Health & Illness 4 PDF

Health and Illness 4 Class 1: Anxiety What is Anxiety? A universal human experience and a basic emotion! A feeling of uneasiness, apprehension, uncertainty, or dread deriving from a real or perceived threat. Anxiety is typically FUTURE-ORIENTED Often confused with fear, however, fear is a reactio...

Health and Illness 4 Class 1: Anxiety What is Anxiety? A universal human experience and a basic emotion! A feeling of uneasiness, apprehension, uncertainty, or dread deriving from a real or perceived threat. Anxiety is typically FUTURE-ORIENTED Often confused with fear, however, fear is a reaction to a specific danger or circumstance Stress reactions include Autonomic NS (initial epinephrine release) and HPA axis (keeps you high and dry) Anxiety Disorders 20% Of the general population is affected by an anxiety disorder in which anxiety impairs individual functioning (the most common mental health dx in adults) 3-5% Of children/adolescents have a diagnosed anxiety disorder Risk Factors Brain functioning of the amygdala is different with anxiety Fight or Flight Symptoms Remember the body is HIGH from Autonomic NS/HPA axis activation Vitals are increased Dilated pupils Hyperglycemia Dilated bronchioles Peripheral vasoconstriction Think back to the stress response (HPA axis). We see high HR, BP, glucose, cortisol, water retention Risk of infection from suppressed immunity with HPA axis prolonged response Spectrum of Anxiety Mild Example: taking a quiz This is a part of everyday life. Problem-solving becomes more effective in this state (I know I need to study, I make a plan) Physical symptoms may be restlessness, irritability, mild tension-relieving behaviours (nail-biting) Moderate Perceptual field narrows Selective inattention Ability to process information becoming impaired but can still problem- solve Physical symptoms may include pounding heart, high HR and RR, perspiration, mild somatic symptoms (GI upset, headache, urinary urgency) Severe Anxiety Behaviour becomes automatic (wringing hands, pacing) May have headaches, nausea, dizziness, insomnia, trembling, tachycardia, hyperventilation, sense of dread Need help to refocus PANIC SENSE OF IMPENDING DOOM Borders on psychosis; may have hallucinations, disorganized or irrational reasoning. May feel like they are dying Can be the result of an unexpected, anxiety-inducing situation, or a panic disorder (needs a formal diagnosis) Panic Attacks 1. Stay with the patient during a panic attack 2. Assist them into a quiet place 3. Speak calmly and with simple, clear words Panic attacks may occur suddenly with no warning, but usually build to a peak intensity in 10-15 minutes. Score 0-4: Minimal Anxiety. Score 5-9: Mild Anxiety. Score 10-14: Moderate Anxiety. Score greater than 15: Severe Anxiety. PHQ 9 questionnaire Generalized Anxiety Disorder (GAD) (What is it? A persistent and exaggerated apprehension and tension causing dysfunction WORRY is the major issue. Events are misinterpreted due to worry. More common in women 5% of the population is diagnosed with GAD Diagnosis with DSM-5 Symptoms DSM-5  Manifestations Digestive —> eating habits change (over or under eating) Thoughts are PERSISTENT AND UNREASONABLE. They may also be aware their fears are unreasonable but cannot stop worrying Sleep May ruminate over (real or imagined) mistakes, events, problems, and future difficulties Lack of sleep contributes to worsening symptoms Treatments (Often a combination) Other therapies work well (behavioural) Modelling – demonstrate appropriate behavior and patient imitates it Systematic desensitization – Patient is gradually introduced to feared object Flooding – Exposes patient to a large amount of undesirable stimulus at once Response prevention – patient not allowed to perform compulsive ritual Thought stopping – Negative thought of obsession is interrupted Risk for self-medicating with alcohol/drugs to reduce anxiety without treatments Medications SNRI is selective serotonin-norepinephrine reuptake inhibitor Anxiolytics may be avoided as they can result in dependency or abuse Serotonin syndrome increased likelihood with st. john’s wort Take time to work (4-6w) Take in AM (insomnia at night) Don’t abruptly stop Monitor for suicide risk!! May give them the boost of energy to carry out their plan. Nursing Post-Traumatic Stress Disorder (PTSD) (When is it Diagnosable? Sometimes a delay in development of PTSD Nurses also at a high risk for PTSD especially those in critical care positions May be Acute PTSD if within 6 months of event or Chronic if 6 months or longer following the event Risk Factors for PTSD Main features of PTSD Re-experiencing (flashbacks) Avoidance of stimuli associated with trauma Increased arousal Numbing of general responsiveness/Negative changes Children Less likely to show distress, but this does not mean they don’t feel it Children often express memory through acting it out via play Negative Stress Coping Mechanisms ** Regression and rationalization are NOT typical of PTSD Denial and repression are more common Patient Interview It is essential that the clinician conducts the diagnostic interview in a manner that acknowledges the patient’s worst fears and that provides an environment of sensitivity, safety, and trust. In the case of chronic PTSD, where protective layers have solidified for years or decades, the clinician must be patient and obtain the trauma history at a pace that the patient can tolerate. Therapeutic management: validate feelings, promote coping, offer relaxation techniques, encourage therapy/support groups, therapy/service animals Treatment Complicated as those with PTSD may be reluctant to engage in trauma thoughts, emotions, and conversations Exposure and group therapy shown to be beneficial Medications such as SSRI and SNRI may minimize flashbacks and nightmares Anxiolytics and sleep aids may be used to treat physiological arousal and sleep issues Group therapy is a safe place to relive the event. Supportive. Learn and understand their “triggers” Risk Somatic Disorders Somatoform Disorders Symptoms are not intentional and are very real Co-occur with depressive, psychotic, or anxiety disorders High level of functional impairment; an extreme focus on symptoms which can lead to decreased quality of life Caused by periods of extreme stress *only in the case of factious disorder or malingering are the symptoms intentional* Somatic Symptom and Related Disorders Understanding Conversion Risk Factors for Somatic Symptom Disorders Somatic symptoms vary, most commonly include: These are most common symptoms. Location, kind, and severity changes over time, but generally PAIN remains consistent.  Once medical causes ruled out Lasts at least 6m and other illness RULED OUT Don’t memorize this table! This is just to show you an example Interventions CBT and medication for other psychiatric/mood disorders can be helpful depending on root cause but not always effective Class 2: Mood and Affect What’s the Difference? Mood may also encompass states like grief, sadness, melancholy, depression, joy, sorrow. It is these mood states or emotions that define our existence, give color to our world, and allow us to connect and empathize with others. Normal mood states can vary from hour to hour and day to day and are influenced by biological, psychological, sociological, cultural, and spiritual experiences. Examples of how normal mood states can be influenced by experience include joy at the arrival of a new baby, weariness from caring for an infant, happiness and relief at graduating from college, and grief at the death of a loved one. These are all normal variations of mood that are part of the human experience and are not associated with mental illness. Refer to sustained emotional states that are a departure from the individual’s usual functioning and that cause significant impairment in social or vocational functioning. Mood disorders are outside the boundaries of normal mood states by virtue of their intensity and duration; they tend to have a periodic or cyclical nature. Mood disorders fall into two major categories: DEPRESSIVE AND BIPOLAR!!! Bipolar Disorder