Oncology Edited

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					                                                   Oncology, Page 1 of 19



Cancer Contd
1. Physical agent – white people has less pigmentation, prone to skin cancer. Blue or green eye get
   cancer more. More sun, more cataract.
2. Chemical agents. – can cause Aplastic anemia. So wash fruits/veges well.
       Polycyclic aromatic hydrocarbons and nitrosamine in tobacco.
       Asbestos, Benzene, Polyvinyl chloride used in plastics.
       Ultraviolet, high frequency, and ionizing radiation.
       Insecticide ingredients such as Naphthalene and 2-Acetylaminofluorene, arsenic, aflatoxin B, a
        mold found on some nuts, fruits, and grains.
3. Genetic and familial factors.
4. Dietary factors – high fat diet (prostate cancer), Salt cured, smoked, nitrate cured foods, Burned
   protein, alcohol.
5. Hormonal agent – Oral contraceptives, Diethylstilbestrol, used in 1950 to prevent spontaneous
   abortion. Corticosteroid – cause Cancer.(MDs abuse it.) Mask-like effect. 8am is the best time to
   take.
6. Stress. – fight and flight phenomenon. Adrenal cortex producing mineral corticoid. (BP↑,
   gluconeogenesis)
    Increased lactic acid, you’re more likely to get injured.
    Antioxidant is good. Ex.Salad.


Acrylamide in food
        Foods                                             mcg of Acrylamide per serving
       Boiled potatoes 4 oz                                                0
       Honey nut cheerios 1 oz                                             6
       Tostitos tortilla chips 1 oz                                        5
       Fritos corn chips 1 oz                                              11
       Pringes potato crisps 1 oz                                          25
       Wendy’s French fries biggies 5.6 oz                                 39
       KFC potato wedges, Jumbo 6.2 oz                                     52
       Burger King French fries, large, 5.7 oz                             57
       McDonald’ s French fries, large, 6.2 oz                             82

Preventions : Exercise, stop smoking/drinking, Vit. A, C, E, Selenium. High fiber diet, fresh fruit, Green
tea(Polyphenol) – Cathechins. Salary, Cabbage are the high fiber.


Tumor Markers (substances produced by cancer cells that are found on tumor or plasma membranes or
in blood, spinal fluid or urine. And enzymes.) Elevated.
1. Alpha-fetoprotein                   - Liver, Testis
2. CEA (GI area)                       - Colon, Lung, Stomach, Pancreas, breast
                                               Oncology, Page 2 of 19


3. HCG(human chorionic gonadotropin)- Germ cell tumors, pancreas, Lung, liver, stomach.
4. PSA                            - Prostate (specific antigen)
5. Ca-125                         - Ovary, Colorectal, Gastric cancer
6. Ca-19-9 - Gastric cancer, bowel, Biliary disease
7. Ca-15-3                        - Breast Ca
8. C-Reactive Protein             - Metastic cancer, Lymphoma (M.I too)
9. Hepatoglobin                   - Hodgkin’s, lungs, intestine, stomach, breast
10. Uric acid     - Leukemia, MM, Hodgkin’s (Gall problem, bone marrow, cancer pt)
11. LDH (lactic dehydrogense)     - Liver, Brain, Kidney (heart)
12. ALP (alkaline phosphatase) - Liver, Bone, Breast, MM.
13. Ca-242                        - Pancreatic cancer
14. Ca-72-4                       - Ovarian.

Stage and Grading of Cancer.
TNM system.
Tumor 0 = no evidence, Tumor is in situ = 1,2,3.
Node
Metastasis

Adjuvant therapy – is treatment in addition to the primary approach to control or
                      prevent any micrometastic disease that may occur.
Palliative therapy – shrinks neoplasms by irradiation, decrease pain.(cure is not a
                      realistic expectation)
CytoReductive surgery (as control method) – called (Debulking) is undertaken with the instrument to
reduce tumsor mass to a level that is more manageable for the other treatment modalities.
Radiation therapy – to destroy malignant cells with minimal exposure of the normal cells to the cell
damaging actions of radiation. (Gamma ray – the most common type of radiation). Rad is an acronym
meaning “radiation absorbed dose”
        Therapeutic dose in unit id called grays (Rad) which refer to the dose of radiation absorbed by
         the tissue. One gray is absorption of 1 j per kg. According to type of cancer, the amount of Rad
         is different : e.g. Liver tumor 1200 rad, 5000-6000 rad for breast cancer.
        Radiation safety is based on time, distance, and shielding.
        Distance – 1m(full) 2m(1/4), 3m(1/9), 4m(1/16 of exposure)


Treatment Modalities :
         1. Surgery
         2. Radiation
         3. Chemotherapy
         4. Biotherapy
                                                Oncology, Page 3 of 19


            a. Enhancing the patient’s own immune response

1. External radiation therapy (Teletherapy) – administered by high energy (Cobalt or linear
   accelerator) Co-60
       Advantage – skin sparing effect : e.g. salivary gland tumors, sarcomas, tumors of prostate and
        lung.
Nursing implications :
   Skin mark – do not erase, no soap, no lotion, have pad.
   Fractional doses – dividing total radiation dose into small doses. The purpose of fractional dose
   is allow normal cell time to repair themselves between treatment to minimize side effects.
   “Boost” dose – One time for beginning therapy (loading dose)
   *Dry desquamation first – Wet desquamation later (oozing out, fluid leaking out)

