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What causes cancer?
genetics
viruses
immune suppression
carcinogens
environmental
dietary
lifestyle
factors affecting response to chemotherapy
types of neoplasm
hematologic mealignancies vs solid neoplasms
characterisitcs of tumor
location
size/ tumor burden
growth rate
presence of resistant cells
ratio of sensitivity of malignant cells and normal target cells
adequate blood supply with adequate drug uptake
characterisitics of client
physical status
performance
age
co-morbidities
prior therapies
psychological status
social support
socioeconomic issues
nutrition
living conditions
expense of treatment
goals of cancer treatment
cure
control
palliation
cancer treatment options
hormone therapy
surgery
bone marrow transplant
chemotherapy
targeted therapy
radiation therapy
immunotherapy
combination chemotherapy
different therapies affect cancer cells differently
decreases drug resistance
enhances tumoricidal effect
reduces drug toxicity
Cell cycle non specific drugs
act during any phase of the cell cycle, including the Go (resting) phase.
Cell cycle specific drugs
exert their influence during a specific phase of the cell cycle
are most effective against rapidly growing cancer cells
Alkylating agents
cell cycle non specific
treat cancer
hematologic malignancies
leukemia
lymphoma
multiple myeloma
solid tumors
breast
lung
ovarian
bladder
uterus
MOA: kill fast growing cancer cells by altering DNA structure and preventing cell reproduction
Anti-metabolites
S-phase
cancer treatment
most effective againts hematologic malignancies:
leukemia
lymphoma
myelodysplastic syndrome
effective against solid tumors:
breast
head and neck
osteosarcoma
MOA: interferes with DNA synthesis
cyclophosphamide (Cytoxan)
MOA: prevents cell division
cell cycle non specific
oral or IV
severe vesicant
hydration is imperative to prevent hemorrhagic cystitis
administer in AM, void before bed
monitor for blood in urine
can give MESNA as a cytoprotectant to prevent hemorrhagic cystitis
other adverse effects: N/V, bone marrow depression, alopecia
methotrexate
MOA: interfere with DNA synthesis, repair, and cellular replication (S-phase)
IV, oral, topical
Adverse effects:
N/V/D
bone marrow depression
mucositis (may affect entire GI tract)
alopecia
cisplatin (Platinol)
MOA: inhibits DNA, RNA, and other protein synthesis
cell cycle non specific
IV Q 4 weeks
AE: N/V, bone marrow depression, peripheral neuropathy, ototoxicity, nephrotoxicity
monitor input and output, BUN, CREA (kidney function)
Fluorouracil (5-FU)
MOA: affect DNA and RNA synthesis
adverse effects:
N/V
bone marrow depression
burning, pain, itching at site of administration
stomatiitis is early sign of toxicity
mucositis
painful inflammation and ulceration of the mucous membrane lining the digestive tract
stomatitis
when mucositis is limited to mouth only
antitumor antibiotics
cell cycle non specific
MOA: kills cancer cells by stopping the synthesis of RNA, DNA, or proteins
chemotheraputic agents use to treat various cancers:
leukemia
lymphoma
soft tissue sarcoma
osteosarcoma
solid tumors
breast
bladder
ovarian
lung
bleomycin
dactinomycin
mitomycin
anthracylines
daunorubicin
docorubicin
idarubicin
epirubicin
bleomycin
MOA: inhibits DNA synthesis
AE:
mucositis
N/V
alopecia
pulmonary toxicity
hormonal inhibitor agents
cell cycle non specific
MOA: suppress the function of estrogens and adrogens (slows or stops growth of hormone deprendent cancers)
breast, endometrial, prostate
ease symptoms of some types
brain
renal
broadly classified as
sex hormones
antiestrogens
aromatase inhibitors
antiandrogens
gonadotropin: releasing hormone analogs
doxorubicin (Adriamycin)
MOA: inhibits nucleic acid and protein synthesis
cell cycle non specific
IV (vesicant)
AE:
bone marrow depression
alopecia
muscositis
cardiotoxicity
red urine, sweat, tears
antitumor antibiotic that treats cancer
think “ruby” red because it caues red discoloration
antiestrogens: tamoxifen (Novaldex)
oral
used to treat estrogen dependent breast cancers
MOA: binds to estrogen receptors in both malignant and normal cells
