulate, if needed e) Consider appropriate options f) Decide and take action g) Evaluate decision and action

ethical decision-making framwork

a) Identify ethical issues and dilemmas b) Find meaningful context c) Obtain all relevant facts d) Reformulate, if needed e) Consider appropriate options f) Decide and take action g) Evaluate decision and action

risk factors for osteoporosis

a) Increased age, Family history, Low weight and BMI, Late menarche, early menopause, and low endogenous estrogen levels b) lifestyle factors such as smoking, lack of weight-bearing exercise, ETOG, nutrition c) ethnicity (asians/NA/hispanic/white men/AA women and AA men d) history: older age, women, fam history, dietary intake, activity level, certain medications and age at mesopause (if having menopause before 45 increases risk)

advance directives

a) Legal document that allows patients to express their desires regarding terminal care and life-sustaining measures b) Nurses need to determine if patients have advance directives, review the patients wishes, and place the document in the medical record

nutritional therapy r/t HF

a) Low-sodium diet to control edema i) Sodium Restriction (about 2 grams/day) *avg American is 7-15g ii) DASH diet (Dietary Approaches to Stop Hypertension) iii) On this diet, processed meats, cheese, bread, cereals, canned soups, and canned vegetables must be limited. b) Weight management

arthritis

a) Not well understood b) More than 100 different types of arthritis c) Affects all ages, sexes and races (over 50 mil adults and 300K children) d) Most common among women e) Occurs more frequently as people get older f) Common S/S: swelling, pain, stiffness, decreased ROM g) Symptoms may come and go h) Symptoms may be mild, moderate or severe i) Some joint changes can be visible, such as knobby fingers j) May even impact heart, eyes, lungs, kidneys and skin

What are the EPA's 6 pollutants that are tightly regulated?

a) Ozone: ground level ozone can be harmful instead of protective like the ozone in the stratosphere that protects us from UV rays from the sun b) Sulfur Dioxide: can come from industries that process materials that contain sulfur, industries that burn fossil fuels like coal or from motor vehicle exhaust c) Nitrogen Dioxide: comes from burning fossil fuels at high temperatures (coal, oil, gas or diesel) d) Particulate matter: particles suspended in the air. They may be large or small. Eg. Dust, pollen, soot, smoke or liquid droplets e) Carbon monoxide: colorless, odorless, tasteless gas produced by burning fossil fuels. If it accumulates to high levels, it can cause sudden illness or deat f) Lead: emissions into the air come from ore or metal processing or piston engines in aircrafts. Lead smelters are the biggest contributor (lead production plant)

prevention, screening in cancer

a) Primary prevention i) Healthy diet ii) Regular physical activity iii) Smoking cessation iv) Avoidance of excessive exposure to sunlight v) Prophylactic surgery b) Screening i) Mammogram ii) Prostate-specific antigen iii) Colonoscopy iv) Guaiac test for occult blood

late chemotherapy and radiation therapy effects

a) Radiation therapy: Late radiation effects occur most commonly in post-mitotic cells (e.g., liver, kidney, lung, heart, muscle, bone, and connective tissues). i) Examples range from telangiectasias to strictures, fistulas, or radiation necrosis. alteration of the lymphatic channels (e.g., axillary lymph node dissection) may contribute to lymphedema. b) Chemotherapy: Cardiac toxicity, cataracts, arthralgias, endocrine alterations, renal insufficiency, hepatitis, osteoporosis, neurocognitive dysfunction, or other effects depending on the agents. c) The additive effects of multiagent chemotherapy before, during, or after a course of radiation therapy can significantly increase the resulting late effects. d) The potential risk for developing a secondary cancer does not contraindicate the use of cancer treatment.

TB vaccine: BCG: Bacille Calmette-Guérin (BCG)

a) Recommended in countries or settings with a high incidence of TB b) 1 dose administered to healthy neonates at birth (in countries with higher prevalence) c) Recommended to school children coming from or moving to high incidence settings d) Not recommended during pregnancy or immunocompromised f) May cause a false (+) TST

Concussion Dilemma

a) The "invisible" injury b) Concussions are more common and more serious than c) previously recognized d) Media contributions i) High level athletes sustain concussions but play through ii) CTE headlines e) Youth are assumedly more at risk for adverse outcomes than older athletes given their vulnerable/developing brains

common HF meds

a) Vasodilators b) ACE inhibitor (Angiotensin-converting enzyme) c) Angiotensin II receptor blockers d) Beta blockers e) Diuretics f) Digitalis g) Antidysrhythmic drugs

Diagnostic tests for colorectal cancer

a) sigmoidoscopy, colonoscopy (gold standard because the entire colon is examined and biopsies can be obtained, polyps can be removed) i) Colonoscopy Q 10 yrs beginning at age 50 ii) Radiological examinations to detect metastases iii) Chest x-ray, CT, MRI, ultrasound (detecting metastases, retroperitoneal and pelvic disease, depth of tumor into bowel wall) iv) Laboratory tests (1) Fecal occult blood (2) CBC (anemia?) (3) CEA level : used only post surgery or post chemo, not a good screening tool d/t false positives

Libertarian

a) view of justice holds that the right to private property is the most important right.

Progression of increased ICP

body tries to compensate--> fails --> symptoms of increased ICP fails--> Cushings Triad where increased SBP with widening PP (by increase SBP and decreasing DBP), bradycardia, altered repirations

swelling and limited ROM can indicate

both OA and RA

marked by progressive deterioration of articular cartilage

both RA and OA

What are the two major contributors to air pollution?

burning of fossil fuel and waster incineration

Colorectal cancer

cancer of 3rd segment of large bowel (can be anus or not) -a) Colorectal cancer: Involves both colon and rectum b) Reduce risk with regular colonoscopies and Removal of polyps before become malignant tumors

post-operative care and complications related to amputations

care: assess VS, incision, PCA, narcotics/gabapentin, anti-platelets, statins, BP meds, diabetic management, antibiotics, AGRESSIVE PT, LOS 3-7 days, DC rehab, SNF or outpatient PT, care of stump, psych support COMPLICATIONS: -MI or CHF due to underlying disease -wound issues such as delayed healing, dehiscence, hematoma, infection -ileus: d/t extensive surgery and narcotics -phantom limb (sensation of amputated part; pain due to severed nerve--> mirror therapy) -limb contractures (wont straighten) -VTE or PE due to poor mobility

Endovascular aneurysm aneurysm repair

catheter inserted into femoral artery, stent graft released from catheter -postoperative care: assessing VS, pulse, groin/incision checks, I&O -tight monitoring of arterial-line BP control, foley, imaging follow up (1 and 6 months then annually) LOS: 2-3 nights

PAD causes incidences and risks

cause: atherosclerosis incidence: 10million people (>65yrs) greatest risk: AA males and smokers general risk: diabetes & smoking (highest risk of infection), HTN, high cholesterol, ischemic heart disease, stroke, metabolic syndrome

Tuberculosis

caused by mycobacterium TB -airborne transmission, but the number/concentration of organisms, length of exposure, and immune system of exposed person depends on infection -symptoms: Cough lasting 3+ weeks, coughing up blood or sputum, chest pain, weakness/fatigue, poor appetite, chills, fever, night sweats, weight loss

symptoms of PAD

claudication (pain with activity), weak/absent LE pulses, non healing LE wounds, pale/blue skin, cold on one side of extremity, poor nail or hair growth on LE, erectile dysfunction

procedures for amputation

closed incision through healthy tissue and skin flaps closed and sutured together open incision used for severe trauma or infection, allows for drainage and observation of the wound (then close wound once it is stable)

Beneficence

complementary to nonmaleficence and requires that we do good. We are limited by time, place, and talents in the amount of good we can do. We have general obligations to perform those actions that maintain or enhance the dignity of other persons whenever those actions do not place an undue burden on health care providers.

