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Pneumonia
Pneumonia 150 150 Tony Guo

Pneumonia

  • Acute infection of lung parenchyma
  • Associated with significant morbidity and mortality rates
  • Pneumonia and influenza are 8th leading cause of death in the U.S.

 

Etiology

  • Likely to result when defense mechanisms become incompetent or overwhelmed
  • Decreased cough and epiglottal reflexes may allow aspiration
  • Mucociliary mechanism impaired 
    • Pollution
    • Cigarette smoking
    • Upper respiratory infections
    • Tracheal intubation 
    • Aging 
  • Chronic diseases suppress immune system
  • Chronic diseases suppress immune system
  • Three ways organisms reach lungs:
    • Aspiration from nasopharynx or oropharynx
    • Inhalation of microbes present in air
    • Hematogenous spread from primary infection elsewhere in body

Types of Pneumonia

  • Can be classified according to causative organism 
  • Clinical classification:
    • Community-acquired (CAP)
      • Occurs in patients who have not been hospitalized or resided in a long-term care facility within 14 days of the onset of symptoms
      • Can be treated at home or hospitalized dependent on patient condition
      • Empiric antibiotic therapy started ASAP
    • Hospital-acquired (HAP)
      • HAP: Occurs 48 hours or longer after hospitalization and not present at time of admission
      • Ventilator-associated  (VAP): Occurs more than 48 hours after endotracheal intubation
      • Associated with longer hospital stays, increased costs, sicker patients, and increased risk of morbidity and mortality
  • Multidrug-resistant (MDR) organisms are major problem in treatment
    • Staphylococcus aureus
    • Gram-negative bacilli
  • Risk factors
    • Advanced age
    • Immunosuppression
    • History of antibiotic use
    • Prolonged mechanical ventilation
    • Aspiration Pneumonia
      • Results from abnormal entry of secretions into lower airway
      • Major risk factors:
        • Decreased level of consciousness
        • Difficulty swallowing
        • Insertion of nasogastric tubes with or without tube feeding
      • Aspirated material triggers inflammatory response
      • Primary bacterial infection most common
      • Empiric therapy based on severity of illness, where infection acquired, and probable causative organism
      • Aspiration of acid gastric contents initially causes chemical (noninfectious) pneumonitis
    • Necrotizing Pneumonia
      • Rare complication of bacterial lung infection
      • Often results from CAP
      • Signs and symptoms
        • Immediate respiratory insufficiency and/or failure
        • Leukopenia
        • Bleeding into airways
    • Opportunistic Pneumonia
      • Patients at risk 
        • Severe protein-calorie malnutrition
        • Immunodeficiencies
        • Chemotherapy/radiation recipients
        • Long-term corticosteroid therapy
      • Caused by microorganisms that do not normally cause disease
    • Pneumocystis jiroveci pneumonia (PJP) 
      • Onset slow and subtle
      • Diffuse bilateral infiltrates to massive consolidation
      • Can be life threatening
      • Spread to other organs
      • Treat with trimethoprim/sulfamethoxazole IV or orally
    • Cytomegalovirus (CMV) pneumonia
      • Herpes virus
      • Asymptomatic and mild to severe disease
      • Life threatening in immunosuppressed person
      • Treat with antiviral medications and high-dose immunoglobulin

    Pathophysiology

    • Inflammatory response
      • Attraction of neutrophils
      • Release of inflammatory mediators
      • Accumulation of fibrinous exudates, red blood cells, and bacteria
    • As a result, the inflammatory process attracts more neutrophils, edema of the airways occurs, and fluid leaks from the capillaries and tissues into alveoli
      • Alveoli fill with fluid and debris (consolidation)
      • Increased production of mucus (airway obstruction)
    • Normal O2 transport is affected, leading to clinical manifestations of hypoxia (e.g., tachypnea, dyspnea, tachycardia)
    • Resolution of infection
      • Macrophages in alveoli ingest and remove debris
      • Normal lung tissue restored
      • Gas exchange returns to normal

    Risk factors

    • Abdominal or thoracic surgery
    • Age >65 yr.
    • Air pollution
    • Altered consciousness: alcoholism, head injury, seizures, anesthesia, drug overdose, stroke
    • Bed rest and prolonged immobility
    • Chronic diseases: chronic lung and liver disease, diabetes mellitus, heart disease, cancer, chronic kidney disease
    • Debilitating illness
    • Exposure to bats, birds, rabbits, farm animals
    • Immunosuppressive disease and/or therapy (corticosteroids, cancer chemotherapy, human immunodeficiency virus [HIV] infection, immunosuppressive therapy after organ transplant)
    • Inhalation or aspiration of noxious substances
    • Intestinal and gastric feedings via nasogastric or nasointestinal tubes
    • IV drug use
    • Malnutrition
    • Recent antibiotic therapy
    • Resident of a long-term care facility
    • Smoking
    • Tracheal intubation (endotracheal intubation, tracheostomy)
    • Upper respiratory tract infection

    Clinical manifestation

    • Most common
      • Cough
      • Fever, chills
      • Dyspnea, tachypnea
      • Pleuritic chest pain
      • Green, yellow, or rust-colored sputum
    • Change in mentation for older or debilitated patients
    • Nonspecific manifestations
    • Physical examination findings
      • Fine or coarse crackles
      • Bronchial breath sounds
      • Egophony
      • Increased fremitus
      • Dullness to percussion if pleural effusion present

    Complications

    • Atelectasis
      • (Collapsed, airless alveoli) of one or part of one lobe may occur. These areas may clear with effective deep breathing and coughing.
    • Pleurisy
      • Inflammation of the pleura
    • Pleural effusion 
      • Fluid in the pleural space
    • Bacteremia
      • (Bacterial infection in the blood) is more likely to occur in infections with Streptococcus pneumoniae and Haemophilus influenzae
    • Pneumothorax
      • Can occur when air collects in the pleural space, causing the lungs to collapse
    • Meningitis 
      • Can be caused by Streptococcus pneumoniae. 
      • The patient with pneumonia who is disoriented, confused, or drowsy may have a lumbar puncture to evaluate the possibility of meningitis.
    • Acute respiratory failure 
      • One of the leading causes of death in patients with severe pneumonia. 
      • Failure occurs when pneumonia damages the lungs’ ability to facilitate the exchange of O2 and CO2 across the alveolar-capillary membrane.
    • Sepsis/septic shock 
      • Can occur when bacteria within alveoli enter the bloodstream. Severe sepsis can lead to shock and multisystem organ dysfunction syndrome (MODS)
    • Lung abscess
      • Not a common complication of pneumonia.
      • It may occur with pneumonia caused by S. aureus and gram-negative organisms
    • Empyema
      • The accumulation of purulent exudate in the pleural cavity, occurs in less than 5% of cases and requires antibiotic therapy and drainage of the exudate by a chest tube or open surgical drainage

    Diagnostic tests

    • History and physical examination
    • Chest x-ray
    • Gram stain of sputum
    • Sputum culture and sensitivity test
    • Pulse oximetry or ABGs (if indicated)
    • Blood cultures
    • Thoracentesis
    • Bronchoscopy  with washings
    • Biologic markers to guide clinical decisions:
      • C-reactive protein (CRP)
      • Procalcitonin

    Interprofessional Care

    • Pneumococcal vaccine
      • To prevent Streptococcus pneumoniae
    • Prompt treatment with antibiotics is essential
      • Response generally occurs within 48-72 hr
        • Drop in temperature
        • Improved breathing
        • Decreased chest discomfort
      • Repeat chest x-ray in 6-8 weeks
    • Supportive care
      • Oxygen for hypoxemia
      • Analgesics for chest pain
      • Antipyretics
      • Individualize rest and activity
    • No definitive treatment for majority of viral pneumonias
    • Antivirals for influenza pneumonia

    Drug therapy

    • Start with empiric therapy 
      • Based on likely infecting organism and risk factors for MDR organisms
      • Varies with local patterns of antibiotic resistance
    • Should see improvement in 3-5 days
    • Start with IV and then switch to oral therapy as soon as patient stable

    Nutritional therapy

    • Adequate hydration
      • Prevent dehydration
      • Thin and loosen secretions
      • Adjust for older adults, patients with heart failure, those with preexisting respiratory conditions
    • High calorie, small, frequent meals
      • Monitor for weight loss

    Nursing assessment

    • Subjective Data
      • Important Health Information
        • Past health history: 
          • Lung cancer, COPD, diabetes mellitus, chronic debilitating disease, malnutrition, altered consciousness, immunosuppression, exposure to chemical toxins, dust, or allergens
        • Medications: 
          • Antibiotics, corticosteroids, chemotherapy, or any immunosuppressants
        • Surgery or other treatments: 
          • Recent abdominal or thoracic surgery, splenectomy, endotracheal intubation, or any surgery with general anesthesia. Tube feedings
      • Functional Health Patterns
        • Health perception–health management: 
          • Cigarette smoking, alcoholism; recent upper respiratory tract infection, malaise 
        • Nutritional-metabolic: 
          • Anorexia, nausea, vomiting. Chills
        • Activity-exercise: 
          • Prolonged bed rest or immobility. Fatigue, weakness. Dyspnea, cough (productive or nonproductive). Nasal congestion
        • Cognitive-perceptual: 
          • Pain with breathing, chest pain, sore throat, headache, abdominal pain, muscle aches
    • Objective Data
      • General
        • Fever
        • Restlessness or lethargy
        • Splinting affected area
      • Respiratory
        • Tachypnea
        • Asymmetric chest movements
        • Use of accessory muscles (neck and abdomen)
        • Crackles
        • Friction rub on auscultation
        • Dullness on percussion over consolidated areas
        • Increased tactile fremitus on palpation
        • Sputum amount and color (Pink, rusty, purulent, green, yellow, or white sputum [amount may be scant to copious])
      • Cardiovascular
        • Tachycardia
      • Neurologic
        • Changes in mental status
      • Possible Diagnostic Findings
        • Leukocytosis. 
        • Abnormal ABGs with decreased or normal PaO2, decreased or normal PaCO2, and increased or normal pH initially, and later decreased PaO2, increased PaCO2, and decreased pH. 
        • Positive sputum on Gram stain and culture. Patchy or diffuse infiltrates, abscesses, pleural effusion, or pneumothorax on chest x-ray

    Nursing Diagnoses

    • Impaired gas exchange
    • Ineffective breathing pattern related to inflammation and chest discomfort
    • Acute pain (chest) related to inflammation and ineffective pain management and/or comfort measures
    • Activity intolerance related to chest discomfort, inflammation, shortness of breath, generalized weakness

    Planning

    • Clear breath sounds
    • Normal breathing patterns
    • No signs of hypoxia
    • Normal chest x-ray
    • Normal white blood cell (WBC) count
    • Absence of complications related to pneumonia.

    Nursing implementation

    • Health Promotion
      • Teach hygiene, nutrition, rest, regular exercise to maintain natural resistance
      • Cough or sneeze into elbow, not hands
      • Avoid cigarette smoke
      • Prompt treatment of URIs
      • Influenza and pneumococcal vaccination
    • Prevent pneumonia in at risk patients
      • Proper positioning to prevent aspiration
      • Reposition patient every 2 hours
      • Strict adherence to ventilator bundle to prevent VAP
      • Elevate head-of-bed 30 degrees and have sit up for all meals
      • Assist with eating, drinking, taking meds as needed
      • Assess for gag reflex
      • Early mobilization
      • Incentive spirometry
      • Twice-daily oral hygiene
      • Pain management
      • Strict medical asepsis
      • Hand hygiene
      • Respiratory devices
      • Suctioning 
      • Avoid unnecessary antibiotic usage
    • Ambulatory care
      • Teach the patient about 
        • Importance of taking every dose of the prescribed antibiotic, any drug-drug and food-drug interactions for the prescribed antibiotic, and the need for adequate rest to facilitate recovery. 
        • Drink plenty of liquids (at least 6 to 10 glasses/day, unless contraindicated) and to avoid alcohol and smoking. 
        • A cool mist humidifier or warm bath may help the patient breathe easier.
        • Explain that a follow-up chest x-ray may be done in 6 to 8 weeks to evaluate resolution of pneumonia
        • Information about available influenza and pneumococcal vaccines.

