med surg exam 3

Vesicant infiltration evisceration examples of non chemo vesicants Q: Why do we give IV medications in different volumes and at ordered rates of infusion?

ALL three antineoplastic agents we just spoke about are VESCICANTS. Vesicant refers to any medication or fluid with the potential to cause tissue injury, blistering or necrosis if it extravasates. Infiltration is the inadvertent leakage of a non-vesicant solution into surrounding tissue; Whereas extravasation is the inadvertent leakage of a vesicant solution into surrounding tissue *** Failure to assess and treat this complication in a reasonable time-frame can lead to devastating injury to the patient as well as medical malpractice lawsuit Non-chemotherapy vesicants include, but are not limited to: Ca+ chloride, Ca+ gluconate, magnesium sulfate, Valium, Phenergan, IV Robaxin, Acyclovir, concentrated IV potassium chloride. Vasoactive drugs like Levophed, Dopamine, Dobutamine Q: An extravasation injury can arise by giving caustic medications and but if you administer IV solutions high in osmolarity or extreme pH

Cancer-related fatigue (CRF) Quality of Life... is influenced by

"a distressing, persistent sense of physical, emotional, and/or cognitive exhaustion r/t cancer or cancer treatment that interferes with functioning and is disproportional to level of activity." mood, outlook, physical function, social interaction, family connections, cognitive function ,school/work performance, community involvement and sense of well-being *Cancer-related fatigue is not completely relieved by sleep or rest*

In the event of an extravasation, what do you do? important information and assessments

*Initial steps*: •Stop the infusion immediately •Disconnect IV line from the hub of the angoicatheter •Do not remove the cannula •Do not flush the line •Aspirate as much as possible •Notify MD •If port extravasation •Try to aspirate from hub •MD only, may use sterile needle to aspirate pocket. Next steps vary depending on specific vesicant: Collaborative care is necessary to decide on appropriate treatment Notify physician and pharmacy; also notify charge nurse incidence report Check protocols: Observation (watch and wait) Supportive care (*cool or warm compress depends on vesicant* ) Antidotes - Intravenous - Topical Saline lavage/suction Surgery Know the drug Know the damage it can do Know appropriate response BEFORE starting infusion!

ASCITES: fluid accumulates in peritoneum s/s medical mgmt. Nursing management

*Liver fails to metabolize aldosterone* Increases sodium and water retention by kidney -Increased intravascular fluid volume -Increased lymphatic flow -Decreased synthesis of albumin by damaged liver *Low serum albumin* contributes to movement of fluid from vascular system into peritoneal space. Self-perpetuating as this causes further sodium and water retention by kidney in effort to maintain the vascular fluid volume serum albumin level drops; *serum osmotic pressure drops* LOW BP *need to replace albumin before removing fluid in the third space*. Clinical manifestations: Increased abdominal girth, rapid weight gain, shortness of breath, umbilical hernias, striae, distended veins, electrolyte imbalances Medical management: -Restrict sodium to reduce fluid retention -Diuretics e.g., Aldactone (aldosterone blocking agent) -Paracentesis Nursing mgmt: -Monitor I&O, abdominal girth daily wt. to assess fluid status -Monitor serum ammonia, *electrolyte levels to assess electrolyte balance*, response to therapy and indicators of encephalopathy -Provide diet low in sodium -*Monitor for hypovolemia, electrolyte shifts, changes in mental status, encephalopathy, s/p paracentesis*.

Nursing Management Priorities - post Thyroidectomy structural emergencies s/s metabolic emergencies s/s only treat if? what do you give for tx?

*Structural Emergencies*: Hemorrhage *LOOK* (look for swelling changes, watch swallowing for obstructive- increasing RR) *LISTEN* (air movement- put stethoscope on main bronchus. listen for stridor) *FEEL* ( feel neck for changes - is it tighter?) •An unrecognized rapidly expanding hematoma can cause airway compromise. what will you do??? Call a RAPID Response *Metabolic Emergencies*: Hypocalcemia s/s: Numbness, tingling of digits or circumoral, carpo-pedal spasm, positive Chvostek or Trousseau sign. •If severe: tetany, mental status and ECG changes, seizures *dont treat unless they're symptomatic* = give *calcium gluconate* IV (vesicant) daily serum calcium level checks •Nursing ACTION? Call a RAPID Response

Radiation pneumonitis s/s The risk of developing Radiation Pneumonitis and its severity depends on: Radiation pneumonitis is treated by ?

*not an infectious process, its an inflammatory process* resulting in lung injury that impacts lung function by *decreasing diffusion capacity*. Diffusing capacity is a measure of how well o2 and co2 are transferred (diffused) between the lungs and the blood. In Radiation Pneumonitis, an early change is a decrease in the levels of *surfactant*, the substance that helps keep the air passages open and the lungs from fully expanding, which results in the symptoms seen. S/S: Shortness of breath that usually gets worse with exercise =DOE *Chest pain, which is often worse when taking in a deep breath* Cough; Pink-tinged sputum Low-grade fever, Weakness In some cases, no symptoms are noticed, and radiation pneumonitis is found on a chest x-ray. The risk of developing Radiation Pneumonitis and its severity depends on: *radiation dose*, amount of lung tissue in the treatment field, whether you had radiation in the past, and whether you are getting chemo at the same time (combination therapy). *more likely if you have other lung diseases, like COPD, pulmonary HTN*. This inflammation may occur 6 weeks to 6 months after completing external radiation therapy. It can also be caused by radiation to the chest for breast cancer, lymphomas, or other cancers. Radiation pneumonitis is treated by trying to decrease the inflammation. treatment: *Steroids*, like prednisone, are usually used. Most people recover from radiation pneumonitis without any lasting effects with tx. If untreated or persists. can lead to pulmonary fibrosis (stiffening or scarring of the lungs). When this happens, the lungs can no longer fully inflate. If these changes affect a large enough area of the lungs, symptoms of shortness of breath and less tolerance for physical activity will persist

potential Complications of PN

-Hyperglycemia -Fluid Overload -Refeeding Syndrome (sudden shifts in the electrolytes when giving food after starvation) -Rebound Hypoglycemia if discontinued abruptly Pneumothorax r/t central line displacement *Embolism r/t clot dislodgement from thrombus in central line or precipitate formation from not using a micron filter with TPN*

Fatigue Nursing Considerations -Radiation Safety EXTERNAL Hazzard

3 key principles to protect from External Hazzard from Gamma ray ionizing radiation: TIME...Less Time =Less Exposure DISTANCE...Greater Distance =Less Exposure SHIELDING...More Shielding = Less Exposure Dosimeter- -Use own badge only -Regulated Occupational Dose Limit ... Exposure must be monitored if staff likely to receive 10% of dose limit

ICD-10: Criteria for Cancer related Fatigue: significant fatigue plus 5 or more associated S/s

1. Generalized limb heaviness 2. Diminished concentration/attention/focus 3. Decreased motivation / interest to engage 4. Insomnia or hyperinsomnia 5. Sleep is unrefreshing or nonrestorative 6. Struggle to overcome inactivity 7. Emotional reactivity; sadness; irritability 8. Difficulty staying on task 9. Problems w/ short term memory (retaining info) 10. Post-exertional fatigue lasting several hours 5 of more of associated sx

Invasive bladder cancer process 1 &2 URINARY DIVERSION (2 types) SUPERFICIAL Bladder CA METASTATIC Bladder CA

1. Neo-adjuvant (chemo before surgery) chemotherapy then Radical Cystectomy (surgery = removal of bladder) followed by External Beam Radiotherapy (EBRT) 2. Bladder reconstruction (in order to eliminate) URINARY DIVERSION: Continent Cutaneous Reservoir - small bowel attaches to ureters to a stoma so patients can self- cath. 90& in day. (Reservoir with abdominal wall stoma) Orthotopic Neobladder (new bladder that takes small bowel attached to ureters' and urethra and allows for more natural emptying) Reservoir anastomosed to urethra Transurethral resection of bladder tumor (TURBT) - reset bladder tumor- then has intravesical chemo (bladder filled with chemo) Post-operative : 1. intravesical chemotherapy (fill bladder with chemo to get residual cells) 2. Bladder surveillance program (lifelong- watching for s/s of recurrence) 1. Palliative chemotherapy and radiation (for distant metastasis) 2. Alleviate symptoms; Preserve renal function

Nursing Management/ meds / life style changes Peptic Ulcer Disease

Antibiotics to eradicate *H. pylori. Lowers recurrence rate* H-pylori contributes to ulcer formation. Medications: (antibiotics, H2 receptor antagonists, proton pump inhibitors of gastric acid, prostaglandin E1 analog; e.g. Carafate), lifestyle changes, surgical intervention/ cauterize. Manage gastric acidity. Lifestyle/dietary changes that reduce over secretion of acid and hypermotility of GI tract: *smoking cessation*, stress reduction, rest, avoiding extreme temperatures in food, avoiding alcohol, caffeine, dairy products. Avoid foods that produce pain; eat foods which are tolerated (individualized diet)

Acute Pancreatitis causes dx s/s nursing mgmt

Acute Pancreatitis: may be mild and self-limiting or severe and fatal (10% mortality rate) Causes: gallstones, other gallbladder (biliary) disease, and alcohol use. Viral infection (mumps, coxsackie B (hand-foot-mouth), mycoplasma pneumonia, and campylobacter), hereditary conditions, traumatic injury, pancreatic or common bile duct surgical procedures and certain medications (especially estrogens, corticosteroids, thiazide diuretics, and azathioprine), Pancreatitis without any apparent cause is known as idiopathic pancreatitis. It is thought that enzymes normally secreted by the pancreas in an inactive form become activated inside the pancreas and start to digest the pancreatic tissue. This process is called *autodigestion* and cause swelling, hemorrhage, and damage to the blood vessels. An attack may last several days and the pain may be severe. Diagnosis: patient interview, medical exam, and several tests including blood (*amylase/lipase/glucose/calcium*), stool, CT scan, endoscopic retrograde holangiopancreatography (ERCP), and MRI. S/S: Anoxia, shock, hypotension, electrolyte imbalances, severe mid-epigastric or back pain from edema of inflamed pancreas which stimulate nerve endings. Nausea, vomiting, abdominal distension, decreased peristalsis. Respiratory distress, hypoxia, dyspnea, tachycardia, DIC. Nursing mgmt: Goal: relieve symptoms, prevent complications -NPO status to prevent stimulation of pancreas -TPN/enteral feedings -Nasogastric suction: decrease distension and paralytic ileus, relieve nausea/vomiting. -H2 antagonists: decrease pancreatic activity -Antiemetics prn as ordered -Monitor and provide interventions for altered respiratory status, pain, nutrition, skin integrity

