- TEST 1 OVER DIABETES AND HEMATOLOGY ONLY!

qwq Type 1 Type 2 Gestational diabetes Diabetes mellites with other conditions or syndromes (ex- corticoid sterioA. Sds) Type1 diabetes - insulin-producingbeta cells destroyedby an autoimmuneprocess - Requires insulin: little or no insulin is produced - Acute onset- usually the diverence between type 2 - 5% to 10% of persons with diabetes- usually in people less then 30 yrs Risk factors for type 1 - genetic *most common - Immunologic - Environmental Complications for type 1 - diabeticketoacidosis : no insulin for use for energy, then uses ketones from fat- develop to small resperations to blow off the acid - Normal blood ph- 7.35-7.45--- with this blood is going tobe less becuase more acidicmay cause pt to lapse into a coma - Why its important to watch for a change - Order bicarbonate Type2 diabetes-aaa 30b plusyrs old - Problemwith insulinresistant - Or problemwith Insulinsecretion - 90-95% of persons with diabetes - More common in person greater then 30 yrs old and obese - Slow, progressive glucose intolerance - Treated initially : diet and exercise-- dont go on crash diet - Oral hypoglycemic agents and insulin Type 2- complications - not likely to develop ketoacidosis - Goingto get hhns-hyperglycemichyperosmolernonketoticsyndrome-goingto be more concentrated-goingto orderfluid treatment - With HHNKS, blood glucose are significantly increased, well over 500 mg/dL, blood pH remains within the normal range of 7.35 to 7.45, and serum potassium and sodium levels are low. Inadequate fluid intake during hyperglycemic episodes commonly leads to HHNS

Type 2 risk factors -family history - obesity - Race - Age - Fasting glucose - Htn - Hdl less then or equal to 35 - Gestational diabetes/ 9 lbs Complications of diabetes - type 1 or type 2 - Control to prevent further health problems and complications Clinical manifestations - the three ps- usually in type 1 - Polyuria- pull fluids with the glucose and excrete through the kidney - Polydipsia- loosing a lot of fluids so you get thirsty - Polyphagia- not using the carbs that we eat- so using our fat so they eat a lot Clinical manifestations - fatigue, weakness - Vision changes- if fam hx/hx of diabetes, get eyes check regularly! Retinopathy. May be ignored d/t normal changing of eyes in elderly - Tingling/ numbness in hands or feet- if caught early, may save limb. step on nail or smash foot not gonna feel it--lead to infection etc - Dry skin - Skin lesions/ wounds slow to heal- if infection gets worse, get to doctor. Don't even try any home remedies - Recurrent infection Criteria for the diagnosis of diabetes mellitus. How do I know I'm a diabetic? - symptoms of diabetes plus casual plasma glucose concentration > or equal to 200 mg/dl (no restriction on diet/time/fast taken at any time during the day) - OR fasting(8 hrs) plasma glucose > or equal to 126 mg/dl - OR two hour postload glucose >200 mg/dl during an oral GTT (after you eat 2 hrs later give you glucose) not commonly recommended Treatment goal is to "normalize" blood glucose levels (do not want the up down effect)-best way to Prevent complications on body

- intensivecontrol dramatically decreases vascular and neuropathic complications(the numbness, the tingling,risk for infections) - 5 components - Nutrition therapy - Education - Pharmacologic therapy- how pt should most effectively take their meds - Exercise- glucose is driven into the muscles; CV benefits and weight loss - Monitoring All 5 components allow patient control in their diagnosis/treatment Dietary management- goals - provide optimal nutrition: all essential food constituents. No yoyo diets. Must have consistent diet - Meet energy needs- balance - Achieve/ maintain reasonable weight. If overweight, 5-10% fat loss has shown to help in regulating bs. Slow&steady weight loss - Prevent wide fluctuations of BG levels- diet - Decrease serum lipids, if elevated-- can have stroke, MI. Diabetics are prone to macro vascular complications such as atherosclerosis-- accumulation of lipids Mealplanning- diabetics-- DONOTSKIPMEALS - carb - 50-60% (emphasize whole grains) - Fat- 20-30% with limiting 10% from sat fat and <300 mg cholesterol - Protein - 10-20% - Fiber- slows glucose absorption(legumes, etc); lowers cholesterol and LDL's. slow&steady changes to avoid cramping, diarrhea etc - Provide exchange lists - Glycemic index- how food is going to spike your blood sugar. Avoid sharp inc/dec - Alcohol- female- 1 drink a day, male- 2 drinks a day -- moderation. does not rewuire insulin fof absorption! however, too much can cause HYPOglycemia- because not taking in the other nutrients-- should eat while drinking. Ketoacidosis may result. May dull sensation of hypoglycemia; mistaken for drunk. - Nutritive(have calories) and non-nutritive sweeteners(nutra-sweet and Splenda don't have calories)--- have calories even if it is sugar free - Reading labels Exercise- uptakes the glucose into the muscle - lowers blood sugar - Aids in weight loss - Lowers cardiovascular risk - Want HDL high - LDL low

