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Research for queens park common cases


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Research for queens park common cases

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Research for queens park common cases

  1. 1. Research for Queens Park common cases: PATH-MED (Patient Assessment to Home Medicine) > Common cases are related to musculoskeletal and neurovascular complications. > Most of the patients in Queens Park comes from the Royal Columbian Hospital and Surrey Memorial Hospital.Itismore of a rehabilitationcenterweremostof the patientstayforlongerperiodof time itcan even rich to a month or longer. > Every shift they have only 1 RN and all of them are LPN’s. My preceptor Irene Askew is an LPN. They need to communicate withthe RN if there are nursing skills that are not belong in the scope of practice for LPN’s. 1. Fracture What Are Fractures? A fracture is the medical term for a broken bone. There are many types of fractures,but the maincategories are displaced, non-displaced, open, andclosed. Displaced and non-displaced fractures refer to the way the bone breaks. Ina displacedfracture,thebonesnapsintotwoormore partsandmovessothatthe twoendsare notlined up straight. If the bone is inmanypieces,it iscalleda comminuted fracture. Ina non-displaced fracture,the bone cracks either part or all of the way through, but does move and maintains its proper alignment. A closedfractureiswhenthebonebreaksbutthereisnopunctureor openwoundintheskin.Anopenfracture isone inwhichthe bone breaksthroughtheskin;itmaythen recedebackintothe woundandnotbe visible throughtheskin.Thisisanimportantdifferencefromaclosedfracturebecausewithanopenfracturethereis a risk of a deep bone infection. Some fracture types are:  A Greenstickfractureisanincompletefractureinwhichtheboneisbent.Thistypeoccursmostoften in children.  A transverse fracture is when the broken piece of bone is at a right angle to the bone's axis.  An oblique fracture is when the break has a curved or sloped pattern.  A comminuted fracture is when the bone breaks into several pieces.  A buckledfracture,alsoknownasanimpactedfracture,isonewhoseendsaredrivenintoeachother. This is commonly seen in arm fractures in children.  A pathologic fracture is caused by a disease that weakens the bones.  A stress fracture is a hairline crack. The severity of a fracture depends upon its locationand the damage done to the bone and tissue near it. Serious fracturescan have dangerouscomplications if not treated promptly; possible complications include damage to blood vessels or nerves and infection of the bone (osteomyelitis) or surrounding tissue. Recuperation time varies depending on the age and health of the patientand the type of fracture. A minor fracture inachildmayhealwithinafewweeks;aseriousfractureinanolderpersonmaytakemonthstoheal. What Are the Symptoms of a Broken Bone? Signs and symptoms of a broken bone include:  Swelling or bruising over a bone  Deformity of an arm or leg  Pain in the injured area that gets worse when the area is moved or pressure is applied  Loss of function in the injured area  In open fractures, bone protruding from the skin Fractures are usually caused by a fall, blow, or other traumatic event.
  2. 2. Pathologicfracturesarethose causedbydisease (suchas cancer)thatweakensthe bonesandcanoccurwith littleornotrauma. Osteoporosis,adisorderinwhichthebonesthinandlose strengthastheyage,causes1.5 million fractures each year in the U.S. -- especially in the hip, wrist, and spine. Fall prevention: Simple tips to prevent falls 1. Make an appointment with your doctor Begin your fall-prevention plan by making an appointment with your doctor. Be prepared to answer questions such as:  What medicationsare youtaking? Make a listof your prescriptionandover-the-countermedications and supplements, or bring them with you to the appointment. Your doctor can review your medications for side effects and interactions that may increase your risk of falling. To help with fall prevention,yourdoctor may considerweaningyouoff certainmedications — such as sedativesand some types of antidepressants.  Have youfallenbefore? Writedownthe details,includingwhen,whereand how youfell.Be prepared to discuss instances when you almost fell but were caught by someone or managed to grab hold of something just in time. Details such as these may help your doctor identify specific fall-prevention strategies.  Couldyourhealthconditionscause afall? Certaineye andeardisordersmayincreaseyourriskof falls. Be prepared to discuss your health conditions and how comfortable you are when you walk — for example,doyoufeel anydizziness,jointpain,numbnessorshortnessof breathwhenyouwalk?Your doctor may evaluate your muscle strength, balance and walking style (gait) as well. 2. Keep moving Physical activitycango a longway towardfall prevention.Withyourdoctor'sOK,consideractivitiessuch as walking, water workouts or tai chi — a gentle exercise that involves slow and graceful dance-like movements. Such activities reduce the risk of falls by improving strength, balance, coordination and flexibility. If you avoid physical activity because you're afraid it will make a fall more likely,tell your doctor. He or she may recommend carefully monitored exercise programs or refer you to a physical therapist. The physical therapist can create a custom exercise program aimed at improving your balance, flexibility, muscle strength and gait. 3. Wear sensible shoes Considerchangingyourfootwearaspartof yourfall-preventionplan.Highheels,floppyslippersandshoes with slick soles can make you slip, stumble and fall. So can walking in your stocking feet. Instead wear properly fitting, sturdy shoes with nonskid soles. 4. Remove home hazards Take a look around your home. Your living room, kitchen, bedroom, bathroom, hallways and stairways may be filled with hazards. To make your home safer:  Remove boxes, newspapers, electrical cords and phone cords from walkways.  Move coffee tables, magazine racks and plant stands from high-traffic areas.  Secure loose rugs with double-faced tape, tacks or a slip-resistant backing — or remove loose rugs from your home.  Repair loose, wooden floorboards and carpeting right away.  Store clothing, dishes, food and other necessities within easy reach.  Immediately clean spilled liquids, grease or food.  Use nonslip mats in your bathtub or shower. 5. Light up your living space Keep your home brightly lit to avoid tripping on objects that are hard to see. Also:  Place night lights in your bedroom, bathroom and hallways.
