Adult III Exam V Study Guide

Differentiate benign tumor cells and malignant (cancer) cells

Benign Tumor Cells

• Normal cells growing in the wrong place or at the wrong time

• Benign cells are not cancerous

• They can grow, but they do not spread to other organs

Malignant Cells (Cancer)

• Cancer (malignant) cells are abnormal, serve no useful function, and are harmful to normal body tissues

• Cancer cells have abnormal cell proliferation—they ignore growth regulating signals resulting in uncontrolled cell growth that follows no physiologic demand

• Cancer cells can spread to other organs

What viruses are known to be carcinogenic?

1. HPV—linked to cervical cancer in women

2. Hepatitis B

3. Epstein-barr virus

What bacteria is known to be carcinogenic?

H. pylori—increases risk of gastric cancer

What physical agents are linked to cancer development?

List interventions to prevent/lower the likelihood of cancer development from these sources

1. Sun

2. Tobacco

3. Chemicals

4. Asbestos

Physical prevention:

1. Sunscreen

2. Clothing

3. Habits

4. Occupation

5. Environment

What chemical agents are linked to cancer?

1. Tobacco products

2. Secondhand smoke

3. Workplace chemicals

4. All types of smoke substances

What lifestyle factors are linked to cancer development?

What cancers are linked to thse factors?

• Diet—high in fats and meats (red meat, salt cured, processed)

• Obesity and lack of activity

• ETOH abuse

Cancer risk:

• Diet and lifestyle increase risk of breast CA, colon CA, Kidney CA, esophageal CA, and endometrium CA

What hormonal agents are linked to cancer development?

• Hormonal imbalances caused by endogenous or exogenous hormones can raise the risk of cancer

• Early puberty, delayed menopause, and estrogen increases risk of cancer post-menopause

How does being immunocompromised increase cancer risk?

Immunocompromised patients have an increased risk of cancer b/c their immune systems fail to identify + stop the growth of transformed cells, which can allow a tumor to form

List/describe the 3 strategies of cancer prevention

1) Primary prevention: Use of strategies to prevent the occurrence of cancer

Examples

• Reduce the risks of cancer—use sunscreen, HPV vaccine, active lifestyle/increase physical activity, and healthy diet

2) Secondary prevention: Use of screening to detect cancer early, at a time when a cure or control is more likely

Examples of Screening/Early Detection Activities:

• Routine blood work

• CT scans

• PET scans to detect possible cancers

• PAP smears

• Colonoscopy

• Breast/testicle exams

3) Tertiary prevention: Screening for 2nd malignancies in cancer survivors = preventing + screening for recurrence of cancer in cancer survivors

• Tertiary = for people who have had cancer, we are screening/monitoring them to look for new cancer cells + growth/spread of cancer

Differentiate cancer grading and staging

Grading: Classifies cellular aspects of the CA

• Description of the tumor based on how abnormal the cells and tissue look under a microscope vs normal cells from that area

• Tells how quick is the tumor growing and spreading

• Tells how cancer cells look vs normal cells + tells where cancer originated

Staging: Classifies clinical aspects of the cancer

• Determines the size, location, if lymph nodes are involved, and if metastasis has occurred

(Where the CA is located, how bad, and did it spread)

List the different methods of cancer management

1. Surgery—removal of the enitre cancer is ideal

2. Radiation

3. Chemotherapy

4. Immunotherapy

5. Molecularly targeted therapy

6. Photodynamic therapy

7. Hormonal therapy

—>a lot of these are used in conjunction w/ one another

What is the goal of cancer management

Eradication of malignant disease is the goal

• Prolonged survival and containment of CA cell growth means that the CA is under control

• Relief of symptoms associated with the disease and improvement of quality of life is palliative CA management

List/explain the different diagnostic surgeries for cancer

Surgery can be diagnostic—biopsy; a bx can be excisional, incisional, or needle

1. Excisional—for easy to access tumors

2. Incisional—tumors too large to be removed

3. Needle bx—take a sample of mass w/ needle aspiration, normally outpatient

What is the primary surgical treatment for cancer?

Surgical debulk or total removal of tumor w/ either a local or wide excision

• Local is a small excision to remove tumor only

• Wide excision = remove tumor and other areas affected by cancer, not just cancer itself

What is prophylactic surgery for cancer, and why is it used?

List common examples

Prophylactic: The patient has the gene for the cancer, but do not have the cancer yet, so preventative surgery may be used to prevent the pt from getting CA by removing nonvital tissues at high risk of becoming cancerous

Examples: Mastectomy, colectomy, and orchiectomy (testicle removal) are common as prophylactic surgeries

What is palliative surgery for cancer, and when is it used?

Palliative—Performing surgery to relieve/decrease the sx the patient is having from the cancer; palliative surgery is used when a cure is not possible,

• Might be debulking as well if not able to remove whole tumor, but relieving sx is the goal

What is reconstructive surgery for cancer, and why is it used?

