Cancer

Antimetabolites

1. "counterfeit metabolites" 2. impairs cell division

Motor and sensory deficits caused by cancer or chemo

1. Compression of nerves 2. Thinning of bone, increasing fracture risk 3. pain from bone metastasis 4. peripheral neuropathy from chemo 5. chemo brain - altered cognition

Most common side effects of Multikinase inhibitors

1. Hypertension 2. nausea, vomitting, diarrhea, constipation 3. mucositis 4. mild neuthropenia/thrombocytopenia

Three classifications of the TNM cancer staging

1. Primary Tumor (T) 2. Regional Lymph Nodes (N) 3. Distant Metastasis (M)

Teach chemo patients with mucositis to follow these mouth care guidelines

1. Soft-bristled toothbrush or mouth sponge 2. rinse with plain water or saline frequently 3. rinse after meals, at bedtime, increase to every 2 hours then to 1 hour 4. avoid alcohol mouthwash 5. keep oral hygiene equipment clean 6. dentures in only at meals

Drugs that promote purine excretion

1. allopurinol 2. rasburicase 3. febuxostat

Acute side effects of radiation on the brain

1. alopecia, radio dermatitis of scalp 2. ear irritation 3. cerebral edema 4. nausea and vomiting 5. somnolence syndrome

Two common side effects common regardless of the radiation site

1. altered taste sensations 2. fatigue

Acute side effects of radiation on the abdomen and pelvis

1. anorexia 2. nausea and vomiting 3. diarrhea and proctitis 4. cystitis 5. vaginal dryness/vaginitis

Nerve-damaging drugs that can cause chemotherapy-induced peripheral neuropathy (CIPN) include

1. antimitotics 2. platinum-based drugs

Nursing priority for patients receiving BRMs

1. assess for complications of systemic inflammation

important care for patients with diarrhea

1. assess peri area - clean and dry 2. hydration status - electrolytes (potassium, mag)

Late side effects of radiation on the breast and chest wall

1. atrophy 2. fibrosis of breast tissue 3. lymphedema

Molecularly targeted therapy

1. biologic agents that target specific cancer cells 2. have less impact on normal cells

Thalidomide

1. biologic response modifier 2. reduces VEGF, which is needed to maintain blood supply to the tumor, causing malnourishment to the tumor and death of cancer cells

What preventive drug therapy is given to reduce infection risk in patients receiving chemotherapy?

1. biological response modifiers (BRMs) 2. growth factors to stimulate bone marrow production of immune cells

For patients with SIADH monitor for these signs of fluid overload

1. bouding pulse 2. JVD 3. crackles in lungs 4. increasing peripheral edema 5. reduced urine output

interferons

1. cell-produced proteins 2. slow tumor cell division 3. stimulate growth and activation of NK cells 4. cause cancer cells to resume normal function/appearance 5. inhibit oncogene expression

Extravasation management may include

1. cold compress to area 2. warm compress to area 3. antidote injection

Monoclonal antibody therapy

1. combines actions from immunotherapy and targeted therapy to help treat specific cancers 2. target specific antigens, bind to them 3. prevent cell division 4. make tumor cells more sensitive to chemo

superior vena cava syndrome

1. compression or obstruction of the thin walls of the superior vena cava by tumor growth or clots leading to congestion

Low spinal compression can cause

1. constipation 2. incontinence 3. difficulty starting, stopping urine

Effect of chemotherapy on blood components

1. destroys circulating blood 2. reduces replacement due to bone marrow suppression 3. reduces circulating leukocytes, erythrocytes, platelets 4. causes neutropenia, hypoxia, increased risk for infection, fatigue, impaired clotting 5. extreme risk for sepsis

Topoisomerase inhibitors

1. disrupt enzyme essential to DNA synthesis and cell division 2. leads to DNA breakage and cell death

Important considerations for oral chemotherapy

1. do not skip doses - can cause resistance 2. nurses wear PPE equipment 3. biohazardous - discard according to policy

Teaching points for patients with fatigue

1. encourage light exercise to promote energy 2. treat reversible causes such as anemia and depression 3. fatigue journal of when most tired, active periods 4. rest before important activities 5. do not ignore fatigue 6. nutrition - high calorie, high protein foods (yogurt, small amounts packed with calories)

Nursing priority for drug therapy with patients taking antiemetics for CINV

1. ensure adequate control to prevent uncontrollable nausea and vomiting 2. make sure given before chemotherapy 3. teach patient to continue even when CINV seems to be controlled

These biological response modifiers are used as supportive treatment for chemotherapy induced anemia, fatigue, and renal failure

1. epoetin alfa (epogen procrit) 2. darbepoetin alfa (aranesp)

Acute side effects of radiation on the chest and lung

1. esophagitis and pharyngitis 2. taste changes 3. pneumonia

What are the three interacting factors that influence cancer development?

