Oncology, blood admin, musculoskeletal

Benign vs malignant

Benign

slow growth, doesnt spread, No generalized effects, cause localized, does not usually cause tissue damage/death

Malignant

undifferentiated, growth variable, Can cause anemia, weakness, systemic inflammation, weight loss, extensive tissue damage, eventually causes death unless controlled

Carcinogenesis

Some gene mutations: inherited
Most mutations acquired in specific cells
Genetics: BRACA1, BRACA2, ovarian, prostate, colorectal, melanoma

Family hx with cancer

Three generations; parent, sibling, child
Multiple cancers in one individual
Two or more close relatives with the same cancer
maternal and paternal sides

Refer for genetic testing, support if positive

Factors that induce carcinogenesis

Viruses: HPV, HepB, Epstein Barr
Bacteria: H. Pylori
Sunlight, radiation, tobacco, asbestos
Tobacco smoke, passive smoke, cigars, pipes, chewing tobacco, workplace Chemicals
fats, alcohol, salted/smoked meats. red/processed meats

Tobacco smoke is...

The most lethal carcinogen
Second hand smoke is also strongly correlated with developing lung cancer

the only way to confirm whether a tumor is cancerous or benign is with...

a biopsy/fine needle aspiration

staging

stage 1-localized
stage 2- local spread to nearest lymph
stage 3- extensive lymph involvement
stage 4- distant spread

what is TNM staging

tumor: extent of size
nodes: absence/presence of regional lymph involvement
metastasis: absence or presence

grading of tumors

grade I: well differentiated, resembles tissue of origin
grade IV: poorly differentiated, more aggressive

Use of radiation

prevent local recurrence, prevent metastasis, reduce tumor size
- replicating cells are most vulnerable

what are the body cells that undergo frequent cell division?

bone marrow
lymph tissue
epithelium of GI
hair follicles
ovaries
testes

radiation therapy

- altered skin integrity most common

acute toxicities: 2 weeks

normal cells within tx area are damaged, rapidly dividing cells

radiation therapy side effects

radiation dermatitis
anorexia, N/V/D
thoracic radiation (esophageal irritation, chest pain, dysphagia)

what is radiation dermatitis? what is the nursing management for it?

erythema, dry skin, wet desquamation, ulceration

AVOID USING soaps with scent, powders, lotions, ointments unless perscribed, aluminum deodorant, sun exposure, tight clothing, ice, heat

use ONLY room temp water to bathe area, no rubbing/scratching, only electric razor

nursing management for specifically wet desquamation

do not disrupt blisters, report blisters

avoid frequent washing

only perscribed ointment

non adhesive dressing

surgical treatment for cancer

diagnostic: biopsy (fine needle aspiration)
primary treatment
prophylactic surgery
reconstructive surgery
palliative

chemotherapy

kills rapidly dividing cells (IV, oral, intrathecal, intraabdominal)
MUST BE CERTIFIED TO ADMINISTER
TWO RN CHECK, chemo gear

manage N/V as side effect of tx

avoid strong scent
anti anxiety, antiemetic, steroids
no fried or spicy food
BLAND FOOD (baked chicken, baked potato, white rice, soup, coke/gingerale, pasta)

manage diarrhea as side effect of tx

avoid bran, seeds, nuts, coconut, dried fruit, raw veggies, dairy, very hot/cold food
imodium or lomotil per order
eat low fiber, low bulk

mouth effects and management

stomatitis (local), mucositis (anywhere in GI, painful), thrush

good oral hygiene, sodium bicarb or NS rinse 4x/day, soft tooth brush

mucositis is more specfic because...

it is more severe

eat bland/moist/soft/pureed foods, chilled foods, straw to bypass sores, lips moisturized, pain meds, topical anesthetic

other side effects of treatment

fatigue, psychosocial distress, neutropenia, myelosupression

myelosuppression is...

low RBC, WBC, platelets

What does a CBC with differential include?

-WBC count (neutrophils, basophils...)
-RBC count (hemoglobin, hematocrit, size, volume, shape, etc)
-platelet count (size, volume, shape, etc)

neutropenia management

neuopgen, neulasta (warm before giving, SQ)
HIGH INFECTION RISK
VS q4hr
monitor WBC daily
hand hygiene
private room
avoid rectal/vaginal procedures (caths)
encourage ambulation

what s/s should be reported with neutropenia?

fever > 100.5
chills
swelling
BP drop
cough
infection signs
absent signs

what is the biggest risk with neutropenia?

SEPSIS/SEPTIC SHOCK!
sepsis or two or more of:
fever > 100.4
HR >90
RR >20
WBC >12000 or <4000

septic shock is sepsis but with hypotension and circulatory collapse

how is thrombocytopenia defined?

platelets <150,000

thrombocytopenia management

petechiae is seen!!

