Med. Surg. Test 1 Reviewing unfamiliar material from chapters!
STRESS
3 Stress Hormones Cortisol, Epi, Nor-Epi
Glucocroticoid Cortisol (Released from Adrenal Cortex)
Adrenocorticoids Epi (Adrenaline), Nor-Epi (vasoconstriction)
(Both released from Adrenal Medulla)
Cough & Deep Breathe Prevents stasis of mucous, microbial set-up,
helps keep sacs open.
Stress Mediators (Hardiness, SOC, Resilience, Attitude)
Hardiness Clear view of personal goals, BE INTERNAL!
Internal YOU CONTROL YOUR ENVIRONMENT!
SOC (Sense of Coherence, OPTIMISM) Christians have a good sense of
coherence because they feel ordered/organized/planned.
Worldview has a lot to do with this.
Under SOC falls, 1-comprehensibility, 2-manageability,
and 3-meaningfulness
Resilience Being able to bounce back! BE RESILIENT!
Resilient Pt.’s heal faster!
Hassles vs. Uplifts (Attitude) DIFFERENT FROM SOC! CHECK LEWIS!
Balance between hassles and uplifts, and how stress is viewed.
Positive attitude means quicker recovery!
ALL PATIENTS ARE UNDER STRESS IN THE HOSPITAL!!!
When under stress SNS KICKS IN! increase HR, increase BP, increase RR, pupils
dilate, skeletal muscle tightens, GI tract decreases, decreased NKA (Natural Killer
Cells), decreased cytokines (inflammatory mediators), decreased lymphocytes,
decreased phagocytes, sustained elevations of cortisol results in increased blood
sugar!!
** Bacteria and Infection LOVE dark spots full of SUGAR (Cortisol!) Hyperglycemia
also causes poor wound healing! This is why glucose levels are checked on non-
diabetic patient’s too because higher sugar levels indicate infection caused by stress!
Patient’s under stress, are experiencing IMMUNODEPRESSION!
Note: NKA’s are responsible for attacking foreign organisms. They are first
responders. If these are DECREASED, infection risk is INCREASED
ASSISTING PATIENTS TO HANDLE STRESS!! READ IN TEXTBOOK!
-Imagery Patient’s can visualize their cancer cells being destroyed during
treatment by envisioning them being eaten by a shark.
-Relaxation
-Meditation
-Therapeutic Touch
**KNOW THE DIFFERENCE BETWEEN BIOFEEDBACK AND IMAGERY, Very
similar yet DIFFERENT! (CHECK IN LEWIS!)
4x4 BREATHING!! KNOW THIS INSIDE AND OUT AND BACKWARDS AND
FORWARDS!!! EASY!! SEE Textbook PAGE 93!
*Mrs. Clark says 4x4 breathing is what she wants to see most during clinicals and
that this is the most important!!
Acute Stress or Eustress is GOOD! We need stress to keep us motivated!
Chronic Stress or Distress is BAD! It is prolonged and unhealthy and leads to
exhaustion!
Also, REMINDER: Catecholamines & Adrenocorticoids are the same thing!
ADAPT & COPE AND KNOW HOW TO HANDLE YOUR STRESS
HEMATOLOGY
**** SEE HEMATOLOGY LAB VALUES CHART!!!! THIS IS SO SO IMPORTANT!***
Definition includes study of blood and blood forming tissues, including blood
cells, bone marrow, the spleen and the lymph system.
Soft center of bones are the home of stem cells.
Erythopoesies (Formation of RBC’s) Happens in bone marrow
Erythrocytes are RBC’s, Leukocytes are WBC’s, & Thrombocytes are platelets!
Terms to know:
PANCYTOPENIA Low blood cells (all blood cells!)
HEMOLYSIS Destruction of damaged or abnormal RBC’s.
Sequester’s Stores, attracts
COMPLETE BLOOD COUNT (CBC) (KNOW THESE NORMAL VALUES)
Erythroctyes RBC’s, RBC’s are higher in men b/c men are bigger than women
Hemaglobin combination of heme (iron) and glob (protein)! Hemaglobin binds
with O2 and CO2 and acts as the O2-carrying capacity of RBC’s.
RBC’s are low in cases of anemia and conditions resulting in hemodilution.
Hematocrit Always measured as a percentage, it is the % of RBC’s in relationship
to total blood VOLUME. Hematocrit is your BEST representation of blood volume
loss.
MCV (Mean Corpuscular Volume) measurement of the average volume or size
of a single RBC. MCV is used to help classify anemia’s.
Increases – alcoholism, pernicious anemia (B12 deficiency), folic acid
deficiency
Decreases – iron deficiency anemia, thalassemia
MCH (Mean Corpuscular Hemaglobin) measurement of the average amount
(weight) of hemoglobin within an RBC. Iron deficiency would result in LOW MCH!
