Med-Surg: Oncological Emergencies

Question 1

Onological Emergencies

Answer 1

• Bowel Obstruction
• Hypercalcemia
• Leukostasis
• Pericardial effusion/tamponade
• Pleural Effusions
• Spinal Cord Compression
• Superior Vena Cava Syndrome
• Syndrome of Inappropriate Antidiuretic Hormone (ADH)
• Tracheobronchial Obstruction
• Tumor Lysis Syndrome

Question 2

Bowel Obstruction

Answer 2

masses in bowel lumen obstruct normal flow of enteral contents, GI fluids, and wastes

> S/S:

• reverse peristalsis w/ vomiting and abdominal distention
• bowel sounds increased before the obstruction and diminished or absent after the obstruction on auscultation
• stool thin, ribbon-like
• constipation with intermittent diarrhea

> Treatment:

• surgery when resectable
• NPO/parenteral nutrition
• peristaltic stimulants unless complete obstruction

> Nurse: GI assessment

• appetite
• bowel movements
• bowel sounds
• constipation or diarrhea
• thin, ribbon-like stools
• nausea/vomiting
• abdominal distention
• pain

Question 3

Hypercalcemia

Answer 3

produced by bone demineralization (resorption) with release of calcium into systemic circulation
-found in cancers that metastasize to bone (breast, lung, and renal cancers)

> S/S:

• delirium
• somnolence/ sleepiness
• muscle weakness (b/c of bone demineralization)
• polyuria
• bradycardia
• nausea
• constipation

> Treatment

• hydration with normal saline dilutes calcium and enhances excretion of calcium
• Bisphosphonates (pamidronate, zoledronate) used as treatment or prevention of hypercalcemia in patients with bone metastasis
• Monoclonal antibody directed at the RANK ligand (denosumab) lowers calcium

> Nurse:

• monitor calcium, phosphorus, and renal function
• assess for hypercalcemia: delirium, somnolence, muscle weakness, polyuria, bradycardia, nausea, constipation
• hydration and medications as ordered

Question 4

Leukostasis

Answer 4

excessive immature WBCs cause capillary sludging, thrombosis, and rupture of vessels

> S/S:
-congestion and dysfunction due to cell migration, inflammatory response, and hemorrhage within the organ

> Treatment:

• emergency chemotherapy
• leukopheresis
• supportive interventions

> Nurse:

• monitor WBC count
• assess for signs of occluded microcirculation: blurred vision, headache, transient ischemic attacks, cerebrovascular accidents, dyspnea, poor peripheral perfusion, oliguria
• assess for bleeding (hemorrhage)

Question 5

Pericardial Effusion/Tamponade

Answer 5

small amounts of pericardial fluid exist in the pericardial space to allow for heart distention with blood filling the ventricles; when there is excess fluid accumulation in the space, it causes positive pressure in the space and impedes venous return of blood
-reduced blood inflow leads to impaired cardiac output

> S/S:

• dyspnea
• acute signs of poor perfusion

> Treatment:

• immediate evacuation of excess fluid by needle or catheter pericardiocentesis or
• surgical placement of a pericardial window or shunt
• until these are done, large amounts of fluids are administered to increase the venous pressure above the pericardial pressure, permitting inflow of blood

> Nurse:

• assess vital signs
• assess signs of dyspnea
• assess poor perfusion
• assess signs of HF (respiratory distress, fatigue, and edema)
• prepare for pericardiocentesis; administer IV fluid as ordered

Question 6

Pleural Effusion

Answer 6

approximately 50-150 mL of fluid is normally in the pleural space to provide lubrication for lung expansion, but when excess fluid is in the space, it impedes breathing, increasing the work of breathing and compressing alveoli

> S/S:

• dyspnea
• increased work of breathing with use of accessory muscles
• unequal chest excursion
• diminished breath sounds
• hypoxemia can result in confusion, anxiety, and agitation

> Treatment:

• intermittent therapeutic thoracentesis
• catheter drainage of pleural fluid
• surgical talcpleurodesis
• bedside catheter pleurodesis with bleomycin, doxycycline, and talc

> Nurse: Assess

• dyspnea
• SOB
• breath sounds
• chest excursion equality
• signs of hypoxemia

Question 7

Spinal Cord Compression

Answer 7

infectious or tumorous masses compress or invade the epidural space or its blood supply, leading to lack of communication from that level of the spine downward

