ATI NUR 426 Exam 1 Study Guide PDF

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Study guide for exam 1 content covering a variety of topics....

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1 NUR 426 Exam 1 Concept & Medication Quizlet ● ● ●

Module 1: DIC, Hematologic Drugs Module 2: Sickle Cell, Hemophilia, and blood products Module 3: Complementary and Alternative Therapies, Cancers, Chemotherapy/Radiation, End of Life

You should know normal values for the following (use your Harding et al.(2020) text for reference): Quizlet ● INR: 0.8-1.1 ● aPTT: 30-40 sec ● Platelet count: 150,000-400,000 ● RBCs ○ Men: 4.7-6.1 ○ Women: 4.2-5.4 ● Hemoglobin: ○ Men: 14-18 ○ Women: 12-16 ● Hematocrit: ○ Men: 42-52% ○ Women: 37-47% ● WBCs: 5000-10,000 ● ANC (Absolute Neutrophil Count): 2,500-6,000 You should know the significance of the following (why would it be high vs low), but do not need to know normal ranges ● The concept of “therapeutic ranges” (pertaining to PT/INR, aPTT, PTT) ○ HIGH (longer time to clot → higher risk of bleeding) ○ LOW (faster to clot → higher risk of clotting) ● PT → prothrombin time, sometimes referred to as PT or pro time test, is a test to evaluate blood clotting. Prothrombin is a protein produced by your liver. It is one of many factors in your blood that help it to clot appropriately ○ HIGH (longer time to clot → higher risk of bleeding) **often prolonged in DIC ○ LOW (faster to clot → higher risk of clotting) ● PTT → partial thromboplastin time is a blood test that measures the time it takes your blood to clot. A PTT test can be used to check for bleeding problems. Blood clotting factors are needed for blood to clot (coagulation). ○ HIGH (longer time to clot → higher risk of bleeding) **often prolonged in DIC ○ LOW (faster to clot → higher risk of clotting)

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Fibrinogen ○ LOW in DIC: one of the clotting factors (all circulating factors are being diminished) ■ Less fibrin → higher risk of bleeding Clotting factors ○ Platelets LOW in DIC: being used in microclots, presence of large platelets (smaller platelets being used in microclots, larger ones are “free” D-dimer ○ HIGH in DIC: results from clot breakdown (D-dimer is specific type of FSP)

The following medications could be tested on this exam. You should know the medication’s indications, side effects, and nursing considerations when administering these: ● Hydroxyurea ● Aspirin ● Ibuprofen ● Celecoxib ● Acetaminophen Medications from your Pharmacology Made Easy (4.0) modules will also be on the exam. Note the associated learning objectives listed in Module 1a and 3a below in blue. The following additional drugs/drug categories could be tested as potential drug interactions. Be able to identify how these medications/drug categories would interact with medications related to your Pharmacology Made Easy modules listed below. - All other drugs reviewed in the Hematologic System module (eg. how do these drugs interact with each other) - NSAIDS → increase bleeding - Vitamin C → increases absorption of ferrous sulfate - Glucocorticoids → increase bleeding - Vitamin K → warfarin (coumadin) antidote - Aspirin → increase bleeding

3 Total questions: 55 Module 1: Hematologic Drugs and DIC (16 questions) Associated Learning Outcomes: 1.

Discuss the pharmacokinetic and pharmacodynamic concepts of hematologic drugs including: mechanisms of action, adverse drug reactions, drug and food interactions, nursing implications, and client education. 4 Q’S ● Look at them drug tables 2. Apply knowledge of the pathophysiology of Disseminated Intravascular Coagulation (DIC) to providing quality nursing care. (includes etiology) 4 Q’S ● DIC: is an abnormal response of the clotting cascade stimulated by a disease process/disorder (it is not a disease) ○ Acute DIC: Acute cancer, shock, burns, post-op, transplant rejection, vascular disorders ○ Subacute DIC: Metastatic cancer, retained fetus ○ Chronic DIC: Cancer, liver disease, SLE

