question

(1) _____________ is the force exerted on the vessels by the blood. It can be calculated by multiplying (2) _________ by (3) ____________.

answer

1) Blood pressure 2) cardiac output 3) systemic vascular resistance

question

Where is systemic vascular resistance (SVR) primarily created?

answer

arterioles and smaller arteries

question

Angiotensin and norepinephrine are two types of neurohormonal _______________.

answer

vasoconstrictors

question

Local regulation of systemic vascular resistance occurs with prostaglandins and nitric oxide (NO) which are (1) ______________ and endothelin which is a (2) _____________.

answer

1) vasodilators 2) vasoconstrictor

question

What type of adrenergic receptors, when stimulated by the SNS, result in vasoconstriction?

answer

alpha 1 and alpha 2 adrenergic receptors

question

What type of adrenergic receptors, when stimulated by the SNS, result in vasodilation?

answer

beta 2 adrenergic receptors

question

Compensatory mechanisms help to maintain blood pressure homeostasis. Vessels (1) _________ to increase BP, and they (2) ________ to decrease blood pressure.

answer

1) constrict 2) dilate

question

(1) _____________ are located in the aortic arch and carotid sinus and are sensitive to stretch or pressure within the arterial system. When stimulated by increased stretch or pressure, they send information to the vasomotor center of the brainstem resulting in temporary (2) __________ of the SNS and (3) __________ of the PNS. This leads to (4) __________ HR and peripheral (5) _______________.

answer

1) Baroreceptors 2) inhibition 3) enhancement 4) decreased 5) vasodilation

question

Name 3 situations in which the juxtaglomerular apparatus of the kidney would secrete renin.

answer

1) Sympathetic nervous system (SNS) stimulation 2) Decreased blood flow to the kidneys 3) Decreased serum sodium concentration

question

Component of the RAAS that increases BP by acting as a potent vasoconstrictor, stimulating the adrenal cortex to secrete aldosterone, and stimulating tissue growth and remodeling of the vessel walls.

answer

Angiotensin II (AII)

question

What 3 groups created guidelines to treating hypertension?

answer

JNC 8 - The Joint Commission ACC - American College of Cardiology AHA - American Heart Association

question

What is considered normal blood pressure?

answer

< 120/80 mmHg

question

Classification for prehypertension

answer

SBP = 120-139 mmHg or DBP = 80-89 mmHg

question

Classification for stage I hypertension

answer

SBP = 140-159 mmHg or DBP = 90-99 mmHg

question

Classification for stage 2 hypertension

answer

SBP >/= 160 mmHg or DBP >/= 100 mmHg

question

Classification for isolated systolic hypertension (ISH)

answer

Average SBP >/= 140 mmHg and Average DBP <90 mmHg

question

True or False: Secondary hypertension is the most common form of hypertension

answer

False - Primary hypertension is the most common form of hypertension accounting for 90-95% of all cases

question

Elevated blood pressure without an identified cause

answer

Primary hypertension (idiopathic hypertension)

question

Name 7 contributing factors to the development of primary hypertension.

answer

1. Increased SNS activity 2. Overproduction of sodium-retaining hormones and vasoconstricting substances 3. Increased sodium intake 4. Greater than ideal body weight 5. Diabetes mellitus 6. Tobacco use 7. Excessive alcohol consumption

question

Elevated blood pressure with a specific cause that often can be identified and corrected. It is usually acute in onset and treated by treating/eliminating the underlying cause.

answer

Secondary hypertension

question

What is the hemodynamic hallmark of hypertension?

answer

Persistently increased systemic vascular resistance

question

Describe the genetic etiology to hypertension.

answer

Having a family history of hypertension is a risk factor for hypertension. This must be a close relative (i.e., sibling, parent, child, etc.).

question

Describe how sodium and water retention can lead to hypertension.

answer

Excessive sodium intake is linked to the start of hypertension. A high sodium intake may activate a number of pressor mechanisms and cause water retention.

question

What 2 populations is the effect of sodium on BP greatest?

answer

1. African Americans 2. Middle-aged and older adults

question

Described how alteration of the RAAS may lead to hypertension?

answer

Too much renin is produced with malfunction of the negative feedback loop. Any rise in the BP should inhibit the release of renin from the kidneys. However, this does not occur in some individuals with hypertension.

question

Describe how increased SNS stimulation results in hypertension.

answer

Causes increased vasoconstriction, increased heart rate, and increased release of renin. Normally, increased SNS stimulation is protective in stressful situations. However, if prolonged, it may result in pathology. People exposed to high levels of repeated psychologic stress develop HTN to a greater extent than those who experience less stress.

question

True or False: Abnormalities of glucose, insulin, and lipoprotein metabolism are present in both primary and secondary hypertension.

answer

False - Abnormalities of glucose, insulin, and lipoprotein metabolism are present only in primary hypertension and not in secondary hypertension.

question

True or False: Insulin resistance and hyperinsulinemia improves with treatment of hypertension.

answer

False

question

What role does insulin resistance have for developing hypertension and cardiovascular disease?

answer

1. Stimulates SNS activity 2. Impairs nitric oxide-mediated vasodilation 3. Stimulates vascular hypertrophy 4. Increases renal sodium reabsorption

question

Describe how some individuals with endothelial dysfunction may develop hypertension.

answer

Some people with hypertension have reduced vasodilator production or response to nitric oxide. Some people with hypertension have high levels of endothelin, producing pronounced and prolonged vasoconstriction.

question

True or False: Systolic blood pressure increases with age.

answer

True

question

Describe how gender can be a risk factor for hypertension.

answer

Men in younger adulthood and early middle age (64 y.o. (post-menopausal).

question

Excessive alcohol use can be a risk factor for hypertension. What is the daily alcohol restriction for patients with hypertension?

answer

1 oz daily

question

Explain how smoking tobacco greatly increases one's risk for developing cardiovascular disease whether they do or do not have hypertension.

answer

Tobacco contains nicotine which is a vasoconstrictor. Increased vasoconstriction causes an elevation in blood pressure, and elevated blood pressure can cause more stress and damage to vessel walls leading to atherosclerosis.

question

What type of obesity is most especially associated with increased frequency of hypertension?

answer

central abdominal obesity

question

When ____________ and _____________ coexist, end organ damage is more severe.

answer

hypertension and diabetes mellitus

question

Why is hypertension termed, the "silent killer?"

answer

Many people who have hypertension don't even know it because they are completely asymptomatic. Essential (primary) HTN can affect anyone at any age, and those with HTN can have it for years before they are diagnosed and begin treatment. Usually patients develop clinical manifestations of end organ damage which prompts them to see their doctor who then discovers their hypertension as the underlying cause.

question

What is the ultimate consequence of hypertension?

answer

End-organ damage

question

What are 3 conditions associated with end-organ damage to the heart (i.e., hypertensive heart disease)?

answer

1. Coronary artery disease (HTN is a major risk factor for CAD) 2. Left ventricular hypertrophy** 3. Heart failure **Progressive LVH, especially in the presence of CAD, can lead to HF.

question

Form of end-organ damage that may occur when BP exceeds the body's ability to autoregulate, the cerebral vessels suddenly dilate, capillary permeability increases, and cerebral edema develops. The subsequent rise in intracranial pressure can cause brain damage and death if left untreated. Clinical manifestations are often similar to the neurologic changes related to a stroke; however, there are no focal or lateralizing signs --> Severe headache, nausea and vomiting, confusion and disorientation, seizures, possible coma.

answer

Hypertensive encephalopathy

question

Ischemic leg pain precipitated by activity and relieved with rest. Classic symptom of peripheral vascular disease

answer

Intermittent claudication

question

Hypertension is one of the leading causes of CKD. What patient population is this most especially the case?

answer

African Americans

question

What are 4 laboratory indications of renal disease?

answer

1. Microalbuminuria/proteinuria 2. Microscopic hematuria 3. Elevated serum creatinine (or decreased creatinine clearance) and BUN 4. Decreased GFR

question

What is the earliest clinical manifestation of renal disease?

answer

Nocturia

question

What 2 things help differentiate between the two forms of hypertensive crises?

answer

1. Degree of target organ disease 2. How quickly the BP must be lowered

question

Form of hypertensive crisis that develops over hours to days and is more acute in onset. Characterized by a markedly elevated BP and clinical evidence of end-organ damage (e.g., hypertensive encephalopathy, intracranial or subarachnoid hemorrhage, acute LV failure and/or MI, renal failure, dissecting aortic aneurysm, and/or retinopathy). Patients usually require hospitalization for close monitoring and IV anti-hypertensive medication.

answer

Hypertensive emergency

question

What BP parameters define a hypertensive emergency?

answer

BP > 220/140 mmHg

question

Condition that may result from hypertensive induced end-organ damage which manifests as severe back pain and/or chest pain and reduced or absent peripheral pulses due to the loss of perfusion to the peripheral tissues.

answer

Dissecting aortic aneurysm

question

Why do we want to GRADUALLY decrease BP back to normal when treating a patient with a hypertensive emergency?

answer

Prevent under-prefusion of the major organs (i.e., heart, kidneys, brain).

question

When treating a hypertensive crisis, treatment is focused more so on the (1) ___________ rather than SBP or DBP. We want to decrease this by no more than (2) ____ to ____% or to (3) ______ to _____ mmHg.

answer

1. MAP (mean arterial pressure) 2. 20-25% 3. 110-115 mmHg

question

In what 3 situations would we want to decrease BP more quickly and/or to a greater extent than what is recommended for treating a hypertensive crisis?

answer

1. Aortic dissection 2. Acute ischemic stroke (BP is lowered more quickly to allow use of thrombolytic agents) 3. Post stroke patients (elevated BP is believed to be a compensatory response to improve cerebral perfusion to ischemic brain tissue).

question

When initiating IV hypertensive medication to treat a hypertensive emergency, it can have a rapid effect. How often, should the patient's blood pressure be monitored?

answer

Every 2-3 min

question

What type of diagnostic studies are used with hypertensive emergency patients?

answer

1. EKG - monitoring for heart dysrhythmias and signs of ischemia or MI while receiving anti-hypertensives 2. Urine output/urinalysis to assess renal perfusion

question

Treating a patient with antihypertensives may induce (1) ________________. Therefore, it's imperative to advise the patient to get up (2) ______________. (3) ____________ (e.g., muscle strength, orientation, pupil responsivity) may also be performed to assess progression/improvement of the patient's encephalopathy symptoms.

answer

1. orthostatic hypotension 2. slowly 3. Neuro-checks

question

Form of hypertensive crisis that develops over days to weeks. Characterized by an elevated BP but no clinical evidence of end-organ damage. Patients can be managed with oral agents. They may not need hospitalization but will require at least a 24-hr follow up.

answer

Hypertensive urgency

question

What BP parameters define hypertensive urgency?

answer

> 180/110 mmHg

question

What is the disadvantage of managing a hypertensive urgency with oral medications?

answer

PO medication doses cannot be regulated on a moment-to-moment basis, as can be done with IV medications.

question

The ________ in rise of blood pressure is more important than the absolute value in determining the need for emergency treatment for a patient in a hypertensive crisis.

answer

rate

question

If you obtain different blood pressure readings from both arms, which reading should you use?

answer

The higher reading

question

Where should the arm be when obtaining a blood pressure?

answer

At the level of the heart

question

During an office visit, what is the minimum number of readings you should obtain?

answer

Obtain at least 2 readings taken at least 1 minute apart. Record the average of these readings as the value for the visit.

question

How long should you wait between taking blood pressure readings from the same arm?

answer

1 minute

question

What are the consequences of using the incorrect cuff size when measuring blood pressure?

answer

1. Too big = measured BP is lower than actual BP 2. Too small = measured BP is higher than actual BP

question

Where should the bladder of the BP cuff be placed when obtaining a BP?