Bipolar disorder involves dramatic shifts in mood, emotions, and energy Changes may occur over days to weeks and vary in severity Depressive episodes are coupled with manic or hypomanic episodes Risk Factors Genetic: having a family member diagnosed with bipolar disorder increases your risk 10x SSRIs may trigger manic episodes! Use with caution Brain structure may play a role HPA axis dysfunction (associated with hypothyroidism) May co-occur with anxiety disorders, substance abuse, etc. Hypothyroidism may not be severe, but does co-occur commonly Presents in TIMES OF STRESS Giving birth can act as a trigger for first time symptoms of bipolar disorder (thought to be hormonal changes and sleep deprivation) Overall occurs the same between men and women, but different response What is Mania? (DSM-5) 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep 3. More talkative than usual or pressure to keep talking 4. Flight of ideas 5. Distractibility 6. Increase in goal-directed activity or psychomotor agitation 7. Excessive involvement in high-risk activities with high-risk of negative consequence Need 3+ symptoms Hypomania is the same criteria but to a lesser extent (does not require hospitalization and shorter in duration) Feel euphoric. Active denial, irritable, impulsive, can’t sit still. May be provocative, increased sexual interest, substance abuse, omnipotent feelings, decreased need for sleep, endless energy As there is progression from hypomania to mania, sociability and euphoria are replaced by hostility, irritability and paranoia During mania, may experience Flight: content is often sexually explicit and inappropriate Clang: “cinema I and II, last row. Row, row, row your boat. Don’t be cutthroat! Cut your throat. Get your goat. Go out and vote. And so I wrote” Graniosity: example à God is speaking to them, they are secretly friends with celebrities What is Depression? (DSM-5) 1. Depressed mood 2. Diminished interest in activities 3. Significant weight loss or gain 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue/loss of energy 7. Feelings of worthlessness or guilt 8. Decreased concentration or indecisiveness 9. Suicidal ideation or attempt MUST have symptom #1 or 2 and a minimum of 5/9 in total People with bipolar disorders tend to spend more time in depressed states than manic states and treatment is very similar to MDD We tend to overuse the phase depression here. This graph highlights what a low mood from losing a job might look like compared to a true clinical depression Types of Bipolar Disorder Bipolar 1 Depression lasting a minimum of 2 weeks Mania lasting a minimum of 1 week or requires hospitalization Often resistant to treatment Frequently experience hallucinations and delusions during mania More common in men and presents around 18 years of age Mania may last 3-6 months Lows are identical to MDD Initial euphoria gives way to irritability and exhaustion and eventually collapses into depression Hallucinations tend to be auditory and are usually the voice of God. Believe they are a person of extreme influence and power Bipolar 2 Mania is less severe (hypomania) but depression may be profound Hypomania lasts a minimum of 4 days Psychosis is never present during mania More common in women and presents around 20 years of age High suicide risk Hypomania may be weeks to months. Although less severe, it causes significant relationship and occupational issues. Cyclothymia Less severe (hypo)mania and less severe depression Lasts a minimum of 2 years in adults or 1 year in children Can be difficult to distinguish from Bipolar II, but tend to experience more irritability during hypomanic episodes. Differs from persistent depression as there are periods of hypomania sometimes difficult to differentiate from bipolar II Mixed Episode An episode lasting a minimum of one week in which patient’s fulfill criteria for both a depressive episode AND a manic episode A mixed episode, sometimes called a mixed state, is when you feel both high and low. You may experience symptoms of depression, plus mania or hypomania at the same time. For example, you may feel very energised and impulsive, while feeling upset or tearful. Or you may feel very agitated or irritable. Rapid Cycling 4 or more episodes of mood changes (depression and/or mania) within a 12-month period Associated with severe symptoms and high recurrence rat Not just true of bipolar – this can happen in all mood disorders Resistant to traditional treatments Phases of Bipolar Acute: want to keep hydrated, promote sleep and rest, and see them demonstrate self-control. DO NOT ATTEMPT SELF HARM Continuation: want to promote knowledge of disease, medication, and consequences of substance addiction/relapse, knowledge of early signs and symptoms, control and decrease stress Assessment Safety: mania is exhausting. May not eat or sleep. Poor impulse control and engage in harmful behaviours Protection: may give away all possessions or go into bankruptcy Medical status: is this substance induced behaviour? Is it explained by another medical condition or medication? Summary of Mania Main Findings Mood swings Euphoric Agitation Poor judgment Non-stop talking Increased sexual interest Imuplsitivity Substance abuse Can’t sit still (poor concentration) Omnipotent feelings Decreased sleep Endless energy Main Medications Lithium inhibits about 80% of actue manic and hypomanic episodes in 10-21 days Lithium Ensure salt is NOT reduced and ensure plenty of fluids (~2-3L/day) Low serum sodium leads to toxicity Suspect toxicity if excessive diarrhea, vomiting, or diuresis Avoid diuretics Low sodium in the body, the body uses lithium in its place (it is Ensure proper hydration! similar) which causes toxicity Do not give with NSAIDs Dehydration can raise lithium levels in the blood to toxic levels. Risk of arrhythmias Do not take fluid pills (i.e. Lasix, hctz) while you are taking Link to hypothyroidism lithium. NSAIDs are bad for the kidneys and decrease renal blood flow which increases risk of toxicity. Give Tylenol instead Want a salt balance – don’t add extra salt, but do not reduce intake Summary Lithium Side Effects Signs of Lithium Toxicity Leukocytosis (high WBC) Increased urination Thirst and tremor Hypothyroidism Interactions with medications common Upset stomach (nausea, vomiting, diarrhea) Must get levels checked frequently All signs advance as lithium toxicity becomes more severe Tremor may become seizure, lethargy may become confusion then coma Early signs include scattered thoughts and tremors Clients with lithium toxicity may develop polyuria, due to the resistance to anti-diuretic hormone potentially leading to nephrogenic diabetes insipidus with chronic lithium toxicity. Lithium Level Monitoring It may take some time to get to a proper lithium level, an antipsychotic or benzodiazepine may be used in the meantime to prevent exhaustion, coronary collapse, and death until lithium reaches therapeutic levels. Antipsychotics act promptly. They may be discontinued when lithium takes effect. EPS involve involuntary motor symptoms similar to those associated with Parkinson's disease. Also known as pseudoparkinsonism and includes such symptoms as akathisia (distressing motor restlessness) and acute dystonia (painful muscle spasms).. Watch in those taking antipsychotics, especially gen 1 and SSRI! Due to its often vague and non-specific presentation of nervousness and discomfort, akathisia is often misdiagnosed as anxiety, restless leg syndrome, or agitation. Symptoms of TD Most common with 1st gen antipsychotics Symptoms usually improve with ceasing medication, but may not always be reversable. Literally tardive means “late appearing” and is found in long-term antipsychotic use Treatments Pharmacology Although Carbamazepine, valproic acid, and lithium are the most commonly prescribed, the balance of bipolar disorder is difficult to attain Antipsychotics (gen 1 and 2) and antidepressants are also commonly prescribed Psychotherapy Unhelpful during mania After mania has ended, will help to handle stress and may help prevent future manic episodes from occurring Cognitive-behavioural therapy (CBT) Interpersonal therapy (IPT) Time-limited focused psychotherapy Behaviour therapy There is no cure but treatment is very important. BIG SAFETY ISSUE, HIGH SUICIDE RISK Other Treatments ECT Electroconvulsive therapy where electrical currents are passed through the brain which intentionally triggers a brief seizure This changes brain chemistry Used when other therapies are unsuccessful Has a “bad reputation” but that is not supported by the literature 1 in 5 Wash and dry hair the night before, no hairspray or Young people with bipolar creams to reduce the risk of burns. NPO 6-8h prior disorder will attempt suicide Due to seizure activity you need to have oxygen, oxygen monitoring, suction, and a heart monitor on hand! Suicide LITHIUM shown to decrease suicide risk by 60% Is a risk that as energy increases while depressed, (treatment initiated) Persistent Depressive Disorder Why do some individuals develop depression while others do not? Like many disease processes, depression is a multifaceted illness that is most likely due to a complex and dynamic interaction among biological, psychological, sociological, cultural, and spiritual factors. We do know that neurotransmitters such as dopamine, norepinephrine and serotonin have a powerful role in mood regulation by regulating sleep, appetite, thought, emotion, mood, learning, memory, motivation and concentration. Excessive or insufficient levels of neurotransmitters are associate with mood disorders and other mental health conditions What is it? Dysthymia May also be referred to as dysthymia and occurs when depression occurs most of the day on the Persistent is CHRONIC majority of days MDD is episodic Differs from MDD The symptoms in dysthymia are lower-level and last at least 2 years in adults, or 1 year in children Perception Athough we’ve come a long way in public perception and understanding over the last number of years, many people still view depression as a disease for the ‘weak’ We have no more control over our neurotransmitters than we do over our blood pressure. It isn’t an issue of strong or weak, simply biology. Persistent Depressive Disorder Depressed Mood + Two or more additional symptoms Decreased appetite or overeating Insomnia or hypersomnia Low energy Poor self-esteem Difficulty thinking Hopelessness Symptoms cause significant distress and impairment of critical areas of functioning Beck’s TRIAD Beck & Rush (1995) found that individuals with depression process information in negative ways, even in the midst of positive factors. Beck’s Triad A negative, self-deprecating view of self “Nobody loves me, I’m worthless and inadequate” A pessimistic view of the world “ Everyone is against me , because I am worthless” The belief that negative reinforcement (or no validation for the self) will continue in the future. “ I will always be a failure” Beck argues by challenging these thoughts, an individual can experience new feelings and beliefs. Treatments CBT Skill training and problem-solving through therapy ECT Used if resistant to treatment with medication with good result Medications SSRI and SNRI are most common, may also have atypical antidepressants, or tricyclic antidepressants Some Common Medication Options SSRI First choice treatment Monitor for suicide, serotonin syndrome MONITOR FOR SUICIDE RISK WITH ALL ANTIDEPRESSANT! Energy to carry out plan Most medications take several weeks to reach effective levels SNRI MAOI Risk of excessive serotonin as they inhibit the breakdown of serotonin Hypertensive crisis risk TCA Risk of arrhythmias Double Depression Not an official diagnosis, but a common phrase if MDD and persistent depressive disorder co-occur Nursing Considerations Monitor for suicidal ideation or attempt Create activities in which the client can succeed and develop a sense of accomplishment Assist with appropriate decision making Ensure medication and treatment compliance Set realistic expectations Summary of Persistent DD Symptoms Provide positive reinforcement May need suicide protocols Hoplessness Energy low Self-esteem low 2+ years Sleep impaired Appetitie changes Decision making impaired Class 3: Self - Personality Disorders Self Self-Awareness Introspection Exploration of thoughts, behaviours, emotions, and values Self-Esteem The degree to which an individual likes or values themselves Self Concept Body image, role performance, personal identity Issues may be: Ego Syntonic The person experiencing the problem doesn’t think they have a problem (typical of personality disorders) Ego Dystonic The person experiencing the problem is aware of and distressed about their problems (ex: Obsessive Compulsive Disorder) In ego-syntonic you’re not likely to seek help since you don’t believe there’s an issue. Personality Your personality summarizes your personality traits; how you think and act. When those traits are harmful and negatively impact life, work, and social interactions, it is indicative of a personality disorder. PDs typically manifest in adolescence and continue over life. Sometimes diminish with age. May contribute to interpersonal difficulties, identity problems, lack of intimate relationships, poor social skills Personality stabilizes around age 30  Be aware of changes in a person’s life before making judgments. Being new to a country and suspicious of unfamiliar customs is NORMAL and not indicative or paranoia for example When is a personality disorder diagnosed? THINK TIDE Traits become Inflexible, Disabling, and/or Extreme 5 main personality traits Openness Are you open or closed to new experiences? Conscientiousness Antagonism vs adherence. Can you control impulses? Extroversion Extrovert vs. introvert Agreeableness Generosity/amiability vs. aggressiveness/temper. How do you interact with others? Neuroticism Emotional stability vs dysregulation. May encompass anxiety, moodiness, confidence, security, etc. Risk Factors for PD Genetic Factors Tend to run in families Little data Environmental Factors Exposure to trauma and abuse Perception of events Low socioeconomic status Neurobiological Factors Certain neurotransmitters may regulate or influence temperament Some brain size and functional differences in some PD cases What do we know? Personality disorders are a challenging and complex group of disorders Although each disorder is unique, they all have difficulty with: Often experience other mental health conditions such as anxiety and depression due to the consequences of their PD Believe problems originate outside of themselves/if others behaved differently, their problems would be solved For success, the person with the disorder has to recognize and take responsibility for their contributions in their difficulties “Weird” “Wild” “Worried” Cluster A Most at Risk for Cluster A Behaviour is characterized as Odd Reclusive Eccentric  Paranoid Personality Disorder (accusatory) Prevalence Defining Characteristics 2-4% of population Strong distrust and suspicion Assume others will disappoint them; often a self- fulfilling prophecy Only able to maintain superficial relationships Use projection as a defense mechanism Severe reaction to being lied to; hold intense grudges Very hostile and hypervigilant Treatment of Paranoid PD Nursing Considerations Unlikely to accept treatment Be clear and straightforward Stick to promises, appointments, and schedules Set limits on threatening behaviours Deal with accusations in a realistic manner without humiliation Too friendly = suspicious You can’t “fix” a personality with medication, it comes from therapy. Pharmacology can help with QOL as they struggle with delusions, agitation, anxiety, and depression that may result from their PD. Therapy Psychotherapy is the first line treatment; focus on development of trust Pharmacology Antianxiety(valium) and antipsychotic (haloperidol) medications may help with delusional thinking or severe agitation. May be reluctant to accept pharmacological help  Schizoid Personality Disorder (aloof) Prevalence Defining Characteristics 5% of the population Disinterest in social interactions Lifelong pattern of social withdrawal Loners, generally poor school performance, victims of bullying Have