Oncology Emergencies NUR486 PDF

Oncology Emergencies  NUR486  AWimsattMSNRN UofL Oncologic Emergencies Myelosuppression – Neutropenia Infection/Sepsis – Thrombocytopenia – Anemia Hypercalcemia Tumor Lysis Syndrome (metabolic disturbances) SIADH Superior vena cava synd...

Oncology Emergencies  NUR486  AWimsattMSNRN UofL Oncologic Emergencies Myelosuppression – Neutropenia Infection/Sepsis – Thrombocytopenia – Anemia Hypercalcemia Tumor Lysis Syndrome (metabolic disturbances) SIADH Superior vena cava syndrome Spinal cord compression  Neutropenia  Nadir  point at which the lowest blood cell count is reached after chemotherapy. Usually occurs at about 7-14 days.  Neutropenia is the single most dose-limiting toxicity of chemotherapy (#1 reason patients will not receive their chemotherapy)  ANC will indicate relative risk for infection:  1500-1000: low risk  1000-500: moderate risk  500-0: severe risk  Hold chemo if risk is severe or sometimes moderate  Fever may be the only sign of infection the immunocompromised patient can exhibit  Infection is a major cause of mortality in patients with CA  55%-75% of fevers in oncology patients are caused by infection  Neutropenia  Neutrophils constitute approx 50-60% of WBCs.  Segmented or Poly-segmented neutrophils are mature WBCs  Bands are immature neutrophils  Neutropenia Calculating an ANC ANC= Segmented neutrophils + bands X White blood cell count 100 EX: wbc 1600, segs/polys= 48 , bands= 5 ANC= 48 + 5 = 53/100=.53 x 1600 = 848 100  Neutropenia  Nursing Care:  Anticipate  Pancultures-blood, sputum, urine, discharge & drainage, invasive lines  CBC, Chemistry (BMP or CMP)  CXR  IV fluid hydration (with Normal Saline)  Anti-pyretic therapy  Antibiotics  Colony Stimulating Factors (ie. Filgrastim/Pelfilgrasim Neulasta)  Prevention is Key  Handwashing is still the #1 way to reduce incidence of infection!!!!  Neutropenia  Nursing Care  Patient Teaching  Wash hands  Bathe daily  Good skin care  Meticulous oral care  Only electric razors  Cough & Deep Breathe  Avoid persons w/ active infections  Avoid persons recently vaccinated (within last 30 days) w/ live vaccines  Thrombocytopenia Low circulating platelets  Normal= 150,000- 400,000 Nursing Care Anticipate H & H  Platelet count  PT & PTT  Possible platelet transfusion Generally for plt. Counts below 20,000  Thrombocytopenia  Assessfor physical/objective S/S of bleeding (serious risk when PLTs < 50,000) Petechiae Bruising Ecchymosis (purplish bruising) **sign of bleeding in capillary beds Frank bleeding Frequent nose bleeds Prolonged bleeding times Hematuria Blood in stool c/o “worst headache of my life” hypotension  Thrombocytopenia Institute bleeding precautions (for hospital and home) – Reduce activity that may result in injury – Maintain integrity of skin – Meticulous oral care Don’t floss Rinse frequently Don’t use mouthwashes that contain alcohol Soft bristled toothbrushes/or soft sponge – Electric razors – No restrictive clothing – No tourniquets – Minimize needle sticks – Blow nose gently – Stool softeners – Safe home environment – GI tract **may need soft diet  Hypercalcemia  Most common oncologic emergency  Common in metastatic disease of bone or multiple myeloma  Normal Calcium level: 9-11 mg/dl (symptoms > 12)  Most calcium stays in bone  Metastatic tumor in bone—causing bone lysis  Ca++ plays major role in: o Muscle contraction (including cardiac muscle) o Neurotransmission o Several Metabolic functions o Blood clot formation  Hypercalcemia Assessment Findings Assessment Findings Increased temp Decreased BP N&V Pulse= rapid & weak Extreme thirst Polyuria Anorexia Bone pain Confusion Constipation *EKG Changes (mostly *Hyporeflexia sinus bradycardia, prolonged PR and Seizures shortened QT intervals) Fatigue Renal failure  Hypercalcemia  Treatment  Hydration o 3-4 liters orally/day for mild or no