NSG 4513 Adult Health 3 Study Guide PDF

**NSG 4513 Adult Health 3 Study Guide** **Chapter 24 -- Management of Patients with Structural, Infectious, and Inflammatory Cardiac Disorders** **Left Ventricular Hypertrophy:** patho, symptoms, assessment **Aortic Stenosis:** patho, risk factors, symptoms, assessment - **Patho:** - Na...

**NSG 4513 Adult Health 3 Study Guide** **Chapter 24 -- Management of Patients with Structural, Infectious, and Inflammatory Cardiac Disorders** **Left Ventricular Hypertrophy:** patho, symptoms, assessment **Aortic Stenosis:** patho, risk factors, symptoms, assessment - **Patho:** - Narrowing over a [long period of time] - Obstruction to left ventricular outflow - LV hypertrophy, pulmonary congestion, and Heart failure - **Risk Factors:** - High LDL (L for LOUSY) // Low HDL (H for HAPPY) - High cholesterol - Smoking - Older age \~ due to degeneration - "Most likely to get aortic stenosis...86 yr old lady w atherosclerosis" - Old people like to SING - Diabetes mellitus - Stimulant use - **Symptoms:** - Asymptomatic - Dyspnea on exertion & fatigue - S/S pulmonary congestion - Orthopnea, PND, pulmonary edema - Loud aortic murmurs & S4 (Lub Dub Dub) - "Diastolic murmur" - They singin' (loud then soft) SINGIN = STENOSIS - Dizzy / syncope - Angina \~ HIGH O2 demand - Not enough blood in coronaries - **Assessment:** - S/S of heart failure: ascites, JVD, peripheral edema (grading it +1, +2), capillary refills, grading pulses, skin temperature (core temp through foley catheter, central line, or oral) - Auscultating heart sounds - Murmurs, clicks, rubs, extra heart sounds (S3-lub lub dub, S4 lub dub dub) - Auscultating lung sounds - Crackles - Dysrhythmias (Afib, Aflutter) - TELEEEEE - Frequently assess their rhythm - Decreased cardiac output - Perfusing adequately and effectively: urine output - Daily weights - first thing in the morning, right after the patient voids - I&Os / fluid restriction - O2 sats - Lab values - BNP, BUN & creatinine, electrolytes - Educate the patient about: - HOB (pillows or sleep in recliner) - Low sodium diet, fluid restriction - Medication adherence - About the disease - The progressive nature of the disease - Treatment plans - Internal cardiac defibrillator \~ pt gets PTSD after being shocked a few times - Senses whether pt goes into VTACH or VFIB & if they do it delivers a shock - Holter monitor \~ a small, wearable device that records the heart\'s rhythm **Mitral Valve Regurgitation:** patho, symptoms, assessment - **Patho:** - Blood flows backwards - This directly affects cardiac output, blood is not pushing forward like it should - Left atrium becomes hypertrophied and fails Pulmonary congestion (pulmonary edema, pulmonary HTN) Will eventually cascades to Right Sided Heart Failure (Cor Pulmonale) - RV hypertrophy and dilation **Symptoms:** - Typically, patients are asymptomatic (Not an issue till it is) - Triggered and becomes a serious issue when a pt has an MI - Severe ACUTE CONGESTIVE HF \~ ppl on ECMO (Extracorporeal membrane oxygenation), balloon pumps very advanced life support therapy - Fatigue, weakness, dyspnea "trouble breathing when i lay down" - Palpitations, SOB, dyspnea of exertion - High pitched murmurs d/t the regurgitation **Assessment:** - ECHO - Management is similar to what is seen with heart failure - Afterload Reduction - ACEs and ARBs - We're not trying to control the blood pressure, we are trying to alleviate stress on the heart and allow the heart to naturally beat as comfortably as it can - CCBs - Blocking the activation of skeletal and cardiac muscle excitation - \~ thus, slowing down heart rate - Really good for people prone to tachycardia rhythms - These slow down conduction and impulses so that the heart can focus on performing naturally - Beta Blockers - Rate control - Want to control how fast the heart is pumping so that it can adequately fill and get blood out - Activity restrictions - Valve replacement \~ surgical intervention when it can't be managed any more. **Valve Replacement Surgery / TAVR:** indications, valve types, education **Indications:** - Used for pt too high risk for open heart surgery - Usually used w congenital pediatric pt or elderly with too many comorbidities **Valve Types:** - Mechanical Valves - More durable than tissue - Everytime the valve opens you'll hear an audible click - Used with younger patients - Thromboembolic complications \~ need to start anticoagulant SOON after surgery, might need lifetime anticoagulation 1\. Which of the following statements shows pt understands teaching about his mechanical valve replacement... "I will have to take warfarin anticoagulant therapy for the rest of my life" - Tissue Valves - Not as durable (but more natural) and may require replacement - Heterografts - Bioprosthetics: can come from pigs (Oink Oink), cows, horses Bovine and pig = most common - Homografts (from a cadaver) - Autografts (take a portion of the patient's own pulmonic valve, will have to replace the pulmonic valve as well) **Education:** - Anticoagulant therapy - Prevention for infective endocarditis - Need for regular echocardiograms \~ to make sure the valve is working appropriately **Endocarditis:** risk factors, management, complications - Poor dental health is a big risk factor! - IV drug users - FREQUENT neurovascular assessments - A key strategy is prevention!! - Antibiotic prophylaxis \~ monitor for SEPSIS - Good oral hygiene !!! - Increased vigilance for hospitalized patients - They NEED to stick to their agreement (diet, no smoking, ect) or no surgery - Surgeons can refuse to treat patient surgically bc the surgery would be futile **Medical Management** - Long term IV antibiotics (6 weeks or more) & probably multiple - PICC line!! Prolly hard to stick a druggy - Livin in the hospital for 6-8 weeks - The unit mascot - Monitor temperature **Surgical management if necessary** - Valve replacement or scrape away the vegetation **Nursing Management** - Monitor patients HR and temperature - Administer medications as ordered - Encourage fluid intake - Plan rest periods - Assess heart sounds