Week 5: Oncology Part 2 - FOR 362 NOT 363 Flashcards
What is radiation therapy
use of high energy ionizing rays or particles to treat cancer
destroys ability of cancer cells to grow and multiply - cell cycle interruption
Radiation therapy can be ___ or ___
external or internal
How often is radiation therapy administered usually
usually administered daily for 5 days with a 2 day “holiday” for 2-8 weeks
treatment planning is extensive
Radiation Dosimetry
radiation dose being determined by mesurement, calculation or a mix of borth
IMRT
intensity modulated radiation therapy - external
delivers high dose radiation to a tumor while sparing vital healthy tissues around the tumor
The beam can mold to the tissues shape and bombard the tumor with small beans of different intesities from all sides
Bracytherapy
Internal radiation therapy
Radioactive substances like unsealed or sealed sources deliver large amounts of radiation to a specific area over a short time
Example of Brachytherapy
Prostate Seeds
Unsealed Brachytherapy Sources
liquid radiation
Sealed Brachytherapy Sources
Implants - needles, seeds, wires
Types of Cancer that respond well to Radiation therapy
lymphoma
leukemia
squamous cell cancers of oropharynx, glottis, bladder, skin, prostate
breast cancers
adenocarcinomas of the ailmentary tract
Radiation Safety Measures
radiation madge
minimize exposure
care - limit time, distance to radiation exposure (6 feet), shielding (lead shield)
monitoring implant placement (sealed sources) every 4-6 hours –> if found, long handled forceps into a lead lined container
no one under 18 or pregnant visiting the radioactive implant pt
mark client room with radiation precautions
body secretions considered contaminated
pt vomitting within the first 4 hours –> everything vomit touches is contaminated
use of disposable gowns, dishes, etc
visitors limited to 1 hour/day and must keep distance from pt
Radiation Safety Measures are important in what time period of sealed source implants
24-72 hours
Common effects of radiation therapy can be what?
acute, sub acute or late
Common effects of radiation therapy
impaired skin integrity
risk for infection r/t skin breakdown - erythema, dry and wet desquamation
activity intolerance and fatigue
altered nutrition less than body requirements r/t anorexia
bone marrow suppression - r/t irradiation of areas with large volumes of production
What are common R Therapy effects in the head and neck
Stomatitis/Mucositis
Xerostomia
Tooth decay and caries
osteoradionecrosis
What are common R therapy effects in the brain/scalp
alopecia - hair texture - color changes
cerebral edema
What are common R therapy effects in the pelvis
diarrhea
cystitis
ED
sexual disorders
What are common R therapy effects in the abdomen
N and V
WHat are common R therapy effects in the chest
cough
esophagitis
radiation pneumonitis
Nursing assessment wants to look at what for a pt with radiation therapy
note skin in field of radiation
monitor labs for neutropenia
Important topics of education for pt.s in radiation therapy
equipment, length of treatment
good skin and oral care
safety concerns with implants
Chemotherapy
antineoplastic agents used to kill tumor cells by interfering with the cell cycle
Immunotherapy
“Biotherapy”
use of agents derived from biologic sources or agents that enhance immune system to kill cancer cells
How does immunotherapy kill cancer cells
enhance the immune response, modify actions of the cells, and icnrease vulnerability of the cells
ex: Cytokines, monoclonal antibodies
Targeted Therapy
most intesnive/scientific
molecular based therapies that target receptors, proteins, transduction pathways to prevent growth of cancer cells
Chemotherapy Types/Routes
Oral, SQ, IM
Topical
IV (Peripheral, central lines)
Intra arterial
Intra cavity
Intra peritoneal
Intrathecal
CVA (Chemo)
Central Venous Access
Extravasation
the leakage of blood, lymph, or other fluids like anti cancer drugs from a blood vessel or tube into the tissue around it
It is a complication from a vesicant leading to blistering
What is the fundamental of safe administration of chemotherapy
safe handling! !!!
consider any chemo/bio drug to be HAZARDOUS TO YOUR HEALTH - so minimize exposure
Routes for Chemo Administration
absorption
injections
inhalation
ingestion
What sort of PPE is used for chemo?
Gloves - powder free and tested with chemo agents - double gloving recommended for prep and waste handling
gowns - low permiability fabric with a solid front
respirators - if any aerosol risk
eye or face protection if splash potential
Chemotherapy adminsitration situations requiring PPE
introducing or withdrawing needles from vials
transferring drugs form vials to other containers suing needles or syringes
opening ampulse
adminsitering drugs by any route
spiking, priming IV tubing
handling leakages
handling bodily fluids of someone who has received agents in the last 48 hours
Nursing assessment areas for clients receiving chemo/bio agents
patient concerns and questions
support systems
coping
nutritional status
CBC and other chemistries
infusion site and CVAD care!!!!!!
