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MedSurg II - SIADH, Leukemia, Etc

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olanjones's version from 2017-04-19 20:52

Anemia

Question Answer
What is absolute anemia?decrease in total number of RBCs or Hgb
What is relative anemia?a reduction in red cell mass as a result of increased plasma volume (e.g. during pregnancy)
What is the most common type of anemia?Iron deficient anemia. Can be due to lack of consumption, absorption of iron or due to slow bleeds
What risk factors are associated with Fe anemia?low income, pregnancy, adolescence, elderly, infancy, heavy menstrual flow/poor intake
What are the manifestations of Fe anemia?glossitis, stomatitis, koilonychia (spoon-shaped nails), pale conjunctiva
What is post-hemorrhagic anemia?anemia from sudden blood loss, can be from trauma or surgery
What are the manifestations of post-hemorrhagic anemia?10% loss: fatigue, 20% tachy/slight postural hypotension, 40% decreased BP, rapid breathing, cold/clammy skin, 50% shock/death
What is aplastic anemia?decrease in all blood cell production due to bone marrow depression, will have symptoms of thrombocytopenia, anemia, and leukopenia
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Hematological Cancer

Question Answer
Who has ↑incidenceradiologists, people who have lived near nuclear bomb test-sites/reactor accidents, people previously tx w/radiation or chemotherapy
Acuteclonal proliferation of immature hematopoietic cells (a malignant transformation of a single type of immature hematopoietic cell →cellular replication/expansion of malignant clone
Chronicinvolve more mature forms of the WBC; the disease onset is more gradual
2 types of acuteAcute Myeloid (onset usually around age 64 - about 80% of acute leukemias in adults)
Acute Lymphocytic (common in children)
2 types of chronicChronic myelogenous (slow, insidious onset, more mature cells but do not function normally), Chronic lymphocytic (slow progression, malignant cells invade lymph but not usually other organs)
General manis of hematologic malignanciesfatigue, bruising, frequent infection, fever/night sweats, weight loss, bone pain, liver spleen lymph enlargement, elevated uric acid
Characteristics of Hodgkin lymphomapresence of Reed-Sternberg cells (in lymph nodes), usually movable/non-tender lymph node enlargement (cervical, axillary, inguinal) spreads in an orderly fashion. Curable in early stages
Characteristics of Non-Hodgkin lymphomacan originate outside the lymph nodes, spread can be unpredictable, majority of pts have widely disseminated disease at the time of diagnosis; primary clinical manifestation is painless lymph node enlargement, can also manifest in nonspecific ways (airway obstruction, hyperuricemia/renal failure from TLS, pericardial tamponade, GI complaints)
Hodgkin's lymphoma• Localized lymph node involvement • Spreads continguously (from node to node) • Mesenteric nodes & Waldeyer ring rarely involved • Extra-nodal presentation rare
Non-Hodgkin's lymphoma• Multiple lymph node involvement • Spreads non-continguously • Mesenteric nodes & Waldeyer ring often involved • Extra-nodal presentation common
Characteristics of Multiple myelomaB-cell cancer that forms masses in skeletal system. Slow/insidious onset; Causes pain, hypercalcemia, fractures, proteinuria, renal failure, recurrent pneumonia
Blast cells areNonfunctional, cannot fight infection, multiply continuously
Early signbone pain
Acute Myelogenuous Leukemia (AML)uncontrolled proliferation of myeloblasts (precursors of granulocytes); hyperplasia of bone marrow
-S/S: Fever, pallor, bleeding, anorexia, fatigue/weakness; bone/joint/abd pain; generalized lymphadenopathy, infections, weight loss, hepatosplenomegaly, headache, mouth sores; CNS involvement, ↑ICP secondary to meningeal infiltration
-Labs: ↓RBC, Hgb, Hct, platelets; low-nl WBC; ↑LDH; Transverse lines of rarefaction at ends of metaphysis of long bones on x-ray; hypercellular bone marrow w/lymphoblasts (also poss in CSF)
Acute Lymphoid Leukemia (ALL)immature small lymphocytes proliferate in the bone marrow; most are of B-cell origin (fever often present at diagnosis)
-S/S: Fatigue/weakness, headache, mouth sores, anemia, bleeding, fever, infection, sternal tenderness, gingival hyperplasia, mild hepatosplenomegaly (one third of patients)
-Labs: ↓RBC, Hgb, Hct, platelets; low-high WBC w/myeloblasts; ↑LDH; hypercellular bone marrow w/myeloblasts
Chronic Myelogenous Leukemia (CML)excessive development of mature neoplastic granulocytes in bone marrow; excess neoplastic granulocytes move into peripheral blood in ↑numbers & infiltrate liver/spleen; Chronic phase→blastic (accelerated) phase - needs more aggressive tx
-S/S: No symptoms early in disease. Fatigue and weakness, fever, sternal tenderness, wt loss, joint/bone pain, massive splenomegaly, ↑sweating
-Labs: ↓RBC, Hgb, Hct; ↑platelet early but ↓later; ↑ Neutrophils, nl #lymphocytes,nl-low # monocytes; ↓leukocyte alkaline phosphatase
Chronic Lymphocytic Leukemia (CLL)production & accumulation of functionally inactive but long-lived, small, mature-appearing lymphocytes (usu B cells); infiltrate bone marrow, spleen, liver; Lymph node enlargement throughout body
-S/S: Frequently no symptoms (often found on exam for unrelated condition), chronic fatigue, anorexia, splenomegaly/lymphadenopathy, hepatomegaly. May progress to fever, night sweats, weight loss, fatigue, frequent infections
-Labs: Mild anemia & thrombocytopenia w/ disease progression; Total WBC count >100,000/μL; ↑lymphocytes (peripheral & in bone marrow); Hypogammaglobulinemia; May have autoimmune hemolytic anemia, idiopathic thrombocytopenic purpura
Cancer CAUTION signs
(not just in heme CA)
Change in bladder/bowel habits; A sore that won't heal; Unusual bleeding/discharge from an oriface; Thickening/lump in breast or elsewhere; Indigestion/difficulty swallowing; Obvious change in wart/mole; Nagging hoarseness/cough
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SIADH