Reconstructive—Cosmetic surgery after treatment

• Reconstructive surgery is used to improve function of patient or obtain a desirable effect after surgery to remove the cancer has been completed

• Reconstructive breast surgery is common post-mastectomy and post-cancer tx

Regarding the care of a patient post-surgery for cancer:

1. What is important to keep in mind regarding their function?

2. Psychosocial support?

3. What might they need post-op to recover?

4. What are your priorities post-op?

5. What is commonly combined with surgery as a form of treatment?

1) Any organ loss reduces function

2) Psychosocial support

• Be aware that the stress of the diagnosis can significantly impact the patient and family’s ability to understand any teaching provided at this time

• May need to provide support group information (ostomy society, American Cancer Society-etc.)

• May need to reiterate education to ensure they understand what we are trying to tell them

3) May need rehab after surgery-post mastectomy (i.e., like PT), head or neck cancer surgery may need swallowing or speech therapy following surgery

4) Manage pain and prevent infection—most surgeries are now laparoscopic (less invasive), but these are still priorities w/ laparoscopic surgery

5) Combining surgery with other therapies has increased—Patients may have surgery w/ placement of a radioactive source or chemotherapy directly into the cavity

• May have catheters implanted or pumps placed for chemotherapy or analgesic medications

1. What is the purpose of radiation therapy regarding cancer management?

2. When is it considered local tx vs systemic tx?

3. What radiation types are used and how are they different?

4. Explain radiation dose and exposure

5. What are the 3 factors that determine the absorbed dose of radiation?

1) The purpose of radiation therapy for cancer is to destroy cancer cells w/ minimal damaging effects on the surrounding normal cells + we want to maintain a safe environment w/ radiation

• Use of radiation can be standalone or used in conjunction w/ other cancer therapies

2) Local tx: Radiation is most often considered local treatment as only effects tissue in the radiation beam path

• The effects of radiation may be apparent within days or weeks, but some may take months to years after radiation to be seen

Systemic tx: When total body irradiation is used-all body areas are affected

3) All types of radiation are identical in their effects on cells, but the energy produced by radioactive elements( gamma rays, alpha particles, beta particles) vary in their ability to penetrate tissues and damage cells

4) Radiation dose vs exposure

• The amount of radiation delivered to a tissue is the exposure

• The amount of radiation absorbed by the tissue is the radiation dose

—>The dose is always less than the exposure b/c some energy is lost on its way to the tissue

5) 3 factors determining the absorbed dose of radiation:

1. Intensity of exposure

2. Duration of exposure

3. Closeness or distance of the radiation source to the cells

1. What is brachytherapy?

2. Is brachytherapy dangerous to those around the patient receiving therapy?

3. Types of brachytherapy?

4. Source of radiation in brachytherapy?

5. Examples of patients/cancer that receive brachytherapy?

1) Brachytherapy: The placement of radioactive sources within or immediately next to the cancer site for a specific time period in order to provide a highly targeted, intense dose of radiation; “close therapy”

• This form of radiation delivery helps to spare exposure to normal surrounding tissue

2) The radiation source is inside the patient; therefore, the patient emits radiation for a period of time and is a potential hazard to others

• The patient is radioactive while the radiation is live—so as long as the seeds/rods/whatever is implanted, they are radioactive

3) Types:

Temporary implant: Delivered as high-dose radiation (HDR) for short periods of time

Permanent implant: Low-dose radiation (LDR) is delivered over a more extended period

4) The radiation source can be implanted by means of needles or rods, seeds, beads, ribbons, or catheters placed into body cavities (vagina, abdomen, pleura), lumens within organs, or interstitial tissue compartments (breast, prostate)

5) Radioactive sources are placed w/in or immediately next to the CA site:

1. Women w/ cervical cancer—they put radioactive rods in vaginal cavity for 5-7 days

2. Other common population = men w/ prostate cancer—they place radioactive seeds in the rectum to tx prostate cancer, left for 3-4 days

What is brachytherapy?

List safety precautions for patients receiving brachytherapy

Brachytherapy: The placement of radioactive sources within or immediately next to the cancer site for a specific time period in order to provide a highly targeted, intense dose of radiation; “close therapy”

Safety Precautions

1. These patients must lay flat (no ambulation or sitting up to prevent the rods/seeds from coming out of the cavity they are placed)

2. Will be in private room and visitors are not allowed (in most hospitals) or visitors limited to 30 min a day to limit radiation exposure

3. Appropriate notices about radiation safety precautions/use (i.e., sign/sticker on door)

4. Staff members must wear dosimeter badges to monitor exposure

5. No pregnant staff members/visitors allowed, no children allowed to visit

6. Caregivers/visitors need to maintain a 6 foot distance when possible

7. Will have PCA pump + a foley catheter

8. As caregivers, we do interventions quickly so we do not have to stay in that room long

9. There are lead shields in front of the bed to prevent direct contact w/ radiation or you will need to wear lead apron when providing care

What does systemic radiotherapy involve?