Increases – Macrocytic anemia
Decreases – microcytic anemia
MCHC (Mean Corpuscular Hemoglobin Concentration) measurement of the
average concentration or percentage of hemoglobin within a single RBC
Increases – intravascular hemolysis
Decreases – Iron deficiency anemia, thalassemia
LEUKOCYTES OR WBC’s
Granulocytes
Nautrophil – Phagocytosis, early phase of inflammation, PRIMARY WORK
FORCE, #1 FIGHTING CELL!, tells you if Pt. needs to be put on precautions!
Eosinophil – Phagocytosis, parasitic infections
Basophil – Inflammatory response, allergic response
Agranulocytes
Lymphocyte – Cellular, humoral immune response
Monocyte – Phagocytosis, cellular immune response
**When you see a lot of immature cells it is called a “SHIFT TO THE LEFT”, and
it indicates an infection, cells with a lot of mature cells are called “SHIFT TO
THE RIGHT” and indicates an immunological disorder (aplastic anemia).
Leukopenia less than 4,000 leukocytes
Neutropenia less than 1,000 neutrophils
If above values are present, put Pt. on Neutropenic Precautions!
1)Frequent hand hygiene
2) private room
3) limit / screen visitors
4) remove fresh flowers and plants from room
5) no fresh fruits, vegetables and peppers from diet
6) Freq Temperatures / monitor for S/S infectsions
**READ ABOUT NEUTROPENIC PRECAUTIONS IN LEWIS!**
Platelets
<50,000 = bleeding out
>1 million = clotting
Clotting is activated by interstitial collagen, aggregate and form a plug, vascular
response + plug + clotting factors = fibrin clot … stop the leak!
Spleen Filters out old RBC’s, take the hemoglobin during hemolysis and
catabolizes the Iron, contains lots of lymphocytes and monocytes, stores 30% of
platelets, If Pt.’s spleen is removed, platelet rate increases and the normalizes
because the spleen sequesters platelets. If Pt. has their spleen removed, you will see
a SHIFT TO THE LEFT. Patient should be places on neutropenic precautions. If no
spleen, Liver takes place and acts as spleen.
Aging
Stem cells drop after age 30 and again after age 65.
Hemoglobin drops after middle age and WBC increase less with infection.
*The elderly are more likely to bleed more, need O2 quicker, and also have a higher
risk of developing infection.
ESR Erythrocyte Sedimentation Rate
-The rate that RBC’s settle in saline over a specific period of time.
-How fast does it take RBC’s to get to the bottom? If RBC is lighter, it will take
longer to get to the bottom.
-It is a NONSPECIFIC measure of inflammatory conditions.
-SED rate NON SPECIFIC lab MCV’s that tell us if inflammation is occurring,
it may indicate disease. Normal value is 0!
-SED rates for women are normally higher.
LAB STUDIES TO MEASURE IRON METABOLISM:
** Without binding to protein, iron cannot utilize!
Serum IRON Iron + Proteins (50-175 mcg/dl)
TIBC (Total Iron binding Capacity) Proteins available to bind Iron (250-425
mcg/dl)
Ferritin Major Iron storage protein (10-250 mcg/dl)
Transferrin Largest protein that binds with Iron (190-380 mcg/dl)
**Ferritin & Transferrin are BOTH MOBILIZERS!**
LAB STUDIES TO EVALUTE CLOTTING:
Prothrombin Time (PT) assessment of clotting times for factors I, II, V, VII, & X.
(11-16 sec).
Activated Partial Thromboplastin Time (PTT) assessment of clotting times for
factors I, II, V, VIII, IX, X, XI, XII (25-35 sec.)
INR (International Normalized Ratio standardized method of reporting PT (2-3).
-do not fluctuate with different machines in different hospitals.
-Coumadin & Heparin are common blood thinners.
-PT measures effectiveness of Coumadin , Pt.’s on Coumadin have a higher PT
(about 20).
-Heparin IV, if patient using Heparin, monitor PTT!! Heparin is rapid-acting!
Patient’s on Heparin may have levels between 40 and 60 sec.
-Coumadin may take several days to become effective.
HEMATOLOGICAL DISORDERS – HEMOPHILIA
-Hereditary bleeding disorder due to deficient clotting factors.
-Type A: Classic hemophilia, factor VIII, 80%, looks like a Christmas tree under the
microscope???
-Type B: “Christmas disease”, factor IX
-Von Willebrand Disease – involved a congenitally acquired deficiency of the Von
Willebrand coagulation protein.
-In the past, most Hemophilia’s died from HIV.
-Medical Management includes replace clotting factor.
-Cryoprecipitate is retrieved from plasma containing factor VIII and
fibrinogen.
-Factor IX is treated with factor IX concentrate
-Assess for blood born infections, thrombosis.
