Med Surg: ATI: Cancer Disorders Flashcards
Leukemia
cancers of white blood cells (WBCs) or of cells that develop into white blood cells
-the white blood cells are not functional
-they invade and destroy bone marrow
-can metastasize to liver, spleen, lymph nodes, tests, and brain
>overgrowth of leukemic cells prevents growth of other blood components (platelets, erythrocytes, mature leukocytes)
-lack of mature leukocytes leads to immunosuppression; infection
-lack of platelets leads to increased risk of bleeding
Leukemia: Health promotion
- use protective equipment, such as mask, and ensure proper ventilation while working in environments that contain carcinogens or particles in the air
- influenza and pneumonia vaccinations are important for all clients who are immunocompromised
Leukemia: Risk Factors
- immunosuppression
- exposure to chemotherapy agents or medications that suppress bone marrow
- genetic factors (hereditary)
- ionizing radiation
> Older adult clients
- often have diminished immune function and decreased bone marrow function
- have decreased energy reserves and can tire more easily during treatment; safety is a concern with ambulation
Leukemia: Expected Findings
- bone pain
- joint swelling
- enlarged liver and spleen
- weight loss
- fever
- poor wound healing (infected lesions)
- manifestations of anemia (fatigue, pallor, tachycardia, dyspnea on exertion)
- evidence of bleeding (ecchymoses, hematuria, bleeding gums)
- headaches, behavior changes, decrease attention
Leukemia Diagnostic Procedures
> CBC
- WBC can be high, low, or normal
- Hemoglobin, hematocrit, and platelets decreased
> Coagulation time
- increased with leukemia
- monitor for bleeding
> Biopsy of bone marrow (core or fine-needle)
-large quantities of immature leukemic blast cells
Nurse actions during procedure:
-administer pain medications
-apply pressure for 5 to 10 minutes, then pressure dressing
-monitor bleeding and infection for 24 hours
Leukemia Nursing Care
> Monitor for infection; assess for physiological indicators of infection (lung crackles, cough, urinary frequency or urgency, oliguria, lesions of skin or mucous membrane)
> Manifestations that stem from the immune response (increased WBC, fever, pus, redness, inflammation) are not likely due to immunosuppression
> Implement neutropenic precautions (for chemotherapy induction and for bone marrow transplant client)
> prevent injury
- monitor platelets
- assess for obvious or occult bleeding
- protect from trauma (avoid injections an venipunctures, apply firm pressure, increase vitamin K intake)
- use electric shaver, soft bristled-toothbrush, avoid contact sports
> Conserve energy
- encourage rest, adequate nutrition, and fluid intake
- ensure client gets adequate sleep
- assess clients energy resources/capability
- plan activities as appropriate
Leukemia: Treatment
- Chemotherapy
- Colony-stimulating Medications: Filgrastim to stimulate production of leukocytes; assess bone pain
- Hematopoietic bone stem cell transplantation
Complications of Hematopoietic Stem Cell Transplantation
Graft-versus-host disease (graft rejection)
-administer immunosuppressants as prescribed
Complications of Leukemia
> Pancytopenia: decrease in WBCs, RBCs, and Platelets
- risk of infection increases as ANC falls; An ANC less than 1,000/mm3 = weak immune system; implement neutropenic precautions
- maintain hygienic environment
- monitor for infection (cough, alterations in breath sounds, urine, or feces)
- report temperature greater than 100 Degrees F
- administer antimicrobial, antiviral, and antifungal medications as prescribed
- administer blood products (granulocytes) as needed
> Thrombocytopenia
- increases risk of bleeding
- greatest risk is at platelet counts less than 50,000/mm3
- spontaneous bleeding can occur at less than 20,000/mm3
- monitor for petechiae, ecchymosis, bleeding of gums, nosebleeds, and occult frank blood in stool, urine, or vomitus
- institute bleeding precautions (avoid IVs and injections; apply pressure for 10 min after blood is obtained; handle client gently
