cancer chapter 6

cancer
a group of distinct diseases with different causes, manifistations, treatments and prognosis.
normally people older than 65, higher in men than women
1.5 million in US diagnosed every year
more than 560,000 die from a malignant process every year.
in order of frequency
lung, prostate, breast.
more deaths than heart disease in people younger than 85.
African Americans have less chance of survival due to exposure risks, economic, education, and access to health
etiology of cancer
viruses and bacteria
physical agents
genetics and familial factors
dietary factors
dietary factors
homronal agents
role of the immune system
virus and bacteria
think HPV (human papilloma virus)
virus gets into the genetic structure of a cell=cancer. accounts for 100% of cervical cancer, 80-90% anal cancer.
physical agents
sunlight and radiation
chemical agent
tobacco, 30% of cancer deaths,
strongly associated with cancers of the lung, head and neck, esophagus, pancreas, cervix, and bladder. Tobacco may also act synergistically with other substances, such as alcohol, asbestos, uranium, and viruses, to promote cancer development
genetics
cancers cluster in some families. This may be due to genetics, shared environments, cultural or lifestyle factors, or chance alone.
hormonal agents
disturbances in hormonal balance, either by the body’s own (endogenous) hormone production or by administration of exogenous hormones.
Cancers of the breast, prostate, and uterus are thought to depend on endogenous hormonal levels for growth.
role of the immune system
some evidence indicates that the immune system can detect the development of malignant cells and destroy them before cell growth becomes uncontrolled. When the immune system fails to identify and stop the growth of malignant cells, clinical cancer develops.
Patients who are immunoincompetent are more prone to cancer, transplant recipients who receive immunosuppressive therapy to prevent organ rejection have an increased incidence of lymphoma, Kaposi’s sarcoma, squamous cell cancer of the skin, and cervical and anogenital cancers.
cancer has presence by

1.A series of cellular and genetic changes that cause a loss of normal cell regulation; this is the hallmark of malignancy

2.Abnormal cell proliferation or growth

3.Unchecked local growth and invasion of surrounding tissue

4. The ability to metastasize to distant organs

cancerous cells have this in common
*Prone to mutations
*monoclonal origin of cancer (proliferates and doesn’t care whats around it)
*Pleomorphism: Cells vary in size and shape
*Polymorphism: Nucleus is enlarged and variable in shape
*Chromosomal mutations including translocations, deletions, amplification, and aneuploidy (abnormal number of chromosomes)
*Production of surface enzymes that aid in invasion and metastasis
Loss of antigens that label the cell as “self”
*Production of new tumor-associated antigens that label the cell as “non-self”
*Increased rate of anaerobic metabolism
*Loss of contact inhibition, which normally halts cell division once cells are in contact with one another
*Defect in cell recognition and adhesion (cancer cells do not recognize and adhere to each other as normal cells do)
*Loss of control of proliferation
Increased mitotic index: Tumors have a larger number of cells that are in mitosis
*Abnormal lifespan: Cancer cells tend to live longer than do normal cells
Tumor classifications
Tumors that are classified on the basis of the cell or tissue of origin are carcinomas, sarcomas, lymphomas, and leukemias.
Tumors classified on the basis of growth are described as benign or malignant.
benign tumors
cell characteristics
well differentiated cells that resemble cells in that tissue of origin.mode of growth
grow by expansion but don’t invade surrounding tissue

Rate of growth
usually progressive and slow. may just stop growing or even regress

metastasis
doesn’t spread by metastasis.

malignant tumors
cells or process have characteristics of cancer.
cell characteristics
undifferentiated, don’t resemble cells in the tissue of origin.mode of growth
it invades, infiltrates surrounding tissues, have abnormal regulation of growth. The cells continue to grow, even at the expense of their host.

Rate of growth
variable depends on differentiation. The more undefined the more rapid.

Metastasis
gets to blood and lymph channels so it can metastasize to other areas in the body.
It gains access to the blood and lymphatic channels

Malignant tumors metastasizes to other areas of the body. Cells of malignant tumors are undifferentiated. Malignant tumors demonstrate variable rate of growth; however, the more anaplastic the tumor, the faster its growth. A malignant tumor grows at the periphery and sends out processes that infiltrate and destroy surrounding tissues.

