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Health Implications Across the Life Span

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Long-Term CAreLong-term care includes those services provided in ✽

institutional settings, such as a nursing home, rehabilitation center, or adult day care program, after the acute phase of the illness has passed. It often involves restorative care for clients with chronic health care problems.

A. Types of long-term care facilities. 1. Nursing home: Provides services ranging from maintenance to restorative care with skilled nursing anduseofcertifiednursingassistants(CNAs), licensedpracticalnurses(LPNs),andregistered nurses(RNs). 2. Adultdaycarehome:Clientlivesathomeduring the evening and overnight hours and spends the day in a facility that provides a range of care from skilled nursing to restorative care. 3. Hospicecare:Careisprovidedinboththehomeand inpatientcaresettings;fundedbyMedicareforthe terminallyillolderadult,withotherprograms availableforotheragegroups. a. Doesnotinstitutelifesupportbyextraordinary means. b. Emphasisonpaincontrolforclientandsupport offamilymembersthroughtheend-of-life process. 4. Respitecare:Thisisatypeofshort-termcarefor theprimarycaregiver(oftenafamilymember)to givecaregiverabreakfromthedailyresponsi- bilitiesoftakingcareofthelong-termclient. 5. Rehabilitationcenter:Thisisafacilitythatprovides multiple services for the client and family to make adjustments to daily living. 6. Home care: Nursing care is provided in the home toclientswhodonotneedhospitalization,butdo needadditionalassistancewithmedicalproblems. 7. Adult housing or assisted living centers: These are placeswhereclientscanliveindependently,but under minimal supervision; meals and other services are offered to the residents.

Rehabilitation ✽ Rehabilitation is the restoration of an individual to

his/her optimal level of functioning. This includes physical, mental, social, vocational, and economic parameters. A. Rehabilitation:termusedwhenanindividualhas lostfunctionalabilityduetoillnessorinjury.

B.Habilitation:termusedtorefertocongenitalprob- lemsordeficiencies.

Goals of RehabilitationInorderfortherehabilitationclienttoachievethehighestlevelofproductivity,therehabilitationprocessmustbeginwhentheconditionbecomesevident,orwhenthediseaseisdiagnosed. 1. Prevent deformities and complications. a. Maintainfunctionandpreventdeteriorationof unaffected organs or areas. b. Preventfurtherinjurytoaffectedareaororgan. c. Preventorreducecomplicationsofimmobility. 2. Assist client to perform activities of daily living (ADLs)withminimalornoassistance,depending onlevelofdisability. Examples of ADLs: Eating, dressing, bathing. 3. Assist client with independent activities of daily living(IADLs). Examples of IADLs: Shopping for groceries, paying bills, lawn care. 4. Promote continuity of care when the client is dis- charged or transferred.

Psychological Responses to DisabilityNot every client will progress through all stages of grief in anorderlyfashion.Clientswillfluctuatebetweenemotionalcrises.A. Initialresponsesofconfusion,disorganization,and denialrepresentastateofinternalconflict.Conflictis precipitatedby: 1. Forced dependency. 2. Lossofself-esteem. 3. Threat to personal and family integrity.B. A period of depression may occur as the client mourns forthelostbodyfunctionoractivity.C. Anangerstagemayoccurastheclientprojectsblame and hostility on family and health care providers.D. Adaptation and adjustment will occur as the client beginstoredirecthisorherenergytowardcopingwith thedisability.E. Newsituations(e.g.,goinghomefromhospital,new job)mayprecipitateemotionaloutburstsandtrauma.F. Someclientswillrefusetoaccepttheirdisabilityand will not put forth any effort to adapt to everyday living.

24 CHAPTer 2 Health Implications Across the Life Span

CAre of THe CHronICALLy ILL CLIenTA chronic illness may be defined as an illness or ✽

condition that is present for more than 3 months in a year and interferes with daily function and lifestyle.

Nursing ConsiderationsA. Clientmayremainfreefromsymptoms,butmustre- main in contact with health care provider in order to maintain optimal level of wellness.B. The condition of the client and the level of the disease willhaveavariableimpactontheclient’slifestyleand coping strategies.C. Themajorityofclientswithextendedhealthcareneeds are suffering from at least two chronic health condi- tions.Theseconditionsmayormaynotbeinterrelated.D. The focus of care for the chronically ill client is on assisting the client to control his/her disease and manage his/her lifestyle. This is true of the pediatric chronically ill client as well as the adult client. 1. Prevention and management of medical crises. 2. Controlofdiseasesymptoms,whichmayfocuson pain control and comfort measures. 3. Implementationoftheprescribedtherapeutic regimens. 4. Psychosocial implications and adjustment of lifestyle; frequently requires dealing with social isolation. 5. Adjustments of lifestyle as disease and/or condition changes. 6. Financial strain to pay for medical care and supplies. 7. Copingwithstrainonmarriageandonfamily structure.E. Themajorityofclientswithchronichealthcareneeds are over 65 years of age. The feeling of powerlessness is not uncommon in the older adult.

Nursing Considerations in the Chronically Ill Pediatric ClientThediagnosisofachild’schronicillnessisamajorsitua-tionalcrisisinthefamily.Supportsystems,perceptionoftheproblem,andcopingmechanismswillultimatelydeterminethe resolution of the crisis.A. Focuscareonthechild’sdevelopmentalagerather thanthechronologicalage.Emphasisshouldbemade onthechild’sstrengthsratherthanonthechild’s disabilities.B. Promotethechild’smaximallevelofgrowthand development. The current trend is to return the child totheacademicenvironmentofthechild’speergroup. Avarietyofsupplementalprogramsarebeingde- veloped in the school systems to meet the needs of these children.C. Assessthefamilyresponsetothechild’sillnessand evaluateforparentaloverprotection.Overprotectionby the parents prevents the child from developing self-

esteem,independence,andself-controloverdiseaseand activities of daily living. The practical nurse should observeforthefollowingparentalcharacteristics: 1. Showsinconsistencywithdiscipline;forexample, discipline often differs from that of the other children in the family. 2. Attempts to protect the child from every discomfort,bothphysicalandpsychosocial;forexample, frequently restricts play with peers for fear of injury and/orrejectionbypeers. 3. Makesdecisionsforthechildwithoutinvolvingthe child. 4. Does not allow the child the opportunity to learn self-care; frequently afraid the child cannot handle therequirementsforself-care,forexample,encour- agingandassistingthediabeticchildtobecome responsibleforadministrationofowninsulin. 5. Continuestodothingsforthechild,evenwhenthe childiscapableofperformingtasksforself. 6. Showsself-sacrificeandisolationoffamilyfrom social interactions.

growTH And deveLoPmenT

A. Normalgrowthanddevelopmentprogressinasteady, predictablepatternacrossthelifespan. 1. Developmentprogressesinacephalocaudal(head totail)manner. 2. Developmentprogressesfromproximaltodistal, withaprogressionfromgrosstofinemotorskills.B. The developmental age of a client is important to consider in the implementation of nursing care. 1. Nursesneedtobeawareofthemajordevelopmental milestones. 2. Nursingcareisplannedaroundtheclient’sdevelop- mentallevel,nothisorherchronologicalage.

TEST ALERT: Provide care appropriate to devel-opmental level (e.g., newborn, child, older adult), especially for the adult and older adult.

C. PhysicaldevelopmentisdescribedinTable2-1.

Dietary Considerations throughout the Life Span

Infant A. Growth. 1. Birthweightdoublesin4months. 2. Birth weight triples at 1 year. 3. Infantgainsonlyanother4to6lbuntil2yearsold. Example: Birth weight 7 lb; at 4 months infant should weigh 14 lb; another 7 lb will be added in the next 8 months.

