ANGINA PECTORIS Definition Angina pectoris is a symptom characterized by discomfort in the chest.

It is caused by inadequate blood supply to the myocardium. 1.Stable Angina predictable and consistent pain; occurs in exertion; relieved by rest. 2. Unstable Angina symptom occur more frequently and last longer than stable angina. Pain threshold is lower, pain may occur at rest 3.Variant Angina or Prinzmetals Angina-pain at rest with reversible ST-segment elevation;caused by coronary artery vasospasm, it usually occurs when a person is at rest or sleep and not after physical exertion or emotional stress. It is associated with acute myocardial infarction,severe cardiac arrhythmias including ventricular tachycardia and fibrillation and sudden cardiac death

Pathophysiology Myocardial ischemia is caused primarily by an inadequate blood supply or an increased demand for oxygen. The symptoms of angina differs from myocardial infarction in that angina is relieved by nitroglycerin and MI is not.

Risk factors smoking alcohol obesity sedentary life DM Diagnostic tests ECG ABG Cardiac Enzymes hyperlipidemia age (45 for male and 55 female) race stress personality

Assessment Discomfort in chest: -aching -tightness Tachycardia Activity or exertion Hypertension

-heaviness Circulatory status -dull pain Hypotension -may radiate to the neck,jaw,shoulder and inner aspect of the upper arms

Associated Nursing Diagnosis Ineffective cardiac tissue perfusion secondary to coronary artery disease as evidenced by chest pain Death anxiety Deficient knowledge about underlying disease and methods for avoiding complications Noncompliance,Ineffective therapeutic regimen Nursing Interventions Identify exact site of distress Direct patient to stop all activities and sit or rest in bed in a semi-fowlers position if chest pain is sensed Administer nitroglycerin: 1 tab every 5-15 minutes x 3 doses, report to MD if no relief; can also be given prior to an exhausting activity Encourage deep breathing to induce relaxation Monitor length of time (if not relieved in 15 minutes, other problems should be considered)

Pharmacologic Therapy Medicine Nitroglycerine Beta adrenergic blockers Calcium channel blocker Antiplatelet agent

NITROGLYCERINE (Nitrostat, Nitrol, Nitrobid IV) -A vasodilator ; mainstay for treatment of angina pectoris -it decrease myocardial oxygen consumption thus decrease ischemia and relieves pain BETA ADRENERGIC BLOCKERS ( propanol , metropol ,atenolol ) -it helps to decrease myocardial O2 consumption by blocking the -adrenergic sympathetic stimulation to the heart HR, slow circulation of an impulse through the heart ,BP Myocardial contractility control chest pain and delay onset of ischemia Contraindicated (+) asthma

CALCIUM CHANNEL BLOCKERS (amlodipine,verapamil,diltiazem) have different effect

Decrease SA node automaticity and AV node conductivity resulting in slower HR and decreased heart muscle contraction. Relax the blood vessel causing a decreased BP and increase coronary artery perfusion Dilates smooth muscle wall of coronary arterioles to increase myocardial O2 supply Used by patient who cannot take and with side effect with beta blockers and nitrates Prevent and treat vasospasm Amlodipine ( NORVASC) and felodipine (PLENDIL) DOC for heart failure

ANTIPLATELET & ANTICOAGULANT ( aspirin,clopidogrel & ticlopidine ,heparin ,GPIIb / IIIa agent) -To prevent platelet aggregation w/c impedes blood flow -aspirin- prevent platelet activation and reduce incidence of MI an death from CAD. -clopedogril & ticlopidine alternative for pt. with allergy on aspirin -heparin-it prevent the formation of new blood clot , it decreased the occurrence of MI to pt.with unstable angina. -GPIIIb / IIIa agent (abciximab,tirofibam,eptifibatide)-for Pt.with unstable angina It prevents the aggregation by blocking GPIIb/IIIa receptor on platelet to prevent adhesion of fibrinogen and other factors to each other forming a clot.

