What should be done when there is an obstruction in a chest tube and why?
Milk the tube, never strip due to pressure changes
When is it normal to find bleeding in a chest tube?
Only with a hemothorax
Is tidaling normal with a chest tube?
Yes, on respirations
What does it mean when there is no longer tidaling with a chest tube?
That the tube is ready to be taken out
Is constant bubbling with a chest tube good or bad?
Bad
Is crepidous supposed to be at the chest tube site?
No, but usually resolves back into the body
What is crepidous?
Air bubbles in the subcutaneous tissue surrounding chest tube site
How should a chest tube be observed for any issues?
From the patient to the machine
What is the first thing the nurse should do if she suspects any issues with a patients chest tube?
Make sure the chest tube connections are secure
What are the steps to a self breast exam?
Step 1: Lie down and place left arm behind head (lying down spreads breast tissue evenly)
Step 2: Use finger pads of 3 middle fingers on your right hand to feel for lumps in the left breast. Use overlapping dime-sized circular motions to feel breast tissue. Light, medium, and firm pressure to feel each layers. (A firm ridge on the curve of each breast is normal)
Step 3: Move around breast in a vertical pattern at an imaginary straight line down your side from the underarm.
Respect for right breast.
Step 4: Stand in front of mirror and tighten pectoral muscles for any redness, lumps, shapes, or scaliness near nipples.
Step 5: Examine each underarm for and knot, or thickening tissue
What prevents lymphedema?
Exercise, healthy diet (health maintenance)
Treatment for lymphedema?
Healthy diet, exercise, compression stockings, good skin/nail care, decongestive therapy, elevate extremity, isometric exercises
What are neutropenic precautions?
Avoid fresh fruits/veggies, no fresh flowers, good hand hygiene (infection prevention)
Signs and symptoms of thrombocytopenia?
Most patients are asymptomatic, but s\s include bleeding (mucosal or cutaneous), bruising, petechiae, purpura, and s\s of hemmorhaging.
Adverse affects of chemo/radiation?
Nausea, vomiting, anorexia, diarrhea, skin breakdown, reproductive dysfunction, nephrotoxicity, neuropathy, anemia
Fatigue management for chemo?
Encourage moderate exercise as tolerated, encourage rest when fatigued but to continue to maintain lifestyle patterns as much as possible while pacing activities to energy level, and reassure that fatigue is a common side affect
Stages of cancer?
1-Initiation
2-Promotion-Can be reversed with lifestyle changes.
3-Latent
4-Progression
Initiation stage
Injury to DNA, genetic changes.
Promotion stage
Proliferation, reversible (lifestyle changes can reduce risk)
Latent stage
Tumor present, no evidence of cancer
Progression stage
Tumor has own blood supply, increased growth rate, invading surrounding cells, metastases
Are all side effects of chemo instant?
No, can be latent for a few days to a week
Proper PPE for nurse administering chemo?
Gloves, gown, and mask
Proper skin care for a patient on radiation therapy?
Aloe or lotion without perfume, metal, alcohol, or additives. No heating pads or ice packs. Frequent skin assessments.
S\S of adverse affects of IV chemo?
Painful, red, swollen, or blistered IV site.
Primary prevention for cancer?
Lifestyle changes, healthy diet, exercise, smoking cessation.
Secondary prevention for cancer?
Screenings (breast/testicle self exam, Pap smear, PSA)
What is an important nursing intervention for a patient with a mastectomy
No BP or injections on the side with mastectomy, and elevate arm to help with flow of lymph due to the risk of lymphedema
Characteristics of benign tumors?
slow steady growth, remains localized, contained within a capsule, crowds normal tissue, rarely fatal, rarely reoccurs after removal, movable when palpated
A patient is receiving chemo, which lab result would mean the patient should be put on neutropenic precautions?
WBC
The nurse is teaching a nursing student about the stages of cancer development. Which statement by the student indicates a need for further teaching?
1.The promotion stage includes strategies for preventing cancer.
2.Progression indicates that abnormal cells are being produced at the same rate as normal cells without stopping.
3.The event that begins the initiation stage is when the DNA in a cell is damaged or altered
Progression indicates that abnormal cells are being produced at the same rate as normal cells without stopping.
A patient is being treated with chemotherapy for breast cancer. The patient’s meal tray was just delivered. What foods would the nurse remove from the tray?
1.Roast beef with gravy
2.Salad with ranch dressing
3.Steamed vegetables
4.Chocolate cake
Salad with ranch dressing
A patient is being treated with chemotherapy for breast cancer. What lab test would the nurse evaluate to determine if there is concern for spontaneous bleeding?
1.White blood cell count
2.Hemoglobin
3.Basophil count
4.Platelet count
Platelet count
Which genetic marker indicates that a patient may be at an increased risk of breast and/or ovarian cancer?
BRCA1/BRCA2
Anatomical site classifications of cancer
Carcinoma-skin, glands, mucous membranes.
Sarcoma-muscle, connective tissue, bone, and fat.
Lymphoma/leukemia-Originate in blood.
Cancer Staging
Stage 0-Cancer in situ-localized cells with no threat of metastasis.
Stage 1-Limited local growth-limited to tissue of origin.
Stage 2-Limited local spread.
Stage 3-Extensive local and regional spread.
