Acute Respiratory Distress Syndrome Exam

Acute Respiratory Distress Syndrome Vent Modes Video – ●​ All vents are positive pressure ●​ Volume Control ○​ Set volume of air ○​ Pressurized air -> Air into lungs ○​ Pressure required will change from patient to patient, and breath to breath ○​ Ensure pt receives set volume of air each minute ○​ Settings: ■​ Tidal Volume (Vt) - Volume of air set to be delivered with each breath ■​ Freq/Resp Rate ( f RR): # of breaths per minute ■​ Oxygen Concentration (FiO2): .35-1.0 (35-100% ■​ Positive End Expiratory Pressure (PEEP): Constant pressure applied throughout expiration. * 5 cm H2O for “Physiologic” PEEP (5-20) ■​ Pressure Support (PS): Push of air to help pt with spontaneous breath. (5-20) * minimum of 8-10 ●​ Pressure Control ○​ Set pressure delivered ○​ Understanding is different from our natural intuition. ○​ Volume of air delivered will change from patient to patient and from breath to breath ●​ Monitoring ○​ Minute Ventilation (Ve): Amount of air delivered per minute. ■​ Ve = Vt x f ■​ 5-10 l/min ■​ Ve = CO2 Clearance ○​ Peak Insp. Pressure (Pip): Max pressure during inspiration. ■​ <35 ○​ Plateau Pressure (Pplat): Lung compliance, measure at end of inspiration with hold. ■​ Increase Pplat could mean problem with pts lung compliance ■​ < 30 ●​ Most Support -> Least Support: WOB ○​ Assist Control (AC, VC) ■​ Set: Vt, f, FiO2, PEEP ■​ No pressure support ■​ Spont Breath = Full Vt ■​ Can lead to excessive ventilation of tachypnea for non respiratory reasons ○​ Synchronized Intermittent Mandatory Ventilation (SIMV) ■​ Set: Vt, f, FiO2, PEEP, PS ■​ Spontaneous Breath = Pt. determines volume ■​ No spontaneous breaths = AC ■​ Allow pt to take over WOB over time ■​ Close observation of the pts to see how they are responding (physiologically and psychologically) ○​ Pressure Support ■​ Form of spontaneous breathing ■​ Set: FiO2, PEEP, PS ■​ No Vt or f ■​ Ve and WOB = Pt effort “Trial” before extubation ■​ 10/5 -> 5/5 ARDS Lecture Notes: ●​ ●​ ●​ ●​ A: Assault to pulmonary system. R: Respiratory distress D: Decreased lung compliance (stretch) S: Severe respiratory failure Surfactant creates surface tension -> there is a decrease in surfactant 25-40% mortality rate ●​ Occurs in alveoli ●​ Fluid enters alveoli ●​ Hypoxemia Three Hallmark Features 1.​ Bilateral patchy infiltrates on chest X-ray. “White Out” 2.​ No signs and symptoms of heart failure. Wedge pressure less than 15 indicates ARDS and not a cardiac issue. 3.​ No improvement in PaO2 despite oxygen delivery – refractory hypoxemia. Giving O2 but pulse oxygen is not coming up. Common Predisposed Factors Indirect (NOT LUNG) ●​ ●​ ●​ ●​ ●​ Sepsis (poor prognosis) Pancreatitis Burns Blood Transfusions (Multiple) Overdose Direct (LUNG) ●​ ●​ ●​ ●​ ●​ ●​ Pneumonia Aspiration – Impaired Swallowing COVID-19 Inhalation (Toxic Substances) Embolism Near Drowning *Both direct and indirect causes systemic inflammation. * Gram - Bacteria increase mortality. Three Phases Exudative – ●​ 24 hours post injury to 7 days ●​ Early changes of dyspnea and tachypnea resulting from the alveoli becoming fluid filled and from pulmonary shunting and atelectasis. ●​ Early interventions focus on supporting the patient and providing oxygen. ●​ Refractory hypoxemia ●​ Respiratory alkalosis -> Respiratory Acidosis (holding onto CO2) ●​ Dyspnea ●​ Decreasing breath sounds ●​ Normal to increased RR and HR Proliferative – ●​ +/- 14 days ●​ Increased lung injury leads to pulmonary hypertension and fibrosis. ●​ The body attempts to repair the damage, and increasing lung involvement reduces gas exchange and oxygenation. ●​ Multiple organ dysfunction syndrome can occur. ●​ Interventions focus on delivering adequate oxygen, preventing complications, and supporting the lungs. ●​ **Can still recover in this phase. ●​ ** Every patient will go through this phase. ●​ Increased respiratory distress ●​ Accessory muscle use ●​ Restless, apprehensive, agitated, mental