oncology handouts.pdf

7/29/2019 Oncology handouts.pdf

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Oncology Branch of medicine that deals with the

study, detection, treatment andmanagement of cancer and neoplasia

In the Philippines, cancer ranks third inleading causes of morbidity and mortalityafter communicable diseases andcardiovascular diseases

In the Philippines, 75% of all cancers occurafter age 50 years, and only about 3% occurat age 14 years and below

If the current low cancer preventionconsciousness persists, it is estimated that

for every 1800 Filipinos, one will developcancer annually most Filipino cancer patients seek medical

advice only when symptomatic or atadvanced stages: for every two new cancercases diagnosed annually, one will diewithin the year

The top cancer sites in the Philippinesinclude those cancers whose major causesare known (where action can therefore betaken for primary prevention), such ascancers of the lung/larynx (anti-smokingcampaign), liver (vaccination againsthepatitis B virus), cervix (safe sex) andcolon/rectum/stomach (healthy diet). Exceptfor the liver, the top Philippine cancer sitesare also the top cancers worldwide

Terms to Definea. Hyperplasia increase in the number of

cellsb. Metaplasia conversion of one cell to

another cellc. Dysplasia bizarre cell growth resulting

in difference in size, shape andarrangement

d. Anaplasia cells that lack normal cellularcharacteristic

e. Neoplasia uncontrolled cell growthPredisposing Factorsa. Age

Older individuals are more prone to Cab. Sex

women breast, uterus, cervix cancerMen prostate, lung Ca

c. Urban Vs Rurald. Geographic Distributione. Occupationf. Hereditaryg. Stressh. Precancerous lesions

Pigmented moles, burn scars, benignpolyps, adenoma, fibrocystic disease ofthe breast

i. Obesity

- Breast and colorectal Ca

Cancer IncidenceCarcinogenesisa. Initiation

- first step, chemicals, physical factors andbiologic agents, escape the normal enzymaticmechanisms and alter the genetic structure of thecellular DNA- normally these alterations are reversed by DNArepair mechanism or programmed cellular suicide(apoptosis)

2. Promotion- Repeated exposureCauses expression of abnormal or mutant

genetic information

- Proto-oncogenes, on switchCa suppressor genes, turn offP53 gene, a tumor suppressor gene regulateswhether cells repair or die after DNA is damaged

3. Progression-Third step of cellular carcinogenesisThe cellular changes formed during initiation andpromotion now exhibit increased malignantbehavior

Etiologic Factors1. VirusesOncogenic virusesa. Epstein Bar virus, burkitts lymphoma,nasopharyngeal Ca, non-Hodgkin and hodgkinslymphoma

b. Herpes simplex Type II, cytomegalovirus andHPV type 16,18,31,33, Cervix Ca

c. HIV, kaposi sarcomad. H. pylori, gastric Ca2. Physical Agents- Ultraviolent rays, especially in fair skinned blueor green eyed people, skin Ca- Radiation from x-ray or nuclear, leukemia,multiple myeloma, Ca of lung, bone, breast andthyroid3. Hormones- Oral contraception or HRT, Inc. incidence ofhepatocellular, endometrial and breast Ca

4. Chemical Agents- 75% related to environmentTobacco smoking, single most lethal carcinogen,30% of Ca deaths, lung, head and neckesophagus, bladder panceas, cervix cachewing tobacco, ca of the oral cavity in menyounger than 40 years old

5. Industrial compounds

- Vinyl chloride (plastics, asbestos)


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Polycyclic aromatic hydrocarbons (burning, autoand truck emission)Fertilizers and weed killersDyes, (analine dyes, hair dyes)

6. Dietary FactorsCarcinogenic- fats, alcohol, salt cured or smoked meats,high caloric contentProactive- high fiber, Cruciferous vegetables ( cabbage,

broccoli, cauliflower, brussels, sprouts)Carotenoids (carrots, tomatoes, spinach,apricots, peaches, dark green and yellowvegetables), vit E, C, zinc and selenium

