NUR 2392 / NUR2392: Multidimensional Care II/ MDC 2 Exam 1 Blueprint , Exams of Nursing

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NUR 2392 / NUR2392:

Multidimensional Care II

/ MDC 2 Exam 1 Blueprint (Latest

2021 / 2022)

Rasmussen

NUR 2392 Multidimensional

Care II

Exam 1 Blueprint

Tumor

- Define (associate the 9 characteristics/features of each) Benign:

• Specific morphology – resemble the tissues they originated from
• A smaller nuclear-to-cytoplasmic ratio – similar to normal cells
• Specific differentiated function – contributes to the body function
• Tight adherence - bind closely together due to the

production of fibronectin

• No migration – do not invade other tissues
• Orderly growth – rate of growth is normal by expansion
• Euploidy – normal chromosomes per cell Malignant tumor:
• Anaplasia – loss of appearance of parent cell
• A larger nuclear-to-cytoplasmic ratio – larger nucleus
• Specific functions are lost – serve no purpose
• Loose adherence – loosely bound due to the lack of fibronectin production
• Migration – spread easily (metastasize)
• Contact inhibition does not occur – loss of cellular regulation
• Rapid or continuous cell division – loss of cellular regulation
• Aneuploidy – Abnormal chromosomes - What elements influence the growth of a cancer tumor?
• Exposure to the carcinogens (tobacco, radiation, chemotherapy, hormone drugs, pollution)
• Genetic predisposition
• Immunity - List and describe the steps of the Carcinogenesis:
• Initiation – normal cells become damaged which is irreversible and leads to cancer development
• Promotion – repeat exposure enhances cell growth which leads to mutation
• Progression – increase in the production of malignant cells
• Metastasis – movement of cells from the primary site - What step in carcinogenesis is irreversible? - Initiation - Describe the origin of the following cancers (where in the

body)

• Leukemias and lymphomas – Leukemias arise from organs that form blood and invade the production of the normal blood cells. Lymphomas affect the lymphocytes, which fight infections and produce enlarged lymph nodes in the armpits, chest, abdomen, and groin.
• Carcinomas – originate in the epithelial cells of the skin, lungs, liver, kidneys, stomach, breast, prostate, and thyroid and are likely to metastasize
• Sarcomas – originate in soft tissues such as the muscles, blood vessels, bone, and connective tissues. - Signs of cancer. Describe each letter in the acronym
• Change in bowel or bladder habits
• A sore that does not heal
• White patches in the mouth or tongue
• Unusual bleeding or discharge
• Thickening or lump in the breast or other location
• Indigestion or difficulty swallowing
• Obvious change in a wart or mole
• Nagging cough or hoarseness - Define - Primary Tumor: The original tumor is called the primary tumor. It is usually identified by the tissue from which it arose (parent tissue) such as in breast cancer or lung cancer. When primary tumors are located in vital organs such as the brain or lungs, they can grow and either lethally damage the vital organ or interfere with that organ's ability to perform its vital function. - Metastasis: Metastasis occurs when cancer cells move from the primary location by breaking off from the original group and establishing remote colonies. - What does cancer grading tell us (correlate with differentiation p. 376-377) - Gx_Grade cannot be determined.

• G1: Tumor cells are well differentiated and closely resemble the normal cells from which they arose. This grade is considered a low grade of malignant change. These tumors are malignant but are relatively slow growing.
• G2: Tumor cells are moderately differentiated; they still retain some of the characteristics of normal cells, but also have more malignant characteristics^ than do G 1 tumor cells.
• G3: Tumor cells are poorly differentiated, but the tissue of origin can usually be established. The cells have few normal cell characteristics.
• G4: Tumor cells are poorly differentiated and retain no normal cell characteristics. Determination of the tissue of origin is difficult and perhaps impossible.
• Primary Tumor (T)
• Tx^ • Primary tumor cannot be assessed
• T^0 • No evidence of primary tumor
• Tis • Carcinoma in situ
• T 1 , T 2 , T 3 , T 4 • Increasing size and/or local extent primary tumo
• Regional Lymph Nodes (N)
• Nx • Regional lymph nodes cannot be assessed
• N 0 • No regional lymph node metastasis
• N 1 , N 2 , N 3 • Increasing involvement of regional nodes
• Distant Metastasis (M)
• Mx (^) • Presence of distant metastasis can assessed