Education areas for the nurse to convery for pts receiving chemo or biotherapy
side effect onsets and durations
how to manage the side effects at home
recognizing emergency situations
how to manage CVAD
Common SE of Cancer that needs nursing management
alopecia
anorexia
diarrhea or constipation
fatigue
myelosuppression
mucositits (other places in addt to oral)
cardiac toxicity
hypersensitivity rxns
lyte disturbances (hypercalc, hypergly, hyper kal, hypernat, hyperuricemia, hypomag, hypocalcemia)
When does alopecia usually start after chemotherapy and radiation therapy and when can regrowth begin
beings 2-3 weeks post initiation but can regrown as often as within 8 weeks after last treatment
Nursing Diagnosis for Alopecia
alteration in body image r/t alopecia
Nursing interventions for Alopecia
mild, protein based shampoos, cream rinse and conditioner
avoid hair dryers, curling irons, bobby pins
wrap or turban to keep head warm
sunscreen scalp if needed
How soon can skin breakdown begin in chemo patients
as soon as 2 weeks into radiation therapy, it is dose dependent
Nursing Diagnosis for Skin Breakdown from Radiation therapy
Actual or Risk for Impaired Skin Integrity
Risk for infection r/t skin breakdown
Nursing Interventions for Altered Skin Integrity / Skin Breakdown
Assess skin integrity
Minimize trauma and protect the skin
If skin with dry breakdown - hydrophilic moisturizing lotion (aquaphor)
If skin weeps - apply non adhesive absorbent dressing
After treatment - protect skin, sunblock
Consult wound ostomy continence nurse
Nursing Diagnosis for Oral Care Issues (Mucositis or Stomatitis)
Mucositis or Stomatitis r/t Chemo or Radiation therapy
Nursing Interventions for Oral Care Issues r/t chemo or radiation therapy
Inspect mouth daily - check for yeast
Soft bland diet and maintain hydration
Saliva Substitute
Topical Anesthetics (BMX sol’n) and oral care
Antifungals as needed if yeast - ie Nystatin
A client has been receiving chemotherapy to treat cancer. Which of following assessment findings suggest that the client has developed mucositis?
A - White cottage cheese - like patches on tongue
B - Yellow Tooth Discoloration
C - Red, open sores on the oral mucosa
D - Rust colored sputum
C
Xerostomia
More specific to Radiation Therapy, especially if near the salivary glands
Saliva changes from thin fluid to thick sticky and acidic unable to cleanse mouth, person at risk for dental caries
Nursing Diagnosis for Xerostomia
Altered oral mucous membrane (xerostomia) r/t chemo or irradiation
Nursing Interventions for Xerostomia
excellent mouth care, soft bristle brushes
sauces, gravies, liquids on foods to make them moist
sugarless sour candies
saliva substitutes
no commercial mouthwashes with alcohol
Oral Pilocarpine may stimulate saliva
Myelosuppression
Decreasing in most cell counts - WBCs, platelets, RBCs
Nursing Diagnoses for Myelosuppression
Risk for infection r/t immunosuppression, skin breakdown or contamination of supplies
Risk for injury r/t alteration in immune system; clotting factors
How to calculate Absolute Neutrophil Count (ANC) to check for neutropenia in cancer patients
ANC = % neutrophils (bands + segs) * WBC count
What is one way they treat neutropenia and anemia
CSF - colony stimulating factors
- Filgastrim (Neupogen) - WBC
- Pefilgrastim (Neulasta) - WBC
- Epogen - RBC
Nursing Interventions to minimize infection risks
Monitor CBC and granulocyte count
Monitor ANC level - infection risk
Watch for NADIR - lowest white cell count post-therapy
HANDWASHING
Restrict visitors
What does EBP suggest is the best ways to prevent infection
Hand hygiene using soap and water or antiseptic hand rub for all patients with cancer and their cancer caregivers
Colony stimulating factors for all patients with cancer undergoing chemo with >20% risk of febrile neutropenia
Flu, COVID, and pneumonia vaccines
Do not allow visitors with respiratory infections
Prophylactic antibodies/antivirals for some patients
Thrombocytopenia: What sort of injuries can occur with these levels of platelets:
- <100,000/mm3
- <20,000/mm3
- <10,000/mm3
- injury or surgery may provoke excess bleeding
- spontaneous bleeding may occur
- often associated w/ serious hemorrhage
Nursing Interventions for thrombocytopenia
assess bruising, bleeding from CVAD sites, gross blood from other sites
Petechiae
Monitor platelet levels & transfuse under provider order
No IM injections, rectal temps
Use electric razors for shaving, soft toothbrush
Nursing diagnosis for Anemia
Risk for activity intolerance r/t chemo therapy and irradiation
Nursing Interventions for Anemia
assess blood counts (H&H)
pace activities, rest activities
Assistive devices
Adequate nutrition
Encourage exercise ==> can actually reduce fatigue
Nursing Diagnosis for N/V
Altered nutrition less than body requirements r/t N/V
Nursing Interventions from N/V
assess strategies that have worked for pt.