-Management of joint bleeds includes resting joint, pack in ice, analgesics without
aspirin, mobilize as soon as bleeding is under control without weight bearing (ROM)
-Assess for intracranial bleeds and airway obstruction from hemorrhage into the
neck and pharynx.
**Know that neurological issues can occur.
HEMATOLOGICAL DISORDERS - ANEMIA
-Deficiency in the number of erythrocytes, the quantity of HGB, and/or the volume
of packed RBC’s (HCT).
-Compensates by shifting oxygen from tissues to blood, shunting blood from tissues
that don’t need as much, increasing cardiac output, heart rate, and stroke volume,
and increasing the number of RBC’s produced.
DIFFERENT TYPES OF ANEMIA’S
Iron Deficiency
-Most common
-Caused by inadequate diet, poor absorption, GI bleed, menstruation
-S&S include pallor, glossitis, burning of the tongue, cheilitis (mouth numbness),
headache, paresthesia (tingling or numbing sensation).
-Dx: Full panel and Dx of cause
-Tx: Treat underlying cause and Iron replacement
**TICB is inversally proportional
Thalassemia
-Inadequate production of HGB.
-Etiology: Genetics, Mediterranean, and Equatorial regions of Asian, Middle Eastern
and African cultures.
-Can be born with or triggered later in life.
-Minor 1 recessive gene causing HGB not to be produced, probably need blood
transfusions monthly.
-Major 2 genes have been altered, rapid decrease in ability to make hemoglobin
and is life-threatening! Tranfusions are needed once or twice a week.
-S&S: pale, thickening of cranium and maxillary cavity, hyperplasia of the bone
marrow, growth retardation and death.
-Tx: Palliative Transfusions and IV Desferal or Terriprox
Cobalamin (B12) Deficiency (Pernicious Anemia)
-Pernicious definition means lacking IF (Intrinsic Factor).
-IF mucousa of gut that allows us to take in Vitamin B12. If Pt. does not have IF,
Pt. can take in all the B12 they want but will STILL BE Vit. B12 DEFICIENT!
-Etiology: Insufficient amounts of IF. Possible causes include Pernicious Anemia,
chronic alcoholism, GI surgery, Crohns disease, ileitis, diverticuli
-S&S: similar to iron deficiency but see neurological symptoms that include
parasthesia (tingling,numbing), ataxia (lack of voluntary muscle coordination),
weakness, confusion, or dementia
Tx: 1,000ug Vit. B12 IM q day x 2wk, then q week until HCT is normal, the monthly.
-If taking supplement B12, it is given nasally SOMETIMES but it is MOSTLY given IM
q day and eventually monthly.. FOR REST OF LIFE! (Cannot be given PO, because gut
does not have IF!!)
Folic Acid Deficiency
-Issue of not getting enough Folic Acid.
-commonly seen in ETOH patients.
-Common causes include poor diets, malabsorption disorders, oral contraception,
patient’s on anti-seizure drugs, alcohol abuse/anorexia, hemodyalisis Pt.’s
-Tx: Replacement therapy (usually a pill)
Anemia of… Chronic Disease
-Causes include inflammatory diseases, autoimmune, infectious disease, malignant
disease
-Tx: Treat underlying disease
Aplastic Anemia
-Life-threatening stem cell disorder resulting in Pencytopenia (low blood cells).
-Etiology: Congenital –OR- Acquired (through cancer Tx’s, Tx of infections,
pregnancy, idiopathic), Sequelae- increased risk of infection, fatigue and dyspnea,
cardiovascular and cerebral vascular response, thrombocytopenia
Sickle Cell Anemia
-These Pt.’s have GREAT amounts of pain.
-Family of genetic disorders caused by the abnormal properties conveyed to RBC by
mutated sickle cell hemoglobin.
-Affects African American’s, Mediterranean, Caribbean, South and Central America,
Arabian or East Indian ancestry.
-Pain is caused when the cell sickles and CLOGS capillary beds which prevents O2
transport to tissues. Pain can be wherever tissue is not getting adequate O2 supply.
-Cells sickle because the cells are not receiving sufficient amounts of O2.
-Be worried about patient stroking or having an MI (Myocardial Infarction)!!
-Incidence of Sickle Cell: 1 in 375 births, incurable and often fatal by middle age, if
both parents have the trait, 25% chance that each pregnancy will result in a child
with sickle cell.
-Presentation: Much like chronic anemia until a crisis, Vascular occlusion leading to
pain and tissue death. May last days to weeks. Often without a known cause and
may result in shock.
-Nursing Management: Lifestyle, avoid high altitudes, hydrate well, treat infections
promptly, pneumovax and H flu vaccines, Treat the areas of tissue necrosis – Ex:
chronic leg ulcers, large doses of continuous narcotics to control pain during crisis.
