X Oncology - Pain / Cancer (Burke 8, 12) Flashcards
Methods of heat loss
- sweating
- vasodilation
Methods of heat conservation
- vasoconstriction
- curling up (fetal position)
result of heat applied to large body area
Excessive Peripheral Vasodilation
-diverts lots of blood from internal organs
DOWN BP (Orthostatic Hypotension)
Effects of HEAT
- vasodilation
- UP capillary permeability (leaky)
- UP local cellular metabolism
- UP blood flow in area
- UP lymph flow
Effects of COLD
- vasoconstriction
- DOWN capillary permeability
- DOWN local cellular metabolism
- DOWN nerve conduction
- DOWN blood flow
- DOWN lymph flow
What part of brain senses temperature and reacts
Hypothalmus
Body will adapt to hot and cold in a short time, but rarely adapts to what kind of pain?
DEEP pain
Rebound Phenomenon: HEAT
- cells w vadodilate with applied heat.
- Max vasodilation 20-30min
- after 30-45min, tissue becomes congested and blood vessels constrict
- 1 hr recovery time before reapplication
Rebound Phenomenon: COLD
-max vasoconstriction at skin temp 15c, 30min - 60min
-DOWN blood flow
recovery time, 1 hr advised
30min on, 30min off (Ms Green said)
Therapeutic uses of heat
- relax muscles
- reduce swelling (open capillaries, lymph picks up interstitial)
- UP inflammatory process to fight infection
- UP cellular metabolism to promote healing and new tissue growth
- DOWN pain
Therapeutic uses of cold
- prevent edema on new injuries
- DOWN pain
- vasoconstriction to reduce bleeding
DO NOT use Heat or Cold on….
- neuro-sensory impairment (diabetic neuropathy)
- impaired mental status
- impaired circulation (PVD, Buergers disease)
- right after surgery
- hemorrhage
PVD: peripheral vascular disease
Buergers: blood vessels become inflamed, swell and can become blocked with blood clots (thrombi). This eventually damages or destroys skin tissues and may lead to infection and gangrene.
Complication of Heat/Cold
HEAT
- pain
- blotching
- numbness
COLD
- masceration (wet, wrinkly, pruny skin)
- ischemia
- burns
when applying temp therapy, DO NOT allow patient to ….
- adjust temp
- move an application
- move away from temp source (proper positioning)
- do not leave alone if patient has impaired ability to sense temp.
***What # Vital Sign is PAIN?
5th Vital Sign
description of Pain
subjective response to physical and phsychologic stressors
Nocicepters
nerve endings in skin activated when NOXIOUS stimuli applied
NOXIOUS stimuli
unpleasant stimuli
What causes pain process to begin?
Noxious Stimuli
once tissue damage from noxious stimuli occurs, what begins?
Inflammation
Inflammation causes release of what?
nociceptors
Four steps of PAIN impluses
1) transduction
2) transmission
3) perception
4) modulation
Transduction
noxios stimuli change into electrical action potential stimulus that send implulses through CNS
through mylenated fibers (white matter)
Transmission
2nd step, sending impulses from AFFERENT neurons (towards CNS) to dorsal horn in spinal cord where they synapse (transmit an impulse)
Perception
processing of pain impulse to thalamus and cerebral cortex. Pain perceived and interpreted.
When sensation reaches a conscious level, patient experiences pain
Pain Threshold
point which person recognizes pain. (varies little between people)
Closely related to actual tissue damage
Pain Tolerance
amount and duration one can stand before seeking relief. (varies among all)
each person’s tolerance is NOT to be judged as acceptable or unacceptable. Should be accepted as basis for pain management
Modulation
last step in pain conduction
bodies attempts to decrease perception of pain by releasing endorphins.
Efferent fibers run from cerebral cortex to dorsal horn.
Pain inhibited or modulated. ENDORPHINS released.
** How do ENDORPHINS stop pain process
Endorphins bind with opiate receptors on neurons and inhibit release of substance P. STOPS pain impulse transmission
Gate-Control Theory of Pain
when pain travels from skin to substantia gelatinosa from dorsal horn of spinal cord, substantia gelatinos can OPEN or CLOSE the gate to transmit pain impulses to brain
when small Cfibers stimulated, gate OPEN andpain transmitted
when large ADelta fibers stimulated, gate CLOSED, pain inhibited
Whichever sensation makes it through far first is the sensation that is perceived .
Types of Pain
1) ACUTE: temporary, sudden onset, localized. 6mos or less.
