Cancer Pt 1

chemo adverse effects- Anemia

(low red blood cells, hemoglobin, & hematocrit) · Normal RBCs: ~ 3.8 - 5.2 million/µL · Normal Hgb: ~ 11.5-16.0 g/dL · Normal Hct: ~ 34.0-47.0 % · Causes extreme fatigue, pallor, dizziness, shortness of breath o Schedule activities with rest periods, o Energy-saving measures o Oxygen therapy o Erythropoietic medications (epoetin alfa) o Antianemic medications (ferrous sulfate) o Blood product administration

Cancer Antigens 15-3, 27-29

- Breast CA · Help dx liver CA · Staging monitor TX in women with advanced breast CA

CT scan for CA

- Can be done with or without contrast - Make sure they are not allergic · Ask if allergic to shellfish/iodine - Ask radiology tech the type of contrast used. - Can be oral prep or IV · Pref 20 or 18g in a vein that will not blow d/t high pressure - Do not wear jewelry, can cause glint - If any weird s/s from contrast, let nurse know ASAP · Difficulty breathing/swallowing, swollen tongue, itchy skin - Remain very still - Hydrate very well and then give contrast or withhold if poor renal fxn

LFT for CA detection

- Can indicate primary liver or metastasis to the liver.

what should a nurse screen for before completing imaging on a woman?

- Make sure they are not pregnant- need urine preg test - Radioactive tracer, contrast interact with breastfeeding - Make sure they are not breastfeeding prior to imaging

Skin biopsies

- Shave Biopsy · For basal or squamous cell skin cancers - Punch Biopsy · For deeper skin lesions

surgical tx for CA - cytoreductive (debulking)

removes part of the tumor and improves chances of success with other therapies

surgical tx for CA - curative

removing ALL at risk tissue

Oncologic Complications/Emergencies: SIADH

· Abnormal production of antidiuretic hormone (ADH) · Blood sodium becomes diluted · Normal serum sodium: 135-145 mEq/L o Low <135; usually 115-120 or even lower o Oliguria o Weakness o Muscle cramps o Decreased appetite o Fatigue o Can lead to pulmonary edema and heart failure o Weight gain · Treat with hypertonic saline

Oncologic Complications/Emergencies: Hypercalcemia

· Normal 8-10 mg/dL · High 10.5 mg/dL and above · Polydipsia, frequent urination · Stomach upset, N/V, constipation · Bone, muscle pain, weakness · Confusion, lethargy, fatigue, depression · Palpitations, fainting, arrhythmia (all rare) · Normal saline, furosemide, pamidronate, phosphates

chemo adverse effects - Nausea, Vomiting (Chemo-Induced Nausea & Vomiting (CINV) and Anorexia

· Ondansetron (Zofran) - Serotonin blocker · Mouth care · Assess for dehydration · Small meals · Remove tray cover before placing in front of patient · Cold foods are less smelly

what does cancer staging determine?

· Stage: Extent of cancer o Size of tumor o Spread to lymph nodes, other parts of body · Staging helps with o Understanding severity and chances of survival o Treatment planning o Identification of appropriate clinical trials · Cancer is referred to by stage at diagnosis, even if gets worse or spreads · Many staging systems

Where are stem cells found?

· Stem cell transplant: Peripheral blood · Bone marrow transplant: Bone marrow

What does the "T" stand for in the TNM staging system?

· T: Size and extent of main (primary) tumor. As number goes up, size goes up. o TX: Main tumor cannot be measured o T0: Main tumor cannot be found T1, T2, T3, T4: Size/extent of main tumor increases with number

Oncologic Complications/Emergencies: Sepsis

· Widespread infection · Triggers whole-body inflammation · Leads to septic shock and death

CBC, CMP for cancer detection

- Monitor patient status - Identify abnormal blood cell counts - Discover abnormal electrolyte levels

Beta-2 macroglobulin (B2M)

- Multiple myeloma, some lymphomas and leukemias · Is tx working? · Predict chances of recovery

What is teletherapy radiation?

