Med Surg Ch 16: Oncology – Flashcards

a group of diseases characterized by abnormal growth and spread of cells (uncontrolled and unregulated growth of cells)

-most common cause of death in US -tends: increased incidence w/ aging, cancer incidence is higher in men-women have better survival rate, increased death among African Americans, lung cancer-highest death rate, 2nd most occuring

-cure: means pt has no evidence of disease and has the same life expectancy as someone who was never diagnosed w/ cancer -remission: S/S are reduced, cancer can come back

-benign: well differentiated, looks like the tissue (cell) it came from -malignant: poorly to well differentiated, doesn't look like the cell the surrounding tissue, expands and metastasizes (can invade other tissues) drugs work on the cells that are dividing, in the Go phase cell division isn't occuring

drugs work on the cells that are dividing, in the G0 phase cell division isn't occurring; when cancer 1st begins to develop most cells are actively dividing, as the tumor increases in size more cells become inactive and convert to a resting state (G0), because most drugs are effective against dividing cells, cells can escape death by staying in the G0 phase

-staging: classifying the extent and spread of disease, helps plan Tx and get prognosis -grading: the appearance of cells and the degree of differentiation is evaluated, well differentiated (G1) to poorly (G4) -TNM (solid tumors): determines anatomic extent of disease involvement according to tumor size and invasiveness, presence or absence of regional spread to lymph nodes and metastasis to distant organ sites; the higher the number the worse the prognosis

-characteristics of tumor -physical (functional) status of pt (ADL, Katz, ECOG) -psychosocial status of pt

measures to prevent a cancer from occurring -tobacco: #1 risk factor for cancer, accounts for 30% of deaths, 90% lung cancer, 2nd hand smoke may be more dangerous than smoking, smokeless cigarettes cause oral and esophageal cancer -viruses: EBV, HBV, HPV; 2nd highest risk factor -diet: decrease fat, increase fiber, decrease smoke foods, moderate alcohol -exercise: 30 min 5 times a week -sunlight/radiation: 3 severe burns before age of 60 increases chance of melanoma, highest risk (fair skin, blue eyes, blonde hair); SPF 15+ (30 min), hats, collars, cover, avoid sun -sexual behavior: multiple partners, unprotected sex increases risk of HPV -chemoprevention: Tamoxifen/Raloxifen, Retinoic acid, ASA/NSAIDs, vit E -7 warning signs of cancer: CAUTION (pg. 255)

screenings and early detection -breast: mammography annually after 40; clinical breast exams every 3 years, age 20-40, annually after 40; breast self exam-self awareness; at risk-begin screening early -prostate: discuss benefits and risks of PSA, Digital Rectal Exam beginning at age 50; higher risk, discuss at age 45 -colorectal: average risk starts at age 50; find polyps and cancer-flexible sigmoidoscopy ever 5 yrs, double contrast BE every 5 yrs, virtual colonoscopy every 5 yrs, colonoscopy every 10 yrs; find cancer-gFOBT or FIT yearly; prep-GI clean out -cervical/endometrial: cervical: begin at 21; age 21-29 PAP every 3 yrs, age 30-65 PAP + HPV every 5 yrs or PAP every 3 yrs; stop at age 65 or w/ total hysterectomy if no abnormal results; HPV vaccine-follow guidelines for age; endometrial (uterine): at time of menopause-informed of risks and Sxs, report unexpected bleeding or spotting, high risk may need yearly endometrial biopsy if hx of cancer, continue screenings 20 yrs after cancer is removed -lung: lung screening; high risk r/t cigarette smoking, may be a candidate for screening (recommendations for screening-ACS) -cancer related check up: health counseling depending on age and gender, check thyroid, oral cavity, skin, lymph nodes, testes and ovaries; take control and reduce risk (pg. 255)

-reduce or avoid exposure to known or suspected carcinogens and cancer promoting agents including cigarette smoke and sun exposure -eat balanced diet that includes veggies and fresh fruit, whole grains and adequate amounts of fiber; reduce dietary fat and preservatives including smoked and salt cured meats containing high nitrate concentrations -limit alcohol intake -participate in regular exercise (30 min or more of moderate physical activity 5x weekly) -maintain a healthy weight -obtain adequate consistent periods of rest (6-8hrs per night) -eliminate, reduce or change the perception of stressors and enhance the ability to effectively cope w/ stressors -have a regular physical exam that includes health hx, be familiar w/ your own family hx and your risk factors for cancer -learn and follow recommended ACS cancer screening guidelines for breast, colon, cervical and prostate cancer -learn and practice self examination (breast, testicular) -know 7 warning signs of cancer and inform HCP if they are present -seek immediate medical care if you notice a change in what is normal for you and if cancer is suspected

