Nursing 2400 Acute Illness | Cambrian College | Nursing Course

Nursing 2400- Acute Illness Frances Cavanagh [email protected] NUR2400 In this course, students will utilize the nursing process as the organizing framework for critical thinking, knowledge development, and the care and management of hospitalized adults. St...

Nursing 2400- Acute Illness Frances Cavanagh [email protected] NUR2400 In this course, students will utilize the nursing process as the organizing framework for critical thinking, knowledge development, and the care and management of hospitalized adults. Students will recognize priority nursing assessments and interventions associated with symptom management of common illness conditions relevant to hospitalized medical and surgical clients. Students will reflect on the lived experience of clients and families coping with acute illness, as well as cultural and ethical concerns and their implications for nursing practice. Content in this course is presented within a framework of evidence-informed decision- making.  DCO Moodle Syllabus Learning Activities How to navigate Case studies – concept-based this course? Course Assessments Midterm Exam: 30% Final Exam: 30% Kaplan Testing (2 parts): 15% Case Study 1: In-class, individual 15% (week 4) Case Study 2: Group 15% (week 10)  1-5 Evidence- Informed Practice  An assertive, problem-solving approach to the identification and treatment of The Nursing patient health problems Process Provides an organizing framework for the knowledge, judgements, and actions that nurses bring to patient care Phases of the nursing process Assessment Priorities Planning Implementation Evaluation  1 2 3 4 Evaluation Phase Determine whether sufficient assessment data Determine if patient outcomes and interventions are Determine if patient outcomes have been met Determine whether plan should be maintained, have been obtained realistic modified, revised, or to make a nursing discontinued diagnosis Cancer Characteristics and Numbers… > 200 diseases Uncontrolled and unregulated growth of cells and defective differentiation… caused by mutations ~ 1 in 4 Canadians will die from cancer Prevalence vs incidence Progress: modifiable risk factors Malignancy, metastasis, neoplasm and immunosuppression Benign vs. malignant neoplasm Classification and Staging** Prevention and early detection Nurses play a large role in prevention & detection Early detection and prompt treatment=increased survival rates Public education and recommendations Prevention and early detection Carcinogens: Agents that cause cancer 1. Chemical: long latency period 2. Radiation 3. Viral (HIV, HPV, Hep B) 4. Genetics Promoters: Dietary Fat, Obesity, Cigarette smoking, Alcohol consumption Prevention and early detection Breast: mammograms and BSE Colon and rectum: FOBT Prostate: PSA test and digital rectal examination Uterus (cervical): Pap test and HPV vaccine Diagnosis of Cancer Fear and anxiety Role of the nurse… Screening and diagnosis Manifestations based on site, tumor size Diagnostic testing Tumor markers Tumour Markers Substances produced by cancer cells or that are found on plasma cell membranes, in the blood, CSF, or urine Hormones Enzymes Genes Antigens Antibodies Diagnosis of Cancer: Diagnostics Cytology studies Hematology and chemistry Sigmoidoscopy or colonoscopy Radiological studies (e.g., CXR, mammography, CT, MRI) Radioisotope scans (e.g., bone, liver, thyroid) Assays for presence of antigens or genetic markers Bone marrow examination Biopsy: histological examination** definite Needle, incisional or excisional Treatment GOALS Can change over time prevention (prophylaxis) – prevent the growth of cancer cells or to remove precancerous tissue cure – cure the cancer. control – control the tumour and stop cancer from growing and spreading + reduces the risk of recurrence palliation – cure not possible, so treatment is given to: temporarily shrink tumours reduce symptoms, such as bleeding, pain or pressure treat problems caused by cancer or its treatment improve a person's comfort and quality of life Collaborative Care Cure, Control, Palliation Factors that determine treatment modality offered Cell type Location and size of tumour Extent of disease Physiological and psychological status Expressed needs and desires Clinical Trials Treatment Plans Based on each person's unique situation Primary treatment Combination of treatments: together or at different times, depending on the type or stage of cancer. neoadjuvant – tx given before the primary tx to shrink a tumour so that it is easier to treat with the primary