N372 Week 15 Hematology/Oncology

Survivorship Care

1. Prevention and Detection of new cancers 2. Surveillance for cancer spread, recurrence, or second cancers 3. Intervention for consequences of cancer and its treatment 4. Coordination among health care team to ensure survivor health needs are met - Immunizations, prevention, nutrition, etc

Nursing Care of Patient Receiving Radiation

1. Protect skin: Pt edu! 2. Follow radiation-oncology department's policy for skin care product use 3. Avoid skin irritation 4. Care for xerostomia (dry mouth) 5. Provide emotional support 6. Exercise and sleep interventions for fatigue 7. Risk for falls: Impaired bone density --> pathological fractures 8. Monitoring for S+S of bleeding (platelet levels) 9. Monitor nutritional status: Altered taste: Registered Dietician 10. Do not remove temporary ink markings

Surgery

1. Range of surgical intervention - Extent of disease - Actual pathology - Age and physical condition of pt - Anticipated outcomes/results 2. Prophylactic, Diagnostic (biopsy), Curative, Palliative, Reconstructive

Treatment Options

1. Surgery 2. Radiation 3. Chemotherapy 4. Bone Marrow Transplant 5. Others: Gene therapy, immunotherapy, hyperthermia

Chemotherapy

1. Tx of cancer with chemical agents 2. Used to cure and increase survival time 3. Interferes with cellular function and reproduction 4. Cytotoxic effects exerted on healthy cells and cancer cells 5. Systemic effects: Targets all fast-growing cells 6. Adjuvant therapy = Chemotherapy + surgery or radiation 7. Combination chemotherapy vs single agent 8. Goals: Cure, Control, Palliation 9. Most common routes PO and IV

Managing Nutrition

1. Weight loss can occur as a result of disease or treatment 2. Work closely with a Registered Dietician for food choices 3. Maintain weight and provide nutrients 4. Maintain diet high in protein and carbohydrates 5. Eat small, frequent meals

Prevention: Secondary

(Doesn't reduce cancer but reduces mortality rate; Early detection) 1. Yearly mammogram in women over 40 yrs 2. Yearly clinical breast exams (women > 40) and every 3 years (women 20-39) 3. Colonoscopy at 50 and then every 10 yrs 4. Yearly fecal occult blood in all adults 5. Prostate Specific Antigen (PSA) with or without Digital rectal exam (DRE) for all men > 50

Cancer Patho Review

1. Abnormal, unrestricted cell growth originating from normal tissue 2. Kills host through local invasion or distant spread (metastasize) 3. Multiple hit theory: Genes, environment, lifestyle 4. Classified by: - Origin - Manner of growth (benign vs malignant) 5. Types (carcinomas, lymphomas, leukemias, sarcomas) 6. Stages (I-IV vs TNM)

Side Effects of Radiation Therapy

1. Acute and long-term site-specifc changes 2. Vary according to site 3. Local skin changes and hair loss 4. Altered taste sensations 5. Fatigue 6. Bone marrow suppression

Nursing Interventions for Surgical Treatment of Cancer

1. Assess ability of pt/family coping and understanding of diagnosis/treatment 2. Changes in body image 3. Changes in roles 4. Encouragement and support for physical rehabilitation

Managing Nausea and Vomiting

1. Dry and salty foods 2. Ginger tea, ginger ale, other herbal teas 3. Small and frequent meals of easily digestible foods 4. Medication more effective --> Encourage pt to remain open relationship with healthcare team about anti-emetic meds BRAT diet (Bananas, Rice, Applesauce, Toast)

Identify whether the statement characterizes sealed, unsealed or both. 1. Emits radiation - wear dosimetry badge 2. Radiation has "spilled" into the patient's blood stream contaminating all body fluids 3. Once source is gone, there is no more radioactivity 4. Maximize distance, minimize time 5. Source is removed after a period of time 6. Do not remove anything from the room 7. Lead shields are used to block exposure 8. Urine, saliva and sweat are contaminated 9. Radiation in the body must dissipate over time

