Oncology Flashcards
Oncology Patho
Cancer refers to a class of diseases. Classfied by The tissue or blood cell where it starts and the type.
Two types:
Solid tumors and Hematologic malignancies
Solid tumors
Arise from specific tissue
Sarcomas
Begin in the connective tissues ( bones, muscles, tendons, cartilage)
Carcinoma
Originate from the epithelial tissues and this is the tissue that lines your organs like lungs, liver, breast, and prostate
Hematologic malignancies
Originate from blood and lymphatic cells
Begins with one abnormal cell that starts growing and dividing out of control
Metastasis
Travelling or extension of the original cancer to other sites of the body.
Occurs by
direct invasion
Though the blood system
Through the lymphatic system
Risk Factors for Cancer
Tobacco is the #1 cause of preventable cancer.
Alcohol and Tobacco = co-carcinogenic
Suspected dietary causes of cancer:
A low fiber diet, Increased red meat, Increased animal fat, Nitrates (process sandwich meats), Alcohol, Preservatives and additives
Obesity, physical inactivity and poor nutrition and aging
Increased incidence in the immunosuppressed
Hereditary, exposure to UV radiation, exposure to carcinogens, Chronic irritation can cause uncontrolled growth of abnormal cells.
Previous history of other types of cancer or chemo.
Prevention and Screening : Primary
Ways to help prevent the actual occurrence of cancer.
No smoking
Exercise and Nutrition
Maintain normal body weight
Limit or eliminate alcohol
Vacines for preventable viral exposures such as hep b and HPV
Avoid exposure to known carcinogens
Prevention and Screening: Secondary for females
This is when we use screenings to puck up on cancer early, when there is a greater chance for cure or control.
Breast self awareness/ Monthly breast self exams - done anytime on day 7 to 12 of the menstrual cycle.
Post menopausal or woman who have had a hysterectomy should perform the breast self exam on the same day every month
Yearly clinical breast exams for woman greater than 40 years of age. Woman between ages of 20 to 39 need one every three years.
Paps beginning at age 21 and performed every 3 years if there have been no problems
Colonoscopy at age 50 then every 10 years if no problems
Testing stool for fecal occult blood should be done yearly beginning at age 50 unless previous problems or positive family history
Mammograms
Mammogram - annually starting at age 40
Do not put lotion, powder or deodorant before exams
Prevention and Screening: Secondary for males
Yearly clinical testicular exams
Testicular tumors grow vee fast so monthly self exams are recommended.
Major age group is 15 - 36.
Digital rectal exam and prostate specific antigen may be checked annually for men over the age of 50.
Colonscopy at age 50 then every 10 years and yearly fecal occult blood testing
Tertiary Prevention
Focuses on the management of long term care for clients with complex treatments for cancer.
Includes support groups and rehabilitation.
Cancer Symptoms : CAUTION
CAUTION
Change in bowel/bladder A sore that does not heal Unusual bleeding/discharge Thickening or lump in breast or elsewhere Indigestion of difficulty swallowing Obvious change in wart or mole Nagging cough or hoarsenes
Cancer General Signs and Symptom
Cancer can invade bone marrow which can lead to anemia ( hypoxia), leukopenia (Risk for infection) and thrombocytopenia (Low platelets - bleeding precautions)
Unexplained weight loss
Cachexia
Fever - Leukaemia and Lymphomas (first sign)
Fatigue is the #1 symptoms that clients report with a diagnosis of cancer. ( exhaustion that doesn’t get better with sleep)
Pain (Early sign of bone and brain and testicular cancer), colon, rectumn
Cachexia
Extreme wasting and malnutrition
Blood tests
Abnormal CBC and Dif
Most concerned about neutrophils
Elevated liver enzymes (AST and ALT) we don’t want liver involved
Tumor Markers
Positive diagnostic studies
CXR CT MRI PET scan Bone Marrow Biopsy Tissue Biopsy Imaging Studies
Total Laryngectomy
Long term and smaller. Removal of vocal cords, epiglottis and thyroid.
Since the whole larynx ( remember this includes the epiglottis - which stops aspiration into the lungs) is removed the client will have a permanent trach.
All breathing is done through the stoma. Cannot whistle, swim or drink through a straw.
