NUR 334 Exam 3

Brachytherapy

*Internal radiation implantation* -Delivers a high dose of radiation to a localized area through implants -Internal radiation can be implanted by means of needles, seeds, beads, or catheters into body cavities or interstitial compartments -The farther the target tissue is from the radiation source = the lower the dosage -This spares noncancerous tissue from radiation dose and toxicity -Brachytherapy may also be administered orally which is used to treat thyroid carcinomas

Burn Total Body Surface Area (TBSA) Evaluation

*Rule of nines* -Quick way to estimate extent of burns -Percentages in multiples of nine assigned to body surfaces *The Lund and Browder method* -More precise method of estimating extent of burns -Recognizes surface area of body parts in relation to growth and age

The nurse is assessing a patient with a diagnosis of scleroderma. What clinical manifestations of scleroderma does the nurse assess?

-Dysphagia owing to hardening of the esophagus -Decreased ventilation owing to lung scarring -Dyspnea owing to fibrotic cardiac tissue

Burn Renal Alterations

-Renal function may be altered as a result of *decreased blood volume* -Destruction of red blood cells at the injury site results in free hemoglobin in the urine -If muscle damage occurs, myoglobin is released from the muscle cells and excreted by the kidney -If there is inadequate blood flow through the kidneys, the hemoglobin and myoglobin occlude the renal tubules, resulting in acute tubular necrosis and renal failure *Blood urea nitrogen (BUN), serum creatinine levels, and urinary output are monitored* -Adequate fluid volume replacement restores renal blood flow, increasing the glomerular filtration rate and urine volume

Burn Upper Airway Injury

-Results from direct heat and edema -It is manifested by mechanical obstruction of the upper airway -Upper airway injury is treated by *early intubation, or emergency* tracheotomy (if edema makes intubation difficult)

Rheumatic Disorders

-Rheumatic disorders affect the joints, bones, muscles, and connective tissues -Common symptoms include joint swelling, limited movement, stiffness, weakness -Systemic effects caused by rheumatic disorders result in obvious limitations in mobility and activities of daily living (ADL), and more subtle manifestations such as pain, fatigue, insomnia, and disturbed body image

Deep partial-thickness (similar to second-degree)

*Deep partial-thickness (similar to second-degree)* -Causes: scalds, flash flame contact -Skin involvement: epidermis, upper dermis, portion of deeper dermis -Symptoms: pain, hyperesthesia, sensitive to cold air -Wound appearance: blistered, mottled red base; broken epidermis; weeping surface, edema -Recuperative course: recovery in 2 to 4 weeks, some scarring and depigmentation contractures, infection may convert it to full thickness

Superficial partial-thickness (similar to first-degree)

*Superficial partial-thickness (similar to first-degree)* -Causes: sunburn, low-intensity flash -Skin involvement: epidermis destroyed; possibly a portion of dermis -Symptoms: tingling, hyperesthesia (supersensitivity), pain that is soothed by cooling -Wound appearance: reddened; blanches with pressure, dry, minimal or no edema, possible blisters -Recuperative course: complete recovery within a week; no scarring, peeling

Risk of 25% of the body burned

-Burns that exceed 25% TBSA may produce a *local and a systemic* response and are considered major burn injuries -An NG tube should be inserted and connected to low suction (all patients who are intubated should have a nasogastric tube inserted to decompress the abdomen and prevent vomiting)

A patient is seen in the office for complaints of joint pain, swelling, and a low-grade fever. What blood studies does the nurse know are consistent with a positive diagnosis of RA?

-Positive C-reactive protein (CRP) -Positive antinuclear antibody (ANA) -Red blood cell (RBC) count of <4.0 million/mcL

Full-thickness (similar to third-degree)

*Full-thickness (similar to third-degree)* -Causes: flame, prolonged exposure to hot liquids, electric current, chemical contact -Skin involvement: epidermis, entire dermis, and sometimes subcutaneous tissue; may involve connective tissue, muscle, and bone -Symptoms: *pain free*, shock, hematuria (blood in the urine) and possibly hemolysis (blood cell destruction), possible entrance and exit wounds (electrical burn) -Wound appearance: dry; pale white, leathery, or charred, broken skin with fat exposed, edema -Recuperative course: eschar sloughs, grafting necessary, scarring and loss of contour and function; contractures, loss of digits or extremity possible

Burn Immunologic Alterations

-Burn injury diminishes the resistance to infection -The loss of skin integrity is compounded by the release of abnormal inflammatory factors -There is a significant impairment of the production and release of granulocytes and macrophages from bone marrow; the resulting immunosuppression places the patient with burn injury at high risk for sepsis

Radiation Dosage

-Dosage is dependent on the sensitivity of the target tissues to radiation and on the tumor size -Lethal tumor dose is defined as the dose that will eradicate 95% of the tumor yet preserve normal tissue -With external radiation, the total radiation dose is delivered over several weeks to allow healthy tissue to repair and to achieve greater cell kill by exposing more cells to the radiation as they begin active cell division

Considering Depth of a Burn

-The following factors are considered in determining the depth of a burn: -How the injury occurred -Causative agent (such as flame, scald, chemical) -Temperature of the burning agent -Duration of contact with the agent -Thickness of the skin in area burned

Burn Pain Management

-Three types of burn pain: background or resting pain (24 hours a day), procedural pain, and breakthrough pain -Opioid administration via the IV route is the mainstay for burn pain *Morphine sulfate remains the analgesic of choice* -Fentanyl, MS Contin or oxycodone (OxyContin) as well -PCA pumps to control analgesia

Burn Wound Care

-Topical antibacterial therapy (to reduce number of bacteria) -Wound débridement (to remove tissue contaminated by bacteria and foreign bodies and to remove devitalized tissue or burn eschar in preparation for grafting and wound healing) -If wounds are full-thickness or extensive, spontaneous healing is not possible, and treatment of the wound is necessary until coverage with a graft of the patient's own skin *AUTOGRAFT* -Graft to decrease risk of infection, prevent further loss of protein, fluid and electrolytes, minimize heat loss through evaporation

A patient is brought to the ED by paramedics who report the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is a priority in the care of a patient who has been burned and suffered smoke inhalation? A) Pain B) Fluid balance C) Anxiety and fear D) Airway management

AIRWAY MANAGEMENT

First Systemic Event in Burns

*Hemodynamic instability* -Results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces -Leaky capillary syndrome

Assessing a possible DVT on oncology treatments

-50% of patients with a DVT are asymptomatic *S/S* -Aching, pain in calf aggravated by standing or walking -Swelling, warmth, erythema, asymmetry in extremity with DVT -Venous distention in the affected limb that persists despite elevation of the extremity may be noted. -May have low-grade fever and tachycardia *Some cancer types result in an increase in circulating pro-coagulants (precursors that help clot blood), which can significantly increase the risk for DVT*

Burn Abdominal Compartment Syndrome

-Fluid shifts into the abdominal cavity, causing increased abdominal distention that interferes with pulmonary ventilation *MASSIVE FLUID SHIFT* -The volume loss into the peritoneal space results in a decreasing CO, hypotension, and a decreasing urine output -The increased intra-abdominal pressure compresses the inferior vena cava and restricts blood flow and perfusion to abdominal organs, further compromising renal, hepatic, and visceral organ function -Drainage of fluid via an abdominal tap or laparotomy aids in reducing abdominal pressure *Clinical presentation* -Tense, distended abdomen, progressive oliguria (urine output <400 mL), and increased ventilatory requirements

Systemic Lupus Erythematosus S/S

-S/S may be insidious or acute -SLE may remain undiagnosed for many years -Systemic and musculoskeletal manifestations, particularly *fatigue and myalgias/arthralgias* (pain in muscles/joints) -Can affect any body system -Clinical manifestations can resemble RA and may be mistaken for it -Unlike RA, the arthritis is nonerosive and not seen on X-ray *Skin manifestations* -Photosensitivity rashes -Butterfly-shaped rash across the bridge of the nose and cheeks -Discoid (coinlike) lesions are scarring and ring-shaped that may result in erythematous, scaling plaques and alopecia (hair loss) -Lesions are provoked by sunlight or artificial ultraviolet light *Central nervous system* -Mood disorder, depression, and psychosis are common *Cardiopulmonary disorders* -Pericarditis -Pleuritis -Atherosclerosis *Renal disorders* -Renal disease -Glomerulonephritis

Burn Shock

-Shock occurs when oxygen supply does not meet tissue demand -Burn shock develops from several abnormalities of the circulation -The initial systemic event is *hemodynamic instability*, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces -This leaky capillary syndrome increases cell permeability at the burn site, as well as throughout the body -Progressive edema develops in unburned tissue and organs causing hypoperfusion and hypovolemic shock -As fluid loss continues and vascular volume decreases, the cardiac output (CO) and blood pressure (BP) fall (ONSET OF BURN SHOCK) *Burn shock is characterized by capillary leak, "third spacing" of fluid, severe hypovolemia, and decreased CO*

Myelosuppression

-Suppression of the blood cell-producing function of the bone marrow resulting in decreased production of blood cells -Common SE of CHEMOTHERAPY or RADIATION *Myelosuppression decreases the number of*: -WBCs (leukopenia) -Red blood cells (RBCs) (anemia) -Platelets (thrombocytopenia) -AND increases the risk of infection and bleeding -Depression of these cells is a common reason for decreasing the dose of the chemotherapeutic agents -Monitor *blood cell counts*

Burns

-The two most common burn etiologies are flame and scald (burn caused with hot liquid or steam) -Morbidity and mortality rates associated with burns are greater in the elderly -Burns are categorized as thermal, radiation, electrical, or chemical -The skin and the mucosa of the upper airways are the sites of tissue destruction -Disruption of the skin can lead to increased fluid loss, infection, hypothermia, compromised immunity, and changes in body image -Classification of burns are to do with DEPTH the EXTENT of total body surface area (TBSA) burned

The nursing students are doing clinical hours on the burn unit. A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. A nursing student asks why this goal is important when the patient is fighting for his life. What should the burn nurse respond? A) To prevent neuropathies B) To prevent wound breakdown C) To prevent contractures D) To prevent heterotopic ossification

PREVENT CONTRACTURES **To prevent the complication of contractures the nurse will establish a goal to maintain position of joints in alignment. Gentle range of motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures.