GASTRITIS: Inflammation of the gastric mucosa chronic s/s Nursing Management: Gastritis

Acute/chronic Causes: Irritating foods (spicy, fatty foods), excessive alcohol intake, NSAIDS, bile reflux, radiation therapy s/s: Abdominal pain, headache, nausea, anorexia, vomiting, hiccupping, heartburn, belching, sour taste in mouth. chronic gastritis: usually have *b12 deficiency* from malnourishment (pernicious anemia and peripheral neuropathies) Dietary modification -Acute: NPO until mucosa heals: monitor IVF: I&O, electrolytes. Offer ice chips/ clear liquids after symptoms subside. Gradually increase diet to incorporate solids. Avoid caffeine (stimulates gastric motility/pepsin secretion), alcohol, cigarettes (nicotine reduces secretion of pancreatic bicarbonate, inhibiting neutralization of gastric acid in the duodenum). Stress reduction - find out what their stressors are Pharmacological agents: H2 receptor antagonists, proton pump inhibitors, etc. What medications should the patient avoid? nsaids

peripheral nerve damage Neuropathic pain peripheral Central neurotoxicity

Affects sensory nerves that receive sensations such as heat, cold, pain. Patient may report: Extreme sensitivity to touch, even light touch; heat intolerance or inability to discern hot and cold Neuropathic pain/ nerve pain: has distinct language: Burning pain; it may be Sharp or Electric-like pain; Radiating, Shooting, Stabbing, Pulsating, Pins and Needles ...The location of pain is often back, hips, shoulders, legs, hands, and feet. Gradual onset of Numbness and Tingling *in feet or hands, which may spread upward into legs and arms*. *You need to differentiate acute from chronic neuralgias*. Is it new or changing! Peripheral nerve damage also means *Autonomic nerves* that control functions such as: blood pressure, heart rate causing dizziness or lightheadedness; altered bowel and bladder control - constipation or urinary retention Central neurotoxicity ranges from acute toxicity to delayed onset; S/S: cognitive deficits, memory deficit, confusion; tremors; difficult swallowing (aphasia) and progressive dementia. Notice NEW changes. Toxicity to the central nervous system primarily affects the cerebellum, (the part of the brain that processes sensory information concerning body position, coordination of muscle activities, and maintenance of body posture) Damage produces: *ataxia* - notice NEW difficulty with movement control, coordination, and balance; resulting in an unsteady ataxic gait.

Patient and Family teaching for Metastatic spinal cord compression (MSCC)

An example of a patient information leaflet Name: Consultant: Sometimes when people have cancer it can spread to the spinal column and cause the spinal nerves to be squeezed. This leaflet is not intended to scare you but to help you recognize the important symptoms to report early so that tests and treatment may be done as soon as possible. When the spinal nerves are squeezed it can cause damage to the spinal cord to the point of complete paralysis from the neck, chest or waist down. This is quite rare, and unlikely to affect you, but it is very important to pick it up quickly as the earlier treatments are started the better the result usually is. Symptoms to watch out for: •Back pain in one bit of your spine that is severe, distressing or different from your usual pain(especially if it affects the upper spine or neck). •Severe increasing pain in the spine that changes with lying down or standing up, when lifting or straining, wakes you at night or prevents sleep. •Pain which starts in the spine and goes around the chest or abdomen. •Pain down the leg or arm. •A new feeling of clumsiness or weakness of the arms or legs or difficulty walking. •Numbness in the arms or legs. •Difficulty in control of your bladder or bowels If you have any of the above symptoms: •Speak with a doctor, nurse or paramedic as soon as is practical (certainly within 24 hours). •Tell them that you have cancer, are worried about your spine and would like to see a doctor. •Show the doctor this card. •Try to bend your back as little as possible. For the doctor or healthcare professional •This patient has cancer and is therefore at risk of metastatic spinal cord compression (MSCC). •If they have any of the symptoms on the front of this card then please consider MSCC as a possible diagnosis and discuss further management with the local MSCC Coordinator

Why do we give IV medications in different volumes and at ordered rates of infusion?

An extravasation injury can arise by giving caustic medications and but if you administer IV solutions high in osmolarity or extremes of pH. *pH*- Infused medications with extremes values of pH such as Ca+ Gluconate with pH a of 3 can cause CHEMICALPHLEBITIS: phenytoin (Dilantin) is extremely alkaline and is a non-chemotherapy vesicant Promethazine (Phenergan) has a pH of 4-5 and must be diluted before infusing -12.5 mg (1 mL) diluted in a minimum of 9 mL of NS and injected over one minute. Vancomycin, which has a pH <4, close to the ph of stomach acid. High acidity irritates venous endothelial cells....pt will c/o of discomfort; assess for redness traveling up the arm proximally to the insertion site the nurse should recognize the drugs may be injuring the lining of the vein. Appropriate interventions: stop the infusion, check site, consider diluting medication further, change IV site to a larger vein, or administer med through a CVAD access *Osmolarity*: can also influence the degree of tissue injury. Extravasation of HYPERTONIC FLUIDS such as hypertonic saline, 10% dextrose or TPN solutions, 1300-1800 mosm/L!!! ...can cause serious tissue damage & necrosis *TPN* has high osmolality Hypo-osmolar solutions can swell cells and lead to cell rupture. *To minimize venous irritation, infused solutions should be close to physiologic pH* (7.35-7.40) AND serum osmolarity (281-300 mOsm/L). INS standards recommend infusions with a pH outside the range of 5 to 9 and/or an osmolarity greater than 600 mOsm/L should be administered through venous access device into a vessel with higher rate of flow With the exception chemotherapy drugs, the injury potential is concentration dependent - so we use of lower concentrations, slower infusion rates, and larger blood vessels.

Q: Is phlebitis only an infectious process? How does site selection and size of the angiocatheter help? Mechanical phlebitis and infiltration, can be reduced if?

Answer: NO Phlebitis (inflammation of vein) can be caused by chemical, mechanical or infectious irritation. The palmar and lateral side of the wrist and the three-inch area just above the thumb are areas where nerve injury is most likely to occur because the nerves are superficial. if catheter tips are not located in areas of flexion, such as antecubital fossa and wrist sites and if IV catheters are properly taped and secured. tape and secure IV.

upper GI bleed

Assess for blood in NGT if present Assess for hematemesis: -Positioning patient in recovery position (left lateral recumbent) -Prevent *aspiration* -NGT to suction - need IV access Endoscopy/Sengstaken-Blakemore tube *management of upper gastrointestinal hemorrhage due to esophageal varices* Administration of blood products Surgery

Obstructive Jaundice

DUCT prob: Bile cannot flow normally into intestine and backs up into liver and blood. *Stools become light/clay colored*, skin itches; impaired digestion of fatty foods Intrahepatic obstruction: -small bile ducts: pressure or inflammation, thickening of bile from medication (phenothiazines, antithryroid medication, sulfonylureas, tricylic antidepressant, estrogens, etc.) Extrahepatic obstruction: -*Occlusion of bile duct form gallstone, tumor, inflammation, pressure from enlarged organ* (liver, gallbladder) diagnostics: ultrasound, hydascan, ERCP whos at risk for gallbladder attacks: 4Fs. Female, forty, fertile,

Gastroesophageal Reflux Disease (GERD) Nursing and Medical Management: GERD

Back flow of gastric acid or duodenal contents into esophagus Clinical manifestations: *Heartburn* Regurgitation *Hoarseness/sore throat* Dysphagia Chronic cough Diagnosis: Upper endoscopy: *EGD* esophagogastroduodenoscopy (Directly visualize the esophagus and the other associated structures) obtain biopsies and eliminate other potential etiologies of symptoms that are suggestive of reflux disease. allows clinicians to quantify the degree of erosive esophagitis present. mgmt.: Teach patient to avoid situations that decrease lower esophageal sphincter pressure or cause esophageal irritation Teach patient to avoid caffeine, tobacco, beer, milk, foods containing peppermint/spearmint, carbonated beverages; eat a low fat diet, avoid eating before bedtime, maintain ideal body weight, elevate head of bed raise bed on blocks Antacids or H2 receptor antagonists (Pepcid, Zantac); Prokinetic agents (Reglan, etc.) Surgical intervention: Nissen fundoplication (Wrapping a portion of the gastric fundus around sphincter area of esophagus) Nursing: *NGT Management: Who may replace/adjust it? only the doc/surgeon - dont mess with it. it helps to decompress gas

Seven WARNING Signs of CANCER

C.A.U.T.I.O.N. Seven WARNINGS of CANCER C-hange in bowel or bladder habits A- sore that does not heal U-nusual bleeding or discharge from any body orifice T-hickening or a lump in the breast or elsewhere I-ndigestion or difficulty swallowing O-bvious change in a wart or mole N-agging cough or hoarseness

Diagnostics for Staging may include...