- only electric razors, no IM injection, foley as last resort, soft toothbrush, no aspirin/NSAIDS

monitor H&H, VS changes, neuro, LOC for bleeds

anemia management

monitor VS, dyspnea, hypovolemia, O2 sat

aminister IV fluids/packed RBC

keep O2 >92

when is hair loss temporary? when is it permanent?

temporary with chemo
permanent with radiation

physical assessment with breast cancer

redness, prominent venous pattern, edema, new nipple inversion, ulcerations, rashes, spontaneous discharge
palpation of lymph

difference between breast malignant tumor and cysts

malignant tumor: hard, poorly defined, non tender
cysts: menstruating, well defined, freely moveable, possibly tender if premenstrual

if a breast mass is detected, you should take note in...

location
size
shape
consistency
border delineation
mobility

dx evaluation of breast cancer

40-44: annual screening IF YOU WANT

45-54: mammograms every year

55+: mammograms q2yr

continue screening if expected to live 10+ yrs

biopsies confirm diagnosis

high risk of breast cancer if...

multiple 1st degree relatives have early breast cancer, or breast/ovarian cancer in same family
DO GENETIC TESTING

surgical management of breast cancer

total/simple mastectomy

modified radical masectomy: removes axillary nodes!!!!! pectoralis major/minor muscle

What is the only way to diagnose cancer?

With a biopsy/fine needle aspiration

sentinel node with breast cancer

first node in lymph that gets drainage from breast tumor
SLNB is done and if positive ALND must be done, if negative there is no node dissection

complications of axillary lymph node dissection (ALND)

cellulitis
decreased arm mobility
lymphedema (chronic swelling, painful, arm weakness, tingling)
collateral lymph circulation
chronic when develops

how to prevent lymphedema in arm with ALND

avoid blood draws, IV insertion, BP, injections, only electric razor in armpit, suntan lotion, insect repellant, avoid objects >10lbs, skin trauma

radiation with breast cancer

for stage 1&2
5x/week for 5-6 weeks
mild erythema, breast area, fatigue

systemic chemotherapy with breast cancer

delay or prevent recurrrence and spread
may also use surgery and radiation
+ lymph
invasive tumor >1cm
poorly differentiated

hormonal therapy for breast cancer

depend on progesterone and estrogen for growth and nourishment, both means the greatest likelihood of responsiveness

lung cancer classification

small cell: very aggressive, rapid growth, spread rapidly
non small cell: poor survival rate

lung cancer s/s

asymptomatic until later
cough/change in chronic cough
dyspnea, hemoptysis, chest/shoulder pain, pain with bone mets, anorexia, weight loss

preventative early screening

fecal occult blood testing every year
flexible sigmoidoscopy q3yrs
colonoscopy q10yr

most common s/s of colon cancer

change in bowel habits!!
blood in stool, melena
unexplained anemia, anorexia, weight loss, fatgiue, abdomen pain, cramping, constipation, distension

Stages of cancer

1 - Localized to one region; early stage

2- Localized and adjacent. Example: right breast to right axilla

3- Localized, adjacent and another region Or organ.

4- Multiple organs or organ systems. Widespread.

Cancer grading is based on...

Type of tissue, differentiation, helps prognosis

Cancer radiation

Bone marrow, lymph tissue, GI epithelium, hair follicles, ovaries, testes
Localized treatment, altered skin integrity is most common

Injuries of soft tissues and joints

Contusion: bruise
Strain: injury to muscle or tendons
Sprain: injury to tendons or ligaments surrounding a joint
Dislocation: joint no longer in alignment
Subluxation: partial dislocation

Management of soft issue injuries

Rest, ice, compression, elevation

Fractures

Dx by s/s and x-ray

Emergency management:

- assess neuromuscular (nerve/blood), remove clothing, minimize movement, prevent damage

- immobilization: splints, cast, internal

- reduction: manipulation, screws, pins, plates, ORIF

Complications: shock, compartment syndrome, fat embolism

What is compartment syndrome?

a serious condition that involves increased pressure in a muscle compartment. It can lead to muscle and nerve damage and problems with blood flow
S/s: swelling, internal bleeding nerve injury, pallor, pins and needles

What is fat embolism?

Fat globules migrate into the blood stream and combine with platelets to form emboli

Cast or splint care

Neurovascular assessment: five p’s

Skin care: assess, protect, minimize friction

Safety: fall precautions, when to call

Education: limitations, restrictions, care at home, consider ADL

NO POWDERS! LOTION LIMITED!

Nurse needs to help patient get up FOR THE FIRST TIME

What are the 5 P's?

pain, pallor, pulselessness, paresthesia, paralysis
(Cap refill, can you feel touch, any pain, can you move)

Traction care

- Evaluate traction apparatus and pt position (maintain alignment, manage weight per prescription and correctly hanging)

- Assess and report pain promptly

- Frequent skin care (pin care, regular shifting position, special mattress/pressure reduction)

- VTE prophylaxis

- Exercises to maintain muscle tone and strength (active exercises every hour)

Hip/fracture care

Assessment: health hx, pain, neurovascular assessment, bowel/bladder elimination, skin condition, anxiety, coping

Post care: correct position and alignment (supine, HOB slightly elevated), abductor splints, avoid crossing legs, assess for dislocation