7. Genetics- Oncogenes ( hidden/repressed genetic code forCa that exist in all individual

8. Age: Advancing age is a significant risk factors

9. Immunologic Factorsa. Immunosuppressed individuals moresusceptible to cancer

Characteristics of Caa. Metastasis1. Lymphatics- the most common mechanismbreast tumors, axillary, clavicular, and thoracic

LN

2. Hematogenous- disseminated through the blood streamrelated to the vascularity of the tumor

Angiogenesis ability to induce the growth ofnew capillaries from the host tissue to meet thenutrients and oxygen

Classification and stagingTissue of OriginCarcinoma:

a. Squamous cell Ca surface epitheliumb. Adenocarcinoma glandular or parenchymalc. Sarcoma connective tissued. Leukemia, Lymphoma

B. Staging determines the size of the tumor

and the existence of metastasis

TNM ClassificationT extent of primary tumorN absence or presence and extent of regionallymph node metastasisM absence or presence of distance metastasis

Primary Tumor (T)TX primary tumor cannot be assessedTO no evidence of primary tumor

Tis carcinoma in situ

T1,2,3,4 increasing size or local extent ofprimary tumor

Regional lymph nodes (N)NX regional LN cannot be assessed

NO no regional LN metastasisN1,2,3 increasing involvement of LN

Distant MetastasisMX Distance metastasis cannot be assessedMO No distant metastasisM1 distant metastasis

GradingClassification of tumor cellsGrade I IV, define the type of tissue which the

tumor originatedNormal T0, N0, M0Stage I T1, N0, M0Stage II T2, N1, M0Stage III T3, N2, M0Stage IV with metastasis

2. HistologicGrade 1 - well differentiatedGrade 2 - Moderately differentiated moreabnormalGrade 3 - Poorly differentiated, Very abnormalGrade 4 - Very immature, anaplastic hard toeven determine the tissue of origin

Nomenclature of NeoplasiaTumor is named according to:1. Parenchyma, Organ or CellHepatoma- liverOsteoma- boneMyoma- muscleNomenclature of NeoplasiaTumor is named according to:2. Pattern and Structure, either GROSS orMICROSCOPICFluid-filled CYSTGlandular ADENOFinger-like PAPILLOStalk POLYP

Nomenclature of NeoplasiaTumor is named according to:3. Embryonic originEctoderm ( usually gives rise to epithelium)

Endoderm (usually gives rise to glands)Mesoderm (usually gives rise to Connectivetissues)

BENIGN TUMORSSuffix- OMA is usedAdipose tissue- LipOMABone- osteOMAMuscle- myOMABlood vessels- angiOMAFibrous tissue- fibrOMA


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MALIGNANT TUMORNamed according to embryonic cell origin1. Ectodermal, Endodermal, Glandular, EpithelialUse the suffix- CARCINOMAPancreatic AdenoCarcinoma

Squamos cell Carcinoma

Named according to embryonic cell origin2. Mesodermal, connective tissue originUse the suffix SARCOMAFibroSarcomaMyosarcomaAngioSarcoma

PASAWAY1. OMA but Malignant

HepatOMA, lymphOMA, gliOMA, melanOMA2. THREE germ layersTERATOMA3. Non-neoplastic but OMAChoristomaHamatoma

Warning signs of CaC change in bowel or bladder habitsA sore that does not healU unusual bleeding or dischargeU unexplain sudden weight lossU unexplained anemiaT thickening or lumpI indigestion or difficulty in swallowingO obvious change in wart or moleN nagging cough or hoarseness of voice

Screeninga. Early detection and treatment are the

cornerstones of cancer survivalb. Educating the public about a healthy

lifestyle and early detectionc. Health educationd. Reduce and avoid exposure to known

carcinogense. Eat a balanced diet of vegetables, fruits

and whole grains, reducing fat and redsmoked and cured meat.

f. Limit alcohol beveragesg. Exercise regularlyh. Reduce stress and encourage adequate

rest and relaxationi. Follow screening recommendationsj. Know the seven warning signsk. Seek medical attention

Diagnostic test1. Biopsy- removal of tissue for histologic examination- essential for choosing treatment

Types

a. FNAB

b. Incisionc. Excisiond. Punch

Preprocedure

a.

