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OCN ONS Bundle > Symptom Management > Flashcards

Symptom Management Flashcards

1
Q

Hematologic alterations (3)

A

Anemia
Neutropenia
Thrombocytopenia

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2
Q

Pathophysiology of anemia (3)

A

Increased destruction of RBC
Decreased production of RBC
Blood volume loss

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3
Q

Causes of anemia (4)

A

Frank bleeding
Renal insufficiency
Hemolysis
Anemia of chronic disease

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4
Q

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

A

1) hematopoiesis
2) Cytokine
4) loss, coagulation
5) myelosuppression, erythropoietin

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5
Q

First subtle changes of Anemia

A

Decreased activity tolerance
Mild SOB/SOB on exertion
Fatigue

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6
Q

Cardiovascular effects of Anemia

A

Bruits, Murmurs, Tachycardia, Dysrhythmias, Postural Hypotension

Less rbcs in blood -> blood flows more aggressively, less viscosity

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7
Q

Pulmonary effects of Anemia

A

Dyspnea at rest
Hypoxia
Tachypnea
Pulmonary edema

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8
Q

Genitourinary effects of Anemia

A

Water retention
Menorrhagia
Amenorrhea
Proteinuria

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9
Q

CNS effects of Anemia

A 
HA, Dizziness
Confusion
Inability to concentrate 
Irritability 
Weakness 
Retinal hemorrhage 
Loss of sensation
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10
Q

GI effects of Anemia

A 
Indigestion 
Decreased motility/constipation
Ascities
Stomatitis 
Hepatosplenomegaly 
Blood loss
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11
Q

Musculoskeletal effects of Anemia

A

Bone pain

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12
Q

Integumentary effects of Anemia

A 
Pallid skin 
Poor skin turgor 
Hair loss
Brittle nails 
Ecchymosis 
Poor wound healing 
Cyanosis 
Hypothermia
Edema
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13
Q

Grades of Anemia

Grade 1 (mild) = 
Grade 2 (moderate) = 
Grade 3 (severe) = 
Grade 4 = 
Grade 5 =
A 
Hb 10g/dl (lower limit of normal 
Hb 8-10
Hb 6.5-8 
Life threatening
Death
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14
Q

Tx for Anemia (3)

A

RBC transfusion
Erythropoietic therapy
Iron (Ferritin) level monitoring

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15
Q

RBC transfusion show increased risk for?

A

Venous and arterial thromboembolism

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16
Q

Erythropoietic therapy

Types (2)
Black box warning =

A

Epoetin alfa
Darbepoetin alfa

Should only be used for chemo induced anemia and dc’d once chemo is complete

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17
Q

Iron deficiency defined as

Ferritin level < 
Transferrin saturation (TSAT) <
A

30ng/dl

20%

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18
Q

Neutropenia =

A

Decrease in # of circulating neutrophils

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19
Q

Causes of neutropenia (3)

A

1) Abnormal neutrophil production or function
2) Infection
3) SE of drug

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20
Q

Absolute neutrophil count =

A

Represents number of mature white blood cells in the peripheral circulation

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21
Q

Neutropenia is an ANC < _____

A

<500

or <1,000 with predicted decline to <500 in next 48 hours

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22
Q

Formula to calculate ANC =

A

%neutrophils (band and segments) x WBC

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23
Q

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

A

1) Granulocyte
2) first, infection
3) 10-14
4) 4-8, constant

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24
Q

Neutropenia

Early infections =
Later infections with chronic neutropenia =

A

Bacterial

Fungal

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25
Q

Neutropenia associated infection

Most febrile neutropenia is caused by _____ infection of gram ____ bacteria, more than 80% of infections are from patients own ____

A

nosocomial (in hospital), negative, flora

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26
Q

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 =

A

1) 38.3
2) chills, “rigors”
3) tenderness, erythema
4) Cough
5) Dysuria
6) Mucositis
7) Diarrhea
8) Perirectal pain
9) AMS

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27
Q

Patient education for Neutropenia

Report what?
Avoid what?

A

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

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28
Q

Colony Stimulating Factors =

Hematopoietic growth factors (HGFs

A

Proteins that promote production of rbc, wbc, platelets

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29
Q

Examples of granulocyte CSFs

A

Filgrastim
Pegfilgrastim
TBO-filgrastim
Sargramostim

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30
Q

Potential SE of GCSFs

A

Long bone pain
Injection site pain
Allergic reactions

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31
Q

Oprelvekin, Promegapoietin are examples of

A

Platelet stimulants

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32
Q

Potential SE of platelet stimulants

A 
Ventricular arrhythmia
Visual/ophthalmologic defect 
Fluid retention
Anaphylaxis 
Pulmonary edema
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33
Q

Thrombocytopenia defined as platelet count <

A

< 150,000

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34
Q

Normal platelet count

A

150,000-400,000k

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35
Q

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?

A

1) infiltrated
2) DIC, TTP
3) Splenomegaly
4) NSAIDS, aspirin, thiazide diuretics, tricyclic antidepressants, some antibiotics, heparin

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36
Q

Management of Thrombocytopenia (3)

A

Platelet transfusion
Mesna
Nursing interventions

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37
Q

Mesna =

A

Should be given to patients receiving ifosfamide and high dose cyclophosphamide to decrease possibility of hemorrhagic cystitis

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38
Q

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 _____

A

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

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39
Q

2 types of Immune defenses

A

Innate

Adaptive

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40
Q

What type of immunity?

1) Generic immune response, no memory
2) Secondary line of defense, specific memory

A

1) Innate

2) Adaptive

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41
Q

Innate immunity consists of?

1) Physical barriers =
2) Inflammatory response =
3) Com____ system
4) Large granular ____: Natural ____ cells

A

1) skin, mucous membranes, lining of respiratory tract
2) Monocytes, macrophages, polymorphonuclear cells (neutrophils)
3) Complement
4) lymphocytes: killer

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42
Q

Adaptive immunity consists of?

1) L_____
2) T cell:cell-mediated immunity (2)
3) B cell: Humoral immunity (4)

A

1) Lymphocytes
2) Cytotoxic T cells, helper T cells
3) B lymphocytes, memory B cells, plasma cells, immunoglobulins

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43
Q

An obstruction of the lymphatic system, causing a fluid collection of excess interstitial fluid, water bacteria, and cellular waste in interstitial spaces

A

Lymphedema

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44
Q

Lymphedema causes

1) Primary
2) Secondary to injury such as?
3) Lymph ____ _____

A

1) without known etiology
2) extravasation of a vesicant
3) Lymph node dissection

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45
Q

Risk factors for Lymphedema

A 
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
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46
Q

Sx of lymphedema

A 
Edema
Increased tightness of clothes/jewelry 
Stiffness
Numbness or paresthesia 
Pain
Increased weakness of affected limb 
Erythema
47
Q

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

A

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)

48
Q

Mucositis =

A

Sometimes called stomatitis, is inflammation and ulceration of the oral mucosa

49
Q

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

A

Phase I: Initiation (soon after chemo/rt

50
Q

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

A

Phase II: Primary damage response

51
Q

Phase of Mucositis

Cytokines amplify the acceleration and amplify the original injury
Tissue is biologically altered but still may appear normal

A

Phase III: Signal amplification

52
Q

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

A

Phase IV: Ulceration

53
Q

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

A

Phase V: Healing

54
Q

Symptoms of Mucositis

A 
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
55
Q

Chemo agents that commonly cause ______

Busulfan
Capecitabine
Cyclophosphamide 
Doxil
5FU
Mechlorethamine
A

Mucositis

56
Q

Risk factors of Mucositis

A

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
57
Q

Tx of oral mucositis (3)

A

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)

58
Q

Grade of Mucositis

Erythema of oral mucosa

A

Grade 1

59
Q

Grade of Mucositis

Confluent ulcerations or pseudomembranes, bleeding with minor trauma

A

Grade 3

60
Q

Grade of Mucositis

Patchy ulcerations or pseudomembranes (a thick, tough fibrinous exudate on the surface of a membrane)

A

Grade 2

61
Q

Grade of Mucositis

Tissue necrosis; significant spontaneous bleeding; life-threatening consequences

A

Grade 4

62
Q

Grade of Mucositis

Death

A

Grade 5

63
Q

Xerostomia =

A

Dry mouth

64
Q

Causes of Xerostomia

A

Surgery, chemo, RT

65
Q

Patho of Xerostomia

A

60% of saliva produced by parotid gland which is very radiosensitive (rt will damage it)

66
Q

S/S of Xerostomia

A 
Difficulty speaking, swallowing
Feeling of gagging, choking
Pain
Halitosis: periodontal disease
Cheilitis or lip inflammation, chapping
Increased oral infections (no cleansing function of saliva)
67
Q

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)

A

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)

68
Q

What part of the brain is the vomiting center?

A

Medulla v

69
Q

Patho of chemo induced nausea, what chemicals are involved?

A

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

70
Q

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)

A

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

71
Q

Meds given to treat CINV

A 
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)
72
Q

Nonpharmacologic management of CINV

A 
Acupressure
Acupuncture
Acustimulation
Guided imagery, music therapy, progressive muscle relaxation 
Psychoeducational support
73
Q

Dysphagia =

A

Difficulty swallowing

74
Q

Transfer dysphagia =

A

Alteration in the oral-pharyngeal passage of food

75
Q

Transit dysphagia =

A

Absence of esophageal peristalsis

76
Q

Obstructive dysphagia =

A

Mechanical obstruction due to stenosis or tumor involvement in the pharynx, esophagus, esophagogastric junction

77
Q

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

A

1) Laser
2) feeding
3) Thickening
4) Steroids, expectorants, bronchodilators, pain, anxiety meds
5) speech, physical
6) dietician

78
Q

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

A

1) cold
2) soft, pureed
3) spicy, hot, coarse
4) numbing (lidocaine viscous)
5) weights
6) tube, parenteral

79
Q

Anorexia =

A

involuntary loss of interest in eating

80
Q

Cachexia =

A

Wasting syndrome that combines weight loss of muscle and protein, includes anorexia, nausea, weakness

81
Q

Patho of Anorexia

A 
Tumor burden
Response to tx 
slowed GI motility 
Pain
Distress
Fatigue
82
Q

Patho of Cachexia

1) Primary etiology =
2 Secondary etiology =

A

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

83
Q

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____

A

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

84
Q

What lab value is increased in cachexia?

A

BUN/creatinine ratio

85
Q

Meds to help Anorexia and Cachexia (2)

A

Corticosteroids

Progestins (Megestrol Acetate)

86
Q

Cystitis

A

Inflammation of lining in bladder

87
Q

Hemorrhagic or severe cystitis is an adverse SE for which chemos (3)?

What class of chemo?

A

Ifosfamide
Cyclophosphamide
Busulfan

Metabolites

88
Q

Symptoms of Cystitis

A 
Suprapubic pain or pressure 
Abdominal pain 
Urinary urgency, frequency, burning 
Hematuria 
Bladder spasms 
Incomplete bladder evac
89
Q

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

A

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

90
Q

Urinary incontinence =

A

involuntary leakage of urine

91
Q

Causes of urinary incontinence

1) Surgery (4)
2) Radiation (2)

A

1) Prostatectomy, Hysterectomy, Colectomy, low anterior or abdominoperineal resection (rectal)
2) external beam to pelvis, brachytherapy

92
Q

Management of UI

1) ____ floor muscle ____*
2) Encourage adequate ____ intake
3) Avoid ca____ and al_____
4) Manage cons____, which can exacerbate symptoms

A

1) Pelvic, exercises
2) fluid
3) caffeine, alcohol
4) constipation

93
Q

Dermatologic emergencies

1) S___ J____ syndrome
2) T____ e_____ ne____
3) Drug ______ syndrome (DHS)
4) Ang______

A

1) Steven Johnsons syndrome
2) Toxic epidermal necrolysis
3) hypertensive
4) Angioedema

94
Q

Cardiac toxicities are commonly associated with

1) Anthracyclines (1)
2) RT for which diangoses

A

1) Doxorubicin

2) non-hodgkin, hodgkin, left sided breast ca

95
Q

Chemos associated with peripheral neuropathy

4 classes

A

Platinums (Cisplatin, Oxaliplatin)
Taxanes
Vinca Alkaloids
Proteasome inhibitors

96
Q

Practical interventions to promote safety for those that have peripheral neuropathy

A 
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
97
Q

Medications used for nutritional support/appetite (3)

A

Megestrol acetate
Steroids (but should be given routinely bc of SE)
Dronabinol

98
Q

Types of pain (3)

A

Nociceptive
Neuropathic
Referred

99
Q

Nociceptive pain =

A

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

100
Q

Neuropathic pain =

A

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)

101
Q

Referred pain =

A

originated in one part of body but felt in another part

102
Q

S/S of Acute Pain

A

Tachycardia
Pale skin
Diaphoresis
Increased BP

103
Q

S/S of Chronic Pain

A 
Autonomic sx absent 
Fatigue, insomnia, depression, social withdrawal 
Anorexia 
Constipation
Weakened immune system 
Mood changes (fear, anxiety, stress) 
Impatience, loss of motivation
Disability
104
Q

Pharmacologic therapy steps for cancer related pain

Step 1:
Step 2:
Step 3:

A

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)

105
Q

Treatments for Neuropathic pain (3)

A 
Tricyclic antidepressants 
Calcium channel alpha 2 delta ligands (gabapentin, pregabalin) 
Topical therapy (lidocaine)
106
Q

Nonpharmacologic interventions for pain

A

Radiation
Surgery
hot/cold compress
Cutaneous stimulation (transcutaneous electrical nerve stimulation)
complementary/integrative therapies (massage, acupuncture, aromatherapy, relaxation, visualization)

107
Q

Cancer-Related Fatigue =

A

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
108
Q

Risk factors for CINV

1) Emetogenic potential of chemo agent
2) Dose of chemo
3) Administration schedule
4) C_____ chemotherapy
5) Duration of infusion =

A

3) Dose dense
4) Combination
5) Short infusions

109
Q

Breakthrough emesis treatment

A

Corticosteroids
Haloperidol
Metoclopramide
Scopolamine

110
Q

Postchemotherapy prevention of N/V

A

Prophylactic dexamethasone and aprepitant

111
Q

Best antiemetics for Acute N/V

A

5HT3 antagonists
Steroids
Antihistamines

112
Q

Best anti-emetics for delayed N/V

A

P antagonist (aprepitant)
Neuroleptics (prochlorperazine)
Anticholinergics (scopolamine)
Motility agents (reglan)

113
Q

Tx for anticipatory nausea

A

Benzodiazepines

114
Q

Nonpharmacologic management for N/V

A 
Acupressure
Acupuncture
Acustimulation 
Guided imagery, music therapy, progressive muscle relaxation 
Psychoeducational support

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