2. Internal therapy (Brachy therapy)
   Intracavity – Gynecologic cancers (prostate, vaginal)
   Interstitial – into tissue (seeds, needle, capsule) Head, neck, intra-abdominal,
                 thoracic tumor.
   Metabolized – ingestion, instillation, injection of radioactive materials.
        a. Sealed      source    radiation   therapy       –    needle,   seeds,   intracavity   Iridium(192   Ir),
            Cesium(137Cs), 131 I, 32P, AU198. (Nurses are protected, no worry)
        b. Unsealed source radiation therapy – by IV, Orally or Direct.
            Sodium phosphate (32P) IV for Polycythemia vera. 131 I orally for grave’s disease. (Distant
            Technique is needed, you CANNOT spill the medicine on the floor)
Nursing Care
       Sealed sources – Radioisotope can not circulate thru client’s body, nor can it contaminate
        urine, sweat, blood, or vomitus. Avoid direct contact with sealed isotope.(only when you go
        home, you’re not encouraged to breastfeed the baby) *After Isotope eliminated from the body, No
        longer radioactive after 48 hours.
       Unsealed sources – used for internal radiation therapy. Come into direct contact with body
        tissue(given IV, orally, by instillation directly into body cavity.)
        1. All body fluid – “Radioactive” labeled.
        2. Place linen, trash, laundry in labeled bag and keep in room until disposal.
Nursing implications :
   a. Place the client in Private room
   b. Limit visitors
   c. No children under 18 years old
   d. No pregnant woman allowed
   e. Visitors 6 feet away from the client
   f.   No more than 30 minutes per day exposure
                                              Oncology, Page 4 of 19


    g. If prolonged contact or care of unshielded are – use lead apron or lead shield.
    h. Provide care for client standing at client’s shoulder (for cervical implants) or at foot of bed
          (for head and neck implant), avoid any close contact with unshielded area.
    i.    Never care for more than one client with a radiation implant at same time.
    j.    Keep long handled forceps and a lead-lined container available on the client
    k. Wear appropriate monitoring devices.
    l.    Serve with disposable tray.


Side-effects from Radiation :
Skin – the most common skin effect – change in color (tanned, or red) - Burn
         Tanned – increased pigmentation, red(Erythema causes itching.) No oil based,
         or Alcohol based lotion.
Dry desquamation – flaking of skin caused by accumulation of dead skin cells. If basal cell worn out,
dermal ell causes leakage of serum. Causes moist desquamation.

Patient teaching :
    1. Wear loosely fitting clothing.
    2. Gently wash the affected area with a mild soap and pat dry.
    3. Avoid lotion, perfume, deodorants.
    4. Avoid pressure on the area
    5. Avoid exposure to sun (for 6mo – 1 year)
    6. Avoid swimming in salted water or Chlorinated water
    7. Avoid heat/cold application
    8. Use Water Soluable lubricant for dry desquamation.
Chemotherapy
The use of Antineoplastic drugs to promote tumor cell death by interfering with cellular functions and
reproduction. Can damage Nerves, Tendons, Muscles (do not start IV on hand, wrist)
Routes of administration
Topical, Oral, IV, intramuscular, subcutaneous, intracavity, arterial(catheter into tumor via main artery),
intrathecal (CAN via spinal canal thru LP). Commonly – IV.

Goals and Principles of cancer chemotherapy
    1. Cure
    2. Control
    3. Palliation
          a. comfort when cure or control is impossible
          b. Reduction of tumor
    4. Adjuvant therapy
          a. Adjuvant cytotoxic therapy or biotherapy : Use of chemotherapy following surgery. Surgery
                                              Oncology, Page 5 of 19


             is the primary treatment.
         b. Neoadjuvant cytotoxic therapy : Use of chemotherapy before surgery, chemotherapy is the
             primary treatment.
    5. Chemoprevention : use of agents by individuals to prevent cancer in high risk individuals (e.g.
         administration of tamoxifen to woman who have a high risk of breast cancer)
    6. MyeloAblation : obliteration of bone marrow(stopped B.marrow) in preparation for blood or
         marrow transplantation.

**Cancer pt’s blood vessel is very fragile – easy to infiltrate – so use Central venous catheter.
        Peak line – basilic vein to supra venacava.(reflush everyday. Only problem is fibrin sleeve –
         inside the blood, create clot). Use it no more than 6 months.
        Dacron cuff is absorbed to your tissue – so the catheter never falls out. Why we use it? - We
         don’t want it to be dislodged. Easy for the nurse to care.