• M^0 • No distant metastasis
• M 1 • Distant metastasis - - What does the TNM staging tell us - Application: - 53 year female is diagnosed with Lung Cancer it is stage T3 N2 MO how would you describe this patient’s lung cancer status. Tumor is present and fairly large in size, nearby lymph nodes involved, no metastasis - Is there metastasis No - Describe the difference between these type of cancer prevention and list the correlating strategies:

Primary prevention is the use of strategies to prevent the actual occurrence of cancer. This type of cancer prevention is most effective when there is a known cause for a cancer type. Secondary prevention is the use of screening strategies to detect cancer early, at a time when cure or control is more likely.

• Example: You identify that your 30 year old patient has a “family history of colon cancer” that hasn’t reached the patient. What level of prevention will you focus on? Primary prevention - Examples of modifying behaviors to reduce the risk of cancer (Page 381 under primary prevention): Avoidance of known or potential carcinogens, Modifying associated factors, Removal of “at-risk” tissues, Chemoprevention, Vaccination **Cancer Management: Drug Therapy, Surgery, Radiation, photodynamic therapy
• Treatment approach: Describe these terms** in reference to a cancer diagnosis and surgical approach. Pg 386. In your own words describe a scenario for each surgical approach.
• Curative: removes all cancer tissue
• Prophylactic: removes potentially cancerous tissue as a means of preventing cancer development
• Diagnostic: (excisional biopsy) is the removal of all or part of a suspected lesion for examination and testing to confirm or

rule out a cancer diagnosis

• Palliative: focuses on providing symptom relief and improving the quality of life but is not curative
• Reconstructive: or rehabilitative surgery increases function, enhances appearance, or both
• What nursing intervention would you expect for your patient post-op surgery for cancer removal (mastectomy). Coordinate with the interprofessional team to provide support and assistance to the patient and his or her family. Encourage the patient and family to ask questions and express their concerns. Help the patient accept changes in appearance or function by encouraging him or her to look at the surgical site, touch it, and participate in its care, including dressing changes. Provide information about support groups.
• Cancer management requires a collaborative approach, including a multidisciplinary team. Determining the plan following diagnosis is which collaborative intervention? - List some diagnostic imaging procedures used for various types of cancer:
• Breast
• Lung
• Colon
• Esophageal Treatment approach, when does this occur:
• Neo-adjuvant: When something is used before another ie when chemo is used to shrink a tumor before surgery.

• Adjuvant: When chemo is used to kill remaining cells following surgery or radiation
• Combination Therapy **Drug therapy
• Chemotherapy (cytotoxic therapy)**
• Antimitotic Agent: interfere with the formation and actions of microtubules so cells cannot complete mitosis during cell division. As a result the cancer cell either does not divide at all or divides only once.
• Antitumor:
• Topoisomerase: disrupt an enzyme (topoisomerase) essential for DNA synthesis and cell division. When drugs disrupt the enzyme, proper DNA maintenance is prevented, resulting in increased DNA breakage and eventual cell death. a. Side Effects of Chemo:
• Describe each side effects and measures of each. A serious complication of IV infusion is extravasation , which occurs when drug leaks into the surrounding tissues (also called infiltration ). When the drugs given are vesicants (chemicals that damage tissue on direct contact), the results of extravasation can include pain, infection, and tissue loss
• Risk Factors of chemo administration (what is the patient at risk for, what measures will you implement to reduce the risk). Common distressing side effects include nausea and vomiting, alopecia (hair loss), mucositis ( open sores on mucous membranes), many skin changes, anxiety, sleep disturbance, altered bowel elimination, and changes in cognitive function.

