Test #3 Flashcards
Respiratory, cancer & Hematology
What is cancer?
A group of cells that lost its control mechanisms and results in unregulated growth
Heart trouble is the 1st cause of death, what is the 2nd?
Cancer
Cancer
- can develop from any tissue in an organ forming a mass called tumor
- cancerous cells from the primary site can spread (metastasize) throughout the body
- cancer cells need more glucose & O2
- spread through lymphatics
Spreading of cancer (Initiation)
(first)
- change in genetic material brought on spontaneously or by a carcinogen (could be a virus)
Spreading of cancer (Promotion)
(second)
-agents in the environment allow the cell that has undergone initiation to become cancerous
-several factors: combo of susceptible cell and carcinogen
Spreading of cancer (progression)
(third)
- invasion directly
- through lymphatic system
- through bloodstream
Types of cancer
Blood & blood forming
Solid tumors
Blood & blood forming cancers
- leukemias, lymphomas & multiple myelomas
- these cells remain separate and harm by crowding out normal blood cells in the bone marrow and blood stream.
- Gradually replace normal cells
Solid tumor cancers
Carcinomas
-epithelial cells that cover inside and outside of body, produce hormones, make up glands
(adeno, basal, squamous, transitional)
-Elders
Sarcomas
- mesodermal cells that form muscles & connective tissues
- younger people
Adeno
Produced in a place that produces fluids
basal
lower level of the epidermis
squamous
below outer layer of skin linings
transitional
lining of stretchy things (bladder)
Risk factors of cancer
- Family history-chromosomal defect passed down
- Age-77% before age 55
- Environment-anything causing irritation
- Geography
- Diet-obesity, high fat, nitrates
- Viral infections-puts you at risk (Hep B, mono, HPV)
- Inflammatory diseases-Chron’s
Defenses against cancer
Immune system:
- normally the body recognizes the tumor antigen as foreign & can contain or destroy it before it becomes established.
- If the cells have reproduced rapidly and formed a mass, the system may be unable to contain/destroy
- Antibodies are formed but may not be powerful enough to overcome in some cancers
- Some antigens can be detected with blood test tumor markers (used to screen & evaluate response to treatment)
**Might not have enough T cells
S/S of cancer info
Some occur with almost all cancers & other are specific to the type of cancer and its location
-growing in large space-minimal S/S
- s/s due to growing into, thus irritating and destroying tissue
- putting pressure on tissue
- producing toxins
- using nutrients normally available for normal tissue
While growing in primary site may have one set of S/S but different with metz
-complications–paraneoplastic syndrome
(symptoms that occur at sites distant from a tumor or its metastasis)
S/S of cancer
Pain
-painless > mild discomfort > worsens with time & enlargement
(compression/erosion into nerves & other structures)
Bleeding
- slight since cells are not well attached to each other and vessels are fragile
- with better organization, bleeding may be massive
- site of cancer determines site of bleeding
Weight loss/fatigue -increases as cancer progresses -appetite good > anorexia with nausea -advanced stage-tired and sleepy -if anemic, tired and SOB with exertion (unexplained weight loss, food is nourishing cancer cells)
Swollen lymph nodes
- swell as the lymph system tries to clear
- start to become immovable and possibly painful
Depression
- related to illness, fear of dying & loss of control
- could be from spread to brain
- respiratory system
- due to blockage, pressure, bleeding, anemia
Diagnostics of cancer
Physical exams (risk factors looked at-smoker, drinker, obese)
Screeners-not defenitive
- further testing necessary
- tumor markers in blood-test further
Staging
- clinical (labs, x-rays, scans, biopsies, etc.)
- pathological (excision of tumor and node exam-more precise)
What is cytology?
biopsy of cells
What is excision?
take lump out
Staging of cancer
- Determines size & location and growth into near structures
- helps determination of treatment and prognosis
Most common is TNM
- tumor
- nodes
- metastasis
Cancer staging number doesn’t change, even if condition does
TNM system (T)
T-Primary tumor
size, how deep into organ, has it grown into surrounding tissue?