cell division
G0 PHASE
resting phase, inactive phase can be after mitosis or during G1 phase
G1 PHASE
RNA and protein synthasis
S PHASE
DNA synthasis
the cell creates 2 copies of its DNA in preparation for dividing
G2 PHASE
Premitotic phase; DNA synthesis is complete, mitotic spindle forms, goes through a 2nd growth phase and makes more proteins
M PHASE
or mitosis, the cell splits into 2 daughter cells/ cell division, mitosis happens more in malignant cells than normal cells
oncogenes and oncogenesis
Cellular oncogenes are responsible for the vital cellular functions of growth and differentiation, The cell cycle.
Cellular proto-oncogenes act as an “on switch” for cellular growth. When proto-oncogenes are mutated, cell growth and differentiation are stimulated.
tumor suppressors normally turn off uneeded cells proliferation. with cancer the suppressor gene is mutated and they just keep growing, this also effects mutation in apoptical signal so the mutated cell wont kill itself
carcinogenesis
“The two hit theory”
the process in which cancer arises.
Categories of agents or factors implicated in carcinogenesis include viruses and bacteria, physical agents, chemical agents, genetic or familial factors, dietary factors, and hormonal agents.
Carcinogenesis is a multistep process
initiation, promotion, progression, and metastasis
*initiation= Altered DNA
*Promotion=cell transformation
*progression=cells divide
*metastasis= tumor cells spread to body cavities via lymphatic and blood circulation
Metastasis
both lymphatic spread and Hematogenous spread.
the spread of malignant cells from the primary tumor to distant sites like body cavities, blood and lymphatic system.
Most commonly bones, lungs, liver, CNS
lymphatic spread
most common. Tumor emboli enter the lymph system. They either lodge in lymph nodes or pass between lymphatic and venous system.
Breast tumors normally metastasize via axillary, clavicular, and thoracic lymph channels.
hematogenous spread
malignant cells via blood stream. They attach to endothelium and attract fibrin and platelets and clotting factors to protect themselves from the immune system.
Angiogensis
cell gets new blood for survival. The cell releases growth factors like VEGF
Vascular endiothelial growth factor, they stimulate new blood vessels. There are therapies to combat the VEGF
3 goals with cancer
include complete eradication of malignant disease (CURE), prolonged survival and containment of cancer cell growth (CONTROL), or relief of symptoms associated with the disease (PALLIATION).
these options depend on tumor type, stage, grade, functional or performance status of the patient, organ function.
the most important factors are:
tumor type
performance status.
Performance status is used to quantify cancer patients’ general well-being and ability to perform daily activities
difference between primary and secondary prevention

PRIMARY PREVENTION

trying to reduce the risk by educating on avoiding known carcinogens.
Make dietary and lifestyle changes, daily use of tamoxifen can reduce womens risks.

SECONDARY PREVENTION
focus on early detection. cancer screening, mammograms, digital rectal examinations, and prostate-specific antigen (PSA) blood tests, pap test PSA levels

diagnosing cancer
*determine the presence and extent of tumor.
*identify metastisis
*evaluate body systems and organs
*obtain cells for path to allow tumor staging/grading
what should the treatment plan be for a patient
A number of factors are considered when determining a treatment plan, including the tumor type, stage, grade; functional or performance status of the patient.
Performance status is used to quantify cancer patients’ general well-being and ability to perform daily activities.
staging for cancer
Staging determines the size of the tumor and the extent of disease.
we use the TNM system
TNM
used for solid types of tumors.
T= extent of primary tumor.
N= the absence or presence and extent of regional lymph node metastasis.
M= The absence or presence of metastasis.for T=Tumor
TX= primary tumor cannot be assessd
T0= no evidence of primary tumor
TIS= carcinoma in situ (on site)
T1, T2, T3, T4 = increase in size/or local extent of the primary tumor

For N=Nodes
NX= regional lymph nodes cannot be assessed
N0= no regional lymph nodes metastisis
N1,2,3= increasing involvement of regional lymph nodes

M= distance of the metastisis
MX=distance metastisis cannot be measured
M0= no distance metastisis
M= distance metastisis

examples of staging
TNM classification.
Tumor size nodel involvement
nodol
matastasized.Stage I. This stage is usually a small cancer or tumor that has not grown deeply into nearby tissues. It also has not spread to the lymph nodes or other parts of the body. It is often called early-stage cancer.

Stage II and III. These stages indicate larger cancers or tumors that have grown more deeply into nearby tissue. They may have also spread to lymph nodes but not to other parts of the body.

Stage IV. This stage means that the cancer has spread to other organs or parts of the body. It may also be called advanced or metastatic cancer. You have nodol involvement.
hodgkins patient still has 80% chance of survival

Grading

refers to classification of the tumor cells, histology of the cell

GX cannot be assessed
G1 Well-differentiated (resembles tissue of origin)
G2 Moderately differentiated
G3 Poorly differentiated (little resemblance to tissue of origin)
G4 Undifferentiated (unable to tell tissue of origin)

Surgical treatment
DIAGNOSTIC SURGERY
biopsy, normally taken from the tumor and or lymph nodes near the tumor.SURGERY AS PRIMARY TREATMENT
remove entire tumor or as much as possible (debulking)
LOCAL EXCISION when mass is small, includes removal of the mass and small amount of surrounding tissue.
WIDE/RADICAL EXCISION.
includes removal of primary tumor, lymph nodes, adjacent structures, and surrounding tissue that may be at high risk of spreading. This can result in disfigurement or altered function.
PROPHYLACTIC SURGERY
removing non vital tissue or organs that are likely to develop cancer. family history, genetic predisposition,
positive BRCA1 or BRCA2 gene findings
presence or absence of symptoms.
examples are :
colectomy (resection of colon)
mastectomy (breasts)
oophorectomy (removal of ovaries)

PALLIATIVE SURGERY
cure is not possible but it can make patient comfortable. Ulcerations, obstructions, hemorrage, pain.
it relieves complications of cancer

nurses role and concern for surgery for cancer patients

Combining other treatment methods, such as radiation and chemotherapy, with surgery also contributes to postoperative complications, such as infection, impaired wound healing, altered pulmonary or renal function, and the development of venous thromboembolism (VTE), also known as deep vein thrombosis (DVT). Some cancer types result in an increase in circulating procoagulants, which can significantly increase the risk for DVT.

