1. What is the leading causes of death in the US? 1 and 2?
    • chronic degenerative disease
    • cancer
  2. Where do the majority of deaths occurs in the U.S.
    hospitals or long term care facilities
  3. Who and when changed the way we view dying and hospice in the US
    • Dame Cicely Saunders
    • 1963 when giving talk at Yale
  4. What book, by whom and what year had a huge impact on the stages of grieving
    • On Death and Dying
    • Kubler-Ross
    • 1969
  5. When was the first hospice formed in the US and where
    • 1974
    • Connecticut
  6. What year did Medicare grant a hospice benefit?
  7. When was the Palliative care task force published for nurses? How many competencies?
    • 1997
    • 15 competencies
  8. What is the most important competency of the Last Acts campaign?
    • Recognize one's own
    • -attitudes
    • -feelings
    • -values
    • -expectations
    • about death and the individual, cultural, and spiritual diversity existing in these beliefs and customs
  9. Define advanced directive.
    written document prepared by a competent person that defines what is to be done or not done when they can no longer make decisions about their health care
  10. Define durable power of attorney
    • this is a type of an advanced directive
    • this document appoints a person who is responsible for articulating your wishes once you are unable
  11. Define living will
    • This is a type of an advanced directive
    • This document what you want done or not done if you are unable to speak for your self
  12. Define DNR order
    • do not resusitate
    • This is an order that CPR will not be initiated if the pt has a cardiac or respiratory arrest; there are different levels: can be no chest compressions, no antibiotics, even
  13. TF: A nurse is legally obligated to check the medical record for a DNR order
  14. Define hospice
    Hospice is a program of care provided across a variety of settings based on the understanding that dying is part of the normal life cycle
  15. TF: Once someone enters hospice, they agree that they are DNR status.
  16. Define palliative care
    Palliative care is a comprehensive care for patients whose disease is not responding to cure where care also extends to the family
  17. Which is least restrictive and why: hospice or palliative care?
    Palliative care b/c it can be instituted earlier in the disease process and the pt ican still get chemo, antibiotics, blood transfusions (even though not responding). Also pt may have longer than 6 mos to live as with hospice care
  18. TF: When one is receiving hospice care, they are not receiving palliative care.
    False. You receive both in hospise; recall that the goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families
  19. What is the major difference between hospice and palliative care?
    treatment. In hospice, the disease is not treated, but suffering is prevented and relieved. In palliative care, the disease is treated but the patient is not doing well despite it. Still sufferening is prevented and relieved

    Also timeline: hospice begins with 6 months or less to live; Palliative care begins much earlier than that
  20. What about respite care for those who have family member in hospise
    Medicare covers up to 5 days to relive home caregiver
  21. What is life review?
    structured process of reflecting on one's life which is often facilitated by an interviewer
  22. Give an example of psychosocial care for the dying
    Help the pt settle issues with their families and come to terms with what they have done
  23. What is the role of hope in hospice and what can you do as a nurse?
    Hope is an expectation of something desired and it may or may not come true. The nurse can help them with hoping. The hope may be that the person has a peaceful death or knowing that their family will be ok after they die
  24. TF: Patient do not usually have automony with their care and the end of life.
    False. They can state how sedated they want to be or whether they want a catheter
  25. What is the role of the family in a "good death"
    • There is communication with the family
    • Family is cared for
    • The pt's death is meaningful for the family
  26. Describe the process of actively dying
    • anorexia
    • decreased bowel motility
    • decreased circulation
    • shallow repirations with periods of apnea
    • disorientation
    • restless
    • lethargy
  27. What are the key symptoms to be concerned with at end of life?
    • Pain
    • anxiety
    • restlessness
    • dyspnea
    • nausea/vomiting
    • seizures
  28. Does one have to be sedated to control pain at end of life?
    no, you can have good pain control w/o sedations. Often though, it is a necessary side effect to control symptoms but is temporary and wears off after 2-3 days.
  29. At the end of life, are treatment plans based on protocols
  30. What do you do if extremely high doses of narcotics are needed at end of life to control symptoms?
    Nothing except give what is needed!!!!
  31. What is your concern about the control of symptoms and hastening death at the end of life
    • You need to give what is need to control the symptom but realize that there may be a fine line regarding the dosages given.
    • Still - an increased risk of earlier death COUNTS LITTLE against the benefit of pain relief and painless death
  32. For end of life care, what are alternative medication routes to oral and IV?
    • transdermal
    • rectal
    • buccal cavity
    • pupillary
  33. TF: Pain relief can cause delirium in addition to sedation
  34. TF: Hydration at end of life is not considered a treatment or curative approach.
    False. It is althought there is an exception if a medaport is in place
  35. Name some complimentary therapies for end of life care.
    • massage
    • therapeutic touch
    • music
    • aromatherapy
  36. What drugs do we give to relieve dyspnea at end of life?
    • morphine
    • -dilates pulmonary blood vessels
    • -alters perception of air hunger
    • -reduces anxiety & associated o2 comsumption
    • antibiotics
    • -due to respiratory infections for symptom control
    • bronchdilators
    • -relieve bronchospams
    • corticosteroids
    • -inflammatory processes
    • anticholinergics
    • -reduce secretions
  37. What are some nonpharmalogical interventions to reduce dyspnea at the end of life?
    • fans blowing across the pt's face
    • o2 if it helps
    • positioning
    • relaxation
  38. TF: Not drinking fluids at the end of life causes thirst and discomfort.
    False. can cause more distress
  39. Nausea and vomiting at the end of life is most common in pts that are dying from
  40. What are the causes of Nausea/Vomiting at end of life
    • Uremia as the kidney's shut down
    • Electrolyte imbalances esp. hypercalcemia
    • ICP due to brain tumors
    • GI obstruction due to large doses of narcotics
    • Sepsis
    • Pain medication side effects
    • Eating or drinking (it would be forced at this point)
  41. What are some interventions for nausea/vomiting at the end of life
    • antiemetics
    • aromatherapy
    • diet adjustment
    • constipation relief
  42. At the end of life, what are potential causes of restlessness?
    • bladder distention
    • constipation
    • position (pt is uncomfortable)
  43. What drug do we use to treat restlessness at end of life? what is the dosing?
    • Sedatives (Benzodiazepines): Ativan
    • Around the Clock - NOT PRN
  44. What are some non pharamalogical interventions to control restlessness?
    • aromatherapy
    • music therapy
    • positioning
    • indwelling catheter