-Tx: Stem cell transplant, donors, walk Pt.
Note: Flank pain may indicate a renal system problem.
ONCOLOGY
*All tissues have stem cells
Stem cells activate and form new cells when
1) cells are damaged or die
2) when the body needs more (like WBC’s)
*When a person has cancer, something ALTERS the cell genome (genetic, external).
Theory of Development
Initiation Phase Inherited mutation, when host exposed to a carcinogen (could
be environmental, physical, or biological), sets cellular change into motion.
-Something triggers a cell mutation.
-Once trigger has been turned ON, it can not be turned off. INITATION IS
IRRVERSIBLE.
Carcinogen chemicals, etc. that cause cancer (smoking, radiation are ex.)
Promotion Phase Presence of a promoting agent creates the correct
environment for development. PROMOTION FACTORS ARE REVERSIBLE.
Latent Phase timeframe from mutation until actual clinical evidence of disease (1-
40 years) which includes promotion phase. Length of latent phase based on cellular
division rate and environmental factors.
-1/2 cm in order to able to detect on MRI.
-replicate at same rate as normal cells except cancer cells do not die.
-promotors are carcinogens and unhealthy lifestyles.
-WE CAN HELP CONTROL PROMOTION.
-Degree of cell mutation is important.
-CRITICAL MASS: when they are detectable. Palpable when 1 cm in diameter (1
billion cells). MRI at 0.5 cm.
-IMMUNOLOGICAL ESCAPE: Most are CAUGHT. Early cancer cells may have weak
cell-surface antigens, antigenic tolerance, overwhelming antigen exposure,
suppression f factors that stimulate T cells t react.
**Oncofecal antigens: markers to track tumor presence and development (ex: CEA
and colon cancer).
-Most cancer cells are killed by NK cells. (Natural Killer)
-As cancer cells develop, they coat themselves with oncofecal antigens to protect
themselves and be able to go through immune. Escape. They also try to cover
themselves in these antigens to look normal (like healthy cells).
-Prostate cancer PSA increases because of Oncofecal antigens.
Progression Phase (when we reach threshold)
-Metastasis – going from one side to another side, determines Prognosis & Tx
-invasiveness
-seeding of the tumor away from the primary tumor
-usually via blood or lymph
-can be spread by physical manipulation
-Lymphatic and Vascular system are common places for Metastasis.
-Proliferation of primary tumor and Mets.
-Each cell type has its own t ypical pattern of mets and sits of colonization.
-The most common sites are brain, bone, lung, liver, and adrenals.
**These are not always the site of origin. Could be a SECONDARY SITE!
DIFFERENTIATION LOOKS AT MATURITY OF CELL.
APPEARANCE LOOKS AT APPEARANCE OF CELL.
Histologic Grading of Tumors
Grade I: Well Differentiated, Slightly different from normal cells in appearance.
Grade II: Moderately differentiated, moderate dysplasia (not normal appearance).
Grade III: Poorly differentiated, severe dysplasia, very abnormal
Grade IV: Undifferentiated, Anaplasia, Immature, Primitive cells. Most difficult to
treat and poorest response rate.
Clinical Staging
Stage O: Cancer in situ (self contained entity)
Stage I: Tumor limited to tissue to origin, ex: localized to the point of origin.
Stage II: Limited local spread
Stage III: Extensive local and regional spread, may have lymphatic activity
happening but not metastasis.
Stage IV: Metastasis (Mets)
TNM Classification (TNM System)
*** WANT TO BE T0, N0, and M0!! (That is ideal!)
T= Primary tumor
T0- no evidence of primary tumor
Tis – carcinoma in situ (situ = hasn’t spread to surrounding tissues, just in
one spot).
T1-4 – ascending degree of increase of tumor size and involvement
N= Regional lymph involvement
N0= no involvement of nodes
N1-4 – ascending degree of node involvement
Nx – cannot access nodes clinically
M= Distant Metastasis
M0 – no evidence of distant mets
M1-4 – ascending degree of distant mets
Treaments (Pg. 255 Cation Chart!!!!)
**Most CA patient’s will not just receive one course of Tx
Goals of CA Tx is to:
-cure, control, or palliation by utilization of surgical Tx, chemotherapy, radiation,
biological and targeted therapy.
Care of surgical patient loss of self-image, body alteration, threat of recurrence.
Chemotherapy Use of chemicals as systemic therapy for cancer, goal is to reduce
number of malignant cancer cells in tumor sites, mainstay for most solid tumors and
hematologic cancers, Factors that determine response include mitotic rate of tissue
of origin, size of tumor, age of tumor, location of tumor, presence of resistant tumor
cells! Toxins = (THERE WILL BE COLLATERAL DAMAGE)!
