Friday, October 27, 2006

N8 quiz 1 notes

These notes for the first N8 quiz from the textbook have been moved to the comments section so as not to bog down the blog.
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2 comments:

Bonnie Boss said...

Thanks Debbie, you are the best! I am trying to stay alive and meet my N10 paper due date!

11/01/2006 5:53 PM
Bonnie Boss said...

Breast cancer

Rate: higher in Caucasian women
Mortality: higher in African-American women
Same frequency of BSE, clinical BE, and mammograms
Black women diagnosed at later stage than white.

Etiology

Cause unk-some factors known to increase risk
Box 6-6 page 139
Risk Factors for Breast Cancer (risk factors are cumulative-the more risk factors present, the greater the likelihood of breast cancer occurring.
Age
Previous history of breast cancer
Family history of breast cancer, especially a mother or sister (rticularly significant if premenopausally)
Early menarche (before age 12 years)
Late menopause (after age 55 years)
Use of estrogen replacement therapy
Daily alcohol use
Obesity after menopause
Previous history of benign breast disease with epithelial hyperplasia
Race (Caucasian women have highest incidence)
High socioeconomic status
Sedentary lifestyle

Most important predictor-age.

Risk increases with age
Most of the other risk factors are menstrual-reproductive cycle (? Due to estrogen/progesterone?)
Fewer menstrual cycles and early childbearing appear to be protective.

Heredity
Most not related
BUT
BRCA1 and BRCA2-demonstrated heredity and mutation in disease

Approx. 5% of CA attributed to heredity and mutation in BRCA 1&2 account for 30-70% of those

Environmental
Exposure to organochlorine and other synthetic chemicals.
Hormonal factors-endogenous and exogenous
Diet
Tobacco
Alcohol
Radiation-doubles cancer risk exp during breast formation-as in teenage years
Magnetic fields

Risk factors ID less than 30% of women who will develop BCA. Increase risk should lead to more frequent screening.

Prevention/protection
Normal weight
Eat more fruits/vegetables
Regular exercise

Breast Cancer Risk Assessment Tool (NCI website)
Some of the risk factors used are in Box 6-7
They are:
Age
Number of first-degree relatives affected
Age of woman at menarche
Age of women at first live birth
Number of breast biopsies
History of abnormal hyperplasia in biopsy specimens

Used to predict the risk of BCA from age 5 years over the lifetime of the women to age 90.

Hormonal therapy
Impossible to draw firm conclusions
Suggested: long term use of estrogen replacement therapy (>10 years) may slightly increase the risk, but the risk decreases after discontinuing use.

Chemoprevention

Tamoxifen-decreases recurrence of BCA in women with prior malignancies. It has occasional serous side effects.
Raloxifene prevents osteoporosis without the possible increased cancer risks of estrogen replacement. May be the choice for women at high risk for both.

Pathophsiology

Genetic alterations in DNA of breast epithelial cells.
Many types of BCA
Alterations in:
Epithelial cells of ductal or lobular tissue, may have been inherited or be spontaneouls.
Can be invasive (infiltrating) on noninvasive (in situ)
Most frequently occurring: invasive ductal carcinoma
Originates in the lactiferous ducts and nvades surrounding breast structures.
Tumor: usually unilateral, not well delineated, solid, nonmobile and nontender

Metastasis: results from seeding of the breast cancer cells into blood and lymph systems: tumors develop n the bones, lungs, brain and liver.

Clinical manifestations and diagnosis

Earliest form can be found on mammogram
90% of all lumps detected by the woman.

Out of 90% only 20-25% are malignant

Over 50% in upper outer quadrant of breast

Most common initial symptom is lump or thickening of breast tissue.

Lump may be hard/soft and spongy

May be wel defined or have irregular borders

May be fixed to skin causing dimple to appear

May have bloody or clear unilateral nipple discharge

Early detection
Decreases mortality rate:
CA smaller
Lesions more localized
Lower % of positive nodes

Table 6-7 Screening Guidelines for Breast Cancer: Detection in Asymptomatic Women
Recommended by the American Cancer Society

AGE (Yr) EXAMINATION FREQUENCY
20-39 Breast self-examination (BSE) Monthly
Clinical breast examination Every 3 years

40 and older BSE Monthly
Clinical breast examination Yearly
Mammography Yearly


Diagnosed by FNA, core needle biopsy, needle localization biopsy using radiologist and surgeon.
Pts need specific information regarding:
Procedures
Duration
Outcome

Major barriers to screening behaviors:
Cost
Lack of access to health care
Lack of availability of mammography services

Cultural factor may influence woman’s decision to participate in screening.

