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Medical-Surgical – Adult Unit 2Burn – Adult Unit 2 Week 1 – 9/14/18 BURNS Superficial = 1st degree burnEquivalent to sunburn Redness on skin Skin is still intact but some discoloration Ex: hot stove, straightener Partial Thickness = 2nd degree burn Blistering Full Thickness = 3rd Most severe burn BURN CLASSIFICATION Characteristic 1st 2nd 3rd AppearanceDry, no blisteringBlistering, weepy, edematous Dry, leathery, may be edematous ColorPink/rednessWhite/ pink/ redWhite to charred, black eschar Pain(Mild) painfulMost painful type of burn Little to no pain, past the nerves DepthEpidermis Epidermis, post-dermis, *can dip down to subQ* Subcutaneous, deep as muscle and bone, goes through all layers ** NEED TO CONSIDER HOW MUCH PERCENTAGE OF THE BODY THE BURN COVERS**BURN CARE “Running feeds the fire”0345440Question: Someone presents with a 2nd degree burn, and they as the nurse, what do I do?Answer: run it under cool water, use non-adhesive covering, remove anything that may be touching the burn, once something is stuck in the burn leave it and the hospital will remove it00Question: Someone presents with a 2nd degree burn, and they as the nurse, what do I do?Answer: run it under cool water, use non-adhesive covering, remove anything that may be touching the burn, once something is stuck in the burn leave it and the hospital will remove itTrying to suffocate the fire DO NOT USE ICE on a burnLeads to vasoconstrictionPrevents healingSuggest not to put anything on a burnRun it under COLD water Chart 62-4 on pg. 1815Running fans flamesRun cool water over burn brieflyNo iceDon’t use cold cloth soaks longer than few minRemove any restrictive itemsMay leave open to air or better to cover with non-adhesive clean & dry cloth to prevent infection & decrease painRULE OF NINES2024830113849To estimate the percentage Total Body Surface Area (TBSA) of burnArm = 9% forearm & upper arm, and front & back Ex: Anterior/Posterior forearm = 4%Face = total face front and back 9% Anterior = whole front 18% Posterior = whole back 18% Legs = whole front and back 18% 00To estimate the percentage Total Body Surface Area (TBSA) of burnArm = 9% forearm & upper arm, and front & back Ex: Anterior/Posterior forearm = 4%Face = total face front and back 9% Anterior = whole front 18% Posterior = whole back 18% Legs = whole front and back 18% 0176530Question: Client burnt chest, front of right leg, front of right arm, & part of face. Calculate %Answer: 24.75 – is this bad? yes, very bad burn of chest = 9%, front of right leg = 9%, front of right arm = 4.5%, part of the face = 2.25% 0Question: Client burnt chest, front of right leg, front of right arm, & part of face. Calculate %Answer: 24.75 – is this bad? yes, very bad burn of chest = 9%, front of right leg = 9%, front of right arm = 4.5%, part of the face = 2.25% PHYSIOLOGIC CHANGES Burns <20% TBSA produce primarily a local response.Burns >20% may produce a local and systemic response and are considered major burnsSystemic response includes release of cytokines and other mediators into systemic circulationFluid shifts and shock result in tissue hypoperfusion and organ hypofunctionSimilarities to shock PHASES OF BURNS Emergent is still developing Acute phase is still very dangerous Very long, painful and tedious rehabilitation phase IMMEDIATE/EMERGENT PHASE OF BURN CARE (first 24hrs)Capillary permeability Losing fluid from capillaries BREATHING IS NUMBER ONE CONCERN HEREImpaired gas exchange or Ineffective airway clearanceDo we have a patent airway?Worrying about smoke inhalation ARDS any inflammation of the airways Consider location of burn & smoke inhalationFriction, electrical, radiation burn Concerned if the burn is near the face, chest or lungs Make sure there is no swelling behind there Fluid & electrolyte shiftsEdema AND risk for hypovolemic shockGreatest fluid loss in first 12 hrs, decreased COAdminister IV Fluids (LR most common); consider albumin, plasmaLACTATED RINGERS MOST COMMON Fluid resuscitation WORRIED ABOUT HYPOVOLEMIC SHOCK Albumin Can potentially help to pull third spacing fluid back into vasculature, has protein pulling ability Watch UO (titrate fluid to UO)What is the main electrolyte imbalance?POTASSIUM HYPERKALEMIA When cells are damaged they leak potassium High amount of serum potassium level Issue with THIRD SPACING in one sense you are loosing a lot of fluidgetting a lot of capillary permeability getting fluid in vascular areas where we can’t use it How do we know if the fluid is working? Blood pressure Unirary output HypothermiaRisk for temperature imbalance Skin keeps the body warm so when skin is burned you lose heat Specialized blankets Can’t use regular blankets b/c they could stick to the patient Acute painAdminister pain medsINTERMEDIATE/ACUTE PHASE OF BURN CARE May begin as soon as 48-72 hours after acute stageCirculatory overloadFluid shifts back into cells from interstitial areas & kidneys begin to excrete large volume (diuresis) If the patient has poor heart or kidney function, you will have trouble getting rid of fluid you just poured into them Risk for infection & wound careLots of wound care Continue to watch VS, UO, airway (ARDS may have delayed development)Diuresis Lots of urinary output Airway is still a worry here Delayed ARDS Delayed edema How do you know if there was smoke inhalation?HoarsenessSinged nasal hairsSooty sputumErythema/blistering of lipsREHABILITATION PHASE OF BURN CARE Risk for infectionMay require further debridementDebridement = wound care May require skin graftingTake skin from one area of the body to put healthy skin on a burn area Can use skin from fish because it is high protein content Imbalanced nutrition: what type of diet do they need? high protein, high caloric need, vitamins Need more protein because of cell growth Need carbohydrates, more calories Acute painDuring wound care Assess pain, give pain and wait 30 mins Impaired physical mobilityPrevent contracturesWhere the body resets in an abnormal formationLot of passive range of motion Pain will limit mobility Ineffective copingInterrupted family processesDeficient knowledgeEducate on the process of healing Psychosocial copingLooking at yourself after a burn Compartment Syndrome Muscular swelling Cuts off circulation Often have to open up the facia to allow