  3. 3.  Place a lamp within reach of your bed for middle-of-the-night needs.  Make clear paths to light switches that aren't near room entrances. Consider trading traditional switches for glow-in-the-dark or illuminated switches.  Turn on the lights before going up or down stairs.  Store flashlights in easy-to-find places in case of power outages. 6. Use assistive devices Your doctor might recommend using a cane or walker to keep you steady. Other assistive devices can help, too. For example:  Hand rails for both sides of stairways  Nonslip treads for bare-wood steps  A raised toilet seat or one with armrests  Grab bars for the shower or tub  A sturdyplasticseatforthe showerortub — plusa hand-heldshowernozzleforbathingwhilesitting down If necessary,askyourdoctorforareferral toanoccupational therapist.He orshe canhelpyoubrainstorm otherfall-preventionstrategies.Some solutionsare easilyinstalledandrelativelyinexpensive.Othersmay require professional help or a larger investment. If you're concerned about the cost, remember that an investment in fall prevention is an investment in your independence. 2. Dementia Dementia is a general term for a decline in mental ability severe enough to interfere with daily life. Memorylossisan example.Alzheimer'sisthe mostcommontype of dementia. Dementiaisnotaspecific disease.It'sanoveralltermthatdescribesawide range of symptomsassociatedwithadeclineinmemory or other thinking skills severe enough to reduce a person's ability to perform everyday activities. Alzheimer'sdiseaseaccountsfor60to80percentof cases. Vasculardementia,whichoccursafterastroke, isthe secondmostcommondementiatype.Butthereare manyotherconditionsthatcancause symptoms of dementia, including some that are reversible, such as thyroid problems and vitamin deficiencies. Dementia is often incorrectly referred to as "senility" or "senile dementia," which reflects the formerly widespread but incorrect belief that serious mental decline is a normal part of aging. While symptoms of dementia can vary greatly, at least two of the following core mental functionsmust be significantly impaired to be considered dementia:  Memory  Communication and language  Ability to focus and pay attention  Reasoning and judgment  Visual perception  People withdementia may have problems withshort-term memory, keeping track of a purse or wallet,payingbills,planningandpreparingmeals,rememberingappointmentsortravelingoutof the neighborhood.  Many dementiasare progressive,meaningsymptomsstartoutslowlyandgraduallygetworse.If you or a loved one is experiencing memory difficulties or other changes in thinking skills, don't ignore them. See a doctor soon to determine the cause. Professional evaluation may detect a treatable condition.Andevenif symptomssuggestdementia,earlydiagnosisallowsa personto getthe maximumbenefitfromavailabletreatmentsandprovidesanopportunityto volunteerfor clinical trials or studies. It also provides time to plan for the future. Causes
  4. 4. Dementia is caused by damage to brain cells. This damage interferes with the ability of braincellstocommunicate witheachother.Whenbraincellscannotcommunicate normally, thinking, behavior and feelings can be affected. The brainhasmanydistinctregions,eachofwhichisresponsiblefordifferentfunctions (forexample,memory,judgmentandmovement).Whencellsinaparticularregionare damaged, that region cannot carry out its functions normally. Differenttypesof dementiaare associatedwithparticulartypesof braincell damage inparticularregions of the brain.For example,inAlzheimer'sdisease,highlevelsof certainproteinsinside andoutside brain cells make it hard for brain cells to stay healthy and to communicate with each other. The brain region calledthe hippocampusisthecenterof learningandmemoryinthebrain,andthe braincellsinthisregion are often the first to be damaged. That's why memory loss is often one of the earliest symptoms of Alzheimer's. While mostchangesinthe brainthat cause dementiaare permanentandworsenovertime,thinkingand memory problems caused by the following conditions may improve when the condition is treated or addressed:  Depression  Medication side effects  Excess use of alcohol  Thyroid problems  Vitamin deficiencies Diagnosis of dementia There isnoone testtodetermineif someone hasdementia.Doctorsdiagnose Alzheimer'sandothertypes of dementia based on a careful medical history, a physical examination, laboratory tests, and the characteristic changes in thinking, day-to-day function and behavior associated with each type. Doctors can determine thata personhasdementiawithahighlevel of certainty.Butit'sharderto determinethe exact type of dementiabecause the symptomsandbrainchangesof differentdementiascan overlap.In some cases,a doctor may diagnose "dementia"andnotspecifya type.If thisoccurs it may be necessary to see a specialist such as a neurologist or gero-psychologist. Dementia treatment and care Treatment of dementia depends on its cause. In the case of most progressive dementias, including Alzheimer'sdisease,there isnocure and no treatmentthatslowsor stopsits progression.Butthere are drug treatments that may temporarily improve symptoms. The same medications used to treat Alzheimer's are among the drugs sometimes prescribed to help with symptoms of other types of dementias. Non-drug therapies can also