Pathophysiology of Concussions

complex cascade of ionic and metabolic events: i) Microscopic diffuse axonal injury: stretching and tearing of brain cells à vasoconstriction ii) Requires energy to re-establish homeostasis iii) Increase need for energy in the presence of decreased cerebral blood flow

complications of aneurysm if left untreated

death -rupture (back pain) -thrombosis (acute ischemia of all downstream branches)

alternate antiresorptive meds

denosumab (AQ 60 mg every 6month) decreases vertebral and nonvertebral fx, but requires high cost and injections -it also can cause osteonecrosis of jaw, atypical femoral fx, rebound vertebral fx, when DC and hypocalcemia raloxifene (60mg per day) decreases vertebral fx and breast cancer risk, but has no reduction in hip fxs also can cause VTE

Prevention of Colorectal Cancer

for average risk patients: start exams at age 45 until 75 high risk patients (personal, family, or confirmed cancer syndrome or hx of radiation to belly) -depends on risk factors and provider, yearly fecal occult blood test, weight, physical exercise, diet of large fruits/veggies/grains

Personalized cancer medicine

genetic info used in prevention, diagnosis, and treatment diagnostic studies such as tumor markers, genetic markers, and molecular receptor status are helpful in determining treatment options -By performing more genetic tests and analysis, treatments can now be personalized NOT all cancers have personalized treatment options

obstacles to using oral bisphosphonates

gi intolerance (so consider IV zoledronate), impaired kidney function (dc if Ccl<30-35mL/min), poor adherence (consider zolendronate), and risk of serious harm (limit treatment to less than 5years and consider drug holidays)

AAA risk/incidence

greatest risk: men: Caucasian men over 60, smokers, and first generation relative incidence: 200,000 new cases each year, tenth leading cause of death in the US -screen yearly if under 4cm or every 4 months if over 4cm (surgery at 5.5cm)

Diagnosing aneurysm

health history, physical exam, ultrasound, CT, MRI, echocardiogram, angiography

leading cause of death in the US

heart disease most common reason for hospital admission for those over 65years old annual cost of 40 billion dollars

heart failure definition

heart is unable to pump enough blood to meet demand which causes intravascular and interstitial volume overload and poor tissue perfusion -caused by a deficient in either ventricular filling (diastolic function)*preserved EF* or ventricular ejection (systolic function) *reduced EF*

pathophysiology of heart failure

heart tries to compensate by enlarging (heart stretches), developing more muscle mass (cells get bigger), pumping faster -BVs also narrow to keep BP up -body diverts blood away from less important organs -usually affects left side of heart first -these compensatory mechanisms mask HF until these fail

post-operative complications of EVAR

hemorrhage, stroke (thrombosis migration), spinal cord ischemia (thrombosis migration), infection (groin incision), renal failure (contrast dye), endo-leak (not a tight enough)

OA pathophys

i) "Wear and Tear" disease ii) Gradual loss of articular cartilage with formation of bony outgrowths (osteophytes) iii) Affects: (1) Bone (osteophytes) (2) Connective Tissues (deterioration) (3) Joint Lining (inflammation) all influenced by genetic, metabolic, and local interact that cause cartilage deterioration

Incidence of concussions

i) 1.7 to 3.8 million concussions occur in the United States annually. ii) Approximately 640,000 children and adolescents visit United States emergency departments (EDs) for concussion annually iii) Overall, 70% of concussions are sports related, but varies by age: iv) • 18% for age 0-4 v) • 67% for age 5-11 vi) • 77% for age 12-14 vii) • 73% for age 15-17 viii) Non-sport concussion mechanisms of injury: falls, MVAs, work- related injuries, abuse/maltreatment & assault

Symptoms of a Concussion

i) 20-30% remain symptomatic for a month or more ii) Physical: headache, nausea, vomiting, balance problems, dizziness, visual problems, fatigue, sensitivity to light, sensitivity to noise, dazed or stunned iii) Cognitive: feeling mentally foggy, feeling slowed down, difficulty concentrating, difficulty remembering, forgetful of recent information, confused about recent events, answers questions slowly, repeats questions iv) Emotional: irritability, sadness, more emotional, nervousness v) Sleep: drowsiness, sleeping more than usual, sleeping less than usual, trouble falling asleep

Genetics in breast cancer

i) 5-10% due to inherited abnormality from mom or dad ii) 85-90% genetic abnormalities from aging process & "wear and tear" of life iii) Family history is important, especially if involved family member has also had ovarian cancer, was diagnosed prior to menopause or had bilateral breast involvement, or is a first-degree relative (mother, father, sister, brother, daughter) iv) Refer patient for genetic counseling if they are at risk v) First degree relative with breast cancer increases a woman's risk of breast cancer 1.5-3x vi) Incidence (1) Approximately 5% to 10% of breast cancers are related to BRCA1 and BRCA2 gene mutations. (2) • Women with BRCA1 and BRCA2 gene mutations have a 40% to 80% lifetime risk of developing breast cancer. (3) • BRCA1 and BRCA2 gene mutations are associated with early-onset breast cancer that is more likely to involve both breasts. (4) • Men with mutations in BRCA1 and BRCA2 have an increased risk of breast cancer and prostate cancer. (5) • Family history of both breast and ovarian cancer increases the risk of having a BRCA mutation.

risk factors for breast cancer

i) Age and gender (women 99%; >50yrs majority and increases in incidence around 60yrs) iii) 1st degree relative iv) Personal history of colon cancer, endometrial cancer, ovarian cancer. Personal history significantly increases risk of breast cancer, risk of cancer in other breast, and recurrence. v) Menstrual history: early menarche (before 12yrs), late menopause (after 55) increases ris vi) Full term pregnancy after age 30, nullparity (prolonged exposure to unopposed estrogen) vii) Atypical epithelial hyperplasia of breast tissue: biopsy U Hyperplasia is an abnormal overgrowth of cells but rarely presents with a "lump". increases risk 4-5x. It is usually seen on imaging and diagnosed via biopsy. viii) Breast Density: more connective tissue than fatty tissue, which can sometimes make it hard to see tumors on a mammogram ix) Weight gain & obesity after menopause: fat cells store estrogen which increase the likelihood of developing breast cancer x) Radiation (damages DNA) xi) Alcohol consumption

Drug therapy for for advanced/metastatic prostate cancer

i) Androgen Deprivation (hormone) therapy (ADT) (1) Prostate cancer growth is largely dependent on presence of androgens (2) Tumors become resistant within a few years so watch PSA levels (3) Risk for cardiovascular side effects, osteoporosis & fractures (meds may be prescribed to decrease bone mineral loss (Reclast, Evista) (4) Medications will either inhibit synthesis or block the androgen receptors ii) Chemotherapy (1) Reserved for when the cancer progresses despite other treatments (2) Goal: Palliative care iii) Combination (ADT & Chemo) iv) Radium - 223: reserved for bone metastases (1) dichloride (Xofigo) In most men with metastatic castration-resistant prostate cancer—prostate cancer that no longer responds to hormone therapy—the cancer spreads (metastasizes) to the bones. Bone metastases can cause intense pain, weakness, and bone fractures, greatly impairing quality of life—and in some cases causing death. (2) Several drugs have been approved by the Food and Drug Administration (FDA) to prevent pain and fractures in patients with bone metastases, but none of these drugs improves the survival of men with prostate cancer. v) Orchiectomy (1) Surgical removal of testes *gold standard for androgen deprivation* as there are no side effects to be managed (2) Low cost, rapid relief of bone pain from metastases (3) Usually shrinks prostate and relives urinary obstructions seen in later stages (4) Side Effects: weight gain and loss of muscle mass, depression dt physical changes (5) Performed rarely because it cannot be reversed

