Chapter 13: Cancer Care PDF

**Chapter 13: Cancer Care** **Overview of Cancer Care:** -Cancer is the second leading cause of death worldwide. It is a malignant transformation of cells that is caused by a carcinogen. -carcinogens can include excessive sun exposure, tobacco products, excessive alcohol consumption, environmenta...

**Chapter 13: Cancer Care** **Overview of Cancer Care:** -Cancer is the second leading cause of death worldwide. It is a malignant transformation of cells that is caused by a carcinogen. -carcinogens can include excessive sun exposure, tobacco products, excessive alcohol consumption, environmental exposures, chemicals such as agent orange, asbestos, benzene (found in gasoline), and radiation. A carcinogen causes DNA destruction, resulting in cellular mutations that may ultimately lead to malignant transformation of cells. The exposure alone to these does not cause cancer. Cancer is caused by carcinogenesis which is the initiation and promotion of cancer involving molecular changes after exposure. **Incident of cancer:** -78% of cases in the US found in adults are 55 years or older -most common types of cancer worldwide are lung, breast, colorectal, stomach, prostate **Cancer risk factors:** -genetics: age (person has a greater exposure to carcinogens overtime, immune function lessons, making them more susceptible to cancers), race, genetic predispositions  -nutrition/lifestyle: GERD (esophageal cancer), obesity (many different cancers), sexual lifestyle (ovarian or pelvic cancer), sun/radiation exposure, use of tobacco (risk for 20 different types of cancer) or alcohol -immune function: chronic irritation of tissue or trauma, chronic disease, exposure to some viruses or bacteria -Living conditions: poverty, air pollution, or occupational exposures -non-modifiable risk factors include age, genetics, race **Carcinogenesis:** -occurs when a person is first exposed to the carcinogen. The exposure to this carcinogen, most likely occurs multiple times. Genetic mutations also occur overtime. The immune system typically recognizes mutation and initiates cell death. Although sometimes the mutation is missed which can lead to cell death not happening or the system does not detect the mutation and begins replicating developing into cancer. **Cancer characteristics:** -uncontrolled cell growth: cancer cell growth is unregulated, lacks contact inhibition, does not undergo apoptosis, no anchorage dependence, dysplasia, neoplasia. -Contact inhibition: is when normal cells stop growing and reproducing when they come into contact with other cells. This does not happen in cancer. -Apoptosis: is when the cell cycle ends with programmed cell death. Meaning most cells do not stay around forever. This does not happen in cancer cells, they lack apoptosis (no programmed cell death). -Anchorage dependence: normal cells need to anchor to neighboring cells or basement cells so that they can plug into a nutrient rich, extracellular matrix to remain viable. Cancer cells grow and floorage in atypical patterns and environments. -dysplasia: uncontrolled growth or deranged cell growth, cells, and size, shape, and organization. Dysplasia does not always mean cancer it can mean abnormal size, shape, and organization of the cell, however, cancer cells do exhibit dysplasia. -neoplasia: uncontrolled cell proliferation (rapid increase in numbers), new cell growth, pattern, again this does not necessarily mean cancer, but does happen in cancer. Overall cancer cells are malignant neoplasms that grow uncontrollably and invade surrounding tissues and vessels. They have the capacity to destroy normal tissue, steel nutrition, create their own blood vessels, and survive under anoxic or acidic conditions. -Altered cell differentiation: Anaplasia, cancels cells (well differentiated, undifferentiated, a mix **Metastasis:** -metastasis means the cancer cells are no longer at the primary site. They can spread through the lymphatic system or through the blood system. Once they are in lymph nodes, cancer cells may be destroyed, grow into a mass, remain dormant, or spread to a more distant lymph node, and potentially into the vascular. Hematological spread occurs when the cancer cells migrate into the Venous system that drains the organ where the cancer originated. Many cancers metastasize in a predictable pattern. Once cancer has metastasized. It keeps the same properties and has simply relocated. -a primary tumor is considered the original origin  -secondary tumor or metastatic tumor is the new location -ex of metastasis: colon cancer often spreads to the liver through the blood. Prostate cancer often spreads to the rectum, pelvic floor, lower spine, and hip through the lymph nodes. Lung commonly spreads to the bone and to the brain. **Types of cancer:** -There are essentially two types of cancer, a solid tumor, which is specific to a body organ (examples include lung, breast, bladder, kidney, brain, colon, rectal) and hematological which arises from hematopoietic cell lines, leukemia involves blood cells, lymphoma involves lymphatic system, and multiple myeloma is cancer that involves plasma cells and immunoglobulins (these three arise from the hemophilic cell lines).  **Classification of cancer:** -Stages one through four: I-small tumor without obvious spread II-invasion of deer, tissues or involvement or lymph nodes III-Large or locally invasive tumors IV-cancers that have metastasized -all hematological cancers are considered stage four at time of diagnosis as they are not well contained or localized. **Clinical presentation:** -Caution symptoms: Change in bowel/bladder, A sore that doesn't heal, Unusual bleeding/discharge, Thickening or lump, Ingestion/dysphasia, Obvious changes in wart/mole, Nagging cough/hoarseness. (These are symptoms/signs that bring people to the hospital or the doctor.) -constitutional signs are vague symptoms, such as fatigue, significant unexplained, weight loss, fever of unknown etiology, night sweats -Malignancy specific are related to location of primary tumor and possibly secondary tumors (ex: Brain Cancer (symptoms could be pain secondary to tumor compression of nerves in the skull, memory deficits or visual disturbances). Breast cancer (axillary, node, involvement or nipple discharge.) Bladder (you could have low back pain, distended abdomen, abdominal discomfort, or hematuria). Leukemia (fatigue, anemia, chronic infection, bruising, gum bleeding). Esophageal cancer (dysphasia, indigestion, or chest discomfort). Multiple myeloma. (Fatigue, dark and frequent urinations, bone pain)). These malignancy specific signs are related to the tumor in mass compression or erosion into normal anatomical structures. **Complications:** -anorexia/cachexia syndrome: lack of eating, lack of appetite, wasting syndrome. -hypercoagulation: anyone with cancer is at risk for blood clots. This is a very common occurrence for someone with cancer. -effusion: effusion is the buildup of fluid this could be pericardial (fluid in the space around the heart) or plural (between the layers of tissues that line the lungs) -Fluid or electrolytes and glucose imbalances: the presence of a malignancy alters the micro environment of the body causing changes in hormonal balances, metabolic