Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Med/Surg-Cell. Reg.
Cellular Regulation
| Question | Answer |
|---|---|
| disease process that begins when abnormal cell is transformed by genetic mutation of cellular DNA | cancer |
| abnormal cells have invasive characteristics; infiltrate other tissues | metastasis |
| cells that demonstrate uncontrolled growth that does not follow physiologic demand | malignant cancer cells |
| the process that results in an increase of the number of cells, and is defined by the balance between cell divisions and cell loss through cell death or differentiation; increased in tumors | cell proliferation |
| malignant tumors spread by way of? | lymphatic spread, hematogenous spread, angiogenesis |
| Malignant transformation, or _________, is thought to be at least a three-step cellular process, involving initiation, promotion, and progression. | carcinogenesis |
| programmed cellular death | apoptosis |
| During _______, carcinogens (such as chemicals, physical factors, or biologic agents) cause mutations in the cellular DNA. | initiation |
| During _______, repeated exposure to promoting agents (co-carcinogens) causes proliferation and expansion of initiated cells with increased expression or manifestations of abnormal genetic information, even after long latency periods. | promotion |
| During ______, the altered cells exhibit increasingly malignant behavior. These cells acquire the ability to stimulate angiogenesis (growth of new blood vessels that allow cancer cells to grow), to invade adjacent tissues, and to metastasize. | progression |
| Currently, one in ____ deaths is caused by cancer. | four |
| leading cancers in men in U.S. | lung, prostate, and colorectal cancer |
| leading cancers in women in U.S. | lung, breast, and colorectal cancer |
| In U.S., which race has highest cancer death rate? | African-American |
| viruses that are known to cause cancer? bacteria known to cause cancer? | HPV, HBV, EBV; H. pylori |
| exposure to sunlight, radiation, chronic irritation or inflammation, tobacco carcinogens, industrial chemicals and asbestos | physical/chemical factors associated with carcinogenesis |
| lifestyle factors linked to cancer | poor diet, obesity, insufficient physical activity |
| cancer-linked foods | fats, alcohol, salt-cured or smoked meats, nitrate- and nitrite-containing foods (processed foods--hot dogs, bacon, ham), and red meats |
| hormonal carcinogenic agents | birth control, hormone therapy (ie-estrogen) |
| Which specific agents/factors are associated with the etiology of cancer? A-Dietary and genetic factors; B-Hormonal and chemical agents; C-Viruses; D-All of the above | D-All of the above. |
| type of prevention concerned with reducing cancer risk in healthy people; ex-immunizations, public/pt education on avoiding known carcinogens and lifestyle/dietary changes to reduce cancer risk | primary prevention |
| type of prevention that involves detection, screening to achieve early diagnosis, intervention; ex-mammogram, Pap tests, colonoscopies | secondary prevention |
| cancer classification: involves epithelial cells; most commonly diagnosed cancers -- originate in the skin, lungs, breasts, pancreas, and other organs and glands | carcinoma (adenocarcinoma, squamous cell carcinoma) |
| cancer classification: involves connective and supportive tissues; arise in bone, muscle, fat, blood vessels, cartilage, or other soft or connective tissues of the body; are relatively uncommon | sarcoma (bone, soft tissue) |
| cancer classification: involves plasma cells | myeloma |
| cancer classification: involves blood, bone marrow; does not usually form solid tumors | leukemia |
| cancer classification: involves lymphocytes | lymphoma (Hodgkins, Non-Hodgkins) |
| three largest primary cancer locations | bone, liver, lung |
| cancer grade that is normal | 0 |
| cancer grade that is well-differentiated with slight abnormalities | 1 |
| cancer grade that is moderate | 2 |
| cancer grade that is poor differentiated | 3 |
| cancer grade that is very undifferentiated; immature cells; no resemblance to tissue of origin | 4 |
| determines size of tumor, existence of metastasis | staging |
| tumor staging: TNM | T: extent of primary tumor (tumor size) N: lymph node involvement (node involvement) M: extent of metastasis (distance) |
| term for classification of tumor cells | grading |
| cancer management: complete eradication | cure |
| cancer management: prolonged survival and containment of cancer cell growth | control |