List safety precautions for patients receiving systemic radiotherapy

Systemic radiotherapy: Involves IV administration of radioactive isotope to target specific tumor

Safety Precautions

1. Will be in private room and visitors are not allowed (in most hospitals) or visitors limited to 30 min a day to limit radiation exposure

2. Appropriate notices about radiation safety precautions/use (i.e., sign/sticker on door)

3. Staff members must wear dosimeter badges to monitor exposure

4. No pregnant staff members/visitors allowed, no children allowed to visit

5. Caregivers/visitors need to maintain a 6 foot distance when possible

6. Will have PCA pump + a foley catheter

7. As caregivers, we do interventions quickly so we do not have to stay in that room long

8. There are lead shields in front of the bed to prevent direct contact w/ radiation or you will need to wear lead apron when providing care

List the common side effects that any patient receiving any type of radiation therapy may experience

What later onset side effects of radiation therapy might patients experience?

Common side effects

1. Radiation dermatitis—mild erythema to open sores; w/ any radiation, particularly external radiation, their skin can have severe burns around radiation site

2. Hyperpigmentation

3. Alopecia

4. Alterations in oral mucosa

5. Xerostomia (dry mouth)

6. Change/loss of taste

7. Malaise

8. Anorexia

Later-onset side effects

1. Dysphagia

2. Incontinence

3. Cognitive impairment

4. Sexual dysfunction

What is chemotherapy?

When/why is chemotherapy used?

Risks associated with chemotherapy?

What is essential to prevent regarding chemotherapy? How is this achieved?

Chemotherapy: Treatment of cancer with chemical agents to cure and to increase survival time

• Drugs used for chemotherapy are systemic and exert their cell-damaging effects against healthy cells as well as cancer cells (so chemo cannot differentiate b/t healthy cells and cancer cells)

When/why is chemo used?

1. Used to reduce tumor size pre-op

2. Used to destroy CA cells post-op

3. Used as primary treatment for some CAs such as leukemia (no surgery for leukemia, just chemo)

Risks associated with chemotherapy?

• IV chemo has a high risk of damaging veins and surrounding tissues (b/c it is a vesicant)

• Chemo causes inflammation, tissue damage, necrosis of tendons, nerves, muscles, and blood vessels

What is essential to prevent regarding chemotherapy?

• Prevention of extravasation is essential w/ chemo:

How is this achieved?

1. Never give IV chemo in wrist, hand, or AC PIV—only time when a wrist or hand PVI can be used for chemo is if the chemo will be completed in 1 hour or less; b/f giving chemo through a wrist or hand or AC PIV, need to see if it draws back blood, if it does not draw back blood will not use, will start a new one

2. Prefer to use a central line, PICC, or port for these drugs b/c chemo is hard on veins = helps avoid extravasation and damage

What is the MOI of alkylating agents?

Example med?

Common side effects?

MOI: Bonds with DNA, RNA and proteins to impair DNA replication, RNA transcription, and cell functioning, all leading to cell death

Example: Cisplatin

Common side effects:

1. Bone marrow suppression,

2. N/V

3. Cystitis (cyclophosphamide, ifosfamide)

4. Stomatitis

5. Alopecia

6. Gonadal suppression

7. Renal toxicity (cisplatin)

8. Development of secondary malignancies

What is the MOI of nitrosoureas?

Example med(s)?

Common side effects?

MOI: Similar to alkylating agents; cross the blood–brain barrier

Example: Carmustine

Side effects:

1. Bone marrow suppression: leukopenia, thrombocytopenia, anemia, and pancytopenia

2. N/V/D

3. Anorexia

4. Mucous membrane deterioration

5. Hepatic and renal toxicity

6. Alopecia 

7. ***Capillary leak syndrome and pulmonary edema***--big side effect w/ nitrosoureas, when we think of this syndrome/pulm edema, the sx we look for is pink frothy sputum that leads us to think they have this

What is the MOI of topoisomerase I and II inhibitors?

Example med(s)?

Common side effects?

MOI: Causes breaks in the DNA strand by binding to the enzyme topoisomerase = prevents cells from dividing

Example(s):

Topoisomerase I Inhibitors: Irinotecan, Topotecan

Topoisomerase II Inhibitors: Teoposide, Teniposide

Common side effects:

1. Bone marrow suppression

2. N/V/D

3. Flulike symptoms (topotecan)

4. Rash (etoposide)

5. Hepatotoxicity (teniposide)

What is the MOI of antimetabolites?

Example med(s)?

Common side effects?

