Chronic Exam Review: CKD, BPH, Anemia, Lung Cancer, and More

**Exam Categories:** **CKD (12Qs):** - Characterized by the progressive, irreversible loss of kidney function - Kidney damage: - Caused by pathologic abnormalities - Markers of damage are especially prevalent in BUN and Creatinine - We can...

**Exam Categories:** **CKD (12Qs):** - Characterized by the progressive, irreversible loss of kidney function - Kidney damage: - Caused by pathologic abnormalities - Markers of damage are especially prevalent in BUN and Creatinine - We can additionally use blood, urine, and imaging tests to determine the extent of kidney damage - Low Glomerular filtration rate is also a commonality: - Less than 60 mL/min/1.732 for greater than 3 months (Note: a normal GFR is 125 mL/min) - Epidemiology: - African Americans and Native Americans are more likely to experience CKD compared to white counterparts; Men are more likely to experience CKD as compared to women - Common co-morbidities that lead to CKD: - Hypertension - Diabetes (I & II) - Lupus - Polycystic kidney disease - Pyelonephritis - AKI (see table 62.4) - Etiology: - Leading Cause: - Diabetes (50% of cases) - Hypertension (25% of cases) - Individuals with CKD are frequently asymptomatic until the disease has reached advanced stages; thus, it is often underdiagnosed and undertreated - Staging: - Disease staging based on decrease in GFR: - GFR is calculated from Cr, age, body size and gender - Normal GFR is roughly 125 mL/min - Last stage of kidney failure is known as ESRD, which occurs when GFR is less than 15 mL/min A screen shot of a chart Description automatically generated - Clinical Manifestations: - Figure 62.5 - With low GFR, the body retains toxic substances, leading to imbalances in: - Urea - Creatinine - Phenols - Hormones - Electrocytes - Water - Clinical manifestations are related to these imbalances, where blood filtering problems is the first cause of symptoms; later, urinary and kidney specific symptoms occur - Psychologic: - Anxiety, Depression - Cardiovascular: - HTN, HF, CAD, pericarditis, PAD - Gastrointestinal: - Anorexia, Nausea, Vomiting, GI Bleeding, Gastritis - Endocrine/Reproductive: - Hyperparathyroidism, Thyroid abnormalities, Amenorrhea, ED - Metabolic: - Carbohydrate intolerance, Hyperlipidemia - Hematologic: - Anemia, Bleeding, Infection - Neurologic: - Fatigue, HA, Sleep disturbances, Encephalopathy - Ocular: - Hypertensive retinopathy - Pulmonary: - Pulmonary edema, Uremic pleuritis, Pneumonia - Integumentary: - Puritis, Ecchymosis, Dry, scaly skin - Musculoskeletal: - Vascular and soft tissue calcifications, Osteomalacia, Osteo fibrosa - Peripheral Neuropathy: - Paresthesia, Restless legs syndrome - Additional clinical manifestations are most commonly seen within HTN, Hyperkalemia, Uremia, Anemia, Acidosis, Hypocalcemia, Hyperphosphatemia, and Bone loss - Clinical Manifestations: Urinary System: - Early stages result in no change in urine output, polyuria may be present related to diabetes - As CKD progresses patients have increasing fluid retention - ESRD may cause patients to become anuric (GFR less than 15 mL/min) - With anuria, patients will experience uremia: - Urine is not excreted, toxic waste products build up in the blood, and symptoms occur in multiple body systems  - Assessment: - Complete history of any existing kidney disease, family history: - Long-term health problems - Drugs and herbal preparations especially NSAIDS and nephrotoxic agents - Dietary habits - Support systems - Measure height and weight and evaluate any recent weight changes (to monitor fluid gain) - Monitor and evaluate input and output - Systemic effects - Fatigue - Anorexia, nausea, vomiting - Depression - Monitor for changes in vital signs - Respirations - Cardiac rhythm - In early stages we will see an increased BP - SpO2 - Monitor Labs - Diagnostic Studies: - Urinalysis - Dipstick evaluation of protein - Renal ultrasound/biopsy - Renal CT - Albumin-to-creatinine ratio (first morning void) - GFR - Treatment: - Goals - Retain kidney function - Treat symptoms - Prevent compilations A screenshot of a medical test Description automatically generated - Interprofessional Care of CKD: - Measures to lower potassium - Restriction of high-potassium food and drugs - Sodium polystyrene sulfonate (Kayexalatea) - Assess for paralytic ileus - Dialysis may be needed - When K+ is severely elevated and/or cardiac arrhythmias - IV glucose and insulin to move K+ into the cells - IV 10% calcium gluconate to stabilize cardiac membrane - Antihypertensive Therapy with Goal BP 130/80 - Weight loss (if indicated) - Therapeutic lifestyle changes - Diet recommendations (DASH Diet) - Administration of antihypertensive drugs - ACE inhibitors (Check K+ before administering) - ARB agents - Diuretics (e.g. Lasix) help to increase urinary