• Describe chemo precautions and its importance.
• Develop teaching statement for the patient and family for someone who is returning home after chemotherapy. Explain to the patient the importance of reporting signs and symptoms of infection, any change in skin and mucous membranes, or other changes in health status. Instruct him or her to report the presence of pimples, sores, rash, or other open skin areas. Also teach him or her to report a cough, burning on urination, pain around the venous access site, or new drainage from any area of the body. Good handwashing before contact with the patient is essential for infection prevention. - Immunotherapy
• Biological Response Modifiers: enhance or alter the patient's biologic responses to cancer cells. BRMs have a variety of effects. Some have direct antitumor activity (i.e., helping the body recognize cancer cells as foreign so the immune system destroys them). BRMs also can improve IMMUNITY and enhance the repair or replacement of cells damaged by cancer treatment.
• Targeted Therapies: Targeted therapies used in cancer treatment are drugs that act on specific components needed for cellular function and reproduction. These therapies include monoclonal antibodies and small molecule drugs.
• Radiation: What does radiation do to the cancer cells, include exposure and radiation does. Radiation therapy (radiotherapy) uses high- energy radiation from gamma rays, radionuclides, or ionizing radiation beams to kill cancer cells, provide disease control, or relieve

symptoms. The delivery of radiation should accomplish these actions with minimal damaging effects on the surrounding normal cells. When cancer cells are exposed to ionizing radiation, the cell's DNA is damaged directly, or DNA-damaging charged particles (free radicals) are formed, resulting in a change in CELLULAR REGULATION. These damaged cells usually can no longer reproduce or function, leading to cell death. However, normal cells in the field of radiation are also affected by radiation.

• Explain to your patient in your own how radiation works to destroy cancer cell (What is the goal of radiation)
• Discuss the implications of internal radiation? Brachytherapy, also known as internal radiotherapy, means “short” (close) therapy. The radiation source comes into direct, continuous contact with the tumor for a specific time period. This method provides a higher dose of radiation in the tumor over a specified time period, limiting the dose in surrounding normal tissues.
• Considerations to external radiation? External beam or teletherapy is radiation delivered from a source outside of the patient. Because the source is external, the patient is not radioactive, and there is no hazard to others. The technique called intensity- modulated radiation therapy (IMRT) reduces the amount of normal tissue exposed to radiation by breaking up the single beam into thousands of smaller beams, allowing differing intensities to be delivered to specific areas of the tumor. Stereotactic body radiotherapy (SBRT) uses three- dimensional tumor imaging to identify the exact tumor location, which allows precise delivery of higher radiation doses and spares more of the surrounding tissue. Usually the total dosage is delivered in one to five separate treatment sessions.

• List the side effects of radiation
  • Create a teaching statement for a patient who will be receiving radiation. Include how to address side effects.
• Describe radiation exposure? The amount the of radiation delivered to tissue.
• Describe radiation dose? The amount that the tissue absorbs. Radiation dose is always less than radiation exposure. - Describe Oncologic Emergencies, presentation and treatment
• Metabolic
• Hypercalcemia (Metabolic Emergency): occurs in up to a third of patients with cancer. It is a metabolic emergency and can lead to death. Breast, lung, and renal cell carcinomas; multiple myeloma; and adult T-cell leukemia and lymphoma are the most common causes among cancer patients. These cancers can secrete parathyroid hormone, causing bone to release calcium. Bone metastasis can stimulate bone breakdown (osteoclast activity) and bone resorption, which releases more calcium from bone and leads to hypercalcemia. In addition, systemic secretion of vitamin D analogues by the tumor can also cause elevated calcium levels in the bloodstream. Dehydration worsens hypercalcemia.
• Tumor Lysis Syndrome (TLS) Metabolic
• What are the characteristics of this syndrome? Severe or untreated TLS can cause tissue damage, acute kidney injury (AKI), and death. Serum potassium levels can increase to the point of hyperkalemia, causing cardiac dysfunction. The large amounts of purines