sluggish ●​ Dry cough or frothy sputum ●​ Tachycardia ●​ Cool, clammy - perfusion ●​ Basilar crackles Fibrotic – ●​ ●​ ●​ ●​ ●​ ●​ 3 weeks Resolution of the injury is possible; if not, the patient either dies or has chronic disease. Fibrosis may or may not occur. Patients surviving ARDS usually have neuropsychological deficits. Obvious respiratory distress Tachypnea, accessory muscles, decreased mental acuity ●​ ●​ ●​ ●​ ●​ Tachycardia with arrhythmias (PVCs) Labile hypertension Pale, cyanotic Decreased breath sounds, basilar crackles, rhonchi Mechanical ventilation ** Ecmo is last resort Diagnostic Assessments ABGs Refractory hypoxemia Chest XRay ECG CT Image ECG Pulmonary capillary wedge pressure (PCWP) - (4-12) ○​ <18 Resp ○​ > 18 Cardio -> Not ARDS -> HF ●​ Sputum and blood culture ●​ Toxicology test - direct/indirect ●​ Serum Amylase - Pancreatitis ●​ ●​ ●​ ●​ ●​ ●​ ●​ Treatment ●​ Antibiotics and steroids ●​ Diuretics ●​ Respiratory Support ○​ Humidified O2 ○​ CPAP ○​ PEEP ○​ Suctioning ●​ Prone Position (Proning) ○​ Prone up to 12 hours/day ●​ Sedatives, benzos, general anesthesia, opioids, neuromuscular blocking agents ●​ Conservative Fluids 5 P’s – 1.​ P: Perfusion: a.​ Increase fluid volume w/o overloading, related to leaky capillaries. 2.​ P: Positioning: a.​ Proning and turn Q2 Positioning to decrease atelectasis and keep alveoli open. 3.​ P: Protective lung ventilation: a.​ Early ARDs, it can support adequate ventilation of O2 while decreasing work of breathing. 4.​ P: Preventing complications: a.​ DVTs b.​ Pressure ulcers c.​ VAP d.​ Nutrition 5.​ P: Protocol weaning: a.​ Either full vent or weaning – NO PARTIAL Interventions ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ Assess respiratory status every 2 hours or more often if indicated. Administer oxygen, monitor FIO2 levels. Check ventilator setting often Monitor VS, LOC Administer medications Proning, Semi-Fowler’s, high Fowler’s Rest breaks Monitor PCWP levels Monitor labs Record caloric intake Passive ROM exercises Skin integrity Endotracheal Intubation – ** Hyper oxygenate prior to intubation ** Each intubation attempt should take less than 30 seconds (preferably <15 secs) before needing to be stopped for delivery of additional oxygen ●​ Verify tube placement ○​ End-tidal carbon dioxide levels ○​ Chest XRay ○​ Bilateral breath sounds, no GI distention -> first thing ○​ Symmetrical chest movement ○​ *have half size up and down of tube ●​ Stabilize Tube ○​ Measurement of tube at lip ○​ Face clean, dry ○​ 2-person job ○​ Bite Block -> if they are fighting the tube ○​ Tape ○​ Secure it/measure it at the lip ○​ Document Endotracheal Nursing Care Assess: ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ Tube placement Cuff leak -> whistling air sound Breath sounds Chest wall movement VS/ABGs Prevent pulling/tugging -> restraints Administer sedation medications -> allows them to rest Skin care Positioning Mechanical Ventilation ●​ Positive Pressure Ventilators ○​ ET Tube or Tracheostomy (Ventilator) ●​ Noninvasive Positive Pressure ○​ Mask or Nasal Prongs (CPAP or BiPAP) ** Both generate pressure that drives gas flow to push air into the lungs - both have same goal ** Does not cure, just provides support. Mechanical Ventilation Settings/Terms ●​ ●​ ●​ ●​ ●​ ●​ Tidal Volume (VT) - 6 to 8 mL/kg of body weight Rate (breaths/min) - 10 to 14 Fraction of inspired oxygen (FiO2) - 21% to 100% Peak airway (inspiratory) pressure (PIP) Positive end-expiratory pressure (PEEP) - 5 to 15 cm H2O Flow Rate - 40L/min Assist Control (A/CV) Mode ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ Preset rate and tidal volume Patient initiates and ventilator takes over Can cause hyperventilation and respiratory alkalosis Investigate and correct hyperventilation causes Sedation to decrease RR - the amount of breath and hyperventilation FULL VENT SUPPORT Every breath fully supported Cant be weaned by decreasing rate