Nursing_Skills 2

• Impaired immune and blood-producing function
• Altered GI structure and function
• Motor and sensory deficits
• Decreased respiratory function

death

Surgery

• Prophylaxis
• Diagnosis
• Cure
• Control
• Palliation
• Second-look Surgery
• Renconstruction or rehabilitation

Prophylaxis

Diagnosis

Cure

Control

Part may be removed

Palliation

Second-look surgery

to destory cancer cells with minimal exposure of the normal cells to the damaging actions of radiation

• radiation
• distant treatment- source external to patient
• pt is not radioactive and is not a hazord to others

• radiation
• internal-in the patient and amit radiation

isotopes are eliminated in waste products with are radioactive and should not be touched, once isotope is eliminated (w/i 48) pt and waste no longer radioactive

pt emits radiation while implant is in place but are not radioactive and are not a hazard to anyone

• vary according to the site
• Local skin changes
• Permanent hair loss (depending on dose)
• Altered taste sensations
• Fatigue related to increased energy demands
• inflammatory responses that cause tissue fibrosis and scarring

• Teach accurate objective facts to help patient cope
• Do not remove markings
• Administer skin care
• Do not use lotions or ointments
• Avoid direct exposure of the skin to the sun
• Care for xerostomia
• Bone exposed to radiation is more vulnerable to fracture

dry mouth

• Treating cancer w/ chemical agents
• major role in cancer therapy
• used to cure and increase survival time
• some selectivity for killing cancer cells over normal cells

• skin
• hair
• intestinal tissues
• spermatocytes
• blood forming cells

affected normal cells

• Antimetabolics
• Antitumor antibodies
• Antimitotic agents
• alkylating agents
• Topoisomerase inhibitors
• Miscellaneous chemotherapeutic agents
• Combination chemotherapy

• Anemia, neutropenia, thrombocytopenia
• Temporary alopecia or hair loss
• nausea or vomiting
• Musocitis in the entire GI tract
• Skin changes
• Anxiety, sleep disturbance
• altered bowel elimination
• Changes in cognitive function

a condition of an abnormally low number of neutrophils (white blood cells)

is any disorder in which there is an abnormally low amount of platelets

Antimetabolite

Topoisomerase I inhibitors are

antitumor antibodies

Antineoplastic agents

Mucositis

• Infection risk (reverse isolation when WBC low)
• CIN-Chemotherapy induced nausea and vomiting (antimetics)
• Mucositis (Swish and spit, no alcohol)
• Alopecia (help w/ body image disturbance)
• Changes in cognitive function (reorienate them-Safety)
• Peripheral Neuropathy (refer pain management-Safety)

• not as common
• not cure, increases survival time

• Some hormones make hormone sensitive tumor frow more rapidly
• Some tumors actually require specific hormones to divide-decreasing the amount of these hormones to hormone-sensitive tumors can slow the cancer growth rate

• Androgens and antiestrogen receptor drugs cause masculinizing effects in women (chest, facial hair, no mentstral, lack breast)
• for men and women receiving androgens, acne may dvelop, hypercalcemia is common and liver dysfunction may occur with prolonged therapy
• feminine manifestation in men who take estrogen, progestins or antiandrogen receptor drugs
• gynecomastia

Breast development in males

• Experimental as a cancer treatment
• renders cancer cells more susceptible to damage or death by other treatments
• inj into tumor cells, enabling the immune system to better recognize cancer cells and kill them

• Sepsis and disseminated intravascular coagulation
• Hypercalcemia
• Tumor lysis syndrome

• prevention (the best measure)
• IV antibiotic therapy
• Anticoagulants, cryoprecipitated factors

• Oral hydration
• Normal Saline IV
• Drug Therapy
• Dialysis

• Prevention-through hydration
• Hydration- dilute serum potassium and increase kidney filtration
• Drug therapy-to treat specific high levels

occurs most often in patients with bone metastasis

s/s Fatigue, loss of appetite, nausea and vomiting, constipation, polyuria, severe muscle weakness, loss of deep tendon reflexes, paralytic ileus, dehydration, electrocardiographic changes

Large number of tumor cells are destroyed rapidly, resulting in intracellular conrents being released into the bloodstream faster than the body can eliminate them

