MedSurge Unit 1 Cancer

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cswett
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MedSurge Unit 1 Cancer
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2012-01-28 14:46:30
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MedSurge Unit LeMone 12 Adams 58 Huether 10
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MedSurge Unit 1 Cancer LeMone Ch 12, Adams, Ch 58, Huether Ch 9 & 10
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  1. hypertrophy
    enlargement of an organ due to enlargment of the component cells
  2. neoplasm
    Tumor - an abnormal proliferation of cell growth that exceeds the growth of the tissue around it - even when the stimuli has ceased - neoplasms can be benign, pre malignant, or malignant
  3. Benign Tumors
    • Suffix- oma
    • not cancer - benign tumors are well encapsulated and well, differentiated, retain some normal tissue structure, and do not invade the capsule - they do not spread to regional lymph nodes or distant locations
  4. Malignant Tumors
    • rapid growth rates
    • specific microscopic alterantions - loss of differentation
    • absence of normal tissue organization
    • lack of a capsule (organ)
    • invation into blood vessels, lymphatic, and surrounding structures
    • distant spread (metastasis)
    • anaplasia - loss of normal differentation, nuclear irregularities, and loss of normal tissue structure
  5. carcinomas
    adenocarcinomas
    sarcoma
    lymphomas
    leukemias
    carcinoma in situ
    • carcinomas - cancers arising in epithelial tissue
    • adenocarcinomas - in ductal or glandular epithelium
    • sarcoma -arising in connective tissue
    • lymphomas- in lymphatic tissue
    • leukemias - in blood-forming cells (bone)
    • carcinoma in situ - pre malinoma - preinvasive epithelial tumors of glandular or squamous cell origin
  6. Stages of Cancer Spread
    • 1 - confined to organ of origin
    • 2 - locally invasive
    • 3 - spread to regional structures such as lymph nodes
    • 4 - spread to distant sites (metasis)
  7. Autonomy
    Anaplasia
    • Autonomy - cancer cell's independence from normal cellular controls
    • Anaplasia - without form - cells are variable size and shape (pleomorphic)
  8. What is Cancer?
    • •Greek for “crab” due to the invasive claws.
    • • Defined as a group of complex diseases which are characterized by uncontrolled growth and abnormal spread.
    • • Incidence - second more common cause of death in the US - 1.5 million new cancer cases each year
  9. Classification
    • Carcinoma- epithelial
    • • Sarcoma- connective
    • • Lymphomas- lymphatic (ex. Hodgkin's,non-Hodgkin’s)
    • • Leukemia-blood forming cells
    • • Adenocarcinomas-glandular or ductal epithelium - breast & thyroid
  10. Risk Factors
    • • Heredity - 5% of all cancers have hereditary component
    • • Age - 78% after age 55/ Antioxidants in cell decrease with age while oxidents increase
    • •Gender - women breast/ men prostate, bladder cancer
    • • Poverty
    • • Stress
    • • Diet
    • • Alcohol
    • •Occupation
    • • Infection
    • • Tobacco
    • • Recreational drugs
    • •Obesity
    • • Sun exposure
  11. Proliferation
    Normal Cells Vs. Cancer Cells
    • Normal cells
    • • Contact inhibition
    • • Finite number of cell divisions before cell death
    • • Different tissues have different proliferation rates.

    • Cancer cells
    • • Divide at same rateas normal cells.
    • • Do not respond to signals
    • • Divide continuously
    • • No contact inhibition
    • • Never die
  12. Differentiation
    Anaplasia
    Dysplasia
    Metaplasia
    Hyperplasia
    • Differentiation - normal process that allows cells to specialize in certain tasks
    • • Extent tumor cells resemble cells of origin
    • • Degree of maturity of cells
    • • More poorly undifferentiated cells are, the poorer the prognosis

    • Terms:
    • Anaplasia-immature cells, loss of differentiation - not under DNA control.
    • Dysplasia- abnormal size, shape, appearance - loss of DNA control.
    • Metaplasia- cells in abnormal location - normal cell not in the right place - endometrial cells near ovaries
    • Hyperplasia- increase in number or density of normal cells - under DNA control.
  13. Differentiation
    Normal Cells Vs. Cancer Cells
    • Normal Cells
    • • All start from stem cells
    • • Become endo-,meso-, or ectoderm
    • • Cell division =specialization.
    • • Once specialized does not reverse.