TX-cannot be measured
T0-cannot be found
T1, T2, T3, T4-size of tumor and/or the more spread to surrounding tissue
Higher the number, larger the tumor or more it has spread
TNM System (N)
N-Nodes
Number of nearby lymph nodes that have cancer
NX-cannot be measured
N0-do not contain cancer
N1, N2, N3-describes size, location and/or number affected
Higher the number, greater the spread`
TNM system (M)
M-Metastasis
has the cancer spread or not?
MX-cannot be measured
M0-no distant cancer spread found
M1-cancer has spread to other parts of body
Grouping of cancer
Once these values have been achieved, they can be grouped into stages I-IV.
Stage 0 is very early and Stage I is next least advanced and has good prognosis.
Higher the stage, poorer the outlook.
Stage I-cells slightly different, not differentiated
Stage II-slight differentiated
Stage III-severe, differentiated
Stage IV-immature, primary, totally differentiated
In situ
abnormal cells are present but have not spread to other tissue
Localized
cancer is limited to the starting place with no sign of spread
Regional
cancer has not spread to nearby nodes, tissue or organs
Distant
Cancer has spread to distant part of body
Unknown
there isn’t enough info to figure out stage
Primary prevention of cancer
clean eating
stop smoking
limit drinking
exercise
Secondary prevention of cancer
screening (mammogram, etc)
health promotion
Treatment of cancer
-Surgery (includes portacath)
-Radiation (destroys cells-directly on tumor)
(also brachial therapy)
-chemo
-immunotherapy
-combo
-alternative
Where is bone marrow found?
- long bones
- sternum
- vertabrae
- ribs
- hip bone/pelvis
What is hematology?
study of blood and blood forming tissues
includes blood, bone marrow, spleen and lymph system
What is blood?
**a unique organ because it’s fluid
- composed of plasma, various cells, proteins, clotting factors, electrolytes, nutrients, to include O2 & waste products
- kidneys are stimulated to produce erythropoietin when oxygen levels are low.
Hematopoiesis
Occurs in 5 days
low O2 level > stimulates kidney to secrete erythropoietin > increases erythroblast formation > forms reticulocytes (immature RBCs)
If rapid erythropoiesis is necessary, may release reticulocytes and nucleated RBCs
- After maturity, cells live about 120 days
- when destroyed, causes increased billi > liver filters out
RBC function
- 95% of cell mass is hemoglobin
- No nucleus
- flexible & disk shaped to facilitate absorption and release of gases
- transport gases through diffusion
- main function–transport O2 between lungs
- aids in buffer system (tries to keep us from going into acidosis)
What is epogen?
Used to treat anemia
-creates RBCs
What is neupogen?
Used to treat neutropenia
- bone marrow stimulant
- creates WBCs
RBC needs
- Iron stores & metabolism
- Vitamin B12 & folic acid metabolism
- destruction
WBC
Total amount=5,000-10,000
- 60-70% granulocytes
- 30-40% lymphocytes (fights germs)
- agranulocytes
WBC function
Protects against bacterial invasion and other foreign entities
- neutrophils
- monocytes
- lymphocytes
- eosinophils
- basophils
Neutrophils
fast arrival for short lived phagocytosis
monocytes
long term phagocytosis as macrophages, also digest old RBC (spleen)
Lymphocytes
produces substances that attack foreign material that kill directly or that enhance phagocytic cells (T cells)
B cells differentiate into plasma cells which produce immunoglobulins
Eosinophils
allergic reactions (neutralizes histamine) and phagocytosis of parasites
Basophils
produce and store histamine which when released provokes an allergic reaction
Platelets (thrombocytes)–granular fragments
- produced in marrow
- regulated by the hormone thrombopoitin
- controls bleeding (initiates clotting process)
- -collects & activates at the site of injury forming a plug
- -releases substances that activate coagulation factors
-Nurture and maintain the lining of the vessels
Plasma & plasma protein
90%=water rest=plasma proteins, clotting factors, nutrients enzymes, waste and gases
- serum
- protein–albumin, globulins
alpha & beta (transport)
gamma (immune system)
Reticuloendothelial system
- monocytes derived cells live within the tissues
- liver, spleen, lymph nodes, & lungs
- protect against foreign invaders
- stimulate inflammatory process
Hemostasis
Primary
-formation of platelet plug (vessels constrict)
Secondary
- inactivated coagulation factors are activated on the surface of the plug
- end result is fibrin anchoring to plug forming a clot
What is ecchymosis?
bruising without a cause
Acquired coagulation disorders
Liver disease-prolonged pt
Vit K deficiency-gut isn’t helping reduce
Complications of anticoag therapy-warfarin
Disseminated intravascular coagulation (DIC)-mini clots
-give heparin!