symptoms o 5-8 liters/day in moderate to severe hypercalcemia w/symptoms o Loop diuretics after adequate rehydration—to enhance kidney excretion of Ca++  Possibly administer meds to inhibit bone break-down or increase bone formation Calcitonin = inhibit bone resorption  Biophosphonates o Etidronate o Pamidronate  Severe cases may require hemodialysis  At least Daily Lab values  Increase mobility if possible  Hypercalcemia Nursing Care Daily labs: – CMP or BMP – Ionized calcium Seizure precautions until serum Ca++ level falls below 12 Neuro checks Q 4Hrs & PRN VS Q 4 Hrs & PRN Daily weight Pathological fractures (assess for bone pain) OOB & Ambulate when able—at least 3 times a day Patient education: – Hydration – Mobilization – Taking pulse at home  Anemia  Long term chemo and / or radiation and suppression of RBCs  Fatigue main symptom o Contributing factors Products of cell destruction Inflammatory response Depression Medications Inadequate nutrition o Anticipate RBC counts RBC growth factors Epoetin (Epogen, Procrit) Rarely RBC transfusion  Tumor Lysis Syndrome – Serious metabolic disturbance caused by the death of cancer cells during cancer treatment & the release of their intracellular components into the bloodstream – Characterized by rapid development of: Hyperkalemia Hyperuricemia Hyperphosphatemia Hypocalcemia  S/S may occur a few hours after start of treatment but are more likely to occur 24-48 hours after chemotherapy  Tumor Lysis Syndrome Clinical Manifestations – Diarrhea – Lethargy – Muscle cramps – Nausea – Vomiting – Numbness/tingling – Parasthesias – Weakness Overall danger/concern is metabolic acidosis  Tumor Lysis Syndrome  ***ongoing hydration is Key***  Treatment for TLS induced hyperkalemia o Stop any IV infusions that may contain K+ o Lasix o IV infusion of hypertonic glucose & insulin o Calcium gluconate o Possibly kaexylate o Extreme situations may require dialysis  Treatment for TLS induces hyperphosphatemia: o Phosphate-binding antacids o Hypertonic glucose & insulin infusion  Tumor Lysis Syndrome  Treatment for TLS induced hypocalcemia: o IV calcium gluconate  Controversy over this because may increase calcium phosphate salts—which could lead to deposition of these solids in tissue and glomerulous of Kidney  Treatment for TLS hyperuricemia: o Allopurinol—inhibits uric acid synthesis ( results in decreased amounts of uric acid crystal precipitation in kidneys) o Possible urinary and serum alkalinization with IV infusion of Sodium Bicarbonate o Controversy over this treatment because alkaline pH increases risk for calcium phosphate salt precipitation in renal tubules.  Tumor Lysis Syndrome Nursing Care of TLS: Assessment – Cardiac monitor – VS at least Q 4 hrs & PRN – Neuro checks Q 4 Hrs & PRN – Strict I & O—UOP should be in balance with intake – Daily weights – Fluid overload AEB edema, distended neck veins, adventitious lung sounds (monitor for crackles, S3) – Urine color, appearance, and pH – Monitor BUN & Creatinine, serum uric acid levels – Muscle twitching/spasm  Tumor Lysis Syndrome  Anticipate: o Serum electrolytes, BUN/Creatinine, and uric acid Q 6-12 Hrs until normal levels are achieved and physical condition is stable  Patient/Family Teaching o Watch for s/s of electrolyte imbalances o Hydration o I&O  Syndrome of Inappropriate Anti Diuretic Hormone (SIADH) Cancer cells in tumors can manufacture, store, and release ADH—excess secretion of ADH Chemotherapeutic agents vincristine and Cytoxan stimulate release of ADH from pituitary and tumor cells Results in water retention and hyponatremia Symptoms – Weight gain without edema – Personality changes (mental status changes), disorientation – Decreased reflexes, generalized muscle weakness – Seizures / coma - ***serum concentrations of less than 125mEq/L (high risk of seizures, coma, respiratory arrest)  Syndrome