Latent TB (LTBI)

i) Asymptomatic ii) + skin or blood test iii) Normal CXR iv) Negative sputum tests v) Not contagious vi) Treatment: (shorter therapies increased adherence) (1) Isoniazid (INH) (2) Rifampin (RIF) (3) Isoniazid (INH) + Rifapentine (RPT) (4) Isoniazid (INH) + Rifampin (RIF)

Prevalence of arthritis

i) By 2040, an estimated 78 million (26%) US adults aged 18 years or older are projected to have doctor-diagnosed arthritis. ii) Prevalence by Race and Ethnicity iii) 4.4 million Hispanic adults ever reported doctor-diagnosed arthritis. iv) 41.3 million Non-Hispanic whites ever reported doctor-diagnosed arthritis. v) 6.1 million Non-Hispanic blacks ever reported doctor-diagnosed arthritis. vi) 1.5 million Non-Hispanic Asians ever reported doctor-diagnosed arthritis

Blood tests for EVALI

i) CBC (look for infection) ii) liver enzymes (damage and inflammation) iii) inflammatory markers (e.g., erythrocyte sedimentation rate (H- fall quicker, inflame makes RBCs stick together) iv) C-reactive protein (H- with inflammation).

prevalence and risk factors of RA

i) Can occur at any time of life; incidence increases with age, peaking at 30-50yrs ii) 1.5 million adult American are affected by RA. iii) Women 3x more than men iv) Affects all ethnic groups v) More common in whites and African Americans that Hispanics. vi) Activity limitations associated with arthritis are more common in Hispanics and African Americans. vii) Genetic Factors in combo with smoking = increased risk

post-operative complications of open aneurysm repair

i) Cardiac (prevalence of CAD in Vascular pts) (1) MI-most common is prevalent in vascular patients; patients can have cardiac stress due to hemodynamic changes with aortic cross-clamping and de-clamping. (2) CHF: Due to prevalence of CAD; surgical blood loss worsens morbidity. (3) Arrhythmias: related to an underlying cause such as hypoxemia, MI, or electrolyte imbalance. ii) Pulmonary (1) Atelectasis: Due to decreased lung function or incisional pain. The goal is to re-inflate the alveoli to assist in oxygenation and prevent pneumonia. iii) GI/GU (1) Renal failure: Multiple causes from surgery-suprarenal occlusion can decrease renal blood flow by 80%, the blockages can result in renal hypoperfusion. Ureteric injury can occur during dissection and arterial repair and passage of the aortic graft can cause compression of iliac artery (2) Ischemic colitis/perforation: occurs in the first 24-28 hours post-op. Ischemia and colonic perforation=multi-system organ failure. Most often caused by inadequate blood supply to the sigmoid colon and rectum from marginal collateral mesenteric flow. (3) Prolonged Ileus: due to bowel manipulation and fluid sequestration. (4) Aortoenteric fistula: Due to erosion of graft into small bowel, most often involves duodenum. iv) Graft occlusion & LE ischemia: Due to embolization from manipulation of the aorta, an occluded graft, or hypoperfusion. v) Compartment syndrome: Prolonged ischemia from acute occlusion or clamp time. Pressure in the muscle builds to dangerous levels, preventing blood flow to nerve and muscle cells and causing damage. Can cause permanent disability if not corrected vi) Hemorrhage: most common are residual anticoagulants, leakage from suture lines, retroperitoneal bleed. vii) Graft infection: Risk is greatest at implantation. Caused by skin flora, GI tract flora, infected lymph, bacteria plaque of diseased vessel viii) Incision infection ix) Paraplegia: most concerned with TAA repairs. Risk is 10x higher after an emergent repair. Due to hypoperfusion and reperfusion injury-results from prolonged aorta clamp

Pharmacologic therapy

i) Chemotherapy: 5-FU and folinic acid used postoperatively for colorectal cancer (1) Often combined with radiation therapy ii) Radiation: Not primary treatment (used to reduce tumor and relieve symptoms) (1) Goal: shrink tumor size, pain relief (2) Chemotherapy + Radiation (3) Palliative for Metastatic Cancer (4) Preoperatively or postoperatively

Drug therapy in Breast Cancer Treatment

i) Chemotherapy: use of cytotoxic drugs to destroy cancer cells. (1) A combination of drugs is usually superior to the use of a single drug. Combination treatment is beneficial because the drugs have different mechanisms of action and work at different parts of the cell cycle. (2) Before and after surgery, chemotherapy is usually given for 3 to 6 months. (3) However, when a patient has metastasis, chemotherapy may be given for the rest of the patient's life. ii) iii) Trastuzumab (Herceptin) (1) Immunotherapy - targets cells and alters gene expression (kills from inside): use of cytotoxic drugs to destroy cancer cells. (1) A combination of drugs is usually superior to the use of a single drug. Combination treatment is beneficial because the drugs have different mechanisms of action and work at different parts of the cell cycle. (2) Before and after surgery, chemotherapy is usually given for 3 to 6 months. (3) However, when a patient has metastasis, chemotherapy may be given for the rest of the patient's life. ii) Tamoxifen citrate or toremifene (Fareston), and fulvestrant (Faslodex) (Oral)à Interferes with estrogen activity (1) Estrogen receptor blocker (2) Tamoifen= choice therapy in ER-positive patients with all stages of breast cancer (also used in high risk premenopausal and postmenopausal women to prevent breast cancer) iii)

Key points in managing a concussion during the acute phase

i) Child/adolescent-validated assessment and symptom scales should be used ii) The expected duration of symptoms is < 4 weeks iii) Prolonged recovery is defined as > 4 weeks iv) A brief period of cognitive and physical rest should be followed v) Individualized approach vi) Early sub-threshold exercise is associated with improved recovery patterns and outcomes vii) A graduated return to learn and return to physical activity plan is crucial viii) All schools should be encouraged to have a concussion policy and should offer appropriate academic support. ix) Children and adolescents should not return to sport until they have successfully returned to school. Early introduction of symptom-limited physical activity is appropriate and encouraged x) Partnership with multi-disciplinary team xi) Management should be individualized xii) Symptom-limited aerobic exercise xiii) A targeted PT program in patients with cervical spine or vestibular dysfunction should be considered xiv) A collaborative approach, including cognitive behavior therapy, to assist with any undiagnosed or new onset/persistent mood or behavioral issues should be considered

RA pathophys

i) Chronic, systemic autoimmune disease ii) Inflammation of connective tissue in synovial joints iii) Marked by periods of remission and exacerbation iv) Cause: Unknown (1) Autoimmune, genetics, environment v) Antigen -> triggers formation of IgG ->autoantibodies form = rheumatoid factor (RF). RF combines with IgG to form immune complexes & deposit on synovial membranes ->activates inflammation. Neutrophils are attracted -> they release enzymes that damage cartilage and thicken synovial lining. vi) The exact cause of RA is unknown. However, it probably results from a combination of genetics and environmental triggers. An autoimmune etiology is currently the most widely accepted theory, suggesting changes of RA begin when a genetically susceptible person has an initial immune response to an antigen. Although a bacterium or virus has been proposed as a possible antigen, no infection or organism has been identified to date. Starts with an antigen (probably not the same in all patients) à triggers formation of an abnormal immunoglobulin G (IgG). RA is marked by autoantibodies to this abnormal IgG. The autoantibodies are known as rheumatoid factor (RF). They combine with IgG to form immune complexes and deposit on synovial membranes à activates inflammation. Neutrophils are attracted and they then release enzymes that damage the cartilage and thicken the synovial lining. vii) Other inflammatory cells include T helper (CD4) cells, which stimulate cell-mediated immune responses. Activated CD4 cells cause monocytes, macrophages, and synovial fibroblasts to secrete the proinflammatory cytokines interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor (TNF). These cytokines drive the inflammatory response in RA.

