DISSEMINATED INTRAVASCULAR COAGULATION (consumptive coagulopathy)

·         A grave blood coagulation disorder occurs as a complication of conditions that accelerate clotting wherein activation of thrombin & fibrinolytic system results in simultaneous bleeding & thrombosis.

·         Caused by infections, obstetric complications, neoplastic disease, tissue necrosis, cardiac arrest, stroke, incompatible blood transfusion, etc.

Signs & Symptoms:

ü  Petechiae

ü  Ecchymosis

ü  Dyspnea

ü  Prolonged bleeding after venipuncture

ü  Joint pain

ü  Hemorrhage

ü  Purpura

ü  Oliguria

ü  Anxiety

ü  Restlessness

Screening & Diagnosis:

·         Hematology -  ↓platelets, RBC, fibrinogen, factor assay (II,V,VII), ↑fibrin split products, thrombin, PT, PTT, (+) protamine sulfate test 

·         ABG analysis – metabolic acidosis

·         D-dimer test – result (+) ; specific test for DIC

Treatment:

·         Medications

o    Anticoagulants: heparin, antithrombin III (ATnativ^®, Thrombate^® III)

·         Blood transfusion – platelets, PRBC, FFP, whole blood, volume expanders, cryoprecipitates.

·         Bed rest

·         Oxygen therapy

·         IV therapy : hydration, electrolyte replacement, heparin lock

·         Hemodialysis

Complications:

·         Acute renal failure

·         Shock

·         CVA

·         Convulsions

·         Hemorrhage

·         Coma

Nursing Interventions:

·         Administer prescribed medications & IV fluids.

·         Monitor cardiovascular, respiratory, & fluid balance.

·         Avoid intramuscular injections, enemas, rectal temperatures & straight razors.

·         Check all IV & venipuncture sites frequently for bleeding.

·         Enforce complete bed rest during bleeding episodes.

·         Monitor for transfusion reactions.

·         Monitor results of blood studies & report any signs of complications.

·         Maintain seizure precautions.

ANA poll result, shows more Nurse seeking new employment

The American Nurses Association would like to thank its website visitors who participated in the March 2012 "Have Your Say" online poll. The poll asked respondents if they plan to seek a new place of employment once the economy recovers.

According to the results, 41% of respondents plan to seek new employment while 59% plan to remain at their current job. The results were based on 813 online responses.

To participate in the new poll, go to the NursingWorld homepage and answer the new poll question under the section titled "HAVE YOUR SAY" at the bottom of the left margin. Polls are posted on a monthly basis, with results from the previous poll made available on the Nursing Insider and the poll results archives.

Sources

ANA

http://www.nursingworld.org

Study Guide for Nurses

Here is a compilation of key points in medical surgical nursing and pharmacology, with mnemonics to help in memorizing

Click Here to download

New bill changes US visa requirements for foreign nurses

By Dymphna Calica-La Putt – asianjournal.com
Non-immigrant nurses working in the US may yet have the freedom to change employers even while their new visa is still in process.

This is after the House of Representatives passed recently a bill that will modify the requirements for admission of nonimmigrant nurses in health professional shortage areas.

“We just passed a bill that changes the visa requirements to allow more foreign nurses to come and stay in the country,” US Rep. Joe Heck told a forum with Asian business leaders in Las Vegas last August 15.

The bill, House Resolution 1933 (HR 1933) states, “A nonimmigrant alien…who was previously issued a visa or otherwise provided nonimmigrant status…is authorized to accept new employment performing services as a registered nurse…upon the filing by the prospective employer of a new petition on behalf of such nonimmigrant.”

“Employment authorization shall continue for such alien until the new petition is adjudicated. If the new petition is denied, such authorization shall cease,” the bill also states.

HR 1933, which amends the Immigration and Nationality Act, was passed in the House last August 1 and has been forwarded to the Senate for deliberation.

Heck, US Rep. of Nevada’s third district, said this piece of legislation will help the country’s nursing shortage, noting that it will help improve healthcare delivery in the US.

“(Nurses) would come to the US on a visa that is tied to their job at a particular hospital. We are trying to change that,” Heck told the discussion organized by the Las Vegas Asian Chamber of Commerce.

The congressman is a physician who used to work at the Emergency Room of the University Medical Center (UMC) in Las Vegas.

“There is a large Filipino nurse population at UMC,” Heck said, noting that this made him familiar with the work issues of healthcare professionals in the city, particularly those from other countries.

