NSG-320 Exam 3

hepatic encephalopathy

-A neuropsychiatric manifestation of liver disease -Can occur after placement of transjugular intrahepatic portosystemic shunt (TIPS), which is used to treat portal hypertension Signs and Symptoms: -Changes in neurologic and mental responsiveness -Impaired consciousness -Inappropriate behavior, ranging from sleep disturbances to lethargy to deep coma -Asterixis (flapping tremors) -Fetor hepaticus (musty sweet breath, comes from the accumulation of digestive by-products that the liver is unable to degrade) -Impairments in writing (difficulty in moving the pen or pencil from left to right) -Apraxia (the inability to construct simple figures) -Hyperventilation -Hypothermia -Grimacing and grasping reflexes

parenteral nutrition

-Administration of nutrients directly into the bloodstream -Goal: meet nutritional needs and allow growth of new body tissue -Customized to meet each patient's needs Common Indications: -Chronic severe diarrhea and vomiting -Complicated surgery or trauma -GI obstruction -Intractable diarrhea -Severe anorexia nervosa -Severe malabsorption -Short bowel syndrome -GI tract anomalies and fistulae -Normal adult requires minimum 1200 to 1500 calories/day. -Patients who sustain severe injury, surgery, or burns and those who are malnourished as a result of medical treatment or disease processes have greatly increased nutritional needs. -Used when GI tract cannot be used for ingestion, digestion, and absorption of essential nutrients. Composition: -Base solutions contain dextrose and protein in the form of amino acids -Prescribed electrolytes, vitamins, and trace elements are added to customize and meet the needs of each client -Reformulated as the patient's condition changes -IV fat emulsion is added to complete the nutrients -Individual requirements for electrolytes are assessed -Sodium, potassium, chloride, magnesium, calcium, and phosphate are added to the base solution. -Zinc, copper, chromium, manganese, selenium, molybdenum, and iodine supplements may be added according to the client's condition and needs. Total Parenteral Nutrition (TPN) Intralipids: -Fat emulsion may cause side effects: vomiting, shivering, fever, chills -Lipids should be used with caution in clients with: disturbance in fat metabolism, in danger of fat embolism, allergies to eggs -Do not infuse lipids too quickly Methods of Administration: -Central parenteral nutrition is used for long-term support -Peripheral parenteral nutrition is used for short-term therapy or special conditions -Both methods require IV access: a central venous catheter or PICC line can be used. If the lipid/glucose content is low enough, a peripheral IV site can be used. Tube Placement: -Under sterile conditions by physician or advanced practice nurse -Isotonic IV solution infused until x-ray confirms correct placement -Site covered with sterile dressing -Date marked on dressing Nursing Considerations: -Verify order, client, rights of medication administration -Verify patent IV/catheter site PRIOR to starting infusion -Discontinue PN solution at end of 24 hours -Examine bag for signs of contamination -Must be refrigerated until 30 minutes before use -Must be labeled with nutrient content, all additives, time mixed, and date and time of expiration -Also examine solutions for leaks, color changes, particulate matter, clarity, and fat emulsion cracking -It is the nurse's responsibility to ensure that the PN solution is discontinued and replace with a new solution if the bag is not empty at the end of 24 hours -If a PN formula bag should empty before the next solution is available, a 10% or 20% dextrose solution (based on the amount of dextrose in the central PN solution) or a 5% dextrose solution (based on the amount of dextrose in the peripheral PN solution) may be administered to prevent hypoglycemia -Vital signs every 4 to 8 hours -Daily weights -Maintain accurate infusion rate -Never increase or decrease flow rate by more that 10% -Never stop PN abruptly unless it is replaced by another glucose source -Infusion pump must be used -Need to periodically check volume infused -Monitor lab values daily: hyperkalemia, hypokalemia, hypophosphatemia, hypomagnesemia, BUN, CBC, liver enzymes -Carefully observe the catheter site for signs of inflammation and infection. -Phlebitis can readily occur in the vein as a result of the hypertonic infusion, and the area can become infected. -The client receiving PN may be immunosuppressed and thus more susceptible to opportunistic infections. Blood Glucose: -Check initially every 4 to 6 hours -Administer sliding scale dose of insulin per order -Monitor for signs of hyperglycemia: thirst, polyuria, confusion, elevated BS, blurred vision, dizziness, N/V, and dehydration -Monitor for signs of hypoglycemia: sweating, hunger, weakness, and tremors -Make an effort to maintain a glucose range of 110-150 Complications: -Refeeding syndrome: characterized by fluid retention and electrolyte imbalances (hypophosphatemia hypokalemia, hypomagnesemia); clients predisposed by long-standing malnutrition states -Hypophosph atemia is the hallmark of refeeding syndrome and is associated with serious outcomes, including cardiac dysrhythmias, respiratory arrest, and neurologic disturbances (e.g., paresthesias). -Conditions that predispose patients to refeeding syndrome include long-standing malnutrition states such as chronic alcoholism, vomiting and diarrhea, chemotherapy, and major surgery. -Refeeding syndrome can occur any time a malnourished patient is started on aggressive nutritional support. -Metabolic problems: hyperglycemia, hypoglycemia, prerenal azotemia, fatty acid deficiency, electrolyte disturbances, hyperlipidemia, mineral deficiencies -Mechanical problems: insertion problems, dislodgement, thrombosis of great vein, phlebitis -Air embolus: can occur whenever a blood vessel is open and a pressure gradient exists favoring entry of gas, may lead to difficulty breathing or respiratory failure, chest pain or heart failure, stroke, pneumothorax, hemothorax, hydrothorax, and hemorrhage Infection and Speticemia: -Local manifestations: erythema, tenderness, and exudate at catheter insertion site -Systemic manifestations: fever, chills, nausea/vomiting, malaise -Blood and catheter cultures if infection suspected -X-ray: to check changes in pulmonary status -After PN therapy, daily dressing changes until heals -When the catheter tip of a short-term catheter is the source of infection, antibiotic therapy may not be necessary because removal of the catheter can eliminate the problem. Home Nutrition Support: -Teach the client and caregiver catheter or tube care, mixing and handling of solutions and tubing, and side effects and complications -Discharge planning needed

hemodialysis

-Arteriovenous (AV) fistula or graft for long-term permanent access -Hemodialysis catheter, dual or triple lumen, or AV shunt for temporary access Drugs to treat: -Hyperkalemia -Hypertension -CKD-MBD to decrease phosphate -Anemia -Dyslipidemia Postdialysis Assessment: -Hypotension -Headache -Nausea, vomiting -Malaise, dizziness -Muscle cramps or bleeding Vascular Access Complications: -Thrombosis or stenosis -Infection -Aneurysm formation -Tissue ischemia -Heart failure Complications: -Dialysis disequilibrium syndrome -Infectious disease -Hepatitis B and C -Human immunodeficiency virus (HIV)

excess fluid volume interventions

-Assess for s/s of fluid volume excess, keep accurate I&O, and daily weights -Limit fluid to prescribed amounts -Identify sources of fluid -Explain to patient and family the rationale for fluid restrictions -Assist patient to cope with the fluid restrictions -Provide or encourage frequent oral hygiene

urinary diversions

-Causes are often: bladder cancer, neurogenic bladder, congenital anomalies, strictures, chronic infections with deteriorating renal function, renal trauma, bladder removal Three main types of surgery: -Cutaneous ureterostomy -Ileal conduit -Nephrostomy Post-Op Nursing Care: -Stoma care & appliances -Skin care -Psychosocial

corticosteroids

-Decrease inflammation -Used to achieve remission -Helpful for acute flare-ups -Used to achieve remission in IBD. -They are given for the shortest possible time because of side effects associated with long-term use. -Clients with disease in the left colon, sigmoid, and rectum benefit from suppositories, enemas, and foams because they deliver it directly to the inflamed tissue with minimal systemic effects. -Oral prednisone is given to clients with mild to moderate disease who did not respond to either 5-ASA or topical corticosteroids. -Those with severe inflammation may require a short IV course. •Must be tapered to very low levels when surgery is planned to prevent postoperative complications (e.g., infection, delayed wound healing, fistula formation).

