TOPICS SUBTOPICS

CONTENT
ASSESSMENT
CARDIOVACULAR

I.               HEALTH HISTORY AND CLINICAL MANIFESTATIONS

CARDIAC SIGNS AND SYMPTOMS

1.     Chest pain or discomfort (angina pectoris, Myocardial infarction, Valvular heart disease)
2.     Shortness of breath or dyspnea (Myocardial infarction, Left ventricular Failure, Heart failure)
3.     Palpitations (dysrythmias resulting from myocardial ischemia, valvular heart disease, ventricular aneurysm, stress, electroly
4.     Fatigue (earliest symptoms associated with several cardiovascular disorders)
5.     Dizziness and syncope or loss of consciousness (postural hypotension, dysrythmias, vasovagal effect, cerebrovascular diso
6.     Intermittent claudication characterized by extremity pain with exercise (this indicate peripheral vascular disease)

II.             ASSESS FOR CHEST PAIN

a.     Angina Pectoris
•          Substernal or retrosternal pain spreading across chest; may radiate to inside of arm, neck or jaw.
•          5-15 minutes in duration
•          Usually related to exertion, emotion, eating, cold and smoking
•          Rest, nitroglycerine, oxygen are the relieving measures

b.    Myocardial Infarction
•          Substernal pain or pain over precordium; may spread widely throughout chest. Pain in shoulders and hands may be presen
•          15 minutes in duration
•          Occurs spontaneously but may be squeal to unstable angina.
•          Morphine sulfate is the relieving measure

c.     Pleuritic pain
•          Pain arises from inferior portion of pleura; may be referred to costal margins or upper abdomen. Patient may be able to loca
•          30 + minutes in duration
•          Often occurs spontaneously. Pain occurs or increases with inspiration
•          Rest, time is the relieving measures

d.    Pericarditis
•          Sharp, severe substernal pain or pain to the left sternum; may be felt in epigastrium and may be referred to neck, arms and
•          The duration is intermittent
•          Sudden onset. Pain increases with inspiration, swallowing, coughing, and rotation of trunk.
•          Sitting upright, analgesia, anti-inflammatory medications are the relieving measures

e.     Esophageal pain
•          Substernal pain; may be projected around chest to shoulders
•          5-60 minutes in duration
•          Recumbency, cold liquids and exercise. May occur spontaneously
•          Food, antacid, nitroglycerine are the relieving measures
 f.      Anxiety
•          Patient may complain of numbness and tingling of hands and mouth
•          2 –3 minutes in duration
•          Stress, emotional tachypnea
•          Removal of stimulus and relaxation are the relieving measures

III.            PHYSICAL ASSESSMENT

A Physical Examination is performed to confirm the data obtained in the health history. In addition to observing the patients’ g
should include the evaluation of the following:
1.     Effectiveness of the heart as a pump
2.     Filling volumes and pressures
3.     Cadiac output
4.     Compensatory mechanisms

HEAD TO TOE EXAMINATION

1.     General Appearance
2.     Cognition
3.     Skin
4.     Blood pressure
5.     Arterial pulses
6.     Jugular Venous Pulsation and Pressures
7.     Heart
8.     Extremities
9.     Lungs
10.  Abdomen

CORONARY ARTERY DISEASE

•          A narrowing or obstruction of one or more coronary arteries as a result of atherosclerosis

•          An accumulation of lipid-containing plaque in the arteries
•          Causes decreased perfusion of myocardial tissue and inadequate myocardial oxygen supply.
•          Can cause angina, dysrythmias, myocardial infarction, heart failure and death.
•          Collateral circulation, more than one artery supplying a muscle with blood, is normally present in coronary arteries, especia
•          Symptoms occur when the coronary artery is occluded to the point that inadequate blood supply to the muscle occurs, caus
•          Coronary artery narrowing is significant if the lumen diameter of the left main artery is reduced at least 50%, or if any major
•          The goal of treatment is to alter the atherosclerotic progression.

Non Modifiable Risk Factor

ü  Family History of Coronary Heart Disease (CHD)
ü  Increasing age
ü  Gender (3x in men)
ü  Race (Africans Americans)
A.    Clinical Manifestation
•          Chest Pain
•          Palpitations
•          Dyspnea
•          Syncope
•          Cough or hemoptysis
•          Excessive fatigue

B.    Diagnostic Studies
1.     Electrocardiogram (ECG) – recording of the electrical impulses of the heart
•          When blood flow is reduced and ischemia occurs, ST segment depression or T wave inversion is noted; ST segment return
•          With infarction, cell injury results in ST segment elevation, followed by T wave inversion

Common ECG Changes

Hypokalemia

u-wave

Depressed ST segment

Short T wave

2.     Cardiac Enzymes

ENZYME
Normal Value

Onset
Peak

Return to Normal

3.     Cardiac Catheterization
 A.    Provides the most definitive source of diagnosis
B.    Shows the presence of atheroslerotic lesions
•          Assess O2 level, pulmonary blood flow, Cardiac Output, heart structures
•          Coronary artery visualization; use to diagnose CAD; assess coronary patency and determ
•          R sided heart catheterization – medial cubital or brachial vein
•          L sided heart catheterization – brachial or femoral artery

4.     Blood Lipids Levels

•          May be elevated
•          Cholesterol-lowering medications may be prescribed to reduce the development of ather

C.    Implementation
1.     Instruct client regarding the purpose of diagnostic medical surgical procedures expectations
2.     Assist the client to identify risk factors that can be modified
3.     Assist the client to set goal to promote lifestyle changes that will reduce the impact of risk factors
4.      Assist the client to identify barriers to compliance with the therapeutic plan and to identify methods to overcome barriers
5.     Instruct the client regarding a low-calorie, low-sodium, low-cholesterol, and low-fat diet, with an increase in dietary fiber
6.     Stress to the client that dietary changes are not temporary and must be maintained for life; instruct the client regarding pres
7.     Provide community resources to the client regarding exercise, smoking reduction, and stress reduction.

D.    Surgical Procedure
1.     Percutaneous Transluminal Coronary Angioplasty (PTCA) to compress the plaque against the walls of the artery and di
2.     Laser angioplasty to vaporize the plaque
3.     Atherectomy to remove the plaque from artery
4.     Vascular stent to prevent the artery from closing to prevent restenosis
5.      Coronary Artery Bypass graft improve flow to the myocardial tissue that is at risk for ischemia or infarction because of the

E.    Medications
A.    Nitrates to dilate coronary arteries to decrease preload and afterload.
B.    Calcium channel blockers to dilate coronary arteries and reduced vasospasms.
C.    Cholesterol-lowering medications to reduce the development of atherosclerotic plaques
D.    Beta-blockers to reduce blood pressures in individuals who are hypertensive

ANGINA PECTORIS

A.    Description
a.     Chest pain resulting from Myocardial Ischemia caused by inadequate myocardial blood and oxygen supply
b.    Caused by imbalance between oxygen supply and demand
c.     Causes include obstruction of coronary blood flow because of atherosclerosis, coronary artery spasm and conditions increa
d.     The goal of treatment is to provide relief of an acute attack, correct imbalance between the myocardial oxygen supply an
and further attack to reduce the risk of MI
 B.    Patterns of Angina
a.     Stable Angina
•          Also called exertional angina
•          Occurs with activities that involved exertion or emotional stress, and is relieved by rest or
•          It is usually has a stable pattern of onset, duration, severity, and relieving factors

b.    Unstable Angina
•          Also called preinfarction angina
•          Occurs with unpredictable degree of exertion or emotion and increase the occurrence, du
•          Pain may not be relieved with Nitroglycerine

c.     Variant Angina
•          Also called Prinzmetal’s or Vasospastic Angina
•          Result from coronary artery spasm, similar to classic angina but last longer
•          May occur at rest
•          Attack may be associated with ST segment division noted on the ECG

d.    Intractable Angina
•          A chronic incapacitating angina that is unresponsive to intervention

e.     Preinfarction Angina
Associated with the acute coronary insufficiency
Last longer than 15 minutes
Symptoms of worsening cardiac ischemia

f.     Post infarction
•          Occurs after MI, when residual ischemia may cause episode of angina

C.    Assessment
1.     Pain
2.     Dyspnea
3.     Pallor
4.     Sweating
5.     Palpitations and tachycardia
6.     Dizziness and faintness
7.     Hypertension
8.     Digestive disturbance

