Oncology Flashcards
2 types of cancer
- Solid tumors
2. Hematologic malignancies
Types of solid tumors
- Sarcomas
2. Carcinomas
Sarcomas
Begin in connective tissues
Carcinomas
Originate from epithelial tissues
Epithelial tissues
Line organs
Which race has the greatest risk for cancer?
African Americans, then caucasians
Primary prevention of cancer
Prevention with modifying risk factors (lifestyle, vaccines)
Secondary prevention of cancer
Screening to detect cancer early (breast exams)
What days of the menstrual cycle are best for doing the breast self exam?
7-12, after the period is just about over. Not before, because they will be swollen. If breasts have been removed, tell them to do the same day each month.
Who should get clinical breast exams?
Yearly for women over 40, every three years for ages 20-39
Client teaching before mammogram
No lotion, powder, deoderant (can be picked up as a Ca deposit which would mean cancer), two views of each breast
When should pap smears be performed?
Beginning at age 21 and done every 3 years if there have been no problems
When should colonoscopies be performed?
Every 10 years beginning at age 50
When should fecal occult blood be tested?
Yearly beginning at age 50, unless previous family history
When should testicular exams be performed?
Yearly at the clinic, monthly at home (testicular tumors grow fast)
What age is most at risk for testicular cancer?
15-36, so teach self exams early
When should digital rectal exams for prostate specific antigens be checked?
Yearly for men over 50
Tertiary prevention of cancer
Focuses on management of long term care for pts with complex treatments of cancer. (Support groups, rehab programs)
CAUTION
Change in bowel/bladder habits A sore that doesn't heal Unusual bleeding/discharge Thickening or lump in breast/elsewhere Indigestion/difficulty swallowing Obvious change in wart or mole Nagging cough/hoarseness
Leukopenia
Low WBC count, leads to infection
When cancer invades the bone marrow, what can happen?
Anemia, leukopenia, thrombocytopenia
Cachexia
Extreme wasting and malnutrition
1 symptom of clients complaining of with cancer
Extreme fatigue
CBC with diff
Tells the # of different WBC in the blood
With cancer, what are you most concerned about with a CBC?
Neutrophils
With blood tests, there will also be elevated liver enzymes (AST, ALT, tells if the liver is being damaged) and tumor markers (found at higher than normal levels in the blood, also called bio markers)
How is lung cancer diagnosed?
Bronchoscopy
Teaching for bronchoscopy
NSP re and NOP until gag reflex returns, watch for respiratory depression, hoarseness, dysphagia, or SQ emphysema (feels like rice krispies sound)
Is it normal or abnormal to have respiratory depression when returning from a bronchoscopy?
Abnormal, respiratory depression is different than a decreased respiratory rate
Best time to get a sputum specimen
1st thing in the morning
How to get a sputum specimen
Sterile specimen, pt should wash mouth out with water to decrease the bacteria count in the mouth, don’t let their mouth touch the cup.
Do this before a bronchoscopy because it’s less invasive.
You can get one from a trach if they have one
Total laryngectomy
Removal of vocal cords, epiglottis, thyroid cartilage
Care post op for laryngectomy
Mid-Fowlers, they will have permanent trach or laryngectomy.
NG feeds to protect the suture line (peristalsis can disrupt sutures)
Monitor drains to prevent fluid accumulation
Frequent oral care to decrease bacteria in mouth (NPO pts tend to get pneumonia)
What do you watch for post op laryngectomy?
Carotid artery rupture (hemorrhage), rupture of the innominate artery (bleeds massively from trach) (Go to OR immediately)
When to hyper oxygenate when suctioning trach
Before and after
When do you stop advancing the catheter when suctioning a trach?
When you meet resistance or when the client coughs
When do you suction a trach?
On the way out, intermittent, no longer than 10 seconds
What to watch for while suctioning a trach
Arrhythmias, vagal nerve stimulation (HR drops, not hypoxic bc with hypoxia HR goes up, this is how you will know it’s the vagus nerve)
What to do if you suspect vagal nerve stimulation while suctioning a trach?
Stop suctioning, hyperoxygenate
When the trach client leave the hospital, what covers the trach?
A bib will act like a filter since they aren’t using their nose as a filter, don’t use plastic or anything with fibers
Laryngectomy tube
Smaller around than a trach, not as long, for long term use, they go home on them
How do pts breathe with a total laryngectomy?
Through the stoma
How do pts with a total laryngectomy talk?
Use an electrolarynx, blom-singer device is commonly used
What can the client do with a total laryngectomy?
Not whistle
Not drink through a straw
Can smoke, not recommended
Can’t swim
Cancer staging
Classifies the size of tumor (T),
If lymph nodes are involved (N)
Presence of metastasis (M)
Trick for situating clients
Highest position that isn’t high fowlers
Cancer grading
Compares the cancer cells with the parent cell they evolved from. The less they look like the parent tissues, the more aggressive. 1-4 grade scale. 4 being the worst
Goals of treatment for cancer
Cure
Control
Palliation
Adjuvant therapy
When two therapies are used together
Neoadjuvant therapy
Time specific therapy, one before the next
Chemo or radiation may be used before removal surgery to shrink the size of a tumor
Mastectomy
Removal of breast tissue, can be partial or total (radical)
Hemovac or Jackson-Pratt drains
Reconstruction of breasts
Can be done with mastectomy or at a later time.