Need tailored messages: culturally sensitive that appeal to the unique concerns, beliefs and reading abilities of target groups

Prognosis

CA theory is that breast cancer is:
Systemic
Micrometastasis could be present at eh initial presentation w/ or w/o nodal involvement
Nodal involvement and tumor size are the MOST significant prognostic criteria for long term survival
Estrogen receptor tumors respond better to therapy and have higher survival rates.

Management

Surgery
Beast reconstruction
Radiation therapy
Adjuvant hormone therapy
Chemotherapy

Surgery:
Lumpectomy
Modified radical mastectomy

Lumpectomy:
Removal of the breast tumor, a small amount of surrounding tissure and a sampling gof axillary lymph nodes.
Usually followed by radiation

Partial mastectomy:
Tylectomy
Wide excision
Quadratectomy or segmental mastectomy

Total (simply)
Removal of all breast tissues, nipple and areola(adillary nodes and pectoraly muscles are NOT removed.
Lumpectomy offers survival rates = modified radical

Modified radical
Removal of entire breast
A sample of axillary lymph node
Spares the pectoral muscles

Radical (rarely performed)
Removes:
Entire breast
Axillary nodes
Pectoral muscles

Mets at time of dx-no mastectomy-removal of breast DOES NOT increase survival

Surgeries lead to body image disturbances secondary to cosmetic changes and perceptions of femininity and sexual image and interest.

Breast reconstruction is an option.

Endometriosis

Characterized by the presence and growth of endometrial tissue outside of the uterus.

Tissue may be implanted on the ovaries, cul-de-sac, uterine ligaments, rectovaginal septum, sigmoid colon, pelvic peritoneum, cervix, and inguinal area
Lesions have been found in the vagina and surgical scars as well as on the vulva, perineum and bladder.
Have also been found in the thoracic cavit, gallbladder and heart

In ovary may be called a “chocolate” cyst secondary to the dark color of the cyst caused by old blood.

Endometrial tissue contains glands and stoma and responds to hormonal stimulation as uterine endometrium but may not be in sync with uterine endometrium.
The tissue grows during the proliferative and secretory phases and bleeds during or immediately after menses—inflammatory response with fibrosis and adhesion on adjacent organ.

Overall incidence:
5-15% in reproductive-age women
30-45% in infertile women
33% in women with chronic pelvic pain

Condition usually develps int eh 3rd or 4th decado of life, has been foun in adolescents with disabling pelvic pain or abnormal vaginal bleeding.

May worsen with repeated cycles or may remain asymptomatic and undiagnosed.
Eventually disappears after menopause

Appears equally in Caucasian, African-American, and Asian women, across all socioeconomic levels and appears to have a familial tendency.

Theories:
The etiology and pathology are poorly understood
Most widely accepted: transplantation or retrograde menstruation
Endometrial tissue is refluxed through the uterine tubes during menstruation in the peritoneal cavity.
Retrograde menstruation has been documented in surgical studies and poss occurs in 96% of menstruation women.

For most women the tissue is destroyed before it can implant or seed.

Symptoms:
Nonexistent to incapacitating
Vary among women
Severity can change over time and may not reflect the extent of the disease

Major symptoms:
Dysmenorrheal
Deep pelvic dyspareunia (painful intercourse)

Sometimes:
Chronic noncyclic pelvic pain
Pelvic heaviness
Pain radiating into thighs
Bowel symptoms
Diarrhea, pain with defecation and constipation caused by avoiding defecation to not cause pain.


Less common symptoms:
Abnormal bleeding (hypermenorrhea, menorrhagia or premenstrual staining
Pain during exercise secondary to adhesions

May result in impaired fertility from adhesion the fix and retrovert the uterus, block the fimbriated ends or prevent the movement that carries the ovum to the uterus, or blocks the end of the tubes.

Management

Based on severity of symptoms and goal of the woman or couple

Women who are:
w/o pain, don’t want pregnancy don’t need treatment.
Mild pain, may want future pregnancy may be limited to NSAIDs


Suppression on endogenous estrogen production and suppression on lesion growth are the corner stones of management

2 main classes on medication used to suppress endogenous estrogen levels:
Gonadoropin-releasing hormone (GnRH) agonists
Androgen derivatives

GnRH agonist therapy: leuprolide or nafarelin
Act by suppressing pituitary gonadotropin secretion

Androgen derivatives:
Suppresses FSH and LH secretion

Surgical intervention:
Needed for sever, acute, or incapacitating symptoms.

In spite of treatment (except for hysterectomy) recurs in approx 45% of women.
Is chronic disease with problem like chronic pain and infertility.

Counseling and education are critical components of nursing care.