Depends on the location and type ofbiopsyb. May need to be NPO if sedation or

contrast is usedc. Inform the client about the procedure

Postprocedurea. Control bleedingb. Monitor for infectionc. Manage paind. Inform the client how to obtain the results

B. Imaging- X-ray, ultrasound, MRI, Ct scan- Methods of obtaining information about

the presence, location and extend oftumor

Method chosen is based on1. ability to visualize tumor2. Risk3. Client comfort4. Cost

Preprocedurea. Assess for allergy if contrast is to be usedb. NPO depending on the area being

imaged, use of sedation or contrastc. Prepare patient for length of imaging,

possible noise of machinery, need toremain still.

d. Monitor the client for flushing, itching ornausea, indicating allergy to contrast.

Points to Remembera. Most client fear of death upon

confirmation of Cancerb. Clients usually ignored cardinal signs

of Cancerc. Most often cancer is detected during

routine examd. Questions that need to be answered:

Example (Is the disease curable ornot?)

Nursing Diagnosisa. Ineffective copingb. Anticipatory grievingc. Disturbed body imaged. Fatiguee. Impaired eliminationf. Hopelessnessg. Impaired oral mucous membrane

Common Cancer complainta. Nausea


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Impaired nutrition less than bodyrequirements

acute pain Impaired skin integrity Signs and symptoms of malignant

neoplasia Proliferation of Ca cells Pressure Obstruction

2. Pain ( late sign of Ca ) Pressure on nerve endings Distention of organs/vessels Lack of O2 to tissue and organ Release of pain mediators Pleural effusion and ascites

3. Ulceration and necrosis As tumor erodes BV and pressure on

tissue causes ischemia, tissue damage,bleeding and infection

Vascular throbosis, Embolus,Thrombophlebitis

Tumors tends to produce abnormalcoagulation factors

Paraneoplastic Syndrome1. Anemia Ca cells produces chemicals that

interfere with rbc production Iron uptake is greater in the tumor than

that deposited in the liver Blood loss from bleeding

2. Hypercalcemia Increases and acce;erates bone

breakdown and release of Calcium3. Anorexia Cachexia Syndrome Final outcome of unrestrained Ca growth Ca deprived normal cells nutrition Protein depletion, serum albumin

decreases Tumors take up Na Act in the satiety center causing anorexia Taste sensation diminishes

Pain: Cancer and End of Lifea. 30% of clients experience pain at the

time of diagnosis.

b. 30% to 50% experience pain whileundergoing therapy.

c. 70% to 90% experience pain as canceradvances and overcomes their defenses

d. Cancer pain is complex, interactive, andever-changing. It comes from twogeneral sources: the cancer itself, and itsvarious treatments

e. Cancer pain is more than a physicalsymptom. It is a reminder of onesmortality and a harbinger of death.

f. It interferes with normal routines,degrades the quality of life, and robs oneof rest, creativity, joy, and peace.

g. Cancer pain adds stress and worry to itssufferers and friends and family. For this

reason, healthcare professionalsh. Take pain seriously, recognizing thatonly the person in pain knows how itfeels.

i. Provide information and resources forpain control.

j. Communicate with genuineness,accurate empathy, and nonpossessivewarmth.

k. Encourage sufferers to share theirfeelings and network with other

survivors.l. Respect culture norms and wishes ofsufferers, maximizing their control

m. Encourage release of energy throughjoy-producing activities.

n. Monitor pain medications, effectiveness,and adverse effects

Management of Cancer1. Cure eradication of malignant diseases

2. Control prolonged survival and containment of

cancer cell growth3, Palliation relief of symptoms associated with the

disease

Therapeutic Modalities for Cancera. Surgeryb. Chemotherapyc. Radiation therapyd. Immunotherapye. Bone Marrow Transplantation