answer

at the brachial artery

question

Describe how to assess a patient for orthostatic hypotension.

answer

Obtain BP readings when the patient is in a lying, sitting, and standing position and assess for drops in BP and/or a rise in HR.

question

How long should you wait before taking BP readings when a patient changes position (e.g., from sitting to standing) during an orthostatic hypotension assessment?

answer

2-3 minutes

question

What blood pressure/heart rate parameters would indicate that a patient has orthostatic hypotension?

answer

1. A drop in SBP >/= 20 mmHg and/or 2. A drop in DBP >/= 10 mmHg and/or 2. A rise in HR >/= 10 BPM from supine to standing

question

In what 3 situations would you assess a patient for orthostatic hypotension?

answer

1. Older adults 2. Patients on antihypertensives 3. Patients experiencing symptoms consistent with reduced BP on standing (e.g., lightheadeness, dizziness, syncope).

question

What are 2 common causes of orthostatic hypotension?

answer

1. Intravascular volume loss 2. Inadequate vasoconstrictor mechanisms related to disease or medications

question

Noninvasive, fully automated system that measures blood pressure at preset intervals over a 24-hr period. Can be used to assess for possible white coat HTN, suspected anti-hypertensive drug resistance, hypotensive symptoms with antihypertensive drugs, episodic hypertension, SNS dysfunction, and/or presence or absence of diurnal variability in BP. Patients are asked to hold their arm still by their side when they feel the device is taking a reading and to maintain a diary of activities that may affect their BP.

answer

Ambulatory Blood Pressure Monitoring (ABPM)

question

Phenomenon in which some individuals have elevated BP readings in a clinical setting and normal readings when BP is measured elsewhere.

answer

White coat hypertension

question

Sleep-wakefulness difference in blood pressure. For day-active people, BP is highest in the early morning, decreases during the day, and is lowest at night. BP drops by >/= 10% from daytime (awake) BP.

answer

Diurnal variability

question

Term used to describe some patients with hypertension who do not show a normal nocturnal dip in BP throughout their day.

answer

Nondippers

question

Why is a uric acid level obtained during a patient's work up for hypertension?

answer

Uric acids may be elevated in patients on a diuretic to treat their hypertension.

question

What are the 3 overall goals in collaborative care for a patient with hypertension?

answer

1. Maintain a goal blood pressure 2. Reduce cardiovascular disease risks 3. Prevent/limit any end-organ damage

question

Overweight persons have an increased incidence of hypertension and increased risk for cardiovascular disease. Moderate weight loss of (1) __________ may decrease SBP by (2) _____ to ______ mmHg.

answer

1. 22 lb (10 kg) 2. 5-20 mmHg

question

What does DASH stand for?

answer

Dietary Approaches to Stopping Hypertension

question

What types of food does the DASH diet recommend?

answer

Fruits, vegetables, fish, poultry, beans, seeds, nuts, fat-free or low-fat milk and milk products, whole grains

question

What types of food does the DASH diet recommend we avoid/limit intake of?

answer

Red meat, salt, sweets, added sugars, and sugar-containing beverages.

question

Reduction in blood pressure with proper execution of the DASH diet are comparable to those achieved with BP-lowering medications. What is an additional benefit of the DASH diet?

answer

Lowering LDL and thus lowering cardiovascular disease risk

question

What is the dietary recommendation for sodium for both healthy individuals and individuals with or at risk for hypertension (e.g., African Americans, people middle-aged and older, and those with HTN, DM, or CKD)?

answer

1. Healthy individuals </= 2300 mg 2. Individuals with HTN </= 1500 mg

question

What is the most frequent cause of secondary hypertension?

answer

Alcohol-induced cirrhosis

question

Excessive alcohol consumption is strongly associated with hypertension. Consumption of greater than or equal to _____ alcoholic drinks daily is also a risk factor for cardiovascular disease and stroke.

answer

>/= 3

question

What are the dietary recommendations for alcohol consumption for individuals with and without hypertension?

answer

1. Without - 2 drinks or less daily for men, 1 drink or less daily for women 2. With - 1 oz or less daily

question

What is considered 1 drink of alcohol?

answer

12 oz of beer, 5 oz of wine, and 1.5 oz of distilled spirits

question

What are the American Heart Association and American College of Sports Medicine recommendations for physical activity?

answer

1. Moderate-intensity aerobic physical activity for at least 30 minutes ~5 days a week 2. Vigorous-intensity aerobic activity for at least 20 minutes ~3 days a week. 3. All adults should perform muscle-strengthening activities at least twice a week. 4. Flexibility and balance exercises are recommended at least twice a week for older adults, especially for those at risk for falls.

question

Regular moderate physical activity can reduce SBP by approximately ____ to ___ mmHg. It can also promote relaxation and decrease or control body weight.

answer

4-9

question

1. What is a common goal BP for patients being treated for HTN? 2) What about for patients with high risk for cardiovascular disease (e.g., individuals with DM, CKD, and use tobacco)?

answer

1. <140/90 2. less than or equal to 130/80 mmHg

question

What are the 2 main actions of drugs available for treating hypertension?

answer

1. Decrease the volume of circulating blood 2. Reduce systemic vasoconstriction

question

True or False: Most patients with hypertension achieve their goal BP with 1 antihypertensive medication.

answer

False - Most patients who are hypertensive require 2 or more antihypertensive medications to achieve their goal BP.

question

Once antihypertensive therapy is started, patients should return for follow up and adjustment of medications at __________ intervals until the goal BP is reached.

answer

monthly

question

After initiation of antihypertensive therapy and once BP is stabilized, recommended follow ups for monitoring blood pressure are every ____ to ____ months.

answer

3-6

question

What are some reasons patients may not be compliant with their blood pressure medications?

answer

Side effects and cost 1. Orthostatic hypotension 2. Reduced libido/ED 3. Dry mouth 4. Frequent voiding 5. Dizziness/lightheadedness and fatigue 6. Cough (with ACE-Is)

question

What are some important points of patient education for patients on an antihypertensive and are experiencing orthostatic hypotension?

answer

1. Change positions slowly 2. Stay hydrated and drink plenty of water and fluids 3. Compression stockings

question

What is something you can recommend to patients experiencing dry mouth from their antihypertensives to increase compliance?

answer

Sugarless gum or hard candy

question

What is something you can recommend to patients who have frequent voiding while on their antihypertensives?

answer

Recommend taking diuretics earlier in the day when they are already up and about rather than at night time to preserve sleep

question

How often and at what times should patients take their blood pressure when monitoring this at home?

answer

**Self-monitoring of BP is an easy, cost-effective approach that may be chosen before ABPM. Patients should take their BP twice a day - first thing in the morning before taking their BP medications and at nighttime just prior to going to bed. This is the best way to assess how well their BP medications are working.

question

What are 2 reasons patients are encouraged to bring their BP cuff and monitor at their office visit?

answer

1. Allows the nurse to ensure the patient is using the proper technique when measuring BP by asking for a return demonstration 2. Allows for verification on the accuracy of the machine

question

Why are patients encouraged to keep a home blood pressure log for one week once every 3 months even after their blood pressure is controlled?

answer

It helps patients see improvement and maintenance of a goal BP which improves compliance.

question

What are 7 age-related physiologic changes that make the prevalence of hypertension increase with age?

answer

1. Loss of elasticity in large arteries from atherosclerosis 2. Increased collagen content and stiffness in the myocardium 3. Increased peripheral vascular resistance 4. Decreased adrenergic receptor sensitivity 5. Blunting of baroreceptor reflexes 6. Decreased renal function 7. Decreased renin response to sodium and water depletion

question

Name 2 drug pharmacokinetic changes that should be considered in older adults being treated for hypertension.

answer

1. Absorption of some drugs may be altered as a result of decreased blood flow to the gut 2. Metabolism and excretion may also be prolonged due to the natural decline in liver and kidney function. This can lead to possible toxicity and dosing issues as well as electrolyte imbalances.

question

Why should vasoactive medications not be given with or before meals in older adults?

answer

Older adults experience postprandial drops in blood pressure. The greatest decrease occurs approximately 1 hour after eating. These medications, therefore, should be given between/after meals.

question

Type of drug often taken by older adults for their arthritis (the second most prevalent disease in older adults) that can cause loss of blood pressure control and heart failure. There is the potential for adverse renal effects and/or hyperkalemia when these drugs are used with ACE-Is, ARBs, or aldosterone antagonists.

answer

NSAIDs

question

What type of antihypertensive should always be the first or second drug ordered for blood pressure control in older adults?

answer

diuretic

question

The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which mechanism? a. Hypertension promotes atherosclerosis and damage to the walls of the arteries. b. Hypertension causes direct pressure on organs, resulting in necrosis and replacement of cells with scar tissue. c. Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems. d. Hypertension increases blood viscosity, which contributes to intravascular coagulation and tissue necrosis distal to occlusions

answer

Answer: A Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, once atherosclerosis develops, it damages the walls of arteries and reduces circulation to target organs and tissues.

question

When teaching a patient about dietary management of stage 1 hypertension, which instruction is most appropriate? a. Restrict all caffeine. b. Restrict sodium intake. c. Increase protein intake. d. Use calcium supplements.

answer

Answer: B --> The patient should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Wrong Answers: Caffeine and protein intake do not affect hypertension. Calcium supplements are not recommended to lower BP.

question

In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage? a. BUN of 15 mg/dL b. Serum uric acid of 3.8 mg/dL c. Serum creatinine of 2.6 mg/dL d. Serum potassium of 3.5 mEq/L

answer

Answer: C --> The normal serum creatinine level is 0.6-1.2 mg/dL. This elevated level indicates target organ damage to the kidneys. Normal BUN levels = 7-18 mg/dL Normal potassium levels = 3.5-5.0 mEq/L

question

When providing dietary instruction to a patient with hypertension, the nurse would advise the patient to restrict intake of which meat? a. Broiled fish b. Roasted duck c. Roasted turkey d. Baked chicken breast

answer

Answer: B Roasted duck is high in fat, which should be avoided by the patient with hypertension. Weight loss may slow the progress of atherosclerosis and overall CVD risk. The other meats are lower in fat and are therefore acceptable in the diet.

question

The nurse is caring for a patient admitted with a history of hypertension. The patient's medication history includes hydrochlorothiazide (Hydrodiuril) daily for the past 10 years. Which parameter would indicate the optimal intended effect of this drug therapy? a. Weight loss of 2 lb b. Blood pressure 128/86 c. Absence of ankle edema d. Output of 600 mL per 8 hours

answer

Answer: b Hydrochlorothiazide may be used alone as monotherapy to manage hypertension or in combination with other medications if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, but the antihypertensive effect remains. Since the patient has been taking this medication for 10 years, the most direct measurement of its intended effect would be the blood pressure.

question

In reviewing medication instructions with a patient being discharged on antihypertensive medications, which statement would be most appropriate for the nurse to make when discussing guanethidine (Ismelin)? a. "A fast heart rate is a side effect to watch for while taking guanethidine." b. "Stop the drug and notify your doctor if you experience any nausea or vomiting." c. "Because this drug may affect the lungs in large doses, it may also help your breathing." d. "Make position changes slowly, especially when rising from lying down to a standing position."

answer

Answer: D Guanethidine is a peripheral-acting α-adrenergic antagonist and can cause marked orthostatic hypotension. For this reason, the patient should be instructed to rise slowly, especially when moving from a recumbent to a standing position. Support stockings may also be helpful. Tachycardia or lung effects are not evident with guanethidine.