CHAPTer 2 Health Implications Across the Life Span 25

TABLE 2-1 GROWTH AND DEVELOPMENT

Birth-4 months

4-9 months

9-12 months

Toddler(12-24months)

Preschool(3-5years)

School-age(6-10years)

Adolescence(11-17years)

Youngadult(18-30years)

Adult(30-60years)

Olderadult(60+years)

Consistentlygainsweight(5-7ozperweek)Posterior fontanel closesRespondstosoundsandbeginsvocalizingGains head control → lifts chest → rolls over one waySmiles responsively → smiles when spoken to

Doublesbirthweight(gains3-5ozperweek)TeethingbeginswithlowerincisorsSitswithsupport;beginscrawlingTurnsoverinbothdirectionsLaughsaloud

Birth weight triplesHead and chest circumferences are equalAnteriorfontanelbeginstocloseTeething:has6-8teethSits alone → moves from prone to sitting positionCrawling→ pulling up → walks holding on to furniture

50%ofheightat2yearsExaggeratedlumbarcurveMobile:walks,runs,jumpsWalksupanddownstairs,onefootatatimeBegins using eating utensilsObeyssimplecommandsBeginstodevelopvocabulary

Birthlengthdoublesat4yearsCoordinationcontinuestoimproveRidestricycle,throwsaballWalks up and down stairs with alternating feet

GrowthspurtsbeginIncreasingly activeVeryconcernedwithbodyimageNeed for conformity: rules and rituals

BeginningandcompletingpubertyGirlsmatureearlierthanboysVeryconsciousofchangesinbodyRapidgrowth

Physical maturityFull mental capacityAssumesresponsibilityforownlearningAdult relationship with parents

PhysiologicalprocessesbeginslowdeclineCognitiveskillspeakCreativityatmaximumIncrease in community involvementIncrease in concern for future of society

Decline of physiological statusDemineralizationofbones↓Cardiacoutput↓Respiratoryvitalcapacity↓Glomerularfiltrationrate↓Serumalbumin↓ Glucose tolerance

TeethingmaybeginCoordinationprogressesfromjerkymovementtograspingobjectsProvide toys that increase hand-eye coordination

ReachesforobjectsandgraspsthemBegins“strangeranxiety”Begins vocalizing with single consonantsProvidebrightlycoloredtoysthatareeasytograspEnjoysnoisemakersandmirrors;playspat-a-cake

MaystandaloneHasdevelopedcrudetofinepincergraspTransfersobjectsfromonehandtoanotherRecognizesownnameEnjoysplayingalone(solitary)Exploresobjectsbyputtingtheminmouth

SpeechbecomesunderstandableThumbsuckingmaybeatpeakSolitaryplayat12months;parallelplayat18monthsBeginningtodevelopbladderandbowelcontrolAttention-seekingbehavior:tempertantrumsEnjoysactivitiesthatprovidemobility:ridingve-hicles,wagons,pulltoys

Beginstodemonstrateself-careabilitiesKnows own nameGoodverbalization:talksaboutactivitiesPlays“dressup”;playswithcars,dolls,groomingaids

Increasing importance of peer groupsPlayswithgroupsofsamesexCompetesforattention

MovesfromconcretetoabstractthinkingIncreased independenceStrong peer group associationIncreasedinterestinoppositesex

LaunchescareerSelectsamate,beginsownfamilyBegins involvement in community

Family tasksAssistchildrentoresponsibleadulthoodRolereversalwithagingparentsDefinesroleofgrandparenting

MaintainsreasoningabilityandabstractthinkingRestructureinfamilyrolesRetirementReorganizationofactivitiesContinueswithcommunityinvolvementandpolitics


4. Prefersfingerfoods(e.g.,bananas,greenbeans, crackers). 5. Tendstorefusecasseroles,salads,andmixed dishes. C. Nursingimplications. 1. Struggleforautonomymaybemanifestedbyre- fusaloffood,mealtimenegativism,andritualism. 2. Briberyandrewardsforeatingshouldbeavoided. 3. Donotmixfoodonplate.

Preschooler A. Growth. 1. Growth rate slows and appetite decreases. 2. Activity level and nutrient requirements remain high. B. Diet. 1. Food jags are common; may refuse to eat anything exceptonefoodateachmeal. 2. Continuestorefusecasserolesandmixedfood items. 3. Finger foods remain popular. C. Nursingimplications. 1. Shouldnotbeforcedtoeatallfoodonplate.Ifsuffi- cientamountsarenoteatenduringmealtimes,then eliminate snacks. 2. Recognizethatrefusingtoeatisawaytoattract attention.

School-Age Child A. Growth. 1. Growth is slow and steady. 2. Food intake gradually increases while energy needs perunitofbodyweightdecline. 3. There is a yearly gain of 3 to 5 kg in weight and 6cminheight,endingwithagrowthspurtin puberty.B. Diet. 1. Food intake is more varied. 2. Enjoysmostfoods,withvegetablesbeingleast favorite. C. Nursingimplications. 1. After-schoolsnacksarepopular;encouragefruits, rawvegetablesticks,andpeanutbuttersandwiches. 2. Childlearnsgoodtablemannersfromimitating parents. 3. Promotegoodhealthhabits(e.g.,regularexercise; weightcontrolisabalancebetweenphysicalactiv- ityandfoodintake);encourageroutinedental checkups for dental caries.

Adolescent A. Growth. 1. Rapidgrowthratesandmaturationchangesmake adolescentsvulnerabletonutritionaldeficiencies.

4. Newbornwillloseweightforthefirstfewdaysfol- lowingbirth,butshouldnotlosemorethan10%of thebirthweightortakelongerthan10to14daysto regain it. 5. Newbornhasahigherfluidrequirementinrelation tobodysizethananadult.B. Diet. 1. Idealfoodisbreastmilk,becauseitisnutritionally superior to alternatives. 2. Cerealisusuallythefirstsolidfood,givenat4to6 months; rice cereal is easily digested and less likely to cause an allergic reaction. 3. Orderofintroductionoffoodiscereal,thenveg- etablesorstrainedfruitswithmeatbeinglast. 4. Beforeaddinganotherfooditem,wait4to7days to ensure no allergic or adverse reaction has oc- curred due to previously added food item. 5. Maintaininfantonformulaorbreastmilkuntil12 monthsold,mayneedironsupplementafter6 months if on formula.

PEDIATRIC PRIORITY: ✔ Infants should not be given honey until after their first birthday.

C. Nursingimplications. 1. Newbornscannotswallowvoluntarilyuntil10to12 weeks of age. 2. Extrusionreflex(pushingfoodoutofmouthwith tongue)lastsuntil4months. 3. Usualprogressionoffoodtextureisstrainedto mashedtomincedtochoppedtocuttablefoods. 4. Increasetheuseofsmall-sizedfingerfoodsas pincergraspdevelops(9months). 5. Textureoffoodbecomesincreasinglyimportant from6monthsto1year,butthefoodmustbeeasily dissolved(e.g.,crackersorzwieback).

PEDIATRIC PRIORITY: ✔ Raw carrots, celery, pop-corn, nuts and hard candies should not be given until the toddler stage due to problem with choking.

Toddler A. Growth. 1. Steady increases in growth. 2. Legsgrowmorerapidlythanthetrunk.B. Diet. 1. Needs 16 oz of milk daily; more than 24 oz can lead tomilkanemia(peakincidenceat18months). 2. Milkintakeshouldnotexceed800to1000mLdaily in toddlers and young children in order to prevent refusal of other foods. 3. Fruitsnacksshouldbegivenratherthanfruitjuices.


2. Girl’speakgrowthoccursbetween10and13years of age. 3. Boy’speakgrowthoccursbetween11and14years ofage.Energyneedsarehighestinboysbetween 15and18yearsofage,whenmusclemassis developing. B. Diet. 1. Dietsingeneralaredeficientincalciumand vitaminC. 2. Outof10girls,6eatonlytwothirdsofthenutrients required.Girlstendtobedeficientiniron,while boystendtobedeficientinthiamine.

Adult A. Growth. 1. Forages20to80,bodyfatinproportiontobody weightincreases35%. 2. Forages20to80,plasmavolumedecreasesby8%. 3. Forages20to80,leanbodymassandtotalbody waterdecreaseby17%.B. Diet. 1. Energyrequirementsdecreasewithage. Example: 55-year-old man requires 2400 kcal; at age 76 requires only 2050 kcal. Example: 55- year-old woman re-quires 1800 kcal; at age 76 only requires 1600 kcal. 2. Improvedfinancialstatusduringmiddleadulthood increases intake of rich foods and frequency of dining out. 3. Obesitygraduallybecomesaproblemasaseden- tary lifestyle develops. C. Nursingimplications. 1. Encourageadherencetoaprudentdietpattern. 2. Promotearegularexerciseprogram. 3. Reducesodiumintaketo3to6gdaily. 4. Maintainserumcholesterollevelatorbelow 200mg/dl,withhigh-densitylipoprotein(HDL) levelabove35mg/dl.

TEST ALERT: Provide care that meets the special needs of the older client (Box2-1).

Older Adult A. Diet. 1. Encourageadiethighinfiber,iron,vitaminC,and thiamine with adequate sources of calcium. 2. Ifconfinedtobedrest,theolderadultrequiresan increasedfluidintakeashighas3L/daytopromote goodrenalfunction,providingtherearenofluid restrictions(e.g.,heartfailure).

OLDER ADULT PRIORITY: ✔ The older adult may intentionally restrict fluids because of nocturia or stress incontinence.