Approximately 50% of patients with DVT are asymptomatic. The nurse should inquire about an ache or pain in the calf, aggravated by standing or walking. In addition, it is important to assess for asymmetry of the limbs, as slight swelling may be noted as well as erythema and warmth of the involved extremity. Venous distention in the affected limb that persists despite elevation of the extremity may be noted. Patients may also present with low-grade fever and tachycardia.

BCG treatments
Bacille Calmette-Guerin
for bladder cancer,
When injected into the patient, these agents serve as antigens that stimulate an immune response. The hope is that the stimulated immune system will then eradicate malignant cells. Extensive animal and human investigations with BCG have shown promising results, especially in treating localized malignant melanoma. In addition, BCG bladder instillation is a standard form of treatment for localized bladder cancer
Radiation therapy
In radiation therapy, ionizing radiation is used to interrupt cellular growth. More than half of patients with cancer receive a form of radiation therapy at some point during treatment. Radiation may be used to cure the cancer, as in Hodgkin’s lymphoma, testicular seminomas, thyroid carcinomas, localized cancers of the head and neck, and cancers of the uterine cervix. Radiation therapy may also be used to control malignant disease when a tumor cannot be removed surgically or when local nodal metastasis is present, or it can be used prophylactically to prevent leukemic infiltration to the brain or spinal cord.
Palliative radiation therapy is used to relieve the symptoms of metastatic disease, especially when the cancer has spread to brain, bone, or soft tissue, or to treat oncologic emergencies, such as superior vena cava syndrome (SVCS) or spinal cord compression.
there are 2 types of radiation
treatment external radiation
*local targeted therapy designed to kill cancer cells that may still exist after surgery.
*Given to the area where the cancer started or to another part of the body to which the cancer spread.
*The actual delivery of radiation treatment is painless. But the radiation itself may cause some discomfort over time.
*Most common kind of radiation therapy
*Radiation will not make you lose your hair, unless radiation is given to your head
*skin can trun pink, red, or tan, and may be sensitive and irritate, peeling, ulcer.
*don’t lose hair unless it is around the head.
External radiation
If external radiation therapy is used, one of several delivery methods may be chosen, depending on the depth of the tumor. KILOVOLTAGE therapy devices deliver the maximal radiation dose to superficial lesions, such as lesions of the skin and breast, whereas LINEAR ACCELERATORS and BETATRON machines produce higher-energy X-rays and deliver their dosage to deeper structures with less harm to the skin and less scattering of radiation within the body tissues.
External Beam Radiation (Teletherapy)
*most common form of radiation therapy.
*patient is never radioactive
*Use fluoroscopy, the critical area is identified
*skin is marked so that the field can be reproduced on a daily basis.
*Patient is NOT radioactive.often used for palliation to control distressing symptoms can reduce tumor size

nusing considerations with external radiation
Because external radiation commonly causes skin irritation, the nurse should wash the irradiated area with water only and leave the area open to air. No soaps, deodorants, lotions, or powders should be applied.
internal radiation

Internal radiation implantation, or BRACHYTHERAPY, delivers a high dose of radiation to a localized area.

This internal radiation can be:

interstitial radiation=

implanted into or next to the tumor by means of needles, seeds, beads.
permanent brachytherapy pellets implanted for several weeks or months.

Intracavitary radiation=

Catheters into body cavities (e.g., vagina, chest, rectum, uterus. used a lot for gynecologic cancers.
The patient is maintained on bed rest and log-rolled to prevent displacement of the intracavitary delivery device. The head of the bed must not be elevated greater than 15 degrees due to the risk of perforating the uterus with the appliance. An indwelling urinary catheter is inserted to ensure that the bladder remains empty. This minimizes the exposure of the bladder to radiation. Low-residue diets and antidiarrheal agents, such as diphenoxylate (Lomotil), are provided to prevent bowel movements during therapy to prevent displacement of the radioisotopes. Pain management is also a priority for these patients, as the presence of the appliance can be painful. Patient-controlled analgesia is a common method used for pain management in this population.
Temporary brachytherapy are
cylinders, hollow needles, catheters, tubes, fluid filled balloons.

