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Leslie Wagner

on 19 November 2015

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Transcript of Cancer

Leslie Wagner, MS-RN
NURS 303

Diagnostic and Lab Tests
Labs: CBC, kidney function, LFT
Cytology: study of cells sloughed off by tumor
Biopsy: appearance of cells and degree of differentiation
Frozen section
Radiological studies: X-ray, GI series, IVP, radioisotopes, US
Endoscopy: broncoscopy, sigmoidoscope, colonoscope
Tumor markers: CEA, PSA, CA-125
Released by tumor
Used for monitoring tumor status after chemo
Bone Marrow Biopsy
Done for leukemia
Patient lies on stomach and MD inserts needle into sacral area
Patient will feel "pressure" sensation
Marrow squirted on a slide and cells analyzed
Staging and Disease Progression
Bone scan
CAT scan: computer axial tomography
PET scan: positive electron tomography
Cancer Prevention
Primary: Prevent it from happening with education
Teach lifestyle changes
Participate in talking to groups: health fairs, schools, civic groups
Secondary: early detection and prompt treatment
Screening: Breast
Clinical breast exam every 3 years between 20-39
Annually after 40
Fibrocystic disease
Typically if cancer, seen as a single mass/lump
Screening: Colorectal
At age 50, one of the following must be selected
FOBT (Occult blood) yearly
Flexible sigmoidoscopy every 5 years
Combine the two
Colonoscopy: every 10 years starting at 50
Screening: Prostate
Digital rectal exam and PSA
Yearly at 50, earlier with family history
PSA >4 needs further evaluation and biopsy
PSA between 2.5-4: monitor carefully
Screening: Cervix
Yearly starting 3 years past initiation of sexual intercourse but no later than 21
Pap smears yearly until 3 are negative and patient is over 30 with no history
If paps have been negative, every 3 years
Screening: Ovarian
No effective screening
Must teach awareness
Symptoms are vague:
Abdominal pain or bloating
Urinary frequency
Back pain
Weight loss
7 Warning Signs of Cancer
C: hange in bowel or bladder habits
A: sore that does not heal
U: nusual bleeding or discharge
T: hickening or lump in breast or elsewhere
I: ndigestion or difficulty swallowing
O: bvious change in wart or mole
N: agging cough or hoarsness
Use of specific enzymes, growth factors, and immune cells to alter the host immunity or to alter the biochemical process of the tumor
Modify the host response
Modify the tumor cell biology
Monoclonal antibodies
Hormone and Anti-hormone therapy
Drugs that are designed negatively alter the environment of the cells
Used for specific cancers that respond to hormones for growth
Breast, prostate, endometrium
Tamoxifen: estrogen blocker that causes hot flashes in pre-menopausal women
Prostate receptor blockers
Diagnosis and treatment of cancer
Tumor removal
Sometimes done to debulk the tumor
Large tumors have "resting" cells
Curative: Hodgkin's or leukemia
Palliative: reduces tumor size for comfort
Post-surgical: destroys what they were not able to clean out
It's job is destruction of fast growing cells
Chemotherapy: Administration
Combination of protocols
Cell cycle specific or non-specific
Cycles of administration
More effective with smaller tumors in phases of rapid growth
Large tumors contain more "resting" cells
Maximum dose achieves maximum results
Limitations may exisit due to myelosuppression and other side effects
Medications can be given tor myelosuppression
Can be given PO or IV
Some are considered vesicants and have to be given rapidly in large vessel
Check blood return
Nursing Considerations: Handling Chemo
Drugs are fetotoxic and some can be carcinogenic
Pharmacy mixes IV medications in controlled area
Use mask and gloves to administer
Dispose in biohazard area
Be careful of body waste when patient is on chemo
Injections held for platelets under 50,000
If platelets below 20,000 this is an emergency
Spontaneous bleeding
