cellular regulation part 2

exploratory surgery

We may think there's a tumor in the colon but until we get in there and take that tumor out and then send it to lab or cytology and the pathologist to look at, we really don't have a diagnosis

every time someone goes to an appointment they will be given a

distress thermometer

most clients are given both cell cycle meds for a better

kill response

nontumor cancers

leukemia, lymphoma multiple myeloma

prevention of infection

o Avoid crowds and other large gatherings of people who might be ill o Do not shar personal toiletries such as toothbrushes, toothpaste, washcloths, or deodorant sticks with others o If possible, bathe daily with an antimicrobial soap. If total bathing is not possible, wash the armpits, groin, genitals, and anal area twice a day with antimicrobial soap. o Keep your toothbrush dry o Wash your hands thoroughly with an antimicrobial soap before you eat and drink, after touching a pet, after shaking hands with anyone, as soon as you come home from any outing, and after using the toilet

prevention of infection

o Follow the cancer center's instructions for eating fresh salads; raw fruits and vegetables; meat, fish, and eggs; and pepper and paprika o Wash dishes between use with hot, sudsy water or use a dishwasher o Do not drink water, milk, or juice or other cold liquids that have been standing at room temperature for longer than an hour o Do not reuse cups and glasses without washing o Do not change pet litter boxes o Take your temperature at least once a day and whenever you do not feel well

selection of chemo drug is based on clinical trial

o For brain tumors, that there's sensitivity to certain types of drugs and also what kind of side effects to expect. Side effects do become a concern.

cell cycle specific

o It works in a specific part of the cell cycle § it might only work in mitosis and that's where it works.

prevention of infection

o Report any of these indications of infection to your oncologist immediately § Temperature greater than 100 F § Persistent cough (with or without sputum) § Pus or foul smelling drainage form any open skin area or normal body opening § Presence of a boil or abscess § Urine that is cloudy or foul smelling or that causes burning on urination o Take all prescribed drugs o Wear clean disposable gloves underneath gardening gloves when working in the garden or with houseplant o Wear a condom when having sex. If you are a woman having sex with a male partner, ensure that he wears a condom.

internal radiation (brachytherapy) nursing priorities

o Safety is for the client, family members, and caregivers o Three things can be done to protect the nurse § Time · Limit time in the room to 30 min per shift § Distance · Maintain a maximum distance as much as possible after the initial assessment § Shielding · Protecting the nurse from the waist down o Shielding on the bed o Lead apron o To the client § They can go home and even to work § Need to know that if any of those seeds come out, they should not be touched. They should use some type of forceps if it becomes dislodged to retrieve it and it needs to be deposited into a radioactive lead container § Inpatient · Always keep the door shut · Place a caution radioactive materials sign on the door · Wear a lead apron when providing care- nurse · Wear a dosimeter film badge at all times o They document how much time you've been exposed to the radiation · Limit visitors to half hour per day · Do not touch the radioactive material

external radiation (teletherapy) nursing priorities

o Skin protection- priority § If its going into the skull, it can actually cause permanent alopecia § Abdominal area- N/V/D Depending on where that radiation is sent can change what the nursing priorities are

oprevelkin

o Stimulates the production of platelets Used for thrombocytopenia

cell cycle non specific

o Works in all of the cell cycles

filgastrim

o granulocyte colony stimulating factor o specific for neutrophils o good for the client with decreased WBC count o used for that neutropenia

mucositis

o inflammation of the mucosa (extends from mouth to anus) o it shreds the skin on the inside of the mouth and lips § like you have canker sores all over the mouth o frequent oral care is important § use mouth sponges § rinse mouth with plain water or saline every hour § avoiding spicy, salty, acidic, and dry and rough foods

epoetin alfa

o stimulates the production of erythrocytes (RBCs) o used for anemia

surgery

only one part of a comprehensive treatment approach for cancer therapy

late site specific effects of radiation therapy- lung

pulmonary fibrosis

late site specific effects of radiation therapy-abdomen and pelvis

small and large bowel injury

chemotherapy

§ Absolutely used for those blood cancers § Unless the tumor has metastasized to somewhere else, typically surgery and radiation will only be used, not chemo. § Use of chemical or drugs to treat cancer, used in sickle cell disease, RA, and sometimes in lupus § Treatment of choice for cancers of the hematologic systems and solid tumors that have metastasized