3. Monitorrenalfunction,proteinmaybelimitedif renal function is compromised. B. Nursing implications. 1. Incomeisusuallyfixed;mayhavelessmoneyto spend on food. 2. Foodshoppingandtransportationmaybeaproblem becauseofphysicaldisability. 3. Alteration in taste and reduced digestive function occurs. 4. Often needs to wear dentures. 5. Constipationisachronicproblem;encouragefluid intakeandhigh-fiberdiet. 6. Lonelinessanddepressionareoftenassociatedwith poor appetite.

OLDER ADULT PRIORITY: ✔ Usually it takes more time for an older person to eat and early satiety is reached. Encourage frequent small feedings rather than three meals a day. May need additional liquid supplements.

Nutritional Evaluation A. Determine nutritional needs. B. Examineclientprofile:age,sex,height,weight,socio- economicstatus,culture.C. Determinenutritionalstatus:foodhabits;observefor physical signs indicative of nutritional status. D. Determine disease or pathophysiological process. E. Bealerttohigh-riskclients:overweight;underweight; surgeryofGItract;problemswithingestion,digestion, orabsorption;andclientsonintravenous(IV)therapy for10daysormore.

• Frequentabsenceofsocialandfinancialsupport Examples:Diseaseand/orlossofspouse,inadequate income from pension• Presenceofsignificantconcurrentillness Examples:Dementia,chronicobstructivedisease, congestiveheartfailure,depression,diabetes• Alteredpainperception Example: Increased incidence of referred pain• Impairedhomeostaticmechanisms Examples:Increasedproblemswithdehydration, incontinence,impaireddefecation,alteredimmunestatus• Impairedmobility Examples:Dependenceonwalkers,needforassistance withbedtransferring,changeinuseoftransportation, presence of Parkinsonism or degenerative joint disease• Increasedfrequencyofadversereactionstodrugs• Impairedequilibrium,resultinginfalls

BOX 2-1 OLDER ADULT CARE FOCUS Age-Related Factors Influencing Older Adult Care


Diet Therapy for High-Level Wellness A. MyPyramid(Figure2-1).B. Prudent diet. 1. Increasedamountsoffruits,vegetables,andgrains. 2. Reducedamountsofanimalfats,cholesterol,re- finedsugar,salt,andalcohol. 3. Adaptations to the MyPyramidPlan(seeFigure2-1). a. Meat:increaseamountsoffish,chicken,turkey, andveal;alsoincreaseuseoflegumes,nuts,and seeds as a source of protein; limit egg yolks to twoorthreeweekly,includingthoseusedin cooking. b. Milk:uselow-fatdairyproducts. c. Fruitsandvegetables:increasetotalintake. d. Grains,breads,andcereals:selectwhole-grain products and eat at least 3 oz every day.

Therapeutic Meal Plans A therapeutic meal plan or prescription diet is a ✽

modification of an individual’s normal nutritional needs based on the pathophysiological disease process (Table2-2).

TEST ALERT: Collect data on client’s nutrition or hydration status; identify client’s ability to eat (chew, swallow); provide for nutritional needs by encouraging client to eat, feeding client, or assisting with menu.

CommUnICABLe dISeASeS

TEST ALERT: Understand communicable diseases and modes of organism transmission (air-borne, droplet, contact); apply principles of infection control.

A. Incubationperiod:timefromexposuretothepathogen until clinical symptoms occur.B. Communicability:periodoftimeinwhichaninfected person is most likely to pass the pathogens to another person.C. Prodromalperiod:beginswithearlymanifestationsof the disease or infection and continues until there are overt clinical symptoms characteristic of the disease.D. Vaccinationsforhealthcareworkers(Table2-3).

Varicella (Chicken Pox)

CharacteristicsA. Herpesvirus:varicellazoster;highlycontagious,usually occurs in children under 15 years of age.B. Maculopapularrashwithvesicularscabsinmultiple stages of healing.

C. Incubationperiod:14to16days.D. Transmission:contact,airborne.E. Communicability:1daybeforelesionsappeartotime when all lesions have formed crusts.

Data CollectionA. Prodromal:low-gradefever,malaise.B. Acute phase: red maculopapular rash. C. Newcropsofvesiclescontinuetoformfor3to5days, spreadingfromtrunktoextremities.D. Rashappearsprofuselyonthetrunk;beginsasmacule andprogressestopapule,vesicleandthencrusts. All three stages are usually present in varying degrees at one time; pruritus.E. Complications:secondaryinfectionmayleadtosepsis, abscess,cellulitis,orpneumonia.

Health Care InterventionsA. Preventive:varicellaimmunization(seeFigure2-2, Figure2-3).B. Skin care to decrease itching. 1. Topicalantihistamines,antipruritics,calamine lotion. 2. Coolbaths.C. Keepchild’sfingernailsshort;applymittensif necessary.D. Isolate affected child from other children until vesicles have crusted.E. Providequietactivitiestokeepchildoccupiedtolessen pruritus and prevent scratching.F. Avoid use of aspirin.G. Checkwithhealthcareproviderbeforeadministering vaccine to immunocompromised clients. Vaccine shouldnotbegiventopregnantwomen.

Parotitis (Mumps)CharacteristicsA. Anacuteviraldiseasecharacterizedbytendernessand swellingofoneorbothoftheparotidglandsand/or the other salivary glands.B. Incubationperiod:14to21days.C. Transmission:directcontactanddroplet.D. Communicability:immediatelybeforeandafter swellingbegins.

Data CollectionA. Prodromal:headache,fever,malaise.B. Acutephase:Swellingofsalivaryglands(peaksin3 days),leadingtodifficultyinswallowing,earache.C. Complications. 1. Postinfectious encephalitis. 2. Sensorineural deafness. 3. Orchitis,epididymitis.


fIgUre 2-1 myPyramid. (From United States Department of Agriculture, Center for Nutrition Policy and Promotion, April 2005. Retrieved from http://www.mypyramid.gov/downloads/MiniPoster.pdf _ )

U.S. Department of AgricultureCenter for Nutrition Policy and Promotion

April 2005CNPP-15

USDA is an equal opportunity provider and employer.


TABLE 2-2 THERAPEUTIC MEAL PLANSDiet

Clearliquid

Full liquid

Soft diet

Mechanicalsoftdiet

Bland diet

Low-residuediet

High-residue diet

Lactose-freediet

PKU diet

Low-fat/low-cholesteroldiet

Low-sodiumdiet

High-potassium diet

Renaldiet

Low-purinediet

Purpose/Use

TobeginintroductionoffoodafterremovalofNGtube,afterGIsurgery.Prior to GI diagnostics.

Tobeginintroductionoffood;usedafterremovalofNGtubeorafterGIsurgery

To progress diet as tolerated; food shouldbeeasytochewandswallow

To assist clients who cannot chew effectively

To eliminate foods irritating to the digestive system; used in clients after GI surgery and those with peptic ulcer disease and GI inflammatoryproblems

TodecreasefiberorstoolinGItract;acuteepisodesofenteritis,diarrhea;beforeand/orafterGIsurgery

To prevent constipation and prevent acute diverticulitis

To prevent GI effects of lactose intolerance

Tocontrolintakeofphenylalanine,an essential acid; affected children cannotmetabolizeit

Topreventgallbladderspasms,clients with increased cholesterol levels,orproblemswithmalabsorptionoffat(cysticfibrosis)

To reduce sodium intake to decrease retentionoffluids,especiallyinclients with cardiac disease or hypertension

To replace lost potassium in clients taking diuretics and/or digitalis

Controlpotassium,sodium,andprotein levels in clients with renal problems

To decrease serum levels of uric acid;prescribedforclientswithgoutand high levels of uric acid

Foods Allowed

Liquidsthatareclear

Any food that is liquid at room temperature

Soft,tenderfoodseasytoswallowand digest

Soft foods that are easy to chew and swallow

Milk,custards,refinedcereals,creamedsoups,potatoes(bakedorbroiled);allfoodsarewhite;nobright-coloredfood

Clearliquids,meats,fats,eggs,refinedcereals,whitebread,peeledwhitepotatoes,smallamountofmilk

Rawfruitsandvegetables;wholegrains;high-carbohydratefoods,whicharehighinresidueandfiber

Nonmilkproducts,yogurt

Specially prepared infant formula ifinfantisnotbreast-fed,vegetables,fruits,juices,somecereals,andbreads;mayallow20-30mgofphenylalanineperkilogramofbodyweighttofulfillnormal growth needs

Low-fatorfat-freemilk,fruits,vegetables,breads,cereals,reducedamounts of red meat