Question Answer
SIADHsyndrome of inappropriate ADH, high ADH in absence of normal stimuli for release
Causes of SIADH-Malignant tumors
-CNS disorders (head inj/stroke/infection/disease)
-Drugs that stimulate production/potentiate existing ADH (anesthesia agents/opioids/thiazide diuretics/SSRIs/TCA/Chemo)
-Misc (hypothyroid/lung infection/COPD/HIV/adrenal insuf)
SIADH s/stachycardia, bounding pulse, HTN, ↓H&H, ↓sodium, ↓UO, weight gain
SIADH key featuresfluid retention, ↓serum osmolality, dilutional hyponatremia, ↓urine volume, normal urinary sodium
Dilutional hyponatremiaSerum sodium <134 mEq/L, serum osmolality < 280 mOsm/kg (280 mmol/kg), and a urine specific gravity >1.025
SIADH complicationswater intoxications, hyponatremia (s/s: personality change, HA, lethargy, N&V, diarrhea, ↓ tendon reflex, seizure/coma)
SIADH NI-Monitor: I&O/VS/heart & lung sounds; Signs of hyponatremia, inc seizures, N&V, muscle cramping, ↓neurologic function
-HOB flat (no more than 10 degrees) to enhance venous return to heart
-Frequent turning, ROM exercise to maintain skin integrity/joint mobility
-Frequent oral care & distractions (↓discomfort of fluid restriction)
SIADH TxFluid restriction (800 - 1000 mL/day); Diuretics (only if serum sodium is at least 125 mEq/L)
SIADH teachinguse ice chips/sugarless gum to decrease thirst; weigh daily; supplement diet w/ sodium & potassium (w/ food to help prevent GI irritation)
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Nursing Process End of Life