MOI: Inhibits DNA replication and repair

Example(s): Fluorouracil, aka 5FU

Common side effects:

1. GI toxicity

2. Bone marrow suppression

3. Alopecia

4. Skin rash—Fluorouracil shouldn’t be used with occlusive dressings

5. Pulmonary toxicity

6. Hepatic and renal toxicity.

What is the MOI of antitumor antibiotics?

Example med(s)? What should you remember about each of these medications?

Common side effects?

MOI: Interferes with DNA synthesis by binding DNA, prevents RNA synthesis

Example(s):

1. Bleomycin—can cause pulmonary fibrosis

2. Doxorubicin—aka “red devil” b/c it turns urine red—patients who get this should also get mesna b/c it protects the lining of the bladder (does not turn color back to normal, just helps prevent hemorrhagic cystitis)

Common side effects:

1. Bone marrow suppression

2. N/V

3. Alopecia

4. Anorexia

5. Cardiac toxicity (daunorubicin, doxorubicin)

6. Rd urine (doxorubicin, idarubicin, epirubicin)

7. Pulmonary fibrosis (bleomycin)

What is the MOI of mitotic spindle inhibitors?

Example med(s)?

Common side effects?

What is a major side effect to remember with mitotic spindle inhibitors?

MOI: Arrest metaphase by inhibiting mitotic tubular formation (spindle); inhibit DNA and protein synthesis

Example(s): Vincristine-

Common side effects:

1. GI toxicity, alopecia

2. Syndrome of inappropriate secretion of antidiuretic syndrome (SIADH)

3. Bone marrow suppression

4. Hepatic and renal toxicity

5. Cranial nerve issues

6. Muscle wasting

7. Neuritic pain

Mitotic Spindle Inhibitors—-Neuritic pain is a major side effect of mitotic spindle inhibitors, they can cause profound peripheral neuropathy

What is the MOI of hormonal agents?

Example med(s)?

Common side effects?

MOI: Bind to hormone receptor sites that alter cellular growth

Example(s):

1. Androgens and antiandrogens

2. Estrogens and antiestrogens

3. Progestins and antiprogestins

4. Aromatase inhibitors

5. Luteinizing hormone-releasing hormone analogues

6. Steroids

Common side effects:

1. Hypercalcemia

2. Jaundice

3. Increased appetite

4. Masculinization

5. Feminization

6. Sodium and fluid retention

7. N/V

8. Hot flashes

9. Vaginal estrogen dryness

What should the nurse do if a patient experiences severe side effects from a chemotherapeutic agent, but they are due for another dose?

1. When a pt experiences one of the severe side effects from one of the chemotherapeutic drugs, this would be a reason to hold the next dose (ex—if they have pulmonary edema w/ a nitrosurea like carmustine or if they are on vincristine and they have profound peripheral neuropathy)

2. If possible will draw a chemo level or additional lab values

3. Always notify the MD about signs/symptoms of toxicity and severe side effects

What are reasons that the nurse may choose to hold a patient’s next chemo dose?

What should the nurse do in these situations?

1. The patient is experiencing a severe side effect of the chemo med

• If possible will draw a chemo level or additional lab values

• Always notify the MD about signs/symptoms of toxicity and severe side effects

• Manage side effect

2. If the chemo they are receiving is making their values drop (i.e., super low plts, RBCs, WBCs, H&H, ect.)

• Replace whatever is low (i.e., low RBCS give PRBCs, lot plts give plt transfusion, give fresh frozen plasma)

• If replacement is sufficient, give next dose

What should the nurse always review before administering the next dose of chemo?

1. Assess patient for serious side effects

2. Review daily labs to see if the patient needs any form of replacement before admin of chemo (i.e., low plts, WBCs, RBCs, H&H)

1. How is dosage of chemotherapy determined?

2. What are the types of dosages patient’s can receive?

3. What should the administering nurse be aware of regarding the chemotherapy?

1) Dosage of chemotherapy is determined by total body surface area, weight, previous exposure, response to chemo/radiation, and organ function

2) Patients can get a standard-dose, dose-dense (more frequent) or myeloablative therapy (high-dose chemotherapy, often with radiation, designed to destroy all bone marrow cells so they do not react to the stem cell transplant—including cancer cells—often get right before a stem cell transplant)

3) Anyone preparing, giving, or disposing of chemotherapy drugs or handling excreta from patients within 48 hours of receiving IV therapy must use extreme caution and wear PPE

Why is it important for the oncologic nurse to stay on top of the review of their patient’s lab results?

The nurse should review the chemo patient’s daily lab work to monitor for severe side effects of chemotherapy such as a major drop in the patient’s lab values (i.e., super low plts, RBCs, WBCs, H&H, ect.)