the muscle to swell up fasciotomy 0176530Question: A client presents to the unit with full-thickness electrical burns on his torso and legs. In the first 24 hours, what is he at risk for?Fluid volume overloadHypernatremiaHypokalemiaDysrhythmiasAnswer: D – fluid LOSS in the first 24hrs, tend to see hypernatremia, hyperkalemia, high potassium leads to arrhythmias 0Question: A client presents to the unit with full-thickness electrical burns on his torso and legs. In the first 24 hours, what is he at risk for?Fluid volume overloadHypernatremiaHypokalemiaDysrhythmiasAnswer: D – fluid LOSS in the first 24hrs, tend to see hypernatremia, hyperkalemia, high potassium leads to arrhythmias Endocrine – Adult Unit 2Week 2 – 9/14/18 0349250Question: A client’s lab results return with an elevated TSH and decreased thyroid hormones. Which s/sx does the nurse expect?Exopthalmos (eyes bulge forward) SweatingWeight lossConstipationAnswer: D constipation decreased thyroid hormoneSweating is a metabolic action that is FAST, fast metabolism hyperthyroidism, exophthalmos gravis disease, constipation slow metabolism HYPOthyroidism SLOW metabolism HYPERthyroidism FAST metabolism 0Question: A client’s lab results return with an elevated TSH and decreased thyroid hormones. Which s/sx does the nurse expect?Exopthalmos (eyes bulge forward) SweatingWeight lossConstipationAnswer: D constipation decreased thyroid hormoneSweating is a metabolic action that is FAST, fast metabolism hyperthyroidism, exophthalmos gravis disease, constipation slow metabolism HYPOthyroidism SLOW metabolism HYPERthyroidism FAST metabolism Chapter 52: Assessment and management of patients with endocrine disordersTHYROID DYSFUNCTIONHigh/Low Thyroid Hormone High/Low Adrenal High/Low ADH High thyroid = TSHHypothyroid = trigger an increase TSH HYPOTHYROIDISM – ADDISON’S DISEASEThink: slowOften feel coldDry skinTreat with levothyroxine (Synthroid)Expect HRGiving thyroid hormone Could risk making someone have HYPERthyroidism HYPERTHYROIDISM – GRAVES DISEASEThink: fastExophthalmosMay require surgical treatment0176530Question: A client’s lab results return with an elevated TSH and decreased thyroid hormones. This is likely due to brain damage from an MVA.TrueFalseAnswer: B – false, Could lose the feedback loop from brain damage, you could see cases where there isn’t an imbalance, but sometimes you see that both are low or both are high, if TSH is low, then T3/T4 should be high, with a brain damage you would see both up or both down because there is damage to pituitary 0Question: A client’s lab results return with an elevated TSH and decreased thyroid hormones. This is likely due to brain damage from an MVA.TrueFalseAnswer: B – false, Could lose the feedback loop from brain damage, you could see cases where there isn’t an imbalance, but sometimes you see that both are low or both are high, if TSH is low, then T3/T4 should be high, with a brain damage you would see both up or both down because there is damage to pituitary Usually your thyroid is high or low is that there is an issue with the thyroid gland itself Thyroid gland is producing too much or too little ADRENAL GLAND Adrenal gland is above the kidneys Aldosterone “salt” activated RAAS system, retain sodium Retain sodium and water Catecholamines Cortisol ” sweet” helps trigger glucoseAllows for normal inflammatory system Stress hormone Sex hormones “sex” MNEUMONIC: “Sweet, salty, sex”Addison’s (Primary adreno-cortical Insufficiency)Decrease aldosterone Na+ (hyponatremia) H2O (hypotension)Fluid levels go down, can lead to low BP K+ (hyperkalemia)Decrease cortisol Risk for infection glucose (hypoglycemia)Fatigued Treatment: ADD sodium and water Cushing’s (Primary adrenal hyperplasia) Opposite Aldosterone BP Blood sugar Risk for infection K+ EITHER WAY YOU CAN END UP WITH DYSRHYTHMIAS*Note: Either hyperkalemia or hypokalemia, both pose a risk for what?*Name some high potassium foods. : It is important for the nurse to monitor a client with Addison’s disease for the development of which condition?Urinary retentionDysrhythmiasGlycosuriaWater intoxicationAnswer: B 0Question: It is important for the nurse to monitor a client with Addison’s disease for the development of which condition?Urinary retentionDysrhythmiasGlycosuriaWater intoxicationAnswer: B ADH ABNORMALITY (AKA VASOPRESSIN) ADH = Anti-diuretic hormone ADH is helping to keep fluid in SIADH = Syndrome of Inappropriate ADH Hyponatremia from too much water retentionDilutional hyponatremia BP Treatment: vasopressin antagonistDI = Diabetes Insipidus Looks like DM but is not related to blood sugar, it is related to lots of urine Polydipsia = intense thirstPolyuria = high urinary output (UO)Can’t hold enough fluids Decrease in ADH Usually damage to pituitary or hypothalamus, causing decreased ADHRisksElectrolyte imbalance Dehydration Treatment: nasal vasopressin (ADH) How do you know if tx is working?Relax on urination Urine looks clear Measure urine specific gravity Relax on thirst 00Question: The nurse cares for a client with diagnosed DI. Provider prescribes vasopressin. Nurse determines med is effective if which observation is made?Client’s 24-hr UO is 5000 mLClient’s weight decreases by 4 lbs in one weekClient c/o thirstClient’s urine specific gravity is 1.015Answer: D, not A because that is a lot of urine, B they are losing volume, if we want them to get better you should see weight gain Question: The nurse cares for a client with diagnosed DI. Provider prescribes vasopressin. Nurse determines med is effective if which observation is made?Client’s 24-hr UO is 5000 mLClient’s weight decreases by 4 lbs in one weekClient c/o thirstClient’s urine specific gravity is 1.015Answer: D, not A because that is a lot of urine, B they are losing volume, if we want them to get better you should see weight gain – 1.03 normal urine specific gravityDiabetes – Adult Unit 2Week 2 – 9/14/18 NORMAL GLUCOSE LEVELS VariableNormal PrediabetesDiabetes Fasting plasma glucose level (no intake for 8 hrs)70-99 mg/dL100-125 mg/dL≥126 mg/dLRandom blood sugar (depends when you last ate)<125 mg/dL or <140 mg/dL post- prandial≥200 mg/dLHemoglobin A1C level*<5.7%5.7-6.4%≥6.5%*aka- glycosylated hemoglobin, reflects average BS level for past 2-3 months, what %of your hgb is coated with sugar (glycated)Baseline insulin = basal insulin