Test #5 Med-Surg

Discuss diagnostic testing for patients with CHD.

Cardiac catheterization:Catheters are inserted in to the heart via a large peripheral vein and advanced into the heart to measure pressures and oxygen lev- els in heart chambers and visualize heart structures and blood flow patterns. Reveals location of aortic narrowing and VSD or PDA if present. Pulse oximetry (SpO2): Device used to evaluate the degree of oxygen saturation in the blood using a small infrared light probe. May be nor- mal or decreased if CHF is present. Electrocardiogram: Detects electrical events normal and abnormal cardiac rhythm in the heart. Signs of right and left ventricular hypertrophy noted. Echocardiogram: Two-dimensional Doppler evaluation to detect evidence of valve leakage, cardiac anatomy, size, and function.

Reinforce patient and family teaching for procedures to identify and counteract the side effects.

- If stomatitis pain is severe, an analgesic may be prescribed, or topical agents may be prescribed to promote eating. - Monitor the client taking an antineoplastic agent for symptoms of gout, which include increased uric acid levels, joint pain, and edema. Allopurinol may be prescribed to decrease the uric acid level. Encourage the client to increase fluid intake (up to 2000 mL/day) if his or her condition permits. - Most antineoplastic agents are teratogenic. Female clients taking these drugs must use birth control measures throughout therapy. If a client suspects pregnancy, she must notify the primary healthcare provider immediately. - Keep all appointments for chemotherapy treatments. l If hair loss is anticipated, purchase a wig, cap, or scarf before therapy begins. Hair usually begins to grow again within 4 to 6 months after therapy; new growth may have a slightly different color and texture. - Report excessive fluid loss or gain,change in level of consciousness, increased weakness or ataxia (lack of muscle coordination), paresthesia (numbness, prickling, or ting- ling), seizures, persistent headache, muscle cramps or twitching, nausea and vomiting, or diarrhea. - Have periodic evaluations and examinations as recommended.

Develop a plan of care for a patient with CHD.

-Designed to increase pulmonary blood flow to relieve hypoxia. Treatment is usually surgery. COA - Balloon angioplasty Resection of the coarcted portion with end-to-end anastomosis of the aorta Enlargement of the constricted section by a graft prosthetic TOF - Blalock-Taussig procedure to increase pulmonary blood flow Complete repair by • Closing the VSD • Resectioning the infundibular stenosis • Enlarging the right ventricular outflow tract

Choose foods to avoid or limit on a restricted Na diet.

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Discuss the nursing care of a chronically or terminally ill patient.

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Discuss uses, actions, side effects and nursing implications for medications to treat leukemia.

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Discuss why Na intake is limited in some cardiovascular conditions.

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Distinguish the relationship between sodium intake and blood pressure.

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Explain how to perform breast self examination.

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List current recommendation for breast exam, mammography, self breast exam.

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Normal VS for a child.

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Discuss fetal circulation.

1- Cardiac output in infants is the total cardiac output rather than the left and the right ventricle . so we talk about combined cardiac outout because the fetus dosen't use his lungs, the blood that supposed to go to the lungs goes through Ductus Artereosus to the Left Ventricle then to the Descending Aorta. 2- The organ that is responsible for O2 saturation is the placenta not the lungs. 3- There are 3 comminucations in the fetal circulation: - PDA: which directs blood away from the lungs (pulmonary to Aortic). - Patent Foramen Ovale: between right and left atrium, to direct blood from right to the left. - Ductus Venousus: Comminucation between umbilical vein with rich oxygenation across hepatic vein to the Inferior Vena Cava. All these communications disappears after birth. After birh, the circulation becomes 2 circulations; the pulmonary and systemic.

Discuss five preventative measures recommended.

1. Increase consumption of fresh vegetables (especially those of the cabbage family) because studies indicate that roughage and vitamin-rich foods help to prevent certain kinds of cancer. 2. Increase fiber intake because high-fiber diets may reduce the risk for certain cancers (eg, breast, prostate, and colon). 3. Increase intake of vitamin A, which reduces the risk for esophageal, laryngeal, and lung cancers. 4. Increase intake of foods rich in vitamin C, such as citrus fruits and broccoli, which are thought to protect against stomach and esophageal cancers. 5. Practice weight control because obesity is linked to cancers of the uterus, gallbladder, breast, and colon. 6. Reduce intake of dietary fat because a high-fat diet in- creases the risk for breast, colon, and prostate cancers. 7. Practice moderation in consumption of salt-cured, smoked, and nitrate-cured foods; these have been linked to esophageal and gastric cancers. 8. Stop smoking cigarettes and cigars, which are carcinogens. 9. Reduce alcohol intake because drinking large amounts of alcohol increases the risk of liver cancer. (Note: People who drink heavily and smoke are at greater risk for cancers of the mouth, throat, larynx, and esophagus.) 10. Avoid overexposure to the sun, wear protective clothing, and use a sunscreen to prevent skin damage from ultra- violet rays that increase the risk of skin cancer. 11. Get screenings (breast, colon/rectum, cervix/uterus, prostate)

Interpret a dissecting aneurysm.

A dissecting aneurysm happens when the vessel wall splits, forming a blood-filled channel between its layers. Dissection can occur anywhere along the aorta, but is most common in the ascending aorta. It is a life threatening emergency. S&S is sudden excruciating pain (ripping or tearing), HTN initially but eventually leads to hypotension and may be inaudible due to the dissection and how it occludes blood flow. peripheral pulses area also absent.

Compare the six classifications of drugs used to treat hypertension.

ACE Inhibitors (or ARBs) - Lotensin, Capoten, Zestril, Accupril. Lisinopril action: ACE inhibitors inhibit the renin-angiotensin system, stimulate vasodilation, and may reduce sympathetic nervous system activity. nursing implications: give 1 hour before meal or two hours after to increase absorption, take BP efore dose, report changes in edema/persistent cough/SOB, do not skip doses because of rebound HTN teaching: report peripheral edema, change positions slowly, do not skip or stop doses. Beta-Adrenergic Blockers - propranolol (Inderal), metoprolol (Lopressor), nadolol (Corgard) action: Block the sympathetic nervous system (beta-adrenergic receptors), especially the sympathet- ics to the heart, producing a slower heart rate and lowered blood pressure nursing implications: can cause urinary retention, Reduce pulse rate in patients with tachycardia and blood pressure elevation and are useful as an adjunct with medications that act at the neuroeffector site of the blood vessel Contraindications: Bronchial asthma, allergic rhinitis, right ventricular failure from pulmonary hypertension, congestive heart failure, depression, diabetes mellitus, dyslipidemia, heart block, peripheral vascular disease, heart rate under 60 bpm Centrally Acting-Sympatholytics - catapres, wytensin, tenex, aldomet action: these drugs slow the heart rate and reduce vasoconstriction, lowering the blood pressure. They may be given in combo with a diuretic. nursing implications: administer PO: tablets may be crushed, methldopa ay be given IV over 30-60min, do not give subQ or IM, report abnormal lab values, VS, report peripheral edema. Vasodilators - ie Apresoline, Loniten action: reduces bood pressure by relaxing vascular smooth muscle and decreasing peripheral vascular resistance. nursing implications: administer PO with meals: tablets may be crushed. Assess BP before giving the drug. Monitor bowel movements. Monitor weight. Monitor for heart failure, fluid retention, and angina. Monitor CBCs, VS teaching: change positions slowly, eat to reduce GI upset, report muscle aches, tearing/nasal congestion may occur, s&s HA/palpitations/rapid pulse - should stop with 10 days, report black tarry stools. Alpha-Adrenergic Blockers - Cardura, Minipress, Hytrin action: alpha-adrenergic blockers promote vasodilation, loering blood pressure. They also reduce LDL and VLDL levels. Doxazosin and terazosin may cause tachycardia and palpitations, and other unwanted side effects. nursing implications: maintain safety during position changes; severe hypotension may develop. give first dose at bedtime to reduce risk of fainting (first-dose-syncope). assess apical pulse and BP immediately before each dose and every 15-30 minutes thereafter until stable. teaching: use sips of water or sugarless gum to relieve dry mouth. eat to reduce GI upset, nasal congestion is common, do not expect benefits for 3-4 weeks, change positions slowly, do not stop drug without asking doctor. Calcium Channel Blockers - Norvasc, Procardia, Isoptin action: relaxes atrial smooth muscle, causing vasodilation nursing implications: take BP daily, may cause dizziness, do not abruptly stop meds, report SOB NTG - check expiration date, do not handle nitrates - always ask if taking viagra

Explain the leukemia classification system.

Acute s&s - fatigue, fever, anemia, HA, bone pain, bleeding, infection, lymphatic enlargement Chronic s&s - early: weakness, dyspnea on exertion, possible spleen enlargement. late: fever, weight loss, night sweats Acute Lymphoblastic (ALL) (peds) s&s - recurrent infections, bleeding, pallor, bone pain, weight loss, sore throat, fatigue, night sweats, weakness Acute Myeloid Leukemia (AML) (peds) - differs from ALL only by the type of WBC it effects.

Describe the symptoms generally observed in the patient with leukemia.

Acute patients: • Fatigue and weakness due to anemia • Fever due to increased susceptibility to infection • Bleeding, petechiae, ecchymosis (bruising), epistaxis (nosebleed), gingival (gum) bleeding—due to decreased platelet count • Bone pain due to bone infiltration and marrow expansion • Lymph nodes (lymphadenopathy) enlarged as leukemic cells invade nodes • Liver (hepatomegaly) and spleen (splenomegaly) enlarged as leukemic cells invade • Headache, nausea, vomiting, and weight loss • Papilledema, cranial nerve palsies, seizure if there is central nervous sys- tem involvement Chronic patients: • Fatigue due to anemia • Weight loss due to chronic disease process and loss of appetite • Poor appetite • Enlarged lymph nodes (lymphadenopathy) due to infiltration of lymph nodes • Enlarged spleen (splenomegaly) due to involvement of the spleen

Discuss common lab values and diagnostic testing associated with CHF and nursing interventions.