This is important b/c:

• Disrupting the schedule or reducing dosages has a negative impact on therapy outcomes and leads to drug resistance among cancer cells, disease progression, and reduced survival = so we do not want to interrupt their schedule any more than we have too

—>Monitoring their labs closely and providing early interventions when necessary (i.e., PRBCs, plt transfusion, fresh frozen plasma) minimizes disruptions in chemo admin

1. What is extravasation?

2. How can extravasation during chemotherapy be prevented?

3. What are signs that extravasation has occurred?

4. What should be available on unit to manage extravasation if it occurs?

1) Extravasation is damage to the tissue from an infiltrated IV

2) Prevention of extravasation is a priority goal of chemotherapy admin; to help prevent extravasation:

1. Use PICC, port or other long term central venous access

2. PIV should only be used when chemo will take 60 mins or less, with frequent observations for signs/symptoms of extravasation and infiltration

3) When checking for extravasation look for redness, swelling, irritation

4) Medications (antidotes), heat packs, or cold packs, should be available on unit to manage extravasation (or contact pharmacy to get the antidote to reverse extravasation)

• Often when chemo has infiltrated, there is an antidote for infiltration, depends on the chemo you are giving—if you do not have a reference form on the unit, contact pharmacy to see what you need to do for infiltration—could be med to inject around infiltration, heat pack, cold pack, ect.

What are the common side effects of most chemotherapeutic agents?

1. Impair hematopoiesis: Bone Marrow suppression = low WBC + leads to low ANC (absolute neutrophil count) counts; increases risk of anemia and need for RBC/plt transfusion

• Low ANC = increased risk of infection (b/c neutrophils fight infection)

• For low RBCs and platelets the patient may need blood or platelet administration

2. N/V/D

3. Anorexia (due to lack of appetite)

4. Alopecia

5. Mucositis (really sore mouth, can tx w/ magic mouth wash—has lidocaine to help soothe the mouth)

6. Skin changes—increased risk of skin breakdown and rash

7. Anxiety

8. Altered bowel elimination

9. Changes in cognitive function— “Chemo brain”—altered cognitive function/forgetfulness

10. Decreased renal function and nephritis which are often irreversible

11. Decreased reproductive system health, possible sterility

What can be used to help treat chemotherapy induced anorexia?

1. Megace (megestrol acetate)—A synthetic progestin used to treat advanced breast or endometrial cancers and to stimulate appetite/weight gain in patients

2. Marinol—synthetic marijuana used to increase appetite in chemo patients

1. What is myelosuppression (bone marrow suppression) from chemotherapeutic agents?

2. What are the consequences of myelosuppression?

3. What do these effects put patients at high risk of?

4. So what are the goals of care for these patients?

1) Bone Marrow Suppression (Myelosuppression)—decrease in production of blood cells (RBCs, WBCs, Platelets)

2) Consequences of Myelosuppression:

• Decreases production of WBCs = weakens immune system (particularly from low ANC—low absolute neutrophil counts)

• Decreases production of RBCs = increased risk for anemia + need for RBC transfusion

• Decreases production of platelets = increased risk of bleeding + need for platelet transfusion

3) Patients are at high risk of infection, bleeding, and bruising.

4) For neutropenia—reduce risk of infection; for low RBCs/platelets—goals are to reduce risk of bleeding, injuries, and falls

Chemotherapeutic agents have the risk of causing bone marrow suppression.

How is chemo-induced neutropenia treated/managed?

1) Neutropenia (decreased WBC count, abs neutrophil count is low) may be treated with prophylactic antibiotics

2) Patients with neutropenia should be on neutropenic precautions

Neutropenic precautions include:

1. Need to be in a private room with reverse isolation (not negative pressure—that would blow germs from hall into room, should be a positive pressure room) for their protection

2. All visitors wear a mask for the patient’s protection

3. HEPA filter put in room to help purify the air

4. Careful hand hygiene

5. Educate patient’s/families on good hand hygiene

6. Neutropenic patients need to avoid contact with infections or recently vaccinated individuals

7. No need to avoid raw/fresh fruits/vegetables with neutropenic (FROG) this is not part of neutropenic precautions anymore

3) Filgrastim is used to increase neutrophil production in the bone marrow

Side effects:

• HA

• Fatigue

• Alopecia

• N/V/D

• Stomatitis (inflammation and sores in the mouth)

• Loss of appetite

• Anorexia

• Bone pain

• Cough

• Spleen rupture—if the patient starts c/o sharp abd pain when taking filgrastim, need to notify the provider immediately b/c they could be experiencing splenic rupture

A patient taking filgrastim to treat neutropenia induced by chemotherapy is c/o of sharp abdominal pain, what should you do as the nurse?

Notify provider about risk of spleen rupture

Chemotherapeutic agents have the risk of causing bone marrow suppression.

How is chemo-induced thrombocytopenia treated/managed?

1. Bleeding precautions:

• Soft toothbrush

• Electric razor

• Wear shoes

• Fall precautions

• If they do have any bleeding apply firm pressure for at least 5 mins

2. Oprelvekin is used to stimulate platelet production

Side effects

• N/V/D

• Fluid retention

• Fever

• Joint pain

• Arrhythmias

• Blood clots

• Optic neuropathy

• Respiratory difficulty

Chemotherapeutic agents have the risk of causing bone marrow suppression.

