Cancer

- a disease process that begins when an

abnormal cell is
transformed by the genetic mutation of cellular
DNA.
- an umbrella term for a group of disorder in
which certain
cells grow and multiply uncontrollably,
eventually forming
tissue masses called tumors.
Risk Factor Assessment
1. Internal risk factors
- age
- gender
- race
- genetic factors
- immunologic factors
- psychological factors
- tobacco use
2. External Factors
- chemical carcinogens
- radiation
- viruses
- diet
- alcohol use
- chemotherapeutic drugs
Etiology
1. Viruses and Bacteria
1.1 Herpes simplex virus type II
1.2 Cytomegalovirus
1.3 Human papillomavirus are associated with
dysplasia
and cancer of the cervix.
1.4 The Hep B virus is implicated in cancer of
the liver;
1.5 The Human T-cell lymphatic virus may be
a cause of
some lymphocytic leukemias and
lymphomas;
1.6 The HIV is associated with Kaposis
Sarcoma
1.7 The bacterium helicobacter pylori has
been associated
with an increased incidence of gastric
malignancy,
perhaps secondary to gastric cells.
2. Physical Agents
2.1 Exposure to sunlight or radiation.
2.2 Chronic irritation or inflammation
2.3 Tobacco use
3. Chemical Agents
3.1 About 75% of all cancer are thought to be
related to
the environment.

3.2 Tobacco smoke, though to be the single

most lethal
chemical carcinogen, accounts for at
least 30% of
cancer deaths.
3.3 Smoking is strongly associated with
cancer of the
lungs, head and neck, esophagus,
pancreas, cervix and
bladder.
3.4 Tobacco may also act synergistically with
other
substances such as alcohol, asbestos,
uranium and
viruses to promote cancer development.
3.5 E.g: Asbestos, Benzene, Betel nut and
Lime, Cadmium,
Wood dust, Pesticides and
Formaldehydes.
4. Genetic and Familial Factors
4.1 Almost every cancer type has been shown
to run in
families
4.2 Due to Genetics, Shared environment,
Cultural/Lifestyle, Chance alone.
4.3 Cancer Associated with Familial
Inheritance includes:
4.3.1 Retinoblastomas
4.3.2 Nephroblastomas
4.3.3 Pheochromocytomas
4.3.4 Malignant neurofibromatosis
4.3.5 Breast, ovarian, endometrial,
colorectal,
stomach, prostate and lung cancer.
4.4 Conditions Associated with a Genetic
Predisposition
4.4.1 Inherited Cancer
- Breast Cancer
5. Dietary Factors
5.1 Dietary factors are thought to be related
to 35% of all
environmental cancer.
5.2 Dietary substances associated with an
increased
cancer risk includes :
5.2.1 Fats (animal fats)
5.2.2 Alcohol
5.2.3 Salt-cured/smoked meats
5.2.4 Foods containing nitrates and
nitrites
5.2.5 High caloric dietary intake
5.2.6 Red meat
5.3 Food Substances that Appear to Reduce
Cancer Risk
Includes:
5.3.1 High Fiber foods

5.3.2 Cruciferous vegetables (Cabbage,

broccoli,
cauliflower, Brussels, sprouts)
5.3.3 Carotenoids (Carrots, tomatoes,
spinach,
apricots, peaches, dark-green and
deep yellow
vegetables)
5.4 Obesity is associated with endometrial
cancer and
possible post-menopausal breast cancer.
5.5 Obesity may also increase the risk for
cancer of the
colon, kidney and gallbladder.
6. Hormonal Agents
6.1 Tumor growth may be promoted by
disturbances in
hormonal balance either by the bodys
own
(endogenous) hormone production or by
administering of exogenous hormones.
6.2 Cancer of the breast, prostate and uterus
are thought
to depend on endogenous hormonal
levels of growth.
6.3 Diethylstilbestrol (DES)(HormoneEstrogen-decrease
vaginal atrophy) has long been
recognized as a cause
of vaginal carcinomas.
6.4 Oral contraceptives and prolonged
estrogen
replacement therapy are associated with
increased
incidence of hapatocellular, endometrial,
and breast
cancer, whereas they appear to decrease
the risk for
ovarian and endometrial cancer.
6.5 The combination of estrogen and
progesterone
appears safest in decreasing the risk for
endometrial
cancer.
6.6 Increase numbers of pregnancies are
associated with a
decreasing incidence of breast,
endometrial and
ovarian cancer.
Warning Signs of Cancer
Change in bladder and bowel habits
A sore that does not heal
Unusual bleeding
Thickening/lump in the breast or
elsewhere
Indigestion

Obvious change in wart/mole

Nagging cough
Unexplained anemia
Sudden unexpected weight loss
Cancer Assessment Consideration
Colorectal Cancer
- Ask the client whether bowel habits have
changed over the
past year (e.g. in consistency, frequency or
color)
- Is there an obvious blood in the stool.
- Test at least one stool specimen for occult
blood during the
clients hospitalization.
- Encourage client to have a baseline
colonoscopy. (a must
for diagnosis)
Bladder Cancer
- Ask the client about the presence of:
- pain on urination
- blood in the urine
- cloudy urine
- increased frequency/urgency
Prostate Cancer
- Ask the client about:
- hesitancy
- change in the size of the urine stream
- pain in the back/legs
- history of UTI
Skin Cancer
- Examine skin areas for moles/warts
- Ask the client about changes in moles (e.g.
color, edges, or
sensation)
Leukemia
- Observe skin for color, petechiae, or
ecchymosis.
- Ask the client about:
- fatigue
- bruising
- bleeding tendency
- history of infection or illnesses
- night sweats
- unexpected fevers
Lung Cancer
- Observe the skin and mucous membranes for
color.
- How many words can the client say between
breaths?

- Ask the client about:

- cough
- hoarseness
- smoking history
- exposure to inhalation irritants
- shortness of breath
- activity intolerance
- frothy/bloody sputum
- pain in the arms/chest
- difficulty swallowing
****DIAGNOSTIC TEST FOR CANCER
Pathophysiology of the Malignant Process
Cancer begins when an abnormal cell is
transformed by the genetic mutation of the
cellular DNA
This abnormal cell forms a clone and begins to
proliferate abnormally.
The cells acquire invasive characteristics and
changes occur in surrounding tissues.
The cells infiltrate these tissues and gain access
to lymph and blood vessels; which carry the cells
to other areas of the body called Metastasis.
Note:
The abnormal cells have invasive characteristics
and infiltrate other tissues and this phenomenon
is metastasis.

Differences between Malignant and Benign

Cells
- Cellular growth characteristics
- The method and rate of growth
- Ability to metastasize or spread
- General effects
- Destruction of tissue
- Ability to cause death
Benign
Malignant
Have continuous/
Have rapid/continuous
inappropriate cell
cell division.
Show anaplastic
growth.
Show specific
morphology.

Lose
some or all
morphology.
Perform specific
differentiated functions.
Adhere loosely together.
differentiated
Able to migrate.
functions.
Adhere tightly together. Grow by invasion.
Metastasize to other
Are nonmigratory
Does not spread by
areas of the body.
Often causes extensive
metastasis.
Does not usually cause
damage as the tumor

tissue damage unless

grows.
its location interfering Usually causes death
unless growth can be
with blood flow.
Does not usually cause
controlled.
death unless its
location interferes with
vital functioning.
Malignant Process
1. Cell Proliferation
- uncontrolled growth with the ability to
metastasize
and destroy tissues and cause death.
2. Cell Characteristics
- presence of tumor-specific antigens,
altered shape,
structure and metabolism.
3. Metastasis
- the dissemination/spread of malignant
cells from
the primary tumor to distant sites
through:
- Lymphatic spread- lymphatic
circulation
- Hematogenous spread- blood stream
- Angiogenesis- induce growth of new
capillaries
4. Carcinogenesis
- also called malignant transformation
- process of transforming normal cells to
malignant
cells
- thought to be at least a three-step
cellular process
- Initiation
- Promotion
- Progression
Detection and Prevention of Cancer
Primary
- Concerned with decreasing cancer risk in
healthy people.
- Avoid known carcinogen or potential
carcinogen.
- Lifestyle and dietary changes to
decrease cancer risk.
- Modification of associated factors.
- Removal of at risk tissues.
- Chemoprevention
- Public and patient education.
Secondary
- Involves detection and screening to achieve
early diagnosis
and Intervention
- Identification of patients at high cancer
risk.

- Cancer screening
- Monthly self-breast exam
- Yearly mammography for women
older than 40
- Self-testicular exam
- Colonoscopy at age 50 then every
10 years
- Pap Smear test
- Yearly fecal occult blood in adults
of all ages
- Yearly prostate specific antigen
(PSA) test and
digital rectal exam (DRE) for
men over age 50
- Public and patient education
Diagnosis of Cancer
Tumor Staging and Grading
Grading- determines the size of the tumor
and the
existence of metastasis.
- refers to the class of the tumor cells.
- grading systems seek to define the
type of
tissue from which the tumor
originated and the
degree to which the tumor cells
retain the
functional and hystologic
characteristics of the
tissue of origin.
- samples of cells to be used to
establish the
grade of a tumor may be
obtained through
cytology (examinations of cells
from tissue
scrapings, body fluids, secretion,
or washings),
biopsy or surgical excision.
TNM- frequently used system
T- extent of the primary tumor
N- lymph node involvement
M- extent of metastasis
- Primary Tumor (T)
Tx- primary tumor cannot be
assessed
T- no evidence of primary tumor
Tis- carcinoma in situ
T,T,T,T- increase size and/or
local
extent of primary tumor.
- Distant Metastasis (M)
Mx- distant metastasis cannot be
assessed

M- no distant metastasis
M- distant metastasis
- Regional Lymph Nodes (N)
Nx- regional lymph node cannot be
assessed
N- No regional lymph node
metastasis
N,N,N- increase involvement of
regional lymph
nodes
Management of Cancer
- Treatment options offered to cancer patients
should be based on realistic and achievable
goals for each specific type of cancer.
- The range of possible treatment goals may
include:
- Cure- complete eradication of malignant
disease.
- Control- prolonged survival and
containment of
cancer cell growth.
- Palliation- relief of symptoms associated
with
disease
1. Surgery
- Surgical removal of the entire cancer
remains the ideal
and most frequently used treatment.
- Diagnostic Surgery is the definitive method
of identifying
the cellular characteristics that influence all
treatment
decisions.
- Surgery may be the primary method of
treatment, or it
may be prophylactic, palliative or
reconstructive.
Diagnostic Surgery
1. Biopsy
- usually performed to obtain a tissue
sample for
an analysis of cell suspected to be
malignant.
- Common Methods
1.1 Excisional Method
1.2 Incisional Method
1.3 Needle Method
2. Prophylactic
- removing non-vital tissues/organs
prone to
cancer.
- Consider:
-Family history and genetic
predisposition
- Presence/absence of symptoms
- Risks and Benefits

- Ability to detect cancer at early

stage
- Patients acceptance of post op
outcome
3. Palliative
- relieve complications:
- Ulcerations
- Obstructions
- Hemorrhage
- Pain
- Malignant effusions
- Ascitis
4. Reconstructive
- may follow curative/radical surgery
- to improve function/obtain a more
desirable
cosmetic effect.
- Nursing Management
- Provide education and emotional
support.
- Communicate frequently with physician
and other
health care team members.
- After the surgery, assess the patients
response to
the surgery and monitor for possible
complications.
-Infection
- Bleeding
- Thrombophlebitis
- Fluid and Electrolyte Imbalance
- Organ Dysfunction
- Provide comfort
- Teaching
- Wound care
- Activity
- Nutrition
- Medication information
2. Radiation Therapy
- Used to interrupt cellular growth .
- May be used to cure the cancer, as in
Hodgkins disease,
testicular seminomas, thyroid carcinomas,
localized
cancers of the head and neck, and cancers
of the uterine
cervix.
- May be used to control malignant disease.
- Can be used prophylactically to prevent
leukemic
infiltration to the brain/spinal cord.
External Radiation
- x-rays can be used to destroy
cancerous cells at
the skin surface or deeper in the
body.
- The higher the energy, the deeper the

penetration into the body.