of Inappropriate Anti Diuretic Hormone (SIADH)  Treatments o Correct sodium-water imbalance Do not correct rapidly o Fluid restriction o IV 3% NS in severe cases  Ongoing monitoring of Na levels  Superior Vena Cava Syndrome  Obstruction of the blood flow returning to the heart from the head, neck, upper thorax, and upper extremities. o Set of symptoms that results when blood flow through the SVC is blocked  4 Most Common Causes: o Extrinsic mass o Mass invading vessel wall o Thrombus around a central venous catheter o Thrombus in the vessel  Superior Vena Cava Syndrome  Clinical Manifestations: o Caused by buildup of pressure in the Superior Vena Cava  Chronic Onset or Acute o BP will be higher in arms than in legs o Dyspnea/SOA/Cough on exertion o Possible stridor o cyanosis o Progressively c/o facial and arm swelling (“feel full”) o Edema of upper body o Progressive head, neck and thoracic vein distention o Headache o Visual changes o Seizure o Can lead to CHF and vascular collapse  Superior Vena Cava Syndrome Medical Treatment: – Radiation therapy : first line treatment of acute-onset when trachea, esophagus, vocal cords, and/or pericardium are compressed and/or invaded – Chemotherapy—to shrink an inoperable mass PALLIATIVE – Anticoagulants to prevent clotting – Surgery ASAP, if possible, to remove the mass – Possible stenting of the SVC  Superior Vena Cava Syndrome – Diuretics **use with caution because could cause even further decreased venous return related to dehydration (decrease pre-load) – Steroids to reduce edema – Bronchodilators, vasopressors, antidysrhythmics as needed – IF due to thrombus IV heparin drip to prevent or resolve thrombosis Possible “Clot Buster” ie. Urokinase – Anti-anxiety medications  Superior Vena Cava Syndrome Nursing Care:  Assessments o VS at least Q 15 mins and PRN while actively in distress o Maintain patent airway o HOB at 45-90 degree angle at all times (unless cardiac or pulmonary arrest) o Take BP in lower extremities o Strict I & O  Superior Vena Cava Syndrome – Suction Equipment at bedside – Monitor for signs of respiratory distress or cardiac failure – ABGs and oxygen administration – Assist w/ ADLs Space ADLs with frequent rest periods – Instruct patients not to engage in activities that will increase intracranial pressure Bending Straining sneezing  Spinal Cord Compression  Malignant tumor in epidural space of spinal cord o Malignant spinal cord compression occurs when cancer cells grow in, or near to, the spine & press on the spinal cord & nerves  Neurologic emergency due to potential of rapid deterioration of neurologic symptoms  Most commonly associated with metastatic disease of the breast, lung, prostate; multiple myeloma; and lymphomas  Spinal Cord Compression  Manifestations-caused by increased pressure on the spinal cord & nerves o Intense, localized, persistent back pain Back pain worse when recumbent, bearing weight, coughing, sneezing, or valsalva maneuver 1st symptom is usually unrelieved back or neck pain Relieved with sitting o Motor weakness & dysfunction- difficulty walking o Sensory paresthesia & loss –numbness, coldness o Autonomic dysfunction Bowel & bladder function disrupted- Passing very little urine or none at all; constipation or problems controlling bowels  Diagnosis o X-rays, MRI, or CT scan o MRI is gold standard  Spinal Cord Compression  Management o Corticosteroids to reduce swelling/edema – usually started immediately if suspected Dexamethasone every 6 hours o External Radiation therapy – primary treatment o Surgical/decompressive laminectomy –only small # of patients suitable candidates for o Chemotherapy occasionally used o Neuro checks q4 hours & prn (more frequently if required) o Monitoring lab work – potential tumor lysis issues (esp. with lymphomas) o Activity limitations o Pain management-Bisphosphonate drugs