Symptom Management Flashcards
Hematologic alterations (3)
Anemia
Neutropenia
Thrombocytopenia
Pathophysiology of anemia (3)
Increased destruction of RBC
Decreased production of RBC
Blood volume loss
Causes of anemia (4)
Frank bleeding
Renal insufficiency
Hemolysis
Anemia of chronic disease
Anemia of Cancer
1) Suppression of _______
2) _____ production that kills rbcs prematurely
3) Tumors may cause chronic blood ____directly or change _____
4) Chemo/RT causes _____, or decreased production of ____ by kidneys
1) hematopoiesis
2) Cytokine
4) loss, coagulation
5) myelosuppression, erythropoietin
First subtle changes of Anemia
Decreased activity tolerance
Mild SOB/SOB on exertion
Fatigue
Cardiovascular effects of Anemia
Bruits, Murmurs, Tachycardia, Dysrhythmias, Postural Hypotension
Less rbcs in blood -> blood flows more aggressively, less viscosity
Pulmonary effects of Anemia
Dyspnea at rest
Hypoxia
Tachypnea
Pulmonary edema
Genitourinary effects of Anemia
Water retention
Menorrhagia
Amenorrhea
Proteinuria
CNS effects of Anemia
HA, Dizziness Confusion Inability to concentrate Irritability Weakness Retinal hemorrhage Loss of sensation
GI effects of Anemia
Indigestion Decreased motility/constipation Ascities Stomatitis Hepatosplenomegaly Blood loss
Musculoskeletal effects of Anemia
Bone pain
Integumentary effects of Anemia
Pallid skin Poor skin turgor Hair loss Brittle nails Ecchymosis Poor wound healing Cyanosis Hypothermia Edema
Grades of Anemia
Grade 1 (mild) = Grade 2 (moderate) = Grade 3 (severe) = Grade 4 = Grade 5 =
Hb 10g/dl (lower limit of normal Hb 8-10 Hb 6.5-8 Life threatening Death
Tx for Anemia (3)
RBC transfusion
Erythropoietic therapy
Iron (Ferritin) level monitoring
RBC transfusion show increased risk for?
Venous and arterial thromboembolism
Erythropoietic therapy
Types (2)
Black box warning =
Epoetin alfa
Darbepoetin alfa
Should only be used for chemo induced anemia and dc’d once chemo is complete
Iron deficiency defined as
Ferritin level < Transferrin saturation (TSAT) <
30ng/dl
20%
Neutropenia =
Decrease in # of circulating neutrophils
Causes of neutropenia (3)
1) Abnormal neutrophil production or function
2) Infection
3) SE of drug
Absolute neutrophil count =
Represents number of mature white blood cells in the peripheral circulation
Neutropenia is an ANC < _____
<500
or <1,000 with predicted decline to <500 in next 48 hours
Formula to calculate ANC =
%neutrophils (band and segments) x WBC
Patho of Neutropenia
1) Neutrophils are the most common type of _____ (a subtype of WBC)
2) Neutrophils are the ___ to respond to ____
3) Takes __-__ days to produce neutrophils in bone marrow
4) They only live _- _ hours once released into circulation therefore are in ___ production in bone marrow
1) Granulocyte
2) first, infection
3) 10-14
4) 4-8, constant
Neutropenia
Early infections =
Later infections with chronic neutropenia =
Bacterial
Fungal
Neutropenia associated infection
Most febrile neutropenia is caused by _____ infection of gram ____ bacteria, more than 80% of infections are from patients own ____
nosocomial (in hospital), negative, flora
S/S of Neutropenia Associated infection
1) Fever of
2) Fever with
3) Vascular access device ___ or ___
4) Respiratory sx =
5) Urinary sx =
6) Oral sx =
7) GI sx =
8) Rectal sx =
9) Neuro sx =
1) 38.3
2) chills, “rigors”
3) tenderness, erythema
4) Cough
5) Dysuria
6) Mucositis
7) Diarrhea
8) Perirectal pain
9) AMS
Patient education for Neutropenia
Report what?
Avoid what?
Fever, chills
Use good hand hygiene
Avoid uncooked or unwashed fruits/vegetables, others who have s/s of contagious diseases, barn animals, reptiles, birds, litter, areas of construction, contact with ppl who recently vaccinated with a live virus, undercooked meats, seafood, eggs
Colony Stimulating Factors =
Hematopoietic growth factors (HGFs
Proteins that promote production of rbc, wbc, platelets
Examples of granulocyte CSFs
Filgrastim
Pegfilgrastim
TBO-filgrastim
Sargramostim
Potential SE of GCSFs
Long bone pain
Injection site pain
Allergic reactions
Oprelvekin, Promegapoietin are examples of
Platelet stimulants
Potential SE of platelet stimulants
Ventricular arrhythmia Visual/ophthalmologic defect Fluid retention Anaphylaxis Pulmonary edema
Thrombocytopenia defined as platelet count <
< 150,000
Normal platelet count
150,000-400,000k
Causes of Thrombocytopenia in Cancer patients
1) If bone marrow is _____ by primary or metastatic malignancy
2) _ _ _ or _ _ _ can cause destruction
3) ____omegaly
4) Meds such as?
1) infiltrated
2) DIC, TTP
3) Splenomegaly
4) NSAIDS, aspirin, thiazide diuretics, tricyclic antidepressants, some antibiotics, heparin
Management of Thrombocytopenia (3)
Platelet transfusion
Mesna
Nursing interventions
Mesna =
Should be given to patients receiving ifosfamide and high dose cyclophosphamide to decrease possibility of hemorrhagic cystitis
Nursing interventions to minimize complications of Thrombocytopenia
1) Avoid invasive procedures
2) Use ___ toothbrush, do not ____
3) Alter environment?
4) Observe for dark, tarry ____, br____, pet_____
5) Use an ____ razor
6) No _____ injections
7) ____ healthcare provider if uncontrolled bleeding
8) Avoid use of ta____
9) Avoid s____ acitivity
10) Use stool ___ or laxitives to avoid constipation
11) Avoid den____ procedures
12) Immediately report sudden onset of _____
1) Enemas, rectal temps, fingersticks, IM injections
2) soft, floss
3) rugs
4) stools, bruising, petechiae
5) electric
6) IM
7) Notify
8) Tampons
9) sexual
10) softeners
11) dental
12) Headache
2 types of Immune defenses
Innate
Adaptive
What type of immunity?
1) Generic immune response, no memory
2) Secondary line of defense, specific memory
1) Innate
2) Adaptive
Innate immunity consists of?
1) Physical barriers =
2) Inflammatory response =
3) Com____ system
4) Large granular ____: Natural ____ cells
1) skin, mucous membranes, lining of respiratory tract
2) Monocytes, macrophages, polymorphonuclear cells (neutrophils)
3) Complement
4) lymphocytes: killer
Adaptive immunity consists of?
1) L_____
2) T cell:cell-mediated immunity (2)
3) B cell: Humoral immunity (4)
1) Lymphocytes
2) Cytotoxic T cells, helper T cells
3) B lymphocytes, memory B cells, plasma cells, immunoglobulins
An obstruction of the lymphatic system, causing a fluid collection of excess interstitial fluid, water bacteria, and cellular waste in interstitial spaces
Lymphedema
Lymphedema causes
1) Primary
2) Secondary to injury such as?
3) Lymph ____ _____
1) without known etiology
2) extravasation of a vesicant
3) Lymph node dissection
Risk factors for Lymphedema
Axillary node dissection and removal Sentinel lymph node biopsy Chemo/RT DM Traumatic injury Excessive physical use of affected limb Long distance air travel Smoking Tumor stage Surgical disruption Infection
Sx of lymphedema
Edema Increased tightness of clothes/jewelry Stiffness Numbness or paresthesia Pain Increased weakness of affected limb Erythema
Management of Lymphedema
Recommended
1) Complete ____ therapy (CDT)
2) ______ bandages
3) Prompt treatment of _____
Likely to be effective
1) Maintain optimal body ____
2) Manual lymph d_____
3) Impeccable ___ care
1) decongestive
2) compression
3) infections
1) weight
2) drainage
3) skin (emollients, avoidance of scented products, avoid cutting cuticles, inspect for cuts, insect bites)
Mucositis =
Sometimes called stomatitis, is inflammation and ulceration of the oral mucosa
Phase of Mucositis
DNA and non-DNA damage, causing basal and epithelial damage in submucosa
Reactive oxygen species develops, contributes to injury in later phase
Mucosa appears normal
Phase I: Initiation (soon after chemo/rt
Phase of Mucositis
DNA damage and cell death in epithelium of mucosa
Transcription factor nuclear factor-kB is activated and amplification of injury occurs
Multitude of genes activated including proinflammatory cytokines, tumor necrosis factor-alpha, interleukin beta, interleukin 6 -> more cell injury and death
Patients may still not feel any damage has occurred
Phase II: Primary damage response
Phase of Mucositis
Cytokines amplify the acceleration and amplify the original injury
Tissue is biologically altered but still may appear normal
Phase III: Signal amplification
Phase of Mucositis
Fibrous exudates* may thinly cover oral ulcers, which can then fill with bacteria
Pain, dysphagia, decreased intake, difficulty talking, increased risk of bleeding
Phase IV: Ulceration
Phase of Mucositis
When chemo/rt are dc’d, new messenger molecules direct the epithelium to heal and increased wbc production to fight local mucosal infection
Phase V: Healing
Symptoms of Mucositis
Mucosal changes, pallor, white patches, erythema, lesions Change in saliva texture, quantity Foul odor Cracks, fissures in mucosa Difficulty swallowing, talking, eating Pain Changes in voice quality
Chemo agents that commonly cause ______
Busulfan Capecitabine Cyclophosphamide Doxil 5FU Mechlorethamine
Mucositis
Risk factors of Mucositis
Younger Age*,
Type of malignancy (esophogeal)
Women
Condition of oral cavity prior to tx Type/Dose of tx Nutritional status Oral hygiene Tobacco/alcohol use Comorbid conditions
Tx of oral mucositis (3)
Oral care (soft toothbrush, flossing if not bleeding risk, consistent oral care)
Cryotherapy: ice before during after chemo to vasoconstrict oral mucosa (especially those receiving 5FU or melphalan)
Low level laser therapy
Palifermin (recombinant human keratinocyte growth factor)
Sodium Bicarbonate (alkaline, baking soda)
Grade of Mucositis
Erythema of oral mucosa
Grade 1
Grade of Mucositis
Confluent ulcerations or pseudomembranes, bleeding with minor trauma
Grade 3
Grade of Mucositis
Patchy ulcerations or pseudomembranes (a thick, tough fibrinous exudate on the surface of a membrane)
Grade 2
Grade of Mucositis
Tissue necrosis; significant spontaneous bleeding; life-threatening consequences
Grade 4
Grade of Mucositis
Death
Grade 5
Xerostomia =
Dry mouth
Causes of Xerostomia
Surgery, chemo, RT
Patho of Xerostomia
60% of saliva produced by parotid gland which is very radiosensitive (rt will damage it)
S/S of Xerostomia
Difficulty speaking, swallowing Feeling of gagging, choking Pain Halitosis: periodontal disease Cheilitis or lip inflammation, chapping Increased oral infections (no cleansing function of saliva)
Management of Xerostomia
1) Thorough d___ examiniation
2) Meticulous teeth ____ /____
3) Avoid what types of foods?
4) Limit s___ intake
5) P___ management
6) Saliva _____/increase ___ intake
7) Prophylactic _____ coverage
8) Meds (2)
1) dental
2) brushing/flossing
3) spicy, rough, harsh
4) sugar
5) pain
6) substitutes, fluids
7) Sialagogues (drug to increase saliva production)
8) Amifostine (cytoprotectant)
What part of the brain is the vomiting center?
Medulla v
Patho of chemo induced nausea, what chemicals are involved?
Chemo releases serotonin (5-HT3) through GI pathway -> Serotonin binds to serotonin receptors on vagus nerve in GI tract
Neurotransmitter substance P also involved, binds to neurokinin 1 receptors
Dopamine and Cholecystokinin
Patient risk factors for CINV
1) Poor control of N/V with prior ___
2) Gender?
3) Age?
4) Hx of?
5) Low ____ intake, or no intake
6) High level of pretx ____
7) Presence of strong ____ disturbances during chemo
8) Susceptibility to G______ distress
9) _____ stage disease
10) ____ burden
11) Concomitant medical conditions (2)
1) tx
2) Female
3) Younger <50 yrs
4) motion, morning sickness
5) alcohol
6) anxiety
7) taste
8) Gastrointestinal
9) Advanced
10) Tumor
11) Pancreatitis, hepatic mets
Meds given to treat CINV
Neuroleptics (Prochlorperazine, chlorpromazine) Motility agents (Metoclopramide) Antihistamines (Promethazine, Diphenhydramine, hydroxyzine) Benzodiazepines (Diazepam, Lorazepam) Steroids (Dexamethasone, Prednisone) Cannabinoids (Dronabinol, marijuana) Anticholinergics (scopolamine) 5-HT3 antagonists (Ondansetron) Substance P antagonist (aprepitant)
Nonpharmacologic management of CINV
Acupressure Acupuncture Acustimulation Guided imagery, music therapy, progressive muscle relaxation Psychoeducational support
Dysphagia =
Difficulty swallowing
Transfer dysphagia =
Alteration in the oral-pharyngeal passage of food
Transit dysphagia =
Absence of esophageal peristalsis
Obstructive dysphagia =
Mechanical obstruction due to stenosis or tumor involvement in the pharynx, esophagus, esophagogastric junction
Dysphagia management
1) Endoscopic ____ therapy
2) Alternative methods of f____
3) Th____ agents for liquids
4) Pharmacologic agents
5) S____ or Ph____ therapy for swallowing therapy and exercises
6) Registered ____ consultation for nutritional advice and menu planning
1) Laser
2) feeding
3) Thickening
4) Steroids, expectorants, bronchodilators, pain, anxiety meds
5) speech, physical
6) dietician
Strategies to aid in comfort for patients experiencing dysphagia
1) eat foods that are ___
2) s___ and pur___ foods
3) Avoid what foods?
4) Localized ___ agent
5) Daily w____
6) Assess need for ___ feeding, total p____ nutrition
1) cold
2) soft, pureed
3) spicy, hot, coarse
4) numbing (lidocaine viscous)
5) weights
6) tube, parenteral
Anorexia =
involuntary loss of interest in eating
Cachexia =
Wasting syndrome that combines weight loss of muscle and protein, includes anorexia, nausea, weakness
Patho of Anorexia
Tumor burden Response to tx slowed GI motility Pain Distress Fatigue
Patho of Cachexia
1) Primary etiology =
2 Secondary etiology =
1) Paraneoplastic syndrome of wasting that is mediated through cytokines
2) Barriers to intake of food leading to wasting, altered fat metabolism, inefficient use of glucose, decreased protein mass
Risk factors for cachexia
1) What type of tumors?
2) age of people
3) chronic _morbities/H__/A__
4) Inf____, Inf____ disease
5) Treatments
6) Surgery of what body parts?
7) Ps___ distress, loss of hope, dep____
1) Solid, advanced
2) Very young, older
3) comorbities, HIV, AIDS
4) Infection, Inflammatory
5) Chemo, biotherapy, RT, multimodal
6) Head, neck, stomach, pancreas, bowel
7) Psychological, depression
What lab value is increased in cachexia?
BUN/creatinine ratio
Meds to help Anorexia and Cachexia (2)
Corticosteroids
Progestins (Megestrol Acetate)
Cystitis
Inflammation of lining in bladder
Hemorrhagic or severe cystitis is an adverse SE for which chemos (3)?
What class of chemo?
Ifosfamide
Cyclophosphamide
Busulfan
Metabolites
Symptoms of Cystitis
Suprapubic pain or pressure Abdominal pain Urinary urgency, frequency, burning Hematuria Bladder spasms Incomplete bladder evac
Management of Cystitis
1) _______ is key
2) Adequate hy____ and d____ to remove m_____ from urine
3) Take oral cyclophosphamide ____ in the day to allow for increased hydration and diuresis of metabolites prior to evening
4) M____ IV as uroprotectant if taking (2)
5) Am_____* as cytoprotectant if taking c_____
6) treat in______
7) Avoid alk____ agents
8) Use antis______
9) Avoid what types of food?
10) Continuous bladder i______
11) May include _____ oxygen therapy
1) Prevention*
1) hydration, diuresis, metabolites
3) early
4) Mesna, ifos, high dose cyclophos
5) Amifostine, cisplatin
6) infections
7) alkalizing
8) antispasmotics
9) caffeine, spicy foods, coffee, alcohol
10) irrigation
11) hyperbaric
Urinary incontinence =
involuntary leakage of urine
Causes of urinary incontinence
1) Surgery (4)
2) Radiation (2)
1) Prostatectomy, Hysterectomy, Colectomy, low anterior or abdominoperineal resection (rectal)
2) external beam to pelvis, brachytherapy
Management of UI
1) ____ floor muscle ____*
2) Encourage adequate ____ intake
3) Avoid ca____ and al_____
4) Manage cons____, which can exacerbate symptoms
1) Pelvic, exercises
2) fluid
3) caffeine, alcohol
4) constipation
Dermatologic emergencies
1) S___ J____ syndrome
2) T____ e_____ ne____
3) Drug ______ syndrome (DHS)
4) Ang______
1) Steven Johnsons syndrome
2) Toxic epidermal necrolysis
3) hypertensive
4) Angioedema
Cardiac toxicities are commonly associated with
1) Anthracyclines (1)
2) RT for which diangoses
1) Doxorubicin
2) non-hodgkin, hodgkin, left sided breast ca
Chemos associated with peripheral neuropathy
4 classes
Platinums (Cisplatin, Oxaliplatin)
Taxanes
Vinca Alkaloids
Proteasome inhibitors
Practical interventions to promote safety for those that have peripheral neuropathy
Remove throw rugs, clear hallways Test water temp before using Use pot holders Use non skid mats in shower/tub Wear socks and protective gloves for chores or outdoors
Medications used for nutritional support/appetite (3)
Megestrol acetate
Steroids (but should be given routinely bc of SE)
Dronabinol
Types of pain (3)
Nociceptive
Neuropathic
Referred
Nociceptive pain =
Result of activation of pain fibers in deep and cutaneous tissues
a) somatic = bone, joint, connective tissue; usually well localized
b) Viseral = thoracic or abdominal tissue, or surrounding organs, usually poorly localized
Neuropathic pain =
Damage to peripheral or central nerves
a) peripheral (numbness and tingling)
b) centrally mediated: radiating shooting sensations with burning and aching
c) sympathetically mediated: pain caused by autonomic dyregulalation (complex regional pain syndrome)
Referred pain =
originated in one part of body but felt in another part
S/S of Acute Pain
Tachycardia
Pale skin
Diaphoresis
Increased BP
S/S of Chronic Pain
Autonomic sx absent Fatigue, insomnia, depression, social withdrawal Anorexia Constipation Weakened immune system Mood changes (fear, anxiety, stress) Impatience, loss of motivation Disability
Pharmacologic therapy steps for cancer related pain
Step 1:
Step 2:
Step 3:
1) Nonopioid analgesics (mild pain) - Ibuprofen, aspirin, NSAIDS
2) Opioid analgesics with or without nonopioid analgesics (mild to moderate pain) -hydrocodone and oxycodone in fixed combos with acetaminophen or aspirin)
3) Opioid analgesics with or witout nonopioids (moderate to severe) - morphine, oxycodone, hydromorphone, fentanyl)
Avoid demerol bc metabolite can cause CNS toxicity)
Treatments for Neuropathic pain (3)
Tricyclic antidepressants Calcium channel alpha 2 delta ligands (gabapentin, pregabalin) Topical therapy (lidocaine)
Nonpharmacologic interventions for pain
Radiation
Surgery
hot/cold compress
Cutaneous stimulation (transcutaneous electrical nerve stimulation)
complementary/integrative therapies (massage, acupuncture, aromatherapy, relaxation, visualization)
Cancer-Related Fatigue =
Distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer tx
- not relieved by sleep or rest
- reported as the most distressing sx asctd with cancer and its tx
Risk factors for CINV
1) Emetogenic potential of chemo agent
2) Dose of chemo
3) Administration schedule
4) C_____ chemotherapy
5) Duration of infusion =
3) Dose dense
4) Combination
5) Short infusions
Breakthrough emesis treatment
Corticosteroids
Haloperidol
Metoclopramide
Scopolamine
Postchemotherapy prevention of N/V
Prophylactic dexamethasone and aprepitant
Best antiemetics for Acute N/V
5HT3 antagonists
Steroids
Antihistamines
Best anti-emetics for delayed N/V
P antagonist (aprepitant)
Neuroleptics (prochlorperazine)
Anticholinergics (scopolamine)
Motility agents (reglan)
Tx for anticipatory nausea
Benzodiazepines
Nonpharmacologic management for N/V
Acupressure Acupuncture Acustimulation Guided imagery, music therapy, progressive muscle relaxation Psychoeducational support
