Level II, Exam II

Review and apply etiological factors and physiology of cancers arising from various cell and tissue types. Extrinsic/Environmental Factors

(80%, within our control) Chemical -Cigarette smoke (has 20 carcinogens) Physical -Exposure to sunlight or radiation -Chronic irritation/inflammation Virus: HPV (cervical), HIV (decreased immune), Hep B, Epstein Barre Dietary -High calorie diet/obesity increases risk of cancer -Fats, alcohol, salt-cured or smoked meats, nitrate containing foods, and red or processed meat increase cancer risk

Review and apply etiological factors and physiology of cancers arising from various cell and tissue types Intrinsic Factors

(Internal, immutable factors) Immune system: body doesn't recognize the tumor, immune response isn't stimulated -Tumors may alter their appearance or produce susbstances to impair the typical immune response Age Cellular alterations: genetic predisposition due to an abnormal chromosomal pattern that represents a susceptibility to cancer and is hereditary Hormonal Imbalances: may be due to the body's own hormone production, or to the administration of exogenous hormones

Apply knowledge of anaomy, physiology, pathophysiology, nutrition, and developmental variations when helping to plan care for adults and older adults who have an alterationi n mobility.

ANATOMY -Bones: classisfied by shape and structure --Contain red and yellow marrow; highly vascular tissue --Accounts for 99% of calcium and 90% of phosphorous in the body --Reaches its maturity/maximum growth after puberty -Joint: a space in whcih two or more bones come together --Synarthroidial: completely immovable (i.e., skull) --Amphiarthrodial: slightly movable (i.e., pelvis) --Diarthrodial/synovial: freely movable (i.e., elbow or knee) Physiology -Function of the musculoskeletal system --Protection of vital organs (i.e., heart and lungs) --Mobility and movement: provides a framework for the body: assists in movement through muscle attachment and joint formation --Production of blood cells (hematopoiesis): occurs in red bone marrow --Reservoir for vital minerals (i.e., calcium and phosphorous) NUTRTION CONSIDERATIONS -Low calorie/high protein diet -Minerals affecting bone growth development --Calcium, phosphorous, calcitonin, vitamin D -Hormones affecting bone growth/development: --Parathyroid hormone (PTH), growth hormone --Glucocorticoids, thyroxine, insulin --Estrogens and androgens DEVELPOMENTAL VARIATIONS RELATED TO AGING -Decreased bone density: bone is in a continuous process of formation and resorption at equal rates until 35 years; then, resorption begins to increase (especially in women) --Teach safety tips to prevent falls --Reinforce need to exercise (especially weight bearing) --Patient may move slower, do not rush them. -Increased bone prominence --Prevent pressure on prominences to reduce skin breakdown -Kyphotic posture: widened gait, shift in center of gravity --Teachproper upper body mechanics --Instruct paitent to sit in supportive chair with arms -Cartilage degeneration --Provide moist heat (i.e., shower; warm moist compresses); this increases blood flow to the area -Decreased ROM: patient may need assistance with self care skills -Muscle atrophy: decreased muscle strength --Teach isometric exercises to increase muscle strength

Discuss the correct use and functioning of therapeutic devices that support mobility.

ASSESSMENT -Goniometer: Used by rehabilitation therapists or RNs to provide an exact measurement of flexion/extension or joint ROM IMAGING -Standard X-Ray: most common; shows bone density, alignment, swelling, intactness; joint condition (size of space, smoothness of cartilage, swelling) may also be assessed -Tomography: Produces places/slices for focus and blurs images of other structures -Xeroradiography: highlights contrast between structure; "edge enhancement" Disadvantages: higher levels of radiation, inability to determine tissue densities -Myelography: contrast medium is injected into subarachnoid space of spine; allows visualization of column, intervertebral disks, spinal nerve roots, blood vessels; uncommon, replaced by CT and MRI -Arthrogram: visualization of a joint after contrast medium (air or solution) is injected -MRI and CT: MRI is most appropriate for joints, soft tissue, bony tumors involving soft tissue; CT is the test of choice for injuries/oathology involving only bone -Ultrasonography: used to view soft-tissue disorders (masses, fluid accumulation), traumatic joint injuries, osteomyelitis, surgical hardware placement NUCLEAR IMAGING SCANS -Bone Scan: radionuclide test in which radioactive material is injected for viewing entire skeleton; primarily used to detect tumors, arthritis, osteomyelitis, osteoporosis, vertebral compression factors, unexplained bone pain (especially related to hairline fractures) -Gallium and Thallium Scans- similar to bone scan but more specific/sensitive in detecting bone problems; thallium preferred for osteosarcoma OTHER DIAGNOSTIC TESTS -Biopsy: may be bone or muscle; needle or open -Electromyography: evaluates diffuse or localized muscle weakness and aids diagnosis of neuromuscular and nerve disorders, multiple small needle electrodes inserted and patient performs activities to measure muscle potential; nerve/muscle activity is recorded for later interpretation. *Contraindicated with patients in anticoagulant therapy; skeletal muscle relaxants discontinued several days prior -Arthroscopy: arthroscope is inserted intoa joint for direct visualization (common for knee. shoulder) DEVICES TO AID WITH ADLs -Shower chair or handheld shower; long handled bathing sponge -Reacher, grabber, or dressing stick -Safety bars IMMOBILIZATION DEVICES -Bandage, splint; used to keep bone in place during healing; removable -Cast: a rigid device that immobilizes the affected body part; used for more complex fractures ---Arm cast: elevate arm above the heart to reduce swelling; ice may be prescribed for first 24-48 hours. Arm is supported with sling for first few days ---Leg cast: allows mobility but requires use of mobility aid (i.e., crutches); leg should be elevated on pillows to reduce swelling; apply ice for first 24 hours ------Leg cylinder exposes the ankle/foot; walking cast has a walking device on the bottom to protect the cast ---Cast brace: weight bearing or knee high cast ---Body cast: not commonly used for adults ---Spica cast: encases a portion of trunk and one or two extremities; monitor for complications such as skin breakdown, respiratory dysfunction, constipation, joint contractures -Traction: application of a pulling force to a part of the body to provide reduction (realignment of bones); maintain alignment, and provide rest; may be continuous or intermittent ---Running traction: pulling force in one direction; patient's body acts as countertraction ---Balanced suspension: provides countertraction so that pulling force of traction is not altered when bed or patient is moved (allows for increased movement) ---Skin traction: uses a velcro boot, belt, or halter secured around affected leg; primary purpose is to decrease painful muscle spasms w/hip fractures, and weight is limited to 5-10 lbs ---Skeletal traction: pins, wires, tongs, or screws are surgically inserted into bone: allows for longer traction time with heavier weights (15-30 lbs); aids in bone realignment ---Inspect all ropes, knots, and pulleys at least every 8-12 hours; check weights for consistency

Apply knowledge of anatomy, physiology, pathophysiology, nutrition, and developmental variations when helping to plan care for adults and older adults who have an alteration in cognition and sensation. Nutritional Concerns

Dysphagia diets -Pureed -Ground -Soft -Modified general diets Nutritional supplements and tube feedings

Identify priority actions for adults and older adults who have an alteration in mobility.