An echocardiogram is usually performed to confirm the diagnosis of HF, assist in the identification of the underlying cause, and determine the patient's ejection fraction, which assists in identification of the type and severity of HF. This information may also be obtained noninvasively by radionuclide ventriculography or invasively by ventriculogram as part of a cardiac catheterization procedure. A chest x-ray and an electrocardiogram (ECG) are obtained to assist in the diagnosis and to determine the underlying cause of HF. Laboratory studies usually completed in the initial workup include serum electrolytes, blood urea nitrogen (BUN), creatinine, B-type natriuretic peptide (BNP), thyroid-stimulating hormone (TSH), a complete blood cell count (CBC), and routine urinalysis. The results of these laboratory studies assist in determining the underlying cause and in establishing a baseline from which to measure effects of treatment. Exercise testing or cardiac catheterization may be performed to determine whether coronary artery disease and cardiac ischemia are causing the HF. Ventricular function should be determined before discharge from a hospital of patients with acute myocardial infarction (MI) who are at risk for the development of HF. Patients who are at low risk for HF are those who meet all of the following criteria: no pre- vious myocardial infarction, inferior myocardial infarction, small (less than two to four times normal) increase in cardiac enzymes, no Q waves on the ECG, and an uncomplicated clinical course. Evaluation of ventricular function may also be performed for patients whose initial assessment of HF suggested noncardiac causes but who failed to respond to treatment.

Discuss the factors that contribute to the formation of an aneurysm.

Aneurysms usually affect the aorta and arteries, because of the high pressure within these vessels. Most aneurysms are caused by arteriosclerosis or atherosclerosis. Trauma and congenital weakness of a vessel also may cause an aneurysm to form.

List the American cancer Society seven warnings signs of cancer.

persistent cough change in bowel or bladder function a sore that does not heal unusual bleeding or discharge thickening or lump in breast or other parts of body indigestion or difficulty swallowing obvious or recent change in a wart or mole

Explain nursing interventions related to caring for the patient receiving chemotherapy.

Assessing Fluid and Electrolyte Status Anorexia, nausea, vomiting, altered taste, mucositis, and diarrhea put patients at risk for nutritional and fluid and electrolyte disturbances. Therefore, it is important for the nurse to assess the patient's nutritional and fluid and electrolyte status frequently and to use creative ways to encourage an adequate fluid and dietary intake. Modifying Risks for Infection and Bleeding Suppression of the bone marrow and immune system is expected and frequently serves as a guide in determining appropriate chemotherapy dosage but increases the risk of anemia, infection, and bleeding disorders. Nursing assessment and care address factors that would further increase the patient's risk. Administering Chemotherapy The local effects of the chemotherapeutic agent are also of concern. The patient is observed closely during its administration because of the risk and consequences of extravasation, particularly of vesicant agent. Local difficulties or problems with administration of chemotherapeutic agents are brought to the attention of the physician promptly so that corrective measures can be taken immediately to minimize local tissue damage. Impaired skin integrity 1. In erythematous areas: a. Avoidtheuseofsoaps,cosmetics, perfumes, powders, lotions and ointments, deodorants. b. Use only lukewarm water to bathe the area. c. Avoidrubbingorscratchingthearea. d. Avoid shaving the area with a straight-edged razor. e. Avoid applying hot-water bottles, heating pads, ice, and adhesive tape to the area. f. Avoid exposing the area to sunlight or cold weather. g. Avoid tight clothing in the area. Use cotton clothing. h. Apply vitamin A and D ointment to the area. impaired oral mucous membranes 1. Assess oral cavity daily. 2. Instruct patient to report oral burning, pain, areas of redness, open lesions on the lips, pain associated with swallowing, or decreased tolerance to temperature extremes of food. 3. Encourage and assist in oral hygiene. impaired skin integrity: alopecia 3. Prevent or minimize hair loss through the following: a. Use scalp hypothermia and scalp tourniquets, if appropriate. b. Cut long hair before treatment. c. Use mild shampoo and conditioner, gently pat dry, and avoid excessive shampooing. d. Avoid electric curlers, curling irons, dryers, clips, barrettes, hair sprays, hair dyes, and permanent waves. e. Avoid excessive combing or brushing; use wide-toothed comb. 4. Prevent trauma to scalp. a. Lubricate scalp with vitamin A and D ointment to decrease itching. b. Have patient use sunscreen or wear hat when in the sun. 5. Suggest ways to assist in coping with hair loss: a. Purchase wig or hairpiece before hair loss. b. If hair loss has occurred, take photograph to wig shop to assist in selection. c. Begin to wear wig before hair loss. d. Contact the American Cancer Society for donated wigs, or a store that specializes in this product. e. Wear hat, scarf, or turban. 6. Encourage patient to wear own clothes and retain social contacts. 7. Explain that hair growth usually begins again once therapy is completed. chronic pain 1. Use pain scale to assess pain and discomfort characteristics: location, quality, frequency, duration, etc. 2. Assure patient that you know that pain is real and will assist him or her in reducing it. 3. Assess other factors contributing to patient's pain: fear, fatigue, anger, etc. 4. Administer analgesics to promote optimum pain relief within limits of physician's prescription. 5. Assess patient's behavioral re- sponses to pain and pain experience. 6. Collaborate with patient, physician, and other health care team members when changes in pain management are necessary. 7. Encourage strategies of pain relief that patient has used successfully in previous pain experience. 8. Teach patient new strategies to re- lieve pain and discomfort: distraction, imagery, relaxation, cutaneous stimu- lation, etc.

Describe nursing care related to mastectomy.

Assessment • Discuss the client's medical, drug, allergy, and family history. • Take vital signs and weight. • Determine the location of the breast lesion. • Establish what diagnostic tests were performed before admission (if any). • Discuss information the physician has given the client about the type and extent of surgery. Provide an opportunity for the client to express feelings and discuss concerns. Answer all questions; consult with other team members about matters that involve their expertise. Collaborate with physician on arranging for a visit from a Reach to Recovery or I Can Cope volunteer sponsored by the American Cancer Society. Do not stifle crying; stay with client when emotions are overwhelming. Encourage client's significant other or whomever the client turns to for support to remain with client as much and as long as possible. Keep client informed of the routine that will be followed in preparation for surgery and postoperative care. Obtain vital signs according to agency routines. Do not take blood pressure on the arm on the side of the mastectomy. Check color and amount of blood loss from the wound and drain, if one is present. Feel underneath client's side or back for obscured bleeding. Administer IV fluids or blood transfusions at the rate prescribed. Instruct client to deep breathe and cough every 2 hours dur- ing waking hours or use an incentive spirometer. Splint incision to reduce discomfort. Administer oxygen as prescribed. Instruct client to self-administer analgesia before deep breathing and coughing if a patient-controlled analgesia (PCA) pump is available. Administer pain medication liberally according to prescribed dose and frequency. Avoid giving injections in the arm on the same side as the surgery. Monitor response to analgesia 30 minutes after administration or more frequently if PCA is in use. Pin the tubing of the drain or the drain collection chamber to the client's gown. Implement nursing techniques such as changing positions, relaxation, distraction, and guided imagery. Collaborate with the physician if pain control is inadequate. Limit movement, especially abduction, of the arm on the side of surgery until the wound edges are intact. Inspect the wound for swelling, unusual drainage, odor, redness, or separation of the suture line. Empty and reestablish negative pressure in closed wound drains at least once per shift. Administer antibiotic therapy as prescribed. Monitor the trend in temperature and white blood cell counts. Allow the client to shower after the sutures and drains are removed. Do not take blood pressures, give injections, administer IV infusions, or have blood drawn from the arm on the side of the mastectomy. Support and elevate the arm on the side of the mastectomy with pillows so it is kept higher than the heart. Place the arm in a sling when the client ambulates initially; eventually the arm can be positioned at the client's side. Show the client how to squeeze and release a soft rubber ball or a rolled pair of cotton socks several times a day. Remove and reapply an elastic roller bandage from the fin- gers to the axilla twice a day, or insert the affected arm into a pneumatic sleeve, an air-filled device that mechanically pumps the arm, for a half hour or the prescribed amount of time twice a day. Assess the hand for swelling, dusky color, delayed nail blanching, coldness, and tingling and report abnormal findings.

Name the most common cancers and sites of origin.

Benign Neoplasms - neoplasms are localized growths with well-defined borders; they are frequently encapsulated. Malignant Neoplasms - grow aggressively and do not respond to the body's control. Breast Lung Colon/Rectum Cervix/Uterus Prostate

Describe the nursing responsibilities for the patient receiving medications to treat CHF.

Beta-Blockers: do not take with apical under 60, monitor glucose levels and BP, taper dosage when d/c, monitor UA Loop Diuretics: give in AM to prevent night disturbances, no alcohol, monitor WT/VS/I&O, slowly rise to stand, avoid direct sunlight, give with food to decrease GI irritation ACE inhibitors: give 1 hour before meal or two hours after to increase absorption, take BP before dose, report changes in edema/persistent cough/SOB, do not skip doses because of rebound HTN Calcium Channel Blockers: take BP daily, may cause dizziness, do not abruptly stop meds, report SOB Hydralazine/Isosorbide Dinitrate: monitor all VS, tolerance may develop, obtain CBC ARBs - monitor BP, BMP, BUN + Creatinine, may cause hyperkalemia - warn about salt substitutes Digitalis - do not give with apical under 60, monitor digoxin serum levels, monitor for s&s of toxicity, monitor BMP, CBC

Describe the ACS screening recommendations related to breast, prostate, colon and cervical cancer.

