Final Exam Module 7 & 8 Flashcards
What condition?
Genetic hemoglobin disorder; formation of abnormal hemoglobin chains. Autosomal recessive pattern of inheritance.
Patho: Clumps block flow (vaso-occlusive event) causing tissue to become hypoxic. Results in inadequate perfusion and ischemia
Sickle cell crisis
Conditions that may cause sickling
hypoxia, dehydration, infection, venous stasis, pregnancy, alcohol consumption, nicotine use, high altitudes, acidosis, strenuous exercise, emotional stress, anesthesia, low/high environmental or body temperature
Important to understand the s/sx of sickle cell crisis and to prioritize which one(s) are of most concern!
Pain and reduced perfusion
**Pain is the most common SCD crisis symptom
Cardiovascular changes
Murmurs, JVD, peripheral pulses, capillary refill. Signs of decreased perfusion?
Respiratory changes
Risk for recurrent pneumonia, pulmonary HTN; assess for shortness of breath
Skin changes
Pallor, cyanosis (lips, nail beds), etc.
Lower extremity ulcers > may become infected and necrotic
Abdominal changes
Damage to spleen and/or liver > enlargement; jaundice
Kidney and urinary changes
Decreased urine output? Risk for chronic kidney disease
Musculoskeletal changes
Joint pain; assess range of motion and pain with movement
Central nervous system changes
Seizures, stroke-like symptoms
Potential complications r/t Sickle cell crisis
-Infection
-Chronic Kidney Disease
-Necrotic Ulcers on LE
-Acute Chest Syndrome (common reason for hospitalization & most common cause of death)
-Respiratory infection or embolism
It is important to know the treatment options for managing pain in a sickle cell patient. Which pain management intervention is the better option?
Remember- SCD patients face a lot of healthcare stigma
-IV Analgesia – typically Morphine or Dilaudid for 48 hours via PCA
-Oral opiates or NSAIDS for moderate pain
-Integrative therapies: keeping room temp. warm, distraction and relaxation, aromatherapy, warm soaks and compresses
-Hydroxyurea: stimulates fetal hemoglobin production (long term risk for leukemia)
-Endari: delays and decreases complications of SCD. Composed of amino acid glutamine (lowers oxidative stress and decreases sickling rates)
-Crizanlizumab: monoclonal antibody that inhibits selection. Prevents adhesion and vaso-occlusive crises.
Why should we nebulize O2 when providing oxygen to SCD patients?
prevent dehydration
What antibiotic is used to prevent infection in SCD patients?
This antibiotic decreases the number of pneumonia and streptococcal infections.
Penicillin BID
SCD- Things to remember regarding transfusions
-Increased HbA levels and dilutes HbS levels
-Risk for iron overload with repeat transfusion
-Assess for transfusion reactions
What condition?
Destructive reduction of circulating platelets after normal platelet production
Thrombocytopenia
What are the three types of thrombocytopenia?
Autoimmune thrombocytopenia purpura (ATP)
Thrombotic thrombocytopenia purpura (TTP)
Heparin-induced thrombocytopenia (HIT)
What type of thrombocytopenia?
Antibodies are produced against platelets, then platelets are destroyed by macrophages in the spleen. Platelet production still occurs but may not be able to keep up with the number of platelets being destroyed.
Clotting impaired with decreased number of platelets
Autoimmune thrombocytopenia purpura (ATP)
Important to understand the medications used to treat ATP and why they are being used.
Treatment is initiated with platelet counts less than 50,000, active bleeding, or high risk for bleeding.
Main MOA is immunosuppression
-Corticosteroids
-Azathioprine (DMARD)
-Eltrombopag
-Rituximab
-Romiplostim
ATP complications include:
hemorrhage and intracranial bleeding-induced stroke
Surgical management for ATP?
splenectomy for pts who do not respond to drug therapy
Spleen is site of excessive platelet destruction
What type of thrombocytopenia?
Abnormality of platelet clumping during trauma or surgery. Caused by autoimmune reaction in small blood vessels that starts platelet clotting and aggregation at the endothelial cells. Clots and platelet plugs formed where not needed, and failure to clot at site of trauma. Tissue becomes ischemic leading to kidney failure, MI, and stroke.
