Exam 2 Study Guide PDF

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Study guide for Exam 2...

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Intravenous (IV) Therapy IV Therapy  Assessment – renal/cardiac function  Monitor patient status o Weight, I/O, lab studies  Doctor’s orders – rate and solution  Patient safety o Be aware of “high alert” drugs (KCl)  Smart pump  Computerized physician order entry Sterile Principles  IV container changed q24 hours  Tubing changed routinely q48-72 hours  IV site dressing changed q48-72 hours o Not usually done for no reason  changing the dressing when your changing the IV site (same time frame)  IV site changed q48-72 hours  Check expiration of tubing, fluids, etc.  If break in sterile technique  discard & start over IV Therapy Peripheral IV Therapy – Flow Rates via Gravity (without pump)  Factors influencing gravity flow rate: o Height of solution o Patency of cannula – can be positional o Venous spasms  Trauma, stress o Size of cannula  Smaller the number gauge, the greater diameter of the needle o Blood in tubing o Present of local complications IV Therapy Central Venous Therapy  Peripherally Inserted Central Catheters (PICC) o Placed in the antecubital fossa o Tip resides in SVC (superior vena cava) o Low complication rates and less expensive o No BP or blood draws in this extremity  Multi-Lumen Catheter o Can deliver two or more solutions at same time via separate pathways  Tunneled and Non-Tunneled Central Catheters

**Tunneled are preferred – especially in confused patients, hyperactive patients (seizures, tremors, etc.) **Non-tunneled are typically referred to as by the placement location – jugular line, femoral line, etc.  Implanted Ports o No part of catheter is visible o Venous system most common placement o Accessed with a needle through the skin  Indications for Central Venous Access Device (CVAD) (**select all that apply question) o Medication administration o Nutrition o Blood samples/transfusions o Conditions  Renal failure, burns, etc.  Intraosseous Route (IO – into bone marrow) o High infusion rates are possible o Pain meds may be required o Good for severe dehydration or during cardio/resp emergencies o Proximal humerus, proximal and distal tibia Central Line Care  XR before starting fluids! o Cannot use central line before an XR is obtained  Sterile dressing change  Observe site for signs & symptoms of infection  Observe for IV systemic complications  Care depends on complication assessed  Complications of CVADs o Catheter occlusion o Embolism o Infection o Pneumothorax o Catheter migration - make sure it’s covered with a sterile dressing & then call the doctor Local Complications – typically seen with PIV but possible in central lines too  Infiltration o 1st sign is coolness; should pull the line if it’s infiltrated  Extravasation o Do not pull line until doc is contacted  Nerve damage  Hematomas/ecchymosis  Phlebitis o Classic sign is a red line  Thrombophlebitis o Blood clot  Site of infection

Systemic Complications

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Catheter related infection (pyrogenic, septic) o Abrupt rise in temp., severe chills, shaking, increase HR, RR, headache o Interventions – stop infusion, call doctor, most likely will order blood cultures, treat symptoms & give antibiotics Circulatory overload o Increase BP, distended neck veins, SOB o Interventions – Stop the infusion, raise the HOB, oxygen, then call the doctor Pneumothorax o Decreased or absent breath sounds on one side, respiratory distress, distended unilateral chest o Interventions – Raise HOB, administer oxygen, call the doctor/RR Air embolism – pocket of air that has traveled from somewhere else in the vascular system; generally occurs during insertion of central line OR altered patient that becomes disconnected from infusion and allows air into the vascular system o Chest pain, SOB, decrease BP, increase HR, cyanosis, anxiety, confusion o Interventions – clamp the central catheter and get them in the left lateral decubitus position (trying to prevent it from traveling to the pulmonary system)

