Acute illness Lecture 1

Nursing 2400 Course Overview

• Nursing 2400 is a course focused on acute illnesses.
• Students will use the nursing process as a framework for critical thinking and knowledge development.
• Key topics include care of hospitalized adults, priority nursing assessments, and interventions for common illnesses in medical and surgical clients.
• The course covers lived experiences of clients and families, cultural/ethical concerns, and evidence-informed decision-making.

Course Navigation

• DCO and Moodle are the main platforms for accessing course materials.
• The syllabus, learning activities, and concept-based case studies are key components.

Course Assessments

• Midterm Exam contributes to 30% of the final grade.
• Final Exam also contributes to 30% of the final grade.
• Kaplan Testing makes up of 15% of the final grade (in two parts).
• Case Study 1 is an individual in-class assignment worth 15% (week 4).
• Case Study 2 is a group assignment, also worth 15% (week 10).

Evidence-Informed Practice

• Clinical expertise integrates clinical state, setting, circumstances, research evidence, healthcare resources, and patient preferences/actions.

The Nursing Process

• The Nursing Process is a problem-solving approach for identifying and treating patient health problems.
• The Nursing Process provides an organizing framework for nurses' knowledge, judgments, and actions in patient care.
• The phases of the nursing process includes: Assessment, Priorities, Planning, Implementation, and Evaluation.
• Evaluation consists of four steps.

The Four Steps of Evaluation

• Determine if sufficient assessment data has been obtained to make a nursing diagnosis
• Determine if patient outcomes and interventions are realistic.
• Determine if patient outcomes have been met.
• Determine is the plan should be maintained, modified, revised or discontinued.

Characteristics and Numbers

• Cancer includes over 200 diseases.
• Cancer is when uncontrolled and unregulated growth of cells and defective differentiation occur, often caused by mutations.
• 1 in 4 Canadians may die from cancer.
• Progress of cancer can depend on modifiable risk factors.
• Malignancy, metastasis, neoplasm, and immunosuppression are also signs of cancer.
• There are key distinctions between benign and malignant neoplasms.

Cancer in Canada (2022 Projections)

• An estimated 233,900 Canadians will be diagnosed with cancer.
• 85,100 Canadians will die of cancer.
• The number of cancer deaths is 13% higher in males than in females.
• Lung cancer is expected to cause more deaths than breast, colorectal, and pancreatic cancers combined.
• Cancer death rates are projected to be lowest in western Canada.
• Pancreatic cancer is expected to be the 3rd leading cause of cancer death.
• The lung cancer incidence rate among males has declined significantly by approximately 52% since 1984.

Cancer Prevention

• Nurses play a key role in cancer prevention and early detection.
• Early detection and prompt treatment can lead to increased survival rates.
• Education and recommendations may aid in prevention and better outcomes.

Cancer - 7 Danger Signals of Cancer - CAUTION

• Change in bowel or bladder habits, A sore that does not heal, Unusual bleeding or discharge, Thickening or lump in breast or elsewhere.
• Indigestion (Persistent) or difficulty in swallowing, Obvious change in wart or mole, Nagging cough or hoarseness of voice.
• If these symptoms continue for three weeks and are not cured by ordinary treatment, one should consult a specialist.

Carcinogens and Cancer Prevention

• Carcinogens are agents that can cause cancer and may have chemical qualities with long latency period.
• Radiation, viruses (HIV, HPV, Hepatitis B), and genetics can also cause cancer.
• Promoters of cancer are dietary fat, obesity, cigarette smoking, and alcohol consumption.
• Early detection and screening include that of the breasts using mammograms and BSE, and also colon/rectum screening for FOBT.
• Early detection includes prostate screening for PSA tests and also digital rectal exams and uterine cervical screening via a PAP test and HPV vaccine.

Diagnosis of Cancer

• Diagnosis can cause fear and anxiety for patients, and a nurse's role includes providing support, managing manifestations based on the cancer and providing diagnostic testing.
• Diagnostic testing includes tumor marker checks to identify substances produced by cancer cells found in plasma, urine, and CSF.
• Substances include hormones, enzymes, genes, antigens, and antibodies.
• Other diagnostics include cytology and hematology studies, sigmoidoscopy/ colonoscopy, radiological studies, radioisotope scans, and assays for genetic markers.
• Bone marrow exams and biopsies which require histological examination for definitive results are also used.