    Evaluation

    • Effective respiratory rate, rhythm, and depth of respirations
    • Lungs clear to auscultation
    • Reports pain control
    • SpO2 ≥ 95
    • Free of adventitious breath sounds
    • Clear sputum from airway
Asthma
Asthma 150 150 Tony Guo

 

Asthma

  • Heterogeneous disease characterized by a combination of clinical manifestations along with reversible expiratory airflow limitation or bronchial hyper-responsiveness 
  • Affects about 18.8 million Americans
  • Women are 62% more likely to have asthma than men
  • Older adults may be undiagnosed

Risk factors and triggers

  • Related to patient (e.g., genetic factors) 
  • Related to environment (e.g., pollen)
  • Male gender is a risk factor in children (but not adults)
  • Obesity is also a risk factor
  • Genetics-inherited component is complex
  • Immune response–hygiene hypothesis
  • Allergens: May be seasonal or year-round depending on exposure to allergen
    • Cockroaches, Furry animals, Fungi, Pollen, Molds

Trigger of Asthma attacks

  • Exercise
    • Exercise-induced asthma (EIA) or exercise-induced bronchospasm (EIB) is induced or exacerbated during physical exertion
      • Occurs after vigorous exercise
      • Pronounced with exposure to cold air
  • Air pollutants
    • Can trigger asthma attacks
      • Cigarette or wood smoke
      • Vehicle exhaust
      • Concentrated pollution
        • Aerosol sprays
        • Oxidants
        • Perfumes
        • Sulfur dioxides
  • Respiratory infections
    • Major precipitating factor of an acute asthma attack
      • Increase Inflammation and hyper-responsiveness of tracheobronchial system
        • Sinusitis, allergic rhinitis
        • Viral upper respiratory tract infection
  • Allergic rhinitis and nasal polyps
    • Large polyps need to be removed 
    • Sinus problems are usually related to inflammation of the mucous membranes
      • Animal dander (e.g., cats, mice, guinea pigs)
      • Cockroaches
      • House dust mite
      • Molds
      • Pollens
  • Drugs and Food additives
    • Asthma triad: Nasal polyps, asthma, and sensitivity to aspirin and NSAIDs
      • Wheezing develops in about 2 hours.
      • Sensitivity to salicylates
        • Found in many foods, beverages, and flavorings
    • β-Adrenergic blockers 
    • ACE inhibitors
    • Food allergies may cause asthma symptoms
      • Rare in adults
      • Oral food challenges
        • Beer, wine, dried fruit, shrimp,
        • processed potatoes
        • Monosodium glutamate
        • Sulfites (bisulfites and metabisulfites)
        • Tartrazine
  • Gastroesophageal reflux disease
    • GERD more common in persons with asthma
      • Reflux may trigger bronchoconstriction as well as cause aspiration
      • Asthma medications may worsen GERD symptoms
  • Emotional stress
    • Psychologic factors can worsen the disease process
      • Extreme emotional expressions 
      • Attacks can trigger panic and anxiety

 

Pathophysiology

  • Primary response is chronic inflammation from exposure to allergens or irritants
    • Leading to airway bronchoconstriction, hyper-responsiveness, and edema of airways
    • Exposure to allergens or irritants initiates inflammatory cascade
  • Inflammatory mediators cause early-phase response
    • Vascular congestion
    • Edema formation
    • Production of thick, tenacious mucus
    • Bronchial muscle spasm
    • Thickening of airway walls
  • Early-phase response
    • As the inflammatory process begins, mast cells (found beneath the basement membrane of the bronchial wall) degranulate and release multiple inflammatory mediators.
      • IgE antibodies are linked to mast cells, and the allergen cross-links the IgE. 
      • Inflammatory mediators such as leukotrienes, histamine, cytokines, prostaglandins, and nitric oxide are released. 
    • Some inflammatory mediators have effects on the 
      • Blood vessels, causing vasodilation and increasing capillary permeability (runny nose)
      • Nerve cells causing itching
      • Smooth muscle cells causing bronchial spasms and airway narrowing
      • Goblet cells causing mucus production
  • Late-phase response
    • Occurs within 4 to 6 hours after initial attack
    • Occurs in about 50% of patients
    • Can be more severe than early phase and can last for 24 hours or longer
    • If airway inflammation is not treated or does not resolve, it may lead to irreversible lung damage
    • Structural changes in the bronchial wall known as remodeling

 

Clinical manifestation

  • Recurrent episodes of wheezing, breathlessness, cough, and tight chest
  • Expiration may be prolonged.
    • Inspiration-expiration ratio of 1:2 to 1:3 or 1:4
    • Bronchospasm, edema, and mucus in bronchioles narrow the airways
    • Air takes longer to move out
  • Most common manifestations
    • Cough
    • Shortness of breath (dyspnea)
    • Wheezing
    • Chest tightness
    • Variable airflow obstruction

 

Complications and classification

  • Mild
    • Dyspnea occurs with activity and patient may feel that he or she “can’t get enough air.”
    • PEF ≥70%
    • Usually treated at home
      • Prompt relief with inhaled SABA such as albuterol (delivered via a nebulizer or MDI with a spacer)
      • Patients instructed to take 2 to 4 puffs albuterol every 20 min three times to gain rapid control of symptoms
      • Occasionally short course of oral corticosteroids is needed.
  • Moderate
    • Dyspnea interferes with or limits usual activities.
    • PEF 40%69%
      • Usually requires office or ED visit
      • Relief is provided with frequent inhaled SABA.
      • Oral systemic corticosteroids. (Symptoms may persist for several days even after corticosteroids are started.)
  • Severe exacerbations
    • Respiratory rate >30/min 
    • Dyspnea at rest, feeling of suffocation
    • Pulse >120/min
    • PEFR is 40% at best
    • Usually seen in ED or hospitalized
      • Partial relief from frequent inhaled SABA
      • Oral systemic corticosteroids. Some symptoms last for >3 days after treatment is begun.
      • Adjunctive therapy: ipratropium, IV magnesium
  • Life-threatening asthma
    • Too dyspneic to speak
    • Perspiring profusely
    • Drowsy/confused
    • PEFR <25%
    • Require hospital care and often admitted to ICU
      • Minimal or no relief from frequent inhaled SABA
      • IV corticosteroids
      • Adjunctive therapy: ipratropium, IV magnesium

 

Diagnostic studies

  • Detailed history and physical exam
  • Spirometry
  • Peak expiratory flow rate (PEFR)
  • Chest x-ray
  • Oximetry
  • Allergy testing
  • Blood levels of eosinophils

Diagnostic Assessment

  • History and physical examination
  • Spirometry, including response to bronchodilator therapy
  • Peak expiratory low rate (PEFR)
  • Chest xray
  • Measurement of oximetry
  • Allergy skin testing (if indicated)
  • Blood level of eosinophils and IgE (if indicated)

Management

Intermittent or Persistent Asthma

  • Identification and avoidance or elimination of triggers
  • Patient and caregiver teaching
  • Drug therapy 
  • Asthma action plan 
  • Desensitization (immunotherapy) if indicated
  • Assess for control (e.g., Asthma Control Test [ACT])*

Acute Exacerbations 

  • SaO2 monitoring
  • ABGs
  • Inhaled β2adrenergic agonists
  • Inhaled anticholinergics
  • O2 by nasal cannula or mask
  • IV or oral corticosteroids
  • IV fluids
  • IV magnesium
  • Intubation and assisted ventilation

 

Interprofessional care

  • The current guidelines focus on 
    • Assessing the severity of the disease at diagnosis and initial treatment and then 
    • Monitoring periodically to control the disease
  • Intermittent and persistent asthma
    • Avoid triggers of acute attacks
    • Pre-medicate before exercising
    • Short-term (rescue or reliever) medication
    • Long-term or controller medication
  • Acute asthma exacerbations
    • Respiratory distress
    • Treatment depends upon severity and response to therapy
      • Classified as mild, moderate, severe, or life-threatening 
      • Management focuses on correcting hypoxemia and improving ventilation
    • O2 given via nasal cannula or mask to achieve a PaO2 of at least 60 mm Hg or O2 saturation greater than 90%
      • Continuous oxygen monitoring with pulse oximetry
    • Bronchodilator treatment
      • Short-acting β2-adrenergic agonists (SABAs)
  • Assessment during acute exacerbation
    • Respiratory and heart rate
    • Use of accessory muscles
    • Percussion and auscultation of lungs
    • PEFR to monitor airflow obstruction
    • ABGs
    • Pulse oximetry
  • Severe and life-threatening exacerbations
    • “Silent chest”
      • Severely diminished breath sounds
      • Absence of wheeze after patient has been wheezing
      • Patient is obviously struggling
      • Life-threatening situation
      • Requires ED and possible ICU
      • IV magnesium sulfate
      • 100% oxygen
      • Hourly or continuous nebulized SABA
      • IV corticosteroids
  • Bronchial thermoplasty
    • Catheter applies heat to reduce muscle mass in the bronchial wall
    • Reverses accumulation of excessive tissue that causes narrowing of airway
  • Drug therapy
    • Three types of anti-inflammatory drugs
      • Corticosteroids (e.g., beclomethasone, budesonide)
        • Suppress inflammatory response
        • Reduce bronchial hyper-responsiveness
        • Decrease mucous production
        • Inhaled form is used in long-term control
        • Systemic form to control exacerbations and manage persistent asthma
        • Oropharyngeal candidiasis, hoarseness, and a dry cough are local side effects of inhaled drug
        • Can be reduced using a spacer or by gargling after each use
      • Leukotriene modifiers or inhibitors (e.g., zafirlukast, montelukast, zileuton)
        • Block action of leukotrienes—potent bronchoconstrictors
        • Have both bronchodilator and antiinflammatory effects 
        • Not indicated for acute attacks
        • Used for prophylactic and maintenance therapy
      • Monoclonal antibody to IgE 
        • Anti-IgE (e.g., Xolair)
          • Decrease in circulating IgE levels
          • Prevents IgE from attaching to mast cells, preventing release of chemical mediators
          • Subcutaneous administration every 2 to 4 weeks
        • β-Adrenergic agonists (SABAs)
          • Examples: albuterol, pirbuterol
          • Effective for relieving acute bronchospasm
          • Onset of action in minutes and duration of 4 to 8 hours
          • Prevent release of inflammatory mediators from mast cells
          • Not for long-term use
        • Methylxanthines (e.g., theophylline)
          • Less effective long-term bronchodilator
          • Alleviates early phase of attacks but has little effect on bronchial hyper-responsiveness
          • Narrow margin of safety
        • Anticholinergic drugs 
          • Block action of acetylcholine
          • Promote bronchodilation
          • Short-acting drugs used for severe acute asthma exacerbation
    • Patient teaching related to drug therapy
      • Correct administration of drugs is a major factor in success 
        • Inhalation of drugs is preferable to avoid systemic side effects
        • MDIs, DPIs, and nebulizers are devices used to inhale medications
        • Using an MDI with a spacer is easier and improves inhalation of the drug
        • DPI (dry powder inhaler) requires less manual dexterity and coordination
          • DPIs are simpler to use than MDIs.
          • The DPI contains dry, powdered medication and is breath-activated. No propellant is used. 
          • Instead an aerosol is created when the patient inhales through a reservoir containing a dose of powder.

 

Nursing management

  • Health promotion
    • Teach patient to identify and avoid known triggers
      • Use dust covers
      • Use scarves or masks for cold air
      • Avoid aspirin and NSAIDs
    • Prompt diagnosis and treatment of upper respiratory infections and sinusitis may prevent asthma exacerbation
    • Fluid intake of 2 to 3 L every day
    • Good nutrition
    • Adequate rest
  • Nursing Assessment
    • Subjective Data
      • Important Health Information
        • Past health history: Allergic rhinitis, sinusitis, or skin allergies.
        • Previous asthma attack and hospitalization or intubation. Symptoms worsened by triggers in the environment. Gastroesophageal reflux disease (GERD). Occupational exposure to chemical irritants (e.g., paints, dust)
        • Medications: Adherence to medication, inhaler technique. Use of antibiotics. Pattern and amount of short-acting β2 –adrenergic agonist used per week. Medications that may precipitate an attack in susceptible asthmatics such as aspirin, nonsteroidal anti-inflammatory drugs, β-adrenergic blockers
      • Functional Health Patterns
        • Health perception–health management: Family history of allergies or asthma. Recent upper respiratory tract or sinus infection 
        • Activity-exercise: Fatigue, decreased or absent exercise tolerance. Dyspnea, cough (especially at night), productive cough with yellow or green sputum or sticky sputum. Chest tightness, feelings of suffocation, air hunger, talking in short sentences or words or phrases, sitting upright to breathe
        • Sleep-rest: Awakened from sleep because of cough or breathing difficulties, insomnia
        • Coping–stress tolerance: Emotional distress, stress in work environment
        • or home
    • Objective Data
      • General
        • Restlessness or exhaustion, confusion, upright or forward-leaning body position
      • Integumentary
        • Diaphoresis, cyanosis (circumoral, nail bed), eczema
      • Respiratory
        • Nasal discharge, nasal polyps, mucosal swelling. Crackles, diminished or absent breath sounds, and wheezes on auscultation. Hyperresonance on percussion. Sputum (thick, white, tenacious), Increased work of breathing with use of accessory muscles. Intercostal and supraclavicular retractions. Tachypnea with hyperventilation. Prolonged expiration
      • Cardiovascular
        • Tachycardia, pulsus paradoxus, jugular venous distention, hypertension or hypotension, premature ventricular contractions
      • Possible Diagnostic Findings
        • Abnormal ABGs during attacks, 
        • Decreased O2 saturation, serum and sputum eosinophilia
        • Increased serum IgE, positive skin tests for allergens, chest x-ray demonstrating hyperinflation with attacks
        • Abnormal pulmonary function tests showing decreased flow rates; FVC, FEV1, PEFR, and FEV1/FVC ratio that improve between attacks and with bronchodilators
  • Nursing diagnoses
    • Ineffective airway clearance related to bronchospasm, excessive mucus production, tenacious secretions, and fatigue
    • Anxiety related to difficulty breathing, perceived or actual loss of control, and fear of suffocation
    • Deficient knowledge related to lack of information and education about asthma and its treatment
  • Planning
    • Minimal symptoms during the day and night 
    • Acceptable activity levels (including exercise and other physical activity)
    • Maintenance of greater than 80% of personal best PEFR
    • Few or no adverse effects of therapy
    • No acute exacerbations of asthma
    • Adequate knowledge to participate in and carry out the plan of care.
  • Nursing implementation
    • Important patient teaching
      • Seek medical attention for bronchospasm or when severe side effects occur
      • Maintain good nutrition
      • Exercise within limits of tolerance
      • Uninterrupted sleep is important
      • Written asthma action plan
      • Measure peak flow at least daily
      • Patients with asthma frequently do not perceive changes in their breathing
    • Peak flow results
      • Green Zone
        • Usually 80% to 100% of personal best
        • Remain on medications
      • Yellow Zone
        • Usually 50% to 80% of personal best
        • Indicates caution
        • Something is triggering asthma. 
      • Red Zone
        • 50% or less of personal best
        • Indicates serious problem
        • Definitive action must be taken with health care provider
  • Evaluation
    • Maintain clear airway with removal of excessive secretions
    • Have normal (for the individual) breath sounds and respiratory rate
    • Report decreased anxiety with increased control of respirations
    • Describe the disease process and treatment regimen
    • Demonstrate correct administration of inhaled drugs
    • Express confidence in ability for long-term management of asthma