Post op - Keep client at mid fowlers and avoid airway edema
NG feedings to protect the suture line (peristalsis can disrupt the suture line)
Monitor drains and prevent fluid accumulation
Watch for Carotid arter rupture - MASSIVE BLEEDING
Frequent oral care
NPO ppl get pneumonia easily
Tracheostomy tube
Needs lots of care. When changing string, don’t move your hand to hold it in place.
If the trach shoots out, re-insert and re-establish airway
This is the new airway. don’t cover it with plastic/ only something breathable.
Bib to cover trach as a filer
Humidified environment helps - decreases the secretions and make them thinner
Goals of Cancer Treatment
Cure Control Palliation Adjuvant therapies Neoadjuvant Therapies
Treatment plan is based on recommended treatment plans for the diagnosis, grade of cancer and what the client wants.
Adjuvant
is when two therapies are used together such as chemo and radiation
Neoadjuvant
Time specific therapies or one before the next. Surgery and then chemo.
Mastectomy : Post op
Bleeding - check dressings, front and back (pooling of blood can occur in the tissues)
If reconstruction includes using their own tissues, they will also have an abd surgical site from harvesting adipose tissue.
Hemovac or Jackson Pratt drains
If any lymph nodes have been removed, they are unable to fight off infection
Avoid procedures on arm of affected side for lifetime of client. No constriction, no BP, no blouses with elastics, No watch, No IV or injections on affected side.
Wear gloves, watch small cutes, no nail biting and no sunburn
Brush hair, squeeze tennis balls, wall climbing, flex and extend elbow - this promotes new circulation.
Radiation Therapy: Internal Radiation (brachytherapy)
Brachytherapy is used to get radiation close to the cancer or target tissue (INSIDE THE BODY)
The client emits radiation for a period of time and is a hazard to others.
Can be sealed or unsealed.
Unsealed: Client and body fluids emit radiation -> given IV or PO, radioactive for 24 to 48 hours
Sealed or solid - Client emits radiation; bodily fluids are NOT radioactive
Can be temporary or a permanent implant that is placed close to or inside the tumor
GENERAL RADIATION PRECAUTIONS FOR INTERNAL RADIATION - remember (time, distance and shielding)
Nursing assignments should be rotated daily, so nurse is not continuously exposed
Nurse should only care for one client with a radiation implant in a given shift.
Private Room
Wear a film badge at alltimes
Restrict visitors
Limit each visitor to 30 mins a day and must stay 6 feet away
No one less than 16 years of age and no preg visitors or nurses
Mark the room with instructions for specific isotopes
Wear gloves with risk of exposure to body fluids
Don’t forget that this client is immunosuppresed
What do you do if implant gets dislodged?
Put on gloves and put it into lead lined container
Preventing dislodgement of implant
How can you help prevent dislodgement of the implant?
Keep the client on Bed rest
Decreases Fiber in the diet as it distends the bowel
Prevent Bladder distention - use an indwelling cath
Can the client sleep in the same bed with spouse or children?
NO
They should also not use public transportation, return to work immediately, share utensils or cook for others.
Must flush toilet twice
External Radiation
A carefully focused beam is delivered by machine outside of the body.
Client is NOT radioactive.
Side effects are usually limited to exposed tissues:
Erythema
Shedding of skin
Altered Taste
Fatigue
Pancytopenia ( All blood components are decreased)
S&S depends on location and dose.
Don’t wash off or put lotion on markings
Protect the site from sunlight and UV exposure for one year after completion of therapy.
Alkylating Agents (Chemotherapy) - Cyclophosphamide (Cytoxan)
Common uses: Breast cancer Leukemia Lymphoma Hodgkin Disease Multiple myeloma
Contraindications: Hypersensitivity Myelosuppression Pregnancy Liver or kidney disease
PO/IV/ 7 days Interactions: Garlic and ginko increase antiplatelet effect. Echinacea decreases effects of immunosuppressive drugs. Ginseng and kava kava alters bleeding times
MoA: Directly damages DNA (the genetic material in each cell) to keep the cell from reproducing. These drugs work in all phases of the cell cycle.
Advantages: Especially useful for Hodgins’s disease if
resistant to other drug combinations.
