Oncology Week 12 P2 PDF

Oncology part 2 Metabolic panel Cytology looking at the cells within the fluids Caution to catch cancer in its earlier stage is best C- change in bladder or bowel patterns A- a sore that does not heal (mouth cancer) two weeks to heal if it doesn't heal you should seek medical advise U- unusual...

Oncology part 2 Metabolic panel Cytology looking at the cells within the fluids Caution to catch cancer in its earlier stage is best C- change in bladder or bowel patterns A- a sore that does not heal (mouth cancer) two weeks to heal if it doesn't heal you should seek medical advise U- unusual bleeding or discharge from an Orphus, bleeding from the bladder, thickening or presence of a lump, indigestion or difficulty swallowing, obvious change in a wart or a mole, nagging cough or hoarseness. With cancer you are not only treating the patient you are treating the family, but they are also very involved in the care, there are no limited visiting hours Management of cancer Aim for a cure with complete eradication of the malignancy Control- prolonged survival and containment of the cancer cell growth Palliative or palliation-relieve the symptoms of complications associated with the disease Healthcare teams and patients and family must have an understanding of the goals and treatment options. Usually there is a combination of treatments modalities, sometimes there\'s one, but usually it\'s a combination that is most affective (surgery and radiation, surgery and chemo) Surgeries Prophylactic- removal of the at-risk tissue (BRCA gene may removal the breast, uterus of fallopian tubes) Diagnostic is removal of a part or all suspicious tissue, there are different classifications of diagnostic one is incisional -- take a piece of the tumor, excisional- take the entire mass and tissue, needle aspiration biopsy- sample suspicious tissue that is ultrasound guided of cat scan guided, curative is when the remove all the cancer tissue, cancer control or cytoreductive as known as debulking its done at end stage disease or stage 4 it decreases the amount of tumor but because it\'s so extensive they can\'t remove it all. Palliative helps to improve the quality of life also helps to improve with symptom relief (urinary stent, colostomy usually done in stage 4), reconstructive usually follows curative surgery to obtain a more desirable and cosmetic look or effect (double mastectomy and then have implants put in) Treatment options Radiation- destroys cancer cells with hopefully minimizing effect on surrounding tissue usually is localized, but you must think about the other structures within that area (neck- carotid and jugular veins, esophagus, thyroid, swallowing difficulties) can be curative, palliative, help with bone metastasis and relieve pain, neoadjuvant --means used in addition to( decrease the size of the tumor then have surgery), can also be used prophylactically to prevent spread of primary cancer Two types of ionizing radiation Electromagnetic- Particulate- Complication called SVC superior vena cava syndrome sometimes use radiation if it\'s a tumor that caused SVC then use radiation to help decrease the size of the tumor in SVC patients EBRT- external beam radiation therapy- most common type of radiation comes from a source outside of the body and involves an invisible beam of highly charged electrons that penetrate the body and target the tumor (no precautions necessary, there are no risk to you) low dose over a longer period of time SBRT- stereotactic body radiation therapy --increased dose over a shorter period of time, treatment days (doc may order 5 days over a period of time, (can go for a week everyday, one a week 4-5 treatments depends on the type of cancer and the patient\'s ability to tolerate it) typically used to treat deep seated tumor proton therapy- delivers a high dose of radiation to a tumor, helps to spare healthy tissues, used a linear transfer, more linear than other radiations Breaky therapy- needs radiation precautions, involves the private room, end of the hallway, with radiation signs, nurse will wear a dosimeter and use precautions of time, distance and shield, no roommate, can be Temporary- intraluminal-insertion of catheters to deliver a radioisotope to the tumor bed, intracavity- an applicator that\'s inserted within a cavity(vaginal), systemic- time distance and shielding, private room end of the hallway, radiation precaution signs, when they are getting an IV of an isotope radiation that targets a specific tumor usually used for thyroid Dosimeter- Measure the exposure to radiation therapy, put it on when you arrive and leave it when you leave, every month the radiation safety officer will measure your exposure and tell you if you can continue working in radiation areas, room could be lead lined, don't always assign the same nurse to take care of radiation patients to limit exposure, principles of time, distance, and shield, limit visitors to 30 ins a day, no pregnant ppl or staff, post appropriate notices and signs, radiation officer leaves specific instructions, rotate the staff no children, if seeds gets dislodged we use tings to pick it up and put in a container lead bind and call radiation officer Time- time spent with the patient, attempt to do a lot of the