TYPES OF DIABETES Type 1 Diabetes Type 2 DiabetesAbsence (or decrease) of insulin from pancreasTx: insulin, may use pump common cause of hypoglycemia: physical activity without foodDawn Phenomenon & Somogyi Effect (also with DM II)Lack of insulin production or insulin resistanceTx: first oral diabetic meds, may need insulin, tooDawn Phenomenon Blood sugar tends to be higher in the morning Somogyi Effect Take insulin before bed and then wake up with high blood sugar Basal = long-acting (GLARgine, lantus) Insulin drip = check blood glucose every hour Increase risk for infection if increased blood sugar If you are going to give insulin, then make sure that there is food, breakfast near Blood sugar shoots up from illness or surgery Cortisol release that naturally happensSliding scales Scale is not only for patients without diabetes but also for patients that have diabetes ORAL DIABETIC MEDICATIONS Causes beta cells in pancreas to produce more insulin = glyburide (Diabeta)Decreases glucose production in the liver = metformin (Glucophage)CautionHepatotoxic! Check LFTs nephrotoxic! AST, ALT Check renal labsInsulin cannot be taken orally because will be digested in stomach & intestines before reaching bloodstreamSubQ or IV DIABETIC SICK DAY When someone is sick, their blood sugar increases For diabetic patients, when you are sick from something other than diabetes Continue to check BS q3-4hContinue meds as prescribedIf BS > 300 mg/dL, notify providerToo high!! Continue eating, but adjust intake if feeling anorexia* Important DM education even on healthy days: try not to skip meals*If you cannot eat meals, you will need about 50 grams of carbohydrate every 4 hours.Increase exercise Low-carb diet 00Question: A diabetic client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if sheUses an electric blanket at night Dresses in extra layers of clothing Applies a heating pad to her feet Takes a hot bath morning and eveningAnswer: B – wear more clothes, A – loss of sensation, neuropathy, heat may not feel it, risk of burns, D – dry skin in hypothyroidism Question: A diabetic client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if sheUses an electric blanket at night Dresses in extra layers of clothing Applies a heating pad to her feet Takes a hot bath morning and eveningAnswer: B – wear more clothes, A – loss of sensation, neuropathy, heat may not feel it, risk of burns, D – dry skin in hypothyroidism 00Question: The nurse recognizes which symptoms are characteristic of impending diabetic ketoacidosis (DKA)?Hyperreflexia, peripheral neuropathy, numbnessHot, dry, flushed skin, increased thirst, rapid pulseHot flashes, severe hunger, bradycardiaProfuse diaphoresis, headache, bradycardiaAnswer: B - extremely high blood sugar, rapid pulse, high HRQuestion: The nurse recognizes which symptoms are characteristic of impending diabetic ketoacidosis (DKA)?Hyperreflexia, peripheral neuropathy, numbnessHot, dry, flushed skin, increased thirst, rapid pulseHot flashes, severe hunger, bradycardiaProfuse diaphoresis, headache, bradycardiaAnswer: B - extremely high blood sugar, rapid pulse, high HRHYPOGLYCEMIA Will progress to Loss of Consciousness if left untreatedLethargic Which is best?SUGAR can they swallowOrange juicePeanut butter crackers PROTEIN Injectable sugar glucagon IV Dextrose 50% Dextrose DIABETIC COMPLICATIONS Hyperglycemia-induced vascular damage: This metabolic abnormality has been shown to cause an overproduction of reactive oxygen species.This in turn damages the endothelial layer of blood vessels, causing inflammation and leading to macro- & microvascular damageRetinopathySmall microvasculature in eye can get damaged Diabetic blindness NephropathyDamage to the kidneys NeuropathyFeet Loss of sensation Infection Could step on something, and not realize it and could get infected diabetic ulcer Gangrene Hyperglycemia itself increases risk of bacterial infectionRenal – Adult Unit 2Week 3 – 9/17/18 ANATOMY OF NEPHRON Glomerulus is a bunch of capillaries Often where we discuss kidney failure CAUSES OF ACUTE KIDNEY INJURY (AKI) Prerenal = lack of blood Hypovolemia HypotensionObstruction or vasoconstrictionIntrarenal = damage to the kidneys InflammationNephrotoxic or ischemic damagePostrenal = obstruction of urine Obstruction in ureters, bladder or urethra NAME COMMON NEPHROTOXIC AGENTS Antibiotics Alcohol NSAIDS Contrast dye 00Question: A nurse is caring for a client in ARF/AKI. The nurse should expect to use glucose and insulin to treat:HypernatremiaHyperphosphatemia HyperkalemiaHypercalcemiaAnswer: C – hyperkalemia, it allows for potassium to be reabsorbed into the cell, renal failure have to consider potential electrolyte imbalance Question: A nurse is caring for a client in ARF/AKI. The nurse should expect to use glucose and insulin to treat:HypernatremiaHyperphosphatemia HyperkalemiaHypercalcemiaAnswer: C – hyperkalemia, it allows for potassium to be reabsorbed into the cell, renal failure have to consider potential electrolyte imbalance CAUSES OF CHRONIC KIDNEY FAILURE AKI Diabetes mellitus Hypertension AMOUNT OF URINE Anuria = <50mL in a DAY Oliguria = < 0.5mL/kg/hr Polyuria When is urine output TOO LITTLE? < 30 mL per hour is insufficient urine output Worried about renal failure 2000mL per day Question: How many kg is someone who is 150lbs? Answer: 68.04kg 70kg pt, want to know if they are urinating enough per hour 70kg (0.5mL) = 35mL an hour Question: Person is 85kg, want to know how much urine they urinated in 8hrs. 850mL in an 8hr shift. Answer: per hour 106mL/hr KNOW kg to pounds 1kg = 2.2lbs SOMETHING IN THE URINE Bacteriuria Infection Hematuria RBC in urine Kidney stones could have blood in urine but not as serious Proteinuria Protein in urine TIMING IN THE URINE Incontinent More common in elderly Frequency BPHUrgencyInflammation Hesitancy BPHAZOTEMIA & UREMIA Uremia Urine in the blood CONCERN IF BUN OR CREATININE IS HIGHBUN influenced by: dehydration & protein BUN = protein Creatinine higher in: males & increased weight &age Worries us a little more Muscle RatioIf one is elevated and the other is not, might be a different issue and not kidney Both eleveated then possible renal failure Creatinine clearance used to calculate GFRGlomerulus FiltrationRate (GFR) GFR < 90 RENAL LABS Know normal diagnosticsBUN 7-18 mg/dLCreatinine 0.6 to 