- Patient will receive dosages daily for a set period - Skin is marked with permanent marker or tattoos to guide radiation equipment · Instruct patient to not wash these off · Has several adverse effects

chemo adverse effects - thrombocytopenia

- Platelets: Normal is approx. 150-450 K/µL (150,000-450,000/µL) - Bleeding, hemorrhagic cystitis (bleeding in the bladder) are main concerns · Implement fall precautions - like what? o Fall can lead to hemorrhage, stroke, or brain bleed o Make sure call light is within reach, do not get up without assistance (be on standby) · Implement bleeding precautions · Administer platelets · Other interventions? o Avoid IM injections, switch to another route, pause order, or discontinue o Do not shave with straight razor, use electric Soft bristle toothbrush

hormonal manipulation side effects: estrogens/progestins

- feminine manifestations in men · Facial hair thins · Facial skin smoother · Body fat moves · Gynecomastia · Testicular/penile atrophy · Bone loss · Irregular menstruation · Fluid retention · Breast tenderness · Increases risk for blood clotting

chemo adverse effects- Mucositis

- irritation of MM of upper GI from mouth to stomach and Stomatitis: mouth only · Prescribed mouthwashes provide anesthetic, antifungal, and coating properties · Lubricating agents for xerostomia · Gentle oral care o Rinse mouth with saline solution before and after meals o Avoid lemon glycerin swabs o drink at least 2L of water a day o Soft bristle toothbrush · Soft, bland foods · No alcohol, tobacco o Saline solution o Increase fluid intake, ensure, protein o Avoid carbonated beverages, eat cold foods/popsicles for relief

hormonal manipulation side effects: androgens/antiestrogens

- masculinizing effects in women · Chest/facial hair · Menstruation stops · Breasts become smaller · Fluid retention · Acne · Hypercalcemia · Liver dysfunction

photodynamic therapy

· Photosensitizing Agent + Special Light = kills nearby cells · Specific photosensitizers and specific wavelengths are chosen to treat different areas of body · Photosensitizer is injected · Tumor is exposed to light 24-72 hours after injection; photosensitizer absorbs the light and produces a chemical reaction, destroying cancer cells · Usually outpatient · Can be repeated and may be used with other therapies

teletherapy adverse effects - dysgeusia

· altered taste o Avoid red meats, other distasteful foods; gums/mints; encourage experimenting with different flavors; plastic utensils; drink with meals

Biologic therapies: Molecularly Targeted Therapies

· Treatment that targets specific molecules involved in growth and spread of cancer · SE: rash, dry skin, nail changes, hair depigmentation, problems with blood clotting, wound healing, high BP; rarely GI perforation

Oncologic Complications/Emergencies: Superior Vena Cava Syndrome

Compression or obstruction of SVC; increased pressure causes edema

CA staging: Other

· 0 - Abnormal cells are present but have not spread to nearby tissue. Also called "carcinoma in situ" or CIS. CIS is not cancer but may become cancer · I, II, III - CA is present. The higher the number, the larger the CA tumor and the more it has spread to nearby tissue · IV - The CA has spread to distant parts of the body

Nursing Care for Biopsy- Pre op

· Answer questions · Review chart for signed consent · NPO as needed · Vital signs - baseline PT, platelet count, renal function as needed

what is included in neutropenic precautions?

· Assign the client a private room. Have the client remain in the room unless they need to leave for a diagnostic procedure or therapy. In this case, place a mask on the client during transport. · Protect the client from possible sources of infection (live plants, stagnant water, contaminated equipment). · Have client, staff, and visitors perform frequent hand hygiene. Restrict visitors who are ill. · Avoid invasive procedures that could cause a break in tissue (rectal temperatures, injections, indwelling urinary catheters) unless necessary. · Keep dedicated equipment (blood pressure machine, thermometer, stethoscope) in the client's room. · Administer colony‑stimulating factors (filgrastim) as prescribed to stimulate WBC production. · Follow agency policy regarding prohibitions of fresh flowers and plants in the room.

Biologic therapies: monoclonal antibodies (mAbs)

· Laboratory-produced antibodies used to mimic body's immune system · SE: fever, chills, weakness, headache, NVD, low BP, rashes, allergic reaction · High doses must be given in hospital

teletherapy adverse effects - alopecia

· Loss of hair in path of radiation o Therapeutic communication for self-esteem o Suggest wigs, hats, turbans

chemo adverse effects - Nadir

· Lowest point · Chemo: point at which blood cells counts are at lowest

what does the "M" stand for in the TNM staging system?