    NOTE: we are not worried about UTIs or skin breakdown
  45. At end of life, who usually experiences seizures?
    • Pts with:
    • - AIDS
    • - Brain Lesions
    • - History of seizure
  46. At end of life, when do seizures typically occur?
    Sometimes they occur just right before death
  47. What medication is given at end of life to control seizure activity?
    • Anti seizure medications are given around the clock to contribute to a high seizure threshold
    • Benzodiazepines: Valium, Ativan - (NOT DILANTIN)
  48. TF: Gift of life must be notified even if the deceased if not a viable tissue/organ donor
    True; Notification must be done with one hour
  49. When is the medical examiner notified of a patient's death?
    • If the death is unexpected,
    • hadn't been under a physician care for the past 24 hours,
    • if malice is suspected
  50. TF: When a pt dies, if he or she was in restraints within the last 24 hours, the medical examiner must be notified
    False: the Center for Medicare & Medicaid Services (CMS) must be notified
  51. How do you care for the body postmorten?
    • close eyes
    • insert dentures (within 2 hours) or take with you to be inserted
    • document any jewelry or valuables with the body
    • make sure the body is properly identified
  52. Does the withdrawl of treatment cause death?
    No, the pt was dying anyway
  53. Can withdrawl of treatment be a result of an advanced directive?
  54. What are some examples of treatment that can prolong life in a patient that cannot be cured (medically futile)?
    • dialysis
    • BP medications
    • ventilator support
  55. Define euthanasia
    Actions that purposefully and directly cause death
  56. Define active euthanasia
    health care provider taking action that purposefully and directly causes pt death
  57. Define passive euthanasia
    discontinuing one or more therapies that may prolong the life of a person who cannot be cured by the therapy
  58. define voluntary euthanasia
    permission given by the pt to have another end their life
  59. define involuntary euthanasia
    permission is not given by the pt to have another end their life
  60. non-voluntary euthanasia
    the person is not able to give consetnt for another person to end their life
  61. define assisted suicide
    someone provides the means to a pt with the knowledge that the pt will use the means to commit suicide
  62. Blood is composed of ___________ and ________
    plasma, cells
  63. In adults, which bones produce blood
    The bone marrow of the flat bones and the ends of the long bones in adults produce blood componenents: RBCs, WBCs and platelets
  64. The liver is the site for production of .....
    prothrombin and most of the blood clotting factors
  65. TF: The liver stores large quantities of whole blood and blood cells
  66. What does the spleen do in terms of blood production
    • major site for antibody production
    • storage site for platelets
    • filters out debri (antigens)
  67. What pts frequently lose their spleens
    • trauma pts
    • sickle cell pts maybe
  68. what are considerations for someone who has no spleen
    • they are more prone to infection: pneumonia, colds, other diseases
    • They should be on top of immuinizations
  69. Those that injure spleen and liver have a major risk of hemorrhaging. Why?
    these organs contain extra supply of blood so lots of internal bleeding
  70. Blood celss start off as an undifferiented stem cell and then follow what committed stem cell pathway?
    myeloid stem cell pathway
  71. What is the role of RBCs
    Red blood cells carry oxygen attached to hemoglobin
  72. What is the shape of the RBC? Does it have a nucleus?
    Biconcave shape. No nucleus
  73. What is the life span of the normal RBC
    120 days
  74. What is the normal range of RBCs in the blood
    • 4,200,000 - 6,100,000/mm^3
    • Women: 4.2 - 5.4
    • Men: 4.7 - 6.1
  75. The WBCs or leukocytes, that are part of the immune system, have five types. Name them:
    • monocytes
    • macrophages
    • basophils
    • eosinphils
    • neutrophils