frequently - Assess for signs of embolism or heart failure - Care of invasive lines - Education **Complications:** - Heart valve damage, heart failure, myocardial abscess - Neuro complications: stroke, meningitis, seizures - Other complications: kidney damage spleen enlargement joint pain and swelling, skin lesions, pneumonia - Systemic complications: sepsis, multi-organ failure **Myocarditis:** management, education - **Management:** **Medical Management:** - Treat the cause - Bacterial? Antibiotics - Viral? Symptom management - Bedrest and restricted activity **Nursing Management:** - Monitor VS and for S/S of complications - Anti-embolism stockings and passive ROM **Education:** - Recognize S/S: chest pain, respiratory distress, lethargy - When to take medications and how they work - Activity restrictions- when they can resume activities and exercise - Balanced diet- fruits, vegetables, whole grains, lean proteins, and healthy fats **Pericarditis:** risk factors, symptoms, assessment **Risk Factors:** - Can be primary or secondary - Multiple causes - Bacterial, viral, inflammation from internal heart disease - Can also be acute, chronic, or recurring - Inflammation of the pericardium leads to pericardial effusion (buildup of fluid around the heart sac) and if severe it can go into cardiac tamponade (Beck's triad) - If pericardium becomes inflamed, fluid can build up and accumulate friction rub **Symptoms:** - May be asymptomatic - Chest pain and friction rub are characteristic - Beck's triad - Muffled heart sounds - JVD - Widening pulse pressures (Low blood pressure) - Pulsus paradoxus \~ if patient has an ART and they hold their breath systolic drops, when they exhale the systolic will go back up - Creating intrathoracic pressure which does not allow the heart to expand and contract as much as it should - Hallmark slam dunk **Asssesment:** - Diagnosis based on S/S, echo, EKG - EKG: global ST (ST seen in every lead) **Cardiac tamponade:** patho, treatment **Patho:** reduced diastolic filling of the right ventricle, due to pressure from the adjacent expanding pericardial sac. This results in backup of fluid into the veins draining into the heart, most notably, the jugular veins. **Treatment:** emergency treatment is required. Usually, a needle or small tube is used to drain excess fluid. (pericardiocentesis) **DVT:** risk factors, prevention - **Risk factors:** age (being older than 60 yrs old), lack of movement, injury or surgery, pregnancy, birth control pills, being overweight, smoking, cancer, heart failure, IBD, personal or family history of PE, genetics - **Prevention:** - lifestyle modification- move frequently, exercise regularly, maintain healthy weight, quit smoking, limit alcohol intake - medications: anticoagulants **Chapter 22: Management of Patients with Arrhythmias and Conduction Problems** **Recognize the following ECG rhythms: Identify causes, relevant assessments, priority actions, & treatments for each rhythm** **Normal Sinus Rhythm** 60-100 bpm **QRS Complex**: Narrow, \ - **Supraventricular Tachycardia -** **SVT\ ** Atrial rate is 150-250 bpm\ Ventricular rate is 150-250 bpm\ Rhythm -- regular\ QRS -- normal, but may be abnormal\ P wave -- no discernible P waves\ PR-i cannot be measured\ Ratio is 1:1 - **Premature Ventricular Contractions:** PAC complex that occurs when an\ electrical impulse starts in the atrium before the next normal impulse of the sinus node\ Rate depends on rhythm\ Rhythm is irregular\ P wave is seen or be hidden in T wave\ PR-i is shorter than normal but still 0.12- 0.20 sec\ 1:1 ratio - **Management:\ ** No tx needed**\ ** Avoid stimulants -- caffeine**\ ** Replace K+ - **Ventricular Fibrillation** - Most common arrhythmias in patients with cardiac arrest ventricular fibrillation, which is rapid, disorganized ventricular rhythm that causes ineffective quivering of the ventricles. Most common cause is coronary artery disease - **Ventricular Tachycardia (with & without pulse) pg.706**- 3 or more PVC's in a row, occurring a rate exceeding 100 bpm. Patients with larger MI's and lower ejection fractions are at higher risk of lethal VT. - **Medical Management:** Procainamide, amiodarone, sotalol, lidocaine (antiarrhythmic medication) - **Torsades de Pointes -** **This is tx with Mag -- 4g or more IV** - **1^st^ degree AV Block-** occurs when all the atrial impulses are conducted through the AV node into the ventricles at a rate slower than normal. - **2^nd^ degree AV Block, Type I-** Occurs when there is a repeating pattern in which all but one of a series of atrial impulses are conducted through the AV node into the ventricles. It takes a longer time for conduction than the one before, until one impulse is fully blocked. - **2^nd^ degree AV Block, Type II**- occurs when only some of the atrial impulses are conducted through the AV node into the ventricles. - **3^rd^ degree AV Block**- occurs when no atrial impulse is conducted through the AV node into the ventricles. **Always assess your patient!** **Medications to Know:** - **Adenosine** Class V antiarrhythmic  **Action:** Temporarily blocks the AV node to interrupt abnormal electrical pathways, used to treat certain **supraventricular tachycardias (SVT)**, like **PSVT**.  **Administration:** Rapid IV push, followed by a saline flush. - **Atropine** Anticholinergic  Action: Blocks the effects of the **vagus nerve** on the heart, increasing heart rate, and improving conduction in **bradycardia** or **heart block**.  Administration: IV, usually in emergency situations. - **Magnesium**  **Class**: Electrolyte.  **Action**: Regulates heart electrical activity, used for **torsades de pointes** and arrhythmias.  **Administration**: IV or oral - Warfarin - Antiarrhythmics -- - **Amiodarone- III antiarrhythmic.** - **Diltiazem: Calcium channel blocker.**  **Action: Slows AV conduction, used for atrial fibrillation and SVT.**  **Administration: Oral or IV.** - Metoprolol: **Class**: Beta-blocker. ** Action**: Reduces heart rate, used for **atrial fibrillation**, **angina**, and **heart failure**. ** Administration**: Oral or IV. - Digoxin: Cl**ass**: Cardiac glycoside.  