med surge

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med surge
2010-07-17 23:09:15
pt cancer

ch 18
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  1. understanding cancer
    • new growth of abnormal tissue called neoplasms or tumors
    • carcimonas- cancer from epithelial cells
    • lyphoma- cancer from organs that fight infection
    • leukemias-cancer from organs that form blood
    • sacomas- cancer from connective tissue (like bone & muscle)

    • benign tumors- dont spread, grow large, but slower than malignat, usually dont cause death unless it impairs function of vital organs
    • malignant- undergo metastasis (spread), uncontrolled growth unless completly removed

    • carcinogenesis- process of melignant transformation
    • initiation- involves carcinogens, alters gentetic factors of DNA w/i cells
    • promotion- transforms genetic info so that cell starts to produce mutant cells
    • progression- malignant cells could invade adjacent tissue & metstasize

    carcinogenics- chemical, enviromental, dietary, viruses, defective genes, medically RX interventions
  2. diets that reduce risk of cancer
    • decrease red meats, processed meats that have nitrates & nitrates preservatives
    • increase servings of cruciferous vegetables ike broccoli, cabbage, caulliflower
    • increase fiber
    • decrease ft to 20-30% of total daily calories
    • increase foods w/ vit. A & C, like fruits & yellow & leafy green vegetables
    • reduce alcohol 2 more more than 2 drink daily 4 men, & 1 for women
  3. how immune system fights cancer
    • recognizes tumor-associated antigens
    • poduces macrophages & T lymphocytes that eliminates malignant cells
    • generating interferons
    • making antibodies
    • producing natural killers
  4. S/S
    • change in bowel habits or bladder infection
    • sores that dont heal
    • unusual bleeding or discharge
    • lumps on breast or other part of body
    • indigestion or difficulty swallowing
    • change of wart or mole
    • persistant cough or hoarsness

    SEE pg 215 box 18-2
  5. DX of cancer
    • tumor marker- checks for specific protiens, antigen, hormones, genes, & enzymes that cancer cells release
    • CBC (EX. could show anemia that caoulf come from colon cancer or occult blood in stool)
    • x-ray- uses contrast to see tumor in organs
    • CT- 3D- to see tumor density, location, shape, size, value
    • MRI- to differentiate diseases tissue from healthy & to study blood flow, help when tumor hidden by other structures
    • Nuclear scans- tracer injected, checking 4 hot spots/cold spots
    • ****PET- used in brain, ling, colon, liver, & pancrease
    • ****radioimmunocojugates- used in colorectal, breast, ovarian, head & neck, also 4 lymphomas, & melanomas
    • ultrasound- differentiate solid & cystic tumors of abd, breast pelvis, & heart
    • fluoroscopy- for moving body structures w/ continuous x-ray (ex. barium study)
    • biopsy- excise tissue, best method
    • frozen section- when tumor remove itz froze & cut, the DRthen decides what surgy needed
    • endoscopy- shines light thru specific body structure
    • cytology- microscopic exam, cells obtained by needle aspiration, scaping, brushing, sputum (ex. pap)
  6. stages of tumors
    • staging system referred as TNM
    • t- size, N-involement of lymph node, M- presence of metastasis
    • then simplified to
    • stage 0- in situ, no metastasis
    • stage 1,2,3- higher # means tumor is of greater size or spread to nearby lymph nodes/organs
    • stage 4- cancer invaded other organs

    • Well-differentiated- resemble more the tissue or origin
    • undifferentated- no resemblance
    • cell differentation graded from 1-4, higher the # less differentated, when poorly diffentiation graded @ 4- tumors aggressive & unpredicatable, dont respond to tx
  7. tx
    • surgery
    • radiation
    • chemotherapy
    • bone marrow transplant
    • stem cell transplant
    • immunotherapy
    • gene therapy
  8. surgery
    • depends on extent of disease, pathology, pt age, physical condition, anticipated result
    • when tumor confined & hasnt invaded other organs surgery is curative or called primary tx
    • when tumor cant b removed they remove as much as possibile itz called debulking or cytoreduction surgery
    • 2 types of excisions
    • local- tumor & healthy tissue removed
    • wide/radical- removes primary tumor, lymphnodes, & involved adjacent structures or surrounding tissue @ risk 4 metastasis

