Essentials Exam 3

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Essentials Exam 3
2011-11-16 23:58:20
Essentials Nursing exam

HTN, Cancer, CH 8, 9, 10
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  1. Nursing considerations for assessing blood pressure
    • Initially
    • you should take the BP at least 2 times, at least 1 min apart (allows
    • the venous blood to drain from the arm and prevents inaccurate
    • readings). Record average pressure as value for that visit.You must place the patient’s arm at the level of the heart, no matter what position.If
    • neither arm can be used for BP measurement, use the forearm. Position
    • midway between elbow and wrist. Ascultate over the radial artery or use a
    • doppler to detect systolic. The forearm and upper arm positions are not
    • interchangable and it must be documented if you used forearm. Measure
    • BP in both arms initially to detect differences. Atherosclerotic
    • narrowing of the subclavian artery can cause a falsely low reading.If BPs are not equal on both sides, document the highest reading.Assess
    • for orthostatic changes in BP and pulse in older adults, in people
    • taking antihypertensive drugs, and in patients who report symptoms.
    • Check BP in the supine, sitting, and standing positions with 1-2 mins of
    • rest in between. A decrease of 20 mmHg in systolic and a decrease of 10
    • mmHg or more in diastolic and/or an increase in heart rate greater than
    • 20 beats from supine to standing defines orthostatic hypotension. Screening:
    • controlling BP in persons already indentified as having HTN,
    • identifying and controlling BP in at-risk groups, and screening those
    • with limited access to the health care system.Primary
    • nursing responsibilities for long term managment of HTN are to assist
    • the patient in reducing BP and complying with the treatment plan.BP readings taken at home are often lower than in the office setting due to the white coat effect.Instruct patient not to smoke, exercise, or drink caffeine for 30 mins before measuring BP.Major
    • problem is poor compliance: reasons include inadequate patient
    • teaching, unpleasant side effects of drugs, return of BP to normal range
    • while on meds, lack of motivation, high cost of drugs, lack of
    • insurance, and lack of a trusting relationship between patient and care
    • provider.
  2. Risk factors for the development of HTN
    Primary HTNAge- SBP rises with increasing ageAlcohol- limit daily intake to 1 oz of alcoholCigarette smoking- increases risk of cardiovascular diseaseDM- combined with HTN, complications become more severeElevated serum lipids- increase risk for artherosclerosisExcess dietary sodium- can also decrease effectiveness of certain anti-HTN medsGender- more prevelant in men <55. After age 55, HTN more prevelent in women.Family historyObesity- risk is greatest with central abdominal obesityEthnicity- 2x higher in blacksSedentary lifestyle- physical activity decreases BPSocioeconomic status- more prevelent in lower socioeconomic groups and among the less educatedStress Secondary HTNCirrhosisCoarctation or congenital narrowing of the aortaEndocrine disorders (Cushing syndrome)Medications (stimulants)Pregnancy- induced HTNRenal diseaseSleep apneaNeurologic disorders (brain tumors)Estrogen replacement therapy, oral contraceptives, NSAIDS
  3. What is pre hypertension? What do you do about it?
    Pre-hypertension is defined as:Systolic BP: 120 to 139 mmHg ORDiastolic BP: 80 to 89 mmHgPt’s with pre-hypertension should:No hypertensive drug indicated Increased screening and monitor BPLifestyle ModificationExerciseDietReduce sodium and salt intake Limit consumption of alcohol Weight reduction
  4. Consequences of HTN
    HTN is often called the “silent killer” b/c it is frequently asymptomatic until target organ disease occursTarget organ diseases occur most frequently in the:Heart: Hypertensive Heart DiseaseCoronary artery diseaseleft ventricular hypertrophyheart failurebrain: Cerebrovascular diseasetransischemic attack (TIA)stroke (CVA)peripheral vasculature: Peripheral Vascular Diseaseintermittent claudicationaneurysmkidney: nephrosclerosiseyes: retinal damage5. Patient education considerations for
  5. Patient education considerations for HTN<--Listed all the “Hypertension Collaborative Care”
    Overall GoalsControl blood pressureReduce CVD Risk FactorsStrategies for Adherence to RegimensEmpathy increases patient trust, motivation, and adherence to therapyConsider patient’s cultural beliefs and individual attitudes when formulation treatment goalsFrequent blood pressure measurement Lifestyle ModificationsWeight Reduction: Weight loss of 10 kg (22lb) ay derease SBP by approximately 5-20 mmHgDASH Eating PlanDietary Sodium Reduction: <2300 mg of sodium/dayModeration of Alcohol ConsumptionMen: No more than 2 drinks/dayWomen: No more than 1 drink/dayPhysical Activity: Regular physical (aerobic) activity at least 30 minutes. most day of the weekAvoidance of tobacco productsPsychosocial risk factorsDrug Therapy: Primary Actions of drugs to treat hypertensionReduce SVRReduce Volume of Circulating BloodIdentify, repor and minimize side effects with drug therapy and patient teaching:Orthostatic HypotensionSexual DysfuctionDry MouthFrequent Urination Classificaitons of drugs used to treat hypertension:DiureticsAdrenergica inhibitorsDirect vasodilatorsAngiotensin-converting enzyme inhibitorsAngiotensin II receptor blockersCalcium channel blockers