CT scan with contrast shows the lung tumor's size, location and spread. PET scan: patient receives an injection of a small amount of radioactive sugar. Because cancer cells use sugar faster than normal cells, areas with cancer cells look brighter on the computerized images. MRI: A strong magnet linked to a computer is used to make detailed pictures of your head or spine. An MRI can show cancer spread. Bone scan: A small amount of a radioactive tracer will be injected into a blood vessel. The scanner detects the HIGHER amounts of the radioactive substance that collect in skeletal areas where cancer is present which can show cancer has spread to the bon

Thrombocytopenia: Call your doctor immediately if:

Call your doctor immediately if: Bleeding that does not stop after 10 to 15 minutes of pressure. Blood in the urine Blood from the rectum or stool is black. Watch for ALOC, visual or pupil changes that might indicate intracranial bleeds: -Abrupt change in your vision - ex: double or blurred vision -A persistent or sudden severe headache -Change in level of consciousness, excessive sleeping, confusion, and/or difficulty being awakened. -New weakness, lo loss of function

Gallbladder

Cholecystitis: inflammation of gallbladder Cholelithiasis: presence of calculi in gallbladder Risk factors: obesity, multiparous women, frequent weight changes, estrogen therapy, ileal (chrons) disease, cystic fibrosis, diabetes mellitus Clinical manifestations: pain, biliary colic, jaundice, pruritis, dark colored urine, clay-colored stool, signs of fat soluble vitamin deficiency (A,D,E,K)

Biliary Disorders: Cholecystitis Cholelithiasis S/S: tx diagnostic : ERCP

Cholecystitis: inflammation of gallbladder Cholelithiasis: presence of calculi in gallbladder S/S: pain, biliary colic, jaundice, pruritis, dark colored urine, clay-colored stool, signs of fat soluble vitamin deficiency (A,D,E,K) Nursing responsibilities: improving respiratory status, relieving pain, promoting skin care and biliary drainage, nutritional status, monitoring for complications (bleeding, infection, GI motility) -Uses fluoroscopy and multiple x-rays to evaluate presence and location of ductal stones. Treatment : *Cholelithiasis* -Surgery: laparoscopic, cholecystectomy (open) -Nonsurgical: lithotripsy (uses shock waves or a laser to break down stones) -Stones fragmented by laser pulse technology under fluoroscopic guidance with devices that can distinguish between stones Diagnostics: ERCP examination of hepatobiliary system via flexible, fiberoptic endoscope Uses fluoroscopy and multiple x-rays to evaluate presence and location of ductal stones

Chronic Pancreatitis Signs and Symptoms:

Chronic Pancreatitis: progressive destruction of pancreas Cells replaced by fibrous tissue results in mechanical obstruction of pancreatic and common bile ducts and the duodenum; destruction of secreting cells of pancreas Major Causes: alcoholism, malnutrition -Alcohol causes hyper-secretion of protein in pancreatic secretion resulting in protein plugs and calculi within pancreatic ducts •Direct toxic effect on cells of pancreas •Exocrine insufficiency- impairment in digestion because of dysfunction of pancreatic enzymes and •Endocrine insufficiency - impairment of insulin production resulting in elevated levels of blood sugar. Signs and Symptoms: Pain in the back and abdomen. *In some cases, abdominal pain goes away as the condition advances, probably because the pancreas is no longer making digestive enzymes*. Weight loss is often a symptom of chronic pancreatitis because the body does not secrete enough pancreatic enzymes to break down food and nutrients are not absorbed normally. *Poor digestion leads to excretion of fat, protein and sugar in the stool. If the insulin-producing cells of the pancreas have been damaged, diabetes may develop*. If the pancreas is unable to produce the hormone insulin, these symptoms of diabetes mellitus may develop: increased thirst increased appetite increased urination fatigue / weight loss.

HEPATIC CIRRHOSIS

Chronic disease wherein *normal liver tissue is replaced by scar tissue* that disrupts normal liver function and structure Alcoholic cirrhosis: scar tissue forms around portal areas. (*most common*) Post-necrotic cirrhosis: broad bands of scar tissue form following bout of acute viral hepatitis Biliary cirrhosis: scarring occurs around bile ducts resulting from chronic biliary obstruction and infection Increase in severity as disease progresses -Failure of liver to synthesize proteins, clotting factors; signs of portal hypertension, ascites, varices, hepatic encephalopathy, liver enlargement, nodular borders Nursing Responsibilities: Interventions based on symptoms: 1. Activity intolerance r/t fatigue, general debility, muscle wasting 2. Imbalanced nutrition, less than body requirements r/t chronic gastritis, decreased GI motility, anorexia 3. Impaired skin integrity r/t *compromised immune status* (from lack of proteins = lack of antibody formation), edema, poor nutrition. 4. Risk for injury and *bleeding* r/t altered clotting mechanisms

Impact of Neutropenia and Febrile Neutropenia on Survival

Common gram + pathogens: MRSA, VRE, Strep Common gram negative pathogens: E-choli Klebsiella Enterobactor Pseudomonas Etc Causative pathogen often not identified

Thyroid Cancer Total Thyroidectomy: Complications

Complications •*Hypothyroidism* - expected (will use Synthroid) •*Hypocalcemia* - occurs in 30%-50% of cases • Permanent vocal cord palsey - <1% •*Infection* - <2% (watch for localized heat, abscess formation (superficial or deep) fever, leukocytosis) •Hemorrhage - <3%

Chemotherapy in LUNG CANCER: the nursing process

Concepts to keep in mind: 1. RISK factors-...individual vs treatment specific risk 2.FUNCTION-... current vs normal vs known baseline 3. Onset-..ACUTE vs. CHRONIC or PRE-EXISTING 4. PROTECTION and/or PREVENTION measures- before, during and after 1. RISK factors-.individual vs treatment specific risk To determine how is this patient uniquely AT RISK you will need to know about treatment history; Combination therapies and/or Cumulative dosing present higher risk to a patient; recognize if they are farther along in their treatment course- higher risk; Comorbidity of chronic illness also adds to risk. 2.FUNCTION-Preexisting dysfunction or chronic illness involving major organ systems - liver, kidney require you to consider.. current vs known baseline level of function; keep NORMAL organ function in mind...in contrast to the status now Assess: PMH of chronic disease Report known baseline values and current labs indicating organ function Liver disease - Paclitaxel for example is mainly metabolized by the liver. Liver dysfunction with Abnormal liver function tests (LFTs) can predispose to more toxic effects warranting dose reduction or treatment modification. 3. Onset-...ACUTE vs. PRE-EXISTING must consider timing of symptom manifestation: In a Diabetic for example - assess for presence and map the extent of any preexisting diabetic neuropathies HELPS you differentiate CHRONIC from ACUTE symptoms and... HELPS you be alert to new or changing symptoms. Especially with neurotoxic chemo agents like Paclitaxil. 4. PROTECTION and/or PREVENTION measures- think about what you need to consider before, during and after . ex: pre-medicating, administering ordered neuroprotective agents, IV hydration; based on current data decisions may be necessary for dose adjustment/reduction; delaying treatment; alternate treatments; additional protective measures Chronic kidney disease for example -ask about baseline creatinine Cisplatin is known to be nephrotoxic. Kidneys are a major elimination pathway - renal impairment can delayed excretion of chemotherapeutic agents, resulting in systemic toxicity. *Requires dose adjustment*..renal dosing Physical assessment and review of labs ...*indicating current hydration status*

LUNG CANCER Mesothelioma non small cell lung cancer small cell lung cancer

Leading cause of cancer deaths in U.S. for both men and women -Most cases of lung cancer are diagnosed between the age of 55 and 74 (also high risk ages) Mesothelioma: associated with asbestos exposure Non-small cell lung cancer (NSCLC) -most common. It doesn't grow and spread as fast as small cell lung cancer. diagnostic: CT, MRI, PET - small amount of radioactive sugar is injected and cancer cells appear brighter on imaging. BONE scan - radioactive injection in blood vessels and cancer cells will appear brighter. treatment of choice = surgery (Segmental or wedge resection •Lobectomy; Pneumonectomy) Small cell lung cancer (SCLC) - 15% of cases; more aggressive subtype •NO general screening. •Low-dose CT scan screening only for high risk •Diagnostics: CT scan; MRI, Bronchoscopy; PET and Bone scan - assess for metastas

Neutropenia Neutropenic precautions:

Febrile Neutropenia: Recognize it!!!! -Pan-culture without delaying Antibiotics -Promptly initiate broad spectrum antibiotics -*Be alert to HYPOTENSION-nadir sepsis*!!! neutropenic precautions •Private room •Reverse isolation •Strict handwashing •Monitor temp q 4 hours, monitor for s/s infection •Limit visitors to healthy adults •No flowers or plants •Monitor ANC through nadir point until ANC recovers to greater than 1500 cells / mm •Neutropenic diet •Well cooked foods only •Omit fresh fruits and vegetables Neulasta (pegfilgrastim) or Neupogen (Filgrastim), are granulocyte colony stimulating factor (G-CSF), that stimulate production of neutrophils

Liver metastases

From primary sites reach liver via lymphatic channels, portal system or direct extension from an abdominal tumor. SEEDING. tx with chemo S/S: -Pain in right upper quadrant, epigastrum or back -Weight loss (5lbs/week), weakness, anemia, jaundice, ascites

Thrombocytopenia Chemotherapy-Induced Thrombocytopenia

General teaching and precautions especially below 40,000 •Avoid punctures for IV or IM •Avoid contact sport, trauma or strenuous activity; handle patient gently •Use electric razor •Avoid foley; no rectal thermometers or suppositories •Soft bristle brushes, avoid flossing •Stool softeners to avoid straining •Do not cough or blow nose forcefully •Do not take anti-platelet meds.. DO NOT take meds that affect clotting. Chemotherapy-Induced Thrombocytopenia is a Drop in platelet count below 100,000 Below 10,000 per mm3, patient will likely require transfusion of platelets. Transfuse if below 40,000 when surgery is needed

Causes of superior vena cave syndrome

More than 80% of SVC Syndrome cases are caused by Bronchogenic carcinomas Most of the malignant mediastinal tumors are small-cell lung carcinomas. Non-Hodgkin lymphoma (especially the large cell type) represents 10-15% of cases. Patients with signs and symptoms of *laryngeal and cerebral edema* have the most life-threatening manifestations of this syndrome and are in danger of sudden death. Patients with untreated malignant SVC syndrome survive only ~30 days Treatment is most effective when patients are treated within 5 days after the onset of symptoms.