Hemostasis disorders
Clinical manifestations
Occasionally, none
Bleeding
- mucosa/skin
- hemorrhage
- prolonged bleeding for venipuncture sites
- with TTP, increased range of PCs due to clots in systems
Hemostasis Disorders
Diagnostics
Labs
- platelet counts
- peripheral smears
- pt
- ptt
- RBC morphology (size, shape)
- bone marrow exams
Hemostasis Disorders
Thrombocytopenia-platelets below 150,000
- decreased production of platelets within the bone marrow (aplasticanemia)
- increased destruction of platelets (septicemia, certain drugs, cancer)
- increased construction of platelets (large bleed)
Inherited
Acquired
-immune-(ITP) Immune thrombocytopenia purpura (most common)
-non-immune-due to shortened circulation, turbulent blood flow (causes damage), decreased production
**avoid rough activity. Pt needs to be aware of any bruising or bleeding
Acquired Immune: Immune thrombocytopenic purpura (ITP)
Normal function of platelets-shortened life
- coated with antibodies
- recognized by spleen as foreign material & destroyed by macrophages
- marrow cannot keep supply to demand
Acute-most common in kids. Usually 1-6 weeks after viral infection (measles or chicken pox, or immunizations to either), self limiting
Chronic-due to autoimmune problems, or a drug reaction
Acquired Non-immune: Thrombotic thrombocytopenia purpura (TTP)
RARE!!!
Absence of anti-clotting plasma enzyme leads to enhanced agglutination of platelets form micro-clots that deposit in capillaries, decreasing # in system.
***Medical emergency-clotting/bleeding at the same time
micro-clots will form and go to the brain, heart, kidney; may have headache, confusion, coma, disrrhythmias, kidney failure.
Special, shorter tubing when giving platelets!
Acquired Non-immune: Heparin Induced Thrombocytopenia and Thrombosis Syndrome (HITTS)
- Microclotting with reduction of circulating platelets
- Immune-mediated response to heparin=antibodies=removal=decreased platelets & platelet/fibrin clots
- Heparin neutralized–NO HEPARIN!!!
Special, shorter tubing when giving platelets!
Other Acquired-Non-immune
- end stage renal disease
- multiple myeloma (bone cancer)-will have abnormal proteins that interfere with platelet function
- cardiopulmonary bypass-destroys platelets
Disseminated Intravascular Coagulation (DIC)
Starts with small clots in blood stream, blocking vessels.
- stimulated by infection, toxins, complication of child birth or dead fetus.
- Hemorrhage
- Severe head injury
Increased clotting depletes platelets and clotting factors needed to control bleeding
DIC treatment
Correct underlying cause
Heparin therapy to slow clotting
Platelet transfusion and clotting factors to replace those depleted
Temporary fix-steroids or IV immune globulin
Spenectomy
Marrow aspiration
Purpose
- hematopoiesis evaluation
- cytopathology
- chromosomal study
site-anterior/posterior iliac crest, sternum
MD under local anesthesia
Needle inserted, stylet removed, 0.2-0.5 mL removed, needle removed and pressure applied 10 min to avoid bleeding!
Graft vs Host rejection
Fatal in 20% of patients
S/S- peeling of hands and feet
Call Dr STAT!
Bone marrow transplant
Kill off bone marrow with drug (chemo)
Increase doses so patient doesn’t reject immune cells
Wait 2-3 days, keep in reverse isolation
Give stem cells IV and they will repopulate marrow and will start to put out healthy cells
Monitor: fluids, infections, toxicity, small meals-high protein, low calories.