Exercise precautions - avoid exercise when BS levels are elevated (>250 mg/dl) and ketones are present in urine(will cause ketoacidosis if they exercise) - If on exogenous insulin(taking insulin), 15g Carb snack before moderate exercise& after(to avoid hypoglycemia) - If exercising to control or reduce weight, insulin must be adjusted - Potential for postexercise hypoglycemia- check bs before and after exercise. If levels arellw, eat snack - Monitor BG glucose levels after exercise and before - Try to exercise same time each day so body gets on a cycle Exercise recommendations-- plan must be individualized to the individual(wheel chair bound, elderly, spinal stenosis); stress test must be completed before regimine is planned; exercise when the bs is at the peak - regular daily exercise - Gradual increase - Modifications - Stress testing - Gerontologic considerations Exercise precautions - Footwear- proper fitting shoes that will not cause pressure on any pt of toes/feet - Temp - Foot inspection* may have to use a mirror on the floor regularly - Poor metabolic control during illness Insulin therapy Can check bg without an order if there is change in LOC, etc. If pt is on insulin, check 23x/day. - blood glucose monitoring- most reliable is HgA1c--4-6% normal- but want <7% target for diabetics. Implicates insulin levels over a 2-3month period to assess complianc e - Categoriesof insulin- knowtheseand peaktimes!!!!!! - Rapid acting - Short acting - Intermediate acting - Very long acting - inhaled insulin - Bs monitors should be checked ever 6 months, 4x day, before meals and before bed or anytime you notice a change, make sure pt can read it (eye sight), or can push the buttons with their hands (arthritis) , refrigerate if not used in a month, but can be stored out on countertop. cloudy insulin- roll in hands, short before long- clear before cloudyE before O- because will contaminate the short acting to make it longer acting, when at home do not need to clean off site- alcohol can cause irritation, 90 degrees, dont

need to asperate, SQ,Alcohol swab before injection is not necessary. Abdomen is best injection area. For best absorption, find one site, use all spots in that site and then proceed to the next site- dont give in an extremity where there will be exercise bc there will be quicker absorption- causes hypoglycemia, teach pt on TPN signs and symptoms of hypo/hyperglycemia--- dont d/c this IV need to taper off, observe new pt on insulin for reaction. Regular insulin is the only thing you can give IV. Lantus lasts for 24hrs- used to be given at night, but people would fall asleep & forget to take it. Cannot mix lantus! Morning hyperglycemia- once a week check BS at 3:00 am; may need to fix regimine - dawnphenomenon - usually type 1, have normal Bs until 3:00 am and then climbs up and goes up with nocturnal effect w increase of growth hormone - Somogyieffect-(thinks-sleep) . decreasedbs at night and when wake up it spikes up - Insulinwaning- normal and then in morning will peak up. Typical w NPH insulin. To fix, take closer to bedtime Teachingpt insulinself management-control& complianceis important - Educate on the use and action of insulin- too much glucose in body, so on insulin, it is necessary, tell them about complications- retina damage, kidney damage, poor circulation - Symptoms of hypoglycemia and hyperglycemia - Required actions: - blood glucose monitoring - Self injections of insulin- pre filled pens are great for travel - Insulin pump use- basically an artificial pancreas. changesite 1-3 days, tubing can get clogged, kinked, or disconnected- go into ketoacidosis, good for ppl who are compliant& check bs 4xday. May be disconnected temporarily for shower, etc. A continuous subcutaneous insulin regimen uses a basal rate and boluses of rapidacting insulin. Oral antidiabetic agents - type 2 diabetic who cannotbe treatedwith diet and exercisealone - Combinations of oral drugs may be used initially, and may be able to work away from any meds at all - Majorside effects-hypoglycemia . KnowS&Spt and family - Nursinginterventions - still need to monitor bs, this med can interact with other medsmeds that can increase bs-- corticosteriods, K sparing diuretics, antisiezure meds, propanolol(beta blocker)- will see less exagerated symptoms of hypoglycemiaimportant to look at trends of pt bs , sulfonurides - Pt teaching --not a cure, best absorption in abdomen Acute complications of diabetes mellitus - hypoglycemia