  6. Symptoms for HTN
    • Pts are usually ASYMPTOMATIC until it becomes severe and secondary target organ disease occursSymptoms
    • in severe HTN occur secondary to effects on blood vessels in the
    • various organs and tissues due to increased work load of the heart. They
    • can include:FatigueReduced activity toleranceDizzinessPalpitations, AnginaDyspnea
  7. Stage I HTN
    Stage 1SBP 140-159or DBP 90-99Symptoms:AsymptomaticPossible Symptoms:dull headaches, dizziness, nosebleedsTreatment:Thiazide-type diuretics for more. May consider ACE Inhibitor, ARB, BB, CCB or combination Lifestyle Modifications (See Question 5)Diet Considerations DASH Diet
  8. Stage II HTN
    SBP ≥160or DBP ≥100Symptoms:Mostly asymptomaticTreatment:Two-drug combination for most (usually thiazide-type diuretic and ACE inhibitor or ARB or BB or CCB)Lifestyle Modifications (See Question 5)
  9. Primary HTN
    • Primary Hypertension:
    • elevated BP without identified cause. Contributing factors: SNS
    • activity, overproduction of sodium-retaining hormone and
    • vasoconstricting substances, increased sodium intake, greater than ideal
    • body weight, DM, and excessive alcohol consumption. Most times patinets
    • are asymptomatic but can develop symptoms secondary to effects on blood
    • vessels in the various organs and tissues or the increased work load of
    • the heart including: fatigue, reduced activity tolerance, dizziness,
    • palpitations, angina, and dyspnea. Pt with hypertensive crisis may
    • experience: headache, dyspnea, anxiety, and nosebleeds. Treatment
    • includes lifestyle modifications ( weight reduction, DASH eating plan
    • that emphasises fruits, veggies, fat free/low fat milk products, whole
    • grains, fish poultry, beans, seeds, and nuts; Dietary sodium reduction,
    • moderation of acohlol consumption, physical activity, avoidance of
    • tobacco products, and management of psychosocial risk factors. Also Drug
    • therapy can be used to treat patients (beta blockers, ace inhibitors,
    • diuretics).
  10. Secondary HTN
    • elevated
    • BP with a specific cause that can be identified and treated. Symptoms
    • include unexplained hypokalemia, abdominal bruit heard over renal
    • artery, variable BP with history of tachycardia, sweating, and tremor,
    • or a family Hx of renal disease. Treatment is aimed at eliminating the
    • underlying cause.
  11. Abnormal Laboratory findings in patients with organ damage associated with HTN
    Urinalysis, creatinine clearanceSerum electrolyte, glucoseBUN and Serum CreatinineSerum lipid profileECGEchocardiogram
  12. Definition of HTN crisis; clinical manifestations of HTN crisis
    Severe increase in BP (>220/140)Often occurs in patients with a history of HTN who have failed to comply with medications or who have been undermedicatedEvidence of Acute Target Organ Damage:Hypertensive Encephalopathy, Cerebral HemorrhageAcute Renal FailureMyocardial Infarction Heart Failure with Pulmonary EdemaNursing and Collaborative ManagementHospitalizationIV Therapy: Titrated to MAPMonitor cardiac and renal functionNeurologic ChecksDetermine CauseEducation to avoid future crisis
  13. Nursing considerations for administration of chemotherapy agents (including patient education)
    • Very
    • important to know the specific guidelines for administration of
    • chemotherapeutic drugs and to understand that drugs may pose an
    • occupational hazard to health care professionals.A
    • person preparing, transporting, or administering chemo may absorb the
    • drug through inhalation of particles when reconstituting a powder in an
    • open ampule and through skin contact if there is droplet exposure or
    • exposure to powder from other agents.Risk in handling body fluids and excretions of persons receiving chemo immediately following administration for 48 hours.Only
    • those specifically trained in chemo handling techniques should be
    • involved with the preparation and administration of antineoplastic
    • agents. IV site is most commonly used.Drugs
    • may be irritants (damages the intima of the vein, causing phlebitis and
    • sclerosis and limiting future peripheral access) or vesicants (if
    • infiltrated into skin, may cause severe local tissue breakdown and
    • necrosis. If these happen, turn off infusion.Pain
    • is cardinal Sx of extravasation, but it can occur without causing pain.
