CANCER 1st Tutor Session

Everyone has cancer cells in their body but not everyone goes through promotion..

1 stage..initiation..everyone goes through inititation - cell changes from different factors(sunlight, carcinogen exposure etc) most of the time our bodies fight these effects

2ND STATE..PROMOTION

can take 1-40 years depending on risk factors, genetics etc

Latent period..the 1-40 years

PROGRESSION STAGE...

What causes cancer..the proliferation ..normal cells have contact inhibition..they die..cancer cells dont...Differentiation...

Stem Cells have the most amount of potential(dna)..they can become anything

as cells progress they become specialized and have less potential

Cancer cells gain more potential.. they can regain embryonic appearance and funtion.

Cancer cells start off as specialized but go backward

Cancer cells proliferate at the same rate as a regular cell...

GI, hair follicle, wbc, platelets all have a fast turn over rate...cancer in these areas have fast growth

malignant cells unecapsulated ..to invade and metastasize

Inititation is irreversible

hpv, hiv, hep b, epstein barr...all viruses that can cause a cancer

complete promoter...something that causes inititation and proliferation (ex. being a smoker)

Cancer patients all experience severe fatigue(because of tumor angiogenisis anemia occurs) even before chemo.

If patients are anemic suggest diet changes, iron rich foods, Vit C, supplements, moderately tolerated exercise(walking everyday, 20-30 mins)

obesity high risk for cancer...Fat cells release hormones

Brain, bone, lung, liver and adrenal glands are common areas for cancer

Staging - extent of the disease(local and regional spread) tnm

Grading - look shape and appearance of the cell(metaplasia)

Anatomical Classification: carcinoma(endoderm-skin,brain,glands ectoderm-), sarcomas(mesoderm), leukemia/lymphomas

7 warning signs of cancer... CAUTION,

Chemo

Irritants - cause phlebitits (inflammation of the vessel)

Vesicants - cause tissue damage

CVADs should be used for vesicants to lower chance of tissue damage

If extravasation occurs (pain, swelling) Stop infusion, cold compresses

IV

Intrarterial..into arteries

Intraperitoneal ...into abdominal cavity..dwelling time..adminsitered for 2-4 hrs, then drained...pt may have abdominal pain, ascities, infection, paralytic ileus, perforation

Intathecal into spine

intraventricular(into ventricles of brain)...patient will experience headache, nausea vomitting, nuchal rigidity ..ICP- keep patient supine, decrease lights/decrease stimuli, shunts may be necessary to release swelling

Intravesicle(?)... into bladder..may experence bladder spasms,

hematuria, uti

GI, Hair follicles, bone marrow will be most affected by chemo

(possible)Acute side effects - anaphalaxis(worst), extravation, cardiac dysrhythmias, N/V

Delayed - mucositosis, rashes,

Chronic - organ damage, 2nd malignancies

Radiation - usually done before chemo ..works locally

Chemo is done after radiation and in later spread cancers ...has a systemic effect

Low beam Energy - used for skin and superficial cancers

High Beam - for deeper cancers

Fractionization - doses split ..5 days a week for 2-8 weeks

Patient must go through simulation before receiving radiation

Simulation - pin point cancer..body measured and marked for exact spots radiation will be adminsitered

ALARA - As low as reasonably achievable ..

Shielding, wrist band (monitors the amount of radiation you have been exposed to -- everyone has a lifetime max dose)

Bone marrow suppresion occurs with radiation and chemo

Pelvis and sternum are the areas where myeolosuppresion is most effected

RBC live 120 dyas

neutophils - 1-2 weeks

Platelets - all the time

anemia and neutropenia(will be seen before anemia)

neutropenic patient..reverse isolation, no fresh fruits/vegetables/plants... pts psychosocial is important ...they will be limited to visitors-but still have visitors.. monitor for infection... will receive growth factors neumega, epogen, neupogen..

Growth factors take some time... they stimulate but they will take the amount of time that it normally takes for wbc, rbcs and platelet to grow

spontaneous bleeding may occur if platelet counts are below 20,000...monitor for bleeding in mucous membranes, mouth/nose.(epitaxis), petechia....mouth care important - no flossing, encourage rinsing..no alcohol based mouthwshes,..dont use razors, needle sticks should been done as little as possible - smallest gauge needles shoudl be used..20/22

Anemia - check Blood levels ...

HGB & HCT

HGB below 7/8 may need tranfusions

HCT should be above 38%

GI effects - N/V - can give reglan, zofran, emend

N/V causes electrolyte, fluid and acid/base imbalance

Dysphagia - trouble swallowling

dycgeusia(taste loss), - season foods, moisten foods, provide food the paitents enjoy

Odynophagia - painful swallowing ...give patient soft foods, smaller portions, meds- lidocaine

keep N/V, diarrhea logs

Diarrhea - metabolic acidosis, dehydration, fluid/electrolyte, acid/base imbalance....reduce fiber, low residue diet, no roughage, nuts, avoid oily food....you want to decrease motility ..monitor for hemmoroids, skin break down...sits baths

radiation to the bowels can cause temporary lactose intolerance

Radiation assects glands that make salivia ..chemo can cause dryness..mucositosi/stomatitis

Stomatitis- monitor for infection, frequent oral care ..saline/hurricane rinses, artifical saliva, nystatin ..no toothbrush, no flossing, no alcohol based mouthwashes...no extremem temps - no hot no cold

always monitor gag reflexes

soft diet..increase protein and calories,...decrease fiber and residue

weigh patient 2x week

Skin reactions occur in the main skin folds ..

May cause cracking skin, infection

with radiation monitor skin reactions...dry and wet desquamation

keep dry skin moist with aloe and eucerin,aquaphor (do not use petroleum jelly)

keep wet skin dry

Chemo can cause

desquamation on palms of hands and feet ...chemo dose may be held a week or two in order for healing

Alopecia with chemo is reversible - may start to return in 3-4 weeks

Radiation may be irreversible

when hair does grow back it may gow back thicker, different color/texture

Explain hair loss and options ot patient..encourage wig fitting/purchase before hair loss

Radiation:

Pulmonary toxicity -

pneumonitis can occur 1-3 months after radiation (delayed reaction) ..increase in cough, fever, night sweats, ..give expectorant for productive cough ...cough suppresant for non productive..corticosteroids to reduce inflamation...bed rest becasue patient wil have lowe O2 rate ...

Pumonary fibrosis(Chronic reaction)...

Pulmonary Edema - fluid escaping into pulmonary space..noncardiogenic

Cardio - radiation induced heart disease can occur...