D.    Diagnostic Study
1.    ECG: normal during rest, with ST depression or elevation and/or T wave inversion during
2.    Stress Test: Pain or changes in the ECG or vital signs during testing may indicate ischem
3.    Cardiac Enzymes: Normal findings in Angina
4.    Cardiac Catheterization: Provides a definitive diagnosis by providing information about po

E.    Implementations
1.     Immediate management
•          Assess pain
•          Provide bed rest
•          Administer oxygen at 3 L nasal cannula as prescribe by the doctor
•          Administer Nitroglycerine as prescribe to dilate coronary arteries, reduced the oxygen requirements of the myocardium, and
•          Obtain a 12-lead ECG

2.     Following Acute Episodes

•          Instruct the client regarding the purpose of diagnostic medical and surgical procedure and the pre procedure and post proc
•          Assist the client to identify angina-precipitating event
•          Instruct the client to stop activity and rest if the chest pain occurs and to take nitroglycerine as prescribe
•          Instruct the client regarding the prescribe medication
•          Instruct client to seek medical attention if pain persist
•          Provide diet instruction to the client, stressing the dietary changes are not temporary and must be maintain for life
•          Assist the client to identify risk factor that can be modified
•          Assist the client to set goals that will promote changes in lifestyle to reduce impact of risk factor
•          Assist the client identify barriers to compliance with therapeutic plan to identify methods to become barriers
•          Provide community resources to the client regarding exercise and stress reduction

F.    Medications
1.     Refer medication to treat Coronary Artery Disease
2.     Antiplatelet therapy to inhibit platelets aggregation and reduce the risk of developing an Acute MI

MYOCARDIAL INFARCTION

A.    Description
•          Occurs when Myocardial Tissues is abruptly and severely deprived of oxygen.
•          Ischemia can lead to necrosis of myocardial tissue if blood flow is not restored.
•          Infarction does not occur instant but evolves over several hours
•          Obvious physical changes do not occur in the heart until 6 hours after the infarction, when the infarction area appears blue
•          After 48 hours, the infarction turns to gray with yellow steaks as neutrophils invade the tissue
•          By 6 – 10 days after infarction, granulation to tissue forms
•          Over 2 –3 months, the necrotic area develops into scar, scar tissue permanently changes the size and shape of the entire v

B.    Location Of Myocardial Infarction

•          Obstruction of the left anterior descending (LAD) artery results in the anterior septal MI o
•          Obstruction of the circumflex results in the posterior wall MI or lateral wall MI
•          Obstruction of the right coronary artery results in the inferior wall MI

C.    Risk Factors
•          Atherosclerosis
•          Coronary Artery Disease
•          Elevated Cholesterol Levels
•          Smoking
 •          Hypertension
•          Obesity
•          Physical Inactivity
•          Impaired Glucose Tolerance
•          Stress

D.    Diagnostics Study
A.    Total Creatinine Kinase
a.     Rise within 3 hours after the onset of chest pain
b.    Peak within 24 hours after the damage and death of the tissue

B.    Creatinine Phosphokinase-MB isoenzymes

a.     Peak elevation occur 12 –24 hours after the onset of the chest pain
b.    Levels returns to normal 48 – 72 hours later

C.    Troponin Level
a.     Rise within 3 hours
b.    Remain elevated for up to 7 days

D.    Myoglobin
a.     Rises within 1 hour after cell death, peaks in 4 – 6 hours and returns to normal within 24- 36 hours or less

E.    Lactate Dehydrogenase (LDH) Levels

a.     Rises within 12 –24 hours after MI
b.    Peak between 40 – 72 hours and fall to normal in 7 days
c.     Serum levels of LDH isoenzymes rise higher than serum level of LDH2

F.    White Blood Cells (WBC) counts

a.     An elevated white blood cell counts of 10,000-20,000 cells/mm3 appears on the second day following after the MI and last u

G.    Electrocardiogram (ECG)
a.     ST segment elevation, T wave inversion, abnormal Q wave
b.    Hours to days after MI; ST and T wave changes will return to normal but the Q wave usually remain permanently

H.    Diagnostic Test for The Acute Stage

a.      Exercise tolerance test or stress test may be prescribed to assess for ECG changes and ischemia to evaluate for medica
therapy
b.    Thallium Scan may be prescribed to assess for ischemia or necrotic muscle tissue
c.     Cardiac catheterization: performed to determine the extent and location of the obstruction of the coronary artery

E.    Assessment
1.     Pain
2.     Nausea and vomiting
3.     Diaphoresis
4.     Dyspnea
5.     Dysrhytmia
6.     Feeling of fear and anxiety
7.     Pallor, cyanosis, coolness of the extremities
 8.     Feeling of doom, restlessness

F.    Complications of Myocardial infarctions

1.     Dysrythmias
2.     Heart failure
3.     Pulmonary Edema
4.     Cardiogenic Shock
5.     Thrombophlebitis
6.     Pericarditis
7.     Mitral valve insufficiency
8.     Post Infarction Angina
9.     Ventricular Rupture
10.  Dressler’s Syndrome (a combination of pericarditis, pericardial effusion, which can occur several weeks to months following

G.    Implementations of Myocardial Infarctions

1.     Obtain description of chest discomfort
2.     Assess vital signs
3.     Assess cardiovascular status and maintain cardiac monitoring
4.     Obtain 12 lead ECG
5.     Administer nitroglycerine as prescribed
6.     Administer morphine sulfate as prescribe to release chest discomfort that is unresponsive
7.     Administer oxygen at 2 – 4 L by nasal cannula as prescribe
8.     Place the client in semi-fowlers position to enhance comfort and tissue oxygenation.

CANCER

Definition of Terms:
Cancer- a group of diseases in which cells multiply w/o restraint, destroys healthy tissue, & endangers life
Neoplasia – new, altered and abnormal development of cells that may be benign or malignant
Tumor – mass or swelling in or on the body
Anaplasia – means lack of differentiation
Biopsy – the removal & examination of tissue from the living body
Carcinogenesis – development of cancerous cells from normal ones
Carcinoma – any malignant tumor derived from epithelial tissue
Chemotherapy – treatment of disease, especially cancer, by means of chemical agents/drugs
Dysplasia – means deranged development, disordered maturation
Hyperplasia – constitutes an increase in the number of cells in organ or tissue, which may then have increased
Proliferation- refers to the process of cell renewal or replacement. In cancer, proliferation process continues w
Differentiation- refers to the process by which cells diversify, acquire specific structural and functional charact

Carcinogenesis: the origin of cancer

Cellular Transformation & Derangement Theory= normal cells may be transformed into cancer cells due to
Failure of the Immune Response Theory= all individuals possess cancer cells, however, cancer cells are rec

AGENTS THAT CAN PREDISPOSE TO CANCER:

1. Chemical carcinogens-( tobacco, ether, benzene, coal tar and asbestos)
Ø  These act by causing cell mutation or alteration in cell enzymes & proteins causing altered cell repli
 2. Physical Agents
o    Radiation Physical irritation/trauma, ultraviolet rays form diagnostic or therapeutic x-rays
o    These will usually cause cancer after long time of exposure and interaction
3. Genetics. The human DNA has specific genes for cancer called= Oncogene. When this gene is exposed to
4. Viruses- these viruses are called oncogenic viruses. They infect the host DNA or RNA resulting in cell mutat
5. Immune system alterations- as seen in patients with immunodeficiency disease, the elderly and those rece
6. Hormonal factors- hormones make the cell more sensitive to the process of carcinogenesis or may encoura
7. Dietary factors- some studies link dietary factors to cancer development. High fat diet and low fiber intake

PREDISPOSING FACTORS
1. Age – older people are more prone. This is a very important factor for cancer development.
2. Sex – women for breast, men for prostate
3. Urban versus Rural residence
4. Geographic distribution
5. Occupation
6. Heredity
7. Stress
8. Precancerous lesions- these can lead to transformation into Cancer
9. Obesity [breast and colorectal]

WARNING SIGNALS OF CANCER [CAUTION] by the American Cancer Society (ACS)

C – Change in bowel or bladder habits
A – A sore that does not heal
U – Unusual bleeding/discharge; unexplained anemia and sudden weight loss
T – Thickening or lumps in breast or elsewhere
I – indigestion or difficulty of swallowing
O – Obvious change in wart or mole
N – Nagging cough or hoarseness of voice