| cancer management: relief of Sx associated with disease and improvement of quality of life | palliation |
| performed to obtain a tissue sample for histologic analysis of cells suspected to be malignant | diagnostic surgery, or biopsy |
| used for small, easily accessible tumors of the skin, upper or lower gastrointestinal and upper respiratory tracts | excisional biopsy |
| performed if tumor mass is too large to be removed; a wedge of tissue from tumor is removed for analysis | incisional biopsy |
| performed to sample suspicious masses that are easily and safely accessible, such as some masses in the breasts, thyroid, lung, liver, and kidney | needle biopsy |
| often performed on an outpatient basis; is warranted when the mass is small; includes removal of the mass and a small margin of normal tissue that is easily accessible | local excision |
| removal of the primary tumor, lymph nodes, adjacent involved structures, and surrounding tissues that may be at high risk for tumor spread | wide (or radical) excision |
| removing non-vital tissues or organs that are at increased risk of developing cancer; ex-getting a mastectomy d/t family history of breast cancer | prophylactic (or risk reduction) surgery |
| performed in an attempt to relieve symptoms, such as ulceration, obstruction, hemorrhage, pain, and malignant effusions; ex-PEG tube insertion for enteral nutrition, colostomy for bowel obstruction | palliative surgery |
| may follow curative or extensive surgery in an attempt to improve function or obtain a more desirable cosmetic effect | reconstructive surgery |
| most common type of radiation therapy used for cancer treatment; a machine is used to aim high-energy rays from outside the body into the tumor | external beam radiation therapy (ERBT); aka-teletherapy |
| radiation therapy in which a small container of radioactive material is implanted in the body, in or near the cancerous tumor | internal radiation (aka brachytherapy) |
| agents used to destroy tumor cells by interfering with cellular function, including replication and DNA repair | chemotherapy |
| type of transplant? from a donor other than the patient (may be a related donor such as a family member or a matched unrelated donor from the National Bone Marrow Registry or Cord Blood Registry) | allogeneic |
| type of transplant? from the patient | autologous |
| type of transplant? from an identical twin | syngeneic |
| an immune response initiated by T lymphocytes of donor tissue against the recipient’s tissues (skin, gastrointestinal tract, liver); an undesirable response | Graft-vs-host disease |
| disease? the small blood vessels that lead into the liver and are inside the liver become blocked | Venous occlusive disease |
| T or F? The most common cause of bleeding in cancer patients is thrombocytopenia. | True |
| 1-inflammation/irritation of the mucous membranes in the mouth (gums, tongue, lips); 2-a complication of some cancer therapies in which the lining of the digestive system becomes inflamed (often seen as sores in the mouth) | 1-stomatitis, 2-mucositis |
| leakage of blood, lymph, or other fluid (ie-anticancer drug) from a blood vessel or tube into the tissue around it; it is also used to describe the movement of cells out of a blood vessel into tissue during inflammation or metastasis | extravasation |
| sudden hair loss that starts with one or more circular bald patches that may overlap | alopecia |
| a general state of ill health involving marked weight loss and muscle loss | cachexia (aka-wasting syndrome) |
| Which measure should the RN not teach a client about protecting the skin between radiation treatments? A-Handle the area gently. B-Avoid irritation with soap and water. C-Use a heating pad every day on the area. D-Wear loose fitting clothes. | C-Use a heating pad every day on the area. |
| S/Sx: altered mental status, either subnormal or elevated temperature, cool and clammy skin, decreased urine output, hypotension, tachycardia, other dysrhythmias, electrolyte imbalances, tachypnea, abnormal arterial blood gas values | septicemia |
| decrease in circulating platelet count; most common cause of bleeding in patients with cancer, usually defined as platelet count of less than 100,000/mm3 (0.1 × 1012/L) | thrombocytopenia |
| cancer cells starting in the ductal system of breast but not penetrating surrounding tissue; non-invasive; does not metastasize and woman generally does not die of this unless it develops into invasive breast cancer | ductal carcinoma in situ (DCIS) |