Antidiarrheal Medications. (from irritated mucous membrane)
    1. Diphenoxylate : contains Atropine sulfate(anti-cholinergic). – Lomotil, lofene, Lo-trol, Low-quel.
         (anti-cholinergic)
    2. Loperamide : inhibits GI peristaltic activity.
         -   less side-effects than diphenoxylate
         -   Imodium, Kaopectate 3, Peptobismol.
    3. Octreotide – a synthetic hormone analog used to treat chemotherapy induced diarrhea.
            Sandostatin – most common

Agents used to treat Mucositis
    1. Cleanliness – Normal Saline, Hydrogen Peroxide(half strength followed by NS)
    2. Provide moisture - Water soluble moisturizer(KY Jelly), Synthetic Saliva
    3. Maintain mucosal integrity – Sucralfate(Carafate-stomach lining protection), Vit.E, Maslox,
         Kaopectate.
    4. Topical anesthesia – viscous Lidocaine 2% - sore anesthetic(swoosh and swallow)
    5. Antiviral – Acyclovir
    6. Antifungal – Nystatin, clotrimazole, Fluconazole, Ketoconazole.

ExtraVasation(IV Infiltrate) – if vesicant drugs are infiltrated in Subcutaneous tissue, cause
Tissue Necrosis and damage to underlying Tendons, Nerves, Blood Vessels.

Vesicant drugs : adriamycin, nitrogen mustard, mitomycin, vinblastine, vincristine, vindesine,
mithramycin, dactinomycin. (*Watch pt’s IV Every 5 Minutes, Always look over IV site, Document
WELL).

If Extravasation is suspected.
    1. Stop infusion
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    2. Call MD (AntiDote comes from MD)
    3. Aspirate any residual vesicant agent
    4. Report to physician for any further treatment (heat, cold or antidote)

Patient teaching for Chemotherapy induced diarrhea
1. Eat foods containing Pectin, such as bananas, avocados, and asparagus tips, beets, unspiced
   applesauce, peeled apples.
2. Drink ginger tea, which has a high Pectin level.
3. Eliminate from the diet foods that are stimulating or irritating to the GI tract (e.g., whole grain
   products, nuts, seeds, popcorn, pickles, relishes, rich pastries, raw vegetables)
4. Eat a low residue, low roughage, low fat diet that induces potassium rich foods. The BRAT diet is for
   Banana, Rice, Apple and Toast(dry).
5. Avoid alcohol, caffeine containing products and tobacco.
6. Avoid greasy foods, spicy foods and fried foods
7. Avoid prune juice and orange juice.
8. Avoid milk and dairy products.
9. Avoid Hyperosmotic supplements (Ensure, Sustacal)
10. Take warm sitz baths.

Potential routes of exposure
    1. Absorption through skin or mucous membranes after direct contact.
    2. Injection by needle stick
    3. Inhalation of drug aerosols, dust, or droplets.(wear mask while hanging
    4. Ingestion with contaminated food, beverage, or tobacco products.
Vesicants and antidotes
    Nitrogen mustard – If you have been Extravasated by it – MD orders Isotonic
                           sodium theosulfate. (not to make it Necrosis)
    Actinomycin – cold pad, Oncovin – warm pack. (depends on MD’s order)


Dietary interventions.
1. Small, frequent meals
2. Medicate the patient prior to meals so that the antiemetic effect is active during and immediately after
eating.
3. Avoid fatty, spicy, or highly salted foods or foods with strong odors.
4. Encourage the pt to eat Cold or room temperature food.
5. Ginger. (high associated with anti-nausea, has lot of immunity too)


Myelosuppression.
1. Neutropenia : ANC less than 500 - profound Neutropenia.
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2. Anemia - low number of RBCs
3. Thrombocytopenia - low platelets
4. Cytopenia : the lack of cellular elements in circulating blood.(messed up Electrolyte)
5. Nadir : after Chemotherapy, the point at which the lowest blood cell count is reached. The nadir
usually occurs 7-10 days after treatment.


Mixing Chemotherapeutic and Biotherapeutic drugs.
Prepare cytotoxic drugs, including oral drugs that must be compounded or crushed, in a Biological
Safety Cabinet(BSC). The BSC should :
A. Provide Vertical Laminar Airflow. Vertical airflow is important because it will carry contaminated air
way from the BSC operator.
B. Eliiminate exhaust through a High Efficiency Particulate Air(HEPA) filter. Ideally, a BSC should be
vented to the outside.
C. Have a blower(sterile room) that operates continuously.
D. Maintain sterile technique during the prepation of parenteral drugs.
key point : sterile as much as possible.


Guidelines regarding Personal Protective Equipment(PPE)
1. Gloves : made of polyurethane and neoprene were found to be impermeable to 18 cytotoxic agents.
2. Gowns : wear a disposable, lint free gown made of a low permeability fabric.
3. Respirators and face masks : approved by the NISH.
4. Face Shield or Goggles : wear a Face Shield or Goggles.