imaginary friends or fantasies Don’t enjoy physical contact Flat affect Treatment May feel like an ‘observer’ in life Nursing Considerations Avoid being overly friendly and do not force socialization Protect from ridicule from group members Therapy Treatment with psychotherapy; very introspective and often do well in therapy Open up as trust develops Therapy may improve sensitivity to social clues Psychotherapy may be DBT, CBT, Schema, group, family, or a variety of additional therapies Pharmacology Antidepressants (Wellbutrin) to increase pleasure in life, 2nd gen antipsychotics (risperidone) to improve emotional expressiveness Schizotypal Personality Disorder (awkward) Prevalence 0.6-4.6% of population Defining Characteristics Withdrawn and alone Socially detached Use magical thinking Strikingly unusual; odd speech patterns, inappropriate affect Overconfidence and self-centred speech; poor at gauging other’s perspectives WANT social relationships, but unable to maintain them (different from schizoid) Both a PD and a schizophrenia spectrum disorder Extreme social anxiety and suspicions of others Treatment of Schizotypal PD Nursing Considerations Respect their need for social isolation Be aware of suspicions Be respectful that they may have odd beliefs and activities as a part of everyday life Therapy Psychotherapy; may be involved in cults or unusual religious groups so interview cautiously Pharmacology Antipsychotic medications help with symptom management Antidepressants and antianxiety medications help with comorbid symptoms  SchizoiD – distant à shares some of the negative symptoms of schizophrenia like flat affect or blunted emotional responses SchizoTypal – magical Thinking People with schizotypal personality disorder are also more open to the idea that their ideas and perceptions are distorted (magical thinking), while people with schizophrenia are not. Cluster B Behaviour is characterized as Impulsive Dramatic Antisocial Personality Disorder (Psycho/Sociopathy) Prevalence Defining Characteristics 2-3.3% of the population Impulsive, manipulative for personal gain Overrepresented in the prison population Disregard for rights of others Women are likely underdiagnosed No remorse Cannot be diagnosed until 18 years of May be verbally charming, but can quickly age AND a history of conduct disorder turn violent Risk with caregiver with ASPD or Poor impulse control alcoholism and victim of child abuse Often begins with excessive lying, fighting, Associated with antagonism and disinhibition stealing, violence, and manipulation from Associated with animal cruelty in childhood young age Peak symptoms in late teens. Symptoms lessen with age around 40. Lack of conscience for wrongdoing even towards friend/family Children may show lower than normal response to fear and do not care about consequence Treatment for Antisocial PD Nursing Considerations Conduct an assessment of life stressors, history of violent thoughts, behaviours, and substance abuse be aware of distrust, hostility, and inability to connect and its effect on therapeutic relationships. Actively listen. provide consistency, support, boundaries, and limits; we can’t allow manipulation be aware admission is often involuntary Listening and not correcting can help diffuse tension Manipulate when not getting their way; be aware Therapy Often long and intense therapy; reluctant to participate Anger-management therapy Pharmacology None approved evidence to support mood stabilizers, and antipsychotics Reduced frontal cortex in a person with antisocial personality disorder (right). The frontal cortex is responsible for emotional and behavioural control and personality among other things. Borderline Personality Disorder Prevalence 9% in general population 20% in inpatient psychiatric care More common in women 5x more likely to develop if a first degree relative has BPD Higher incidence of childhood sexual trauma Higher rate in those who suffer verbal abuse from a parent Risk with early abandonment  Defining Characteristics Borderline because it is the border between psychosis and High mortality rate neurosis but many do not agree with the name suggesting it has negative connotations Unstable moods; intense joy to rage Self harm, promiscuity, substance abuse are common Impulsive maladaptive coping strategies. Depression May be manipulative (use flattery, seduction, or instill guilt) to get their way and have violent outbursts at times Splitting Commonly engage in harmful self-soothing habits like cutting, Men more likely experience substance promiscuity, and substance abuse abuse, women more likely to self harm and lead to hospitalization Physical violence, hostility, irritability Maladaptive coping strategies Associated with self-mutilation Example: I love my partner and they’re the greatest Seek out help for anxiety, depression, thing that ever happened to me (100% good). They can suicidality, self-harming do no wrong! But when they do something I don’t like, lets say they choose to go to a friends house instead of spend time with me, I am irate. They are now the worst Treatment of Borderline PD thing in the world; how could they do that to me? I hate Nursing Considerations them and will never forgive them (100% bad) Therapeutic relationship is essential Beware of splitting; may try to pit staff against one another Pharmacology Thorough assessment of risk of harm Anti-depressants, lithium, and Set realistic outcomes anticonvulsants for mood and emotional Clear, consistent boundaries and limits dysregulation Change nursing assignment often to Naltrexone may help with self-injury avoid attachment behaviours Therapy 2nd generation antipsychogics for anger Dialectical Behaviour Therapy helpful and psychosis with a healthy therapeutic relationship Assess any self-harm behaviour immediately Schema-focused  Want to improve ability to manage stress and improve interpersonal skills Treatment focuses on BEHAVIOUR and identifying interventions to stop them Dialectical is striking a balance between the therapist understanding and validating behaviours and feelings, while also imposing limits and making the client responsible for changing unhealthy patterns. Reduction of self-destructive behaviour Schema Therapy Combination of CBT with other psychotherapy to change self-perception Aims to help clients view themselves differently so they can create new and more effective interactions with their environment and others Histrionic Personality Disorder Prevalence Defining Characteristics 2% of the population Want to be the centre of attention Less common in Asian cultures Big, dramatic personality May have suicidal behaviours Difficulty developing meaningful relationships if affection and attention Exaggerated or shallow emotional expression needs not met or be irate Seek constant gratification Have superficial relationships Manipulate for attention (lots of acquaintances, few of Strong sense of inadequacy and helplessness relationships with depth as May have highly sexualized behaviour they’re viewed as shallow, Speech vague flighty, egocentric Treatment of Histrionic PD Nursing Considerations Understand that seductive behaviour may be in response to distress Keep communication professional Encourage concrete language Assess for suicidal ideation or self-harm Therapy Individual psychotherapy to promote clarification of inner feelings and expressions Group therapy unlikely to be appropriate Pharmacology Antidepressants of antianxiety medications helpful for comorbid symptoms Antipsychotics if suffering from derealization Narcissistic Personality Disorder Prevalence Defining Characteristics 1-6% of the population Believe they are perfect Familial tendency Act entitled, arrogant, and grandiose More common in men Have an intense fear of abandonment Risk with childhood neglect Antagonistic and criticism Tolerate rejection poorly Common in conjunction with Attempt to maintain self-esteem through substance abuse disorders, admiration feeding and eating disorders, Lack empathy and depression Fragile and low self-esteem May be seen in conjunction with eating disorders, depression, and substance abuse Treatment of