With internal radiation therapy, the farther the target tissue is from the radiation source, the lower the dosage. This spares the noncancerous tissue from the radiation dose and toxicity. Brachytherapy may also be administered orally, as with the isotope iodine-131, which is used to treat thyroid carcinomas.

radiation dose for patient
dependent on the sensitivity of the target tissues to radiation and on the tumor size. The lethal tumor dose is defined as the dose that will eradicate 95% of the tumor yet preserve normal tissue. With external radiation, the total radiation dose is delivered over several weeks to allow healthy tissue to repair and to achieve greater cell kill by exposing more cells to the radiation as they begin active cell division. Repeated radiation treatments over time (fractionated doses) also allow for the periphery of the tumor to be reoxygenated repeatedly, because tumors shrink from the outside inward. This increases the radiosensitivity of the tumor, thereby increasing tumor cell death
nurses role to educate patient about their radiation treatment
Use safety measures
provide education
explain procedure for radiation delivery.
Duration of procedure
restrictions placed on family if radioactive implants are involved.protect skin and mucosa.
patient should avoid using ointments, lotion or powder on treated area.
Clean with mild soap and fingertips not a wash cloth and gently pat dry.
Dont remove markings.
Emollients such as Aquaphor® may be used as directed by the radiation oncologist to soothe and moisturize irritated skin. However, even approved emollients should not be used up to 4 hours before the treatment time.
use electric razors
avoid constrictive clothing
avoid sun exposure, heating lamps, pads, ice packs may cause thermal injury.

advises the client undergoing radiation therapy to use a soft toothbrush and avoid electronic toothbrushes to avoid skin lacerations.

focus on nutritional status, and general feeling of well being

Internal radiation/brachytherapy caution
TIME, DISTANCE, & SHIELD
*Patient is radioactive
*radioactive materials directly placed in patient.
TIME= spend no more than 30 min with patient per 8 hour shift
DISTANCE= when not providing direct care stand 6ft from patient.
SHIELD=use a lead shield as a buffer
NURSING CARE*Have patient wear radiation badge.
*Follow policies such as double flushing toilet.
*private room
*post notices
*dosimeter badges
*no pregnant individuals
*no children visitors
*organize care outside of room when possible (meds)
*staff and family education
*emergency action if source dislodges

what to do in a radiation emergency
If the radiation implant becomes dislodged, the nurses’ first priority is to ensure the safety of the patient. Metal forceps and a lead-lined container should be available in the room. The nurse can use the forceps to pick up the radiation source and place the source into the lead-lined container. Once the source is contained, the radiation safety officer should be contacted immediately. The patient, nurse, and room will then be monitored for radioactivity using a Geiger counter.
side effects of radiation
alopecia hair loss
stomatitis/xerostomia dry mouth, change of taste.
esophagus irritation, chest pain, vomiting and diarrhea
sites containing bone marrow, ie illiac crest and sternum you may see anemia and leukopenia, decrease in wbc and thrombocyteopenia less platelets
antiemetic drugs
first thing to give for nausea and vomiting you can administer metoclopramide and dexamethasone as ordered.
to prevent renal damage
Encourage fluid intake, if possible, to dilute the urine
To prevent renal damage, it is helpful to dilute the urine by increasing fluids as tolerated
chemotherapy
In chemotherapy, antineoplastic agents are used in an attempt to destroy tumor cells by interfering with cellular functions, including replication. Chemotherapy is used primarily to treat systemic disease rather than localized lesions that are amenable to surgery or radiation. Chemotherapy may be combined with surgery, radiation therapy, or both, to reduce tumor size preoperatively (neoadjuvant), to destroy any remaining tumor cells postoperatively (adjuvant), or to treat hematologic malignancies such as lymphoma and leukemia. The goals of chemotherapy (cure, control, palliation)
Each time a tumor is exposed to a chemotherapeutic agent, a percentage of tumor cells (20% to 99%, depending on dosage) are destroyed. Repeated doses of chemotherapy are necessary over a prolonged period to achieve regression of the tumor. Eradication of 100% of the tumor is almost impossible. Instead, the goal of treatment is eradication of enough of the tumor so that the remaining tumor cells can be destroyed by the body’s immune system.
chemotherapy at the cellular level
chemotherapy drugs disrupt cell division. ie
cell cycle-specific agents
prevent the cell from making a copy of RNA and DNA, interferes at the S stage in the cell cycle.cell cycle-nonspecific agents
such as the vinca or plant alkaloids
prevent the cell from dividing into 2 daughter cells, it interferes with the M stage, mitosis stage.