1.2 mg/dLSpecific gravity of urine: 1.003 to 1.030 (water is 1)Urine s/g is 1.06 concentrated urine UO-52899281221Question: A client with ESKD is admitted with these findings: 190/110, HR 122, RR 32, JVD, bibasilar crackles. Which nursing diagnosis should receive the highest priority?FearUrinary RetentionSelf Care DeficitFluid Volume ExcessAnswer: D0Question: A client with ESKD is admitted with these findings: 190/110, HR 122, RR 32, JVD, bibasilar crackles. Which nursing diagnosis should receive the highest priority?FearUrinary RetentionSelf Care DeficitFluid Volume ExcessAnswer: DContents of urineHEMODIALYSIS CATHETER CONTINUOUS RENEAL REPLACEMENT THERAPY TRANSPLANT LIST Alcohol or drug use Co-morbidities INTERNAL ARTERIOVENOUS FISTULA AND GRAFT Feel for thrill Listen to bruit No BP or IV on fistula arm PERITONEAL DIALYSIS >10% ESKD in USWhy PD vs HD?Culture in US is more to use hi-tech machines Physician control Warm diasylateDuration of exchangeSigns of peritonitisInflammation of cavity Positioning to empty diasylatePositioning if SOB NURSING PROCESS: HOSPITALIZED PATIENT ON DIALYSIS Protect vascular access: signs of potential infection, do not use for blood pressure or blood drawsCarefully monitor fluid balance, IV therapy, accurate I&O (Look at supplemental article on Canvas)Relationship of Hct to fluid levelsS/sx of uremia and electrolyte imbalanceMonitor cardiac/respiratory status carefullyRespiratory b/c of fluid Cardiovascular medications held prior to dialysisSometimes you hold the meds so their BP doesn’t drop too much before dialysis -635175895Question: Why do CKD patients develop anemia?Loss of ability to activate vitamin DLoss of ability to produce erythropoietinBlood loss through damaged glomerulusIncreased fluid retention dilutes the bloodAnswer: B making RBC00Question: Why do CKD patients develop anemia?Loss of ability to activate vitamin DLoss of ability to produce erythropoietinBlood loss through damaged glomerulusIncreased fluid retention dilutes the bloodAnswer: B making RBCRENAL DIET Reduced SodiumReduced PotassiumReduced PhosphorusWeakening in the bonesLead to leaks Pulling calcium out of the bonesLevel calcium levels normal May reduce ProteinWhat foods contain phosphorus?Diary Sodas Dr. Pepper MANAGEMENT OF PATIENTS WITH URINARY DISORDER UTI URINARY TRACT INFECTION (UTI) Lower UTI (ascending)CystitisProstatitisUrethritisUpper UTI (less common)Pyelonephritis Risk FactorsHygiene Sex Cranberry juice better to have cranberry pills b/c they don’t have sugar Research is inconclusive NURSING PROCESS: THE CARE OF THE PATIENT WITH A UTIFlank pain, burning upon urination, frequency, nocturia, incontinence, hematuriaAbout half are asymptomaticAssociation of symptoms with sexual intercourse and personal hygieneGerontologic considerationsAssessment of urine: urinalysis and urine cultureLimited efficacy, but cranberry juice found to acidify urine, which may decrease incidence of infectionCaution with irritants: bubble bath, nylon underwear & scented toilet tissuePt to void 2-3 hrs, drink 8-10 glasses H2O/day, UO min of 0.5mL/kg/hr (eg. 70 kg is 150 lbs = 35mL/hr), no temp-45085203179Question: A postoperative client hasn’t been able to void. The provider has ordered a Foley catheter. Nurse can facilitate insertion by asking client toInitiate stream of urineBear down as if trying to voidTurn to the sideHold the labia or the shaft of the penisAnswer: BQuestion: A postoperative client hasn’t been able to void. The provider has ordered a Foley catheter. Nurse can facilitate insertion by asking client toInitiate stream of urineBear down as if trying to voidTurn to the sideHold the labia or the shaft of the penisAnswer: B-67945320Question: A pt with an indwelling urinary catheter is suspected of having a UTI. The nurse should collect a urine specimen for culture & sensitivity by:Empty contents of drainage bag, wait 10 min & take specimen from drainage bagClamp drainage tube below the post, using sterile needle, aspirate a specimen of urine via the portSwab the tubing where the catheter connects to the drainage bag with Betadine, disconnect the tubing, and collect a specimen of urine directly from the catheterTake a random specimen of urine from the drainage bagAnswer: B Question: A pt with an indwelling urinary catheter is suspected of having a UTI. The nurse should collect a urine specimen for culture & sensitivity by:Empty contents of drainage bag, wait 10 min & take specimen from drainage bagClamp drainage tube below the post, using sterile needle, aspirate a specimen of urine via the portSwab the tubing where the catheter connects to the drainage bag with Betadine, disconnect the tubing, and collect a specimen of urine directly from the catheterTake a random specimen of urine from the drainage bagAnswer: B URINARY INCONTINENCENot necessary to have when older An underdiagnosed and underreported problem that can have significant impact on the quality of life and decrease independence, which may lead to compromise of the upper urinary systemUrinary incontinence is not a normal consequence of agingRisk factors: refer to chart 55-6Stress incontinenceLaughing SneezingCoughingPregnancy URINARY CALCULICalculi (stones) in the urinary tract or kidneyMost common urological problem in adultsCauses: may be unknownMore common in malesDepend on location and presence of obstruction or infectionAcute Pain: Flank pain (& possible hematuria & systemic signs)Diagnosis: KUB, urinalysis, and stone analysis; strain all urine and save stonesTREATMENT CALCULIEncourage increased fluid intake (Goal UO 3-4L/day, colorless urine)AnalgesicMay give diuretic or antibiotic, as wellMay try alpha blocker: tamsulosin (Flomax)Larger require lithotripsy (extracorporeal shock wave lithotripsy)Hematuria s/p procedurePain as stone fragments passCalcium oxalate stones commonMay need to restrict oxalate, but continue with Ca because it binds to oxalate in GI system to remove itEat normal protein levelsFoods with oxalateSpinach POTENTIAL SITES OF URINARY CALCULI NEPHROSTOMY TUBE 00Question: The nurse is caring for a client who underwent percutaneous lithotripsy. The nurse should instruct the client to:Limit oral intake for 1-2 weeksReport presence of fine, sandlike particles through nephrostomy tubeNotify provider about cloudy or foul-smelling urineReport bright pink urine 