Hemorrhagic CVA
Platelet administration
Most concern is for thromobocytopenia and neurtopenia
White Blood Count
Common reason for death in cancer patients is infection
Check WBC before chemo cycles
If <4,000 chemo could kill the patient
Nurse's responsibility
Fertility and Side Effects
Decreased during treatment
May return to normal
Sperm banking
Side effects: N/V, low platelets and WBCs, hair loss, fatigue, weakness, mucous membrane compromise
Radiation Therapy: External
Cancer cells more sensitive to radiation
Daily treatment: 5 days/week for 4-6 weeks
Gamma rays pass through skin using cobalt beam
Takes minutes to complete
External Radiation: Side Effects
Destroys the tissue it passes through
General: "radiation illness"
Bone marrow suppression
Chest and bronchus
Male genetalis
Nursing Management
Patient is not radioactive
Skin will become very red and tender
Skin can sclerose and lose elasticity
Radiation causes a “burn”
Marks on skin should be left on
Lotions on skin may contain oil and cause burns
Avoid heat, cold and sunlight to the skin in the radiated area
Shields for the one administering
Internal Radiation
Brachytherapy (Sealed): the temporary or permanent placement of radioactive sources within or near a tumor
Intracavitary radiation: implanted “seeds” or rods
The patient is considered the source of radioactivity
Cervical cancer
Prostate cancer
Accidental rod removal
nurse should call radiation team to come and remove it
Long handled forceps, put in lead container
All the sheets etc need to be saved until the radium is located and removed
Adults only
Allowed for 30 minutes if they sit behind a lead shield away from patient HDR (High Dose Rate)
Unsealed Internal Radiation
Unsealed: patient drinks radioactive iodine and is considered radioactive
Must be apart from others
Geiger counter test
Discharge: must remain a certain distance from others and limit amounts of time for several weeks
Nursing Care:
Private room with lead walls
No pregnant or breastfeeding nurses
Body fluid are radioactive
TDS: Time, Distance, Shielding
Time: Limit exposure time in room to 30 minutes per shift
Distance: involves squares/meters
Exposure badge
Bone Marrow Transplant
Synegeneic: Identical twin with perfect match
Allogenic: related or non-related
Autologous: uses patient’s own marrow
Stem cell: plasmapheresis collection of cells after getting neupogen to stimulate production
Bone marrow aspiration for later re-infusion
Steps to BMT
Collect cells
Storage: harvested and frozen
Conditioning: high dose chemo and irradiation prior to new cell infusion
Infused via IV
8-12days for stem cells to grow
12-28 days for bone marrow cells to reproduce
Nursing Care and Complications
Isolation is strict for weeks
Highest risk is death by infection
Graft versus host disease: the donated bone marrow stem cells (graft) reject the patient’s body
Failure to engraft: donated stem cells fail to grow in the bone marrow
Most common in allogenic
Caused by too few living cells transplanted, attack or rejection on donor cells
Veno-occlusive disease: blockage of liver blood vessels by clotting and inflammation
Oncological Emergencies: Spinal Cord Compression
Neoplasm within epidural space; encroachment on cord
Emergency but rarely fatal if treated
Paralysis below level of lesion can occur
Neuro deficits result from compression by tumor
Vascular supply to neural structure becomes interrupted
Back pain and vertebral tenderness on percussion
Muscle weakness
Stiffness/heaviness of affected extremity
Foot drop
Unsteady gait
Sensory: B&B, loss of proprioception, deep pressure, position sense
Bone scan
Place on bedrest
Immediately started on steroid and radiation
Radiation: 2-4 weeks after to kill tumor and prevent further damage
Steroids: decrease edema and relieve symptoms, help with pain control
Surgery may follow to stabilize spine
Oncological Emergencies: Superior Vena Cava Syndrome