Stage 4-Metastasis.
TNM classification
T-Tumor size and invasiveness.
N-Spread to lymph nodes.
M-Metastasis.
CAUTION
C-changes in bowel/bladder habits.
A-A sore that doesn’t heal.
U-Unusual bleeding or discharge.
T-Thickening or a lump in breast or elsewhere.
I-Indigestion or difficulty swallowing.
O-Obvious changes in wart or mole.
N-Nagging cough or hoarseness.
Thrombocytopenia
Platelet count <50,000.
DELAYED TOXICITY caused by chemotherapy, may cause bleeding and hemorrhage. Pt should avoid straining, platelet transfusion may be needed.
Caused by radiation to head and neck and chemo
Mucousitis, Stomatitis, Esophagitis
Delayed effects of chemotherapy
Occur 2 hours to months after treatment. Include: alopecia, mucousitis, neurotoxicity, thrombocytopenia, bone marrow suppression, neutropenia, anemia, fatigue that interferes with normal daily living, nausea, vomiting diarrhea.
Acute toxicity
Occurs during or immediately after chemo administration. Usually anaphylactic or hypersensitivity reaction. Nausea, vomiting, and heart dysrhythmias are anticipated.
Cell cycle phase specific chemo
Attacks cells in proliferation stage to reduce spread of cancer.
Cell cycle phase non-specific
Will attack any area of cell proliferation, in any cell cycle.
Breast cancer screening guidelines
Consistent monthly self breast exams starting at age 20.
Age 45-54-annual mammograms.
Age 55 and older, mammograms every 2 years.
Clinical manifestations of lung cancer
Early signs-nagging cough, mild to severe chest pain, dyspnea.
Late signs-anorexia, vomiting, cardiac tamponade, dysrhythmias.
Non-small cell lung cancer (NSCLC)
a group of lung cancers that includes squamous cell carcinoma (slow progression), adenocarcinoma (moderate progression), and large cell carcinoma (rapid progression).
Small cell lung cancer (SCLC)
Very rapid progression, most malignant form of lung cancer. Spreads via lymph and blood with frequent metastasis to the brain. Radiation and chemo may be used to shrink tumor and make breathing easier.
Tamoxifen
Used for treatment of breast cancer, can precipitate thromboembolism/pulmonary embolism-monitor closely. May cause irregular vaginal bleeding and decreased visual acuity. Pt should report vision changes. Females with history of DVT should avoid smoking and oral contraceptives.
Pneumothorax
Complication of lung cancer, may require chest tube.
Radical mastectomy (Halsted mastectomy)
Removal of breast tissue, nipple, lymph nodes, muscles are left in tact. Increased risk for lymphedema. Assess cap refill, brachial and radial pulses, monitor pain and skin color.
Lactated Ringers (LR)
If prescribed for patients with liver issues/psorosis-call Dr. to verify order. Monitor closely.
A confused patient recently began an antidiuretic, what actions should the nurse take?
Offer water frequently, monitor mucous membranes.
Letrazole (Femara)
May cause osteoporosis, pt. should take vitamin D/calcium supplement.
The diet for stomatitis
Soft foods, neutral or cool temp-avoid very hot and very cold foods. Avoid spicy foods and strong spices.
Diet for cachexia (malnutrition) with non small cell lung cancer
High protein, high calorie.
Kubler-Ross stages of grief
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
Hyoscine (scopolamine)
Used sublingually to decrease drooling in hospice patients.
Cheyne-Stokes respirations
An irregular pattern of breathing characterized by alternating rapid or shallow respiration followed by slower respiration or periods of apnea.
Highest priority symptoms to manage for dying patient:
Pain, agitation, nausea.
Solu-Medrol (Methylprednisolone) side effects
Potassium loss, weight gain/fluid retention, insomnia.
Physical manifestations at end of life
Cheyne Stokes respirations, decreased sensation, irregular pulse, mottling skin/wax like appearance, wet/noisy respirations.
Goals of palliative care
- Provide relief from symptoms including pain.
- Offer support to the family during illness and bereavement.
- Regard dying as normal process. 4. Support holistic patient care and quality of life.
- Support patients to live as actively as possible until death.
- Affirm life and neither hasten nor postpone death.
Cancer Grading
Grade I-cells differ slightly from normal cells are are well differentiated.
Grade II-cells are more abnormal and are moderately differentiated.
Grade III-cells are very abnormal and are poorly differentiated.
Grade IV-cells are immature and undifferentiated; cell of origin is difficult to determine.
Platelets (thrombocytes)
150,000-400,000
white blood cell count
5,000-10,000
Hemoglobin (Hgb)
12-18
What are the differences of cancer in men than women?
-More men than women die from cancer-related deaths each year.
-Mortality rate from lung cancer is higher in men (26%.)
-Cancer with the highest incidence among men is prostate cancer (19%.)
-Men are more likely to develop liver cancer.
-Head and neck cancers occur more often in men.
What are the differences of cancer in women than men?
-Cancer with the highest death rate among women is lung cancer (25%.)
-Cancer with the highest incidence among women is breast cancer (30%.)
-Thyroid cancer is more prevalent in women.
-Women are less likely to have colon cancer screenings.
What does it mean if a tumor has a Grade I Histologic rating?
