Oncology

200

uncontrolled and unregulated growth of cells

77%

• Declining
• (except for Non-Hodgkin's Lymphoma- HIV, and skin cancers)

Non- Hodgkins Lymphoma (HIV)

Skin Cancers (from tanning)

2nd

• immune 
• (this is why people with HIV are so susceptible)

African Americans

11 million

Poor regulatory controls over proliferation and differentiation

Loss of Equilibrium (in a perfect world cell death should be = to cell growth)

Lack of respect for boundaries (between tissues)

Cells divide indiscriminately and haphazardly

Mutated cells continue to grow

The cancer cell has defective differentiation (it does NOT look like host tissue)

Cancer is graded by pathologist (how much it looks like "parent" cell)

The higher the grade of the cancer cell, the more unlike the normal cancer (more advanced) it is

• Something triggers cells to begin to change
• (radiation, genetics, chemicals, viruses...we don't really know)

Certain factors seem to encourage the growth of abnormal cells (dietary fats - colon cancer, obesity - breast cancer/ovarian cancer, smoking - lung cancer, alcohol - pancreatic/bladder cancer)

Colon

breast cancer/ovarian cancer

lung

Pancreatic and Bladder

• (not really clear)
• Increased growth of the tumor, increased invasiveness and metastasis. (Determines Staging)

• Carcinomas
• Sarcomas
• Leukemia and Lymphoma

Carcinomas

Sarcomas

Leukemia and Lymphoma

• Grades (1-4)
• (how much it looks like or doesn't look like the cells it was taken or metastisized from)

Grade 1

Grade 2

Grade 3

Grade 4

Extent of the Spread of the Cells

Stage 0

Stage 1

Stage 2

Stage 3

Stage 4

Cancer cells invade surrounding tissues and blood vessels

Cancer cells are transported by the circulatory system to distant sites

Cancer cells reinvade and grow and new location

(cancer spreads through the lymphatic system)

• T= Tumor
• -is there evidence of tumor? is it in situ? size? location

• N= Nodes
• -is there indication of cancer in the lymph nodes? in one region or throughout body?

• M= Metastasis
• -is there evidence of distant metastasis? (ie: testicular cancer in lungs)

• Mammograms
• Prostate stimulating antigen
• Colonoscopy (men over 50)

• False Assurance
• "with"

Change in Bowel or Bladder habits

Sore that doesn't heal

Unusual bleeding or discharge

Thickening or lump in breast or elsewhere

Ingestion or difficulty in swallowing

Obvious change in wart or mole

Nagging cough or hoarseness

Bloating and indegestion

Normal Screenings (PAP, mammograms, PSA, colonoscopy)

Examination of abnormal cells via biopsy

Law work (CBC, liver function, pancreatic enzymes, tumor markers like CA-125 ovarian cancer, PSA, BRCA 1 gene breast cancer)

Radiology Studies (x-rays, CT, MRI, PET)

Endoscopic exams (Colonoscopy, Upper GI, Cystoscopy)

Bone marrow biopsy (if hematopoietic cancer suspected)

100,000 (normal is 5,000-10,000)

blood in urine (even microscopically)

• Cure
• Control (if it can't be cured, it can be maintained for long periods of time)
• Palliation (relief and control of sx)

To remove tumor while sparing as much normal tissue as possible

CLEAR MARGINS (re-suctioning until all cancer cells are gone)

Debulking (removal of as much tumor as possible, even if it all cannot be removed for risk of damaging vital tissue...makes chemo and radiation more effective because it has less cancer to attack)

Done to assure QOL and preserve body image

*can be done for cure, control, or palliation

To provide systemic therapy

Used for Most Solid Tumors and Hematologic Cancers!!

Can be done for cure, control or palliation

Cellular

Cell-cycle specific, non-specific

To maximize effectiveness and attack at different stages of the cell cycle

Central Venous Access Device

*Because many chemo agents are vesicants and will cause local tissue breakdown and necrosis if there is infiltration (extravagation )

Extravagation: Local tissue breakdown and necrosis if infiltration occurs


**STOP CHEMO IMMEDIATELY IF THERE IS ANY PAIN

straight to the tumor

metastasis on the lining of the peritoneal cavity

Intra-bladder chemo (chemo sits directly in bladder for a while to target the specific area)

Ommaya Reservoir

Rapidly Dividing

It cannot tell the difference in a fast-growing cancer cell and fast growing cells of hair follicles, GI lining, or bone marrow

