356 exam Flashcards
(266 cards)
1
Q
what are the steps of the clinical reasoning cycle
A
- consider the patient situation
- consider cues/ information
- process information
- identify problems / issues
- establish goal/s
- take action
- evaluate outcomes
- reflect on processes and new learning
2
Q
what to include in consider patient situation? ( CRS)
A
- List facts, people and context
3
Q
what to include in collect cues/ information (CRS)
A
Review:
Age, gender, occupational history, chest x-ray, medical progress notes, blood gases?
Gather new information: Observations History of foreign travel? COVID risk? Blood gases?
Recall knowledge:
Anatomy and physiology of resp system
Pharmacology
Risk factors for pneumonia
4
Q
What to include in process information (CRS)?
A
Interpret
- Look at each observation / investigations
- Within normal limits
Discriminate
- What findings can you safely disregard?
- Which obs are most relevant?
Relate
- Cluster cues together e.g. tachypnoea and SaO2
Infer / Match
- Make a decision that based on the information you have what it means
Predict
- If you don’t do something what is most likely going to happen?
- Why?
5
Q
What to include in Identify problems/ issues (CRS)?
A
Synthesise facts and establish diagnosis
- Be able to say this is the problem because.
E.g.
hypoxic due to untreated pneumonia.
6
Q
What to include in establish goals (CRS)?
A
Set out what you want to happen
Why not use SMART:
7
Q
What to include in take action of (CRS)?
A
- Describe what needs to happen
- List alternative and describe rationale for choice
- Is it evidence based?
- Can you defend your chosen path?
8
Q
What to include in evaluate outcomes (CRS)?
A
- Have the actions improved the situation?
- What is the best way of evaluating effectiveness?
9
Q
What to include in Reflect on process and new learning (CRS)?
A
Reflect on what YOU have learned
What would you do differently?
10
Q
palliative care is a philosophy of care that involves:
A
- holistic care
- comprehensive care
- coordinated care
11
Q
Palliative care patients are cared for in:
A
- acute hospital settings
- community settings
- in the home
12
Q
examples of life limiting conditions
A
Cancer Dementia/frailty Heart/vascular disease Respiratory disease Kidney disease Liver disease Neurological disease Any condition /complications that are not revisable
13
Q
what is the SPICT tool?
A
Supportive and Palliative Care
Indicators Tool
SPICTTM tool is used to help identify people whose health is deteriorating.
Assess them for unmet supportive and palliative care needs. Plan care
14
Q
SPICT indicators of poor or deteriorating health to look for
A
Unplanned hospital admission(s).
Performance status is poor or deteriorating, with limited reversibility.
(eg. The person stays in bed or in a chair for more than half the day.)
Depends on others for care due to increasing physical and/or mental health problems.
The person’s carer needs more help and support.
Progressive weight loss; remains underweight; low muscle mass.
Persistent symptoms despite optimal treatment of underlying condition(s).
The person (or family) asks for palliative care; chooses to reduce, stop or not have treatment; or
wishes to focus on quality of life
15
Q
what is end of Life care
A
‘Person and family-centred care provided for a person with an active, progressive, advanced disease, who has little or no prospect of cure and who is expected to die, and for whom the primary treatment goal is to optimise the quality of life.’
16
Q
how to improve Quality of Life of the palliative patient
A
Dying is deemed to be part of life
Needs to be cared for in the same way
Holistic care
Five domains of Holistic care
- spiritual care
- cultural care
- physical care
- social care
- emotional care
17
Q
Five domains of Holistic care
A
- spiritual care
- cultural care
- physical care
- social care
- emotional care
18
Q
How does quality of care affect the family
A
Not just the patient
- Family
- Friends
- Principle carer
Stressful
Emotionally/psychologically/Spiritully challenging
- Need to be
- Informed
- Educated
- Supported
19
Q
Multidisciplinary team in palliative care?
A
- Whole team approach
- Physicians/Oncologists/ Surgeons
- Nurses
- Palliative Care Team
- Nuclear Medicine Specialists
- Physio
- OT
- Social workers
20
Q
how to communicatie during palliative care
A
Continuous through the patient journey Involve patient, Family, Loved ones Needs to be Effective Efficient Difficult Communication Frameworks PREPARED SPIKES
21
Q
What does the abbreviation PREPARED stand for in palliative care
A
P- Prepare for discussion
R- Relate to the person
E- elict preferences from person/ carers
P- provide information tailored to person/carers
A- Acknowledge emotions/ concerns
R- (Foster) Realistic hope
E- Encourage questions and further discussion
D- Document
22
Q
What does the abbreviation spike stand for in palliative care?
A
S- setting up the conversation
P- Perception …Assessing the persons perception
I- Invitation.. Obtaining the persons invitation
K- Knowledge… providing knowledge and information to the person
E- Emotions…Addressing the person’s emotions with emphatic response
S- Strategy and Summary
23
Q
when to begin goals of care
A
soon after life limiting illness
24
Q
Communication expectations in goals of care during palliative care
A
Good communication skills essential
Listening and enquiring
Checking and Clarifying
Documentation
25
purpose of goals of care for palliative care patients
A way of beginning advanced care planning process
‘Our ultimate goal after all is not a good death, but a good life to the very end’
26
what is to be involved in palliative care plan
- Who participated in the plan
- Contact details – coordinators of care
- Clearly defined Goals & Responsibilities
- Ongoing holistic assessment (5 domains)
- Multidisciplinary involvement
- Sharing/re-evaluation details
- Links to relevant documentation
- Planning for expected evens/changes
27
symptoms to be managed during palliative care?
pain
dyspnoea
nausea/ dehydration
neuro deficits
hypotension
28
pain management in palliative patients
Pain Management
- Pain control can be achieved in 90% of palliative patients
- Stepwise Ladder Approach
- Control of breakthrough pain
29
what is the stepwise ladder approach to pain management in palliative care?
...
30
dyspnoea management in palliative care
- Positioning
- O2
- Suctioning
- Anticholergic drugs – secretions
31
how to optimise care during palliative care
Continuous assessment
- Physical functioning
- Social functioning
Clinical assessment
Self reporting
32
what are the 9 palliative care standards
1- Assessments of needs
2- developing the care plan
3- caring for carers
4- providing care
5- transitions within and between services
6- grief support
7- service culture
8- quality improvement
9- staff qualifications and training
33
how to care for palliative care carers
- Health care workers need care too
- End of life care
...Burnout
...Moral Distress
...Compassion fatigue
- Non-Health care workers
- Stressful
...Carer Support-Assessment
...Respite Care
...Spiritual support
34
pharmalogical interventions for end of life care?
- Analgesics
- Nausea and Vomiting
- Hydration therapy
- Anticholergic drugs
- Administration
...Many drugs administered via pump/single doses
...Sub cutaneous via butterfly needles
35
Pharmacodynamics of Anticholergic drugs for palliative care?
- Blocks Transmission of acetylcholine throughout the body
- Relaxation of smooth muscle
- Drying up of secretions
- Used in end of life care for secretion management
36
example of Anticholergic drug
Hyoscine BUTYLbromide
37
what is pharmacodynamics
what a drug does to the body
38
what is pharmacokinetics
what our body does ADME
39
pharmacokinetics of Hyoscine BUTYLbromide
ADME:
Poorly absorbed in the GI tract
Does not cross the blood brain barrier – no effect on CNS
40
Indicationsof Hyoscine BUTYLbromide
Spasm of GI tract, renal spasm, secretion management in EOL care
41
adverse effects of Hyoscine BUTYLbromide
Urinary retention, dizziness, tachycardia
42
contraindications of Hyoscine BUTYLbromide
paralytic ileus, urinary retention, glaucoma
43
What makes us breathless?