male physical assessment

-Examination of external genitalia -Assess for inguinal hernia -Examination of rectum and prostate -Psychosocial assessment

peptic ulcer disease

-Erosion of the GI mucosa from the action of HCL (hydrochloric acid) -Affects the lower esophagus, stomach, and duodenum -Ulcers can be ACUTE or CHRONIC: depends on degree and duration of mucosal involvement -Acute: superficial erosion, minimal inflammation, short duration, resolves when cause treated -Chronic: erodes through the muscular wall, present continuously for years or intermittent through life, most common type of ulcers Causes: -Hydrochloric acid and pepsin -Helicobacter Pylori -Medications: aspirin, NSAIDS, corticosteroids, anticoagulants, SSRIs -Lifestyle: excessive ETOH, coffee, smoking, stress Diagnostic Studies: -Endoscopy with biopsy: most often used as it allows for direct viewing of mucosa, tissue specimens can be obtained to identify H. pylori and rule out stomach cancer, determine degree of ulcer healing after treatment -Invasive tests for H. pylori infection: endoscopic procedure - biopsy of stomach, rapid urease testing -Noninvasive tests for H. pylori: urea breath test - can determine active infection -Stool antigen test -Serum or whole blood antibody tests: immunoglobulin G (IgG), will not distinguish between past and current infection -Barium contrast study: reserved for patient who cannot undergo endoscopy, not accurate for shallow, superficial ulcers; used in diagnosis of gastric outlet obstruction -Gastric analysis: analysis of gastric contents for acidity and volume; NG tube is inserted, and gastric contents are aspirated; contents analyzed for HCl acid -Laboratory analysis: CBC, liver enzyme studies, serum amylase determination, stool examination for blood Drug Therapy: -Use of PPIs, H2R blockers, antibiotics, antacids, anticholinergics, cytoprotective therapy -Antibiotic therapy: eradicates H. pylori infection, no single agent has been effective in eliminating H. pylori, prescribed concurrently with a PPI for 7 to 14 days -H2R blockers and PPIs may be stopped after the ulcer has healed or may be prescribed in the form of low-dose maintenance therapy -Because recurrence of ulcers is frequent, interruption or discontinuation of therapy can have harmful results. -Patients should not take any other drugs, unless prescribed by the health care provider, before taking any medication because they may have an ulcerogenic effect. Nursing Interventions: -Client and family education -Emphasize long term follow up care -Nutrition plan and dietary consult -Medication management and compliance -Psychosocial interventions appropriate to the client: coping, manage stress and frustration -Correct fluid/electrolyte imbalances Complications: -Hemorrhage: most common complication, also called a GI bleed; hematemesis, melena, EGD, type and screen, PRBCs give/hold, IV access, oxygen -Perforation: sudden sharp epigastric pain, peritonitis, rebound tenderness, rigid -Gastric outlet obstruction: can be acute or chronic; edema/inflammation, pylorspasm, fibrous scar tissue formation; pain/discomfort is worse towards the end of the day, stomach is full; burping and self-induced vomiting can provide relief; constipation from dehydration and decreased diet intake Medical Interventions: -Lifestyle modifications and medication management -If unsuccessful, surgery is indicated Surgical Interventions: -Partial gastrectomy: a portion of the stomach (the diseased area) is removed -Vagotomy: part/all of the vagus nerve is removed -Pyloroplasty: enlarge the pyloric sphincter to facilitate movement of contents from the stomach Post-Op Care: -Usual post-op priorities with A,B,C, vitals, deep breathing & coughing, VTE prophylaxis, etc... -Pain management, splint incision, out of bed walking, etc. -NG tube management: assess contents: amount, color, odor, consistency -Initial drainage is bright red, should become darker and change to yellow/green bile within 48-72 hours -Provider may order gentle irrigation if it becomes clogged -Incorrect management leads to stomach distension causing rupture of the suture, contents leak into the peritoneum, hemorrhage, possible abscess formation -ONLY the PROVIDER should adjust/move/reinsert the NG tube: large risk of perforation Complications: -Dumping syndrome (management): -Observe for signs/symptoms 15-30 minutes after a meal -Fall precautions -Frequent vital signs -Replace fluids/electrolytes -Advance diet as tolerated -Give small amounts of fluid over the duration of the day, not with meals -Frequent small meals -Monitor blood sugar -Monitor borborygmic - hyperactive bowel sounds -Postprandial hypoglycemia: part of dumping syndrome, check glucose -Bile reflux gastritis: Cholestyramine (Questran) is given before or with meals -Risk to develop pernicious anemia due to loss of intrinsic factor, treated medically with cobalamin

cirrhosis

-Extensive irreversible scarring of the liver, usually caused by a chronic reaction to hepatic inflammation and necrosis. -It typically has a progressive, slow, destructive course resulting in end-stage liver disease. -It is characterized by widespread fibrotic scarring that changes the liver. Risk Factors: -ETOH -Viral hepatitis (chronic B&C) -Autoimmune hepatitis -Fatty liver disease -Drugs and chemical toxins -Gallbladder disease -Metabolic causes -Genetic causes -Cardiovascular disease Clinical Manifestations: -Fatigue -Jaundice -Peripheral edema -Ascites -Skin lesions -Hematologic disorders -Endocrine disturbances -Peripheral neuropathies Labs: -AST elevated: enzyme directly related to the number of damaged liver cells -ALT elevated -LDH elevated -Total serum protein and albumin decreased: as a result of decreased synthesis by the liver -Prolonged PT and increased INR -Bilirubin elevated -Hypokalemia -Liver biopsy (IR) -Ultrasound studies Diagnostics: Biopsies: -Gold standard to diagnose cirrhosis, identify liver cell changes -Most clients require biopsies to determine the exact pathology and the extent of disease progression -Biopsies are problematic since a large number of patients are at risk for bleeding. X-rays of the abdomen may show: -Hepatomegaly -Splenomegaly -Massive ascites Ultrasound of the liver: -Often the first assessment for an individual with suspected liver disease to detect ascites, hepatomegaly, and splenomegaly or the presence of biliary stones or biliary duct obstruction. -Detects cirrhosis Magnetic resonance imaging (MRI): -Used to reveal mass lesions. Esophagogastroduodenoscopy (EGD): -Directly visualizes the upper GI tract -Detects the presence of bleeding or oozing esophageal varices, stomach irritation and ulceration, or duodenal ulceration and bleeding. Nursing Interventions: -Assist with paracentesis -Paracentesis: done for patients with cardiac and respiratory discomfort -Monitor fluid and electrolyte balance -Administer albumin infusions -Nutrition: Na restriction diet 2 g/day, watch for malnutrition, need vitamin supplementation -Administer Drug Therapy: diuretics reduce fluid accumulation in ascites and prevent cardiac and respiratory impairment -Spironolactone (Aldactone) -Furosemide (Lasix): problems with fluid and electrolyte balance, such as dehydration, hypokalemia (decreased potassium), and hyponatremia (decreased sodium) may occur with loop diuretic therapy -Skin Care: use cool water on skin that has pruritis from jaundice, don't use excessive soap, use lotion to soothe skin, assess for infection from scratching Complications: -Portal Hypertension: caused by blockage of blood flow through the portal vein; can lead to splenomegaly, dilation of veins in stomach, intestines, abdomen, and rectum, and esophageal varices (distended veins in the esophagus) -Bleeding esophageal varices is a life-threatening medical emergency. Severe blood loss may occur, resulting in shock from hypovolemia. -Bleeding -Jaundice -Hepatic encephalopathy (with hepatic coma) -Hepatorenal syndrome (complex cognitive syndrome) -Ascites -Esophageal varices -Biliary obstruction leads to decreased production of bile and prevents the absorption of vitamin K which can lead to bleeding and bruising

GERD

-HCl acid and pepsin secretions in refluxate cause irritation and inflammation (esophagitis) -Intestinal proteolytic enzymes and bile salts add to irritation Predisposing factors: -Incompetent lower esophageal sphincter (LES) -Decreased LES pressure -Increased intraabdominal pressure -Hiatal hernia Symptoms: -Heartburn (pyrosis): most common clinical manifestation; burning, tight sensation felt beneath lower sternum and spreading upward to throat or jaw; felt intermittently -GERD-related chest pain: described as burning, squeezing; radiating to back, neck, jaw, or arms; can mimic angina; more common in older adults with GERD; relieved with antacids -May report respiratory symptoms: wheezing, coughing, dyspnea, nocturnal discomfort and coughing with loss of sleep Complications: -Barrett's esophagus: replacement of flat epithelial cells with columnar epithelium; precancerous lesion; thought to be primarily due to GERD -Esophageal varices -Esophageal ulcers -Respiratory (from irritation of upper airway by secretions): cough, bronchospasm, laryngospasm Diagnostic Tests: -Upper GI endoscopy: useful in assessing LES competence, degree of inflammation, scarring, strictures; obtain biopsy and cytologic specimens -Ambulatory esophageal pH monitoring -Radionuclide tests: detect reflux of gastric contents, evaluate rate of esophageal clearance Medications: Proton pump inhibitors (PPIs): -Promote esophageal healing in 80% to 90% of patients -Available in prescription and OTC preps -Example: omeprazole (Prilosec) -Headache: Most common side effect Histamine-2 receptor (H2R) blockers: -Decrease secretion of HCl acid -Reduce symptoms and promote esophageal healing in 50% of patients -Example: cimetidine (Not as widely used), ranitidine (Zantac), and famotidine (Pepcid) -Side effects uncommon Acid protective: -Used for cytoprotective properties -Example: sucralfate Prokinetic drugs: -Promote gastric emptying -Reduce risk of gastric acid reflux -Example: metoclopramide (Reglan) Antacids: -Quick but short-lived relief -Neutralize HCl acid -Taken 1-3 hours after meals/at bedtime -Example: Maalox, Mylanta Nursing Interventions: -Elevate head of bed 30 degrees -Do not lie down for 2-3 hours after eating -Avoid factors that cause reflux: stop smoking, avoid alcohol and caffeine, avoid acidic foods -Stress reduction techniques -Weight reduction, if appropriate -Small, frequent meals Medical Interventions: -Medication & lifestyle changes -Surgical therapy: goal is to reduce reflux by enhancing the integrity of the LES, most procedures done laparoscopically; reserved for those with complications such as failure of conservative therapy, medication intolerance, Barrett's metaplasia, esophageal stricture and stenosis, chronic esophagitis -Nissen fundoplication: used to treat more than 1 clinical condition (GERD, hiatal hernia)

prostatectomy

-Retropubic is done when lymph node biopsies are likely. -If they are unable to spare the nerves, the client will become impotent after the surgery. -Radical retroperitoneal lymph node dissection is done when there are concerns the cancer is spreading. -This is an extensive surgery -Perineal is less involved and has a faster recovery time.

hepatitis C

-Spread by IV drug needle sharing -Blood Products and organ transplants -Needle stick injuries -Unsanitary tattoo equipment -Sharing intranasal cocaine paraphernalia -Does damage over decades because the body is not able to clear the virus -Causes inflammation of the liver -Causes cells to scar -Can lead to cirrhosis -Clinical manifestations same as for Hep B

The nurse is caring for a client with terminal cervical cancer. Which clinical manifestations would the nurse expect to observe based on this diagnosis?