· M: Metastasis o MX: Metastasis cannot be measured o M0: Cancer has not spread to other parts of body o M1: Cancer has spread to other parts of body

Nursing Care for Biopsy- Post op

· May require post-op recovery · Monitor for bleeding, ensure adequate wound closure or dressing · Teach care of wound · When to follow up, signs and symptoms to look for that require immediate follow up · May require avoidance of coughing, lifting, or other limitations based on site

Nursing Care for the Patient Receiving Chemotherapy

· Monitor for and administer medications as needed for pain, other side effects · Implement interventions as needed for side effects · Perform medication reconciliation regularly · Address psychosocial needs · Provide patient and family education

teletherapy adverse effects - radiation injury to mucous membranes

· Mouth (see chemo) · Neck (Throat) o Mucositis causing difficulty swallowing o Small bites; soft, smooth foods, moisten dry foods; sit upright; small, frequent meals; high-calorie, high-protein foods · Abdomen (Stomach and Intestines) o Gastroenteritis (radiation enteritis) - Antidiarrheals, steroids, opioids, bland, lactose-free, low-fat diet, antibiotics

Nursing Care for Stem Cell/Bone Marrow Transplant

· Provide anti-rejection meds ·Protect from infection · Monitor for se or complications o GVHD o Graft failure o Infection o Hepatic veno-occlusive disease (VOD) o Interstitial pneumonitis

surgical tx for CA - reconstructive/rehabilitative

rehabilitative improves function, reconstructive improves appearance

surgical tx for CA- prophylactic

removing at risk tissue

Nursing Care for Biopsy- Intra op

· (only pertinent if you are the RN in the room) · Instruct patient proper positioning, talk patient through process · Administer moderate sedation, pain medications, antianxiety medications as needed · Monitor vital signs as needed

Nursing Care for Pt receiving biologics

· *Patients receiving high doses should be in ICU · Monitor for side effects · Promote comfort · Acetaminophen for fever · Meperidine (Demerol) for rigors · Antiemetics for N/V · What are nonpharmacological ways to promote comfort? · Identify neurological and psychosocial manifestations early · Apply unscented moisturizers to dry skin (if allowed); mild soap · Teach to protect skin from sun; sunscreen; avoid swimming · Do not use topical steroid creams on skin · Observe for allergic reactions

External Beam Radiation Therapy (Teletherapy) vs Internal Radiation Therapy (Brachytherapy)

· External Beam Radiation Therapy (Teletherapy) - Source of radiation is external to patient · Internal Radiation Therapy (Brachytherapy) - Source of radiation is within the patient Radiation is in direct, constant contact with the tumor

Mass/Lump, Infection, Inflammation Biopsy

· Needle Biopsy: o For many soft-tissue tumors and skin; fine (1:40) or core (1:30) o Tiny needle · Open Biopsy (surgical biopsy): o Incisional (1:00) (remove part) or Excisional (remove all) · Core biopsy o Small, hollow needle attached to syringe. Take a small amount of fluid from tumor, more lidocaine to area and longer time for bleeding to stop

what is the only definitive way to dx and determine the type of CA?

a biopsy

Alpha-fetoprotein (AFP)

a fetal protein that appears in the blood of adults with certain types of cancer - Liver cancer, ovary, testicles · Help dx liver CA · Staging · Is CA tx working? · Predict chances for recovery

prostate-specific antigen (PSA)

blood test to screen for prostate cancer · Prostate CA o Screening for Prostate CA o Help dx prostate CA o Monitor Tx Has CA come back after Tx?

surgical tx for CA - second look

do surgery after tx to determine if CA is improving or if tx should be continued

CA Grading- GX

grade cannot be determined

Biologic therapies: Interleukins vs Interferons

· Interleukins o Seek and destroy o SE: chills, fever, fatigue, confusion, NVD, low BP; rarely arrhythmias, chest pain o High doses must be given in hospital · Interferons o Slow cell division; boosts ability of immune cells to attack cancer cells o SE: chills, fever, headache, fatigue, loss of appetite, nausea, vomiting, low WBC, skin rash, thinning hair; rarely damage to nerves, include those in brain and spinal cord

lymph node biopsy

· Sentinel Lymph Node Biopsy o Use special dye (usually blue) to map out lymph nodes fed by tumor o Node(s) closest to tumor (sentinel node[s]) studied; if neg for cancer, other surrounding are assumed to be cancer free o If sentinel node(s) positive, all surrounding nodes are surgically removed (dissection) Look at closest lymph nodes to tumor to monitor for metastasis. If spread, worry about where else it has metastasized. If present, will take out all surrounding lymph nodes.

CA Grading- G1

· Cells are well differentiated; closely resemble normal cells from which they originated; malignant but slow-growing (low grade) Still look like normal cells.

Cancer Antigen 125

CA-125 - Ovarian CA · Is the CA tx working · Has CA come back after tx?

what should be avoided by patients who have neutropenia due to chemo?

