Oncogic Emergencies Flashcards
the inappropriate, systemic activation of the regulation Cascade that results in thrombosis and bleeding / hemorrhage is what oncologic emergency
disseminated intravascular coagulation
clot formation is also known as
thrombosis
clot breakdown is also known as
fibrinolysis
how is the process of thrombosis initiated?
through the destruction of the endothelial membrane and tissue injury.
tissue injury causes the release of_______ _______ into the circulation which leads to coagulation
tissue thromboplastin
what enzyme digests the components of a fibrin clot?
plasmin
what is the proteolytic enzyme that is responsible for both coagulation and fibrinolysis?
thrombin
what underlying conditions in the oncology patient may lead to excess circulating thrombin?
infection, malignancy, or trauma
excess thrombin results in what problem in the circulation?
multiple fibrin clots
excess clots in the circulatory system results in platelet traps which then causes what condition?
microvascular and macrovascular thrombosis
clot lodged in the vascular system leads to what problem?
ischemia, impaired organ perfusion, end-organ damage
the excess use of the coagulation factors in DIC is unable to be replaced which then leads to what problem?
excessive bleeding
excess plasmin in the circulatory system leads to what symptoms in DIC
shock, hypotension, increased vascular permeability
what diagnostic tests are done to diagnose disseminated intravascular coagulation,?
platelet count, fibrinogen level, D-dimer assay, FDP ( fibrin degradation products) titer
what tests are done to determine if accelerated quag ulation is a problem?
antithrombin III level, fibrinopeptide A level, prothrombin activation peptides, thronbin- antithrombin complexes
what tests are done to determine if accelerated fibrinolysis is a problem?
plasminogen level, plasmon Alpha 2 anti plasmin complex levels
what is the main goal of treatment related to DIC?
treatment of the underlying condition causing DIC, supporting the hemodynamics, manage the bleeding or thrombosis
how is the underlying condition for DIC typically treated?
chemotherapy for malignancy, antibiotics for infection
what hemodynamic support is often used in the patient with the DIC?
fluid replacement, oxygen therapy, administration of platelets, red blood cells, fresh frozen plasma, fibrinogen, cyroprecipitate
what treatment is used to replace quag ulation factors?
plasmapheresis
what does plasmapheresis do to help the patient with DIC?
it removes the triggers of coagulation
what lab values are decreased in the patient with DIC?
platelet count, fibrinogen level, antithrombin 3 level, plasminogen level, plasmon Alpha 2 antiplasmin complex
what lab values are increased in the patient with DIC?
D-dimer assay, fdp tighter, fibrinopeptide A, prothrombin activation peptides, thrombin antithrombin complex
What patients are at increased risk for developing DIC?
acute leukemia, mucin producing solid tumors, infection and sepsis, liver disease, hemolytic transfusion reactions, transplant reactions, Burns, trauma, pregnancy and obstetric complications, peritoneovenous shunts
what is the most common cause of DIC?
sepsis / infection
what are the early signs and symptoms of DIC in the skin?
pallor, petechiae, jaundice, ecchymosis, hematomas, bleeding, acral cyanosis
what are the early signs and symptoms of DIC in the GI system?
tarry stools, hematemesis, abdominal pain, abdominal distension
what are the early signs and symptoms of DIC in the GU system?
hematuria, decreased urinary output
what are the early signs and symptoms of DIC in the respiratory system?
dyspnea, tachypnea, hypoxia, hemoptysis, cyanosis
what are the early signs and symptoms of DIC in the neurological system?
headache, restlessness, confusion, lethargy, altered level of consciousness, obtundation, seizures, coma
what are the early signs and symptoms of DIC in the musculoskeletal system?
joint pain and stiffness
what are the early signs and symptoms of DIC in the cardiovascular system?
tachycardia, hypotension, diminished peripheral pulses, changes in color and temperature of extremities
What nursing interventions will help maximize patient safety in the diagnosis of DIC?
fall precautions, assistance for adl’s, bleeding precautions, discourage dangling feet and pressure causing devices
what are the signs and symptoms of progressing DIC?
septic shock symptoms, proteinuria, anuria, decreased mental status, changes in breathing, bleeding
what important patient education should take place in the patient with known or suspected DIC?
signs and symptoms of DIC, report new bleeding, save all urine, emesis and stool for the nurse to check, bleeding precautions
the systemic inflammatory response to a documented infection is known as
sepsis
sepsis is the inflammatory response to what in the blood?
pathogenic microorganisms and associated endotoxins
sepsis usually presents with two or more of what signs and symptoms?