Anemia, cachexia, weight loss

A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?

Increase intake of fluids

The nurse is educating a client about the manifestations of breast cancer. Which signs should the nurse include to help the client detect a potentially cancerous lump in the breast?

Nodule in the upper outer quadrant, presence of a painless, nonmobile lump, puckering or induration of the breast tissue

traditional cystectomy

Preoperative Care: -Monitor for bleeding -Monitor for infection -Pain control -IV fluid -NPO with NG tube -Antiemetics Postoperative Care: -Opioids via PCA pump -T-tube (and care of) -Antiemetics -Wound care -NPO -Nutrition therapy -Percutaneous trans hepatic biliary catheter T-tube

endometrial cancer

Risk Factors: -Exposure to estrogen -Obesity is a risk factor because adipose cells store estrogen, thus increasing the amount of circulating estrogen -Increasing age -Never being pregnant -Early menarche -Late menopause -Smoking -Diabetes mellitus -Personal or family history of hereditary nonpolyposis -Colorectal cancer Clinical Manifestations: -Early: abnormal uterine bleeding, especially in postmenopausal women -Later: pain during urination (dysuria) or intercourse (dyspareunia) or in the pelvic area, unintentional weight loss Diagnostics: -No routine screening test is available -Most cases are diagnosed at an early stage because of postmenopausal bleeding -An endometrial biopsy is the primary diagnostic test Treatment: -Total hysterectomy and bilateral salpingo-oophorectomy with lymph node biopsies -External radiation either to the pelvis or abdomen or internal radiation (brachytherapy) intravaginally if there is local or distant metastasis.

bladder cancer

Risk Factors: -Smoking -Dyes -Chemo -Actos -Recurrent renal calculi Assessment: -Hematuria -Irritable bladder -Frequency -Dysuria -Urgency Diagnostic Testing: -U/A -Cystoscopy with biopsy -CT -MRI Surgery -Urinary diversion -Radiation -Chemo -Immunotherapy

biologic and targeted therapies

TNF (antitumor necrosis factor) agents: -Infliximab (Remicade) -Adalimumab (Humira) -Certolizumab pegol (Cimzia) -Golimumab (Simponi) Integrin receptor antagonists: -Natalizumab (Tysabri) -Vedolizumab (Entyvio) -Infliximab is a monoclonal antibody to TNF (proinflammatory cytokine). This drug is given IV to induce and maintain remission in patients with Crohn's disease and in patients with draining fistulas who do not respond to conventional drug therapy. -The other TNF agents are given subcutaneously and have effects similar to those of infliximab. -The anti-TNF agents have similar side effects. The most common adverse effects are upper respiratory and urinary tract infections, headaches, nausea, joint pain, and abdominal pain. -More serious effects include reactivation of hepatitis and tuberculosis (TB); opportunistic infections; and malignancies, especially lymphoma. -Clients need to know the risks before starting therapy. They are tested for TB and hepatitis before treatment begins and cannot receive live virus immunizations. -Teaching includes how to prevent infection and recognize early signs and symptoms (e.g., fever, cough, malaise, dyspnea). -Two biologic and targeted medications are integrin receptor antagonists: natalizumab (Tysabri) and vedolizumab (Entyvio). They inhibit leukocyte adhesion by blocking α4-integrin, an adhesion molecule. -The use of integrin receptor antagonists is limited to those who have not had an adequate response with other therapies (corticosteroids, immunosuppressants, or TNF agents). Both are given by IV infusion. -Their use is associated with increased risk of infection, hepatotoxicity, and hypersensitivity reactions. -Because of the risk of progressive multifocal leukoencephalopathy, natalizumab is available only through a restricted program. -The biologic and targeted agents do not work for everyone. -They are costly and may produce allergic reactions. -They are immunogenic, meaning that patients receiving them frequently produce antibodies against them. -Immunogenicity leads to acute infusion reactions and delayed hypersensitivity-type reactions. -The drugs are most effective when given at regular intervals. -Infusion reactions are more likely if a drug is stopped and then restarted.

breast cancer

Risk Factors: -Female gender -Advancing age -Family history - especially if the involved family member also had ovarian cancer, was premenopausal, had bilateral breast cancer, or is a first-degree relative (i.e., mother, father, sister, brother, daughter). -Genetic link - BRCA1 and BRCA2 (BRCA stands for BReast CAncer). -Women who have BRCA1 or 2 mutations have a 40% to 80% lifetime chance of developing breast cancer. -Most breast cancers (about 90%-95%) are not inherited. -Prior breast cancer -Past history of thoracic radiation therapy -Atypical findings on a prior breast biopsy -First period before age 12 -Menopause after age 55 -Dense breast tissue -Age of 50 or more -Benign breast disease with atypical biopsy -Weight gain and obesity -Alcohol consumption -Exposure to ionizing radiation Clinical Manifestations: -Lump or thickening in the breast -Abnormal mammography -Most often in upper, outer quadrant -Nipple discharge -Nipple retraction Sites of Breast Cancer Recurrence and Metastasis: -Skin, chest wall -Lymph nodes -Spinal cord -Brain -Pulmonary -Liver -Bone marrow Diagnostic Studies: -Mammography: a method used to visualize the breast's internal structure using x-rays -Digital mammography: x-ray images are digitally coded and stored in a computer. Digital mammograms are more accurate than traditional film mammography in younger women with dense breasts. -Three-dimensional (3D) mammography: produces a 3D image of the breast. It provides a clearer view of overlapping breast tissue structures. Biopsy of breast tissue: FNA (fine needle aspiration) biopsy: -Performed by inserting a needle into a lesion to sample fluid from a breast cyst, remove cells from intercellular spaces, or sample cells from a solid mass -Before the procedure, the breast area is first locally anesthetized -Needle is placed into the breast, and fluid and cells are aspirated into a syringe -Three or four passes are usually made -If the results are negative with a suspicious lesion, an additional biopsy may be necessary. Core (core needle) biopsy: -Involves removing small samples of breast tissue using a hollow "core" needle -For palpable lesions, this is accomplished by fixing the lesion with one hand and performing a needle biopsy with the other. Stereotactic mammography, ultrasound, or MRI image guidance: -Used for nonpalpable lesions -Uses computers to pinpoint the exact location of a breast mass from a mammogram -With ultrasound, the radiologist or surgeon watches the needle on the ultrasound monitor to help guide it to the area of concern. -Because a core biopsy removes more tissue than an FNA, it is more accurate. Vacuum-assisted biopsy: -Version of core biopsy that uses a vacuum technique to help collect tissue -Needle is inserted only once into the breast, and the needle can be rotated -Allows for multiple samples through a single needle insertion. Axillary lymph node biopsy: -One of the most important prognostic factors in breast cancer. -Axillary lymph nodes are often examined to determine if cancer has spread to the axilla on the side of the breast cancer. -The more nodes involved, the greater the risk of recurrence. Sentinel lymph node biopsy (SLNB): -Helps to identify the lymph node(s) that drain first from the tumor site (sentinel node) -1-4 SLN are removed, sent to pathology -If SLN are negative, no other nodes are removed -If SLN are positive, surgeon will remove 12-20 nodes Surgery: -Primary treatment -Lumpectomy: for early stage breast cancer (tumors smaller than 5 cm), breast conservation surgery -Mastectomy (with or without reconstruction): a total or simple mastectomy removes the entire breast; a modified radical mastectomy includes removal of the breast and axillary lymph nodes, but it preserves the pectoralis major muscle Post Op Mastectomy Assessment: -Bleeding -Chest and upper arm pain -Tingling down the arm -Continuous aching and burning, numbness, edema, shooting or pricking pain, and unbearable itching that persists beyond the normal 3-month healing time. -Clients usually discharged from hospital within 24-48 hours -Fluids, pain management, wound care -May have Jackson Pratt (JP) drains in place -Teach dressing and drain care Exercises After Breast Surgery: -Teach post-op exercises after a mastectomy -After breast cancer surgery you might develop a stiff shoulder or arm. Your nurse or a physiotherapist will ask you to do regular exercises after surgery to help you recover. -They should give you a leaflet which explains the exercises. -Simple arm exercises can help to: •Keep your movement full in your arm and shoulder •Relieve pain and stiffness •Reduce swelling -Begin finger, wrist, and hand exercises to facilitate muscle contraction and to help prevent edema. Active exercises, such as pendulum swings and wall-climbing, are started after the incision has healed. As the area heals, abduction and external rotation will help improve the range of motion. -If trauma to the arm occurs, the area should be washed thoroughly with soap and water and observed. A topical antibiotic ointment and a bandage or other sterile dressing may be applied. Radiation Therapy: -Used after surgery -Prevents local breast cancer recurrences after breast-conserving surgery -Prevents local and lymph node recurrences after mastectomy -Relieves pain caused by local, regional, or distant spread of cancer. -Done for 5 days a week for 5-7 weeks -Fatigue, skin changes, and breast edema may be temporary side effects of external radiation therapy. -Brachytherapy: 5 days Chemotherapy: -Several combinations of drugs -Given for several weeks to months -Doxorubicin (Adriamycin) -The most common side effects involve rapidly dividing cells in the gastrointestinal tract (nausea, anorexia, weight loss), bone marrow (anemia), and hair follicles (alopecia). -Monitor for signs of cardiotoxicity and heart failure (e.g., new onset of shortness of breath, pedal edema, decreased activity tolerance, dysrhythmias, ECG changes).