Action: Increases contraction force, used for **heart failure** and **atrial fibrillation**.  Administration: Oral or IV. **Decreased Cardiac Output (Chapter 23 pg.759) --** causes, symptoms, assessment **Causes:** - **Heart failure, arrhythmias, MI, valvular disease, cardiomyopathy, hypovolemia, sepsis, cardiac tamponade.** **Symptoms:** - **Fatigue, dizziness, shortness of breath, hypotension, chest pain, pale/cool skin, edema, confusion.** **Assessment:** 1. **Vital signs: Low BP, irregular heart rate, tachypnea.** 2. **Physical exam: Skin color, JVD, edema, lung crackles.** 3. **Heart sounds: Murmurs, gallops.** 4. **Tests: Elevated BNP, electrolyte imbalances, ECG for arrhythmias, echocardiogram for heart function.** 5. **Chest X-ray: Signs of pulmonary edema.** **Symptoms:** **Prioritize between multiple patients based on severity of symptoms --** ABCs, acuity **Cardioversion vs Defibrillation --** indications for each, procedural considerations **Cardioversion:** tachyarrhythmias **Procedure:** - **Synchronization**: A synchronized shock is delivered to the heart to restore normal rhythm. - **Timing**: Shock is delivered **during the QRS complex** (when the heart is not in the refractory period). - **Conscious sedation** is usually administered (patient may be awake). **Defibrillation:** Emergent situations for ventricular fibrillation and Pulseless Ventricular Tachycardia (most common abrupt cardiac function and sudden cardiac death) **Procedure:** - **Unsynchronized shock is delivered to the heart.** - **Shocks are delivered at any point in the cardiac cycle.** - **No sedation is required (typically performed during CPR and while the patient is unresponsive).** **Cardioversion is used for stable arrhythmias like AF, while defibrillation is used in life-threatening,** **Code Blue / BLS:** priority order of interventions **CODE PROCEDURE\ ** Assess ABCD's (quickly, no more than 10 seconds)\ Call a Code Blue and have someone bring the crash cart\ Begin CPR (need a backboard)---ESSENTIAL!!\ Push hard and fast\ Code procedure is determined by patient's underlying pathology**---LOOK FOR THE\ UNDERLYING CAUSE!\ Remain present even after the code team arrives!\ Need to provide code team with information** **"H's & T's"** -- what are they, interventions to treat **H's:** 1. **Hypoxia** - **Treatment**: Administer **oxygen** or improve ventilation. 2. **Hypovolemia** - **Treatment**: Administer **IV fluids** or **blood** for hemorrhage. 3. **Hydrogen Ion (Acidosis)** - **Treatment**: Administer **sodium bicarbonate** if metabolic acidosis is present. 4. **Hypothermia** - **Treatment**: **Rewarm** the patient gradually (e.g., heated blankets, warm IV fluids). 5. **Hypokalemia** - **Treatment**: **Potassium replacement** via IV. 6. **Hyperkalemia** - **Treatment**: **Calcium chloride** or **calcium gluconate**, **sodium bicarbonate**, **insulin/glucose**, and **dialysis** if severe. 7. **Hypoglycemia** - **Treatment**: Administer **dextrose** or **glucose**. **T's:** 1. **Tablets/Drug Overdose** - **Treatment**: Administer antidotes (e.g., **naloxone** for opioids), or treat with **activated charcoal** if indicated. 2. **Tamponade (Cardiac)** - **Treatment**: **Pericardiocentesis** to remove fluid around the heart. 3. **Tension Pneumothorax** - **Treatment**: **Needle decompression** or **chest tube** to relieve pressure. 4. **Thrombosis (Pulmonary)** - **Treatment**: **Thrombolytics** (e.g., alteplase) or **embolectomy** for pulmonary embolism. 5. **Thrombosis (Coronary)** - **Treatment**: **Percutaneous coronary intervention (PCI)** or **thrombolytics** for a myocardial infarction (MI). **Pacemakers** -- indications for pacing : Treat advance HF, pulse impulse formation, symptomatic AV, or ventricular conduction. **Transcutaneous Pacing** - **Indication**: Temporary measure for symptomatic bradycardia or heart block. - **Procedure**: External electrodes deliver electrical impulses to stimulate the heart. - **Cause**: Pacemaker impulses fail to stimulate the heart. - **Management**: Reposition electrodes, adjust settings, correct electrolyte imbalances. **Permanent pacer education-** restrict activity on that side of the implantation - **Follow-up**: Regular checkups for pacemaker function. - **Activity Restrictions**: Avoid heavy lifting or electromagnetic interference. - **Signs to Watch**: Dizziness, fainting, swelling, or infection at the pacemaker site. - **Care**: Keep the site clean and avoid pressure. **Implanted Cardioverter-Defibrillator** -- indications and function **Indications:** detects and terminates life threatening episodes of tachycardia or fibrillation. Ventricular arrhythmias (VT, VF) especially after a cardiac arrest or in patients with symptomatic VT. **Function:** Continuous heart monitoring for abnormal rhythms; Defibrillation for VF or pulseless VT; Cardioversion for fast VT; Anti-tachycardia pacing (ATP) for certain VT; Bradycardia pacing if the heart rate is too slow. **The ICD detects dangerous arrhythmias and delivers shocks or pacing to restore a normal rhythm.** **Chapter 28 -- Assessment of Hematological Function and Treatment Modalities** **Blood Transfusions** -- nursing assessments prior, symptoms/types of transfusion reactions, nursing interventions in event of reaction **Nursing Asssessments prior:** - Blood Count - Hematocrit \< 21 or hemoglobin \< 8 - Patient History - Verify allergies - Transfusions before? - Transfusion reactions? What type, what symptoms, what happened - Not everyone can be premedicated if they've had a previous reaction - Physical Assessment - Gain a baseline - IV access: at LEAST a 20g (can do 22g - but has to be run SLOW) - Patient Education - The procedure - Inform the patient to report S/S of an chills, itching, rash, or unusual symptoms - Nursing responsibilities for blood transfusions - Informed consent - Type and screen: is valid for 72 hours up until midnight of that 3rd day - Take baseline vital signs prior to beginning transfusion - Start the infusion of the blood product and record