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TOPICS

AIDS

·         ELISA and Western blot test are done to screen an individual for being HIV positive

·         Effectiveness of medications are determined by viral load

·         Immunocompromised patients should avoid foods that may be high in bacteria such as raw fruits and vegetables.  Provide high caloric, high protein but low fat food.

·         Don’t have drinking water stand for more than 15 minutes to prevent contamination.

·         If patient is exposed to any other disease, the patient should be treated immediately from the new disease since the patient is already immunocompromised.

·         Meat should be cooked well to avoid toxoplasmosis

·         Yogurt contains live cultures that these patients should avoid.

·         Pneumocystis carinni pneumonia is the most common opportunistic infection for AIDS patients.

·         CMV - ONE OF THE 26 INDICATORS of AIDS though it can be reversed it requires a long term treatment. If there is delayed in treatment,  vision loss may occur.

 

Anemia

·         A decrease in the amount of hemoglobin which could be caused by several factors (i.e. deficiency in iron or Vitamin B12 or genetic disease)

·         All types of anemia can experience lightheadedness, difficulty breathing after exertion, and faster heart rate (palpitations).

   

     Types of Anemia

 

  1.     Pernicous Anemia

  • Usually due to deficiency in Vitamin B12 caused by the body’s inability to produce enough intrinsic factor that is needed to absorb Vitamin B12.
  • Deficiency in Vitamin B12 causes nerve problems, thus, patient may feel a tingling sensation and numbness of extremities. The numbness and tingling sensationare common in comparison to other types of anemia.
  • RBC is normochromic and macrocytic.
  • Patient may exhibit loss of coordination and loss of sense of position
  • Schilling test is done to diagnose Pernicious Anemia. It involves fasting for at least 12 hours and the individual is given a small does of radioactive B12 in water to drink and it is followed by a nonradioactive dose, usually IM. A 24 hour urine collection is done and measured for radioactivity.
  • A main deficiency for pure vegetarian who do not eat meat or any meat products.



  2.     Iron Deficient Anemia

  • The most common form of anemia mainly due to bleeding (i.e. menstruation in women) and can be due to lack of iron in diet or lack of absorption of the iron in the intestines.
  • RBC is microcytic and hypochromic.
  • Person may exhibit Glossitis (inflammation of the tounge)
  • PICA (cravings for certain substances such as clay, dirt, or licorice) is a characteristic of iron deficiency
  • Having spoon shaped finger and toe nails and having sores at corners of the mouth are also characteristics of iron deficiency.
  • Most of iron is stored as Ferritin, a protein, and some as Hemosiderin, a complex of iron, proteins and other materials. Both are mainly in the liver but could be found in bone marrow, spleen and skeletal muscle



3.     Aplastic Anemia 

  • A disease where there is a decrease in the number of RBCs produced due to failure in the bone marrow. In essence, the RBS is lysing. s.
  • Symptom may include longer bleeding time, easy bruising because of reduced platelets, susceptibility to infections because of low WBC count.    


4
.     Hemolytic Anemia

  • RBC has abnormal shape and shortened life span. Normally, RBC live for about 4 months. This has Nothing to do with color and size of RBC.
  • RBC destruction leads to bilirubin accumulation leading to jaundice.  

                      A. Sickle Cell Anemia 

·              A hereditary abnormality where the RBC is formed in “sickle”  manner causing it to clog joint and lead to pain.

·              May not be detected in newborns until after six months since the baby will be protected by fetal hemoglobin  

                      B. Thasalemia 

·              A hereditary abnormality where the RBC appears very small almost similar to iron deficiency. This is common to Medterranean, African and to Asian decent.     

 

Autoimmune Thrombocytopenic Purpura

·         Very low platelet counts so bleeding is a major concern.
 

 Blood

·         At least two nurses should verify the compatibility of donor against recipient.

·         A mother refusing blood transfusion for her child or a patient refusing the transfusion for religious reasons: Notify the doctor.

·         Any allergic reaction to blood, immediately STOP the transfusion and run the IV normal saline. Only then will you call the doctor.

·         Allergic reaction – patient has urticaria.

