Cancer Unit 4

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Cancer Unit 4
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Cancer Unit 4
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  1. Benign
    altered cell growth that does not require intervention
  2. Cancer pathophysiology
    • Cells of the skin, hair, mucous membranes, bone marrow, and linings of organs (lungs, stomach, intestines, bladder uterus) have the ability to divide throughout a person's life.
    • Some tissues stop growing by cell division after completing development (heart cells)
    • Growth that causes tissue to INCREASE IN SIZE by enlarging each cell is Hypertrophy
    • Growth that causes tissues to increase in size by INCREASING THE NUMBER of cells is Hyperplasia
    • Any new or continued cell growth not needed for normal development or replacement of dead and damaged tissues is neoplasia; neoplastic cells develop from normal (parent cells) and therefore cancer cells were once normal cells but changed to no longer look, grow, or function normally
  3. Biology of Normal cells
    • Specific morphology- each normal cell type has a distinct and recognizable appearance, size, and shape
    • Small nuclear to cytoplasmic ratio- the nucleus of a normal cell does not take up much space inside the cell and is small in comparison with the rest of the cell
    • Differentiated function- every normal cell has at least one special function it performs to contribute to whole body function
    • Tight adherence- normal cells make proteins that protrude from membranes, allowing cells to bind closely and tightly together. Fibronectin keeps most normal tissues bound tightly to each other
    • Nonmigratory- normal cells do not wander throughout the body except for blood cells
    • Contact inhibition-stopping of further rounds of cell division where the dividing cells is completely surrounded and touch by other cells, each cell divides only when some of its surface is not in direct contact with another cell
    • Apoptosis-programmed cell death; with each cell division, the telemetric DNA at the ends of the cell's chromosomes shorten; it ensures that each organ has an adequate number of cells at their functional peak
    • Normal chromosomes (euploidy)- 23 pairs
    • Limited division- cells divide for only 2 reasons: to develop normal tissue or to replace lost or damaged tissue; normal cells divide only when body conditions, including the need for more cells, adequate space, and sufficient nutrients and other resources are just right
    • Amount of time needed for one cell to divide completely into 2 cell is the generation time
    • Proteins that promote cells to enter and complete cell division are produced by oncogenes (cyclins) that then drive the cell to progress through the different phases of the cell cycle and divide; thus normal cell division is a balance between cyclins and proteins that limit cell division (suppressor gene products)
  4. Features of benign cells
    • Moles, skin tags, endometriosis, nasal polyps; normal cells growing in the wrong place at the wrong time; parent cell is a normal cell, it looks like parent cell, carries out function, just not normally
    • Specific morphology- they look like the tissues they come from, retaining specific morphology of the parent cell
    • Small nuclear to cytoplasmic ratio-just like normal cells
    • Specific differentiated functions- continue normal function, just in the wrong place
    • Tight adherence- continue to make fibronectin; many are encapsulated or surrounded with fibrous connective tissues, helping to hold the benign tissue together
    • No migration- they do not wander because they remain tightly bound and do not invade other body tissues
    • Orderly growth- normal growth patterns even though the growth is not needed; the benign tumor grows by hyperplastic expansion, it doesn't invade
    • Normal chromosomes- most have 23 chromosomes
  5. Features of cancer cells
    • abnormal, serve no useful function, and are harmful to normal body tissues
    • Anaplasia- loss of the specific appearance of their parent cells; with more malignancy, the cells become smaller and more rounded
    • Large nuclear cytoplasmic ratio- cancer cells nucleus is larger and the cell is small
    • Specific function-lost partially or completely; serve no useful purpose
    • Loose adherence- do not make fibronectin; easily break off from main tumor
    • Migration- with loose adherence, cells break off easily and they slip through blood vessel walls and between tissues, spreading from the main tumor site to many other body sites; ability to spread (metastasize) is unique to cancer cells; expand by mitosis and invade other tissues close and distant to tumor
    • Contact inhibition does not occur even when all parts of cell are in contact
    • Rapid or continuous cell division- re-enter cell cycle for mitosis almost continually; short generation time (2-4h), but may have a generation time similar to parent cell; do not respond to signal for apoptosis; a lot of telomerase to maintain telomeric DNA; immortal (unlimited life span)
    • Abnormal chromosomes (aneuploidy)- chromosomes are lost, gained, or broken; can have more or less than 23 chromosomes; may be broken and rearranged
  6. Characteristics of normal and abnormal cells
    • Cell division- normal (none or slow); benign (continuous or inappropriate); malignant (rapid or continuous)
    • Appearance- normal (specific morphology features); benign (specific morphology features); malignant (anaplastic)
    • nuclear to cytoplasmic ratio- normal (small); benign (small); malignant (large)
    • differentiated functions- normal (many); benign (many); malignant (some or none)
    • Adherence- normal (tight); benign (tight); malignant (loose)
    • Migratory- normal (no); benign (no); malignant (yes)
    • Growth- normal (well regulated); benign (expansion); malignant (invasion)
    • Chromosomes- normal (diploid (euploid)); benign (diploid (euploid)); malignant (aneuploidy)
    • Mitotic index- normal (low); benign (low); malignant (high)
  7. Carcinogenesis/Oncogenesis
    • cancer development; process of changing from a normal cell into a cancer cell is malignant transformation
    • Neoplastic cells originate from normal body cells; transformation of a normal cell into a cancer cell involves mutation of the genes (DNA) of the normal cell; oncogenes that are overexpressed can cause a cell to develop into a tumor; only one cells has to undergo malignant transformation for cancer to begin; benign tumors grow by expansion, whereas malignant tumors grow by invasion; most tumors arise from cells that are capable of cell division; a key feature of cancer cells is the loss of apoptosis, these cells have an infinite life span; primary prevention of cancer involves avoiding exposure to known causes of cancer; secondary prevention of cancer involves avoiding exposure to known causes of cancer; tobacco use is a causative or permissive factor in 30% of all cancers; tumors that metastasize from the primary site into another organ are still designated as tumors of the originating tissue
  8. Initiation
    • first step in carcinogenesis; normal cells can become cancer cells if their genes promoting cell division (oncogenes) are turned on excessively (overexpressed)
    • A change in gene expression caused by anything that can penetrate the cell, get into the nucleus, and damage the DNA
    • Initiation leads to excessive cell division through DNA damage that results in either loss of suppressor gene function or enhancement of oncogene function
    • Irreversible event that can lead to cancer development; A cancer cell is not a health threat unless it can divide
    • If growth conditions are right, widespread metastatic disease can develop from just one cancer cell
    • Substances that change the activity of a cell's genes so that the cell becomes cancer are carcinogens- chemicals, physical agents, viruses
  9. Promotion
    • enhancement of growth of an initiated cell
    • Promoters-substances that promote or enhance growth of the initiated cancer cell
    • Once initiated and a cancer cell, it can become a tumor if growth is enhanced
    • Insulin and estrogen can act as promoters and make altered cells divide more frequently
    • The time between a cell's initiation and the development of an over tumor is called the latency period, may take months to year, exposure to promoters can shorten the latency period
  10. Progression
    • continued change of a cancer making it more malignant over time
    • <1 cm, tumor does not show on PET Scan
    • >1 cm, tumor must develop its own blood supply; 1 cm contains 1 billion cells; the tumor begins to make substances that trigger nearby capillaries to grow new branches into the tumor, ensuring the tumor's continued nourishment and growth
    • As tumor cells continue to divide, some of the new cells change features from the original, initiated cancer cell and form groups that differ from the original cell; these tumor changes may allow it to become more malignant; over time, tumor cells have fewer and fewer normal cell features
  11. Primary tumor
    • the original tumor; identified by the tissue from which it arose
    • When located in vital organs, they can grow excessively and either lethally damage the vital organ or interfere with that organ's ability to perform its vital function; when located in soft tissue it can expand without damage as the tumor grows and is slower
    • When the tumor spreads fromt he original site into vital areas, life functions can be disrupted and death may follow
  12. Metastasis
    • cancer cells move form the primary location by breaking off from the original group and establishing remote colonies
    • Metastatic or secondary tumors-even though the tumor is now in another organ, it is still a cancer from the original altered tissue
    • Tumors first extend into surrounding tissues; pressure, created as the tumor increases in size, forces tumor cells to invade new territory
    • Bloodborne metastasis- tumor cell release into the blood is most common cause of cancer spread; because tumor cells are loosely held together, clumps of cells break off of the primary tumor into blood vessels for transport
    • Clumps of cancer cells get trapped in capillaries, damage the capillary wall and allow cancer cells to leave the capillary and enter the surrounding tissue
    • When conditions in the remote site can support tumor cell growth, the cells stop circulating (arrest) and invade the surrounding tissues, creating secondary tumors
    • Lymphatic spread is related to the number, structure, and location of lymph nodes and vessels; primary sites that are rich in lymphatics have more early metastatic spread than areas with few lymphatics
  13. Stages of metastasis
    • Malignant transformation- some normal cuboidal cells have undergone malignant transformation and have divided enough times to form a tumorous area within the cuboidal epithelium
    • Tumor vascularization- cancer cells secrete tumor angiogenesis factor (TAF), stimulating the blood vessels to bud and form new channels that grow into the tumor
    • Blood vessel penetration- cancer cells have broken off from the main tumor; enzymes on the surface of the tumor cells make holes in the blood vessels, allowing cancer cells to enter blood vessels and travel around the body
    • Arrest and invasion- cancer cells clump up in blood vessel walls and invade new tissue areas; if the new tissue areas have the right conditions to support growth of cancer cells, new tumors (metastatic tumors) will form at the site
  14. Common sites of metastasis
    • Breast-bone, lung, liver, brain
    • lung- brain, bone, liber, lymph nodes, pancreas
    • colorectal- liver, lymph nodes, adjacent structures
    • Prostate- bone (spine and legs), pelvic nodes
    • Melanoma- GI tract, lymph nodes, lung, brain
    • Primary Brain Cancer- CNS
  15. Classification of Tumors
    • classified by the type of tissue from which they arise
    • other ways to classify include biologic behavior, anatomic site, and degree of differentiation
    • Solid tumors develop from specific tissues; hematologic cancers arise from blood cell-forming tissues
    • Adeno- epithelial glands; benign-adenoma; malignant- adenocarcinoma
    • chrondro- cartilage; benign- chondroma; malignant- chondrosarcoma
    • fibro- fibrous connective; benign- fibroma; malignant- fibrosarcoma
    • glio- glial cells (brain); benign- glioma; malignant- glioblastoma
    • hemangio- blood vessel; benign- hemangioma; malignant- hemagiosarcoma
    • hepato- liver; benign- hepatoma; malignant- hepatocarcinoma, hepatoblastoma
    • leiomyo- smooth muscle; benign-leiomyoma; malignant- leiomyosarcoma
    • lipo- fat/adipose; benign- lipoma; malignant- liposarcoma
    • lympho- lymphoid tissue; malignant- lymphomas (Hodgkin's, Non-Hodgkins, Burkitts, Cutaneous T-cell)
    • melano- pigment-producing cells; malignant- melanoma
    • meningioma- meninges; benign- meningioma; malignant- malignant meningioma, minigioblastoma
    • neuro- nerve tissue; benign- neuroma, neurofibroma; malignant- neurosarcoma, neuroblastoma
    • osteo- bone; benign- osteoma; malignant- osteosarcoma
    • renal- kidney; malignant- renal cell carcinoma
    • rhabdo-skeletal muscle; benign- rhabdomyoma; malignant- rhabdomyosarcoma
    • squamous- epithelial layer of skin, mucous membranes, and organ linings; benign- papilloma; malignant- squamous cell carcinoma of skin, bladder, lungs, cervix
  16. Grading
    • tumor classifies cellular aspects of the cancer; needed because some cancer cells are "more malignant" than others, varying in their aggressiveness and sensitivity to tx. On basis of cell appearance and activity, grading compares the cancer cell with the normal parent tissue from which it arose.
    • Ploidy-tumor chromosomes as normal or abnormal; description of cancer cells by chromosome number and appearance
    • Gx- grade cannot be determined
    • G1- Tumor cells are well differentiated and closely resemble the normal cells from which they arose; this grade is considered a low grade of malignant change; these tumors are malignant but are relatively slow growing
    • G2- tumor cells are moderately differentiated; they still retain some of the characteristics of normal cells but also have more malignant characteristics than G1 cells
    • G3- Tumor cells are poorly differentiated but the tissue of origin can usually be established; the cells have few normal cell characteristics
    • G4- tumor cells are poorly differentiated and retain no normal cell characteristics; determination of the tissue of origin is difficult and perhaps impossible
  17. Staging
    • determines the exact location of the cancer and its degree of metastasis at dx. the smaller the cancer is at dx and the less it has spread, the greater the chances of tx that will result in a cure
    • Clinical staging assesses the pt clinical manifestations and evaluates clinical signs for tumor size and possible spread
    • Surgical staging assess the tumor size, number, sites, and spread by inspection at surgery
    • Pathologic staging is the most definitive, determining tumor size, number, sites, and spread by pathologic examination of tissues obtained at surgery
    • Stages 1-4 with 4 being the worst
  18. TNM (tumor, node metastasis)
    • describe the general anatomic extent of cancers; not useful for leukemia or lymphomas
    • Primary Tumor (T)-
    • Tx- primary tumor cannot be assessed
    • T0- no evidence of primary tumor
    • Tis- carcinoma in situ
    • T1,T2,T3,T4- increasing size and/or local extent of the primary tumor; 1 smallest and 4 largest in size
    • Regional Lymph Nodes (N)-
    • Nx- regional lymph nodes cannot be assessed
    • N0- no regional lymph node metastasis
    • N1,N2,N3- increasing involvement of regional lymph nodes; 1 least and 4 most involved
    • Distant Metastasis (M)-
    • Mx- presence of distant metastasis cannot be assessed
    • M0-No distant metastasis
    • M1- distant metastasis
  19. Doubling time and mitotic index
    • Doubling time- the amount of time it takes for a tumor to double in size
    • Mitotic index- the percentage of actively dividing cells within a tumor
    • The smallest detectable tumor is about 1 cm and contains about 1 billion cells
    • To reach this size, it must undergo at least 30 doublings
    • Fast growing tumors, such as lymphomas, may double in 4 weeks; an adenocarcinoma in the lung may double in 20-40 weeks
  20. Etiology and Risk
    • Oncogene activation is the main mechanism of carcinogenesis regardless of the specific cause; these oncogenes are turned on (expressed) under controlled conditions when cells need to divide for normal growth and replacement of dead or damaged tissues
    • When a normal cells is exposed to any carcinogen, the normal cell's DNA can be damaged or mutated often damaging suppressor genes, preventing them from producing proteins that control the expression of oncogenes
    • When oncogenes are overexpressed in a cell, excessive amounts of cyclins are produced and upset the balance between cell growth enhancement and cell growth limitation; the effect of these excessive cyclins is greater than the effect of the suppressor gene products, thus allowing uncontrolled cell division
    • These oncogenes are not abnormal genes but are a part of every cell's normal makeup; oncogenes become a problem only if they are overexpressed as a result of exposure to carcinogenic agents or events
  21. External factors
    • chemical carcinogens can occur from exposure to many known chemicals, drugs, and other products used in everyday life
    • Normal cells that have the ability to divide are at greater risk for cancer development than are normal cells that are not capable of cell division
    • Tobacco is the single most important source of preventable carcinogenesis; long term tobacco use first initiates and then promotes cancer; depends on a person's immune function, genetic susceptibility, amount of tobacco exposure, type of tobacco exposure, and tobacco tar content
    • Physical carcinogenesis from physical agents or events causes cancer by the same mechanism as chemical carcinogens; radiation and chronic irritation; even small does of radiation affect cells to some degree; two types of radiation are ionizing and UV; other sources of ionizing radiation is XRays, cosmic radiation; UV radiation comes from tanning beds and germicidal lights; both mutate genes; chronic irritation and tissue trauma are suspected causes; they go through frequent cell division and are at a higher risk for DNA mutation
    • Viral carcinogenesis- viruses infect body cells and break the DNA strands; viruses that cause cancer are oncoviruses
    • Dietary factors are poorly understood but include poor fiber intake, high intake of red meat, high animal fat intake, preservatives, contaminants, preparation methods, additives
  22. Cancer types associated with tobacco use
    lung, oral, pharyngeal, laryngeal, esophagus, pancreatic, cervical, kidney, bladder, liver, stomach, myeloid leukemia
  23. Cancers associated with a known viral cause
    • Epstein-Barr virus- Burkitt's lymphoma, B-cell lymphoma, nasopharyngeal carcinoma
    • Hepatitis B- primary liver carcinoma
    • Hepatitis C- primary liver carcinoma, possibly B-cell lymphoma
    • HPV- cervical carcinoma, vulvar carcinoma, other anogenital carcinomas
    • Human lymphotrophic virus type 1- adult t-cell leukemia
    • human lymphotrophic virus type 2- hairy cell leukemia
  24. Personal Factors
    • immune function- the immune system in protecting against cancer is supported by an increased cancer incidence in immunosuppressed people
    • Advancing age- with aging, immune protection decreases and external exposures to carcinogens accumulate; teach older adults to be aware and report symptoms such as 7 warning signs of cancer
    • Genetic testing- confirm or rule out a person's genetic risk for a few specific cancers; when a patient tests positive for a cancer-causing gene mutation, their risk for developing cancer is greatly increased; the cancer still may never develop
  25. Seven Warning Signs of Cancer
    • C-changes in bowel or bladder habits
    • A-a sore that does not heal
    • U-unusual bleeding or discharge
    • T-thickening or lump in the breast or elsewhere
    • I-indigestion or difficulty swallowing
    • O-obvious change in wart or mole
    • N-nagging cough or hoarseness
  26. Primary Prevention
    • use of strategies to prevent the actual occurrence of cancer
    • Avoidance of known or potential carcinogens; teach everyone about the dangers of cigarette smoking and other forms of tobacco use; teach people exposed to asbestos to use PPE to reduce direct contact with this substance
    • Modifying associated factors such as modifying behavior to reduce the associated factor, limit intake of alcohol to 1 once per day, include more fruits, veggies, and whole grains to diet; instruct women about limiting sexual partners and to use safe sex
    • Removal of risk by removing things known to cause cancer from the body (polyps from the colon or mole from skin
    • Chemoprevention uses chemicals, drugs, natural nutrients, and other substances to disrupt one or more steps in cancer development; aspirin and Celebrex (colon cancer), vitamin D and tamoxifen (breast cancer), lycopene (prostate cancer)
    • Vaccination with Gardasil for women and men for HPV; women 11-26 to prevent vaginal, cervical, vulvar cx; males to prevent warts
  27. Secondary Prevention (Early Detection)
    • regular screening for cancer to detect cancer early or genetic screening
    • Mammogram-40+
    • Breast exam- 40+
    • Colonoscopy- 50 then every 10 years
    • fecal occult blood- all adults
    • PSA and DRE- 50+; PSA 4 or less is normal; no ejaculation for 48 h prior
    • Genetic screenings such as BRCA1 which increases risk for breast and ovarian cancer; BRCA 2 which increases risk for breast cancer; APC, MLH1, MSH2 increase risk for colon cancer
    • create a 3 generation pedigree to more fully explore possibility of genetic risk
    • Screening can help a person at increased genetic risk for cancer to alter their lifestyle factors, participate in early detection methods, or even have at risk tissue removed
  28. Reduced Immunity and Blood producing functions
    • If left untreated or with treatment cancer causes bad side effects
    • Pt who have cancer, especially leukemia, are at an increased risk for infection
    • When cancer invades bone marrow, it causes anemia by decreasing the number of RBCs and causes thrombocytopenia by decreasing the number of platelets
    • The pt feels weak and fatigued and is at risk for bleeding.