- safe environment
- administer blood products (platelets) if count less than 10,000/mm3
> Hypoxemia
- anemia increases risk for hypoxemia
- plan care to balance rest and activity and use assistive devices
- monitor RBCs
- provide diet high in protein and carbohydrates
- administer colony-stimulating factors such as epoetin alfa (to stimulate RBC production)
- administer blood products (packed red blood cells)
Lung Cancer
- non-small cell: squamous, adeno, and large cell carcinomas
- small-cell: fast-growing and is linked to cigarette smoking
> Risk Factors:
- exposure to cigarette smoke
- radiation exposure
- inhaled environment irritants (air pollution, asbestos, coal, other talc dusts)
- older adult clients have decreased pulmonary reserves due to normal lung changes (decreased lung elasticity and thickened alveoli) contributing to impaired gas exchange
- structural changes in the skeletal system decrease diaphragmatic expansion, restricting ventilation
Lung Cancer: Assessment
- determine the pack-year history for clients who smoke
- evaluate use of other tobacco products (cigars, pipes, and chewing tobacco)
- ask about exposure to second hand smoke
- monitor for cough that changes in pattern
Lung Cancer: Expected Findings
- fatigue, weight loss, anorexia
- fever (pneumonitis or bronchitis that occurs with obstruction)
- persistent cough with or w/o hemoptysis
- hoarseness
- altered breathing pattern: dyspnea, prolonged exhalation alternated with shallow breaths (obstruction), rapid shallow breaths (pleuritic chest pain, elevated diaphragm)
- altered breath sounds (wheezing)
- diminished or absent breath sounds (obstruction)
- chest pain or tightness
- chest wall masses
- muffed heart sounds
- pleural friction rub
- clubbing of fingers
- increased work of breathing (retractions, use of accessory muscles, stridor, nasal flaring)
- decreased bone density
Lung Cancer: Diagnostic Procedures
> Cytologic Testing
-sputum specimen contains cancer cells
> Thoracoscopy, bronchoscopy, mediastinoscopy
-presence of cancer cells
-can include biopsy or tumor or lymph nodes
Nursing:
-NPO after midnight
-provide throat lozenges or sprays for report of a sore throat once gag reflex returns
> X-ray, CT scan
- lung lesions
- presence of tumor
> Thoracentesis with pleural biopsy; MRI, PET scan
-presence of cancer and metastatic disease
> Pulmonary function tests and arterial blood gases
-compromised respiratory status
Lung Cancer: Nursing Care
> monitor nutritional status, weight loss, and anorexia
-adequate nutrition; provide needed calories for increased work of breathing and prevention of infection
-encourage fluids for hydration
Maintain patent airway and suction as needed
Fowler’s position to maximize ventilation
Lung Cancer: Medications
> Bronchodilators and corticosteroids
-help decrease inflammation and to dry secretions
Lung Cancer: Therapeutic Procedures
> Chemotherapy
-primary choice
-cisplatin used
adverse effects: nausea, vomiting, hair loss, mucositis, neutropenia, thrombocytopenia, peripheral neuropathy
> Photodynamic therapy
-performed through bronchoscopy to treat small, accessible tumors
> Radiation
-effective for lung cancer that has not spread beyond the chest wall and is used as an adjuvant therapy
Lung Cancer: Surgical interventions
- goal= remove all tumor cells, including involved lymph nodes
- pneumonectomy (removal of lung)
- lobectomy (removal of lobe)
- wedge resection (peripheral lung tissue)
- reserved for early stage (I or II) with no metastasis
> Nursing:
- monitor vital signs, oxygenation (saO2, and ABGs), and evidence for hemorrhage
- manage chest tube
- administer oxygen and manage ventilator if appropriate
- manage pain; teach about PSA pump
Lung Cancer: Palliative procedures
- thoracentesis or pleurodesis to ease breathing
- laser therapy and photodynamic therapy can be used in treatment and palliative therapy to open airways blocked by tumors
- pericardiocentesis or pericardial window to improve cardiac function