- Diabetic ketoacidosis (DKA) - Hyperglycemic hyperosmolar nonketotic syndrome (HHNS), or hypoerosmolar nonketotic coma, or hyperglycemia hyperosmolar sydrome (HHS) Hypoglycemia - abnormally low blood glucose level (below50 to 60 mg/dl)- take into play what their normal bs is- if normal is 200- and drop to 120 may be hypoglycemia with symptoms - Causes: 1. Too much insulin or oral hypoglycemics - 2. Too little food - 3. Excessive physical activity - adrenergicsymptoms : if on a Beta Blocker- Sx may be masked. Look for subtle changes!! - Sweating - Tremors - Tachycardia - Palpitations - Nervousness - Hunger - Numbness in extremities - Level of consciousness change - Confusion - Drowsiness - goal- to catch it & correct before the extreme drop- 20-30s - assessment - Abrupt, unexpected - Symptoms vary - Symptoms vary r/t rapid decrease in BG and usual blood glucose range - Decreased adrenergic response: - DMfor manyyrs probablyrelatedto autonomicneuropathy - management - Treatmentmustbe immediate - catch before rock bottom - Give15 g of fast acting,concentratedcarb- theseare for the consciouspt- dextrosefor nonconscious . Avoid high fat bc it decreases absorption! Ex no French fries - 3-4 glucose tab - 4-6 ounces of juice or regular soda (not diet) **do not admin OJ with sugar packs added. Bg will spike and then bottom ou again - 6-10 hard candies - Or 2-3 tsp of honey - retest blood glucose in 15 min - Retreat if bg still <70 mg/dl or if symptoms persist more than 10-15 min and testing is not possible (out shopping, in car) - Provide a snack with protein and carb unless the pt plans to eat a meal within 3060 min

- emergencymeasures - If pt cannot swallow or is unconscious: - Sub Q or IM glucagon 1 mg (takes about 20 min for pt to regain consciousness) - 25-50 ml 50% dextrose solution IV ("50 of 50")- very fast acting! - prevention - Sick day rules: see chart 41-9- continue to take insulin or oral hypoglycemic as usual- check bg 3-4x a day and check urine for ketones, sick is a stressor- may need to alter insulin during this time, can have regular food- regular jello/soda (NOT diet soda) to not have problems with insulin -- stay away from sugar free. Eat about 6-8x a day and drink fluids every 30mntosn hour to prevent dehydration if n&v. "If bg >300 an ketones in urine, contact PCP!" - Assess for underlying causes - Diagnosis and proper management of diabetes- patient teaching Pts on TPN/Gtube are both on nutritional supplements and have a high glucose content in them. Pt will need supplemental insulin, even though they're not a diabetic. E plain that both the nutrition supplements have high glucose and needs coverage. Don't just shut TPN or supplement cold turkey, bc pt may drop into hypoglycemia. Long term complications of diabetes - macrovascular complications-- need to quit smoking - Accelerated atherosclerotic changes - **Coronary artery disease(on htn- take as prescribed), cerebrovascular disease(looking for signs stroke), and peripheral vascular disease( look for cut that doesnt heal) - microvascular complications - Diabetic retinopathy- retinal artery only artery you can visualize from the outside, may look and seem healthy- no pain, may have blurring, monitor bg levels to prevent blindness, and nephropathy - neuropathic changes - ulcers on feet (poor circulation) portal of entry for infection. Nursing process- assessment of the pt with diabetes - primary presenting problem - Needs r/t diabetes - Pt knowledge of diabetes and diabetes care skills- ask them "do you take insulin, how do you do it, do you know about exercise, illness, what kind of shoes do you wear" - Blood glucose levels- know their trends - Skin- very important. Explain why you're looking and how to look, "you can look here in the shower, use a mirror to look here" - Explain preventive health measures, eating sweets etc - See chart 41-4 Nursing processes- diagnosis of the pt with diabetes