alleviate some symptoms of dementia. Ultimately,the pathtoeffectivenewtreatmentsfordementiaisthroughincreasedresearchfundingand increased participation in clinical studies. Right now, volunteers are urgently needed to participate in more than 180+actively enrolling clinical studies and trials about Alzheimer's and related dementias. Dementia risk and prevention Some riskfactorsfordementia,suchas age andgenetics,cannotbe changed.Butresearcherscontinue to explore the impact of other risk factors on brain health and prevention of dementia. Some of the most active areas of research in risk reductionand prevention include cardiovascular factors, physical fitness, and diet. Cardiovascular risk factors: Your brain is nourished by one of your body's richest networks of blood vessels. Anything that damages blood vesselsanywhere in your body can damage blood vessels in your brain,deprivingbraincellsofvitalfoodandoxygen.Bloodvessel changesinthe brainare linkedtovascular dementia. They often are present along with changes caused by other types of dementia, including Alzheimer'sdisease anddementiawithLewybodies.These changesmayinteractto cause fasterdecline or make impairmentsmore severe.Youcanhelpprotectyourbrainwithsome of the samestrategiesthat
  5. 5. protect your heart – don't smoke; take steps to keep your blood pressure, cholesterol and blood sugar within recommended limits; and maintain a healthy weight. Physical exercise:Regularphysical exercise mayhelplowerthe riskof some typesof dementia.Evidence suggests exercise may directly benefit brain cells by increasing blood and oxygen flow to the brain. Diet: What you eat may have its greatest impact on brain health throughits effect on heart health. The best current evidence suggests that heart-healthy eating patterns,such as the Mediterraneandiet,also mayhelpprotectthe brain.A Mediterraneandietincludesrelativelylittleredmeatandemphasizeswhole grains, fruits and vegetables, fish and shellfish, and nuts, olive oil and other healthy fats. 3. Parkinson a. What isParkinson’s diseaseandwhatcausesit? Parkinson's disease is a chronic, degenerative neurological disorder that affects one in 100 people over age 60. While the average age at onset is 60, some people are diagnosed at 40 or younger. There is no objective test, or biomarker, for Parkinson's disease, so the rate of misdiagnosis can be relatively high, especiallywhenthe diagnosisismade by a non-specialist.Estimatesof the numberof people livingwith the disease therefore vary, but recent research indicates that at least one million people in the United States, and more than five million worldwide, have Parkinson's disease. Parkinson's disease was first characterized extensively by an English doctor, James Parkinson, in 1817. Today, we understand Parkinson's disease to be a disorder of the central nervous system that results from the loss of cells in various parts of the brain, including a region called the substantia nigra. The substantia nigra cells produce dopamine,achemical messengerresponsiblefortransmittingsignalswithinthe brainthatallow for coordinationof movement.Lossof dopamine causesneuronsto fire withoutnormal control,leaving patients less able to direct or control their movement. Parkinson's disease is one of several diseases categorized by clinicians as movement disorders. The exact cause of Parkinson's disease is unknown, although research points to a combination ofgenetic and environmental factors.If a continuum existed, with exclusively genetic causes at one end and exclusivelyenvironmental causes at the other, different Parkinson'spatientswouldlikelyfallatmanydifferentplacesalongthatcontinuum. Inthe past 10 years, researchers have identifieda number of rare instances where Parkinson's disease appears to be caused by a single geneticmutation.Inthese cases,the mutatedgene is passedfromgenerationto generation, resultingina great numberof Parkinson'sdisease caseswithinanextendedfamily.Onthe opposite end of the continuum, in the early 1980s, a group of heroin users in California took drugs from a batch contaminated with a substance called MPTP. After ingesting this chemical,the drug users were stricken with a form of Parkinson's disease that was primarily, if not exclusively, "environmental" in origin. For most Parkinson's patients, the cause lies somewhere in the middle. While many Parkinson's patients reportone or more familymemberswiththe disease,itisnotalwaysclear that one or several genesare the cause. Similarly, while some patients suspect that exposure to one or another chemical or environmental toxincausedtheirParkinson'sdisease,thisalsocannot be conclusivelyproved.Scientists currently believe that in the majority of cases, genetic and environmental factors interact to cause Parkinson'sdisease.Researchintothissubjectcontinuesaggressivelyeveryday.Unfortunately,however, it is generally impossible to determine what specifically caused an individual's Parkinson's disease. b. What are the riskfactors forParkinson’sdisease?Isthere anythingthatcan be done to reduce the risk? Because the causes of Parkinson's disease are unknown, there is no scientifically validatedpreventive course to reduce the risk of its onset. The single biggest risk factor for Parkinson's disease is advancing age. Men have a somewhat higher risk than women.