| the most common histologic type of breast cancer (80% of all cases); the tumors arise from the duct system and invade the surrounding tissues; they often form a solid irregular mass in the breast | infiltrating ductal carcinoma |
| 10% to 15% of breast cancers; the tumors arise from the lobular epithelium and typically occur as an area of ill-defined thickening in the breast.; often multicentric and can be bilateral | infiltrating lobular carcinoma |
| about 5% of breast cancers, and it tends to be diagnosed more often in women younger than 50 years; the tumors grow in a capsule inside a duct; can become large and may be mistaken for a fibroadenoma; prognosis is often favorable | medullary carcinoma |
| about 3% of breast cancers and often presents in women who are postmenopausal and are 75 years and older; a mucin producer, the tumor is also slow growing; thus, the prognosis is more favorable than in many other types | mucinous carcinoma |
| about 2% of breast cancers; a subtype of invasive ductal carcinoma; usually small (about 1 cm or less) and made up of tube-shaped structures called "tubules" | tubular ductal carcinoma |
| rare and aggressive type of breast CA; diffuse edema and erythema of the skin, often referred to as peau d’orange (resembling an orange peel)---caused by malignant cells blocking the lymph channels in the skin; can spread to other parts of body rapidly | inflammatory carcinoma |
| rare type of breast cancer involving the areola; most people with this disease also have one or more tumors inside the same breast (either ductal carcinoma in situ or invasive breast cancer) | Paget Disease of Breast |
| presently, is there a cure for breast cancer? | no |
| risk factors for breast cancer | (no single, specific cause) Personal and family history, including genetic mutations Hormonal factors Exposure to radiation-environmental 80% occur sporadic, no family history Some evidence with long-term smoking, night shift work |
| genes that, when damaged or mutated, increase a woman’s risk for breast and/or ovarian cancer compared with women without the mutation | BRCA1 and BRCA2 |
| mammograms begin annually at what age? | 40 years |
| clinical breast examinations may be performed twice a year starting as early as what age? | 25 years of age |
| area where breast cancer usually found | upper outer quadrant |
| advanced signs of breast cancer | skin dimpling nipple retraction skin ulceration |
| removal of the breast tissue, nipple–areola complex, and a portion of the axillary lymph nodes (ALND); used for invasive breast cancer | modified radical mastectomy |
| removal of the breast and nipple–areola complex but does not include ALND; used for non-invasive breast cancer | total mastectomy |
| surgery/Tx to remove a breast tumor and a margin of tissue around the tumor without removing any other part of the breast; may or may not include lymph node removal and radiation therapy | breast conservation treatment |
| biopsy of first node (or nodes) in the lymphatic basin that receives drainage from the primary tumor in the breast; less invasive alternative to ALND and is considered a standard of care for the treatment of early-stage breast cancer | sentinel lymph node biopsy |
| chronic swelling of an extremity due to interrupted lymphatic circulation, typically from an axillary lymph node dissection | lymphedema |
| a solid swelling of clotted blood within the tissues | hematoma |
| a pocket of clear serous fluid that sometimes develops in the body after surgery | seroma |
| a test to determine whether the breast tumor is nourished by hormones | estrogen and progesterone receptor assay |
| drug class? tamoxifen and raloxifene; blocks the effects of the hormone estrogen in breast tissue, which may help keep breast cancer cells from growing; also used for women at high risk of breast cancer | selective estrogen receptor modulators (SERMs) |
| drug class? anastrazole, letrozole, exemestane (all for treatment of breast cancer); drug that prevents the formation of estradiol | aromatase inhibitors |
| method of breast reconstruction in which a flap of skin, fat, and muscle from the lower abdomen, with its attached blood supply, is rotated to the mastectomy site | transverse rectus abdominal myocutaneous (TRAM) flap |
| leading cause of death in the U.S. | lung cancer |
| almost all cases are d/t cigarette smoking; very aggressive; grows quickly; usually starts in the airways in the center of the chest; ~15% of lung tumors are this | small cell lung cancer (SCLC) |