- imbalanced nutrition - Risk of impaired skin integrity- keep heels off bed, if sitting for long periods don't cross legs, etc - Deficient knowledge Improving nutritional status - monitor - Nutritional intake- look at tray-- to see how much food they eat vs how much insulin - Blood glucose - Urine ketones - Daily weight- are we gaining or losing nutrients? - Monitor: DKA -type 1 or HHNS- type 2 - How they Plan food= primary goal of glucose control** - Understand Alternative strategies if sick-- alterations in diet (N&v) If patient says "I'm scared to give myself an injection", talk pt through it and say "let me show you how to do it" Make sure family is involved in plan of care so that they understand what to look out for Maintaining skin integrity - assess skin daily - Provide diabetic foot care (see chart 41-10) - Position legs and feet: keep heels off bed Teaching pt self care - assess knowledge and adherence to plan - Provide basic information- s/s of hypoglycemia , gi and cardiac problems due to neuropathy- prone to constipation - Teach self care activities - Prevent long term complications - Family in plan - Health promotion activities - Health screenings- retina, kidney, stress test, peripheral screaning

Hematologicdisorders 5-6 liters circulating blood in body - can cause cardiac problems- heart works harder- hypertrophy Hematologic system - the blood and blood forming sites - Bone marrow and RE system - Blood: for blood transfusion- going to give whole blood or platelets and rbc - Plasma= 55% - Blood cells= 40-45% - hematopoiesis - KNOWHCT(35-47) and Hg (12-17) - reticulocyets- immature red blood cells - is the body making appropriate RBC's? - RBC lifespan 120 days - Neutrophil- when have infection going to the site first within an hour-- phagocytosis- if pt has low count then prone to infection-- going to have to look for the suddle s/s of infection bcuz dont have the wbc to fight it off. ANC will be ordered- absolute neutrophil count- how fragile your isolation pt is. If very low neutrophil count, that pt may not manifest the normal signs and symptoms of infection. Look for mild fever, mild redness on the skin, mild complaints. Then the monocytes kick into action Hemostasis

- 1. vascular - 2. Platelet normal count is 150,000-400,000 - 3. Coagulation - 4. Clot retraction - 5. Clot destruction Hematological problems - 1. initially few symptoms - 2. Quantity (production) - Increased- more immature RBC not always good! Either lost it or making an inappropriate kind - Decreased- suppression of the formation of RBC, lacking essential nutrients - 3. quality - Defective - 4. CBC/ bone marrow aspirations (Bx)-- bone marrow is the best way to identify-- need a permit, usually sample the iliac crest. Biopsy is invasive- risk for infection- informed consent must be signed after physician has explained the procedure. As nurse take vitals. During procedure, pt should not feel acute pain, but maybe some discomfort. After, vitals, pulses before n after, and assure no bleeding. Anemia - not a specific disease - Sign of an underlying disorder - Lower then normal hemoglobin - Fewer then normal RBCs - Internal bleeding, b12 intrinsic factor in GI, etc that needs to be cured to fix anemia Classification of anemias - production= hypoproliferative anemia -- decreased production of hemoglobin. Lack of b12, lack of iron, or other meds that pts are on (autoimmune) bc bone marrow is suppressed - Destruction= hemolytic anemia-- mechanical heart valves, sickle cell disease, autoimmune. Body is producing it, but something is destroying it - Loss= blood loss Manifestations - Rapidity- going to show symptoms faster if have a fast loss- if slow loss people may not show signs and symptoms even though their hemaglobin is low.more active people will have more obvious symptoms - Duration- how long has this process been going on - Metabolic requirements- hypothyroid- not going to have obvious symptoms.. Hyperthyroid will have more symptoms. Thyroid controls metabolism - Concurrent problems