PCA Pumps  Enables the patient to self-administer medication on prn basis  Programmed according to medical orders (dosage, time intervals between doses, and lock-out intervals)  Can record the amount of medications received and the number of requests by the patient **Know which IV Fluids are hypertonic, hypotonic, and isotonic** Even if a patient is hypo-osmolar or hyperosmolar you’re still going to administer isotonic first because the body is already naturally compensating **IV push – want to use the IV port closest to the patient Cellular Regulation: Hematology/Oncology Perfusion, Clotting, and Immunity – Lab Studies  CBC o RBC: 4.1 – 5.3 million/mm3 o Hemoglobin  Male: 13.2 – 17.3 g/dL  Female: 11.7 – 15.5 g/dL o Hematocrit  Male: 43 – 49%  Female: 38 – 44% o WBC: 4,500 – 11,000/cubic mm3 o Platelets: 150,000 – 450,000/uL  ESR (Erythrocyte Sedimentation Rate) o Reflects inflammation or infection o 1 million skin cancers in 2003  Some cancers related to viruses which could be prevented with vaccine (HPV & cervical cancer)  1/3 of all cancers related to dietary factors and lack of physical activity in adulthood Types of Tumors  Benign Tumors o Not cancerous o Can often be removed o Most cases do not reoccur o Cells do not spread to other areas of the body o Example: Lipoma  Malignant Tumors o Cancerous o Can invade other areas of the body – metastasize o Examples:  Carcinoma – skin and tissues lining internal organs  Sarcoma – bone, connective, and supportive tissue  Leukemia – starts in blood  Lymphoma & myeloma – immune system  CNS – brain & spinal cord Seven Warning Signs of Cancer: CAUTION  Change in bowel habits  A sore that does not heal  Unusual bleeding or discharge from body  Thickening or a lump in the breast or elsewhere  Indigestion or difficulty swallowing  Obvious change in wart or mole  Nagging cough or hoarseness

Cancer: Diagnosis & Staging

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BIOPSY is the only definitive means of diagnosing For most cancers, the stage is based on 3 main factors o The original (primary) tumor’s size and whether or not the tumor has grown into nearby lymph nodes o Whether or not the cancer has spread to the nearby lymph nodes o Whether or not the cancer has spread to distant areas of the body

Surgical Therapy  Diagnosis – biopsy  Prevention – removal of non-vital organs to prevent cancer  Determine treatment plan – clinical staging  Cure and control of cancer – removal of localized cancer tissue  Supportive care – insertion of therapeutic devices o Ex: feeding tube  Rehabilitation – reconstructive surgery  Palliation of symptoms – relief of pain, obstruction, hemorrhage Radiation Therapy  Destroys cancer cells  Types o External beam radiation (teletherapy)  Delivery of radiation from a source placed at some distance from the target site in the RT department o Internal radiation (brachytherapy)  Involves placement of specifically prepared radioisotopes directly into/near the tumor itself or close proximity  Radiation safety precautions – sealed-source internal radioactive implants o Distance, timing, shielding o Patients require private room & bath o Rooms at ends of halls o Rooms with lead-shielded walls o Sign on door o Turn patient away from door and keep door closed as much as possible o Nurse wears dosimeter film badge o Pregnant nurses, pregnant women or children < 16 should not care for/visit patient o Visitors limited to 6” from source and time-limit of 30 mins/day o Leaded shields at doorway to wear; lead container and pair of long-handled forceps in case implant comes out of place o Ensure proper handling of bed linens/clothing o Call radiation therapist & radiation officer immediately to retrieve and secure source

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Nursing/collaborative care

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Skin integrity  Don’t wash treatment area until instructed to do so  Wash treated skin gently with mild soap, rinse well, pat dry  Use warm or cool water  Use hands for bathing in place of washcloths  Don’t remove tattoo marks  Avoid powders, lotions, creams, alcohol, & deodorants on treated skin  Loose-fitting clothing to avoid friction over treatment field  No tape/dressings on site  No direct sunlight, chlorinated swimming pools, or temperature extremes  Don’t use heat pads – the tissue is already excoriated from radiation so you don’t want to add more heat

Chemotherapy  Can cure disease  Increases mean survival time  Decreases the risk for specific life-threatening complications  Combination therapy usually more successful than the use of a single medication  Safety standards for nurses: o Put on gown, double or chemo gloves, mask and goggles  Gown & double gloves when handling excreta & body fluids within previous 48 hours of patient receiving chemo o If accidental chemo spill occurs, RN makes sure that no one has contact with the spill and it is kept from spreading until they can clean it up with a special chemotherapy spill kit  Administration o Chemotherapy can be an irritant or a vesicant  Irritant: damages intima of vein  Vesicant: can cause severe local tissue breakdown and necrosis o Extravasation  Pain, swelling, redness, presence of vesicles on the skin o Requires antidote or chemoprotective agent; may require skin grafts for closure o Stop the infusion immediately!