output and waste such as potassium - Mineral Dysregulation and Bone Disease: - Monitoring bone loss is done through x-rays, bone scans, biopsy, and densitometry - Labs should be checked regularly - Nutritional Phosphate intake not restricted until patient requires renal replacement therapy (then restricted to less than 1g a day) - Phosphate binders: - Should be administered with each meal - Side effect: constipation - Calcium acetate (PhosLo) - Calcium carbonate (Caltrate) - Bind phosphate in bowel and then excrete - Sevelamer hydrochloride (Renagel) - Lowers cholesterol and LDL levels - Avoid aluminum/magnesium preparations - Depend on kidneys for excretion - Aluminum is associated with dementia and bone disease - Supplement vitamin D - Calcitriol - Serum phosphate level must be lowered before calcium or vitamin D is administered - Controlling secondary hyperparathyroidism - Calcimimetic agents - Cinacalcet (Sensipar) -- increases sensitivity of calcium receptors in the parathyroid glands - Subtotal or total parathyroidectomy (severe cases only) - Management of Anemia: - Iron supplements (common) - If plasma ferritin level is less than 100 ng/mL - Side effects include gastric irritation and major constipation - May make stool dark/green in color - Folic acid supplements - Needed for RBC formation - Removed by dialysis (thus, give after dialysis) - Avoid blood transfusions - May increase the development of antibodies - May lead to iron overload and fluid imbalance - Erythropoietin (EPO) (in advanced CKD) - Epoetin alfa (Epogen, Procrit) - Darbepoetin alfa (Aranesp) - Administer IV or subcutaneously - Increased hemoglobin and hematocrit in 2 to 3 weeks - Side effects: thromboembolism and HTN - Dyslipidemia Management: - Statins (HMG-CoA reductase inhibitors) - Most effective for lowering LDL level - Atorvastatin (Lipitor) - Fibrates (fibric acid derivatives) - Used to lower triglyceride levels - Gemfibrozil - Management of Complications: - Drug toxicity is a risk due to poor excretion of medication substrates - Digoxin - Diabetic agents - Antibiotics - Opioid medications (can lead to depressed respirations and pneumonia) - Fluid overload - Hypertensive crisis - HF - Nutritional Therapy: - Designed to manage electrolyte and fluid imbalances - General recommendations: low protein and low phosphorus - Nutrition shakes like Glucerna - Monitor laboratory parameters - Protein intake: - Normal of a hemodialysis patient, increased for a peritoneal dialysis patient - Fluid restriction: - Intake depends on daily urine output - Monitor intake and output (inpatient) - Sodium restriction: - Recommendations vary from 2 to 4 g/day - High salt foods should be avoided (i.e. cured meats, canned foods, soy sauce) - Salt substitutes containing potassium chloride should be avoided - Potassium restriction: - Limit to 2 to 3g - High potassium foods should be avoided (e.g. tomatoes, bananas, melons, raisins, beans, etc...) - Phosphate restriction in ESRD: - Limit 1g/day - Foods high in phosphate: meat, dairy products - Most foods high in phosphate are also high in protein and calcium, such that the use of phosphate binders is essential - Interprofessional Care of ESRD: - Dialysis options: - Hemodialysis - Continuous veno-venous hemodialysis - Peritoneal dialysis - Kidney transplant - Palliative care - In all cases, active case management is highly beneficial - Stable Dialysis: - Line management: - Hickman/central line (short term solution) - AV fistula - AV graft - Pre-dialysis assessment: - Vitals - Meds - Access - During dialysis: - Process (pp. 1464) - Maintain BP - Post dialysis - Vitals - Meds - Complications: - Hypotension, electrolyte imbalance (cramps, headaches, nausea, dizziness), bleeding, infection, dialysis-related dementia, disequilibrium syndrome (usually if HD is too fast), access complications - Nursing Management: - Diagnoses: - Excess fluid volume, risk for electrolyte imbalance, disturbed thought process, fatigue r/t anemia, risk for injury, imbalanced nutrition: less than body requirements - Health Promotion: - Identify individuals at risk for CKD - DM - HTN - Hx or Family hx of kidney disease - Repeated urinary tract infection - Regular checkups and monitor changes in urine/labs - Acute care: - Inpatient care required for management of complications: - Sudden change in output, fluid overload, co-morbid heart failure, changes in mental status - Kidney transplantation - Ambulatory care: - Most care for CKD occurs on an outpatient basis - Teach patient and caregiver about - Diet: limit protein, phosphorous and sodium - Drugs - Common side effects, pill organizer, discuss all over-the-counter drugs with provider (e.g. NSAIDS) - Take daily weight and BP - Identify signs of fluid overload and electrolyte imbalances - Report if weight gain is greater than 4lbs in a week - As disease advances, help patients and their families think through options: - PD and home dialysis modalities - HD - Transplantation - Palliative care **BPH/Prostate Cancer (4Qs):** **BPH:** - Epidemiology: - 25% of men by age 40; 75% of men by age 70; effects individuals equally across race - Pathophysiology: - Prostate becomes enlarged, obstructing the urethra, and preventing urine flow - Clinical Manifestations: - Lower urinary tract symptoms (LUTS) - Difficulty starting the flow of urine, even when straining - Weak stream of urine - Multiple interruptions during urination - Dribbling once urination is complete - Bladder changes related to retention: - Urgency, frequency, feeling of not emptying the bladder - Incontinence, nocturia - Diagnosis: - Based on symptoms - Confirmed with digital rectal examination (an enlarged prostate is palpable) - Prostate specific antigen (PSA) - Blood test - Considered a tumor marker but may also be stimulated by infection - Complications: - Bladder outlet obstruction - Acute urinary retention - Bladder stones - Infection - Hydronephrosis - Postrenal acute kidney injury - Pyelonephritis - Medical Management: - Watchful waiting or active surveillance: - For patients with minimal symptoms - Yearly DRE - Avoid tranquilizers or OTC decongestants (may worsen symptoms) - Avoid excess fluids in evening to decrease nocturia - Medications: - Improve symptoms 30%-60% of the time - 5-alpha reductase inhibitors - Block hormone changes that lead to enlarged prostate - Does not work on circulating testosterone - Can take 3-6 months to see effectiveness - Alpha-adrenergic blockers - Act on alpha receptors in the prostate causing smooth muscle relaxation - Improvement may take 2 weeks-4 months - Alternative Therapies: - Intermittent catheterization - Long-term indwelling catheter - Changed monthly - Saw palmetto - Used by 2 million people in the US - Surgical Management: - Transurethral resection of the prostate (TURP) - Most common BPH surgery - Inner prostate is removed  - Nursing Diagnosis: - Disturbed sleep pattern r/t nocturia secondary to obstruction of the bladder - Risk for infection r/t urinary stasis secondary to impaired bladder emptying - Nursing Assessment: - Urinary symptoms (subjective data, interview) - Temperature - Focused abdominal examination - Bladder scan - Urinalysis - Nursing Interventions: - Indwelling catheter care - Administer medications as ordered - Education: - Watchful waiting - Decreased fluid intake in the evening - Drug therapy education - Follow-up - Surgical options - Post-surgical care **Prostate Cancer:** - Epidemiology: - Most common cancer in those assigned male at birth - Risk/occurrence for transgender women depends on hormone therapy and the age therapy was started - Fisk factors: - Family hx - Age 55 and older - Diet low in fruits and vegetables - Pathophysiology: - Slow growing cancer - Generally, grow in periphery of the prostate - Metastasis: lymph nodes, lungs, bones - Diagnosis: - Yearly digital rectal exams beginning at age 45-50 (depending on risk for developing the disease) - Prostate specific antigen - Can give false negative or false positive - However, better than no screening at all - Biopsy - Clinical Manifestations: - Many patients are asymptomatic - As cancer progresses, symptoms mimic BPH - Weak urinary stream, hesitancy, frequency, urgency, incontinence - Hematuria, hemospermia - Pain - Rectal symptoms - Rectal pain/cramping - Tenesmus (feeling of incomplete defecation) - Medical Management: - Ablative hormone therapy: - Testosterone suppression - Can be used to shrink prostate prior to radiation - Chemotherapy: - Used in advanced prostate cancer refractory to ablative hormone therapy - May be given PO or IV - Nonsurgical Management: - Radiation - External beam - Brachytherapy - Implanted radioactive seeds or pellets through perineum into prostate - Left in permanently - Must abstain from sex for 2 weeks and use condoms thereafter - Cryotherapy: - Liquid nitrogen delivered to prostate through perineum to freeze the prostate - Surgical Management: - Radical prostatectomy: - Prostate and seminal vesicles are removed - Lymph nodes may be removed - May be open or laparoscopic - Almost always result in impotence -- nerve sparing procedures are emerging - Nursing Assessment: - Risk factors - Prostate Specific antigen levels - Greater than 4 ng/mL requires further assessment - Digital rectal exam results - Urinary symptoms - Weak stream, distended bladder, etc - Nursing Diagnoses: - Risk for infection r/t surgical intervention/pharmacological intervention - Sexual dysfunction r/t disease process/surgical intervention - Interventions: - Administer medications as ordered - Wound care after surgical procedure - Administer stool softeners - Education: - Treatment options - Signs of infection - Prevention/screening **Peripheral Arterial Disease (2Qs):** - Epidemiology: - Majority of contractors are 65 years or older - African Americans are affected more often than any other group - Risk Factors: - Atherosclerosis -- most common; shares risk factors (e.g. smoking, HTN, DM, LDL and lipids, sedentary lifestyle, obesity, stress) - Age, gender, ethnicity, family history - Pathophysiology: - Progressive and chronic - Obstruction of blood flow through larger peripheral arteries causing arterial occlusion - Cause may be related to atherosclerosis, inflammation, stenosis, embolus, thrombus - Clinical Manifestations: - Vary depending on tissue involvement and severity of impaired blood flow - May be asymptomatic - Identified by a reduced ankle BP (indicates decreased blood flow) - May present as symptoms of intermittent claudication: an ache, cramp, numbness, or fatigue that occurs during exercise and is relieved at rest (due to rest of tissue after experiencing a period of oxygen deficiency) - Diagnosis: - Ankle-brachia index (ABI) \[Ankle BP/Brachial BP\] - Interpreting Ankle-Brachial Index Values: - Greater than 1.30 = noncompressible arteries (stiff arteries) - 1 to 1.29 = Normal - 0.91 to 0.99 = Borderline PAD - 0.41 to 0.90 = Mild to moderate PAD - 0 to 0.4 = Severe PAD A list of pain in a person\'s hand Description automatically generated - Complications: - Critical limb ischemia (occurs over time due to prolonged occlusion) - Acute limb ischemia -- cool or cold, pulseless, and molted (sudden onset) - The following are the "six Ps" of ischemia: - Pain - Pallor - Pulselessness - Paresthesia - Paralysis - Poikilothermic (cool) - Medical Management: - Provide relief of symptoms - Prevent progression of disease and complications (mainly, we want to prevent ischemia and ulcers) - Improve quality of life - Medications: - Pentoxifylline (Trental) -- decreases blood viscosity - Anti-hypertensives - Platelet inhibitors (aspirin, Plavix) \[Used to stop adhesion to already narrow lumens\] - Statins - ACE inhibitors - Nonsurgical Management: - Percutaneous transluminal angioplasty - Laser-assisted angioplasty - Rotational atherectomy - Surgical Management - Revascularization - Nursing Assessment: - Palpate or doppler all pulses bilaterally - Visual assessment of feet and limbs - Temperature of extremities - Assess muscle tone - Assessment findings: - Delayed capillary refill (greater than 3 seconds) - Decreased or absent pulses - Loss of hair on lower calf, ankle, and foot - Dry, scaly, mottled skin - Thick toenails - Cold and cyanotic extremity - Pallor of extremity with elevation - Rubor (redness) of the extremity when dependent - Muscle atrophy - Ulcers leading to possible gangrene - Nursing Diagnoses: - Ineffective peripheral tissue perfusion r/t interruption of arterial blood flow to the peripheral tissue AEB - Risk for impaired skin integrity r/t altered circulation or sensation AEB - Chronic pain r/t decreased peripheral perfusion AEB - Nursing Interventions: - Administer medications as ordered - Positioning: Keeping extremity dependent facilitates blood flow - Meticulous skin care and prevention - Encourage activity - Maintain bleeding precautions - Maintain open discussion about quality of life - Refer to palliative care - When to contact a provider: - RED: Emergency (911) - Absent pulses and sensation - YELLOW: Call provider - Progressively worse pain, weak pulses, decrease in ability to perform ADLs, s/s of infection - GREEN: Good to go, stay the course - Pt is at baseline determined with their provider - Education: - Avoid crossing legs (can impede blood flow) - Inspect feet daily - Report chest discomfort or neurological symptoms immediately - Lifestyle Changes: - DASH diet - Limit alcohol - Quit smoking - Moderate exercise **Anemia (8Qs):** - Disorders of the hematopoietic system: - Primary Hematopoiesis: - Hematopoietic cells are committed and developed in the bone marrow - Primary disorders occur during cell development - Secondary Hematopoietic organs: - Storage sites: spleen, lymph - Secondary disorders - Lukemia/lymphoma - Anemia: - Blood loss anemia - Anemia of chronic illness - Nutritional anemia - Iron deficiency - B12 deficiency - Folic Acid deficiency - Sickle cell anemia - Thrombocytopenia - Assessment of Hematologic Disorders: - Risk factors/past history: - Genetic tendency, bone marrow depressing medications, chemical exposures, radiation exposure, infectious disease (especially viral) nutrition - Suspicious signs and symptoms: - Bleeding, bruising, pale/cyanotic, fatigue, fever, frequent infections - Physical exam is based upon risks and differential diagnoses - Diagnosis of Hematologic Disorders: - Complete Blood Count (CBC) - Hgb and Hematocrit, RBCs - RBC indices (differentiate nutritional anemias) - WBCs - Platelets - Extended hematologic