  29. Altered GI Structure and Function
    • Cachexia (extreme body wasting and malnutrition) develops from an imbalance between food intake and energy used (increased catabolism)
    • Nutritional support for the pt with cancer is complex; diet high in protein and carbs is used to better maintain body weight and provide the nutrients needed for energy and cellular repair.
    • Pt usually has N/V
  30. Motor and sensory deficits
    • the bone sites most often affected are the vertebrae, ribs, pelvis, humerus, scapula, sternum, skull, and clavicle; causes pain, fx, spinal cord compression, hypercalcemia, which reduces mobility; any tumor benign or malignant growing in the brain can destroy healthy brain tissue and cause death
    • Pain does not always accompany cancer, but it can be a major problem for pt
    • Pt has change in tastes, increased metabolic rate, change in LOC, and decreased RR due to pressing on lungs
  31. Decreased respiratory function
    • Tumors in airways cause airway obstruction; removed lung tissues decreases lung capacity; tumors can press on blood and lymph vessels in the chest causing pulmonary edema and dyspnea; can thicken alveolar membrane
    • With any lung tumor, hypoxia and poor oxygenation
  32. Surgery
    • removal of diseased tissue
    • Prophylactic- removes at risk tissue to prevent cancer development
    • diagnostic- (biopsy) removal of all or part of a suspected lesion for examination and testing
    • Curative- removes all cancer tissues (lumps or tumor)
    • Cancer control (cytoreductive surgery)- removes part but not all of the tumor; it decreases the number of cancer cells and increases the chances that other therapies can be successful
    • Palliative- improving the quality of life during the survival, but not a cure; to provide comfort
    • Second-look- "rediagnosis" after treatment to assess the disease status in pt who have been tx and have no symptoms of remaining tumor; most commonly used for ovarian cancer; confirm cure
    • Reconstructive or rehabilitative- increase function, enhance appearance, or both; scar revision
  33. Surgical Side effects
    • Any organ loss reduces function; depends on location and extent of surgery
    • Assess the pt and family ability to cope with the uncertainty of cancer and its tx and with the changes in body image and role
    • Encourage the pt and family to express their concerns, accept change in appearance or function; encourage them to look at the surgical site, touch it, and participate in dressing changes
    • Reduced function may be an outcome for some types of cancer surgery; teach pt about the importance of performing and increasing the intensity of the exercises to regain as much function as possible and prevent complications
  34. Radiation therapy
    • destroy cancer cells and have minimal damaging effects on the surrounding normal cells; effects are seen only in the tissues in the path of the radiation beam- local treatment
    • Most radiation therapy for cancer is ionizing radiation; particles within the cell's nucleus are rearranged, resulting in tremendous release of intracellular energy
    • Cells damaged by radiation either die outright or become unable to divide; radiation damage can occur anytime a cell is exposed to radiation, not just when the cell is actively dividing; the damage is greater to dividing cells when exposed to radiation
    • Gamma rays are used most for radiation therapy because of their ability to deeply penetrate tissue
    • Beta particles are weaker and must be placed within or very close to the cancer cells for cancer therapy (brachytherapy)
    • exposure-amount of radiation delivered to a tissue
    • radiation dose- amount of radiation absorbed by the tissue
    • The 3 factors determining the absorbed dose are the intensity of exposure, the duration of exposure, and the closeness of the radiation source to the cells
    • The intensity of radiation decreases with the distance from the radiation source; know as the inverse square law
    • If the dose of radiation is high enough, all cells are killed immediately; Does not happen with cancer radiation because cells within a tumor absorb the radiation dose slightly differently
    • Gray (gy)- absorbed radiation doses described in units
    • Total dose of radiation used depends on tumor size and location and on the radiation sensitivity of the tumor and nearby tissues
  35. Teletherapy
    • radiation delivered from a source outside of the pt;
    • Pt is not radioactive or hazardous to others
    • Intensity modulated radiation therapy (IMRT) breaks up the single beam in to thousands of smaller beams that allow better focus on the tumor
    • Stereotactic body radiotherapy (SBRT)- uses 3-D tumor imaging to identify the exact tumor location to allow more precise delivery of higher radiation doses and spares more of the surrounding tissue (use for small, localized lung cancers)
    • Once the pattern of radiation delivery is determine, the pt must always be exactly in the same position for all tx
    • Position-fixing devices include customized vacuum-type body molds, foam-based body mold, and fiberglass splints
  36. Brachytherapy
    • uses radioactive isotopes either in solid foam or within body fluids
    • With all types of brachytherapy, the radiation source is within the pt, the pt emits radiation for a period of time and is a hazard to others
    • With unsealed and suspended in fluid, they are given oral or IV or instilled into a body cavity
    • When unsealed, they enter the body fluids and eventually are eliminated in waste products, which are radioactive and should not be directly touched by other people; once completely eliminated from the body, the pt nor the body wastes are radioactive
    • Solid or sealed radiation sources are implanted within or near the tumor; emit continuous, low-energy radiation to tumor tissues; while solid implants are in place, the pt emits radiation, but excreta are not radioactive and do not pose a hazard to anyone
    • Traditional implants deliver low dose rates (LDRs) of radiation continuously and pt are hospitalized for several days
    • High dose rate (HDRs) implant radiation is another delivery type; pt has therapy several times a week with a stronger implant placed for an hour or so at a time; pt is only radioactive when implant is in place
  37. Skin Protection during radiation
    wash the irradiated area gently each day with either water or a mild soap and water as prescribed; use your hand rather than a washcloth to be more gentle; rinse soap thoroughly from skin; if ink or dye marks are present, do not remove them; dry irradiated area with patting motions rather than rubbing, use a soft, clean towel; use only powders, ointments, lotions, or creams on your skin at the site that are prescribed; wear soft clothing over the skin at the radiation site; avoid wearing belts, buckles, straps, or any type of clothing that binds or rubs the skin at the site; avoid exposure to the sun, protect with clothing, go outdoor in the morning or evening, when outdoors stay out of the sun and in the shade; avoid heat exposure
  38. Care with sealed implants
    • assign the pt to a private room with a private bath
    • place a Caution: Radioactive Material sign on the door of the room
    • If portable lead shields are used, place them between the pt and the door
    • Keep the door closed as much as possible
    • Wear a dosimeter film badge at all times; it measures exposure to radiation, each separate person should have their own
    • Wear a lead apron while providing care; keep the font of the apron facing the source of the radiation (do not turn your back)
    • Pregnant nurses should not care for these pt; pregnant women and children under 16 cannot visit
    • Limit each visitor to 1/2 hour a day; must stay at least 6 ft from pt
    • never touch the radioactive source with bare hands; if dislodged, use long-handled forceps to retrieve it; deposit in the lead container kept in the pt room
    • Save all dressings and bed linens until after the source is removed, then dispose of dressings and linens in usual manner; other equipment can be removed from the room at any time without special precautions and does not pose a hazard to others.
    • Can be dislodged by cough, sneezing, bm
    • 24 h without visitors
    • Explain they are not being shunned, but danger for nurse to stay in room for long periods
  39. Side effects of radiation therapy
    • Side effects vary according to the site
    • Skin changes and hair loss are local but are often permanent depending on the total absorbed; burning sensation; most people with hair loss have it come back a different color and texture
    • Altered taste and fatigue are 2 common systemic side effects of teletherapy; radiation induced fatigue can be debilitating and may last for months; this can be a cause of altered nutrition
    • Radiation damage to normal tissues can start an inflammatory response that lead to tissue fibrosis and scaring
    • Fatigue related to increased energy demands that increase metabolic rate and burning of tissue
    • Accurate, objective information about radiation helps pt cope with the treatment and continue to participate in normal activities; teach a pt about skin care needs during therapy is a priority intervention; instruct pt not to remove temporary markings until entire course is complete; avoid using lotion or other skin care products within 4 hours of therapy; teach pt to follow radiation dept policy for skin care; teach pt things to expect ahead of time; clean site-no alcohol, lotion, or ointments; them skin is very sensitive to the sun
    • Head and neck radiation can cause xerostoma (dry mouth) which increases risk for life long tooth decay; teach good oral care; NOTHING WITH ALCOHOL
    • Bone exposed to radiation is less dense and breaks more easily; teach about symptoms that might be expected from the location and dose of radiation; fall precautions
  40. Chemotherapy
    • treatment of cancer with chemical agents to cure and increase survival time; the killing effect is related to the ability of chemotherapy to damage DNA and interfere with cell division
    • Chemotherapy is useful in tx because its effects are systemic, providing the opportunity to kill metastatic cancer that may have escaped local tx; can be used with surgery or radiation as adjuvant therapy
    • Drugs used for chemotherapy are usually given systemically and exert their cell damaging (cytotoxic) effects against healthy cells as well as cancer cells
    • normal cells affected by chemo are those that divide rapidly including skin, hair, intestinal tissues, spermatocytes, and blood-forming cells
    • Mixed in a bag of fluids; each tx is catered to pt; some selectivity, but cannot differentiate with skin, hair, GI tract, nails, blood forming cells, sperm
    • Causes anemia, decreased sperm (infertility or sterility), N/V, decreased appetite, change in taste (metallic), alopecia, skin changes
  41. Chemo Drugs
    • Administered IV, PO, IM, SQ, topical, intrathecally (spine), intraperitoneally
    • Antimetabolites
    • Antitumor Antibodies
    • Antimitotic agents
    • Alkylating agents
    • Topoisomerase inhibitors
    • miscellaneous chemotherapeutic agents
    • combination therapy
  42. Alkylating agents
    • cross-link DNA making 2 DNA stands bind tightly together, preventing DNA and RNA synthesis that inhibits cell division
    • altretamine, bendamustine, busulfan, carboplatin, carmustine, chlorambucil, cisplatin, cyclophosphamide, dacarbazine, estramustine, ifosfamide, lomustine, mechlorethamine, melphalan, oxaliplatin, streptozocin, temozolomide, thiotepa 
  43. Antimetabolites
    • similar to normal metabolites; are counterfeit metabolites that fool cancer cells into using the antimetabolites in cellular reactions; their presence impairs cell division
    • azacitidine, capecitabine, cladribine, clofarabine, cytarbine, decitabine, floxuridine, 5-fluorouracil, fludarabine, femcitabine, 6-mercaptopurine, methotrexate, nelarabine, pemetrexed, pentostatin, 6-thioguanine
  44. Antimitotic agents
    • interfere with the formation and actions of microtubules so cells cannot complete mitosis during division
    • cabazitaxel, docetaxel, etoposide, eribulin mesylate, paclitaxel, teniposide, vinblastine, vincristine, vinorelbine
  45. Antitumor Antibiotics
    • damage the cell's DNA and interrupt DNA or RNA synthesis
    • cleomycin, dactinomycin, daunorubicin, doxorubicin liposomal, epirubicin, idarubicin, mitomycin C, mitoxantrone, valrubicin
  46. Topoisomerase inhibitors
    • disrupt and enzyme (topoisomerase) needed for DNA synthesis and cell division; prevent proper DNA maintenance, causing DNA breakage and cell death
    • irinotecan, topotecan
  47. Miscellaneous
    • mechanism of action that are either unknown or do not fit into other drug categories
    • arsenic trioxide, asparaginase, hydroxyurea, ixabepilone, pegaspargase, procarbazine, vorinostat
  48. Combination Chemo
    • giving more than one specific anticancer drug in a timed manner; more effective in killing cancer cells than using a single drug, but the side effects and damage to normal tissues also increases
    • Selection is based on known tumor sensitivity and the degree of side effects expected
    • Nadir-time when bone marrow activity and WBC counts are at their lowest after chemotherapy
    • To reduce immunosuppression, combination therapy avoids using drugs with nadirs that occur at or near the same time
  49. Treatment Issues
    • Calculations are based on milligrams per square meter of total body surface area (TBSA), which considers both height and weight
    • Schedule may vary to accommodate pt response to therapy, but chemo is usually scheduled q3-4wk for a specified number of times (4-12 times)
    • Dose-dense chemo is used for aggressive cancer tx
    • Most drugs are given IV, route is most preferred; intrathecal (spinal canal), intraventricular (ventricles of the brain), intraperitoneal (within the abdominal cavity), intravesicular (into the bladder), intra-arterial (high dose locally; not for bone cancer; limited bases for head and neck cancer)
    • Special education for RN via a chemotherapy course; allows responsibility for monitoring the pt during chemo administration, providing pt care
    • extravasation- drug leaks into the surrounding tissues (infiltration); priority is prevention; <0.5 ml usually resolves without extensive tx; >0.5 ml, surgery may be needed for extensive tissue damage; caused from IV, rapid onset and very caustic; only central line; painful, infection, damage to tissue; STOP IV THEN GET DOC ORDER; close monitoring of the site is critical during administration to prevent leakage; cold compresses to area for some, others warm conpresses, antidotes or chemoprotective agents may be injected
    • vesicants- chemicals that damage tissue on direct contact; absorbed thorugh the skin and mucous membranes; risk for preparers to absorb, wear PPE such as eye protection, masks, double gloves or chemo gloves; anyone preparing, giving, disposing of chemo drugs or excreta within 48 h of receiving IV chemo
    • Oral anticancer drugs are just as toxic as the IV drugs to the person handling the drug
    • Pt require much education and support to self-manage this therapy; oral agents must not be crushed, split, broken, or chewed; adherence to schedules and dosages is a problem; disrupting the schedule or reducing the dosages has a negative impact on therapy outcomes and leads to drug resistance among cancer cells, disease progression and reduced survival
  50. Documentation of Extravasation
    Document the date and time when extravasation was suspected or identified; document the date and time when the infusion was started; record the time when the infusion was stopped; document the exact contents of the infusion fluid and the volume of fluid infused; document the estimated amount of fluid extravasated; diagram the exact insertion site, and indicate whether this is a venous access device, an implanted port, or a tunneled catheter; document the method of administration (pump, controller, etc; rate of infusion); document the needle type and size; indicate on the diagram the location and number of venipuncture attempts; record the time between the extravasation and the last documented full blood return; identify all agents administered in the previous 24 h through the site (list agent administered, dosage and vol, order of administration); take and record pt vitals; ask and record pt subjective sensations and symptoms; record all observations of the site, including size, color, and texture; take a photo of the site; document the administration of neutralizing or antidote agent; document the application of compresses and their temp; document other nursing interventions; record the pt responses to nursing interventions; document the prescribing physician notification (include time); document the written and oral instructions given tot the pt about follow up care; document any consultation request; sign the documentation