AE:
stroke/ thromboembolism
N/V
hot flashes
Aromatase inhibitors: anastrazole (Arimidex)
oral
used for breast cancer in postmenopausal women
MOA: blocks estrogen production
AE:
stroke/ thromboembolism
N/V
hot flashes
potential adverse affects of chemotherapy
hematopoietic:
neutropenia
thrombocytopenia
anemia
GI:
anorexia
taste change
N/V/D or constipation
mucositis
stomatitis
integumentary:
dermatitis (rash)
hyperpigmentation
alopecia
nail changes
urticaria
pruritus (itching)
Antiandrogens: bicalutamide (Casodex)
oral
MOA: binds to androgen receptors in cells of the prostate gland
AE:
low energy, libido
weight gain
potential for liver damage, monitor for jaundice
Plant Alkaloids
M phase specific
stop cell divison during mitosis
potential organ toxicities
neurotoxicity- nitrosoureas
ototoxicity- cisplatin
pulmonary toxicity- bleomycin
cardiotoxicity- doxorubicin
nephrotoxicity- cisplatin
hemorrhagic cystitis- cyclophosphamide
peripheral neuropathy- vincristine
bone marrow supression- antimetabolites
Plant Alkaloids: Taxanes and Vinca
Taxanes: docetaxel (Taxotere), paclitaxel (Taxol)
adv. breast cancer and non small cell lung cancer
AE: bone marrow depression, N/V, peripheral neuropathy
Vinca: vincristine (Oncovin)
IV (only in central line)
MOA: stops mitosis in M phase
AE: peripheral neuropathy, extravasation may lead to tissue necrosis (vesicant)
chemotherapy administration
usually requires 2 RNs
exposure to hazardous drugs pose a potential health risk to those who prepare, handle, administre and dispose of drugs
may be genotoxic, cardiotoxic, teratogenic, and may impair fertility
exposure may be direct or indirect contact
minimization of indirect contact
protective clothing
place linen with contaiminated body fluid in specially marked bag placed inside an impervious and labeled bag
double flush toilets with lid down for 48 hours following drug administration
keep chemo drugs out of reach of children
home care instructions for chemo patients
provide written information on treatment, diet, hydration, self-care
administration schedule, medication, side effects, management of side effects
avoid infection
oral hygiene
handwashing
avoid nail salons
consult with HCP before dentist
when to call HCP
Neoadjuvant theraphy
adjuvant med used to treat cancer
purpose- reduce primary tumor size, eliminate cancer cells that spread
treament- chemotherapy, hormone theraphy, targeted therapy, radiation therapy
primary therapy
adjuvant med used to treat cancer
purpose- eliminate tumor
treatment-surgery, radiation therapy
adjuvant therapy
adjuvant med used to treat cancer
purpose-eliminate remaining cancer cells
treatment- chemotherapy, hormone therapy, targeted therapy, radiation therapy
monoclonal antibodies
made in the lab that seek out anitgens, attatch to them, and mark them for destruction
used for:
cancers
autoimmune disorders
infections, like COVID 19
adverse effects
risk for infusion reaction
anaphylaxis
hematopoietic cytokines
signaling proteins that help mediate immune responses, inflammation, and hematopoiesis
3 types used to treat cancer or chemo side effects
interferons
communicate between cells to trigger the immune system in response to pathogens
hematopoietic cytokine
interleukins
activate and stimulate proliferation of immune cells
hematopoietic cytokine
hematopoietic growth factors
hematopoietic cytokine
promote production, growth, and differentation of blood cells
bevacizumab (Avastin)
MOA: prevents angiogenesis by attaching to the VEGF growth factors
AE:
HTN
hemorrhage
thromboembolism
GI perforation
not given within 28 days of surgery
colony stimulating factors
MOA: stimulate or regulate bone marrow cell growth, maturation, and differentiation
Erythropoietin- epoetin alfa (Epogen, Procrit)
AE:
bone pain, HTN, N/V/D, increase risk of MI/CVA
IV or SQ- 3/week
granulocyte colony stimulating factors (G-CSF)
filgastrim (Neupogen)
MOA: stimulates WBC (neutrophil) production, treat neutropenia
SQ or IV; Neupogen daily for up to 2 weeks
AE: drowsiness, fatigue, flu-like symptoms, nausea, bone pain
monitor absolute neutrophil count (ANC)