discontinuing Parenteral Nutrition

Must be discontinued gradually: ◦Administer an *isotonic dextrose* solution for 1 to 2 hours after discontinuing the PN. ◦Allows patient to adjust to decreased levels of glucose Abrupt discontinuation may result in *rebound hypoglycemia* ◦Weakness, faintness, sweating, shakiness, feeling cold, confusion, increased heart rate

Superior Vena Cava Syndrome: treatment

Goals of SVCS management are to relieve symptoms and to attempt treat of the primary malignant process. reduce tumor EMERGENCY treatment is necessary when life-threatening symptoms from cerebral edema (confusion, obtundation), hemodynamic compromise d/t decreased cardiac output (syncope, hypotentsion), or upper airway edema (stridor)are present. - corticoid steroids/ diuretics Patients who present with life-threatening symptoms (central airway obstruction, severe laryngeal edema, coma from cerebral edema are in a true medical emergency, following initial stabilization (securing airway, supporting breathing and circulation), these patients require immediate intervention (endovenous) recanalization with SVC stent placement, to decrease the risk of sudden respiratory failure and death. Treatment may include: Chemotherapy only for patients with tumors known to be chemo-sensitive, otherwise Radiation therapy - is the *standard treatment*; high dose Radiation therapy palliates superior vena cava (SVC) obstruction in 70% of patients with lung carcinoma and in more than 95% with lymphoma. The likelihood of patients benefiting from such palliative treatment is high, but the overall prognosis of these patients is poor. The nurse should anticipate orders for Supportive therapies including: *immediate tx*= steroids/diuretics Steroids - corticosteroids If thrombus present, systemic anticoagulation is recommended to limit thrombus extension Osmotic or loop Diuretics (reduces edema) Anxiolytics (for anxiety) and Oxygen (for respiratory distress) Analgesics - for pain Significant symptomatic improvement achieved with combined interventions

Hepatitis C

Hepatitis C: 1/3 cases of liver cancer and most common reason for liver transplant Transmitted via *blood/blood products, contaminated needles, sex with infected partner* Frequent occurrence of chronic/carrier state and chronic liver disease/increased risk of liver cancer

Hepatitis D:

Hepatitis D: *needs HEP B to replicate*. if you have D you have B. Same mode of transmission as HBV (blood via percutaneous or permucosal routes) Likely to develop fulminant hepatitis and progress to chronic active hepatitis and cirrhosis

is oral cancer curable? Cancer of the Oral Cavity common risk factors tx

Highly curable if caught early before spread to lymph nodes Alcohol & tobacco use-synergistic effect if used together risk factors: help us with prevention. Smokeless tobacco, prolonged sun exposure, dietary deficiencies and smoked meat ingestion also predisposing factors Treatment: Medical treatment may include surgery to remove lesion and affected tissues, chemotherapy , and radiation

Portal hypertension

Increased pressure throughout portal venous system (*varices*) r/t obstructed blood flow through damaged liver - problematic bc inflammation leaves scar tissue behind. Ascites: -fluid accumulates in peritoneal cavity -Cancer, kidney disease, heart failure, liver damage - *liver cant clear aldosterone which increases ascites* -puts pressure on the lungs can cause pleural effusions, impaired gas exchange - assess abdomen by tapping to determine air or liquid, daily weight (1kg=1L) if there's weight gain assess lungs- crackles / bp/ *o2* Varices: -varicosities r/t elevated pressure in veins that drain into the portal system -Prone to rupture; source of hemorrhage - mechanical soft diet, no alcohol, no caffeine - can cause hemorrhoids -caput medusae

jaundice what causes yellow skin? hemolytic

Jaundice: Elevated serum bilirubin causes body tissues to become yellow-tinged (skin, sclerae) Hemolytic : increased destruction of red blood cells floods plasma with bilirubin and overwhelms the liver Hemolytic transfusion reaction (The reaction occurs when the red blood cells that were given during the transfusion are destroyed by the person's immune system) Levels > 20-25 mg/dL pose risk for brain damage Hepatocellular: Inability of damaged liver cells to clear normal amounts of bilirubin Hepatitis viruses, Epstein-Barr virus, medications, chemical toxins, alcohol cause liver cell necrosis Cirhossis caused by alcohol or viral infection

Manifestations of Hepatic Dysfunction jaundice portal HTN, ascites, varices nutritional deficiencies hepatic encephalopathy or coma

Jaundice: resulting from increased bilirubin in the blood = liver dysfunction is not filtering bili Portal hypertension causing ascites, or varices: -resulting from increased circulatory changes within the diseased liver -producing severe GI hemorrhages and marked sodium and water retention. -caused by inflamed liver Nutritional deficiencies: liver stores ADEK ( important for clotting(K) bone development (D) -result from the inability of the damaged liver cells to metabolize certain vitamins. -Responsible for impaired functioning of the central and peripheral nervous systems -Results in abnormal bleeding tendencies and impaired ability to synthesize proteins Hepatic Encephalopathy or coma: -end stage liver disease accumulation of *ammonia* in the serum r/t *impaired protein metabolism* by diseased liver. - assess changes in mental status, ammonia levels

how do you bring ammonium level down?

Lactulose - polysaccharide , hypertonic solution that will promote bowel movement ( which will pull ammonia out)

Liver Transplantation Complications Post-operative nursing responsibilities: Liver Transplant

Liver Transplantation -May be used to treat end stage liver disease -*Success relies on immunosuppressive therapy post-op* Complications: -*Bleeding* -*Infection* -Rejection T-lymphocytes may attack transplanted liver Long-term therapy with immunosuppressants necessary E.g. Tacrolimus, corticosteroids responsibilities: Monitoring hemodynamic stability, Respiratory status *Signs of rejection*: Elevated liver enzymes, Nausea, pain, fever, jaundice, fever, tachy Rejection diagnosis: *liver biopsy is needed to be sure that the transplanted liver is being rejected*. rejection can happen months after surgery - ask about medication compliance for steroid rx Patient education about medications and preventing infection, *rejection*: e.g. Tacrolimus, Cyclosporine, Steroids

Four main classifications of cancer

Lymphomas (cancers of infection-fighting organs, such as lymphatic tissue). Leukemias (CA in blood-forming structures, ex: spleen and bone marrow). Sarcomas (cancers occurring in connective tissue, such as bone). Carcinomas (occur in epithelial tissue, such as the skin) melenomas

Primary liver tumors

May be benign/malignant determined by biopsy *Increased rate of benign tumors among oral contraceptive users* Primary tumors (malignant) usually associated with Cirhossis, hepatitis B and C, exposure to chemical toxins (vinyl, chloride, arsenic); cigarette smoking & alcohol use; toxic mold

GASTRIC SURGERY Possible problems: Gastric Surgery

May be performed on patients with Peptic ulcer, hemorrhage, obstruction, perforation, gastric cancer, trauma, or whose condition does not respond to medication Elective surgery: Gastric Bypass Possible problems: Gastric Surgery Hemorrhage Dietary deficiencies -Malabsorption of iron -Low serum *B12* -Lack of intrinsic factor: s/p gastrectomy. -Results in B12 deficiency and signs of pernicious anemia (neurologic disorders, macrocytic anemia) within 5 years -*May be fatal if B12 not replaced with monthly IM injections*. gastric surgery can cause: Bile reflux: removal of pylorus allows reflux of duodenal contents *Dumping syndrome* : rapid passage of food from stomach to jejunum draws fluid from circulating blood volume into jejunum in order to dilute hypertonic intestinal contents to facilitate absorption of electrolytes and carbohydrates. *causing diarrhea and nutrient deficiencies , avoid sugary substances and alcohol*

Metastatic spinal cord compression (MSCC) Treatment modalities:

Metastatic spinal cord compression (MSCC) is an oncologic emergency. Unless diagnosed early and treated appropriately, MSCC can lead to permanent neurologic impairment. The main objectives of treatment are: -*preservation further deficits* or improvement of neurologic function (particularly walking) -pain relief -preservation or improvement of quality of life Treatment modalities: *The combination of corticotherapy and radiotherapy* has for a long time been considered the preferred treatment in most MSCC patients. *Corticosteroids (mainly dexamethasone) widely used as first-line treatment* Steroids reduce edema and inflammation and promote stabilization of vascular membranes at the compression site, consequently reducing back pain and neurologic deficits. High dose *radiation treatment* Surgical options limited to Vertebroplasty and Kyphoplasty (inject substance to build back height and re-stabilize vertebrae) Vertebroplasty and Kyphoplasty: Considered for patients with vertebral metastases with *no evidence of MSCC* or spinal instability if they have: −mechanical pain resistant to conventional analgesia, −or if they have evidence of vertebral body compromise. take off potential for compression and vertebral collapse. These procedures are minimally invasive and offer potential to significantly reduce pain and can avert MSCC from vertebral collapse Focus of nursing assessments during treatment is safety; pain management; neurological assessment and reassessment of presenting S/S for evidence of palliation. Patient and Family Teaching: what to do if XYZ how to maintain spinal alignment s/s to report (direct pain after baring down

Clinical presentation of infection in patients with neutropenia

Minimal or subtle changes or symptoms (especially if severely neutropenic or combined w/ anemia): -Fatigue; sudden onset malaise; feeling unwell -Feeling different w/o clear explanation -Changes in behavior; change in mental status -Feeling faint -Dyspnea, tachypnea -New pain, irritation, or discomfort Sites to assess carefully: -Respiratory -Disruption of mucosal barriers; dysphagia, thrush -Urinary tract -Nervous system -Skin: vesicular lesions, ulcerations, abscess/ chills, sweat, fever =Febrile Neutropenic Episode

Myelosuppression Guiding principles impacting therapy : NADIR patient teaching

NEUTROPENIA THROMBOCYTOPENIA ANEMIA ...OR... PANCYTOPENIA Guiding principles impacting therapy : 1. pre-treatment risk stratification; early identification measures 2. early initiation of preventive strategies 3.*NADIR point* =*the point when blood counts are at their lowest.* point reached after start of cancer treatment; timeframe varies. low platelet: soft bristle, rinse and spit, avoid contact sports, limit/avoid anticoagulants (nsaids- naproxen, ibuprofen, indomethacin) no suppository's, no IM injections worrisome: watch for unusual bleeding in urine or stool = *GI/GU*, vomiting blood, petechiae, acute change in vision, acute change in motor activity = *brain bleed*.

