What is the leading causes of death in the US? 1 and 2?
chronic degenerative disease
cancer
Where do the majority of deaths occurs in the U.S.
hospitals or long term care facilities
Who and when changed the way we view dying and hospice in the US
Dame Cicely Saunders
1963 when giving talk at Yale
What book, by whom and what year had a huge impact on the stages of grieving
On Death and Dying
Kubler-Ross
1969
When was the first hospice formed in the US and where
1974
Connecticut
What year did Medicare grant a hospice benefit?
1985
When was the Palliative care task force published for nurses? How many competencies?
1997
15 competencies
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
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
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
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
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
TF: A nurse is legally obligated to check the medical record for a DNR order
True
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
TF: Once someone enters hospice, they agree that they are DNR status.
True
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
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
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
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
What about respite care for those who have family member in hospise
Medicare covers up to 5 days to relive home caregiver
What is life review?
structured process of reflecting on one's life which is often facilitated by an interviewer
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
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
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
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
Describe the process of actively dying
anorexia
decreased bowel motility
decreased circulation
shallow repirations with periods of apnea
disorientation
restless
lethargy
What are the key symptoms to be concerned with at end of life?
Pain
anxiety
restlessness
dyspnea
nausea/vomiting
seizures
REMEMBER: PARDoNS
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.
At the end of life, are treatment plans based on protocols
Yes
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!!!!
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
For end of life care, what are alternative medication routes to oral and IV?
transdermal
rectal
buccal cavity
pupillary
TF: Pain relief can cause delirium in addition to sedation
True
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
Name some complimentary therapies for end of life care.
massage
therapeutic touch
music
aromatherapy
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
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
TF: Not drinking fluids at the end of life causes thirst and discomfort.
False. can cause more distress
Nausea and vomiting at the end of life is most common in pts that are dying from
AIDs
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)
What are some interventions for nausea/vomiting at the end of life
antiemetics
aromatherapy
diet adjustment
constipation relief
At the end of life, what are potential causes of restlessness?
bladder distention
constipation
position (pt is uncomfortable)
What drug do we use to treat restlessness at end of life? what is the dosing?
Sedatives (Benzodiazepines): Ativan
Around the Clock - NOT PRN
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
At end of life, who usually experiences seizures?
Pts with:
- AIDS
- Brain Lesions
- History of seizure
At end of life, when do seizures typically occur?
Sometimes they occur just right before death
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)
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
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
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
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
Does the withdrawl of treatment cause death?
No, the pt was dying anyway
Can withdrawl of treatment be a result of an advanced directive?
Yes,
What are some examples of treatment that can prolong life in a patient that cannot be cured (medically futile)?
dialysis
BP medications
ventilator support
Define euthanasia
Actions that purposefully and directly cause death
Define active euthanasia
health care provider taking action that purposefully and directly causes pt death
Define passive euthanasia
discontinuing one or more therapies that may prolong the life of a person who cannot be cured by the therapy
define voluntary euthanasia
permission given by the pt to have another end their life
define involuntary euthanasia
permission is not given by the pt to have another end their life
non-voluntary euthanasia
the person is not able to give consetnt for another person to end their life
define assisted suicide
someone provides the means to a pt with the knowledge that the pt will use the means to commit suicide
Blood is composed of ___________ and ________
plasma, cells
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
The liver is the site for production of .....
prothrombin and most of the blood clotting factors
TF: The liver stores large quantities of whole blood and blood cells
True
What does the spleen do in terms of blood production
major site for antibody production
storage site for platelets
filters out debri (antigens)
What pts frequently lose their spleens
trauma pts
sickle cell pts maybe
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
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
Blood celss start off as an undifferiented stem cell and then follow what committed stem cell pathway?
myeloid stem cell pathway
What is the role of RBCs
Red blood cells carry oxygen attached to hemoglobin
What is the shape of the RBC? Does it have a nucleus?
Biconcave shape. No nucleus
What is the life span of the normal RBC
120 days
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
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
TF: Platelets repair damage to small vessels
True, but note that it is the beginning step for clot formation
what is the life span of the platelet?