Salt-freepreparations,freshfruits,vegetableswithnoaddedsalt

Driedfruits,fruitjuices,freshfruits(e.g.,bananas,apricots,grapefruit,oranges,andtomatoes)

Highbiologicalprotein(limitedintake):eggs,milk,meat;decreased sodium products and decreasedpotassium(cabbage,peas,cucumbersarelowinpotassium)

Vegetables,fruits,cereals,eggs,fat-freemilk,cottagecheese

Foods Restricted

Milkproducts,juicewithpulp,any solid food; anything that is not liquid at room temperature

Any solid food

Highlyseasonedfoods,wholegrains,fruits,vegetables,nuts,fried foods

Toughfoodsthataredifficulttochest and swallow

Highly seasoned or strong-flavoredfoods;tea,colas,coffee,fruits,wholegrains,rawfruit,mostvegetables

Cheeses;wholegrains;rawfruitsandvegetables;high-carbohydratefoods,whichareusuallyhighinresidueandfiber

Indigestiblefibers:celery,wholecorn; seeds such as sesame and poppy; foods with small seeds

Milkandmilkproducts,processed foods that may have driedmilkasfiller

Mosthigh-proteinfoods,including meat and dairy products,aresignificantlyreduced

Eggyolks,wholemilk,friedfoods,processedcheese,shrimp,avocados,pastries,butter

Processedfoods,smokedorsaltedmeats,preparedfoods,frozenandcannedvegetables,breadsandpastries

Nospecificrestrictions

High-potassiumfoods(driedfruits),high-sodiumfoods(processedfoods),saltsubstituteswith high-potassium content

Glandularmeats,fish,poultry,nuts,beans,oatmeal,wholewheat,cauliflower

GI,Gastrointestinal;NG,nasogastric;PKU,phenylketonuria.


Health Care InterventionsA. Preventive:measles,mumps,andrubella(MMR)immunization(seeFigure2-2,Figure2-3).MMRvaccine shouldnotbegiventopregnantorseverelyimmuno- compromised clients.B. Bedrestuntilswellingsubsides.C. Fluidsandsoft,blandfood.D. Orchitis: warm or cold packs; light support to scrotum.E. Coolcompressesappliedtoswollenneckarea.

Rubeola (Measles, Hard Measles, Red Measles)CharacteristicsA. Anacuteviraldiseasecharacterizedbyfeveranda rash.B. Incubation:10to20days.C. Transmission:directcontactwithrespiratorydroplet.D. Communicability:4daysbeforerashto5daysafter rash appears.

Data CollectionA. Prodromal:fever,malaise,cold-likesymptoms.B. Koplik’sspots:small,irregularredspotsnoticedonthe buccalmucosaoppositethemolars;usuallyappear2 daysbeforerash.C. Acutephase:begins3to4daysafterprodromalsymp- toms;maculopapularrashbeginsonfaceandgradually spreads downward from head to feet.D. Photophobia,conjunctivitis,andbronchitis.E. Complications:otitismedia,pneumonia,laryngotrache- itis,andencephalitis.

Health Care InterventionsA. Preventive:MMRimmunization(seeFigure2-2,Figure 2-3).MMRshouldnotbegiventopregnantorseverely immunocompromised clients.B. Bedrestuntilfeversubsides,acetaminophenoribupro- fen for fever control.C. Dimlightstodecreasephotophobia.D. Tepidbathsandlotiontorelieveitching.E. Encourageintakeoffluidstomaintainhydration;temperature may spike 2 to 3 days after rash appears.

Rubella (German Measles, Three-Day Measles)CharacteristicsA. Anacute,mildsystemicviraldiseasethatproducesa distinctive 3-day rash and lymphadenopathy.B. Incubation:14to21days.C. Transmission:nasopharyngealsecretions,direct contact.D. Communicability:fromupto7daysbeforerashuntil5 days after rash.

Data CollectionA. Prodromal:low-gradefever,headache,malaise,and symptoms of a cold.B. Rashfirstappearsonfaceandspreadsdowntoneck, arms,trunk,andthenlegs.C. Diagnostics:persistentrubellaantibodytiterof1:8usu- ally indicates immunity.D. Complications:canhaveteratogeniceffectsonfetus.

TABLE 2-3 CENTERS FOR DISEASE CONTROL (CDC) AND PREVENTION HEALTH CARE PERSONNEL (HCP) VACCINE RECOMMENDATIONS

FromCentersforDiseaseControlandPrevention: Healthcare personnel vaccine recommendations, Atlanta, 2009,CenterforDiseaseControlandPrevention. RetrievedOctober,2009,fromhttp://www.immunize.org/catg.d/p2017.pdf.Forrecentupdatesandafullexplanationoffootnotes,refertotheCentersforDiseaseand PreventionWebsiteatwww.cdc.gov.

of disease or immunity (HCP who have an “indeterminate” or “equivocal” level of immunity upon testing should be considered nonimmune) or (b) appropriate vaccination against measles, mumps, and rubella (i.e., 2 doses of live measles and mumps vaccines given on or after the first birthday, separated by 28 days or more, and at least 1 dose of live rubella vaccine).Although birth before 1957 generally is considered acceptable evidence of measles, mumps, and rubella immunity, healthcare facilities should consider recommending 2 doses of MMR vaccine routinely to unvaccinated HCP born before 1957 who do not have laboratory evidence of disease or immunity to measles, mumps, and/or rubella. For these same HCP who do not have evidence of immunity, healthcare facilities should recommend 2 doses of MMR vaccine during an outbreak of measles or mumps and 1 dose during an outbreak of rubella.

Varicella It is recommended that all HCP be immune to varicella. Evidence of immunity in HCP includes documentation of 2 doses of varicella vaccine given at least 28 days apart, history of varicella or herpes zoster based on physician diagnosis, laboratory evidence of immunity, or laboratory confirmation of disease.

Tetanus/Diphtheria/Pertussis (Td/Tdap)All adults who have completed a primary series of a tetanus/diphtheria-containing product (DTP, DTaP, DT, Td) should receive Td boosters every 10 years. As soon as feasible, HCP younger than age 65 years with direct patient contact should be given a 1-time dose of Tdap, with priority given to those having contact with infants younger than age 12 months.

MeningococcalVaccination is recommended for microbiologists who are routinely exposed to isolates of N. meningitidis. Use of MCV4 is preferred for persons younger than age 56 years; give IM. Use MPSV4 only if there is a permanent contraindica-tion or precaution to MCV4. Use of MPSV4 (not MCV4) is recommended for HCP older than age 55; give SC.

References1. See Table 3 in “Updated U.S. Public Health Service Guidelines for the Manage-

ment of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis,” MMWR, June 29, 2001, Vol. 50, RR-11.

For additional specific ACIP recommendations, refer to the official ACIP statements published in MMWR. To obtain copies, visit CDC’s website at www.cdc.gov/vac-cines/pubs/ACIP-list.htm; or visit the Immunization Action Coalition (IAC) website at www.immunize.org/acip.

Hepatitis BHealthcare personnel (HCP) who perform tasks that may involve exposure to blood or body fluids should receive a 3-dose series of hepatitis B vaccine at 0-, 1-, and 6-month intervals. Test for hepatitis B surface antibody (anti-HBs) to document immunity 1–2 months after dose #3. If anti-HBs is at least 10 mIU/mL (positive), the patient is immune. No further serologic testing or vaccination is recommended.

If anti-HBs is less than 10 mIU/mL (negative), the patient is unpro-tected from hepatitis B virus (HBV) infection; revaccinate with a 3-dose series. Retest anti-HBs 1–2 months after dose #3.

– If anti-HBs is positive, the patient is immune. No further testing or vac-cination is recommended.

– If anti-HBs is negative after 6 doses of vaccine, patient is a non-responder. For non-responders: HCP who are non-responders should be considered susceptible to HBV and should be counseled regarding precautions to prevent HBV infection and the need to obtain HBIG prophylaxis for any known or probable parenteral exposure to hepatitis B surface antigen (HBsAg)-positive blood.1 It is also possible that non-responders are persons who are HBsAg positive. Testing should be considered. HCP found to be HBsAg positive should be counseled and medically evaluated.Note: Anti-HBs testing is not recommended routinely for previously vac-cinated HCP who were not tested 1–2 months after their original vaccine series. These HCP should be tested for anti-HBs when they have an exposure to blood or body fluids. If found to be anti-HBs negative, the HCP should be treated as if susceptible.1

Influenza All HCP, including physicians, nurses, paramedics, emergency medical tech-nicians, employees of nursing homes and chronic care facilities, students in these professions, and volunteers, should receive annual vaccination against influenza. Live attenuated influenza vaccine (LAIV) may only be given to non-pregnant healthy HCP age 49 years and younger. Inactivated injectable influenza vaccine (TIV) is preferred over LAIV for HCP who are in close contact with severely immunosuppressed persons (e.g., stem cell transplant patients) when patients require protective isolation.