Because cancer is cells dividing rapidly the medication hones in on these cells and is good at killing cancer cells.
Chemo can damage normal cells that are dividing this is what causes the side affects like hair loss.

cyrosurgery
Cryoablation, or cryosurgery, is the use of liquid nitrogen or a very cold probe to freeze tissue and cause cell destruction. It is used for cervical, prostate, and rectal cancers
chemotherapy
attacks rapidly dividing cells like
hairorgan system =Hair
cells affected =hair follicle
physical effect =alopecia

oral cavity
basal layer of epidermis
abnormal pigmentation nail dystrophy

lungs
type 2 alveolar epithelial cells
fibrosis

intestine
intestinal crypts
gut disorders

testes
spermatogonia
hypogonadism

bone marrow
progenitor stem cells
failure to produce blood cells

what does chemo do to normal tissue
chemo agents cannot distinguish between normal and cancer cells.
Body’s response to product of cellular destruction in circulation may cause fatigue, anorexia, and taste alterations:vomiting, allergic reactions, arrhythmias, mucositis, alopecia, bone marrow suppression

chronic toxicities damage to
heart, kidneys, liver, lungs

administering chemo
*oral
*IV most common, the concern is Extravasation (leakage of drug into surrounding tissue)
*Intracavitary =pleural or peritoneal
*Intrthecal
*Intraarterial
*IM
the methods can be
*continuous infusion
*subcutaneous
*topical
dosages of chemo for a patient

Dosage of antineoplastic agents is based primarily on the patient’s total body surface area, previous response to chemotherapy or radiation therapy, function of major organ systems, and performance status.

They use the Mosteller Equation for calculation of body surface area is the most commonly used formula in the United States

Mosteller Equation used for dosing how much chemo to give a patient.

Use BSA =body surface area

2 NURSES VERIFY DOSE
Mosteller Equation for calculation of body surface area is the most commonly used formula in the United States: square root of (height in cm × weight in kg) ÷3600Since chemotherapeutic medications have a narrow index of safety, it is recommended that dosage be determined using a standard
body surface area =(BSA) formula.
calculate the BSA using the Mosteller Equation (take the square root of height in cm × weight in kg ÷ 3,600).
there are 2.5cm in an inch so times the inches by 2.5

adminestering iv chemo
A nurse must wear disposable gloves and protective clothing to prevent skin contact with chemotherapeutic agents. The nurse should use a sterile gauze pad when priming I.V. tubing, connecting and disconnecting tubing, inserting syringes into vials, breaking glass ampules, or other procedures in which chemotherapeutic agents are being handled. Contaminated needles, syringes, I.V. tubes, and other equipment must be disposed of in a leak-proof, puncture-resistant container.
safety with chemo drugs
*Use a biologic safety cabinet for the preparation of all chemotherapy agents.
*Wear gloves that have been tested with chemotherapeutic agents when handling antineoplastic drugs and the excretions of patients who received chemotherapy.
*Wear disposable, nonabsorbent long-sleeved gowns with cuffs when preparing and administering chemotherapy agents.
*Use Luer-Lok fittings on all IV tubing used to deliver chemotherapy.
*Dispose of all equipment used in chemotherapy preparation and administration in appropriate, leak-proof, puncture-proof containers.
*Dispose of all chemotherapy wastes as hazardous materials.
infusion related issues
assess the patient for infusion-related events such as hypersensitivity and extravasation.
hypersensitivity
Common symptoms observed in patients experiencing hypersensitivity reactions range from flushing, rash, and anxiety to bronchospasm and hemodynamic collapse. Nursing response to HSRs includes stopping the infusion as soon as symptoms are observed; monitoring vital signs; maintaining a patent airway; administering oxygen as needed; maintaining a patent IV with running normal saline; administering emergency medications such as antihistamines, epinephrine, and corticosteroids as ordered; and providing emotional support to the patient. In most cases, the treatment can be safely resumed after the resolution of symptoms by infusing the agent at a slower rate
Extravasation

Special care must be taken whenever IV vesicant agents are administered

Vesicants are agents deposited into the subcutaneous tissue. (extravasation), cause tissue ulceration and necrosis, and damage to underlying tendons, nerves, and blood vessels.

pH of many antineoplastic drugs is responsible for the severe inflammatory reaction as well as the ability of some of these drugs (e.g., anthracyclines) to bind to tissue DNA. Sloughing and ulceration of the tissue may be so severe that skin grafting may be necessary. The full extent of tissue damage may take several weeks to become apparent.

while administering daunorubicin through a peripheral I.V. line the client hopefully won’t exhibiting signs of extravasation, which occurs when the medication leaks into the surrounding tissues and causes swelling, burning, or pain at the injection site.

Be concerned if:
*Absence of blood return from the IV catheter
*Resistance to flow of IV fluid
*Swelling, pain, or redness at the site, or if using a central venous access device, pain in the upper arm, upper back, chest, neck, or jaw

If extravasation occurs:
*The medication administration should be stopped immediately.
*The nurse should attempt to aspirate any residual drug from the IV line.
*If an antidote is indicated, the nurse should administer it immediately.