24h after procedureAnswer: C – Question: The nurse is caring for a client who underwent percutaneous lithotripsy. The nurse should instruct the client to:Limit oral intake for 1-2 weeksReport presence of fine, sandlike particles through nephrostomy tubeNotify provider about cloudy or foul-smelling urineReport bright pink urine 24h after procedureAnswer: C – 00Question: Nursing interventions for patient who is not voiding, place in order of first actionAssist client with urinal or to bedside commode or bathroomEncourage fluid intake or increase IVFAssess with bladder scannerOffer client straight catheterNotify providerQuestion: Nursing interventions for patient who is not voiding, place in order of first actionAssist client with urinal or to bedside commode or bathroomEncourage fluid intake or increase IVFAssess with bladder scannerOffer client straight catheterNotify provider BENIGN PROSTATIC HYPERPLASIA Benign Prostatic Hyperplasia50% by age 60, 90% by 85Normal function of prostate?PSA levels with enlargementProstate specific antigen Concern prostate cancerMed tx: Alpha blocker E.g. Tamsulosin (Flomax)5-alpha reductase inhibitor E.g. finasteride (Proscar)SymptomsDifficulty initiating Nocturia Hesitancy Frequently Urgency Incomplete fully voidingWeak stream/dribbling TURPTransurethral resection of the prostateInsertion site: tip of penis, through urethra to trim away excess prostrateTURP: ? Dribbling after catheter removal? S/p TURP irrigation: ANATOMY OF LIVER LIVER FAILURE More than 70% of liver parenchyma may be damaged before liver function tests become abnormalLiver converts ammonia to urea, therefore: ammonia Confusion from ammonia Proteins are manufactured in the liver, therefore: albuminGluconeogenesis, therefore: glucose Damaged liver cells release enzymes:AST (norm = 10 – 40) ALT (norm = 7 – 56) If these liver enzymes get elevated, concerned about liver cells being damaged Increased prothrombin timeIncreased risk for bleeding ~40% deaths from liver disease attributed to alcohol ASCITIES Backing up of blood that leads to fluid being pushed out into interstitial space Clinical Presentation & Nursing InterventionsOften caused by destruction of hepatocytes, which causes backflow of blood into hepatic portal vein, causing HTNMeasure abdominal girth daily * catch early ascites*Daily weightLiver and heart function Ineffective breathing pattern….why?As the fluid increases it pushes on diaphragm Paracentesis ASTERIXIS“Flapping tremor”Sign of hepatic encephalopathyAbnormal function of motor center in brain ENCEPHALOPATHY Looks similar to alcohol intoxication or withdrawalBut as ammonia and glucose , can progress to comaEarly symptoms may be mild, such as mental fogginessTests:Serum Ammonia (AA broken down in liver, NH3 formed, unable to convert to urea without liver)EEGLFTsTreatment:Cephulac (lactulose) is used to treat constipation, but draws ammonia from the blood into the colon where it is then removed from body (oral or enema)BLEEDING OF ESOPHAGEAL VARACIESOccurs in about one third of patients with cirrhosis and varicesFirst bleeding episode has a mortality rate of 30% to 50%Manifestations include hematemesis, melena, general deterioration, and shockMelena = blood in the stool Patients with cirrhosis should undergo screening endoscopy every 2 yearsNursing intervention: Consider swallowing difficulty with both food & medsSofter foods CUTANEOUS MANIFESTATIONS Jaundice HyperbilirubinemiaBilirubin Normally:Hgb breaks down to bilirubin, binds with bile in liver, conjugated (soluble), eliminated in feces & excreted in urine as urobilinogenBilirubin is excreted both in feces and urine Abnormal: see dark urine, light stoolClay color stool Fat in stool b/c no bile to breakdown fat Bile = water + salt + cholesterol + bilirubin to emulsify fatPruritusItching Also itch with uremia, toxins on the skin Salt accumulation Due to bile salt accumulationNursing interventions or education?Keep skin well moisturized Baby oil or mentholated lotion (cooling, external analgesic)Hot showers/baths and powder can dry out skin furtherItch responds best to coldKeep short nailsAlso: calamine, antihistaminePalmar erythema (mottling of palms)Spider angiomas (red, branching lesion on trunk)HEPATITIS Viral hepatitis: a systemic viral infection that causes necrosis and inflammation of liver cells with characteristic symptoms and cellular and biochemical changes. Nonviral hepatitis: toxic and drug induced – usually leads to acute liver failureAcetaminophen – 4g or 4000mg max dose Symptoms:Fever- Dark urineFatigue- Clay-colored BMN/V & abd pain- JaundiceKnow the differences of Heps Hep AHep BHep CMode of transmissionFecal-oral, poor sanitation, waterborne or foodborneMost commonly through sex, also mother to baby during birth, sharing needles, needlestick, direct contact with blood Most commonly through sharing needles, also mother to baby during birth, needlestick, but sex infrequent*No vaccine*OutcomeUsually mild with recovery in couple weeks; no carrier state(avg of 65 cases/yr in NYC)Acute treated with rest & nutrition; Chronic may require meds; more serious than Hep AMajority are chronic, leading indication for liver transplant in US (along with cirrhosis)* New treatments with anti-virals! (no/less interferon)A & E = vowels = fecal-oral Hepatitis DOnly persons with hepatitis B are at riskBlood and sexual contact transmissionLikely to develop fulminant liver failure or chronic active hepatitis and cirrhosisHepatitis ETransmitted by fecal–oral route,Incubation period. 