exam 4 Flashcards
Can affect people of all ages
Most cancers occur in people > 65 years of age
More than 1.5 million people are diagnosed with CA each year
Leading cause of death among cancers:
-Lung
-Prostate
-Colorectal
Combination of managing illness and psychosocial factors
Determine which crisis the patients want to treat and which ones they don’t (risk/benefit ration)
Which treatments can be suspended?
Patho
-Cancer is characterized by the presence of the following:
–Cellular or genetic changes within the body
–Abnormal cell proliferation or growth
–Unchecked local growth and invasion of surrounding tissue
–Ability to metastasize to distant organs
-Hallmark: cells no longer resemble what they originally were (now they’re foreign)
-Lymph carries blood, so close to this spreads faster
cancer
Neoplasms – a new and abnormal growth of tissue in some part of the body
Malignant cells have abnormal regulation of growth (worse)
-Cancer cells continue to grow even at expense of the host
-Follows no physiological demand
-Uncontrolled growth
Benign – not harmful in effect (of a tumor) (could be in a bad area and obstruct ducts, etc)
-Not malignant
-Does not invade surrounding tissue
Benign neoplasms
-well differentiated, resemble cells in the tissue of origin
-usually encapsulated
-progressive and slow
-doesn’t spread
Malignant neoplasms
-cells are undifferentiated, bear little resemblance to cells in tissue of origin
-grows by invasion
-variable rate of growth - can be rapid
-gains access to blood and lymph channels to metastasize
cancer 2
Diagnosis
-Complete H&P: unexpected changes, bleeding, pain
-Diagnostic tests determined on s/s of patient: if lump, take picture (1. size/extent of tumor/location 2. metastasized? 3. effects on where it’s at like pancreas = pancreatitis 4. biopsy for grading)
-Tumor Staging and Grading
–Staging – determines the size of the tumor and extent of the disease
—TNM system
–Grading – refers to the classification of the tumor cells
—Find the tissue from where the CA originated
Management
-Surgery
–Diagnostic surgery: check location - cut out piece/whole thing; send down to frozen section, keep removing as need
–Surgery as primary treatment
–Prophylactic surgery: remove r/t high probability of cancer - like breast cancer
–Palliative surgery: removed without ability to cure (if it’s blocking blood flow, etc)
-Multidisciplinary approach
-Other combined treatment methods – radiation & chemotherapy
cancer 3
Ionizing radiation is used to interrupt cellular growth
Palliative radiation – relieves symptoms of metastatic disease
*Cells that undergo cell division are most sensitive
-Bone marrow, lymphatic tissue, epithelium of GI tract, hair cells, gonads
External & internal radiation (brachytherapy) (insert radiation into cancer)
NM
-Safety Precautions with implanted radiation
-Limit visitors and time with patients
–30 minute daily max, stand 6 feet away from radiation source
-Private rooms
-Posting radiation safety precautions: shows exposure of radiation
-Staff members wear dosing monitors
-No pregnant women or children r/t they have lots of growing cells
-Education on radiation source – external vs. internal
-Protecting skin
–Avoid lotions, ointments, and powders on treated area
–Gently cleanse skin with mild soap with fingertips & gently pat dry
–No emollients (even approved) 4 hours prior to radiation treatment
-Protecting oral mucosa
–Provide gentle oral hygiene & use daily fluoride
–Use bland mouth rinse before and after meals
Radiation therapy safety
1. time
2. distance
3. shielding
radiation therapy in cancer
Antineoplastic agents are used to destroy tumor cells by interfering with cellular functions (replication) through meds
Used to treat systemic disease and not localized lesions
Often combined with surgery and radiation (or both)
Chemotherapeutic agents are characterized by their relationship to the cell cycle
Administered PO, IV, IM, SQ, arterial, intracavitary, intrathecal, topical
NM
-Monitor for extravasation with IV vesicants
-Indications:
–CVC = pain in upper arm, upper back, chest, neck, or jaw (port, triple lumen - Huber needle placed wrong –> flow under skin –> extravasation of vesicant)