Disadvantages: Severe vesicant that can cause tissue
necrosis if it infiltrates into the tissues. Can cause long term damage to thebone marrow
Side Effects: Nausea Vomiting Diarrhea Weight loss Hematuria Alopecia Impotence Sterility Ovarian fibrosis Headache Dizziness
Adverse Effects: Leukemia Vesicant: Tissue necrosis Hemorrhagic cystitis Cardiotoxicity Hepatotoxicity
Interventions:
Monitor IV site for extravasation: Cold compresses
Assess need for IV hydration. The client should be well hydrated
(2L/day) to prevent hemorrhagic cystitis.
Observe for s/s of hematuria.
Monitor BUN and creatinine
Avoid direct skin, eye, and mucus membrane contact with drug
Education:
Take medication early in the day to prevent accumulation of
drug in the bladder.
Report signs of infection.
Do not visit anyone who has a respiratory infection
Emphasize protective precautions.
Rationale for chemotherapy.
Teach importance of birth control while receiving therapy
Anthracyclines (Chemotherapy) - Doxorubicin
Adriamycin
Common Uses: Breast cancer Ovarian cancer Lung cancer Bladder cancer Leukemi
Contraindications:
Pregnancy
Severe cardiac
disease
IV/7-10 days Contraindications: Calcium channel blockers increase risk of cardiotoxicity. Green tea may enhance effects. Garlic, St John’s wart may decrease effects of chemo
MoA: These drugs are not like the antibiotics used to treat infections. They work by altering the DNA inside cancer cells to keep them
from growing and multiplying.
anti-tumor antibiotics that interfere with enzymes involved in DNA replication. These drugs work in all phases of the cell cycle.
They are widely used for a variety of cancers.
Disadvantages: Severe cardiotoxic side effects can occur.
Potent vesicant.
Cannot exceed lifetime dose of 550mg/m2
Side Effects: Stomatitis Anorexia Nausea/Vomiting Diarrhea Rash Alopecia
Adverse Effects: Vesicant Esophagitis Thrombocytopenia Anemia Cardiotoxicity CHF Anaphylaxis
Interventions: Give through large bore IV needle. Monitor IV site for extravasation: Apply ice pack. Notify MD. Dexrazoxan IV. Assess cardiac status.
Client Education: Signs/symptoms of cardiac dysfunction Drug causes urine to turn pink or red Report signs of infection or bleeding Protective precautions Do not visit anyone with a respiratory infection
Anti-Estrogens (Hormone Therapy) - Tamoxifen (Nolvadex)
Common Uses: Palliative treatment of advanced breast cancer positive lymph nodes in postmenopausal women
Contraindications:
Pregnancy
Breastfeeding
Hypersensitivity
PO
Interactions: Increased risk of bleeding with anticoagulants
MoA: This male hormone (androgen) promotes regression of tumors by competing with estradiol at estrogen receptor sites. Decreases
DNA synthesis. Reduces risk of breast cancer in postmenopausal women
Advantages: Prevents tumor recurrence in both
pre-menopausal and postmenopausal
women
Side Effects: Masculine secondary sexual characteristics. Hot flashes Irregular menses Fatigue Headaches Impotence Decreased interest in sexual activity
Adverse Effects: Increases risk of developing uterine cancer. Stroke Pulmonary embolism Thrombocytopenia
Interventions:
Monitor CBC, platelet count weekly.
Monitor for allergic reactions.
Education:
Avoid use of St. John’s wart, dong qui, black cohosh.
Use nonhormonal contraception during and for 2 months
after discontinuing treatment.
Notify prescriber of signs of stroke.
Increase fluids to 2 liters/day unless contraindicated.
Protect from sun.
Antimetabolites (Chemotherapy) - 5-Fluorouracil (5-FU)
(Adrucil), Methotrexate
(Rheumatrex)
Leukemias
Breast cancer
Ovarian cancer
Intestinal tract cancer
Contraindications: Pregnancy and Severe Infection
IV/IM/1 - 9 days Interactions: Cimetidine increases effect of F-FU Methotrexate: ASA, phenytoin increase toxicity of the drug.
MoA: Interfere with DNA and RNA growth by substituting for the normal building blocks of RNA and DNA. These agents damage cells
during the S phase, when the cell’s chromosomes are being copied.
Methotrexate acts as a substitute for folic acid, which is needed for the synthesis of proteins and DNA.
Disadvantages: Clients receiving methotrexate must
receive leucovorin calcium to “rescue” normal cells from the adverse effects of the drug.