pathways, and cellular nutrition. Fluids can be high or low, electrolytes can be higher low, and glucose can be high or low -clinical depression: onset of clinical depression can almost be sudden when patient is given the diagnosis of cancer or can take a little longer to show face **Ontological Emergencies: ** -This includes what emergencies can happen with cancer. These are acute clinical complications where urgent treatment is required. These emergencies are due to either two or growth, metabolic changes, or from the result of treatment. -metabolic emergencies: include hypercalcemia, hyponatremia, hypoglycemia, tumor lysis syndrome (occurs when tumor cells release their content into the bloodstream, this could happen either spontaneously or in response to treatment, leads to the characteristic finding of hyperuricemia (high levels of uric acid), hyperkalemia, hyperphosphatemia, hypocalcemia). -infectious/hematologic emergencies: include neutropenic fever, hyperviscosity syndrome (occurs when the blood thickens so much that it doesn't flow freely through blood vessels), leukocytosis  -neurological emergencies: malignant spinal cord compression, increased intracranial pressure, seizures -cardiovascular emergencies: pericardial effusion, and cardiac tamponade (cardiac tamp, what happens when extra fluid builds up in the space around the heart, that would be from a pericardial effusion, however, pericardial effusion develop into a cardiac tamponade when the fluid put so much pressure on the heart that it prevents it from pumping blood, this is a medical emergency), superior vena cava syndrome (a group of problems caused when blood flow through the superior vena cava is slowed. Remember that the SVC is a large vein that draws blood away from the head, neck, arms, and upper chest into the heart. Superior vena cava syndrome is most often seen in people who have cancer in most cases of the syndrome, the blood flow slows down over a few days or even weeks And symptoms cause the person to get medical help. In very rare cases this syndrome happens fast and may lead to a blockage of the SVC.  -Respiratory emergencies: malignant airway obstruction (if someone has neck or throat cancer) -Chemotherapeutic emergency: Extravasation of chemotherapy (when medication vesicant leaks into the tissue, causing necrosis. All chemotherapeutic agents are considered vesicants.) anaphylactic reactions to chemotherapy. -different types of cancer are prone to developing different types of emergencies, meaning anticipate the diagnosis, treatment and outcomes based on certain cancers. **Prevention:** -what are the modifiable changes we can make? -Diet: healthy body weight, participate in physical activity, minimal high fat, processed foods, breast-feed infants for the first six months -lifestyle: avoid smoking, alcohol and tobacco, avoid risky, sexual behavior, avoid environmental exposures, protection from UVA and UV rays, immunizations.  **Treatment:** -curative: disease free state. Means that the treatment is aimed at completely eradicating the cancer from the body leaving a permanent cure. -remission: disease, free state, unclear if disease has been eradicated or if this disease free state will remain stable. The cancer symptoms are red, reduced, or disappear, remission can be partial where some cancer cells remain or complete where there are no detectable signs of cancer. -oncogene: this is the gene that produces cancer. In a normal cell oncogenes control, cell growth, and division, however when mutated or over expressed they can drive uncontrollable cell proliferation leading to cancer. Long-term suppression is based on suppression of the oncogene through medication. A disease free state can occur as long as the medication is being consistently taken. This targets the faulty cellular pathway and is common in lymphomas. Disease free with medication assistance. -palliation: alleviating burden of symptoms. This occurs when curing the cancer is not generally a primary consideration. The focus is on relieving symptoms and improving the quality of life, such as reducing pain and other discomfort. If the cancer is not curable, the goal may be to reduce tumor, burden, or prevent progression. **Diagnosis:** -biopsy: shave or needle or incisional sentinel lymph node biopsy. A piece of tissue is taken to the lab and analyzed. -laboratory studies: blood, urine, cerebral spinal fluid (CSF), bone marrow are all analyzed and are looking for abnormalities -Imaging studies: CT, MRI, X-ray, ultrasound, positron emission tomography (PET scan). This is when the location of the tumor can be determined. Biopsies will give you more information on the type of tumor. Biopsy tell you more about the type of cancer -endoscopy/bronchoscopy/colonoscopy: a deeper, closer looked at a tumor -order is: laboratory studies, imaging, biopsy, endoscopy if needed (Least invasive to most of massive) -tumor marker assay: a lab test that indicates whether or not someone is a candidate for a particular targeted therapy. It is sometimes referred to as biomarkers for cancer treatment. Tests for these biomarkers are typically genetic tests that look for changes in genes that affect cancer growth. A tumor marker is anything present in or produced by cancer cells or other cells of the body in response to cancer or certain benign conditions that provide information about a cancer, such as how aggressive it is, whether it can be treated with a targeted therapy, or whether it is responsive to treatment. PSA tests can be related to cancer. **Treatment modalities:** -Includes surgery, radiation, and medication treatment.  -Surgery includes tumor removal and margins of surrounding tissue. Reconstruction might be necessary after the tumor is resected. Patients put a greater risk of infection after surgery as well as blood clots. They may take the whole tumor out or just part of the tumor and treat the rest with other modalities rehabilitation in consultation with PT and OT are required for optimal. Return to activities. -Radiation is a localized delivery of ionizing radiation to internally destroy DNA structures within malignant cells and induce cell death. Because cell death is occurring with radiation you want to minimize exposure to normal tissues and cells. The radiation is given through an external beam and pt is positioned so that the part of the body that has the cancer is hopefully only being radiated. Brachytherapy happens internally via placement into a cavity or reservoir in the body (common in prostate cancer). Radiation dose is dependent on size and type of tumor. It is common to have five days of radiation into days of rest on the weekend, this can be completed anywhere between five and 18 cycles which can be a lot for patience -neoadjuvant therapy is the first step to shrink a tumor before treatment, which is usually surgery or destruction (examples include chemotherapy, radiation, therapy, and hormone therapy) **Chemotherapy:** -a type of cancer treatment that uses medication to kill or stop the growth of rapidly dividing cancer cells. This is a systemic treatment meaning it is not targeted to one specific area of the body.  -There are multiple routes available to administer chemotherapy: topical, oral, parental, IV intra-arterial (method of delivering concentrated doses of cancer, killing medications directly to the affected area of the eye. In intra-arterial therapy, the chemotherapy dose is released into the ophthalmic artery which is the primary blood supply to the back of the eye, this can often be for retinoblastoma), intraventricular, intracavitary, intravesicular (when chemotherapy is instilled in a vessel and example of this is in the bladder.) intrapleural (includes hyperthermic intraperitoneal intrapleural chemotherapy, which is a procedure performed by highly skilled surgeons following surgery. During the procedure, the surgeons deliver heated chemotherapy directly into the abdominal or plural cavity where it can penetrate disease tissue directly), intrathecal (when the medication is given in the fluid around the brain and spinal cord, it is given during a lumbar puncture procedure).  -IV is still the most common!! The nurse must handle all chemotherapy agents utilizing appropriate techniques due to toxicity. -Patients who receive chemotherapy typically have a more advanced disease, diseases of the blood, or the bone marrow, or cancers that are not amenable to single modality, surgical or radiation therapies. Because it is systemic, normal cells are destroyed with cancer cells, including hair, skin, intestinal, tissues, blood forming cells; which is why patients will lose her hair and it will cause nausea and vomiting. medication doses are based on the tumor location, size, type, growth rate. -complications that nurse nurses must monitor for include immunosuppression/neutropenia, nausea/vomiting/anorexia, alopecia, mucositis/stomatitis, anemia, thrombocytopenia.  **Additional therapies:** -Ablation therapy: where the cancer is burned or frozen -Hormone therapy: used to treat prostate and breast cancer that use hormones to grow. This type of therapy is most often used along with other cancer treatments. The types of treatments that you need depend on the type of cancer, how far it has spread, it uses hormones to grow, if you have other health problems. -Immunotherapy: A type of cancer treatment that helps your immune system fight cancer. The immune system helps your body fight infections and other diseases. It is made up of white blood cells and organs and tissues of the lymph system. Immunotherapy is a type of biological therapy. Biological therapy is a type of treatment that uses substances made from living organisms to treat cancer. -Transplants: (such as organ transplants, mom, liver, typically these patients will be in early stages -supportive therapy can be for spiritual or psychosocial care. **Nursing management:** -Care of patients with cancer crosses all subspecialties of medical Dash surgical nursing and ambulatory primary care. This disease can't affect any organ system and can be managed in a variety of clinical settings. **Chapter 34: coordinating care for patients with hematological disorders** -when there is a hematological disorder, it can affect blood, Blood cells, lymph, and organs involved with blood formation and storage. Blood is important in helping the body. It helps circulate oxygen, nutrients, hormones, and metabolic waste. It protects against invasion of pathogens, maintains blood, coagulation, in regulates, fluids, electrolytes, acid, bases, and body temperature. **Blood makeup:** -plasma: mixture of water, proteins, nutrients, electrolytes, nitrogenous, waste, hormones, and gasses. Plasma is clear, yellow protein, rich fluid. -solutes: proteins, electrolytes, and organic elements. 55% of blood and contains 90% water. -RBC -WBC -platelets: fragments of cells that circulate and are inactive until a vascular injury occurs. About 25 to 40% of platelets are in the spleen and live for approximately 7 to 10 days. **RBC's and WBC's:** -Red blood cells are the most abundant of the formed elements in blood, and have a larger surface area. They are flexible so they are able to go through small capillaries. Red blood cells pick up oxygen from the lungs and are transported to the systemic tissue. They also pick up CO2 from the tissues and deliver it to the lungs. The membrane of the cell is thin so oxygen in carbon dioxide gasses can easily diffuse across it. -White blood cells protect the body against infection and disease And are the least abundant formed element in the body. Granulocytes which contain granules (a type of protein) include neutrophils, eosinophils, basophils. There are also agranulocytes which don't contain granules; these include lymphocytes and monocytes. Granulocytes and agranulocytes make up white blood cells. **Left shift WBCs:** -a left shift is seen within an acute infection, inflammation, and some other physical stress. A left shift indicates presence of immature neutrophils in the blood, and usually but not always indicates an inflammatory leukogram. Immature neutrophils are usually band neutrophils, but early on other forms can be seen. A larger left shift indicates a larger neutrophil consumption in the blood and represents a more severe bacterial infection. High white blood cell count in the blood shows sufficient neutrophils supply to the infection site. **Hematological Assessment:** -HbB/HcT: oxygen carrying components of red blood cells, volume of blood, composed of erythrocytes. -MCV, MCH, MCHC: give further info about red blood cells and help determine cause of anemia -platelets: thrombocytes, form cloth and prevent bleeding. If this level is too high blood clots if this level is too low patients are at risk for bleeding -Reticulocyte Count: measure how fast red blood cells are made and released into the blood. reticulocytes are in the blood for about two days before developing into mature red blood cells. -Ferritin: stores of iron in the liver. Which really measures the body\'s ability to store iron. -transferrin: measures level of iron carrier.  -If there are issues with any of these levels, further investigation of the bone marrow would need to take place. **Bone Marrow Aspiration:** -How do we look at the bone marrow? -Through a bone marrow aspiration. An aspiration is the removal of a fluid specimen in a bone marrow aspiration is done through a needle biopsy which is the removal of a core of Moro cells. These are done at the same time. A bone marrow aspiration is used to diagnose cytopenia, leukemia, granulomas, anemia, and primary metastatic tumors. It is also performed to determine the cause of an infection. It helps stage diseases and evaluates chemotherapy, and monitors myelosuppression.  **Age related changes to the hematological system:** -number of cells decrease, lean body, mass decreases, bone, mass and intracellular, fluids decrease, decrease in total body water **Iron deficiency anemia:** -when the body has exhausted its iron stores. This is the most prevalent nutritional deficiency in the world and is highest among non-Caucasian Americans of lower socioeconomic status. This is so important because every living cell contains iron. And iron is essential to the formation of the hemoglobin molecules of red blood cells. Patients develop iron deficiency and anemia from men with an adequate amount of iron in the diet. -Who is at risk? -Infants, children, pregnant women, menopausal, women, cancer, bleeding diseases. Demand for iron occurs primarily in periods of growth and development and secondary to pathological causes. Premenopausal women have heavy menstrual bleeding. People with cancer have less iron due to treatment such as radiation and chemotherapy. Ulcerative and G.I. problems have bleeding. Poor absorption of iron and chronic use of medication such as NSAIDs, acids, PPI, and H2 inhibitors decrease iron absorption. Patient with a history of G.I. Surgery like a bypass or gastrectomy have absorption issues of iron. -anemia is actually a later manifestation of iron deficiency, manifestations include pallor, tachycardia, Tachia, fatigue, headache, muscle, weakness, PICA, glossitis (the painful swelling of the tongue with a smooth and shiny surface), koilonychia (Spoon shaped fingernails), hypotension (which would be a sign).  Diagnostic and treatment: CBC, MCV, dietary modification, and iron supplement as well as vitamin C supplements  -complications from prolonged iron deficiency include cognitive impairment, low birthweight babies, preterm labor, complications from congestive heart failure, and chronic renal failure. Remember that iron supplementation can change the color of your stool. -nursing involves assessing vital signs, hemoglobin levels, fatigue, shortness of breath (SOB), blood loss. Actions to take include increasing dietary, iron, and vitamin C, administering iron, and minimizing blood loss. Evaluate a child's exposure to lead as lead, may impede iron absorption, and metabolism. **Vitamin B12 Anemia:** -also known as cobalamin deficiency, is a coenzyme in the DNA synthesis of red blood cells and Myelin sheath in the nervous system. It is needed for normal function of the central nervous system. -causes: the deficiency occurs when the body has inadequate source of vitamin B 12, or through mouth absorption disorders, gastric atrophy, aging, decrease intake, G.I. absorption issues, long-term vegetarians, and vegans are at a risk as well as those of lower socioeconomic status. Besides lack of intake about 15 to 25% have this condition due to gastric atrophy and decrease in gastric acid production associated with aging and not necessarily as a result of decreased intake. -clinical manifestations include tachycardia, tachypnea, shortness of breath, dizziness, fatigue, neurological, and psychiatric dysfunctions, Lhermitte sign (an electrical shock sensation that runs down the spine and into the arms and legs when the neck is moved), constipation/diarrhea, anorexia, tinnitus. -complications include, demyelination of nerves that lead to the spinal cord degeneration, peripheral neuropathy, altered level of consciousness and depression. The longer the body goes without adequate levels of vitamin B 12, the more severe neurological deficits become and the increased possibility of the symptoms becoming irreversible. -Diagnosis is done through a CBC, vitamin B12 assay, treatment is through prevention and supplementation. Supplementation is given orally or with weekly IM injections. -increase B12 needs: pregnancy, hyperthyroidism, advanced stages of cancer, intestinal tapeworms. **Vitamin B 12 anemia: nursing management:** -Assess: vital signs, neurological status, lab levels (including folic acid. Folic acid resolves, anemia neurological degeneration due to B12 deficiency continues), fall risk, bowel movements, pain level. -actions: ensure adequate intake, administer vitamin B12 (through diet administration of supplemental B12), monitor use of folic acid. Teaching should consist of dietary sources, the knee for supplementation, reporting symptoms to the physician, prenatal teaching, actions of acid reducing medication. **Folic Acid Deficiency:** -folic acid is also water soluble. It is also known as B9. Fully along with vitamin B 12 form a complex pathway that is involved in DNA synthesis. It is essential for cell maturation. Folic Acid deficiency and B12 deficiency coexist. Acid is important in embryonic neural tube formation, the formation of heme for red blood cell maturation, and neurotransmitter synthesis of certain neurotransmitters. Fully is the form that is naturally found in foods, and folic acid is the synthetic form. This deficiency generally results from inadequate dietary intake or chronic illness, alcohol, abuse, or extreme diets, malnutrition, malignancies, Crohn's disease, celiac disease, malabsorption due to G.I. surgeries. Alcohol can damage or kill bone marrow and progenitor cells leading to cytopenia, , and platelets. Patients taking methotrexate for rheumatoid arthritis often have fold acid deficiencies. Hemodialysis increases the risk of acid deficiency as it increases folate excretion. -Clinical manifestations include mood changes, memory, difficulties, weakness, tachycardia, tachypnea, dizziness, fatigue, thrombocytopenia, pallor, these neurological manifestations are reversible unlike vitamin B 12 deficiencies. Deficiencies during pregnancy are linked to fetal neural tube defects and some congenital oral facial abnormalities. Patients may also develop anemia. -diagnosis is through a CBC, fasting serum, folate, and serum vitamin B 12. -management is through diet and oral supplementation. -nurses assess neurological status, vital signs, and labs -The nurse\'s action is to ensure adequate intake, and administer supplements as needed. -Education involves prenatal, teaching, dietary sources of Folic acid, and supplementation.  **Sickle Cell Anemia:** -Genetic disorder of hemoglobin where the red blood cells are elongated, stiff, and lose flexibility. It is the most severe form of an inherited blood disorder. The sickle cell trait is a genetic mutation that must be present in both parents. Meaning, just like cystic fibrosis, individuals can be carriers without being infected by the condition. Those affected are dominantly descendants from tropical Africa. About 50% of children with sickle cell disease live to adulthood, and ironically, sickle cell disease gives some sort of protection against malaria. 2 million people are carriers in the United States and 72,000 people have the disease. In Africa, the incident is as low as 20% and as high as 40% in some areas. **Sickle Cell Crisis:** -Patients with sickle cell disease are at risk for sickle cell crisis. Red blood cells are normally malleable and can squeeze through my loot capillaries to deliver oxygen. In sickle cell disease, these red blood cells carry less oxygen due to their sickled shape, which is fragile, and break apart as they pass through the capillary beds, resulting in congestion and clumping, leading to thrombus formation. A normal red blood cell lifespan is about 120 days. In sickle cell disease a red blood cell\'s lifespan is about 15 to 20 days. Destruction of the red blood cells causes hemolytic (destruction of cells) anemia. release of Bilirubin, which causes an increase in serum Bilirubin levels, possible congestion in the spleen due to increased red blood cell fragments that must be phagocytized leading to enlargement of the spleen and possibly pain. When the process is rapid and severe, the patient is in a sickle cell crisis. The crisis is precipitated by anything causing hypoxemia including, dehydration, cold temperatures, infection, and environments with low