Onco APN talk Flashcards
(Superior vena cava syndrome) What is the superior vena cava?
Major drainage vessel for venous blood
from the head, neck, upper extremities,
and upper thorax
Located at the middle mediastinum
Surrounded by relatively rigid structures
(sternum, trachea, right bronchus, aorta,
pulmonary artery, and the perihilar and
paratracheal lymph nodes)
Extends from the junction of the right
and left innominate veins to the right
atrium, a distance of 6-8 cm
Thin-walled, low-pressure, vascular
structure
S&S of SVCO
Giddiness
Face and neck swollen
Breathless / SOB
Mechanism of Superior vena cava syndrome (2)
Extrinsic compression
Intravascular thrombosis
Initial medical management of mediastinal
mass (investigations and disposition) - Condition (Is it a mediastinal mass?)
Chest XR > CT scan (contrasted)
Initial medical management of mediastinal
mass (investigations and disposition) - Cause (What is the mass?)
- Tumor markers: AFP, HCG (germ cell tumor)
- FBC: anemia, thrombocytopenia and leukopenia (Non-HL?)
- Biopsy! Histology
- how to biopsy safely? PT/INR/aPTT, FBC (platelet count)
Initial medical management of mediastinal
mass (investigations and disposition) - Complications
What if patient collapses during the procedure?
CTVS team onboard, CTICU and HD care
Initial medical management of mediastinal
mass (investigations and disposition) - Complications
What if the SVC collapses?
urgent stenting or removal of external compression
Initial medical management of mediastinal
mass (investigations and disposition) - Complications
What if tumor breaks down spontaneously?
management of tumor lysis syndrome
Medical management of SVCO
Treat the cause of mediastinal mass
* Treat the breast cancer – medical oncologist
Treat the complication of mediastinal mass
* Invasive life support, stenting?
Look out for complications of treatment
* Chemotherapy toxicity: neutropenic fever, nausea and vomiting, central line
sepsis, renal impairment
* Others: fluid overload
Nursing management of SVCO
Do not increase SVC return:
* No setting of IV plugs on upper limbs
* No BP measurement on upper limbs
* Nurse patient with head of bed at least 30 degree
* Advocate for central line insertion to administer treatment safely
Fall precaution for neurological changes
* Look out for giddiness, altered mental status in patient
- Chemotherapy side effects
- Strict intake output charting
- Daily weight if indicated
Nursing diagnosis for SVCO (2)
Increased risk for fall due to risk for loss of consciousness
Increased risk for airway compromise due to SVCO
(SVCO) Increased risk for fall due to risk for loss of consciousness is EVIDENCED by:
Subjective sensation of ”blacking out”
(SVCO) Increased risk for airway
compromise due to SVCO is EVIDENCED by:
- Subjective sensation of SOB
- Increased face and neck swelling
Nursing diagnosis for SVCO (interventions)
- Educate on position change and height of bed at least 30 degree
- No BP taking and IV plug insertion on upper limbs
- Timely carry out medical
interventions as
ordered, such as
administration of
chemotherapy /
radiotherapy
(SVCO) Rationale behind nursing interventions
Change pt position
Increase ht of bed
Avoid BP taking over upper limbs decrease pooling of blood in SVC and decreases risk of blacking out, amt of facial swelling & SOB
(SVCO) Expected outcomes of Nursing Interventions
Patient does not
suffer a fall
- Patient
experiences an
acceptable level
of breathlessness
that does not
affect her ADLs
Presentation of hypercalcemia
CNS - Fatigue, confusion, depression
Renal - urination, thirst, renal calculi
Pancreatitis
GIT - Anorexia, nausea, vomiting, constipation, abdominal pain
BONES - Bone pain, fractures
Medical management of hypercalcemia
Treat the hypercalcemia
✓ IV Normal Saline 3L/day x 3/7
✓ IV Normal Saline 1.5L/day x 2/7
✓ IV Pamidronate 60mg in 500ml NS over 6 hours
• Investigate the cause of hypercalcemia
✓ CT scan and Xray shows lytic lesion
✓ underlying bone metastasis → treat the cancer with chemotherapy
/radiotherapy
• Investigate complications of hypercalcemia
✓ Bones, stones, groans and psychic moan: Acute delirium, constipation, nausea
and vomiting, pancreatitis,
• Look out for complications of treatments
✓ Hyperhydration – fluid overload
✓ Bisphosphanate and denosumab – hypocalcemia and osteonecrosis of the jaw
✓ Chemotherapy
Treatment of mild and moderate hypercalcemia
→ does not require immediate treatment
•Remove factors that aggravate hypercalcemia
•Ensure volume repletion: adequate hydration
Treatment of severe hypercalcemia
→ immediate, aggressive treatment!