Doxirubicin and danorubicin can cause this

Abdominal radiation (for male) must use shield

Biological/Targeted therapies :

affect just the tumors

Will cause patient to have flulike symptoms - low grade fever..give patient tylenol...monitor for capillary leak syndrome, orthostatic hypotension

secondary cancers - radiation and chemo can cause leukemias

Stem Cell Transplant - (from umbilical cord, bone marrow(ileum or sternum), peripheral blood(donor must have growth factor a week or two before))

Allogenic - from someone who is a match (may see graft vs host disease--the donor blood may attack the recipient..recipient will be immunocompromised)

Syngenic - from identical twins

Autologus - From self

With autologus you will be given high doses of chemo to get rid of as much cancer as possible and then harvested

2-4 weeks to work...while waiting pancytopenia is a concern,( bleeding issues, anemia, infection)

Malnutrtion:

increase protein, calories, decrease vegetables and raw foods..watch for weight loss of 5%

Monitor albumin.. if you see more albumin you have less blood volume(fluid) normal albumin level is 3.5-5 ..if above 5 the patient is dehydrated

If albumin is below below 3.5 patient is malnourished (lack of pure protien in the blood

Pt should inform doctor if temp is 100.4 or more

Emergencies:

Obstructive - ex vena cava syndrome, cvad can cause

Compression -- spinal cord compression , can cause pain, affect movement , cervical can affect upper body, heart, lungs, lumbar affects lower(legs,bowels(

Vasalva manuever... bearing down and pop ears ... (it increases pressure in head ..close nostrils and mouth and try to breath out..to pop ears) it decreases your heart rate (but also increases B/P..can also fix heart rythym in some instances) , affects supraglottic swallow (Vasalva maneuver can aggravate spinal cord compression)

Laminectomy - cutting out of tumor round spine

3rd space syndrome ..shifting of fluid from vascular into tissue ..initially you will see hypovolemia-tachycardia, decrease in B/P, urine output down, administer fluid but watch out for revocery hypervolemia-decrease in H/r but decrease in B/P ... then restrict fluid..maintain I/O

Metabolic emergencies caused by ectopic hormones -

Siadh S/S - FLAT..fatigue, lethary, anorexia, thirst ....retaining fluid.. electolytes will be dilute-hyponatremia

seizures, oliguria, decrease reflexes,

can treat with NaCl ...

(dysrythmia -anytime there is a change in electrolytes & O2)

Hypercalcemia - (dehydration and lack of movement can cause hypercalcemia) can cause kidney problems... give fluids and then loop diuretics

Tumor Lysis Syndrome - tumor or normal cells break up too rapidly..all the iside contents are spilling into the body...hyperuricemia(dna floating around after spilling out of cells)give allopurinal , hyperphosphatemia, hyperkalemia, hypocalcemia ...usually happens withim 24-48hrs of chemo

Tumor Lysis Syndrome treatment -- fluids to flush out and allopurinol

Cardiac Tamponade - fluid around heart - heart cant beat ..this is an emergency ..must be drained

Carotid Artey Rupture - spurtting of blood... apply pressure and yell for help

If patient is too sedated ..wake them up and administer oxygen ...if overdosed they will need narcan ..but this will cause severe withdrawal at the moment

LARYNGEAL-

Trach

S/S airway obstruction ..Stridor-coughing breathing , gasping for air , accessory muscles being used, retractions, wheezing(musical sounds) restlessness, tachycardia, cyanosis

Early signs of Hypoxia - RAT (early signs)- Restessness, Anxiety, tachycardia....BED(late signs) , bradycardia, extreme restlessness, Dyspnea

aspiration, pneumonia,

cricodthyroidotomy-cut into

Tracheotomy - procedure to administer tracheostomy

Precutaneous Tracheostomy better than trach in OR ..local anesthesia used..lowers post op complications/less bleeding

Tracheostomy better than endotracheal intubation..patient can move, be awake, eat, less trauma around entry area

endotracheal intubation - patient must be sedated ..tube down throat..affects speech, eating etc ..patient cant move out of bed

Cleaning trach - sterile procedure ..

Pt needs humidified air ..reduces secretions

Uncuffed trach can be used if patient has epiglottis function

Cuffed can cause erosion if left inflated for too long or if over inflated.

If patient cant cough out secretions you must suction... suction top of cuff before deflating so pt doesnt aspirate ..then deflate cuff during exhalation ..reinflate cuff during inhalation.

monitor the amount of air daily ..

Know amount to fill

do not change tape until 24hrs after trach inserted

1st tube change is done by surgeon 7 days after insertion

change tube once a month

if tube is accidently dislodged move obturator so air can flow through tube??? (watch video on trach care) assess respiratoy distress ..alleviate breathing problems in semi fowlers ..

p.530/531..trach care tables in book

inner canula care done 3x a day..assess need for suctioning every 2hours(not done routinely - only when needed and not on someone that can cough secretions out)

Baseline must be established for Pulse ox, HR and rythym must be done

if HR drops 20 beats or increases by 40 stop suctioniong See table 27-6

Checking for aspiration... add blue food coloring to a small amount of water and let patient drink or monitor glucose in secretions ...secretions normally have low glucose content... shouldnt see glucose in secretions or the blue food coloring ..this means that food/water is getting into lungs...Best way is to have speech

therapist do a gag and swallow test

Speech with trach:

(if on a fulltime mechanical ventilator this is a closed pressure system - cuff must be inflated to maintain the closed pressure system) ..If part time the cuff does not need to be inflated when not on)

deflate cuff a little to allow air to pass over vocal cords. ..no food or water at this time

When a fenestrated tube is used it allows air to pass through and over without deflating the cuff

(fenestrated tube poses aspiration because of holes in top of tube..mucus can also clog holes and crust around it ..will impair speech-must be checked) fenestrated tubes also pose risk for tracheal polyps (cancer risk)

Cannot speak with cuff.. must be deflated

can speak with tube with no cuff (for patient with no aspiration risk)

Speaking tracheostomy tube - you dont deflate cuff for it to work - which is better for person with risk of aspiration(can be used with pt that has aspiration risk or on mechanical vent) ...air is pumped in from an O2 source outside the body ..must be on.. air bypasses cuff

Passy-MuirSpeaking Tracheostomy - allows air and speaking upon expiration ...valve has a diaphragm in it ..it closes when exhaling to go up over the vocal cords(cuff must be deflated)..cannot be used on pt that has risk for aspiration or pt with respiratory distress

...p.535

decanulation - only do when patient can spontaneously breathe and prodcutively cough

After removal..it will close on its own..cover with occlusive dressing... splint when coughing,sneezing etc

Head and Neck Cancer -

increased risk with age, tobacco use, alcohol abuse , HPV, decreased vegetable and fruit intake

usually caught late

Palpate lymph node, leukoplakia, erythroplakia in mouth/on tongue(white or red patch)

Total larngectomy - will have a trach for the rest of life.