inform provider if ANC is <10,000
trastuzumab (Herceptin)
used to treat metastatic breast cancer
MOA: inhibits growth factor receptors (HER2 receptors) to prevent growth of HER2 + cancer cells
major AE is cardiotoxicity
Colony stimulating factors (interleukin 11)
oprevlekin (Neumega)
synthetic interleukin 11 (thrombopoietic growth factor)
MOA: helps prevent chemo induced thrombocytopenia, by stimulating thrombocyte production
SUB Q injection should be given 6-24 hours after chemotherapy is completed
AE: fluid retention (peripheral edema, exertional dyspnea)
interferon alpha 2b (Intron A)
MOA: inhibit reproduction and growth of cancer cells; increase phagocytic acitivity
route: IV, IM, Sub Q
AE: chest pain, alopecia, anemia, neutropenia, thrombocytopenia, flu-like symptoms
nursing interventions: monitor blood counts, may give tylenol for flu-like symptoms
interleukin 2
aldesleukin (Proleukin)
activates B and T lymphocytes to enhance anticancer immune response and inhibit tumor growth
IV
high risk med, should be in hospital setting when recieving
AE: risk of heart and lung problems, neutropenia, capillary leak syndrome (fluid in tissues, causes hypotension, reduced organ perfusion, edema, renal failure)
Macules
a discolored spot on the skin that is not raised above the surface
example: freckles
papules
small solid rounded bumps rounding from the skin that are each usually less than 1 centimeter in diameter (less than 3/8 inch across)
vesicles
small circumscribed elevation of the epidermis containing a serous fluid localized abnormal patch on a body part or surface and especially on the skin
plaques
localized abnormal patch on a body part or surface and especially on the skin
causes of skin lesions
eczema dermatitis
contact dermatits
drug induced dermatits
urticaria
psoriasis
rosacea
bacterial infections
fungal infections
viral infections - herpes simplex, herpres zoster
acne vulgaris
alopecia
burns- wound care
parasites
eczema (atopic dermatitis)
inflammation of the skin: reddening and itching, formation of scaly or crusty patches that may leak fluid (scalp, elbows, and knees)
may use topical coricosteroids
tacrolimus (Protopic)
pimecrolimus (Elidil)
1% cream
calcineurin inhibitor
fewer adverse reactions than corticosteroids
safe to use on face and neck
safe to use on patients > 2 years of age
for severe reactions
drug induced dermatitis
allergic reaction
characteristics
rash, urticaria, papules, vesicles
life threatening skin eruptions
stevens-johnson syndrome
penicillins can be a culprit
stevens johnson syndrome
disrupts skin/mucous membrane
flu like symptoms
develop rash-painful
blisters appear- eventually pop on own
once blisters pop 1st layer of skin is damaged, which means infection is a BIG risk
contact dermatitis
lesion is not likely to be systemic
characterisitcs- rashes, redness, blisters, hives, peeling, itching, ulcers
causes- poison ivy, poison oak
nonpharmacologic measures
avoid contact
cleanse skin immediately
protective clothing
drug therapy
patch testing
topical
systemic - oral meds
antipruritic baths- helps with itching
LEAVES OF 3, LET IT BE
psoriasis
autoimmune disorder
epidermis regenrates about every 20 days normally, with this disorder skin regenerates every 4 days
characteristics
chronic skin disorder that affects 1-2% of U.S. population
more common in whites than african americans
Erythematous papules and plaques covered with silvery scales (scalp, elbows, knees)
have periods of exacerbations/ remissions
severe or mild
severe psoriasis
biologic agents
etanercept (Enbrel)
subq injection site reactions and reactivation of TB
adalimumab (Humira)
moderate to severe
TNF-alpha inhibitor (tumor necrosis factor)
subq every other week
CI: active infection , cancer
adverse reaction: reactivation of latent TB, increased risk for infection
etanercept (Enbrel)
tumor necrosis factor (TNF) inhibitor, prevents binding of TNF to receptors and prevents the cell-mediated inflammatory response
increase rate of opportunistic infections or malignancy observed
given as weekly subq injections