 

Cultural considerations: Asthma

  • African Americans and Hispanics have higher rates of poorly controlled asthma and deaths
    • Disparities in socioeconomic status and access to proper health care
    • Cultural beliefs about management of asthma

 

Tuberculosis
Tuberculosis 150 150 Tony Guo

Tuberculosis

 

  • Infectious disease caused by Mycobacterium tuberculosis
  • Lungs most commonly infected
  • 1/3 of world’s population has TB
  • Leading cause of death in patients with HIV/AIDs
  • Prevalence is decreasing in the United States

 

Risk factors

  • Homeless
  • Residents of inner-city neighborhoods
  • Foreign-born persons
  • Living or working in institutions (includes health care workers)
  • IV injecting drug users
  • Poverty, poor access to health care
  • Immunosuppression

 

Multidrug-Resistant Tuberculosis (MDR-TB)

  • Resistance to 2 of the most potent first-line anti-TB drugs
  • Extensively drug-resistant TB (XDR-TB) resistant to any fluoroquinolone plus any injectable antibiotic
  • Several causes for resistance occur
    • Incorrect prescribing
    • Lack of case management
    • Nonadherence 

 

Etiology and pathophysiology

  • Spread via airborne particles
  • Can be suspended in air for minutes to hours
  • Transmission requires close, frequent, or prolonged exposure
  • NOT spread by touching, sharing food utensils, kissing, or other physical contact
  • Once causative organisms gains entrance, particles lodge in bronchioles and alveoli
  • Local inflammatory reaction occurs
    • Ghon lesion or focus – represents a calcified TB granuloma
    • Infection walled off and further spread stopped
  • Only 5% to 10% will develop active TB
  • Aerophilic (oxygen-loving) – causes affinity for lungs
  • Infection can spread via lymphatics and grow in other organs as well
    • Cerebral cortex
    • Spine 
    • Epiphyses of the bone
    • Adrenal glands

Classification

  • Classes
    • 0 = No TB exposure
      • No TB exposure, not infected (no history of exposure, negative tuberculin skin test)
    • 1 = Exposure, no infection
      • TB exposure, no evidence of infection (history of exposure, negative tuberculin skin test)
    • 2 = Latent TB, no disease
      • TB infection without disease (significant reaction to tuberculin skin test, negative bacteriologic studies, no x-ray findings compatible with TB, no clinical evidence of TB
    • 3 = TB, clinically active
      • TB infection with clinically active disease (positive bacteriologic studies or both a significant reaction to tuberculin skin test and clinical or x-ray evidence of current disease)
    • 4 = TB, not clinically active
      • No current disease (history of previous episode of TB or abnormal, stable x-ray findings in a person with a significant reaction to tuberculin skin test. Negative bacteriologic studies if done. No clinical or x-ray evidence of current disease)
    • 5 = TB suspected
      • TB suspect (diagnosis pending). Individual should not be in this classification for >3 months
  • Primary  infection
    • When bacteria are isoniazidaled
  • Latent TB infection (LTBI)
    • Infected but no active disease
  • Active TB disease
    • Primary TB
    • Reactivation TB (post-primary)

Clinical manifestations

  • LTBI – asymptomatic
    • Cannot spread TB bacteria to others
    • Usually has a skin test or blood test result indicating TB infection
    • Has a normal chest x-ray and a negative sputum smear
    • Needs treatment for latent TB infection to prevent active TB disease
  • Pulmonary TB
    • Takes 2-3 weeks to develop symptoms
    • Initial dry cough that becomes productive
    • Constitutional symptoms (fatigue, malaise, anorexia, weight loss, low-grade fever, night sweats)
    • Dyspnea and hemoptysis late symptoms
  • Cough becomes frequent
    • Hemoptysis is not common and is usually associated with advanced disease
    • Dyspnea is unusual
  • Can also present more acutely
    • High fever
    • Chills, generalized flulike symptoms
    • Pleuritic pain
    • Productive cough
    • Crackles and/or adventitious breath sounds
  • Extrapulmonary TB manifestations dependent on organs infected
  • Immunosuppressed people and older adults are less likely to have fever and other signs of an infection
    • Carefully investigate respiratory problems in HIV patients
      • Rule out opportunistic diseases
    • A change in cognitive function may be the only initial sign of TB in an older person

Complications

  • Miliary TB
    • Large numbers of organisms spread via the bloodstream to distant organs
    • Fatal if untreated
    • Manifestations progress slowly and vary depending on which organs are infected
    • Fever, cough, and lymphadenopathy occur
    • Can include hepatomegaly and splenomegaly
  • Pleural TB
    • Chest pain, fever, cough, and a unilateral pleural effusion are common
    • Pleural effusion
      • Bacteria in pleural space cause inflammation.
      • Pleural exudates of protein-rich fluid
    • Empyema
      • Large numbers of tubercular organisms in pleural space
  • TB pneumonia
    • Large amounts of bacilli discharged from granulomas into lung or lymph nodes
    • Manifests as bacterial pneumonia
  • Other organ development
    • Spinal destruction
    • Bacterial meningitis
    • Peritonitis

 

Diagnostic Studies

  • Tuberculin skin test (TST) 
    • AKA: Mantoux test
    • Uses purified protein derivative (PPD) injected intradermally
    • Assess for induration in 48 – 72 hours
    • Presence of induration (not redness) at injection site indicates development of antibodies secondary to exposure to TB
    • Positive if ≥15 mm induration in low-risk individuals
    • Response decrease in immunocompromised patients
    • Reactions ≥5 mm considered positive
    • A waning immune response can cause false negative results
    • Repeating TST may boost reaction
    • Two-step testing recommended for health care workers getting repeated testing and those with decreased response to allergens
    • Two-step testing ensures future positive results accurately interpreted
  • Interferon-γ gamma release assays (IGRAs) 
    • Detects  T-cells in response to Mycobacterium tuberculosis
    • Includes QuantiFERON-TB and T-SPOT.TB tests 
    • Rapid results
    • Several advantages over TST but more expensive
  • Chest x-ray
    • Cannot make diagnosis solely on x-ray
    • May appear normal in a patient with TB
    • Upper lobe infiltrates, cavitary infiltrates, lymph node involvement, and pleural and/or pericardial effusion suggest TB
  • Bacteriologic studies
    • Required for diagnosis
    • Consecutive sputum samples  obtained on 3 different days
    • Stained sputum smears examined for AFB
    • Culture results can take up to 8 weeks
    • Can also examine samples from other suspected TB sites

Interprofessional care

  • Hospitalization not necessary for most patients
  • Infectious for first 2 weeks after starting treatment if sputum +
  • Drug therapy used to prevent or treat active disease
  • Need to monitor compliance

Drug therapy

  • Active disease
    • Treatment is aggressive  
    • Two phases of treatment
      • Initial (8 weeks)
      • Continuation (18 weeks)
    • Four-drug regimen
      • Isoniazid
      • Rifampin (Rifadin)
      • Pyrazinamide 
      • Ethambutol
    • Patients should be taught about side effects and when to seek medical attention
    • Liver function should be monitored
    • Alternatives are available for those who develop a toxic reaction to primary drugs
  • Directly observed therapy (DOT)
    • Noncompliance is major factor in multidrug resistance and treatment failures
    • Requires watching patient swallow drugs
    • Preferred  strategy to ensure adherence 
    • May be administered by public health nurses at clinic site
  • Latent TB infection
    • Usually treated with Isoniazid for 6 to 9 months
    • HIV patients should take Isoniazid for 9 months
    • Alternative  3-month regimen of Isoniazid and rifapentine OR 4 months of rifampin
  • Vaccine
    • Bacille-Calmette-Guérin (BCG) vaccine to prevent TB is currently in use in many parts of world
    • In United States, not recommended except for very select individuals
    • Can result in positive PPD reaction

 

Nursing Assessment

  • History
  • Physical symptoms
    • Productive cough
    • Night sweats
    • Afternoon temperature elevation
    • Weight loss
    • Pleuritic chest pain
    • Crackles over apices of lungs
  • Sputum collection

Nursing diagnoses

  • Ineffective breathing pattern related to decreased lung capacity
  • Ineffective airway clearance related to increased secretions, fatigue, and decreased lung capacity
Fractures Part II
Fractures Part II 150 150 Tony Guo
  • Fracture heals in abnormal position in relation to midline of structure (type of malunion)
  • Pseudoarthrosis
    • Type of nonunion occurring at fracture site in which a false joint is formed with abnormal movement at site.
  • Refracture
    • New fracture occurs at original fracture site
  • Myositis ossificans
    • Deposition of calcium in muscle tissue at site of significant blunt muscle trauma or repeated muscle injury

 

Fracture reduction

  • Closed reduction
    • Nonsurgical, manual realignment of bone fragments 
    • Traction and countertraction applied
    • Under local or general anesthesia
    • Immobilization afterwards
  • Open reduction
    • Surgical incision
    • Internal fixation
    • Risk for infection
    • Early ROM of joint to prevent adhesions
    • Facilitates early ambulation

 

Traction

  • Purpose 
    • Prevent or decrease pain and muscle spasm 
    • Immobilize joint or part of body
    • Reduce fracture or dislocation
    • Treat a pathologic joint condition
  • Pulling force to attain realignment – countertraction pulls in opposite direction
  • Two most common types of traction
    • Skin traction
    • Skeletal traction
  • Skin traction
    • Short-term (48-72 hours) 
    • Tape, boots, or splints applied directly to skin 
    • Traction weights 5 to 10 pounds 
    • Skin assessment and prevention of breakdown imperative
  • Skeletal traction
    • Long-term pull to maintain alignment
    • Pin or wire inserted into bone
    • Weights 5 to 45 lbs.
    • Risk for infection
    • Complications of immobility
    • Maintain countertraction, typically the patient’s own body weight
      • Elevate end of bed
    • Maintain continuous traction
    • Keep weights off the floor

 

Fracture immobilization

  • Cast
    • Temporary 
    • Allows patient to perform many normal activities of daily living 
    • Made of various materials
    • Typically incorporates joints above and below fracture

Upper extremity immobilization

  • Sling
    • To support and elevate arm
    • Contraindicated with proximal humerus fracture
    • Ensures axillary area is well padded
    • No undue pressure on posterior neck
    • Encourage movement of fingers and non-immobilized joints

Vertebral immobilization

  • Body jacket brace
    • Immobilization and support for stable spine injuries 
    • Monitor for superior mesenteric artery syndrome (cast syndrome)
      • Assess bowel sounds (decreased bowel)
      • Treat with gastric decompression

Lower extremity immobilization

  • Elevate extremity above heart 
  • Do not place in a dependent position
  • Observe for signs of compartment syndrome and increased pressure

External fixation

  • Metal pins and rods
  • Applies traction 
  • Compresses fracture fragments 
  • Immobilizes and holds fracture fragments in place
    • Assess for pin loosening and infection 
    • Patient teaching
    • Pin site care

Internal fixation

  • Internal fixation devices (pins, plates, intramedullary rods, metal and bioabsorbable screws) are surgically inserted to realign and maintain position of bony fragments
  • These metal devices are biologically inert and made from stainless steel, vitallium, or titanium

Electric bone growth stimulation

  • Used to facilitate healing process
    • Increase calcium uptake
    • Activate intracellular calcium stores
    • Increase bone growth factor production
  • Non-invasive, semi-invasive, and invasive methods

Drug therapy

  • Central and peripheral muscle relaxants 
    • Carisoprodol (Soma)
    • Cyclobenzaprine (Flexeril)
    • Methocarbamol (Robaxin)
  • Tetanus and diphtheria toxoid
  • Bone-penetrating antibiotics

Nutritional therapy

  • Increase protein (1 g/kg of body weight)
  • Increase Vitamins (B, C, D)
  • Increase calcium, phosphorus , and magnesium 
  • Increase fluid (2000-3000 mL/day)
  • Increase fiber with fruits and vegetables prevent constipation
  • Body jacket and hip spica cast patients: six small meals a day

 

Role of Nursing Personnel

Registered Nurse (RN)

  • Perform neurovascular assessment on the affected extremity.
  • Assess for manifestations of compartment syndrome.
  • Monitor cast during drying for denting or flattening.
  • Teach patient and caregiver about cast care and complications of casting.
  • Determine correct body alignment to enhance traction.
  • Instruct patient and caregiver about traction and correct body positioning.
  • Teach patient and caregiver ROM exercises.
  • Assess for complications associated with immobility or fracture (e.g., wound infection, constipation, VTE, renal calculi, atelectasis).
  • Develop plan to minimize complications associated with immobility or fracture.