Localized

The delivery of high energy beams generates free radicals which break chemical bonds in DNA to where cells can't replicate

Permanently Damaged

Maximal tolerated dose

Rapidly growing normal cells are also damaged by radiation (hair, GI, blood cells)

Local reactions to skin

Redness and irritation can develop 1-24 hours after first dose

Usually dry, red, itchy, sore skin

If the rate of cellular sloughin is faster than the ability of new epidermal cells to replace dead cells, wet desquamation occurs with weeping of serous fluid

Protect skin from temperature extremes

No tight clothing, no rubbing, no chemicals or deoderants

Lubricate with approved lotion only! (aloe vera)

biologic and targeted therapy

• cell proliferation
• (some inhibit enzymes for cell growth and some prevent new blood vessel development in a tumor)

Can kill cancer cells with less damage to normal cells

Interferon (leukemia, melanoma, kidney, ovarian, multiple myeloma)

Rituxin (NHL and chronic leukemia)

Avastin (colorectal, lung cancer, breast)

Interferon

Rituxin

Avastin

Hematopoietic Stem Cell Transplant

when tumors have developed resistance or failed to respond to standard doses of chemo

By Bone Marrow from a donor (surgery) 

OR

Stem cells can be removed from blood through a separator machine

Harvesting

CURE...or long, long remission

10 days before the transplant

Infusing new healthy cells "rescues" the damaged bone marrow through the engraftment and subsequent normal proliferation of healthy cells

• Allogenic- given by donor (risk of rejection)
• Synegeneic- identical twin (no rejection)
• Autologous- pt's own stem cells (if no suitable donor can be found)

Allogenic

Synegeneic

Autologous

Blood counts are taken down to 0

• Keep Environment sterile
• --Sepsis is BIGGEST risk
• --Pt is critically ill
• --Bleeding is large risk

Watch for Graft vs Host Disease! (occurs when T-Lymphocytes from donated marrow recognize the recipient as foreign and begin to attack skin, liver, GI)

Biggest risk is SEPSIS

Bleeding

Graft vs Host Disease

Graft vs Host disease

50%

Massage therapy reduces cancer patient's pain and anxiety

Massage is perfectly fine for pt who enjoys it...it is worthwhile if the pt feels better and if they feel like it improves QOL

Acupunture reduces nausea, vomiting and pain from cancer

Although the evidence conflicts, it appears that accupunture does reduce pain and n/v ...with low risk interventions like acupuncture, some experts believe that the importance of a perceived benefit may trump clinical benefit

Engaging in physical activity such as walking, running, or recreational sports can improve cancer survival

CONFIRMED! The evidence showing that regular moderate-vigorous exercise improves survival for men and women diagnosed with range of cancers is compelling

Cutting sugar out of one's diet will stop a tumor from growing

Unconfirmed for a potential anticancer effect from eliminating sugar, but it's important to minimize excess sugar intake as a part of maintaining a generally health diet

Consuming antioxidant supplements may protect against cancer and prevent tumor growth

Busted for supplements, though it is plausible that antioxidants from food may be beneficial, supplemental vit E actually INCREASES  the risk of PROSTATE CANCER!!!! Supplemental A, C, E and beta-carotene actually increases overall mortality in esophageal, gastric, colorectal, pancreatic and liver cancers

Reiki can diminish cancer pain and stress

Busted, but harmless if it increases an individual's sense of well-being

Medication "mindfulness" diminishes anxiety, stress, and depression in cancer patient

Confirmed for diminishing anxiety, stress and depression in people with cancer

• Anemia and Fatigue
• (fatigue can also be due to pain meds, pain, lack of sleep)

Heart works harder when there are too few RBC

Feel weak, tired, heart pounding, SOB, dizzy

•Rest, limit activities (do just what is necessary)

•Accept help from family and friends

•Well-balanced diet with plenty of calories and proteins

•Stand up slowly

• •EPOGEN (ProCrit) to stimulate bone
• marrow to produce more RBCs

•Blood transfusions only if symptoms of anemia are severe

Anorexia and Malnutrition

• Nausea
• Mouth/Throat pain
• Metallic Taste (from medications and cancer cells dying)

•Teach importance of eating

•Nutrient Density!