Scleroderma S/S

*Cutaneous Symptoms of Scleroderma* (CREST*) -Calcinosis (calcium deposits in the tissues) -Raynaud's phenomenon (spasm of blood vessels in response to cold or stress) -Esophageal dysfunction (acid reflux and *dysphagia*) -Sclerodactyly (thickening and tightening of skin on fingers and hands) -Telangiectasia (capillary dilation that forms vascular red marks on surface of skin) -Scleroderma starts with Raynaud's phenomenon and swelling in the hands -The hallmark of scleroderma is when the skin and the subcutaneous tissues become increasingly hard and rigid and cannot be pinched up from the underlying structures (fibrosis) -Wrinkles and lines are obliterated -The skin is dry because sweat secretion over the involved region is suppressed -The extremities stiffen and lose mobility -The *condition spreads slowly; for years, these changes may remain localized in the hands and the feet* -The face appears masklike, immobile, and expressionless, and the mouth becomes rigid -Left ventricle of the heart is involved, resulting in heart failure-Lungs become scarred, impeding respiration -Digestive disturbances occur because of hardening (sclerosing) of the intestinal mucosa -Progressive renal failure may occur *ULCERS- RAYNAUDS*

Hospice Care

*END OF LIFE CARE* -Hospice care is in fact palliative care -The difference is that hospice care is associated with the *end of the patient's life*, and although it focuses on quality of life, hospice care by necessity usually includes realistic emotional, social, spiritual, and financial *preparation for death* -Hospice care begins after treatment of the disease is stopped and when it is clear that the person is not going to survive the illness -Usually offered only when the person is expected to live 6 months or less

When providing care for a burn patient's skin graft site, the nurse should: A) Ensure that the site is completely free of moisture at all times B) Ensure that the graft is not moved or disturbed C) Maintain consistent, high pressure on the graft D) Apply a hypertonic solution two to three times daily

*Ensure that the graft is not moved or disturbed* -The patient with a skin graft is positioned and turned carefully to avoid disturbing the graft or putting pressure on the graft site -It is not necessary to keep the site completely dry, but hypertonic solutions are not applied

Radiation Delivery

*External* -External-beam radiation therapy (TELETHERAPY) directs a beam of radiation from outside the body at cancerous tissues inside the body -Kilovoltage therapy devices for superficial lesions, such as lesions of the skin and breast -Linear accelerators and betatron machines for deeper structures *Internal* -Internal radiation implantation (brachytherapy) delivers a high dose of radiation to a localized area -Intracavitary radiation for gynecologic cancers -Radioisotopes are inserted into applicators specially positioned in the cervix and vagina, after the position is verified by X-ray -These radioisotopes remain in place for a prescribed time period and then are removed -The patient is on bed rest and log-rolled to prevent displacement of the delivery device -The HOB must not be elevated greater than 15 degrees due to the risk of perforating the uterus with the appliance -Catheter is inserted to ensure that the bladder remains empty -Anti-diarrheals to prevent bowel movements during therapy to prevent displacement of the radioisotope

Emergency Procedures at Burn Scene

*Extinguish the flames* -Stop, drop and roll -Smother the flames (blanket, rug, or coat), don't run -If the burn source is electrical, the electrical source must be disconnected *Cool the burn* -Application of cool water or applying cool towels *Remove restrictive objects* -If possible, remove clothing immediately to allow for assessment and to prevent constriction secondary to rapidly developing edema *Cover the wound* -To minimize bacterial contamination and decrease pain by preventing air from coming into contact with the injured surface -Sterile dressings are best -No medication or material should be applied besides dressing *Irrigate chemical burns* -Chemical burns resulting from contact with a corrosive material are irrigated immediately -Flush and rinse with cool, clean water

Burn Emergent/Resuscitative Phase

*From onset of injury to completion of fluid resuscitation* *Priorities* -First aid -Prevention of shock/fluid electrolyte imbalances -Respiratory distress -Wound assessment and initial care -Airway, breathing, and circulation PRIORITY -Neurological status must also be rapidly assessed -Analgesia is also a priority -Transfer to a regional burn center should be facilitated -Fluid and electrolyte replacement (LR) -Vitals and I & O -Circulation (peripheral pulses, cap refill and warmth, color), sensation, and mobility (CSM) of burn area is assessed hourly -Elevation of burned extremities is crucial to decrease edema

Burn Fluid and Electrolyte Alterations in Emergent Phase

*Generalized dehydration* -Plasma leaks through damaged capillaries *Reduction of blood volume* -Secondary to plasma loss, fall of blood pressure, and diminished cardiac output *Decreased urinary output* -Secondary to fluid loss, decreased renal blood flow, sodium and water retention caused by increased adrenocortical activity, hemolysis of red blood cells, causing hemoglobinuria and/or myoglobinuria *Potassium (K+) excess* (HYPERKALEMIA) -Massive cellular trauma causes release of K+ into extracellular fluid (ordinarily, most K+ is intracellular) -Hypokalemia (potassium depletion) may occur later, with fluid shifts and inadequate potassium replacement *Sodium (Na+) deficit* (HYPONATREMIA) -Large amount of Na+ is lost in trapped edema fluid and shifts into cells as K+ is released from cells (ordinarily, most Na+ is extracellular) *Metabolic acidosis (base-bicarbonate deficit)* -Loss of bicarbonate ions accompanies sodium loss -Hypovolemia and hypoperfusion cause acidosis *Hemoconcentration (elevated hematocrit)* -Liquid blood component is lost into extravascular space.

Fluid and Electrolyte Changes in the Acute Phase

*Hemodilution (decreased hematocrit)* -Blood cell concentration is diluted as fluid enters the intravascular compartment; loss of red blood cells destroyed at burn site occurs *Increased urinary output* -Fluid shift into intravascular compartment increases renal blood flow and causes increased urine formation *Sodium (Na+) deficit* HYPONATREMIA -With diuresis, sodium is lost with water; existing serum sodium is diluted by water influx. *Potassium (K+) deficit* (occurs occasionally in this phase) HYPOKALEMIA -Beginning on the fourth or fifth post-burn day, K+ shifts from extracellular fluid into cells. *Metabolic acidosis* -Loss of sodium depletes fixed base; relative carbon dioxide content increases.*

Thrombocytopenia

*Platelet count of less than 100,000/mm3* -Normal platelet count 150,000- 450,000/mm3 *Low platelet level that can result from various factors:* -Decreased production of platelets in the bone marrow -Increased destruction/consumption of platelets -Can result from: malignancy, infection, medications, and DIC -Often results from bone marrow depression after certain types of chemotherapy and radiation therapy -When the platelet count decreases to between 20,000 and 50,000/mm3 the risk of bleeding increases -Platelet counts lower than 20,000/mm3 are associated with an increased risk for spontaneous bleeding (CNS or GI hemorrhages)

Classification of Burns

*Superficial* -First degree burn -Damages only epidermis -Area is pink, red, dry, slight swelling, NO blister *Superficial partial thickness burn* -First type of second degree burn (similar to first degree) -*Epidermis destroyed, part of dermis is damaged* -Painful, pink, dry, hair follicles intact, often blisters -Heal in 5-10 days without scarring *Deep partial-thickness burn* -Second type of second degree burn -Extends into the reticular layer of the dermis (dense connective tissue that gives the skin strength and elasticity and houses sweat glands, lymph vessels, and hair follicles) and is hard to distinguish from a full-thickness burn -Red or white, mottled, moist or dry -Severe pain -14 days to heal with scarring *Full thickness burn* -Third or fourth degree burn -Total destruction of dermis and extends into SQ fat -Can involve muscle and bone -Requires skin grafting -Mottled red, to white, brown or black -Leathery, hair follicles and sweat glands destroyed

Cancer and Pain Management 3 Step Approach

*Three-step approach to treat cancer pain* 1. Nonopioid analgesics (e.g., acetaminophen) are used for mild pain 2. Weak opioid analgesics (e.g., codeine) are used for moderate pain 3. Strong opioid analgesics (e.g., morphine) are used for severe pain -If the pain escalates, the dose of the analgesic medication is increased until the pain is controlled -Adjuvant medications are also administered to enhance the effectiveness of analgesics (antiemetics, antidepressants, anxiolytics, antiseizure agents, stimulants, local anesthetics, radiopharmaceuticals (radioactive agents that may be used to treat painful bone tumors), and corticosteroids)

Burn GI Alterations

*Two potential gastrointestinal (GI) complications may occur:* *Paralytic Ileus* -Decreased peristalsis and bowel sounds are manifestations of paralytic ileus resulting from burn trauma -Gastric distention and nausea may lead to vomiting unless gastric decompression is initiated *Curling's Ulcer*(gastric or duodenal erosion) -Gastric bleeding secondary to massive physiologic stress (occult blood in the stool, regurgitation of "coffee ground" material from the stomach, or bloody vomitus)

Rheumatoid Arthritis S/S

-*Joint pain, swelling, warmth and erythema and lack of function* -Deformities of the joint are common in PIP (proximal interphalangeal joints) and metacarpophalangeal joints -Hyperextension of PIP joints (swan neck), flexion of PIP joints, and ulnar deviation (in which fingers point toward ulnar) -Palpation of the joints reveals spongy or boggy tissue -*Rheumatoid nodules* can develop, non-tender and movable common over bony prominences -Fluid can often be aspirated from the inflamed joint -Joint involvement begins in the *small joints* of the hands, wrists and feet then progresses to the knees, shoulders, hips, elbows, ankles, cervical spine and TMJ joints -Muscle atrophy, reduced tendon and ligament elasticity *Systemic S/S*: -Fever -Weight loss -Fatigue -Anemia -Raynaud's phenomenon (cold and stress induced vasospasm causing episodes of blanching or cyanosis) -Lymph node enlargement -S/S are usually BILATERAL and SYMMETRIC *IMPORTANT S/S is morning stiffness that lasts 30-45 minutes and can even appear before pain*

Burn Pulmonary Alterations

-An inhalation injury can occur when a person is trapped inside a burning structure *Pulmonary injuries fall into two categories:* -Upper airway injury -Inhalation injury below the glottis, including carbon monoxide poisoning -Pulmonary abnormalities are not always immediately apparent, they *do not initially* demonstrate pulmonary S/S -Any patient with possible inhalation injury must be observed for at least *24 hours* for respiratory complications

Rheumatoid Arthritis Treatment

-Arthocentesis shows abnormal synovial fluid that is cloudy or dark yellow -*NSAIDs* FIRST LINE treatment, provide anti-inflammatory effects as well as analgesia -*DMARDs* (disease-modifying antirheumatic drugs) -*Glucocorticoids* (corticosteroids) are used in RA especially during exacerbations or when needing a "bridging" medication while waiting for the slower DMARDs to begin taking effect (prednisone and prednisolone) -*Intra-articular injections* may be employed if only one or two joints are affected and are commonly used in severe RA -*Antibiotics* (tetracycline) are given to improve symptoms and are used in patients who have not responded to DMARDs -*The Prosorba Column*, a blood filtration device binds IgG (immune complex) and removes RF, used in treating patients with more severe and longstanding RA who have had no response to or are intolerant of DMARDs -*Surgery*: removal of inflamed synovium, total joint replacement (arthroplasty )