Cells differ slightly from normal cells (mild dysplasia) and are well differentiated (low grade.)
What does it mean if a tumor has a Grade II Histologic rating?
Cells are more abnormal (moderate dysplasia) and moderately differentiated (intermediate grade.)
What does it mean if a tumor has a Grade III Histologic rating?
Cells are very abnormal (severe dysplasia) and poorly differentiated (high grade.)
What does it mean if a tumor has a Grade IV Histologic rating?
Cells are immature, primitive (anaplasia), and undifferentiated; cell of origin is hard to determine (high grade.)
What does it mean if a tumor has a Grade X Histologic rating?
Grade cannot be assessed.
What does a Stage 0 cancer indicate?
Cancer in situ.
What does a Stage I cancer indicate?
Tumor limited to the tissue of origin; localized tumor growth.
What does a Stage II cancer indicate?
Limited local spread.
What does a Stage III cancer indicate?
Extensive local and regional spread.
What does a Stage IV cancer indicate?
Metastasis (spread of the cancer to a distant site.)
What should you teach patients and the public about cancer prevention and early detection?
-Limit alcohol use.
-Get regular physical activity (e.g., 30 minutes or more of moderate physical activity 5 times weekly.)
-Maintain a normal body weight.
-Have regular physical examinations.
-Obtain regular colorectal screenings.
-Avoid cigarette smoking and other tobacco use.
-Get regular mammography screening and Pap tests.
-Be familiar with your own family history and risk factors for cancer.
-Obtain adequate, consistent periods of rest (at least 6 to 8 hours per night.)
-Use sunscreen with a sun protection factor of 15 or higher. Avoid the use of tanning beds.
-Eliminate, reduce or change the perception of stressors and enhance the ability to effectively cope with stress.
-Eat a balanced diet that includes vegetables and fresh fruits, whole grains, and adequate amounts of fiber. Reduce dietary fat and preservatives, including smoked and salt-cured meats with high nitrate concentrations.
What are the warning signs of cancer?
-Change in bowel or bladder habits.
-A sore that does not heal.
-Unusual bleeding or discharge from any body orifice.
-Thickening or a lump in the breast or elsewhere.
-Indigestion or difficulty in swallowing.
-Obvious change in a wart or mole.
-Nagging cough or hoarseness.
What are some problems caused by chemotherapy and radiation therapy?
-Hyperuricemia
-Cardiotoxicity
-Pericarditis and Myocarditis
-Fatigue
-Anorexia
-Constipation
-Diarrhea
-Hepatotoxicty
-Nausea and Vomiting
-Stomatitis, Mucositis, and Esophagitis
-Hemorrhagic Cystitis
-Nephrotoxicity
-Reproductive Problems
-Anemia
-Leukopenia
-Thrombocytopenia
-Alopecia
-Chemotherapy-Induced Skin Changes
-Radiation Skin Changes (dry to moist desquamation)
-Cognitive Changes (“chemo brain”)
-Intracranial Pressure
-Peripheral Neuropathy
-Pneumonitis
What are some examples of oncologic emergencies?
-Spinal Cord Compression
-Superior Vena Cava Syndrome (SVCS)
-Third Space Syndrome
-Hypercalcemia
-Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
-Tumor Lysis Syndrome (TLS)
-Cardiac Tamponade
-Carotid Artery Rupture
What are the manifestations of Superior Vena Cava Syndrome?
-Facial edema, periorbital edema
-Distention of veins of head, neck, and chest
-Headache- seizures
-Mediastinal mass on chest x-ray
What are factors that affect how patients cope with cancer?
-Ability to cope with stressful events in the past.
-Ability to express feelings and concerns.
-Age at the time of diagnosis.
-Attitude associated with the cancer.
-Availability of significant other.
-Disruption of body image.
-Extent of disease.
-Past experiences with cancer.
-Symptoms.
In the TNM Classification System, what does TX indicate?
Tumor cannot be measured.
In the TNM Classification System, what does T0 indicate?
No evidence of primary tumor (tumor cannot be found.)
In the TNM Classification System, what does Tis indicate?
Tumor in situ, meaning only malignant cells only within superficial layer of tissue; no extension into deeper tissue.
In the TNM Classification System, what does T1/T2/T3/T4 indicate?
A description of primary tumor based on size and/or invasion into nearby structures; the higher the T number, the larger the tumor and/or the more it has grown into nearby tissues.
In the TNM Classification System, what does NX indicate?
Nearby lymph nodes cannot be evaluated.
In the TNM Classification System, what does N0 indicate?
No evidence of cancer cells in regional lymph nodes.
In the TNM Classification System, what does N1/N2/N3 indicate?
A description of size, location, and/or number of lymph nodes involved; the higher the N number, the more extensive the lymph node involvement.
In the TNM Classification System, what does MX indicate?
Metastasis cannot be evaluated.
In the TNM Classification System, what does M0 indicate?
No evidence of metastasis can be found.
In the TNM Classification System, what does M1/M2/M3/M4 indicate?
A description of extent of metastasis; the higher the M number, the more extensive the metastasis.
What is palliative care?
A holistic approach to care or treatment that focuses on reducing the severity of disease symptoms, rather than trying to delay or reverse the progression of the disease itself or provide a cure.
What are the goals of palliative care?