the time - Start administration of blood slowly no more than 2 mL/min for the first 15 minutes or as required **Symptoms/types of transfusion reactions:** - Febrile Non-Hemolytic Reaction - Most common - Occurs when patient has had a previous reaction or if they have an increased sensitivity reaction (like with allergies) - Chills, fever, anxiety - Acute Hemolytic Reaction - Most dangerous - can result in death - Bc antibodies of the patient are rapidly combining with the antigens of the red cells that are being delivered to them, and destroying them - Fever, chills, low back pain, chest pain and dyspnea - Symptoms can worsen - Can be premedicated: benadryl, corticosteroid or tylenol - Allergic Reaction - Itching and hives - Transfusion associated circulatory overload (difference between TACO and TRALI) - Hypervolemia as a result of blood being transfused too fast - S/S of fluid overload - Dyspnea, orthopnea, tachycardia, HTN, sudden onset anxiety, JVD, lung congestion, crackles, pulmonary edema - High risk: HF, CKD, elderly, previous MI - Diuretics ordered after every unit of blood is delivered - Can develop up to 6 hr after the infusion has completed - Bacterial Contamination - Rare, but can occur at any time in the processing of the blood - Transfusion related acute lung injury (TRALI) - Can be potentially fatal - No known cause of why it develops ¯\\\_(ツ)\_/¯ - Can develop up to 6 hr after the infusion has completed - Interstitial and alveoli become extremely edematous: fluid fills the lungs rapidly, triggers a mini ARDS reaction (WBC and histamine reaction can cause capillary permeability allowing more fluid to enter) - When white cells get involved and enter into the lung spaces, it creates a barrier of fluid and gas exchange can't happen - SOB, extremely hypoxic, low PaO2 - Segway to P to F ratio (measurement for lung function) LOW P to F ratio (\ - Encourage a balanced diet that includes **iron-rich foods** and other essential nutrients to support overall health. In addition to iron, foods rich in vitamin C (like citrus fruits and bell peppers) can help enhance iron absorption. - **Heme iron** (found in animal products) is more easily absorbed by the body: - Red meat (beef, lamb) - Poultry (chicken, turkey) - Fish and shellfish (salmon, tuna, shrimp) - **Non-heme iron** (found in plant-based foods) is less efficiently absorbed but still valuable: - Legumes (lentils, chickpeas, beans) - Leafy green vegetables (spinach, kale) - Tofu - Fortified cereals and grains - Dried fruits (raisins, apricots) - **Oral iron supplement is the primary mode of treatment:** - **On an empty stomach**: Iron supplements are usually best absorbed when taken on an empty stomach (ideally 1 hour before or 2 hours after meals). However, if they cause stomach discomfort, it's okay to take them with food. - **Vitamin C**: Taking iron with a source of vitamin C (like orange juice) can improve absorption. - **Iron supplements can cause gastrointestinal side effects**, including: - Nausea - Constipation - Stomach upset or cramping - Dark stools (which is harmless, but can be alarming for patients) - If GI issues persist, suggest trying a **slow-release** or **ferrous gluconate** formulation, which might be easier on the stomach. - **Additional considerations:** - **Check for underlying conditions**: If a person's anemia is due to something like chronic blood loss or another medical condition (e.g., IBD), those issues need to be managed alongside the iron supplementation. - **Monitor iron levels**: Regular follow-up with blood tests can help track progress and adjust supplementation if needed. - **Vitamin B12 deficiency** **Causes/Risk Factors:** 1. **Malabsorption Disorders:** - Conditions like Celiac disease, Crohn's disease, or tropical sprue can affect the intestines\' ability to absorb vitamin B12. 2. **Medications that Decrease Stomach Acid Production:** - Proton pump inhibitors (PPIs) and H2 blockers reduce stomach acid, which is necessary for the release of vitamin B12 from food for absorption. 3. **Dietary Deficit (Rare):** - A vegan diet or a diet lacking animal products (which are the primary sources of B12) can lead to a deficiency, although this is uncommon if a balanced diet is followed. 4. **Lack of Intrinsic Factor:** - Pernicious anemia occurs when there is a lack of intrinsic factor, a protein in the stomach needed for B12 absorption. This is an autoimmune condition that impairs vitamin B12 uptake. - **Assessments:** **General Symptoms:** - Fatigue and weakness due to reduced oxygen delivery by low red blood cells. - Paleness or pale skin. - Shortness of breath and dizziness. **Neurological Symptoms:** - Numbness or tingling in the hands, feet, or legs (due to nerve damage). - Memory problems or difficulty concentrating (cognitive dysfunction). - Balance problems or difficulty walking. **Gastrointestinal Symptoms:** - Glossitis: A smooth, red, sore tongue. - Mouth ulcers or sores. - Nausea, vomiting, and loss of appetite. **Anemia Symptoms:** - Fatigue, pale skin, and heart palpitations due to the decrease in red blood cells. **Blood Tests:** - Low B12 levels: Confirm the deficiency. - Elevated homocysteine and methylmalonic acid (MMA): These markers are often elevated in B12 deficiency and can help confirm the diagnosis. **Management/Education:** - **Folic acid deficiency** **Causes/Risk Factors:** **Dietary Deficiency:** - **Inadequate intake of folate-rich foods like leafy greens, legumes, and fortified grains can lead to folate deficiency, though this is less common in developed countries with fortified food products.** **Alcoholism:** - **Chronic alcohol use can impair folate absorption and increase folate excretion in urine, leading to a deficiency.** **Pregnancy:** - **Pregnant women have increased folate requirements to support fetal growth and prevent neural tube defects. Without adequate supplementation, folate deficiency can occur.** **Malabsorption Disorders:** - **Conditions like Celiac disease, Crohn's disease, or tropical sprue can interfere with folate absorption in the intestines.