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3. Prioritize clinical manifestations of DIC 4 Q’S ● Laboratory Findings Widespread coagulation → increased microclots (uses up clotting factors and platelets) ○ Platelets: LOW ○ Blood Smears: fragmented red cells (schistocytes) due to trauma to RBCS from excessive clotting ○ Fibrinogen: LOW ○ Bleeding/coagulation times: often prolonged, not enough factors available to coagulate efficiently ■ PT > 15 sec, INR > 1.2 sec ■ PTT > 60 sec, aPTT > 40 sec Fibrinolysis being triggered → produces FSPs ○ D-dimer: HIGH results from clot breakdown BLEEDING Manifestations ● Integumentary ○ Pallor ○ Petechiae ○ Purpura ○ Oozing blood ○ Venipuncture

CLOTTING Manifestations ● Integumentary ○ Cyanosis ○ Ischemic tissue necrosis ○ Hemorrhage necrosis ● Respiratory

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○ Site bleeding ○ Hematoma ○ Occult hemorrhage Respiratory ○ Tachypnea ○ Hemoptysis ○ Orthopnea Cardiovascular ○ Tachycardia ○ Hypotension GI ○ U/L GI bleeding ○ Abdominal distension ○ Bloody st Pain tool GU ○ Hematuria Neuro ○ Vision changes ○ Dizziness ○ Headache ○ Mental status changes ○ Irritability Musculoskeletal ○ Bone + Join

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Tachypnea Dyspnea Pulmonary emboli Acute Respiratory Distress Syndrome (ARDS) Cardiovascular ○ ECG changes ○ Venous distension GI ○ Abdominal pain ○ Paralytic ileus GU ○ Kidney damage ○ Oliguria ○ Leading to failure ○ ○ ○ ○

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4. Differentiate between priority collaborative interventions for DIC *can include drugs from Pharmacology Made Easy module. 4 Q’S Module 1a: Pharmacology Made Easy: The Hematologic System (5 questions) ● ● ● ● ● ● ● ● ● ●

Anticoagulants- Warfarin 1 Q’s Anticoagulants- Heparin 1 Q Lovenox 1 Q Antiplatelets (ADP Inhibitors)- Clopidogrel 2 Q’s Desmopressin 2 Q’s Factor VIII/IX 2 Q’s Folic Acid 2 Q’s Iron Preparations- Ferrous sulfate, Iron dextran 1 Q Pernicious Anemias- Vitamin B12 1 Q Thrombolytics - Alteplase 1 Q

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Module 2: Sickle Cell, Hemophilia, and Blood Products (19 questions) Associated Learning Outcomes: 1. Discuss the pathophysiology of sickle cell anemia 2 Q’s ● Sickle Cell Anemia - Inherited red blood cell disorders (most common inherited disorder for blood in US) ○ ABNORMAL form of hemoglobin within RBCs ○ Most common form: HbSS rather than HbS (Inherit two sickle cell genes “S”) ○ HbSC ■ Inherit one sickle cell gene “S” and one abnormal “C” hemoglobin gene ■ Usually milder ○ Other forms: ■ HbS beta thalassemia ■ HbSD, HbSE, & HbSO (Rare Forms) ○ Sickle Cell Trait: ■ Inherit one sickle cell gene S and one normal HbG gene ■ They are asymptomatic to mild disease ■ Can pass trait on to their children ■ Resistant to malaria ● Complications: ○ Abnormal cells sickle when deoxygenation and dehydration present ○ Sickling causes the cells to get sticky and thick or viscous and inflexible ○ Vascular occlusion, pain and organ infarction are the main complications ● Causes: ○ S - significant blood loss, e.g. surgery trauma ○ I - Illness – the spleen is already affected due to the short life span of the RBC with HgB S, so increased potential for illness as the spleen, if working properly, filters out pathogens ○ C - Climbing to high altitudes – there is less available oxygen at high altitudes but these patients can’t tolerate it ○ K - Keeping continued stress, either physical or mental as this alters the way the body uses oxygen ○ L - Low fluid intake – avoid dehydration, keep up your blood volume ○ E - Elevated temperature as from fever or strenuous exercise. Both increase the body’s demand for oxygen. Also going from warmth to cold quickly can cause a SCC

