-
Kulber-Ross' stages of dying
- DABDA
- denial, anger, bargaining, depression, and acceptance
-
impending death
vs 4
- temp incr
- c/o feeling hot when skin feels cool
- pulse is weak and irregular
- bp drops
-
impending death
pupils
2
- fixed, eyes stare
- no response to light
-
impending death
CNS
4
- change in LOC
- confusion/disorientation
- lethargy
- drowsiness --> coma
-
impending death
reflexes
2
- decr blinking, gag, and cough
- involuntary movements
-
impending death
respirations
4
- irregular (dyspnea)
- stridor
- periods of apnea (Cheyne-Stokes resp)
- noisy/congested ("death rattle")
-
impending death
elimination
3
- bowel/bladder incontinence
- decr UOP, dark, concentrated
- decr peristalsis, constipation
-
impending death
nutrition
2
- dysphagia/inability to swallow
- anorexia and nausea
-
impending death
extremities
3
- CMS changes
- Cool
- pulses weak/thready
-
impending death
skin
5
- facial pallor
- mottling/cyanosis of extremeties
- edema (pitting, dependent)
- fragile
- cool to touch/clammy
-
impending death
other physical changes
4
- muscles weaken
- atrophy catabolism (loss muscle and adipose tiss)
- decr strength
- bones fragile
-
immobility causes
bone calcium loss = bones fragile
-
fear of the unknown
nursing measures to decr anxiety and fear
-
fears of the dying patient
13
- 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)
-
nursing management
comfort needs
5
- pain management
- supportive positioning (pillows)
- carful assistance w movement
- t and r
- skin care: heavy perspiration, incr susceptibility to skin brkdwn
-
nursing management
comfort needs prt 2
9
- bathing
- mouth care
- incontinence care
- linen changes
- climate control
- rest periods
- quiet environment
- assistance w adls
- room deodorizers
-
nursing management
nutrition and gi function
6
- anorexia
- sml, freq meals/tube feedings
- dietary changes/stool softener-constipation
- supplements prn
- fluids (po, iv)
- antiemetics before meals prn
-
nursing management
respiratory function
4
- semi-fowlers/fowlers (most comfortable)
- o2 and suctioning prn
- resp tx/bronchodilators prn for airway maintanence and relief congestion
- expect periods of apnea
-
nursing management
cns needs
3
- touch as appropriate
- communication (talk even if comatose, hearing last sense lost, avoid whispers)
- soft, indirect lighting (not bright, not dark)
-
nursing management
psychosocial needs
12
- 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"
-
nursing management
spiritual needs
5
- 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"
-
hospice
- accept death as natural paart of life cycle
- serve persons w end-stage illness (prognosis: life expectancy less than 6 mos)
-
hospice symptom management
5
- 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
-
pt may leave hospice care at any time to
seek more aggressive curative care
-
organ donation
1. follow agency policy for:
3
- 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
-
organ donation
2. organs, tissues that may be donated
11
heart, lung, liver, kid, pancreas, int, cornea, long bones, middle ear bones, skin, conn tiss, others
-
organ donation organizations
CORE and UNOS
-
care of dead bd
6
- 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
-
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
-
livor mortis
- rbcs break down, bruising/mottling occurs, esp in most depenent tissues
- positioning and handling affect this
-
CAUTION
- 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
-
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
-
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
-
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
-
primary prevention
- true prevention
- health education-eg good eating habits, discouraging smoking, smoking cessation tx, avoiding occupational hazards
-
secondary prevention
- screening, early detection, prompt treatment
- acs screening guide
-
tertiary prevention
- minimizing the effects of disease and disability; preventing recurrence/complications
- rehabilitation
-
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
-
acs breast ca
- 20-39: clinical exam q 3 yrs; monthly self exam
- 40+: annual mammogram, yearlyclin, montly self
-
acs prostate ca
50+ (45 blacks): annual prostate-specific antigen (PSA) and digital rectal exam
-
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
-
acs uterus ca
18+ and sexually active: annual pelvic exam and papalicolauo (pap) test (frequency may be decr after normal findings for 3+ years)
-
TNM tumor
extent of primary tumor
-
TNM Node
absence/presence of lymph node involvement
-
TNM metastasis
absence/presence of distant metastases
-
t2n2m0
moderate size tumor involving multiple lymph nodes w no metastasis
-
TNM
tumor, node, metastasis
-
metastasis
movement of malignant ca cells from one part of the bd to another (ca spread)
-
common sites of metastasis 3
- lymph nodes
- lung
- bone
- liver
- brain
-
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
-
radiation skin site
s/e
erythma, desquamation (peeling), permanent darkening
-
radiation skin site
implications
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
-
radiation scalp site
s/e
partial or complete alopecia that may be permanent
-
radiation scalp site
implications
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
-
radiation digestive tract
s/e