oxygen tension. Crisis can also occur without any apparent reason and can last days two weeks. **Sickle cell anemia: clinical manifestations** -manifestations do not present until after six months of age because the infant is protected by an increased level of fetal hemoglobin in the first few months of life. -Patients often have fatigue, pallor, and SOB, due to the lack of oxygen in the sickle cells. They also experience swelling and pain in the joints, bones, chest, and abdomen due to the Vaso Occlusion of blood vessels. They can also have ischemic organ damage such as a cerebral vascular accident or a stroke, or a pulmonary insplic infarctions. Males experience priapism, which is a disorder in which the penis maintains a prolonged rigid erection in the absence of appropriate stimulation. They also can experience kidney and liver damage. People with sickle cell are prone to respiratory infections due to the impaired function of the spleen and phagocytic action. Educating on the necessity of flu and pneumococcal vaccines are imperative. Women have difficulty with pregnancies due to the increased demand on the body. Death usually occurs from a CVA infection or long-term organ system damage. **Sickle cell anemia: treatment and complications:** -there is no cure. The only cure for sickle cell is a stem cell transplant. The match is generally through a sibling who does not have the sickle cell trait. Success rate of transplant is 85% with a 5% death rate after a stem cell transplant. Graft versus host disease increases morbidity and occurs when the donor of bone marrow or stem cells attack the recipients tissues, and occurs if the T cells in the graft are mature and can destroy the tissues in the graph recipient. Graft versus host disease can cause multi system organ failure, or death if a transplant is not an option. Treatment is focused on preventing crises and managing symptoms. A medication called hydroxyurea causes myelosuppression, 80% decreased the ability of the bone marrow to produce any type of blood cell, however, it does have teratogenic effects and cannot be taken during pregnancy. Blood transfusions are common with the entire blood volume exchange for the angle of less than 50% of red blood cells being tickled. However, the bone marrow will keep producing sickle cell cells so transfusions are done often. Patients can have possible reactions to the transfusions or develop in iron overload leading to hepatomegaly. Penicillin is often given. Prophylactically sense infections can be detrimental. Developmental delays also can occur with sickle cell anemia. CVA are very common and even occur in children. Other complications include infections, tissue, hypoxia, developmental delays, and pregnancy complications. **Sickle cell anemia: nursing management:** -an assessment includes taking vital signs, assessing for shortness of breath, pain, looking for jaundice, hand foot syndrome (uneven growth of fingers, and toes due to episodes of crisis in bone infractions. Look for signs of infections, lab values (decrease lifespan of red blood cells in an increased destruction of RBC, which may lead to an increase in Bilirubin levels. Other labs to assess our iron, B12, and Folate levels, psychosocial issues. -nursing options include administration of oxygen, ration, administering pain, medication, blood transfusions, antics, emotional support.  -the nurse helps to educate on infection prevention, avoiding cold temperatures, dehydration, and over excretion as well as genetic counseling. Malnutrition is a potential complication. Avoiding wearing tight restrictive clothing to avoid Vaso construction, maintain ADLs within prescribed limits, educate about fetal complications, including low birthweight, gestational, hypertension, preterm, labor, spontaneous, abortions, and stillbirths. **Thalassemia: ** -Results from defective synthesis of hemoglobin. This condition has varying degrees of severity. There is a partial or complete deficiency in synthesis of the beta chain of the hemoglobin molecule. So a compensatory increase in this synthesis of alpha chains remains activated resulting in the defective hemoglobin formation. There is an unstable imbalance in polypeptides, causing damage to the red blood cells and anemia. -It is characterized by deficiencies in the rate of production of specific globin chains in the hemoglobin. There are four types of thalassemia, thalassemia minor, thalassemia trait, thalassemia intermedia, thalassemia major (most severe form). To compensate for the hemolytic process, an over abundance of erythrocytes is formed, unless the bone marrow is suppressed by transfusion therapy. RBC changes can be seen by six weeks of age in which the child can present with severe anemia and failure to thrive. -clinical manifestations include pallor, fever, poor feedings, enlarged spleen/liver, headache, small stature, delayed sexual maturation, bronze, freckled complexion, patients often develop chronic hypoxia. -diagnosis include hemoglobin, electrophoresis (test that measures the different types of hemoglobin in the blood), lab levels, clinical manifestations -Treatments include blood transfusions to maintain normal hemoglobin levels however, side effects may include hemosiderosis (iron overload) and occurs with direct deposition of iron, which takes place in the body organs, such as the liver, spleen, pancreas, and skin that causes tissue damage. Hemosiderosis leads to hemochromatosis (severe iron accumulation, accompanied by organ damage). Treatment also includes iron collating drugs, such as deferoxamine. or vitamin C may facilitate finding with iron other treatments include a hematopoietic stem cell transplant and a splenectomy with multiple blood transfusions, the splenectomy decreases the disabling effect of abdominal pressure and increases the lifespan of supplemental red blood cells. The goal for treatment is to keep a hemoglobin above 9.5 with transfusions every 3 to 5 weeks. -Nursing management includes providing support to the patients and family, providing transfusions and treatment, observing for transfusion complications, and assisting with coping strategies. Goal is to prevent bone marrow expansion and body deformities and to provide sufficient red blood cells to support normal growth and normal physical activity. Patients are expected to live well into adulthood with proper clinical management. When death happens, it is from heart disease, post splenectomy sepsis, or multi organ failure secondary to a hemochromatosis. **Polycythemia Vera (Erythrocytosis):** -is a primary or secondary disorder of the mutation of the JAK2 gene which stimulates overproduction of red blood cells and possibly white blood cells and platelets. Erythrocytes is the increase in red blood cells relative to the volume of blood. The body becomes hypoxic as the hyperviscosity slows oxygen exchange to the tissues. Thicker blood is harder for the heart to pump. Women have a hemoglobin above 16 and hematocrit above 48%. Men have a hematocrit greater than 52% and hemoglobin level greater than 18.5.  -the primary disorder is of the bone marrow in which there is an increased production of red blood cells that may be accompanied by an increased production of white blood cells and platelets. This is a genetic mutation visible after birth and can have a familial tendency. -the secondary disorder is response to the hypoxic state. It may be considered appropriate or inappropriate. In the secondary disorder, the white blood cells and platelets remain normal. This condition is appropriate in environments with low oxygen tension, such as high altitude and heavy smoke. High altitudes have lower pressure decreasing the rate of oxygen exchange, this is why athletes train at higher levels as the body has elevated red blood cells and more oxygen carrying capacity. This would be inappropriate if the body responds to a stimulus in an inappropriate way, additional erythropoietin, Resulting in an increased production of red blood cells. This might occur in kidney disease as erythroid is released from the kidneys which stimulates red blood cell production, in order to resolve the body\'s perceived oxygen deprivation. This condition may also be seen in the presence of tumors **Polycythemia Vera: Clinical Manifestations** -headache, dizziness, weakness, splenomegaly (from the congestion of red blood cells), shortness of breath, orthopedic, blurred vision, pruritus, flushing of the face, epoxies, gout.  **Polycythemia Vera: Management:** -diagnosis is through a CBC, erythropoietin level, bone marrow biopsy -complications include thrombosis which can be seen by (MI, CVA, pulmonary infarction) or after a thrombosis happens, a hemorrhage can form, which can be seen by G.I. hemorrhage (this occurs due to the abnormally farmed platelets and a decreased circulating platelets) -medical management: therapeutic phlebotomy (patients have one unit of blood removed per week until their hematocrit is less than 45%), monitor serum ferritin (needs to occur because repeated donations can't cause iron deficiency, anemia), antiplatelet therapy (helps reduce the risk of clots), exercise (increase circulation). The underlying condition needs to be treated if this is a secondary condition. -nursing care includes assessing the patient for flushing, asking about their energy levels as fatigue can be caused by an increased workload of the heart and poor tissue perfusion. Determining if there has been any weight loss since the feeling of fullness leads to abdominal pain and anorexia. Assessing uric levels Which would be elevated in gout and kidney stones. Conditions which may cause secondary polycythemia vera. Actions of the nurses include increasing fluid intake to decrease the viscosity of the blood, ensuring adequate rest and elevating lower extremities to promote blood flow. **Polycythemia vera education:** -Educate patients with symptoms of severe thrombotic events. The rationale for aggressive hydration, eating small, frequent meals, avoiding tight restrictive clothes, avoidance of extreme temperature changes, observing for bleeding, and taking bleeding precautions, keeping in the routine of moderate exercise, regular lab test, genetic testing, quit smoking, and stop mountain climbing. **Leukemia:** -cancer of the white blood cells, where the cells are not functional and invade and destroy bone marrow. The white blood cells are multiplying uncontrollably known as leukocytosis. Leukemia originates from lymphocytes or myeloid stem cells, which include granulocytes, neutrophil, erythrocytes, monocytes, and platelets. There is an unknown stimulus that mutates either myeloid Or lymphoid stem cell which never matures. The clone process becomes uncontrollable filling the bone marrow with these leukemic cells. These cells never lead to a pop ptosis. The bone marrow, spleen and lymph tissue become congested with the blast, leading to lymphadenopathies, omegaly, infiltration of the bodies, mucous membranes and lungs. There are four different forms of leukemia: -ALL or acute lymphoma leukemia which affects lymphocytes and is harder to treat. More commonly found in children. -AML acute myelogenous leukemia and affects the myoblast, red blood cells, and platelets. Found in adults and children. -CLL (chronic lymphocytic leukemia, found in older adults and grows slowly) and chronic myelogenous leukemia (CML, less commonly seen in adults.), both of which eventually degenerate into an acute phase and profess to death if untreated. -risk of leukemia includes Down syndrome (due to the Philadelphia chromosome), previous chemo agents or radiation due to the alterations in the bone marrow function, white nails over the age of 60s. **Leukemia:** -lymph nodes swell due to the blast congestion, the risk of infection is substantially increased due to the increased number of mature infections, fighting cells known as neutrophils, and patients are in neutropenia. Patient's first develop flu-like symptoms or can be asymptomatic. -symptoms that occur include anemia, pallor, weakness, SOB, bone pain joint, swelling, enlarged liver and spleen, weight loss, fever, poor wound healing, evidence of bleeding, lymph node swelling.  -lab tests reveal anemia, leukocytosis, and thrombocytopenia. These are done through CBC, other tests are done due to the effects that leukemia can have on other areas of the body. These test include coagulation studies, liver, and kidney function test, lumbar puncture to assess for any central nervous system involvement and a bone marrow biopsy, the bone marrow biopsy gives us information about immature, leukemic, blast cells, and protein markers, which identify the specific type of leukemia. **Leukemia complications:** -complications usually are a result of treatment. Patients are at high risk for infection and any infection can be life-threatening. -Thrombocytopenia leads to excessive bruising, petechiae, nosebleeds, conjunctival hemorrhaging, bleeding gums, hemoptysis, hematuria, gastrointestinal bleeding -if a patient develops a fever with low neutrophil it is considered a neutropenic fever. And neutropenic precautions are implemented. **Leukemia nursing management:** -this is through frequent, vital signs, fatigue, pallor, dizziness, signs of bleeding, infection, CBC values. -Nursing actions include administering chemotherapy, institute, neutropenic precautions, prophylactic use of antibiotics, antivirals, antifungals, symptom management **Lymphoma:** -malignant lymphoma is divided into two main classifications. Hodgkin lymphoma and non-Hodgkin lymphomas. -Hodgkin lymphoma: accounts for 14% of lymphoma and is determined by the presence of Reed-Sternberg cells. These are specific giant lymphocytes often multinucleated with a particular morphology in an unusual immunophenotype that does not resemble any normal cell in the body. Hodgkin's lymphoma is one of the most curable types of cancer. non-Hodgkin's lymphoma accounts for 4% of all cancers and is more common in men and older adults. Patients with non-Hodgkin's lymphoma do not have reed Sternberg cells. -The causes of lymphoma are not well understood: -non-Hodgkin lymphoma can be linked to pesticides, history of autoimmune disorders, organ transplantation, various viruses (Epstein-Barr virus, HIV, herpes, chlamydia, H. pylori), radiation treatment. -Hodgkin lymphoma has a higher incidence in those with a higher socioeconomic status, infection with Epstein-Barr virus, first-degree relative with Hodgkin\'s disease. -lymphoma develops from a single cell and a lymph node that develops into a solid tumor or mass. as a develops it spreads from one lymph node through the lymph system and can affect other lymphoid tissues and the spleen. -Clinical manifestations of lymphoma include painlessness, enlargement of lymph nodes, fever, weight, loss, fatigue, infections, night sweats, colitis, alcohol induced pain at the site of involvement. **Lymphoma management:** -diagnosis is done through a CBC, CT/MRI/PET scan, biopsy, as well as a lumbar puncture to see if there's any central nerve system involvement. -Treatment may include chemotherapy, radiation, stem, cell transplant, splenectomy.  -Nursing assessment: vital signs, pain (chest pain, shortness of breath, dysphasia), neurological status (expanding lymphoma may cause spinal cord or nerve root compressions) enlarged lymph nodes, skin (looking for itching), CBC results (looking for decreased red blood cell and white blood cell as well as platelets), lower extremities (assessing for pain or swelling, secondary to thrombolytic formation), serum calcium levels (may have hypercalcemia if the cancer has spread to the bones), activity intolerance (because of fatigue due to anemia). -Nursing interventions may include blood transfusions due to the milo suppression that occurs as a result of the treatment regimen, administering chemotherapy, IV fluids, and blood products. Symptom management (easing discomfort or pain, itching, night sweats, and helping with nausea, vomiting), monitoring for infection, routine CBC, emotional support, stressing importance of treatment regimen.  **Chapter 28: Assessment of Cardiovascular Function ** **Overview of the cardiovascular system** -primary function is to deliver oxygenated blood to the tissues and return deoxygenated blood to the heart to be pumped to the lungs. This function is accompanied by using the heart, artery, and veins.  **Vascular System:** -the vascular system is made up of arteries, veins, and capillaries. -Arteries are a high pressure system that carry oxygen blood with the exception of the pulmonary artery. -Veins are a low pressure system, but carry the blood back to the heart. -capillaries are a very low pressure system where oxygen and nutrients are delivered to the tissues and cellular waste are removed. -In oxygen delivery, it starts with the arteries to the arterials, to the meta-artierales, to the capillaries. This is accompanied through a series of vessels gradually decreasing in size eventually entering the smallest vessels which are the capillaries, where the actual oxygen in nutrient exchange takes place. The real work of the vascular system is done at the capillary bed. Their abundance makes them close to virtually every cell in the body. The vascular system provides the delivery of oxygen and blood to the tissues. The removal and transportation of cellular waste, the return of circulatory volume to the right heart, and the return of fluid back to general circulation. **Cardiac Conduction system:** -the work of the cardiac conduction system happens through three avenues: -automaticity: ability to generate impulses immediately. Done through atrial node and atrioventricular node. The normal pacemaker, the atrial node or the SA node has an inherent rate of 60-100 bpm. The atrioventricular node or the AV node, has an inherent rate of 40- 60 bpm. If these two pacemakers fail, ventricular cells can generate an impulse. They have an inherent rate of 20-40 bpm. -excitability: ability to respond with a stimulus and generate an impulse. Sometimes this does not occur. You might have automaticity without excitability. -conductivity: allows cardiac tissue to transmit the impulses to neighboring connected cells for a heartbeat to occur **Cells of the electrical conduction system:** -there is a right and a left bundle branch which travels down the interventricular septum to the end of the purjinke fibers, which extend the impulse into ventricular tissue, facilitating ventricular contraction. A stimulus begins the movement that produces the cardiac action potential. A process in which the membrane potential, the difference in charge between the interior and exterior of the cell, changes or goes up and down in a consistent pattern. Cells at the electrical conduction system include the bundled branches and purkinje fibers. **Action potential of the cardiac system:** -depolarization: movement of ions, proceeding and facilitating, cardiac mechanical contraction -repolarization: cardiac resting membrane potential to allow for the initiation of another action potential. movement of ions back to the resting state -Absolutely refractory period: immediately following depolarization. When the cell is unresponsive to any stimulus, this happens immediately following depolarization -Relatively factory period: represents a time when a greater than normal stimulus may initiate an impulse -medication utilized to control irregular heart rhythms, dysrhythmias typically manipulate the movement of ions in some way. **Diagnostic assessment:** -ECG (evaluate electrical conduction system) -chest x-ray (provides information about size, shape, and position of the heart, general screening tool) -echocardiography (an ultrasound to provide information on the size and pumping function of the heart, blood volume status, and valve function. that can be completed through a trans thoracic echocardiogram or a TTE. This is a standard echocardiogram and a non-invasive test through the skin of the chest. There is also a transesophageal echocardiogram or a TEE which is completed through a tube that passes through the mouth down the throat and into the esophagus. Because the esophagus is so close to the upper chambers of the heart, very clear images of those structures and valves can be obtained) -stress test: cardiac stress test is a way to evaluate the functional mobility of the heart during times of increased workload. Through ECG. This is completed through exercise or what is known as a treadmill test. And can also be done through a chemical stress test with the use of the drug dobutamine meant for those who may not be able to use a treadmill or exercise. A nuclear stress test is a more advanced test that uses a small amount of radioactive material known as a tracer and an imaging machine to create pictures showing the blood flow to your heart. The test measures blood flow while you rest and during activity. It shows areas of poor blood flow or damage to the heart. **Electrocardiogram:** -produces a picture of cardiac electrical activity with way forms and can be amplified and viewed on tracing paper. And ECG looks at different angles and different chambers of the heart. **Cardiac Output:** -the amount of blood or cardiac output ejected from the left heart varies, depending on the body\'s metabolic demand. It increases with exercise and decreases when it rests. After circulating through the body, the blood returns to the right heart through the great veins known as the superior and inferior vena cava to be delivered to the lungs to receive oxygen and remove carbon dioxide, cardiac output equals the heart rate multiplied by stroke volume. The heart rate is simply the number of cardiac contractions per minute, stroke volume is the amount