    • NOTE: a monocyte is an immature macrophage
    • NuMBEM or MMBEN
  76. TF: Platelets repair damage to small vessels
    True, but note that it is the beginning step for clot formation
  77. what is the life span of the platelet?
    1-2 weeks
  78. TF: RBCs carry oxygen and carbon dioxide
  79. What happens in the liver when there is hypoxia?
    The liver releases globulin and then erythropoetin which trigger erythrocyte production in the bone marrow
  80. What happens in the kidney when there is hypoxia?
    The kidney releases renal erythropoetic factor and then erythropoetin which trigger erythrocyte production in the bone marrow
  81. How long does it take for the signals to make more erythrocytes take
    4-5 days to end up in the periphery
  82. What are the three types of plasma proteins?
    albumin, fibrinogen, globulins
  83. what does albumin, a plasma protein do?
    albumin is made in the liver and is increases osmotic pressure. So if someone has low albumin, fluid will leak into the tissues
  84. what does globulin, a plasma protein do?
    Protects the body against infection
  85. what does afibrinogen, a plasma protein do?
    It is an inactivated protein that is activated to form fibrin
  86. What are teh three steps to blood clotting?
    • 1. platelet aggregation
    • 2. blood clotting cascade
    • 3. formation of the fibrin clot
  87. What is the normal platelet count?
    150,000 - 350,000/mm^3
  88. What happens in platelet aggregation
    The platelets become sticky due to an activation and change to their cell membranes. This temporary patch initiates the clotting cascade
  89. What are the two pathways of the blood clotting cascade? Define them.
    Intrinsic factor: factors within the blood stream itself initiate the cascade i.e. debris, venous stasis

    Extrinsic factors: factors that usually involve the blood vessels like trauma, inflammation, bacteria, sepsis
  90. What is required to make the blood clotting cascade happen?
    • clotting factors
    • enough platelets
    • calcium
  91. What is the role of calcium in clotting?
    Low Ca will cause problems with clotting
  92. What are some anti - platelet drugs?
    • Aspirin
    • Plavix
  93. Which pathway is faster in the clotting cascade?
    The extrinsic pathway

    THINK: If you have a hole, you want to clot faster
  94. Define clotting factors
    Clotting factors are inactive enzymes that come active in sequences in the clotting cascade
  95. What is the final common (both intrinsic & extrinsic) pathway in the clotting cascade?
    • prothrombin --> thrombin
    • fibrinogen --> fibrin
    • Active fibrin molecules--> fibrin threads
    • Clotting factor XIII (13) tighten things up
    • more platelets come
    • blood cells come
    • proteins come -->
    • Blood clot is formed
  96. Aspirin and other platelet inhibitors like Plavix work where in the clotting cascade
    They work very high, almost at the start of the cascade
  97. What is the dosage for prophylactic anticoagulation? What drugs do we give?
    • Warfarin
    • Heparin
    • Lovenox
    • 5000 units Q 12 hours
  98. How do we fully anticoagulate someone? What drugs do we use? Who receives this?
    • Lovenox (low molecular weight heparin)
    • Heparin (unfractionated) IVP + 3000-4000 units bolus/hr

    • Pt with a PE
    • documented DVT
    • PT with a clot that we don't want to get bigger
  99. Is there a test to regulate low molecular weight heparin?
  100. Is there a way to reverse low molecular weight heparin (lovenox)?
  101. Can heparin be reversed?
    It depends. If it is low molecular weight heparin --> No. It is is IV heparin, Yes.
  102. What are the advantages of low molecular weight heparin (lovenox)?
    • It can be taken at home
    • It works in 30 minutes
    • It doesn't require a blood test to regulate it.
  103. Do anticoagulants dissolve clots that have already formed?
  104. What is the action of fibrinolytics?
    Thes dissolve clots once they are in place.
  105. When do you use fibrinolytics?
    To dissolve clots in cases of MI or thrmbotic strokes
  106. Vitamin ____ increases clotting
  107. TF: some antibiotics can interfere with clotting
  108. What are the age related changes in regard to blood: older patients have less....
    • blood volume
    • plasma proteins
    • RBCs
    • WBCs
    • hemoglobin
  109. Why are older people more likely to become dehydrated
    They have less blood volume as they age
  110. What happends to bone marrow in relation to aging
    There is less that actively makes blood cells because it is replaced by fatty tissue
  111. What is anemia?
    inadequate o2-carrying capacity of the blood
  112. Anemia is related to RBCs, hematocrit and hemoglobin in what way
    There is either not enogh RBCs, low hematocrit or not enough hemoglobin
  113. When there is a nutrional deficiency that causes anemia, what is lacking?
    • low iron
    • low B12
    • low folic acid, copper, cobalt, nickel
  114. What is aplastic anemia? What is it caused by?
    there is not enough any of blood cell (pancytopenia) produced = RBCs, WBCs, platelets

    Can be caused by chemicals, viruses
  115. What is hemolytic anemia?
    Anemia that results from the destruction of RBCs
  116. In what cases do ppl adjust to anemia?
    When anemia has a slow onset like with GI bleed
  117. What is the number one symptom of anemia? What will you see as the nurse
    • Fatigue.
    • THe nurse witll see pallor, increased HR for compensation
  118. What does Hgb test in the test for anemia and what are the normals?
    • oxygen carrying ability
    • WOmen 12 - 16g/dl
    • Men: 14 - 18 g/dl
  119. What does Hct test in the test for anemia and what are the normals?
    • Hematocrit measures that volume of packed RBCs.
    • Women: 37-47%
    • Men: 42-52%
  120. What do low levels of RBCs, Hgb or Hct indicate
    possible anemia or hemorrhage
  121. What do high levles of RBCs, Hgb or Hct indicate?
    chronic hypoxia or polycythemia vera
  122. What is MCV and what do high and low levels indicate?
    • Mean corpuscle volume
    • High: macrocytic cells (anemia)
    • Low: microcytic cells (iron deficiency anemia)
  123. What is MCH and what do high and low levels indicate
    • mean corupscular hemoglobin
    • High: hyperchromic cells (anemia)
    • Low: hypochromic cells (iron deficiency anemia)
  124. How much iron is stored in the blood stream?
    only about 1% is in blood stream as free iron
  125. What are the normal levels for iron in the blood test
    • Women: 60-160 mcg/dl
    • Men: 80 - 180 mcg/dl
  126. How is the reticulocyte test helpful? What are indicative of low and high values?
    • It is helpful in determining bone marrow function.
    • Low: low RBC production
    • High: bone marrow is responding to a loss of RBCs

