Oncology

Question 0

Prevention female

Answer 0

• Monthly self-breast exam over age 20 on days 7-12 of cycle
• yearly clinical breast exam for women >40 years old
Between ages 20-39 needed every 3 years
• annual pelvic exam
• Pap smear: every 3 years if there’s been no problem - no sex, no douche
• Mammogram: yearly starting at age 40 (2 views of each breast) - no lotion, deodorant, powder they show as calcium deposit
• Colonoscopy: at age 50 then every 10 years after that time.

Question 1

Risk factors

Answer 1

a. Alcohol + tobacco = co-carcinogenic
b. tobacco is the #1 cause of preventable cancer.
c. Suspected dietary causes of cancer:
Low fiber diet, Increased red meat, Increased animal fat, Nitrites (processed sandwich meat), Alcohol, Preservatives, and additives
d. Increased incidence of cancer in the immunosuppressed *That is why there is a higher incidence of cancer > age 60
e. The most important. risk factor for cancer= Aging

f. Diet/exercise habits:
• Cruciferous veggies (broccoli, cauliflower, and cabbage), Vitamin A foods
(colored veggies), and Vitamin C could decrease risk
• Regular physical activity

g. African Americans have a greater incidence than Caucasians.
h. Primary prevention: ways to prevent actual occurrence (sunscreen and no
smoking)
i. Secondary prevention: Using screening to detect cancer early when there is a greater chance for a cure or control
j. Chronic irritation brings about uncontrolled growth of abnormal cells.

Question 2

Prevention male

Answer 2

• monthly self-breast exam
• Monthly testicular exam- testicular tumors grow fast. Usually 15-36 yrs old
• Yearly digital exam and yearly PSA (prostate specific antigen) for men over age 50
• Colonoscopy at age 50 then every 10 years

Question 3

General s/s

Answer 3

a. Caution: Change in bowel/bladder habits
A sore that does not heal
Unusual bleeding/discharge
Thickening or lump in breast or elsewhere
Indigestion or difficulty swallowing
Obvious change in wart or mole
Nagging cough or hoarseness
b. Cancer can invade bone marrow→ anemia, hypoxia, and thrombocytopenia
c. Cachexia-extreme wasting and malnutrition

Question 4

Brachytherapy

Answer 4

Internal radiation

• With all brachytherapy, the radioactive source is inside the client; radiation is being emitted
• Types of Internal Radiation
Unsealed: client and body fluid emit radiation Isotope is given IV or PO
Radioactive for 24-48 hours
Sealed or solid: client emits radiation; body fluids not radioactive Implanted close to or in the tumor
• In general terms, do radiation implants emit radiation to the general environment?
Nursing assignments should be rotated daily, so that the nurse in not continuously exposed.
The nurse should only care for 1 client with radiation implants in a given shift.
• Precautions with Internal Radiation Private room
Wear a film badge at all times
Restrict visitors
Limit each visitor to 30 min per day
No visitors less than 16 years of age
Visitors must stay at least 6 feet from source No pregnant visitors/nurses
Mark the room with instructions for specific isotope
Wear gloves with risk of exposure to body fluids
• How can you help prevent dislodgment of the implant? Keep the client on bedrest.
Decrease fiber in the diet.
Prevent bladder distension.
• What do you do if the implant becomes dislodged and you see it? Gloves, forceps, put in lead container, call radiation to get it.
*Don’t forget this client is immunosuppressed

Question 5

External radiation

Answer 5

Teletherapy/beam therapy

• Side effects of external radiation are usually limited to the exposed tissues: Erythema
Shedding of skin
Altered taste
Fatigue
Pancytopenia (all blood components are decreased)
• Many signs and symptoms are locatio. And dose related
• Is it okay to wash off the markings? No
• Is it okay to use lotion on the markings? No
• Protect site from sun for 1 year after completion of therapy.