Routes include Oral, IM, IV (most common) (If Pt. is on IV and there is swelling
around IV, take out IMMEDIATELY) (CHANGE IV that is administering Chemo. Every
3 days to prevent break down of vessel), Intracavitary, Intrathecal, Intra-arterial,
perfusion, continuous infusion, subcutaneous, topical, central vascular access device
Care of Chemotherapy patient Antiemetics for nausea and vomiting, Alopecia
(hair loss), watch counts for immunosuppression, Monitor IV sites for
Extravasations., encourage activities that require less energy, nutritional concerns.
-Give anti-nausea meds before administering chemo. Meds!
-After chemo. Hair can grow back even thicker.
-Prepare patient’s for hair lose, suggest a wig before hair starts to fall out.
-Most chemo. Pt.’s are on neutropenic precautions
-Central line for chemo. administration is better than peripheral line if available.
**Administer prescribed anti-emetics 1 hour before treatment administration!
Radiation Therapy Local Tx modality, Emission of energy through space or
material medium, normal tissues are usually able to recover, cancer cells are more
likely to be permanently damaged, 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.
-Radiation is a carcinogen! Which is why every other person in room (health care
providers) needs to protect themselves!
-Radiation has a greater potential to help than cause more harm in CA Pt.’s because
the CA has already been initiated. In normal Pt.’s radiation can actually trigger the
initation of CA!!!!
Care of Radiation Pt.’s Nausea & Vomiting, Care of skin PRIOR to Tx, Care of skin
reactions, observe for normal tissue damage, maintain clarity of markings, be gentle
with skin, no perfumes, do not use high concentrations of sodium (No ocean, lake
pond, or pool swimming because of high risk of infection from lake critters (leeches,
chlorine, etc).
Care of Pt.’s receiving Chemo. & Radiation
Common Side affects include bone marrow suppression (remember stem cells are
made in bone marrow – Neutropenic Precautions), fatigue, GI disturbances,
integumentary and mucosal reactions, pulmonary effects, reproductive effects.
Care of Pt. and Pt. Family emotional care, grief, financial arrangements,
counseling for survivors, managing survival guilt and anger, reassigning of life roles.
Leukemia Types (4), (TABLE 31-25, REVIEW!)
AML- Acute Myelogenous Leukemia
-Most Pt.’s are older
-Incidence ages 60-70 (25% of Leukemia) 85% of all acute Leukemia’s in adults.
-Clinical Manifestations – mouth sores, anemia, bleeding, HA, lymphadenopathy,
fatigue, weakness. sudden and dramatic onset with infection and bleeding, bone
pain
-Dx: low RBC, Hgb, Hct, platelets
Low to high WBC with lots of immature cells, myoblasts, that are the
precursors to granulocytes.
ALL- Acute Lymphocytic Leukemia
-ALL is more commonly seen in children, ALL is very treatable
-Incidence: before age 14 with greatest number between age 2 and 9 (11%)
-Can occur in adults as well but much rarer 15% of adult Leukemia’s.
-Rapid, young, lymphocytes invading bone marrow.
-These immature lymphocytes can go through arachnoic membrane and cause
Leukemia meningitis.
-Presentation: FEVER, pallor, bruising, bleeding, weight loss, abdominal pain, CNS,
hepatospleenomegly, etc., Leukemic meningitis occurs following arachnoid
infiltrations
-Low RBC, Hgb, Hct, platelets. Low, normal, high WBC, transverse lines at ends of
metaphysis of long bones, immature lymph cells (lymphoblast)
CML- Chronic Myelogenous Leukemia
-Chronic is more insidious (gradual & harmful).
-Incidence: between ages 25 and 60. Peak around 45 years old (15%)
-Many CML Pt.’s have been facing disease and are used to hospital visits every-so-
often (long-dwelling), and then all of a sudden, they become acute and can die.
-S&S: asymptomatic early on. Develop typical fatigue and then see sternal pain,
joint tenderness, bone pain, massive splenomegaly, increase in sweating.
-Dx: Low RBC, Hb, Hct. High platelet levels early then a drop. Normal lymph count.
-Can change to AML during a blast crisis.
CLL- Chronic Lymphocytic Leukemia
-Also long-dwelling
-Incidence: ages 50-70, more common in men and rarely seen before 30 y.o.
-S&S: Chronic fatigue, anorexia, splenomegaly, increased incidence of infection, but
clinically asymptomatic. May develop pain from in lymph nodes that are swollen.
-Dx: Mild anemia and thrombocytopenia with disease progression. Proliferation of
lymphoctyes in the blood (more than normal) and more lymphoctyes in the bone
marrow.
Note: Proliferation= immature granulocytes myelocytes
Chronic vs. Acute
-Acute – characterized by proliferation of immature (“debilitates now”) cells. They
become defective past the myeloblast or the lymphoblast stage, so that the blood
does not have mature cells.
