OUR LAST NURSING EXAM!!!!!!!
Intracranial Regulation
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Overview
○ Cerebrospinal Fluid
■ 125-150mL on average in the ventricles and central canal at any time.
● Typical production is 500mL per day, 20mL per hour.
■ Functions of CSF:
● Protection, cushioning
● Supplies nutrients to CNS
● Waste product removal
○ Breakdown of Components
■ Primary injury
● Occurs at the initial time of injury (car accident, blunt force trauma,
etc.)
● Results in bruising or damage to any of the three components
■ Secondary injury
● Occurs several hours to days after the primary injury.
● Secondary injury is hypoxia, ischemia, hypotension, edema, or
increased ICP.
● This is a primary concern when managing brain injuries.
○ Cerebral Blood Flow
■ Amount of blood passing through the brain tissue.
■ Blood provides the brain with oxygen and glucose.
■ The brain autoregulates through cerebral vasodilation/constriction to
maintain blood flow during changes in arterial blood pressure.
● Monitor CO2!
Cerebral Perfusion Pressure
○ Pressure is needed to ensure blood flow to the brain.
○ CPP Normal = 60-100 mmHg
○ When the CPP falls below 30 the result can be ischemia and is incompatible with
life.
○ CPP may not reflect perfusion pressure in all areas of the brain.
■ Swelling and compression may limit regional perfusion pressure.
○ Patients with an acute stroke may require a higher BP, increasing MAP and CPP
to increase perfusion to the brain preventing further tissue damage.
○ CPP calculation
● CPP = MAP – ICP
● MAP = [SBP + 2(DBP)]/3
Measuring ICP
○ Gold Standard is ventriculostomy
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Normal ICP = 5-15 mmHg (<20)
■ Waveform monitoring consists of 3 waves
● P1 = percussion wave, representing arterial pulsation
● P2 = tidal wave represents intracranial compliance
● P3 = dicrotic wave represents venous pulsation
○ Normal ICP waveform P1 should have the highest upstroke, P2 in between and
P3 should be the lowest. If P2 is higher than P1 indication of intracranial
hypertension
Increased Intracranial Pressure
○ Increases in ICP can compound the extent of brain injuries and can be
life-threatening.
○ If the volume of one component increases, the volume of one or both of the other
components must decrease, or an increase in the ICP occurs.
Cerebral Edema
○ Increased accumulation of fluid in extravascular spaces can be caused by a
variety of issues.
○ Causes
■ Mass Lesions (Tumors, Hematoma, Hemorrhage)
■ Head Injuries (Contusion, Hemorrhage)
■ Cerebral Infections (Encephalitis, Meningitis)
■ Vascular Insults (Anoxic or ischemic events, Stroke)
■ Toxic or Metabolic Encephalopathy conditions (Hepatic encephalopathy,
Lead or arsenic intoxication, or Uremia)
○ Three types of cerebral edema
■ Vasogenic
● Most common type. Mainly in white matter.
● There is an increase in the permeability of the blood-brain barrier.
● Fluid flows from intravascular to extravascular space.
● Can be caused by brain tumors, abscesses, and ingested toxins.
S&S range from headache to varying levels of
consciousness/coma and focal neurologic deficits
■ Cytotoxic
● Disruption of the functional integrity of the cell membranes, the
blood-brain barrier remains intact.
● Fluid and protein shift from extracellular space directly into the
cells.
● Develops from destructive lesions or trauma to brain tissue
resulting in cerebral hypoxia or anoxia, syndrome of inappropriate
antidiuretic hormone (SIADH) secretion
■ Interstitial
● Uncontrolled hydrocephalus (buildup of fluid in brain -> ventricular
enlargement)
Causes of Increased ICP
○ Suctioning
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Intubation
Coughing
Bad Positioning
■ Trendelenberg
■ Prone
■ Extreme hip flexion
■ Neck flexion
○ Noxious stimuli
○ Emotional distress
○ Seizures
○ REM sleep
Symptoms of increased ICP
○ Changes in LOC
■ The most sensitive and reliable indicator of neuro status
○ Changes in vital signs
■ Cushing’s Triad
● Increased SBP (increased pulse pressure)
● Decreased HR (+ bounding pulse)
● Decreased, irregular respirations (Cheyenne-Stokes)
○ Vision changes
■ Pupil dilation, slow or no response to light
■ Fixed, dilated pupil on one
side is indicative of herniation
○ Headache
○ Vomiting
○ Decreased motor function
■ Contralateral (opposite)
hemiparesis or hemiplegia
■ Posturing (next slide)
Posturing
○ Decorticate Posturing (flexor)
■ Damage to one or both
corticospinal tracts.
■ Arms are adducted and
flexed. Legs stiffly extended
and internally rotated, feet
plantar flexion.
■ DeCORticate = towards the CORE
○ Decerebrate Posturing (extensor)
■ Indicates more serious damage, the upper brain stem.
■ Arms abducted and extended, wrists pronounced fingers flexed. Legs
stiffly extended with plantar flexion of feet.
Diagnostic procedures
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Aimed at identifying underlying cause:
■ MRI
■ CT
■ Cerebral angiography
■ EEG
■ Transcranial Doppler study
■ ICP measurement
■ PET
■ Papilledema (retinal exam – edematous optic disc)
■ Nuchal rigidity
■ ECG
Complications from an uncontrolled increase of ICP
○ Inadequate cerebral perfusion, causing brain tissue hypoxia
○ Cerebral herniation – sustained increase in ICP cause brainstem compression
and herniation from one compartment to another
■ Tentorium – midbrain & diencephalon through the tentorial notch
■ Uncal – anterior temporal moves into the anterior portion of tentorial
■ Tonsillar - cerebellar tonsils pushed through the foramen magnum
Management of increased ICP
○ What:
■ Decrease Cerebral Volume
● Remove Tumor via surgery
● Craniotomy
● Maintain Euvolemia
● Hyperosmolar therapy - Mannitol (a diuretic that is used to reduce
swelling and pressure inside the eye or around the brain)
■ Decrease Cerebral Spinal Fluid
● Ventriculostomy to drain
● Lumbar drain
■ Decrease Cerebral Blood Volume
● Maintain head at the midline
● Elevate HOB (30 degrees)
● Maintain normal CO2 (CO2 is a potent vasodilator),
○ Consider mild hyperventilation (blow off CO2 -> cause
vasoconstriction)
■ Decrease Metabolic Rate
● Normothermia (We don’t want sweating or shivering)
○ Mild hypothermia may be used with paralytics or sedatives
to avoid shivering
● Sedation / Analgesia
● Prevent / manage seizures
● Barbituates
○ Maintain adequate oxygenation and perfusion
○ Routine ABGs to guide O2 therapy; MAP; CVP
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Surgery
■ Craniotomy may be required to reduce ICP and prevent herniation
○ Drug Therapy
■ Mannitol (a diuretic that is used to reduce swelling and pressure inside the
eye or around the brain)
■ Corticosteroids
■ Hypertonic solutions (so the fluid goes into the vascular space and can be
peed out)
● Nursing care
○ Assessment
■ Glasgow coma scale
■ Complete neuro exam
■ VS
■ Respiratory status
■ F/E balance
■ ICP monitoring
■ Safety
○ Interventions
■ HOB 15-30 degrees
■ Neutral head position
■ Prevent shivering
■ Avoid hyperthermia
■ Optimize BP
■ Watch fluids - aggressive resuscitation (ARDS)
■ Avoid Hypoxia
■ Watch Blood Glucose (better outcomes if not hyperglycemia)
■ Limit External Stimulus - Keep to a minimum (noise, light, visitors)
Traumatic Brain Injury - TBI
● Head injuries and trauma
○ Table 56-6
○ Location determines the clinical manifestations
■ Basilar
■ Frontal
■ Orbital
■ Parietal
■ Posterior Fossa
■ Temporal
● Brain injuries
○ Diffuse (generalized)
■ Concussion – minor diffuse
● Brief LOC changes, amnesia, headache – short duration
■ Diffuse axonal injury (DAI) – widespread axonal damage after TBI
● Decreased LOC, increased ICP, posturing, cerebral edema
○ Focal (localized)
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Minor to severe...