***watch trach videos on youtube

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(continued session)

Head and Neck Chapt 27

**Airway obstruction

can be complete - emergency

or

partial

will hear stridor(coughing sound), see retractions(accessory muscles, restlessness, tachycardia, later on will see cyanosis

in the event of complete airway obstruction: look in mouth, heimlich, endotracheal intubation may be necessary

Tracheotomy - procedure to make the hole..usually done in OR

if done at bedside percutaneous tracheotomy- local anestetic(less anesthesia , less bleeding, less chance of post op infection

Trach better than intubation tube because with intubation(endotracheal) must be sedated , cant eat, trauma, may need to be done numerous times, immobility because bed bound, *must watch phosphate levels(found in intracellular) 3.5-5 normal level

Trach can eat, no need for sedation, can talk, less trauma, can ambulate

Trach Care:

suctioning airway when you hear secretions...no suctioning if patient can cough it out, ..assess airway..no routine suctioning- only when needed

Cleaning around stoma

Changing trach ties (prevent skin breakdown, infection)

cuff tracheostomy tubes ..to prevent aspiration and anchor tube

*cuff pressure ..20 hg/mm or 25cm/h20

over pumping will cause ersion of esophagus

use minimum use technique..pump up then decrease .1

Cuff pressure changes over time becasue the cuff pressure expands the area..after long term use may need an increase in pressure to prevent aspiration ..to check for aspiration use blue dye, glucose test or speech therapist to test

Glucose test may show false positive if there is any blood in the mucous

Deflating cuff only on exhalation because secretions are on top of cuff ..deflating on inhalation will pull secretions into airway

reinflate cuff only on inhalation

monitor cuff pressure daily

Monitor Stoma site 5-7 days post trach since stoma is immature

Surgeon does trach care, first tube change, movement, for the first week post op

bedside precautions: 2nd trach set, ambu bag..if trach is dislodged try to put it back in ...

use obturator to put outer canula into trach ..if cant be inserted

assess respiratory distress ..raise bed into semi fowlers positions, cover stoma, bag through mouth ..if laryngectomy there is obstruction so bag the stoma site

patient must have humidified air..moistens and decreases secretions

change tube approximately once a month after first tube change by surgeon

Once stoma is fully healed after several months a patient can go home and clean their own trach

Trach Care ..table 26-7 & 27-7

reassess respiratory every 2 hrs

If vitals change from baseline while suctioning adminsiter oxygen ..if baseline is still off, notify doctor

Suctioning:

Hyperoxygenate ..100% O2 for 1 minute

suction 10-15 seconds

no suction on way in

suction intermittent on way out while twirling catheter

Oxygenate again

repeat suction ..

don't suction more than twice at a time

(also suction mouth)

If there is increase or decrease of 20 breaths per minute, dysrhythmias, HYPEROXYGENATE

check breath sounds..should be clear..record time, amount, character, patients reaction

Cuff..pushing against esophagus can cause dysphagia...may cause weight loss, anorexia

Patient with risk for aspiration may have inflated cuff

Best way to check cuff for aspiration is calling in speech therapist

when take out Inner canula, deflate cuff, cap

Decanulating - complete removal of trach the stoma will begin to close on its own in 2-3 days

LARYNGEAL CANCER:

columnar cells changing to squamous

Major indicator for cancer: Age

50 +

Tobacco use

alcohol

decreased fruit and vegetable intake

HPV virus

males infectd 2-3x more than females

Main S/S:

Hoarseness

Cough

Asymmetry of throat

pain is later sign (as tumors expand)

athralgia(ear pain)

Dysphagia

Cranial nerve 11

assess:

palpate throat/neck

leukoplakia(white patch)

erythroplakia(red/dark patch)

Staging: TNM...extent of spread

Grade: look, appearance, histology

TNM used for solid tumors(not leukemias)

Brachytherapy- (patient radioactive)

wear bracelet to measure exposure

wear protective shield

if seed comes out cover patient and call Dr, or use forceps and put in lead container if available

Teletherapy - external ..patient never radioactive

Cordectomy ..no trach required..removal of 1 vocal cord..can still speak

HemiLaryngectomy ..needs temporary trach..can still speak

Supraglottic Laryngectomy ...removal of epiglottis .. aspiration risk...patient needs cuffed trach (temporary trach)

Total laryngectomy requires permanent trach..larynx, voice box. epiglotal region..everything removed) (can never go swimming again)

Complications:

hoarseness

Esophageal speech needed to speak with total laryngectomy..air pulled in and speech with trapped air ..must be taught..talk with burping... side effect: flatulence

cant be heard by deaf/hard of hearing

Radical Neck DIssection - Most organs there removed...must be careful of carotid artery ..rupture or burst may occur...put pressure, call for help ..emergency

If parathyroid removed must worry about calcium levels

if thyroid removed must be on synthroid

Post op -

first 24-48hrs on tpn or ppn

after will be on feeding tube

then test must be done for swallow mechanism

superglottic swallow - done to prevent aspiration..for people that have no epiglottis ...swallow, cough, close airway then swallow.. teaching: start off with carbonated beverages ..avoid watery or thin liquids but soda in this case is ok..for patient to be able to feel location...

Teaching Supraglottic Swallowtable 27-8

• take deep breath

• perform Valsalva maneuver(pinch nostrils close mouth, try to blow out air, bear down)

• place food in mouth, swallow

• some food will enter airway(will be on top of closed vocal cords)

• Cough (to move food)

• Then can swallow

Radiation for Laryngeal:

complications: Stromatitis (from xerostomia of radiation hitting parotid glands)...moisten mouth, sugarfree candy, encourage water... once platelets fall below 50,000 use swab or sponge instead of soft brush..(when count falls below 20,000 patient will need transfusion)

Skin

for dry skin: aloe , eucerin, aquaphor

Wet Skin: Keep dry

loose clothing, avoid sun exposure

Assess patient for dysphagia after lung or upper radiation

(chemo and radiation affect hair follicles, bone marrow, GI cells-higher mitotic rate cells)

Radiation in chest area will affect sternum blood production ..

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LUNG CANCER:

leading cause of cancer deaths

Deeper the smoker inhales and longer they hold the smoke, the higher chance of lung cancer

E-cigarrettes can also cause cancer..it is an irritant..any irritatant can lead to cancers

Cleaning solutions, gasolines, hydrocarbons

Starts in the bronchus..entry area of lungs

detectable at 1cm

earliest signs: hoarseness, nagging cough

hypersecretions at first

Metaplasia - abnormal change of cells

(?)Non-small Cell worse.., most prevalent 80% of cases

(?)Small Cell - 20% of cases

Paraneoplastic Syndrome.. tumor secretes parathyroid hormone, causes hypercalcemia,(lead to renal stones, renal failure).. patient needs fluids to flush out excessive calcium(with diuretics), phosphate levels will drop

(IPPA assessment: inspect, palpate, percuss, auscultate)

Mass in lung can be inspected on xray

Percuss..will hear dullness(not hyper-ressonance)

Thoracentesis..can be done at bedside...needle inserted into side of lung

Staging: TNM used

Screening recommendations dont exist

can encourage smoking cessation

Surgery not recommended for small cell(?)