Licensed Practical/Vocational Nurse (LPN/LVN)

  • Check color, temperature, capillary refill, and pulses distal to the cast.
  • Mark circumference of any drainage on the cast.
  • Monitor skin integrity around cast and at traction pin sites.
  • Pad cast edges and traction connections to prevent skin irritation.
  • Monitor pain intensity and administer prescribed analgesics.
  • Notify RN of changes in pain or if pain persists after prescribed analgesics are administered.

Unlicensed Assistive Personnel (UAP)

  • Position casted extremity above heart level as directed by RN.
  • Apply ice to cast as directed by RN.
  • Maintain body position and integrity of traction (after being trained and evaluated in this procedure).
  • Assist patient with passive and active ROM exercises.
  • Notify RN about patient complaints of pain, tingling, or decreased sensation in the affected extremity.

 

Role of Other Team Members

Physical Therapist

  • Assess patient’s current mobility and need for assistance.
  • Teach safe ambulation with assistive device based on patient’s weight-bearing restrictions.
  • Establish exercise regimen and teach patient to perform exercises safely.
  • Coordinate physical therapy with RN so that patient can receive timely analgesia.
  • Discuss home environment with patient and identify possible modifications to facilitate recovery (e.g., stair training if allowed by patient’s weight-bearing restrictions, bed placement on first level to avoid stairs).

Occupational Therapist

  • Assess impact of patient’s condition on ability to perform ADLs.
  • Instruct patient in use of assistive devices (e.g., long-handled reacher, shoe donner) to facilitate self-care while maintaining activity restrictions.
  • Discuss home environment with patient and identify possible modifications to facilitate recovery (e.g., bed placement on first level for access to bathroom).

 

Nursing Management: Fractures

Neurovascular assessment

  • Peripheral vascular
    • Color and temperature
    • Capillary refill
    • Pulses
    • Edema 
    • Motor function
    • Sensory function
    • Paresthesia

Nursing diagnoses

  • Impaired physical mobility related to loss of integrity of bone structures, movement of bone fragments, and prescribed movement restrictions
  • Risk for peripheral neurovascular dysfunction related to vascular insufficiency and nerve compression secondary to edema and/or mechanical compression by traction, splints, or casts
  • Acute pain related to edema, movement of bone fragments, and muscle spasms
  • Readiness for enhanced self–health management

Nursing implementation

  • Health Promotion
    • Teach safety precautions 
    • Advocate  to decrease injuries 
    • Encourage moderate exercise
    • Safe environment to reduce falls 
    • Calcium and vitamin D intake
  • Traction
    • Inspect exposed skin 
    • Monitor pin sites for infection
    • Pin site care per policy
    • Proper positioning
    • Exercise as permitted
    • Psychosocial needs
  • Ambulatory care
    • Do
      • Frequent neurovascular assessments
      • Apply ice for first 24 hours
      • Elevate  above  heart for first 48 hours 
      • Exercise joints above and below
      • Use hair dryer on cool setting for itching
      • Check with health care provider before getting wet
      • Dry thoroughly after getting wet
      • Report increasing pain despite elevation, ice, and analgesia
      • Report swelling associated  with pain and discoloration OR movement
      • Report burning or tingling under cast
      • Report sores or foul odor under cast
    • Do not
      • Elevate if compartment syndrome 
      • Get plaster cast wet
      • Remove  padding
      • Insert objects inside cast
      • Bear weight for 48 hours
      • Cover cast with plastic for prolonged period

Evaluation

  • Report satisfactory pain management
  • Demonstrate appropriate care of cast or immobilizer
  • Experience no peripheral neurovascular dysfunction
  • Experience uncomplicated bone healing

 

Complications of fractures

  • Prevent complications of immobility
    • Constipation
    • Renal calculi
    • Cardiopulmonary deconditioning
    • DVT/pulmonary emboli
  • Infection
    • High incidence in open fractures and soft tissue injuries
    • Devitalized and contaminated tissue  an ideal medium for pathogens
    • Prevention is key
    • Can lead to chronic osteomyelitis
    • Antibiotics for treatment
  • Compartment Syndrome
    • Swelling and increased pressure within a confined space
    • Compromises neurovascular function of tissues within that space
    • Usually involves the leg but can occur in any muscle group
    • Two basic types of compartment syndrome
    • Decrease compartment size 
    • Increase compartment  contents
    • Arterial flow compromised → ischemia → cell death → loss of function
      • Clinical manifestations
        • Early recognition and treatment essential
        • May occur initially or may be delayed several days
        • Ischemia can occur within 4 to 8 hours after onset
        • Six Ps 
          • Pain
  • Out of proportion to the injury that is not managed by opioid analgesics and pain on passive stretch of muscle traveling through the compartment
  • Pressure
  • Increase in pressure in the compartment
  • Paresthesia
  • Numbness and tingling
  • Pallor
  • Coolness, and loss of normal color of the extremity
  • Paralysis
  • Loss of function
  • Pulselessness
  • Diminished or absent peripheral pulses
  • Interprofessional care
    • Prompt, accurate diagnosis via regular neurovascular assessments
      • Notify of pain unrelieved by drugs and out of proportion to injury
      • Paresthesia is also an early sign
    • Assess urine output  and kidney function
    • NO elevation above heart
    • NO ice
    • Surgical decompression (fasciotomy)
  • Venous thromboembolism
    • High susceptibility aggravated by inactivity of muscles 
    • Prophylactic anticoagulant drugs 
    • Antiembolism stockings
    • Sequential compression devices
    • ROM exercises
  • Fat embolism (FES)
    • Presence of systemic fat globules from fracture that are distributed into tissues and organs after a traumatic skeletal injury 
    • Contributory factor in many deaths associated with fracture
    • Most common with fracture of long bones, ribs, tibia, and pelvis
    • Interprofessional care
      • Treatment is directed at prevention
      • Careful immobilization and handling of a long bone fracture probably the most important factor in prevention
      • Management is supportive and related to symptom management
      • Coughing and deep breathing
      • Administer O2
      • Intubation/ intermittent positive pressure ventilation

 

Fractures
Fractures 150 150 Tony Guo

Fractures

 

  • Disruption or break in continuity of structure of bone
  • Majority of fractures from traumatic injuries 
  • Some fractures secondary to disease process
    • Cancer or osteoporosis

 

Classifications

  • Classification according to external environment
    • Open fracture
      • The skin is broken and bone exposed, causing soft tissue injury
    • Closed fracture
      • The skin remains intact
  • Fractures can be classified as 
    • Complete
      • if the break goes completely through the bone
    • Incomplete
      • Fracture occurs partly across a bone shaft but the bone is still intact. 
      • An incomplete fracture is often the result of bending or crushing forces applied to a bone.
  • Based on direction of fracture line
    • Linear
    • Oblique
      • The line of the fracture extends across and down the bone
    • Transverse
      • The line of the fracture extends across the bone shaft at a right angle to the longitudinal axis
    • Longitudinal
    • Spiral
      • The line of the fracture extends in a spiral direction along the bone shaft.
  • Displaced or nondisplaced
    • Displaced: two ends separated from one another
      • Often comminuted or oblique
    • Nondisplaced: periosteum is intact and bone is aligned.
      • Usually transverse, spiral , or greenstick

 

Clinical manifestation

  • Localized pain
  • Decreased function
  • Inability to bear weight or use 
  • Guard against movement
  • May or may not have deformity
  • Immobilize if suspected fracture

 

Manifestation Description Significance
Edema and swelling Disruption or penetration of skin or soft tissues by bone fragments, or bleeding into surrounding tissues Unchecked bleeding and swelling in closed space can occlude blood vessels and damage nerves (e.g., increased risk of compartment syndrome).
Pain and Tenderness Muscle spasm due to involuntary reflex action of muscle, direct tissue trauma, increased pressure on nerves, movement of fracture fragments. Pain and tenderness encourage the patient to splint muscle around fracture and reduce motion of injured area.
Muscle Spasm  Irritation of tissues and protective response to injury and fracture. Muscle spasms may displace nondisplaced fracture or prevent it from reducing spontaneously
Deformity Abnormal position of extremity or part as result of original forces of injury and action of muscles pulling fragment into abnormal position. Seen as a loss of normal bony contours. Deformity is cardinal sign of fracture. If uncorrected, it may result in problems with bony union and restoration of function of injured part.
Contusion Discoloration of skin (bruising) as a result of extravasation of blood in subcutaneous tissues. Bruising may appear immediately after injury and may appear distal to injury. Reassure patient that process is normal and discoloration will eventually resolve.
Loss of Function Disruption of bone or joint, preventing functional use of limb or part. Fracture must be managed properly to ensure restoration of function to limb or part
Crepitation Grating or crunching of bony fragments, producing palpable or audible crunching or popping sensation Crepitation may increase chance for nonunion if bone ends are allowed to move excessively

Micromovement of fragments (postfracture) assists in osteogenesis (new bone growth).

 

Fracture healing

  • Multistage healing process (union)
    • Fracture hematoma
      • Bleeding creates a hematoma that surrounds the ends of the bone fragments
      • The hematoma is extravasated blood that changes from a liquid to a semisolid clot. 
      • This occurs in the first 72 hours after injury.
    • Granulation tissue
      • Active phagocytosis absorbs the products of local necrosis. 
      • The hematoma converts to granulation tissue. 
      • Granulation tissue (consisting of new blood vessels, fibroblasts, and osteoblasts) forms the basis for new bone substance (osteoid) during days 3 to 14 after injury.
    • Callus formation
      • As minerals (calcium, phosphorus, and magnesium) and new bone matrix are deposited in the osteoid, an unorganized network of bone is formed and woven about the fracture parts. 
      • Callus is primarily composed of cartilage, osteoblasts, calcium, and phosphorus. 
      • It usually appears by the end of the second week after injury
    • Ossification
      • Callus ossification is sufficient to prevent movement at the fracture site when the bones are gently stressed. 
      • During this stage of clinical union, the patient may be allowed limited mobility or the cast may be removed.
    • Consolidation
      • As callus continues to develop, the distance between bone fragments decreases and eventually closes
      • Ossification continues and can be equated with radiologic union, which occurs when an x-ray shows complete bony union.
      • Can occur up to 1 year after the injury
    • Remodeling
      • Excess bone tissue is resorbed in the inal stage of bone healing, and union is complete. 
      • Gradual return of the injured bone to its preinjury structural strength and shape occurs.
  • Factors influencing healing
    • Displacement and site of fracture
    • Blood supply to area
    • Immobilization
    • Internal fixation devices
    • Infection or poor nutrition
    • Age 
    • Smoking
  • Complication of fracture healing
    • Delayed union
      • Fracture healing progresses more slowly than expected. Healing eventually occurs.
    • Nonunion
      • Fracture fails to heal despite treatment. No x-ray evidence of callus formation
    • Malunion
      • Fracture heals in expected time but in unsatisfactory position, possibly resulting in deformity or dysfunction
    • Angulation
Stroke
Stroke 150 150 Tony Guo

Stroke

  • Also known as cerebrovascular accident (CVA)
  • Occurs when there is 
    • ischemia (inadequate blood low) to a part of the brain 
    • hemorrhage (bleeding) into the brain
  • 5th most common cause of death in the United States
  • Leading cause of serious, long-term disability
    • About 800,000 people have a stroke each year
      • 15%-30% with permanent disability
      • Lifelong change for survivor and family

Risk factors

  • Non-modifiable
    • Age
      • Stroke risk doubles each decade after 55
    • Gender
      • More common in men; more women die
    • Ethnicity/race
      • Higher incidence in African Americans
    • Heredity/family history
  • Modifiable
    • Hypertension
    • Heart disease
    • Serum cholesterol
    • Smoking
    • Obesity
    • Sleep apnea
    • Metabolic syndrome
    • Lack of physical exercise
    • Poor diet
    • Drug and alcohol abuse

