Module 5

Malabsorption Dumping Syndrome S/S

Dumping syndrome is caused by food entering the small intestine too quickly instead of being digested in the stomach. Happens after gastric bypass, Vasomotor symptoms 30min after eating S/S: vertigo, tachycardia, syncope, sweating, pallor, palpitations, nausea, diarrhea, and abdominal cramping.

Dx lung cancer

Dx: Lung lesions are first identified on X-rays. A CT may be ordered to better visualize the lesions and guide biopsy. Biopsy is how the definitive Dx is made—cells or pleural fluid is examined. Thoracscopy is done through a small incision in the chest wall, the scope enters the lungs to view the tissue with the used of a video camera. MRI's and radionucleotide scans are used to identify the spread of the disease to the liver, spleen, brain, and bone. PET scans locate metastasis.

Oncologic Emergencies Syndrome of Inappropriate Antidiuretic Hormone

SIADH: disorder of impaired water retention. Water is excessively reabsorbed by the kidneys and put into systemic circulation. Causes hyponatremia. S/S: Mild symptoms include weakness, muscle cramps, loss of appetite, and fatigue. With greater fluid retention and decreased sodium levels, weight gain, nervous system changes, personality changes, confusion, and extreme muscle weakness occur. -As the sodium level drops toward 110 mEq/L (mmol/L), seizures, coma, and death may follow depending on how rapidly hyponatremia occurs. -Interventions: SIADH is managed by treating the condition and the cause. Nursing priorities focus on patient safety, restoring normal fluid balance, and providing supportive care. Management includes fluid restriction, increased sodium intake, and drug therapy. Immediate cancer treatment with radiation or chemotherapy may cause enough tumor regression that ADH production returns to normal. -Monitor patients at least every 2 hours to recognize signs and symptoms of increasing fluid overload (bounding pulse, increasing JVD, crackles in lungs, increasing peripheral edema, or reduced urine output) because pulmonary edema can occur very quickly and lead to death. When symptoms indicate that the fluid overload from SIADH either is not responding to therapy or is becoming worse, respond by notifying the primary health care provider immediately.

PDs Cluster A

-A: Described as odd or eccentric, paranoid, demonstrate behavior sometimes seeing in schizophrenia. Often with a co-occurring disorder. -Schizotypal Personality disorder: social interpersonal deficits marked by a reduced capacity for close relationships. resemble people with the diagnosis of schizophrenia. Up to 10% of people with Schizotypal PD complete suicide. Later develop schizophrenia. -Paranoid Personality disorder: characterized by pervasive, persistent, and inappropriate suspiciousness and distrust of others. Nurses may consider this diagnosis when patients present with hostile, irritable, angry mood and affect. these individuals lack warmth, pay close attention to power and rank, and express disdain for those who are weak, sickly, and impaired. -Schizoid Personality disorder: inability to establish relationships with others and a restricted range of emotions and interpersonal settings. May later develop schizophrenia or a delusional disorder. Some individuals with those traits have conceived, developed, and given our world generally original and creative ideas.

Testicular Cancer

-Assess risk factors for testicular cancer, when taking a history from a patient with a suspected testicular tumor. Including a hx or presence of an undescended testis and a family hx of testicular cancer. -Rare cancer, effects men 20-35 yrs. 95% cure rate if early detection. Germ-cell: sperm producing cells. Non-Germ: Leydig, interstitial, stromal. -Monthly self testicle exam.-If patient wants kids, recommend they freeze their sperm at a sperm bank. -Surgery: one or both tested + chemo. Orchiectomy-for localized dz, unilateral-curative. -Seminoma- 1 surgery to remove testicle through groin, frozen sample used to stage and determine cancer, use saline prosthetic to replace testicle. -Advanced Dz: RPLND or MIS, erection possible without nerve damage, otherwise they will have retrograde ejaculation. -Chemo can be performed without surgery, with surgery orchiectomy, or if the dz has metastasized.

Breast Cancer

-Describe the specific information about a breast mass Location using the "face of the clock": Shape, Size, Consistency. Is the mass mobile of fixed at the surrounding tissue? Skin change. -Psychosocial: women fear losing their "femininity", men with this cancer fear the stigma of it being "feminine". -Labs: Increase level of serum Calcium and Alkaline Phosphate level can suggest BONE METASTASES, Elevated liver enzyme indicate possible liver metastases -Monthly BSE in shower, then look in mirror to assess symetry. CBE is done by HCP. Mammography age 40-54 annually, 55+yrs every other year. US clarifies the mammography by differentiating between massess and fluid filled cycsts. -Interventions: guided imagry, massage, prayer, herbs, cancer diets. Surgical: lumpectomy, masectomy, with chemo as an adjuvant therapy. Axillary Lymph Node Dissection (ALND) for effected L.N. -Avoid using affected arm for measuring blood pressure, giving injections, or drawing blood If lymph nodes are removed, it is critical to prevent trauma to the affected arm. -Breast reconstruction: Common. May lessen the psychological strain associated with undergoing a mastectomy. Should have close-surveillance breast cancer screening in the opposite breast, including imaging with mammography or MRI

Extravasation

-Extravasation occurs when a vesicant fluid leaks into the surrounding tissue--infiltration. -Pain, infection, tissue loss, blistering, slough, necrosis can result. -Chemo meds: doxarubicin, vinblastine, vincristine -Hyaluronidase, an enzyme that breaks down hyaluronic acid, has long been used to increase the absorption of drugs into tissue and to reduce tissue damage in cases of extravasation of a drug. It is the antidote for doxarubicin. -Each agency will have protocol for extravasation, antidotes will be administered, surgery may be needed depending on severity. -ALWAYS assess for patency before administering any med!

DIALECTICAL BEHAVIOR THERAPY for BPD

-It is a form of CBT that helps change the self-destructive behaviors associated with the diagnosis of Borderline PD. It includes individual sessions that emphasize problem solving plus group sessions where patient will learn adaptive behavioral skills. -mindfulness - living in the moment -interpersonal effectiveness - achieving goals without damaging a relationship or one's self-respect -distress tolerance - learn to deal with pain emotions by accepting self -emotional regulation - recognizing & coping with negative emotions in a healthy manner . -It may be reinforced with smartphone apps.

Ulcerative Colitis classification system Mild Moderate Severe Fulminant

-Mild: <4 stools/day without blood. Asymptomatic, usually normal labs. -Moderate: >4 stools/day without blood. Minimal S/S, mild abdominal pain, mild intermittent nausea, possible increased C-reactive protein or ESR. -Severe: >6 bloody stools/day. Fever, tachycardia, anemia, abdominal pain, elevated C-reactive protein and/or ESR. -Fulminant: >10 bloody stools/day. Increasing S/S, anemia may require transfusion, colonic distention on x-ray.

PD comorbidities

-PDs often occur with other psyc-dz: anxiety, depression, ED, Substance abuse, somatic ds, PTSD. -Also occur with other PDs or medical ds.

Prostate Cancer

-Prostate cancer, most common form of cancer in men and 2nd leading cause of cancer deaths in men in the US, first leading cause of death is lung and bronchial cancers. Age is a risk factor and incidence increases with age.Higher incidence in African American men. -Normally in periphery of gland, BPH is in the center. -Risk factors: diets high in animal fat and refined CHOs low fiber, family Hx, 65+yrs.-100% cure rate if found early, slow growing with predictable metastasis-"bone loving" cancer. Prostate-Lymph nodes-bone. -Pain, weight loss, change in sexuality, frequent bladder problems. Gross blood in urine-late stage sign. -Dr performs DRE, cancer feels hard/stony.-PSA: prostate specific antigen, normal <2.5 (<50yrs), 6.5 (70yrs), >4 notated in 80% of men with this cancer. In advance prostate cancer the Alkaline phosphate will rise. -TRUS: transrectal US, through rectum to get image, biopsy if cancer is suspected.-Can metastasize if it gets into blood-Active Surveillance, surgery MIS or radical prostatectomy, palliative removal of testicles because it removes testosterone. -Radiation: Low dose brachytherapy "seeds" placed in prostate, guided by TRUS, MRI, or CT--ED, urinary incontinence, rectal problems can occur. -External beam RT- 5 days/wk for 4-6wks. -Chemo, Androgen deprivation therapy (ADT)- tumors are hormone dependent. LHRH- make pituitary gland release all its LH over 3weeks, reduced testosterone production. Systemic chemo-dz spread and other therapies arent working.

Interventions for PDs

-Provide patients with a structured approach to problem solving. Encourage patients to practice self control. Help patients connect feelings to events and actions. Be active in response so that the person feels validated. Discuss countertransference issue with staff members -Interventions for Manipulation: assess your own reactions toward patient, assess patient before labeling as manipulative, set the limits such as: arguing or begging, flattery or seductiveness, constantly seeking attention, pitting one person against another, frequently disregarding the rules, constant engagement in power struggles, angry demanding behaviors. -Intervene in manipulative behavior: set limits, be consistent, document behaviors, establish boundaries and consequences. Avoid: discussing yourself with patient, promising to keep a secret, accepting gifts, doing special favors -Interventions for Impulsive Behaviors: discuss previous impulsive acts, identify the thoughts and feelings that precede the impulsive acts, explore effects of acts, discuss potential alternative, teach needed coping skills

Calculating BMI

-The formula is BMI = kg/m2 where kg is a person's weight in kilograms and m2 is their height in metres squared. -lbs/2.2= kg -The length in meters is equal to the inches multiplied by 0.0254. -Normal BMI 18.5-24.9 -overweight it's a BMI of 25 to29 / -obesity it's a BMI of 30 or above o Class I BMI of 30 - 35 o Class II BMI off 35 - 40 o class III BMI of 40 or higher

Mammography Breast Exam Self-breast exam Flexible Sigmoidoscopy Colonoscopy PSA FOBT Digital rectal exam (DRE) PAP/Pelvic exam/FOBT

1. The choice of annual mammography for women 40 to 44 years of age, annual mammography for women 45 to 54 years of age, and annual or biennial mammography for women older than 55 years 2. Annual clinical breast examination for women older than 40 years, and every 3 years for women age 20 to 39 years 3. Monthly self breast exam 20-39 yrs 4. Flexible sigmoidoscopy every 5 years 5. Colonoscopy at age 50 and then every 10 years 6. PSA and then digital, do not get PSA measured after a DRE. 7. Annual fecal occult blood text for adults of all ages 8. Digital rectal examination (DRE) for men older than 50 years 9. Annual PAP and pelvic exam with FOBT, start at 21 and then every 3 years

Anorexia nervosa Acute and Long term care

Anorexia nervosa Acute Phase -Intensive care unit (ICU), critical care unit (CCU), ED unit (crisis state)- stabilize the patient Establishment of trust. Monitoring of weight and eating to prevent hoarding or inappropriate disposing of food. Continue to monitor for 1-3 hours after meals to prevent purging. NG feedings or liquid supplements may be instituted if weight is lost, or certain amount of food isn't consumed each day. Countering distorted ideas Milieu therapy, counseling, health teaching, and medications. Patient privileges linked to treatment plan compliance -Long-Term Phase -Chronic illness- realapses. Possible long-term treatment: Periodic brief hospital stays, outpatient psychotherapy, and medications. Greatest success with a combination of individual, group, family, and couples therapy -Pharmacological AN: Fluoxetine (SSRI) may be prescribed after weight is stabilized to treat depression and obsessive compulsive symptoms. SSRIs can increase risk of suicide. Olanzapine (1st gen. antipsychotic) can be helpful with weight gain and changing obsessive thinking. Can cause cardiac problems.