•Aggressive hydration (initial rate can be 200-300mls/hr) + Frusemide
•Bisphosphanates: Zolendronic acid/pamidronate
•Denosumab: RANKL inhibitor
•Calcitonin: alternative to aggressive NS hydration (e.g CCF, CKD)
•Rapid response within 12-24hrs
•can cause rebound hypercalcemia (tachyphylaxis)
Nursing management of hypercalcemia
Targeting at complications of hypercalcemia and treatments
Accurate intake and output
Weigh patient daily
• Daily weight recommended
• Give PRN frusemide based on doctor’s order – watch out for side effects of
frusemide
Clear bowel
Neurological assessment
▪ Look out for confusion
Pain chart
▪ Abdominal pain, bone pain, loin to groin pain
Ensure dental clearance done prior to administration of bisphosphonates (unless
in emergency)
Nursing diagnosis of hypercalcemia (there are 2)
Increased risk of fluid overload due to hyperhydration
Constipation due to hypercalcemia
Evidence of increased risk of fluid overload due to hyperhydration (hypercalcemia)
Feeling SOB
Evidence of Constipation
due to hypercalcemia
Unable
to BO x
5 days
- Patient
has
stomach
pain
(Hypercalcemia) Nursing interventions for Increased risk
for fluid
overload due to
hyperhydration
Daily weight
- Strict IO charting
- IV frusemide as
needed
(Hypercalcemia) rationale for nursing interventions (daily wt, IV frusemide, etc) for Increased risk
for fluid
overload due to
hyperhydration
- To detect and
manage fluid
retention timely
Expected outcomes of nursing interventions for Increased risk
for fluid overload due to hyperhydration
Patient can
tolerate the
hyperhydration
without
complications
- Pt calcium level
can decrease to
acceptable level
Nursing interventions for Constipation
due to hypercalcemia
Laxatives as
needed
- Intake and
output chart
(stool chart)
- Per rectal
examination (if
trained)
Rationale for Nursing interventions for Constipation
due to hypercalcemia
To monitor the
number of days pt
has BNO, and
relieve constipation
timely
- Monitor the
response after
laxatives
Expected outcomes for Nursing interventions for Constipation
due to hypercalcemia
- Patient has
regular BO
according to
baseline - Patient abdominal
pain is well
managed
Initial medical management of spinal cord compression - condition (how to find out if there is spinal cord compression?)
MRI spine
Initial medical management of spinal cord compression - cause (What is the mass?)
- Biopsy! Histology
- how to biopsy safely? PT/INR/aPTT, FBC
(platelet count) - Tumor markers: myeloma? Mets disease
from lung vs breast vs prostate in man? - What is the primary cancer? PET CT
Initial medical management of spinal cord compression - complication (Is the spine unstable?)
Surgical fixation?
Initial medical management of spinal cord compression - complication (Is it causing pain?)
- Glucocorticoid
- RT first? What type of RT?
- Chemo-sensitive
- Pain management – opioids
Initial medical management of spinal cord compression - complication (risk of venous thromboembolism)
– the need for prophylaxis
Initial medical management of SCC - Glucocorticoid is considered….
Considered part of the standard treatment, bridge to definitive treatment
Initial medical management of SCC - Glucocorticoid dose/s
- High dose: IV dexamethasone 10mg -> PO dexamethasone 16mg daily > taper
Initial medical management of SCC - Pain management
Glucocorticoid can usually improve the pain within several hours, but many
patients require opioid analgesics
Initial medical management of SCC - Venous
thromboembolism prophylaxis
Advanced cancer – increased risk for VTE
Weakness and immobility – further increase the risk of VTE
Prophylactic low molecular weight heparin, clexane (enoxaparin) for e.g.