•5-6 small meals/day

•Use plastic utensils (helps prevent metal taste)

•Do something active

•Milkshakes or smoothies, juice or soup even if no solids

BLEEDING

*thrombocytopenic precautions

•Brush teeth with baby toothbrush (hot water on bristles)

•Blow nose very gently

•Be careful using scissors or knives

•Use electric razors only

•Apply pressure for 5 minutes on any cut or stick

•Loose, comfortable shoes

•NO dental floss or toothpicks

•NO tampons, rectal temps, enemas, suppositories

•Notify if unexplained bruising

NUMEGA

Constipation

Drink at least 8 cups of liquid/day

Warm liquids may stimulate peristalsis

Be as active as possible

High fiber foods (whole grains and cereals, dried beans, peas, raw veggies, fresh and dried fruits, nuts, seeds)

May need stool softeners or laxatives

Observe for distention, bowel sounds, firmness

Keep close track of bowel movements

Diarrhea

• 5-6 small meals/day
• Foods high in salts and potassium to  replace what is lost

8-12 cups of fluid while diarrhea is present

LOW fiber foods (bananas, white rice, white toast, plain yogurt, chicken, cooked cereals, cottage cheese, eggs, noodles, canned fruits)

Meds like Immodium may be needed

Alopecia

2-3

The best time to get a wig is right before chemo begins (insurance will pay, or there are wig banks)

Many people cut/shave their own hair to have control

Protect tender scalp = hat, turban, sunscreen

May feel colder than normal with no hair

Sleep on satin pillow case- less friction than cotton

Experiment with hats, scarves, extra make-up

Neutropenia

Infection

Strict Handwashing

Use sanitizing wipes to clean surfaces you touch (phone, TV remote, ATM, elevator buttons)

Be gentle when wiping after bowel movement (baby wipes)

Stay away from people who are sick with colds, flu

Stay away from children with drippy noses or who have had "live" vaccines (polio, chicken pox)

Stay away from crowds

Be careful not to cut/nick yourself (shaving or washing dishes)

Check temp ever day  and notify if over 100.5

• DO NOT TAKE TYLENOL, IBUPROPHEN, or ASPIRIN WITHOUT TALKING TO HEALTH CARE PROVIDER (ie: liver pt with tylenol, low plt count patient with aspirin)
• Watch for infection around port

Good mouth care with soft tooth brush

Skin Care (esp feet)...gently pat skin dry

Clean cuts right away

Be careful of animal waste products (liter box, fish tanks, bird cages)

No flu shot or other vaccines without MD

Keep hot foods hot, cold foods cold

NO fresh, unwashed foods (SALADS!)

Beware of undercooked fish, seafood, meat, chicken or eggs

Watch expiration dates on food or drinks

No standing water!!! (pseudomonas)

No plants (flowers have cirratia???)

Neupogen

Mouth Sores, Increased sensitivity to hot/cold, infections of gums or teeth or tongue, changes in taste and smell (dry mouth)

See Dentist BEFORE starting chemo and get all necessary dental work done 

Check mouth and tongue every day looking for sores

Keep mouth moist (water, ice, sugar-free candy or gum)

Alcohol-free mouth wash or warm water, baking soda, and salt (BIOtene)

Choose foods that moist, soft, easy to chew and swallow

Soften foods with gravy, sauces, broth yogurt

Avoid Citrus

Avoid foods that may scrape mouth (chips)

1 hour before each chemo and for a few days after

Bland foods and drinks (crackers, toast, gelatin)

Plan when it's best to eat/drink (5-6 small meals)

Do not drink a lot during meals

Do not lie down after eating

Cold foods are better tolerated (no odor)

Allow fizz to leave carbonated drinks

Small bites of popsicles or fruit ices

Suck on sugar-free mints or tart candies (not if mouth is sore)

Deep Breathing, cold cloth on head/neck

zofran, compazine, decadron > for nausea

Zofran, Compazine, Decadron

Tingling, burning, weakness, numbness, feeling cold, pain when walking, soreness, achy muscles, being clumsy and losing balance, shaking/rambling, "chemo confusion"

Avoid falls (walk slowly, handrails, no-slip bath mats, rubber soled shoes)

Extra rest

Antidepressants may help

50%

80-90%

Pain

Inadequate pain assessment

Vital Signs, Patient Behaviors

on a regular schedule (not PRN)

Do not skip doses because the pt "looks" okay

Pain

Oxycodone

Percocet

Changes in hormone levels

Decrease blood supply to penis

Vaginal dryness/early menopause

Fatigue decreases interest in sex

Physical changes make men/women feel unattractive

Stress importance of NOT GETTING pregnant

Vaginal creams, Water based lubricants, Encourage open communication, Explore new ways to show love, Encourage counseling with psychologist, social worker, marriage counselor, sex therapist