of blood ejected with each ventricular contraction. Normal 4-7L/min **Stroke Volume:** -The amount of blood ejected with each ventricular contraction. It is affected by preload, afterload, contractility. Preload refers to the amount of blood in the ventricles at the end of the diastole. Afterload refers to the resistance to flow, the ventricle must overcome to open the semilunar valves and eject its contents. Contractility is the force that is increased with sympathetic stimulation or calcium release, mechanical contraction. **Laboratory predictions of heart disease:** -laboratory markers: CKMB, troponin, BNP. These markers provide information about acute cardiac damage or injury. These markers include enzymes or proteins that are elevated by response of cellular injury. Some are specific to cardiac tissue others are more general and must be evaluated in conjunction with other specific tests. Creating kindness or CK is a general marker of cellular injury. CKMB is a marker that is more specific to myoglobin. It elevates within three hours and returns to normal within 36 hours. Troponin is another specific marker of cardiac muscle damage, and is the preferred method for diagnosing cardiac injury. It is the most sensitive marker. Troponin can elevate within less than six hours and will rise subtly until it reaches its maximum level at 12 to 48 hours a level above.4 is abnormal. BNP or brain natriuretic peptide. hours a level above.4 is abnormal. BNP or brain natural attic peptide is released from overstressed ventricular tissue, elevations are indication of heart failure however other conditions can raise BNP levels as well. -coagulation studies: INR, PT, PTT. Coagulation studies tell you if the patient is prone to clotting or bleeding.  -lipid panel: cholesterol, HDL, LDL, triglycerides.  -homocysteine:  amino acid also implicated in the development of heart disease. It can damage the lining of arterial walls, causing clot formation. **Age-related changes in cardiac function:** -heart disease is the number one cause of death in the elderly. Changes related to age include atrophy of the left ventricle, so the heart doesn't pump as efficiently as it used to. Decrease the elasticity of the aorta and rigidity of the valves, causing blood to back up. The elderly must also experience stenosis of heart valves, stiffening of arterial walls, increased fibrosis of heart chambers leading to hypertension. Formation of arthroscopic plaque and narrowing of artery walls is common in the elderly and leads to an increased risk of thrombosis and stroke. **Chapter 29: Coordinating care for patients with cardiac Dysrhythmias** **Cardiac Dysrhythmia:** -the disruption in cardiac conduction, pathway or disorders of the electrical impulse conduction within the heart. Both arrhythmias and dysrhythmias refer to an abnormal rhythm of the heartbeat. If you experience an arrhythmia, the rhythm of the heartbeat is too fast or too slow. If you experience dysrhythmia, the rate of your heartbeat is irregular. For the most part, these are interchangeable terms. **Risk factors that contribute to a dysrhythmia: ** -Unmodifiable: age, men, genetics -Heart conditions: myocardial, infraction, HTN, valve disease, heart failure, cardiomyopathy (disease of the heart muscle that makes it harder to pump blood to the rest of the body), heart surgery -comorbidities: infection, diabetes, sleep apnea, electrolyte and balances, drug toxicities -lifestyle: use of recreational drugs -Age is a primary factor. Older adults have fewer pacemaker cells in the SA node, in the SA node may be surrounded by fat deposits. The slowed impulse transmission may be related to calcification around the AV node, which happens with aging as well. **Symptoms of Dysrhythmias:** -symptoms of a dysrhythmias include hypotension with lightheadedness, shortness of breath, syncope, palpitations, patient might feel anxiety, weakness, fatigue, dizziness. Dysrhythmias causing changes in the heart rate and or the rhythm lead to a decreased cardiac output. The patient can be symptomatic, or asymptomatic. decrease cardiac output. The patient can be symptomatic, or asymptomatic. **Normal Conduction Pathway of the heart: ** -that electrical activity begins with firing of the SA node. The impulse spreads through the atrial myocardium and travels to the AV node. The impulse then leaves the AV node through the bundle of his., impulse travels through the bundle branches, and then the impulse extends into the ventricular tissue through the purkinje. 1. P-wave: atrial depolarization, and activation of the electrical conduction system. The S a note is located in the upper wall of the right atrium. 2. after the P-wave is one that atrial depolarization is complete. The impulse is delayed at the AV note this is where we measure the PR interval. 3. The QRS complex, or the activation of the ventricles is when ventricular depolarization begins at the Apex, atrial repolarization occurs in this as well. A short QRS is desirable as it proves that the ventricles are depolarized rapidly. This implies that the conduction system functions properly. 4.  Then ventricle depolarization is complete. This happens between the QRS and the T  5. The T wave is one ventricular repolarization begins at the apex, causing this wave. Repolarization leads to a rapid decline in ventricular pressure hence the reduced rate of ejection. 6. ventricular repolarization is complete at the end of the T wave. The ST interval is the period in between ventricular depolarization and repolarization. -depolarization is a contraction, and repolarization is the return of the ions to the previous resting state, which corresponds with relaxation of the myocardial muscle. The P-wave is the atrial depolarization in activation of the atria. The PR segment is the slow impulse conduction through the atrioventricular node. The QRS complex represents ventricular depolarization in activation of the ventricle. The ST segment is the interval between ventricular depolarization and ventricular repolarization. The T wave is the positive deflection after each QRS complex, and represents ventricular repolarization. Typically the atrial repolarization wave is not perceptible on an ECG as it has a low magnitude and is usually concealed by the QRS complex. The U wave comes after the T wave after ventricular repolarization and may not always be observed as a result of its size. The U wave represents repolarization of the fibers. However, the exact source of the U wave remains unclear. after ventricular repolarization and may not always be observed as a result of its size. The wave represents repolarization of the purkinje  fibers. However, the exact source of the U wave remains unclear. ** ** **Interpretation an ECG:\ **-Represents time and amplitude.  -Rate: 60-100 -PR interval: 0.12-0.20 (if the measurement is greater than.2 the patient has a heart block, if it is less than.12 the patient has pre-excitation which is the presence of an accessory pathway between the atria and ventricles, or there's an AV or junctional rhythm if it is less than.12, the patient has pre-excitation, which is the presence of an accessory pathway between the atria and ventricles, or there's an AV or junctional rhythm. -QRS interval: \