2) CHRONIC: prolonged pain, longer than 6mos. may not know cause (causes depressed, withdrawn, immobile, irritable, controlling) Body adapts to constant pain. (i.e. arthritis, migraine etc)
3) NEUROPATHIC: damage/dysfunction of CNS or PNS (CNS result from brain lesions/stroke, PNS nerve compression from tumor, trauma, trigeminal neuralgia, long term ETOH use)(numbness, burning, shooting, tingling
4) PSYCHOGENIC: from emotional causes. often accompanied by depression
Type of Acute Pain
1) Cutaneous pain: skin/superficial (sharp, cutting, burning, localized) Throbbing when blood vessels involved
2) Deep somatic pain: injury to deep body structures (muscles, bones, ligaments, tendons, joints) Dull, diffuse
3) Visceral pain: from body organs lined w viscera. Deep, dull, poorly localized (nausea, vomiting, hypo tension, weakness)
* ** 4) Referred pain: unpleasant sensation starts onsite but perceived in another area distant from site and stimuli
*** Referred Pain
pain begins on one side but felt in another area. (i.e. inflamed gallbladder felt in shoulder. Angina form Ischemia of heart felt in left arm or jaw.)
Chronic Malignant Pain aka
Cancer Pain
pain resulting from Cancer disease. tumor pressing on nerves or other structures, stretching of Viscera, metastasis to bones)
Acute vs Chronic Pain:
Automonomic Responses
Autonomic Responses
ACUTE:
- UP BP, Pulse, Resp
- pupils dilated
- skin diaphoretic, pale, cool
CHRONIC:
- Vital signs normal
- pupils normal
- skin dry, warm, normal color
Acute vs Chronic Pain:
Psychologic Responses
Phsychologic Responses
ACUTE: Anxious, facial grimacing, guarding, crying
CHRONIC: depression, hopelessness, frustration
DOWN sleep and appetite
Allodynia
pain resulting from stimulus hat usually would not cause pain. (in neuropathic pain)
Phantom Limb pain
occurs after surgical or traumatic amputation of a limb. steel feel itching, tingling, pressure, burning or stabbing. may be due to stimulation of severed nerves at site of amputation. treatment often complex and unsuccesful
Types of Pain meds
- analgesics: releive/reduce pain
- nonopioids: pain releif NOT derived from Opium (Tylenol (analgesic w NO anti inflammatory effects, and NSAIDs)
- opioids
- adjuvant analgesics
NON Opioid / NSAIDs
MILD pain
Non steroidal anti-inflammatory drugs
ACT of peripheral nervous sytsem.
reduce pain by interfering w prostoaglandin synthesei. (ie.e aspirin, ibuprofen, ketorolac)
DO have an analgesic ceiling
Analgesic Ceiling
increasing dose beyond certain dose will NOT increase pain relief effect.
Opioids
MILD - SEVERE pain
derived from opium plant
analgesia by binding to opioid receptors in CNS (brain /spinal cord)
types: Agonist (morphine, hydromorphone, codeine) / Antagonists (buprenorphine, nalbuphine)
Adjuvent Analgesics
drugs with other specific used that provide analgesia in clients w chronic nonmalignant and cancer pain.
i.e.
Anticunvulsants for diabetic neuropathy and neuralgia
Antidepressants used to promote sleeping patterns
Systemic anesthetics for cancer pain
Corticosteroids for mestatic bone cancer pain
Giving Meds Safely - p155
review Table 8-3
** NOTE: Client teaching on Opioids: used to treat severe pain and unlikely to case ADDICTION
Routes of Pain Med administration
Oral Rectal Transdermal IM IV SubQ Intraspinal Nerve Blocks
Equianalgesic doses
See chart pg 156, Burke
different narcotics given by different routes have same analgesic effect
Surgery as a pain relief measure only performed when? Types
after all other methods have failed.
Cordotomoy: cut nerve. message doesn’t travel
Neurectomy: removal of nerve
Sympathectomy: destroy involved sympathetic nerve
Rhizotomy: sever dorsal spinal roots (relieve cancer pain of head, neck, lungs)
TENS unit
Transcutaneous Electrical Nerve Stimulation (Gate Control Theory)
relieve chronic benign pain and acute post-op pain. sends low voltage to muscles.
Relaxation Techniques
- Diaphragmatic breathing
- Progressive muscle relaxation (squeeze, release)
- Guided imagery
- mediation
Addiction
condition of seeking drugs habitually and of not being able to give them up without adverse effects
Physical dependence
occurs when body adapts to chemical substances over an extended period of time. abrupt cessation causes withdrawal
Prostaglandins
Released from damaged tissue
Afferent
Towards brain
WHITE MATTER
Efferent
Away from brain to limb
Grey matter
Why is pain beneficial?