1-2 weeks
TF: RBCs carry oxygen and carbon dioxide
True
What happens in the liver when there is hypoxia?
The liver releases globulin and then erythropoetin which trigger erythrocyte production in the bone marrow
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
How long does it take for the signals to make more erythrocytes take
4-5 days to end up in the periphery
What are the three types of plasma proteins?
albumin, fibrinogen, globulins
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
what does globulin, a plasma protein do?
Protects the body against infection
what does afibrinogen, a plasma protein do?
It is an inactivated protein that is activated to form fibrin
What are teh three steps to blood clotting?
1. platelet aggregation
2. blood clotting cascade
3. formation of the fibrin clot
What is the normal platelet count?
150,000 - 350,000/mm^3
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
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
What is required to make the blood clotting cascade happen?
clotting factors
enough platelets
calcium
What is the role of calcium in clotting?
Low Ca will cause problems with clotting
What are some anti - platelet drugs?
Aspirin
Plavix
Which pathway is faster in the clotting cascade?
The extrinsic pathway
THINK: If you have a hole, you want to clot faster
Define clotting factors
Clotting factors are inactive enzymes that come active in sequences in the clotting cascade
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
Aspirin and other platelet inhibitors like Plavix work where in the clotting cascade
They work very high, almost at the start of the cascade
What is the dosage for prophylactic anticoagulation? What drugs do we give?
Warfarin
Heparin
Lovenox
5000 units Q 12 hours
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
Is there a test to regulate low molecular weight heparin?
NO
Is there a way to reverse low molecular weight heparin (lovenox)?
No.
Can heparin be reversed?
It depends. If it is low molecular weight heparin --> No. It is is IV heparin, Yes.
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.
Do anticoagulants dissolve clots that have already formed?
No.
What is the action of fibrinolytics?
Thes dissolve clots once they are in place.
When do you use fibrinolytics?
To dissolve clots in cases of MI or thrmbotic strokes
Vitamin ____ increases clotting
K
TF: some antibiotics can interfere with clotting
True
What are the age related changes in regard to blood: older patients have less....
blood volume
plasma proteins
RBCs
WBCs
hemoglobin
Why are older people more likely to become dehydrated
They have less blood volume as they age
What happends to bone marrow in relation to aging
There is less that actively makes blood cells because it is replaced by fatty tissue
What is anemia?
inadequate o2-carrying capacity of the blood
Anemia is related to RBCs, hematocrit and hemoglobin in what way
There is either not enogh RBCs, low hematocrit or not enough hemoglobin
When there is a nutrional deficiency that causes anemia, what is lacking?
low iron
low B12
low folic acid, copper, cobalt, nickel
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
What is hemolytic anemia?
Anemia that results from the destruction of RBCs
In what cases do ppl adjust to anemia?
When anemia has a slow onset like with GI bleed
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
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
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%
What do low levels of RBCs, Hgb or Hct indicate
possible anemia or hemorrhage
What do high levles of RBCs, Hgb or Hct indicate?
chronic hypoxia or polycythemia vera
What is MCV and what do high and low levels indicate?
Mean corpuscle volume
High: macrocytic cells (anemia)
Low: microcytic cells (iron deficiency anemia)
What is MCH and what do high and low levels indicate
mean corupscular hemoglobin
High: hyperchromic cells (anemia)
Low: hypochromic cells (iron deficiency anemia)
How much iron is stored in the blood stream?
only about 1% is in blood stream as free iron
What are the normal levels for iron in the blood test
Women: 60-160 mcg/dl
Men: 80 - 180 mcg/dl
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
What is the most common type of anemia?
iron deficiency anemia
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)
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
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
What type of anemia results from failure to absorb vitamin B12?
penicious anemia (there is a lack of intrinsic factor)
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.,
Other than anemai, vitamin B12 deficiency can cause __________
neurological damage
Which diets can results in vitamin B12 deficiencies
vegetarian or low dairy diets
What are the s/s of vitamin B12 deficiency?
pallor
jaundice
glossitis
fatigure
weight loss
paresthesias
poor balance
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
Who usually presents with folic acid deficiency anemia as a result of chronic malnutrition?
homeless
chronic alcholics
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.