```
Pain
Exercise
Trauma
Obesity
Genetics
Smoking
Allergy
-Dust
-Pollen
-Fur
-Grass
Etc, etc, etc
```
44
Common respiratory conditions
```
Chest Infection
Pneumonia
Emphysema
Dyspnoea
Respiratory failure
ARDS
Asthma
COPD
```
45
Aetiology meaning
The study of the causes
46
Acute Respiratory Distress Syndrome: Aetiology
Acute inflammatory response of the lungs
it is a form of non-cardiogenic pulmonary edema, due to diffuse alveolar injury.
Characterised by:
Hypoxemia, Decreased lung compliance, Bilateral infiltrates, Non-hydrostatic pulmonary oedema
- 10% of all ICU admissions have ARDS
- 46% mortality rate
- Most cases attributed to Pneumonia or Sepsis (40-60%)
47
ARDS pathophysiology
Acute Respiratory Distress Syndrome is a form of non-cardiogenic pulmonary edema, due to diffuse alveolar injury. This diffuse alveolar damage occurs secondary to an inflammatory process. The initiative of inflammation can be Direct injury to the Lung or indirect injury by systemic causes.
Non-hydrostatic pulmonary oedema – Hydrostatic pressure in the lungs is not affected – pathological processes act on the pulmonary vascular permeability result in protiens leaking from the capillaries, increasing the oncotic pressure – it exceeds that of blood and fluid is therefore drawn from the capillaries.
48
ARDS pathophysiology stages
Exudative phase: Injury to the alveolar capillary membrane – accumulation of protein rich fluid impairing gas exchange and release of various substances including proinflammatory cytokines which causes significant inflammatory response in the lungs – Significant ventilation-perfusion mismatch evolves causing hypoxaemia and reduced lung compliance
Proliferative phase: occurs after 1 – 2 weeks . Fibrosis and remodelling occurs. Patients have reduced alveolar ventilation, pulmonary compliance and ventilation perfusion mismatch
Fibrotic phase: Alveola become fibrotic, emphysema alterations to lungs, linked to prolonged ventilation
49
ARDs Management
- Treatment limited
- Treat the cause – i.e pneumonia
- Supportive care
- Ventilation – Prone!
- Fluid management
- Nutrition
50
What is asthma
- A chronic inflammatory disease of the airways
...Causes hyper-responsiveness, mucosal oedema and mucous production
...Allergy is the strongest predisposing factor
-Inflammation leads to cough, chest tightness, wheezing and dyspnoea
-The most common chronic disease of childhood
Can occur at any age
-Fully reversible (unlike COPD)
51
describe asthma in australia
-More than 2 million Australians have asthma
Most common chronic childhood disease
1 in 10 adults (usually mild)
- Children have higher rates of hospitalisations for asthma than adults
- Over 400 Australians die from asthma annually Australian Centre for Asthma Monitoring (cited in Considine, 2014)
52
why asthma makes it hard to breath
Parasympathetic stimulation leads to bronchoconstriction
Sympathetic stimulation leads to bronchodilation
Inflammation causes swelling of the bronchial mucosa
Inflammation causes increased mucous production
53
how is asthma diagnosed
Clinical manifestations
- Wheeze & chest tightness
- Dyspnoea &/or cough
- Airflow limitation/prolonged expiration
....Often recurrent & seasonal/worse nocte
Triggers:
-exercise/allergies/emotions /irritants /infections/cold air
Patient history & examination
Diagnostic testing
- Serial peak expiratory flow
- Reversibility (often with short-acting broncho-dilator)
- Various spirometry/lung function testing/exercise testing
54
asthma treatment/ pharmacological options
salbutamol
| Ipratopium Bromide
55
pharmacodynamics of salbutamol
- Beta2-adrenoreceptor agonist
| - Relaxes bronchial smooth muscle by acting on calcium in the cell (see p593 - Bryant et al, 2019)
56
Pharmacokinetics of salbutamol
Absorbed rapidly - inhalation
Metabolised by liver, excreted by kidneys
ADME – Absorption, distribution, metabolism and excretion
Absorbed rapidly – inhalation – 5-15mins peak effect within 1-2 hours
57
indications, adverse effects and contraindications of salbutamol
Indications – Asthma, bronchitis, emphysema
Adverse effects – tremor, palpitations, restlessness, Tachycardia
Contraindications – Beta blockers, sensitivity, hypokalaemia
58
pharmacodynamis of Ipratopium Bromide
- Anticholinergic drug
- Blocks the action of ACh – Bronchodilator (blocks the effects of stimulation on the parasympathetic nervous system
(see p185-186 - Bryant et al, 2019)
59
pharmakokinetics of Ipratopium Bromide
ADME
Absorbed rapidly - inhalation
Metabolised by liver, excreted faeces, urine and bile
60
Indications, adverse effects and contraindications of Ipratopium Bromide
Indications – Asthma, bronchitis, emphysema
Adverse effects – Tachycardia, arrythmias, SVT, AF, Nausea, Dry mouth/throat
Contraindications – hypersensitivity to atropine
61
what is asthma like for the patient
Can be challenging to treat
And very scary for the patient
62
different cardiovascular conditions
```
CHD
ACS (see algorhythm, Aitken et al p285)
Heart failure
Cardiomyopathy
Endocarditis
Aneurysm
```
63
ACS algorithm
view in word
64
what is ACS
```
Umbrella term
- MI
- Unstable Angina
.....Associated with transient or permanent thrombotic occlusion
.....Leads to ischemia or infarction
```
acute coronary syndrome (ACS). A broad spectrum of clinical presentations, spanning ST-segment elevation myocardial infarction
through to an accelerated pa
65
discuss prevalence of ACS
2014-15 77,007 ACS events
>500,000 pts present with CP annually in Au
≥ 80% of potential ACS patients do not have a Dx
Cost and resources burden (nearly $2B)
66
why is chest pain complex/ a problem
Multiple causes
High rates of admissions
```
Resource intensive:
Nursing
Medical
Length of hospital stay
Medication
COST
```
67
cardiovascular causes of chest pain
```
Myocardial ischaemia
Coronary artery spasm
Myocardial infarction
Pericarditis
Pulmonary embolism
Mitral valve prolapse
Ca usually secondary cancer
```
68
non cardiovascular causes of chest pain
```
Dissecting Thoracic Aneurysm
Herpes Zoster
Oesophageal reflux
Oesophageal spasm
Hiatus hernia
Pneumonia
Pneumothorax
Pleurisy
Peptic ulceration
Gallbladder disease
Musculoskeletal pain
Costochondritis
```
69
anatomy and physiology components that can cause problem in cardiovascular patients
Mechanical components
Electrical components
Vascular components
...of the heart
70
review diagram of the heart
- superior vena cava
- right pulmonary artery
right pulmonary vein
- Opening of SVC & Pulmonary semi-lunar valve
- Right Atrium
- Opening of IVC & Tricuspid valve
- Right Ventricle
- IVC
- Aortic arch
- Ligamentum arteriosum & pulmonary artery
- Left pulmonary veins
- Left atrium
- Mitral valve & Aortic semilunar valve
- Septum & Chordae tendonae
Left ventricle
71
the hearts conduction system
watch video on conduction system
- The sinoatrial node, or SA node, located in the right atrium near the entrance of the superior vena cava. This is the natural pacemaker of the heart. It initiates all heartbeat and determines heart rate.
- The electrical impulses from the SA node spread throughout both the right and left atria to stimulate them for contraction.
- The atrioventricular node, or AV node, which is located between the right Atria of the Heart and RIght Ventricle serves as an electrical gateway to the ventricles. It delays the passage of weak electrical impulses to the ventricles, and if the SA node does not fire, the AV node serves as the SA Node's backup pacemaker hence why the AV node is called the "Gatekeeper of the Heart."
- The AV node receives signals from the SA node and passes them onto the atrioventricular bundle - AV bundle or bundle of His which divide into the right and left bundle branches that conduct the impulses toward the apex of the heart.
- The signals are then passed onto Purkinje fibers, turning upward and spreading throughout the ventricular myocardium.
- Electrical activities of the heart can be recorded in the form of an electrocardiogram, ECG, or EKG.