- oxygen therapy to correct hypoxemia
Colorectal Cancer
cancer of the rectum or colon
- can begin as a poly that is benign and if left untreated can grow and risk of malignancy increases
- can metastasize (through blood or lymph) to liver (most common), lungs, brain, or bone
Colorectal Cancer: Health promotion
- diet rich in calcium (calcium binds to free fatty acids and bile salts in the lower GI tract)
- diet low in fat and simple carbohydrates but high in fiber
- age-specific screening
- genetic testing for familial adenomatous polyposis
- healthy lifestyle
- no smoking/ alcohol
Colorectal Cancer: Risk Factors
- adenomatous colon polyps
- African American descent
- inflammatory bowel disease (ulcerative colitis, Crohn’s)
- high-fat, low-fiber diet
- long-term smoking
- physical inactivity
- heavy alcohol consumption
- infection exposure to helicobacter pylori, streptococcus bovis, HPV
- personal or family hx
Colorectal Cancer: Expected findings
> changes in stool consistency or shape (with or without noticeable blood)
Blood in stool
-left-sided tumors likely to produce frank bleeding and change in bowel pattern, consistency
-right-sided tumors cause stools to be darker due to ulceration of the colon and intermittent bleeding
cramps and/or gas
palpable mass
weight loss and fatigue
vomiting
abdominal fullness, distention or pain
-abnormal bowel sounds indicative of obstruction (high-pitched tinkling bowel sounds)
rectal pain
sensations of bowel fullness after defecation
Diagnostic Procedures
- virtual colonoscopy can be performed using CT scans or MRI; noninvasive, no sedation
- fecal testing recommended every year if guaiac-based fecal occult blood testing or fecal immunochemical testing is used, or every 3 years if the stool DNA test is used
- screening guidelines for individuals with polyps of family hx
> Guaiac-based fecal occult blood testing (FOBT)
-findings:2 positive stools within 3 days
Nursing:
-do not use stool from digital rectal examination to avoid false-positive results
-negative results do not completely r/o CRC
Client Education:
-avoid red meat, anti-inflammatory medications, and vitamin C for 48 hours prior to testing
> Biopsy
-definitive diagnosis
> Endoscopy: colonoscopy, sigmoidoscopy
-visualization of polyps or lesions
> Double contrast barium enema
-uses the two contrasts of air and barium
-expected findings: visualization and location of tumor
Nursing:
-administer stimulant laxative following procedure as prescribed (facilitates evacuation of barium, which can harden in the intestine)
> CBC
-decreased hemoglobin and hematocrit
> Carcinoembryonic antigen (CEA)
- expected: positive (denotes malignancy; not specific to CRC)
- positive may = many types of cancer
> CT/MRI
-visualization and location of tumor/ metastasis
Colorectal Cancer: Therapeutic Procedures
> Chemotherapy
-prescribed for clients who have stage III and IV or stage I
> Targeted medication therapy
- Monoclonal antibodies:
- angiogenesis inhibitors (inhibit growth of new blood vessels to tumors): bevacizumab
- tyrosine kinase inhibitors (decrease cell proliferation and increase cell death): cetuximab and panitumumab
> Adjuvant therapy
-given to decrease the chance of metastasis for stage II and distant metastasis for stage III
> Radiation
- minimize localized manifestations around the tumor
- used a palliative measure to control pain, hemorrhage, bowel obstruction, or metastatic disease
Colorectal Cancer: Surgical Intervention
following tumor excision, the colon might be reconnected (end-to-end anastomosis), a colostomy created (temporary or permanent), or a coloanal reservoir, or j-pouch, created temporarily
> Colon resection (colectomy): removal of portion of the colon to excise tumor
Colectomy: removal of colon with temporary or permanent colostomy or ileostomy
Abdominal-perineal (AP) resection: the tumor, sigmoid colon, rectum, and anal sphincter are removed, and the client has a permanent sigmoidostomy
Colorectal Cancer: Preoperative Education
