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Oncology
Fhp Adults Iv (NSG 404)
Misericordia University
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ONCOLOGY CANCER Neoplastic disorder. Can involve all body organs. Cells lose their normal mechanism, the growth of cells is uncontrolled. Produces serious health problems. TUMORS o o Characteristics Benign: of a mild type or character that does not threaten health or life Malignant: tending to produce death or tending to infiltrate, metastasize, and terminate fatally Metastasis Cancer cells move from their original location to other sites. Routes of metastasis: Local seeding: Distribution of shed cancer cells occurs in the local area of the primary tumor. o Ex breast seeding to lungs o This is a near structure metastasis: Tumor cells enter the blood, which is the most come cause of cancer spread. o Ex. Prostate cancer spread to brain and spine o Tumor cells enter blood stream Lymphatic spread: Primary sites rich in lymphatics are more susceptible to early metastatic spread. o Ex. Breast cancer spread through lymphatic system going to brain Common sites based on type Breast cancer o Bone o Lung o Brain o Liver Lung cancer o Brain o Liver Colorectal cancer o Bladder cancer o Lung o Bone o Liver o retroperitoneal structures (kidneys) Prostate Cancer o Bone o Spine legs o Lung o Liver o Kidneys Brain tumors o o Liver Central nervous system Testicular cancer o Lung o Bone o Liver o Retroperitoneal lymph nodes o Adrenal glands Knowing this can help identify symptoms that may be indicative of spreading or another active cancer after remission Classification Solid tumors Hematological cancers: 2 Associated with the organs from which they develop, such as breast cancer or lung cancer. Originate from blood tissues, such as leukemias or lymphomas. Classified the tissue or blood cells in which it originates. o Stage 1: Tumor limited to the tissue of localized tumor growth. No longer encapsulated however it has not moved much further than the one area o Limited local spread. Spread through local tissue Ex. Most of the breast area, maybe both UQ Stage 3: Extensive local and regional spread. Spread more o Ex. RUQ of breast Stage 2: o Ex. Breast tumor in one lobe of the breast Ex. Maybe whole breast and moving outward Stage 4: Metastasis Moved to other tissues Ex. Lymph node spreading the breast cancer to other areas. TNM Staging System Primary Tumor (T) o TX No primary tumor can be assessed o T0 No evidence of primary tumor o NX Cannot be assessed Small or hard to assess o N0 No regional lymph node involvement o N1, N2, N3 Increasing involvement of regional lymph nodes Distant Metastasis (M) o MX Presence of metastasis cannot be assessed 4 Regional Lymph Nodes (N) o Encapsulated in one area T1, T2, T3, T4 Increasing size and extent of the primary tumor Ex. Treated or removed so it cannot be seen TIS Carcinoma in situ o Ex. Tumor so small or in difficult location so it is hard to tell type, size, characteristics, etc. Ex. Whole belly is full of cancer o M0: No distant metastasis o M1 Distant metastasis Factors that influence Cancer Development Chemical carcinogen virus, Hep B virus, human papillomavirus Dietary factors Ionizing radiation, ultraviolet radiation, chronic irritation, tissue trauma Viral carcinogen Chemicals, drugs, tobacco Physical carcinogen o o high animal fat intake, preservative, additives, nitrates Genetic predisposition Trisomy 21 has a higher risk for leukemia More cell reproductions increase the risk for diseases and mutations Age Immune function HIV Elderly Immunosuppressant Decreased ability to mutations Early Detection Preventions Primary o 5 Vaccines, you do not have a disease yet but you are being given something to prevent the disease Secondary o You have a disease, identifying it early o Self exams Already have cancer or the lump, but you are aware of it and can get treatment Monthly o Mammography yearly after age 40 o test yearly after sexually active or age 18 o Stools for occult blood (OB) yearly after age 50 Indigestion or difficulty in swallowing Possible indication of thyroid cancer Obvious change in a wart or mole Nagging cough or hoarseness ONCOLOGY EMERGENCIES o o o Superior vena cava syndrome Obst. of SVC tumor or thrombosis. Radiation tx to site of obstruction SVC drains head of blood Could be caused tumor or thrombosis (greater risk in cancer patients due to breakdown of blood cells) Swelling (in the morning) of Tightness around collar of shirt sign) Swelling will go away with gravity once up out of bed Later o Dyspnea o Persistent facial swelling o Erythema of upper body o Epistaxis Cancer growing in spinal column or fractures that form in the spinal column from broken down cells Back pain Vertebral tenderness Neurological issues o Numbness tingling o Difficulty walking Third space syndrome Fluid shift from intravascular to interstitial space Peripheral edema Intestinal obstruction 7 Swelling in arms, hands Spinal cord intense