question

The nurse is caring for a patient admitted with chronic obstructive pulmonary disease (COPD), angina, and hypertension. Before administering the prescribed daily dose of atenolol 100 mg PO, the nurse assesses the patient carefully. Which adverse effect is this patient at risk for, given the patient's health history? a. Hypocapnia b. Tachycardia c. Bronchospasm d. Nausea and vomiting

answer

Answer: C Atenolol is a cardioselective β1-adrenergic blocker that reduces blood pressure and could affect the β2-receptors in the lungs with larger doses or with drug accumulation. Although the risk of bronchospasm is less with cardioselective β-blockers than nonselective β-blockers, atenolol should be used cautiously in patients with COPD.

question

The nurse is caring for a patient with hypertension who is scheduled to receive a dose of esmolol (Brevibloc). The nurse should withhold the dose and consult the prescribing physician for which vital sign taken just before administration? a. Pulse 48 b. Respirations 24 c. Blood pressure 118/74 d. Oxygen saturation 93%

answer

Answer: A Because esmolol is a β1-adrenergic blocking agent, it can cause hypotension and bradycardia as adverse effects. The nurse should withhold the dose and consult with the health care provider for parameters regarding pulse rate limits.

question

Despite a high dosage, a male patient who is taking nifedipine (Procardia XL) for antihypertensive therapy continues to have blood pressures over 140/90 mmHg. What should the nurse do next? a. Assess his adherence to therapy. b. Ask him to make an exercise plan. c. Instruct him to use the DASH diet. d. Request a prescription for a thiazide diuretic.

answer

Answer: A A long-acting calcium-channel blocker such as nifedipine causes vascular smooth muscle relaxation resulting in decreased SVR and arterial BP and related side effects. The patient data the nurse has about this patient is very limited, so the nurse needs to assess his adherence to therapy.

question

The nurse is teaching a women's group about prevention of hypertension. What information should be included in the teaching for all the women (select all that apply)? a. Lose weight. b. Limit nuts and seeds. c. Limit sodium and fat intake. d. Increase fruits and vegetables. e. Exercise 30 minutes most days.

answer

Answer: C, D, and E Primary prevention of hypertension is to make lifestyle modifications that prevent or delay the increase in BP. E) Along with exercise for 30 minutes on most days, the (C) and (D) DASH eating plan is a healthy way to lower BP by limiting sodium and fat intake, increasing fruits and vegetables, and increasing nutrients that are associated with lowering BP. (B) Nuts and seeds and dried beans are used for protein intake. (A) Weight loss may or may not be necessary for the individual.

question

When assessing the patient for orthostatic hypotension, after taking the blood pressure (BP) and pulse (P) in the supine position, what should the nurse do next? a. Repeat BP and P in this position. b. Take BP and P with patient sitting. c. Record the BP and P measurements. d. Take BP and P with patient standing.

answer

Answer: B When assessing for orthostatic changes in BP after measuring BP in the supine position, the patient is placed in a sitting position and BP is measured and then repositioned to the standing position with BP measured again. The results are then recorded with a decrease of 20 mm Hg or more in SBP, a decrease of 10 mm Hg or more in DBP, and/or an increase in pulse of greater than or equal to 20 beats/minute from supine to standing indicating orthostatic hypotension.

question

The patient has chronic hypertension. Today she has gone to the ED, and her blood pressure has risen to 200/140. What is the priority assessment for the nurse to make? a. Is the patient pregnant? b. Does the patient need to urinate? c. Does the patient have a headache or confusion? d. Is the patient taking antiseizure medications as prescribed?

answer

Answer: C The nurse's priority assessments include neurologic deficits, retinal damage, heart failure, pulmonary edema, and renal failure. The headache or confusion could be seen with hypertensive encephalopathy from increased cerebral capillary permeability leading to cerebral edema. Wrong Answers: A) Pregnancy can lead to secondary hypertension. B) and D) Needing to urinate and taking antiseizure medication do not support a hypertensive emergency.

question

When collecting subjective data related to the cardiovascular system, which information should be obtained from the patient (select all that apply)? a. Annual income b. Smoking history c. Religious preference d. Number of pillows used to sleep e. Blood for basic laboratory studies

answer

Answer: B, C, D

question

When assessing the cardiovascular system of a 79-year-old patient, you might expect to find a. a narrowed pulse pressure. b. diminished carotid artery pulses. c. difficulty in isolating the apical pulse. d. an increased heart rate in response to stress.

answer

Answer: C Myocardial hypertrophy and the downward displacement of the heart in an older adult may cause difficulty in isolating the apical pulse.

question

Which BP-regulating mechanism(s) can result in the development of hypertension if defective (select all that apply)? a. Release of norepinephrine b. Secretion of prostaglandins c. Stimulation of the sympathetic nervous system d. Stimulation of the parasympathetic nervous system e. Activation of the renin-angiotensin-aldosterone system

answer

Answer: A, C, E Norepinephrine (NE) is released from the sympathetic nervous system nerve endings and activates receptors located in the vascular smooth muscle. When the α-adrenergic receptors in smooth muscle of the blood vessels are stimulated by NE, vasoconstriction results. Increased sympathetic nervous system stimulation produces increased vasoconstriction and increased renin release. Increased renin levels activate the renin-angiotensin-aldosterone system, leading to elevation in blood pressure (BP).

question

While obtaining subjective assessment data from a patient with hypertension, the nurse recognizes that a modifiable risk factor for the development of hypertension is a. a low-calcium diet. b. excessive alcohol consumption. c. a family history of hypertension. d. consumption of a high-protein diet.

answer

Answer: B Alcohol intake is a modifiable risk factor for hypertension. Excessive alcohol intake is strongly associated with hypertension. Patients with hypertension should limit their daily intake to 1 oz of alcohol.

question

In teaching a patient with hypertension about controlling the condition, the nurse recognizes that a. all patients with elevated BP require medication. b. obese persons must achieve a normal weight to lower BP. c. it is not necessary to limit salt in the diet if taking a diuretic. d. lifestyle modifications are indicated for all persons with elevated BP.

answer

Answer: D

question

A major consideration in the management of the older adult with hypertension is to a. prevent primary hypertension from converting to secondary hypertension. b. recognize that the older adult is less likely to adhere to the drug therapy regimen than a younger adult. c. ensure that the patient receives larger initial doses of antihypertensive drugs because of impaired absorption. d. use careful technique in assessing the BP of the patient because of the possible presence of an auscultatory gap.

answer

Answer: D Careful technique is important in assessing BP in older adults. In some older people, there is a wide gap between the first Korotkoff sound and subsequent beats; such a wide interval is called an auscultatory gap. Failure to inflate the cuff high enough may result in a serious underestimate of systolic BP.

question

A patient with newly discovered high BP has an average reading of 158/98 mm Hg after 3 months of exercise and diet modifications. Which management strategy will be a priority for this patient? a. Medication will be required because the BP is still not at goal. b. BP monitoring should continue for another 3 months to confirm a diagnosis of hypertension. c. Lifestyle changes are less important, since they were not effective, and medications will be started. d. More vigorous changes in the patient's lifestyle are needed for a longer time before starting medications.

answer

Answer: A The patient has hypertension, stage 1. Lifestyle modifications will continue, but drug initiation of therapy is a priority. Reduction of BP can help to prevent serious complications related to hypertension.

question

A patient is admitted to the hospital in hypertensive emergency (BP 244/142 mm Hg). Sodium nitroprusside is started to treat the elevated BP. Which management strategy(ies) would be appropriate for this patient (select all that apply)? a. Measuring hourly urine output b. Decreasing the MAP by 50% within the first hour c. Continuous BP monitoring with an intraarterial line d. Maintaining bed rest and providing tranquilizers to lower the BP e. Assessing the patient for signs and symptoms of heart failure and changes in mental status

answer

Answer: A, C, E Measure urine output hourly to assess renal perfusion. Patients being treated with IV sodium nitroprusside should have continuous intraarterial BP monitoring. Hypertensive crisis can cause encephalopathy, intracranial or subarachnoid hemorrhage, acute left ventricular failure, myocardial infarction, renal failure, dissecting aortic aneurysm, and retinopathy. The initial treatment goal is to decrease the mean atrial pressure (MAP) by no more than 25% within minutes to 1 hour. Patients receiving IV antihypertensive drugs may be restricted to bed rest. Getting up (e.g., to use the toilet) may cause severe cerebral ischemia and fainting.

question

What are the 2 main functions of the kidney?

answer

1. Filter the blood 2. Maintain the body's internal homeostasis

question

Excessive (1) _________ production by the kidneys caused by impaired renal perfusion may be a contributing factor in the etiology of (2) ___________.

answer

1. renin 2. hypertension

question

(1) ____________ production from arachidonic acid occurring at the levels of the kidneys is related to the kidney's role in causing (2) __________. In renal failure with a loss of functioning tissue, these renal vasodilators are also lost.

answer

1. Prostaglandin 2. hypertension

question

Hormone produced by the kidneys to stimulate erythropoiesis. Increased production occurs in hypoxic states to stimulate the bone marrow to produce more RBCs to carry more oxygen to our tissues.

answer

erythropoietin

question

Hormone that is activated in the kidneys and is essential for calcium absorption in the GI tract

answer

Vitamin D

question

The amount of blood filtered each minute by the glomeruli

answer

Glomerular filtration rate (GFR)

question

What is considered a normal GFR?

answer

125 mL/min

question

Persistent and progressive, irreversible loss of kidney function with a decreased GFR <60 mL/min for greater than 3 months. Increased prevalence has been partially attributed to the increase in risk factors, including an aging population, rise in rates of obesity, and increased incidence of DM and HTN.

answer

Chronic kidney disease (CKD)

question

Why are patients with chronic kidney disease often underdiagnosed and undertreated?

answer

Even though our kidneys cannot repair, they are extremely adaptive. This can be an issue because many people don't know they have CKD because their kidneys are compensating so well. Approximately 80% of GFR can be lost before CKD is diagnosed.

question

As the stage of kidney disease progresses, the ________ rate also increases.

answer

mortality

question

Stage 1 CKD GFR Value

answer

GFR >/= 90 mL/min

question

Stage 2 CKD GFR Value

answer

GFR = 60-89 mL/min

question

Stage 3 CKD GFR Value

answer

GFR = 30-59 mL/min

question

Stage 4 CKD GFR Value

answer

GFR = 15-29 mL/min

question

Stage 5 CKD or ESRD GFR Value

answer

GFR <15 mL/min

question

What lab value is considered the gold standard for staging renal function?

answer

Glomerular filtration rate (GFR)

question

What stage of CKD is considered end stage renal disease (ESRD) or kidney failure?

answer

Stage 5 CKD

question

What are 5 causes of CKD?

answer

1. Diabetes mellitus 2. Hypertension 3. Glomerulonephritis 4. Cystic Disease 5. Urologic Diseases

question

What causes the clinical manifestations of chronic kidney disease?

answer

Retained substances including urea, creatinine, phenols, hormones, electrolytes, and water

question

A syndrome in which kidney function declines to the point that symptoms may develop in multiple body systems. It often occurs when the GFR is 10 mL/min or less.

answer

Uremia

question

True or False: Patients stop producing urine (anuria) once they are placed on dialysis.

answer

False - It takes a while for the body to stop producing urine even if CKD is present. Typically, patients become anuric after they have been on dialysis for awhile.

question

What is the leading cause and 2nd leading cause of CKD?

answer

Leading cause = diabetes mellitus 2nd leading cause = hypertension

question

Why do some individuals in the early stages of CKD NOT experience a decrease in urine output?

answer

Diabetes mellitus is the leading cause of CKD, and a common symptom of DM is polyuria. Therefore, the lack of decrease in the urine output during the initial stages of CKD is more so a result of DM rather than CKD.

question

A possible clinical manifestation of CKD is altered carbohydrate metabolism. Cells can become insensitive to the normal action of ____________, leading to mild to moderate hyperinsulinemia and hyperglycemia.