| type of non-small cell lung cancer that is more centrally located; arises more commonly in the segmental and subsegmental bronchi | squamous cell carcinoma |
| type of non-small cell lung cancer that is the most prevalent carcinoma; grows peripherally and masses/nodules often metastasize | adenocarcinoma |
| type of non-small cell lung cancer that is fast growing; arises peripherally | large cell carcinoma (undifferentiated carcinoma) |
| lung cancer clinical manifestations | -often asymptomatic until late in course; depends on location and size of tumor -cough -dyspnea -blood tinged sputum -chest or shoulder pain -anorexia, fatigue, and weakness |
| removal of entire lung | pneumonectomy |
| a single lobe of the lung is removed | lobectomy |
| two lobes of the lung are removed | bilobectomy |
| a segment of the lung is removed | segmentectomy |
| removal of a small, pie-shaped area of the segment | wedge resection |
| the partial or full surgical removal of soft tissue, cartilage, sternum and/or ribs | chest wall resection |
| clinical manifestations of colon cancer | -change in bowel habits (most common) -blood in or on stool (second most common) -anemia -anorexia -weight loss -fatigue |
| a malignant tumor formed from glandular structures in epithelial tissue; begins in glands but can spread to other areas of the body | adenocarcinoma |
| risk factors for colon cancer | -cigarette smoking -family history -previous colon cancer -high consumption of alcohol -diet (>fat, > protein, low fiber) -h/o genital cancer in women -h/o IBD -obesity -racial/ethnic background (African American or Ashkenazi Jewish) |
| recommended annually for men >50 years old or >45 years of age for high risk (African American and men with family history); examiner assesses size, symmetry, shape and consistency of the posterior surface of the prostate gland | digital rectal exam |
| risk factor for prostate cancer | -increasing age -familial predisposition -African American race |
| symptoms of prostate cancer | -early--few or no symptoms -urinary obstruction, blood in urine or semen, painful ejaculation -Sx of metastasis may be the first manifestations |
| treatment for prostate cancer | -therapeutic vaccine, prostatectomy, hormonal therapy (ADT-androgen deprivation therapy) -radiation therapy, chemotherapy |
| symptoms of prostate cancer metastasis; these symptoms may be the first indications of prostate cancer | backache, hip pain, perineal and rectal discomfort, anemia, weight loss, weakness, nausea, oliguria, and spontaneous pathologic fractures |
| lowest point of white blood cell depression after therapy that has toxic effects on the bone marrow | nadir |
| lab test to check for a protein made by the prostate gland and found in the blood; levels may be higher than normal in men who have prostate cancer, BPH, or infection or inflammation of the prostate gland | prostate-specific antigen (PSA) |
| complete surgical removal of the prostate, seminal vesicles, tips of the vas deferens, and often the surrounding fat, nerves, and blood vessels; considered first-line Tx for prostate cancer and is used w/ patients whose tumor is confined to the prostate | radical prostatectomy |
| used to ablate prostate cancer in patients who cannot tolerate surgery and in those with recurrent prostate cancer; transperineal probes are inserted into the prostate under ultrasound guidance to freeze the tissue directly | cryotherapy of prostate |
| surgery to remove one or both testicles | orchiectomy |
| most common treatment procedure for prostate cancer; prostate gland is removed in small chips with an electrical cutting loop | transurethral resection of the prostate (TURP) |
| dissection of this area (anterior and lateral to the external iliac vessels) is associated with an increased risk of lymphedema; used in some pts to provide info for staging the tumor and to remove an area of microscopic metastasis | pelvic lymph node dissection (PLND) |
| potential post-op prostatectomy problems/complications | Hemorrhage and shock Infection Venous thromboembolism Catheter obstruction Complications with catheter removal Urinary incontinence Sexual dysfunction |
| useful in irrigating the bladder and preventing clot formation; continuous irrigation may be used with TURP | three-way drainage system |
| another (longer!) name for leukemia | hematopoietic malignancy with unregulated proliferation of leukocytes |
| unregulated proliferation of leukocytes in the bone marrow; leaves little room for normal cell production; acute forms can infiltrate into other organs | leukemia |
