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NUR2392/NUR 2392 Multidimensional Care II Exam 1 Study Guide 2024 QUESTIONS AND ANSWERS ALL ANSWERS 100% CORRECTLY VERIFIED GRADED A+.
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Multidimensional Care II Exam 1 Study Guide *The exam questions are not limited to only what is listed on this guide, please refer to your chapter readings and module materials Ch. 21: Principles of Cancer Development ● Benign vs. Malignant cells ○ Benign: ■ Specific Morphology- they resemble the tissue they originated from (they look like the host). ■ Small Nuclear to Cytoplasmic Ratio- they have a similar structure inside the cell to normal cells and small nucleus. ■ Specific Function- they contribute to the body in some way. ■ Tight Adherence- they bind close together. ■ No Migration- they do not move around the body or invade other tissue sites. ■ Orderly Growth-they grow at a normal rate. ■ Euploidy- they have a normal amount of chromosomes per cell. ○ Malignant (Cancer): ■ Anaplasia- loss of appearance of the parent cell. ■ Large Nuclear to Cytoplasmic Ratio- they have a large nucleus and occupy space. ■ Specific Functions are Lost- they serve no purpose to the body. ■ Loose Adherence- loose binding of the cells, causing potential spread into the blood and body. ■ Migration/Metastasis- spreads and moves easily. ■ Loss of cellular regulation and contact- the cells will crowd, push, and grow on top of other cells. ■ Rapid Cell Division- the cells will be produced and grow at a faster rate
■ Aneuploidy- abnormal number of chromosomes per cell. ● Seven warning signs of cancer ○ “CAUTION” ■ C: changes in bowel or bladder habits ■ A: a sore that does not heal or mouth sources (mucositis) ■ U: unusual bleeding or discharge ■ T: thickening of a lump in a tissue ■ I: indigestion and dysphagia ■ O: obvious change in a wart or mole ■ N: nagging cough ● Cancer development stages of malignancy ○ Initiation: the normal cell becomes damaged which is irreversible and can lead to cancer developing ○ Promotion: repeat exposures to a damaging stimuli enhances growth- mutations can cause this ○ Progression: because of repeat exposures, there is an increase in production of malignant cells ○ Metastasis: movement of the cancer cells ■ Malignant transformation: some cells will divide enough to form a tumor area on top of tissue. ■ Tumor vascularization: cancer cells secrete tumor angiogenesis factor stimulating the blood vessels to bud and for channels to grow. ■ Blood Vessel Penetration: cancer cells break off from the main tumor and enzymes on the surface of the tumor cells make holes in the blood vessels, allowing the cancer cells to enter blood vessels and travel around the body. ■ Arrest and Invasion: cancer cells clump up in the blood vessel walls and invade new tissue aera to support continued growth of cancer cells and new tumors. ● Cancer classification: monitor tumor growth, aggression, progression, and to determine appropriate treatment. ○ Tumor grading: based on cellular aspects of cancer. ■ Based on the aggressiveness of the cancer cell and differentiation from the normal tissue. ● G0: the 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 do G1 tumor 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. ○ Plodiy: based on the number of chromosomes the cell has ■ Cancer cells will have an abnormal number of chromosomes in their cells. ● Euploidy: normal amount of cell chromosomes- 46 with 23 pairs. ● Aneuploidy: abnormal number and formation of chromosomes in cancer cells. ○ Staging: determines the exact location of the cancer, how large the tumor is, and if it is spreading. ■ Clinical staging: assesses patient symptoms to determine size and spread. ■ Surgical staging: assesses size, number, sites, and spread by visualization at surgery. ■ Pathological staging: determining the tumor size, number, sites, and spread by pathologic examination of tissues obtained at surgery. ○ TNM- tumor, node, metastasis ■ Describes the anatomic extent of cancers. 1-4. 1 is that there is no spreading or is small and 4 is that there is a large spread and that the tumor is large also. ● Primary tumor (T): how large the tumor is. ○ Tx: primary tumor cannot be assessed ○ T0: no evidence of primary tumor ○ Tis: carcinoma in situ- pre cancer ○ T1, T2, T3, T4: increasing size and/or local extent of primary tumor ● Regional lymph nodes (N): based on how many nodes the tumor takes over in the body. ○ Nx: regional lymph nodes cannot be assessed ○ N0: no regional lymph node metastasis ○ N1, N2, N3: increasing involvement of regional lymph nodes ● Distant metastasis (M): if the cancer is moving or not moving. ○ Mx: presence of distant metastasis cannot be assessed ○ M0: no distant metastasis ○ M1: distant metastasis ○ Doubling time: the amount of time it takes for a tumor to double in size. Will help determine tumor growth. ○ Mitotic index: the percentage of actively dividing cells within a tumor. ○ Cancers are classified by the tissue they originate from. Other ways to classify cancer include: biologic behavior, anatomic site, and degree of differentiation ■ Adeno = epithelial ■ Chondro = cartilage ■ Fibro = fibrous connective ■ Glio = glial cells (brain) ■ Hemangio = blood vessel ■ Hepato = liver
