Cancer/Oncology Exam Notes PDF

CANCER/ ONCOLOGY Biology of Cancer - characteristics between cancer cells (parasite) 1) Immortality → never dies, keeps reproducing 2) Metastasis → lungs, liver, brain, bone (vertebrae) 3) Angiogenesis → own blood supply → RBC- carries oxygen 4) Ectopic prod...

CANCER/ ONCOLOGY Biology of Cancer - characteristics between cancer cells (parasite) 1) Immortality → never dies, keeps reproducing 2) Metastasis → lungs, liver, brain, bone (vertebrae) 3) Angiogenesis → own blood supply → RBC- carries oxygen 4) Ectopic production of hormones → leads to more complications Demographics: Age 65-74 years old; avg 66 yr old Gender → males ○ ALL GENDERS → LUNGS, COLORECTAL, SKIN ○ MALE → PROSTATE ○ FEMALE → BREAST, THEN endometrial Ethnicity ○ African American – (PPCMM) prostate, pancreas, colorectal, multiple myeloma ○ White skin, leukemia, lymphoma, brain ○ Latino cervical, liver (hep B), gastric, GALLBLADDER ○ Asian esophageal, liver (hep B), gastric ○ Native Americans kidney, liver (hep B), gastric, ○ YOUNG ADULTS cervical, thyroid, leukemia, lymphoma, skin, malignant melanoma, testicular cancer Risk Factors Advancing age Family history/ genetics (1st degree relatives, 40s and 50s) Exposure to radiation Smoking/ second-hand smoke Diet - LOW IN FIBER, HIGH IN NITRATES ○ Berries: HIGH in antioxidants Sedentary lifestyle/ inactivity ○ OBESITY – breast, ovarian, endo/ uterine, prostate, colorectal, liver cancer Occupation/ environmental exposure- ○ asbestos, silica, mining company, air pollution; air dye  Drinking ○ LIVER, PANCREAS, ESOPHAGEAL Immunodeficient ○ HIV/AIDS, organ transplant Medications → CHEMOTHERAPY, immunosuppressants Hormones ○ too much estrogen → breast cancer Ethnicity/ racial groups Previous history of cancer ONCOGENIC VIRUS ○ HPV 16 and 18: vulva, vagina, cervix, penile, anal, head/neck, esophageal ○ Hepatitis B and C → liver infection/ chronic inflammation → ○ Chronic GERD → cell mutation where there is chronic inflammation ○ Chronic gastritis ○ Chronic pancreatitis (from drinking a lot) ○ 3-4th degree burn → prone to skin cancer SPECIFIC RISK FACTORS Lung ○ smoking, second hand, asbestos or silica, air pollution ○ SCREENING 50- 80 years - low dose CT scan Smokers even those who quit Pack year of 20 Breast ○ obesity, smoke, alcohol ○ oral contraceptives ○ early menarche (period=high exposure to estrogen), late menopause (after 55) ○ nulliparity, late pregnancy after age 32 ○ SCREENING 45 YO - mammography annually til 54, then every other year Prostate ○ african americans, advancing age, obesity, smoker, low in fiber ○ SCREENING: 50 yr old - annually- PSA test/ DRE - digital rectal exam Cut off value: 2.5 or 4 ng/ mL; things that can affect PSA infection/ fever/ UTI masturbation/ ejaculation  Ride a bicycle or horse – anything that increase pressure to hips ○ Testicular ○ young caucasian (15-35) ○ cryptorchism (undescended testicles) ○ mental retardation Liver ○ hepatitis B and C ○ fatty liver, alcohol ○ aflatoxins (found in crops) Gastric ○ diet high in nitrates ○ h. Pylori → chronic gastritis ○ pernicious anemia (vitamin B12) Colorectal ○ low fiber diet, African Americans, obesity, smoking, presence intestinal polyps, IBD → crohn’s & ulcerative colitis ○ SCREENING FOBT - stool test - 45 yo, every year Colonoscopy → start 45 y.o, every 10 yrs Sigmoidoscopy and virtual colonoscopy – 45 yo, every 5 years More f/u every 2-3 years → intestinal polyps, IBD Pancreatic ○ advancing age, smoking, obese, African Americans, alcohol Cervical ○ young women with multiple sex partners, hispanics, exposure to HPV, early coitarche, immunodeficiency, low socioeconomic