Diagnostic tests for Colorectal cancer

i) DRE reveals nodular, fixed prostate gland (1) Abnormal prostate may feel hard, nodular, and asymmetric ii) PSA used to diagnose, stage, monitor, usually 55-69yrs (1) Most men are diagnosed by elevated levels of PSA (glycoprotein produced by the prostate above 4ng/mL) (2) Many men will live and die with prostate cancer, but will not die from it iii) An elevated level of prostatic isoenzyme of serum acid phosphatase (prostatic acid phosphatase [PAP]) is another indicator of prostate cancer, especially if the cancer has spread outside of the prostate. With advanced prostate cancer, serum alkaline phosphatase is increased as a result of bone metastasis. iv) Transrectal ultrasonography v) Urinalysis vi) Cytoscopy vii) Bone scan, MRI, CT Grade and stage determine prognosis

Clinical manifestations of colorectal cancer

i) Slow growing ii) Rectal bleeding may be initial manifestation iii) Early manifestationsà Change in bowel habits iv) Late manifestationsà Pain, Anorexia, weight loss v) Right Side (1) Early: anemia (bleeding) (2) Diarrhea vi) Left Side (1) Hematochezia -fresh blood in stool (2) Bowel obstruction dt late tumor detection

OA risk factors

i) Decreased estrogen at menopause ii) Obesity (hip & knee OA): increased weightà increased weight-bearing joints (1) fat tissue produces proteins that can cause harmful inflammation in and around joints iii) Quick stops & pivoting (eg. Football or soccer) iv) Frequent kneeling and stooping (carpenter, plumber, PT) repeated stress v) Older Age vi) Genetics - cartilage defects b) Gender Differences i) Men: overall, men experience less incidence of OA, Hip OA is more common in men (1) Except for traumatic arthritis, men do not experience OA as often as women until age 70 or 80 years ii) Women: Hand and Knee OA more common in women, especially after menopause (1) Hand OA (interphalangeal joints and thumb base) is more common in women than in men. (2) • Knee OA is more common in women than in men, especially after menopause, and is likely to be more severe

Types of Arthritis

i) Degenerative Arthritis (1) "wear & tear" disease; causes pain, swelling and stiffness (2) Example: Osteoarthritis (most common type: when cartilage on the ends of bones wears away and rubs against bones à pain, swelling, stiffness) ii) Inflammatory Arthritis (1) Immune system attacks joints; uncontrolled inflammation (2) Example: Rheumatoid arthritis or psoriatic arthritis iii) Infectious Arthritis (1) Bacteria, virus or fungus can enter joint and trigger inflammation (2) Example: salmonella + shigella (food poisoning), chlamydia, gonorrhea, Hep C (blood:blood) iv) Metabolic Arthritis (1) Uric acid forms as body breaks down purines; crystals form and cause severe pain (2) Some people have high levels of uric acid because they naturally produce more than is needed or the body cant get rid of the uric acid quickly enough, so it builds up and forms needle like crystals in the joint à sudden spikes of extreme pain known as gout attack (3) Example: Gout

Stages of Death (and nursing interventions)

i) Denial: First stage (1) Initial awareness of impending death& deny the reality of the situation (5) Nursing care and interventions: to accept the individual's reactions and to provide an open door for honest dialogue ii) Anger: Second stage (1) Feeling that nothing is right (2) Difficult for individuals around the dying person (3) Unfilled desires and unfinished business (4) Family may feel guilt, embarrassment, grief, or anger in response to the dying person's anger (5) Nursing care and interventions (a) The nurse should not take the anger personally, but provide structure and continuity, which provides a sense of security. Allow the patient to maintain control as much as possible. The nurse may need to share the experience with a colleague. iii) Bargaining: Third stage (1) Postponement of the inevitable (2) Promises in return for an extension of life (3) Most bargains are made with God and usually kept as secret (4) Nursing care and interventions at this stage (a) The nurse should be available to listen and allow the patient to share his or her thoughts and feelings. iv) Depression: Fourth stage (1) Reality of the dying process is emphasized (2) Many losses can lead to depression (3) Usually a silent depression (4) Interest in prayer and desire for clergy (5) Nursing care and interventions during this stage (a) The nurse should allow the expression of sorrow and support periods of silence as well as respect the desire of the patient to be alone at times. The nurse should not try to cheer up the patient. Referrals to spiritual or religious leaders may be appropriate. v) Acceptance: Fifth stage (1) Struggling ends and relief ensues (2) Possibility of this being a final rest to gain strength for the long journey (3) Come to terms with death and gain a sense of peace (4) Nursing care and interventions during this stage (a) The nurse should support the patient's choice of selective contacts. The nurse should help simplify the environment with what is most important to the patient and provide support for family members

Assessments for OA

i) Diagnose: Bone Scan, CT Scan, MRI, xray (stage joint damage) (1) Joint space narrows as disease advances, look for osteophytes ii) Labs = Not used with OA iii) Synovial Fluid Analysis: used to rule out other types of arthritis (inflammatory) Clear, yellow= no inflammation iv) Nursing Assessment: (1) Joint Deformity, Presence of Nodes, knee and/or hip alignment (2) Pain, tenderness, stiffness, crepitation (3) Level of Disability, ROM (4) Ability to perform ADL's

interprofessional care for OA

i) Drug Therapy (1) Mild (a) Acetaminophen (b) Topical Agents: Capsaicin Cream, Voltaren gel, Aspercreme (2) Moderate (a) Low Dose NSAIDs (b) Salicylate (aspirin- some patient prefer but not as common now) (3) Corticosteroids (a) Intraarticular Injections (up to 4) (b) Systemic - not needed with OA (4) Hyaluronic Acid Injections -knee OA (5) DMARDs: Disease-Modifying Antirheumatic Drugs ii) Surgery (1) Only for loss of function, unmanaged pain or decreased independence (2) Arthroscopy or Joint Replacement

Biopsies in breast cancer (4)

i) FNA biopsy (fine needle aspiration) is performed by inserting a needle into a lesion to sample fluid from a breast cyst, remove cells from intercellular spaces, or sample cells from a solid mass. Before the procedure, the breast area is first locally anesthetized. Then the needle is placed into the breast, and fluid and cells are aspirated into a syringe. Three or four passes are usually made. If the results are negative with a suspicious lesion, an additional biopsy may be necessary. ii) A core (core needle) biopsy involves removing small samples of breast tissue using a hollow "core" needle. For palpable lesions, this is accomplished by fixing the lesion with one hand and performing a needle biopsy with the other. In the case of nonpalpable lesions, stereotactic mammography, ultrasound, or MRI image guidance is used. Stereotactic mammography uses computers to pinpoint the exact location of a breast mass based on mammograms. With ultrasound, the radiologist or surgeon watches the needle on the ultrasound monitor to help guide it to the area of concern. Because a core biopsy removes more tissue than an FNA, it is more accurate. iii) Vacuum-assisted biopsy is a version of core biopsy that uses a vacuum technique to help collect the tissue sample. In core biopsy, several separate needle insertions are used to acquire multiple samples. During vacuum-assisted biopsy, the needle is inserted only once into the breast, and the needle can be rotated, which allows for multiple samples through a single needle insertion. iv) Minimally invasive breast biopsies have become the standard of care for diagnosing abnormalities found either on imaging studies or through clinical examination. However, in some cases an excisional biopsy is recommended. An excisional biopsy is performed in an operating room