How is chemo-induced anemia treated/managed?

1) Epoetin alfa used to treat anemia by stimulating RBC production in the bone marrow

• Do not give epoetin alfa to pts with hemoglobin greater than 11 or SBP greater than 140**

Side effects

1. HA

2. Fatigue

3. Dizziness

4. Seizures

5. N/V/D

6. HTN

7. Edema

8. Chest pain

9. DVT

In what situation should you never give epoetin alfa?

Do not give epoetin alfa to patients with hemoglobin greater than 11 or SBP greater than 140

1. How might alopecia present in patients undergoing chemotherapy?

2. What are your priority nursing actions regarding alopecia?

Alopecia: Hair loss may occur as a whole-body hair loss or may be as mild as only a thinning of scalp hair, could also be complete hair loss

• Some of the hair may not grow back (i.e., may loose eyebrows, eye lashes, any body hair)

• Hair on head will normally come back, but will grow back different from before they lost their hair

Nursing Actions:

1. Talk with pts before they start losing their hair, connect them to appropriate resources, educate them on wigs—most chemo agents will cause alopecia, so it is best to start having conversations about alopecia b/f they start losing their hair, so that way they can start preparing for it, get them resources for hats, carves, wigs to help protect the head

2. Priority nursing actions are to teach avoiding scalp injury and assist in coping with the body image change

1. What is mucositis?

2. Recommendations to manage mucositis?

3. What can mucositis progress to? What sx are common with this condition?

4. What can these conditions lead to in the patient receiving chemotherapy? Based on this, what education/care should you provide?

1) Mucositis—A painful inflammation and ulceration of the mucous membranes lining the digestive tract, extending from the mouth to the anus

• Causes pain and interferes with eating and quality of life

2) Management

• Frequent oral care with soft toothbrush is recommended

• Avoid mouthwash with alcohol (it will burn them)

• Can use magic mouthwash (has lidocaine) to help with mouth pain and blisters, or a sodium bicarb mouth rinse

• Want to give antiemetics such as ondansetron an hour before their chemo to prevent vomiting, which will worsen the oral tissue integrity if they have mucositis or stomatitis

3) Mucositis can progress to stomatitis, which in an inflammation of the mouth around the gums

• Edema and erythema are common w/ stomatitis.

4) Due to increased pain, stomatitis/mucositis lead to poor oral hygiene, dental disease, dehydration and nutrition impairment

• So providing mouth care and educating them about mouth care is extremely important

Chemotherapy commonly causes cognitive changes.

1. What cognitive changes commonly occur?

2. What are these cognitive changes associated with?

3. How do these changes affect the patient?

4. What comorbidities can worsen chemo brain?

5. What is the priority intervention regarding these cognitive changes?

6. What education can you give patients to help manage cognitive changes?

1) Many on chemo have a decline in cognition and a decrease in the ability to process information

• Poor attention and concentration

• Impaired executive function and slower processing speed

• Will have difficulties w/ language, visual-spacial skills, memory, and learning

• Their cognitive function doesn’t always go back to normal after treatment or remission of CA

2) Chemo brain can be associated with the actual cancer or the treatment including: chemo, radiation, and surgery (any of it can cause chemo brain in patients)

3) This negatively effects the pts functional ability and quality of life

4) Other comorbidities such as age, mediations, organ function, and infection can all further worsen it

5) Priority intervention with cognitive function is teaching to prevent injury

6) Education on management of chemo brain:

• Increase exercise

• Increase time outside (walking, working in the garden)

• Educate that activity needs to be early in the day when they have more energy and encourage rest when they start feeling tired/depleted

• Fluid and electrolyte therapy

• Balanced nutrition

• Pain/infection management

CIPN (chemotherapy induced peripheral neuropathy) is a common side effect, what does this put patients at increased risk of?

CIPN = increased risk of falls, so patients w/ this need to be on fall precautions

1. What are biological response modifiers (BRMs) and what is their role in cancer therapy?

2. What are the main types and how do they work?

1) Biological Response Modifiers: Naturally occurring agents that alter the immunologic relationship between CA and the host (patient) to kill CA cells

= Modify the pt’s response to tumor cells—immunotherapy boosts the body’s immune system to fight the CA cells

2) BRMs and how they work

1. MoAbs (Monoclonal antibodies) antibodies that specifically target a certain antigen on CA cells to destroy CA and spares normal cells

• MoAbs are an immunotherapy as well as a targeted treatment

2. Cytokines act during every phase of the CA immunity cycle

• Antigen priming that increase the number of effector immune cells which induces CA cell death. There are 2 types of cytokines:

—>—>Interleukin therapy—is systemic so the treatment reaches all the parts of the body through the blood stream. Regulates inflammation and immunity

—>—>Interferons—cell-produced proteins; slow tumor division, stimulate growth and activation of NK (natural killer) cells, induce cancer cells to resume a more normal appearance and function and inhibit expressions oncogenes

What side effects can occur with biological response modifiers (BRMs)?