temperature greater than 100.4, heart rate greater than 90 BPM, respiration rate greater than 20 breaths / minutes, WBC greater than 12000 or less than 4000, or greater than 10% bands
sepsis results when the body fails to initiate an adequate___________ to an infection.
immune response
what are the signs and symptoms of septic shock?
fever, chills, tachycardia, tachypnea, mental status changes, hypotension
what are the phases of septic shock?
infection, bacteremia, systemic inflammatory response syndrome, sepsis, severe sepsis, septic shock, multiple organ dysfunction syndrome
what is the most common source of infection related sepsis?
bacterial organisms
which gram-negative organisms are common in septic shock cases?
e-coli,klebsiella pneumonia, pseudomonas aeruginosa
which gram-positive bacteria are most commonly associated with septic shock cases?
streptococcus pneumonia, staphylococcus aureus
which patients are at increased risk for gram-positive bacterial infections?
patients with vascular access devices, and those with a lack of mucosal integrity
patients with fungal infection related sepsis are at an increased risk for what problems?
increased length of hospitalization and death
where do most infections arise in the oncology patient?
endogenous Flora
mortality from sepsis is associated with what three factors?
causative organism, site of infection, level of duration of neutropenia
what are the basic infection control precautions?
good hand-washing, oral and perianal care, identification of patients at risk for infection, avoidance of invasive procedures
what diagnostic procedures are done to diagnose and treat sepsis?
blood cultures, chest x-ray, cultures of erudite, CBC, electrolytes,LFTs, PTL, PTT, ABGs, EKG
what tests are done to diagnose the degree of organ failure in a patient with sepsis?
echocardiogram, CT scans, ventilation perfusion scan, angiography
what is done to maintain hemodynamic support in the patient with sepsis?
administration of fluids, blood transfusions, vasopressors, oxygen therapy
what base oppressors are used to combat hypotension in the patient with sepsis?
dopamine, norepinephrine, dobutamine
what is the treatment recommendations for the patient with sepsis?
empiric antibiotics started at the first sign of sepsis
when is empiric antifungal therapy started in the patient with sepsis?
five to seven days after empiric antibiotic therapy has been started and the patient continues a fever
what are the risk factors for sepsis?
immunosuppression either from therapy or malignancy, comorbidities, age greater than 65, invasive devices, loss of skin or mucosal integrity
what comorbidities put a patient at increased risk for sepsis?
diabetes, renal, hepatic, cardiovascular, and / or pulmonary disease, GI abnormalities
a life-threatening metabolic imbalance that occurs with a rapid release of potassium, phosphorus, and nucleic acid into the bloodstream due to tumor cell kill is known as
tumor lysis syndrome
what electrolyte abnormalities are present in tumor lysis syndrome?
hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia
why is the calcium decreased in tumor lysis syndrome?
increased phosphorus binding to the calcium to form phosphatase salts
what does tumor lysis syndrome lead to in the cancer patient?
cardiac arrhythmias, renal failure, multi-system organ dysfunction
why do cancer patients with tumor lysis syndrome develop renal failure?
kidneys are the primary route of excretion of phosphatase salts, uric acid, and potassium and they become over taxed
what tests are done to diagnose and monitor for tumor lysis syndrome?
LDH, bun, creatinine, serum electrolytes
what is the treatment for tumor lysis syndrome?
IV hydration, alkalinization of urine, decrease the production of uric acid with medication, diuretics, manage electrolyte imbalances
what type of diet would be recommended in a patient with tumor lysis syndrome?
low potassium and low phosphorus
what foods are high in potassium?
bananas, oranges, orange juice, tomatoes
what foods are high in phosphorus?
eggs, meat, fish, nuts, cheese, bread, poultry, legumes, cereal, carbonated drinks
What patients are at the highest risk for developing tumor lysis syndrome?
patients with bulky or high-growth fraction hematologic tumors, recent chemotherapy, recent RT or surgery, comorbid renal and cardiac disease
which cancers are generally known to have a higher risk for being a large, bulky tumor?
lymphoma, small cell lung cancer, breast cancer, neuroblastoma
what level do patients have signs and symptoms related to hyperkalemia
serum levels exceed 6.5 mil mEq / L
what are the signs and symptoms of hyperkalemia?
EKG changes, nausea, vomiting, diarrhea, muscle weakness, cramps, tingling, twitching, paresthesia, paralysis
what are the signs and symptoms of hyperphosphatemia?
edema, oliguria, anuria, renal insufficiency, azotemia, acute renal failure
what are the signs and symptoms of hypocalcemia?
hypotension, EKG changes, muscle cramps, twitching, paresthesias, seizures, tetany, altered mental status
what are the signs and symptoms of hyper uricemia?
oliguria, anuria, azotemia, edema, neuropathy, flank, nausea, vomiting, diarrhea, hematuria, lethargy, somnolence, seizure
what safety precautions may need to be initiated in the acute tumor lysis syndrome patient?