MYOCARDIAL INFARCTION causes of MI include coronary artery obstruction due to the progressive development of atherosclerosis; coronary artery spasm; embolism. Assessment Chest pain (described as substernal, crushing with radiation to the arm, neck, jaw, or back; pain is unrelieved by nitroglycerine) Dyspnea Changes in heart area Nausea Vomiting Fever (up to 101F over the first 24 to 48 hours) Increased WBC count and sedimentation rate Diagnostic test Echocardiogram use to evaluate ventricular function -detect hyperkinetic and akinetic wall motion and determine ejection fraction. -12-lead ECG may show ST elevation as the MI is evolving or Q waves when the MI is complete.

Laboratory test -After the onset of MI, enzyme elevation occurs as follows: Serum glutamic oxaloacetic transaminase (SGOT) peaks in 24 to 48 hours.(AST)

 Myoglobin found in many tissues heme protein thet help to transport O2 -found in cardiac and skeletal muscle -increase between 1-3 hours peak within 12 hrs. -(-) result repeat after 3 hrs Creatine Kinase Normal values: Males -38-174 U/L and Females 26-140 U/L Isoenzymes CKMM- skeletal ( 96-100%) CKBB brain (0%) CKMB cardiac (0-4%) Troponin normal level is <0.6 mg/ml Lactic acid dehydrogenase (LDH) found in many tissues

MARKER Myoglobin Creatine kinase CK MB Troponin I Lactic Acid Dehydrogenase

BEGINNING OF RISE AFTER INJURY 1-2 hours 4-6 hours 6-8 hours 1-6 hours 24 hours

PEAK AFTER INJURY 4 6 hours 24 hours 14 -36 hours 14-18 hours 72 hours

RETURN TO NORMAL 20-24 hours 3-4 days 48 72 hours 6-14 days 10 days

Nursing diagnosis Acute pain Ineffective cardiac tissue perfusion related to reduced coronary blood flow Risk for imbalanced fluid volume Anxiety Knowledge Deficit about post-MI self care NURSING INTERVENTIONS 1. Establish perfusion as soon as possible, because the heart cells can sustain ischemia for only about 20 minutes before cell death occurs. 2. Administer morphine sulfate or nitrates, as prescribed, to relieve chest pain. Goal is to minimize damage to the muscle and preserve function MONA Morphine

 Oxygen Nitroglycerin ASA Administer thrombolytic agents as streptokinase or tissue plasminogen activator (TPA), as prescribed, to limit infarct size. Provide supplemental oxygen via nasal cannula. 3.Monitor vital signs every 1 to 2 hours 4.Monitor cardiac rhythm for dysrhythmias, such as premature ventricular contractions (PVCs), ventricular tachycardia, second-degree type II Atrioventricular (AV) block, and complete heart block. 5.Monitor for signs of congestive heart failure. 6. Maintain intravenous line for emergency access. 7. Maintain bedrest, with the patient in Semi-Fowlers position, for the first 24 hours. Administer medications (eg, digitalis, antiarrhythmics, vasodilators, vasopressors, anticoagulants, diuretics, potassium, Colace, and sedatives) to limit the potential of complications, as ordered 8.Institute measures to decrease the oxygen demand (eg, provide a calm and restful environment, encourage the patient to rest, control pain). 9.Provide patient teaching to identify and reduce risk factors. 10.Prepare the patient for surgical interventions such as percutaneous transluminal coronary angioplasty (PCTA) or coronary artery bypass graft (CABG), if indicated.

Drug therapy Goal: to minimize myocardial damage ;prevent heart function and prevent complication Thrombolytics IV direct to coronary artery -to dissolve and lyse thrombus in a coronary artery ( thrombolysis) -to allow blood flow to the coronary artery again ( reperfusion ) -to minimize size of infarction,amd preserve ventricular fuction. Streptokinase most frequently used ( ateplase,reteplase,anistreplase) -increase the amount of circulating plasminogen activator w/c then increase the amout of circulating and clot bound plasmin. Ateplase tissue plasminogen activator ; increase the amount of plasminogen on the clot Analgesic Morphine sulfate analgesic of choice for acute M.I ;given in IV boluses -reduced pain and anxiety -relaxed bronchioles to enhance oxygenation Angitensin Converting Enzyme Inhibitor Angiotensin I form when the kidney release rennin in response to decrease BP

ACE found in the lumen of all blood vessel esp.in the lungs convert angiotensin I angiotensin II Angiotensin II- vasoconstrictor ;causing kidney to retain Na and excrete K ACE inhibitor prevent conversion of angiotensin I angiotensin II Contraindication to use ACE inhibitor -hypotension huponatremia -hypovolemia -hyperkalemia