Lacerations, contusions (coup-contrecoup), hematomas, cranial nerve
injuries
Hematomas (Not for exam but need to know for NCLEX)
○ Review of hematomas and complications
○ Hematomas (intracranial)
■ Subdural (Slow to grow - usually venous)
● Ensure ABC’s
● GCS < 8 – Intubation (less than 8, intub8)
● Neurosurgical Consultation
● Evacuate Hematoma?
● Non-surgical
○ Imaging to watch
○ Anticoagulation
○ PLT transfusions
○ Frequent Neuro Assessments
○ Control HTN
○ Steroids?
■ Epidural (Emergency, fast to grow - arterial or venous)
● ATLS (advanced trauma)
○ Airway (ventilation/circulation)
● IV access
● GCS (if <8)
○ Intubation
○ Neurosurgical Consultation
● Evacuate Hematoma
● STOP bleeding source
○ *Note: some, if small, may resolve
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Epilepsy & Seizures
○ Review
■ Epilepsy – continued predisposition to seizures caused by a group of
abnormal neurons that spontaneously fire
■ Seizure – Transient, uncontrolled electrical discharge in brain ->
interruption of normal function
● Teach Patients
○ note onset & time
○ characteristics of the seizure (lateral or bilateral
movement)
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Care of Seizure patient in ED
○ IV / IO
○ O2 (NC or intubation)
○ Medications
■ Phenytoin
■ Lorazepam - Ativan
■ Phenobarbitol
■ Diazepam
■ Carbamazepine (Carbatrol, Tegretol, others)
■ Valproic acid (Depakene)
■ Oxcarbazepine (Oxtellar, Trileptal)
■ Lamotrigine (Lamictal)
■ Gabapentin (Gralise, Neurontin)
○ DX:
■ Medical & family history - did they get into any medication or cabinets
■ CT
■ EEG
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Meningitis
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Toxicity screen (Serum / Urine)
Glucose / Electrolytes
Lumbar Puncture - Meningitis?
Neuro consult
Acute inflammation of meningeal tissues
■ Bacterial (B = bad)
■ Viral (V = Very common)
Bacterial meningitis
○ Medical emergency
■ If left untreated – the mortality rate is near 100%!!
■ If treated with abx, mortality rate 15% or less
Common bacterial “culprits”
○ Haemophilus influenzae type b – Hib
■ Hib vaccine has drastically diminished this as a common cause
○ Neisseria meningitidis
○ Streptococcus pneumonia
Pathophysiology review
○ Infection -> inflammatory response -> increased CSF -> increased ICP
○ Purulent secretions spread through CSF and cover the cranial nerves, other brain
structures
Clinical manifestations
○ Key signs of meningitis:
■ Fever
■ Severe headache
■ Nausea, vomiting
■ Nuchal rigidity (neck stiffness)
■ (+) Kernig’s and Brudzinski’s signs
● Kernig - Severe stiffness of the hamstrings causes an inability to
straighten the leg when the hip is flexed to 90 degrees.
● Brudzinski - clinical sign in which forced flexion of the neck elicits
a reflex flexion of the hips
○ Other symptoms that may be present
■ Photophobia
■ ↓ LOC
■ Signs of ↑ ICP
● Seizures occur in 1/3 of all cases.
● Headache becomes progressively worse and may be
accompanied by vomiting and irritability.
○ Coma is associated with poor prognosis and occurs in 5-10% of cases.
Collaborative care
○ Medical emergency!
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Rapid diagnosis crucial
■ Based on history and assessment as the patient is usually critical when
health care is initiated
■ Lumbar puncture and CSF analysis (cloudy/opaque = bacterial)
○ Start Abx ASAP
■ Antibiotic therapy is instituted after the collection of blood, sputum,
nasopharyngeal cultures and before a diagnosis is confirmed
● Able to cross the blood-brain barrier
● Ampicillin, Vanco, penicillin, among others
○ Pain management
■ Codeine - Headache
○ Steroids
■ Dexamethasone - inflammation/ICP
○ Temp control
■ Tylenol - fever
○ Seizure prevention
Viral meningitis
○ The most common causes are enterovirus, arbovirus, HIV, and HSV.
