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2013-08-25 23:37:18

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  1. Kulber-Ross' stages of dying
    • DABDA
    • denial, anger, bargaining, depression, and acceptance
  2. impending death
    vs 4
    • temp incr
    • c/o feeling hot when skin feels cool
    • pulse is weak and irregular
    • bp drops
  3. impending death
    • fixed, eyes stare
    • no response to light
  4. impending death
    • change in LOC
    • confusion/disorientation
    • lethargy
    • drowsiness --> coma
  5. impending death
    • decr blinking, gag, and cough
    • involuntary movements
  6. impending death
    • irregular (dyspnea)
    • stridor
    • periods of apnea (Cheyne-Stokes resp)
    • noisy/congested ("death rattle")
  7. impending death
    • bowel/bladder incontinence
    • decr UOP, dark, concentrated
    • decr peristalsis, constipation
  8. impending death
    • dysphagia/inability to swallow
    • anorexia and nausea
  9. impending death
    • CMS changes
    • Cool
    • pulses weak/thready
  10. impending death
    • facial pallor
    • mottling/cyanosis of extremeties
    • edema (pitting, dependent)
    • fragile
    • cool to touch/clammy
  11. impending death
    other physical changes
    • muscles weaken
    • atrophy catabolism (loss muscle and adipose tiss)
    • decr strength
    • bones fragile
  12. immobility causes
    bone calcium loss = bones fragile
  13. fear of the unknown
    nursing measures to decr anxiety and fear
  14. fears of the dying patient
    • unknown
    • suffering and pain
    • dependence
    • abandonment/loneliness
    • sorrow
    • loss of self-control
    • financial loss
    • regression
    • separation
    • loss of bd (physical) and mind (cognition)
    • loss of identity
    • inability to work/contribute to society
    • family suffering and loss (spouse, children)
  15. nursing management
    comfort needs
    • pain management
    • supportive positioning (pillows)
    • carful assistance w movement
    • t and r
    • skin care: heavy perspiration, incr susceptibility to skin brkdwn
  16. nursing management
    comfort needs prt 2
    • bathing
    • mouth care
    • incontinence care
    • linen changes
    • climate control
    • rest periods
    • quiet environment
    • assistance w adls
    • room deodorizers
  17. nursing management
    nutrition and gi function
    • anorexia
    • sml, freq meals/tube feedings
    • dietary changes/stool softener-constipation
    • supplements prn
    • fluids (po, iv)
    • antiemetics before meals prn
  18. nursing management
    respiratory function
    • semi-fowlers/fowlers (most comfortable)
    • o2 and suctioning prn
    • resp tx/bronchodilators prn for airway maintanence and relief congestion
    • expect periods of apnea
  19. nursing management
    cns needs
    • touch as appropriate
    • communication (talk even if comatose, hearing last sense lost, avoid whispers)
    • soft, indirect lighting (not bright, not dark)
  20. nursing management
    psychosocial needs
    • fear of unknown
    • patience, empathy, hope, honesty, respect, understanding
    • explain procedures
    • autonomy and confidentiality
    • involve family
    • life review/reminisce
    • appropriate humor
    • encourage sharing and expression (active listener)
    • watch bd language-own and pts
    • encourage communication
    • pt may feel need to have "permission" to "let go"
  21. nursing management
    spiritual needs
    • assessment of beliefs
    • cultural and spiritual sensitivity
    • prayer
    • religious leader
    • no religious beliefs? fear? =share w pt that near-death experiences described as "peaceful, joyous, light-filled journey"
  22. hospice
    • accept death as natural paart of life cycle
    • serve persons w end-stage illness (prognosis: life expectancy less than 6 mos)
  23. hospice symptom management
    • focuses of supportive, palliative care vs. aggressive, curative care:
    • comfort measures (including pain)
    • pschosocial issues, esp death w dignity
    • autonomy and participation in decision making
    • pt and fam support
  24. pt may leave hospice care at any time to
    seek more aggressive curative care
  25. organ donation
    1. follow agency policy for:
    • phone call and completion of forms
    • organs must be procured quickly
    • donor on life support? take off, declare dead, than back on to maintain circulation
  26. organ donation
    2. organs, tissues that may be donated
    heart, lung, liver, kid, pancreas, int, cornea, long bones, middle ear bones, skin, conn tiss, others
  27. organ donation organizations
    CORE and UNOS
  28. care of dead bd
    • pronounced dead
    • notify people/departments according to facility policy; physician, family/nok, supervisor, admitting office, organ don fac, medical exam.