Breast: Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health Clinical breast exam (CBE) about every 3 years for women in their 20s and 30s and every year for women 40 and over Women should know how their breasts normally look and feel and report any breast change promptly to their health care provider. Breast self-exam (BSE) is an option for women starting in their 20s. Cervical: All women should begin cervical cancer screening about 3 years after they begin having vaginal intercourse, but no later than 21 years old. Screening should be done every year with the regular Pap test or every 2 years using the newer liquid-based Pap test. Beginning at age 30, women who have had 3 normal Pap test results in a row may get screened every 2 to 3 years. Women older than 30 may also get screened every 3 years with either the conventional or liquid-based Pap test, plus the human papilloma virus (HPV) test. Women 70 years of age or older who have had 3 or more normal Pap tests in a row and no abnormal Pap test results in the last 10 years may choose to stop having Pap tests. Women who have had a total hysterectomy (removal of the uterus and cervix) may also choose to stop having Pap tests, unless the surgery was done as a treatment for cervical cancer or pre-cancer. Women who have had a hysterectomy without removal of the cervix should continue to have Pap tests. Prostate: Starting at age 50, If you are African American or have a father or brother who had prostate cancer before age 65, should have this talk with doctor starting at age 45. If decide to be tested, should have the PSA blood test with or without a rectal exam. Colon: Beginning at age 50, both men and women should follow one of these testing schedules: Flexible sigmoidoscopy every 5 years, or Colonoscopy every 10 years, or Double-contrast barium enema every 5 years, or CT colonography (virtual colonoscopy) every 5 years Yearly fecal occult blood test (gFOBT), or Yearly fecal immunochemical test (FIT) every year, or Stool DNA test (sDNA), interval uncertain

Discuss drugs used to treat CHF including uses, administration, interactions, adverse reactions, lab values, patient/family teaching.

Calcium Channel Blockers (amlodipine) - HTN, angina s&s: CNS: headache, somnolence, fatigue, dizziness, light-headedness, asthenia, pares- thesia. CV: edema, flushing, palpitations. GI: dyspepsia, nausea, abdominal pain. GU: sexual difficulties. Musculoskeletal: muscle cramps. Respiratory: dyspnea. Skin: rash, pruritus. Digitalis - for Heart failure, paroxysmal supraven- tricular tachycardia, atrial fibrillation and flutter. s&s: CNS: agitation, fatigue, generalized mus- cle weakness, hallucinations, dizziness, headache, malaise, paresthesia, stupor, vertigo. CV: arrhythmias, heart block. EENT: blurred vision, diplopia, light flashes, photophobia, yellow-green halos around visual images. GI: anorexia, nausea, diarrhea, vomiting. interacts: amiodarone, verapomil, diuretics, antibiotics Beta-Blockers (metoprolol) - used for HTN, angina s&s: CNS: fatigue, dizziness, depression. CV: hypotension, bradycardia, heart failure, AV block, edema. GI: nausea, diarrhea, constipation, heart- burn. Respiratory: dyspnea, wheezing. Skin: rash. interacts: phenobarbital, lidocaine, verapamil Angiotensin II Receptor Blockers (ARBs) - Angiotensin II Receptor Blockers (ARBs). Although their action is different than that of ACE-Is, ARBs (eg, losartan [Cozaar]) have a similar hemodynamic effect as ACE-Is: lowered blood pressure and lowered systemic vascular resistance. Whereas ACE-Is block the conversion of angiotensin I to angiotensin II, ARBs block the effects of angiotensin II at the angiotensin II receptor. ACE-Is and ARBs also have similar side effects: hyperkalemia, hypoten- sion, and renal dysfunction. ARBs are usually prescribed when patients are not able to tolerate ACE-Is. CNS: asthenia, fatigue, fever, hypesthesia. CV: chest pain, hypotension, orthostatic hypotension. EENT: sinusitis, cataract. GI: diarrhea, dyspepsia, gastritis. GU: UTI. Hematologic: anemia. Respiratory: cough, bronchitis. Skin: cellulitis. Other: flulike syndrome, diabetic vascular disease, angioedema, infection, trauma, diabetic neuropathy. interactions: lithium, NSAIDS Hydralazine and Isosorbide Dinitrate - Nitrates (eg, isosorbide dinitrate) cause venous dilation, which reduces the amount of blood return to the heart and lowers preload. Hydralazine lowers systemic vascular resistance and left ventricular afterload. It has also been shown to help avoid the development of nitrate tolerance. As with ARBs, this combination of medications is usually used when patients are not able to tolerate ACE-Is. CNS: headache, peripheral neuritis, dizziness. CV: angina pectoris, palpitations, tachy- cardia, orthostatic hypotension, edema, flushing. EENT: nasal congestion. GI: nausea, vomiting, diarrhea, anorexia, interactions: antihypertensives, MAO inhibitors, diuretics, beta blockers ACE Inhibitors - Lotensin, Capoten, Zestril, Accupril. Lisinopril action: ACE inhibitors inhibit the renin-angiotensin system, stimulate vasodilation, and may reduce sympathetic nervous system activity. Loop Diuretics (furosimide) - used to decrease edema s&s: hypotension, muscle weakness, dehydration, hyperglycemia, hypokalemia, HA, vertigo, N/V/D, oliguria, orthostatic hypotension, tinnitus interacts: cardiac glycosides, NSAIDS, antihypertensives, amino-glycoside

Describe pathophysiology and incidence of cancer.

Cancer is a disease process that begins when an abnormal cell is transformed by the genetic mutation of the cellular DNA. This abnormal cell forms a clone and begins to proliferate abnormally, ignoring growth-regulating signals in the environment sur- rounding the cell. The cells acquire invasive characteristics, and changes occur in surrounding tissues. The cells infiltrate these tissues and gain access to lymph and blood vessels, which carry the cells to other areas of the body. This phenomenon is called metastasis (cancer spread to other parts of the body). Cancer is not a single disease with a single cause; rather, it is a group of distinct diseases with different causes, manifestations, treatments, and prognoses.

Discuss pathophysiology and incience of breast cancer.

Certain factors appear to increase the risk of breast cancer. Being female, being older than 50 years of age, and having a family history of breast cancer are the most common risk factors. Relatives of women with breast cancer who carry a defective gene (BRCA1 or BRCA2) are very likely to develop breast cancer. Additional factors include exposure to ionizing radiation in childhood or adolescence, previous breast cancer, a history of colon or endometrial cancer, chronic alcohol consumption, early menarche, late meno- pause, obesity, and having no children or having children after 30 years of age. White women are at higher risk for breast cancer than African American women, but African American women are more likely to die of it. Most of the women diagnosed with breast cancer have none of the identified risk factors except being female or being older than 50 years of age. Each normal breast contains 15 to 20 lobes connected by ducts to smaller lobules. The most common malignancy is ductal carcinoma (80%), followed by infiltrating lobular carcinoma (10%), medullary carcinoma, mucinous carcinoma, tubular ductal carcinoma, and inflammatory breast cancer, the rarest but most aggressive form of breast cancer. Some malignant breast tumors are hormone dependent,meaning that estrogen or progesterone enhances tumor growth. Regardless of the type or its etiology, untreated cancer spreads elsewhere through the axillary lymph nodes to distant areas such as the lungs and brain.

Describe treatment options for leukemia.

Chemotherapy is used to destroy leukemic cells and produce remission. Radiation therapy is used to shrink enlarged lymph nodes and destroys leukemic cells in the CNS. Biologic therapy such as interferons and interleukins may be used. It moderates immune function and slows abnormal cell proliferation and growth. s&s flulike symptoms, fatigue, weight loss, muscle/joint pain. Bone marrow transplant may be used with chemo or radiation. ALLOGENIC BMT has a healthy donor that is infused. At risk for graft-versus-host disease. AUTOLOGOUS BMT has the patient infuse their own bone marrow. After aspiration, the marrow is treate to kill tumor cells, and then frozen for storage. Massive chemo and/or radiation is then given to destroy all of the tumor cells in the body. These high doses destroys any remaining bone marrow and the client's immune system. Then the marrow is infused. Complications include malnutrition, infection, bleeding. Stem cell transplant is an alternative to BMT.

Examine community resources available for patients and families with CHD.

Community Support Groups Using Social Media for CHD Support Online Groups and Forums Grief Support Support Books Online Guides for Newly Diagnosed Families Family Matching

Examine common complications of CHD.

Congestive heart failure. This serious complication, which makes it difficult for the heart to pump blood to the body, usually develops in the first six months after birth in babies who have a significant heart defect. Signs of congestive heart failure include rapid breathing, often with gasping breaths, and poor weight gain. Slower growth and development. Children with congenital heart defects often develop and grow more slowly than do children who don't have heart defects. Your child may be smaller than other children of the same age, and if the nervous system has been affected, may learn to walk and talk later than other children. Emotional issues. Some children with congenital heart defects may feel insecure or develop emotional problems because of their size, activity restrictions or learning difficulties. A need for lifelong follow-up. Treatment for children who have congenital heart defects may not end with surgeries or medication while they're young. Children who have heart defects should be mindful of their heart problems their entire lives, as their defect could have complications, such as increased risk of heart tissue infection (endocarditis), heart failure or heart valve problems.

Examine common types of congenital heart disease (CHD).

Cyanotic (Right to left shunt) - Cardiac causes of cyanosis is always secondary to intracardiac shunt which is the blue blood going to red blood areas this is the cause of cardiac cyanosis. Acyanotic (Left to right shunt) - Types: ASD, VSD, PDA. - Red blood goes to the lung. - Ineffective circulation because the blood is fully oxygenated, when it goes back to the lungs, all what it will do is just volume overload at the lungs. - Doesn't cause cyanosis because there is Left to Right shunt not Right to Left, so the shunt doesn't affect the blood oxygenation. - VSD and PDA is the same story. Coarctation of the Aorta - (noncyanotic) - Non- shunt obstructive lesions. - The obstruction is in the distal part of the aortic arch just distal to the left subclavian artery and because there is obstruction there, the heart starts to pump at a high pressure in order to perfuse the lower extremities. So there will be a hypertension in the upper extremities and normal or low pressure in the lower extremity there will be left jugular hypertrophy. - The apex beat will be dilatedand eventually there will be a collateral blood flow across the area of obstruction. s&s: high blood pressure and bounding pulses in the upper extremities, lower extremities cool with decreased pulses and blood pressure, symptoms of CHF, hypertension, older children experience headaches, fainting, and epistaxis. Tetralogy of Fallot - (cyanotic) pulmonary artery is stenosed, hypertrophy of the right ventricle, dextroposition of the aorta, ventral septal defect. Blue blood going to the left side of circulation, so this is pure right to left shunt. s&s: Cyanosis, Hypoxia, Anoxic spells when infant's oxygen supply exceeds blood supply

List common sites of metastasis of breast cancer.

Despite treatment even in the early stages of breast cancer, some women develop metastatic disease. Metastasis is the migration of cancer cells from one part of the body to another. Malignant cells are spread by direct extension, through the lymphatic system, bloodstream, and cerebrospi- nal fluid. Pathophysiology Lymph nodes most commonly are involved in metastasis, and the skeletal and pulmonary systems may also be involved (in that order). In addition, metastases may be found in the brain and liver. Once metastasis occurs, the prognosis is less favorable. Some metastases progress slowly, but others progress more rapidly.

Identify common symptoms of leukemia in children.

History: Describe onset as acute to vague (insidious) with few symptoms. Cold that does not resolve completely. Pallor, fatigue, listlessness, irritability, fever, and anorexia may be noted. May mimic symptoms of rheumatoid arthritis symptoms or mononucleosis. Regular physical can reveal lab values indicating disease.

Discuss hypertension guideline values.

Hypertension is a systolic blood pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg over a sustained period, based on the average of two or more blood pressure measurements taken in two or more contacts with the health care provider after an initial screening. Primary HTN - Of this population, between 90% and 95% have primary hypertension, meaning that the reason for the elevation in blood pressure cannot be iden- tified. The remaining 5% to 10% of this group have high blood pressure related to specific causes, such as narrowing of the renal arteries, renal parenchymal disease, hyperaldosteronism (miner- alocorticoid hypertension) certain medications, pregnancy, and coarctation of the aorta a. accelerated HTN - also known as a hypertensive crisis - a rapid increase in systolic pressure 240mmHg or diastolic pressure 120mmHg. Requires immediate treatment (within 1 hour) to prevent irreversible damage to brain, kidneys, and heart. Clients may have manifestations such as HA, confusion, blurred vision, restlessness, and motor and sensory deficits. b. malignant HTN - a diastolic pressure greater than 130mmHg. Secondary HTN -elevated blood pressure relating to another disorder, like: kidney disease, coarctation of the aorta, pregnancy, endocrine, neurologic disorder, use of stimulants diagnostic tests used: blood, urine tests

Discuss the teaching plan to assist the patient and family with cancer.

Identify potential threats to patient's self- esteem (eg, altered appearance, decreased sexual function, hair loss, decreased energy, role changes). Validate concerns with patient. Encourage continued participation in activities and decision making. Encourage patient to verbalize concerns. Individualize care for the patient. Assist patient in self-care when fatigue, lethargy, nausea, vomiting, and other symptoms prevent independence. Assist patient in selecting and using cosmetics, scarves, hair pieces, and clothing that increase his or her sense of attractiveness. Encourage patient and partner to share concerns about altered sexuality and sexual function and to explore alternatives to their usual sexual expression. Encourage verbalization of fears, concerns, and questions regarding disease, treatment, and future implications. Encourage active participation of patient or family in care and treatment decisions. Visit family frequently to establish and maintain relationships and physical closeness. Encourage ventilation of negative feel- ings, including projected anger and hostility, within acceptable limits. Allow for periods of crying and expres- sion of sadness. Involve clergy as desired by the patient and family. Advise professional counseling as indicated for patient or family to alleviate pathologic grieving. Allow for progression through the grieving process at the individual pace of the patient and family. Avoid tobacco, secondhand smoke, alcohol, obesity. Eat low-fat, high-fiber diet and antioxidant foods. Take meds as ordered. What to call the Dr. about (SOB, acute symptoms)

Identify method(s) used to protect immunocompromised patients from exposure to infectious conditions.

Institute infectious disease precautions if normal white blood cells are suppressed to dangerous limits. Protective isolation techniques provide an environmental barrier against pathogens while a client is highly susceptible to disease. FULL precautions.

Compare and contrast left and right sided failure.

Left-Sided: activity intolerance, fatigue, weakness, dizziness/syncope, SOB, dyspnea, orthpnea, cough, tachycardia, crackles in lung bases, pulmonary edema, increase BP Right Sided: fatigue, activity intolerance, jugular vein distention, peripheral edema, anorexia, nausea, abdominal distention, ascites, liver, spleen enlargement, tenderness, tachycardia, increase BP

Discuss risks and complications following mastectomy.

Lymphedema, soft-tissue swelling from accumulated lymphatic fluid, occurs in some women after they have undergone breast cancer surgery. The condition, a consequence of removing or irradiating the axillary lymph nodes, is evidenced by temporary or permanent enlargement of the arm and hand on the side of the amputated breast. Impaired lymphatic circulation predisposes to disfigurement, reduced range of motion, heaviness of the limb, skin changes, infection, and, in severe cases, tissue necrosis that may require amputation of the limb. • Hematoma/seroma formation • Infection Because nerves in the skin and axilla are often cut or injured during breast surgery, patients experience a variety of sensations. Common sensations include tenderness, soreness, numbness, tightness, pulling, and twinges. These sensations may occur along the chest wall, in the axilla, and along the inside aspect of the upper arm. After mastectomy, some patients experience phantom sensations and report a feeling that the breast or nipple is still present. Overall, patients do not find these sensations severe or distressing

Describe pathophysiology and effects of leukemia.

Malignant transformation of a single stem cell. Leukemic cells proliferate slowly, but do not become functional WBCs. The bone marrow becomes almost totally filled with leukemic cells. They leave the bone marrow eventually and infiltrate the CNS, testes, skin, GI tract, and lymph nodes, liver, spleen. Death usually results from internal hemorrhage and infections.

Describe diagnostic and lab tests.

Mammography detects breast lesions earlier than they can be palpated. The radiologist often can differentiate a benign tumor from a malignant one on a radiograph. Even in women who are 65 years of age or older, regular mammograms ensure an early diagnosis and a decreased mortality rate from breast cancer. In addition to mammography, the American Cancer Society (ACS) recommends annual breast cancer screening with magnetic resonance imaging (breast MRI) for women at high risk for breast cancer. Biopsy and microscopic cell examination confirm the diagnosis.

Discuss the etiology of CHF.

Myocardial dysfunction is most often caused by coronary artery disease, cardiomyopathy, hypertension, or valvular disorders. Atherosclerosis of the coronary arteries is the primary cause of HF. Coronary artery disease is found in more than 60% of the patients with HF. Ischemia causes myocardial dysfunction because of resulting hypoxia and acidosis from the accumulation of lactic acid. Myocardial infarction causes focal heart muscle necrosis, the death of heart muscle cells, and a loss of contractility; the extent of the infarction correlates with the severity of HF. Revascularization of the coronary artery by a percutaneous coronary intervention or by coronary artery bypass surgery may correct the underlying cause so that HF is resolved.

List signs and symptoms of breast cancer.

The primary sign of breast cancer is a painless mass in the breast, most often in the upper outer quadrant. The tumor may have been developing in situ, without invading the surrounding tissue, for as long as 2 years before becoming palpable. Other signs of breast cancer include a bloody discharge from the nipple, a dimpling of the skin over the lesion, retraction of the nipple, peau d'orange (or- ange peel) appearance of the skin, and a difference in size between the breasts. The lesion may be fixed or movable, and axillary lymph nodes may be enlarged. Many of these signs depend on several factors, such as the type, location, and duration of the tumor.

Discuss nursing management for the patient with pulmonary edema.

O2 THERAPY might have to be intubated. POSITIONING THE PATIENT TO PROMOTE CIRCULATION Proper positioning can help reduce venous return to the heart. The patient is positioned upright, preferably with the legs dan- gling over the side of the bed. This has the immediate effect of decreasing venous return, lowering the output of the right ventricle, and decreasing lung congestion. If the patient is unable to sit with the lower extremities dependent, the patient may be placed in an upright position in bed. PROVIDING PSYCHOLOGICAL SUPPORT As the ability to breathe decreases, the patient's sense of fear and anxiety rises proportionately, making the condition more severe. Reassuring the patient and providing skillful anticipatory nursing care are integral parts of the therapy. Because this patient feels a sense of impending doom and has an unstable condition, the nurse must remain with the patient. MONITORING MEDICATIONS The patient receiving morphine is observed for respiratory depression, hypotension, and vomiting; a morphine antagonist, such as naloxone hydrochloride (Narcan), is kept available and given to the patient who exhibits these side effects. The patient receiving diuretic therapy may excrete a large volume of urine within minutes after a potent diuretic is administered. A bedside commode may be used to decrease the energy required by the patient and to reduce the resultant increase in cardiac workload induced by getting on and off a bedpan. If necessary, an indwelling urinary catheter may be inserted. Vasodilators, inotropic medications, afterload or preload agents, or contractility medications may be given. Additional cardiac measures (eg, intra-aortic balloon pump) may be indicated if the patient does not respond.

Describe the long term effects of cancer related to the older patient.

Older adults and their caregivers have special needs and considerations, including increased risk of drug reactions, the presence of additional health conditions, increased financial burdens of care, and caregiver stress and strain. Older adults may be at risk for vitamin and mineral deficiencies that affect nutrition status and warrant therapeutic restrictions and medical nutrition therapy.

Describe the nursing care of the patient with CHF.