Pathophysiology of colorectal cancer

i) Most (about 95%) of CRC cases are adenocarcinomas (which is cancer that begins in glandular or secretory cells that are found in tissue that line internal organs) ii) Begin as type of polyp called an adenoma (2 types of polyps: hyperplastic and adenomas; adenomas develop into cancer) iii) Typically, few effects until spread iv) Metastasis to regional lymph nodes common v) Seeding of tumor: into muscularis mucosae and eventually gains access to lymph nodes vi) Since venous blood leaving the colon and rectum flows through the portal vein and the inferior rectal vein, the liver is a common site of metastasis

nursing care of OA

i) Rest and Joint Protection ii) Heat and Cold iii) Nutrition iv) Exercise v) Avoid Smoking vi) Transcutaneous Electrical Nerve Stimulation (TENS) vii) Complementary and Alternative Therapies (1) Herbs (2) Nutritional Supplements (3) Glucosamine Chondroitin (4) Movement therapies (5) Acupuncture (6) Massage viii) GOALS: maintain joint function, protect joint, achieve independence in self-care, and drug/nondrug pain relief

clinical manifestations of RA

i) Fatigue, Anorexia & Weight loss: The onset of RA is typically insidious. Nonspecific manifestations such as fatigue, anorexia, weight loss, and generalized stiffness may precede the onset of joint symptoms. ii) General Stiffness (1) After activity & in morning (2) Stiffness becomes more localized in the following weeks to months. Specific joint involvement is marked by pain, stiffness, limited motion, and signs of inflammation (e.g., heat, swelling, tenderness). Joint symptoms occur symmetrically and often affect the small joints of the hands (PIP and MCP) and feet (MTP). Larger peripheral joints such as wrists, elbows, shoulders, knees, hips, ankles, and jaw may also be involved. The patient typically experiences joint stiffness after periods of inactivity. Morning stiffness may last from 60 minutes to several hours or more, depending on disease activity. MCP and PIP joints are typically swollen. In early disease, the fingers may become spindle shaped from synovial hypertrophy and thickening of the joint capsule. Joints are tender, painful, and warm to the touch. As the disease progresses, inflammation and fibrosis of the joint capsule and supporting structures may cause deformity and disability. Muscle atrophy and tendon destruction cause one joint surface to slip past the other (subluxation). Metatarsal head dislocation and subluxation in the feet may cause pain and walking disability (Fig. 64-3, D). Ulnar drift ("zig-zag deformity"), swan neck, and boutonnière deformities are common in the hands (Fig. 64-4). iii) Joint stiffness (usually second) (1) Symmetric Involvement (2) Small Joints (3) "Spindle fingers", "zig-zag" & Subluxation (4) Tender, painful, warm iv) Precipitation Event? (1) Stressful event or work stress (2) Infection (3) Physical exertion (4) Childbirth (5) Surgery (6) Emotional Upset

adverse side effects to treatments of osteoporosis

i) GI distress: abdominal pain, nausea, vomiting and esophageal and gastric irritation ii) Important to maintain an upright posture for 30-60mins and renal toxicity so check serum Cr before administering

Assessment of RA

i) History and Physical ii) Complete blood cell (CBC) count iii) Erythrocyte sedimentation rate (ESR)à inflammation iv) C-reactive protein (CRP)à inflammation v) Rheumatoid factor (RF) occurs in 80% of patients with RA and higher in active disease vi) Antibody to citrullinated peptide (anti-CCP): often more accurate than RF (use for early diagnosis and treatment) vii) Antinuclear antibody (ANA) increased in 20-30% of RA patients (part of the autoimmune response- reaction to the antigen) viii) X-ray studies of involved joints (soft tissue swelling and demineralization) ix) Synovial fluid analysis: early: slightly, straw colored

reasons for declining vaping since 2019

i) Increased public awareness of the risk associated with THC-containing e-cigarette, or vaping, product use as a result of the rapid public health response, Removal of vitamin E acetate from some products & Law enforcement actions related to illicit products

Screening guidelines for breast cancer

i) Mammogram: X-rays to visualize internal breast structure ii) Starting at age 45 & Annually until 54 yrs iii) >55yrs = biannually until health conditions worsen and life expectancy is <10yrs iv) Consistent Self-Breast Exams

synovial fluid analysis related to RA

i) Management (1) Nutritional and weight management counseling (2) Therapeutic exercise (3) Psychologic support (4) Rest and joint protection, use of assistive devices (5) Heat and cold applications ii) Drug Therapy (Table 64-3) (1) Disease-modifying antirheumatic drugs (DMARDs) (2) Intraarticular or systemic corticosteroids (3) Nonsteroidal antiinflammatory drugs (NSAIDs) (4) Biologic response modifiers (BRMs) iii) Positive RF occurs in approximately 80% of adults with RA, and titers rise during active disease. iv) ESR and C-reactive protein (CRP) are general indicators of active inflammation. An increase in antinuclear antibody (ANA) titers is also seen in 20% to 30% of patients with RA.3 v) Testing for the antibodies to citrullinated peptide (anti-CCP) is also important in the diagnosis of RA. Levels of anti-CCP are more specific than RF for RA. In some cases, testing may allow an early, accurate diagnosis.3 vi) Synovial fluid analysis in early disease often shows slightly cloudy, straw-colored fluid with many fibrin flecks. The enzyme MMP-3 is increased in the synovial fluid of the patient with RA, and it may be a marker of progressive joint damage. The WBC count of synovial fluid is elevated. i) X-rays alone are not diagnostic of RA. They may show only soft tissue swelling and possible bone demineralization in early disease. A narrowed joint space, articular cartilage destruction, erosion, subluxation, and deformity are seen in later disease.

Diagnosing TB

i) Mantoux TB Skin Test (TST) (1) Positive >5cm *Positive does not determine if they are latent or active (just determines antibodies)* ii) Interferon-gamma release assays (IGRAs) Blood Tests measure immune response to TB bacteria (1) QuantiFERON-TB Gold (2) T-SPOT test iii) Sputum specimens (1) 3 consecutives (2) Smear is not definitive, but culture IS (isolates bacteria, but takes up to 8 weeks) iv) Chest x-ray: cannot be used alone

Surgeries in Breast Cancer Treatment

i) Mastectomy (1) Radical: breast, chest muscle and nodes (2) Simple (total): entire breast (3) Segmental (4) Modified radical: breast and axillary nodes (keeps pectoralis muscle) (5) Axillary node dissection (6) Nipple-sparing: areola are left in place (a) Women who have a small cancer near the outer part of the breast, with no signs of cancer in the skin or near the nipple ii) Lumpectomy or Breast conservation (if less than 5cm and used in combination with chemo) (1) involves removal of the entire tumor along with a margin of normal surrounding tissue (Fig. 51-6, A). In some cases, it may take two to three additional surgeries to remove all the cancer from the margins. After surgery, radiation therapy is delivered to the entire breast, ending with a boost to the tumor bed. If the risk for recurrence is high, chemotherapy may be administered before radiation therapy iii) Breast reconstruction (1) Individual preference (2) Timing of reconstruction (3) Several procedures iv) Axillary Lymph Node Analysis (1) Sentinel lymph node biopsy (SLNB) is the preferred standard for axillary lymph node analysis and staging. It was described on p. 1212. However, if the sentinel lymph node cannot be identified, or if the node is positive for cancer, ALND may have to be performed.

Complications of TB

i) Military TB: Spread of TB bacteria to distant organs--> Fever, cough, hepatomegaly or splenomegaly ii) Pleural TB: Extrapulmonary TB (TB outside of lungs)--> Unilateral, exudative pleural effusion (cloud fluid buildup: congestion, cough and diminished breath sounds) AND Empyema: pus pockets from infection *need chest tube* iii) Organ involvement: spine (obstruction of discs/vertebrae, abdomen (peritonitis), lymph nodes, kidneys, urogenital tract, etc

Genetics involved in Prostate Cancer

i) No single gene causes prostate cancer ii) Prostate Cancer Categories (1) Sporadic: 75% (by chance, after birth) (2) Familial: <20% (genes + environment) (3) Hereditary (inherited): 5-10% (passed down in a family from one generation to next) (a) (1) three or more first-degree relatives with prostate cancer, (2) prostate cancer in three generations on the same side of the family, and (3) two or more close relatives (father, brother, son, grandfather, uncle, nephew) on the same side of the family diagnosed with prostate cancer before age 55. (b) Only genetic testing can determine whether a man has a genetic mutation. However, no genetic tests are available to determine if a man is predisposed to developing prostate cancer. (c) Having a family history does not mean that a man will develop prostate cancer; it indicates that he has an increased risk.