- The P-Q segment represents the time the signals travel from the SA node to the AV node, and the QRS complex marks the firing of the AV node and represents ventricular depolarization.
- Atrial repolarization also occurs during this time but the signal is obscured by the large QRS complex because the heart's ventricles contract stronger than the Atria.
- The T wave represents ventricular repolarization
- The cycle repeats itself with every heartbeat.
```
DEPOLARIZATION= CONTRACTION
REPOLARIZATION= RELAXATION
```
- SA node
- AV node
- right atrium and ventricle
- aortic arch
- left atrium
- Right and left bundle of His
- Left ventricles
- Perkinje fibres
72
what are the coronary arteries
- right coronary artery
- left coronary artery
- branch of left coronary artery
- branch of right coronary artery
-
73
what is atherosclerosis/ causes of CHD
Atherosclerosis- A complex and progress disorder of the arteries. Thought to involve endothelial injury or inflammation, which becomes the focal point of lipids and fibrous tissue in the form of plaques, particularly around arterial curvature and branches.
Responsible for much CHD
74
what are the different anginas
Stable angina
- artery spasm, closes off vessel, less o2 getting to myocardium
- Often relieved by rest alone
Unstable angina
- May come on at rest
- plaques moving through, or spasm not bought on from exertion
75
stable vs unstable angina process
both- plaque formation with no symptom
stable- plaque becoming more, but little blood flow is still able to flow with o2
unstable- blockage and rupture more serious
watch vid
76
pharmacodynamics of aspirin
Inhibits COX-1 (cyclo-oxygenase)
| COX is needed to allow platelets to aggregate
see p556 - Bryant et al, 2019
77
pharmacokinetics of aspirin
Absorbed rapidly buccally, orally
Metabolised by liver, excreted by kidneys
78
indications adverse effects and contraindications of aspirin
Indications – ACS, stroke risk, fever
Adverse effects – gastritis, GI bleeding, dizzness
Contraindications – sensitivity, haemophilia, gastric ulcer…
79
pharmacodynamics of morphine
Opioid receptor agonist – opioid receptors ‘receive’ endorphins
Morphine mimics endorphins
Reduces pain interpretation
80
Pharmacokinetics of morphine
Very susceptible to 1st pass effect – if taken orally liver metabolises approx. 60% of drug
Give IV, IM in acute setting to avoid this
Morphine can actually be taken orally, intramuscularly, intravenously, subcutaneously, via
epidural, intrathecally and rectally Parenteral administration is the most ideal route due to the medication's poor
bioavailability of 40% when taken orally (Bryant & Knight,2015) .
absorbed fast with peak concentration occurring within 60 minutes when taken
intramuscularly and within 90 minutes when taken subcutaneously.
Morphine is distributed widely throughout the body, especially to organs such as the kidney,
lung, liver and spleen. It can diffuse across the placenta.
Morphine is then metabolised in the
liver AND excreted in the urine It is because of
the first pass metabolism in the liver that oral bioavailability is so poor
81
indications, adverse effects, contraindications and cautions of morphine
Indications – Moderate to severe pain
Adverse effects – Nausea, constipation, respiratory depression
Contraindications – sensitivity, acute respiratory depression
Cautions – acute head injury, COPD
82
glyceryl trinitrate pharmacodymanics
Causes smooth muscle relaxation
Causes vasodilation – reduces cardiac preload and stroke volume
83
Pharmacokinetics of GTN
Metabolised by liver rapidly – short lived therapeutic effect
84
Indications, adverse effects, contraindications and cautions of GTN
Indications – Stable angina, ACE
Adverse effects – headache, dizziness, orthostatic hypotension
Contraindications cardiomyopathy, hypotension, hypovolaemia, raised ICP
Caution - interactions with alcohol, erectile dysfunction medication e.g. viagra
85
metaclopramide pharmacodynamics
Blocks (antagonises) dopamine receptors in chemoreceptor trigger zone (CTZ) in brain
CTZ relays message to vomit centres – block reduces this
Accelerates gastric emptying
86
metaclopramide pharmacokinetics
ADME:
Easily absorbed orally, IM, IV
Metabolised in liver
Half life 2.5 – 5 hrs
87
Indications, adverse effects, contraindications and cautions of metaclopramide
Indications – nausea, vomting, GORD
Adverse effects – diarrhoea, restlessness, dizziness
Contraindications – previous reaction to dopamine antagonists
Caution - patients with Parkinsons Disease
88
describe the brain
2% of body weight
20% of cardiac output
- Massive oxygen and glucose requirements
- Most required by neuronal activity
- ...therefore maintenance of supply essential for normal neurological function
89
structure of the brain
```
review diagram
- lateral ventricle
- third ventricle
- subarachnoid space
- pia mater
- skull
- skin
- arachnoid villi
- subdural space
epidural space
- dura mater
- arachnoid
- falx cerebri
```
90
describe brain layers
```
The bra blancmange
... wrapped in cling film (arachnoids),
... in a paper bag (dura)
...inside a cardboard box (skull)
...wrapped in brown paper (scalp).
ain is….
```
91
any of the brain layers can be damaged by
Direct impact on the box (blow),
Dropping the box (fall) or
Shaking the box (acceleration/deceleration)
92
what are different mechanisms of injury
Primary Injury
eg. Blow to the head
eg. The head hitting an object
eg. Acceleration-deceleration (whiplash)
...Scalp lacerations can bleed profusely and cause hypovolaemia – be aware
93
secondary injury from head injury examples ...
```
From this we get:
Haemorrhage
Oedema
Haematoma
Dura tearing
Structural movement
Obstruction to CSF flow
Hypoxia
pH alterations
```
94
what is the monro kellie doctrine
the sum of volumes of brain, cerebrospinal fluid (CSF) and intracerebral blood (venous and arterial) is constant. An increase in one should cause a reciprocal decrease in either one or both of the remaining two.
95
what is herniation
Brain herniation occurs when something inside the skull produces pressure that moves brain tissues.
96
pharmacodynamics of mannitol
Osmotic Diuretic (Type of sugar)
Mannitol elevates blood plasma osmolality, resulting in enhanced flow of water from tissues, including the brain and cerebrospinal fluid, into interstitial fluid and plasma.
97
mannitol pharmacokinetics
ADME – Induces movement of intracellular water to extracellular and vascular spaces. Excreted from kidneys.