1. Fu-like symptoms including fever, chills, nausea, and appetite loss

2. Rashes or swelling may develop at the site where they are injected.

3. Blood pressure may also be affected, usually decreasing it

4. Fatigue

What is the main risk from oncologic emergencies related to?

List the common oncologic emergencies

The main risk from oncologic emergencies is due to immunocompromise, or due to the location of the CA or the treatment for the CA

Common oncologic emergencies

1. Sepsis and DIC

2. Spinal Cord Compression

3. Hypercalcemia

4. Superior Vena Cava Syndrome

5. Tumor Lysis Syndrome

These are all life-threatening, all need to be addressed immediately/are emergencies

Why are cancer patients at increased risk for sepsis?

What are patients with leukemia at higher risk of?

• Patients will have weaker immune systems due to the CA or the treatments for CA, which increases the risk of infection and sepsis

• Patients with blood CA such as leukemia have higher risk of neutropenia

1. What is DIC, and what is occurring during DIC?

2. S/s of DIC?

3. How is DIC treated?

1) DIC (disseminated intravascular coagulation)

• The proteins that control blood clotting become overactive

• The bloods ability to clot and stop bleeding is affected

• Small clots form inside the vessels which increases clotting factors and causes massive bleeding in other places

• DIC thrombocytopenia—decrease in platelet count and bone marrow suppression occurs

= patients w/ DIC are clotting and bleeding at the same time

2) S/s of DIC

• Bleeding—Uncontrollable oozing or bleeding from puncture sites, surgical wounds, catheters; spontaneous bleeding from the nose, gums, or mouth; blood in the urine or dark, tarry stools; lots of petechiae

• SOB/chest pain from blood clots in the lungs

• Swelling/pain in legs (from DVTs)

• Dizziness/confusion

• Jaundice

• Oliguria or anuria

3) Tx of DIC—patients w/ DIC need fluids, blood thinners, and blood products

1. Fresh frozen plasma is given to replace blood clotting factors

2. pRBCs and platelet transfusions are given for the bleeding

3. Anticoagulants (heparin) are given to prevent blood clotting

4. Fibrinogen (it is in the fresh, frozen plasma, but it can also be given separately)

Spinal cord compression is an oncologic emergency.

1. What occurs during this emergency?

2. What do the s/s of spinal cord compression depend on?

3. What s/s would the patient have for spinal cord compression caused by lung cancer?

4. What s/s would the patient have for spinal cord compression above S2?

5. What are the txs for spinal cord compression?

1) Spinal Cord Compression—Compression of the spinal cord and its nerve roots due to tumor suppressing the spinal cord. Will have local inflammation, edema, venous statis, and impaired blood supply to nerve tissues.

2) Signs and sx will depend on the location of the tumor.

3) If have lung cancer, tumor pressed against spine = decreased ability to walk

4) Bladder and bowel dysfunction occur if the spine is compressed above S2

• Compression of the spine above S2 can also cause neurologic dysfunction +related motor and sensory deficits (pain, numbness, and weakness)

5) Treatment for spinal cord compression

• Radiation therapy to reduce tumor size and halt progression; corticosteroid therapy to decrease inflammation and swelling at the compression site

• Surgery to debulk tumor and stabilize the spine if symptoms progress despite radiation therapy or if vertebral fracture or bone fragments lead to additional nerve damage

• Other surgeries: May be used for patients with vertebral fractures to attain stability of the bone, prevent nerve compression, and decrease pain

—>Vertebroplasty: involves percutaneous injection of polymethyl methacrylate (PMMA), a bone cement filler, into the vertebral body.

—>Kyphoplasty: a balloon is inserted into the damaged vertebral body and then inflated to create a cavity within the bone that can be filled with bone cement. The balloon helps to compress the fracture fragments together as the cavity is created.

• Goal of txs = to reduce the size of the tumor and prevent further progression.

Hypercalcemia is an oncologic emergency.