PDs Cluster B

B: Share emotional reactivity, such as dramatic, erratic, flamboyant behavior, poor impulse control, and unclear sense of identity. Manipulation is a common behavioral mechanism among people with these disorders. -Antisocial personality disorder: characterized by a persistent disregard for and violation of the rights of others, with a lack of remorse for actions or hurting others. Have sense of entitlement they believe they have the right to take what they want, treat others unfairly, destroy the property of others and family if it's in their best interest. Common in males. Criminal arrests, including violent offenses. -Borderline Personality Disorder: can be summarized as experiencing ongoing patterns of difficulty with self-regulation, an inability to sooth oneself in times of stress. The emotional dysregulation in instable interpersonal relationships demonstrated as part of this disorder can create many problems in a therapeutic milieu. High risk of suicide, safety is priority. -Narcissistic Personality Disorder: is a maladaptive response characterized by a person's grandiose sense of self-importance. People with this disorder consider themselves special and expect special treatment. -Histrionic Personality Disorder: is a pattern of excessive emotionality in attention seeking. People with this PD manipulate others through self-dramatization , theatricality, and exaggerated expressions of emotions

BN acute and long term care

Bulimia Nervosa -Acute Care: Patient is admitted into an inpatient unit. CBT is highly effective. Binge and purge cycle is interrupted. Eating habits are normalized-- watch 1-3 hours after eating to prevent purging. Underlying conflicts and distortions are examined. Co-morbid depression and substance abuse are treated. -Long-Term Therapy: On discharge, the patient is referred for long-term care to solidify goals and to address attitudes and perceptions that maintain the ED. Patient and family benefit from connecting with the national network www.anred.com Psychotherapy is performed. -Pharmacological BN: Fluoxetine (Prozac) an SSRI can be used for BN. SSRIs seem to decrease the binging and purging behaviors. There is an increased risk of suicide, as with all SSRIs. Topiramate (mood stabilizer) can supress the urge to binge and reduce preoccupation with eating and weight. -Meds + therapy is the most successful treatment.

PDs Cluster C

C: Anxiety and fearfulness. Acute anxiety in social situations through social inhibitions. -Avoidant Personality Disorder: high levels of anxiety and outward signs of fear with feelings of low self-worth. -Obsessive Compulsive Personality Disorder: preoccupied with orderliness and mental and interpersonal control at the expense of openness or efficiency. -Dependent Personality Disorder: are inhibited and fearful or reluctant to express disagreement for fear of rejection and loss of support. They do not respond with anger rejection, but withdraw or become passive.

S/S of AN

Clinical S/S of AN: Orthostatic changes, Bradycardia, Cardiac murmur, Sudden cardiac arrest, Prolonged QT interval, Acrocyanosis, Symptomatic hypotension, Leukopenia, Lymphocytosis, Carotenemia, Hypokalemic alkalosis, Electrolyte imbalances, Osteoporosis, Fatty degeneration of liver, Elevated cholesterol levels, Amenorrhea, Abnormal thyroid functioning, hematuria, Proteinuria · Malnutrition, including poor circulation, dizziness, palpitations, fainting, or pallor · Menstrual or other endocrine disturbances · Unexplained gastrointestinal symptoms · Cachectic appearance (severely underweight with muscle wasting) · Lanugo (a growth of fine, downy hair on the face and back)

S/S of BN

Clinical S/S of BN: Cardiomyopathy (ipecac toxicity), Cardiac dysrhythmias, Sinus bradycardia, Sudden cardiac arrest, Orthostatic changes in pulse and blood pressure, Electrolyte imbalances, Metabolic acidosis, Hypochloremia, Hypokalemia, Dehydration and renal loss of potassium as a result of self-induced vomiting, Attrition and erosion of teeth, Loss of dental arch, Diminished chewing ability, Parotid gland enlargement, Esophageal tears as a result of self-induced vomiting, Gastric dilation, Russell sign · Binge-eating behaviors · Binging may occur after attempts to fast to prevent weight gain. Dieting almost always precedes the binge eating. · Compensatory behavior, often self-induced vomiting (or laxative or diuretic use) after bingeing · History of anorexia nervosa in one-fourth to one-third of individuals · Depressive signs and symptoms · Problems with: Interpersonal relationships, Self-concept · Impulsive behaviors; reports feeling "out of control" at times · Increased levels of anxiety and compulsivity · Possible comorbid substance use disorder · Bingeing may be motivated by feelings of emptiness or attempts to feel less depressed

Interventions for C.A.N.C.E.R.

Comfort, Altered body image, Nutrition, Chemotherapy, Evaluate response to treatment, Respite for the caregivers.

Permanent Ileostomy: The procedure involves the removal of the colon, rectum, and anus with surgical closure of the anus. A permanent ileostomy is created with the end of the ileum, it is pulled out through the abdominal wall to create a stoma. How to care for an ileostomy?

a. Immediately post-op, the stool coming from it will be a loose dark green liquid. Over time, adaptation occurs. The small intestine begins to perform some of the functions that had previously been done by the colon, including the absorption of increased amounts of sodium and water. Stool volume decreases, becomes a thicker paste, and turns yellow-green or yellow-brown. b. Patient must always wear a pouch system because the drainage is relatively constant. The stool from the small intestine contains many enzymes and bile salts, which can quickly irritate and excoriate the skin. c. Skin Protection: Use a skin barrier to protect your skin from contact with contents from the ostomy. Use skin-care products, such as skin sealants and ostomy skin creams. d. Pouch Care: Empty your pouch when it is 1/3 to 1/2 full, Change the pouch during inactive times, such as before meals, before retiring at night, on waking in the morning, and 2-4 hours after eating, Change the entire pouch system every 3-7 days. e. Nutrition: Chew food thoroughly, Be cautious about high-fiber and high-cellulose foods, may need to eliminate certain ones ex. coconut, popcorn, tough-fiber meats, rice, cabbage, and vegetables with skins (tomatoes, corn, and peas). f. Drug Therapy: Avoid taking enteric-coated and capsule medications, Inform any HCP that you have an ostomy. Before having prescriptions filled, inform your pharmacist that you have an ostomy, Do not take any laxative or enemas. You should usually have loose stool and should contact your primary health care provider if no stool has passed in 6 to 12 hours.

COLORECTAL CANCER interventions surgical

o Colon resection: removal of the part off the column and regional lymph nodes with reanastomosis. o Partial Colectomy with colostomy: temporary or permanent o Total Colectomy with ileostomy/ileoanal pull-through o Abdominoperineal resection: rectal tumors, removal of the sigmoid colon, rectum and anus. o Colon resection is preferentially performed via laparoscopy (MIS) o Low rectal surgery risk for postoperative sexual dysfunction and urinary incontinence as a result of nerve damage during surgery. o Older adults may become dehydrated from bowel prep. o An NG tube may be placed for decompression of the stomach. An IV or central venous catheter is also placed for fluid in electrolyte replacement while the patient is NPO after surgery. o Patient who had MIS can eat solid foods very soon after the procedure, Ambulate and heal sooner, and the hospital stay is shorter, typically one to two days.

· Benign tumor cells:

o Grow in wrong place at the wrong time from problems in cellular regulation. o The retain the specific morphology of their parent cell. o Like normal cells, they have a smaller nuclear-to-cytoplasmic ratio. o Specific differentiated functions continue to be performed. o Tight adherence still occurs because of their adhesion molecules. o No migration or wandering occurs because of their tight adherence. o Orderly and normal growth patterns occur, even though their growth is not needed. There is a problem with cellular regulation, but the growth rate is normal. It grows by expansion and it does not invade. o Euploidy- the normal number of chromosomes are usually found in benign cells, 23 pairs.

· Malignant Cancer Cells:

o Rapid and continuous division that doesn't respond to check-point controls because of changes in genes that reduce effective cellular regulation. Rate of growth varies, but it's usually rapid. o Contact inhibition doesn't occur because of lost cellular regulation, even when all sides are touched by other cells—making cancer difficult to manage. o The cells are "immortal", apoptosis doesn't occur because telomerase maintains the telomeric DNA. o Aneuploidy- increases with malignancy. The chromosomes can be lost, gained, or broken/rearranged. o It is rarely contained within a capsule. o It is irregular and more mobile when palpated. o Doesn't really resemble parent tissue, this is called anaplasia. o The more malignant cancers are smaller and more rounded than normal cells. o They have a larger nucleus to cytoplasm ratio because it has a larger nucleus and the cell size is smaller than a normal cell. o The specific function of its original parent cell is totally or partially lost, no useful purpose. o They lose their adherence because they do not have adhesion molecules (CAMs), so they break off from the main tumor. o They migrate because they do bind tightly together, there are many enzymes on their surface. They can slip through BVs and tissue. o They invade normal tissue. May recur after removal. Fatal without treatment

Priority Assessments for a patient with an ED

· 1. Acknowledge their emotional and physical difficulties. State the obvious of what you are seeing. · 2. Assess for suicidal thoughts and self-injurious behaviors. This may be their primary Dx on admission. · 3. Monitor physiologic parameters (ex vitals, F&E) · 4. Weigh the patient using strict protocol—daily, same time, same scale, in the morning before breakfast. Don't let them see the number! Set a weight goal with them, come to an agreement on a certain number within a certain amount of time and stick to it. · 5. Monitor during and after meals to prevent throwing away or purging of the food. At least 1 hour after they eat, they must remain in the milieu with the other patients and staff. · 6. Recognize their distorted image and value of body shape. Help them deal with their disturbed body image, this wont be easy because it is "burned" into their mind. · 7. Educate the patient regarding the ill effects of low weight and impaired health. · 8. Assist in identifying strengths.

Describe components of interprofessional and interprofessional teamwork and collaboration to effectively treat eating disorders. QSEN: Teamwork and Collaboration

· Milieu therapy- the MH environment, includes the intercollaborative team: Doctors, psychiatrists, psychologists, therapists, RN, technicians, social workers, etc. · Health teaching and health promotion- teach patients self care activities, coping skills, social skills, problem solving. · Psychotherapy- talk therapy with a mental health provider. Change distorted self image, catastrophizing though process, "all or nothing" rationalizations, personalization, paranoid ideas of reference. · CBT- change distorted thoughts/perceptions in order to change behaviors/attitudes. · Dialectical behavior therapy (a type of CBT)- address emotional dysregulation. Effective for adults with BN and BED. Active listening, guidance with problem solving, and consistent limit setting using a "here and now" approach, feelings are validated. · Psychodynamic therapy- Focuses on childhood trauma, unconscious awareness, ego psychology. · Group and family therapy- help with isolation while addressing key concerns and issues. Learn adaptive behaviors, normalize eating, coping skills. · Most effective care includes a multidisciplinary approach, with expertise in treatment of patients with EDs. (AED, 2011) · Team approach in treatment of EDs includes medical, psychologic, nutritional, and psychopharmacologic services. · Family and spouses are always encouraged to participate.

Apply behavioral and communication strategies that facilitate patient-centered care for the individual with an eating disorder. QSEN: Patient-Centered Care

· You must build a repore with these individuals. Do not be overly authoritarian, coercive, antagonistic, or judgmental. Nurses may find it difficult to appreciate the force of the illness, thinking that it's a self-imposed choice, rather than a disease. Assess your own biases and opinions, and then work towards becoming empathetic, understanding, and trusting of the patient's words. · After you establish repore, you need to create rules/boundaries and then enforce them. Make sure the rules are known to the patients and agreed upon. Ex no extreme exercise, no unmonitored bathroom visits after meals. Enhancing the client's involvement in the decision-making process builds trust and a therapeutic relationship between the nurse and client. · Compared with the patient with AN who is restricting food, the patient with BN more readily established a therapeutic alliance because the eating behaviors are so ego-dystonic (against what they want). · This therapeutic alliance allows the team to provide counseling that gives useful feedback regarding distorted beliefs. · Be aware BN patients are very sensitive to the perceptions of others. · BN patient may feel shame and totally out of control. · The therapeutic alliance empathizes with feelings of low self-esteem, unworthiness, and dysphoria. · Nurse may suspect dishonesty when the patient does not report bingeing and/or purging. · Accepting, having a nonjudgmental approach, and understanding the subjective experience of the patient will help build trust.

Psychosocial care with chemotherapy patients

Chemotherapy: Drugs are given over a period of time ranging from 30min to 8 hours or longer. Patient may be confined to a treatment area. Use distraction methods that may help reduce the sense of unpleasantness o Virtual reality o Guided imagery o Reading o Watching television o Talking with visitors

Interpret assessment findings for patients with a suspected or actual GI problem.

-INSPECTION: If movement is observed, note the quadrant or origin and the direction of peristaltic flow. This can indicate INTESTINAL OBSTRUCTION. If there is a bulging, pulsating mass DO NOT TOUCH the area because the patient may have an ABDOMINAL AORTIC ANEURYSM**life threatening** -AUSCULTATION: High pitched bowel sounds—loud gurgling sounds are heard in patients with DIARRHEA. Vascular sounds or bruits (swooshing sounds) heard over the aorta usually indicates the presence of aneurysm. -PERCUSSION: Dullness in the left anterior axillary line indicated enlargement of spleen

IRRITABLE BOWEL SYNDROME What is it?