things need to do at the same time to minimize time spent Distance- maximize distance about 6ft Shielding- patients will have a lead shield and or you stay behind a lead shield (things we can do to prevent exposure- talking from the doorway, lead shield) Permanent -- intestinal- delivers radiation close to the site via seeds (breast and prostate) or seeds (inside the person), still need precautions but not as intense as temporary, could have a roommate, (exposure being within 3ft of a pt with seeds) Seed side effects- sexual disfunction, incontinence if its the prostate Side effects of radiation- skin changes, skin that is in the area that is being radiated, they can get skin dermatitis, can range from erythema to ulceration, things to do- care plans in the text book, when drying the skin use a patting motion, in the sun use a shirt, lose fitting cloths, don\'t use soap in the area that\'s reddened, can impair healing if it's done before surgery, local hair loss with radiation to the brain, altered taste metabolites releasee from the dying cells, could have mucositis connected with radiation to the, stomach, esophagus or colon. Radiation can be associated with the oral tissue. It is in the mouth called stomatitis it like a mouth sore, normal pain times several, when it goes down the track and effects the stomach, esophagus and colon it\'s called mucositis, xerostomia- dry mouth (alters appetite and nutrition), cytopenia- decrease in platelets in the bone marrow due to radiation especially if it is in the sternum or iliac crest, fatigue because of the increase energy needed to repair the damaged cells, could have fever, malaise, anorexia has to do with some of the substances that are released when the cells are being destroyed, could have long term affects scar tissue that leads to fibrosis, atrophy or ulceration or necrosis to tissue that was radiated Erythema dry desquamation- skin altered dry flaky skin Erythema wet desquamation- skin having an ulcer or a wound if it is red we will use a warm wet cloth with no soap, pat dry avoids hot water bottles Chemotherapy-used to treat systemic disease, leukemia, lymphoma, treats solid tumors to decrease the size of the tumor in hopes that the body will get rid of the remaining cells, can be used to shrink the tumor before surgery would allow the patient to rests for a few weeks then move forward with surgery, used after surgery to eliminate any remaining malignant cells, can be combined with radiation and surgery, goals can be different for each patient it can be for cure, control, or for palliative care. 100% eradication with chemo is not possible but the goal is to reduce it enough then allow the body to get rid of the rest Chemotherapy is given in regiments and cycles, it's designed to treat a certain cancer, and it has shown to be effective, each patient\'s regiment or cycle is individualized, (example-patient may be on 24hr chemotherapeutic agents and multiple agents will be given in combination 5days 1 a month), treat after chemo- counts drop 7-10 days after so we will give filgastram Pre chemotherapy checklist- V/S- making sure there\'s no temp wed have to look for infection, blood counts, WBC are low we would hold the chemotherapy (chemo would destroy their WBC even further)- could treat the with filgastram or nucogin (cancer meds, we'd have to get their count up before starting their regiment) Premedicate with Zofran to prevent nausea, give small frequent bland meals, lorazepam in lower dose can help with nausea Alopecia- loss of hair, cryotherapy used to help with hair loss Chemo can cause neuropathy, decrease cognitive function, fever, fatigue, and malaise Myelosuppression- it affects the bone marrow, you\'re going to have neutropenia, cytopenia, thrombocytopenia (body is constantly producing cells from the bone marrow its rapidly dividing, in the bone marrow there are RBC, decrease RBCs create anemia(associated with anemia SOB, pale color , WBCs it\'s going to affect the production, and the patient will become neutropenic with higher risk for infection, platelets patient is going to have thrombocytopenia, bleeding ) Chemotherapy precautions- double gloving, flushing twice any bodily fluids- emesis, stool, urine done during the time that they are getting chemo and 48 hours after Repeated cycles are better for destroying cancer, can be given IV, ORAL, intrathecal (in the spine) Radiation has localized effects whatever is being radiated that the effect it\'s going to have with chemotherapy it is going to have a more systemic effect, it targets rapidly dividing cells, cells like the lining of your mucous membranes, some of the side effects are because it's destroying the rapidly dividing cells N/V diarrhea- 24-48hrs after administration but can be delayed up to one week When we administer chemotherapy, some facilities have thick gloves if not you double glove, the pharmacy makes up the chemotherapy and the prime the line for you so you don't have to, when you\'re done you would dispose of it in a chemotherapy waste receptacle (hazard waste receptacle- no other garbage goes in there expensive to dispose) Dosage will be based on the person body weight as well as previous response to chemotherapy or radiation and functions of major organs (we would look