Question 6

General chemotherapy

Answer 6

Works on the cell cycle
Usually scheduled every 3-4 weeks
Most chemo drugs are given IV via a port.
Many chemo drugs absorb through the skin and mucous membranes; be careful handling them.
Usual side effects: alopecia, N/V, mucositis, immunosuppression, anemia, thrombocytopenia
A vesicant is a type of chemo that if infiltration (extravasation) occurs will cause tissue necrosis.
What are S/S of extravasation? Pain, swelling and no blood return.
The #1 thing to remember with extravasation is prevention! What do you do if this happens?
For NCLEX®, stop the infusion and think vasoconstriction to prevent spreading. Use ice. Call doc. Follow protocol and inject bicarb

Slight increase in temp may mean sepsis
Absolute neutrophil count is most important lab value.

Question 7

Cervical cancer

Answer 7

a. Risk factors:
• The number one risk factor is Human Papilloma Virus.
• Repeated STD’s
• multiple sexual partners
• Smoking and exposure to second hand smoke
• Dietary factors such as certain nutritional deficiencies: folate, beta-carotene and vitamin C.
• Prolonged hormonal therapy
Mothers who took DES during pregnancy put their daughters at higher risk.
• Family history.
• Immunosuppression
• Sex at a young age and multiple pregnancies
b. S/S:
• Often asymptomatic in pre-invasive cancer
• Invasive cancer symptoms: painless vaginal bleeding
• Other general S/S: watery, blood-tinged vaginal discharge, pelvic pain (and it may occur with intercourse), leg pain along sciatic nerve, and flank/back pain,
• 100% cure if detected early

c. Dx:
• Pap smear. Abnormal? Repeat test

d. Tx:
• Electrosurgical excision
• Laser
• Cryosurgery
• radiation and chemo for late stages
• Conization- remove part of cervix
• Hysterectomy

Question 8

Uterine/endometrial cancer

Answer 8

a. Risk Factors:
• Greater than 50 years of age
• Taking estrogen therapy without progesterone
• Positive family history
• late menopause
• No pregnancy (null parity)

b. S/S:
• Major symptoms: post menopausal bleeding
• Other S/S: watery/bloody vaginal discharge, low back/abd pain, pelvic pain

c. Dx:
• CA-125 (blood test) to R/O ovarian involvement
• Test to evaluate for metastasis:
CXR (chest x-ray) 
CT
IVP (Intra Venous Pyelogram)
Liver and bone scan 
BE (Barium Enema)
• The most definitive diagnostic test is a D & C (dilatation & curettage) and endometrial biopsy.

1) Surgery: Hysterectomy
• TAH (total abd hysterectomy) = uterus and cervix only! : • Tubes & ovaries removed?
Bilateral oophorectomy (ovaries) Bilateral salpingectomy (tubes)
• Radical Hysterectomy:
2) Radiation: intra-cavitary radiation to prevent vaginal recurrence
3) Chemotherapy: Doxorubicin (Adriamycin®), Cisplatin (Platinol-AQ®)
4) Estrogen inhibitors: Medroxyprogesterone (Depo-Provera®), Tamoxifen (Nolvadex® / Soltamox®)

Question 9

Radical hysterectomy

Answer 9

• May remove all of the pelvic organs
• Client may have colostomy or ileal conduit
• The greatest time for hemorrhage following this surgery is during the first 24 hours
• Why? Pelvic congestion of blood
• Major complication with abdominal hysterectomy? Hemorrhage
• Major complication with vaginal hysterectomy? Infection
• Will probably have a foley; if she doesn’t you better make sure she does what in the next 8 hours? Voids
• Why is it so important to prevent abdominal distention after this surgery?
We do not want tension on the suture line. Dehiscence and evisceration
• Why do we avoid high-fowler’s position in this client? Because high fowlers will make more blood go where. To the pelvis
• May have an abdominal and perineal dressing to check
• As this client is at risk for pneumonia, thrombophlebitis, and constipation, what is one thing you can do to prevent this? Early ambulation
• Avoid sex and driving. ☺
• Also avoid girdles and douches.
• Any exercise, including lifting heavy objects that will increase pelvic congestion should be avoided.
• Is it possible that the client could hemorrhage 10-14 days after this surgery? Yes
• Is a whitish vaginal discharge okay? Yes, but worry if it changes colors
• Showers OR baths? Showers