- Gamma Rays
- deliver this radiation dose
beneath the skin.
- Particle-beam Radiation Therapy
- treat hypoxic, radiation resistant
tumors.
- also known as high linear energy
transfer
radiation, damages target
tissue.
Internal Radiation
- Brachytherapy
- Delivers a high dose of radiation to a
localized
area.
- Implanted by means of needles,
seeds, beads/
catheters into cavities (vagina,
abdomen,
pleural/intestinal compartments
(breast))
- Can be orally as with the isotope 1131
used to
treat thyroid carcinomas
- Intracavity Radioisotopes
- frequently used to treat
gynecologic cancers.
- radioisotopes are inserted into
specially
positioned applicators after their
placement are verified by x-ray.
- Observe for:
- Patients are maintained on bed
rest and log
rolled to prevent displacement of
the
intracavitary delivery device.
- An indwelling urinary catheter is
inserted
to ensure that the bladder
remains empty.
- Low-residue diets and anti
diarrheal
agents, such as diphenoxylate
(Lomotil) are
provided to prevent bowel
movement
during therapy, to prevent the
radioisotopes from being
displaced.
- Interstitial Implants
- Used in treating such malignancies
as
prostate, pancreatic or
breast cancer may

be temporary/permanent,

- Changes and loss of taste and

- Decreased salivation
- The entire gastrointestinal mucosa

depending on
the radioisotope used.
- Because patients receiving
internal
radiation emit radiation while the
implant
is on place, contacts with the
health care
team are guided by the following:
Principles Of:
-Time
- Distance
- Shielding
to minimize exposure of personnel
to
radiation.
- Safety Precautions:
- Assign the person to a private
room.
- Post appropriate notices about
radiation
safety precautions.
- Have staff members wear
dosimeter
badges.
- Make sure that pregnant staff
members are
not assigned to these
patients care.
- Prohibit visits by children/pregnant
visitors.
- Limit visits from others to 30
minutes daily.
- See to it that visitors maintain a 6
foot
distance from the radiation
source.
- Radiation Dosage
- Depends on:
- Sensitivity of the target tissues to
radiation.
- Tumor size
- Side Effects:
- Toxicity
- Localized to the region being
irradiated.
1. Altered skin integrity is a common
effect and
can include alopecia(hair loss),
erythema, and
shedding of skin(disquamation).
2. Alterations in oral mucosa
secondary to
radiation therapy includes:
- Stomatitis
- Xerostomia(dryness of the mouth)

may
be involved and esophageal
irritation
with chest pain and dysphagia
may
result.
- Anorexia, nausea, vomiting, and
diarrhea may occur if the
stomach/colon
is the irritated field.
3. Bone marrow cells proliferate rapidly
and if
bone marrow-producing sites are
included in
the radiation field, anemia,
leucopenia
(decreased WBC) and
thrombocytopenia
(decreased platelets) may result.
4. Chronic anemia may occur.
Research
continues to develop radio
protective agents
that can protect normal tissue
from radiation
damage.
5. Certain systemic side effects are also
commonly expected by patients
receiving
radiation therapy.
- Fatigue
- Malaise
- Anorexia
- Nursing Care
1. Protect the skin and oral mucosa
- Assess the patients skin, nutritional
status and
general feeling of well being.
- The skin is protected from irritation
and the
patient is instructed to avoid using
ointments,
lotions or
powders on the area.
- Gentle oral hygiene is essential.
- Offer reassurance by explaining that
these
symptoms are a result of the
treatment and do
not represent
deterioration/progression of the
disease.
2. Protect the caregiver

- When the patient has a radioactive

implant in
place, nurses and other healthcare
providers
need to protect themselves as well
as the
patient from the effects of radiation.
3. Chemotherapy
- Antineoplastic agents are used in an attempt
to destroy
tumor cells by interfering with cellular
functions and
reproduction.
- May be combined with surgery/radiation
therapy/both
to:
- Decrease tumor size pre op
- Destroy any remaining tumor cells post
op
- Treat some forms of leukemia.
- Goals
- Cure
- Control
- Palliation
- Phases of Cell Cycle

- Chemo agents are also classified according

to various
chemical groups, each with a different
mechanism of
action.
- These includes the alkylating agents,
nitrosureas,
antimetabolites, antitumor antibiotics, plant
alkaloids,
hormonal agents and miscellaneous agents.
- Administration of Chemo Agents
- Topical
- IM
- Oral
- Subq
- IV
- Arterial
- Intracavity
- Intrathecal
- Route depends on
- Type of agent
- Required dose
- Type, location and extent of tumor being
treated
- Dosage
- Based primarily on patients total body
surface area,

previous response to
chemotherapy/radiation
therapy and major organ function.
)))))))))))DRUG CLASSIFICATION AND EXAMPLE
- Special Problems
1. Extravasation
- Vesicants are those agents that if
deposited
into the subcutaneous tissue
causes tissue
necrosis and damage to
underlying
tendons, nerves and blood
vessels. (e.g.
Vesicants)
2. Toxicity
- Associated with chemotherapy can be
acute/chronic.
- Cells with rapid growth rates (e.g.
epithelium,
bone marrow, hair follicles, sperm)
are very
susceptible to damage and various
body system
may be affected as well.
2.1 Gastrointestinal System
- Nausea and vomiting
- Medications that decrease nausea
and
vomiting
-Serotonin blockers block
serotonin
receptors of GI track.
-e.g. ondansetron
granisetron
dolasetron
2.2 Hematopoietic System
- Most chemotherapy agents cause
myelosuppression(depression of
bone
marrow functions), resulting in
decreased
production of blood cells(anemia)
and
platelets (thrombocytopenia) and
increase
the risk for infection and bleeding.
2.3 Renal System
- Chemotherapy agents can
damage the
kidneys because of their
direct effects
during excretion and the
accumulation of
end products after cell lysis.
- Cisplatin, methotrexate and
mitemycin are

particularly toxic to the kidneys.

- Rapid tumor cell lysis after chemo
results in
increasing urinary excretion of
uric acid
which can cause renal damage.
- Intracellular contents are released
into the
circulation, resulting in excessive
levels of
potassium and phosphates and
hypokalemia.
- Nursing Responsibilities
- Monitor
- BUN
- Serum creatnine
- Creatnine clearance
- Serum electrolyte levels
- Provision of adequate
hydration,
alkalinization of the urine to
prevent
formation of uric acid crystals
and the
use of allopurinol are frequent
indicated
to prevent these side effects.
(CHON=
6.6-7.9)
2.4 Cardiopulmonary System
- Antitumor antibiotics
(daunorubicin and
doxorubicin) are known to
cause
irreversible cumulative cardiac
toxicities,
especially when total dosage
reaches
550mg/m.
- Bleomycin carmustine(BCNU) and
busulfan
are known for their cumulative
toxic effects
on lung function.
- Pulmonary fibrosis can be a long
term
effect of prolonged dosage.
2.5 Reproductive System
- Testicular and ovarian function can
be
affected resulting in possible
sterility.
- Normal ovulation, early
menopause/
permanent sterility may result.
- In men temporary/permanent,

azoospermia (absence of
spermatozoa)
may develop.
2.6 Neuro System
- Repeated dosage
- Peripheral neuropathies
- Loss of deep tendon reflex
- Paralytic ileus
- Hearing loss
2.7 Miscellaneous
- Fatigue is a distressing side effect
for most
patients that greatly affects
quality of life.
- Nursing Management
1. Assess Fluid and Electrolyte Status
- Anorexia, nausea, vomiting, altered
taste and
diarrhea put the patient at risk for
nutritional,
fluid and electrolyte disturbances.
2. Modify Risks for Infection and Bleeding
- Suppression of the bone marrow and
IS is an
expected consequence of
chemotherapy.
- Infection- increased vs;
redness
3. Administer Chemotherapy
- The patient is observed closely during
its
administer because of the risk and
consequences of extravasation
particularly of
vesicant agents, which may
produce necrosis if
deposited in the subcutaneous
tissues.
4. Implement Safeguards
- Nurses involved in handling
chemotherapeutic
agents may be exposed to low doses
of the
drugs by direct contact, inhalation
and
ingestion.
- Urinalysis of personnel repeatedly
exposed to
cytotoxic agents demonstrate
mutagenic act.
- Nausea and vomiting, dizziness,
alopecia and
nasal mucosal ulcerations have been
reported in
health care personnel who have
handled
chemotherapeutic agents.

4. Bone Marrow Transplantation

- Used for hematologic cancer that affects the
marrow of
solid tumors, which are treated with a
chemotherapy
dosage that ablates the bone marrow.
- Types Based on the Source of donor cells
- Allogeneic- others
- Autologous- patient itself
- Syngeneic- identical twin
- Nursing Management
1. Implement Pre-transplantation Care
- All patients must undergo extensive
pretransplantation evaluations.
- Nutritional assessment, extensive
physical
examination and organ function tests
and
psychological evaluation.
- Blood work includes assessing past
antigen
exposure.
- The patients social support system
and financial
and insurance resources are also
evaluated.
- Informed consent and patient
teaching about
the procedure and pre-transplantation
and postransplantation care are vital.
2. Provide Care during Treatment
- Skilled nursing care is required during
the
treatment phase when high dose
chemotherapy
(conditioning regimen) and total
body
irradiation are administered.
- Closely monitor
Nursing Process for Patients with Cancer
Assessment
- Infection
- Pain
- Bleeding
- Fatigue
- Skin problems
- Psychosocial
status
- Nutritional concerns
- Body image
- Hair loss
Nursing Interventions
1. Manage Stomatitis
* An inflammatory response of the oral
tissues commonly
develops within 5-14 days after the patient
receives

certain chemotherapeutic agents such as

doxorubicin
and 5% fluorouracil, and BRMs, such as 1L-2
and IFN.
- Good oral hygiene that includes brushing,
flossing and
rinsing is necessary to minimize the rise for
oral
complications associated with cancer
therapies.
- Soft-bristled toothbrushes and non-abrasive
toothpaste
To prevent/reduce trauma to the oral
mucosa.
- Oral swabs with sponge like applicators may
be used in
place of a toothbrush for painful oral tissues.
- Oral rinses with saline solution/ tap water
may be
necessary for patients who cannot tolerate
a
toothbrush.
- Products that irritate oral tissues/impair
healing such as
alcohol-based mouth rinses are avoided.
- Foods that are difficult to chew/ are hot or
spicy are
avoided to minimize further trauma.
- The patients lips are lubricated to keep from
becoming
dry and cracked.
- Topical anti-inflammatory and anesthetic
agents may be
prescribed to promote healing and minimize
discomfort.
- Products that coat/protect oral mucosa are
used to
promote comfort and prevent further
trauma.
- The patient who experience severe pain and
discomfort
with stomatitis require systemic analgesics.
- Adequate fluid and food intake is
encouraged.
- In some instances, parenteral hydration and
nutrition
are needed.
- Topical/systemic antifungal/ and antibiotic
medicines
are prescribed to treat local or systemic
infection.
2. Maintain Tissue Integrity
- Some of the most frequently encountered
disturbances
of tissue integrity in additional to stomatitis
includes:

- Skin and tissue reactions to radiation

therapy
- Alopecia- starts 2-3 weeks after 1st
chemotherapy.
- Metastatic skin lesions
- Rubbing and use of hot/cold water, soaps,
powders,
lotions and cosmetics are avoided.
- Avoid tissue injury by wearing loose fitting
clothes and
avoiding clothes that constrict, irritate/rub
the affected
area.
- Moisture and vapor-permeable dressings
such as
hydrocolloids and hydrogels, are helpful in
promoting
healing and reducing pain.
- Aseptic wound care to minimize the risk for
infection
and sepsis.
- Topical antibiotics, such as 1% silver
sulfadiazine cream
(silvadene), may be prescribed for use on
areas of moist
desquamation (painful, red, moist skin).
3. Assist Patients to Cope with Alopecia
- Provide information about alopecia.
- Support patient and family in coping with
disturbing
Effects of therapy.
- Patients are encouraged to acquire a
wig/hairpiece
before hair loss.
- Use of attractive scarves and hats may
make the patient
less conspicuous.
4. Manage Malignant Skin Lesions
- Careful assessment and cleansing the skin.
- Decreased superficial bacteria.
- Control bleeding
- Decrease odor
- Protect the skin from pain and further
trauma.
5. Promote Nutrition
- Nutritional Problems
- Anorexia
- Malabsorption- tumors produce
hormone/enzymes
like gastrin that
irritates the
abdomen.
- Cachexia- inadequate intake with
increased
metabolic demand.
6. Relieve Pain
- Identify sources of pain

- Analgesics are administered based on the

patients level
of pain.
1. Non Opioid Analgesics
- acetaminophen
- mild
2. Weak Opioid Analgesics
- codeine
- moderate
3. Strong Opioid Analgesics
- morphine
- severe
- Adjuvant Medications
- Antiemetics
- Antidepressants
- Anxiolytics
- Antiseizures
- Stimulants
- Local Anesthetics
- Radiopharmaceutical (painful bone
tumors)
- Corticosteroids
7. Decrease Fatigue
8. Improve Body Image and Self-esteem
9. Assist in the grieving process
- Loss of health
- Normal sensations
- Body image
- Social interaction
- Sexuality
- Intimacy
10. Monitor and Manage Potential Complications
- Infection
- Septic shock
- Bleeding and Hemorrhage
************ONCOLOGIC EMERGENCIES
Supportive Care and Rehabilitation for
Cancer Patients
Cancer Rehabilitation
- Objectives
- Psychological support upon diagnosis
- Optimal physical functioning after
treatment
- Vocational counseling when indicated
- Optimal social functioning (ultimate goal)
- In its broadest sense, the goal of cancer
rehabilitation is
to enable patients to achieve as normal and
full life as
possible in light of the effects of the disease
and its
treatment.
- Members of Rehabilitation Team
- Physician- the one closest to the patient.
- either the oncologist or
the primary

physician.
- Support Team
- Oncology Nurse
- Psychologist/other Health
professional
- Physiatrist
- Physical Therapist
- Occupational Therapist
- Social Worker
- Home Care Nurse
- Clergy
- Lay Volunteers
- Interventions
1. Preventive Interventions
- Lessen the impact of anticipated
disability through
patient training and education.
- e.g. Teaching a woman about to
undergo
mastectomy the exercises she will
need to
perform post-op to prevent swelling
and loss of
arm function.
2. Restorative Procedures
- Aim to restore,as closely as possible,
the patients
state before the treatment.
- e.g. Breast reconstruction following
mastectomy.
3. Supportive Intervention
- May be provided for the patient who has
a disabling
condition as a result of the cancer and
its treatment.
- e.g. Teaching esophageal speech to a
patient who
has had a total laryngectomy.
4. Palliative Intervention
- Provide comfort, assistance in every
functioning and
emotional support in those cases where
cancer is
advanced and recovery is not
expected.
- Nurses Role
1. Pre-op teaching that includes discussion
about changes
to expect in care of stoma and
communication
alternatives.
2. Focuses with general care issues such as
post op
complications caused by prolonged bed
rest and
immobility.

3. Ongoing assessment of a patients coping

skills, use of
defensive mechanisms and compare
patterns with
family and significant others.
4. To participate in group effort to improve the
patients
quality of life.
5. Activities as resource speaker or referral
source.
6. In educational groups, the nurse is often
the teacher,
organizer and evaluator.
7. Identifies and coordinates services
available in the
community.
- Supportive Services
- Are those that assists the patients and
families in
dealing with the many emotional,
physical, and
practical problems that follow the
diagnosis and
treatment of cancer.
- Home care
- Hospice care
- Postural Care
Acute Leukemia
- Malignant proliferation of white blood cell
precursors
(blasts) in bone marrow or lymph tissue and
their
accumulation in peripheral blood, bone
marrow, and body
tissues.
- Types
1. Acute Lymphoblastic (lymphocytic)
Leukemia (ALL)
- Abnormal growth of lymphocyte
precursors
(lymphoblast).
2. Acute Myeloblastic (myelogenous)
Leukemia (AML)
- Myeloid precursors (myeloblast) rapidly
accumulate
3. Acute Monoblastic (monocytic) Leukemia
- Schillings type
- Marked increase in monocyte
precursors
(monoblasts).
- Pathophysiology
Immature, non functioning WBCs appear to
accumulate 1st in the tissue where they
originated (lymphocytes in lymph tissues ad
granulocytes in bone marrow).

These immature WBCs then spill into the blood

stream
Infiltrate other tissues
Organ malfunction from
encroachment/hemorrhage
- Lab exams and Results:
- CBC- decreased hemoglobin (anemia)
- decreased platelets (Thrombocytopenia)
- decreased neutrophils (neutropenia)
- Bone Marrow Aspirations
- shows proliferation of immature WBCs
and confirms the
diagnosis.
- A slew of immature WBCs, plus anemia,
thrombocytopenia, and neutropenia
(definitively
suggest leukemia).
- Treatment
- Systemic Chemotherapy
- Other Treatments
- Antibiotics
- Antivirals
- Antifungals
- RBC Transfusion
- Bone Marrow Transplant for some
- Nursing Interventions
1. Control Infection
2. Monitor vital signs every 2-4 hours.
3. Watch for bleeding
4. Watch for signs and symptoms of
meningeal leukemia
5. Take steps to prevent hyperuricemia.
6. Control mouth ulcers
7. Check the rectal area daily for induration,
swelling,
erythema, skin discoloration and drainage.
8. Minimize stress
9. Provide psychological support
10. Evaluate patient
Breast Cancer
- Risk Factors
1. Gender- more than 90% of breast cancer
occur in
women
2. Age- Risk increases after 50
3. Personal history of the diseases (15% in
women)
4. Family history of the disease (women who
have 1st
degree relatives with breast cancer have 23 fold
increased risk)
- Secondary Risk Factors

- Never having given birth

- Giving birth to a 1st child after 30
- Prolonged hormonal stimulation (menarche
before age
12 and menopause after 50)
- Atypical hyperplasia on a previous breast
biopsy.
- Spread Pattern
- Breast cancer spreads via the lymphatic
system and bloodstream through the right side
of the heart to the lungs, and eventually to other
breast, chest wall, liver, bone and brain.
- Lab Results
1. Detection of a breast lump/tumor on BSE,
clinical
breast exam/mammography suggested
breast cancer.
2. Diagnosis hinges on biopsy and pathologic
evaluation of
the suspicious tissue.
3. The staging workshop may include CXR as
well as liver
and bone scans.
- Management
- Chemotherapy
- Radiation Therapy
- Surgery
Cervical Cancer
- 3rd most common cancer of the female
reproductive system
(after uterine and ovarian cancer)
- May be pre/invasive
- With early detection and treatment
- Lab Exams and Results
1. Papanicolaou (Pap) can detect cervical
cancer before
symptoms arise.
2. Colposcopy- can reveal the presence and
extent of
preclinical lesions.
3. Biopsy and histologic exam
- Management
- Preinvasive lesions may warrant total
- excisional biopsy
- kryosurgery
- laser destruction of the tumor
- conization
- Invasive squamous Cancer
- Radical hysterectomy
- Radiation therapy (internal/external)
- Nursing Management
- Provide comprehensive patient teaching.
- Provide emotional and psychological
support.
- If patient is to receive internal radiation,
remember the

safety precautions- time, distance and

shielding.
- Check vital signs every 4 hours.
- Watch for skin reactions, vaginal bleeding,
abdominal
discomfort and evidence of dehydration.
Cancer of the Uterus
- Endometrium
- Cancer of the uterine endometrium
(fundus/corpus) has
increased incidence, partly because people are
living
- Risk Factors:
1. Cumulative exposure to estrogen is
considered the
major risk factor. This exposure occurs
with the use of
estrogen replacement therapy without the
use of
progestin.
2. Early menarche
3. Late menopause
4. Never having children
5. Others: infertility; diabetes; HTN;
gallbladder disease;
obesity; Tamoxifen may also cause
proliferation of the
uterine lining, women receiving this med for
treatment/prevention of breast cancer are
monitored by
their oncologist.
- Assessment and Diagnostic Findings
1. All women should be encouraged to have
annual check
Ups including a gynecologic exam.
2. Any woman who is experiencing irregular
bleeding
should be evaluated promptly.
3. If a menopausal/premenopausal woman
experience
bleeding, an endometrial aspiration/biopsy
is
performed to rule out hyperplasia, a
possible precursor.
- Medical Management
-Total hysterectomy
- Bilateral Salpingoophorectomy
- Node Sampling
- Depending on the stage, the therapeutic
approach is
individualized and is based on:
- Stage
- Type
- Differentiation
- Degree of invasion
- Node involvement

- Whole pelvis radiotherapy is used if there is any

spread
beyond the uterus.
Colorectal Cancer
- Risk Factors
- Breast and gynecologic cancer
- Inherited tendency toward colon polyps
- High fat diet
- Signs and Symptoms
-Malaise and Fatigue
- Later Signs and Symptoms
- Laboratory Exam and Results
1. Tumor biopsy- verify colorectal cancer
2. Direct Rectal Exam (DRE)- can be used to
detect
suspicious\
rectal and
perineal lesions.
3. Fecal Occult Blood Test (FOBT)- detects
blood in the
stool- a warning
sign of
rectal cancer.
- Management
1. Surgery- most effective
2. Chemotherapy- as adjuvant therapy for
patients with
metastasis, residual disease/ recurrent
inoperable
tumors
3. Radiation
- Nursing Intervention
- Evaluate the patient
- He should verbalize an understanding of
the
treatment regimen including ostomy
care and long
term follow-up.
Hodgkins Disease
- May involve a virus
- Pathophysiology
- Enlargement of lymph nodes, spleen and
other lymphoid
tissues results from proliferation of
lymphocytes,
histiocytes.
- Sign and Symptoms
- Early
- Late
- Nodular infiltration of the spleen, liver
and bones.
- Enlarged retroperitoneal lymph nodes.
- Laboratory Examinations and Results
1. Lymph nodes reveals abnormal histologic
proliferation,

nodular fibrosis, necrosis and ReedSternberg cells.