Monitor lab values r/t nutrition
stimulate appetite and facilitate caloric intake
oral and parenteral anti-emetics that are carefully timed
cold, salty, dry crackers, toast may be tolerated
Medications for N/V
Benzodiazepines for anticipatory N/V
Mayneed a 5-HT3 receptor antagonist - kytril and zofran
corticosteroids
metoclopramide - Reglan
Nursing Interventions for Diarrhea
Avoid - high roughage, greasy, spicy foods, milk products, caffeine, alcohol
Encourage - bland diet, increasing fluid intake (weak tea, broth, grape juice)
May need loperamide (immodium) if persistent
Nursing Interventions for Constipation
Increase fluid intake
Increase high fiber foods (whole grains, bran, fruits and veggies, popcorn)
CACS
Cancer Related Anorexia Cachexia Syndrome
Biology process that results from a combination of increased energy expenditure and decreased intake
increased nutrient intake cannot always reverse the process !!!
(Do not need: may take dronabinal, megestrolacetate, steroids)
What are some s/s of CACS
Wasting
weight loss
weakness
fatigue
impaired immune fxn
Nursing Diagnosis for Esophagitis/Pharyngitis
Impaired Swallowing r/t side effects of rad. therapy or chemo
Nursing Interventions for Esophagitis/Pharyngitis
assess for difficult or painful swallowing
eat a soft, bland or pureed diet
scheduled medications to promote comfort - BMX 15 min before meals, systemic pain medication
Nursing Diagnosis for Pain
Chronic pain r/t rad therapy and chemotherapy
Nursing Interventions for Pain
Pharmacological intervention
adjuvant co analgesics
non pharmacological interventions
education
collaborate w/ interdisciplinary team including palliative providers
Reproductive/Sterility Issues r/t Chemo and Irradiation
ED after pelvic radiation
vaginal stenosis - dyspareunia
ovarian failure - try to shield from rad therapy
testicles - avoid radiation to area
impaired sexual enjoyment - assess feelings
Ways Females can overcome repro/sterility issues
cryopreservation of embryos - may delay chemotherapy by 2-6 weeks
oocyte cryopreservation - regarded as experimental, pregnancy rate low
cryopreservation of ovarian tissue
Ways Males can overcome repro/sterility issues
cryopreservation of sperm
ethical issues r/t this area
BMT v HSCT (Bone marrow v Hematopoietic Stem Cell Transplantation)
Intense chemo followed by infusion of stem cells
Used in hematologic malignancies (i.e. malignant myeloma, acute leukemia, and non-Hodgkins Lymphoma)
Harvesting bone marrow tissues v. peripheral blood stem cell collection (apheresis)
> Allogenic HCST (AlloHSCT) from donor
Autologous (AuHSCT) from patient
Nursing Management for BMT & HSCT Pre-Transplant
Support pt. through extensive work up and evaluation
Nursing Management for BMT & HSCT During-Transplant
Preparing patient for transplant - high dose chemo destroys immune system and toxic effects of chemo/RT
Watch for GVHD (graft v host disease)
High risk for infection, sepsis, bleeding
Monitor s/s of acute toxicity
Nursing Management for BMT & HSCT Post Transplant
recipient and the donor
recipients - infection risks
donors - mood alterations, guilty feelings if doesnt work
GVHD
Graft v Host Disease
Complication of allogeneic transplants - immune mediated rxn to the newly grafted stem cells
Nursing Care and Management of GVHD
Prevention!