Clinical manifestations - fatigue (lack of o2 and iron), weakness, and malaise-- lack of o2 and iron - Pallor (heme carries iron and color)/jaundice(rbc's being destroyed, hemolytic anemia)-check sclera and mouth - Cardiac / respiratory symptoms- increased respirations trying to increase o2, and heart will increase BPM bc trying to work harder. May cause heart failure, heart will work harder to get the blood out, muscle gets stressed, larger, and perfusion difficulty-pace activities - Tonguechanges: smooth and red- iron deficiency anemia. beefy red and soreamegiloblastic anemia - Nail changes- brittle and rigid - Anular cheilosis- corners of the mouth cracked and ulcerated - Pica - abnormal cravings- starch, dirt, ice suspicion Medical management: - corrector controlthe cause - Transfusion of PRBCs may need to be given- fast fix, not the cure - Treatmentis specificto the typeof anemia - Dietary - Iron or vitamin supplementation, BMT(bone marrow transplant) or PBSCT(peripheral blood stem cell transplantation) - Immunosuppressive therapy- immune system may be putting out RBC destructive cells Assessment - health history and physical exam- conjuctiva will be pale and mucosa (S&S), skin color will be pale and TUGOR- if you're losing a lot of RBC quickly, TUGOR will be increased. - Labs- CBC, hemoglobin, hct - Presence of symptoms and impact symptoms- listen to your pt- low Hgb, low o2, low energy, shortness of breath, INCREASE IN PULSE and DECREASE in bp; heart may enlarge, liver fxn impaired over time - Nutritional assessment- how much alcohol- drinking diet can be anemic, gatritis, inheritted history of anemia ; what do you eat on a daily? Bowel/GI - Medications- problems with absorption - Cardiac and gi assessment- increase workload on heart, sob, increase size heart, increase size of liver- should not be able to palpate the liver normally, color of stool, dark tarry bowels, or bright red, emesis- coffee ground, or bright red- how often does it happen? Is there a change in the color? - Blood loss- abnormal bleeding. May not be visible overall-- slow steady ooze. Menstruation- over 50? Flow?

- Neurologic assessment - pernicious anemia dx may have a lot of numbness, tingling-not always a diabetic related! changes in behavior-- Not always just old and senile Goals - 1. decrease fatigue - 2. Attainment or maintenance of adequate nutrition - 3. Maintenance of adequate tissue perfusion- pulses will be weak - 4. Compliance - prevent complications: confusion, heart failure, angina, paristhesia

Interventions - balancephysical activity, exercise and rest- plan your day prioritize - eat, bath, physical activity all important- make sure you dont do everything for them - Maintain adequate nutrition-- make sure foods they are going to eat - teach about alcohol- moderation, three meals a day (may be broken up into 6 if difficult to finish) - Provide pt education- be careful about vitamin supplimentation- body is only going to store so much and will cause iron toxicity espicially people with too many immature RBC- only take what is prescribed by the doctor - Monitor VS and pulse oximetry - Supplemental oxygen as needed, but shouldn't need it 24/7 when they go home - Monitor : potential complications-- heart failure, paresthesia, confusion, angina-- look for weight gain with heart failure 2 lbs a day 5 lbs in a week- indicator of heart failure; c/o shortness of breath worsening needs to be explored. Angina: c/o chest pain, order and EKG. Pt calls and has chest pain. Take vitals, ask pt hat they were doing before the pain started, and if they have ever had this happen before. Iron- can give IM- ztrack, to not cause tissue trauma, draw up with one needle, then switch needle- can be irritating/ traumatic to the skin, PO- take prescribed dose only, empty stomach(one hour before eating, two hours after eating), orange juice (vit C-citrus berries tomatoes) helps absorption, there is liquid iron but stains the teeth, drink through a straw, constipation- some has stool softer, eat fiber, fluids, exercise, stool dark- pt teach this is normal . Compliance even though of constipation SE - need to take the iron for 6-12 months. Types of anemias- iron deficiency - the stores are depleted in the body- not able to hold on to what we need, most common- common cause is blood loss- could be female when menstruating, peptic ulcers, alcoholism, gastritis- diagnose by labs but sometimes colonoscopy to check for bleeding- bone marrow, may need surgery, may need supplement to replace- iron therapy - Aplastic - rare- suppression of the bone marrow- down in WBC, RBC, and plateletsbone marrow transplant <60 yrs old or immunosuppressive therapy- shows improvement. May be congenital, unknown.