status, commercial sex workers, promiscuous partners ○ SCREENING Pap smear/ HPV → start at 25 y.o (avg risk) → q 3-5 years until age 65 Skin ○ caucasian, blue/ green eyes, freckles, easily get sunburned, tanning beds or salon ENDOMETRIAL ○ AFTER menopause and experience vaginal bleeding?? → GO TO GYN!! SIGNS AND SYMPTOMS OF CANCER → CAUTION UP Change in bowel and bladder bowel- blood in stool, ribbon like stool, alternating constipation and diarrhea Blood in urine– bladder or kidney cancer A sore that does not heal - skin cancer Unusual bleeding or discharge Lung– hemoptysis, bladder- hematuria, stomach- hematemesis, colorectal- melena, prostate- hematospermia, reproductive- vaginal bleeding - ovarian Thickening or lump → breast, testicular, thyroid Indigestion or difficulty swallowing – GI tract, gastric, esophageal, laryngeal Obvious changes in moles → ABCDE Nagging or persistent cough → more than 1-2 weeks, REPORT TO DOCTOR Unexplained weight loss → cachexia, extreme muscle wasting Pernicious anemia → weakness and fatigue, anemia due to chronic blood loss, if its due to blood loss → IDA (iron deficiency anemia) PREVENTION OF CANCER 1. PRIMARY → maintain healthy lifestyle ○ Avoid smoking, drinking, ideal BMI, regular activity (40-45 mins/ 5x wk) BMI is 18.5 to 24.9 - HEALTHY BMI is 25.0 to 29.9 - OVERWEIGHT BMI is 30.0 or higher- OBESE ○ Diet: fiber, fruits, vegetables, antioxidants ○ Vaccination: Hep B, HPV ○ Sunscreen, avoid chemicals, avoid sun 9-3pm ○ Regular f/u with provider 2. SECONDARY →SCREENING/ EARLY DETECTION AMERICAN CANCER SOCIETY GUIDELINES 3. TERTIARY → TREATMENT AND REHABILITATION Diagnostic Tests Radiological Procedures → x-ray, ultrasound (liver, gallbladder), CT scan, MRI, PET scan Biopsy → sample tissue and examined by pathologist TNM Staging → SOLID CANCERS Tumor size → bigger means more advanced Nodes → the more lymph nodes damaged, more advanced Metastasis → spread to LUNGS, LIVER, BRAIN, BONES (VERTEBRAE) ○ M0 (no metastasis) and M1 (with metastasis, stage 4) CANCER BIOMARKERS → aids in diagnosis and prognostic indicator AFP (alpha-fetoprotein) – LIVER, TESTICULAR  CEA (carcinoembryonic antigen) – GI → COLORECTAL, STOMACH, SMALL INTESTINE, ESOPHAGUS CA 125 → OVARIAN CA 19-9 → PANCREATIC, LIVER AND GALLBLADDER CA 15-3/ CA 27-29 – BREAST LDH (lactic dehydrogenase) → LIVER, BRAIN, SKIN, LEUKEMIA, LYMPHOMA, MULTIPLE MYELOMA → (tissue damage) ALP (alkaline phosphatase) - BONE, LLMM PSA (prostate-specific antigen) - PROSTATE Philadelphia chromosome - CML Reed- Sternberg cell - hodgkin's lymphoma Bence Jone protein - multiple myeloma Beta 2 Microglobulin - liquid CA, leukemia, lymphoma, multiple myeloma BRCA 1 and BRCA 2 - breast, ovarian, prostate, pancreatic (BOPP), ENDOMETRIAL, COLORECTAL EGFR→ lung KRAS GENE MUTATION→ lung, colorectal Her2/ ER/ PR receptor - breast Thyroglobulin/ calcitonin → THYROID TREATMENT FOR CANCER - CRISPY Chemotherapy or antineoplastics Radiation therapy Immunotherapy Surgery Palliative Care/ Hospice → COMFORT/ pain management You→ compassionate, provide hope, hope for peaceful death, education, collaboration with other members of the healthcare team **CHEMOTHERAPY SIDE EFFECTS** ➔ Kills rapidly dividing cells ◆ Hair follicles alopecia (hair loss) ◆ Oral cavity stomatitis or mucositis → painful oral sores ◆ GI tract CINV → chemotherapy-induced nausea and vomiting → RISK FOR DEHYDRATION AND ELECTROLYTE IMBALANCE (potassium) → Risk for aspiration from vomiting TX: ANTIEMETIC +LORAZEPAM + DEXAMETHASONE +OLANZAPINE (optional)  ANTIEMETICS → prevents nausea and vomiting ○ Metoclopramide ○ Ondansetron ○ Granisetron ○ Palonestron ○ Prometh-azine ○ Prochlor-perazine ○ Aprepitant OTHERS ○ Lorazepam → sedative/ benzodiazepine (for anxiety) ○ Dexamethasone → corticosteroids ○ Olanzapine → antipsychotic- good for N/V ○ Cannabinoids - dronabinol or nabilone NONDRUGS OR HERBAL ◆ Cardiotoxic HEART FAILURE (baseline 12 lead ECG, 2D echocardiogram) ○ S/S → EDEMA, WEIGHT GAIN, DOB/SOB (pulmonary edema) ○ PRIORITY— fluid retention (hypervolemia), pulmonary edema, heart enlargement, SNS ◆ Nerve endings CIPN → chemotherapy induced peripheral neuropathy s/s → pins and needles, tingling and numbness sensation Tx – gabapentin, pregabalin; antidepressant– TCAs amitriptyline, SSRI - duloxetine ◆ SEX organs INFERTILITY OR STERILITY → SPERM OR EGG BANK ◆ HEPATOTOXIC ALT/ AST, bilirubin ◆ NEPHROTOXIC BUN/ creatinine ◆ VESICANT (subcutaneous) EXTRAVASATION → necrotic arm, amputation, frequent monitoring of IV site– s/s swelling, pallor, pain If pt complains of pain, STOP, THEN NOTIFY PROVIDER ◆ BONE MARROW - myelotoxic - PANCYTOPENIA RBC – 4-6 MILLION – anemia, body weakness and fatigue, activity and exercise intolerance Platelet – 150-400 K → THROMBOCYTOPENIA - risk for bleeding KILLER SITE → BRAIN, LUNG, GI TRACT  WBC – (5,000-10,000) - neutropenia- risk for serious infection - ○ SEPSIS → fever, chills, low BP ◆ Signs of bleeding → high HR, low BP ANEMIA → low RBC, Hgb, Hct CAUSES FOR CANCER PTS: ○ Chemotherapy, Radiation therapy ○ Chronic blood loss ○ Poor nutritional intake → you get iron from food you eat ○ Frequent blood draws as a pt in the hospital S/S OF ANEMIA ○ body weakness, fatigue, activity and exercise intolerance ○ pallor, mucus membrane, DOB/ SOB ○ tachycardia (palpitations) → because heart tries to pump more ○ dizziness and lightheaded (implement fall precautions) NURSING MANAGEMENT DRUG THERAPY ○ IRON - oral, injection, IV Dialysis pt always gets IV iron → IV IRON CAN GET ANAPHYLAXIS, especially the first dose!! Can cause constipation, GI upset (so take it with food), discoloration stool Give vitamin C (absorption) ○ EPOETIN OR ERYTHROPOIETIN INJ (SUBQ, multiple times a week) → stimulates bone marrow to produce RBCs Darbepoetin (only 1 injection) SIDE EFFECTS ** cancer pts could die early since cancer cells will spread more **HYPERTENSION→ RISK FOR STROKE Before administering → CHECK HGB LEVEL AND BP If above hgb 10, DO NOT GIVE If BP high, hold the medication and NOTIFY PCP ○ BLOOD TRANSFUSION → PACKED RBC (PRBC) USED FOR Critical HGB → BELOW 6 OR 7 NON-DRUG THERAPY ○ Iron rich foods → green leafy veggies, dried fruits, meat products ○ ENERGY CONSERVATION TECHNIQUE -** will ask energy conservation questions  Provide frequent rest periods Cluster activity throughout the day Encourage naps Assist with ADLs Assistive devices THROMBOCYTOPENIA → low platelets CRITICAL LEVEL: PERIPHERAL MALIGNANT HYPERCALCEMIA (8.5-10.5) → advanced metastasis cancer ○ CRITICAL LEVEL ABOVE 13!!! - FATAL DYSRHYTHMIA - PRIORITY ○ S/S (BBBBB): DEAD/QUIET MUSCLE AND NERVES Bone pain BISPHOSPHONATES- zoledronic acid → MOST POWERFUL, given once or twice a year Side effects ○ Esophagitis — sit 30 mins with full glass of water, early morning ○ Osteonecrosis of jaw bone — ask if they have recent dental procedure ○ Nephrotoxic !! KIDNEYS Bradycardia Back pain – renal calculi – fluids Belly pain (quiet intestinal contraction, SEVERE constipation)- laxative Bladder- polyuria Behavior- depression, somnolence (sleepy), lethargic, decreased LOC ○ Treatment BOMBARD WITH NORMAL SALINE HYDRATION calcitonin, pamidronate drip WOF FOR SIGNS OF FLUID OVERLOAD– PE DIC (disseminated intravascular coagulation)- THROMBOCYTOPENIA W CLOTS ○ 40% of pts with sepsis will develop DIC ○ Massive bleeding/ 3 unrelated bleeding site ○ VITAL SIGNS → hypotension, tachycardia Management: BLOOD TRANSFUSION/ REPLACEMENT ○ RULE : treat the underlying cause ○ Lab tests:  D-dimer → elevated means clotting FSP or FDP- fibrin split product → BIOMARKER FOR DIC EFFUSION→ CARDIAC TAMPONADE – breast, lung, lymphoma ○ pleural effusion – EXTRA FLUID IN LUNGS ○ Pericardial effusion– cardiac tamponade (heart collapse) when there is TOO much fluid– CAN DIE IN MATTER OF SECONDS !!! ○ S/S OF CARDIAC TAMPONADE: Dyspnea, tachycardia, tachypnea faint or muffled heart sounds decreased LOC, AMS, fainting Impending sense of doom (nurse i think i'm going to die) ○ TREATMENT → PERICARDIOCENTESIS (removal of fluid) LEUKOSTASIS: WBC >100,000-300,000 → ○ Hyperviscosity syndrome – if blood is super thick, can form CLOTS BRAIN - STROKE→ FAST HEART - MI LUNGS - DOB/ impending sense of doom – PRIORITY** BLEEDING → Thrombocytopenia: CRITICAL LEVEL: 20,000 ○ Killer sites → BRAIN, LUNGS, UPPER/ LOWER GI ○ Tx → oprelvekin 100k → bleeding precautions; hypovolemic or hemorrhagic shock 20k → platelet transfusion SEPSIS - ○ IV fluids, then C&S, multiple IV antibiotic (usually 2-3 abx) ○ Febrile neutropenia (100.4) ○ Low BP, older adults- AMS ○ Neutropenic precautions/ isolation- positive pressure room ○ Diet: neutropenic diet ○ 15-20 sec handwashing LEUKEMIA Demographics → older population, MALE, caucasian/ white STEM CELL (MOTHER) MYELOblast (daughter) LYMPHOblast (daughter) ○ Megakaryocyte → PLATELETS ○ NK cells ○ Reticulocytes → RBCs ○ Small lymphocytes (viral infection)  ○ WBCs B cells → plasma cell - produce Basophils (parasites) antibodies eosinophils (allergies) T cells (cancer cells) neutrophils (BACTERIAL) Acute → a lot of baby immature (20% of all cells are immature)- MORE FATAL Chronic → alot of MATURE cells ETIOLOGY Family history Radiation Chromosomal abnormalities → Philadelphia chromosome, down syndrome Previous h/o cancer → due to exposure to chemotherapy Slight risk - smoking MYELODYSPLASTIC SYNDROME → preleukemia APLASTIC ANEMIA→ total dysfunction of RBC which can lead to leukemia Exposure to toxic chemicals ○ benzene, petrochemical, farmers- pesticides, insecticides, herbicides 4 TYPES OF LEUKEMIA AML → acute myelogenous leukemia ○ MOST FATAL, death within 1-2 years - AFFECTS ALL ADULTS ○ Lots of immature RBC, platelets, or WBC – blast - 20% CML → chronic myelogenous leukemia ○ Lots of MATURE/ useless RBC, platelets, or WBC ○ Usually asymptomatic ○ THIS CAN TURN INTO AML!!! ○ CAB phases CHRONIC → asymptomatic ACCELERATED/ ACUTE → more s/s BLASTIC PHASE → symptomatic phases ○ Philadelphia chromosome ALL → Acute lymphocytic leukemia (PEDIATRIC POPULATION) ○ Lots of immature NK, T-cells and B cells CLL → chronic lymphocytic leukemia ○ Lots of MATURE but useless NK, T-cells and B cells ○ Slow growing, popular among older population CLINICAL MANIFESTATION (symptoms similar to lymphoma/MM) Bone marrow infiltration → so many cells but CYTOPENIA → cells decrease!! ○ s/s anemia - weakness/ fatigue, activity intolerance ○ s/s thrombocytopenia - gingival bleeding, epistaxis, heavy menstrual, dermal bleeding (commonly seen): petechiae, purpura, ecchymosis ○ s/s neutropenia → recurrent infections: pneumonia, (most common infection), shingles (herpes zoster, contact precautions), cold sores HSV1, meningitis → prone to septicemia Organ infiltration ○ Liver hepatomegaly (RUQ PAIN or tenderness) ○ Lymph Nodes → garbage can Lymphadenopathy ○ Spleen → dumps all the bad lymph nodes LUQ pain or tenderness, IF SPLEEN IS BIG → RISK FOR INFECTION/ BLEEDING FUNCTIONAL ASPLENIA - useless ○ Brain → leukemia meningitis Decreased