1. exposure to carcinogens 2. genetic predisposition 3. immune function

Results of sepsis and disseminated intravascular coagulation

1. extensive bleeding from multiple sites 2. clots blocking vessels, decrease blood flow 3. pain 4. strokelike manifestations 5. dyspnea 6. tachycardia 7. reduced kidney function 8. bowel necrosis

These biological response modifiers are used as supportive treatment for chemotherapy induced neutropenia

1. filgrastim (neupogen) 2. Pegfilgrastim (Neulasta)

Interventions for patients with SIADH

1. fluid restriction 2. increased sodium intake 3. drug therapy

Side effects of TKI (Tyrosine Kinase Inhibitors)

1. fluid retention 2. electrolyte imbalances 3. bone marrow suppression

Side effects of interleukins

1. generalized inflammatory reactions 2. fluid shift, capillary leak 3. edema *flu-like symptoms

interleukins

1. help regulate inflammation and immunity (these are large group of substances the body makes) 2. can be synthesized as anticancer drugs

Biologic response modifiers (BRM)

1. help the body recognize cancer cells as foreign so the immune system will destroy them 2. improve immune function 3. enhance ability to repair and replace cells damaged by cancer treatment

Interventions for TLS

1. hydration - dilutes potassium levels and increases kidney flow rates 2.

Angiogenesis inhibitors side effects

1. hypersentivity 2. hyperglycemia 3. bone marrow suppression 4. anemia, neutropenia, thrombocytopenia

Growth factors to stimulate red blood cell and platelet production comes with these risks:

1. hypertension 2. blood clots 3. strokes 4. heart attacks

Most common side effects of vascular endothelial growth factor/receptor inhibitors (VEGFRIs)

1. hypertension 2. impaired healing 3. bone marrow suppression, neutropenia, thrombocytopenia

Antimitotic agents

1. interferes with microtubule formation and action 2. mitosis

Two common types of BRMs used as cancer therapy

1. interleukins 2. interferons

Tumor lysis syndrome

1. large numbers of tumor cells are destroyed rapidly 2. intracellular components release in bloodstream faster than can be eliminated 3.

CIPN commonly results in

1. loss of sensation in hands and feet 2. orthostatic hypotension 3. erectile dysfunction 4. neuropathic pain 5. loss of taste discrimination 6. severe constipation

Side effects of hormonal manipulation

1. masculinizing effects in women 2. stop in menstruation 3. breast tissue shrinks 4. fluid retention 5. acne 6. hypercalcemia 7. liver dysfunction 8. increased risk of venous thromboembolism

Grading of Malignant Tumors: G2

1. moderately differentiated 2. retain some of characteristics of normal cells 3. have more malignant characteristics than G1

These aspects of personal hygiene cannot be deferred for neutropenic patient, even if the patient is very tired and does not feel well.

1. mouth care 2. washing of axillary and perineal regions *should be performed every 12 hours

Most common side effects of proteasome inhibitors

1. nausea 2. vomitting 3. anorexia 4. abodominal pain 5. bowel changes 6. decreased taste sensation 7. peripheral neuropathy

Manifestations of spinal cord compression

1. neurologic changes 2. back pain 3. muscle weakness 4. heaviness in arms, legs 5. numbness, tingling in hands or feet 6. inability to sense hot or cold 7. unsteady gait 8. paralysis

Interventions for hypercalcemia

1. oral hydration 2. normal saline when IV hydration needed 3. loop diuretics to promote calcium loss in urine 4. dialysis for life-threatening hypercalcemia 5. bisphosphonates, calcitonin, oral glucocorticoids

Acute side effects of radiation on the head and neck

1. oral mucositis 2. taste changes 3. oral candidiasis 4. oral herpes 5. acute xerostomia (dry mouth) 6. dental caries 7. esophagitis and pharyngitis