-Regard dying as a normal process.
-Provide relief from symptoms, including pain.
-Affirm life and neither hasten nor postpone death.
-Support holistic patient care and enhance quality of life.
-Offer support to patients to live as actively as possible until death.
-Offer support to the family during the patient’s illness and in their own bereavement.
What are the main goals of hospice care?
To assist the patient to live as fully and comfortably as possible while dying with dignity.
What is the major difference between palliative care and hospice care?
Palliative care allows a person to simultaneously receive curative and palliative treatments.
When does hospice care become an option?
When the physician determines a person has 6 months or less to live and that person or health care proxy decides to forgo curative treatments.
What are the goals of end of life care?
-Provide comfort and supportive care during the dying process.
-Improve quality of the patient’s remaining life.
-Help ensure a dignified death.
-Provide emotional support to the family.
What are the physical manifestations at end of life related to the cardiovascular system?
-Increased heart rate, later slowing and weakening of pulse
-Irregular rhythm
-Decreased BP
-Delayed absorption of drugs given IM or subcutaneously
What are the physical manifestations at end of life related to the gastrointestinal system?
-Slowing or cessation of GI function (may be enhanced by pain-relieving drugs)
-Gas accumulation
-Distention and nausea
-Loss of sphincter control, producing incontinence
-Bowel movement before imminent death or at time of death
What are the physical manifestations at end of life related to the integumentary system?
-Mottling on hands, feet, arms and legs
-Cold, clammy skin
-Cyanosis of nose, nail beds, knees
-“Waxlike” skin when very near death
What are the physical manifestations at end of life related to the musculoskeletal system?
-Gradual loss of ability to move
-Sagging of jaw resulting from loss of facial muscle tone
-Difficulty speaking
-Swallowing becoming more difficult
-Difficulty maintaining body posture and allighment
-Loss of gag reflex
-Jerking seen in patients on high doses of opioids
What are the physical manifestations at end of life related to the respiratory system?
-Increased respiratory rate
-Cheyne-Stokes respiration
-Inability to cough or clear secretions resulting in grunting, gurgling, or noisy congested breathing (death rattle or terminal secretions)
-Irregular breathing, gradually slowing down to terminal gasps (may be described as guppy breathing)
What are the physical manifestations at end of life related to the sensory system?
-Hearing usually last sense to disappear
-Blurring of vision
-Sinking and glazing of eyes
-Blink reflex absent
-Eyelids stay half-open
-Taste and smell become decreased with disease progression
-Decreased sensation of pain and touch
What are the physical manifestations at end of life related to the urinary system?
-Gradual decrease in urine output
-Incontinence of urine
-Inability to urinate
What are the psychosocial manifestations at end of life?
-Altered decision making
-Anxiety about unfinished business
-Decreased socialization
-Fear of loneliness
-Fear of meaninglessness of one’s life
-Fear of pain
-Helplessness
-Life review
-Peacefulness
-Restlessness
-Saying goodbyes
-Unusual communication
-Vision-like experiences
-Withdrawal
What are the five stages in the Kubler-Ross Model of Grief?
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
What might a person say while in the Denial stage of grief?
“No, not me, it cannot be true.”
What might a person say while in the Anger stage of grief?
“Why me?”
What might a person say while in the Bargaining stage of grief?
“Yes me, but…”
What might a person say while in the Depression stage of grief?
“Yes me, and I am sad.”
What might a person say while in the Acceptance stage of grief?
“Yes me, but it is okay.”
How does the nurse manage an individual’s psychosocial needs at the end of their life?
-Encourage the dying person and family to share their feelings of sadness, loss, forgiveness and to touch, hug, cry. Allow the patient and family privacy to express their feelings and comfort one another.
-Assess spiritual needs. Allow patient to express his or her spiritual needs.
-Encourage visit by appropriate spiritual care service provider, chaplain, or family member.
-Encourage the family to talk with and reassure the dying person.
-Affirm the dying person’s experience as a part of transition from this life.
-Converse as though the patient were alert, using a soft voice and gentle touch.
How does the nurse provide postmortem care?
-Close the patient’s eyes and jaw.
-Replace dentures, remove jewelry and eyeglasses.
-Wash the body as needed then apply a clean gown and bed linen.
-Place a waterproof pad or incontinence brief to absorb urine and feces.
-Comb and arrange the hair neatly.
-Remove tubes and dressings if appropriate.
-Straighten the body, placing the arms at their sides or across the abdomen with palms down.
-Place a pillow under the head.
What are the goals of treatment for Inflammatory Bowel Disease?
-Rest the bowel
-Control the inflammation
-Combat infection
-Correct malnutrition
-Provide symptomatic relief
-Improve quality of life
What types of diagnostic assessments would you perform if a patient has IBD?
-History and physical examination
-CBC, erythrocyte sedimentation rate
-Serum chemistries
-Testing of stool for occult blood and infection
-Capsule endoscopy
-Radiologic studies with barium contrast
-Sigmoidoscopy and/or colonoscopy with biopsy
What type of diet should a person with IBD be on?
High calorie, high vitamin, high protein, low residue, lactose free (if lactase deficiency.)
What are the assessment findings related to Ulcerative Colitis?