  51. Side effects of chemo
    • anemia, neutropenia, thrombocytopenia (damage to blood forming cells), if neutropenic or very low platelets, hold chemo to allow time for cells to regenerate; alopecia or hair loss; N/V (decreases nutrition, dehydration); skin changes; anxiety, sleep disturbance (anxiety causes sleep disturbance); altered bowel elimination (GI mucousitis); changes in cognitive function (forgetful, decrease short term memory, have someone there for teaching, chemobrain)
    • hemorrhagic cystitis, cardiac muscle damage, and loss of bone density
    • Drug therapy is often used to reduce symptom distress for some side effects; general nonpharmacologic interventions are distraction (virtual reality, guided imagery, reading, watching TV, talking with visitors), massage, guided imagery, reiki, aromatherapy
    • Priority care issues are protecting the pt from life threatening side effects and managing the distressing symptoms
  52. Infection Risk (Bone Marrow Suppression)
    • decreased numbers of leukocytes, erythrocytes, and platelets; decreased neutrophils (neutropenia) greatly increase infection risk; decreased erythrocytes and platelets cause hypoxia, fatigue, and increased bleeding risk
    • Neutropenia causes high risk for sepsis; most common are fungal, bacterial, residual viral breakthrough; overgrowth of pt normal flora; negative pressure room, limit visitors to very healthy, no children or sick, no fruits or fresh flowers
    • Tx with biological response modifiers (BRMs) and growth factors stimulate bone marrow production of the immune system cells; actual infections tx with anti-infectives such as antibiotics, anitfungals, antivirals
    • Explain importance of reporting skin, mucous membrane, or health changes; teach UAP importance of neutropenic precautions from cross contamination; teach importance of mouth care and washing the axillary and perianal area at least q12h; pt is not infection hazard to others, but others are infection hazard to pt
    • Anemia and thrombocytopenia cause fatigue and bleeding; platelets <50,000 with a small trauma can cause prolonged bleeding;<20,000 spontaneous and uncontrolled bleeding may occur; may require transfusion therapy
    • Growth factors to stimulate marrow production of RBC and platelet is common; erythropoiesis stimulating agents (ESAs) such as darbepoetin (aranesp) and epoetin alfa (Epogen and Procrit**) can prevent or improve anemia and reduce need for infusion; drugs increase risk for HTN, blood clots, stroke, MI, especially older adults; some cancers grow faster with ESAs, such as head and neck, leukemia, and some lymphomas
    • Growth factor for thrombocytopenia is oprelvekin (Neumega); version of interleukin !! (IL-11) to increase platelet production; causes fluid retention and risk for heart failure and pulmonary edema, conjunctival bleeding, hypotension, tachycardia; teach pt to weight daily, report sudden weight gain or dyspnea
    • Priority care for thrombocytopenia is provide a safe hospital environment; teach UAP to use bleeding precautions; teach pt and family to avoid injury and excessive bleeding when d/c occurs
  53. Chemo-induced Nausea and Vomiting (CINV)
    • arises from a variety of GI and neural mechanisms; emotgenic (vomiting inducing) drugs; Most distressing side effect; can be delayed for a few days after therapy starts; one or more antiemetics are given before, during, and after chemo; pt response to antiemetic is variable, and drug conbinations are individualized; advocate for pt experiencing N/V; Most effective when used aggressively and on a schedule
    • Zofran!!
    • Priority is to coordinate with pt and physician to ensure adequate control of CINV; ensure antiemetics are given before therapy; teach pt to continue prescribed therapy, event CINV is controlled; if pt stops taking drugs, teach to start taking again at the first sign of nausea to prevent it from becoming uncontrollable; teach older adults to be proactive with taking their prescribed antiemetics and to contact their provider if CINV does not resolve within 12h or becomes worse
    • Music, progressive muscle relaxation, guided imagery, acupressure, distraction, or drinking Concord grape juice before meals may help or relive nausea; assess for vomiting, dehydration, and electrolyte imbalances
  54. Antiemetic Drugs for CINV
    • Serotonin Antagonists- Blocks the 5-HT3 receptors in the brain (chemotrigger zone) and in the intestines; prevents serotonin from binding to the receptors and activating the N/V centers-teach pt to change positions slowly, assess for headache; may induce hypotension, bradycardia, vertigo(odansetron (Zofran)- 8mg IV or PO q8h; granisetron (kytril)-1 mg IV or PO q12h; granisetron transdermal (Sancuso)- 1 patch per day starting 24-48h before chemo and for 7 days after chemo; dolasetron (Anzemet)- 100 mg IV or PO 30 minutes before chemo; palonosetron (Aloxil)- 0.25 mg IV as a single dose 30 min before chemo
    • Neurokinin Receptor Antagonists- blocks the substance P neurokinin receptor; when used with a serotonin antagonist and corticosteroid, both acute and delayed N/V are controlled; teach pt who are taking Coumadin to have their INR checked before and after the 3 days of therapy, teach women using OC to use additional form of BC; interferes with the effectiveness of Coumadin, reduces the effectiveness of OC (aprepitant (Emend)- 3 day PO regimen (day 1, 125 mg 1 hour before chemo, day 2/3, 80 mg in the am)
    • Corticosteroids- decreases swelling in the brains chemotrigger zone; teach pt to reduce Na intake to 4 g daily; causes fluid retention and HTN (dexamethasone (Decadron)- 5-10 mg IV or PO qd)
    • Prokinetic Agents- blocks dopamine receptors in the brains chemotrigger zone; teach pt to about driving or operating machinery; increased drowsiness (metoclopramide (Reglan)- 204-40 mg IM or IV BID/TID)
    • Benzodiazepines- enhance cholinergic effects by decreasing person's awareness; teach pt and family to avoid driving, operating machinery, making legal decisions, and going up and down stairs; induces amnesia and drowsiness (lorazepam (Ativan)- 1-3 mg PO or IV BID/TID
  55. Mucositis
    • sores in the mucous membranes; develops in the GI tract, especially the mouth (stomatitis)
    • Frequent mouth assessment and oral hygiene; use a soft bristled tooth brush or disposable mouth sponges; gentle flossing once daily; rinse with plain water or saline qh while awake; toothbrushes cleaned once weekly by dishwasher or rinsing with concentrated solution of liquid bleach/hydrogen peroxide then rinsing with hot water
  56. Alopecia
    • hair loss may occur as whole body or mild and thinning of scalp hair; hair regrowth usually occurs about 1 month after chemo completion; tell pt ahead of time about hair loss to allow for adjustment time; use a wig, head wrap to protect from the sun
    • Priority intervention is to teach the pt to prevent injury to the scalp and assist with coping with body image change
    • Preserve hair loss by applying ice cap during or for a few hours after chemo administration, may causes cancer cells to escape chemo exposure so not recommended; avoid direct sunlight to scalp by wearing a hat or covering the head; skin can be damaged by headphones, helmets, headsets, items that rub the head; wear head covering underneath the item; assist pt in selecting head covering to fit their income and lifestyle; cutting hair short before chemo allows better wig fit; suggest purchasing wig before chemo and have hairdresser shape wig to mimic usually hair style
  57. Changes in Cognitive Function
    • reduced ability to concentrate, memory loss, and difficulty learning new information during treatment and for months to years after tx
    • Chemobrain
    • Priority nursing care is to support the pt; listen to concerns, tell them other pt have experienced problems; a common sense approach includes pt should be warned against participating in other behaviors that could alter cognitive functioning such as excessive alcohol intake, recreational drug use, and activities that increase risk for head injury
  58. Chemo induced peripheral neuropathy
    • loss of sensory or motor function of peripheral nerves associated with exposure to certain anticancer drugs; loss of sensation in hands and feet, orthostatic hypotension, ED, neuropathic pain, loss of taste discrimination, sever constipation
    • Prevent injury!! Assess pt ability to cope with changes, coordinate with OT to help pt adjust for sensory deficits
    • Protect feet and other body areas where sensation is reduced (no bare feet, wear shoes); be sure shoes are long enough and wide enough to prevent creating sores or blisters; buy shoes in the afternoon or evening to accommodate for swelling; provide for long break in period of new shoes, no longer than 2 hours at a time; avoid pointed toe shoes and shoes with heels higher than 2 inches; inspect your feet daily; avoid temp extremes; test water with thermometer; use potholders; use gloves for gardening and washing dishes; do not eat steaming hot foods; eat food high in fiber; drink 2-3L of fluid daily; change positions slowly; look at your feet and the floor where you walk; avoid area rugs; use handrails
  59. Hormonal Manipulation
    • Some hormones make hormone-sensitive tumors grow more rapidly; some tumors actually require specific hormones to divide, decreasing the amount of these hormones to hormone-sensitive tumors can slow the cancer growth rate; does not cure
    • When hormone antagonists are given, they bind to specific hormone receptors on or in the tumor cell and prevent the needed hormone from binding to the receptor; hormone inhibitors inhibit the production of specific hormones in the normal hormone producing organs
  60. Hormonal Manipulation Drugs
    • Hormone Agonists- Androgen (fluoxymesterone (Halotestin), testolactone (Teslac)); estrogen (chlorotrianisene (Tace), conjugated equine estrogen (Premarin), diethylstilbestrol (DES, Stilphostrol), ethinyl estradiol (Estinyl); progestin (medroxyprogesterone (Amen, Provera), megestrol (Megace); luteinizing hormone-releasing hormone (LHRH) (leuprolide (Eligard, Lupron, Viadur), goserelin (Zoladex))
    • Hormone Antagonists- antiandrogens (bicalutamide (Casodex), flutamide (Eulexin)); antiestrogens (fulvestrant (Casodex), tamoxifen **(Nolvadex), toremifene (Fareston)
    • Hormone Inhibitors- aminoglutethimide (Cytadren, Elipten), anastrozole (Arimidex), exemestane (Aromasin), letrozole (Femara)
  61. Side effects of Hormone therapy
    • Androgen and antiestrogen receptor drugs cause masculinizing effects in women (facial/chest hair, stop periods, decreased breast tissue, fluid retention); men and women receiving androgens may develop acne, hypercalcemia, liver dysfunction with prolonged therapy; feminine manifestations appear in men taking estrogens, progestins, or antiandrogen receptor drugs (gynecomastia, testicular or penile atrophy, decreased erection, smoother hair, body fat redistribution, bone loss)
    • Women on estrogens or progestins have irregular periods, fluid retention, breast tenderness, increased risk for VTE
  62. Photodynamic Therapy
    • selective destruction of cancer cells through a chemical reaction triggered by types of laser light; most often used for non-melanoma skin cancer, ocular tumors, GI tumors, and lung cancers located in the airways
    • An agent that sensitizes cells to light is injected IV along with dye that enter all cells but leave normal cells more rapidly than cancer cells; most of the drug collects in high concentrations in cancer cells, laser light is focused on the tumor and the light activates a chemical reaction within those cells retaining the sensitizing drugs that induces irreversible damage
    • Priority teaching the pt and family to prevent complications and coordinating changes in the care environment for the protect of the pt; pt has general sensitivity to light for up to 12 weeks after drug is injected; high risk for sunburn; bring clothing, hat, and eye protection to appt; gloves, blouse with long sleeves and high collar, long pants, socks; skin and eyes remain sensitive for 30-90 days; keep lighting to a minimum, even penlight or pulse ox can burn skin
  63. Oncologic Emergencies
    • Sepsis and disseminated intravascular coagulation
    • Syndrome of Inappropriate ADH (SIADH)
    • Spinal Cord Compression
    • Hypercalcemia
    • Superior Vena Cava Syndrome
    • Tumor Lysis Syndrome
  64. Sepsis and disseminated intravascular coagulation
    • Sepsis (septicemia)-organisms enter the bloodstream (bloodstream infection) and can result in septic shock (low WBC and impaired immune function cause risk)
    • Disseminated intravascular coagulation (DIC)- trigged by severe illness, often caused by gram-negative sepsis, by the release of thrombin or thromboplastin form cancer cells or blood transfusion; extensive, abnormal clotting occurs throughout the small blood vessels; clots block blood vessels and decrease blood flow to major body organs and result in pain, strokelike manifestations, dyspnea, tachycardia, reduced kidney function, and bowel necrosis
    • Body uses up all clotting factors to stop bleeding, once all used up, start bleeding out; pt becomes so septic that DIC occurs; Prevent sepsis!; identify pt at greatest risk for sepsis and DIC; practice strict adherence to aseptic technique at all times, teach pt and families the early manifestations of infection and when to seek tx
    • IV antibiotics initiated, DIC called for heparin to limit clotting and prevent the rapid consumption of circulating clotting factors; clotting factors are given when DIC has progressed and hemorrhage is the primary problem
  65. Syndrome of inappropriate antidiuretic hormone (SIADH)
    • water is reabsorbed to excess by the kidney and put into systemic circulation; the retained water dilutes blood serum Na levels; can be seen in anybody, most common in carcinoma of the lung; fluid overload can cause CHF and lead to pulmonary edema, hyponatremia
    • Manifestations weakness, muscle cramps, loss of appetite, fatigue, weight gain, nervous system changes, confusion, personality changes, extreme muscle weakness; SOB, crackles, pink frothy sputum, bounding pulse, JVD, edema, decreased urine output
    • Fluid restriction, increased Na intake,demeclocycline; prevent fluid overload, monitor for increasing fluid overload q2h
  66. Spinal Cord compression
    • when a tumor directly enters the spinal cord or when the vertebrae collapse form tumor degradation of the bone; may cause back pain before nerve deficits, paralysis
    • Early recognition and tx is key; assess neuro changes (back pain, muscle weakness or sensation of heaviness of arms or legs, numbness or tingling of hand/feet, inability to distinguish hot and cold, unsteady gait), if low on spine (constipation, incontinence, difficulty starting/stopping urine)
    • teach pt and family manifestation and to report
    • Tx is palliative with high dose corticosteroids (glucose, insulin) to reduce swelling around the spinal cord and relieve symptoms, then high dose radiation to reduce tumor and relieve compression or surgery to remove the tumor and rearrange the bony tissue so less pressure is on the spinal cord, external back or neck braces may be used to reduce weight bearing by the spinal column and reduce pressure on spinal cord and nerves
  67. Hypercalcemia
    • pt with bone metastasis
    • fatigue, loss of apetite, nausea, vomiting, constipation, increased urine output then can lead to muscle weakness, loss of DTR, paralytic ileus, dehydration, ECG changes
    • Oral hydration may be enough, NS for parenteral hydration; oral glucocorticoids, **calcitonin, diphosphonate, gallium nitrate, mithramycin will lower temporarily; possibly dialysis
  68. Superior Vena Cava Syndrome
    • the SVC is compressed or obstructed by tumor growth or by clots in the vessel; painful and life threatening; most often in lymphomas, lung cancer, and breast cancer
    • pt arises after a night's sleep with edema of face, especially around the eyes and tightness of shirt or collar; worsens to develop blood vessels engorged and erythema of upper body, edema in arms and hands, dyspnea, epistaxis; late manifestations are hemorrhage, cyanosis, change in mental status, decreased CO, hypotension
    • blockage of blood flow to head and neck; pt could die if not removed
    • High dose radiation for upper chest to provide temporary relief; metal stent in SVC to relieve swelling; best ex is prevention
  69. Tumor Lysis Syndrome
    • large numbers of tumor cells are destroyed rapidly and cellular contents are released into the bloodstream faster than the body can eliminate them; can cause tissue damage and death; positive sign that tx is effective; common with leukemias, lymphomas, small cell lung cancers, and multiple myeoloma
    • K levels increase to hyperkalemia causing cardiac dysfunction, purines from uric acid cause hyperuricemia that block kidney tubules and lead to acute kidney injury