Transient ischemic attack

  • History of TIA is associated with an increased risk of stroke
  • TIA is a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, but without acute infarction of brain
  • Symptoms typically last < 1 hour
  • There is no way to predict outcome
    • 1/3 do not experience another event
    • 1/3 have additional TIAs
    • 1/3 progress to stroke

Types of Stroke

  • Strokes are classified based on underlying pathophysiologic findings 
    • Ischemic
      • Thrombotic
  • Men more than women
  • The process of clot formation (thrombosis) results in a narrowing of the lumen, which blocks the passage of the blood through the artery.
  • Most common cause of stroke (60%) 
  • Often associated with HTN and DM
  • Many times they are preceded by TIA
  • Extent of stroke depends on
    • Rapidity of onset
    • Size of damaged area
    • Presence of collateral circulation
  • Embolic
  • Men more than women
  • An embolus is a blood clot or other debris circulating in the blood. When it reaches an artery in the brain that is too narrow to pass through, it lodges there and blocks the flow of blood.
  • Results in infarction and edema of area supplied by involved vessel
  • 2nd most common cause of stroke
  • Sudden onset with severe clinical manifestations
  • Warning signs are less common
  • Patient usually remains conscious
  • Prognosis is related to amount of brain tissue deprived of blood supply
  • Commonly recur
  • Hemorrhagic 
  • A burst blood vessel may allow blood to seep into and damage brain tissues until clotting shuts off the leak.
  • Intracerebral/intraparenchymal hemorrhage
  • Slightly higher in women
  • Bleeding within brain caused by rupture of a vessel
  • Sudden onset of symptoms
  • Progression over minutes to hours because of ongoing bleeding
  • Prognosis is poor with a 30-day mortality rate of 40%-80%
  • Manifestations 
    • Neurologic deficits
    • Headache
    • Nausea and/or vomiting
    • Decreased levels of consciousness
    • Hypertension
  • Subarachnoid/ intraventricular hemorrhage
  • Slightly higher in women
  • Intracranial bleeding into cerebrospinal fluid–filled space between arachnoid and pia mater
  • Commonly caused by rupture of a cerebral aneurysm, trauma, or drug abuse
  • Cerebral aneurysm
    • Majority are in Circle of Willis
    • Incidence ↑ with age; higher in women
    • Silent killer
  • Loss of consciousness may or may not occur
  • High mortality rate
  • Survivors often suffer significant complications and deficits

Clinical manifestation

  • Related to location of stroke
    • Neural tissue destruction is basis for neurologic dysfunction
    • Affects many body functions
      • Related to artery involved and area/half of brain it supplies
      • Time of the onset of symptoms /length of period of ischemia is important
  • Manifestation of right-brain and left brain stroke
Right-brain damage (stroke on right side of the brain) Left-brain damage (stroke on left side of the brain)
  • Paralyzed left side: hemiplegia
  • Paralyzed right side: hemiplegia
  • Left-sided neglect
  • Impaired speech/language aphasias
  • Spatial-perceptual deficits
  • Impaired right/left discrimination
  • Tends to deny or minimize problems
  • Slow performance, cautious
  • Rapid performance, short attention span
  • Aware of deficits: depression, anxiety
  • Impulsive, safety problems
  • Impaired comprehension related to language, math
  • Impaired judgment
  • Impaired time concepts

 

  • Motor function
    • Most obvious effect of stroke
    • Include impairment of
      • Mobility
      • Respiratory function
      • Swallowing and speech
      • Gag reflex
      • Self-care abilities
    • An initial period of flaccidity 
      • May last from days to several weeks 
      • Related to nerve damage
    • Spasticity of muscles follows flaccid stage
      • Related to interruptions of upper motor neuron influence
  • Communication
    • Aphasia occurs when stroke damages dominant hemisphere of brain and affects language
      • Receptive –  loss of comprehension
      • Expressive – loss of production of language 
      • Global – total inability to communicate
    • Dysphasia refers to impaired ability to communicate
      • Before initiation of feeding, assess the gag reflex by gently stimulating the back of the throat with a tongue blade. 
      • If a gag reflex is present, the patient will gag spontaneously. If it is absent, defer the feeding and begin exercises to stimulate swallowing. 
      • To assess swallowing ability, elevate the head of the bed to an upright position (unless contraindicated) and give the patient a small amount of crushed ice or ice water to swallow.
    • Used interchangeably with aphasia
      • Nonfluent
        • Minimal speech activity with slow speech
      • Fluent 
        • Speech is present but contains little meaningful communication
  • Affect
    • Patients who suffer a stroke may have difficulty controlling their emotions
    • Emotional responses may be exaggerated or unpredictable
      • Magnified by 
        • Depression
        • Changes in body image
        • Loss of function
  • Intellectual function
    • Both memory and judgment may be impaired as a result of stroke
    • Although impairments can occur with strokes affecting either side of brain, some deficits are related to hemisphere in which stroke occurred
  • Spatial-Perceptual alterations
    • Stroke on right side of brain is more likely to cause problems in spatial-perceptual orientation
      • Incorrect perception of self and illness
      • Unilateral neglect of affected side
        • Homonymous hemianopsia
      • Agnosia
      • Apraxia
  • Elimination
    • Most problems with urinary and bowel elimination occur initially and are temporary
    • When a stroke affects one hemisphere of brain, prognosis for normal bladder function is excellent

Diagnostic studies

  • Diagnostic studies are done to
    • Confirm that it is a stroke 
    • Identify the likely cause of stroke
  • MRI or non-contrast CT scan 
    • Indicate size and location of lesion 
    • Differentiate between ischemic and hemorrhagic stroke
  • Other studies
    • CTA or MRA
    • Cerebral angiography
    • Digital subtraction angiography 
    • Transcranial Doppler ultrasonography
    • Lumbar puncture
    • LICOX system
    • Cardiac imaging

Emergency management

Etiology Assessment finding Interventions
  • Sudden vascular compromise causing disruption of blood low to brain
  • Thrombosis
  • Trauma
  • Aneurysm
  • Embolism
  • Hemorrhage
  • Arteriovenous malformation
  • Altered level of consciousness
  • Weakness, numbness, or paralysis of portion of body
  • Speech or visual disturbances
  • Severe headache
  • Heart rate  increase or decrease
  • Respiratory distress
  • Unequal pupils
  • Hypertension
  • Facial drooping on affected side
  • Difficulty swallowing
  • Seizures
  • Bladder or bowel incontinence
  • Nausea and vomiting
  • Vertigo
Initial
  • If unresponsive, assess circulation, airway, and breathing.
  • If responsive, monitor airway, breathing, and circulation.
  • Call stroke code or stroke team.
  • Remove dentures.
  • Perform pulse oximetry.
  • Maintain adequate oxygenation (SaO2 >95%) with supplemental O2, if necessary.
  • Establish IV access with normal saline.
  • Maintain BP according to guidelines (e.g., Cardiac Life Support).*
  • Remove clothing.
  • Obtain CT scan or MRI immediately.
  • Perform baseline laboratory tests (including blood glucose) immediately, and treat
  • if hypoglycemic.
  • Position head in midline.
  • Elevate head of bed 30 degrees if no symptoms of shock or injury.
  • Institute seizure precautions.
  • Anticipate thrombolytic therapy for ischemic stroke.
  • Keep patient NPO until swallow reflex evaluated.
Ongoing monitoring
  • Monitor vital signs and neurologic status, including level of consciousness (NIH Stroke Scale), motor and sensory function, pupil size and reactivity, SaO2, and cardiac rhythm.
  • Reassure patient and family.

 

Interprofessional care for stroke

  • Management of modifiable risk factors 
    • Healthy diet
    • Weight control
    • Regular exercise
    • No smoking
    • Limiting alcohol consumption
    • BP management
    • Routine health assessments
  • Preventive drug therapy
    • Measures to prevent development of a thrombus or embolus are used in patients at risk for stroke
      • Antiplatelet drugs are used  in patients who have had a TIA related to atherosclerosis
      • Aspirin is most frequently used antiplatelet agent
  • Surgical therapy
    • Surgical interventions for patient with TIAs from carotid disease include
      • Carotid endarterectomy 
      • Transluminal angioplasty
        • insertion of a balloon to open a stenosed artery in the brain and improve blood low
      • Stenting
        • intravascular placement of a stent in an attempt to maintain patency of the artery
    • Postoperative care is important
      • Neurovascular assessment
      • BP management
      • Assessment for complications
        • Stent occlusion 
        • Retroperitoneal hemorrhage 
      • Minimize complications at insertion site
  • Acute care for Ischemic stroke
    • Begins with managing 
      • Airway
      • Breathing
      • Circulation
    • Baseline neurologic assessment
      • Monitor closely for 
        • Signs of increasing neurologic deficit
        • Increased ICP
      • Elevated BP is common immediately after a stroke
        • May reflect body’s attempt to maintain cerebral perfusion
    • Recombinant tissue plasminogen activator (tPA)
      • Used to reestablish blood flow through a blocked artery to prevent cell death 
      • Must be administered within 3 to 4 ½   hours of onset of clinical signs of ischemic stroke
      • Patients are carefully screened
    • After the patient has stabilized and to prevent further clot formation, patients with strokes caused by thrombi and emboli may be treated with anticoagulants and platelet inhibitors
    • ASA, ticlopidine, clopidogel, dipyridamole
  • Endovascular therapy
    • Stent retrievers
      • Becoming the most effective way of managing ischemic stroke
  • Acute care for hemorrhagic stroke
    • Goals are the same as for the patient with ischemic stroke
      • Manage 
        • Airway
        • Breathing
        • Circulation
        • Intracranial pressure
    • Hyperdynamic therapy
      • Increase mean arterial pressure
      • Increase cerebral perfusion
      • Crystalloid or colloid solutions
    • Vasospasms can be treated with calcium channel blocker nimodipine (Nimotop)
  • Drug therapy for hemorrhagic stroke
    • Anticoagulants and platelet inhibitors are contraindicated
    • Management of hypertension is main focus
      • Oral and IV agents are used to maintain BP within a normal to high-normal range
    • Seizure prophylaxis is situation-specific
  • Surgical therapy for hemorrhagic stroke
    • Surgical interventions used to treat hemorrhagic strokes include
      • Resection
      • Clipping of an aneurysm
        • The neurosurgeon places a metallic clip on the neck of the aneurysm to block blood low and prevent rupture. 
        • The clip remains in place for life
      • Evacuation of hematomas
    • Procedure is chosen based on cause of stroke
  • Rehabilitation
    • After stroke has stabilized for 12 to 24 hours, interprofessional care shifts from preserving life to lessening complications, disability and attaining optimal functioning
      • Patient may be transferred to a rehabilitation unit, outpatient therapy, or home care–based rehabilitation

 

Nursing management: Stroke

  • Stroke survivorship and coping
    • Stroke support groups within rehab facilities and community are helpful
      • Mutual sharing
      • Teaching
      • Coping
      • Understanding

Nursing diagnoses

  • Decreased intracranial adaptive capacity related to decreased cerebral perfusion pressure of ≤50 to 60 mm Hg and sustained increase in ICP secondary to thrombus, embolus, or hemorrhage
  • Risk for aspiration related to decreased level of consciousness and decreased or absent gag and swallowing reflexes
  • Impaired physical mobility related to neuromuscular and cognitive impairment and decreased muscle strength and control
  • Impaired verbal communication related to aphasia
  • Unilateral neglect related to visual ield cut and loss on one side of body (hemianopsia) and brain injury from cerebrovascular problems
  • Impaired swallowing related to weakness or paralysis of affected muscles
  • Situational low self-esteem related to actual or perceived loss of function and altered body image

Planning

  • Typical goals are that the patient will
    • Maintain a stable or improved level of consciousness
    • Attain maximum physical functioning
    • Attain maximum self-care abilities and skills
    • Maintain stable body functions (e.g., bladder control)
    • Maximize communication abilities
    • Maintain adequate nutrition
    • Avoid complications of stroke
    • Maintain effective personal and family coping

 

Role of Nursing Personnel

  • Assess clinical manifestations of stroke and determine when clinical manifestations started.
  • Screen patient for contraindications for tissue plasminogen activator (tPA) therapy.
  • Infuse tPA for patients with ischemic stroke who meet the criteria for tPA administration.
  • Assess respiratory status and initiate needed actions such as O2, oropharyngeal or nasopharyngeal airways, suctioning, and patient positioning to prevent aspiration, obstruction, and atelectasis.
  • Assess neurologic status, including intracranial pressure (ICP), if needed.
  • Monitor cardiovascular status, including hemodynamic monitoring, if needed.
  • Assess patient’s ability to swallow (in conjunction with the speech therapist).

Licensed practical/vocational nurse (LPN/LVN)

  • Administer scheduled anticoagulant and antiplatelet medications

Unlicensed Assistive Personnel

  • Obtain vital signs frequently and report these to RN.
  • Measure and record urine output.
  • Assist with positioning patient and turning patient at least every 2 hr (as directed by RN).
  • Perform passive and active range-of-motion exercises (after being trained and evaluated in these procedures).
  • Place equipment needed for seizure precautions in patient room

 

Role of Other Team members

Speech therapy

  • Assess swallowing reflex.
  • Evaluate patient for communication defects (e.g., aphasia).