-cure: Tx is expected to have the greatest chance of disease eradication, may involve local therapies (surgery or radiation) alone or in combo, w/ or w/o periods of adjunctive systemic therapy (chemo), -control: Tx plan for many cancers that can't be completely eradicated but are responsive to anti-cancer therapies, cancer can be maintained for long periods of time w/ therapy, pt may undergo an initial course of Tx followed by maintenance therapy for as long as the disease is responding -palliation: Tx goal when relief of pain or control of Sxs and maintenance of a satisfactory quality of life are the primary objectives Theses goals are achieved through surgery, RT, CT and biologic and targeted therapy-combined Tx is more effective

remove cancer and as much of the surrounding normal tissue as possible-surgical cure is possible only if tumor is localized and relatively small -role of surgery in cancer care: -diagnose: biopsy -prevention: surgical intervention can be used to eliminate or reduce the risk of cancer development, prophylactic removal of non-vital organs to reduce incidence of some malignancies -treat (cure) or control: remove all or as much tumor as possible while sparing normal tissue -palliate: ease Sxs, relief of pain, obstruction or hemorrhage -supportive care: supportive care that maximizes bodily function or facilitates cancer Tx (Ex. insertion of feeding tube to maintain nutrition during head and neck cancer Tx, placement of CVAD to deliver chemo agents) -reconstruction

use of chemicals as a systemic therapy for cancer -role of chemo: cure, control, palliative relief of Sxs -basics of chemo: goal is to eliminate or reduce the # of malignant cells in tumor, cell cycle specific (most effective during certain phases of cell cycle) and non-specific (effective on cells during all phases of cycle)-administered in combo to maximize effectiveness, dose limiting toxicities (hypersensitivity, alopecia, vomiting, organ damage), adjuvant therapy (helps get rid of any cancer that was missed), doesn't work if it isn't taken -administration: routes: IV (most common)-concerns include venous access difficulties, device or cath related infection and extravasation (infiltration of drugs into tissues surround the infusion site) causing local tissue damage, oral, subQ, etc; safety: for pt and nurse-make sure you have very good IV access; where gown and gloves (special chemo gloves), urine handling-flush commode twice, double glove and gown Tx: combining agents in multi drug regimens is most effective but increase in toxicity occurs Nursing: monitor for and promptly recognize Sxs associated w/ extravasation of a vesicant (causes severe local tissue breakdown and necrosis), immediately turn off the infusion and follow protocols for drug specific extravasation procedures to minimize further tissue damage, admin IV chemo through CVAD

delivery of high energy beams when absorbed into tissue produces ionization of atomic particles, the energy ionizing radiation act to break the chemical bonds in DNA damaging it and causing cell death -role of RT: cure, control, palliation -basics of RT: 1. prescription: field-area being treated w/ RT, dose-maximal tolerated dose (ability to deliver maximal doses to target vol. while sparing critical structures) and fractionate doses (small doses) to avoid serious toxicity and long term complications of Tx 2. simulation: process by which the radiation Tx fields are defined, filmed and marked out on the skin, the dose and vol. of area to be treated are specified, radiation needs to go to exactly the same spot each time; goals of radiation plan are met by determining the orientation and size of radiation beams, defining the location of field-shaping blocks and outlining the field on the pt's skin -blocks/positioning devices: used to immobilize pt so pt maintains a stable position 3. Tx: -methods of delivery: external radiation (teletherapy)-pt is exposed to radiation from a machine, pt isn't radioactive; internal application (brachytherapy)-radiation is in the body-implantation or insertion of radioactive materials directly into the tumor or in close proximity to it, pt is a source of radiation -radiation safety: time-decrease exposure to radiation, minimize time w/ pts; *distance*-the farther away the less radiation exposure; shielding-lead (aprons, containers) -pt concerns

WBC: 3-5 days (effected 1st by RT and CT) platelets: 10 days RBC: 120 days

-SE occur when normal cells within radiation Tx field are temporarily or permanently damaged-directly r/t the area being radiated. Chemo SE are dependent on drug and dose but are systemic! -occurrence: rationale; types: acute-occurs during or within 6 months of Tx and chronic