The nurse is caring for a client newly diagnosed with breast cancer and working with the treatment team and her family. Which client activities demonstrate that the client is meeting the treatment goals?

The client talks about the side effects of chemotherapy, the client brings a list of questions to her next appointment with the oncologist, the client discusses the need to continue treatment despite the difficulties that she is experiencing

ostomy

The creation of a stoma (opening) from the small or large intestine to the outside of the body

A client with breast cancer asks the nurse what is meant by "in situ." What is the nurse's best response?

"In situ means that the cancer is currently noninvasive within the duct."

endometriosis

-A condition in which endometrial tissue accumulates outside the endometrium of the uterus Clinical Manifestations: -Secondary dysmenorrhea -Infertility -Pelvic pain -Dyspareunia -AUB -Backache, painful bowel movements, dysuria (less common) Diagnostics: -History and physical examination -Pelvic examination -Laparoscopy -Pelvic ultrasound -MRI Drug Therapy: -Danazol (use is limited by the occurrence of androgenic side effects) -GnRH agonists (e.g., leuprolide [Lupron]) -NSAIDs to control pain -Oral contraceptives used to control symptoms Surgical Therapy: -The only cure is surgical removal of all endometrial tissue by laparoscopic laser surgery or laparotomy -Definitive surgery involves removal of the uterus, fallopian tubes, ovaries, and as many endometrial implants as possible

polycystic ovary syndrome

-A disorder that includes ovulatory dysfunction, polycystic ovaries, and hyperandrogenism. It most commonly occurs in women under 30 years old and is a cause of infertility. -It is thought to be due to the ovaries producing estrogen and excess testosterone but not progesterone -Pelvic ultrasound reveals enlarged ovaries with multiple small cysts Clinical Manifestations: -Irregular menstrual periods -Amenorrhea -Hirsutism -Obesity -Excess androgens -Infertility Treatment: -Based on symptoms -Oral contraceptives useful in regulating menstrual cycles -Hirsutism may be treated with spironolactone -Hyperandrogen ism can be treated with flutamide and a GnRH agonist, such as leuprolide -Metformin reduces hyperinsulinemia, improves hyperandrogenism, and can restore ovulation -For women wishing to become pregnant, fertility drugs (e.g., clomiphene [Clomid]) may induce ovulation Nursing Interventions: -Teaching about the importance of weight management and exercise to decrease insulin resistance -Monitor lipid profile and fasting glucose levels -Hirsutism: support the patient as she explores measures to remove unwanted hair (e.g., depilating agent, electrolysis) -Stress the importance of regular follow-up care to monitor the effectiveness of therapy and to detect any complications

paracentesis

-A procedure in which fluid is withdrawn from the abdominal cavity -May be indicated if drug therapy fails to control ascites Pre-op Care: -Ensure permit is signed -Baseline vital signs -Patient teaching -Have to empty their bladder -Ensure their IV is patent Post-op Care: -Monitor vital signs -Lie down on side without wound for 2 hours -Monitor for leakage from site -Measure drainage -Check dressing -Don't get up until the nurse tells you to -Check for new orders for fluids

continuous bladder irrigation

-A three-way (lumen) irrigation is used to decrease bleeding and to keep the bladder free from clots—one lumen is for inflating the balloon (30 mL); one lumen is for instillation (inflow); one lumen is for outflow. Closely monitor the drainage system to prevent complications: -Bladder distension -Pain -Bleeding, clot formation -Ensure the catheter is patent and draining correctly. -Educate and provide medications to relieve bladder spasms. -Minimal activity for the first 24 hours to decrease pain and allow healing to start. -Avoid straining (Valsalva) with BMs - provide increased dietary fiber and laxatives if needed. Other complications: -Hemorrhage - if the urinary output is cloudy (you can't see through it - looks like ketchup) -Urinary incontinence can occur - teach the client Kegel exercises -Venous thromboembolism (low dose heparin, SCDs, ankle/foot exercises, activity) Client Education: -Discomfort with the catheter in place -Initially, urine should be clear, may have occasional small blood clots in it -As the irrigation continues, urine may have a pink tinge or remain clear -Empty the client's drainage bag frequently -CBI is usually stopped when urine has been clear or slightly pink urine for 1 to 2 days. -Report bladder pain or if bladder feels full. -Report if fluid is leaking around your catheter.

lymphedema

-Accumulation of lymph in soft tissue -Occurs from lymph node removal from a biopsy or surgery, or from radiation therapy -Tissue is no longer able to drain lymph fluid Client Education: -Teach measures to prevent and reduce lymphedema -No BP readings, venipunctures, or injections on the affected arm -Affected arm should not be dependent for long periods. -Caution should be used to prevent infection, burns, or compromised circulation on the affected side. -Use of compression sleeve common -If lymphedema is acute: decongestive therapy with a pneumatic sleeve

central parenteral nutrition

-Administered through a catheter whose tip lies in the superior vena cava -Subclavian or jugular vein -Peripherally inserted central catheters (PICCs) -Long-term parenteral support -Indicated when the client has high protein and caloric requirements -Solutions are hypertonic, measuring at least 1600 mOsm/L: large central vein can handle high glucose content ranging from 20% to 50% -Must be infused in a large central vein so that rapid dilution can occur -A pump is used to control the rate of infusion

peripheral parenteral nutrition

-Administered through a peripherally inserted catheter or vascular access device -Short term nutritional support -Compared with central PN, it contains fewer nutrients -It is less hypertonic than central PN, but it still has an osmolality of up to 800 mOsm/L -This increases the risk of phlebitis -Another potential complication is fluid overload -It requires large volumes of fluid, which many patients cannot tolerate. -Solutions are hypertonic: peripheral vein can handle glucose up to 20% -The use of a peripheral vein for hypertonic, central PN solutions would cause irritation and thrombophlebitis -To control the rate of infusion, solutions should be administered with a volumetric controller Indications: -Protein and caloric requirements not high -Risk of central catheter too great -Supplement inadequate oral intake

enteral nutrition

-Also called tube feeding -The administration of nutritionally balanced liquefied food through a tube inserted into the stomach, duodenum, or jejunum -Used with the patient who has a functioning GI tract but is unable to take any or enough oral nourishment, or when it is unsafe to do so -Feedings can be started when bowel sounds are present, usually 24 hours after placement Indications include those with: -Any condition that impacts ability to safely swallow -Anorexia -Facial features -Head/neck cancer -Neurologic or psychiatric conditions -Extensive burns -Critical illness -Chemotherapy -Radiation therapy -Stroke Delivery options include: -Continuous infusion by pump -Cyclic feedings by pump -Intermittent by gravity -Intermittent bolus by syringe -Critically ill patients often receive it through continuous infusion -Intermittent feeding may be preferred as the patient improves or is receiving EN at home Aspiration Risk: -Ensure proper position of tube -Maintain head-of-bed elevation -Check gastric residual volume Client Position: -Patient should be sitting or lying with HOB at 30 to 45 degrees -HOB remains elevated for 30 to 60 minutes for intermittent delivery -Proper patient positioning decreases the risk of aspiration. -If you need to lower the head of bed for a procedure, return the patient to an elevated position as soon as possible. -Follow institution policy for suspending feeding while the patient is supine. Tube Position: -X-ray confirmation for new nasal or orogastric tubes -To determine if a feeding tube has maintained proper position, mark the exit site of the feeding tube at the time of the initial x-ray, and observe for a change in the external tube length during feedings -Check placement before each feeding/drug administration or every 8 hours with continuous feeds -Check insertion length regularly: if a significant increase in the external length is observed, use other bedside tests to help determine if the tube has become dislocated. -When in doubt, obtain an x-ray to determine tube location. -A small bowel tube may dislocate upward into the stomach or the tube's tip can dislocate upward into the esophagus. -Check gastric residual volumes: every 4 hours during the first 48 hours, increased volume leads to aspiration. After attaining the enteral feeding rate goal, decrease gastric residual monitoring to every 6 to 8 hours in noncritically ill patients or continue every 4 hours in critically ill patients. -Promotility drugs such as erythromycin or metoclopramide improve gastric emptying and may reduce aspiration risk Methods Used to Check Tube Placement: -Aspiration of stomach contents -pH check: pH <5, which is indicative of stomach contents -Most accurate assessment: x-ray visualization -Because each of these measures has limitations, confirm placement with more than one test. -Consider applying a nasal bridle in patients who attempt to pull out a tube or for whom taping the nose is difficult. Site Care: -Skin care around gastrostomy and jejunostomy tube sites is important because the action of digestive juices irritates the skin -Assess the skin around the tube daily -Monitor bumper tension -Apply a dressing until the site is healed -After healed, wash with soap and water -A protective ointment (zinc oxide, petroleum gauze) or a skin barrier (karaya, Stomahesive) may be used on the skin around the tube Tube Feeding Administration: -Tube patency: flush with 30 mL of water every 4 hours during continuous feeding or before/after each intermittent feeding, drug administration, residual check -Continuous feedings administered on feeding pump with occlusion alarm -If no pump is available, feedings require frequent monitoring of the drip rate, so that blockage does not occur from the patient lying on the tubing inadvertently, or from too slow a drip rate. -Pump feedings: gradually increase rate or volume over 24 to 48 hours -Intermittent feedings: volume usually 200 to 500 mL per feeding -Administer flush water or water boluses as tolerated -The use of disposable gloves is recommended during administration -It is important to remember that the patient still needs water (1 mL per calorie of formula received), and this may be administered with flush water or as additional boluses of water as tolerated. Misconnection - SAFETY ALERT: -Inadvertent connection between an enteral feeding system and a nonenteral feeding system such as an IV line, a peritoneal dialysis catheter, or a tracheostomy tube cuff -With an enteral feeding misconnection, nutritional formula intended for the GI tract is given IV or into the respiratory tract. -Severe patient injury or death can result General Nursing Considerations: -Daily weights -Assess for bowel sounds before feedings -Accurate I&O -Initial glucose checks -Label with date and time started -Pump tubing changed q24h Complications: -Vomiting -Dehydration: more calorically dense, less water formula contained; check for high protein content -Diarrhea -Constipation