Assess fall risk and implement precautions Treat for pain

Perform a focused assessment that should be included when collecting data on adults and older adults who have an alteration in cognition and sensation (Conciousness, Speech, and Motor Function, Strength, Reflex, Glasgow Scale). Current Health Problems

Assess signs/symptoms (location duration, onset, characteristics, and frequency) Exacerbation, progression, remission

Perform a focused assessment that should be included when collecting data on adults and older adults who have an alteration in cognition and sensation (Conciousness, Speech, and Motor Function, Strength, Reflex, Glasgow Scale). Motor Function

Assessment should focus on voluntary arm and leg movements; note involuntary movements and "posturing" Muscle strength and tone -Squeezing (check for symmetry) -Lift arms with eyes closed (drop is muscle weakness); ROM against gravity -Push against you (lifting up) with hands or feet; ROM against resistance Reflex activity and involuntary movement -Deep tendon reflexes (DTRs): biceps, triceps, brachioradialis, quads, Achilles tendon; striking tendon with reflex hammer should cause contraction of muscle -Superficial (cutaneous) reflexes: plantar (toes), abdominal -Pathologic reflexes: not normal ---Babinski response: dorsiflexion of the big toe with fanning of other toes; indicates upper motor neuron disease (normal in infants) Abnormal motor responses: -Flexion (decorticate posturing): indicates damage to cerebral cortex -Extension (decerebrate posturing): indicates damage to brainstem midbrain, or pons -Flaccidity (worse than posturing): indicates severe damage

Review the basic principles to help determine the patient's knowledge of chemotherapy, immunotherapy, hormonal, and radiation therapy. Immunotherapy

BRMS (biologic response modifiers); supportive cancer therapy meant to stimulate the immune system to help fight the cancer Particularly effective for melanomas, leukemia, kidney, breast, and lung cancers and lymphomas Types of BRMS -Cytokines: enhance immune system response ---Interleukins: increase immune system; increase attack on cancer cells ---Monoclonal antibodies: bind to protein produced by cancer cells; prevent division of cancer cells while promoting death by immune system cells ---Interferons -Gene therapy (alteration): inserting genes into cells to render them more susceptible to damage/death Side effects of BRMS -Fever, chills, flu-like symptoms -General malaise, inflammatory reactions

Recognize alterations in pulse oximetry and other laboratory values related to alterations in mobility (CBC, Chemistry Panel, Coagulation Studies) Test: Chemistry Panel or Comprehensive Metabolic Panel (CMP) (Info related to bone/musculoskeletal specifc values)

CALCIUM: 9.0-10.5 mg/dL -High calcium significance: bone cancer, Piaget's disease, healing bone fracture -Low calcium significance: osteoporosis, osteomalacia; decreased in older adults PHOSPHOROUS: 3.0-4.5 mg/dL -High phosphorous significance: bone tumor, acromegaly, healing bone fracture -Low phosphorous significance: osteomalacia; decreased in older adults ALKALINE PHOSPHATASE: 30-120 units/L -High ALP: metastatic bone cancer, Piaget's disease, osteomalacia; slightly increased in older adults CREATININE KINASE: 55-170 (M) 30-135 (F) -High Ck: muscle trauma, muscular dystrophy, effect of electromyography LACTIC ACID DEHYDROGENASE: 100-190 units/L -High LDH: skeletal muscle necrosis, extensive cancer, muscular dystrophy ALDOLASE: 3.0-8.2 units/dL -High ALD: polymyositis, dermamyositis; muscular dystrophy ASPARTATE AMINOTRANSFERASE: 0-35 units/L -High AST: skeletal muscle trauma, muscular dystrophy, increased in older adults

Compare and contrast various grading and staging systems. Types of malignant tumors

Carcinoma: tumor of glandular tissue Sarcoma: tumor of connective tissue Blastoma: tumor of less differentiated, embryonal tissue Lymphoma: cancer of lymphoid tissue Glioma: tumo of the brain

Huntington's Disease

Description -A chronic, progressive, hereditary disease; it is fatal Pathophysiology -Transmitted as an autosomal dominant trait; involves the destruction of neurons in cerebral cortex; also associated with high levels of dopamine Signs and Symptoms -Choreiform (rapid, jerky) movements in limbs, trunk, facial muscles -Dementia Treatment/Nursing Implications -Palliative care (no cure) -Patient usually dies from pneumonia, HF, or other immobility complication

Parkinson's Disease

Description -A progressive neurogenerative disease affecting motor ability Pathophysiology -Associated with decreased levels of dopamine due to destruction of cells in the substantia nigra in the basal ganglia; also, increase in acetylcholine Signs and Symptoms -Tremors, rigidity -Bradykinesia/akinesia -Postural instability -Depression, psychiatric changes, dementia -Autonomic symptoms -Sleep disturbances Treatment/Nursing Implications -Fall risk assessment -Pharmacologic treatment (dopamine agonists or anticholinergic agents -Surgical procedures -Occupational therapy

Cholinergic Crisis

Caused by overmedication with cholinesterase inhibitors Severe muscle weakness with respiratory and bulbar weakness Patient may develop respiratory compromise and failure Atropine on standby

Apply knowledge of anatomy, physiology, pathophysiology, nutrition, and developmental variations when helping to plan care for adults and older adults who have an alteration in cognition and sensation. Anatomy of Neurological System

Central Nervous System consists of brain and spinal cord The brain is divided into three parts: cerebrum, brain stem, cerebellu -Cerebrum ---Frontal lobe: largest lobe, in the front of the skull; thought processes, concentration, word meaning, emotions, judgement; important for speech, personality, and inhibitions ---Parietal lobe: near the crown of the head; analyzes and interprets sensory formation (touch/taste), body awareness, awareness of space, size, shape, and L/R orientation ---Temporal lobe: located around the temples; contains auditory receptive areas /memory of sound; plays the most dominant of any area in thinking; auto-regulation; recognize faces, long term memory ---Occipital lobe: located at the lower back of the head; sight ---Limbic lobe: in the brain; controls emotions ---Basal ganglia: responsible for control of fine motor movements ---Thalamus: relay station for smell, memory, sensation, and pain impulses ---Hypothalmus: plays a role in the emotional response to odor and the endocrine system; also the site of the hunger center and is involved with appetite control; regulates sleep, BP, emotional responses, and the ANS -Cerebellum: fine motor skills; balance, coordination -Brain Stem: regulates CNS, sleep cycle, and basic functions ---Midbrain: center for auditory and visual reflexes; CN 3 and 4 ---Pons: motor and sensory pathways; helps regulate respiration; CN 5-8 ---Medulla: reflex centers for respiration, BP, heart rate, coughing, vomiting, swallowing, sneezing, and sleep/wake cycles The spinal column is divided into five sections -Cervical vertebrae:: top section; C1-C7 -Thoracic vertebrae: middle section; T1-T12 -Lumbar vertebrae: lower section; L1-L5 -Sacrum: lower; 5-fused -Coccyx: very bottom; 4-fused The peripheral nervous system encompasses the automatic nervous system, cranial nerves, and spinal nerves -Autonomic nerves go from your spinal cord to your lungs, heart, stomach, intestines, bladder, and sex organs -Central nerves: located in your brain and spinal cord -Cranial nerves: go from your brain to your eyes, mouth, ears, and other parts of your head -Peripheral nerves: go from your spinal cord to arms, hands, legs, and feet -Autonomic nervous system encompasses the sympathetic and parasympathetic nervous system; regulates activities of internal organs (heart, lungs) and restores internal homeostasis ---Sympathetic: fight or flight response; main neurotransmitter is norepinephrine ---Parasympathetic: calm; dominant controller for visceral function; regulated by centers in teh spinal cord, brain stem, and hypothalmus The neurological system is protected by: -Skull: protects the brain -Meninges: cover the brain and spinal; three layers ---Dura Mater: double layer; thick, fibrous, means "tough mother" ---Arachnoid membrane: delicate, very thin layer (gossamer network); cobwebbed appearance, contains blood vessels ---Pia Mater: innermost layer that covers entire surface of the brain, especially gray matter; mesh like, very vascular, rich in blood supply -Cerebrospinal Fluid (CSF): acts as a shock absorber; liquid cushion to protect the brain and spine ---Clear, colorless, and odorless ---Composed of H2O, O2, CO2, glucose, and protein ---CSF is produced at approximately 20cc/hr (500cc/hr) -Blood brain barrier protects brain from certain bacteria, which cannot cross

Multiple Sclerosis

Description -A progressive immune-related demyelination disease of the CNS -4 types ---Relapsing-remitting ---Primary progressive ---Secondary progressive ---Progressive-relapse Pathophysiology -Characterized by an inflammatory response that results in random areas of plaque in the white matter of the CNS, damagin the myelin sheath. Impulses between the brain/spinal cord and the body are not effectively transmitted and eventually may not be transmitted at all. Signs and Symptoms -Fatigue, weakness -Numbness -Difficulty in coordination -Loss of balance -Visual disturbances -Disease may relapse and remit with exacerbated symptoms Treatment/Nursing Implications -Disease modifying therapies include interferon B-1a and interferon B-1b, glatiramer acetate, and IV methylprednisolone -Symptom management -Voiding schedule, bowel training program, adequate fluid/fiber to prevent constipation -Strategies to reduce risk of aspiration (swallowing exercises/instructions) -Memory aids, structured environment, daily routine -Activity and daily exercise program with relaxation, coordination, walking, and muscle stretching exercises -Avoid strenuous activity and extreme fatigue