studies: - Reticulocytes--immature RBCs - Iron studies detect iron deficiency anemia - Nutritional studies (e.g. folate level) - Bone marrow biopsy based on CBC - If RBCs, WBCs, and platelets are all abnormal - Coagulation profile - Prothrombin time (PT) - Partial thromboplastin time (PTT) - Fibrinogen level - Chemistry tests: LDH, Bilirubin (RBC breakdown) - Anemia Broadly: - Inadequate RBC quantity or RBC dysfunction - Hgb -- amount of heme protein that carries O2; best indicator - HCT -- mass of RBC; affected by fluid volume - Classified by etiology and cell characteristics - Clinical consequences -- decreased O2 carrying capacity and tissue perfusion - Reticulocytes: - Slightly immature, immediate precursor to mature RBC - Indicative of RBC turnover, bone marrow release of immature cells - Indicates recent acute loss of blood cell mass (e.g. bleeding or hemolysis), causing early bone marrow release of reticulocytes - Elevated (greater than 2% of RBC count) in blood loss, hemolysis is typically higher than this - Types of Anemia: - Aplastic Anemia: bone marrow does not produce any cells - Nutritional Anemia: specific cellular abnormalities directly related to lack of nutrient - Hemolytic Anemia: inappropriate lysis of RBCs outside normal spleen/liver pathways - Bone marrow dysfunction: inadequate stem cells or differentiation in marrow - Blood loss - Anemia of chronic illness: metabolic depletion of reserve and ability to replenish red cells - S/S of Anemia: - Neuro: HA, confusion - CV: tachycardia, full, bounding pulses, cardiac murmurs, hypertension; weak, thready pulses, hypotension, cool extremities - Resp: tachypnea, dyspnea - GI/GU: oliguria, constipation - Other: acidosis, hypothermia - Iron Deficiency Anemia: - Iron deficiency is the most prevalent nutritional deficiency in the world - R/t chronic blood loss through menstrual bleeding, cancers, ulcerative colitis, and PUD - R/t insufficient absorption secondary to Crohn's, celiac, meds like proton pump inhibitors, NSAIDS, etc.... - Pica -- compulsion to eat non-food items, often resolved with iron repletion - Iron supplements are horrible constitutors -- can exacerbate anemia - Nutritional Anemia: Clinical Assessment: - Neurologic symptoms -- paresthesia - Glossitis -- painful, smooth, red tongue, cracks in corners of the mouth (iron deficiency anemia) - Koilonychias -- spooning and thinning nails - Nursing Assessment: - Fatigue, pallor, tachycardia, tachypnea, SOB, blood loss, bruising, cognitive impairment - Nursing Diagnosis: - Inadequate tissue perfusion, fatigue, activity intolerance - Nursing Action and Education: - Decrease/minimize blood loss - Increase dietary iron and vitamin C (increases iron absorption) - Don't take vitamin C with calcium - Dark green leafy vegetables - Meats - Iron-fortified cereal/bread - Supplements - Report SOB, increased fatigue, and bleeding (especially in the stool) - Vitamin B12 Anemia: - More likely to cause neurological and psychiatric dysfunction r/t demyelination of nerves - Paresthesia (numbness and tingling in hands and feet) - Lhermitte sign = electric shock sensation with neck flexion - Dietary sources of B12 - Meat, dairy, seafood, eggs - B12 supplements -- oral and injection - Folic Acid Anemia: - Folate insufficiency is associated with: - Gastric bypass surgery, Whipple, alcoholism (pancytopenia), oral contraceptives, metformin, and some chemotherapy - Also commonly has neuro symptoms of confusion or disorientation - Folic acid supplements - Can increase metabolism of Dilantin, increasing the risk of seizures  - Nursing Care of Patients with Anemia: - Balance physical activity, exercise, and rest - Adequate nutritional support and administration of supplements - Iron -- give with ascorbic acid, anticipate black stools and constipation - Erythropoietin - Oxygenation assessment and support to maximize tissue oxygenation - Transfusion - Management of Anemia: - Ensure adequate safe perfusion first - IV fluids - Blood transfusions - Protein/coagulation factors - Crystalloid fluids (lactate ringers) - Remove the underlying cause - Rest/reduce oxygen demands - Bone marrow stimulants -- erythropoietin - Give only when HGB is less than 10 mg% - Monitor for hypertension and hypercoagulability (since we are worried about thromboembolism) - Make sure adequate ferritin and iron precursors are present - Immunosuppressives (if etiology is autoimmune destruction of cells) - Blood and marrow transplant (BMT)/hematopoietic stem cell transplant (HSCT) (if anemia is permanent stem cell damage) **Sickle Cell (4Qs):** - Sickle Cell Disease: Inherited Disorder of Hemoglobin: - Sickling of the RBC in the presence of hypoxemia due to abnormal Hemoglobin S DNA structure - Sickled cells are longer and stiffer, with a very short lifespan (20 days as compared to 120 days) - Autosomal