Narcissistic PD Nursing Considerations Remain neutral; recognize behaviour stems from shame and fear of abandonment Avoid power struggles or becoming defensive Role model empathy; allow them to practice interactions without your nurse/patient relationship Only involved if it advances their personal agenda Therapy Unlikely to participate as they do not see themselves as the issue. More likely to be involved in couples or family therapy Cognitive behavioural therapy most helpful with faulty thinking Family therapy to help family cope with stress Pharmacology No approved medications but may benefit from antidepressants as common comorbidity Cognitive Behavioural Therapy CBT combines cognitive aspects to change negative/distorted thoughts and beliefs with behavioural aspects to alter problematic action patterns Focus on skill training and problem solving Therapist guides to assist recognition of harmful ways of thinking and analyzing and reinterpreting past and current experiences to adopt positive behaviours and interactions Provides a supportive setting to explore anxieties or fears Family Therapy Family therapy helps to educate about the disorder and how to improve interactions and support the client Cluster C Behaviour is characterized as Anxious Fearful Avoidant Personality Disorder (cowardly) Prevalence Defining Characteristics 4% of the population Avoid social interactions Equal in men and women Fear ridicule Risk with parental and peer Overly concerned about looking foolish rejection and criticism Shy, timid, socially inhibited May have early symptoms in They want close relationships childhood that increase during Intense fear of social situations adolescence and early adulthood Hypersensitive to rejection/negative feedback Feel inferior to peers Treatment of Avoidant PD Few relationships that aren’t familial Nursing Considerations Be friendly but do not push into social situations Convey acceptance of fears Provide with opportunities to advance social skills but do so with caution; failure can increase feelings of worthlessness Therapy CBT is helpful with processing anxiety-provoking symptoms and assertiveness Social skills training Pharmacology None approved, but may have some relief with antianxiety and antidepressant medication for comorbidities Obsessive Compulsive Personality Disorder (Compulsive) Prevalence Defining Characteristics 1-7.9% of population Strive for perfection More common in men Inflexible rule followers Oldest siblings more likely Preoccupation with orderliness, Perfectionism, Risk with excessive parental control, rules, details, and schedules criticism and control Inefficient as so much time on planning First degree relative Limited emotional expression Controlling in relationships Extreme fear of mistakes Different from OCD Treatment of OCPD Nursing Considerations Pharmacology Guard against power struggles; the need for control is Clomipramine is helpful is high reducing obsessions, anxiety Have difficulty with unexpected changes and depression Provide structure Fluoxetine also proven to be Help them accept less than perfect and relinquish control helpful Therapy Focus on coping skills and anxiety with CBT Dependent Personality Disorder (Clingy) Prevalence Defining Characteristics 5% of population (rare) Extreme dependency in relationships and fear Risk with chronic physical illness of separation or punishment for independence Seek out dominant personalities in childhood See themselves as “dumb” or “inadequate” If we see that they are planning Cling to relationships that indicates improvement. Often trapped in a cycle of abuse Showing initiative Submissive Treatment of Dependent PD Nursing Considerations Identify stressors Beware of counter-transference Role model assertiveness Therapy Psychotherapy is first choice of treatment. CBT helps with healthy, accurate thinking and attitudes Pharmacology Antidepressants and antianxiety medications for symptom management Tricyclic antidepressants (imipramine) helpful for panic attacks Monitor for medication dependence Assessment Semi-structured interviews Often lack insight and trust May possess poor communication skills Ask how others might describe them Assess work history, behaviour problems, violence history, drug use Use open-ended questions Rule out non-psychiatric illness Assure safety Typical Interview Highlights Diagnosis Often go underdiagnosed Traits may develop early but are unlikely to be diagnosed before adulthood. Personality is still developing in childhood, but early intervention may help. Do not try to diagnose during an active phase of another illness; traits are amplified during crisis or illness Maintaining Boundaries May have unclear, unhealthy, or nonexistent boundaries Manipulation is a breach. Be alert. Let them know what is and is not appropriate and establish consequences with patient input Use clear language, nonpunitive Anger Control Impulse Control Class 3: Immunity Two Main Branches of Immunity Innate Immunity Acquired Immunity First line of defence Second line of defence Born with this immunity Acquired throughout life Responds quickly, limited Slower to respond (weeks) response (minutes to hours) Specific Non-specific (general response) Long-term Short-Lived Aids Epidemic - A Brief Timeline The Epidemic Continues Stigma and Hysteria From the beginning of the AIDS epidemic to current day, those with HIV have faced overwhelming stigma Stigma and shame keep people with HIV from disclosing their HIV status, receiving testing, and receiving treatment NURSES have been pivotal in decreasing stigma, but stigma is still an issue today Ward 5B: The First AIDS Ward How AIDS was spread was not understood and patients did not receive appropriate care due to fear and discrimination Patients faced extreme isolation and dehumanization. Medical professionals from San Francisco General Hospital built the first unit in the USA designed to treat AIDS patients This unit allowed AIDS patients to die with dignity and compassion Nurses made a point to touch patients, especially on camera to show they were human and deserving of love and affection HIV —> AIDS Transmission What is CD4? Primarily T Cells CD4 Levels Patho HIV is a retrovirus that targets CD4 lymphocytes (T-cells) and injects itself inside. HIV sheds a protein coat and uses reverse transcriptase to convert viral RNA to DNA Viral DNA integrates the host DNA and is duplicated with each cell division HIV causes a malfunction of CD4 T-cells which protect the body from invading microorganisms. Once CD4 is too low, our immune system is virtually nonexistent (AIDS) During seroconversion antibodies are produced to the virus, but the body is unable to complete eradicate it as it is in the body’s DNA Viral load is the amount of HIV detectable in the bloodstream. More HIV viral load means more CD4 destroyed (inverse relationship) and higher chance of transmission Window Period When is it AIDS? AIDS-Defining Illness Organisms that normally do not affect the immune system lead to debilitation and life-threatening infections May have several opportunistic diseases occurring at the same time Common examples include candidiasis of the esophagus, Kaposi sarcomas, pneumocystis pneumonia (PCP) Candidiasis Kaposi’s Sarcoma Oral Hairy Leukoplakia Preventing Disease Progression/OIs Water should be treated Eat food that are not raw or unpasteurized Avoid high risk activities like IV drug use, unprotected sex Keep vaccines up to date Exposure to animals faces should be limited (toxoplasmosis) Need to take ART Diagnostics Interpreting Testing Results New Diagnosis Lab Monitoring Interprofessional Care Initial Visit Gather baseline data Complete history & physical Immunization history Psychosocial evaluations Identify barriers to optimal care What are some examples? Education What would we educate on? Considerations? How should this information be given? Goals of Care What is ART Antiretroviral Therapy Allows individuals to live longer, healthier lives Six types of medications used in combination (2-3) Combination therapy slows HIV replication and allows the immune system to recover Able to reduce HIV to undetectable