    • Swelling, reddness, and the presence of vesicles on the skin are other
    • signs of extravasation. After a few days the, the tissue may begin to
    • ulcerate and necrose.To
    • minimize the associated physical discomforts, emotional distress, and
    • risks of infection, IV chemo can be delivered by a central venous access
    • device. Although
    • single drug chemo can be and sometimes is prescribed, combining agents
    • in multidrug regimens has proven to be more effective in managing most
    • cancers. Choosing agents with different mechanisms of sction and varying
    • toxicity profiles avoids tumor cell resistance and may minimize the
    • occurence and severity of side effects. When chemo agents are used in
    • combo however, patients can hav an increased toxicityChemo
    • is most effective when the tumor burden is low, therapy is not
    • interrupted, and pt recieves the intended dose. Dose based on body wt
    • and height using the body surfacce area calculation.
  14. Disadvantages of chemotherapy (I’m not really sure about this one so I’m listing the obvious)
    Side effects: Short-Term and Long Term (Discussed in #3)Toxicity: Chemo cannot distinguish between normal cells and cancer cells Can result in the destruction of rapidly proliferating cells (bone marrow, Integumentary, GI cells)Treatment ScheduleIt may require you to visit daily or weeklyChemo has to be administered through IV, Pill, Central Line or PortTreatment Cost: Expensive especially if long-term treatment is required
  15. Stomatitis, mucosistis, esophagitis
    Assess oral mucosa daily and teach patients to do this· Be aware that eating, swallowing and talking may be difficult (may require analgesics)· Encourage pt to use artificial saliva to manage dryness· Discourage use of irritants such as tobacco and alcohol· Apply topical anesthetics (e.g. viscous lidocaine, oxethazine)· May need feeding tube and high calorie diet· “Magic mouthwash” (Lidocaine, antacid, Benadryl, antibiotic)· Monitor for weight loss
  16. Nausea and Vomiting
    Teach patient to eat and drink when not nauseated· Administer antiemetics (e.g. Zofran or Phenergan) prophylactically prior to chemotherapy and also on as-needed basis· Use diversional activities (if appropriate)· Monitor for electrolyte imbalanceo Hydrate before and after treatment
  17. Anorexia
    Monitor weight· Encourage patient to eat small, frequent meals of high-protein, high-calorie foods· Gently encourage pt to eat to avoid nagging· Serve food in pleasant environment
  18. Diarrhea
    Give anti-diarrheal agents as needed· Encourage low-fiber, low residue diet· Monitor Electrolyte Imbalance· Anal Examination to monitor for irritation and prevent infection
  19. Constipation
    Instruct patients to: Take stool softeners as neededo Eat high fiber foodso Increase fluid intake
  20. Hepatotoxicity
    Monitor liver function tests
  21. Anemia
    · Monitor hemoglobin and hematocrit levels· Administer iron supplements and erythropoietin· Encourage intake of foods that promote RBC production· May require blood transfusion
  22. Leukopenia
    Monitor WBC count, especially neutrophils· Teach pt to report temperature elevation and any other manifestations of infections· Teach pt to avoid large crowds and people with infections· Administer WBC growth factors
  23. Thrombocytopenia·
    Observe for signs of bleeding (e.g. petechiae, ecchymosis)· Monitor platelet counts
  24. Alopecia
    • Suggest ways to cope with hair loss (e.g. hair pieces, scarves, wigs)·
    • Cut long hair before therapy· Avoid excessive shampooing,
    • brushing and combing of hair· Avoid use of electric hair dryers,
    • curlers, and curling rods· Discuss impact of hair loss on self
    • image
  25. Chemo-induced changes
    • · Alert pt to potential skin changes· Encourage pt to avoid sun exposure·
    • Implement symptomatic management as needed depending on skin
    • effect (e.g. application of lotions, benzoyl peroxide for acne,
    • corticosteroid creams)
  26. Hemorrhagic Cystitis
    • Monitor manifestations such as urgency, frequency, and hematuria·
    • Administer cytoprotectant agent (Mesnex) and hydration·
    • Administer supportive care agents for management of symptoms (e.g.