    • salvage surgery- when reoccurance of cancer, more extensive (lumpectomy-mastectomy)
    • prophylactic surgery- when hx of cancer
    • palliative surgery- ex. paracentisis, thoracentisis

    • surgical interventions-
    • cryosurgery-liquid nitrate to freeze tissue & desroys cells
    • electrosurgery- uses electric current to destroy cell
    • laser-vaporizes cells, destroying & sealing tissue
    • Mohs surgery(chemosurgery)- shaving off thin layer of skin, layer by layer until normal cells seen under micrscope
    • stereotatic surgery- single high dose of radiation, used 4 brain, head, & neck tumors
  9. Radiation
    kills both abnormal & normal cell, but kills abnormal faster

    • external radiation
    • kilovoltage therapy- superficial lesion
    • linear accelerators & betatron machines- high enegy x-ray, deeper tumors & spare damage to skin
    • gamma rays- high energy, 4 deeper structures
    • introoperative radiation therapy(IORT)- high-fraction single dose to exposed tumor, avoids radiation to skin & other tissue

    • internal radiation (brachytherapy)
    • high dose of radiation to specific tumor, not tissue around it
    • intersatitial or intracavitary cavitiy- use needle, seeds, cath, ribbons, capsules radiation
    • *intersatitial- inserted directly to tumor or tissue near like tumor head/neck
    • *intercavitary- placed directly into body cavity & applicator hold in place, when implany removed, noradioactivity left, when seeds left (prostate/brain cancer) the radioactivity decays takin wks-mon dependin on itz half-life, pt usually go home with it, but need to stay away from peeps few day, then vistors should stay for min & 6ft away

    • systemic/internal radiation- given sm. dose, orally, IV, or into bos cavity, could be excreted thru urine, feces, sweat, saliva
    • To reduce exposure- wash hand reg, flush several times, use differant eating utensils, wash laundry seperate, drink alot of fluids, avoid kissing & sex
  10. effects of raditation
    • aloplacia
    • erythema(local redness & inflammation of skin)
    • desquamation- shedding of epidermis
    • alterations of oral mucosa- stomatitis, xerostomia, change or loss of taste, decrease salivation
    • anorexia
    • nausea, diarrhea, vomiting
    • cystitis inflammation of bladder
    • pneumonits- inflammation of lungs
    • fatigue
    • myeosupression- depression of bone marrow function, leading 2 anemia, leukopenia, thrombocytopenia
  11. nursing interventions when recieving radiation
    • give info on safety of radiation (effect on tumor & side effects
    • teach pt about procedure
    • explain nutritional needs
    • teaching on care of mucous membrane
    • protecting skin from irritation
    • assess skin/mucous membrane 4 changes 2 tx areas (redness, tanning, peeling, itching, hairloss, dereased prespiratipion)
    • clean the pt skin w/ mild soap & tepid water
    • moisterize skin, lips
    • maintain intact oral mucous membrane
    • assess lesion (culture necessary)
    • monitor for signs bone marrow supression
    • assess 4 signs of bleeding
    • assess 4 signs of irradiation(cerebral edema, malabsorption,pleural effusion, pneumonitis, esophagitis, cystitis, urethritis)
    • encourage pt to talk about what emotions
    • inform that fatique is likly to happen, wear loss clothes
    • avoid extreme cold/heat, irritating soaps & shampoo
    • report oral pain, burning, open lesions, cant swallow, use non-alcoholic mouth wash, floss gently,
    • protect skin from sun exposure, chlorine, & wind
    • avoid hot drink/foods, alcohol, highly seasoned foods, acidic foods, tobacco
  12. chemotherapy
    • uses antineoplastic agents locally & systemically, prevents metastasizing, slows growth, relieves pain,
    • interfers w/ cellular function & reproduction

