265 exam 4

cardiac tamponade

The tumor direct pressure in or around pericardial sac resulting in dec venous return & sudden dec in CO o Pressure is placed upon heart and decreases ability to expand (fill), pressure inc in ventricles

allergy

***EPI PEN, STOP INFUSION, LATEX CONDOM USE*** · "Hypersensitivity" increased immune response to the presence of an allergen "antigen"

Systemic Sclerosis (Scleroderma)

***SWALOWING PROBLEM*** · Uncommon, chronic, inflammatory, autoimmune connective tissue disease. · Similar to SLE, but w/a higher mortality rate · DOESNT RESPOND TO STEROIDS OR IMMUNOSUPPRESANTS, WHY MORTALITY IS HIGHER THAN SLE · Inflamed tissue becomes fibrotic and then sclerotic (hard) - renal involvement leading cause of death · Women 25-55, most in 40s

critical rescue with kidney transplant

- notify the surgeon immediately if hypotension occurs or excessive diuresis (urine output 500-1000 mL > intake over 12-24 hours). The reduction of blood flow & O2 threatens graft survival

sealed radiation source

- placed in sealed container (beads, capsules or ribbons) and placed in a body cavity or interstitial tissue often for 24 - 72 hours With sealed sources radiation does not contaminate urine, sweat, blood or vomit Pts require a private room, shields & special container for implant if it becomes dislodged Visitor ½ hr per day & stay 6 feet away from source Wear led apron while providing care *DO NOT turn back toward pt Save all dressings and bed linens until after radioactive source is removed, equipment is ok

Creatinine

0.5-1.2

INR

0.9-1.2 (Theraputic level 1.8-3.6 seconds)

Urticaria

o "hives" § Papules or plaques that often fade within 24 hrs. § If hives last over 6 weeks - chronic urticaria § ASA & NSAIDS can exacerbate hives- § Antihistamines mainstay of treatment

specific gravity

1.005-1.030

Mg

1.5-2.5

BUN

10-20

PT

11-1.5 (16.5-31.25 seconds on coumadin)

· Hbg

12-18

Na

135-145

PLT

150-400

Phosphorus

2-4.5

Albumin

3.5-5

K+

3.5-5

Hct

37-52

RBC

4.2-6.1

WBC

5-10

PTT

60-70 (90-175 on heparin)

moderate hyopthermia

82.4-90

Ca

9-10.5

mild hypothermia

90-95

Cl

98-106

skin protection during radiation therapy

Cleanse w/ hand and not washcloth, pat dry Do not remove dye markings from skin ONLY powders, lotions, ointments, or creams than are prescribed by radiation department Soft clothing, no belts, buckles, straps, or clothing that binds or rubs on skin. Avoid exposure of irradiated skin to the sun o More sensitive to sunburn and sun damage, no direct sun exposure for 1y o Go outdoors in the early morning or evening o Stay under awnings, umbrellas, or other shade when sun rays most intense (10am -7pm)

malignancy with organ transplant

§ Development of post-transplant malignancy is well documented § Basal cell & squamous cell skin & lip cancer, Ca of vulva, perineum & lungs § All patients should be screened for development of cancer after transplantation § Monitor clients for Epstein Barr virus - may convert to seropositive and put at higher risk for cancer

acute graft rejection diagnosis

§ Diagnosis of rejection is by organ biopsy (both acute & chronic rejection)

chronic rejection with kidney transplant

· ONSET: Gradually from months -yr · Gradual INC in BUN and creatinine · Fluid retention · Changes in electrolyte levels · Fatigue · TX: Conservative management until dialysis is required

Prevention of Injury for Pt w/ Thrombocytopenia

Avoid IM injections and venous punctures (use smallest gauge needle, pressure 10 min) Apply ice to trauma areas Nothing rectally, test all urine and stool for blood Electric shaver, soft toothbrush, NO water pick Do not blow nose, shoes w/firm soles Fall prevention - priority is to provide safe environment

bone cancer risk factors

Big risk factor is previous radiation exposure All ages, Men, Genetic disorders Previous BMT Primary tumors - prostate, breast, kidney, thyroid, and lung are bone-seeking cancers

biotherapy

Biologic response modifiers - can augment modulate or restore immune response Rituximab (Rituxan) for Non-Hodgkin's Lymphoma Hematopoietic growth factors - proteins that mediate forming and developing blood cells Used after chemo they stimulate bone marrow recovery

severe hypothermia s/s

Bradycardia Severe hypotension Cardiac dysrhythmias Dec resp. rate Acid base imbalance

hyperacute rejection kidney transplant

· ONSET: W/i 48 hr after surgery · Increased Temp · Increased BP · Pain at transplant site · TX: immediate removal of the transplanted kidney

superior vena cava syndrome

Can be caused by internal or external obstruction of SVC Reduces venous return to heart & compromises CO, causes pain and is an emergency Typically secondary to lung tumors and radiation or chemo used to dec. tumor size Early s/s - edema of face & eyes, tightness of shirt or blouse collar, engorged blood vessels, erythema of upper body, **edema of arms and hands**, dyspnea, epistaxis, Late s/s - hemorrhage, cyanosis, mental status changes, dec CO, hypotension Late-stage manifestation; the tumor is widespread SOB, cough, hoarseness, chest pain, HA, dysphagia, JVD, inc ICP w/ visual disturbances High-dose radiation to provide temporary relief, Chemo only option long term, stent

yellow tag

Can wait short time - class II Major injuries, tx w/I 30-2hr Open fx w/distal pulses Large wounds Require hospital admission

spinal cord compression

Caused by direct pressure on cord or its vascular supply, can cause permanent paralysis if not tx promptly Report immediately New onset of back pain is a red flag in cancer patients, weak or heavy feeling in arms, numbness or tingling in hands or feet, loss of ability to distinguish hot or cold, unsteady gait, and paralysis Mostly seen in lung, prostate, breast, and colon TX - Palliative w/ high-dose corticosteroids, high-dose radiation

chemotherapy s/e

Suppresses bone marrow (anemia, neutropenia, thrombocytopenia) • Inc r/f infection (sepsis risk), bleeding, hypoxia, fatigue N/V, alopecia, mucositis, altered bowel elim, anxiety, changes in cognitive function

tumor lysis syndrome

Develops as the tumor responds to tx, positive sign that cancer tx is effective o Begins 1-2 days after tx starts & is potentially fatal o Large tumor call destruction leads to elevated serum potassium (>5), phosphorus (2-4.5) & uric acid o Sx - muscle weakness, muscle cramps, N/V/D, flaccid paralysis, EKG changes, oliguria, flank pain hypotension, edema and altered mental status o Treatment § Can be prevented and managed with aggressive IV fluids and oral fluids (3-5 L/day) § Allopurinol to dec uric acid § Sodium bicarbonate to promote excretion of phosphates § 50% dextrose & IV insulin or dialysis to treat hyperkalemia At risk pts need to drink at least 3-5L day before, day of, and up to 3 days after treatment.

surgery with cancer pts

Diagnostic surgery - cytological specimens, needle biopsies for tissue samples Treatment surgeries to remove all or part of tumor and are often followed by radiation or chemotherapy Can also be palliative, reconstructive or preventive

prevent infection with chemotherapy

Do not share personal toilet articles Bathe daily w/ antimicrobial soap OR wash armpits, groin, genitals and anal area 2x day Clean toothbrush weekly in dishwasher or with bleach Do not drink cold liquids standing at room temp for > 1 hr Do not change pet litter boxes Take temp daily & report >100, persistent cough, foul drainage, urine burn or cloudy

red tag

Emergent - class I Immediate threat to life Airway obstruction Shock Severed legs Chest pain, SOB Hemorrhage

black tag

Expected to die - Class IV Expected and allowed to die Lethal injuries Massive bleeding Extensive full thick burns Massive head trauma High cervical spine injury

urothelial cancer risk factors

Exposure to toxins esp chemicals used in hair dyes, rubber, paint, electric cable, & textile industries Greatest risk factor is tobacco use; >60 years Other risk- shistosoma haematobium (parasite), infection, excessive use of drugs containing phenacetin, and long term use of cyclophosphamide (Cytoxan)

good death

Free from avoidable distress and suffering for pts, families, and caregivers; in agreement with patients' and families' wishes; and consistent w/clinical practice standards.