·         Hemolytic transfusion - pain is present and no fever, includes vomiting.

·         Any non-hemolytic reaction can occur within 10-15 mins, usually is febrile.

·         If one had to stop transfusion, send the remaining blood to Lab for further analysis and repeat type and cross match.

·         There is no need to have a separate administration set for every unit of transfusion for the same patient.

·         Autologous donation - must be done no more beyond 5 wks before surgery and can be done until 3 days before surgery; can donate 2-4 units

           

     Blood Type

  1.     O = Universal donor

     2.    AB = Universal recipient  

 

Breast Cancer

            A. Mammogram

·              Instruct patient not to use deodorants nor powders because they can cause false positive readings.

·              Check for any mass that is not movable, firm and hard.  

            B. Post-Operative Care

·              For lumpectomy on breast, Do not apply any hot or cold on area nor tape, creams, nor lotions.

·              Wear loose fitting bra.

·              Encourage to exercise both arms to increase muscle tension. Best beginning exercise is squeezing of a ball.

·              DO NOT put sling on arm.

·              Affected side should not be used for any clinical tests (i.e. blood pressure check).

·              Encourage patient not to lie on the affected side.

·              Put arm over head to enhance circulation and prevent edema by allowing gravity to facilitate in the removal of fluid  from venous pathway

 

CANCER

General Common Concerns

  • Patients with complications of cancer is documented with superior vena cava syndrome -- SYMPTOMS are facial edema in the morning, dyspnea and epistaxis; since the backup in the inferior and superior veins is causing pressure evidenced in edema  THIS IS NOT IADH, which leads to fluid retention, sudden drop in Na, hyponatremia dilution, thus experiencing muscle cramps.

  • When mixing drug medications, it is recommended to wear surgical glove, use Luer lok IV  tubings, and use disposable long sleeve gown. Most antineoplastic medications have the following side effects:
    1. Bone Marrow suppression, thus, lowers the RBC, causes neutropenia and thrombocytopenia (low platelets). So, watch for nose bleeds and bleeding gums.
    2. GI problems – causes can be anorexic. Have nausea and vomiting since most of these medications stimulate the vomit center. Patient can also have diarrhea.
      • Cachexia (wasting) is common
      • Encourage patient to eat frequent small meals and to take fluids. TPN as needed.
    3. Stomatitis – inflammation of the mucous membrane of the mouth. See mouth care.
    4. Alopeica – loss of hair, which alters serlf image and a nurse encourage to possibly use hair piece, wigs or hats, scarves.
    5. Infertility – this is a huge issue especially if the patient is childbearing woman.  
  • Cancer medications can lower the immune system of the patient. So, tell patient to be careful when in contact with people with colds, flu or other contagious illnesses. Also, tell patient NOT to have and vaccines that contain live strains (i.e. oral polio vaccine) or DO NOT come in contact with those who were vaccinated with a live virus.
  • Skin care - exposure to cancer medications can cause skin irritation. If it happens, rinse well with soap and warm water. Encourage use of cotton and loose fitting clothing.
  • Mouth care - Check patient's mouth for any stomatitis that can develop within 5 - 14 days after chemotherapy and encouage patient not to sue rinses tha contain alcohol to limit buccal mucosa irritation. Also, encouarge patient to avoid spicy foods and hot temperature foods.
  • Provide pain medication, usually in a step ladder approach of mild pain (use of Tylenol), moderate pain (use of weak narcotics such as codeine), and sever pain (use of strong narcotics such as morphine)
  • Patients on Methotrexate medication should avoid vitamins containing Folic Acid, the antidote for methotrexate.
  • Give some anitemetic medication prior to radiation therapy to avoid nausea and vomiting.  

            A. Staging of Cancer

      1. TNM

·              T - the primary tumor

·              N - Extent in which lymph nodes are involved.

·              M - Whether the cancer has metastasized of not

 

            B. Common types of Cancer

      1. Lung

·              Mainly due to smoking.

·              Can be caused by asbestos

      2. Gastric

·              Mainly due to smoking.

·              Can be caused by NSAIDs ingestion for long period of time.

      3. Bladder

·              Cigarettes are the main culprit.

