1
Q
pain
A
- whatever the patient experiencing the pain says it is
- pain with someone who has dementia can be experienced as aggitation
- comotose and metnally disabled pts can feel pain just the same
- pain clinics and pain teams in hospitals assigned to deal specifically with pain
2
Q
why is pain undertreated?
A
- physicians have: inadequate knowledge in assessment, unwilling to believe pts, lack of time, may think pain management can cause death, inadequate info about addiciton
- pts might not report pain due to: fear of addiction, fear of side effects, belief that pain means they are getting worse, desire to be a “good pt”
3
Q
pain mechanisms
A
- nociception: physiologic process by which info about tissue damage is communicated to CNS
1 transduction
2. transmission
3. perception
4. modulation - acute, unrelieved pain leads to chronic pain
- pts can develop adaptive and maladapative mechanisms for dealing with pain (behavioral, addiciton)
4
Q
how does pain affect pts?
A
- pysiologic: prolonged stress response, increased HR, increased BP, increase o2 demand, decreased GI motility, immobility, decreased immune response, delayed healing, increased risk for chronic pain
- quality of life: interferes with ADLs, causes anxiety, depression, fear, anger, poor sleep, impairs relationships
- financially: very expensive (lost income, medications, hospitalizations)
5
Q
Acute pain
A
- diminishes as healing occurs; responds well to analgesics
6
Q
chronic pain
A
- lasts longer than 3 months, nerves may become oversensitive and react to even a slight stimulus
7
Q
neuropathic pain
A
- c/b(?) damage to CNS or PNS; not well-controlled by opiods alone, needs adjuvant therapy
- shingles, diabetic neuropathy
- gabapentin, lyrica
- numbing, shooting, stabbing, sharp, electric shock like, burning
8
Q
tolerance
A
- body adapts so that exposure to a drug causes changes that result in a decrease in one or more of the drug’s effects
9
Q
physical dependence
A
- symptoms c/b abrupt cessation, rapid dose reduction, decreased blood level, and/or administration of an antagonist
10
Q
addiction
A
- primary, chronic, neurobiologic disease with genetic, psychosocial and environmental factors
11
Q
pain assessment
A
- 5th vital sign
- must assess in a mutlidimensional way
- document the specific words the patient uses
- pattern: onset, duration
- location: local, generalized, referred, radiating
- describe the site, point to the site, drawon on body map, describe every location
- intensity
- quality
- associated symptms
- management strategies
- impact
- DOCUMENT and REASSESS every 30-60 minutes
12
Q
paint nursing diagnosis
A
- asses an ‘acceptable’ level of pain for your patient
- don’t plan to make the pain go away all together
- “decrease in pain within one hour of nursing intervention”
13
Q
OLDCARD & PQRST
A
- onset, location, duration, characteristics, aggrivating factors, relieveing factors, treatment
- provoke, quality, radiate, severity, time
14
Q
basic principles of pain treatment
A
1) follow the principles of pain assessment
2) evert pt deserves adequate pain management
3) base the tx plan on the pt goals (acceptable level according to pt)
4) use both drug and nondrug therapies
5) when appropriate, use a multimodal approach to analgesic thearpy
6) address pain using mutidisciplinary appraoch
7) evaluation the effectiveness of all therapies to ensure they are meeting the pt goals
8) prevent and/or manage med side effects
9) incorporate pt/caregiver teaching throughout assessment and treatment
* administer PRN pain meds “PER DR ORDER”
15
Q
Drug Therapy for Pain
A
- non-opiods: mild pain; IBprofen, tylenol, naproxin
- opioid with tylenol: moderate pain
- opioid: moderate to severe pain; morphine; must be on a stool softener 2x day
- adjuvant: neuropathic pain and moderate pain
- treatment can be more effective using meds from more than one group - nonstepor w opiod can help with diff types of pain (bone, cancer)
- “drug ceiling”: drug no longer has an effect after a certain dose
16
Q
non-opiods for pain
A
- NSAIDs, acetomenophen, aspirin, tylenol
- NSAIDs, acetomenphehn, aspirin
1) have analgesic ceiling
2) do not produce tolerance or dependence
3) available OTC (most) - mild to moderate pain
- used with opioids to allow for lower opioid levels “opioid sparing effect”
17
Q
types of Opioids
A
- work by modifying pain perception
- agonists, and agonist-antagonists
- AVOID giving: darvon and demerol (produce toxic metabolite causeing seizures; DO NOT give to 65+)
- bind to receptors in the CNS and cause 1) inhibition of the transmission of nociceptive input from the periphery to the spinal cord 2) altered limbic system activity 3) activation of the descending inhibitory pathways that modulate transmission in spinal cord
- act on NOCICEPTIVE processes
18
Q
Opioids for pain
A
- use for moderate to severe pain; breakthrough pain
- only need one b/c they are all very similar pharmacologically
- can be given by any route - prefer oral route unless pain is severe or need dose titration
- use an equianalgesic chart when changing from IV to oral (conversion chart)
19
Q
codeine
A
- weak opioid
- requires an enzyme to break it down to work
- not good for severe pain
- use with a stool softener
20
Q
hydrocodone
A
- opioid
- always combined with tylenol or Ibuprofen (lortab, vicodin, vicoprogen) so dose limited
21
Q
Oxycodone
A
- opioid- single or combined
- oxycontin is long acting
22
Q
morphine
A
- gold standard opioid
- roxanol, avinza, MS contin = long acting
- drug of choice for the elderly, can be given in small doses
23
Q
hydromorphone
A
- opioid
- dilaudid
- 8x more potent than morphine
- only short acting
24
Q
fentanyl (duragesic)
A
- 72 hour patch (duragesic)
- oral losange (actiq, lollypop)
- not for the opioid-naive
25
methadone
- opioid
- works on 2 receptors
- long hald-life (24-36 hours)
- sedation
- bad for elderly
26
tramadol
- ultram
- atypical opioid
- can cause seizures; avoid in pts with history of seizures
- effective in: low back pain, osteoarthritis, fibromyalgia, diabetic peripheral neuropathy,
- side effects: nausea, constipation, dizziness, sedation
27
opioid common side effects and treatment
* constipation - bowl regimen, stool softener
* nausea/vomiting - antiemetics, resolves with tolerance (24-48 hours)
* sedation - resoolve with tolerance 2-3 days, stop sedatives
* respiratory depression - used a sedation scale, decrease dose, narcan
* itching (pruritis) - benadryl, low dose infusion of narcan with epidural use
28
Less common side effects of opioids
- urinary retention
- dizziness
- confusion
- hallucinations
- opioid induced hyperalgesia (OIH) - opioids taken over time can increase sensitivity to pain
29
adjuvants
- can be used alone or in combination
- meds that are not typically used for pain but can be used for it in special cases
- common adjuvants: antidepressants, antisizure drugs, GABA receptoragonist, anesthetics
30
corticosteroids, adjuvant
- corticosteroids (prednisone, dexamethasone): best for cancer pain, spinal cord compression, inflammatory joint pain; many side effects; don't give with NSAIDs
31
antidepressants, adjuvant
- antidepressants (TCAs - elavil, SNRIs - cymbalta)
- increase seratonin & norepinephrine, promotes sleep, don't give if history of seizures or cardiac disease, bad for older adults, many side effects, SNRIs have less side effects but cost more)
- inhibit transmission of nociceptive signals in the CNS
32
antiseizure drugs, ajuvant
- lamictal, neurontin, lyrica
- affect peripheral nerves and CNS
- used for chronic pain
33
