NUR2392 Final Exam Multidimensional Care II MDC 2 Exam 1 StudyGuide

Multidimensional Care II Exam 1 Study Guide *The exam questions are not limited to only what is listed on this guide, please refer to your chapter readings and module materials Ch. 21: Principles of Cancer Development  Benign vs. Malignant cells o Benign: Harmless; does not usually require intervention  Normal cells growing in the wrong place or at the wrong time  Result of small problem with cellular regulation  Moles, uterine fibroid tumors, skin tags, endometriosis, nasal polyps  Features of Benign Tumor Cells  Specific morphology occurs with benign tumors. They look like the tissues they come from, retaining the specific morphology of parent cells.  A smaller nuclear-to-cytoplasmic ratio is a feature of benign tumors just like completely normal cells.  Specific differentiated functions continue to be performed by benign tumors. For example, in endometriosis, a type of benign tumor, the normal lining of the uterus (endometrium) grows in an abnormal place (e.g., on an ovary or elsewhere in the abdominal or even the chest cavity). This displaced endometrium acts just like normal endometrium by changing each month under the influence of estrogen. When the hormone level drops and the normal endometrium sheds from the uterus, the displaced endometrium, wherever it is, also sheds.  Tight adherence of benign tumor cells to each other occurs because they continue to make fibronectin.  No migration or wandering of benign tissues occurs because they remain tightly bound and do not invade other body tissues.  Orderly growth with normal growth patterns occurs in benign tumor cells even though their growth is not needed. The fact that growth continues beyond an appropriate time or occurs in the wrong place indicates some problem with CELLULAR REGULATION, but the rate of growth is normal. The benign tumor grows by expansion. It does not invade.  Euploidy (normal chromosomes) are usually found in benign tumor cells, with a few exceptions. Most of these cells have 23 pairs of chromosomes, the correct number for humans. o Malignant: Indicates cancer; serious and can lead to death without intervention  Abnormal  Serve no useful function  Harmful to normal body tissues  Features of malignant/cancer cells  Anaplasia is the cancer cells' loss of the specific appearance of their parent cells. As a cancer cell becomes more malignant, it becomes smaller and rounded. Thus many different types of cancer cells look alike under the microscope.  A larger nuclear-cytoplasmic ratio occurs because the cancer cell nucleus is larger than that of a normal cell and the cancer cell is smaller than a normal cell. The nucleus occupies much of the space within the cancer cell, especially during mitosis, creating a large nuclear-to-cytoplasmic ratio.  Specific functions are lost partially or completely in cancer cells. Cancer cells serve no useful purpose.  Loose adherence is typical for cancer cells because they do not make fibronectin. As a result, cancer cells easily break off from the main tumor. Migration occurs because cancer cells do not bind tightly together and have many enzymes on their cell surfaces. These features allow the cells to slip through blood vessel walls and between tissues, spreading from the main tumor site to many other body sites. The ability to spread (metastasize) is unique to cancer cells and is a major cause of death. Cancer cells invade other tissues, both close by and more remote from the original tumor. Invasion and persistent growth make untreated cancer deadly.  Contact inhibition does not occur in cancer cells because of lost CELLULAR REGULATION, even when all sides of these cells are in continuous contact with the surfaces of other cells. This persistence of cell division makes the disease difficult to manage.  Rapid or continuous cell division occurs in many types of cancer cells because they do not respond to check-point control of cell division because of gene changes that reduce the effectiveness of CELLULAR REGULATION and reenter the cell cycle for mitosis almost continuously. In addition, these cells also do not respond to signals for apoptosis. Most cancer cells have a lot of the enzyme telomerase, which maintains telomeric DNA. As a result, cancer cells do not respond to apoptotic signals and have an unlimited life span (are “immortal”).  Abnormal chromosomes in which the chromosome number and/or structure is not normal (aneuploidy) are common in cancer cells as they become more malignant. Chromosomes are lost, gained, or broken; thus cancer cells can have more than 23 pairs or fewer than 23 pairs. Cancer cells also may have broken and rearranged chromosomes with mutated genes.  