Cardiac rehabilitation -program that target risk reduction by means of education ,individual and group suppot and physical activities Goal: to improve quality of life of post MI patient to limit the effect end progression of atherosclerosis to enhance psychosocial status of the patient to prevent another cardiac event PHASES Phase I begin w/ dx.of atherosclerosis ;when pt.is admitted for ACS consist of low level activities and initial education for pt. and family. -teaching the S/Sx requiring emergency assistant,medication regimen,rest and activity balance and follow up check-up. Phase II occurs after the pt.has been discharged -last for 4-6 weeks up to 6 months -OPD program consist of ECG monitored ,exercise training program. -support and guidance related to treatment

Phase III focused on maintaining CV stability and long term conditioning -pt. is self directed during this phase -does not required supervised program

CONGESTIVE HEART FAILURE Referred to as Congestive Heart Failure (CHF) or Ventricular Failure Only cardiac disorder on the rise Clinical state in which the heart is unable to maintain the cardiac output necessary to meet the bodys metabolic demands: Diastolic (ventricle pumps against extremely high afterload as in hypertension) and Systolic (ventricles are damage and cannot pump leading to extremely high preload.

Risk factors Coronary Artery disease Carditis Post Coronary Bypass Surgery DM

COPD Hypertension

Diagnostic test: ECG,ABG. Pulse Oximetry, X-ray Assessment: Dyspnea upon exertion Chest pain Distended Neck Veins Paroxysmal Nocturnal dyspnea

Orthopnea Peripheral Edema Fatigue

Nursing Diagnosis Activity Intolerance related to imbalance between oxygen supply and demand secondary to decreased cardiac output Fatigue secondary to heart failure Excess fluid volume related to excess fluid or sodium intake Anxiety related to breathlessness and restlessness secondary to inadequate oxygenation Powerlessness related to inability to perform role responsibilities secondary to chronic illness Noncompliance related to lack of knowledge Deficient knowledge of self-care program related to nonacceptance of necessary lifestyle changes Nursing Interventions Monitor patients response to activities. Encourage patient to perform an activity more slowly than usual for a shorter duration or with assistance Identify barriers that could limit patients ability to perform an activity and discuss methods of pacing an activity Administer diuretics early in the morning so that diuresis does not disturb nighttime rest Monitor fluid status closely: Auscultate lungs,compare daily weights and monitor input and output Teach patient to adhere to a low sodium diet. Encourage salt restrictions to 2-3g/day Restrict fluids as ordered,Strict I& O Place in high fowlers position Administer Oxygen as ordered Monitor for cardiogenic shock

Drug Of Choice: 1.Lasix- NI: Avoid to rapid IV push causes toxicity 2.Inotropin 3.Lanoxin- NI: Monitor apical pulse for 1 full minute prior to digoxin, hold if <60 bpm.Monitor for toxicity if given with furosemide 4.Analgesia

ADULT RESPIRATORY DISTRESS SYNDROME -Is characterized by noncardiac pulmonary edema and progressive refractory hypoxemia. It is known that ARDS does not occur as a primary process but may follow a number of diverse conditions producing direct or indirect lung injury Etiologic factors Aspiration (gastric secretions, drowning, hydrocarbons) Drug ingestion and overdose Hematologic disorders (disseminated intravascular coagulopathy [DIC], massive transfusions, cardiopulmonary bypass) Prolonged inhalation of high concentrations of oxygen, smoke, or corrosive substances Localized infection (bacterial, fungal, viral pneumonia) Metabolic disorders (pancreatitis, uremia) Shock (any cause) Trauma (pulmonary contusion, multiple fractures, head injury) Major surgery Fat or air embolism Systemic sepsis Manifestation Dyspnea tachypnea anxiety intercostal retractions crackles Diagnostic test arterial blood gases chest x-ray- shows bilateral infiltrates and pulmonary edema pulmonary function testing pulmonary artery pressure monitoring Nursing Diagnosis Impaired Gas Exchange related to congestion Ineffective breathing pattern Agitation Confusion Lethargy