-A functional GI disorder that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. -IBS causes chronic or recurring diarrhea (IBS-D), Constipation (IBS-C), alternating diarrhea and constipation (IBS-A), or a mix of both (IBS-M) and or abdominal pain and bloating. -Cause is unknown but could be environmental factors such as foods and fluids, infectious agents, immunological and genetic factors. -It is related to behavioral or mental illness, especially anxiety in depression. - Assessment: fatigue? Malaise? Pain? Changes in the bowel pattern? Consistency of stools? Mucus? GI infections? Drugs taking? -Nutrition history: caffeinated drinks, sorbitol, or fructose. Food intolerance may be associated with IBS. Dairy products, raw fruits, and grains can contribute to bloating flatulence, and abdominal distension. -Pain in the LLQ. Location? Quality? Intensity? -Patient with IBS often exhales an increased amount of hydrogen. Hydrogen breath test - NPO.

Anal Fissure

-Anal Fissure: tear in anal lining, very painful. Occur from straining on bowel movement. Deep or large fistulas occur from other diseases like Crohn's, Tb, leukemia, or from trauma to the anal region. -Manage the local pain with analgesics, stool softeners to reduce trauma and decrease pain on bowel movements, Sitz baths, Metamucil, topical anti-inflammatory products.

Anal FIstula

-Anal Fistula: abnormal tract in anal canal to perianal skin from an anorectal abscess that causes obstruction to the anal gland. -Treatment is surgery, then Sitz baths, analgesics, and stool softeners (ex. Metamucil).

Anorectal Abscess

-Anorectal Abscess: local area or induration and pus from an infection of soft tissue near rectum. Causes of duct/gland obstruction: feces, foreign body, trauma—leads to obstruction, stasis, and infection. -Surgery: main mode of management. Incision and drain, exercise small part of tissue, done with a local anesthetic.

Diagnosing Cancer Oncofetal antigens CEA ALT LDH AFP PSA

-Tissue sample or biopsy, Endoscopic procedures, Imaging studies. CT or MRI. -Laboratory test: normal values -Oncofetal antigens (tumor markers): CEA&CA19-9 -Carcinoembryonic antigens (CEA)<5 ng/mL -Alanine aminotransferase 4-36units(ALT) and lactic dehydonase 100-190(LDH) elevation = liver cancer or liver metastasis Alpha-fetoprotein (AFP) [tumor marker] ovarian Prostate-specific antigen (PSA): <5ng

Metastasis, where does it spread to? Breast Lung Colorectal Protate Melanoma Brain

Can occur through extension into surrounding tissues, BV penetration, release of tumor cell, invasion, local seeding, bloodborne metastasis, lymphatic spread. Breast----->bone, liver, lung, brain Lung----->brain, bone, liver, lymph nodes, pancreas Colorectal-----> liver, lymph nodes, adjacent structures Prostate----->bone (spine and leg), pelvic nodes Melanoma-----> GI, lymph nodes, lung, brain Brain----->CNS

Apply knowledge of pathophysiology to assess patients with common side effects and complications caused by cancer and cancer treatment -Radiation therapy and Chemo

Side Effects of Radiation Therapy: high energy radiation kills cancer cells (locally)with the intent to cure or relieve S/S. External beam or Brachytherapy(seeds). · Changes to the skin; Radiation Dermatitis, alopecia likely permanent dependent on dose absorbed. · Altered taste · Fatigue r/t increase energy demand · Bone marrow suppression; reduced immunity -Infammatory response causes fibrosis and scaring Side Effects of Cytotoxic Systemic Therapy: antineoplastic drugs used to kill cancer cells and disrupt cellular regulation. It also kills normal cells. Can be used alone, combined with other treatments, or before or after treatments. **serious complication of the IV is EXTRAVASATION** · Short term effects: · Hematopoietic (blood-producing) · Decreased numbers of RBC and hemoglobin, bone marrow suppression -N/V, anorexia, GI upset · Neutropenia- nadir is the time when WBC counts and bone marrow activity are at their lowest after chemo--patient is at high risk for complications/infection. · Thrombocytopenia · Alopecia -Men/women need to avoid pregnancy

Oncologic Emergencies TLS: Tumor lysis syndrome

TLS: large numbers of tumor cells are destroyed rapidly. The intracellular contents and subsequent cellular by-products of damaged cancer cells are released into the bloodstream faster than the body can eliminate them. Severe or untreated TLS can cause acute kidney injury (AKI) and death. Serum potassium levels increase, causing hyperkalemia, which can lead to cardiac dysfunction. The large amounts of cellular by-products form uric acid, causing hyperuricemia. These uric acid crystals precipitate in the kidney, blocking kidney tubules and leading to AKI. Sudden development of hyperkalemia, hyperuricemia, and hyperphosphatemia has life-threatening effects on the heart muscle, kidneys, and central nervous system. -Patients with high-grade cancer or bulky tumors. -S/S: stem from electrolyte imbalances and can include lethargy, nausea, vomiting, anorexia, flank pain, muscle weakness, cramps, seizures, and altered mental status. -Interventions: drink at least 3000 mL (3 L) 24-48 hrs before and during treatment to help prevent TLS, diuretics, drugs that promote excretion of uric acid: allopurinol, rasburicase, or febuxostat, drugs that reduce k: sodium polystyrene sulfonate can be given orally or as a retention enema. Severe hyperkalemia, IV infusions containing glucose and insulin may be given. Patients who have severe hyperkalemia and hyperuricemia may need dialysis and intensive care.

UNDERNUTRITION

UNDERNUTRITION: from hospitalization, Dx surgery, coma, AN, BN, BED -protein energy undernutrition (PEU): acute PEU happens for hospitalized patients experiencing is starvation because of infection, stress, or injury. Chronic PEU may happen because of a chronic health condition such as cancer, end stage kidney or liver disease, or chronic neurologic disease. Older adults are most at risk for PEU, physiological changes of aging, environmental factors, and health problems. -3 common forms of PEU: -starvation: a complete lack of nutrients. -marasmus : calorie malnutrition in which body fat and protein are wasted. Serum protein is preserved -Kwashiorkor: A lack of protein quantity and quality in the presence of adequate calories. Body weight is more normal, and serum proteins are low.

UC interventions

o Ulcerative Colitis: -Drugs: aminosalicylates for mild-moderate disease and to maintain remission. Glucocorticoids (ex. Prednisone, Prednisole) for exacerbations. Antidiarrheal to reduce peristalsis. Immunomodulators alter immune response, used in conjunction with steroids for a synergistic effect—a quicker response with less steroid needed. Educate that immunomodulators cause immunosuppression, report S/S of infection (ex. Cold), stay away from crowds and sick people. Teach about side effects and adverse effect of all drugs. -Diet: some patients report that alcohol and caffeine increase diarrhea and cramping, others say raw fruits/vegetables and high fiber cause GI distress. Patients will vary individually on their tolerances. Teach patients to avoid GI stimulation, carbonated beverages, pepper, nuts/corn, dried fruit, smoking. For patients with lactose intolerance tell them to reduce or eliminate it.

Seven warning signs of cancer: C.A.U.T.I.O.N.

· Changes in bowel or bladder habits · A sore that does not heal · Unusual bleeding or discharge · Thickening or lump in breast or elsewhere · Indigestion or difficulty swallowing · Obvious change in a wart or mole · Nagging cough or hoarseness.

IBS interventions

· Interventions: o Dietary fiber and bulk help reduce bulky coma soft stools and establish regular bowel elimination habits. Ingest about 30 to 40 G of fiber each day. Eat regular meals, drink 8 to 10 glasses of water each day, chew food slowly. o Drug therapy might be bulk-forming (IBS-C: psyllium hydrophilic mucilloid, lubiprostone, linaclotide) o IBS-D: loperamide, psyllium, alosetron.

How to prioritize your assessment for a patient with an ED

· These patients are admitted to the MH unit because of other factors, including depression, self-harm, suicide, self-neglect, or other psychologic comorbidities. They may be admitted by a court order because they pose a harm to themselves. · SCOFF questionnaire can help you assess for an ED. Answering yes to 2+ question can indicate an ED. o Sick: Do you make yourself sick or vomit after a meal because you feel uncomfortably full? o Control: Do you fear loss of control over how much you eat? o One stone: Has the patient lost 14 lb in a 3-month period? (A stone is a unit of weight in Great Britain equivalent to 14 lb.) o Fat: Do you believe you are fat even when others tell you that you are too thin? o Food: Does food dominate your life?

Assessing tumor growth: doubling time- Mitotic Index-

· Tumor growth is assessed in terms of doubling time- the time it takes for the tumor to double in size. It is also assessed in terms of mitotic index- percentage of actively dividing cells within a tumor. If mitotic index is <10% the tumor is slow growing. If the mitotic index is 85% it is faster growing. Different tumors have different growth rates. · The smallest detectable tumor is 1cm in diameter (1 billion cells).

Ulcerative Colitis assessment

· Ulcerative colitis (UC) is a disease that creates widespread chronic inflammation of the rectum and rectosigmoid colon but can extend to the entire colon when the disease is extensive. Distribution of the disease can remain constant for years. It is associated with periodic remissions and exacerbations. Exacerbations could be caused by infections. The intestinal mucosa becomes hyperemic, edematous, and reddened. If severe, the lining can bleed and small erosions/ulcers can occur. Abscesses can form in these ulcerative areas and result in tissue necrosis. Continued edema and mucosal thickening can lead to a narrowed colon and possibly a partial bowel obstruction. o S/S: Patients report tenesmus(fecal urgency) and lower abdominal colicky pain relieved with defecation. Malaise, anorexia, anemia, dehydration, fever, and weight loss are common. Temperature normal when disease is mild, when severe they may exhibit a low fever 99-100 degrees. Fever with tachycardia may indicate dehydration, peritonitis, or perforation of the bowel. Assessment findings: age 15-25 and 55-65, 10-20 liquid/bloody stools per day, can have hemorrhaging and nutritional deficiencies, only 20-40% of clients need surgery.

Hormonal Therapy

·Tumors grow more rapidly. ·Decreasing the amount of these hormones to hormone-sensitive tumors ·Can slow the cancer growth rate and increase survival time. -Side effects:·Androgens and antiestrogen receptor drugs cause masculinizing effects in women. ·For men and women receiving androgens, acne may develop, hypercalcemia is common & liver dysfunction (w/ prolonged therapy). ·Gynecomastia can occur (men).

Care for patients undergoing Radiation therapy

•Provide accurate information •Do not remove temporary ink markings •Avoid direct exposure of the skin to the sun and other skin irritation -Follow policy for skin care product use •Nutritional support •Care for xerostomia (dry mouth)-losenges, sprays, rinses, regular dental appointments. •Irradiated bone is more vulnerable to fracture •Exercise and sleep interventions for fatigue •Private room, and visitors should maintain a distance of 6 feet with visits limited to 10 to 30 minutes (especially with an internal radiation implant)

HEMORRHOIDS interventions

-Interventions: cold packs applied to the anorectal region for a few minutes, sitz bath three or four times per day. Topical anesthetics such as lidocaine. Dibucaine ointment should be used only temporally because can mask worsening of symptoms. Hydrocortisone for itching. -Spicy foods, nuts, coffee, alcohol, and Irritating laxatives are avoided

appendicitis interventions

-Appendicitis: fecaliths obstruct the GI tract, mucosa secretes fluid in response, increasing pressure decreasing blood flow and causing severe pain. If appendicitis is suspected or Dx, patient will be NPO in preparation for surgery. -Fluid balance: patient will be NPO and receiving IV fluids, and antibiotics. Do NOT give patient laxatives or enemas to help with elimination—could cause it to rupture. -Pain: opiates will be given for pain control. Don't use heat, it can increase circulation and inflammation and cause rupture. -Pre-Op: consent forms must be signed. There will be limited pre-op education because it's an emergency surgery. -Post-Op: if during an open surgery they find peritonitis or an abscess, the patient will continue to stay in hospital for 3-5 days receiving opiates for pain and antibiotics. An NG tube may be placed for decompression and drains may be inserted into incision to drain fluid. Patient will be helped out of bed the evening of surgery, to prevent atelectasis. They may return to normal activity in 4-6 weeks.

LAB ASSESSMENTS: for patients with GI problems CBC: WBC= 5,000-10,000, Hgb=12-18, Hct= 35-50% PT: 11-12.5 seconds or 85-100% AST: 0-35 ALT: 4-36 Amylase: 30-220 Lipase: 0-160 Bilirubin: Conjugated/direct 0.1-0.3, Unconjugated/indirect 0.2-0.8 Ammonia: 10-80 CA19-9: <37 CEA: <5

-CBC- Dx anemia and infection -PT- clotting, rate at which prothrombin converts to thrombin. -Aspartate aminotransferase (AST) and Alanine Aminotransferase (ALT) - elevated in liver disorders but highest in conditions that cause necrosis such as HEPATITIS and CIRRHOSIS -Amylase and Lipase - elevated levels may indicate acute PANCREATITIS -BILIRUBIN - pigment in bile, elevated levels can indicate impaired excretion. (Jaundice, liver/billary tract functioning) -AMMONIA - elevated levels are seen in conditions that cause pancreatitis, cholecystitis, and GI disease. -Oncofetal antigens (CA19-9 and CEA) if increased, indicated benign GI conditions.