gaba receptor agonists, adjuvant
- baclofen
- inhibits pain transmission, used for muscle spasms, best used intrathecally
- spinal cord injuries, cerebral palsy
- used for muscle spasms
34
alpha adrenergic agonists, adjuvant
- clonidine, zanaflex
| - used for chronic headaches, neuropathic pain
35
local anesthetics, adjuvant
- interrupes transmission of pan signals to the brain, works for types of neuropathic pain
- bupivacine, ropivacaine
36
pain med administration
- scheduling: focus on preventing and controlling pain, pre-medicate before painful activities, give regularly with constant pain, fast acting for breakthrogh or incident pain, sustained release for constant pain
- titration: adjusting dose based on adequacy of analgesic effect vs side effect (switching from one med to another)
- equianalgesic dosing: carefully monitor and adjust for each individual pt
37
oral pain meds
- route of choice if GI system is good
- opioids requires a larger dose than IV or IM due to first-pass effect
- skiwer inset, peak 1-2 hours
- dont crush, break, chew sustainted release drugs (MS contin, oxycontin)
38
sublingualbuccal pain meds
- bypasses the first pass effect
- doesnt always work well
- fentanyl can be given in a lollypop
39
intranasal pain meds
- stadol, sumatriptan
| - used for headaches
40
rectal pain meds
- often overlooked
- good if pt has nausea and vomiting, NPO
- lasts 4-6 hours
- can't use if a bleeding risk
41
transdermal pain meds
- fentanyl patch
- slow to reach affect when first applied
- can cause death from overdose (slow rr, confusion, dizziness)
- can absorb med too quickly if febrile
42
topical pain meds
- creams and lotions
- trolamine salicylate for joint/muscle pain; capsaicin; EMLA
- little systemic absorption, can cause skin reactions
43
parenteral pain meds
- SC, IM, IV
- IM not recommended due to pain, unreliable absorption, avscesses with frequent use
- SC is rarely used due to slow response, but can be used if no IV access
- IV is best for immediate analgesia and rapid titration; fastest onset but shortest duration; peaks 5-15 minutes; not good for constant pain
44
intraspinal pain meds
- epidural or intrathecal
- intermittent bolus or continuous
- can place tip of catheter as close to the nerve as possible
- highly potent requiring much smaller doses
- side effects are itching, nausea, urinary retention
- uses: catheter displacement, accidental infusion of neurotoxic agents, infection
- implantable pumps, intrathecal delivery by pump
45
Patient Controlled Analgesia (PCA)
- IV delviery system or epidural catheter
- pt decides when does is needed
- can have a continuous basal rate
- be careful with opioid naieve patients
- monitor sedation level and resp rate
- important to do good patient teaching
- give before pain is severe
- assure them they can not overdose
- only the pt can push the button
46
interventional therapies for pain
- nerve block: regional anesthesia, used during and after surgery, sometimes used for chronic pain syndromes
- neuroablative techniques: used for severe pain unresponsive to other tx, destorys the nerves by surgical resection or thermocoagulation
- neuroaugmentation: electrical stimulation of the brain and spinal cord, used for chronic back pain from severe nerve damage, also CRPS, spinal cord injury
47
non-drug pain therapies
- massage: superficial, deep, trigger point
- exercise: esp with chronic MSK pain
- TENS: transcutaneous electrical nerve stimulation, for acute pain
- acupuncture
- heat
- cold
- distraction
- hypnosis
- relaxation strategies
48
nursing care for pain
- effective communication
- overcome barriers to pain management
- tolerance: opioid rotation, remeber there is no uipper limit with pur opioid agonists
- dependence: taper when discontinuing
- addiction: no true risk factors, dont let it keep you from treating moderate to severe pain and chronic pain
49
joint commission requirements for pain
- recognize pt right to appropriate assessment and management of pain
- identify pain during initial assessment and during ongoing, periodic reassessments
- educate and ensure competency of HCPs regarding pain assessment and management
- educate patients and familites about pain management
50
ethical issues with pain
- fear of hastening death, no scientific evidence of this even at end of life, rule of double effect
- requests for assisted suicide, aggressive pain management could actually decrease this
- use of placebos, condemned by several professional organizations
51
gerontologic considerations for pain
- often inadequatly assessed and treated
- pts/HCPs often believe it is a normal, inevitable part of aging and nothign can be done
- elderly often don't report pain, may have trouble taking about it
- they have a high prevalance of cognitive, sensory-perceptual, and motor problems that make pain harder to assess
- metabolize drugs slower, start low and go slow (tylenol)
- NSAIDs cause serious GI bleeding in elderly
- often taking many drugs for chronic problems
- cognitive impairment/ataxia can be worsened with analgesics
- very important to incorporate nondrug therapies
52
nonverbal pts and pain meds
- ask anyway
- look for potential causes of pain
- observe for behaviors indicating pain (grimacing, rubbing, goaning, agitation)
- try an analgesic and see if it works
53
substance abusers and pain meds
- still have a right to pain management
- can still use opioids but don't use opioid agonist-antagonist
- avoid psychoactive drugs
- may need higher doses or increased frequency
- need a multidisciplinary approach
54
primary role of nurse in pain management
- believe the patient's report of pain
55
NSAIDs, non-opioid pain
- NSAIDS: decrease production of pain-sensitizing chemicals, pts should try a variety of NSAIDs; all have COX in them; ibuprofen, naproxen, ketorolac, celecoxib;
- used for mild to moderate pain
- do not produce tolerance or dependence
- have an analgesic ceiling
- used with opiods to give locer opiod doses
- can cause GI problems, cognitive impariment, hypersensitivity
- at risk for NSAID toxicity: history of ulcer disease, older than 65, using corticosteroids or anticoagulants; more at risk for cardicascular events like MI, stroke and heart failure; patients who have just had heart surgery should not take NSAIDS
- NSAIDs: can caused bleeding, renal toxicity, CHF in elderly, some interactions with anticoagulatns, oral hypoglucemics, antihypertensive, diuretics
56
acetomenophen, non-opioid for pain
- acetomenophen: can cause hepatoxicity; percocet and lortab have acetomenophen in them
- Tylenol: does not cause bleeding, but can be toxic to the liver; has analgesic and antipyretic effects; no antiplatelet or antiinflammatory effects
- ceiling = 3mg
57
aspirin, non-opioid for pain
- ASA: use limited by side effects (bleeding, ulcers), mild pain
58
opioid agonists
- agonists: morphine, oxycodone, hydrocodone, codeine, methadone, hydromorphone; often combined with non-opiod analgesics limiting the total daily dose that can be given
- used for acute and chronic pain
- pure opioid agonists: morphine, oxycodone, hyrdocodone, codeine, methadone, hydromorphone
- moderate to severe pain; no ceiling
- moderate pain = opioid combined with non-opioid
59
opioid agonist-antagonist
- agonist-antagonist: nubain, talwin, stadol; produce less resp depression but causes more dysphoria and agitation, have analgesic ceiling, can lead to withdrawl, not used much
- work on kappa (agonists) and mu (antagonist) receptors
- less resp depresion than pure agonists
- more dysphoria and agitation
60
substance abuse