interstitial cystitis

-Also known as painful bladder syndrome -Unknown cause, irritation/inflammation/ulcerations -Pain varies in severity, UTIs, frequency, urgency, role of stress, frequent urination (60X/day) -Remission and exacerbations Assessment: -PQRST of pain -Voiding dysfunction -Bladder or voiding log to identify diet & lifestyle factors for at least 3 days -Diet: quality nutrition, role of vitamins (avoid excess doses) -Clothing that avoids perineal & pelvic pressure -Psychosocial: frustration, guilt, anger, coping Systemic Medications: -Tricyclic antidepressants: amitriptyline, nortriptyline, pentosan -Short course of opioids to treat acute pain Local Medications: -Instilled directly into the bladder -Dimethyl sulfoxide (DMSO) -Heparin, hyaluronic acid, lidocaine, heparin Avoid Bladder Irritants: -Caffeine -Alcohol -Citrus products -Aged cheeses -Nuts -Foods containing vinegar -Curries -Hot peppers

risk for situational low self-esteem interventions

-Assess patient and family responses to illness and treatment -Assess relationships and coping patterns -Encourage open discussion about changes and concerns -Explore alternate ways of sexual expression -Discuss role of giving and receiving love, warmth, and affection

urinary tract infection

-Bacterial cause most frequent (vagina and rectum) -Complications: the infections can migrate up to the kidneys, causing infection and injury to the kidney Assessment: -Risk factors, normal bladder/bowel elimination pattern, perineal care -Fever, chills, dysuria, suprapubic pain, hesitancy, intermittent stream, postvoid dribbling, painful urination, urgency, incontinence, nocturia -Urine: cloudy, hematuria, foul odor -Diagnostic tests Interventions: -Empty bladder regularly & completely -Empty bowels regularly -Cleanse perineum front to back -Drink adequate fluids daily; avoid caffeine, alcohol, citrus juices, chocolate, spicy foods -Take full course of prescribed antibiotics, even if symptoms subside. -Teach about Bactrim (trimethoprim/sulfamethoxazole) & Macrodantin (Nitrofurantoin)

nasogastric and nasointestinal tubes

-Can clog easily when the feedings are thick because of their small diameter -More difficult to use for checking residual volumes -Partially prone to obstruction when oral drugs have not been thoroughly crushed and dissolved in water before administration -Failure to flush the tubing after both drug administration and residual volume determinations can result in tube clogging -Can be dislodged by vomiting or coughing -Can be knotted/kinked in GI tract -Problems with a tube may necessitate removal and insertion of a new tube, which adds to cost and patient discomfort

chronic pancreatitis

-Continuous, prolonged inflammatory, and fibrosing process of the pancreas -Results in strictures, calcifications, and progressive destruction of the pancreatic tissue -Can result from acute pancreatitis -Most common causes: ETOH abuse, cholelithiasis -Attacks can continue over months/years, or disappear Causes: -Chronic alcohol use -Obstruction: inflammation of the sphincter Oddi -Tumor -Pseudocysts -Trauma -Systemic diseases (SLE, aka systemic lupus erythematosus) -Autoimmune pancreatitis -Cystic fibrosis Clinical Manifestations: -Pancreatic insufficiency -Acute and/or chronic pain - gnawing/heavy, burning/cramping -Malabsorption & weight loss -Constipation -Mild jaundice & dark urine -Steatorrhea: can be severe with large BMs that are foul-smelling -Abdominal tenderness -Diabetes mellitus Diagnostics and Lab Tests: -Amylase: slight elevation -Lipase: slight elevation -Serum bilirubin -ALP -ESR -ERCP: to visualize pancreatic and common bile ducts -CT -MRI -Abdominal ultrasound -Stool samples for fecal fat Medical Interventions: -Analgesics for pain control -Control of diabetes - diet, exercise, hypoglycemics, insulin -Low fat diet -Small bland frequent meals -Pancreatic enzyme replacement -Abstain from smoking, caffeine, and ETOH use -Antidepressants to decrease neuropathic pain -Acid neutralizing/inhibiting drugs to decrease acid -Surgery - open or endoscopic to move or bypass sphincter Interprofessional Care: -Pain control: morphine or fentanyl patch (Duragesic) -Diet: small, bland, frequent meals that are low in fat -Stop smoking: accelerates progress of disease -Pancreatic enzyme replacement: pancrease, bile salts (to facilitate absorption of vitamins A, D, E, and K) -Control of diabetes Nursing Care: -Encourage to take meds (enzymes are taken with meals) -Observe stools for steatorrhea; determines the effectiveness of enzymes -Avoid alcohol -Stop smoking

ovarian cancer

-Deadliest gynecologic cancer in the United States Risk Factors: -Family or personal history of ovarian, breast, or colon cancer -Personal history of hereditary nonpolyposis colorectal cancer -Hormone replacement therapy -Mutant BRCA -Early menarche and late menopause -Increasing age -Never been pregnant or nulliparity -High-fat diet Protective Factors: -Oral contraceptive use (for > 5 years) -Breastfeeding -Multiple pregnancies -Early age at birth of the first baby Clinical Manifestations: -Early ovarian cancer usually has no obvious symptoms -Vague and non-specific symptoms: pelvic or abdominal pain, bloating, urinary urgency or frequency -Late symptoms: difficulty eating or feeling full quickly, abdominal enlargement with ascites, unexplained weight loss or gain, menstrual changes Diagnostics: -Pelvic examination -Abdominal and transvaginal ultrasound -CA-125 level -Laparotomy for diagnostic staging Interprofessional Care: -Options for high risk women include prophylactic removal of the ovaries and fallopian tubes and the use of OCPs -Initial treatment for all stages is a total abdominal hysterectomy and bilateral salpingoophorectomy (TAH-BSO) with removal of the omentum and as much of the tumor as possible (i.e., tumor debulking) -Other treatment options include intraperitoneal and systemic chemotherapy, intraperitoneal instillation of radioisotopes, and external abdominal and pelvic radiation therapy -Combination chemotherapy and radiation therapy should be considered before a single-modality treatment

ERCP

-Endoscopic retrograde cholangiopancreatography -This procedure is usually done in radiology, and sometimes the operating room. -This is partly through the GI system - they place a scope into the mouth, to the stomach, and duodenum. -Here they look for the Sphincter of Oddi to insert a small catheter up the biliary tree. -Once the catheter is in place, they inject a similar kind of radiopaque dye. This will show up on xray. It's very similar to the dye used for other procedures (CT, angiogram) that we have already learned about. -They look at the inside physical structure, plus x-rays of how the dye flows through the biliary tree. They can also retrieve/remove an obstruction sometimes as well. -This is often done as an emergency procedure due to sudden onset of a very painful abdomen & other signs/symptoms - like if someone had pancreatitis. Client Preparation: -NPO status -Bowel prep for 1 day to empty their intestines of food, also allowed clear liquids until midnight before -Usually take their normal medications unless directed otherwise. -IV access for sedation -Cardiac monitor -Lab tests for electrolytes & CBC usually, just in case. -Who will be looking after them after the procedure? Remember they are vulnerable because of the sedation received. Some facilities will not do the procedure unless that person is present in the waiting room the whole time. -Do discharge teaching if time, they will not recall teaching after the procedure due to the sedation. Care After Procedure: -ABCs -Vitals, LOC, especially RR & O2 sats -Complications of bleeding & perforation -Anticipate diet needs -The clients can go home once they can swallow and have exhibited stable vitals signs; no s/s of complications (usually 1-2 hours)

percutaneous endoscopic gastrostomy

-Gastrostomy tube placement via percutaneous endoscopy -Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then is pulled through a stab wound made in the abdominal wall -Requires esophageal lumen wide enough for endoscope. -Because they require no general anesthesia and only minimum or no sedation of the patient, these techniques can be done at a lower cost. -PEG tube and radiologically placed gastrostomy tube procedures have fewer risks than surgical placement. The procedure requires IV sedation and local anesthesia. IV antibiotics are given before the procedure. -Most PEG tube feedings can start within 2 hours of insertion