loss and grieving

The most valuable support is your presence as a caring person Patients responses to cancer & level of distress may be based on: Disease - disabilities & disfigurements it causes Preexisting medical condition that limits treatment options Patient's psychological & spiritual makeup Patient's family & social community support Availability of medical & financial resources

er emergent

Immediate threat to life or limb · Crushing chest pain w/ SOA and diaphoresis · Critically injured trauma · Active arterial hemorrhage · Acute respiratory distress - Pyridoxal chest movement, stridor, cyanosis · Unstable VS · Stroke s/s · Open fx w/blood loss

skin cancers s/s

Irregular shaped, pigmented, crust, or firm & nodular

moderate hypothermia s/s

Muscle weakness Acute confusion Incoherence Stupor Decreased clotting

cancer diagnostics

Need a complete history Assess symptoms Lab tests CBC with diff (may be non specific) Tumor markers - PSA, CEA, CA-125 Hematologic changes - anemia, leukopenia, leukocytosis, bleeding disorders - markers of disease but not often diagnostic of specific cancer Radiological tests § Basic x rays § CT § MRI § PET scans § Ultrasounds o Mammograms o Tissue testing from biopsies o Direct imaging from fiber optic scope o Radioisotope testing

green tag

Non-urgent - Class III Minor injuries, tx >2hr "Walking wounded" Closed fx, sprains, strains, abrasions, contusions

radiotherapy

Radiation More than 60% of cancer patients receive during therapy May be primary, adjunct, or palliative Uses high energy ionizing radiation to destroy the cells ability to reproduce by damaging DNA Well oxygenated tumors respond better to radiation than other tumors

hypercalcemia

Second most common emergency and is due to bone reabsorption Defined as a serum calcium > 11 mg/dl (normal 9-10.5) 80% occurs w/ solid tumors like breast, lung, head, neck, renal - Occurs w/bone metastasis S/S - Skeletal pain, abd discomfort, altered cognition, N/V/C, Inc UOP, Severe muscle weakness (airway), loss of DTR, paralytic ileus, dehydration and ECG changes Medical tx is w/ calcitonin and steroids, NS, disphosphonates (diuretics), dialysis if life threatening

mild hypothermia interventions

Shelter from cold Remove wet clothing Warm blankets Warm high carb fluids - no caffeine or alcohol

mild hypothermia s/s

Shivering Dysarthria Mental slowness Diuresis

moderate hypothermia interventions

Supine position Withhold IV drugs until temp above 86 F Active external and internal warming - trunk warmed before extremities - Warm IV fluids,heated cavity fluids

severe hypothermia interventions

Supine position Withhold IV drugs until temp above 86 F Cardiopulmonary Bypass Internal warming only, NO EXTERNAL WARMING

cancer s/s

Weight loss Weakness or fatigue CNS alterations Pain - bone cancer is extremely painful, but pain is not an early manifestation in most cancers Hematologic & metabolic alteration depending on primary site Seven Warning Signs of Cancer (Advancing age is single most important r/f for cancer) C- changes in bowel or bladder habits A- a sore that does not heal U- unusual bleeding or discharge T- thickening or lump in the breast or elsewhere I- indigestions or difficulty swallowing O- obvious change in a wart or mole N- nagging cough or hoarseness

Preventing Injury or Bleeding with chemotherapy

When platelet count is low.... • DO NOT have dental work • DO NOT take aspirin • NO contact sports • If bumped, ice for 1 hr • Avoid hard foods and hot foods (caution w/ cheese topping on pizza) • Check skin daily for petechiae • Avoid trauma w/intercourse & NO anal intercourse • Avoid bending at waist • Avoid musical instruments that IICP (brass wind, woodwinds, or reed instruments)

SLE s/s

butterfly rash, discoid rash, photosensitivity, oral ulcers, polyarthritis, plueritis, FEVER is major sign of exacerbation, generalized weakness, faigue, anorexia, weight loss, renal disorders (protienuria, cellular cast), neuro disorders (seizures, psychosis, peripheral neuropahties), raynauds phenomenon, alopecia

anaphylaxis

o (Distributed Vasodilated Shock) § Most common causes drugs, food, latex exposure, insect bites & stings (BEES) § Symptoms · Often present with hives, angioedema, dyspnea & wheezing · Syncope, hypotension · N&V, diarrhea, abd pain · Flushing, headache, rhinitis, itching · CV collapse, shock, resp tract obstruction § Symptoms can begin 5-30 min after encountering trigger or be delayed an hour or more

intra abdominal injuries

can be blunt (spleen) or penetrating (liver) injuries § Once assess ABCs, focus on hemorrhage, shock, and peritonitis § Be sure pt is typed and crossmatched for 4-8 units of packed RBCs § Mental status, VS, and skin perfusion (most reliable for assessing hypovolemic shock) · Mild shock - skin is pale, cool, and moist · Moderate shock - Diaphoresis more marked and anuria · Severe shock - Changes in mental status (agitation, disorientation, & recent memory loss) § Inspect abd, flanks, back, genitalia, and rectum for injuries, ecchymosis, and asymmetry · Ecchymosis (bruising) may indicate internal bleeding · Ecchymosis in distribution to lap seat belt reported immediately · If open abd wound cover it with dry sterile dressing

HIV/AIDS pain managment

esp. with neuropathies § Pregabalin (Lyrica), TCAs- amitriptyline (Elavil) § Anticonvulsants- gabapentin (Neurontin), phenytoin (Dilantin), carbamazepine (Duragesic) § Opioids - hydrocodone, tramadol, or codeine, oxycodone, morphine, hydromorphone or fentanyl o Maintenance of skin integrity

er urgent

not immediately life threatening but needs care in the next 1-2 hours · New onset of pneumonia w/o acute respiratory failure · Severe abdominal pain · Renal colic · Displaced fractures (closed) or multiple fx, or dislocations · Complex or multiple soft tissue injuries · Complex lacerations not associated w/ major hemorrhage · Temp >101

HIV/AIDS preventing infection

o (when neutropenic, low WBCs) § Clean toothbrush weekly by running it through dishwasher or bleaching § Avoid fresh fruits and vegis; undercooked meats, fish, and eggs; and pepper and paprika § Do NOT drink water, milk, juice that have been standing for longer than 1 hour § Do not change pet litter boxes, if unavoidable, use gloves & wash hands § Take temp once a day and report if > 100, have persistent cough, cloudy urine, etc. § Do not dig in garden or work with houseplants

External Beam Radiation(Teletherapy

o - from a machine outside the body aimed at tumor cells § Advantage is it is usually skin sparing - most of cell destruction is at tumor depth Patient is not radioactive so there are restrictions

SLE diagnostics

o ANA most sensitive but antinuclear antibodies not specific to SLE o C reactive protein can help differentiate SLE flare from an infection (remains normal if SLE flare) o CBC shows pancytopenia (a decrease in all cell types)

allergy diagnostics

o Allergy skin testing - Has to be red & raised § avoid antihistamines & corticosteroid inhalers 2 weeks before testing § Emergency equipment (resuscitation bag, suction, IV, drugs) for anaphylaxis o RAST (radioallerosorbent test) or fluroenzyme blood tests used to measure IgE levels to specific allergens o Pulmonary function measurements for allergic asthma o Blood test measuring levels of IgE (normal 39 IU/ml) o CBC may show inc eosinophils (normal 1-2%)

bone marrow transplant

o Allows use of a lethal dose of chemotherapy and radiation to kill tumors o Client's own marrow is harvested prior to treatment, treated & frozen for after treatment o Marrow can also come from matching donor (allogeneic) o Primary treatment modality in leukemia o May also be used for breast cancer or lymphomas