- in the last 12 months, have had one or more of the following:
1) failure to fullfill major role obligations (school, work, home)
2) recurrent use even when it is hazardous (driving, operating machinery)
3) recurrent substance related legal problems
4) continued use despite relationship problems
61
addiction
- primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors:
1) loss of control over use
2) continued use despite knowledge of harmful consequences
3) compulsion to use
4) craving "surviving to get fix"
62
dependence
- reliance on a substance that has reached the level that absence of it will cause an impairement in function
- in the last 12 months, have had 3 or more of the following:
1) tolerance
2) withdrawl
3) taking in large amounts or for longer than intended
4) uable to control use
5) great deal of time spent getting the substance, using the substance or recovering from the substance
6) important social/recreational activities are given up because of the substance
7) continued use even with known health or psychological problems caused by substance
63
common health related problems related to substance abuse/dependence
- COPD - smoking
- Cancers - smoking, drinking
- heart disease
- peptic ulcer disease
- GERD
- chronic sinusitis - cocaine
- uncontrollable tremors
- respiratory depression
- memory impairment
- skin infections - heroin, meth, absesses
- blood clots
- hepatitis B & C - IVs
- HIV/ADIS
- malnutrition
64
Nicotine
- most common addictive behavior
- smoking is the most harmful method
- injures nearly every organ in the body: lung disease, CV disease, cancer, cataracts, pneumonia, periodontitis, aortic aneurysms, menstrual problems, infertility, delayed wound healing
- damage from chronic respiratory irritation, carbon monoxide (decreased oxygen carrying capacity of the blood)
65
tobacco cessation products
- every healthcare provider is required to address this with patients
- nicotine replacement products to reduce craving and withdrawl (with patient in hospital)
- chantix: gives some nicotine effects but also blocks the effects of nicotine if they resume smoking (vivid dreams, suicidal thoughts)
- zyban: atnidepressant, reduces the urge to smoke. reduces some withdrawl symptoms, prevents weight gain
- tobacco cessation programs should be used with nicotein replacement programs
66
tobacco cessation 5As and 5Rs
* 5 As:
1. ask - identify all tobacco users at every contact
2. advise - strongly urge all tobacco used to quit
3. assess - determine willingness to quit
4. assist - aid the pt in developing a plan to quit
5. arrange - schedule follow-up contact
* 5 Rs:
1. relevance - ask the pt to tell you why quitting is personally relevant
2. risks - ask the pt to identify consequences of tobacco use
3. rewards - ask the patient to idetify potential benefits of stopping tobacco use
4. roadblocks - ask patient to identify barriers to quitting
5. repetition - repeat process every clinic visit
67
Benefits of smoking cessation
- in 20 minutes: BP decreases, HR decreases, body temp and hangs/feet increase
- in 12 hours: carbon monoxide levels in blood drops to normal, oxygen level increases to normal
- in 24 hours: chance of heart attack decreases
- in 48 hours: nerve endings start regrowing, ability to smell and taste is enhanced
- in 2 weeks to 3 months: circulation improves, walking becomes easier, lung function increases, coughing/sinus congestion/fatigue/SOB decrease
- in 1 year: risk of heart disease decreases to half that of a smoker
- 10-15 years: risk of stroke, lung and other cancers, and early death returns to nearly the level of people who have never smoked
68
Stimulants
- work by increasing the amount of dopamine in the brain producing euphoria, alertness, and raid dependence
- Nicotine, cocaine, amphetamines, methamphetamine, ritalin, caffeine
- overdose is common, death does occur
69
stimulants overdose
- overdose: restlessness, paranoia, agitated deliruym, confusion, reptetive behaviours, seizures, combative, fever, high HR/BP
- no antidote for cocaine or amphetamines
- patent airway, IV access, 12-lead ECG, treat dysrhythmias, treat HTN, tachy, give ASA to prevent MI, give valium or ativan for seizures, avoide resptraints
- withdrawl: few physical symptoms but intense cravings, may become depressed
70
depressants
- alcohol, sedatives, hypnotics, opioids
- sedative-hypnotics: barbituates, benzodiazepines, barbituate-like drugs; depress CNS at low doses and sleep at high doses; high doses can give initial euphoria
- opioids: illegal or legal; cause CNS depression and major effect on the brain regawrd system; usually injected IV so increased risk of disease
71
depressant overdose
- causes death from resp depression/arrest, nausea and vom, slurred speech, confusion, drowsiness, low HR, low BP, low RR
- need serum and urine drug screens
- ABCs is priority
- ensure pt airway, IV access, 12 lead EKG, drug levels, give antidotes, gastric lavage, activated charcoal
- need to see a psyhiatric professional before being released
- sedative hypnotics: antidote for benzodiazepines is flumazenil (romazicon) - can cause seizures in people with physical dependence; charcoal can be given within 4-6 hours
- opioids: antidote is naloxone (narcan), does may have to be repeated
72
depressant withdrawl
- most dangerous and should be observed for in any patient with a history of substance abuse (including alcohol)
* sedative-hypnotics: severe symptoms can start within 24 hours, persist for 3-5 days, with mild symptoms persisting for 2-3 weeks
- signs and symptoms: craving, delirium, seizures, resp/card arrest
- tx: long acting meds (valium, klonopin) gradually taper after stabalization
* opioids: happens when drug is decreased or stopped or naloxone is given
- s/s: craving, abdominal cramps, diarrhea, n/v, sweating
- tx: symptom-based and doesn't always require medications
- uncomfortable but isn't life threatening
- methadone in decreasing doses can decrease symptoms
73
methadone
- PO opioid
- blocks the "high" caused by using opiates (doesnt cause euphoria or intoxication)
- produces stable levels of the drug in the brain so the patients odesnt get a rush
- helps decrease the patient's desire to use opioids (reduces cravings, prevents withdrawl)
- do not use with alcohol
- sometimes used to treat chronic pain
- usually taken in a supervised setting
74
alcohol
- alcohol dependence usually occurs over a period of years
- chronic, progressive, potentially fatal disease
- affects almost all cells of the body, but particularly CNS (depressant)
- women have higher blood alcohol levels than men with the same amount
- Blood alcohol concentration BAC:
* 0.02 - one drink, light drinkers will feel it
* 0.06 - judgement is mildly impaired
* 0.08 - judgement is clearly imparied, legal intoxication in some states
* 0.1 - legally intoxicated in most states
* 0.3 - usu lose consciousness
* 0.45 - stop breathing
75
health problems with alcohol
- alcohol dimentia
- wernicke's encephalopathy (increased amonia levels)
- depression
- ADD
- seizures
- peripheral neuropathy
- decreased immune system
- increased cancer risk (GI)
- anemia
- osteoporosis
- liver disease
- testicular atrophy
- spider angiomas (spider veins of face, red butterfly effect on face)
76
alcohol intoxication
- occurs after binge drinking or using alcohol with CNS depressants causing resp and ciruclatory failure
- maintain ABCs until detox is complete and alcohol is metabolized
- closely monitor VS and LOC
- no antidote for alcohol, should not give stimulants or depressnts