acute site specific effects of radiation therapy- brain

§ Alopecia and radiodermatitis of the scalp § Ear and external auditory canal irritation § Cerebral edema § N/V § Somnolence syndrome

acute site specific effects of radiation therapy- abdomen and pelvis

§ Anorexia § N/V § Diarrhea and proctitis § Cystitis § Vaginal dryness/vaginitis

late site specific effects of radiation therapy- breast/chest wall

§ Atrophy, fibrosis of breast tissue § Lymphedema

late site specific effects of radiation therapy- central nervous system

§ Brain necrosis § Leukoencephalopathy § Cognitive and emotional dysfunction § Pituitary and hypothalamic dysfunction § Spinal cord myelopathies

prophylactic surgery

§ Can remove the potentially cancerous tissue as a means of preventing cancer development § Ex: removing a mole, wart, or polyp; removing breast tissue for someone who may be at risk for breast cancer

acute site specific effects of radiation therapy- eye

§ Conjunctival edema and tearing

acute site specific effects of radiation therapy- chest and lung

§ Esophagitis and pharyngitis § Taste changes § Pneumonia

palliative surgery

§ Focuses on providing symptom relief and improving quality of life Not meant to cure but to control symptoms

reconstruction or rehabilitative surgery

§ Helps provide reconstruction; best example is after a mastectomy and even bowel surgery § These things can be sued for cosmetic reconstruction and preparing for some types of rehabilitation whether that be breast implants or some other device related to the type of cancer the client has

cancer control surgery

§ Just removes part of the tumor when removal of the entire mass is not possible · Reducing the number of cancer cells will help with symptom management and enhance success of other types of treatment

anemia (perfusion)

§ Low RBCs and low Hgb level § They will have problems with perfusion · Because there's not enough RBCs= problem with perfusion and oxygenation § Normal count 4-6 § Treatment might be a blood transfusion to replace that clients RBCs

neutropenia (infection control)

§ Low WBC count § Immune system is suppressed · Infections, pneumonia, UTIs, even sepsis § Normal count - 5,000-10,000 High risk for infection

thrombocytopenia (safety)

§ Normal platelet count is about 150-500 § Concern = bleeding § Platelets help with clotting

acute site specific effects of radiation therapy- head and neck

§ Oral mucositis § Taste changes § Oral candidiasis § Oral herpes § Acute xerostomia § Dental caries § Esophagitis and pharyngitis

late site specific effects of radiation therapy- heart

§ Pericarditis § Cardiomyopathy § CAD

perioperative care for surgery

§ Psychosocial support § Achieving and maintaining maximum function · Colon cancer- client may be concerned about whether or not they're going to have a colostomy afterwards § Establishing a diagnosis can be done, determining the stage of cancer with lymph node resection can be done, and treating the disease and providing preparation for reconstruction are all parts of surgery in cancer therapy

late site specific effects of radiation therapy-subcutaneous and soft tissue

§ Radiation-induced fibrosis

curative surgery

§ Remove all the cancer tissue

acute site specific effects of radiation therapy- breast and chest wall

§ Skin reactions § Esophagitis

radiation therapy

§ The use of electromagnetic rays to help treat the cancer

multiple myeloma

§ WBC cancer that involves the B-lymphocyte plasma cell) · treated with chemotherapy

late site specific effects of radiation therapy- head and neck

§ Xerostomia and dental caries § Trismus § Osteoradionecrosis § Hypothyroidism

lymphomas

§ cancer of the lymphoid tissue) · treated with external radiation and chemotherapy · treated with monoclonal antibodies · treated with stem cell transplants

alopecia

§ hair loss § expected side effects § provide support · wig § hair will come back

cancer symptoms: distress related to

§ practical problems § family problems § emotional problems § spiritual and religious physical problems