• C=comfort
• A= altered body image
• N=Nutrition
• C=Chemotherapy
• E=Evaluate Response to Meds
• R= Respite for Caretakers

Pathogen

Communicable

pathogenicity

the degree of communicability (strength)

characteristic bacteria of a body location, often competes with other microorganisms to prevent infections

the micoorganism present in tissue but not yet causing symptomatic disease

the tracking and reporting of infections

CDC

• Reservoirs (where its being held ex. soil, animal, water)
• Pathogens (Toxins, Endotoxins)
• Host Defenses (Susceptibility-risk)

resistance to infection is usually associated with the presence of antibodies or cells acting on specific microorganisms

• short duration, either naturally by placental transfer or artificially by injection of antibodies
• ex-mother to child

last for years and occurs naturally by infection or artificially by stimulation (vaccine) of immune defenses

• Respiratory Sites (breathing)
• GI tract (eating)
• Genitourinary tract (cathater)
• Skin/mucos membranes
• Bloodstream (Cuts)

• Contact transmission-direct or indirect contact
• Droplet transmission- i.e. influenza
• Airborne transmission- tuberculosis
• Contaminated food or water- covleria
• Vector-borne transmission (insect or animal carriers)- Lyme disease

• Body Tissues(skin, mucous membranes, flushing urine, tears)
• Phagocytosis ( neutrophils engolf and kill, digest)
• Inflammation (Histamine realease bring neutrophils)
• Immune Systems (antibody mediated, cell mediated)

• Health care associated Infection
• Endogenous Infection
• Exogenous Infection

is acquired in the inpatient setting, not present at admission

from a patients flora

is from outside the patient, often from the hands of health care workers

• Practice hand hygiene and proper handwashing
• Personal protective equipment (mask, gloves, gown, hairnet)

• Adequate staffing-have time to be safe
• Sterilization- sterlizing equipment, cohoarding pts
• Disinfection
• Patient placement
• Patient Transportation- wear mask

putting patients with same illness in same room

• Standard Precautions
• Respiratory hygiene/cough etiquette (RH/CE)
• Safe Injection Practices (1 needle, 1 syringe per patient)

• Airborne Precautions- Negitive Airflow room (TB, rubeola, chickenpox)
• Droplet Precautions- (Flu, whopping cough)
• Contact Precautions-(MRSA, VRE, CDIFF, Lice)

• Treated with Vancomycin, Linezolid (Zyvox)
• the best way to decrease the incidence of this growing problem is health teaching

• Vancomycin-resistant Enterococcus (VRE)
• Multidrug resistant Tuberculosis
• Gonorrhea
• Vancomycin-intermediate Staphylococcus aureus (VISA)
• Vancomycin-resistatn S. aureus (VRSA)

History (MRSA, immunosupprese, age, meds, travel, family, nutrition, sexual )

Physical assessment and clinical manifestions (Fever, swollon lymphnodes, GI problems, pain, swelling, heat)

Psychosocial assessment( How do you feel? Social stigmas)

• Culture and antibiotic testing
• complete blood count (with diff, include 5 tyoes WBC)
• Erythrocye sedimentation rate (increase ESR=inflammation)
• serologic testing (identifies antibody)
• imaging assessment (X-rays)

in increase in inmuture white blood cells (Bands)

CDIFF

protect patient from others aka reverse isolation

• No flowers, fruit, childeren
• No people with fevers, vacinations, sick

decrease

through blood or sex, not salvia (unless bloody)or urine (unless bloody)

Failure of immune mechanisms of self defense

Primary (congenital) immunodeficienc-born with

Secondary (acquired) immunodeficiency-caused by another illness (cancer,infection) More common

hypersensitivity

• Type I: IgE mediated ex. Immediate
• Type II: Tissue-specific reactions
• Type III: Immmune complex mediated
• Type IV: Cell Mediated

• Type 1 hypersensitivies
• IgE mediated reaction
• Rate of development-Immediate
• Antibody involved-IgE

• Type 2 hypersensitivies
• Tissue specific reaction-cytotoxic
• Rate of development-Immediate
• Antibody involved- IgG and IgM

• Type 3 hypersensitivies
• Immune complex mediated reaction
• Rate of development-Immediate
• Antibody involved-IgG and IgM