form uric acid, causing hyperuricemia. These uric acid crystals precipitate in the kidney, blocking kidney tubules and leading to AKI. Sudden development of hyperkalemia, hyperuricemia, and hyperphosphatemia has life- threatening effects on the heart muscle, kidneys, and central nervous system. Early symptoms of TLS include lethargy, nausea, vomiting, anorexia, flank pain, muscle weakness, cramps, seizures, edema, and altered mental status.

• What would you expect the intervention? Hydration prevents and manages TLS by diluting the serum potassium level and increasing the kidney flow rates. These actions prevent the precipitation of uric acid crystals, increase the excretion of potassium, and flush any kidney precipitates.
• SIADH: water is reabsorbed in excess by the kidneys and put into systemic circulation. The retained water dilutes blood sodium levels, causing hyponatremia. Mild symptoms include weakness, muscle cramps, loss of appetite, and fatigue. Serum sodium levels range from 115 to 120 mEq/L (mmol/L) or lower (normal range is 135 to 145 mEq/L [mmol/L]). With greater fluid retention, weight gain, nervous system changes, personality changes, confusion, and extreme muscle weakness occur. As the sodium level drops toward 110 mEq/L (mmol/L), seizures, coma, and death may follow depending on how rapidly hyponatremia occurs.

• Hematologic
  • Febrile Neutropenia
• Sepsis: is a condition in which organisms enter the bloodstream (bloodstream infection [BSI]) and can result in septic shock, a life- threatening condition. Adults with cancer who have low white blood cell counts (WBCs) (neutropenia) and impaired IMMUNITY from cancer therapy are at risk for infection and sepsis.
• DIC: is a problem with the blood- CLOTTING process. DIC is triggered by many severe illnesses, including cancer. In patients with cancer DIC often is caused by gram-negative sepsis, although viral and other bacterial infections can trigger it. A patient's normal bacterial flora enter the bloodstream through any site of skin breakdown and cause a severe infection, especially when neutropenia is present. Other causes of sepsis include liver disease, intravascular hemolysis, prosthetic devices, or metabolic acidosis. Extensive, abnormal CLOTTING occurs throughout the small blood vessels of patients with DIC. This widespread clotting depletes circulating clotting factors and platelets. As this happens, extensive bleeding occurs. Bleeding from many sites is the most common problem and ranges from oozing to fatal hemorrhage. Clots block blood vessels and decrease blood flow to major body organs and result in pain, ischemia, strokelike symptoms, dyspnea, tachycardia, reduced kidney function, and bowel necrosis.
• Structural
  • Spinal Cord Compression (oncologic emergency): is an oncologic emergency that requires immediate intervention to relieve pain and prevent neurologic damage. Damage from SCC occurs either when a tumor

directly enters the spinal cord or spinal column or when the vertebrae collapse from tumor degradation of the bone. Tumors metastasizing from the lung, prostate, breast, and colon account for most SCC. Primary tumors of the spinal cord causing compression are less common. The most frequent area for SCC is the thoracic spine.

• Superior Vena Cava Syndrome
  • Your patient has developed Superior Vena Cava Syndrome, What is it? The superior vena cava (SVC), which returns all blood from the head, neck, and upper extremities to the heart, has thin walls, and compression or obstruction by tumor growth or by clots in the vessel leads to congestion of the blood. This is known as superior vena cava syndrome (SVCS) and can occur quickly or develop gradually over time.
  • What treatment will be used to treat this? SVC syndrome is often associated with late-stage disease when the tumor is widespread. Occasionally SVCS occurs with obstruction in an indwelling vascular device by a blood clot. This type of obstruction can be treated successfully with fibrinolytic drugs. High-dose radiation therapy to the upper chest area may be used to provide temporary relief of airway obstruction. Chemotherapy may be the only option for long- term control of the cancer causing the compression. Surgery is rarely performed for this condition. A metal stent can be placed in the vena cava in an interventional radiology

department to relieve swelling. Follow-up angioplasty can keep this stent open for a longer period.