Surgery The ideal and most frequently used

Goalsa. Primaryb. Prophylacticc. Palliatived. reconstructive Removal of tissue for diagnosis, staging,

palliation or treatment of cancer. Most frequently used cancer therapy Most successful single therapy if cancer

has not spread Very often performed on an OPD or brief

stay basis

Diagnostic SurgeryBiopsyExcisional biopsy


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- most frequently used for easily accessibletumors of the skin, breast, ULGIT,URTI- provides the pathologist the cells and the entire

tissue- decreases the chance of seeding the tumor

Incisional Biopsy- used if the tumor mass is too large to beremoved- a wedge of tissue from the tumor is taken

Needle Biopsy- done on suspicious masses that are easily

accessible- fast, inexpensive and easily performed

Surgery as primary treatment- Remove the entire tumor or as much as

is feasible

1. Local excision- if the mass is small

2. Wide or Radical Excision- removal of the primary tumor, LN, adjacent and

surrounding tissue- results in disfigurement and altered function

3. Salvage surgery

Prophylactic Surgery- Removal of non-vital structures that are likely

to develop Ca

Palliative Surgery- when cure is not possible, the goal of treatment

is to make the patient as comfortable as possibleand to promote a satisfying and productive life foras long as possible

Radiation Therapy Used to control malignant disease when

a tumor cannot be removed surgically To relieve the symptoms of metastatic

disease, especially when the Ca spreadto the brain, bone.

A radiosensitive tumor is one that can bedestroyed by a dose of radiation that stillallows for cell regeneration in the normaltissue

Radiation Therapy Uses ionizing radiation to kill or limit the

growth of cancer cells. May be internal or

external Effect cannot be limited to cancer cells

only is a cancer treatment that uses high

doses of radiation to kill cancer cells andstop them from spreading. At low doses,radiation is used as an x-ray to seeinside your body and take pictures, suchas x-rays of your teeth or broken bones.

Radiation use in cancer treatment worksin much the same way, except that it isgiven at higher doses.

Radiation therapy is used to:

a. Treat cancer. Radiation can be used to cure,stop, or slow the growth of cancer.b. Reduce symptoms. When a cure is notpossible, radiation may be used to shrink cancertumors in order to reduce pressure. Radiation therapy used in this way can

treat problems such as pain, or it canprevent problems such as blindness orloss of bowel and bladder control.

Cells are most vulnerable to radiationduring DNA synthesis and mitosis

Most sensitive are those body tissue thatundergo frequent cell division. (BM,Lymphatic, GIT, gonads)

Tumors that are well oxygenated aremore sensitive to radiation

Cells most sensitive during M and G2phase

Radiosensitivity

Highly sensitive- ovaries, testes, bone marrow, blood, intestinesLow sensitivity- muscle, brain, spinal cord

TypesTeletherapy (External Beam)

a. x-rays are used to destroy cancerouscells at the skin surface or deeper

b. b. Used more commonlyc. Client is not radioactive during treatmentd. Simulation X-ray or Ct planning

session to identify the field which deliversmaximum radiation to the tumor andminimal to normal tissue. Involves skinmarkings

e. Administered in fractions of the full dose,5 days a week for 4-6 weeks

b. Brachytherapy (Internal)a. used primarily in the head and neck,

gynecologic, prostate cancerb. delivers a high dose of radiation in a

local area using implants

c. Client is radioactive only when implaint isin placed

d. plan cares efficiently to minimize nurses,exposure to implant, use shielding, weara film badge and maintain safe distance.

e. Pregnant nurses should not care forclients with implanted radiation

f. Pickup dislodge implants with longforceps placed in a special container.

g. Body fluids of clients treated withsystemic radioactive iodine are


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radioactive; fluids of client with implantsare not

Radiation Dosage The lethal tumor dose is defined as the

dose that will eradicate 95% of the tumoryet preserve normal tissue

Adverse Reactiona. Seen only in the organs in the radiation

field, except for systemic effects ofnausea, anorexia and fatigue

b.