    • religious/cultural considerations
    • ensure privacy
    • bd prepared for viewing by family and subsequent transfer to morgue
    • documentation
  29. rigor mortis
    • rigidity and contracture of bodily muscles (head to toe) due to chemical changes (ATP decr and acid buildup)
    • begins 1-2 hrs after death, peaks about 12 hrs, and may cont for 24-48 hrs, then subsides
  30. livor mortis
    • rbcs break down, bruising/mottling occurs, esp in most depenent tissues
    • positioning and handling affect this
    • change in bowel or bladder habits
    • a sore that will not heal
    • unusual bleeding or discharge
    • thickening or lump in breast or elsewhere
    • indigestion or difficulty swallowing
    • obvious change in wart or mole
    • nagging cough or hoarseness
  32. benign 8
    • grows slowly
    • enclosed capsule
    • does not infiltrate surrounding tissue
    • partially to well-differentiated
    • (similar to tissue of parent/stem cell)
    • remains localized
    • no recurrence after removal
    • not harmful to host, location may interfere w organ function
    • prognosis almost always good
  33. malignant 8
    • grows rapid
    • rarely enclosed capsule
    • infiltrates surrounding tissue
    • poorly differentiated (much diff from tissue parent/stem cell)
    • may spread from primary site =metastasis
    • may recur after removal
    • harmful to host
    • pronosis dependent on type, location, time of diagnosis (early vs late), metastasis
  34. ABCDEs of skin cancer
    • Assymetry-one half of mole doesnt match other
    • border-irregular, edges jagged, notched, or blurred
    • color-pigmentation not uniform, shades of tan, brown, and black; bleeds
    • diameter-larger than 6 mm (size of eraser)
    • elevation-raised above skin w uneven surface
  35. primary prevention
    • true prevention
    • health education-eg good eating habits, discouraging smoking, smoking cessation tx, avoiding occupational hazards
  36. secondary prevention
    • screening, early detection, prompt treatment
    • acs screening guide
  37. tertiary prevention
    • minimizing the effects of disease and disability; preventing recurrence/complications
    • rehabilitation
  38. canver incidence and death rate
    • overall: skin ca (basal and squamous cell)
    • males: prostate (#cases), lung (#deaths)
    • females: breast (#cases), lung (#deaths)
    • high in colorectal ca incidence and death rate
  39. acs breast ca
    • 20-39: clinical exam q 3 yrs; monthly self exam
    • 40+: annual mammogram, yearlyclin, montly self
  40. acs prostate ca
    50+ (45 blacks): annual prostate-specific antigen (PSA) and digital rectal exam
  41. acs colorectal ca
    50+: fecal occult bld 1 yr and flexible sigmoidoscopy q 5 yrs OR colonscopy q 10 yrs OR incr risk individuals consult dr about scheduling
  42. acs uterus ca
    18+ and sexually active: annual pelvic exam and papalicolauo (pap) test (frequency may be decr after normal findings for 3+ years)
  43. TNM tumor
    extent of primary tumor
  44. TNM Node
    absence/presence of lymph node involvement
  45. TNM metastasis
    absence/presence of distant metastases
  46. t2n2m0
    moderate size tumor involving multiple lymph nodes w no metastasis
  47. TNM
    tumor, node, metastasis
  48. metastasis
    movement of malignant ca cells from one part of the bd to another (ca spread)
  49. common sites of metastasis 3
    • lymph nodes
    • lung
    • bone
    • liver
    • brain
  50. radiation s/e
    • fatigue
    • anorexia/stomatitis/gastritis/nausea/vomiting/diarrhea
    • bone marrow suppression/myelosuppression
    • skin and mucosal reactions
    • alopecia (hair loss)
    • late effects: cataracts, pulm fibrosis, strictures
  51. radiation skin site
    erythma, desquamation (peeling), permanent darkening
  52. radiation skin site
    skin is easily injured; avoid exposure to sun, trauma, harsh chems, or soaps, until therapy is complete; no lotions or topical medications; do not remove markings