Side Effects: Bone marrow suppression Stomatitis Nausea/Vomiting Anorexia Alopecia Rash Photosensitivity Erythema Hematic and renal dysfunction
Adverse Effects: Bone marrow suppression Thrombocytopenia Hemorrhage Renal failure Extravasation
Intervention:
Monitor IV site for extravasation: Apply ice pack. Notify MD.
Avoid direct skin contact with medication.
Administer antiemetic 30-60 minutes before therapy
I&O
Monitor blood counts. Encourage mouth rinses every 2 hours with
normal saline
Client Education:
Report signs of infection
Examine mouth daily/ report signs of stomatitis
Do not visit anyone with a respiratory infection
Use sunscreen when outdoors
Maintain protective precautions
Good oral care with soft toothbrush
Encourage small, frequent meals. Encourage cool, bland foods.
Gonadotropin-Releasing Hormone - Leuprolide (Lupron),
Goserelin (Zoladex)
Common uses:
Advanced Breast
cancer
Prostate cancer
Contraindications: Pregnancy
Breastfeeding
IM/SubQ/1-2 weeks Interactions: Increased antineoplastic action with megestrol. Black cohosh may interfere with treatment.
MoA: Suppress the secretion of follicle-stimulating hormone and luteinizing hormone from the pituitary gland. Initially an increase in testosterone
levels is seen. However, with continued use the pituitary gland becomes insensitive to this stimulation, leading to a reduction in the production
of androgens and estrogens..
Side Effects: Memory impairment Depression Peripheral edema Alopecia Anorexia Diarrhea Hot flashes Impotence Nausea/vomiting
Adverse Effects: Seizures MI PE Dysrhythmias GI bleeding
Interventions:
Assess for increased bone pain.
Monitor for allergic reaction.
Education:
Notify prescriber if menstruation continues – menstruation
should stop.
Bone pain should disappear after 1 week.
Monitor weight. Report weight gain of > 2 lbs (0.9 kg)/day.
How to administer SubQ/IM medication.
Plant Alkaloids - Mitotic Inhibitors (Chemotherapy) - Paclitaxel (Taxol)
Common Uses: Breast cancer Lung cancer Myelomas Lymphomas Leukemias
IV
Interactions:
Increased bleeding risks with NSAIDS and Anticoagulants
MoA: Mitotic inhibitors are often plant alkaloids and other compounds derived from natural products. They work by stopping mitosis in the M phase of the cell cycle but can damage cells in all phases by keeping enzymes from making proteins needed for cell
reproduction.
Disadvantages: These medications can cause nerve damage
Side Effects: Peripheral neuropathy Bradycardia Hypotension Nausea/Vomiting Diarrhea Mucositis/stomatitis Alopecia Arthralgia
Adverse Effect: SVT Neutropenia Leukopenia Thrombocytopenia Anemia Tissue necrosis Pulmonary edema
Interventions: ECG monitoring. Monitor for hypotension Assess for paresthesias. Premedicate with antiemetics. VS during first Monitor IV site for extravasation: Apply ice pack.
Education: Report signs of infection: fever, sore throat, flulike symptoms. Report signs of anemia: fatigue, headache, faintness, SOB, irritability. Report bleeding. Bleeding precautions. Avoid vaccinations.
Plant Alkaloids - Topoisomerase Inhibitor (Chemotherapy) - Topotecan (Hycamtin), Irinotecan
(Camptosar, CPT-11)
Common Uses: Leukemia Lung cancer Ovarian cancer GI cancer
Contraindications: Pregnancy Breastfeeding Bone marrow depression
PO/IV Interactions: Increased bleeding risk with NSAIDS, anticoagulants, platelet inhibitors
MoA: These drugs interfere with enzymes called topoisomerases, which help separate the strands of DNA so they can be copied
during the S phase. (Enzymes are proteins that cause chemical reactions in living cells.)
Side Effects: Alopecia Constipation Diarrhea Nausea Vomiting Damage peripheral nerve fibers Motor instability
Adverse Effects: Leukopenia Hypersensitivity Neurotoxicity Loss of DTRs Bone marrow suppression
Interventions:
Monitor IV site for extravasation: Apply ice pack. Notify MD.
Assess liver and renal function studies.
Increase fluid intake to 2-3 L/day unless contraindicated.
Education:
Rinse mouth 3-4 times/day with water; Brush teeth with soft
toothbrush for stomatitis.
Teach that total alopecia may occur. Hair grows back but is
different in color and texture.