Scleroderma Treatment

-Assessment focuses on the hallmark sclerotic changes in the skin, contractures in the fingers, and color changes or ulcerations in the fingertips due to poor circulation -*NO CURE* -Decrease pain, maintain moderate exercise, and prevent joint contractures -*No specific medication*, antiarthritic drugs can help treat organ system involvement -Calcium channel blockers and other antihypertensive agents for Raynaud's phenomenon -Avoid the cold and to protect fingers with mittens, warm socks and properly fitting shoes are helpful in preventing ulcers (Raynaud's)

Rheumatoid Arthritis

-Autoimmune disease in which the normal immune response is directed against an individual's own tissue, including the joints, tendons, and bones, resulting in inflammation and destruction of these tissues -Auto-immune reaction primarily occurs in synovial tissue -Body produces antibody rheumatoid factor (RF) that goes against its own antibody (IgG) and transforms IgG into an antigen that must be destroyed -Inflammation results and enzymes are produced that breaks down collagen, causing edema of the synovial membrane and pannus formation -*Pannus formation* is a characteristic of RA that differentiates it from other forms of inflammatory arthritis, it causes DEFORMITIES -Pannus destroys adjacent cartilage and bone, resulting in loss of motion -Most common inflammatory arthritic disorder and serves as a prototype for the study of many inflammatory and immune-mediated disorders -Occurs more in females than males

Cancer and Pain Management

-Cancer pain may be related to cancer itself, pressure exerted by the tumor (nerve compression), diagnostic procedures, or the cancer treatment (surgery pain, stomatitis from chemo, skin and organ inflammation from radiation) -Neuropathic pain (pressure on nerves), bone pain, soft tissue pain, phantom pain, chronic pain -Fear and apprehension, fatigue, anger, and social isolation may increase perception of pain -Chronic cancer pain is a cycle progressing from pain to anxiety to fear and back to pain (become anxious about pain, heightened perception of pain, increased fear) -Adequate rest and sleep, antidepressants, antianxiety agents, and analgesics enhance tolerance to pain *Inadequate pain control leads to suffering, anxiety, fear, immobility, isolation, and depression*

Scleroderma

-Chronic connective tissue disease generally classified as one of the autoimmune rheumatic diseases -Hardening of the skin and connective tissues -Classified into localized and systemic (systemic sclerosis: progressive) -Pathogenesis integrates three cardinal features: *vascular injury and damage, activation of immune system autoimmunity, and generalized interstitial and vascular fibrosis* -Scleroderma commonly begins with skin involvement, cells cluster on the skin and stimulate procollagen, insoluble collagen is formed and accumulates excessively in the tissues -Initially, the inflammatory response causes edema formation, with a resulting taut, smooth, and shiny skin appearance -The skin then undergoes fibrotic changes, leading to loss of elasticity and movement -Eventually, the tissue degenerates and becomes nonfunctional -This chain of events, from inflammation to degeneration, also occurs in blood vessels, synovium, skeletal muscles, and internal organ(s) of the heart, lungs, GI tract, and kidneys

Systemic Lupus Erythematosus

-Chronic inflammatory autoimmune disease -A result of disturbed immune regulation that causes an exaggerated production of autoantibodies and antigens -Five phases: susceptibility, abnormal immune responses, autoantibodies immune complexes, inflammation, and damage -Interactions of predisposing factors (genes, female gender, and environment) result in abnormal immune responses -These responses produce pathogenic autoantibodies and immune complexes that cause inflammation -Inflammation stimulates antigens, which in turn stimulate additional antibodies -The cycle repeats and, over time, leads to irreversible organ damage

Chest Tube

-Drains air, blood and fluid from thorax -Treatment of pneumothorax, hemothorax and pleural effusions -Catheters are inserted through a skin incision, connected to a chest drainage system -Three chambers: 1. Collection chamber: To drain and collect fluid 2. Water seal chamber: One way valve to prevent air from going back into the chest when the patient inhales 3. Wet suction control: Regulates suction (-20 STANDARD)

Thrombocytopenia S/S

-Ecchymosis, petechiae -Bleeding with mouth care (gingival bleeding), epistaxis -Excessive menstrual bleeding, excessive bleeding after surgery or dental extractions -Blood in stools (melena) -Blood in urine (hematuria) -Blood in sputum (hemoptysis) -Blood in vomit (hematemesis) -Oozing at injection sites -Changes in mental status

Acute/Intermediate Phase

-Follows the emergent/resuscitative phase and begins *48 to 72* hours after the burn injury, *from beginning of diuresis to near completion of wound closure* -*Priorities*: Maintenance of respiratory and circulatory status, fluid and electrolyte balance, pain management, promoting mobility -Nutritional support -Infection prevention -Wound care and closure *Respiratory and Circulatory status* -Remove ET tube ASAP -As capillaries regain integrity, diuresis begins -If cardiac or renal function is inadequate, fluid overload occurs and symptoms of congestive heart failure may result -May need blood products for anemia *Infection Prevention* -Standard precautions, clean environment *Wound Care* *Pain Management* *Nutritional Support* -The enteral route of feeding is far superior to the parenteral route -Protein and calorie rich feedings *Promote Mobility* -Deep breathing, turning, and proper positioning -To prevent atelectasis and pneumonia, control edema, and prevent pressure ulcers and contractures

Tumor Grading and Staging

-Grading and staging tumor is accomplished before treatment begins to provide baseline data -Treatment options and prognosis are based on stage and grade of disease *Staging* -Determines the *size of the tumor and the extent of disease* -The *TNM* system is frequently used for many solid tumor types -"T" refers to the extent of the primary tumor, "N" refers to lymph node involvement, and "M" refers to the extent of metastasis *Grading* -Refers to the *classification of the tumor cells* -Grading systems seek to define the *type of tissue from which the tumor originated and the degree to which the tumor cells retain the histologic characteristics of the tissue of origin* -Samples of cells to be used to establish the grade of a tumor may be obtained through cytology (examination of cells from tissue scrapings, body fluids, secretions), biopsy, or surgical excision -The tumor is assigned a numeric value ranging from *I to IV* -Grade I tumors (well-differentiated tumors) closely resemble the tissue of origin in structure and function -Tumors that do not clearly resemble the tissue of origin in structure or function are described as poorly differentiated or undifferentiated and are assigned grade IV -These tumors tend to be more aggressive and less responsive to treatment than are well-differentiated tumors

Burn Thermoregulatory Alterations

-Loss of skin also results in an inability to regulate body temperature -Patients with burn injuries may therefore exhibit low body temperatures in the early hours after injury (HYPOTHERMIA) -Then, as hypermetabolism resets core temperatures, the patient becomes hyperthermic for much of the post-burn period, even in the absence of infection (HYPERTHERMIA)

Systemic Lupus Erythematosus Medical Treatment

-NSAIDs, antimalarials, glucocorticoids, and immunosuppressive agents -*Corticosteroids* are the MOST IMPORTANT medication available for SLE (immunosuppressive therapy) -B-cell depleting therapies are the newest form of treatment for SLE and are reserved for patients who have serious forms of SLE

Nurse Safety with Radiation Therapy

-Nursing care for no more than 30 minutes per 8-hour shift -Stand *6 feet* from the patient to minimize exposure -Lead shield to buffer the exposure to radiation -Dosimeter badges (monitor radiation) -Prohibit visits by children or pregnant visitors -Limit visits from others to 30 minutes daily

Burn Systemic Edema

-Patients with a major burn develop massive systemic edema -As fluid resuscitation proceeds, the edema worsens -As the taut, burned tissue becomes unyielding to the edema underneath its surface, it begins to act like a tourniquet -This complication is similar to a compartment syndrome -Provider may need to perform an *escharotomy*, surgical incision into the eschar (black necrotic tissue) to relieve constricting effect of burned tissue

Characteristics of Cancer Cells

-Pleomorphism: Cells vary in size and shape -Polymorphism: Nucleus is enlarged and variable in shape -Chromosomal mutations including translocations, deletions, amplification, and aneuploidy (abnormal number of chromosomes) -Production of surface enzymes that aid in invasion and metastasis -Loss of antigens that label the cell as "self" and production of new tumor antigens that label the cell as "non-self" -Increased rate of anaerobic metabolism -Loss of contact inhibition, which normally halts cell division once cells are in contact with one another -Defect in cell recognition and adhesion (cancer cells do not recognize and adhere to each other as normal cells do) -Loss of control of proliferation -Increased mitotic index: Tumors have a larger number of cells that are in mitosis -Abnormal lifespan: Cancer cells tend to live longer than do normal cells

Burn Fluid Resuscitation

-Prompt fluid resuscitation maintains the BP in the low-normal range and improves CO -Generally, the greatest volume of fluid leak occurs in the first 24 to 36 hours after the burn -As the capillaries begin to regain their integrity, burn shock resolves and fluid returns to the vascular compartment, blood volume increases, urinary output increases *Lactated Ringer's (LR) solution* is the preferred IV fluid for burn resuscitation because the sodium and potassium concentrations are similar to normal intravascular levels (isotonic solution) -LR also contains lactate, which can be converted by the liver to *bicarbonate* (the blood buffer) to aid in correcting the metabolic acidosis frequently seen in burn shock

Radiation Therapy

-Radiation may be used to cure the cancer or control the cancer (when tumor cannot be removed surgically or when metastasis is present) or it can be used prophylactically to prevent leukemic infiltration to the brain or spinal cord *Two types of ionizing radiation* -Electromagnetic rays (X-rays and gamma rays) -Particles (electrons, protons, neutrons, and alpha particles) -Radiation disrupts malignant cell's DNA -Radiation breaks the strands of the DNA helix, leading to cell death -Damaged DNA prevents cancer cells division and INTERRUPTS GROWTH causing tumor to shrink -Cells are most vulnerable to radiation during DNA division -Therefore, those body tissues that undergo frequent cell division are most sensitive to radiation therapy (cancer) -Slow-growing tissues (muscle, connective tissue) are radio-resistant

Burn Rehabilitation Phase

-Rehabilitation begins ASAP after the burn has occurred and often extends for years after injury *-From major wound closure to return to individual's optimal level of physical and psychosocial adjustment* *Priorities* -Prevention of scars and contractures -Physical, occupational rehabilitation -Functional and cosmetic reconstruction (to improve body appearance) -Psychosocial counseling (body image) *Hypertrophic Scarring* -The wound is in a dynamic state for 1.5 to 2 years after the burn occurs -The scar tissue loses its redness and softens if treated appropriately -Healed areas that are prone to hypertrophic scarring require the patient to wear a pressure garment (*pressure needs to be continuous*) -Gentle superficial massage aids in softening the connective tissue -Patients need lubrication and protection of the healing skin and need to use pressure garments for at least 1 year after the injury -Treatment includes: *elastic pressure garments* (for HYPERTROPHIC SCARRING), splints, and exercise under supervision *Continuing Care* -Follow-up care and home care -Patients who have survived burn injuries frequently suffer profound losses (body image due to disfigurement, losses of personal property, homes, loved ones, and ability to work) -Promote a healthy body image -Support groups

Diffuse Connective Tissue Diseases

-Rheumatic disorders with diffuse inflammation and degeneration in the connective tissues are referred to as connective tissue diseases -Unknown causes, they are thought to be the result of immunologic abnormalities in which the immune system loses its ability to tell the difference between foreign invaders and the body's normal cells *Connective tissue diseases include*: -Rheumatoid arthritis -Systemic lupus erythematosus (SLE) -Scleroderma

Thrombocytopenia Treatment

-Soft toothbrush -Electric razor -Avoid unnecessary invasive procedures (rectal temperatures, intramuscular injections, catheterization) -Fall precautions -Soft foods, increased fluid intake, and stool softeners, if prescribed, may be indicated to reduce trauma to the GI tract -Joints and extremities are handled and moved gently to minimize the risk of spontaneous bleeding -Following venipuncture, pressure must be applied for 3 to 5 minutes -Monitor hemoglobin and hematocrit -Test urine, stool, and emesis for occult blood -Platelet transfusions, blood products and fluid replacement

The immune abnormalities that characterize systemic lupus erythematosus (SLE) include which of the following?