- preoperative diet (clear liquids several days prior to surgery)
- complete bowel prep with cathartics
- understand administration of antibiotics (neomycin, metronidazole) to eradicate intestinal flora
Colorectal Cancer: Postoperative Nursing Actions
- assess stoma (should be reddish pink, moist, small amount of blood); report ischemia, necrosis, or frank bleeding
- manage pain; teach PCS pump
- maintain nasogastric suction (decompression)
- progress the diet slowly after suctioning is d/c and monitor client’s response (bowel sounds present, no nausea, or vomiting)
- discuss possible incontinence and sexual dysfunction with the client
- provide ostomy teaching
Breast Cancer
- can present as a hard painless mass
- gynecomastia can be present in men
- can be noninvasive (in situ) or invasive
> Ductal Carcinoma in situ (DCIS)
- cancer cells are located in the duct and have not invaded surrounding tissue
- DCIS cells lack the biologic capacity to metastasize
> Lobular Carcinoma in situ (LCIS)
- abnormal cell growth occurs in the milk-producing glands
- can increase risk of developing a separate breast cancer at a later time
- managed with observation
- when other risk factors exist, prophylactic treatment (tamoxifen, raloxifene, or mastectomy) can be considered
Breast Cancer: Health promotion
- consume five servings of fruits and vegetables daily
- screening mammography
- healthy weight
- physical exercise
- minimize alcohol intake
- breast feeding for a year or more decreases breast cancer risk
- avoid hormone replacement therapy
- avoid environmental estrogens
Breast Cancer: Risk Factors
>High genetic risk -inherited mutations of BRCA1 and BRCA2 >history of previous breast cancer -dense breast tissue -biopsy confirmed atypical hyperplasia -first degree relative -early menarche -late menopause -nulliparity or first pregnancy after 30 -Males: testicular disorders -use of oral contraceptives -high-fat diet -low-fiber diet -excessive alcohol intake -cigarette smoking -exposure to low-level radiation -hormone replacement therapy -obesity
Breast Cancer: Expected Findings
-breast change (appearance, texture, presence of lumps)
-breast pain or soreness
>Physical:
-skin changes
-dimpling
-breast tumors (usually small, irregularly shaped, firm, nontender, and nonmobile)
-increased vascularity, erythema
-nipple discharge
-nipple retraction or ulceration
-enlarged lymph nodes
-male clients report a mass around the areola that is hard and painless, nipple inversion, ulceration or swelling of the chest; lymphedema and gynecomastia may be present
Breast Cancer: Diagnostic Procedures
> Breast self-examination (BSE), clinical breast exam
-findings: palpable tumor or lesions
education: have regular CBE every 3 years age 20 to 39; yearly over age 40)
> Biopsy
-definitive; sentinel lymph node biopsy can be performed during surgery
> Genetic Testing
-gene mutation of BCRA1 and BCRA2
> Mammography
-visualization of lesion
> MRI, ultrasound CT scan, X-ray, PET scan
Breast Cancer: Hormone therapy
most effective in cancer cells with estrogen and progesterone receptors
> Ovarian ablation: luteinizing releasing hormone (LH-RH) leuprolide or goserelin
- inhibits estrogen synthesis
- used in premenopausal clients to stop or prevent the growth of breast tumors
> SERMs (Selective Serotonin receptor modulators): toremifene (Tamoxifen and raloxifene)
- used for high-risk for breast cancer or who have advanced breast cancer
- suppress the growth of remaining cancer cells postmastectomy or lumpectomy
- tamoxifen may increase risk of DVT and pulmonary emoblism
Breast Cancer: Chemotherapy/ Radiation
can augment or replace a mastectomy
-usually given combination of medications (cyclophosphamide, doxorubicin, and fluorouracil)
> radiation therapy usually reserved for clients who had a lumpectomy or breast-conserving procedure
- whole or partial breast radiation
- skin care priority due to radiation damage and generalized fatigue
- brachytherapy with radioactive seeds
Clients who have metastatic cancer can receive what?
