Exemplars

Colorectal risk factors

• IBS

• Crohn’s disease

• High fat-diet/obesity/inactivity

• More than 50 y/o

others: alcohol, fam hx of cancer, genetic predisposition, smoking

What is IBS

Irritable bowel syndrome

• Characterized by abd. Pain, altered bowel pattern, diarrhea, and constipation

• Distension (flatulence/held stool), bloating, urgency, and mucus in stool can occur

What is Crohn’s disease

Inflammatory bowel disease that can affect gastrointestinal tract (mouth to anus)

• Skip lesions (normal/inflamed pattern)

• Transmural inflammation (thickening)

• Cobblestone pattern (deep ulcers)

• Granuloma (mass of inflammation)

What is important for Crohn’s disease

• DO NOT give NSAIDS

• AVOID low fiber, high carb diet

Screenings for colorectal cancer

1. Fecal occult blood test (per year)

2. CT colonography (virtual every 5 years)

3. Flexible sigmoidoscopy (every 5 years)

4. Colonoscopy (every 10 years)

What does is a fecal occult test, what does it show

Measures blood in the stool invisible to the naked eye and helps detect colorectal cancer, benign/malignant growth, peptic ulcers, hemorrhoids, etc.

What is flexible sigmoidoscopy

Examination w/a flexible scope that allows visualization of the LOWER PORTION of the colon

S/S to look for when colorectal cancer is suspected during physical assessments

• Vomit

• Bowel habit changes

• Rectal bleed/Anemia

• Pain/cramps

• Incomplete evacuation

Why is radiation used in colon cancer if it’s NOT THE PRIMARY TREATMENT for it

• Used prep-op to shrink tumors

• Is palliative (controls pain, hemorrhage, bowel obstruction, and metastasis to lungs)

• Rectal cancer radiation may be coupled too

What if chemo and radiation are combined for colorectal cancer patients

Reduces occurrence and prolongs survival

• For stages II & III

Noninvasive colorectal treatment

Chemo and radiation

Invasive treatment for colorectal cancer

Surgical treatments

• Colon resection

• Colectomy

• Colostomy

Colon resection

Removes diseased portion of the colon and connects the remaining healthy segments

• Fistulas from Crohn’s disease may cause the need for this treatment

Colectomy

Removes all/part of the colon (total/subtotal)

• Usually an ileostomy follows to filter out waste

• Done for Crohn’s disease or ulcerative colitis

Colostomy

Opening created when part of colon or rectum is removed and remaining colon is brought to skin level for passage of stool (may be temporary or permanent)

Care coordination for colorectal patients

• Teach home care

• Show self management (e.g. for colostomy and its psychosocial concerns)

• Provide healthcare resources

What must a colostomy patient keep in mind when caring for their wound

• Cut and opening 1/8-1/6 larger than stoma to avoid constricting tissue

• Clean AROUND stoma w/mild soap and water

• AVOID moisture soaps and lubricants as it prevents adhesion

Complications from surgical processes in colorectal cancer patients

• Retracted stoma

• Pale/black stoma color

• Dehiscence of wound

What does “penia” indicate

Decrease in levels

What does “tosis” indicate

Increase in levels

What is leukemia

Uncontrolled production of IMMATURE WBC in BONE MARROW

How is leukemia classified

1. Acuity (acute vs chronic)

2. Predominant cell type (Lymphocytic vs myeloid)(origin)

What does lymphocytic cancer mean

Involves high levels of Immature lymphocytes (lymphoblasts) that often infiltrate the spleen, lymph nodes, and CNS

• interferes with the ability to fight viruses/make antibodies

• The more immature lymphoblasts=more nonfunctional cells occupying the bone marrow

What does myeloid cancer mean

Involves high levels of Myeloid stem cells (myeloblasts) that interfere w/maturation of ALL BLOOD CELL granulocytes (white blood cells other than lymphocytes), RBC, and THROMBOCYTES