Chemo is the only real treatment for small cell(once metastisized chemo is the only effective treatment) ex.Cisplatin, Carboplatin, Cyclophosphamide, Docitaxil

Photodynamic Therapy - gets rid of the mass after radiation or

chemo has killed the cells

Stent used to prevent thrombosis..prevents blockage

Table 28-17..assessment

must always obatin patients understanding or knowledge of their condition...Nurse should not be the first person to inform patient of their condition ..this is the Dr.s job

Assess Breath sounds, Heart Sounds

Less oxygen means brain and heart(b/p will slow, HR will increase, dysrythmias) will be effected...assess Cardiac & LOC ...may see Superior Vena Cava Syndrome(patient receiving chemo will have a central line in vena cava or carotid..cause rupture or blockage), JVD, Periorbital edema, dysphagia, N/V(administer antiemetic)

Thrombophlebitis ..inflamation caused by irritants

Vesicants cause extravassation

tension pneumothorax...emergency

check for kink in chest tube or clog..fluid builds up and lung collapses

observe for subcutaneous emphysema..will sound like rice

crispies..crackles...mark spots where heard

Primary prevention for lung cancer - smoking cessation/avoiding smoking

Secondary - check sputum

Hypovolemic shock..will see increased HR first, then decrease BP

Increase Beta Carotine, Vit C, Vit E ..for all cancers

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Tutoring

NEXT TEST:

A lot of aftercare

drain care, positioing

radical neck dissection

radical mastectomy ...

Breast cancer chemo agent ..Herceptin

trach - suctioning ...steps

jp draincare (and hemovac)- will see blood in the begining...after

first 2 days a mix of clear and blood..after that should be clear..shouldnt smell ...drastic changes are an issue either infection, hemmorhage

care: empty, measure, note smell and color.. cant take bath with jp drain in..must be removed before a bath can be taken...otherwise sponge bath

Lung Cancer -

1 leading cause of death

2nd cause - breast

Difference between lung cancer and other cancers - it is not genetic ..other cancers can be.

Lung cancer is due to life choices, environmental factors and/or secondary metastasis( a lot of blood flow and high turn over rate of cells

Smoking..type of cigarettes and depth of inhalation increases chance of cancer ...e-cigarettes can still cause cancer - there is nicotine in them

men have higher death rate than women from lung cancer...though women can smoke same amount of cigarettes of as a man and get lung cancer faster

Originally cells are columnar looking ..as they are affected they

turn into squamous epithelial(metaplasia-changing) ...squamous cells replicate

Lung cancer usually starts in the main(rt or lt) bronchus..then to bronchiole..then to alveoli

As air comes down the trachea most of the air is concetrated in the bronchus

1st thing you see is - sputum (from the irritation in the lungs).. *Cough with productive sputum, then persistent pneumonitis(fever,chills,cough) ...eventually fibrosis occurs, shortness of breath and wheezing(use pulse ox, listen for breath sounds on both sides,, pain unilaterally usually

hemoptysis(spitting up blood)- not a common sign...later sign of a lot of damage

anorexia, fatigue, weight loss, nausea, vomitting , anemic(angiogenesis ..tumor is making its own blood supply) .

tumor in esophagus..touble swallowing, mucositis

Tumor in chest area concerns: heart, superior vena cava(svc syndrome)-to fix: radiation to reduce size (of tumor that is pushing on svc) before doing chemo(if necessary) ...simulation must be done before raditaion(map out and mark tumor before procedure)

Lung cancer can spread to lymph nodes...if it accumulates in a lymph nodes you get lymphadenopathy (swollen lymph node)

Lymphadema - selling because fluid accumulates and can't drain becasue of blockages

Mediastinum involvement - fluid accumulation in pleural sac ..won't be able to expand the lungs

Cardiac Tamponade - fluid build up around the heart - need immediate pericardiacentesis(?)..to drain fluid

(if fluid builds up becasue its blocked it will leak out- into spaces it isnt supposed to

Diagnostics:

Chest Xray can be done to see

CT scan is the best non-invasive procedure

Sputum cytology can be done

Biopsy - gives definitive

TNM would be done -- because its a solid tumor

Leukemias arent staged with TNM...there is no tumor - it is everywhere in the blood

NonSmall is better to get than small cell...nonsmall is a surgical candidate

Small cell usually only has 6-7 month prognosis

Smoking cessation is the key even if you have smoked your whole life... even if you have lung cancer.

Surgeries - nonsmall cell (early stages 1-3A) (3b-4 is bad prognosis..regional spread and metastisis)

Pneumonectomy - entire lung removed

Lobectomy-1 lobe removed

Segmental or wedge - smaller than lobe removed

Before surgery pulmonary function tests must be done to see if the patient can survive with parts of lung missing

Radiation can be used for small cell and Non-small cell...to shrink tumor causing blockage)

If you have bronchial obstruction(wheezing would be heard)

If you have Super Vena Cava Syndrome

After radiation care - skin irritation, esophagitis,

Photodynamic therapy - laser light better than radiation because it targets better..patient given IV of photo ..travels to tumor cells and stays there...tumors are exposed to light (patient must not be exposed to light before test (even pulseox light can affect it) ..when tumor cells are exposed to the light they die

radiation gets tumor and everything before(skin) and after

***Tumor Lysis Syndrome: cells burst and spill into ECF ...patient becomes Hypkerkalemic, Hyperphosphatemia, Hypocalcemia, Hyperuricemia(uric acid comes from the inner parts of the cells)...you will see kidney issues ... must be cleared up right away....patients fluid is hypertonic... flush it out...hydrate patient with NS..then a diuretic (lasix - loop diuretic --dont want a potassium sparing because patient is hyperkalemic already)... allopurinol to correct the hyperuricemia

Hypocalcemia - twitching

hypercalcemia - muscle weakness

Paraneoplastic Syndrome (usually in small cell but can occur in nonsmall cell)..tumor secretes hormones that are not normal and cause things like SIADH, DIabetes Insipidus, Parathyroid secretion etc- hyper or hypocalcemia ..(listen to recording) ..will have either too much or too little of certin hormones

(Cranial Radiation for brain cancer ....methotrexate and cyterabineonly two drugs that cross blood brain barrier)

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2nd and 3rd Tutor Session

Breast -

Higher hormone levels increase risk to breast cancers

Her 2 is marker

if receptors for these hormones are on the cells then you give then a blocking agent because cell responds to the hormones .

triple negative breast cancer means dont respond to ....listen to recording

PostMastectomy Care

Elevate affected side at level of the heart (or slightly higher) to maintain drainage

After care for Breast cancer ..immediately following surgery(in PACU) start exercising the fingers, hand, wrist ...arm raises and range of motion after wound has healed

No heavy lifting

Montior for edema

Never B/P or IV in affected arm

If double mastectony then finger stick done in toes, IV in legs or CVAD and BP done in leg

Assess for drainage ... should decrease over time (color,amount,odor)

Provide privacy for client

Clinical breast exam 20-30 year olds every 3 years, 40 ..every year

Self Breast Exam should for menstruating woman every month after period ends ..for non-menstruating women they should choose a date (birthday day) and do it on that day every month

Upper outer part of breast is most common spot

Usually BC tumors are hard(mass), nonmobile, non-tender (may eventually become painful because it is pushing on surrounding area

IPPA - Inspection, Palpation, Percussion, Auscualtate

inspect breasts for symmetry, color, orange peel look(inflammatory BC),nipple discharge....then palpate ..