Complications of Chemotherapy :
         GI : Mucositis (inflammatioin of mucosa lining)
         Hematology - bond marrow supression
         Renal function - BUN, serum creatine, uric acid.
         Cardio-pulmonary - CHF, pulmonary function
         Neuro - Neurological change
!!! Andriamycin causes Cardiac Muscle Damage (very dangerous drug)
*Vincristine - Peripheral Nerve Changes
Cycolphosphamide*cisplatin) and Methotrexate - Nephrotoxic.


Hormonal therapy (work as Chemotherapy)
        Glucocorticoids(Cortison) - Synergenic effect.(Prednisone)
        Estrogens (Prostate cancer) – Estrogen for men.
        Anti-Estrogen(Tamaxifen) - for breast cancer. (for women)
        Progestins - breast cancer, renal carcinoma
                                               Oncology, Page 8 of 19


       Lupron - prostate or breast cancer. Endometrits


Common Oncologic Emergencies
    1. Metabolic
        a. SIADH - producing too much anti-diuretic hormone - gain weight, look puffy
                       too much fluid in tissue.
        b.     HyperCalcemia - bone cancer pt - allowed to Ca out of bone - fracture of
                               bone. Increased Uric acid, chemotherapy itself cause it too.
        c.     Tumorlytic syndrome - electrolyte leaking out. K is out of tissue -
                   hyperkalemia - Cardiac arrest(knock out SA node). Ca+ go into intracellularly, nutrients
                   are blocked off - oxidation is blocked off too. Na+ go into cells and cells become large.


        d.     DIC, Septic shock - main artery is bleeding. Local vessels' clotting.


    2. Infiltrative
        a. Cardiac Tamponade - cardiac membranes under Pericardiac sac is
             weakened.(<10cc) Water is filled up in the c.membranes. Preload is going up.
             Ventricle has no rest - decreased cardiac output – cardiac arrest.
        b. Carotid Artery Rupture – pressure. Blood vessel’s weakened.


    3. Obstructive
        a. Superior vena cava syndrome - Obstruction. Blood doesn't come back
        b. Spinal cord compression – from osteoporosis – shifting off, fracture,
                                         compression.
        c. Third space syndrome - ARDS - inside the fluid(cardiac tamponade is part of
             third apace syndrome, membrane is weakened, so allow the fluid to come in)
        d. Intestinal obstruction - electrolyte imbalance. (peristalsis shut down)




Hodgkin's Desease (***More Common in YOUNG PEOPLE)
       A chronic, progressive, painless, inflammatory neoplastic disease characterized by Enlarged
        lymph nodes(lymphoadenopathy), spleen, liver, digestive tracts, genitourinary tract, bones,
        rarely CNS. (Epstein Barr virus takes part, T-cell/B-cell problem)
Can start in young age (18, over 35). Early recognition is important.(better cure)
       Cause : unknown.
       Bacterial or oncogenic Viral infection, immunololgical defect)
       Epstein-Barr Virus related
                                               Oncology, Page 9 of 19


      Prevalent : early 15-34 year *increased at 50 years old.
      20-30 years MF 2:1 Boys:girls 5:1
      Curable : 90% curable. (stage 1 and 2)
      Pathophysiology : The origin cell is unknown, probably from T and B lymphocytes or
       macrophage/reticulum cell line.Immune deficiency, especially cellular is characteristic of
       Hodgkin's disease and places persons at risk for infection, especially herpes zoster and PCP.
       Proliferative cells are abnormal histocytes - Reed-Sternberg cells – confirming.
      Symptoms and signs :
       Early - pruritis (unknown)
       Painless, firm, Palpable, rubbery, freely movable progress Enlargement of lymph nodes.
       Found in *1st Supraclavial nodes and *Cervical (90%), Axillary, inguinal nodes, mediatinal,
       retroperitoneal, liver, spleen, bone marrow.
             Elderly : 1st SubDiaphragmatic lymph nodes. (over the Diaphragm)
             Neutrophil Leukocytosis, anemia, fatigue, Cachexia,
             Eosinophilia, Edema in neck, face, lymph node obstruction
             Fluid in chest and abdomen, night sweat, Alcohol induced pain over the involved
                nodes.(good indication)
             Infection (bacterial, viral, fungal, protozal infections)
             Late - Leukopenia, Hepatomegaly, Spleenomegaly, Renal Failure.


      Diagnosis :
       CT scan of abdomen(MRI) - involvement of abdomen. And Pelvic lymph nodes. (shows
       hepatomegaly, spleenomegaly, renal failure etc)
       LymphoAngiogram – look just like blood vessel. Inject fluid/iodine to lymph nodes. (very
       beneficial, something’s wrong with the lymphatic system)
       Inferior vena cava gram (blood vessel is checked)
       **Lymph node biopsy (reed-sternberg cells – Clearly Hodgkins’ disease)
       *ESR, Serum copper, WBCs, alk.Phosphates↑(to do with B.Marrow)
       Bone marrow aspiration
       Liver/renal function tests
                                        2. 14. Tu Lecture. (Hodgkin’s disease Contd)
Treatment
Radiation therapy – 95% curable(stage1) and 80%(stage2)
Combination with chemotherapy (for 3 and 4)
Recent therapy : (combination of chemotherapy drugs)
      *MOPP – Nitrogen Mustard, Oncovin(Vincristin), Procarbazine, Prednisone
      *ABVD - Adriamycin(doxorubicin), Bleomycin, Vinblastine, Dacarbazine
      *VBM (Vinblastine, Bleomycin, Methotraxate)
                                                 Oncology, Page 10 of 19