■ Leiomyo = smooth muscle ■ Lipo = fat/adipose ■ Lympho = lymphoid tissue ■ Melano = pigment producing cells ■ Meningioma = meninges ■ Neuro = nerve tissues ■ Osteo = bone ■ Renal = kidney ■ Rhabdo = skeletal muscle ■ Squamous = epithelial layer, mucous membranes, organ lining ● Cancer prevention (primary vs. secondary) ○ Primary ■ Use of sunscreen ■ Stop tobacco use ■ Use PPE in workplace ■ Reduce alcohol consumption ■ Modify diet ■ Limit sexual partners/safe sex practices ■ Remove at-risk tissue: removing polyps, breast tissue, etc ■ Chemoprevention: strategy that uses drugs, chemicals, natural nutrients, or other substances to disrupt one or more steps important to cancer development ■ Vaccinations: Currently the only vaccines approved for prevention of cancer are related to prevention of infection from several forms of the human papilloma virus (HPV) ○ Secondary ■ Routine screenings: annual mammography after 40yrs, colonoscopy at 50yrs and then every 10, annual fecal occult, digital rectal exam for men after 50yrs ■ Genetic testing for those with genetic predisposition- BRCA gene ● Types of cancers (carcinoma, sarcoma, melanoma, lymphoma, leukemia, blastoma) ○ Carcinoma: cancer of the epithelial tissue (skin, liver, kidney) ○ Melanoma: cancer of the pigment cells, or melanocytes ○ Sarcoma: cancer of the connective tissues ○ Lymphoma: cancer of the lymphatic cells ○ Leukemia: cancer of the bone marrow ○ Blastoma: cancer of the immature, building cells Ch. 22: Care of Patients with Cancer ● Diagnostic tests and lab values (biopsy, imaging, absolute neutrophil count, RBC/PLT/WBC ranges) ○ Biopsy: GOLD STANDARD FOR CANCER DIAGNOSIS
■ Different types will be used depending on the type of cancer. ■ Will often be run through a microscope to see the cells. ○ Imaging: CT, MRI, PET scans ○ ANC- Absolute Neutrophil Count: percentage and actual number of mature circulating neutrophils. The higher the number, the greater the risk of infection resistance. ○ Other labs: ■ RBC”s: 4.7-6.1, Hemoglobin= 12-18, Hematocrit 36-50, WBC 5000-10000, Platelets 150000- ■ Pancytopenia= low RBCs,WBCs and platelets. ● Risk factors ○ AGE is the BIGGEST #1 RISK ○ Oncogene activation: something mutates the cell and we do not know why. ○ Chemicals: tobacco, hairspray, gases, pesticides, asbestos ○ Physical: radiation, drugs, UV radiation ○ Viruses: HPV can change pelvic structure ○ Dietary -red meat ○ Immune function ○ Genetic risk- remember about genetic testing. ● Other Terms regarding Cancer care to know ○ Pancytopenia: low numbers of RBCs,WBCs and platelets. ○ Neutropenic precautions: we must place our patient receiving cancer treatment because their immune system is suppressed, and they are a higher chance of infection ■ No fresh flowers ■ No fresh food ■ No kids ■ Must have caretaker wear a mask ■ Patient must wear mask outside of room ■ Wash hands. ○ Mucositis: inflammation of the mouth due to cancer treatment or progression ○ Extravasation: the cancer treatment leaks out of the IV and damages the surrounding skin. ○ Epoetin: medication that stimulates the production of rbcs ○ Neupogen: stimulates WBC production ● Types of therapy (i.e. surgery, radiation, chemotherapy) ○ Surgery: the provider will take out as much of the cancer as possible. ○ Radiation: uses high levels of radiation to kill cancer cells, control the disease, or provide symptom relief. Used locally often based on exposure (amount of radiation delivered to a tissue) and radiation dose (amount of radiation absorbed by the tissue) ■ Often in divided doses in small amounts due to radiation sensitivity and location to other body tissues. ■ Will often not cause complete destruction of all cancer cells at once. Some can also repair themselves from the radiation. ■ Can be from a radiation emitting beam externally, or by an implanted radiation device that emits doses of radiation.
■ Types of Radiation ● External beam: radiation delivered from a source outside of the patient. Because the source is external, the patient is not radioactive, and there is no hazard to others. ○ The exact tumor location is determined and then small markings are placed for precision, and a device may be placed in a splint or mold. ● Brachytherapy: internal radiotherapy. Radiation is delivered to the patient internally, making the patient a source of radiation as there is potential for one to emit radiation for a period of time and be hazardous to others. ○ Seeds can be placed and they are small pieces of radioactive material. Patients are still hazardous with them, even if they run out. ○ Chemotherapy: treatment of cancer cells with the use of chemical agents that damages cell DNA and regulation. Specific to the type of tumor and the movement. ■ Systemic effects, but can cause damage to normal healthy cells ■ Drug Types: ● Alkylating Agents: cross-link DNA, making the DNA strands bind tightly together. This action prevents proper DNA and ribonucleic acid (RNA) synthesis, which inhibits cell division. ● Antimetabolites: closely resemble normal metabolites and act as “counterfeit” metabolites that fool cancer cells into using the antimetabolites in cellular reactions. Because antimetabolites cannot function as proper metabolites, their presence impairs cell division. ● Antimitotic Agents: interfere with the formation and actions of microtubules so cells cannot complete mitosis during cell division. As a result the cancer cell either does not divide at all or divides only once. ● Anti-tumor Agents: drugs that were originally developed as antibiotics that have effects on cancer cells. These drugs damage the cell's DNA and interrupt DNA or RNA synthesis. The exact mechanism of interruption varies with each agent. ● Topoisomerase inhibitors: disrupt an enzyme (topoisomerase) essential for DNA synthesis and cell division. When drugs disrupt the enzyme, proper DNA maintenance is prevented, resulting in increased DNA breakage and eventual cell death. ● Miscellaneous Chemotherapeutic Agents: those with mechanisms of action that are either unknown or do not fit those of other drug categories. ■ Done in a combination: will give more than 1 chemo drug to more effectively kill cancer cells ■ Dose dense Chemo: giving chemo rounds closer together w/ growth factors to minimize neutropenia.