Cancer-new cases vs deaths for males Prostate Lung Colon and rectum Cancer-new cases vs deaths for females Breast Lung & Bronchus Colon& Rectum

-Cancer-new cases vs deaths for males Prostate- 21% of new cases, 10% of deaths Lung- 13% of new cases, 23% of deaths Colon and rectum- 9% of new, 9% of deaths -Cancer-new cases vs deaths for females Breast- 30% of new cases, 15% of deaths Lung & Bronchus- 12% of new cases, 22% of deaths Colon& Rectum- 8% of new cases, 9% of deaths

Chemo precautions

-Chemo is only to be administered by RNs who have completed an approved chemo program. -All nurses are responsible for monitoring the patient recieving chemo. -Maintaining the intended dosage and timing schedule to ensure that the patient receives the maximum recommended doses is a critical factor in the successful response to chemotherapy and overall survival. -Anyone preparing, giving, or disposing of chemotherapy drugs or handling excreta from patients within 48 hours of receiving IV chemotherapy must wear approved PPE. Ex eye protection, masks, double gloves or "chemo" gloves, and nonpermeable gown. -Monitoring of blood return at the access site during the infusion at regular intervals is critical during chemotherapy administration to prevent extravasation. -Warm or cold compressed may be prescribed. -When vesicants are part of therapy, the use of an implanted port or central line to decrease extravasation risk is highly recommended. -Oral anticancer drugs are just as toxic to the patient taking the drug and to the person handling the drug as are IV chemotherapy agents. DO NOT crush, chew. -Do not touch PO meds, do not flush.

Nonsurgical treatments for lung cancer

-Chemotherapy is often the treatment of choice for lung cancers, especially SCLC. It may be used alone or as adjuvant therapy in combination with surgery for NSCLC. -Targeted therapy is common in the treatment NSCLC. These agents take advantage of one or more differences in cancer cell growth or metabolism that is either not present or only slightly present in normal cells. -Immunotherapy for lung cancer is a type of targeted therapy designed to allow the patient's own immune system to better recognize and attack his or her cancer cells. -Radiation therapy can be an effective treatment for locally advanced lung cancers confined to the chest. Best results are seen when radiation is used with surgery or chemotherapy. -Photodynamic therapy (PDT) may be used to remove small bronchial tumors when they are accessible by bronchoscopy. This therapy first involves injecting the patient with an agent that sensitizes cells to light and remains in cancer cells longer than normal cells. A laser light is focused on the tumor to kill the cancer cells.

OBESITY interventions non-surgical

-Diet: short term fasting and very low kCal (200-800)dont work in the long term. ST fasting can cause ketosis. Diets that are nutritionally balanced and 1200-1800 work better. Supplements may be used. Unbalanced low energy diets (ex low carb diets) have mixed results. -Exercise program: protect against cardiovascular disease and diabetes. Encourage walking 20 minutes a day. -· Drug therapy: LIRAGUTIDE: activates appetite regulation in the brain. NALTREXONE-BUPROPION: combines the opioid antagonist with the ANTIdepressant. ORLISTAT: inhibits lipase. Fats are only partially digested and absorbed. Fat intake needs to be reduced to less than 30% of daily intake. PHENTEMINE-TOPIRAMATE: combine short term weight loss drug with seizure medication -Cryolipolysis, behavioral management, complementary (acupuncture, acupressure, Ayurveda, hypnosis)

Interventions for diverticulosis

-Drugs: Broad-spectrum antimicrobial drugs, such as metronidazole in conjunction with trimethoprim/sulfamethoxazole (TMZ) or ciprofloxacin, are often prescribed. A mild analgesic may be given for pain. The patient with more severe pain may be admitted to the hospital for IV fluids to correct dehydration and IV drug therapy. Do not give patients laxatives or enemas because it will increase peristalsis, bulk laxatives like psyllium hydrophilic mucoids are okay. -Surgery: Diverticulitis can result in rupture of the diverticulum with peritonitis, pelvic abscess, bowel obstruction, fistula, persistent fever or pain, or uncontrolled bleeding. The surgeon performs emergency surgery if peritonitis, bowel obstruction, or pelvic abscess is present. Colon resection, with or without a colostomy, is the most common surgical procedure for patients with diverticular disease. They typically have a nasogastric tube (NGT) after open surgery and receive IV PCA for the first 24 to 36 hours. After NGT removal, the diet is slowly progressed from liquids to solid foods as tolerated.

CD interventions

-Drugs: similar to UC drugs. Aminosalicilates 5-ASA may be used for mild to moderate disease, with mixed results. BRM are monocolonial antibody drugs, used when others are not effective, they inhibit TNF-Alpha which reduced immune response. BRM ex. infliximab, adalimumab, natalizumab, and certolizumab pegol. -Nutrition: Poor nutrition can lead to inadequate fistula and wound healing, loss of lean muscle mass, decreased immune responses, and increased morbidity and mortality. During severe exacerbations of the disease, the patient may be hospitalized to provide bowel rest and nutritional support with total parenteral nutrition (TPN). Nutritional supplements such as Ensure or Sustacal can be given to provide nutrients and more calories. Teach the patient to avoid GI stimulants, such as caffeinated beverages and alcohol. If patient has a fistula, increase Kcal to 3000/day. Vitamin supplements may be needed (ex. Monthly B12 injection). Diet needs to be low residue, high calorie, avoid foods that can cause GI discomfort like milk, gluten, GI stimulants like coffee. -Wound care for patient/family for fisulas. -Surgery: surgery with CD is not as successful as with UC, because of the extent of the disease. Indications for surgery are fistula, perforation, massive hemorrhage, intestinal obstruction, or strictures, abscesses, cancer. Resection of the bowel (ex. Fistula) can be performed with MIS via laparoscopy. For other patients an open surgery may be necessary so the surgeon can better see the bowel.

Gastroenteritis interventions

-Gastroenteritis: diarrhea and vomiting related to inflammation of the stomach and intestines. Usually within the small bowel, viral or bacterial. Usually lasts 3 days, but could cause hospitalization in the elderly—dehydration and hypovolemia. -Hand hygiene, sanitization, patient not to prepare food for others. -Fluid replacment, could be oral or IV. Pedialyte and sports drinks can replace F&E. -Maintain skin integrity of peri-anal area, warm washcloth with mild soap. -Drugs: do NOT give drugs that suppress intestinal motility (anti-diarrheal), this can prevent the pathogen from being eliminated from the body. If the healthcare provider decides to give an antidiarrheal agent, Loperamide may be given. Antibiotics or anti-infective will be prescribed. Depending on the type and severity of the illness, examples of drugs that may be prescribed include ciprofloxacin or azithromycin. If the gastroenteritis is caused by shigellosis, anti-infective agents such as ciprofloxacin, ceftriaxone, or azithromycin are prescribed.

Apply knowledge of anatomy and physiology, genetic risk, and principles of aging to perform a focused GI assessment.

-Genetic Risk: Familial adenomatous polyposos (FAP) inherited autosomal dominant disorder that presupposes the patient to colon cancer -Physiologic change: Atrophy of the gastric mucosa leads to decrease hydrochloric acid levels usually a consequence of bacterial overgrowth. -Peristalsis decreases and nerve impulses are dulled which can lead to constipation and impaction -Distention and dilation of pancreatic ducts. -Calcification of pancreatic vessels occurs with a decrease in lipase production. This can result in STEATORRHEA because of the decreased fat absorption. -A decrease in the number and size of the hepatic cells leads to decreased liver weight and mass. This change and an increase in fibrous tissue lead to decreased protein synthesis and changed in liver enzymes. -Enzyme activity and cholesterol synthesis are diminished. -This can lead to the accumulation of drugs possibly to toxic levels because of depressed drug metabolism. -Delicate microbial balance if good anaerobic and aerobic flora is disrupted over time, negatively affecting the immune response. This can lead to obesity, inflammatory disease and reduced immunity.

Interventions for Undernutrition

-High calorie nutrient rich meals, 6 small meals are better tolerated, purred or soft for patients with chewing problems. Provide mouth care and keep food at proper temp., encourage patient to eat by providing relaxing enviroment, remove bedpans from site, provide pain relief, music therapy, do not rush them. -Nutritional supplements like Ensure or sustacal is good for older adults. -Drug therapy: multivitamins, zinc, and iron. Iron can cause Constipation and zinc can cause nausea and vomiting. -Total enteral nutrition (TEN): enteral feeding tube may be necessary to supplement or to provide total nutrition. always check for advanced directives. A therapeutic combination of carbohydrates, fat, vitamins, minerals, and trace elements is available in liquid form. HOB at least 30 degrees during and 1hr after feeding. Check GRV every 6hrs. Assess for F&E complications, Refeeding syndrome: life threatening complication related to fluid and electrolyte shifts. Recognize signs which include heart failure, peripheral edema, seizures, hemolysis, rhabdomyolysis. Labs values may indicate hyponatremia and hyperkalemia from hyperglycemic fluid and increased urine output. Assess for PE(edema, weight gain, crackles, SOB) esp. in elderly. -Check tube placement to prevent aspiration pneumonia, life threat esp. in elderly. FVO and hyperosmolar states are possible. -Peripheral parenteral- patients usually able to eat, but need more nutrients than what they are getting orally. Monitor patient for fever , increased triglycerides, clotting problems, and multi system organ failure, with may indicate fat overload syndrome, especially in patients who are critically ill. -TPN- central access. Hypertonic with high glucose content. F&E imbalances are very common, closely monitor for elec. imbalance (k, Na, Ca)

Assessing lung cancer

-Hx: smoking Hx, calculate the "pack year" smoking Hx, Occupational Hx-determine exposure to carcinogens. Ask about presence of cancer S/S: hoarseness, sputum, hemoptysis, SOB, change in endurance. Ask if change in position affects them. Assess for chest pain or discomfort—fullness, tightness, pressure may indicate obstruction. Piercing or pleuritic pain may occur on inspiration. Pain radiating to the arm may be from the tumor invading the nerves in advanced disease. · Physical: Pulmonary S/S: nonspecific and late in the disease. Warning S/S: Hoarseness, Change in respiratory pattern, Persistent cough or change in cough, Blood-streaked sputum, Rust-colored or purulent sputum, Frank hemoptysis, Chest pain or chest tightness, Shoulder, arm, or chest wall pain, Recurring episodes of pleural effusion, pneumonia, or bronchitis, Dyspnea, Fever associated with one or two other signs, Wheezing, Weight loss, Clubbing of the fingers. -Ask about dyspnea at rest and when supine. -Late S/S: fatigue, weight loss, anorexia, dysphagia, N/V. -SVCS can occur from pressure around the heart—medical emergency, immediate radiation*+chemo. (also surgery, stent, steroids, but radiation is the main treatment).

Hypertrophy Hyperplasia Neoplasia

-Hypertrophy: growth that causes a tissue to increase in size because its cells enlarge. -Hyperplasia: growth that causes a tissue to increase in size because the number of cells increase. -Neoplasia: any new or continued cell growth not needed for normal development or to replace dead/damaged tissues.

Esophagogastroduodenoscopy (EGD)

-It is a visual examination of the esophogus, stomach, and duodenum by means of a fiber optic scope. -If bleeding is found the doctor can use clips, thermocoagulation, infection therapy, or a topical hemostatic agent to stop the bleed. -An esophogeal stricture (narrowing of the esophageal opening) can be fixed by dilation during EGD. -Lesions can be visualized and celiacs Dx. -Pre-Op: usually patients are asked to avoid anticoagulants, aspirin, or other NSAIDs for several days before EGD unless it is absolutely necessary. -Patient will be NPO for 6-8hrs before, placed on IV fluids before procedure. -Dentures will be removed. -Intra-Op: monitor RR and depth, O2Sat via pulseox, ventilation via capnography, capnometry, or spectroscopy. Moderate sedation is used, if RR<10BPM or exhaled CO2<20% use sternal rub to increase RR and depth. -Post-Op: monitor vitals every 15-30min until sedation begins to wear off, keep side rails up. -NPO status maintained until gag reflex returns 30-60min. -Iv fluids will be discontinued when oral fluids are tolerated without N/V. Preventing aspiration is priority. -Monitor for S/S of perforation: pain, bleeding, fever. -Tell patient they cant drive for the next 12-18hrs. -Teach them that hoarse voice and sore throat may persist for a few days, lozenges will help.