      *MOPP – ABVD (alternating monthly cycles) – based on MD’s order.
      Examples :
                                            st          th
          Nitrogen Mustard (IV)           1 and 8 day
                                            nd           th
          Oncovin(Vincristin) (IV )       2 and 9 day
                                            rd               th
          Prednisone (po)                 3 and 10 day
                                            th               th
          Procarbazine (po)               4 and 11 day


Repeat cycle every 28days for a minimum of 6 cycles.(depend on where the pt is) Complete remission
must be documented before discontinuing therapy. Therapy may continue for two cycles after remission.


Progression : 85–95%               Ⅰ&Ⅱ (Early detection is very important)
                70%                ⅢA
                40-50%             ⅢB
                If 5 years relapse, almost cured. (Stage 1 and 2)


Nursing implications :
      Shock period
      Night sweat
      Pruritis – Antihistamine, with skin care
      Fever
      Pharyngitis, Esophagitis, Stomatitis(mucousitis is #1 targer) – Xylocaine viscous, gargles,
       throat lozenges. Decreased citrus fruit (orange juice - burning)
      Susp. to herpes
      Infection (potential for)
      Bleeding. (lymphatic system – high risk)


LymphAngiogram : to see hyperplasia of lymphocytes.
      Before procedure
       1. No restriction of fluid/drink (No NPO)
       2. Procedure for 3-4 hours.
       3. Foot(dorsum) Anesthetized and immobilized for lymphatic vessels
       4. Lie still during procedure
       5. Dye unusual taste, fever, HA(headache), Insomnia, retrosternal burning sensation, bluish-
           green discolor urine/stool.(reaction : need to be informed)
       6. Check for allergy (iodine, seafoods) (remind the MD first – usually give benadryl
           first)
       7. Void before the test.


      After procedure(flush out the iodine – fluid up)
                                                    Oncology, Page 11 of 19


         1. Check for cut-down site.
         2. Oil embolism(oil base dye) – Fever, Chills, Dyspnea, Cough, Chest pain,
            SOB. – very important***.
         3. Bedrest for 24 hours
         4. Elevate Leg for edema, Cold Compress for swollen foot.(important)
         5. Do not get original dressing wet.



Non-Hodgkin’s Lymphomas
        Most non-Hodgkin’s lymphoma involve with the malignant B or T-lymphocyte. 50 – 60 years old
         pts.(aging process)
Clinical manifestations.
        Symptoms are highly variable, by the time we find out, it’s too late. Poor prognosis.
Therapeutic modalities.
        If the disease is not an aggressive form – radiation alone may be effective, but basically
         treatment is depend on MD’s decision.


Multiple Myeloma (Infiltration of the bone marrow by cancerous plasma cells. Malignant plasma cell – no antibodies,
Tumors composed of malignant plasma cells grow within the skeleton, making bones fragile and prone to fracture.)
        Plasma cell Myeloma (malignant plasma cell) – so no antibodies made.
        Malignant plasma cell produce M Protein(bence jones protein) – Toxic to Renal Tubular→
         Renal Failure.
  Etiology
        Unknown (family, radiation exposure, occupational chemical exposure, 50-60 years, M=F)
  Assessment :
        Anemia(weakened B.Marrow by M-Protein not making healthy RBCs), Proteinuria(RF - kidney tubular is not
         filtering protein)
        Hypercalcemia(calcium          leaking   out   to    blood),     Bone   pain,    Fracture,      Osteoporosis.
         Backpain(Osteolytic process, in pelvis, spine, ribs – easily fracture), Renal stone.(calcium accumulation)
        Hgb↓, Ht↓, RBC↓, WBCs↓(Neutropenia - Infection) (WBC down is worse than up, Neutropenia is more
         dangerous than the opposite), Thrombocytopenia.

  Diagnosis :
        Bone marrow aspiration (immature plasma cells)
        X-ray (shows Osteolytic lesion)
        Hypercalcemia, HyperUricemia(uric acid) (chemotherapy enhances it)
        Urine – **Bence Jones Protein
        Blood : LDH, CRP, Microglobulin, Quantitative immunoglobulin ***(IgG(major antibody) should
         be higher than IgM(stimulate complement activity))
                                                Oncology, Page 12 of 19