Types of head trauma with bleeding

Contusion -Localized and macroscopic; longer period of unconsiousness (more than a few seconds/minutes) = more symptoms of neuro deficits and VS changes; symptoms depend on amount of damage/cerebral edema; scalp is bruised Concussion -Widespread and microscopic; more severe; look for difficulty awakening, dizziness, confusion/irritability/anxiety, severe headache/vomiting; arouse and assess patient frequently and report changes in LOC Abrasion -Affects the top layer of the scalp; minor injury Laceration -Scalp is torn, bleeding, and may need suturing Subgaleal Hematoma -Hemorrhage in the subgaleal compartment (the inner surface of the scalp); if infection starts here, it could affect the brain

Tension Headache

Description -A chronic and less severe headache; probably the most common Pathophysiology -May be caused by physical o emotional stress causing contraction of the muscles in the neck and scalp Signs and Symptoms -Feels like a weight on top of your head or squeezing -Steady, constant pressure that usually begins in the foreead, temple, or back of neck Treatment/Nursing Implications -Individualized care and treatment

Cluster Headache

Description -A severe form of vascular headache; come in clusters of 1-8 daily; lasts 15 minutes to 3 hours Pathophysiology -The exact cause is not fully understood; however, it effects men 5x more often than women -May be caused by dilation of orbital and nearby extracranial arteries Signs and Symptoms -Pain is usually in and around one eye, radiates to facial region -Watery eyes, nasal congestion Treatment/Nursing Implications -Symptomatic medications ASAP

Migraine

Description -A symptom complex characterized by periodic and recurrent attacks of a severe headache that lasts from 4-72 hours Pathophysiology -The exact cause is not clearly known; however, it appears to be hereditary and effects primarily women -May be triggered by menstrual cycles, bright lights, stress, depression, sleep deprivation, and fatigue Signs and Symptoms -Pain, nausea -Visual changes -Photophobia Treatment/Nursing Implications -Prophylactic medications -Symptomatic medications ASAP -Sleep for an extended time after the headache

Seizure

Description -Abnormal episodes of motor, sensory, autonomic, or psychic activity (or combination) -Partial seizures: begin in one part of the brain (simple partial, conciousness remain intact; complex partial, impaired conciousness) -Generalized seizures: involve the whole brain -3 stages: aura, ictus, postictal Pathophysiology -Caused by sudden, abnormal, uncontrolled electrical discharge from cerebral neurons -Could be caused by cerebrovascular disease, hypoxia, fever, head injury, hypertension, CNS infections, brain tumor, drug/alcohol withdrawal, allergies -May also be caused by metabolic/toxic conditions: renal failure, hyponatremia, hypocalcemia, hypoglycemia Signs and Symptoms -Tonic-Clonic ---Lasts 2-5 minutes; muscle rigidity; loss of LOC; jerking -Tonic ---Increase in muscle tone; lasts 30 seconds to a few minutes -Clonic ---Rhythmic jerking -Absence (Petit Mal) ---Common in children, genetic, blank staring -Atonic ---Sudden loss of muscle tone, confusion -Myoclonic ---Brief jerking/stiffening of extremities, lasts a few seconds -Unclassified ---Incomplete date Treatment/Nursing Implications -ALWAYS RESCUE, THEN REPORT -Diagnose with CT scan, EEG (to classify seizure) -Turn patient on their side -O2 and suction available -Provide privacy ASAP -Loosen clothing -Side rails up and padded -Bed in lowest position -One pillow under head -After seizure, prevent complications -Antiseizure medications (diazepam, lorazepam) -Observe and record the sequence of signs

Amyotrophic Lateral Sclerosis (ALS; Lou Gehrig's Disease)

Description -Adult-onset upper and lower motor neuron disease Signs and Symptoms -Caused by a loss of motor neurons in the anterior horn of the spinal cord and loss of motor nuclei in the brain stem -Contributing factors may be genetic, viral, or environmental Signs and Symptoms -Progressive weakness and atrophy of the muscles of the trunk extremity -Weakness of bulbar muscles -Impaired swallowing/talking -Impaired respiratory function -Locked in syndrome; brain is still fully functional Treatment/Nursing Implications -Be aware of educational issues and family support -One medication: Riluzole; it is not a cure but does extend survival time -Palliative care

Sinus Headache

Description -An acute headache related to sinus pressure Pathophysiology -Caused by sinusitis, allergies, an upper respiratory infection, or anything that causes sinus pressure Signs and Symptoms -Pain is usually behind the forehead and/or cheekbones Treatment/Nursing Implications -Mucolytics, nasal decongestants -Steami nhalations

Infectious and Inflammatory Disorders Alteration: Osteomyelitis

Description -An infection in bony tissue Pathophysiology -Caused by bacteria, viruses, or fungi; causes bone ischemia and bone becomes necrotic Signs and Symptoms -Bone pain (constant, localized, pulsating; worses with movement) -Fever >101 -Edema, erythema, heat -Elevated WBCs -May result in chronic infection, immobility, amputation, or death -Chronic: --Ulceration of skin --Sinus tract formation --Drainage from infected area --Localized pain Treatment/Nursing Implications -ASAP antimicrobial therapy; usually IV for several weeks -Contact precautions initiated with wound drainage -Chronic: --May require >3 months of antimicrobial therapy --Oral drug therapy may follow for weeks/months --Wound irrigation --Hyperbaric therapy may be utilized to promote wound healing

Myasthenia Gravis

Description -Autoimmune disorder affecting the myoneural junction; it is a motor disorder- no effect on sensation/coordination Pathophysiology -Caused when antibodies directed at acetylcholine at the myoneural junction impair the transmission of impulses Signs and Symptoms -Generalized voluntary muscle weakness which increases with activity -Initial symptoms involve ocular muscles (diplopia, ptosis) -Weakness of facial muscles -Impaired swallowing -Voice impairment (dysphonia) -Disease process moves from the top down Treatment/Nursing Implications -Tensilon test (atropine on hand) -Anticholinesterase (pyrostigmine bromine) side effects are vast -Immunomodulating therapy (steroids, IV immune globulin; increased infection risk) -Plasma exchange -Thymectomy (takes up to 3 years to see full benefit) -If patient is in crisis ---Educate re: signs/symptoms ---Ensure adequate ventilation, airway, and respiratory support ---Monitor ABGs, serum electrolytes, I&O, daily weight ---NG tube if swallowing impaired ---Avoid sedatives, tranquilizers

Guillian Barre Syndrome

Description -Autoimmune disorder with acute attack of peripheral nerve myelin Pathophysiology -Usually follows a viral infection Signs and Symptoms -Weakness, paralysis, parasthesias, pain -Diminished or absent reflexes (starts with lower extremities, works up) -Bulbar weakness -Cranial nerve symptoms -Tachycardia, bradycardia -Hyper or hypotension -Complications may include ---Respiratory failure ---ANS dysfunction ---DVT, pulmonary embolism ---Urinary retention Treatment/Nursing Implications -Requires immediate hospitalization -Intensive care management with continuous monitoring and repiratory support -Plasmapheresis and IVIG are used to reduce circulating antibodies -Most patients fully recover

Pituitary Adenomas

Description -Benign; cause symptoms as a result of pressure on adjacent structures and hormonal changes Pathophysiology -Occurs in anterior lobe Signs and Symptoms -Visual disturbances, visual field defects -Loss of body hair -Diabetes insipidus -Infertility -Headaches Treatment/Nursing Implications -General treatment

Angiomas

Description -Benign; masses of abnormal blood or lymph vessels Pathophysiology -Most are congenital Signs and Symptoms -Risk of cerebral hemorrhage Treatment/Nursing Implications -General treatment -Some may disappear spontaneously

Epilepsy

Description -Group of syndromes characterized by unprovoked, recurring seizures Pathophsiology -Unknown cause, but often occurs in childhood Signs and Symptoms -Unprovoked, recurring seizures -May or may not lose conciousness Treatment/Nursing Implications -Antiseizure medications -Goal of treatment; stop the seizure