Key Treatment Goals

• Treatment goals for cancer can change over time.
• Prevention is the prophylaxis method used to prevent the growth of cancer cells and or remove precancerous tissue.
• Curing the cancer is a goal of treatment, and if a cure is not likely, control may be beneficial.
• Controlling the growth of the tumor and stopping the cancer from growing and spreading reduces the chance of reoccurrence.
• Palliation is the means of treatment when a cure isn't possible and aims to shrink tumors, reduce symptoms, treat problems, and improve comfort.

Collaborative Care

• Collaborative care aims to cure, control and palliate symptoms.
• Factors such as cell type, tumor size/location, the extent of disease, status (physiology and psychology), desires, clinical trials are factors to determine the treatment modality offered.

Types of Cancer Treatments

• Treatment plans are based on each person's unique situation.
• Primary approach treatments are the main method of treatment.
• Neoadjuvant treatments occur before the primary method of treatment.
• Adjuvant treatments occur after the primary method of treatment.

Cancer Treatment - Surgery

• Surgery aims to eliminate or reduce cancer risks in at risk clients.
• In terms of curing of controlling cancer, only as much tissue as necessary will be removed.
• Good prognostic indicators include small size, clean tissue margins, absence of lymph node involvement and absence of abnormal tumour marker values.
• Surgical measures can include adjuvant therapy and preventive measures to avoid surgical seeding of cancer cells.

Cancer Treatment - Chemotherapy

• Chemotherapy treatment uses chemicals as a systemic therapy for cancer.
• The main goal is to reduce the number of malignant cancer cells in the tumor site.
• This is the mainstay therapy for most solid tumors and hematological cancers.
• The response to treatment can be influenced by mitotic rate, tumor size, and the presence of resistant tumor cells.
• Chemotherapy actions can be cell cycle dependent or non specific.

Chemotherapy - Action

• Chemotherapy action may be cell cycle phase-nonspecific (all phases + Go) and Cell cycle phase-specific.
• Preparation and handling requires protocol at Health Science North (HSN).
• The most common route is IV.

Chemotherapy - Considerations

• Chemotherapeutic agents cannot selectively distinguish between normal and cancer cells.
• Myelosuppression, infection, bleeding, anemia can occur in bone marrow stem cells, but can be managed by administering Leukopenia, infection.
• Anorexia, stomatitis, esophagitis, nausea and vomiting, diarrhea can occur in Gl tract lining epithelial cells.
• Alopecia can occur from the use of chemotherapeutics in hair follicle cells.
• Chemotherapeutics can cause reproductive dysfunction if used with ova cells or in the testes. Chemotherapy - Adverse Effects
• Adverse effects may include acute, delayed and chronic health conditions and can occur on the skin, or internally.

Chemotherapy - Treatment

• The treatment plan consists of drugs in combination of synergistic actions that help to minimize occurrences/severity of effects on the side.
• Dosage is determined by body surface area or weight.
• The goal of treatment is to reduce the number of malignant cancer cells while reducing the occurrence of side effects.
• Nadir is the lowest peripheral blood cell count.
• Nadir following most chemo occurs within 7 to 28 days; drugs with different nadirs are wanted.

Radiation Treatment

• Radiation is a local treatment modality which includes the emission/distribution of energy.
• This measure aims to help cure, control and often palliate symptoms which includes the generation of free radicals that break bonds in DNA, causing loss of cell proliferative capacity.
• Cellular damage may be lethal or sublethal, although normal tissue should be able to recover more than tumor (cancer) cells.
• Fractionated doses are cell cycle phase dependent.

Radiation - Considerations

• To be considered during treatment including dose a size, type, treatment setting, radiation field, external vs internal radiation and Brachytherapy and precautions.

Bone Marrow Transplant

• Bone Marrow Transplants have risky and low cure rates but may help to manage tumor cells.
• May eradicate tumor cells/bone marrow by infusing healthy leukemia fighting cells. Collection may require use of iliac crest or sternum, and it takes approximately 2-4 weeks for recipient cells start producing blood cells.