    • Hydration prevents TLS; drink at least 3000 ml (preferably 5000 ml) the day before, the day of, and for 3 days after tx, some should be alkaline (sodium bicarb) fluids, keep consistent throughout day, draw up fluid schedule; call if nausea prevents adequate fluid intake
    • Diuretics are given to increase urine flow
    • Drugs to promote purine excretion (allopurinol) are given; sodium polystyrene sulfonate for hyperkalemia or IV glucose and insulin for sever hyperkalemia; possible dialysis
  70. Lung Cancer
    • leading causes of cancer related deaths worldwide; poor long term survival rate because most lung cancers are dx at a late stage, when metastasis is present; treatment of lung cancer is aimed towards relieving symptoms (palliation) than cure
    • Most primary lung cancers arise form the bronchial epithelium (bronchogenic carcinomas)
    • Lung cancers are classified according to their histological cell type; small cell lung cancer (SCLC), (epidermoid (squamous cell) cancer, adenomcarcinoma, large cell cancer) which are non-small cell lung cancer (NSCLC)
    • Metastasis occurs by direct extension, through the blood, and by invading lymph glands and vessels; compression of the alveoli, nerves, blood vessels, and lymph vessels can occurs and interfere with oxygenation; patterns of metastasis depend on the type of tumor cell and the location of the Paraneoplastic syndromes are additional manifestations that complicate certain lung cancers and are caused by hormones secreted by the tumor cells; common with SCLC
    • Staging is performed to assess the size and extend of the disease and based on TNM system
    • Eitology- nonsmokers exposed to passive (secondhand) smoke are at a greater risk than nonsmokers who have minimal cigarette exposure; risk factors include chronic exposure to asbestos, beryllium, chromium, coal distillates, cobalt, iron oxide, mustard gas, petroleum distillates, radiation, tar, nickel, and uranium; air pollution with benzopyrenes and hydrocarbons increase risk
  71. Health Promotion and Maintenance
    • Primary prevention is directed at reducing tobacco smoking; encourage nonsmokers not to begin to smoke, promote smoking cessation programs, establish smoke free environment; teach workers about safety precautions (specialized masks, protective clothing, reduce exposure)
    • Secondary prevention by early detection has not been considered feasible
  72. Assessment
    • Hx- risk factors (smoking, workplace hazards, warning signals); pack years
    • Manifestations-hoarseness, cough (productive or nonproductive), sputum production, hemoptysis, SOB, change in endurance, chest pain, change in breathing, weight loss, N/V, SVC Syndrome; describe any recent changes in symptoms or if position effects symptoms; sensations of fullness, tightness, or pressure in the chest; piercing chest pain or pleuritic pain on inspiration; Pain radiating to the arm from tumor invasion of nerve plexuses in advanced disease
  73. Warning Signals of Lung Cancer
    hoarseness, change in respiratory pattern, persistent cough or change in cough, blood streaked sputum, rust colored or purulent sputum, frank hemoptysis, chest pain or chest tightness, shoulder, arm or chest wall pain, recurring episodes of pleural effusion, pneumonia or bronchitis, dyspnea, fever associated with one or two other signs, wheezing, weight loss, clubbing of the fingers
  74. Physical Assessment/Clinical Manifestations-Pulmonary
    Chills, fever, and cough may be related to pneumonitis or bronchitis that occurs with obstruction, assess sputum quality and quantity; hemoptysis is later in disease; breathing painful or labored; rapid, shallow breathing occurs with pleuritic chest pain and elevated diaphragm; look for and document abnormal retractions, use accessory muscles, flared nares, stridor, asymmetric diaphragmatic movements on inspiration; dyspnea and wheezing; compare participation in activities with that of a month or year ago; areas of tenderness or masses may be felt when palpating chest wall; increased vibrations felt on chest wall (fremitus) may indicate air spaces are replaced with fluid; areas with masses sound dull or flat; wheezes indicate partial obstruction; decreased or absent breath sounds indicate complete obstruction; increased loudness or sound intensity of the voice while listening to breath sounds indicated increased density of lung tissue; pleural friction rub may be heard with inflammation
  75. Physical/Clinical Manifestations-Non Pulmonary
    • heart sounds may be muffled by tumor or fluid around the heart (cardiac tamponade); dysrhythmias from hypoxemia; cyanosis of lips and fingertips or clubbing of the fingers; bones lose density and break easily
    • Late manifestations include fatigue, weight loss, anorexia, dysphagia, N/V, SVC syndrome may result from tumor pressure on or around the SVC (medical emergency), confusion, personality changes (brain metastasis, bowel and bladder tone or function may be affected by tumor spread to spine and spinal cord
  76. Psychosocial Assessment
    Convey acceptance, interact with pt in nonjudgmental way, encourage pt and family to express feelings, fear of death and pain is common
  77. Diagnostic Assessment
    • Dx made by examination of cancer cells; cytological testing of early-morning sputum, cancer cells may not be present in the sputum; pleural effusion is present, fluid is obtained by thoracentesis
    • Most lung lesions are first identified by CXR then CT to view them more clearly; fiberoptic bronchoscopy provides direct visualization, needle biopsy may be used during procedure; thorascopy, mediastinoscopy
    • Procedures to determine spread include needle biopsy of lymph nodes, direct surgical biopsy, and thoracentesis with pleural biopsy; MRI and radionuclide scans of liver, spleen, brain, and bone; PFT, ABG; PET
  78. Nonsurgical management
    Chemo- tx of choice for SCLC; alone or adjuvant for NSCLC; most include platinum based agents; side effects include CINV, alopecia, mucositis, thrombocytopenia, neutropenia, anemia, and peripheral neuropathy; give antiemetics before, during and after therapy; frequent mouth assessment and oral hygiene for mucositis, teach pt to use soft bristled toothbrush, avoid dental floss and water pressure gum cleaners; immunosuppression is managed by growth factors to stimulate marrow cell production, teach pt to take infection precautions; targeted therapy for NSCLC are erlotinib (Tarceva) and gefitinib (Iressa) that are antibodies that work to disrupt cancer cell division, target and block growth factor receptors, especially epithelial growth factor receptors (EGFRs) or vascular endothelial growth factor receptors (VEGFRs), not used alone for tx; radiation for locally advanced cancer confined to chest and used in addition to surgery or chemo, performed daily for 5-6 weeks, s/e of skin irritation, peeling, fatigue, nausea, taste changes, esophagitis, teach pt to eat foods that are soft, bland, and high in calories, drink liquid nutrition supplements, do not wash off markings, avoid direct skin exposure to the sun during tx and at least 1 year after; photodynamic therapy to remove small bronchial tumors when accessible by bronchoscopy, the sloughing tissue can block airway as can airway edema from the inflammation from tissues, risk for bronchial hemorrhage, fistula, and hemoptysis, super sensitive to light for 30-90 days
  79. Surgical Management
    • Main tx for stage I and II NSCLC
    • specific surgery depends on stage of cnacer and pt overall health and functional status
    • lobectomy-removal of a lung lobe
    • pneumonectomy- removal of the lung
    • segmentactomy- removal of a segment of a lung
    • wedge resection- removal of a wedge of the lung
    • Preop- relieve anxiety and promote pt participation, encourage to express fears and concerns, reinforce surgeons explanation, and teach about what to expect after, teach about the probable location of incision or thoracoscopy openings, shoulder exercises, chest tube and drainage system (except after pneumonectomy)
    • Operative Procedures- posterolateral, anterolateral, and median sternotomy incisions; segmental resection includes the bronchus, pulmonary artery and vein, and tissue of involved lung segments; wedge resection is removal of peripheral portion of small, localized areas of disease; lobectomy is removal of the entire lung lobe; pneumonectomy- removal an entire lung with severing of the bronchus
  80. Post Op care
    • thoracotomy (except pneumonectomy) requires closed-chest drain to drain air and blood that would accumulate in the pleural space
    • chest tube, a drain placed in the pleural space to restore intrapleural pressure, allows re-expansion of the lung and prevents air and fluid from returning to the chest; nursing care is to ensure the integrity of the system, promote comfort, ensure chest tube patency, and prevent complications
  81. Chest Tube placement and care
    • The tip of the tube is used to drain air is placed near the front lung apex, the tube that drains liquid is placed on the side near the base of the lung, the puncture wounds are covered with an air tight dressing, the tubing allows the pt to turn and move without pulling on the chest tube, keeping the collection device below the chest allows gravity to drain the pleural space
    • Stationary chest tube drainage usually use a water seal mechanism that acts as a one way valve to prevent air or liquid from moving back into the chest cavity, Pleur-evac system is common with a one piece disposable plastic unit with three chambers; pt is connected to the first chamber (drainage container), the second chamber is the water seal to prevent air from moving back up the tubing into the chest, the third when suction is applied is the suction regulator; Collection chamber 1 collects the fluid draining from the pt and is measured hourly during the first 24h, must never overfill to the point that it comes into direct contact with either the tube draining from the pt or the tube connecting to chamber 2, if the tubing enters the fluid, drainage stiops and can lead to tension pneumothorax; Chamber 2 is the water seal that prevents air from re-entering the pt pleural space, should always contain at least 2 cm of H2o, it serves as a one way valve, the water will bubble but should stop and is seen when intrathoracic pressure is greater than atmospheric pressure (pt exhales, coughs, sneezes), excessive bubbling indicates an air leak, water normally rises 2-4 in during inhalation and falls during exhalation (tidaling), absence in fluctuation may mean that the lung has fully re-expanded or that there is an obstruction; Chamber 3 is the suction control system, wet or dry
    • Check hourly to ensure sterility and patency of chest drainage, tape tubing junctions to prevent disconnection, keep an occlusive dressing at the insertion site, keep sterile gauze at bedside to cover insertion site immediately, keep padded clamps at bedside in case of interruption, position drainage tubing to prevent kinks and large loops of tubing; manipulation of tube should be kept at a minimum, do not vigorously "strip" the tube because this can cause up to -400 cm of water negative pressure and damage lung tissue, gently milk tubing and sop between each hand hold to move blood clots and prevent obstruction
    • Assess respiratory status and document the amount and type of drainage; notify physician of drainage more than 100 ml/h; after 24h assess q8h; check water seal for unexpected bubbling and notify physician, gently apply padded clamp to close the occlusive dressing, if bubbling stops the air leak may be at the chest tube insertion site or within the chest, air bubbling that does not cease when padded clamps are applied indicated an air leak between the clamp and the drain
    • Mobile or portable chest tub (dry) do not use a water seal
  82. Management of Chest Tube Drainage
    • Pt-ensure that the dressing on the chest around the tube is tight andintact, depending on agency policy and surgeon's preference reinforce or change loose dressings; assess for difficulty breathing; assess breathing effectiveness; listen to breath sounds for each lung; check alignment of trachea; check tube insertion site for condition of the skin, palpate area for puffiness or crackles that may indicate subcutaneous emphysema; observe site for signs for infection or excessive bleeding; check to see if tube "eyelets" are visible; assess for pain and its location and intensity, administer pain meds as prescribed; assist pt to deep breathe, cough, and perform maximal sustained inhalations, incentive spirometer; reposition the pt who reports a burning pain in chest
    • Drainage system- don't strip the chest tube; keep drainage system lower than the level of the pt chest; keep the chest tube as straight as possible, avoiding kinks and loops; ensure the chest tube is securely taped to the connector and the connector is taped to the collection chamber; assess bubbling in the water seal chamber, should be gentle bubbling on pt exhalation, cough, position changes; asses for tidaling; check water level in the water seal chamber, keep at the level recommended by the manufacturer; check water level in suction control chamber, keep at the level prescribed by the surgeon; clamp the chest tube only for brief periods to change the drainage system or when checking for air leaks; check and document amount, color, characteristics of fluid in the collection chamber; empty collection chamber or change the system before the drainage makes contact with the bottom of the tube; when sample drainage is needed, obtain from chest tube, after cleansing tube, used a 20 G or smaller needed to draw a specimen into a syringe
    • Immediately notify physician or rapid response team- tracheal deviation; sudden onset or increased intensity of dyspnea; O2 sat <90%; drainage greater then 70 ml/h; visible eyelets on chest tube; chest tube falls out of the pt chest (first cover with dry, sterile gauze); chest tube disconnects from drainage system (put end of tube in a container of NS and keep below pt chest); drainage tube stops (in first 24h)
  83. Pain management
    most pt have intense pain for first 24h; administer prescribed drugs, assess response; teach PCA device before pain is too severe; monitor vitals before and after
  84. Respiratory management
    • Immediately after surgery, pt is mechanically ventilated
    • Once pt breathing on their own, priorities are to maintain a patent airway, ensure adequate ventilation, prevent complications; assess pt q2h for adequacy of ventilation and gas exchange, check trachea alignment, assess o2 sat, rate and depth of respirations, listen to breath sounds; assess oral mucous membranes, cap refill and suction if needed
    • O2 via mask of NC for first 2 days; warm and humidify the air; assist pt to semi-fowlers or to chair asap; use incentive spirometer qh while awake; help cough by splinting and ensure chest tube doesn't pull out
  85. Pneumonectomy Care
    • Complications are empyema (purulent material in pleural space), bronchopleural fistula (abnormal duct that develops between the bronchial tree and pleura)
    • O2 therapy is prescribed for hypoxia
    • Drug therapy with bronchodilators and corticosteroids for pt with bronchospasms to decrease spasm, inflammation and edema; mucolytics to ease removal of thick mucus and sputum; bacterial infections tx with antibiotics
    • Radiation therapy to relieve hemoptysis, obstruction of bronchi and great veins (SVC Syndrome), dysphagia, and pain from bone metastasis; for palliation uses higher doses for shorter periods
    • Thoracentesis when pleural effusion is a problem; increases dypnea, discomfort, risk for infection; remove pleural fluid to temporarily relieve hypoxia; fluid can reform in the pleural space rapidly; a continuous draining catheter may be places
    • Dyspnea management place pt in semi-fowlers with arms propped out to side to allow expansion
    • Pain management with opioid drugs, positioning, hot/cold compresses, distractions, guideded imagery; meds around the clock; ongoing pain assessment
    • Hospice Care can be beneficial for terminal pt
  86. Skin Cancer
    • Overexposure to sunlight is the major cause
    • Actinic keratosis- small (1-10 mm) macule or papule with dry, rough, adherent yellow or brown scale, base may be erythematous, associated with yellow, wrinkled, weather-beaten skin, thick, indurated keratosis more likely to be malignant; on cheeks, temples, forehead, ears, neck, backs of hands, and forearms; may disappear spontaneously or reappear after treatment, slow progression to squamous cell carcinoma is possible; usually premalignant lesions of epidermis
    • Squamous Cell Carcinoma- firm, nodular lesion topped with crust or central area of ulceration, indurated margins, fixation to underlying tissue with deep invasion; sun-exposed area, especially head, neck and lower lip, sites of chronic irritation or injury (scars, irradiated skin, burns, leg ulcers); rapid invasion with metastasis via lymphatics, larger tumors are more prone to metastasis; cancer of the epidermis; lesions on the ear, lip, external genitalia are more likely to invade and spread