Outcomes: demonstrate weight loss, decreased edema, decreased jugular venous distention, and abdominal distention. Achieve improved activity tolerance. Verbalize understanding of diet and fluid restrictions. The nurse is responsible for administering the medications and for assessing their beneficial and detrimental effects to the patient. It is the balance of these effects that determines the type and dosage of pharmacologic therapy. Nursing actions to evaluate therapeutic effectiveness include the following: • Keeping an intake and output record to identify a negative balance (more output than input) • Weighing the patient daily at the same time and on the same scale, usually in the morning after urination; monitoring for a 2- to 3-lb gain in a day or 5-lb gain in week • Auscultating lung sounds at least daily to detect an increase or decrease in pulmonary crackles • Determining the degree of JVD • Identifying and evaluating the severity of dependent edema • Monitoring pulse rate and blood pressure, as well as monitoring for postural hypotension and making sure that the patient does not become hypotensive from dehydration • Examining skin turgor and mucous membranes for signs of dehydration • Assessing symptoms of fluid overload (eg, orthopnea, paroxysmal nocturnal dyspnea, and dyspnea on exertion) and evaluating changes Encourage rest Maintain quite environment Administer oxygen and meds as ordered. Watch for manifestations of decreased cardiac output: changes in mental status; decreased urine output; cool, clammy skin; tachycardia, diminished pulses; pallor or cyanosis; dysrhythmias. Encourage small frequent meals. Restricted fluid intake. High Fowler's Profuse and repeated diuresis can lead to hypokalemia (ie, potassium depletion). Signs are weak pulse, faint heart sounds, hypotension, muscle flabbiness, diminished deep tendon reflexes, and generalized weakness. Hypokalemia poses new problems for the patient with HF because it markedly weakens cardiac contractions. In patients receiving digoxin, hypokalemia can lead to digitalis toxicity. Digitalis toxicity and hypokalemia increase the likelihood of dangerous dysrhythmias. Low levels of potassium may also indicate a low level of magnesium, which can add to the risk for dysrhythmias. Hyperkalemia may also occur, especially with the use of ACE-Is or ARBs and spironolactone. To reduce the risk for hypokalemia, the nurse advises patients to increase their dietary intake of potassium. Dried apricots, bananas, beets, figs, orange or ! tomato juice, peaches, and prunes (dried plums), potatoes, raisins, spinach, squash, and watermelon are good dietary sources of potassium. An oral potassium supplement (potassium chloride) may also be prescribed for patients receiving diuretic medications. If the patient is at risk for hyperkalemia, the nurse advises the patient to avoid the above products, including salt substitutes. Prolonged diuretic therapy may also produce hyponatremia (deficiency of sodium in the blood), which results in apprehension, weakness, fatigue, malaise, muscle cramps and twitching, and a rapid, thready pulse. Periodic assessment of the patient's electrolyte levels will alert health team members to hypokalemia, hypomagnesemia, and hyponatremia. Serum levels are assessed frequently when the patient starts diuretic therapy and then usually every 3 to 12 months. It is important to remember that serum potassium levels do not always indicate the total amount of potassium within the body. Other problems associated with diuretic administration are hyperuricemia (excessive uric acid in the blood), volume depletion from excessive urination, and hyperglycemia.

Discuss the causes of occlusive disorders of the peripheral blood vessels.

PVD is often characterized by a narrowing of the vessels that carry blood to the leg and arm muscles. The most common cause is atherosclerosis (the buildup of plaque inside the artery wall). Plaque reduces the amount of blood flow to the limbs and decreases the oxygen and nutrients available to the tissue. Clots may form on the artery walls, further decreasing the inner size of the vessel and potentially blocking off major arteries. Other causes of peripheral vascular disease may include trauma to the arms or legs, irregular anatomy of muscles or ligaments, or infection. Persons with coronary artery (arteries that supply blood to the heart muscle) disease are frequently found to also have peripheral vascular disease.

PND

Patients with congestive heart failure and pulmonary edema experience this symptom when they recline in bed, paroxysmal noctural dyspnea

Name 3 methods of treating breast cancer.

SURGERY - Surgery is performed immediately after obtaining the results of the biopsy or shortly thereafter. The type of surgery recommended depends on the stage of the tumor and the client's informed decision about treatment options. Compared with more extensive types of mastectomy procedures, breast- conserving surgeries such as lumpectomy, partial mastectomy, and segmental mastectomy followed by radiation have demonstrated equivalent outcomes in terms of survival rate for treatment of early-stage breast cancer CHEMOTHERAPY - The goal of chemotherapy is to destroy any cancer cells that may have escaped surgical removal. Recent drug research has affected chemotherapy recommendations and proposals for candidates who may benefit from them. RADIATION THERAPY - Radiation therapy can be given before or after surgery. If the surgeon finds that the axillary nodes contain cancer cells, that there is chest wall involvement, or that the tumor is larger than 5 cm, a series of radiation treatments usually is ordered prophylactically, even after a modified radical mas- tectomy. Side effects of radiation therapy include fatigue, skin redness similar to a bad sunburn, rash, minor discomfort, or pain.

Describe the post op nursing care for patient undergoing surgery for varicose veins.

Surgery can be performed in an outpatient setting, or patients can be admitted to the hospital on the day of surgery and discharged the next day, but nursing measures are the same as if the patient were hospitalized. Bed rest is maintained for 24 hours, after which the patient begins walking every 2 hours for 5 to 10 minutes. Elastic compression stockings are used to maintain compression of the leg. They are worn continuously for about 1 week after vein stripping. The nurse assists the patient to perform ex- ercises and move the legs. The foot of the bed should be elevated. Standing still and sitting are discouraged. Analgesics are prescribed to help patients move affected extremi- ties more comfortably. Dressings are inspected for bleeding, particularly at the groin, where the risk of bleeding is greatest. The nurse is alert for reported sensations of "pins and needles." Hypersensitivity to touch in the involved extremity may indicate a tem- porary or permanent nerve injury resulting from surgery, because the saphenous vein and nerve are close to each other in the leg. Usually, the patient may shower after the first 24 hours. The patient is instructed to dry the incisions well with a clean towel using a patting technique rather than rubbing. Application of skin lotion is to be avoided until the incisions are completely healed to decrease the chance of developing an infection. If the patient underwent sclerotherapy, a burning sensation in the injected leg may be experienced for 1 or 2 days. The nurse may encourage the use of a mild analgesic (eg, propoxyphene napsylate and acetaminophen [Darvocet N], oxycodone and acetaminophen [Percocet], oxycodone and acetylsalicylic acid [Percodan]) as prescribed by a physician or nurse practitioner and walking to pro- vide relief.

Discuss treatment modalities and options available.

Surgical removal of the entire cancer remains the ideal and most frequently used treatment method. The specific surgical ap- proach, however, may vary for several reasons. Diagnostic surgery is the definitive method of identifying the cellular characteristics that influence all treatment decisions. Surgery may be the primary method of treatment, or it may be prophylactic, palliative, or reconstructive. Prophylactic surgery involves removing nonvital tissues or organs that are likely to develop cancer. The following factors are con- sidered when electing prophylactic surgery: • Family history and genetic predisposition • Presence or absence of symptoms • Potential risks and benefits • Ability to detect cancer at an early stage • Patient's acceptance of the postoperative outcome Colectomy, mastectomy, and oophorectomy are examples of prophylactic operations. In radiation therapy, ionizing radiation is used to interrupt cellular growth. A radiosensitive tumor is one that can be destroyed by a dose of radiation that still allows for cell regeneration in the normal tis- sue. Tumors that are well oxygenated also appear to be more sen- sitive to radiation. In theory, therefore, radiation therapy may be enhanced if more oxygen can be delivered to tumors. Internal radiation implantation, or brachytherapy, delivers a high dose of radiation to a localized area. The specific radio- isotope for implantation is selected on the basis of its half-life, which is the time it takes for half of its radioactivity to decay. Some centers nationwide treat more hypoxic, radiation-resistant tumors with particle-beam radiation therapy. This type of ther- apy accelerates subatomic particles (neutrons, pions, heavy ions) through body tissue. This therapy, which is also known as high linear energy transfer radiation, damages target cells as well as cells in its pathway. A few centers are using intraoperative radiation therapy (IORT), which involves delivering a single dose of high-fraction radiation therapy to the exposed tumor bed while the body cavity is open during surgery. Toxicity with IORT is minimized because the radiation is precisely targeted to the diseased areas, and exposure to overlying skin and structures is avoided. In chemotherapy, antineoplastic agents are used in an attempt to destroy tumor cells by interfering with cellular functions and reproduction. Chemotherapy is used primarily to treat systemic disease rather than lesions that are localized and amenable to surgery or radiation. Biotherapy - immunotherapy used to treat solid tumors, hematologic malignancies, and bone marrow transplants and as supportive therapy for myelosuppressive chemotherapy. biotberapy includes injections of monoclonal antibodies, cytokines, hematopoetic growth factors, natural killer cells, and newer agents that specifically target abnormal DNA within malignant cells. severe s&s. When cure is not possible, the goals of treatment are to make the patient as comfortable as possible and to promote a satisfying and productive life for as long as possible. Whether the period is ex- tremely brief or lengthy, the major goal is a high quality of life— with quality defined by the patient and family.

Discuss the path of fetal circulation.

The circulatory system of an unborn infant, or fetus, functions quite differently from that of a baby after birth. The most significant difference is that, while a baby after birth acquires life-giving oxygen from its lungs, a fetus receives oxygen from its mother through the placenta. Oxygenated blood travels from the placenta to the fetus's heart by way of the umbilical vein. The heart structure of the fetus differs from the normal postnatal heart in that there is an opening in the atrial septum called the foramen ovale (FO in diagram). This allows most of the blood that enters the right atrium to flow into the left atrium instead of into the right ventricle. From the left atrium, the oxygenated blood is pumped into the left ventricle and into the aorta, which carries it to the body tissues. From there it returns to the placenta via the umbilical arteries. The second feature of the fetal heart that differs from the postnatal heart is the presence of the ductus arteriosus (DA in diagram). This vessel connects the pulmonary artery to the aorta and allows blood to flow from the pulmonary artery into the aorta, which carries it to the placenta for oxygenation. The ductus arteriosus normally closes soon after birth and blood in the pulmonary artery goes to the lungs for oxygenation. The lungs in a fetus are non-functional and filled with fluid. The presence of this fluid makes the lungs resistant to the flow of blood into them and they receive only enough blood for their own nourishment. At birth, a dramatic change in the circulatory pattern occurs. The lungs inflate, which tends to draw blood into them from the right ventricle. The increase in blood flow into and out of the lungs increases pressure in the left atrium. This causes a one-way flap on the left side of the foramen ovale, called the septum primum, to press against the opening, effectively separating the two atria. This also increases blood flow to the lungs as blood entering the right atrium can no longer bypass the right ventricle, which pumps it into the pulmonary artery and on to the lungs. Also, within a day or two of birth, the ductus arteriosus closes off, preventing blood from the aorta from entering the pulmonary artery. If the changes described above do not take place after birth, congenital heart disease may result. For example, if the foramen ovale remains open (termed a patent foramen ovale) or if the ductus arteriosus remains open (or patent), heart failure may occur. Interventional and/or pharmaceutical treatments are often successful in correcting these conditions.