a vascular endothelial growth factor inhibitor (bevacizumab) to reduce blood flow to the growing tumor
Breast Cancer: Surgical Interventions
- Lumpectomy (breast-conserving)
- Partial mastectomy (wide excision)
- Total mastectomy
- Modified radical mastectomy (lymph nodes and muscle removed)
- reconstructive surgery
Breast Cancer: Surgical Interventions Nursing Actions
- sit with head of bed elevated 30 degrees when awake and support their arm on a pillow; lying on unaffected side can relieve pain
- client wear a sling while ambulating (to support arm)
- avoid administering injections, taking blood pressure, or obtaining blood from the client’s affected arm; place a sign above patients bed regarding these precautions
- emphasize importance of well fitted breast prothesis for a client who had a mastectomy
- emotional support
- monitor surgical drains
- perform early arm and hand exercises (squeezing rubber ball, elbow flexion and extension, hand-wall climbing)
- report numbness, pain, heaviness, or impaired motor function to affected arm
- do not wear constrictive clothing
Prostate Cancer
-slow-growing cancer in response to androgen (testosterone)
Prostate Cancer: Health promotion
- diet low in animal fat and include omega 3 fatty acids (fish), fruits and vegetables
- regular exercise
- discuss PSA screening
Prostate Cancer: Risk Factors
- hx of vasectomy
- age greater than 65
- family hx
- high-fat, complex carbohydrate, or low fiber diet
- hereditary prostate cancer
- rapid growth of prostate
- exposure to environmental toxins such as arsenic
Prostate Cancer: Expected Findings
- urinary manifestations: hesitancy, weak stream, urgency, frequency, nocturia
- recurrent bladder infections
- urinary retention
- blood in urine and semen (late manifestation)
- painful ejaculation
- pain, particularly bone (pelvis, spine, hips, ribs)
- unexplained weight loss
- loss of sexual desire or function
- penile discharge or scrotal pain/swelling
- residual urine after voiding a small amount of urine
- swollen lymph nodes, especially in groin
Prostate Cancer: Diagnostic Procedures
> Digital Rectal Exam (DRE)
- expected: hard prostate with palpable irregularities
- discuss prostate screening after age 50
> Biopsy:
- expected: presence of cancer
- Gleason score or 7 or higher: moderately differentiated
- Gleason score of 8 to 10: poorly differentiated
- PSA, age, race, and family hx used to determine if biopsy is needed
> Genetic Testing
-expected: hereditary prostate cancer 1 (HPC1), BRTCA1, or BRCA 2 positive
> Prostate Specific Antigen (PSA)
- Findings: elevation (greater than 4 ng/mL)
- have the PSA assessed prior to Digital rectal exam
> Transrectal ultrasonography (TRUS)
-visualization of lesions
Education: extra fluids, no strenuous exercise, manifestations to report
-enema will be administered prior to procedure
> Urinalysis
-hematuria, bacteriuria
> Bone scan, MRI, CT, x-ray
-determines metastasis
Prostate Cancer: Medications
Sipuleucel-T
- a vaccine against cancer
- destroys existing cells and prevents future cancer development
Prostate Cancer: Hormone Therapy
Leuprolide, Goserelin, Triptorelin: luteinizing hormone -releasing- hormone (LH-RH) agonist
-used in advanced prostate cancer to produce chemical castration
>education:
-hot flashes are an adverse effect
-impotence and decreased libido
-monitor for osteoporosis which can occur due to testosterone suppression
Prostate Cancer: Chemotherapy
used on clients whose caner has spread or who have had minimal improvement with other therapies
-have routine blood tests performed to monitor for neutropenia, leukopenia, thrombocytopenia, and anemia
Prostate Cancer: Surgical
-PSA levels should reduce within a few days postoperatively
> Radical Prostatectomy: treatment of choice
- not likely beneficial id spread to lymph nodes, bones or other organs
- removal of prostate gland, along with seminal vesicles, the cuff at the bladder neck, and regional lymph nodes
- perineal nerves are seldom disrupted, so client should not experience sexual dysfunction
- dry climax can occur; removal of tissue at bladder neck allows seminal fluid to travel upward rather than down the urethral tract, results in retrograde ejaculation
> Nursing:
- provide catheter care and administer bladder antispasmodics
- monitor suprapubic catheter output; usually removed when output is less than 75 mL