-Anorexia
-Weight loss
-Malaise
-Abdominal tenderness and cramping
-Severe diarrhea that may contain blood and mucus
-Malnutrition, dehydration, and electrolyte imbalances
-Anemia
-Vitamin K deficiency
What are the assessment findings related to Crohn’s Disease?
-Fever
-Cramp-like and colicky pain after meals
-Diarrhea (semisolid), which may contain mucus and pus
-Abdominal distention
-Anorexia, nausea and vomiting
-Weight loss
-Anemia
-Dehydration
-Electrolyte imbalances
-Malnutrition (may be worse than that seen in ulcerative colitis)
What are the differences of lung cancer in men compared to women?
-Men have a 1 in 15 chance of developing lung cancer (smokers and nonsmokers.)
-Men are diagnosed with lung cancer more than women.
-More men die from lung cancer more than women.
-Male smokers are 10 times more likely to develop lung cancer than nonsmokers.
-Lung cancer incidence and deaths are decreasing in men.
What are the differences of lung cancer in women compared to men?
-Women have a 1 in 17 chance of developing lung cancer (smokers and nonsmokers.)
-Lung cancer incidence and deaths are increasing in women.
-Women develop lung cancer after fewer years of smoking than men.
-Women develop lung cancer at a younger age than men.
-Nonsmoking women are at greater risk for developing lung cancer than nonsmoking men.
-Women with lung cancer live, on the average, 12 months longer than men.
What is the most common symptom that is reported first if someone has lung cancer?
A persistent cough.
What are the assessment findings related to lung cancer?
-Cough
-Wheezing, dyspnea
-Hoarseness
-Hemoptysis, blood-tinged or purulent sputum
-Chest pain
-Anorexia and weight loss
-Weakness
-Diminished or absent breath sounds, respiratory changes
What type of diagnostic assessments would you perform if a patient has lung cancer?
-History and physical examination
-Chest x-ray
-Bronchoscopy
-Cytologic study of bronchial washings or pleural space fluid
-Transbronchial or percutaneous fine-needle aspiration
-CT scan, MRI, PET
-Mediastinoscopy
-Video assisted thoracoscopic surgery (VATS)
What are the risk factors for breast cancer?
-Age 50 years or older
-Alcohol use
-Benign breast disease with atypical epithelial hyperplasia, lobular carcinoma in situ
-Early menarche (before age 12), late menopause (after age 55)
-Exposure to ionizing radiation
-Family history
-Female
-Full term pregnancy after age 30, nulliparity, no breastfeeding
-Genetic factors (BRCA1, BRCA2, P53, PTEN, PALB2, ATM, CHEK2, NBM)
-Hormone use
-Long term heavy smoking
-Personal history of breast, colon, endometrial, or ovarian cancer
-Physical inactivity
-Weight gain and obesity after menopause
What are the assessment findings related to breast cancer?
-Mass felt during BSE (usually felt in the upper outer quadrant, beneath the nipple, or in axilla)
-Presence of lesion on mammography
-A fixed, irregular nonencapsulated mass; typically painless except in the late stages
-Asymmetry
-Blood or clear nipple discharge
-Nipple retraction or elevation
-Skin dimpling, retraction, or ulceration
-Skin edema or peau d’orange skin
-Axillary lymphadenopathy
-Lymphedema of the affected arm
-Symptoms of bone or lung metastasis in late stage
What is Euthanasia?
The deliberate act of hastening death.
What is Physician-Assisted Suicide?
The physician provides the means and/or information about how the patient can commit suicide.
What is Palliative Sedation?
The use of medications to intentionally produce sedation to relieve intractable symptoms and distress in a patient who is imminently dying.
What is the Principle of Double Effect?
A principle that regards it morally permissible to give a medication that has the potential for harm if it is given with the intent of relieving pain and suffering and not intended to hasten death.
What are the common adverse effects of Letrozole?
Musculoskeletal pain and nausea. Other reactions include headache, arthralgia, fatigue, constipation, dyspnea, cough, vomiting, diarrhea, and hot flashes. It can also cause osteoporosis, fractures, and rarely thromboembolism.
What are the common adverse effects of Tamoxifen?
Hot flashes, fluid retention, vaginal discharge, nausea, vomiting, and menstrual irregularities. In women with bone metastases, tamoxifen may cause transient hypercalcemia and a flare in bone pain. Because of its estrogen agonist actions, tamoxifen poses a small risk of thromboembolic events, including deep vein thrombosis, pulmonary embolism, and stroke. The biggest concern is endometrial cancer.
What is the 1st stage of cancer development?
Initiation, which involves a mutation in the cell’s genetic structure.
What is the 2nd stage of cancer development?
Promotion, which is characterized by the reversible proliferation of the altered cells.
What is the 3rd (last) stage of cancer development?
Progression, which is characterized by increased growth rate of the tumor, increased invasiveness, and metastasis.
When does Acute toxicity occur?
During and right after drug administration. It includes anaphylactic and hypersensitivity reactions, extravasation or a flare reaction, anticipatory nausea and vomiting, and dysrhythmias.
What is involved in Chronic toxicities?
Damage to organs, such as the heart, liver, kidneys and lungs. Chronic toxicities can be either long term effects that develop during or right after treatment and persist or late effects that are absent during treatment and manifest later.
What is cachexia?