If frequent, prolonged administration of antineoplastic vesicants is anticipated, central venous access devices may be inserted to promote safety during medication administration and reduce problems with access to the circulatory system. Complications associated with their use include infection and thrombosis.

how chemo effects other body systems
it attacks any cells that have rapid growth rate/cell division such as:
epithelium, bone marrow, hair follicles, sperm, gi.
Nausea and vomiting are the most common side effects of chemotherapy and may persist for as long as 24 to 48 hours after its administration. Delayed nausea and vomiting may persist for up to 1 week after chemotherapy. The vomiting centers in the brain are stimulated by the following mechanisms
best action for nausea

give prescribed ondansetron (Zofran)

include serotonin antagonists, such as ondansetron, granisetron, dolasetron, and palonosetron, which block serotonin receptors of the GI tract and CTZ, and dopaminergic blockers, such as metoclopramide (Reglan), which block dopamine receptors of the CTZ. Newer agents include neurokinin-1 receptor antagonists.

Nausea and vomiting involve multiple pathways; therefore, corticosteroids, phenothiazines, sedatives, and antihistamines are helpful, especially when used in combination with serotonin blockers to provide improved antiemetic protection. Delayed nausea and vomiting that occur longer than 48 to 72 hours after chemotherapy are troublesome for some patients. To minimize discomfort, antiemetic medications may be necessary for the first week at home after chemotherapy.

chemo drugs
cyclophosphamide
paclitaxel
Central vascular access devices with
huber needle
*permit frequent, continuous, or intermittent administration.
can also be used to administer additional fluids.
MAJOR TYPES ARE:
*silastic right atrial catheters
*Implanted infusion ports
*infusion pumps
ommaya reservoir
used to give intrathecal chemotherapy through the skull because most drugs dont cross the brain barrier.
post administration : body fluids

found in urine, feces, sweat, vomitus, breast milk and seminal fluid

consider all bodily fluids as contaminated for at least 48 hours after completion of drug administration

cover toilets without a lid before flushing to avoid spray contamination. encourage use of toilet not urinal/bedpan

protect the skin incontinent patients

diapers can be conminated too

wear ppe when emptying foley catheters, urinals etc

post administration linen
prevent exposure use plastic backed disposable pads under incontinent patient.
Wash linens twice.
normal levels prior to cancer therapies
CBC
rbc differential 4200-5900
hemoglobin men 14-18g/dl
hemoglobin women 12-16g/dl
hematocrit men 42%-52%
hemotocrit women 37%-47%
platelets 150,000-400,000mm3
WBC 4300 to 10,800
SEGS 40%-70% (mature)
Band 0%-3% (babies)
neutrophils 40%-60% 1500-8000ANC =SEGS+BANDXWBC

side effects of chemo
#1 reason treatment held is
(myelosuppression
Suppression of bone marrowwhich is leukopenia, neutropenia, and thrombocytopenia,
anemia)

When neutrophils get down to 1500 may hold treatment

leukopenia
WBC= body should have 4300-10800
decrease in circulating wbc
less than 4300

neutropenia

common problems 32 min

neutrophils =
body should have 1500-8000
40%-60% of your wbc count.
decrease in neutrophils
increased risk for infection
can be dose limiting due to toxicity
Neutropenia is an abnormally low ANPRisk of infectionR/T decreased resistance secondary to neutropenia/leukopenia

Neutropenic precautions begin when
ANC less than 500
neutropenia levels
mild =ANC<1000
moderate=ANC<500
profound=ANC<100
Neutrophills
ANC<1,500/mm3: treatment is held
ANC<1000/mm3: threshold of moderate severity with increased risk of infection. Watch them closely
ANC<500/mm3 they should be on neutropenic precautions such as:
hand hygeine
no raw foods, fruits and flowers,
they wear the mask.
NEUPOGEN
BRM
colony stimulating factors

Give them this as the 1st line of defense along with antibiotics.

give this to patient to boost neutrophills.

Decreases risk of infection with patients with neutropenia.

neutropenia concerns
7-14 days NADIR
Nadir is when patient has lowest amount of WBC RBC neutrophils and platelets.if they have ANC <500 and temp above 100.4 neutropenic fever 38.0 degree cellcius.
iv antibiotic within 2 hours.
Ask when was there last dose.

Calculate the ANC

Evidence Based Interventions
recommended for practice with neutropenic patients

adherence to general published infection control recommendations is crucial for all patients with cancer

Hand hygiene with soap and water or alcohol-based hand rubs is the most effective means of preventing transmission of infection.

BRM colony stimulating factors (CSFs) (example neupegen)

CLABSI
central line associated blood stream infection.
central venous catheter care bundles of interventions are recommended

Patient education for neutropenia:
*vaccines
*get flu vaccine prior to treatment
*medication adherence
*crowds
*foods
*no animal care

nursing alert neutropenia
For African American adults, normal levels are 3,200 to 10,000 cells/mm3.
nursing alert neutropenia fever
Fever is often the only sign of infection in immunocompromised patients. Although fever may be related to a variety of noninfectious conditions, including the underlying cancer, any temperature of 38.0°C (100.4°F) or higher is reported and addressed promptly.
Thrombocytopenia low platelet count
platelet counts 150,000-400,000
thrombocytopenia <150,000
start being concerned<100,000
<50,000 moderate risk of bleeding,you may be able to put a central line in but patient probably won’t be cleared for surgery
<40,000 don’t floss
<20,000 severe risk, increased risk of spontaneous bleeding, ie nose bleed.
avoiding use of a blood pressure cuff or tourniquet below 20,000
<10,000 severe hemorrhage.
under 10,000 be concerned about inracranial and gi bleeds.complication thrombocytopenia, a decrease in the circulating platelet count, is the most common cause of bleeding in patients with cancer and is usually defined as a count less than 100,000/mm3. The risk of bleeding increases as the count drops lower. The risk of spontaneous bleeding occurs with a count of less than 20,000/mm3.