■ Most often spread through direct contact with respiratory secretions
○ Clinical manifestations: Headache, fever, photophobia, stiff neck
○ Test CSF (typically clear, can be cloudy)
○ Treat with antibiotics initially and discontinue if found to be viral
○ Manage symptoms … Usually self-limiting
Pain
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Types of pain
○ Acute
■ Sudden onset
■ Typically linked to an event
■ Expected to diminish with normal healing
■ Example: surgery
○ Chronic
■ Longer than 3 months, may last for years
■ Result of pathology or medical condition
■ Example: extensive tumor growth
■ Types of pain
○ Nociceptive
■ Aching, cramping, throbbing
■ Somatic - sharp or dull, has a specific area like bone or connective
tissues
■ Visceral - arises from a body cavity, may radiate, deep
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Neuropathic
■ Damage to nerves
■ Burning, sharp, shooting
■ Constant, electrical quality
Pathophysiology of pain
○ Pain->stress response->activation of excessive hormones (cortisol, glucagon,
catecholamines)->insulin and testosterone decreases; accelerated carbohydrate,
protein, fat destruction-> weight loss, tachycardia, increased respiratory rate
->shock, death
Assessment of pain
○ Characteristics
■ Location
■ Intensity
■ Quality
■ Pattern
■ Relief measure
○ Nonverbal indicators of ACUTE pain
■ Agitation
■ Grimacing
■ Elevated HR, RR, BP
■ Diaphoresis, pupil dilation
■ Splinting of area
○ Nonverbal indicators of CHRONIC pain
■ Depression
■ Lethargy
■ Anger
■ Weakness
Barriers to effective pain management
○ Inadequate assessment
○ Inadequate education of client regarding medications
○ Knowledge of health care provider regarding medications
○ Reluctance to report pain
○ Fear of addiction
○ Inadequate dosing
Management & treatment
○ Treatments
■ Medications (NSAIDs, opioids, adjuvants)
● Opioids recommended for severe, acute pain
■ Nerve blocks, intrathecal analgesia
■ Antidepressants, anticonvulsants - Neuropathic pain
○ Alternative approaches
■ Transcutaneous electrical nerve stimulation (TENS)
■ Relation techniques & Imagery
■ Distraction
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■ Heat or cold, pressure, massage, vibration
■ Acupuncture
■ Hypnosis
■ Peer Support Group
Interrelated concepts
○ Pain affects many concepts; physiological and psychological
○ Identify suggested strategies under the correct slide.
○ Concepts:
■ Mobility & Functional Ability
● Severe pain can be immobilizing, and lead to multiple physical
complications such as GI disturbances, infection, muscle atrophy
● Inability to participate in activities and treatments prolongs
recovery
● Can lead to long term disability, loss of independence, and greater
reliance on the health care system
■ Tissue integrity
● Dependent on where the cancer is located, cancer pain may be a
result of direct tissue injury (nociceptive) or pressure/damage to
nerves (neuropathic).
● The patient can expect to experience acute types of pain
■ SLEEP & Fatigue
● Often related to interrupted sleep, cancer treatments, the disease
process, and unresolved pain, patients will complain of fatigue.
● Fatigue and pain can lead to further impairment of mobility and
functional ability
■ Mood and affect
● Poorly controlled pain can have a large effect on a patient’s mood
and affect and lead to consequences such as depression and
suicidal thoughts.
● Research has shown a relationship between chronic pain and
mortality
■ Culture, SPIRITUALITY, & Development
● Expression of pain varies widely amongst cultural groups and may
change with age
● Unfamiliarity with cultural and spiritual differences can make pain
assessment complicated and lead to poorly controlled pain levels
Cellular Regulation - Cancer
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Cancer: What does it bring to mind?
○ Death/dying
○ Tumor
○ Pain
○ Bleeding
○ Hospice
○ Hospitalizations
○ Chemo/radiation
○ Age
● 7 Early Signs of Cancer:
○ C- Change in bowel/bladder habits
○ A-A sore throat that does not heal
○ U- Unusual bleeding in stool
○ T- Thickening lump in breast or testis
○ I-Indigestion or difficulty swallowing
○ O-Orange peel skin with small, indented areas
○ N-No energy (fatigue). Nagging cough or voice hoarseness
A nurse is caring for a client with suspected Non-Hodgkin’s lymphoma. Which of the following
would the nurse anticipate taking place first?
○ Palpation of the liver and spleen
○ Percussion of upper abdominal quadrants for tympany
○ Endoscopy
○ Needle biopsy
● Prevention
○ Primary
■ Eliminate smoking/ limit alcohol use
■ Physical activity
■ Eat a balanced diet/ maintain a healthy weight
■ Use sunscreen with a factor of 15 SPF or higher
● THIS FOUR AMOUNT TO 60% OF CANCERS!
■ Prophylactic surgery
■ Avoid carcinogens (chemical, viral, radiation) and promoting agents
(increase likelihood of additional mutations)
■ Behavior modification
■ Environmental modification
■ Vaccination
■ Treatment of infections
○ Secondary prevention (Screening)
■ Before symptoms develop
■ Goal: early detection for treatment at an early stage
■ Who needs further testing?
■ Recommendations change with the latest scientific evidence
● ASSESSMENT
○ examination findings
■ Seven Warning Signs
● Change in bowel or bladder
● A sore that does not heal
● Unusual bleeding or discharge
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● Thickening or a lump
● Indigestion or difficulty in swallowing
● Obvious change in a wart or mole
● Nagging cough or hoarseness
■ Assess for Neoplastic growth
● Visible lesions, asymmetry, palpable masses, abnormal sounds,
presence of blood
○ Assessment: History
■ Early on: asymptomatic
■ Complaints regarding physical presence of tumor or symptoms related to
tumor
● Bleeding
● Pain
● Cough
● Fatigue
● Anorexia/weight loss
● Fever/infections
○ Assessment: diagnostic tests
■ The testing period can be a long- stressful/fearful time
■ Radiographic tests
■ Direct visualization
■ Laboratory tests
■ Pathology
■ Cytology
■ Biopsy (incisional, surgical, or excisional)
■ Grading & Staging
■ Helps plan appropriate treatment
■ Gives common language between physicians/researchers
■ Evaluates effectiveness of treatments
Neoplasms: Malignant vs Benign
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Benign vs malignant tumors
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Malignant
○ Carcinoma & Adenocarcinoma
○ Sarcoma
○ Lymphomas
○ Leukemia
○ Skin cancers
Benign (-oma)
○ Benign prostatic hypertrophy (BPH)
○ Lipoma
○ Fibroma
○ Adenoma
○ Meningioma
○ Papilloma
Classification: staging
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Classification: Grading
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GX - grade can not be assessed
G1- Well differentiated (low
grade)
○ G2 - Moderately differentiated
(intermediate)
○ G3 - Poorly differentiated
(high grade)
○ G4 - undifferentiated (high
grade)
Metastasis
○ See Photo to Right ->
Interventions
○ Collaborative Courts
■ Surgery
■ Radiation therapy Palliative or curative
(hurts normal cells)
■ Chemotherapy - medication, systemic - can be curative for metasstic
cancer (oral, IV, topical, subcut, etc.) / attacks health cells too
■ Hormonal therapy - Uses in endocrine based cancers (breast etc)
■ Targeted therapy - medication / antibodies that prevent growth signals so
that it is more localized than chemo
■ Biologic therapy (immunotherapy) - stimulates immune system to attack
cancer cells
■ Bone marrow and hematopoietic stem cell transplantation - replaces
diseased cells (monitor for rejection / poor healing)
○ Symptom management resulting from cancer & Cancer treatment
■ Chemotherapy:
● Access issues (device infection, extravasation, or vesicants)
● Myelosuppression (infection, bleeding, anemia)
● Leukopenia, infection
● Anorexia, mucositis, N/V, diarrhea
● Alopecia
● “Chemo brain”
● Reproductive dysfunction
■ Radiation:
● Myelosuppression & N/V less common (infection, bleeding,
anemia)
● Skin changes
○ Erythema->dry desquamation ->wet desquamation
○ Some areas more affected
● Pulmonary tissue damage
● Damage to pericardium (pericarditis)
● Reproductive dysfunction
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*Both treatments put patients at risk for secondary malignancies*
Side Effect list:
○ Stomatitis, mucositis, esophagitis
○ Nausea and vomiting
○ Anorexia
○ Diarrhea & constipation
○ Hepatoxicity
○ Anemia
○ Leukopenia
○ Thrombocytopenia
○ Alopecia
○ Pericarditis/myocarditis
○ Cardiotoxicity
○ Chemo skin changes (photosensitivity, hyperpigmentation)
○ Hemorrhagic cystitis
○ Reproductive dysfunction
○ Nephrotoxicity
○ Intracranial pressure
○ Peripheral neuropathy
○ Cognitive changes
○ Pneumonitis
○ Hyperuricemia
○ Fatigue
Nursing Safety with Chemotherapy Drugs and Radiation
■ CHEMOTHERAPY
■ RADIATION
○ Nursing Management
■ Damage to skin/tissues
■ Breakdown of cells and release of toxins
■ Challenges with thinking, eating & elimination, activity
■ Potential for infection/bleeding
■ How are these treated?