Risk for hyperventilation if agitated Synchronized Intermittent Mandatory Ventilation (SIMV) Mode ●​ ●​ ●​ ●​ YOU GET WHAT YOU GET AND CAN’T THROW A FIT Preset rate and tidal volume Patient initiates breath, tidal volume depends on effort Ventilator breaths synchronized ●​ ●​ ●​ ●​ ●​ ●​ Regular or weaning mode Can cause respiratory muscle fatigue PARTIAL VENT SUPPORT Vent synchronizes to support patient effort Patient takes own breaths between vent breaths Increased work of breathing vs CONTROL Bi-Level Positive Airway Pressure (BiPAP) Mode ●​ NPPV: Delivers a mixture of air and oxygen to the lungs via noninvasive interface. ●​ Examples: ○​ CPAP ○​ BiPAP ●​ Requirements ○​ Spontaneous breaths ○​ Intact respiratory drive ○​ Able to protect airway ○​ Useful in sleep apnea Nursing Care – *** PRIORITY – Maintain a patent airway position /placement of tube Document tube placement at lips (cm) Soft- wrist restraints Suction oral and tracheal secretions - PRN Suctioning/pausing ALWAYS have a resuscitation bag with face mask at bedside at all times Begin with assessing VS and breath sounds every 30 to 60 mins Breathing pattern in relation to ventilator cycle Reposition pattern in relation to ventilator cycle Reposition oral ET every 24 hours (or facility policy) Assess area around tube every 4 hours Assess cuff pressure every 8 hours (20-30 cm H2O) *Look and listen for signs of a leak ○​ Patient talking ○​ Air hissing ○​ Decreasing SaO2 ●​ Ventilator settings hourly ●​ Provide adequate nutrition ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ Possible Causes for Ventilator Alarms – ●​ Low-pressure Alarm ○​ Tube disconnection ○​ Tube displaced above vocal cords ○​ Underinflated cuff or ruptured cuff or leak in cuff ■​ Picking at sheets ■​ Fidgeting ○​ Ventilator malfunction ○​ Leak in ventilator circuitry (hole in tubing, cracked humidification jar) ●​ High-Pressure Alarm ○​ Increased air pressure/ decreased lung compliance (don't have the stretch) ○​ Biting tube ○​ Kinks in tubing ○​ Coughing, gagging, trying to speak (figure out why) ○​ Bronchospasm ○​ Pulmonary edema ○​ Pneumothorax Medications – ●​ ●​ ●​ ●​ ●​ Analgesics: morphine, fentanyl Sedatives: propofol, diazepam, lorazepam, midazolam, haloperidol Neuromuscular blocking agents: pancuronium, atracurium, vecuronium Ulcer-Preventing Agents: Famotidine, lansoprazole Antibiotics Mechanical Ventilator Complications – ●​ Cardiac ○​ Hemodynamic compromise ■​ Hypotension ■​ Tachycardia ■​ Cool, clammy extremities ■​ Decreased peripheral pulses ■​ Decreased LOC ■​ AVOID Valsalva Maneuver ○​ Fluid Retention ■​ I/O ■​ Weight ■​ Breath sounds ■​ Endotracheal secretions ●​ GI/Nutritional ○​ Stress Ulcers ■​ Alters nutrition status ■​ Risk for systemic infection ■​ Check GI drainage and stool for blood ■​ Administer preventive meds ○​ Malnutrition ■​ Consult dietician ■​ Enteral or parenteral feeding ■​ Cause of failing to wean off the vent ■​ Affects respiratory muscle and diaphragm ●​ Respiratory ○​ Barotrauma - by positive pressure ■​ Pneumothorax ●​ Stat XRay ●​ If not getting breath sounds and expansion on left side, could be tube displacement ■​ Subcutaneous emphysema ■​ Pneumomediastinum ○​ Volutrauma - by volume ○​ Ateletrauma - shear injury to alveoli ○​ Biotrauma - inflammatory response ○​ Oxygen toxicity ●​ Infection ○​ Ventilator-associated pneumonia (VAP) ○​ Ventilator Bundle Sets ■​ HOB 30 degrees ■​ Oral care facility policy ■​ Ulcer prophylaxis ■​ Preventing aspiration ■​ Pulmonary hygiene Weaning Methods – Patients ability for strong respiratory effort LOC within normal limits Normal ABGs Intermittent Mandatory Ventilation (IMV) ○​ Reduce ventilator breaths ○​ Allows patient to increase resp strength and endurance ●​ Pressure-support ventilation (PSV) ○​ Alone or in adjunct to IMV ○​ Preset burst of pressure during inspiration ●​ Spontaneous breathing trials ○​ Minimum pressure support ○​ CPAP ○​ T-Piece ●​ ●​ ●​ ●​ Nursing Considerations ●​ Observe for: ○​ Respiratory distress ○​ Fatigue ○​ Hypoxemia ○​ Cardiac arrhythmias ●​ Schedule to comfortably and realistically for daily regimen ●​ Avoid – Meals, baths, or lengthy therapeutic procedures - anything tiring ●​ Document length or trial and patients tolerance Extubation – 1.