Question 10

Breast cancer risk

Answer 10

• One has a 3 fold risk increase of developing breast cancer if a 1st degree relative (mother, sister, and daughter) had pre-menopausal breast cancer.
• High dose radiation to thorax prior to age 20
• periodonset prior to age 12
• Menopause after age 50
• No pregnancy (null parity)
• First birth greater than 30 years old

Question 11

Breast cancer s/s

Answer 11

• Change in the appearance of the breast (orange peel appearance, dimpling, retraction, discharge from breast) or lump
• Tail of Spence is where 48% of breast tumors occur: located in upper outer quadrant

Question 12

Breast cancer treatment

Answer 12

1) Surgery:
• Post op care:
Bleeding→ check dressings, back (pooling of blood), hemovac, Jackson-Pratt drain
Elevate arm on affected side.
Associated nursing care: Stay away from arm on affected side for lifetime of client:
* No watch, no constriction, no BPs or injections, wear gloves when gardening, watch small cuts, no nail biting, no sunburn and no IV
• Brush hair, squeeze tennis balls, wall climbing, flex and extend elbow
• Why? Promotes collateralcirculation
• Look at incision
• Reach to Recovery (Support Group)
• Lymphedema
*Two functions of the lymphatic system:
fights infection and promotes drainage
2) Chemotherapy drugs: Paclitaxel (Taxol®), Doxorubicin (Adriamycin®)
3) Hormonal Therapy:
• Estrogen receptor blocking agents: Tamoxifen (Nolvadex®/
Soltamox®)
• Estrogen synthesis inhibitors: Leuprolide (Lupron®), Goserelin (Zoladex®) (puts them into menopause)
4) Radiation

Question 13

Lung cancer risk

Answer 13

a. Risk Factors:
• Leading cause of cancer death worldwide
• Five year survival rate is 16%
• Major risk factor: smoking
*When you have stopped smoking for 15 years, the incidence of lung
cancer is almost like that of a non-smoker.

Question 14

Lung cancer s/s

Answer 14

• Hemoptysis, dyspnea (may be confused with TB, but TB has night sweats), hoarseness, cough, change in endurance, chest pain, pleuritic pain on inspiration, displaced trachea
• May metastasize to bone

Question 15

Lung cancer diagnosis

Answer 15

1) Bronchoscopy:
• NPO pre and NPO until gag reflex returns
• Watch for respiratory depression, hoarseness, dysphagia, SQ emphysema.
What is SQ emphysema? Air under skin indicating perforated airway. Emergency
• Is it normal or abnormal to have respiratory depression after a bronchoscopy? Abnormal
2) Sputum specimen:
• Best time to obtain? In the morning
• Is this sterile? Yes
• What should the client do first? Rinse water
* Trying to decrease the bacterial count in the mouth
3) Chest x-ray
4) CT:
5) MRI:

Question 16

Lung cancer trtmnt.

Answer 16

• Surgery: The main treatment for stage I and II
• Lobectomy: part of lung
• Chest tubes and surgical side up
• Pneumonectomy: entire lung
• Position on affected side (surgical side down, good lung up).
• No chest tubes, why? No lung in pleural space
• Avoid severe lateral positioning→ mediastinal shift.

Question 17

Laryngeal cancer

Answer 17

Risk Factors:
• smoking (any form of tobacco use), alcohol, voice abuse, chronic laryngitis, industrial chemicals

S/S:
• Hoarseness, lump in neck, sore throat, cough, problems breathing, earache, weight loss, no early signs

Dx:
• Laryngeal exam, MRI

1) Surgery:
• Total laryngectomy (removal of vocal cords, epiglottis, thyroid cartilage)
• Since the whole larynx (remember this includes the epiglottis) is removed this client will have tracheostomy
• Position post op? Sitting up, but not high fowlers
• NG feedings to protect the suture line (peristalsis could disrupt suture line)
• Monitor drains.
• Watch for carotid artery rupture.
• Rupture of innominate artery-medical emergency
• Frequent mouth care to decrease bacterial count in the mouth
• NPO clients tend to get pneumonia.
• Bib (acts like a filter)
• Humidified environment
* Remember, with a total laryngectomy ALL breathing is done
through the stoma.
2) Radiation:
3) Chemotherapy:
4) Speech Rehabilitation