** **General Symptoms:** - **Fatigue and weakness due to decreased red blood cell production.** - **Paleness or pale skin from anemia.** - **Shortness of breath and dizziness with exertion.** **Gastrointestinal Symptoms:** - **Glossitis: A swollen, red, sore tongue.** - **Mouth ulcers or sores.** - **Loss of appetite, nausea, and vomiting.** **Neurological Symptoms (less common, but possible):** - **While folate deficiency typically does not cause significant neurological symptoms on its own, it may coexist with vitamin B12 deficiency (which can cause neurological issues), so neurological signs may be present in some cases.** **Blood Tests:** - **Low folate levels in blood tests confirm the deficiency.** - **Normal or slightly elevated B12 levels (to help differentiate from B12 deficiency).** - **Elevated homocysteine levels: This marker can be elevated in folate deficiency.** **-Management/Education:** **Increase the amount of folic acid in the diet and administer a supplement** 1. **Increase Folate-Rich Foods:** - **Eat more leafy greens, legumes, citrus fruits, and fortified grains.** 2. **Folic Acid Supplements** 3. **Address Underlying Causes:** - **Treat any issues like alcoholism or malabsorption.** 4. **Monitoring:** - **Regular blood tests to track folate levels and treatment response.** **Education:** - **Diet and Supplements: Encourage a balanced diet and adherence to supplements.** - **Monitor for Symptoms: Be aware that excessive folic acid can mask B12 deficiency.** - **Aplastic** A rare disease caused by a decrease in or damage to stem cells in the\ bone marrow\ Will lead to neutropenia and thrombocytopenia as well - **Causes/Risk Factors:** **1. Idiopathic (Unknown Cause):** - In many cases, the exact cause of aplastic anemia is unknown. This is referred to as idiopathic aplastic anemia, which means there is no clear, identifiable trigger or reason why the bone marrow stops producing blood cells. However, it is believed to result from an immune system attack on the bone marrow or stem cells, which leads to the failure of blood cell production. **2. Certain Medications or Toxins:** - Several medications and toxins can damage the bone marrow, leading to aplastic anemia. Some examples include: - **Chemotherapy drugs:** These are used to treat cancer but can also harm the bone marrow as a side effect. - **Certain antibiotics:** Medications like chloramphenicol (rarely used today) have been associated with aplastic anemia. - **Anticonvulsants:** Drugs like phenytoin (Dilantin) may be linked to this condition. - **Nonsteroidal anti-inflammatory drugs (NSAIDs):** Long-term use of these, especially in higher doses, may sometimes cause bone marrow suppression. - **Benzene:** A chemical found in some industrial environments, solvents, and gasoline, has been linked to aplastic anemia. - **Pesticides and some heavy metals:** Exposure to certain environmental toxins may increase the risk of developing aplastic anemia. **Other Causes and Risk Factors:** - **Viral infections:** Some viral infections, such as hepatitis, Epstein-Barr virus (EBV), cytomegalovirus (CMV), and HIV, can trigger aplastic anemia by affecting bone marrow function. - **Autoimmune diseases:** Conditions like systemic lupus erythematosus (SLE) can cause the immune system to mistakenly attack the bone marrow. - **Genetic conditions:** Some inherited conditions can increase the risk of aplastic anemia, such as Fanconi anemia and Diamond-Blackfan anemia. - **Radiation exposure:** Exposure to high doses of radiation, such as from nuclear accidents or excessive medical imaging, may cause damage to the bone marrow. - **Pregnancy:** Though rare, aplastic anemia can occur during pregnancy due to immune system changes or other unknown mechanisms. - **Assessments:** - **Asymptomatic initially**: Often no symptoms until bone marrow function is significantly reduced. - **Symptoms of anemia** (low red blood cells): - Fatigue, paleness, shortness of breath, dizziness. - **Low white blood cells** (leukopenia): - Frequent infections, fever. - **Low platelets** (thrombocytopenia): - Easy bruising, petechiae (red spots), excessive bleeding, nosebleeds. - **Severe symptoms** (if untreated): - Risk of severe infections, bleeding, and organ damage. **-Management/Education:** 1. **Stem Cell Transplant:** - **Goal:** To replace the damaged bone marrow with healthy stem cells, typically from a matched donor. - **Consideration:** Often recommended for young patients or those with severe aplastic anemia. 2. **Immunosuppressive Medications:** - **Goal:** To suppress the immune system, which may be attacking the bone marrow. - **Common drugs:** Antithymocyte globulin (ATG), cyclosporine, and corticosteroids. 3. **Supportive Therapy:** - **Blood Transfusions:** To manage low red blood cell or platelet counts and prevent severe anemia or bleeding. - **Antibiotics/Antifungals:** To treat infections due to low white blood cell counts. - **Iron Supplements:** If blood transfusions lead to iron overload. **Education:** - **Infection prevention:** Emphasize good hygiene and avoiding crowds to reduce infection risk. - **Blood count monitoring:** Regular check-ups to monitor blood cell levels. - **Medications adherence:** Stress the importance of following prescribed treatments, including immunosuppressants and any necessary antibiotics. - **Stem cell transplant care:** If undergoing a transplant, educate on pre-transplant conditioning, possible complications, and post-transplant care. **Immune Thrombocytopenic Purpura (ITP) --** patho, management **-Patho:** **Autoimmune Disorder**: ITP is a condition where the immune system mistakenly attacks and destroys **platelets** (blood cells responsible for clotting). **Common in Children and Young Women**: It\'s more prevalent in these populations, though it can occur at any age. **Platelet Destruction**: The body produces **autoantibodies** that bind to platelets, leading to their destruction in the spleen or liver. **Unknown Trigger**: The exact cause is unclear, but it may be triggered by infections, vaccines, or other unknown environmental