• Type 4 hypersensitivies
• Cell-mediated reaction
• Rate of development-Delayed
• Antibody involved-None
• Effector cells involved-lymphocytes and macrophages

attack on host cell

ex- Systemic lupu erythematosus (SLE), Rheumatoid arthritis (RA), chronic fatigue syndrome

• be HIV positive and
• have a CD4 count less than 200/mm3
• or
• Have any of the health problems (OI's) listed under clinical category C, regardless of CH4 count

Organisms produce infection in persons w/impaired immune function

• want viral load low
• want CD4 cound high
• Reverse transcriptase low

• 1= >500
• 2= 200-499
• 3= <200

• HIV positive, asymptomatic
• or Persistent generalized lymphadenopathy
• or Acute (primary) HIV infection with accompanying illness or history of acute infection as the only manifestations

and A1, A2, A3

• Bacterial endocarditis, meningitis, pneumonia, sepsis, Vulvovaginal Candidiasis, Oropharyngeal Candidiasis (thrush), Severe cervical dysplasia or carcinoma, Fever, diarrhea >1 month, Oral hairy leukoplakia, Herpes Zoster
• Idiopathic thrombocytopenia purpura, Listeriosis, Pulmonary Mycobacterium tuberculosis, Nocardiosis
• Pelvic inflammatory disease, Peripheral neuropathy,

and B1, B2, B3

Bronchial, tracheal, pulmonary, esophageal candidiasis, Invasive cervical cancer, Disseminated or extrapulmonary coccidioidomycosis, Chronic intestinal cryptosporidiosis, cytomegalovirus, encephalopathy, Herpes Simplex, Disseminated or extrapulmonary histoplasmosis, Chronic intestinal isosporiasis, Kaposi's sarcoma, Lymphoma, Extra pulmonary M. Tuberculosis, Pneumocystis jiroveci pneumonia, leukoencephalopathy, Salmonelle septicemia, Toxoplasmosis, Wasting Syndrome

and C1, C2, C3

Usual skin condition and changes that have occurred

When did this problem start/how long has it been there.

Is the problem associated with anything?

What is nutritional status

Does anything help or make worse?

Assess family hx, meds, allergies, social history and travel

Color-erythema, pallor, cyanosis, jaundice

Temperature

Moisture-Dry, moist, oily

Elasticity, turgor, edema-assess turgor of back of hand, sternum

Texture-soft, smooth, rough, scarred

Vascular changes-petechia, ecchymosis, birthmarks

Alcohol

Mucousa and Nailbeds

Thickness-callus, scarring, keloids, skin changes with aging

Odor-draining lesions which should be cultured.

Hair and Nails-alopecia, hirsutisim, infestionation of nits, capillary refill, clubbing (table 26-5, 26-6)

Skin lesions Fig. 26-13

Skin changes related to aging Chart 26-1

Assessing changes in dark skin:Chart 26-3

Skin problems can reduce protection

Minor skin irritations-priority is increasing pt comfort and preventing skin injury

• Xerosis-Dry
• Pruritis-Itching
• Uticaria-Hives

Review p480-481

• 1.Sensory perception-ability to respond to pressure related discomfort
• 2. Moisture-degree to which skin exposed to moisture
• 3. Activity
• 4. Mobility
• 5. Nutrition
• 6.Friction and shear

Swab cultures helpful only inidentifying types of bacteria present on ulcer and may be misleading when trying to identify or quantify bacteria in deep tissue.

Wound biopsies allow # of bacteria to be analyzed but are time consuming, costly and unavailable in many labs.

Therefore clinical findings of size , depth, change to quantity and quality of exudate and systemic signs of bacteria (fever, Elevated WBC)are used

Positioning

Nurtrition-2 to 3K mL/day

Skin Care

Skin Cleaning

23-High skin integrity

16-Mild

11-Severe

Higher the score-less risk involved

• 1.Describe characteristics including size, location, exudate, granulation/necrotic, epithelialization at regular intervals
• 2.Monitor color, tem,edema, moisture, and appearance
• 3.Keep moist to aid in healing
• 4. clean w/mild soap and water
• 5. debride as needed
• 6.apply dressings prn
• 7.adequate dietary intake and nutritional status
• 8.teach
• 9. initiate consult with CWS-certified wound specialist
• 10. position q1-2 hr