15 to 65 daysResembles hepatitis A; self-limiting, abrupt onset, not chronicCIRRHOSIS Destruction of hepatocytes with fibrotic regeneration; “scarring of the liver”Caused by inflammation (e.g. viral hepatitis) or toxins (e.g. alcohol or acetaminophen)00Question: The nurse identifies which diet best meets the needs of the client newly diagnosed with cirrhosis?High in calories plus vitamin supplementsHigh in protein and carbohydratesHigh in calcium and low in fatHigh in iron and low in salt’Question: The nurse identifies which diet best meets the needs of the client newly diagnosed with cirrhosis?High in calories plus vitamin supplementsHigh in protein and carbohydratesHigh in calcium and low in fatHigh in iron and low in salt’Answer: B – wasting EtOH WITHDRAWL ~5% progress to Delerium Tremens with loss of GABA inhibitory NTTremors or SeizuresAgitation Hallucinations & Mood disturbancesTachycardia and HTNSweatingCareful not to over sedate (usually Ativan)Can take up to 4 daysNONALCOHOLIC FATTY LIVER DISEASE Lipids accumulate in the hepatocytes Nonalcoholic steatohepatitis (NASH) is the more extreme form of NAFLD because of inflammation that can lead to cirrhosis “scarring”Liver failure symptomsReversible with lifestyle changeLIVER BIOPSY AND TRANSPLANT For liver biopsy:May give Vit K pre-opPosition client on left side for 1-2 hrs s/p biopsyLiver is able to regenerateFor transplant: Documented sobrietyTake immunosuppressant for life to prevent rejectionSigns of rejection are liver failure signsFive-year survival 75%Exam TopicsNursing Intervention Prioritization Topics BurnEndocrineDiabetesHepatic (more focus) Renal (more focus) Hematological – Adult Unit 2Week 3 – 9/21/18 COMPOSITION OF BLOOD Hematocrit Looks at RBC count High HCT 36287534260850Dehydration (BUN elevated also dehydration – if just BUN is elevated that is a sign of dehydration but if BUN and creatine are elevated could mean kidney failure) Lower HCTExcess fluid Fluid overload Ratio of RBC to plasmaNormal Ranges of HCT Men 40-54%Women 37-47%Hemoglobin (Hgb) Hgb is O2 carrying capacity of bloodNormal Ranges of HgbMen 13-18 g/dLWomen 12-15 g/dLLow Hgb <6-8 consider blood transfusion RBC (actual # RBC in 100mL blood): Men 4.6-6.2 million/mm3Women 4.2-5.4 million/mm3SICKLE CELL ANEMIA Hemolytic anemia: Hgb 6-9Extreme activity, especially in warm weather, can lead to dehydration and increased sickling, as well as cold weather can affect perfusion Hypovolemia3352800-21045700Dry mucous membranesRisk of infectionOften times pts have to go for blood transfusionsH.O.P.Hydration Oxygenation PainSickle cell pain Ischemic pain (same as heart attack pain) Struggle to manage the pain A lot of the times patients come in with pain, but they may not look like they are in pain, and they know a lot about their pain and what pain medications work and may ask for specific medications and providers may think they are drug seekersGENETICS OF SICKLE CELL ANEMIA Autonomic Recessive 2786743520337Heterozygous Carrier Father 00Heterozygous Carrier Father For people from African descent, one copy of sickle cell can actually be beneficial because it can protect against malaria, however, two copies of sickle cells will lead to sickle cell anemia -464502123690Heterozygous CarrierMother 00Heterozygous CarrierMother HSHNHSHS HSHS HNHNHS HNHN HN 25% have normal hemoglobin 25% will have sickle cell disease50% will be carriers (bold = carriers) SCD EXACERBATION = VASOOCCLUSIVE CRISIS Incidence underestimatedMany people can die of stroke from this Acute pain episode vs crisisEnlarged spleen (role of Spleen from Marisa: )ANEMIA Signs:DOE = dyspnea on exertion Tachycardia = compensation DizzyPallorHow does this compare to Pernicious anemia? PN (peripheral neuropathy) Nerve pain that is tingly B – vitamins Need B12 to convert mature RBC as a co-factor, you can make RBC but not mature RBC Energy vitamin Intrinsic factor = produced through lining of GI factor which allows us to absorb B12Need to be given as an injection To treat iron deficiency: Ferrous sulfate & Iron-rich foodsTo treat iron toxicity: Desferal (deferoxamine)NUTRITION FOR ANEMIA High Iron (consider vegetarians)Beans and peas (legumes)Dark, leafy greens Dried fruitRed meat, pork, poultry, and seafoodHigh Vitamin C (esp important for plant-based non-heme iron)CitrusTomatoesStrawberriesPeppersPapaya & mangoLeafy greens (esp kale)2709331848062Question: A spouse of a client diagnosed with pernicious anemia asks why Vitamin B12 can’t be given in pill form. Which response by the nurse is best?“Your spouse’s symptoms of deficiency are quite severe & large doses can only be given by injection.”“Your spouse’s stomach doesn’t secrete the necessary substance for B12 to be absorbed orally.”“Is your spouse afraid of needles?”“The intramuscular route is the fastest way for the B12 to be absorbed.”Answer: B 00Question: A spouse of a client diagnosed with pernicious anemia asks why Vitamin B12 can’t be given in pill form. Which response by the nurse is best?“Your spouse’s symptoms of deficiency are quite severe & large doses can only be given by injection.”“Your spouse’s stomach doesn’t secrete the necessary substance for B12 to be absorbed orally.”“Is your spouse afraid of needles?”“The intramuscular route is the fastest way for the B12 to be absorbed.”Answer: B 270510261620Question: The nurse counsels a client with iron-deficiency anemia. The nurse determines teaching is effective if the client selects which menu?Broiled fish, green vegetables, and milkFried chicken, yellow vegetables, and fruit juiceFlank steak, green leafy vegetables, and prunesGrilled cheese, creamed soup, and tomato saladAnswer: C0Question: The nurse counsels a client with iron-deficiency anemia. The nurse determines teaching is effective if the client selects which menu?Broiled fish, green vegetables, and milkFried chicken, yellow vegetables, and fruit juiceFlank steak, green leafy vegetables, and prunesGrilled cheese, creamed soup, and tomato saladAnswer: CBroccoliPOLYCYTHEMIA VERA Increases RBC hyperviscosity (blood too thick) Increase hematocrit >55%Blood moves slowly, increased vasodilation dark, flushed face & itchingHTN = high BP Remove blood, avoid ironConsidered a cancer of bone marrowCan get DIC THROMBOCYTOPENIC PURPURA Excessive destruction of plateletsS/sx: purpura bruising (blood bruise),easy bleeding Often idiopathic, autoimmune*Know thrombocytopenic precautions*SYSTEMIC LUPUS ERYTHEMATOUS (SLE) AutoimmunePresentationInflammatory Butterfly rash comes across the bridge of the nose and cheeks Primary concernKidney failureSkin concerns Sunscreen Corticosteroids risk for infection Infection prevention Daily temperatures Hand hygiene CARBON MONOXIDE POISONING COOdorlessColorlessMore common in the winter heating elements, where you are burning fuel in an enclosed space Any combustion (any carbon-based fuel source mixed with oxygen) Power outages Generators Cars Car exhaust Start your car up with the garage open CO vs O2Body has an affinity for CO more than O2PresentationDrowsy Foggy Headache Cherry red mucous membranes/skin Pulse Ox SpO2 will still look normal CO-oximeter Blood test to find