| leukemia causes | -cause not fully known -exposure to radiation and chemicals -genetic and/or viral influences -bone marrow damage from pelvic radiation or chemo |
| most common non-lymphocytic leukemia; affects all ages; Sx: fever and infection, weakness and fatigue, bleeding tendencies, pain from enlarged liver or spleen, hyperplasia of gums, bone pain; Tx: aggressive chemotherapy, possible HSCT | Acute Myeloid Leukemia (AML) |
| uncommon in people <20 y.o., increased incidence with age; Sx: initially may be asymptomatic, malaise, anorexia, weight loss, confusion or SOB caused by leukostasis, enlarged/tender spleen, or enlarged liver; Tx: chemotherapy, HSCT | Chronic Myeloid Leukemia (CML) |
| most common in young children (boys>girls), uncommon p 15--peaks again p 50; Sx: leukemic cell infiltration more common w/this type (pain from enlarged liver/spleen, bone pain, CNS--H/A, emesis) | Acute Lymphocytic Leukemia (ALL) |
| type of leukemia? Tx: chemotherapy, HSCT, monoclonal antibody therapy, corticosteroids | Acute Lymphocytic Leukemia (ALL) |
| common malignancy of older adults; most prevalent type of adult leukemia; Sx: “B symptoms” (a constellation of Sx--fevers, drenching sweats (especially at night), and unintentional weight loss, later stages- lymphadenopathy, hepatomegaly, splenomegaly | Chronic Lymphocytic Leukemia (CLL) |
| type of leukemia? Tx: early stage--“watch and wait”, chemotherapy, monoclonal antibody therapy, IVIG for recurrent infections, and HSCT | Chronic Lymphocytic Leukemia (CLL) |
| assess for what symptoms/complications with leukemia pts? | -anemia, infection, and bleeding (the big 3) -weakness and fatigue, dyspnea, petechiae, ecchymosis, pallor, abd pain |
| lab tests for assessment of leukemia? | leukocyte count, absolute neutrophil count (ANC), hematocrit, platelets, creatinine, electrolytes, coagulation, Hepatic function, & culture reports as ordered |
| nursing interventions for mucositis | -Frequent, gentle oral hygiene, before and after meals -Soft toothbrush or if counts are low, sponge-tipped applicators -Rinse only with NS, NS and baking soda, or prescribed solutions -Perineal and rectal care |
| nursing interventions to improve nutritional intake | -Oral care before and after meals -Administer analgesics before meals -Appropriate treatment of nausea -Small, frequent feedings -Soft foods that are moderate in temperature -Low-microbial diet -Nutritional supplements |
| nursing interventions for maintaining fluid and electrolytes | -Intake and output, daily weights -Assess for dehydration and overload -Laboratory studies including electrolytes, blood urea nitrogen, creatinine, and hematocrit -Replacement as necessary |
| How do you pass this course? | READ THE ENTIRE BOOK!!! EVERY WORD OF EVERY CHAPTER!!! EVERY TABLE, CHART...JUST MEMORIZE THE WHOLE DAMN THING!!! |
| most common cancer in U.S.? | skin cancer |
| small waxy nodule with rolled, translucent, pearly borders; may appear shiny, flat, gray, yellow; most common type and recurrence is also common (rarely metastasizes); locally invasive malignancy arising from epidermal basal cells | basal cell carcinoma |
| generally appears in sun exposed areas of the body (i.e. face, neck, hands, and scalp); localized tumor---therefore prognosis is good; least deadly---rarely causes morbidity or death | basal cell carcinoma |
| rough, thickened, scaly tumor; may be asymptomatic or bleed; border is wide, more infiltrated, more inflammatory; arises from epidermis, sun damaged skin; commonly found on upper extremities/face/lower lip/ears/nose/forehead | squamous cell carcinoma |
| prognosis depends on metastasis, type, level and depth of invasion; 4-8% metastasize by blood and lymphatic system; less aggressive than melanoma, can cause death | squamous cell carcinoma |
| medical management: eradicate tumor, Tx depends on location/type/depth; alternatives: radiation, photodynamic therapy, topical chemotherapeutic creams; surgical: surgical incision, Mohs micrographic surgery, electrosurgery, cryosurgery | basal cell carcinoma and squamous cell carcinoma |
| manifests as a change in nevus or a new growth on the skin; color is dark, red, blue colored or a mix; irregular shape; itching, rapid growth, ulceration, bleeding; cancerous neoplasm preset in dermis and epidermis | melanoma |
| 2x more common in men then women; found anywhere on the body (lower extremities – women; head, neck, trunk – men); Tx: surgical excision, chemotherapy | melanoma |