Inadequate tissue perfusion Anxiety related to fear of death

Planning: The goal of patient care may include -Achieving adequate spontaneous,nonlabored ventilation -Maintaining Arterial blood gas values within normal limits for patient with ventilatory assistance -Ensuring that patient experiences minimal anxiety Nursing Intervention Monitor for life-threatening changes Provide chest physiotherapy Place in Semi or High Fowlers position Provide Supportive therapy for anxiety and fear Encourage rest to minimize O2 consumption Monitor mechanical ventilation Administer O2 at high flow 8-10 L/min (often with ventilator ET PEEP) Suction PRN Encourage fluid intake Monitor pulmonary artert pressure monitoring

Drug therapy inhaled nitric oxide surfactant corticosteroid Medical Management -prone positioning in conjuction with mechanical ventilation reduces the pressure surrounding tissue on dependent regions and improve oxygenation -fluid replacement -enteral and parenteral feeding -low-molecular-weight heparin may be ordered

DIABETIC KETOACIDOSIS -it is caused by an absence or inadequate amount of insulin.This results in disorders in the metabolism of carbohydrates, protein and fat 3 main clinical features 1.Hyperglycemia- due to decreased use of glucose by the cells and increased production of glucose by the liver 2.Dehydration and Electrolyte loss- resulting from polyuria 3.Acidosis- due to an excess breakdown of fat to fatty acids and production of ketone bodies, which are also acids

Etiological Factors Decreased or missed dose of insulin Illness or infection Undiagnosed or untreated diabetes

Assessment Polyuria and Polydipsia Blurred Vision, weakness and headache Orthostatic hypotension weak,rapid pulse anorexia,nausea, vomiting and abdominal pain acetone breath (fruity odor) Kussmaul respirations: hyperventilation with very deep, but not labored respirations Mental status changes Diagnostic Findings Blood glucose level:300 to 800mg/dl Low serum bicarbonate level:0 to 15mEq/L Low ph:6.8 to 7.3 Elevated creatinine ,BUN Nursing Diagnosis: Fluid Volume Deficit Risk for Electrolyte Imbalance Nursing Interventions Administer fluids as ordered, and monitor infusion carefully Monitor fluid volume status Monitor urine output to ensure adequate renal function Monitor for signs of fluid overload in elderly patients and those at risk of congestive heart failure Monitor carefully for hypokalemia due to rehydration and insulin treatment Observe frequently for signs of hyperkalemia (tall peaked T waves on ECG) Monitor blood glucose every 3 to 4 hours Take usual insulin dose Monitor VS hourly

ECG Electrocardiography (ECG) graphically measures & records the electrical current traveling through the conduction system generated by the heart measured by electrodes placed on the skin & connected to an amplifier & strip chart recorder

P WAVE Atrial depolarization /systole (contraction) Indicates impulse comes from SA node If (-) or abN position, impulse originates outside the SA node PR INTERVAL Time impulse travels from SAAV BB PF Normal: 0.12-0.20 sec. Short: impulse comes from AV node

Long: delayed conduction heart block

QRS COMPLEX Ventricular Depolarization Impulse traveled through R & L Ventricle resulting to ventricular contraction Normal: <0.12 sec. Q 1st (-) deflection R 1st (+) deflection S 2nd (-) deflection ST SEGMENT Normal is in isoelectric line (ventricles at rest) Elevated: MI (myocardial injury) Depressed: myocardial ischemia T WAVE Rounded wave form, taller & wider than P wave Ventricular Repolarization (rest or recovery) Inverted & sharply pointed: ISCHEMIA U WAVE Small, rounded, low amplitude after P wave Usually not seen in a normal ecg (+) late polarization of ventricles; low K+ Opposite direction w/ T wave: cardiac dse, HPH

ANALYZING ECG STEP 1: DETERMINE REGULARITY OF R WAVES -After finding out the patient's medical history, begin by labeling the P wave, PR interval, QRS complex, QT interval and T wave. -Determine if the rhythm is regular or irregular. This is done by accessing whether the RR Intervals and PP intervals are regularly spaced STEP 2. CALCULATE HEART RATE - FOR REGULAR RHYTHM Big Block Method: (300/# of R waves) in 3-sec strip. 1500/# small boxes bet R Memory Method: (300,150,100,75,60,50,43,33,30) FOR IRREGULAR RHYTHM: For 6 sec strip(#of R x 10) For 3 sec strip (#of R x 20) If less than 3 sec, count # of Rs x 40 STEP 3. IDENTIFY & EXAMINE P WAVES P waves should precede each QRS complex identical or near identical STEP 4: MEASURE PR INTERVALS Count # of boxes X 0.04sec STEP 5:MEASURE QRS COMPLEX # of boxes X 0.04