Lung cancer

-Lung cancer is the Leading cause of cancer deaths worldwide. Long term survival is so poor because it is often diagnosed late, when metastasis has already occurred. Only 15% of patients have small tumors and localized disease at time of Dx. -Treatment focuses on relieving symptoms or increasing survival time (palliation). -Most primary lung cancers arise as a result of failure of cellular regulation in the bronchial epithelium. Lung cancers are collectively called bronchogenic carcinomas and are classified as small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). -Paraneoplastic syndromes are additional symptoms that complicate lung cancer, caused by hormones secreted by tumor cells and they occur mostly with SCLC. -Etiology and Genetic risk: high risk for smokers, but 2nd and 3rd hand smoke can also increase risk. Other factors include: genetics, familial predisposition, old age, exposure to chemicals, asbestos, coal distillates, mustard gas, air pollution, etc.

Steps of Metastasis

-Malignant transformation- normal cuboidal cells have undergone malignant transformation and have divided enough times to form a tumorous area within the cuboidal epithelium. -Tumor vascularization- cancer cells secrete VEGF (vascular endothelial growth factor), stimulating BVs to bud and form new channels that grow into the tumor. -BV penetration- cancer cells have broken off from the main tumor. Enzymes on their surface make holes in the BVs, allowing them to enter the BVs and travel around the body. -Arrest and Invasion- cancer cells clump in blood and invade new tissue areas. If these areas have the right conditions to support growth, new metastatic tumors will form at the site.

INTESTINAL OBSTRUCTION (non inflammatory disorder) What is it? Mechanical and Nonmechanical

-Mechanical obstruction: the bowel is physically blocked by: Adhesions (scar tissue from surgeries or pathology), benign or malignant tumor, complications of, appendicitis, Hernias, fecal impactions specially in older adults, Crohn's disease or previous radiation therapy Intussusception (telescoping of a segment of the intestine within itself), volvulus (twisting of the intestine), Fibrosis (endometriosis). -non mechanical obstruction: does not involve a physical obstruction in or outside the intestine. Also known as paralytic ileus or functional obstruction. -POI: postoperative ileus - hambling off the intestines during abdominal surgery. Vascular insufficiency through the bowel, also referred to as intestinal ischemia, is another potential cause of an ileus. Hypovolemia.

Diet for diverticular disease

-Nutrition: disease will not become diverticulitis if diet is followed. For diverticulosis increase cellulose and hemicellulose fiber: wheat bran, whole grain bread and cereal—25-35g/day. Fat no more than 30% of daily calories. Fresh fruit and vegetables will help create bulk in stool. Increase fluid because of high fiber diet, to reduce bloating. No alcohol, seeds, or indigestible material like nuts, corn/popcorn, cucumbers, tomatoes, figs. -When disease becomes diverticulitis, need to avoid fiber in their diet because it causes irritation, if severe patient will be on clear liquid diet, or NPO with a NG tube for decompression. As inflammation resolves fiber can slowly be added back in to their diet till a high fiber diet is established again.

Peritonitis interventions

-Peritonitis: peristalsis slows or stops from severe peritoneal inflammation and infection, lumen becomes distended with gas and fluid. -Infection: administer broad spectrum antibiotics, strict asepsis, hand hygiene, wound and catheter care. -Fluid balance: "third spacing" of fluid. NG on suction, patient will be NPO. Restore fluid and electrolyte balance with IV fluids—hypertonic concentration + broad spectrum antibiotics. Rate of administration will change frequently bases on labs, assessments, and patients condition. If irrigating, monitor input vs return, to see if patient is retaining the fluid. -Pain: Pain is expected to be a 2-3 out of 10, as the infection and inflammation resolves. Opiates may be used, if so teach patient importance of using stool softeners/laxatives. Avoid taking extra Tylenol/acetaminophen to prevent liver toxicity. -Educate: on S/S of dehiscence and infection and to report to health care provider immediately (foul drainage, swelling, redness, warmth, bleeding and incision site). If surgery was open don't lift or do strenuous activity for 6weeks, if it was laparoscopic you can resume normal activities in 1-2 weeks. -Post-Op: monitor vitals-RR, HR, O2sat, BP, lung sounds, I&O, LOC. Maintain patient in semi-fowlers position to allow fluid to drain into lower abdomen, as well as increase lung expansion.

CRC assessment

-Physical assessments: ask whether vomiting and changes in bowel elimination habits such as Constipation or changing shape of stool with or without blood, have been noted. Fatigue? Fullness? Pain? Weight loss? Most common signs are rectal bleeding, anemia, and a change in stool consistency and shape. -Blood is not detected with tumors of the right side but it's common with tumors of the left side of the colon and rectum. -Tumors in the transverse in the sending result in symptoms of obstruction. -Tumors in the rectosigmoid column are associated with hematochezia - the passage of red blood via the rectum - straining to pass stools, and narrowing of stools. -Labs: FOBT or FIT (fecal immunochemical test): avoid aspirin, vit C, red meat, and iron for 48 hours prior tests. Stop NSAIDs. FOBT 3 samples,for 3 days. -Carcionoembryonic antigen (CEA) elevated (> 5ng/ml) -CT guided virtual colonoscopy, sigmoidoscopy.

Risk factors for CRC

-Risk factors: age older than 50 years, genetic predisposition, and or personal or family history of cancer, some disease predispose the patient to cancer, such as familial adenomatous polyposis (FAP) - 1% of CRCs. If a family members have had hereditary CRC test for FAP and Lynch syndrome, and general screening more often. 40 years older need screening for colon cancer. Fecal occult blood testing every year, colonoscopy every 10 years, sigmoidoscopy or CT colonography every 5 years. -Genetic/ Genomic considerations: People with the first group relative as parent, sibling, or child, diagnosed with colorectal cancer have three to four times the risk for developing the disease. Lynch syndrome (hereditary nonpolyposis colorectal cancer - HNPCC) - 3% of CRCs. -Some lower GI cancers are related to Helicobacter pylori, streptococcus bovis, and HPV infections. -Long term smoking, obesity, physical inactivity, and heavy alcohol consumption are risk factors for CRC.

Oncologic Emergencies Sepsis and Disseminated Intravascular Coagulation (DIC)

-Sepsis, or septicemia, is a condition in which organisms enter the bloodstream through any site of skin breakdown and cause a severe infection. Severe sepsis can result in septic shock, a life-threatening condition. -DIC, triggered by sepsis, extensive abnormal clotting deletes clotting factors and platelets. At the same time extensive bleeding occurs--oozing to fatal hemorrhage. S/S- pain, ischemia, stoke-like S/S, reduced kidney function, and bowel necrosis. -Interventions: control infection and halt DIC. IV antibiotics, give anticoagulants (heparin) to limit clotting and prevent the depletion of clotting factors. If hemorrhage is the problem, give clotting factors.

Surgical treatments for lung cancer

-Surgery: is the main treatment for stage 1 and 2 NSCLC. Total tumor removal may result in a cure, but if complete resection is not possible the surgeon will try to remove the bulk of the tumor. The surgery may be removal of a tumor, removal of a lung segment, removal of a lobe (lobectomy), or removal of an entire lung (pneumonectomy). This can be done as an open thoracotomy or a MIS. -Pre-Op: reduce anxiety, promote participation in care, reinforce surgeons explanations and provide education on what is to be expected. Teach about probable placement of a chest tube and drainage system (except after pneumonectomy). -Post-Op: RN must ensure the integrity of the drainage system, check for patency, and prevent complications. Tubes that drain air will be at the lung apex, tubes that drain fluid will be at the lung base. The wounds will be covered in air tight dressings—silicone foam is commonly used. Teach patient about PCA use, monitory for respiratory depression. -Respiratory: immediately post-op the patient will be mechanically ventilated. Once they are breathing on their own the priority is to maintain a patent airway, ensure adequate ventilation, and prevent complications. Sit up in high fowlers, use IS every hr while awake, give O2 for the first 2 days.

Colonoscopy

-Traditional scope placed in rectum and goes up to transverse colon, can visualize/Dx, biopsy, or do minor surgery (ex. polyp removal). -Virtual just used to Dx, if anything is found a followup will be needed. Pre-Op: usually patients are asked to avoid anticoagulants, aspirin, or other NSAIDs for several days before unless it is absolutely necessary. -Bowel prep will be done the night before (chill solution to improve taste), clear liquid diet the day before surgery. Some patients will also need to use laxatives, suppositories, or enemas. -Use Gatorade to replace F&E, avoid red, orange, purple colors and gelatin. -Patient will be NPO for several hrs before. -Intra-Op: IV access will be started for admin of moderate sedation. Process lasts 30-60 min. -Monitor for bradycardia or vasovagal response--Atropine will treat this. Monitor RR/depth and O2sat. -Post-Op: check vitals every 15min until stable. -Side rails kept up until patient is alert. Maintain NPO status. -Keep patient in LEFT LATERAL position to promote passing of flatus--feeling of fullness, cramping, passage of flatus will last for several hrs. -Monitor for perforation: severe pain, hemorrhage: rapid drop in BP. -Once patient is passing flatus, indicating peristalsis has returned, fluids will be allowed. -Discontinue IV once patient tolerates oral fluids without N/V. -If polypectomy or biopsy was performed there will be a small amount of blood in first stool. -Report excessive bleeding or severe pain immediately to HCP. Tell patient to not enter any legal agreements and to get a ride home with friend/family (ambulatory surgery).

COLORECTAL CANCER (CRC) What is it?

-Tumors occur in different areas of the colon, with about 2/3 occurring within the rectosigmoid region. -Most CRCs are adenocarcinomas, which are tumors that arise from the glandular epithelial tissue of the colon. -Most CRCs are believed to arise from adenomatous polyps that present as a small growth covered with mucosa and attached to the surface of the intestine. -CRC metastasize by direct extension or by spreading through the blood or lymph. The tumor may spread locally into the four layers of the bowel wall and into neighboring organs. It may enlarge into the lumen of the bowel or spread through the lymphatic or the circulatory system. -The liver is the most common site of metastasis from circulatory spread. Metastasis to the lungs, brain, bones, and adrenal glands may also occur.

Teach the patient and caregiver(s) about common drugs used for cancer therapy and the side effects, including impaired immunity and impaired clotting. -Tyrosine Kinase Inhibitors (TKIs) -Epidermal Growth Factor Receptor Inhibitors (EGFRIs) -Vascular Endothelial Growth Factor Receptor Inhibitor (VEGGFRI) -Multikinase Inhibitors -Proteasome Inhibitors -Angiogenesis/mTOR Kinase Inhibitors -Monoclonal Antibodies -Checkpoint Inhibitors

-Tyrosine Kinase Inhibitors (TKIs); disrupt cancer cell growth. Side effects: Bone marrow suppression. Drugs: Dasatinib, Erlotinib, Imatinib, Lapatinib -Epidermal Growth Factor Receptor Inhibitors (EGFRIs); blocks EGF from activating TK. *COLON CANCER. Side effects: mild rash progressing to excessive skin peeling and fissures. Drugs: Cetuximab, Panitumumab, Trastuzumab -Vascular Endothelial Growth Factor Receptor Inhibitor (VEGGFRI); stops tumor from creating its own blood supply. Side effects: hypertension, impaired wound healing, GI perforation and hemorrhage. Drugs: Bevacizumab. -Multikinase Inhibitors; prevent activation of kinase. Side effects: hypertension, nausea/vomiting, diarrhea/constipation, mucositis, erythematous rash on the hands and feet and mild neutropenia. Drugs: Crizotinib, Sorafenib, Sunitinib -Proteasome Inhibitors; prevent formation of large proteins, promote cell death. Side effects: nausea/vomiting, anorexia, abdominal pain, bowel changes, hypotension and peripheral neuropathy Drugs: Bortezomib -Angiogenesis/mTOR Kinase Inhibitors; disrupt growth Side effects: hyperglycemia, hyperlipidemia, hypersensitivity, hepatic impairment and skin problems. Drugs: Everolimus, Lenalidomide, Pomalidomide, Temsirolimus -Monoclonal Antibodies; prevent cancer cell division. Side effects: Infusion related reactions, Hyper-sensitivity reactions**premedications like diphenhydramine and acetaminophen can decrease the incidence of infusion-related reactions**. Drugs: Daratumumab, Yibritumomabtiuxetan, Pertuzumab, Rituximab, Trastuzumab -Checkpoint Inhibitors; PD1, PD-L1, and CTLA-4; deactivate enzymes. Side effects: Fatigue, Rash, Risk for infection. Drugs: Avelumab, Atezolizumab, Durvalumab, Ipilimumab, Nivolumab, Pembrolizumab

Enteroscopy/ Small Bowel Capsule Endoscopy

-Video capsule endoscopy: Swallow a capsule that videos the small bowel. Used to evaluate/locate source of bleeding. -Pre: NPO 12hrs before, and then 2hrs after swallowing capsule. -Intra: abdomen is marked for location of sensors, then sensors are applied, abdominal belt is worn that houses the recorder to capture the images. -Capsule is swallowed with glass of water., normal activity is allowed, but tell patient to avoid rigorous activity. -Post: Clear liquid allowed 2 hours later, then light lunch allowed after 4 hours. -Procedure lasts about 8 hrs, until capsule is passed from the body. Patient will see it in the stool and it is discarded after elimination. -Patient will report S/S of GI obstruction: fever chest pain, difficulty breathing. Or if the capsule is not passed in 2 weeks. -No other follow up is necessary.