98
indications, contraindications and adverse effects of mannitol
Indications - Diuresis, >Intraocular Pressure (Glaucoma), >ICP
Contraindications - hypersensitivity, severe heart failure, pulmonary congestion, disturbance to the blood – brain barrier, dehydration
Adverse effects - nausea & vomiting, dizziness, hypotension, ARF, acidosis
99
tazopip pharmacodynamics
Broad spectrum semisynthetic penicillin antibiotic – contain Piperacillin and Tazobactam. Piperacillin inhibts bacterial cell wall synthesis – Tazobactam inhibits the enzyme beta-lactamase – that would normally prevent Piperacillin from working. Combining the two makes it more effective
Active against Gram-positive and Gram-negative aerobic and anaerobic bacteria
100
tazopip pharmacokinetics
ADME – excreted from kidneys. Caution in acute kidney injury and renal disease
101
indications, contraindications, adverse effects and interations of tazopip
Indications - Used for: LTI’s, UTI’s, intra abdominal infections, skin infections, gynae infections
Contraindications - Allergic reactions to penicillin/cephalosporins & clauvalinic acid (Augmentin), jaundice
Adverse effects - nausea, vomiting, clotting problems, raised liver enzyme, resistance to therapy in prolonged use, false positives for glucose in urine
Interactions - Other antibiotics, Vecuronium, Methotrexate, Heparin and anticoagulants
102
what is cancer
Cancer is a genetic disorder at cellular level
Chronic disease
Uncontrolled proliferation of cells
Normal body responses:
....Cells grow and divide
....Damaged/old cells removed – replaced by new cells
Cancer
....Abnormal cells divide/replicate
.....Grow beyond normal tissue
Incidences increase with age
103
what can cancer be caused by
Genetic eg. oncogenes and tumor supressor genes
Environmental factors
Behavioural factors
Only >10% of cancers genetic in origin
Abnormal cell behaviour = damaged genes = mutation
theory of cellular mutations applies that Carcinogenesis causes mutation in the cellular dna
104
what are Oncogenes
Abnormal genes, promote cell proliferation (BRCA1, BRCA2)
105
what are tumour supressor genes
Encode proteins that in their normal state negatively regulate proliferation
106
describe carcinogenesis
view flow chart
aquired/ dna damaging agents= dna damage to normal cell= failure to repair dna ( may be caused by genetics)= mutations in somatic cell genome= altered genes causing apoptisis OR increased oncogene/ tumour supressor gene promotion= unregulated proliferaion= clonal expansion (Angiogenesis, escape from immunity and additional mutations contrubute to this)= tumour progression= malignant neoplasm= invasion and metastasis
107
describe normal cell repair
normal cell-> one genetic change-> genetic repair-> genetic information normal, cell normal
108
describe development of cancer
normal cell-> one genetic change-> another genetic change-> another genetic change-> AND abnormal cell becomes abnormal-> cell death OR avoids apoptosis-> cell is cancerous and replicates-> continued replication-> angiogenesis-> tumour growth-> tumour cells break away-> cancer spreads to other areas ( known as metastasis)
109
types of tumours
Malignant (Neoplasm)
Benign
110
benign tumours vs malignant
benign- grow slowly, well defined capsule, not invasive, well diffrentiated, do not metastasise
malignant- grow rapidly, non encapulated, invasive, poorly differentiated, can spread distantly (metastasis)
111
what must occur for a tumor to englarge
angiogenesis ( new bloodcells formed around or near the tumor)
112
cancer metastatsis
angiogenesis
Primary tumours ( in initial organ)
Local and regional invasion
Metastasis
113
describe process of metastasis
primary tumour
proliferation/ angiogenesis
detatchment/ invasion (lymphatics, venules, capillaries)
embolism/ circulation (interation with platelets
transport
arrest in organs
adherance to vessel wall
extravasation
establishment of a microenvironment
proliferation/ angiogenesis
114
common sites of metastasis
brain and CSF
Lung
Liver
Adrenals
Bone
115
Pharmaceutical therapy for cancer
Antineoplastic Drugs
- Cytotoxic drugs (Chemotherapy)
- Hormonal drugs
- Immunotherapy drugs
116
5 phases of cell cycle and chemotherapy effect
```
Cell cycle has 5 phases:
Presynthesis gap phase
DNA synthesis phase
Premitotic phase
Mitosis Phase
Resting Phase
```
Cytotoxic drugs interfere in one or more phases
Damages healthy cells as well as cancer cells
117
side effects of chemotherapy
Produces side effects
- Alopecia (damage to follicle cells)
- Impaired bone marrow production of blood cells (myelosuppression)
- Infertility
118
chemotherapy dose regimen?
review diagram
| has to be within range to be effective but not dangerous to too many healthy cells
119
why use hormonal drugs on cancer
Tumours can be stimulated by hormones
- Breast
- Prostate
- Ovaries
Impact on hormone production = cancer cell death
Can be achieved by:
- Blocking hormone production
- Fooling signal pathway
- Blocking hormone receptors
120
purpose of immunotherapy drugs in cancer patients
Biological treatment to manipulate immune system ( increased activation against the cancer cells)
- Immune system works more effectively
- Tag and destroy
used in combination with cytotoxic treatments
121
types of immunotherapy drugs for cancer
Different types
- Adoptive cell transfer (T cell treatment)
- Cytokines (cell Protiens)
- Vaccines
- Monoclonal antibodies (
122
types of respiratory disorders
Upper respiratory
Lower respiratory
Minor conditions (common Cold)
Major conditions (COPD, Cancer)
Classification
- Acute
- Chronic
123
airways levels of defence
nasopharynx
| oropharynx
124
what causes pneumonia
inhalation of microorganisms
- viral
- mycobacteria
- bacteraemia
125
types of pneumonia aquisitions
Community-acquired or hospital-acquired
Immuno-compromised or aspiration type
126
patho of pneumonia
Acute inflammation of the lung
- By an infection (bacterial/viral/fungal/mycobacterial)
Resulting in:
- Alveoli & surrounding tissues become oedematous
- Alveoli fill with exudate & then consolidate
....Affects ventilation & diffusion
....Shunting occurs -> hypoxia/arterial hypoxaemia
127
t or f pneumonia has a high mortality rate
t
128
pneumonia treatment
Oxygen therapy
- Humidification may be used to loosen secretions
(explore more)
- Deep breathing & coughing exercises (physio)
- Antibiotics (as ordered)
For bacterial types
For viral types to prevent secondary bacterial infections
129
amoxicillin pharmacodynamics
Β Lactamase-sensitive penicillin
A moderate spectrum antibiotic that kills bacteria by weakening bacterial cell walls
Not effective in bacteria that produce Β Lactamase – e.g. staph aureus
130
amoxicillin pharmacokinetics
ADME:
Absorbed readily via oral, IM, IC routes
Excreted through kidneys
131
indications, adverse effects and contraindications of amoxicillin
Indications – Gram negative infections
Adverse effects – nausea, diarrhoea, skin rash, oral thrush
Contraindications – allergy to penicillins / cephalosporins
132
paracetamol pharmacodynamics
Inhibits prostaglandin synthesis in CNS (prostaglandins ‘activate’ pain receptors)
133
paracetamol pharmacokinetics
ADME:
Rapidly absorbed – orally, rectally, IV
Metabolised in liver – but limited amount of enzyme to metabolise available - toxic in higher doses
134
indications, adverse effects and contraindications of paracetamol
Indications – Mild to moderate pain, fever
Adverse effects – rare – rash, nausea.
Contraindications – hepatic impairment, hypersensitivity
135
purpose/ benefis of ABGs
Most commonly formed lab test in critical care
Allows for rapid analyse of pt status
Allows for rapid interventions to assist with maintaining homeostasis
136
how are ABGs taken
Taken from an artery via an arterial stab or in situ arterial catheter
137
for what conditions would we take abgs for
```
Trauma
Shock
Sepsis
Uncontrolled Diabetes (can affect blood pH)
Asthma
COPD
Pulmonary embolus
Haemorrhage
Lung or kidney failure
Drug overdose
Chemical poisoning
```
138
Homeostasis of blood - Compensation (Buffers)
what is compensation
Compensation – the body adjusting chemistry to rebalance
139
what are the 3 buffer systems
lungs, kidneys and protein buffers
140
how to buffers work- lungs?
C02 + H20 = H2C03 (Carbonic Acid (ACIDOSIS!!)
Pt >PaC02 therefore >H2C03 = Acidosis
Response - resp rate > - ‘Blowing off’ C02
141
How do buffers work- kidneys?
Response – Mops up acid - Increases/decreases production of H+ ions (creates or decreases Bicarbonate (HC03)
142
How do buffers work- protein?
Intracellular – combines with H+ ions – Splits H2C03 for elimination
143
what do i need to know about abgs?
Is it Normal or Abnormal?
Is it Acidotic or Alkalotic?
Is it Respiratory or Metabolic
do practice qs
144
What pH indicates acidosis
<7.35
145
What pH indicates alkalosis
>7.45
146
normal pH range
7.35- 7.45
147
how to tell if ABG indicates Respiratoy
It’s all about the PaC02…
>45 (High)
(and HC03 Normal )
Broadly speaking the causes can be either metabolic or respiratory. The changes in pH are caused by an imbalance in the CO2(respiratory) or HCO3– (metabolic). These work as buffers to keep the pH within a set range and when there is an abnormality in either of these the pH will be outside of the normal range.