CEREBROVASCULAR ACCIDENT -It is an infarction that occurs in the brain. It is usually caused by a thrombus,embolism or haemorrhage Pathophysiology -It occurs when a local area of the brain is deprived of blood. Local or general disorders may cause the alteration of the blood supply. If cerebral circulation is interrupted extensively,cerebral anoxia or lack of oxygen to the brain develops.After 10 minutes changes to the brain resulting from cerebral anoxia are irreversible. Assessment Pupil response Rhythm and depth of respirations Level of consciousness Decerebrate posturing Decorticate posturing Nursing Diagnosis Impaired physical mobility re lated to hemiparesis,loss of balance and coordination,spasticity and brain injury Acute pain related to hemiplegia and disuse Deficient self-care related to stroke sequelae Disturbed sensory perception Impaired swallowing Total urinary incontinence related to flaccid bladder Disturbed thought processes related to brain damage Impaired verbal communication related to brain damage Risk for impaired skin integrity related to hemiparesis Interrupted family processes related to catastrophic illness and caregiving burdens Sexual dysfunction related to neurologic deficits or fear of failure Nursing Interventions Maintain airway Suction prn Insert foley catheter Watch for thrombophlebitis Monitor VS, watch out for increase in ICP Keep patient turned to side, change of position every 2 hours Position to prevent contractures, use measures to relieve pressure, assist in maintaining good body alignment and prevent compressive neuropathies, provide tennis shoes or therapeutic shoes to prevent footdrop Provide elastic hose to prevent deep vein thrombosis Elevate affected arm to prevent edema and fibrosis Provide passive Range of Motion exercises Observe patients for paroxysms of coughing,food dribbling out or pooling in one side of the mouth,and nasal regurgitation when swallowing liquids ( the client is at risk of aspiration) Advise patient to take smaller boluses of food and provide thicker liquids or pureed diet as indicated Provide high-fiber diet and adequate fluid intake

Monitor I& O Monitor LOC Auscultate for breath sounds ( the client is at risk of pneumonia) Provide safety Pharmacologic therapy 1.Thrombolytics 2.Diuretics 3.Calcium Channel blockers GLASGOW COMA SCALE Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment. GCS was initially used to assess level of consciousness after head injury, and the scale is now used by first aid, EMS, and doctors as being applicable to all acute medical and trauma patients. In hospitals it is also used in monitoring chronic patients in intensive care.

The scale comprises three tests: eye, verbal and motor responses. The three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15 (fully awake person). Best eye response (E) There are 4 grades starting with the most severe: 1. No eye opening 2. Eye opening in response to pain. (Patient responds to pressure on the patients fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.) 3. Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.) 4. Eyes opening spontaneously Best verbal response (V) There are 5 grades starting with the most severe: 1. No verbal response 2. Incomprehensible sounds. (Moaning but no words.) 3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange) 4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.) 5. Oriented. (Patient responds coherently and appropriately to questions such as the patients name and age, where they are and why, the year, month, etc.) Best motor response (M) There are 6 grades starting with the most severe: 1. No motor response 2. Extension to pain (abduction of arm, internal rotation of shoulder, pronation of forearm, extension of wrist, decerebrate response) 3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response) 4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched) 5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.) 6. Obeys commands. (The patient does simple things as asked.) Interpretation Individual elements as well as the sum of the score are important. Hence, the score is expressed in the form "GCS 9 = E2 V4 M3 at 07:35".

Generally, brain injury is classified as:

Severe, with GCS 8 Moderate, GCS 9 - 12 Minor, GCS 13.