Once there is node involvement it becomes serious... once node involvement node resection nd/or chemo is neessary

before node involvement other options available

Receptor positive tumor is a good thing(lower proliferation rate) - because can be treated with blocking agents...

if not responding to estrogen(receptor negative) we can't treat it with blocking agents (hirmone therapy ...they will need chemo

Her-2 , estrogen, progesterone negative -- triple negative breast cancer is the worst ... palliative treatment usually with radiation or chemo ..will have recurrence all the time

Lumpectomy - breast conservation therapy - tumor removed only ..contraindicated if small breasts and large tumor...multi focal tumors, at nipple

Cant do radiation is you have active lupus or had radiation at same site

Radical Mastectomy - everything removed (can have breast reconstruction surgery during surgery or after)..follow care up every 6 months for 2 years and then every year after that ...and BSE every month every....*** highest chance of recurrence at surgical site ...

Post Mastectomy Pain Syndrome... can cause frozen shoulder from not moving arm...treat with NSAIDS, Topical lidocaine,Antidepressants..etc

Breast reconstruction flap - primary care is flap perfussion: assess for color, palpate, cap refil, ...if you check a patient and there is poor flap perfussion ..NOTIFY DOCTOR

TRAM procedure(muscles from abdomen moved to chest under flap)..now there are two surgical sites to assess... better than silicone gel implant

Wont lactate or have nipple erection after surgery

assess for Perfussion, infection, drainage

Tamoxifen and Herceptin for receptor positive tumor ... major side effect is visual acuity..must notify dr if there are visual issues

Goal is to have range of motion in 4-6 weeks..give pain med before ROM , elevate arm to level of heart even when sleeping

To relieve acute lymphadema: massage(decongestive therapy), wrap with pressure bandage, intermittent compression sleeves(not overnight), exercise, ..diuretics if nothing else is working

Fitted weighted bra as prosthesis 4-8 weeks after surgery

No lifting anything for at least 6 weeks after surgery ..and not more than 10 pounds after

Lumps during menstrual cycle fibroadenoma..not cancer usually

Lymphatic mapping ... injected with blue dye (radioisotope) ..patient may be blue all over

Sentinnel Lymph Node: node right after(closest to) affected lymph node

Paget's Disease - nipple affected ..death rate high, starts off as severe itch, bloody discharge, becomes open wound..can be biopsied but only treatment is a mastectomy

Mastitis - can happen during breat feeding..infection in glands

Inflammatory Breast Disease - looks like mastitis..is aggressive ..skin will look like an orange, assymetry, redness, heat..surgery is too late... chemo and/or radiation more common..goal is control

Hyperestrogenism(?) - alcholo abusers have higher levels of estrogen so it predisposes them to breast cancer

Benign breast disease and breast cancer difference ..benign cells are typical..malignant cells are atypical

Secondary Prevention..screenings..if you have atypical cells you are at much higher risk for breast cancer

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Hematology 4th Tutor Session

RBCs - 4-6,000,000

Shistocyte - malformed RBC (can't carry right amount of oxygen or perform proper RBC functions)..body will compensate and try to make more RBCs... more problems will arise

Reticulocyte - immature RBC

WBC- 4-10,000

Bands ....shift to the left ...larger number of new WBCs...seen with leukemia or infection (WBC production s working overtime)

Neutrophils...(50-70% of WBCs) ...less than 1000 neutropenic..less than 500 severe

if count of WBC 100,000 the normal functioning WBCs RBCs PLT are crowded out and pancytopenia happens... and you will have symptoms of anemia, thrmbocytopenia, infection (immature cells go into the organs and will have hepatomeglia and other problems

ANC- Absolute Neutrophil Count..less than 1000 , less than 500 severely neutropenic

Best way to protect patient from infection: HAND WASHING

Beast way to protect staff: isolation, protection, mask, gloves

Neutropenia - low number and rapid decrease of cells..the faster

the drop and longer the duration the higher the likelyhood of developing long term problems or death (can be from chemo drugs, deficiencies in vitamins, reactions ..most common cause is immunosupression and chemotherapeutic patients ...radiation to sternum and iliac crest)

Normal Flora - most infection start from normal flora in neutropenic patients... assess pt for even the slightet increase in basal temp ... can go quickly from low grade fever to septic shock ..monitor for pain... WBC count will be high (bands to the left) but be neutropenic ..obtain blood cultures from 2 sites..start antibiotic treatment right away with neutropenia(not vancomycin though first- that is last line..they would get vanco after cultures done)

Axillary temp for pancytopenic patient

Platelets - 150,000 - 400,000 ...under 150,000-thrombocytopenia

Normal Levels:

WBC - 4,000-10,000

ANC - 2500-6000

RBC - 4.5-5.1(f) 4.5-5.9(m)

PLT - 150,000-400,000

HGB - 12-16g/dl(f) 14-18g/dl(m)

HCT - 36-46%(f) 40-54%(m)

PT 11-16

PTT 17-23

INR 2-3

BUN- 6-20

CREATININE 0.5-2.0

Creatinine Clearance - 70-135ml/min

Na- 135-145

K- 3.5 -5

Ca- 8.6-10.2

Mg- 1.5-2.5

Ph- 2.4-4.4

Iron, Folic Acid, B-12, B-6 for RBC production (dark green leafy vegetables, beans, red meats)

Lymphadema - Swelling ...edema accumulation due to failure of the lymph system..can be caused when nodes are removed, lymphoma, fracture causing blockage of a node(leading to compartment syndrome)

Nodes - drain fluid

Inflamed lymph nodes - due to infection, lymphoma

inflammation -node will fill with fluid, wbc, puss

with lymphoma it will be hard(non-tender), hard, immoble

Assessing lymph nodes...look for symmetry, palpate both sides to compare..if it is not painful, it is hard, doesnt move may be lymphoma

....Hodgkins Lymphoma - nodes can sometimes be tender to the touch because it is pushing on something else- take note if it is also

hard

Start from the neck down..(most are nodes are cervical)

ABO ...AB universal recipient

O universal donor

Rh factor..look out for it

Pos or Neg ...take note that they match from donor to recipient.

...if mismatched the reaction will cause clotting can lead to DIC - watch patient for fever, chils, back, pain

Testing for Rh - Rogam for mother if her and baby don't match(?) Check this ..Coums test

Bone marrow aspiration usually done from sternum or iliac crest

Posterior iliac crest is preferred, then anterior iliac crest, then sternum

Pt in prone position during aspiration of posterior

Baseline V/S before procedure

Pain during aspiration even though under local anesthesia - comfort patient during procedure....after aspiration cover site with sterile pressure dressing, monitor v/s until patient stable, assess site for bleeding, (with V/S due to blood loss will see HR speed up then BP will drop, respiration will increase after HR increases) If

site is bleeding , put pressure on site ...(patient should lay on site for pressure..if bed is too soft, roll up towel and put it underneath)

(listen to recording)...about thick blood and B/P

Thrombocytopenia can be inherited..can happen due to certain food ingestion(blood thinning foods like garlic, quinine, tonic water)

Immune Thrompocytopenia Purpura (ITP)- abnormal destruction of circulating platelets...for some reason antibodies covering platelets are attacked when they pass through the spleen- as they start to be destroyed the body cant keep up with making new ones(may see large bruised areas of skin) .... this destruction is a an autoimmune response...pt will usually be given corticosteroids....patient will have other issues after being on the corticosteroids that must be monitored ...spleen can be removed (give Plt when plt level is below 10,000)

ITP - usually females and over 40, in presence of infection

(will see petechiae, then purpura, then echymosis)

TTP - Thrombotic Thrombocytopenic Purpura - not auto immune, not as common, involves fever without infection, renal abnormalities ...blood starts to clot ...due to enhanced clotting of platelets you wont have enough platelets everywhere else (similiar to process of DIC but not as bad) .. can happen due to drug toxicity(chemo, oral contraceptives)... give pt heparin and Plt when

level is below 10,000

no NSAIDS, coumadin , heparin for thrombocytic patients

HIT - Heparin Induced Thrombocytopenia - caused by broad, increased use of heparin, ...

main issue is venous thrombosis - clotting in the venous system can lead to DVT, will see swelling distal to the area, pain,..can lead to pulmonary embolism, CVA(stroke)... need to treat clot..but need to avoid HIT ...