2. Blood Tests- show mild to severe
normocytic anemia;
normochromic anemia.
3. Serum alkaline phosphatase levels may be
elevated
indicating liver/bone involvement.
- Management
- Chemotherapy
- Radiation
- Both
Lung Cancer
- Histologic Headings
- Small cell (oat cell) carcinoma (cancer of the
wall of a
majore bronchus, having round/elongated
cells)
- Large cells (anaplastic) carcinoma (a
bronchogenic
tumor with undifferentiated large cells).
- Adenocarcinoma (involves cells that line the
lungs
walls).
- Prognosis
- Generally poor
- Etiology
- Tobacco smoking- 90%
- Others:
- Genetics
- Exposure to carcinogenic industrial/air
pollutants
(asbestos, uranium, arsenic, nickel,
iron oxides).
- Signs and Symptoms
- Late stage response findings with small cell
and squamous
Cancer:
- Smokers cough
- Hoarseness
- Laboratory Examination Results
- Others: liver function test
- Management
- Combination of :
- Surgery
- Radiation
- Chemotherapy
Malignant Melanoma
- Uncommon
- Most lethal skin cancer
- Risks
- Family Tendency
- A history of melanoma/dysplastic nevi
- Excessive sun exposure
- History of severe sunburns

- Fair skin
- When any skin lesions/nerves
- enlarges
- changes color
- becomes inflamed/sore
- itches
- ulcerates
- bleeds
- changes texture
- pigment recession
- Laboratory Examinations and Results
D. Chest X-ray= aid staging
E. Blood Studies anemia; ESR
- Management
- Wide surgical resection
- Chemotherapy
- Radiation Therapy
Prostate Cancer
- Second leading
- 50years increases risk
- Important
- to detect prostate cancer early, all males
over 40 should
undergo DRE and prostate-specific antigen.
- Risks
- Age over 40
- High saturated fats
- Hormonal factors
- Signs and Symptoms
- Hematuria
- Laboratory Examinations
1. PSA- detect cancer
2. Transrectal prostatic ultrasonography can
detect a
mass.
3. Biopsy- confirms diagnosis
4. Serum acid phosphatase levels are
elevated in 2/3 of
patients with metastasized prostate cancer.
5. Increased alkaline phospatase levels.
- Management
- Radiation
- Prostatectomy
- Orchiectomy to decrease androgen
production
- Cryoablation
- Hormone therapy with synthetic estrogen
- chemotherapy
- Nursing Interventions
- If in continence/impotence follows
treatment, the
patient and significant others must be
informed.
Heart Failure
- Sometimes referred to as pump failure.
- Often referred to as Congestive Heart Failure.

- Is often referred to as congestive heart failure

(CHF).
- The inability of the heart to pump sufficient
blood to meet
the needs of the tissues for oxygen ad
nutrients.
- Types
1. Left-sided Heart Failure
- Two ventricles; Two pumping systems.
- Most failures begins with failures of the
left
ventricle
and progresses to failure of both
ventricles.
- Formerly referred to as CHF
- Typical Causes:
- HTN- blood viscosity (Thinckened)
- CAD
- Valvular disease involving the
mitral/aortic
valve.
- It could be acute/chronic, mild-severe.
- It is further divided into subtypes:
- Systolic heart failure
- Diastolic heart failure
* Systolic Heart Failure (Systolic Ventricular
Dysfunction)
- Results when the heart is unable to contract
forcefully
enough during systole to eject adequate
amounts of
blood into the circulation.
- Result- preload (amount of myocardial
stretch) increase
with contractility, and afterload (myocardial
resistance)
increase as a result of increasing peripheral
resistance
(e.g. HTN).
- The ejection fraction (the percent of blood
ejected from
the heart during systole) drops from a
normal of 50%70% to less than 40%
- As the ejection fraction decreases, tissue
perfusion
diminishes and blood accumulating in the
pulmonary
vessels.
- Manifestations
- Symptoms of inadequate tissue perfusion
- Pulmonary and Systemic Congestion
* Diastolic Heart Failure (Diastolic Ventricular
Dysfunction)
- Occurs when the left ventricle is unable to
relax
adequately during diastole.

- inadequate relaxation/ stiffening prevents

the
ventricle from filling the sufficient blood to
ensure an
adequate cardiac output, however, the
ejection fraction
may remain near normal.
2. Right-sided Heart Failure
- It may be caused by:
- left ventricular failure
- right ventricular myocardial infarction
- pulmonary hypertension
- Increase volume and pressure develop in
the
systemic veins, and systemic venous
congestion
develops with peripheral edema.
3. High Output Failure
- can occur when cardiac output remains
normal/above normal.
- it is caused by:
- increased metabolic
needs/hyperkinetic
conditions such as septicemia,
fever.
- Clinical Manifestations
- Right-sided Failure
- Right ventricle cannot eject sufficient
amounts of
blood and blood backs up in the
venous system.
- Peripheral edema
- Hepatomegaly
- Ascites- measure abdominal girth; daily
weight
- Anorexia
- Nausea
- Weakness
- Weight gain
- Left-sided Failure(High back rest)
- Left ventricle cannot pump blood
effectively to the
systemic circulation.
- Pulmonary venous pressures increases,
resulting in
pulmonary congestion with
- dyspnea
- cough
- crackles
- impaired oxygen exchange
- Pulmonary Venous Congestion
- dyspnea
-cough
-pulmonary crackles and lower than
normal oxygen
saturation levels.

- an extra heart sound, s3, may be

detected on
auscultation.
-dyspnea or shortness of breath, may be
precipitated
by minimal to moderate act (dyspnea
on exertion
(DOE))
-dyspnea also can occur at rest
- the patient may report orthopnea,
difficulty in
breathin when lying flat.
- They may need pillows to position
themselves up in
bed, or they may sit in a chair and
even sleep
sitting up.
- Some patients have sudden attacks of
orthopnea at
night, a condition known as PHD.
- Classification of Heart Failure
- New York Hospital Association (NYHA)
-classification I, II, III, IV
- AHA
- stages A,B,C,D

- Pathophysiology

-Etiology
- coronary artery disease is found in 60% of
patients with
heart failure.
- Cardiomyopathy- disease of the myocardium
- Hypertension- systemic/pulmonary
hypertension
- valvular disorder
****Primary Focus in CAD: compliance to
medications
- Medical Management
- eliminate/reduce etiologic/contributory
factors
- decrease the workload of the heart by
decreasing
afterload and pre-load.
- optimize all therapeutic regimens
- prevent exacerbations of heart failure
- medications are routinely prescribed for
heart failure.
- Managing the patient with Heart Failure
includes
- Providing general counseling and education
about
sodium restriction
- monitoring daily weights and other signs of
fluid
retention
- reencouraging avoidance of excessive fluid
intake,
alcohol and smoking.

- Medications
1. Angiotensin-Converting Enzymes Inhibitors
- ACE inhibitors (ACE Is) have a pivotal role in the
management of HF due to systlic dysfunction.
- Relieve s/s and decrese mortality and morbidity
(when
used to treat a smptomatic) by inhibiting
neurohormonal
activation.
- Vasodilation and diurhetics.
- Diuresis- decrease secretion of aldosterone
(hormone that
causes kidneys to retain Na)
- Promotes Na secretion
- Block conversion of Angiotensin 1- Angiotensin
II
- side effects: Hyperkalemia, Hypotension and
renal
dysfunction.
2. Angiotensin-Receptor Blockers
- have similar hemodynamic effect as ACE Is
- lowers BP
- lowers systemic vascular resistance
- block the effects of angiotensin I at the
angiotensin II
receptor.
- side effects: Hyperkalemia, Hypotension and
renal
dysfunction.
3. Hydralazine and Isosorbide Dinitrate
- Combination of hydralazine (Apresoline) and
Isosorbide
dinitrate (Dilatrate- SR, Isordil, Sorbitrate) may
be another
alternative for patients who cannot take ACE Is.
- Nitrates- causes venous dilation
4. Beta blockers
- Beta blockers with ACE Is decreases mortality
and
morbidity in NYHA class II/III HF patients and
decrease
cytotoxic effects from the constant stimulation
of the SNS.
- Side Effects: Exacerbation of HF
- to avoid: titrate doses
- Most frequent side effects:
- dizziness; hypotension; bradycardia
5. Diuretics
- Increase urine production and remove excess
extracellular
fluid from body.
- most common:
- thiazide- increase K and bicarbonate
excretion
- loop- inhibit Na and Chloride
reabsorption in the
ascending loop of Henle.

- Potassium- sparing diuretics

- inhibits reabsorption in the
late distal
tubule and collecting
duct.
* Important:
- serum creatnine and potassium levels
are
monitored frequently (e.g: within the
first week
and then with four weeks when this
medicine is
first administered.)
* Side Effects of Diuretics:
- Electrolyte imbalances
- symptomatic hypotension (especially
with
overdiuresis)
- Hyperuricemia (causing gout)
- Ototoxicity
6. Digitalis
- digoxin (Lanoxin)- the most commonly
prescribed from of
digitalis for patients with HF.
- increase force of myocardial contraction and
slows
conduction through the AV node.
- improves contractility, increase left ventricular
output.
- enhance diuresis.
7. Calcium Channel Blockers
- First generation- contraindicated with systolic
dsfunction;
may be used in patients with diastlic
dysfunction.
- Amlodipine, felodipine, dihydropyridine
- Vasodilation
* Nursing Alert:
- Decrease risk for hypokalemia
-dried apricots
-figs -beets -orange/tomato
juice
-peaches -prunes
-potatoes
raisins
-spinach -squash
- watermelon
- oral potassium supplement may also be
prescribed.
Nursing Management:
Assessment
-Health history
- Sleep and activity
- Knowledge and coping
- Physical Exam
- mental status
- lung sounds: crackles and wheezes
- heart sounds: S3
- Fluid status/signs of fluid overload.
- daily weight and I&O

- Assess response to medications

-I. Activity Intolerance
- bed rest for acute exacerbation
- encourage regular physical activity; 3045minutes daily
- exercise training
- pacing of activities
- wait two hours after eating before doing
physical
activity.
- modify activities to conserve energy.
- Avoid activities in extremely hot, cold/humid
weather.
- Modify activities to conserve energy
- Positioning; elevation of HOB to facilitate
breathing and
rest, support of arms.
-II. Fluid Volume Excess
-Assessment for symptoms of fluid overload.
- Daily weight
- I and O
- Diuretic therapy; timing of medications
- Fluid intake; fluid restriciton
- Maintainance of sodium restriction.
-III. Patient Teaching
- medications
- Diet: low-sodium diet and fluid restriction.
- Monitoring for signs of excess fluid,
hypotension, and
symptoms of disease exacerbation, including
daily weight.
- Exercise and activity program.
- Stress management.
- Prevention of Infection
- Know how and when to contact health care
provider.
- Include family in teaching
Myocardial Infarction
- Occurs when mycocardial tissue is abruptly and
severely
depreived with oxygen.
- When the blood flow is acutely reduced by
80%-90%
ischemia develops.
- Ischemia can lead to injury and necrosis
(infarction) of
myocardial tissue if blood flow is not restored.
- Most Mis are athe result of
- Atherosclerosis of a coronary artery.
- Rupture of the plaque
- Subsequent thrombosis
- Occlusion of blood flow.
- Other factors:
- Coronary artery spasm
- Platelet aggregation