PATIENT RECEIVING A TUBE FEEDING Salem sump tube Dobbhoff tube Nursing Responsibilities Tube feeding: Potential Complications mechanical metabolic

Nasogastric (most common) -Salem sump tube: contains both a gastric decompression lumen and a duodenal lumen for feedings. can give medication/nutrition for a *short time* bc its large and uncomfortable used for suction Nasoenteric: Dobbhoff: Tungsten-weighted tip, radiopaque, stylet. for *long term* nutrition goes in the duodenum for max absorption X-ray (sees the guide wire/stylet) to confirmation for placement . dont pull out stylet until after X-ray. responsibilities: Monitor patient: assess abdomen for distention. make sire suction is on. Maintain tube function Provide oral/nasal hygiene and care Monitor for potential complications suction amount, when it was emptied? HOB elevated at least 30 degrees potential complications: Gastrointestinal: D/N/V from hypertonic sol aspiration *hyperglycemia* monitor glucose q6h alkalosis from diarrhea losses *nausea could mean rate is too high or blockage* -*Check residuals before every feeding and each time medications are administered*. Check a minimum of q shift. -*Replace TF formula q 4hrs and change tubing q24 hours* -Inform M.D. if n/v persist. Change TF formula or rate as ordered Mechanical: Aspiration pneumonia, tube displacement -Check placement; *keep head of bed elevated at least 30 degrees* Metabolic: Hyperglycemia, dehydration -Implement changes in TF formula, rate of ratio to water. *Provide adequate hydration through IV fluids* (*assess for possible fluid overload*)

NEUROTOXICITY

Neurotoxicity may be temporary and resolve when the treatment is stopped. But some are permanent and have lifelong implications for a patient's quality of life. Vinca alkaloids were the first class of drugs to be recognized as neurotoxic; they cause degeneration and atrophy of axons. Vincristine primarily causes peripheral nerve damage. CISPLATIN: primarily affect the peripheral nervous system because the drug causes *demyelination of nerve cells and damage to large fibers*. Cisplatin-related neurotoxicities may be dose-limiting, especially with cumulative dosing pushes pt toward higher risk for neurotoxicities. need to maintain *hydration*. . PACLITAXEL, neuropathic symptoms occur in more than 50% of patients receiving a low dose Paclitaxel, and 100% in those on high doses. *dose and duration effect incidence and severity* Neurotoxicity is a major dose-limiting factor of this agent. It is the dose and duration of infusion that affect the incidence and severity of neurotoxicity. NEED to see what sighs are chronic or NEW

Neutropenia total WBC ANC count why neutropenia s/s so obscure?

Neutrophils-most abundant type of WBC "first-responders" Normal total white blood cell (WBC) count is: 4.5 - 11,000 cells/ mm is calculated: ANC = WBC X (% neuts + % bands) ANC: is a measure of the total # of neutrophils (mature and immature) •Grade 2 Neutropenia: ANC < 1500 cells / mm •Grade 3 Moderate Neutropenia: 500-999 cells / mm •Grade 4 Severe Neutropenia: < 500 cells /mm Neutropenia is a common and serious complication of anti-cancer therapy: infections *may not be reported until they are already life threatening*, due to *obscured or lack of S/S* higher risk of infection is during the nadir period *lack of s/s due to: symptoms not manifesting in the same way* (no puss) neutropenia is the most common reason for reduced and *delayed chemotherapy*. can impact outcome of treatment plan. *the duration and severity of neutropenia increases risk for Febrile Neutropenia* educate: bc WBC count is low - watch out for infection in lungs, bladder, skin surfaces, feel or observe anything that looks like cough, worsening in breathing, LOOK sick, lightheaded, hypotensive crisis = Life threatening

Hiatal Hernia s/s Nursing management: Hiatal Hernia

Opening in diaphragm (through which esophagus passes) becomes enlarged: part of upper stomach moves up into the lower portion of the thorax Clinical manifestations: Heartburn, regurgitation, dysphagia; *sense of fullness, chest pain after eating* nursing mgmt.: Frequent, small feedings Advise patient to sit upright for 1 hour after eating to prevent reflux or movement of hernia Elevate head of bed on 4-8 inch blocks to prevent hernia from sliding upward Surgery: may be required to correct torsion of the stomach that leads to restriction of blood flow Instruct patient to report intractable nausea, vomiting and abdominal pain after a meal. torsion: severe pain, acute onset, nausea, vomiting. torsion and potential perforation Is life threatening situation

PEPTIC ULCER DISEASE patho risk factors s/s

PEPTIC ULCER DISEASE -Gastric, duodenal, *or* esophageal -Hollowed-out area that forms in the mucosal wall due to erosion -Erosion may extend through muscle layers or peritoneum -Increased concentration or activity of HCL acid-pepsin -Damage to mucosa allows decreased resistance to H. pylori bacteria -*Risk factors*: Alcohol, smoking, use of NSAIDS, stress, cirhossis S/S: -Dull, gnawing PAIN or burning sensation in mid-epigastrum or back -Duodenal ulcer: GI bleed resulting in melena (tarry stools). -Gastric ulcer: vomiting common, hematemesis priority concern: *active bleeding* call rapid, get vitals priority concern: *perforation*- patients *pain will go away*

HEPATIC ENCEPHALOPATHY AND COMA patho s/s

Pathophysiology: Life threatening complication of liver disease Accumulation of *ammonia* (dietary & blood proteins) and toxic metabolites in blood r/t inability of hepatic cells to convert ammonia to urea. happens from altered protein metabolism -Causes brain dysfunction -Coma is the most advanced stage of hepatic encephalopathy S/S: Mental/*motor disturbances*, *confusion*, alterations in mood and sleep patterns -*Asterixis* (flapping tremor of hands) -constructional apraxia (inability to draw a simple figure) -Deep tendon reflexes at first hyperactive; later hypoactive

Oral and Esophageal Disorders post op care

Post-operative care *Hemodynamic stability* assess vital signs vs. baseline. get H&H (indicates blood loss) Patent airway; management of oral secretions (suctioning) risk for aspiration Monitor graft perfusion- assess: color, temp, Nutrition- TPN, IV fluids, - assess efficiency by labs, glucose, *weight*. Pain management- assess pre-op Preventing infection - give antibiotics on time. Promoting effective communication

Metastasis to the spine compromises vertebral structures and can result in cord compression and neurological compromises cord compression nursing mgmt

Priorities for nursing management: #1 Recognize this urgency #2 Prevent further neurological damage...... Assess and identify S/S: *Severe back pain* = *most frequent first symptom*,occurring in 95% of patients. Vertebral pain aggravated by spinal movement, lifting light weights, even by standing. Pain also aggravated by coughing, sneezing and defecating. bc these activities increase pressure within the spinal canal #2 *New weakness of the limbs* = second most common symptom of cord compression. Sensory symptoms include paresthesia, decreased sensation, numbness of toes and fingers which may extend to the level of cord compression Autonomic dysfunction = late consequence of MSCC ; may include impotence or bladder and bowel dysfunction ... How would the patient present? The ANS is part of peripheral nervous system that functions without conscious effort. It controls the cardiovascular, respiratory, and endocrine systems, among others. Autonomic dysfunction results in loss of motor or sensory function, paralysis, ileus, may include impotence or bladder and bowel dysfunction ... presenting as:urinary retention, incontinence or severe constipation Immediate care nursing *PRIORITIES* to prevent additional damage: *Protect spinal alignment*, NO bend/lift/twist (BLT) My require strict bedrest; lay flat; log roll for toileting with caution; implement bowel mgmt prevent constipation *Maintain cord perfusion by preventing further damage* /avoiding hypotension Administer *dexamethasone*/high dose steroids. Monitor blood glucose levels in all patients receiving corticosteroids prevent constipation *Manage pain*: NSAIDS, opioids, and non-opioids

anemia: problem s/s 2 key sx in cancer fatigue labs tx

Problem= decreased O2 carrying capacity in RBCs most common SE of cancer s/s: •Shortness of breath •Dyspnea on exertion (DOE)•Activity intolerance •Dizziness; lightheadedness •Syncope •Tachycardia•Chest pain •Insomnia•Headache •Swelling of hands and/or feet •Pale skin, nail beds, mucosa •Extreme fatigue; weakness •Decreased level of functioning Symptoms can be debilitating *level of fatigue is disproportionate to exertion* *is not relived by rest/sleep* Mild anemia: Hgb 10 to 11 g/dL Moderate anemia: Hgb 8 to 10 g/dL Severe anemia: Hgb 6.5 to 8 g/dL Lung, heart, and renal comorbidities intensify consequences of anemia Treatment: •Goals = Treat cause; raise hemoglobin •Blood transfusion, when Hgb <8 •Epoetin drugs: Epogen; Procrit; Aranesp (darbepoetin) *common S/E = *Bone pain* •Iron supplementation

Paracentesis

Removes accumulated fluid in peritoneum Fluid removed using a long, thin needle put through the belly. The fluid is sent to a lab and studied to find the cause of the fluid buildup. Find the cause of fluid buildup in the belly. (liver scarring, otherwise known as cirrhosis increases pressure inside the liver's blood vessels) indications: -Diagnose an infection in fluid. -Check for certain types of cancer, such as liver cancer. -Remove a large amount of fluid that is causing pain or difficulty breathing or that is affecting how the kidneys or the intestines (bowel) are working. does not cure patient, its palliative care Nursing care: *monitor for signs/symptoms of hypovolemia*

Systemic RAI External and INTERNAL Hazzard

RAI emits both Beta particles and Gamma rays; half-life is 8 days *Radioactive material can be present in: blood, urine, saliva and perspiration AND on surfaces, ingesting this contamination by "surface-to-hand-to-mouth" contact* presents an INTERNAL Hazzard *Instruct patient to* :shower daily; flush toilet 2-3 times; wash hands frequently & carefully, separate utensils, towels, laundry drink extra - 2.5-3 L/day, no kissing or sexual contact for 1 week, keep an arms length away. *Restrict*/ Limit contact w/ infants, young children, pregnant women

Fatigue Interventions level 1 recommended practice? sleep hygiene importance

RECOMMENDED FOR PRACTICE *Walking EXERCISE; avoid inactivity* (helps appetite, psychological thoughts) Treat correctable correlates - ex: anemia (they treat if they can) ALSO LIKELY TO BE EFFECTIVE... Energy Conservation /Activity mgmt. Pace, Prioritize and Plan daily tasks Massage; Relaxation / Guided Imagery Manage stressors; Set realistic goals Modafinil- psychostimulant nurses help manage sx and provide emotional support limit naps to 1 hour or less get up at same time everyday if they sleep too much it can be counter productive.