Measles, Mumps, Rubella (MMR)HCP who work in medical facilities should be immune to measles, mumps, and rubella.

HCP born in 1957 or later can be considered immune to measles, mumps, or rubella only if they have documentation of (a) laboratory confirmation

Healthcare Personnel Vaccination Recommendations

Hepatitis B Give 3-dose series (dose #1 now, #2 in 1 month, #3 approximately 5 months after #2). Give IM. Obtain anti-HBs serologic testing 1–2 months after dose #3.

Influenza Give 1 dose of influenza vaccine annually. Give inactivated injectable influenza vaccine intramuscularly or live attenuated influenza vaccine (LAIV) intranasally.

MMR For healthcare personnel (HCP) born in 1957 or later without serologic evidence of immunity or prior vaccination, give 2 doses of MMR, 4 weeks apart. For HCP born prior to 1957, see below. Give SC.

Varicella For HCP who have no serologic proof of immunity, prior vaccination, or history of varicella disease, (chickenpox) give 2 doses of varicella vaccine, 4 weeks apart. Give SC.

Tetanus, diphtheria, Give all HCP a Td booster dose every 10 years, following the completion of the primary 3-dose series. pertussis Give a 1-time dose of Tdap to all HCP younger than age 65 years with direct patient contact. Give IM.

Meningococcal Give 1 dose to microbiologists who are routinely exposed to isolates of N. meningitidis.

Vaccine Recommendations in brief

Hepatitis A, typhoid, and polio vaccines are not routinely recommended for HCP who may have on-the-job exposure to fecal material.

Adapted from the Michigan Department of Community Health


Health Care InterventionsA. Symptomatic:providetepidbaths,offerfluids frequently,keepchildcool.B. Acetaminophenand/oribuprofenforfevercontrol.

DiphtheriaA. AninfectioncausedbyCorynebacterium diphtheriae.B. Incubationperiod:3to6days.C. Transmission:directcontact,contaminatedarticles (fomites).D. Communicability:variable,usually2weeks,butmay belongerE. Smooth,whiteorgraymembraneovertonsillarregion; hoarsenessandpotentialairwayobstruction.F. Preventive:diphtheria,tetanus,andpertussis(DTaP) immunization(seeFigure2-2,Figure2-3)beginningat 2-4 months of age.

Pertussis (Whooping Cough)A. Anacuteinflammationoftherespiratorytractcaused byBordetella pertussis; is most severe in children under 2 years of age.B. Incubationperiod:6to20days;average,7days.C. Transmission:airdroplet,communicabilityisgreatest beforeonsetofparoxysmsofcoughing.D. Prevention:DTaPimmunization.(seeFigure2-2, Figure2-3)

Health Care InterventionsA. Primarilysymptomatic;bedrestuntilfeversubsides.B. Preventive:MMRimmunization(seeFigure2-2,Figure 2-3).MMRshouldnotbegiventoseverelyimmunosup pressed clients.C. Pregnantwomenshouldavoidcontactwithchildren whohaverubella.Ifnotimmunizedbeforepregnancy, vaccinationshouldnotbegivenuntilcompletionof pregnancy.

Roseola Infantum (Exanthema Subitum)CharacteristicsA. Acommon,acutebenignviralinfection,usuallyoccur- ringininfantsandyoungchildren(ages6monthsto3 years),characterizedbysuddenonsetofahightem- perature,followedbyarash.B. Incubationperiod:usually5to15days.C. Transmission:unknown,generallylimitedtochildren ages 6 months to 3 years.D. Communicability:unknown.

Data CollectionA. Sudden onset of high fever.B. Asfeverdrops,amaculopapular,nonpruriticrashap- pearsabruptly;rashblanchesorfadesunderpressure and disappears in 1 to 2 days.C. Complications:febrileseizures.

fIgUre 2-2 recommended Immunization Schedule for Persons Aged 0-6 years, 2009. For recent updates and a full explanation of footnotes, refer to the Centers for Disease Control and Prevention website, http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable. (From Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices [ACIP], United States, 2009. Retrieved from www.cdc.gov.)


Tetanus (Lockjaw)A. Anacute,veryserious,potentiallyfataldiseasecharac- terizedbypainfulmusclespasmsandconvulsions causedbytheanaerobicgram-positivebacillusClos- tridium tetani.B. Incubationperiod:generallyfrom2daysto2months; averageis10days.C. Transmission:throughapuncturewoundthatiscon- taminatedbysoil,dust,orexcretathatcontainClos- tridiumtetaniorbywayofburnsandminorwounds (e.g.,infectionoftheumbilicusofanewborn).D. Prevention 1. Carefulcleansinganddebridementofwounds. 2. Immunization:DTaP(Figure2-2);adulttetanus toxoid(Td)every10years(seeFigure2-3). 3. Encourageallclientstomaintaincurrentimmuniza- tion.

PoliomyelitisA. Anacute,contagiousdiseaseaffectingthecentral nervous system.B. Incubationperiod:5to35days;average,7to14days.C. Transmission:fecal-oralorpharyngeal-oropharyngeal contact.

D. Communicability:virusinthroatfor1weekafteronset; infeces,intermittentlyfor4to6weeks.E. Preventive:inactivatedpoliovirusvaccine(IPV),(see

Figure2-2,Figure2-3).

Scarlet Fever (Scarlatina)A. GroupAbeta-hemolyticstreptococcalinfectionthat often follows acute streptopharyngitis.B. Incubationperiod:1to7days;average,3days.C. Transmission:directcontactordropletofnasopharyn- geal secretions.D. Communicability:variable,approximately10days.E. Suddenonsetofhighfeverandtachycardia,“straw- berry”tongue.F. Diagnostics:historyofarecentstreptococcalinfection, positiveantistreptolysin-O(ASO)titer,andathroat culture positive for group A beta-hemolytic streptococci.G. Complications:otitismedia,tonsillarabscess,glomeru- lonephritis.H. HealthCareImplications 1. Administrationofafullcourseofpenicillin(or erythromycininpenicillin-sensitiveclients). 2. Encourageintakeoffluidstopreventdehydration duringfebrilephase.

Recommended Adult Immunization ScheduleUNITED STATES · 2009

Note: These recommendations must be read with the footnotes that follow containing number of doses, intervals between doses, and other important information.

VACCINE AGE GROUP 19–26 years 27–49 years 50–59 years 60–64 years >65 years

Tetanus, diphtheria, pertussis (Td/Tdap)1,*

Human papillomavirus (HPV)2,*

Measles, mumps, rubella (MMR)5,*

Influenza6,*

Pneumococcal (polysaccharide)7,8

Hepatitis A9,*

Hepatitis B10,*

Meningococcal11,*

Zoster4

Varicella3,*

3 doses

1 or more doses

2 doses

1 or 2 doses 1 dose

3 doses (females)

Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs

2 doses

1 or 2 doses 1 dose

1 dose

*Covered by the Vaccine Injury Compensation Program.

Figure 1. Recommended adult immunization schedule, by vaccine and age group

Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available at www.vaers.hhs.gov or by telephone, 800-822-7967.Information on how to file a Vaccine Injury Compensation Program claim is available at www.hrsa.gov/vaccinecompensation or by telephone, 800-338-2382. To file a claim for vaccine injury, contact the U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington, D.C. 20005; telephone, 202-357-6400.Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination is also available at www.cdc.gov/vaccines or from the CDC-INFO Contact Center at 800-CDC-INFO (800-232-4636) in English and Spanish, 24 hours a day, 7 days a week.Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

For all persons in this category who meet the age requirements and who lack evidence of immunity (e.g., lack documentation of vaccination or have no evidence of prior infection)

No recommendation Recommended if some other risk factor is present (e.g., on the basis of medical, occupational, lifestyle, or other indications)

1 d o s e a n n u a l l y

Td booster every 10 yrs

fIgUre 2-3 recommended Adult Immunization Schedule, 2009. For recent updates and a full explanation of footnotes, refer to the Centers for Disease Control and Prevention website, http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm#print. (From Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices [ACIP], United States, 2008. Retrieved from www.cdc.gov.)


d. Seeding: a primary tumor sloughs off tumor cellsintoabodycavity,suchastheperitoneal cavity. D. Etiology: 1. Viruses 2. Exposuretocarcinogens:sunlight,radiation,to- baccouse,orchemicalagentscanproducetoxic effectsbyalteringDNAstructureinbodysites distantfromchemicalexposure(e.g.,dyes,asbestos) 3. Genetic and familial factors 4. Hormonalagents:tumorgrowthispromotedby disturbancesinhormonalbalanceofthebody’sown (endogenous)hormonesoradministrationofexog- enoushormones(e.g.,prolongedestrogenreplace- ment,oralcontraceptives).