- Emboli from mural thrombi (thrombi

lining the
walls of the heart chambers)
Process of Infarction
- Infarction is a dynamic process htat does not
occur
instantly; rather, it evolves over period of
several hours.
Classification of MI by Location
- the clients response to an MI also depends on
which
coronary artery/arteries were obstructed and
which with
the left ventricle wall was damaged.
- Anterior; lateral;septal;inferior;posterior
Etiology and Genetic Risk
- Atherosclerosis is the primary factor in the
development of
CAD.
Men: 65.8 y/o
Women: 70.5 y/o
Clinical Manifestations
- Chest pain that occurs suddnely and continues
despite rest
and medication is the preenting symptom in
most patients
with an MI.
- Patients may also be anxious and restless
- Cool, pale, moist skin
- HR and RR may be faster than normal.
- In many cases, the s/s of MI cannot be
distinguished from
those of unstable angina.
KEY FEATURES OF ANGINA AND MI
Diagnosis
- Presenting symptoms
- ECG
- Lab results
Prognosis depends on
- Severity of coronary artery obstruction
- Extent of myocardial damage
ECG
- Should be obtained within 10 minutes
from the time patient reports pain.
- Location evaluation and resoution of an MI
can be identified and monitored.
- Classic ECG changes
o T-wave inversion
o ST- segmental elevation
o Development of an abnormal Q
wave.
ECHOCARDIOGRAM
Laboratory Tests
- Creatnine Kinae and its Isoenzumes.
Medical Mangement
-Goal
- minimize myocardaial damage

- preserve myocardial function

- prevent comlicaitons
* Achieved by reperfusing the area with the
E use of
thrombolytic medicines or Percutaneous
Transluminal
Coronary Angioplasty (PTCA)
* Minimizing Myocardial Damage
- reduce myocardial oxygen demand and
- increase oxygen supply with medicines
- oxygen administration, and bed rest.
Pharmacologic Management
1. Thrombolytics
- Intravenous
- Direct administration into the coronary artery in
the
Cardiac catheterization laboratory.
- Purpose:
- dissolve and lyse the thrombus allowing
reperfusion
- Door-to-needle time
- administer within 30 minutes
- Agent used often: Streptokinase (1st)
- risk for allergic reaction
- vasculitis has occurred up ot 9 days after
administration
2. Analgesics
- Acute MI= Morphine Sulfate= IV
= decrease pain and anxiety
= decrease pre-load
= relaxes bronchides to enhance
oxygen
3. ACE Is
- decrease mortality and prevent heart
failure
- before administering, patient should be:
- hypotensive
-hyponatremic
- hypovolemic
- hyperkalemic
- monitor closely:
- BP
- Potassium - Serum
Na
- Urine Output - Creatnine levels
- Emergen Percutaneous Coronary
Intervention(PCI)
- Patient with acute MI may be reffered
immediately
to E PCI.
- Door-to-balloon
- less than 60 minutes
-Cardiac Rehabilitation
- after MI patient is free of symptoms
- education
- individual and group support

- physical activities
Phases:
I. Diagnosis of atherosclerosis
- admitted
- low level activities and initial education for
the patient
and family.
II. Discharge
- 4-6 weeks but may last up to 6months
III. Maintain cardiovascular stability and long
term condition.
Nursing Process
Goal
- Relief of pain/ischemic sign and symptoms
- Prevention of further myocardial damage
- Absence of response dysfunction
- Decrease anxiety
- Adhere to self-care program
Nursing Interventions
- Relieve pain and other signs and symptoms of
ischemia
- Improve respiratory funtion
- scrupulous attention to fluid volume
status prevents overloading the heart and lungs
-Promote adequate tissue perfusion
- Reduce Anxiety
- Monitor and manage potential complications
Metabolic Emergencies
Diabetic Ketoacidis (DKA)
- Caused by an absence or markedly inadequate
amount of insulin.
- This deficit in available insulin results in
disorder in the metabolism of carbohydrate,
protein and fat.
- The three main clinical featurs
- Hyperglycemia
- Dehydration and Electrolyte loss
- Acidosis
PATHO
Causes:
- decrease/missed dose of insulin
- illness/infection
- undiagnosed and untreated diabetes
- DKA may be the initial manifestation of
diabetes.
- An insulin deficit may result from an insuficient
dosage of
insuline prescription/from insulin dosage may
be made by
patients who are ill and who assume that if they
are eating
less/ if they are monitoring, they must decrease
their
insuline doses.
- Because illness, especially infection, may cause
increase

blood glucose levels, patients do not need to

decrease their
insulin doses to compensate for decrease food
intake when
ill and may even need to increase the insulin
dose.
-Other potential causes of decreased insulin
- patient error in drawing up or injecting
insulin
- intentional skipping of doses.
- equipment problems
- Illness and infection are associated with insulin
resistance.
Assessment and Diagnostic Finding
- Blood glucose levels may vary from 300800mg/dL (16.644.4mmoL/L)
- some patients may have severe acidosis with
modestly
elevated blood glucose levels whereas others
may have no
evidence of DKA despite blood glucose levels of
400500mg/dL (22.2-27.7mmoL/L)
- Evidence of ketoacidosis is reflected in low
serum
bicarbonate (0-15mEz/L) and low pH (6.8-7.3)
values
- a low PCO2 level (10-30mHg) reflects
Acute Respiratory Failure
- Sudden and life threatening deterioration of the
gass
exchange function of the lung.
- A fall in arterial oxygen tension (PaO2) to
greater than
50mmHg (hypoxemia) and a rise in arterial
carbon dioxide
tension (PaCO2) to greater than
50mmHg(hypercapnia),
with an arterial pH of les than 7.35.
- The ventilation or perfusion mechanisms in the
lung are impaired.
Respiratory system mechanisms leading to ARF
includes:
- Alveolar hypoventilation
- Diffusion abnormality
- Ventilation- perfusion mismatching
Pathophysiology
- Causes
1. Decrease respiratory drive
- may occur with
- severe brain injury
- large lesions of the brain stem (multiple
sclerosis)
- use of sedative medications, and

- metabolic disorder such as

hypothyroidism.
2. Dysfunction of the chest wall
- These includes:
- musculoskeletal disorder (muscular
dystrophy,
polymositis)
- neuromuscular junction disorder
(myasthemia
gravis poliomyelitis)
- some peripheral nerve disorder, and
- spinal cord disorder (amyotrophic lateral
sclerosis,
Guillain-Barres syndrome and cervical
spinal cord
injury)
3. Dysfuntion of lung parenchyma
- Pleural effusion
- Pleural effusion
- Hemothorax
- Pneumothorax
- Upper airway obstruction are conditions that
interfere
the ventilation by preventing expansion of
the lung.
4. Others:
- Pneumonia
- status asthmaticus
- loabr atelectasis
- pulmonary embolism
- pulmonary edema
A mismatch of ventialation to perfusion is
the usual cause of respiratory failure after
major abdominal, cardiac, or thoracic
surgery.
Clinical Manifestations
- Impaired oxygenation and may include:
restlessness,
fatigue, headache, dyspnea, air hunger,
tachycardia and
increased bp.
- As the hypoxemia progresses:
- confusion
- lethargy
- tachycardia
- tachypnea
- central cyanosis
- daiphoresis
- respiratory arrest
Medical Management:
- Objectives
- to correct underlying cause
- restore adequate gas exchange in the lung.
- intubation
- mechanical ventilation may be required to
maintain

adequate ventilation and oxygenation while

the
underlying cause is corrected.
Nursing Management
- Assit with intubation
- Maintains mechanical ventilation
- Assesses the patients respiratory staus by
monitoring the patients level of response.
- Arterial blood gases
- Pulse oximetry
- Vital signs
- Assess the respiratory system
- Come up with strategies to prevent
complications (e.g., turning schedule), in mouth
care, skin care, ROM.
- Assess the patients understanding of the
management strategies.
Acute Renal Failure
- Results when the kidneys cannot remove the
bodys
metabolic wastes or perform their regulatory
functions.
- The substances normally eliminated in the
urine
accumulate in the body fluids as a result of
impaired renal
excretion, leading to a disruption in endocrine
and
metabolic functions as well as fluid, electrolyte,
and acidbase distrubances.
- Reanl failure is a systematic disease and is a
final common
pathway of many different kidney and urinary
tract disease.
Acute Renal Failure is reversible syndreom
that results in decreased glomerular
filtration rate (GFR) and oliguria
Chronic Renal Failure is progressive;
irreversible deterioration of renal function
results in azotemia.
Pathophisiology
- Acute Renal failure is a sudden and almost
complete loss of
kidney function (decrease GFR) over a period of
hours to
days.
- ARF manifests with oliguria, anuria, or normal
urine
volume.
- Oliguria (less than 400mL/day of urine) is the
most
common clinical situation seen in ARF;
- Anuria (less than 50mL/day of urine)
- Normal urine output.
Cathegories

I.Parenal (hypoperfusion of kidney) conditions

occur as a
result of impaired blood flow that leads to
hypoperfusion
of the kidney and a drop in the GFR.
- Common clinical situations are volumedepletion states
(hemorrhage or GI losses),
- Impaired cardiac performance (MI,
HF/cardiogenic shock),
and
- Vasodilation (sepsis/anaphylaxis)
II.Intrarenal (actual damage to kidney
tissue)causes of ARF
are the result of actual parenchymal damage
to the
glomeruli or kidney tubules.
- Conditions such as:
- burns
- crush injuries
- infections
- nephrotoxic agents, may lead to Acute
tubular necrosis
and cessation of renal function.
- Sever transfusion reactions
- Medications may also predispose patient to
intrarenal
damage, especially nonsteroidal
antiinflamatory drugs
and ACE Is
III. Postrenal (obstruction to urine flow) causes of
ARF are
usually the result of an obstruction
somewhere distal to
the kidney.
- Pressure rises in the kidney tubules.
Causes:
- Hypovolemia
- Hypotention
- Decrease CO and HF
- Obstruction of the kidney/ lower urinary tract.
- Obstruction of renal arteries/veins.
Four Clinical Phases of ARF
1. Initiation- begins with the initial insult and
ends when
oliguria develops.
2. Oliguria- accompanied by a rise in the serum
concentration of substances usually
excreted by
the kidneys (urea, creatnine, uric
acid, organic
acids and intracellular cations (K
and Mg)).
- In this phase uremic symptoms first
appear and
life threatening conditions such as
hyperkalemia

develops.
3. Diuresis- the patient experience gradually
increasing urine
output, which signals that GFR has
started to
recover laboratory values stop
rising and
eventually decreases.
4. Recovery- signals the improvement ofrenal
function and
may take 3-12months. Laboratory
values return
to normal.
Clinical Manifestations
- Appear critically ill and lethargic
- With persistent N&V and diarrhea.
- Skin and mucous membranes are dry from
dehydration.
- Breath may have the odor of urine (uremic
fetor).
- CNS S&S includes:
- drowsiness, headache, muscle twitching
and
seizures.
Assessment and Diagnostic Findings:
I. Changes in urine
- urine output varies (scanty to normal
volume)
- Hematuria
- Low specific gravity (1.010/less, compared
to normal
value of 1.015-1.025).
II. Change in kidney contour
III. Increased BUN and Creatnine levels
(Azotemia)
IV. Hyperkalemia
- With a decline in the GFR, the patient cannot
excrete
potassium normally.
- Hyperkalemia may lead to dysrhtythmias
and cardiac
arrest.
V. Metabolic Acidosis
VI. Calcium and Phosphorus abnormality
- there may be an increase in serum
phosphate
concentrations.
- Serum calcium levels may be low in
response to
decreased absorption of calcium from the
intestne and
as a compensatory mechanism for the
elevated serum
phosphate levels.
VII. Anemia
- Inevitably accompanies ARF due to
decreased

erythropoietin production, uremic GI lesions,

reduced
RBC lifespan, and blood loss, usually from
the GI tract.
Medical Management
- Objectives of Treatment of ARF:
- to restore normal chemical balance.
- to prevent complications until repair of renal
tissue and
restoration of renal function can take place.
- Overall Medical Management:
- maintaining fluid balance.
- avoiding fluid excesses,/
- possibly performing dialysis (hemodialysis;
peritoneal
dialysis)
- maintainance of fluid balance.
Assessment of the Patient with Renal Failure:
I. Excess Fluid Volume
- Assess for s/s of fluid volume excess; keep
accurate I&O
and daily weight records.
- limit fluid to prescribed amounts.
- identify sources of fluid
- Explain to patient and family the rationale
for restricion.
- Assist patient in coping with the fluid
restriction.
II. Imbalance Nutrition
- Assess nutritional staus, weight changes and
laboratory
data.
- Assess patient nutritional patterns and
histroy ; note
food preferences.
- Provide food freferences within restricitons.
- Encourage high-quality nutritional foods
while
maintaining nutritional restrictions.
- Assess and modify intake related to factors
that
contribute to altered nutritional intake,eg.,
stomatitis/anorexia.
III. Risk for Situational Low Self Esteem
- Assess patient and family responses to
illness and
treatment.
- Assess relationships and coping patterns.
- Encourage open discussion about changes
and concerns.
- Explore alternate ways of sexual expression.
- Discuss role of giving and receiving lose,
warmth, and
affection.
IV. Provide Skin Care
- meticulous skin care.
- massage bony prominences.