factors. **-Management:** - **Medical Management\ **\Primary goal is to maintain a "safe" platelet count (at least 30,000)\ \Decision to treat is based on platelet count and severity of bleeding\ \>Approaches include:\ \>Stop medications that may be causing the disease\ \>Use of immunosuppressive agents or IVIG - **Nursing Management**\ \> Assessment of patient's lifestyle to determine bleeding risk\ \>Education on S/S to observe for, medication regimens, and frequency of\ platelet monitoring\ \>Explore patients fatigue and often strategies for it **Sickle Cell Disease --** patho, symptoms, interventions for crisis **-Patho:** - Inheritance of HbS Gene: Sickle cell anemia is caused by inheriting the sickle hemoglobin gene (HbS), which leads to the production of abnormal hemoglobin. - Hemoglobin Crystallization: Under low oxygen conditions, HbS molecules crystallize, causing red blood cells (erythrocytes) to become rigid and sickle-shaped. These sickled cells are less flexible and can block blood flow in small vessels. - Hemolysis: The sickle-shaped cells are fragile and break apart more easily, leading to hemolytic anemia (destruction of red blood cells). This decreases the number of circulating healthy red blood cells. - Impaired Oxygen Transport: The sickled cells have trouble transporting oxygen efficiently, leading to symptoms like fatigue, pain, and organ damage. - Diagnosis in Childhood: Sickle cell anemia is typically diagnosed in early childhood, often through newborn screening. - Reduced Life Span: Due to complications from blocked blood flow and organ damage, the average life expectancy is shortened, though it varies depending on the severity of the condition and access to medical care. **-Symptoms:** - **Anemia** - **Thrombi formation** - **Hypoxia and Ischemia** - **High infection risk** **Acute Vaso-occlusive crisis** - **Trapping of RBC's in the circulation causing hypoxia and ischemia** **Aplastic Crisis** - **Rapid drop in HGB level as a result of the human parvovirus** **Sequestration Crisis** - **Organ damage as a result of pooling of sickled cells** **Other manifestations of sickle cell anemia** - **Acute chest syndrome -- fever, respiratory distress, and lung infiltrates** - **Pulmonary HTN** - **Stroke and reproductive problems** **-Interventions for Crisis:** **1. Managing Pain and Fatigue:** - **Administer pain meds (opioids/NSAIDs).** - **Encourage rest and warmth to reduce pain.** 1. **Promote and Manage Infection:** - **Administer antibiotics as needed.** - **Monitor for infection signs and promote good hygiene.** 2. **Promote Coping Skills:** - **Provide emotional support and encourage open communication.** - **Refer for counseling or support groups.** 3. **Minimize Knowledge Deficit:** - **Educate about sickle cell, pain management, and crisis triggers.** - **Teach lifestyle changes (hydration, temperature control).** 4. **Monitor for and Manage Complications:** - **Monitor vital signs and assess for complications (acute chest syndrome, stroke).** - **Ensure hydration and coordinate necessary treatments (e.g., transfusions, oxygen).** **Hemophilia --** patho, complications **-Patho:** **1. Genetic Disorder: Hemophilia is an X-linked recessive genetic disorder, meaning it is passed down through the X chromosome. It primarily affects males, as they have only one X chromosome.** **2. Deficiency in Clotting Factors: The condition is caused by a deficiency in one of the clotting factors:** - **Hemophilia A: Deficiency of Factor VIII.** - **Hemophilia B: Deficiency of Factor IX.** **3.Impaired Blood Clotting: Without sufficient clotting factors, the blood does not form clots properly, leading to prolonged bleeding after injury or surgery.** **4.Bleeding Tendency: Individuals with hemophilia may experience spontaneous bleeding into joints, muscles, and soft tissues, as well as severe bleeding episodes even from minor cuts or bruises.** **5. Severity: The severity of hemophilia depends on the amount of clotting factor present in the blood:** - **Mild: 5-40% of normal clotting factor.** - **Moderate: 1-5% of normal clotting factor.** - **Severe: Less than 1% of normal clotting factor.** **-Complications:** **Joint Damage:** - **Repeated bleeding into the joints (hemarthrosis) can lead to chronic joint damage and arthritis, especially in weight-bearing joints like the knees, elbows, and ankles.** **Internal Bleeding:** - **Bleeding into muscles, soft tissues, or organs can lead to swelling, pain, and, in severe cases, organ damage.** **Brain Bleeding (Intracranial Hemorrhage):** - **Bleeding in the brain is a life-threatening complication that can occur from head trauma or spontaneously, leading to neurological damage, seizures, or even death.** **Prolonged Bleeding:** - **Even minor injuries or surgeries can lead to excessive bleeding, which can be difficult to stop without proper treatment.** **Infections from Blood Transfusions:** - **In the past, patients receiving clotting factor concentrates were at risk of blood-borne infections (like HIV or hepatitis), though modern blood products are now safer.** **Inhibitor Development:** - **Some individuals with hemophilia develop inhibitors (antibodies) that neutralize the clotting factors, making treatment less effective and complicating management.** **Death:** - **Severe bleeding episodes, especially into critical areas like the brain, throat, or chest, can be fatal if not treated promptly.** **Bleeding Precautions** -- who is at risk, assessments, precautions, education **Bleeding Precautions** **Who is at Risk?** - **Patients with bleeding disorders (e.g., hemophilia, thrombocytopenia)** - **Those on anticoagulants (e.g., warfarin, heparin, direct oral anticoagulants)** - **Patients with liver disease (e.g., cirrhosis, hepatitis)** - **Chemotherapy or radiation patients who have suppressed platelet production** - **Patients with low platelet counts or vitamin K deficiency** - **Recent surgery or invasive procedures patients** **Assessments:** - **Monitor for signs of bleeding: Check for easy bruising, petechiae (small red or purple dots), nosebleeds, or gums bleeding.