Initial medical management of SCC - Surgical stabilisation
Spinal instrumentation – e.g. pedicle screws, percutaneous cement injection
Initial medical management of SCC - Radiotherapy
- Conventional external beam radiation therapy (cEBRT): for radiosensitive tumors (RT first unless there is spinal instability)
- Stereotactic body radiation therapy (SBRT): now the preferred approach for low-grade ESCC due to relatively radioresistant tumors. Also for patients with radioresistant high-grade Epidural SCC who
has undergone surgical decompression and stabilization
Nursing management of SCC
Management of unstable spine
* Log rolling
Management of urinary retention and constipation
* IDC insertion
* Use of laxatives
* Intake output charting
Fall precaution
VTE prophylaxis
* Calf compressors
* Bed exercise
Nursing diagnosis for SCC (2x)
Back pain on movement impacting ADL
Risk for fall
(Spinal cord compression) Back pain on movement impacting ADL is evidenced by:
- Increasing
pain score
upon
movement - Patient
verbalized
difficulty in
completing
ADLs
(Spinal cord compression) Risk for fall is evidenced by:
- Pt verbalized
lower limb
weakness
(Spinal cord compression) Back pain on movement impacting ADL - nursing interventions are:
- Pain
management,
such an pre-
emptive pain
medications
before
movement and
investigations - Timely
evaluation of
pain medication
(Spinal cord compression) Risk for fall - nursing interventions are:
- Fall interventions
are instituted
correctly based
on fall risk
assessment - Institute
appropriate
lower limb
exercise
(Spinal cord compression) Rationale for nursing interventions for Back pain on movement impacting ADL
- Timely
administration of
pain medications
could improve
patient’s tolerance
to ADLs - Evaluate timely and
escalate to
physician for
titration of pain
medications should
pain is still not well
tolerable
(Spinal cord compression) Rationale for nursing interventions for risk for fall is:
- Fall interventions
could effectively
reduce patient’s risk
for and severity of fall - LL exercise to
strengthen the
muscles to increase
stability when walking
(Spinal cord compression) Expected outcomes of nursing interventions for back pain on movement impacting ADLs
- Patient is able to
verbalize pain
score <3 upon
movement - Patient is able to
perform ADLs with
tolerable pain
(Spinal cord compression) Expected outcomes of nursing interventions for risk for fall
- Patient does not
sustain a fall during
admission
S&S of Tumor Lysis Syndrome
Fatigue
Muscle cramps
Breathless
Swollen legs
Occassional chest tightness
Definition of tumor lysis syndrome
An oncologic emergency caused by massive tumor cell lysis
- release of large amounts of potassium, phosphate and nucleic acids
into the systemic circulation - hyperkalemia, hyperphosphatemia, secondary hypocalcemia,
hyperuricemia, and acute kidney injury
(Tumour lysis syndrome) What is nucleic acids breakdown and what does it cause?
- Highly insoluble
- Form crystals in the
renal distal tubules - Deposition of the
crystals > acute kidney
injury
(Tumour lysis syndrome) What is phosphate and what does high conc of phosphate cause?
- Concentration in
malignant cells is 4x
higher than in normal
cells - Calcium binds with
phosphate > calcium
phosphate
precipitation >
hypocalcemia > acute
kidney injury and
cardiac arrhythmias
(Tumour lysis syndrome) What is potassium and what does it cause?
- Highly insoluble
- Form crystals in the
renal distal tubules - Deposition of the
crystals > acute kidney
injury
there are 2 types of tumor lysis syndrome. what are they?
Spontaneous
Treatment-induced
What is spontaneous Tumor Lysis Syndrome?
- Happens spontaneously
before initiation of treatment - Often without
hyperphosphatemia
What is treatment-induced Tumor Lysis Syndrome?
- After treatment initiation including steroid
Risk factors for Tumor Lysis Syndrome - what are the tumour specific risk factors?
High proliferation rate
Chemo/radiosensitivity
Haemotological cancer (e.g. lymphoma, leukemia)
Large tumour burden
(Tumour specific Risk factors for Tumor Lysis Syndrome) What is large tumour burden?
> 10cm in diameter
WBC count > 50,000/microL
Pre-treatment serum LDH > 2 times the upper limit of normal
Bone marrow involvement
Risk factors for Tumor Lysis Syndrome - what are the patient factors?