1. Emits radiation - wear dosimetry badge: BOTH 2. Radiation has "spilled" into the patient's blood stream contaminating all body fluids: UNSEALED 3. Once source is gone, there is no more radioactivity: SEALED 4. Maximize distance, minimize time: BOTH 5. Source is removed after a period of time: SEALED 6. Do not remove anything from the room: UNSEALED 7. Lead shields are used to block exposure: SEALED 8. Urine, saliva and sweat are contaminated: UNSEALED 9. Radiation in the body must dissipate over time: UNSEALED

Tumor Markers

1. Estrogen and progesterone receptors - ER +/- and PR +/- 2. Her-2 - Identifies ppl who might benefit from Herceptin and anthracycline-based chemo (adriamycin, daunorubicin, idaubicin) 3. CEA: Colon, stomach, lung, breast, ovary 4. CA 19-9: Pancreatic 5. PSA: Prostate 6. AFP: Hepatocellular 7. HCG: Germ cell tumors Limitations: 1. Most are found in low levels in normal cells, presence of markers might not be detected until tumor has spread 2. Tumor markers are known to sometimes generate false positives 3. Many tumor markers are not specific to a certain type of cancer

Appropriate Teaching Materials

1. Giving out teaching materials is not sufficient 2. Pts are often too tired or don't feel well enough to read the materials 3. Make sure they have options but don't overwhelm them 4.Use appropriate teaching methods for patient AND family

Managing Diarrhea

Often the result of infection, enteritis due to radiation, side effect of chemotherapy or immunotherapy Foods that can help: 1. Soluble fibers: bananas, applesauce, sticky white rice 2. Probiotics: Yogurt, kefir, tempeh, miso 3. Stay well-hydrated, and replace electrolytes 4. Use of medications

Health Care Provider Safety

Personal Protective Equipment (PPE) (Eye protection, masks, double gloves (or "chemo" gloves), non-permeable gown) - Wear PPE during *administration* of chemotherapy and safe *handling* of body fluids during and 48 hours after infusion

Immunotherapy Mechanisms

Process Targeted: Mechanism of Action Angiogenesis: Inhibition of tumor vascularization Apoptosis: Apoptosis inducers Signal transduction pathways: Specific blocking agents Tumor growth factors: Neutralizing antibodies or agents that block cell growth Altered immune function: Immune stimulation, dendritic cells, tumor-specific killer T cells Gene mutation: Gene replacement - p53, others

Nursing Care for Patients Receiving Chemotherapy

1. Identify risk vs actual problems 2. Monitor/treat: - Anemia - Thrombocytopenia - Neutropenia (7-12 days after treatment) 3. Ensure increased fluid intake 4. Monitor/treat N/V 5. Dietary modification 6. Pt edu 7. Adherence challenges for PO 8. Non-pharm treatments: Complementary modalities 9. Safe Handling: - Absorbed through skin and mucous membranes - Oral chemotherapy cannot be split or crushed 10. Central line care: CLABSI prevention 11. Encourage rest (sleep disturbances) 12. Bowel regimens 13. Monitor for cognitive changes

Immunotherapy related adverse effects (irAEs)

1. Immunotherapy works by disrupting the homeostatic mechanisms that regulate the immune system, causing an abnormal inflammatory response and the adverse effects you see 2. Varying susceptibility of pts to irAEs 3. Self-reporting of irAEs by pts can help with identifying 4. *Common Adverse Effects (toxicities):* Dermatitis, fatigue, musculoskeletal inflammation, endocrinopathies, colitis, neuro toxicites, Pneumonitis, Hepatitis, CAR-T related effects; *Many are organ specific inflammations and resemble autoimmune diseases* 5. *Treatments:* Immunosuppressants (steroids, chemotherapy, steroid-sparing immune-modulating agents)

Radiation Therapy: External Beam

1. Linear accelerator 2. Simulation

Prevention Strategies: Primary vs Secondary 1. Yearly Mammogram 2. Avoid high fat diet 3. Prophylactic mastectomy 4. Schedule your colonoscopy if you are over 50 5. Avoid smoking 6. Avoid multiple sex partners 7. Obtain vaccination for HPV 8. Remove suspicious moles 9. Avoid prolonged time in the sun