• Alginate
• Biologic
• Cotton Gauze
• Foam
• Hydrocollodial
• Hydrogel
• Adhesive Transparent film

Electrical stimulation-CWS, 1 hr/day 5-7 days/wk-contraindicated for pacermaker pt or near heart

Wound vac complications-failure of VAC is d/t inability to maintain adequate and consistent dressing seal

Hyperbaric Oxygen(HBO)-100% Oxygen for 60-90 min time

Topical growth factors (PRP, PDGF)

Skin substitutes (apligraf, dermograf, biobrane, oasis) manufactured skin

Graft sites immobilized with bulky cotton pressure dressing for 3-5 days to allow "take" of newly grafted skin.

Do not disturb dressing and encourage elevation and complete rest of area

After dressing removed, monitor for failure to vascularize, nonadherence to wound or graft necrosis

• Discharge
• odor
• color
• size depth
• pain

Potassium Hydroxide-identifies fungal

Tzanck smear-viral like herpes zoster

• Culture-Gram stain and culture and sensitivity
• Common skin infection staph and MRSA

Skin biopsy-examine lesion to differentiate benign from skin ca

Wood's Light-aids in diagnosis of fungal infections of scalp and body (color noted in dar room)

Folliculitis

Furuncle

Carbuncle-more than one infected follicle

cellulitis

MRSA-methicillin resistant stahylococcus aureus

hospital associated

Community associated

Dx:drainage or blood culture

• Bactrim
• clindamycin
• Minocycline
• Doxycycline

More severe cases

• Vancomycin
• Zyvox
• Synercide

• Hand hygiene
• good nutrition
• Not sharing personal items
• Do not squeeze or try to open pimple or boil
• Take full course of ATB
• ATB teaching (chart 27-9)
• Preventing spread of MRSA(chart 27-8)

Viral

• Assessment:
• Hx of chickenpox,declined immune
• Vesicular lesions in linear patter along dermatone
• Macules, vesicles, crusting
• malaise, fever, itching
• Postherpetic neuralgia

DX:Tzanck smear and viral culture

Anitvirals:Acyclovir (Zovirax), valacyclovir (valtrex)

Analgesics, topical antipruritics, corticosteriods (lyrica and lidoderm patches)

Loose clothing

Avoid exposure to susceptible persons

Pain management for post herpetic neuralgia

• Pregnant women
• Children
• Those not exposed to chickenpox

Prevent spread of infection

Trim nails, hands clean, don't scratch

Care of lesions

Yes-Zostavax for 60 yrs and older

SQ injection

• Fungal
• Feet-pedis
• Body-corporis
• hands-manus
• head-capitis
• groin-cruris

Red raised borders, pruritis and erythema

circular patches with raised red border, painful fissures in toe webs

Warm moist environments

Microscopic exam using KOH or wood's light

Antifungals: Oral, topical

Drugs:Nystatin, clotrimazole, ketoconazole (nizoral) systemic

• For tx regimen
• Keep affected areas clean and dry
• Dry all skin folds, assess daily
• Wear cotton socks and underclothing

• (lice)
• Parasitic

• Assess
• Head, body, pubic
• Mite and Nits (eggs)
• papules and pruritus
• Person to person contact
• hats, brushes, combs, clothing

Dx-Inspection and microscopic exam

parasitic

• Assess
• Skin to skin contact
• small red/brn some with vesicles pruritic lesions
• Brn lines on webs b/t fingers,wrists, axilla, waist
• Intense itching at night

Dx:scraping under microscope

permethrin (NIX, Elimite, Acticin)

Malathion (ovide)

Lindane (kwell)-for scabies lotion entire body neck down and leave 12 hrs then shower

Oral antihistamines or steriods for itching

Antibiotics for secondary infection

Treat close contacts

Educated to prevent spread and use direction for prescribed tx

Soak combs and brushes

Wash cloths and linens in hot water and dry

Items that cannot be laundered placed in plastic bags for several weeks

Inflammatory-dyes, metals, poison ivy

Assessment-erythema, vesicles, swelling, pruritus, burning

Diagnosis:symptoms, scratch, patch or intradermal tests

management-antipruritics, antihistamines, oral or topical steroids

Teaching-avoid contact with allergan, follow instructions with meds-how to apply topical preps, if oral steroids-how to taper, antihistamines cause drowsiness