Physical therapy

  • Position patient in a functional position.
  • Assess function and together with patient, plan a rehabilitation program.

 

Inflammatory Brain Disorder
Inflammatory Brain Disorder 150 150 Tony Guo

Inflammatory Brain Disorder

  • Most common inflammatory conditions of the brain and spinal cord
    • Brain abscesses
    • Meningitis
    • Encephalitis 
      • 10% to 30% mortality rate
      • Long-term neurologic deficits among survivors

Bacterial meningitis

  • Acute inflammation of meningeal tissue surrounding brain and spinal cord
    • Usually occurs in fall, winter, or early spring
      • Often secondary to viral respiratory disease
  • Mandatory reporting to CDC
  • Mortality rate near 100% if untreated

Etiology and pathophysiology

  • Leading causes of bacterial meningitis
    • Streptococcus pneumoniae 
    • Neisseria meningitidis
      • Replaced Hemophilus as flu vaccine emerged
      • Organisms enter CNS through upper respiratory tract or bloodstream
      • May enter through skull wounds or fractured sinuses
  • Inflammatory response
    • Increase CSF production
    • Purulent secretions spread to other areas of brain through CSF
    • Cerebral edema and increased ICP become problematic
      • If process extends into parenchyma 
      • If concurrent encephalitis is present

Clinical manifestation

  • Key signs of meningitis
    • Fever
    • Severe headache
    • Nausea, vomiting
    • Nuchal rigidity 
  • Coma associated with poor prognosis 
    • Occurs in 5% to 10% of cases
  • Other symptoms that may be present
    • Photophobia
    • Decreased LOC
    • Signs of increased Intracranial pressure
      • Seizures occur in 1/3 of all cases
      • Headache worsens 
      • Vomiting and irritability may occur

Complications

  • Increased ICP
    • Major cause of altered mental status
  • Residual neurologic dysfunction
    • Cranial nerves III, IV, VI, VII, or VIII can become dysfunctional
    • Sequelae varies by cranial nerve
  • Optic nerve (CN II) compressed by ↑ ICP
    • Papilledema with possible blindness
  • Ocular movements affected with irritation to nerves III, IV, and VI
    • Ptosis
    • Unequal pupils
    • Diplopia
  • CN V irritation 
    • Sensory loss and loss of corneal reflex
  • Inflammation of CN VII 
    • Facial paresis 
  • Irritation of CN VIII 
    • Tinnitus, vertigo, deafness
    • Hearing loss may be permanent
  • Hemiparesis, dysphagia, hemianopsia 
  • Suspect the following if above do not resolve 
    • Cerebral abscess, subdural empyema, subdural effusion, or persistent meningitis
  • Acute cerebral edema may cause
    • Seizures
    • CN III palsy
    • Bradycardia
    • Hypertensive coma
    • Death

Diagnostic studies

  • Blood culture
  • CT scan and  MRI
  • Diagnosis verified 
    • Lumbar puncture 
    • Analysis of CSF (for protein, WBC, and glucose)
    • Specimens of secretions are cultured to identify causative organism
    • Gram-stain to detect bacteria
  • Neutrophils are predominant WBC in CSF 
  • X-rays of skull

Interprofessional care

  • Bacterial meningitis is a medical emergency
  • Rapid diagnosis crucial
    • Patient  usually critical when health care is initiated
    • Antibiotic therapy instituted before diagnosis is confirmed

Nursing Assessment

  • Initial assessment should include
    • Vital signs
    • Neurologic assessment
    • Fluid intake and output
    • Evaluation of lungs and skin

Nursing diagnosis

  • Decreased intracranial adaptive capacity related to decreased cerebral perfusion or increased ICP
  • Risk for ineffective cerebral tissue perfusion related to reduction of blood low and cerebral edema
  • Hyperthermia related to infection
  • Acute pain related to headache and muscle aches

Planning

  • Overall Goals
    • Return to maximal neurologic functioning
    • Resolve the infection
    • Control pain and discomfort

Nursing implementation

  • Health Promotion
    • Vaccinations for pneumonia and influenza
    • Meningococcal vaccines
      • MCV4 (Meningococcal conjugate vaccine), MPSV4 (Meningococcal polysaccharide vaccine), Serogroup B
    • Early, vigorous treatment of respiratory tract and ear infections
    • Prophylactic antibiotics for anyone exposed to bacterial meningitis
      • Bacterial meningitis is a medical emergency. Rapid diagnosis based on history and physical examination is crucial because the patient is usually in a critical state when health care is sought. When meningitis is suspected, antibiotic therapy is instituted after the collection of specimens for cultures, even before the diagnosis is confirmed.  
  • Acute Care
    • Revolve around the nursing diagnoses of
      • Decreased intracranial adaptive capacity
      • Risk for ineffective cerebral perfusion
      • Increased fever
      • Acute pain
    • Close observation and assessment
    • Provide relief for head and neck pain
    • Position for comfort
    • Darkened room and cool cloth over eyes for photophobia
    • Minimize environmental stimuli
    • Provide safety
  • Observe and record seizures
    • Prevent injury
    • Administer antiseizure medications 
  • Vigorously manage fever
    • Fever increases cerebral edema and the frequency of seizures
    • Neurologic damage may result from high, prolonged fever
  • Assess for dehydration
    • Evaluate fluid intake and output
    • Compensate for diaphoresis in replacement fluids
  • Maintain therapeutic blood levels of antibiotics
  • Respiratory isolation until cultures are negative (Droplet precautions)
  • Ambulatory Care
    • Provide for several weeks of convalescence
    • Increase activity as tolerated
      • Stress adequate nutrition
      • Encourage adequate rest and sleep
    • Progressive ROM exercises and warm baths for muscle rigidity
    • Ongoing assessment for recovery of vision, hearing, cognitive skills, motor and sensory abilities
    • Tend to signs of anxiety and stress of family and caregivers

Evaluation

  • Patient will
    • Demonstrate appropriate cognitive function
    • Be oriented to person, place, and time
    • Maintain body temperature within normal range
    • Report satisfaction with pain control

 

  • As a nurse, since bacterial meningitis is very contagious and potentially a fatal infection, Universal precautions should ALWAYS be in place – you have the right to implement more conservative care (respiratory isolation) at any time as a professional nurse.

 

Viral Meningitis

  • Most common causes are enterovirus, arbovirus, HIV, and HSV
    • Most often spread through direct contact with respiratory secretions
  • Usually presents as headache, fever, photophobia, and stiff neck
    • Fever may be moderate or high
  • Diagnostic testing of CSF
    • Rapid diagnosis with Xpert EV test
      • Sample of CSF is evaluated for enterovirus
      • Results available within hours
    • PCR to detect viral-specific DNA/RNA
  • Treat with antibiotics after obtaining diagnostic sample but before receiving test results
    • Symptomatic management 
    • Disease is self-limiting
    • Full recovery expected
Certain Tumors
Certain Tumors 150 150 Tony Guo
  • Certain tumors are more susceptible to the effects of radiation than others
  • Simulation
    • A process by which radiation treatment fields are defined, filmed, and marked out on skin
    • Radiation oncologist specifies dose and volume of area to be treated
  • Immobilization device
    • The patient is positioned on a simulator, which is a diagnostic x-ray machine that recreates the actions of the linear accelerator and the radiation fields are marked on the patient’s skin.
    • Simulation uses immobilization devices to help the patient maintain a stable position.
    • In this example, a head holder and immobilization mask may be used to ensure accurate positioning for daily treatment of head and neck cancer.
  • Linear accelerator
    • A linear accelerator, which generates ionizing radiation from electricity and can have multiple energies, is the most commonly used machine for delivering external beam radiation.

 

  • Internal radiation
    • Patient is emitting radioactivity
    • Limit amount of time near patients being treated
      • Organize care
      • Use shielding
      • Wear film badge to monitor exposure

 

Obstructive Emergencies
Superior Vena Cava Syndrome (SVCS)
  • Results from obstruction of superior vena cava by tumor or thrombosis.
  • Common causes are lung cancer, non-Hodgkin’s lymphoma, and metastatic breast cancer.
  • Presence of central venous catheter and previous mediastinal radiation increase risk of development.
  • Facial edema, periorbital edema.
  • Distention of veins of head, neck, and chest
  • Headache, seizures.
  • Mediastinal mass on chest x-ray.
  • Considered a serious medical problem.
  • Radiation therapy to site of obstruction.
  • Chemotherapy for tumors more sensitive to this therapy.
Spinal Cord Compression
  • Neurologic emergency caused by cancer in epidural space of spinal cord.
  • Common causes are breast, lung, prostate, GI, and renal cancers and melanomas.
  • Lymphomas can also invade epidural space.
  • Intense, localized, and persistent back pain accompanied by vertebral tenderness.
  • Motor weakness, sensory paresthesia and loss.
  • Autonomic dysfunction (e.g., change in bowel or bladder function)
  • Radiation therapy and corticosteroids.
  • Surgical decompressive laminectomy.
  • Activity limitations and pain management.
Third Space Syndrome
  • Shifting of fluid from vascular space to interstitial space.
  • Occurs secondary to extensive surgical procedures, immunotherapy, or septic shock.
  • Signs of hypovolemia: hypotension, tachycardia, low central venous pressure, decreased urine output
  • Fluid, electrolyte, and plasma protein replacement.
  • During recovery hypervolemia can occur, resulting in hypertension, elevated central venous pressure, weight gain, and shortness of breath.
Metabolic Emergencies
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
  • Tumor cells can produce abnormal or sustained production of antidiuretic hormone (ADH).
  • Many chemotherapy agents may also contribute to ectopic ADH production or potentiate ADH effects
  • Water retention and hyponatremia (hypotonic hyponatremia).
  • Weight gain without edema, weakness, anorexia, nausea, vomiting, personality changes, seizures, oliguria, decrease in reflexes, and coma
  • Treat underlying malignancy.
  • Take measures to correct sodium-water imbalance, including fluid restriction, oral salt tablets or isotonic (0.9%) saline administration, and IV 3% sodium chloride solution (severe cases).
  • Furosemide (Lasix) used in initial phases.
  • Monitor sodium level because correcting SIADH rapidly may result in seizures or death.
Hypercalcemia
  • Occurs in metastatic disease of bone or multiple myeloma, or when a parathyroid hormone–like substance is secreted by cancer cells.
  • Immobility and dehydration can contribute to or exacerbate hypercalcemia.
  • Serum calcium in excess of 12 mg/dL (3 mmol/L) often produces symptoms.
  • Apathy, depression, fatigue, muscle weakness, ECG changes, polyuria and nocturia, anorexia, nausea, and vomiting.
  • High calcium elevations can be life threatening.
  • Chronic hypercalcemia can result in nephrocalcinosis and irreversible renal failure.
  • Treat primary disease.
  • Hydration (3 L/day) and bisphosphonate therapy.
  • Diuretics (particularly loop diuretics) used to prevent heart failure or edema.
  • Infusion of bisphosphonate zoledronate (Zometa) or pamidronate (Aredia)
Tumor Lysis Syndrome (TLS)
  • Metabolic complication characterized by rapid release of intracellular components in response to chemotherapy and radiation therapy (less commonly).
  • Massive cell destruction releases intracellular components (potassium, phosphate, DNA, RNA) that are metabolized to uric acid by liver.
  • Hallmark signs: hyperuricemia, hyperphosphatemia, hyperkalemia, hypocalcemia.
  • Weakness, muscle cramps, diarrhea, nausea, and vomiting.
  • Occurs within first 24 to 48 hr. after initiation of chemotherapy.
  • May persist for about 5 to 7 days.
  • Metabolic abnormalities and concentrated uric acid (which crystallizes in distal tubules of kidneys) can lead to acute kidney injury.
  • Identify patients at risk.
  • Increase urine production using hydration therapy.
  • Decrease uric acid concentrations using allopurinol.
  • Use IV sodium bicarbonate to counter effects of acidic properties that are released
Infiltrative Emergencies
Cardiac Tamponade
  • Fluid accumulation in pericardium.
  • Caused by constriction of pericardium by tumor or pericarditis secondary to radiation therapy to the chest
  • Heavy feeling over chest, shortness of breath, tachycardia, cough, dysphagia, hiccups, hoarseness.
  • Nausea, vomiting, excessive perspiration.
  • Decreased level of consciousness, distant or muted heart sounds.
  • Extreme anxiety.
  • Decrease fluid around heart using (1) surgery to create a pericardial window or an (2) indwelling pericardial catheter.
  • Administer O2 therapy, IV hydration, and vasopressor therapy
Carotid Artery Rupture
  • Invasion of arterial wall by tumor or erosion following surgery or radiation therapy.
  • Occurs most frequently in patients with head and neck cancer
  • Bleeding: ranges from minor oozing to spurting of blood in the case of a “blowout” of artery.
  • Administer IV fluids and blood products.
  • Surgery: ligation of carotid artery above and below rupture site and reduction of local tumor

 