-Susceptibility -Abnormal innate and adaptive immune responses -Autoantibodies immune complexes -Inflammation -Damage

Rheumatoid Arthirtis Diagnosis

-Swelling of three or more joints, involvements of MCP or metatarsophalangeal joints, or early morning stiffness

Systemic Lupus Erythematosus Nursing Management

-Teach patients to avoid sunlight or ultraviolet (UV) exposure and to protect themselves with sunscreen and clothing

Treatment of Risk for Infection of a Burn Patient

-The immunosuppression that accompanies extensive burn injury places the patient at high risk of sepsis -Despite aseptic precautions and the use of topical antimicrobial agents, the burn wound is an excellent medium for bacterial growth and proliferation -A primary source of bacterial infection is the patient's intestinal tract, the source of most microbes -A major secondary source of pathogenic microbes is the environment *Infection control is a major role of the burn team in providing wound care* -Cap, gown, mask, and gloves are worn while caring for open burn wounds -Clean technique is used when caring directly for burn wounds -Antibiotics are seldom prescribed prophylactically because of the risk of promoting resistant strains of bacteria -Systemic antibiotics are administered when there is documentation of positive cultures *Topical antibacterial therapy* is BEST for local treatment

Chest Tube Management

-Tidalling SHOULD occur: Ball in water seal chamber moves up and down with pt.'s inspiration and expiration, increase in water level with inspiration, a return to baseline level during exhalation -Bubbling in water seal chamber indicates AIR LEAK -Bubbling in suction chamber is NORMAL -NEVER CLAMP CHEST TUBE: Can increase positive pressure within the lungs and collapse the lungs even more -ONLY clamp chest tube if tube was severed, or if changing collection system or when removing chest tube to see if pt. can handle no chest tube in place -Ensure drainage system is BELOW the level of the chest -Reposition the patient every 1.5-2 hours (promotes drainage -Make sure the tubing is patent at all times

Which of the following maybe the first and only physical sign of symptomatic osteoarthritis (OA)?

Limited passive movement

What should the nurse do to combat the most common adverse effects of chemotherapy?

-Administer an antiemetic -Nausea and vomiting are the most common and debilitating adverse effects of chemotherapy

A nurse is teaching a client who is receiving radiation treatment for left lower lobe lung cancer. Which client statement indicates a need for further teaching?

"I'll use hats to protect my head from the sun when my hair falls out." -Alopecia is an acute, localized adverse effect of radiation -The treatment area for this client's cancer will be localized to the lower aspects of his lungs, not his head -Nausea and fatigue are expected generalized adverse effects of radiation therapy -Most adverse effects of radiation are temporary and will stop when treatment is complete.

A patient will be receiving radiation for 6 weeks for the treatment of breast cancer and asks the nurse why it takes so long. What is the best response by the nurse?

"It will allow time for the repair of healthy tissue." -In external-beam radiation therapy (EBRT), the total radiation dose is delivered over several weeks in daily doses called fractions -This allows healthy tissue to repair and achieves greater cell kill by exposing more cells to the radiation as they begin active cell division -Repeated radiation treatments over time (fractionated doses) also allow for the periphery of the tumor to be reoxygenated repeatedly, because tumors shrink from the outside inward -This increases the radiosensitivity of the tumor, thereby increasing tumor cell death

During a client's examination and consultation, the physician keeps saying "Mrs. Isaacs, you have an abdominal neoplasm." Which of the following statements accurately paraphrases the physician's statement?

"Mrs. Isaacs, you have a new growth of abnormal tissue in your abdomen." "Mrs. Isaacs, you have an abdominal tumor." -Neoplasms are abnormal growths of tissue (tumors)

You are the clinic nurse caring for a patient whose grandmother, mother, and sister all had breast cancer. She has requested a screening test to determine her risk of developing breast cancer and it has come back positive. The patient asks you what she can do to help prevent breast cancer from occurring. What would be your best response?

"Research has shown that taking tamoxifen can reduce your chance of breast cancer." -Tamoxifen can reduce the incidence of breast cancer by 50% in women at high risk for breast cancer

Ovarian Cancer Risk Factors

-Age over 40 or postmenopausal -Nulliparous (never given birth) -Northern American or Northern European descent -Personal history of breast, colon, or endometrial cancer -Obesity -Use of fertility drugs -Long-term use of hormone replacement therapy -Family history of ovarian cancer

A male patient, 16 years old, comes to the emergency department (ED) after burning his right hand and arm while working on a friend's car. The injury is determined to be a superficial burn and it is treated. What would the nurse teach the patient before discharging him home to return on a daily basis for dressing changes? A) "As your arm swells, push on your fingernails. If it takes longer than 5 seconds for them to get pink come back to the ED." B) "You should be fine until you come back tomorrow for your dressing change." C) "Drink lots of fluids and elevate the arm." D) "The burned area will start to swell in about 4 hours and blisters will form. If you think the dressing is too tight come back to the ED."

"The burned area will start to swell in about 4 hours and blisters will form. If you think the dressing is too tight come back to the ED." **In a superficial burn there is loss of capillary integrity and fluid is localized to the burn itself, resulting in blister formation and edema only in the area of injury.

A patient with cancer complains of fatigue and weakness after his first round of radiation therapy. How should the nurse best reassure this patient?

"These symptoms usually result from radiation therapy; we will continue to monitor your health closely."

Zones of burn injury

*3 distinct zones* -Zone of coagulation (in the center) is where the tissue is completely destroyed, cellular death -Zone of stasis surrounds non-viable tissue and is potentially viable, compromised blood supply, inflammation and tissue injury -Zone of hyperemia has increased blood flow secondary to inflammatory response

Stomatitis Nursing Management

*Assessment* -Routine oral assessments -Pain assessments -Assess impact on speech, nutritional intake and ability to sleep *Nursing Care* -Routine oral hygiene (brushing, flossing, and rinsing) minimizes the risk of oral complications associated with cancer therapies -Soft-bristled toothbrushes and nonabrasive toothpaste -Oral swabs with sponge-like applicators may be used in place of a toothbrush for painful oral tissues -Oral rinses with saline solution or tap water after meals and at bedtime may be necessary for patients who cannot tolerate toothbrushing -AVOID alcohol-based mouth rinses (irritating) -AVOID foods that are difficult to chew or are hot or spicy -Lubricate patient's lips to prevent cracks and dryness -Topical anti-inflammatory and anesthetic agents -For severe pain, may require systemic analgesics -Adequate fluid and food intake is encouraged -May need parenteral hydration and nutrition

Patient Care after Axillary Node Dissection (Breast Cancer)

*Axillary lymph node dissection (ALND) occurs during a radical mastectomy* ARM and HAND will be at a greater risk for swelling and infection once the lymph node is gone *Hand and Arm Care* -Avoid BP, injections, and blood draws in affected extremity -Sunscreen for sun exposure -Insect repellent to avoid insect bites -Gloves for gardening -Avoid cutting cuticles -Use electric razor for shaving armpit -Avoid lifting objects greater than 5-10lbs -If a trauma or break in the skin occurs, wash the area with soap and water, and apply an OTC antibacterial ointment (Bacitracin or Neosporin) -Observe the area and extremity for 24 hours; if redness, swelling, or a fever occurs, call the medical professional

Risks for Breast Cancer

*Being a woman* *Increasing age* -Inherited genetic mutation for breast cancer -Family history (or personal hx) -History of benign breast disease (atypical hyperplasia) -History of high-dose radiation therapy to the chest *Hormonal factors:* -Early menarche (<12 years) -Late menopause (>55 years) -Nulliparity (have never given birth) -Late age at first full-term pregnancy (>30 years) -Recent contraceptive use -Long-term use of estrogen and progestin (hormone replacement therapy) -History of ovarian cancer or endometrial cancer -Obesity -Alcohol consumption -Jewish ethnicity

Systemic Lupus Erythematosus RASH

*Butterfly Rash* -A tell-tale sign of lupus is a butterfly-shaped rash across the cheeks and bridge of the nose -Rash is erythematous, flat or raised lesion, pruritic or painful

Ovarian Cancer Diagnosis

*Diagnosis* -No reliable screening tools are available for this disease -Bimanual examinations diagnose one-third of ovarian masses -Pelvic ultrasounds and blood tests for tumor markers are performed when ruling out an ovarian mass -If either of these tests is suggestive of a tumor, an abdominal and pelvic CT scan is performed

Cancer and disturbed body image

*Disturbed body image and self-esteem due to*: -Disfiguring surgery -Hair loss -Cachexia, skin changes -Altered communication patterns -Sexual dysfunction *RN should assess threats to body image, and pt.'s ability to cope, as well as threats to pt.'s self concept * -Positive approach, nurse is a listener and counselor -Encourage independence and participation in self-care and decision-making -Support group can aid patient coping -Cosmetologists for hair or wig styling, makeup, and the use of scarves and turbans to help with body image concerns. -Alternative forms of sexual expression are explored with patients and their partners to promote positive self-worth and acceptance