    • Cancer Cells
    • • Regulating genes ineffective.
    • • Differentiation lost.
    • • Cells loose function and reverse.
    • • Produce abnormal hormones and proteins.
  14. Neoplasms
    Benign Vs. Malignant
    • BENIGN=NONCANCEROUS
    • • Localized
    • • Solid mass
    • • Defined borders
    • • Pushes tissue out
    • • Slow growth
    • • Encapsulated
    • • Easy to remove
    • • Doesn’t reoccur

    • MALIGNANT=CANCEROUS
    • • Invasive growth
    • • Non-cohesive
    • • Irregular borders
    • • Invades tissues
    • • Rapid growth
    • • Metastasizes
    • • Difficult to remove
    • • Can reoccur.
  15. Carcinogenesis
    3 Theories of Carcinogenesis
    carcinogenesis - normal cell transformed into a cancer cell

    • Cellular Mutation- carcinogens cause mutations in the cell DNA.
    • carcinogens - agents that couse mutations

    • Oncogenes-abnormal genes which promote cell proliferation.

    • Tumor suppressor Genes- normally suppress oncogenes but will decrease immunity.
  16. The Carcinogenic Process
    • 1. Initiation
    • 2. Promotion
    • 3. Progression
  17. THE CARCINOGENIC PROCESS:
    1. Initiation
    • 1- INITIATION
    • • Exposure of cell to carcinogen.
    • • Irreversible alteration of DNA.
    • • More than one carcinogen may beresponsible.
    • • Must get total carcinogen history when evaluating patient risks.
  18. THE CARCINOGENIC PROCESS:
    Promotion
    • 2- PROMOTION
    • • Reversible proliferation of altered cells
    • • Promoting agents increase the number of altered cells
    • • The more altered cells, the more likely the second mutation needed to cause cancer cells.
    • • Agents that initiate and promote altered cells are called complete carcinogens. Example: cigarette smoke.
    • Remove promoting factors:
    • • Likely to reverse the proliferation and reduce the riskof the second mutation.
  19. THE CARCINOGENIC PROCESS:
    Progression
    • 3- PROGRESSION
    • • End of latency period which can last 1-40 years.
    • • Increased tumor growth
    • • Increased invasiveness
    • Metastasis:
    • • Cells that leave the primary tumor site
    • • Can evade the immune system
    • • Have different characteristics than the primary tumor
    • • More difficult to treat than primary tumor.
  20. CARCINOGENS
    • Genotoxic
    • -directly alter DNA
    • -sun, radiation, chemotherapy

    • Promotional
    • -indirectly cause adverse effects and promote cancer.
    • • Viruses - HPV & Eptsein-Barr
    • • Physical agents - radon gas
    • • Chemical agents
    • • Hormones/Drugs - cocaine
  21. •Oncology
    -study of cancer
  22. cell cycle
    • four phases
    • G1 - prep for replicaiton
    • S - synthesis - DNA replicates
    • G2 - prep for miotosis
    • M - mitosis
    • G0 - restings phase
  23. cachexia
    wasted appearance of cancer victims - unexplained rapid weight loss
  24. Diagnosis of Cancer
    • Diagnostic Methods:
    • • Exfoliated cells with histological exam - Ex. PAP
    • histological - compare parent & daughter cells
    • • Needle biopsy- aspirate fluid
    • • Direct visualization with biopsy- Ex. Bronchoscopy
    • • Exploratory surgery with frozen section
    • • Radiology/ imaging
    • • Blood screening – Ex. CBC (anemia)
    • • Tumor markers- Ex. PSA, CEA
  25. Classification of Cancer
    • classification - naming the tumor
    • grading - describing its aggressiveness
    • stagin - spread within or beyond the tissue of origin
    • • Anatomic site - named by tissue of origin
    • • Biopsy (this is the histology analysis)
    • # will not reveal the extent of the disease.
    • # may help determine treatment modalities
    • # differentiation of the cell
    • # benign or malignant