hiatal hernia

-Herniation of portion of stomach into esophagus through an opening or hiatus in diaphragm -Also referred to as diaphragmatic hernia and esophageal hernia -Most common abnormality found on upper GI x-ray -More common in older adults and women Factors Involved: -Structural changes occur with aging: weakening of muscles in diaphragm -Increased intraabdominal pressure: obesity, pregnancy, heavy lifting Two Types: -Sliding: stomach slides through hiatal opening in diaphragm when patient is supine, goes back into abdominal cavity when patient is standing upright; most common type -Paraoesophage al or rolling: fundus and greater curvature of stomach roll up through diaphragm, forming a pocket alongside the esophagus; paraoesophageal junction remains in normal position; acute paraoesophageal hernia is a medical emergency Complications: -GERD -Esophagitis -Hemorrhage from erosion -Stenosis -Ulcerations of herniated portion Diagnostic Studies: -Esophagogram (barium swallow): may show protrusion of gastric mucosa through esophageal hiatus -Endoscopy: visualize lower esophagus; information on degree of inflammation or other problems that may be happening at the same time as the hernia Medical Interventions: -Conservative therapy: medication, lifestyle modifications -Surgical therapy: goals to reduce hernia, provide acceptable lower esophageal sphincter (LES) pressure, prevent movement of gastroesophageal junction -Lifestyle modifications: eliminate alcohol, elevate head of bed (place 3-4'' blocks of wood under the head bed posts), stop smoking, avoid lifting/straining, reduce weight (if appropriate), use antisecretory agents and antacids Surgeries: -Gastropexy: anti-reflux procedure, attachment of stomach sub-diaphragmatically to prevent re-herniation -Herniotomy: reduction of herniated stomach, excision of hernia sac -Herniorrhaphy: closure of hiatal defect Gerontological Considerations: -Increased incidence with age -Older patients may take medications known to decrease LES pressure -Other agents can irritate the esophageal mucosa (medication-induced esophagitis) -First indication may be esophageal bleeding or respiratory complications -Lifestyle changes may be challenging for older adult: eliminate dietary factors (caffeine-containing beverages and chocolate), elevation of head of bed on blocks -Laparoscopic procedures reduce risk associated with surgical repair

prostate cancer

-If caught early, has nearly 100% cure rate -Assessment is similar to BPH -A prostate biopsy will confirm the diagnosis -The care provided is similar to that of BPH

cholecystitis

-Inflammation is the major pathophysiologic condition and may be confined to the mucous lining or involve the entire wall of the gallbladder. -During an acute attack of, the gallbladder is edematous and hyperemic, and it may be distended with bile or pus. -Most common causes: gallstones or biliary sludge, inflamed bile duct Causes: -Critical illness -Prolonged immobility and fasting -Prolonged parenteral nutrition -Diabetes mellitus -Adhesions -Neoplasms -Anesthesia -Opioids -Bacteria reaching the gallbladder via the vascular or lymphatic route (such as E. coli, streptococci, and salmonellae) -Chemical irritants in the bile Clinical Manifestations: -Severe pain (biliary colic): pain is steady, excruciating, tachycardia, diaphoresis, prostration, may last up to an hour, occurs 3-6 hours after eating fat. -If total obstruction occurs: see S/S of obstructed bile flow -Indigestion to severe pain, fever, chills, and jaundice, tenderness in RUQ, which may be referred to the right shoulder and scapula

chronic glomerular nephritis

-Inflammation of the glomeruli -Changes also occur to the tubular, interstitial, and vasculature structures of the kidney -Insidious onset, frequently clients are unaware of their declining kidney function -They will develop ESKD between 2-30 years Assessment: -Hematuria, WBCs & casts in urine -Proteinuria -S/s of uremia -Elevated BUN & Creatinine -History of: drug use, Lupus, Scleroderma Labs/Diagnostic Tests: -Kidney Biopsy -Ultrasound -CT -CBC, CMP -Abnormal laboratory test results: urine with fixed specific gravity, casts, proteinuria, electrolyte imbalances and hypoalbuminemia

gastroenteritis

-Inflammation of the mucosal lining -Can occur across the GI tract -Often caused by a bacteria/bug (food poisoning) -Causes: bacterial, viral, food contamination -Sudden diarrhea, nausea, vomiting, fever, abdominal cramping -Self-limiting -Management: fluids replacement, antipyretics

gastritis

-Inflammation of the stomach lining -Breakdown of the normal mucosal barrier -Causes: Drugs, diet, microorganisms, environment, diseases, and other factors -Nausea, vomiting, anorexia, epigastric tenderness, feeling of fullness, GI bleed -Chronic management: remove causes, manage symptoms, treat pernicious anemia for stomach tissue atrophies

peritoneal dialysis

-Involves siliconized rubber catheter placed into abdominal cavity for infusion of dialysate -Types: automated peritoneal dialysis and continuous ambulatory (CAPD) -Before treatment: evaluate baseline vital signs, weight, laboratory tests -Continually monitor patient for respiratory distress, pain, discomfort -Monitor prescribed dwell time, initiate outflow -Observe outflow amount and pattern of fluid -When it is automated, patients can undergo dialysis while sleeping at night Complications: -Peritonitis -Pain -Exit site/tunnel infections -Poor dialysate flow -Dialysate leakage -Other complications

chronic pyelonephritis

-Kidneys are small, atrophic, shrunken, loss of function from scarring (fibrosis) -Diagnosis: kidney biopsy -Frequently progresses to end stage renal disease -Decreased kidney function depends on previous infections and subsequent scarring -Treatment is based on stage of kidney failure

chronic liver failure complications

-Portal hypertension -Ascites -Peripheral edema -Esophageal varices -Coagulopathy -Hepatic encephalopathy -Hepatorenal syndrome -Biliary obstruction/jaundice

chronic kidney disease

-Progresses over time -Irreversible kidney injury (kidney doesn't recover) -End-stage kidney disease (ESKD) -Azotemia -Uremia -Uremic syndrome Causes: -Diabetes mellitus -Hypertension -Vascular disorders -Chronic glomerulonephritis -Pyelonephritis or other infections -Nephrotic syndrome -Medications or toxic agents -Obstruction of urinary tract -Hereditary lesions Stages (glomerular filtration rate, GFR): -Stage 1: >90 mL/min -Stage 2: 60-89 mL/min -Stage 3: 30-59 mL/min -Stage 4: 15-29 mL/min -Stage 5: <15 mL/min

bariatric surgeries

-Purpose: to decrease the client's weight as safely as possible and decrease risks of obesity related diseases -Restrictive surgeries: adjustable gastric binding, sleeve gastrectomy -Combination of restrictive and malabsorptive surgery: roux-en-Y gastric bypass

invasive imaging

-Main purpose is to give us an inside look at the GI system -Allows for direct visualization of the inside of our bowels, stomach, and ducts that connect the gallbladder, liver, and pancreas to our intestines -Commonly requested to evaluate bleeding, ulceration, inflammation, tumors, and cancer of the esophagus, stomach, biliary system, or bowels -Procedures are often done in an outpatient clinic -MDs use various types of flexible scopes that can all take biopsies, irrigate, and move/angle the end of the scope -Different types of sedation are used to ensure the client is comfortable; clients receive a medication to forget the procedure (moderate sedation) -Bleeding, perforation are potential complications Recovery for Clients Focuses On: -LOC, swallowing, or gag reflex -Stable vitals -Usually discharged the same day: once they can swallow and have exhibited stable vital signs and no s/s of complications (usually 1-2 hours) -Someone who is older will take longer to recover from the sedation due to the complications of aging -Sigmoidoscopy: direct visualization of sigmoid colon -Colonoscopy: direct visualization of the colon -Esophagogastroduodenoscopy (EGD): direct visualization of esophagus, stomach, and duodenum Client Preparations: -NPO status -Bowel prep for 1-2 days to empty their intestines of food, also allowed clear liquids until midnight before the procedure -Usually take their normal medications unless directed otherwise -IV access for sedation -Cardiac monitor -Lab tests for electrolytes and CBC usually, just in case -Do discharge teaching Discharge Teachings: -Call MD if bleeding in vomit and stool, unable to poop, nausea and vomiting -Don't make any major decisions or sign any legal paperwork -Start easy with clear fluids: if no nausea, can try full fluids; if no nausea, can then try soft bland food and work their way back to regular diet

aminosalicylates

-Mainstay in achieving and maintaining remission and preventing flare-ups of IBD -Ex: sulfasalazine (Azulfidine); new generation of sulfa-free drugs: olsalazine (Dipentum) and mesalamine (Pentasal) -More effective for ulcerative colitis. -However, they are first-line therapies for mild to moderate Crohn's disease, especially when the colon is involved. -The exact mechanism is unknown, but topical application to the intestinal mucosa suppresses proinflammatory cytokines and other inflammatory mediators. -The benefits of these drugs usually depend on the dose: The larger the dose, the more likely patients will improve during the acute phase and remain in remission. -However, many people cannot tolerate the side effects of sulfasalazine. -Headaches, nausea, and fatigue occur at the higher doses. -In men, long-term sulfasalazine treatment may cause abnormal sperm production, leading to infertility. These effects are reversible if sulfasalazine is discontinued. -The sulfa-free drugs are as effective as sulfasalazine and better tolerated when administered orally. -Topical preparations include rectal suppositories and enemas. Topical treatment offers the advantage of delivering it directly to the affected tissue and minimizing systemic effects. -The combination of oral and rectal therapy is better than oral or rectal therapy alone. -Sulfasalazine (Azulfidine): may cause yellowish orange discoloration of skin and urine; avoid exposure to sunlight and ultraviolet light until photosensitivity is determined.