Looking at the level of CO2 quickly helps rule in or out the respiratory system as the cause for the derangement in pH.
148
how to tell if ABG indicates metabolic
(and PaC02 Normal / low)
It’s all about the HCO3…
<80mmHg (Low)
Broadly speaking the causes can be either metabolic or respiratory. The changes in pH are caused by an imbalance in the CO2(respiratory) or HCO3– (metabolic). These work as buffers to keep the pH within a set range and when there is an abnormality in either of these the pH will be outside of the normal range.
Looking at the level of CO2 quickly helps rule in or out the respiratory system as the cause for the derangement in pH.
149
Conditions that may cause Respiratory Acidosis
```
respiratory acidosis
asthma
copd
emphysema
pneumonia
pulmonary odema
severe obesity
neuromuscular disorders 9 eg. muscular dystrophy)
shock/ trauma
```
150
Conditions that may cause Respiratory alkalosis
```
hyperventilation caused by:
Pain
Asthma
Pyrexia
COPD
Infection
MI
PE
Pregnancy
Panic attack/anxiety
Shock/trauma
```
151
conditions that may cause metabolic acidosis
```
diabetic acidosis
hyperchloremia
lactic acidosis
renal tubular acidosis
anorexia
```
152
conditions that may cause metabolic alkalosis
chloride responsive alkalosis
chloride resistant alkalosis
Chloride-responsive alkalosis results from loss of hydrogen ions, usually by vomiting or dehydration.
Chloride-resistant alkalosis results when your body retains too many bicarbonate (alkaline) ions, or when there's a shift of hydrogen ions from your blood to your cells.
153
WHAT DO I NEED TO KNOW ABOUT ABGs??
Is it normal or abnormal
Ph indicates acidosis or alkalosis
C02 and HC03 tell you if its respiratory or metabolic
C02 and HC03 tells you if compensation is occurring
```
- Base Excess – shows what is happening from a metabolic perspective
High BE (+) - >HC03 - primary metabolic alkalosis
Low BE (-) -
```
154
what is Base excess
Base Excess – shows what is happening from a metabolic perspective
Base Excess, the more abnormal the more significant the acidosis/alkolosis – the body has used up the Bicarbonate reserves
```
High BE (+) - >HC03 - primary metabolic alkalosis
Low BE (-) -
```
155
why take abgs
Evaluate a critically ill patient’s acid-base
| balance and oxygenation
156
can you use venous blood for abgs
Arterial blood used
| - provides truer reflection of gas exchange in pulmonary system
157
6 key measurements from abg test?
```
Six key measurements
pH
PaO2
SpO2
PaCO2
Bicarbonate (HCO3)
Base excess (BE)
```
158
normal paCO2
35-45mmHg
159
normal HCO3
22-26mmol/L
160
normal Base excess range
-2 to +2 ml/L
161
normal Pao2
80-100mmHg
162
System to interpret ABGS/ way to process
Step 1: Assess pH to determine if it is acidotic or alkalotic.
Step 2: If the blood is alkalotic or acidotic → determine if caused by respiratory or metabolic problem.
Step 3: Assess PaCO2 level → if pH ↓, PaCO2 should ↑ (visa-versa).
Step 4: Compare pH and PaCO2 values → opposite directions = problem primarily respiratory
Step 5: Assess HCO3 → as pH ↑ so does HCO3 (visa-versa).
Step 6: Compare pH and HCO3 values→ same direction = problem primarily metabolic
Step 7: Assess base excess (BE) → plus sign (+) = base excess (alkalosis)
→ minus sign (-) = base deficit (acidosis)
(WATCH TIC TAC TOE APPROACH VID :))
https://www.registerednursern.com/arterial-blood-gas-interpretation-for-nurses-and-nursing-students/
163
Initial assessment of acute CP or ACS symptoms involves :
Acute CP or ACS symptoms:
- 12 Lead ECG recorded and assessed within 10 mins of presentation
- Receive care based on the ACS Assessment Protocol
- Cardiac specific Troponin
Oxygen Therapy
- Only if SaO2 <93%
- COPD Patients Maintain SaO2 88-92%
Aspirin
- 300mg PO administered to all Pts ASAP (unless contraindicated)
164
assessment protocol for suspected ACS
view flow chart
```
troponin and ECG testing on presentation
=
if no high risk features
=
repeat troponin/ ECG at 6-8 hrs after pres
=
if no futher symptoms
= further objective testing or very low risk for ACS
```
(if futher symptoms= high risk for ACS protocol)
high risk for ACS
=
repeat troponin 6-8h
165
how to assess chest pain
```
P – precipitating factors
Q – quality
R – radiation
S – severity
T – time of onset
```
166
symptoms of acute coronary syndrome
Pain:
- Chest
- Left arm
- Right arm
- Both arms
- Neck
- Jaw
- back
Skin:
- Pale
- Sweaty
- Clammy
- cyanosed
Respiratory:
- Tachypnoea
- Dyspnoeic
- Pulmonary oedema
Physical signs:
- Nausea
- Vomiting
Psychological:
- Anxiety
- confusion
167
what is a Differential Dx
wo or more conditions that could be behind a person's symptoms.
168
Differential Dx for ACS
Ischaemic Cardiovascular causes
- ACS
- Stable Angina
- Severe aortic stenosis
- Tachyarrythmia
Non-ischaemic Cardiovascular causes
- Aortic dissection
- PE
- Pericarditis/myocarditis
- GI Causes
Non-CV causes
- Muscoskeletal causes
- Pulmonary
- Other (sickle cell crisis, herpes zoster)
169
review decision making and timing considerations in reperfusion of STEMI flowchart
review decision making and timing considerations in reperfusion of STEMI flowchart
170
normal sinus beat + how it coinsides with the conduction system
pqrst
- The P-Q segment represents the time the signals travel from the SA node to the AV node, and the QRS complex marks the firing of the AV node and represents ventricular depolarization ( conducting of electrical impulses into the ventricle bypassing the AV-His Purkinje conduction system).
- Atrial repolarization also occurs during this time but the signal is obscured by the large QRS complex because the heart's ventricles contract stronger than the Atria.
- The T wave represents ventricular repolarization
- The cycle repeats itself with every heartbeat.
```
DEPOLARIZATION= CONTRACTION
REPOLARIZATION= RELAXATION
```
review picture showing how each wave coinsides with heart conduction
171
describe ECG paper
ECG paper is standardised
All our monitors and ECG machines run the paper at 25mm/sec
The rate of the QRS complexes can be calculated
The width of the complexes can be measured.
172
compare regular and irregular ECG rhythms
compare regular and irregular ECG rhythms
173
how is regular ecg rate calulated
Count the number of large boxes between 2 R waves
Divide the number of large squares by 300
Eg 300/4 = 75
HR=75
174
how is irregular ecg rate calculated
On a 10 second rhythm strip - Count the number of QRS complexes and multiply by 6
Eg if there are 9 QRS complexes on the strip 9x6=54
HR=54
175
how to tell if ECG gap is normal or abnromal
Normal p-r interval = less than 5 small squares
The normal width for a QRS is 2.5 small squares
176
System for recognising a rhythm
What is the ventricular (QRS) rate (Fast/slow/normal)?
- Is the QRS rate regular or irregular
- Are p waves present
- is the QRS complex normal or prolonged
- is there a QRS for every p wave
177
common arrythymias?
The most important thing is to CHECK FOR A PULSE. It might be Pulseless Electrical Activity on your monitor
Arrhythmias can be:
Fast or slow
Narrow complex or broad complex
pulseless as with V.F. or asystole.
178
arrest rhythms
Ventricular fibrillation (VF), pulseless ventricular tachycardia (VT), pulseless electrical activity (PEA), and asystole.
179
what arrest rhythms are shockable
ventricular fibrillation (VF), pulseless ventricular tachycardia (VT)
180
what arrest rhythms are non shockable
pulseless electrical activity (PEA), and asystole.