- NPO for possible surgery

Nursing management of trauma/injuries

Assess: 5 p's, alignment, skin integrity
Dx: impaired mobility, pain, fall risk, infection risk
Planning: priority, consider baseline, ADL focused
Interventions: manage pain, position, safety
Evaluate: compare to baseline, specific to pt

Osteoarthritis

Non inflammatory degenerative disorder; most common
Idiopathic
Secondary: previous joint injury, inflammatory disease
Risk factors: older, work related, female, obese

Arthroplasty- joint replacement

Surgical removal of unhealthy joint, replace with metal/synthetics
Hip, knees, fingers, joints most frequently replaced
TOTAL HIP ARTHROPLASTY (THA)
TOTAL KNEE ARTHROPLASTY (TKA)

Osteoporosis and management

Most prevalent bone disease in the world (leads to bone fracture)

- Reduced bone mass, deterioration of bone matrix, diminished bone architectural strength

- primary: women after menopause, osteopenia development w/o bone loss, interventions to reduce fracture risk

- secondary: meds affect bone metabolism, men more likely than women

MANAGEMENT: calcium, vitamin D, calcium rich foods, dairy, limit alcohol, no tobacco, weight bearing exercise, fall prevention

Osteomyelitis

Infection of the bone
Causes; secondary from soft tissue infection, direct bone contamination, bloodborne (s.aureus, pseudomonas, E. coli)
S/s: pain, edema, limp
Tx: IV antibiotics, may be long term, may need PICC line

Septic arthritis

Infection of joint (knee and hip most common)

Causes: 2/2 soft tissue infection, direct bone contamination, bloodborne (s.aureus, pseudomonas, E. coli)

S/s: VERY painful, edema, decreased ROM, may cause sepsis, pus/fever

Tx: prompt recognition and tx, IV antibiotics, aspiration of synovial fluid, immobilization

Nursing management of musculoskeletal disorders

Assess: 5 p's, alignment, skin integrity
Dx: impaired mobility, pain, fall risk, infection risk
Planning: priority, consider baseline, ADL focused
Interventions: manage pain, position, safety, calcium, vitamin D, weight bearing exercises
Evaluate: compare to baseline, specific to pt

Rheumatoid arthritis

Autoimmune disease, synovial inflammation, destroys cartilage, erodes bone
Risk: women 3x more than men, pollution, smoking, bacterial/viral illness
S/s: symmetric joint pain, morning stiffness >1hr, extra-articular s/s

Management of RA

Goals: prevent joint damage, reduce acute disease, minimize disability
Meds: DMARDs, TNF blockers, Steriods, NSAIDs, topical agents
Education: OT/PT, assistive devices, fall prevention, support groups, reconstructive

What could occur with long term steroid use?

Immunosuppressed, increased blood sugar, prolonged healing

What can happen with long term NSAID use?

Kidney issues, blood thinning

systemic lupus erythematosus (SLE)

Inflammatory autoimmune, effects ALL organs in body

Risks: women 4-12x than men, Caucasian less likely, genetic links, pollution, environmental, smoking

S/s: BUTTERFLY RASH, joint swelling, fever, fatigue

Management of SLE

Goals: prevent organ damage, reduce acute disease, minimize disability, prevent complications

Meds: monoclonal antibodies, steroids, antimalarial, NSAIDs, immunosuppressants

Education: routine screening, smoking cessation, avoid sun/UV, monitor s/s infection, adequate sleep, pregnancy

Gout

Most common form of inflammatory arthritis; primary or secondary
Risk: men more common, age, BMI, alcohol use, HTN, diuretic use
S/s: pain, redness, swelling, warmth

Gout management

Goals: protect joints, avoid triggers, pain management, promote mobility (decrease uric acid!)
Meds: colchicine, NSAIDS, steroids, allopurinol, probenecid
Education: low purine diet, active/passive ROM, low impact exercise, identify triggers

What food should you avoid with gout?

Organ meats, red meat, alcohol, shellfish

Nursing management of rheumatic disorders

Assess: 5 p's, alignment, skin integrity
Dx: impaired mobility, pain, fall risk, infection risk
Planning: priority, consider baseline, ADL focused
Interventions: manage pain, position, safety, meds to address issue
Evaluate: compare to baseline, specific to pt

Parkinson's disease

Slow progressive neurologic movement disorder DEC LEVELS OF DOPAMINE!!
Risks: more common in men than women, degenerative/idiopathic most common, symptoms usually begin in 50s, some causes early as 30s
S/s: tremors, rigidity, bradykinesia/akinesia, postural instability, dysphagia/micrographia (early symptom), dysphonia

Parkinson's disease management

Goals: improve function and mobility, independent ADL, adequate bowel elimination, maintain nutrition, coping/communication

Meds: dopamine agonist (LEVODOPA/CARBIDOPA), anticholinergics, antivirals, MOA inhibitors

Education: fall precautions, home modifiers, aspiration prevention, diet modifications, skin care, social support

Nursing management of Parkinson's

Assess: 5 p's, alignment, skin integrity
Dx: impaired mobility, pain, fall risk, infection risk
Planning: priority, consider baseline, ADL focused
Interventions: manage pain, position, safety, educate about meds
Evaluate: compare to baseline, specific to pt