■ Can give IV, but more than likely other routes such as a port, PICC, TLC to prevent complications. ■ Can have potential to cause healthcare worker toxic effects- why people who are chemo certified can only give chemo. ○ Immunotherapy Biological response modifiers: enhance or alter the patient's biologic responses to cancer cells. Can help the body recognize cancer cells as foreign and improve immunity and repair cells. ■ Interleukins: substances the body makes to help regulate inflammation and immunity. Helps different immune cells recognize and destroy abnormal body cells. ■ Interferons:cell-produced proteins that have some effect in the treatment of melanoma, hairy cell leukemia, renal cell carcinoma, AIDS-related Kaposi's sarcoma, and lymphoma. Slowing tumor cell division.Stimulating the growth and activation of NK cells. Inducing cancer cells to resume a more normal appearance and function.Inhibiting the expression of oncogenes ■ Supportive therapy: helps with growth factor and induces more rapid recovery of bone marrow cells after suppression by chemotherapy. ○ Monoclonal Antibodies: bind to their target antigens, which are often specific cell surface membrane proteins. Binding prevents the protein from performing its functions. By binding these proteins, monoclonal antibodies change cellular regulation and prevent cancer cell division. ○ Tyrosine Kinase Inhibitors: Drugs with the main action of inhibiting activation of tyrosine kinases. TKI drugs are effective in disrupting the cellular regulation and growth of some cancer cell types and not others. ○ Epidermal Growth Factor/Receptor Inhibitors: block epidermal growth factor from binding to its cell surface receptor. When this receptor is blocked, it cannot activate tyrosine kinase. As a result, the signal transduction pathway for promotion of cell division is inhibited. ○ Vascular Endothelial Growth Factor/Receptor Inhibitors:It binds to vascular endothelial growth factor (VEGF) and prevents the binding of VEGF with its receptors on the surfaces of endothelial cells present in blood vessels. This inhibits formation of new blood vessels within a tumor. As a result, tumor cells are poorly nourished and growth is inhibited. ○ Multikinase Inhibitors: inhibit the activity of specific kinases in cancer cells and tumor blood vessels. ○ Proteasome Inhibitors: prevent the formation of a large complex of proteins (a proteasome) in cells. Limit the amount of proteasome present, impairing the tumor’s
cellular regulation and making its cells less likely to divide and more likely to respond to signals for cell death. ○ Angiogenesis Inhibitors: target a specific protein kinase known as the mammalian target of rapamycin (mTOR). When the drug binds to an intracellular protein, a protein- drug complex forms that inhibits the activity of mTOR. When mTOR is inhibited, the concentrations of vascular endothelial growth factor (VEGF) are greatly reduced, and many pro–cell division signal transduction pathways are disrupted. ○ Photodynamic Therapy: selective destruction of cancer cells through a chemical reaction triggered by high energy laser light. It can be used to destroy some cancers, reduce the size of tumors to allow subsequent complete surgical removal, and shrink tumors in airways or the esophagus to relieve obstruction. ○ Hormonal Manipulation: involves changing the body's usual hormone responses.Hormones exert their effects only on their specific target tissues. Some hormones cause hormone-sensitive tumors to grow more rapidly, thus decreasing the amount of these hormones that reach hormone-sensitive tumors can slow cancer growth.Uses steroids, steroid analogues, and enzyme inhibitors. ● Surgical classification types ○ Prophylactic: removes potentially cancerous tissue as a prevention of cancer development. ○ Diagnostic: removal of all or part of a suspected lesion for examination to confirm or rule out cancer. ○ Exploratory: extensive approach if the cancer cannot be confirmed with less intensive means. ○ Curative: removes all the cancer tissue. Done for many localized or noninvasive lesions. ○ Cytoreductive: removes part of the tumor when removal of the whole mass is not possible. Decreases the size of the tumor and number of cancer cells. ○ Palliative: focus on providing symptom relief and improving the quality of life. ○ Reconstructive/Rehabilitative: increases function, enhances appearance, or both. (Breast reconstruction after mastectomy). ● S/E of therapies ○ Surgery: ■ Reduction of function when either a part or the whole organ is taken out. ■ Scarring or disfigurement may occur. ■ Potential risk for depression, grief, and decreased quality of life. ○ Radiation ■ Systemic: altered taste, fatigue, bone marrow suppression ■ Inflammation and tissue fibrosis ■ CV disease