-bone marrow suppression: neutropenia, thrombocytopenia -fatigue -GI -skin rxns -neuropathies -reproductive -organ toxicities (chemo cathy) -cognitive changes -alopecia

one of the most common effects of chemo, Tx induced reduction in blood cell production can result in infection, hemorrhage and overwhelming fatigue -RT: severity depends on area being radiated, only bone marrow within the Tx field is affected -CT: severity depends on chemo drugs used and dosages of drugs (dose limiting), affects bone marrow function throughout the body -onset is r/t life span of the type of blood cell: WBC- 3-5 days (effected 1st by RT and CT), platelets-10 days, RBC-120 days Nursing: monitor the CBC esp. neutrophil, platelet and RBC counts -neutropenia -thrombocytopenia

decreased neutrophils -serious risk factor for infection and sepsis -nadir: lowest blood cell count (neutrophils), usually 7-14 days after starting chemo, period where pt is most susceptible to infection -ANC: absolute neutrophil count, capacity to fight infection, if less than 500 pt doesn't get Tx -assessment: assess for normal signs of infection-*fever* (if pt as slight fever start inspecting) redness, drainage (if there aren't any neutrophils normal signs of infection won't occur), inspect mouth, cath sites, skin and anal area (bacteria enters through here) -precautions: *hand washing* prevents the transmission of infection, stagnant water is a source of bacteria, diet-avoid fresh fruit and veggies, bananas are usually permitted as long as they are peeled and not cut -management and education: monitor WBC, obtain differential, VS-monitor fever, any sign of infection should be treated promptly since fever is a medical emergency prohibit ill staff and visitors, avoid having ill staff care for infect pts; fever -> culture -> antibiotics -> antifungals -educate pt: hand washing, check temp, explain Nadir, inspection, diet restrictions, avoid crowds and small children

-early: fever, decreased temp, mild hypotension, change in mental status, skin is warm and flushed, possible decreased U/O -late: fever, severe hypotension, restlessness, anxiety, skin is cold and clammy, oliguria

low platelets -can result in spontaneous bleeding or major hemorrhage -normal platelet count 150,000-400,000; high risk of serious bleeding below 50,000; acute bleeding below 20,000-blood transfusions -physical safety: advise pt to avoid activities that place them at risk for injury or bleeding-bumps, bruises, cuts, scrapes, irritations -parenterals: avoid IM, IV when possible, smallest gauge, pressure to injection site, pressure on dressings, no ASA -avoid invasive procedures -constipation: no straining or valsalva (can blow blood vessels), no enemas or suppositories; stool softeners, high fiber -menses -epistaxis: no drying agents, no nose blowing, correct sneezing (done w/ mouth open), High Fowler's, ice packs-nasal packing

persistent subjective sense of tiredness associated w/ cancer and its Tx that interferes w/ day to day functioning -cause: anemia, accumulation of toxic substances left in the body after cells are killed by cancer Tx, the need for extra energy to repair and heal body tissue damage by Tx, lack of sleep caused by chemo drug Nursing: get pt up and walking, encourage energy conservation strategies-resting before activity, doing activities when you feel your best