• Myeloblasts→ immature white blood cells that are not lymphoblasts

What happens when erythrocytes (mature) are low

Anemia

• leads to weakness and pallor

What happens when lymphocytes (mature) are low

Immunosuppression

• High risk for infection (causes frequent fever)

• Neutropenia, anemia, and thrombocytopenia is also common

What happens when platelets (mature) are low

Bleeding, decreased clotting

• Thrombocytopenia (low platelet levels) can lead to

  • Petechiae (small hemorrhages)

  • Bruising

  • Purpura

Leukemia risk factors

• Ionizing radiation

• Viral infection

• Exposure to chemicals/drugs

• Damages to genes controlling cell growth

What is ionizing radiation

Radiation that removes orbital electrons from atoms → free electrons and positively charged atoms

• X-rays, gamma rays, and alpha particles are examples

What type of leukemia is more common in children

Acute lymphocytic leukemia (ALL)

• means it is an aggressive, fast paced cancer originating from the abnormal rise in lymphoblasts

What type of leukemia is more common in adults

Acute myeloid leukemia (AML) and chronic lymphocytic leukemia (CLL)

1. It means it is an aggresive, fast paced cancer originating from the stem cells and rise in myeloblasts

2. It means it is a slow, progressive cancer originating from the rise and abnormal growth in immature lymphocytes (lymphoblasts)

Where do cells infiltrate

CNS, and testicles

• others include: lymph nodes, liver, spleen, and joints

Chronic myelogenous leukemia

Usually in Philadelphia chromosome positive (w/ALL)

• Common after 50 y/o

• 3 phases (chronic, accelerated, and blast)

Acute promyelocytic leukemia (APL)

• Most curable of adult leukemias

• Subtype to AML

Leukemia is more common in what age group

2-3 y/o boys

• 90% lives +5 after diagnosis

• 15-20% relapse

What to look for during physical assessment

S/S of anemia, Infection, or bleeding

S/S common in leukemia for the intergumentary system

• Ecchymoses

• Petechiae

• Infected lesion

• Pallor

S/S common in leukemia for the GI system

• Bleeding gum

• Anorexia

• Weight loss

• Enlarged spleen/liver

S/S common in leukemia for the renal system

Hematuria → blood in the urine

S/S common in leukemia for the musculoskeletal system

Bone pain and joint swelling

S/S common in leukemia for the cardiopulmonary system

• Tachycardia at REST

• Orthostatic hypotension

• Papitations

• Dyson era of exertion (out of breath)

S/S common in leukemia for the neurologic system

• Fatigue

• Headache

• Fever

Common diagnostic test for leukemia

• Bone marrow examination

• Imaging (x-rays of chest and skeleton)

• Lab (platelets, clotting times, chromosome analysis, CBC w/differentials)

Invasive treatments for leukemia

Bone marrow transplant and stem cells transplant

Bone marrow transplant

1. Allogeneic BMT→From a donor matching tissue antigens

2. Autologous BMT→ From pt. own bone marrow during periods of remission

Stem cell transplant

Complete replacement of blood cell lines with cells from donor stem cells (MUST MATCH TISSUE TO RECIPIENT)

• Hematopoietic growth factor is added before to harvest concentration of stem cells in peripheral blood

Graft Versus Host Disease (GVHD)

Immune cells identify body tissue (from BMT or SCT) as foreign

• Occurs within 3 MONTHS of transplant

• Rash, jaundice, nausea, vomit, pruritic (itchy), dry eye, and diarrhea occurs

How to treat GVHD

• Steroids

• Antibiotics

• Immunosuppressants

What is the science in chemotherapy

Cytotoxic drugs that destroy cancer cells by INHIBITING CELL DIVISION

• Vincristine → ALL in children doesn’t suppress bone marrow

• Bleomycin→ AML in adults. Antibiotic for actively dividing cells (pulmonary toxicity)

• Methotrexate → ALL. Slows progression

• Cisplatin→ AML. Stops cell growth

TLS (tumor lysis syndrome)