> S/S:

• numbness
• tingling

> Treatment:

• radiation
• if cord compressed completely, laminectomy (removing the lamina — the back part of a vertebra that covers your spinal canal) can restore cord function
• rapid-onset corticosteroids provides reduction of inflammation and symptoms
• vertebroplasty or kyphoplasty allows injection of cement between vertebrae for treatment of compression fractures

> Nurse: Assess for

• back pain, numbness, and tingling
• unsteady gait
• loss of ability to distinguish hot and cold
• constipation or incontinence

Question 8

Superior Vena Cava Syndrome

Answer 8

tumor or tumor involved lymph node compression of the soft-walled superior vena cava, causing reduced return of blood flow to the heart and venous congestion

> S/S:

• dyspnea
• venous congestion and edema of upper body
• visual disturbances, headache, and altered mental status occur with cerebral edema
• prominent jugular veins, brachial veins, and chest vessels

> Treatment:

• immediate chemotherapy or radiation
• corticosteroids to reduce inflammation
• if thrombus present, systemic or catheter-directed thrombolytics
• if vessel rupture is of concern, a superior vena cava stent with or w/o a graft may be performed

> Nurse:

• early assessment for dyspnea
• edema of neck, face, and eyes (most severe in morning)
• prominent upper body vasculature
• later assess for signs of poor perfusion and decreased cardiac output (confusion, cyanosis, hypotension, and tachycardia)

Question 9

Syndrome of Inappropriate Antidiuretic Hormone (ADH)

Answer 9

excess antidiuretic hormone (ADH) causes fluid volume retention and vasoconstriction; some tumors create their own ADH-like substance and ADH receptors are triggered

> S/S:

• hyponatremia; mental status changes or seizures
• fluid volume overload with effusions and edema
• dilutional reduced electrolytes and hematocrit (volume of RBCs)
• hypertension

> Treatment:

• fluid restriction that causes increased sodium concentration and increased urine osmolarity
• if ineffective, hypertonic saline
• for chronic, lithium carbonate or demeclocycline

> Nurse:

• assess for fluid overload (hypertension, hyponatremia)
• assess for confusion, seizures, and coma
• restrict fluids and administer medications as ordered

Question 10

Tracheobronchial Obstruction

Answer 10

tumor-related obstruction or invasion of the major air-exchanging airways

S/S:

• dyspnea with stridor
• wheezing
• in severe, breath sounds absent and chest excursion reduced
• more hypoxic than hypercarbic

> Treatment:

• bronchodilators or corticosteroids provides immediate relief of symptoms to permit time for assessment for airway stent, laser therapy, cryotherapy, endobronchial brachytherapy, or photodynamic therapy
• antineoplastic simultaneously

> Nurse:
-assess for signs of respiratory distress, stridor, wheezing, and hypoxemia

Question 11

Tumor Lysis Syndrome

Answer 11

rapid cell lysis either with rapidly proliferative disease or after antineoplastic treatment

• lysing cells that cannot be cleared accumulate and cause electrolyte imbalance or renal dysfunction
• occurs when tumors are rapidly destroyed, releasing intracellular content into the bloodstream faster than the body can process them; this rapid release causes hyperkalemia, hyperphosphatemia, and hyperuricemia
• without correction, TLS leads to kidney injury and changes in cardiac function that can lead to death

> S/S: reflect degree of electrolyte imbalance

• hypocalcemia and hyperkalemia
• acidosis may produce heart block and tachypnea
• hyperphosphatemia can cause renal dysfunction and worsening symptoms
• GI distress
• flank pain muscle cramps and weakness
• seizures
• mental status changes

> Treatments:

• large-volume IV fluid with diuretics to enhance excretion of electrolytes
• hyperuricemia is treated with Rasburicase if the uric acid is already elevated
• Alopurinol is given to prevent hyperuricemia for patents at risk for TLS
• given Amphojel or other phosphate binders
• if renal failure occurs, an initial hemodialysis treatment followed by continuous renal replacement therapy (CRRT)

> Nurse:

• assess for signs of hypocalcemia (paresthesias and numbness of the fingertips and perioral area, neuromuscular irritability, and severe signs such as laryngeal contraction)
• signs of renal dysfunction: elevated BUN, creatinine, and decreased urine output
• assess for ECG changes such as heart block or peaked T waves indicative of dangerous hyperkalemia
• assess for hypotension