  6. 6. That being said, a number of studies have highlighted factors that are associated with either greater or lesserriskof Parkinson's disease.Forexample,smokingandcaffeine consumptionhave beenassociated with lower rates of Parkinson's disease, while head injury and pesticide exposure have been associated withhigherrisk.WhilesuchstudiesdonotdefinitivelylinkthesefactorswithParkinson'sdiseaseone way or another, they highlight areas where further research may guide us to risk-prevention or treatment strategies. c. How isParkinson’sdiseasediagnosed? The cardinal symptoms of Parkinson's disease are resting tremor, slowness of movement (bradykinesia) andrigidity.Manypeoplealsoexperience balanceproblems(postural instability).These symptoms,which often appear gradually and with increasing severity over time, are usually what first bring patients to a neurologist for help. Typically, symptoms begin on one side of the body and migrate over time to the otherside. Thereisnoobjectivetest(suchas abloodtest,brainscanorEEG) tomake adefinitivediagnosis of Parkinson's disease. Instead, a doctor takes a careful medical history and performs a thorough neurological examination, looking in particular for two or more of the cardinal signs to be present. Frequently, the doctor will also look for responsiveness to Parkinson's diseasemedications as further evidence thatParkinson'sisthe correct diagnosis.(However,startingonmedicationrightawaycan limit your ability to participate in clinical trials that urgently need newly-diagnosed Parkinson's patients.) In 2011, the Foodand Drug Administration(FDA) approvedaspecializedimagingtechnique calledDaTscan that allowsdoctorsto capture detailedpicturesof the dopamine systeminyourbrain.It is the first FDA- approved diagnostic imaging technique for the assessment of movement disorders such as Parkinson's disease. DaTscan alone can't diagnose Parkinson's disease by itself, but it can help confirm a physician's clinical diagnosis -- something that has never been possible before. Unfortunately, because there is no definitive testforParkinson'sdisease,andbecause Parkinson'sdisease symptomsare similartothose of other neurological conditions, the misdiagnosis rate remains significant. It is worthwhile to consider a second opinion, and to reach out to a neurologist with specific expertise in movement disorders. d. What are the range of symptomsforParkinson’sdisease? People are generally most familiar with the motor symptoms of Parkinson's disease, since they are the mostexternallynoticeable.Thesesymptoms,which are alsocalledthe"cardinal"symptomsof Parkinson's disease,are restingtremor,slownessof movement(bradykinesia),postural instability(balanceproblems) and rigidity.Some otherphysical symptomssuch asgait problemsandreducedfacial expressionare also of note. These are due to the same discoordination of movement that causes the better-knowntremor and slowness. There is also increasing recognition of the importance of other Parkinson's disease symptomsthatare sometimescalled"non-motor"or"dopamine-non-responsive."While neitherof these terms is ideal, these symptoms are common and can have a major impact on Parkinson's patients.For example, cognitiveimpairment, rangingfrommildmemorydifficultiesto dementia,andmooddisorders, such as depression and anxiety, occur frequently. Also common are sleep difficulties, loss of sense of smell,constipation,speechandswallowingproblems,unexplainedpains,droolingandlow bloodpressure when standing. Parkinson's disease symptoms manifest differently in different patients. Many patients experience some symptomsandnotothers,andeventhe pace at whichthe disease worsensvariesfrom person to person. e.Will I die fromParkinson’sdisease? Most doctors say that Parkinson's disease itself is not fatal. You die with Parkinson's disease, not from it. However, as symptoms worsen they can cause incidents that result in death. For example, in advanced cases, difficulty swallowing can cause Parkinson's patients to aspirate food into the lungs, leading to pneumonia or other pulmonary conditions. Loss of balance can cause falls that result in serious injuries or
  7. 7. death. The seriousness of these incidents depends greatly on the patient's age, overall health and disease stage. f. How can I help speed a cure? A Parkinson's disease diagnosis is life changing, and at times, it can feel as if things are spinning out of control. One way to regain control is to get involved in the search for a cure by volunteering for clinical research.Volunteersare vitallyneededforclinical studies,whichare the lastandcritical stage of research before new treatments are brought to market. There is a particular need for newly-diagnosed patients and for people who don't have Parkinson's disease (referred to as "controls"). Additionally, learn aboutPPMI (Parkinson'sProgressionMarkersInitiative),aclinical studytofindbiomarkersof Parkinson's disease.Currently,yourdoctordependsonthe descriptionyouprovide of yoursymptomsandtheirown examinationinmakingdecisionsregardingyourdiagnosisandmanagement.Imagine havinganobjective markertheycoulduse instead,muchlike aglucose measurementinthe managementof diabetes.That's the goal of PPMI. Whetheryouyourselfare facingthe challenge of Parkinson'sdisease,orare touchedby the disease inanotherway,everysingle personcan playa role in the search for a cure.The answeris in all of us. 4. Hepatitis C What Is Hepatitis C? This infectionof the liveriscausedby the hepatitisCvirus.About3.5 millionpeople inthe U.S.have the disease. But it causes few symptoms, so most of them don't know. There are many formsof the hepatitisC virus.The mostcommoninthe U.S.istype1.None ismore serious than any other, but they respond differently to treatment. What Are the Symptoms? Many people with Hepatitis have no symptoms. But you could notice these:  Jaundice (a condition that causes yellow eyes and skin, as well as dark urine)  Stomach pain  Loss of appetite  Nausea  Fatigue How Do You Get It? The virus spreads through the blood or body fluids of an infected person. You can catch it from:  Sharing drugs and needles  Having sex, especially if you have an STD, an HIV infection, several partners, or have rough sex  Being stuck by infected needles  Birth -- a mother can pass it to a child Hepatitis C isn’t spread through food, water, or by casual contact. Who Gets It? The CDC recommends you get tested for the disease if you:  Received blood from a donor who had the disease.  Have ever injected drugs.  Had a blood transfusion or an organ transplant before July 1992.  Received a blood product used to treat clotting problems before 1987.  Were born between 1945 and 1965.  Have been on long-term kidney dialysis.  Have HIV.  Were born to a mother with hepatitis C.