Explain the importance of identifying and reporting abnormal laboratory and diagnostic results. (cancer)

The survival rate for many cancers is similar to the cliff-like curve that defines ovarian malignancies. Find the disease early, thanks to a stray blob on an x-ray or an early symptom, and the odds of survival approach 90 percent. Treatment—surgery—is typically low risk. But find it late, after the tumor has metastasized, and treatment requires infusions of toxic chemicals and blasts of brutal radiation. And here the prognosis is as miserable as the experience.

Explain the use of immunotherapy to treat cancer.

The concept of immunotherapy is based on the body's natural defense system, which protects us against a variety of diseases. Although we are less aware of it, the immune system also works to aid our recovery from many illnesses. For many years, physicians believed that the immune system was effective only in combating infectious diseases caused by such invading agents as bacteria and viruses. More recently, we have learned that the immune system may play a central role in protecting the body against cancer and in combating cancer that has already developed. This latter role is not well understood, but there is evidence that in many cancer patients the immune system slows down the growth and spread of tumors. The body's ability to develop an immune reaction to tumors may help determine which patients are cured of cancer using conventional therapies, including surgery, radiation and drugs. One immediate goal of research in cancer immunology is the development of methods to harness and enhance the body's natural tendency to defend itself against malignant tumors. Immunotherapy represents a new and powerful weapon in the arsenal of anticancer treatments. Immunotherapy seems to offer great promise as a new dimension in cancer treatment, but it is still very much in its infancy. Immunotherapies involving certain cytokines and antibodies have now become part of standard cancer treatment. Other examples of immunotherapy remain experimental. Although many clinical trials of new forms of immunotherapy are in progress, an enormous amount of research remains to be done before the findings can be widely applied.

Discuss the factor influencing the development of varicose veins.

The condi- tion is most common in women and in people whose occupations require prolonged standing, such as salespeople, hair stylists, teachers, nurses, ancillary medical personnel, and construction workers. A hereditary weakness of the vein wall may contribute to the development of varicosities, and it is not uncommon to see this con- dition occur in several members of the same family. Varicose veins are rare before puberty. Pregnancy may cause varicosities. The leg veins dilate during pregnancy because of hormonal effects related to distensibility, increased pressure by the gravid uterus, and increased blood volume which all contribute to the development of varicose veins.

Discuss the medical management of the patient with HTN.

The goal of hypertension treatment is to prevent death and complications by achieving and maintaining the arterial blood pressure at 140/90 mm Hg or lower. The optimal management plan is inexpensive, simple, and causes the least possible disruption in the patient's life. Research findings demonstrate that weight loss, reduced alcohol and sodium intake, and regular physical activity are effective lifestyle adaptations to reduce blood pressure. Studies show that diets high in fruits, vegetables, and low-fat diary products can prevent the development of hypertension and can lower elevated pressures. The DASH diet can also be used.

Discuss nutritional considerations for a patient with a CHD.

The main reason for decreased growth in children with CHD is the inability to take in enough calories for normal growth. This can occur because the child tires easily and hasn't got the energy to keep eating without supplemental feedings or because the child's condition requires a higher than normal amount of calories for growth, problems that can also occur in adulthood. Excessive protein loss may contribute to malnutrition. Medications such as diuretics can also cause loss of appetite and feeling full after eating a reduced amount. Risk of nutritional anemia. Small frequent meals.

Discuss the nursing management of the patient with HTN.

The objective of nursing care for hypertensive patients focuses on lowering and controlling the blood pressure without adverse effects and without undue cost. To achieve these goals, the nurse must support and teach the patient to adhere to the treatment regimen by implementing necessary lifestyle changes, taking medications as prescribed, and scheduling regular follow-up appointments with the health care provider to monitor progress or identify and treat any complications of disease or therapy.

Explain the preventive care for patient teaching regarding varicose veins.

The patient should avoid activities that cause venous stasis, such as wearing tight socks or a constricting panty girdle, crossing the legs at the thighs, and sitting or standing for long periods. Chang- ing position frequently, elevating the legs when they are tired, and getting up to walk for several minutes of every hour promote circulation. The patient should be encouraged to walk 1 or 2 miles each day if there are no contraindications. Walking up the stairs rather than using the elevator or escalator is helpful in promoting circulation. Swimming is also good exercise for the legs. Elastic compression stockings, especially knee-high stockings, are useful. Patients are more likely to use knee-high stockings than thigh-high stockings. The overweight patient should be encouraged to begin a weight-reduction plan.

Discuss of common treatments for lymphoma.

Treatment depends on the staging, which is based on the number of involved lymph nodes, and the number of cavities, and bone marrow involvement. • Radiation in the affected tissue to shrink the nodes. • Administer Hodgkin's disease medication like dacarbazine, radiation, chemo • Administer non-Hodgkin's lymphoma medication like cyclophosphamide, prednisone, radiation, chemo

Discuss medical, surgical, and nursing management of the patient with an aneurysm.

Treatment is based on whether the aneurysm is symptomatic, is expanding in size, is caused by an iatrogenic injury, con- tains a dissection, and involves branch vessels. General measures such as controlling blood pressure and correcting risk factors may be helpful. It is important to control blood pressure in patients with dissecting aneurysms. Preoperatively, the systolic pressure is maintained at approximately 100 to 120 mm Hg with a beta-blocker such as esmolol (Brevibloc) or metoprolol (Lopressor). Occasionally, antihypertensives such as hydralazine (Apresoline) are used for this purpose. Sodium nitroprusside (Nipride) may be used by continuous IV drip to emergently lower the blood pressure. The goal of surgery is to repair the aneurysm and restore vascular conti- nuity with a vascular graft. Intensive monitoring is usually required after this type of surgery, and the patient is cared for in the critical care unit. Anticoagulant therapy may be used to prevent emboli from forming or after surgical repair of an aneurysm. Before surgery, nursing assessment is guided by anticipating a rupture and by recognizing that the patient may have car- diovascular, cerebral, pulmonary, and renal impairment from atherosclerosis. The functional capacity of all organ systems should be assessed. Medical therapies designed to stabilize physiologic function should be promptly implemented. Avoid valsalva maneuver (give stool softener). Management of anxiety, pain, ineffective tissue perfusion Continuing care; control HTN, diet, stress reduction, alcohol, smoking, medications prevent complications, rest, preventing constipation, keeping appointments.

Identify risk factors and high risk behaviors.

Uncontrolled: heredity, age, gender, poverty Controlled: emotion, diet, weight, occupation, infection, drug and alcohol use, sun exposure, continued stress, cigarette smoking (the bladder never forgives a smoker)

Differentiate between arterial and venous PVD.

VENOUS: venous thrombosis - Although the exact cause of venous thrombosis remains un- clear, three factors, known as Virchow's triad, are believed to play a significant role in its development: stasis of blood (venous sta- sis), vessel wall injury, and altered blood coagulation. At least two of the factors seem to be necessary for thrombosis to occur. Venous stasis occurs when blood flow is reduced, as in heart failure or shock; when veins are dilated, as with some med- ication therapies; and when skeletal muscle contraction is reduced, as in immobility, paralysis of the extremities, or anesthesia. venous insufficiency - Venous insufficiency results from obstruction of the venous valves in the legs or a reflux of blood back through the valves. Superficial and deep leg veins can be involved. Resultant venous hypertension can occur whenever there has been a prolonged in- crease in venous pressure, such as occurs with deep venous throm- bosis. Because the walls of veins are thinner and more elastic than the walls of arteries, they distend readily when venous pressure is consistently elevated. varicose veins - Varicose veins (varicosities) are abnormally dilated, tortuous, superficial veins caused by incompetent venous valves. Varicose veins may be considered primary (without involvement of deep veins) or secondary (resulting from obstruction of deep veins). s&s: Symptoms, if present, may take the form of dull aches, muscle cramps, and increased muscle fatigue in the lower legs. Ankle edema and a feeling of heaviness of the legs may occur. Nocturnal cramps are common. When deep venous obstruction results in varicose veins, patients may develop the signs and symptoms of chronic venous insufficiency: edema, pain, pigmentation, and ulcerations. Susceptibility to injury and infection is increased. ARTERIAL peripheral atherosclerosis - Consist of the accumulation of lipids, calcium, blood components, carbohydrates, and fibrous tissue on the intimal layer of the artery. These accumulations are referred to as atheromas or plaques.The most common direct results of atherosclerosis in arteries include narrowing (stenosis) of the lumen, obstruction by thrombosis, aneurysm, ulceration, and rupture. Its indirect results are malnutrition and the subsequent fibrosis of the organs that the sclerotic arteries supply with blood. arterial thrombus/embolism - Acute vascular occlusion may be caused by an embolus or acute thrombosis. Acute arterial occlusions may result from iatrogenic injury, which can occur during insertion of invasive catheters such as those used for arteriography, PTA or stent placement, or an intra-aortic balloon pump. Other causes include trauma from a fracture, crush injury, and penetrating wounds that disrupt the arterial intima. The accurate diagnosis of an arterial occlusion as embolic or thrombotic in origin is necessary to initiate appropri- ate treatment. buerger's disease - Buerger's disease is characterized by recurring inflammation of the intermediate and small arteries and veins of the lower and (in rare cases) upper extremities. It results in thrombus formation and occlusion of the vessels. It is differentiated from other vessel diseases by its microscopic appearance. In contrast to atheroscle- rosis, Buerger's disease is believed to be an autoimmune disease that results in occlusion of distal vessels. raynaud's phenomenon (see above)

Explain the importance of monitoring peripheral pulses.

absent or decreased peripheral pulses can indicate risk of gangrene and eventual amputation. also may indicate an aneurism. risk for impaired tissue integrity.