AIDS criteria

o CDC definition - patient has AIDS if he or she is infected with HIV & presents with ONE of the following: o A CD4+ T-cell count < 200 OR o Patient has one of the defining illnesses ***NO DROPLET OR CONTACT, ONLY STANDARD*** § Candidiasis of lung, bronchi, or esophagus; Coccidioidomycosis; Cryptosporidiosis; CMV; TB; Histoplasmosis; Kaposi's sarcoma (cancer); Pneumocystis Jiroveci Pneumonia (kills most AIDS pt.) § Defining illnesses usually do not make us sick, with a heathy Immune system (standard precautions) EXCEPT for TB which needs airborne and standard. · Until parameters other than a skin test come back negative for TB in a pt w/ AIDS who has TB sx, maintain airborne precautions along with standard precautions.

medical managment with organ transplants

o Complex patient management o Immunosuppressants - continuous to prevent rejection of transplanted organ (use 2-3 different ones) § Calcineurin or Interleukin 2(IL-2) inhibitors - suppress T cells & inhibit production of interleukin 2 · Cyclosporine, Tacrolimus, Sirolimus, and Corticosteroids § Antiproliferative agents inhibit production of T & B cells & interfere w/ DNA & RNA synthesis · Azathioprine(Imuran) & Mycophenolate mofetil (CellCept ) § Antibodies - monoclonal or polyclonal & inhibit T call function, dec circulating T cells or block IL- 2 · Muromonab - CD3, Antithymocyte globulin ( ATG), and IL-2 Receptor antagonists

heat exhaustion

o Dehydration caused by heavy perspiration and inadequate fluid intake, o S/s - Flus like sx, HA, weakness, N/V, body temp not significantly elevated o Tx - Cold packs on the neck, chest, abd, and groin; soaking in cool water or fanning while spray w/water o Sports drink, NO water to rehydrate, no salt tablets

DIC

o Extensive abnormal clotting inside blood vessels o Clotting consumes all clotting factors & pt bleeds from IV sites, Foley, needle sticks, gums, mucous mem o Trigger is gram negative infection or release of thrombin or thromboplastin from tumor cells o Most commonly seen in leukemia and adenocarcinomas of lung, pancreas, stomach and prostate o Clots block blood vessels and decrease blood flow to major body organs o Pain, stroke like manifestations, dyspnea, tachycardia, reduced kidney function, & bowel necrosis. o Best management is prevention, strict aseptic technique o Tx w/heparin to limit clotting & prevent rapid consumption of clotting factors & w/ clotting factors

skin cancer risk factors

o Factors for melanoma § UV exposure is most common cause § Genetic predisposition, precursor lesions that resemble unusual moles § Fair complexion, >60, multiple moles, & exposure to coal tar, pitch, creosote, arsenic or radium

frostbite

o Frostnip - superficial cold injury, waxy white appearance, relieved by applying warmth § Warm hands on effected area or hands under arm pits o First-degree - Inc blood flow and edema o Second-degree - large fluid filled blisters w/partial thickness necrosis o Third-degree - small blisters w/dark fluid, cool, numb, blue, or red tissue that doesn't blanch o Fourth-degree - NO blisters or edema, numb, cold and bloodless, gangrene, amputation

chronic rejection

o Gradually during period of months to years, after the first 3 months after transplantation o May be a result of frequent acute rejection episodes, increased ischemic time, or CMV infection o Usually slow progressive loss of graft function o Transplanted organ develops persistent perivascular inflammation associated with local myocyte necrosis o Treated like acute rejection & new organ transplant may be needed

advanced directives

o Have to have original there with you and it must be notarized for it to be valid o Durable Power of Attorney for Health Care - makes one's decisions related to health care when can't o Living Will - Identifies what one would or would not want if they were near death. · Discusses - CPR, artificial ventilation and artificial nutrition or hydration o DNR Form - Actual order form a Dr. that instructs that CPR not be attempted o PT: states, "I don't want to be coded" and has ZERO paperwork proving wishes according to an advanced directive, WE CODE THE PATIENT · Morphine tx for dyspnea near death as reduces o2 consumption, air hunger, anxiety, & pulmonary congestion · Loud, wet respirations (death rattle) - reposition pt to one side to reduce gurgling & towel to collect secretions · Manage N/V, agitation and delirium

scleroderma pt education

o How to dress in cold weather-gloves, socks, etc. o Eliminate alcohol, cigarettes, extreme stress, and caffeine (vasoconstrictive) o Biofeedback for stress management o Disease process - Only gets worse

cervical cancer s/s

§ Classic sx of invasive cancer is painless vaginal bleeding Watery, blood tinged vaginal discharge that becomes dark and foul-smelling

nurses role in organ donation

o Identifying potential donors, notifying OPO, assisting in management of donor § In Kentucky & S. Indiana all hospital deaths must be called to KODA § Potential brain death with low GCS must be called prior to death o Preparation of recipient - organs have limited viability outside the body § Heart 4 - 5 hrs § Lung 4 - 6 hrs § Liver 24 - 30 hrs § Pancreas - 24 hrs § Kidney - 48 - 72 hours- often a 72 hr kidney will need dialysis before it starts on its own

monitoring response to tx with cancer

o Imaging studies o Lab tests - CBC, tumor markers, electrolytes o Vital signs - because infections are associated with greater morbidity & mortality, development of a fever in a pt with neutropenia is considered a medical emergency- antibiotics must be started promptly § Patients are taught to report a temp > 100.4, cough, sore throat, chills or frequent urination · Diet - maintain adequate nutrition & fluid intake - anorexia and N&V are common o Weight loss of 5% in 1 month is significant o Diet high in protein and carbs o Antiemetic needs to be administered before chemotherapy o No raw or uncooked foods during nadir (period of lowest WBC count) o No sharing of utensils or dishes o Oral care 4-6 X/day with soft toothbrush & alcohol free mouthwash · Activity - need adequate rest & exercise o Avoid exposure to crowds, people with infections, and children who have had recent vaccinations · Pain management - will be very patient specific o Needs to be based on good assessment o Can use extended release meds & pain patches

post op care with organ transplants

o Immediate postop - monitoring of all systems plus evaluation for hyperacute rejection § Hemodynamics, ventilator, vasoactive drips, cardiac rhythms, frequent labs, etc § Monitor function of transplanted organ (kidney I&O, heart CO, lung ABGs, pancreas BS) o Infection control - Meticulous care § May not have usual manifestations of infection bc immune suppressed § Low-grade fever, mental status changes, and vague reports of discomfort may be only manifestations before sepsis o Medication administration o Psychosocial care

scleroderma nursing managment

o Keep HOB elevated 60 degrees during meals and at least an hour after o Maintain skin integrity- esp with steroids & vasospasm o Small frequent meals w/semisoft foods - avoid liquids (thickit) due r/f choking - small amounts & chew well o Teach to avoid foods that inc gastric secretion-spices, caffeine, pepper o Promote bowel elimination - have both constipation & diarrhea

Scleroderma medications

o Medications - Tx sx § Vasoactive agents - CCB for Raynaud's symptoms § Anti - inflammatory meds - steroids § Immunosuppressants o Reduce renal complications § ACE inhibitors and HTN control o Treat PAH (Pulmonary Artery Hypertension) § Bosentan - endothelin receptor antagonist - Liver toxic