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Regional chemotherapy

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o Intraarterial o Intraperitoneal o Intrathecal o Intravesical bladder chemotherapy Nursing/collaborative care o Monitor for weight loss (may also be indicative of depression) o Eat small, frequent, low fat meals o Avoid spicy foods o Take nutritional substances as prescribed o Encourage 2-3 L of fluid per day if not contraindicated o Administer antiemetics 30 mins prior to chemo o Continue daily activities, but rest in between Side effects o Coping with therapy, bone marrow suppression, fatigue, skin reactions, nausea & vomiting o Mucositis (inflammation of the mucous membranes in the entire GI tract), stomatitis (inflammation of the mouth and lips), & xerostomia (dry mouth) o Diarrhea o Anorexia o Thrombocytopenia o Neutropenia o

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Hair loss/alopecia  Can occur systematically with chemo and locally with radiation  Managed with wigs, scarves, caps Peripheral neuropathy  Caused by certain chemotherapies  Pins & needles Cognitive dysfunction Urethral cystitis

Items To Review:  Lab values  Nursing care related to altered lab values – think nursing process  Bone/lymph node biopsy and nursing  Risk factors  CAUTION – 7 warning signs of cancer  Side effects of chemo (esp. related to bone marrow suppression)  Nursing care – nursing process – teaching to assist the patient to deal with the side effects  Safety precautions related to chemotherapy and radiation  General risk factors – do not need to know the exact age for screening tests but should recognize that patients at risk require earlier screening

Genetic Basis of Diseases

Genetics & Nursing  Important to know basis of genetic transmission  Requirements for the nurse o Demonstrate an understanding of the relationships of genetics to health, prevention, diagnosis, treatment, and effectiveness of care o Assess patient’s knowledge of conditions o Educate patients o Advocate for patients Inheritance  Parents and offspring often share observable traits  Grandparents and grandchildren may share traits not seen in parents o Skips a generation o Why do traits disappear in one generation and reappear in another? Mendel’s Conclusion  Law of Unit Character o Heredity “factors” (genes) are discrete units that maintain their characteristics when they are passed down  Do not blend  Do not acquire new or modified characteristics through use o Each individual has two versions of each factor called alleles  Responsible for variation in traits  Law of Dominance o When two plants expressing different forms (alleles) of the trait are crossed, only one form of the trait is expressed  The gene that is masked is recessive  The gene that is expressed is dominant Mendelian Genetics  Genotype – the combination of alleles (two genes, 1 from mom and 1 from dad) o Homozygous – alleles are the same o Heterozygous – alleles differ o Hemizygous – only one copy (genes on the X chromosome in males)  Phenotype – the physical characteristic that is expressed  Genotype rules o First letter of dominant form used to represent both forms of the trait o Dominant trait is capitalized o Recessive trait in lower case o Use italics (or script) o Genotype is represented by two letters representing alleles o Homozygous alleles are the same (TT) o Heterozygous allele pair are different (Tt)

Mendelian Inheritance

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Dominant inheritance o Trait or disorder is expressed in the heterozygote (Dd) Recessive inheritance o Trait is expressed in the homozygote (dd) Autosomal inheritance o Trait expressed on genes on chromosome 1-22 X-linked (sex linked) o Trait expressed genes on the X (or Y) chromosomes

Punnett Square  Mathematical chart or grid used to determine the results of simple genetics crosses o A Punnett square represents each pregnancy

Autosomal-Dominant Inheritance  Carried on the autosome  Male to male transmission can occur o Rare in x-linked  Each offspring has at least a 50% probability of inheriting the mutant allele  Does not skip generations, offspring can pass on only the recessive gene  Occurs equally frequently in males and females of all ethnic groups

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Examples

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Huntington Disease – progressive uncontrollable movements and personality changes, beginning in middle ages Familial hypercholesterolemia – very high serum cholesterol levels resulting in heart disease Marfan Syndrome – long limbs, sunken chest, weakened aorta Polydactyly – extra fingers and/or toes

Autosomal Recessive  25% chance of having the disease  50% of being a carrier (inherited one allele)  Must have both alleles for disease (one from each parent)  Males and females are affected  Affected males and females can transmit the gene, unless it causes death before reproductive age  The trait can skip generations  Parent of an affected individual are heterozygous or have the disease

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Examples o Cystic Fibrosis – lung congestion, malabsorption, male infertility, etc. o Phenylketonuria (PKU) – mental retardation, fair skin o Sickle Cell Disease (SCD) – pain, spleen involvement, anemia