Need an honest discussion of treatment options, potential risks and benefits reviewed.

Human Immunodeficiency Virus

Heterosexual transmission is now most common means of infection in women

Women are now the fastest-growing population with HIV infection and AIDS

Between 1985 and 1997 the proportion of women with AIDS tripled.

HIV/AIDS are seen disproportionately in African-American and Hispanic women.

Transmission occurs primarily through exchange of semen, blood, or vaginal secretions (body fulides)

HIV is a retrovirus

Severe depression of the cellular immune system in the presence of the virus constitutes AIDS

For both genders the most common opportunistic diseases are pneumocystis carinii pneumonia, candida, esophagitis, and wasting syndrome.

Viral infections such as HSV and cytomegalovirus infections are more prevalent in women. PID may be severe in HIV-infected women and rates of HPV and cervical dysplasia may be higher.

The course of HPV n women is accelerated and recurrence is more frequent

After infection seroconversion to positive usually occurs w/I 6-12 weeks. May be totally asymptomatic but is usually accompanied by flu like symptoms. Symptoms include fever, headache, night sweats, malaise, generalized, lymphadenopathy, myalgias, nausea, diarrhea, weight loss, sore throat and rash.

Lab: leucopenia, thrombocytopenia, anemia, and an elevated erythrocyte sedimentation rate.

AHIV has an affinity for T lymphocytes which lead to T-cell destruction.

Declining CD4 levels are associated with increased incidence of AIDS-related diseases and death.
Nursing roles: screening, teaching, and counseling regarding risk factor, indications for being tested, and testing.

Risk factors: intravenous drug use, high risk sex partners, multiple sex partners and a previous history of multiple STIs.

Dx: HIV-1 and HIV-2 antibody tests.

First test is with a sensitive screening test- the enzyme immunoassay. (EIA)

Confirmed by a Western blot or an immunofluorenscence assay. If positive the women is infected and can transmit HIV. HIV antibodies are detectable in at least 95% of patients w/I 3 months after infection

HIV antibody crosses the placenta, dx of HIV in children younger than 18 months is based on lab evidence of HIV in blood or tissues by culture, nucleic acid or antigen detection.

CDC guideline: offer HIV testing to all women whose behavior places them at risk for HIV infection.

Counseling for HIV testing

Counseling before and after HIV testing is standard nursing practice.

Assess:
Understanding of the information such a test would provide and help the patient thoroughly understand the emotional, legal, and medical implication of a positive or negative test before the test.
Think about the stigma associated with HIV infection and the quality of life with a positive dx.

Pregnancy is not encouraged for HIV positive women. Evidence indicates that 15% and 25% of infants born to untreated HIV-infected women are infected with HIV, 12%-14% are infected by breast milk when breastfeeding for longer than 1 year.

All pregnant women should be offered counseling and testing. Early treatment can reduce perinatal transmission and help the woman stay healthy.

Administration of antiretroviral prophylaxis had reduced the perinatal transmission.

Treatment of pregnant women and treatment of newborns has reduced a 66% decrease in trials.
Factors that influence transmission to the fetus: length of time membranes are ruptured before birth, mode of birth, duration of labor (es. Prolonged second stage expulsion efforts), increased maternal viral load levels, multiple births.

Exposure to cervical and vaginal secretion is the mechanism of transmission suspecete rather than in utero exposure. C-sections help prevent that.

Legal Tip: HIV testing. If test results are placed in the woman’s chart-the appropriate place for all health information-they are available to all who have access to the chart. The woman must be informed of this before testing. Informed consent must be obtained before an HIV test is performed. In some states written consent is mandated. All pretest and posttest counseling should be documented. From the book, p. 132

Generall 1-3 week wait for test result, reassure pt that is normal.

Test results must be communicated in person and the pt should know this in advance.

Some women, given negative results, accelerate or engage in risk taking behaviors. Think “negative” means “immune”/ Some may think that negative is bad and positive is good. Provide education. Emphasis on how to remain HIV free.
Management
Contact with HIV-infected woman, establish what the woman knows about HIV infection. Find out if she is seeing a doctor or hospital with expertise in HIV. Referral to psych counseling may be indicated, financial assistance may be needed, suicide prevention, death and dying and legal advocacy may also be needed.

Contraceptive: Positive test should use 1.) oral contraceptives and latex condoms or 2.) tubal sterilization or vasectomy and latex condoms.

No cure is available, rare and unusual diseases are characteristic of HIV. Manage them vigorously with infection or disease specific treatments. Screen for syphilis, gonorrhea, Chlamydia, and other vag infection.

Further information: website of CDC.

11/14/2006 12:03 AM

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