Discuss lab value deviations as a result of BMS.

anemia (decreased red blood cells, hemoglobin, or volume of packed red blood cells), leukopenia (decreased white blood cell count), and thrombocytopenia (decreased platelet count)

Hypercyanpotic Spells

are episodes of intense cyanosis, seen in patient with TOF and other cyanotic heart diseases, and it could be life- threatening, and these spells are indication for the need of surgical intervention.

Discuss the nursing care of a patient with an occlusive disorder of peripheral blood vessels.

aspirin, plavix, pletal, vasodilators foot care needs to be done, extremities warm, post-op care for angioplasty/stent/atherectomy, frequent position changes, pain scale, monitor peripheral pulses, I&O, skin care, anti-embolism stockings, prompt active/passive ROM, evaluate capillary refill/skin color/temperature/pain

Describe changes in patient care based on patient's response to lab and diagnostic tests.

assess for bleeding, protective precautions, blood transfusion

Discuss therapeutic effects of chemotherapy (antineoplastic drugs).

attacks rapidly producing cancer cells.

Discuss common classifications of chemotherapy.

cell-cycle specific - acts on specific phases plant alkaloids - cells unable to divide (and multiply), inhibits DNA synthysis antimetabolites - interferes with dna/rna synthesis - unable to devide, NO mitosis (ie Methotrexate) cell-cycle non-specific - interferes with cell division (and therefor multiplication) alkylating agents - alkaline environment => damages the cell, cells more susceptible, interferes with RNA, DNA, & protein antineoplastic antibiotics - inhibits cell division (and therefor multiplication)

Discuss drugs used to treat CHD including uses, administration, interactions, adverse reactions, lab values, patient/family teaching.

corticosteroids - decreased inflammation anticoagulants - post-surgery surgery antianginals - post-surgery

Squatting

is when the patient squat (knee to chest position), trying to reduce the cyanosis by angulation and kinking of femoral arteries with increased SVR, decreasing Right to Left shunt.

Discuss the teaching plan for a patient with CHF.

he nurse provides patient education and involves the patient in implementing the therapeutic regimen to promote understanding and adherence to the plan. When the patient understands or believes that the diagnosis of HF can be successfully managed with lifestyle changes and medications, recurrences of acute HF lessen, unnecessary hospitalizations decrease, and life expectancy increases. Patients and their families need to be taught to follow the medication regimen as prescribed, maintain a low-sodium diet, perform and record daily weights, engage in routine physical activity, and recognize symptoms that indicate worsening HF. Although noncompliance is not well understood, interventions that may promote adherence include teaching to ensure accurate understanding. The patient and family members are supported and encouraged to ask questions so that information can be clarified and under- standing enhanced. The nurse should be aware of cultural factors and adapt the teaching plan accordingly. Patients and their fami- lies need to be informed that the progression of the disease is in- fluenced in part by choices made about health care and the decisions about following the treatment plan. They also need to be informed that health care providers are there to assist them in reaching their health care goals. Patients and family members need to make the decisions about the treatment plan, but they also need to understand the possible outcomes of those decisions. The treatment plan then will be based on what the patient wants, not just what the physician or other health care team members think is needed. Ultimately, the nurse needs to convey that monitoring symptoms and daily weights, restricting sodium intake, avoiding excess fluids, preventing infection with influenza and pneumococcal immunizations, avoiding noxious agents (eg, alcohol, tobacco), and participating in regular exercise all aid in preventing exacerbations of HF.

Discuss patient and family teaching for the nursing care for the patient with CHF and prevention of exacerbations.

help them understand the etiology of heart failure, signs and symptoms, med usage, diet and activities.

Discuss community resources available for the patient and family with CHF.

home health agencies, community agencies such as cardiac rehab programs, heart support group, AHA.

Discuss nursing interventions for graft-vs-host disease.

immune cells in the donated blone marrow identify the recipient's body tissues as foreign. The t-cells attack the liver, skin, GI tract, causing skin rashes and sloughing, diarrhea, GI bleeding, and liver damage. It is treated with antibiotics and steroids, and sometimes other drugs that suppress the immune response.

Describe risk factors associated with lymphomas.

impaired skin integrity, nausea, fatigue, disturbed body image

Explain lymphomas including Hodgkin's disease and Non-Hodgkin's Lymphoma.

in non-Hodgkin's Lymphoma - painless lymph nodes, abdominal pain, nausea, vomiting, bloody diarrhea. in Hodgkin's Disease: fever, night sweats, pruritus, weight loss, fatigue, malaise, painless enlarged lymph nodes. Prognosis depends on what stage the patient was in upon diagnosis, and on response to treatment. Survival is generally <10 years for non-Hodgkins; may be more for Hodgkins, with an optimistic staging.

Discuss the nursing care for the patient with arterial occlusive disease.

ineffective protection: thrombolytic drugs, report bleeding, H&H. decreased sensitivity to extreme cold or hot.

Discuss patient/family teaching for the management of CHD.

instruct parents that children with CHD should avoid competitive sports because the pressure for a team win can interfere with the child's need to stop activity if specific symptoms arise Nutritional guidance aimed at preventing anemia and promoting optimal growth and development vacations to high altitudes or very cold environments may cause adverse responses in a child who is already hypoxic or has cardiac problems.

Discuss the nursing care of the patient with intermittent claudication.

intermittent claudication is a type of pain that is described as a cramping or aching sensation in the calves of the legs or the arch of the foot. develops with exercise such as walking, and is relieved by rest. nursing care is to administer vasodilators or anticoagulants and to reduce physical activity.

Discuss Acute Pulmonary Edema.

is accumulation of fluid in the interstitial spaces and alveoli of the lungs, may occur with several left-ventricular failure. The client in pulmonary edema has acute and severe dyspnea, SOB, and anxiety. This skin is cool, clammy, and cyanotic. A productive cough with pink, frothy sputum is also present. If cerebral hypoxia occurs, the client may be confused or lethargic. Crackles are heard throughout the lung fields. As the condition worsens, breathing becomes more labored and lung sounds harsher. Pulmonary edema is a medical emergency: The client is "drowning" as a result of fluid in the alveolar and pulmonary spaces and must be treated immediately. Respiration can be up on the 60s.

Discuss the nutritional needs of patients on chemotherapy.

l Make the following dietary modifications: l Eat small, frequent meals. l Eat slowly. l Eat cool,bland foods and liquids. l Suck on hard candy during chemotherapy if taste alterations occur. l Avoid hot or very cold liquids, food with fat and fiber, spicy foods, and caffeine. l Increase fluid intake to 2500 to 3000mL/day (unless contraindicated or advised by physician). Assessment of the patient's nutritional status is conducted at diagnosis and throughout the course of treatment and the disease process. The patient's weight and caloric intake are monitored closely. Diet history, episodes of anorexia, changes in appetite, situations and foods that aggravate or relieve anorexia, and medication history are assessed. Diffi- culty in chewing or swallowing and the presence of nausea, vomiting, or diarrhea are noted.

Discuss nursing care of the child with CHD.

monitor vital signs observing for thrombosis formation neuro-vascular checks of the limb emotional support Prepare the patient for cardiac catheterization: • Take complete nursing history. • Patient must be NPO for 4 to 6 hours. • Complete assessment including calculation of body surface area. • Check for allergies; allergies to iodine, contrast dyes, and shellfish should be relayed to the physician prior to the procedure. • Document baseline assessment of pedal pulses and pulse oximetry. • Utilize child life specialists to alleviate anxiety for the child and family. • Arrange a tour of the lab with the child if age appropriate. • Explain specific aspects of the procedure such as the placement of the IV and ECG electrodes. • Demonstrate how the skin will be washed with brown soap and how the skin will be numbed. • Explain how the contrast affects the patient and how sedation will make the child feel. Care of the patient after cardiac catheterization: • Monitor patient with cardiac monitor and pulse oximeter prior to discharge. • Monitor the patient for Temperature and color distal to the catheter insertion site A pulse of the extremity distal to the catheter insertion site • Take vital signs every 15 minutes for the first hour and hourly thereafter. • Monitor for trends and assess for possible hypotension, tachycardia, and bradycardia. • Check the pressure dressing for evidence of bleeding. • Observe for bleeding at the insertion site or evidence of hematoma. • Monitor intake and output for diuresis from contrast material. • The patient and family should be provided with education upon discharge to: Observe the site for signs of inflammation and infection Monitor for fever Avoid strenuous activities for a few days Avoid tub baths for 48 to 72 hours Use acetaminophen or ibuprofen for discomfort Provide preoperative care of the child undergoing cardiac surgery: • Make inquiries to parents and caregivers as to any questions they may have about the procedure. • Orient child and family to strange surrounding prior to surgery day. • Check chart for signed informed consent forms. • Check identification band with surgical personnel to ensure identity. • Ensure side rails are securely fastened. • Use restraints for transport. • Check laboratory values for signs of systemic alterations. • Bathe and groom the child. • Provide mouth care for comfort while NPO. • Cleanse operative site with prescribed method. • Administer antibiotics as ordered. • Remove jewelry, makeup, and prosthetics as needed. • Check for loose teeth. • Institute preoperative teaching to reduce anxiety. • Prepare child and family for postoperative procedures such as nasogastric tube, wound care, and monitoring apparatus. • Administer preoperative sedation. Provide postoperative care for the child undergoing cardiac surgery: • Make sure child is in safe position of comfort according to the physician's order. • Perform stat orders. • Use proper handwashing. • Assess wound for bleeding and signs of infection. • Provide appropriate wound care. • Assess breath sounds. • Perform neurologic checks. • Take frequent vital signs. • Administer fluids to prevent hypotension. • Monitor fluids losses through chest tube. • Administer pharmacologic support as ordered. • Monitor electrolytes and supplement with infusion as ordered. • Administer sedatives and analgesics for comfort. • Allow caregivers to visit as soon as possible. • Explain procedures and equipment to caregivers. • Encourage caregivers to ask questions. • Involve child life specialist and social services in the care to support the child and family.