Nursing Management
○ Bone Marrow Suppression
■ Neutropenia - very low in the weeks following treatment
● NEED to look out for low grade fever - it could mean really
bad infection (they can’t produce normal fever response)
■ Thrombocytopenia
■ Anemia
■ Bruises, petechiae
○ Fatigue
○ GI Problems
■ N&V
■ Diarrhea
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Mucositis
Anorexia
Malnutritional
● Everything hurts, so nurses need to get creative in order to help
the patient meet nutritional needs
● Cold foods are usually better
● Avoid super smelly items
■ Good oral care is important
■ No Alcohol
■ Encourgae Iron rich food - to improve healing
○ Skin Reactions
■ Monitor and document skin changes,
○ Pulmonary Problems
○ Cardiovascular Problems
○ Cognitive Changes
■ Assess for LOC / MS
■ Planner / Schedule to keep structure
■ Ensure patient that it is normal to feel fatigued
○ Reproductive Effects
○ Late Effects
■ cardiac toxicity, cataracts, arthralgias, endocrine and renal problems,
hepatitis, etc
Oncologic Emergencies
○ Obstructive
■ Superior Vena Cava Syndrome
■ Spinal Cord Compression
■ Third Space Syndrome
○ Infiltration
■ Cardiac Tamponade
● fluid compresses the heart so that it can no longer function
properly, significant decrease in CO (Tx: aspiration)
● Could be caused by Chemo or other cancer treatments
■ Carotid artery rupture
○ Metabolic
■ Hypercalcemia - bone metastasis caused increased Ca released in blood
■ Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
■ Tumor Lysis Syndrome
○ Hematologic
■ Anemia
■ Thrombocytopenia
■ Neutropenia
■ Disseminated intravascular coagulation (DIC)
Superior Vena Cava Syndrome
○ Obstruction of the superior vena cava (SVC)
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SVC collects blood that drains from the head and neck and upper thoracic cavity
■ EX: Central Line placements, tumors etc.
○ Blockage-> pleural effusion-> facial, chest, arm, and neck edema-> impaired
cardiac filling
○ Manifestations
■ Periorbital and conjunctival edema
■ Facial swelling
■ Stoke’s sign
■ Visual disturbances, headaches, Altered LOC
■ Distention of veins in the thorax (late)
■ Dysphagia, dyspnea, cough, hoarseness
■ Tachypnea
■ Pleural effusions
■ More prominent in am- why?
○ Nursing Management
■ Avoid chest and neck catheter placement
■ AIRWAY
● Avoid lying flat
● Short term intubation
● O2 therapy
■ Medications
■ Avoid Valsalva
■ Elevation of arms
■ Assess for complications
Hypercalcemia
○ Metabolic complication- serum calcium > 11 mg/dL
○ Most common emergency
○ Most common cause:
■ Bone with metastasis releases more calcium into the extracellular fluid
than can be filtered by the kidneys and excreted in the urine
○ Manifestations
■ Nausea
■ Constipation
■ Polyuria
■ Mental status changes
● Somnolence
● Combativeness
● Confusion
■ Cardiac - need to monitor (arrhythmias)
○ Nursing Management
■ Watch for constipation
■ Careful I&O with increased fluids
■ Remain physically active
■ Maybe need dialysis
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Nutrition
● Limit dairy and Vit D foods - limit oral calcium supplements - NO
TUMS
● Eat salty foods
● K+ supplementation
● Increase oral fluids (or IVF)
Syndrome of inappropriate antidiuretic hormone (SIADH)
○ Excessive levels of antidiuretic hormones-> body retains water-> dilution of
electrolytes (like sodium) in the blood
○ Associated with lung and brain cancers (pituitary tumor)
○ Manifestations
■ Nausea & vomiting (early)
■ Lethargy
■ Hostility2
■ Seizures
■ Coma
■ Hyponatremia - delusional
■ Fluid retention
○ Nursing management
■ IV fluids (Saline)
■ Furosemide
■ Phosphates
Hematologic Disorders
■ Can be a result of cancer or the cancer treatment
○ Anemia - low hemoglobin (give RBCs)
○ Thrombocytopenia - low blood platelets (at risk for bleeding)
○ Neutropenia - low neutrophils (at risk for infection)
○ Disseminated intravascular coagulation (DIC) (at risk for clotting and
bleeding)
○ Nursing management
■ Observe for bleeding, apply pressure as needed
■ Transfusions, clotting factors (plasma)
■ Heparin
Types of Cancer - KEY DIFFERENTIALS
Cancer:
Symptoms
Risk Factors
Diagnostic /Labs
Complications
Interventions
Carcinomas & Adenocarcinomas:
originates from skin, glands, mucous membrane lining of respiratory, gastrointestinal, and genitourinary tracts
Prostate
Similar to BPH
Urinary hesitancy,
weak-stream,
urgency,
frequency, nocturia
History of
vasectomy
Digital rectal
examinations
Urinary
incontinence
Age greater than 65
Biopsy
Erectile dysfunction
High fat, low fiber
diet
Genetic testing (for
BRCA2)
Radiation cystitis or
proctitis
Acute Interventions:
Hormone therapy (produces chemical
castration, will have hot flashes and
reduced libido)
Chemo
Urinary retention
Blood in urine and
semen (late stage)
Radiation
Associated with
BRCA2 gene
PSA (obtain prior to
digital rectal exam for
accuracy) & EPCA-2
Surgery- radical prostatectomy
(treatment of choice, not beneficial if it
has spread), altered ejaculation
Painful ejaculation
Unexplained
weight loss
Exposure to
environmental toxins
such as arsenic
Ultrasound, transrectalvisualization procedure
Nursing Actions:
Medication education
Manage pain and observe for infection
Catheter care if necessary
Bladder antispasmodics may be
necessary, monitor output
Avoid heavy lifting and baths for 2-3
weeks
Kegels for incontinence
Sex therapist if necessary
UA- looking for
hematuria, bacteriuria
Loss of sexual
desire or function
Penile discharge,
scrotal
pain/swelling
Swollen lymph
nodes in groin
Breast
Gynecomastia in
men
Thickening, pitting
of breast skin
Dimpling
Nipple discharge
Nipple retraction
or ulceration
Enlarged lymph
nodes
hard, painless
mass
Tumors/lumps are
usually small,