** - **Vital signs: Pay attention to changes in blood pressure or heart rate, which may indicate blood loss.** - **Hemoglobin and hematocrit levels: Track these lab values to detect any significant blood loss.** - **Assess for changes in urine or stool color: Look for blood in the urine (hematuria) or stool (melena).** - **Check for abnormal bleeding after procedures: Any signs of excessive bleeding post-surgery or post-procedure should be noted.** - **Monitor for confusion or dizziness: These may indicate low blood volume or oxygen levels due to internal bleeding.** **Precautions:** 1. **Minimize Invasive Procedures: Avoid injections, venipunctures, and invasive procedures unless absolutely necessary.** 2. **Use Soft Toothbrushes and Electric Razors: Prevent cuts and gum bleeding.** 3. **Apply Pressure After Blood Draws/IV Insertions: Apply pressure to sites of blood draws or injections for a longer duration to prevent excessive bleeding.** 4. **Avoid Antiplatelet Medications: Discontinue or avoid medications like aspirin or NSAIDs that can increase bleeding risk.** 5. **Use Protective Gear: Consider wearing protective gear (e.g., helmets, knee pads) for patients at risk of falls or injury.** 6. **Monitor for Excessive Bleeding: Any signs of internal bleeding (e.g., abdominal pain, swelling, black or tarry stools) should be reported immediately.** 7. **Limit Physical Activity: Encourage rest and avoid activities that increase the risk of injury or trauma (e.g., contact sports).** **Education:** - **Teach the patient and family about recognizing signs of bleeding (e.g., blood in urine/stool, excessive bruising, prolonged nosebleeds).** - **Instruct on avoiding activities that may cause injury: For example, avoid heavy lifting, contact sports, and using sharp objects.** - **Educate about medication management: Make sure the patient knows to avoid aspirin and NSAIDs, and follow prescribed anticoagulant therapy strictly.** - **Promote safety measures: Use soft toothbrushes, electric razors, and ensure that the home is free of potential hazards to prevent falls or injuries.** - **Stress the importance of prompt medical attention: Encourage the patient to seek medical help immediately if they notice any abnormal bleeding or bruising.** **Neutropenic Precautions** -- who is at risk, assessments, precautions, education **Who is at Risk?** - **Cancer patients (especially those undergoing chemotherapy or radiation)** - **Bone marrow disorders (e.g., leukemia, myelodysplastic syndromes)** - **Immunosuppressive therapy (e.g., organ transplant patients, those on corticosteroids or biologics)** - **HIV/AIDS patients with low CD4 counts** - **Severe infections that suppress bone marrow function** - **Advanced age or malnutrition leading to a weakened immune system** **Assessments:** - **Monitor vital signs: Check for fever, which is a common sign of infection in neutropenic patients.** - **Inspect skin and mucous membranes: Look for signs of infection (redness, swelling, drainage, sores).** - **Monitor lab values: Track absolute neutrophil count (ANC) to assess the level of neutropenia.** - **Monitor for symptoms of infection: Chills, cough, pain, dysuria, or any signs of localized infection.** - **Assess for fatigue or weakness: Often linked to infections or neutropenia.** **Precautions:** 1. **Strict Hand Hygiene: Healthcare providers and visitors should wash hands thoroughly before entering the room.** 2. **Protective Isolation: Patients should be kept in a private room with air filtration (reverse isolation) if necessary.** 3. **Limit Visitors: Only healthy individuals should visit. Sick visitors should be excluded.** 4. **Avoid Crowded Areas: Limit exposure to potential sources of infection.** 5. **Daily Vital Sign Monitoring: Especially temperature---fever is a sign of infection.** 6. **Avoid Raw Foods: No raw fruits, vegetables, or undercooked meats to prevent infection from foodborne pathogens.** 7. **Wear Mask, Gloves, and Gown: Healthcare providers and visitors should use personal protective equipment (PPE) to prevent infection transmission.** **Education:** - **Teach the patient and family about the importance of hand hygiene and infection prevention.** - **Explain the risk of infection and when to contact healthcare providers (e.g., if fever develops or any symptoms of infection appear).** - **Provide guidelines for diet: Instruct the patient to avoid raw or undercooked foods and to only drink pasteurized beverages.** - **Encourage the patient to stay in a clean environment and avoid crowded places to minimize exposure to infections.** - **Educate on the signs of infection (fever, chills, redness, pain) and the importance of prompt medical attention.** **Disseminated Intravascular Coagulation --** patho, risk factors **Pathophysiology of Disseminated Intravascular Coagulation (DIC):** 1. **Inflammatory Response:** - **DIC is triggered by an inflammatory response, often due to infections, trauma, cancer, or other underlying conditions.** 2. **Activation of Coagulation Cascade:** - **The inflammatory process leads to the excessive activation of the coagulation system, causing a widespread activation of clotting factors throughout the body.** 3. **Formation of Thrombi:** - **Multiple thrombi (blood clots) form in small blood vessels, restricting blood flow and leading to ischemia (lack of oxygen) in various organs and tissues.** 4. **Consumption of Clotting Factors:** - **As clotting factors are consumed in excessive clotting, the body becomes deficient in clotting factors, which leads to bleeding in other areas (such as the skin, gastrointestinal tract, or internal organs).** 5. **Resulting in Ischemia or Bleeding:** - **The combination of ischemia from thrombi and bleeding due to clotting factor consumption causes a dangerous cycle of clotting and bleeding, leading to severe organ dysfunction, tissue damage, and potential multi-organ failure.** **-Risk Factors:** - **Aggressive management of the underlying cause is key to preventing or treating DIC.