Nursing Management

• Need to differentiate between toxic effects of treatment and progression of the malignant process
• Monitor body's response to products of cellular destruction, determine what is tolerable, implement supportive therapies that may include supportive therapies and provide the adequate resources.

Management

• Pain and Fatigue are key management priorities.
• Managing Cachexia/Anorexia, bone marrow suppression, infection and skin reactions are also key to managing the client.
• Gl tract and pulmonary effects can be signs of secondary malignancies.

Pain

• Pain can exacerbate to moderate or severe pain and approximately 50% of active treatment patients experience it.
• Pain occurs for 80% of those with advanced cancer.
• Undertreatment has some serious effects on the patients quality of life, ability to function/family burdens.
• Treatment should aid in helping to prevent increased survival rates by managing the causes of treatment related death for cancer clients.

Management - Fatigue

• Identifying when client is feeling better may allow more activity, such as resting before activity or getting assistance with activity.
• Treatment for can be exacerbated by other SEs, so manage symptoms while maintaining nutritional and hydration status and promoting mild physical activity.

Management - Anorexia and Malnutrition

• May develop as a general reaction to treatment and is seen as a peak after approximately 4 weeks.
• Management should be done after measurement the bodies weight at least twice weekly while monitoring electrolytes.
• The goal to small, frequent meals that are high in nutrients (protein, calories, carbs) and to supplement electrolytes as needed after 5% weight loss is noted/concerned.
• Be cognizant when exacerbated by Gl issues, so use referrals to dietitians for expert management.

Management - Bone Marrow Suppression

• Myelosuppression is a frequent side effect of chemotherapy as it reduces immune capacity.
• Can cause treatment-induced reductions r/t lifespan of blood cell type, which induces chemo &rad type dose.
• Neutropenia, or WBC growth factors, put the cancer client at risk for infections.
• Treatment consist of transfusions for thrombocytopenia to increase platelets to a regular platelet count for transfusion if platelets 150-400x109/L.
• For Anemia: transfusions, erythropoietin, later... other SE's, while managing infections and hemorrhage.

Management - Infection

• The primary cause of death in cancer clients includes the presence of acute infections.
• Some most common infection sites can be due to temperature changes which results in a fever greater than 38 degrees.
• Infection sites include the lungs; Genitourinary tract system, mouth (rectum), and peritoneal cavity.
• In these cases, manage Febrile Neutropenia in clients and clinical pathways through managing with panculture, early antibiotic therapy and treatment (for fever?).

Management - Skin Reactions

• Lubricate dry skin should be lubricated with nonirritating lotion/solution with safe additives (no metal,alcohol, perfumes).
• Wet reactions must be kept clean, should be protected and healed as wounds with facilitated measures.
• Erythema can develop within a 1-24 hour timeframe after a single radiation treatment.

Management - Gl Effects

• Assessment is important! which includes hydration, nutrition and alkalosis.
• Oral mucosa assessment covers taste (affected); difficulty swallowing, muctosis which requires substitutes for saliva and reduction to exposure from extreme temperature factors.
• For Esophagitis and intestines can be treated prophylactically with antimetics with antidarrheal/antimotility through soft fibres/high protein management.

Management - Pulmonary Effects

• A progressive and irreversible effect is pulmonary effects.
• Radiation management includes dilators, expectorants and bed rest.
• Edema, fibrosis and coughs require oxygenation.

Obstructive Emergencies - Conditions and Treatments

• Superior vena cava syndrome: facial/periorbital edema, head/neck/chest vein distension treated via tumour and thrombosis treatment.
• Spinal cord compression treated via Sensory paresthesia/loss pain control.
• Third space syndrome treatment via bowel obstruction assessment/analgesics like pain, nausea, vomiting, bloating, loss of flatulence and more.

Metabolic Emergencies - Conditions and Treatments

• Caused by production of ectopic hormones that include the following causes.
• Syndrome of inappropriate antidiuretic hormone (SIADH).
• Treat Hypercalcemia which comes in various health effects like bone degradation (bone myeloma) with fluids that counter effects from nausea/vomiting.
• Other conditions that require management includes tumour lysis syndrome, septic shock (use antibiotics) and disseminated intravascular coagulation.