       Lymphocytes (Norm : 20 to 40, but it’s increased 40-50%)
       MRI (to detect presence of Bone, Tissue abnormalities – not 100%))
Complication:
       Spinal Cord Compression (***careful with Turning pt)
       ARF (Acute Renal Failure by M-Protein, Bence Jones Protein)
       NephroCalcinosis (Renal Stone)
       Bleeding
       Infection. (pick up all kinds of fungal infection)
Treatments :
       Chemotherapy : Prednisone & Melphalan orally for 7 days and repeated at 6 wk intervals.
       If Alkylating agents(N.Mustard) are not effective, VAD(Vincristin(oncovin), Adriamycin,
        Dexamethone, Doxorubicin.(others : cytoxan, leukeran, mithramycin, BCNU)
       For Hypercalcemia – Dexamathasone(corticosteroid), Mithramycin(hypocalcemic),
                               Lasix(flush out), Aredia(bone reabsorption inhibitor)
       For Hypocalcemia – Calcitonin (Ca supplement)
Nursing interventions :
       Give analgesia (they don’t know where it is b/c it’s BONE PAIN)
       Avoid fast movement to prevent injury.
       Watch for fracture.
       Increased fluid intake (3000-4000cc per day) : wash Ca+ out.(hypercalcemia)
       Avoid infection(No Invasive Procedure, Avoid Attenuated immunization, reduce
        nosocomial infection and cross infection.
       Use soft, bristle tooth brush. (bleeding)
       Anemia – blood transfusion.
       Renal insufficiency. (check monitor often), Plasma percolation(dialysis-3/wk).
       Reduce Uric acid (Zyloprim – production from bone marrow)
       For Hypercalcemia(avoid thiazide, antacids with high Ca – Malata, no Tums)


*for elders : if complaints of bone pain,
       Osteoporosis, Osteoarthritis, Multiple Myeloma) – common in old people.
       Degenerative joint disease
       Then referral for MM.



Systemic Lupus Erythematosus (Lupus) – “Wolf” (Blushing face)
  Def. A chronic Autoimmune inflammatory disease of Connective Tissue that produces biochemical and
  structural changes in Skin, Joints and Muscles, usually with multiple organ involvement. (has exacerbation
  and remission) – Black, Pregnant, Female disease.
       Etiology :
                                         Oncology, Page 13 of 19


       Viral, bacterial infections, Drugs, Food, UV light etc. – Triggers immune activity –
        Inheritied defect (on Chromosome6) – LE.
       Genetic defect or Environmental factors stimulate production of Autoreactive B-
        lymphocytes – B lymphocyte produces AutoAntibodies (AAB) known as Antinuclear
        antibodies(ANA) – ANA Kills your own body cells instead of non-self cells.
       Shortage or functional Failure of T lymphocytes is believed to be partially responsible.
       ANA attack the Nuclei of cells, cell membrane of RBC, WBC, platelets as well as active
        particles inside the cell such as lysosomes, mitochondria and RNA.
       ANA stimulate an inflammatory response that can involve tissue throughout the body.
   Drugs that create Lupus like symptoms(So assess which medication pt’s on)
       Procainamide, Hydralazine, Phenytoin(Dilantin), Quinidine, Chlorpromazine, Isoniazid,
        Tegretol. Penicillamine, Sulfasalazine.
   Prevention :
       8-10 times greater in Women than men. (Estrogen is responsible)
       Age : 13 – 40 years.
       Race : African and Latin, Asian, Native American > White
       Child bearing year > estrogen fluctuate
       Birth control pills could exacerbate Lupus due to Estrogen.
       Pregnant Women with lupus could pass about 5% to their babies.
       Baby with mother who has Lupus - 43% of baby have positive ANA antibody titer.
       Connective tissue problem(Third space syndrome – Joints & all organs - pericarditis,
        pleuritis, hemothorax, pneumothrax, pulsus paradoxus etc.
   Assessment : This disease appears in Two forms :
       Discoid Lupus Erythematosus(Subcutaneous – all other system is okay)
       Systemic Lupus Erythematosus. (All Connective Tissues)
         Renal(predominantly damaged) : 50-70% imipairment : Hematuria, Proteinuria, HTN,
            Edema, BUN, Kidney – Lupus Glomerular Nephritis.
         CNS
         Vasculitis : Raynaud’s phenomenon(Cyanosis of finger arteries – White Fingers), HTN,
            facial edema.
         Joint :Non-deformity arthriti, joint warm/swelling.
           Skins : (Discoid) Sensitivity to sun – SPF 30 or more.(No out 10am-3pm)
         Resp : Pleuritis, lung infiltration(weak membranes), pul.Hemorrhage.
         CV : Pericarditis, Murmurs, friction rub.
         GI : Peritonitis
         Eye : Conjunctivitis, Photophobia, Diplopia(2 images at the same time)
         Behavior : personality change, depression, psychosis
         Hematology : Anemia.
                                          Oncology, Page 14 of 19