A complex, multifactorial syndrome characterized by anorexia and/or unintended loss of weight and appetite. It is accompanied by generalized tissue wasting, skeletal muscle atrophy, immune dysfunction, and metabolic problems.
cellular regulation
all functions carried out within a cell to maintain homeostasis, including its responses to extracellular signals and the way each cell produces an intracellular response
proliferation
reproduction of new cells through cell growth and cell division
Differentiation
process that progresses from a state of immaturity to a state of maturity
protooncogenes
normal cell genes that are important regulators of normal cell processes
oncogens
mutation of protoocogenes, which then induce tumors. oncogenic viruses cause genetic alterations and mutations that allow the cell to express the abilities and properties it had in fetal development and may lead to cancer
carcinogens
agents that cause cancer can be chemical radiation or viral
BRCA1
BRCA2 (tumor suppressor genes)
alterations in these genes increase a persons risk for breast and ovarian cancer
APC gene (tumor suppressor gene)
alterations in this gene increase a persons risk for familial adenomatous polyposis, which is a precursor for colorectal cancer
p53 (tumor suppressor gene)
mutations of this gene MANY cancers
bladder
breast
colorectal
esophageal
liver
lung
ovarian cancers
three stages of the development of cancer
initiation
promotion
progression
initiation (first stage of the development of cancer)
involves a mutation in the cells genetic structure
mutation
any change in the usual DNA sequence
promotion (second stage of development of cancer)
reversible proliferation of the altered cells
latent period
includes both the initiation and promotion stages in the history of cancer
progression (final stage of development of cancer)
characterized by increased growth rate of tumor,increased invasiveness, and metastasis
metastasis
spread of cancer to a distant site
tumor angiogenesis
process of the formation of blood vessels within the tumor itself
most frequent sites of metastasis
lungs, brain, bone, liver, and adrenal glands
immunologic escape
process by which cancer cells evade the immune system
cancer stage 0
cancer in situ
cancer stage I
tumor limited to the tissue of origin:localized tumor growth
cancer stage II
limited local spread
cancer stage III
extensive local and regional spread
cancer stage IV
metastasis
TNM classification system
Primary tumor (T)
Regional Lynph nodes (N)
Distant Metastases (M)
seven warning signs of cancer
CAUTION
change in bowel or bladder habits
a sore that does not heal
unusual bleeding or discharge from any body orifice
thickening of a lump in the breast or elsewhere
indigestion or difficulty in swallowing
obvious change in a wart or mole
nagging cough or hoarseness
prevention and early detection of cancer
limit alcohol use
get regular physical activity
maintain normal body weight
obtain regular colorectal screenings
avoid cigarette smoking and other tobacco use
get regular screening and pap tests
use sunscreen with a sun protection factor of 15 or higher
practice healthy dietary habits, such as reducing fat consumption, avoid eating processed meats, and increasing fruit and vegetable consumption
goals of cancer treatment
cure
control
palliation
teletherapy
external beam radiation, most common
brachytherapy
close or internal radiation treatment, implantation or insertion of radioactive materials directly into the tumor, or in close proximity of the tumor
immunotherapy
uses the immune system, biologic therapy
targeted therapy
interferes with cancer growth by targeting specific cell receptors and pathways that are important in tumor growth
cancer cachexia
wasting syndrome, is a complex, multifactorial syndrome characterized by anorexia and/or unintended loss of weight and apetite
oncologic emergencies
life threatening emergencies that can occur as a result of cancer or cancerhormome treatment, these emergencies can be obstructive, metabolic or infiltrative
pain assessment in cancer patients
location
intensity
quality
pattern
relief measures
palliation
relieves pain
relieve obstruction
improve sense of well being
control
breast cancer
non hodgkins lympjome
small cell lung cancer
ovarian cancer
cure
burkitts lymphoma
wilms tumor
neuroblastomaacute lymphoctic leukemia
hodgkins lymphoma
testicular cancer
chemotherapy (antineplastic therapy)
is the use of chemicals as a systemic therapy for cancer
biopsy
removal of a tissue sample for pathologic analysis
benign neoplasms
well differentiated
malignant neoplasms
range from well differentiated to undifferentiated
the ability of malignant tumor cells to invade and metastasize is the major difference between benign and malignant neoplasms
carcinoma in situ (CIS)
refers to a neoplasm whose cells are localized and show no tendency to invade or metastasize to other tissues
what defect of cellular proliferation is involved in the development of cancer?
indiscriminate and continuous proliferation of cells with loss of contact inhibition
A patient is admitted with acute myelognous leukemia and a history of Hodgkins lymphoma, what is the nurse most likely to find n patients history?
alkylating agents for treating the hodgkins lympjoma
what is the name of a tumor from the embryonal mesoderm tissue of origin located in the anatomic site of the meninges that has malignant behavior?
meningeal sarcoma
which condition would be most likely to be cured with chemotherapy as a treatment measure?
neuroblastoma
nitrosoureas
cell cycle phase- non specific, break the DNA helix, and cross the blood brain barrier
antimetabolites
cell cycle phase- specific drugs that mimic essential cellular metabolites to interfere with DNA synthesis
mitotic inhibitors
cell cycle phase-specific drugs that arrest mitosis
antitumor antibiotics
cell cycle phase- non specific but bind with DNA to block RNA
bladder cancer treatment?
intravesical regional chemotherapy is administered into the bladder via a urinary catheter
leukemia treatment?