gastrostomy and jejunostomy tubes

-May be used when a patient requires tube feedings for an extended time -Patient must have intact, unobstructed GI tract -Can be placed surgically, radiologically, or endoscopically -The esophageal lumen must be wide enough to pass the endoscope for percutaneous endoscopic gastrostomy (PEG) tube placement Two Potential Problems: -Skin irritation: skin assessment and care -Pulling out of tube: teach patient/family about feeding administration, tube care, and complications

laparoscopic cholecystectomy postoperative care

-Monitor for bleeding -Pain control: clients may complain of shoulder pain because of the CO2 used to inflate the abdominal cavity during surgery. The CO2 may irritate the phrenic nerve and diaphragm, causing some difficulty in breathing. Place in Sim's position to help move the gas pocket way from the diaphragm -Diet teaching: low fat diet, take vitamin supplements, watch for stool and urine changes -Jaundice may occur if common bile duct becomes inflamed

liver cancer

-Most common cause of death in patients with cirrhosis -Metastatic carcinoma of the liver is more common than primary carcinoma -Common sites for metastasis: lung, gallbladder, peritoneum, diaphragm -Most common type is hepatocellular carcinoma -The liver is a common site of metastatic growth because of its high rate of blood flow and extensive capillary network Initial Signs and Symptoms (can be difficult to detect): -Hepatomegaly -Splenomegaly -Fatigue -Peripheral edema -Ascites -Portal hypertension Late Signs and Symptoms: -Fever/chills -Jaundice -Anorexia -Weight loss -Palpable mass -RUQ pain At risk clients with liver diseases are screened regularly: -CT -MRI -Liver biopsy -Serum alpha-fetoprotein Nursing Interventions: -Focus: keep the patient as comfortable as possible -Nursing interventions are the same as for cirrhosis -Has same problems as advanced liver disease -Prognosis is poor -Without treatment, death occurs in 6-12 months (often due to hepatic encephalopathy and massive blood loss from GI bleeding) Medical Treatments: -Surgical removal of the cancerous part of the liver -Percutaneous ablation -Chemoemboliz ation -Radioembolizat ion, -Sorafenib (Nexavar) oral therapy -TACE & TARE

urinary incontinence

-Not a normal part of aging -Most common among older men and women, related to previous childbirth, various disease processes -Quality of life issues, contributes to other health issues -Cause: anything that interferes with urethral sphincter or bladder control -Different types: stress, urge, overflow, reflex, trauma or surgery, functional Causes (DRIP) -Delirium, dehydration, depression -Restricted mobility, rectal impaction -Infection, inflammation, impaction -Polyuria, polypharmacy Anticholinergic medications: -Tolterodine (Detrol) - watch for s/s of overdose: gi cramping, diaphoresis, blurred vision, urinary urgency Interventions: -Lifestyle modifications -Bladder retraining and urge-suppression strategies -Habit retraining -Prompted voiding -Timed voiding

chronic hepatitis

-Occurs when liver inflammation lasts longer than several months, usually defined as 6 months -Usually occurs as a result of hepatitis B or C -Can lead to cirrhosis and liver cancer Complications: -Skin manifestations: spider angiomas and palmar erythema -Gynecomastia -Splenomegaly -Hepatomegaly -Cervical lymph node enlargement -HE -Ascites Drug Therapy: -Decreases viral load and slows the rate of disease progression -Directed at eradicating the virus and preventing complications -Nucleoside and nucleotide -Interferon therapy -Antivirals

benign prostatic hyperplasia (BPH)

-The prostate gland increases in size, leading to disruption of the outflow of urine Risk Factors: -Aging -Obesity (in particular increased waist circumference) -Lack of physical activity -Alcohol consumption -Erectile dysfunction -Smoking -Diabetes -A positive family history of BPH in first-degree relatives may also be a risk factor Irritative Signs and Symptoms: -Nocturia -Urinary frequency -Urgency -Dysuria -Bladder pain -Incontinence Obstructive Signs and Symptoms: -Decrease in caliber and force of the urinary stream -Difficulty initiating a stream -Stopping and starting stream several times while voiding -Dribbling at the end of urination Labs and Diagnostics: -International prostate symptom score (I-PSS) -CBC -BUN -Creatinine -PSA -EPCA - 2: Flomax & Proscar -Digital rectal exam -Urinalysis with culture -Prostate-specific antigen (PSA): screen for prostate cancer -Postvoid residual -Transrectal ultrasound -Cytoscopy Complications: -Acute urinary retention: sudden and painful inability to urinate. Treatment: catheter inserted. Surgery may also be indicated. -UTI secondary to stasis of urine and could lead to sepsis -Bladder calculi: alkalinization of the residual urine -Hydronephrosis (distention of pelvis and calyces of kidney by urine that cannot flow through the ureter to the bladder): renal failure -Bladder damage Interprofessional Care: -Surveillance -Finasteride (Proscar): reduces the size of the prostate gland; takes about 6 months to be effective -Doxazosin (Cardura), tamsulosin (Flomax): relaxes smooth muscles of prostate but do not reduce size of prostate -Minimal invasive therapy -Making dietary changes (decreasing intake of caffeine, artificial sweeteners, and spicy or acidic foods), avoiding medications such as decongestants and anticholinergics, and restricting evening fluid intake may improve symptoms. Flomax (Tamsulosin): -Alpha-Blocker -Relaxes the muscles in the prostate and bladder causing the patient to have an easier time voiding -This does not shrink the prostate -Can cause •Dizziness •Drowsiness •Runny/stuffy nose -Ejaculation problems Proscar (Finasteride) -5-alpha reductase inhibitor -Inhibits hormone changes and helps to shrink the prostate -May take up to 6 months to be effective -May cause retrograde ejaculation, can affect hormones and have false PSA levels

testicular cancer

-Rare, less than 1% of all cancers -Most common in young men between 15 and 44 years of age -More common in males with undescended testes or a family history Risk Factors: -Orchitis -HIV -Maternal exposure to exogenous estrogen -Testicular cancer in the other testis Clinical Manifestations: -May grow fast or slow depending on tumor type -Painless lump in scrotum, scrotal swelling, feeling of heaviness -Scrotal mass usually nontender and firm -Some patients complain of dull ache or heavy sensation in the lower abdomen, perianal area or scrotum -Acute pain in 10% of patients Diagnostic Studies: -Palpation, digital rectal exam -Cancerous mass if firm and does not transilluminate -Ultrasound, transrectal -Labs: alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), human chorionic gonadotropin (hCG) -Chest x-ray and CT scan of abdomen and pelvis: to detect metastasis Interprofessional Collaboration: -Surgery: radical orchiectomy (surgical removal of the affected testis, spermatic cord, and regional lymph nodes). -After surgery: surveillance, radiation therapy, chemotherapy (cisplatin) -More surgery: RPLND-retroperitoneal lymph node dissection Follow Up: -Prognosis very good: 95% obtain complete remission -Side effects of treatment: pulmonary toxicity, kidney damage, nerve damage, hearing loss -Continue with follow-up with physical exams -Infertility -Ejaculatory dysfunction may result from RPLND

kidney failure

-Results when the kidneys cannot remove wastes or perform regulatory functions -A systemic disorder that results from many different causes -Acute renal failure is a reversible syndrome that results in decreased glomerular filtration rate and oliguria -Chronic renal failure (ESRD) is a progressive, irreversible deterioration of renal function that results in azotemia Assessment (Nutrition): -Nutritional status; weight changes, laboratory data -Nutritional patterns, history, preferences -Provide food preferences within restrictions -Encourage high-quality nutritional foods while maintaining nutritional restrictions -Stomatitis or anorexia: modify intake related to factors that contribute to alterations -Adjust medication times related to meals Complications: -Hyperkalemia -Hypervolemia and overload -Pericarditis -Pericardial effusion -Pericardial tamponade -Hypertension -Anemia -Medication toxicity -Bone disease and metastatic calcifications Diagnostic Imaging of the Kidney: -Ultrasound -KUB (kidney, ureter, bladder) scan -CT -MRI, without contrast -Aortorenal angiography -Cytoscopy -Retrograde pyelography -Kidney biopsy Labs: -Fluid volume overload -Urinalysis and 24 hour urine -Serum creatinine -BUN -Electrolytes -CBC

polyurethane or silicone tube

-Soft, long, small in diameter, and flexible, decreasing the risk of mucosal damage from prolonged placement -Radiopaque -Placement in small intestine decreases the chance of regurgitating gastric contents into the esophagus and subsequent aspiration. However, the patient can still aspirate gastric secretions if the stomach is not emptying properly -Stylet may be used for placement in a comatose patient because the ability to swallow is not essential during insertion. A complication that can result from using a stylet is increased risk for perforation. -Decreased likelihood of regurgitation and aspiration when placed in the intestine

hepatitis B

-Spread by unprotected sex -Sharing needles -Blood transfusions -Hemodialysis -Close contact with open cuts and sores Clinical Manifestations: -Anorexia -N/V -Fever -Fatigue -Right upper quadrant pain -Dark urine and light stool -Jaundice -Malaise -Easy fatigability -Patients usually have no symptoms and use blood tests to confirm