   Labs *Hb Platelets WBCs
       *FANA(Fluorescent AntiNuclear Antibody test) – 95% > of SLE pt.
       If FANA results are positive, then ANA test should be obtained >99%
       Complement is a series of proteins that assists in the removal of bacteria or destruction of
        cells that the body does not recognize as its own.
       *Complement level(C2, C3, C4) – are two of the nine major complement protein that bind
        with antigen-antigen complexes for the purpose of lysis.
       Especially C3 – reduced.
       *CRP, ESR, RF(Rheumatoid Factor)(Bone pain, Arthritis and Autoimmune Disease
        suspected)
       *Thrombocytopenia, Leukopenia.
       *Skin/Kidney Bx
       *Creatinine clearance test. (kidney function test)
   Potential complications:
       Infection
         RF, M.I, CVA, Pneumonia, (heart failure, Infarction)
         Myopathy (steroid induced – too much of it), Increased Blood Glucose because of
            too much Cortisone.
         BS - increased, imbalanced electrolytes, Osteopenia.
         Hypertension
   Medications: (to control, No cure)
       NSAIDS (for pain)
       CorticoSteroids : Deltasone and Florinef (keep it minimum)
       AntiMalarial drugs(Plaquenil, Aralen) – Block inflammatory organ damage and decreases
        the required dose of corticosteroids. For itching – AntiMalarial cream(Quinine, Plaquenil).
       Antineoplastic agents – Immuran, Cytoxan(for exacerbation with cortisone)
   Nursing Diagnosis :
       Risk for infection
       Alteration in comfort : Arthralgia (joint pain) – control.
   Nursing interventions:
       Nutrition : well balanced diet with low in sodium, low fat.
       Rest : good rest, stress accelerate the progression of the disease (Flare-ups – no crowded
        area)
       Activity : avoid the sun during peak hours of 10 to 3pm because it has an impact on the
        epidermal DNA, promoting an inflammatory response and exacerbation of current skin
        problems.(tint the car window, wear hat, sunglasses etc. Avoid certain medications that
        may cause a photoallergic or a phototoxic reaction (e.g., tetracyclines, phenytoin, sulfa
        containing agents.)
                                                  Oncology, Page 15 of 19




***No Prostate Cancer Questions on Exam1.



Immunizations :
      Immunizations with weakened LIVE(attenuated) organisms(e.g., Polio, Measles, Measles,
       Mumps, Rubella - Never to be given to patients on CorticoSteroid, Cytotoxic therapy -
       Immunologic problem, Lupus) produce a very mild case of the disease to stimulate
       production of antibodies to protect against the disease.
      Killed vaccines (e.g. pneumococcus, influenza, tetanus) are safe.
      Osteoporosis : Bone Density test to determine the degree of osteoporosis, joint
       arthroplasty.(surgery to reshape, reconstruct or replace a joint)
      Plasma dialysis to remove the autoantibody. (regular visit to control)
                                             Oncology, Page 16 of 19


Cancer of Larynx. (throat)
 - Squamous cell cancer from vocal cord epithelium.
 - 60-65% of laryngeal cancer over in glottic larynx.
 - 90% occur in Men who over 50-70 year old.
    Causes :
          Alcohol and tobacco intake, smoking, vocal strain
          Chronic laryngitis, environmental pollution
          Exposure to radiation, Genetic factor
          Metastasis – to lungs(common)
    Four major Types
          Glottic – intrinsic
          Supraglottic(above voice box) - extrinsic
          Subglottic(under voice box) - extrinsic
          Transglottic – extrinsic
      Clinical Manifestations for laryngeal cancer.
          Persistent hoarseness over 2 weeks.(husky voice)
          Voice change
          Pain in throat, esp. During swallowing.
          Pain or burning sensation when drinking hot liquid or juices.
          Dyspnea, stridor, hemoptysis, dysphasia.
          Feeling “something in the throat” for 4 wks.
          Swelling of the neck.
          Pain referred to ear (otalgia)
          Pain (late sign)
          Sxs(metastasis) enlarged cervical nodes, weight loss, discomfort of pain radiating to ear.
    Diagnostic Tests
          CBC, SMA-18 (sometimes the symptom is like Anemic)
          ↑Alk. Phosphate(cancer), low protein level, low albumin
          MRI > CT (soft tissue invasion)
          Needle Biopsy of enlarged nodes
          Laryngoscope with Biopsy (NPO after midnight)
          Radiation therapy
            External beam radiation : For early stage (85-90% curable) – 5000-7500 rads over 6
               wks or 2x/daily. (Teletherapy)
            Implants of iridium seeds into needles inserted in tumor site (brachytherapy)
      Chemotherapy
          Methotrexate, Oncovin, Bleomycin, Vincristine, Cisplatin,
          5-Fluorouracil, Carboplatin, Cyclophosphamide
                                              Oncology, Page 17 of 19




Supraglottic Laryngectomy
            Removal of portion of larynx above true vocal cord. (voice is still there)
            This procedure is performed on clients who have cancer of epiglottis and adjunct structure
             above vocal cords.
            Without epiglottis, patient must learn a new way to eat, without aspiration. (take a
             deep breath, hold the breath, put your head down and swallow). Liquids are great challenge for
             epiglottis removal patient.
            Teaching after supraglottic surgery.