levels Should begin immediately upon diagnosis regardless of CD4 count  ART Types of ART Reduce the risk of ART resistance Take them more than 95% of the time. Take in combination (generally at least 3) May need to set reminders. Work with Know what medications you take and how to the patient to fit medication times into take them their lifestyle Take the full dose as prescribed and on Do not take any new medications schedule – missing even a few doses can without discussing with a pharmacist/ lead to resistance HCP Monitor your viral load regularly Healthy Immune System Nursing Assessment Nursing Concerns Adhere to medication regimen Maintain/develop healthy, supportive relationships Promote healthy lifestyle Maintain activities and productivity Prevent opportunistic disease Come to terms with issues r/t disease, death, and spirituality Cope with symptoms caused by HIV and its treatment Protect others from HIV Reduce Risk of Transmission Care Workers - Universal PPE Use of universal precautions Gloves for all procedures involving direct skin or mucous membrane contact with blood or fluids capable of transmitting bloodborne pathogens Masks and eye protection for procedures likely to generate splashes of blood or fluids capable of transmitting bloodborne pathogens Gowns for procedures likely to generate splashes of blood or fluids capable of transmitting bloodborne pathogens Prevention of Perinatal Health Promotion Transmisson It is recommended to take ART throughout the entirety of pregnancy if mother is HIV infected Rate of transmission decreases from 25% to less than 1% if we treat throughout pregnancy! Class 4: Cancer & Exemplars Cancer Disease of the cell Cancer is abnormal growth resulting from uncontrolled proliferation; it serves no physiologic function Neoplasm is an abnormal mall of tissue that forms when cells divide more than they should can be benign to malignant Bone marrow – makes WBC, RBC and platelets. Only limited space. If you have proliferation of one particular cell. Not enough room to have adequate supply of normal cells. leukemia abundance of blood cells Immature cells – cells in the bone marrow and blood stream not matured or differentiated. Function is affected. Less than normal RBC – anemia is not uncommon Cancer Biology Cancer begins when an abnormal cell is transformed by the genetic mutation of its DNA Two major dysfunctions are present in the process of cancer: - Defective cellular proliferation (growth) - Defective cellular differentiation (undifferentiation occurs) Cellular Regulation Cellular replication is activated in the presence of cellular degeneration and death or based on physiological need. I.e. new cells are made as old cells die or “stop and go” mechanism in time of need Sometimes, these signals can function abnormally whereby a “go” signal can be produced when it should not be or a “stop” signal may be ignored by surrounding cells. Such errors could result in uncontrolled growth and the development of neoplasms. Abnormal cell + Mitosis = A bunch of copies of defective cell. This is known as a neoplasm If these cells form a lump, this is known as a tumor Every now and then, apoptosis does not occur and not only does not eliminate itself, but deforms the cell. Undifferenetiated cells will not have same function Cellular Differentiation Cellular differentiation is a process where an unspecialized cell acquires traits that allows it to perform specialized functions. Normally, an orderly, sequential process In cancer, this process may be reversed Revert to a previous undifferentiated state Biology of Cancer Cells Cell Mutation Loss of intracellular control of proliferation results from DNA mutation of the stem cells. Mutation may result from Exogenous sources (pesticides, radiation, viruses)– known as mutagen or carcinogen DNA mutation or transcription Mutation possibilities: 1. The cell can die 2.The cell can recognize the damage and repair itself 3.The mutated cell can survive and pass along the damage to its daughter cells……….cancer Inflammation as a cause for Cancer Chronic inflammation: Is an imp. factor in the development of cancer. Active inflammation predisposes a person to cancer. By stimulating a wound-healing response that includes proliferation and new blood vessel growth Susceptible organs Gastrointestinal (GI) tract, pancreas Thyroid gland Prostate, urinary bladder Pleura, skin Inflammation as a cause for Cancer Examples Those with ulcerative colitis for 10 years or more have up to a 30-fold increase in developing colon cancer. Hepatitis B (HBV) or hepatitis C (HCV) increase the risk of liver cancer. H. pylori increases the risk of stomach cancer. Carcinogenesis Process whereby N cells are transformed into cancer cells Thought to be multifactorial Environment Change in gene expression (hereditary) Infection in some cases) Exposure to risk factors Can you give som examples from each category? Classification and Nomenclature Benign tumors Are named according to the tissues from which they arise. Some examples: Lipoma: Fat Neurofibroma: nerve tumor Leiomyoma: Smooth muscle Classification and Nomenclature Malignant tumors Are also named according to the tissues from which they arise. Malignant epithelial tumors: Carcinomas Ducts or glands: Adenocarcinomas Malignant connective tissue tumors: Sarcomas Cancers of lymphatic tissue: Lymphomas Cancers of blood-forming cells: Leukemias Classification and Nomenclature Carcinoma in situ (CIS) Are preinvasive epithelial malignant tumors of glandular or squamous origin. Have not broken through the basement membrane or invaded the surrounding stroma. Considered “stage 0” Three prognoses: 1.Can remain stable for a long time. 2.Can progress to invasive and metastatic cancers. 3.Can regress and disappear. Cancer Invasion and Metastasis Cancer cells secrete protease. Proteases digest the extracellular matrix & basement membranes. Create pathways through which cells can move. Metastatic cells must be able to withstand the physiologic stresses of travel in the blood and lymphatic circulation. Metastatic cells must then survive in a new environment. Cancer Invasion and Metastasis Metastasis: Is the spread of cancer cells from the site of the original tumor to distant tissues & organs thru the body. Is a complex process that requires cells to have many new abilities. Spread Survive Proliferate in distant locations Destination must be receptive to growth of cancer Cancer Invasion and Metastasis Invasion: Local spread Is a prerequisite for metastasis (the first step in the metastatic process). Cancer often spreads first to regional lymph nodes thru the lymphatic system & then to distant organs thru the bloodstream. Invasion then requires the cancer attach to specific receptors & survive in the specific environment. Pathways of Spread Dissemination of cancers may occur thru one of three pathways: Direct seeding of body cavities or surfaces Occurs when a malignant neoplasm penetrates into an “open field” (i.e. peritoneal cavity, pleural space) Often seen with ovarian cancer Lymphatic spread Dissemination of carcinomas by lymphatic system Most common pathway for initial carcinoma spread Typically involves lymphatic vessels located at the tumor margins Ex: Breast, Lung Hematogenous spread Dissemination by arteries and veins Typical of sarcomas, but is also seen with carcinomas Most often involves the lungs and liver Classification of Cancer Tumors can be classified acc. to anatomic site, histology (grading) & extent of disease (staging). Tumor classification systems are intended to provide a standardized way to: Communicate the status of the Ca to members of the health care team, Assist in determining the most effective treatment plan, Evaluate the treatment plan, Predict prognosis, Compare like groups for statistical purposes. Anatomic Site Classification Tumor is identified by the tissue of origin, anatomic site & the behavior of the tumor (i.e., benign or malignant) Carcinomas originate from embryonal ectoderm (skin/glands) and endoderm (mucous membrane linings of the respiratory tract, GI tract & genitourinary [GU] tract). Sarcomas originate from embryonal