Inflammatory/autoimmune

• Assessment-scaling, erythema, pruritus
• Papules, plaques, silvery, white scale
• Scalp, elbows, knees
• Exacerbations and remissions

Dx: Clinical s/s or skin bx

Methotrexate-chemo dx used for RA and psoriasis, MABS, etanercept (enbrel)

corticosteriods

Dovonex (vit D)

Tazarotene (Tazorac)

Uv light therapy

Photochemotherapy

Follow up with tx

Discuss body image issues

Discuss chronic nature

Guidelines for apply topical meds

Seborrheic keratoses-common in older adults

Keloids-overgrowth of scar, common in dark skinned

Nevi-mole

Actinic keratosis-Premalignant lesions. Common in chronic sun-damaged skin, can progress to squamous cell carcinoma if untreated.

Basal cell carcinoma-metastatsis rare, but invasive and may cause destruction of underlying tissue. Genetic predisposition. UV exposure most common cause

Squamous cell carcinoma-invade locally but potentially metastatic. Often on lip, ear, face.

• Genetic predisposition
• previous melanoma
• Presence of one or more precursor lesions that resemble unusual moles
• Fair complexion
• Hx of blistering sunburns
• Excessive exposure to uv light
• immunosuppressive drugs

Prevention of skin cancer (chart 27-11)

Total skin self exam (TSSE) on month basis

ABCDE of skin lesions

if had skin cx, schedule reg f/u's q 3mo first 2 yrs

utilize resources(ACS, Skin cancer foundation)

Surg excision-most common way of managing-often done with local

• Curettage and electrodesiccation-small lesions non melanoma
• -scraping/scooping out of lesion
• -electric current used to remove tissue and bleeding

• Cryosurgery
• -rapid freezing
• swelling, increased tenderness and blistering common

Drug therapy-5 FU cream (efudex) and immunotherapy(aldara)

Biotherapy-interferon for malignant melanoma

Radiation-older pt with deep invasive BCC, or poor risk of surgery. Does not work on malignant melanoma

Don't disrupt scab if forms, keep dry.

Report signs of infection

If dressing, give instructions to care for and changing

Avoid aspirin products and other anticoagulant drugs for 7 days before and after surgery

Clinical Category A

No-not in less their CD4 counts drop below 200/mm3 (when they have A3)

Clinical category B

Clinical category C

All of them do

• How HIV was acquired
• Personal factors-reexposure, stress, nutritional
• Interventions/early tx

Seroconversion

Window Period

Enzyme-Linked Immunosorbent Assey (ELISA aka EIA)

99.5% accuracy after 13 wks

Always retest on ELISA with Western Blot

Western Blot

99.9% accuracy

+ELISA confirmed with Western blot

Rapid Tests

800-1000

<200

With progression of AIDS, CD4 drops

Viral Load (viral burden testing)

Used to assess disease progression

• Monitor effectiveness of antiretroviral therapy
• Levels of 5000-10000 need therapy

Non antibody tests

RT-PCR - reverse transcriptase test and want low

p24 antigen-Detects p24 protein of AIDS

• 1. Suppress infection, prolong life
• 2. Prevent opportunistic infections (OI)
• 3. Stimulate hematopoetic response
• 4. Treat OI and malignancies

Does not eradicate HIV infection (only inhibits replication)

Combines multiple antiretroviral drugs to reduce incidence of drug resistance

Expensive

Meds cause adverse S/E

Adherence to regimen imperative

Classes of HIV drugs: NRTIs, NNRTIs, PI, Fusion inhibitors, and integrase inhibitors (p 376-378)

Compliance

Delaying dose or skipping

Reducing dosage to save $$

Basic:2 drugs for low risk exposures

Expanded:3 or more drug for high risk exposures

28 day recommended course of tx

Best to start asap of exposure (no later than 72 hrs) Best if started 2-3 hrs after.