Leukemia

Fatal

"Blasts"

"blasts"

WBC and bone marrow exam (WBC will be over 100,000)

"Induction Chemotherapy"

Induction Chemotherapy

Consolidation Chemo and possibly bone marrow transplantation

Hodgkin's Lymphoma

2/3

Epstein-Barr Virus or HIV

Quiet

• Little weight loss
• Low grade temp
• Fatigue
• Weakness
• Chills
• Night Sweats

lymph node biopsy, bone marrow exam, CT

• Chemo ALWAYS
• Radiation if confirmed to small area

90%

B or T lymphocytes

HIV

Infection

Multiple Myeloma

• Skeletal Pain
• (pelvis, spine, ribs)

Vertebral destruction leads to collapse of vertebrae, spinal cord compression

Pathological Fractures

Hypercalcemia (causes neurologic, renal, GI probs)

Changes in LOC, Constipation, Elevated BUN

(neuro, renal, GI probs)

Anemia, Thrombocytopenia, Neutropenia

• Bone marrow biopsy
• X rays (bone erosion, thinning, or fractures)

Hydration (want 1-2 liters of urine/day)...diuretics may be given

Allopurinol

Advanced

90%

Throat Cancer

Oral Cancer

Hoarseness "lump in my throat"

Visualization 

CT to see local and regional spread

Biopsy to confirm

Head and neck is rich in blood supply and lymph nodes

Radiation to the exact area...if it has spread, use Chemo

Surgery to remove cancer (laryngeal cancer surgery always requires at least a temporary tracheostomy)

temporary or permanent tracheostomy

Radial Neck Dissection

• AIRWAY!!!!! (tracheostomy)
• Suction as needed-- very bright blood the first 24-48 hours

Unable to eat/drink for a while after surgery

Speech therapy to help swallowing

Tube feedings until swallowing is easier

Hydration with IV

Elevate HOB to prevent aspiration

Jackson-Pratt Tube will be in place so blood from deep muscles can escape

Saliva may be decreased or absent...INCREASE fluid intake, sugarless gum/candy and always have water bottle

Artificial larynx for communication

How to communicate with pt once they have a trach

Inform everyone on unit that pt will not be able to talk at first and to GO into room

Put pt in room near nursing station

Lung Cancer

Smoking

Chronic Cough, Blood in Sputum, Pneumonitis

Anorexia, Fatigue, Weight Loss

Difficulty breathing if tumor is large or encroaches on bronchi

Hoarseness

Routine chest x-ray

CT scan- tumor enlargement

PET scan- "hot spots"

Surgical resection if stage 1 or 2 (only 30-50% survival rate at 5 years)

Radiation

Chemo or Biologic Therapy (avastatin)

Ineffective airway clearance

Ineffective Breathing patterns

Anxiety

Acute Pain

Imbalanced Nutrition

Liver Cancer

50-60

20%

Liver

Cirrhosis, Hepatomegaly, Splenomegaly, Jaundice, Weight loss, peripheral edema, Ascites, RUQ pain, anorexia

• Ultrasound
• CT
• MRI
• Biopsy

RIGHT SIDE!

Surgical resection (15%)

Liver Transplant (only if metastasis hasn't occurred)

Radiofrequency ablation (thin needle inserted into core of tumor and electrical energy destroys cells)

Cryoablation (liquid nitrogen)

Chemo (slows progress)

Chemoembolization-- cath is placed in artery going to tumor site

4-7 months

•4th leading cause of death. Risk increases with age, smoking

•Adenocarcinomas, arising from epithelial cells of ductal system

•Common bile duct gets obstructed and jaundice occurs (usually the first symptom)

•Majority of times the cancer has metastasized by the time of diagnosis, and death between 5-12 months later

•Five year survival rate is just 5%

•Jaundice, anorexia, rapid weight loss, pruritis, unrelenting pain

Diagnosed by ultrasound and CT

•Resection of proximal pancreas, adjoining duodenum, distal stomach, and distal common bile duct.