-Chronic – (“debilitates with time”) Involves more mature forms of WBC’s.
and disease onset is more gradual.
Hairy Cell Leukemia
-Easier to Dx and Treat
-Incidence: 2% of all adult Leukemia’s.
-Chronic disease of lympho-proliferation involving B lymph that infiltrate spleen and
bone marrow.
-Typically males over 40.
-S&S: splenomegaly, pancytopenia, infection due to impaired host defense
-Insidious (gradual & harmful)
-May go undetected for years
Unclassified Leukemia
-Mixed presentation
-Poor response
-More rapid onset
-Mixture of mature and immature cells!
-Most concerning!!!!
-No absolute plan!
-REVIEW TABLE 31-26!
Treatments of Leukemia
-AML Tx: Stem cell and bone marrow transplant
-ALL Tx: Cranial radiation and intrathecal (space between layers in spinal cord)
Methotrexate, stem cell transplant
-CML Tx: Total body radiation, bone marrow and stem cell transplant, alpha
interferon, leukapheresis
-CLL Tx: Radiation (total body, lymph node, spleen), splenectomy, alpha interferon,
colony stimulating factors to stimulate cell formation, stem cell transplant
***Stem cell replacement/transplant is the most definitive treatment if Chemo.
does not work! Do not need perfect match, must use donors stem cells that do not
have Leukemic cells, kill all stem cells in Pt. (you literally take them to the point of
death), then give new (donors) stem cells to go in bone marrow to start forming
normal, healthy cells.
Bone Marrow Biopsy
-Used to Dx leukemias, some lymphomas, and to stage solid tumors such as breast
cancer. Give definite Dx.
-Sedate, cleanse site, local anesthesia (surface and deeper)
-Bore into the periosteum, resulting pressure pain, then aspirate about ½ mL of fluid
marrow resulting in a suction pain.
-Apply pressure, bedrest for several hours post procedure.
***READ THIS SECTION OF LEWIS!
Lymph Node Biopsy
-Open or closed method (needle aspirate)
-May be done under enhanced guidance
-pressure applied to avoid excessive bleeding
-observe for infection
-Needle biopsy only indicates that the site aspired does or does not have cancer cells
-The only thing this lymph node biopsy tells you is what is going on with lymph node
individually (one being looked at) NOT all lymph nodes together.
Lymphoma - Hodgkins
-Hodgkins (12% of all lymphomas) is a malignant condition characterized by the
proliferation of giant, multinucleated cells called Reed-Sternberg cells in the lymph
nodes.
-Normally effected at age 15-35 or after 50… twice as many men as women…
-Three associating factors have been identified: Epstein Barr Virus, genetic
predisposition and exposure to chemical toxins.
-Good prognosis
-STAYS WITHIN LYMPHATIC SYSTEM
Lymphoma – Non-Hodgkins (NHL)
-Heterogeneous group of malignant neoplasms Bad
-Most common hematologic cancer and the 5th leading cause of cancer death.
-No Reed Sternberg cells
-Tend to include extra-nodal sites. MRI and lymph node biopsy can help determine
patterns.
-Prognosis for NHL generally not as good as Hodgkins.
-CAPABLE OF LEAVING LYMPH. SYSTEM AND METASTISIZING!
Multiple Myeloma
-Plasma cell cancer that invades the marrow and destroys bone. Twice as common
in men than women. Appears after age 40 with peak around 65.
-bone gets very fragile.
-calcium cannot be reabsorbed into bone.
-give lots of fluids to these Pt.’s to help absorb calcium.
-the heart does not like calcium
-Biophosphate is recommended because it helps reabsorption of calcium in blood.
-Bones need to be stressed! Make Pt. as mobile as possible!!! Use ROM!
-S&S: Generally only with advanced disease and presents as pain in ribs, spine, and
pelvis. Lesions and bone destruction common. Hypercalcemia can cause renal, GI,
neurological changes (anorexia, confusion). May see granulocytopenia,
thrombocytopenia, and anemia.
-Dx: with blood, urine, x-rays, and bone marrow biopsy.
Nursing Management of Multiple Myeloma
-I&O to achieve urinary output of 1.5-2 liters per day (may require intake of 3-4
liters per day)
-fracture precautions
-Pain management: May use opiates and NSAID’s. Aredia used for skeletal pain and
instability.
-Adjust to impact of disease upon their life and also manage the chemo and/or
radiation therapy needed to treat the disease.
*Seven Warning Signs of CA (Pg. 255, Chart at top!) (Caution Acronym!)
STUDY FOR TEST:
-Questions in back of textbook
-ATI questions
-Evolve questions
-Read Textbook (Especially Pages & Tables SUGGESTED IN CLASS!)