    • • Extent of disease
    • # Clinical Staging
    • # TNM classification
  26. Staging of Cancer
    • Stage 0- cancer “in situ” – pre-invasive
    • • Stage I – tumor limited to tissue of origin and a single lymph node
    • • Stage II – limited to local spread to 2 or more lymph nodes on the same side of the diaphragm
    • • Stage III- extensive local and regional spread to lymph nodes on both sides of diaphragm
    • • Stage IV – metastasis or diffuse, disseminated disease to distant sites and lymph nodes.
  27. TNM Classification
    • T- Tumor size (T)
    • * To = no evidence of primary tumor
    • * Tis = carcinoma in situ
    • * T1-4 = degrees of increased tumor size

    • • N- Regional lymph nodes involved (N)
    • * N0 = no evidence of disease in nodes
    • * N1-4 = ascending degrees of nodal involvement
    • * N x = unable to assess regional lymph nodes

    • • Distant metastasis (M)
    • * M0 = no evidence of distant metastasis
    • * M1-4 = ascending degrees of metastaticinvolvement
  28. Seven Signs of Cancer
    • • C Change in bowel or bladder
    • • A A lesion that does not heal
    • • U Unusual discharge from any orifice
    • • T Thickening lump in breast or elsewhere
    • • I Indigestion or difficulty swallowing/dysphagia
    • • O Obvious change in a wart or mole
    • • N Nagging cough or persistent hoarseness
  29. Health Promotion
    • • Prevention and early detection
    • • Avoid carcinogens
    • • Improve nutrition
    • • Self exams
    • • Regular health care screening
    • • Identify high risk population
  30. Diagnostic Phase Nursing Responsibilities:
    • • Completion of studies can take weeks
    • • Lack of answers causes anxiety
    • • Anger
    • • Nurse’s role
    • * Actively listen
    • * Don’t give false hope
    • * Repeat explanation of procedures
  31. GENERAL SIGNS AND SYMPTOMS OFCANCER
    • • Pain in later stages
    • • Fatigue
    • • Cachexia
    • • Anemia
    • • Infection/leukopeniaWBC’s < 4,000 (Normal 5,000-10,000)
    • • Bleeding/thrombocytopenia Platelets < 150,000 (Normal 150,000-400,000 uL)
  32. Cancer Treatment Goals
    • • Cure- complete eradication of disease
    • • Control- prolonged survival with thepresence of malignancy
    • • Palliation- relief of symptoms like pain.
  33. Treatment Modalities
    • Surgery
    • Cure- primary treatment (60%)
    • Diagnostic (90%)
    • Prophylaxis
    • Debulking procedure
    • Palliation
    • Body image disturbance

    • RADIATION THERAPY
    • Teletherapy- external radiation
    • Brachytherapy- internal radiation - place seeds of radiation into cancer tissue

    • Radiation
    • -Damages DNA
    • -Cancer cells usually die
    • -Normal cells usually recover
    • - Requires daily sessions for weeks
    • - Side effects- fatigue, anorexia and skin/mucusirritations.
  34. Radiation Therapy Nursing Considerations
    • Keep skin clean and dry, water to wash-pat dry.
    • Water only, no soaps, deodorants
    • No perfumed oils or creams
    • Sunblock for one year
    • Don’t remove radiation marks - purple marker
    • May have nausea, vomiting, diarrhea, bleeding.
    • May develop radiation pneumonia.
    • Fatigue, anorexia
  35. Chemotherapy
    • • Uses cytotoxic medications to interfere at the cellular level with cancer.
    • • May be used alone or with biotherapy.
    • • Disrupts the cell cycle in various phases.
    • • Interrupts cell metabolism and replication.
    • • Medications may be used in combination oralone.
    • -doasge is taylored to the individual client
    • -frequent labs to find therapeutic level
  36. Chemotherapy Drug Classifications
    • Antimetabolite Agents
    • (Methotrexate, 5-fluorouracil)
    • * interferes with metabolic processes in the S phase causing cell death.

    • Alkylating Agents
    • (Nitrogen Mustard, Cyclophosphamide)
    • * interferes with DNA replication and RNA protein synthesis. Non- phase specific

    • Mitotic Inhibitors
    • (Vincristine, vinca alkaloids)
    • * Interferes in the M phase and inhibits cell division by blocking mitosis. Slows or stops the disease process.