Pt/PTT will be about normal with ITP, TTP, HIT

(raised troponin level means heart damage)

Neumega can be given for thrombocytopenia

Neupogen for neutrophils

Epogen or Procrit for RBCs

for Thrombocytic Patients:

If unsure what is causing thrombocytopenia - pt will receive corticosteroids

Platelet transfusion - if at 10,000 or below or if at 50,000 and

actively bleeding

Early bleeding signs: nose bleed, gingival bleeding,

for nose bleed - pressure on bridge of nose, lean forward.. after 5 mins still bleeding use ice..if still bleeding after 10 mins contact HCP or go to ER

Wear fitted shoes(not open toe, no heels) to prevent falls leading to bleeding, trauma to ankles/joints

Minimum amount of injections - SubQ...pressure for 5 minutes, ice pack, stay with patient ...no IM injection because muscle has more blood supply

For women: watch menstrual cycle..50ml 1 soaked sanitary napkin ..no tampons can tell how much blood and may lead to infection, ...may be given hormones to decrease mensetruation until thrombocytopenia is resolved

Diet: no nuts, - nothing to damage on the way in or out, bland foods (spicy, acidic foods may lead to GRD- damage esophagus causing bleeding), no orange juice, tomato, citrus...

Avoid lemon glycerin swabs, sugared gum/candy can cause

dryness/irritation

Do not bend with head lower than waist - pressure build up can cause bleeding in the upper mucosal membranes

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DIC- clots form... sepsis(toxins in blood) ..immune repsonse to toxins - platelets attach to the toxins causing clotting...other factors are acting like blood thinner...so low platelets in system (because they are at site of clots) and blood thinning going on...will have heavy bleeding ...will see DVT and throbocytopenia at the same time....pt bleeding-losing volume.... give patient blood(check blood type), heparin(because the platelets in the new blood will go to clotting sites)... will see an increased D-dimer, increase clotting time(PT/PTT) ..FDP increase(destroy fibrin) .. will also see shistocytes because RBC are damaged squeezing through clots

Signs of bleeding in DIC...pale, petechiae, oozing from eyes,nose,IV site, hematuria, internal bleeding(distented abdomen-measure girth),bloody stool, increased respirations, hemoptysis, orthopnea(positional breathing)(difficulty sleeping so pt will use a lot of pillows to prop themselves up to breath better), tachycardia, decrease B/P, confusion, dizzyness, LOC, pupils, weakness, clubbing, swelling, later signs: necrosis due to no perfusion ..(listen to recording) clots lead to: obstruction: shortness of breath, dysrythmias, venous distension(JVD), paralytic ileus, will hear hyperresonnance with obstruction, Clotting in kidney area - oliguria,

Care: below 10,000 get platelets, or 50,000 and actively bleeding

If thrombus is present they get heparin or low molecular weight heparin

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Myeloidy Dysplastic Syndrome - composition of what bone marrow is producing is different ..hypercellular actions are causing changes ...pancytopenic - highest prevalence in males over 70 ..cause unknow but results from an issue in stem cells(ploidy) in 30% of cases becomes AML. with AML you will see more Leukemic cells (much more immature).. MDS progression is lower than AML

Care for MDS - if the MDS isnt that bad they will get Erythropoeitin ...for higher risk patient will get HST(stem cell transplant) ... HST contraindicted in:

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Leukemia:

AML - 85% occurs in adults , onset can be abrupt,dramatic. patient will have signs of pancytopenia

S/S: infections(due to drop in neutrophils) , fatigue, anemia, bleeding, mouth sores, everything drops(all blood levels) ...60-70yr olds

CML - Philadelphia chromosome marker ... starts off chronic and leads to acute-blastic phase(immature cell phase) ..chronic phase can be controlled by treatment ..once becomes acute patient may only live a few months...S/S: not many...may see fever, bleeding..peak onset 45

ALL - children, mostly 2-9yr olds... only about 15% of cases are adults(usually their prognosis is very bad)...children's prognosis is good- have a 90% chance of remission (they also have more stem cells so treatment can be done) First signs: high fever, pallor, petechia, fatigue, joint pain, abdominal pain... will see pancytopenia -- will see CNS manifestations ..will see leukemic meningitis because the cells infiltrate the meninges ... (philadelphia marker seen in some cases)

Treatment: chemo,

Methotrexate, Cyterabine for Brain treatment ,.cross BBB

Radiation to head will lead to permanent Alopecia

CLL most common leukemia in adults 50-70yr olds..overporduction but functionally inactive Bcells..infilltrate bone marrow, spleen, liver..will see lymph node enlargement similar to lymphoma.....early signs will be fatigue(slight over period of time..patient may see changes in things they used to do

i.e hobbies, time they wake up, sleep patterns), (CLL usually becomes AML) ...leukemic cells will high..WBC count will be high but patient will be neutropenic

Overall... S/S: anemia, thrombocytopenia, neutropenia,

Leukemic cells bunch up into a solid mass Chloroma...if WBC 100,000 do a leukophoresis - will receive Hydroxyurea to reduce the one that are floating around (too many circulating will cause all other problems)

Acute Leukemic Treatment:

Induction phase ..attempt to bring about remission- aggressive treatmenet - chemo- patient will severely ill becasue bone marrow and healthy cells will be affected too ..pancytopenic precautions(neutropenic precautions), psychosocial support,

Consolidation Phase: continue chemo dose but will be longer to get hidden leukemic cells from tissues/organs

Maintainence phase..less dose to get any leukeic cells that are left

Once (acute) Leukemia returns after remission it becomes chronic

Pneumococcal vaccine, re-diagnosis, - every 5 years and annual flu shot

LYMPHOMAS:

Hodkins - usually 15-35yr olds, 50+...multinucleated cells...(better than non.-hodgkins) diploidy(double amount of chromosomes?) Reed-Sternberg cells marker found in lymph nodes (lymph node aspiration or biopsy) common in males, people thath have had Epstein Bar, HIV, most prevalent in cervical nodes ...(have OCD-starts from one and goes to sentinnel node..in order) ..nodes will be hard, non-mobile, non-tender usually(tender if pushing on something)

S/S: after nodal involvement: weight loss, fatigue, fever, anorexia(when cervical nodes pushing on esophagus)....B symptoms: Fever, Night Sweats, Weight Loss..if you have all of them you have Hodgkins

Hodgkins patients will have uncurable severe itch(pruritis)everywhere ..cant be treated

Late Signs: hepatosplenomegally, SVC, JVD, blood flow to brain, pressure to brain causing seizures

Treatment CHEMO -ABVD (Adryomycin, Bleomycin, Vinblastine, Dacarbazine)

Non-Hodkins- will have aneuploidy(abnormal cells) (have ADD- jumps around ... multiple lymph nodes affected) mostly Bcells- slight t-cell involvement...affects all ages ...usually involved with HIV patients, on chemo, radiation...may be related to previous

Epstein Barr infection..