They will have an abdominal surgical site (most common site for adipose tissue harvesting)
What to check for after mastectomy
Bleeding, check front and back dressings for pooling of blood (pooling could be inside tissues)
How to care for and educate a patient if lymph nodes were removed with a mastectomy
- Avoid procedures on arm affected forever
- No constriction, BPs, elastic shirts, watches, IV, injections on affected side
- Wear gloves when gardening, watch small cuts, no nail biting, no sunburn
Post op mastectomy
Brush hair, squeeze tennis balls, wall climbing, flex and extend elbow to promote new/collateral circulation
Palliative care
Sx to improve client’s quality of life when there is no cure
Can remove parts of tumor to make you more comfortable even though it will not cure you
Internal radiation is also called what?
Brachytherapy
Internal radiation
Used to get the radiation close to the cancer. It is inside your body, so you will emit radiation for a period of time and be a hazard to others
Adequate margins
Amount of regular tissue removed around tumor. Clear margins means there can still be micro metastasis
Unsealed brachytherapy
Client and body fluids emit radiation
Radioisotope is given IV or PO
Radioactive for 24-48 hours
Sealed or solid brachytherapy
Client emits radiation, not through body fluids
Can be temp or permanent implant that is placed close to or inside the tumor
What to generally remember for internal radiation precautions
Time, distance, shielding
Nursing assignments with internal radiation
Rotated daily, wear film badge, only one radiation implant in a given shift, no pregnant nurses, mark room with instructions for specific isotope, wear gloves with risk of exposure to body fluids
Precautions for internal radiation
Private room
Restrict visitors-30 min per day, 6 feet from source, none under 16, no pregnant
How can you help prevent dislodgment of an internal radiation implant?
Keep client on bedrest
Decrease fiber in the diet (fiber distends bowel)
Prevent bladder distention (use foley)
What do you do if a brachytherapy implant becomes dislodged and you see it?
Wear gloves, pick it up with tongs, put it in a lead-lined container
After brachytherapy, can the client sleep in the same bed with their spouse or children?
No, stay 6 feet away for 1-11 days
Should clients use public transportation after brachytherapy?
No, should stay 6 feet away for 2-3 days
Can clients with brachytherapy share utensils or cook for others or return to work immediately?
No
How to flush toilet with brachytherapy client
Close lid, flush 2-3 times
External radiation is also called what?
Teletherapy, external beam radio therapy
How does external radiation delivered?
Pt lays on x-ray table, a carefully focused beam of high energy rays is delivered by a machine outside of the body
Is the client radioactive with external radiation?
No
Side effects of teletherapy
-Usually limited to exposed tissues, location and dose related
Erythema, shedding of skin, altered taste, fatigue, pancytopenia
Pancytopenia
All blood components are decreased
Number one complaint of radiation
Fatigue
What should you think of first with tele therapy?
Skin problems
Is it okay to wash off or use lotion on tele therapy markings?
No
Common side effects of brain external radiation
Lose hair, have sores in mouth
How to care for the tele therapy site
Protect from sunlight and UV exposure for 1 year after completion of therapy, skin is still very sensitive, no lotions without doc order
When is chemo usually scheduled?
Every 3-4 weeks, it can knock them down for a week after. They should eat well when they can before they come again.
Can a regular RN have a chemo pt?
Must take a course to administer, but can still monitor pts on it if you haven’t
Growth fraction
% of cells dividing at a given time, can be a good thing when giving chemo, can kill more cells
Tumor burden
How much tumor is present
Body systems affected by chemo
Blood, GI, Skin/Hair (these are the areas where cells are dividing the most rapidly)
Cell cycle non specific chemo drugs
Work best when cells are in resting phase, don’t care which phase the cell is in, they just destroy it
Can you combine specific and non specific cell cycle chemo drugs?
Yes, kills more cells
Full chemo precautions
Chemo (isolation) gown
2 pairs of chemo gloves (thicker, longer)
Goggles/mask if splashing or inhalation can occur
Excretion precautions
2-7 days after chemo is administered, when handling body fluids: wear two pairs of chemo gloves and a chemo gown. Add face shield if worried about splashing
*Teach client’s family excretion safety as well
Disposal of chemo drugs
Yellow rigid chemo wast container for sharps, yellow chemo bag for gowns, gloves, disposable items
Sequence for cleaning chemo spill
- Wash hands w/ soap and water
- Get spill kit from client’s room
- Facemask
- Gown
- Gloves (1 under gown, 1 over)
- Goggles
- Use absorbent pads to wipe up spill
How to manage chemo spill
Handle as hazardous chemical spill, obtain spill kit and use all protective equipment for clean up
How are most chemo drugs given?