Warns us of tissue damage
Factors affecting pain
- past experience w pain
- pain tolerance LOW because of stress, fatigue, anxiety
- pain tolerance UP when warm?
- ETOH - distration
- Spiritual Practice
The Meaning of pain has an affect on patient as well
child birth - baby (positive)
cancer - surgery (negative)
Lung cancer usually metastasises where?
Liver
PIGS
Lead container that radiation implant should be placed in w long forceps
How does Chemo work?
Targets rapidly dividing cells,
Cancer cells,hair, nails, bone marrow, gut lining
Anemia
LOW RBC
Neutropenia
Neutropenic Precautions
Common result of chemo
Low WBC
Precautions:
NO fresh fruit/flowers
NO farm
NO cat litter etc.
Anemia
LOW RBC
pale, SOB, easily fatigues
Blast cells
Young cells.
Blast affected disease happen mostly in your children
Retinoblastoma, eye
Glioblastoma, brain
Thrombocytopenia
LOW platelets
SYMP easily bruised bleeding gums occult bleeding petichea
Normal rates of
WBC
PLATELETS
RBC
Red blood cell count Male: 4.32-5.72 trillion cells/L*
(4.32-5.72 million cells/mcL**)
Female: 3.90-5.03 trillion cells/L
(3.90-5.03 million cells/mcL)
White blood cell count 3.5-10.5 billion cells/L
(3,500 to 10,500 cells/mcL)
Platelet count 150-450 billion/L
(150,000 to 450,000/mcL**)
Osteosarcoma
Bone tumor
Usually in kids, amputation
Cancer hotspots
Types of cancer common in certain areas
Oncology
Study of taking care of cancer patient
Tumor
Lump/swelling or abnormal cells
Neoplasms
Mass of abnormal cells
Benign
Malignant
Benign
Cels grow slower
Stays local
Well encapsulated
Respond to body controls
Malignant
- Not responsive to body controls
- Irregular shape
- Local necrosis
- Expands out
- Aggressive
- Create own blood supply by stimulating blood vessels to grow towards them
Metastasis
spread of malignant cells
Cause factors of Cancer
External: chemicals, radiation, viruses
Internal: hormones, chemo drugs, recreational drugs, immune conditions, inherited mutations
Risk factors for Cancer
Uncontrollable:
Heredity, age, gender, poverty
Controllable:
emotion, diet, weight, occupation, infection, drug/alch use, sun exposure, stress, cig smoking
Routine Cancer Checkups
- breast
- colon/rectum
- cervix/uterus
- prostate
Physiologic manifestations of cancer
- pain (acute, chronic)
- disruption of function
- hematologic alterations
- infection
- hemorrhage
- anorexia/cachexia
- stress
Psychologic manifestions
-stress, greif, guilt, fear, anxiety, powerlessness, isolation, body image, sex dysfunction
The ONLY way to diagnose cancer
Biopsy
Tumor ID by a,b,c?
- Classification: tissue/cell of origin
- Grading: amount of differentiation/rate of growth
- Staging: size and extent of disease
Staging System
TNM (Tumor, Node, Matastasis)
TUMOR:
0: no evidence of primary tumor
IS: in situ (no change, still confined orig site.)
T1,T2,T3,T4: degrees of tumor size
NODE:
0:
Staging Syste
see table 12-4
TNM (Tumor, Node, Matastasis)
TUMOR:
0: no evidence of primary tumor
IS: in situ (no change)
T1,T2,T3,T4: degrees of tumor size
NODE:
0: no abnormal regional nodes
N1,
Goals of Medica Treatment
- eliminate tumor or malignant cells
- prevent metastasis
- reduce cellar growth and tumor burden
- promote functional abilities and provide pain relief
Cancer treatments
-surgery
- radiation therapy: internal/external
- chemo
- bio therapy/ immunotherapy
- bone marrow transplant
- complementary therapies
-
Oncological Emergencies
- periodical effusion and neoplasticism cardiac tamponade
- superior vena cava syndrome
- sepsis and septic shock
- spinal cord compression
- obstructive uropathy
- Hypercalcemia
- hyperuricemia
- tumor lysis syndrome
77% of cancer cases occur after age…
55
Most frequent cancer in women
breast
most frequent cancer in men
prostate
Leading cause of cancer deaths in men and women
lung
How does cancer metastasize?
malignant cells break away from the primary tumor, traveling through blood or lymph to invade other tissue.