SITE OF CANCER and DANGER SIGNAL

1.    Breast – lump or thickening in breast
2.    Colon & rectum – change in bowel habits/bleeding
3.    Kidney & bladder – urinary difficulty/bleeding
4.    Lung – persistent cough/lingering respiratory ailment
5.    Prostate – urinary difficulty
6.    Mouth, larynx & pharynx – sore that does not heal, difficulty in swallowing & hoarseness
7.    Skin – sore that does not heal, change in wart or mole
8.    Stomach – indigestion
9.    Uterus – unusual bleeding or discharge

CHARACTERISTICS OF BENIGN & MALIGNANT NEOPLASM

Characteristics
Speed of Growth
Mode of Growth Remains localized
Capsule
Cell characteristics Well differentiated Poorly differentiated
Recurrences Extremely unusual Common following surgery
Metastasis
Effect of neoplasm
Prognosis

Distinguishing Characteristics of Neoplastic cells

PATHOPHYSIOLOGIC BASIS OF MALIGNANT NEOPLASM

Predisposing Factors/Etiologic Factors

HOW CANCER SPREADS: Metastasis
Pathways of Spread:
Cellular
•         1. Direct seeding of body cavities orAberrations
surfaces

•         2. Lymphatic spread

Cancer Cell Proliferation Malignant cells produce
Disrupt Normal cell growth & enzymes, hormones &
Interfere w/ tissue function other substances
ü•Pressure
         3. Hematogenous spread (Paraneoplastic Syndrome)
ü Obstruction ü Anemia
ü Hypercalcemia
ü Pain -Liver & lungs – most frequently involved in hematogenous dissemination
ü Effusion ü Edema
•         4. Direct transplantation of tumor cells: (ex: on surgical instrument)
ü Thrombosis, ü DIC – theoretically, it can occur but exceedi
PRIMARY PREVENTION OF CANCERS
üEmbolus
üthrombophlebitis
1.    Skin
Avoid exposure to sunlight, use protective sunscreen, limit sun exposure bet 10am-3pm
Avoid artificial sources of UV light
Avoid environmental l & occupational carcinogens [arsenicals, pesticides, coal tar products]
Avoid frequent exposure to ionizing radiation,
X-rays & radioisotopes
2.    Oral. Annual oral examination.
3.    Breast. Monthly BSE from age 20-21
Avoid high-fat foods
Reduce weight; avoid obesity
4. Lung
Do not smoke, avoid secondhand smoke
Avoid environmental & occupational carcinogens [asbestos, hydrocarbons, radon]
Wear protective clothing & mask when exposed to carcinogens
Annual CXR
5. Prostate
Avoid high-fat foods
Limit intake of alcohol
Avoid occupational carcinogens

6. Colorectal.
Digital rectal examination [> 40y/o]; rectal biopsy, proctoscopic examination,
Reduce fat intake to no > 30% of calories
Avoid salt-cured & nitrite-cured foods
Reduce weight, avoid obesity
7. Uterus
Annual Pap’s smear from age 40.
8. Basic. Annual PE and blood examination.

DIETARY RECOMMENDATIONS AGAINST CANCER

Avoid obesity
Cut down on total fat intake
Increase intake of high fiber foods
Include foods rich in Vitamin A & C in daily diet
Include cruciferous vegetables [broccoli, cauliflower, cabbage, Brussels sprouts]
Moderate consumption of alcoholic beverages
Moderate consumption of salt-cured, smoked-cured and nitrate-cured foods

CANCER EARLY DETECTION

§             Breast self-examination [BSE]

•                                                    Done 1x a month, 1 wk after the 1st day of menstruation start
§             Testicular self-examination [TSE]
•                                                    Done by males 15-35 y/o, monthly preferably after a warm sho
§             Mammography
•                                                    Baseline at 35-39y/o, then every 1-2 yrs
§             Papanicolau smear
•                                                    Every 3yrs after 3 negative test for three consecutive years
§             Rectal digital examination
•                                                    Yearly starting at age 40 / yearly at >50yo

THERAPEUTIC MODALITIES FOR CANCER and the GOALS OF CANCER

1.    Cure- the aim of this modality is to make sure that the client will be disease-free & live normal expe
2.    Control- this modality deals with cancer not cured but controlled by therapy over long periods of tim
3.    Palliative- cure & control not possible but maintain as high as quality for the client

Surgery
Ø  May be done for curative, palliative, reconstructive, preventive and prophylactic purposes.
Radiotherapy
Ø  Used for radiosensitive cancers like skin cancer, seminoma and early stage Hodgkin’s. the response
Chemotherapy
Ø  This involves administering cytotoxic drug to intervene and interrupt the cell cycle.
Immunotherapy or biotherapy
Ø  Involves treatment with agents derived from biologic sources or with agents that affect biologic res

Surgical Interventions

Preventive. Removal of precancerous lesions/benign tumors

Diagnostic. Biopsy
Curative. Removal of an entire tumor [en bloc resection]
Reconstructive. Improvement of structure/function of an organ
Palliative. Relief of distressing signs & symptoms [oophorectomy w/ breast Ca to reduce estrogen secretion r

Chemotherapy
Ø  use of drugs to retard the growth of or destroy cancerous cells
Ø  use to cure, for palliation, combined w/ surgery, combined with radiation
•          Classification/Effect
ü  Anti-neoplastic agents
§  Cell-cycle specific: attack cells at a specific point in the process of cell division
§  Cell-cycle non-specific: act at one time during cell division
ü  Hormones.
§  Alter hormone balance
§  Modify growth of hormone-dependent tumor
•          Administration
ü  IV – most common route
ü  Arterial infusion - direct
ü  Regional perfusion
ü  Intraperitoneal
ü  Oral, IM [less common]

Nursing Interventions for Chemotherapeutic Side-Effects

q  GI system
  N & V= Antiemetic are given
  Diarrhea. Replace fluid-electrolyte losses, low-fiber diet
  Constipation. increased fluid intake & fibers
q  Integumentary system
  Pruritus, urticaria. Provide good skin care
  Stomatitis. Provide good oral care; avoid hot & spicy food
  Alopecia/skin pigmentation/nail changes. Reassure that it is temporary & encou
q  Hematopoeitic
  Anemia. Provide frequent rest periods
  Neutropenia. Protect from infection. Avoid people with infection, crowds
  Thrombocytopenia. Protect from trauma. Avoid ASA
q  Genito-Urinary system
  Hemorrhagic cystitis. Provide 2-3L fluids/day
  Urine color changes. Reassure that it is harmless
q  Reproductive system
   Premature menopause/amenorrhea. Reassure menstruation resumes after che

Radiation Therapy
 Ø  use of ionizing radiation to cause damage and destruction to cancerous growths

q  Effect: Radiation → damage at the cellular level

§  indirectly: water molecules w/in the cell are ionized
§  directly: causes strand breakage in the double helix of DNA
§  Not every cell is damaged beyond repair
q  use to cure, for palliation, combined w/ surgery
ü  PreOP: to reduce size of tumor
ü  PostOP: to retard or control metastasis
q  Administration
ü  External
§  Orthovoltage machines –superficial lesions
§  Megavoltage (Co-60) – deeper structures
§  Linear accelerators – deep lesions; less harmful
ü  Internal [Brachytherapy]
§  Sealed [implants
§  Unsealed [radioactive iodine]
Principles of Radiation Protection [DTS]
q  Distance
ü  Maintain a distance of at least 3 ft. when not performing nursing procedures.
q  Time
ü  Limit contact for 5 min each time, a total of 30min/shift.
q  Shielding
ü  Use lead shield during contact with client.
Nursing Interventions for Radiotherapy Side-Effects
q  Skin reactions [erythema, desquamation, atrophy, necrotic/ulcerative lesions, depigment
ü  Keep area dry
ü  Wash area w/ water, no soap, pat dry, do not rub
ü  Do not apply ointments, powders or lotion, heat
ü  Use soft cotton fabrics for clothing

q  Bone marrow suppression

ü  Monitor blood counts weekly
ü  Good personal hygiene, nutrition, adequate rest
ü  Teach signs of infection to report to physician