Nursing Implications

  • Bone marrow suppression
    • Myelosuppression: most common side effect of chemotherapy
    • Treatment-induced reductions in RBCs and WBCs can result in
      • Infection
      • Hemorrhage
      • Overwhelming fatigue
  • Fatigue
    • Encourage conservation strategies
      • Rest before activity
      • Get assistance with activity
      • Remain active during periods of time patients feel better
    • Maintain nutritional and hydration status
    • Assess for reversible causes of fatigue
  • Gastrointestinal (GI) effects 
    • Prophylactic administration of antiemetics
    • Assess for signs and symptoms of 
      • Alkalosis, dehydration, and I and O
    • Nonirritating, low-fiber, high-calorie, high-protein diet
    • Antidiarrheal, antimotility, and antispasmodic medications
    • Anorexia
      • Monitor carefully to avoid weight loss
        • Weigh twice weekly
      • Recommend small, frequent, high-protein, high-calorie meals
      • Involve dietitian before treatment begins
  • Skin reactions
    • Occur in radiation treatment field
    • Acute or chronic
      • Develop 1 to 24 hours after treatment
      • Generally progressive as treatment dose accumulates
    • Dry desquamation
      • Erythema is an acute response followed by dry desquamation. 
      • Dry reactions are uncomfortable and result in pruritus. Lubricate the dry skin with a nonirritating lotion emollient (such as aloe vera) that contains no metal, alcohol, perfume, or additives that can be irritating to the skin.
    • Wet desquamation
      • If the rate of cell sloughing is faster than the ability of the new epidermal cells to replace dead cells, a wet desquamation occurs with exposure of the dermis and weeping of serous fluid.
      • Wet reaction must be kept clean and protected from further damage.
      • Wet desquamation of tissues generally produces pain, drainage, and increased risk of infection.
    • Prevent infection
    • Facilitate wound healing
    • Protect irritated skin temperature extremes
    • Avoid constricting garments, harsh chemicals, and deodorants
    • Help patients deal with hair loss (alopecia)
  • Reproductive effects
    • Inform patient of expected sexual side effects
    • Use appropriate shielding
    • Encourage discussion of issues related to reproduction and sexuality
    • Refer to counseling if needed

 

Immunotherapy

  • Immunotherapy uses the immune system to fight cancer
  • Some types called biologic therapy
  • Boost or manipulate the immune system and create an environment not conducive for cancer cells to grow
  • Attack cancer cells directly

Target therapy

  • Interferes with cancer growth by targeting specific cell receptors and pathways that are important in tumor growth
    • Does less damage to normal cells
    • Agents that target specific oncogenes are being developed

Hormone therapy

  • Sex hormones
    • Can stop the growth of cancer cells
  • Corticosteroids
    • Used in combination with drug regimens to help curb side effects

Hematopoietic Stem Cell Transplantation (HSCT)

  • Bone marrow transplant (BMT) 
  • Peripheral stem cell transplantation (PSCT) 
  • Allows high doses for treatment 
    • Failing to respond to standard doses of chemotherapy or radiation
    • Develop resistance (refractory)
  • Procedure with many risks, including death
  • Highly toxic
  • Overall cure rates are steadily increasing
  • Tumor cells are eradicated and bone marrow is rescued by infusing healthy cells

Gene Therapy

  • Experimental therapy
    • Genetic material is introduced into cells to fight disease
    • Investigational

 

Complications of cancer

  • Patients with cancer may develop complications from 
    • Continual growth of the cancer into normal tissue
    • Side effects of treatment

Nutritional problems

  • Malnutrition
  • Altered taste sensation (dysgeusia)
    • Physiologic basis of altered taste is unknown
  • Wasting syndrome (Cancer cachexia)
    • Upper gastrointestinal and pancreatic cancer patient are at great risk
  • Infections
    • Usual sites of infection include the lungs, GU system, mouth, rectum, peritoneal cavity, and blood (septicemia).
    • Infection occurs as a result of the ulceration and necrosis caused by the tumor, compression of vital organs by the tumor, and neutropenia caused by the disease process or the cancer treatment.

Cancer pain

  • Patient report should always be believed and accepted as primary source for pain assessment data
  • Drug therapy should be used to control pain
  • Inadequate pain assessment is single greatest barrier to effective cancer pain management
    • Management of cancer pain
      • Fear of addiction is unwarranted
      • Numerous drug options for pain management
      • Nonpharmacologic interventions, including relaxation therapy and imagery, can be used effectively
    • Moderate to severe pain occurs in approximately 50% of patients who are receiving active treatment for their cancer and in 80% to 90% of patients with advanced cancer.
    • It is essential to perform a comprehensive pain assessment on an ongoing basis and to enact a pain management plan that addresses both components of pain if they are present.

 

Coping with cancer and treatment

  • Nursing assessment and support are key
    • Pervasive anxiety and fear
      • Fears of dependency
      • Loss of control
      • Family relationship stress
      • Financial burden
      • Fear of death
        • Be available, especially during difficult times
        • Exhibit caring
        • Actively listen
        • Provide symptom relief
        • Provide accurate information
        • Build trust
        • Use touch
        • Assist setting realistic goals
        • Support usual lifestyle patterns
        • Maintain hope
        • Reassure of ongoing support
        • Offer support from survivors
          • Improvement in early detection and treatment
          • > 14.5 million in the United States

Summary of cancer

  • Initiation, the first stage, is a mutation in the cell’s DNA structure following exposure to a chemical, radiation, or viral agent. The mutation may also be inherited.
  • Promotion, the second stage in the development of cancer, is characterized by the reversible proliferation of the altered cells.
  • Progression, the final stage, is characterized by increased growth rate of the tumor, increased invasiveness, and spread of the cancer to a distant site (metastasis).

Factors that may influence ability to cope

  • Ability to cope with stressful events in the past, availability of significant others, ability to express feelings and concerns, age at the time of diagnosis, extent of disease, disruption of body image, presence of symptoms, past experience with cancer, and attitude associated with cancer.

 

Cancer: Interprofessional Care and Complications
Cancer: Interprofessional Care and Complications 150 150 Tony Guo

Cancer: Interprofessional Care and Complications

 

Cancer treatment goals

  • Goals
    • Cure therapy 
      • Surgery alone or periods of adjunctive systemic therapy
      • Timeframe to “cure” may differ according to the tumor and its characteristics
    • Control therapy 
      • Initial course and maintenance therapy
    • Palliation therapy
      • Palliation goal 
        • Relief or control of symptoms 
        • Maintain quality of life
      • Palliative care and treatment are not mutually exclusive and can take concurrently

Personalized cancer medicine

  • Genetic information is used to customize decisions about
    • Prevention
    • Diagnosis
    • Treatment
  • Targeted therapy
    • Aims at a cancer’s specific genes or proteins that contribute to cancer growth and survival
    • Biopsy can help determine whether a tumor has the specific target
  • Pharmacogenomics
    • Study of genomic variation associated with drug responses
  • Not all types of cancer have personalized treatment options
    • Costly
    • Time-consuming
    • Not covered by insurance

Cancer treatment 

  • Surgical therapy
    • Oldest form of cancer treatment
    • Meets a variety of goals
    • Trend is toward less radical surgeries
  • Role of surgery in cancer treatment
  • Prevention
    • Removal of non-vital organs to prevent cancer
  • Diagnosis
    • Biopsy
  • Palliation of symptoms
    • Relief of pain
    • Obstruction
    • Hemorrhage
  • Rehabilitation
    • Reconstructive surgery
  • Determine the diagnostic and treatment plan 
    • Clinical staging
  • Cure and/or control of cancer
    • Removal of localized cancer tissue
      • Primary site
      • Site of metastasis
  • Supportive care
    • Insertion of therapeutic devices (e.g., feeding tubes, suprapubic catheter)

 

Chemotherapy

  • Antineoplastic therapy
    • Use of chemicals given as a systemic therapy for cancer
    • Mainstay for most solid tumors and hematologic cancers
    • Can offer cure, control, or palliative care
      • Cure
        • Burkitt’s lymphoma
        • Wilms’ tumor
        • Neuroblastoma
        • Acute lymphocytic leukemia
        • Hodgkin’s lymphoma
        • Testicular cancer
      • Control
        • Breast cancer
        • Non-Hodgkin’s lymphoma
        • Small cell lung cancer
        • Ovarian cancer
      • Palliation
        • Relieve pain
        • Relieve obstruction
        • Improve the sense of well-being
  • Effect on cells
    • Effective against dividing cells, so cancer cells escape death by staying in G0 phase (resting phase)
    • Problem: Presence of drug-resistant resting and non-cycling cells
    • As tumors get bigger, more cells become inactive and convert to G0
    • Chemotherapy agents cannot distinguish between normal and
      cancer cells
    • Side effects are result of destruction of normal cells
  • Nursing management

 

Etiology Effects Nursing managements
Gastrointestinal System 
Stomatitis, Mucositis, Esophagitis Epithelial cells are destroyed by chemotherapy or radiation treatment when located in field (e.g., head and neck, stomach, esophagus).

Inflammation and ulceration occur due to rapid cell destruction.

Assess oral mucosa daily and teach patient to do this.

Encourage nutritional supplements (e.g., Ensure, Carnation Instant Breakfast) if intake decreasing.

Be aware that eating, swallowing, and talking may be difficult (may require analgesics).

Instruct in avoidance of irritating spicy or acidic foods or too hot or too cold food (extremes in temperature).

Instruct on how to select moist, bland, and softer foods.

Encourage patient to keep oral cavity clean and moist by performing frequent oral rinses with saline or salt and soda solution.

Encourage patient to use artificial saliva to manage dryness (radiation).

Discourage use of irritants such as tobacco and alcohol.

Apply topical anesthetics (e.g., viscous lidocaine, oxethazaine)

Nausea and Vomiting Release of intracellular breakdown products stimulates vomiting center in brain.

Drugs also stimulate vomiting center in brain

GI lining destroyed with radiation and chemotherapy.

Encourage patient to eat and drink when not nauseated.

Administer antiemetics pro phylactically before chemotherapy and also on as-needed basis.

Instruct patient to take antiemetics on a scheduled basis for 2-3 days after highly emetogenic chemotherapy.

Use diversional activities (if appropriate).

Anorexia Release of TNF and IL-1 from macrophages has appetite-suppressant effect.

Therapy-induced GI effects (mucositis, nausea and vomiting, bowel disturbances) and anxiety reduce appetite.

Monitor weight.

Encourage patient to eat small, frequent meals of high-protein, high-calorie foods.

Gently encourage patient to eat, but avoid nagging.

Recommend keeping a food diary to track daily calories and fluids.

Serve food in pleasant environment

Diarrhea From denuding of epithelial lining of intestines.

Side effect of chemotherapy.

Follows radiation to abdomen, pelvis, and lumbosacral areas.

Give antidiarrheal drugs as needed.

Encourage low-fiber, low-residue diet.

Encourage fluid intake of at least 3 L/day.

Constipation Decreased intestinal motility is related to autonomic nervous system dysfunction.

Caused by neurotoxic effects of plant alkaloids (vincristine, vinblastine).

Instruct patient to take stool softeners as needed, eat high-fiber foods, and increase fluid intake.

Instruct patient to increase activity (e.g., walking) if tolerated.

Hepatotoxicity Toxic effects from chemotherapy drugs (usually transient and resolve when drug is stopped). Monitor liver function tests. 
Hematologic System
Anemia Bone marrow depressed secondary to therapy.

Malignant infiltration of bone marrow by cancer.

Monitor hemoglobin and hematocrit levels.

Administer iron supplements and erythropoietin.

Encourage intake of foods that promote RBC production

Leukopenia Depression of bone marrow secondary to chemotherapy or radiation therapy.

Infection most frequent cause of morbidity and death in cancer patients.

Respiratory and genitourinary system usual sites of infection.

Monitor WBC count, especially neutrophils.

Tell patient to report temperature elevation and any other manifestations of infection.

Teach patient to avoid large crowds and people with infections.

Administer WBC growth factors

Thrombocytopenia Bone marrow depressed secondary to chemotherapy.

Malignant infiltration of bone marrow crowds out normal marrow.

Spontaneous bleeding can occur with platelet counts ≤20,000/μL.

Observe for signs of bleeding (e.g., petechiae, ecchymosis).

Monitor platelet counts.

Integumentary System
Alopecia Destruction of hair follicles by chemotherapy or radiation to scalp.

Hair loss usually is temporary with chemotherapy, but usually permanent in response to radiation.

Suggest ways to cope with hair loss (e.g., hair pieces, scarves, wigs).

Cut long hair before therapy.

Avoid excessive shampooing, brushing, and combing of hair.

Avoid use of electric hair dryers, curlers, and curling rods.

Discuss impact of hair loss on self-image.

Radiation skin changes (dry to moist desquamation) Radiation damages skin
Chemotherapy-Induced Skin Changes Hyperpigmentation.

Telangiectasia.

Photosensitivity.

Acneiform eruptions.

Acral erythema.

Alert patient to potential skin changes.

Encourage patient to avoid sun exposure.