irregularly shaped,
firm, non-tender,
nonmobile
Lung
High genetic riskinherited mutations
of BRCA1 and
BRCA2
Early age at
diagnosis, age over
65
Early menarche, late
menopause
Childless, or first
child after 30
Early or prolonged
use of oral
contraceptives,
High fat, low fiber
diet, excessive
ETOH, cigarette
smoking
Open or fine needle
biopsy- definitive
diagnosis
MRI- for dense breast
tissue
Destruction of chest
wall
Mastitis
Chemo/radiation
Nuclear imaging, PEM
(type of PET scan),
Ultrasound, x-ray,
mammography- visualize
tumor
Target therapy - Metastatic cancers
may receive medication that reduces
blood flow to the growing tumor
Surgery- lumpectomy wide excision or
partial mastectomy, total mastectomy,
radical mastectomy and reconstructive
surgery
Looking for metastatic
disease:
Chest x ray, CT scan,
MRI, liver enzymes,
serum calcium, alkaline
phosphatase
Possibly stem cells for high risk of
recurrence/late stages
Nursing Actions:
Sling or positioning to reduce painavoid dependent positions
Avoid injections/BP from affected arm
Teach incision and drain care
Teach/reinforce BSE
Genetic counseling
edema, swelling,
skin redness, pain
Exposure to low
level radiation
obesity
Orthopnea
Cigarette smoking/
second hand smoke
Cytologic testing,
thoracentesis
Superior vena cava
syndrome:
Radiation exposure
Thoracoscopy
Chronic exposure to
inhaled irritants (air
pollution, asbestos,
talc)
Biopsy (bronchoscopy)
related to radiation
of chest- watch for
facial edema and in
neck, mental status
changes, may need
radiation or stent
placement
Chronic cough and
dyspnea
Chest wall pain
Fatigue, weight
loss, anorexia
Late disease
manifestations:
Fever, persistent
cough,
hemoptysis,
hoarseness,
altered breathing
pattern, chest pain
or tightness, chest
wall masses,
Structural changes
in the skeletal
system that restricts
Acute Interventions:
Hormone therapy (works for cancers
that have estrogen or progesterone
receptors- better prognosis)
CT, xray,
Looking for metastatic
disease: MRI, PET scan
Needle biopsy of lymph
nodes
Looking at lung function:
PFTs and ABGs
Acute Interventions:
Medications- bronchodilators and
corticosteroids
Chemo
Radiation
Surgical intervention- often removal of
lung (pneumonectomy), lobe
(lobectomy), segment
(segmentectomy), or peripheral lung
tissue (wedge resection).
Palliative- Thoracentesis or
pleurodesis to ease breathing,
pericardial window for cardiac function
Nursing Actions:
Determine pack-year history and use
of other tobacco products
Determine exposure to secondhand
smoke
muffled heart
sounds, pleural
friction rub,
clubbing of fingers,
decreased bone
density
Colon
Position in high fowlers to maximize
ventilation
Manage pain (PCAs), tubes and
drainage
May need pulmonary rehab to treat for
weakness
Changes in stool
consistency or
shape
Inflammatory bowel
disease (UC or
Chron’s)
Blood in stoolsometimes only
symptom
High fat, low fiber
diet
Cramps or gas
Palpable mass
(found on digital
rectal exam or
abdominal)
Age older than 50
years, may happen
in younger clients
with HPV
Long term smoking,
heavy etoh
Fecal occult blood
testing
Incontinence or
sexual dysfunction
Endoscopic biopsy
Intestinal
obstruction
CT guided colonoscopy
Endoscopy (colon or
sigmoid)
Barium enema
Second primary
colorectal tumor
CBC- low hemoglobin
counts
CT/MRI- metastasis
Weight loss,
fatigue, vomiting
Exposure to H
pylori, HPV
Abdominal
distention or pain
History of breast,
ovarian, endometrial
cancer
Acute Interventions:
Colon resection
Colectomy with colostomy/ileostomy
Chemo
Radiation
Adjuvant therapy- decrease risk of
metastasis
Targeted therapy
Nursing Actions:
Assess stoma as necessary
Stool softeners
Ostomy teaching
NG suction as appropriate
Clear diet prior to surgery
Care of incision, watch for infection,
activity limits
Many need ostomy nurse referral or
psychosocial support
Bowels sounds:
high pitched
tinkling)
Sarcomas:
originates from muscle/bone/connective tissues
Osteosarcoma
Swelling near a
bone
Previous radiation
therapy
Bone or joint pain
Bone injury/break
without etiology
Certain genetic
conditions
Most common
malignant cancer in
kids and
adolescents
Wilms
Abnormal mass
(one-sided)
kidney
Abdominal
swelling
Abdominal pain
Fever
Blood in urine
Nausea or
vomiting
Hematuria
Loss of appetite
SOB
High blood
pressure
Heredity may play a
role, family history
Can occur as part of
other rare, genetic
childhood
syndromes
Biopsy: incisional,
percutaneous or fine
needle
Hypercalcemia
anemia
Manage bone pain (more pronounced
with resting)
Prevent fractures
Xray
CT
MRI
PET
Bone scan
CBC, renal function
tests, LFTs, UA
Biopsy
Abdominal ultrasound
Abdominal CT
Looking for mets: MRI,
Chest X-ray
Care of incision, care of stump
Rehabilitation
Cancer treatments
can cause other
cancers- especially
since treatment is
at an early age
Slowed growth and
development
Changes in sexual
development and
ability to have
children (especially
in girls)
Acute: Chemotherapy- may shrink
tumor preoperatively
Surgery: nephrectomy
radiation
Nursing Actions:
Manage treatment related
complications
Manage fatigue and weakness. Ensure
good nutrition
Genetic testing may be warranted
Monitor reduced kidney function
Psychosocial support
DO NOT palpate the abdomen
Lymphomas:
originates from lymph system/ white blood cells
Hodgkin’s
Enlarged lymph
node- usually in
the neck, may be
underarm or groin
Fever
Night sweats
Unexplained
weight loss
Fatigue
infections
Increased incidence
in clients exposed to
pesticides,
insecticides, and
dust
Medications that
suppress the
immune system
Being older than 45
Spleen biopsy will
show Reed
Sternberg Cells
CBC
Biopsy: excisional,
needle, or bone marrow
aspiration
Lumbar puncture
Thoracentesis or
paracentesis (for cancer
that has spread)