therapy adjuvant – tx given after the primary therapy to control the cancer more effectively, to destroy any remaining cancer cells or to reduce the risk of the cancer recurring Treatment: Surgery Eliminate or reduce risk of cancer in at-risk clients Cure and Control Remove only as much tissue as necessary: tumor+margins Good prognostic indicators: small size, clean tissue margins, absence of lymph node involvement and absence of abnormal tumour marker values Adjuvant therapy Preventive measures to ↓ surgical seeding of cancer cells Supportive and Palliative Rehab Treatment: Chemotherapy Use of chemicals as systemic therapy for cancer Goal: reduce # of malignant cancer cells in tumour site(s) Mainstay for most solid tumours and hematological cancers (leukemia/lymphoma) Response r/t: Mitotic rate of tissue of origin Size, Age and Location of tumour Presence of resistant tumour cells Treatment: Chemotherapy Action: Cell cycle phase–nonspecific (all phases + G 0) Cell cycle phase–specific Preparation and Handling Protocol at HSN Route: IV (most common) Drugs may be irritants or vesicants Complications: vessel damage, catheter problems (infection), extravasation CVAD Treatment: Chemotherapy Chemotherapeutic agents cannot selectively distinguish between normal and cancer cells Bone marrow stem cell Myelosuppression, infection, bleeding, anemia Neutrophils Leukopenia, infection Epithelial cells lining GI tract Anorexia, stomatitis, esophagitis, nausea and vomiting, diarrhea Cells of the hair follicle Alopecia Ova or testes Reproductive dysfunction Treatment: Chemotherapy Adverse effects can be: Acute, Delayed, Chronic Treatment: Chemotherapy Treatment plan Drugs given in combination: different actions and synergistic Also minimizes occurrences and severity of side effects Dosages: body surface area or weight nadir: lowest level of the peripheral blood cell count (esp WBC) 2o. bone marrow suppression nadir following most chemo occurs in 7-28 days Want drugs with different nadirs Treatment: Radiation Local treatment modality: emission and distribution of energy Cure, control and often palliation* Generates free radicals that break bonds in DNA, causing loss of proliferative capacity Cellular damage may be lethal or sublethal Normal tissues are usually able to recover Cancer cells are more likely to be permanently damaged Fractionated doses; cell cycle phase dependent Treatment: Radiation Dose α size, type, tx setting Radiation field External vs internal Brachytherapy and precautions Treatment: Bone Marrow Transplant Cure and control: risky and low cure rates Allows high doses for treatment Tumour cells eradicated and bone marrow is rescued by infusing healthy cells - leukemia Collect from iliac crest or sternum (+ peripherally or cord) 2-4 weeks for recipient to start producing blood cells: pancytopenic period = problem Graft-versus-host disease Pain after harvesting Nursing Management Differentiate between toxic effects of treatment and progression of the malignant process Body’s response to products of cellular destruction ?what is tolerable Supportive therapies Resources See Table 18-14 : common adverse effects Management Pain Fatigue Cachexia/Anorexia Bone marrow suppression Infection Skin Reactions GI tract effects Pulmonary effects Increased risk for leukemias and other secondary malignancies And many more! Management: Pain*** Moderate to severe pain = ~ 50% of active tx pts Occurs in 80% of those with advanced cancer Under-treatment is common and has serious outcomes on Patient’s quality of life Patient’s ability to function Family caregiver burden Why and what can we do about it? WHO ladder- Freedom from Cancer Pain Management: Fatigue Identifying when client is feeling better may allow more activity Rest before activity Get assistance with activity Other SE exacerbate (anorexia, fever, anemia, nausea) Maintain nutritional and hydration status Mild physical activity May continue after treatments  Management: Anorexia and Malnutrition Anorexia May develop as a general reaction to treatment Peaks at about 4 weeks and resolves more quickly than fatigue Body weight should be measured at least twice weekly Small, frequent meals of high-protein, high-calorie foods ?supplements → 5% weight loss is noted Exacerbated by GI issues Referral to dietitian Management: BM suppression Myelosuppression: Most common side effect of chemotherapy – why? Infection Hemorrhage Overwhelming fatigue Treatment-induced reductions r/t lifespan of blood cell type, chemo/rad dose and type Neutropenia: WBC growth factors, at risk for infection Thrombocytopenia: transfusion if platelets 150-400x109/L Anemia: transfusions, erythropoietin, later… other SE’s Management: Infection Primary cause of death in cancer clients Some sites of infection (>38oC) Lungs Genitourinary tract system Mouth, rectum Peritoneal cavity, blood Febrile Neutropenia * (neutrophils 3,000-5,800 x106/L) Clinical pathways – panculture, early antibiotic therapy Treat fever? Management: Skin Reactions Dry desquamation should be lubricated with nonirritating lotion or solution that contains no metal, alcohol, perfume, or additives Wet reaction must be kept clean and protected from further damage Facilitate wound healing and prevent infections Erythema can develop 1-24 hours after a single rad tx Management: GI effects Assessment is important! Hydration, nutrition and alkalosis too Oral mucosa Taste affected, dry mouth, difficulty swallowing, mucositis Saliva substitutes or drink water frequently Avoid extreme temperatures, alcohol, and tobacco Esophagitis and intestines – n/v/d Prophylactic administration of antiemetics (table 43-1) Antidiarrheal, antimotility, and antispasmodic medications Soft, nonirritating, low-fibre, high-calorie, high-protein Management: Pulmonary Effects May be progressive and irreversible Rad: pneumonitis Bronchodilators, expectorants, bed rest, O2 Chemo: pulmonary edema, fibrosis, pneumonitis Cough, SOB… frightening Obstructive Emergencies Superior vena cava syndrome (tumour or thrombosis) Facial and periorbital edema; Distension of veins of head, neck and chest; Seizures; Headache Spinal cord compression (tumour) Intense, localized, persistent back pain; Motor weakness; Sensory paresthesia/loss; Δ bladder or bowel function Third space syndrome Bowel Obstruction (acute abdomen) Pain, n/v, bloating, no flatulence, constipation (or diarrhea if partial) Metabolic Emergencies Caused by production of ectopic hormones Syndrome of inappropriate antidiuretic hormone (SIADH) secretion Hypercalcemia (usually bone or multiple myeloma) nausea and vomiting, anorexia, polyuria/nocturia, muscle weakness, confusion, fatigue, ECG changes Fluids, loop diuretics, bisphosphonate*, calcitonin Tumour lysis syndrome Septic shock… (acute circulatory failure) Disseminated intravascular coagulation (DIC) Infiltrative Emergencies Cardiac tamponade Fluid accumulation in pericardial sac, constriction of pericardium by tumor, or pericarditis Carotid artery rupture Invasion of the arterial wall by tumour or erosion following surgery or radiation therapy Pleural effusion Thoracentesis (“tapping”) for drainage/analysis Management: Psychosocial Emphasis placed on maintaining optimal quality of life Positive attitude of client, family, and health care providers can have a positive impact on the client’s quality of life Common fears? Management: Psychosocial Coping with cancer depends on… HOW CAN WE SUPPORT PT AND FAMILY? PERFORMANCE ASSESSMENT Karnofsky Performance Status quantify cancer patients' general well-being and activities of daily life… evaluate a patient's ability to survive chemotherapy for cancer Zubrod score/WHO Nursing Priorities r/t symptoms from disease location or treatment SE Constipation r/t treatment interventions Urinary retention r/t obstruction of urethra or bladder neck by the prostate Deficient fluid volume r/t ↓ in intestinal fluid absorption and loss of fluids secondary to vomiting Imbalanced nutrition: less than body requirements r/t intestinal obstruction and vomiting Ineffective airway clearance r/t increased secretions and presence of tumour Ineffective breathing pattern r/t decreased lung capacity Nursing Priorities Acute pain r/t surgery, tumour enlargement, metastasis… Sexual dysfunction r/t effects of treatment Decisional conflict r/t lack of knowledge about treatment options and their effects Body image disturbance r/t… Anxiety/fear r/t anticipated physical and emotional effects of treatment modalities Breast cancer Numbers… Risk factors for women ≥60 years of age Family history Personal history of cancer (breast, colon, endometrial, ovarian) Early menarche or late menopause Full-term pregnancy >30 years of age Benign breast disease with atypical epithelial hyperplasia, lobular carcinoma in situ Weight gain and obesity after menopause Exposure to ionizing radiation Combined hormone replacement therapy BRCA genes S&S Most are ductal and invasive Detected as lump or mammographic abnormality Most often in upper, outer quadrant of breast Dense with glandular tissue Rate of lesion growth varies Slow-growing lesions associated with lower mortality rates Hard, irregular, poorly