Nursing Interventions for Radiotherapy Side-Effects

q  Hemorrhage [Platelets are vulnerable to radiation]
ü  Monitor platelet count
ü  Avoid physical trauma or use of aspirin
ü  Teach signs of hemorrhage
ü  Monitor stool & skin for signs
ü  Use direct pressure over injection sites until bleeding stops
q  Fatigue [Results from high metabolic demands for tissue repair & toxic waste removal]
ü  Plenty of rest and good nutrition

Nursing Interventions for Radiotherapy Side-Effects

q  Stomatitis
ü  Administer analgesics before meals
 ü  Bland diet, no smoking/alcohol
ü  Good oral hygiene/ saline rinse q 2 hrs
ü  Sugarless lemon drops or mint to ↑ salivation
q  Weight loss [anorexia, pain & effect of Ca]
q  Diarrhea
q  Nausea & vomiting
q  Headache
q  Hair loss/ alopecia
q  Cystitis
q  Social isolation
Immunotherapy
Ø  Use of biologic response modifiers that have ability to alter immunologic relationship betw

q  Types:
ü  Interferons
ü  Monoclonal antibodies
ü  Lymphokines & cytokines [interleukin –2]
ü  Colony stimulating factors
q  Side effects
ü  Influenza-like ss, fatigue, leukopenia, N&V

Bone Marrow Transplantation

q  used to treat
ü  Acute lympphoblastic leukemia
ü  Acute myelogenous leukemia
ü  Aplastic anemia
ü  Chronic myelogenous leukemia
q  Types:
ü  Allogeneic BMT: bone marrow comes from a healthy donor [usually immediate f
ü  Autologous BMT: client is given own bone marrow

DIAGNOSTIC TESTS

Only with understanding of the most common laboratory examination can the nurse provide the patient with clear explanati

1.             BLOOD TESTS

•                     Blood chemistries, complete blood count and other specialized assay can provide important information
•                     Tumor markers can be used to measure hormones, oncofetal proteins secreted by malignant tumors. T

2. CYTOLOGIC tests
•         These tests help detect suspected primary or metastatic disease and monitor therapy
•         They cannot determine the location and size of a malignancy
•         ASPIRATION TESTS- fine needle aspiration of body fluids permits evaluation of a palpable mass, a lymph no
•         BONE MARROW ANALYSIS allows examination of bone marrow aspirate to identify leukemic cells.
•         PAPANICOLAOU TESTS- is widely used to detect cervical cancer, endometrial and extrauterine malignancy in

3. ENDOSCOPY
•         These can be performed on the entire GIT, respiratory tract, urinary tract and peritoneal cavity.
4. HISTOLOGIC TESTS
•         Biopsy is a common procedure that provides a detailed description that helps classify malignancy

5. NUCLEAR imaging and Scanning

•         Include CT, MRI and Radionuclide imaging

6. RADIOGRAPHIC test
•         Are used to visualize internal body structures to detect, identify, and localize malignancy and guide biopsy.
•         These include CXR, mammography
7. Ultrasonography
•         This non-invasive procedure is used to evaluate organs and localize masses except the lungs and bones.

8. STOOL OCCULT EXAMINATION

•         Permits early detection of colorectal cancer, providing positive results in 80% of patients with this disorder

GENERAL Promotive and Preventive Nursing Management for Can
1. Lifestyle Modification
2. Nutritional management
3. Screening
4. Early detection
Nursing Interventions for Cancer
MAINTAIN TISSUE INTEGRITY
¯  Handle skin gently
¯  Do NOT rub affected area
¯  Lotion may be applied
¯  Wash skin only with SOAP and Water

MANAGEMENT OF STOMATITIS
  Use soft-bristled toothbrush

  Oral rinses with saline gargles/ tap water

  Avoid ALCOHOL-based rinses

MANAGEMENT OF ALOPECIA
Alopecia begins within 2 weeks of therapy
Ø  Regrowth within 8 weeks of termination
Ø  Encourage to acquire wig before hair loss occurs
Ø  Encourage use of attractive scarves and hats
Ø  Provide information that hair loss is temporary BUT anticipate change in texture and color

    MANAGEMENT TO  PROMOTE NUTRITION
Ø  Serve food in ways to make it appealing
Ø  Consider patient’s preferences
Ø  Provide small frequent meals
Ø  Avoids giving fluids while eating
Ø  Oral hygiene PRIOR to mealtime
Ø  Vitamin supplements
       MANAGEMENT TO RELIEVE PAIN
Ø  Mild pain- NSAIDS
Moderate pain- Weak opiods (meperidine)
Ø  Severe pain- Morphine
Ø  Administer analgesics round the clock with additional dose for breakthrough pain

MANAGEMENT TO DECREASE FATIGUE
Ø  Plan daily activities to allow alternating rest periods
Ø  Light exercise is encouraged
Ø  Small frequent meals
MANAGEMENT TO IMPROVE BODY IMAGE
Ø  Therapeutic communication is essential
Ø  Encourage independence in self-care and decision making
Ø  Offer cosmetic material like make-up and wigs

MANAGEMENT TO ASSIST IN THE GRIEVING PROCESS
Ø  Some cancers are curable
Ø  Grieving can be due to loss of health, income, sexuality, and body image
Ø  Answer and clarify information about cancer and treatment options
Ø  Identify resource people
Ø  Refer to support groups

      MANAGE COMPLICATION: INFECTION
Ø  Fever is the most important sign (38.3 Celsius)
Ø  Administer prescribed antibiotics X 2weeks
Ø  Maintain aseptic technique
Ø  Avoid exposure to crowds
Ø  Avoid giving fresh fruits and veggie
Ø  Hand-washing
Ø  Avoid frequent invasive procedures

     MANAGE COMPLICATION: Bleeding
Ø  Thrombocytopenia (<100,000) is the most common cause
Ø  <20, 000à spontaneous bleeding
Ø  Use soft toothbrush
Ø  Use electric razor
Ø  Avoid frequent IM, IV, rectal and catheterization
Ø  Soft foods and stool softeners

CHEMOTHERAPEUTIC AGENTS

•         These are drugs that are utilized to destroy cancer cells by interfering with neoplastic cell growth and functio
 •         The following are included: Alkylating agents, nitroureas, antimetabolites, Plant alkaloids, anti-tumorigenic a
1.    ALKYLATING AGENTS
•         These agents produce breaks in the DNA and are most effective in the S (synthesis) phase of the
•         examples are busulfan, carboplatin, chlorambucil, cisplatin and cyclophosphamide

2.    NITROSOUREAS
•          Act in the same manner as alkylating agents but they can pass the brain barrier because they care lip
•          Examples are carmustine, lomustine and steptozocin

3.    ANTIMETABOLITES
•          They interfere with DNA synthesis and inhibit purine synthesis
•          Examples are: Mercaptopurine, 5-FU, Cytarabine and Thioguanine

4.    PLANT ALKALOIDS
•          They kill cancer cells by inhibiting mitosis and the vital enzymes that protect the DNA strands
•          Examples are paclitaxel, doxetaxel, vinblastine and vincristine

5.    ANTIBIOTIC anti-neoplastics
•          Achieve their effects by binding with DNA
•          Examples are bleomycin, dactinomycin, doxorubicin and mitomycin

6.    HORMONAL ANTINEOPLASTICS
•          Useful in treating cancer because they inhibit neoplastic growth in specific tissues without directly cau
•          Examples are tamoxifen, aminogluthetimide, androgens, mitotane, corticosteroids

NURSING CARE OF TERMINALLY ILL PATIENT

Ø  Directed towards making the pt. physically & psychologically as comfortable as possible

1. Nutrition
q  High calorie & protein diet
q  Small frequent feedings
q  ↑ fluids intake, 1000-1500ml above the N
2. Activity
3. Prevent tissue breakdown & vascular complications
q  Frequent turning, skin massage, air mattresses
q  Active and passive ROM
4. Observe for toxic reactions to tx [diarrhea]

Ø  Directed towards making the pt. physically & psychologically as comfortable as possible

5. Supportive measures & drugs for pain relief

6. Maintain open communication with patient & family
7. Control of odor
q  Infectious organisms cause formation of offensive odors
q  Frequent change of dressings

VEHICULAR ACCIDENT
 •          An unforeseen and unplanned event or circumstance frequently causing loss or injury in any vehic

WOUNDS

•          Wounds involving injury to soft tissues can vary from minor tears to severe crushing injuries.