    If there is no precipitating factor like blood loss or trauma and the count is high, the pt may have polycythemia vera
  127. What is the most common type of anemia?
    iron deficiency anemia
  128. How does one treat iron deficiency anemia?
    • You need iron.
    • - increase dietary intake
    • - take supplements (ferrous sulfate)
    • - give IM (iron dextran)
    • - give IV (iron dextran)
  129. What are considerations for giving iron IM and IV
    • IM: give it Z track
    • IV: very carefully b/c there is a risk of anaphylactic shock in those that haven't been absorbing
  130. What type of anemia results from Vitamin B12 deficiency?
    macrocytic (megaloblastic) anemia. This is because there is a disruption to folic acid transport and reduced DNA synthesis in precursor cells --> huge abnormal cels
  131. What type of anemia results from failure to absorb vitamin B12?
    penicious anemia (there is a lack of intrinsic factor)
  132. What is the Shilling's test used for? Describe it.
    It tests for pernicious anemia. It measures the presence of B12 in the urine after the pt is given an oral dose of radioactive vitamin B12. If it is not absorbed, then it won't be in the urine.,
  133. Other than anemai, vitamin B12 deficiency can cause __________
    neurological damage
  134. Which diets can results in vitamin B12 deficiencies
    vegetarian or low dairy diets
  135. What are the s/s of vitamin B12 deficiency?
    • pallor
    • jaundice
    • glossitis
    • fatigure
    • weight loss
    • paresthesias
    • poor balance
  136. What happens or fails to happen in folic acid deficiency anemia
    Like vitamin B12 deficiency, there is a failure in folic acid transport which results in problems with DNA synthesis. There is no neurological damage in this anemia though
  137. Who usually presents with folic acid deficiency anemia as a result of chronic malnutrition?
    • homeless
    • chronic alcholics
  138. When someone is admitted and given folic acid in an IV, what does it look like?
    It is banana yellow and usually contains B12, folic acid and thiamin.
  139. Why does Dilantin have an ADR of anemia?
    Dilanin affects the absorption of folic acide
  140. Who need a treatment of folic acid?
    • may be needed in pregnancy
    • for those with pressure ulcers that won't heal
    • pts with chronic hemolytic anemia
  141. Describe the genetic disorder of sickle cell disease.
    • The mother carries the trait on one of her X chromosomes (recessive autosomal disorder). So, when mating, if the mother has the trait, 50% chance that both girls and boys will also have the trait. If the father has the trait and the mother does not, no son will get trait, but daughters will.
    • Recall that women are XX and men are XY.
  142. In sickle cell anemia, what % of chains is of the abnormal form? Normally, what does one have
    • In SSD: 40%+ HgS
    • Normally, one has 98%+ HgA and little HgF
  143. How does HgS chains respond to low oxygen
    they sickle, become rigid and stick together
  144. What is the relationship between high altitudes and sickle cell disease
    there is less oxygen and it leads to sickling of HgS chains
  145. Some things that those with sickle cell should avoid:
    • anesthesia
    • extreme temperatures
    • strenuous activity
    • alcohol consumption
    • Think: anything that stresses the body or leads to less oxygen: pregnancy, dehydration, high altitudes, sickness
  146. How is the presence and quantity of HgS detected in sickle cell disease
    hemoglobin electrophoreses
  147. How does one with sickle cell disease develop chronic pain?
    Result of tissue hypoxia
  148. What is the lifespan of HgS cell
    10-15 days
  149. Explain why there is severe abdominal pain in sickle cell disease crisis?
    Liver and spleen are where the HgS is stored and they sickle, become stuck and the liver and spleen are congested with these cells -> necrosis
  150. Why is there jaundice in sickle cell disease?
    the HgS cells die and spill out bilirubin. Remember they only live 10-15 days
  151. why are those with sickle cell disease at high risk for infection
    Often, the spleen is damaged
  152. Why is high output cardiac failure seen in sickle cell disease?
    this is due to increased metabolic needs that has the heart working overtime trying to compensate for hypoxia
  153. Explain why a pt. with sickle cell disease has protein in urine.
    because of damaged tubules
  154. Explain why a pt. with sickle cell disease complains of pruritis
    High levels of bilirubin from the breaking of the HgS causes itching
  155. Describe early intervention for a sickle cell patient.
    Early intervention is key to prevent a crisis. If they have a cold, they need antibiotics
  156. Describe the treatment of pain for someone that has sickle cell disease
    these pts have a high tolerance because of chronic pain. Give them long term basal narcotic doses
  157. What is the preferred method of delivery for pain meds in sickle cell crisis?
  158. Why is hydration a necessary treatment for the pt in sickle cell crisis?
    the more dehydrated, the more the cells stick together
  159. How long does a crisis usually last for a sickle cell pt
    one week
  160. Describe why there is a risk of iron overload in a sickle cell patient
    The HgS break down and release iron (life span is only 10-15 days) and then we given them a packed RBC transfusion which gives them more iron
  161. TF: There is an increased risk of stroke and seizures for sickle cell pts.
    True: do neuro checks. There is often neuro damage
  162. What is polycthemia vera
    It is a type of cancer where there are too many RBCs, WBCs and platelets - many or most are abnormal
  163. What are the manifestations of polycthemia as it relates to its abnormal blood cells?
    • Hypertension
    • Thrombosis
    • Hyperkalemia due to RBC destruction
    • Hypoxia
    • Abnormal bleeding b/c of platelet impairment
  164. Why is chemotherapy no longer indicated for treatment of polycthemia vera?
    Usually causes leukemia
  165. What are the treatments for polycthemia vera?
    • phlebotomy - decreases RBCs & blood viscosity
    • hydration
    • anticoagulation
  166. Is there a cure for polycthemia vera?
  167. What happens when one has leukemia
    • The is either leukopenia (decreased WBC) or increase leukocytes (immature WBCs).
    • Either way, the WBCs are ineffective and there is decreased defence against infection
  168. What is the greatest risk factor in leukemia?
  169. Why is there anemai and thrombocytopenia with leukemia?
    decreased RBC and platerlet production
  170. How are the different leukemias differentiated?
    • Whether they are acute or chronic and based on the affected cell type:
    • Myelogenous leukemia - acute or chronic
    • Lympocytic leukemia - acute or chronic
  171. What are the signs and symptoms of leukemia?
    • bruising (ecchymoses)
    • petechiae
    • pallor
    • bleeding
    • tachycardia
    • palpitations
    • decreased bp (remember in contract to heart rate)
  172. When one dies and had leukemia, they die from an ________
  173. Prognosis in acute vs. chronic leukemia
    Chronic leukemia may be present for years before changes appear. Acute leukemia, involves rapid changes that without intervention proceed to death
  174. Indications of the presence of infection in those with leukemia - describe
    manifestations are not obvious since the pt has leukopenia. Note that the development of feve and pus depend on the presence of WBCs
  175. TF: with leukemia, chemotherapy results in severe bone marrow suppression and organ toxicity
    True: the organs are the kidney, heart and liver
  176. Hospitalization time for leukemia patients is ......
    extended because of time to get chemo and prevent infections since they have little or no immune system
  177. How to implement bleeding precautions in someone with leukemia who has risk of bleeding
    • No IM
    • No venipuncutes
    • Stool softeneres
    • pressure on bleeding sites
    • electric razor
    • no dental work or flossing
    • ETC
  178. What are two of the most important factors in infection prevention for a leukemia pt
    • good peri care
    • room with ventilation