- Megaloblasticd/t folic acid or b12 deficiency(pernicious) - large cell- folic acid- no neurologic symptoms, with b12- there is neurologic-numbness, confusion- dietary deficiency, alcoholics, minimal to no intrinsic factor in stomach- gastrectomy, crohns- on lifetime replacement, give b12 once a month IM for life. shillings test- give radioactive b12 to pt to see if it can be absorbed - Chronic disease - cancer, rheumatoid arthritis, know that this is a side effect and will need treated - Renal disease - not getting good blood flow to kidneys- not able to get erythropoietin to make red blood cells, treated with meds- epogins, to stimulate rbc, can cause HTN because too much concentrated blood Polycythemia - too many cells inthe blood- Primary- polycythemia vera- body makes too many RBCs then normal- pt at risk for HTN, STroke - Secondary- there is a cause- high altitude, excessive smoking, O2 binding problemsCOPD - Assessment- cheeks red, itching, gout, increased hct, - Treatement- phlebotomy- drawing out some of the blood 500 mL blood (~1 unit), sometimes once a week sometimes 2x week . Goal: keep the Hct less than 45. - Teaching- activity- dont cross legs, smoking - may cause stroke, heart attack, clot Neutropenia - low neutrophil count 4000-11000, normal - can get because of cancer treatment "Neutropenic Precautions" - Skin largest defense- break in skin is portal for bacteria causing a problem, not going to show clasic s/s of infection, low grade temp, pink around site rather then red, lower level of pain, get bloodculturesdrawnbeforeyou givethe antibiotic- effectively find out what the bacteria is resistant to and what will work for that. CNS- colony stimulating factor-may be given to stimulate the growth and production of WBC's. visitors wash hands, no one with colds, give cooked foods, private room, no flowers in the room period, assessment is very important- outside and in mouth, call physician if temp higher than 101, if give aceteminohphen and give it to them, or see change in mental status. On discharge- tell pt to get their own thermometer, monitor temp, inspect skin (redness, inflammation, soreness) - neutrophil count <2000- how fast did it drop and how long has it occurred - Differential count - ANC- absolute neutrophil count - <1000- significant risk for infection-pt NEEDS private room- discard any fluids after 24 hr and changed, stay away from rectal temps, suppository, meticulous care with IV sites and check sites per shift. Call phys right away - <500- high risk for infection

- <100- certain you will have infection Leukemia - hematopoietic malignancy - Unregulated proliferation of leukocytes- not responding to bodies supply and demandwill just make them-- classified by the stem cell it affects - Affects: blood - Blood forming tissue (Bone Marrow) - Lymph system and spleen Types of leukemia - acute myeloid leukemia (AML)- comes spontaneously without warning- bleeding problems and infection- requires aggressive chemotherapy and BM transplant if chemo is unsuccessful - Chronic myeloid leukemia (CML)- asymptomatic- usually older people- Acute lymphocytic leukemia (ALL)- kids, - Chronic lymphocytic leukemia (CLL)- adults. Tx chemo. B-symptoms. Night sweats, fever, weight loss. May be a consequence of being treated with chemo early on. Usually people forget about long term effects-- mostly worried about short term hair loss etc. Assessment of pt with leukemia - health history - Assess for symptoms of leukemia and complications of anemia, infection , and bleeding - Weakness and fatigue- bleeding gums, infections- wounds, sob - Lab- can affect all the blood cells - Leukocyte count, ANC, hct, platelet, electrolytes, and cultures reports Interventions - risk of infection and bleeding- if platelets go down <10,000 call dr ASAP or rapid decrease- use common sense and call the physician - stay away from givin IM injections d/t risk of bleeding!!! Give another route if possible, stool softners so they dont strain for Bowel movement, hold pressure 5 min if start iv then take out if bleeding does not stop by 10 min, call dr. no straight razor - Mucositis- inflammation of the mouth- use soft toothbrush, rinse mouth before and after meals with saline or such. Stay away from alcohol base- pain - Improving nutrition- sometimes treated with chemo- causing nausea and mouth soresoral assessment, give a topical anesthetic for mouth- be careful not to bite cheek - Pain / fatigue-go back an reassess, tylenol- check liver function. Say medicated, pace activities. Exercise within limitation, stay out of bed as tolerated, if need to leave room use mask - Fluid/ electrolyte- weight, lab values, turgor, level of conciousness. Rid pt of n&v: antiemetic before eating, mouth care before/after, sit upright to eat, no fresh salads,