teach client with mucositis

§ soft bristle toothbrushes § never use commercial mouth wash because they can dry out the mouth § providing relief to area that is irritated § avoid tobacco and alcohol

colony stimulating growth factors

§ these do not fix the cancer; just to stimulate the production of cells and for recovery of the bone marrow after suppression by chemotherapy filgastrim, epoetin alfa, oprelvekin

leukemia

§ unregulated proliferation of WBC in the bone marrow) · treated with chemotherapy · treated with blood transfusions · treated with bone marrow transplant · supportive therapy

teach client with anemia

· Alternate periods of rest with activity · Increase protein intake · Have family members help with some of their ADLs · Make sure that we limit visitors when the client is resting or sleeping · We want them to be as independent as possible, but we definitely want to give them time to have some rest. Give them some time to take a little nap before we do our next activity

the patient with thrombocytopenia

· Apply ice to areas of trauma · Test all urine and stool for the presence of occult blood · Observe IV sites every 2 hours for bleeding · Avoid trauma to rectal tissues o Do not give enemas o Administer well lubricated suppositories with caution Advise patient not to have anal intercourse

care of the patient with sealed implants of radioactive seeds

· Assign the patient to a private room with a private bath · Place a caution: radioactive material sign on the door of the patient's room · If portable lead shields are used, place them between the patient and the door · Keep the door to the patient's room closed as much as possible · Wear a dosimeter film badge at all times while caring for patients with radioactive implants. The badge offers no protection but measures a person's exposure to radiation. Each person caring for the patient should have a separate dosimeter to calculate his or her specific radiation exposure · Wear a lead apron while providing care. Always keep the front of the apron facing the source of radiation (do not turn your back toward the patient) · If you are attempting to conceive, do not perform a direct patient care, regardless of whether you are male or female · Pregnant nurses should not care for these patients; do not allow pregnant women or children younger than 16 years to visit · Limit each visitor to one-half hour per day. Be sure visitors stay at least 6 feet from the source · Never touch the radioactive source with bare hands. In the rare instance that it is dislodged, use a long handled forceps to retrieve it. Deposit the radioactive source in the lead container kept in the patient's room · Save all dressings and bed linens in the patient's rom until after the radioactive source is removed. After the source is removed, dispose of dressings and linens in the usual manner. Other equipment can be removed form the room at any time without special precautions and does not pose a hazard to other people

the patient at risk for bleeding

· Avoid bending over at the waist · Do not wear clothing or shoes that are tight or that rub · Avoid blowing your nose or placing objects in your nose. If you must blow your nose, do so gently without blocking either nasal passage

internal radiation (brachytherapy)

· Delivers radiation to a localized area using radioisotopes that are implanted into body cavities or they're put in interstitially somewhere next to the tumor. · Some white little small round balls of a radioisotope and they are put somewhere inside the patient. They will stay there next to that tumor and it does deliver radiation into that body cavity. Since those little seeds stay inside the client, the client IS radioactive.

oncologic emergency SIADH

· Disruption in fluid and electrolytes · Syndrome of inappropriate antidiuretic hormone · Cancer is a common cause esp small cell lung cancers · Water is reabsorbed in excess by the kidneys and put into systemic circulation · Mild symptoms o Weakness, muscle cramps, low sodium levels (seizure precautions) · Nurses o Patient safety o Management of fluid restriction o Drug therapy o Managing that clients fluid and electrolytes

mouth care mucositis

· Drink 2 or more liters of water per day if another health problem does not require limiting fluid intake · Take all drugs, including antibiotics and drugs for nausea and vomiting as prescribed · Use topical analgesic drug as prescribed · Take pain medications on schedule as needed · Apply a water based moisturizer if your lips after each episode of mouth care and as needed

prevention of infection

· Eat low bacteria diet and avoid salads, raw fruits and vegetables, and undercooked meat. · Do not drink water that has been standing for longer than 15 minutes · Avoid keeping turtles and reptiles as pets · Do not feed pets raw or undercooked meat · Take your temp at least twice a day · Avoid travel to areas of the world with poor sanitation or inadequate health care facilities · Do not dig in the garden or work with houseplants