–Absence of blood return from IV catheter (in wrong place)
–Resistance to flow of IV fluid (in wrong place)
–Swelling, pain, or redness at the site (in wrong place)
-If occurs - Stop infusion immediately
-Then aspirate any residual drug in the line (take empty siring and pull back as much as possible - warm cloth isn’t enough)
-Administer the antidote
Don’t want absorption into the skin
-GI System – nausea and vomiting most common side effect (premediate with Zofran)
-Hematopoietic System – myelosuppression
–Leukopenia: low WBC
–Anemia: low RBC
–Thrombocytopenia: low platelets
(all those s/e of chemo)
-Reproductive System – possible sterility
-Alopecia
chemotherapy
chemo is poison
Obstruction of the superior vena cava (SVC)
Blockage-> pleural effusion-> facial (see 1st), chest, arm, and neck edema-> impaired cardiac filling r/t not draining properly
SVC collects blood that drains from the
head and neck and upper thoracic cavity
Treatment
-Diagnostics: spiral CT with contrast
-Radiation therapy to shrink to decrease compression
-Chemo, if the tumor is responsive
-Antifibrinolytics or anticoagulants (if hypercoagulability is cause)
-Stent placement (issue = device can clog like others)
-Steroids (decrease swelling and obstruction)
NM
-Avoid chest and neck catheter placement
-AIRWAY
–Avoid lying flat
–Short term intubation
–O2 therapy
-Medications
-Avoid Valsalva (close mouth, breather/pressure)
-Elevation of arms to get excess fluid drained
-Assess for complications:
–fluid = excess edema, fluid -> HF
–pressure on SVC can rupture vessel
–excess fluid in lungs -> pneumonia
superior vena cava syndrome
oncologic emergencies
Tumor/clot -> compression/obstruction of SVC -> collects excess fluid
Risks:
-chest, neck or epigastric tumor (more likely to compress SVC)
-devices in the SVC (has fibrin clot on it) (especially triple lumen r/t more lumens = higher risk r/t tube/catheter is bigger)
-hypercoagulability syndromes
S/S
-Periorbital and conjunctival edema 1st
-Facial swelling 1st
-Stoke’s sign (collar shirt is tightening)
-Visual disturbances, headaches, Altered LOC (fluid going to brain -> cerebral edema)
-Distention of veins in the thorax (late) trachea –>
-Dysphagia, dyspnea, cough, hoarseness
-Tachypnea (compensate for narrow airway)
-Pleural effusions
-More prominent in am r/t less movement and decreases throughout day
superior vena cava syndrome 2
oncologic emergencies
Tumor/clot -> compression/obstruction of SVC -> collects excess fluid
Tumor cells or vertebrae put pressure on spinal cord or broken vertebrae from bone metastasis
What (pathophysiolocally) will happen to these patients? - compression of tumor -> pressure on cord -> decrease circulation -> ischemia/neuro issues
For long term survival you need…
-Favorable diagnosis (treatable/responsive to treatment)
-No visceral metastases
-Long course radiation therapy schedule
S/S
-Pain
-Early = Sensory changes
-Elimination changes (emergency)
-Cauda equine “horse’s tail”: loss of bladder function (emergency)
-hypotension, bradycardia, temperature fluctuation r/t spinal column is compressed
-Autonomic dysfunction
-What might you hear patient’s say? slipped disc = numbness/tingling down back, cold skin, don’t feel light touch
spinal cord compression
oncologic emergencies
Treatment -Diagnostics -Corticosteroids -Radiation therapy -Laminectomy and decompression: remove tumor/pick out bone fragment to decrease pain on spinal column -Vertebroplasty: use cement to bind broken bokes (falls can sever spinal column) -Chemo (if chemo sensitive) NM -Good Assessments/documentation (5 P's) -Treat the patient’s symptoms --Pain meds --Bedrest careful transfers (halo traction) --ROM --Bowel retraining --Urinary Catheterization --Skin integrity
spinal cord compression
oncologic emergencies
Metabolic com plication- serum calcium > 11 mg/dL
Most common emergency r/t metastasis of bone
Most common cause:
-Bone with metastasis release more calcium into the extracellular fluid than can be filtered by the kidneys and excreted in the urine
High Risk Cancers:
-Bone metastases
-breast cancer
-Lung
-GI
-Hematological