Endoscopic Retrogade Cholangiopancreatography (ERCP)

-Visual and radiographic exam of liver, gallbladder, bile ducts, and pancreas--find cause/location of obstruction. Used for Dx, biopsy, remove gallstones, stent stricture. -Pre-Op: usually patients are asked to avoid anticoagulants, aspirin, or other NSAIDs for several days before EGD unless it is absolutely necessary. -Patient will be NPO for 6-8hrs before, placed on IV fluids before procedure. -Ask about contrast allergies and implanted medical devices. -Dentures will be removed. -Post-Op: Assess vital signs frequently, usually every 15 minutes until patient is stable. -Check to ensure gag reflex has returned before offering fluids or food to prevent aspiration. -Discontinue IV when the patient is able to tolerate oral fluids without N/V. -Colicky abdominal pain and flatulence can result from air instilled during procedure. Instruct patient to report abdominal pain, fewer, nausea, or vomiting that fails to resolve after returning home. -Remind patient to not drive for at least 12-18 hours.

intussusception irreducible (incarcerated) hernia reducible hernia obstipation polyps strangulated obstruction volvulus

-intussusception- Telescoping of a segment of the intestine within itself. -irreducible (incarcerated) hernia- A hernia that cannot be reduced or placed back into the abdominal cavity. Any hernia that is not reducible requires immediate surgical evaluation. -reducible hernia- A hernia that can be reduced or placed back into the abdominal cavity. -obstipation- No passage of stool. -polyps- In the intestinal tract, small growths covered with mucosa and attached to the surface of the intestine; although most are benign, they are significant because some have the potential to become malignant. -strangulated obstruction- Bowel obstruction or hernia that has compromised blood flow (can be life-threatening). -volvulus- Twisting of the intestine.

Nursing care of patients with an intestinal obstruction:

-monitor vital signs for indications of fluid balance -assess the patient's abdomen at least twice a day for bowel sounds, distention, and passage of flatus -monitor fluid and electrolyte balance status, including labs -give analgesics for pain as prescribed -maintain IV therapy for fluid and electrolyte replacement -give alvimopan as prescribed for patients with a postoperative ileus -maintain parenteral nutrition if prescribed -manage the patient who has NGT, at least every 4h: monitor drainage, ensure tube patency, check tube placement, irrigate tube as prescribed, maintain the patient on NPO status, provide frequent mouth and nares care, maintain the patient in a semi-Fowler position.

PERINEAL WOUND CARE:

1. WOUND CARE: place an absorbent dressing over the wound. Instruct patient that he or she may use a feminine napkin as a dressing, wear jockey-type shorts rather than boxers. 2. COMFORT MEASURES: soak the wound area in a sitz bath for 10 to 20 minutes three or four times per day or use warm or hot compresses or packs. Administer energetic. Educate about activities. The patient should assume a sideline position in bed and avoiding sitting for long periods. Use foam pads or soft pillow on which should sit whenever in a sitting position. Avoid the use of air rings or rubber donut devices. 3. PREVENTION OF COMPLICATIONS: maintain fluid and electrolyte balance, monitoring taking output, and output from the wound. Observe incision integrity any monitor wound drains, watch for erythema, edema, bleeding, drainage, unusual odor, and excessive or constant pain.

Cancer Assessment: BITES

Bleeding- suggests low platelets Infection- low WBCs and risk for septicemia, bone marrow suppression. Tiredness- anemia from low Hgb/Hct Emesis- risk for F&E imbalance or alteration in nutrition. Skin- radiation rx or skin breakdown

Neoplasia/Neoplasms Benign tumor cells Malignant tumor cells

Neoplasia/Neoplasms- any new or continued cell growth not needed for normal development or tissue replacement. Its growth is abnormal, whether it is benign or malignant. The develop from normal parent cells. Benign tumor cells- are normal cells growing in the wrong place or at the wrong time as a result of impaired cellular regulation. Normally doesn't require intervention. Malignant tumor cells- indicates cancer. These cells are abnormal, have no useful function, and are harmful to normal body tissues. Early Dx will increase chance of successful treatment. Educate/promote early Dx and screening. RN's must educate the public about prevention and early detection.

OBESITY

OBESITY: from hormones know as adipokines affect appetite in fat metabolism. Dysregulation of these chemicals result in conditions such as appetite increase, overstimulation of the autonomic nervous system, blood vessel inflammation, and ventricular hypertrophy. -Assess eating habbits, what are their triggers, when do they eat most of their food? · the waste circumference (WC) is a stronger predictor of CAD, greater than 89cm or 35in in women & greater than 102cm or 40in in men indicates central obesity, which is a major risk factor for CAD, brain attack, type 2 diabetes, some cancers, sleep apnea, and early death. · the waist to hip ratio (WHR) is also predictor of CAD, greater than 0.95 for men and greater than 0.8 for woman indicates Android obesity. WHR differs peripheral from central obesity. · eating high fat and high cholesterol diets is a common cause of being overweight, also linked to a higher risk of heart disease. physical inactivity is also a factor. -Monounsaturated and polyunsaturated fats are healthy Fats. -some drugs like corticosteroids, estrogens, NSAIDs, antihypertensives, antidepressants and other psychoactive drugs, antiepileptic drugs, and certain oral antidiabetic agents also contribute to overweight.

Protect yourself and others from cytotoxic agents and radiation.

Patients with Sealed Implants: · Assign the patient to a private room with a private bath · Place a "CAUTION: RADIOACTIVE MATERIAL" sign on the door · If portable lead shields are used, place them between the patient and the door · Keep the door to the patient's room closed as much as possible · Wear a dosimeter film badge at all times while caring for patients with radioactive implants. The badge offers no protection but MEASURES a person's exposure to radiation. · Wear a LEAD APRON while providing care. Always keep the front of apron facing the source of radiation · If you are attempting to conceive, do not perform direct patient care, regardless the sex · Limit each visitor to a 1 half-hour per day. Be sure visitors stay at least 6 feet from the source. · NEVER TOUCH the radioactive source with bare hands. If dislodged, use long-handled forceps to retrieve it. Then put it in lead container. · After source is removed, dispose dressings and linens in the usual place. **Ingested isotopes are eventually eliminated in waste products. You must ensure that these waste products are not directly touched by anyone because it is RADIOACTIVE. **Skin in the radiation path becomes photosensitive so there is an increased RISK FOR SUNBURN. Advise the patient against skin exposure to the sun during treatment and for at least 1 year after completion of radiation therapy.

INTESTINAL OBSTRUCTION assessment

Physical assessments: -Small-bowel obstructions: abdominal discomfort or pain, with peristaltic waves in upper and middle abdomen. Upper or epigastric abdominal distention. Nausea and early profuse vomiting. Obstipation. Severe fluid in electrolytes imbalance. Metabolic alkalosis. -Large-bowel obstructions: intermittent lower abdominal cramping, lower abdominal distention, minimal or no vomiting, obstipation or ribbon-like stools, no major fluid and electrolyte imbalances, metabolic acidosis. -Laboratory assessment: WBC levels are normal, unless there is a strangulated obstruction, infection, or gangrene. Hemoglobin, Hematocrit, and BUN are often elevated , indicating dehydration. Sodium, chloride, potassium is decreased. Elevations in serum amylase levels may occur with strangulating obstructions. CT or MRI. Sigmoidoscopy or Colonoscopy. -An obstruction high in the small intestine causes a loss of gastric hydrochloric acid, which can lead to metabolic alkalosis. Obstructions at the end of the small intestine and lower in the intestinal tract causes loss of alkaline fluids, which can lead to metabolic acidosis. obstruction below the duodenum but above the large bowel results in a loss of both acids and bases, so acid-base balance is usually not compromised.

Prevention of Infection (cytotoxic agents)

Prevention of Infection (cytotoxic agents) 1. Avoid crowds and other large gathering of people who might be ill 2. Do not share personal toiletries 3. Bathe daily. Wash armpits and entire perineal area twice a day with an antimicrobial soap. 4. Wash your hands thoroughly with an antimicrobial soap before you eat and drink., after touching a pet, shaking hands with anyone, and after using the toilet. 5. Do not drink perishable liquids that have been standing in room temperature for longer than an hour. 6. Use food safety when preparing meals 7. Wash fresh fruits and vegetables prior to eating 8. Do not change pet litter boxes or clean up after pets. Wear gloves if necessary. 9. Take your temperature at least once a day and whenever you do not feel well. 10. Take all drugs as prescribed 11. Wear gardening gloves when working in the garden 12. Wear a condom when having sex (abstinence is key) 13. Report any signs of infection to your oncologist

Help adults identify behaviors that reduce the risk for cancer development.

Primary prevention: · Smoking cessation, avoidance of known carcinogens—use of PPE when around carcinogens, skin protection during sun exposure · diet: high fiber and whole grains, low animal fat and trans fat. Avoid nitrates in lunch meats, sausage, bacon. Minimize intake of red meat. No more than 1-2 alcoholic drinks perday. Eat more bran. Eat more cruciferous vegetables like broccoli, cauliflower, brussel sprouts, and cabbage. Eat food high in vitamin A (yellow, orange vegetables, and leafy greens), vitamin C (fruits, cirtus, vegetables). · Use safe sex practices or try to limit sexual partners to avoid exposure to cancer causing viruses—HPV. · "At Risk Tissues"- Remove moles to prevent skin cancer. Remove breasts to prevent breast cancer, remove colon polyps to prevent colon cancer. · Chemo prevention can reverse existing gene damage. · Aspirin and celcoxib can reduce risk of colon cancer. · Vitamin D and Tamoxifen can reduce risk of breast cancer. · Lycopene can reduce risk of prostate cancer. · Vaccination is the newest method to prevent cancer. Gardisil and Cervarix can precent cervial cancer. Secondary prevention: · Regular screening will not reduce the incidence of cancer, but early detection can reduce risk of death. Adults can be screened for genetic variants that increase risk of cancer—and then take subsequent action.

Obesity interventions surgical

SURGICAL: candidates have repeated failure of non-surgical interventions, BMI 40+ (or 35 or greater with other risk factors), 100% above IBW -Open approach or MIS: laparoscopic adjustable gastric band (LAGB): laparoscopic sleeve gastrectomy (LSG) -preoperative care: Some surgeons require specific amount of weight loss before bariatric surgery. The primary role of the nurse is to reinforce health teaching in preparation for surgery. · Operative procedures: vertical banded gastroplasty, gastric banding, vertical sleave gastroplasty, biliopancreatic diversion with duodenal switch, Roux-en-Y gastric bypass -cardiovascular and respiratory care: place the patient in semi fowlers position to improve breathing, monitor oxygen saturation, apply SCDs, & administer prophylactic anticoagulant therapy as prescribed. -Abdominal binder will be used to prevent dehiscence. Observe for S/S such as tachycardia, nausea , diarrhea, and abdominal cramping for dumping syndrome (caused by food entering the small intestine instead of the stomach) after gastric bypass. Provide 6 small feedings - clear and then full liquids - and plenty of fluids. Measure and record abdominal girth daily. Monitor NGT. · anastomotic leaks are the most common serious complication and cause of death after gastric bypass surgery. recognize that you must monitor for symptoms of this life-threatening problem which include increasing back, shoulder, or abdominal pain, restlessness, and unexplained tachycardia and oliguria.