the patient with thrombocytopenia

· Encourage the patient not to blow the nose or insert objects into the nose · Advise the patient to avoid contact sports · Instruct the patient to wear shoes with firm soles when ambulating

mouth care mucositis

· Examine your mouth (including the roof, under the tongue, and between the teeth and cheek) every 4 hours for fissures, blisters, sores, or drainage · If sores or drainage is present, contact your cancer health provider to determine whether these areas need to be cultured · Brush the teeth and tongue with a soft bristled brush or sponges every 8 hours and after meals · Avoid the use of mouthwashes that contain alcohol or glycerin · Swish and spit room temperature tap water, normal saline, or salt and soda water on a regular basis (at least 4 times a day) and as needed according to changes in the oral cavity

§ Protection for the nurse during chemotherapy administration

· Exposure can happen by 3 methods o Absorption during administration o Inhalation- a lot of times happens in pharmacy when they're preparing the med o Ingested- without washing hands providing chemo to a client and then you go eat lunch · Special PPE o Thicker gown that is resistant to fluid o Thick rubber gloves

teach client with neutropenia

· Good handwashing · Limit the number of health care personnel entering the room · Inspect mouth and mucous membranes · Change dressings daily · Encourage activity so they don't get pneumonia · Change IV tubing · Strict aseptic technique · No kids around, just healthy adult · Avoid use of urinary catheter · Restrict fresh flowers, plants, even foods in the patients room o Bacteria · Don't change the pet litter boxes · Take temperature frequently · Don't drink any beverage that has been sitting out for longer than an hour at room temp · Don't reuse things · Avoid crowds · Bathe daily · No reptiles for pets · Temperature is the only thing that we will see as a problem for infection

the patient with thrombocytopenia

· Handle the patient gently · Use a lift sheet when moving and positioning in bed · Avoid IM injections and venipunctures · When injections or venipunctures are necessary, use the smallest gauge needle for the task · Apply firm pressure to the needlestick site for 10 minutes or until the site no longer oozes blood

conserving energy

· Help the patient identify one or two lead visitors (those designated as allowed to visit at any time and who do not disturb the patient). · Selectively limit nonlead visitors when the patient is resting or sleeping · Remind families that, although independence is important, independence in ADLs during extreme fatigue can be detrimental to the patient's health. · Monitor oxygen saturation and respiratory rate during any activity to determine patient responses and activity tolerance.

extravasation chemo

· If the drug starts to infiltrate, it will cause this - vesicant

the patient at risk for bleeding

· If you are bumped, apply ice to the site for at least 1 hr · Notify your primary care provider if you o Experience an injury and persistent bleeding results o Have excessive menstrual bleeding o See blood in your urine or bowel movement o Have a headache that does not respond to acetaminophen · Avoid anal intercourse · Take a stool softener to prevent straining during a bowel movement · Do not use enemas or rectal suppositories

cytotoxic wastes chemo

· Includes the tubing, the empty bag · Will go in a yellow box for cytotoxic wastes

the patient with thrombocytopenia

· Measure abdominal girth daily · Advise the patient to use and electric shaver · Teach the patient to avoid mouth trauma: o Use soft bristled toothbrush or tooth sponges o Do not floss between teeth o Avoid dental work, especially extractions o Avoid hard foods o Make sure that dentures fit and do not rub

care of the patient with myelosuppression and neutropenia

· Monitor vital signs every 4 hours, including temperature · Inspect the patient's mouth at least every 8 hours · Inspect the patient's skin and mucous membranes (especially the moth and anal area) for the presence of fissures and abscesses at least every 8 hours · Inspect open areas such as IV sites every 4 hours for indications of infection · Change wound dressings daily

administration of chemo

· Nurses need to know how to administer chemotherapy · Oral or IV · Can only be administered by a trained and competent nurse in the state of TN · Usually through a central line · Many will have a permanent type access, port-a-cath in place for their chemo