-Renal: issue r/t kidneys pull out calcium
-Thyroid: r/t parathyroid hormone regulates calcium
-Other risk factors: immobility, renal insufficiency, head/neck radiation with N/V/A -> malnourished/dehydration
hypercalcemia
oncologic emergency
serious diagnosis
sometimes find this before cancer diagnosis
S/S -Nausea -Constipations -Polyuria -Mental status changes --Somnolence --Combativeness --Confusion Treatment -lab work -ECG/telemetry may show bradycardia and prolonged PR, QRS, QT if symptomatic -IV fluids: dilute it out and make it less concentrated (if renal issue this is harder) -Dialysis NM -Watch for constipation -Careful I&O with increased fluids: ensure what goes in comes out -K+ supplementation -Increase oral fluids -Eat salty foods -Remain physically active -Limit dairy and Vit D foods
hypercalcemia
oncologic emergency
serious diagnosis
sometimes find this before cancer diagnosis
Results from rapid destruction of a large number of tumor cells
-Fast growing and chemo sensitive
Occurs within 24-48 hours after chemotherapy
Can lead to renal failure MODS – Death
S/S
-Hallmark manifestations (and 3 causes of tumor lysis)
–Hyperkalemia (>6)
–Hyperuricemia (>10)
–Hyperphosphatemia (>10)
–Hypocalcemia (<6)
-Uremia due to renal failure
-Possible fluid volume overload
Treatment
-Treat electrolyte imbalances
–Potassium: kayxelate to decrease K - immediate = insulin
–Phosphate
—Calcium carbonate
—Calcium acetate
—Sevelamer – phosphate binder
–Control of hyperuricemia
—Allopurinol: can give ahead of time PRN
–Adequate hydration
NM
-Cardiac Monitoring/telemetry
-Force fluids
-Monitor labs/electrolytes
-Monitor for infections: bone marrow suppression -> decrease WBC/Platelets/etc. so can’t fight infection
-Monitor for bleeding – thrombocytopenia
-Assess and manage stomatitis: sensitive to radiation - can inflame - keep dry/moist
-Manage nausea and vomiting with Zofran
-Maintain skin integrity
-Improve nutritional status: small frequent high calorie
-Relieve pain: light/music therapy, acupuncture, narcotics (risk for tolerance/constipation)
-Promote self-care activities at home to give patient back power
tumor lysis syndrome
oncologic emergencies
metabolic
can predict - fight cancer with chemo/radiation, kill it, release to blood -> tumor lysis syndrome
Risks = damage to kidneys
Hypothalamus: regulates hunger, thirst sleep, body tempt
Pituitary Gland – posterior and anterior: controls other endocrine glands, influences growth, metabolism and regeneration
Thyroid Glands – thyroid hormones & calcitonin: regulates energy, metabolism
Parathyroid Glands – PTH: secretes hormones necessary for calcium absorption
Pancreas: digestion of protein, fats, carbs, produces insulin/control BS
Adrenal Glands: secretes cortisone, adrenaline, regulates metabolic process
endocrine system is made of up this
Produce the following: -Thyroxine (T4) & Triiodothyronine (T3): metabolism, growth/development, metabolic rate -- too much/overproduce = hyperthyroidism and graves disease -- too little = hypothyroidism -Calcitonin Gland produces too much hormone -Hyperthyroidism -Grave’s disease Gland does not produce enough hormone -Hypothyroidism
2nd most prevalent endocrine disorder
Increased thyroid hormone production
-Results in overproduction of T3 &/or T4
These patients have a significantly increased metabolic rate
Causes:
-Graves disease, thyroiditis, overmedication, thyroid nodules r/t tumor produces too much
Graves disease: cause of hyperthyroidism
- Autoimmune disease of the thyroid gland
- Antibodies bind to TSH causing the overproduction of hormones
- Symptoms may appear after an emotional shock, stress, or infection – relationship not understood
- Overproduction of TSH by pituitary gland and TSH is what makes T3/T4
hyperthyroidism
S/S
-Weight loss with increased appetite
-Heat intolerance – excessive sweating
-Flushed skin
-buldging eyes
-Nervousness: can’t sit still, overly active
-Palpitations: sinus tachy or a fib
-Frequent bowel movements
-Muscular weakness and fatigued easily
Untreated = delirium, heart failure
Nursing assessment
-Palpation of enlarged thyroid gland: note any tenderness, pain, pulsations, bruie?