mesoderm (connective tissue, muscle, bone & fat). Lymphomas and leukemias originate from the hematopoietic system. Histologic Classification The appearance of abnormal cells & degree of differentiation are evaluated pathologically. For many tumor types, four grades are used to evaluate abnormal cells based on the degree to which the cells resemble the tissue of origin. Tumors that are poorly differentiated (undifferentiated) have a worse prognosis than those that are closer in appearance to the N tissue Histologic Classification Grade I: Cells differ slightly from N cells (mild dysplasia) and are well differentiated. Grade II: Cells are more abnormal (moderate dysplasia) and moderately differentiated. Grade III: Cells are very abnormal (severe dysplasia) and poorly differentiated. Grade IV: Cells are immature and primitive (anaplasia) and undifferentiated; cell of origin is difficult to determine. Clinical Staging Classifying the extent and spread of disease is termed staging. Stage 0: cancer in situ Stage I: tumour limited to the tissue of origin; localized tumour growth Stage II: limited local spread Stage III: extensive local and regional spread Stage IV: metastasis. Is completed after the diagnostic workup and determines the treatment options. TNM Classification System Determines the anatomic extent of the disease involvement acc. to 3 parameters: Tumor size and invasiveness (T), Presence or absence of regional spread to the lymph nodes (N), Metastasis to distant organ sites (M). Cannot be applied to all malignancies. For example, the leukemias are not solid tumors and therefore cannot be staged using these guidelines. Prevention Prevention & Detection of Cancer We have a prominent role in the prevention and detection of cancer. Elimination of modifiable predisposing risk factors reduces the incidence of cancer and may favorably affect survival of patients who have cancer. An important aspect of nursing care is to educate the public about cancer prevention and early detection. Preventative Measures Self-examination Early detection if done consistently Breast, testicular, and skin examinations Routine screening Essential for early detection Following treatment to detect any further tumors Disease monitoring Status of disease at diagnosis Progression of disease Diagnostic Studies Tests to be performed will depend on the suspected primary or metastatic site(s) of the cancer: Cytology studies e.g., Papanicolaou [Pap] test, bronchial washings Tissue biopsy Chest x-ray Complete blood count, chemistry profile Liver function studies (e.g., aspartate aminotransferase [AST]) Diagnostic Studies Endoscopic examination: upper GI, sigmoidoscopy or colonoscopy (including guaiac test for occult blood) Radiographic studies (e.g., mammography, ultrasound, CT scan, MRI) Radioisotope scans (e.g., bone, lung, liver, brain) PET scan Tumor markers (e.g., CEA, AFP, PSA, CA-125) Genetic markers (e.g., BRCA1, BRCA2) Bone marrow examination (if a hemato-lymphoid malignancy is suspected or to document metastatic disease) Biopsy Tumor Markers Substances produced by benign & malignant cells that are present in or on tumor cells Found in blood, spinal fluid or urine Includes hormone, enzymes, genes, antigens or antibodies Capable of producing symptoms if they emit some type of biologic activity. Example- Secretion of catecholamine epinephrine by the adrenal medulla Support clinical decision making Screen and identify ind. at high risk for cancer Assist in diagnosing specific type of tumor Follows the clinical course of a tumor  Common Tumor Markers Goals of Care Cure…Control…Palliation Factors that determine the therapeutic approach are: tumor histology, and staging outcomes. Other considerations of treatment are the 1.Patient’s physiologic status e.g., presence of co- morbid illnesses 2.psychologic status 3.personal desires (e.g., active treatment vs palliation of symptoms) Evidence-based cancer treatment guidelines guide Surgery treatment Tx of Ca that do not spread beyond the limits of surgical excision. Palliative: Is indicated for the relief of symptoms. In selected high-risk diseases, surgery plays a role in prevention of cancer. Women with BRCA1/2 mutations have a significantly increased risk of breast and ovarian cancer: Prophylactic mastectomy or bilateral salpingo-oophorectomy or both. Margins are very important factor in surgeries Chemotherapy Eradicates enough tumor cells to enable the body’s Neoadjuvant chemotherapy: Is natural defenses to eradicate the remaining cells. administered before localized Can be a single-agent or combination chemotherapy. (surgical or radiation) treatment Induction chemotherapy: Causes shrinkage or the Micrometastases - small collection of disappearance of tumors. cancer cells that have been shed from Adjuvant chemotherapy: Is administered after the the original tumor and spread to surgical excision with a goal of eliminating another part of the body through the micrometastases. blood or lymph nodes Radiation Therapy Used to kill Ca cells while minimizing the damage to normal structures Ionizing radiation Damages cells by imparting enough ionizing radiation to cause molecular damage to the DNA. Causes irreversible damage to normal cells. Lifetime radiation dose Brachytherapy Internal radiation Risk Factors Vary based on particular cancer but certain trends are common Age – increased risk with age. 87% of cancer dx occur > 50 Smoking – 30% of cancer deaths and 80% lung deaths can be attributed to smoking Smoking is a known risk factor for 18 types of cancers Genetic risk – ~10% of cancers are from inherited genetic alteration Lynch syndrome – get thorough history BRCA Infectious Agent – Hepatitis, H. Pylori. HPV Diet - High in red meat, increased ETOH intake, Clinical Manifestations Systemic Effects of Malignant Tumors Weight loss & cachexia (severe tissue wasting) R/t inc. metabolic demand, altered carbohydrate and protein metabolism, cachectic factors Anemia R/t chronic bleeding, bone marrow depression, anorexia, dec food intake Bleeding R/t Erosion of bld vessels, tissue ulceration Infections R/t bone marrow depression, impaired immune response Paraneoplastic Syndromes R/t release of substances by tumor cells that affect neurological function, bld clotting, hormonal effects Hyper-coagulation Effusions Inflammation causing fluid buildup in body cavities. Warning Signs of Cancer Cancer in Children Etiology Mutated DNA in cells that occur most often early in life Second leading cause of death in children < 15 years Advances in treatment have increased survival Often difficult to detect Osteosarcoma Osteosarcoma is the most common bone cancer in children Osteosarcomas grow on the outside of bones where Ewing sarcoma grow on bone tissues Usually found in the metaphysis of long bones, especially in the lower extremities, with most tumours occurring in the femur. The peak age of incidence is between 10 and 25 years. Symptoms in early stage are often attributed to extremity injury or normal growing pains.’ Swelling near a bone Bone or joint pain Bone injury or bone break for no clear reason Treatment may include surgical resection (limb salvage procedure) to save a limb or remove affected tissue, or amputation. Chemotherapy is used to treat the cancer and may be used before and after surgery. Assessment 1. Localized pain at the affected site (may be severe or dull) that may be attributed to trauma or the vague complaint of “growing pains”; pain often is relieved by a flexed position. 2. Palpable bony mass 3. Limping if weight-bearing limb is affected 4. Progressive limited range of motion and the child’s curtailing of physical activity 5. The child may be unable to hold heavy objects because of their weight and resultant pain in the affected extremity. 