LOC, AMS, seizure, blind, deaf ○ Skin Leukemia cutis → looks like petechial rash ○ Spinal cord Bone pain OTHERS ○ Hypermetabolic → weight loss, night sweats, excessive sweating ○ Children → can go to their bones and develop bleeding in between joints (hemarthrosis) will complain of bone pain WBC >100,000-300,000 → LEUKOSTASIS ○ Hyperviscosity syndrome – if blood is super thick, can form CLOTS BRAIN - STROKE→ FAST HEART - MI LUNGS - DOB/ impending sense of doom – PRIORITY** DIAGNOSTIC FOR LEUKEMIA Bone marrow aspiration/ biopsy → prioritize BLEEDING ○ Sternum-supine ○ Iliac crest- prone BIOMARKERS → LDH, ALP CBC with peripheral smear (put it in slide and check under microscope)  LYMPHOMA Cancer of the lymphoid tissue- lymph nodes, blood, spleen, bone marrow Lymph nodes: cervical (biggest), axillary, inguinal, most in chest cavity (mediastinal) - expect cough/ SOB Demographics → 15-35/ after 35, males, caucasian/ white, HIV/ AIDS HL → hogkin’s lymphoma - Less common/ More treatable/ higher survival rate - REED-STERNBERG NHL → non- Hodgkin's lymphomas - More common and MORE FATAL BECAUSE EXTRANODAL SITES - EXTRANODAL SITES → OTHER PARTS - Brain → CNS lymphoma → HIV/AIDS - Oral cavity - Thyroid - Testicles - GI tract → BURKITT'S lymphoma - GU tract - Spinal cord → Paraspinal - Skin → Mycosis fungoides - Sinuses → Sinonasal lymphoma ETIOLOGY: Family history Radiation Previous hx of cancer – exposure to chemotherapy Virus - EPSTEIN BARR VIRUS (EBV), HIV, hepatitis C Chronic inflammation- ○ hashimoto’s thyroiditis (hypothyroidism) ○ GI lymphoma- celiac disease; h.pylori Immunodeficiency Toxic chemicals CLINICAL MANIFESTATIONS → BASH BETA SYMPTOMS → weight loss, night sweats, coughing (TB symptoms) ○ Lymphoma is more advanced  ○ ALERT DOCTOR !! Adenopathy/ lymphadenopathy → painless BUT IF THEY DRINK ETOH→ becomes painful Splenomegaly → LUQ, early satiety (always feel full when they barely ate) Hepatomegaly → RUQ pain or tenderness OTHER SIGNS ○ Bone pain ○ Develop intermittent fever ○ Chest- cough, DOB/SOB ○ Oncologic emergency → SVC, effusion- cardiac tamponade Bone marrow infiltration ○ s/s anemia, thrombocytopenia, neutropenia Herpes zoster – contact + airborne especially immunocompromised DIAGNOSTIC FOR LYMPHOMA Lymph Node biopsy → REED-STERNBERG CELL Bone marrow aspiration/ biopsy CHEST X-RAY, CT scan of lungs ○ Advanced if entire diaphragm is damaged with cancer BIOMARKERS → LDH, beta 2 microorganism, inflammation ESR (erythrocyte sedimentation rate)AND CRP (c-reactive protein) MULTIPLE MYELOMA ** bone/ renal CANCER OF PLASMA CELLS (mature B cells)- responsible for producing antibodies DEMOGRAPHICS→ older adults, AA/ caribbean blacks, loves to hangout bone (vertebrae), kidney failure ETIOLOGY Family hx Exposure to radiation Chronic inflammation Virus Toxic chemicals - benzene, asbestos, hair dye, farming CLINICAL MANIFESTATIONS BONE PAIN (#1) – plasmacytoma pathologic fracture ○ Bone broken without any kind of injury ○ SPINAL CORD COMPRESSION – paralyzed  Nerve damage → neuropathy and paresthesia (numbness, tingling, pins/ needles), carpal tunnel syndrome Hypercalcemia ○ Super dead and quiet nerves ○ AMS, lethargy, somnolence ○ Constipation ○ Thirst bc polyuria ○ Nauseate ○ s/s renal failure: Proteinuria Elevated BUN/ creatinine anuria HYPERVISCOSITY → prone to clots ○ WOF for blurred vision, chest pain, AMS, nose bleeding (epistaxis) Bone marrow infiltration ○ s/s anemia, thrombocytopenia ○ Neutropenia→ die of pneumonia, herpes zoster, septicemia, meningitis (SIGN OF MENINGITIS IS STIFF NECK) DIAGNOSTIC FOR MULTIPLE MYELOMA 24 hour urine collection→ PROTEINURIA- BENCE JONES PROTEIN UPEP - urine electrophoresis → looks at antibodies SPEP - serum electrophoresis IMMUNOFIXATION STUDIES – to know immunoglobulin count CBC with peripheral smear BUN/CREATININE Skeletal survey → x-ray most of your bones ○ Skull, vertebrae, chest, pelvic, arms and legs BIOMARKERS → LDH, beta 2 microorganism, ALP, Electrolyte → calcium TREATMENT LEUKEMIA, LYMPHOMA, MM → CHEMOTHERAPY + STEROIDS CHEMOTHERAPY → high dose (leukemia, lymphoma, MM) ○ HIGH DOSE RESULTS IN TUMOR LYSIS → HYPERKALEMIA RADIATION ○ LYMPHOMA – chest cavity SURGERY  ○ Burkitt's lymphoma → tumor in abdomen- intestinal obstruction IMMUNOTHERAPY → medicine that boost immune system especially for MM ○ RITUXIMAB → IV INFUSION WOF infusion rxn (hypotension, body shaking, anaphylaxis) Make sure to have emergency cart ○ DO YOU WANT SOME PREMEDICATION? Acetaminophen, diphenhydramine BONE MARROW TRANSPLANT/ STEM TRANSPLANT → ○ MYELOABLATIVE CHEMOTHERAPY (destroy old bone) +RADIATION – neutropenic precautions (positive pressure room) CLINICAL TRIALS → EXPERIMENTAL DRUGS PALLIATIVE CARE/ HOSPICE BLOOD TRANSFUSION (BT) PRBC PLATELETS FFP - FRESH FROZEN PLASMA CRYOPRECIPITATE PRE- BLOOD TRANSFUSION Informed consent Medical order (2 nurses check) Blood work → type and crossmatch/ latest H&H Insert IV 18-20, 22 (for older patients) Prepare Y TUBING – BT SET Ask doctor if they want some premedication pre-BT vital signs Verification process- 2 NURSES - IV ○ ONLY RN’s → name, DOB, type of blood, expiration date, lot # ○ Then sign document Prepare NS 250 mL or 500 mL INTRA IV PUMP; Prime tubing → NS During actual transfusion → especially first 15-30 mins Do vital signs after 5 mins, 10 mins, 15 mins, and q30 mins after Monitor for any transfusion reactions PRBC → 4 hours max POST-BT  post-BT vital signs Return the signed document to the blood bank Repeat the blood work after 6 hours→ H&H ○ If you give 1 unit→ usually Hgb goes up by 1-2 BLOOD TRANSFUSION REACTIONS TRALI - Transfusion Related Associated Lung Injury ○ s/s PULMONARY EDEMA → RESPIRATORY DISTRESS ○ This patient can end up on mechanical ventilator TACO - Tranfusion Associated Circulatory Overload –hypervolemia ○ Hypervolemia: DOB/ SOB, hypertension, tachycardia, tachypnea, crackles ○ ASK FOR FUROSEMIDE (diuretic) for pulmonary overload If patient has 3 units, ask doctor in between the units as prophylactic HEMOLYTIC **when you give wrong blood ○ Fever, chills, hypotension, DOB/SOB → SHOCK ○ Hemoglobinuria ○ Back pain - renal shutdown → STOP TRANSFUSION AND NOTIFY AKI: Intrarenal injury FEBRILE ○ Fever only – WILL NOT DIE FROM THIS Give tylenol? Nothing crazy ALLERGIC ○ Rash, itchiness, flushed skin, hives (urticaria) ○ Wheezing (airway obstruction), angioedema (swelling of lips) TX: DIPHENHYDRAMINE BACTERIAL CONTAMINATION ○ REASONS: nurse didn’t wash hands; non sterile environment the nurse gave it for 4+ hours → SEPSIS!!! BEFORE ABX, DO CULTURE HIV/ AIDS HIV 1 (most common) and HIV 2 Demographics 1. MSM - male having sex with male 2. IV drug users - injecting drugs like heroin - especially in CA and NY 3. 15-24 / 25-29 (now) 4. Heterosexual woman with a bisexual partner 5. occupation - commercial sex worker 6. Healthcare workers- needlestick injury 7. Black/ African Americans/ Latinos/ Hispanic MODES OF TRANSMISSION BODILY FLUIDS ○ Blood, semen/ vaginal fluid, breast milk SEX ○ unprotected anal sex - receptive partner has high incidence of HIV ○ unprotected vaginal sex ○ oral sex - fellatio (BJ), cunnilingus (female stimulation) ○ kissing if partner has an open sore LEAST/ NEVER ○ masturbation, hugging MATERNAL TRANSFER- vertical transmission ○ C-section delivery ○ Pregnant woman including