-Assess for respiratory distress: thyroid could block trachea/compress airway
-Monitor cardiac function – telemetry
-Body temperature: risk for hyperthermia so cool bath/clothes (don’t want pt to shiver r/t that increases metabolic rate)*
hyperthyroidism
Diagnosis:
-Look at both manifestations and laboratory/diagnostic data
–Total T4 (thyroxine): increase in hyper, decrease in hypo
–Free T3 & free T4 – will be elevated r/t excess amount being produces already
–TSH – extremely low levels
–Radioactive Iodine Uptake
–Fine Needle Biopsy: check nodule for malignancy, 1st for nodule
–US: check structure for cysts, nodules, etc.
–ECG
Treatment
-Anti-thyroid medications
–Propylthiouracil (PTU) & Methimazole (Tapazole)
-Iodine solutions – Na+ iodide or K+ iodide
-Glucocorticoids: inhibit thyroid release
-Radioisotope Iodine 131 Therapy (usually cured in 1 dose)
–Goal is to destroy overactive thyroid cells
-Thyroidectomy – Surgical removal of most of the thyroid gland: post op concern is airway*
-Beta blockers – Propanolol (Inderal): decrease HR, BP, and work on heart
NM
-Treat precipitating factors
-Administer IV fluids as ordered
-Monitor airway: trach tray at bedside* be prepared to lose airway (intubation is hard)
-Give extra O2 r/t body increase metabolic demand so want to increase tissue oxygenation
-Monitor cardiovascular – assess BP, HR, and rhythm
-Monitor neurological status
-Monitor for hyperthermia – give antipyretics, cooling
-Nutritional support: increase metabolic demand r/t it uses up calories/diarrhea
hyperthyroidism 2
Severe form of hyperthyroidism – medical emergency
Abrupt onset - associated with physiological and psychological stress
Often referred to as thyroid storm
Sudden release of thyroid hormones causes hypermetabolic state
Stimulates sympathetic nervous system
Risk Factors:
-Infection, trauma, stress, medical illness, pregnancy, exposure to cold
Admitted to ICU for supportive measures
-Antithyroid meds, steroids, continuous nursing care
Manifestations:
-Delirium
-N/V
-Hyperpyrexia (102 – 106) High fever*
-Tachycardia (>130 bpm) & hypertension
-Mental status changes & psychosis
-Multisystem organ failure
Untreated = heart failure, MI, total cardiovascular collapse, coma, death
thyroid crisis
with hyperthyroidism
like hyperthyroidism on crack
Have decreased thyroid hormone production
-T3 & T4
Slow onset – 10 times more common in women
Severe hypothyroidism
-Myxedema = non - pitting edema throughout the body
Can be primary or secondary
Patho
-1. Primary hypothyroidism (thyroid is the issue) – thyroid gland unable to produce the amount of hormones the pituitary gland is requesting
–Thyroid gland is the problem
-Possible causes:
-Hashimoto’s Thyroiditis
-Congenital defects
-Loss of thyroid tissue post treatment or thyroidectomy
-Iodine deficiency
-Medications - Amiodorone (Cordarone) therapy – contains iodine
-2. Secondary hypothyroidism (pituitary is the issue)– the pituitary gland is not stimulating the thyroid to produce hormones
–Pituitary gland is the problem
-May result from:
–Pituitary TSH deficiency
–Peripheral resistance to thyroid hormones
hypothyroidism
Hashimotos Thyroiditis
- Most common cause of goiter and primary hypothyroidism
- Autoimmune disorder, antibodies develop that destroy the thyroid tissue
- Goiter in early stages due to TH deficiency
Myxedema Coma
-Life threatening complication of long standing, untreated/uncontrolled hypothyroidism
-Triggered from infection, trauma, med incompliance, stress
-Characterized by:
–Severe metabolic disorders
–Cardiovascular collapse
–Impaired mentation
–Coma or near coma
Treatment