Extravasation with vesicants can lead to

1. pain 2. tissue loss 3. infection

nursing priorities for patients with SIADH

1. patient safety 2. restoring normal fluid balance 3. supportive care

Late side effects of radiation on the heart

1. pericarditis 2. cardiomyopathy 3. coronary artery disease

Grading of Malignant Tumors: G4

1. poorly differentiated cells 2. retain no normal cell characteristics 3. difficult or impossible to determine tissue of origin

Grading of Malignant Tumors: G3

1. poorly differentiated cells 2. tissue of origin usually can be established 3. few normal cell characteristics

Precautions taken with patients receiving sealed radiation implants

1. private room with private bath 2. "Radioactive Material" caution door sign 3. lead shield at door, keep door closed 4. carry dosimeter during care 5. lead apron worn during care 6. no pregnant women or visitors under 16 7. half hour visits only 8. 6-foot distance from source 9. Dressings/linens removed after radioactive source is removed

Priority care during chemotherapy

1. protecting patient from life-threatening side effects 2. management of distressing symptoms

Priority care for patients who have undergone cancer surgery

1. psychosocial support* 2. assist patient achieve maximum function* 3. early mobility 4. pain management 5. prevention of infection

Advanced cancers often cause

1. reduced immunity and blood-producing functions 2. altered GI structure and function 3. motor and sensory deficits 4. decreased respiratory function

Effect of SIADH on blood

1. retained water dilutes blood sodium levels 2. weakness, muscle cramps, loss of appetite

Oncologic emergencies

1. sepsis and disseminated intravascular coagulation 2 . syndrome of inappropriate diuretic hormone 3. spinal cord compression 4. hypercalcemia 5. superior vena cava syndrome 6. tumor lysis syndrome

severe complications of hypercalcemia

1. severe muscle weakness 2. loss of deep tendon reflexes 3. paralytic ileus 4. dehydration 5. electrocardiographic changes

Benefits of BRM supportive therapy

1. shorter period of bone marrow suppression 2. patients may be able to tolerate higher doses of chemo, increasing chance for cure

Common manifestations of hypercalcemia

1. skeletal pain 2. kidney stones 3. abdominal discomfort 4. altered cognition 5. nausea, vomiting, fatigue, loss of appetite, constipation, increased urine output

Patients with neutropenia should be taught to report any

1. skin changes - pimple, sore, rash, open skin area 2. cough 3. burning on urination 4. pain around venous access site 5. new drainage from any body area

Acute side effects of radiation on the breast and chest wall

1. skin reactions 2. esophagitis

Most common side effects of EGFRIs (epidermal growth factor receptor inhibitors

1. skin reactions - rash, peeling, issues 2. cardiac effects

Priority nursing intervention for patients with alopecia

1. teach patients how to avoid scalp injury 2. assist in coping with body image change

Results of severe or untreated TLS

1. tissue damage 2. acute kidney injury 3. death 4. hyperkalemia 5. uric acid crystals forming in kidneys

Grading of Malignant Tumors: G1

1. tumor cells well differentiated 2. closely resemble normal cells from which they arose 3. low grade of malignant change 4. malignant but slow growing

Common targeted therapy agents

1. tyrosine kinase inhibitors 2. epidermal growth factor receptor inhibitors (EGFRIs) 3. vascular endothelia growth factor receptor inhibitors (VEGFRIs) 4. multikinase inhibitors 5. proteasome inhibitors 6. monoclonal antibodies

Late side effects of radiation on the head and neck

1. xerostomia 2. dental caries 3. trismus (jaw spasm causing forced closed) 4. osteoradionecrosis (bone death) 5. hypothyroidism

Other drugs used as antiemetics

1. zofran (endo...) 2. steroids 3....