Thrombotic thrombocytopenia purpura (TTP)
Drug therapy used for TTP
Antiplatelets (aspirin, alprostadil, plicamycin) and immunosuppressive therapy
How do we manage TTP?
Prevent platelet clumping and stopping the autoimmune process- plasma removal and FFP.
If TTP is left untreated it is fatal within 3 months.
What type of thrombocytopenia?
Potentially devastating immune-mediated adverse drug reaction caused by the emergence of antibodies that activate platelets in the presence of heparin. Can occur in patients receiving any type of heparin, although it is more common after exposure to unfractionated heparin.
Heparin-induced thrombocytopenia (HIT)
Higher incidence of HIT among patients with risk factors of:
-Duration of heparin use longer than one week
-Exposure to unfractionated heparin
-Postsurgical thromboprophylaxis
-Being female
S/sx of HIT
venous thromboembolism (VTE) such as DVT and PE
What is the hallmark sign of HIT? What labs are important to monitor?
Thrombocytopenia after heparin exposure.
Important to monitor pt’s platelet levels when they are on heparin therapy. A drastic drop in platelets is a RED FLAG and a can’t miss!
Drug management for HIT is focused on direct thrombin inhibitor. What meds are used?
argatroban (Acova) and lepirudin (Refludan)
HIT cues to watch out for?
large bruises, mucosal bleeding, petechial rash, and anemia
What type of transfusion?
Replaces cells lost form trauma or surgery. Donor and recipient must be assessed for compatibility.
RBC transfusion
What type of transfusion?
Given for low platelet counts (less than 10,000), active bleeding episode, or scheduled invasive procedure.
May be from multiple donors. Do not have to be from a donor with the same blood type. Must be immediately transfused once brought into the room & over 15-30 minute period of time.
Platelet transfusion
What type of transfusion?
Replaces blood volume and clotting factors.
May be given fresh, but is often frozen after donation.
Infuse immediately after thawing (clotting factors still active). Infuse rapidly over 30-60 minutes.
Plasma transfusions
What type of transfusion is given to neutropenic clients? Requires strict monitoring due to reaction rate being high.
Granulocyte (WBC) transfusion
What type of transfusion?
Given when H&H levels are low from trauma situation or other active bleed.
Massive transfusion
Active Transfusion Reactions
It is important to understand what an acute transfusion reaction looks like and what to do if the patient experiences a reaction!
Febrile – chills, fever, tachycardia, hypotension, and tachypnea
-Occurs in people with anti-WBC antibodies
-Leukocyte-reduce blood reduces risk
Hemolytic
-Blood type or Rh incompatibility
-Antigen-antibody complexes initiate inflammatory response
-May be mild (fever or chills; or severe (DIC)
Allergic – itching, bronchospasm, or anaphylaxis
-Experienced in individuals with multiple allergies
Bacterial – tachycardia, hypotension, fever, chills, and shock
-Contaminated blood products
Circulatory overload – HTN, bounding pulse, JVD, dyspnea, restlessness, and confusion
-Whole blood or multiple transfusions
Transfusion-associated graft-versus-host disease (TA-GVHD)
-Rare, but serious in immunocompromised individuals
-Thrombocytopenia, anorexia, n/v
Interventions, if transfusion reaction occurs
-Immediately stop the transfusion and disconnect the tubing
-Initiate Rapid Response team
-Notify blood bank
-Often blood products are returned for evaluation
-Flush IV site with NS
-Apply oxygen
-IV push diphenhydramine
-Assess vitals and need for hemodynamic monitoring
What do you do FIRST if there is a transfusion reaction?
STOP THE INFUSION
What condition?
A serious disorder in which proteins that control blood clotting become overactive. The underlying cause is usually due to inflammation, infection, or cancer.
Disseminated Intravascular Coagulation (DIC)
Most common cause of DIC? Other causes?
Sepsis is the most common cause.