6. Pathological fractures occur at the tumour site. Interventions Prepare the child and family for prescribed treatment modalities, which may include surgical resection by limb salvage to remove affected tissue, amputation, and chemotherapy. Communicate honestly with the child and family and provide support. Prepare for prosthetic fitting as necessary. The child may have challenges adapting to a changed self-image and may benefit from consulting with a child life worker or counsellor. Instruct the child and parents about the potential development of phantom limb pain that may occur after amputation, characterized by tingling, itching, and a painful sensation in the area where the limb was amputated. What are some community resources we could make family aware of. Colon Cancer Signs and Symptoms Colorectal cancer includes two types of A change in your bowel habits. cancers: cancer of the colon (large intestine (obstruction, pencil stools, constipation, or bowel) referred to as colon cancer, and diarrhea) cancer of the rectum (the end portion of the Blood in your stool, either apparent large intestine) or rectal cancer. Both types (visible) or occult (hidden). of cancer have many features in common, Pain in your lower abdomen or pelvis. so they are collectively called colorectal Anemia (low iron in your blood) cancer. Feeling very tired Risk factors that increase the chance of Nausea or vomiting developing colorectal cancer include: Weight loss and weakness a family history of colorectal cancer inherited syndromes benign polyps a personal history of colorectal cancer inflammatory bowel disease, such as ulcerative colitis ColonCancerCheck recommends that people with Screening no symptoms who are at increased risk of getting Asymptomatic people should be screened colorectal cancer get screened with a colonoscopy. with a fecal immunochemical test (FIT) every Someone at increased risk should start screening 2 years. Abnormal FIT results should be at age 50, or 10 years earlier than the age followed up with colonoscopy within 8 their relative was diagnosed with colorectal cancer, whichever comes first. weeks. The amount of time someone should wait until Average risk = Ages 50 to 74 with no first getting screened again after a normal colonoscopy degree relative diagnosed with colorectal result should be based on their family history: cancer and no personal history of pre- Every 5 years for people with a first-degree cancerous colorectal polyps requiring relative who was diagnosed with colorectal surveillance or inflammatory bowel disease cancer before age 60 (i.e., Crohn’s disease involving the colon, or Every 10 years for people with a first-degree ulcerative colitis) relative who was diagnosed with colorectal cancer at age 60 or older Diagnosis General physical exam including a digital rectal examination (a doctor or nurse practitioner puts their finger in your bum to examine you). Lab and blood tests Testing of stool sample for occult (hidden) blood. Colonoscopy: Scope that looks at entire bowel Biopsy of colon or rectal tissue: A doctor removes a small portion of the colon or rectum to examine under a microscope. This is the most accurate test of all, but because it involves cutting the body, the other tests are usually done first. CT (computed tomography) scan of abdomen and pelvis: to see the tumour and if the cancer has spread Surgery/Follow Up Care Various types of surgery can be done based on a multitude of factors (i.e. tumor resection vs. hemicolectomy) Chemo / Radiation based on staging Monitor the patient’s bowel patterns. Monitors the patient’s diet modification, and assess the adequacy of his nutrition intake. Direct the patient to follow a high fiber diet. Caution him to take laxatives or an antidiarrheal medications only as prescribed by the doctor. Inform the patient about screening and early detection. Melanoma Demographics Melanoma is the most aggressive of all skin cancers The leading cause of melanoma is (UV) radiation from the sun or artificial sources (tanning beds, sunlamps) According to World Health Organization (WHO) 85% of melanomas among Canadian men and women aged 30+ years are attributed to UV radiation exposure.  Melanoma is one of the fastest growing cancers worldwide. In Canada, incidences of melanoma have more than tripled in the last 30 years and continue to rise. Over 1,300 Canadians will die from melanoma each year. Survival rates are high if melanoma is detected early Signs Continued & Diagnosis Mole that changes shape or colour. Mole that is itchy or has a burning or tingling feeling. Mole that has been bleeding Excision biopsy: completely remove the mole or area of skin. If the area is quite large, only part of it may be removed. The tissue is then examined by pathology to assess if margins are clear Based on results, follow-up imaging – CT scan Types of Melanomas Superficial spread melanoma (SSM) About 66% of all melanomas. May start from an existing mole (dysplastic nevus). Nodular melanoma (NM) A nodule appears, usually not related to an existing mole. Lentigo maligna melanoma (LMM) - Less common. Most commonly appears on the sun-exposed faces of the elderly. Acral lentiginous melanoma Occurs on the palms or the soles of the feet or under the nail Accounts for the majority of malignant melanomas for dark-skinned people but for only a small percentage of all melanomas for light-skinned people. Treatment Surgery Standard treatment for the primary site of melanoma (where the cancer started). Surgery to cure melanoma is usually done after a biopsy. For lower risk melanomas, the excision margin (area removed by surgery) may be 1 cm or less. Wider margins of up to 2 cm are often recommended for higher risk lesions. A skin graft is sometimes required. This is when skin is taken from one part of your body to help repair another part of your body. Lymph nodes are not usually removed if there is no evidence of spread Radiation therapy -May be used after lymph nodes are removed. Systemic therapy (chemotherapy) - Used in some cases depending on staging Nursing Interventions Wound care teaching Discuss the importance of sun safety, including wearing protective clothing, sunscreen, hats and sunglasses, and avoiding sun during high ultraviolet peak times. Provide support and education about the likelihood of recurrence, and the risk of melanoma in family members. Nurse should explain to patients how to perform skin and lymph node examinations. Patients with a history of melanoma are encouraged to Monitor their skin and lymph nodes regularly, and to inform their physician of new or changing lesions or palpable lymph nodes. Having a spouse or other partner assist in skin examination is helpful. Follow-up routinely with their dermatologist at the recommended intervals, depending on the stage of the melanoma. Benign Brain Tumors Meningioma makes up 54% of all benign brain tumors Predominantly benign tumour of the meninges occurring at both cranial and spinal sites. Produces symptoms from local mass effect due to compression of neural structures or may present with seizure. Diagnosis confirmed by the characteristic appearance on magnetic resonance imaging (MRI) with and without contrast enhancement. Asymptomatic lesions may be followed up with serial observation. Treatment of symptomatic meningioma is usually surgical resection, although, in some cases, local radiotherapy is used as primary treatment. Radiation therapy considered as adjuvant treatment for grade III meningiomas and in some cases grade II lesions. Meningioma — Risk Factors Family history Headaches Neurological Deficits Seizure Radiotherapy Investigations MRI – definitive diagnosis CT Scan – may not be as cut and dry but more accessible Asymptomatic lesions may be monitored by serial observation. The majority of incidental meningiomas show minimal growth; thus, they may be observed without surgical intervention unless specific symptoms appear of the tumour demonstrating growth. The treatment of meningiomas is generally considered surgical. An open surgical approach is usually indicated. Follow Up & Monitoring All meningiomas should have a 6 month MRI follow-up after diagnosis then annually After 5 years, the interval can be doubled In those patients who have not had treatment of their meningioma, any change in headache pattern or development of new or progressive neurological symptoms should prompt a return for evaluation of the tumour. In patients with seizure presentation, maintenance of anticonvulsant therapy may be required,