Liver Cancer/Medical management

Radiation Chemotherapy or Surgery -Lobectomy -Cryosurgery: destroys tumors with liquid nitrogen -Liver transplantation

Thyroid Cancer RADIATION Treatment RAI (Radioactive Iodine) External beam radiation therapy

Radioactive Iodine (RAI) Systemic Therapy: for patient post thyroidectomy for possible cancer cells left behind. •prepare for this treatment? patient needs to avoid consuming food/products with iodine (shellfish, seaweed, milk, yogurt, bacon, ham, patient medication, no diagnostic procedures with iodine based contrast) Emits beta particles and gamma rays. external hazard. teach patient how to be safe at home up to 8-10 days. radioactive substance can come out of any body fluids and remain on surfaces (surface to mouth can become internal exposure). shower daily, flush toilet 2-3 times after use, wash clothing separately, increase fluids, no kissing/sexual contact, minimum arms-length away from people. avoid: pregnant, kids •Will I-131 therapy cause side effects? Neck tenderness, swelling Dry mouth, taste changes Nausea, vomiting Reduced tear production What can I do? External Beam Radiation Therapy: patients can get this in sequence over several weeks. *Deploys gamma rays and can harm people around them*. precautions: TIME, DISTANCE, SHEILDING wear dosimeter. do not share these. *skin problems can develop* dry and wet desquamation ERBT is painless but may cause common SE: sore throat; trouble swallowing Skin changes - red, irritated, tender, flaking Fatigue •Will I be able to do my normal activities with radiation treatment

Nursing Interventions for superior vena cava syndrome

Respiratory support; Supplemental oxygen Positioning; Elevate head of bed bending forward or lying flat may aggravate symptoms Strict I&Os ; Quantify diuresis; Monitor vital signs Monitor for mental status changes, confusion, increasing somnolence... Why?... WATCH FOR PROGRESSION (you're watching for worsening cerebral edema.) PRECAUTIONS: Fall Risk Aspiration Precautions Safe environment - Seizure Precautions

Treatment for SIADH

Restrict free water Increase enteric intake of sodium Hypertonic saline given if acute drop in NA+ and *symptomatic*

Cancer of the Esophagus: risk factors and s/s Management

Risk factors: *Chronic* irritation- lead to cell changes Alcohol/tobacco use GERD associated w/adenocarcinoma S/S: Dysphagia; sensation of mass in throat; painful swallowing; substernal pain/fullness; regurgitation of undigested food, foul breath, hiccups mgmt.: Medical: Surgery, chemotherapy, radiation Nursing: hemodynamic stability, airway, Adequate nutritional intake, decreasing risk of aspiration, relieving pain, patient education (information about treatments, reassurance)

Metabolic EMERGENCIES: SIADH S/S

SIADH is an urgency if there is a rapid/acute drop in serum sodium. S/S: SIADH can be due to hyponatremia and decreased ECF osmolality which causes the water to move into the cells causing cerebral edema. Signs and symptoms: depend upon the rate and severity of hyponatremia and the degree of cerebral edema. The earliest clinical manifestations of acute hyponatremia include nausea and malaise, which may be seen when the serum sodium concentration falls below 125 to 130 mEq/L (normal 135 to 145mEq/L). Vomiting is an ominous sign for patients with acute hyponatremia. With a more severe and acute fall in sodium concentration, headache, lethargy, obtundation, and eventually, seizures can occur. Coma and respiratory arrest can occur if the serum sodium level falls below 110-115 mEq/L. Chronic hyponatremia allows cerebral adaptation, and the patients remain asymptomatic despite a serum sodium concentration below 120mmol/L. Nonspecific symptoms like nausea, vomiting, gait disturbances, memory and cognitive problems, fatigue, dizziness, confusion, and muscle cramps can occur with chronic hyponatremia

main treatment options for LUNG CANCER

SURGERY-treatment of choice for NSCLC •Segmental or wedge resection •Lobectomy; Pneumonectomy (entire lung); RADIATION THERAPY (RT) -external beam radiotherapy may be given... •alone with curative intent in *early stage NSCLC*; •as adjuvant (in addition to) surgery; •in combination or sequentially with chemotherapy •Prophylactic Cranial Irradiation (PCI) to prevent/delay brain metastasis CLINICAL trials: participation recommended b/c of poor prognosis in Lung CA CHEMOTHERAPY •Treatment of choice for SCLC (more aggressive); used as adjuvant or combination therapy in NSCLC •Traditional *cytotoxic chemotherapy works primarily through the inhibition of cell division*.. kills rapidly dividing cells - hair, GI, bone marrow.. In contrast, targeted therapies, AKA: biological modifiers (mab suffix), are designed to block specific molecules required for tumor growth, progression, or spread of cancer. TARGETED THERAPY - NIBs and - MABs suffix Have held out new hope in the treatment of for non-small cell lung cancer These drugs target and promote death of cancer cells: -by interfering with cell growth signaling -by stimulating the immune system to recognize, target, and destroy cancer cells -they can be programmed to deliver toxic drugs specifically to cancer cells; -Targeted Therapies such as VEGF Inhibitors. impede tumor blood vessel development. The tumor needs a blood supply to grow... Renal Cell Carcinoma, for example is the most vascularized of all solid tumors VEGF is the strongest proangiogenic protein. Vascular endothelial growth factor (VEGF) *the more VEGF that is expressed the more tumor vascularization there will be*.. over the past 10+ yrs most of the new anti-CA agents approved by the FDA have been targeted therapies. Drugs that target VEGF- Bevacizumab (Avastin) Drugs that target EGFR - Epidermal growth factor receptor (EGFR) is a protein found on the surface of cells that helps the cells to grow and divide. Erlotinib (Tarceva) .

Superior Vena Cava Syndrome (SVCS) (structural emergency) Where would you expect to see S/S?

Seen most often with lung cancer and lymphoma Superior vena cava is compressed or obstructed by tumor growth. Sx result from blockage of venous blood flow from head, neck and upper body Condition can lead to a painful, life-threatening emergency. s/s: Early in the clinical course, partial superior vena cava (SVC) obstruction may be asymptomatic. As the syndrome advances toward total superior vena cava (SVC) obstruction, the classic symptoms and signs become more obvious. DYSPNEA is the most common symptom Characteristic physical findings of SVCS include: venous distension of the neck and chest wall, facial edema, upper extremity *edema* - face, eyes, periorbital -head fullness, -*cough* -*chest pain* -dysphagia, orthopnea, distorted vision, hoarseness, *stridor*,*headache*, nasal stuffiness, nausea, pleural effusions, and light-headedness. Severe s/s: *mental status changes*, *cerebral edema*, cyanosis, papilledema, *stupor*, and even coma. o Thrombus formation may occur and is due to thoracic central venous obstruction of subclavian vessel but also because of slow, impeded flow axillary, and brachiocephalic veins

what causes lung cancer? High risk criteria includes:

Smoking increases risk + risk also is increased by exposure to secondhand smoke and environmental exposures such as radon and workplace toxins (e.g., asbestos, arsenic). guidelines for lung cancer screening is ONLY for high risk patients with Low-dose CT (LDCT) of the chest which uses lower amounts of radiation than a standard chest CT and does not require the use of intravenous (IV) contrast high risk: people aged 55 to 74 who were current or former smokers; in fairly good health; AND those with at least a *30 pack-year history of smoking*. A pack-year is the number of cigarette packs smoked each day multiplied by the number of years a person has smoke

bladder cancer staging stage 0-4

Stage 0 - bladder lining Stage I -lining and muscle Stage II -muscle layer Stage III - into perivesical fat Stage IV -distant metastasis 4x more common in men than women

Signs and Symptoms of Oral Cancer

Swelling, thickening or roughness on the tongue, cheek or on the floor of the mouth. *White patches along the side of the tongue or on the lip, gums*. Unexplained bleeding in the mouth or throat. Soreness in the back of the mouth or in the throat. *Hoarseness*, chronic sore throat, or changes in the voice. *Persistent sores in the lips, tongue, palate or throat*. Unexplained red or white patches anywhere on the gums, tongue, throat, or lips.