Skin reactions are common andexpected with external beamc. Toxicityd. Localized to the area being irradiatede. Alteration in oral mucosa, stomatitis,

xerostomia, change and loss of taste,decreased salivation

f. Altered skin integrity, alopecia, erythema,shedding, desquamation

g. Thrombocytopeniah. Anemia

Radiation Safety Distance - the greater the distance the

lesser the exposure Time - the less time spent close to

radiation the less exposure (max of 30min per shift)

Shielding - use lead aprons andgloves

Standards - kept as low as reasonablyachievable

Monitoring device - film badge(measure the whole exposure of thenurse)

Side Effectsa. Skin: Itching, redness, burning, sloughing Keep skin free of foreign substance Avoid use of medicated solutions Avoid pressure, trauma, infection Avoid exposure to heat, cold or sunlight

b. Anorexia, vomitting, nausea

Provide small, attractive feedings Avoid extremes of temperatures Administer antiemetics before meals

c. Diarrhea Encourage low residue, bland, high

protein foods Provide good perineal hygine Monitor electrolytes, Na,K,Cl

d. Anemia. Leukopenia, thrombocytopenia Isolate patient provide frequent rest period

Encourage high protein diet Assess for bleeding Monitor lab results CBC, WBC, Plt

ChemotherapySystemic treatment with chemicals which destroyrapidly proliferating cellsUsed for cure in testicular, Hodgkin disease, ALL,neuroblastoma, Wilms and Burkitts lymphomaUsed to control breast, nod-Hodgkin, small celllung and ovarian cancerUsed palliative for relief of pain, obstruction andto improve comfort

What does chemotherapy do?Cure cancer- when chemotherapy destroyscancer cells to the point that your doctor can nolonger detect them in your body and they will notgrow back.Control cancer- when chemotherapy keepscancer from spreading, slows its growth, ordestroys cancer cells that have spread to otherparts of your body.Ease cancer symptoms (also calledpalliativecare) - when chemotherapy shrinks tumors thatare causing pain or pressure.

Chemotherapya. Chemotherapy works by stopping or

slowing the growth of cancer cells, whichgrow and divide quickly. But it can alsoharmhealthy cellsthat divide quickly,such as those that line your mouth andintestines or cause your hair to grow.Damage to healthy cells may cause sideeffects. Often, side effects get better orgo away after chemotherapy is over.

b. Sometimes, chemotherapy is used asthe only cancer treatment. But moreoften, you will get chemotherapy alongwith surgery,radiation therapy, orbiological therapy. Chemotherapy can:

c. Make a tumor smaller before surgery orradiation therapy. This is calledneo-adjuvant chemotherapy.

Destroy cancer cells that may remain after

surgery or radiation therapy. This is calledadjuvant chemotherapy.

Help radiation therapy and biological therapywork better.

Destroy cancer cells that have come back(recurrentcancer) or spread to other parts ofyour body (metastaticcancer).
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Cell CycleTime required for one tissue cell to divide andreproduce two identical daughter cells

Go resting phaseG1 RNA and protein synthesis occursS DNA synthesis occursG2 Premitotic phaseM cell division occurs

Chemotherapy may be given in many ways.Injection. The chemotherapy is given by a shotin a muscle in your arm, thigh, or hip or rightunder the skin in the fatty part of your arm, leg, orbelly.

Intra-arterial (IA). The chemotherapy goesdirectly into the artery that is feeding the cancer.Intraperitoneal (IP). The chemotherapy goesdirectly into theperitoneal cavity(the area thatcontains organs such as your intestines,stomach, liver, and ovaries).Intravenous (IV). The chemotherapy goesdirectly into a vein.Topically. The chemotherapy comes in a creamthat you rub onto your skin.Orally. The chemotherapy comes in pills,capsules, or liquids that you swallow.

Antineolplastic agentCell Cycle non-specific1. Alkylating agents- acts with DNA to hinder cell growth and

division- cisplatin, cyclophosphamide

2. Steroids and sex hormones- alter the endocrine environment to make it less

conducive to growth of cancer cells.3. Antitumor antibiotics- interfere with DNA synthesis by binding DNA.