•Anastamosis of the pancreatic duct, common bile duct, and stomach to the jejunum

•Very difficult surgery and requires ICU stay for monitoring of fluid status and bleeding

•Biggest danger is pancreatic enzymes eating into suture material

•Radiation not usually helpful except maybe to relieve pain

•Chemo not very effective

•Nursing diagnoses:  Pain and alteration in nutrition

•3rd most common cancer, 2nd leading cause of death

•No symptoms until disease is advanced

• •85% arise from polyps which could be seen on colonoscopy.  Polyp can invade and
• penetrate the muscular wall of the colon; tumor cells then have access to regional lymph nodes and vascular system

•90% in people over age 50.  Colonoscopy should be done at age 50 and every 10 years after

•Stool check for occult blood should be done every year

•Surgical resection of the colon will be done; may require colostomy

Chemo if metastasis, biologic therapy with Avastin

•Usually begins as a papillomatous growth within the bladder

•Risk factor is smoking.  More common in men 60-70

•Microscopic or gross, painless hematuria is most common clinical finding

•Urinalysis can determine cancer cells.  CT and ultrasound

•Staging is determined by the depth of invasion of the bladder wall

•80% are superficial (inside lining of the bladder only)

• •Treat with BCG (weakened strain of mycobacterium bovis)…it activates the
• immune system to kill the cancer.  Instill via foley, let it dwell.  Done every other week for 3-6 months

•If bladder wall is invaded, partial or total cystectomy with urinary diversion (see page 1155 of your book)

•One in every 5 men will develop prostate cancer in their lifetime.  75% of cases are in men over 65.  Often slow-growing

• •Prostate cancer is androgen-dependent.  Can spread by direct extension, through
• pelvic lymph system or through blood

•Bone is most common site of metastasis

•Asymptomatic in early stage, or perhaps BPH symptoms

•PSA is recommended along with digital rectal exam every year in men 50 and older

•Radical prostatectomy, external radiation, or internal radiation (seeds or high dose brachytherapy)

•Side effects of surgery or radiation:  impotence and incontinence

•Hormone deprivation therapy may be done to block the effects of testosterone on the cancer

•Osteoporosis, loss of muscle mass, erectile dysfunction, hot flashes, gynocomastia are side effects

•Chemo is given only to men with hormone-refractory prostate cancer in late stages

• •Nursing diagnoses: 
• Decisional conflict related to numerous alternative treatment options,
• sexual dysfunction, anxiety related to possible sexual and urinary dysfunction
• and incontinence

•Most common cancer in men 15-34.  Usually the right testicle

•Painless lump in the testicle with sometimes scrotal swelling and feeling of heaviness.  Non-tender, firm

•Diagnosed with ultrasound of testicle.  Blood may show increased levels of AFP. 

•Testicular self-exam every month starting at puberty!

•Orchiectomy with regional lymph node removal.  Chemo and radiation if metastasis

•Fertility is an issue…cryopreservation of sperm should be discussed

•Due to repeated injury to the cervix over years.  Strong relationship between HPV and cervical cancer

•Peak incidence is in women in their early 30’s

•Thin, watery discharge is often the first sign, then spotting

•PAP tests should be done within the first 3 years of the first sexual intercourse, but no later than 21

•Colposcopy (exam of the cervix with binocular microscope along with a biopsy)

•Cone biopsy (cores out the cervix; maintains fertility)

•Cryotherapy (freezing the bad tissue)

• •Loop Electrosurgery Excision Procedure (LEEP) removes superficial cervical
• tissue and allows more comprehensive exam of the cells

•Vaccine against HPV (Gardasil and Cervarix) for 18-26 year olds

•If invasive, hysterectomy

• •Most common gyn malignancy.  Low
• mortality because it’s usually diagnosed early.

•Survival rate is 95%

•Major risk factor is unopposed estrogen (without progesterone).  Also increasing age, nulliparity, late menopause, obesity

• •Arises from lining of endometrium.  Hyperplasia occurs when estrogen is not
• counteracted by progesterone

•If invasion of the myometrium occurs, regional lymph nodes can become involved.  Usual sites of metastasis are lung, bone, liver, brain

•First sign is uterine bleeding.  Diagnosed by endometria biopsy

•Hysterectomy may result in total cure

•5th leading cause of cancer death in women.  Usually advanced at time of diagnosis.  Most often 55-65 when diagnosed

•Metastasizes by shedding malignant cells which may implant on the uterus, bladder, bowel, and omentum.  Also metastasizes by lymphatic spread

•Symptoms are vague in early stages…accumulation of fluid (ascites) causes abdominal distention. Also pelvic pain, bloating, urinary frequency, difficulty eating or feeling full quickly.  Diagnosis may be delayed as GI causes are ruled out

• •Bimanual pelvic exams should be done to identify presence of an ovarian mass. 
• Post-menopause, ovaries should not be palpable

•Diagnosed by abdominal or transvaginal ultrasound.