  53. radiation scalp site
    partial or complete alopecia that may be permanent
  54. radiation scalp site
    new hair may be different color and texture; cover scalp w wif, cap, or scarf if desired; refer to acs for free hairpieces and help w styling and care
  55. radiation digestive tract
    anorexia, imfl and dryness of mouth, decr sense of taste; dental caries; painful swallowing; n/v/d
  56. radiation digestive tract
    sched smll, freq meals; respect preferences; promote oral hygiene; artificial saliva; monitor wt and assess nutritional state; encourage good dental care; conduct mouth care per protocol; provide antacids and viscous lidocaine; provide antiemetic agents; monitor intake; antidiarrheal agents; good perianal care
  57. radiation urinary tract
    • cystitis
    • contracted bladder
    • crystalluria
  58. radiation urinary tract
    incr fluid intake; have pt empty bladder often; keep i and o records
  59. radiation bone marrow
    suppressed production of rbcs, wbcs, and platelets
  60. radiation bone marrow
    prevent overtiring; protect from inf or injury; watch for bruisin/bleeding; check bld test results, report fever; soft toothbrush and electric razor
  61. radiation lungs
  62. radiation lungs
    tcdb to prevent pneumonia; humidifier; protect from resp infections
  63. radiation reproductive organs
    harm to embryo or fetus; sterility; impotence
  64. radiation reproductive system
    advise not to become pregnant; sperm banking counsil by dr
  65. radiation caregiver safety
    • time, distance, shielding
    • double distance reduces exposure by 1/4
    • wear film badge
    • lead shields
    • private room w sign; limit visitors
    • efficient care
    • gloves handling bd fluids, bedpans, linens, clothes
    • double flush
    • dressings w forceps
    • do not provide care when pregnant
    • dislodged sealed source: wear gloves, use forceps, place in lead container, contact dr
  66. s/e chemo
    • bone marrow suppression (myelosuppression)
    • n/v/d, mucositis, stomatitis, gastritis, anorexia
    • alopecia
    • reproductive dysfunction (infertitily)
    • fatigue
    • organ toxicities (heart, liver, lung, kid/bladd)
    • arrythmias
    • allergic/hypersensitivity reaction
    • vesicant/irritant reaction
  67. chemo nursing diagnoses
    • pain
    • impaired gas exchange
    • imbalanced nutrition less than
    • impaired oral mucous membrane
    • nausea
    • fatigue (anemia and leukopenia)
    • anxiety
    • disturbed bd image
    • ineffective individual coping
    • def knowledge
    • risk for inf (leukopenia, esp neutropenia)
    • risk for injury
  68. nadir
    time when blood counts (wbc, rbs, platelets) are lowest (about 7 to 10 days after drug administration); high risk for inf and blding
  69. infection and blding precaution
    monitor cbc closely; pt at high risk when absolute neutrophil count less than 1000 and platelets less than 50K
  70. neulasta/Neupogen
    sc injections
    incr wbc count
  71. epogen/Procrit
    sc injections
    incr rbc count
  72. MOPP protocol
    • used to treat Hodgkin's Lymphoma
    • Mechlorethamine (nitrogen mustard) IV 1&8
    • Oncovin (vincristine) IV 1&8
    • Procarbazine PO 1-14
    • Prednisone PO 1-14
    • *days 15-28 are rest period
    • repeat cycle for 6 mos
  73. high alert med - significant pt harm if used in error
    2 drugs
    • morphine
    • fentanyl transdermal (duragesic)
  74. main s/e & a/e: CNS depressant effects, resp depress, consti, dependence
  75. morphine antidote
    • Narcan naloxone
    • reverses resp depression and coma
  76. morphine teaching
    may cause drowsiness/dizziness, change positions slowly, avoid etoh/cns depressants, tcdb to prevent atelectasis, aggressive constipation prevention
  77. main s/e: cns despressant effects, apnea, resp depression, anorexia, constipation, dry mouth, n/v, sweating, dependence
    fentanyl duragesic