■ Acute effects: ● Brain: ○ Alopecia and radiodermatitis of the scalp ○ Ear and external auditory canal irritation ○ Cerebral edema ○ Nausea and vomiting ○ Somnolence syndrome ● Head and Neck: ○ Oral mucositis ○ Taste changes ○ Oral candidiasis ○ Oral herpes ○ Acute xerostomia ○ Dental caries ○ Esophagitis and pharyngitis ● Breast and Chest wall: ○ Skin reactions ○ Esophagitis ● Chest and lung: ○ Esophagitis and pharyngitis ○ Taste changes ○ Pneumonia ● Abdomen and Pelvis ○ Anorexia ○ Nausea and vomiting ○ Diarrhea and proctitis ○ Cystitis ○ Vaginal dryness/vaginitis ● Eye ■ Late Effects ○ Conjunctival edema and tearing ● Subcutaneous and Soft Tissue ○ Radiation-induced fibrosis ● CNS ○ Brain necrosis ○ Leukoencephalopathy ○ Cognitive and emotional dysfunction ○ Pituitary and hypothalamic dysfunction ○ Spinal cord myelopathies ● Head and Neck
○ Xerostomia and dental caries ○ Trismus ○ Osteoradionecrosis ○ Hypothyroidism ● Lung ○ Pulmonary Fibrosis ● Heart: ○ Pericarditis ○ Cardiomyopathy ○ Coronary Artery disease ● Breast/Chest Wall ○ Atrophy, fibrosis of breast tissue ○ Lymphedema ● Abdomen and Pelvis ○ Small and Large bowel injury ○ Chemotherapy ■ Extravasation can occur if given through IV. Must give cancer through PICC/CL/Port ■ Vesicant: will destroy and eat away tissue ■ Risk for infection due to bone marrow and immune suppression and neutropenia. ■ Risk for bleeding: impaired clotting ■ Chemo induced nausea and vomiting may occur ■ Mucositis ■ Alopecia ■ Cognitive changes ■ Peripheral neuropathy ○ Immunotherapy: biological response modifiers: ■ Severe inflammatory reactions ■ widespread edema that can affect the function of all organs ■ Flu like symptoms ■ Peripheral neuropathy ■ Neurological symptoms ■ skin dryness and reactions ○ Photodynamic therapy ■ Airway issues ○ Hormonal Manipulation ■ Masculine effects in women ■ Feminizing effects in men (gynecomastia) ■ Fluid retention ■ Acne
■ Hypercalcemia ■ liver dysfunction ■ VTE ● Patient Teaching Points ○ Surgery: ■ Must have psychosocial support since diagnosis and surgery fall within a short time frame of each other. ■ Assess coping mechanisms based on the diagnosis and changes in body image and roles. ■ Coordinate with the team for assistance with the patients concerns regarding feelings, ADL’s and body acceptance ■ Refer to support groups. ■ Rehab may be needed to improve functioning. ■ Teach patients the importance of regular exercise. ○ Radiation: ■ Assist with calming the patient and family with the procedure ■ Brachytherapy (Internal Radiation): ● Assign the patient to a private room with a private bath. ● Place a “Caution: Radioactive Material” sign on the door of the patient's room. ● If portable lead shields are used, place them between the patient and the door. ● Keep the door to the patient's room closed as much as possible. ● Wear a dosimeter film badge at all times while caring for patients with radioactive implants. The badge offers no protection but measures a person's exposure to radiation. Each person caring for the patient should have a separate dosimeter to calculate his or her specific radiation exposure. ● Wear a lead apron while providing care. Always keep the front of the apron facing the source of radiation (do not turn your back toward the patient). ● If you are attempting to conceive, do not perform direct patient care, regardless of whether you are male or female.
● Pregnant nurses should not care for these patients; do not allow pregnant women or children younger than 16 years to visit. ● Limit each visitor to one-half hour per day. Be sure visitors stay at least 6 feet from the source. ● Never touch the radioactive source with bare hands. In the rare instance that it is dislodged, use long-handled forceps to retrieve it. Deposit the radioactive source in the lead container kept in the patient's room. ● Save all dressings and bed linens in the patient's room until after the radioactive source is removed. After the source is removed, dispose of dressings and linens in the usual manner. Other equipment can be removed from the room at any time without special precautions and does not pose a hazard to other people. ■ Skin teaching: ● Wash the irradiated area gently each day with either water or a mild soap and water as prescribed by your radiation therapy team. ● Use your hand rather than a washcloth when cleansing the therapy site to be gentler. ● Rinse soap thoroughly from your skin. ● If ink or dye markings are present to identify exactly where the beam of radiation is to be focused, take care not to remove them. ● Dry the irradiated area with patting rather than rubbing motions; use a clean, soft towel or cloth. ● Use only powders, ointments, lotions, or creams that are prescribed by the radiation oncology department on your skin at the radiation site. ● 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 radiation site.