  8. 8. How Is It Diagnosed? You can get a blood test to see if you have the hepatitis C virus. Are There Any Long-Term Effects? Yes. About75% to 85% of people whohave it developalong-terminfectioncalled chronichepatitisC.It can leadto conditionslikelivercancerandcirrhosis,orscarringof the liver.Thisisone of the topreasons people get liver transplants. How Is It Treated? Hepatitis C treatments have changed a lot in recent years. In January 2016, the FDA gave approval to a once-daily pill combinationof elbasvir and grazoprevir called Zepatier. It has been shown to have the ability to cure the disease in almost 100% of those treated. It follows the success of another once-daily treatment called Harvoni that cures the disease in most people in 8-12 weeks. Harvoni combines two drugs: sofosbuvir (Sovaldi) and ledipasvir. In clinical trials, the most common side effects in both drugs were fatigue and headache. How Is It Treated? continued... Other fairly recent drugs are ombitasvir-paritaprevir-dasabuvir-ritonavir(Viekira Pak), ombitasvir-paritaprevir- ritonavir(Technivie)anddaclastasvir(Daklinza) whichdonotrequire interferonandcure more people in lesstime. Ombitasvir-paritaprevir-dasabuvir-ritonavirandombitasvir-paritaprevir-ritonavircarryan FDA warning of severe liver injury if given to someone with underlying severe liver disease. All of these medicines are quite expensive. Instead, your doctor could recommend a combination of boceprevir(Victrelis), simeprevir (Olysio), sofosbuvir (Sovaldi), or ), or telaprevir (Incivek) with interferon (which you take by injection), and ribavirin(which comes as a liquid, tablet, or capsule). Interferon and ribavirin used to be the main treatments for hepatitis C. They can have side effects like fatigue, flu-like symptoms, anemia, skin rash, mild anxiety, depression,nausea, and diarrhea. Your treatmentwill dependonmanythingsincludingwhattype of hepatitisCvirusyouhave. Inthe U.S., the mostcommontype isgenotype 1,followedbygenotypes2and3. Genotypes4,5,and 6 are veryrare in the U.S. Your doctor will help you figure out what's right for you, based on your medical needs and insurance coverage. What Are the Side Effects? The most common effects of hep C drugs are:  Flu-like symptoms  Fatigue  Hair loss  Low blood counts  Trouble thinking  Nervousness  Depression Can You Prevent Hepatitis C Infection? There’s no vaccine to prevent hepatitis C. To avoiding getting the virus:  Use a latex condom every time you have sex.  Don't share personal items like razors.  Be careful if yougeta tattoo,bodypiercingor manicure.The equipmentmayhave someone else'sblood on it.  Don't donate blood or tissue if you’re infected. 5. Cytotoxic Precaution (Antineoplastic Drugs) What are cytotoxic drugs?
