Symptom Management Flashcards
hemorrhagic cystitis
Complication of
Symptoms
Prevention is the key
Complication: Cyclophoshamide ifofamide Busulfan Rad (occur 10-14d)
Inflammation of bladder defined by lower urinary tract symptoms
Symptom: dysuria, hematuria, hemorrhage
Prevention
- Mensa IV as uroprotectant if taking ifofamide or high-dose cyclophosphamide
- AMIfosine as cytoprotectant for cisplatin
- avoid alkalizing agents
- Avoid caffeine, spicy food, alco
- hydration
- po cyclophosphamide early AM to allow for increased hydration and diuresis of metabolites prior to evening
Anemia
Complication of
Symptoms
Hb <10
Ferritin - no change or decrease (<30)
Reticulocyte count:
Low- in hypoproliferative disease
High (LDH, Bili)- hemolysis because of increase erythropoiesis and Tx response anemia
Tx with:
- Transfusion to Stable Hb 7-8
- Erythropoietic therapy (Epoetin, darbepoetin)
_____________
- Cancer exacerbate anemia – by suppression of hematopoiesis
- by cytokine production that kills RBC prematurely
- Chemo/Rad causes myelosuppressive effects
Symptoms:
Flank bleeding
RENAL insufficiency
hemolysis
____________
severe Anemia can cause:
Cardio: as RBC decreases, blood flow more aggressively with less viscosity. Bruits, murmur, tachy, postural hypo
Pulmo: Dyspnea @ rest, hypoxia, tachypnea, pulmonary edema
GU: water retention, proteinuria
CNS: headache, dizziness
GI: decrease motility/constipation, hepatospenomegaly
MS: bone pain
Other: brittle nails
Neutropenia
Symptoms
ANC = %neutrophils xWBC
%neutrophils = segment%+bands%
ANC<500
ANC <1000 (risk of infection)
-______
Neutrophils - takes 10-14 days to produce in BM they only live 4-8 hours once release into the circulation. Continual production in BM
_____
Symptoms:
Fever: >100.4, maybe the only sign (risk >65yrold) Fever with chills, rigors Vascular access device tenderness or erythema Cough Dysuria Mucositis Diarrhea perirectal pain changes in Mental staus
___
Patient education:
-Report fever >100.4
-Good hygiene
-avoid uncooked and unwashed fruits and veg
-avoid barn animals, reptiles, birds and litter
-avoid construction areas
-avoid contact with peple who recently vaccinated with a live virus
-avoid undercooked meats, seafood, and eggs
Tx for chemo induced Neutropenia
SE
Treatment
- GCSF (white blood cells stimulants) for chemo induced neutropenia
- Filgrastim (neulasta-act fast)
- Pegfilgrastim (neupogen)
- tbo-filgrastim
- Sargramostim
Mechanism of action: Trigger stem cells in BM to produce more of a particular WBC. Stimulate hematopoietic development of GRNULOCYTES, reducing the duration of neutropenic episodes
SE:
Pain to long bones
Tx for chemo induced Anemia
SE
RBC stimulants for chemo induced ANEMIA
POIETIN
- Erythropoietin
- Epoetin-alfa
- Darbepoetin
Mechanism of action: Stimulate stem cells to develop into RBC
SE:
- HPT
- increased risk of venous thromboembolic (Particularly in MM)
- diarrhea
- fluid retention
Platelet stimulants for chemo induced thrombocytopenia
SE
- Oprelvekin
- ProMEGApoietin (can affect all blood cells but primarily PLT)
Mechanism of action: stimulate thrombopoietin, a hormone that stimulates development of stem cell MEGAkaryocytes (immature precursors of PLT) to produce PLT faster than normal
SE:
- ventricular arrhythmia
- visual/opthalmologic defect
- FLuid retention
- anaphylaxis
- pulmonary edema
Nursing Consideration - Prevention of infection
- CSFs for high-risk patient
- influenza vaccine annually
- 23-valent pneumococcal polysaccharide vaccine for cancer aged >5
- 7-valent pneumococcal polysaccharide protein-conjugate vaccine for cncer aged <5yr
- Prevention of Pneumoncystic carnii pneumonia
- give AntiFungals to prevent oral candidiasis if pat is receiving chemo
High risk pt
- antifungal prophy
- antibacterial prophy
- HEPA filters/masks for those with prolonged neutropenia
- clean of oxygen humidifier andnebulizers
- use automatic ice machines rather than ice bins. Do not handle ice
Thrombocytopenia
PLT <150k
Normal 150-400k
\_\_\_\_ CAUSE: s/s: Mgt: info:
Cause:
- BM infiltrated y malignancy
- DIC or thrombotic thromboytopenic purpura can cause destruction
- Splenomegaly
- occur 8-14D after chemo
- Meds: NSAIDs, aspirin, thiazide diuretics, tricyclic antidepressants, abx (piperacillin, ampicillin), HEPARIN
s/s:
- bleeding 9any orifice_
- mucosa or skin (petechiae, ecchymosis)
- Menorrhagia
- change in mental or neurologic status
- epitaxis
Mgt:
MESNA: given to pt receiving ifosfamide, high dose cyclophoshamide to decrease pos of hemorrhagic cystitis
Nurs intervention:
- soft toothbrush, no flossing
- avoid invasic procdure (enemas, rectal temp, IM injection)
- observe for dark, tarry stools, easy brusing or petechiae
- avoid electric razor, dental
- avoid tampons
- avoid constipation
- immediatly report sudden onset of headache.