● Avoid exposure of the irradiated area to the sun: ● Protect this area by wearing clothing over it. ● Try to go outdoors in the early morning or evening to avoid the more intense sun rays. ● When outdoors, stay under awnings, umbrellas, and other forms of shade during the times when the sun's rays are most intense (10 AM to 7 PM). ● Avoid heat exposure. ○ Chemotherapy ■ Remember neutropenic precautions: private room, hand washing, dedicate supplies for use, limit personnel into room, monitor vitals, inspect mouth and skin and IV, change wound dressings daily, assist with coughing and deep breath, encourage activity, monitor blood levels, no fresh fruits or flowers, must wear mask when outside room. ■ Remember chemo precautions: chemo can be very sensitive and harmful when handled incorrectly. Remember to wear chemo gloves, have patience not to touch the drug, no chewing of the drug, chemo gloves, placing oral or IV remains in the yellow boxes, wear eyewear, mask, gown, and double flush. ■ Reducing mucositis: Examine your mouth (including the roof, under the tongue, and between the teeth and cheek) every 4 hours for fissures, blisters, sores, or drainage.If sores or drainage is present, contact your cancer health care provider to determine whether these areas need to be cultured.Brush the teeth and tongue with a soft-bristled brush or sponges every 8 hours and after meals.Avoid the use of mouthwashes that contain alcohol or glycerin.“Swish and spit” room- temperature tap water, normal saline, or salt and soda water on a regular basis (at least 4 times a day) and as needed according to changes in the oral cavity.Drink 2 or more liters of water per day if another health problem does not require limiting fluid intake.Take all drugs, including antibiotics and drugs for nausea and vomiting, as prescribed.Use topical analgesic drugs as prescribed.Take pain medications on schedule as needed.Apply a water-based moisturizer to your lips after each episode of mouth care and as needed.Use prescribed “artificial saliva” or mouth moisturizers as needed.Avoid using
tobacco or drinking alcoholic beverages.Avoid spicy, salty, acidic, dry, rough, or hard food.Cool liquids to prevent burns or irritation.If you wear dentures, use them only during meals. When not in place, soak them in an antimicrobial solution. Rinse thoroughly before placing them in your mouth. ■ Prevent bleeding: Wash the irradiated area gently each day with either water or a mild soap and water as prescribed by your radiation therapy team.Use your hand rather than a washcloth when cleansing the therapy site to be gentler.Rinse soap thoroughly from your skin.If ink or dye markings are present to identify exactly where the beam of radiation is to be focused, take care not to remove them.Dry the irradiated area with patting rather than rubbing motions; use a clean, soft towel or cloth.Use only powders, ointments, lotions, or creams that are prescribed by the radiation oncology department on your skin at the radiation site.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 radiation site.Avoid exposure of the irradiated area to the sun. Protect this area by wearing clothing over it.Try to go outdoors in the early morning or evening to avoid the more intense sun rays.When outdoors, stay under awnings, umbrellas, and other forms of shade during the times when the sun's rays are most intense (10 AM to 7 PM).Avoid heat exposure. ■ Give antiemetic for nausea and vomiting ■ Offer mints for metallic taste ■ Educate about alopecia (hair loss), and provide strategies and coping mechanisms to support the patient when they lose their hair. ■ Reducing peripheral neuropathy: Protect feet and other body areas where sensation is reduced (e.g., do not walk around in bare feet or stocking feet; always wear shoes with a protective sole).Be sure that shoes are long enough and wide enough to prevent creating sores or blisters.Buy shoes in the afternoon or evening to accommodate any size change needed for foot swelling.Provide a long break-in period for new shoes; do not wear new shoes for longer than 2 hours at a time.Avoid pointed-toe shoes and shoes with heels higher than 2 inches.Inspect your feet daily (with a mirror) for open areas or redness.Avoid extremes of temperature; wear warm clothing in the winter, especially over hands, feet, and ears.Test water temperature with a thermometer when washing dishes or bathing. Use warm water rather than hot water (less than 105° F or 40.6° C).Use potholders when cooking.Use gloves when washing dishes or gardening.Do not eat foods that are “steaming hot”;
allow them to cool before placing them in your mouth.Eat foods that are high in fiber (e.g., fruit, whole grain cereals, vegetables).Drink 2 to 3 liters of fluid (nonalcoholic) daily unless your health care provider has told you to restrict fluid intake.Use the actions for “Falls Prevention” supplied by the cancer center during all activities.Get up slowly from a lying or sitting position. If you feel dizzy, sit back down until the dizziness fades before standing; then stand in place for a few seconds before walking or using the stairs.To prevent tripping or falling, look at your feet and the floor or ground where you are walking to assess how the ground, floor, or step changes.Avoid using area rugs, especially those that slide easily.Keep floors free of clutter that could lead to a fall.Use handrails when going up or down steps ○ Immunotherapy: biological response modifiers: ■ Use moisturizers and mild soap for skin cleaning. ■ Protect skin from sun ■ No swimming ■ No use of steroid creams ■ Assess for fever and use acetaminophen to treat ■ Use antiemetic for n/v ■ Teach early recognition of neuro s/s ○ Photodynamic therapy ■ Avoid sunlight exposure for 24-48 hours. must educate the family ○ Hormonal Manipulation ■ Educate about side effects ■ Must understand the implications of falls and body changes ● Oncological emergency classification types (what are they, how do you assess it, how do you treat it?) ***Life- threatening emergencies affecting cancer patients. Can occur at any time from diagnosis through treatment. They may be directly related to the tumor or a result of treatment therapy. Oncological emergencies are classified as metabolic, hematologic, & structural or side effects of treatment. Early detection and treatment of these emergencies are imperative to reduce patient harm and preserve life. *** ○ Sepsis or Febrile Neutropenia (Hematologic Emergency) ■ A condition in which organisms enter the bloodstream causing an infection resulting in septic shock (septicemia). ■ Widespread infection triggering whole-body inflammation ■ Leads to distributive shock when infectious microorganisms are present in the blood and then commonly referred to as septic shock.