delineated, non-mobile, and non-tender S&S Small percentage cause nipple discharge Usually unilateral and clear or bloody Nipple retraction may occur Peau d’orange Infiltration, induration, dimpling of overlying skin in large cancers Breast asymmetry Correlation with menstrual cycle Recurrence Diagnostics Mammography, Ultrasound, Biopsy Screening: BSE Tests for recurrence: axillary lymph node status, tumour size, hormone status, cell proliferation Treatment Treatment - dictated by stage classification Single most powerful prognostic factor after primary therapy = presence or absence of malignant cells in lymph nodes Surgery: Lumpectomy or Mastectomy Axillary node dissection vs sentinel lymph node dissection Lymphedema Post-mastectomy pain syndrome F/up q6mo x2yrs Chemo and radiation Hormonal therapy Nursing Management: Breast Cancer Decisional conflict related to lack of knowledge about treatment options and their effects Fear, anxiety, or both related to diagnosis of breast cancer Disturbed body image related to anticipated physical and emotional effects of treatment modalities Overall goals: active participation in tx decision, adherence with tx plan, management of adjuvant SE, support by others and health care team. Nursing Management: Breast Cancer Assessment: Subjective: past health history, meds, surgeries/other tx, symptoms Objective: -general and all systems Nursing Management: Breast Cancer Implementation: Acute interventions- physical and psychological Nursing Management: Breast Cancer Psychological Care Nursing Management: Breast Cancer Post op care Restore arm function Pain Acute lymphedema Complete decongestive therapy Elevation of arm (level with heart) Diuretics Isometric exercises Wearing a fitted elastic pressure gradient sleeve during waking hours Nursing Management: Breast Cancer Ambulatory and home care Emphasize annual mammography and BSE May need referral to a mental health care provider Specific instructions about appointment times and treatment locations, if adjuvant therapy is used Explain symptoms that should be reported after discharge and in the future Transitions in Care Are a significant point in the provision of health care during which a person’s information and care needs are transferred between health and social service providers, interprofessional teams and settings. Occurs when a person moves from one setting or sector to another setting or sector where care or services are provided, including (but not limited to): primary care; home and community care; mental health and substance use health settings; acute care; rehabilitation; LTC; correctional facilities; and shelters. RNAO BPG, 2023 Transitions in Care - BPG It is good practice that health and social service providers collaborate with persons and their support network before, during and after a transition in care in order to ensure a safe and effective transition. It is good practice that health and social service providers assess with persons and their support network their care needs and readiness for a transition. It is good practice that members of the interprofessional team collaborate to develop a transition plan that supports the unique needs of persons and their support network. Transitions in Care - BPG In order to ensure medication safety, it is good practice for health providers to conduct the following in collaboration with the person encountering a transition and their support network: obtain a best possible medication history; and perform medication reconciliation at all transition points. It is good practice for health and social service providers to provide persons and their support network with information and support to manage their needs during and after transitions in care. Transitions in Care: Role of the Nurse Nurses play a key role in promoting successful transitions by developing and evaluating the transition plan and identifying and communicating barriers to the plan. Nurses must engage patients and caregivers as active partners and advocates for their healthcare and community support needs. Nurses must extend their scope of influence on longer term outcomes by identifying and documenting transition issues early, implementing strategies to address concerns, and communicating the transition plan to the next level of care. SBAR (IHI - https://youtu.be/aR-S8UUAG6Y?si=FvFFQ6EkScS6xFPk) (S) Situation: What is the situation you are calling about? Identify self, unit, patient, room number. Briefly state the problem, what is it, when it happened or started, and how severe. (B) Background: Pertinent background information