· Avoid crowds while undergoing chemotherapy. · Take temperature daily. Report elevated temperature to the provider. · Avoid yard work, gardening, or changing a pet's litter box. Wear disposable gloves when working with house plants or doing outdoor gardening. · Discard liquid beverages that have been sitting at room temperature for longer than 1 hr. · Wash all dishes in hot, soapy water or a dishwasher. Wash glasses and cups after each use. · Wash toothbrush daily in the dishwasher or rinse in a bleach solution. · Do not share toiletry or personal hygiene items with others. · Report manifestations of bacterial or viral infections immediately to the provider

Oncologic Complications/Emergencies: Spinal Cord Compression

· Back pain - early symptom · Pain, weakness, loss of sensation, tingling · Loss of continence, constipation · Foot drop, unsteady gait · High-dose corticosteroids given to reduce swelling · Back brace may be worn

what does the "N" stand for in the TNM staging system?

· N: Nearby lymph nodes with cancer o NX: Cancer in nearby lymph nodes cannot be measured o N0: No cancer in nearby lymph nodes o N1, N2, N3: Number and location of lymph nodes containing cancer increases with number

MRI for CA

· Create highly detailed images · Make sure not pregnant or breastfeeding · NO METAL · Can use contrast o Gadolinium o Ask if they have a known allergy to MRI contrast Stay still, noise cancelling headphones

Oncologic Complications/Emergencies: Tumor Lysis Syndrome

· Hyperkalemia · Hyperuricemia (excess uric acid) · Hyperphosphatemia · Hypocalcemia · Can cause damage to kidneys, heart · Prevent with hydration o Goal is 3000-4000 mL per day as tolerated · Kayexalate · Allopurinol, rasburicase · Calcium

chemo adverse effects- Immunosuppression/neutropenia

· Absolute neutrophil count (ANC): normal is approx. 1500-8000µL) o <1000 and <500 · WBCs: normal is approx. 3-12 K/µL · Infection is main concern o What are some interventions we can implement? - Protective precautions (reverse isolation) · Full PPE · Wipe gloves with hand sanitizer · Avoid fresh fruit, veggies, and flowers · Along with stuffed animals, large amount of guests, children · Monitor temperature, white blood cell (WBC) count, and ANC. · Report a fever greater than 37.8° C (100° F) to the provider immediately.

what does unknown mean when staging CA?

There is not enough info to figure out the stage

chemo adverse effects- pancytopenia

· Low RBCs, WBCs, and platelets/H&H

Autologous vs. Allogenic Bone Marrow Transplant

· Autologous: Collected from the patient · Allogeneic: Collected from donor (relative or other matching person) o At risk for graft-versus-host disease o Rejection can occur anywhere in body

What does in situ mean?

Abnormal cells are present but have not spread to nearby tissue

what are the types of imaging used for CA detection?

X-Ray, CT, MRI, PET, SPECT

Oncologic Complications/Emergencies: Cardiac Tamponade

Needle inserted into pericardial sac to drain fluid - pericardiocentesis

surgical tx for CA - diagnostic

a biopsy

CA Grading- G2

Cells are moderately differentiated; have some characteristics of origin cell but more malignant characteristics (intermediate grade)

CA Grading- G3

Cells are poorly differentiated; tissue of origin can still be determined; few normal characteristics (high grade)

endoscopic biopsy

removal of a piece of tissue through an endoscope Usage of scope to visualize inside the body, take biopsies · Arthroscopy (joints) o Go into joint (i.e knee) · Bronchoscopy : (respiratory system) o Down into bronchus and into the lungs, pull out abnormal tissue for biopsy. · Mediastinoscopy, Thoracoscopy: (for body cavities) · Enteroscopy, Sigmoidoscopy, Colonoscopy :, etc. (small intestine, sigmoid, GI tract, etc.)

Genetic testing for cancer detection

· Identify presence of genes that are responsible for certain cancers are present · Positive results can indicate higher level of risk for developing that type of cancer

Oncologic Complications/Emergencies: DIC

· Often caused by gram-negative sepsis in patients with cancer · Underlying Disorder - > Systemic activation of coagulation -> Enhanced fibrin formation - > Microvascular thrombosis OR · Underlying Disorder - > Systemic activation of coagulation - > Consumption of platelets and clotting factors -> Bleeding

CA Grading- G4

Cells are poorly differentiated; retain no normal cell characteristic; determination of originating tissue is difficult or impossible (high grade)

surgical tx for CA - palliative surgery

not curative, doing so to improve quality of life

does biopsy need sedation?