■ One of the most common side effects of chemotherapy ■ Life-threatening condition (requires immediate medical care) ■ Adults w/cancer w/ low WBCs (neutropenia) and impaired immunity from cancer therapy are at an increased risk for infection and sepsis. ■ s/s associated with sepsis/ septic shock includes erythema, swelling, warmth, high fever. ■ Other s/s associated w/ febrile neutropenia is absolute neutrophil count less than 500 per mm^ ■ Often a low-grade fever (100.4) is the only sign of infection initially seen in septic patients. ■ Infection and sepsis have a high mortality rate in adults w/ neutropenia ■ Treatment options: ● Inpatient treatment ● Antibiotic therapy ● Determine the cause of the infection ● Temperature management Nursing Care: ● Assess for s/s ● Monitor and treat temperature ● Collect cultures ● Implement isolation precautions ● Monitor labs ● Administer medications as prescribed ● Manage comfort ● Provide emotional and spiritual support ○ Disseminated Intravascular Coagulation (DIC) (Hematologic Emergency) ■ Occurs when there is a problem w/ the blood clotting process ■ Triggered by severe illness including cancer ■ In patients w/ cancer DIC is caused by gram-negative sepsis ■ Normal bacterial flora enter the bloodstream through any site of skin breakdown causing severe infection
■ Extensive & abnormal clotting occurs in the small blood vessels depleting circulating clotting factors and platelets resulting in extensive bleeding for patient w/ DIC ■ Bleeding from many sites is the most common problem and ranges from oozing to fatal hemorrhage ■ DIC causes decreased blood flow to major body organs ■ s/s include pain, ischemia, stroke like symptoms, dyspnea, tachycardia, reduced kidney function, and bowel necrosis ■ DIC is life-threatening even when proper therapies are instituted ■ Prevention of both sepsis and DIC are key ■ Identify patients at greatest risk for sepsis and DIC ■ Practice strict adherence to aseptic technique during invasive procedures and during contact w/ nonintact skin and mucous membranes ■ Teach patients and families the early indicators of infection and to seek prompt assistance ■ Focus of treatment therapies is halting the DIC process ■ IV antibiotic therapy is initiated ■ Anticoagulants (especially heparin) are given to limit clotting and prevent rapid consumption of circulating clotting factors during the early phase of DIC ■ When DIC has progressed and hemorrhage is the primary problem clotting factors and blood transfusions ■ Some of the most common clotting factors given to treat DIC patients ● Factor 1 - Fibrinogen ● Factor 2- Prothrombin ● Factor 3- Thromboplastin ● Factor 4- Calcium ● Factor 5- Proaccelerin or Labile Factor ● Factor 6- Stable factor ● Factor 8- Antihemophilic factor
○ Hyperviscosity Syndrome (Hematologic Emergency) ■ Elevated blood viscosity due to red blood cell shape deformity or an increase in serum proteins, RBCs, WBCs, or platelets. ■ Presents w/ a triad of systems including neuro deficits, visual disturbances, and mucosal bleeding ■ Hyperviscosity syndrome is associated w/ Waldenstrom’s macroglobulinemia, multiple myeloma, and leukemia ■ S/s include spontaneous bleeding, hemorrhagic retinal veins, neuro deficits, and elevated serum viscosity levels ■ Treatment options: ● Plasmapheresis- a method of removing blood plasma and separating the plasma and cells and transfusing the cells back to the patient ● Targeted chemotherapy ● Hydration ● Diuresis ■ Nursing Care: ● Assess for s/s ● Administer I.V. fluids as prescribed ● Administer diuretics as prescribed ● Prepare patient for plasmapheresis ● Monitor for signs of bleeding ● Provide emotional and spiritual support ○ Malignant Pericardial Effusion (Structural Emergency) ■ Fluid accumulation around pericardial sac ■ Increased amount of fluid in the sac causes compression of the heart possibly leading/ resulting in a cardiac tamponade ■ Prompt treatment to remove fluid must be performed to avoid death ■ Associated w/ metastatic lung and breast cancer, melanoma, leukemia, lymphoma, and chemotherapy to the chest wall
■ S/s include dyspnea, fatigue, distended neck veins, distant heart sounds, tachycardia, orthopnea (SOB or difficulty breathing when lying down), narrow pulse pressure, and pulsus paradoxus (exaggerated blood pressure variation) ■ Treatment options: ● Radiation ● Surgical intervention ■ Nursing Care: ● Assess for neuro deficits ● Manage pain ● Administer meds as prescribed ● Prevent skin breakdown ● Provide emotional and spiritual support ○ Syndrome of Inappropriate Antidiuretic Hormone (SIADH) (Metabolic Emergency) ■ A syndrome resulting in hyponatremia (low sodium) causing a disorder of water balance. Water is reabsorbed in excess by the kidneys and put into systemic circulation. The retained water dilutes blood sodium levels. ■ Characterized by elevated serum blood levels of ADH, excessive water retention, hypo-osmolality, and hyponatremia ■ s/s include anorexia, loss of appetite, nausea, vomiting, constipation, muscle weakness, myalgia (muscle pain), fatigue, polyuria, polydipsia, seizures, personality changes, confusion, nervous system changes, and coma ■ Treatment: ● Fluid restriction ● Correction of serum sodium imbalance ● Furosemide therapy Nursing Care: ● Assess for s/s ● Monitor I&Os ● Monitor labs ● Implement seizure precautions
● Manage comfort ● Provide emotional and spiritual support to patient and family ○ Epidural Spinal Cord Compression (Structural Emergency) ■ Life-threatening complication of metastatic cancer caused by tumor compression of the spinal cord. ■ Can result in permanent neurological deficits ■ Early recognition and treatment are imperative to improve and maintain patient function ■ Epidural spinal cord compression is associated with breast, lung, renal, prostate cancer and myeloma ■ S/s include new onset of back pain that worsens when lying down, late paraplegia, incontinence, constipation, and loss of sensory function ■ Treatment options include radiation and surgical intervention Nursing Care: ● Assessment for neurological deficits (diminished DTRs, numbness or tingling in hands or feet, unsteady gait, inability to distinguish a pinprick, or determine hot or cold sensations) ● Manage pain (both pharmacological and non-pharmacological (i.e. external back or neck braces to reduce pressure on spinal cord or spinal nerves) ● Administer medications as prescribed (i.e. IV corticosteroids to reduce swelling & inflammation) ● Prevent skin breakdown ● Provide emotional and spiritual support ○ Hypercalcemia of Malignancy (Metabolic Emergency) ■ Increased serum calcium level occurs in up to a third of patients w/ cancer ■ Metabolic emergency that can lead to death ■ Completely treatable condition ■ Dehydration worsens hypercalcemia ■ Associated w/ lung, breast, and kidney cancer as well as multiple-myelomas
■ Three major triggers that result in hypercalcemia of malignancy ● Tumor secretion of parathyroid hormone-related protein ● Osteolytic metastasis w/ release of cytokines ● Tumor production of 1.25-dihydroxyvitamin D ■ S/s include fatigue, anorexia, nausea, vomiting, constipation, mental status changes/altered sensorium, renal failure, coma, myalgia, and headache. ■ Treatment options: ● Inpatient monitoring ● Aggressive rehydration followed by diuresis ● Monitor serum phosphate levels ● Phosphate replacement ● I.V. bisphosphonate ● Hemodialysis Nursing Care: ● Assess for s/s ● Monitor I&Os ● Administer fluids as prescribed ● Monitor for side effects of medications ● Monitor vital signs and cardiac rhythm ● Prepare patient for hemodialysis ● Provide emotional and spiritual support ○ Superior Vena Cava Syndrome (Structural Emergency) ■ Compression of the superior vena cava walls by a tumor prohibiting venous return of blood to the heart. ■ Associated w/ lung cancer, metastatic mediastinal tumors, lymphoma, and indwelling venous catheters. ■ s/s include swelling of the face, neck, and arms, dysphagia, and cough ■ Late s/s include hemorrhage, cyanosis, mental status changes, decreased cardiac output, dyspnea, and hypotension ■ Imaging w/ CT or MRI is essential for diagnosis and treatment planning ■ Death results if compression is not relieved ■ Treatment options include radiation and chemotherapy
Nursing Care: ■ Assessment of respiratory and cardiac systems ■ Maintain a patent airway ■ Monitor oxygenation ■ Monitor labs ■ Provide emotional and spiritual support to the patient and family ○ Tumor Lysis Syndrome (Metabolic Emergency) ■ Large number of tumor cells are destroyed rapidly ■ TLS results in a release of large amounts of intracellular products such uric acid, calcium phosphates, and potassium. These products disrupt homeostasis and destroy the nucleus of cells. ■ Uric acid formation causes hyperuricemia and precipitate in the kidney blocking kidney tubules resulting in AKI ■ Intracellular contents of damaged cancer cells, including potassium and purines (DNA components), are released into the bloodstream faster than the body can eliminate them. ■ TLS differs from the other types of oncologic emergencies because it is a positive sign that cancer treatment is effective in destroying cancer cells. ■ TLS is associated w/ hematologic malignancies, acute leukemia, and high- grade lymphoma. ■ Severe or untreated TLS can cause tissue damage, acute kidney injury (AKI), and death. ■ Serum potassium levels can increase to the point of hyperkalemia causing cardiac dysfunction ■ Adults receiving radiation or chemotherapy for cancers are at risk for TLS and more likely to develop/ occur in older adults ■ Early symptoms of TLS include lethargy, nausea, vomiting, anorexia, flank pain, muscle weakness, cramps, seizures, edema, and altered mental status. ■ Other s/s include azotemia (damaged kidneys), acidosis, hyperphosphatemia, hypocalcemia. ■ Hydration prevents and manages TLS by diluting the serum potassium level and increasing kidney flow rates.