AIDS/HIV complications

o Opportunistic infections-CMV(visual disturbances), pneumocystis o Kaposi's sarcoma § Most common AIDS related malignancy § Small, purplish brown, raised lesions on skin or mucous membranes, not painful or itchy · Painful if large lesions, open, and weeping § Make-up ok if lesions are closed § With HAART therapy many lesions will disappear o AIDS dementia- most antiretrovirals do not cross the blood brain barrier o Wasting syndrome- HIV affect absorption in small intestine

contraindications to organ transplant

o Presence of active systemic infection o HIV/AIDS o Malignant disease(except skin cancer) o Active peptic ulcer disease o Active abuse of alcohol or other substances o Severe damage to organ systems other than one to be transplanted (ex. Cardiac Disease) o Severe psychiatric disease- to where they can't understand and follow the post-transplant protocol o Demonstration of past or current inability to comply with a prescribed medical regimen o Lack of a functional social support system o Lack of resources to pay for surgery, hospitalization, medication, and follow up care

cancer prevention

o Primary § Avoidance of known or potential carcinogens § Removal of at risk tissues (polyps, breasts) § Chemoprevention - reverse existing gene damage or halt progression or transformation process o Aspirin and celecoxib to reduce r/f colon cancer o Vit D and tamoxifen to reduce r/f breast cancer o Lycopene to reduce r/f prostate cancer § Vaccines (only one, for HPV) o Secondary § Regular screenings o Yearly mammogram for women >40y o Yearly breast exam for women >40y; every 3 years women 20-39 o Colonoscopy at age 50 and every 10 years o Yearly fecal occult blood for adults of all ages o Digital rectal exam for men >50y

HIV/AIDS S/S

o Primary infection-initial period after a person acquires HIV § Fever, fatigue, lymphadenopathy, N/V § HA, truncal rash, ulcers of mouth & genitals, thrush, pharyngitis, diarrhea, hepatomegaly, myalgia, arthralgia, leukopenia § CD4+ count may rapidly drop to below 100/mm3 (But rebounds) § This is the time when antibodies are developed but not detected for 4-12 weeks - seroconversion · HIV enzyme immunoassay - if positive Western Blot is performed to confirm HIV infection § Preliminary studies show that starting retrovirals at this time can prevent damage to the immune system and other body systems · Once you start the antiretrovirals you cannot come off of them § Some not dx bc of mild sx, not seeking medical attention or healthcare professional does not recognize & take adequate hx (symptoms can mimic mono)

triage assessment primary

o Primary survey - ABCDE § To identify client problems that pose a threat - immediate or potential - to life, limb or vision § Airway/cervical spine · Non-rebreather mask is best for spontaneous breathing pt. · If GCS <8 pt is at risk for airway compromise, prepare for intubation & vent · Clear airway of any secretions or debris · Protect cervical spine in any trauma by manually aligning the neck in neutral, in-line position, and using jaw-thrust maneuver when establishing an airway. § Breathing · Determines whether or not ventilatory efforts are effective · If CPR necessary, disconnect vent and use BVM to manually vent to assess lung compliance § Circulation · Adequacy of HR, BP, and overall perfusion · Common threats - Cardiac arrest, Myocardial dysfunction and Hemorrhage leading to shock § Disability · Rapid baseline assessment of neuro status · AVPU - Alert, Responsive to Voice, Responsive to Pain, Unresponsive · Evaluate GCS - Score 3-15 § Exposure · Always cut away clothing to do through assessment · When clothing removed, r/f hypothermia (temp <97) o Cover pt w/blankets, heating devices, infuse warm solutions Also includes brief LOC and pupil response

triage

o Purpose is to expediently determine severity of a pt's problem & deliver emergency care in the most appropriate time frame - Take into account preexisting conditions (Transplant, AIDS, DM, Anticoags)

HIV/AIDS education

o Recurrent labs o Annual TB test o PAP test- every 6 months o Chest x-rays o Long term medication, dosing, S/E, timing around the clock o Diet high in calories and protein, 2-3 L H2O, avoid fatty foods (causes diarrhea) due to intolerance from s/e of antiretrovirals. · Home care and Infection spreading control o Do not share razors or toothbrushes o Wipe up body fluids, flush, and clean area with bleach o Needles or sharps in coffee can or bleach bottle & decontaminate when full w/bleach, seal w/tape, place in paper bag, and put in regular trash o Condoms all the time

HIV/AIDS patho

o Retrovirus infects T helper cells, macrophages & B cells o Normal CD4+ T cell level is 500 - 1600/mm3 - Decrease w/age o With CD4+ T cell level < 200/mm3 - infection is likely to develop o Antiretrovirals inhibit ability of virus to enter cells or replicate, reduce amount circulating virus & halting its destructive activity o Usually at least two to three drug protocol o 5 % of HIV people after 10 y show no progression and are called long-term non-progressors (LTNP's) o Main target of HIV is immune system but also damages other parts of body as a result of HIV in body tissues § Cranial & peripheral neuropathies § Cardiomyopathy § Pneumonitis § Malabsorption in small intestine § Nephritis § Arthritis, psoriasis § Adrenalitis Anemia, granulocytopenia, thrombocytopenia

nursing diagnosis with organ transplant

o Risk for Imbalanced Nutrition § More than r/t steroids § Less than r/t inc caloric needs after transplant o Ineffective Protection & Risk for Infection r/t immunosuppression o Deficient Knowledge r/t post-transplant regimen o Acute Pain r/t transplant surgery o Risk for Ineffective Coping after transplant Risk for Injury r/t infection or immunosuppression

SLE medical management

o Topical steroids for skin lesions o Acetaminophen or NSAIDS (caution with kidneys) - tx joint & muscle pain & inflammation o HYDROXYXHLOEOQUINE (anti-malarial agent) - dec absorption of ultraviolet light by skin, dec skin lesions § Frequent eye exams - b4 starting and q 6 mon o GLUCOSTEROIDS - Chronic steroid therapy § Take in the am b4 breakfast § Take Ca to prevent osteoporosis § Maintain skin integrity o Immunosuppressants - METHOTREXATE, AZATHIOPRINE o BELIMUMAB - do not receive live vaccines for 30 days b4 tx

latex allergy

o Type 1 hypersensitivity reaction o People at greatest risk for developing a latex allergy are those with high exposure to natural latex products like patients with spina bifida, frequent use of latex condoms and healthcare workers. o Allergic to bananas, avocados, and some nuts more likely to have latex allergy

HIV/AIDS risk factors

o Virus is spread through sexual practice (primary), exposure to blood & body fluids and through perinatal o Male homosexual activity still greatest risk for most Americans o Increased risk with IV drug users, women & heterosexuals noted recently o Women over 50 acquire HIV primarily through heterosexual contact o IV drug use accounts for largest number of HIV infections through exposure to infected blood o Accidental needle stick exposure poses greatest hazard to healthcare workers o Standard Precautions markedly reduce healthcare workers exposure

acute graft rejection

o W/i first three months after transplant o Either a cellular immune response mediated by T cells or an antibody mediated response or a combination o Diagnosis is made based on clinical manifestations, labs & results of a biopsy o S/S of acute graft rejection § Fever § Graft tenderness § Fatigue § Heart - SOA, irregular heartbeat § Lung - SOA § Liver- tachycardia, RUQ or flank pain, diminished bile drainage, change in bile color, inc jaundice § Pancreas- kidney issues occur before pancreatic problems; high glucose levels is a late sign

SIADH

o Water reabsorbed in access due to too much antidiuretic hormone o Small cell lung cancer is the most common cause, some tumors make and secrete ADH or stimulate release o Some chemotherapy meds like cytoxan, vincristine, vinblastine and cisplatin may cause SIADH as a s/e o Dilutes NA levels to 110-120 (normal 135-145) - weakness, cramps, anorexia, confusion, fatigue, Seizures o Monitor for fluid overload - Bounding pulse, JVD, crackles, edema, Dec UOP o Tx w/ demeclocycline (works in opposition to ADH), fluid restriction, and increase sodium intake.

hyperacute graft rejection

o Within 48 hrs after surgery o Caused by presence of antibodies - results in organ necrosis o Prevented by histocompatibility testing, crossmatching & PRA (preformed reactive antibody) testing o Tx w/ plasmapheresis - but if it fails the patient needs a new organ transplant o Diagnosis is made based on serologic labs, physical assessment data & hemodynamic measures