how much CO in blood Percentage of carboxy hemoglobin CO + Hgb Treatment Flood body with LOTS of oxygen 100% non-rebreather mask Hyperbaric chamber BLOOD 327660014986000Order of steps Type & Cross 2 units PRBC’s (packed RBC) 2 RN’s Verify patient ID Order Verify type Sign together Prime bloodVital Signs Give BLOOD Verify patient ID Order Verify type Cannot leave the room Signs of transfusion reaction Pain (CP) Fever Rash/itch STOP INFUSION IF ANY REACTION, CALL THE PROVIDER Risk for fluid overload careful with rate, go slow to avoid fluid overload 00Question: Which blood type is the universal receiver?O+O-A+A-B+B-AB+AB-Answer: F Universal donor = O- 0Question: Which blood type is the universal receiver?O+O-A+A-B+B-AB+AB-Answer: F Universal donor = O- A = A antigen B = B antigen AB = A & B antigen Most are Rh+ (extra antigens on the outside) RH- will not have proteins on the side If you have Rh- then you can only take Rh- THROMBOCYTOPENIA Overall reduction in Platelets Normal 150-400, <150 is technically thrombocytopenia, only start holding meds at 100Main concern: How do we prevent bleeding?Bruising Soft bristle toothbrush ShavingAvoid contact sportsFlossASA or NSAIDSWear closed shoesAvoid constipation straining IV sites Know meds that affect plateletsPlavix = hold if platelets lowAspirin = hold if platelets low Melena = digestive bleedingOccult Frank, red blood Oncology – Adult Unit 2Week 3 – 9/21/18 CANCER IN THE U.S., 2018 What is cancer?In US2nd common cause of death15.5 million Americans with Hx of CA alive in 2016$87.8 billion est. direct medical cost in US (2014)Uninsured substantially more likely to be diagnosed at later stage ?Many reasons unknown but there are established causesLifestyle:Non-modifiable:External factors:≥10years between exposure and cancer Rates for populations other than white and black may be underestimated due to incomplete information on race/ethnicity in medical records. 7 WARNING SIGNS OF CANCER - C.A.U.T.I.O.N C – Change in bowel or bladder habits.A – A sore that does not heal in a normal amount of time U – Unusual bleeding or discharge.T – Thickening of breast tissue or a lump.I – Indigestion and/or difficulty swallow O – Obvious changes to moles or warts.N – Nagging cough.PREVENTABLE - CANCER 42% estimated to be potentially avoidableAll cancers caused by what could be preventable?20% of all cancers dx in US caused by combination of excess body weight, physical inactivity, excess alcohol consumption, and poor nutritionInfectious agentsHPV, Hep B and C, HIV, H. pyloriExcessive sun exposure – 5 million skin cancer cases / yr CANCER TREATMENT – SURGICAL THERAPY PreventionAt-risk patients (e.g. BRCA +)Prophylactic removal of organs to reduce the incidence (e.g. Breast tissue)Usual sites of regional spread may be removedCure and controlRemove only as much tissue as necessary and spare normal tissueFollowed by chemotherapy or radiation therapySupportive and palliative careCure or control not possibleSupportive care includes:Insertion of gastric feeding tubePlacement of central venous access deviceProphylactic surgical fixation of bones at risk for pathologic fracturePalliative care: decreasing tumor burden to decrease pain or effects caused by encroachment of tumor on vital organs S/P MASECTOMYEmpty drain reservoir 2x/dayOk to use affected arm, but nothing strenuousAxillary area should not use for BP (concern for lymphedema) Should you exercise it?Do not lift heavy objects Keep the limb still moving to prevent atrophy of muscle, clotting Radical vs simpleModified radical most common, all breast tissue + axillary lymph nodeWhat is the danger?Lymphedema How do we prevent?Compression Swelling elevate it above the heart CHEMOTHERAPY Chemotherapy is extremely toxic! It has to be in order to kill the cancer… but because of this, it can also lead to DNA mutations and ultimately cause cancer in healthy individuals. Special equipment has to be worn, and waste needs to be disposed of properly. We also have to be VERY careful with administration- avoid extravasation, use central lines, be very picky about veinsKill rapidly dividing cells Skin cells Immune cells GI cellsOral/mucous membranes Central vascular access device (VAD) administrationPlacement in large blood vessels- most commonly enters the superior vena cavaIncludes: port-a-cath, PICC lineFrequent, continuous, or intermittent administrationCan be used to administer other fluids (blood, electrolytes, etc.)Effective against dividing cellsCause of many side effects related to chemocancer cells escape death by staying in G0 phase (resting phase)As tumors get bigger, more cells become inactive and convert to G0Classified by: Molecular structure Mechanism of actionTwo major categories:Cell cycle phase nonspecificCell cycle phase specificTypically given in combinationChemotherapy is systemic, meaning it works throughout the entire body (excluding in most cases the CNS). It works by killing of the rapidly dividing cells, which is what causes most side effects- nausea/vomiting due to GI cell destruction, hair loss, nail death, mouth sores, etc.Chemotherapies are classified by their structure and mechanism of action, some work on a specific portion of the cell cycle and some don’t. RADIATION One of the oldest nonsurgical methods of cancer treatment50% of all cancer patients will receive radiation therapy at some point in their treatmentRadiation is the emission of energy from a source and travels through space or some material Damage to skinLung tissue and heart tissue (putting other tissue at risk) Total doses divided into fractions Typically delivered once a day for 5 days a week for 2 to 8 weeksSymptom of radiation or treatment of cancerFatigue Radiation is used to treat a carefully defined area of the bodyNot a primary treatment for systemic diseaseMay be used by itself, or with chemotherapy or surgery To treat primary tumorsFor palliation of metastatic lesionsExternal radiation (teletherapy)Most common radiation treatmentPatient exposed to radiation from a megavolt machineInternal radiation (brachytherapy)Implantation or insertion of radioactive materials into or close to tumorMinimal exposure to healthy tissueCommonly used in combination with external radiationPatient is emitting radioactivityPutting a little block of radioactive in the body BRACHYTHERAPY Internal