Avoid foods with citric acid or hot and rough texture if
stomatitis is present.
Avoid vaccines, toxoids.
Report signs of anemia: fatigue, headache, faintness, SOB,
irritability.
Platinum Drugs (Chemotherapy) - Cisplatin
Common uses:
Advanced bladder cancer
Metastatic testicular cancer
Metastatic ovarian cancer
Contraindications: Pregnancy Breastfeeding Preexisting hearing impairment Bone marrow suppression
IV Interactions: ASA, NSAIDS, Alcohol increase bleeding risk. Bumetanide, furosemide increase ototoxicity risk. Loop diuretics increase nephrotoxicity risk.
MoA: Alkylates DNA, RNA; Inhibits enzymes that allow for the synthesis of amino acids in proteins; activity not cell-cycle-phase specific.
Advantages: Less likely to cause leukemia later than
alkylating agents.
Disadvantages: Extravasation can occur damaging
tissue
Side EffectS: Tinnitus Blurred vision Altered color perception N/V Diarrhea Weight loss Impotence Amenorrhea Alopecia
Adverse Effects: Extravasation Bone marrow depression Renal toxicity Bleeding Ototoxicity Seizures
Nursing interventions:
Monitor IV site for extravasation: Sodium Thiosulfate. Cold
compresses.
Monitor CBC, platelet count weekly. Hold drug for WBC < 4000 or
platelet <100,000.
Monitor BUN, creatinine.
Monitor for signs of anaphylaxis.
Monitor temperature q4h
Monitor for bleeding.
Increase fluid intake to 2-3 L/d to prevent calculi and promote
elimination of medication
Education:
Report s/s of infection.
Report s/s of anemia.
Report bleeding, bruising, petechiae
Bleeding precautions.
Report decreased urine output/flank pain.
Do not receive vaccinations during treatment
Progestins - Medroxyprogesterone
acetate (Depo-Provera),
Megestrol acetate (Megace)
Common uses: Breast cancer Endometrial carcinoma Renal cancer Stimulate appetite
PO
MoA: Act by shrinking the cancer tissues - brings about cell death
Advantages: Megace stimulates appetite by unknown action.
Side Effects: Mood swings Insomnia Depression Indigestion Diarrhea Weight gain Flatus Nausea/vomiting
Adverse Effects:
Fluid retention
Thrombotic disorders
Nursing interventions:
Assess PSA levels in men with prostate cancer.
Monitor for thrombophlebitis.
Education:
Report vaginal bleeding
Teach signs of fluid retention.
Monitor glucose if diabetic.
Selective Estrogen Receptor Modulators (SERMS) -
Raloxifen (Evista),
Toremifene (Fareston)
Common uses:
Breast cancer prophylaxis in
postmenopausal
women
Contraindications: Pregnancy and breastfeeding
PO
Interaction: Decrease action of anticoagulants
MoA: Act like antiestrogens to slow tumor growth, but have fewer side effects than tamoxifen.
Side Effects: Insomnia Depression Hot flashes Peripheral edema N/V Diarrhea Dyspepsia Vaginitis Weight gain Hypocalcemia
Adverse Effects: Stroke Thromboembolism Pulmonary embolism Osteoporosis
Interventions:
Bone density test at baseline and throughout treatment.
Client education:
Take calcium supplements, Vitamin D if intake is inadequate.
Increase exercise with weights.
Report fever, acute migraine, emotional distress.
Cervical Cancer: Risks factors, S&S, Diagnosis and Treatment
Risk Factors:
The number one risk factor is Human Papilloma Virus.
Repeated STDs
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
Family history.
Immunosuppression
Sex at a young age and multiple pregnancies
Signs and Symptoms:
Often asymptomatic in pre-invasive cancer
Invasive cancer classic 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
Excellent cure rate if detected early
Diagnosis: Pap Smear
Treatment: Electrosurgical excision Laser Cryosurgery Radiation and chemo for late stages Conization - remove part of the cervix Hysterectomy
Uterine Cancer ( Endometrial Cancer) Risks factors, S&S, Diagnosis and Treatment
Risk Factors: Greater than 50 years of age Taking estrogen therapy without progesterone Positive Family history Late menopause NO pregnancy
S/S
Major symptoms: Post menopausal bleeding
Other: watery/bloody vaginal discharge, low back/abd pain, pelvic pain
Diagnosis: CA-125 (blood test) to ovarian involvement. Most definitive is D&C and endometrial biopsy
Treatment:
Radiation, Chemotherapy, Estrogen inhibitors
Hysterectomy TAH = uterus and cervix only Bilateral oophrectomy (ovaries) Bilateral salpingectomy (tubes)
Radical/abdominal hysterectomy - may remove all of the pelvic organs. Client may have colostomy or ileal conduit. 24 hour risk for hemorrhage because of pelvic congestion of blood.