the baby should receive HIV medication ○ Avoid breastfeeding PATHOPHYSIOLOGY HIV will attack T cells - CD4 OR CD8 CD4 (normal 500 -2,000) ○ CRITICAL BELOW 200 → AIDS PATIENT PLWH (person living with HIV); PLWA (person living with AIDS) MOST COMMON CANCERS FOR HIV PTS: ○ lymphoma (NHL) ○ Cervical ○ anal and colorectal cancer ○ lung cancer ○ KAPOSI’s SARCOMA THREE STAGES OF HIV ➔ Acute ◆ Flu-like illness→ Fever, malaise, body aches seroconversion ➔ Asymptomatic ◆ Enough CD4 to protect phase (longest) ◆ How do you stay at this stage and not progress to AIDS? Maintain a healthy lifestyle SAFE SEX; SYPHILIS (AORTA AND BRAIN); gonorrhea, chlamydia Compliance with HIV medications (antiretroviral ARVs medications) ➔ AIDs stage ◆ OPPORTUNISTIC INFECTIONS→ serious infections- BRAIN ○ HIV dementia or HIV encephalopathy ◆ psychotic, hallucinations, delusions, paranoid ○ Toxoplasmosis ◆ TX: TRIMETHOPRIM-SULFAMETHOXAZOLE (BACTRIM) ○ Cryptococcal meningitis (FUNGUS) ◆ TX: AMPHOTERICIN B (MOST POWERFUL antifungal) NEPHROTOXIC, DYSRHYTHMIAS, phlebitis EYES ○ CMV - cytomegalovirus retinitis- blindness ◆ TX: GANCICLOVIR ORAL/ ESOPHAGUS ○ oral , bronchial, esophageal candidiasis ◆ (fluconazole (very powerful), nystatin) LUNGS ○ PJP- pneumocystis jiroveci pneumonia ◆ DOB/ SOB- WEIGHT LOSS **NO COUGHING ◆ TX: trimethoprim-sulfamethoxazole (BACTRIM) ○ TUBERCULOSIS ◆ Night sweats, weight loss, productive cough, coughing blood, afternoon fever ◆ RIFAMPIN ◆ ISONIAZID ◆ PYRAZINAMIDE ◆ ETHAMBUTOL ○ MAC- mycobacterium avium complex ◆ TX: azithromycin or clarithromycin (Z-PACK) GI TRACT ○ Chronic diarrhea – test for salmonella, cryptosporidiosis HERPES zoster - shingles -  ○ TX: ACYCLOVIR HIV WASTING SYNDROME – CACHEXIA ○ TX: megestrol acetate, dronabinol or nabilone VAGINAL CANDIDIASIS- cottage cheese discharge ○ Fluconazole DIAGNOSTIC AND TESTING P24 ANTIGEN ELISA - detects antibodies ○ if its positive; they will test again with western blot Western blot – detects specific proteins IF YOUR HIV+, 2 most important tests at checkups: 1. CD4 count (500-2,000) 2. Viral load (25-75 copies/ mL) → higher viral load, higher chance of DEATH a. IF VIRAL LOAD LOW→ UNTRANSMITTABLE (25-75) by taking medication TREATMENT→ HIV drugs/ antiretrovirals: side effects/ adverse effects GI upset Rash- hypersensitivity → sign of ALLERGY OR SJS Hepatotoxic – ALT/AST Nephrotoxic- kidney stones Acute pancreatitis - develop severe abdominal pain LACTIC ACIDOSIS - pH is low - lethargic, muscle weakness, abdominal pain Sleep disturbance- nightmares Peripheral neuropathy METABOLIC SYNDROME → abdominal obesity, hyperglycemia, hyperlipidemia ○ RISK OF MI AND HF!!! Fat redistribution syndrome – loss of facial fats, buffalo hump, thin extremities OSTEOPOROSIS PREVENTION Monogamous relationship Practice safe sex Abstinence- be faithful - condom (ABC) ○ DRUG (TRUVADA OR DESCOVY) PreP– pre-exposure prophylaxis Nurses- do not recap or bend needles Know your status MANAGEMENT FOR HIV Practice healthy lifestyle  Strict compliance with medications Advanced directives Infection control- updated list of vaccinations Screening for cancer if needed Provide emotional and psychosocial support Practice safe sex REFER TO SOCIAL WORKERS FOR COMMUNITY RESOURCES Skin integrity - some medications can give hypersensitivity reactions Patient teaching → side effects of medications, self management, complications REVIEW LAB RESULTS → CD4 AND VIRAL LOAD → every 6 months DIET – high calories, high protein, vitamins and minerals if needed AUTOIMMUNE DISORDERS - producing antibodies even though there are no antigens- auto antibodies CAUSE: Women Low levels of vitamin D