  78. fentanyl duragesic
    • nolaxone Narcan
    • reverses resp depression and coma
  79. fentanyl duragesic
    patch application/speicifies and disposal, may cause drowsiness/dizziness, change positions slowly, acoid etoh/cns depressants, fever/heat sources incr absorption, aggressive constipation prevention, measures to relieve dry mouth, remove for MRI testing (burns skin()
  80. controlled substance
    cannabinoid (marijuana derivative)
    dronabinol Marinol
  81. dronabinol Marinol
    used for
    prevention of n/v and appetits stimulation
  82. main s/e: cns stimulation, mood change, dry mouth, dependence
    dronabinol Marinol
  83. Marinol
    n/v, appetite, bowel sounds/abd, hydration, i and o
  84. dronabinol Marinol given
    1-3 hr before chemo and may be repeated 4-6 times daily; give twice daily (before lunch and dinner) for appetite stimulant
  85. dronabinol Marional
    take as directed; cns effects - safety w abulation, driving, other activities; change positions slowly; avoid etoh/cns depressants, other measures to decr n/v
  86. epoetin Egogen/Procrit
    used for
    antianemic hormone; stimulates erythropoeisis (red bld cell preduction in bone marrow)
  87. main s/e: seizures, chf, mi, stroke, thrombus/embolus, htn
    epoetin Epogen/Procrit
  88. epoetin Epogen/Procrit
    monitor bp freq; severe htn can be fatal; cbc, esp hemoglobin (do not give if henoglobin 10+); s/s anemia
  89. epoetin Epogen/Procrit
    read medication guide; how to administer; supplemental iron (incr rbc production requries iron); seizure risk- safety; may shorten survival and encourage tumor progression; s/s bld clots, return of menses in childbearing age (birth control)
  90. darbepoetin Aranesp
    used for
    antianemic hormone; stimulates erythropoiesis (rbc production in bone marrow)
  91. Darbepoetin vs epoetin
    darbepoetin has longer half-life
  92. darbepoetin Aranesp
    monitor bp freq; severe htn can be fatal; cbc, esp hemoglobin (do not give if hemo over 10); s/s anemia; s/s allergy
  93. pegfilgrastim Neulasta
    used for
    colony-stimulating factor; stimulates neutrophils to divide and differentiate

    available sc only
  94. main s/e: ards, splenic rupture, sickle cell crisis, bone pain, allergy/anaphylaxis
    pegfilgrastim Nulasta
  95. pegfilgrastim Neulasta
    bone pain (control w analgesics), ards s/s (fever, resp distress), cbc (esp wbcs- neutrophil count)
  96. filgrastim Neupogen
    used for
    colony-stimulating factor; stimulates neutrophils to divide and differentiate
  97. main s/e: bone pain
    filgrastim Neupogen
  98. filgrastim Neupogen
    vitals, bone pain (control w analgesics), cbc (esp wbc-neutrophil count)
  99. ondansetron Zofran
    used for
  100. main s/e: ha, constipation, diarrhea, epse
    ondansetron Zofran
  101. tamoxifen
    used for
    antineoplastic (antiestrogen) drug used as adjuvant therapy in breast ca tx; prevention of breast ca in high risk pts
  102. main s/e: pulm emboli; stroke, n/v, hot flashes
  103. tamoxifen
    po - taken once or twice daily for five years
  104. tamoxifen
    bone/tumor pain (tx w analgesics), cbc, ca levels, lipids, lfts, thyroxine/thyroid function, gynecologic exams (may cause abnormal pap)
  105. tamoxifen
    give w food
  106. tamoxifen
    take as directed (if miss dose, omit that one), skin lesions may incr in size/redness, report bone pain; weekly wt; report edema; induce ovulation; teratogenic effect-avoid preg; hot flashes
  107. ectoderm
    outer layer of embryo= forms the skin, nerv system, and glands (eg malignant melanoma)
  108. mesoderm
    middle layer= forms some organs, conn tiss, bones, bld, cart, fat, fibrous tiss, muscle, and bld/lymph vessels (eg sarcoma)
  109. endoderm
    inner layer= forms some organs, epithelial tiss, digestive/resp tract linings, bladder, and urethra (eg carcinoma)
  110. original ca site
    primary (may be more than one)
  111. metastasis site
    secondary site (may be more than one)