  9. 9. Cytotoxicdrugsinhibitorpreventthe functionof cells.Cytotoxicdrugsare primarilyusedtotreatcancer, frequently as part of a chemotherapy regime. Recently, their uses have expanded to treat certain skin conditions (e.g., psoriasis),rheumatoid and juvenile rheumatoid arthritis, and steroid-resistant muscle conditions. The most common forms of cytotoxic drugs are known as antineoplastic. The terms ‘antineoplastic’ and ‘cytotoxic’ are often used interchangeably. Cytotoxicdrugscanpreventthe rapidgrowthanddivisionof cancercells.Theycanalsoaffectthe growth of otherquickdividingcellsinthe body,like hairfolliclesandthe liningof the digestivesystem.Asaresult of the treatment, many normal cells are damaged along with the cancer cells. There are no exposure limits set for cytotoxic drugs. CUPE’s position is that even low-level exposure to cytotoxicdrugsshouldbe avoided.The onlysafeoccupational exposure tocytotoxicdrugsisno exposure. What are the risks of occupational exposure to cytotoxic drugs? The toxicityof cytotoxicdrugscan make themdangerousto people whohandle them.Healtheffectsare well documented.Studiesshowfrequentlydetectablelevelsof cytotoxicdrugsinthe airof hospital areas where the drugs are prepared without proper biological safety cabinets. Health care workers preparing the drugs without adequate precautions have tested positive for cytotoxic drugs in their urine. Exposure to cytotoxicdrugs has beenreportedto cause increasedfrequencyof chromosome damage in exposed workers.1 Theycan cause acute skin, eye,and mucous membrane irritations, as well as nausea, headaches, and dizziness. Cytotoxic drugs have also been associatedwith negative health effects for developing fetuses,including higher incidences of spontaneous abortions, congenital malformations, low birth weight, and infertility. As part of any cytotoxicexposure reductionplan,protective reassignmentfora workerwho ispregnant, breastfeeding or intends to conceive a child must be put in place. Repeated long-term occupational exposure to small amounts of cytotoxic drugs has not been identified to cause of cancer. However, many cytotoxic drugs are known to be:  Genotoxic: a substance that damages DNA. Such damage can lead to the growth of a malignant tumor.  Carcinogenetic: a substance that may cause mutations leading to the developmentof tumors in otherwise healthy cells.  Mutagenic: a substance that alters the DNA of a living being, increasing the likelihood of a mutation. Who is at risk? Anyone who works withpatients receiving cytotoxic drugs is at risk of exposure,and must be protected while working withcytotoxic drugs. Exposure may occur when preparing,administering, or transporting drugs, handling patient waste, transporting and disposing of waste, or cleaning spills. If at any time there is skincontact withany cytotoxicdrug, the affectedworkershouldthoroughlywash the affectedareawithsoap and water.The workershouldnotscrape or abrade the skinbyusinga scrub brushas thiscouldincrease exposure.If eyecontacthasoccurred,flushthe affectedeye(s),while holding back the eyelid(s),withcopiousamountsof waterforatleast15 minutes.Afteranytype of exposure,itis always recommended to seek a medical evaluation by a physician. Training and information All staff whomay handle cytotoxicdrugsor waste by-productscreatedbytheiruse,includingphysicians, nurses, assistants, pharmacists, stores and receiving personnel, housekeeping and maintenance staff should receive training. Management and the health and safety committee should develop specific pre- employmentworkertrainingproceduresforthe properhandling,mixing,anddisposal of cytotoxicdrugs and waste by-products. These training procedures should:  Be written, posted, and available to all employees.  Explain how training is developed, delivered, and evaluated.  Describe the roles of supervisors to ensure proper regulations are followed.
  10. 10. A complete training program should cover the following topics:  Hazards of cytotoxic drugs  Methods of preparation  Use and disposal procedures  Patient care  Proper use of protective equipment  Spill procedures  Maintenance of the facilities and equipment The department responsible for cytotoxic drugs should maintain a record of information on toxicity, exposure treatment procedures,solubility, stability, and general descriptions of the appearance of all cytotoxicdrugs that are used in the facility.Thisrecord shouldbe easilyaccessible andavailable tostaff who may come into contact with cytotoxic drugs. Drug preparation and reconstitution Cytotoxicdrugsshouldonlybe preparedbypersonnel withthe propertraininginacentralizeddedicated location. The hierarchy of hazard control should be put into effect to control the hazard as much as possible. 1. Engineering controls The followingengineeringcontrolsshouldbe put in place where cytotoxic medications are being used: 1. A minimum of a Class II biological safety cabinet with HEPA filter exhaust systemsthat does not allowairto be circulatedback intothe room shouldbe usedwhilemanipulatingcytotoxic drugs. 2. The preparation area within the cabinet should be covered with a plastic backed, absorbent material to reduce dispersion and facilitate the clean-up of any spilled medication. 3. Medicationsshouldbe isolatedandlockedoutinsucha mannerthat onlythose properlytrained have access to the storage location. 4. CSA approved,puncture proof containersforthe disposal of needles,syringesandvialsmustbe provided. Labelled,sealable refuse bagsforthe puncture proofcontainersshouldalsobe available inthe preparationarea.Contaminatedneedles,syringes,andvialsshouldbe disposed of intact. 5. Negative pressure rooms that prevent any spilled medication from leaving the room are also recommended. 2. Personal Protective Equipment (PPE) While handling any cytotoxic drugs, workers should use: 1. Protective gloves made of vinyl or nitrile rubber. Gloves should be changed frequently, or immediatelyif punctured,cut,or torn. It is alsorecommendedthatworkerswear two pairs at a time for additional protection. 2. A moisture resistant, long sleeved gown with elastic cuffs. 3. Chemical splash goggles, and if necessary, full-face protection. 4. Incaseswhere there isapossibility of the medicationbecomingairborne,apoweredairpurifying respirator is recommended. To prevent the spread of medication, protective clothing should not be worn outside of the preparation area. 3. Additional controls Special controls are required for the housekeeping and custodial staff regarding the potential hazards involved in handling laundry or other materials that may be contaminated with biological fluids contaminated with cytotoxic drugs. Safe work procedures for handling these materials should be developedand taught to all affected staff. Proper signage informing all employees of the presence of cytotoxic drugs and their hazards must be developed and displayed in highly visible locations. Eating, drinking,smoking, applying makeup and the storage of food should be completely prohibited in the preparation area.