    • Basal Cell Carcinoma- pearly papule with a central crater and rolled waxy borders, telangiectasias and pigment flecks visible on close inspection; sun-exposed areas, especially head, neck, and central portion of the face; metastasis is rare, may cause local tissue destruction, reoccurrence rate; basal cell layer of epidermis; genetic predisposition and chronic irritation are factors
    • Melanoma- irregularly shaped, pigmented papule or plaque, variegated colors with red, white and blue tones; can occur anywhere on the body, especially where nevi (moles) or birthmarks are evident, commonly found on upper back and lower legs, soles of feet and palms of dark skinned people; horizontal growth phase followed by vertical growth phase; rapid invasion and metastasis with high morbidity and mortality; risk factors are genetic predisposition, excessive UV, presence of one or more precursor lesions that resemble unusual moles; HIGHLY METASTATIC; survival depends on early detection
  87. Prevention of Skin Cancer
    • Avoid sun exposure between 11 and 3; use sunscreen with appropriate protection factor; wear a hat, opaque clothing, and sunglasses; keep a body map, examine your body monthly
    • Asymmetry
    • Borders irregular
    • Changing
    • Diameter
    • Envolvement/elevation
  88. Health promotion and maintenance
    • PREVENTION!! avoid tanning beds and salons
    • Secondary prevention, early detection, keep a total body spot and lesion map; systemically inspect body monthly
    • Ask pt about family hx of skin cancer; changes in size, color or sensation of mole, birthmark, wart, or scar; geographic areas lived in; occupational and recreational activities; skin lesions irritated by clothing; previously injured is higher risk (Koebner's phenomenon)
    • Document location, size, color, surface features; punch, shave, or excisional biopsy to test
  89. Surgical Management
    • Cryosurgery-local application of liquid nitrogen to isolated lesions causing cell death and tissue destruction; prepare pt for swelling and increased tenderness; 1-2 day blister; clean site with hydrogen peroxide
    • Curettage and electrodesiccation- small lesions that are not melanoma; wounds created heal by second intention and scarring is minimal; teach wound care, cleaning the wound, antibiotics, and applying dressings
    • Excision- biopsy of small lesions; surgical excision with primary closure; skin grafts and flaps are used to repair large defects
    • Moh's surgery- used to treat basal cell and squamous cell carcinoma by sectioning horizontal layers and each layer is examined histologically to determine presence of residual tumor cells
    • Wide excision- deeper melanoma; removing full thickness skin in the area of the lesion; skin is easily moved without creating extensive tension, wound is sutured closed; if too tight or large, skin grafts are used
  90. Nonsurgical management
    • Drug therapy- topical or systemic chemo, biotherapy, or targeted therapy; topical (5-fluorouracil cream) for multiple actinic keratosis or widespread superficial basal cell carcinoma for several weeks and area becomes increasingly tender and inflamed as the lesion crust, ooze, and erode; cool compresses and topical corticosteroids to decrease inflammation and promote comfort
    • Biotherapy- interferon for melanomas stage III or higher; high dose, 5 days a week for 4 weeks (IV) then maintenance dose 3 times a week for 1 year (SQ); ipilimymab (Yervoy) or CTLA4; side effects are significant inflammation
    • Radiation therapy-malignant melanoma are resistant to radiation; limited to older pt with large, deeply invasive basal cell carcinoma or poor risk for surgery; combo with corticosteroids
  91. Oral Cancer
    Prevention strategies include minimizing sun and tanning bed, tobacco cessation, decreasing alcohol intake; excessive prolonged radiation from xrays
  92. Squamous Cell Carcinoma
    • Most common oral malignancy; can be found on lips, tongue, buccal mucosa, and oropharynx
    • Highly associated with aging, tobacco use and alcohol ingestion
    • Alterations in thickness of epithelium development results in atrophy; usually slow growing, lesions may be large before symptoms unless ulceration occurs; mucosal eryhtroplasia is earliest sign; oral lesion that appear red, raised, eroded area are suspicious, does not heal within 2 weeks or a lump or thickening of the cheek
    • Older than 40
    • Increased rate in textile workers, plumbers, and coal and metal workers; sun exposure, poor nutrition, poor oral hygiene, infection with HPV; periodontal disease with mandibular loss
  93. Basal Cell Carcinoma (Oral)
    • Occurs primarily on the lips; is asymptomatic and resembles a raised scab; evolves into ulcer with raised pearly border; aggressively involves the skin of the face but does not metastasize; major factor is sun exposure
    • result of the failure of basal cells to mature into keratinocytes
  94. Kaposi Sarcoma
    malignant lesion arising in the blood vessels; usually painless; raised purple nodule or plaque; found on the hard palate, gums, tongue, or tonsils; most often associated with AIDS
  95. Oral Cancer Key Features
    bleeding from the mouth; poor appetite; difficulty chewing; difficulty swallowing; poor nutritional status and weight loss; thick or absent saliva; painless oral lesion that is red, raised, or eroded; thickening or lump in cheek
  96. Assessment
    • Routine oral hygiene, use of dentures or oral appliances; oral bleeding; past or current appetite and nutritional state; exam oral cavity with adequate lighting; inspect for lesions, evidence of pain or restriction of movement; change in speech; change in voice or swallowing; thick or absent saliva; assess self-concept; assess educational or cultural needs; evaluate support system
    • Oral CDx brushing of lesion is helpful to determine if precancerous; biopsy is the definitive d MRI to detect perineural involvement and in evaluating thickness in cancers of the tongue; CT and MRI to determine spread; aqueous solution of toluidine blue can be applied to determine malignancy, stains malignant lesions; lesion that is a result of inflammation may also absorb the stain
  97. Interventions
    • AIRWAY!!! increase air exchange, remove secretions, prevent aspiration; assess dyspnea; quality, rate, depth of respiration; auscultate lungs; promote deep breathing; semi-fowlers or high-fowlers position; encourage fluids; chest physiotherapy; oral suction with a dental tip or tonsil tip; if edema, pt may receive steroids to reduce inflammation, antibiotics, cool mist by face tent to assist with oxygenation
    • Establish oral hygiene routine, q2h; if platelets drop below 40,000, use chemobrush (not toothettes or disposable foam brush); teach pt to avoid chemical mouthwash and lemon-glycerin swabs; encourage frequent mouth rinsing with HCO3 or warn NS
    • Radiation for 5 daily treatments per week with 2 day break each week over 6-9 weeks via external beam; interstitial radiation or brachytherapy to boost the dosage or deliver radiation close to tumor bed; place pt on radiation transmission precautions
    • Chemo teach of side effects and give antiemetics
  98. Surgical management
    • cryotherpay for small lesions; photodynamic therapy; goal of resection is to remove all the tumor with a surgical margin that is free of cancer cells; assess level of understanding
    • Local excisions postop includes liquid diet for one day then advance as tolerated
    • Large surgical restrictions include placement of temporary tracheostomy, o2 therapy,a dn suction; temporary loss of speech; frequent monitoring of postop vitals; NPO status until intraoral suture lines are healed; IV lines for drug therapy and hydration; postop drug therapy and activity (out of bed first postop day); surgical drains; coordinate method of communication; urge to practice communication method
    • Postop maintain pt airway, protect the incision site to avoid infection, pain relief, nutritional status, swallowing exercises, community based resources; use predetermine method of communication; when pt has adequate airway and can effectively clear secretions by coughing, the trach may be removed; may have slurred speech or difficulty speaking; provide gentle mouth care at least q4h and assess oral cavity; elevate head of bed to decrease edema; inspect donor site q8h for bleeding or infection; pain relief is subjective and objective, pain described as throbbing or pounding; IV morphine initially then Tylox or Percocet; NPO for several days; NG or parenteral feeding may be needed; when fluid intake is started assess for dysphagia, aspiration, and leakage of saliva; daily weights and hydration; encourage swallowing exercises
    • acute effects are mucositis, stomatitis, change in taste; long term is xerostoma, dental decay, fatigue from radiation and chemo; may need suction equipment, nutritional supplements and nursing care at home
    • Changes in taste (dislike of beef, pork, metallic taste); teach to add seasoning; use high protein foods; inspect oral cavity daily; reinforce oral hygiene routine, frequent rinsing, adequate hydration; saliva substitutes; avoid sun exposure, perfume lotions or powders, cleanse with nondeodorant soap; men to use electric razor and avoid aftershave; depression is common
  99. Leukemia
    • type of cancer with uncontrolled production of immature WBCs in the bone marrow; may be acute or chronic; classified by cell type- from lymphoid pathways (lymphocytic or lymphoblastic) or from myeloid pathways (myelocytic or myelogenous)
    • Biphenotypic leukemia is acute and shows lymphocytic and myelocytic features
    • Occurs in the stem cells or early precursor leukocyte cells causing excessive growth of a specific type of immature leukocyte
    • excessive production in the bone marrow stops all normal bone marrow production of RBCs, platelets, and mature leukocytes; anemia, thrombocytopenia, and leukopenia result; without tx, pt will die of infection or hemorrhage
    • Acute leukopenia changes occur rapidly and without intervention progress to death
    • Chronic leukopenia may be present for years before changes occur
  100. Etiology and genetic risk
    • Exact cause is unknown; genetic and environmental factors are involved that damage genes controlling cell growth; possible risk factors include ionizing radiation, viral infection, exposure to chemicals and drugs, bone marrow hypoplasia, genetic factors, immunologic factors, environmental factors, interaction with these factors
    • Ionizing radiation exposures such as radiation therapy or heavy radiation exposure; increase risk for leukemia particularly acute myelogenous leukemia (AML)
    • Chemicals and drugs have the ability to damage DNA
    • Bone marrow hypoplasia increase by reducing or changing the rate of bone marrow cell production; Fanconi's Anemia and myelodysplastic syndromes
    • Genetic factors- Down Syndrome, Bloom Syndrome, Klinefelter Syndrome, Fanconi's anemia
    • Immunologic factors, promote leukemia development; result of loss of immune protection or same mechanisms cause the immune deficiency trigger cancer in WBCs
    • Interaction- difficult to determine origin
  101. Prevalence
    • acute myelogenous leukemia (AML) most common adult onset leukemia; dx and classified based on the number of healthy blood cells, the number of leukemic cells, and specific chromosomal abnormalities
    • acute promyelocytic leukemia (APL) subtype of AML and most curable AML
    • acute lymphocytic leukemia (ALL) most common in children; Philadelphia chromosome is hallmark
    • chronic myelogenous leukemia (CML) adult onset leukemia in people older than 50; Philadelphia chromosome; chronic phase-slow progressing with mild symptoms and respond to standard tx; accelerated phase-spleen enlargement, progressive manifestation with intermittent night sweats, unexplained wt loss, doesn't respond to standard tx, typically last 6-12 mo; blast phase- indicates transformation to aggressive acute leukemia; promyelocytes and blast cells spread to other tissues
    • Chronic lymphocytic leukemia (CLL) most common in people over 50; survival time ranges from less than 19 to more than 10 years
  102. Assessment
    Hx-exposure to risk factors and related gentic factors; occupation and hobbies; previous illnesses and med hx; changes in immune function; frequency and severity of infections during the last 6 months; excessive bleeding (bruise easily, nosebleeds, increased menstrual flow, bleeding of gums, rectal bleeding, hematuria, prolonged bleeding); weakness or fatigue from anemia, increased metabolism; headaches, behavior changes, increased somnolence, decreased alertness, decreased attention span, lethargy, muscle weakness, loss of appetite, weight loss, increased fatigue; list activities in last 24h;
  103. Key feature of Acute Leukemia
    ecchymoses; petechiae; open infected lesions; pallor of the conjunctivae, nail beds, palmar creases, around the mouth; bleeding gums; anorexia; weight loss; enlarged liver and spleen; hematuria; tachycardia at basal activity levels; orthostatic hypotension; palpitations; dyspnea on exertion; fatigue; headache; fever; bone pain; joint swelling and pain
  104. Physical Assessment/Clinical Manifestations
    • CV- oxygenation is reduced due to anemia; heart rate increased; BP decreased; murmurs and bruits; cap refill is slow; highly viscous blood from greatly elevated WBC count causing high BP and bounding pulse
    • Respiratory- reduced tissue oxygenation from anemia and infection; RR increases; pt may have cough and SOB or abnormal breath sounds
    • Skin changes- pallor and coolness related to reduced tissue perfusion related to anemia; pallor, petechial (legs and feet); inspect for infections or injured areas that have failed to heal; mouth for gum bleeding, sores, or lesions
    • Intestinal changes- increased bleeding tendency; weight loss, anorexia, nausea; rectal fissures; occult blood tests; reduced bowel sounds; constipated; decreased peristalsis; enlargement of liver and spleen cause abdominal tenderness
    • CNS changes- cranial nerve problems, headache, papilledema from leukemic invasion of CNS; seizures and coma may occur
    • miscellaneous- bone and joint tenderness and lymph node enlargement
  105. Psychosocial/lab assessment
    • Pt very anxious and fearful; assess coping patterns
    • decrease hct, hgb, platelet, WBC counts; WBC may be low, normal, or elevated; high WBC count consisting of most blast cells has a poorer prognosis
    • definitive test is bone marrow aspiration and biopsy (full of leukemic blast phase cells; proteins (antigens) on the surface help dx); T11 protein, terminal TDT, CALLA, CD33 anitgen
    • Blood clotting times and factors are usually abnormal with acute leukemia; reduced levels of fibrinogen is common and clotting time is prolonged
    • Chromosome analysis-marker chromosomes to help dx (Philadelphia chromosome)
    • Imaging- is based on specific manifestations
  106. Preventing infection
    • Infection is a major cause of death in the pt with leukemia because WBC is immature or cells are depleted from chemo, sepsis is common
    • autocontamination is overgrowth of normal flora; cross contamination- organisms from another person), three most common sources are skin, respiratory tract, and GI tract; gram negative bacteria are most common
    • Risks
    • general-age; hx of allergies; hx of chemo, radiation, or other immunosuppression (steroids); chronic disease; hx of febrile neutropenia and associated symptoms; nutritional status; functional status (immobility); tobacco use (cigarettes, pipe, cigars, oral); recreational drugs, alcohol, otc/RX drug use; baseline and ongoing vitals (BP, HR, RR, T)
    • Skin and Mucous Membranes- thorough inspection of all skin surfaces with attention to axilla, anorectal, under breasts, color, vascularity, bleeding, lesions, edema, moist areas, excoriation, irritation, erythema, hair nails, pressure areas, swelling, pain, tenderness, biopsy, wounds, lymph nodes, catheters; inspection of oral cavity, lips, tongue, mucous membranes, gingiva, teeth, throat, color, moisture, bleeding, ulcerations, lesions, exudate, mucositis, stomatitis, plaque, swelling, pain, tenderness, taste changes, amount and character of saliva, ability to swallow, changes in voice, dental caries, oral hygiene routine; hx of current skin or mucous membrane problems
    • Head, eyes, ears, nose- pain, tenderness, exudate, crusting, enlarged lymph nodes
    • Cardiopulmonary- respiratory rate and pattern, breath sounds, quantity and characteristics of sputum, SOB, use of accessory muscles, dysphagia, diminished gag reflex, tachycardia, BP
    • GI- pain, diarrhea, bowel sounds, character and frequency of stool, constipation, rectal bleeding, hemorrhoids, change in bowel habits, sex, erythema, ulceration
    • Genitourinary- dysuria, frequency, urgency, hematuria, pruritus, pain, vaginal or penile dc, vaginal bleeding, burning, lesions, ulcerations, characteristics of urine
    • CNS- cognition, LOC, personality, behavior