Oncologic Emergencies superior vena cava (SVC)

SVC: Compression or obstruction by tumor growth or by clots in this vessel leads to congestion of blood returning to the body, can occur quickly or develop gradually over time. -S/S: edema of the face, esp. periorbital edema on arising in the morning, and reports of head fullness. As the compression worsens, the patient develops engorged blood vessels and erythema of the upper body, edema in the arms and hands, and dyspnea. The development of stridor (a high-pitched crowing sound) indicates narrowing of the pharynx or larynx and is an alarming sign of rapid progression. S/S apparent when the patient is in the supine position. Late symptoms include hemorrhage, cyanosis, mental status changes, decreased cardiac output, and hypotension. Imaging with CT or MRI is essential for diagnosis and treatment planning. Death results if compression is not relieved. -Interventions: immediate radiation therapy to shrink tumor. Chemo for LT therapy. -Surgery, stents, corticosteroids can also be used.

· Care and maintenance of total parenteral nutrition:

o check each bag of total parenteral nutrition compared with the original prescription. o Administer insulin as prescribed. o Monitor the IV pump for accuracy. o If the TPN solution is temporarily unavailable, Administer 10% dextrose/ water or 20% dextrose water until the TPN solution can be obtained. o do not attempt to catch up by increasing the rate o weight daily o monitor serum electrolytes and glucose o monitor for fluid and electrolyte balance and intake and output o assess the patients IV site for signs of infection or infiltration o change the IV tubing every 24 hours and the dressing around the IV every 48 to 72 hours. o before administering TPN have a second nurse check the prescription.

Colostomy Managment

· A clear pouch allows the health care team to observe the stomach. If not pouch systems in place, a petrolatum gauze dressing is usually placed over the stoma to keep it moist. Another name for a pouch system is appliance. They are available in one- and two-piece systems and are held in place by adhesive barriers or wafers. · A healthy stoma should be reddish pink and moist introduce about 1 to 3 cm from the abdominal wall but most commonly about 2 cm. A small amount of bleeding at the stoma is common. · Report to the surgeon: Stoma ischemia and necrosis (dark red, purplish, black color, dry), continues have bleeding, breakdown of the suture line securing the stoma to the abdominal wall. · The peristomal skin should be intact, smooth, and without redness or excoriation. Some complications could be dermatitis (from fecal content), skin stripping (from the adhesive barrier or wafer), and candidiasis (fungal infection). · the pouch may need to be emptied frequently Because of excess gas collection. It should be done when it is 1/3 to 1/2 full of stool.

MNA - Mini Nutritional Assessment

· Add the numbers together to get score. If score is 11 or less, continue with the assessment to malnutrition indicator score. · 24 to 30 points normal nutritional status · 17 to 23.5 points at risk of malnutrition · less than 17 points malnourished

· Anorexia nervosa

· Anorexia nervosa- intense irrational fear about shape and weight. They self starve, fear weight gain, have a disturbance in self evaluation of their weight and its importance. o 2 subtypes: restriction of food or restriction of food with episodes of binging and purging. They see themselves as overweight, when they are actually emaciated and cachectic (severely underweight with muscle wasting). They wear baggy clothes and have a constant preoccupation with food—collecting recipes, meal planning, and making food for others. o Appears in early to middle adolescents o Almost always comorbid with other psychiatric illnesses (50%), esp. BPD, PD, OCD o Always assess for self-harm and suicidal intent o Compensatory behaviors may be seen: vomiting, laxatives, diuretics. o Cognitive distortions, judges worth by weight, views self as fat even when emaciated o Appears emaciated, lanugo, cachectic. o "Control" is a big aspect of their psyche, controlling diet and managing the food prep of those around them is how they feel powerful. o Prominent parotid glands if purging o Terrified of weight gain, yet "obsessed" with food o Odd handling of food: cutting it into small pieces, pushing it around the plate

Appendicitis assessment

· Appendicitis is an acute inflammation of the appendix that occurs most often among young adults. It is the most common cause of right lower quadrant (RLQ) pain. Inflammation occurs when the lumen (opening) of the appendix is obstructed, leading to infection as bacteria invade the wall of the appendix. The initial obstruction is usually a result of fecaliths (very hard pieces of feces) composed of calcium phosphate-rich mucus and inorganic salts. The blockage causes the mucosa to secrete fluid, which increases pressure, reduced blood flow, and causes pain. If it occurs slowly an abscess will form, but if it is rapid peritonitis will occur. o S/S: Abdominal pain followed by nausea and vomiting. Classical s/s is cramping pain in the epigastric or periumbilical area. Anorexia is also a frequent symptom. Pain is located at McBurneys point. If pain is relieved by bending the right hip or knee, indicated perforation or peritonitis. Rebound tenderness-Positive Bloomberg's sign. -Moderate increase in WBCs with a "shift to the left". More than 20,000 WBCs indicates perforation.

Assessing for skin cancer ABCDE

· Assessment: ask patient about age, race, family Hx of skin cancer, and past removal of growths. Recent change in size, sensation, color—of any mole, birthmark, wart, scar. Is the lesion irritated by the rubbing of clothing. Ask about where the patient has lived and currently lived, as well as an occupational Hx to determine exposure to carcinogens. Previously injured skin has a higher risk of cancer, examine all scars. A chronic open wound that wont heal may need to be biopsied. Look at all areas of body, even if it is an area that isnt comonly exposed to the sun, as well as areas covered with hair (ex. Scalp, genitalia). Palpate the lesions to determine texture and document using the ABCDE method: o A= Asymmetrical lesion o B= Border is irregular o C= Colors of lesion are multiple o D= Diameter of lesion is >0.5cm (>6mm) o E= Elevated or Enlarging lesion

Hemorrhoid assessment

· Assessment: bleeding, swelling, and products. Blood is typically bright red pain is a common symptom often associated with thrombosis . Other symptoms include itching and a mucous discharge. Diagnosis is usually made by inspection in digital examination.

IBS assessment

· Assessment: fatigue? Malaise? Pain? Changes in the bowel pattern? Consistency of stools? Mucus? GI infections? Drugs taking? · Nutrition history: caffeinated drinks, sorbitol, or fructose. Food intolerance may be associated with IBS. Dairy products, raw fruits, and grains can contribute to bloating flatulence, and abdominal distension. · Pain in the LLQ. Location? Quality? Intensity? · PT with IBS often exhalates an increased amount of hydrogen. Hydrogen breath test - NPO.

Herniation assessment

· Assessment: patient will report a lump or protrusion. The development of the hernia may be associated with straining or lifting. Perform an abdominal assessment.

Binge Eating Disorder

· Binge eating disorders- engage in repeat episodes of binge eating, followed by significant distress. They don't regularly use compensatory mechanisms. · A variant of compulsive overeating, resembles the eating pattern of obesity. Episodes of thinking about food and eating large amounts of food in a short period. Followed by disgust, depression, and guilt after the binge—without any attempt to purge the calories. · This is a psychiatric condition within the DSM5, it is a symptom of depression. Food is their coping mechanism for stress. · These patients have high rates of mood disorders and PDs. They report a Hx of major depression more often than non-binge eaters. Binging is soothing and helps regulate their moods.

· Bulimia nervosa-

· Bulimia nervosa- engage in repeat episodes of binge eating and then use compensatory mechanisms--self induced vomiting, diuretics, pills, or excessive exercise. o Appears in late adolescents o Almost always comorbid with other psychiatric illnesses (95%), esp. BPD, PD, OCD o Always assess for self-harm and suicidal intent o Compensatory behaviors seen: vomiting, exercise, diuretics, laxatives, other pills. o Cognitive distortions, problems with self-concept, problems with relationships. o Appears to have a normal weight, or slightly under or over weight. o May be impulsive or compulsive, ex. stealing/shoplifting, drug use o Anxiety, depression o Prominent parotid glands if purging o Cycles of binge eating, followed by purging o Hx of AN seen in ¼-1/3 of BN patients

Celiacs disease assessment

· Celiac disease: is a chronic inflammation of the small intestinal mucosa that can cause bowel wall atrophy, malabsorption, and diarrhea. It is an autoimmune disease. The primary complication of celiac disease is cancer, specifically non-Hodgkin lymphoma or GI cancers and nutrition deficiencies. Patients with celiac disease have varying signs and symptoms with cycles of remission and exacerbation (flare-up), usually related to how well they monitor their diet. -Classic symptoms include anorexia, diarrhea and/or constipation, steatorrhea (fatty stools), abdominal pain, abdominal bloating and distention, vomiting, and weight loss. Some patients have no symptoms. - Atypical Symptoms: Osteoporosis, Joint pain and inflammation, Lactose intolerance, Iron deficiency anemia, Depression, Migraines, Epilepsy, Autoimmune disorders, Stomatitis, Early menopause, Protein-calorie malnutrition, Infertility.

· Common complications of obesity:

· Common complications of obesity: o cardiovascular : coronary artery disease, hyperlipidemia, hypertension, peripheral artery disease o endocrine: insulin resistance, metabolic syndrome, type 2 diabetes o gastrointestinal: cholelithiasis o genitourinary / reproductive: erectile dysfunction in men, menstrual irregularities in woman, urinary incontinence o integumentary: delayed wound healing, susceptibility to infections o musculoskeletal: chronic back &/or joint pain, early onset of osteoarthritis o neurologic: stroke o psychiatric: depression o respiratory: obesity hyperventilation syndrome, obstructive sleep apnea

Crohn's Disease assessment

· Crohn's disease (CD) is a chronic inflammatory disease of the *small intestine*, the colon, or both. It can affect the GI tract from the mouth to the anus its usually within the terminal ileum—patchy involvement throughout all layers of the bowel. CD is a slowly progressive and unpredictable disease with involvement of multiple regions of the intestine with normal sections in between (called skip lesions on x-rays). Like ulcerative colitis (UC), this disease is recurrent, with remissions and exacerbations. Bacteria can cause exacerbations. -S/S: CD presents as inflammation that causes a thickened bowel wall. Strictures and deep ulcerations with a cobblestone appearance also occur, which put the patient at risk for developing a bowel fistula—an abnormal tract between two organs or structures. Resulting in severe diarrhea and malabsorption of vital nutrients. Anemia is common, usually from iron deficiency or malabsorption issues. Severe malabsorption is more common with CD than UC. Hemorrhaging is more common with UC, but it can also occur with CD. Peak age 15-40yrs, surgery needed for 75% of patients. Most patients report diarrhea, abdominal pain, and low-grade fever. Fever is common with fistulas, abscesses, and severe inflammation. If the disease occurs in only the ileum, diarrhea occurs 5-6 times per day, often with a soft, loose stool. Steatorrhea (fatty diarrheal stools) is common. Stools may contain bright red blood. Can have fistulas, fibrosis, abscesses. -Periumbilical pain and fever are signs of fistula formation or severe inflammation, report to HCP!

ACS 7 healthy C.H.O.I.C.E.S. : for cancer prevention

· Cut out the tobacco · Hold the fat · Only moderate use of alcohol if at all · Increase high fiber fruits and vegetables and grains · Call your doctor for regular checkups · Exercise 30 minutes most days · Safeguard your skin from the sun

diverticular disease assessment

· Diverticular Disease: Diverticula are pouchlike herniations of the mucosa through the muscular wall of any part of the gut, but most commonly the colon(sigmoid). Diverticulosis is the presence of many abnormal pouchlike herniations (diverticula) in the wall of the intestine. Acute diverticulitis is the inflammation or infection of diverticula. Diverticula without inflammation cause few problems. However, if undigested food or bacteria become trapped in a diverticulum, blood supply to that area is reduced. Bacteria invade the diverticulum, resulting in diverticulitis, which then can perforate and develop a local abscess. A perforated diverticulum can progress to an intra-abdominal perforation with peritonitis. Lower GI bleeding may also occur. -No S/S usually seen with diverticulosis. -Diverticulitis is suspected, ask about a history of low-grade fever, nausea, and abdominal pain(LLQ)--intermittent at first and then becomes steady. Inquire about recent bowel elimination patterns because constipation may develop as a result of intestinal inflammation. Also, ask about any bleeding from the rectum. Labs will show elevated WBC count, decrease H&H if bleeding is occurring, positive occult blood test. -Peritonitis: fever/chills, tachycardia, N/V, general abdominal Pain. Shock-hypotension. -Perforation: palpable tender mass, orthostatic changes, massive bleeding-hypovolemia-shock.