answer

insulin

question

True or False: Patients with diabetes who develop uremia may require less insulin than before the onset of CKD.

answer

True Because patients with CKD have a decrease in GFR, they also have a decrease in the excretion of insulin allowing it to remain in circulation longer. As a result, a number of patients who required insulin before starting dialysis will be able to discontinue it when they start dialysis and their kidney disease progresses.

question

Hyperinsulinemia in CKD stimulates hepatic production of (1) ___________. Thus, when patients suffer from uremia, they are likely to develop (2) ____________, increasing risk for cardiovascular disease.

answer

1) triglycerides 2) dyslipidemia

question

What are the 2 most common cardiovascular clinical manifestations seen in patients with CKD?

answer

1. Hypertension 2. Elevated lipids

question

What is considered a normal potassium level?

answer

3.5-5.0 mEq/L

question

What is considered a normal sodium level?

answer

135-145 mEq/L

question

What is considered a normal total calcium level?

answer

8.5-10.5 mg/dL

question

What is considered a normal ionized calcium level?

answer

4.5-5.6 mg/dL

question

What is considered a normal magnesium level?

answer

1.8-3.0 mEq/L

question

What is considered a normal chloride level?

answer

95-105 mEq/L

question

What is considered normal urine output (in mL/kg body weight/hr)?

answer

1 mL/kg body weight/hr

question

What is considered normal arterial pH?

answer

7.35-7.45

question

What is considered normal PaO2?

answer

80-100 mmHg

question

What is considered normal SaO2?

answer

95-100%

question

What is considered a normal PaCO2?

answer

35-45 mmHg

question

What is considered a normal bicarbonate (HCO3-) level?

answer

22-28 mEq/L

question

What is considered a normal BUN level?

answer

7-18 mg/dL

question

What is considered a normal creatinine level?

answer

0.6-1.2 mg/dL

question

What is considered a normal total WBC count?

answer

5,000-10,000 cells/microliter

question

What is considered a normal hematocrit for males?

answer

40-50%

question

What is considered a normal hematocrit for females?

answer

37-47%

question

What is considered a normal hemoglobin for males?

answer

13-18 gm/dL

question

What is considered a normal hemoglobin for females?

answer

12-16 gm/dL

question

What is considered a normal erythrocyte count for males?

answer

4.4-6.0 million/microliter

question

What is considered a normal erythrocyte count for females?

answer

4.0-5.3 million/microliter

question

What is considered a normal platelet count?

answer

140,000-400,00/microliter

question

What is considered a normal hemoglobin A1c?

answer

4-6%

question

What is considered a normal fasting plasma glucose?

answer

75-110 mg/dL

question

_______________ have been reported when serum potassium levels reach 7-8 mEq/L.

answer

Fatal dysrhythmias **Remember normal potassium levels are 3.5-5.0 mEq/L, and fatal dyshrythmias can occur with hypokalemia and hyperkalemia.

question

What 3 types of magnesium-containing medications should be avoided in patients with CKD to avoid hypermagnesemia? Clinical manifestations of hypermagnesemia include absence of reflexes, decreased mental status, cardiac dysrhythmias, hypotension, and respiratory failure.

answer

1. Magnesium citrate (used for constipation) 2. Antacids containing magnesium 3. Milk of magnesia (used for constipation)

question

Describe how metabolic acidosis can develop in patients with CKD.

answer

Kidneys fail to excrete H+ and fail to regenerate and reabsorb HCO3-, resulting in a drop in pH.

question

Decreased number of RBCs due to the decreased production of erythropoietin. Other contributing factors include nutritional deficiencies (especially folic acid and iron-containing foods), for patients receiving HD experience blood loss in the dialyzer, frequent blood samplings, and GI bleeding

answer

Anemia

question

Describe how elevated levels of PTH in CKD patients can contribute to anemia.

answer

Elevated PTH can cause 1. Decreased erythropoiesis 2. Bone marrow fibrosis 3. Shorten survival of RBCs

question

Why are uremic patients more susceptible to bleeding and bruising (e.g., hemorrhagic tendencies and GI bleeding)?

answer

There is a qualitative defect in platelets resulting in decreased function This can usually be corrected with regular HD or PD

question

What are 3 major reasons patients with CKD are at increased risk for infection.

answer

1. Changes in leukocyte function/altered immune responses 2. Hyperglycemia due to altered carbohydrate metabolism and insulin response having an immunosuppressant effect 3. External trauma (e.g., catheter insertions, needle insertions, and vascular access sites).

question

______________ is highly prevalent in patients with CKD and is both a cause and a consequence.

answer

Hypertension

question

Because of the many effects of HTN, ___________ is one of the most important therapeutic goals in the management of CKD.

answer

BP control

question

Long-standing hypertension, ECF volume overload, and anemia in patients with CKD contribute to the development of (1) __________ that may eventually lead to cardiomyopathy and (2) ____________.

answer

1. left ventricular hypertrophy (LVH) 2. heart failure (HF)

question

What is the most common cause of death in patients with chronic kidney disease?

answer

Cardiovascular disease

question

Inflammation, irritation, and formation of painful exudates and ulcerations in the mouth

answer

Stomatitis

question

Urinous odor of the breath; can occur in patients with CKD

answer

Uremic fetor

question

CKD mineral bone disorder (CKD-MBD) is a systemic disorder caused by decreasing kidney function, less vitamin D activation, resulting in decreased (1) ______ absorption in the GI tract and decreased serum levels. (2) ______ is the primary regulator of serum calcium levels. When (3) __________ occurs, it is secreted to stimulate bone demineralization, thereby releasing (4) ______ from the bones.

answer

1. calcium 2. PTH 3. hypocalcemia 4. calcium

question

In CKD mineral bone disorder (CKD-MBD), (1) _______ is released in addition to calcium leading to elevated serum levels. This will bind to free calcium ions further decreasing serum calcium levels. This significant drop in calcium puts CKD patients at increased risk for (2) __________.

answer

1. phosphate 2. fractures

question

How do the extraskeletal complications of CKD-MBD contribute to the development of cardiovascular disease in CKD patients?

answer

Calcium deposits in the vascular medial layer are associated with stiffening of the blood vessels contributing to hypertension and atherosclerosis development. Intracardiac calcifications can also occur disrupting the conduction system and causing cardiac arrest.

question

What are 2 clinical manifestations of patients with CKD involving the integumentary system?

answer

1. Pruritus 2. Uremic frost

question

Rare condition in which urea crystallizes on the skin. This is usually only seen when BUN levels are extremely elevated (> 200 mg/dL, recall normal BUN 7-18 mg/dL)

answer

Uremic frost

question

Decreased levels of what 3 hormones cause anovulation and menstrual changes (usually amenorrhea) in women with CKD?

answer

1. estrogen 2. progesterone 3. luteinizing hormone (LH) **Menses and ovulation may return after dialysis is started.

question

Redness of the eye due to irritation from calcium deposits in the blood vessels of the eye due to CKD.

answer

uremic red eye

question

What lab finding is usually the first indication of kidney damage?

answer

Proteinuria

question

What lab indicators are consistent with persistent proteinuria?

answer

1+ protein on standard dipstick evaluation >/= 2 times over a 3 month period **A person with persistent proteinuria should have further assessment of risk factors and a diagnostic work up with blood and urine tests to evaluate for CKD.

question

What 5 things can be detected on a routine urinalysis?

answer

1. WBCs 2. RBCs 3. Protein 4. Casts 5. Glucose

question

What 2 things can a renal ultrasound be used for during a work up for CKD?

answer

1. Determine the size of the kidneys 2. Assess for any obstructions

question

What 6 serum laboratory tests can be obtained to help assess for CKD?

answer

1. GFR **gold standard in measuring kidney function 2. H&H 3. Electrolytes 4. Lipids 5. BUN 6. Creatinine

question

Medication given to patients suffering from hyperkalemia secondary to their CKD. Can be taken on an outpatient basis. Binds to potassium in the GI tract and prevents its absorption, resulting in elimination of the potassium in formed stool. Diarrhea is a normal side effect.

answer

Kayexalate or sodium polystyrene solfonate

question

When is giving Kayexalate contraindicated?

answer

Never given Kayexalate to a patient with hypoactive bowel (paralytic ileus) because fluid shifts could lead to bowel necrosis.

question

What EKG changes are associated with hyperkalemia?

answer

Peaked T waves and widened QRS complexes **If the patient has these ECG changes, they may require dialysis for rapid removal of excess potassium

question

If hyperkalemia is mild, potassium restriction may be sufficient to correct it. What is the potassium restriction for CKD patients?

answer

2-3 g/day

question

Give some examples of high-potassium foods.

answer

Bananas, apricots, cantaloupes, white and sweet potatoes, leafy green vegetables, and beans

question

What is the goal BP for a patient with CKD?

answer

<130/80 mmHg or <125/75 mmHg if protein is present in their urine **For some, the progression of CKD can be delayed by controlling their HTN

question

When should phosphate be restricted in patients with CKD?

answer

When the patient requires dialysis/renal transplant or phosphate binders are needed.

question

For CKD patients requiring phosphate restriction, how much phosphate can they consume daily?

answer

1 g/day **If a patient requires phosphate restriction, their hyperphosphatemia may not be controlled with diet restriction alone

question

Give some examples of phosphate-containing products.

answer

Cheese, shell fish, meats (pork, veal, beef), seeds, carbonated beverages

question

Form of active vitamin D that is administered either PO or IV that helps maintain calcium and vitamin D levels within normal limits

answer

Calcitrol

question

In treating CKD patients who have anemia, (1) _________ is given. This can cause a(n) (2) ____________ deficiency, requiring supplementation. (3) __________ is also recommended because it too is needed for RBC formation, but because it is water-soluble, it can be easily removed by dialysis.

answer

1. erythropoietin 2. iron 3. Folic acid

question

What 2 situations would a blood transfusion be warranted in patients with CKD who have anemia?

answer

1. Acute blood loss 2. Patient becomes symptomatic (e.g., dyspnea, excess fatigue, tachycardia, palpitations, chest pain)

question

What are 2 reasons why blood transfusions are avoided in patients who have CKD with anemia?

answer

1. Increases sensitization and development of antibodies, thus making it more difficult to find a compatible donor for transplantation 2. May lead to iron overload

question

What type of drugs are given to CKD patients to help reduce their LDL cholesterol?

answer

Statins (HMG-CoA inhibitors) **Evidence supports the use of statins in patients with CKD, especially patients with diabetes, not on dialysis.

question

What can be given to CKD patients to lower their triglyceride levels and possibly increase their HDLs?

answer

Fibrates (fibric acid derivates)

question

Name 4 reasons why CKD patients are at risk for calorie protein malnutrition.

answer

1. Altered protein metabolism 2. Experience bouts of nausea and suppression of appetite, which is exacerbated when the patient is depressed. 3. Some protein is lost in the urine 4. Many foods that are restricted contain protein (e.g., beans, meat, etc.). **Because of this increased risk for calorie protein malnutrition, protein restriction is not normally recommended for CKD patients.

question

What labs can you monitor to assess a CKD patient's protein status and development of calorie protein malnutrition?

answer

1. Albumin/pre-albumin 2. Urinalysis (to assess for protein in the urine

question

Patients with CKD, especially if they are on hemodialysis, can be on fluid restrictions. What is the recommended fluid intake for these patients?

answer

Whatever the previous day's daily output was + 600 cc's to account for insensible losses

question

Generally, CKD patients are on a potassium-restricted diet. However, those that receive _________ do not have potassium restrictions. In fact, this may even be supplemented because they lose potassium during their treatment.

answer

peritoneal dialysis

question

Many foods that are high in phosphate are also high in protein. Since patients on dialysis are encouraged to eat a diet containing protein, what can be given to patients to control their hyperphosphatemia while also allowing them to eat protein-containing foods?