*** Most common sites of metastasis
1 -lympth
then
liver, lungs, bones, brain
Carcinogens
cancer causing agent, damage cellular DNA
how many mutations required for a malignant tumore cell to develop
6 or more mutations
Carcinogenesis
INITIATION and proliferation of mutant cell
PROMOTION of abnormal cell growth
PROGRESSION of the abnormal mutant cells to malignancy
Oncogenes
genes capable of promoting uncontrolled cellular growth, normally repressed
Angiogenesis
growth of new blood vessels within the tumor, tumor releases chemicals to stimulate blood vessel growth.
Causes of certain
VIRUS
HIV - lymphoma, Kaposi’s sarcoma
HEP B/C - liver cancer
HPV - malignant melanoma, cervical, penile, laryngeal CA
Hormones
Testorsterone - Prostate CA
Estrogetn - Breast CA
drugs Chemicals polycyclic hydrocarbons (micro plastic, nail salons, auto) Aflatoxins (fungus on peanuts) Nitrosamines Radiation
Causes of certain cancers
HIV - lymphoma, Kaposi's sacoma HEP B - liver cancer HPV - malignant melanoma, cervical, penile, laryngeal CA Hormones drugs chemicals
Tumor Markers
substances secreted by malignant cells, found in blood
- Cell surface proteins (CA125, CA19-9, CA50)
- Oncofetal antigens, AFP, CEA
- Cell Enzymes, PSA (prostate-specific antigen)
- ACTH, ADH
- uric
- antibodies to specific cancer antigens
Direct Visualization
fiberoptic flexible scope. invasive but allow inspection of organs
lungs
bronchoscopy
colonoscopy
cystoscopy
Direct Visualization
fiberoptic flexible scope. invasive but allow inspection of organs
non resectable tumor
cannot be removed
Brachytherapy
internal radiation - radioactive implant inserted into body
Types of Radiation
External, Brachytherapy (internal)
Adverse effects of radiation therapy
- Skin damage (blanching, erythema, sloughing)
- Ulcerations of mucous membrane (stomatitis, mouth)
- immuno supression, vulnerability to infection
- myelo suppresion (bone marrow suppression)
- gastrointestinal effects (nausea, vomiting, diarrhea, bleeding
- exudate in lungs (radiation pneumonia)
- fistulas/necrosis of adjacent tissue
Radiation Therapy
causes lethal injury to cellular DS. use to kill tumor, reduce size, decrease pain, relieve obstructin
Chemotherapy
disrupts malignant and rapidly dividing cells by interrupting cell metabolism and replication.
Box 12-7 Nursing care checklist for Radiation Therapy
p 276
.
CSF (colony stimulating factors)
or hematopoietic growth factors, given to rescue bone marrow after chemo
Epogen (promote RBC)
Neupogen - promote neutrophils
They regulate growth and differentiation of blood cells and use dot help reduce bone marrow suppression
side effects:
bone pain, fever, chill, anorexia, muscle aches, lethargy
CSF (colony stimulating factors)
or hematopoietic growth factors, given to rescue bone marrow after chemo
They regulate growth and differentiation of blood cells and use dot help reduce bone marrow suppression
side effects:
bone pain, fever, chill, anorexia, muscle aches, lethargy
*** Chemo Drug Classes
see Table 12-5, p277
Alkylating Agents Antimetabolites Antitumor Antibiotics Plant Alkaloids Hormones Hormone Antagonist Misc BIologic Response Modifiers
Biotherapy
use of meds that stimulate clients immune system to target and destroy cancer cells
Types of BMT (Bone Marrow Transplant)
Allogeneic - from healthy donor
Autologous - clients own marrow
Graft-Versus-Host Disease
in allogeneic donations, when immune cells of donated marrow identify the recipient as foreign body tissue. T cells in donation attack patients liver, skin, gastro tract
SYMTOMS
skin rash, sloughing, diarrhea, gastro bleeding, liver damage
Fever and sympathetic nervous system responses, such UP Pulse
UP Respiration
are common early signs of ?
Infection
Oncological Emergencies
Superior Vena Cava Syndrome: facial, arm edema, Perfusion and tracheal edema to resp distress - dyspnea - cyanosis - altered consciousness, neuro. Pericardial Effusion Cardiac Tamponade Sepsis Septic Shock
Superior Vena Cava Syndrome
Upper lobe LUNG CA.
-tumor puts pressure on SVC causing upper body extremity edema.
facial, arm edema, Pleural effusion and tracheal edema to resp distress - dyspnea - cyanosis - altered consciousness, neuro.