care of the patient with myelosuppression and neutropenia

· Obtain specimens of all suspicious areas for culture (as specified by the agency) and promptly notify the primary health care provider · Assist the patient in coughing and deep breathing exercises · Encourage activity at a level appropriate for the patient's current health status · Change IV tubing daily or according to unit protocol · Keep frequently used equipment in the room for use with this patient only (blood pressure cuff, stethoscope, thermometer) · Limit visitors to healthy adults

conserving energy

· Perform complete bed bath only very other day. Between complete baths, ensure cleaning of face, hands, axillae, and perineum. · In collaboration with other members of the health care team, cancel, or reschedule nonessential tests and activities · Provide 4-6 small, easy to eat meals instead of three larger ones · Urge the patient to drink small amounts of protein shakes or other nutritional supplements · During periods of extreme fatigue, encourage the patient to allow others to perform personal care

care of the patient with myelosuppression and neutropenia

· Place the patient in a private room whenever possible · Use good handwashing technique or alcohol based hand rubs before touching the patient or any of the patient's belongings · Ensure that the patient's room and bathroom are cleaned at least once each day · Do not use supplies from common areas for patients with myelosuppression and neutropenia. For example, keep a dedicated box of disposable gloves in his or her room and do not share this box with any other patient. Provide single use food products, individually wrapped gauze, and other individually wrapped items · Limit the number of health care personnel entering the patient's room

conserving energy

· Reassure the patient that fatigue is temporary and energy levels will improve over a period of weeks to months. Stress that a return to previous energy levels may take as long as a year · Teach the patient that SOB and palpitations are symptoms of over activity · Instruct the patient to stop activity when SOB or palpitations are present · Space care activities at least an hour apart and avoid the tie right before or right after meals · Schedule care activities at times when the patient has more energy (immediately after naps)

oncologic emergency spinal cord compression

· Requires immediate intervention to relieve pain and prevent neurologic damage · The tumor is in an area that compresses the spinal cord and the symptoms depend on the severity · Back pain is typically the first symptom but you may also see weakness of the extremities, urinary retention, constipation, loss of reflexes · Early recognition is important o Assess for that numbness and tingling · Treatment may be radiation to shrink tumor or high dose steroids to reduce the swelling around that spinal cord

external radiation (teletherapy)

· Skin integrity o After days and days of radiation, you will begin to see a painful area § It's going to be reddened/burn looking § They need to · wear soft clothing · avoid heat exposure · wash the area with water or a mild soap and that they use their hands instead of a washcloth, they need to rinse it very thoroughly · No powders, ointments, or lotions on unless it's been prescribed by the radiation oncologist. · Avoid wearing straps that are built over that area · Protect it from the sun · Make sure they watch that area for possible signs of infection

biopsies

· The removal of part of the suspected lesion for examination · The ability to test it to either rule out or receive a cancer diagnosis

external radiation (teletherapy)

· Think of it as an invisible beam of light that is focused on one specific area of the body and it's meant to treat the cancer. We only want that beam to go a that specific point. · It comes from an external source and it pinpoints the area where radiation is delivered in small doses, typically daily for a set period of time. Client may have 4 weeks of radiation or 6 weeks depending on the type and size of the cancer. · They will have specific markings on them with a permanent type marking to ensure the correct position every single time that radiation is delivered o Don't wipe these off · The patient is NOT radioactive

oncologic emergency superior vena cava syndrome

· Tumor sits in that thoracic area and it compresses or obstructs vessels that lead to the heart · You will see swelling, edema · It can be life threatening where that fluid return cant happen because a blockage · Early s/s: edema of the face around the eyes, · Major concern: respiratory distress, you may hear stridor or difficulty breathing o Sit them up, help them breathe · Late symptoms- hypotension, usually when widespread- chemo or high dose radiation is used

vesicant/nonvesicant drug chemo

· Typically going to be vesicants o Highly toxic and can cause necrosis if they extravasate · Nonvesicant o Don't cause necrosis but can be irritating · Close monitoring is going to be essential