There is an estimated 2000 Filipino nurses living in Las Vegas, a large percentage of which come from the Philippines.

A large percentage of these healthcare professionals eventually set up their own businesses in the healthcare field, an official from the Philippine Medical Association of Nevada (PMAN) noted.

In fact, US Census Bureau records state that 49% of Filipino-owned businesses are in the healthcare sector. Filipino-owned firms, meanwhile, are the third fastest growing group in the US.

Dr. Ben Calderon, former PMAN president, in an earlier interview said, “It is widely known (Filipinos) have a very caring and compassionate culture.” Thus, he noted, the leaning towards opening businesses in the healthcare field.

The new bill is expected, not only to help improve healthcare delivery, but generate businesses and job opportunities, Heck noted.

“Everything we do is aimed at trying to revamp the entrepreneurial spirit,” the congressman said at the discussion.

Antineoplastic drugs

ALKYLATING AGENTS

·         Alters DNA structure by misreading DNA code, initiating breaks in the DNA molecule, cross-linking DNA strands

·         Indication:

o    Target malignancies: Hodgkin’s disease, Lymphosarcoma, Lung cancer, Adenocarcinoma of lung and breast, Leukemias, Multiple Myeloma

·         Contraindication:

o    Radiotherapy and chemotherapy within 1 month, thrombocytopenia, recent smallpox vaccination

Example:

busulfan (Myleran®)

carboplatin (Paraplatin®)

chlorambucil (Leukeran®)

cisplatin (Platinol®)

cyclophosphamide (Cytoxan®)

dacarbazine (DTIC-Dome®)

ifosfamide (Ifex®)

melphalan (Alkeran®)

thiotepa (Thioplex®)

mechlorethamine (Mustargen®)

Side Effects:

·         Anorexia

·         Nausea and vomiting

·         Stomatitis

·         Skin rash

·         Chlorambucil (Leukeran) and Mechlorathamine (Mustargen): hyperuricemia and gonadal suppression

·         Busulfan (Myleran): renal failure and pulmonary fibrosis

·         Cyclophosphamide (Cytoxan) and Ifosfamide (Ifex): renal failure, hemorrhagic cystitis, liver dysfunction

§  *administer Mesna (Mesnex) with ifosfamide to reduce potential of cystitis

·         Cisplatin (Platinol): renal toxicity and gonadal suppression

§   *administer amifostine (Ethyol) before cisplatin to reduce renal side effects

Nursing Considerations:

ü  Maintain good hydration.

ü  Administer antiemetics 30 to 60 mins. prior to chemotherapy.

ü  Withhold medication if platelet count is <75,000 cells/µL or WBC is <4000 cells/ µL and notify the physician.

ü  Monitor WBC, BUN, liver enzymes.

ü  Assess for infection.

ü  Encourage daily fluid intake of 2 to 3 L during treatment and monitor for signs of hemorrhagic cystitis (during cyclophosphamide and ifosfamide therapy).

ü  Assess lungs for fibrotic (coarse, loud) rales (during busulfan therapy).

ü  Assess for dizziness, tinnitus, hearing loss, incoordination, and numbing or tingling of extremities (during cisplatin therapy)

ü  Monitor IV site for inflammation and phlebitis.

Instruct patient about good oral hygiene

NITROSOUREAS

·         Similar to alkylating- agents; cross the blood-brain barrier

·         Indication:

o    Target malignancies: colorectal cancer, gastric cancer, skin cancer, pancreatic cancer

·         Contraindication:

o    Hypersensitivity

Example:

carmustine (BiCNU®, Gliadel®)

lomustine (CeeNU®)

semustine (methyl CCNU®)

streptozocin (Zanosar®)

Side Effects:

·         Nausea and vomiting

·         Delayed cumulative myelosuppression, especially thrombocytopenia

Nursing Considerations:

ü  Assess vital signs and temperature for signs of infection.

ü  Monitor CBC, uric acid and electrolyte levels.

ü  Maintain good hydration.

ü  Administer antiemetics 30 to 60 mins. prior to chemotherapy.

ü  Withhold medication if platelet count is <75,000 cells/µL or WBC is <4000 cells/ µL and notify the physician.

ü  Instruct client to report signs of infection and bleeding.