Major complication with vaginal hysterectomy - think infection! will probably have an indwelling cath, if not, make sure in the next 8 hours she voids.
Prevent abdominal distention after surgery because don’t want tension on suture line, it can lead to dehiscence and evisceration.
Avoid high fowler’s because it makes more blood go to the pelvis
May have 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 all these complications - Early ambulation
Avoid sex and driving, girdles and douches, any excercise that increase pelvic congestion should be avoided, Client can hemorrhage 10 - 14 days, Whitish vaginal discharge is normal, shower is best.
Breast Cancer : Risks factors, S&S, Diagnosis and Treatment
Risk:
one has a 3 fold risk increase of developing breast cancer if a first degree relative had pre-menopausal breast cancer
high dose radiation to thorax prior to age 20
Period onset prior to age 12
Menopause after age 50
No preg
First birth after 30 years of age
S&S
Change in the appearance of the breast ( orange peel appearance, dimpling, retraction and discharge from the breast or lump)
Tail of Spence is where 48% of breast tumors occur: located in upper
outer quadrant
Treatment: Surgery Chemo Hormonal therapy: Estrogen receptor blocking agents and synthesis inhibitors Radiation
Lung Cancer
Smoking
S/S
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
Diagnosis: Bronchoscopy Chest XRAY CT MRI
Treatment:
Surgery:
The main treatment for stage I and II lung cancer
Lobectomy: only take out part of the lung
Chest tubes and surgical side up
Pneumonectomy: the entire lung is removed
Position on affected side (surgical side down, good lung up).
No chest tubes, Why? There is not lung!
Avoid severe lateral positioning = mediastinal shift
Laryngeal Cancer
Smoking, alcohol, voice abuse, chronic laryngitis, industrial chemicals
Signs and Symptoms
Hoarseness, lump in neck, sore throat, cough, problems breathing, earache, weight loss, no early signs,
Laryngeal exam, MRI
Treatment:
Surgery:
Total laryngectomy
Humidified environment
*Remember, with a total laryngectomy ALL breathing is
done through the stoma.
Radiation
Chemotherapy
Speech Rehabilitation
When should client teaching begin? Preoperatively at
admission
Be a good client advocate:
Refer to International Association of Laryngectomees.
*See if there are local groups such as the Lost Cord Group
Colorectal Cancer
Risks:
May start as a polyp
2/3s of colorectal cancer occurs in the rectosigmoid region
Most frequent site of metastasis: the 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
Diagnosis:
Fecal occult blood testing should begin at age: 50
The definitive test for colorectal cancer is a colonoscopy.
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)
Treatment:
Surgery, radiation, and chemo
May have a colostomy post op or may require an abdominoperineal resection
Abdominoperineal resection-removal of the colon, anus,
rectum
*Can you take a rectal temp on this client? No, there is no rectum!
Don’t take rectal temp if thrombocytopenic, abdominoperineal resection, or
immunosuppressed
Bladder Cancer
Smoking
Painless, intermittent gross/microscopic hematuria
Cystoscopy
Treatment:
Surgery (remove all or part of bladder) - urinary diversion (urostomy)
Ileal conduit (a piece of the ileum is turned into the bladder; ureters are placed in one end; the other end is brought to the abdominal surface as a stoma)
May be impotent
Hourly outputs
Increase fluids (2,000-3,000 ml of fluid per day).
* Fluids help flush out conduit
Is mucus in the urine normal? Yes
The intestines always make mucus (the bladder is made from a part of intestine).
Change appliance in the 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!
Prostate Cancer S/S and Diagnosis
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 hematuria
Digital rectal exam is done and if the prostate is hard/nodular; usually means prostate cancer.