Hypercalcemia of Malignancy: S/S

Symptom Prevalence: Calcium > 3.5mmol/L CNS symptoms 80% *Polyuria* 35% Calcium < 3.5mmol/L Malaise and fatigue 65% *Polyuria* 34% *use fluid to correct* due to polyuria causing depletion Mild hypercalcemia - Ca+ <12 mg/dL •asymptomatic or may report nonspecific S/S: *constipation*, *fatigue*, depression. Moderate - serum Ca+ 12 - 14 mg/d L (3 - 3.5 mmol/L) •Bone pain; secondary fractures •Acute rise may cause marked S/S: polyuria, polydipsia, dehydration, anorexia, N/V, weakness, *fatigue* changes in sensorium and cognition; and hypertension Severe elevation - Calcium >14 mg/dL (>3.5 mmol/L) •*CNS symptoms*: Confusion, delirium, disorientation, incoherent speech, hallucinations and delusions [Mental status changes worsen by dehydration.] ECG changes. • lethargy, stupor, and coma •**S/S more prominent in elderly and with any rapid rise* *Levels exceeding 16 mg/dL increased cardiac risk caused by conduction block brady arrhythmias* which may progress to *Complete Heart Block, V-tach degenerating to V-Fib, arrest...asystole* degree of hypercalcemia, along with the rate of rise of serum calcium concentration, determines symptoms and urgency of therapy.

fastest growing cancer in women? s/s Treatment options

THYROID CANCER Symptoms consistent with malignancy: •*Enlargement of lump/mass* most common •Hoarseness (kinda late sx) •Dysphagia (very late sx) •Pain •Hemoptysis •Stridor •Surgery (thyroidectomy) •Chemotherapy (metastasis) •Radioactive Iodine Therapy •Thyroid Hormone Therapy •External Radiation Therapy •Surveillance Targeted Therapy Slow growth types: Papillary - most common ; 86% Follicular - 9%; much higher incidence of distant metastasis, Medullary - 3% Rapid growth and spread: Anaplastic - 1%; aggressive, very hard to control

Hepatitis B:

Transmitted primarily through *blood via percutaneous or bodily fluids*. 10% mortality rate *Post-exposure treatment: *Hepatitis B immune globulin* (passive immunity- antibodies someone else made injected in their body) and active immunization (Recombivax HB) Acute infection (1-3 months—highly infectious) may involve prolonged convalescence, 3-6 months S/S: Jaundice, fatigue, anorexia, weakness, tender, enlarged liver/spleen, generalized malaise, aches, abdominal pain Treatment: *interferon injections*, antivirals (Epivir, Hepsera). *Must not drink alcohol or eat raw shellfish*. Abstinence or use of condoms necessary to avoid transmission. Bed rest with gradual increased activity following resolution of symptoms. 10% progress to carrier state or develop chronic hepatitis. Worldwide cause of cirrhosis and liver cancer

vesicant extravasation failure to assess ?

Vesicant refers to any medication or fluid with the potential to cause tissue injury, blistering or necrosis if it extravasates. (Cisplatin; Paclitaxel; Vincristine) Infiltration is the inadvertent leakage of a nonvesicant solution into surrounding tissue; extravasation is the inadvertent leakage of a vesicant solution into surrounding tissue causes tissue damage/injury. *Failure to assess & treat this complication in a reasonable time-frame can lead to devastating injury to the patient as well as medical malpractice lawsuit

Risk factors for thyroid cancer include:

age btw 25 - 65 years gender - being female exposure to radiation of head and neck as a child, *exposure to radioactive fallout*, hx of goiter, family hx of thyroid dx, or thyroid CA, certain genetic conditions.

The most common cancers associated with hypercalcemia (metabolic emergencies) Hypercalcemia of malignancy Hypercalcemia in patients with cancer is due to? norm calcium level

breast and lung cancer and multiple myeloma. foreshadows prognosis Production of humoral factors by the primary tumor, is the mechanism responsible for 80% of cases. The vast majority is caused by *tumor-produces parathyroid hormone*-whaaaat related protein disrupting the hormone control of calcium. increased bone resorption and *release of calcium from bone* into circulation. Bone resorption is the process by which osteoclasts break down bone and release the minerals, resulting in a transfer of calcium from bone into blood circulation Lab Values and Interpretation: Measure albumin level and Serum Calcium: 8 to 10 mg/dl Ionized (free) Calcium: 4 to 5.6 mg/d

Febrile Neutropenia Risk Factors for Febrile Neutropenia

definition of febrile neutropenia: Pt has a Fever •Single oral temperature >38.3 ºC (101ºF) •Temperature >38.0ºC (100.4ºF) sustained for > 1 hour and... •Pt is Neutropenic •Absolute neutrophil count (ANC) <500 cells/mm •ANC expected to decrease to <500 cells/mm within 48 hours Risk Factors for Febrile Neutropenia: ●Age> 65 ●Previous chemotherapy or radiation therapy ●Pre-existing conditions; comorbidities ●*More severe neutropenia, lasting >7days* ●Poor Renal or Liver function ●Higher treatment dose or intensity •Causative pathogens •Identified in only 30% of FN episodes •*Bacterial* in 85-90% of cases •Endogenous flora in 80% of cases •Common sites of infection: Skin; Respiratory tract; Urinary tract; and Gastrointestinal tract.. so focus your assessment

MOST common complaint r/t cancer Underlying correlations may be:

fatigue Thought to be r/t: accumulation of byproducts from tissue damage, cell death, and the pro-inflammatory response. *Fatigue is a subjective experience, best assessed by patient self-report* Underlying correlations may be: Impaired oxygenation Impaired organ function Deconditioning or Deficits Stressors increasing demand and expenditure Injury / Illness / Inflammation /Tissue damage / Cell death

Hepatitis A:

hepatitis A: 20-25% cases of clinical hepatitis in developing countries. Vaccine is available-confers 6-7 years of protection. -Transmitted primarily through *fecal-oral route* by ingestion of food or liquids infected by virus -Illness may last 4-8 weeks. Rarely fatal. No chronic hepatitis. S/S: diarrhea, fluid & electrolyte loss nursing mgmt: replete fluid and electrolyte loss high risk: very young/very old pts

Structural emergencies

in advanced lung cancer there is risk for metabolic structural emergencies . occur in advanced lung cancer and metastatic progression of other cancers. superior vena cava syndrome (SVCS) Spinal cord compression (SCC)

Clinical Indications for PN Formulas

inability to ingest, digest, or absorb adequate oral or enteral food or fluids within 7 days Examples: ◦Severe burns, malnutrition, short bowel syndrome, AIDS, sepsis, cancer ◦Paralytic ileus, Crohn's disease ◦Major psychiatric illness ◦Extensive bowel surgery, acute pancreatitis. 1-3 liters of fluid over 24 hour period -PPN (Partial Parenteral Nutrition) does not include lipids. -Intravenous fat emulsions may be added ◦This is called "*TPN" when lipids are added to the parenteral solution* ◦A special filter must be used (1.5 *micron filter*) ◦Mixed by Pharmacy based on recommendations from physician/Registered Dietician

Initiating Therapy Administration Methods

initiate slowly and advanced gradually each day to the desired rate Monitor Lab results/patient's response to PN therapy Standing orders for : ◦Daily CBC, glucose readings (Q 6 hours), Chemistry profile, ABGs, liver function tests, kidney function tests urine nitrogen, daily weight. PERIPHERAL METHOD: PN solutions may be administered via peripheral line or central line ◦Less hypertonic (lower dextrose content ◦Usual length of therapy is 5-7 days ◦An infusion pump must always be used ◦Formulations with dextrose concentrations ◦greater than 10% should not be administered via peripheral veins, as they may cause chemical phlebitis. central method: entral Parenteral Solutions (e.g.,TPN) ◦High solute concentration ◦Large blood vessels ◦Give via central venous access device Nontunneled central catheters; e.g. subclavian line Less than 6 weeks of therapy (short term) Peripherally inserted central catheters (PICCS) Several days to months (intermediate term therapy) Tunneled central catheters e.g., Hickman, Groshong Long term (years) Implanted ports (long term) *Do not administer meds, blood or other IV fluids through the same line as parenteral nutrition due to possible incompatibility, clot formation, etc.

Patients can be experiencing several or more of these at the same time

metabolic disturbances / Hormonal imbalance Taxing Cancer Treatments Myelosuppression...Anemia Cachexia; Anorexia; Nutrition Deficiencies Stomatitis; Mucositis; Psychological Distress , Stressors; or Depression Nausea, Dehydration Sleep Disturbances and Excessive Inactivity Polypharmacy Sustained Inflammatory Response; Infection Chronic illness / Comorbidities Physical deconditioning, advanced disease or age Pain, neuralgias Impaired cardiac, pulmonary, renal function

what is Parenteral Nutrition? Goals of Therapy

method of providing nutrition to the body by an IV ROUTE. Admixture of proteins, carbohydrates, fats, electrolytes, vitamins, minerals, sterile water goals of Therapy: -Establish a positive nitrogen balance -Maintain electrolyte balance -Improve nutritional status -Maintain muscle mass -Promote weight maintenance or gain -Enhance the healing process

myelosuppression Assessing RISK considers: pts at high risk

myelosuppressive potential of proposed cancer therapy decreased bone marrow reserve R/T prior treatments or direct bone marrow involvement in disease decreased ability to repair cellular damage R/T poor nutritional status or advanced age *potential for prolonged exposure to chemo agent due to*: -Renal or hepatic dysfunction -Presence of physiologic effusions (*pleural effusion*) which can sequester chemo agent high risk for myelosuppression: -combination therapy = higher risk -higher dose higher risk -patient specific increased risk = previous hx of treatment malnutrition patients -patient with chronic diseases =higher risk -patients with longer exposure (pleural effusions) continue to expose patient to chemotherapy

Extravasation/infiltration should be suspected if:

patient c/o burning, stinging, pain or discomfort at site, swelling, edema, erythema, leakage at the site: • there is loss of blood return at IV access • stay away from hands and 3 in near wrists. •there is absence of gravity free flow on infusion: chamber on drip sluggish/doesn't prime easily •there is an increase in resistance when administering IV push drug Can occur with central line/ port cytotoxic Drug Extravasation is a progressive injury... *Immediately post incident*: Burning/Stinging around cannula site, Swelling, erythema, pain Hours after Extravastion... there is an evolution of the injury •-vasodilatation...leads to •-increasing pain... and •-oedema *Over the first days* and weeks post incident... the impact of complications can include: •-Ulceration •-Infection *Longer term disabilities* as a result of the extravasation injury become evident even farther out... Weeks to months post incident, the full extent of consequence from injury may be: •-Contractures •-Dystrophy •-Loss of function •-Disability; disfigurement *Severity of injury ranges from local irritation to amputation*