Internal Radiation (Brachytherapy)

o placement of isotopes directly into or near the tumor or in systemic circulation - this patient is radioactive for a short time and is harmful to others

pt teaching with organ trandplants

o this is a huge issue and involves many disciplines & often has written material as well § Schedule of return visits is given at discharge (usually by transplant coordinator RN) § Must reside close to transplant center for 2-8 weeks before going home § When to call transplant team § S/S of rejection & infection § Routine care - temp, weight, skin & incision care, fluid intake & output § Immunosuppressant meds, S/E and how to administer · Management of immunosuppressive regimen is crucial and lifelong · When immunosuppressed latent infections (TB & Herpes) can be reactivated · S/E- HTN, nephrotoxicity, GI disturbances § Diet after transplant § Activities after transplant § Self-care - BP, BS, Medical ID bracelet, sun exposure, OTC meds, birth control § Psychosocial issues - family support, contacting donor family, cost of transplant & med maintenance § Health maintenance - dental care, eye exams, GYN exams & yearly transplant evaluation (biopsy)

er non-urgent

requires evaluation & possible treatment but time is not critical factor · Strains & sprains · Simple fracture (non-displaced) · Cold sx, Skin rashes

chemotherapy

systemic intervention used If disease is widespread As an adjunct to radiation in hard to treat cancers Implanted port or central line to reduce r/f extravasation Oral and IV routes have same toxic effects and need same precautions

altitude illness interventions

§ Decent to lower altitude, especially for sleep § Acetazolamide - prevent and tx AMS, rids the body of excess fluid and induces metabolic acidosis which increases RR and dec apnea during sleep · Take 24 hrs b4 ascent and continue for first 2 days of trip · Sulfa drug, don't take if allergic to sulfa § Dexamethasone - reduces cerebral edema, anti-inflammatory, to relief sx § Tadalafil and sildenafil to prevent HAPE, pulmonary dilator § CCB nifedipine to dec pulmonary vascular resistance in HAPE

unsealed radiation source

usually used with systemic therapy but sometimes instilled in a body cavity o Radioisotope circulates through the clients body so body fluids are contaminated and contain active isotope o Patients receiving unsealed isotope need a private room & bath, all room surfaces are covered, food is served on disposable supplies, linen & trash kept in room until pt. discharge & visitor & staff contact is strictly limited Staff in these units wear dosimeter badges & are rotated to limit the amount of exposure o Patient is scanned before discharge to be sure radiation level has decreased to a safe level. Two common side effects - altered taste sensations and fatigue

colorectal cancer screening

§ **Colonoscopy every 10 years starting at age 50, more often if have personal or family hx** § Modify diet - Dec fat, refined carbs, and low-fiber foods, encourage baked or broiled food § Increase brassica vegis - broccoli, cabbage, cauliflower, and sprouts § Fecal occult blood testing - avoid aspirin, vitamin C and red meat for 48 hrs b4

prostate cancer risk factors

§ 1st - Age is leading risk factor, >65 has greatest risk § 2nd - African American men most risk, then Caucasians men second § 3rd - Risk increases 2x if have first-degree relative (brother, father) § Pt w/PIN (Prostatic Intraepithelial Neoplasia) at higher risk § Diet high in animal fat and complex carbs or low fiber intake § Exposure to cadmium or arsenic, firefighters, eating charred food, vasectomy

head and neck cancers risk factors

§ 2 most important r/f use of alcohol & tobacco, especially in combination § Poor oral hygiene, asbestos, Oral infection with HPV, Long term or severe GERD § Textile workers, plumbers, coal and metal workers § Periodontal gum disease, sun exposure, poor nutrition

Food allergy vs food intolerance

§ 8 foods 90% of true food allergies - milk, eggs, peanut, tree nuts, shellfish, fish, soybeans & wheat Diagnosis & treatment are avoidance

lung cancer risk factors

§ 80% of lung cancers are related to smoking or second hand smoke § Other causes are TB, asbestosis, exposure to radiation and air pollution, beta-carotene, family Hx

colorectal risk factors

§ AA, Men (slightly more); >50; personal or family cancer hx , hereditary colon cancer, ulcerative colitis, Crohn's disease, H Pylori, and HPV § Alcohol, sedentary lifestyle, and smoking are also contributing factors § High fat diet (animal fat from red meat)

breat cancer screening

§ ACS recommends diet with 5 servings of fruits & vegetables as added preventive step § Screening- Annual CT scan for high risk individuals § Dx-Sputum (early morning) cytology, chest x-ray, CT scan

breast cancer screening

§ ACS recommends self-breast exam monthly and mammograms yearly over age 40 § No single method is effective when used alone: mammogram, exam, & self-awareness

indicators of adequete early graft function with liver transplants

§ Adequate bile output § Decreasing AST/ALT levels § Increasing serum protein levels § Normal to slightly elevated glucose levels

hemorrhage

§ Always pay attention to history of accident/injury § Maintain blood flow to vital organs · Oxygen at 100% via mask § Stop or decrease bleeding if possible - Priority is to stop bleeding b4 fluids · Firm, direct pressure w/ thick dry dressing · Tourniquet occlude arterial blood flow distal to injury if pressure fails · Internal hemorrhage invisible - suspect in injuries & when present in shock state · Suture or staple bleeding site · Nosebleeds—need HX: warfarin, ASA, Tylenol, OTC; apply direct pressure & pack nose § Replace fluids · Large bore venous access - 16 gauge IV · Blood for labs need done thru IV if possible · Replace crystalloids & colloids as needed (warm before given to prevent hypothermia) o RBC, FFP, & platelets when significant hypotension persists after 2 L infusion § Potential complication is hemorrhagic shock · By time hypotension occurs, compensatory mechanisms have been exhausted. · Palpate pulse for BP - Radial at least 80S; Femoral at least 70S; Carotid at least 60S

allergy medications

§ Antihistamines - diphenhydramine - 2nd line drugs (angioedema & urticaria) § Decongestants - most OTC - are sympathomimetic § Steroids - 2nd line drugs · Nasal sprays - beclomethasone, triamcinolone, fluticasone (limit 5 days at a time) · Topical creams for dermatitis - hydrocortisone · Oral - have systemic effects also - prednisone · Inhaled steroids for allergic asthma - fluticasone, salmeterol o Desensitization - allergy shots

HIV/AIDS medications

§ Antiretrovirals · Inhibits viral replication, but doesn't kill the virus · Offer treatment asymptomatic with CD4+ < 250-300 · CD4+ >350 can defer if asymptomatic or consider if viral load is high · Buffalo humps or cervical (neck) fat development & lg abd fat accumulations § HAART - Highly Active Antiretroviral Therapy, uses 4 classes of antiretrovirals to reduce viral load, improve CD4+ T-cell counts, and slow disease progression · Multiple drugs taken to prevent drug resistance · Drugs need to be taken correctly 90% of the time forever · Missed doses of drugs contributes to drug resistance due to inc viral replication · Drawbacks o Expensive, food and timing requirements, significant s/e o IRIS - Immune Reconstruction Inflammatory Syndrome § T-cells slowly rebound and generate inflammatory reaction from opportunistic infections § High fever, chills, and worsening of infection (ex. TB becomes worse) § Tx with short term corticosteroids to reduce inflammatory response

heat stroke s/s

§ Body temp >104 § Skin is hot and dry, may not perspire § Mental status changes: Confusion, bizarre behavior, anxiety, hallucinations, loss coordination § Hypotension, Tachycardia, Tachypnea § Electrolyte imbalances (Na & K+) § Dec renal function (oliguria) - NO OR LITTLE URINE § Coagulopathy, Pulmonary edema (crackles)