radiation (implants)High grade Lots of radiation Low gradeMuch lower quantity Can have visitors limit time Life-long dose Slowly leaves the body Urine, feces & linen are not radioactiveLimited time in roomBed rest with implantMust wear radiation badge? (dosimeter)Encourage client to do self-careEnema before cervical radioactive implantNo pregnant or immunocompromised visitorsNURSING MANAGEMENT DURING RADIATION Skin reactionsGenerally progressive as treatment dose accumulatesPrevent infectionSoftest, non-stick dressing Avoid constricting garments, harsh chemicals, and deodorantsHelp patients deal with hair lossPositioning Pain management Prescribe lotion NURSING MANAGEMENT FOR EXTERNAL RADIATION CAREWash gently with lukewarm water & mild soap, washcloth too roughNo powders, ointments on area (only prescribed vit A/D ointment ok)Don’t expose to sun or heatPat dry, wear soft clothingTry not to touchWhen would you cover? RENAL COMPLICATIONS AKIHTNElectrolyte disorders (very common); can be overall loss from N/V & diarrheaChemotherapy-induced diarrhea could lead to which acid/base disturbance? (metabolic acidosis)Hyponatremia common in solid tumorModerate 120-129, severe <120SIADH most commonHypokalemia common in nonsolidPET SCAN PET = positron emission tomographyIV Radioisotope used to assess nodules for malignancyMeasures extent of glucose metabolismBlood glucose level must be norm before testing <130Takes 45-60 min for tracer to absorb into bodyApprox 90 min start to finish, will have to lie flat on narrow table for 15-30 minProduces scan with “hot spots”Can display abnormal metabolic changes in tissue, including regional blood flowMore accurate than CT, but equivalent to invasive procedures (such as thoracotomy for lung CA)Can even be superimposed onto CT & MRI filmsNo food or fluid 4-6 hrs before scanBut encourage fluid s/p to eliminate radioisotopes through urine (or feces)Decay quickly & do not harm bodyNursing intervention = check blood sugar before they go for PET Scan MANAGEMENT OF SIDE EFFECTS Stomatitis, mucositis, esophagitisAssessmentPre-medication Avoid irritating foodsOral rinses with salineTopical anesthetics (viscous lidocaine, Magic Mouthwash, etc.)Dry mouth Nausea and vomitingEncourage intake when possibleAnti-emetics, pleasant smellsOndansetron (Zofran) HCl 6mg PO q6h: 30 min prior to start of chemoAnorexiaMonitor weightSmall, frequent meals high in protein/caloriesFood diary Diarrhea Anti-diarrhealsFluid intake at least 3 L/dayConstipationStool softeners, high-fiber foods, increase fluidsIncrease activity as toleratedHepatotoxicityMonitor LFTsAnemiaMonitor hgb/hctGive Fe and erythropoietin (hormone of RBC) Blood transfusionsLeukopeniaMonitor WBCs, neutrophilsMONITOR FOR FEVER!Avoid large crowds or those with infectionsAdminister WBC growth factorsThrombocytopeniaLook for signs of bleeding (Petechiae, ecchymosis)Watch platelet countsBlood transfusionsAlopeciaCope with loss: wigs, hair pieces, scarvesDiscuss self-imageScalp cooling caps Radiation skin changesDry and moist desquamation (skin sloughing/flaking off)Chemo skin changesAvoid sun exposureCreams/LotionsHemorrhagic cystitisInflammation of blood, bloody urineEncourage increased fluid intake for 2-3 daysMonitor for urgency, frequency, and hematuriaAdminister cytoprotectant agents and hydrationReproductive dysfunctionDiscuss this possibility with patients prior to treatmentOffer sperm/ova banking if applicableNephrotoxicityMonitor BUN and creatinineAlkalinize the urine with sodium bicarb or allopurinolIncreased ICP Monitor neuro statusPeripheral neuropathyNumbness/tinglingMost often in hands/feetMeds, PT, Ice gloves, stop/reduce therapy, gabapentinCognitive changes (“chemo brain”)Fogginess PneumonitisMonitor for dry, hacking cough, fever, exertional dyspnea Pericarditis/MyocarditisMonitor for dyspnea CardiotoxicityMonitor EKG and ejection fractionsHyperuricemiaMonitor uric acid levelsAllopurinolFatigueAssess for reversible causesEncourage rest when fatigued, and pace activities with energy levelANOREXIA & CACHEXIA Anorexia = Decreased appetite What can we do for them? What are your favorite foods? Ensure Hard candy to help nausea Meds? Cachexia = complex metabolic syndrome associated with late stage illness, characterized by muscle loss, often with fat loss (wasting)Weight loss >5% or BMI < 20STOMATITIS Examine client’s mouth for blisters, sores or drainageWhy does this happen?Rapidly dividing cells in the mouth What do patient’s struggle with most?Dry mouth How can we help them? Mouthwash 00Question: The home care nurse visits a client undergoing external radiation for treatment of lung cancer. It is MOST important for the nurse to include which of the following interventions in the client’s plan of care?Use a washcloth to gently cleanse the irradiated areaApply cream to the irradiated area dailyApply sunscreen to irradiated area if exposed to sunUse patting motion to dry irradiated areaAnswer: CQuestion: The home care nurse visits a client undergoing external radiation for treatment of lung cancer. It is MOST important for the nurse to include which of the following interventions in the client’s plan of care?Use a washcloth to gently cleanse the irradiated areaApply cream to the irradiated area dailyApply sunscreen to irradiated area if exposed to sunUse patting motion to dry irradiated areaAnswer: CNEUTROPENIA = LEUKOPENIA Overall reduction in WBC and neutrophil countNeutrophils fight bacterial infectionsMain concern: How do we prevent infection?No sushi Unpat cheese Nurse/visitor mask Prophylactic antimicrobials Q72h-96h change IV site and tubing Cat liter No fresh flowers Private room, well cleaned, handwashing, restricted visitors, no fresh fruit or vege, only essential invasive proceduresReverse isolationNeutrophils < 1500 cells/mm3 = risk for infectionNote: <500 = serious riskNurses must be vigilant, inspect all sites that may serve as ports of entryLook for signs of infection around bodyNeutrophil < 500 mm3No working in garden or with houseplants, no fresh flowers, no cat litterNeutropenic FeverMaintain temp of 38 deg C (101.4 deg F)Pegfilgrastim (Neulasta)Colony stimulating factor to increase production of WBC in marrowCost a lot of money each injection is maybe $350Subcutaneous SE: Bone pain ................
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