• H/A
• Fever
• Involuntary wt loss
• Fatigue
• Night sweats
• Lymphadenopathy-PGL does not go away
• Rashes/skin lesions
• Diarrhea
• Dehydration/ FVD-metabolic acidosis
• Electrolyte imbalance
• Acid/base imbalance
• Mental changes
• Appearance of OI and malignancies

Guidelines for safer sex practices (ABC) chart 21-1

Maintain nutrition, rest, exercise

Teach infection transmission and prevention

Identifying S/S of OI

Medication regimen, adverse effects, and FU

Community resources (support groups, hospice, respite care)

Abstinence

Be Faithful

Condoms

An OI

Bacterial

Dx:Blood Culture

Tx:Combination ATB therapy

Affects resp and GI

• High fever
• malaise
• wt loss
• Diarrhea-#1
• Respiratory symptoms

Neprotoxicity

Ototoxicity

• Fever, chills
• night sweats
• productive cough
• chest pain
• dyspnea
• hemoptysis
• +skin test

Ineffective airway clearance

Imbalanced Nutrition:LBR

Support resp system, comb drug therapy

P. 671 What do you remember about TB drugs

• Isoniazid
• Rifampin *liver failure possible w/both*

• Airborne precautions
• Neg air flow room

• Dyspnea
• persistent dry cough
• intermittent fever
• tachycardia
• crackles

Dx:CXR, biopsy, sputum test, ABGs

Tx:IV or oral TMP-SMX (bactrim)

Pentamidine IV-for severe-can cause hypotension

Corticosteriods- decrease inflammation of airways

• Oxygen
• Respiratory Care

PJP

75-85%

1st OI typically to occur

• Severe watery diarrhea (4Lt/day)
• Wt loss
• F & E imbalances

Dx:stool culture

Tx:Sandostatin (octreotide) must be refrigerated. given sq or iv

• White, curdlike patches of mouth and throat
• erythema
• dysphagia
• rectal lesions
• vaginal infections

Impaired skin integrity

DX:S/S and oral scraping

• TX:
• Soft foods
• soft toothbrush
• Nystatin
• Fluconazole (diflucan)

CMV-inflammatory reactions in lungs, gi tract, and eyes causing blindness

Herpes-painful vesicular lesions, genital or perianal, or shingles

Valcyte-oral

Ganciclovir, Foscarnet IV

• DX:S/S, antibodies in serum
• TX:Avoid sources of infection

Acyclovir (zovirax)

Valacyclovir (valtrex)

• DX:S/S, antibodies in serum
• TX:Avoid sources of infection

Kaposi's Sarcoma-#1

Lymphoma

Invasive cervical cancer

Purple, red papular lesions

On skin, mouth, tongue, sclera, internal organs

Non Hodgkins

Most common brain, GI and bone marrow

• Biopsy
• PAP q 6 mo to assess for cerv CA

Interferon (KS)

Radiation therapy

Surgery of local lesions/masses

Chemo

Brachytherapy-Short distance radiation

Monitor wt loss, decreased muscle tone, decreased energy, nausea, stomatitis

Monitor labs-protein, albumin, H/H

Antiemetics, meds to stimulate appetite

Oral analgesics, antifungal drugs, mouth care

Offer soft foods, assist with eating

• High calorie, high protein diet-6 small mls and supplements
• Pleasant environment for meals, encourage family to bring fav foods

monitor skin

lesions for s/s infection and impaired healing

turn q2

Pressure relieving devices

skin clean/dry

Dressings/lotions as ordered

Avoid intense scratching

monitor freq and consistency of stools and bowel sounds

I&O

Encourage oral fluids, maintain IV

Monitor labs(Lytes)

obtain stool cultures

Assess for S/S dehydration

Diet:low residue, lactose free, high K, high protein, high cal (BRAT)

assist to recognize fear

• reduce barriers to social contact
• Assess social support network
• Encourage pt to discuss their concerns with consistent, uninterrupted time and assign primary nurse

Encourage involvement in decision making

• Assess coping skills
• community resources

assess signs of OIs

V/S

Monitor WBC

Prevention of infection (chart 21-7)

Care of hospitalized immunosuppressed pt (chart 21-8)

• hand hygiene
• assess s/s of infection
• monitor labs
• reverse/protective isolation
• avoid contact crowds, children, recently vaccinated and infectious sources
• addequate nutrition-no fresh fruits/vegs or flowers
• avoid invasive lines
• good mouth care
• monitor adverse effects of meds