ENDOTRACHEAL SUCTIONING Endotracheal Suctioning involves the insertion of a catheter into the clients artificial tracheal airway. Endotracheal Suctioning maintains airway patency, facilitates removal of airway secretions, and stimulates a deep cough. In the acute health care environment, tracheal suctioning is a sterile process. In the home setting, the client may be instructed to use a clean suction technique as long as there are no signs of infection Purpose: To maintain a patent airway and prevent airway obstruction To promote respiratory functions (optimal exchange of oxygen and carbon dioxide into and out of the lungs) To prevent pneumonia that may result from accumulated secretions Assessment: Observe for signs and symptoms of lower airway obstruction Secretions in airway, wheezes or crackles on inspiration and/or expiration Ineffective cough Unilateral or Bilateral absence or diminished breath sound Tachypnea Acutely shallow respiration Tachycardia or bradycardia Hypertension or hypotension Cyanosis Decreased level of consciousness Planning: Prepare patient Explain procedure and patients participation. Explain importance of coughing during procedure. Assist patient to assume comfortable position for nurse and client, usually semi-fowlers of Fowlers. If unconscious, place in side-lying position. Place towel across patients chest Implementation 1.Wash hands and turn suction device set on and set vacuum regulator to appropriate negative pressure. Wear mask. 2. If using sterile suction kit A. Open package. If sterile drape is available, place it across patients chest B. Open suction catheter package. Do not allow suction catheter to touch any unsterile surface C. Unwrap or open sterile basin and place on bedside table. Be careful not t touch inside basin. Fill with about 100 ml sterile normal saline 3. If indicated, open lubricant and squeeze on sterile catheter package without touching package.

4. Apply one sterile glove to each hand or apply non sterile to non-dominant hand and sterile glove to dominant hand. 5. Pick up suction catheter with dominant hand without touching non-sterile surfaces. Pick up connecting tubing with non-dominant hand. 6. Check the equipment if functioning properly by suctioning small amount of saline from basin 7. Coat distal portion 6-8 cm of catheter with water-soluble lubricant. In some situations, catheter is lubricated only with normal saline. Nursing assessment indicates needs for lubrication 8. Remove oxygen or humidify delivery device with dominant hand 9. Hyperinflate and/or oxygenate client before suctioning, using manual resuscitation bag or sigh mechanism on mechanical ventilator 10. Without applying suction, gently but quickly insert catheter with dominant thumb and forefinger into artificial airway (best to time catheter insertion with inspiration). 11. Insert catheter until resistance is met, then pull back 1 cm. 12. Apply intermittent suction by placing and releasing non- dominant hand thumb over vent of catheter while rotating back and forth between dominant thumb and forefinger. Encourage patient to cough. 13. Replace oxygen delivery device. Encourage patient to deep breath. 14. Rinse catheter and connecting tubing with normal saline until clear. Use continuous suction. 15. Repeat steps 10-14 as needed to clear secretions. Allow adequate time (at least 1 full minute) between suction passes for ventilation and reoxygenation. 16. Assess patients cardiopulmunary status between suction passes. 17. When artificial and tracheobronchial trees are sufficiently cleared of secretions, perform nasal and oral pharyngeal suction are performed. When catheter is contaminated, do not reinsert into ET or TT. 18. Disconnect catheter from connecting tubing. 19. Remove towel and place in laundry, or remove drape and discard in appropriate receptacle. 20. Reposition patient. 21. Discard remainder of normal saline into appropriate receptacle. If basin is disposable, discard into appropriate receptacle. If basin is reusable, place it in soiled utility room. 21. Wash hands and place unopened suction kit on suction machine or at head of bed.

Evaluation 1. Recording and Reporting Chart in nurses notes: Respiratory assessment before and after suctioning. Size of suction catheter used. Amount of negative suction pressure used. Duration of suctioning period. Route(s) used to suction. Secretions obtained and odor, amount, color, consistency, frequency of suctioning. Patients tolerance of procedure.