Seven warning signs of cancer o C- Changes in bowl and bladder habits o A- A sore that does not heal o U- Unusual bleeding or discharge o T- Thickening or lump in the breast or elsewhere o I- Indigestion or difficulty swallowing o O- Obvious change in a wart or mole o N- Nagging cough or hoarseness  Cancer development stages of malignancy Cancer classification o Classification of Tumors by Tissue of Origin  Prefix: Adeno; tissue of origin: epithelial glands; benign: adenoma; malignant: adenocarcinoma  Prefix: chondro; tissue of origin: cartilage; benign: chondroma; malignant: chondrosarcoma  Prefix: fibro; tissue of origin: fibrous cartilage; benign: fibroma; malignant: fibrosarcoma  Prefix: glio; tissue of origin: glial cells (brain); benign: glioma; malignant: glioblastoma  Prefix: Hemangio; tissue of origin: Blood vessel; benign: Hemangioma; malignant: Hemangiosarcoma  Prefix:Hepato; tissue of origin: Liver; benign: Hepatoma; malignant: Hepatocarcinoma/Hepatoblastoma  Prefix: Leiomyo; tissue of origin: Smooth muscle; benign: Leiomyoma; malignant: Leiomyosarcoma  Prefix: Lipo; tissue of origin: Fat/adipose; benign: Lipoma; malignant: Liposarcoma  Prefix: Lympho; tissue of origin: Lymphoid tissues; no benign; malignant: Malignant lymphomas/Hodgkin's lymphoma/Non-Hodgkin's lymphoma/Burkitt's lymphoma/Cutaneous T-cell  Prefix: Melano; tissue of origin: Pigment-producing skin; no benign; malignant: Melanoma  Prefix: Meningioma; tissue of origin: Meninges; benign: Meningioma; malignant: Malignant meningioma/Meningioblastoma  Prefix: Neuro; tissue of origin: Nerve tissue; benign: Neuroma/Neurofibroma; malignant: Neurosarcoma/Neuroblastoma  Prefix: Osteo; tissue of origin: Bone; benign: Osteoma; malignant: Osteosarcoma  Prefix: Renal; tissue of origin: Kidney; no benign; malignant: Renal cell carcinoma  Prefix: Rhabdo; tissue of origin: Skeletal muscle; benign: Rhabdomyoma; malignant: Rhabdomyosarcoma  Prefix: Squamous; tissue of origin: Epithelial layer of skin/mucous membranes/organ linings; benign: Papilloma; malignant: Squamous cell carcinoma of skin/bladder/lungs/ cervix o Carcinogenesis/Oncogenesis  Development of cancer o Tumor Grading  Grading is needed because some cancer cells are “more malignant” than others, varying in their aggressiveness and sensitivity to treatment.  Poorly differentiated: cells barely resemble the mature tissue from which they arose, aggressive, and spread rapidly.  Well differentiated: less malignant, more closely resemble the mature tissue from which they arose, less aggressive.  Grade Cellular Characteristics  Gx  Grade cannot be determined  G1  Tumor cells are well differentiated and closely resemble the normal cells from which they arose.  Grade is considered a low grade of malignant change.  These tumors are malignant but are relatively slow growing.  G2  Tumor cells are moderately differentiated; they still retain some of the characteristics of normal cells, but also have more malignant characteristics than do G1 tumor cells. G3  Tumor cells are poorly differentiated, but the tissue of origin can usually be established.  The cells have few normal cell characteristics.  G4  Tumor cells are poorly differentiated and retain no normal cell characteristics.  Determination of the tissue of origin is difficult and perhaps impossible. o Ploidy  The description of cancer cells by chromosome number and appearance.  Euploidy is normal number of chromosomes (46, 23 pairs)  Aneuploidy: gain or lose of whole chromosomes, may have structural abnormalities of the remaining chromosomes. o Staging  determines the exact location of the cancer and whether metastasis has occurred.  Clinical staging  Assesses the patient's symptoms and evaluates tumor size and possible spread.  Surgical staging  Assesses the tumor size, number, sites, and spread by inspection at surgery.  Pathologic staging  The most definitive type, determining the tumor size, number, sites, and spread by pathologic examination of tissues obtained at surgery. o Tumor, node, metastasis (TNM) system  used to describe the anatomic extent of cancers.  TNM Classification  Primary Tumor (T)  Tx: Primary tumor cannot be assessed  T0: No evidence of primary tumor  Tis: Carcinoma in site  T1, T2, T3, T4: increasing size and/or local extent of the primary tumor  Regional Lymph Nodes (N)  Nx: regional lymph nodes cannot be assessed  N0: no regional lymph node metastasis  N1, N2, N3: increasing involvement of regional lymph nodes  Distant Metastasis (M)  Mx: presence of distant metastasis cannot be assessed  M0: no distant metastasis  M1: distant metastasis o Tumor growth is assessed in terms of  Doubling time  The amount of time it takes for a tumor to double in size  Mitotic index  The percentage of actively dividing cells within a tumor  Cancer prevention (primary vs. secondary) o Primary Prevention  Avoidance of known carcinogens  Use sunscreen during sun exposure  Don’t use tobacco  Eliminate exposure to asbestos particles  Modifying associated risk  Limit alcohol use High fat, low fiber diet is associated with colon, breast, and ovarian cancer  Multiple sex partners is associated with cervical cancer  Removal of “at risk” tissue  Remove moles to prevent conversion to skin cancer  Remove colon polyps  Remove breasts to prevent breast cancer  Chemoprevention  Uses drugs, chemicals, natural nutrients, or other substances to disrupt one or more steps important to cancer development.  Vaccination  Currently the only vaccines approved for prevention of cancer are related to prevention of infection from several forms of the human papilloma virus (HPV). o Secondary Prevention  Regular screening  Does not reduce cancer incidence but can greatly reduce some types of cancer deaths.  