Types of Brain Tumors

*Gliomas* -Intracerebral tumor -POOR prognosis -Surgery, radiation therapy, and/or chemotherapy -Total surgical resection is difficult *Meningiomas* -Most common type of brain tumor -Benign, encapsulated, slow-growing tumor -Tumor grows on the membrane covering of the brain (meninges) -Can die unaware they have a meningioma -Treatment is surgery with complete removal or partial dissection of the tumor *Acoustic Neuromas* -Benign tumor of the eighth cranial nerve (hearing and balance) -Loss of hearing, tinnitus, episodes of vertigo and staggering gait -As the tumor becomes larger, painful sensations of the face may occur on the same side, as a result of the tumor's compression of the fifth cranial nerve (trigeminal nerve) resulting in facial numbness (paresthesia) and pain -Diagnosis is suggested by unilateral hearing loss -Surgery and radiation *Pituitary Adenomas* -Slow growing, benign or malignant -Nonfunctioning (tumors that do not produce hormones) and functioning (tumors that produce one or more hormones by the anterior pituitary) -Prolactin-secreting pituitary adenomas (prolactinomas), growth hormone-secreting pituitary adenomas that cause acromegaly in adults, and ACTH producing pituitary adenomas that cause Cushing's disease -Amenorrhea is suggestive of a pituitary lesion -Surgery, or radiation for recurrent tumors *Angiomas* -Brain angiomas are masses composed largely of abnormal blood vessels -Occur in brain or on surface, most often on cerebellum -Asymptomatic or S/S of brain tumor (H/A, seizures) -Walls of the blood vessels in angiomas are thin, so patients are at risk for hemorrhagic stroke -Cerebral hemorrhage in people younger than 40 years of age should suggest the possibility of an angioma *Cerebral Metastases* -Metastatic lesions to the brain occur more often than do primary tumors -Lung and breast cancers commonly metastasize to the brain

Electrolyte Imbalance with Secondary Bone Tumors

*Hypercalcemia* -Results from breakdown of bone -DUE TO: -Bone destruction by tumor cells and release of calcium -Production of prostaglandins and osteoclast-activating factors, which stimulate bone breakdown and calcium release -Tumors that produce parathyroid-like substances that promote calcium release (PTH) *S/S*: -Muscle weakness -Incoordination -Anorexia -Constipation (decreased contractility in abd. region) -N/V -Abdominal and bone pain, OSTEOPOROSIS, pathological fractures, RENAL STONES, peptic ulcer and acute pancreatitis -EKG changes and dysrhythmias -Altered mental states (confusion, lethargy, psychotic behavior) *Treatment* -IV NS administration (help dilute and excrete calcium) -Diuretics (help dilute and excrete calcium) -Medications such as bisphosphonates and calcitonin (increase calcium deposits in bones) -Increase activity and ambulation (inactivity leads to loss of bone mass and increased calcium in the blood) -Stool softeners and laxatives for constipation -Give *PHOSPHATES* Phosphates work opposite to calcium: -Increased phosphates = decreased calcium -Decreased phosphates = increased calcium

Brain Cancer Diagnostic Tests

*Magnetic resonance imaging (MRI)* -GOLD STANDARD *Computed tomography (CT)*

Guidelines for Women to Obtain a Clinical Breast Exam/Mammography

*Mammography* -Women should begin annual screening mammography at age 40 -Women may have a baseline mammogram at age 35, and return at age 40 provided they receive normal results *Clinical Breast Exam* -Women should also have a clinical breast exam every *3 years beginning at age 20* and *annually at age 40* -Women who are at increased risk for breast cancer should talk with their care provider to establish the optimal age to begin screening mammography -A general guideline is to begin screening 10 years earlier than the age at which the youngest family member developed breast cancer, but not before 25 years of age *SELF BREAST EXAMS SHOULD BE ONCE A MONTH*

Hematopoietic Stem Cell Transplantation (HSCT) (Bone Marrow Transplantation) Nursing Care AFTER Procedure

*Monitor for Late effects* -Infections (varicella zoster) -Restrictive pulmonary abnormalities, pneumonias -Sterility often results -Chronic GVHD involves the skin, liver, intestine, esophagus, eyes, lungs, joints, and oral and vaginal mucosa -Cataracts may also develop after total body irradiation

Stomatitis Medication

*Palifermin (Kepivance)* is an IV medication approved for treatment of stomatitis in patients with hematologic malignancies who are undergoing high-dose chemotherapy or total body radiation

Radiation Therapy Nursing Management

*Patient Education* -Must avoid using ointments, lotions, or powders on the treated area -Gently cleanse the skin with a mild soap using fingertips and gently pat the area dry -Emollients such as Aquaphor® may be used to soothe and moisturize irritated skin, but should not be used up to 4 hours before the treatment time -Electric razors should be used for shaving -Avoid constrictive clothing that may irritate skin, loose, cotton clothing is comfortable -Avoiding sun exposure, heating lamps, heating pads, and ice packs to the area being treated (sources of thermal injury) *Mouth care for patients receiving head and neck radiation therapy* -Salt water or baking soda/water rinse to soothe dry and sore mouth -8 ounces of water every 2-3 hours for dry mouth, humidifier -Avoid acidic juices, alcohol, mouthwash with alcohol and rough foods

Cancer Prevention

*Primary* -Avoiding known carcinogens -Dietary and various lifestyle changes -Tamoxifen to reduce breast cancer risk *Secondary* -Involves DETECTION AND SCREENING to achieve early diagnosis and prompt intervention to halt the cancer process -Focus on EARLY DETECTION -*Examples:* mammograms, digital rectal examinations, prostate-specific antigen (PSA) blood tests (BREAST AND PROSTATE CANCER) PAP SMEARS *Tertiary* -Prevention of disease progression and care, treatment, and rehabilitation of patients after cancer diagnosis

Prostate Cancer Treatment

*Radical prostatectomy* -Complete surgical removal of the prostate, seminal vesicles, and often the surrounding fat, nerves, lymph nodes, and blood vessels -It is FIRST-LINE treatment for prostate cancer. *Radiation Therapy* -If detected early, the treatment may be curative radiation therapy -Teletherapy (external) and brachytherapy (internal) *Hormonal Therapy* -For advanced prostate cancer, suppresses androgenic stimuli to the prostate by decreasing the level of circulating testosterone -As a result, the prostatic epithelium atrophies -This effect is accomplished either by surgical castration (orchiectomy -removal of testicles ) or by meds -Causes EMOTIONAL IMPACT *Cryosurgery of Prostate* (freezing) -Ablate prostate cancer in patients who cannot tolerate surgery and in those with recurrent prostate cancer

Testicular Cancer S/S

*S/S appear gradually* -Mass or lump on the testicle -*Enlargement of the testis without pain* -Heaviness in the scrotum, inguinal area, or lower abdomen -Backache, abdominal pain, weight loss and general weakness may result from metastasis

Ovarian Cancer S/S

*S/S are subtle and start with:* -Persistent bloating -Early satiety (being full) -Change in bowel or bladder habits -Weight gain in abdominal area -Due to the close proximity of the ovaries to the intestines, patients will typically complain of GI symptoms and because of this can often be misdiagnosed as IBS, GERD, menopause, or UTIs *Late S/S*: -Ascites (fluid accumulation in the peritoneal cavity)

Detecting Breast Cancer Metastasis

*S/S* -Shoulder, hip, or pelvic pain, cough, anorexia, persistent dizziness, enlarged axillary or supraclavicular lymph nodes -Breast cancer may recur locally (on the chest wall or in the conserved breast), regionally (in the remaining lymph nodes), or systemically (in distant organs) -In metastatic disease, the bone is the most common site of spread (usually the hips, spine, ribs, or pelvis) -Other sites of metastasis include the lungs, liver, pleura, and brain -Complete blood count; comprehensive metabolic panel; tumor markers; bone scan; CT of the chest, abdomen, and pelvis; and MRI of symptomatic areas -Additional X-rays may be performed to evaluate areas of pain or abnormal areas seen on bone scan

Infiltrated IV of a Vesicant (ex. chemo drug) Nursing Management

*STOP MED IMMEDIATELY* -Aspirate any residual drug from the IV line -Administer antidote or neutralizing solution -Examples of neutralizing solutions include sodium thiosulfate, hyaluronidase, and sodium bicarbonate -Ice is applied to the site -Avoid further trauma to the site (including heat, constrictive clothing, sunlight) -If frequent, prolonged administration of antineoplastic vesicants (anticancer drugs) is anticipated, central venous access devices may be inserted to promote safety (central line instead of peripheral line)

Chemotherapy Administration Safety

*Safety recommendations for the preparation and handling of antineoplastic (anti-cancer) agents include:* -Use a biologic safety cabinet for the preparation of all chemotherapy agents -Wear gloves that have been tested with chemotherapeutic agents when handling antineoplastic drugs and the excretions of patients who received chemotherapy -Wear disposable, nonabsorbent long-sleeved gowns with cuffs during preparation and administration -Use Luer-Lok fittings on all IV tubing used to deliver chemotherapy -Dispose of all equipment in leak-proof, puncture-proof containers -Dispose of all chemotherapy wastes as hazardous materials -These precautions greatly minimize the risk of exposure to chemotherapy agents

Brain Cancer Risk Factors

-Cause of most primary brain tumors is unknown *Risk Factors* -Exposure to ionizing radiation and cancer-causing chemicals -Nonionizing radiation, physical and acoustic trauma, and dietary factors (still investigating) -Brain tumors occur more often in females than males

Brain Cancer Medical Management

*Surgical management* -To remove part of or the entire tumor without increasing the neurologic deficit *Radiation Therapy* -Decreases the incidence of recurrence of incompletely resected tumors *Chemotherapy* -Intravenously, orally, or intrathecally (injected directly into the subarachnoid space) -*Temozolomide (Temodar)* part of the systemic therapy because of its ability to pass through the blood-brain barrier -Corticosteroids to reduce cerebral edema, headache, and alterations in LOC, nausea and vomiting -Anti-seizure agents -Pain management for H/A -Morphine can be infused into the epidural catheter

Hematopoietic Stem Cell Transplantation (HSCT) (Bone Marrow Transplantation) Side Effects and Nursing Care DURING Procedure

*Toxicities of chemotherapy:* -Nausea, vomiting, diarrhea -Mucositis, and cystitis (inflammation of bladder) *Adverse effects*: -Fever, chills, shortness of breath, chest pain, cutaneous reactions (hives), N/V, hypotension or hypertension, tachycardia, anxiety, and taste changes *Bone marrow aplasia (inability to create new cells) occurs until engraftment of the new marrow happens* -DEATH FROM SEPSIS AND BLEEDING -Blood products and hematopoietic growth factors (promote blood cell growth) *Renal Complications* -May arise from the nephrotoxic chemotherapy agents or those used to treat infection due to sepsis (amphotericin B, aminoglycosides) *Tumor Lysis Syndrome* -When malignancies are killed, their intracellular contents are released into the bloodstream, leading to hyperkalemia, hyperphosphatemia, and hyperuricemia = KIDNEY DAMAGE -Treat with hydration, and medications that decrease uric acid levels -Monitor electrolytes and I&O *Graft vs. Host Disease* -Affects skin, liver, and GI tract -Red maculopapular rash commonly found on the palms of the hands and soles of the feet -Elevated liver function tests (LFTs), weight gain, jaundice, right upper quadrant pain, abdominal pain -Early satiety, and diarrhea *Hepatic Venous Occlusive Disease (VOD* -Resulting from chemotherapy -Jaundice, abdominal pain, ascites, tender and enlarged liver, and encephalopathy *Pulmonary Complications* -Pulmonary edema, pneumonia

The root cause of cancer is damage to cellular deoxyribonucleic acid (DNA). Such damage results from multiple factors. Which of the following is a carcinogen?