- administer IV thiamine first and then IV glucose = banana bag
- watch for hypoglycemia, low magnesium levels
- expect agitaiton and anxiety
- risk for injury, agitation
- continue assessment and intervention until BAC is 0.1
77
alcohol withdrawl syndrome
- tell pts to be honest about how much they use to help with withdrawls
- delirium tremens
- if you are non-dependent, you have a hangover
- if dependent and hospitalized, can develop alcohol withdrawl syndrome:
> occurs 4-6 hours after last drink and contunues 3-5 days
> minor: anxiety, increased HR, increased BP, sweating, nausea, hyperreflexia, insomnia
> major: visual/auditory hallucinations, tremors, seizures, delirium
> alcohol withdrawl delirium: disorientation, visual/auditory hallucinations, hyperreactivity, death from hyperthermia, peripheral vascular collapse, cardiac failure
- prevent this by giving benzodiazepine (ativan), tegretold or dilantin to prevent seizures, antipsychotics (haldol, throazine) if benzodiazepines dont work
- quiet calm environment, don't restrain
78
CIWA
alcohol withdrawl assessment
79
cannabis
- important to ask about use
- key active ingredient is THC (tetrahydrocannabinol)
- medical use is marinol for n/v for chemo and appetite stimulation fo AIDS pts
- low doses: less effects than alcohol
- high doses: euphoria, sedation, hallucinations
- causes problems in brain, CV, resp systems
- intoxication: panic, flashbacks
80
summary
- Opiate withdrawl: sweating, diarrhea, watery eyes, n/v, cramps; treat symptoms
- sedative/hypnotic withdrawl: high HR, seizures, delirium, tremors, hallucinations; close observation, valium to start tapering
- depressant overdose: pinpoint pupils, slow RR, sedation; priority is antidotes (narcan, flumazenil), support breathing, activated charcoal
- stimulant overdose: high HR/BP, chest pain, agitation, fever, pupil dilation; priority vital signs, ECG, 02, can die from dysrhythmias or MI
81
substance abuse, assessment
- question all patients about substance abuse
- Alcohol use disorders identification test (AUDIT)
- GMAST = elderly pop substance abuse quesitonaire
- CAGEDAID questionaire = elderly alcohol questionaire
- physical exam
82
substance abuse, nursing interventions
- prevention
- early detection of substance abuse
- treatments if needed - giving antagonistic drugs, promotion of metabolism/elimination of drug, intensive supportive care
- operative pts: increased risk for post-op complications and death; standard amounts of anesthetics may not be enough; sedatives may have prolonged effects if their liver is damaged; postpone surgery if BAC is >0.2
- avoid drug of abuse, suspect abuse if normal doses aren't working
83
nursing intervention, motivational interviewing
- nonconfrontational communication to motivate pts to change
- identify current stage of rediness for change
- listen, rather than tell
- focus on pt strengths
- avoid arguement or direct confrontation
- precontemplation: inrease pt awarenes of risks/problems r/t current behavior and create doubt about the use of substances
- contemplation: help the pt consider the positive and negative aspects of substance use
84
substance abuse, gerontologic considerations
- HCPs are much less likely to recognize substance problems in older adults
- misuse or abuse can cause confusion, delirium, memory loss, neuromuscular impairment
- can become intoxicated at much lower levels
- screening questionares must be specific to geriatrics
- advise them not to drink alcohol when taking prescrive or OTC meds
85
postoperative period
- beings immediately after surgery, continues until patient is discharged from medical care
- PACU is located adjacent to OR: minimizes transport, provides immedate access to anesthesia and OR personnel
- nursing care focus: protect patient and prevent complications
86
PACU Progression
- Post anesthesia care unit
- can include phase 1, phase 2, and/or extended observation
- Phase 1: care during immediate post anesthesia period, includes EKG and close monitoring
- Phase 2: ambulatory surgery patients to be observed until ready for discharge or need for extended observation
- extended observation: 23 hour stay
87
PACU Admission
- anesthesia care provider (ACP) will provide verbal report
- priorities of PACU: ABCs, pain, temp, surgical site
- goal of care: identify acutal and potential problems due to anesthetic or surgery and intervene quickly
88
postoperative assessment
- airway: patency, oral and nasal airway, laryngeal mask airway, E tube
- breathing: resp rate and quality, auscultated breath sounds, pulse ox, supplemental o2
- circulation: ECG monitoring/rate and rhythm, blood presure, temp, cap refill, color and temp of skin, peripheral pulses
- neurologic: level of consciousness, orientation, sensory and motor status, pupil size and rxn
- GI: N/V, I & O
- Surgical site: dressings and drainage
- pain: incision, other
89
postoperative assessment
- airway: patency, oral and nasal airway, laryngeal mask airway, E tube
- breathing: resp rate and quality, auscultated breath sounds, pulse ox, supplemental o2
- circulation: ECG monitoring/rate and rhythm, blood presure, temp, cap refill, color and temp of skin, peripheral pulses
- neurologic: level of consciousness, orientation, sensory, glasgow coma scale, and motor status, pupil size and rxn
- GI: N/V, I & O
- Surgical site: dressings and drainage
- pain: incision, other
* low RR can lead to high HR and high BP
* hearing is the first sense to return
90
regional anesthesia
- includes spinal or epidural
- sensory and motor blockade may still be present
- dermatome level should be checked to determine the level of return
- sensory and motor fxn return from the extremeties to the site of injection
91
postoperative complications: respiratory
- airway obstruction: tongue, supine/sleepu
| - hypoxemia: atelectasis, PAO2
92
atelectasis
- alveoli collapse
- mucous blocks bronchioles or surfactant is reduced on alveoli
- good coughing helps
- incentive spirometer
- maintain pulse ox 90-92%
93
nursing interventions to prevent respiratory complications postop
- reposition head or perform suctioning
- lateral recombant position then when conscious, supine position
- perform a good assessment: airway, chest symmetry, depthy, rate, character of respiration, use of accessory muscles, breath sounds, sputum color/consistency; close monitor of vital signs
- signs and symptoms of hypoxemia: increased RR, increased HR, gasping, restlessness
- encourage coughing and deep breathing (10 minutes every hour they are awake), change position every 1-2 hours, early mobilization, adequate hydration, pain management
94
postoperative complications: cardiovascular
- hypotension: disorientation, chest pain, most commonly caused by fluid loss but if giving fluid doesnt work then look for other issues
- hypertension: from pain, revascularization, hypothermia
- dysrhythmias
- venous thromboembolism (VTE)
- syncope
- patients most at risk for cardio issues postop: decreased resp fxn, history of cardio issues, elderly
95
nursing interventions to prevent cardio complications postop
- assessments: frequent vitals (every 15 minutes) in phase 1. notify MD if systolic BP 160, HR 120, narrowed pulse pressure, gradual decreasing BP, change in rhythm, significant deviation from baseline
- continouse ECG monitoring
- adequate fluid replacement
- assessment of skin color, temp, moisture
- surgical incision for excessive bleeding or drainage
* hypotension: o2 therapy, IV fluid bolus, may need vasoconstrictive meds; can be caused by vasodilation from anesthesia (normal) with dry skin (normal); hypotension with rapid, weak thready pulse and cool skin can mean hypovolemic shock