Venous flow obstruction created from lymph node enlargement in sternum
Obstruction of SVC and engorgement of vessels in head, upper extremities, upper thorax and collateral venous pathways occurs
Increased jugular venous pressure
Dilatation/prominence collateral veins in neck and upper thorax, telangiectasia (spider veins)
Cerebral edema
Headache, visual changes, dizziness
Pulmonary complications
dyspnea, tachypnea, cough, orthopnea, hoarseness and chest pain
CXR : abnormal in patients with SVCS
CT, MRI: may further define lesion
Bronchoscopy: establishes diagnosis in 70%
Mediastinoscopy, thoracoscopy, thoracotomy, SC lymph node biopsy
XRT: best response seen in lymphoma, SCLC
Chemo: best response seen in SCLC, germ cell
Surgery: bypass or stent
Remove obstructed catheters
Anti - coagulation treatment
Oncological Emergencies: Hypercalcemia
Most frequent oncologic complication
Serum calcium >10.5 mg/dl
Variable onset, often not noticed till severe
Etiology and Risk Factors
Bony metastases from any malignant primary tumor
Treatment of cancer with estrogens or anti-estrogens increases risk
ECG changes and dysrhythmias
Gastric groans
Psychic moans
Renal stones
Brittle bones
Isotonic solutions
Medications: Adreduia, didronyl
Lasix in conjunction with hydration
Discontinue precipitating meds
Chemo for underlying cancer
Oncological Emergencies: Tumor Lysis Syndrome
Metabolic imbalance caused by rapid cancer cell death
Untreated can result in uric acid nephropathy
Risk Factors
Bulky tumors
Chemo-sensitive tumors
Renal dysfunction
Oliguria, urine crystals, hematuria, flank pain, renal failure
Cardiac dysrhythmia
Muscle cramps, seizures from calcium drop
Elevated uric acid
Elevated BUN/Creatinine
Elevated phosphate
Renal US: rule out obstruction
Phosphate binders
Hydration: IVF and PO
Up to 3L in 24 hours
No bicarb
Emotional Support
Anticipatory Grieving
Encourage discussion
Patient communication with family regarding plans
Stages of grieving: shock, denial, anger, bargaining, depression, acceptance
Body Image Changes
Hair loss: 1-2 weeks after first chemo
Grows back: weeks after last treatment
Different texture and color
Hair loss is temporary
Purchase wig and turban before loss occurs
Body Image Disturbances
Weight loss
Amputated or altered body parts
Altered Nutrition
Keep food palatable
Small frequent meals
Spicy foods: tastes change
Food consistency
Soothing foods
Antiemetics and viscous lidocaine
Risk for Infection
Neutropenia: leading cause of death
Admittance with infection: priority
Monitor for s/s infection
Prophylactic antibiotics
Avoid invasive lines if possible
Risk for Infection
Neutropenic precautions
Fresh fruit
Fresh flowers
Good hand washing
Reverse isolation: for severely neutropenic
As soon as possible
Call with temp >99-100
Abnormal temperature elevations
Holding Chemotherapy
Low platelets
<20,000: Emergency
<50,000: concerning
Blow nose gently
Avoid constipation
Avoid increasing ICP
No IM injections
Altered Oral Mucosa
Caused by chemo and/or radiation
Alters oral mucous membranes because of the rapid growing cells present
Prevent with excellent hygiene: brushing and flossing
Patient Teaching
Oral care: after meals and bedtime
Soft brush or oral sponges: minimal bleeding expected
Floss only when no gum bleeding
No tobacco
Extreme hot or cold foods should be avoided
Medications: magic mouth wash, mycostatin, mycelex troches, BMX
Viscous lidocaine
Avoid alcohol based/commercial mouth washes
Nursing Diagnosis
Fluid volume deficit: N/V/D and decreased ability for intake
Fluid selection and timing
Hydrate well to prevent sclerotic effects of chemo on kidneys
Monitor I&O, electrolytes
Other Nursing Diagnosis
Potential for altered skin integrity
Overwhelming in early stages
Walking program or oncology rehab
Social Isolation
Altered Comfort
Pain: medicate with maximum dose until pain under control
Sleep disturbances
Full transcript