Fallen seizure precautions, intake and output, dietary modifications
what types of problems in the cancer patient can lead to hypercalcemia?
increased bone resorption or bone destruction, increased level of parathyroid hormone or protogladin produced by the cancer
what is calcium necessary for in the human body?
maintenance of bones and teeth, muscle contraction, nerve impulse transmission, normal clotting maintenance
what hormonal substances help regulate calcium levels?
parathyroid, vitamin D, calcitonin
what is the most common metabolic complication in the cancer patient?
hypercalcemia
what are the most common cancers associated with hypercalcemia
breast, lung, head and neck, multiple myeloma, renal, lymphoma
what is considered in the correction of calcium levels?
the effect of altered albumin concentration on the calcium levels
what non- pharmacologic treatments are recommended for hypercalcemia?
weight bearing exercise, active or passive range of motion
what are the pharmacologic treatments that are frequently used for hypercalcemia?
hydration, diuresis, antineoplastic therapy for primary and metastatic tumors, antiresoorptive therapy with biophosphonates, steroids
what are the contributing factors for hypercalcemia?
immobility, dehydration, Advanced age, renal dysfunction, tpn, vitamin A and D intoxication, lithium, thiazide, and anti acid use
what signs and symptoms of hypercalcemia should the patient and or caregivers be instructed to report?
nausea and vomiting, constipation, fatigue, weakness, changes in mental status or personality
what safety precautions should be initiated in the patient with hypercalcemia?
fall precautions, seizure precautions, patient may have mental confusion so may need to keep close observation
what is the name of an endocrine paraneoplastic syndrome resulting from the non physiologic release of antidiuretic hormone?
syndrome of inappropriate secretion of antidiuretic hormone
where is the antidiuretic hormone synthesized and secreted from in the body?
synthesized in the hypothalamus, secreted from the pituitary gland
ADH regulates water re-absorption in the renal tubules based on what factors?
increased plasma osmolality, decreased plasma volume
what signs and symptoms are present in the patient with SIADH?
hyponatremia, concentrated urine, elevated urine sodium concentration, intracellular edema, cerebral edema
what cancer is associated with the highest number of SIADH cases?
small cell lung cancer
what diagnostic tests are recommended to diagnose and monitor the patient with SIADH?
serum: sodium, plasma osmolality
urine: osmolality, specific gravity,
sodium: electrolytes, thyroid, adrenal, cardiac, hepatic, renal function tests, chest x-ray, CT scan of the head
what are the nonpharmacologic treatments for SIADH?
fluid restriction to 500-1000 ml per day
why is it important to correct sodium levels over time instead of immediately?
correcting sodium levels to rapidly may cause brain damage from brain cell dehydration
what medications may increase the risk for SIADH?
morphine, diuretics, antidepressants
what medications can be used to help correct SIADH?
demeclocycline, urea, lithium, hypertonic saline solutions
what are the early signs and symptoms of SIADH?
nausea, anorexia, malaise, fatigue, weakness, muscle cramps, thirst, headache, confusion, vomiting, lethargy, weight gain, psychotic behavior
what are the late signs and symptoms of SIADH?
delirium, obtundation refractory seizures, coma, and death
and immediate, systemic hypersensitivity reaction that usually occurs within seconds to minutes after the administration of a foreign protein and can be life-threatening is known as
anaphylaxis
anaphylactic reactions are predictable true or false
false, they are unpredictable. Anaphylaxis can result in respiratory failure, cardiovascular collapse, and possibly death.
which classes of chemotherapy are more commonly associated with hypersensitivity reactions?
taxanes, Platinum compounds, monoclonal antibodies, biotherapy
immediate hypersensitivity reactions are Medicated by what protein?
immunoglobulin E (igE)
what factors influence the development of anaphylaxis?
route of Entry, amount, and absorption rate of the antigen and the patients degree of hypersensitivity to the antigen
what systemic effects occur as a result of the release of mediators of hypersensitivity such as histamine and leukotrienes?
bronchospasm, inflammation, smooth muscle spasm, increased capillary leak, and mucosal edema
what are the early signs and symptoms of an anaphylactic reaction?
Purists, urticaria, erythema, anfioedema, dyspnea, wheezibg, warmth, flushing, dizziness, hypertension, chest tightness, nausea, vomiting, diarrhea, abdominal discomfort, anxiety, dizziness, agitation, feeling of Doom
what are the late signs and symptoms of an anaphylactic reaction?