* hypertension: address the cause of SNS stimulation (exp, full bladder), may need pain meds, help void, correct resp problems, rewarm, antihypertensive meds
* dysrhythmias: treat the cause, cardiac life support
96
nursing interventions to prevent cardio complications postop
- assessments: frequent vitals (every 15 minutes) in phase 1. notify MD if systolic BP 160, HR 120, narrowed pulse pressure, gradual decreasing BP, change in rhythm, significant deviation from baseline
- continouse ECG monitoring
- adequate fluid replacement
- assessment of skin color, temp, moisture
- surgical incision for excessive bleeding or drainage
- early ambuation: increases muscle tone and circulation
- VTE prophylaxis: heparin, TEDs, SCDs
- monitor orthostatic BP with increase in mobility
97
common cardiac postop interventions
* hypotension: o2 therapy, IV fluid bolus, may need vasoconstrictive meds; can be caused by vasodilation from anesthesia (normal) with dry skin (normal); hypotension with rapid, weak thready pulse and cool skin can mean hypovolemic shock
* hypertension: address the cause of SNS stimulation (exp, full bladder), may need pain meds, help void, correct resp problems, rewarm, antihypertensive meds
* dysrhythmias: treat the cause, cardiac life support
98
common cardiac postop interventions
* hypotension: o2 therapy, IV fluid bolus, may need vasoconstrictive meds; can be caused by vasodilation from anesthesia (normal) with dry skin (normal); hypotension with rapid, weak thready pulse and cool skin can mean hypovolemic shock
* hypertension: address the cause of SNS stimulation (exp, full bladder), may need pain meds, help void, correct resp problems, rewarm, antihypertensive meds
* dysrhythmias: treat the cause, cardiac life support
99
postop complications:neuro/psychologic
* emergence delirium: agitation, disorientation, thrashing, shouting; common and normal to "wake up wild"; caused by pain, ET tube, anesthesia
* delayed emergence: staying unconscious too long; caused by anxiety, prolonged drug action, neuro injury
* anxiety: waking up in unfamiliar location, normal
* post op cognitive dysfunction (POCD): common in older patients, dimentia may not use anesthesia because it can make memory problems worse
* alcohol withdrawal delirium: know how much and last time they drank
100
nursing interventions to prevent neuro/psych complications
- most common cause of neuro issues postop: hypoxia
- monitor o2 levels with continous pulse ox
- pain management
- sedation to control agitation
- maintain pt safety: siderails, secure IVs and airways
- alcohol protocols
- maintain normal physiologic fxn
101
postop complications: alterations in temperature
* hypotehermia/shivering: less than 36 C or 96.8 F
- causes: compromised immune fxn, bleeding, cardiac problems, impaired wound healing, altered drug metabolism, skin exposure during surgery, inhaled gases
- treatment: temp every 30 minutes, external warming decides
102
postop complications: alterations in temperature
* hypotehermia/shivering: less than 36 C or 96.8 F
- causes: compromised immune fxn, bleeding, cardiac problems, impaired wound healing, altered drug metabolism, skin exposure during surgery, inhaled gases
- treatment: temp every 30 minutes, external warming decides, o2 to meet increased demands (shivering), supression of shivering with opioids (demerol)
* demerol: dont give to elderly, very small doses to help with shivering
103
PACU Progression
- Post anesthesia care unit
- can include phase 1, phase 2, and/or extended observation
- Phase 1: care during immediate post anesthesia period, includes EKG and close monitoring
- Phase 2: ambulatory surgery patients to be observed until ready for discharge or need for extended observation
- extended observation: 23 hour stay
- RRP: rapid PACU progresion - through phase 1 to phase 2
- fast tracking: admit patient directly to phase 2, helps with mobidity
104
aldrete scoring system
- used to determine if pt is ready to transition from phase 1 to phase 2 or for fast tracking
- must score between 9 and 10
105
discharge criteria
- patent airway
- pt awake or at baseline
- hemodynramic stability: BP and HR
- no resp depression
- o2 sat >90%
- pain under control
- condition of surgical site (no excessive bleeding)
- report given
106
discharge from PACU
- call verbal report - nurse to nusre
- SBAR: situation, background, assessment, recommendations
- receiving on the floor: move pt taking care with iv lines, drains, get VS immediately after receiving, compair to baseline from PACU, do a full assessment
107
potential resp problems on the nursing unit
- atelectasis: inadequate deep breathing is most common cause, often due to retained secretions or decreased resp exertion
- low grade fever in the first 2 days post-op is almost always from atelectasis
- treatment is turn, cough and deep breathe!! = prevents pneumonia, atelectasis
108
potential resp problems on the nursing unit postop
- atelectasis: inadequate deep breathing is most common cause, often due to retained secretions or decreased resp exertion
- low grade fever in the first 2 days post-op is almost always from atelectasis
- treatment is turn, cough and deep breathe!! = prevents pneumonia, atelectasis
109
nursing care postop on nursing unit
- good assessment
- closely monitor VS and pulse ox
- oxygen
- deep brathing
- coughing
- incentive spriometer
- diaphragmatic/abdominal breathing
- change positon every 1-2 hours: sit in chair and ambulate
- provide adequate and regular analgesics, esp before deep breathing and abulation
- good hydration
110
potential cardio issues on the nursing unit post op
- F&E imbalances contribute to CV problems since it directly affects cardiac output
- fluid retention occurs post op 2-5 days: can lead to fluid overload, a stress response
- sometimes have fluid defecit from NG suctioning
- syncope
- hypokalemia from urinary and GI losses
- VTE
- Pulmonary embolism
111
nursing care for cardio issues post op in nursing unit
- strict I&Os
- monitor labs
- early abulation
- VTE/PE prevention: heparin, SCDs, TEDs
- syncope: change positions slowly
112
potential temp issues on nursing unit post op
- temp every 4 hours for first 48 hours
- true fever: 101.3 F (38.5 C)
- fever can occur at any time post op
WIND: atelectasis (days 3-4)
WATER: UTI (days 3-4)
WOUND: infection (Days 5+)
WALK: DVT (days 7-10)
113
nursing intervetions for temp issues on nursing unit post op
- frequent temp and watch for signs of inflamm and infection
- meticulous asepsis with wound and IV care
- cough, deep breath, incentive spirometer C/DB/IS
- chest x-ray, cultures
- start antibiotics immediately after obtaining cultures
- if temp >103, give antipyretics and use body-cooling measures (Kpad)
114
potential pain problems on the nursing unit post op
- causes: skin/tissue tramatized by incision and retraction, reflex muscle spasms around incision, anxiety and fear cause tension further increasing muscle tone and spasm
- deep visceral pain can suggest complications
- pain itself can cause complications
- pain: delays GI fxn, decrease immune response
115
nursing unit post op nursing care for pain
- pt's self report of pain is the most reliable
- analgesics: IV opioids give rapid relief
- RN responsiblity since pain meds are written PRN per dr order
- 1st 48 hours - opioid analgesics
- combination opioid and NSAID
- give pain meds before painful activities
- always fully asses before giving meds
- pain meds can increase gas pain: ambulate!