Implement symptomatic management as needed depending on specific skin effect (e.g., application of lotions, benzoyl peroxide for acne, corticosteroid creams

Genitourinary Tract
Hemorrhagic Cystitis Cells lining bladder are destroyed by chemotherapy (e.g., cyclophosphamide, ifosfamide).

Side effect of radiation when located in treatment field.

Encourage increased fluid intake 24-72 hr after treatment as tolerated.

Monitor manifestations such as urgency, frequency, and hematuria.

Administer cytoprotectant agent (mesna [Mesnex]) and hydration.

Administer supportive care agents to manage symptoms (e.g., lavoxate [Urispas]).

Reproductive Dysfunction Cells of testes or ova are damaged by therapy. Discuss possibility with patients before treatment initiation.

Offer opportunity for sperm and ova banking before treatment for patients of childbearing age.

Nephrotoxicity Direct renal cell damage from exposure to nephrotoxic agents (cisplatin and high-dose methotrexate).

Precipitation of metabolites of cell breakdown (tumor lysis syndrome [TLS]).

Monitor BUN and serum creatinine levels.

Avoid potentiating drugs.

Alkalinize the urine by adding sodium bicarbonate to IV infusion and administer allopurinol (Zyloprim) or rasburicase for TLS prevention

Nervous System
Intracranial Pressure May result from radiation edema in central nervous system. Monitor neurologic status.

May be controlled with corticosteroids.

Peripheral Neuropathy Paresthesias, arelexia, skeletal muscle weakness, and smooth muscle dysfunction can occur as a side effect of plant alkaloids, taxanes, and cisplatin Monitor for these manifestations in patients on these drugs.

Consider temporary chemotherapy dose interruption or reduction until symptoms improve.

Anti-seizure drugs (e.g., gabapentin [Neurontin]) may be considered.

Cognitive Changes (“chemo brain”) Occur during and after treatment (especially with chemotherapy).

Difficulties in concentration, memory lapses, trouble remembering details, taking longer to finish tasks.

May happen quickly and last a short time. Sometimes people have mild long-term effects

Teach patients to do the following:

Use detailed daily planner.

Get enough sleep and rest.

Exercise brain (learn something new, do word puzzles).

Focus on one thing (no multi-tasking) 

Respiratory System
Pneumonitis Radiation pneumonitis develops 2-3 months after start of treatment.

After 6-12 months, fibrosis occurs and is evident on x-ray.

Side effect of some chemotherapy drugs.

Monitor for dry, hacking cough; fever; and exertional dyspnea.
Cardiovascular System
Pericarditis and Myocarditis Inflammation secondary to radiation injury.

Complication when chest wall is irradiated. May occur up to 1 yr after treatment.

Side effect of some chemotherapy drugs

Monitor for clinical manifestations of these disorders (e.g., dyspnea)
Cardiotoxicity Some chemotherapy drugs (e.g., anthracyclines, taxanes) can cause ECG changes and rapidly progressive heart failure Monitor heart with ECG and cardiac ejection fractions.

Drug therapy may need to be modified for symptoms or deteriorating cardiac function studies

Biochemical
Hyperuricemia Increased uric acid levels due to chemotherapy-induced cell destruction.

Can cause secondary gout and obstructive uropathy

Monitor uric acid levels.

Allopurinol may be given as a prophylactic measure.

Encourage increased fluid intake

Psychoemotional
Fatigue Anabolic processes result in accumulation of metabolites from cell breakdown. Assess for reversible causes of fatigue, and address them as indicated.

Reassure patient that fatigue is a common side effect of therapy.

Encourage patient to rest when fatigued, to maintain usual lifestyle patterns as much as possible, and to pace activities in accordance with energy level.

Encourage moderate exercise as tolerated

 

  • Preparation and handling of chemotherapy agents
    • May pose an occupational hazard
    • Drugs may be absorbed through 
      • Skin 
      • Inhalation during preparation, transportation, and administration
    • Only properly trained personnel should handle cancer drugs
  • Chemotherapy methods of administration
    • Oral
      • More available options today
      • Storage and side effects 
    • IM – Intramuscular
    • IV – Intravenous (most common)
      • Central venous access device (CVAD)
    • CVAD administration
      • Placement in large blood vessels
      • Frequent, continuous, or intermittent administration
      • Can be used to administer other fluids (blood, electrolytes, etc.)
  • Regional administration
    • Delivery of drug directly into
      tumor site
    • Higher concentrations of drug can be delivered with less systemic toxicity
    • Types of regional delivery methods
      • Intraarterial 
        • Delivers drug through arteries supplying tumor
      • Intraperitoneal
        • Delivers drug to peritoneal cavity for treatment of peritoneal metastases
      • Intrathecal or intraventricular
        • Involves lumbar puncture and injection of chemotherapy into subarachnoid space
      • Intravesical bladder
        • Agent added to bladder by urinary catheter and retained for 1 to 3 hours
  • Effects on normal tissue
    • General and drug-specific adverse effects are classified
      • Acute
      • Delayed
      • Chronic
  • Radiation therapy
    • One of the oldest nonsurgical methods of cancer treatment
    • 50% of all cancer patients will receive radiation therapy at some point in their treatment
    • Radiation is emission of energy from a source and travels through space or some material 
    • Different types of ionizing radiation are used to treat cancer
    • Technologic advances
      • Low-energy beams 
        • Expend energy quickly 
        • Penetrate a short distance 
        • Useful for skin lesions
      • High-energy beams 
        • Greater depth of penetration 
        • Suitable for optimal dosing of internal targets while sparing skin
    • Total doses divided into fractions 
    • Typically delivered once a day for 5 days a week for 2 to 8 weeks
      • Standard fractionation
Cancer
Cancer 150 150 Tony Guo
  • Oncofetal antigens
    • Found on tumor cell surfaces, inside tumor cells, and fetal cells
  • Examples of oncofetal antigens
    • Carcinoembryonic antigen (CEA)
      • On cancer cells of GI tract
      • Normal cells (fetal gut, liver, and pancreas)
    • α-Fetoprotein (AFP)
      • Malignant liver cells and fetal liver cells
    • CA-125 (ovarian carcinoma)
    • CA-19-9 (pancreatic and gallbladder cancer)
    • PSA (prostate cancer)
    • CA 15-3, CA 27-29, HER-2 (breast cancer)
    • kRAS (colon cancer oncogenes)
    • EGFR (lung cancer)

 

Benign vs Malignant Neoplasms

  • Tumors can be classified as benign (well differentiated) or malignant (range from well differentiated to undifferentiated.). 
  • Tumors can be classified according to 
    • Anatomic site, 
    • Histology (grading)
    • Extent of disease (staging). 
  • Tumor classification systems provide a standardized way to 
    • Communicate the status of the cancer to all members of the Interprofessional care team 
    • Assist in determining the most effective treatment plan
    • Evaluate the treatment plan
    • Predict prognosis
    • Compare like groups for statistical purposes.
  • Ability of malignant tumor cells to invade and metastasize is major difference between benign and malignant neoplasms

 

Classification of cancer

  • Tumors can be classified by
    • Anatomic site
    • Histology 
      • Grading severity
    • Extent of disease
      • Staging
  • Classification systems provide a standardized way to 
    • Communicate with health care team
    • Prepare and evaluate treatment plan
    • Determine prognosis
    • Compare groups statistically
  • Anatomic site classification
    • Identified by tissue of origin
    • Carcinomas originate from 
      • Embryonal ectoderm (skin, glands) 
      • Endoderm (mucous membrane of respiratory tract, GI and GU tracts)
    • Sarcomas originate from 
      • Embryonal mesoderm (connective tissue, muscle, bone, and fat)
    • Lymphomas and leukemias originate from 
      • Hematopoietic system
  • Four grades of abnormal cells
    • Grade I
      • Tumor limited to tissue of origin; localized tumor growth
    • Grade II
      • Limited local spread
    • Grade III
      • Extensive local and regional spread
    • Grade IV
      • Cells are immature and primitive and undifferentiated
      • Cell of origin is difficult to determine
      • Metastasis
  • TNM classification system
    • Anatomic extent of disease is based on 3 parameters:
      • Tumor size and invasiveness (T)
      • Spread to lymph nodes (N)
      • Metastasis (M)
  • Staging
    • Performed initially and at several evaluation points
      • Clinical staging
        • Done at completion of diagnostic workup to guide effective treatment selection
          • Bone and liver scans, ultrasonography, CT, MRI, PET scans
      • Surgical staging
        • Determined by surgical excision, exploration, and/or lymph node sampling
        • Exploratory surgical staging is being used less frequently

Diagnosis of cancer

  • Diagnostic plan includes
    • Comprehensive Health History 
    • Identification of risk factors
    • Physical examination
    • Specific diagnostic studies
  • Indicated diagnostic studies depend on site of cancer
    • Lab works
    • Cytology studies
    • Chest x-ray
    • Endoscopic examinations
    • Radiographic studies
    • Radioisotope scans
    • PET scan
    • Tumor markers
    • Genetic markers
    • Bone marrow examination
    • Biopsy
  • Patient may experience fear and anxiety
    • Actively listen to patient’s concerns
    • Manage your own discomfort
    • Give clear explanations; repeat if necessary
    • Give written information for reinforcement
    • Refer to oncology team when possible
  • Manage your own discomfort
    • Avoid 
      • Communication patterns that may hinder exploration of feelings
      • Use of overly technical language
    • Encourage patients to share the meaning of their experience
    • Listening is an important skill at this time
  • Prevention is key
    • The war on cancer will not be won with drugs or radiation therapy
    • A stronger emphasis on prevention is needed
    • Nurses have an essential role
  • Education is essential
    • Goals of public education
      • Motivate people to recognize and modify behaviors that may negatively affect health
      • Encourage awareness of and participation in health-promoting behaviors
    • What you would tell the patient about cancer
      • Cell proliferation, or growth, originates in the stem cell and begins when the stem cell enters the cell cycle. Normally, cells differentiate and become mature, functioning cells of a certain kind of tissue.  There is an equilibrium between cell proliferation and cell degeneration.  In cancer, cells respond differently than normal cells to the intracellular signals that regulate the state of dynamic equilibrium. Cells respond differently and divide indiscriminately and haphazardly.  When they produce more than 2 cells at the time of mitosis, there is continuous growth of a tumor mass, called the pyramid effect. 
      • Cell differentiation is normally a stable, orderly process that progresses from a state of immaturity to a state of maturity. Cancer results in malfunction in that process. 
      • Cancer involves the malfunction of genes that control differentiation and proliferation.
    • Is cancer genetically linked?
      • A common misbelief is that the development of cancer is a rapid, haphazard event. However, cancer is usually an orderly process comprising several stages and occurring over a period of time. 
      • The first stage, initiation, is a mutation in the cell’s genetic structure. 
      • Gene mutations can occur in two different ways: inherited from a parent (passed from one generation to the next) or acquired during a person’s lifetime. 
      • About 5% to 10% of all cancers or the predisposition to the cancers are inherited from one’s parents. These genetic alterations lead to a very high risk of developing a specific type of cancer. 
      • However, most cancers do not result from inherited genes but are acquired from damage to genes occurring during one’s lifetime. An acquired mutation is passed on to all cells that develop from that single cell. 
      • The damaged cell may die or repair itself. However, if cell death or repair does not occur before cell division, the cell will replicate into daughter cells, each with the same genetic alteration.
    • Role of UV light
    • UV radiation is considered a carcinogen.
    • Carcinogens may be chemical, radiation, or viral.
    • Ultraviolet (UV) radiation has long been associated with melanoma and squamous and basal cell carcinoma of the skin. 
    • Skin cancer is the most common type of cancer among whites in the United States. Of great concern is the increase in the incidence of melanoma. Although the cause of melanoma is probably multifactorial, UV radiation secondary to sunlight exposure is linked to the development of melanoma.
  • Prevention and detection of cancer
    • Cancer is a group of diseases characterized by uncontrolled and unregulated growth of cells. 
    • Cancer affects people of all ages and affects men more than women.
    • It is the second most common cause of death in the United States after heart disease.
    • More people are surviving cancer.
    • Lifestyle habits to reduce risks
      • Practice recommended cancer screenings
        • Learn and practice the recommended American Cancer Society cancer screening guidelines for breast, colon, cervical, and prostate cancer.
      • Practice self-examination
      • Know seven warning signs of cancer
      • Seek medical care if cancer is suspected
      • Avoid or reduce exposure to known or suspected carcinogens
        • Cigarette smoke, excessive sun exposure
      • Eat a balanced diet
        • Eat a balanced diet that includes vegetables and fresh fruits, whole grains, and adequate amounts of fiber. 
        • Reduce dietary fat and preservatives, including smoked and salt-cured meats containing high nitrite concentrations.
      • Limit alcohol intake
      • Exercise regularly
        • Participate in regular exercise (i.e., 30 minutes or more of moderate physical activity five times weekly).
      • Maintain a healthy weight
      • Get adequate rest
        • Obtain adequate, consistent periods of rest (at least 6 to 8 hours per night).
      • Eliminate, reduce, or cope with stress
        • Enhance the ability to effectively cope with stressors.
      • Have a regular health examination
        • Be familiar with your family history
        • Know your risk factors