Primary sign: painless lymph node enlargement

Treatment : chemo or radiation to nodes, or systemic , comfort, palliation,

MULTIPLE MYELOMA - Bone damage because neoplastic cells infiltrate bone marrow ...can also be called Plasma Cell Myeloma... more prevalent in males 65... caused by radiation, benzine, chemical, pesticides, insecticides, ... Bcells (over production, nonfunctioning..they migrate back into the bone marrow and cause destruction) .. .....monitor patient for Hypercalcemia ...Treat Hypercalcemia - Hydrate patient to flush calcium

M-protein marker, Bence-Jones protein marker(can be found in urine)--large molecules ..they will cause kidney blockage eventually leading to kidney failure

S/S: insidious until advance..by then you have skeletal pain - bone damage has occurred ... usually the pain is during movement ...can have pathological fractures.. calcium being released into blood - will have problems from hypercalcemia- ...bone marrow being destroyed so you will have pancytopenia(destruction of all blood cells-wbc,rbcs,thrombocytes)

Treat pancytopenia, hypercalcemia(fluid then diuretic)... Bone

pain- try to prevent fractures, limit stress or activities that can cause bone trauma , heavy lifting, ... walking necessary to keep things moving ..

early stage: watch patient "watchful waiting"(not really a cure) treat other symptoms with corticosteroids..ambulation, hydration for hypercalcemia treatment...

Blood Products:

for transplant ...blood taken out of donor ..platelets taken out and blood returned to donor

platelets can be stored 1-5 days at room temp

blood cannot - must be refrigerated

need 2 nurses to verify blood product and patients type

must shake bag before administering so blood doesnt clot..

blood must be started within 30mins(?) and infused within 4 hours

minimum 19 gauge for blood(?)

blood not mixed with anything except Normal Saline...not LR, Not dextrose, no crystalloids ..will cause RBC hemolysis

flush line with NS before giving meds ..

remain with patient for first 50mls(15mins)...assess v/s every 15 mins for an hour ..should be infused within 4 hours...

Priority: you will see AML patient before CML patient (A is acute)

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(Last tutor session before test)

Laryngeal Cancer

Complications: obstruction, hemmorrhage, carotid artety problems, metastasis, complications from treatmenets

Trach: done in Or..can be done at bedside--bedside better: less blood loss, less cutting, less infection risk

Cuff to prevent aspiration... inflate cuff during inhalation... deflatine on exhalation...

Suction before deflating..

suction mouth last ..dont go back in throat after doing mouth

cuff pressure ...20 mm/mercury...25mm/water

use minimum leak technique..fully inflate and withdraw 0.1

Cuff size will increase over time

Chart for teaching (supraglottic swallow, trach cleaning, cuff pressure or any teaching) ... steps: teach, return demonstration,

post chart on wall with steps(for while patient in still in hospital) ....pamphlets to go home with

Decanulation: obturator, trach set, ambubag near bedside..use forceps or finger to open if necessary

(if trach is fresh and it slips out ..pull on suture lines to open it and get trach back in(p.243 of saunders)

Dr always does first change (tube, ties etc)after surgery ..

When suctioning.. insert catheter until you feel resistance

....patient should be on humidified air to prevent mucous plug..in the event of mucous plug insert 3-5ml saline bullet and suction(not recommended regulary)

Tube change once a month

open established stoma shouldnt have anything covering it that has a large amount of fabric(wool, gauze pads with fibers)...

10 secs to suction (intermittent suction)

No routine suction...only when needed

baseline vitals before suction...oxygenate..suction..oxygenate

Goal for suctioning: better airway clearance...should hear clear breath sounds and increased pulse ox level

After trach is done..patient should be in semi fowlers position...may see blood tinged mucous right after insertion

If secretions are bubbling out of fresh trach... position patient first-it facillitates better breathing(most noninvasive thing to do)... then suction...

To clean trach tube...sterile technique...1 part peroxide, 2 parts sterile water(NS) to clean..soak cannula, use brush...tap to remove excess water...(dont shake)...may use sterile gauze but may leave fibers

No surgery to close stoma...will close on its own once trach is removed

Leukoplakia (white patch on tongue)...early sign of laryngeal cancer

Stomatitis/mucositosis...oral care: clean with baking soda 1tsp to 8oz water, or peroxide 1:3 with water, hurricaine solution (lidocaine, benadryl,antacid ...is a prescribed medication )..clean teeth after meals and before bed...no alcohol rinses or lemon glycerin swabs

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Radical neck dissections and BC:

FLAPS..main concern: perfusion...check perfusion: skin should not be HOT or COLD - hot means infection, cold means no blood flow ..doppler can be used to check blood flow

If FLAP feels cold: they don't need oxygenation... Call doctor (if there is a choice to collect assessment date do that)

Supraglottic Swallow....

High protein high calorie after surgery

Carbonated water or soda for supraglottic swallow study

Xerostomia.. early sign of stomatitis

dont swallow lidocaine solutions...will numb swallowing

HPV...risk factor for laryngeal cancer

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HIV, Hep B, Epstein Barr, HPV... infections that can lead to cancers

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LUNG CANCER

Cigarette smoking is #1 cause

E-cigarettes can still pose risk...irritation

Promote smoking cessation to all patients

Small Cell is worse than non-Small cell cancer

80% of lung cancer is non-Small cell

No petroleum jellies to skin after radiation

After radiation Aloe for dry desquamination, keep wet skin dry

Paraneoplastic syndrome - hormones or extra hormones being secreted ...parathyroid hormone, ADH etc

JP drain..to re-establish suction: squeeze pump FIRST...then cap

Early signs: cough, hoarseness, sputum

Dont give false reassurance to patients

After bone marrow aspiration lay patient on affected side (wound)to put pressure on wound to stop bleeding

Once there is nodal involvement ..then you have to worry about metastasis

Pulmonary function tests must ne done before removal of any kind

Radiation to chest area: ..worried about bone marrow suppression-because it is in area of sternum

Photodynamic therapy...chemical given,, goes to cancer cell... 48 hours later a light is shined on them and kills the cancer cell..problems: very expensve, takes a lot of time, cant be exposed to any light

Patient must go through simulation before radiation therapy

Metastasis to Brain Bone Blood Liver and Adrenal most common

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Hematology:

know all normal levels

Lymphadema(fluid in lymph system not draining)can occur at anytime..especially to people with node removal ..if removed you are on lymphadema watch forever

Elevated arm to level of heart..not above .....use compression sleeve or glove ...if you cant reduce the lymphadema you can have perfussion problems

RBCs..need iron, folic acid and cobalamin...

nontender, hard, fixed lymph nodes would be cancerous ...