Release of intracellular contents into circulation

• Results in cardiac arrhythmia, renal failure, and death

Remember this about treatments

Radiation damages cellular DNA and biological agents modify body’s response to cancer cells

• either way cells recover or can be recovered by colony stimulating factors

Nursing care for leukemia

Promote:

• reserve isolation (neutropenia)

• Handwashing

• Aseptic techniques

Remember that chemo and radiation can further depress bone marrow and make pt susceptible to infections

Why is anemia important to treat

Fatigue can occur due to low gas exchange and high energy demands so avoid:

• straining, invasive procedures, apply pressure to punctures, etc.

How is breast cancer categorized

1. Triple negative breast cancer

2. HER2

3. Paget disease

4. Invasive

5. Noninvasive

Triple negative breast cancer (TNBC)

Found in pt w/ BRCA mutations + grows quickly

HER2 positive

Extra HER2 receptor causing overexpression (cells multiply too quick too often)

Paget disease

Disease in the nipple causing scaly, red, irritation

Non invasive cancer

• Ductal carcinoma in situ (DCIS)

• Lobular carcinoma in situ (LCIS)

Invasive cancer

• Invasive ductal carcinoma → originates in mammary ducts and breaks into surrounding tissue

  • Develops fibrosis and peau d’orange

• Inflammatory breast cancer(IBC) → diffuse erythema, pain, breast lump/itching, and peau d’orange

Risk factors for breast cancer

• woman + 65 y/o

• Early/late menarche

• Nulliparity/birth after 30

• Genetic risk factors

• Breast density

• Hormone replacement w/estrogen + progesterone

• Abnormal breast biopsy

• Obesity, inactivity, alcohol, personal hx

Women 40-44should have a mammogram every

Every year (optional)

Women 45-54 should have a mammogram every

Every year

Women 55+ should have mammograms every

Every other year or yearly depending on her health

In case of a suspected breast cancer case, assess what

• Beast mass

• OB/GYN hx

• Alc and med use

• Risk factors

In her physical assessment of breast cancer examine

Location, shape, size, consistency, mobility, and mass (6 things/LSSCMM)

• skin changes, enlarged nodes, and pain/tenderness

Psychosocial assessment in breast cancer patients

• Shock and disbelief

• Prev hx of mental health

• Encourage expression

• Refer to counselor

• Assess sexuality concerns

Manifestations of breast cancer

• Non tender (Upper Outer Quadrant)

• Abnormal nipple d/c

• Rash around nipple

• Nipple retraction, dimpling, change in position

• Burning or stinging sensation

• Pain, erythema, and edema (IBC)

TUMORS MAY NOT BE REVEALED UNTIL AFTER 8-10 YEARS

• a mammography can detect this 2 years before tumor is palpable

Imaging testing for breast cancer

• mammography

• Tomosynthesis

• Ultrasonography

• MRI and PET scan

• Breast biopsy

• Genomic tests

• Labs: breast mass tissue, lymph nodes, liver, serum calcium, and alkaline phosphatase

Therapeutic management

• surgery

• Adjuvant therapy

• Radiation, chemotherapy, hormonal therapy, and immunotherapy

• Complementary and integrative health

Lumpectomy

Excision of PRIMARY tumor and some normal breast tissue

Total (simple) mastectomy

Removal of ALL the breast

Modified radical mastectomy

Removes breast and lymph nodes but PECTORALIS MAJOR is spared

Radical mastectomy

Removes ALL breast, lymph nodes, and underlying muscles

Sentinel lymph node biopsy

Analyzes lymph node involvement. Less invasive.

What is adjuvant therapy

Radiation→ Localized, kills cells near tumor

• causes fibrosis, fatigue bone marrow suppression, burning, swelling, nausea vomit and firmness

Hormone therapy→ SERMs prevents estrogen from attaching to cancer cells, preventing growth

Aromatase imhibitor→ Inhibite androgen turning to estrogen (watch it in osteoporosis pt and use on postmenopausal pt)