7 Pathophysiology: ○ As sickling begins, blood flow slows which promotes hypoxemia and perpetuates sickling ○ The decrease in pH decreases the hemoglobin's affinity for oxygen so less oxygen is transported ○ So as less oxygen is taken up by the hemoglobin in the lung, PO2 drops promoting sickling further. ○ This all is a great example of positive feedback making things worse! ○ Once sickling begins, it continues until the PO2 returns to normal and then it ceases spontaneously. ○ Sickled cells regain normal shape initially after homeostasis is achieved. ● There are different types of Sickle Cell Crisis (aka SCA) ○ Vaso-occlusive Crisis ■ sickled cells clump together and results in ischemia, infarction, Fever, pain, swelling, CVA. ○ Acute chest syndrome is an emergency-s/s similar to PNA ■ Potential for pulmonary embolism ■ Is the cause of death in 25% of all with SCD ○ Sequestration ■ Sickled cells are hemolyzed in the spleen ■ Life threatening pooling of blood in spleen and infrequently in liver ○ Aplastic Crisis ■ Due to decreased production of RBCs and their short lives ■ Decrease in reticulocyte count ○ Hyperhemolytic Crisis ■ An acceleration of RBC destruction 2. Interpret appropriate nursing assessments based on presenting symptoms of sickle cell anemia 1 Q’s ● Assessment of pain ● Assess for any presenting symptoms and provide treatment ● Assess for infection, neuro, respiratory, abdominal region (splenic complications are associated) ● Encourage fluid intake ● Assess kidneys (take cautions with NSAIDs) 3. Compare interventions that can help to prevent or treat a sickle cell crisis. 4 Q’s ● Prevent infections ● Avoid hypoxia ● Avoid use of cold packs for injuries ● Remain hydrated ●

8 Medications: ○ Hydroxyurea: increases production of HbF, reduces adhesion, improves cell hydration ○ Folic Acid ● Glutamine: reduces number of pain crisis ● Prophylactic penicillin ● Should you give oxygen? NO, the oxygen can’t reach the sickled RBCs in the clogged vessels ● Apheresis: Red blood cell exchange for acute treatment ● If in crisis, treatment is: pain management, hydration, rest, use of warm heat ● Cure: bone marrow transplant 4. Discuss the pathophysiology of hemophilia 2 Q’s ● X Linked recessive genetic disorder - (transmitted by female carriers, displayed almost exclusively in men) ○ Hemophilia A: Caused By mutations in F8 gene that provides instructions for making coagulation factor VIII ○ Hemophilia B: Caused by mutations in F9 gene that provides instructions for making coagulation factor IX 5. Interpret appropriate nursing assessments based on presenting symptoms of hemophilia 2 Q’s ○ Preventative care ○ Replacement during acute bleeding or prophylactically ○ Medications ■ Desmopressin: stimulates and increases factor VIII ● Can only be given to hemophilia A pts ● Can only be given if enough factor VIII are present in the body → useless if there is none ○ This can be tested by drawing up labs ■ Antifibrinolytic therapy: inhibits fibrinolysis and results in clot stability ○ Health promotion: genetic counseling 6. Compare interventions that can help to prevent or treat a bleeding episodes associated with hemophilia. 5 Q’s ○ Apply pressure or topical hemostatic agents to site ○ Give specific factor ○ Analgesic - NO NSAIDS OR ASPIRIN ○ Promote range of motion when bleeding stops ○ Avoid weight bearing until swelling has resolved and muscle strength returns ○ Mange life threatening conditions ■ Airway obstruction ●

9 ■ Compartment syndrome ■ Intracranial bleeding 7. Select appropriate blood products dependent on the patient's assessment and identify blood product transfusion reactions. 4 Q’s ● Packed RBCs ○ Red blood cells that have been separated for blood transfusions ○ Used for the treatment of anemia usually when Hemoglobin levels are less than 7-8 g/dL ○ Does not have a high number of platelets or clotting factors but may contain many leukocytes ○ Can administer leukoreduced PRBCs to certain populations: ■ BMT patients ■ Immunosuppressed patients ● Granulocytes ○ A type of WBC that is released during infections, allergic reactions, and asthma ○ Indicated for BMT patients who develop a bacterial or fungal infection not responsive to antibiotics ○ Can only be administered within 24 hours of collection from compatible donor ● Platelets (Thrombocytes) ○ Derived from megakaryocytes ■ Fragments into platelets ■ 1 megakaryocyte can produce 1000’s of platelets ○ 2/3 are in circulation ○ 1/3 in the spleen ○ Live for 10 days and destroyed in the spleen ○ Increase in times of infection ○ normal = risk for spontaneous blood clots, stroke, M ○ Transfusions of may be from one donor or multiple donors ● Plasma (Fresh Frozen Plasma) ○ Liquid portion of whole blood that is separated from cells and frozen ○ Lot of clotting factors but no platelets ○ Volume is usually 250 to 300 mL ○ Use: ■ Bleeding due to deficiency of some clotting factors, DIC, hemorrhage, liver disease, vitamin K deficiency, excess warfarin, correction of abnormal INR/PTT ● Cryoprecipitates ○ Derived from plasma