- List the normal electrolyte ranges for Potassium, Sodium, Magnesium, Calcium and Chloride. Potassium: 3.7-5. Sodium: 136- Magnesium: 1.8-2. Calcium: 8.5-10. Chloride: 96- - What electrolyte disorder would you expect with hypoparathyroidism? Calcium down and phosphorous up

• What electrolyte disorder would you expect to find with diabetic keto- acidosis? Hyperkalemia, hyponatremia, hyperglycemia
• Working in the ED, you were assigned a patient who just finished running a marathon. The temperature was 87 degrees. What electrolyte disorder will you anticipate? Hypovolemia, hyponatremia, hypochloremia - List 4 nursing diagnosis for a patient with dehydration (what is happening on a physiological level) -Risk for falls due to hyponatremia which can cause seizures or orthostatic hypotension

List characteristics of how that patient would present to you in the ED. Describe how they would look and their vitals.

-. -. -. -. - What is your priority intervention in correcting severe dehydration? Rehydrating with possibly hypertonic solution if low in sodium - A patient was admitted with Congestive Heart Failure who is up 50 lb second to fluid overload after having consumed chips and hot dogs all weekend (high in sodium content). The treatment plan in aggressive diuresis with a loop diuretic called furosemide. Morning labs indicate that Serum Potassium levels 1.5 mEq/dl.

• What is the normal serum potassium range? 3.5-5.
• What is your patient as risk for because of the potassium level? Cardiac issues, decreased DTR, muscle cramping, flaccid paralysis
• How^ did the Potassium level get so low in the 1 st^ place?^ The^ diuretic^ pulled^ all of the potassium and he peed it out
• What is the treatment plan to correct the electrolyte imbalance? Give IV of potassium and potassium rich diet, don’t push IV do it slowly with IV monitor
• What is the dose and route of administration? No more than 20/hour through IV
• The CHF patient is ready for discharge. He is back down to his baseline weight. He interested and

ready to learn. What will you teach this patient and prevent him from going into fluid overload and better manage his CHF. CHF can cause a fluid overload so he needs to have a low sodium diet so that there won’t be a high serum sodium level which will pull more water into his blood causing his heart to work harder. Chances are a lot of his hormones aren’t working probably anymore either so his body isn’t able to regulate RAAS very well which can cause his BP to escalate along with sodium levels

• Discuss probable lab findings of a patient who is hypovolemic. Increased everything
• List causes of hypovolemia? Trauma, Burns, Bleeding, Shock, Dehydration - A patient is admitted with alcoholism. - List characteristics of a patient admitted with delirium tremens.
  • What electrolytes disorders would you anticipate? Hypomagnesemia, as well as low phosphate, potassium, calcium - What is palliative care? a. What does palliative care focus on? Palliative care provides support to the patient and family from the time of diagnosis through the treatment plan. Palliative care supports the whole person and not just the disease. The goal of

palliative care is to prevent and treat symptoms and side effects of cancer treatment as soon as possible. In addition to treatment of the disease, palliative care also focuses on psychological, social, and spiritual issues. It provides a support system for the patient and family during the entire disease process. Palliative care can be provided in both the hospital, outpatient, and home setting.

• What is Hospice? provides care to patients who are facing an incurable disease in which treatment is no longer an option for possible cure. The goal of hospice is to improve the quality of life for the patient in their final days. Hospice provides supportive care to the patient to help relieve the symptoms of cancer. It also serves as a support system for the patient and family during this difficult time. Hospice care can be performed in the hospital, hospice facility, or home setting. It offers a variety of services such as therapy, counseling, financial and emotional support to the patient and family, and includes support to the family once their loved one has passed.