ITP(immune throbocytopenic purpura ...Spleen problems(immune)...wont see d-dimers(clot formation) .. (not enough clotting going on)

DIC will see d-Dimers and increase in Pt/Ptt (clots happening [in bigger veins]and less platelets everywhere else)

Corticosteroids for auto immune problems

Thrombocytopenic patients: mouth care, epitaxis(lean forward with pressure on bridge of nose..if still bleeding use ice..if still bleeding after 10/15mins call doctor) , proper shoes to prevent falls, after subq injections hold pressure at injection site for 10 mins... avoid IMs... Neumega may be given to add more platelets.. menstruating women - monitor pads(1 full equals 50mls)- no tampons, hormones may be given to lessen or stop menstruation(can be scheduled if person will be pancytopenic - like for a patient that will receive radiation), no bending over,

Neutropenia - neutophils below 4,000... below 1,000 is a problem - precautions enacted..below 500 is horrible...Main way to prevent infection: WASH HANDS ... reverse isolation, no fresh/raw foods, limited visitors, no live vaccines

MDS- Myelodysplastic Syndrome - abnormal bone marrow cells...similar to but not as bad as leukemia.. but both are putting out immature cells but leukemis cell are MORE immature(can lead to leukemia

AML - adults usually

ALL - children usually

CLL - has CNS involvement (prolhylactic cranial radiation may be used..Methotrexate, Cytarabine ..because they cross blood brain barrier)

CML - Philadelphia Chromosome ...wont see increase in neutrophil count... most patients remain indiagnosed

when you have Chronic disorder(CLL, CML) you wouldnt worry much about chronic fatigue-wouldnt be a priority(its expected)

Treatments for Leukemia... Induction - high dose of chemo(will be on strict reverse isolation, pancytopenic precautions, Hepa mask, bleeding precuations etc)

Consolidation: further chemo to get any hiding cells

Maintainence phase- Longer time to maintain remission

total body radiation before marrow transplant

Intrathecal (in spinal cord) administration of chemo drugs ...uneven distribution

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Lymphomas:

Hodgkins - 1st lymph node involvement is sentinnel

Non-Hodgkins is all over ..hard to treat by radiation or removal

Reed-Steinberg cell for Hodgkins ....not non hodgkins

Cervical node is most common start

Hodgkins patient - extreme itch(puritis)

Will have non-tender fixed, hard tumor

Hodgkins prognosis is better than non-Hodgkins

Hodgkins is diploid

Non-hodgkins is aneuploidy - damaged (more severe)

Chemo treatment: drug pneumonic (ABVD)

Non-Hodgkins: much worse ..treament drug pneumonic(RCHOP)

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Multiple Myelomas -- bone destruction....calcium into blood.. Hypercalcemic patient (muscle weakness, kidney

stones)...treatment: Fluids..then diuretic

BENCE JONES marker for Multiple Myeloma

Joint pain, fractures,

Move patient with chuck or sheet, encourage walking, fluid

(dehydration and immobility can cause calcium increase in blood)

Treatments: Corticosteroids, Chemo(MPT- Melphalan, Prednison, Thalidamide)

Blood Products:

when giving blood product..2 RNS need to check patient, blood mathc etc

must be used within 30 mins, must finish infusing in 4hrs...if takes longer than 4 throw away... 19 gauge needle for blood

can give platelets at room temperature..not refrigerator(can stay out 1-5 days.... shake bag so platelets dont clump...

Y tubing..

must give blood product only with Normal Saline ..nothing else ...LR is a crystalline solution..and no dextrose

Must stay with patient 15 minutes or until 50mls transfusses..no more than 2mls per minute

check patient every 30 mins during infusion..

after infusion complete check for at least an hour (2x in 1 hour)

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Breast Cancer:

Harder to treat becasue the mitotic rate of breast cells are slower...chemo and radiation are most effective against high mitotic rate cells

Axillary node involvement ..once you have 4 or more it is very bad

Hormones can cause BC..contraceptives, nuliparity.. estrogen hormones(from adipose tissue)

Upper outer quadrant is most common spot

Benign - typical cells, encapsulation, differentiated

Malignant - atypical cell, undifferentiated

Estrogen receptor status: if cells have receptors for estrogen (estrogen receptor positive) patient can be given estrogen like med (antagonist) so it sits on the cell and blocks estrogen then the cancer cell cant get estrogen and cant grow...

Triple Negative Breast Cancer ...negative to Her-2, estrogen Progesterone.... not much treatment

Herceptin - treatment for people positive to HER-2 receptor

Tamoxifen treatment for receptor positive

Herceptin -- major side effect: cardiotoxicity ... signs of cardiotoxicity: peripheral edema, dysrhythmias,

Tamoxifen: Major side effect: visual problems... contraindicated for glaucoma patients

Modified Radical Mastectomy - muscle still there to rebuild

Lumpectomy - just tumor removed... contraindicated if breast is too small in relation to size of tumor - radiation would be done then chemo ...cant do surgery is in all different quadrants ot near nipple

For 2 years , BSE,, Tumor may come back at same site

Mastectomy Pain Syndrome - immobility due to pain ... priority is keep it at level of heart to prevent compartment syndrome...

Brachytherapy - seeds.... are radioactive

Breast reconstruction FLAP surgery ...priority is perfusion:

TRAM FLAP - trans abdominal rectus muscle used with Flap .... problem is 2 surgical sites to monitor now

JP Drain care -

can hold 100mls ...

grenade at end...must be pressed to restablish suction

PennRose... tube hanging out

Arm Care of affected side - no finger sticks, no IV, No BP, protect arm/hand from any injuries, no sun burn, wear gloves when gardening, dont clean up dog poop or liter boxes

Immediately after mastectomy start off with finger, hand, wrist exercise... give anagesic 30 mins before, semi fowlers, elevated arms, ..shower with warm water-not hot or cold,

Lymphadema - elevation, decongestion therapy(massage, compression band- remove when sleeping)

Explain to patient they will always be at risk for lymphadema

Breast Reconstruction: tissue expanders ...slow increase to expand tissue and then filling with saline

Later on if there is back pain ...could be from spinal cord compression

Breast implants - afterward need well fitted bra

no showering with JP drain in

no lifting more than 10lbs for at least 2-3 weeks

Lumps with menstruation that go away is normal

SBE 5-7 days after menses.... after menopause date of bday or anniversary same day every month

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Oncologic Emergencies:

Radiation for SVC ..

Spinal Cord compression ..laminectomy

SIADH (from paraneoplastic syndrome)

Tumor Lysis Syndrome ... give lasix, allopurinol

Inflammatory BC..worst type - orange peel skin, red warm skin..surgery usually too late...will be for control not cure

Pagets Disease - tumor in nipple...high death rate, unilateral bloody discharge