Mammography  Annual for women 40-54  Annual or biannual for women 55+  Clinical breast examination  Every 3 years for women 20-39  Annual for women 40+  Colonoscopy  At age 50 then every 10 years  Fecal occult blood test  Annual for adults of all ages  Digital rectal examination (DRE)  Men older than 50  Types of cancers (carcinoma, sarcoma, melanoma, lymphoma, leukemia, blastoma) o Carcinoma: Starts in the cells that make up the skin or tissue lining organs. Basal cells, Squamous cells, Renal cells, Adenocarcinoma. o Sarcoma: Begins in the bones and in the soft connective tissue. o Melanoma: serious form of skin cancer that begins in melanocytes. More dangerous than carcinoma. Spreads rapidly. o Lymphoma: cancer that begins in the lymphocytes (immune system) lymph nodes, spleen, thymus, bone marrow. Lymphocytes grow out of control. o Leukemia: Cancer of the blood forming tissues including bone marrow and lymphatics. o Blastoma: Type of cancer that is caused by malignancies in precursor cells or ‘blasts.’ Like osteoblastoma, nephroblastoma, retinoblastoma. Ch. 22: Care of Patients with Cancer  Diagnostic tests and lab values (biopsy, imaging, absolute neutrophil count, RBC/PLT/WBC ranges) o Biopsy o Imaging  Imaging with CT or MRI is essential for diagnosis and treatment planning. o Absolute neutrophil count o RBC range o PLT range o WBC range  Risk factors  Types of therapy (i.e. surgery, radiation, chemotherapy)o Surgical Therapy  Oldest form of cancer treatment  Prophylactic  Removes potentially cancerous tissue as a means of preventing cancer development.  Diagnostic (excisional biopsy)  The removal of all or part of a suspected lesion for examination and testing to confirm or rule out a cancer diagnosis.  Curative  Removes all cancer tissue  Surgery alone can result in a cure when all visible and microscopic tumor is removed or destroyed.  Control/cytoreductive  Removes part of the tumor when removal of the entire mass is not possible.  “debulking”  Palliative  Focuses on providing symptom relief and improving the quality of life but is not curative.  Reconstructive/rehabilitative  Increases function, enhances appearance, or both.  Breast reconstruction after mastectomy  Cosmetic reconstruction in head and neck cancer  Assessing therapy effectiveness o Radiation Therapy  Purpose—Destroy cancer cells with minimal damaging effects of surrounding normal cells; maintain safe environment  Local treatment  The effects of radiation are seen only in tissues within the radiation field or path, thus this type of therapy  Ionizing radiation  The cell's DNA is damaged directly, or DNA-damaging charged particles (free radicals) are formed, resulting in a change in CELLULAR REGULATION.  Exposure—Amount of radiation delivered  Radiation dose—Amount of radiation absorbed o Cytotoxic Systemic Therapy  Refers to use of chemotherapy drugs that are used to kill cancer cells and disrupt their cellular regulation.  Treatment of cancer with chemical agents  Used to cure and increase survival time  Adjuvant therapy = Chemotherapy + surgery or radiation  Cytotoxic effects exerted on healthy cells and cancer cells  Chemotherapy Drugs  Alkylating agents  Antimetabolites  Antimitotic agents  Antitumor antibodies  Topoisomerase inhibitors  Miscellaneous chemotherapeutic agents o Immunotherapy Biological response modifiers and targeted therapies  Modify patient’s biologic responses to tumor cells  Can have direct antitumor activity  Can interfere with cancer cell differentiation, transformation, metastasis  Can improve immune function  Monoclonal Antibodies  Bind to target antigens (often specific cell surface membrane proteins)  Prevents protein from functioning, prevents cell division  Rituximab (Rituxan)  Tyrosine Kinase Inhibitors  Inhibits activation of tyrosine kinase inhibitors (TKIs)  Side effects—Fluid retention, electrolyte imbalances, bone marrow suppression  Epidermal Growth Factor/Receptor Inhibitors  Block epidermal growth factor from binding to cell surface receptor  Trastuzumab (Herceptin)—Side effects include skin reactions, adverse effects on heart  Vascular Endothelial Growth Factor/Receptor Inhibitors  Bind to vascular endothelial growth factor (VEGF), prevents binding of VEGF with its receptors on surfaces of endothelial cells present in blood vessels  Bevacizumab (Avastin)—Side effects include hypertension, impaired wound healing, bone marrow suppression  Multikinase Inhibitors (MKIs)  Inhibit activity of specific kinases in cancer cells and tumor blood vessels  Sunitinib (Sutent)—Side effects include hypertension, GI distress, mucositis, mild neutropenia and thrombocytopenia  Proteasome Inhibitors  Prevents formation of a large complex of proteins into cells  Bortezomib (Velcade)—Side effects include GI distress, decreased taste sensation, peripheral neuropathy  Angiogenesis Inhibitors  Targets mammalian target of rapamycin (mTOR)  Temsirolimus (Torisel)—Side effects include bone marrow suppression, headache, GI distress, muscle, and joint pain o Photodynamic Therapy  Selective destruction of cancer cells via chemical reaction triggered by types of light o Hormonal Therapy  Changing usual hormone responses  Some hormones make hormone-sensitive tumors grow more rapidly  Decreasing the hormone amounts to hormone-sensitive tumors can slow cancer growth rate  Steroids, steroid analogues, enzyme inhibitors  Surgical classification types o  Side Effects of therapies o Surgical Therapy  Loss of a body part or its function to ensure removal of all cancerous tissue.  