    • Musculoskeletal- tenderness, pain, loss of function
  107. Drug therapy
    • Acute leukemia-induction therapy is intense and consists of combining chemo       started at the time of dx to achieve rapid and complete remission (antracycline, anthracenedione, cytosine arabinoside), a side effect is severe bone marrow suppression with neutropenia, prolonged       hospitalizations for bone marrow recovery of 2-3 weeks, nausea, vomiting, diarrhea, alopecia, stomatitis, kidney toxicity, liver toxicity, and cardiac toxicity; consolidation therapy is another course of the same       drug  at different dosages or different combo, intent is to cure and occurs early in remission, hemotopoietic stem cell transplantation may be considered; maintenance therapy is for months to years after successful induction and consolidation for pt with ALL and APL, maintain the remission achieved through induction and consolidation, ALL are milder drugs and       are oral for 2-5 years
    • Chronic Leukemia- Imatinib mesylate is first line for CML that is Philadelphia       chromosome positive, prevents activation of enzyme tyrosine kinase for growth of FML cells, it is oral; interferon alpha (reduces growth of leukemic cells with side effects of flu like symptoms and fever; for resistant to imatinib the second line is dasatinib or nilotinib; CLL is started with chemo that can cause remissions but not cure and treated with an alkylating agent (chlorambucil w/ or w/o prednisone; fludarabine; and combo cyclophosphamide, vincristine, prednisone); Rituximab is combo with these or alone; target therapy with ofatumumab for CLL that does not respond to fludarabine and alemtuzumub; lenalidomide is used for relapse or doesn't respond to other tx for CLL
    • Hematopoietic stem cell transplantation with CLL is an option for curative potential or       prolonged disease survivalbendamustine       (alkylating agent with antimetabolite properties) alone or with rituximab for CLL; rituximab with monoclonal antibodies (ofatumumab and alematuaumab)Infection- for AML-antibiotics like aminoglycosides (amikacin, gentamicin, tobramycin) and a penicillin or third generation cephalosporin (ceftazidime); vancomycin for MRSA or indwelling venous catheter       infection; systemic antifungals for fever lasting 4-7 days after starting antibiotics (amphotericin B, ketoconazole, voriconazole, fluconazole, nystatin); antivirals to prevent or treat viral infections (acyclovir at the start of chemo for pt who are cytomegalovirus pos; ganciclovir,       foscarnet or steroids), side effects include ototoxicity, nephrotoxicity
  108. Infection Protection
    thorough hand washing; upper respiratory tract infections must wear mask if      entering pt room; asepsis when changing dressings or accessing central venous line and strict aseptic technique with catheter care; private room; no raw foods, no standing water in denture cups or vases or humidifiers; HEPA filtration; continually assess for infection (low grade fever without pus); Daily CBC with diff and absolute neutrophil count; inspect oral      cavity q shift; assess lungs q8h; assess urine and urination; vitals q4h; blood for bacterial and fungal cultures from peripheral sites and from central venous catheter; urine specimens, sputum specimens, drainage specimens, pus specimens; CXR; skin care, daily bathing, turn hourly and skin lubricants; pulmonary hygiene q2-4h, cough and deep breathe qh while awake
  109. Hematopoietic Stem Cell Transplantation
    • standard  tx for leukemia pt with closely matched donor and in temporary remission  after induction therapy; also used for lymphoma, multiple myeloma, aplastic anemia, sickle cell disease, solid tumors; chemo is used to  purge the marrow of leukemic cells and is lethal without replacement of  stem cells by transplantation
    • Allogenic- transplantation from a sibling or matched unrelated donor
    • Autologous- pt own stem cells that were collected and treated
    • Syngeneic- taken from identical sibling
    • allogenic- closely matched
    • HLA-matched sibling or unrelated but matched donor
    • May be obtained from bone marrow harvest, peripheral stem cell pheresis, umbilical cord stem cell banking
  110. Classification of Transplants
    • autologous- self-donation- bone marrow harvest, peripheral stem cell pheresis,       umbilical cord blood
    • Syngeneic- HLA identical twin- bone marrow harvest, peripheral stem cell pheresis
    • Allogenic- HLA-matched relative, Unrelated HLA-matched donor, Mismatched or       partially HLA-matched family member or unrelated donor- bone marrow harvest, peripheral stem cell pheresis, umbilical cord blood
  111. Bone Marrow Harvesting
    • after a suitable donor is identified by tissue typing; occurs in operating room and removed through iliac crest or sternum; 500-1000 ml aspirated; filtered (if autologous, treated to rid marrow of cancer cells), then frozen (autologous) or used immediately (allogenic)
    • Monitor donor for complication of anesthesia and manage pain, hydrate with NS       before and after; assess harvest site for bleeding; teach to inspect for bleeding and take analgesics for pain with oral non-aspirin analgesics
  112. Peripheral Blood Stem Cell Harvesting
    • 3 phases: mobilization, collection pheresis, and reinfusion; stem cells that have       been released from the bone in to the circulating blood
    • Mobilization, chemo or hematopoietic factors are given for autologous or just       hematopoietic factor for allogenic; plerixa for to mobilize stem cells
    • Stem cells are then collected by pheresis (withdrawing of whole blood, filtering the cells, then returning the plasma to the pt) with 1-5 pheresis procedures lasting 2-4h each and cells are then frozen and       stored
    • Monitor for catheter clotting, hypocalcemia (numbness or tingling in fingers and       toes, abdominal or muscle cramping, chest pain) and give oral calcium supplement; monitor vitals qh during pheresis; hypotensive from fluid loss during procedure
  113. Cord Blood Harvesting
    Conditioning Regimen
    • obtaining stem cells from umbilical cord blood of newborns first must undergo conditioning to wipe out pt own bone marrow (myeloablation) and to giver higher than normal does of chemo or radiotherapy to rid cancer cells and takes 5-10 days
    • For AML: Days T-5-T-4- high dose chemo with thiotepa, busulfan, carmustine,       cyclophosphamide, cytosine arabinoside, eptoside, melphalan; Days T-3-T-1- Delivery of TBI (total body irradiation) at 1200 rads given as 200 rads BID for 3 days
    • Non-myeloablative therapy may be used with lower doses of chemo and TBI to allow pt to recover immune system; decreases chemo side effects but relies on development of graft vs hose disease (GVHD) for control of cancer
    • During conditioning , bone marrow and normal tissues respond immediately to       chemo and radiation; chemo side effects are more intense with N/V, capillary leak syndrome, diarrhea, bone marrow suppression; late effects occurring as late as 3-10 y after transplantation include veno-occlusive disease (VOD), skin toxicities, cataracts, lung fibrosis, second cancers,       cardiomyopathy, endocrine complications, neurologic complications
  114. Transplantation
    • Day T-0, frozen marrow, PBSCs, or umbilical cord blood is thawed and infused like ordinary blood
    • S/E- fever, HTN; use Tylenol, hydrocortisone, and diphenhydramine to prevent before infusion; antihypertensives or diuretics may be needed to treat fluid volume changes; red urine for short time period from RBC breakage
  115. Engraftment
    • successful take of transplanted cells in bone marrow; takes 8-12 days for PBSC and       12-28 for bone  marrow stem cells; growth factors (granulocyte colony-stimulating factor) may be given to aid; WBC, RBC, platelets begin to rise
    • Check pt blood for chimerism (presence of blood cells that show a genetic profile or other marker that is different from those of the pt); engraftment has taken with progressive chimerism with increasing       percentages of donor cells is present
  116. Prevention of complications
    • Infection and bleeding because pt has no natural immunity; prophylactic antibiotics
    • Graft vs Host Disease (GVHD)- mostly in allogenic transplantation; graft is       actually attacking the host tissue cells; T lymphocytes from donated marrow recognize recipient as foreign; can be mild or severe; onset is soon after transplant or moths to years later; Symptoms- skin rash, abdominal pain, nausea, vomiting, and diarrhea; tx with cyclosporine,       tacrolimus, methotrexate, corticosteroids, mycophenolate mofetil, antihymocyte globulin
    • Veno-occlusive Disease- blockage of liver blood vessels by clotting and inflammation (phlebitis); begins within first 30 days; symptoms include jaundice, pain in the RUQ, ascites, wt gain, liver enlargement; PREVENTION; fluid       management 
  117. Interventions
    Minimize injury- bleeding precautions, nadir (lowest bone marrow suppression)Conserve energy- nutrition (small frequent meals high in proteins and carbs); blood transfusions (packed RBCs); drug therapy- colony-stimulating growth factors (epogen qweek or q2weeks or Area esp sq weekly to q3 weeks), may cause HTN, watch for MI, headeaches, myalgia, rashes, stings when injected); activity management (postpone PT, dx tests if needed)Plan       for home care as soon as remission is achieved; nurse visits pt 1-2 week for 4-8 h/day; PROTECT FROM INFECTION, no live virus immunizations (polio, measles, rubella) for 2 years; assess financial resources and refer as needed
  118. Hodgkin's Lymphoma
    • Cx that starts in a single lymph node or a single chain of nodes; peak in 2       age groups (teens and young adults or adults in 50-60), younger men and women and more prevalent in older men
    • Causes include viral infections (EPSTEIN-BARR VIRUS, human T-cell       leukemia/lymphoma, HIV) and exposure to chemical agents
    • Specific marker called the REED STERNBERG CELLS
    • large painless lymph node or nodes, distinct finding is rare with pain in the lymph nodes brought on or made worse by alcohol ingestion; B symptoms include fever, drenching night sweats, unexplained weight loss; dx and subtype is established with biopsy of node or mass reveals REED STERNBERG CELLS; staging includes physical exam, CBC, electrolyte, kidney and LFTs, ESR, bone marrow aspiration, biopsy; CT of neck, chest, abdomen, pelvis for staging; PET to assess areas not detected by CT; Ann Arbor Staging (stage I,II is external radiation of lymph node region; more extensive uses chemo and radiation)Acute side effects- drug induced pancytopenia (increases risk for bleeding, infection, anemia); severe N/V (impairs nutrition); skin problems (radiation site); constipation or diarrhea; impaired liver function (liver metastasis or chemo); permanent sterility; secondary cancer       development
  119. Ann Arbor Staging for Hodgkin's Lymphoma
    • Ia-disease is present only in a single lymph node region or in only one non lymph       node site
    • Ib- disease location is the same as Ia; pt has some or all of these manifestations-fever, weight loss, night sweats
    • IIa- disease is present in two or more separate lymph node regions on the same side of the diaphragm or two in two non lymph node sites on the same side       of diaphragm
    • IIb- same as IIa with some or all manifestations
    • IIIa- disease extends to lymph node regions on both sides of diaphragm
    • IIIb- same as IIIa with manifiestations
    • IIIc- same as IIIb with disease present in spleen
    • IV- disease is present in many body areas including one or more non nodal tissues and organs
  120. Non-Hodgkin's Lymphoma
    • all lymphoid cancers that DO NOT HAVE REED STERNBERG CELLS; generally spread through the lymphatic system in a less than orderly fashion; more common       in men and older adults; most common hematologic disorder; exact cause is       unknown but both autoimmune disease and immunosuppressive disorders appear to be associated with increased risk; chronic infection with H. pylori associated with mucosa-associated lymphoid tissue (MALT) lymphoma; Epstein-Barr virus associated with Burkitt's Lymphoma; may be inherited gene damage causing loss of suppressor gene function; exposure to       pesticides, insecticides, dust
    • Usually have swollen lymph nodes or tumor spread; common extranodal sites are GI, skin, bone marrow, sinuses, thyroid, CNS; enlarged lymph nodes may be the       only symptom; painless swelling of the cervical, axillary, inguinal, femoral nodes is common; dx made after biopsy of involved lymph node; classification is based on cytology, immunophenotyping, genetic, and clinical features
    • lactate dehydrogenase (LDH) levels and beta-2 microglobulin levels are elevated       (high LDH and beta-2 macroglobulin levels are associated with poor prognosis), CSF is evaluated when lymphoma is around in CNS, spine, brain, testes, or HIV related; indolent (slow growing) lymphomas usually have painless lymph node swelling at dx; B-cell lymphoma may have large       abdominal masses or mediastinal masses with symptoms of fever, drenching night sweats, unintentional weight loss, and bone marrow involvement
    • Tx includes chemo combo drugs or chemo and monoclonal antibodies (rituximab       and alemtuzumab), localized external radiation, radiolabeled antibodies,       hematopoietic stem cell transplantation, investigational agents; biotherapy (monitor infusion related reactions)
  121. Multiple Myeloma
    • WBC cancer that involves more mature lymphocytes called plasma cells which       secrete antibodies; overgrowth of B-lymphocyte plasma cells in the bone       marrow (gammopathy); myeloma cells are overproduced causing fewer functional RBCs, WBCs, and platelets leading to anemia, risk for infection, and bleeding; produces excess cytokines; excess antibodies are released into the blood, increasing serum protein levels and clogging blood vessels in the kidney and other organs; causes progressive BONE LOSS,       bleeding problems, kidney failure, immunosuppression and death; rare       under 40, people over 65, higher in blacks than whites and higher in men
    • Possible risk factors include radiation exposure, infection with human herpes       virus 8; can be distinguished by changes in immunoglobulin structure that begins with in a single clone of cells even before transformation to cancer occurs; can be seen and recognized as unique spike pattern on serum electrophoresis; abnormal immunoglobulin is monoclonal       immunoglobulin (IgG 60%, IgA 20%)Elevation in total protein levels or detection of monoclonal protein (paraprotein)in the blood or urine; fatigue, anemia, bone pain, pathological fractures, recurrent bacterial infections, kidney dysfunction, hypercalcemia, hyperviscosity
    • monoclonal gammopathy of undetermined significane (MGUS) is premalignant with       monoclonal protein concentrations <3g; distinguished MGUS from multiple myeloma by having more than 10% of bone marrow infiltrated with plasma cells, presence of monoclonal protein in serum or urine, presence of osteolytic bone lesions
    • Staging based on beta-2 macroglobulin and albumin tests; first usually notices       fatigue, easy bruising and bone pain then BONE FRACTURES, HTN, infection,       hypercalcemia, and fluid imbalance
    • Dx made by xray of bone thinning that resembles Swiss cheese, high       immunoglobulin and plasma protein levels, and BENCE-JONES PROTEIN in the       urine; bone marrow biopsy to dx and determine chromosomal abnormalities       of chromosome 11 (longer survival) and chromosome 13 (poor prognosis)
    • Tx for minimal disease is chemo with bortezomib (proteasome inhibitor), and       thalidomide and lenalidomide which are immunomodulating drugs; can be used alone or in combo with steroids (dexamethasone); eligible for       autologous stem cells transplant has drug therapy to reduce tumor burden; if not eligble, chemo such as melphlan, prednisone, vincristine,       cyclophosphamide, doxorubicin, carmustine are used to control but not cure, side effects are myelosuppresion, thromboembolic events, peripheral neuropathy (pain), n/v/d, constipation; bone pain is local or generalized (analgesics and alternative therapy, aromatherapy, relaxation, hypnosis), bone density is tx with fosomax (inhibit bone reabsorption)
    • Chemo is first; acetaminophen or NSAIDs, prevent falls and breaks, limit weight       bearing or use mechanical life if needed; spinal cord compression; guided       imagery; increased uric acid is treated with hydration and allopurinol (3-4 L/day)
  122. Colorectal Cancer