____________
- healthy adult: 1/3 store in spleen
- PLT circulate abt 708 days and are then removed by the normal body macrophage system.
- no reserve in BM
- myelosuppressive therapy puts pt at increased risk for thrombocytopenia
Lymphedema: Definition Cause Management complete decongestive therapy (CDT)
-greater than 1.5cm difference in circumference of affected limb to unaffected lumb
-Caused by diseases w/invasion into lymphatics ( lymphoma, breast, melanoma, H/N), scarring of radiation, metastasis
Mgt of Lymphedema
-manual lymph drainage
-skin care
- compression
-exercise/movement therapy
-PT massage
-Elevate
-AVOID bp and iv start only if LN was removed on that side
Mucositis
s/s
cause (med)
inflammation of mucosal lining
Stomatitis (oral)**
Esophagitis (esophagus)
Gastroenteritis (intestine)
Stomatitis is so painful and disruptive that pt may d/c Tx prematurely.
- 100% in HN rad
- 80% HSCT
- 40% in chemo
___
s/s
- Mucosal: pallor, WHITE patches, erythema
- Foul odor, cracks, fissures in mucosa
- changes in voice quality
Cause:
- BusulFAN
- Capacitabine
- Cyclo
- DOxil
- 5-FU
- Mechlorethamine
___
Tx
Ice chips are placed in the mouth, beginning 5 minutes before administration of chemotherapy and replenished as needed for up to 30 minutes.
diphenhydramine-lidocaine-antacid mouthwash (so-called magic mouthwash)
Mucositis
Patho ( 5 phases)
2: Primary damage response
Indirect Tox:
- myelosuppression
- loss of immune cells in the mucosal tissue
- loss of protective saliva
- FIVE phases of pathology occur in the development and resolution mucositis
#1 (soon after chem or rad)
- DNA and non-DNA damange, causing basal and epithelial damange in submucosa
-Mucosa appears normal
- DNA damage and cell death in epithelium of mucosa
- Pt may still not feel that any damage has occurred
- mutitude of GENES are activated, ncluding proinflammtory cytokines, tumor necrosis factor-alpha, interleukin-beta and interleukin-6 causing more cell injury and death
- cytokines amplify the acceleration and amplify the original injury
- Tissue is biologically altered but still may appear NORMAL
- fibrous exudates may thinly cover oral ulcer, which then can fill with bacteria
- Pain, dysphagia, decreased intake, diffifult talking, INCREASED risk of bleeding
#5 Healing -when d/c chemo/rad, new molecules direct the epithelium to heal and increase WBC production to fight local mucosal infection
Refractory to random PLT and reports bleeding gum
What’s next
Admin Human Leukocyte antigen-matched PLT
May be considered to manage patients who have developed refractory responses to standard PLT transfusion
DoxeTAXOL
Combo with Dex
Why?
Docetaxol is associated with
fluid retention and associated
alveolar permeability and
Pulmonary infiltration
Which can be prevented with
Corticosteroids as pre-med
palonosetron
Aloxci
Common side effect?