Surgical Procedures for laryngeal Cancer.
        Laser surgery – tumor reduced by laser beam thru laryngoscopy (Ablation therapy – no more
         hyperplasia). (metaplasia becomes anaplasia no more)
        TransOral cordectomy – tumor resected thru laryngoscopy.
        Supraglottic partial laryngetomy
        Hemilaryngectomy
        Total laryngectomy
        Except total, voice is not gone.


Total Laryngectomy
        Removal     entire   larynx,   thyroid   cartilage,      vocal   cords,   epiglottis,   cervical   fascia,
         sternocleidomastoid muscle, jugular vein and lymph nodes, hyoid bone. (they take out the
         surrounding lymph node too)
        Pre-op intervention and teaching:
            Reduce anxiety/depression (especially with spouse)
            Introduce Speech Therapist
            Alumni(well adjusted laryngectomees : who went thru same surgery)
            Losses :
              Ability to Speak, blow nose, sense of Taste, Smelling(could be back)
              Ability to do Valsalva maneuver, coughing, drinking thru straw
              Ability to gargling, Whistling, Singing, Laughing (all gone)


Nursing Diagnosis for post Laryngectomy
    1. Ineffective Airway Clearance(need to do lots of suctioning) – vital signs, HOB
        30 degrees(prevent choking) ABG, TCDB(Turn, Cough & Deep Breathing), humidification of
        inspired gases, lung sound, check mental status.
            Check for Carotid artery bleeding (spontaneous swallowing) – check VS(BP) very
             frequently. (q 15 min)
                                             Oncology, Page 18 of 19


           Check dressing every 1 hour(post-op floor) Tracheostomy care with aseptic tech.
            ***Obturator – STICK IT IN IMMEDIATELY in case of Tracheostomy falls off.
           Fluid (IV fluid)
           Do not worry about Aspiration. (keep trachea open)
           Check Hemovac for bleeding(or Jackson Pratt drain) (fluid & exudate causing infection 30ml
            first day, 10ml second day...)
           Humidify O2. (pt gets irritated by cold dry air with particles – goblet cells)
   2. Pain related to surgery incision.
           PCA pump, Back rub, Neck support, Back support is needed.
   3. Impaired Verbal communication – provide Pencil and Paper.
           Keep call light by patient’s hand
           Use Open Close question (Yes or No)
           Locate patient near nursing station.
           Check pt every 30 min. (Do not forget to go back to check pt)
           Avoid sweet food (saliva, decreased appetite)
   4. Impaired skin integrity related to Tracheostomy – temp, dressing.
           Antibiotics, aseptic tech, Y-dressing.
   5. Alteration in Nutrition – HOB30, Weigh pt q 3days, aspirate gastric removal
       before next feeding, dysphagia, odynophagia.
           Maintain IV fluid or TPN(with NG Tube while pre-op and post-op) until gastrostomy /
            jejunostomy tube.(PEG/PEJ)
           Start with Thick fluid – custards, jello, apple sauce(the reflex is still there)
   6. Alternation in Body image
           Advise him/her to wear Long Necklace or Cover around neck.


Complications from Laryngectomy (good for Observation - Documentation)
       Salivary fistula – easily become fissured.
       Hemorrhage (Carotid artery rupture)
       Cutaneous fistula, Nerve damage
       Pulmonary complication.(from secretion going into the lung)
        Ostomy opening stenosis – reason why put Laryngectomy Tube.(wider, shorter)
        Facial edema(from radical neck dissection of lymph node, due to venous congestion)
                                            Oncology, Page 19 of 19


Prevention of health problems after Laryngectomy
      A lump anywhere in neck or rest of body.
      Persistent cough, sore throat or ear ache. (means Metastasis of tumor)
      Hemoptysis
      Sores around the stoma or inside the trachea that do not heal
      Diff. of swallowing or breathing
      Change in voice quality.
      Any problems that do not, spontaneously or quickly resolve.
Discharge Instructions.
      Teach Clean suctioning technique.(Family / Spouse needs to learn)
      Review the plans of care for radiation or chemotherapy
      Teach the client how to clean the incision and provide stoma care including cleaning and
       inspection for signs of infection.
      Instruct the client to avoid swimming and to take showers with caution. (water should be lower
       than the site)
      Advise the client to increase humidity in the home.
      Tell the client to continue to use the alternative communication method.
      Recommend the client to wear a medic alert bracelet.
   ***After your surgery site is all healed – start chemotherapy. (up to 6 month)
Speech rehabilitation
      Mechanical Devices – Western Electric Electrolarynx (battery operates) Placed against the
       side of the neck.
          Cooper Rand – consists of a plastic tube placed within the client’s mouth, that vibrates on
           articulation.
      Esophageal speech – pt swallows air, expels air in belch and pressure esophagus.
      TracheoEsophageal Fistula (TEF) – surgical fistula is created between trachea and
       esophagus either at the time of laryngectomy or in the post op. period. A catheter is sutured.
       It’s called Blom-singer voice prosthesis.
       When there’s a voice prosthesis, the cuff should be deflated to make sound.
Discharge Planning.
Laryngostomy tube will be removed 4-6 wks, then Tracheostomy tube.
                                                   Breast cancer - next week

				
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