Prevention A. Cancerprevention. 1. Eatabalanceddietthatincludesfreshfruitsand vegetable,adequateamountoffiber,andade- creased fats and preservatives; avoid smoked and salt-cured foods containing increased nitrates. 2. Avoidexposuretoknowcarcinogens—e.g., cigarettesmokingandsunexposure. 3. Maintainweightinnormalrange 4. Get enough rest and sleep. . 5. Decreasedstress,orperceptionofstress,improves abilitytoeffectivelymanagestress. 6. Regularexercise,encourageleast30minutesof moderatetovigorousexercise5daysaweek. 7. Limitalcoholuse.B. Screeningguidelines—earlydetection. 1. Paptest:screeningshouldbeginwithin3yearsof becomingsexuallyactiveoratage21;thereafter shouldbedoneannuallyorevery2years.Age30, after3normalPaptests,thenPapscreeningevery 3-4 years. 2. Digitalrectalexamination(DRE):DREwith prostate-specificantigenbloodtestshouldbe offeredtomenannuallybeginningatage50. African-American males and those men with strong familyhistoryshouldbeginatage45. 3. Colon:beginningatage50,allclientsshouldhave eitherayearlyfecaloccultbloodtestoraflexible sigmoidoscopyevery5yearsand/orboth,depend- ingontheclient’sriskfactors. 4. Breast:annualmammogramandclinicalbreast exam(CBE)forwomenover40.Womenages20-39 shouldhaveaCBEevery3years.Monthlybreast self-examinationisanoptionforwomenintheir 20s,butdoesnotreplaceneedforCBEor mammogram. 5. Testicularself-examination:monthlyfromage20 to40.

Infectious MononucleosisA. Anacute,self-limitinginfectiousdiseasecausedbythe Epstein-Barrvirus;memberoftheherpesgroupof viruses,occurringmostoftenamongyoungpersons under25yearsold,;oftencalledthe“kissingdisease.”B. Incubationperiod:30-50days.C. Transmission:directorindirectcontactwithoralsecre- tions—intimatecontact,sharingsamedrinkingcup, handtomouth;probablyoralpharyngealroute.D. Onsetofsymptomsoccursanytimefrom10daysto6 weeksafterexposure;maybeacuteorinsidious; malaise,sorethroat,feverwithgeneralizedlymphade- nopathy.E. Diagnostic:apositiveheterophilantibodytest(titerof 1:160isconsidereddiagnostic);positiveMonospottest result.

CAnCer

Characteristics of Cancer Cancer must be regarded as a group of disease ✽

entities with different causes, manifestations, treatment, and prognoses. The basic disease process begins when normal cells undergo change and begin to reproduce in an abnormal manner.

Major Dysfunction in the Cell A. Cellularproliferation:cancercellsdivideinanindis- criminate,unregulatedmanner.B. Thereisalossofcontactinhibition.Thecancercells havenoregardforcellularboundaries;normalcells respectboundariesanddonotinvadeadjacentareasor organs. C. Tumors(neoplasm). 1. Benign: encapsulated neoplasm that remains local- ized in the tissue of origin. a. Exertspressureonsurroundingorgans. b. Willdecreasebloodsupplytothenormaltissue. 2. Malignant:nonencapsulatedneoplasmthatinvades surrounding tissue. The stage of the neoplasm de- termines whether or not metastasis or spread to distantbodypartshasoccurred.Therearefour primarymechanismsbywhichthemetastasis spreads: a. Vascular system: cancer cells penetrate vessels and circulate until trapped. The cancer cells may penetrate the vessel wall and invade adjacent organs and tissues. b. Lymphaticsystem:cancercellspenetratethe lymphaticsystemandaredistributedalonglym- phatic channels. c. Implantation:cancercellsimplantintoabody organ.Certaincellshaveanaffinityfor particularorgansandbodyareas.


Treatment of Cancer A. Diagnostic studies. 1. Chestx-ray. 2. Tissuebiopsy. 3. Radiologicstudies:mammography,ultrasono- graphy. 4. Radioisotopicscans:bone,liver,lung,brain. 5. Spiralcomputedtomography(CT). 6. Cytologystudies(bonemarrowaspiration,urine andcerebrospinalfluidanalysis,cellwashings,Pap smearsandbronchialwashings). 7. Positionemissiontomography(PET)scan. 8. Tumormarkers. 9. Sigmoidoscopyorcolonoscopyexaminations— includingstoolforoccultblood. 10. CBC,chemistryprofile,liverfunctiontests. 11. Bonemarrowexamination(ifhematolymphoid malignancyissuspected).B. Biopsy. 1. Usedfordefinitivediagnosis. 2. Needle:tissuesamplesareobtainedbyaspirationor withalarge-boreneedle. 3. Incisional:tumormassmaybetoolargefor removal;thismaybedoneforstagingthedisease level. Incisional: a scalpel or dermal punch is used toobtainatissuesample. 4. Excisional:involvesremovaloftheentiretumor. 5. Endoscopicbiopsy:directbiopsythroughanendos- copyofthearea(gastrointestinal,respiratory, genitourinarytracts).

Goals of Cancer Therapy A. Cure:clientwillbedisease-freeandlivetonormallife expectancy.B. Control:client’scancerisnotcuredbutcontrolledby therapy over long periods of time. C. Palliative:maintainashighaqualityoflifeforthe clientwhencureandcontrolarenotpossible;neither hastensnorpostponesdeath,butprovidesreliefof symptomsexperiencedbythedyingclient.D. Prophylaxis:providetreatmentwhennotumoris detectablebutwhenclientisknowntobeatriskfor tumordevelopment,spread,orrecurrence.

Modalities of Cancer Treatment A. Surgery:excisionofthetumororextensiveresectionof tumor and surrounding tissue. 1. Evaluateanyadverseeffectsofprevioustreatment andtheirimplicationsforproposedsurgery(e.g., poornutritionalstatusorfibrosisfromeffectsof radiation therapy that may lead to poor wound healing,leukopeniafromchemotherapeuticagents). 2. Evaluateextentofdisfigurementordebilitation causedbysurgeryandconsideritsimpactonclient (e.g.,ostomyformation,amputation).

3. Promote healthful self-image and return to normal lifestylebyrecommendingcancersupportgroups andotherrehabilitationresources.B. Chemotherapy:overallgoalofchemotherapyisto attackthecancercellduringitsmostvulnerablestage. 1. Chemotherapyagentsareadministeredindoses largeenoughtodamageorkillcancercells,but small enough to limit adverse effects to safe and tolerablelevels. 2. Nursingimplicationsinchemotherapy(Table2-4): a. Collectdataonclientforsymptomsofbone marrowdepression(increasedbruisingand bleeding,sorethroat,fever). b. Preventexposureofclienttopeoplewithcom- municablediseases. c. Beforetherapy,establishabaselineregarding intakeandoutput,bowelhabits,oralhygiene, psychologicalstatus,andfamilyrelationships. d. Monitorfluidintakeandoutput;maintainad equate hydration to prevent urinary complications. e. Clienteducation. (1) Clientshouldavoidallover-the-counter (OTC)medicationswhileonchemo- therapy. (2)Iftreatedonanoutpatientbasis,client should not alter dosages and should maintain schedule of administration.

TEST ALERT: Follow procedures when han-dling biohazardous materials (such as sharps,

radioactive sources, and chemotherapeutic materials).

C. Radiationtherapy. 1. The purpose of radiation therapy is to destroy the rapidlydividingcancercells.Cellsthatarerepro- ducing rapidly are more sensitive to the radiation. a.Time:clientcareshouldbecoordinatedtoallow greatestamountofcaretobeprovidedin shortesttimeframepossible. b.Distance:exceptwhengivingdirectcare, attempt to maintain a distance of 6 feet from the source of radiation. c. Shield: some institutions provide lead shielding; generally not necessary if time and distance principlesareobserved. 2. Commonsideeffectsofradiationtherapy.

NURSING PRIORITY: ✔ Adverse effects are related to the radiation dose delivered within a specified time, the method of delivery, and the client’s overall health status.