answer

Phosphate binders

question

What is considered a contraindication to giving erythropoietin for CKD patients with anemia?

answer

Uncontrolled HTN - EPO may further exacerbate an individuals HTN due to underlying hemodynamic changes.

question

What important pieces of information should you educate your patient, who is on iron supplements and phosphate binders, on?

answer

1. Iron supplements can cause your stool to turn dark/black in color. 2. Iron supplements can cause gastric irritation and constipation. 3. Do not take your iron supplement at the same time as your phosphate binder. Some phosphate binders contain calcium which will bind the iron and prevent its absorption.

question

What 2 types of medications should CKD patients avoid?

answer

1. NSAIDs - can cause AKI or worsen the progression of CKD 2. Antacids containing aluminum and magnesium (CKD patients are already at risk for hypermagnesemia and elevated aluminum levels)

question

At approximately what age do ~30-50% of the glomeruli in our kidneys lose function?

answer

70 y.o.

question

Form of kidney disease that develops over 2-30 years and is characterized by inflammation of the glomeruli. It is the 3rd leading cause of ESKD if left untreated and affects both kidneys bilaterally. Causes: Some type of immunologic process attacking the glomerulus and causing inflammation, viral causes (e.g., HIV, hepatitis B and C, bacterial causes (can occur after a streptococcal infection, such as endocarditis or strep throat), and illicit drug use Characterized by proteinuria, hematuria, and slow development of uremia. Other clinical manifestations include urinary excretion of RBCs, WBCs, and casts; elevated BUN and creatinine levels, and fatigue. Treatment is supportive and symptomatic.

answer

Chronic glomerulonephritis

question

Genetic disorder in which the cortex and medulla of the kidneys develop large, thin-walled cysts that enlarge and destroy surrounding tissue by compression. It is considered the most common life-threatening genetic disease in the world. It involves both kidneys and occurs in both men and women. Early in the disease, patients are generally asymptomatic. Symptoms appear when the cysts begin to enlarge: Hypertension; hematuria (from rupture of the cysts;, feeling of heaviness or discomfort in the back, side, or abdomen; UTI; and urinary calculi formation.

answer

Polycystic kidney disease (PKD)

question

What are 4 complications of a patient with polycystic kidney disease?

answer

1. Cyst formation of the liver 2. Abnormal heart valves 3. Aneurysm formation 4. Diverticulosis

question

What is the most serious complication of a patient with polycystic kidney disease?

answer

A cerebral aneurysm which can rupture

question

Polycystic kidney disease usually progresses from loss of kidney function to ESKD requiring dialysis or kidney transplant by age ________ in 50% of patients.

answer

60 y.o.

question

What should be recommended to patients with adult-onset polycystic kidney disease.

answer

Genetic counseling and screenings for their children to help in family planning

question

Disease in which the kidneys become small, atrophic, and shrunken losing their function due to fibrosis (scarring). It is usually the result of a recurring infection involving the upper urinary tract but can occur in the absence of an infection. Can affect one or both kidneys, but it often progresses to ESKD even if the underlying infection is successfully treated. Clinical manifestations: Hypertension, anemia, fatigue, pruritus, and flank pain. Treatment is supportive and symptomatic.

answer

Chronic pyelonephritis

question

What are 3 indications from a biopsy result that are consistent with the diagnosis of chronic pyelonephritis?

answer

1. Loss of functioning nephrons 2. Infiltration of the parenchyma with inflammatory cells 3. Fibrosis

question

A technique in which substances move from the blood through a semipermeable membrane and into a solution. It used to correct fluid and electrolyte imbalances, remove waste products in kidney failure, and treat drug overdoses.

answer

Dialysis

question

What are the 2 methods of dialysis available?

answer

1. Hemodialysis (HD) 2. Peritoneal dialysis (PD)

question

Patients that do NOT require severe imbalance correction are better candidates for this type of dialysis as it is more for maintenance.

answer

Peritoneal dialysis (PD)

question

Describe the 3 steps in the process of peritoneal dialysis.

answer

1. Inflow - dialysis solution drains into the peritoneum 2. Dwell - through diffusion and osmosis, wastes and toxins move into the dialysate. 3. Drain - dialysate containing wastes and toxins is removed and drains into the drain bag. This can be facilitated by gently massaging the abdomen or changing positions.

question

What are some complications of peritoneal dialysis?

answer

1. Superficial infection at the catheter site, which if left untreated can result in peritonitis 2. Hernia 3. Lower back problems 4. Bleeding 5. Pulmonary complications (atelectasis, pneumonia, bronchitis) 6. Protein loss ** **The peritoneal membrane is permeable to plasma proteins, amino acids, and polypeptides; therefore, these substances are lost in the dialysate fluid.

question

Inflammation of the peritoneum that can occur in patients who receive peritoneal dialysis. Can be caused by contamination of the exit site or progression of a superficial infection, improper technique in making or breaking connections for exchanges, or can occur from bacteria in the intestine crossing over into the peritoneal cavity (less common).

answer

Peritonitis

question

What are some clinical manifestations of peritonitis?

answer

1. Abdominal pain 2. Cloudy peritoneal effluent 3. Bacteria present in the peritoneal effluent by Gram stain or culture 4. Diarrhea, vomiting, abdominal distention, and hyperactive bowel sounds 5. Fever may or may not be present

question

What is a major complication of peritonitis for patients receiving peritoneal dialysis?

answer

Repeated infections can lead to the formation of adhesion in the peritoneum interfering with the peritoneal membrane's ability to act as a dialyzing surface. Repeated infections may require the removal of the catheter and discontinuing PD altogether

question

About how often do patients receive hemodialysis on an outpatient basis?

answer

3 days a week, lasting for 3-4 hours each day

question

This form of dialysis is more appropriate for patients requiring correction of more severe imbalances.

answer

Hemodialysis (HD)

question

What three vascular access sites can be created in order for a patient to receive hemodialysis?

answer

1. Arteriovenus fistula (AVF) 2. Arteriovenus graft (AVG) 3. Temporary vascular access

question

Vascular access that creates a connection between an artery and vein so that the vein becomes more "arterlialized." Because it requires maturation time, it should be placed at least 3 months before the need to initiate hemodialysis.

answer

Arteriovenous fistula (AVF)

question

What are common physical exam findings when examining a fistula?

answer

1. Palpable thrill over the fistula site 2. Bruit auscultated over the fistula site

question

What types are usually NOT good candidates for an arteriovenous fistula?

answer

1. Patients with PVD 2. Patients with a history of prolonged IV drug use 3. Obese women

question

Vascular access site where a synthetic material is used to form a "bridge" between the arterial and venous blood supplies.

answer

Arteriovenous graft (AVG)

question

Why are arteriovenous grafts (AVGs) more likely to become infected, develop aneurysm, and are thrombogenic when compared to arteriovenous fistulas (AVFs)?

answer

Presence of the synthetic material - anything that is perceived as a foreign object in the body will create a clotting response and can harbor pathogenic material

question

Complication that can occur in patients with an arteriovenous graft in which there is ischemia of the tissues distal to the graft causing pain, numbness, and/or tingling of the fingers which may be worse during dialysis. Poor capillary refill is observed.

answer

Steal syndrome

question

Form of vascular access inserted when immediate vascular access is required. Catheterization of the jugular vein or femoral vein is performed. Patients should not be discharged from the hospital with this in place as they have high rates of infection, dislodgment and malfunction.

answer

Temporary vascular access

question

What 4 things should be assessed prior to hemodialysis?

answer

1. Assess fluid status (weight, BP, peripheral edema, lung and heart sounds) 2. Condition of the patient's vascular access 3. Temperature 4. General skin conditions

question

How many needles are inserted into the fistula or graft when a patient receives hemodialysis? What is occurring there?

answer

1. 2 large needles are inserted into the fistula or graft to obtain vascular access 2. One needle is placed to pull blood from circulation to the dialysis machine, and the second needle is used to return the dialyzed blood back to the patient.

question

What is added to the blood of a hemodialysis patient as it flows into the dialyzer to prevent clotting?

answer

heparin

question

How often should you be assessing a patient's vital signs while they are receiving hemodialysis?

answer

Every 30-60 minutes to assess for rapid BP changes

question

What is the biggest side effect of hemodialysis?

answer

Hypotension

question

If a patient, who is receiving hemodialysis, becomes hypotensive, lightheaded, and nauseated while receiving dialysis; what should you do?

answer

1. Lower the head of the bed or recliner 2. Check their blood pressure 3. Decrease the volume of fluid being removed 4. Infuse 0.9 saline solution

question

What is a good piece of information to recommend to patients on hemodialysis prior to coming to their hemodialysis appointment?

answer

Do not take BP medications as hypotension is a common side effect of dialysis **If this is an admitted patient, phone the physician and ask if you can hold their blood pressure medication until after dialysis is performed

question

Why is anemia a special concern for patients on hemodialysis?

answer

They are at increased risk for bleeding because blood may not be completely rinsed from the dialyzer, and bleeding after the removal of the needle at the end of dialysis may be excessive if too much heparin was administered. Other complications that can occur while receiving HD are rupture of the dialysis membrane and accidental separation of the blood tubing.

question

What is a complication of hemodialysis for both the patient and caregiver due to the increased exposure to blood during exchanges?

answer

Hepatitis ** All patients and care providers are vaccinated for hepatitis B and C as a preventative measure

question

Under normal cellular biology, describe the relationship between cell proliferation/reproduction and cellular degeneration/death.

answer

Under normal circumstances, cell proliferation = cell degeneration. Cellular proliferation only occurs when cell death occurs and when there is an increased need for those cells.

question

When cells are __________, cancer treatments (i.e., chemo and radiation therapy) are most effective.

answer

actively dividing/proliferating/reproducing

question

What 2 major dysfunctions are present in the process of cancer?

answer

Dysfunction in 1. Cellular proliferation 2. Cellular differentiation

question

What about cancer cell proliferation is abnormal?

answer

Cancer cells lack contact inhibition. They have no regard for cell boundaries and grow on top of one another and also on top of or between normal cells.

question

True or false: Cancer cells proliferate at a faster rate than that of the normal body cells from their tissue of origin.

answer

False - This is a common misconception. Cancer cells usually proliferate at the same rate as the normal cells of the tissue from which they arise. They differ from normal cells because they proliferate indiscriminately and continuously.

question

Give some examples of cell/tissue types that have a rapid rate of cell proliferation.

answer

epithelial lining of the GI tract, hair follicles, bone marrow

question

Cells that _______ reproduce are most affected by chemotherapy and radiation.

answer

rapidly

question

What about cancer cell differentiation is abnormal?

answer

When cancer cells reproduce, they do so in a disorganized pattern. Sometimes they do not look like a cell from their tissue of origin. They are poorly differentiated and present in various degrees of differentiation.

question

What are 2 types of NORMAL genes that control cellular differentiation and proliferation?

answer

1. Proto-oncogenes 2. Tumor suppressor genes

question

When proto-oncogenes are exposed to carcinogens, they can mutate and become __________ or tumor-inducing genes.

answer

oncogenes

question

Type of tumor antigen found on both the surfaces and the inside of cancer and fetal cells. They are an expression of the shift of cancerous cells to a more immature metabolic pathway and are believed to occur as a result of the cell regaining its embryonic capability to differentiate into many different cell types.

answer

Oncofetal antigens

question

True or false: Elevated levels of oncofetal antigens can provide a definitive diagnosis for associated cancers.

answer

False - Oncofetal antigens are used to 1) measure the success of treatment, 2) assess for recurrence or remission of cancer, and 3) alert the provider to perform more studies. **A definitive cancer diagnosis can only be made if a biopsied tissue sample was performed, and cancer cells were found in the tissue.

question

Which oncofetal antigen is associated with colon cancer?