CT, PET- used for
staging
Looking for METS: MRI,
bone scan
Predictable spread
(Easier to treat)
Non
Hodgkin’s
Enlarged lymph
nodes
Fever
Night sweats
Unexplained
weight loss
Fatigue
infections
Pancytopenia-decre
ase in WBC, RBC,
platelets
(neutropenia)
Thrombocytopeniasecondary to
disease or
treatment
Hypoxemia- due to
anemia
Bone Marrow
Transplant
Complications
Failure of stem cells
to engraft
Graft-versus-host
disease
Phlebitis (veins in
the liver up to
one-month post)
Increased incidence
in clients exposed to
pesticides,
insecticides, and
dust
Medications that
suppress the
immune system
Erratic spread
CBC
Biopsy: excisional,
needle, or bone marrow
aspiration
Lumbar puncture
Thoracentesis or
paracentesis (for cancer
that has spread)
CT, PET- used for
staging
Looking for METS: MRI,
bone scan
Pancytopenia-decre
ase in WBC, RBC,
platelets
(neutropenia)
Thrombocytopeniasecondary to
disease or
treatment
Hypoxemia- due to
anemia
Bone Marrow
Transplant
Complications
Failure of stem cells
to engraft
Graft-versus-host
disease
Phlebitis (veins in
the liver up to
one-month post)
Acute: Chemotherapy
Immunotherapy
Targeted therapy
Radiation therapy- external beam
Stem cell transplant
Surgery (rarely, depending on the
organ of origin)
Nursing Actions:
Monitor for infection and indicators of
infection
Observe for pus, redness,
inflammation
Place patient on neutropenic
precaution
Prevent injury:
Conserve energy:
In case of stem cells, watch for
infection and bleeding until the body
starts producing white blood cellswatch for jaundice, abd pain, liver
enlargement, daily weights for fluid
retention)
Acute: Chemotherapy
Immunotherapy
Targeted therapy
Radiation therapy- external beam
Stem cell transplant
Surgery (rarely, depending on the
organ of origin)
Nursing Actions:
Monitor for infection and indicators of
infection (lung crackles, cough, urinary
frequency or urgency, oliguria, lesions
of the skin)
Observe for pus, redness,
inflammation
Place patient on neutropenic
precautions
Prevent injury
Conserve energy
In case of stem cells, watch for
infection and bleeding until the body
starts producing white blood cellswatch for jaundice, abd pain, liver
enlargement, daily weights for fluid
retention)
0Leukemias:
originates from hematopoietic system
CML
Chronic
Result of low
blood counts:
fatigue, weakness,
Age over 50 years
Genetic conditions,
CBC
Coag times
Biopsy of bone marrow
Pancytopenia-decre
ase in WBC, RBC,
platelets
Acute:
Chemotherapy in phases
Colony stimulating medications-
myeloid
leukemia
dizzy, SOB, fever,
infections that
don’t go away or
keep coming back,
bruising easily,
bleeding
(nosebleeds or
gums)
Weight loss
Loss of appetite
Bone or joint pain
Enlarged lymph
nodes
Enlarged thymus,
liver, spleen
involving
Philadelphia
chromosome
Radiation exposure
Confirmation of mets:
xray, CT scan, PET
scan, bone scan
Low H/H
Low platelets
High WBC
Chronic
ALL
Acute
lymphocytic
leukemia
Result of low
blood counts
fatigue, weakness,
dizzy, SOB, fever,
infections that
don’t go away or
keep coming back,
bruising easily,
bleeding
(nosebleeds or
gums)
Weight loss
Loss of appetite
Bone or joint pain
Enlarged lymph
nodes
Enlarged thymus,
liver, spleen
Down’s syndrome
and some other
genetic disorders
can be a risk factor
Family history
Radiation or
chemical exposure
CBC
Coag times
Biopsy of bone marrow
Confirmation of mets:
xray, CT scan, PET
scan, bone scan
Low H/H
Low platelets
High WBC
Previous cancer
therapy
Acute
Skin cancers:
originates from the skin
Basal Cell
Small, waxy
nodule with
superficial blood
vessels,
well-defined
borders
Erythema and
ulcerations
Occupational history
of chemical
carcinogens
History of severe
skin injury or
immunosuppression
therapy
Exposure to UV light
Chronic skin
inflammation, burns,
scars
Fair complexion
many moles
Family history
Biopsy (punch, shave, or
excisional)
(neutropenia)
Thrombocytopeniasecondary to
disease or
treatment
Hypoxemia- due to
anemia
Bone Marrow
Transplant
Complications
Failure of stem cells
to engraft
Graft-versus-host
disease
Phlebitis (veins in
the liver up to
one-month post)
stimulates the production of leukocytes
Targeted therapy
Bone marrow transplantation- using
autologous cells or donor cells
Pancytopenia-decre
ase in WBC, RBC,
platelets
(neutropenia)
Thrombocytopeniasecondary to
disease or
treatment
Hypoxemia- due to
anemia
Bone Marrow
Transplant
Complications
Failure of stem
cells to engraft
Graft-versus-host
disease
Phlebitis (veins in
the liver up to
one-month post)
Acute: Chemotherapy in phases:
induction (place client in remission),
consolidation (cure by eradicating
cells), maintenance (prevent relapse),
reinduction (put the client back in
remission)
Colony stimulating medicationsstimulates the production of leukocytes
Targeted therapy
Bone marrow transplantation- using
autologous cells or donor cells
Nursing Actions:
Monitor for infection and indicators of
infection
Observe for pus, redness,
inflammation
Patient on neutropenic precautions
Prevent injury
Conserve energy: encourage rest,
nutrition, fluids, sleep, plan activities as
appropriate
In case of stem cells, watch for
infection and bleeding until the body
starts producing white blood cellswatch for jaundice, abd pain, liver
enlargement, daily weights for fluid
retention)
Nursing Actions:
Monitor for infection and indicators of
infection (lung crackles, cough, urinary
frequency or urgency, oliguria, lesions
of the skin)
Observe for pus, redness,
inflammation
Place patient on neutropenic
precautions
Prevent injury:
Conserve energy:
Living in higher
elevations or close
to the equator
Age 50 years or
older
Squamous
Slough / Scab like
appearance
*More likely to
metastasize over
basal cell* otherwise
similar.