Tutoring 9/2/14 - Hematology
-Post surgery from bone aspiration, have Pt. lay on affected side for 30-60 minutes.
-Posterior iliac crest is most common place for bone marrow aspiration.
-Apply pressure over site immediately after bone aspiration.
(RE-READ BONE ASPIRATION IN LEWIS!!!)
-MCV&MCH, MCV=THINK SIZE, MCH=THINK WEIGHT
-Low WBC = immunosuppression, high WBC = infection
-KEEP FRESH FLOWERS AND FRESH FRUIT OUT OF ROOM WHEN neutropenic
precautions, keep everything from outside OUT of the room.
-Spleenectomy (Know about this), place these patients in isolation because their
WBC’s are low.
-Coumadin – PT, Heparin – PTT (Know what level PT and PTT are normally and what
they are when Pt. on Coumadin and Heparin).
-Hemophilia Von Whilebran Disease (Read Lewis).
-Know which factors goes with what (ex: Type B – Christmas disease)
-Know treatment for clotting issues
-Do not put heat on a joint bleed! ICE AND ROM ARE important for joint bleed.
-Iron deficiency Pt.’s will have dark green stool and they will be constipated.
-Replace Iron!
-Glossitis Inflammation of the tongue, IRON DEFICIENCY
-Cancer treatment can suppress stem cells and cause anemia
-Sickle Cell These patients need O2 and narcotics for rest of their lives. They
switch pain meds often to avoid tolerance.
-Discharge instructions with sickle cell Patients
-SEE ATI BOOK FOR SICKLE CELL
-DIC (Disseminated Intervascular Coagulation) Clotting and bleeding at the same
time. Platelets form and get caught in one area but then bleed in other places. These
patients have massive bruises!
-Decreased level of consciousness is ALWAYS PRIORITY! b/c the brain is priority
-SCENERIO: You have a Pt. who comes in to ED who was involved in MVA and Pt.’s
BP is 180/95, rapid HR, rapid RR, what is intervention for BP?
Always recheck blood pressure!!!
-Pt. getting mammogram done, exercise 4x4 breathing.
-Know what biofeedback is & music therapy & imagery.
-If doing music therapy ALWAYS ask patient what genre they prefer. Always do what
patient wants!
-Guided imagery takes time to learn. In ER with Pt. panicking, use 4x4 breathing
technique b/c Pt. cannot learn guided imagery at that moment.
? Thalessemia (too much Iron) – IV Deserol binds to Iron and gets rid of it.
Tutoring – 9/2/14 Oncology
-Know about classifying tumors!
-Brain, Blood, Lung, Liver, Adrenals (BBLLA)
-Institue
-Immunological escape
-Oncofecal Antigen If present, tumor is present. It is a marker on a tumor cell.
-Make sure Pt. is coping effectively, if Pt. says, “I know I’m gonna die”, ask open
ended questions to help pt. express his or her feelings.
-Always give antiemetic meds an hour before giving Chemo.
-Know the difference between radiation therapy and chemotherapy.
-Have Pt.’s on Chemo use only Dove soap or saline because skin is very sensitive.
-Never wash radiation markings off Pt.
-Make sure Pt. is eating nutrient-dense foods, and make sure Pt. is participating in
small activities, no bed rest. Pt. should be eating high-protein foods.
-Know difference between Hodgkins and Non-Hodgkins lymphoma.
-Non-Hodgkins is most common type of lymphoma but Hodgkins is the better Dx.
-Bone marrow biopsy Not usually in sternum.
-Bone marrow aspiration – normally take out 1/2mL.
***Read about bone marrow transplants and aspirations in Lewis***
-Multiple myelonoma calcium is really high, have Pt. drink lots of fluid to help
absorb calcium.
-Fracture precautions do not do anything to put your Pt. at risk for breaking a
bone (ex: bed alarm always on, don’t let Pt. go to bathroom by themselves, etc.)
-I&O’s O’s – 1.5.-2cc’s (to achieve this, take in 3-4 cc).
-When assessing Pt. with septicemia (blood infection), white blood cells are
elevated.
Tutoring – 9/9/14 TEST REVIEW
*ALL – ALL the little children, greatest between ages 2 and 9, before age 14
*CML – M for Mid life
*AML – AM for GRAMMA
* KNOW TUMOR GRADING SYSTEM! (Histological)
*know what to do when infiltration happens IMMEDIATELY STOP
*Know difference between Chemo. and radiation
REVIEW SLIDES HERE
*Know in situ
*Know one hour before meds give anti-emetics
*4 grades for tumors (will use EXACT words)
differentiated maturity
Where are the five sites that tumors most likely spread to?
-BBLLA bone brain liver lung adrenals
*What does critical mass mean? When it is finely detectable!