- Turn the patient frequently

- Bathe the patient with cool water are often
comforting
to prevent skin breakdown.
V. Provision of Support
- The patient and family need assistance,
explanation and
support during this time.
- The purpose and rational of the treatments
are explainte
to the patient and family by the physician.
- Repeated experience and clarification by the
nurse may
be needed.
- Encourage family members to touch and
talk to the
patient.
Hyperglycemic Hyperosmolar Nonketotic
Syndrome
- HHNS is a serious condition in which
hyperosmolarity and
hyperglycemia predominate, with alterations of
sensorium.
- Check LOC
- Basic biochemical defect is lack of effective
insulin (ie,
insulin resistant)
- Occurs most often in older people (50-70) with
no known
history of diabetes/with mild type 2 DM(non
dependent).
- Because of possible delays in therapy,
hyperglycemia,dehydration, and
hyperosmolarity may be
more severe in HHNS.
Clinical Manifestations
- Hypotension
- Profound dehydration
- Tachycardia
- Neurologic signs
- alteration of sensorium
- seizures
- hemiparesis
- Mortality 10-40% r/t underlying illness.
Assessment and Diagnostic Findings
- Laboratory Tests
- blood glucose- FBS, CBG
- electrolytes
- BUN
- Complete blood count
- Serum osmolality
- Arterial blood gas analysis
* The blood glucose level is usually 6001200mg/dL, and the
osmolality exceeds 350mOsm/kg.
Medical Management

- fluid replacement
- correction of electrolyte imbalances
- insulin administration
* Close monitoring of volume and electrolyte
status is important
for prevention with fluid overload, HF and
cardiac dysrhythmias.
Nursing Management
- Close monitoring of vital signs
- Fluid status
- Laboratory values
- Maintain safety and prevent injury
- Fluid status and urine output are closely
monitored.
- The nurse must direct nursing care to the
condition that
may have precipitated the onset of HHNS.
- Careful assessment of cardio muscular;
pulmonary and
renal function.
Shock
- Can be best be defined as a condition in which
systemic blood pressure is inadequate to deliver
oxygen and nutrients to support vital organs and
cellular functions.
- Lack of circulating blood volume
- Cell death
- Inadequate tissue perfusion
Without Treatment
- Inadequate blood flow to the tissue results in
poor delivery of oxygen and nutrients to the
cells.
- Cellular starvation
- Cell death
- Organ dysfunction progressing to organ failure.
- Eventual death.
Classification
1. Hypovolemic
2. Cardiogenic
3. Septic
4. Neurogenic
5. Anaphylactic
Stages
I. Compensatory Stage
- the BP remains within normal limits.
- vasoconstriction, increased HR, and
increased
contractility of the heart contribute to
maintaining
adequate CO.
Clinical Manifestations
- Increase HR
- Cahnge in mental status such as
confusion/combativeness,
as well as arteriolar dilation
- Patients skin is cold and clamy

- Hypoactive bowel sound

- Decreased urine output
Medical Management:
- Fluid replacement and medication therapy must
be initiated to maintain an adequate BP and
establish and maintain tissue perfusion.
1. Monitor Tissue Perfusion
- observe for changes:
- LOC
- Vital signs (plus pulse pressure=30-40)
- Urinary output
- Skin
- Laboratory Values
2. Reduce anxiety
3. Promote safety
- monitoring potential threats to the patients
safety.
II. Progressive Stage
- The mechanism that regulate BP can no longer
compensate and BP and the MAP decrease
(Mean Arterial Pressure)
- All organs suffer from hypoperfusion.
- Mental status further deteriorates.
MAP= systolic + 2(diastolic)/3
Assessment and Diagnostic Findings
1. Respiratory Effects
- Respirations are rapid and shallow
- Crackles are heard over the lung fields.
- Decreased pulmonary blood flow.
2. Cardiovascular Effects
- Lack of adequate blood supply leads to
dysrhythmias
and ischemia.
- The patient has a rapid heart rate.
- The patient may complain of chest pain and
even suffer
a MI.
- Cardiac enzymes level increase
3. Neurologic Effect
- Confusion/a subtle change in behavior
- Lethargy increase and the patient begins to
lose consciousness.
- The pupils dialte are only sluggishly reactive
to light
4. Renal Effects
- ARF can develop
5. Hepatic Effects
- Patient becomes more susceptible to
infection and
patient appears jaundiced.
6. GI Effects
7. Hematologic Effects
- Disseminated intravascular coagulation
(DIC) can occur
either as a cause.
Medical Management

- use appropriate IV fluids and medications to

restore tissue perfusion.
- includes early enteral nutritional support
Nursing Management:
1. Prevent Complications
- Evaluate blood levels of medications
- Observe invasive vascular lines for signs of
infections.
- Checking neurovascular state if arterial lines
are
inserted.
- Invasive procedures and arterial and venous
punctures
are carried out using asseptic techniques.
- Venous and arterial puntures and infusion
sites are
maintained.
- Positioning and repositioning the patient to
promote
comfort, prevent pulmonary complications
and
maintaining skin integrity.
2. Promotes Posture and Comfort
- Decrease the patients physical activity and
fear/anxiety.
- Nurses perform only essential nursing
activities.
- Nurses protects the patient from
temperature extremes
(excessice warmth/ shivering cold).
- Patient should not be warmed too quickly.
3. Support family members.
III. Irreversible
- Organ damage is so severe that the patient
does not respond to treatment and cant survive.
- BP remains low.
- Renal and liver functions fail
Overall Management Strategies in Shock
1. Fluid Replacement
- Avoid cardiovascular overloads
- Pulmonary Edema
- CVP line is inserted.
2. Vasoactive Medical Therapy
- Increase the strength of myocardial
contractility, regulate HR, decrease myocardial
resistance and initiative vasoconstriction.
Vasoactive Agents in Treatment of Shock
- Sympathomimetics
- Improve contractility
- Vasodilators
- Vasocontrictor
3. Nutritional Support
- 3,000 calories daily.
Types:
1. Hypovolemic Shock
- Pathophysiology
- decrease blood volume

- decrease venous return

- decrease stroke volume
- Fluid Replacement in shock
- Crystalloids
- Colloids
- Redistribution of fluid
- Modified trendelenburg
Nursing Management
- Administer blood and fluids safely
2. Cardiogenic Shock
- The hearts ability to contract and to pump
blood is impaired and supply of oxygen is
inadequate for the heart and tissues.
- Pathophysiology
- decrease cardiac contractility
- decrease stroke volume and CO
- Pulmonary
-Decrease systemic
Decrease coronary
Congestion
tissue perfusion
artery
perfusion
Clinical Manifestation
- Angina pain
- Dysrhythmias
- Hemodynamic instability
Medical Management
- Correction of underlying causes
- may require:
- thrombolytic therapy
- angioplasty
-CABG
- Oxygenation (2-6Lpm)90%
- Pain control
- Hemodynamic Therapy
Pharmacologic Therapy
- Vasoactive medicines
- Sympathomimetic
- Vasodilators
- Antiarrhythmic
- Fluid Therapy
Nursing Management
- Maintain oxygenation
- I&O
- Medications
- Laboratory Results
3. Circulatory Shock
- Septic Shock
- Neurogenic shock- spinal
- Anaphylactic shock
A. Septic Shock
- most common
- caused by widespread infection
Pathophysiology
- Precipitating event
- Vasodilation
- Inflamatory response
- Decrease venous return
- Decrease CO

- Decrease tissue perfusion

Risk Factors
- Septic Shock
- Immunosuppresion
- Extremes of age (<1y/o and >65y/o)
- Malnourishment
- Chronic illness
- Invasive procedures
- Neurogenick shock
- Spinal cord injury
- Spinal anesthesia
- Depressant action of medications
- Glucose deficiency
- Anaphylactic Shock
- Penicillin Sensitivity
- Transfusion reaction
- Bee sting allergy
- Latex sensitivity
Medical Management
1. Pharmacologic Therapy
- 3rd generation cephalosporin + an
aminoglycoside may be prescribed initially
2. Nutritional Therapy
Nursing Management
- Assess high risk patients
- Prevent infection (insertion sights, catheter)
B. Neurogenic Shock
- Vasodialtion occurs as a result of a loss of
sympathetic tone.
- Causes
- Spinal cord injury
- Spinal anesthesia/ nervous system damage
- depressant action of medications
Medical Management
- Specific treatment depends on its cause
- stabilization of a SCI
- Instance of spinal anesthesia by positioning
the patient
- Hypoglycemia
Nursing Management
- elevate and maintain the HOB at 30 degrees
- in suspected SCI carefully immobilizing the
patient to prevent further damage to SC.
- NI are directed toward supporting cardio and
neuro functions.
- Elastic compression stock infection and
elevating the foot of bed to minimize pooling of
blood in legs.
C. Anaphylactic Shock
- Severe allergic reaction when a patient who has
already produced antibodies to a foreign
substance.
Medical Management

- Remove cause agent

- Administer medications that restor vascular
tone.
- Providing E support of baisc life functions.
- Epinephrin is given for vasoconstriction-DOC
- Dipenhydramin- reverse effects of histamine
Nursing Management
- Assess/Identify allergies
- How she react the last time she reacted to it.
Multiple Organ Dysfunction Syndrome (MODS)
- Progression of shock
- Altered organ function that requires medical
intervention to support continued organ function.
- classified as primary/ secondary
- Prevention is best.
Management of Patients Burn Injury
Classification
1. Superficial Partial Thickness- epidermis;
sunburn
2. Deep Partial Thickness- second degree
burn; scalds; epidermis, upper dermis.
3. Full Thickness- electric current; prolonged
exposure to hot water; may need skin
graftings.
Classification by Extent of Injury
1. Minor Burn- TBSA
- second degree burns; < 15% adults and
<10% children.
2. Moderate, uncomplicated burn
- third degree burn; do not include
eyes,ears,joints
3. Major Burn
- eyes, ears, joints
- all second degree burn that exceeds 25%
Zones of Burn Injuries:
-Zone of Hyperemia- least damage
-Zone of Stasis- compromised blood supply
-Zone of Coagulation- cellular death
Factors to consider in Determining Born Depth
- how the injury occurred
- causative agent
- temperature of agent
- duration of contact with the agent
- thickness of the skin.
Method to Estimate Total Body Surface Area
(TBSA) Burned
- Rule of nnes- simplest/easiest
- Lund and Browler method
- Palm method (1% of TBSA)
Effects of Major Burn Injury
- fluid and electrolyte shifts (hypovolemia)