Degenerative Musculoskeletal Disorders Alteration: Joint Replacement

Description -Knee and hip are most common; finger, wrist, elbow, shoulder, toe, and ankle replacements are also performed Pathophysiology -Used most often to manage OA pain and improve mobility -Other contributing factors include rheumatoid arthritis, trauma, and osteonecrosis Signs and Symptoms -May be sore, edemous Treatment/Nursing Implications -Active infection is an immediate disqualifier; advanced osteoporosis may also be a contraindication -Obtain assistive/adaptive equipment to use post-surgery -Monitor for joint dislocation and venous thromboembolism (promote early ambulation) -Anticoagulants may be given

Brain Tumor

Description -Localized intracranial lesion that occupies space within the skull; may be benign or malignant; classified based on location/characteristics Pathophysiology -Primary brain tumors originate from cells and structures within the brain -Secondary brain tumors originate from structures outside the brain -May be intracerebral, arising from supportive structures, developmental metastatic lesions Signs and Symptoms -Localized or generalized neurologic symptoms -Symptoms of increased ICP -Headache -Vomiting -Visual disturbances Treatment/Nursing Implications -Depends on type, location, rate of growth, and accessibility of the tumor -Radiation, chemotherapy -Surgery

Degenerative Disc Disease

Description -Lower back pain with a duration of 3 months or longer Pathophysiology -Herniation of a disk = ruptured disk Signs/Symptoms -Pain/numbness Treatment/Nursing Implications -MRI is diagnostic tool of choice -Bed rest, brace -Meds (neuropathic, pain, muscle) -Surgery (fusion) considered when sciatic pain is unresponsive to conservative management -Goal: reduce pressure on nerve root and reverse neurological deficits -Lumbar (L4-5 or L5-S1) ---Check motor, temp, color, pulse, strength of lower extremities ---Logroll patient to check bandage -Cervical (C5-6 or C6-7) ---Hot moist compresses several times per day to increase blood flow ---Meds (NSAIDS, muscle relaxants, corticosteroids) ---Watch for breathing

Spinal Cord Tumor

Description -May be primary or secondary; occur most often in thoracic area; may occur in lumbar/cervical Pathophysiology -Tumors involving the bones of the vertebral column are usually the result of metastasis Signs and Symptoms -Related to compression of the spinal cord -Patient usually has surprisingly few symptoms -Most common is pain -Mobility problems -Decreased muscle tone -Positive Babinski's reflex Treatment/Nursing Implications -Carefully monitor vital signs and neuro status (every 4 hours) -Primary treatment is surgery -If surgery is not possible, radiation therapy is used -Chemotherapy is rarely used

Degenerative Musculoskeletal Disorders Alteration: Osteoarthritis

Description -Most common arthritis; major form of disability among adults Pathophysiology -Progressive deterioration and loss of cartilage in one or more joints, primarily due to aging but may also result from joint trauma Signs and Symptoms -Chronic joint pain/stiffness -Bone hypertrophy (anlarged joint) -Edema (joint effusions; excess joint fluid) -Crepitus (grating sound) Treatment/Nursing Implications -Routine x-ras may be used for diagnosis -Acetaminophen is the drug of choice, followed by NSAIDs -Cortisone injections (q 3 months) -Rest with joint in their optimal position -Heat or cold for pain relief -Acupuncture, glucosamine, chondroitin -Joint replacement

Meningiomas

Description -Most common type of benign tumor Pathophysiology -Arise from the meninges; occurs most often in middle aged females Signs and Symptoms -General symptoms -Causes compression/displacement of nearby tissue Treatment/Nursing Implications -Surgery and partial dissection -Tumor tends to recur

Gliomas

Description -Most common type of brain tumor; composed of malignant glal cells Pathophysiology -SPreads by infiltrating the surrounding connective tissue Signs and Symptoms -General symptoms Treatment/Nursing Implications -Cannot be totally removed without causing considerable damage

Metastatic Tumors

Description -Secondary tumors Pathophysiology -Cancer cells from the lungs, breast, colon, pancreas, and kidney can travel to the brain via blood/lymphatic system Signs and Symptoms -General symptoms Treatment/Nursing Implications -Multiple metastatic lesions are common

Acoustic Neuromas

Description -Tumor on the 8th cranial nerve (responsible for hearing/balance) Pathophysiology -Grows slowly; twice as likely to occur in women as in men Signs and Symptoms -Loss of hearing -Tinnitus -Vertigo -Staggering gait Treatment/Nursing Implications -Can be surgically removed; good prognosis, but removal may cause permanent cranial nerve dysfunction

Trauma Related Disorders Alteration: Fracture

Description: -A break or disruption in the continuity of the bone that often affects mobility and sensation -May be complete (two distinct sections) or incomplete; open/compound (skin is broken) or closed/simple Pathophysiology -Pathologic/spontaneous fracture: caused by minimal trauma to a bone weakened by disease -Fatigue/stress fracture: caused by excessive strain/stress on the bone -Compression fracture: caused by a loading force applied to the long axis of a cancellous bone; common in vertebrae of older adults Signs and Symptoms: -Severe pain -Ecchymosis -Complications: --Hypovolemic shock --Fat embolism syndrome (when yellow marrow enters bloodstream) --Venous thromboembolism --Infection --Ischemic necrosis Treatment/Nursing Implications -Diagnosed witha standard x-ray or CT scan -May require reduction (realignment of bone ends) -Immobilization with bandage, splint, cast, or traction -Drug therapy for pain, muscle spasms -Physical therapy

Degenerative Musculoskeletal Disorders Alteration: Osteoporosis

Description: -Chronic metabolic disease resulting in decreased bone density -Osteomalacia is similar but is the result of vitamin D deficiency Pathophysiology -Decreased bone density is caused by one loss, most commonly due to the body's natural aging process; most common in postmenopausal women -Secondary osteoporosis may be related to various disease processes including DM, cirrhosis, AIDS, and chronic airway limitation Signs and Symptoms -Dowager's hump -Potential for fractures related to weak, porous bone tissue Treatment/Nursing Implications -Prevention; build strong bones prior to age 30 --Increase calcium intake --Limit carbonated beverages --Increase exercise, especially weight bearing exercises; avoiding jarring exercises -Management --Increase calcium, vitamin D, protein, magnesium, and vitamin K intake -Avoid excessive alcohol, caffeine -Increase exercise -Drug therapy options include supplements, hormore therapy (SERMs), bisphophonates

Ischemia Related Disorders Alteration: Amputation

Description: -The removal of part of the body Pathophysiology -Amputations may be elective (due to tissue ischemia related to impaired circulation) or traumatic (the result of an accident) Signs and Symptoms -Complications include: --Hemorrhage --Infection --Phantom limb pain --Neuroma (sensitive tumor consisting of damaged nerve cells) --Flexion contractures Treatment/Nursing Implications -Pay attention to psychological needs of patients -Monitor to ensure that there is sufficient tissue perfusion but no hemorrhage -Use a firm mattress to prevent contractures with leg amputation -Use of the word "stump" is controversial, and HCPs have differing opinions about it -Traumatic Amputation: --Elevate extremity above the patient's heart --Do not remove semi-detached body parts

Explore the nursing challenges when assisting clients and their families as they deal with end of life issues. Client Rights

Desired outcomes for end-of-life care include having the patient's needs and preferences met, control of symptoms of distress, meaningful interactions with family, a peaceful death Advance directive written to provide guidance (especially to health care professionals) regarding how to make decisions regardind life-sustaining treatment when one loses his or her decision-making ability -Patient must be able to perform three tasks ---Receive information (but not necessarily oriented x4) ---Evaluate, deliberate, and mentally manipulate information ---Communicate a treatment preference -Two types of advance directives ---Instructional directive (living will, DNR) ---Durable power of attorney for health care: legal document in which a person appoints someone else to make their decisions in case they lose decision-making capacity Patient Self Determination Act of 1990 requires all patients admitted to health care agencies to be asked if they have written advance directives

Discuss the correct use and functioning of therapeutic devices that support cognition and sensation.

Difficulty with speech -Communication boards: used for patients with expressive aphasia Difficulty with ambulation/muscular tone -Walkers and lifts may be used to aid ambulation -Braces may be used to aid posturing/positioning

Compare and contrast medications and IV therapies commonly given for nausea and vomiting secondary to chemotherapy (actions/outcomes).