answer

CEA - Carcinoembryonic antigen

question

Which oncofetal antigen is associated with primary liver cancer or metastatic liver growth?

answer

AFP - Alphafetaprotein

question

Which oncofetal antigen is associated with ovarian cancer?

answer

CA-125

question

Which oncofetal antigen is associated with pancreas and gallbladder cancer?

answer

CA-19

question

Which oncofetal antigen is associated with prostate cancer?

answer

PSA - Prostatic specific antigen

question

Which oncofetal antigens are associated with breast cancer?

answer

CA-15-3 and CA-27-29

question

What types of cancer are associated with EBV (Epstein-Barr virus)?

answer

1. Burkett's lymphoma 2. Hodgkin's disease

question

What type of cancer is associated with HBV (hepatitis B virus)?

answer

hepatocellular carcinoma

question

What types of cancer are associated with HIV (Human immunodeficiency virus)?

answer

1. Kaposi's sarcoma 2. Non-Hodgkin's lymphoma

question

What 2 cancer types have strong genetic links?

answer

breast and ovarian cancer

question

Oral contraceptives and estrogen therapy increase the risk for what 3 cancer types?

answer

1. Breast 2. Hepatic 3. Endometrial

question

Oral contraceptives and estrogen therapy decrease the risk for what type of cancer?

answer

ovarian cancer

question

What 4 reproductive cycle characteristics will increase one's risk for developing breast cancer?

answer

1. Nullparity 2. Early menopause (<12 y.o.) 3. Menopause after 55 y.o. 4. Having children after 30 y.o. **Increased exposure to estrogen throughout life increases one's risk for breast CA

question

As a tumor increases in size, development of its own ____________ is critical to survival and growth.

answer

blood supply

question

Formation of blood vessels within the tumor itself

answer

Tumor angiogenesis

question

What are the 2 most common routes for primary tumor cells to metastasize to other tissues?

answer

1. Hematogenous/vascular - through penetration of the blood vessels 2. Lymphatic - invasion of the lymph vessels

question

What is the major difference between benign and malignant neoplasms?

answer

The ability of malignant tumor cells to invade and metastasize

question

Tumors that are (1) _______ differentiated have a worse prognosis than those that are (2) ________ differentiated.

answer

1) poorly 2) well

question

What are the 3 parameter of the TNM classification system used to determine the anatomic extent of the cancer involvement?

answer

1. Tumor (based on size and invasiveness) 2. Node (presence or absence of regional spread to the lymph nodes) 3. Metastasis (has the cancer spread elsewhere?) Each parameter is rated on a scale of 0-4 with higher ratings indicating a poorer prognosis

question

Form of cancer prevention that is primarily involved in risk reduction. Ex: 1) Reduce or avoid exposure to known or suspected carcinogens and cancer-promoting agents, including cigarette and sun exposure. 2) Eating a balanced diet, regular physical activity, and maintaining a healthy weight 3) Limiting alcohol intake

answer

Primary prevention

question

Form of cancer prevention that is primarily involved in early screening and detection. Ex: 1. Having regular physical exams. 2. Following the American Cancer Society's recommended cancer screening guidelines. 3. Learn and practice self breast examinations

answer

Secondary prevention

question

Form of cancer prevention that is primarily involved in monitoring and preventing recurrence. These are interventions that may not necessarily cure but may allow for the patient to be more comfortable or slow the progression of their disease.

answer

Tertiary prevention

question

What is the acronym for the 7 warning signs of cancer, and what do they stand for?

answer

CAUTION 1. Changes in bowel or bladder habits 2. A wound that does not health 3. Unusual bleeding or discharge from any orifice 4. Thickening or lump present in tissues 5. Indigestion or difficulty swallowing 6. Obvious changes to a wart or mole 7. Nagging cough

question

What are the 3 goals of cancer treatment?

answer

1. Cure 2. Control 3. Palliation

question

When is the risk for recurrence of cancer highest?

answer

After treatment ** Risk gradually decreases the longer the patient remains disease-free following treatment.

question

Cancers with a (1) _________ mitotic rate (e.g., testicular cancer) are less likely to recur than cancers with (2) ___________ mitotic rate (e.g., postmenopausal breast cancer).

answer

1. faster/higher 2. lower/slower

question

Treatment goal for cancers that cannot be completely eradicated but are responsive to anticancer therapies. They may slow down the progression of cancer.

answer

Control

question

Treatment goal for cancer where the primary objectives are relief or control of symptoms and the maintenance of a satisfactory quality of life.

answer

Palliation

question

Why are 2 or more treatment modalities (termed multimodal therapy or combined modality therapy) used to cure or control many cancers?

answer

It is more effective because it takes advantage of more than one mechanism of action. **but often at the expense of greater toxicity

question

What are 4 types of treatment for cancer?

answer

1. Surgery 2. Radiation therapy 3. Chemotherapy 4. Biologic/targeted therapy

question

Surgical procedure in which as much of the tumor as possible is resected prior to the patient receiving chemotherapy and/or radiation therapy; decreases tumor burden

answer

Debulking procedure

question

Why is radiation therapy generally not appropriate as the primary treatment for systemic disease?

answer

RT only influences tissues within the treatment field. Its goal is to deliver a lethal dose of radiation to the tumor while sparing healthy tissue.

question

Most common form of radiation treatment where treatments are given daily over several weeks, depending on type and severity of cancer. It is a form of local treatment where the site to receive radiation is demarcated as the treatment port. Radiation source is a linear accelerator; therefore, the patient is never considered radioactive.

answer

External beam radiation therapy (teletherapy)

question

Implantation of radioactive materials either into the tumor or in close proximity to allow for directly delivery of radiation to the target tissue with minimal exposure to the surrounding healthy tissues. Used when high doses of radiation are needed to kill the tumor cells.

answer

Internal beam radiation therapy (brachytherapy)

question

During temporary brachytherapy, while the radioactive material is inserted in the patient, they are considered _________, and thus, warrant a private room when in the hospital.

answer

radioactive

question

High-dose rate brachytherapy can usually be given on a(n) (1) ___________ basis because several doses are administered over a few minutes each time. Low-dose rate brachytherapy is a continuous treatment given over several hours or days; therefore, these patients are usually treated on a(n) (2) __________ basis.

answer

1) out-patient 2) in-patient

question

Form of brachytherapy where the radioactive material is inserted directly into the tissue where they remain. Because the material emits low energy, there is little tissue penetration and patients are NOT considered radioactive.

answer

Permanent brachytherapy

question

When taking care of a patient on systemic radiation therapy, why must you wear personal protective equipment?

answer

Any of the patient's body fluids or excretions are considered radioactive (e.g., stool, sweat, saliva, urine, etc.).

question

What does ALARA stand for, and what is its significance?

answer

1. As Low As Reasonably Achievable 2. Caregivers of patients with a source of temporary internal radiation should be exposed to as little radiation as possible

question

Badge that a caregiver can wear to measure the amount of radiation exposure

answer

Dosimeter (film badge)

question

What is the ideal distance from and amount of time spent with a patient who has a temporary internal source of radiation?

answer

6 feet for 30 min or less daily

question

What is an important nursing consideration when following ALARA while caring for a person who is considered radioactive?

answer

Explain to the patient the reason for time and distance limitations to avoid eliciting anxiety and confusion

question

What 2 types of people are not allowed to visit patients receiving temporary brachytherapy?

answer

1. Children 2. Pregnant women

question

Redness and pruritus to the skin due to external RT. Because of the severe itching, patients tend to scratch and can break the skin increasing these immunocompromised patients' risk for infection. Lotion can be applied to the patient's skin to alleviate dryness and itching; however, avoid lotions containing metal, alcohol, perfume, or additives that may interfere with RT.

answer

Dry desquamation

question

Complication of external radiation therapy causing greater cell slough compared to the ability of new epidermal cells to replace dead cells. This results in exposure of the dermis and weeping of serous fluid. This generally produces pain and increased risk for infection as the first line of defense has been compromised. Important to keep the tissues clean with normal saline compresses, avoid tight fitting clothing to avoid further damage, and to protect with moisture vapor-permeable dressing.

answer

Wet desquamation

question

What are 5 important points for patient education regarding protecting irradiated skin?

answer

1. Protect the skin from extreme temperature - avoid hot/cold packs. 2. Avoid tight clothing, rubbing, harsh chemicals, and deodorants. 3. Avoid direct exposure to the sun - use sunscreen and wear protecting clothing 4. Do not remove port markings 5. Avoid swimming in chlorinated pools or salt water while receiving treatment

question

Form of cancer treatment using chemicals/drugs that act systemically. They work at the cellular level with the goal of eliminating or reducing the number of malignant cells in the primary tumor and metastatic tumor sites.

answer

Chemotherapy

question

Chemotherapy drugs that have their effect on cells during ALL phases of the cell cycle, including the process of cell replication and proliferation and the resting phase (G0).

answer

Cell cycle phase-nonspecific

question

Chemotherapy drugs that exert their most significant effects during specific phases of the cell cycle (i.e., when cells are in the process of cell replication or proliferation during G1, S, G2, or M).

answer

Cell cycle phase-specific

question

Time at which the patient undergoing radiation or chemotherapy experiences the lowest blood cell counts. This is usually 7-10 days after initiation of therapy.

answer

Nadir

question

Why is it important to space out the component drugs of multimodal therapy?

answer

Avoid having all nadirs occur at the same time and completely wiping out the patient's blood counts

question

What protocol is usually initiated to treat Non-Hodgkin's lymphoma?

answer

MOPP Protocol M - nitrogen Mustard O - Oncovin P - Procarbazine P - prednisone (steroid and not antineoplastic)

question

While preparing and administering chemotherapy drugs, what type of PPE should the provider wear?

answer

1. 2 pairs of chemotherapy drugs 2. Gown 3. NIOSH-approved respirator 4. Protective eyewear

question

What is the most common route and the best route for chemotherapy administration?

answer

1. Most common - IV 2. Best - Central venous access device (CVAD)

question

Infiltration of drugs into tissues surrounding the infusion site causing local tissue damage.

answer

Extravasation

question

Type of chemotherapy drugs that damage the intima of the vein, causing phlebitis and sclerosis limiting future peripheral venous access. If infiltrating the tissues, it will not cause tissue damage.

answer

Irritants

question

Type of chemotherapy drugs that cause severe local tissue breakdown and necrosis if inadvertently infiltrated into the skin.

answer

Vesicants

question

It is extremely important to monitor for and promptly recognize symptoms associated with extravasation of a vesicant while administering chemotherapy. What are some signs and symptoms of this?

answer

1. Pain (cardinal sign) 2. Redness 3. Swelling 4. Vesicles on the skin

question

What is the FIRST or most immediate action that should be taken if you suspect extravasation of a vesicant while administering chemotherapy to your patient?

answer

Turn off the infusion

question

Catheter placed in large blood vessels (usually tip is in the superior vena cava) to permit frequent, continuous, or intermittent administration of chemotherapy, biologic and targeted therapy, and other products. It is considered the best route for chemo administration as it avoids extravasation complications with vesicant chemotherapy agents.

answer

Central venous access device (CVAD)

question

Route in which chemotherapy can be delivered directly to the tumor site via the blood vessels supplying the tumor.

answer

Intra-arterial

question

Form of regional chemotherapy where chemotherapy is delivered into the peritoneal cavity via a percutaneous or surgically inserted catheter port.

answer

Intracavitary/intraperitoneal

question

Why are CNS cancers or cancers that metastasize to the CNS difficult to treat?

answer

The blood brain barrier (BBB) prevents distribution of chemotherapy to this area

question

Method of chemotherapy administration in which a lumbar puncture is used to inject chemo into the subarachnoid space. This method can result in incomplete distribution of the drug in the CNS.