- PCA
- epidural analgesic
- repositioning, massage, distraction, deep breathing, music therapy, guided imagery, aromatherapy
116
post op complications: GI
- after abdominal surgery, takes 3-5 days to get motility in large intestine, 24 hours for small intestine
- nausea and vomiting
- abdominal distention
- postop ilieus (expected after major abdominal surgery, n/v, blockage in intestines)
- delayed gastric emptying
- hiccups
117
nursing interventions to prevent post op GI complications
- N/V: antiemetics, prokinetics (stimulate bowel motility)
| - Adequate hydration
118
nursing interventions to prevent post op GI complications
- N/V: antiemetics, prokinetics (stimulate bowel motility), NG suction as ordered
- Adequate hydration: give oral fluids when gag reflex returns
- assess bowel function: presence of bowel sounds/flatulence, is the pt hungry?
- early abulation, repositioning, dulcolax suppository
- gurgling in any section of the stomach is good, doesn't need to be all 4 quadrants
119
postoperative complications: urinary
- low urine output (800-1500ml) in first 24 hours r/t fluid restriction and fluid loss and physiologic stress. this is expected on day one
- urine output should increase by 2nd or 3rd day (>30ml/hr)
- retention due to anesthesia, opioids, lower abd/pelvic surgery, immobility
- oliguria: not common but sign of renal failure
120
nursing internveitons to prevent urinary complications post op
- monitor urine output
- adequate hydration
- removed urinary catheter when no longer indicated
-
121
nursing internveitons to prevent urinary complications post op
- monitor urine output
- adequate hydration
- removed urinary catheter when no longer indicated
- put pt in normal position for elimination, run water, give privacy
- bladder scan first before straight cath if >8 hours without voiding
122
potential wound problems on the nursing unit
- delayed wound healing due to preexisting nurtionatl defecits esp those with diabetes, obesity, elderly
- high risk for infection if bowel surgery after trauma
- infection can occur from exogenous flora, oral flora or intestinal flora
- usually do not see s/s for 3-5 days
- drains may be used to prevent pressure, maintain circulation and wound healing
123
postop complications: surgical site infection
- surgical site infection SSI
- hematoma
- dehisence
124
types of wound drains
- jackson pratt/JP Drain: circular drain that collects
- nephrostomy tube: directly collects from kidneys
- T tube: collects urine from bilary ducts
- hemovac: wound drain
125
nursing interventions to prevent wound infecitons/SSI
- assess wound: TACO drainage, assess effect of position changes on tube drainage, s/s of infection, order prophylactic antibiotics, maintain glycemic control (blood sugar for healing and recovery)
126
discharge to home from nursing unit post op
- controlled pain and n/v
- stable and near preop level of functioning
- must have a driver
- must give verbal and writing discharge info
- tell them: activities allowed/prohibited, how to care for incision, side effects of drugs, dietary restrictions/modifications, symptoms to be reported, where/when for follow up care
127
gerontologic considerations for postop patient
- decreased resp fxn: pneumonia most common complication
- altered vascular fxn: decreased circulation and blood colume, HTN common
- drug toxicity due to decreased clearance via kidneys
- mental status changes: delirium common post op
- pain control can be challenging: afraid of addiciton, low and slow pain meds
128
cancer facts
- 1/4 people will die of cancer
- 1/2 men will get it, 1/3 women will get it
- 2nd leading cause of death in US, heart disease is 1st
129
role of the immune system
- cytotoxic T cells: killers
- NK cells and activated macrophages: eat cells
- B cells: antibodies
- weak surface antigens allow cancer cells to sneak through immune surveillance
- cancer cells are "self"
130
benign vs malignant tumors
* BENIGN:
131
cancer and gender differences
MEN
- incidence: prostate, lung
- deaths: lung, prostate
WOMEN
- incidence: breast, lung
- deaths: lung, breast
132
benign vs malignant tumors
* BENIGN: differentiated, no metastasis, no/slight vasculature, fairly normal cell characteristics
* MALIGNANT: poorly differentiated, capable of spreading, moderate/marked vascularity, infiltrative and expansive growth, abnormal cells more unlike parent cells
133
development of cancer
- growth of tumor with angiogenesis (tumor forms own blood supply)
- invasiveness
- metastasis - tumor cells travel and grow in new sites
- most common sites: brain, lung, liver, adrenals, bone
- poorly differentiated cells have a worse prognosis than those more simialre to normal cells
134
cancer staging
0: cancer in situ
1: tumor limited to tissue of origin; localized tumor growth
2: limited local spread
3: extensive local and regional spread
4: metastasis
*TNM: tumor, node, metastasis
T1N2M2 = bad, any M = bad
135
nurse education lifestyle havits to reduce risks
- avoid exposure or reduce to carcinogens: cig smoke excessive sun exposure
- eat a balanced diet
- exercise regularly
- obtain adequate rest
regular health exams
- change stressors
- know 7 warning sings of cancer
- practice cancer screenings
- self exams
- seek medical care if suspicious
136
7 warning signals of cancer
1. change in bowel or bladder habits
2. sore that does not heal
3. unusual bledding or discharge
4. thickening of lump in breast or elsewhere
5. indigestion or difficulty in swallowing