    • division of cells to daughter cells
    • *G1- growth phase where RNA & protien synthesis
    • *S phase- RNA synthesis complete & DNA synthesis occurs
    • *G2- anothr growh phase where DNA synthesis complete & cell mitosis starts
    • *M phase- mitosis/cell division takes place
    • *G0- dormant or resting phase, which can occur after mitosis & during G1 phase

    most chemotherapuetic agent affect S phase
  13. cell cycle-specific drugs & cell cycle-nonspecific drugs
    cell cycle-specific drugs- used 4 fast growing tumors b/c they attack cancer cells when they enter specific phase of reproduction

    Cell cycle-nonspecific drugs- effective in any phase, used 4 lrg, slow growing tumors, amount of drug more important then frequency, more prolonged effect on cells which leads to cells damages & distruction
  14. routes & devices 4 administration of chemo
    • oral, IV, IM, intraperitoneally, intra-arterially, topically, intrathecally, directly into cavity
    • dose bsed on pt total bod surface area before chemo response
    • monitor 4 extravasion when given IV, inspecting 4 tenderness, pain, swelling, & induration caused by vesicants,
    • PIC lines, PICC, & external cath(hickman cath, Broviac cath) & also implanted vascular acces device(IVAC) aka port
  15. Adverse reactions of chemo
    • affects fast growing cells like pithelial tissue, hair follicle & bone marrow
    • nausea, vomiting duing 1st 24hrs after chemo admin. give antiemetics to reduce effect
    • stomatitis & mouth soreness or ulcertion from destruction of epithelial cells
    • aloplecia
    • myelosupression
    • fatique
  16. safety measure when admin chemo
    • prepare in designated area
    • wear gloves, gowns
    • use Luer-lok fitting IV tubing used
    • dispose all equipment used
    • dispose all waste
  17. nursing mangemant when getting chemo
    • monitor symptoms of anaphylactic shock
    • Assess 4 electrolyte imbalance
    • prevent extravasion of vesicant drugs
    • assess 4 signs bone marrow supression
    • assess 4 bleeding & infection
    • monitor 4 signs of renal insufficiancy
    • ***elevated urine specific gravity
    • ***abnormal elelctrolyte values
    • ***low urine output <ml/hr
    • ***elevated b/p, BUN, serum creatinine
    • inform bout nasuea & vomitng
    • give antimetics before & during admin
    • assess oral mucosa for drying, redness, swelling, lesions, ulceration, viscous(sticky)saliva, white patches

    • outpt
    • keep all appt
    • what actions to take b/c of hair loss, usually grow back in 4-6mon, but diffrant color texture
    • diet- eat sm. frequent meals, slow, eat cool bland & liquids, avoid hot/very cold, foods high in fiber & fat, spicy & caffine
    • increase fluid 2500-3000ml/day
    • report high wt loss/gain, LOC, weakness, ataxia, parathesia, siezures, headache, muscle cramps/twitching, nausea, vomiting, diarrhea

    pt could suck on hard candy during chemo to reduced bitter/metallic taste
  18. bone marrow & peripheral blood stem cell tranplants
    • when cancer sensitie to high doses of chemo & radiation
    • stem cells refer to young immature cells called hematopoietic(blood forming) stem cells
    • used to replace bone marrow destroyed by cancer or cancer tx
    • new stem cells develope into healthy blood cells settling in bone marrow and producing new cells process called engraftment
    • adults stem cells obtained from bone marrow or peripheral blood
    • for children stem cells obtain from umbilical cord blood
  19. autogous stem cell transplant
    • comes from pt. either from bone marrow or blood
    • stem cells removed before tx and frozen to be reinfused after cancer treatment complete
    • pt. doesnt need immunosuppressant drugs
    • risk that tumor cells may be present in stem cells and blood may be tx with chemo before infusion
  20. allogeneic stem cells transplant
    • uses stem cells from doner whose tissue matches pt.
    • doner stem cells produce immune cells that can destroy any remaining cancer cells
    • engraftment may not occur
    • pt. prone to infection carried by doner
    • other risk is graft vs. host disease (gvhd)-doner cells make new cells that attack the pt.'s body
    • used for cancer effecting blood (leukemia and other bone marrow disorders)