answer

Intrathecal chemotherapy

question

Form of intraventricular therapy where a dome-shaped disk is inserted into the cranium and is the site where chemotherapy is injected. The disk has an attached extension catheter which drains into the lateral ventricle where chemotherapy can be more uniformly distributed. Used for when medications need to be delivered directly to the brain and to avoid the BBB.

answer

Ommaya reservoir

question

Method of chemotherapy administration in which the chemotherapy agent is instilled into the bladder via a catheter and retained for 1-3 hours. While the drug remains in the bladder, the catheter is clamped, and the patient can change positions to allow for more direct contact of the drug to the effected tissues.

answer

Intravesicular

question

True or false: Myelosuppression occurs to a greater extend when patients receive chemotherapy when compared to radiation therapy.

answer

True - Chemo is a SYSTEMIC form of therapy and affects bone marrow function throughout the body. RT is more of a local therapy. Myelosuppression can occur but only in the treatment field. There is an increased risk if RT is to the long bones or pelvic bones.

question

List the forms of myelosuppression that can occur in patients receiving chemotherapy and/or radiation therapy in order from when they will occur (earliest to latest).

answer

1. Leukopenia/neutropenia (within 1-2 weeks of starting treatment) 2. Thrombocytopenia (within 2-3 weeks of starting treatment) 3. Anemia (~3-4 months after starting treatment)

question

WBC count consistent with leukopenia

answer

<4,000 cells/microliter

question

What type of isolation precautions is a patient with neutropenia/leukopenia placed on?

answer

Reverse isolation --> Because the patient is severely immunocompromised, we do not want the patient to be exposed to any pathogens from outside. Even normal flora can cause illness.

question

What is an important point of patient education for patients in reverse isolation precautions?

answer

Explain to these patients why they are being placed in reverse isolation and why you need to wear personal protective equipment while caring for them

question

What 2 drugs can be given to patients with neutropenia/leukopenia to help stimulate WBC proliferation?

answer

1. Filgrastim (Neupogen) 2. Pegfilgrastim (Neulasta) **These drugs can also be given prophylactically to prevent neutropenia when highly myelosuppressive chemotherapy drugs are being used.

question

At what point should a patient with thrombocytopenia likely require a platelet transfusion?

answer

Platelet count of < 20,000 cells/microliter

question

What medication can be given to patients with thrombocytopenia to stimulate platelet production?

answer

Interleukin-11 or Neumega

question

What are 4 clinical manifestations of hypoxia which can occur in anemic patients?

answer

1. Low SpO2 2. Dyspnea, fatigue, pallor, lethargy 3. Low H&H's 4. Decreased/sluggish capillary refill

question

What 2 medications can be given to a patient with anemia to stimulate erythropoiesis?

answer

1. Epogen 2. Procrit

question

At what point should an anemic patient receive a RBC transfusion?

answer

When their anemia becomes symptomatic (e.g., lightheadedness)

question

What is the greatest cause of mortality in patients receiving chemotherapy/cancer treatment?

answer

Sepsis/infection

question

What are the 2 most common sites of infection for a patient with leukopenia/neutropenia?

answer

1. Lung 2. Urinary tract

question

At what temperature should a neutropenic/leukopenic/immunocompromised patient call their healthcare provider?

answer

>100.4 deg F or 38.0 deg C **Fevers are a big deal for immunocompromised patients. Because they are immunocompromised, it takes a lot of work for them to generate a fever.

question

Why might purulent drainage not be exhibited in a patient with an infected access port?

answer

If the patient is severely immunocompromised, they may not produce enough white blood cells that make up purulent drainage.

question

What recommendations would you make to a patient who is thrombocytopenic and still menstruating?

answer

1. Warn them of the risk for increased bleeding 2. Monitor the number of pads they use daily 3. Avoid tampon use to avoid vaginal irritation

question

What are 5 possible causes of fatigue in cancer patients?

answer

1. Anemia 2. Accumulation of toxic substances that are left in the body after cells are killed by cancer treatment 3. The need for extra energy to repair and heal body tissue damaged by treatment 4. Lack of sleep or quality/restful sleep caused by side effects of therapy and/or pain/discomfort 5. Inadequate nutrition - Patients need extra nutrients to repair cells, but they often have poor appetites and thus have inadequate nutrition

question

What medication can be given before and/or after cancer treatment for patients suffering from nausea and vomiting?

answer

ondansetron (Zofran)

question

What are the 2 major concerns for patients experiencing diarrhea after radiation therapy?

answer

1. Electrolyte imbalances 2. Dehydration

question

What 3 types of foods should patients receiving RT and experiencing diarrhea avoid?

answer

1. High-fiber/high-residue foods (e.g., fresh fruits, vegetables, seeds, and nuts) 2. Fried, fatty, highly seasoned/spicy foods 3. Lactose / milk products

question

Patients experiencing diarrhea due to radiation therapy are recommended probiotics and a BRAT diet. What does BRAT stand for?

answer

Bananas Rice Applesauce Toast

question

Inflammation, irritation, redness, pain, and ulcer formation extended from the mouth, to the oropharynx, and esophagus.

answer

Mucositis

question

Common yeast infection that is not normally pathogenic in healthy individuals but can affect immunocompromised patients. Produces thrush and can cause a change in taste perception of effected patients.

answer

Candidiasis albicans

question

Painful swallowing caused my mucosal irritation and ulceration.

answer

Odynophagia

question

What 2 medications can be given to patients with mucositis/stomatitis prior to meals to help alleviate discomfort while eating?

answer

1. Viscous xylocaine 2. Nystatin

question

What are the 3 major complications that can occur due to the GI side effects (e.g., nausea, vomiting, diarrhea, anorexia, stomatitis, mucositis) of cancer treatment?

answer

1. Electrolyte imbalances 2. Dehydration 3. Impaired nutrition

question

Hair loss from (1) _______ is localized to the treatment area and is generally (2) ____________.

answer

1. radiation therapy 2. irreversible

question

Hair loss from (1) _________ is systemic or occurs throughout the body and is (2) _____________.

answer

1. chemotherapy 2. reversible

question

What 2 chemotherapeutic agents can cause renal impairment?

answer

1. Cisplatin (can also cause hearing loss) 2. Cyclophosphamide (Cytoxan) - can cause hemorrhagic cystitis **If patients are on these medications, it is important to monitor their BUN and creatinine

question

What should patients on nephrotoxic chemotherapeutic agents, such as Cisplatin be given prior to chemotherapy?

answer

Because patients on nephrotoxic agents should be well hydrated, patients on Cisplatin are specifically given IV fluids prior to receiving the medication to help prevent adverse effects.

question

Chemotherapeutic agent that is an anthracycline that can cause cumulative cardiotoxic effects - damages the contractility of the myocardium, affecting the ability of the heart to pump, and possibly leading to heart failure and ECG abnormalities.

answer

doxorubicin (Adriamycin)

question

What clinical indicator should be monitored closely in patients receiving doxorubicin (Adriamycin), an antineoplastic drug?

answer

ejection fraction (EF) Adriamycin is a cardiotoxic drug that can lead to heart failure

question

What are 2 reproductive effects that can occur in females receiving chemotherapy?

answer

1. Early menopause 2. Sterility

question

True or false: Males receiving chemotherapy will always regain their sterility once treatment is complete.

answer

False - Sterility can be temporary or permanent **Patients can be given the option to bank their sperm prior to treatment

question

Chemotherapeutic agent that is a plant alkaloid that can cause peripheral neuropathy. Patients can experience progressive numbness and tingling of their extremities. These manifestations are typically dose dependent, as the drug dose is decreased, symptoms will decrease.

answer

vincristine (Oncovin)

question

Chemotherapeutic agent that can cause hearing loss due to damage of the acoustic nerve. Patients usually undergo a hearing test prior to and throughout treatment to monitor for hearing loss.

answer

Cisplatin

question

What are 3 types of biologic response modifiers?

answer

1. Interferons 2. Monoclonal antibodies 3. Interleukins

question

Type of biologic response modifier that activates the immune system or alters the functional capacity of cancer cells to stop malignant growth.

answer

Interleukins

question

Type of biologic response modifier that has antiviral and antiproliferative properties.

answer

Interferon

question

Type of biologic response modifier whose goal is to stimulate and try to kick-start the immune system to respond to and kill cancer cancers.

answer

Monoclonal antibodies

question

Whether the diagnosis is a malignant or nonmalignant disease, the goal of hematopoietic stem cell transplant is _______.

answer

cure

question

High-risk procedure in which a higher than usual dose of chemotherapy with or without RT is given to a patient to eradicate diseased tumor cells and/or clear the marrow of its components to make way for the engraftment of the transplanted healthy stem cells. Healthy stem cells are then infused, and within a few weeks the stem cells will hopefully develop/mature into healthy blood cells that can regenerate the bone marrow.

answer

Hematopoietic stem cell therapy (HSCT)

question

True or false: Hematopoietic stem cell therapy is such a high-risk procedure that many patients die from the treatment rather than the cancer.

answer

True **Because patients receiving HSCT are so immunocompromised after receiving high-dose chemotherapy/RT, they are placed in reverse isolation to avoid infections.

question

What sources can stem cells be harvested from?

answer

1. Bone marrow 2. Peripheral blood 3. Embryonic cord blood

question

Type of hematopoietic stem cell therapy (HSCT) where the stem cell donor is another person, usually a family member. It is the most common type of HSCT and depends on HLA tissue typing/matching.

answer

Allogeneic HSCT

question

Type of hematopoietic stem cell therapy (HSCT) where the stem cell donor is the patient's identical twin. Because identical twins have identical HLA types, they are a perfect match. Neither the graft-versus-host nor the graft-versus-tumor effect occurs.

answer

Synergeneic transplantation

question

Type of hematopoietic stem cell therapy (HSCT) where the patients receive their own stem cells back after myeloablative chemotherapy. This is performed in patients with healthy bone marrow but require aggressive chemo to treat the disease. Its aim is purely to "rescue." Takes the longest amount of time for restoration of the bone marrow to occur.

answer

Autologous

question

Complication from any type of transplantation procedure, including hematopoietic stem cell transplantation, in which T lymphocytes from the donor marrow (graft) recognize the recipient (host) as foreign and initiate an immune response against the host's tissues. Signs and symptoms: Blistering and desquamation, diarrhea, abdominal pain, hepatomegaly

answer

Graft-versus- host disease **This can be beneficial if the attack is against the host's tumor cells.

question

What are 2 forms of immunosuppressant drugs we can give patients post-transplant to prevent graft-versus-host disease?

answer

1. cyclosporine (Sandimmune) 2. tacrolimus (Prograf)

question

Type of oncologic emergency caused by the obstruction of the superior vena cava by a tumor or thrombosis. Clinical manifestations include facial edema; periorbital edema; distention of the veins of the head, neck, and chest; headache; seizures, and a mediastinal mass may be visible on chest x-ray. These patients are at risk for severe respiratory depression given significant upper body edema. Treated with RT or chemo to shrink the tumor and alleviate the obstruction.

answer

Superior vena cava syndrome (SVCS)

question

Oncologic emergency caused by a malignant tumor in the epidural space compressing the spinal cord. Signs and symptoms: Intense, localized, and persistent back pain; vertebral tenderness aggravated by the Valsalva maneuver; motor weakness and dysfunction; bowel or bladder changes reflecting autonomic dysfunction; tingling sensation, numbness of the extremities. Diagnosed by MRI and treated either with RT and corticosteroids for initial improvement and/or decompressive laminectomy.

answer

Spinal cord compression (SCC)

question

What type of cancer often metastasizes to the spinal cord and can cause spinal cord compression?