veggies, cooked everything, if nauseated feed them 6 small meals, smaller portions (more appetizing). Daily weight, I&O, monitor consumption - Self care- explain benefits of self care to pt-- have them be as involved as possible! Muscle tone, self esteem Lymphoma - neoplasm of lymph origin - Hodgkins lymphoma- better choice, better survival rate, younger pt(adolescent, early 20), can cause difficulty swallowing, cough, night sweats, severe pain with alcohol intake- dont know why.fever, weight loss, night sweats. Chemo/radiation hospitalization. Anger and confusion-- I look ok and feel ok. - Non-hodgkins lymphoma- more lymphadnopathy, reed sternberg cell, treat with surgery, radiation, chemo, immunosuppression- HIV pt will develop, organ transplant will develop, tx depends on stage Multiple myeloma - malignant disease of plasma cells- affects the bone, causes destruction of the bone, not a cure- but palliative care , might try chemo, or corticosteriods - Hydration-ca in blood- galstone, kidney stones, stasis of fluid- causes severe pain in kidney, want to dilute the blood- drink at least 3 L of fluid a day, - Activity-walk- will help ca go back into the bone, zomeda- put ca back in bone--- dont forget to assess for pain , more likely to move if pain controled, non slip slippers, 2 person assist- can get fracture and get other problems, - Safety -prone to pathological fractures- bones are weak, calcium is out of the bone, Transfusion therapy/ complications - can get donated blood, pt can donate own blood- usually 6-8 weeks before surgery- if pt hemaglobin is below 8-- need a permit for blood, make sure there is a type and crossed, universal doner- O, universal recipiant- AB... First assess the pt, any trouble before with blood transfusion, check permit, vitals, start IV, infuse over 2 hr period, normal saline ONLY, nothing else can go through that line!!!!, at least a 19 g needle, free flowing line, whole blood or packed cells, get RN to check numbers with you, if not sure get clarification on the blood, blood started slow- 5 mL chekc vitals 15 min,every 20 min sqeeze the bag to keep from sedementation , chekc vitals every hour for 3 hrs. Admin blood for 24 hours, 4 is max - febrile non hemolytic- most common, cells are not lysing, antibodies with the donors platelets or leukocytes, going to have a temp, and chills, stop the blood, give aspirin, see this with pt with multiple transfusions, - Acute hemolytic- worse- incompatibility- wrong blood to the pt, can see within 2 drops24 hrs, stop blood, sever- naseau, vomiting, low back pain, decrease urine output, might see hemaglobin in the urine, DO NOT THROW AWAY BLOOD- goes back to the lab, run the normal saline, going to give benedryl, o2, check airway

- Allergic- pt reaction to donor antibodies, hypersensitivity, could be mild- itch, if anaphylactic- low bp, give O2 give corticosteroids, benedryl - Circulatory overload- dyspnea, tachycardia, think fluid overload- usually older person or pt with heart disease, slow the blood, give pt lasix between units, if severe then stop the blood, - Bacterial contamination - contaminated blood product, sometimes less then 24 hrs, signs of infection- inc HR, dec BP, fever, stop blood, blood cultures, treat with antibiotics

Know sickle cell- pain management and fluid