Sometimes whole organs are removed (kidney, lung, breast, testis, limb, tongue)  Any organ loss reduces function  Scarring or disfigurement The removal of the affected area can cause profound changes in appearance or activity level and can lead to depression, grief, and decreased enjoyment in life. o Radiation Therapy  Acute and long-term site-specific changes  Vary according to site  Local skin changes and hair loss  Altered taste sensations  Fatigue  Bone marrow suppression o Chemotherapy  Infection risk  Bone marrow suppression  Neutropenia  Anemia, thrombocytopenia risk  Bone marrow suppression  Impaired clotting  Chemotherapy-induced nausea and vomiting (CINV)  Mucositis  Alopecia  Cognitive changes  Chemotherapy-induced peripheral neuropathy (CIPN) o Hormonal therapy  Masculinizing effects in women  Feminizing effects in men (gynecomastia)  Fluid retention  Acne  Hypercalcemia  Liver dysfunction  Venous thromboembolism  Oncological emergency classification types (what are they, how do you assess it, how do you treat it?) o Sepsis (septicemia)  A condition in which organisms enter the bloodstream (bloodstream infection [BSI]) and can result in septic shock, a life-threatening condition.  Adults with cancer who have low white blood cell counts (WBCs) (neutropenia) and impaired IMMUNITY from cancer therapy are at risk for infection and sepsis. o Intravascular coagulation  Disseminated intravascular coagulation (DIC) is a problem with the blood-CLOTTING process.  In patients with cancer DIC often is caused by gram-negative sepsis, although viral and other bacterial infections can trigger it.  Extensive, abnormal CLOTTING occurs throughout the small blood vessels  Clots block blood vessels and decrease blood flow to major body organs and result in pain, ischemia, stroke-like symptoms, dyspnea, tachycardia, reduced kidney function, and bowel necrosis. o SIADH (syndrome of inappropriate antidiuretic hormone)  Mild symptoms include weakness, muscle cramps, loss of appetite, and fatigue.  Serum sodium levels range from 115 to 120 mEq/L (mmol/L) or lower.  With greater fluid retention, weight gain, nervous system changes, personality changes, confusion, and extreme muscle weakness occur. o Spinal cord compression  Requires immediate intervention to relieve pain and prevent neurologic damage. Occurs either when a tumor directly enters the spinal cord or spinal column or when the vertebrae collapse from tumor degradation of the bone. o Hypercalcemia  Increased serum calcium level  Occurs in up to 1/3rd of cancer patients.  Metabolic emergency and can lead to death  Common symptoms include skeletal pain, kidney stones, abdominal discomfort, and altered cognition that can range from lethargy to coma.  Additional symptoms include fatigue, loss of appetite, nausea/vomiting, constipation, and increased urine output.  More serious problems include severe muscle weakness, loss of deep tendon reflexes, paralytic ileus, dehydration, and electrocardiographic (ECG) changes. o Superior vena cava syndrome (compression of SVC by lymph nodes and tumors)  Which returns all blood from the head, neck, and upper extremities to the heart, has thin walls, and compression or obstruction by tumor growth or by clots in the vessel leads to congestion of the blood.  Painful and life threatening  Early signs and symptoms  edema of the face, especially around the eyes (periorbital edema) on arising in the morning, and tightness of the collar.  Engorged blood vessels and erythema of upper body  edema in arms and hands  dyspnea  Stridor (indicates narrowing of pharynx or larynx)  Late symptoms  Hemorrhage  Cyanosis  Mental status changes  Decreased cardiac output  Hypotension.  Death results if compression is not relieved o Tumor lysis syndrome  Large numbers of tumor cells are destroyed rapidly. The intracellular contents of damaged cancer cells, including potassium and purines (DNA components), are released into the bloodstream faster than the body can eliminate them Ch. 7: End-of-Life Care Concepts  Hospice vs. Palliative care o Hospice  Model for quality, compassionate care for those facing life-limiting illness or injury  Patients have a prognosis of 6 months or less to live  Care is provided when curative treatment such as chemotherapy has been stopped.  Care is provided in 60- and 90-day periods with an opportunity to continue if eligibility criteria are met.  Ongoing care is provided by RNs, social workers, chaplains, and volunteers. o Palliative  Philosophy of care for those with life-threatening disease  Provided by physician, nurse practitioner, or team  Patients can be in any stage of serious illness  A consultation is provided that is concurrent with curative therapies or therapies that prolong life.  