recessive inheritance - Some reverses with correction of hypoxemia, others remain sickled and are removed by extra-splenic hemolysis - Sickled cells easily hemolyze and destroy organs - Sickling of cells is intermittently triggered. When not in "sickling crisis", there may be few symptoms - Diagnosis of Sickle Cell Disease: - CBC - RBC Indices - Coagulation profile - Chemistry tests - Bilirubin -- RBC breakdown - Haptoglobin -- binds with heme - Transferrin -- binds with iron - Ferritin -- early iron precursor - Hemoglobin electrophoresis -- specific diagnosis shows presence of abnormal hemoglobin - S/S Related to Sickle Cell Crises: - Triggered by hypoxemia --\> vasoconstriction --\> increased occlusion - Dehydration - Cold temperatures - Infection - Low atmospheric oxygen (mountains, planes) - 4 types of crises: Vaso-occlusive, aplastic, sequestration and hemolytic: - Vascular occlusion (most common) --\> tissue hypoxia and pain - Cool, cyanotic extremities - Splenic infarction - Stroke - MI - Aplastic -- bone marrow stops producing RBCs - Sequestration -- sudden splenic pooling with hypovolemic shock - Hemolytic - Joint Complications: - Sickle cell anemia dactylitis - Sausage digit or hand foot syndrome - Swelling of right thumb, fist, and second fingers - There is a high frequency of dactylitis in children with sickle cell anemia between the time of birth and four years of age within a mode at about one year - This swelling is associated with limited vascular necrosis of marrow and may affect the hands and feet - Management of Patients with Sickle Cell Disease: - Primary treatment of disease: - Help patient identify and avoid triggers for sickle cell crisis - Prevent hypoxemia - Avoid cold - Healthy lifestyle -- nutrition, sleep - Limit sickling episodes - Control hypoxemia -- oxygen - Control thromboses -- fluids - Manage crisis-induced pain aggressively -- opioids - Compensate for past hemolysis - Rapid initiation of opioids to reduce pain during crisis - Incentive spirometry to decrease pneumonia risk - Supportive care - Challenges of exercise and limiting sickling - Chronic illness issues - Minimize long-term organ dysfunction - Education and counseling - Pre-pregnancy counseling - Planning and anticipating - Health insurance - Parental testing - Parental counseling - Infant testing - Health care planning - Developmental development - Psychologic challenges **Thrombocytopenia (1Q):** - Table 33.3,4 - Figure 33.12 A diagram of a medical procedure Description automatically generated - Medicines commonly cause anemia and thrombocytopenia: - Anticoagulants: - Coumadin - Heparin - Lovenox - Fibrinolytics: - Alteplase - Platelet Inhibitors: - Plavix - NSAIDS - Drugs that interfere with platelet production and function: - Antibiotics - Thiazide diuretics - Quinidine - Sulfonamides - Drugs that interfere with clotting factors: - Amiodarone - Anabolic steroids - Coumadin - Heparin - Drugs that decrease vitamin K: - Antibiotics - Clofibrate - Thrombocytopenia: - Not a disease, but a complication or syndrome - Common etiologies: - Bone marrow disease - Chemicals (e.g. insecticides, dry cleaning chemicals) - Medications esp. heparin - Radiation - Splenic disease - Hypo/hyperthermia - Large indwelling venous catheters - Hemorrhagic conditions (like DIC -- disseminated intravascular coagulation) - Assessment for Platelet Disorders: - Patient and Family History - Unusual bleeding with injury - Liver disease - GI disease - Alcohol or drug use - Occupation - Viral illness - Medications - Physical exam - Bruising - Jaundice - Soft tissue bleeding -- bruising, petechiae - Mucosal bleeding -- gum bleeding, hematuria, occult blood in stool - Diagnostic tests: - Platelet quantity and platelet count - Mild-platelet count (less than 50,000 mm3) - Moderate-platelet count (less than 20,000 mm3) - Severe-platelet count (less than 10,000 mm3) - Platelet quality -- bleeding time - Bleeding related to platelet defects commonly manifests in skin, soft tissue, and mucus membranes. Occurs with minor injury related to damage of capillaries rather than major vessels - Thrombocytopenia Management: - Remove cause of thrombocytopenia - Glucocorticoids - Platelet transfusions - More reactions than RBCs - Single donor vs multi-donor: fewer donors reduce reaction risk and are important if patient may later need a bone marrow transplant - Bone marrow growth factors (Oprelvekin, Neumega) - Anti-thrombolytic therapy -- e.g. aminocaproic acid (amicar) is supportive rather than corrective of platelet abnormality - Immunosuppressives may be helpful if etiology is immunologic destruction of platelets - Extreme cases -- splenectomy  - Nursing Management of Thrombocytopenia: - Assess all excrement for visual blood - Fresh blood -- red - Maroon -- recent - Dark, black -- old - Visualize orifices/skin/mucosa