** - **Improving oxygenation: Inadequate oxygen levels can trigger DIC, so ensuring proper oxygenation is vital.** - **Replacing fluids: Fluid resuscitation helps support circulation and prevent tissue damage.** - **Correcting electrolyte imbalances: Imbalances in electrolytes can worsen DIC, so it's important to restore normal levels.** - **Administering vasopressors: These medications may be necessary to support blood pressure and organ perfusion.** - **Replacing depleted platelets and coagulation factors: Platelet transfusions and clotting factor replacements help manage bleeding.** - **Heparin/Low Molecular Weight Heparin (LMWH): These anticoagulants may be used cautiously to prevent excessive clotting in certain cases of DIC.** - **Nursing management: Nurses must be vigilant in identifying patients at risk for DIC (e.g., those with sepsis, trauma, or malignancy) and frequently assess for early signs and symptoms of DIC.** **Risk Factors for Disseminated Intravascular Coagulation (DIC) (chat gpt):** 1. **Infections:** - **Sepsis (particularly bacterial infections like Gram-negative sepsis)** - **Viral infections (e.g., COVID-19, influenza)** 2. **Trauma or Surgery:** - **Severe trauma (e.g., burns, crush injuries)** - **Major surgery (especially obstetric, vascular, or cancer-related surgeries)** 3. **Cancer:** - **Leukemia and other solid tumors, particularly when metastasizing** - **Obstetric complications like amniotic fluid embolism, placental abruption, or eclampsia.** 4. **Obstetric Complications:** - **Pregnancy-related complications like HELLP syndrome, abruptio placentae, and eclampsia.** 5. **Severe Allergic Reactions:** - **Anaphylaxis can trigger an inflammatory response leading to DIC.** 6. **Acute Liver Disease:** - **Liver failure or cirrhosis, since the liver produces many clotting factors.** 7. **Toxins or Drug Reactions:** - **Severe drug reactions, such as thromboplastin release from damaged tissue or certain medications like heparin (causing heparin-induced thrombocytopenia).** 8. **Massive Transfusions:** - **Receiving large volumes of blood products or transfusion reactions can trigger DIC.** 9. **Vascular Disorders:** - **Aortic aneurysms or arterial trauma.** 10. **Hypoxia and Shock:** - **Low oxygen levels and inadequate blood circulation (e.g., from shock) can induce DIC.** **Chapter 30 -- Management of Patients with Hematologic Neoplasms** **Myelodysplastic Syndrome --** patho, education, treatment **Patho:** A group of disorders in which the myeloid stem cells in the bone marrow undergo dysplasia **Education:** - Education about chelation therapy: - Iron is bound to a cheating agent and excreted in the urine - Long term therapy, especially if the pt is getting repeated transfusions + chelation therapy only removes a small amount of iron at a time - Side effects: diarrhea and abnormal cramping - Take medication in the evening prior to bedtime - Monitor kidney function bc nephrotoxic **Treatment:** - Medical management is based on the stage of the disease and the prognosis - Low risk disease: improve low blood counts, giving repeated blood transfusion, improving quality of life - High risk disease: aggressively repeating blood transfusion decreasing the likelihood of it evolving into AML - Success rate isn\'t too high with the use of chemotherapy w high risk pt - Infection rates are high - Iron overload is one of the biggest issues for these patients - Requires frequent chelation therapy - Nursing Management focused on: - Extensive education about infection and bleeding risk, fatigue, frequent monitoring of labs - The chronic nature of the disease and risk of progression to AML **Acute Myeloid Leukemia (AML) --** patho, diagnosis, symptoms, treatment **Patho:** Results from a defect in the stem cells that produce myeloid cells **Diagnosis:** Any age group can be affected, but more common over the age of 45 (peak is around age 67) - CBC - Bone Marrow Biopsy - Hallmark is an excess of blast cells **Symptoms:** - Manifestations develop without warning (over a few weeks) - Result from a decreased production of all normal blood cells - Fever, infection, weakness, dyspnea, fatigue, bruising and bleeding (decrease in RBCs and platelets) - Leukemic cells can also collect in organs enlarged liver or spleen splenectomy or part of the liver removed **Treatment:** - Overall goal is to achieve complete remission - Induction therapy - Aggressive administration of chemotherapy (high dose, highly toxic, \ 60% - Prevalence - Median onset is 65 years old - Survival rate: 14-24 years - Over time the spleen can get bigger (because of the overproduction of RBCs) and start to participate in erythropoiesis - The bone marrow can become fibrotic and stop producing RBCs ³ causing this disease to go into AML (when it becomes AML ³ it's resistant to treatment & the survival rate is only a few months) **Treatment:** - Medical Management - Therapy is based on the age of the patient and if they have a history of thrombosis - Phlebotomy is the primary source of treatment - Goal: reduce the risk of thrombosis without increasing the risk of bleeding - Keep the HCT less than 45 - Reduce the risk of evolution to AML - We're removing blood to reduce the blood viscosity and deplete the patient's iron stores - ½ L of blood once or twice/week iii. Aggressive management of atherosclerosis and hyperlipidemia - Decreasing the risk of thrombus formation - Hydroxyurea: suppresses bone marrow production - Nursing Management: Focus on symptom management - Managing Fatigue: cluster care, encourage ambulation - Managing the Pruritus: use of SSRIs, UV therapy, cold baths, oatmeal based lotions - Management and preventive strategies for complications - Encourage changing modifiable risk factors: losing weight, eating healthier, exercise, medication adherence, use of TED hose, discouraging sedentary lifestyle, avoid the use of aspirin - Educate the s/s of bleeding (esp. Internal bleeding) **Prioritization of assessment & care --** based on patient symptoms, severity, acuity **Dosage Calculations -- IV infusions** -- calculate infusion rate in mL/hr