related to the situation could include the following: The admitting diagnosis and date of admission List of current medications, allergies, IV fluids, and labs Most recent vital signs Lab results: provide the date and time test was done and results of previous tests for comparison Other clinical information Code status (A) Assessment: What is the nurse’s assessment of the situation? (R) Recommendation: What is the nurse’s recommendation or what does he/she want? Examples: Notification that patient has been admitted Patient needs to be seen now Order change Content Review  2-75 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 Improve services to enhance access to Health Equity and reduce exclusion from healthcare Health inequality comprises differences in the health status of individuals and groups as a result of the determinants of health. Health inequity refers to health inequalities that are a result of factors that are generally considered to be unfair or unjust and modifiable.  2-76 Cultural Competence A process by which nurses recognize the need for the knowledge and skills to modify assessment and intervention strategies in order to achieve equity in heath quality and outcomes A critical attribute for the provision of safe, effective, quality care Different from cultural safety  2-77 Cultural Competence ABCDE of Cultural Competence 1. Affective (awareness and sensitivity) 2. Behavioural (skills) 3. Cognitive (knowledge, theory, research, cross-cultural approaches to care) 4. Dynamics of differences (discrimination, racism, social power imbalances) 5. Equity in health care (context, environment) Nursing Management: 2-78 Cultural Competence in Care LEARN Model for Cross-Cultural Care* Listen with sympathy and understanding to the patient’s perception of the problem. Explain your perception of the problem. Acknowledge and discuss the differences and similarities. Recommend treatment. Negotiate agreement. Pain  Unpleasant sensory Whatever and and emotional whenever the person experience associated experiencing pain says with actual or potential Definitions it is tissue damage of Pain Pain can be Multidimensional and experienced in the entirely subjective absence of identifiable tissue damage. Dimensions of Pain and the Pain Process Physiological Dimensions of Pain: Transmission  Causes and Types of Pain By underlying By duration pathology Nociceptive- damage to somatic or visceral Neuropathic Acute Persistent tissue Damage to peripheral Burning, shooting, Sudden, intense, Somatic Visceral nerve or central stabbing, or electrical short-lived, or nervous system in nature lingering Arises from bone, Arises from internal Tumour involvement Aching or throbbing Localized joint, muscle, skin, or organs such as the or obstruction connective tissue intestine and bladder Initial Pain Assessment Initial assessment focuses on eight areas (OPQRSTUV): Onset Provocative/Palliative Quality- acute, chronic, breakthrough Region- localized, generalized, referred Severity- Reliable measure to determine treatment Treatment/Timing Understanding Values  Pattern, area, intensity, and nature (“PAIN” Pain acronym) Assessment: Patients may use words other than “pain.” Sensory– Discriminative The nurse documents words that the patient Component uses in describing pain. The nurse asks the patient about pain, using those words Pain Assessment: Intensity of Pain Pain Assessment: Motivational– The effects of pain on the patient’s sleep and Affective, daily activities, relationships, physical activity, and emotional well-being should be assessed. Behavioural, Cognitive– Past pain experiences, meaning of pain for Evaluative, and the patient, ways the patient expresses the pain, and the patient’s pain-control strategies Sociocultural should all be included. Components  Pain Treatment: Basic Principles ROUTINE ASSESSMENT IS UNRELIEVED ACUTE PAIN PATIENTS’ SELF-REPORT MULTI DIMENSIONAL AND ESSENTIAL FOR COMPLICATES RECOVERY. OF PAIN SHOULD BE USED MULTI MODAL TREATMENT EFFECTIVE MANAGEMENT. WHENEVER POSSIBLE. PLAN  10-90 Scheduling analgesics Focus on prevention or ongoing control. Do not wait for severe pain to occur. Constant pain requires around-the- Medication clock administration (not PRN). Therapy for Pain Fast-acting medications for incident or breakthrough Long-acting medications for constant pain  These strategies control pain before it starts and usually result in lower analgesic requirements.  10-91 Medication Therapy for Pain: Analgesic Ladder Medication Alert Opioids may cause respiratory depression. Withhold medication if respirations are