1. What occurs during this emergency?

2. What serum calcium and ionized calcium are considered hypercalcemia?

3. What are the cancers that most commonly cause hypercalcemia?

4. List clinical manifestations of hypercalcemia

5. How is hypercalcemia treated?

1) Hypercalcemia: Is a potentially life threatening metabolic abnormality resulting when the calcium released from the bones is more than the kidneys can excrete or the bones can reabsorb. (serum calcum > 10.5, ionized > 1.9—check)

2) Hypercalcemia ranges:

• Total serum calcium level >10.4 mg/dL (2.6 mmol/L)

• Ionized serum calcium >1.29 mmol/L

3) Commonly seen with lung, renal, and breast CA = most common cancers that cause hypercalcemia

4) S/s of hypercalcemia:

• Fatigue

• Weakness

• Confusion

• Decreased level of responsivenes

• Hyporeflexia

• N/V

• Constipation

• Ileus

• Polyuria (excessive urination)

• Polydipsia (excessive thirst)

• Dehydration

• Arrhythmias

5) Treatments (reduce serum calcium levels)

1. 2-4 L of fluid daily (unless contraindicated by renal or cardiac disease) or IV hydration followed by forced diuresis

2. Avoid dietary supplements and medications that can increase serum calcium levels (e.g., thiazide diuretics, nonsteroidal anti-inflammatory drugs; and vitamins A and D, and calcium supplements)

3. Stool softeners and laxatives for constipation (also increases # of BMs to help excrete more calcium)

4. Antiemetic therapy for nausea and vomiting

5. Maintenance of nutritional intake without restricting normal calcium intake (we do not want to restrict calcium intake unless the increased fluid we give them does not help, if that is the case we will cut back on dietary calcium they are receiving)

6. Place on continuous ECG due to arrythmias

Superior vena cava syndrome is an oncologic emergency.

1. What occurs during this emergency?

2. Common cause?

3. Clinical manifestations?

4. Diagnosis?

5. Treatments?

1) Superior Vena Cava Syndrome: Compression or invasion of the superior vena cava by a tumor, enlarged lymph nodes, or an intraluminal thrombus that obstructs venous circulation or drainage of the head, neck, arms, and thorax

• Leads to cerebral anoxia due to lack of oxygen to the brain + laryngeal edema

2) Most often associated with lung cancer

3) Gradual or sudden impaired venous drainage gives rise to: (sx occur b/c the tumor is not allowing blood to flow back to the heart)

• Progressive SOB, cough, hoarseness, chest pain, facial swelling

• Edema of the neck, arms, hands, and thorax w/ dysphagia and stridor

• JVD, dilated thoracic vessels

• Elevated intercranial pressures, visual disturbances, HA, AMS

4) Diagnosis confirmed by:

• Clinical findings

• Chest x-ray

• Thoracic CT scan

• Thoracic MRI

• Venogram if intraluminal thrombosis is suspected

5) Treatments:

1. Radiation therapy to shrink tumor or enlarged lymph nodes and relieve symptoms.

2. Chemotherapy for sensitive cancers (e.g., lymphoma, small cell lung cancer) or when the mediastinum has been irradiated to maximum tolerance.

3. Anticoagulant or thrombolytic therapy (to prevent clots from blood stasis)

4. Percutaneously placed intravascular stents (to get blood flowing correctly)

5. Supportive measures such as oxygen therapy, corticosteroids, and diuretics (in cases of fluid overload—helps w/ sx management)

6. Surgery is often very risk for superior vena cava syndrome

Tumor lysis syndrome is an oncologic emergency.

1. What occurs during this emergency?

2. Clinical manifestations?

3. What can be done to prevent tumor lysis syndrome?

4. Interventions (management/treatments) once tumor lysis syndrome has/is occurring?

1) Tumor lysis syndrome: When a large number of CA cells die within a short period, releasing their contents into the blood = CA is dying too fast

2) Clinical Manifestations:

Electrolyte: Hyperkalemia, hyperphosphatemia, hyperuricemia

Neurologic: Fatigue, weakness, memory loss, altered mental status, muscle cramps, tetany, paresthesias (numbness and tingling), and seizures.

Cardiac: Elevated blood pressure, shortened QT complexes, widened QRS waves, altered T waves, arrhythmias, and cardiac arrest.

Gastrointestinal: Anorexia, nausea, vomiting, abdominal cramps, diarrhea, and increased bowel sounds

Renal: Flank pain, oliguria, anuria, kidney injury, and acidic urine pH.

Other: Gout, malaise, and pruritis

3) Preventing tumor lysis syndrome:

1. Aggressive fluid therapy 24-48 hours before treatments are given to prevent tumor lysis syndrome from happening and after the initiation ot therapies

2. Identify at-risk patients

3. Institute essential preventive measures (e.g., fluid hydration, medications) as prescribed

4. Assess patient for signs and symptoms of electrolyte imbalances

4) Treatments:

1. Fluids and diuretics to increase UOP and prevent kidney damage

2. Allopurinol to prevent uric acid build up (hyperuricemia)

3. For hyperkalemia admin of IV sodium bicarb, regular insulin, and hypertonic dextrose and/or cation-exchange resin (sodium polystyrene sulfonate—binds K+ and eliminates through the bowels)

4. Administration of phosphate-binding gels, such as aluminum hydroxide, to treat hyperphosphatemia by promoting phosphate excretion in the feces

5. HD (hemodialysis) or CRRT when all the other txs don’t work

6. Continuous ECG monitoring due to dysrhythmias