TABLE 2-4 NURSING IMPLICATIONS AND CHEMOTHERAPYProblem

Bone marrow suppression:Thrombocytopenia(decreasedplatelets)

Anemia(decreasedhemoglobin)

Leukopenia(decreasedwhitecells)

Pulmonarytoxicity

Hyperuricemia(increasedserumlevelsofuricacid)

Alopecia

Stomatitis(mucositis)

GI:anorexia,nauseaandvomiting,diarrhea,andconstipation

Tissueirritation,necrosis,ulceration from infusion therapy

Nursing Implications

1.Initiatebleedingprecautionsandobserveforbleedingtendency(bruising,hematuria,bleedinggums,etc).2. Decrease invasive procedures; minimize injections.

1.Fatigueisnormalwithchemotherapy;clientshouldreportanysignificantincreaseinfatigue.2.Encouragediethighinprotein,calories,andiron;administerironsupplements.

1.Advisehealthcareproviderregardinganyunexplainedtemperatureelevationabove100°F.2.Monitorwhitecell(neutrophil)levels.3.Protectclientfromexposuretoinfections:frequenthandhygiene,locationofroom,screenvisitors,etc.4.SeeGoalsforHome-Care.

1.Monitorforpersistentnonproductivecough,fever,exertionaldyspnea,andtachypnea.2.Medicationsmaybecumulative,pulmonarycomplicationsmaybefatal.

1.Encouragefluidintakeupto3000mLdaily,ifallowed.2.Assessforinvolvementofthekidney,ureters,andbladder.3.Allopurinol(Zyloprim)maybeusedaspreventionorastreatment.

1.Encourageclienttowearsomethingtocoverthescalp(e.g.,wig,scarf,turban,hat).2.Avoidexposureofscalptosunlight.3.Donotrubscalp;donotusehairrollers,hairdryers,curlers,orcurlingirons.4.Hairusuallygrowsbackin3-4weeksafterchemotherapy;isusuallyadifferenttextureand color.

1.Encouragegoodoralhygieneandfrequentoralchecks.a.Encouragefrequentmouthrinsesofsalinesolutiontokeepmucousmembranesmoist.b.Brushteethwithasmall,softtoothbrushaftereverymealandatbedtime.c.Removedenturestopreventfurtherirritation.2.Avoidalcohol,spicyorhotfoods;mechanicalsoft,blanddietmaybeordered.3.Rinsemouthwithantacidsolutionsorviscouslidocaineforpaincontrol.

1. Assist client to maintain good nutrition.a.Discussfoodpreferenceswithclientanddietitian;encouragesmall,frequentmeals.b.Correlatemealswithantiemeticmedications.c.Encouragefamilytoprovideclientwithfavoritefoods.d.Increasecalories,protein,andiron;encouragesupplementalvitamins.2.Monitorhydrationstatusandelectrolyteimbalances.3.Evaluateskinaroundanalareaintheclientwithdiarrhea;preventexcoriation.4.Maybepronetoconstipation—maintainhighfluidandhighfiberintake.5.Monitorweight

1.Monitorinfusionsiteforinfiltration,extravasationandforinfection.2.Extraprecautionsshouldbetakentopreventextravasation(infusionofchemotherapymedicationintosubcutaneoustissue):tapesecurely,assessforbloodreturn,observeforcontinuousflowofIV.


a. Skin reactions. (1)Skinerythema,followedbydrydesquama- tionoftheskininthetreatmentfield. (2) Wetdesquamation,particularlyinareasof skinfolds(breast,perineum,axillary);skin maybeblistered. (3) Lossofhairontheskininthetreatment field. (4) Skinpigmentationanddiscoloration. b. Gastrointestinaldisturbancesaremorepro- nounced when radiation is delivered to area closely associated with the GI tract. c. Cystitiswhenradiationsourceisneartourinary tract. d.Radiationpneumonitis.

3. Nursing implications for a client with an internal radiationsource(implantorsealedsource) (Box2-2): a. Privateroomandbath. b. Aleadcontainerandtongsshouldbepresentin theclient’sroom. c. Ifimplantbecomesdislodged,itshouldbe picked up with the forceps and returned to the lead container. Notify radiation therapist or officerimmediately. d. Observetime,distance,andshieldprecautions. e. Examplesofthistypeofradiationtherapyin- cludeuterineimplants,testicularimplants,or implants used in head and neck tumors. f. Inform all people coming in contact with the clientofthespecificprecautionsnecessary. g. Usebadgesorradiationmonitorsforcaregivers having direct client contact. h. Listontheclient’schart: (1) Typeofradiation. (2) Timeinserted. (3) Anticipatedremovaltime. (4) Specificprecautionsforthetypeofradia- tion used.

NURSING PRIORITY: ✔ Check linens, bedpans, and other items for signs of a dislodged implant. Move client away from implant and use tongs to place it in a protective safety lead container, which should be in the client’s room. Notify radiation therapy department of any problems.

4. Nursing implications for the client receiving systemic radiation therapy. a. Systemicallyadministeredradionuclides(radio- isotopes)maycauseradioactivebodysecretions. b. Maybenecessarytohavethelinensandtrash checkedforradioactivitybeforeremovingthem from the room.

Nursing Interventions v Goal: To maintain client at optimal psychosocial level. A. Encourageverbalization.B. Assist client to understand disease process and therapeutic regimen. C. Includefamilyinthecare.D. Assistclienttocopewithchangesinbodyimagedueto hair loss. 1. Encourageclienttoselectaheadcoveringtheyare comfortablewith(e.g.,wig,turban,scarf,cap). 2. Instruct client with regard to hair care. a. Usemildprotein-basedshampooandconditioner to help prevent hair dryness. b. Adviseclienttoshampooonlyevery3to5days. c. Teachclienttopat,notrub,hairdryaftersham- pooingtoavoidexcessivehandlingofbrittle hair. d. Encourageclienttoavoidexcessivebrushingto prevent tearing or unnecessary manipulation of hair. e. Suggest client sleep on a satin pillowcase to decrease hair tangles and friction. f. Discourageuseofelectrichairdryers,hotrollers orcrimpers,hairclips,sprays,dyes,or permanents to prevent further hair damage. E. Recognizeclient’semotionaloutburstsandangeras part of coping process. F. Encouragemeasurestomaintainego. 1. Allow client to participate in own care and decision- making. 2. Maintainactivelistening. 3. Encouragepersonallifestylechoices(e.g.,clothing, makeup,hobbies).

v Goal: To maintain nutrition. A. Diet: appropriate to age level. 1. Increase calories; increase protein intake. 2. Supplement diet with vitamins. 3. Institutesmall,frequentfeedings. 4. Increasefluidintake. 5. Usebetween-mealsupplements.B. Totalparenteralnutrition(seeChapter13).C. Preventand/ordecreasecomplicationsassociatedwith nutrition. 1. Anorexia. 2. Nausea and vomiting. 3. Stomatitis. a. Follow good oral hygiene after each meal and at bedtime. b. Observeoralmucosadaily. c. Provide nonirritating foods. d. Keepmucousmembranesmoist;encouragefluid intake to prevent dehydration.

v Goal: To maintain normal elimination pattern. A. Provideadequatefluidsandfiberindiettoprevent constipation.


B. Prevent and/or decrease complications of diarrhea. 1. Antidiarrheal medications. 2. Low-residue,high-protein,blanddiet. 3. Evaluatefluidstatus. 4. Prevent anal irritation. a. Thorough cleansing of rectal area with mild soap and water. b. Avoidirritationoftherectalarea. c. Use ointments and sprays to decrease discomfort and promote healing.

C. Preventurinarytractinfections,primarilycystitis. 1. Maintainadequatefluidintake:3000mL/day. 2. Frequentlyassessforsymptomsofcystitis(see Chapter18). 3. Avoidbladdercatheterizationifpossible.D. Minimizeembarrassmentofincontinenceandprovide appropriate hygiene measures.

v Goal: To prevent and/or decrease infectious process. A. Carefullyassessfortemperatureelevationsgreaterthan 100˚Forally.B. Administerantibiotics.C. Maintaingoodpersonalhygiene.D. Childshouldbeisolatedfromcommunicablediseases, especiallychickenpox.E. Frequentlyassessforpotentialinfectiousprocesses –urinarytract,upperrespiratorytract.F. Donotcleanbirdcagesorcatlitterboxes.G. Cookorpeelfruitsandvegetables.

NURSING PRIORITY: ✔ Implement measures to protect the immunocompromised client.

v Goal: To prevent and/or decrease hematological com-plications(seeChapter9).A. Observeforbleedingproblemsassociatedwithbone marrow depression. 1. Increasedbruising. 2. Bleeding gums. 3. Hematuria. 4. Anemia(decreasedhemoglobinlevels). 5. Nosebleed(epistaxis). 6. Presenceofbloodinthestool.