TOPOISOMERASE I INHIBITORS

·         Introduces breaks in the DNA strand by binding to enzyme topoisomerase I, preventing cells from dividing

·         Indication:

o    Target malignancies: Colon cancer, lung cancer, ovarian cancer

·         Contraindication:

o    Hypersensitivity, concurrent administration of irinotecan with irradiation, chronic inflammatory bowel disease and bowel obstruction

Example:

irinotecan (Camptosar®)

topotecan (Hycamtin®)

Side Effects:

·         Bone marrow suppression

·         Nausea and vomiting

·         Irinotecan (Camptosar): diarrhea

·         Hepatotoxicity

Nursing Considerations:

ü  Assess vital signs and temperature for signs of infection.

ü  Maintain good hydration.

ü  Monitor CBC.

ü  Assess results of liver function studies.

ü  Administer antiemetics 30 to 60 mins. prior to chemotherapy.

ü  Withhold medication if platelet count is <75,000 cells/µL or WBC is <4000 cells/ µL and notify the physician.

ü  Instruct patient to report signs of infection and bleeding.

ANTIMETABOLITES

·         Interferes with the biosynthesis of metabolites or nucleic acids necessary for RNA and DNA synthesis

·         Indication:

o    Target malignancies: leukemia, osteosarcoma, colorectal cancer, breast cancer, gastric cancer, pancreatic cancer

·         Contraindication:

o    Marked bone marrow depression, anemia, psoriasis patients with severe hepatic disorders, alcoholism or alcoholic liver disease, severe renal impairment, diarrhea and ulcerative colitis

Example:

cytarabine (ara-C, Cytosar®)

capecitabine (Xeloda®)

5- fluorouracil (Adrucil, 5-FU®)

fluxoridine (FUDR®)

edatrexate fludarabine (Fludara®)

hydroxyurea (Hydrea®)

cladribine (Leustatin®)

6-Mercaptopurine (Purinethol®)

methotrexate (Folex®)

6-thioguanine

pentostatin (Nipent®)

Side Effects:

·         Nausea and vomiting

·         Diarrhea

·         Bone marrow suppression

·         Alopecia

·         Stomatitis

·         Cytarabine (Cytosar): hyperuricemia, hepatotoxicity

·         5-fluorouracil (Adrucil): phototoxicity reaction and cerebellar dysfunction

·         Methotrexate (Folex): hyperuricemia, photosensitivity, hepatotoxicity, hematological, gastrointestinal and skin toxicity

§  *Administer leucovorin as prescribed to prevent toxicity

·         6-Mercaptopurine (Purinethol): hyperuricemia and hepatotoxicity

Nursing Considerations:

ü  Monitor vital signs and temperature for signs of infection.

ü  Monitor CBC, WBC differential count, BUN, uric acid and  creatinine.

ü  Withhold medication if platelet count is <75,000 cells/µL or WBC is <4000 cells/ µL and notify the physician.

ü  Maintain good hydration.

ü  Monitor renal function studies (especially during methotrexate therapy).

ü  Assess for photosensitivity and monitor for cerebellar dysfunction (during 5-Fluorouracil therapy).

ü  Assess oral mucus membranes and treat ulcers prn.

ü  Instruct patient to use sunscreen and protective clothing.

ü  Teach care for hair loss.

ANTITUMOR ANTIBIOTICS

·         Interferes with DNA synthesis by binding DNA; prevents RNA synthesis

·         Indication:

o    Target malignancies: Leukemias, Neuroblastoma, Nephroblastoma, breast caner, ovarian cancer, thyroid cancer and lung cancer

·         Contraindication:

o    Lung disease, renal and hepatic disorders, ulcers, and gastrointestinal disease

Example:

bleomycin (Blenoxane®)

dactinomycin (Actinomycin D®, Cosmegan®)

daunorubicin (DaunoXome®, Cerubidine®)

doxorubicin (Adriamycin®)

idarubicin (Idamycin®)

mitomycin (Mutamycin®)

mitoxantrone (Novantorone®)

plicamycin (Mithracin®)

valrubicin (Valstar®)

Side Effects:

·         Bone marrow suppression

·         Nausea and vomiting

·         Alopecia

·         Anorexia

·         Vesication

·         Daunorubicin (DaunoXome), Idarubicin (Idamycin) and Doxorubicin (Adriamycin): cardiotoxicity

·         Bleomycin (Blenoxane): pulmonary toxicity

·         Plicamycin (Mithracin): affects bleeding time

Nursing Considerations:

ü  Assess vital signs and temperature for signs of infection.

ü  Withhold medication if platelet count is <75,000 cells/µL or WBC is <4000 cells/ µL and notify the physician.