6. obvious change in a wart or mole
7. nagging cough or hoarseness
137
diagnosing cancer
- biopsy: histologic exam by pathologist of a piece of tissue
- tissue can be obtained by: needle or aspiration, incisional procedure, excisional procedure
- PET, CT, xrays, MRI scans
- blood tests: look for markers/antigens - CEA, CA 27-.29, CA-125, AFP, PSA
138
Goal of cancer treatment
- initial treatment phase: chemo, rad, surgery, diagnostics, biologic and targeted therapy
- cure --> follow up phase, no return of cancer, usual life span
- control --> follow up phase, retreatment phase (surgery, chemo, rad, biologic therapy), usual or reduced life span
- palliation or no response to initial treatment --> treatment phase, advanced disease phase, supportive phase, reduced life span, hospice care
139
debulking
- take out part of cancer and makes it easier to fight in other ways
- used if tumor cannot be completely removed then use chemo/rad on rest of tumor
140
collaborate care of cancer treatment
- curative therapy: surgery alone or with systemic thearpy
- control treatment: intial course and maintenance thearpy
- palliation goal: relief or control of symptoms
- prevention: surgery used to eliminate or reduce risk of cancer
141
good prognostic indicators include
- small tumor size
- absence of lymph node involvement and abnormal tumor marker values
- remove only as much tissue as necessary
142
supportive and palliative care for cancer
- preserving quality of life
- insertion of G tube
- creation of colostomy
- suprapubic cystostomy
- placement of venous access device
- removal of metastatice liver lesions
143
rehab care for cancer
- create a bladder resevoir
- breast reconstruction
- creation of ostomies
144
Radiation Therapy
- local treatment
- 50% of all cancer pts will receive radiation
- produces ionization of atomic particles when absorbed in tissue
- generates free radicles that break bonds of DNA
- normally tissue likely to recover and cancer cells more likely to de damages
- side effects occur wherever patient is receiving radiation
- can in internal or external
145
Radiation Therapy
- local treatment
- 50% of all cancer pts will receive radiation
- produces ionization of atomic particles when absorbed in tissue
- generates free radicles that break bonds of DNA
- normally tissue likely to recover and cancer cells more likely to de damages
- side effects occur wherever patient is receiving radiation
- can be internal or external
146
Radiation Therapy
- local treatment
- 50% of all cancer pts will receive radiation
- produces ionization of atomic particles when absorbed in tissue
- generates free radicles that break bonds of DNA
- normally tissue likely to recover and cancer cells more likely to de damages
- side effects occur wherever patient is receiving radiation
- can be internal or external
- simulation: pre-rad therapy to find spots to radiate and place tattoo marks on pt
- external: teletherapy, most common, patient exposed from a megavolt machine - make sure to do a skin and nutritonal assessment
- internal: brachytherapy, implantation or inerstion of radiation, patient is emitting radiation, protect yourself (Time, distance shielding)
147
side effects of radiation
- skin reactions
- mucosal reactions
- fatigue
- bone marrow supression
- nutritional issues
148
dry desquamation
- symptom of radation
- do not apply heat or cold, lotion, friction
- give pain meds, nutrition, sleep
149
wet desquamation
- symptom of radiation
- leaks fluid wet
- assess for infection, low blood counts
- dry and soak area with solution
150
radiation nursing implications
- head and neck: very challenging with mucous issues
| - be proactive and help patients prepare for hair loss (if rad to head)
151
chemotherapy
use of chemicals for systemic therapy for cancer
- goal is to reduce # of malignant tumor sites
- used for most solid tumors and hematologic cancers
- most affective against currently dividing cells
- factors that determine response: miotic rate, size of tumor, age of tumor (younger easier to kill, peds cancers easier to kill), location of timor
- administration routes: IV most common, oral, IM, SQ, intrathecal, regional admin can go directly into tumor
- chemo dose is calculated per body surface area
152
irritants
- damage intima of vein, but not tissue
153
vesicants
- severe local tissue breakdown and necrosis
| - assess IV site for redness, swelling, pain
154
side effects of chemo
- appear within 7-10 days
- chemo half life is one day, leaves body within 2 days
- chemo canno distinguish between normal and cancer cells
- fatigue, anorexia, taste alteration
- areas of active cell division: skin, hair, nails, GI
- expected side effects: rash, hair loss, dry skin, infected finger nails, canker sores, GERD, diarrhea
- bone marrow supression - low CBC count
155
nurse management of chemo side effects
- bone marrow supression: myelosuppression is most common side effect of chemotherapy, causes pancytopenia (all blood counts low), overwhelming fatigue
- fatigue: limit activities, don't work, frequent naps
- GI disturbances: proactive antiemetics for N/V
- integumentary and mucosal reactions: monitor airway and breathing
- cardio
- reproductive effects: DO NOT get pregnant, used birth control
156
pre-care for chemo
- CBC count
- allergies
- previous rxns
- electrolytes
- kidney and live fxn
- previous test results
- teach: side effects, bleeding precautions, when to call doctor --- 100.4 F!