back pain, vertebral tenderness. Tx radiation and corticosteroids, possible laminectomy o o Due to tumor growth or metastasis o Metabolic SIADH Treat with fluid restriction and treat the cause of the disorder Hypercalcemia Tx. Hydration loop diuretic (flush kidney) bisphosphonates (push Ca into bones) Due to the breakdown or lysis of the bone Treat like hyperparathyroidism Tumor Lysis Syndrome hyperuricemia, hyperphophatemia, hyperkalemia, hypocalcemia Breaking up the cells of the tumor Generally, it occurs when large amount of cancer cells are broken up and damaged from chemotherapy or radiation Broken cells release waste products (uric acid, phosphate (which affects Ca) and potassium) o o Fluids to flush Septic Shock and DIC 404 Infiltrative Emergencies Cardiac Tamponade Fluid accumulation in the pericardial sac, constriction of pericardium tumor or pericarditis. Drawing out fluid is a fix (pericardiocentisis) Tx. o Pericardial window o 8 O2, IV hydration, vasopressor therapy. Carotid artery rupture in presence of surgery apply pressure to area, IV fluid, blood products prior to emergency surgery surgical square cut out to allow drainage to go into the thoracic cavity which will be absorbed the blood stream and lymphatic system Can be external (like blood spurting out) or internal Saunders book? Talks about this o Antiplatelet aggregation (prevents clotting) Dose depending on dose SE: GI Bleeding GI upset Bruising All others Motrin (PO) (Ibuprofen, Advil) General dosing rules: 10 q hours prn Adult max: 3 hrs max: 40 Fluid retention Specific nursing Do not take any additional medications that contain ibuprofen, Motrin, or Advil o Aleve (Naprosyn) (PO) q 8 Diclofenac (Volterin, Cambia) (PO, Gel, Powder (Cambia)) SE: GI Bleeding GI upset Bruising o Percocet (Oxycodone and acetaminophen) o Vicoden (Norco) (Hydrocodone and acetaminophen) o Tylenol with codeine Number corresponds with the amount of codeine (1 has less than 2, 2 less than 3, etc.) 10, 15, 30, 60 mg of codeine Vicoprofen (Hydrocodone with ibuprofen) Narcotics o 10 Toradol (ketorolac) (PO, IM, IV) q 6 Combination o SE: Respiratory Depression Decreased HR, BP, RR Constipation Urinary Retention Drowsy, dizzy, euphoric Dry mouth o Increase in strength as you go down the list, except demerol o Codeine Sulfate Antitussive (cough suppressant) (in small doses) Antidiarrheal (in small doses) Morphine Sulfate Analgesic Good for cardiac and respiratory problems o o Decreases oxygen consumption of heart No ceiling dose (no max dose) Given almost any route (IV, IM, PO, subQ, sublingually, Suppository, lollipops, etc.) Demerol (meperidine) Breaks down into toxic metabolites that can cause activities (tremors) that can become seizures if untreated or dosing continues Dose not work very not really used for pain Good for preventing shivering in postoperative patients PO, IM, IV Dilaudid (hydromorphone) 10x stronger than morphine Wears off very quickly Good for patients with end stage organ failure because there are no toxic metabolites o Do not have them sign legal documents, preform dangerous tasks, drive, etc. o Get up slowly or call for assistance because of orthostatic hypotension o Gum, sugarless candy, ice chips, and fluids for dry mouth o Take with food to avoid GI upset o Fiber and fluids for constipation TREATMENTS o Chemotherapy SE: 11 Infection o From neutropenia o Avoid sick people, raw foods, o Avoid fresh flowers, pets o Avoid regular mouth washes (Listerine) o Avoid hot, spicy, acidic, or crunchy foods o Magic mouth wash o Radiation External Beam Radiation (tele therapy) Cages and molds help set the patient Run through with MRI to make sure it is set right Tattooed markers o Water and mild soap to wash over areas o Need to keep marking in place Radiation comes from outside source Patient does not emit radiation after treatment SE o Radiation burns o Fatigue, dehydration, decrease in blood cells o Changes in the area being treated Changes in mentation from center being affected. No heat, sun exposure, lotions, sprays, deodorant, etc. to that area Radiation source comes in direct contact with the cancer. o Ex. Cervical cancer, radioactive container in vagina to radiate the cervix o Ex. Radiation seed in the same area where the cancer is Radiation can spread to other people. The patient is radioactive. o Avoid children and pregnant women (within 6 feet of is bad) o Limit time with other people Bone Marrow Transplants o Ex. Brain Brachytherapy o Benedryl, Milk of magnesia, viscous lidocaine If there is an aplastic anemia or hematologic cancer Complications of treatment WBC disorders 13 Leukopenia and neutropenia o Leukocytosis Additional Drug therapy Colony Stimulating Agents Proteins that the growth, maturation, and differentiation of bone marrow stem cells. Made with recombinant DNA techniques. Do not directly kill tumor cells, but are still useful in cancer treatment. Erythropoietin (Procrit) darbepoetin alfa erythrocyte stimulant o Pharmacodynamics: stimulates division and differentiation of in the bone marrow to increase the number of circulating erythrocytes. o Pharmacotherapeutics: Treatment of anemia associated with cancer treatment, chronic renal failure, and that due to Acute Iron Deficiencies. o Side Effects: Generally, well tolerated. Occasionally, injection site SOB o Route: subcutaneous, IVP o Nursing Interventions: rub injection give at same time each MONITOR HEMATOCRIT Filgrastim (Neupogen) pegfilgrastim (Neulasta) (Neulasta Onpro) o Granulocyte colony stimulating factor o Pharmacodynamics: a recombinant DNA product that regulates the production of neutrophils (granular leukocytes) within the bone marrow. o Pharmacotherapeutics: To decrease the incidence of infection in clients receiving myelosuppressive (bone marrow suppressive) chemotherapy. o Side Effects: skeletal sore skin rash o Route: IV infusion o Nursing Interventions: 14 With too many RBC there is a polycythemia which causes most of these symptoms. Do not administer within 24 hours of chemotherapy as a new dividing white cells may be destroyed the chemotherapy. 16 Reconstructive or rehabilitative surgery is performed to improve quality of life restoring maximal function or appearance (ex: breast reconstruction after mastectomy CANCERS TYPES o Breast Cancer days after first day of period before performing breast exam because of hormonal changes. Look in Lewis book to see how many days it says (there is gonna be a test question about this) Secondary prevention Mammograms yearly after age 40, men and women Risk factors 17 Self examinations Gender Age Personal history Family history Secondary Risk Factors: o Nullipara never had a child o Giving birth to 1 st child after age 30 o Prolonged hormonal stimulation (menarche before age 12 and menopause after age 50) o Atypical hyperplasia o Exposure to excessive ionizing radiation (such as with disease treatment) o Hx of endometrial, ovarian, or colon cancer Pathophysiology BRCA1 BRCA2 genes linked to breast cancer. Breast cancer is more common in the left (UOQ) breast than the right and in the upper outer quadrant. Growth rates vary. Spreads via the lymphatics bloodstream. Painless lump or mass in the breast (on BSE) Asymmetry, with affected breast being higher Changes in breast skin: o Dimpling o Retraction (nipple is inverted) o Ulceration o Peau skin o Edema Pathophysiology Cigarette smoking. cervical cancer o ranges from minimal cervical dysplasia (the lower of the epithelium contains abnormal cells) o to carcinoma in situ (involves the full thickness of the epithelium). In invasive cancer, cancer cells penetrate the basement membrane and may spread to adjunct pelvic structures or to distant sites via the lymphatic system. Painless vaginal postmenstrual and postcoital bleeding or serosanguanous vaginal discharge Dysuria (painful urination) Hematuria Cytology changes on Pap Advanced disease may cause: o Pelvic pain o Vaginal leakage of urine and feces from fistula o Anorexia o Weight loss o Fatigue Tx Nonsurgical: o Chemotherapy o Cryosurgery Freeze top layer of cells and scrape away o External radiation o Internal radiation implants (intracavitary) o Laser therapy Surgical: o Conization o o Remove a pie shaped sliver from the cervix where the tumor was located Hysterectomy 19 From growing into bladder or bowel Removal of cervix and uterus Pelvic exenteration Taking out multiple abdominal organs (look these up) Posterior Anterior Ureter, bladder, uterus, cervix Total Ovaries, bowel, bladder, uterus, cervix Diversions such as Ileal conduit and ostomy must be placed. Interventions Provide comprehensive teaching and emotional support. If receiving internal radiation, determine if it is being placed in the operating room or at the bedside (afterloaded). Remember that safety precautions timing, distance, shielding must start as soon as the radioactive source is in place. Tell the patient she will require a private room. o 20 Bowel, uterus, cervix Radiation precautions Limit time with patients, use lead radiation jackets, and keep distance as best as possible. Pregnant women, children under 16, and women of childbearing age should not visit or take care of this person if they are a nurse Visitors must take same precautions Rotating care between nurses to reduce the amount of radiation everyone is exposed to Day to day and hour to hour differences Wearing the radiation badge to be aware of over exposure. Check VS q 4 hrs. Watch for skin reactions, vaginal bleeding, abd discomfort, and evidence of dehydration with internal radiation source. Make sure she can reach everything she needs without stretching or straining. Assist with ROM exercise. Some leg exercises may dislodge the radiation source. If ordered, give to help her relax and remain still to not dislodge internal radiation if used. Organize the time you spend with the patient to minimize your radiation exposure time. Inform visitors of safety precautions hang signs listing precautions on the door.