Drug therapy for CINV (chemotherapy induced nausea/vomiting) is most effective when given before N/V is out of control and on an aggressive, scheduled basis -Patient should continue therapy, even when CINV appears controlled -If patient does stop taking the drug, they should retake it at the first sign of nausea Nursing priority is to coordinate with the patient and HCP to ensure adequate control of CINV Alternative/complementary approaches to controlling CINV may include: -Music, guided imagery, distraction -Progressive muscle relaxation, accupressure -Drinking concord grape juice before meals

General Headache Information

During assessment, detailed description of headache should be obtained Include medication and history use The types of headaches manifest differently in different persons, and symptoms in one individual may also change over time Most headaches do not indicate serious disease, but most persistent headaches require investigation Teaching -Help patient identify triggers and develop preventative strategies and lifestyle changes -Provide medication instruction and treatment regimen -Implement stress reduction and treatment regimen -Implement stress reduction techniques and nonpharmacologic therapies -Provide follow up care

Compare and contrast medications and IV therapies commonly given for nausea and vomiting secondary to chemotherapy (actions/outcomes). Medication: Neurokinin Antagonists

Example -Aprepitant Uses/Actions -Prevents/treats CINV -When used together with a serotonin antagonist and corticosteroid, both acute and delayed N/V are controlled Side Effects -Interferes with warfarin -Reduces effectiveness of oral contraceptives Nursing Implications -If patient is on warfarin, INRs should be checked before and after the 3 day therapy

Compare and contrast medications and IV therapies commonly given for nausea and vomiting secondary to chemotherapy (actions/outcomes). Medication: Corticosteroids

Example -Dexamethasone Uses/Actions -Reduces CINV -Decreases swelling in the brain's chemotrigger zone Side Effects -Increased drowsiness Nursing Implications -Teach patient to reduce salt intake to ~4g/daily

Apply knowledge of the actions, potential side effects, and nursing implications when administering medications to adults and older adults who have an alteration in cognition and sensation. Medication: Sedatives

Example -Diazepam Uses/Actions -Used to treat muscle spasms -Depresses the CNS Side Effects -Nasuea, drowsiness -Stevens-Johnson Syndrome -Blood dyscrasias -Risk of dependency Nursing Implications -Administer the lowest possible dose for therapeutic response -Avoid alcohol -Use exactly as prescribed at regular intervals

Compare and contrast medications and IV therapies commonly given for nausea and vomiting secondary to chemotherapy (actions/outcomes). Medication: Benzodiazepines

Example -Lorazepam Uses/Actions -Reduces CINV -Enhances cholinergic effects and decreases patient's swareness Side Effects -Amnesia -Profound drowsiness Nursing Implications -Teach patient to avoid patient operating heavy machinery -Patient should also avoid making legal decisions and using stairs unassisted

Apply knowledge of the actions, potential side effects, and nursing implications when administering medications to adults and older adults who have an alteration in cognition and sensation. Medication: Osmotic Diuretics

Example -Mannitol Uses/Actions -Used to aggresively manage intracranial hemorrhage (traumatic brain injury) -Increases osmotic pressure of glomular filtrate, decreasing net absorption of sodium Side Effects -Dehydration -Weakness -Edema Nursing Implications -Give through a filter to eliminate microscopic crystals -Monitor intake/output -Measure serum electrolyte and osmolarity levels every 6 hours -Monitor for severe dehydration

Compare and contrast medications and IV therapies commonly given for nausea and vomiting secondary to chemotherapy (actions/outcomes). Medication: Prokinetic Agents

Example -Metoclopramide Uses/Actions -Reduces CINV -Blocks dopamine receptor in the brain's chemotrigger zone Side Effects -Increased drowsiness Nursing Implications -Teach patient to avoid driving or operating heavy machinery

Apply knowledge of the actions, potential side effects, and nursing implications when administering medications to adults and older adults who have an alteration in cognition and sensation. Ergot Alkaloids

Examples -Dihydroergotamine mesylate Uses/Actions -Used to prevent or stop migraine attack Side Effects -Side effects are rare -Gangrene, muscle pain/weakness -Chest pain, numbness/tingling -Blindness -Uterine bleeding -Vomiting Nursing Implications -Report decreased effectiveness or increased symptoms -Take only as directed

Compare and contrast medications and IV therapies commonly given for nausea and vomiting secondary to chemotherapy (actions/outcomes). Medication: Serotonin Antagonists

Examples -Ondansetron (Zofran) -Granisetron -Other -setrons Uses/Actions -Prevents/treats CINV -Prevents serotonin from bonding with 5-HT3 receptors in the brain/intestines Side Effects -Bradycardia -Hypotension -Vertigo -Headache Nursing Implications -Teach patient to change positions slowly to avoid falls -Assess for headache

Apply knowledge of the actions, potential side effects, and nursing implications when administering medications to adults and older adults who have an alteration in cognition and sensation. Medication: Anticonvulsants

Examples -Phenobarbitol -Phenytoin Uses/Actions -Used to treat seizures -Increases AV conduction and alters ion transport Side Effects -Bradycardia, cardiac arrest, hypotension -Diplopia, blurred vision -Nausea, vomiting -Constipation, abdominal pain -Jaundice, hepatities, nephritis -Rash, hypocalcemia -Exacerbates myasthenia gravis -Purple glove syndrome Nursing Implications -Therapeutic level for phenytoin is 7.5-20 mcg/mL -Do not discontinue abruptly -Do not use antacids within 2 hours -Use nonhormonal contraception -Notify MD of any unusual bleeding

Apply knowledge of the actions, potential side effects, and nursing implications when administering medications to adults and older adults who have an alteration in cognition and sensation. Medication: Beta Blockers

Examples -Propranolol -Timolol Uses/Actions -Used to prevent migraines Side Effects -Bradycardia, CHF, dysrhythmias, pulmonary edema -Laryngospasm -Impotence -Facial swelling -Sensitivity to cold Nursing Implications -Take with 8oz of water and food -Smoking increases the levels -Do not stop abruptly

Apply knowledge of the actions, potential side effects, and nursing implications when administering medications to adults and older adults who have an alteration in cognition and sensation. Medication: Serotonin Reuptake Antagonists (Triptans)

Examples -Sumatriptian -Rizartriptan benzoate Uses/Actions -Used to treat acute migraines -Cerebral vasoconstrictor Side Effects -Tingling, burning, numbness, cold sensation -Tightness, dizziness, headache -Anxiety, fatigue -Weakness, neck stiffness Nursing Implications -Assess BP, ECG -Assess renal function, urinary output

Apply knowledge of the actions, potential side effects, and nursing implications when administering medications to adults and older adults who have an alteration in cognition and sensation. Medication: Centrally Acting Muscle Relaxants

Examples -Tizanidine -Baclofen Uses/Actions -Used to control severe muscular spasticity (as in SCI); also used for headaches, Huntington's disease, epilepsy/seizures -Inhibit synaptic responses in the CNS Side Effects -Severe drowsiness -Sedation Nursing Implications -Do not use with other CS depressants unless prescribed -May require 1-2 months of treatment for full effect -Avoid hazardous activities until response to med is known -Taper off over 1-2 weeks

Apply knowledge of the actions, potential side effects, and nursing implications when administering medications to adults and older adults who have an alteration in cognition and sensation. Medication: Immunosuppressants

Examples: -Cyclophosphamide -Methylprednisolone Uses/Actions -Used to stabilize disease process and reduce inflammation in MS; also used in some reproductive cancers Side Effects -Headache, dizziness -CHF, pericarditis -N/V/D -Weight loss -Gonadal suppression -Alopecia, dermatitis -Pulmonary fibrosis Nursing Implications -Taper gradually over 2-4 weeks -Monitor renal an hepatic function -Monitor pulmonary function -Take adequate fluids -Report signs of infection or anemia -Report bleeding, use reliable contraception

Perform a focused assessment that should be included when collecting data on adults and older adults who have an alteration in cognition and sensation (Conciousness, Speech, and Motor Function, Strength, Reflex, Glasgow Scale). History

Family history, diseases, allergies Medications (blood thinners, etc.); smoking/alcohol use

Review the basic principles to help determine the patient's knowledge of chemotherapy, immunotherapy, hormonal, and radiation therapy. Surgical Therapy

Goal of treatment is to improve quality of life and prolong survival; surgery is the mainstay of treatment Prophylactic: preventative Diagnoses: biopsy Cure: removal of tumor Cytoreductive: decrease the size, but unable to remove it all Palliation: decrease pain and increase comfort; do what you can Second-Look: secondary assessment Reconstructive/Rehabilitation: breast reconstruction; post surgical reconstruction

Perform a focused assessment that should be included when collecting data on adults and older adults who have an alteration in mobility (pain, altered sensations, gait/posture, skin, neurovascular, muscle strength, joint function).