​ 2.​ 3.​ 4.​ 5.​ ●​ ●​ ●​ ●​ ●​ Explain the procedure (if awake) Hyperoxygenate and suction tube and oral cavity Rapidly deflate cuff and remove tube at peak inspiration Immediately instruct patient to cough Give oxygen, face mask or NC Monitor every 5 minutes Interventions to promote good gas exchange Observe for resp fatigue and obstruction Be prepared for everything!! Limit speaking - use incentive spirometer Oncology Emergencies, HIV/AIDs HIV — ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ Everyone who has AIDS has HIV infection; not everyone who has HIV has AIDS Is a virus, but acts as a parasite Viral cell invades a healthy cell, mutates it, and forces it to take over other healthy cells. AIDS is a progression of HIV. Opportunistic infections are occuring? They have AIDS Normal CD4+ T-Cells (Normal 800-1000) ○​ Lower the count = More likely to progress to AIDS Highest concentrations are in blood and semen. ○​ Sexual: Genital, Anal, or Oral ○​ Safer Sex Methods: Abstinence, monogamy, use of condom (not a guarantee) ○​ More easily transmitted male to female, than female to male, due to more surface area of mucous membrane in the female. ○​ Anal sex is MOST risky sex practice, whether hetero or homo, due to tearing of the mucous membrane of receiving partner ○​ Condom is LEAST effective method of protection Parenteral: Sharing needles, other equipment, contaminated w/ infected blood; receiving infected blood products. ○​ Proper cleaning of drug paraphernalia: fill and flush needle/syringe with clear water, then fill w/ household bleach and shake 30-60 seconds and rinse. ○​ Blood products: All donated blood in NA is screened for HIV antibodies. ■​ If antibodies are present, blood is discarded ■​ Slight risk remains due to the time period between HIV exposure and dev. of antibodies. ■​ Might use growth factors to increase products of blood or autotransfusion. Perinatal: From the placenta, maternal blood and/or body fluids during birth, or breast milk of infected mother. ○​ 25% risk of infecting infants if NOT on medication regimen. ○​ 8% risk of infecting infants if ON medication regimen. Health Care Workers: Needle sticks are the most common mode of transmission in HC. ○​ Best prevention is consistent use of standard precautions for ALL patients. ○​ If exposed, or possibly exposed, follow facility guidelines concerning PEP (post exposure prophylaxis) Testing – ●​ Testing for antibodies is important in prevention of transmission. ●​ All sexually active people should be tested. ●​ Pre and post-test counseling should be available for both education and support purposes. Stages – 1.​ STAGE ONE a.​ T-Cell Count > 500/cubic mm of blood, or at least 29% b.​ No AIDs defining illness - They have the virus, but it is not affecting them. 2.​ STAGE TWO a.​ T-Cell Count of 200-499/cubic mm of blood, or percentage between 14% and 28% b.​ No AIDs defining illness 3.​ STAGE THREE a.​ T-Cell Count < 200/cubic mm, or < 14% b.​ Higher T-Cell Count or %, with presence of AIDs defining illness 4.​ STAGE FOUR a.​ Confirmed HIV dx, but no information related to T-Cell count, %, or AIDs defining illness Progression to AIDs – ●​ ●​ ●​ ●​ Takes months to years, depending on how virus was acquired Blood transfusion: Quickly Single Sexual Encounter: Longer Influencing Factors: Nutritional status, other STD, Stress AIDS – ●​ Most North American cases are men who have sex with men, or IV drug users. ●​ Mortality of 60% for adults ●​ No cure AIDS: Diagnosis – ●​ HIV + ●​ CD4+ T-Cell Count of < 200 cells per cubic mm of blood ○​ We can check antibodies or if virus is in the blood ●​ Presence of opportunistic infection: infections caused by organisms normally found in environment that are usually suppressed by immune system) ○​ Organism is taking advantage of the opportunity because they do not have the immune system to squash it HIV/AIDS : Assessment – ●​ Monitored regularly for lab changes or opportunistic infections ●​ Age, gender, occupation, sexually active?, monogamous? protection used?, presence of infections?, how long since dx?, did the patient receive blood products 1978-1985 in the US?, hx of TB or hepatitis?, hx of clotting disorders?,any IV drug use? ●​ Assess level of knowledge of disease process, prevention, symptom management, treatment, resources, and transmission ●​ Psychosocial: Support system ? ADL’s ? Employment status, hobbies, living arrangements, financial resources ? insurance ? ●​ Lab Testing: ○​ Lymphocyte count ○​ CD4+ T-Cell Count ○​ Antibody Tests: Produced within 3 months of contracting infection (window period) ○​ ELISA (Enzyme-Linked Immuno-Absorbant Assay): Inexpensive and VERY accurate ■​ Patients serum is mixed with HIV in culture, if patient has antibodies, they bind to antigen ■​ First test to do on a patient ○​ Western Blot: Used to confirm ELISA test; detects serum antigens to 4 specific HIV antigens, and is positive if at least 2 antigens are detected. ■​ Expensive to perform ■​ Used as a second test ○​ Viral Load: Measures the presence of HIV viral genetic material in patients blood HIV/AIDS: Complications – ●​ Opportunistic Infections: Pose no threat to immunocompetent HC worker ○​ Pneumocystis Pneumonia (Fungal): Most common OI in HIV patients ■​ Dyspnea ■​ Tachypnea ■​ Persistent dry cough ■​ Persistent low grade fever ■​ Fatigue ■​ Weight loss ○​ Toxoplasmosis Encephalitis: Acquired through contact w/ cat feces or ingesting undercooked meat. Cook meat VERY well. Get someone else to change the litter box. ■​ Subtle AMS - start slowly, might not be noticed immediately ■​ Neuro deficits ■​ Headache ■​ Fever ■​ Difficulty with speech ■​ Unsteady gait ■​ Visual disturbances ■​ Seizures - Late ■​ Lethargy ■​ Confusion - Late ○​ Cryptosporidiosis: Intestinal infection ranging from mild diarrhea to severe wasting and electrolyte imbalance ■​ Presence of diarrhea ■​ Weight loss of over 5 lbs ○​ Candida Albicans: Fungal overgrowth of normal flora. ■​ Altered taste ■​ Mouth pain ■​ Difficulty swallowing ■​ Yellow-ish white plaques in mouth and throat ■​ Persistent vaginal itching and discharge in females ○​ Pneumonia (Bacterial): 2 or more within 1 year, by definition – this is when it would be considered an OI. Very common in AIDs patients. ■​ Chest pain ■​ Productive cough ■​ Fever ■​ Dyspnea ○​ Herpes Simplex Virus (HSV): Found in genital areas ■​ Numbness/tingling at the site up to 24 hours before blistering occurs ■​ Painful at site of lesions ■​ Fever ■​ Bleeding ■​ Enlarged lymph nodes in affected area ■​ Headache ■​ Fatigue ●​ Malignancies: Decreased immunity increases risk for cancers ●​ Endocrine: Gonadal dysfunction, adrenal insufficiency, Diabetes Mellitus, Increasing triglycerides and cholesterol, low testosterone, irregular menses, decreased muscle mass, libido changes, decreased energy HIV/AIDS: Additional Manifestations – ●​ AIDS Dementia Complex: Occurs in 70% of AIDS patients (cognitive dysfunction) - This is strictly cognitive/to do with the brain. This is caused by the virus itself. ●​ AIDS Wasting Syndrome: Not due to single factor (diarrhea, decreased metabolism, etc) ●​ Skin Changes: Dry, Itchy, Rashes ●​ Kidney Problems: 16 times higher for renal failure. Planning – ●​ Primary goal is to control the infection with antiviral medications in order to support pt’s own immunity, and obtain/maintain optimal health. Interventions – ●​ Immuno-support: bone marrow transplant, etc ●​ Enhance oxygenation: maintain gas exchange w/ adequate perfusion and decrease dyspnea ●​ Control pain to an acceptable level: NSAIDs, Lyrica, Elavil, Neurontin, hydrocodone, tramadol, codeine, dilaudid, fentanyl (determined by level and location of pain) ●​ Maintain optimal weight through nutrition/hydration ●​ Minimize confusion ●​ Support psychosocially, patient and family ●​ Minimize diarrhea to help maintain fluid/electrolyte balance ●​ Maintain skin integrity ●​ Medication Regimen: Antiretroviral Drugs ○​ Inhibit (slow) viral growth, but do not kill the virus ○​ Using just one (monotherapy) promotes drug resistance and does nothing to improve life span. ○​ HAART (highly active antiretroviral therapy) is used… combination of drugs ○​ Missed doses of medications contribute to drug resistance, so must be taken correctly 90% of the time. ○​ Once resistant to a drug, always resistant ○​ HAART is very expensive and involves multiple daily medication doses. ○​ Many have significant side effects ○​ IRIS (immune reconstitution inflammatory syndrome): detected early, anti-inflammatories & corticosteroids; NOT caught in time, can lead to death. Common for people with TB in the past. T4 Cells start to climb, a lot of T4 Cells start flooding the body as an immune response, surge of T Cells in the body causes a rapid inflammatory response, both at site and vascular structure. Will develop symptoms, chills and very high fever – diagnosis will go undetected initially. Patient needs to understand low grades and true fever. Joint pain and achiness more than usual. Is it different ?? ●​ Education ○​ Avoid exposure to disease processes (no large crowds) – Close exposure to multiple people. ○​ S/S of infectious process ○​ Nutritional plan and importance: no raw fish or rare meat, thorough washing of vegetables/fruits ○​ Medications: Regimen, expected outcome, adhere to medication regime 90% of the time for effectiveness, for life-time ○​ Precautions against transmission ○​ Skin care ○​ Continue social activities, as long as not too ill or too weak – do not want them to isolate, can lead to psychosocial issues ○​ Available resources: home health, hospice, support groups, counseling, etc. ONCOLOGY EMERGENCIES — 1:08 Cancer ●​ ●​ ●​ ●​ In civilized countries, cure rate > 68% Thousands above the 68% live > 5 years Regardless of tx type, cancer affects a person’s psychological and physical wellbeing Cancer does not just affect the patient, but also family and loved ones ●​ Can develop in any organ or tissue ●​ Destroys normal tissue ●​ Can cause death when metastasizes to vital organs Advanced Cancers: Complications – ●​ Reduced immunity and blood-producing functions ○​ Most often occur with leukemia and lymphoma ○​ Can occur in bone marrow ○​ S/S: ■​ Weakness ■​ Fatigue ■​ Impaired clotting ■​ SOB ●​ Altered GI structure and function ○​ Obstruction: Complete or partial ○​ Increased metabolic rate ○​ Liver: Disrupts metabolism, leading to malnutrition and death ○​ Anorexia - Loss in interest of eating/no desire to eat ○​ Cachexia - Wasting away d/t chronic illness ○​ Changes in taste = reduced appetite/food aversions ○​ False feeling of being full ●​ Motor and sensory deficits ○​ Bone ○​ Brain ○​ Nerve compression ●​ Decreased respiratory function ○​ Obstruction ○​ Lung capacity decreased ○​ Compression of vascular system Management – Facts: ●​ ●​ ●​ ●​ Purpose of treatment is to prolong survival time and improve quality of life Without tx, many patients will die within months of DX Might receive more than one type of tx Tx determined by type, location, severity, and overall health of patient Treatment Options: ●​ Surgery ●​ Radiation ○​ Purpose: destroy cancer cells ■​ Have minimal damaging effect on surrounding tissue ■​ Maintain safe environment Localized tx Amount of radiation delivered to tissue – “exposure” Amount of radiation absorbed by the tissue – “radiation dose” Radiation dose < exposure Side Effects: ■​ Skin changes – fibrosis, scarring ■​ Hair loss at site ■​ Altered taste ■​ Fatigue/tired ■​ Some bone marrow suppression ■​ Uterine = colon changes ■​ Development of secondary