- cardovascular effects (ECG)

- pulmonary injection (Pulmonary Congestion)
- Renal(Anuria, IFC, I&O) and GI alterations(no
appetite;NGT- risk for aspiration..fowlers)
- Immunologic Alterations (Infection)
- Effect upon thermoregulation (tempterature)
Phases of Burn Injury
- Emergent/resuscitative phase
- onset of injury to completion of fluid
resiscitation
- Acute/Intermediate phase
-from beginning of diuresis to wound closure
- Rehabilitation phase
- from wound closure to return to optimal
physical and psychososcial adjustment.
Guidelines and Formulas for Fluid Replacement
in Burn Patient
1. Consensus Formula
- Lactated Ringers Solution (or other balanced
saline solution)
- 2-4mL x kg body/weight x % TBSA burned
- Half to be given in first 8 hours remaining
half to be given the
next sixteen hours\
2. Evans Formula
- Colloids:1mL x kg body weight x % TBSA
burned
- Electrolytes:
3. Brooke Army Formula
- Colloids: 0.5mL x kg body weight x % TBSA
burned.
- Electrolytes (Lactated Ringers Solution)
1.5mL x kg body weight x % TBSA burned
- Glucose (5% in water): 2000mL for
insensible loss
4. Parkland/Baxter Formula
- Lactated Ringers Solution: 4mL x kg body
weight x %TBSA
burned.
Patients with burns exceeding 20-25% should
have an NGT for suction.
1. Emergent/ Resuscitative Phase
- Catheter- bonano catheter/ suprapubic
catheter
- Address pain, IV meds only
- ECG- 3 leads
2. Acute/ Intermediate Phase
- 48-72 hours after injury
3. Rehabilitation Phase
- May need reconstructive surgery.
Burn Wound Care
1. Wound Cleaning
- Hydrotherapy (shower carts; individual
showers; bed bath)

- Water= 37 degrees celcius.

2. Use of Topical Agents
- silver sulfadiazine 1% (silvadene)
watersoluble cream
- Matenide acetate 5% to 10%(sulfamyton)
hydrophilic-based
cream.
- silver nitrate 0.5% aquaeous solution
3. Wound Depridement
- natural debridement
- mechanical debridement- forcep scissors
- surgical debridement- deeper-facia;bone
4. Wound Dressing- impregnated with antimicrobial agents
5. Skin grafting
Types of Skin Grafting(biologic dressing)
- homografts/allographs- living or recently dead
humans
- heterografts- animals; pig
- biosynthetics/ Synthetic dressing
- Biobrane dressing- most common; indefinite
shelf life
1. Pain Management:
A. Analgesics
- IV used during emergement and acute
phases.
- Morphine
- Fentanyl
- Sustained-release opioids, such as MS
Contin/oxycodone
(Ocy Contin)
B. Nonpharmacologic Measures
- music therapy
2. Nutritional Support
- prefer jejunal feeding than NGT
3. Other Major Care Issues
- Pulmonary Care
- Psychological Support of patient and family
- Patient and Family education
- Restoration of function
Collaborative Problems/Potential Complications
- HF and pulmonary edema
- Sepsis
- ARF
- Cisceral Damage (electrical burns)
Nursing Interventions
- Restoring normal fluid balance
- Preventing Infection
- Maintaining adequate nutrition
- Promoting skin integrity
- Relieving pain and discomfort
- Promoting physical mobility
- Strengthening coping strategies

- Monitoring and managing potential

complications.
Managemet of Patients with Poisoning
Poison- any substance that when ingested,
inhaled, absorved, appliedto the skin, or
produced with in the body in relatively small
aounts injures the body and its chemical action.
Treatment Goals:
- Removal/inactivate the poison before it is
absorved.
- Probide supportive care in maintaining vital
organ system.
- Administer specific antidotes.
- Implement treatment to hasten the elimination
of the poison.

Measures to Remove the toxin/ decrease its

absorption
- Use of emetics
- Gastric lavage
- Activated charcoal
- Cathartic when apporpriate
- Administration of specific antagonist as
early as possible.
- May include: diuresis/dialysis
- dimercaprol- mercury/heavy metal;
arsenic.
Management for patient with Carbon Monoxide
- Inhaled carbon monoxide binds to hemoglobin
as carboxyhemoglobin, which does not transport
oxygen
Manifestations: CNS symptoms predominate

Ingested Poisons
* Corrosive poison includes
- Alkaline Products:
-lye; drain cleaners; toilet bowl cleaners;
bleach;
Non phosphate detergents; oven cleaners;
button batteries
- Acid Products
- toilet bowl cleaners; pool cleaners; metal
cleaners; rust
removers and battery acid
Assessment of Patients with Ingested Poisons
- use ABC
- Monitor VS, LOC, ECG, UO
- Assess laboratory specimens
- Determine what, when and how much
substance was ingested.
- Assess s/s of poisoning and tissue damage
- Asseses Health history
- Determine age and weight.
Management of Patient with Ingested Poisons
- The patient who ingested a corrosive poison is
given water/ milk for dilution
- Gastric emptying procedures may be used as
prescribed.
- syrup of ipecac to induce vomiting in the
alert patient.
- Gastric lavage for the obstunded patient.
Gastric aspirate is
saved and sent to the laboratory for testing
(toxicology
screens.)
- Activated charcoal is administered if poison is
one that is
absorved by charcoal.
- Cathartic, when appropriate.

Treatment
- Get to fresh air immediately
- CPR if necessary
- Administer 100% oxygen
- Monitor patient continuously
Other
-

S/S
Headache
Muscular weakness
Palpitation
Dizziness
Confusion
Which can rapidly progress to coma
Skin color, which can range from
pink/cherry-red to cyanotic and pale, is not
a reliable sign.

Management
Goals
- to reverse cerebral and myocardial hypoxia and
- to hasten elimination of carbon monoxide
Whenever a patient inhales a poison
- Carry the patient to fresh air immediately;
open all doors and windows.
- Loosen all tight clothing
- Initiate CPR if require; administer oxygen
- Prevent chilling; wrap patient in blankets
- Keep patient as quiet as possible
- Do not give alcohol in any form
Management of Patients with Food Poisoning
Food Poisoning
- sudden illness due to the ingestion of
contaminated food/drink.
- food poisoning, such as botulism/fish poisoning,
may result in respiratory paralysis and death.
- Salmonylosis; e-coli; staphylococcus

Management
- ABCs and Supportive measures
- Treatment fluid and electrolyte imbalances
- control N&V
- Provide clear liquid diet and progression of diet
after N&V subside.
- Measures to control N are also important to
prevent vomiting.
- An antiemetic medicine is administered
parenterally
- For mild nausea, the patient is encouraged to
take sips of weak tea, carbonated drinks/ tap
water.
- After N&V subside, clear liquids are usually
prescribed for 12-24 hours and the diet is
gradually progressed to a low- residue, bland
diet.
Management for Skin Contamination Poisoning
(Chemical burns)
1. Immediately flush the skin with running water
from a shower, nose or faucet.
- Lye/white phosphorus must be brushed off the
skin dry.
2. Protect health care personnel from the
substance.
3. Determine the substance
4. Some substance may require prolonged
flushing/irrigatin.
5. Antimicrobial treatment, debridement, tetanus
prophylaxis as prescribed is instituted.
6. The patient may require plastic surgery for
further wound management.
7. Follow-up care includes re-exam of the area at
24hours,
72 hours and 7days.

FINALS
Emergency Nursing
Scope and Practice of Emergency Nursing
* Emergency Management:
- traditionally refers to urgent and critical
care needs.
- however the ED has increasingly been used
for non-urgent problems and E
management has broaden to include the
concept that an E is whatever the
patient/family considers it to be.
*Qualifications of an E Nursing
- has special training
- education
- experience
- expertise in assessing and identifying
health care
problems in crisis situations.

* Tasks of an E Nurse
1. Establish priorities
2. Monitors
3. Continuously assesses acutely ill and
injured patients.
4. Supports and attends to families.
5. Supervises allied health personnel
6. Teaches patients and families within a
time-limited,
high pressured environment.
* Focus of E Care
1. Preserve life
2. Prevemt deterioration before definitive
treatment
can be given.

3. Determine the patients ability to follow

commands and evaluate motor skills and
pupillary size.
4. Carry out a rapid initial and ongoing physical
exam.
5. Start cardiac monitoring if appropriate.
6. Splint suspected fracture.
7. Protect and clean wounds and apply sterile
dressing.
8. Identify allergies and medical history that is
significant (DM; seizure).
9. Document vital signs; neuro status; I&O to
guide decision making.
* Special Considerations in E Nursing
1. Data collection
2. Information control
3. Make safety the first priority
4. Preplan to ensure security and a safe
environment
5. Closesly observe patient and family members
in the event that they respond to stress with
physical violence.
6. Discharge planning.
7. Psychological support
- patient focused
- family focused
- Relieve anxiety and provide a sense of
security.
- Allow family to stay with patient if possible,
to alleviate
anxiety.
- Provide explanations and informations.
- Provide additional interventions depending
upon the
stage of crisis.
8. Documentation
* Triage
- To sort patients by heirarchy based on the
severity of health problems and the immediacy
with which these problems must be treated.

- It is used to determine those patients in need

of immediat treatment and those who can safely
wait.
* Three Main Categories of Triage
1. Emergent- life- threatening/ potentially life
threatening injuries or illness requiring
immediate treatment.
2. Immediate- non-acute, none-life threatening
injury or illness.
3. Urgent- minor illness/injury needing first-aid
level treatment.
- can be referred to a primary
physicains office/clinic.
* Priorities in E Nursing
1. Establishing an airway
2. controlling hemorrhage
2.1 fluid replacement.
3. Controlling hypovolemic shock
- shock condition in which there is loss of
effective
circulating blood volume.
* Managemenbt
1. Ensure a patent airway and maintain effective
breathing.
2. Restoration of the circulation of blood bolume
which is accomplished by rapid fluid and blood
replacement as ordered.
3. CVP line- to know the pressure in the right
atrium
- normal: 4-10cm H2O
2-7mm Hg
- manometer- oxygen level of right atriem.
4. BT
5. IFC
6. on going nursing surveillance of which total
patient is maintained.
7. BP, RR, HR, Skin temp, color, pulse oxy, neuro
stat, CVP, ABGs, ECG, Hct, Hgb, etc..
1?
2. Wounds- vary from tears to severe crushing
injuries.
* Management:
- shave/clip hair around
- clean with NSS/betadine/H2O2
- do not get deep into the wound without
thorough rinsing.
- if indicated, the area is infiltrated with
anesthesia before cleaning.
- irrigate copiously with sterile NSS.
3. Traumas
Priorities of Care of the Patient with Multiple
Trauma
- use a team approach
- determine the extent of injuries and establish
priorities of treatment.
- assume cervical spine injury.