Other causes: pancreatitis, severe burns, trauma or major surgery, cancer, pregnancy complications, blood transfusion reaction, organ transplant reaction, & snake bites
It is important to understand what DIC looks like & red flags
Assessment:
Skin- rash of small purplish spots or red spots, bruising
Acute renal failure, bleeding, blood clots, bruising, liver failure, mental confusion, or respiratory distress
What labs would be ordered for DIC?
CBC, PT/INR, PTT, Fibrinogen level, D-dimer to assess for blood clots
DIC Tx includes:
-Must treat underlying condition
-Plasma transfusion to reduce bleeding (usually FFP)
-PRBC and/or platelet transfusions
-Anticoagulant medication to release clothing factors
-Cryoprecipitate- prepared from plasma and contains fibrinogen, von Willebrand factor, factor VIII, factor XIII, and fibronectin. Only adequate fibrinogen concentrate available for IV use.
What condition?
Infection in bony tissue. Caused by bacteria, virus, parasites, or fungi
Osteomyelitis
It is important to know the s/sx of Osteomyelitis
-Bone pain- constant and localized
-Fever- greater than 101
-Erythema, tenderness, edema, and heat in the area of the infected bone
-Elevated WBC count
Osteomyelitis: MRI and radionuclide scans to evaluate extent of infection to surrounding soft tissue. MRI contraindications?
Consult with the provider if contraindications are present.
Antibiotic therapy key points for Osteomyelitis
-4-6 weeks IV antibiotic therapy (acute cases)
-Prolonged therapy >3 months (chronic cases)
Requires PICC line
-History of IV drug use? If so, patient will need skilled nursing facility to complete therapy.
Break or disruption in continuity of bone that affects mobility and comfort
Fractures
How to manage acute pain caused by fractures
-Opioid analgesics (oxycodone, oxycodone with acetaminophen, or oxycodone with hydrocodone), anti-inflammatory drugs, muscle relaxants
-Possible Patient-controlled analgesia (PCA)- morphine, fentanyl, or hydromorphone (Dilaudid) for severe and/or multiple fractures
Nonsurgical management for fractures include:
closed reduction and immobilization (most common), splints, orthopedic boots/shoes, casts, traction, drug therapy, and physical therapy
When a hard cast is applied, it is important to …
report any increased pain or numbness, regularly elevate the cast above the level of the heart to promote venous return, never get the cast wet, and continue to move fingers/toes
Surgical management: open reduction with internal fixation (ORIF) and external fixation with closed reduction (chosen for open fractures and involvement of soft tissue injuries)
Preop and post op care for these procedures include:
Preop care: regional nerve blockage
Postop care: Ketorolac (Toradol) to treat inflammation & pain, early ambulation
Stages of Bone Healing
Stage 1: hematoma forms at site of fracture 24-72 hours after injury
Stage 2: 3 days to 2 weeks, granulation tissue invades the hematoma > formation of fibrocartilage (foundation for healing)
Stage 3: vascular and cellular proliferation > callus formed by new vascular tissue.
Stage 4: callus is gradually resorbed and transformed into bone
Stage 5: final stage – consolidation and remodeling of bone. May be around 4-6 weeks after fracture, may continue up to one year
Complications r/t fractures:
Acute Compartment Syndrome
Crush Syndrome- kidney damage & MODS caused by the release of electrolytes and proteins into blood
Hemorrhage –> hypovolemic shock
Fat embolism syndrome
Venous thromboembolism
Infection- osteomyelitis
Avascular necrosis
Delayed bone healing
Complex regional pain syndrome
Compartment syndrome is a complication r/t fractures. Increased pressure leads to reduced circulation to the area.
What is the surgical management?
fasciotomy
Fat embolism is a serious complication r/t fractures. Fat from bone marrow is released into blood stream.
Hallmark sx? Other sx?
Hallmark sx: petechia on chest
Other sx: hypoxemia, dyspnea, and tachypnea
Performing neurovascular assessments prior to fracture treatment is PRIORITY. What are the 6 P’s?
6 P’s of fractures- Pain (even after analgesics are given), Paresthesia, Pressure, Paralysis, Pallor, and Pulselessness
Rib or sternum fracture, assess
ABC’s