at labs to see what the body can handle-depends on the chemotherapy agent) if there was an issue last tie with chemo the may reduce the does this is why we should look at previous response, doses are determines to maximize cell death but minimize health tissue Extravasation- leakage of a VESSICANT (dr recusant, dona recusant) causes necrosis, sloughing of the tissue, erosion, we are constantly monitoring the site of the IV or central line (if you have to do it through a peripheral IV you most constantly monitor the IV)( brand new one, blood return, if you notice pain or it starts to become uncomfortable of you notice redness or swelling you stop the infusion) Protocols followed- depending on the med we would give a certain antidote (dependent on the med that was given) Chemo can be given impatient, outpatient and at home it can be given orally, IV, Interfacial which is the spine group will depend on the agent the dose and the location and extent of the disease Chemo-Can cause anorexia, alopecia, they should avoid pregnancy, GI disturbances, some cause more than others, N/V Toxicities- Blood (all) counts are usually at its lowest 7-14 days after its done, febrile neutropenia is fever of the neutrophil count less then 1500. Give nucogen subq- stimulates bone marrow to produce WBC especially neutrophils its a colony stimulating factor, does stimulate the bone marrow to produce those blood cells, side effect of nucogen would be bone pain, it helps to decrease the duration of neutropenia and episodes of infection and a need for antibiotics, helps to keep the patient on their cycle or regimen on time. Epogen erythropoietin also called Procrit it stimulates erythropoiesis and blood cells to treat anemia, does reduce the chance of the patient needing a blood transfusion and a side effect of this would be high blood pressure if it does too much by producing too much RBCs could cause high BP Interleuken also called numega is used for low platelets, it can cause pulmonary edema, so it\'s not used often and profound diarrhea, alternative is to treat with blood transfusions Kidney damage due to the direct effect of chemo during the excression, medicate to prevent that from happening by giving mannitol to flush them out, monitor their BUN and creatinine and electrolytes there are ones that cause hemorrhagic cystitis which causes bladder toxicity that\'s from a certain chemo which is Cy toxic, some cause neurologic toxicity that\'s where the neuropathy comes into play Safety considerations preparations are done by pharmacy, we don\'t prepare it, we need to wear PPE, double gloves, or chemotherapeutic gloves depending on the facility that may a gown as well, mask, all of the fittings on the tubing\'s are Lural locked, dispose into the hazard waste, spills there are chemo spill kits- chuck that you throw over the spill and absorbs most of it than you would call housekeeping to tell them you have a chemo spill then they would come and clean it.(meta port gets pulled out by accident and the chemo spills everywhere) Education and monitoring -- premeds can be taken at home or in the hospital before chemo but we have to educate what\'s abnormal S/S that you are experiencing at home after you\'re done with chemotherapy that you should be notifying the doctor about. Discuss chances of infection, chances of bleeding, bleeding precautions, what kind of S/S they may experience in those 7-10 days after chemo, they will feel more fatigued or SOB, neutropenic diet- eating things that won\'t cause an infection (listeria in deli meat, no raw foods, fruit that would be ok if it had a skin on them, pasteurized milk, don\'t under cook food) Bone marrow transplant- used for liquid tumors then solid, it replaces damage bone marrow with stem cells, the stem cells are immature cells that can mature to form all different types of blood cells (patients with leukemia, non-Hodgkins\'s lymphoma) we can harvest stem cells from peripheral blood removal, a patient that is going to receive a bone marrow transplant is either going to receive myeloablative or non-myeloablative chemo first Myeloablative means its a high dose chemotherapy, total body radiation to completely wipe out the bone marrow, cancer cells, and prevent rejection Non myeloablative used for older patients that can't tolerate myeloablative, or a patient that has decreases organ function, it\'s not as strong it doesn\'t completely destroy the bone marrow Autologous- patients on cells, take out treated to kill any malignant cells then returned to the patient Allogenic- outside matched donor, markers HLA human leukocyte antigens, the higher the number the more of a match they are Cyanogenic- they have an identical twin Transplant we look for engraftment it happens in 2-4 weeks where the new bone marrow becomes functional and begins to produce WBC, RBC, Platelets it can take up to a month and they stay for a long time. \*They first must get myeloablative or non-myeloablative chemo first, then give them the transplant, then we look for engraftment they stay a month in the hospital Graft vs tumor effect- donor cells recognize malignant cells, and they act to eliminate (is GOOD) Graft vs Host is a BAD thing T lymphocytes from the transplanted donor activate and mount an immune response