•          The primary goal is to restore the physical integrity and function of the injured tissue, with min

•          Proper documentation of the wound, using precise descriptions and correct terminology, is es

•          Such information may be needed in the future for forensic evidence. Photographs are helpful

•          Determining When and How the wound occurred is important, because a treatment delay exc

•          Using aseptic technique, the clinician inspects the wound to determine the extent of damage

•          Sensory, motor, and vascular function are evaluated for changes that might indicate complica

Types of Wounds

•          Laceration – skin tear with irregular edges and vein bridging

•          Avulsion – tearing away from supporting structures

•          Abrasion – denuded skin

•          Hematoma – tumor-like mass of blood trapped under the skin

•          Ecchymosis/Contusion – blood trapped under the surface of the skin

•          Stab – incision of the skin with well-defined edges, usually caused by a sharp instruments

•          Cut – incision of the skin with well-defined edges, usually longer than deep

•          Patterned – wound representing the outline of the objects

Management

•          Hair around the wound maybe clipped or shaved (only as directed) if it is anticipated that the hairs

•          Typically, the area around the wound is cleaned with normal saline solution or a polymer agents (S
 •          Antibacterial agents, such as povidone-iodine (Betadine) or hydrogen peroxide, should not be allow

•          If indicated, the area is infiltrated with a local intradermal anesthetic through the wound margins or

•          The nurse then assists the physician, nurse practitioner, or physician assistant in cleaning and deb

•          The wound is irrigated gently and copiously with sterile isotonic saline solution to remove surface d

•          Devitalized tissue and foreign matter are removed because the impede healing and may encourag

•          Any small bleeding vessels are clamped or tied. Alternatively, hemostasis maybe achieved with ca

•          After wound treatment, a nonadherent dressing is commonly applied to protect the wound.

•          The dressing serve as a splint and also as a reminder to the patient that the area is injured.

TRAUMA

•          The unintentional or intentional wound or injury inflicted on the body for a mechanism against whic

CRUSH INJURIES

•          Occurs when a person is between caught between objects, run over by a moving vehicle or compr

Assessment and Diagnostic Findings

•          Hypovolemic shock resulting from extravasation of blood and plasma into injured tissues after com

•          Paralysis of a body part

•          Erythema and blistering of the skin

•          Damaged body parts (usually an extremity) appearing swollen, tense and hard.

•          Renal dysfunction (prolonged hypotension causes kidney damage and acute renal insufficiency; m

Management

•          In conjunction with maintaining the airway, breathing, and circulation, the patient is observed for ac

•          Injury to the back can cause severe kidney damage. Severe muscular damage causes a significan
 •          Major soft tissue injuries are splinted early to control bleeding and pain. Again, the serum lactic aci

•          If an extremity is involved, it is elevated to relieve swelling and pressure.

•          To restore neurovascular function, the physician may perform Fasciotomy (surgical incision to the

•          Medications for pain and anxiety are then administered as prescribed, and the patient is quickly tra

•          Hyperbaric chamber can be used for hyperoxygenation of the crushed tissue, if indicated.

MULTIPLE INJURIES

•          Care of the patient with multiple injuries requires a team approach, with one person responsible for

•          After injury, the body is hypermetabolic, hypercoagulable, and severely stressed.

•          Mortality in patients with multiple injuries is related to the severity of the injuries and the number of

•          Potentially affects every body system.

•          The nursing staff assumes responsibility for assessing and monitoring the patient, ensuring IV acce

Assessment and Diagnostic Findings

•          X-ray

•          Physical Evidences (eg Hematoma, Lacerations, etc..)

•          CT Scan

•          MRI

•          EEG or ECG

Management

•          The goals of treatment are to determine the extent of injuries and to establish priorities of treatmen

•          Any injury interfering with a vital physiologic function (eg airway, breathing, circulation) is an immed

•          Essential life-saving procedures are performed simultaneously by the emergency team.

•          Clothes are usually cut off, and a rapid physical assessment is performed.

•          Transfer from field management to the ED must be orderly and controlled, with attention given to th

PERSONAL INJURY

Is any physical or mental injury to a person that results from another person’s negligence or harmful act. P

Auto Accidents
Other Vehicle Accidents (Aviation, Bicycle, Boat, Motorcycle, Railroad, Truck)
Construction/On the Job Accidents
Dangerous or Defective Products
Medical Malpractice (Misdiagnosis, Surgical Negligence)
Nursing Home Abuse and Neglect
Construction Accidents
Product Liability

Scope and Practice of Emergency Nursing

Ø  The emergency nurse has had specialized education, training, and experience to gain expertis

Issues in Emergency Nursing Care

Ø  These issues include legal issues occupational health and safety risk for ED staff, and the cha

Documentation of Consent

Consent to examine and treat the patient is part of the ED record. The patient must consent to invasi

Limiting Exposure to Health Risk

•          Increasing numbers of people infected with hepatitis B and with Human Im

o   Providing Holistic Care

 •          Sudden illness or trauma is a stress to physiologic and psychological hom
ü  Patient –focused intervention
ü  Family- focused intervention
v  Anxiety and Denial
v  Remorse and Guilt
v  Anger
v  Grief

o   Emergency Nursing and the Continuum of Care

•          One principle underlying emergency care is that the patient will be rapidly

o   Discharge Planning

§  Before discharge, instructions for continuing care are given to the patient and

o   Community Service

§  Before discharge, some patients require the services of a social worker to he

§  Emergency in this age group may be more difficult to manage because elder
ü  An atypical presentation
ü  An altered response to treatment
ü  A greater risk of developing complications

Principles of Emergency Care

Ø  Emergency care is care that must be rendered without delay.

Triage
•          Word Triage comes from the French word trier, meaning “to sort”. It is use
•          A basic and widely used system uses three categories:
o   Emergent- patients have the highest priority, their conditions are life threate
o   Urgent- patients have serious health problems, but not immediately life thre
o   Non-urgent- patients have episodic illness that can be addressed within 24
•          A fourth increasingly used class is “fast-track” these patients require simpl

Assess and Intervention

•          Patient with an emergency or urgent health problem stabilization, provisio

•          The primary survey focuses on stabilizing life-threatening conditions.
•          The ED staff work collaboratively and follow the ABCD (airway, breathing,
o   Establish a patent airway
 o   Provide adequate ventilation, employing resuscitation measures when nece
o   Evaluate and restore cardiac output by controlling hemorrhage preventing a
o   Determine neurologic disability by assessing neurologic function using the G
•          After these priorities have been addressed the ED team proceeds with the
o   A complete health history and head to toe assessment
o   Diagnostic and Laboratory testing
o   Insertion or application of monitoring devices such as electrocardiogram (EC
o   Splinting of suspected features
o   Cleaning and dressing of wounds
o   Performance of other necessary intervention based on the individual patient

AIRWAY OBSTRUCTION
Acute upper airway obstruction is a life threatening medical emergency.
The airway may be partially or completely occluded.
If the airway is completely obstructed, permanent brain damage or death will occur within 3 to 5 minutes secondary
Partial obstruction of the airway can lead to progressive hypoxia, hypercarbia, and respiratory and cardiac arrest.

PATHOPHYSIOLOGY

Aspiration of foreign bodies.
Anaphylaxis.
Viral or Bacterial infection
Trauma
Inhalation of chemical burn
Aspiration of bolus meat is the most common cause of airway  obstruction in adults.
In children, Peritonsillar abscesses, epiglottitis, and other acute infectious processes of the posterior  pharynx.