CARE OF CLIENTS UNDERGOING CHEMOTHERAPY & RADIATION THERAPY

GOALS OF CANCER THERAPY: CURE: -Disease-free & live to normal life expectancy CONTROL: -Cancer is not cured but controlled over long periods of time PALLIATIVE: -Maintain high quality of life when cure & control are not possible -PROPHYLAXIS: -Provide tx when no T is detectable but at risk

MODALITIES OF CANCER TREATMENT CHEMOTHERAPY: Overall goal is to destroy the cancer cells without excessively damaging the normal cells. NURSING PRIORITY: -The aim is to administer an antineoplastic agent dose large enough to eradicate cancer cells but small enough to limit adverse effecs to safe & tolerable levels Observe for therapeutic effects (appetite,improved mobility,pain) Observe for adverse effects Dosage is based on clients BW Monitor lab values for evidence of Bone Marrow suppression, Liver FT, Renal FT Avoid contact w/skin. Wear gloves, eyewear & barrier protective clothing Prepare drug on disposal tray or towel

Chemotherapeutic agents

ALKYLATING AGENTS: Binds to DNA & prevent mitosis & replication Imitate the action of radiation; Does not cross BBB COMMON SE: BONE MARROW SUPPRESSION, NV, ALOPECIA Cisplatin (PLATINOL) Hyperuricemia, hypo Mg,K,Ca, nephrotoxic SE: Dizziness, tinnitus, numbness

Cyclophosphamide (CYTOXAN) Alopecia, cystitis, hematuria, pulmo toxicity

Melphalan (ALKERAN) Pulmonary toxicity

ANTIMETABOLITES: Take the place of Normal CHON req for DNA synthesis COMMON SE: Bone Marrow Dep, Oral & GI ulceration Fluorouracil (5-FU) Methotrexate Na (Folex, Mexate) Alopecia, stomatitis, hyperuricemia, diarrhea, phototoxicity, hepatotoxicity Assess for glycosuria, GI bleeding, gastric ulceration, CI for 1st tri of preg, avoid alcohol

NURSING CONSIDERATIONS: Give folinic acid or Citrovorum Add leucovorin to prevent toxicity Use sun screen & wear protective covering

ANTI-TUMOR ANTIBIOTICS:

Inhibit DNA synthesis that prevents mitosis SE: bone marrow dep, GI disturbance Monitor VS Doxorubicin (ADRIAMYCIN) Myocardial toxicity, CHF (hypotension, dyspnea, wt gain)

Mitoxantrone HCl (MITHRACIN) Dactinomycin (ACTINOMYCIN)

PLANT/VINCA ALKALOIDS: Prevents mitosis SE: hypotension, neurotoxic, stomatitis, phlebitis, dysrhythmia Vincristine (ONCOVIN) Vinblastine (VELBAN)

NURSING CONSIDERATIONS: Manage constipation Minimize hair loss by applying cold compress to scalp before adm of med Adm Allupurinol for hyperuricemia

NURSING INTERVENTIONS FOR CHEMOTX SIDE EFFECTS GI SKIN PRURITUS / URTICARIA; moisturizing lotion, water at mod temp, avoid soap Nausea: eat dry cracker Full meal before therapy Food not too hot nor cold Anti emetics be given 24hr before therapy Oral Chemotx drugs be taken HS

STOMATITIS: soft toothbrush, avoid extreme temp of food, spices, citrus, smoking, alcohol ALOPECIA/NAIL CHANGES: wear scarf, wig, turban, hat, no hair rollers or dryer SKIN PIGMENTATION : Avoid sun exposure

HEMATOPOEITIC SYSTEM ANEMIA : Monitor RBC wkly, observe for bleeding, high CHON, rest. LEUKOPENIA: Avoid rectal temp & suppositories (rectal abscess) THROMBOCYTOPENIA: avoid trauma, aspirin

EXTRAVASATION: Stop Infusion Remove remaining drug in the tubing Aspirate the infiltrated area DO NOT REMOVE NEEDLE Contact physician Instill antidote Apply ice pack & elevate extremity for the 1st 24-48H

RADIATION THERAPY EXTERNAL BEAM THERAPY (TELETHERAPY) COBALT THERAPY

RADIATION SAFETY PRECAUTIONS: Private room & bath Plan care so minimal time is spent in the room

Use lead shield or lead apron Put up sign on the pts door Check linens & materials from the pt for foreign bodies that might be source of radioactivity Lead container & forceps in pts side For dislodged implants, pick up using forcep Observe time, distance, & shield precautions List on chart (type, time inserted, removal time, spec precaution) For systemic radionuclides may cause radioactive secretions Keep linens & trash in pts room til checked for radioactivity