  11. 11. Safety while caring for patients Personal care workerswhocouldbe exposedtobiological fluidfromapatientwhohasreceivedcytotoxic drugs within the previous 48 hours, and workers handling potentially contaminated linen should wear protective gloves and disposable gowns that are discarded after use. It is up to management to ensure that all staff are informedastowhenandwhere cytotoxicdrugsare beingusedsoappropriate measures can be taken. Waste disposal Plasticbags that are at least2mm thick (if polypropylene) or4mm thick (if polyethylene) shouldbe used to collect potentiallycontaminated materials.Bags should be color-coded and labelled with a cytotoxic warning label. All sharps should be placed in puncture proof containers before bagging. All workplaces should have a policy for segregating waste materials resulting from cytotoxic drug preparation and administration.Theseplansmustmeetorexceedthe provincialregulationsforhazardouswastedisposal. Housekeepingstaffshouldwearprotective gloveswhilehandlingwastecontainers.Cytotoxicwaste must be handleddifferentlythanregulargarbage and mustbe disposedaccordingtoprovincial regulations.In caseswhere the waste istobe incinerated,itshouldbe notedthatcompletelysealed(airtight)containers that could build pressure and explode must be avoided. Temperatures of 1,000°C to 1,600°C should be used to render the cytotoxic drugs harmless. Spills 1. Spill kit A clearly labelled cytotoxic spill kit should be kept wherever cytotoxic medications are being prepared, stored, administered or received (shipping). The kit should contain:  Fit tested NIOSH certified respirators for any one that would be working in these areas  At least two sets of surgical gloves  Disposable eye protection  Shoe covers  Scoop and scraper  Sharps container  Two large plastic disposal bags (minimum of 4mm thick)  Warning signs  Decontamination agent (i.e. a basic detergent of pH 8-9 and water)  Puncture and leak resistant waste container  Two sheets of absorbent material at least 30cm square A spill needstobe cleanedbymembersof the staff thathave receivedthe appropriatetrainingandhave the appropriate protective equipment; others should vacate the area as soon as it is safe to do so until the spill is cleaned. All spills should be immediately marked with a warning sign to prevent exposure to others. Glass should never be handled by hand; always use a scoop. The cleanup should be done by as few people as feasible, but there should be at least two people involved. 2. Small spill cleanup Small spills (less than 5ml or 5mg) that occur outside of a biological safety cabinet should be cleaned immediately by personnel wearing gowns, doubled protective gloves and eye protection. Small amounts of liquid should be wipedwith absorbent pads, while solids should be wiped witha wet absorbentgauze.Spill areasshouldbe cleanedatleastthree timeswiththe detergent(describedabove). Broken glass should be placed in a small container and placed in the disposal bags. All contaminated materials should also be placed in the garbage bags. Unbrokenglassware orreusableitemsthathave beencontaminatedshouldbe placedinaplasticbagand washed, following the procedures for cleaning reusable items that have been developed for the workplace. 3. Large spill cleanup
  12. 12. For spillsthatare larger than 5ml or 5mg, the cleaner’sinitial concern(afterpersonal protection) should be limitingthespreadof cytotoxicdrugsthroughtheworkenvironment.Coverthe spill withanabsorbent sheet or spill control pads. If the drug is in powder form, a wet or damp cloth should be used. For large spills, protective clothing should be worn with the addition of the respirator to protect against any airborne powder or aerosols. The use of chemical inactivates is not recommendedas they may create a hazardousby-product.Aswithsmall spills,all contaminatedareasshouldbe cleanedaminimumof three times, and all contaminated products and equipment should be disposed of or cleaned in an appropriate manner. 4. Spills in a biological safety cabinet Afterthe proceduresdescribedabove are followed,the interiorof the hoodmay alsorequire cleaning.If the HEPA filterhasbeencontaminated,the unitmustbe labelled“Contaminated, DONOTUSE”.The filter must then be changed and disposed of as soon as possible by trained personnel who are wearing the appropriate protectiveclothing.Protective goggles(if notdisposedof) should be thoroughlycleanedwith an alcohol wipe after cleanup. Storing and transport Areas where cytotoxic drugs are stored should be separated from regular storage, and clearly marked. Engineeringcontrols(locks,limitedaccesskeycard systems) shouldbe in place to preventunauthorized personnel fromenteringthe storage area.Aninventoryof the cytotoxicdrugsthatisfrequentlyreviewed shouldbe keptinthe room,alongwithinstructionsforcleaningspills.Wherepossible,otherdrugsshould notbe storedwithcytotoxicdrugs.Clearwarninglabelsshouldbe usedtoidentifythe cytotoxicdrugsand pointouttheirhazards.Shelvesshouldalsobe fittedwithaliporbackslope thatpreventsthe drugsfrom falling to the floor. Whena