CLINICAL MANIFESTATION

Choking
Apprehensive appearance
Inspiratory and expiratory stridor
Labored breathing
Use of accessory muscle ( suprasternal and intecostal refraction)
Flaring  nostrils
Increasing anxiety
Restlessness
Confusion

ASSESSMENT AND DIAGNOSTIC FINDINGS

Assessment of the patient who has a foreign object occluding the airway may involve simply asking the person whe
 If the patient is unconscious inspection of the oropharynx and may reveal the offending object.
Xrays, laryngoscopy or bronchoscopy also may performed.
MANAGEMENT

Head tilt chin maneuver
Jaw-thrust maneuver
Oropharyngeal airway insertion
Endotracheal intubation
Cricothyroidotomy (cricothyroid membrane puncture)

HYPOVOLEMIC SHOCK

•          Shock is a condition in which theres is loss of effective circulatory blood volume.
•          Inadequate organ tissue perfusion following ultimate resulting in cellular metabolic arrangement
•          In any emergency situation the onset of shock should be anticipated by assessing all injured peo

Possible problem associated with hypovolemic shock:

•          Altered tissue perfusion related to failing circulation.
•          Impaired gas exchange related to a ventilation perfusion imbalance.
•          Decreased cardiac output related to decreased circulating blood volume.
•          The goal of treatment are to restore and maintain tissue perfusion and to correct physiologic abn

 MANAGEMENT

•          Ensuring a patient airway and maintaining breathing are crucial.
•          Ventilatory assistance is given as required.
•          A rapid physical examination performed to determine the cause of cause.
•          Restoration of the circulating bllod volume is accomplished with rapid fluid and blood replacem
•          Large- gauge intravenous needles are inserted into peripheral vein. Two or more catheters are ne
•          A Central Venous Pressure (CVP) catheter also may be inserted to serve as a guide for fluid repl
•          Intravenous fluid are infusedat rapid rate until systolic blood pressure or CVP rises to a satisfact
•          Blood component thereapy may also be prescribed.
•          An indwelling urinary catheter is inserted to record urinary output everyhour.

Heat Stroke
Ø  Is an acute medical emergency caused by failure of the heat-regulating mechanism of th
Ø  RISK FACTOR: those not acclimatized to heat, elderly and young people, those unable t
SIGN AND SYMPTOMS

•          profound central nervous system (CNS) dysfunction (confusion, delirium, bizarre behav
•          elevated body temperature
•          hot dry, skin
•          anhidrosis (absence of sweating)
•          tachypnea
•          hypotension
•          tachycardia

MANAGEMENT

•          primary goal is to reduce the high temperature

•          cool sheets and towels or continuous sponging w/ cool water
•          Ice applied to the neck, groin, chest, and axillae while spraying w/ tepid water
•          cooling blanket
•          Iced saline lavage on the stomach or colon if the temperature does not decrease
•          Immersion of the patient in a cold water bath if possible
•          monitored VS, ECG,CVP
•          Fluids are administered
•          urine output is measured frequently
•          Blood specimen is obtained
•          additional supportive care: dialysis for renal failure, antiseizure agent, potassium, Na bi

FROSTBITE
Ø  Is a damage to tissues and blood vessels as a result of prolonged exposure to cold. Fing

ASSESSMENT

•          Numbness
•          paresthesia
•          Pallor
•          Severe pain, swelling, erythema, and blistering that occur once the client is in a warm e
•          Necrosis and gangrene may develop in cases

INTERVENTION
 •          Handle the tissues gently
•          Rearm the affected part rapidly and continuously with a warm water bath (90-107 degre
•          Avoid thawing, interrupted periods of warmth, or massage (may result in further tissue d
•          Do not derided blisters.
•          Leave area exposed initially for continued assessment, and then apply bulky dressings

HYPOTHERMIA
Ø  is a condition in which the core(internal) temperature is 35’C (95’F) or less as a result of e
Ø  occurs when a patient loses the ability to maintain body temperature.

ASSESSMENT AND DIAGNOSTIC FINDINGS

•          Progressive deterioration

•          Apathy
•          Poor judgment
•          Ataxia
•          Dysarthria
•          Drowsiness
•          pulmonary edema
•          Acid-base abnormalities
•          Coagulopathy
•          eventual coma
•          Shivering

MANAGEMENT

•          continuous monitoring:

•          ABC’s of basic life support are the priority.
•          V/S
•          CVC
•          urine output,
•          ABG levels,
•          blood chemistry determinations
•          chest x-ray
•          monitored ECG
•          rewarming:
•          Core rewarming for severe hypothermia
•          Passive external rewarming use of warm blankets or over-the-bed heaters.
 •          supportive care:
•          external cardiac compression
•          Defibrillation temperature < 31’C
•          Mechanical ventilation w/ PEEP
•          Administration of warmed intravenous fluid
•          administration of Na bicarbonate
•          administration of anti arrythythmic medication
•          Insertion of an dwelling urinary catheter

NEAR-DROWNING
Ø  Survival for at least 24 hrs after submission. The most common consequence is hypoxem
Ø  one of the leading causes of unintentional death in children younger 14 years of age

FACTORS

•          Alcohol ingestion

•          inability to swim
•          diving injuries
•          hypothermia
•          exhaustion

MANAGEMENT

•          maintaining cerebral perfusion and adequate oxygenation to prevent further damage to
•          Immediate cardiopulmonary resuscitation – the greatest influence on survival
•          ABG analysis
•          use of endotracheal intubations w/ positive pressure ventilation

DECOMPRESSION SICKNESS
Ø  also called “the bend,” occurs in patient who has engaged in diving, high-altitude flying, o
Ø  result from nitrogen bubbles trapped in the body. They may occur in joint or muscle spac

ASSESSMENT

•          History is obtained from the patient or diving buddy.

•          evidence of rapid ascent
•          loss of air in the tank
 •          buddy breathing
•          recent alcohol intake or lack of sleep
•          a flight within 24 after diving
•          Sign and symptoms: joint or extremity pain, numbness, hypesthesia, and loss of range
•          Neurologic symptoms mimicking those of a stroke or spinal cord injury could indicate an
•          Cardiopulmonnary arrest can also occur in severe cases of DCS

MANAGEMENT

•          Patent airway and adequate ventilation

•          100% oxygen is administered
•          Chest x-ray is obtained
•          At least one intravenous is stared with lactated Ringer’s or normal saline solution.
•          If an air embolus is suspected, the head of the bed should be lowered.
•          The patient’s wet clothing is removed, and the patient is kept warm.
•          Transfer to the closest hyperbaric chamber capable of treating DCS is initiated.
•          If air transport is necessary, low altitude flight (below 1000 ft) is required
•          If aspiration is suspected, antibiotics and other treatment may be prescribed.

Major disorders of the neuromusculoskeletal system

TRAUMATIC BRAIN INJURIES

A. Etiology and path physiology

Motor vehicle accidents are the most common cause; can result from assaults, falls, and sport

Cause by a sudden force to the head

Acceleration injury: immobile head struck by moving object

Deceleration injury: head is hit by stationary object
Deformation injury: force disrupts the integrity of the skull
Fractures
Lineal: simple break in the bone
Depressed: break that results in fragments
Of bone penetrating brain tissue
Basilar: occurs over the base of frontal and temporal lobes; ecchymosis is common over areas invo

Hemorrhages (secondary brain injury)

Epidural: hematoma forms between the dura and the skull; may result from a laceration of the midd
Subdural: hematoma forms between the dura and arachnoid layers; generally follows venous dama
 Intracerebral hematoma

Concussion: temporary distruption of synaptic activity; brief loss of consciousness (<5 minutes)

Contusions: bruising of brain tissue, with slight bleeding of small cerebral vessels into surrounding tiss
Cerebral contusions manifest depending on areas involved
Brainstem contusions result in unresponsiveness

Complications include cerebral edema, brain abscess, meningitis, diabetes insipidus

B. Clinical findings

•          Subjective: lethargy; indifference to surroundings; altered sensory function (e.g., visua

•          Objective
Signs of increased intracranial pressure (ICP)
Lack of oriental to time and place
Positive Babinski reflex
Seepage of cerebral spinal of basilar skull fracture

C. Therapeutic interventions

•          Control seizures with anticonvulsants

•          Mechanical ventilation; hyperventilation constricts cerebral vessels lowering ICP
•          Monitor ICP with external catheter such as ventricular catheter or subarachnoid screw
•          Reduce cerebral edema with glucocorticoides and loop diuretics; there is disagreement
•          Maintain adequate fluid and electrolyte balance
•          Surgical intervention in cases of depressed skull fractures or hematomas

Nursing care of clients with head injuries

A. ASSESMENT

•          Airway and breathing pattern

•          Neurological status (see Neurological Assessment and Glasgow Coma Scale)
•          Signs of increased intracranial pressure (see Brain Tumor)
•          Circumstances of injury
•          Presence of glucose in clear drainage from nose or ears, which indicates cerebrospinal