Care is not limited by specific time periods.  Care is in the form of a consult visit by a primary health care provider who makes recommendations; follow-up visits may be provided.  Assessment findings o Noticing  Weakness  Sleeping more  Anorexia  Changes in organ system function  Cold, mottled, cyanotic extremities  Changes in breathing pattern  Decreased level of consciousness (LOC) o Psychosocial  Fear and/or anxiety  Difficulty coping  Assess cultural considerations, values, religious beliefs  Spiritual assessment HOPE mnemonic  H: Sources of hope and strength  O: Organized religion (if any) and role that it plays in one's life  P: Personal spirituality, rituals, and practices  E: Effects of religion and spirituality on care and end-of-life decisions o Interventions: Responding  Needs and preferences met  Control of symptoms of distress  Meaningful interactions with family  Peaceful death  Managing symptoms and needs o Managing Symptoms  Pain  Nonopioid and opioid analgesics Oral medications may not be easy for patient to swallow, long-acting opioids usually cannot be crushed. Rectal, transdermal, IV, or subcutaneous routes may be necessary.  Short-acting analgesics are quick acting; effective; and safe to administer, even to comatose patients.  Pain in older adults is often underreported and undertreated. Do not withhold opioid drugs from older adults at the end of their lives. Instead give low doses of opioids initially, with slow increases, monitoring for changes in mental status or excessive sedation.  Complementary and integrative health  Massage  Music therapy  Therapeutic touch  Aromatherapy  Weakness  Altered routes of medication administration  Choose least invasive route with most effective treatment  Advised to remain in bed to avoid falls and injuries  Aspiration precautions  Mechanical and electronic beds to elevate head and promote air exchange and facilitate administration of medication, food, or fluids.  Weakness combined with decreased neurologic function may impair the ability to swallow (dysphagia).  Oral intake should be limited to soft foods and sips of liquids, offered but not forced.  Teach families about the risk for aspiration and reassure them that anorexia is normal at this stage.  Impaired COMFORT from fluid replacement could lead to respiratory secretions (and distress), increased GI secretions, nausea, vomiting, edema, and ascites.  To avoid a dry mouth and lips, moisten them with soft applicators and apply an emollient to lips.  Breathlessness/dyspnea  Dyspnea is a subjective experience in which the patient has an uncomfortable feeling of breathlessness, often described as terrifying.  Pharmacologic  Opioids such as morphine sulfate are the standard treatment for dyspnea near death.  They work by (1) altering the perception of air hunger, reducing anxiety and associated oxygen consumption, and (2) reducing pulmonary congestion.  Oxygen therapy for dyspnea near death has not been established as a standard of care for all patients.  2-6L nasal cannula, if not effective, discontinue O2  Bronchodilators via MDI or nebulizer for symptoms of bronchospasm (heard as wheezes)  Corticosteroids for bronchospasm and inflammatory problems within and outside the lungs.  Superior vena cava syndrome and cancer-related lymphangitis causing dyspnea may respond to corticosteroids.  People who have fluid overload with dyspnea, crackles on auscultation, peripheral edema, and other signs of chronic congestive heart failure (CHF) may be given a diuretic such as furosemide (Lasix, Uritol) todecrease blood volume, reduce vascular congestion, and reduce the workload of the heart.  Antibiotics for respiratory infection.  Loud, wet respirations referred to as the death rattle  Anticholinergics to dry up secretions  Fear and anxiety may be components of respiratory distress at end of life.  Benzodiazepines are commonly given when morphine does not fully control the person’s dyspnea.  Nonpharmacologic interventions  Electric fan for air circulation  Limit exertion to avoid external dyspnea  Insert long-term foley catheter to avoid exertion  Reposition patient with head of bed up either in hospital bed or reclining chair to increase chest expansion  Applying wet cloths to the patient’s face  Encouraging imagery and deep breathing  Nausea and vomiting  Pharmacologic  If constipation is identified as the cause of nausea and vomiting, give the patient a biphosphate enema (e.g., Fleet) to remove stool quickly.  If stool in the rectum cannot be evacuated, a mineral oil enema followed by gentle disimpaction may relieve the patient's distress.  N/V related to other causes can be controlled by one or more antiemetics  Prochlorperazine (Compazine)  Ondansetron (Zofran)  Dexamethasone (Decadron, Deronil, Dexasone)  Metoclopramide (Reglan, Maxeran)  In addition to providing medications, be sure to remove sources of odors and keep the room temperature at a level that the patient desires.  Complementary and integrative health  Aromatherapy  Chamomile, camphor, fennel, lavender, peppermint, and rose may reduce or relieve vomiting.  Some patients may have worsening nausea with aroma.  Ask patient and family about preferences.  