HISTORY -Accidents (even long ago, illnesses (such as DM) and lifestyle (activity level; history of high impact sports or occupation) may be factors contributing to the current problem. --Fractures are common in manual labor occupations. --Carpal tunnel syndrome/neck pain is common in desk jobs. --Back injury seen in occupations requiring extended standing. -Assess allergies (especially dairy); drug use --Tobacco slows healing of musculoskeletal injuries. --Alcohol decreases absorption of vitamins/nutrients. --Steroids can negatively affect calcium metabolism and promote bone loss. -Family history (osteoporosis, gout, and some bone cancers can be hereditary) PAIN/MUSCLE WEAKNESS -Pain: date/time of onset, exacerbating factors, continuous vs. intermittent, clinical manifestations and pattern, factors that improve it. -Weakness: myopathy (proximal weakness) is a muscle tissue roblem; neuropathy (distal weakness) is a nerve tissue problem. --Assess ROM, passively or actively per patient ability (joint function) GAIT/POSTURE -Posture is the person's body build and alignment when standing/walking; assess: --Curvature of spine --Length, shape, strength of extremities --Muscle mass (size, symmetry) -Gait is the person's balance, steadiness, and ease/length of stride SKIN -Note bony prominences, areas at risk for impaired skin integrity. -With amputations, check for tissue perfusion. NEUROVASCULAR -Always compare one extremity with the other and begin with injured side -Assess sensations

Review the basic principles to help determine the patient's knowledge of chemotherapy, immunotherapy, hormonal, and radiation therapy. Hormone Therapy

Hormone antagonists are used to control (not cure) cancer growth Side effects include masculinizing manifestations in women and gynecomastia in men

Review the basic principles to help determine the patient's knowledge of chemotherapy, immunotherapy, hormonal, and radiation therapy. Radiation Therapy

Ionized radiation damages the cell and causes cell death or halts ability of the cell to divide Treatments are given sequentially (fractionation) Prognosis outcome is improved when patient receives small doses over a longer period of time Types of radiation -Teletherapy (beam radiation): external radiation source ---Client is not a risk hazard to anyone else ---Patient must be placed in the same position for each treatment ---Patient must be able to stay in the same position for a long period of time -Brachytherapy: direct contact with tumor tissues; delivers radiation directly to the tumor and a low dose to surrounding tissue ---Uses radioactive isotopes ---Client emits radiation and can be an exposure risk to others -Unsealed radiation: emits continuous low dose radiation (sealed radiation is given via implants within targeted tissues) ---Oral, IV, or designated body cavity ---Emits continuous low-dose radiation ---Eliminated via waste (which is radioactive) ---Client emits radiation while implants are in but waste excretions are not radioactive Side effects of radiation -Permanent skin/hair changes to the site of radiation -Altered taste sensations, fatigue -No direct sun for a yea after radiation -Specific lotion has to be prescribed Radiation Precautions: the longer the exposure, the greater the radiation is absorbed -Intensity of radiation decreases as the distance from the source increases -Specific materials can be used as shielding; patients receiving radiation are usually cared for in a lead-lined wall room at the far end of a unit ---Warning signs are posted at the entrance of the patient's room and on the patient's chart ---RNs should plan care carefully in order to decrease the time they spend in the patient's room; general rule is 30 minutes of direct patient care per shift -Careful removal/disposal of any PPE is paramount, along with thorough handwashing after gloves are removed ---Gloves should be made of latex or a strong synthetic material (not vinyl); two sets are reommended -Radiation safety officer issues radiation film badge that measures the amount of radiation staff are exposed to ---Badge should be stored in a place where there is no additional radiation ---Radiation officer establishes plan in case radiation source becomes dislodged -Must conform to US nuclear regulatory commission codes

Perform a focused assessment that should be included when collecting data on adults and older adults who have an alteration in cognition and sensation (Conciousness, Speech, and Motor Function, Strength, Reflex, Glasgow Scale). Mental Status/Level of Conciousness (the most essential component of neurological assessment)

LOC is awareness to self, the environment, and responses to the environment -It's an extremely sensitive indicator of an intact cortex; easily disrupted with injury -Assess orientation to time, place, and person ---Time is lost first ---Place is usually lost next and indicates more serious disturbances ---Person is the last parameter to be lost and occurs with more severe cortical dysfunction -Glasgow Coma Scale: level of responsiveness if not alert ---Rating score to grade the best possible brain response ---Measures eye opening/motor response/verbal response ---Always give patient their best response Arousal is the lowest level of conciousness and is a state of awakeness, as in a patient in a vegetative state -Sleep-wake cycles may be observed -Reflex-type reactions may also be exhibited in response to noise, lights, or noxious stimuli with no meaningful interactions with the examiner -Concurrent assessments focus on the patient's ability to respond to noxious stimuli hopefully in an appropriate manner

Perform a focused assessment that should be included when collecting data on adults and older adults who have an alteration in cognition and sensation (Conciousness, Speech, and Motor Function, Strength, Reflex, Glasgow Scale). Speech and Language

Listening, speaking, reading, writing; extremely high cortical function -Major components: fluency, repetition, comprehension, reading, writing, naming

Describe the role of the nurse in providing quality care to adults and older adults who have an alteration in cognition and sensation

Neurological assessment goal -Diagnose and triage -Establish baseline -Decision making -Predict patient outcome Altered LOC: patient is not oriented, cannot follow commands, or needs peresistent stimuli to achieve a state of alertness -Obtain and maintain a patent airway (PRIORITY) -Maintain functionality of muscles with appropriate exercise -Monitor skin integrity and bony prominences to avoid pressure ulcers -Monitor urine output (avoid autonomic dysreflexia)

Apply knowledge of anatomy, physiology, pathophysiology, nutrition, and developmental variations when helping to plan care for adults and older adults who have an alteration in cognition and sensation. Physiology of Neurological System

Neurotransmitters -Communicate messages from one neuron to another or to a specific target range -Potentiate, terminate, modulate -Excite (acetylcholine, norepinephrine, GABA, glutamic acid, enkephalin, endorphin) or inhibit (dopamine, serotonin)

Differentiate between the characteristics of normal and cancer cells (benign vs. malignant changes)

Normal Cell: well defined border -Cancer cell: irregular borders Normal Cell: has the same appearance, size, and shape -Cancer Cell: becomes anaplastic (little/no resemblance to normal cells) Normal Cell: performs specific functions -Cancer Cell: has no useful function Normal Cell: adheres together, does not migrate -Cancer Cell: does not adhere together, migratory Normal Cell: grows in an orderly fashion -Cancer Cell: grows/divides rapidly and continuously Normal Cell: won't grow into another type of cell's space -Cancer Cell: Invades other cells' space

Explore the nursing challenges when assisting clients and their families as they deal with end of life issues. End of Life Interventions