Melanoma
Irregular shape
and borders with
multiple colors
Occupational history
of chemical
carcinogens
History of severe
skin injury or
immunosuppression
therapy
Exposure to UV
Chronic skin
inflammation, burns,
scars
Fair complexion
Presence of many
moles
Family history
Living in higher
elevations or close
to the equator
Age 50 years or
older
Can be from new
moles or existing
moles
Can come from
intestinesanywhere skin has
pigment
Itching, cracks,
ulcerations,
possible bleeding
Biopsy (punch, shave, or
excisional)
Lymph node
biopsy/dissectionlooking for spread of
cancer
Skin abscesses and
cellulitis
Encourage adequate nutrition and fluid
intake
1. The nurse is teaching a nursing student how to care for a client with acute lymphocytic leukemia
(ALL) on neutropenic precautions. Which of the following actions would require follow up with the
student?
a. The student encourages the client to eat more fresh fruits and vegetables
b. The student requires all visitors to wear a mask
c. The student is diligent in handwashing prior to procedures
d. The student ensures that the client bathes each day
Rationale: Fresh fruits and vegetables put the client at risk for developing infections. The other options
decrease the risk of infection.
2. The nurse understands that to limit radiation exposure, the following must be considered
a. Waves, placement, personnel
b. Time, distance, shielding
c. Medication and biologic response
d. Contamination, hazards, PPE
Rationale: Patients with radiation precautions should be placed in private rooms, 6 feet away from the
source of radiation, no more than 30 minutes a day (cumulative), and no visitors with rapidly dividing cells
(pregnant women and children).
3. The nurse is caring for a client with a positive finding of basal cell carcinoma following a shave biopsy
of a skin lesion. The client asks, “Does this mean that I have cancer?” The best response by the nurse is
a. “Don’t worry, basal cell carcinomas are highly treatable.”
b. “Let’s wait and see what your doctor has to say about this.”
c. “We will need to exercise the lesion to obtain clear margins.”
d. “The test confirmed the presence of cancerous cells.”
Rationale: The nurse should only address the information that is for sure, not make assumptions on
treatment.
4. The nurse is caring for a client receiving chemotherapy through their Groshong port when they start
to complain of pain at the insertion site. Which of the following nursing interventions
would be priority?
a. Ask the client to rate their pain on a scale of 0-10
b. Flush the site with 20 mL of Normal Saline
c. Aspirate and remaining fluid from the line
d. Apply heat to the site of extravasation
Rationale: Immediately stop the medication and remove any excess from the line/skin. Assessment of
pain follows this action when using vesicants. Heat may encourage absorption of the medication
5. The nurse is administering cortisone to a client with cancer to depress the immune system. This
treatment would be an example of
a. Biologic therapy
b. Targeted therapy
c. Hormonal therapy
d. Gene therapy
Rationale: Biologic or immunotherapy creates an environment that is inhospitable to cancer cells or
attacks the cells directly by use of cytokines, vaccines, antibodies etc. Targeted therapy targets specific
receptors that are important for cell growth (ie kinase inhibitors). Gene therapy introduces new genetic
material, and is being researched.
6. The nurse is caring for a client diagnosed with colon cancer who is experiencing anorexia. The most
appropriate nursing action would be to
a. Serve food in isolation to encourage focus
b. Select moist, bland foods
c. Use diversional activities as appropriate
d. Recommend a food diary to track calories and fluids
Rationale: food should be served in a pleasant environment, with gentle encouragement. Moist bland
foods are best for mucositis, esophagitis, etc. Diversional activities are for N/V.
7. The nurse is caring for a client with a diagnosis of lung cancer and a history of thoracic radiation. The
client is experiencing cough, fever, and night sweats. The nurse suspects
a. Pneumonitis
b. Pulmonary fibrosis
c. Tuberculosis
d. Empyema
Pneumonitis is a risk of thoracic radiation, exhibiting those symptoms. Pulmonary fibrosis may happen,
but at a late stage. TB and Empyema are not risks of radiation
8. The nurse is caring for a client that received chemotherapy 36 hours ago. The client complains of
weakness, muscle cramps, diarrhea, and has an elevated potassium level. The nurse also anticipates
finding
a. Hyperuricemia
b. Hypercalcemia
c. Hypophosphatemia
d. Thrombocytopenia
Rationale: The client is experiencing tumor lysis syndrome, which manifests 24-28 hours after chemo.
Cell destruction leads to increased levels of K+ and uremic acid. You would expect calcium to be low,
phosphate to be high. Platelets are not typically affected.
9. A nurse is caring for a malnourished, nauseated client with osteosarcoma undergoing
chemotherapy. Which of the following interventions is the best option to include in the plan of
care?
a. Increase the client’s red meat consumption
b. Serve meals as warm and odorous as possible
c. Administer ondansetron 30 minutes prior to meals
d. Encourage the client to drink large volumes of oral fluids during a meal
Rationale: Red meat can increase nausea, as can warm meals that produce an odor. Large volumes of
fluids can fill the client up so that they eat less. Ondansetron (Zofran) will help alleviate nausea.
10. You are assessing a patient who has received chemotherapy. Which of the following would be of the
most concern and require further evaluation?
a. Dry mucous membranes and reports of thirst
b. Areas of ecchymosis on various sites of the body
c. Reports of intense fatigue and feelings of exhaustion
d. Hair loss on scalp and dryness of the skin
Rationale: A, B, and D are expected complications and require treatment, but are not a priority. B
indicates a risk for bleeding.
11. Which of the following needs to be reported immediately to a health care provider?
a. White vaginal discharge 2 weeks after internal radiation for cancer of the cervix
b. Mild diarrhea after 3 weeks of external radiation for cancer of the cervix
c. A fever of 100.8 after the third week of chemotherapy
d. No bowel movement for 2 days after colonoscopy
Rationale: C is the most priority. Any fever in patients receiving chemo can indicate a serious infection
due to neutropenia. It is often low grade in these clients because their immune response is so
suppressed, so any fever can indicate a serious complication.
12. Shortness of breath, facial edema, trunk and upper extremity edema, neck and chest vein
distention, cough, hoarseness, and stridor are the major clinical signs indicative of which
Oncologic emergency?
a. Cardiac tamponade
b. Superior vena cava syndrome
c. Disseminated intravascular coagulation (DIC)
d. All of the above
Rationale: These are signs of superior vena cava syndrome
Cellular Regulation - Genetics
●
●
●
Genetics/genomics
○ It all started with Mendel and
the pea plants…
○ Genetics vs Genomics
■ Can you think of
diseases that have a
link to a person’s
genes and their
environment?