Causes of drug-resistant TB

i) Nonadherence to full course of treatment ii) Prescription of wrong treatment iii) Drugs for treatment not available iv) Drug quality is poor

Clinical manifestations of breast cancer

i) Nontender lump in breast (hard palpabale) ii) Most often in upper outer quadrant (where glandular tissue lie) iii) Abnormal nipple discharge (usually unilateral and may be clear or bloody) iv) Rash around nipple area v) Nipple retraction vi) Dimpling of skin vii) Change in nipple position viii) Usually painless ix) Peau d'orange (d/t plugging of dermal lymphatics) x) Infiltration, dimpling (pulling in) of overlying skin xi) *Most often found by patient

Paget's breast cancer

i) Paget's (PAJ-its) disease of the breast is a rare form of breast cancer. Paget's disease of the breast starts on the nipple and extends to the dark circle of skin (areola) around the nipple. ii) Paget's disease of the breast occurs most often in women older than age 50. Most women with Paget's disease of the breast have underlying ductal breast cancer, either in situ — meaning in its original place — or, less commonly, invasive breast cancer. Only in rare cases is Paget's disease of the breast confined to the nipple itself.

Medicare coverage for testing of osteoporosis (every 2 years) for the five populations:

i) Persons with vertebral abnormalities ii) Persons with primary hyperparathyroidism iii) Women who are estrogen deficient or at clinical risk for osteoporosis iv) Persons taking long-term glucocorticoids v) Persons being monitored for response to treatment with an FDA- approved osteoporosis medication

Phyllodes

i) Phyllodes (full-OH-deez) tumors of the breast are rare, accounting for less than 1% of all breast tumors. The name "phyllodes," which is taken from the Greek language and means "leaflike," refers to that fact that the tumor cells grow in a leaflike pattern. Other names for these tumors are phylloides tumor and cystosarcoma phyllodes. Phyllodes tumors tend to grow quickly, but they rarely spread outside the breast. ii) Phyllodes tumors can occur at any age, but they tend to develop when a woman is in her 40s. Benign phyllodes tumors are usually diagnosed at a younger age than malignant phyllodes tumors. Phyllodes tumors are extremely rare in men.

Nursing interventions for prostate cancer

i) Promote urinary elimination (1) Assess degree of incontinence and effect on lifestyle (2) Teach Kegel exercises (3) Teach methods to control dampness, odor (a) Do not attempt to prevent accidental voiding by restricting fluids (4) Absorbent pads worn inside underwear (5) Refer to PT or continence specialist (6) Explore options such as external collection device (7) Encourage verbalizing feelings about impact of incontinence ii) Promote communication related to sexual dysfunction (1) Surgical treatment may cause ED (2) Assess pretreatment sexual function (3) Teach client about actual or potential effects of therapy on sexual function (4) Provide opportunity for client and partner to discuss implications and concerns (5) Discuss medical, surgical treatments for ED (6) Refer for sexual counseling as appropriate iii) Promote effective pain management (1) Assess intensity, location, quality of pain (2) Provide optimal pain relief (3) Teach client and family noninvasive methods of pain control

surgery for prostate cancer

i) Prostatectomy (1) Simple (2) Radical- entire gland, seminal vesicles and neck of bladder because the cancer tends to be in different locations within the glad (3) Retropubic: a low midline abdominal incision is made to access the prostate gland, and the pelvic lymph nodes can be dissected (4) Perineal: an incision is made between the scrotum and anus (5) Suprapubic i) Nerve-Sparing Procedure: Near the prostate gland are neurovascular bundles that maintain erectile functioning. The preservation of these bundles during a prostatectomy is possible while still removing all of the cancer. Nerve-sparing prostatectomy is not indicated for patients with cancer outside of the prostate gland. Although the risk of ED is reduced with this procedure, there is no guarantee that potency will be maintained. ii) Cryotherapy: is a surgical technique for prostate cancer that destroys cancer cells by freezing the tissue. It has been used both as an initial treatment and as a second-line treatment after radiation therapy has failed. A TRUS probe is inserted to visualize the prostate gland. Probes containing liquid nitrogen are then inserted into the prostate. Liquid nitrogen delivers freezing temperatures, thus destroying the tissue. The treatment takes about 2 hours under general or spinal anesthesia and does not involve an abdominal incision.

ID team approach to RA

i) Registered Nurse (RN) (1) • Administer drug therapy as ordered. (2) • Teach patient and caregiver about medications, including increased risk of infection with disease-modifying agents. (3) • Assess disease impact on quality of life and joint function. (4) • Assess pain intensity and administer analgesics as ordered. Assess patient response. (5) • Develop program for rehabilitation and education with the interprofessional team. (6) • Teach patient about need for balance of rest and activity, with use of joint protective strategies. ii) Unlicensed Assistive Personnel (UAP) (1) • Assist patient with passive ROM of affected joints. (2) • Notify RN about patient complaints of pain. (3) • Assist patient with self-care needs. iii) Physical Therapist (1) • Assess patient's current mobility and need for assistance. (2) • Establish exercise regimen and teach patient to perform exercises safely. (3) • Coordinate PT with RN so that patient can receive timely analgesia. (4) • Discuss home environment with patient and identify possible modifications to facilitate disease management (e.g., bathroom on first level to avoid stairs). iv) Occupational Therapist (1) • Assess impact of patient's condition on ability to perform ADLs. (2) • Instruct patient in use of assistive devices (e.g., long-handled reacher, long-handled shoe horn) to facilitate self-care without increasing stress on joints. (3) • Discuss home environment with patient and identify possible modifications to facilitate role performance (e.g., kitchen modifications for meal preparation). v) Social Worker (1) • Assess need for durable medical equipment (e.g., walker). (2) • Assess psychosocial and financial impact of disease. Arrange vocational retraining if needed

Stages of Colorectal Cancer

i) Stage 0 cancer has not grown beyond the mucosal layer. ii) Stage I cancer has grown beyond the mucosa into the submucosa, but no lymph nodes are involved. iii) Stage II cancer has grown beyond the submucosa into the muscle but there is no lymph node involvement or metastasis. iv) Stage III cancer is any tumor with lymph node involvement but no metastasis. v) Stage IV cancer is any tumor with lymph node involvement and metastasis

stages of RA

i) Stage I: Synovitis, high WBC (synovial fluid) 5-60k (1) Synovial membrane swelling with excess blood (2) Membrane containing small areas of lymphocyte infiltration (3) High WBC counts in synovial fluid (5000-60,000/µL) Due to swarm of neutrophils at site (4) X-ray results: soft tissue swelling, possible osteoporosis, but no evidence of joint destruction ii) Stage II: Increased joint inflammation, narrowing of joint space (1) Increased joint inflammation, spreading across cartilage into joint cavity (2) Signs of gradual destruction in joint cartilage (3) Narrowing joint space from loss of cartilage iii) Stage III: Pannus formation, cartilage erodes, bone is exposed (1) formation of synovial pannus (2) Joint cartilage becomes eroded, bone exposed (3) X-ray results: extensive cartilage loss, erosion at joint margins, possible deformity iv) Stage IV: end-stage, inflammation subsides, loss of joint function (1) End-stage: inflammatory process subsides (2) Loss of joint function (3) Formation of subcutaneous nodules