The anemias
Deficiency in the number of RBCs
Quantity of hemoglobin
Decreased volume packed RBCs (hematocrit)
**Decreased RBC means decreased O2 (SOB) means increased H&H
Anemia
Decreased production of RBC (hypoproliferative)
Blood loss
Increased RBC destruction (hemolytic)
Clinical manifestations of anemia
Depends on severity
Weakness, fatigue, malaise, pallor are common
Bone pain, yellow sclera, hemorrhage of eyes, blurred vision, enlarged liver & spleen, sore mouth, difficulty swallowing, coffee ground emesis, jaundice, and puritis
Cardiac-high B/P, HF, PAD, heart enlarged
GI-dark stool, red/smooth tongue
Neuro-headache, vertigo, ataxia
Angular cheilitis
cracked corners of mouth
Management of anemia
correcting/controlling cause
replacement of RBCs (epogen, blood transfusion or marrow)
- *B12=problem with vegetarians
- give iron with OJ, sticks with them better
Types of anemia
- Iron deficiency (d/t inadequate intake, but mostly blood loss)
- Anemias or renal/chronic disease
- Aplastic
- Megaloblastic
- Myelodysplastic syndromes
- Sickle cell
- Thalassemia
- Glucose-6-Phosphate Dehydrogenase deficiency
- Hereditary Spherocytosis
- Immune Hemolytic
Sickle Cell Anemia
**Short life!
Genetic defect-hemolytic (may be born with trait, mostly in Mediterranean area)
Low O2 causes crystal-like formations–rigid sickle shape
Tangle causing ischemia/infarctions
Sickling takes time so can fix itself when passes through well oxygenated areas
Cold aggravates condition, so does increased viscosity
Sickle cell anemia S/S
tachycardia
murmurs
cardiomegaly
Hgb 7-9
jaundice
enlarged face/head if severe as child
*most of the time, begins in feet, see scars where clots are that get into capillaries and kill skin cells.
Sickle cell crisis
Can be deadly!
Sickle crisis-painful d/t death to tissue
Aplastic crisis-infection (parvovirus) yields rapid fall in hemoglobin
Sequestration crisis-pooled sickle cells.
Acute chest syndrome
- S/S-rapid fall in Hgb, tachycardia, fever, bilateral infiltrates of lungs
- Potentially lethal
Priapism
erection that won’t go away
Hereditary Hemochromatosis
Iron is excessively absorbed in GI tract
- deposited in organs causing dysfunction
- can be secondary to other anemias, liver disease and multiple transfusions
**Mostly in men, because women have periods.
S/S-fatigue, arthralgia, impotence, abdominal pain, weight loss
- liver enlargement (Cirrhosis, cancer)
- other organ involvement
Removal of excess iron-therapeutic phlebotomy
Genetic counseling
Dietary-low iron
Manage organ involvement-treat organ involved
Polycythemias
Polycythemia Vera-overproduction of RBCs, RBCs, platelets
- increased viscosity/volume
- congested organs/tissues (enlarged spleen/liver)
Secondary Polycythemia-caused by excessive production of erythropoietin
-may occur as response to hypoxia or neoplasms (tumors)
NO cure.
PCs-clots, CVA, DVT, bleeding, MI
Leukopenia & Neutropenia
1 thing to remember-wash hands!!
Leukopenia-fewer WBCs than normal
-could be neutropenia or lymphopenia
Neutropenia-fewer neutrophils than normal
- results from decreased production/increased destruction
- increased risk for infection
Reverse isolation because decreased WBCs at risk for infection, sepsis and septic shock!
Leukocytosis & leukemia
Leukocytosis-increased level of WBCs
-occurs in infection, injury, inflammatory disorders, some drugs
Evaluation-look for immature cells indicating disorder in the marrow
Cause could be malignancy/leukemia
-DIAGNOSTIC: bone marrow biopsy
Treatment: start on antibiotics to reduce need for WBC so body will stop manufacturing them
Therapies for blood disorders
Splenectomy
- may be necessary after trauma
- possible treatment for some hematologic disorders
Therapeutic Apheresis
-removes certain cells from blood
Therapeutic phlebotomy
-removal of certain amount of blood under controlled conditions
Leukemia-what is it? And how does it happen?