answer

Prostate cancer

question

Oncologic emergency in which there is massive release of intracellular components into the bloodstream due to massive cell destruction with chemotherapy. This usually occurs within 24-48 hrs after the initiation of chemotherapy and may persist for ~5-7 days. Early symptoms: Weakness, muscle cramps, diarrhea, nausea, and vomiting. Primary goal of treatment is to prevent renal failure and severe electrolyte imbalances by increasing urine production with hydration therapy and decreasing uric acid concentrations.

answer

Tumor lysis syndrome (TLS)

question

What are the 4 hallmark signs (lab indicators) of tumor lysis syndrome?

answer

1. Hyperkalemia 2. Hyperphosphatemia 3. Hypocalcemia 4. Hyperuricemia

question

What medication can be given to patients suffering from uricemia secondary to tumor lysis syndrome?

answer

allopurinol (Zyloprim)

question

What is the single greatest barrier to effective pain management in patients with cancer?

answer

Inadequate pain assessment

question

What opioid analgesic is the mainstay for cancer pain treament?

answer

Morphine

question

Which opioid analgesic used to treat cancer pain has a no ceiling effect? What is a no ceiling effect?

answer

1. morphine 2. You can continue to increase the dose of morphine, and pain will continue to get better with the higher dose.

question

Opioid analgesic used to treat cancer pain that is structurally similar to morphine but is slightly more rapid in onset

answer

hydromorphone (Dilaudid)

question

Opioid analgesic used to treat cancer pain that is a synthetic morphine derivative with sustained release options available.

answer

oxycodone

question

Opioid analgesic used to treat cancer pain that comes in a controlled release transdermal patch. It is slow in onset, requiring 12-24 hours to reach peak and has a prolonged duration, requiring 17 hours for serum concentrations to decrease by 50% after the patch is removed.

answer

fentanyl

question

What are 8 non-pharmacologic pain management strategies for patients with cancer pain?

answer

1. Massage 2. Distraction 3. Acupuncture 4. Positioning 5. Heat therapy 6. Cold therapy 7. Hypnosis 8. Relaxation techniques

question

Why do males diagnosed with breast cancer have a greater mortality than women?

answer

Although only 1% of all breast cancer diagnoses are made in males, they have a greater mortality because they are not screened as often. By the time they are diagnosed, the cancer has progressed further along.

question

What role do estrogen and progesterone have in breast cancer?

answer

May act as tumor promoters to stimulate breast CA growth if malignant changes in the cells have already occurred.

question

Most inherited cases of breast cancer associated with mutations in what 2 genes?

answer

BRCA1 and BRCA2

question

What types of genes are BRCA1 and BRCA2? Women with a mutation in one of these genes has a __ to ___% lifetime chance of developing breast cancer.

answer

1. tumor suppressor genes 2. 40-80%

question

What are the recommendations to receive mammogram screenings for women who have a mutation of their BRCA1 or BRCA2 gene?

answer

Yearly starting at 25 y.o. or 5-10 years earlier than the youngest effected family member

question

The mutation of what 3 other genes (not BRCA1 or BRCA2) can predispose an individual to being at risk for breast cancer? What are these genes' normal functions?

answer

1. P53 (tumor suppressor gene) 2. CHEK 2 (stops tumor growth) 3. ATM (Repairs damaged DNA)

question

Having a first-degree relative with breast cancer increases a woman's risk of breast CA ___ to ____ times, depending on age.

answer

1.5-3

question

Family history of breast cancer is an important risk factor, especially if the involved family member also had 1) _______ 2) _______ 3) _______ 4) ________

answer

1) ovarian cancer 2) bilateral breast cancer 3) is a first degree relative 4) was premenopausal

question

What 2 drugs can be given to a patient with an increased risk for breast cancer as a form of chemoprevention?

answer

1. tamoxifen 2. raloxifen (Evista)

question

A prophylactic oophorectomy lowers the risk of breast cancer for (1) __________ women but not for (2) ___________ because the ovaries are no longer their main producers of estrogen.

answer

1) pre-menopausal 2) post-menopausal

question

In what region of the breast do most lumps or thickening of the breast tissue form?

answer

upper, outer quadrant (location of most of the glandular tissue)

question

Clinical manifestation of breast cancer where the skin overlying the breast has a dimpled appearance, similar to that of an orange. This may occur due to the plugging of dermal lymphatics.

answer

Peau d'orange

question

What are the recommendations for mammography screenings for women?

answer

1. Yearly for women starting at 40 y.o. 2. If patient has a positive gene mutation and/or a positive family history with a first-degree relative, yearly mammographies are recommended starting at 25 y.o. or 5-10 years prior to the age of the youngest family member with breast cancer

question

What are the recommendations for clinical breast examinations?

answer

1. Every 3 years for women 20-30 years old 2. Yearly for women >/= 40 y.o.

question

What are the recommendations for breast self-examinations?

answer

Monthly for women starting at 20 y.o.

question

A prognostic indicator for breast cancer is tumor size. The (1) _________ the tumor, the (2) __________ the prognosis.

answer

1) larger 2) worse

question

Procedure in which a radioisotope or blue dye is injected into the effected breast, and intraoperatively it is determined in which lymph nodes the dye is located. A local incision is made in the axilla, and the surgeon dissects the blue-stained lymph nodes. Approximately 1-4 lymph nodes are removed and can be sent for pathologic analysis.

answer

Sentinel lymph node dissection

question

Lymph nodes that drain first from the tumor site

answer

Sentinel lymph nodes or sentinel nodes

question

After a sentinel lymph node dissection (SLND), the pathology report shows that there are no cancer cells present. What are the chances that the breast cancer has spread further? What is this patient's prognosis?

answer

1. unlikely 2. better prognosis

question

After a sentinel lymph node dissection (SLND), the pathology report shows that there were cancer cells present. What would likely be the next treatment step?

answer

Axillary lymph node dissection

question

What are 2 major negative side effects of an axillary lymph node dissection?

answer

1. Immunosuppression 2. Lymphedema/impaired circulation

question

What is an important point of patient education for individuals after receiving a sentinel node lymph dissection with dye?

answer

Dye from the study is usually eliminated from the body in the urine and stool. Warn your patients that their urine and/or stool may be blue-green in color for the next 24 hours or so and that this is normal.

question

Gene that promotes cell growth (i.e., dividing and repair). When cancer develops, its amplification will cause an overexpression of receptors which has been associated with aggressive tumor growth, greater risk for recurrence of breast cancer, and poorer prognosis. Approximately 25% of tumors produce excessive amounts of this gene's receptor protein products.

answer

HER-2/neu

question

What drug (form of biologic therapy/monoclonal antibody) can be given to patients with a mutation in their HER-2/neu gene resulting in overexpression of HER-2 receptors?

answer

Herceptin works to block the overexpression of HER-2

question

Tumors that are (1) ________ for estrogen and/or progesterone receptors commonly show histologic evidence of being (2) ________ differentiated. They frequently have (3) ________ DNA content, which is more normal, and (4) ________ proliferative indices. These tumors have a (5) _______ chance of recurrence and are (6) ________ to hormone therapy.

answer

1) positive 2) well 3) diploid 4) low 5) lower 6) responsive

question

Tumors that are (1) ______ for estrogen and progesterone receptors are (2) _________ differentiated histologically. They have a high incidence of (3) ________ (abnormally high or low DNA content) and (4) ________ proliferative indices. These tumors (5) ________ recur and are usually (6) ___________ to hormone therapy.

answer

1) negative 2) poorly 3) aneuploidy 4) higher 5) frequently 6) unresponsive

question

Triple negative breast cancer tests negative for what 3 receptor types?

answer

estrogen, progesterone, HER-2/neu

question

In what 4 populations is the incidence of triple negative breast cancer higher?

answer

1. Hispanic women 2. African American women 3. Younger women 4. Women with a BRCA 1 gene mutation

question

Women with triple negative breast cancer tend to have more (1) _________ tumors with a (2) _______ prognosis. This is because most of the treatments available work at 1 or more of the 3 receptor types that are absent in these patients.

answer

1) aggressive 2) poorer

question

What is considered the primary treatment for breast cancer?

answer

Surgery

question

Procedure in which the axillary nodes and nodes near the tumor (~12-20 nodes) are removed. This can result in multiple negative side effects including immunosuppression and impaired circulation/lymphedema.

answer

Axillary lymph node dissection (ALND)

question

A partial mastectomy which usually involves the removal of the entire tumor along with a margin of normal surrounding tissue. These patients usually receive RT and/or SLND and possible ALND. It preserves the breast, including the nipple. The goal of combined surgery and radiation is to maximize the benefits of both cancer treatment and cosmetic outcome while minimizing risks.

answer

Lumpectomy

question

Removal of the breast and axillary lymph nodes but preserves the pectoralis major muscle. When performed, the patient has the option of breast reconstruction which can be performed immediately after the procedure, or it can be delayed until postoperative recovery is complete.

answer

Modified radical mastectomy

question

What are 2 points of emphasis with post-operative care in patients who have received surgical treatment for their breast cancer (i.e., SLND, ALND, lumpectomy, modified radical mastectomy)?

answer

1. Preserve ROM 2. Prevent/reduce lymphedema

question

When assessing a patient who has recently underwent breast cancer surgery (i.e., SLND, ALND, lumpectomy, or modified radical mastectomy), what should you be focusing on?

answer

1. Ability to maintain normal ADLs 2. Comparing the effected arm to the non-effected arm 3. Comparing the function of the effected arm prior to surgery and after surgery

question

Chronic swelling related to interrupted lymphatic circulation. Functioning lymph channels cannot adequately return flow of lymph fluid to the general circulation, resulting in fluid accumulation in the interstitial spaces. It is a common side effect for post-mastectomy patients, especially if they also received an ALND.

answer

Lymphedema

question

What are 4 methods of treating lymphedema in a patient who has just underwent breast cancer surgery?

answer

1. Elevating the effected arm above the level of the heart 2. Gentle muscle pumping 3. Compression sleeve 4. Exercises to preserve rOM

question

True or False: After a patient is treated for lymphedema, they most likely will not develop it again.

answer

False - Once a patient develops lymphedema, they are more likely to get it again later in life.

question

What is an important nursing implication for a patient suffering from lymphedema after breast cancer surgery in a specific arm?

answer

The patient should not have a BP taken, venipuncture performed, or injections given here.

question

What are 2 types of breast reconstructive surgeries for patients who have underwent a modified radical mastectomy of one or both breasts?

answer

1. Tissue expander 2. TRAM FLAP = Transverse Rectus Abdominus Myocutaneous flap

question

Describe how a tissue expander is a form of breast reconstruction.

answer

The tissue expander is placed in a pocket under the pectoralis major, which protects the implant and provides soft tissue coverage. It is then minimally inflated and then gradually filled by weekly injections of sterile water or saline solution, stretching the skin and muscle. The expander is eventually surgically removed, and a permanent implant is inserted. This procedure can be very painful but is the most common breast reconstruction technique used.

question

Procedure in which a large block of tissue from the lower abdominal area, attached to the rectus abdominus muscle, is used to fashion a breast. The abdominal incision is closed, giving the patient a result that is similar to having an abdominoplasty ("tummy tuck").

answer

TRAM Flap = Transverse Rectus Abdominus Myocutaneous Flap

question

CMF is a form of breast cancer therapy. What does CMF stand for?

answer

C = Cyclophosphamide (Ctyoxan) **Can be nephrotoxic and cause hemorrhagic cystitis M = Methotrexate F = Fluorouracil

question

Taxol and adriamycin are 2 types of chemotherapeutic agents used to treat what type of cancer?

answer

breast cancer **Adriamycin can be cardiotoxic causing decreased contractility of the myocardium, reduced EF, and possible heart failure.

question

What are 2 types of hormone therapies that can be used in treating breast cancer that is estrogen positive?

answer

1. tamoxifen (Nolvadex) 2. anastrozole (Arimidex)

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