•There is a tumor marker (CA-125) which is positive in 80% of women with ovarian cancer.  This test is useful in monitoring the course of the disease

•Treatment:  total abdominal hysterectomy with bilateral salpingo-oophorectomy and debulking

• •IV chemo and/or intraperitoneal chemo and radioisotopes if metastasis to peritoneal
• cavity

•The most common malignancy in women (except skin cancer)

•Second only to lung cancer as leading cause of death

•Can also occur in men (2,000 cases every year)

•Currently 2.5 million women in the US have survived breast cancer

•5 year survival rate in women with localized breast cancer and no node involvement is 98%!

• •Risk factors: 
• family history, estrogen obesity, sendentery life style, increasing age, hormone replacement with just estrogen

•Mutations in the BRCA1 gene may cause as many as 10-40%

• •Most arise from the epithelial lining of the milk ducts.  May be “in situ” (just inside the
• duct) or invasive (grown through the duct and into tissue)

• •Lump or abnormality on mammogram.  Most often the cancer is in the upper outer
• quadrant of the breast.  If palpable,
• usually hard and may be irregularly shaped, poorly delineated, non-mobile and
• non-tender

•Diagnosed with mammogram, ultrasound or CT or MRI of the breast to see lymph nodes and possible metastases

•Lymph node involvement is the most important prognostic factor

•Biopsy determines the grade of the cancer and also if cells are hormone sensitive or not

•Survival rates are about the same for modified radical mastectomy or lumpectomy with radiation

•In surgery, the sentinel lymph node is removed and pathologist looks at it while the patient is in the OR.  If cancer cells are present, then 12-20 axillary nodes are removed

• •Lymphedema (accumulation of
• lymph fluid in soft tissue) can occur as a result of the excision of lymph
• nodes.  When axillary nodes cannot return
• lymph fluid to the central circulation, fluid accumulates in the arm, causing
• obstructive pressure on the veins and venous return (swelling, heaviness, pain,
• impaired motor function, numbness in fingers and hand)

•Lumpectomy…removal of the entire tumor along with a margin of normal surrounding tissue. Radiation to the entire breast with a boost to the tumor bed

•Modified radical mastectomy---removal of the breast and axillary nodes but preserves the pectoralis major muscle.  Done if the tumor is too large to excise with good margins

•Women have the option of breast reconstruction immediately following mastectomy, or it can be delayed until post-op recovery is complete

•Lifetime follow-up with mammograms, monthly BSE

•Radiation can be given traditionally or high dose brachytherapy (see Mammo-site, page 1318)

• •Chemo is sometimes given before surgery to decrease the size of the primary tumor and possibly allow less extensive surgery.  Combo chemo and bone marrow transplant
• possible

• •Hormone therapy…if cancer cells are estrogen receptor positive, meds like Tamoxifen (Nolvadex) can block the
• source of estrogen, thus promoting tumor regression

•Biologic and targeted therapy:  HERCEPTIN is a monoclonal antibody.  It attaches to antigens in breast cancer cells and is taken into the cells and eventually kills them.  AVASTIN (angiogenesis inhibitor)

•Pain management (most pain is from lymph node removal)

•Jackson-Pratt tubes are left in place

•Restoring the affected arm to full function is an important goal (to prevent contractures and muscle shortening as well as lymphatic stagnation)

•After surgery, gently flex the arm on a pillow to provide elevation

•Begin wiggling fingers, moving wrist and elbow slightly even in PACU

•Progressive increases in arm activity and exercises (but medication must be given 30 minutes before!)

•Goal is full ROM within 4-6 weeks

•Never leave the arm dependent (prop even when sleeping)

•No BP or venipuncture or injections in the affected arm

•Instruct to protect arm from even minor injury

•“Decongestive therapy” with massage may be done if lymphedema is severe

•Jobst stocking-type sleeve may be worn for compression

•Chemotherapy infiltration/extravasation

•Superior vena cava syndrome

•Hypercalcemia

•Tumor lysis syndrome

•Inappropriate ADH Secretion Syndrome

•Spinal cord compression

•Septic shock

•Cardiac tamponade

•Pleural effusion


•***See pages 294-295 in textbook

The lungs for adventetious sounds and signs of interstitial edema (ACS)

• Vasoactive
• ***Should never be stopped abruptly
• ***V/S monitored every 15 min

• 3000
• (enteral nutrition is preferred)

• Antacids
• H2 Blockers (Pepcid and Zantac)
• PPI (Prevacid and Nexium)