Immunosuppressant drugs (cyclosporine, methotrexate, steroids)
Assess skin - acute GVHD includes a diffuse rash that can be SIMILAR top 2nd degree burn
Structural Oncology Emergencies
Cardiac Tamponade
Increased ICP
Spinal Cord Compression
Superior Vena Cava Syndrome
Metabolic Oncology Emergencies
DIC
Hypercalcemia
Anaphylaxis/Hypersensitivity Syndrome
Sepsis
Malignant Pleural Effusion
Syndrome of inappropriate antidiuretic hormone
tumor lysis syndrome
Spinal Cord Compression
primary tumors within the cord or vertebral metastases compress neural tissue and its blood supplies, resulting in compromised neurologic fxn
Who is at risk spinal cord compression
breast lung prostate renal melanoma and myeloma often metastasize to bone
lymphoma, seminoma, neuroblastoma often metastasize to spinal cord
persons with primary cancers of the spinal cord
Early S/S of Spinal Cord Compression
BACK PAIN is a first symptom - may be local, radicular or both
Back pain worse when in supine, with coughing , straining, flexion of neck
motor weakness or dysfunction, sensory loss
Local Back Pain d/t Spinal Cord Compression
constant, dull aching, progressive pain
Radicular Back Pain d/t Spinal Cord Compression
constant, initiated with movement, radiates along a dermatome
Late S/S of spinal cord compression
Loss of sensation for deep pressure, vibrations, position
urine or fecal incontinence or retention
impotence
paralysis
muscle atrophy
What is necessary once spinal cord compression is recognized
emergent treatment
Diagnosis methods Spinal Cord Compression
Spinal X rays
bone scan
MRI - preferred
CT scan
Myelogram
Treatment of Spinal Cord Compression
Radiation therapy
Surgery
Pharmacological
Radiation Therapy for Spinal Cord Compression
most common treatment for epidural metastasis and cord compression
often used alone and period of several weeks
Surgery for Spinal Cord Compression
only if radiation didnt work
used to decompress the area
Pharmacological Treatment for Spinal Cord Compression
steroids to reduce edema and pain, can also treat the tumor
chemo - adjuvant treatment to certain types of CA
analgesic - opioids with anticonvulsants and antidepressants
Nursing Interventions for Spinal Cord Compression
decrease severity of symptoms and control pain
perform ongoing neurological assessments
monitor bowel and bladder patterns
maintain muscle tone by assisting ROM exercises
prevent complications r/t immobility
Superior Vena Cava Syndrome (SVC Syndrome)
Compression or invasion of SVC by a tumor, enlarged nodes or thrombus that obstructs circulation
What is SVC Syndrome
associated with lung cancer (small cell), lymphoma or metastasis
How fast is SVC Syndrome onset
gradual or sudden
What is causing the symptoms/signs of SVC Syndrome
usually a result of impaired drainage despite collateral circulation attempts
S/S of SVC Syndrome
progressive dyspnea and cough
facial swelling!!!!
edema in neck, arms, hands
jugular, arm, and temporal vein distention
prominent venous patterns on chest wall
increased ICP - visual disturbances, headache, mental status
engorged neck
trouble breathing w/ chemo
Methods of Diagnosis of SVC Syndrome
clinical findings
CXR
thoracic CT
MRI
Treatment for SVC Syndrome
RT to shrink tumor size
chemo for sensitive cancers or when Rad therapy has reached max tolerance
anticoagulants if thrombosed
O2, corticosteroids, diuretics for symptom management
bypass stents more likely than surgery unless emergent
Nursing Care of SVC Syndrome
Assess for the risk - type of cancer
watch for S/S - particularly FACIAL SWELLING
I&O
cardiac and resp support
manage the complications of RT and chemo
Tumor Lysis Syndrome
a potentially life threatening metabolic imbalance that occurs w/ the rapid release of intracellular potassium, phosphorus, and nucleic acid into th9e blood as a result of rapid tumor cell death
Tumor Lysis Syndrome is a Syndrome of what things?
Hyperkalemia
Hyperphosphatemia
Hyperuricemia - nucleic acid to uric acid conversion
Hypocalcemia - increased phosphorus bindings to calcium to form calcium phosphate salts
Tumor Lysis Syndrome can cause…
cardiac arrhythmias
renal failure
multisystem organ dysfunction
Treatment for Tumor Lysis Syndrome
IV hydration pre and post treatment of chemotherapy
Sodium bicarb to decrease solubility of uric acid, prevents potential kidney injury
decrease uric acid production - allopurinol
forced diuresis - loop diuretics, mannitol
excretion of phosphate through antacids
kayexalate for hyperkalemia
potential for dialysis
Nursing Management/Interventions for Tumor Lysis Syndrome
safety - recognize clients at risk, seizure precautions for problematic calcium
maintain fluid intake
restrict K and phosphorus in diet
assess for the dysrhythmias, renal failure
strict I & O