      4. Breast

·              See Breast Cancer

      5. Laryngeal

·              Tobacco and alcohol use are two frequent causes. See Larynx Cancer topic.

      6. Leukemia

·              See Leukemia topic below.

      7. Skin

·              See Skin cancer topic below.

 

            C. Care with Radiation   

1. External Radiation

  • Do not remove the radiology markings on the skin and do not apply any creams, lotions, deodorants or perfumes since some of these products may interfere with external radiation.
  • Avoid exposing the skin to hot or cold temperatures.

2.. Internal Radiation

      a. Sealed - it is sealed source since a specific area is usually being targeted, thus, position is verified by reaiodgraphy. Also, urine, feces and linens are not radioactive.

      • Radioactive implants should be picked up with tongs or long forceps in the room and is placed in a lead-lined container.
      • All dressings, bed linens are dicarded as usual.

      b. Unsealed - usually an unsealed liquid is given orally or is instilled in a body cavity. So, all body fluids are contaminated, the greatest danger from the fluids are from 24 - 96 hours.

    General Nursing care for Internal radiation

      • Nurse should war a war dosimeter film bade that does not protec the nurse from exposure but measures the amount of exposure.
      • Limit the amount of time and keep a distance from patient -- about 3 feet at all times should be matiened. Staff should be rotated from patient care and a pregnant nurse should not be assigned. .
      • Limit the amount of exposure with radium implants to about 30 minutes per visit .
 

CYANOCOBALMIN

·         This is Vitamin B12

·         Patient is given Vitamin B12 to help increase the level of hemoglobin

 

Cytomegalovirus (CMV)

·         Best diagnosed with fresh specimen and cultures of urine, sputum and oral swab are    preferred to diagnose the infection.

 

Disseminated  Coagulopathy (DIC)

·         Patient clots easily

·         Diagnosed by the presence of fibrin split compound

 

 Genetics

  1.     Autosomal Dominant 

·              If one parent is affected, children have a 50% chance of being affected

         Example: Marfan Syndrome endometrial cancer.

  2.     Autsomal Recessive

            a.     If one parent is affected and the other is not a carrier, all of the offspring will not be affected but will carry the gene.

            b.     If one parent is affected  and the other is a carrier, all offspring will have one in two chance of being affected.

                    Example: PKU and Sickle Cell

 

HELLP Syndrome

·         Hemolytic anemia with Elevated Liver enzymes and Low Platelet count  

 

Hemophilia

  • A blood disorder that is sex linked, that is it is transmitted to male by femail carrier.
  • The most common cuase is the deficiency in Factor VIII (Hemophilia A)
  • Individual may exhibit easy bruising, join pain and bleeding.
  • Avoid aspirin or Nsaids for pain; use analgesics
  • Ask contact sports. A child that is hit by a ball on the nose can easily bleed. So, protection is a must.
  • Individual may be administered Cryoprecipitated antihemphilic factor (AHF)

 

Herpes Zoster (also called Shingles)

·         Caused by a virus.

·         Disseminated zoster would require  airborne precaution

 

Irridium

·         Can be expelled during urination. The patient should be taught to strain their urine.

·         Patient receiving the implant should be on bedrest and have a foley inserted

·         Secreations are not radioactive but the applicator is  

 

Larynx Cancer

  • Watch for change in voice (hoarseness), dysphagia, and hemoptysis. May have enlarged cervical nodes.
  • Pain may radiate to the ear. Can be due to smoking, straining of vocal cords, predisposition, or expsure to chemicals.
  • Laryngtectomy may be done and stoma care and proper suction are important. Watdch for signs of rupture of carotid artery.
  • Nasogastic tube (NGT) may be put in plce to provide nutrition. So, always check for NGT positioning to prevent aspiration and make sure individual is in semi-Fowler position.
  • May be given artificial larynx for speech or provide individual with esphageal speech valve. .