o normally, localized numbing will be sufficient. o May require moderate sedation where they do not require a ET tube, need to be able to respond to commands o If large biopsy, will need full sedation/general anesthesia

stem cell/bone marrow transplant

restore stem cells that were destroyed by high doses of chemotherapy and/or radiation therapy Used to replace bone marrow destroyed by cancer or by chemo/radiation Transplanted stem cells are used to replace body's stem cells after bone marrow and stem cells have been destroyed

brachytherapy

the use of radioactive materials in contact with or implanted into the tissues to be treated · Placed in vagina, prostate, abdomen, IV · Body wastes are radioactive until isotope is eliminated from body · Nursing Considerations: o Private room, away from other patients o Place sign on door o Visits should be limited to 30 minutes; should always stay at least 6 feet away from patient o Anyone pregnant, trying to conceive, or under 18 should not come into contact with patient or body fluids o Lead apron when caring for the patient o Portable lead shield if available o Lead container and tongs should be in room o Wear a dosimeter Keep door closed as much as possible

SPECT

· Gamma ray admission from tracer · Highlight area of blood flow to organs to determine perfusion · Can see areas of bone healing and CA · Track progression of CA that has spread to the bones · Do not undergo if pregnant or nursing Cheaper and more readily available than PET scan

PET scan

· Nuclear medicine test · Make sure not pregnant · Use a radioactive tracer · Finds areas of Higher chemical activity/metabolic rate o Cancer will have a higher metabolic rate and glow under pet scan o Called a hot spot · CT is done first using contrast (unless contraindicated), followed by PET · Some CA might not show up, most solid tumors will show up · NPO prior to surgery, if glucose higher than 150 reschedule · Lie very still, noise cancelling headphones · Drink plenty of water

chemo adverse effects - Chemotherapy-Induced Peripheral Neuropathy

· Set of symptoms caused by damage to peripheral nerves · Can cause sensory or motor dysfunction · Early signs: numbness, tingling, redness · Later signs: loss of taste, orthostatic hypotension, constipation · Duloxetine may help · Teach to protect skin, prevent falls

Blood/Bone biopsies

· To remove some bone marrow and bone tissue · Usually retrieved from posterior iliac crest · Get a core of the tissue, will be liquid · Good for leukemia, lymphomas, CA that has metastasized to the bone from other areas, infection/inflammation, etc.

Chemotherapy

· Used when cancer has spread beyond a localized area · Different meds affect different stages in cell cycle o Represents different classes of chemo agents · Multiple routes can be used o Requires special education and certification · Usually administered through CVL o Usually, PICC or implanted port · Most successful when part of combination therapy · Most chemo drugs are cytotoxic and teratogens

what are the S/S of CA?

o Anorexia (unable to eat) o Weight loss, cachexia o Fatigue, lethargy, weakness o Pain o Masses

chemo adverse effects- Alopecia

o Due to rapidly growing cells being affected. · Self-image is affected; therapeutic communication needed · 7-10 days after onset of treatment · Hairpiece, wigs, turbans, etc. should be chosen before treatment starts · Temporary; starts growing ~ 1 month after stopping · New hair can be different

localized vs regional vs distant

o Localized: CA is limited to the place where it started, with no sign that it has spread o Regional: CA has spread to nearby lymph nodes, tissues, or organs o Distant: CA has spread to distant parts of the body

teletherapy adverse effects - extreme fatigue

o Schedule rest periods between activities, cluster care, sit during showers o Gentle exercise

Carcinoembryonic antigen (CEA)

Oncofetal glycoprotein antigen found in colonic adenocarcinoma and other cancers; also found in nonmalignant conditions. · Colorectal cancer, lung, thyroid, stomach, pancreas, breast, ovary Is CA tx working? Has CA come back after tx?

teletherapy adverse effects - radiation injury to the skin

o Wash with mild soap and water, pat dry o Soft clothing o Avoid sun and heat exposure o Only use creams/ointments prescribed; no powders

chemo adverse effects - Chemotherapy Extravasation

o Closely monitor IV infusions and provide immediate treatment for extravasation. Care includes identifying the antidote (neutralizing solution) for the specific medication the client is receiving. o IV administration can be dangerous to surrounding tissues. Use PICC line or central line for administration.

what are the S/S of CA metastasis?

o Discomfort elsewhere o Lymph node swelling, distant masses o Abdominal swelling o Bone pain, broken bones o Confusion or change in personality o Incontinence o Vision changes o Loss of balance o Headache, seizures