malignancy ○​ Delivery: ■​ Determined by patients health and shape, size, and location of the tumor Chemotherapy ○​ Tx of cancer w/ chemical agents ○​ Used to cure and to increase survival time ○​ Damages DNA and interferes w/ cell division ○​ Effects are systemic ○​ Sometimes used in conjunction w/ surgery and/or radiation therapy ○​ Rapidly growing tumors are most sensitive to chemotherapy ○​ Side Effects: ■​ Temporary and permanent damage can occur to normal tissues ●​ Cardiac muscle damage ●​ Loss of bone density ●​ Hemorrhagic cystitis ■​ N/V ■​ Immune system compromised Immunotherapy Molecularly targeted therapy Photodynamic therapy Hormonal therapy ○​ ○​ ○​ ○​ ○​ ●​ ●​ ●​ ●​ ●​ Oncologic Emergencies – ●​ Cancer is chronic, but there are a number of acute cancer emergencies that can arise ●​ Early detection and immediate intervention of these emergencies are essential to avoid life threatening situations Sepsis – ●​ ●​ ●​ ●​ Organisms enter the bloodstream and can result in septic shock (life-threatening) Cancer patients at increased risk d/t low WBC counts and impaired immune system S/S are those consistent with infection: High fever, confusion, dehydration, lethargy Best management: Prevention ○​ Aseptic technique ○​ Educate about early signs of infection DIC (Disseminated Intravascular Coagulation) – ●​ Sepsis that has gone unresolved ●​ Extensive, abnormal clotting throughout small vessels -> clots block vessels and decrease blood flow to vital organs -> organ destruction begins -> clotting factors are depleted -> extensive bleeding occurs ●​ Triggered by many severe illnesses ●​ In cancer, often caused by gram-negative sepsis – normal flora can be the culprit in patients with neutropenia ●​ Most common problem ? bleeding from many sites, ranging from minimal to hemorrhage ●​ Life-threatening, with high mortality rate … even with appropriate tx ●​ Best management: prevention of infection Sepsis/DIC Treatment – ●​ Focused on reducing infection and stopping DIC process ●​ IV abx initiated ●​ DIC, Early phase: Anticoagulants (Heparin) given to limit clotting in order to preserve clotting factors. ●​ Later phase: hemorrhage will now be the problem due to using clotting factors quicker than they are produced… clotting factors will be given. SIADH (Syndrome of Inappropriate Antidiuretic Hormone) – ●​ Antidiuretic hormone: secreted by pituitary gland when more water is needed in the body. ●​ Cancer can cause ADH secretion when it is not needed, resulting in SIADH ●​ Cancer Culprits: Small cell lung, melanoma, GI, prostate, hematologic malignancies, and especially any tumor located in the brain. ●​ Some tumors make/secrete ADH; some tumors stimulate pituitary gland to secrete more ●​ Some drugs can also cause it: morphine sulfate, cyclophosphamide (chemo med) ●​ Those patients with pre-existing cardiac, kidney, lung, or liver problems are at greater risk ●​ Excessive amount of water is reabsorbed by the kidneys and put back into circulation ●​ Sodium is diluted, so serum levels drop… seizures, coma, and death can occur around NA+ of 110 MEQ/L ●​ S/S: ○​ Low NA+ ○​ Weight gain ○​ Personality changes ○​ Confusion ○​ Muscle weakness ●​ Treatment: ○​ Treat both the condition and the cause ○​ Focus on pt safety, restoring fluid balance, and supportive care ○​ Fluid restriction, increased NA+ intake, drug therapy ○​ Drugs: ■​ Demeclocycline (Declomycin) - Promotes opposite effects of ADH ○​ Radiation or chemo to shrink known tumor(s) ○​ Only cure is to effectively treat SIADH-causing cancer source ○​ Prevent fluid overload to prevent HF, pulmonary edema, etc. Spinal Cord Compression – ●​ Tumor may enter spinal column or spinal cord ●​ Tumor may destroy bone ●​ Tumor may be benign in spinal cord, but usually metastasizes from lung, prostate, breast or colon ●​ Back pain is usually first indicator, then come neuro changes ●​ Neuro complications are determined by the level of interruption/compression ●​ Early recognition and tx are key to positive outcome ●​ Assessment: ○​ Neuro changes? ○​ Back pain? ○​ Muscle weakness/heaviness? ○​ Tingling or numbness? ○​ Decreased sensation? ○​ Unsteady gait? ○​ Constipation, incontinence, urinary difficulty? ●​ Treatment: ○​ Often palliative ○​ High dose corticosteroids ○​ High dose radiation ○​ Surgery ○​ External back or neck brace Hypercalcemia – ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ Can lead to death Occurs in ⅓ of cancer pts Often develops slowly, and body will adapt to changes in electrolyte imbalance S/S may not be present until critically high Serum ionized calcium levels is most reliable lab test Cancer Culprits: breast, lung, renal cell carcinomas, multiple myeloma, adult t-cell leukemia, lymphoma Tumors secrete parathyroid hormone Tumors can secrete systemic secretion of vitamin D Worsened by decreased mobility and dehydration S/S EARLY: ○​ Skeletal pain ○​ Kidney stones ○​ Abdominal pain ○​ Confusion ○​ Fatigue ○​ Loss of appetite ○​ N/V ○​ Constipation ○​ Increased UOP ●​ S/S SERIOUS: ○​ Severe muscle weakness ○​ Loss of DTR ○​ Paralytic ileus ○​ Dehydration ○​ ECG changes ○​ **** Severity depends on how high the level, and how fast it rose Treatment: ○​ ○​ ○​ ○​ ○​ ○​ ○​ Oral hydration IV Hydration (NS) Loop diuretics: promote urine excretion Bisphosphonates: block bone absorption Calcitonin: temporarily lower levels Dialysis: if life-threatening or kidney function decreased **** must treat actual cancer for long-term control of calcium level Superior Vena Cava Syndrome (SVCS) – Compression or obstruction by tumor growth, or clots, leading to congestion of blood SVC is thin-walled, and returns blood from cranial, neck, and upper extremities to the heart SVCS is a late sign, when tumor is usually already wide-spread Cancer Culprits: Lymphomas, lung, breast, any tumor in mediastinum SVCS can develop quickly or gradually ○​ Gradual? Collateral circulation can occur ●​ S/S: ○​ Early (Usually in the morning): Facial edema, orbital edema, tightness of shirt in neck ○​ Progressing: Engorged blood vessels, erythema of upper body, edema to upper extremity, dyspnea, epistaxis ○​ Late: Hemorrhage, cyanosis, AMS, decreased COP, hypotension ●​ Treatment: ○​ High dose radiation to upper chest ○​ Chemotherapy may be only option for long term control ○​ Surgery: rare ○​ Metal stent placement to relieve swelling ○​ Angioplasty may be necessary to keep stent open ○​ *** death occurs if compression is not relieved ●​ ●​ ●​ ●​ ●​ Tumor Lysis Syndrome (TLS) – ●​ When a large number of tumor cells are destroyed quickly, releasing potassium and purines into the bloodstream quicker than the body can eliminate them ●​ TLS is a positive sign that cancer tx is working ●​ Hyperkalemia -> Cardiac Dysfunction ●​ Hyperuricemia -> purines have formed acid crystals, which block kidney tubules -> AKI -> Hyperphosphatemia ●​ Has life threatening effects on heart, muscle, kidneys and CNS ●​ Usually seen in tumors very sensitive to radiation and/or chemo ○​ Leukemia ○​ Lymphomas ○​ Small cell lung cancer ○​ Germ cell tumors ○​ Inflammatory breast cancer ○​ Melanoma ○​ Multiple myeloma ●​ Early S/S: ○​ Lethargy ○​ Nausea ○​ Vomiting ○​ Anorexia ○​ Diarrhea ○​ Cloudy urine ○​ Flank pain ○​ Muscle weakness ○​ Muscle cramping ●​ Treatment: ○​ CONCENTRATE ON PREVENTION ○​ HYDRATE ■​ Diluted serum K+ Level ■​ Increases kidney flow rates, which prevent formation of uric acid crystals ■​ Increases excretion of K+ ■​ Flushes kidney sediment ■​ Patients should drink 3000-5000mL the day before, day of, and 3 days post treatment ■​ Intake should be consistent throughout the 24 hour day… help patient make a schedule ○​ Increased fluid intake ○​ Antiemetics (stress importance) ○​ Diuretics (Caution) ○​ Drugs to promote purine excretion: Allopurinol ○​ Severe hyperkalemia? IV infusion of glucose and insulin ○​ Severe hyperkalemia and hyperuricemia ? may need dialysis