    colon and the rectum together to make up the large intestine; most are      adenocarcinomas; etiology is older than 50, genetic predisposition, personal or family history of cancer; arise from glandular epithelial tissue of colon; increased proliferation of colonic mucosa forms polyps that can turn in to malignant tumors; most occur within the rectosigmoid      region; can metastasize from direct extension or by spreading through the      blood or lymph; may spread locally into the four layers of the bowel wall; may enlarge into the lumen of the bowel or spread through the lymphatics or circulatory systems; also spread by peritoneal seeding during surgical resection of the tumor; complications from increasing growth include bowel obstruction or perforation with resultant peritonitis, abscess formation,      and fistula formation to the urinary bladder or vagina; growing in the bowel lumen can gradually obstruct the intestine and eventually completely block it, if extends beyond the bowel well it may place pressure on other organs causing symptoms to mask cancer
  123. Etiology and Genetic Risk
    • older than 50, genetic predisposition, personal or family hx of cancer and/or       disease that predispose pt to cancer (familial adenomatous polyposis, Crohn's disease, ulcerative colitis); some lower are related to H. pylori, streptococcus bovis, JC virus, HPV infection
    • Long term smoking, increased body fat, physical inactivity, heavy alcohol use are also risk factors
    • People at risk can take action to decrease their chance of getting and/or increase their chance of survival; genetic testing for FAP and HNPCC; teach people about dx screening (50+ colonoscopy q10y or double contrast barium q5y, fecal occult qy); modify diet to decrease fat, refined carbs, increase fiber, baked or broil, stop smoking, drinking, and start exercising, dietary calcium supplements
  124. History
    breast, ovarian, endometrial cancer, ulcerative colitis, Crohn's disease, familial polyposis or adenomas, polyps, or family hx of CRC, use of alcohol and/or tobacco, physical activity changes, vomiting, changing of bowel habits, fatigue, abdominal fullness, vague abdominal pain, or weight loss
  125. Physical Assessment/Clinical Manifestations
    • most common signs are rectal bleeding, anemia, and change in stool consistency       or shape; clinical manifestations depend on location of tumor; dark or bright red stool; in the transverse and descending colons, gas pains, obstruction, cramping, incomplete evacuation; in the rectosigmoid, hematochezia (red blood via rectum), straining to pass stools, narrowing of stools, dull pain, stool consistency is more liquid
    • assess for abdominal mass, peristaltic waves, high pitched or tinkling bowel sounds; fear and anxiety
    • hgb, hct are decrease, positive FOBT (false positive if red meat, aspirin, vit c taken within 48h, stop for 7 days, two or 3 separate stool samples); carcinoembryonic antigen (CEA) is elevated from the normal of 5, may be elevated if benign or malignant disease or smoker
    • Double contrast barium enema or colonoscopy to visualize polyps or small lesions; CT or MRI of chest, abdomen, pelvis, lungs, or liver to confirm mass, extent of disease, location of distant metastasis; sigmoidoscopy to visualize lower colon; colonoscopy is the definitive test for dx
  126. Nonsurgical Management
    • Stage I-tumor invades up to muscle layer
    • Stage II- tumor invades up to other organs or perforates peritoneum
    • Stage III- any level of tumor invasion and up to 4 regional lymph nodes
    • Stage IV- any level of tumor invasion; many lymph nodes affected with distant metastasis
    • Radiation therapy- palliative measure to control pain, hemorrhage, bowel obstruction, or metastasis to the lung
    • Drug therapy- chemo for stage II or III to interrupt the DNA production of cells with IV 5-FLUOROURACIL with leucovorin, capecitabine, or combo FOLFOX (5-FU, leucovorin, and oxaliplatin), side effects are diarrhea, mucositis, leukopenia, mouth ulcers, peripheral neuropathy
    • bevacizumab to reduce blood flow to the growing tumor cells, used in mbocetuximab (monoclonal antibody) to block factors that promote cancer cell growth Intrahepatic arterial chemo with 5-FU
  127. Surgical Management
    • remove the tumor with margins free of disease; colon resection (removal of the       rumor and regional lymph nodes); colectomy (colon removal) colostomy       (surgical creation of an opening of the colon to the surface of the abdomen), abdominoperineal resection (colectomy with colostomy or ileostomy/ileoanal pull through)
    • Enterostomal nurse comes to recommend placement of ostomy, teach pt about the rationale and care of ostomy, mark abdomen for site
    • Low rectal surgery has risk for postop sexual dysfuntion and urinary incontinence, talk with pt about it before surgery, teach pt about pain management, PCA; bowel prep; oral or IV antibiotics; NG tube for decompression; peripheral IV or central cath; identify pt and family needs with social worker
  128. Operative Procedure
    • colon resection- tumor is excised and two open ends are irrigated and anastomosis (reattachment)
    • colostomy- 2 types
    • loop stoma- bringing a loop of the colon to the skin surface, severing, and everting the anterior wall, suturing it the abdominal wall; usually for transverse, temporary end stoma is constructed of the descending or sigmoid colon when permanent; severing the end of the proximal portion of the bowel and bringing the through the abdominal wall
    • Double-barrel stoma- least common, dividing the bowel and bringing both the proximal and distal portions to the abdominal surface to create two stomas; proximal drains feces, distal drains mucous Biggest problem is finding the right product for the right pt; control smell with charcoal tabs; tight but not too tight; good skin care; monitor psychosocial for sexual activity issues
  129. Postop Colonoscopy
    • NG tube and IV PCA for 24-36; after NG removal, progress from liquids to solids; ambulate
    • Colostomy care-clear pouch to observe or place petroleum gauze dressing to keep moist then cover with dry, sterile dressing; place a pouch system asap;       asses the color, integrity of stoma (should be reddish pink and moist, protrude about 3/4 in from abdominal wall); should start to function in 2-4 days; may need frequently emptying due to gas and when 1/3-1/2 full of stool (ascending colon-liquid, transverse-pasty, descending- more solid)
    • Wound management- closed with two bulb sugction drains (JP), monitor drainage, serosanguineous for 1-2 months after surgery; complete healing may take 6-8 months; assess for infection, abscess
  130. Perineal Wound Care
    • place an absorbent dressing over the wound; instruct pt they may use a feminine napkin as dressing, wear jocky type shorts rather than boxers; soak the       wound area in sitz bath for 10-20 minutes 3-4xday; administer pain meds and assess effectiveness; instruct pt about activities (side lying position in bed, avoid sitting too long; use foam pads or a soft pillow to sit ; avoid use of air rings or rubber donuts); maintain fluid and electrolyte balance, monitor intake and output from pt and wound; observe incision site and monitor wound drains, watch for erythema, edema, bleeding, drainage, unusual odor, excessive or constant pain
    • measure the stoma; diet to control gas and odor; protect the skin
  131. Grief
    Encourage pt to verbalize feelings about dx, tx, and change in body functions; sadness, anger, feelings of loss, depression are normal; instruct on what to expect with ostomy; encourage pt to touch and look at it and participate in care
  132. Community based care
    Typically hospitalized for 3 or more days; assess for self management ability; no changes to sleep; consume normal diet on d/c; avoid lifting heavy objects, straining; avoid driving for 4-6 weeks (1-2 if MIS); teach colostomy care before d/c and assess for psychomotor skills; teach pt and caregiver; flat firm abdomens may use flexible or nonflexible wafers; deep creases, flabby abdomen, retracted stoma, convex appliance with stoma belt; shrink within 6-8weeks postop; trace pattern of the stomal area on the wafer portion and cut to an opening about 1/8-1/16 in larger than stoma pattern; clean around the stoma with mild soap and water, no moisturizing soaps; avoid gas producing foods; buttermilk, cranberry juice, parsley, yogurt prevent odor; do not put aspirin tabs in pouch; explore psychosocial concerns, body image, sexual relationships;referrals if needed
  133. Breast Cancer Pathophysiology
    • Begins as a single transformed cell that grows and multiplies in the epithelial       cells lining one or more of the mammary ducts or lobules; heterogenous disease; some present as a palpable lump and others only show on mammogram
    • Noninvasive- cancer remains in the duct
    • Invasive- penetrates to the surrounding tissues
    • Common sites of metastatic disease from breast cancer are bone, lung, brain,       liver
  134. Noninvasive Breast Cancer
    • Ductal Carcinoma in situ, early noninvasive form; located within the duct and have not invaded the surrounding tissues; it may spread if left untreated; DCIS should be treated to prevent it from developing into invasive cancer
    • Lobular carcinoma in situ, rare and usually identified incidentally during biopsy for other problem; increases risk for developing a separate breast cancer
  135. Invasive Breast Cancer
    • infiltrating ductal carcinoma (most common), originates in the mammary ducts and grows in the epithelial cells lining the ducts; grows into the surrounding       tissues in an irregular pattern; fibrosis develops around the cancer causing a shortening of Coopers ligaments and typical skin dimpling; late stage shows peau d'orange
    • Inflammatory breast cancer (IBC)- highly aggressive form; symptoms of swelling, skin redness, pain in the breast; may not show on mammogram; hard to treat
  136. Breast Cancer in Men
    onset is about 60, only about 1%; genetic mutation of BRCA1 or BRCA2gene; hard, painless, subareolar mass, gynecomastia; possible nipple discharge, retraction, erosion, ulceration; usually advanced when detected later than women; tx is similar to women
  137. Etiology and Genetic Risk
    • Older woman or man is primary risk factor; genetic predisposition in young women is a strong risk factor; first degree relative with breast cancer; sporadic (no definite genetic pattern) rather than an inherited or familial disorder
    • Known factors include exposure to high dose ionizing radiation to the thorax (before 20), early menarche (before 12), late menopause (after 50), hx of cancer (breast, colon, endometrial, ovarian); no pregnancies or first birth after 30, nutrition and hormone replacement therapy; alcohol more than 1 drink per day, obesity, postmenopausal HRT for more than 5 years
  138. Risk Factors for Breast Cancer
    • High increased risk (relative risk >4.0)- female gender, age >50, genetic factor (BRCA1 or BRCA 2), family hx (first degree relatives), hx of previous breast cancer, breast density (more dense breast increase risk)
    • Moderate increase risk (relative risk 2.1-4.0)- family hx (1 first degree relative), biopsy confirmed atypical hyperplasia, ionizing radiation, high postmenopausal bone density (high estrogen levels)
    • Low increase risk (relative risk 1.1-2.0)- no pregnancies or after age 30, early menarche, late menopause, oral contraceptives, HRT, obesity
    • Other risk factors- alcohol, high socioeconomic status, jewish heritage
  139. Complications of Breast Cancer
    invasion of lymph channels causing skin edema; metastasis to lymph nodes; bone, lungs, brain, liver sites of metastasis; ulceration of overlying skin
  140. History
    personal and family hx, gynecologic and obstetric hx, HRT, OC, diagnostic procedures, joint or bone pain, alcohol use, OTC drugs
  141. Assessing a Breast Mass
    identify the location of the mass by using the face of the clock method; describe the shape, size, and consistency of the mass; assess whether the mass is fixed or movable; note any skin changes around the mass (dimpling, peau d'orange), increased vascularity, nipple retraction, ulceration; assess adjacent lymph nodes, both axillary and supraclavicular; ask pt if they experience pain or soreness in or around the area of the mass
  142. Clinical Manifestations
    • Unilateral clear or serosangueous discharge; nipple retraction; peau d'orange; dimpling over underlying skin; hard, irregularly shaped, poorly delineated, nonmobile, nontender mass
    • Feelings of shock, fear, disbelief, assess pt need for information; problems with       sexuality
    • Lab assessment relies on pathologic exam of tissue from breast mass; increased liver enzyme (liver metastasis); increased serum calcium and alkaline phosphatase (bone metastasis)
    • BSE as soon as breast tissue develops, 1xmonth, week after period (less tender); inspect first with hands on hips, palpate in a circle, be sure to get axillae (tail of Spence), be symmetrical; in shower
    • Mammograms after 40
  143. Diagnostic Study
    • Mammogram
    • Ultrasound-clarify mammogram findings
    • MRI to determine size of cancer and look for other cancers; breast specific gamma imaging (BSGI) and positron emission mammography (PEM)- injection of a small amount of tracing agent that concentrates in tumor
    • CXR for lungs
    • CT for bone, liver, brain
    • breast biopsy is the only definitive dx
    • Classified according to the size and type of breast cancer, histological grade, and       type of receptors on the cells; estrogen receptors (ER) or progesterone       receptors (PR) usually have better prognosis and tx with hormonal therapy; HER2, neu gene, tx with trastuzumab (target therapy); gene expression profiling systems, predict clinical outcomes by analyzing genes in breast cancer tissue
  144. Mammogram
    • 40+ have screening annually; educate women on risks and benefits of screening
    • genetic mutations or high risk factors should be screened with MRI and mammogram
    • Does not prevent cancer but can save lives
    • Barriers to mammograms are living in rural areas with no hospital that has mammogram machine; travel units
  145. Breast Self Exam (BSE)
    goal is early detection because breast self exam cannot prevent cancer, reduces mortality rate, teach to pt to become       familiar with the feeling and appearance of breast; lumps are not necessarily abnormal; teach as soon as breast tissue develops; report lumps to provider; premenopausal women to perform 1 week after period;       stand in front of mirror with arms raised above head then place on hips and press on her hips; raise one arm above head then start from the middle out or in an up and down motion, be sure to cover entire breast and axillae
  146. Clinical Breast Exam
    q3y for 20-30 and qy for asymptomatic women 40+; inspect then lift arms and perform breast exam
  147. High Risk Options
    • close surveillance as early as 30
    • Prophylactic mastectomy
    • Prophylactic oophorectomy
    • Antiestrogen chemo
    • Consider all options thoroughly
  148. Coping Strategies
    • Assess perceptions of self; flexibility is key; adjust your approach as emotional state changes; assess pt preferences; assess need for knowledge
    • Anxiety begins as soon as the lump is discovered; level of anxiety may relate to past experiences or personal associations with disease; allow pt to vent; be flexible
  149. Decreasing Risk for Metastasis
    • late stage, nonsurgical tx may be the only option, tumor may be removed with local anesthetic, follow up with hormonal therapy, chemo, and sometimes radiation
    • With surgery, follow up with adjuvant radiation, chemo, hormone therapy or       targeted therapy
    • common symptoms are pain, nausea, hot flashes, anxiety, depression, fatigue;       complementary and alternative therapies may use vitamins, diets, herbal therapy; ensure pt is being safe
    • CAM- pain (acupuncture, chiropractic, hypnosis, massage, music, reiki,       shiatsu); N/V (acupuncture, aromatherapy, ginger, hypnosis, progressive muscle relaxation, siatsu); fatigue (acupuncture, massage, meditation, reiki, tai chi, yoga); hot flashes (acupuncture, black chosh, flaxseed); muscle tension (aromatherapy, massage, siatsu); anxiety/stress/fear       (aromatherapy, guided imagery, hypnosis, journaling, massage, meditation, music therapy, progressive muscle relaxation, prayer, support groups, tai chi, yoga); depression (aromatherapy, yoga, journaling, progressive muscle relaxation)
  150. Surgical Management
    • removal of mass, neoadjuvant therapy, axillary node dissection, sentinel lymph       node biopsy, breast-conserving surgery, modified radical mastectomy
    • neoadjuvant therapy- shrink the tumor before surgical removal
    • Axillary lymph node dissection or sentinel lymph node biopsy- axillary for palpable axillary lymph nodes or cancer is suspected; sentinel- during breast surgery by injecting radioisotope or dye that travels to lymph node that takes up dye and they are removed
  151. Preop
    Relieving anxiety and providing info to increase pt knowledge; include spouse or partner in teaching; use open ended questions when reviewing type of procedure with pt; teach about need for drainage tube, location of incision, mobility restrictions, length of stay, possibility of adjuvant therapy, preop and postop care; supplement teaching with written or electronic material; address body image issues before surgery