Pain: this is the most distressing symptom that dying patients fear the most -Patients who have had their pain controlled with long acting opiods continue their scheduled doses to prevent pain recurrence -Nonpharmacologic interventions include massage, music therapy, therapeutic touch, and aromatherapy Weakness: patients often experience weakness/fatigue as death nears -Assess for dysphagia and support/educate family if patient becomes NPO -Choose least invasive route for medication administration Breathlessness/dyspnea: subjective experience in which the patient has an uncomfortable feeling of breathlessness; often considered the major cause of suffering at end of life; loud, wet respirations are known as the "death rattle" -Perform a thorough assessment of patient's dyspnea (include onset, severity, precipitating factors, and quality) -Pharmacologic interventions should begin early in the course of dyspnea near death; nonpharmacological interventions may be used in conjunction with but not in place of meds -Opiods such as morphone are the standard treatment (reduces air hunger, anxiety, and O2 consumption; reduces pulmonary congestion by dilating pulmonary blood vessels); bronchodilators, corticosteroids, O2 therapy may be implemented as well -Nonpharmacologic interventions include circulating cool air, applying wet cloths on the patient's face, elevating HOB or positiong patient upright in a reclining chair, and encouraging imagery and deep breathing Nausea and Vomiting -Determine and treat the cause if possible -Give antiemetic agents (dexamethasone, metoclopramide) -Aromatherapy may also be used (chamomile, camphor, fennel, lavender, peppermint, rose) Restlessness and agitation -Assess for pain, urinary retention, constipation, or another reversible cause -If not relieved by analgesia or catheterization, an antipsychotic or benzodiazepine is given -Music therapy and aromatherapy (chamomile) may be used Seizures: not common but may occur with brain tumors -Benzodiazepines are the drug of choice, followed by bariturates Psychosocial interventions for care of the dying patient and the family -Offer physical and emotional support by "being with" the patient -Respect cultural preferences; promote spirituality -Encourage remiscence (story telling, life review) and foster hope -Be realistic, avoid explanation of the loss, communicate with the patient -Provide referrals to bereavement specialists -Teach about the physical signs of death -Ensure that the patient is receiving palliative care, with an emphasis on symptom management

Spinal Cord Injury

Pathophysiology -Trauma is the leading cause; almost half from car wrecks, 2nd is falls, then acts of violence and sports/recreational injuries -May be complete (severed or damaged to eliminate all innervation below injury level) or imcomplete (some function/movement below injury level) Signs and Symptoms -Loss of motor function -Loss of sensation -Loss of reflex activity -Loss of bladder/bowel control -Flaccid paralysis results from LMN (lower motor neuron) lesions -Muscle spasticity results from UMN (upper motor neuron) lesions Treatment/Nursing Implications -Airway management is priority -Monitor for neurogenic shock -External fixation, orthotic devices, fixed skeletal traction -Halo fixator may be used -Surgery is usually indicated -Maintain proper body alignment -Muscle relaxers for UMNL -Anti-inflammatory drugs -Occupational therapy (ADLs)

Describe primary and secondary cancer prevention activities that can aid clients in the prevention and early detection of cancer.

Primary prevention: specific causes have been identified (diet/lifestyle changes) Secondary prevention: early detection to improve the outcome (mammogram, PSA) -C: change in bowel functions -A: asymmetry -U: unusual bleeding -T: thickening, lump -I: indigestion, difficulty swallowing -O: obvious change in mole -N: nagging cough/hoarseness Cancer prevention: avoid known carcinogens; encourage dietary/lifestyle changes Chemo used as prevention: as in breast cancer, if hormone related Gene alteration

Perform a focused assessment that should be included when collecting data on adults and older adults who have an alteration in cognition and sensation (Conciousness, Speech, and Motor Function, Strength, Reflex, Glasgow Scale). Also Assess

Pupils Eye Function Vital Signs

Recognize alterations in pulse oximetry and other laboratory values related to alterations in cognition and sensation. Diagnostic Exam/Test: Computed Tomography (CT) Scan

Purpose -Accurate, quick, easy, noninvasive, painless, least expensive option; provides information about the structure of the CNS Process -Pictures are taken at many horizontal levels -May be with or without contrast

Recognize alterations in pulse oximetry and other laboratory values related to alterations in cognition and sensation. Diagnostic Exam/Test: Cystologic Studies (Spinal Tap)

Purpose -Detects malignant cells shed by CNS tumors into the CSF Process -Spinal needle is inserted into the subarachnoid space -A small amount of CSF is extracted and tested

Recognize alterations in pulse oximetry and other laboratory values related to alterations in cognition and sensation. Diagnostic Exam/Test: Biopsy

Purpose -Determines the pathology of a tumor Process -Part of the tumor is surgically removed and tested

Recognize alterations in pulse oximetry and other laboratory values related to alterations in cognition and sensation. Diagnostic Exam/Test: Electroencephologram (EEG)

Purpose -EKG of the brain; can detect an abnormal brain wave in regions occupied by a tumor; measures seizures, brain activity Process -Patient is placed on reclining chair or bed -16-24 electrodes are attached to the scalp with a jelly-like substance -EEG tech or MD places glue over electrode to prevent slippage -Patient must first lie still -Rest of the test engages patient in certain activities (hyperventilation, photic stimulation, sleep) -May be done bedside; quiet room is preferred

Recognize alterations in pulse oximetry and other laboratory values related to alterations in cognition and sensation. Diagnostic Exam/Test: Neurological Examination

Purpose -Indicates the areas of the CNS that are involved/experiencing alteration Process -Assess the history of the illness and the manner/time frame in which the symptoms evolved -Assess LOC, reflexes, motor function

Recognize alterations in pulse oximetry and other laboratory values related to alterations in cognition and sensation. Diagnostic Exam/Test: Magnetic Resonance Imaging (MRI)

Purpose -Most helpful diagnostic tool for detecting brain tumors (especially smaller lesions); better images than CT scan Process -Relies on magnetic fields to take multiple sets of images -Images may be enhanced with gadolinium a non-iodine-based medium

Recognize alterations in pulse oximetry and other laboratory values related to alterations in cognition and sensation. Diagnostic Exam/Test: Cerebral Angiography

Purpose -Provides visualization of cerebral blood vessels; can localize most cerebral tumors Process -Iodinated contrast medium is injected into an artery (usually femoral) to identify issues -Images are recorded from different angles over head/neck -Cardiac monitoring is used throughout the procedure

Recognize alterations in pulse oximetry and other laboratory values related to alterations in cognition and sensation. Diagnostic Exam/Test: Tensilon Test

Purpose -Used to diagnose myasthenia gravis Process -Tensilon is given to temporarily block the action of acetylcholinesterase -It is administered IV and muscle response is evaluated -If weakness improves within 1 minute, MG is indicated

Recognize alterations in pulse oximetry and other laboratory values related to alterations in cognition and sensation. Diagnostic Exam/Test: Positron Emission Tomography (PET) Scan

Purpose -Used to supplement MRI scanning (more detailed/colorful); provides information about the function of the brain, especially glucose and O2 metabolism and cerebral blood flow Process -Patient is injected with deoxyglucose tagged to an isotope -Isotope emits activity in the form of positrons -Positrons are scanned and converted into color image by computer -Radiation level is equal to 5-6 x-rays

Myasthenic Crisis

Result of disease exacerbation or a precipitating event (usually respiratory infection) Severe generalized muscle weakness with respiratory and bulbar weakness Patient may develop respiratory failure

Identify health care education and safety needs for adults and older adults who have an alteration in cognition and sensation.

Safety -Implement safety precautions for muscle weakness (i.e., fall risk) -Respiratory muscle weakness is priority Rehabilitation/symptom management -Reorient patient -Keep familiar objects/routines

Compare and contrast medications and IV therapies commonly given for nausea and vomiting secondary to chemotherapy (actions/outcomes). Medication: Cannabinoids

Uses/Actions -Reduces CINV; aids in pain management Side Effects -Sedation, drowsiness -Ataxia -Vertigo disorientation -Dry mouth -Euphoria, increased appetite Nursing Implications -Teach patient to carry a package of Cheetos to prevent polyphagia

Discuss an apply knowledge of cancer cells' ability to proliferate and metastasize to surrounding tissue and distant sites (carcinogenics).