Agitation and delirium  Assess for pain or urinary retention, constipation, or another reversible cause.  If ruled out, delirium is suspected  Pharmacologic  When delirium occurs in the week or two before death, it is referred to as terminal delirium.  Possible causes include the adverse effects of opioids, benzodiazepines, anticholinergics, or steroids.  If medications are suspected causes, they may be decreased or discontinued.  Ideally antipsychotic drugs are given only to control psychotic symptoms such as hallucinations and delusions.  However, if they are needed to facilitate COMFORT, they should be available. Benzodiazepines generally are not used as a first choice for older adults with agitation because of their risk for causing delirium.  Could cause a paradoxical reaction  Complementary and Integrative Health  Music therapy  Aromatherapy with chamomile may help overcome anxiety, anger, tension, stress, and insomnia  Seizures  Not common for end of life but can occur in patients with brain tumors, advanced AIDS , and pre-existing seizure disorders.  Around the clock drug therapy  Benzodiazepines (diazepam and lorazepam) are drugs of choice.  Second choice are barbiturates (phenobarbital)  Refractory symptoms of distress  Proportionate palliative sedation  Care management approach involving the administration of drugs such as benzodiazepines, neuroleptics, barbiturates, or anesthetic agents for the purpose of decreasing suffering by lowering patient consciousness. o Managing Psychosocial Needs  Grief—Emotional feeling related to the perception of loss  Mourning—Outward social expression of the loss  Interventions are based on cultural beliefs, values, and practices  Presence  Listening and acknowledging the legitimacy of the patient's and/or family's impending loss are often more therapeutic than speaking  Therapeutic communication  Life review  A structured process of reflecting on what one has done through his or her life.  This is often facilitated by an interviewer.  Reminiscence  The process of randomly reflecting on memories of events in one's life.  Spirituality  Whatever or whoever gives ultimate meaning and purpose in one's life that invites particular ways of being in the world in relation to others, oneself, and the universe.  A person's spirituality may or may not include belief in God.  Religion  Formal belief systems that provide a framework for making sense of life, death, and suffering and responding to universal spiritual questions.  Often have beliefs, rituals, texts, and other practices that are shared by a community.  Basic Beliefs Regarding Care at End of Life and Death Rituals for Selected Religions  Christianity  There are many Christian denominations, which have variations in beliefs regarding medical care near the end of life.  Roman Catholic tradition encourages people to receive Sacrament of the Sick, administered by a priest at any point during an illness. This sacrament may be administered more than once. Not receiving this sacrament will NOT prohibit them from entering heaven after death.  People may be baptized as Roman Catholics in an emergency situation (e.g., person is dying) by a layperson. Otherwise, they are baptized by a priest. Christians believe in an afterlife of heaven or hell once the soul has left the body after death.  Judaism  The dying person is encouraged to recite the confessional or the affirmation of faith, called the Shema.  According to Jewish law, a person who is extremely ill and dying should not be left alone.  The body, which was the vessel and vehicle to the soul, deserves reverence and respect.  The body should not be left unattended until the funeral, which should take place as soon as possible (preferably within 24 hours).  Autopsies are not allowed by Orthodox Jews, except under special circumstances.  The body should not be embalmed, displayed, or cremated.  Islam  Based on belief in one God Allah and his prophet Muhammad. Qur'an is the scripture of Islam, composed of Muhammad's revelations of the Word of God (Allah).  Death is seen as the beginning of a new and better life.  God has prescribed an appointed time of death for everyone.  Qur'an encourages humans to seek treatment and not to refuse treatment. Belief is that only Allah cures but that Allah cures through the work of humans.  On death the eyelids are to be closed, and the body should be covered. Before moving and handling the body, contact someone from the person's mosque to perform rituals of bathing and wrapping body in cloth. Ch. 11: Care of Patients with Problems of Fluid and Electrolyte Balance  Lab values form for normal ranges o Sodium (Na): 135-145 mmol/L o Potassium (K): 3.5-5 mEq/L o Calcium (Ca): 9.0-10.5 mg/dL o Phosphorus (P): 3.0-4.5 mg/dL o Magnesium (Mg): 1.3-2.1 mg/dL o Chloride (Cl): 98-106 mEq/L  Fluid balance and hormonal regulation o Fluid balance  Closely linked to/affected by electrolyte concentrations  Fluid intake  Regulated through the thirst drive.  Fluid enters the body as fluids and solid food, which contain up to 85% water.  Fluid loss  Kidneys is most important and most sensitive water loss route because it is regulated and adjustable.  