Pre-existing hyperuricemia
Pre-existing renal disease
Oliguria and/or acidic urine
Dehydration, volume depletion or inadequate hydration during treatment
Medical management of Tumor Lysis Syndrome - overall treatment is to: Treat the ____
Treat the electrolyte abnormalities
Medical management of Tumor Lysis Syndrome - Hyperkalaemia
- Serum potassium levels check
- Continuous cardiac monitoring
- Oral potassium-lowering agents (e.g. sodium polystyrene
sulfonate)
Medical management of Tumor Lysis Syndrome - Hyperphosphatemia
- Aggressive hydration with concurrent use of diuretics
- Phosphate binder therapy (e.g. calcium carbonate)
Medical management of Tumor Lysis Syndrome - Hypocalcemia
- If calcium phosphate product is >60mg2/dL2, no calcium
should be given until hyperphosphatemia is treated - Calcium replacement given at lowest dose to relieve
symptoms
Medical management of Tumor Lysis Syndrome - In patients with severe AKI, what should be done?
Renal replacement therapy
Medical management of Tumor Lysis Syndrome - What are the lab investigations to be done?
- Electrolytes – K, Ca, PO4, Uric
acid - Renal function – creatinine
- Cell turnover – LDH
Tumor Lysis Syndrome preventive management
Intravenous hydration
Hypouricemic agents
What are Hypouricemic agents?
- Allopurinol (100mg/m2 every 8 hours in adults)
- Rasburicase (Increase in favor for use, especially in high risk patients, 0.2mg/kg OD for up to 5 days)
(TLS) Allopurinol works by blocking ____ which catalyses the conversion of ___ to ___
Xanthine oxidase, catalyses the conversion of xanthine to uric acid
(TLS) Rasburicase works by mimicking ____ which catalyses the conversion of ___ to ___
Uric oxidase, which catalyses the conversion of uric acid to allantoin
Overall, Nursing management of TLS targets:
Targeting at complications of hyperhydration and electrolyte imbalance
What is the Nursing management of TLS?
Fluid balance
Strict intake output charting
Daily weight if indicated
Renal dialysis management
Furosemide with hyperhydration
Maintaining electrolyte balance timely
Send off and trace electrolytes
Replacement or lowering of electrolytes – e.g. potassium lowering agents
Safe administration of rasburicase
Checking of G6PD status before administration
Send off RP2 and LDH in ice x 72hours post last dose of rasburicase
Nursing diagnosis for TLS (2x)
Increased risk for fluid overload
Increased risk for electrolyte imbalance
(TLS) Increased risk for fluid overload is evidenced by:
- Increased LL swelling
- Increased SOB
- Chest discomfort
(TLS) Increased risk for electrolyte imbalance is evidenced by
- Subjective sensation of cramps
- Chest discomfort
(TLS) Nursing Intervention for Increased risk for fluid overload
- Daily weight
- Strict IO
- Frusemide
as indicated - Creatinine
check
timely
(TLS) Nursing Intervention for Increased risk for electrolyte imbalance
- Electrolyte check and carry out
interventions accordingly - ECG tro myocardiac infarct
(TLS) Rationale for Nursing Intervention for Increased risk for fluid overload
- Maintain a net
fluid balance
through timely
interventions
(TLS) Rationale for Nursing Intervention for Increased risk for electrolyte imbalance
- Replace and
remove
electrolytes timely
(TLS) Expected outcomes for Nursing Intervention for Increased risk for fluid overload
- Patient is able to maintain a net fluid balance and does not go into fluid overload
(TLS) Expected outcomes for Nursing Intervention for Increased risk for electrolyte imbalance
Patient does not suffer from cramps and chest discomfort from electrolyte imbalance
(Handling of chemotherapy) IV and SC chemo is not:
- IV and SC chemotherapy – not to be handled by untrained staff
(Handling of chemotherapy) what should be worn when handling PO chemo?
- PO chemotherapy – to wear gloves when handling the medicine
(Handling of chemotherapy) If need to dilute the medication – e.g. for NG feeding – to approach….?
- If need to dilute the medication – e.g. for NG feeding – to approach SNIC on methods to dissolving it (NCIS has a nursing guide on dilution)
