death

• DABDA
• denial, anger, bargaining, depression, and acceptance

• temp incr
• c/o feeling hot when skin feels cool
• pulse is weak and irregular
• bp drops

• fixed, eyes stare
• no response to light

• change in LOC
• confusion/disorientation
• lethargy
• drowsiness --> coma

• decr blinking, gag, and cough
• involuntary movements

• irregular (dyspnea)
• stridor
• periods of apnea (Cheyne-Stokes resp)
• noisy/congested ("death rattle")

• bowel/bladder incontinence
• decr UOP, dark, concentrated
• decr peristalsis, constipation

• dysphagia/inability to swallow
• anorexia and nausea

• CMS changes
• Cool
• pulses weak/thready

• facial pallor
• mottling/cyanosis of extremeties
• edema (pitting, dependent)
• fragile
• cool to touch/clammy

• muscles weaken
• atrophy catabolism (loss muscle and adipose tiss)
• decr strength
• bones fragile

bone calcium loss = bones fragile

nursing measures to decr anxiety and fear

• 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)

• pain management
• supportive positioning (pillows)
• carful assistance w movement
• t and r
• skin care: heavy perspiration, incr susceptibility to skin brkdwn

• bathing
• mouth care
• incontinence care
• linen changes
• climate control
• rest periods
• quiet environment
• assistance w adls
• room deodorizers

• anorexia
• sml, freq meals/tube feedings
• dietary changes/stool softener-constipation
• supplements prn
• fluids (po, iv)
• antiemetics before meals prn

• semi-fowlers/fowlers (most comfortable)
• o2 and suctioning prn
• resp tx/bronchodilators prn for airway maintanence and relief congestion
• expect periods of apnea

• touch as appropriate
• communication (talk even if comatose, hearing last sense lost, avoid whispers)
• soft, indirect lighting (not bright, not dark)

• 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"

• 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"

• accept death as natural paart of life cycle
• serve persons w end-stage illness (prognosis: life expectancy less than 6 mos)

• 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

seek more aggressive curative care

• 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

heart, lung, liver, kid, pancreas, int, cornea, long bones, middle ear bones, skin, conn tiss, others

CORE and UNOS

• 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

• 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

• 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

• 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

• 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

• 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

• true prevention
• health education-eg good eating habits, discouraging smoking, smoking cessation tx, avoiding occupational hazards

• screening, early detection, prompt treatment
• acs screening guide

• minimizing the effects of disease and disability; preventing recurrence/complications
• rehabilitation

• 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

• 20-39: clinical exam q 3 yrs; monthly self exam
• 40+: annual mammogram, yearlyclin, montly self

50+ (45 blacks): annual prostate-specific antigen (PSA) and digital rectal exam

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

18+ and sexually active: annual pelvic exam and papalicolauo (pap) test (frequency may be decr after normal findings for 3+ years)

extent of primary tumor

absence/presence of lymph node involvement

absence/presence of distant metastases

moderate size tumor involving multiple lymph nodes w no metastasis

tumor, node, metastasis

movement of malignant ca cells from one part of the bd to another (ca spread)

• lymph nodes
• lung
• bone
• liver
• brain

• fatigue
• anorexia/stomatitis/gastritis/nausea/vomiting/diarrhea
• bone marrow suppression/myelosuppression
• skin and mucosal reactions
• alopecia (hair loss)
• late effects: cataracts, pulm fibrosis, strictures

erythma, desquamation (peeling), permanent darkening

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

partial or complete alopecia that may be permanent

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

anorexia, imfl and dryness of mouth, decr sense of taste; dental caries; painful swallowing; n/v/d

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

• cystitis
• contracted bladder
• crystalluria

incr fluid intake; have pt empty bladder often; keep i and o records

suppressed production of rbcs, wbcs, and platelets

prevent overtiring; protect from inf or injury; watch for bruisin/bleeding; check bld test results, report fever; soft toothbrush and electric razor

pneumonitis

tcdb to prevent pneumonia; humidifier; protect from resp infections

harm to embryo or fetus; sterility; impotence

advise not to become pregnant; sperm banking counsil by dr

• 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

• 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

• 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

time when blood counts (wbc, rbs, platelets) are lowest (about 7 to 10 days after drug administration); high risk for inf and blding

monitor cbc closely; pt at high risk when absolute neutrophil count less than 1000 and platelets less than 50K

incr wbc count

incr rbc count

• 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

• morphine
• fentanyl transdermal (duragesic)

morphine

• Narcan naloxone
• reverses resp depression and coma

may cause drowsiness/dizziness, change positions slowly, avoid etoh/cns depressants, tcdb to prevent atelectasis, aggressive constipation prevention

fentanyl duragesic

• nolaxone Narcan
• reverses resp depression and coma

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()

dronabinol Marinol

prevention of n/v and appetits stimulation

dronabinol Marinol

n/v, appetite, bowel sounds/abd, hydration, i and o

1-3 hr before chemo and may be repeated 4-6 times daily; give twice daily (before lunch and dinner) for appetite stimulant

take as directed; cns effects - safety w abulation, driving, other activities; change positions slowly; avoid etoh/cns depressants, other measures to decr n/v

antianemic hormone; stimulates erythropoeisis (red bld cell preduction in bone marrow)

epoetin Epogen/Procrit

monitor bp freq; severe htn can be fatal; cbc, esp hemoglobin (do not give if henoglobin 10+); s/s anemia

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)

antianemic hormone; stimulates erythropoiesis (rbc production in bone marrow)

darbepoetin has longer half-life

monitor bp freq; severe htn can be fatal; cbc, esp hemoglobin (do not give if hemo over 10); s/s anemia; s/s allergy

colony-stimulating factor; stimulates neutrophils to divide and differentiate

available sc only

pegfilgrastim Nulasta

bone pain (control w analgesics), ards s/s (fever, resp distress), cbc (esp wbcs- neutrophil count)

colony-stimulating factor; stimulates neutrophils to divide and differentiate

filgrastim Neupogen

vitals, bone pain (control w analgesics), cbc (esp wbc-neutrophil count)

antiemetic

ondansetron Zofran

antineoplastic (antiestrogen) drug used as adjuvant therapy in breast ca tx; prevention of breast ca in high risk pts

tamoxifen

po - taken once or twice daily for five years

bone/tumor pain (tx w analgesics), cbc, ca levels, lipids, lfts, thyroxine/thyroid function, gynecologic exams (may cause abnormal pap)

give w food

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

outer layer of embryo= forms the skin, nerv system, and glands (eg malignant melanoma)

middle layer= forms some organs, conn tiss, bones, bld, cart, fat, fibrous tiss, muscle, and bld/lymph vessels (eg sarcoma)

inner layer= forms some organs, epithelial tiss, digestive/resp tract linings, bladder, and urethra (eg carcinoma)

primary (may be more than one)

secondary site (may be more than one)