Active TB Disease

i) Symptomatic ii) + skin or blood test iii) CXR can be abnormal iv) Sputum tests may be positive v) Contagious vi) Treatment *need active treatment* (1) Isoniazid (INH) (2) Rifampin (RIF) (3) Ethambutol (EMB) (4) Pyrazinamide (PZA) (5) Total of 6-9 months of treatment

diagnostic criteria for RA

i) Synovitis that is not related to another disease ii) Joint Involvement iii) Serology iv) Acute Phase Reactants v) Duration of Symptoms more than 6 weeks vi) What kind of specialist does a patient with RA see? (1) A doctor or a team of doctors who specialize in care of RA patients should diagnose and treat RA. This is especially important because the signs and symptoms of RA are not specific and can look like signs and symptoms of other inflammatory joint diseases. Doctors who specialize in arthritis are called rheumatologists, and they can make the correct diagnosis.

clinical manifestations of OA

i) Systemic = NONE (no fever, fatigue or organ involvement) ii) Joints (1) Range: Mild discomfort à Significant disability (2) Pain is primary symptom and reason for seeking care (3) Early Stages: pain relief with rest (4) Later Stages: pain at rest, pain with barometric pressure, disability, joint stiffness after period of rest, overactivity can cause inflammation, *crepitation, grating sensation, bone spurs (5) Asymmetrical (typically) (6) Weight-bearing joints are commonly involved iii) Deformity (1) Heberden's Nodes: distal finger joints due to osteophytes and loss of joint space, red, swollen and tender (2) Bouchard's Nodes: proximal finger joints; red, swollen and tender (3) Bowlegged: Knee OA; medial joint arthritis (4) Knock-kneed: Knee OA; lateral joint arthritis (5) Uneven Leg Length: Hip OA

Incidence and Risk factors of colorectal cancer

i) Third most common cancer diagnosed in United States ii) Earlier diagnosis improves survival rate iii) Occurs most often after age 50 iv) Incidence continues to rise with increasing age b) Risk factors i) Family history of colorectal cancer (first-degree relative) ii) Personal history of inflammatory bowel disease iii) Personal history of colorectal cancer iv) Family or personal history of polyps v) Obesity (body mass index ≥30 kg/m2) vi) Red meat (≥7 servings/wk) vii) Cigarette smoking viii) Alcohol (≥4 drinks/wk) ix) Personal history of diabetes mellitus x) Exposure to radiation

types of breast cancer 4

i) Tissue Type (in situ within the duct) (1) Ductal carcinoma (epithelial lining of milk ducts) (2) Lobular carcinoma (epithelial lining of milk glands) (3) Other: inflammatory (rare and aggressive, blocks lymph flow), Paget's disease (infects ducts around nipple then spreads), Phyllodes tumor (leaf-like tumor) ii) Invasiveness (invading through wall of duct) (1) Noninvasive (in situ) (2) Invasive (spreading) iii) Hormone Receptor and Genetic Status: biopsy reveals if there are certain proteins that are estrogen or progesterone receptors (because hormones attach and fuel growth) (1) Cancers are called hormone receptor-positive or hormone receptor-negative based on whether or not they have these receptors (proteins). Knowing the hormone receptor status is important in deciding treatment options iv) HER-2 Genetic Status (human epidermal growth factor receptor 2): HER2-positive breast cancer is a breast cancer that tests positive for a protein called human epidermal growth factor receptor 2 (HER2), which promotes the growth of cancer cells. v) In about 1 of every 5 breast cancers, the cancer cells have a gene mutation that makes an excess of the HER2 protein. HER2-positive breast cancers tend to be more aggressive than other types of breast cancer.

OA causes

i) Trauma: injuries can happen to bones that interrupt the blood supply (dislocations and fractures); this can cause damage to the bones and ultimately causes osteoarthritis because the healing isn't entirely perfect and the stress put on that bone can be uneven. This causes the bone to rub together and break down. ii) Mechanical Stress: repetitive activities like sports cause cartilage deterioration iii) Inflammation: repeated responses to local inflammation can impact cartilage health. iv) Joint Instability: if surrounding supportive structures of a joint are damaged, then there is uneven stress on that joint v) Neurologic Disorders: abnormal movements that result from loss of sensation or reflexes can cause cartilage deterioration vi) Skeletal Deformities: congenital or aquired conditions also impact cartilage (this is where you might see osteoarthritis in children) vii) Hematologic or Endocrine Disorders: bleeding into a joint cavity can impact the cartilage viii) Drugs: certain drugs can stimulate collagen digesting enzymes in the joints (corticosteroids)

Radiation therapy for prostate cancer

i) Used as a primary treatment or palliative treatment ii) Delivered by external beam: most widely used method of delivering radiation treatments for men with prostate cancer. This therapy can be used to treat patients with prostate cancer confined to the prostate and/or surrounding tissue. Patients are usually treated on an outpatient basis 5 days a week for 4 to 8 weeks; each treatment lasts only a few minutes. iii) Brachytherapy (interstitial implants of radioactive seeds into prostate gland allowing for higher radiation doses directly in the tissue while sparing the surrounding tissue such as the rectum and bladder. (1) Seeds are placed in the prostate gland with a needle through a grid template guided by TRUS to ensure accurate placement of seeds

Genetics & Colorectal Cancer

i) Very small portion of CRC are caused by inherited gene mutations ii) Familial adenomatous polyposis (FAP), attenuated FAP (AFAP), and Gardner syndrome are caused by inherited changes in the APC gene. The APC gene is a tumor suppressor gene iii) Lynch Syndrome: 3% (Hereditary Nonpolyposis Colorectal Cancer (HNPCC) - germline variants in DNA MMR genes iv) Peutz-Jeghers Syndrome- STK11 (LKB1) gene, tumor suppressor gene v) MYH-associated polyposis (MAP) - MYH gene, changes how the cell proofreads and fixes errors when cells divide

BRMs (biologic response modifiers) in treatment of RA

i) also called biologics or immunotherapy) are also used to slow disease progression in RA. These drugs are classified based on their mechanism of action (Table 64-3). (1) They can be used to treat patients with moderate-to-severe who have not responded to DMARDs. They can also be used alone or in combination therapy with a DMARD such as methotrexate (most common DMARD)

Inflammatory breast cancer

i) develops rapidly, making the affected breast red, swollen and tender. ii) Inflammatory breast cancer occurs when cancer cells block the lymphatic vessels in skin covering the breast, causing the characteristic red, swollen appearance of the breast. iii) Inflammatory breast cancer is considered a locally advanced cancer — meaning it has spread from its point of origin to nearby tissue and possibly to nearby lymph nodes. iv) Inflammatory breast cancer can easily be confused with a breast infection, which is a much more common cause of breast redness and swelling. Seek medical attention promptly if you notice skin changes on your breast

Direct observation therapy of TB

i) hospitalized for short term and given follow up care for direct therapy) (1) Observe and document individual clients taking TB drugs (2) Prevents antibiotic resistance in community (3) Ensures effective treatment of individuals

Anatomic site classification of tumor

identified by tissue of origin, anatomic site, and behavior 1) carcinomas (from ectoderm like skin/glands or endoderm like mucous) 2) sarcomas from mesoderm such as CT, muscle, bone and fat 3) lymphomas and leukemias from hematopoietic system

indications for surgical intervention for aneurysm

if symptomatic, rapidly enlarging aneurysm greater than 5.5cm

biomarkers related to RA

increased biomarkers can predict extraarticular manifestations i) Biomarkers: measurable substances that can predict the presences of a specific disease, infection or environmental exposure. We can even use biomarkers to track progress, treatment effectiveness and predict outcomes of diseases. They are very objective. They really do not tell us how the patient "feels" or is tolerating the plan of care or progression of the disease- that is very subjective but important when assessing biomarkers.

communitarianism

individual rights need to be balanced with social responsibilities; individuals do not live in isolation but are shaped by values and culture of their communities. Theories with communitarian focus: virtue ethics, ethic of care, feminist ethics

incidence and risk factors for aortic dissection

male, HTN, smoking, cocaine/meth use, PMH of Marfan's syndrome incidence: 3/100,000 males over 60 and women under 40 during pregnancy

Deontology

may conclude that the action is right or wrong in itself, regardless of the amount of good that might come from it.