Prevent RNA synthesis- Bleomycin, dactinomycin, doxorubicin,

mitomycin- cardiac toxicity (daunorubicin, doxorubicin)

Cell Cycle Specific (S phase)1. Antimetabolites- foster cancer cell death by interfering with

cellular metabolic process

-5-flouroracil, methotrexate, cytarabine- renal toxicity (methotrexate)

Cell cycle specific (M phase)1. Plant alkaloids- makes the host body a less favorable

environment for the growth of cancer cells- arrest metaphase by inhibiting mitotic tubular

formation. Inhibit DNA and RNA synthesis-vincristine, vinblastine- Taxanes: Paclitaxel (bradycardia)

Chemotherapya. Used to treat systemic diseases rather

than localized lesions that are amenableto surgery and radiation

b. Used in an attempt to destroy tumor cellsby interfering with cellular function andreproduction

c. Use of chemicals to destroy cancer cellsd. Interferes DNA & RNA activities

associated with cell divisione. Often used in combination with radiation

therapyf. Cytotoxic - is an agent capable of

destroying cellsg. Cytotoxic drug - alkylating and

antimetabolites

h.

Can be combined with surgery orradiation therapyi. Used to reduce the tumor size

preoperatively and to destroy theremaining tumor cells preoperatively

j. Eradication of 100% of tumor is nearlyimpossible

k. Goal is to eradicate enough of the tumorso that the remaining tumor cells can bedestroyed by the immune system

Contraindicationa. Infectionb. Recent surgeryc. Impaired renal or hepatic functiond. Recent radiation therapye. Pregnancyf. Bone marrow depression

Extravasation cause tissue necrosis anddamage to tendons, nerves and blood vessels

Major side effectsGI System1. Nausea and vomitting

- administer anti-emetics- NPO 4-6 hrs before chemotherapy- bland diet foods in small amounts after

treatment

2. Diarrhea3. Stomatitis- Good oral hygiene- rinse with viscous lidocaine before meals- rinse with plain water or hydrogen peroxide

after meals- apply water soluble lubricants- Suck popsicle to provide moisture

Hematologic (Myelosuppression)1. Thrombocytopenia- Avoid bumps or bruishing- protect client from physical injury- Avoid aspirin- Avoid IM injections- Assess for bleeding tendencies

b. Leukopenia
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- use careful handwashing- reverse isolation if WBC


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changing self-perception, and memory ofother persons suffering (

Ethical Issues

caring can be just successful ascuring;when curing is not an option

care is exercised during the finalstage of life

Goals of Intervention to care without functional and

structural impairment

if cure is not possible goals must= prevent further metastasis= relieve symptoms= maintain high quality of life

Bone Marrow Transplant

Used in the treatment of leukemia forclients who have closely matched donors

and experiencing temporary remissionwith chemotherapy

Severe aplastic anemia, breast Ca, brainCa

TypesAutologous

- own bone marrow, most common typeAllogenic

- transplant from a genetically non-identicaldonor- sibbling most common type

procedure

1. Harvest through multiple aspiration from theiliac crest to retrieve sufficient bone marrow forthe transplant

- 500ml- 1000ml2. Conditioning- immunosuppressant therapy is given to

eradicate all malignant cells3. Transplantationa. administered through central line like BTb. infused 30 min

4. Engraftmenta. transfused BM move to marrow forming sitesb. occurs when WBC, erythrocytes, plt ct begin

to rise

c. takes 2-5 weeks

Complications:a. Failure of engraftment.b. Infection: higher risk 3-4 weeksc. Pneumonia: principal cause of death

during first three monthsd. Graft vs host disease principal

complication

a. Acute 1st 100 days post transplant

b. Chronic 100-400 days

Nursing Care: Pretransplant

1. Provide protected environment- strict reverse isolation2. Monitor central lines frequency

3. Provide care receiving chemotherapy

Post transplant

Prevent infection Maintain protective environment Administer antibiotics Check IV set ups q12hrs

2. Provide mouth care for stomatitis andmucositis3. Monitor carefully for bleedinga. check for occult blood in emesis, stools

b. observe for easy bruisingc. Check platelet ct dailyd. replaced blood component4. Maintain fluid and electrolyte balance5. Provide client health teaching

Nursing Assessmenta. Weight lossb. Frequent infectionc. Skin problemsd. Paine.