Sex-Linked (X-Linked)  Genes carried on X chromosome are X-linked  Genes carried on Y chromosome are Y-linked  Y-linked traits are rare because the chromosome has few genes and many have counterparts on the X chromosome  Y-linked are passed from male to male  X-Linked Recessive o Females are carriers (50% chance of transmitting dominant mutant gene to offspring) o Mutant allele is on the X chromosome o Expressed more severely in males (has no other allele to balance it) o High rate of miscarriages in males due to early lethality in males o Affected male has a mother carrier o An unaffected female with an affected brother has a 50% chance of being a carrier o Affected female has an affected father and or carrier mother o Examples

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Hemophilia – bleeding disorder Muscular Dystrophy – Duchenne form; muscular weakness Menkes Disease – abnormal copper transport, brain atrophy

X-Linked Dominant o Expressed in female in one copy o Much more severe effects in males o High rate of miscarriages due to early lethality in males o Passed from male to all daughters but no sons o Sons can only be affected from mothers o Daughters can be affected from either parent o Examples  Incontinentia pigmenti (IP) – skin condition  Hypertrichosis (CGH) – extra hair follicles

Exceptions to Mendel Laws: Mitochondrial DNA (mtDNA)  Mitochondria are structures within cells that convert the energy from food into a form that cells can use  Most DNA is packaged in chromosomes within the nucleus, mitochondria also have a small amount of their own DNA o This genetic material is known as mitochondrial DNA or mtDNA  Alterations is mtDNA has been linked to many cancers (leukemia, breast cancer, etc.)  Transmitted via the maternal gene o All of affected mom’s kids will be affected. If dad is affected, none of the kids are affected. 

Examples o Leigh Syndrome – a progressive brain disorder that usually appears in infancy or early childhood  Fatal within a few years due to respiratory failure o Lebers Hereditary Optic Neuropathy (LHON) – rapid central vision loss and tremors in teens and young adult

Common mtDNA related disorders include migraines, thyroid disease, diabetes, heart failure, pancytopenia Exceptions to Mendel Laws: Multiple Alleles o

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More than two alleles – normally a person has two alleles for any autosomal gene Different allele combination can produce different variation in phenotype Example o Different types of CF and PKU o Eye colors

Additional Exceptions to Mendel Laws  Penetrance o Some individuals with a particular genotype do not have associated phenotype  Expressivity o A genotype is associated with a phenotype of varying intensity  Incomplete dominance o The heterozygous phenotype is intermediate between either homozygote o Ex: flower (snapdragon) with red (dominant) crosses with a white (recessive) results in pink flowers  Co-Dominance o Different alleles are both expressed in a heterozygote o Blood typing (ABO) o A child’s blood type doesn’t have to match parents

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Lethal allele o Deadly o Usually causes death before an individual can reproduce o Usually results in miscarriages Chromosomal Disorders  Occurs as a result of structural rearrangement within or between chromosomes  Arrangement is “balanced” if chromosome set appears to contain all the correct material but arranged in unusual way  “Unbalanced” when there is additional or missing chromosomal material such as depletion or duplication of chromosome  When normal balance is disturbed, mental and physical development is altered  Person who carried a rearrangement does not have any disabilities  Examples o Down Syndrome – Trisomy 21  Symptoms range from mild to severe  Increased risk of thyroid disease, leukemia, sleep apnea, and dementia o Turner Syndrome (Xo) – females sexually undeveloped o Klienefelter Syndrome – males sexually undeveloped, large hands and feet, may develop breast tissue o Trisomy 18 (Edward’s Syndrome) – mental and physical disabilities  Deletion: o Loss of a portion of the chromosome o 22q11.2 deletion syndrome – heart defects, immune problems, cleft palate, low calcium 

Ring Chromosome

A circular structure that occurs when a chromosome breaks in two places and its broken ends fuse together o Variety of conditions depending on chromosome involved Inversion o Breaks in a single chromosome o Piece reinserted o Balanced – may not see any visible changes o Some noticeable anomalies include polydactyly, club foot, cardiac and GI conditions o

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Multifactorial Conditions  Many birth defects as well as adult diseases have a multifactorial cause  Result from gene variations and environmental influences that work together  Conditions cluster in families but do not demonstrate the characteristic pattern of inheritance seen with single gene disorders  Examples o Neural Tube Disorders (Spina Bifida) – taking folic acid has decreased the incidents o Congenital heart defects o Diabetes o Heart disease...