 

Leukemia

  • CBC would indicate an increase in WBC to help in temporarily diagnose the disease but it can only be confirmed by bone marrow aspiration, which is usually don on the iliac crest and sternum. Sterile dressing and pressure should be applied to the site of aspiration to avoid bleeding.
  • Bleeding and infections due to decreased platelet are the main clinical manifestations. So nurses, should monitor for signs of bleeding (bruising, petechieae) and signs of infection (fever, change in vital signs, neutropenia).
  • Often has respiratory infections, experience insomnolence, weight loss and decrease alertness
  • Neutropenia precaution should be exercised by nurses.
    • No fruit or plants should be allowed in patients room since they may carry bacteria.
    • Patient should be in a private room to limie exposure to bacteria.
    • Strict handwashing and good mouth care
    • Prevent breakdown by turning patient

2 Main Types of Leukemia

a. Acute Leukemia - common in young adults and children; it is a rapid onset and could progress to a terminal status within days or months.

b. Chronic Leukemia - Common between ages of 25 - 60 and is a gradual onset with a slower course.

Lupus

  1.     Discoid Lupus 

·              Indicated a “coinlike” lesion on the skin.

  2.     Systemic Lupus

·              Can affect joints, muscles, and other systems (heart, lungs, kidneys).

 

Lymphoma

·         Reed Sternberg cells differentiate Hodgkins lymphoma versus Non-hodgkins lymphoma

 

Neutropenia

  • Patients should refrain from uncooked raw food: fruits and vegetables.
  • Patients should be in a private room to prevent expsoure to bacteria.
  • Pepper as food contains bacteria and can’t be tolerated by the patient with neutropenia.
  • Advice patients to avoid crowded areas to avoid getting infected by others.  

Oral Candidiasis

·         If it develops, use a soft gauze to clean the oral mucosa. Avoid toothbrush, mouthwash, lemon and glycerin that can be too abrasive and cause burning sensation.  

Polycythemia Vera

·         Has an high risk of thrombosis.

·         Hydration of 3 liters is important to prevent thrombus formation.

 

Radium

·         Linear accelerator Therapy is done in the radium department and does not make a patient radioactive.

 

Rheumatic Fever

·         Normal to be positive for C reactive protein.  

 

Schilling Test

  • A test that is performed to diagnose Pernicious anemia due to deficiency in Vitamin B12
  • It involves fasting for at least 12 hours and the individual is given a small does of radioactive B12 in water to drink and it is followed by a nonradioactive dose, usually IM. A 24 hour urine collection is done and measured for radioactivity.

 

Sickle Cell (see Anemia topic above)

·         Pain is the major complain

·         Oxygenation is important since patient has fewer red blood cells

·         Put patient in semi-Fowler position for better oxygenation. No flexion of hips or knees which in so doing would impede circulation

·         Keep the patient hydrated to prevent thrombus formation

·         High altitudes and cold temperatures can cause sickling

 

Skin Cancer

  • Encourage individuals to look for any change in size, color and shape of nodule on skin.
  • Exposure to sun is the main cause and light skin individuals are more at risk. So, encourage individuals to avoid exposure to sun usually from 10am to 3pm, the sun's peak and to use SPF (solar protection factor) containing sunscreens. Sunscreen should be reapplied after a swim or prolonged time under the sun.
  • Avoid tanning booths and encourage individuals to use hats

Main Types

  1. Basal cell carcinoma - the most coomon type of skin cancer but it rarely metastize but often reoccurs; appears small and waxy
  2. Squamous cell carcinoma - appears to be rough and scaly; May metastisixe.
  3. Malignant melanoma - color is irregular with irregular edges and it usually metastisize to bone, liver, spleen and lymph nodes. Common in 30-45 years old
 

Streptococcal Infection

·         Patient who has had the infection would have antibodies that would render streptokinase ineffective.

 

Syphillis

            A. Primary Syphillis

·              Painless lesions on the perineal, palms and soles.

            B. Secondary Syphillis

·              Lesions on palm, sole and perineal areas are well defined.

·              Lesion can get big and erode leaving a contagious pink or grayish lesion.

            C. Late Stage Syphillis

·              Will have large and deep lesions that are granulomatous. 

 

Thalassemia

·         A genetic disorder that causes RBC to have a shorter life span.

 

Vitamin B12 deficiency

·         Glotittis, beefy red tongue.

·         May experience paresthesia and weight loss.

 

 

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