Question Answer
Assessment: closed awarenessClient is not made aware of impending death; nurse may experience ethical problem
Assessment: mutual pretenseAll know prognosis is terminal but do not discuss; nursing focus - heavy burden on dying person/no one in whom to confide
Assessment: open awarenessAll know prognosis and feel comfortable discussing; nursing focus - client may be involved in finalizing affairs/funeral arrangements
Diagnosing: may focus on physical/psychosocial of client/familyFear, Hopelessness, Powerlessness, Risk for Caregiver Role Strain, Interrupted Family Process
Planning: maintaining physiological/psychological comfortMay include arranging for home-care/hospice, Advance directives
Planning: achieving dignified/peaceful deathWork to help client maintain personal control and accept declining health status (nurse supports the client's will/hope)
Implementing (actions)Interventions should work to minimize fear/loneliness/depression, maintain client's dignity/self-worth, help client accept losses, provide physical comfort
Evaluating (actions)Nurse should listen to client's report of feelings r/t control of environment/pain/treatment plans, observe client's relationship with sig others, observe client's thoughts/feelings r/t hopelessness
5 Wishes: Provides legal, physical & emotional directives1. Who will make decisions when I am unable 2. Tx I want/don't want 3. Comfort measures 4. How I want people to treat me 5. What I want my loved ones to know
Alaska Advance Directives: Provides legal & physical directives1. Durable power of attorney for health care decisions 2. Instructions for health care 3. Organ donation 4. Mental health tx 5. PCP to have primary responsibility for heath tx
MOST form: Medical Orders for Scope of TreatmentDesignation of treatment orders- Resuscitation, Interventions if client is breathing, Antibiotics, TPN; encompasses more aspects of tx than DNR
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Loss & Grief Pattern

Question Answer
Types of lossActual, Perceived, Situational/developmental, Anticipatory
How does age influence loss and grief responses?As one ages, they become more familiar with loss, usually increasing their understanding and acceptance of life, loss, and death. Children differ not only in their understanding of loss but also in the way they may be affected (e.g. loss of a parent)
How does bereavement differ from mourning?bereavement is the subjective experience of the survivor, mourning is the behavioral process through which grief is eventually resolved/altered
How do culture and religion impact the grief response?culture may determine how death is viewed and how mourners behave, rituals (religious/spiritual) may help legitimize emotional/physical ventilation, provide a focus for managing confusion, disorganization, and loss of control which promoting social interaction
What is palliative care?care that focuses on control of symptoms and compassion - 1. Help to minimize loneliness, fear, depression 2. Maintain client’s sense of security and dignity 3. Help client accept losses 4. Provide physical comfort
What is hospice care?care that focuses on support and care of dying person and family - 1. Facilitate a peaceful and dignified death (physical & emotional) 2. Usually eligible when certified by PCP < 6 months to live 3. Supports those who remain after client's death
How may a nurse help facilitate the grieving process? Explore and respect cultural, religious, personal values, Teach what to expect, Encourage expression and sharing of grief with support system
When is the grieving process completed?grief work is never completely finished, healing occurs when the pain is less
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Definitions / Signs of Death

Question Answer
Heart-lung deathcessation of apical pulse
Indications of deathtotal lack of response to external stimuli, no muscular movement (esp breathing), no reflexes, flat EEG
Indication of death under artificial life supportabsence of brain waves for at least 24 hours
Cerebral/higher brain deathabsence of responsiveness to external stimuli, absence of cephalic reflexes, apnea (flat EEG for at least 30 mins, in absence of hypothermia/CNS depressant poisoning, supports dx of death)
Loss of muscle tonedifficulty speaking, swallowing, decreased GI activity (nausea, flatus, abd distention), urinary/fecal incontinence, diminished body movement
Slowing of circulationdiminished sensation, mottling/cyanosis of skin, cold extremities, slow/weak pulse, decreased BP
Changes in respirationrapid, shallow, irregular, abnormally slow breathing; noisy breathing d/t accumulation of mucus in throat (death rattle); mouth breathing/dry oral mucous membranes
Sensory impairmentblurred vision, impaired senses of taste/smell
Rigor mortisstiffening of body occurs 2-4 hours after death; starts in involuntary muscles, progresses from core to extremities
Algor mortisgradual decrease of body temp after death (falls about 1 C/hour), skin loses elasticity and is easily broken
Livor mortisred blood cells breakdown (release hgb) which discolors surrounding tissue
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