Strider, bronchospasm, laryngeal edema, hypotension, tachycardia, arrhythmias, chest pain, loss of consciousness
what medication is most commonly used for prophylaxis of an anaphylactic reaction?
epinephrine 1:1000, corticosteroids, H1 blockers, H2 blockers, acetaminophen
What nursing measures can increase the safety of patients with an anaphylactic reaction?
Baseline vital signs, verified and documented allergy history, maintain IV access during administration of potential allergen, have Emergency agents available at all times
at the first sign of an anaphylactic reaction, the nurse should do what?
stop the flow of the offending agent, maintain IV infusion, maintain patent Airway, administer emergency medications for protocol
what are the symptoms of respiratory distress?
adventitous breath sounds, increased respiratory rate, Rhythm and effort, changes in ABGs
what are the signs of fluid overload?
jugular neck vein distention, changes in intake / output ratio, changes and weight greater than 5 pounds per day
what does the inter-cranial cavity contain?
brain tissue, vascular tissue, cerebral spinal fluid
an increase in intracranial pressure can result because of what?
displacement of brain tissue, edema of brain tissue, obstruction of CSF flow, increased vascularity because of tumor growth
what diagnostic test should be done to assess for increased ICP?
CT scan, MRI, cerebral angiography, Myla graphy, biopsy, pet, spect
what nonpharmacologic interventions are available to treat increased intracranial pressure?
surgery, radiation therapy, shunt placement, hyperventilation, fluid restriction
which chemotherapy cross the blood-brain barrier, therefore may help with increased intracranial pressure?
nitrosoureas and procarbazine
which route of administration of chemotherapy may help decrease increased intracranial pressure?
intra-arterial, intrathecal, intraventricular, intra tumor
what what medication is typically the first medication started when symptoms of increased intracranial pressure are present?
corticosteroids
what hyperosmotic agent reduces intracellular water of the brain?
Mannitol
anticonvulsant may need to be started when a patient has what structural emergency?
increased intracranial pressure
which cancers put patients at a higher risk of developing increased intracranial pressure?
cancers of the lung, breast, testes, thyroid, stomach, kidney or melanoma, brain or spinal cord
what problems associated with cancer but not specifically tumors of the brain can cause an increase in intracranial pressure?
thrombocytopenia or platelet dysfunction may lead to bleeding in the brain
what types of headaches an early sign and symptom of increased intracranial pressure?
headache, worse in the morning, aggravated by coughing, bending over, valsalva maneuver
what neurological symptoms are an early sign and symptoms of increased intracranial pressure?
blurred vision, diplopia, decreased visual fields, extremity drifts, lethargy, apathy, confusion, restlessness
what what neurological symptoms are a late sign of increased intracranial pressure?
decreased ability to concentrate, decreased level of consciousness, personality changes, hemiplegia, hemiparesis, seizures, pupillary changes, papilledema
what is the Cushing’s Triad?
hypertension, bradycardia, abnormal respirations, a very late sign of increased ICP, the patient is usually comatose
what activities should be discouraged in order to minimize increased ICP?
isometric muscle contractions, valsalva maneuver, external stimulation, stress, rotating the head or flexing the neck, lying in prone position
what should be regularly assessed in a patient with increased ICP?
blood pressure, pulse, respiration, level of Consciousness, sensory or motor changes, nausea, vomiting, headache
what structural emergency has occurred when a tumor compresses neural tissue and compromised the blood supply?
spinal cord compression
the spinal cord has what three functions?
motor, sensory, and autonomic
what diagnostic tests are done in order to determine if there is a spinal cord compression?
x-rays, bone scan, MRI, CT scan, myelogram, pet
what are the nonpharmacologic interventions for spinal cord compression?
radiation therapy, surgery
what pharmacologic interventions are used to treat spinal cord compression?
corticosteroids, chemotherapy, pain medications, anticonvulsant, antidepressants
which cancers have a higher risk for metastasizing to the Bone?
breast, long, prostate, renal, melanoma, myeloma
which cancers have a higher risk for metastasizing to the spinal cord?
lymphoma, seminoma, neuroblastoma
what are the primary cancers of the spinal cord?
ependymoma, astrocytoma, glioma
what are the early signs and symptoms of spinal cord compression?
neck or back pain, worse in supine position, local, radicular, worse with straining, coughing or flexion, motor weakness, sensory loss
what are the late signs and symptoms of spinal cord compression?
loss of sensation for deep pressure, vibrations, position, incontinence of stool or urine, sexual impotence, paralysis, muscle atrophy
what are the goals for treatment related to spinal cord compression?