*Immunological Escape cancer cells are able to go undetected in the body and
change themselves so that they are not targeted by immune system, cancer cell
escapes our immune system
* each type of cancer has its own oncofetal antigen. Helpful in Dx
*CLINICAL STAGING
extensive local and regional spread stage 3
limited local spread stage 2
actual mets to another area in the body stage 4
*person has liver cancer and cancer has spread to very edge of liver stage 2
because it is still local involvement. If it spreads from liver to brain then stage 4.
*bone marrow aspiration posterior iliac crest , after biopsy apply pressure. And
then have patient lie on the affected side., gives a DEFINITE Dx.
*Non-Hodgkins is most common type of Lymphoma, Spreads
*Hodgkins has Reed Sternberg cells and responds well with Chemo.
*Multiple Myelonoma (MM) HYDRATE THEM! They have too much calcium, walk
patients, and fracture precautions! Use active and passive ROM exercises. These Pt.’s
are at risk for developing contractors (immobility, tenseness of a muscle (s)).
MM targets bone and plasma cells.
*TNM KNOW THIS
Hematology Quiz
*What does pancytopenia mean? LOW BLOOD CELLS (ALL).
- they will give lab values of all LOW values
-Apply pressure for 5-10 min after bone marrow aspiration.
-WBC range – 5,000-10,000
-MCV think SIZE, MCH think WEIGHT, MCHC think CONCENTRATION
-Platelet level = 150,000-400,000
Increased platelet level with spleenectomy bc it is not sequestering!!
Speelectomy will result in SHIFT TO THE LEFT.
-Neutropenia – Neutrophil under 1,000 and a leukocyte count below 4,000
-do not allow fresh flowers and fruits in the room, do not give Pt. salad.
-Pt. can have STEAMED broccoli
-Pt. should be on high protein and high carb diet. (high-dense nutrition)
-give chicken, peanut butter sandwiches
-prevent thrombus formation more platelets means more clotting,
especially when Pt. is laying in bed all day which puts at even higher risk for
clotting.
-do frequent neurovascular checks (cap. Refill test, pallor, pulsiveness?, etc.)
-Petecheia on skin means that Pt. is bleeding somewhere
-KNOW PT, PTT and INR Levels.
-PT 11-16 sec., Coumadin
-PTT 25-35 sec., Heparin
-INR International (2-3)
-A-type Know what factor is missing, factor 8 (VIII)
-B-type Christmas, know what factor is missing, factor 9 (IX)
-Von Willebran know what factor is missing, cannot form a platelet plug between
the platelet and
-Joint bleeds PUT ICE, NOT HEAT !!, ROM exercises after bleeding stops, if don’t do
ROM exercises in time, hemothrosis happens (accumulation of blood in joint).
-Desferol Thalessemia
-Pt. in ICU , alcoholic for years most likely Folic acid deficiency
-Vitamin B12 supplement Pernicious anemia
-Daily shot for two weeks, then one shot per week (for a month), then once a
month FOR REST OF LIFE.
-Inadequate production of Hemaglobin Thalessemia
-Only Tx is blood transfusions
-Folic acid deficiency
-Iron deficiency when treating gives dark green stool
-Glossitis inflammation of tongue
-Cheilitis mouth numbness
-25 year old women, tired, they find she has folic acid anemia they would want to
test for PREGNANCY
-Sickle cell central America populations
-avoid high altitudes
-avoid caffeine
-low maintance exercise, nothing that is going to increase HR and RR
-give O2 and narcotics
-Aplastic Anemia READ IN LEWIS b/c there is not a lot of information on slide!!
-causes pancytopenia
-blood products and stem cell replacement for Tx
-Congenital from birth
-DIC decreased clotting factor and decreased platelets, risk for hemorrhage
-clotting and bleeding at same time!
-Heparin-Induced Thrombocytopenia(HIT) only would know if you read
textbook!, Platelets bind with heparin and form clots so not enough platelets
available and Pt. will bleed out.
Stress
-cortisol is the stress hormone
-hardiness / resilience
-hardiness – ability to endure through trials and learn new ways to cope
-Internal vs. External
-resilience – able to bounce back from a very low point (bad Dx, etc.)
-READ CHART ABOUT COPING
-imagining favorite beach in world using guided imagery
-Pt. says he is so fat and all upset encourage him to exercise! Don’t just say “its
okay” and move on.
-BIOFEEDBACK hook up Pt. up to heart monitor, and show them what is
happening, let them watch there HR decrease as they relax! This is more for chronic
Pt.’s because you have to teach them. Teach!
-Pt. comes to ED for MVA, BP of 218/120, first thing you want to do is RECHECK BP!
RELAX AN HOUR BEFORE TEST, DON’T STUDY!
cancer grades / Clinical & Histological
aplastic anemia
TNM
Iron Deficiency when treating gives dark green stools
Folic acid anemia in 25 y.o. test for pregnancy