B. ANALYSIS/NURSING DIAGNOSIS

•          Risk for aspiration related to loss of gag reflex or inability to expectorate
 •          Decreased intracranial adaptive capacity related to increased ICP
•          Risk for disuse syndrome related to long-term immobility
•          Ineffective role performance related to impaired neuromuscular function

C. PLANNING/IMPLEMENTATION

•          Institute neurologic assessments every 15 minutes for several hours, progressing to ev
•          Maintain airway by suctioning as necessary (coughing increase intracranial pressure); u
•          Keep the client’s head elevated 30 degree to reduce venous pressre within the cranial c
•          Administer glucocorticoids and/or diuretics if ordered
•          Institute seizure precautions; administer anticonvulsants if ordered
•          Monitor for fluid or electrolyte imbalances; diabetes inspidus or syndrome of inappropria
•          I f the client’s eyes remain open, protect the corneas with moistened pads, artificial tear
•          Support client’s nutritional needs; administer tube feedings or assist with small frequent
•          Position the client to prevent pressure ulcers
•          Provide range-of-motion exercises and splints to prevent contractures
•          Provide auditory and tactile stimulation
•          Assist client to avoid activities that increase ICP such as the Valsalva maneuver, lifting,
•          Recognize that confusion upon return of consciousness may be a defense against addi
•          Utilize hypothermia as ordered to reduce temperature and metabolic demands
•          Encourage client and family to participate in planning and care

D. EVALUATION/OUTCOMES

•          Maintains a patient

•          Improves level of consciousness
•          Remains free from complications of immobility
•          Participates in decisions about administration of care

POSTRAUMATIC STRESS DISORDERS

A. Etiologic factors

•          Follows a divesting event that is outside the range of usual human experience (e.g., rap
•          Individual’s response must involve intense fear, helplessness, or horror; in children the
•          The traumatic event of reliving the experience, or exposure to situations that foster reca

B. Behavioral/clinical findings

•          Exposure to a traumatic event resulting in actual death, threatened death, or serious inj
 •          Feeling of isolation and detachment
•          Difficulty sleeping
•          Violet outburst of anger
•          Depression
•          Interrupted concentration
•          Hyper vigilance
•          Avoidance of associated stimuli
•          Duration of disturbance more that 1 month
•          Neurobiology of PTSD does not follow stress response, study indicates a hyperrespons

C. Therapeutic interventions

•          Same as Panic Disorders

•          Behavior modifications to provide controlled exposure to recall of the event
•          Supportive therapy
•          Use of Eye Movement, Desensitization, Reprocessing techniques (EMDR)
•          Imagery, relaxation, and meditation may also be useful

Nursing care of clients with posttraumatic stress disorders

ASSESMENT

•          Behavior associated with anxiety disorders

•          History of traumatic experience
•          Sleep-pattern disturbance
•          Screening for symptoms of major depression, phobias, and substance abuse
•          Presence of depression, outburst of anger, and/of decreased concentration

A. ANALYSIS/NURSING DAIGNOSIS

•          Anxiety related to threat to security and self-concept and recall of traumatic experiences
•          Ineffective coping related to an inability to meet role expectations, and pervasive anxie
•          Fear related to feelings of panic, altered judgment, and pervasive anxiety
•          Risk for injury related to flight from the stress producing object or situation, feelings of p
•          Powerlessness related to overwhelming, pervasive anxiety
•          Compromised family coping related to disturbed relationships, pervasive anxiety, and a
•          Impaired social interaction related to pervasive anxiety
 •          Post-trauma response related to unusual life experience causing avoidance or traumati
•          Risk for violence: self-directed or directed toward

B. PLANNING/IMPLEMENTATION

•          See Fundamental Principles When Caring for clients with anxiety disorders
•          Stay with client memory of the event returns to the conscious level
•          Protect client from acting out violently with disregard for safety of self or other

C. EVALUATION/OUTCOMES

•          Uses coping mechanism to more realistically deal with the traumatic event
•          Verbalizes decrease in dreams or flashbacks regarding the traumatic event
•          Follows prescribes treatment regimen
•          Demonstrates new adaptive ways of coping with anxiety

ANAPHYLACTIC REACTION

Ø  Anaphylactic reaction is an acute hypersensitivity reaction that occurs within second or minute

SIGN AND SYMPTOMS

Respiratory Signs

Nasal congestion
Itching
Sneezing and coughing
Possible repiraory distress
Chest tightness
Other repiratory difficulties suc as wheezing, dyspnea and cyanosis

Skin Manifestation

Flushing with a sense of warmth and diffuse erytheme

Generalized itching over the entire body
Uticaria (hives)
Massive facial angioedema possible with accompanying upper repiratory edema

Cadiovascular Manifestation

Tachycardia or Bradycardia
Peripheral vascular collapse as in dicated by
Ø  Pallor
 Ø  Imperceptible pulse
Ø  Decreasing blood preasure
Ø  Circulatory failure, leading to coma and death

Gastro Intestinal Problem

Nausea
Vomiting
Colicky abdominal pains
Diarhea

NURSING INTERVENTION

Ø  Establishing a Patent aiway and ventilation is essential

Early endotracheal intubation is essential to preserve airway patency
Oropharyngeal suction may be necessary to remove excessive secretion
Resuscitiva measure are used especially for patient with stridor and progdressive pulmonary ede

Pharmacologic management
Additional treatments may include the following;

Antihisatmines (eg, diphenhldramine [bendril] ) to block further histamines binding at target cells

Aminophyline titrated by IV drip for severe broncho spasman wheezing refractory to other treatment.

Albuterol ( proventile, Ventoli ) inhalers or humidified, treatments too decreased bronchoconstriction

Isoproterenol (Isuprel ) or (Inopromine ) for reduced cardiac output; oxygen to enhance tissue perfusion

IV benzodiazepines (eg, diazepam [valium ] ) for control of seizures

INSECT STING

Ø  A person may have an extreme sensitivity to the venoms of the insect in the other hymnoptera

CLINICAL MANIFESTAION

Generalized uticaria,
Itching,malaise, and anxiety due to laryngeal edema to severe broncho spasm,
shock and death

MANAGEMENT
 Stinger removal if the sting is from a bee because the venom is associated with sacs around the barb of
Stringer is remove with one quick scrape of finger nail over the site.
Wound care with soup and water is sufficient for stings.
Scratching is avoided because it result in Histamine responses.
Ice application is reduced the swelling and also reduced venom absorption.
Oral antihistamine and analgesic can be given to decrease the itching and pain.
Epinephrine (aqeous ) injected ubcutaneously-in the case of anaphylactic or sever allergic response.

To Minimize you chances Of being a Stung;

Avoid places where you stinging insects congregate such as a camp and picnic sitesand insect feeding a
Wear covering the feet and avoid going barefoot
Spray garbage scans with quick acting insecticide.
Avoid perfumes, scented soap and bright colors, which attract bees.

If you are stung; do the ff;

Inject self immediately with epinephrine if allergy is known or allergic response occurs
Remove the stinger with one quick scrape of the finger nail; do not squeeze the venom sac.
Clean the area with soapy water and apply ice
Report to the nearest health care facility for further examination if allergic response is suspected.

SNAKES BITE

Ø  Children between the ages of 1 to 9 yr/ old are most the likely victims.
The greatest number of bites occurs through the daylight hours into the early evening during sum

CLINICSL MSNIFESTATION

Classic clinical signs of envenomation are;

Edema
Ecchymosis and hemorrhage bullae
Lymp node tenderness
Nausea and vomiting

Numbness and metallic taste in the mouth

Fasciculation
Hypotension,
Paresthesias, seizures, and coma

MANAGEMENT

§  Initial first aid of the site of the snake bite includes having the person lie down,
§  Removing constrictive items such as rings, providing warmth, cleansing and immobilizing the injured
 §  Airway breathing and circulation are the priorities of care,
§  Initial valuation in the ED is performed
§  And includes information the ff;
Ø  Whether the snakes was venomous or non venomous; if the snake is dead; it should be tran
Ø  Sequence of events sign and symptoms (fang punctures, pain edema and erythema of the b
Ø  Severity of poisonous effects
Ø  Vital signs
Ø  Laboratory data (complete blood count, urinalysis, and coagulation studies)
Ø  Administration of Antivenin (Antitoxin)
Ø  ACP (horse serum- derived antivenin )