181
when use 12 Lead ECG
Essential in critically ill patients even if they have no cardiac symptoms
All patients who have a cardiac event must have an ECG ASAP
Diagnosis can be made rapidly
Treatment can commence
Earlier treatment can lead to better prognosis
182
12 lead ECG placement
RA – Right clavicle
LA – Left clavicle
RL – Right hip
LL – Left hip
V1 – Fourth intercostal space at right sternal border
V2 – Fourth intercostal space at left sternal border
V3- Midway between V2 and V4.
V4 – Fifth intercostal space left of midclavicular line.
V5 – Anterior axillary line at same level as V4
V6 – Midaxillary line at same level as V4
183
review ECG rhythm image (lateral, septal, anterior and inferior)
review ECG rhythm (lateral, septal, anterior and inferior
184
Respiratory acidosis is caused by
Alveolar hypoventilation
eg. copd
Mechanical ventilation
eg. acute respiratory distress syndrome
Inadequate perfusion
eg.copd
185
Physiological compensatory mechanisms in altered ABG patients
Initial response increased respiratory rate and depth of breathing
Increase in minute ventilation
Increased heart rate
Possible vasoconstriction
Peripheral chemoreceptors detect hypoxia and initiate compensatory mechanisms
186
clinical presentation of type 1 respiratory failure
```
Type I
Hypoxaemic
Low PaO2
Normal or low PaCO2
Mismatch between ventilation and Perfusion
```
187
clinical presentation of type 2 respiratory failure
Type II
Hypercapnoeic/hypoxaemic
High PaCO2 and Low PaO2
Alveolar hypoventilation – inadequate exchange of oxygen and carbon dioxide
188
ALTERATIONS IN PULMONARY GAS EXCHANGE common patient presentations
Pt often present with : Tachypnoea small tidal volume, tachycardia, confusion
189
assessment of ALTERAed PULMONARY GAS EXCHANGE
Assessment
......Inspection- RR, pattern, tidal volume, cyanosis, GCS, sweating
.....Auscultation
190
Diagnostic testing of ALTERAed PULMONARY GAS EXCHANGE
```
Diagnostic testing
CXR
ABG
Pulse oximetry
End tidal CO2 monitoring (capnography)
MC&S
```
191
What is non invasive ventilation (NIV)
- Non Invasive Positive Pressure Ventilation delivers positive pressure breaths to a spontaneously breathing patient.
- Delivered by a mask with an airtight seal
- Reduces the occurrence of patients being intubated
192
What is CPAP
CPAP (Continuous positive airway pressure)
Support for spontaneously breathing patients and ventilated patients
Non invasively via a mask
Addition to mechanical ventilation
The raised positive pressure assists in reducing the work of breathing on inspiration
Increases gas exchange and reduces hypoxia
Commonly used in patients with
-pulmonary oedema
COPD
Asthma
193
What is BiPAP
BiPAP (Bilevel positive airway pressure)
Involves-
-IPAP (Inspiratory positive airway pressure)
....A higher pressure is delivered on inspiration
-EPAP (Expiratory positive airway pressure)
....Lower pressure (but still positive) on expiration
Commonly used in-
- high dependency patients
- Neurological disorders (Guillain Barre syndrome)
- OSA (Obstructive sleep apneoa)
- COPD
- Asthma
- Post extubation weaning issues
194
indications for invasive positive pressure ventilation (IPPV) (mechanical ventilation)
Indications
- inability to protect own airway (gag response diminshed, GCS reduced)
- inadequate breathing pattern rate and/or depth (vital capicity <15mL/kg; resp rate < 10 or > 30/min)
- inability to sustain O2 demands of the body PaO2 <55 mmHg, with supplemental O2,
- hypercapnia PCO2 > 50mmHg with acidosis pH< 7.3.
195
Clinical Conditions requiring ventilation support
- Respiratory failure (Type I)
- Post anaesthetic respiratory support
- Acute lung injury (ARDS)
- Asthma
- Pulmonary embolism
- Pneumonia
...Community acquired
...Hospital acquired
...Ventilator associated
...Aspiration
196
what is trage
From the French ‘to Sort’
Been used for over 200 years (Napoleonic War)
A system to categorise patients based on the severity of their condition
197
what are some of the different triage practices
Different dependent on country
Canadian Emergency Department Triage and Acuity Scales (CTAS)
Manchester Triage Scale (MTS)
Australian Triage Scale (ATS)
198
describe triage in the Australian context
Australian Triage Scale (ATS)
Should take 2-5 minutes to complete
Describes clinical urgency – not severity
5 categories
199
What is the order of ATS catergories, colours amd treatement acuities/ max wait time for medical assessment and treatment
ATS1, Red, Immediate
ATS2, Orange, 10 minutes
ATS3, Green, 30 minutes
ATS4, Blue, 60 minutes
ATS5, white, 120 minutes
200
response, description and clinical descriptor/ indicators of ATS catergory 1
R-
Immediate simultaneous assessment and treatment
D- Immediately Life- Threatening
Conditions that are threats to life (or imminent risk of deterioration) and require immediate aggressive intervention.
C- eg.
Cardiac arrest Respiratory arrest
Immediate risk to airway – impending arrest Respiratory rate <10/min
Extreme respiratory distress
BP< 80 (adult) or severely shocked child/infant
Unresponsive or responds to pain only (GCS < 9) Ongoing/prolonged seizure
IV overdose and unresponsive or hypoventilation
Severe behavioural disorder with
immediate threat of dangerous violence
201
response, description and clinical descriptor/ indicators of ATS catergory 2
R- Assessment and treatment within 10 minutes
(assessment and treatment often simultaneous)
D- Imminently life-threatening , Important time-critical treatment, Very severe pain
```
C- eg.
Airway risk – severe stridor or drooling with distressSevere respiratory distress
Circulatory compromise
Chest pain of likely cardiac nature
? Sepsis
BGL <3mmol/l
GCS<13
Acute CVA
Multi Trauma
Chemical to eye – acid/alkali
Major fracture
PE
AAA
Psychiatric/behavioural
```
202
response, description and clinical descriptor/ indicators of ATS catergory 3
R- Assessment and treatment within 30 minutes
D- Potentially life-threatening (life or limb)
, Situational urgency – potential for adverse outcome, Relief of severe discomfort
D-
Severe hypertensionModerately severe blood loss – any cause Moderate shortness of breath
Seizure (now alert)
Persistent vomitingDehydrationHead injury with short LOC- now alert
Suspected sepsis (physiologically stable)
Moderately severe painChest pain likely non-cardiac and mod severity
Abdominal pain without high risk features
Moderate limb injury – deformity, severe laceration, crushLimb – altered sensation, acutely absent pulse
Trauma - high-risk history with no other high- risk features
Stable neonate
Child at risk of abuse/suspected non-accidental injury
Behavioural/Psychiatric:
203
response, description and clinical descriptor/ indicators of ATS catergory 4
R- Assessment and treatment start within 60 minutes
D- Potentially serious (life or limb), Situational urgency – potential for adverse outcome, Significant complexity or Severity, Relief of discomfort within one hour
C- eg.
Mild haemorrhage
Foreign body aspiration, no respiratory distress
Chest injury without rib pain or respiratory distressDifficulty swallowing, no respiratory distress
Minor head injury, no loss of consciousness
Moderate pain, some risk features
Vomiting or diarrhoea without dehydration
Eye inflammation or foreign body – normal vision
Minor limb trauma – sprained ankle, possible fracture, uncomplicated laceration requiring investigation or intervention – Normal vital signs, low/moderate pain
Tight cast, no neurovascular impairment Swollen “hot” joint
Non-specific abdominal pain
Behavioural/Psychiatric
204
response, description and clinical descriptor/ indicators of ATS catergory 5
R- Assessment and treatment start within 120 minutes
D- Less Urgent – chronic/minor, Clinico-administrative problemsResults review, medical certificates, prescriptions only
C- eg.