■ Instruct patients to drink at least 3L - 5L (more desirable) of fluid the day before the day of, and for 3 days after treatment. Fluids should be alkaline (e.g., sodium bicarbonate) to help prevent uric acid formation/ build up. Stress importance of keeping fluid intake consistent throughout a 24-hour day. Assist patients with drawing up a schedule of fluid intake. ■ Due to side effects stemming from cancer therapy such as N/V stress importance of following an antiemetic regimen. The oncologist should be contacted immediately if n/v prevents adequate fluid intake so parenteral fluids can be started. ■ Other treatment options include: ● Inpatient monitoring ● Fluid resuscitation ● Allopurinol or uricase therapy ● Correction of acidosis ● Hemodialysis Nursing Care: ● Maintain patient’s airway, breathing, and circulation ● Monitor vital signs and cardiac rhythm ● Monitor daily weights ● Administer prescribed medications (i.e. diuretics) ● Provide patient and family education ● Provide emotional and spiritual support ● Manage electrolyte imbalances as prescribed ● Prepare patient for hemodialysis Ch. 7: End-of-Life Care Concepts ● Hospice vs. Palliative care ○ Hospice- Model for quality, compassionate care for those facing life-limiting illness or injury. Usually less than 6 months to live. ○ Palliative Care-Philosophy of care for those with life-threatening disease ■ Provided by physician, nurse practitioner, or team. ● Assessment findings ○ Notice these findings in a person who is approaching death: ■ Weakness ■ Sleeping more ■ Anorexia
■ Changes in organ system function- cardiovascular, respiratory and genitourinary function. ■ Cold, mottled, cyanotic extremities ■ Changes in breathing pattern- breathing becomes shallow and rapid with periods of apnea, Cheyne- Stokes respirations (apnea alternating with periods of rapid breathing). ■ Decreased LOC- declines to lethargy, unresponsiveness or coma. As LOC decreases, pt loses ability to speak (Nursing intervention:identify alternative means of communication to assess for symptoms of distress. ■ blood pressure decreases and is often only palpable, heart rate becomes irregular and decreases before dying. ● Psychosocial Assessment- ○ Fear and/or anxiety ○ Difficulty coping with fear and anxiety of death. ○ Assess cultural considerations, values, religious beliefs. ○ Spiritual assessment: HOPE mnemonic ■ H: sources of Hope and strength. ■ O: Organized religion if the patient follows one and the role it plays in one’s life ■ P: Personal spirituality, rituals, and practices ■ E: Effects of religion and spirituality on care and end of life decisions. ○ Interventions- assess cultural considerations, values and religious beliefs of the patient and family. ● Managing symptoms and needs ○ Pain Management: Pain is the symptom that dying patients fear the most. ■ Non Opioid and Opioid analgesics , Non pharmacologic interventions. Massages, music therapy and aromatherapy ○ Managing weakness ■ Aspiration precautions ■ Provide mouth care; apply emollient to lips. ■ Altered routes of medication administration. (Choose the least invasive route with most effective treatment.) ○ Managing breathlessness and dyspnea ■ Opioids, bronchodilators, diuretics, antibiotics, anticholinergics, benzodiazepines ■ Oxygen (for comfort) ■ Electric fan for air circulation ■ Reposition ○ Managing Nausea and vomiting ■ Antiemetic agents ● Prochlorperazine (Compazine) ● Ondansetron (Zofran) ● Dexamethasone (Decadron, Deronil, Dexasone) ● Metoclopramide (Reglan, Maxeran) ■ Remove any source of odors. ■ Comfortable room temperature ■ Aromatherapy
○ Managing agitation and delirium ■ Assess for pain, urinary retention, constipation, other reversible cause ■ Pharmacologic agents- avoid benzodiazepines in older adults as it increases the risk of causing delirium. ■ Music therapy; aromatherapy ○ Managing refractory symptoms of distress ■ proportionate palliative sedation- a care management approach involving the administration of drugs such as benzodiazepines, neuroleptics, barbiturates, or anesthetic agents for the purpose of decreasing suffering by lowering patient consciousness. The intent of proportionate palliative sedation to promote comfort. (it's different from euthanasia). ○ Meeting psychosocial needs. ■ Grief—Emotional feeling related to the perception of loss. ■ Mourning—Outward social expression of the loss ■ Interventions are based on cultural beliefs, values, and practices. ■ Presence ■ Therapeutic communication ■ Life review ■ Reminiscence ■ Spirituality ■ Religion ● Explain the Multidisciplinary method for those with cancer/ death ○ Involves care from every discipline to provide comfort and care for the patient while maximizing life outlook. ○ MD,PT,OT,RT,Specialists, SLP, dietitian, psychologist, social work, chaplain. Ch. 11: Care of Patients with Problems of Fluid and Electrolyte Balance ● Lab values form for normal ranges= Hypomagnesemia and hypophosphatemia = alcoholism ELECTROLYTES REFERENCE RANGE SIGNIFICANCE OF ABNORMAL VALUES Sodium (Na+) 136 - 145 mEq/L Elevated: Hypernatremia; dehydration; kidney disease; hypercortisolism Low: Hyponatremia, fluid overload, liver disease, adrenal insufficiency Potassium (K+) 3.5 - 5.0 mEq/L Elevated: Hyperkalemia; dehydration; kidney disease; acidosis; adrenal insufficiency; crush injuries Low: Hypokalemia; fluid overload; diuretic therapy; alkalosis; insulin administration; hyperaldosteronism Calcium (Ca 2+) 9.0 - 10.5 mg/dL Elevated: Hypercalcemia; hyperthyroidism; hyperparathyroidism