    • Antibiotic Antineoplastic Agents
    • (Adriamycin, Bleomycin)
    • * non phase specific. Attaches to DNA and prevent DNA synthesis in vulnerable cells

    • Hormones
    • (Prednisone)
    • * phase specific and interfere with RNA similar to corticosteroids

    • Biologic-response modifiers
    • (Interferon, interleukins)
    • * enhance immune system

    • Adjuvant agents/rescue
    • * Mesna - protects kidneys from toxic effects of ifosfamide
    • * Procrit -Stimulates erythropoiesis (production of red blood cells)
    • * Leucovorin -
    • * Colony stimulating factors
  37. Chemotheraly General Considerations
    • • Most clients are on a combination of chemotherapy agents.
    • • Chemo drugs are not selective so they also kill normal cells as well as cancer cells
    • • Monitoring for toxic adverse effects is a nursing priority.
    • • Severe nausea & vomiting
    • • Nutrition – stomatitis & xerostomia
    • • Alopecia
    • • Safety precautions
  38. chemotherapy causes:
    stomatitis
    xerostomia
    stomatitis - inflammation of the mucosa of the mouth

    xerostomia - dry mouth due to lack of saliva
  39. General Adverse Effects of Chemotherapy
    • • Nausea
    • • Vomiting
    • • Anorexia
    • • Diarrhea
    • • Constipation
    • • Stomatitis
    • • alopecia
    • • Bone marrow depression
    • * leukopenia
    • * anemia
    • *thrombocytopenia
    • • Hepatic toxicity
    • • Hyper uricemia
    • • fatigue
  40. Nursing Implications of Chemotherapy
    • Wear personal protection when handling antineoplastic agents. May be carcinogenic andmutagenic.
    • • Monitor IV site closely to assess for extravasation.
    • Stop IV immediately
    • • Treat used equipment as hazardous waste
    • • Monitor CBC, I & O, renal function.
    • • Inspect oral cavity.
  41. Biotherapy
    • • Biologic response modifiers which enhance the immune system.
    • Interferon's-
    • • proteins produced in response to antigens.
    • • Tumor associated antigens (TAA)-destroy tumor as a healthy response.
    • • Interfere with cancer cell growth
    • • Side Effects:
    • • Fever/chills
    • • Fatigue & malaise
    • • Mental slowing and confusion
  42. PHOTODYNAMIC THERAPY
    • • Photosensitizing compound / Photofrin - tumor absorbs and can be targeted with laser
    • • Laser treatment to destroy tumor.

    • • Nursing Implications:
    • • Adverse hypersensitivity especially after first injection.
    • • Nausea/chills/hives
    • • Patient teaching-protection from sunlight
  43. BONE MARROW TRANSPLANTS VS.PERIPHERAL BLOOD STEM CELL TRANSPLANTATIONS
    • Bone Marrow Transplant(BMT)
    • • Used in leukemia,melanoma, & testicular cancer
    • • Stimulates nonfunctioning bone marrow
    • • Allogeneic-another donor
    • • Autologous-own
    • • Synergenic –identical twin

    • Peripheral blood stem cell transplant (PBSCT)
    • • Remove blood through apheresis (blood removed from client and desired parts removed and reintroduced after chemotherapy.
    • • Return after high dose chemotherapy.
    • • Fewer side effects
    • • Shorter hospital stay
    • • More economical
  44. LEUKEMIA CANCER OF THE WBC’S
    • • Usual number of white blood cells to red blood cells is reversed.
    • • Bone marrow is replaced by immature white blood cells.
    • • Infiltrates into liver, spleen, and lymph nodes.
    • • Begins with one malignant stem cell.
    • • Do not differentiate normally
    • • Do not function normally so immune system is compromised.
  45. LEUKEMIA SIGNS/SYMPTOMS
    • • Pallor
    • • Fatigue/malaise
    • • Tachycardia
    • • Fever/night sweats
    • • Dyspnea onexertion
    • • Lymphadenopathy
    • • High uric acid/renalcalculi.
    • • Frequent infections
    • • Bleeding (gums,bruises, petechiae
    • • Bone pain
    • • Increased metabolism
    • • Heat intolerance
    • • Wt. loss
  46. TYPES OF LEUKEMIA
    • • Classified by acuity and predominant cell type.
    • • Acute- rapid onset, rapid progression, immature cells.
    • • Chronic- gradual onset, prolonged progression,abnormal mature appearing cells.
    • • Lymphocytic-immature lymphocytes in bone marrow
    • • Myeloid-myeloid stem cells in bone marrow interfere will all cell maturation.
  47. Leukemia - Acute Lymphocytic leukemia- (AML)
    • • 80% of acute leukemia’s in adults
    • • 66% with remission
    • • Decreased neutrophils result in severe infections
    • • Death results from hemorrhage or infection.
    • • Proliferation immature WBC’s
  48. ASC guidelines for cancer screening
    • Breast Cancer:
    • -Anually over 40 years
    • - Q 3 years in 20's and 30's
    • - Regular breast self exams