NURSE INT supply oxygen prepare for tracheostomy monitor VS administer corticosteroids prn to reduce edema safe env
Pericardial Effusion
Cardiac Tamponade
- collection of fluid in potential space betwen visceral and parietal pericardium
- develop secondary to lung or esophogeal CAs.
- compresses heart, restrict movement, resulting in Cardiac Tamponade.
Cardiac Tamponade:
- circulatory collapse or cardiogenic shock, hypotension, tachycaria, tachypnea, dypnea, cyanosis, increased central venous pressuer, anxiety, restlessness, impaired consciousness.
- Muffled heart sounds
NURSE INT
oxyen
respiratory therapy
reassure client
Sepsis/Shock
- bacteria entering the blood, grows rapidly, producing septicemia.
- related to gram- bacteria, progress to systemic shock - multiple system failure
SYMPTOMS Phase 1: Sepsis vasodilation hypovolemia high fever peripheral edema hypotension tachycardia, tachypnea (Kussmauls respiration) hot flushed skin creeping mottling beginning in lower extrem. ? anxiety restlessness
Phase 2: Shock hypotension rapid, thready pulse resp distress cyanosis LOW temp cold, clammy skin LO urine output altered mentation
NURS INT IV fluids monitor hemodynamics Oxygen cultures, wound drainage, urine, blood cultures antibiotics safe env
Sepsis
bacteria entering the blood, grows rapidly, producing septicemia.
related to gram- bacteria, progress to systemic shock - multiple system failure
Obstructive Uropathy
-pelvic malignancies, obstruction of the bladder neck or ureters
SYMPTOMS
urinary retention
ureteral obstruction
NURSE IMP
assess complaints of flank pain or urinary retention
monitor serum BUN, createinine, K
Urine culture
Obstructive Uropathy
-pelvic malignancies, obstructoin of the bladder neck or ureters
SYMPTOMS
urinary retention
ureteral obstruction
NURSE IMP
assess complaints of flank pain or urinary retention
monitor serum BUN, createinine, K
Urine culture
Hypercalcemia
when cancer metastisizes to bone and releases Ca
muscle weakness
fatigue, anorexia, polyuria, constipate
diminisedr eflex
can progress to physchotic behaviour
NURS INT
Ca, K, electrolytes, BUN, creatinine
VS
IV saline to increase urine
Tumor Lysis Syndrome (TLS)
metabolic abnormalities includeing lyperuricemia hyperphophatemia hyperkalemia hypocalcemia lactic acidosi
cardiac dys and renal failure
SYMP
heart failure, cardia dysrhytmias, seizures, muscle cramps, tetany, syncope, sudden death
NURSE INT
- identify client at risk: lymphomas, acute leukemia, eleveated serium uric acid, K, ph, impaired renal function
- hydration, urine
- Na bicarb
Tumor Lysis Syndrome (TLS)
metabolic abnormalities includeing lyperuricemia hyperphophatemia hyperkalemia hypocalcemia lactic acidosi
cardiac dys and renal failure
Wide Excision
when they didn’t get enough sample in the lab and they send back for more. They will biopsy a larger area.
If cancer does not moved it is …
In Situ
Centinel Node Biopsy
remove 1 or 2 axillary nodes on same side as procedure
Centinel Node Biopsy
remove 1 or 2 axillary nodes on same side as procedure
Why do kids usually get blast cell CAs
because cancers require at least 6 mutations to manifest, children haven’t had that many mutations yet.
Stages of Prevention
Primary Prevention: education, prevention
Secondary: screening, early detection
What do Sharks, the Heart, the Spleen have in common?
They don’t get cancer
Kubler Ross 5 stages
Denial Anger Bargaining Depression Acceptance
Kubler Ross 5 stages
Denial Anger Bargaining Depression Acceptance
Radical Masectomy
breast and muscle tissue
raddish/root
PET Scan
use radio-traced glucose to.
high metallic activity w absorb it. (CA)
First chemo drugs
vincristine
vinblastine
First chemo drugs
vincristine
vinblastine
Adriamycin (cardiotoxic)
call DR if any heart issues arise.
Breakthrough Pain
when patient being medicated yet pain breaks through pain med coverage.
‘Short Acting’ drugs are used to treat this.
given prn, or on a schedule if you recognize pattern in breakthrough pain occurrences.
Multiple Myeloma
CA of plasma cells
plasma cells make antibodies. In MM, they make Bence Jones proteins, that clog glomerulus.
Indicator of Multiple Myeloma, Bence Jones Protein
3 stages of Homeostasis
1) Vasoconstriction
2) Platelet Plug
3) Clotting Factors
3 stages of Homeostasis
1) Vasoconstriction
2) Platelet Plug
3) Clotting Factors