    and other common sense: no plants, no raw foods, no sick folks
  179. What are some considerations for the bone marrow aspiration for the leukemia patient?
    • unpleasant
    • risk of bleeding
    • local anesthetic or conscious sedation
    • heavy pressure
    • 12G needle - can do bone biopsy if needed
    • after: lots of pressure to stop bleeding - 20 minutes;
    • vitals signs q15 mins for 2 hours
    • pressure dressing for 24 hours
  180. autologous bone marrow transplant
    using pt's own cells
  181. allogenic bone marrow transplant
    using matched donor cells
  182. bone marrow transplants are used to treat:
    • leukemia
    • lymphoma
    • multiple myeloma

    aplastic anemia

    sickle cell disease
  183. Hodgkins lymphoma
    • Cancer that usually starts in a single lymph node or a single chain of lymph nodes - Reed Sternberg cell
    • spreads in an orderly fashion
    • treatment more successful than for non Hodgkins
  184. Non Hodgkins lymphoma
    spreads in a less orderly way through lymph nodes
  185. Treatment of malignant lymphomas include
    • radiation
    • chemotherapy
    • combination of both radiation and chemotherapy
  186. multiple myeloma
    • cancer with an overgrowth of WBC plasma cells (more mature WBC)
    • there is suppressed production of RBCs, platelets and other WBCs

    Note that plasma cells ordinarily produce antibodies so there is an overproduction of antibodies
  187. With multiple myeloma, what does the excess production of cytokines contribute to?
    • cytokines are messenger cells that tell other cells what to do
    • The cytokines tell the cancerous cells to grow faster
    • The cytokines also contribute to bone desstruction
    • excess antibodies clog kidneys and other organs
  188. Is there a cure for multiple myeloma
    • No. It is treated with:
    • chemotherapy
    • pain control
    • biphosphates for bone disease
  189. When do the symptoms of thrombocytopenia appear
    When the platelet count is less than 100,000/mm^3. there is compensation up until this point
  190. Hemophilia A is a defect in which clotting factor?
    VIII (8)
  191. Hemophilia B (Christmas disease) is a defect in which clotting factor?
    IX (9)
  192. Heparin induced thrombocytopenia (HIT) occurs in what % of pts receiving heparin? Is is dosage related?
    1%; no dosage related
  193. When does heparin induced thrombocytopenia generally occur?
    It is an immune mediated response that occurs 4-10 days after exposure.
  194. How is heparin induced thrombocytopenia avoided
    With the use of direct thrombin inhibitors (???)
  195. What lab tests are used to monitor warfarin therapy?
    • PT/INR: 11 - 13 seconds
    • Clotting factors, 2, 5, 7, 10
  196. What lab tests are used to monitor heparin therapy?
    • PTT: 22.1 - 35.1 seconds
    • evaluates intrinsic pathway
    • clotting factors: 2, 5, 8, 9, 11, 12
  197. Packed red blood cells (PRBC). When given? for what for example? min # of units to give
    • When Hbg is < 6-8g/dl
    • given for anemia & blood loss
    • minimally give 2 units
  198. Platelets). When given? When avoided?
    • Given when platelet count is < 20, 0000 (sever thrombocytopenia)
    • Do not give for idiopathic thrombocytopenia; body will destroy just as fast as transfused
  199. Fresh frozen plasma: When given? What are indications?
    • Given when there indication of deficient coagulation factors
    • The plasma was frozen was within 8 hours of collection; give fast once thawed
  200. Cryoprecipitate. When given? contains what
    • Given to pts with clotting factor disorders (like when we give plasma) i.e. hemophilia
    • contains clotting factors 8 and 9
  201. When do we give WBCs in a blood transfusion?
    Where there is severe sepsis not responding to antibiotices in neutropenic patients
  202. What is the only IV solution to be given with blood?
    Normal saline although you don't mix the saline and blood
  203. How many licensed staff must identify the blood product to be infused
  204. What is the universal donor blood type?
  205. How long does blood usually run in a blood transfusion. What should you do while it is running
    • 2 hours
    • Take BP frequently;
  206. What are the things you need to check on the blood bag
    • Type
    • Unit #
    • Right Pt
    • Correct order
    • Expiration date
  207. A+ can donate to:
    A- can donate to:
    B+ can donate to:
    B- can donate to:
    AB+ can donate to:
    AB- can donate to:
    O+ can donate to:
    O- can donate to:
    • A+ can donate to: A+ AB+
    • A- can donate to: A+ A- AB+ AB-
    • B+ can donate to: B+ AB+
    • B- can donate to: B+ B- AB+ AB-
    • AB+ can donate to: AB+
    • AB- can donate to: AB+ AB-
    • O+ can donate to: A+ B+ AB+ O+
    • O- can donate to: A+ A- B+ B- AB+ AB- O+ O-
  208. Why is it important to take pre vital signs before giving blood?
    You have to know if the change in vitals is due to giving blood
  209. What are the considerations for tubing when transfusing blood?
    You need to always have the correct tubing

    For platelet transfusion, there is a smaller surface area in platelet tubing. Regular tubing causes the platelets to stick to the filter
  210. With a febrile transfusion reaction, what happens
    the recipient reacts to donor leukocytes within one hour of transfusion
  211. with a hemolytic transfusion reaction, what happens
    this is an error of blood type and frequently results in death: fever, hypotension, tachycardia, shock
  212. with an allergic transfusion reaction, what happens
    • recipient's antibodies react to donor proteins
    • most common with fresh, frozen plasma
    • if anaphylactic, more severe
  213. Graft vs host disease
    related to transfusion where the donor's T-lymphcytes react to the recipient's lymph tissue
  214. What is the prevention of graft versus host disease
    irradiate blood prior to transfusion since is destroys T cells and their cytokine products
  215. Who is most at risk for transfusion related graft vs. host disease
    Those with Hodgkin's disease and the immunosuppressed
  216. TF: Iron overload shortens life expectancy no matter the primary diagnosis
  217. TF: There is a physiological mechanism for removal of excess iron
  218. With iron overload, it is common to find the serum ferritin level consistently exceeding
  219. How can we help with iron overload
    Give chelating agent (derofexamine) that binds to iron so it can be excreted in the urine or stool
  220. What's the five year cancer survival rate?
  221. The most new cases and most cancer deaths for men are:
    • lung - deadly,
    • & prostate - more common
  222. The most new cases and most cancer deaths for women are:
    • lung - deadly,
    • & breast - more common
  223. How many new cancers are diagnosed every year
    1.5 million
  224. TF: cancer can arise from any tissue
  225. TF: Nurses must deal with spiritual support for those diagnosed with cancer since outlook affects outcome
  226. Of pain and fatigue, which is the leading symptom reported with a diagnosis of cancer?
  227. Reduced immunity and reduced blood-producing functions are a consequence of cancer. Why?
    • due to:
    • 1. cancer mets to bone marrow
    • 2. suppression to treatment
    • 3. hematologic cancers
  228. how does cancer affect metabolism?
    • 1. increases the metabolic needs because the cancer uses resources to reproduce
    • 2. alters the metabolism because the liver and pancreas may be involved
  229. TF: with cachexia (wasting away) and cancer diagnosis, the pt has a much lower survival rate and responds less well to therapy
  230. How are bones affected in cancer
    • 1. invasion by primary tumors
    • 2. invasion by secondary tumors
    • 3. changes in Ca levels cause pathological fractures
  231. TF: some chemotherapies cause neuropathies
  232. How is respiratory function affected by cancer
    • 1. airway obstruction by tumors
    • 2. chemo causes pulmonary fibrosis which alters gas exchange
    • 3. anemia leads to hypoxia
  233. TF: all abnormal cell growth is cancer
  234. TF: a genetic mutation of cellular DNA starts the disease process of cancer
  235. Define hypertrophy
    growth that causes tissue to increase in size by enlarging each cell
  236. Define hyperplasia
    growht that causes tissue to increase in size by increasing the number of cells
  237. Define aptosis
    repair mechanism; where a cell that isn't right, kills itself
  238. Describe the cell cycle:
    • G0: resting phase
    • G1: bulking up for division
    • S: cell doubles its DNA
    • G2: makes important proteins
    • M: split occurs
  239. How does growth differ in benign and malignant neoplasms?
    • benign: growth by expansion
    • Malignant: growth by invasion
  240. How do chromosomes differ in benign and malignant neoplasms?
    • benign: chromosomes are normal (euploidy)
    • malignant: chromosome are abnormal (aneuploidy)
  241. Define angiogenesis
    creating a new blood supply to support growth; cancer cells do this
  242. TF: Both malignant and benign cells migrate.
    False: only the malignant cells migrate
  243. what are the three steps in the development of cancer?
    • initiation
    • promotion
    • progression
  244. Describe what happens during the inititation phase of cancer development.
    There is irreversible damage to the DNA of the cell
  245. Describes what happens during the promotion phase of cancer development
    Growht is enhanced by promotors i.e. proteins
  246. Describe what happens during the progression phase of cancer development
    the tumor is able to become more malignant; as it grows, it will have to develops its own blood supply and there is continued change and growth
  247. Proto-oncogenes
    • present at birth and turn on when necessary for normal cell division
    • can evolve into oncogenes (bad) with mutation
  248. What are the regulatory genes (in cancer development)
    • proto-oncogenes
    • tumor suppressor genes
    • apoptyosis genes
    • DNA repair genes
  249. TF: Immunosuppression puts you at a greater risk for cancer
    True: HIV and immunological treatments to prevent organ rejection
  250. TF: three cancer preventative agents are aspirin, vitamin D and vaccines
  251. True
  252. What is the primary prevention of cancer
    What is done to reduce the risk i.e. first I quit smoking and stay away from red meat...
  253. What is secondary prevention of cancer
    These are screenings to detect and provide early intervention i.e. First, I limit red meat and second, I get a mammogram and pap
  254. What is the tertiary prevention of cancer?
    This is to develop optimal treatment of the cancer
  255. Distinguish between primary and secondary tumors
    Primary is the original tumor whereas secondary tumors are the result of mets
  256. Cancers are classified by tissue of origin. What are the four classifications?
    • 1) adeno- = glandular structures
    • 2) osteo- = bone
    • 3) rhabodo- = muscle
    • 4) myelo- = bone marrow or spinal cord
  257. TF: A cancer staging will change depending on progression.
    False: staging is done at the time of diagnosis
  258. Why is the mitotic indix important to consider in cancer treatment?
    The index is important because it quantifies the rate of tumor growth. We need to know this because radiation and chemo target rapidly dividing cells
  259. Describe cancer grading
    • The higher the grade, the more malignant.
    • Four levels
    • G1 - closely resemble origin
    • G2 - moderately resembles origin
    • G3 - little resemble to origin
    • G4 - virtually no resemble to origin
  260. Describe the TNM classification of cancer.
    • Usually for solid tumors
    • Tumor size 0-4
    • Nodes 0-3
    • Mets? 0-1

    Note: sometimes x is used in each category when unknown/.

    Want low numbers
  261. What are the four types or aims or surgical treatment of cancer?
    • prophylactic
    • diagnostic
    • curative
    • palliative
  262. What are the two types of radiation therapy to treat cancer. Define them.
    • 1.teletherapy - radiation source is outside the body
    • 2. brachytherapy - radiation source within the body
  263. Define radiosensitization
    When one is given drugs prior to radiationt that sensitizes that cancer cells allowing them to recieve lower, more effective doses of radiation
  264. TF: one of the side effects of radiation is the inability to achieve orgasm
  265. TF: There are late effects of radiation therapy
    • True. This can occur to the pt months or years after treatment:
    • pulmonary fibrosis
    • secondary cancers
    • bone problems
    • risk for stroke
    • risk for MI
    • neuromuscular issues
  266. What is the difference between the aims of chemotherapy and radiation?
    Radiation kills cells whereas chemo stops them from dividing (both act on both healthy and cancer cells)
  267. What are the four body systems most affected by chemo
    • These are the ones with the more rapidly dividing cells:
    • hematopoietic (bone marrow)
    • integumentary
    • gastrointestional
    • reproduction
  268. What are the classes of chemotherapy keeping in mind that combos are given to pts. Define them.
    • anti-
    • 1)metabolites (impair cell division)
    • 2)tumor antibiotics (target DNA, RNA)
    • 3)mitotics (interferes with mitosis)
    • 4)alkylating agents (target DNA, cell division)
  269. Define nadir
    The time when bone marrow activity and WBC counts are at their lowest levels after chemo. varies by drug
  270. When a pt is on bleeding precautions, why do we assess LOC
    head bleeds
  271. Why is chemo delayed after a pt has surgery
    chemo contributes to a delay in wound healing
  272. What is chemo brain
    It's a neurological side effect to chemo that is temporary and goes away
  273. TF: Lots of chemo drugs have a lifetime maximum because of effects on the heart regardless of effectiveness
  274. What are some cardiopulmonary side effects of chemo
    • CHF
    • Cardiomyopathy
    • Pulmonary fibrosis
  275. What is the usual route of chemo administration with liver cancer
    intra arterial: directly into blood supply to tumor itself
  276. Name and describe the intracavity chemo routes of administration
    • Intraperitoneal - abdomen
    • Intraventricular - brain
    • Intrathecal - spinal cord
    • Intravesical - bladder
  277. What are the side effects of hormonal manipulation in fighting cancer?
    • masculinization of women
    • &
    • feminine effects in men
  278. What is the aim of hormonal manipulation in fighting cancer
    It is not curative; it slows growth thereby prolonging life
  279. When using hormone manipulation to treat hormone sensitive tumors, describe the three kinds of hormones.
    • 1) hormone agonist (similar to hormone that tumor relies on, so it confuses it to use the agonist and then won't need to produce the original hormone)
    • 2) hormone antagonist (competes with hormone at receptor sites)
    • 3)hormone inhibitiors (inhibit hormone production)
  280. What is photodynamic therapy in the treatment of cancer?
    Cancer cells are killed by chemical reactions caused by laser light. Prior to treatment, the cells are sensitized by an infused agent
  281. Photodynamic therapy is used in the shrinkage of which tumors...
    • airway
    • esophagus
    • prostate
  282. Give an example of a palliative treatment using photodynamic therapy?
    shrinking a tumor in the esophagus b/c the pt can't breathe

    shrinking a tumor in the prostate b/c the pt can't pass urine
  283. In immunotherapy to treat cancer, what are the cytokines that make the immune system work better?
    • interleukins
    • interferon
  284. What are the side effects of immunotherapy to treat cancer?
    • inflammatory reaction (flu)
    • third spacing of fluids (leaking into interstitial spaces continuously)
    • neuropathies
    • skin issues: rashes, dryness
    • muscle aches
  285. describe gene therapy in the treatment of cancer
    makes cancer cells more noticeable to treatment and body's immune system
  286. What is a syngeneic bone marrow transplant
    cells from an identical twin
  287. In bone marrow transplants, (blood/stem) cells are used
  288. What happens in DIsseminated Intravascular coagulation?
    extensive abnormal clotting occurs throughout body until clotting factors and platelets are depleted; then extensive bleeding
  289. What is the early treatment for DIC
    heparin for anticoagulation
  290. What is the late treatment for DIC
    clotting factors and platelets
  291. DIC is triggered by .......
    cancer, sepsis
  292. An early sign of Superior vena cava syndrome is
    facial edema, redness in face and distentions of upper chest
  293. A late sign of superior vena cava syndrome is
    • swelling in hands, arms
    • dyspnea
    • death!!!
  294. What are the treatments for superior vena cava syndrome
    • high dose radiation to shrink tumor
    • interventional radiology to remove clot
  295. What is the treatment for spinal cord compression
    • high dose corticosteroids
    • high dose radiation
  296. The syndrome of inappropriate secretion of antidiuretic hormone is generally caused by what types of cancers
    • brain
    • lung
  297. The fluid retention caused by the SIADH has what effect on sodium levels in the body
    hyponatremia b/c of dilution
  298. What is the treatment of SIADH?
    • increase sodium intake
    • limit fluids
  299. What are the mild manifestations of SIADH
    • as a result of hyponatremia:
    • muscle weakness
    • muscle cramps
    • fatigue
  300. What are the more serous manifestions of SIADH?
    • as a result of hyponatremia:
    • confusion
    • seizures
    • coma
    • death
  301. What is tumor lysis syndrome
    When a large number of tumor cells are destroyed rapidly, their intracellular contents are released into the bloodstream faster than they can be absorbed
  302. What effect on the blood does tumor lysis syndrome have?
    • hyperkalemia
    • hyperphosphatemia
    • hyperuricemia
  303. TF: Tumor lysis syndrome results in a decrease in cancer.
    True; about 25%
  304. When does tumor lysis syndrome commonly happen?
    24-48 hours after the initiation of cancer treatment
  305. Treatment of which types of cancer gives an increased risk of tumor lysis syndrome?
    • Cancers that are very sensitive to radiation and chemo:
    • leukemia
    • lymphoma
    • multiple myeloma
    • small cell lung cancer

    • those with large tumors
    • those with fast growing tumors
    • hematological tumors
  306. What are the signs and symptoms of hyperkalemia
    • EKG: electrical activity of heart
    • cramps
    • muscle weakness
    • parathesis
    • paralysis
    • anorexia
    • nausea
    • vomiting
    • tingling
    • Helpful Reminder:
  307. What is the normal serum level range for potassium
    3.5 - 5
  308. Why is there hyperuricemia in tumor lysis syndrome/
    The lysis of the cells causes purines to be released with converts into uric acid
  309. Why is there acute renal failure in tumor lysis syndrome?
    The uric acid (excess) in the blood precipitates and clogs the kidney tubules.
  310. What is the normal serum range for Sodium?
    136 - 145 mEq/L
  311. What is the normal serum range for Calcium?
    9.0 - 10.5 mg/dL
  312. What is the normal serum range for Phosphorus
    3.0 - 4.5 mg/dL
  313. What are the signs and symptoms of hypocalcemia
    • cramps
    • paresthesias
    • tetany
    • Trousseau
    • Chvostek
    • dysrhythmias
    • hypotension
    • syncope
    • abdominal cramps
    • syncope
    • Remember: the calcium and phosphorus are inversely related
  314. What is the normal serum range for uric acid?
    3.6 - 8.3 mg/dL
  315. What chemotherapy drugs were mentioned in class?
    • cytarabine - antimetabolite
    • etoposdie - antimiotic
    • cisplatin - alkylating
  316. What are some ways to prevent tumor lysis syndrome?
    • Give IV 2 days before therapy and monitor fluids
    • Control Nausea/vomiting so pt is hydrated
    • Monitor electrolytes
    • Give allopurinol & rasburicase to increase the excretion of purines (alter uric acid metabolism)
  317. What medications should you avoid giving when someone has tumor lysis syndrome?
    • aspirin
    • beta blockers
    • heparin
    • NSAIDS
  318. rasburicase. caution. used for
    • Caution:
    • hypersensitivity reactions
    • never give with allopurinol

    treatment of tumor lysis syndrome to increase the secretion os purines so that they cannot be converted to uric acid in the liver
Card Set