1. Yearly Mammogram: Secondary 2. Avoid high fat diet: Primary 3. Prophylactic mastectomy: Primary 4. Schedule your colonoscopy if you are over 50: Secondary 5. Avoid smoking: Primary 6. Avoid multiple sex partners: Primary 7. Obtain vaccination for HPV: Primary 8. Remove suspicious moles: Primary 9. Avoid prolonged time in the sun: Primary

Identify whether the behavior is appropriate or not appropriate for a pt on bleeding precautions 1. Patient shaving his face with his own razor because his girlfriend is visiting 2. "I need to put on my sneakers to go for a walk in the hall 3. Patient is asking if he can get his COVID vaccine while he is in the hospital 4. Patient is asking for a private conjugal visit with his girlfriend 5. Patient is using his soft bristled toothbrush 6. Patient is asking for an enema because he is unable to have a BM 7. "My nose is so plugged. Can I please have a tissue?"

Appropriate: 2. "I need to put on my sneakers to go for a walk in the hall 5. Patient is using his soft bristled toothbrush Not Appropriate: 1. Patient shaving his face with his own razor because his girlfriend is visiting 3. Patient is asking if he can get his COVID vaccine while he is in the hospital 4. Patient is asking for a private conjugal visit with his girlfriend 6. Patient is asking for an enema because he is unable to have a BM 7. "My nose is so plugged. Can I please have a tissue?"

Early Satiety and Lack of Appetite

Avoid foods that may suppress appetite: 1. Caffeine 2. Fatty, greasy foods which empty slowly 3. Large amounts of water and diet sodas Drugs that promote gastric motility may help: Reglan

Prevention: Primary

Avoid known or potential carcinogens: Sun exposure, tobacco Modify risk factors: 1. Alcohol use 2. High fat/low fiber diet 3. Multiple sex partners Removal of "at risk" tissues 1. Moles 2. Colon polyps 3. Breasts Chemoprevention: 1. Aspirin and Celebrex: Colon cancer 2. Vit D and Tamoxifen: Breast cancer Vaccination: 1. Gardasil and Cervarix: Human papilloma virus (HPV)

A client receiving radiation for head and neck cancer reports that the skin in the radiation field is itching and painful. What teaching will the nurse provide? A. "This is likely from medication, not the radiation treatment." B. "Cover the area with soft clothing." C. "Sunlight to the radiated area can help the skin heal." D. "Use a washcloth to rub the area clean with soap and water." E. "Remove the ink markings on the skin as soon as you have a chance to shower."

B. "Cover the area with soft clothing."

Differences btwn benign and malignant tumors

Benign: 1. Typical cell growth: Look more like tissue they came from 2. Slow growth 3. Slow or unpredictable progression 4. Expands and encapsulated (like a balloon, contained) 5. Rare reoccurrence 6. Rare other effects from tumor 7. Normal chromosomes Malignant: 1. Atypical cell growth: Look less like tissue they came from (Anaplasia) 2. Rapid growth 3. Forward progression 4. Infiltrates surrounding tissue 5. Common reoccurrence 6. Other side effects common 7. Abnormal chromosomes

Priority Complication by Site

Breast: 1. Hematoma 2. Lymphedema 3. Depression 4. Lost interest in sex 5. Self image 6. Metastasis 7. Death Brain: 1. Cerebral herniation 2. Hydrocephalus 3. Hemorrhage 4. Stroke 5. Coma 6. Death Bone: 1. Weak bones 2. Fractures 3. Hypercalcemia 4. Falls 5. Osteomyelitis 6. Metastasis Lung: 1. Respiratory failure 2. Mechanical ventilation pneumonia 3. Cardiopulmonary dysfunction

Seven warning signs: CAUTION

C - Changes A - A sore that doesn't heal U - Unusual bleeding T - Thickening or lump in the breast or elsewhere I - Indigestion or difficulty swallowing O - Obvious change in wart or mole N - Nagging cough or hoarseness

Complementary and Alternative Modalities (CAMs)

CAMs may include: 1. Music therapy 2. Reiki 3. Pet therapy 4. Art therapy 5. Healing touch 6. Aromatherapy 7. Therapeutic massage 8. Meditation 9. Yoga/Tai Chi Goals may include: 1. Disease prevention 2. Symptom relief (nausea, pain, anxiety, swelling, etc) 3. Stress reduction 4. Reduce or eliminate side effects of diseases or treatments 5. Control or cure diseases 6. Essentially to heal the WHOLE person --> holistic nursing

Managing Taste Alterations

Common complaints: 1. Foods taste metallic --> Stop using metal flatware, aluminum cans, etc, AND Keep mouth clean and rinse with baking soda in water before and after eating 2. Foods taste too strong --> Cool, bland foods AND Avoid food preparation and odors 3. Foods are bland --> Experiment with tart and spicy flavors AND Fresh fruit and vegetables

Herbal and Dietary Supplements

Concerns for cancer pts: 1. Blood thinning agent: Vitamin E, gingko, ginger 2. Blood clotting agent: Vitamin K, VItamin C, Coenzyme Q10 3. Interactions with chemotherapy: - St. John's Wort - Glucosamine and Cisplatin - High-dose antioxidants -Copper and TM

Radiation Therapy: Brachytherapy

HDR (Ex: To lungs, sends radiation to lungs in mins) vs LDR

Immunotherapy

How does it work?: Tumor cells bind to T-cells to deactivate them --> Immunotherapy drugs can block tumor cells from deactivating T-cells

Diagnostic Testing

Labs: 1. Tumor markers (CA-125) Radiological Tests: 1. X-rays 2. CTs 3. MRI (soft tissues, blood vessels, organs) 4. PET Scan (3-D image can reveal function) 5. Ultrasound Biopsy: 1. Only test to definitively confirm cancer malignancy 2. Bone Marrow Biopsy

Managing Mucositis

Mucositis Prevention: 1. Cryotherapy with ice chips can be used during chemo administration Mucositis Treatment: 1. Eat meals at room temp 2. Freq saline oral rinses (after meals and at bedtime) 3. Anesthetic meds (swish and spit) 4. Avoid mouth rinses containing alc 5. Brush teeth gently after meals 6. May use pain meds or topical analgesics 7. Use artificial saliva and water-based lubricant or lanolin to prevent dryness 8. Avoid tobacco or alc 9. Avoid spicy, dry, rough, hard or hot foods to protect mucosa 10. Keep dentures clean and well-fitting

Managing Constipation

Often a result of pain medications and side effect of chemotherapy Interventions: 1. High fiber foods like oatmeal and whole grain cereals 2. Adequate hydration 3. Light activity 4.Laxatives, stool softeners

Bleeding Precaution Patient Education

Pt should be on bleeding precautions when platelet count is <50,000 1. Notify your provider if you get injured or see blood in your urine, stool or vomit 2. Avoid IM injections, venipunctures, and invasive procedures 3. If necessary, hold prolonged pressure to injection sites 4. Use a soft bristled toothbrush 5. Avoid dental work 6. Avoid hard or hot foods that may injure the inside of your mouth 7. Use an electric shaver 8. Do not take aspirin 9. Wear supportive shoes for walking to avoid a fall 10. Avoid contact sports 11. Avoid trauma with intercourse, Avoid anal intercourse 12. Avoid enemas or rectal suppositories 13. Avoid activities that increase pressure in your brain 14. Take stool softeners to prevent straining with BM 15. Avoid blowing your nose

Internal Radiation (Brachytherapy) Sealed Sources Unsealed Sources

Sealed Sources: 1. Emits radiation: Wear dosimetry badge 2. Maximize distance, minimize time 3. Lead shields used to block exposure shielding) 4. Removed after designated time (except prostate seeds) 5. Ex: Gynecologic, prostate 6. Once sealed source is gone, no radioactivity Unsealed Sources: 1. Emits radiation: Wear dosimetry badge 2. Maximize distance, minimize time 3. Radiation has "spilled" into the pt's bloodstream, contaminating all body fluids 4. Saliva, urine, sweat is contaminated, Do not remove anything from room (linens, trays, garbage) 5. Examples: Thyroid 6. Radiation must dissipate over time