IV via a port
Vesicant
Type of chemo drug that if it infiltrates will cause tissue necrosis, stay with client during administration
-Any time you’re giving a chemo drug, look it up and see if it’s a vesicant
Dosarubasin chemo drug considerations
EKG as baseline, its cardiotoxic
S/S of extravasation
Pain, swelling, no blood return
What do you do if chemo extravasates?
Stop infusion, cold packs to vasoconstrict (warm would make the vesicant spread), call doc
How to administer PO chemo drugs
Wear gloves
Biologic Response Modifiers
Enhance your own immune system to fight and hopefully kill the cancer
HPV vaccine is what type of vaccine?
BRM because it gives ACTIVE immunity (body has to actively make the antibodies) to the virus to help prevent cervical, anal, and oral cancers
1 risk factor to cervical cancer
HPV infection
Hormone therapy cancer drugs
Slow the growth of cancer by blocking the body’s ability to make the hormone or interferes with the ability to use the hormone
Corticosteroids are hormones, steroids are used to increase the effectiveness of chemo (worry about decreased immunity)
Treatments of hematologic cancers
Bone marrow and stem cell transplants
When are bone marrow and stem cell transplants done?
When high doses of chemo or radiation have destroyed too many blood cells
How to transfer stem cells
Given into a vein, like a blood transfusion, over time they settle in the bone marrow and produce healthy blood cells
Signs of stem cell rejection
Abdominal pain, cramps, n/v, diarrhea
Jaundice, other liver problems
Dark (tea colored) urine
Skin rash, itching, redness on areas of skin
Major complication of stem cell transplants
Infection, this pt is receiving so much chemo they have a very bad immune system
How to treat GVHD
Anti-Rejection drugs and steroids
1 cause of cancer related deaths
Infection
How to bathe cancer pt
Bathe warm moist areas twice daily (groin, under arms)
IV tubing and dressing changes with cancer pt
Change daily
What do you worry about with a slight increase in temp in the cancer pt?
Sepsis. Tell them to come to hospital or clinic for oral temp of 100.4 or greater
Mature WBC
Neutrophil, first line of defense inside body to protect from infections
Normal absolute neutrophil count
2200-7700
Nadir
Lowest point
Neutropenia + infection = ?
Septic shock and death
Risk factors for neutropenia
Very old, very young Advanced metastatic dz Malnourishment B12/Folic acid deficit Impaired tissue integrity Other dz Blood dz (leukemia, lymphomas, myelomas) Result of caner tx
When is fresh water old?
When it has been sitting out for 15 minutes or more
Tx for neutropenia
Antibiotics, neutropenic precautions
Neutropenic precautions
Vitals Q4h
Private room, closed door, posted sign
Antimicrobial soap, not regular soap
No invasive procedures (sticks, rectal med/temp/exam)
Foley, NG tube (avoid when you can)
Limit use of acetaminophen, toxic to liver
Second leading cause of death in cancer clients and why
DVT
Prolonged bed rest, sx, central lines, external compression of vessels by tumor, invasion of vessels by tumor, certain chemo drugs
What are you most worried about with a DVT?
PE
Anticoagulant meds
Decrease circulating platelets
Aspirin, clopidogrel, heparin, warfarin
Tx for thrombocytopenia
Give platelets
How to treat symptomatic anemia
RBC transfusion
What do you not want the hbg/hct to drop below with anemia?
8 and 24%, they’ll need RBC transfusion
Cytomegalovirus (CMV)
Really common herpes virus, bad for immunosuppressed, they’re already sick enough without getting CMV too
Test RBCs and platelets to make sure they’re negative for CMV before transfusions
*Worry about with pregnant women and passing to fetus
Leukoreduction
Removes CMV, 50% of donated blood has CMV in it
How to reduce the risk of transfusion related reactions
Leukoreduction and irradiation since immunosuppressed are more at risk for infusion reactions
Why do you give room temp platelets and not cold platelets?
Spleen will reject them and not absorb well
Most feared side effect of chemo and radiation
N/V
Ondansetron
Blocks effects of serotonin, antiemetic, doesn’t cause drowsiness, pill is just as effective as IV form
Netupitant/palonosetron
Oral combo antiemetic, prevents acute and delayed N/V caused by chemo. Only ONE dose, a pill one hour before the round of chemo
Non-Pharmacologic tx for N/V
Ginger (ginger ale)
Aromatherapy (peppermint, lavender, lemon, basil)
Acupuncture/Acupressure (bands on cruises)
Distraction
Relaxation
Pain with cancer
Usually related to direct tumor involvement, but can be the result of tx, such as with mucositis or peripheral neuropathy
How to treat cancer related pain
Treat without regard to risk of dependence
Opioids are the “gold standard” for cancer pain
NO ceiling on dose of an opioid for a cancer client, it is client dependent
Hydrotherapy
Massage
Cannabis
Medical marijuana