Why does Dilantin have an ADR of anemia?
Dilanin affects the absorption of folic acide
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
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.
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
How does HgS chains respond to low oxygen
they sickle, become rigid and stick together
What is the relationship between high altitudes and sickle cell disease
there is less oxygen and it leads to sickling of HgS chains
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
How is the presence and quantity of HgS detected in sickle cell disease
hemoglobin electrophoreses
How does one with sickle cell disease develop chronic pain?
Result of tissue hypoxia
What is the lifespan of HgS cell
10-15 days
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
Why is there jaundice in sickle cell disease?
the HgS cells die and spill out bilirubin. Remember they only live 10-15 days
why are those with sickle cell disease at high risk for infection
Often, the spleen is damaged
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
Explain why a pt. with sickle cell disease has protein in urine.
because of damaged tubules
Explain why a pt. with sickle cell disease complains of pruritis
High levels of bilirubin from the breaking of the HgS causes itching
Describe early intervention for a sickle cell patient.
Early intervention is key to prevent a crisis. If they have a cold, they need antibiotics
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
What is the preferred method of delivery for pain meds in sickle cell crisis?
PCA
Why is hydration a necessary treatment for the pt in sickle cell crisis?
the more dehydrated, the more the cells stick together
How long does a crisis usually last for a sickle cell pt
one week
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
TF: There is an increased risk of stroke and seizures for sickle cell pts.
True: do neuro checks. There is often neuro damage
What is polycthemia vera
It is a type of cancer where there are too many RBCs, WBCs and platelets - many or most are abnormal
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
Why is chemotherapy no longer indicated for treatment of polycthemia vera?
Usually causes leukemia
What are the treatments for polycthemia vera?
phlebotomy - decreases RBCs & blood viscosity
hydration
anticoagulation
Is there a cure for polycthemia vera?
no
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
What is the greatest risk factor in leukemia?
age
Why is there anemai and thrombocytopenia with leukemia?
decreased RBC and platerlet production
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
What are the signs and symptoms of leukemia?
bruising (ecchymoses)
petechiae
pallor
bleeding
tachycardia
palpitations
decreased bp (remember in contract to heart rate)
When one dies and had leukemia, they die from an ________
infection
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
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
TF: with leukemia, chemotherapy results in severe bone marrow suppression and organ toxicity
True: the organs are the kidney, heart and liver
Hospitalization time for leukemia patients is ......
extended because of time to get chemo and prevent infections since they have little or no immune system
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
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
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
autologous bone marrow transplant
using pt's own cells
allogenic bone marrow transplant
using matched donor cells
bone marrow transplants are used to treat:
leukemia
lymphoma
multiple myeloma
aplastic anemia
sickle cell disease
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
Non Hodgkins lymphoma
spreads in a less orderly way through lymph nodes
Treatment of malignant lymphomas include
radiation
chemotherapy
combination of both radiation and chemotherapy
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
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
Is there a cure for multiple myeloma
No. It is treated with:
chemotherapy
pain control
biphosphates for bone disease
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
Hemophilia A is a defect in which clotting factor?
VIII (8)
Hemophilia B (Christmas disease) is a defect in which clotting factor?
IX (9)
Heparin induced thrombocytopenia (HIT) occurs in what % of pts receiving heparin? Is is dosage related?
1%; no dosage related
When does heparin induced thrombocytopenia generally occur?
It is an immune mediated response that occurs 4-10 days after exposure.
How is heparin induced thrombocytopenia avoided
With the use of direct thrombin inhibitors (???)
What lab tests are used to monitor warfarin therapy?
PT/INR: 11 - 13 seconds
Clotting factors, 2, 5, 7, 10
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
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
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
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
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
When do we give WBCs in a blood transfusion?
Where there is severe sepsis not responding to antibiotices in neutropenic patients
What is the only IV solution to be given with blood?
Normal saline although you don't mix the saline and blood
How many licensed staff must identify the blood product to be infused
2
What is the universal donor blood type?
O-
How long does blood usually run in a blood transfusion. What should you do while it is running
2 hours
Take BP frequently;
What are the things you need to check on the blood bag
Type
Unit #
Right Pt
Correct order
Expiration date
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-
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
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
With a febrile transfusion reaction, what happens
the recipient reacts to donor leukocytes within one hour of transfusion
with a hemolytic transfusion reaction, what happens
this is an error of blood type and frequently results in death: fever, hypotension, tachycardia, shock
with an allergic transfusion reaction, what happens
recipient's antibodies react to donor proteins
most common with fresh, frozen plasma
if anaphylactic, more severe
Graft vs host disease
related to transfusion where the donor's T-lymphcytes react to the recipient's lymph tissue
What is the prevention of graft versus host disease
irradiate blood prior to transfusion since is destroys T cells and their cytokine products
Who is most at risk for transfusion related graft vs. host disease
Those with Hodgkin's disease and the immunosuppressed
TF: Iron overload shortens life expectancy no matter the primary diagnosis
True
TF: There is a physiological mechanism for removal of excess iron
False.
With iron overload, it is common to find the serum ferritin level consistently exceeding
1000ng/mL
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
What's the five year cancer survival rate?
86%
The most new cases and most cancer deaths for men are:
lung - deadly,
& prostate - more common
The most new cases and most cancer deaths for women are:
lung - deadly,
& breast - more common
How many new cancers are diagnosed every year
1.5 million
TF: cancer can arise from any tissue
True
TF: Nurses must deal with spiritual support for those diagnosed with cancer since outlook affects outcome
True
Of pain and fatigue, which is the leading symptom reported with a diagnosis of cancer?
fatigue
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
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
TF: with cachexia (wasting away) and cancer diagnosis, the pt has a much lower survival rate and responds less well to therapy
True
How are bones affected in cancer
1. invasion by primary tumors
2. invasion by secondary tumors
3. changes in Ca levels cause pathological fractures
TF: some chemotherapies cause neuropathies
True
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
TF: all abnormal cell growth is cancer
False
TF: a genetic mutation of cellular DNA starts the disease process of cancer
True:
Define hypertrophy
growth that causes tissue to increase in size by enlarging each cell
Define hyperplasia
growht that causes tissue to increase in size by increasing the number of cells
Define aptosis
repair mechanism; where a cell that isn't right, kills itself
Describe the cell cycle:
G0: resting phase
G1: bulking up for division
S: cell doubles its DNA
G2: makes important proteins
M: split occurs
How does growth differ in benign and malignant neoplasms?
benign: growth by expansion
Malignant: growth by invasion
How do chromosomes differ in benign and malignant neoplasms?
benign: chromosomes are normal (euploidy)
malignant: chromosome are abnormal (aneuploidy)
Define angiogenesis
creating a new blood supply to support growth; cancer cells do this
TF: Both malignant and benign cells migrate.
False: only the malignant cells migrate
what are the three steps in the development of cancer?
initiation
promotion
progression
Describe what happens during the inititation phase of cancer development.
There is irreversible damage to the DNA of the cell
Describes what happens during the promotion phase of cancer development
Growht is enhanced by promotors i.e. proteins
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
Proto-oncogenes
present at birth and turn on when necessary for normal cell division
can evolve into oncogenes (bad) with mutation
What are the regulatory genes (in cancer development)
proto-oncogenes
tumor suppressor genes
apoptyosis genes
DNA repair genes
TF: Immunosuppression puts you at a greater risk for cancer
True: HIV and immunological treatments to prevent organ rejection
TF: three cancer preventative agents are aspirin, vitamin D and vaccines
True
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...
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
What is the tertiary prevention of cancer?
This is to develop optimal treatment of the cancer
Distinguish between primary and secondary tumors
Primary is the original tumor whereas secondary tumors are the result of mets
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
TF: A cancer staging will change depending on progression.
False: staging is done at the time of diagnosis
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
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
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
What are the four types or aims or surgical treatment of cancer?
prophylactic
diagnostic
curative
palliative
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
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
TF: one of the side effects of radiation is the inability to achieve orgasm
True
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
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)
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
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)
Define nadir
The time when bone marrow activity and WBC counts are at their lowest levels after chemo. varies by drug
When a pt is on bleeding precautions, why do we assess LOC
head bleeds
Why is chemo delayed after a pt has surgery
chemo contributes to a delay in wound healing
What is chemo brain
It's a neurological side effect to chemo that is temporary and goes away
TF: Lots of chemo drugs have a lifetime maximum because of effects on the heart regardless of effectiveness
True
What are some cardiopulmonary side effects of chemo
CHF
Cardiomyopathy
Pulmonary fibrosis
What is the usual route of chemo administration with liver cancer
intra arterial: directly into blood supply to tumor itself
Name and describe the intracavity chemo routes of administration
Intraperitoneal - abdomen
Intraventricular - brain
Intrathecal - spinal cord
Intravesical - bladder
What are the side effects of hormonal manipulation in fighting cancer?
masculinization of women
&
feminine effects in men
What is the aim of hormonal manipulation in fighting cancer
It is not curative; it slows growth thereby prolonging life
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)
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
Photodynamic therapy is used in the shrinkage of which tumors...
airway
esophagus
prostate
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
In immunotherapy to treat cancer, what are the cytokines that make the immune system work better?
interleukins
interferon
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
describe gene therapy in the treatment of cancer
makes cancer cells more noticeable to treatment and body's immune system
What is a syngeneic bone marrow transplant
cells from an identical twin
In bone marrow transplants, (blood/stem) cells are used
stem
What happens in DIsseminated Intravascular coagulation?
extensive abnormal clotting occurs throughout body until clotting factors and platelets are depleted; then extensive bleeding
What is the early treatment for DIC
heparin for anticoagulation
What is the late treatment for DIC
clotting factors and platelets
DIC is triggered by .......
cancer, sepsis
An early sign of Superior vena cava syndrome is
facial edema, redness in face and distentions of upper chest
A late sign of superior vena cava syndrome is
swelling in hands, arms
dyspnea
death!!!
What are the treatments for superior vena cava syndrome
high dose radiation to shrink tumor
interventional radiology to remove clot
What is the treatment for spinal cord compression
high dose corticosteroids
high dose radiation
The syndrome of inappropriate secretion of antidiuretic hormone is generally caused by what types of cancers
brain
lung
The fluid retention caused by the SIADH has what effect on sodium levels in the body
hyponatremia b/c of dilution
What is the treatment of SIADH?
increase sodium intake
limit fluids
What are the mild manifestations of SIADH
as a result of hyponatremia:
muscle weakness
muscle cramps
fatigue
What are the more serous manifestions of SIADH?
as a result of hyponatremia:
confusion
seizures
coma
death
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
What effect on the blood does tumor lysis syndrome have?
hyperkalemia
hyperphosphatemia
hyperuricemia
TF: Tumor lysis syndrome results in a decrease in cancer.
True; about 25%
When does tumor lysis syndrome commonly happen?
24-48 hours after the initiation of cancer treatment
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
What are the signs and symptoms of hyperkalemia
EKG: electrical activity of heart
cramps
muscle weakness
parathesis
paralysis
anorexia
nausea
vomiting
tingling
Helpful Reminder:
What is the normal serum level range for potassium
3.5 - 5
Why is there hyperuricemia in tumor lysis syndrome/
The lysis of the cells causes purines to be released with converts into uric acid
Why is there acute renal failure in tumor lysis syndrome?
The uric acid (excess) in the blood precipitates and clogs the kidney tubules.
What is the normal serum range for Sodium?
136 - 145 mEq/L
What is the normal serum range for Calcium?
9.0 - 10.5 mg/dL
What is the normal serum range for Phosphorus
3.0 - 4.5 mg/dL
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
What is the normal serum range for uric acid?
3.6 - 8.3 mg/dL
What chemotherapy drugs were mentioned in class?
cytarabine - antimetabolite
etoposdie - antimiotic
cisplatin - alkylating
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)
What medications should you avoid giving when someone has tumor lysis syndrome?
aspirin
beta blockers
heparin
NSAIDS
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