10 Is rich in clotting factors, especially factor VIII, XIII and vWF Volume is usually 10 to 20 mL Can be frozen for 1 year Use: ■ In hemophilia, DIC, liver disease or massive transfusion Albumin ○ Is a carrier molecule/protein for blood components and drugs with low solubility in water ○ Most important role is regulation of the passage of water and solutes through the capillaries due to oncotic pressure ○ Use: ■ Hypovolemic shock, hypoalbuminemia, after large volume paracentesis IV Immunoglobulins (IVIG) ○ Concentrated fractionated blood component consisting of a diverse collection of antibodies ○ Indicated for 2 situations: ■ Patient is immunodeficient and cannot make their own antibodies ■ Patient’s immune system started attacking its own cells ○ Another form of antibodies called RhD immune globulin (RhoGam) can also be used ○ Ex. Blood-type mismatch between mother and baby Clotting Factors ○ Clotting factor concentrates are available for administration ○ Factor VIII, IX, XI, XIII ○ VWF ○ Prothrombinex ○ Fibrinogen ○ Usually administered as a slow IV push ○ Continuous Factor VIII can be administered for severe bleeds or surgical procedures ○ ○ ○ ○

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Blood transfusion reactions: ○ Six categories of acute transfusion reactions: ■ Acute Hemolytic ■ Febrile Non-Hemolytic ■ Septic ■ Allergic/Anaphylactic ■ Transfusion Related Acute Lung Injury (TRALI) ■ Transfusion Associated Circulatory Overload (TACO) ○ Six Common S/S:

11 Chills/Rigors Fever (>1 degree Celsius Increase) Nausea/Vomiting Increase in SBP >30mmHg Flushing, itching, urticaria, facial swelling ■ Respiratory distress: Dyspnea, tachycardia, or hypoxemia Additional S/S: ■ Chest pain/lower back pain ■ Pain at infusion site ■ Hypotension ■ Hemoglobinuria ■ Circulatory shock with fevers/chills/hypotension Acute Hemolytic Reaction ■ Any ABO mismatched hemolytic transfusion reaction is considered a sentinel event and must be reported to the Joint Commission ■ It is the destruction of RBCs usually due to ABO incompatibility ■ Clerical error is the most common contributing factor ■ Signs and symptoms that can develop within 15 minutes: ● Hemoglobinuria ● Fever ● Renal failure ● Pain in IV site, chest, back, loins ● Hypotension ● DIC Febrile Non-Hemolytic Reaction ■ Caused by patient hypersensitivity to donor WBC antigens, HLA antigens, or platelet antigens ■ Common reaction that can occur with 1-3% of transfusions ■ Signs and symptoms include: ● Increased temperature >greater than 1 degree Celsius with no pre-existing fever ● Chills, headache, flushing, tachycardia ■ ■ ■ ■ ■