septic shock assessment

§ Cardiovascular changes o Early Sepsis & Septic Shock - CO & BP are low in early sepsis & very low in septic shock. o Severe sepsis - INC CO, INC HR, & INC BP o DIC - excessive clotting uses up clotting factors, leads to poor clotting & inc r/f hemorrhage in septic shock stage. § Respiratory Changes o First caused by compensatory mechanisms to try to maintain O2 w/rate increase o ARDS may occur in septic shock from prolonged inflammatory response § Kidney/urinary changes o If pt suddenly has low UOP - severe sepsis or septic shock, Inc serum creatinine levels § Psychosocial o Slightly different in their reactions to greetings, comments, or jokes o Restless or fidgety, change in affect or behavior

urothelial cancer s/s

§ Change in color, frequency, or amount of urine, and any abd discomfort § Hematuria

head and neck cancers screening

§ Dr. or Dentist screening § OralCDx dx procedure performed by dentist during routine oral exam § Airway priority with croupous thick secretions, remove secretions, listen for saliva, High fowlers § Soft-bristled tooth brush, NO toothettes § NO alcohol mouthwash, Rinse with bicarb solution or warm saline

skin cancers screening

§ Early detection is critical - skin & mole screening § Avoid tanning beds, Avoid sun exposure between 11am - 3pm § Wear a hat & protective clothing when outdoors, sunscreen >15 SPF &avoid sunburns esp. children ·

bone cancer screening

§ Elevated serum alkaline phosphate (ALP) levels - inc osteoblastic activity § Elevated ESR § No regular screenings - watch for s/s Pain, swelling & fx

breast cancer risk factors

§ Genetic factors - inherited mutations of BRCA1 and BRCA2 - High risk · Jewish women have higher incidences of BRCA1 and BRCA2 genetic mutations § Early menarche, late menopause, no children or first child after age 30 § Being older woman or man is primary r/f - 77% diagnosed after age 50 (>65 high risk)

cervical cancer risk factors

§ Girls and young women, HPV, multiparity, smoking, younger than 18 at first intercourse, African American, multiple sex partners, oral contraceptives, Hx of STD, obesity and poor diet, family Hx of cervical cancer, HIV/AIDS, lower socioeconomic status, sexual partner who had a previous partner that developed cervical cancer, intrauterine exposure to DES

cervical cancer screening

§ HPV Vaccine - Gardasil and Cervarix, between 9 - 26 b4 first sexual contact (boys too) § PAP test starting at age 21 · Every 3 years from 21-29 · Age 30-65 PAP and HPV test every 5 years § Dx Colposcopy

to recieve a lung transplant a pt must

§ Have stable cardiac function § Ambulatory, able to walk w/o stopping for 30 min § Not ventilator dependent, maintain 90% O2 free of pulmonary fibrosis, ashthma, or cancer not have smoked for 6 months

allergy rhinitis

§ Histamine causes capillary leak, nasal & conjunctival mucus secretion, & itching w/redness § Allergic rhinitis has rhinorrhea (runny nose), stuffy nose, & itchy, watery eyes § Clear or white nasal drainage, HA or feel pressure

lung cancer s/s

§ Hoarseness, cough, sputum production, hemoptysis, SOB, or change in endurance § Blood in sputum, chest pain or tightness, recurrent PNA, pleural effusions, or bronchitis § Fever w/other signs, wheezing, weight loss, dyspnea, clubbing of fingers § Late findings can include Superior Vena Cava Syndrome - Emergency

High Altitude Pulmonary Edema

§ In conjunction w/HACE § Dyspnea at rest, fatigue, weakness, persistent dry cough, cyanosis or lips and nail beds, § Crackles, pink frothy sputum (late sign) § Need quick evacuation to lower altitude § Need O2 and bed rest to save pt life

other complications with liver transplant

§ Infection · Antibiotics prophylaxis; vaccinations § Acute Renal Failure · Early indications - dec UOP, inc BUN & creatinine, & electrolyte imbalance · Caused by hypotension, antibiotics, cyclosporine, acute liver failure, hypothermia · Indicators of hypothermia - shivering, hyperventilation, inc CO, vasoconstriction

cardiac tamponade assessment

§ JVD - Fluid overload w/clear lungs § Pulsus paradoxus - systolic BP 10 mmHg or more higher on expiration than inspiration § Decreased HR & CO, Dyspnea, Fatigue & Hypotension (JVD & hypotension not usually together) § Heart sounds are "distant and muffled" § Hemodynamic Monitoring - compression of heart w/all pressures (RA, PA, & Wedge) elevated

infection with organ transplants

§ Leading cause of morbidity & mortality after transplant § Results from immunosuppression or altered immune defenses § First month postop - nosocomial infections common § 1-6 months - opportunistic infections - pneumocystis carinii, candida, & CMV § Lungs are most common infection site followed by blood, urine, & GI tract

breast cancer s/s

§ Lump in breast; Skin dimpling; Peau d'orange (orange peel skin)

head and neck cancers s/s

§ Lump in mouth, throat, or neck § Thick or absent saliva; thickening or lump in cheek § Difficulty swallowing or chewing; Color changes in the mouth § Numbness of mouth, lips, or face § Burning sensation when drinking citrus juices or hot liquids § Persistent unilateral ear pain § Hoarseness or change in voice quality § Persistent or recurrent sore throat § Oral lesion or sore that doesn't heal in 2 weeks § Mucosal Erythroplasia is earliest sign of oral carcinoma, oral lesions red, raised, eroded

heat stroke complications

§ MODS, renal impairment, electrolyte & acid-base disturbances, coagulopathy, pulmonary & cerebral edema

notify surgeon asap with liver transplant

§ Monitor for Peritonitis by checking temp frequently & report inc; inc abd pain, distention, & rigidity § Monitor for Encephalopathy from a nonfunctioning liver by assessing neuro status § Report signs of Clotting problems - blood oozing from a catheter, petechiae, ecchymosis

colorectal cancer s/s

§ Most common signs - rectal bleeding, anemia, and changes in stool consistency or shape § Mahogany (dark)-colored or bright red stools

atopic dermatitis

§ No cure but goal is to control symptoms with antihistamines & topical steroids § Lesions red, itchy, contain exudates - may be drier in elderly Lesions typically found on cheeks, scalp, & forehead

indicators of adequete early graft function with heart transplants

§ Normal CO and cardiac index § Decreasing to normal CVP § Decreasing to normal PAP, PCWP § Normal SVR § Normal sinus rhythm with a ventricular rate of 90-100 BPM § Normal S1-S2 sounds, 2 unrelated P waves on ECG § Decreasing mediastinal drainage (<200ml/hr in 4 hours)

indicators of adequete early graft function with lung transplant

§ Normal Pao2 § Normal CO2 concentration § Normal oxygen saturation breath sounds clear and present in all lung fields decreased pleural drainage chest x-ray clear and well expanded

bone cancer s/s

§ PAIN, Swelling, Fx, Palpable mass, Impaired mobility, Low-grade fever, Anemia, Leukocytosis

triage secondary survey

§ Performed next to identify any non-life threatening problems § More comprehensive head-to-toe assessment to identify other injuries § History, pain assessment § Insert gastric tub for GI decompression to prevent vomiting and aspiration § Insertion of urinary catheter to measure I&O and for dx studies

cardiac tamponade managment

§ Pericardiocentesis: Puncture pericardial sac w/needle to remove fluid (blood won't clot) o After procedure closely monitor pt for recurrence of tamponade as it is not the cure o Provide adequate fluid volumes to inc CO § Monitor ECG (able to use for placement in non-emergent case) § Pericardiotomy: pericardial window o Removal of a portion of the pericardium o Used for recurrent pericardial effusions, drains in to abd Done under general anesthesia

prostate cancer s/s

§ Problems with urination, Frequent bladder infections, Urinary retention, § Hematuria (late sign), nocturia, pain after intercourse, recent weight loss. Stony hard prostate when palpated rectally, pain in back or legs

high altitude cerebral edema

§ Progression from AMS, key sign is ataxia (defective muscular coordination) § Change in mental status, confusion, impaired judgement, IICP