**Leading cause of death for kids
Cancer of the WBCs or cells that develop into WBCs
(usually takes place in bone marrow)
WBCs develop into stem cells
- if development goes awry, chromosomes get rearranged, interfering with normal cell division
- multiply uncontrollably
Leukemia types
Types define how quickly the progress and kind of cells affected
Myeloid leukemia (MORE RARE) -Acute/Chronic (AML/CML)
Lymphocytic (MORE COMMON)
-Acute/chronic (ALL/CLL)
Acute and chronic-depends on time it takes for S/S to appear and the phase at which the cell stopped development
-in acute form can infiltrate other organs
Etiology of leukemia
connected to possible genetics, viruses, chemical and radiation exposures
Leukemia cell information
Unregulated rapid production of WBCs in the marrow leaving little room for normal cell production
(Although there is overproduction of WBCs, it will still cause you to have a decreased leaukocyte number because they’re IMMATURE)
- decreased RBCs/platelets=anemia/bleeding
- increased IMMATURE WBCs=increased R/F infection
-can also grow in liver
Clinical manifestations of Acute Leukemia
- Abrupt onset
- WBCs undifferentiated or “blasts”
- progresses rapidly
Without aggressive treatment, death occurs in weeks-months
Clinical manifestations of chronic leukemia
S/S occur in months-years
- majority of WBCs are mature
- progresses slowly
What are lymphomas?
Neoplasms of lymphoid cells
-Can be cured but may lead to other malignancies like acute myeloid leukemia
What are the types of lymphomas?
Hodgkin’s disease
Non-Hodgkin’s disease
Multiple myeloma
Hodgkin’s disease cause
Cause unknown-virus or familial pattern
*Nodes upper body
15-24 years of age
Symptoms of Hodgkin’s disease
Painless enlargement of neck nodes on 1 side
Mediastinal mass
- jaundice, itching, shingles, bone & abdominal pain, cough, pulmonary effusion, night sweats
- Aggravated by alcohol
What is Non-Hodgkin’s disease?
Nodes infiltrated by malignant cells
Prevalent in immuno compromised clients
in ages 60+
Non-Hodgkin’s disease survival info
in mild early cases is over 10 years
Treatment for Hodgkin’s disease
chemo
then radiation
followed by BMT or stem cell transplant
Non-Hodgkin’s disease symptoms
No S/S until late
-lymphadenopathy
upper body
rash
can impact different organs
Treatment of Non-Hodgkin’s disease
**Most treatable
Non aggressive type: localized radiation
Aggressive type: radiation and chem
May be followed by BMT and stem cell transplant
S/S of multiple myeloma
Bone pain
- increased with movement
- decreased with rest
- better in AM
Bone breakdown
Hypercalemia (thirst, dehydration, constipation, confusion, coma)
Renal failure
Bleeding, HA, blurred vision, HF
Anemia
Is multiple myeloma curable?
NO, not curable
Clinical manifestations of Multiple myeloma
Bone breakdown-due to osteoclast activating factor and other substances secreted from plasma cells
Due to destruction, excessive ionized Ca++ enters serum (hypercalemia)
Excessive excretion of immunoglobins-renal failure, hyper viscosity of serum
Due to less space for RBC production-anemiWhat is a in late stages and decreased WBC and platelets
What is a lymphogram?
- Insert dye between toes
- Do scan after 30 min
- Scan q24hrs
- then daily for several days to watch lymphatic system
Treatment of multiple myeloma
NOT CURABLE
-survivors develop leukemia
- Pain management
- Teach S/S hypercalemia
- maintain mobility and hydration
- Dialysis
- Infection precautions
- Chemo slows progression
Chemo/Radiation
ChemotherapyYields systemic side effects
- Myelosuppression
- Nausea
- Hair loss
- Infection
Radiation is specific to area being treated
-N/D
- Watch platelets
- Keep moving