A slow-growing tumor has a mitotic index of less than

10%

Platelets lower than _____ can cause spontaneous and uncontrollable bleeding to occur

20,000

fluid consumption for patients with tumors known to be very sensitive to cancer treatment

3-5 L day before, day of, and for 3 days after cancer therapy

Even small trauma can lead to prolonged bleeding when platelet count is less than

50,000

A fast-growing tumor has a mitotic index of greater than

85%

Cytoprotectants/chemoprotectants

Agents given ahead of or with chemotherapy to decrease the impact of these drugs on normal tissue

The gaining or losing of whole chromosomes and possible structural abnormalities of remaining chromosomes

Aneuploidy

The client receiving brachytherapy with implanted radioactive "seeds" for prostate cancer asks the nurse when these seeds will be removed. What is the nurse's best response? A. "The half-life of radiation in these seeds is so short that it is not necessary to remove them." B. "They will only be removed if their presence is painful or leads to an enlarged prostate gland." C. "When we know for certain that all cancerous cells have been killed, the seeds will be removed." D. "The seeds are small enough to be absorbed by your body and excreted in the urine or stool."

Answer: A Rationale: The seeds are small and painless. The half-life of the radiation source is less than 2 weeks. Thus, it is not necessary for the seeds to be removed because they pose no health hazard to the client or anyone else. They are neither absorbed nor excreted by the body.

Which precaution is most important for the nurse to teach the client who has chemotherapy-induced peripheral neuropathy? A. Avoid taking aspirin or any aspirin-containing products. B. Use a bath thermometer to check bath water temperature. C. Do not use mouthwashes that contain alcohol or glycerin. D. Bathe daily using an antimicrobial soap or gel.

Answer: B Rationale: Peripheral neuropathy reduces the ability to discriminate temperature sensation. It is very easy for a person with neuropathy to be unaware of water temperature and to become injured as a result of water for bathing or showering being too hot. Aspirin, although important to avoid when platelets are low, is not contraindicated with peripheral neuropathy. Alcohol or glycerin mouthwashes are contraindicated for mucositis, not peripheral neuropathy. Bathing with an antimicrobial soap helps prevent infection but does not prevent injury.

The client receiving high-dose chemotherapy who has neutropenia asks the nurse whether he and his wife can have sexual intercourse while he is receiving chemotherapy. What is the nurse's best response? A. "No, this activity will increase the side effects of the chemotherapy." B. "No, the danger of impregnating your wife is too great." C. "Yes, as long as you feel like it and use a condom." D. "Yes, if you do not have an infection."

Answer: C Rationale: Many people do not feel well enough to have sexual intercourse during the months they are taking chemotherapy. This activity is fine as long as the client takes precautions to limit chemotherapy drug exposure to his partner and protects himself from infection and trauma. Wearing a condom reduces chemotherapy drug exposure to his partner (as a result of any drugs

Which pathologic description of a client's tumor does the nurse interpret as being the "most malignant" or "high grade" cancer? A. Poorly differentiated; mitotic index = 20%, euploid B. Moderately differentiated; mitotic index = 50%, euploid C. Undifferentiated; mitotic index = 50%, aneuploid D. Highly differentiated; mitotic index = 10%, aneuploid

Answer: C Rationale: Tumors that closely resemble normal cells are "less malignant," and those that have few normal cell features are "more malignant." Thus, those that are euploid are less malignant and those that are aneuploid, with abnormal numbers or structures of chromosomes, are more malignant. Less malignant cells are highly differentiated, and more malignant cells are poorly or undifferentiated. Cells that divide faster (have a higher mitotic index) are more malignant.

Which change in health status indicates to the nurse that the client's superior vena cava syndrome is worsening? A. The client's systolic blood pressure is rising, and the diastolic pressure is decreasing. B. The client's severe nausea and vomiting no longer responds to antiemetics. C. The client has experienced four nose bleeds in the past 2 days. D. Pedal edema is now present.

Answer: C Rationale: With superior vena cava syndrome, blood flow through the vena cava is compromised as a result of tumor growth. As blood backs up in the venous system drained by the superior vena cave, pressure in the veins increases and nose bleeds (epistaxis) occur easily and more frequently. The increased venous pressure would not increase systolic pressure. Response to antiemetics is not affected by superior vena cava syndrome. Pedal edema could occur in response to a blockage in the inferior vena cava but not the superior vena cava.

Seven warning signs of cancer

C.A.U.T.I.O.N. Changes in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty swallowing Obvious change in a wart or mole Nagging cough or hoarseness

A 65-year-old client tells the nurse she does not have mammograms because there is no history of breast cancer in her family. What is the nurse's best response? A. "You are correct. Breast cancer is an inherited type of malignancy and your family history indicates a low risk for you." B. "Performing breast self-examination monthly at home is sufficient screening for someone with your family history." C. "Because your breasts are no longer as dense as they were when you were younger, your risk for breast cancer is now decreased." D. "Breast cancer can be found more frequently in families; however, the risk for general, nonfamilial breast cancer increases with age."