for bleeding - Reduce bleeding risk -- head of bed elevation, avoid constipation, fall precautions, apply pressure after invasive procedures, avoid IM injections - Administer medications to prevent clot break-down - Administer platelets - Monitor for excessive blood loss: blood pressure, tachycardia, pale, diaphoretic - Nursing Diagnosis: - Potential for bleeding - High risk for injury with falls - Potential for tissue perfusion/organ dysfunction due to bleeding into soft tissue or body spaces - Altered comfort due to hematomas **Blood Transfusion (2Qs):** - Blood Component Administration: - Types: - Whole blood - RBCs - FFP - Platelets - Normal saline - Blood tubing with/without filters - Timing: - Patient timing - Transfusion timing (wide open vs over 3 hours) - RN timing - Pre-assessment: - Lung sounds - Skin - Vital signs - The Double Double: - Checking blood requires 2 nurses to validate: - Consent for blood - Patient ID - Blood type of patient - Blood type of product - Blood ID number - Expiration date - Special preparation (neutrophils/irradiated) - Transfusion Reactions: - Recognition of reactions: - Allergic -- facial flushing, hives/rash (mild); increased anxiety, wheezing and dyspnea, decreased BP (severe) - Febrile -- fever, chills, anxiety, HA, tachycardia, tachypnea - Hemolytic -- hemoglobinuria, chest pain, apprehension, low back pain, chills, fever, tachycardia, decreased BP, increased RR - Contaminated product/sepsis - Preventing reactions: - Monitoring; pre-medications - Reaction management: - Discontinue product preserving tubing - Normal saline - New type and crossmatch - Coombs test - Urine - Managing fluid overload with transfusion: - Think about co-morbidities such as HF, renal insufficiency, etc.... - Check lung sounds - Blood pressure - Weight gain - Exercise tolerance - Lasix **COPD (11Qs):** - Epidemiology: - 4^th^ leading cause of chronic morbidity and mortality in the U.S. - There is severe underdiagnosis of COPD - Causes: - Smoking (80%-90% of cases) - Occupational dust and chemicals, outdoor air pollution, and secondhand smoke - Alpha-1 antitrypsin (AAT) deficiency (made in the liver to protect the lungs) - Risk Factors: - Secondhand smoke - Delays in lung growth during gestation and childhood - Aging - Airway hyperactivity - Alcohol consumption - Pathophysiology: - Progressive respiratory disease characterized by airflow limitation and inflammation that is progressive and not fully reversible - Usually a combination of emphysema and chronic bronchitis A diagram of a flowchart Description automatically generated  Diagram of a diagram showing the different types of lung Description automatically generated - Characteristics: - Slow progression of disease - Exacerbations caused by triggers - Infection - Inhalation/exposure - Poor air quality - Diagnosis: - History - Physical assessment - Oximetry - Spirometry (PFT) -- Measurement of lung volumes and air flow - Forced vital capacity (FVC) -- the amount of air that can be exhaled during a forced expiration - Forced expiratory volume in 1 second (FEV1) -- volume of air expired in the first second of maximal expiration after maximal inspiration; ability of lungs to empty quickly - History: - Cough (Sputum? For how long?) - Dyspnea (Use quantitative measures to assess changes over time) - Exposures - Laboratory Studies: - Arterial blood gas analysis (ABG) - Normal Values: - PaO2: 80-100 (decreased in COPD) - PaCO2: 35-45 (increased in COPD) - pH: 7.35-7.45 (decreased in COPD) - HCO3: 22-26 (increased in COPD d/t compensation) - Sputum Culture - Complete blood count (CBC) - WBC, hemoglobin (high in COPD pts) - Alpha-1-antitrypsin deficiency screening - Imaging: - Chest radiography: - Hyperinflation, flattened diaphragm - CT Scan - Thickened walls of bronchi - Diagnostic Procedures: - Electrocardiography (ECG) - Right ventricular hypertrophy - Pulmonary function tests - Forced vital capacity - Forced expiratory volume in 1 second - Physical Findings:  A screenshot of a screen with text Description automatically generated - Complications: - Right-sided heart failure - Cor pulmonale - Arrhythmias - Pneumonia - Pneumothorax - Severe weight loss and malnutrition (all metabolic effort goes towards breathing; energy is decreased, and eating is also difficult) - Osteoporosis - Four Goals of Treatment: - Assess and monitor the disease - Reduce risk factors - Manage stable COPD - Manage exacerbations - Treatment: - Bronchodilators: - Beta-2 adrenergic agonists - Anticholinergics - Inhaled glucocorticoids - O2 - O2 Therapy: - The goal is to achieve an oxygen saturation value of 90% or higher - Precautions in COPD - Complications of oxygen therapy - Oxygen toxicity - Fall risk: Oxygen tubing  - Noninvasive Positive Pressure Ventilation: - Continuous Positive Airway Pressure (CPAP) - Nasal Mask Advantages: - Is best suited for patients who are cooperative - Is indicated for patients with a low severity of illness - Causes less claustrophobia - Allows for speaking, coughing, and secretion clearance - Has a decreased emesis aspiration risk - Is generally better tolerated - Nasal Mask Disadvantages: - Is associated with increased risk of air leads from the mouth - Has limited effectiveness in patients with nasal deformities or blocked nasal passages - Orofacial Mask Advantages: - Is best suited for less cooperative patients - Is indicated for patients with a high severity of illness - Is better suited for patients with mouth-breathing or pursed-lip breathing - Is better for patients without teeth - Generally, provides more effective ventilation - Orofacial Mask Disadvantages: - Increases claustrophobia - Hinders speaking and coughing - Has an increased emesis aspiration risk - Noninvasive Positive-Pressure Ventilation (NIPPV) Considerations: - Skin irritation and breakdown -- device related pressure injury - Nasal irritation and dryness - Eye irritation - Sinus pain and congestion - Barotrauma - Gastric distention - Nutrition (NPO status) - Risk for falls - Delirium - Surgery: - Lung-volume reduction surgery - Lung transplant - Nursing Management: - Vital signs - Cough - Sputum production - Dyspnea (measure in quantitative terms) - Use of accessory muscles - Ability to talk in full sentences - Pursed-lip breathing - Anxiety - Nursing Diagnoses: - Impaired gas exchange r/t altered oxygen delivery and alveolar destruction - Ineffective airway clearance r/t increased mucus production, decreased energy, dyspnea, and ineffective cough - Activity intolerance r/t fatigue and dyspnea - Anxiety related to dyspnea - Interventions: - Administer medications as ordered - Bronchodilators - Antibiotics - Provide oxygen - Provide small, frequent meals with dietary supplements - Position -- semi-fowlers - COPD Indications: - RED: Emergency - Profound SOB (cannot speak in full sentences), abnormal chest pain, high fever - YELLOW: Call provider - Progressively worse shortness of breath, rescue inhaler not as effective, general malaise, change in nutrition habits - GREEN: Good to go, stay the course - Pt is at baseline determined with provider - Education: - Breathing techniques - Pursed lip breathing - Activity - Nutrition - Small frequent meals - Supplements - Medications - Administration of inhaled medications - Taking full course of antibiotics - Vaccines - Symptoms of exacerbations - Coping - Family support **Lung Cancer (3Qs):** - Epidemiology: - 2^nd^ most common cancer in both men and women - Number 1 cancer killer in the U.S. for men and women - Causes: - Smoking (90% of cases) - Secondhand smoke - Radon - Occupational pollutants - Asbestos - Risk Factors: - Smoking (16-fold increase in risk) - Exposure to secondhand smoke or radon gas - Exposure to carcinogenic and industrial air pollutants (asbestos, arsenic, chromium, coal dust, iron oxides, nickel, radioactive dust, and uranium) - Genetic predisposition - Pulmonary fibrosis - Radiation therapy - Pathophysiology: - Uncontrolled growth of abnormal cells in the lungs - Airway obstruction - Metastasis to thoracic structures, brain, liver, bone, and adrenals - 2 major types of lung cancer - Non-small cell (85%-90%; 5-year prognosis is good) - Small cell (only 5%-10% survive 5 years) - Clinical Manifestations: - History - New cough that does not go away - Physical findings - Dyspnea - Cough, hemoptysis (tumors cause bleeding) - Wheezing - Hoarseness - Chest pain - Headache - Bone pain - Weight loss - Diagnostics: - Chest X-ray, CT, PET scan - Sputum for cytology - Bronchoscopy - Mediastinoscopy - Bone and abdominal scans - Management: - Chemotherapy - Radiation - Surgery - Pain management - Complications: - Spread of primary tumor to intrathoracic structures - Metastasis to liver, bone, brain, and adrenal gland - Tracheal obstruction - Esophageal compression with dysphagia - Electrolyte imbalances, especially hypercalcemia - Phrenic nerve paralysis with hemidiaphragm elevation and dyspnea - Hypoxemia - Anorexia and weight loss, sometimes leading to cachexia - Hypertrophic osteoarthropathy A diagram of lungs and lung cancer Description automatically generated - Nursing Assessment: - Vital signs - Cough, wheezing, hemoptysis - Work of breathing (dyspnea) - Chest pain - Headache - Bone pain - Nutrition: appetite/weight - Pain - Interventions: - Administer medications as ordered - Antibiotics, pain, anxiety, antiemetics, bronchodilators - Provide oxygen - Provide small, frequent meals with supplements - Position -- semi-fowlers - Meticulous skin care - Mobility - Consult palliative care early - Assist with advanced directives as indicated **IV Pump Drug Calculation (1Q):** **Intake & Output Calculation (1Q):** **Delegation (1Q):**