the patient at risk for bleeding

· Use an electric shaver · Use a soft bristled tooth rush and do not floss · Do not have dental work done without consulting your primary health care provider · Do not take aspirin or any aspirin containing products. Read the label to be sure that the products do not contain aspirin or salicylates · Wear shoes or slippers with a sole to avoid foot injury · Do not participate in contact sports or any activity likely to result in your being bumped, scratched, or scraped

skin protection during radiation therapy

· Use only powders, ointments, lotions, or creams that are prescribed by the radiation oncology department on your skin at the radiation site · Wear soft clothing over the skin at the radiation site · Avoid wearing belts, buckles, straps, or any type of clothing that binds or rubs the skin at the radiation site. · Avoid exposure of the irradiated area to the sun o Protect this area by wearing clothing over it o Try to go outdoors in the early morning or evening to avoid the more intense sun rays o When outdoors, stay under awnings, umbrellas, and other forms of shade during the times when the sun's rays are most intense (10AM-7PM) · Avoid heat exposure

mouth care mucositis

· Use prescribed artificial saliva or mouth moisturizers as needed · Avoid using tobacco or drinking alcoholic beverages · Avoid spicy, salty, acidic, dry, rough, or hard food · Cool liquids to prevent burns or irritation · If you wear dentures, use them only during meals. When not in place, soak them in an antimicrobial solution. Rinse thoroughly before placing them in your mouth.

care of the patient with myelosuppression and neutropenia

· Use strict aseptic technique for all invasive procedures · Monitor the WBC count daily · Avoid the use of indwelling urinary catheters · Follow agency policy for restriction of fresh flowers and potted plants in the patient's room

skin protection during radiation therapy

· Wash the irradiated area gently each day with either water or a mild soap and water as prescribed by your radiation therapy team · Use your hand rather than a washcloth when cleansing the therapy site to be gentler · Rinse soap thoroughly from your skin · If ink or dye markings are present to identify exactly where he beam of radiation is to be focused, take care not to remove hem · Dry the irradiated area with patting rather than rubbing motions; use a clean, soft towel or cloth

oncologic emergency tumor lysis syndrome

· Where there's a large number of tumor cells that are destroyed rapidly o When they are destroyed rapidly a lot of the debris goes into the bloodstream and that debris cause some tissue damage including acute kidney injury · Hydration is going to be the best thing o Once these cells are killed, they throw out things like uric acid, cytokines, and even some protein o These kind of crystals can cause damage to the kidneys o By diluting their blood and looking at electrolyte levels

oncologic emergency sepsis

· an overwhelming infection resulting from low WBC count

renal (elimination)

· bleeding from the bladder · cystitis- drugs irritate the bladder and cause hemorrhagic cystitis

neurologic (sensory perception)

· changes in cognitive function- "chemo brain" o after chemo, the client has difficulty remembering new information, has difficulty with memory. · Peripheral neuropathy o Be careful with cooking o Don't injure o Protect hands from heat and cold Good shoes for feet

teach patient with thrombocytopenia

· encourage the use of an electric razor · use a soft bristled toothbrush · don't have dental work done · take a stool softener · handle pt gently · be careful with IM injections · encourage not to blow nose

nutrition

· increase calories and protein · food with mucositis o soft foods

GI (elimination)

· n/v · diarrhea · antiemetics can be used · anorexia · cachexia- cancer anorexia o client does not have an appetite · altered taste sensation- may become permanent · teach o promote nutrition o increase calories and protein o small frequent feedings o megestrol/Megase- supplement given to promote appetite

musculoskeletal

· some chemo can affect bone density and can put someone at risk for a fracture or injury

cardiac (perfusion)

· some drugs cause cardiotoxicities and have a lifetime dose limit o daunorubicin o doxorubicin o both called red devils; can cause a pt to have CHF o watch for signs and symptoms of HF is going to be a priority o lifetime limit = you can only have so much of the drug

reproductive

· spontaneous miscarriages · fetal defects · it kills sperm · might be concerns for reproduction later in life · become sterile

Hematopoietic

· the side effects that may pose greatest risk to client and need to stop treatment)- most life threatening side effects that can occur

cancer pain and management

· treated around the clock opioids not PRN