Question 18

Speech rehab

Answer 18

• When should client begin? Preop
• Good client advocate
• Refer to International Association of Laryngectomees.
*See if there are local groups such as the Lost Cord Group.
Speech Devices
• Electrolarynx is a handheld device held up to the client’s cheek or neck, it vibrates while the client forms words
• Most common device is a Blom-Singer device Connection is made between trachea and esophagus
Once the fistula heals, client can insert soft plastic device and move air from lungs to the trachea and then over to the esophagus and out of the mouth. In the mouth the tongue and lips can form words with the rush of air.
Can the client with a total laryngectomy:
• Whistle? No
• Use a straw? No
• Smoke? No
• Swim? No

Question 19

Suctioning laryngectomy

Answer 19

• Sterile or non-sterile technique? Sterile
• Hyper-oxygenate when? before and after
• When do you stop advancing the catheter? When you meet resistance or your client coughs.
• Apply suction when? Pulling it out
• Intermittent
• Suction no longer then 10 seconds.
• Watch for arrhythmias.
Which nerve can be stimulated? vagus nerve
When vagus nerve is stimulated, heart rate drops. Is this client hypoxic? No. The HR increases when hypoxic. You should stop suctioning and hyperoxygenate.

Question 20

Colorectal cancer

Answer 20

a. Risk Factors:
• May start as a polyp
• 2/3s of colorectal cancer occurs in the rectosigmoid region
• Most frequent site of metastasis: liver *Take bleeding precautions
• Other problems to watch for: bowel obstruction, perforation, fistula to bladder/vagina
• Additional risk factors: inflammatory bowel diseases, genetic, dietary factors (refined carbs, low fiber, high fat, red meat, fried and broiled foods) if you have a first degree relative with CRC your risk just increased 3X the norm
• 95% of those who get CRC are greater than 50 years old.

b. Dx:
Screening
• Fecal occult blood testing should begin at age: 50.
• Flexible sigmoidoscopy every 5 years after age 50 or colonoscopy every 10 years after age 50.
• The definitive test for colorectal cancer = colonoscopy.

c. S/S:
• Change in bowel habits, constipation, diarrhea, or narrowing of stool
• Other S/S: blood in the stool, cramping abdominal pain, weakness, fatigue,
anemia, abdominal fullness, unexplained weight loss
• May become obstructed (visible peristaltic waves with high pitched tinkling bowel sounds)

d. Tx:
1) Surgery, radiation, and chemo
2) May have a colostomy post op
• Colectomy-part of colon removed
*May not need colostomy
• Abdominoperineal resection-removal of the colon, anus, rectum *Can you take a rectal temp on this client? No

Question 21

Bladder cancer

Answer 21

a. Risk Factors:
• Greatest risk factor: smoking

b. S/S:
• Major symptom: painless intermittent gross/microscopic hematuria

c. Dx:
• Cystoscopy

d. Tx:
• Surgery (remove all or part of bladder)→ urinary diversion (urostomy)
• Ileal conduit (a piece of the ileum is turned into a bladder; ureters are placed in one end; the other end is brought to the abdominal surface as a stoma)
• May be impotent
• Hourly UO should never decrease
• Increase fluids (2,000-3,000 ml of fluid per day). * Flush out conduit
• Mucus normal? Yes
• Intestines always make mucus (the bladder is made from a part of
intestine).
• Change appliance in morning (This is when output will be at its lowest).
It is OK to place a little piece of 4X4 inside the stoma during skin care to absorb urine… Just don’t forget to remove it☺

Question 22

Prostate cancer

Answer 22

a. S/S:
• This client comes to the physician with S/S of benign prostatic hyperplasia (BPH): hesitancy, frequency, frequent infections (because the bladder is not completely emptied), nocturia, urgency, dribbling. Many clients are asymptomatic.
• Most common sign is painless hemataurea
• Digital rectal exam is done and the prostate will be hard/nodular; this usually
means prostate cancer.