Constipation
Headache
Infusion of cryopreserved stem cells
Common experience for patients
DMSO, the preservative used to stored collected stem cells, cause a strong garlic like taste during infusion
Repeated thoracenteses
Usually for pulmonary Mets
Repeated thoracenthesis may result in the development of unexpected or tapped lung
Trapped lung- inability to expand and fill due to restricted fibrous visceral pleural peel
5-FU
Melphalan
Fluorouracil
To do-
Side effect-
Oral mucositis
- help swish ice chip or cold water around your month for the first half hour of the treatment
Acute toxicities
Persistent toxicities
Long term effects
- Acute: onset w/in days/weeks of treatment, once drug is out of the system, toxicity goes away (Ex: N/V/D, mucositis, myelosuppresion)
- Persistent: occurs during and beyond completion of tx (ex: peripheral neuropathy, fatigue, cognative impairment, dry mouth, ocular)
- Long term effects: toxic effexts on the organ causing damage that can come up later, months to years (Ex: pulmonary, cardiac, neuropathy, fertility, secondary cancers)
Late effects of therapy: Brain tumor Hodgkin disease H/N Testicular Breast ALL Cervical Lung Abdomen/Pelvis
- Brain tumor: memory/cognitive
- Hodgkin disease: cardiac, pulm, xerostomia (dry mouth), thyroid and breast ca
- H/N: xerostomia, thyroid
- Testicular: fertility, pulmonary
- Breast: cardio if rad was on L side
- ALL: neuropathy and 2nd ca, CNS
- Cervical: cystitis, fistulas
- Lung: fibrosis, arm edema, pericarditis, CAD, pneumonitis
- Abdomen/Pelvis: colon perf, fistulas, bladder fibrosis, leg/scrotal edema, impotency, fertility
Dyspnea: Disease related Treatment related Other causes Assessment Testing Treatment
- Lung cancer
- Bleomycin
- other causes: asthma, anemia, COPD, PE, poor physical status
- Assess: wheezing
- CXR,PFT,CT
- Tx: morphine, breathing tx, cool air
Mucositis
Tx
Grade
Symptom
- Cryotherapy (ice)
- PALIfermin for pt receiving HSCT
Grade: 1 - erythema 2- patcy 3- ulcerations, bleeding 4- tissue necrosis
Symptom - pain
Due to tissue damage
Xerostomia
Management
subjective feeling of dryness in mouth
Parotid gland produces 60% of saliva
____
Management
-Dental examination prior to initiation of thearpy
-Meticulous teeth brushing and flossing (if hematologically stable)
-avoid SPICY, rough foods and harsh chemicals
-limit SUGAR intake
-pain management
-saliva substitutes/increase fluid intake
- prophy abx
- SIAlagogues (drug increase saliva producation)
- AmiFOStine (cytoprotectant, HN pt receiving rad, IV)
N/V
Type of chemo induced
Mgt
Acute CINV
- occur 24hrs after chemo
- highly emetogenic drugs (CISplaTIN)
Delayed CINV
- after 24hrs and last upto 6D
- women
- high dose Cisplatin
- Carbopltin
- Cyclophosphamide
- anthraCyclines
Anticipatory nausea
- trigger by tasts, odors, sights, thoughts, or anxiety associate with chemo
- Tx: Benzodiazepine
_______
Patho:
-chemo causes release of serotonin (5-HT3) thr GI tract
Management
- Prevention: begin antiemetic therapy prior to chemo and then for the first 24hr. Prevention is a best weapon for anticipatory N/V
- Postchemo: prophylactic dex and aprepitant two to four days after chemo
Break through emesis Tx:
- challenging to Tx because once it is present, it can be difficult to reverse
- corticosteroids, haloperidol, metoclopramide, scopolamine are sometimes used for breakthrough emesis
N/V Tx
N/V Tx
Neuroleptics Motility agents antihistamines Benzo steroids cannabinoids anticholinergics 5-HT3 antagonist substance P antagonist
Best to treat:
Acute N/V (5-HT3 anta, steroid, antihis)
Delay N/V: Substance P antagonist, neuroleptics, anticholinergics, motility agents)
Anticipatory N/V:
-benzo
Dysphagia
Types
difficulty swallowing
- Transfer dysphagia
alteration in the oral-pharyngeal passage of food - Transit dysphagia
absence of esophageal peristalsis - Obstructive dysphagia
mechanical obstruction dt stenosis or tumor involvement
Anorexia and Cachexia
Labs
Tx
Anorexia: involuntary. 80% pt
Cachexia: wasting syndrome that combines weight loss w/ loss of muscle+proteins and includes anorexia, N & weakness. Often in end stage of disease.