Hair Lossf. Fatigue

g. Disturbance in body image/ depressionh. Managing effects of Cancer and

treatment

Pain

1. Descriptiona. Whatever the client says it is, whenever the

client says it exists.b. may be caused by treatment, cancerdestruction of tissue or pressure or pressure onnearby structures and cancer progressionc. Bone metastasis are very common cause

Nursing Interventionsa.. Assess all clients for pain even if they do notappear to be experiencing it.b. Educate clients and families about narcoticuse1. Correct use of narcotics results in addiction in


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f. Meperidine (demerol) is seldom used to treatcancer pain because it metabolizes andaccumulates during extended use.

Myelosuppression

- reduced numbers of white and red blood cellsand platelets associated with cancer or treatment- Neutropenia


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Thrombocytopenia (


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2.Provide information about post-op care andstoma care3. Administer antibiotics 3-5 day priorColon cancerNURSING INTERVENTION

Pre-Operative care4. Enema or colonic irrigation the evening andthe morning of surgery5. NGT is inserted to prevent distention6. Monitor UO, F and E, Abdomen PEColon cancer

NURSING INTERVENTIONPost-Operative care1. Monitor for complicationsa. Leakage from the site

b. prolapse of stomac. Infectiond. Bowel obstruction

2. Assess the abdomen for return of peristalsis

Colostomy CarePrevent skin breakdown- cleans skin around stoma with mild soap, water

and padding motion- assess skin regularly for irritation- avoid use of adhesive on irritated skin

Control odor- change pouch- empty bag frequently and provide ventilation,

use deodorizer- Avoid gas producing foods

Promote adequate stomal drainage- assess stoma for color and intactness- mucoid/serosanguinous drainage 1st 24hrs- assess for flatus

Irrigate colostomy as needed- position client on toilet or high fowlers- fill irrigation bag with water (500-1000ml)- Remove old pouch and clean skin- lubricate catheter and insert to stoma- allow fecal contents to drain

Provide adequate nutrition2500ml liquids/day

Health teaching when dischargea. change in odor, consistency and color of stoolb. bleeding from stomac. persistent constipation and diarrhead. persistent leakage around the stoma

e. skin irritation

Colon cancerNURSING INTERVENTION: COLOSTOMYCAREColostomy begins to function 3-6 days aftersurgeryThe drainage maybe soft/mushy or semi-soliddepending on the siteColon cancer

NURSING INTERVENTION: COLOSTOMYCARE

BEST time to do skin care is aftershower

Apply tape to the sides of the pouchbefore shower

Assume a sitting or standing position inchanging the pouch

NURSING INTERVENTION: COLOSTOMYCARE

Instruct to GENTLY push the skin downand the pouch pulling UP

Wash the peri-stomal area with soap andwater

Cover the stoma while washing the peri-stomal area

Lightly pat dry the area and NEVER rub Lightly dust the peri-stomal area with

nystatin powder

Colon cancerNURSING INTERVENTION: COLOSTOMYCAREEmpty the pouch or change the pouch when1/3 to full (Brunner) to 1/3 full (Kozier)

Breast CancerThe most common cancer in FEMALESNumerous etiologies implicated

RISK FACTORS1. Genetics- BRCA1 And BRCA 22. Increasing age ( > 50yo)3. Family History of breast cancer4. Early menarche and late menopause5. Nulliparity6. Late age at pregnancy

Breast Cancer7. Obesity8. Hormonal replacement9. Alcohol10. Exposure to radiation

PROTECTIVE FACTORS1. Exercise2. Breast feeding3. Pregnancy before 30 yo

Stages I and 2 are 70-90% curableInvasive or infiltrating, capable of metastasisa. Ductal 70%b. Lobular 10 % higher incidence ofcontralateral breast cancer

Breast CancerASSESSMENT FINDINGS1. MASS- the most common location is the upperouter quadrant