HEMORRHAGE
A. Types

1.    Venous: dark color; steady flow

2.    Arterial: bright color; spurts
3.    Capillary; red; oozes

B. Assessment

•          Restlessness
•          Anxiety
•          Rapid, weak pulse
•          Cool, moist, pale skin
•          Rapid respirations
•          Thirst
•          Nausea/ vomiting
•          Alteration/ vomiting
•          Hypotension

C. Intervention: external

•          Apply direct pressure with a clean cloth for a least 6 minutes (use gloves if available)
•          Elevate injured part above heart level
•          If arterial bleeding does not respond to direct pressure, attempt to control by applying d
•          Tourniquets are not recommended unless an extremity is amputed or severely mutilate
o   Leave tourniquet exposed
o   Tag or lebel victim with location of tourniquet
o   Apply proximal to wound
o   Tourniquet should not be removed except by a physician
•          Treat for shock
Modifiable Risk Factor
ü  High blood cholesterol
ü  Cigarette smoking,
tobacco use
ü  Hypertension
ü  Diabetes Mellitus

ü  Lack of estrogen in
women
 ü  Obesity

Hyperkalemia Myocardial
Infarction
Prolonged QRS complex Elevated ST
segment
Elevated ST segment Inverted T
wave
Peaked T wave Pathologic T
wave

AST CPK-MB LDH

7 – 40 mu/ml 50 – 325 100 – 225
mu/ml mu/ml
4 – 6 hours 3 – 6 hours 12 hours
24 – 36 hours 12 – 18 hours 18 hours

4 – 7 days 3 – 4 days 10 – 14 days

 Cancer is one of the leading causes of death worldwide. The term describes all forms of neoplastic diseases that

are poorly differentiated.

There are numerous theories espoused as to the cause of cancer. Cancer begins when a normal cell is transform

ystem and they undergo destruction. The failure of the immune response system will lead to inability of the WBC to destro

ndustrial compounds, Spoilt Foods, and preservatives like nitrites.

 in cell structure, and growth behavior, leading to become malignant cells.
he Hepatitis B virus, HSV, HPV, Epstein Barr virus. The RNA viruses are the HIV and the HTCLV.

ablished tumor. The hormone-responsive tissues are considered targets for four types of cancers- prostate, breast, brain a
ctices are – coffee intake, nitrosamines and vitamin deficiencies.

Benign Malignant
Grows slowly Grows rapidlly
Infiltrates surrounding tissues
 Encapsulated Not encapsulated

Never occur Very common

Not harmful to host Always harmful
Very good prognosis Poor prognosis

Benign cells are typically encapsulated non-invasive and highly differentiated. Mitosis is rare and the growth is v
Malignant cells are non-encapsulated, invasive and poorly differentiated. They have uncontrolled proliferation th

-whenever malignant neoplasm penetrates into a natural “open field”

-involves: peritoneal cavity, (most often), pleural, pericardial,
space subaracnoid
and joints

-pattern of lymph node involvement follows the natural route of drainage

-This is the most common mode of spread!
sting
eight loss
bilitation - Malignant cells are disseminated through the blood stream
 Guaiac stool exam for occult blood[50 y/o and above].

ype and phase of cell cycle

, and monoclonal antibodies.
 to help modify the host’s biologic response to tumor cells

ipate complications.

e effectiveness of therapy.
cific to a particular tumor and can be used to screen, diagnose, assess prognosis, evaluate response to treatment and check for tumor r
s, planes, motorcycles, boats, bicycles, etc.

e, visible description of the wound.

thout thorough rinsing.

oft tissues injuries usually have localized pain at the site of injury.

the fourth leading causes of death in the US. It is the leading cause of death in children and in adult younger than 44

damage can cause acute renal failure)

result in acute tubular necrosis.

ecreased to less than 2.5 mmol/L is an indication of successful resuscitation.

r wound debridement and fracture repair.

dications, collecting laboratory specimens, and documenting activities and the patient’s response.
hest priority for immediate treatment.

medical services.

ses as opposed to criminal law cases, which involve a defendant and the State of Utah. Personal injury can occur in

ient’s health care problems in crisis situations. The emergency nurse establishes priorities, monitor and continuously

the context of as fast-paced, technology-driven environment in which serious illness and death are confronted on a d

s unconscious or in critical condition and unable to make decision. If the patient is unconscious and brought to the ED

th care providers are at an increased risk for exposure to communicable disease through blood or other body fluids.
 and psychological healing. Some are experience real and terrifying fear of death and other assaults on their persona

o the appropriate setting for ongoing care.

All instructions should be given not only verbally but also in writing, so that the patient can refer to them later.

are needs. For patients and families who cannot provide at home, community agencies may be contacted before disc

ed on the severity of their health problems and the immediacy with which these problems must be treated.

within 1 hour.

pt transfer to the appropriate setting (intensive care unit, operating room, general care unit) are the priorities of emerg
ining or restoring effective circulation.

rinary catheters
t  response to therapy.

ment or until there is  improvement in the patient clinical coordination.

extended heat waves, especially when they are accompanied by high humidity.
chronic and debilitating diseases, and those taking certain medication.
lorpromazine may prescribed
shing occurs.
in 24 hours after diving.
ain, numbness, or hypesthesia.
osite to site (countercoup) as a result of rebound reaction
age situations)
ed or agitated behaviors

nding to the event with intense fear/, helplessness, or horror; onset at any age
ng a general responsiveness

substance, such as medication (eg, penicillin, iodinated contrast material) and other agents, such as latex insect stin
fire ants, and wasps,)venom allergy is thought to be an IgE-medication, and it reaction it constitutes an acute emerge
oisonous snake bite occurs from pit vipers( crotalidae). The most common site is the upper extrememity.
orms of neoplastic diseases that are malignant and can cause death.

when a normal cell is transformed into a neoplastic cell by a transforming agent by exposure or interaction. These agents

o inability of the WBC to destroy cancer cells

ancers- prostate, breast, brain and endometrium.
tosis is rare and the growth is very slow. Metastasis does not happen.
ave uncontrolled proliferation that can be erratic. The cells contain few identified cellular characteristics, they have altered

al “open field”
space and joints

l route of drainage
to treatment and check for tumor recurrence.
n and in adult younger than 44 years of age. The incidence is increasing in adults older than 44 years of age. Alcoho
response.
 . Personal injury can occur in a wide variety of ways. The following are some of the most common accidents resultin

ties, monitor and continuously assess acut ely ill and injured patients, supports and attends to families, supervises all

nd death are confronted on a daily bas is.

nscious and brought to the ED wi thout family or friends, this fact should be documented.

gh blood or other body fluids. The reemergence of tuberculosis, a major health problem.
other assaults on their personal identify and body integrity.

an refer to them later.

may be contacted before discharge to arrange services.

ms must be treated.

unit) are the priorities of emergency care.

gents, such as latex insect stings and wash yellow jacket, hornet or foods (eg, eggs, peanuts). Repeated administra
it constitutes an acute emergency.Although stings in any area of the body can trigger anaphylaxis, stings of the hea
pper extrememity.
sure or interaction. These agents are called carcinogens that can permanently change the DNA structure of the cell. Some
characteristics, they have altered biochemical properties such as hormone-like secretions and they have chromosomal inst
er than 44 years of age. Alcohol and drug abuse are often implicated as factors in both blunt and penetrating trauma
most common accidents resulting in personal injury:

tends to families, supervises allied health personnel, and teaches patients and families within a time-limited, high pre
peanuts). Repeated administration of parenteral or oral therapeutic agents (eg, repeated exposure to penicillin) may
anaphylaxis, stings of the head and neck or multiple stings are especially serious
DNA structure of the cell. Some other agents are called co-carcinogens because they can alter genetic information in the
and they have chromosomal instability. They can potentially cause new mutation in the cancer cells rendering them resista
h blunt and penetrating trauma.
es within a time-limited, high pressured care environment. The strength of nursing and medicine are complementary
ated exposure to penicillin) may also precipitate an anaphylactic reaction when initially only a mild allergic response o
n alter genetic information in the cell enhancing cellular transformation.
ancer cells rendering them resistant to therapy. They metastasize to distant sites!
medicine are complementary in an emerg ency situation. The emergency health care staff members work as a team
only a mild allergic response occurred.
e staff members work as a team in performing the highly technical, hands-on skills required to care for patient’s in an
quired to care for patient’s in an emergency situation.