- assign highest priority to injury intergering with

vital physiological function.
4. Intra-abdominal Injuries
4.1 penetrating
4.2 blunt
-Abdominal trauma can cause massive lifethreatening blood loss into the abdominal cavity.
Assessment:
- Obtain history
- Perform abdominal assessment
- Assess other body system for injuries that
frequently accompany abdominal injuries.
- Assess for referred pain that may indicate:
- spleen- hemorrhage
- liver
- intraperitoneal injury
-Perform the following:
- laboratory studies
- CT scan
- abdominal ultrasound (FAST)
- diagnostic peritoneal lavage
- Assess stab wound via sonography.
Manage Patients with Intra-abdominal Injuries
- Continually monitor the patient
- Immobilize cervical spine
- Document all wounds
- If viscera are protruding, cover with a sterile,
moist saline dressing.
- Hold oral fluids.
- NGT to aspirate stomach contents.
- Ensure airway, breathing and circulation.
- Provide tetanus and anti-biotic prophylaxis.
- Provide rapid transport to surgery if indicated.
5. Crushing Injuries
Assessment:
Observe for the following:
- hypovolemic shock
- paralysis of the body
- erythema and blistering of the skin
- damaged body part appearing swollen, tense
and hard
- renal dysfunction
6. Mlti/Multiple Injuries
Nursing Responsibilities:
- assess and monitor patient
- ensure IV access
- Administer prescribed meds
- Collect laboratory specimen
- Document activites and patients response
Priorities:
- Establish airway and ventilation
- Control hemorrhage
- Prevent and treat hypovolemic shock. Monitor
urine output.
- Assess for head and neck injury. Maintain spine
immobilization.

-Evaluate for other injuries.

-Spine traction
7. Fractures
Management:
-assessment for ABCs including pulse in
extremities.
- evaluate for neuro and abdominal injuries
before the extremities are treated unless a pulse
extremity is detected.
8. Management of Patients with Substance Abuse
+Acute alcohol intoxication: a multisystem toxin.
- Alcohol poisoning may result in death.
- Maintain airway and observe for CNS
depression and hypotension.
- Rule out other potential causes of the
behaviors before it is assumed the patient is
intoxicated.
- Use a nonjudgmental, calm manner5.
- Patient may need sedationif noisy or
belligerent.
- Examine for withdrawal delirium, injuries and
evidence of other disorders.
9. Family Violence, Abuse and Neglect
Clinical Manifestations
- may present with physical injuries/health
problems such as
- anxiety
- insomnia
- GI symptoms, that are r/t stress
*In the ED, the most common physical injuries
are: unexpected bruises; lacerations; abrasions;
head injuries; fracture.
Clinical Manifest of Neglect
- Malnutrition
- Dehydration
Management:
- Focused on the consequences of the abuse,
violence/neglect and on prevetion of further
injury.
10. Sexual Assault
NR: Manner on how we treat our patient affect
their psychological status.
11. Psychological E
- Overactive; underactive;
violent;depressed;suicidal
Management:
- Maintain the safety of all persons and gain
control of the situation.
- Determine if the patient is at risk for injuring
himself/others.
- Maintain the persons self-esteem while
providing care.

- Determine if the person has a psychiatric

history/is currently under care to contact the
therapist.
Crisis Intervention
- Goal:
- Resolution of an immediate crisis.
Focus:
- Supportive
- Restoration of the individual to
his pre-crisis level of functioning/to a higher level
of functioning.
Terrorism, Mass Casualty and Disaster Nursing
Priority 1- RED
- Immediate: Injuries are life threatening but
survivable with minimal intervention. Individuals
in this group can progress rapidly to expectant if
treatment is delayed.
- Sucking chest wound, airway obstruction
secondary to mechanical cause, shock,
hemothorax, tension pneumothorax, asphyxia,
unstable chest and abdominal wounds,
incomplete amputation, open fracture of long
bones, burn with.
Priority 2- YELLOW
- Delayed: injury are significant and require
medical care, but can wait hours without threat
to life/ limb individually in this group: receive
treatment, only after immediate casualties are
treated.
- Stable abdominal wounds without evidence of
significant hemorrhage; soft tissue injury,
maxillofacial wounds without airwya
compromise; cascular injury with adequate
collateral circulation; genitourinary tract; most
eye and CNS injuries.
Priority 3- GREEN
- Minimal: injury are minor and treatment can be
delayed hours to days. Individuals in this group
should be moved away from the main triage
area.
- Upper extremity fracture; minor burns, sprains,
small lacerations without significant bleeding,
behavioral disorder or psychological
disturbances.
Priority 4- BLACK
- Expectant- Injuries are extensive and chances
of survival are unlikely even with definitive care.
Persons in this group should be separated from
other casualties but not abandoned. Comfort
measures should be provided when possibe.
- Unresponsive patients with penetrating head
wounds high spinal cord injuries, wounds
involving multiple anatomical sites and organs,
second and third degree burns in excess of 60%

of body surface area, seizures/vomiting within

24hours after radiation exposure, profound shock
with multiple injuries, agona/respiratory, no
pulse, no BP, pupils fixed and dilated.
Categories of Protective Equipment:
Level A: self contained breathing
apparatus(SCBA) and vapor-tight chemicalresistant suit, glorus and boots.
Level B: high level of repiratory protection
(SCBA)but lesser skin and eye protectin;
chemical resistant suit.
Level C: air purified respirator, cover all with
splash hood, and chemical resistant glorus and
boots
Level D: typical work uniform.
ANTHRAX
SARS
Avian Flue
- Pathogenic strain of Bird Flu
- S/s
- fever
- headache
- fatigue
- sore throat
- dry cough
- runny nose/stuffy nose
Types
-

of Radiation Experience:
External
Contamination
Incorporation

Critical Insident Stress Management (CISM)

- Education
- Field Support
- Defusing
- Debriefing
- Demobilization
- Follow up components
Post Traumatic Stress Disorder (PTSD)
- A condition that generates waves of:
- Anxiety
- Anger
- Aggression
- Depression
- Suspicion
- That threaten the persons sense of self and
interfere with daily functioning
- Some events that place a person at risk for
PTSD:
- Rape
- Family violence
- Torture
- Terrorism

- Fire
- Earthquake
- Military Combat
- It has been postulated that people with PTSD
lose the ability to control their response to
stimuli.
- The resulting excessive arousal can increase
overall
Body Metabolism and Trigger Emotional
Reactivity
- Manifestations:
- Has difficulty sleeping
- Has an exaggerated startle response
- Is excessively vigilant
Symptoms Can Occur Hours to Years After the
Trauma is Experienced.
- Acute- the experience of symptoms for less
than 3month period.
- Chronic- experence of symptoms longer than
3months
- In the case of delayed PTSD, up to 6months
may elapse between the trauma and
manifestation of symptoms
Nursing Implications
- It is important that nurses consider which
of their patients are at risk for PTSD and
be knowledgeable about the common
symptoms associated with it.
- The sensitivity and caring of the nurse
creates the interpersonal relationship
necessary to work with patients who have
PTSD.
Essential components of Treatment for patient
with PTSD
1. Establishing a trusting relationship
2. Addressing and working through thte
trauma experience.
3. Providing education about the coping skills
need for recovery and self- care.
Intravenous Parenteral Therrapy
Intravenous Therapy
- Insertion of a needle/catheter into the vein
based on the physicians written prescription
Goals:
- To provide water, electrolytes and nutrients to
meet daily requirement.
- To replace water and correct electrolyte deficits.
- To administer medicines and blood products.
- To provide ready access for emergency med
particularly in critically ill patients.

Nursing Responsibilities in IV Therapy

1. Starting the infusion
2. Managing the flow rate
3. Monitoring for complications of IV therapy
4. Discontinuing the infusion
Procedure for Starting IV Infusion
1. Prepare the equipment
2. Prepare the patient
3. Prepare the site
4. Perform the venipuncture
5. Document the procedure
Veins of the Hand and Arm
Hand sites:
- Dorsal venous arch
- Metacarpal vein
- Digital vein
Arm sites:
- Cephalic vein
- Accessory Cephalic Vein
- Basilic Veins
- Median Antebrachial.
Documentation
Document the following
- Date and time of procedure
- Type, length and gauge of the
catheter inserted.
- Number of attempts made
- The exact location of each attempt
and the final
successful site.
- Type of dressing applied
- Patients response to the procedure
- Condition of the IV site
- The types of fluids and medicines
used.
- Patient teaching.
Review:
Fluids
1. Body fluids:
- Adults: 60% of the TBW (40% solids, fats,
proteins, minerals, carbohydrates)
2. Main Compartments:
- Intracellular- are within cell -40%
- Extracellular- interstitial- between and
around the cell- 15%
- Intravascular- inside the blood vessels
5%
Movement of Water and Electrolytes
Diffusion- random movement of ions and
molecules in all directions through a
solution/gas.
- spread is from area of greater
to lesser
concetration.

Osmosis- water moves from less

concentration to more concentration(.3
main types of IV)
Active transport
Filtration

Types of IV Solutions:
1. Isotonic- fluids that are classified as isotonic
have a total osmolality close to that of the ECF
and do not cause rbc to shrink/swell.
- Because these fluids expand the intravascular
space, patients with hypertension and heart
failure should be carefully monitored for signs of
fluid overload.
- e.g. D5W, PNSS,LRS
2. Hypotonic Fluids- ro replace cellular fluid,
because it is hypotonic as compared with
plasma.
- to provide free water for excretion of body
wastes.
- used to treat hypernatremia and other
hyperosmolar conditions.
- can be helpful when cells are dehydrated such
as those of a dialysis patient on diuretic therapy.
- used for hyperglycemic patients as diabetic
ketoacidosis in which high serum glucose levels
draw fluids out of the cells into the vascular and
interstitial compartments.
- ex: half strength saline (0.45% NaCl)
solution, with an osmolality of 154 mOsm/L,
- Multiple-electrolyte solutions; D5NSS; a 18%
NaCl
-Excessive infusions of hypotonic solutions can
lead to intravascular fluid depletion, decrease
bp, cellular edema and cell damage.
3. Hypertonic- higher osmolality than serum.
- Pull fluid and electrolytes from the intracellular
nad interstitial space into the intravascular space
and can help stabilize blood pressure, increase
urine output and reduce edema.
- eg: 9% NS; blood products and albumin.
Complications
1. Thrombophlebitis
Causes: Irritating solution and medicines.
Traumatized vein.
Signs and Symptoms
a. Temperature Spikes
b. Pain along the course of the vein.
c. Possible discoloration of skin around of the
injection site.
d. IV leading at injection site.
2. Infiltration- the seepage of solution or
medicines into surrounding tissue.
Causes: Dislodged catheter
Hyperactive patient

Hubs/wings of needle not anchored

properly
IV insertion pushes needle bevel
through posterior of vein.
Needle placed in area of flexion
Signsand Symptoms
- Swelling of affected area
- Coolness of skin around site
- Backflow of blood absent/ pinkish blood
serum
- Slowing of infusion rate.
3. Mechanical Complications- Failure of the
intravenous system to adequately deliver
therapy at the prescribed rate.
4. Hematoma- swelling/mass of blood confined in
the tissue caused by a break in the blood vessel.
Causes: Damaged to vein during unsuccessful
venipuncture attempt.
Inadequate pressure after removal of
cannula
Inappropriate use tourniquet
Signs and Symptoms
- Ecchymosis
- Swelling and discomfort at site.
5. Phlebitis- inflamation of vein

Types 1. Mechanical
2. Chmeical
3. Bacteria
6. Venous Spasms
Causes:
Severe vein irritation
Administration of cold fluids/blood.
Very rapid flow rate
7. Extravasation- infiltration of vesicant
medications
8. Tape burn.