Infiltrative Emergencies

• Cardiac tamponade comes in different types of fluid accumulation that impact tumour and causes pericarditus.
• Carotid artery rupture is causes by the arterial wall tumour, or erosion following surgery and radiation therapy
• Pleural effusion can be drained with thoracentesis (tapping).

Management - Psychosocial

• Maintaining optimal quality of life by building support through attitudes that emphasize maintaining open discussion from those surrounding the client and managing social and cultural fears.

Performance Assessment Tools

• Karnofsky Performance Status: quantifies cancer patients' general well-being and activities of daily life, evaluates a patient's ability to survive chemotherapy for cancer.
• Zubrod score/WHO.

Nursing Priorities

• Consider symptoms from disease locations or treatments that will inform a constipation and treatment based interventions.
• Monitor for deficient fluid volume that requires an electrolyte assessment and the monitoring of the balance from GI absorbtion.
• Consider a nutritional imbalance, due to the loss of lung capacity from breath sounds when a patient is in a state of distress . Sexual problems, conflicts arise between emotions and the physical state.

Nursing Priorities - Other Assessment Factors

• Consider acute pain from surgery due to the tumor, or for metastasis, consider the patients emotion in term of conflict, disturbance or anxiety.
• Assess clients need to manage anxiety based on changes that stem treatment modalities that will impact mental health with different effects

Breast Cancer - Stats

• Factors such as cell type, tumor size/location, the extent of disease, status (physiology and psychology), desires, clinical trials are factors to determine the treatment modality offered.

Breast Cancer - Risks

• Over 60 is a risk factor.
• Genetic factors and lifestyle factors (hormone replacement), a personal history and benign growths can increase the risk.

Breast Cancer - Signs and Symptoms

• Most are classified if its ductal invasive with or without mammographic changes and is high if its dense tissue and in the outer quadrant. Can be related to low mortality and growths, is hard and difficult to be treated with some rare nipple growths are bloody and painful for some cases.

Diagnostics of Breast Cancer

• Can be treated with mammograms, biopsy, BSE exams and hormones.

Implementation

• Lymphedema can be an acute issue and requires elevation and diuretics for mobility and pressure.
• Surgical measures can include adjuvant therapy and preventive measures to avoid surgical seeding of cancer cells.

Nursing Implementation - Considerations

• Acute interventions due to swelling should be prioritized.
• Psychological changes should be addressed

Transitions In Care

• Nurses engage and address patient through a care model transition plan.
• Transition planning requires the implementation of strategy that incorporates the concern, next level of care.
• In order to ensure medication safety, conduct the best possible medication history, and perform medication reconciliation when a change is about to occur.

SBAR Implementation

• SBAR is designed for nurse recommendations.

• Situation: What is the situation you are calling about?

• Background: Pertinent background information related to the situation could include the following.

• Assessment: What is the nurse's assessment of the situation?

• Recommendation: What is the nurse's recommendation or what does he/she want? Examples Health Equity

• Create equal opportunities for good health for everyone by decreasing the effect of the social determinants of health.

• Remove unfair systems and policies that cause health inequalities and improve the services that enhance access to and reduce exclusion from healthcare.

• Address the different social and health statuses for certain ethnic cultural backgrounds

Cultural Competence

• Recognize the knowledge and skills to help to promote and maintain an assessment of integrity when its needed to reduce integrity towards health and quality outcomes.
• Cultural competence requires equity (context and environment) that can be facilitated though a LEAN model, sympathy, explanation and treatment that is specific to them.

Pain

• Is a condition that cannot and needs to be addressed.
• The dimensions of assessment includes the physical, emotional, and the patient sensory that influences behavior and cognition, so it need to be addressed at its specific need.
• Its a cause for damage that can come in forms of tissue or nerve (somatic or visceral) and can be caused by a tumour, or infection.
• Patients requires a baseline to assess their pain

Pain - Assessment and Treatment

• Consider Pattern, area, intensity, and nature (sensory/emotional evaluation), and the use of treatment via multi modal treatment plans and pharmaceuticals (opioids).