| nursing assessment for skin cancer | -Inspect skin carefully -Ask specific questions about pruritus, tenderness, pain, changes in moles, or new pigmented lesions -Assess knowledge level and risk factors -Assess coping and anxiety -Assessing the ABCDEs of Moles |
| ABCDEs of moles | Asymmetry (irregular) Border (variegated) Color Diameter Evolving |
| nursing diagnoses r/t melanoma | -Acute pain r/t surgical incision/ grafting -Anxiety -Depression -Deficient knowledge r/t early signs of melanoma |
| nursing process: planning/goals r/t melanoma | -Relief of pain and discomfort -Reduced anxiety and depression -Increased knowledge of early signs of melanoma -Absence of complications-Infection and metastasis |
| skin cancer prevention | -Minimize sun exposure -Avoid Sun 10am-4pm -Wear protective clothing -Apply sunscreen - > 15 SPF -Avoid artificial UV sources -Perform monthly self examination of skin -Schedule yearly appointments with PCP if >50 years of age |
| severe hemolytic anemia from inheritance of ___ gene | HbS (sickle hemoglobin) |
| sickle cell anemia most commonly found in what ethnicity? | African American, less common in Middle Eastern, Mediterranean, and aboriginal tribes in India |
| Sickle cell hemoglobin C (SC) disease, Sickle cell hemoglobin D (SD) disease, Beta-thalassemia | less severe forms of sickle cell anemia |
| blood flow to region or organ may be reduced; reduced blood flow leads to ischemia or infarction; ischemia/infarction may cause pain, swelling, and fever; crises are intermittent-aggravated by cold causing vasoconstriction and increased blood viscosity | sickle cell anemia |
| anemia is always present in sickle cell anemia (HBG ranges between 5-11 g/dL); anemia can lead to what? | tachycardia, cardiac murmurs, enlarged heart; leads to dysrhythmias & CHF |
| Sx/complications result from chronic hemolysis or thrombosis; often jaundice coloring is obvious in sclera; bone marrow expands; enlargement of bones/face/skull; any organ can be affected by thrombosis (include spleen, lungs, and CNS) | sickle cell anemia |
| Are patients with sickle cell anemia susceptible to infection? If so, primarily what types? | yes; pneumonia, osteomyelitis |
| entrapment of erythrocytes/leukocytes in microcirulation->tissue hypoxia, inflammation, necrosis d/t inadequate blood flow->perfusion resumes, substances are released causing oxidative damage to vessel->damage to the epithelium and vasculopathy develops | acute vaso-occlussive crisis |
| from infection with the human parvovirus, hemoglobin drops rapidly and the marrow cannot compensate, leading to an absence of reticulocytes | aplastic crisis |
| results when organs pool the sickled cells; spleen is often effected in children (splenic infarction happens often by 10 years of age, leaving spleen non-functional); liver and lungs are effected in the adult population | sequestration crisis |
| manifested by fever, respiratory distress (tachypnea, cough, wheezing), and new infiltrates seen on the chest x-ray; it is the main cause of death in young adults with SCD | Acute Chest Syndrome |
| common sequela of SCD; a common cause of death; diagnosing is difficult b/c Sx rarely occur until damage is irreversible; pts may c/o fatigue, DOE, dizziness, CP or syncope, but LCTA with normal SpO2 | Pulmonary Hypertension |
| SCD usually diagnosed when? life expectancy rarely exceeds the __th decade | childhood; 6th |
| SCD nursing assessment | -H&P -Pain assess -Lab data: S-shaped HGB -Presence of Sx and impact of those Sx on pt’s life--swelling, fever, pain -Sickle cell crisis assess -Blood loss: menses, potential GI loss -CV and neuro assess |
| the only curative treatment of SCD? (Tx is limited b/c of compatible donors and severe organ damage already present in the pt) | hematopoietic stem cell transplant (HSCT) |
| a chemo that decreases formation of sickled cells but is unknown if it reverses organ damage; side effects include suppression of leukocyte formation, teratogenesis, and potential development of a malignancy; adherence to medication is a problem | Hydroxyurea |
| antagonistic (estrogen-blocking) effects of tamoxifen in the breast | prevent estrogen from binding to the receptor sites, thus preventing tumor growth |
| agonistic (estrogenlike) effects of tamoxifen | good- for blood lipid profiles and bone mineral density in women who are postmenopausal; bad-also effects endometrial tissue and blood coagulation processes, leading to an increased incidence of endometrial cancer and thromboembolic events |
Created by:
nurse savage
Popular Nursing sets