Labwork PSA increased ( only produced by prostate). normally lass than 4 ng/ml
ALP and acid phosphatase is increased, means bone metastasis
Biopsy must be done to confirm cancer prior to surgery
Prostate Cancer Treatment
Treatment:
Watchful waiting: in early stages (for asymptomatic, older
adults with another illness)
Surgery:
Radical Prostatectomy (done when the cancer is localized to
the prostate)
Take out the prostate and the client is cancer free (if there is
no metastasis).
May have erectile dysfunction due to pudendal nerve dam
age.
May have incontinence (Kegel exercises)
Client is sterile.
If there is no lymph node involvement, no increase 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, because with other procedures they
have an incision.
Is it normal to see bleeding after this surgery? Yes
Continuous bladder irrigation – maintains patency, flushes 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®)
When the catheter is removed what do you watch for?
Urinary retention
Temporary incontinence is expected (perineal exercises-Kegel)
Avoid sitting, driving, strenuous exercise; do not lift too
much…Why? Can cause them to bleed
Docusate (Colace®); avoid straining. Why? Straining will cause them to bleed.
Increase fluids: to flush out the kidneys.
The TURP is used for symptomatic relief of symptoms… to allow the urine to flow out… This is not a cure for prostate
cancer.
Radiation
Chemotherapy
Hormone therapy
May decrease testosterone levels through bilateral orchiectomy
Stomach Cancer
Risk factors:
H-Pylori-associated with stomach cancer
Pernicious anemia and Achlorhydria - There is an increased instance of stomach cancer with people who have pernicious anemia and
achlorhydria.
Related to: pickled foods, salted meats/fish, nitrates,
increased salt
Billroth II (partial gastrectomy with an anastomosis)
Tobacco and Alcohol
Signs/Symptoms:
Most common: Heartburn and abdominal discomfort
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
Signs/Symptoms of an obstruction: abdominal distention, nausea/vomiting, pain.)
Treatment for obstruction: NPO, NG tube to suction for abdominal decompression
Diagnosis:
Upper GI, CT, EGD
Treatment:
Gastrectomy
Fowlers position, decreases stress on the suture line
Will have NG tube for decompression
2 Major complications:
Dumping syndrome andB12 pernicious anemia
No stomach - no intrinsic factor - can’t absorb oral B-12 - can’t make good
RBCs - client is anemic
Chemotherapy
The use of chemo is based on several facts
The oncologists will consider
Which pahse of the cell cycle the drug attacks
Time or how often the drug is given
Growth faction ( % of cells dividing at a given time)
Tumor burder
Regional chemo delivers chemo to a specific site
Usually sced every 3 to 4 weeks
Most common body systems affected by side effects:
Blood, GI and Skin + Hair
Handling Precautions for Chemo
Exposure can occur by drug contact with the skin or mucous membranes inhalation or accidental injection or ingestion
Full precautions require:
Chemo gown, 2 pairs of chemo gloves, googles/mask
Excretion precautions:
Need to be taught to famiy. When handling body fluids wear two pairs of chemo gloves and a chemo gown. add a face shield.
Disposal
Yellow rigid chemo waste container used for sharps and IV containers
Yellow chemo waste bag used for gowns gloves and disposable items
Managing chemo Spills
Handle as a hazardous chemical spill
Obtain spill kit and use all protective equipment for clean up
Delivery methods of chemo
Most given via IV port
A vesicant in infiltrated, will cause tissue necrosis
S/s of extravasation: Pain, swelling and no blood return
Stay with client receiving vesicant. The most important this is PREVENTION.
Stop the infusion if it happens, apply cold packs.
If drug is oral, wear gloves
Transplants
Bone marrow ans stem cells are used as treatments for hematologic cancer.
Occasionally, transplants are necessary when high does of chemo or radidation have destroyed too many blood cells and a transplant is needed as a rescue treatment
2 Types of transplants
Stem cell + Bone Marrow
It can come from the client, a matched donor or frmo an identical sibling or twin
They are given into the vein and over time, settle in the bone arrow and produce healthy blood cells
Complications of transplants
Infection (Immunosuppressed)
Graft vs HOst Disease
The graft rejects or attacks the host. Treated with anti-rejection drugs and steroids.
Signs of rejection Abd pain or cramps, N/V, diarrhea Jaundice or other liver problems Dark, tea colored urine SKin rash, itching, redness on areas of the skin
Major side Effects of Cancer and Treatment
Body Image - Alopecia, Scar, Weight gain and puffiness from steroid therapy or weight loss.