Transformation: the transition from normal to malignant cells -Initiation: carcinogen exposure changes the DNA of the cells and turns them on, causing mutational changes and damage -Promotion: substances enhance cell growth and trigger cell division (accelerators) -Progression: tumor autogenesis factor (TAF) stimulates blood supply growth for nourishment ---Tumors > 1 cm become detectable Metastasis: cells move from the primary site and invade other tissues, vital organs, etc -Secrete enzymes that create areas for new tumor growth -Bore holes into blood vessels to allow for migration of tumor cells -Most tumors metastasize via lymphatic/blood systems

Compare and contrast various grading and staging systems. Grading/Staging Scale

Tumors are graded/ staged based on the degress of metastasis in order to determine patient's prognosis/treatment plan. Ploidy: the description of cancer cells by chromosome number and appearance; classifies tumor chromosomes as normal or abnormal -Euploidy: normal diploid number; 46 chromosomes (23 pairs) -Aneuploidy: structural abnormalties of remaining chromosomes after some have been gained or lost by cancer cells; the degree of aneuploidy increases with the degree of malignancy Grading: classifies cellular aspects of the cancer -GX: grade cannot be determined -G1: tumor cells are well differentiated and closely resemble normal cells; tumor is malignant but relatively slow growing -G2: tumor cells are moderately differentiated; still remain some characteristics of normal cells, but have more malignant characteristics than G1 -G3: tumor cells are poorly differentiated, but tissue of origin can usually still be established; cells have few normal characteristics -G4: tumor cells are poorly differentiated and retain no normal cell characteristics; determination of tissue of origin is difficult and perhaps impossible Staging: classifies clinical aspects of the cancer; TNM is the most commonly used staging classification -T: tumor size 1-4 -N: number of lymph nodes involved (indicated metastasis) -M: number of sites the cancer has metastasized to

Review the basic principles to help determine the patient's knowledge of chemotherapy, immunotherapy, hormonal, and radiation therapy. Chemotherapy

Use of chemical agents to damage cell DNA and interfere with cell division; cytotoxic and classified by biologic action Types of chemo drugs -Antimetabolites: considered counterfeit metabolites that impair or prevent cell division; metabolites play a key role in cell processes/synthesis -Anti-tumor antibiotics: used because they cause damage to a cell's DNA/RNA synthesis -Alkylating agent: inhibits cell division by binding DNA strands closely together -Anti-mitotic agent: prevents cell from completing mitosis so that it does not divide at all, or divides only ones (two cells that have unequal amounts of DNA and cannot continue to divide) -Topoisomerase inhibitor: enzyme needed for DNA/RNA synthesis and cell division; caues DNA to break up, cell death -Combination chemo: increased immunosuppression and bone marrow activity ---Nadir: bone marrow activity and WBC counts at their lowest Chemo Dosage -Based on the type of cancer and mg per sq meter of total body surface area; height of client (in cm)multiplied by weight (in kg); divide result by 10,000 (move decimal point 4 spaces to the left) -Most chemo is given IV (extravasation) -Course isthe planned schedule of chemo; round is the actual days of administration -Side effects include N/V, vomiting, mucositis, stomatitis, inflammation/sores in the mucus membranes, stomach) ---Alopecia is whole body hair loss caused by many chemo drugs ---Immune suppression is the most life-threatening side effect (low neutrophil precautions) Chemo Safety: practice guidelines/protective standards established by OSHA and the Oncology Nursing Society -Chemo drugs can be absorbed through skin and mucous membranes -They are dangerous to others in the following ways: ---Mutagenic: cause abnormal changes in DNA ---Teratogenic: alter development of a fetus or embryo leading to birth defects ---Carcinogenic: able to cause another type of cancer ---May cause localized skin irritation/damage -Administration guidelines ---RNs: wear gloves/gowns when preparing chemo (even pills are absorbed by the skin); must be certified to give it ---Pharmacists/RNs: prepare chemo drugs in areas with special ventilation systems ---Special precautions are used to clean up leaks or spills, and are taken when handling urine or stool for up to a few days after treatment ---Special procedures are used for disposing of materials after mixing and administering teh chemo drugs; separate containers are used to dispose of sharp items, syringes, IV tubing, medication bags

Apply knowledge of the actions, potential side effects, and nursing implications when administering medications to adults and older adults who have an alteration in cognition and sensation. Medication: Glatiramer Acetate

Uses/Actions -Used as a disease modifying drug for MS -This is a synthetic protein that is similar to myelin based protein Side Effects -N/V/D -Anxiety, tremors, confusion, vertigo -Ear pain, blurred vision -Itching, rash, sweating -Back/neck pain, increased tone, irregular menses -Bronchitis, dyspnea Nursing Implications -Assess CNS symptoms -Monitor GI and cardiac status -Do not change dosing or stop taking product

Apply knowledge of the actions, potential side effects, and nursing implications when administering medications to adults and older adults who have an alteration in cognition and sensation. Medication: Mestilon, Tensilon

Uses/Actions -Used to diagnose myasthenia gravis Side Effects -Bradycardia and arrythmias -Cold moist skin -Abdominal cramps, diarrhea, vomiting -Fainting -Increased salivation -Respiratory arrest Nursing Implications -Keep atropine ready at all times

Apply knowledge of the actions, potential side effects, and nursing implications when administering medications to adults and older adults who have an alteration in cognition and sensation. Medication: Fingolimod (Immunomodulator)

Uses/Actions -Used to manage MS Side Effects -Bradycardia Nursing Implications -Monitor pulse daily (especially within first 6 hours)

Apply knowledge of the actions, potential side effects, and nursing implications when administering medications to adults and older adults who have an alteration in cognition and sensation. Medication: Interferon-beta (immunomodulator)

Uses/Actions -Used to modify the course of MS -Has anti-viral effects Side Effects -Headache, fever, chills -Mental changes, depression -Seizures -Irregular menses -Decreased WBC -Diarrhea, constipation -Hypertension, tachycardia Nursing Implications -Store in refrigerator -If a dose is missed, give ASAP

Apply knowledge of actions, potential side effects, and nursing implications when administering medications to adults and older adults who have alterations in mobility. Medication: Aminoglycosides (Examples: azithromycin, gentamicin, tobramycin)

Uses/Actions: -Used for infections (particularly , acute soft tissue infections Side Effects: -Palpitations, chest pain -N/D, abdominal pain -Loss of smell/hearing Nursing Implications: -Give 1 hour before or 2 hours after meals -Do not take Al/Mg antacids -Monitor liver/kidney labs -Watch for serious skin reactions, superinfection

Apply knowledge of actions, potential side effects, and nursing implications when administering medications to adults and older adults who have alterations in mobility. Medication: Antibiotics (Examples: 1st gen cephalosporins, ciprofloxacin, clindamycin)

Uses/Actions: -Used for open fractures

Apply knowledge of actions, potential side effects, and nursing implications when administering medications to adults and older adults who have alterations in mobility. Medication: NSAIDS

Uses/Actions: -Used for relief of pain/inflammation Nursing Implications -Take with or after meals to reduce gastric irritation

Apply knowledge of actions, potential side effects, and nursing implications when administering medications to adults and older adults who have alterations in mobility. Medication: Glucosamine

Uses/Actions: -Used to decrease inflammation in osteoarthritis Side Effects: -Rash -GI disturbance (diarrhea) -Drowsiness, headache Nursing Implications -Contraindicated in HTN -May increase BG levels -Take recommended dose based on weight

Apply knowledge of actions, potential side effects, and nursing implications when administering medications to adults and older adults who have alterations in mobility. Medication: Calcium Supplements

Uses/Actions: -Used to prevent osteoporosis and to promote bone health Side Effects: -Watch for hypercalcemia Nursing Implications -Take with food and 6-8 oz of water -Drink plenty of fluids

Apply knowledge of actions, potential side effects, and nursing implications when administering medications to adults and older adults who have alterations in mobility. Medication: Chondroitin

Uses/Actions: -Used to strengthen cartilage in osteoarthritis Nursing Implications -Monitor for bleeding if on anticoagulant therapy

Apply knowledge of actions, potential side effects, and nursing implications when administering medications to adults and older adults who have alterations in mobility. Medication: Bisphophonates (Examples: alendronate, ibandronate, risendronate)

Uses/Actions: -Used to treat osteoporosis; most common drug choice -Slow bone resorption by binding with crystal elements in bone Side Effects: -May cause esophagitis or esophageal ulcers Nursing Implications: -Take early in the morning with 8 oz of water; wait 30-60 minutes in an upright position before eating -Patient should have an oral assessment/preventative dentistry before taking the drug

Apply knowledge of actions, potential side effects, and nursing implications when administering medications to adults and older adults who have alterations in mobility. Medication: Corticosteroid Injections

Uses/Actions: Used to reduce pain and inflammation in osteoarthritis or carpal tunnel syndrome