lung cancer screening

§ Prostate Specific Antigen (PSA) testing is used as a screening for prostate cancer § Currently ACS recommends men at age 50 start digital prostate exams § Transracial ultrasound w/biopsy · Report fever, chills, Bright red bloody urine, difficulty urinating. · NO strenuous physical activity, drink plenty of fluids § Prostatectomy · PCA pump, SCDs, I&Os, Out of bed into chair night of surgery · Stool softener, avoid straining during BM, avoid suppositories · No lifting more than 15 lbs for 6 weeks · Change catheter drainage bag once a week · Vigorous exercise avoided for 12 weeks · Shower only for 1st 2-3 weeks , no baths

urothelial cancer screening

§ Quit smoking § Precautions w/chemicals, shower or bathe after contact

heat stroke interventions

§ Rapid cooling is 1st priority · Cooling blankets, icepacks to axillae, groin, neck, and head; get wet & fan · Drenching victim w/large amounts of icy water, fastest, most effective § ABCs, high concentration O2 therapy, IV w/NS, Foley § Aggressive interventions to cool until rectal temp is 102 § DO NOT give aspirin or other antipyretics § DO NOT give food or liquid by mouth due to vomiting and aspiration risks § Give benzodiazepines if pt begins to shiver § Tetanus/rabies prophylaxis if appropriate (tetanus toxoid)

treatment for frostbite

§ Rapid warming in water bath w/temp between 104-108 degrees - causes severe pain · *NO apply dry heat* or massage as can produce further injury · Elevate injured area above heart to reduce edema · Assess hourly for compartment syndrome (inc pain, paresthesias, pallor) · Antiprostaglandin therapy w/ ibuprofen to dec tissue damage § PT temp must be at 90F to stop coding; Temp <86—lifesaving meds will not work!! (epi/norepi)

airway obstruction

§ Remove obstruction if possible § Intubate if necessary & verify tube placement If client has also sustained a traumatic injury cervical, thoracic and lumbar spine immobilized

s/s of heart transplant rejection

§ SOB, Fatigue, Fluid gain (edema, increased weight), Abd bloating, New bradycardia, Hypotension § Atrial fib or flutter, Dec activity tolerance, Dec ejection fraction (late sign) o Denervated (disconnected from body's autonomic nervous system) - Unresponsive to vagal stimulation § In early post-op, isoproterenol (Isuprel) may be titrated to support HR and maintain CO § Atropine, digoxin, & carotid sinus pressure NOT used bc do not have usual effects on the new heart.

septic shock

§ Sepsis-induced hypotension persisting despite adequate fluid resuscitation § Tachypnea and tachycardia are early s/s § MODS - Organ failure w/poor clotting w/uncontrolled bleeding (platelets & clotting fact gone) § Even w/interventions death rate is very high § Clinical Manifestations resemble late stage of hypovolemic shock § DIC - Bleeding from any area of non-intact skin § LOW Hct, Hgb, Platelets, Fibrogen levels, Activated protein C - from DIC

s/s of liver transplant rejection

§ Tachycardia, Fever, RUQ pain or flank pain, Dec bile pigment & volume, & Inc jaundice § Lab values- · Increase serum bilirubin · Rising AST & ALT levels · Increased Alkaline Phos level · Increased PT/INR

acute moutain sickness

§ Throbbing HA, anorexia, N/V, chilled, irritable, apathetic, similar to hangover § Tachycardic or bradycardic, normal BP, postural hypotension, DOE

acute graft rejection treatment

§ Treatment of acute rejection is called Rescue Therapy and includes: DON'T NEED TO KNOW NAMES · High dose steroids · Muromonab-CD3 (Orthoclone OKT3) · Antilymphocyte globulin · Includes 2-3 antirejection meds, to further immunosuppress - high risk for infection

surviving sepsis care bundle

§ Within the first 3 hrs of suspecting severe sepsis o Serum lactate levels o Blood cultures B4 antibiotics o Broad-spectrum antibiotics o HYPOtension OR serum lactate level is >4 mmol/L - 30 mL/kg crystalloids IV § Within 6 hrs of initial manifestations of suspected septic shock o Vasopressors for HYPOtension that didn't respond to fluid therapy to maintain MAP>65 • Dopamine, Noreip, Phenylephrine o If Arterial HYPOtension persists despite fluids (indicating septic shock) or lactic acid still >4 • Measure Central Venous Pressure (CVP) • Measure Central Venous Oxygen Saturation o Re-measure lactic acid (lactate) level if initial value was elevated § Target outcomes for sepsis bundle are obtaining & maintaining a Central Venous Pressure (CVP) of 8mm Hg or higher, central venous O2 sat of at least 70% & return of lactic acid levels to normal

indicators of adequete early graft fuction with kidney transplant

§ high volume Urine Output § Decreasing BUN and creatinine , may not start working for 24-48 hrs & need dialysis § Normal K+, glucose levels § Non-tender over graft (avoiding incision)

Limites cutaneous scleroderma

· *Esophagus o Skin thickening limited to sites distal to face, neck and distal extremities o Organ changes rare or late o CREST Syndrome § Calcinosis - calcium deposits in tissues § RAYNAUDS PHENOMENON-intermittent vasospasm of finger tips - first CREST symptom that develops § ESOPHAGEAL DYSMOTILITY- **Dysphagia** § Sclerodactyly - scleroderma of digits - fingers stiff, shiny, and no skin folds § Telangiectasia - capillary dilations that form vascular lesions on face, lips & fingers

Diffues cutaneous scleroderma

· *Major organ problems o FIRST SX- HAND AND FOREARM EDEMA W/ OR W/O BILATERAL CARPAL TUNNEL SYNDROME o Skin thickening on trunk, face, and proximal and distal extremities (most of the body) o Painless symmetric pitting edema of hands & fingers (sausage like fingers) o Changes of pigmentation with loss of skin folds & face can become mask like o Develop early problems w/ GI tract (GERD to dysphagia), heart(myocardial fibrosis), lungs (fibrosis & PAH), & kidneys (malignant HTN) o Complications can be rapid

bad death

· - Persistent pain, not having one's wishes followed at the end of one's life, isolation, abandonment, and agonizing about losses associated w/death. CPR can prevent a peaceful death o Nurses have greatest impact on pts death experience, prevent death w/o dignity (bad death)

Discoid lupus

· Affects only the skin and is not lethal - Caused by UV rays · Macular Rash & Discoid Rash · Skin biopsy to dx

pallative care

· Any stage of serious illness · Concurrent w/curative therapies, that prolong life · Care not limited by specific time periods · Assists pts & families in identifying goals of care, assist w/informed decision making, & facilitates quality sx mgmt · Provided by a physician, nurse practitioner or team of providers, consultation visit w/follow up visits

Anaphylaxis treatment

· Assess respiratory status, airway & O2 sat (do not run and get a probe) · Call the Rapid Response Team · Oxygen via non-rebreather 90-100% and have intubation/tracheostomy equipment ready · 1st - Immediately discontinue IV drug and changing the tubing and hang NS · Prepare to administer Epinephrine IV OR EPI PEN · Elevate HOB 45 degrees if BP normal, 10 degrees if hypotensive · Reassure patient frequently

intra abdominal s/s

· Bruising · Changes in bowel sounds · Hypotension

cellular regulation

· Carcinogenesis - Process by which normal cells are transformed into malignant or cancer cells o Initiation - DNA damage at genetic or molecular level, from carcinogen - can be reversible at this stage o Promotion - additional assaults to cells occur, insulin and estrogen act as promoters o Malignant Conversion - occurs as assaults to cells continue or multiply o Progression - cells develop into new version which can spread to nearby tissue or through the bloodstream to other areas of the body - Metastasis

systemic lupus erythematosus (SLE)