    • Cervix/ Uterus
    • -three years after first intercourse but no later than 21
    • - annual PAP test or liquid test Q2 yrs
    • - After 30 those with three normal tests in a row can do 2 to 3 years
    • ->70 and 3 or more normal tests in last 10 years can stop screening

    • Colon and Rectum - beginning at 50 should do one of the following:
    • -FOBT (fecal occult blood test) or FIT (fecal immunochemical test) Q year
    • -FSIG (flexible sigmoidoscopy) Q 5 yrs
    • - Colonoscopy Q 10 yrs
    • - double-contrast barium enema Q 5 yrs
    • - CT colonograpy Q 5 yrs

    • Prostate
    • PSA - prostate-specific antigen test and DRE (digital rectal exam) annually after age 50 (for men with life expectancy of at least 10 yes)
    • -High risk (family history, African American) should begin at age 45
    • -give info so they can make informed decision
  49. Chronic Myeloid Leukemia (CML)
    • • 15% of adult leukemia's
    • • Men more than women
    • • Associated with chromosome abnormality
    • • Asymptomatic
    • • Progresses in 3-4 years to an aggressive stage
    • • Survival 2-4 months after final stage diagnosis.
  50. Acute Lymphocytic Leukemia (ALL)
    • • Most common type in children/young adults
    • • Onset is usually rapid
    • • CBC with elevated WBC
    • • RBC’s and platelets are decreased
    • • Combination chemo- 80%-90% remission inadults
  51. Chronic Lymphocytic Leukemia (CLL)
    • • More common in older adults
    • • Slow onset
    • • Symptoms vague
    • • Least common type of major leukemia's
    • • 7 year survival rate.
  52. Leukemia Treatments
    • • Chemotherapy
    • • Radiation
    • • Bone marrow transplant
    • • Stem cell transplant
    • • Biologic therapy
    • * interferon
    • * interleukins
  53. Lymphomas
    • • Lymphomas-malignancies of lymphoid tissue.
    • • Identified as :
    • • Hodgkin's disease- Reed Sternberg cells present
    • • or Non-Hodgkin's disease-no Reed Sternberg cells
    • • Cause unknown
    • • Incidence: 61,000 cases of lymphoma/year
  54. Hodgkin's Lymphoma
    • 15-35 years or over 50.
    • • More common in men than women
    • • Cause unknown- Epstein Barr virus and genetic factors suspicious.
    • • Most curable of cancers
    • • Develops in single lymph node or chain
    • • S/S
    • * painless enlarged lymph nodes (cervical or subclavicular)
    • * fever, night sweats, fatigue, wt. loss
    • * enlarged spleen

    Tx: Chemo & Radiation
  55. Non-Hodgkin's Lymphoma
    • • Older adults
    • • Reed-Sternberg cells not present
    • • Spreads early/unpredictable
    • • S/S
    • * painless lymphadenopathy
    • * abdominal pain, nausea & vomiting, headaches
    • • Treatment•
    • * Chemo and radiation
  56. MULTIPLE MYELOMA
    • • Malignant plasma cells invade bone marrow, lymphnodes, spleen, and other tissues.
    • • 19, 920 cases diagnosed.
    • • Blacks nearly twice as often as Whites
    • • Men more than women
    • • Age > 40
    • • Cause unknown
    • • No cure
    • • Treated with Chemo
  57. Female Cancers
    Risk Factors & Prevention
    • Risk factors-
    • • Human papillomavirus (HPV0 genital warts
    • • Chlamydial infections/history of STD’s
    • • Early sexual activity/multiple partners
    • • Family history
    • • DES exposure - Desphesteral - Rx to prevent miscarriage