Minimum urine amount needed to excrete toxic waste products is 400 to 600 mL/day  Insensible water loss—through skin, lungs, stool o Hormonal regulation  Aldosterone Secreted by the adrenal cortex whenever sodium levels in the extracellular fluid (ECF) are low.  Aldosterone prevents both water and sodium loss.  When secreted, it acts on the kidney nephrons, triggering them to reabsorb sodium and water from the urine back into the blood.  Increases blood osmolarity and blood volume.  Aldosterone also promotes kidney potassium excretion.  Antidiuretic hormone (ADH, or vasopressin)  Released from posterior pituitary gland in response to changes in blood osmolarity.  Increased blood osmolarity, especially an increase in the level of plasma sodium, results in a slight shrinkage of these cells and triggers ADH release from the posterior pituitary gland.  Because ADH only retains water, it can only indirectly regulate electrolyte retention or excretion.  ADH acts on kidney nephrons, making them more permeable to water.  Water is reabsorbed, blood osmolarity is decreased, more dilute.  Natriuretic peptides  Hormones secreted by special cells that line the atria and ventricles of the heart.  Secreted in response to increased blood volume and blood pressure, which stretch the heart tissue.  Kidney reabsorption of sodium is inhibited at the same time that urine output is increased.  The outcome is decreased circulating blood volume and decreased blood osmolarity.  Assessment and treatment of dehydration and fluid overload o Assessment of dehydration  Fluid intake/retention does not meet body’s fluid needs; results in fluid volume deficit  Physical/clinical manifestations  Cardiovascular  Orthostatic and postural hypotension  Distended neck veins  Respiratory  Increased RR because decreased volume reduces perfusion and gas exchange.  Compensatory to attempt to maintain oxygen delivery when perfusion is decreased.  Skin  Mucous membrane color, moisture, turgor.  Oral mucous membrane may be dry and covered with thick, sticky coating and may have cracks and fissures  Tongue may have deep furrows  Neurologic  Change in mental status  Change in temperature with reduced perfusion in the brain  With every degree (Celsius) increase in body temperature above normal, a minimum of an additional 500mL of body fluid is lost.  Renal  Urine volume and concentration  Urine specific gravity greater than 1.030  Dark amber color Strong odor  Urine output of 500ml/day for a patient without kidney disease is cause for concern  Weight change of 1lb = fluid volume change of about 500mL o Treatment of dehydration  Increase fluid intake (especially water)  Nutrition therapy  Fluid replacement  Drug therapy  Patient safety  Monitor intake and output o Assessment of fluid overload (overhydration)  Fluid intake or retention is greater than the body’s fluid needs.  Most common type is hypervolemia because the problems result from excessive fluid in the ECF space.  Physical/clinical manifestations  Pulmonary edema  Cardiovascular Changes  Increased pulse rate  Bounding pulse quality  Elevated blood pressure  Decreased pulse pressure  Elevated central venous pressure  Distended neck and hand veins  Engorged varicose veins  Weight gain  Respiratory Changes  Increased respiratory rate  Shallow respirations  Shortness of breath  Moist crackles present on auscultation  Skin and Mucous Membrane Changes  Pitting edema in dependent areas  Skin pale and cool to touch  Neuromuscular Changes  Altered level of consciousness  Headache  Visual disturbances  Skeletal muscle weakness  Paresthesia’s  Gastrointestinal Changes  Increased motility  Enlarged liver o Treatment of fluid overload  S/S of hypo/hyper ______ o Signs and symptoms of  Hyponatremia (weak and shakey)  Cerebral  Cerebral edema  Increased ICP  Confusion/lethargic/trouble concentrating  Neuromuscular Seizures/stupor  General muscle weakness  Late sign= shallow respirations  Decreased DTR  GI/GU  Nausea  Diarrhea  Hyperactive bowel sounds  Frequent and watery stools  Abdominal cramping  Loss of urine  Loss of appetite  Cardiovascular  Rapid, weak, thready pulse  Decreased BP  Orthostatic hypotension  Light-headedness or dizziness  Hypernatremia (big and bloated)  Nervous system  Altered cerebral function  Short attention span  Agitated, confused  Lethargic, stuporous (near-unconsciousness), comatose  Skeletal muscle  Muscle twitching  Irregular muscle contractions  Muscle weakness  Decreased DTR  Cardiovascular  Decreased contractability  Pulse rate increased  Hypotension/severe orthostatic hypotension  Neck veins distended  Increased BP  Additional S/S  Flushed skin  Fever  Increased fluid retention=EDEMA  Decreased urine output  Dry mouth and skin  Hypokalemia (low and slow)  Respiratory  Shallow respiration, diminished breath sounds  Musculoskeletal  Decreased DTR, flaccid paralysis, weak, leg cramps  Cardiovascular  Irregular, thready pulse  Decreased BP  Decreased HR  Orthostatic hypotension  Pulse thready and weak  EKG: decreased ST segment, inverted T wave, prominent U wave Neurologic  AMS  Confusion  GI/GU  Decreased bowel sounds  N/V  Constipation  Abdominal distention  Increased urination  Hyperkalemia (tight and contracted)  Cardiovascular  Irregular heartbeat= ST elevation, peaked T wave  Decreased BP  Decreased HR  Severe VFib  Flat or absent p waves, wide QRS  Neuromuscular  Muscle weakness  Flaccid paralysis  Hyperactive BIG muscle weakness  Cramping, decreased DTRs, tingling, bringing, numbness of hands, feet, and around mouth y  GI  Increased motility  Diarrhea, hyperactive bowel sounds  Frequent and watery  Respiratory  Respiratory failure  Hypocalcemia (wild and crazy)  Neuromuscular  Positive Trousseau sign  Positive Chvostek sign  Tingling around lips, nose, and ears  Cardiovascular  Prolonged QT/ST (severe VTach)  Heart failure  Slow clotting factors= bleeding  Severe hypotension  Weak, thready pulse  GI  GI system going crazy= diarrhea  Hypoactive bowel sounds  Painful cramping  Skeletal  Loss of bone density  Increased brittleness  Vertebrae become more compact and may bend forward  Leads to overall loss of height  Spinal curvatures  Respiratory  Laryngospasms, dyspnea  Neurological ALOC, seizures, confused  Hypercalcemia (slow and swollen)  Neuromuscular  Severe muscle weakness  Decreased muscle excitability  Decreased DTR w/o paresthesia  Confusion  Lethargy  ALOC  Cardiovascular  Decreased HR  Decreased RR  Decreased BP  Short QT, Wide Twave, heart muscle spasm  Increased blood clotting  GI/GU  Hypoactive GI= constipation  Bowel sounds hypoactive or absent  N/V  Abdominal distention  Renal calculi  Skeletal  Bone pain: excess calcium was taken from bone  Respirations  SOB, weak respirations  Hypophosphatemia (brittle and weak)  Neuromuscular  Cardiovascular  GI  Skeletal  Muscle weakness (hint: lungs)  Decreased DTR  Decreased cardiac output  Osteomalacia (risk: fractures)  Immunosuppression= decreased platelets, increased bleeding  Irritable, seizure risk, confusion  Hyperphosphatemia (same as hypocalcemia)  Neuromuscular  Cardiovascular  GI  Skeletal  Trousseau sign  Chvostek sign  Muscle spasms (Tetany) in calves and feet  Hyperactive DTRs, bone pain  Laryngospasms  Confused/mental status changes  Hypomagnesemia (muscles go wild)  Neuromuscular  Cardiovascular  GI  Skeletal Increased HR  Increased RR (shallow)  Prolonged QT interval  Depressed ST segment, inverted Twave  Dyspnea  Diarrhea  Increased DTR (clonus), numbness, tingling  Confusion, insomnia, seizures  Hypermagnesemia (too relaxed)  Neuromuscular  Cardiovascular  GI  Skeletal  Decreased BP  Decreased HR  Decreased RR  Widened QRs, prolonged PR interval  Hypoactive bowel sounds  Decreased DTRs or absent  Drowsy, lethargic  Coma  Hypochloremia  fluid loss  dehydration  weakness or fatigue  difficulty breathing  diarrhea or vomiting, caused by fluid loss  Hyperchloremia  fatigue  muscle weakness  excessive thirst  dry mucous membranes  high BP  Hypoglycemia (cold and clammy, give some candy)  He’S- Headache/Sweaty  T- Tachycardia  I- Irritability  R- Restlessness  E- Excessive hunger  D- Dizziness  Hyperglycemia (Hot and dry, sugar high)  Polydipsia (increased thirst)  Polyphagia (increased hunger)  Polyuria (increased urine)  Glycosuria  Headache, blurred vision, diplopia  Numbness, tingling, N/V  Electrolyte changes with disease processes or treatment (i.e. DKA, end-stage renal failure, vomiting) o DKA  Caused from an imbalance of insulin and improper insulin adherence  Always treat dehydration first! – 0.9% NS  If BG is over 250, IV regular insulin Add K+ during IV insulin  Hourly BG checks with telemetry monitoring  Osmotic diuresis  Electrolyte disturbance  Increased plasma potassium  Reduced/normal plasma sodium o ESRF  Hypervolemia  Hyperkalemia  Hyperphosphatemia  Hypocalcemia  Metabolic acidosis (bicarb deficiency) o Vomiting  Dehydration  Loss of hydrochloric acid (hydrogen and chloride ions)  Hypokalemia and hyponatremia  Electrolyte replacements (type and how is it administered?) o When dehydration is severe or patient cannot tolerate oral fluids, IV fluid replacement is needed. o Crystalloids are IV fluids that contain water, minerals (electrolytes), and sometimes other watersoluble substances such as glucose.  These fluids rapidly disperse to all body fluid compartments and are most useful when dehydration includes both the intracellular and extracellular compartments. o Colloids are IV fluids that contain larger non–water-soluble molecules that increase the osmotic pressure in the plasma volume.  These fluids are most useful in helping to maintain plasma volume with a lower infused volume  Types of fluids (isotonic, hypotonic, hypertonic) o Isotonic  The normal osmolarity value for plasma and other body fluids ranges from 270 to about 300 mOsm/L.  The body functions best when the osmolarity of all body fluid spaces is close to 300 mOsm/L.  Isotonic fluids  0.9% saline (NS)  5% dextrose in water (D5W)  5% dextrose in 0.225% saline  Ringer’s Lactate o Hypotonic  Fluids with osmolarities of less than 270 mOsm/L  Hypotonic fluids  0.45% saline (1/2 NS) o Hypertonic  Fluids with osmolarities greater than 300 mOsm/L  Hypertonic fluids  10% dextrose in water (D10W)  5% dextrose in 0.9% saline  5% dextrose in 0.45% saline (when in IV bag; once infused, the glucose is rapidly metabolized, and the fluid is really hypotonic)  5% dextrose in Ringer’s lactate