acceptable pain control, Optimum level of physical Mobility, bowel and bladder control
what structural emergency is a result of compromised venous drainage of the head, neck, upper extremities and thorax because of compression or obstruction?
superior vena cava syndrome
compression that causes superior vena cava syndrome can be from what sources?
direct tumor invasion, enlarged lymph nodes, thrombus
venous pressure ____________and cardiac output ________ when obstruction of the SVC occurs.
venous pressure increases and cardiac output decreases
what is the goal of treatment in SVCS?
decreasing or eliminating the underlying cause and presenting symptoms
what diagnostic tests are used to determine the cause and extent of SVCS?
chest x-ray, CT scan of the thorax, biopsy
what nonpharmacologic interventions are commonly used for SVCS?
radiation therapy, removal of the central venous catheter, oxygen, angioplasty, stents, surgical reconstruction
what pharmacologic interventions are commonly used for SVCS?
chemotherapy, corticosteroids, diuretics, thrombolytics
which clients are at an increased risk for developing SVCS?
lymphoma, lung and breast cancer, patients with Central lines and pacemakers, previous RT to mediastinum
what are the early signs and symptoms of svcs?
facial swelling worse in the morning, redness and edema around the eyes, swelling of the neck, arms and hands, neck and through a sick vein distention, dyspnea, cyanosis of upper torso, facial erythema, visible collateral veins of the chest and / or breasts
what are the late symptoms of svcs?
severe headache, irritability, visual disturbances, dizziness, syncope, changes in mental status, stridor, tachycardia, CHF, decreased blood pressure, Horner’s syndrome, dysphasia, hemoptysis
what laboratory tests should be considered when evaluating a patient with SVCS?
abg’s, electrolytes, kidney function, CBC, coagulation studies
what interventions are important to decrease the severity of symptoms associated with SVCS?
Elevate the head of bed, avoid valsalva maneuver, maintain lower extremities in dependent position, remove rings and restrictive clothing around arms and neck, avoid pressure in the upper extremities
what are the signs and symptoms of progressive respiratory distress in SVCS?
increased respiratory rate, anxiety, stridor, adventitious breath sounds, difficulty breathing
what are the signs and symptoms of progressive edema and SVCS?
increase swelling in the face, arms, or neck, venous distention of the neck or thorax
what are the signs and symptoms of changes in tissue perfusion related to SVCS?
decreased or absent peripheral pulses, decrease in blood pressure, pallor
what are the adverse effects of long-term steroid therapy?
weakness of involuntary muscles, mood swings, hyperglycemia, dyspepsia, insomnia
the excess accumulation of fluid in the pericardial Sac is known as what structural emergency?
cardiac tamponade
what is the pericardial cavity?
the space between the two-layered sac known as the pericardium that surrounds the heart
intracardiac pressure occurs because of what oncologic reasons?
fluid accumulation, direct or metastatic tumor Invasion, or fibrosis from radiation in the pericardial sac
an increase in intrapericardiac pressure results in what changes in the circulatory system?
decrease left ventricular filling, decreased ability for the heart to pump, decreased cardiac output, impaired systemic perfusion
what diagnostic can be done to determine if a patient has cardiac tamponade?
chest x-ray, CT scan, echocardiogram(most reliable), EKG, pericardiocentesis and cytology if fluid is found
what are the nonpharmacologic interventions for cardiac tamponade?
pericardiocentesis, pericardial window, radiation therapy
what are the pharmacologic interventions for cardiac tamponade?
pericardial sclerosis, chemotherapy, steroids
how is pericardial sclerosis done?
installation of a chemical agent through a pericardial catheter, common agents are doxycycline, thiotepa, bleomycin, mitomycin C sterile talc
what increases the risk for cardiac tamponade?
primary tumors of the heart (mesothelioma, sarcoma), metastatic tumors to the pericardium, > 4000 cGy of RT to the heart
what are the early signs and symptoms of cardiac tamponade?
retrosternal chest pain relieved with leaning forward, dyspnea, cough, muffled heart sounds, weak or absent apical pulse, anxiety, hiccups
what are the late signs and symptoms of cardiac tamponade?
tachycardia, tachypnea, narrowing pulse pressure, pulsus paradoxus greater than 10 mm HG classic, increased CVP, oliguria, peripheral edema, diaphoresis, cyanosis, altered Loc, Beck’s Triad
a classic sign of cardiac tamponade is Becks Triad, what is it?
elevated central venous pressure (CVP), hypertension, distant heart sounds
what interventions should be done for cardiac tamponade to monitor response to therapy?
Vital Signs evaluation, monitor Beck’s Triad, input and outtake, Loc, edema