Fatigue - Plan client care (adequate rest periods)
Infection - private room, wash hands, have their own supplies, limit visitors, change IV tubing and dressings daily, cough and deep breath, no fresh flowers or potted plants, avoid crowds, Do not share toiletries, bathe warm moist areas usually twice daily, wash hands after touching pet, avoid raw fruits and veggies, only fresh water
Nursing considerations for side effects
Watch for a slight increase in temp. It may mean sepsis. Since they are immunosuppressed, the temp spikes will not be big and they won’t have the typical s/s of infection
Come to hospital for 38 temp
Monitor absolute neutrophil count
Neutropenia
A decreased number of neutrophils in the blood.
Absolute neutrophil count is the best way to assess. Indicates how well the client can handle the infection.
Nadir
The lowest point. Neutros are first line defense inside the body to protect us from infections. Don’t wait for cultures - physicians need to treat best guess.
Neutropenia + infection = sepsis, septic shock and DEATH
Risk factors for Neutropenia
Age Advanced Metastatic disease Malnourishment B12 and folic acid deficiencies Impaired tissue integrity Presence of other disease( Diabetes, COPD, HF, HIV/AIDS) Hematologic malignancies Leukemias, lymphomas and myelomas Result of cancer treatments
Treatment of Neutropenia
Antibiotics ( Prophylactic)
Implement Neutropenic Precautions
Include all the general ways to prevent infection plus
Vital signs every 4 hours
Private room with door closed and posted sign
Antimicrobial soap for handwashing, not just regular soap
No invasive procedures ( NO IM, rectal exam or meds), NG tube or indwelling cath.
Limit use of tylenol
DVT
Second leading cause of death in cancer clients
Prolonged bed rest, Surgerym use of central line, External compression of vessels by tumor, certain chemo drugs
We are worried about PE
Thrombocytopenia RIsk factors
Decrease in the number of circulating platelets in the blood - they are responsible for clotting.
Advanced metastatic disease Hematological Malignancies Bleeding disorders such as hemophilia, liver disease, idiopathic thrombocytopenia purpura Bacterial Infections Anticoagulant meds Result of cancer treatment
Thrombocytopenia Assessment and Treatment
History
Vital signs, SPO2, change in LOC, reports headache and pupil changes, conjunctival hemorrhages, Petechiae, Ecchymosis and purpura, Oozing from puncture site or surgical sites, Bleeding from the rectum, ear, nose or mouth
GIVE THEM PLATELETS
Considerations for blood products with oncology patients
RBC transfusions
For clients with symptomatic anemia. Don’t want Hgb/Hct to drop 8 g/dl and 24%.
Platelet Transfusions
TO control or prevent bleeding associated with thrombocytopenia (Don’t infuse cold platelets because the spleen will reject them )
You want cytomegalovirus negative RBC and Platelets.
CMV is a common herpes virus that resembles mononucleosis, usually dormant. To make blood safe, they undergo leukoreduction.
Nausea and Vomiting
Most common side effect of chemo and radiation.
Prevention:
Antiemetic before treatment
Behavioural therapies
Acupuncture/acupressire
Ondasetron Netupitant/paLPNOSTREON Oral combination antiemetic Ginger Aroma therapy - peppermint Acupuncture/Acupressure Distraction Relaxation Techniques
Pain
Treat without regard of risk of opioid dependence
Happens due to direct tumor involvement, but can also be the result of the treatment such as with mucositis or peripheral neuropathy
OPioids are considered the gold standard
NO CEILING DOSE
TNF inhibitor drugs
TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade], adalimumab [Humira]) block the action of TNF, a mediator that triggers a cell-mediated inflammatory response in the body. These drugs reduce the manifestations of rheumatoid arthritis (RA) and slow the progression of joint damage by inhibiting the inflammatory response. The medication causes immunosuppression and increased susceptibility for infection and malignancies.
Clients should have a baseline TST before initiating therapy and yearly skin tests thereafter. Those with latent tuberculosis (TB) must be treated with antitubercular agents before initiating treatment with these drugs. Otherwise, TB reactivation would occur
Major adverse effects of biologic disease-modifying TNF inhibitor drugs (eg, etanercept, infliximab, adalimumab) include severe infections and bone marrow suppression. TB reactivation is a major concern. Therefore, all clients must receive a TST to rule out latent TB.