    • Urimax, flavozate)· Empty bladder every 2 Hours· Keep
    • hydrated· Straight Cath to relieve bladder
  27. Reproductive Dysfunction
    • Discuss possibility with patients prior to treatment initiation·
    • Offer opportunity for sperm and ova banking prior to treatment for
    • patients of childbearing age
  28. Nephrotoxicity
    • Monitor BUN and serum creatinine levels· Avoid potentiating
    • drugs· Alkaline the urine with sodium bicarbonate and administer
    • allopurinol or rasburicase for TLS prevention· Decrease meat or
    • alcohol
  29. Nervous SystemIncreased Intracranial Pressure
    Monitor neurologic status· May be controlled with corticosteroids
  30. Peripheral Neuropathy
    • · Monitor for these manifestations in patients on these drugs:o
    • Paresthesias, aneflexia, skeletal muscle weakness, and smooth muscle
    • dysfunction
  31. Chemo-brain
    Keep challenging patients (e.g. wordsearch)· Reversible after chemo
  32. Pneumonitis
    • · Monitor for dry, hacking cough, fever and exertional dyspnea·
    • Administer breathing treatments· Discontinue Treatment
  33. Pericarditis and myocarditis
    · Monitor for clinical manifestations of these disorders
  34. Cardiotoxicity
    • Monitor heart with ECG and cardiac ejection fractions· Drug
    • therapy may need to be modified for symptoms of deteriorating cardiac
    • function studies
  35. Hyperuricemia
    • Monitor uric acid levels· Allopurinol (zyloprim) may be
    • given as a prophylactic measure· Encourage high fluid intake
  36. Fatigue
    • Tell pt that fatigue is an expected side effect of therapy·
    • Encourage pt to rest when fatigued, to maintain usual lifestyle
    • patterns as closely as possible and to pace activities in accordance
    • with energy levels
  37. Laboratory findings for the patient receiving chemotherapy? Which ones concern you and why?
    • BUN & Creatinine increases may indicate hyperuricemiamay be result of nephrotoxicity from chemo drug (e.g. Renal failure!)may be related to Tumor Lysis Syndrome
    • Pancytopenia caused by bone marrow suppressionanemia- decreased circulation, decreased oxygenationleukopenia- increased risk for infection!
    • neutropenia- decrease in first responders break in immune barriers
    • thrombocytopenia- affect coaguability
    • Monitor Electrolytes: hypokalemia (potassium) may result from severe nausea/vomitinghypercalcemia- may result from bone metastasis prohibiting bones from regulating blood calcium levels
    • Monitor urineproteinuria: could indicate renal dysfunctionhematuria could indicate hemorrhagic cystitis (a common side effect of treatment)
    • Four hallmark signs of Tumor Lysis Syndrome: hyperuricemia, hyperphosphatemia, hyperkalemia, hypocalcemia
  38. Benign Tumor
    • usually Encapsulated
    • normally differentiated
    • absent metastasis
    • recurrence rare
    • vascularity slight
    • mode of growth expansive
    • cell characteristics fairly normalsimilar to parent cells
  39. Malignang Tumor
    • rarely Encapsulated
    • poorly differentiated
    • invade and metastasize
    • recurrence possible
    • vascularity moderate to marked
    • mode of growth infiltrative and expansive
    • cell characteristics cells abnormal become more unlike parent cells
  40. Education regarding prevention of cancer; risk factors for cancer
    • Cancer Prevention:
    • Limit alcohol use
    • Get regular physical activity
    • Maintain a normal body weight
    • Obtain regular colorectal screening
    • Avoid cigarette smoking and other tobacco products
    • Get regular mammogram and Pap Tests
    • Use sunscreen with a sun protection factor of 15 or higher
    • Practice healthy dietary habits, such as reduced fat consumption and increased fruit and vegetable consumption
    • Risk Factors:
    • Growing older
    • Tobacco
    • Sunlight Ultraviolet radiation comes from the sun, sunlamps, and tanning booths. It causes early aging of the skin and skin damage that can lead to skin cancer.
    • Ionizing radiaiton
    • Certain Chemicals and other substances :Carcinogens
    • Some viruses and bacteriaex. HPV- cervical cancer;
    • Certain hormones
    • Family history of cancer
    • Alcohol
    • Poor diet, lack of physical activity, or being overweight
  41. Seven Warning Signs of Cancer
    • Change in bowel or bladder habits
    • A sore that does not heal
    • Unusual bleeding or discharge from any body orifice
    • Thickening or a lump in the breast or elsewhere
    • Indigestion or difficulty in swallowing
    • Obvious change in a wart or mole
    • Nagging cough or hoarseness