D. "Breast cancer can be found more frequently in families; however, the risk for general, nonfamilial breast cancer increases with age."

Staging of Cancer (TNM classification): M1

Distant metastasis

Grading of Malignant Tumors: Gx

Grade cannot be determined

Staging of Cancer (TNM classification): N1, N2, N3

Increasing involvement of regional lymph nodes

Staging of Cancer (TNM classification): T1, T2, T3, T4

Increasing size and/or local extent of the primary tumor

Staging of Cancer (TNM classification): M0

No distant metastasis

Staging of Cancer (TNM classification): T0

No evidence of primary tumor

Staging of Cancer (TNM classification): N0

No regional lymph node metastasis

Staging of Cancer (TNM classification): Mx

Presence of distant metastasis cannot be assessed

Staging of Cancer (TNM classification): Tx

Primary tumor cannot be assessed

Priority nursing care for patients with thrombocytopenia

Provide safe environment

Staging of Cancer (TNM classification): Nx

Regional lymph nodes cannot be assessed

Priority teaching intervention during radiation therapy

Skin care!: 1. do not remove ink markings 2. avoid skin irritation from clothing 3. follow radiation department's policy on use and timing of skin care products

Nadir

The time when bone marrow activity and white blood cell counts are at their lowest levels after cytotoxic therapy.

Normal cells most affected by chemotherapy

Those that divide rapidly: 1. skin cells 2. hair, intestinal tissues, spermatocytes, blood-forming cells

What life-threatening effect can interleukins have?

Tissue swelling can affect function of all organs

cytokines

a type of biologic response modifier

The single most important risk factor for cancer is

advancing age (due to decrease in immune strength)

What is a possible issue with receiving monoclonal antibodies?

allergic reactions due to incorporation of non-human proteins

Main side effect to monitor for in any biologic therapy

anaphylaxis

Invasion of the bone marrow by cancer causes

anemia and thrombocytopenia *may also be caused by chemotherapy

Direct sun exposure should be avoided for how long following radiation therapy?

at least 1 year

sepsis and disseminated intravascular coagulation

bacterial invasion of blood stream that triggers extensive abnormal clotting, causing extensive bleeding from many sites

This type of radiation involves internal delivery of radiation and results in a patient that emits radiation for a time that has the potential to harm others

brachytherapy

Typical sites of metastasis of lung cancer

brain, bone, liver, lymph nodes, and pancreas.

Staging of Cancer (TNM classification): Tis

carcinoma in situ

effect of hyperkalemia in severe or untreated TLS

cardiac dysfunction

Priority nursing action for targeted therapy

careful assessment for adverse reactions

People with this type of cancer most commonly report symptoms of this

chemo brain

CINV

chemotherapy induced nausea and vomiting

Adjuvant therapy

chemotherapy used along with surgery or radiation

Acute side effects of radiation on the eye

conjunctival edema and tearing

Proteins that promote cell division

cyclins

This drug may start nausea and vomiting almost as soon as it is administered

dacarbazine

Antitumor antibiotics

damage the cell's DNA and interrupt DNA or RNA synthesis.

Effect of chemotherapy on cells

damages DNA and interferes with cell division

Side effects for patients on hormone manipulation therapy

dependent on hormones manipulated *table 22-7

Assessment of the amount of time it takes for a tumor to double in size is called

doubling time

Side effects of chemotherapy

due to systemic effects: 1. hemorrhagic cystitis 2. cardiac muscle damage 3. loss of bone density 4. anemia 5. neutropenia 6. thrombocytopenia 7. nausea, vomiting, altered bowels 8. alopecia 9. mucositis (open sores on mucous membranes) 10. anxiety 11. sleep disturbances 12. skin changes 13. cognitive function changes

Drug therapy for SIADH

emeclocycline (Declomycin)

Normal chromosome count is referred to as

euploidy

The amount of radiation delivered to a tissue is called

exposure

A serious complication of IV infusion, which occurs when drug leaks into the surrounding tissue.