*A client with a platelet count less than 40,000/mm3 is at risk for bleeding and shouldn’t floss his teeth.
*Using an electric razor is appropriate because doing so helps minimize the risk of cutting when shaving.
*Taking a stool softener helps decrease potential trauma to the GI tract that may cause bleeding. Removing throw rugs from the house helps prevent falls, which could lead to uncontrolled bleeding.

Platelet count of 60,000/mm3 may indicate that bleeding is occurring

assessment for Thrombocytopenia

Ecchymosis (bruising)

petechiae- itchless rash, no itch but you have little red bumps.

bloody nose- epistaxis,
coughing up blood-hemoptysis,
bloody vomit -hematemisis
bloody poo -melena
bloody urine- hematuria
vaginal bleeding

prolonged bleeding or oozing around wounds and vascular lines.

precautions with a patient with
Thrombocytopenia
medications to avoid are:
no injections of any kind
no asprin
no NSAID’s ie, ibuprophen, maybe a little tylenol.
avoiding use of a blood pressure cuff or tourniquet below 20,000
no anticoagulants
decrease activity so not to hemorage.
use soft toothbrushavoid drinking alcohol
no rugs so you don’t fall

anemia

Erythropoietin stimulating agents (ESAs) stimulate RBC production.

decrease in red blood cells, 02 sats.

treatment for BRM biological response modifier therapy
use of agents or treatment methods that can alter the immunologic relationship between the tumor and the host to provide a therapeutic benefit.
BRM colony stimulating factors (CSFs) (example neupogen, given to cancer patients who are neutropenic)
treatment for hormonal
Bind to hormone receptor sites that alter cellular growth, inhibit RNA synthesis
mucositis/stomatitis
treat with salt and soda
bicarbonate and soda
stomatitis inflammation of oral cavity.
mucositis is whole gi tract.all the way through the gi tract. pain and diarrhea.
respiratory issues it can impair airway.
inflamed membranes and C/O sorenes, may need iv treatment.

oral exam
level of comfort
swallowing ability
taste ability
diet and nutrition

complications of cancer
1.Superior vena cava syndrome because of obstruction by tumor
manifestation include:
*Facial edema
*distention of neck and chest veins
*seizures
*headache2. spinal cord compression
presence of malignant tumor in epidural space.

3. Sensory parasthesia and loss
4. Autonomic dysfunction
5. change in bowel or bladder function

emergencies
SVCS
Superior vena cava syndromespinal cord compressions

cardiac tamponade
fluid tumors pushing against heart.

TLS
tumor lysis syndrome
(monitering electrolytes

hypercalcemia

DIC
disseminated intravascular
coagulation.

SIADH syndrome of inappropriate secretion of antidiuretic hormones

SVCS emergency
Superior vena cava syndrome because of obstruction by tumor
manifestation include:
*Facial edema
*distention of neck and chest veins
*seizures
*headache
spinal cord compression
emergency

happens when cancer grows in, or near, the spine and presses on the spinal cord and nerves. Any type of cancer can spread to the bones of the spine, but MSCC is more common in people with breast, lung or prostate cancers, lymphoma, or myeloma.

manifestations include:
*intense, localized, persistent back pain.
*motor weakness and dysfunction.

cardiac tamponade
Cardiac tamponade is an accumulation of fluid in the pericardial space
oncologic emergency involves the accumulation of fluid in the pericardial space.
NURSING INTERVENTIONS FOR CARDIAC TAMPONADE
• Assessment for pulsus paradoxus
• Maintaining the oxygen saturation of over 92%
• Teaching the patient how to use pursed-lip breathing
• Assessment for pulsus paradoxus which is ( is an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. When the drop is more than 10 mm Hg, it is referred to as pulsus paradoxus).
TLS
tumor lysis syndrome
emergency
Tumor lysis syndrome is a rapidly developing oncologic emergency that results from the rapid release of intracellular contents as a result of radiation- or chemotherapy-induced cell destruction of large or rapidly growing cancers such as leukemia.
your patient will have hyperkalemia, hyperphosphatemia, and hyperuricemia.nursing treatment:
aggressive hydration, Nursing considerations include strict monitoring of urine output and intake, monitoring of weight changes, and assessment of signs and symptoms of electrolyte disturbances.