-cells of mucosal lining of GI tract are highly proliferative (easy for tumors to grow), one of the most sensitive tissues to RT and CT -SEs of RT and Ct significantly affect the pt's hydration and nutritional status and sense of well being -xerostomia: dry mouth Nursing: saliva substitute, water, hard candy, oral care before and after meals and at bedtime -radiation caries (cavities): result of diminished saliva Nursing: dental exam every 6 months, oral care, soft tooth brush, fluoride supplements -N/V: common SE of CT, give anti-emetics and anti-anxiety meds 30-60 min before chemo or RT, RT on empty stomach, delay eating 3-4 hrs before CT or RT; Nursing: assess for S/S of dehydration and metabolic alkalosis, managed w/ anti-emetic regimen, dietary modification and other nondrug interventions (relaxation breathing) -anorexia/nutrition: r/t inflamed mouth or esophagus causing difficulty chewing or swallowing, altered taste occurs Nursing: emotional support, high calorie and protein diet (butter, powdered milk), non-irritating foods, avoid bloating, megace-chemo agent, small frequent meals, stimulate salivation, monitor weight (twice weekly), observe for dehydration, nutrition supplements, avoid temp. extremes, alcohol, tobacco, spice foods and irritants, monitor albumin and prealbumin levels, severely malnourished-enteral or parenteral nutrition -mucositosis (irritation, inflammation, ulceration of the mucosa)/esophagitis/dysphagia/stomatitis: mucosal linings of the oral cavity, oropharynx and esophagus are very sensitive to RT and CT, esophogeal/pharyngeal-dysphagia (difficulty swallowing) and painful swallowing occurs, Nursing: avoid irritants (normal saline rinses), coating agents, local anesthetic, soft, bland foods, oral care-inspect every 12hrs, keep mouth clean, moist and free of debris to prevent infection soft toothbrush, topical analgesics -diarrhea: characterized by increase in frequency and liquidity of stool Nursing: low residue (low fiber) diet-limit foods high in roughage (fresh fruit, veggies, seeds, nuts) and avoid fried, fatty or highly seasoned and gas producing food, monitor F&E, I&O, anti-diarrheals, anti-motility agents, antispasmodics, multivitamin, hydration and electrolyte supplementation, lukewarm sitz baths, rectal area kept clean and dry to maintain skin integrity, check perianal area for skin breakdown, check stools -constipation: assess bowel sounds, monitor fluids, increased fiber diet, stool softeners and laxatives, late and early obstruction

-RT: hair loss is local, may be permanent -CT: affects hair loss throughout the body, temporary and reversible -sometimes distressing -nursing: wigs (before hair loss occurs), scarves, caps, use ice caps w/ chemo

-most at risk are elderly, those w/ small veins -RT: skin effects are local, occurring only in the Tx field, can be acute or chronic depending on area irradiated, dosage and technique S/S: erythema-acute response followed by dry desquamation, if rate of sloughing is faster than ability to replace dead cells, wet desquamation occurs w/ exposure of dermis and weeping of serous fluid -CT: produces skin toxicities-ranges from mild erythema and hyperpigmentation to acral erythema and erythrodysesthesia syndrome, ES can cause redness, tingling of hands and feet, painful moist desquamation, ulceration, blistering and pain irritants and vesicants Nursing: prevent infection and facilitate wound healing, mild soap, lubricate dry skin w/ recommended lotions/creams (cortisone, aloe vera gel), keep tissue clean w/ normal saline compresses, loose fitting garments, no tape, electric razors-no pre or aftershave, avoid temp extremes-sunlight, avoid powders, perfume, lotions, creams, alcohol and deodorant, don't use heating pads, icepacks and hot water bottles in Tx field, protect skin after Tx is completed, extravasation precautions

-RT, CT: transient myelitis -nursing: ongoing assessment of neuro function, stool softeners, laxatives, education of safety precautions

-sperm count: testes are highly sensitive to radiation, dose dependent -ovaries: radiation dose that induces ovarian failure changes w/ age and dose dependent SE: tenderness, irritation, loss of lubrication, vaginal shortening r/r fibrosis and loss of elasticity and lubrication, potential infertility Tx: shielding of ovaries and testes, sperm banking, vaginal lubrication -avoid conception for at least 2 yrs following Tx

-cardiotoxicity: caused by anthracyclines and trastuzumab (Herceptin), late effects include L ventricular dysfunction and HF; baseline and periodic ECG to monitor L ventricular function -pulmonary: acute effects-dry mouth, cough, dyspnea; pneumonitis-delayed acute inflammatory rxn, often asymptomatic but cough, fever and night sweats may occur; late effect-pulmonary fibrosis; most common toxicities-pulmonary edema r/t capillary leak syndrome or fluid retention, hypersensitivity pneumonitis, interstitial fibrosis, pneumonitis produced by an inflammatory rxn or destruction of alveolar capillary endothelium -hepatotoxicity: assess liver enzymes -nephrotoxicity: adequate hydration, BUN and Cr