Minimal pain with no high risk features
Low-risk history and now asymptomatic
Minor symptoms of existing stable illness
Minor symptoms of low-risk conditions
Minor wounds - small abrasions, minor lacerations (not requiring sutures)
Scheduled revisit e.g. wound review, complex dressings
Immunisation only
Behavioural/Psychiatric
205
Triage vs Prioritisation
Triage is sorting patient status depending on clinical presentation
Prioritisation – most important patient problems or issues
206
what are priorities of care base of?
Based on assessment data collected
ABCDE
Breaking down complex clinical situations into manageable parts
eg. Clinical Reasoning Cycle
207
prioritisation of care needs examples
Prioritisation of Care Needs :
- Needs of the patient
- Resources of healthcare system
- Limitations of time
208
describe cancer prevalence in Australia
Nearly 145,000 new cancer cases diagnosed 2019
1 new diagnosis every 4 minutes
1 in 4 men and 1 in 6 women will die from cancer by age 85
137 deaths per day 2019
1 in 9 hospitalisations in 2016/17 due to cancer
209
most common cancers in australian males ( most to least)
```
prostate
colorectal
melanoma skin
lung
head and neck
```
210
most common cancers in australian females ( most to least)
```
breast
colorectal
melanoma skin
lung
uterus
```
211
What is TNM staging
Cancer is staged according to TNM staging. This stands for Tumour, Nodes and metastases.
212
What are the TNM staging catergoies in relation to breast cancer
review diagram
```
T- primary tumour
T0= breast free tumour
T1= lesions less than 2cm
T2= 2-5cm lesion
T3= skin and or/... by invasion
```
```
N= Lymph node invasion
N0= No axillary nodes
N1= Mobile nodes
N2= fixed nodes
```
```
M= extent of distant
M0= no metastases
M1= denomstrable metastases
M2= suspected Metastasis
```
213
What are the TNM staging catergoies in relation to breast cancer
review diagram
Cancer is staged according to TNM staging. This stands for Tumour, Nodes and Metastases.
The tumour is staged according to size and tissue invasion.
The lymph nodes are staged according to their involvement.
0 indication no lymph node involvement, up to 2 – indicating Fixed nodes involved.
M stands for metastases – M0 means that there are no metastases, M2 means there are suspected distant metastases.
```
T- primary tumour
T0= breast free tumour
T1= lesions less than 2cm
T2= 2-5cm lesion
T3= skin and or/... by invasion
```
```
N= Lymph node invasion
N0= No axillary nodes
N1= Mobile nodes
N2= fixed nodes
```
```
M= extent of distant
M0= no metastases
M1= denomstrable metastases
M2= suspected Metastasis
```
214
describe cancer screening in australia
- Testing of asymptomatic population
- Large research project in Australia – significantly fewer deaths in people diagnosed from screening
- Breast cancer diagnosis through BreastScreen Australia = 69% lower risk of dying
- Cervical cancer diagnosis through Screening = 87% lower risk of dying
- Bowel cancer diagnosis through Screening = 59% lower risk of dying
215
decscribe the clinical manifestation of pain in cancer patients
Little or no pain is associated with early stages of malignancy
Influenced by fear, anxiety, sleep loss, fatigue, and overall physical deterioration
Caused by tumour causing pressure, obstruction, stretching, tissue destruction and inflammation
216
decscribe the clinical manifestation of infection in cancer patients
Risk increases when the absolute neutrophil and lymphocyte counts fall
Due to direct tumour invasion of the bone marrow
Cancers (leukaemias) of the blood forming cells
Chemotherapy drugs that are toxic to the bone marrow
217
decscribe the clinical manifestation of anaemia in cancer patients
A decrease of haemoglobin in the blood
Caused by:
- Chronic bleeding = iron deficiency,
- medical therapies
- malignancy in blood-forming organs
- suppression of the bone marrow by disease or treatment,
218
decscribe the clinical manifestation of fatigue in cancer patients
Fatigue
Can be debilitating and difficult to measure
Causes
- Sleep disturbance,
- biochemical changes from circulating cytokines
- secondary to disease and treatment
- psychosocial factors, level of activity
- nutritional status
- anaemia
219
decscribe the clinical manifestation of cachexia in cancer patients
Most severe form of malnutrition
Can lose 80% of adipose and skeletal muscle mass
Manifestations include:
- Anorexia
- weight loss
- taste alterations
- altered metabolism
220
describe breast cancer in australia
Breast cancer is the most common cancer in women in Australia.
Breast cancer is the abnormal growth of the cells lining the breast lobules or ducts.
Both men and women can develop breast cancer, although it is uncommon in men (1 in 8 women, 1 in 719 men).
221
symptoms of breast cancer in australia
Breast Mass or thickening
A lump in the underarm or above the collarbone
Skin rash near the nipple area
Dimpling in an area of the breast
Nipple discharge
Burning, stinging or pricking sensation
The symptoms of breast cancer include a breast mass or thickening – READ FROM SLIDE
Its important to be aware that women can also suffer from other breast conditions that are not cancerous, such as fibrocystic changes.
222
breast cancer diagnisis methods
Breast examination
Mammogram
Fine needle biopsy
Breast cancer can be diagnosed by a number of factors – clinical breast examination can indicate a lump.
A mammogram can identify a lesion up to 2 years before it becomes palpable. Mammograms are recommended every 2 years in women in Australia aged 50 – 69 and also free if you are over 40.
If a suspicious lump is found, a percutaneous needle biopsy can be performed for further analysis.
223
breast cancer treatment options
- Lumpectomy
- Mastectomy
- Radiation
- Chemotherapy
– a lumpectomy focusses on removing the lump and surrounding tissues – this is a good option for smaller carcinomas.
A mastectomy is the complete removal of breast tissue in its simple form or a radical mastectomy is the removal of the entire affected breast, chest muscles and axillary lymph nodes - one of the side effects of this surgery is Lymphedema.
224
lumpectomy vs masectomy
– a lumpectomy focusses on removing the lump and surrounding tissues – this is a good option for smaller carcinomas.
A mastectomy is the complete removal of breast tissue in its simple form or a radical mastectomy is the removal of the entire affected breast, chest muscles and axillary lymph nodes - one of the side effects of this surgery is Lymphedema.
225
what does breast cancer care in the community involve
```
Post op care
Psychological support for the patient and family
Pain relief – Medications, heat packs, alternative therapies
Wound care
Education
...Medications
....Side effects
....Lymphatic drainage massage
.....Handwashing & wound care
Counselling/Support services
```
226
what does breast cancer care in the hospital involve
Psychological support for the patient and family
Pre & post op care
Psychological support for the patient and family
.....Altered body image
.....Personal fear/Anxiety
Pain relief – Medications, heat packs, alternative therapies
Education
....Medications
.....Side effects
227
nursing care for breast cancer hospital vs community
Nursing care for a patient with breast cancer can encompass many different things.
You could be on a surgical ward providing pre and post op care for a patient following a radical mastectomy.
You could be working in a GP clinic or the community setting or administering chemotherapy in an oncology unit.
Whatever are you may be working in, the patient may need psychological support – not only may they have an altered body image, they may also have a lot of fear or anxiety about their condition and treatment options
228
describe prostate cancer
Most common cancer in men in Australia
Curable if diagnosed early
Metastatic prostate cancer is incurable
Almost all primary prostate cancers are adencarcinomas
As the tumour enlarges, it compresses the urethra, impeding the flow of urine
Diagnosed by digital rectal exam or PSA
229
prostate cancer symptoms
Can be asymptomatic in the early stages
Symptoms dependent on size of malignancy
Can include urgency, frequency, hesitancy, dysuria and nocturia
Haematuria, blood in the ejaculate
Erectile dysfunction
Bone pain
Nerve pain
Fatigue
Weight loss
230
prostate cancer treatment options
Surgery
Radiation therapy
Hormonal therapy
231
Describe surgery for prostate cancer
TURP (trans urethral resection of prostate)
Radical Prostatectomy (removal of prostate, prostate capsule, seminal vessels and portion of the bladder neck)
232
describe hormonal therapy for prostate cancer
Focuses on reducing Androgen as prostate cancer cells are androgen dependent and may die if deprived of androgen.