cholelithiasis

-Stones in the gallbladder -Cause unknown -Inflammation occurs due to obstruction in the biliary system from gallstones -Stones may remain in the GB or migrate to the cystic duct or the common bile duct -More common in women multiparous and over 40, postmenopausal women on estrogen replacement therapy, and younger women on oral contraceptives -Risk factors include a sedentary lifestyle, a familial tendency, and obesity Signs and Symptoms of Obstructed Bile Flow: -Obstructive jaundice -Dark amber to brown urine which foams when shaken -Clay colored stools -Pruritus -Steatorrhea -Fever, chills Diagnostic Studies: -Ultrasound -Percutaneous transhepatic cholangiography: the insertion of a needle directly into the gallbladder duct followed by injection of contrast materials. It is generally done after ultrasonography indicates a bile duct blockage. -Elevated WBCs -ERCP Medical Treatment: -Removal of stone via ERCP -Disintegrate stone: extracorporeal shock-wave lithotripsy (ESWL) uses high-energy shock waves to disintegrate stone -Surgical removal of the gallbladder and/or stones: laparoscopic cholecystectomy and cholecystectomy Interprofessional Care: -Pain control -IV fluids -NPO with NG tube -Bile acids: ursodeoxycholic acid (ursodiol) and chenodeoxycholic acid (chenodiol) to dissolve stones -Antiemetics -Antibiotics for secondary infection -ERCP -Shock-wave lithotripsy -Surgery: laparoscopic or traditional Nursing Interventions: -NPO, care of NG tube -Comfort care & pain control -Prepare the client for a procedure or surgery -Client education: diet, medications, post-op recovery -Monitor for signs/symptoms the condition is getting worse -Monitor for infection -Skin care

immunosuppressants

-Suppress immune response -Maintain remission after corticosteroid induction therapy -Require regular CBC monitoring -Ex: 6-mercaptopurine, azathioprine [Imuran] -Are given to maintain remission after corticosteroid induction therapy. -These drugs require regular CBC monitoring because they can suppress the bone marrow and lead to inflammation of the pancreas or liver. -They have a delayed onset of action and are therefore not useful for acute flare-ups. -Methotrexate is most useful in Crohn's disease patients who cannot stop corticosteroid use without a flare-up or in whom other medications have been ineffective. -Many patients have flu-like symptoms with use, and some develop bone marrow depression and liver dysfunction. -Correct dosing is critical to minimize the risk of toxicity. -Careful monitoring of the CBC and liver enzymes is essential. -Advise women of childbearing age to avoid pregnancy because use causes birth defects and fetal death.

hysterectomy

-Surgical removal of the uterus with or without the ovaries and fallopian tubes -Can be used to treat cancers of the uterus, ovaries, and fallopian tubes, endometriosis, and abnormal uterine bleeding Post-Op Nursing Care: -Abdominal distention may develop after the procedure due to the sudden release of pressure on the intestines when a large tumor is removed or from paralytic ileus due to anesthesia and pressure on the bowel -Food and fluids may be restricted if the patient is nauseated -Ambulation will help relieve flatus -Initiate venous thromboembolism (VTE) prophylaxis: apply intermittent pneumatic compression devices and administer anticoagulant therapy -Frequent position changes, avoiding high-Fowler's position, and avoiding pressure under the knees minimize stasis and pooling of blood -Encourage leg exercises to promote circulation -Intercourse should be avoided until the wound is healed (about 4 to 6 weeks) -Heavy lifting should be avoided for 2 months -Avoid activities that may increase pelvic congestion, such as dancing and walking swiftly, for several months -Once healing is complete, all previous activity can be resumed

hepatitis

-The widespread inflammation of liver cells -Can be caused by viruses, chemicals, drugs, alcohol, and herbs Hepatitis A: -Incubation time (days): 15-50 (Avg 28) -Transmission route: Fecal-oral -Those at risk and sources of infection: crowded conditions, poor personal hygiene, poor sanitation, contaminated food/milk/water/shellfish, sexual contact with an infected person, IV drug users, receiving food from someone handling/preparing food -Most infectious when: during the first 2 weeks prior to onset of symptoms and 1-2 weeks after the onset of symptoms Hepatitis B: -Incubation time (days): 45-180 (Avg 56-96) -Transmission route: blood & mucous membranes, perinatal, high risk sexual contact -Those at risk and sources of infection: contaminated needles, syringes, blood, sexual contact with an infected person, tattoos/ body piercings with contaminated needle, asymptomatic person, blood and blood products -Most infectious when: before & after symptoms appear. Infectious 4-6 months, carriers can be infectious for life Hepatitis C: -Incubation time (days): 14-180 (Avg 56) -Transmission route: blood & mucous membranes, perinatal, high risk sexual contact -Those at risk and sources of infection: contaminated needles, syringes, blood, sexual contact with an infected person, tattoos/ body piercings with contaminated needle, blood & blood products -Most infectious when: 1-2 weeks before symptoms appear, during course of disease, 75-85% of people will develop chronic hepatitis C and be infectious during their life

TURP

-Transurethral resection of the prostate -Done for both prostate cancer and BPH -Widens the diameter of the urethra and improves urination -Decreases symptoms of BPH and prostate cancer -The surgeon inserts a resectoscope through the urethra and into the bladder and removes pieces of tissue from the prostate gland

inflammatory bowel disease (IBD)

-Ulcerative colitis and Crohn's disease -Foods that trigger exacerbations vary -Food diary helps identify problems for individuals -Lactose intolerance -High-fat foods -Cold foods -High-fiber foods Complications: -Within the GI system -Hemorrhage -Strictures -Perforation with possible peritonitis -Abscesses -Fistulas -Toxic megacolon - dilated colon Complications outside the GI System: -Peripheral arthritis -Ankylosing spondylitis -Sacroiliitis -Finger clubbing -Erythema nodosum -Pyoderma gangrenosum -Mouth ulcers -Conjunctivitis, -Uveitis, episcleritis -Gallstones -Kidney stones -Liver disease -Osteoporosis -Thromboemboli sm Diagnostic Studies: -History and physical examination -Blood studies: CBC, serum electrolyte levels, serum protein levels -A CBC typically shows iron-deficiency anemia from blood loss. -An elevated WBC count may be an indication of toxic megacolon or perforation. -Decreases in serum sodium, potassium, chloride, bicarbonate, and magnesium levels occur due to fluid and electrolyte losses from diarrhea and vomiting. -Hypoalbumine mia is present with severe disease because of poor nutrition or protein loss. -Elevated erythrocyte sedimentation rate, C-reactive protein level, and WBC count reflect inflammation. -The stool is examined for blood, pus, and mucus and cultures can determine infection preference -Imaging studies: double-contrast barium enema study, small bowel series, transabdominal ultrasonography, CT, MRI -Colonoscopy Goals of Treatment of BID: -Rest the bowel -Control inflammation -Combat infection -Correct malnutrition -Alleviate stress -Relieve symptoms -Improve quality of life Nutritional Therapy: -During acute exacerbations, regular diet may not be tolerated -Liquid enteral feedings are preferred: high in calories and nutrients, lactose free, easily absorbed -Regular foods are reintroduced gradually to help identify food intolerances or sensitivities -Lower the intake amount of fiber -Avoiding milk and milk products improves symptoms -High-fat foods, cold foods, and high-fiber foods (cereal with bran, nuts, raw fruits with peels) may trigger diarrhea Drug Therapy: -Goal of drug treatment is to induce and maintain remission -Aminosalicylat es -Antimicrobials -Corticosteroids -Immunosuppres sants -Biologic and targeted therapy Medical Interventions: -Dietary and medication management -Exacerbations are debilitating and frequent: massive bleeding, perforation, strictures and/or obstruction, tissue changes indicating dysplasia or carcinoma -Surgeries: total proctocolectomy with ileal pouch/anal anastomosis (IPPA) and total proctocolectomy with permanent ileostomy Post Op Care: 1. We will do all of the usual assessments/interventions as we would for any surgery. 2. We focus on the healing of the section of bowel affected and any associated stoma. 3.NUTRITION! 4.We assess for: -Fluid & electrolyte imbalance -Hemorrhage -Abdominal abscesses -Small bowel obstruction -Dehydration 5.NG is removed when bowel function returns. 6.Incontinence & Perineal skin care

The nurse is providing education for a client being discharged following a hysterectomy. Which information should the nurse emphasize to this client?

Intercourse should be avoided for 4-6 weeks, vaginal sensation should return within a few months, bathing in a tub should be avoided for at least four weeks

bowel obstruction

Causes: -Neurogenic (paralytic ileus) -Mechanical: tumors, adhesions, strictures -Vascular: interference of the blood supply Clinical Manifestations: -Vomiting -Abdominal distention -Hyperactive proximal to the blockage -Colicky-type pain -Fluid/electrolyt e imbalances Diagnostics: -Abdominal X-ray -CT scan -Barium enema AFTER perforation is ruled out Complications: -Infection -Ischemia -Infarction -Perforation -Severe dehydration -Electrolyte imbalance Medical Treatment: -NG tube: decompression -Surgery: ileum resection with ileostomy and colon resection with colostomy -Fluid and electrolyte replacement -Antibiotic therapy Nursing Interventions: -NPO -IV fluids -Abdominal assessment -I&O -Monitor labs: CBC, BMP -Pain meds -Anti-emetics -Oral care

cervical cancer

Risk Factors: -Infection with high-risk strains of human papillomavirus (HPV) 16 and 18 -Immunosuppres sion -Low socioeconomic status -Chlamydia infection -Smoking Clinical Manifestations: -Early: no symptoms -Unusual discharge, -AUB or postcoital bleeding eventually occurs (discharge is usually thin and watery but becomes dark and foul smelling as the disease advances). -The vaginal bleeding (spotting) then bleeding becomes heavier and more frequent. -Pain is a late symptom and is followed by weight loss, anemia, and cachexia. Diagnostic Studies: -Pap test: identifies changes in cervical cells that may indicate precancerous changes; 21-29 years old screened every 3 years; 30-65 years old screened every 5 years -HPV testing can be used to identify the high-risk HPV types 16 and 18, which are associated with cervical cancer. Vaccinate at age 11 to 12, but can be as early as 9 Treatment Options: -Surgery (biopsy, cone biopsy, removal) -Combination of chemotherapy and radiation -Fertility concerns