-*Dietary substances* -Environmental factors -Viruses -Chemical agents -Defective genes -Medically prescribed interventions

Chemotherapy

-Antineoplastic agents (anti-cancer drugs) are used in an attempt to destroy tumor cells by interfering with cellular replication -Chemotherapy is used primarily to treat systemic disease rather than localized lesions that are responsive to surgery or radiation -Chemotherapy may be combined with surgery, radiation therapy, or both, to reduce tumor size preoperatively, to destroy any remaining tumor cells postoperatively, or to treat hematologic malignancies such as lymphoma and leukemia -Each time a tumor is exposed to a chemotherapeutic agent, a percentage of tumor cells are destroyed -Repeated doses of chemotherapy are necessary to achieve regression of the tumor -Eradication of 100% of the tumor is almost impossible, the goal of treatment is eradication of enough of the tumor so that the remaining tumor cells can be destroyed by the body's immune system *Administration*: -Chemotherapeutic agents may be administered in routes: topical, oral, IV, intramuscular, subcutaneous, arterial, intracavitary, and intrathecal routes (administration of med into CSF fluid)

S/S Breast Cancer

-Breast cancers usually found in the upper outer quadrant, more common in left breast than right -Lesions are non-tender, fixed rather than mobile, and hard with irregular borders -Wrinkling, dimpling, thickening, or puckering or an area that feels grainy, stringy, or thickened -Change in color of the breast -Swelling of all or part of a breast (even if no distinct lump is felt) -Redness/warmth over painful lump can indicate infection/abscess/mastitis or cancer -Red scaly rash on nipple -Nipple discharge -galactorrhea (other than breast milk) spontaneous -Advanced signs may include skin dimpling, nipple retraction (turning inwards), or skin ulceration

Burn Treatment

-Burn care is divided into three phases: -*Emergent/resuscitative:* from onset of injury to completion of fluid resuscitation -*Acute/intermediate:* from beginning of diuresis to near completion of wound closure -*Rehab*: from major wound closure to return to individual's optimal level of physical and psychosocial adjustment

Brain Cancer S/S

-Can produce focal (localized) or generalized neurologic symptoms -Symptoms reflect either brain invasion, compression by the mass on adjacent structures, or increased ICP *S/S*: GENERALIZED -Headache -Nausea and vomiting -Cognitive impairment -Visual disturbances -Seizures *Focal symptoms may include:* -Weakness, sensory loss, aphasia (language disturbance) *3 MAIN THINGS:* -Increased intracranial pressure -New onset of seizures (seizures may be the initial presenting symptom) -Localized symptoms: hemiparesis, seizures, mental status changes, sensory and motor abnormalities, visual alterations, changes in hearing DEPENDING ON AREA OF BRAIN AFFECTED

Chemotherapy Toxicity

-Cells with rapid growth rates (epithelium, bone marrow, hair follicles, sperm) are most susceptible to the effects of chemotherapy *GI system*: -Nausea and vomiting are the most common side effects of chemotherapy and may persist for as long as 24 to 48 hours after its administration *Hematopoietic system* -MYELOSUPPRESSION (anemia, leukopenia, thrombocytopenia) -Increased risk for infection and bleeding *Reproductive system* -Abnormal ovulation -Early menopause -Permanent sterility -Aazoospermia (absence of spermatozoa) -May need to BANK SPERM OR EGGS *Other S/S*: -Alopecia, anorexia, and fatigue, appetite changes

Relationship Between Viruses and Cervical Cancer

-Cervical cancer nearly always has a viral etiology, commonly caused by HPV

Chemotherapy and Anti-emetics

-Chemoreceptor trigger zone (CTZ) of the medulla can be activated by serotonin, substance P, and other neurotransmitters such as dopamine -CTZ helps initiate vomiting *Serotonin antagonists* *SETRON -Ondasteron, Granisetron, Dolasetron, and Palonsetron -Blocks serotonin receptors of the CTZ (chemoreceptor trigger zone) *Dopaminergic blockers* -Metoclopramide (Reglan) -Blocks dopamine receptors of the CTZ *Neurokinin-1 receptor antagonists* -Aprepitant (Emend) -Blocks the activity of substance P -Corticosteroids, phenothiazines, sedatives, and antihistamines are also helpful, especially when used in combination with serotonin blockers -Delayed nausea and vomiting that occur longer than 48 to 72 hours after chemotherapy are troublesome for some patients -To minimize discomfort, antiemetic medications may be necessary for the first week at home after chemotherapy

A patient, age 67 years, is admitted for diagnostic studies to rule out cancer. The patient is Caucasian, married, has been employed as a landscaper for 40 years, and has a 36-year history of smoking a pack of cigarettes daily. What significant risk factors does the nurse recognize this patient has?

-Cigarette smoking -Age -Occupation -Most cancer occurs in people older than 65 years -Excessive exposure to the ultraviolet rays of the sun increases risk of skin cancer -Clothing styles (sleeveless shirts or shorts), the use of sunscreens, occupation, recreational habits, and environmental variables, including humidity, altitude, and latitude, all play a role in the amount of exposure to ultraviolet light

Pap Smear Guidelines

-DO NOT begin pap smears for women under 21, regardless if they are sexually active or not *Ages 21 to 30* -Every 2 years *Ages 30 to 65* -Every 3 years, if 3 negative Pap tests *Ages 65 and older* -Discontinue if no abnormal Pap tests for 10 years *Patients having had a hysterectomy for noncancerous reasons* -Discontinue after hysterectomy *Those patients with high risk factors:* -HIV, diethylstilbestrol (DES) exposure, or cervical intraepithelial neoplasm -Every 6 months or as directed by health care provider

Long Term Complications for Prostate Cancer

-Each treatment for prostate cancer has some incidence of *SEXUAL FUNCTION ISSUES* and *IMPOTENCE* (inability to achieve an erection) -Also decreased LIBIDO and FATIGUE -With nerve-sparing radical prostatectomy, the likelihood of recovering the ability to have erections is better for men who are younger and in whom both neurovascular bundles are spared -Hormonal therapy also affects the CNS mechanisms that mediate sexual desire and arousability -PDE-5 inhibitors may be effective for treatment of erectile dysfunction in men after radical prostatectomy especially if the neurovascular bundles were preserved and after radiation therapy -If ED does not resolve, options are available to produce erections sufficient for sexual intercourse -Prosthetic penile implants -Vacuum devices -Medications

A patient with uterine cancer is being treated with intracavitary radiation. The patient will emit radiation while the implant is in place. The nurse is aware of the precautions necessary for the provider of care and visitors. Which of the following are appropriate guidelines to follow?

-Family members should stand about 6 feet from the patient -Lead aprons should be worn to buffer the exposure -Visitors may stay for 30 minutes or less -Exposure for the nurse, health care provider or visitors should be limited to 30 minutes/8-hour shift. As time increases, exposure to radiation increases. The goal is to deliver safe, efficient care in the shortest amount of time.

A client who has been diagnosed with osteoarthritis asks if he'll eventually begin to notice deformities in his hands and fingers as the condition progresses. Which concept should the nurse include in her response?

-Hand and finger deformities are associated with the development of rheumatoid arthritis

Testicular Cancer Treatment

-Highly responsive to treatment, GOAL IS TO CURE -*Orchiectomy* to remove testes -A *retroperitoneal lymph node dissection* may be performed after orchiectomy if there is evidence of lymph node metastasis -Patient may develop ejaculatory dysfunction, can result in subfertility or infertility, *cryopreservation* of sperm before treatment should be offered (BANKING SPERM) -Radiation only to affected testicle, other testicle is shielded to protect fertility -Chemotherapy is reserved for the treatment advanced stages *ADDRESS BODY IMAGE AND SEXUALITY -unilateral excision of a testis will not decrease virility (manliness), can still father children after radiation*

Cervical Cancer and HPV

-Human papilloma virus (HPV) has lead to changes in cervical tissue and caused cancer -Cervical cancer has a slow progression from certain strains of oncogenic HPV to invasive cervical cancer and may take years to progress -HPV comprises over 100 strains, some of which have oncogenic potential and are known to cause cervical abnormalities -Women are asymptomatic unless they have external genital warts carrying HPV virus (condyloma) *EDUCATE PATIENTS ON GETTING HPV VACCINE*

Increased Intracranial Pressure (ICP)

-ICP decreases cerebral perfusion, stimulates further edema and may shift brain tissue through openings resulting in herniation -Leads to cessation of cerebral blood flow: cerebral ischemia, infarction, and brain death -Earliest sign of increasing ICP is a change in LOC (changes in GCS eye response, motor response and verbal response) *Early signs include* -Disorientation, restlessness, confusion -*Papilledema (edema of the optic disk) -*Headache, constant -Nausea with or without vomiting *Late signs:* -LOC deteriorates until patient is comatose -Temperature increases -Projectile vomiting *CUSHING'S TRIAD* (hypertension with widening pulse pressure, bradycardia, bradypnea) -Different posturing or flaccidity -Loss of brainstem reflexes (pupillary- fixed, dilated, corneal, gag and swallowing) -Death MAIN 5 S/S OF ICP *Headache* -Most common in the early morning and is made worse by coughing, straining, or sudden movement -Headaches may improve with vomiting *CHECK TEMP* -fever with H/A is infection but H/A without fever is tumor or bleeding *Personality Changes* -Difficulties concentrating, memory loss (short-term memory more affected than long-term memory), confusion *Fatigue* -May have a constant feeling of exhaustion, weakness, and lack of energy *Vomiting* -Rarely related to food intake, is the result of irritation of the vagal centers in the medulla *Visual Disturbances* -Papilledema is associated with visual disturbances -Decreased visual acuity, diplopia (double vision), and visual field deficits