-Maintain airway*, cardiac status, increase body temperature, increase thyroid hormone levels, increase F/E balance
hypothyroidism 2
Serum TA -Hyperthyroidism: increased -Hypothyroidism: normal Serum TSH -Hyperthyroidism: decreased in primary hyperthyroidism -Hypothyroidism: increased in primary hypothyroidism Serum T4 -Hyperthyroidism: increased -Hypothyroidism: decreased Serum T3 -Hyperthyroidism: increased -Hypothyroidism: decreased T3 uptake -Hyperthyroidism: increased -Hypothyroidism: decreased Thyroid suppression -Hyperthyroidism: increased RAI uptake and T4 levels -Hypothyroidism: no change
lab values in thyroid disorders
S/S
-Goiter
-Fluid retention and edema r/t slow metabolism with hypothyroidism or slow blood flow and decrease perfusion to kidneys
-Weight gain with anorexia
-Constipation
-Dry skin
-Dyspnea: r/t weak/slow respiratory drive
-Pallor
Treatment
-Levothyroxine (thyroxine, T4) is treatment of choice
-Surgery may be indicated for large goiters
–Respiratory difficulty
–Dysphagia
hypothyroidism 3
Parathyroid glands secrete parathyroid hormone (PTH)
Causes an increase in PTH which affects kidneys and bone
*PTH regulates calcium levels
-High PTH levels cause high Ca++
Normal = 8.5-10.5 mg/dL
Patho
-Increased PTH levels cause the following:
-Increased reabsorption of calcium and excretion of phosphate
–Increases risk of renal stones
-Increased bicarbonate excretion, decreased acid excretion
–Results in metabolic acidosis and hypokalemia
-Increased release of calcium and phosphorus from bone
-Deposits of calcium phosphate into soft tissues and kidneys
Types:
1. Primary: occurs with hyperplasia of 1 of the parathyroid glands
2. Secondary: compensatory response to chronic hypocalcemia (increase PTH -> increase Ca levels)
3. Tertiary: results from hyperplasia of parathyroid glands
Hyperparathyroidism
S/S:
-Pathologic fractures r/t Ca being pulled from bones
-Muscle weakness and atrophy: increase Ca=neuromuscular depression
-Proximal renal tubule function altered: polyuria and increase thirst
-Metabolic acidosis
-Arrhythmias: acute increase in Ca can lead to cardiac arrest
-Renal calculi formation
-Polyuria
-GI problems: constipation from excess calcium
Treatment
-Diagnosed by excluding all other causes of hypercalcemia
-Treatment geared at decreasing Ca+ levels
–If severe, requires hospitalization and IV fluids
-Meds include:
–pamidronate (Aredia)
–alendronate (Fosamax)
–soledronate (Zometa)
–*Calcitonin: lower plasma levels of calcium by inhibiting bone reabsorption
-Rapid reversal: IV Na+ phosphate or K+ phosphate: give sodium or potassium phosph and make sure they don’t get too low
-Removal of parathyroid glands
NM:
-Provide hydration therapy
–Avoid thiazide diuretics
–At risk for kidney stones so dilute and give >2 L r/t decrease excretion of calcium
-Avoid foods and medications containing Ca++
–These can all increase Ca++ levels
-Encourage activity – bones exposed to stress release less Ca++
-Manage Hypercalcemic Crisis
–Calcium >15 mg/dL result in neurological, cardiac, and renal symptoms that are life threatening
hyperparathyroidism
Occurs because of low PTH levels being secreted from parathyroid glands
Without PTH, there is decrease of GI absorption of dietary Ca++
Usually from damage to or removal of parathyroid glands: MC cause
Causes hypocalcemia and hyperphosphatemia
S/S
-Hypocalcemia: neuromuscular excitability
-Peripheral motor and sensory nerve changes
–*Numbness, tingling around mouth, fingertips
–Muscle spasms in hands, feet
–Convulsions
–Laryngeal spasms/tetany: most severe and can cause asthma attack
–Dysrhythmias: prolonged ST wave is MC
-Chrewsvek and Trevesks
hypoparathyroidism
decrease in calcium r/t decrease PTH levels