common adverse reactions: injection site reactions, URI (upper respiratory infections), headache, nausea, rhinitis (stuffy nose)
TB test, CBC, C- reactive protein, and ESR
rosacea
chronic disease characterized by: persistent skin erythema, telangiectosias (dilated small blood vessels on the skin or mucous membrane), acne-like lesions of the face. Hyperplasia of the nose may develop (small bumps on nose). periods of exacerbation and remission
epidemiology: middle aged men
treatment:
no cure
metronidazole (metrogel) - topically BID
accutane may be beneficial in severe cases - women need birth control
category x drug
must use sunscreen
impetigo
bacterial infection
etiology:
staph aureus
population affected
children 2-5 years old
treatment
topical (mild- mod) - Bactoban
systemic (severe) - oral antibiotic therpy
contagious
verruca vulgaris (warts)
characteristics
hard, horny nodule, may appear anywhere on body
drugs for treatment
salicyclic acid (promotes desquamation)
acne vulgharis
try non-pharmacologic approach first
drugs:
topical: tretinoin (Retin-A)
systemic: isotretinion (Accutane), tetracycline
mild to moderate
side effects: burning, pruritus, erythema
cleanse face first, apply in thin layer, use sunscreen
topical: clindamycin and erythromycin creams
side effects: rash, pruritis, dryness, contact dermatitis
systemic: isotretinoin (Accutane), tetracycline
side effects of Accutane:
skin irritation, thrombocytopenia, nosebleeds, teratogenic effects
side effects of tetracycline:
photosensitivity, severe sunburn, teratogenic effects
acne vulgaris (systemic meds)
isotretinoin (Accutane)
severe, persistent, nodular cystic acne
pregancy category x
oral
avoid sunlight, contact lenses (ocular dryness), and use with tetracyline and vitamin A (increase adverse effects)
pregnancy prevention mandatory
2 pregnancy test prior to start then monthly
monitor CBC, glucose, and lipids
tetracycline (Doryx)
moderate acne
Tx 3-6 months for max effect
Category D
oral
sunscreen
dont take with milk or antacids- binds and becomes insoluble
pregancy prevention
alopecia
etiology
family history
aging
drug induced
febrile illnesses
pregnancy
myxedema (swollen, puffy skin, often in hypothyroidism)
treatment
minoxidil (Rogaine) 2%
finasteride (Propecia) 1 mg tablets
sunscreen
SPF
FDA recommends SPF 30 or higher , blocks 93.7%
national cancer institute states that women who use tanning beds more than once a month are 55% more likely to develop melanoma
Burns
topical drugs
mafenide (Sulfamylon)
side effects: burning sensations, blistering, superinfection, metabolic acidosis
silver sulfadiazine ( silvadene cream)
side effects: skin discoloration, local reactions, burning sensation, rashes, possbile lecuopenia
nursing interventions:
administer pain meds
monitor I&O
use caution with patients in acute renal failure
infection prevention and fluid resuscitation
Scabies
eruption of skin caused by female mites
lesions commonly occur between fingers, on extremeties, in axillary and gluteal folds, around trunk and in pubic area
major symptoms: intense itching and vigorous scratching may lead to secondary infections
spread through contact with upholstery and shared linens
lice
larger than mites
spread by infected clothing or close personal contact
require human blood for survival and die within 12 hours without host
may infest head, body, and pubic area
major symptom: intense itching due to release of saliva
permethrin (Acticin, Nix)
preffered tx for scabies and lice
1% for lice, 5% for scabies
leave on scalp and hair for 10 minutes
itching may last up to 2-3 weeks
adverse reactions: causes few systemic effects
local effects: pruritus, rash, transient tingling, burning, stinging, erythema, and edema
administration alerts
do not use on premature infants and children < 2
do not use on skin that has abrasion, rash, or inflammation
nursing interventions:
assess area daily for 1-2 weeks for reinfestation
louse eggs-nits
vitamin deficiency
lack that can cause cellular or organ dysfunction and slow healing/recovery from illness
RDA
recommended daily allowance
why do clients need vitamin supplements ?