Stomatitis, S/S, Risk Factors

-Inflammation of the mouth leading to pain and ulceration due to radiation therapy (to the head and neck) and some types of chemotherapy (as a secondary infection) *S/S*: -Erythema and edema -Ulcerations, bleeding, secondary infection -Severe pain associated with ulcerated oral tissues can interfere with nutritional intake, speech, and a willingness to maintain oral hygiene -Can lead to hospitalization or interruptions in chemotherapy and radiation administration or decreases in the intended dosing until the inflammation subsides -Stomatitis commonly develops 5 to 14 days after patients receive myelosuppressive chemotherapeutic agents and often coincides with the WBC nadir (low point) *Risk factors that contribute to morbidity of stomatitis* -Poor oral hygiene, existing dental disease -Use of meds that dry mucous membranes -Advanced age, smoking, previous cancer treatment -Diminished renal function, and impaired nutritional status -Radiation-induced xerostomia (dry mouth) -Myelosuppression (bone marrow depression), predisposes the patient to oral bleeding and infection

Testicular Cancer Diagnosis

-Monthly testicular self-exams can detect testicular cancer -Human chorionic gonadotropin (hCG) and alpha-fetoprotein (AFP) are tumor markers that may be elevated -Lactate dehydrogenase (LDH) levels, and ultrasound examination to determine the presence and size of the testicular mass -CT of the abdomen and pelvis is performed to determine the extent of the disease in the retroperitoneum and pelvis -Chest X-ray for lung metastasis *Tissue biopsy is the only definitive way to determine whether cancer is present*

Testicular Cancer

-Most common cancer in men between the ages of 15 and 40 years -Highly treatable and usually curable form of cancer -Testicular tumors tend to metastasize early, spreading from the testis to the lymph nodes in the retroperitoneum and to the lungs -Classified as germinal (having their origins within the germ cells of the gonads -testes) or nongerminal (stromal- stroma is the supportive and hormone-producing tissue in the testicle)

Cervical Cancer

-Most common reproductive cancer among women -Most common type of cervical cancer is squamous cell carcinoma (SCC) -Pap tests are the most effective preventative measure for invasive cervical cancer (screening tool)

When a patient takes vincristine, an antineoplastic agent that inhibits DNA and protein synthesis, the patient needs to be informed that he should report which of the following symptoms that would be an expected side-effect of motor neuropathy?

-Muscle weakness -Cramps and spasms in the legs -Loss of balance and coordination

Neutropenia in Cancer

-Neutropenia is an abnormally low absolute neutrophil count that is associated with an increased risk for infection -The *risk for infection* rises as the ANC decreases *Absolute neutrophil count (ANC)** -Mild neutropenia: ANC 1,500 to 1,000/mm3 -Moderate neutropenia: ANC 999 to 500/mm3 -Severe neutropenia: ANC of less than 500/mm3 (severe risk of infection) -Patients with neutropenia are often not able to manifest the classic signs of infection, such as pus, because pus is comprised of WBCs -*Fever* is often the only sign of infection in immunocompromised patients -Any temperature of 38.0°C (100.4°F) or higher is reported and is EMERGENCY (due to high mortality rate associated with sepsis in neutropenic patients)

Ovarian Cancer

-Ovarian cancer is referred to as a cancer that "whispers" because its clinical manifestations are not apparent until the tumor has invaded surrounding structures and is causing symptoms -High mortality rate due to the aggressiveness of the malignancy (often spreads to peritoneum) -Oral contraceptives have been proven to decrease risk of developing ovarian cancer -NEED EARLY DIAGNOSIS FOR BEST OUTCOME

Tamoxifen for Breast Cancer

-PREVENTS BREAST CANCER IN HIGH RISK POPULATIONS

Significance of a gag reflex in relation to a brain tumor

-Patient with a brain tumor may be at increased risk for aspiration due to cranial nerve dysfunction -Side-lying position with HOB elevated 10-30 degrees if at risk for aspiration -Suction equipment at bedside *May be associated with medulla involvement* -Cranial nerves 9 (glossopharyngeal) and 10 (vagus) or the pons or medulla -If the gag reflex is impaired, food and fluid are withheld until evaluation of swallowing is determined *ASSESS GAG REFLEX BEFORE AND AFTER OPERATION*

Prostate Cancer and S/S

-Prostate cancer is the most common cancer in men other than nonmelanoma skin cancer -It is the second most common cause of cancer death in American men, exceeded only by lung cancer -If treated early, 5 year survival rate is 100%, but if prostate cancer metastasizes, mortality is high *S/S*: -Early stages rarely produce symptoms -If the neoplasm is large enough, urinary obstruction can occur -Difficulty and frequency of urination -Urinary retention -Decreased size and force of the urinary stream -Hematuria if the cancer invades the urethra or bladder -Prostate cancer can metastasize to bone and lymph nodes *Symptoms related to metastases include:* -Backache, hip pain, perineal and rectal discomfort, anemia, weight loss, weakness, nausea, and oliguria *-These symptoms may be the first indications of prostate cancer*

You are giving a report in your pathophysiology class. The subject of your report is cancer cells. In differentiating between benign and malignant cells, what characteristics would you cite?

-Rate of growth -Ability to cause death -Ability to spread

Burn Effects on the Body

-Shock -Abdominal Compartment Syndrome -Systemic Edema -Fluid and Electrolyte Alterations -Pulmonary Alterations -Renal Alterations -Immunologic Alterations -Thermoregulatory Alterations -GI Alterations

Which of the following are true statements about effective radiation therapy?

-Slower-growing tissues at rest (muscle) are more radioresistant. -Tumors that are well oxygenated are more sensitive to radiation (which is why they perform multiple radiation therapy sessions to allow tumor to re-oxygenate to become more sensitive for the next treatment) -Tumors that are small in size and dividing rapidly are more sensitive

Spinal cord compression (SCC) from a tumor

-Spinal cord compression (SCC) occurs because of tumor extension into the epidural space -The cord can be compressed at any area of the spine, resulting in permanent paralysis if not treated -MRI is test of preference for diagnosing SCC -Requires IMMEDIATE TREATMENT *Early S/S*: -Back pain at location of tumor -Percussion tenderness at the level of compression -Pain increases in prone position and by movement -Radicular pain (pain that radiates along the dermatome of a nerve) -Bladder and bowel dysfunction (urinary incontinence or retention, fecal incontinence or constipation) SPHINCTER DYSFUNCTION *Later S/S*: -Motor weakness -Sensory deficits (numbness, tingling, loss of sensation) -Abnormal reflexes -Paralysis *Treatment*: -Relieve cord compression with the use of IV steroids such as dexamethasone (Decadron) to reduce edema -Chemotherapy, radiation, or surgery to debulk the tumor -Surgery is primary intervention

Nursing action for extravasation of a chemotherapeutic agent would include which of the following nursing actions?

-Stop the medication infusion at the first sign of extravasation -Aspirate any residual drug from the IV line -Administer an antidote, if indicated

Neutropenia in Cancer Nursing Management

-Strict asepsis is essential when handling IV lines, catheters, and other invasive equipment -Avoid infection, avoid crowds -May need to be placed in a protective environment, where the air is filtered -Avoid invasive procedures (injections, vaginal or rectal examinations, rectal temperatures, and surgery) -Encourage TCDB (to prevent atelectasis and other respiratory problems) -Prophylactic antimicrobial therapy may be used -DO NOT EAT: soft cheeses, raw meat or fish, and deli meats (reduce risk of food-borne illnesses) -ONLY EAT fruits and vegetables that can be washed well, eliminating soft fruits such as berries

Ovarian Cancer Treatment

-Surgery to remove suspicious tissue and send to lab for immediate analysis (frozen section) -If positive, surgeon performs surgery or debulking to obtain clean margins -Includes a total abdominal hysterectomy (removal of uterus) with bilateral salpingo-oophorectomy (removal of ovaries and fallopian tubes), removal of the omentum (part of peritoneum), peritoneal washings, and partial colectomy if there is any colon involvement -Chemotherapy treats residual tumor and helps to control any metastatic disease *Carboplatin and paclitaxel* are chemo drugs that are considered the gold standard for treatment of ovarian cancer

Hematopoietic Stem Cell Transplantation (HSCT) (Bone Marrow Transplantation)

-The dose of chemotherapy that is delivered is limited by myelosuppression -The use of bone marrow or stem cells from either the patient (autologous) or from a donor (allogeneic) allows the bone marrow to be "rescued" from the toxic effects of the chemotherapy, therefore allowing higher doses of chemotherapy to be safely delivered -Donor cells were obtained by harvesting large amounts of bone marrow tissue in OR -Now, peripheral blood stem cell transplantation uses apheresis methods to collect donor peripheral blood stem cells for reinfusion -The recipient must undergo high doses of chemotherapy and possibly total body irradiation to destroy all existing bone marrow and malignant disease, OR lower doses of chemotherapy to suppress the recipient's immune system to allow engraftment of donor bone marrow -The harvested marrow or peripheral blood stem cells are infused intravenously -The infused cells travel to the bone marrow, when the new bone marrow becomes functional, producing RBCs, WBCs, and platelets, *engraftment* occurs

Radiation Therapy Side Effects

-Toxicity of radiation therapy is *localized* to the region being irradiated -Toxicity may be increased if chemotherapy is administered -Acute local reactions occur when normal cells in the treatment area are also destroyed and cellular death exceeds cellular regeneration *Radiation Pneumonitis* -Inflammation of lungs due to radiation -SOB, chest pain, non-productive cough, fever (similar to pneumonia) -Treat with corticosteroids *Altered skin integrity* -Alopecia (hair loss) IN LOCAL AREA -Erythema -Shedding of skin (desquamation) *Alterations in oral mucosa* -Stomatitis -Xerostomia (dryness of the mouth) -Change and loss of taste -Decreased salivation -The entire GI mucosa may be involved and esophageal irritation with chest pain and dysphagia may result -Anorexia, nausea, vomiting, and diarrhea may occur with stomach or colon radiation *Alterations in cells* -If sites containing bone marrow ( the iliac crest, sternum) are included in the radiation field: -Anemia (a decrease in RBCs) -Leukopenia (decreased WBCs) -Thrombocytopenia (a decrease in platelets) *MYELOSUPPRESSION* -Increased risk for infection and bleeding -Chronic anemia may occur commonly due to the effects of radiation and may be evidenced by shortness of breath, dizziness, fatigue, decreased oxygen saturation, and decreased activity tolerance *Systemic effects* -Fatigue -Malaise/weakness -Anorexia/nausea -Effects are temporary, but may take weeks to subside following the cessation of treatment -Late effects of radiation therapy are chronic, usually produce fibrotic changes secondary to a decreased vascular supply, and are irreversible -These late effects can be most severe when they involve vital organs such as the lungs, heart, CNS, and bladder *After treatments have been completed, re-epithelialization occurs and symptoms subside*

Metastatic Brain Cancer

-Treatment is *palliative*, aims to reduce S/S -Radiation, chemotherapy, surgery -Overall prognosis is poor

Testicular Cancer Risk Factors

-Undescended testicles (cryptorchidism) -Family history of testicular cancer -Cancer of one testicle increases the risk in the other testicle -Caucasian American men

The nurse is responsible for teaching the patient who is receiving head and neck radiation how to protect his mouth. Which of the following teaching points should be included?