ü  Monitor ECG; assess for arrhythmias, gallops and CHF (during dactinomycin [Actinomycin D], daunorubicin [DaunoXome, Cerubidine], Doxorubicin [Adriamycin] therapy.

ü  Monitor CBC with differential, BUN and uric acid.

ü  Assess pulmonary function studies (during Bleomycin [Blenoxane] therapy).

ü  Assess for bleeding; check stool for occult blood. Avoid use of aspirin, anticoagulants and thrombolytic agents (during Plicamycin [Mithracin] therapy).

ü  May see delayed cardiotoxicity months to years after administration of doxorubicin.

ü  To prevent heart failure related to doxorubicin, do not administer more than 550 mg/m²  in a lifetime

ü  Evaluate hydration and nutrition status.

ü  Monitor IV site for vesication.

ü  Instruct oral care for stomatitis.

ü  Teach care for hair loss.

MITOTIC SPINDLE POISONS (Mitotic Inhibitors, Vinca Alkaloids)

·         Arrests metaphase by inhibiting mitotic tubular formation (spindle); inhibit DNA and protein synthesis

·         Indication:

o    Target malignancies: Leukemias, Hodgkin’s and Non-Hodgkin’s lymphomas,lymphocytic and histocytic lymphoma, neuroblastoma, nephroblastoma, Kaposi’s sarcoma, advanced testicular cancer and unresponsive breast cancer 

·         Contraindication: Cardiovascular, hepatic, nerve, and muscle disease

Example:

Plant Alkaloids o    etoposide (VePesid®) o    teniposide (Vumon®) o    vinblastine (Velban®) o    vincristine (Oncovin®) o    vinorelbine (Navelbine®)

Taxanes o    paclitaxel (Nov-Onxol®, Taxol®, Paclitaxel Novaplus®) o    docetaxel (Txotere®)

Side Effects:

·         Alopecia

·         Hoarseness

·         Ptosis

·         Anorexia, nausea and vomiting

·         Stomatitis

·         Hyperuricemia

·         Constipation, paralytic ileus

·         Vinblastine(Velban®): bone marrow suppression

·         Vincristine (Oncovin®): Neorotoxicity/ neuropathies

·         Taxanes: Bradycardia, hypersensitivity reactions and neuropathies

·         Areflexia

Nursing Considerations:

ü  Assess vital signs.

ü  Monitor CBC with differential.

ü  Assess neuromuscular function.

ü  Evaluate gastrointestinal function; manage constipation.

ü  Administer antiemetics prn as ordered.

ü  Monitor eyes for ptosis; monitor for hoarseness.

ü  Teach ways to manage hair loss.

HORMONAL AGENTS

·         Binds to hormone receptor sites that alter cellular growth; block binding of estrogens to receptor sites (antiestrogens); inhibit RNA synthesis

·         Indication:

o    Target malignancies: Advanced breast and prostate cancer

·         Contraindication:

o    Pregnancy, hepatic and renal disease, osteoporosis, hypertension, hypercholesterolemia

Example:

diethylstilbestrol (DES, Stilphostrol®)

letrozole (Femara®)

raloxifene (Evista®)

tamoxifen (Nolvadex®)

goserilin acetate (Zoladex®)

Testosterone

medroxyprogesterone (Depo- Provera®)

asparaginase (Elspar®)

mitotane (Lysodren®)

megestrol acetate (Megace®)

Side Effects:

·         Hypercalcemia

·         Hypertension

·         Jaundice

·         Increased appetite, weight gain

·         Masculinization

·         Feminization

·         Sodium and fluid retention

·         Hot flashes

·         Vaginal dryness

·         Nausea and vomiting

·         Asparaginase (Eslpar): impaired pancreatic function

·         Mitotane (Lysodren): Hemorrhagic cystitis, hyperuricemia and hypercholesterolemia

·         Tamoxifen (Nolvadex): Edema, hypercalcemia, elevated cholesterol and triglyceride levels, decreased effects of estrogen

·         Diethylstilbestrol (DES, Stilphostrol):

§  Female: Fluid retention, feminization and uterine bleeding

§  Male: impotence and masculinization

Nursing Considerations:

ü  Monitor vital signs.

ü  Administer diuretics prn as ordered.

ü  Monitor for bleeding.

ü  Monitor electrolytes, uric acid and cholesterol levels.

ü  Monitor pancreatic function.

ü  Explain reason for sex characteristic alterations.

Provide patient teachings for managing hot flashes