Discuss the S&S of an abdominal aortic aneurysm.

most are asymptomatic, but on examination have a pulsating mass in the mid and upper abdomen and a bruit over the mass. may complain of mild to severe midabdominal or lower back pain. the degree of pain commonly indicates the severity (and urgency) of the problem. pain may indicate an impending rupture.

tumor lysis syndrome

occurs after effective chemotherapy of radiation, but it may occur after treatment with glucocorticoids, antiestrogen, tamoxifen, and interferon. It is most likeyy to occur in pt with poorly diff leukemias and lymphomas, a high WBC, or bulky lymphoma. Rapid release of metabolites exceeds the excretory capacity of the kidneys.

Explain the causes of Raynaud's Disease.

red white and blue skin color. Raynaud's disease is a form of intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of the fingertips or toes. The cause is unknown, although many patients with the disease seem to have immunologic disorders. Symptoms may result from a defect in basal heat production that eventually decreases the ability of cutaneous vessels to dilate. Episodes may be triggered by emotional factors or by unusual sensitivity to cold. The disease is most common in women between 16 and 40 years of age, and it occurs more frequently in cold climates and during the winter. The term Raynaud's phenomenon is used to refer to localized, intermittent episodes of vasoconstriction of small arteries of the feet and hands that cause color and temperature changes. Generally unilateral and affecting only one or two digits, the phenom- enon is always associated with underlying systemic disease. It may occur with scleroderma, systemic lupus erythematosus, rheuma- toid arthritis, obstructive arterial disease, or trauma. The prognosis for Raynaud's disease varies; some patients slowly improve, some become progressively worse, and others show no change. Ulceration and gangrene are rare; however, chronic dis- ease may cause atrophy of the skin and muscles. With appropri- ate patient teaching and lifestyle modifications, the disorder is generally benign and self-limiting.

Discuss the nutritional considerations for the patient with CHF.

restricted sodium (2g) to minimize fluid retention, low-fat, low-cholesterol, high-fiber, high-protein.

Discuss teaching plan for a patient receiving drugs to lower blood pressure and side effects to monitor.

see handout

Discuss the adverse effects of each of these classifications.

see handout

Discuss the teaching responsibility for the patient undergoing diagnostic tests.

stress test: a code cart is needed near by . segmental blood pressures: compare from upper and lower extremities doppler: gel may be cold, bring washcloth oximetry: evaluates tissue oxygenation angiography: performed if surgery is planned to locate and determine the extent of obstructions

Discuss nursing care for oncologic emergencies.

there are three kinds of oncologic emergencies: Obstructive, metabolic or infiltrative. obstructive: (ie superior vena cava syndrome, spinal cord compression, obstructive uropathy) Caused by tumor obstruction of an organ or blood vessel. Perform neurologic assessment, control pain, prevent complications of immobility, maintain muscle tone, assist with bowel and bladder training, provide encouragement and support. SOB, cyanosis, edema, altered LOC infiltrative: (ie cardiac tamponade) Caused when tumors infiltrate vital organs. Assess VS, heart and lungs, neck vein filling, LOC, respirations, skin, I & O, review labs, elevate head of bed, minimize physical activity and encourage to cough and deep breathe. set up for pericardiosynthesis (removes fluid from pericardial sac) metabolic: (ie tumor lysis syndrome) Caused by production of ectopic hormone directly from the tumor or the presence of the tumor. Identify clients at risk, assess for electrolyte imbalance, assess urine pH, institute preventative measures (hydration).

Describe actions, uses, side- & toxic- effects, & nursing implications for chemotherapy.

uses: affect cells that rapidly divide and reproduce to result in cell death. for malignant neoplasms. cancerous tumors are more sensitive to antineoplastic drugs. Some clients experience little discomfort or few adverse effects. Others have a wide range of symptoms. The tissues most susceptible to chemotherapy are those with rapidly growing cells, such as epithelial tissue, hair follicles, and bone marrow. Chemotherapy can potentially harm all body systems. Common adverse effects associated with chemotherapy are as follows: • Nausea and vomiting are common during the first 24 hours after chemotherapy administration; use of concurrent antiemetics helps to reduce the incidence and severity. • Stomatitis and mouth soreness or ulceration may result from destruction to the epithelial layer. • Alopecia develops because chemotherapy affects rapidly growing cells of the hair follicles. • Myelosuppression results from inhibition of the manufacture of red and white blood cells and platelets. Severe anemia, bleeding tendencies, leukopenia, neutropenia (decreased neutrophils), and thrombocytopenia are possible if bone marrow depression is profound. Blood transfusions may be necessary, as well as protection of the client from infections. • Fatigue results from the aforementioned effects, the chemotherapy itself, and the increased metabolic rate that accom- panies cell destruction. Antineoplastic drugs are potentially toxic. Nurses must be thoroughly familiar with their adverse effects and toxicity. The dose or length of treatment depends, in some cases, on the client's response to therapy. nursing implications: crosses blood brain barrier, antiemetic should be used in conjunction to avoid nausea. • Monitor client for symptoms of anaphylactic reaction: urticaria (hives), pruritus (itching), sensation of lump in throat, shortness of breath, wheezing. • Assess for electrolyte imbalances • Prevent extravasation of vesicant drugs. Implement measures to treat extravasation of vesicant medications if it occurs. • Assess for signs of bone marrow depression: decreased white and red blood cell, granulocyte, and platelet counts. • Assess for signs of bleeding and infection. • Monitor for signs of renal insufficiency: • Elevated urine specific gravity • Abnormal electrolyte values • Insufficient urine output (<30mL/hour) • Elevated blood pressure, BUN, and serum creatinine • Inform client about the reasons for nausea and vomiting. • Administer antiemetics before and during administration of chemotherapy, or as indicated. • Assess oral mucosa for dryness, redness, swelling, lesions, ulcerations, viscous (sticky) saliva, or white patches.

Discuss support and adjustment to body image changes.

void trying to diminish the significance of the loss. Acknowledge client's grief and reinforce that feeling angry or sad is normal and expected. Stay with client and ensure privacy during emotional periods. Avoid administering prescribed sedatives or tranquilizers as a substitute for spending time with the client. Encourage sharing with those who can be empathic, such as another breast cancer survivor. Suggest that client pad a bra with one or two cotton socks until a prosthesis is fitted in 6 to 8 weeks. Inform client that cosmetic breast reconstruction is an option to discuss with the surgeon. Advocate that client and sexual partner openly express to each other how the surgery has affected them emotionally. Discuss methods for dealing with the removed breast during sexual activities such as using no or low lighting during intercourse or wearing the upper portion of lingerie.

Describe diagnostic, staging, and lab tests preformed.

• Hodgkin's disease is malignant lymphoma characterized by presence of Reed-Sternberg cells. There are four stages of Hodgkin's disease: • Stage I—Reed-Sternberg cells appear in one lymph node region. • Stage II—Reed-Sternberg cells appear in multiple lymph node regions on the same side of the diaphragm. • Stage III—Reed-Sternberg cells appear in multiple lymph node regions on both sides of the diaphragm. • Stage IV—Reed-Sternberg cells appear throughout the body. • Non-Hodgkin's lymphoma (NHL) are cancers of the B-lymphocytes and are characterized by the absence of Reed-Sternberg cells.

Discuss lab and diagnostic tests specific to leukemia.

• Low RBC count, low hemoglobin—anemia. • Low platelet count—thrombocytopenia. • Elevated WBC count—leukocytosis. • Abnormal amount of immature WBC shown in bone marrow biopsy. - this is what confirms diagnosis.

Discuss nursing care of the patient with leukemia.

• Monitor for bleeding—platelet count may be decreased. • Monitor for infection—patients have increased susceptibility to infection. • Monitor pain control. • Small, frequent meals. • Teach patients about infection control: • Avoid others with infection. • Report signs of infection, sore throat, fevers, etc. • Explain to the patient: Use an electric razor. Use soft toothbrush. Watch for bleeding or bruising. for children: √ Reinforce physician's explanation of diagnosis and treatment plan. √ Explain procedure at child's level of understanding including what will be seen, felt, heard, and smelled; use drawings when appropriate. √ Maintain contact after discharge and between remissions to encourage follow-up care and respond to questions or provide emotional support. √ Provide antiemetic and appetite stimulant to increase nutritional intake. √ Offer foods after antiemetic takes effect to reduce nausea and maximize caloric intake. √ Allow to eat any food that is tolerated; avoid forcing food during nau- sea episode. √ Rinse mouth to remove unpleasant taste sensation.

Discuss nursing care of the patient with lymphoma.

• Monitor vital signs to determine variations from baseline. • Monitor for complications such as new palpable lymph nodes and fever. • Increase fluid intake. • Increase calories, protein, iron, calcium, and vitamins and minerals to counter- act weight loss. • Administer prescribed antiemetic medication for nausea. • Monitor laboratory results for blood counts in response to chemotherapy.

Discuss the nursing process related to caring for a patient with bone marrow suppression (BMS).

• Myelosuppression results from inhibition of the manufacture of red and white blood cells and platelets. Severe anemia, bleeding tendencies, leukopenia, neutropenia (decreased neutrophils), and thrombocytopenia are possible if bone marrow depression is profound. Blood transfusions may be necessary, as well as protection of the client from infections. Bleeding—may result from bone marrow suppression, medications that interfere with coagulation and platelet function, or both

Discuss safety for the health care worker when administering chemotherapy.

• Use a biologic safety cabinet for the preparation of all chemotherapy agents. • Wear surgical gloves when handling antineoplastic agents and the excretions of patients who received chemotherapy. • Wear disposable, long-sleeved gowns when preparing and administering chemotherapy agents. • Use Luer-Lok fittings on all intravenous tubing used to deliver chemotherapy. • Dispose of all equipment used in chemotherapy prepara- tion and administration in appropriate, leak-proof, puncture-proof containers. • Dispose of all chemotherapy wastes as hazardous mate- rials.