· Chronic, progressive, inflammatory connective tissue disorder that affects multiple body systems &organs o REMISSIONS/EXACCERBATIONS (can end up in the ICU) - Autoimmune o Attracted to KIDNEY's—Lupus Nephritis is leading cause of death; this is direct damage to the kidneys · Poor survival associated with high creatinine, low hematocrit, proteinuria o Young Women of child bearing age 20-40 Y (primary AA women) o SLE & DLE both share a disfiguring and embarrassing rash!! TEMP

cold illness

· Cotton clothing strictly avoided in a cold environment

disaster nursing

· Disasters are also referred to as mass casualty incidents (MCIs) and can overwhelm one department or hospital with a rapid surge in clients · ED's are involved in external & internal disaster planning · Hospitals must have an established & practiced plan for disaster management o Understanding of roles involved in responding to disasters o Initiating & following chain of command o Activating the response to the disaster o US Department of Homeland Security encourages providers to any/all types & levels of MCIs · All hazards approach includes teaching healthcare personnel to be aware of toxic exposure potential & protect themselves before initiating care · Mass Casualty Triage

er care

· Documentation of consent to treat o Most adults seeking treatment in ED give voluntary consent for treatment o If client deemed unable to give consent immediate care may be given under implied emergency doctrine o Minors require consent of parent/legal guardian except for: § Emancipated minors - need documentation with them § Seeking tx for STD's, injuries from abuse, & alcohol or drug related rehab § Minor females requesting tx for pregnancy or pregnancy related problems · Federal legislation mandates that any client who presents to an ED seeking tx must be rendered aid regardless of financial ability to pay for services o ED required to stabilize pt b4 transfer to another facility. Facilities can incur fines & penalties if not done. · Mandatory reporting o Every state has mandatory reporting requirements to several agencies o Types of incidents requiring reporting are suspected abuse (any age), assaults, motor vehicle crashes, communicable diseases, food poisoning, first time or recurrent seizures, animal bites and death. o Trauma deaths, suspected homicide or abuse cases require medical examiner § Do not remove tubes or IVs, must leave for corner § Cover the body w/a sheet while leaving face exposed, and dim the lights before family viewing · Advance directives o ED personnel obligated to abide by the pts advanced directive decisions if that info is available in writing o If NOT available, required to stabilize or resuscitate any pt according to standard tx guidelines regardless of a family member's expressed wishes · Staff and Pt Safety Considerations o Standard precautions at all times o Isolate pt w/TB in a negative pressure room, nurse wears powdered air-purifying respirator or N95 o Always verify pt identity using 2 unique identifiers - § Name, DOB, phone number, agency ID, address, SSN

HIV/AIDS

· Infection w/ human immunodeficiency virus (HIV) results in destruction of the body's defenses & immune system

hospice

· Interdisciplinary approach to address holistic needs of pts & families to facilitate quality of life and a peaceful death. · Major focus of care is on quality of life · Prognosis of 6 months or less and forego curative tx · Care provided by RNs, social workers, chaplains, and volunteers

intra abdominal complications

· Internal bleeding · Intraperitoneal injury - often diagnosed by doing a peritoneal lavage in the ED · Genitourinary injury § Pain meds not given until after assessment is complete

acute graft rejection abnormal labs

· Kidney - inc BUN & creatinine · Liver - increase total bilirubin & liver enzyme levels (AST and ALT) · Pancreas - inc urine amylase/lipase, inc creatinine Heart- BNP

acute rejection with kidney tranplant

· ONSET: 1 wk to anytime post-op · Oliguria or Anuria · Temp >100 · INC BP, Lethargy · Enlarged, tender kidney · Elevated creatinine, BUN, K+ · Fluid retention · TX: Increased doses of immunosuppressive drugs

SLE teaching

· Protect the skin o Limit sun/ultraviolet light exposure to prevent exacerbation (fluorescent light too) § Long sleeves, lg-brimmed hat, SPF 30+ o Clean skin with mild soap, pat dry and apply lotion o COSMETICS OK W/ MOSIURIZERS, AND SUN PROTECTION, NO EXCESS POWDER OR DRYING SUBSTANCES · MONITOR TEMP- first sign of exacerbation · Avoid large crowds and people who are ill, bc immunosuppressed · AVOID HARSH HAIR TX (permanents or highlights) Pregnancy can cause exacerbation

drowning

· Surfactant washed out of lungs, destabilizes alveoli and inc airway resistance · Salt water (hypertonic) draws protein rich fluid into alveoli - pulmonary edema · Duration and severity of hypoxia are 2 most important factors in determining outcome · Cold water seems to have protective effect, Diving reflex causes bradycardia, dec CO, and vasoconstriction · Priority is safe removal from water w/spine stabilization · Imitate airway clearance & ventilatory measures (rescue breaths) while still in water if possible · DO NOT attempt to get water out of victims lungs; deliver abd or chest thrusts ONLY if airway Is obstructed o O2 administration, o ET intubation, o gastric decompression

intra abdominal diagnostics

· Urinalysis for blood or protein in the urine · ABGs determine severity as H/H do not initially reflect true blood loss · Elevated WBC indicate injured spleen or intestinal injury · Elevated amylase signal injury to pancreas or the bowel · Diagnostic Peritoneal Lavage - fluid into abd, if drain pink or bloody prepare for surgery

sepsis

· most common enemy - infections!!! o Infection in blood stream & causes widespread inflammation (Systemic Inflammatory Response Syndrome) o Widespread vasodilation and blood pooling (warm extremities) o Low-grade fever and mild hypotension are early signs o Suspected or identified infection w/ some of the following § Temp > 101 (38.3C) or <96.8 (36C); HR >90 BPM; RR >20 § WBC >12,000 or <4,000; Platelet count <100,000 § Arterial HYPOtension (SBP<90; MAP <70) § UOP <0.5 mL/kg/hr; Absent bowel sounds § INR >105 or aPTT >60 § Elevated Lactic Acid Levels § Hyperglycemia (glucose >140) in absence of diabetes § Unexplained change in mental status § Significant edema or positive fluid balance o Clotting w/microthrombi forming causing hypoxia and reducing organ function. Progress unless intervene § If tx at this stage cycle of progression stops and good outcome. If not progresses to severe sepsis Call RRT for any pt who has VS or other conditions that meet sepsis w/SIRS criteria

multi injury managment

· skin & soft tissue § Often involves wound cleaning and closure by ED physician § Must evaluate for sensory, motor or vascular complications § Tetanus /rabies prophylaxis if appropriate § Discharge instructions on wound care in writing

cutaneous anthrax

• Manifests as skin lesions, edema & macule or papule formation • Resembles insect bite but hemorrhagic and sinks inward, necrosis and ulceration • Oral antibiotics (ciprofloxacin or doxycycline) for 60 days • W/o edema or systemic manifestations & not on neck, head IV antibiotics 1st if have fever, lesions on head or neck, are prego, or have extensive edema

inhalaton anthrax

• May not have sx until 8 weeks after exposure • Prodromal Stage (early) • Hard to distinguish form flu or PNA • Low-grade fever, fatigue, mild chest pain, dry harsh cough • NOT accompanied by upper respiratory manifestations (sore throat rhinitis) • Pt starts to feel better and manifestations improve in 2-4 days • If receive tx in this stage survival is high • Fulminant Stage (late) • Sudden onset of severe illness, respiratory distress, Hematemesis (bloody vomit) • Dyspnea, diaphoresis, stridor, chest pain, cyanosis, high fever, pleural effusions • Dec LOC, frank shock, septic shock • Death w/I 24-36 hrs even if antibiotics started at this stage • Prophylaxis and Treatment • Prophylaxis • Oral antibiotics (ciprofloxacin, doxycycline, or penicillin) for 60 days • Treatment • Above tx plus - IV antibiotics (Rifampin, Clindamycin, Vancomycin) for 7 days PLUS oral 60 days § GI ingestion - manifests with fever, N&V, abd. Pain, bloody diarrhea & vomiting § Treatment - isolation, penicillin, erythromycin, gentamycin, ciprofloxin & ventilatory management if inhaled