-Use a bland mouth rinse before and after meals and at bedtime -Avoid carbonated and caffeinated beverages -Use fluoride preparations daily

Infiltrated IV of a Vesicant (ex. chemo drug)

-Vesicants are agents that, if deposited into the subcutaneous tissue (extravasation) cause tissue ulceration and necrosis, and damage to underlying tendons, nerves, and blood vessels -Causes severe inflammatory reaction, sloughing and ulceration of the tissue may be so severe that skin grafting may be necessary -The full extent of tissue damage may take several weeks to become apparent *Indications of extravasation* -Absence of blood return from the IV catheter -Resistance to flow of IV fluid -Swelling, pain, or redness at the site (or if using a central venous access device: pain in the upper arm, upper back, chest, neck, or jaw)

The nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? A) 2 days B) 3 days C) 5 days D) A week

2 DAYS **Airway obstruction caused by upper airway edema can take as long as 48 hours to develop

A patient in the rehabilitation phase of the burn injury is setting goals with the nurse. What goals would be appropriate at this time? (Mark all that apply.) A) Increased participation in activities of daily living B) Increased understanding of the planned follow-up care C) Increased control of treatment D) Adjustment to alterations in lifestyle E) Recognition of complications

A, B, D INCREASED PARTICIPATION IN ADLs, INCREASED UNDERSTANDING OF THE PLANNED FOLLOW-UP CARE, ADJUSTMENT TO ALTERATIONS IN LIFESTYLE **The major goals for the patient include increased participation in activities of daily living; increased understanding of the injury, treatment, and planned follow-up care; adaptation and adjustment to alterations in body image, self-concept, and lifestyle; and absence of complications.

The nursing instructor is going over burn injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection. Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care?

ACUTE **The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury

The nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A) Activity intolerance B) Anxiety C) Impaired nutrition: less than body requirements D) Acute pain

ACUTE PAIN

Prioritization of Burn Care

AIRWAY BREATHING CIRCULATION

Which of the following refers to fixation of a joint?

Ankylosis

The nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment? A) 4 to 6 hours a day for 6 months B) Daily for 2 to 3 months after the injury C) Continuously D) At night while sleeping for a year after the injury

CONTINUOUSLY

The nurse should teach the patient who is being radiated about protecting his skin and oral mucosa. An important teaching point would be to tell the patient to:

Cleanse the skin with a mild soap, using his fingertips, not a rough wash cloth

Which of the following would be consistent with the diagnosis of rheumatoid arthritis?

Cloudy synovial fluid

An emergency department nurse has just received a burn victim brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patient's body. The nurse knows that pathophysiologic changes resulting from major burns during the initial burn-shock period include what? A) Hyper-dynamic anabolism B) Hyper-metabolic catabolism C) Decreased cardiac output D) Organ hyper-function

DECREASED CARDIAC OUTPUT

The acute phase of the burn begins 48 to 72 hours after the burn. What begins at this time? A) Cardiac output decreases B) Renal failure begins C) Diuresis D) Fluid moves from intravascular compartment to interstitial spaces

DIURESIS

A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? A) Early enteral feeding B) Administration of prophylactic antibiotics C) Bowel cleansing procedures D) Administration of stool softeners

EARLY ENTERAL FEEDING **If the intestinal mucosa receives some type of protection against permeability change, infection could be avoided -Early enteral feeding is one step to help avoid this increased intestinal permeability and prevent early endotoxin translocation

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. What would be the nurse's priority concern about this patient? A) Fluid status B) Risk of infection C) Body image D) Level of pain

FLUID STATUS **During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin -Infection, body image, and pain are significant areas of concern, but are less urgent than fluid status

Which grade of tumor is also known as a well-differentiated tumor?

Grade I -Grade I tumors, also known as well-differentiated tumors, closely resemble the tissue of origin in structure and function. In grade II, the tumor is moderately differentiated. Tumors in grade III are poorly differentiated (little resemblance to tissue of origin). Grade IV tumors is undifferentiated (unable to tell tissue of origin).

A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what?

HYPERKALEMIA, HYPONATREMIA, ELEVATED HEMATOCRIT AND METABOLIC ACIDOSIS

The triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? A) Cover the burn with ice and secure with a towel. B) Apply butter to the area that is burned. C) Immerse the child in a cool bath. D) Avoid touching the burned area and seek medical attention.

IMMERSE THE CHILD IN A COOL BATH

The human body is an amazing mechanism with multiple compensatory mechanisms and built-in protection against invasion. One of these systems is the immune system which is a major factor in the prevention or development of cancer. Which of the following is a weapon is the immune system "arsenal"?

Immune suppression -If the immune system fails to recognize malignant cells or is not stimulated in any way to fight cancer cells, tumor growth is not inhibited. Malignant cells survive and proliferate.

Most Common Pain Medication for Burns

Morphine sulfate

What is a priority in the rehabilitation phase of the burn injury? A) Monitoring fluid and electrolyte imbalances B) Patient and family education C) Assessing wound healing D) Documenting family support

PATIENT AND FAMILY EDUCATION **Patient and family education is a priority in the acute and rehabilitation phases. There should be no fluid and electrolyte imbalances in the rehabilitation phase. Assessing wound healing is an ongoing function but it is not a priority in the rehabilitation phase. Documenting family support is not a priority in the rehabilitation phase.

Which diagnostic study is decreased in patient diagnosed with rheumatoid arthritis?

Red blood cell count -There is a decreased red blood cell count in patients diagnosed with rheumatic diseases

NEVER give paralytic without....

SEDATION

Leading cause of cancer

SMOKING

The nursing instructor is teaching about the emergent/resuscitative phase of burn injury. During this phase, what would the nursing instructor tell the students they should closely monitor in the laboratory values? A) Sodium deficit B) Bleeding time C) Potassium deficit D) Decreased hematocrit

SODIUM DEFICIT **Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include potassium excess, sodium deficit, base-bicarbonate deficit, and elevated hematocrit.

Which of the following connective tissue disorders is characterized by insoluble collagen being formed and accumulating excessively in the tissues?

Scleroderma

Which of the following clinical manifestations would the nurse expect to find in a client who has had rheumatoid arthritis for several years?

Small joint involvement

The results of a 22-year-old college student's most recent Papanicolaou (Pap) test are suggestive of cervical cancer. Since learning of this news, the patient has asked numerous questions of all members of the health care team, including the nurses at the campus medical clinic. What patient teaching should the nurse at the clinic prioritize in this patient's care?

The relationship between viruses and cervical cancer -Cervical cancer nearly always has a viral etiology

Which of the following would be consistent with a benign neoplasm?

Usually progressive and slow

What is the best way for the nurse to assess the nutritional status of a patient with cancer?

Weigh the patient daily

The nurse is to administer a vesicant chemotherapeutic drug to a client who had a right mastectomy and inserts the intravenous line...

With a soft, plastic catheter -Vesicant chemotherapy should never be administered in the peripheral veins involving the hand or wrist -A person with breast cancer is to avoid injections in the affected extremity

How to Cool a Burn

*APPLICATION OF COOL WATER IS BEST MEASURE ONCE BURN HAS BEEN SUSTAINED* -Soak burned area and adherent clothing with *cool water or apply cool towels*, to cool the wound, halt the burning process, and limit local edema and damage -*NEVER* apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns

Benign vs Malignant Neoplasms

*Benign Neoplasms* -Well-differentiated cells that resemble cells in the tissue of origin -Grows by expansion without invading the surrounding tissues; usually encapsulated -Rate of growth is usually progressive and slow; may come to a standstill or regress -Does not spread by metastasis *Malignant Neoplasms* -Cells are undifferentiated, with anaplasia (lack of differentiation) and atypical structure that often bear little resemblance to cells in the tissue of origin -Grows by invasion, sending out processes that infiltrate the surrounding tissues -Rate of growth is variable and depends on level of differentiation; the more undifferentiated the cells, the more rapid the rate of growth -Gains access to the blood and lymph channels to metastasize to other areas of the body

Palliative Care

*Both hospice and palliative care improve quality of life and comfort* -Interventions that aim to relieve suffering and improve the quality of life by reducing S/S and SE -Can begin at diagnosis, and at the same time as treatment, can be used for non-terminal patients -Palliative care is instituted when the patient with a chronic illness is not responding to the previous treatments and additional symptom management efforts are needed -Consider physical, psychological, social, and spiritual aspects

Cancer

*Cancer can be characterized by the presence of the following:* -A series of cellular and genetic changes that cause a loss of normal cell regulation; this is the hallmark of malignancy -Abnormal cell proliferation or growth -Unchecked local growth and invasion of surrounding tissue -The ability to metastasize to distant organs -The primary difference between malignant (cancerous) and benign cells is that malignant cells have abnormal regulation of growth -Cancer cells demonstrate uncontrolled cell growth that follows no physiologic demand

Burn Inhalation Injury

-Inhalation injury below the glottis results from inhaling noxious gases -The injury results directly from chemical irritation of the pulmonary tissues at the alveolar level, causes loss of ciliary action, hypersecretion, severe edema, and possibly bronchospasm -The pulmonary surfactant is reduced, resulting in atelectasis (collapse of alveoli) -*Expectoration of carbon particles in the sputum is the cardinal sign of this injury* -The patient is at risk of acute respiratory failure and acute respiratory distress syndrome (ARDS) *Carbon monoxide is the most common cause of inhalation injury* because it is present in smoke

A nurse on the burn unit is caring for a patient who has gone into the acute phase of her burn. What would be important for the nurse to monitor the patient for? A) Hypometabolism B) Hyponatremia C) Hyperkalemia D) Hypoglycemia

HYPONATREMIA Hyponatremia is common during the first week of the acute phase, as water shifts from the interstitial space to the vascular space. *Hypermetabolism* can occur up to 1 year after the burn. Hyperkalemia occurs in the emergent phase of the burn. In a burn patient there is a *hyperglycemic* response, not a hypoglycemic response.

A patient is brought to the Emergency Department from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When you assess the patient he verbalizes no pain in the right arm and the skin appears charred. Based upon these assessment findings, what is the depth of the burn on the patient's right arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness

FULL THICKNESS BURN -Full partial thickness is not a depth of burn