damagedcontainerisfound,itshouldonlybe handledbytrainedpersonnelwithpersonal protective equipmentdescribedpreviously.Brokencontainersandcontaminatedpackingmaterial shouldall be placedinthe appropriate puncture proof containeranddisposedof as cytotoxicbiological waste. Cytotoxic drugs should be securely capped and sealed and should be packed in impervious packing material.Labelsof all boxes,containersandvialsshould indicate that the substance is a cytotoxic drug. 6. Bypass Graft What isfemoral poplitealbypass surgeryandpercutaneous transluminalangioplasty (PTA)of the femoral arteries? Femoral popliteal bypasssurgery isusedtotreatblocked femoral artery. The femoralartery isthe largest artery in the thigh. It supplies oxygen-rich blood to the leg. Blockage is due to plaque buildup or atherosclerosis. Atherosclerosis in the leg arteriescauses peripheral vascular disease. The same process causes heart disease and stroke. There are two methods used to treat a blockage of the femoral arteries.  Femoral poplitealbypass. The healthcare provideraccessesthe femoralartery throughalarge incision inthe upperleg. A veintakenfromanotherareainyourlegisattachedabove andbelowthe blockage. This is called a graft. The blood is rerouted through the graft around the blockage. In some cases, a man-made graft may be used, rather than a vein graft.  Percutaneous transluminal angioplasty (PTA) of the femoral arteries. Percutaneous transluminal angioplasty is a minimally invasive. That means it’s done without a large incision. Instead, the healthcare providerusesalong hollow tube (catheter) insertedintothe femoral artery and guidesit to the narrowed area. There, atiny balloon atthe cathetertipisinflated compressingthe fatty tissue. This makes a larger opening in the artery for better blood flow. A tiny, expandable metal mesh coil (stent) maybe putinthe newly opened areaof the artery. Ithelpskeepthe arteryfromnarrowingor closing again.
  13. 13. Why might I need a femoral popliteal bypass surgery? You may need a femoral popliteal bypass surgery for:  Lifestyle changes and medicine have not improved symptoms, or symptoms are worse  Leg pain that interferes with daily life or ability to work)  Nonhealing wounds  Infection or gangrene  Leg pain at rest  Danger of losing the limb due to decreased blood flow There maybe otherreasons foryourhealthcareprovidertorecommendfemoral poplitealbypasssurgery. What are the risks of the femoral popliteal bypass surgery? Some possible complications may include:  Heart attack  Irregular heart beats  Bleeding  Wound infection  Swelling of the leg  Blood clot in the leg  Fluid in the lungs  Bleeding where the catheter is put in after the procedure  Blood clot or damage to the blood vessel where the catheter is put in  Re-stenosis  Nerve injury  Blockage in the graft used in bypass surgery There may be other risksbasedon your condition. Be sure to discuss any concerns withyour healthcare provider before the procedure. What happens after femoral popliteal bypass? In the hospital—femoral popliteal bypass After the procedure, you will be taken to the recovery room and watched. Once your blood pressure, pulse, and breathing are stable and you are alert, you may be taken to the intensive care unit (ICU) or your hospital room. Your healthcare provider will check your pulsesbelow the surgical site often to check blood flow to the limb.He orshe will alsowatchyourlegforcolor(paleorpink),warmth,sensationsof pain,andmovement. The incision may be tender or sore for several days after the procedure. Take a pain reliever as recommended by your doctor. You may be on special IV medicine to help your blood pressure and your heart, and to control any problems with bleeding. As you stabilize, your provider will gradually decrease, and then stop, these medicines. You can return to eating solid foods as you are able to handle them. When your healthcare team determines that you are ready, you will be moved from the ICU to a postsurgical nursingunit.Yourrecoverywill continue.Youcan graduallyincrease youractivityasyouget out of bed and walk around for longer periods. Arrange for a follow-up visit with your healthcare provider. In the hospital—PTA of the femoral artery Afterthe procedure,youwillbe takentothe recoveryroomatwatched.Once yourbloodpressure,pulse, and breathing are stable and you are alert, you may be taken to the intensive care unit (ICU) or your hospital room. Tell yournurse rightawayif youfeel anychestpainor tightness,oranyother pain,aswell asanyfeelings of warmth, bleeding, or pain at the insertion site.
  14. 14. The nurse will helpyouthe firsttime yougetup.Move slowlywhengettingupfromthe bedsoyoudon’t get dizzy. You may be given pain medicine for pain or discomfort where the catheter was insertedor from having to lie flat and still for a long period. You can start to eat solid foods as you can handle them. Your hospital staywill dependonyour conditionandthe resultsof your procedure.You will getdetailed instructions for your discharge and recovery period. Arrange for your follow-up visit with your healthcare provider.