extravasation (infiltration)

This may be the only assessment finding in patients with the start of serious complications from cancer

fever (100 or higher)

This treatment is used to stimulate production of red blood cells and platelets to improve clotting in patients with bone marrow suppression following chemotherapy.

growth factors, erythropoiesis-stimulating agents (ESAs): 1. darepoetin alfa (Aransep) 2. epoetin alfa (Epogen, Procrit)

Effect of hormonal manipulation for cancer treatment

helps control some types of cancer but does not cure the disease

Growth that causes tissue to increase in size by increasing the number of cells

hyperplasia

Growth that causes tissue to increase in size by enlarging each cell

hypertrophy

meds for diarrhea

imodium, imotal? imotil? limotyl?

Mucositis often develops here

in the entire GI tract, especially mouth *assess mouth and anus

Aim of BRM as supportive therapy for chemotherapy

induce rapid recovery of bone marrow after suppression due to chemo.

Most reliable test for hypercalcemia in cancer patients

ionized calcium levels

Most radiation therapy for cancer uses this type of radiation

ionizing

Reduced immunity and blood-producing functions is most commonly seen in these types of cancer

leukemia, hymphoma, and any cancer that invades bone marrow

Patients with severe rigors in response to interleukin therapy are treated with

meperidine (Demerol)

The assessment of the percentage of actively dividing cells within a tumor

mitotic index

The distinct and recognizable appearance, size, and shape of normal cell types

morphology

Any new or continued cell growth not needed for normal development or replacement of dead and damaged tissues - considered abnormal

neoplasia

This biological response modifier is used as supportive treatment for chemotherapy induced thrombocytopenia

oprelvekin (neumega)

Effect on oncogenes by carcinogenic agents or by events with loss of cellular regulation

overexpression of the the oncogenes, leading to cancer

Term for the classification of tumor chromosomes as normal or abnormal

ploidy

Patient safety measures for patients with SIADH

preventing fluid overload from worsening (causes pulmonary edema and heart failure)

Patients with cancer should have diets high in

protein and carbs

Late side effects of radiation on the lung.

pulmonary fibrosis

The amount of radiation absorbed by the tissue is called

radiation dose

Late side effects of radiation on the brain

radiation-induced fibrosis

Tumors with _____ (slow/rapid) growth usually are more sensitive to chemotherapy.

rapid

Most well known monoclonal antibody for targeted therapy, especially in non-Hodgkin's lymphoma

rituximab (Rituxan)

This biological response modifier is used as supportive treatment for chemotherapy induced leukopenia

sargamostim (leukine, prokine)

Antiemetic drug most often used in chemotherapy

serotonin (5-HT3) antagonists

This biological response modifier is used as supportive treatment for hormone-refractory prostate cancer

sipuleucel-T (provenge) (this is a vaccine)

Late side effects of radiation on the abdomen and pelvis

small and large bowel injury

Mucositis

sores in mucous membranes

This classification of cancer determines the exact location of the cancer and its degree of metastasis at diagnosis.

staging

If hemoglobin higher than 12 patient is at risk of

stroke hold growth factor drugs (epogen)

Priority nursing care for patients with cognitive changes due to chemotherapy

support the patient: 1. listen to concerns 2. teach to avoid behaviors that could further alter cognitive behavior - like alcohol, recreational drug use, activities with risk for head injury

Proteins that limit cell division

suppressor gene products

Priority nursing care for patients experiencing CIPN

teaching them to prevent injury (ie: lack of ability to sense excessive heat, cold, pressure)

Radiation delivered from a source outside of the patient.

teletherapy

Molecularly targeted therapies do not work unless

the cancer cell overexpresses the actual target substance

purpose of hormone manipulation therapy for cancer treatment

to control, not cure

These assessments should be performed every 8 hours for patients with neutropenia.

total patient assessment: 1. skin and mucous membrane inspection 2. lung sounds 3. mouth assessment 4. inspection of venous access device site

Positive sign that cancer treatment is effective

tumor lysis syndrome

secondary cancer prevention

use of screening strategies to detect cancer early, at a time when cure or control is more likely

primary cancer prevention

use of strategies to prevent the actual occurrence of cancer (ie: skin protection during sun exposure to avoid skin cancer)

Chemicals that damage tissue on direct contact

vesicants