against the recipient, the patient could have a rash blistering second degree burns mucosal inflammation of the eyes, GI tract can be affected the can have severe diarrhea greater then 2liters a day, abdominal pain, elevated liver enzymes and jaundice due to hepatomegaly the liver can be affected Engraftment syndrome is noninfectious fevers, skin rash, wt gain, diarrhea, pulmonary infection, treat the with blood products or corticoid steroids, growth factors until engraftment occurs During the bone marrow transplant they could have a reaction, fever chills, SOB, chest pain, hypo/hypertension, could react to the preservative that you use, cardiac or respiratory arrest Tumor lysis syndrome- acute complication due to the chemotherapy has to do with components of the cell spilling out into the blood because those cells are being rapidly destroyed (hyperkalemia, hyperphosphatemia, hypocalcemia) doesn't have to be a negative thing, usually a positive sign that the treatment is working and its caused by large amount of cell destruction, intercellular components are expelled faster than the can be eliminated, could be fatal but if treated the patient can recover, leads to the intracellular components being expelled potassium (hyperkalemia) worried about cardiac, hyperphosphatemia, and hypocalcemia. URIC ACID can be deposited in the kidney and cause acute AKI S/S- fatigue, altered mental status, anorexia, N/V, abdominal cramps, flank pain from the kidneys, oliguria or anuria, acute renal failure, seizures increase prosperous, heart arrythmias due to potassium being elevated Treatments- aggressive IV fluid to flush the uric acid out, 3000-3500mll a day, diuretics, antiemetics, alopurinol to decrease uric acid, meds to decrease the potassium, or dialysis, to IV fluids add sodium bicarb to make urine more alkaline, aluminum hydroxide for increase phosphorus Other treatments- gene therapy, manipulate the gene to induce tumor cell destruction like in clinical trial Cancer vaccine- Gardasil to prevent HPV Complementary and alternative medicine being used (making sure we know everything the patient is on because it can interact with other agents) Unproven and unconventional therapies that ppl may see on the internet- be aware of what the patient is taken to avoid bad interactions LOOK AT CARE PLANS AND ONCOLOGIC EMEGENCIES SVC- caused by a tumor or blood clot, returns blood from the head neck and upper body to the right side of the heart (facial edema, SOB, headache, cough chest pain jugular vein distention engorged blood vessels skin tightens erythema of the upper body edema of the extremities and face, increased intercranial pressure, epistaxis --nosebleed Primary concern- not being able to breath, respiratory, increase the HOB, if its a tumor we will use radiation to decrease the tumor, if its a blood clot we will put them on an anticoagulant, is associated with LUNG cancer, stent placement to keep the area open Emergencies would be spinal cord compression because the tumor is pressing on the spinal cord and nerve roots, 70% at the thoracic level will lead to weakness, paralysis, bladder and bowel incontinence, pain, treat by doing radiation to shrink it, corticoid steroids to reduce inflammation, spinal stabilization surgery kyphoplasty surgery, hypercalcemia level greater than 10.5 when the cancer invades the bone then spills out into the blood, caused by hormones that the cancer can release it leads to fatigue, weakness, confusion, N/V. hyperphosphatemia moans groans and stone, causes constipation, put them on stool softeners and 2-4 liters of fluids to flush the phosphate out SIADH- lung cancer, continuous uncontrolled release of ADH produced by tumor cells leads to increased cellular fluid leads to water intoxication HYPONATREMIA because its dilutional S/S low sodium less then 135, personality changes, dry, depressed depleted/V, anorexia, fatigue, headache, lethargy, confusion LESS THAN 115 it can lead to seizures, coma. Treat by restricting fluids 500-1000ml a day. Increase sodium with replacement, extra fluid gives them a diuretic, intake and output and daily weight Infection- identification and prompt treatment is important with cancer patients, they could have decrease WBC, fever report greater then 100.4, total WBC and neutrophil counts, ANC absolute neutrophil count 1500-8000, less then 1500 greater risk for infection less then 500the risk is severe, neutropenic precautions-mask, gloves, strict hygiene, no fresh flowers or fruit, someone who has just got a vaccine, neutropenic diets and safe food handling, avoiding rectal procedures Psych-social- survivorship living with cancer, follow up plan and screened for recurrent disease secondary cancer caused by radiation and chemo, tlk about terminal illness fear and anxiety, family\'s fears and expectations, common emotional signs withdrawing, end of life experiences, letting go and saying goodbye Interventions care plans Assess for fever, VS every 4 hrs, monitor WBC, inspect sites that could get infected, will hit lowest counts 7-10 days called NADIR, give filgastrim or nucogin, put pt on neutropenic precautions, bleeding avoid IM injections, avoid straining when pooping, administer antiemetic, neutropenic diet, impaired skin integrity associated with radiation