Grading of the symptoms of hepatic encephalopathy grade 1-4 Medical/nursing management: Hepatic Encephalopathy and Coma

performed according to the so-called West Haven classification system: Grade 0 - Minimal hepatic encephalopathy (previously known as subclinical hepatic encephalopathy). Lack of detectable changes in personality or behavior. Minimal changes in memory, concentration, intellectual function, and coordination. Asterixis is absent. Grade 1 - Trivial lack of awareness. Shortened attention span. Impaired addition or subtraction. Hypersomnia, insomnia, or inversion of sleep pattern. Euphoria, depression, or irritability. Mild confusion. Slowing of ability to perform mental tasks. *Asterixis can be detected*. need serum ammonia levels + call doc Grade 2 - Lethargy or apathy. Disorientation. Inappropriate behavior. Slurred speech. Obvious asterixis. Drowsiness, lethargy, gross deficits in ability to perform mental tasks, obvious personality changes, inappropriate behavior, and intermittent disorientation, usually regarding time. Grade 3 -Somnolent but can be aroused, unable to perform mental tasks, disorientation about time and place, marked confusion, amnesia, occasional fits of rage, present but incomprehensible speech Grade 4 -Coma with or without response to painful stimuli nursing mgmt: Hepatic Encephalopathy & Coma -Identifying / eliminating precipitating cause -Monitor neurological status, vital signs, limit protein intake, ammonia levels; administer prescribed therapy -*Lactulose administered to reduce serum ammonia levels* -Promotes excretion of ammonia in stool (3 stools/day is optimal)

Refeeding Syndrome patients at High Risk for Refeeding Syndrome prevention and Treatment of Refeeding Syndrome

potentially fatal shifts in fluids and electrolytes that may occur Strongest risk factor: malnourished patients receiving artificial refeeding (enteral or parenteral). BMI less than 16 Shifts result from hormonal and metabolic changes *Hallmark biochemical feature*: ◦*Hypophosphatemia*. Normal range: 2.5 to 4.5 mg/dL Other clinical manifestations: ◦Abnormal sodium and fluid balance ◦Changes in glucose, protein, fat metabolism ◦Thiamine deficiency, hypokalemia, hypomagnesemia patients at risk: -Anorexia nervosa -Chronic Alcoholism -Oncology -Post-op -Elderly with decreased physiological reserve -Uncontrolled diabetes mellitus -Chronic Malnutrition -Long-term use of antacids -Malabsorptive syndrome -Long-term use of diuretics -Unintentional weight loss: greater than 15% in past 3-6 months or BMI less than 16 -Little or no nutritional intake for more than 5 days prevention and Treatment of Refeeding Syndrome: Assess labs: serum potassium, calcium, phosphate, magnesium, albumin, renal and liver function (creatinine and BUN; liver enzymes). Check for losses in urine as well. Administer thiamine, vitamin B, multivitamin, trace element supplement as ordered by MD. Rehydrate carefully and correct levels of electrolytes which are out of range Monitor labs daily Start enteral or parenteral feedings slowly: no more than 50% of energy requirements according to dietician and MD orders.

Chronic Pancreatitis: additional tests Treatment of Chronic Pancreatitis

progressive destruction of pancreas Cells replaced by fibrous tissue results in mechanical obstruction of pancreatic and common bile ducts and the duodenum; destruction of secreting cells of pancreas Major Causes: alcoholism, malnutrition *nursing int: give insulin, give enzymes* give pancreatic enzymes with food Signs and Symptoms: Pain in the back and abdomen. In some cases, abdominal pain goes away as the condition advances, probably because the pancreas is no longer making digestive enzymes . diagnosis: -The diagnosis of chronic pancreatitis is difficult because routine blood studies (such as amylase and lipase levels) do not necessarily show elevations - diagnosis is an *accurate medical history* -Ultrasonography, CT scan, ERCP,EUS (Endoscopic Ultrasound) , MRI -Additional tests may include the glucose tolerance test (a test to measure damage to the cells in the pancreas that make insulin) and a biopsy (an exam of tissue removed from the pancreas). The *treatment* for chronic pancreatitis *depends on the symptoms*. treatment: -Pain management and nutritional support. -Oral pancreatic enzyme supplements are utilized to aid in the digestion of food -Patients who develop diabetes require insulin to control the blood sugar. -Cessation of alcohol consumption. -A diet low in fat -Eat more frequently in much smaller portions. -Surgery to relieve abdominal pain, to restore drainage of pancreatic secretions, or to reduce the frequency of attacks. -Islet Cell Transplantation for Chronic Pancreatitis.

INITIAL treatment of severe hypercalcemia

simultaneous administration of saline, calcitonin, and a bisphosphonate simultaneously. *depends on how high and how quickly it changed*. #1: *SALINE HYDRATION*- isotonic saline corrects any volume depletion due to hypercalcemia-induced urinary salt wasting and vomiting. *Hypovolemia exacerbates hypercalcemia* by impairing the renal clearance of calcium. Rate of saline infusion depends on severity of hyperCA+, patient's age, and presence of comorbidities, particularly underlying cardiac or renal disease. *Isotonic saline* is given at an initial rate of *150 to 200* mL/h until any fluid deficit is corrected and diuresis occurs -urine output 100 or more mL/h. Saline therapy rarely normalizes the serum CA+ level in patients with more than mild hypercalcemia. (worry about HF and renal failure patients) What nursing interventions and assessments: Strict I&O monitoring. *fluid overload*, watch for s/s. goal of Loop Diuretics: Administration of a loop diuretic once fluid repletion has been achieved further increases *urinary calcium excretion*. Monitor for fluid and electrolyte complications resulting from a massive saline infusion and furosemide -induced diuresis such as hypokalemia, hypomagnesemia. #2:Therapeutic goal of CALCITONIN: Rapidly lowers serum calcium concentration by a maximum of 1 to 2 mg/dL within four to six hours by *increasing renal calcium excretion and, more importantly, by decreasing bone reabsorption* via interference with osteoclast maturation *Efficacy of calcitonin is only useful in the first 48 hours*. Calcitonin and hydration provide prompt reduction in calcium concentration...but *only #3: BISPHOSPHONATES* *provide a sustained effect*, inhibiting calcium release by interfering with osteoclast-mediated bone resorption . Dialysis—indicated in severe hypercalcemia and co-morbidities of *kidney disease or heart failure* where aggressive hydration cannot be safely administered.

common Symptoms of Lung Cancer

tend to be recurring, persisting, or nagging: -A cough that doesn't go away and gets worse over time -Constant chest pain -Coughing up blood -Shortness of breath, wheezing, or hoarseness -*Repeated problems with pneumonia or bronchitis* -Swelling of the neck and face -Loss of appetite or weight loss for no reason -Fatigue

Nursing Considerations: EBRT (External beam radiation therapy): Side Effects Radiation dermatitis principals for skin protection: instructions for patient:

•Acute S/E :fatigue, alopecia, anorexia; dysphagia, myelosuppression, skin problems, mucositis •Delayed and chronic S/E: xerostomia, lymphedema, increased future cancer risk. radiation dermatitis: Skin may be red, irritated, swollen, tender, blistered, sunburned, or tanned; may become dry, flaky, itchy, and will "shed". wet and dry desquamation (shedding skin) need perfusion for healing exposure reposition - protect from pressure friction/ shear instructions: -covering skin, avoiding sun/ sunscreen, chemical (shampoo/lotion, shaving cream, perfume, soap- leaves a film) -wear loose clothing for minimizing friction/shear . dont scrub/rub generally need to do this for 1 year where radiation was done.

Post-PNEUMONECTOMY (removal of entire lung) complications Early, major, ACUTE complications to be alert for

•DEHISCENCE of bronchial stump •RESPIRATORY FAILURE •Incidence up to 18%; watch for acute onset of *hypoxemia and hypercapnia* •Chest physiotherapy, IS, and early ambulation are crucial •CARDIAC HERNIATION •Can occur immediately or within 24 after surgery •Much greater risk post right pneumonectomy •Mortality 50% •Tachycardia; *profound hypotension*; shock •Emergency surgical correction is key to survival •PULMONARY EDEMA s/s: Crackles, SOB, dyspnea, decline sats, increased o2 requirement, inc HR/RR. •R/T entire pulmonary blood flow directed to the remaining lung; increased hydrostatic pressure; loss of lymphatic drainage due to lung removal; endothelial damage due to ventilating pressure •ARRHYTHMIAS: •Incidence is up to 50%! 1/2 of patients develop an arrhythmia •60-70% are *atrial fibrillation* •Antiarrhythmic prophylaxis with *Diltiazem* get BP/ check perfusion Delayed complication = BRONCHOPLEURAL FISTULA ANATOMIC CHANGES- air fills the space previously occupied by the lung, the *postpneumonectomy space* (PPS). Over time, a number of changes result in a decrease in the size of the PPS, including: (1)elevation of the hemidiaphragm, (2) hyperinflation of the remaining lung, and (3) shifting of the mediastinum towards the PPS. At the same time, there is (5) progressive resorption of air in the PPS (6) replacement with fluid. As a general rule, fluid accumulates at a rate of approximately two rib spaces per day. After two weeks, 80 to 90 percent of the PPS is filled with fluid. By chest radiograph, complete opacification of the hemithorax after pneumonectomy takes an average of approximately 4 months to occur. Unexpectedly rapid accumulation of fluid into the PPS in the immediate postoperative period should raise concerns for hemorrhage into the PPS, infection of the PPS

Anemia Bone marrow suppression Decreased number of RBC

•Leads to hypoxia, fatigue •Hgb 9.5-10 gm/dl require oral iron supplements •Hgb below 8 gm/dl require transfusion •May use Epogen to stimulate RBC production

bladder cancer: whos at risk? how's it Diagnosed? s/s of bladder cancer

•Urine cytology •Intravenous Pyelogram (IVP) •Renal ultrasound ...*exposure to people who work with chemicals and fumes.* *cigarette smoking is most preventable risk* diagnostics: •CT/MRI •Bone scan if CT suggests metastatic disease. •*Cystoscopy with Biopsy* (visualize bladder and see tumor) •Lifelong Surveillance via cystoscopy & urine cytology Q3 mos x 1yr, Q4 mos x 1yr, Q6 mos x 1yr, then annual s/s: Gross *hematuria* •Dysuria/frequency/urgency/nocturia •Flank pain-tumor obstructs ureteral flow/ Lower back pain (tells you location of tumor) but pain is a less common sx •Microscopic hematuria in 20% of bladder cancers (more common in prostate cancer)