Adrogen deprivation therapy is used to treat advanced prostate cancer by aiming to increase survivial rate by decreasing testosterone levels since prostate cancer is adnrogen dependent.
233
prostate cancer nursing care in the hospital
```
Pre & Post op care – TURP, Prostatectomy
Health education
Psychological support
....Distorted body image
....Erectile dysfunction
Incontinence assessment
....Promote pelvic floor exercises
....Liaise with physiotherapist or continence specialist
Catheter Care
Pain management
```
234
prostate cancer nursing care in the community
```
Health promotion – Nurses can increase public awareness, early diagnosis saves lives
Post op care
Psychological support
...Distorted body image
...Erectile dysfunction
Incontinence care
Catheter Care
Pain management
Counselling
UTI/Post op Infection care
```
235
describe lung cancer
90 % of lung cancers are caused by tobacco smoking
Ex-smokers do reduce their risk of developing lung cancer, though their risk is still higher than a non smoker
```
Many different types of tumour
Small cell carcinoma
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma
```
236
types of lung cell tumours
```
Many different types of tumour
Small cell carcinoma
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma
```
237
lung cancer symptoms
Chronic cough, haemoptysis, wheezing, SOB
Dull, aching or pleuritic chest pain due to the tumour growing
Hoarseness/dysphagia due to tumour pressing on the trachea or osophagus
238
lung cancer treatment
Prognosis often poor (due to the advanced stage when diagnosed.)
Surgery may be an option
...Wedge resection
...Lobectomy
....Pneumonectomy
Chemotherapy & Radiotherapy
Palliative care
239
lung cancer nursing care in the hospital
```
Pre & Post op care – Lobectomy
Nutritional support
Health education/promotion
Psychological support
Pain management
Palliative Care
End of Life Care
```
240
lung cancer nursing care in the community
```
Post op care
Wound care
Nutritional support
Health education/promotion
Psychological support
Pain management
Palliative Care
End of Life Care
```
241
what do you assess in disability
Disability – Not Mobility
| Assess Conscious level
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why assess disability/ what type of patients need disability assessment
to assess for altered mental status, deterioration
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external Causes of neuro deterioration
External factors:
- Traumatic brain injury
- Alcohol
- Drugs / medication / poisoning e.g. envenomation
- Environment e.g. hypothermia
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internal causes of neuro deterioration
Internal factors
- Stroke
- Blood glucose
- Neuro disorders e.g. - Parkinsons disease
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outline disability assessment components
Think Double ‘D’ - Disability and Diabetes
- Assess conscious level
.....Rapid – AVPU
.....Accurate - Glasgow Coma Score
Capillary Blood Glucose Measurement
Other assessments:
....FAST – Face, Arm, Speech Time
....RACE scale
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what is the gcs used for
To assess the level of consciousness
Eye opening- 4
Verbal response- 5
Motor response (movement)- 6
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GCS
| eye response outlined
spontaneous- The Patient’s eyes open when you come to their side (4)
To voice- The Patient’s eyes open to command. (3)
To pain- The Patient’s eyes open to Sternum rub, nail bed pressure, examples; starting IV or drawing blood. (2)
None- The Patient’s eyes do not open at all (1)
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GCS verbal response outlined
Orientated- The patient can give name, address and day of the week. (5)
Confused- The patient gives name but are less likely to know their address or day of the week. Most patient’s at this level can name the Prime Minister. Names seem to be retained better than numbers. (4)
Inappropriate words- Inconsistent answers: patient can give their name but only occasionally. Profanity is often retained and frequently the patient repeats the same word over and over. (3)
Incomprehensible sounds- The patient may have deteriorated to the point that intubation has to be done. Intoxicated patient’s may be at this level. (2)
No response- no verbal response (1)
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GCS motor response outlines
obeys command- Commands maybe complex, as in cranial assessment e.g.: “squeeze my hand”. A positive response from the patient is only meaningful if the second part of the command, “now let go” is also performed. (6)
Localises pain- The patient is able to localize the source of the pain.
(5)
Withdraws (pain)- The patient knows there is pain, but can not localize it. The whole body withdraws from the pain. (4)
Flexion- Abnormal flexion. The patient flexes their arms tightly on their chest and extends the lower extremities. (3)
Extension- Abnormal extension. The upper extremities extend on stimulation or as the situation worsens spontaneously. (2)
No response- No response; the patient is flaccid. Occasionally as the situation worsens, a weak flexor response develops in the lower extremities. This is a spinal reflex and is a grim prognostic sign.
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What are the 2 waning postures
decorticate posturing/ flexion (HANDS IN)
Decerebrate posturing/ extension (Hands out)
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describe decorticate posturing/ abnormal flexion
Indicates that there may be damage to areas including the cerebral hemispheres, the internal capsule, and the thalamus.
an ominous sign of severe brain damage, and may also indicate lesion(s) in the lower brainstem.
Normally people displaying decorticate or decerebrate posturing are in a coma and have poor prognoses, with risks for cardiac arrythmia or arrest and respiratory failure.
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describe decerebrate posture/ abnormal extension
It is exhibited by people with lesions or compression in the midbrain lesions in the cerebellum.
Progression from decorticate posturing to decerebrate posturing is often indicative of tonsilar brain herniation.
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describe pupillary response assessment
Pupil Size
Reaction to Light
Assessment
- Pupil size and shape
- Pupil Reaction Light (PRL)
- Eye Movements
Documentation
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Internal causes of neuro deterioration
Stroke – ischaemic / haemorrhagic
- Treatment dependent on time since onset, comorbidities, frailty, healthcare resources
Blood glucose levels
- Hypoglycaemia mimics stroke symptoms
Other neuro diseases
- Do not usually present in acute / critical care – BUT - can significantly affect assessment / management
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External causes of neuro deterioration
Alcohol
Drugs / medication / poisoning e.g. envenomation
Environment e.g. hypothermia
Traumatic brain injury
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Alcohol affects function of:
Cerebrum – loss of inhibition, increased pain tolerance
Cerebellum – loss of fine motor function and coordination
Brainstem – depression of reticular activating system
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describe how exposure assessment relates to disability assessment
Expose your patient looking for:
- Needle marks
- Wounds
- Abrasions
- Snake bites/poisons
- Anything else
Environment (Fahrenheit)
- Temperature control
- Patients get cold – quickly!
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what is tbi and possible causes
Previously known as ‘Head Injury’
‘….alteration in brain function, or other evidence of brain pathology, caused by an external force, which can affect the scalp, skull or brain.’ (Aitken et al p585)
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possible causes of TBI
```
may be caused by
Falls
RTA
Hit with object/against object
Gunshot wounds
etc
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TBI Classification
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Mild
GCS 13- 15
Concussions – sports trauma
Dizziness, confusion, vomiting 4hrs
CT head recommended
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Moderate
GCS 9-12
CT Head and 24hr in hospital observation (Minimum)
Severe
GCS<8
Resuscitation
All patients – GCS Lower than 8 - INTUBATE
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TBI mild classification
GCS 13- 15
Concussions – sports trauma
Dizziness, confusion, vomiting 4hrs
CT head recommended
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TBI severe classification
GCS<8
Resuscitation
All patients – GCS Lower than 8 - INTUBATE
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TBI priorities
Identify >ICP
Neuro obs- frequently
GCS
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What is endocarditis
An infection of the heart's inner lining, usually involving the heart valves.
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What is a cardiomyopathy
Cardiomyopathy is a progressive disease of the myocardium, or heart muscle. In most cases, the heart muscle weakens and is unable to pump blood to the rest of the body as well as it should.
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What is an anyrysm
An aneurysm is an abnormal swelling or bulge in the wall of a blood vessel, such as an artery.