chemo brain: not experienced just due to chemotherapy

-2nd malignancies -radiation late effects -psychosocial sequelae -chronic cancer

-role of biotherapy in cancer: diagnosis, TX-primary and supportive -administration: IV infusion, oral -biotherapy: consists of agents that modify the relationship between host and the tumor by altering the biological response of the host to the tumor cells, biological agents affect host tumor response: they have direct antitumor effects, they restore, augment or modulate host immune system and they interfere w/ the cancer cells' ability to metastasize or differentiate -targeted therapy: interferes w/ cancer growth by targeting specific cell receptors and pathways that are needed in cell growth, more selective so they can kill cancer cells w/ less damage to normal cells compared to chemo SE: flu-like Sxs including HA, *fever, chills*, myalgias, *fatigue*, malaise, weakness, photosensitivity, anorexia, nausea; tachycardia, orthostatic hypotension, *capillary leak syndrome-pulmonary edema*, neurological defects, infusion related Sxs including *fever, chills*, urticaria, mucosal congestion, nausea, diarrhea and myalgias; *anaphylaxis*-stop admin of MoAb immediately and start resuscitation measures, skin rashes-erythema, arterial thrombi, hemorrhage, HTN, impaired wound healing, proteinuria, *hepatoxicity, bone marrow depression*, CNS effects Tx: acetaminophen every 4 hrs and large amounts of fluid reduce severity of flu-like Sxs, IV meperidine (Demerol)-severe chills or rigors, monitor VS and temp, plan periods of rest for pt, assist w/ ADLs, monitor for adequate oral intake Nursing: observe for signs of confusion, memory loss, difficulty making decisions, insomnia

-infection, hemorrhage and failure to graft can occur -goal is to cure, approach in HSCT is to eradicate diseased tumor cells and/or clear the marrow of its components to make way for engraftment of the transplanted, healthy stem cells, admin of higher than usual dosages of CT w/ or w/o RT (can produce pancocytopenia), after chemo and RT are done, healthy stem cells are infused which "rescue" damaged bone marrow through proliferation and differentiation of donated stem cells in recipient -autologous: from yourself -syngeneic: from identical twin auto and syng-don't have to worry about G vs H disease because genes are the same -allogeneic: from another person (family) or bank, donor Complications: bacterial, viral and fungal infections; graft vs host disease: T cells from donor marrow (graft) recognize pts cells (host) as foreign and attack them, graft rejects the host, targets skin, liver and GI; SE: redness, pealing, rash, liver disease, jaundice, diarrhea, abdominal pain, infection Tx: prophylactic antibiotic therapy-infection

-defined as an unpleasant sensory and emotional experience associated w/ actual or potential tissue damage, or described in terms of such damage fear of addiction-why pts aren't satisfied / Tx of pain: barriers to effective pain Tx: -addiction: a pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief -tolerance: when larger dose of opioid analgesic is required to maintain the original effect, can be a concern w/ cancer pts, providers need to be aware that larger doses may be required over time to maintain satisfactory pain management -physical dependance: a syndrome characterized by anxiety, irritability, chills, diaphoresis, N/V, insomnia, and abdominal cramps when continuing doses of the drug aren't available -inadequate pain assessment Assessment (pg. 279, Table 16-18): quality, location, intensity, duration, precipitating and alleviating factors, differentiate between types of pain (visceral, bone, neuropathic) Nursing: regularly assess and document pain and any changes that occur Tx: drug therapy (NSAIDs, opioids, adjuvant pain meds), relaxation therapy, imagery

-pt may experience fears of dependency, loss of control, family and relationship stress, financial burden, fear of death, anxiety, hospice Nursing: assess pt's and family's responses and support positive coping strategies-be available, exhibit a caring attitude, listen actively to fears and concerns, help provide relief from distressing Sxs, provide essential info regarding cancer and cancer care, maintain relationship based on trust and confidence-be open, honest and caring, use touch to exhibit caring, assist pt in setting realistic, reachable short and long term goals, *maintain hope*

-cancer is a disease of aging -misdiagnosis: clinical manifestations of cancer in older adults may be mistakenly attributed to age related changes and ignored by the person; they're a decline in physiologic functioning, social and emotional resources and cognitive function -functional status: age alone isn't a good predictor of tolerance or response to Tx, functional status should be taken into consideration when developing a Tx plan

-obstructive: primarily caused by tumor obstruction of an organ or blood vessel Ex. superior vena cava syndrome, spinal compression, 3rd space syndrome -metabolic: caused by the production of ectopic hormones (arise from tissues that don't normally produce these hormones) directly from the tumor or are secondary to metabolic alterations caused by the tumor or by cancer Tx Ex. syndrome of inappropriate antidiuretic hormone secretion, hypercalcemia, tumor lysis syndrome -infiltrative: occurs when malignant tumors infiltrate major organs or secondary to cancer therapy Ex. cardiac tamponade, carotid artery rupture