Gastroenteritis assessment

· Gastroenteritis causes diarrhea and/or vomiting related to inflammation of the mucous membranes of the stomach and intestinal tract. The small bowel is commonly affected and can be caused by either viral (more common) or bacterial infection. -S/S: abdominal distension, hyperactive bowel sounds. N/V at first, then becomes abdominal cramping and diarrhea. Older adults or people with reduced immunity could have weakness, cardiac dysrhythmias from loss of potassium from diarrhea, dehydration. -Ask about tropical travel.

Cancer Grading

· Grading- of a tumor classifies cellular aspects of the cancer. Grading is needed because some cancer cells are "more malignant" than others, varying in their aggressiveness and sensitivity to treatment. Some cancer cells barely resemble the mature tissue from which they arose (are "poorly differentiated"), are aggressive, and spread rapidly. These cells are a "high-grade" cancer. Less malignant cancer cells that are "well differentiated" and more closely resemble the tissue from which they arose are less aggressive. Grading compares the appearance and activity of the cancer cell with the normal parent tissue from which it arose. It is a means of evaluating the patient with cancer for prognosis and appropriate therapy. Grading also allows health care professionals to evaluate the results of management. Rates cancer cells, with the lowest rating given to those cells that closely resemble normal cells and the highest rating given to cancer cells that barely resemble normal cells. -Gx cant be assessed, G1 well differentiated, G2 moderately differentiated, G3 poorly differentiated, G4 undifferentiated.

Loss of cellular regulation leading to cancer- 4 steps

· Initiation is the 1st step, normal cells are exposed to carcinogens that damage DNA, leading to a loss of cellular regulation. Genes that promote cell division turn on excessively, becoming oncogenes. · Promotion is the 2nd step, it is when growth is enhanced of an initiated cell by substances called promoters. Once a cell is initiated it is a cancer cell, it can become a tumor if its growth is enhanced. Body hormones and proteins, like insulin and estrogen, can act as promoters. The latency period is the time between initiation and the development of an overt tumor, promoters can shorten this period. · Progression is the continued change of cancer, becoming more malignant over time. After the cells have grown to the point of being a detectable tumor (1cm=1billion cells), other events must occur for it to become a health problem. The tumor needs to create its own blood supply, it makes VEGF to trigger nearby capillaries to grow into the tumor—giving it nourishment and causing growth. This 1st tumor is called the primary tumor. · Metastasis occurs when the cancer cells migrate from the primary location to create other colonies in remote areas. Additional tumors are called metastatic tumors or secondary tumors. Cancer is still named and classified by its original location—not its secondary location.

Skin cancer interventions

· Interventions: depends on site and severity of malignancy, location, age and general health of patient. o Cryosurgery: destroy cancer cells with liquid nitrogen (-200 degrees) to isolated lesions. o Curettage and electrodesiccation: Removal of cancerous cells with the use of a dermal curette to scrape away cancerous tissue, followed by the application of an electric probe to destroy remaining tumor tissue. o Excision: Surgical removal of small lesions, often done as first-line treatment for squamous cell carcinomas o Mohs surgery: A specialized form of excision usually for basal and squamous cell carcinomas o Wide excision: Deep skin resection often involving removal of full-thickness skin in the area of the lesion. Depending on tumor depth, subcutaneous tissues and lymph nodes may also be removed.

New Stoma

· Monitor stoma for S/S infection, should be pink-red moist and it will shrink 6-8 weeks after surgery and be 1-3cm above the abdominal wall. It will be edematous at first, with a small amount of bleeding. Peristomal skin should be clean, dry, and intact—clip or shave the hair around it. Clean stoma with mild soap and water, cut the wafer 1/8-1/16 larger than the stoma. It will begin to function 2-3 days after surgery, empty frequently at first because of gas accumulation, after it will need to be emptied at 1/3-1/2 way full. Report any of these early postoperative stoma problems to the surgeon: Stoma ischemia and necrosis (dark red, purplish, or black color; dry), Continuous heavy bleeding, Mucocutaneous separation (breakdown of the suture line securing the stoma to the abdominal wall).

Intestinal Obstruction interventions

· Non-surgical: NGT for decompression, IV fluids, NPO. -give analgesics for pain as prescribed -give alvimopan as prescribed for patients with a postoperative ileus -maintain parenteral nutrition if prescribed -provide frequent mouth and nares care -maintain the patient in a semi-Fowler position -disimpaction an enema administration. -Aggressive fluid replacement with 2-4 liters of an isotonic solution with potassium added. Watch for fluid overload by monitoring lung sounds, weight, and I/O's. · Surgical: Exploratory laparotomy to investigate causes or Conventional open surgical approach: large incision, then adhesions are lysed. Colostomy or Colectomy -Patients that had an open search approach have an NGT in place until peristalsis resumes. A clear liquid diet might be prescribed. Remove NGT if tolerated. -Preventing fecal impaction: eat high fiber foods, drink adequate amount of fluid, do not routinely take a laxative . Exercise regularly, use natural foods to stimulate peristalsis like prune juice. Take bulk forming products to provide fiber and stool softeners to ease bowel elimination. -Pain adm: oxycodone and acetaminophen, opioids need more laxatives.

Herniation interventions

· Non-surgical: Truss to help keep the abdominal contents from protruding. · Surgical: -Hernioplasty: open incision, fixed, and muscle wall is reinforced with a mesh patch. -Herniorrhaphy. Minimally invasive inguinal hernia repair (MIIHR) ---Monitor vital signs, Assess and manage incisional pain with oral analgesics, encourage deep breathing and use of incentive spirometer after surgery, teach the patient to avoid excessive cough, encourage ambulation, apply ice packs as prescribed, help the male patient void by helping him stand the first time after surgery -D/C: rest for several days after surgery, observe the incision for redness or drainage, shower after 24 to 36 hours after removing any bandage but do not remove wound closure strips. Monitor temperature. Do not lift more than 10 pounds. Avoid Constipation by eating high fiber foods and drinking extra fluids. Return to work when allowed usually in one to two weeks.

COLORECTAL CANCER interventions non-surgical

· Non-surgical: Type of therapy used is based on the stage of the disease. -Radiation therapy is effective in providing local or regional control of COLON CANCER, can be palliative. o Chemotherapy is recommended for stage 2 or 3. o Drugs Chemo: IV 5-fluorouracil with leucovorin (5FU/LV), capecitabine, and irinotecan hydrochloride. Side effects are diarrhea, mucositis, leukopenia, mouth ulcers, and peripheral neuropathy. o METASTATIC: Bevacizumab is an vascular endothelial growth factor inhibitor, reduces blood flow to the growing tumor cells, thereby depriving them of necessary nutrients needed to grow. Usually given in combination with other chemotherapeutic agents. Cetuximab and panitumumab are epidermal growth factor receptor inhibitors, work by blocking factors that promote cancer cell growth. Intrahepatic arterial chemotherapy, 5-FU for liver metastasis. Opioids analgesics and antiemetics for relief symptoms.

Traits of normal cells

· Normal Cells: o Have a specific morphology—a distinct size, shape, and appearance. o Small nuclear to cytoplasmic ratio, the nucleus is small compared to the rest of the cell. o Each normal cell has a differentiated function (at least one) that it performs. o The have tight adherence because of proteins (fibronectin), cells are "sticky" because of adhesion molecules called CAMs. Blood cells do not have these adhesion molecules. o Cells are nonmigratory (except blood cells), they are bound together with CAMs. o They have an orderly and well-regulated growth, this "cell regulation" is very important. Mitosis only occurs for 2 reasons: to develop normal tissue or to replace lost, damages, or aged tissue. o Contact inhibition occurs to regulate growth, cell division is stopped when all sides of the cell are touched by other cells. o Apoptosis is programed cell death, cells must die at some point for proper body function. This ensures that each organ has an adequate number of cells at their functional peak. Each division shortens the ends of the telomeric DNA (at the ends of the chromosome), once the DNA is gone, apoptosis occurs. o Normal number of chromosomes in humans is 46 (23 pairs), having a complete set is called Euploidy—a feature of most normal human cells.

Skin Cancer -Actinic (solar) keratoses -Squamous cell carcinoma -Basal cell carcinoma -Melanomas

· Overexposure to sunlight is the leading cause of skin cancer—there are other associated factors. Sun damage is a age-related finding, that's why it is very important to screen suspicious lesions on an older adult. -Actinic (solar) keratoses are premalignant lesions of the cells of the epidermis. These lesions are common in adults with chronically sun-damaged skin—yellow, wrinkled, weather beaten skin.These appear as pink, reddish, or reddish-brown scaly macules or papules. -Squamous cell carcinoma (SCC) is a cancer of the epidermis. These cancers can invade locally and are potentially metastatic. SCC is the most common cause of lip cancer, often seen in older Caucasian men. Chronic skin damage from repeated injury or irritation increases risk for this malignancy. Firm, nodular lesion topped with a crust or a central area of ulceration. -Basal cell carcinoma arises from the basal cell layer of the epidermis and is the most common skin cancer worldwide. Early lesions often go unnoticed, and although metastasis is rare, underlying tissue destruction can occur. Pearly papule with a central crater and rolled, waxy borders. -Melanomas are pigmented cancers arising in the melanin-producing epidermal cells. Most often they start as the benign growth of a nevus (mole). Variegated colors, with red, white, and blue tones.

Peritonitis assessment

· Peritonitis is a life-threatening, acute inflammation and infection of the peritoneum and endothelial lining of the abdominal cavity. When the peritoneal cavity is contaminated by bacteria, the body begins an inflammatory reaction, walling off a localized area to fight the infection. If the process of walling off fails, the inflammation spreads and contamination becomes a diffuse infection. o Assessments: Rigid, board-like abdomen (classic), Abdominal pain (localized, poorly localized, or referred to the shoulder or chest), Distended abdomen, Nausea, anorexia, vomiting, Diminishing bowel sounds, Inability to pass flatus or feces, Rebound tenderness in the abdomen, High fever, Tachycardia, Dehydration from high fever (poor skin turgor), Decreased urine output, Hiccups, Possible compromise in respiratory status. Possible hypovolemic shock. Increase in WBCs 20,000+ with high neutrophil count. Blood culture will determine septicemia and type of organism. Monitor fluid and electrolyte labs, BUN, Cr, H&H, O2sat/ABGs. o Cardinal signs: abdominal pain, tenderness, and distension.

Cancer Ploidy

· Ploidy- classifies the number and structure of tumor chromosomes as normal or abnormal. It is a description of cancer cells by chromosome number and appearance/structure. Normal human cells have 46 chromosomes (23 pairs), the normal diploid number (euploidy). When malignant transformation occurs, changes in the genes and chromosomes also occur. Some cancer cells gain or lose whole chromosomes and may have structural abnormalities of the remaining chromosomes, a condition called aneuploidy. The degree of aneuploidy increases with the degree of malignancy. Some chromosome changes are associated with specific cancers, and their presence is used for diagnosis and prognosis. One example is the Philadelphia chromosome abnormality often present in chronic myelogenous leukemia cells. Other gene changes in cancerous tumors alter the tumor's susceptibility to specific treatment. Some changes form the basis of "targeted therapy" for cancer.

Cancer Staging

· Staging- classifies clinical aspects of the cancer. Staging determines the exact location of the cancer and whether metastasis has occurred. Cancer stage influences selection of therapy. Staging is done by clinical staging, surgical staging, and pathologic staging. o Clinical staging assesses the patient's symptoms and evaluates tumor size and possible spread. o Surgical staging assesses the tumor size, number, sites, and spread by inspection at surgery. o Pathologic staging is the most definitive type, determining the tumor size, number, sites, and spread by pathologic examination of tissues obtained at surgery. -Stage I- malignant cell confined -Stage II- local area -Stage III- regional lymph involvement -Stage IV- metastasis to distant areas.

TNM staging system

· The tumor, node, metastasis (TNM) system- -Used to describe the anatomic extent of cancers. The TNM staging systems have specific prognostic value for each solid tumor type. Not for leukemia or lymphomas. - T- primary Tumor: Tx cannot be assessed. T0 no evidence of tumor. Tis carcinoma in situ (precancer)- cells are only growing in layer where they started and not going any deeper. T1, 2, 3, 4 describes an increase in size and/or local extent of primary tumor. - N- regional lymph Nodes: Nx cannot be assessed, N0 no regional lymph node metastasis. N1, 2, 3 increasing involvement of regional lymph nodes - M- distant Metastasis: Mx cannot be assessed. M0 no distant metastasis. M1 distant metastasis.