Labs
Na, K, Alb, Glu decreased
BUN/creatinine ration - increased in cachexia
Folate: decreased (indicates malnutrition)
Both:
Tx: Corticosterids, Progestins
In addition - Cachexia: Metoclopramide, cannabinoid derivates, Enteral or parenteral feeding
Tx underlying etiology (obstruction)
Constipation
unusual-
cause:
Tx:
cause:
hypercalcemia
Autonomic neuropathy
Spinal cord lesion
Tx:
- polyETHYlene glycol w or w/out electrolytes
- polyPHYlactic if taking opioids
- teach diaphragmatic breathing and abd muscle exercis
Pharm:
- Osmotic agents: Lactulose, polyETHYlene glycol 3350
- opioid receptor antagonist: methylnatreXONE
- Prokinetic agents: METOclopromide
CTID
cancer treatment induced diarrhea
Tx
Prevention
Patho:
Osmotic: from consumption of food or drughs that increase osmotic activity of the intestine, drawing more water into the colon
Risk Factors: Female >10% weight Loss Colectomy Inflammation
Treatment:
Chemo induced diarrhea
- Loperamide
- high dose loperamide if tx w/ IRInotecan
- Somatostatin analog or OCTerotide/IM loge acting if refractory to loperamide
Rad induced diarrhea
-oral opiates
Prevention rad induced diarrhea
- Probiotic
- Psyllium fiber
- Octeotide if G2 or 3
Mgt of Sexual Dysfunction
communication tools
PLISSIT
ALARM
Intervention
P LI SS IT Permission, limited information, specific suggestions, Intensive therapy
ALARM Activity libido arousal resolution Med Hx
Intervention for men
- po erectogenic Sildenafil,
- prostaglandin injections
- Psy support
Intervention for women
-Kegel exercise
UI
ICIQ-SF
consequence of what -tomy
Mgt
Urinary Incontinence (UI)
ICIQ-SF
- screening for UI
- assess freq, severity and impact of UI
UI consequence of (below)
- Prostatectomy
- Hysterectomy
- colectomy
- abd-perineal resection
- Rad (external to pelvis or brachy)
Mgt of UI
- Pelvic floor muscle exercise
- FLuid
- avoid caffeine and alco
- Mgt constipation, which can exacerbate sym
Hand foot syndrome
SE Taxane antiangiogenic agent toPOISisomerease inhibitor Sunitinib Sorafinib
Retrograde Pyelography
form of x-ray used to get detailed pic of the
ureters and kidneys
with contrast agent
Tumor lysis syndrome
Temp HR BP RR Hct PLT
TTP - Lab
Thrombotic thrombocytopenia purpura
Lab findings
CBC/PLT: decrease (RBC burst)
ADAMst13: decrease
adam street on TTP
Smear: schistocyte
Combs: -
LDH: increase
Bil: increase
Stereotactic radiosurgery (SRS)
non-surgical, radiatin therapy to treat small tumors of the brain
deliver precisely-targeted radiation in fewer higer dose
Stereotactic radiosurgery (SRS)
non-surgical, radiation therapy to treat small tumors of the brain
deliver precisely-targeted radiation in fewer higer dose
Radiation pneumonitis
inflammation of the lung caused by radiation therapy to the chest. It most commonly develops 1 to 3 months after treatment is over, but it can happen up to 6 months after treatment. Chronic pneumonitis can lead to permanent scarring of the lungs-pulmonary fibrosis.
Posaconazole
Anti-f
Adverse reaction
Life threatening AE
-Torsades de Pointes
-hepatocellular damage
-
Thx
Opioid related conatipation
Bowel stimulant laxatives
Cyclophosphamide
No no .. allopurinol
Why?
Cyclophosphamide is an alkali ting agent that disturbs the synthesis of PROTEIN as a cancer treatment.
The concomitant use of alopurinol can
- increase the toxicity of agent, particularly
- BONE MARROW SUPPRESSION by
- decrease renal excretion
Hypercalcema
Up..up.. s/s
Delay dc of hypercalemia often occurs d/t no specificity of symptoms
- constipation
- lethargy
- CONFUSION
-bradycardia
Down down d/t depression of conduction system
Increased ICP
S/s
Thx
Increased ICP s/s
- drowsiness
- fatigue
- headache
- changes in BP - high
Steroid tx to decrease surrounding edema from the tumor