    • Prevention-
    • • Pap Smears
    • • Limit sexual Partners
    • • Gardasil vaccine
  58. Cervical Cancer
    • Signs & Symptoms
    • • Asymptomatic pre-invasive
    • • Vaginal bleeding after intercourse and between periods
    • • Pain in back and thighs
    • • Anemia/wt. loss
    • • Hematuria or blood in stool if metastasis

    • Diagnosed
    • • PAP smear-atypical cells
    • • Cervical biopsy
  59. Endometrial Cancer
    • Signs & Symptoms
    • • Abnormal painless vaginal bleeding
    • • Pelvic cramping
    • • Low abdominal pressure/abdominal mass
    • • Lymph node enlargement
    • • Pleural effusion with mets to the lung
    • • Ascites (extra pleural fluid) if mets to the liver
  60. Ovarian Cancer
    • Risk Factors:
    • • Family history
    • • High fat, low fruits & vegetable diet
    • • Fertility drugs or hormone replacement therapy
    • • Early menarche, late menopause, no children

    • Signs & Symptoms
    • • Asymptomatic then vague signs
    • • Indigestion, bloating, urinary frequency,constipation, pelvic pain, vaginal bleeding.
  61. Breast Cancer Risk Factors
    • Risk Factors
    • • Age > 55
    • • Family history
    • • Genetics BRCA 1 orBRCA 2
    • • Early menarche (<12)
    • • Late menopause(>55)
    • • No children or firstchild after 35
    • • Caucasian > 40
    • • High fat diet, obesity
    • • Oral contraceptives
    • • Radiation exposure
    • • History of another cancer
    • • Hormone replacement
    • • Alcohol use-more than two drinks per day
  62. Breast Cancer
    S & S
    • Signs and Symptoms:
    • • Asymptomatic
    • • Non-tender lump or thickening-upper outerquadrant
    • • Burning, stinging, or pricking- non painful
    • • Abnormal nipple discharge
    • • Rash around nipple
    • • Nipple retraction
    • • Dimpling of skin or nipple position off
    • • Lump under arm or collar bone
  63. Nursing Dx:
    Fatigue/Activity Intolerance
    • • Prepare the patient to expect it
    • • Plan for rest breaks-fighting it makes it worse
    • • Plan crucial activities for after rest periods
    • • Energy is finite-delegate and/or put off asmuch as possible.
  64. Nursing Dx:
    Imbalanced Nutrition
    • • Small frequent meals
    • • High protein/high calorie diet
    • • Consider nutritional supplements
  65. Nursing Dx:
    Nausea
    • • Antiemetic's
    • • Monitor hydration
    • • Eat and drink slowly
    • • Bland and lukewarm foods
  66. Nursing Dx:
    Impaired Skin/Mucus Membrane Integrity:
    • • Dry skin-lubricate plain white lotion
    • • Wet skin-keep clean
    • • No hot packs or ice packs
    • • Dry mouth-saline rinse before and after meals
    • • Increased p.o. fluids
    • • Pharyngitis/esophagitis-analgesics and anesthetic coating agents
  67. Nursing Dx:
    Disturbed body image:
    • • Alopecia
    • • Emotional support
    • • Women frequently have a grief reaction
    • • Protect exposed scalp from sun

    • Surgical Mutilation (amputation):
    • • Emotional support
    • • Support groups
  68. Nursing Dx:
    Risk for Infection:
    • • Protection from infection
    • • Good hand washing technique
    • • Avoid crowded places
    • • Avoid anyone with a URI or other infection
    • • Do not share cups or utensils
    • • Contact physician immediately if:
    • * temperature above 100.4
    • * sore throat or cough
    • * flu like symptoms
  69. Nursing Dx:
    Pain, Chronic
    • • Cancer pain often under treated
    • • Begin every assessment by asking “do you have pain?”
    • • Client behaviors and vital signs not reliable indicator
    • • If the client says there is pain, there is pain. TREAT IT!
    • • Nonpharmacological methods include positioning,imagery and relaxation techniques
    • • Round the clock analgesics with additional doses for breakthrough pain
    • • Fear of addiction is not warranted and must be addressed.
  70. Cancer Emergencies
    • • Sepsis
    • • Obstructive events
    • • Metabolic emergencies
    • • Infiltrative emergencies

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