    • reduced/intensity transplant a.k.a none- myelo avlative transplant or mini transplant
    • has lower doses of chemo/radiation
    • most effective in pt. whose disease is slow growning and less extensive
  21. syngeneic stem cell tranplantation
    • rare b/c only possible if pt. has identical twin
    • doesnt cause dvhd
    • however all cancer cells must be destroyed before transplantation b/c doner stem cells cant destroy remaining cancer cells
  22. nursing management for pt. getting stem cell transplantation
    • before procedure
    • asses physical condition organ function nutritional status complete blood studies (hiv,hep,CMV) and cycle social status
    • chemo and radiation
    • b/c stem cells takes long to multiply (2-6 weeks) has no way to fight infection
    • pt. @ risk for bleeding renal complications and liver damage

    • after
    • monitior pt. for 3 mon.
    • get blood counts back to normal may take 6/12 mon
    • infection DHVD possible
    • asses pt.'s cyclogical status (pt. gets mood swins and needs support)
  23. nursing management 4 pt. transplant
    • assess nutirtional status
    • monitor S/S of infection & renal insufficient, GVHD-irritability,pulmonary infiltration, hep, enlargment spleen& lymphnodes, anemia, sepsis, diarrhea, macularpaular rash, skin desquamation
    • special precaution(isolation)
    • assess w/ hygiene
    • review info rt prevention of infection, signs of rejection, importance of follow-up appt. med. regimen, meds info, dietary needs
    • encourage to discuss emotional needs
    • provide info on recovery & status recuperation
  24. Immunotherapy
    • uses pt own immune system
    • body's natural immunity, process of surveillance, recognition, & attack of foreign cells is a defence of cancer
    • purpose is 2 manipulate natural immune response by restoring, modifying, stimulating, or augmenting natural defenses
    • not used till after surgery, radiation, chemo hasnt worked

    • 3 types of immunotherapy
    • *non-specific- tx of local melonoma & bladder cancer, cytokines also stimulate immune sytem & inhibits growth, SIDE EFFECT- flu-like symptoms, GI disturbances, alopecia, low blood counts
    • *monoclonal antibody- to purge remainig tumor cells from blood or bone marrow, used in tx of hodgkins lymphoma, breast cancer, & some leukemias

    • cancer vaccines
    • for HPV
  25. hyperthermia
    • temp. greater then 106.7 to destroy tumor cells
    • heat in form of radio waves, ultrasound, microwaves, magnetic wav, hot water baths, hot wax
    • method for delivery is extracorporeal circulators, probes, infusion

    • reason for high temps.
    • *malignant cells cant repair self
    • *tumor cells lack blood supply to give the increased need 4 oxygen req. during hyperthermia
    • *hyperthermia stimuates immune system
    • *tumor blood vessels indequate 4 dispersing heat

    pt may get local burns & tissue damage, electrolyte imbalance, fatique, GI disturbance, & neuropathies
  26. photodynamic therapy (PDT)- porfimer
    • photoactive drug via IV
    • then laser light activates drug & destroy tumor cells, minimal damage to healthy tissue
    • req. pt to protect eyes, & skin from sunlight & bright indoor light 4 @least 30 days after getting porfimer,
    • if failure to comply pt may req. hospitalization to tx pain, dehydration, & local skin care
    • used for lung cancer
  27. Gene therapy
    • replacing altered genes w/ correct genes, inhibiting defective genes & introducing substance that destroys genes & cancer cells
    • used for tx of brain tumors, melanoma, & renal, breast, ovarian, lung, & colon cancer
  28. Apoptosis or "programmed cell death
    many types of cancer cells need a anti-cell-death molecule called (BCL-2) to survive
  29. phases of cancer drugs
    • phase 1- tx give to sm. group 2 determine doses, schedule, & toxicity
    • phase 2- tx given to lrg group, 2 check effectiveness w/ specific cancer & to get better info about dosing, side effects,
    • phase 3- if tx effective in phase 2 then larger group
    • phase 4- further testing & new tx 4 other uses, dosing, & toxicity

    • complimantary & alternative therapies
    • imagery, meds, special diet, spiritual approaches