VIRUS Environmental exposure - dust, smoking, red meats, overconsumption coffee Native americans/ American Indians SLE: SYSTEMIC LUPUS SLE → attacks nucleus of the cells, produce ANA (antinuclear antibodies), anti double stranded DNA - brain, eyes, oral cavity, heart, lungs, kidney bones, joints, skin CLINICAL MANIFESTATIONS: SOAP BRAIN MD Serositis - linings - lungs pleuritis, pneumonitis; heart - pericardium- pericarditis Oral and vaginal ulcers- painless Arthritis- joint pain Photosensitivity Blood cells - cytopenia- DECREASE in cells Renal- elevated BUN/ CREATININE, proteinuria, decrease urine output Antinuclear antibody (ANA) Immunologic phenomena, anti-dsDNA, anti smith antibody Neurological - psychosis and seizure Malar rash- butterfly rash Discoid rash - upper and lower extremities OTHER SIGNS AND SYMPTOMS→ Classic S/S: fever, rash, joint pain → GO TO DOCTOR IMMEDIATELY Other: Weight loss → either diabetes, cancer, or autoimmune, or drug use Anemia - fatigue, body weakness, hives (urticaria), raynaud phenomenon→ digit become blue when exposed to cold weather DANGER: LUPUS CEREBRITIS (psychosis and seizure) DANGER: LUPUS NEPHRITIS (dialysis) DANGER: accelerated heart disease DIAGNOSTICS ANA, anti ds DNA, anti-smith BIOMARKERS: ESR AND CRP ○ → INFLAMMATION, when it goes down, they are responding to treatment AUTOIMMUNE TREATMENT (SLE AND RA) STEROIDS ○ - prednisone, methylprednisolone; CUSHING SYNDROME → INFECTION MAINTENANCE DRUG ○ hydroxychloroquine- damage to eye, cardiac dysrhythmias Low dose CHEMOTHERAPY to suppress immune system to not produce antibodies ○ RISK FOR INFECTION, TERATOGENIC, HEPATOTOXIC ○ METHOTREXATE (HEPATOTOXIC), CYCLOPHOSPHAMIDE RHEUMATOID ARTHRITIS Swan neck deformity Boutonniere deformity Ulnar deviation Hammertoe Rheumatoid nodules → can rupture Morning stiffness for 30 mins How to assess joints? → check for swelling, temperature, color or redness, range of motion, check for deformity, pain, stiffness NURSING MANAGEMENT FOR AUTOIMMUNE DISORDERS 1. VITAL SIGNS 2. Collaboration with PT/OT (rehabilitation team) 3. Medication compliance - steroids, maintenance drug, low dose chemotherapy, immunosuppressant → RISK FOR INFECTION 4. INFECTION CONTROL 5. Exercise 6. Fall and safety precautions – especially for those with severe joint damage  7. Assistive devices if needed 8. 3 enemies → SSS → sunlight, stress, sex (pregnant → more flares of SLE) 9. diet - balanced diet - VITAMIN D 10. Energy conservation techniques 11. Lab works - biomarkers ESR AND CRP 12. Patient teaching→ side effects of medication and self management of illness and complications (accelerated heart disease) 13. Screening test for heart disease, cancer 14. Avoid raynaud's phenomenon; avoid winter sports; wear gloves 15. Emotional and psychosocial support 16. Skin integrity 17. Pain management 18. Monitor for other autoimmune PRACTICE QUESTION A nurse is administering medication to several clients, which of the following medications you should administer first: 1. IV ondansetron for a client receiving chemotherapy – 2. Subq oprelvekin for a client with thrombocytopenia 3. IV cyclophosphamide for a client with lupus celebrities (SLE TO BRAIN) 4. IV vancomycin for client receiving chemotherapy Airway breathing circulation A nurse is receiving first cycle of chemotherapy which of the following adverse of side effects SATA a. Thrombocytosis (elevated platelets) – but decreases with chemo b. Malar rash - SLE manifestation c. osteomalacia - bone softening d. Vaginal ulcer - SLE manifestation e. Low sodium f. Hypercalcemia g. Facial edema h. Tingling pain - ONLY 1 i. Visual disturbance - hydroxychloroquine