157
complete blood count CBC
- important role of oncology nurse is to monitor blood counts
- nadir: lowest counts, usually between 7-10 days
- if counts are too low, chemo or rad may be held
158
neutropenia
- ANC (absolute neutrophil count): segs and bands
| - Neutropenia: 100.4F, patient may be very ill with low grade fever
159
complete blood count CBC
- important role of oncology nurse is to monitor blood counts
- nadir: lowest counts, usually between 7-10 days
- if counts are too low, chemo or rad may be held
- KNOW: WBCs, hemoglobin, hematocrit, platelet
160
neutropenia
- ANC (absolute neutrophil count): segs and bands
- Neutropenia: 100.4F, patient may be very ill with low grade fever
- culture for antibiotics, massive fluids, ABGs, o2
161
neutropenia
- kills more people on chemo than anything else
- ANC (absolute neutrophil count): segs and bands
- Neutropenia: 100.4F, patient may be very ill with low grade fever
- culture for antibiotics, massive fluids, ABGs, o2
- teach: avoid crowds, avoid raw fruits and veggies, hand washing
- treat: neupogen, neulasta injections increase WBC count
162
neutropenic fever
- assess for shock
- vitals signs
- confusion
- temp may be low grade 100.4F
- IV fluids asap
- culture first, antibiotics, chest xray, monitor, treat other symptoms
163
thrombocytopenia
- low platelets cause prolonged bleeding
| - transfuse if
164
anemia
- RBCs live 120 days, takes weeks to see anemia appear
- RN to make sure dietary needs (iron, B vitamins) are met to produce RBCs
- monitor carefully, transfuse if Hgb
165
nursing implications for nausea and vom
- antiemetics
- aggressive management of n/v
- assess for dehydration, weight loss, electrolytes
- diet non-irritating, decrease fiber, increase calories and protein
166
nursing implications for diarrhea
- antidiarrheal, antimotility, antispasmodic meds
- assess for infections diarrhea first
- diarrhea: 6 or more stools a day
- may occur in radiation field
- low residue diet
- may need IV replacement fluid
167
nursing management for cancer anorexia
- monitor, avoid weight loss
- eat what you like
- add spices to increase taste
- increase protein and calories
168
mucositis
```
- destruction of epitheial cells
teach pateintts to assess oral cavity
- taste loss or dysphagia may develop
- salt rinse is best
- no commercial mouth washes or alcohol
- encourage good nutrition
- hydrate
- assess for infections
- witch hazel is ok to put on
-
```
169
chemo skin changes
- very dry skin
- rashes
- hair loss
- alopecia
170
chemo pulmonary effects
- treat like other airway or resp issues
| - tx: bronchodilators, expectorants, cough suppressants, bed rest, oxygen
171
chemo cardio effects
- more vulnerable if have preexisting coronary artery diease
- radiation-induced heart disease
- careful monitoring by RN
172
chemo reproductive effects
- teach: expected sexual effects
- use shielding
- encourage discusison of issues related to sexuality
- refer to counceling if needed
- sperm/egg banking
- prevent pregnancy during treatment
173
later effects of chemo and rad
- increased risk for leukemias and other secondary malignancies (8%)
- usually poor prognosis
- smoking cessation may help prevent
174
biologic and targeted therapies
- effective alone or with surgery, radiation, and chemotherapy
- biologic therapy: agents alter biologic response to tumor cells
- targeted therapy: targets and binds cell receptors that are important for tumor growth
- hormonal therapies
175
biologic and targeted therapies
- effective alone or with surgery, radiation, and chemotherapy
- biologic therapy: agents alter biologic response to tumor cells; work with immune system to help fight the tumor better
- targeted therapy: targets and binds cell receptors that are important for tumor growth
- hormonal therapies
176
biologic and targeted therapies
- effective alone or with surgery, radiation, and chemotherapy
- biologic therapy: agents alter biologic response to tumor cells; work with immune system to help fight the tumor better
- targeted therapy: targets and binds to specific cell receptors that are important for tumor growth
- hormonal therapies
177
interferons and interleukins: biologic therapy
- fluelike syndrome
- anorexia/weight loss
- fatigue
- n/v
- changes in cognitive function
- assess for depression
- dehydration common
- assess lungs for pulmonary edema
178
interferons and interleukins: biologic therapy
SIDE EFFECTS
- fluelike syndrome
- anorexia/weight loss
- fatigue
- n/v
- changes in cognitive function
- assess for depression
- dehydration common
- assess lungs for pulmonary edema
179
targeted therapy
- able to kill cells without damaging normal cells
- end in "ab" or "ib"
- targeted therapies include: tyrosine kinase inhibitors, monoclonal antibodies, vascular endothelial growth factor receptor inhibitors, proteasome inhibitors
*SIDE EFFECTS: infusion reactions (anaphylaxis, fever, chills, nausesa, vom); fatigue, cardiotoxicity, hepatotoxicity, diarrhea, skin reactions (acneiform, erythema), impaired healing
*OTHER side effects: HTN, colon bleeding, imaried wound healing, thomboembolism, hemorrhage, pulm edema, mild bone marrow depression
MONITOR THIS PATIENT VERY CLOSELY
180
biologic thearpy: hematopoietic growth factors
- colony-stimulating factors
- simulate production of cells in hemaologic system
- hasten recovery - bone marrow damage
- we have injections for low WBCs, RBCs and platelets
- exp: granulocyte-macrophage-colony stimulating factor GM-CSF; G-CSF; platelet growth factor
181
hematopoietic stem cell transplantation (HSCT)
- bone marrow transplant
- hematopoietic stem cell transplant
- allows high doses for treatment and potentila for cure
- tumore cells eradicated and bone marrow is rescured by infusing health cells
- high risk with prolonged hospital stay
- side effects: iinfections are common,
182
plasmapheresis
- equipment separates stem cells from blood
- takes about 4 hours
- drugs given to mobalize cells
- cells frozen and sotred until needed
183
complications of cancer
- malnutrition: fat and muscle depleation, monitor albumin levels (shows protein and general nutrition of pt), may need enteral nutrtion
- infection: primary cause of death in cancer pts, neutropenia
184
oncologic emergencies
- life threatening, occur as the result of disease or treatment
185
Superior Vena Cava Syndrome
- Superior Vena Cava Syndrome: obstruciton by tumor or thrombosis; signs include facial and perioribital edema, distnetion of veins, headache and seizurres
186
Spinal cord compression
- Spinal Cord Compression: tumor in epidural space of spinal cord; signs and symptoms include intense, localized back pain, motor and sensory loss and changes, change in bladder or bowel function; report immediately; usually radiation or surgery; corticosteroids
187
third space syndrome
- Third Space Syndrome: shifting of fluid from vascular space to intersistial space; can lead to hypotension, tachy, low urine output
188
syndrome of inappropriate ADH
- cancer cells are able to manudacture, store and release ADH
- leads to fluid retention, weight gain
- assess for hyponatremia: weakness and confusion
- treatment of fluid restriction or IV od 3% NaCl in severe cases
189
hypercalcemia
- parathyroid-like substance secreted from cancer cells
- signs include: apathy, depression, fatigue, weak muscles, EKG changes, polyuria, nocuura, anorexia, N/v
- acute hypercalcemia is treated by: hydration, diuretic administration, bisphosphonate
190
tumor lysis syndrome
- triggered by chemotherapy's rapid destruction of large numbers of tumor cells
- hypocalcemia
- can cause renal failure
- can be fatal
- use allopurinol and hydratin
191
cardiac tamponade
- fluid accumulation in pericardial sca, constriction of pericardium by tumor, or pericarditis
- manifestations: heavy feeling over the chest, shortness of breath, dysphagia, tachycardia
192
cardiac tamponade
- fluid accumulation in pericardial sca, constriction of pericardium by tumor, or pericarditis
- manifestations: heavy feeling over the chest, shortness of breath, dysphagia, tachycardia
- management aimed at decreasing fluid around the heart
- surgical establishment of cardiac window; indwelling pericardial catheter
193
septic shock
- IV fluids
- culture then antibiotics
- protocol for quick response
- disseminaited intravascular coagulation (sepsis is #1 cause in cancer)
194
ANC
Absolute neutrophil count (ANC) is a measure of the number of neutrophil granulocytes (also known as polymorphonuclear cells, PMN's, polys, granulocytes, segmented neutrophils or segs) present in the blood. Neutrophils are a type of white blood cell that fights against infection.
Med Surge 1
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