b. Dx:
1) Lab work:
• PSA will be increased.
Prostate-specific antigen (PSA)
This is a protein that is only produced by the prostate.
Normal is less than 4 ng/ml.
If you have two or more 1st degree relatives with prostate CA, start PSA by at least age 45.
This is a blood test.
• Alkaline phosphatase (if ↑ means bone metastasis)
*Prostate cancer likes to go to the spine, sacrum, and pelvis.
• Increased acid phosphatase (if ↑ means bone metastasis)
2) Biopsy:
• When prostate CA is suspected, a biopsy must be done for confirmation prior to surgery.

c. Tx:
1) Watchful waiting: in early stages (for asymptomatic, older adults
with another illness)
2) Surgery:
Radical Prostatectomy (done with localized prostate CA)
3) Radiation:
4) Chemotherapy:
5) Hormone therapy:
• May decrease testosterone levels through bilateral orchiectomy
• Estrogens decreases testosterone
• Leuprolide (Lupron®) decreases testosterone

Question 23

Prostatectomy

Answer 23

Radical Prostatectomy (done with localized prostate CA)
• Take out the prostate and the client is cancer free (if there is no metastasis).
• May have erectile dysfunction due to pudendal nerve damage.
• May have incontinence (Kegel exercises)
• Client is sterile.
• If there is no lymph node involvement, no ↑ in acid phosphatase, and no metastasis, the surgeon will try to preserve the pudendal nerve.

Prostatectomy (TURP- transurethral resection of the prostate)
• Usually reserved for BPH to help urine flow, NOT a cure for prostate CA
• No incision (go through the urethra)
• Most common complication? Bleeding
• With other procedures you have to explain the risk of impotency/infertility.
• Is it normal to see bleeding after this surgery? Yes but we still worry
• Continuous bladder irrigation – maintains patency, flush out clots
3-way catheter
No kinks
Subtract irrigant from output.
• Keep up with amount of irrigant instilled
• What drug do you give for bladder spasms? Belladonna and Opium
Suppository (B&O suppository®), Oxybutynin (Ditropan®)

TESTING STRATEGY
Never manually irrigate a catheter with a fresh surgery client, without a physician’s order.

When the catheter is removed what do you watch for? Urine retention
• Temporary incontinence expected (perineal exercises-Kegel)
• Avoid sitting, driving, strenuous exercise; do not lift too
much…Why? Bleed
• Docusate (Colace®); avoid straining. Why? Bleed
• Increase fluids: to flush out blood
• The TURP is used for symptomatic relief of symptoms… to allow the urine to flow out… This is not a cure for prostate cancer. It is a comfort measure.

Question 24

Stomach cancer

Answer 24

a. Risk factors:
• H-Pylori-associated with stomach cancer
• Pernicious anemia , Achlorhydria
There is a higher instance of stomach cancer with people who have
pernicious anemia and achlorhydria (not enough acid in stomach).
• Related to: pickled foods, salted meats/fish, nitrates, increased salt
• Billroth II (partial gastrectomy with an anastomosis)
• Tobacco and Alcohol

Ss
Heartburn and abdominal discomfort are the most common. Other S/S: loss of appetite, weight loss, bloody stools, coffee-ground vomitus, jaundice (liver metastasis), epigastric and back pain, feeling of fullness,
anemia, stool (+) for occult blood, achlorhydria (no HCL in the stomach), obstruction (S/S of an obstruction: abdominal distention, n/v, pain.) Tx for obstruction: NPO, NG tube to suction for abd decompression

c. Dx:
• Upper GI, CT, EGD (esophagogastroduodenoscopy)

d. Tx:
1)
Surgery (preferred): Gastrectomy It debulks the tumor and leaves about 30 to 50 mL for the stomach
• Fowlers position (decreases stress on suture line)
• Will have NG tube (for decompression) Is it ok to reposition? Not for new surgeries.
• Two major complications: Dumping syndrome
Vitamin B-12 deficient anemia- Pernicious anemia *Schilling’s test
(Measures the urinary excretion of Vitamin B-12 for diagnosis of pernicious anemia)

No stomach→ no intrinsic factor→ can’t absorb oral B-12→ can’t make good RBCs→ client is anemic. B12 shot needed monthly

2) Chemotherapy: Fluorouracil (5-FU®), Doxorubicin (Adriamycin®), Mutamycin (Mitomycin-C®), Cisplatin (Platinol-AQ®)
3) Radiation: