Oncology HURST Q Cards
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A client receiving chemo for lung CA reports increased fatigue. The family confirms client is sleeping most of day and night. What priority action would the RN take? 1 discuss risks of immobility w/ client and family 2 check current lab values of H/H 3 suggest family seek counseling for client's depression 4 request referral from HCP for physical therapy
2 check current lab values of H/H 1 not priority 2 CORRECT 3 RN is assuming depression 4 wrong action and does not solve problem *Chemo attacks RBC's making it difficult for client to make them, which are the cells that carry O2 throughout our body
**What information should the RN include in teaching an oncology patient the purpose of taking epoietin? 1 Emergency tx of anemia 2 Improves QOL 3 Used for prevention of pure red cell aplasia (PRCA) 4 decreases need for transfusion
4; Stimulates bone marrow to increase RBC production, which reduces need for transfusion 1 False, not fast enough 2 False, not proven to improve QOL 3 False- type of anemia following tx of epoietin; NEVER HEARD OF IT = NO ONE ELSE HAS 4 TRUE- treats low RBCs, or anemia
How to we treat neutropenia?
ABX Implement neutropenic precautions
Thrombocytopenia RF's
Advanced metastatic disease Hematologic malignancies Bleeding DO's Bacterial infections Anticoagulants- ASA, Colpidogrel (Plavix), Heparin, Warfarin (Coumadin)
Increased Incidence of CA
Aging over > 60 r/t weaker immune system and decreased ability for body to recognize CA cells
What are priority assessments for this client?
Airway Edema of neck *along with carotid artery and innominate artery rupture, as well as hemorrhage!!
CA invades in the bone marrow, which leads to...
Anemia Leukopenia Thrombocytopenia
Neutropenia
Assess ANC- tells you exactly how many of your WBCs are neutrophils and indicates how well your client can handle an infection
Mastectomy Education
Avoid procedures on arm of affected side for lifetime NO CONSTRICTION OF ANY KIND Wear gloves w/ gardening, no nail biting, monitor for small cuts, no sunburn Brush hair, squeeze tennis balls, wall climbing, flex/extend elbow to promote collateral circulation = prevent frozen shoulder
Bleeding Assessment
Bleeding hx VS Pulse O2, sats Change in LOC, HA, pupil changes Conjunctival hemorrhages Petechiae, ecchymosis, purpura Oozing from puncture site/surgical site Bleeding from rectum, ears, nose, or mouth *Give platelets via platelet transfusions!! -NEVER give cold platelets = liver will reject; Goal- room temperature platelets
Other Therapies for CA Pain Mgt
CAT- acupressure, acupuncture, cannabis, distraction, hydrotherapy, massage
S/S of CA
CAUTION Anemia, leukopenia, thrombocytopenia Unexplained weight loss or cachexia Fever Fatigue Pain
CAUTION
Change in bowel/bladder habits A sore that does not heal Unusual bleeding/discharge Thickening or lump in breast or elsewhere Indigestion or difficulty swallowing Obvious change in wart or mole Nagging cough/hoarseness
Unsealed Brachytherapy
Client AND body fluids emit radiation Radioactive for 24-48 hours
Sealed Brachytherapy
Client emits radiation, while body fluids are NOT radioactive Temporary or permanent implant close to or inside tumor i.e. Prostate CA = implantable seeds i.e. Cervical CA = vaginal implant
Preventative Screening for BOTH
Colonoscopy at age 50; then every 10 years Fecal occult blood annually
Total Laryngectomy
Example of curative surgery for CA w/ removal of vocal cords, epiglottis, and thyroid cartilage Results in permanent tracheostomy or laryngectomy, so we position them mid-Fowler's post-op NGT feeds to reduce pressure on suture r/t peristalsis, monitor drains, monitor for carotid artery and innominate artery rupture, provide oral care, bib for trach w/ discharge, humidified environment Use of electrolarynx for conversation
Chemotherapy
Excreted for 3-7 days after administration Vesicant drug that can cause necrosis if it infiltrates
General S/E's of CA and/or CA Tx
GI- N/V, Stomatitis, Diarrhea -Lasts 24-48 hours after tx -Give Ondansetron (Zofran) = serotonin receptor antagonist "tron" -Give Netupitant/palonosetron- oral combo antiemetic that prevents acute and delayed N/V from chemo -Antiemetics given first week of chemo -Give ginger, aromatherapy, CAT Integumentary- alopecia Hematopoietic- anemia, leukopenia, thrombocytopenia r/t bone marrow suppression -Concern for INFECTION Fatigue -Periods of rest, naps, limit visitation Pain -No ceiling on opioids = client dependent -Only limit dose due to s/e's not dose and time
Neutropenic Precautions
General precautions to prevent infection PLUS... ABX as prescribed VS at least every 4 hours Private room w/ door closed and posted sign Antimicrobial soap for hand washing No invasive procedures (IM, rectal exams/meds) Avoid indwelling caths or NGT if possible Limit use of acetaminophen (Tylenol)
RBC Transfusions
Given w/ symptomatic anemia Do not want Hb/Ht to drop below 8 g/dL and 24%
Internal Radiation (brachytherapy)
Internal, inside the body Pt emits radiation Sealed or unsealed
How can you prevent dislodgment of implant?
Keep client on bedrest Decrease fiber in diet (distends bowel = dislodge) Prevent bladder distension
Suspected Diet Causes of Cancer
Low fiber diet Increased red meat Increased animal fat Nitrites (processed meats) Alcohol Preservatives/additives
In what position should the client be placed?
Mid-Fowler's
Preventative Screenings Females
Monthly BSE Mammograms at age 40 Annual pelvic/breast exam Pap smear every 1-3 years
Preventative Screenings Males
Monthly BSE and TSE Digital rectal and PSA over age 50
Primary Prevention of CA
No smoking Exercise/good nutrition Maintain normal body weight Limit/eliminate alcohol Vaccine for preventable viral exposures- Hep B and HPV Avoid exposure to carcinogens - sun, smoke
How should client be fed post-op?
Once bowel sounds return and pt is not longer NPO, we initiate NGT feeds to protect suture line and reduce aspiration
External Radiation (tele therapy, external beam radiotherapy)
Outside of body, NOT radioactive S/E's limited to exposed tissues- erythema, shedding of skin, fatigue, pancytopenia (all blood components are decreased) NEVER wash off markings, use lotion on markings Protect site from sun and UV for 1 year after completion of therapy and provide good skin care
Extravasation
Pain Swelling, no blood return STOP infusion, send for extravasation kit, stay w/ client
Is the tracheostomy for this client temporary or permanent?
Permanent
Scenario: A client has just returned from surgery w/ a tracheostomy, post total laryngectomy for laryngeal cancer.
Rapid Fire Game
Radiation Precautions
Restrict visitors and limit each to 30 min/day Visitors must stay at least 6 ft away No visitors under 16 yo No pregnant visitors/nurses Flush toiled w/ closed lid 2-3x
Stem Cell Transplant
Stem cells are transplanted from blood stream
Bone Marrow Transplant
Stem cells are transplanted from bone marrow Stem cells are given into vein, like blood transfusion and over time they settle in bone marrow = produce healthy blood cells
T/F: Mastectomy No BP on affected side May wear a watch on affected side Wear gloves when gardening Keep affected arm at level of hear in post-op period No injections in affected arm No nail biting Avoid sunburn Have client avoid looking at incision Use affected arm to brush hair Flex/extend arm on affected side
TRUE No BP on affected side FALSE May wear a watch on affected side (unaffected side) TRUE Wear gloves when gardening *FALSE Keep affected arm at level of heart in post-op period (there may be swelling, so we want to ELEVATE affected arm) TRUE No injections in affected arm TRUE No nail biting TRUE Avoid sunburn FALSE Have client avoid looking at incision (encourage) TRUE Use affected arm to brush hair TRUE Flex/extend arm on affected side
T/F: Brachytherapy Given IV or PO Radioactive for 1 week RNs should only care for one implant client per shift Visitors must stay at least 6 ft away Clients may ambulate ad lib Decrease fiber in diet of client No pregnant visitors Client should have indwelling catheter RNs should always wear a film badge Visitors should stay no longer than 10 minutes Mark room w/ instructions for specific isotope
TRUE- Given IV or PO FALSE Radioactive for 1 week (24-48 hours) TRUE RNs should only care for one implant client per shift TRUE Visitors must stay at least 6 ft away FALSE Clients may ambulate ad lib (bedrest to prevent dislodgment of implant) TRUE Decrease fiber in diet of client TRUE No pregnant visitors FALSE Client should have indwelling catheter TRUE RNs should always wear a film badge FALSE Visitors should stay no longer than 10 minutes (30 minutes) TRUE Mark room w/ instructions for specific isotope
What anatomical structures are removed w/ total laryngectomy?
Thyroid cartilage, vocal cords, epiglottis
Why is frequent mouth care important for this NPO client?
To decrease bacterial count in mouth = risk for pneumonia
RF's for CA
Tobacco and alcohol Age Immunosuppression Heredity Exposure to chemicals, radiation Hormones Low fiber diet Red meat Animal fat Nitrites Preservatives/additives
Order of Handling Chemo Spill
Wash hands thoroughly w/ soap and water Get spill kit from wall in pt room Put on respiratory mask Put on chemo gown Put on 2 sets of gloves Put on goggles Use absorbent pads to wipe up spill
An oncology client w/ a Hickman catheter is being discharged to receive chemo via cassette pump at home. The RN is aware that discharge instructions should include what information? SATA. 1 always use 2 pairs of gloves when preparing chemo meds 2 discarded chemo cassettes and tubing can be placed in regular trash 3 used needles or syringes must be placed into plastic chemo receptacle 4 linens soiled w/ chemo drugs can be washed w/ regular laundry 5 waste is placed into chemo bags and picked up by medical supplies 6 regular home cleaning products are appropriate for spilled chemo meds
1, 3, & 5 1 TRUE 2 False - never in regular trash 3 TRUE 4 False - must be washed twice; removed from soiled linens for first wash 5 TRUE 6 False - chemo specific kit and clean at least 3x *Same precautions must be followed *Do NOT prep in areas where food is cooked *Double
**A homecare client w/ terminal CA is taking morphine sulfate and reports current dose is no longer relieving the pain. What would the nurse tell the client about increased discomfort? 1 the pain med will need to be taken consistently around the clock 2 a different pain med will need to be prescribed since addiction has occurred 3 as cancer spreads, pain med will no longer helps 4 a tolerance to current dose has occurred, so dose will need to be increased
1 False 2 False- no ceiling on opioids for CA patients 3 False- not accurate 4 TRUE- goal is pain control; morphine can result in tolerance w/ CA patient = increase dose or change medication *Do NOT confuse tolerance with addiction!!
Female client receiving chemo for breast CA reports vomiting, stomatitis, and 10 lb weight loss over past month. HCP orders an antiemetic and daily mouthwashes. When the home care nurse evaluates the client one week later, what change described by the client would best indicate improvement? 1 eating 3 meals/day 2 weight gain of 2 lbs 3 no further mouth pain 4 improved skin turgor
1 False- does not indicate improvement, could still be vomiting 2 TRUE- significant wt loss r/t vomiting 3 False- stomatitis is not reason for weight loss; secondary to vomiting 4 False- "improved" is too vague *Think OBJECTIVE data, like weight
Life-Threatening CA Complications
1 Neutropenia 2 DVTs 3 Thrombocytopenia
After completing several rounds of chemo, a client's lab results indicates severe neutropenia. Following admission assessment, what is RN's priority action for client? 1 Place hand washing sign on client's door 2 Avoid all venipuncture or IM injections 3 Have client wear mask when leaving room 4 Instruct client to use soft toothbrush
1 TRUE- best way to prevent infection 2 False- cannot avoid ALL venipuncture 3 False- hand washing takes priority 4 False- used for bleeding precautions/thrombocytopenia *Concern for INFECTION
While preparing to administer IV chemo the RN accidentally pulls the tubing apart, spilling the solution onto the floor. After clamping the tubing, what is the RN's immediate action? 1 use disposable towels to clean up liquid 2 obtain spill kit specific to this type of solution 3 complete an incident report for supervisor 4 call housekeeping to help clean up the floor
2 1 False, not acceptable for cleanup 2 TRUE 3 False, after cleanup and not immediate 4 False, do not call housekeeping = maintain staff safety
Normal ANC
2500-8000 cells/mm
DVTs
2nd leading cause of death w/ CA pts following infection *Worry about PE!!
**A client has been on the nursing unit for 2 hours following a retropubic prostatectomy for tx of prostate CA. Client is receiving a continuous bladder irrigation of NS infusing at 1000 ml/hr. Client's UO for past 2 hours is 410 mls. What interventions would be best for the nurse to initiate first? 1 inspect catheter tubing for obstruction 2 irrigate catheter w/ large piston syringe 3 notify primary healthcare provider 4 stop irrigation flow
4 stop irrigation flow 1 not first thing to do 2 not first thing to do; do not want to fill bladder up more 3 what would we say?? we did not perform intervention yet 4 catheter output should be at least the amount of irrigation input + clients actual UO = want to prevent further bladder distention, which is one of main causes of hemorrhage w/ post-op client
Reconstructive Surgery
i.e. mastectomy- worry about bleeding, monitor abdominal site if use of own tissue for surgery, monitor Hemovac and JP drains
Why is CA a big RF for development of a DVT?
prolonged bedrest, surgery, central line use, external compression of vessels by tumor, certain chemo drugs *Worry about PE!!