  152. Breast Conserving Surgery
    (lumpectomy) removal of tumor and a small amount of tissue rather than the entire breast; stage I/II; negative margins (area between tumor and tissue is cancer free)
  153. Modified Radical Mastectomy
    • does not conserve breast; complete removal; 4-5 inch long elliptic incision from the midchest to the axilla; when reconstruction is to be performed at the same time, a 1 1/2 in flap of skin around the nipple is left
    • removal of breast, pectoral muscles, axillary lymph nodes, all fat and adjacent tissues
  154. Postop
    AVOID USING ARM FOR BP, INJECTIONS, BLOOD DRAWS!!! assess vitals q30 min for 1h, then qh for 2h, then q 4h; assess dressing for bleeding; JP drains, use gentle suction, monitor drainage color and amount; assess pt position with head of the bed 30 degree with affected arm on pillow; repositioning and analgesics as prescribed; ambulation and regular diet next day; support arm during ambulation at first; avoid humpback position with arm flexed because of elbow contracture; exercises first day, squeezing a soft, round object with arm and flexion/extension of elbow
  155. Post Mastectomy Exercises
    • Hand wall climbing- face the wall and put the palms of your hands flat against the wall at shoulder level; flex your fingers so that your hands slowly walk up the wall; stop when your arms are fully extended; slowly walk your hands back down the wall until they return to shoulder level
    • Pulley Exercises- drape a 6 foot long rope over a shower curtain rod or over the top of a door; grab the ends of the rope, one in each hand, extend your arms out to your sides until they are straight; keeping your arms straight, pull down with your left arm to raise your right arm as high as you can; pull down with your right arm to raise your left arm as high as you can
    • Rope Turning- tie a rope to the knob of a closed door; hold the other end of the rope and step back from the door until your arm is almost straight out in front of you; swing the rope in a circle; start with small circles and gradually increase to larger circles as you become more flexible
  156. Surgical Complications
    • accumulation of lymph in soft tissues; complication of exision or radiation of lymph nodes; axiallary nodes cannot return lymph to circulation; fluid accumulates in arm, causing obstructive pressure on veins and venous return (SVC Syndrome)
    • Compression sleeve or soft tissue expanded for reconstruction Recurrence may be local (skin), regional (lymph nodes), distant (skeletal, spinal cord, brain, pulmonary, liver, bone marrow; metastatic disease can be found in any distant site
  157. Breast Reconstruction
    • many prefer immediately after mastectomy; assess attitude about future plans
    • Breast expanders are most common (balloon like device with a resealable metal port that is placed under the pectoralis muscle that is injected with NS intraoperatively to partially inflate it then weekly injections for 6-8 weeks to fully inflate)
    • Autologous reconstruction uses pt own skin, fat, and muscle; flap can come from latissimus dorsi (back), transverse rectus abdominus myocutaneous lap, gluteal
    • should be closely monitored for opposite breast cancer
    • Assess the incision and flap for sings of infection (excess redness, drainage,       odor) during dressing changes; assess the incision and flap for signs of poor tissue perfusion (duskiness, decreased cap refill) during dressing changes; avoid pressure on flap and suture lines by positioning the pt on nonoperative side and avoiding tight clothing; monitor and measure drainage in collection devices; teach pt to return to usual activity level gradually and avoid heavy lifting; remind the pt to avoid sleeping in the prone position; reach pt to avoid participating contact sports or       other activities that could cause trauma to the chest; teach pt to minimize pressure on the breast during sex; remind pt to refrain from driving until advised; remind pt to ask at the 6-week postop when full activity can be resumed; reassure the pt that optimal appearance may not occur for 3-6 months postop; if implants have been inserted, teach the proper method of breast massage to enhance expansion and prevent capsule formation; emphasize breast awareness, BSE; remind the pt of the       importance of clinical breast exam and follow up
  158. Adjuvant Therapy
    • based on stage of the disease, pt age and menopausal status, pt preferences, pathologic examination, hormone replacement status, presence of known       genetic predisposition
    • Consists of radiation and drug therapy
    • purpose of radiation is to reduce the risk for local recurrence
    • Drug therapy includes chemo, targeted therapy, and/or hormonal therapy
    • neoadjuvant chemo may be given to reduce the size of a tumor before surgery
  159. Radiation Therapy
    • administered after breast conserving surgery; whole or partial breast; use of brachytherapy, delivered over a shorter period of time, eliminating the need for daily tips
    • Partial breast irradiation- interstitial brachytherapy is over 4-5 days; balloon brachytherapy is 10 treatments with at least 6 h between treatments
    • Pt education and side effect management; skin changes are a major side effect; radioactive only while radiation source is dwelling inside of the tissue
  160. Chemo
    • standard for node positive cancer or with a tumor >1cm; usually delivered four to six courses; common is Cytoxan, Adriamycin and 5-FU; most chemo is IV; fatigue and sleep disturbance are a major concern
    • cardiac toxicity is risk with Herceptin, which can result in infertility
    • ESTROGEN DEPENDENT-TAMOXIFEN COMPETES WITH ESTROGEN SITES
    • type used depends on menopausal status, tumor's hormone receptor status, lymph node involvement
    • 5-FU, doxorubicin, cyclophosphamide, methotrexate, tamoxifen (antiestrogen)
    • Cytaden-antiadrenal, blocks adrenal synthesis of estrogen
    • Raloxifene, used as chemoprevention in high risk women, will block estrogen receptor site in breast
  161. targeted therapy
    • drugs that target specific characteristics of cancer cells; does not harm norma,l healthy cells and has fewer side effects
    • trastuzumab (Herceptin)-monoclonal antibody that targets HER2/neu gene; combined with anthracyclines increases risk for cardiotoxicity
    • bevacizumab (Avastin) inhibits tumor growth by targeting the growth factor VEGF and stopping the formation of new blood vessels that are needed for nourishment
  162. Hormonal Therapy
    • reduce the estrogen available to breast tumors to stop or prevent their growth
    • Premenopausal women benefit from LH-RH agonists that inhibit estrogen synthesis; leupolide (Lupron) and goserelin (Zoladex) suppress the hypothalamus from making luteinizing hormone-releasing hormone
    • Selective Estrogen Receptor Modulators (SERMs) block the effect of estrogen in women who have estrogen receptor positive cancer; used as chemoprevention in women at risk; TAMOXIFEN taken for 5 years for risk reduction; s/e wt gain, hot flashes, endometrial cancer, thromboembolic events
    • Aromatase Inhibitors used in postmenopausal women by inhibiting the conversion of androgen to estrogen throught the action of the enzyme aromatase; s/e loss of bone density; monitor for osteoporosis; fulvestrant (Faslodex) is a second line hormonal therapy when others stopped working
  163. Drug Therapy for Breast Cancer
    • Chemotherapy-
    • Anthracyclines- doxorubicin (Adriamycin) epirubucin (Ellence)-inhibit DNA synthesis in susceptible cells
    • Taxanes-docetaxel (Taxotere), paclitaxel (Taxol) paclitaxel protein- bound (Abraxane)- inhibit microtubule network in rapidly dividing cells
    • Alkylating agents- cyclophosphamide (Cytoxan)-interfere with replication of susceptible cells
    • Antimetabolites- methotrexate (Mexate) fluorouracil (5-FU) capecitabine (Xeloda)- inhibit DNA synthesis and cellular replication in rapidly dividing cells
    • Targeted Therapy- trastuzumab (Herceptin)- selectively target critical steps in the processes required for tumor growth, viability, or invasion
    • Hormonal Therapy-
    • LH-RH agonists- goserelin (Zoladex) leuprolide (Lupron)-block release of LH and FSH, thereby preventing ovarian production of estrogen
    • selective estrogen receptor modulators (SERMs)- tamoxifen (Nolvadex) raloxifene (Evista)- bind to estrogen receptors; have both agonists and antagonist properties (selectively block action of estrogen in the breast but not in other organs)
    • Aromatase inhibitors- anastrozole (Arimidex) letrozole (Femara) exmestane (Aromasin) prevent conversion of adrenal and ovarian androgens to estrogens by inhibiting the aromatase enzyme
    • Estrogen receptor down-regulators- fulvestrant (Faslodex)- induce degredation of estrogen receptor


    Stem cell transplantation is also considered
  164. Nursing dx after mastectomy or lumpectomy
    • acute pain
    • anxiety
    • disturbed body image
    • ineffective therapeutic regimen management
    • impaired physical mobility
  165. Prostate Cancer
    • Men older than 65, African American Men and at an earlier age than other men
    • One of the slowest growing malignancies, metastasizes in predictable pattern
    • First symptoms related to bladder neck obstruction (trouble starting and stopping urine)
    • Prostate grows very rapidly, leading to noncancerous high grade prostatic intraepithelial neoplasia (PIN); most are adenocarcinomas and arise from epithelial cells located in the posterior lobe or outer portion of gland; spreads via nearby lymph nodes to bones (pelvis, sacrum, lumbar), lungs, and liver; dietary factors (high animal fat, low fiber, complex carbs) increase risk as well as having a vasectomy, exposure to environmental toxins
  166. Health Promotion
    • men should make an informed decision about whether to have prostate screening (start at 50), first degree relatives, African American men, age 65
    • Teach men to eat a healthy, balanced diet
  167. History
    age, race, ethnicity; problems with urination; drug hx; when symptoms first started (bladder outlet obstruction, difficulty starting urination, frequent urination, bladder infections, urinary retention); hematuria, nocturia; pain on intercourse; weight loss; sex hx, std, penile discharge, scrotal pain and swelling
  168. Assessment
    • gross blood in the urine (late); pain in the pelvis, spine, hips, or ribs; swollen lymph nodes; take and record weight; prepare pt for DRE (prostate is stony, hard, with palpable irregularities or indurations)
    • Assess reaction to dx; determine support system; tell him sexual dysfunction will depend on tx type; a dry climax may occur if prostate is removed
    • PSA is drawn before DRE; men <50 should be <2.5; normal is 4; African Americans have slightly higher value; elevated PSA should decrease a few days after a prostatectomy; early prostate cancer antigen (EPCA-2) may be a serum marker
    • transrectal ultrasound (TRUS) can be done and biopsy to confirm dx; CT of pelvis and abdomen and MRI to assess status of pelvic and para-aortic lymph nodes; advanced disease has elevated serum acid phosphatase; bone metastasis has elevated serum alkaline phosphatase levels
  169. Interventions
    • older asymptomatic men may choose observation (Expectant Therapy); factors to consider in choosing watchful waiting include potential side effects of treatment (urinary incontinence, ED), estimated life expectancy, risk of increased morbidity and mortality
    • Early stage may have TURP; specific management is based on the extent of the disease and pt condition
  170. Surgical Management
    MIS, open surgical technique, prostatectomy, TURP, bilateral orchiectomy, preop care; teach expectations and impotence

    Postop- hydration with IV therapy, wound drains, preventing emobli, preventing pulmonary complications, antibiotics, analgesics
  171. Care after a radical prostatectomy
    • Encourage pt to use PCA as needed; help the pt out of bed into a chair the night of surgery and ambulate the next day; maintain SCD until pt beings ambulation; monitor for DVT and PE; keep an accurate record of intake and output, including JP drainage or other drainage; keep the urinary meatus clean using soap and water; avoid rectal procedures or treatments; teach the pt how to care for the urinary catheter because he may be d/c with the catheter; teach pt how to use a leg bag; emphasize the importance of not straining during bm; advise to use suppositories or enemas; remind the pt about the importance of follow up appointments with the physician to monitor progress
    • Kegel exercises, erectile dysfunction; antispasmodic (Ditropan)
    • Complications are urinary incontinence and erectile dysfunction
  172. Nonsurgical Management
    • Radiation therapy (brachytherapy-seed therapy-can emit low dose radiation; never removed)
    • Hormonal Therapy-LH-RH agonist; antiandrogen drugs (fluramide, bicalutamid, nilutamide) inhibit tumor progression by blocking the uptake of testicular and adrenal androgens at the tumor site; may have hot flashes megestrol acetate may be prescribed
    • Chemo- cisplatin, etoposide are used
    • Others- high doses of ketoconazole to block androgen production and estrogen; can cause liver and adrenal problems; take on an empty stomach without histamine blockers and antacids; interacts with Coumadin, phenytoin, prednisone
  173. Testicular Cancer
    men ages 20-54; early detection by TSE and tx with combo chemo, testicular cancer can be cured; germ cell tumors arise from sperm producing cells; non germ cell tumors; most common is seminoma; TSE 1xmonth; painless lump, scrotal swelling, heavy scrotum
  174. Classification of Testicular Tumors
    • Germ Cell (Germinal) Tumors- Seminoma; nonseminoma (embryonal carcinoma, tertoma, choriocarcinoma)
    • Non Germ Cell (Nongerminal) Tumors- interstitial cell tumor; androblastoma

    Risk for tumors is higher in males with cryptorchidism or HIV
  175. Clinical manifestations
    • Painless lump, scrotal swelling, feeling of heaviness, dull ache or heavy sensation of lower abdomen
    • With metastasis- back pain, cough, dyspnea, hemoptysis, dysphagia
    • May be able to function sexually but not produce offspring
    • Watch for feelings of sexual inadequacy and support systems
  176. Lab Assessment
    • Serum Tumor Markers-
    • alpha-fetoprotein (AFP), beta human chorionic gonadotropin (hCG), lactate dehydrogenase (LDH); persistence markers after orchiectomy is evidence of metastasis; testosterone levels are increased if it affects the Leydig cells; alcohol and antiepileptic drugs can cause in increase in testosterone
    • Change in testis size, shape, texture- ultrasound can determine if mass is solid or fluid filled; CT to identify small metastatic lesions; lymphangiography to view lymph system; MRI enlarged lymph nodes and abnormal nodules that may indicate metastasis; CXR and bone scans if needed
  177. Testicular Self Exams (TSE)
    examine your testicles monthly immediately after a bath or a shower, when your scrotal skin is relaxed; examine each testicle by gently rolling it between your thumbs and fingers; testicular tumors tend to be deep in the center of the testicle; look and feel for any lumps; smooth, rounded masses; or change in the size, shape, or consistency of the testes; report any lump or swelling to the doc asap
  178. Interventions
    • oligospermia (low sperm) azoospermia (absence of living sperm) is common; teach pt about reproduction, fertility, and sexuality before tx; sperm banking before tx; assume role of pt advocate; discuss other options if sperm collection is not possible
    • Radiation can make men infertile; fertility problems
    • Surgery is the main treatment for testicular cancer
  179. Surgical Management
    • orchiectomy- offer support and reinforce teaching and what to expect; inform pt of problems
    • postop- observe, assess, and report complications (paralytic ileus), monitor vitals, pain, hydration, and pulmonary function for first 24 h; ambulate asap; teach to use incentive spirometer; assess patency of NG tube and urinary catheter (1-2 days)
  180. Nonsurgical Management
    • Chemo is adjuvant therapy for nonseminomatous testicular tumors or primary tx when there is metastatic disease (combos of bleomyciin, cisplatin, etoposide, vinblastine); HTN, hyperlipidemia, coronary artery disease, anemia, leukemia; external beam radiation for localized disease (sperm count returns to pretreatment level within 24-30 months after completion)
    • Pain at the incision site and psychsocial issues need to be addressed
  181. Potential for Metastasis
    surgical management; radial retroperitoneal lymph node dissection, orchiectomy; post op care is for pain from surgical incisions, immobility, injuries from invasive catheters or tubes
  182. Testicular Cancer Prevention
    Teach males to perform TSE 1xmonth and start talking about it at the start of puberty; need to be warm

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