hypercalcemia
emergency with chemo
because of calcium coming out of the bones patient will have too much and this affects the kidneys, kidney failure
DIC
disseminated intravascular
coagulation.
emergency with chemo
it is both overbleeding and overclotting. so you may see bleeding and clotting.
no first response.
treatment both heparin and replacing blood clotting factors
SIADH syndrome of inappropriate secretion of antidiuretic hormones
emergency with chemo
too much ADH is excessively released over stimulation of the hypothalamus due to chemo.
decreased urine output
fluid overload
give antineoplastics
the rationale for administering allopurinol for a patient receiving chemotherapy?
It lowers serum and uric acid levels
Adequate hydration, diuresis, alkalinization of the acid crystals, and administration of allopurinol (Zyloprim) may be used to prevent renal toxicity.
chemo and sexuality for women
Following chemotherapy female clients may experience normal ovulation, early menopause, or permanent sterility. Clients are advised to use reliable methods of birth control until reproductivity is known
What to do if a nurse is administering a chemotherapeutic medication to a client, who reports generalized itching and then chest tightness and shortness of breath
The client may be experiencing a type I hypersensitivity reaction, which may progress to systemic anaphylaxis. The most immediate action of the nurse is to discontinue the medication followed by initiating emergency protocols
nursing alert
A normal Serum albumin is 3.5 to 5.2 g/dL or 35 to 52 g/L, and gives the clinician a quick assessment of protein stores. In a seminal study by Seltzer et al. (1979), a sixfold increase in mortality was seen with an albumin level of less than 35 g/L, while additional studies associate serum albumin levels of less than 30 g/L with significant morbidity and mortality regardless of patient age and diagnosis (Agarwall, Acevedo, Leighton et al., 1988; Gibbs, Cull, Henderson et al., 1999). However, since albumin is degraded over 14 to 21 days, it is not a good measure for assessing recent nutritional deficits. Prealbumin has a half-life of 2 days and therefore is a better measure of response to dietary treatments. The normal reference range for prealbumin in males is 19 to 37 mg/dL, and in females, 17 to 31 mg/dL
receiving three different chemotherapeutic agents
Multiple drug regimens are used because the drugs have a synergistic effect. The drugs have different cell-cycle lysis effects, different mechanisms of action, and different toxic adverse effects. They are usually given in combination to enhance therapy. Dosage is not affected by giving the drugs in combination. The second and third drugs do not increase the effectiveness of the first.
HSCT
treatment for HSCT
either autologous, allogeneic, & syngeneic
hematopoietic stem cell transplantation
taking stem cells from donor to patient.
multiple complications
nursing management focuses on:
vital signs
assessing for adverse effects:
fever, chills, shortness of breath, chest pain, hives, nausea, vomiting, hypotension or hypertension, tachcardia, anxiety and taste changes
bone marrow and stem cell transplantation
ALLOGENEIC= related or unrelated preferably a sibling
*infused bone marrow acquired from donor to matched recipient.
*goal is to administer large doses of systemic therapy.
*then replace bone marrow through engraftment and subsequent normal proliferation and differentiation of donated marrow.
bone marrow transplantion
AUTOLOGOUS
comes from your own bone marrow prior to chem treatment and harvested.
*goal is to administer large doses of systemic therapy
*Rescue bone marrow
Marrow is removed, treated, stored, and reinfused.
*Less risky than allogeneic but may have higher relapse rate due to undetected cells in marrow.
bone marrow transplantation
SYNGENEIC
from an identical twin.
concerns for patients who have just undergone a bone marrow transplant
Until transplanted bone marrow begins to produce blood cells, these clients have no physiologic means to fight infection, which makes them very prone to infection. They are at high risk for dying from sepsis and bleeding before engraftment. Therefore, a nurse must closely monitor clients and take measures to prevent infection. Monitoring client’s toilet patterns, physical condition, and heart rate does not prevent the possibility of the client getting an infection.
Monitor patient for at least 3 mths
Fatigue

activity intolerance R/T impaired oxygen transport AEB diminished RBC count and C/O fatigue

you can have them
exercise
likely to be effective
???????????

alterations in comfort pain

Acute or chronic or nausea

factors that decrease tolerance of pain and discomfort

procedure/treatment related
uncertain o

what to do to help with pain
assess
pain meds before treatment or procedure.
take at first sign of discomfort.
reposition
hot cold packs
mobility excercisewhat to do for
NAUSEA
give antiemetics prior to chemo/radiation
eliminate orders
eat small frequent meals
eat bland and chilled foods.

end of life
palliative care preceeds hospice
goals
relieve symptoms
work toward patient goals
assist with advance planning to help prepare patient and family for expected deathHospice
promote dignity and quality of life during the dying process, rather than provide curative treatments to prolong life.

vaccines related to cancer
Autologous vaccines are made from the patient own cancer cells, which are obtained during diagnostic biopsy or surgery. Prophylactic vaccines, such as polio vaccine, are given to prevent people from developing a disease. Therapeutic vaccines are given to kill existing cancer cells and to provide long-lasting immunity against further cancer development. Allogeneic vaccines are made from cancer cells that are obtained from other people who have a specific type of cancer.

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