IV chemotherapy
osteogenic sarcoma treatment?
intraarterial chemotherapy via vessels supplying tumor
metastasis to the brain treatment?
intraventricular or intrathecal chemotherapy via an ommaya reservoir or lumbar punctures
metastasis from a primary colorectal cancer treatment?
intraperitoneal regional chemotherapy
intrathecal chemotherapy administration is used for?
spinal cord or the brain
intraarterial chemotherapy administration is used for?
tumors to specific vessels
What should be done when there is an obstruction in a chest tube and why?
Milk the tube, never strip due to pressure changes
When is it normal to find bleeding in a chest tube?
Only with a hemothorax
Is tidaling normal with a chest tube?
Yes, on respirations
What does it mean when there is no longer tidaling with a chest tube?
That the tube is ready to be taken out
Is constant bubbling with a chest tube good or bad?
Bad
Is crepidous supposed to be at the chest tube site?
No, but usually resolves back into the body
What is crepidous?
Air bubbles in the subcutaneous tissue surrounding chest tube site
How should a chest tube be observed for any issues?
From the patient to the machine
What is the first thing the nurse should do if she suspects any issues with a patients chest tube?
Make sure the chest tube connections are secure
What are the steps to a self breast exam?
Step 1: Lie down and place left arm behind head (lying down spreads breast tissue evenly)
Step 2: Use finger pads of 3 middle fingers on your right hand to feel for lumps in the left breast. Use overlapping dime-sized circular motions to feel breast tissue. Light, medium, and firm pressure to feel each layers. (A firm ridge on the curve of each breast is normal)
Step 3: Move around breast in a vertical pattern at an imaginary straight line down your side from the underarm.
Respect for right breast.
Step 4: Stand in front of mirror and tighten pectoral muscles for any redness, lumps, shapes, or scaliness near nipples.
Step 5: Examine each underarm for and knot, or thickening tissue
What prevents lymphedema?
Exercise, healthy diet (health maintenance)
Treatment for lymphedema?
Healthy diet, exercise, compression stockings, good skin/nail care, decongestive therapy, elevate extremity, isometric exercises
What are neutropenic precautions?
Avoid fresh fruits/veggies, no fresh flowers, good hand hygiene (infection prevention)
Signs and symptoms of thrombocytopenia?
Most patients are asymptomatic, but s\s include bleeding (mucosal or cutaneous), bruising, petechiae, purpura, and s\s of hemmorhaging.
Adverse affects of chemo/radiation?
Nausea, vomiting, anorexia, diarrhea, skin breakdown, reproductive dysfunction, nephrotoxicity, neuropathy, anemia
Fatigue management for chemo?
Encourage moderate exercise as tolerated, encourage rest when fatigued but to continue to maintain lifestyle patterns as much as possible while pacing activities to energy level, and reassure that fatigue is a common side affect
Stages of cancer?
1-Initiation
2-Promotion-Can be reversed with lifestyle changes.
3-Latent
4-Progression
Initiation stage
Injury to DNA, genetic changes.
Promotion stage
Proliferation, reversible (lifestyle changes can reduce risk)
Latent stage
Tumor present, no evidence of cancer
Progression stage
Tumor has own blood supply, increased growth rate, invading surrounding cells, metastases
Are all side effects of chemo instant?
No, can be latent for a few days to a week
Proper PPE for nurse administering chemo?
Gloves, gown, and mask
Proper skin care for a patient on radiation therapy?
Aloe or lotion without perfume, metal, alcohol, or additives. No heating pads or ice packs. Frequent skin assessments.
S\S of adverse affects of IV chemo?
Painful, red, swollen, or blistered IV site.
Primary prevention for cancer?
Lifestyle changes, healthy diet, exercise, smoking cessation.
Secondary prevention for cancer?
Screenings (breast/testicle self exam, Pap smear, PSA)
What is an important nursing intervention for a patient with a mastectomy
No BP or injections on the side with mastectomy, and elevate arm to help with flow of lymph due to the risk of lymphedema
Characteristics of benign tumors?
slow steady growth, remains localized, contained within a capsule, crowds normal tissue, rarely fatal, rarely reoccurs after removal, movable when palpated
A patient is receiving chemo, which lab result would mean the patient should be put on neutropenic precautions?
WBC
The nurse is teaching a nursing student about the stages of cancer development. Which statement by the student indicates a need for further teaching?
1.The promotion stage includes strategies for preventing cancer.
2.Progression indicates that abnormal cells are being produced at the same rate as normal cells without stopping.
3.The event that begins the initiation stage is when the DNA in a cell is damaged or altered
Progression indicates that abnormal cells are being produced at the same rate as normal cells without stopping.
A patient is being treated with chemotherapy for breast cancer. The patient’s meal tray was just delivered. What foods would the nurse remove from the tray?
1.Roast beef with gravy
2.Salad with ranch dressing
3.Steamed vegetables
4.Chocolate cake
Salad with ranch dressing
A patient is being treated with chemotherapy for breast cancer. What lab test would the nurse evaluate to determine if there is concern for spontaneous bleeding?