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● Increase in blood pressure Septic Transfusion Reaction ■ Caused by donor bacteremia or bacterial contamination during the donor collection process ■ Signs and symptoms include: ● Fever ● Rigors ● Tachycardia ● Hypotension/Shock ● Nausea/Vomiting ■ Stop the transfusion, notify the provider, and culture the patient + blood product ■ Broad spectrum antibiotics are usually ordered Allergic/Anaphylactic Reaction ■ Extreme cases of allergic reactions may be due to recipient IgA antibodies attacking the antibodies in plasma containing products ■ Signs and symptoms include: ● Hive ● Anaphylaxis (rare) ■ Stop the transfusion and notify the provider ■ Transfusion can continue if only mild allergic reactions resolve post antihistamine and/or steroid administration ■ Must receive plasma transfusion from IgA deficient donor Transfusion-Related Acute Lung Injury (TRALI) ■ Caused by transfusion of donor HLA or HNA antibodies which activate recipient WBCs and cause vascular leakage and tissue edema ■ Syndrome of acute respiratory distress with hypoxia and bilateral pulmonary edema with evidence of CHF ■ First leading case of death from a transfusion ■ 90% of patients recover within 72 hours ■ Signs and symptoms include: ● Onset within 1-72 hours after a transfusion ● Sudden hypoxia, dyspnea, cyanosis, and tachycardia ● Low grade fever ● Hypotension ■ Treated with oxygen and circulatory support and/or corticosteroids Transfusion Associated Circulatory Overload (TACO) ■ Respiratory distress/pulmonary edema due to transfusion and volume overload

13 Second must common cause of transfusion-associated death Sign and symptoms include: ● Dyspnea/Hypoxemia ● Tachycardia ● Hypertension ● Elevated BNP ● Distended Jugular Veins ● Pulmonary Edema ● Cardiomegaly ■ Occurs in patients with positive fluid balance, CHF, COPD, or renal failure ■ Recommended treatment with diuresis and a slow rate of transfusion Nursing Considerations for Suspected Reactions ■ Stop: Stop the transfusion! DO NOT remove the IV site. ■ Verify: Verify patient identification and blood product for the correct patient receiving the correct blood. ■ Connect: Connect an infusion of 0.9% Normal Saline with new tubing to the existing IV site and infuse at a keep open rate. ■ Assess: Assess and document vital signs (temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). ■ Notify: Notify the provider and blood bank of suspected transfusion reaction. ■ Remain: Remain with the patient until their condition has stabilized. Return blood product and tubing to the blood bank. ■ ■

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Afterwards, ensure correct documentation of suspected transfusion reactions per your hospital’s polixy.

Module 3: Complementary and Alternative Therapies, Cancers, Chemotherapy/Radiation, End of Life (20 questions) Associated Learning Outcomes: 1.

Interpret risk factors for impaired cellular regulation and cancer development. 1Q ● Risk Factors - Modifiable and Nonmodifiable ○ Smoking/Tobacco ○ Poor Nutrition ○ Excess weight ○ Sedentary lifestyle

14 Exposure to environmental carcinogens such as sunlight; pollutants in air, soil, water, or food; or medical treatments such as medications or radiation ○ Genetics ○ Age ● Carcinogens ○ Cancer-causing agents capable of producing cell alterations ■ Many are detoxified by protective enzymes and are harmlessly excreted ■ Failure of protective mechanisms allows them to enter the cell’s nucleus and alter DNA ● Chemical ○ Many chemicals have been identified as carcinogens over the years ○ Long latency makes identification of carcinogens difficult ○ Certain drugs have been identified as carcinogens ● Radiation ○ Radiation an cause cancer in almost any human tissue ○ Damage occurs to DNA ○ Ultraviolet radiation is associated with melanoma and squamous and basal cell carcinoma ● Viral ○ Epstien-Barr virus (EBV) → Burkitt’s Lymphoma ○ Human Immunodeficiency virus (HIV) → Kaposi Sarcoma ○ Human papillomavirus →Cervical, Anal, Esophageal and Squamous cell carcinomas 2. Provide appropriate nursing and collaborative interventions for optimizing cellular regulation and preventing cancer development. 1 Q ● Primary and Secondary Prevention - Eliminate Risk Factors and Provide Education ○ Nurses have an essential role to educate: ■ Lifestyle habits to reduce risks ■ Practice recommended cancer screenings ■ Practice self-examination ■ Know “7 Warning Signs of Cancer” ■ Seek medical care if cancer is suspected ■ Limit alcohol use ■ Prophylactic surgery for genetic risks ■ Smoking cessation ○ Primary Prevention: Lifestyle Habits to Reduce Cancer Risk ■ Healthy diet and healthy weight ■ Regular physical activity ○

15 Have regular health examinations avoidance of excessive exposure to sunlight ■ Get adequate rest ■ Eliminate, reduce, or cope with stress ○ Secondary Prevention: ■ Early disease d...