Genetic mutations
○ Any change in the usual DNA
sequence
○ What is altered? What do cells
make again?
○ How are mutations acquired?
Genetic disorders
○ Inherited genetic disorders are either autosomal dominant or autosomal
recessive, or x-linked.
■ Autosomal dominant
■ Autosomal recessive
■ X-linked
■ Multifactorial inherited conditions
○ Multifactorial genetic disorders
■ Small inherited variations + environmental factors= multifactorial genetic
disorders
● Example: BRCA1 or BRCA2 gene mutation
○ Genetic testing
■ Ethical and social issues- what are the dangers?
■ What does a positive test mean?
■ Genetic Information Nondiscrimination Act (GINA)?
○ Gene Therapy
■ Experimental technique used to treat or prevent disease
■ Replaces a mutated gene with a healthy gene, inactivates a mutated
gene, introduces a new gene that fights disease
■ Requires a vector to deliver the gene for use
○ Stem Cell Therapy
■ Stems cells are unspecialized
■ Two types:
● Embryonic
● Adult
●
●
●
●
■ Where does this have potential for use?
Nursing management
○ Be knowledgeable on the influence of genetics on health and illness
○ Help make decisions related to genetic issues
○ Collaborate with the healthcare team to involve a genetic nurse or genetic
counselor
○ Advocate for family to facilitate access to genetic resources, provide or reinforce
accurate information to a genetic disease or concern
○ Tailor information based on culture, religion, knowledge level, literacy, and
preferred language.
Nursing management: Thoughts for consideration
○ Genetic testing may raise psychological and emotional issues
○ Knowledge of carrier status could influence decisions for career, marriage,
childbearing
○ Ethical concerns regarding who should know the results of a genetic test
○ Possible discrimination
Nursing management: family history
○ Free genetic test!
○ What information is pertinent?
■ Relatives/relationships
■ Disease that affects gender
■ Age of onset
■ Combinations of diseases
Muscular dystrophy
○ X-linked recessive
○ Progressive loss of muscle mass and strength, muscle wasting
○ Most common: Duchenne Muscular Dystrophy
○ Average life expectancy: 27 years old
○ Symptoms
■ Progressive disease: Increasing muscle weakness, leading to respiratory
compromise and heart failure
■ Frequent falls
■ Difficulty rising from a lying or sitting position - Trouble running and
jumping
■ Stiff or loose joint / Muscle pain
■ Learning disabilities
■ Delayed growth
■ Trouble swallowing.
■ Heart problems, such as arrhythmia and heart failure (cardiomyopathy).
■ Curved spine (scoliosis).
■ Breathing problems.
○ Diagnosed with
■ Muscle biopsy
■ Enzyme assay - CPK
●
●
■ Genetic testing
○ Treatments
■ Medications: Corticosteroids, beta blockers and ACEs to help heart
function
■ PT, exercise, increasing ventilation assistance, mobility aids, braces, etc.
■ Heart and lung function monitoring
Turner syndrome
○ X chromosome is missing, or partially missing: female only
○ Commonly diagnosed prenatally or in infancy based on signs and symptoms
○ Symptoms
■ Slowed growth
■ No growth spurts at expected times in childhood
■ Adult height significantly less than might be expected for a female
member of the family
■ Failure to begin sexual changes expected during puberty
■ Sexual development that "stalls" during teenage years
■ Early end to menstrual cycles not due to pregnancy
■ For most women with Turner syndrome, inability to conceive a child
without fertility treatment
○ Treatments
■ Hormonal (missing “sex x”)
● Estrogen
● Growth hormone
■ Treat heart defects
Tay-Sachs
○ Autosomal recessive
○ Absence of an enzyme that breaks down fatty substances (gangliosides)
■ Progressively destroys neurons in brain/spinal cord
■ Build up to toxic levels in the child’s brain
○ Loses muscle control
■ Blindness, paralysis,death
○ Starts showing symptoms at 6 months
■ s/s loss of motor skills- not hitting crawling, sitting up, turning over
■ Exaggerated reactions with loud noises
■ Seizures
■ Vision, hearing loss
■ Cherry red spots in the eyes
■ Muscle weakness
○ Risks: eastern and central European Jewish communities, French Canadian,
Amish community in Pennsylvania, Cajun community of Louisiana
○ Blood test / EEG / CT
○ Care:
■ Medications for anti seizures, CPT (chest physiotherapy) for lung
infections
●
●
●
●
■ Feeding tubes with trouble swallowing or aspiration
■ Physical therapy
Klinefelter’s syndrome
○ Extra chromosome X (more female characteristics), primarily boys
■ Not inherited, random
○ Small testes do not produce much testosterone
○ Risk of developing breast cancer, systemic lupus erythematosus (SLE)
○ May have learning disabilities
Fragile X
○ X-linked, dominant
○ Range of developmental problems
■ Learning disabilities
■ Cognitive impairment
■ Hyperactive
○ Altered Physical Characteristics
■ Elongated face
Huntington's
○ Autosomal dominant
○ Inherited defect in a single gene
○ Mutation in gene alters the production of a protein, huntingtin (enlongates)
○ Progression varies - Time to death is 15-20 years after emergence of symptoms
■ Symptoms generally present: age 30-40
■ Chorea that progresses - Involuntary jerking or writhing movements
■ Muscle problems, such as rigidity or muscle contracture (dystonia)
■ Slow or abnormal eye movements
■ Impaired gait, posture and balance - Injuries related to falls
■ Difficulty with speech or swallowing
■ Cognitive decline/personality changes
■ Pneumonia or other infections
○ Complications related to the inability to swallow
○ Depression with risk of suicide
Immune thrombocytopenic purpura
○ Idiopathic vs immune
○ What is thrombocytopenia?
■ Platelets are coated in antibodies-> spleen sees them as foreign->
macrophages destroy
○ Can run in families, but inheritance pattern is unknown
○ Activated: after virus/vaccine
○ Symptoms
■ Platelets < 150,000
● Life threatening < 20,000
■ Major complication: bleeding
■ Petechiae
■ Purpura (skin and mucous membranes)
■
■
○
○
Epistaxis
Bleeding gums
○ (NOT Splenomegaly)
Treatment
■ Suppress the immune response
● Give steroids before giving platelets
■ Surgery
Nursing Management:
■ Monitor labs
■ Minimize risk for injury
■ Care for skin
■ I&Os
■ Minimize bleeding risk
■ Educate