1.White blood cell count
2.Hemoglobin
3.Basophil count
4.Platelet count
Platelet count
Which genetic marker indicates that a patient may be at an increased risk of breast and/or ovarian cancer?
BRCA1/BRCA2
Anatomical site classifications of cancer
Carcinoma-skin, glands, mucous membranes.
Sarcoma-muscle, connective tissue, bone, and fat.
Lymphoma/leukemia-Originate in blood.
Cancer Staging
Stage 0-Cancer in situ-localized cells with no threat of metastasis.
Stage 1-Limited local growth-limited to tissue of origin.
Stage 2-Limited local spread.
Stage 3-Extensive local and regional spread.
Stage 4-Metastasis.
TNM classification
T-Tumor size and invasiveness.
N-Spread to lymph nodes.
M-Metastasis.
CAUTION
C-changes in bowel/bladder habits.
A-A sore that doesn’t heal.
U-Unusual bleeding or discharge.
T-Thickening or a lump in breast or elsewhere.
I-Indigestion or difficulty swallowing.
O-Obvious changes in wart or mole.
N-Nagging cough or hoarseness.
Thrombocytopenia
Platelet count <50,000.
DELAYED TOXICITY caused by chemotherapy, may cause bleeding and hemorrhage. Pt should avoid straining, platelet transfusion may be needed.
Caused by radiation to head and neck and chemo
Mucousitis, Stomatitis, Esophagitis
Delayed effects of chemotherapy
Occur 2 hours to months after treatment. Include: alopecia, mucousitis, neurotoxicity, thrombocytopenia, bone marrow suppression, neutropenia, anemia, fatigue that interferes with normal daily living, nausea, vomiting diarrhea.
Acute toxicity
Occurs during or immediately after chemo administration. Usually anaphylactic or hypersensitivity reaction. Nausea, vomiting, and heart dysrhythmias are anticipated.
Cell cycle phase specific chemo
Attacks cells in proliferation stage to reduce spread of cancer.
Cell cycle phase non-specific
Will attack any area of cell proliferation, in any cell cycle.
Breast cancer screening guidelines
Consistent monthly self breast exams starting at age 20.
Age 45-54-annual mammograms.
Age 55 and older, mammograms every 2 years.
Clinical manifestations of lung cancer
Early signs-nagging cough, mild to severe chest pain, dyspnea.
Late signs-anorexia, vomiting, cardiac tamponade, dysrhythmias.
Non-small cell lung cancer (NSCLC)
a group of lung cancers that includes squamous cell carcinoma (slow progression), adenocarcinoma (moderate progression), and large cell carcinoma (rapid progression).
Small cell lung cancer (SCLC)
Very rapid progression, most malignant form of lung cancer. Spreads via lymph and blood with frequent metastasis to the brain. Radiation and chemo may be used to shrink tumor and make breathing easier.
Tamoxifen
Used for treatment of breast cancer, can precipitate thromboembolism/pulmonary embolism-monitor closely. May cause irregular vaginal bleeding and decreased visual acuity. Pt should report vision changes. Females with history of DVT should avoid smoking and oral contraceptives.
Pneumothorax
Complication of lung cancer, may require chest tube.
Radical mastectomy (Halsted mastectomy)
Removal of breast tissue, nipple, lymph nodes, muscles are left in tact. Increased risk for lymphedema. Assess cap refill, brachial and radial pulses, monitor pain and skin color.
Lactated Ringers (LR)
If prescribed for patients with liver issues/psorosis-call Dr. to verify order. Monitor closely.
A confused patient recently began an antidiuretic, what actions should the nurse take?
Offer water frequently, monitor mucous membranes.
Letrazole (Femara)
May cause osteoporosis, pt. should take vitamin D/calcium supplement.
The diet for stomatitis
Soft foods, neutral or cool temp-avoid very hot and very cold foods. Avoid spicy foods and strong spices.
Diet for cachexia (malnutrition) with non small cell lung cancer
High protein, high calorie.
Kubler-Ross stages of grief
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
Hyoscine (scopolamine)
Used sublingually to decrease drooling in hospice patients.
Cheyne-Stokes respirations
An irregular pattern of breathing characterized by alternating rapid or shallow respiration followed by slower respiration or periods of apnea.
Highest priority symptoms to manage for dying patient:
Pain, agitation, nausea.
Solu-Medrol (Methylprednisolone) side effects
Potassium loss, weight gain/fluid retention, insomnia.
Physical manifestations at end of life
Cheyne Stokes respirations, decreased sensation, irregular pulse, mottling skin/wax like appearance, wet/noisy respirations.
Goals of palliative care
- Provide relief from symptoms including pain.
- Offer support to the family during illness and bereavement.
- Regard dying as normal process. 4. Support holistic patient care and quality of life.
- Support patients to live as actively as possible until death.
- Affirm life and neither hasten nor postpone death.
Cancer Grading
Grade I-cells differ slightly from normal cells are are well differentiated.
Grade II-cells are more abnormal and are moderately differentiated.
Grade III-cells are very abnormal and are poorly differentiated.
Grade IV-cells are immature and undifferentiated; cell of origin is difficult to determine.
Platelets (thrombocytes)
150,000-400,000
white blood cell count
5,000-10,000
Hemoglobin (Hgb)
12-18