anorexia, imfl and dryness of mouth, decr sense of taste; dental caries; painful swallowing; n/v/d
-
radiation digestive tract
implications
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
-
radiation urinary tract
s/e
- cystitis
- contracted bladder
- crystalluria
-
radiation urinary tract
implications
incr fluid intake; have pt empty bladder often; keep i and o records
-
radiation bone marrow
s/e
suppressed production of rbcs, wbcs, and platelets
-
radiation bone marrow
implications
prevent overtiring; protect from inf or injury; watch for bruisin/bleeding; check bld test results, report fever; soft toothbrush and electric razor
-
radiation lungs
s/e
pneumonitis
-
radiation lungs
implications
tcdb to prevent pneumonia; humidifier; protect from resp infections
-
radiation reproductive organs
s/e
harm to embryo or fetus; sterility; impotence
-
radiation reproductive system
implications
advise not to become pregnant; sperm banking counsil by dr
-
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
-
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
-
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
-
nadir
time when blood counts (wbc, rbs, platelets) are lowest (about 7 to 10 days after drug administration); high risk for inf and blding
-
infection and blding precaution
monitor cbc closely; pt at high risk when absolute neutrophil count less than 1000 and platelets less than 50K
-
neulasta/Neupogen
sc injections
incr wbc count
-
epogen/Procrit
sc injections
incr rbc count
-
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
-
high alert med - significant pt harm if used in error
2 drugs
- morphine
- fentanyl transdermal (duragesic)
-
main s/e & a/e: CNS depressant effects, resp depress, consti, dependence
morphine
-
morphine antidote
- Narcan naloxone
- reverses resp depression and coma
-
morphine teaching
may cause drowsiness/dizziness, change positions slowly, avoid etoh/cns depressants, tcdb to prevent atelectasis, aggressive constipation prevention
-
main s/e: cns despressant effects, apnea, resp depression, anorexia, constipation, dry mouth, n/v, sweating, dependence
fentanyl duragesic
-
fentanyl duragesic
antidote
- nolaxone Narcan
- reverses resp depression and coma
-
fentanyl duragesic
teaching
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()
-
controlled substance
cannabinoid (marijuana derivative)
dronabinol Marinol
-
dronabinol Marinol
used for
prevention of n/v and appetits stimulation
-
main s/e: cns stimulation, mood change, dry mouth, dependence
dronabinol Marinol
-
Marinol
assessment
n/v, appetite, bowel sounds/abd, hydration, i and o
-
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
-
dronabinol Marional
teaching
take as directed; cns effects - safety w abulation, driving, other activities; change positions slowly; avoid etoh/cns depressants, other measures to decr n/v
-
epoetin Egogen/Procrit
used for
antianemic hormone; stimulates erythropoeisis (red bld cell preduction in bone marrow)
-
main s/e: seizures, chf, mi, stroke, thrombus/embolus, htn
epoetin Epogen/Procrit
-
epoetin Epogen/Procrit
assessment
monitor bp freq; severe htn can be fatal; cbc, esp hemoglobin (do not give if henoglobin 10+); s/s anemia
-
epoetin Epogen/Procrit
teaching
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)
-
darbepoetin Aranesp
used for
antianemic hormone; stimulates erythropoiesis (rbc production in bone marrow)
-
Darbepoetin vs epoetin
half-life
darbepoetin has longer half-life
-
darbepoetin Aranesp
assessment
monitor bp freq; severe htn can be fatal; cbc, esp hemoglobin (do not give if hemo over 10); s/s anemia; s/s allergy
-
pegfilgrastim Neulasta
used for
colony-stimulating factor; stimulates neutrophils to divide and differentiate
available sc only
-
main s/e: ards, splenic rupture, sickle cell crisis, bone pain, allergy/anaphylaxis
pegfilgrastim Nulasta
-
pegfilgrastim Neulasta
assessment
bone pain (control w analgesics), ards s/s (fever, resp distress), cbc (esp wbcs- neutrophil count)
-
filgrastim Neupogen
used for
colony-stimulating factor; stimulates neutrophils to divide and differentiate
-
main s/e: bone pain
filgrastim Neupogen
-
filgrastim Neupogen
assessment
vitals, bone pain (control w analgesics), cbc (esp wbc-neutrophil count)
-
ondansetron Zofran
used for
antiemetic
-
main s/e: ha, constipation, diarrhea, epse
ondansetron Zofran
-
tamoxifen
used for
antineoplastic (antiestrogen) drug used as adjuvant therapy in breast ca tx; prevention of breast ca in high risk pts
-
main s/e: pulm emboli; stroke, n/v, hot flashes
tamoxifen
-
tamoxifen
availability
po - taken once or twice daily for five years
-
tamoxifen
assessment
bone/tumor pain (tx w analgesics), cbc, ca levels, lipids, lfts, thyroxine/thyroid function, gynecologic exams (may cause abnormal pap)
-
tamoxifen
implementation
give w food
-
tamoxifen
teaching
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
-
ectoderm
outer layer of embryo= forms the skin, nerv system, and glands (eg malignant melanoma)
-
mesoderm
middle layer= forms some organs, conn tiss, bones, bld, cart, fat, fibrous tiss, muscle, and bld/lymph vessels (eg sarcoma)
-
endoderm
inner layer= forms some organs, epithelial tiss, digestive/resp tract linings, bladder, and urethra (eg carcinoma)
-
original ca site
primary (may be more than one)
-
metastasis site
secondary site (may be more than one)
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