Expected Chemotherapy Adverse Effects (AE)

Serious Short-term AE: 1. Anemia (Decreased Hgb and Hct) 2. Neutropenia (Decreased WBC) 3. Thrombocytopenia (Decreased platelets) 4. Myelosuppression (Bone marrow suppression d/t low production) 5. Pancytopenia: All blood levels suppressed Common distressing AE: 1. Fatigue 2. Mucositis 3. Alopecia 4. Chemotherapy-induced nausea and vomiting (CINV) 5. Cognitive changes (Chemo Brain) 6. Chemotherapy-induced peripheral neuropathy (CIPN)

Infection Prevention Patient Education

Some level of neutropenia occurs in about half of ppl with cancer who are receiving chemotherapy; It is a common side effect in ppl with leukemia 1. Take temp at least once a day and when you do not feel well 2. Call right away if you develop a fever (Teach not to give Tylenol) 3. Know and understand your WBC count 4. If you go to the hospital, make sure you report that you are receiving chemotherapy and that you have cancer 5. Daily personal hygiene and handwashing is imperative 6. Inspect body and IV sites for infection 7. Do not visit with family or friends with symptoms of illness 8. Use food handling safety measures and try to avoid: - Tap water - Fresh fruits, vegetables, garnishes - Dried fruits and vegetables - Nuts - Salads, like coleslaw or egg salad - Pepper added after cooking - Aged cheeses, like blue, brie, and feta - Honey - Food served from a buffet

Tumor Staging (TNM)

T: Extent of primary tumor - Tx: Cannot be assessed - To: No evidence of tumor - Tis: in situ (confined to where it started) - T1-3 N: Nodal involvement - Nx: Cannot be assessed - N0-3 M: Distant metastasis - Mx: Cannot be assessed - Mo: No mets - M1: Distant mets

Managing Dry Mouth and Thick Saliva

Teaching interventions: 1. Stay well-hydrated 2. Use artificial saliva 3.Use mouth care products that contain no alc

Managing Peripheral Neuropathy

The loss of sensory perception or motor function of peripheral nerves associated with exposure to certain anticancer drugs Teach self management to prevent injury: 1. Always wear well-fitting shoes with protective soles (avoid heels, pointed toe shoes, minimize time in new shoes) 2. Inspect feet daily for open areas or redness 3. Test water temperature with washing dishes or bathing to prevent scalding 4. Use gloves while washing dishes or gardening to prevent injury 5. Maintain "Falls Prevention" activites 6. Get up slowly from lying or sitting position 7. Watch where you are walking to prevent tripping or falling 8. Avoid using area rugs that slide around 9. Keep floors free of clutter that could lead to a fall 10. Use handrails when going up and down stairs and in the bath or shower 11. Coordinate with Occupational Therapy as needed

A 26-year-old with acute lymphocytic leukemia received induction chemotherapy. The client's absolute neutrophil count is zero, the client has fatigue, and experiences mild nausea. Which nursing action is the highest priority? a.Administer antiemetics and assess nutrition and hydration status b.Limit contacts with infected visitors and place in positive pressure isolation c.Assess for sources of bleeding and provide pressure on wounds d.Monitor energy levels and begin energy conservating techniques

b.Limit contacts with infected visitors and place in positive pressure isolation

A 22-year-old received chemotherapy last week and calls the clinic to report a temperature of 101.9 F. Their ANC is 0.5. What is the most appropriate response by the nurse? a."You can take 2 Tylenol to reduce the fever but call again later if the fever does not go away." b."Please go to the lab right away so a CBC level can be determined." c."Do any of your family members or close friends have a fever at this time?" d."Please come to the clinic now so we might do further assessment."

d."Please come to the clinic now so we might do further assessment."