NURSING PRIORITY: ✔ Advise client to use electric razor and a soft-bristle toothbrush, and avoid dental flossing if gums are bleeding.

B. Anemia. 1. Maintainadequaterest;encourageclienttopace activities to avoid fatigue. 2. Assess respiratory and cardiac systems and report changes to RN. 3. Encourageadiethighinprotein,vitamins,andiron.

v Goal: To maintain activity level. A. Encouragedailyactivitiesappropriatetodevelopmental level. B. Assist client to evaluate activity patterns and encourage periods of rest. C. Avoidfatigue.

v Goal: Torelievepain(seeChapter3).A. Evaluateclient’sandfamily’sresponsetopain.B. Evaluatecharacteristicsofpain.

Internal Implant • Provideprivateroomandbath.

• Plancaresominimaltimeisspentintheroom.

• Whenprolongedcareisrequired,usealeadshieldorwear a lead apron.

• Wearafilmbadgetomeasureexposure;donotshare badges.

• MarkontheroomandintheKardexthatpregnant women,infants,andyoungchildrenshouldnotcomein contact with the client during treatment.

• Checkalllinensandmaterialsremovedfromthebed forpresenceofforeignbodiesthatcouldbeasource of radioactivity.

• Keeplong-handledforcepsandleadcontainerinthe room of a client with an implant in place.

• Postnoticeonclient’sdoor–visitsshouldbelimitedto 30minutesperdayandadvisethemtostayabout6feet from the client.

External Radiation • Donotwashoffmarksplacedonclient’sbodyfor purposeofidentifyingareaforexternalradiation.

• Skinreactionsafterradiationtherapymaynotdevelopfor 10to14daysandmaynotsubsideuntil2to4weeksafter treatment.

• Gentlycleanseskinwithamildsoap;donotremoveskin markings.

• Avoidtight-fittingclothing;encourageloose-fittingcotton clothes.

• Avoiddirectsunlightonradiationarea.

• Avoidexposureoftreatmentareatoallheatand/orcold sources(hotbaths,hotwaterbottles,icepacks)

• Donotapplyanyperfumedormedicatedlotionsor creams.

• Adviseclienttoavoidswimmingduringtreatmentperiod; chemicals can irritate the skin.

• Donotusetape,adhesivebandages,cosmetics,lotions, perfumes,powders,ordeodorantsontheskininthe treatmentfield.

• Closelymonitorskinconditiononareawherex-ray treatment is directed.

BOX 2-2 RADIATION SAFETY PRECAUTIONS AND NURSING IMPLICATIONS


C. Promotegeneralcomfort,identifyandimplementnon- pharmacologicapproachestopainrelief(positioning, imagery,hypnosis,etc.).D. Administer medications for pain relief.

v Goal: Torecognizecomplicationsspecifictoradiationand chemotherapy.A. Alopecia. B. Hemorrhagicproblems.C. Gastrointestinaldistress.D. Bonemarrowdepression(myelosuppression).E. Skinreactions.F. Decreased immune response.

Home Care

v Goal: To effectively manage pain to provide client op-timal rest and pain relief.A. Assist client to identify provoking and alleviating factors and adjust environment accordingly.B. Assist client with nonpharmacologic pain therapies (Chapter3).C. Layerpainmanagementstrategiesasneeded;medicate with narcotic and non-narcotic analgesics as necessary.D. Assess effectiveness of therapies and medications and modify as necessary.

v Goal: Todecreaseorlimitexposuretoinfection.A. Limitnumberofpeoplehavingdirectcontactwiththe client.

B. Goodoralhygiene:regularflossingifthereisnobleed- ingproblemandnotissueirritation;softtoothbrush; avoid irritating foods.C. Clientshouldavoidcomingindirectcontactwith animalexcreta(catlitterboxes,birdcages,etc).D. Teach client to take his or her temperature daily and reporttemperatureover100°F(38°C).E. Useantipyreticscautiouslybecausetheytendtomask infection.G. Teachclientaboutradiation-inducedskinreactionsand providenursingcarefortheseskinreactions(Box2-2). 1. Moisturizeskin3to4timesadaywithnonper- fumed,nonmedicatedcreamorlotion. 2. Ifmoistdesquamationoccurs,cleansegentlywith normalsalinesolution;areashouldbegentlypatted dryorair-dried;exposeareastoairfor10to15 minutes three times a day. 3. Avoiduseofperfumes,deodorants,powders,and cosmetics to affected area. 4. Wearloose-fittingcottonclothing;avoidswimming. 5. Ifdrydesquamationispresent,applylotionthatis notperfumed,notmedicated,anddoesnotcontain alcohol.H. Teach client importance of frequent handwashing.

v Goal: To maintain optimum psychosocial functionA. Provideopportunitiesforclienttoexpressfeelings, concerns,andfears.B. Encourageactivity;oneofthebestactivitiesiswalking forabout30minutesataratethatiscomfortable.

Study Questions: Health Implications Across the Life Span

1. Thenursefindstheclient’sradiationimplantinthebed. Whatisthebestnursingaction? 1 Usingtongs,replaceitintheleadcontainerinthe room. 2 Immediately evacuate the client and all others from the room. 3 Wearinggloves,replacetheimplantintothebody cavity. 4 Callradiationcontroltopickuptheimplant.2. Whatimmunizationswillbegiventoaninfantwithin thefirst6months? 1 Varicella,diphtheria,polio,hepatitisB. 2 Diphtheria,pertussis,tetanus,hepatitisB,polio. 3 Polio,measles,mumps,rubella,diphtheria,tetanus. 4 Varicella,measles,mumps,rubella,diphtheria.3. Themotherofanewbornaskswhenshecanbeginto giveherinfantsolidfood.Whatisthebestresponse? 1 Begincerealsat3months;thenbeginfruitsat6 months.

2 Startfruitsasthefirstsolidsat6months,then vegetables. 3 Fruitscanbestartedat3months,followedby cereal. 4 Cerealsarestartedat4-6months,followedbyfruit orvegetables.4. Amotherarrivesattheofficewithher9-month-oldin- fantforawell-babycheck.Whatobservationwould causethemostconcern? 1 Cannotsitalonewithoutsupport. 2 Shows no interest in walking. 3 Anterior fontanel remains open. 4 Does not respond to name. 5. Thenurseunderstandsthatthemajordifferencebe- tweenbenigntumorsandmalignanttumoristhat malignant tumors: 1 Areencapsulatedandimmovable. 2 Grow at a faster rate. 3 Invade adjacent tissue and metastasize. 4 Causedeathwhilebenignonesdonot.


10. Aclientisreceivingchemotherapyforlungcancer.The nurse understands that the mediation can cause renal damage.Whatisanimportantnursingaction? 1 Encouragefluidstoincreasetheacidityofurine. 2 Monitordailyweightanddailyintakeandoutput. 3 Decreasefluidstoreduceedemaformation. 4 Monitorurinalysisforpresenceofbacteria.11. Aclientisonfurosemide(Lasix)forhisheartcondi- tion. What foods would the nurse encourage the client toeat? 1 Breadsandfortifiedcereals. 2 Dried fruits and juices 3 Leafygreenvegetables 4 Leanredmeanandwholegrains.12. A client arrives in the emergency department with a penetrating wound he received while working chopping trees.Whatisanimportantnursingaction? 1 Cleansethewoundwithantibacterialsolution 2 Administergammaglobulinintramuscularly 3 Anticipate notifying poison control for plant toxicology. 4 Determine when client received last tetanus injection.

Answers and rationales to these questions are in the section at the end of the book titled Chapter Study Questions: Answers and Rationales.

6. The nurse understands that there are general adverse effects of antineoplastic drugs. Select all that apply: ______1 Peripheral edema. ______2 Anorexia.______3 Stomatitis. ______4 Increaseinurinespecificgravity.______5 Alopecia. ______6 Nausea. 7. What is important to teach a client regarding self-care duringradiationtherapy? 1 Removeskindyetattoosbetweentreatments 2 Avoidexposuretothesunanddonotremovedye markers 3 Reducecarbohydrateandproteinintakeduring treatments. 4 Decreasefluidintakeandincreasecarbohydrate intake after treatment. 8. Aclientonchemotherapytherapyisexperiencing nauseaandvomiting.Whatisthebestnursingaction? 1 Give antiemetics and monitor hydration. 2 Administer oral care and assess for mouth lesions. 3 Decreasefluidintakeandmonitorrenalfunction. 4 Recorddailyweightandencouragesmallmeals.9. Atwhatagedoesachildbegintodiscriminatebetween themother’sfaceandastranger’sface? 1 One month 2 Sixweeks 3 Four months 4 Thirty weeks

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