Open aneurysm repair

mid-line or mid-lateral incision (TAA) -diseased portion opened -aneurysm walls left in place for graft which is inserted into aorta and sutured in placed CARE: assess VS, pulse, I&O, incision checks, DW lines and drains: arterial line-tight BP control, NG, foley, PCA pain medications: nitroglycerin or esmolol infusions, or IV labetalol to keep SBP <160 and monitor K (supplement PRN)

Severity of head injuries based on GCS

mild (13-15)--> possible headache and cognitive defects such as affecting memory and/or stress intolerance -moderate (9-12)--> headache, memory deficient, cognitive deficient, difficulty with ADLS, can result in death Severe (3-8)--> irreversible brain injury (post trauma syndromes, cognitive/emotional/motor/sensory deficits, long-term care, death)

Neoplasm vs benign vs malignant

neoplasm: new but abnormal growth that is uncontrolled and processive benign: noncancerous malignant: cancerous

modifiable and nonmodifiable risk factors of HF

nonmodifiable: fam history, age, gender women over 55, race, CVD, cardiotoxic drugs, congenital heart defects modifiable: HTN, high cholesterol, diabetes, prediabetes, smoking, ETOH, overweight, ETOH, obesity, physically inactive, preeclampsia, unhealth diet

spiritual care needs

nurses need knowledge of different religious views related to death and dying -assessment of religion and spirituality including individual practices -inclusion of clergy and members

complications of aortic dissection if not treated

occlusion of organ for blood (ab, spinal cord, kidneys) rupture (exsanguination bleed to death) cardiac tamponade *medical emergency* where aorta bleeds into pericardium and compresses heart causing heart attack

physical care challenges to dying

pain, respiratory support, constipation, poor nutritional intake

surgical intervention for PAD

percutaneous transluminal angioplasty (PTA) and or stent to treat non-occlusive short arteries (iliac, fem-pop and tibial) assess VS, pulse, incision, hematoma pain meds, anti-contrast meds such as Mucomyst or Bicarb infusion LOS: 1 night

ICP (and its relation to CPP)

pressure in the brain (normal=5-15) -less than 15 concerning -as ICP increases, MAP needs to increase to maintain CPP -CPP=MAP-ICP -the higher ICP, the higher BP needed to maintain perfusion

Interventions to Prevent TB

primary education secondary: TB skin test tertiary: prevent spread of acute cases

complications of PTA for PAD

puncture site hematoma: artery leaks under skin forming hematoma pseudoaneurysm: hematoma from leaking artery that forms outside the arterial wall contained by tissues *pain, swelling, pulsatile puncture site)

Acute nicotine exposure

raises blood pressure and spikes your adrenaline, which increases HR

Tumor necrosis factor inhibitors in treatment of RA

reduce inflammation and can stop disease progression by targeting an inflammation-causing substance called Tumor Necrosis Factor (TNF).It binds to TNF in circulation before TNF can bind to the cell surface receptor. Thus they inhibit the inflammatory response. This drug is given as a subcutaneous injection. There are several different TNF inhibitors that are used for RA.

bone marrow and stem cell transplantation in cancer treatment

replaces diseased or destroyed cells from the bone marrow with normal healthy cells -cells must be a close match (either autologous or allogeneic) because multiple complications can occur

What is toxicology

study of negative effects of chemical exposures

acute decompensated HF (ADHF)

sudden onset, urgent medical care pulmonary and systemic congestion due to elevated L&R sided filling pressures -begins from failure of LV--> increased pulmonary venous pressure--> engorgement of pulmonary vascular system--> lungs not compliant--> increased resistance in small airways--> compensation via increased lymphatic system --> increased RRs and PaO2--> interstitial edema --> tachypnea and SOC -if PVP increases further, alveoli lining ells are disrupted and a fluid containing RBSs moves into alveoli--> alveolar edema--> respiratory acidosis -EARLY: mild increase in RR, decrease in PaO2 -LATER: interstitial edema, tachypnea, SOB -EVEN LATER: ABG's worsen *can manifest as pulmonary edema where the alveolis become filled with serosangious fluid--> dyspnea, orthopnea, JVD, anxious pale, cyanotic, cold and clammy skin, RR>30/min, use of accessory muscles, wheezing, coughing, production of frothy/blood-tinged sputum, crackles and wheezes upon breath sounds, rapid HR, S3/4 sounds, BP elevated or decreased depending on severity

aortic dissection

tear/damage to inner wall of aorta that creates two channels: blood travels in one and pools in the other which pushes on other branches of aorta

amputations indications

to eliminate ischemic, gangrenous, necrotic or infected tissue -relieve ischemic rest pain and promote max independence trauma causes: footwear related, ulcerations, poor wound healing -acute arterial thrombosis: blocked artery causes muscle necrosis that causes ischemia and compartment syndrome and systemic toxicity and renal failure

amputation sites (4)

toes (clinic procedure), tarsometatarsal (TMA), below the knee (BKA), contraindicated for those with infections at knee, above the knee (AKA) stabilize femur with maximum femur length, so this is rare

types of aortic dissection

type A: begins in ascending aorta (needs immediate surgery- open repair) type B: begins in descending (medically managed or EVAR)

Surgical Intervention for PAD: Bypass

types: fem-fem, fem-pop-, femax surgeon re-routes the blood from above a blockage in the artery to below the blockage CARE: assess VS, wound, pedal pulse, foley, coumadin or enoxaparin so that blood doesn't clot and collect in grafts LOS: 2-3 nights

Biologic cancer therapy

use of biological agents to activate the immune system as cancer treatment (colony-stimulating factors, gene therapy, monoclonal antibodies, nonspecific immunomodulating agents, angiogenesis, vaccines

Targeted cancer therapy

use of molecular and genetic biology linked to cell functioning -prevents tumor growth and metastasis by blocking signaling processes responsible for growth and spread of disease

Hormonal cancer therapy

used to treat hormonally responsive cancers such as breast, prostate and uterine -hormones act as agonists or antagonists to block specific receptors with target tissues

symptoms of AAA

usually asymptomatic until it bursts -pain in chest, lower back or scrotum, pulsations in abdomen

How is vitamin E acetate linked to EVALI?

vitamin e acetate found in samples tested by FDA and in patient lung fluid samples from CDC and is a thickening ingredient in e-liquids -no vitamin E acetate found in patients who do not have EVALI -vitamin E acetate does not cause harm when ingested (cream or supplement) but if inhaled, it can impair lung function

normal mechanisms that regulate CO

volume or preload (amount of ventricular stretch at the end of diastole) pressure or afterload (heart working against blood to eject it during systole) contractility: strength of muscle contractions HR increased Ejection fraction (amount of blood pumped by left ventricle with each beat)

When is autoregulation ineffective?

when MAP <70 or >150 if low, then the CBF will decrease and cerebral ischemia will occur if high, the CBF will stop constricting--> dilate--> increase flow

Macrophages can be activated by _________________ and secrete ______________

y-interferon which is produced by T cells to become nonspecifically lytic for tumor cells (1) cytokines, interleukin-1, TNF, and colony-stimulating factors (CSFs) (2) IL-1 and presentation of the processed antigen à T cell activation and production (3) Alpha interferon augments the killing ability of NK cells (4) TNF causes hemorrhagic necrosis of tumors and exerts cytocidal or cytostatic actions against tumor cells (5) CSFs regulate the production of various blood cells in bone marrow and stimulate various WBCs (6) B cells can produce specific antibodies that bind to tumor cells (antibodies are often detectable in patient's serum and saliva)

DO promoting agents increase odds of cancer?

yes because promotion occurs during the second stage which is the reversible proliferation of altered cells which increases likelihood of additional mutations