inaquequate absoprtion
inability to use vitamins
increased vitamin losses
increased vitamin requirements
fat soluble
vitamins A, D, E, K
metabolized slowly
can be stored in fatty tissue, liver, and muscle
slowly excreted in urine
Vitamins A and D are toxic in large amounts
water soluble
vitamins B1, B2, B3, B6 (known as B complex vitamins ) and Vitamin C
are not stored in the body and are usually not toxic
requires steady, consistent suplemetation via diet
readily excreted in urine
vitamin A
function: essential for bone growth, maintenance of epithelial tissue, skin, hair, and eyes
source:
whole milk
butter
eggs
leafy green and yellow vegetables and fruits
deficiency conditions
dry skin
night blindness
vitamin D (Calciferol)
function: regulating Ca+ ( calcium) & phosphorous metabolism (needed for Ca+ absoprtion from intestine)
sources:
fortified milk
egg yolk
tuna
salmon
deficiency conditions
rickets (soft, weakened bones)
blood calcium deficit
Vitamin E
function: promotes formation & functioning of RBCs , muscle and other tissues
sources:
whole grain cereals
wheat germ
vegetable oils
lettuce
sunflower seeds
milk
eggs
meat
deficiency conditions
breakdown of RBC
Vitamin K
function: needed for synthesis of prothrombin & the clotting factors (7,9,10)
sources:
leafy green vegetables
liver
cheese
egg yolk
vegatable oil
tomatoes
deficiency conditions
increased blood clotting time with resulting bleeding and hemorrhage
reversal agent to warfarin (Coumadin)
vitamin B1 (Thiamine)
function: promotes use of sugars needed for good function of nervous sytem and heart
sources:
enriched breads and cereals
yeast
liver
pork
fish
milk
deficiency conditions
often given to ETOH abusers (alcohol abusers)
vitamin B2
function: promotes body use of carbs, proteins & fats by releasing energy to cells, required for tissue integrity
sources:
milk
enriched breads and cereals
liver
lean meat
eggs
leafy green vergetables
deficiency conditions:
blurred vision
photophobia (sensitivty to light)
cheilosis
rash on nose
numbness of extremities
Biotin
part of the vitamin B2 complex
necessary for fat and carb metabolism
sources:
meat
egg yolk
nuts, cereal
most vegetables
deficiency conditions:
anorexia
nausea
depression
muscle pain
dermatitis
Vitamin B3 (Niacin)
function: necessary for energy producing reactions & assists in nervous system
sources:
eggs
meat
liver
beans
peas
enriched bread
cereals
deficiency conditions:
retarded growth
headache
memory loss
anorexia
insomnia
Vitamin B6 (Pyridoxine)
function: essential building block of nucleic acids, RBC formation & synthesis of hemoglobin
sources:
lean meat
leafy green vegetables
whole grain cereals
yeast
bananas
deficiency conditions:
neuritis: caused by INH therapy (TB drug)
seizures
Vitamin B12 (Cyanocobalamin)
building block of nucleic acids, protein synthesis, RBC formation, fat & carb metabolism & functioning of nervous system
energy vitamin
sources:
liver
kidney
fish
milk
deficiency condition:
GI disorders
poor growth
anemia- pernicious anemia
vitamin C (Ascorbic acid)
common during flu season
function: folic acid metabolism, tissue repair, essential for erythropoiesis & enchances absorption of iron
sources:
citrus fruits
tomatoes
leafy green vegetables
potatoes
strawberries
deficiency conditions:
poor wound healing
bleeding gums
scury (bruising, bleeding gums, rash)
increased incidence of infection
folic acid
folate (active form of folic acid) is circulated to all tissues.
stored in the liver and tissues, it is essential for DNA synthesis
without this, cellular divison is disrupted
deficiency during the 1st trimester of pregnancy can cause neural tube defects such as spina bifida or anacephaly (underdevloped brain and incomplete skull) of the fetus
folic acid supplement
400 mcg each day for women
who have had previous NTD
taking certain medications
certain high risk pregnancies - take more
400 mcg = 4 mg
folic acid sources
leafy green veggies
yellow fruit and veggies
yeast
organ meats
black eyes peas
lentils, peas
dried beans
oranges
folic acid deficiency signs and symptoms
anorexia
nausea
diarrhea
fatigue
alopecia
blood disorder
stomatitis (swelling/ sores inside mouth)
iron
also known as ferrous sulfate, ferrous gluconate, or furmarate
60% of bodys iron is found in hemoglobin
foods rich are liver, lean meats, egg yolksm dried beans, green vegetables, fruit
side effects: nausea, vomiting, diarrhea, constipation, dark colored stools
elixir may stain teeth; oral hygiene
poisoning may cause cardiovascular collapse- usually in children
take on empty stomach with orange juice - vitamin C breaks down and helps absorb
iron routes
oral (ferrous sulfate most common)
IM ( Z-track: ferric gluconate")
IV ( iron destran- test dose: wait one hour)
iron poisoning
most common cause of pediatric death in U.S.
Tx: symptomatic & supportive:
suctioning
control of shock state
IV’s for dehydration
oxygen
whole gut lavage
stomach pump
copper
used for formation of RBCs and connective tissue
zinc
important to enzymatic reactions, important for growth and tissue repair, major role in wound healing, taste and smell
large doses may lead to copper deficiency , weakened immune response and decreased HDL
chromium
helpful in control of type 2 diabetes by increasing insulin’s effect on the cells
selenium
cofactor for antioxidant enzyme that protects protein and nucleic acids from oxidative damage. partners with Vitamin E
anticarcinogenic effect (doses < 200 mcg)
H2O facts
adult human body= 60% water
human embryo= 97% water
newborn infant= 70-80% water
fever increases water need by 15%
approximate daily water need for an adult is 15 ml/pound
LBS to KG
weight in pounds: kg weight X 2.2
weight in kilograms: weight in pounds divided by 2.2
Example:
150 IBS/ 2.2= 68.18 kg
75 kg X 2.2= 165 Ibs
Hypovolemia
loss of both Na+ and water- decrease in volume of extracellular fluid (causes diarrhea and vomitting)
signs and symptoms: marked thirst, dry mucous membranes, poor skin turgor, decreased urine output, tachycardia and slight decrease in systolic B/P
hypervolemia
causes: CHF, hypoalbuminemia, increased Na+ intake & primary Na+ renal retention
signs and symptoms: constant irritated cough, dyspnea, neck vein engorgement, hand vein engorgement & moist crackles in lungs
electrolytes in circulation
either a + cation or - anion charge and transmit nerve impulses to muscles and aide in the contraction of both smooth and skeletal muscles
intracellular: potassium, magnesium, calcium
extracellular (blood vessels and tissue spaces): sodium, chloride, and calcium
cations: potassium (K+), sodium (Na+), calcium (Ca+), magnesium (Mg+)
anions: chlroide (Cl-), bicarbonate (HCO3-), phosphate (PO4-), sulfate (SO4-)
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