2. Mass is NON-tender. Fixed, hard with irregularborders


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3. Skin dimpling4. Nipple retraction5. Peau d orangeBreast CancerLABORATORY FINDINGS

1. Biopsy procedures2. Mammography3. Tumor marker CA 2729

Breast CancerBreast cancer StagingTNM stagingI - < 2cmII - 2 to 5 cm, (+) LNIII - > 5 cm, (+) LNIV- metastasis

Metastatic sitesa. Boneb. Liverc. Lungd. Brain

TreatmentSurgical management is the primary treatmentfor breast cancerBreast conservation (lumpectomy, segmentalresection)- removal of the cancer with margin of healthy

tissue- If followed by radiation therapy has equivalent

5 year survival to mastectomy

Simple removal of all breast, nipple and skinModified radical axillary lymphnodes areremovedRadical mastectomy pectoral muscles areremoved

Medical therapyExternal beam radiation therapy 3 weeks aftersurgery. Most commonly usedChemotherapyTamoxifen therapy

Breast Cancer

NURSING INTERVENTION : PRE-OP1. Explain breast cancer and treatment options2. Reduce fear and anxiety and improve coping

abilities3. Promote decision making abilities4. Provide routine pre-op care:Consent, NPO, Meds, Teaching about breathingexercise

Breast Cancer

NURSING INTERVENTION : Post-OP

1. Position patient:SupineAffected extremity elevated to reduce edemaBreast Cancer2. Relieve pain and discomfort

Moderate elevation of extremityIM/IV injection of pain medsWarm shower on 2nd day post-opBreast Cancer3. Maintain skin integrityImmediate post-op: snug dressing with drainageMaintain patency of drain (JP)Monitor for hematoma w/in 12H and applybandage and ice, refer to surgeon3. Maintain skin integrityDrainage is removed when the discharge is less

than 30 ml in 24 HLotions, Creams are applied ONLY when theincision is healed in 4-6 weeks

Promote activitySupport operative site when movingHand, shoulder exercise done on 2nddayPost-op mastectomy exercise 20 mins TIDNO BP or IV procedure on operative site

Promote activityHeavy lifting is avoidedElevate the arm at the level of the heartOn a pillow for 45 minutes TID to relievetransient edema

NURSING INTERVENTION : Post-OPMANAGE COMPLICATIONSBreast CancerLymphedema10-20% of patientsElevate arms, elbow above shoulder and handabove elbowHand exercise while elevatedRefer to surgeon and physical therapistBreast Cancer

NURSING INTERVENTION : Post-OPMANAGE COMPLICATIONSHematomaNotify the surgeonApply bandage wrap (Ace wrap) and ICE pack

Breast Cancer

NURSING INTERVENTION : Post-OPTEACH FOLLOW-UP careRegular check-upMonthly BSE on the other breastAnnual mammographyLung CaThe number 1 cancer killer in men and women

6th to 7th decade of life 70% involvement of lymphnodes 85% caused by inhalation of

carcinogenic chemicals


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PathophysiologyArise from a single transformed epithelial cell inthe tracheobronchial airways.

Adenocarcinoma - most prevalent carcinoma of

the lung for men and women, peripherally locatedand often metastasizedSquamous cell Ca centrally located and arisesin the segmental and subsegmental bronchiLarge cell Ca fast growing tumor that ariseperipherallyBronchioalveolar slower growing and arises atthe alveoli

Classification and stagingNon small cell Ca 70-75%

a. Adenocarcinoma- most common (40%)- slowest growing, metastasize earlyb. Squamous cell 30%c. Large cell rarest- has the worst prognosis

Small cell (25%)a. Oat cell (90%)- very aggressive and metastasize at diagnosis.

5 year survival rate is 48% if detected early andlocalize (rare)Overall 5 year survival rate is 15%

Risk factorsTobacco smoking- single most important preventable cause of

death- 10x more common than in non-smoker- passive smoke exposure increases the risk to

35%Environmental and occupational exposure- arsenic, asbestos, mustard gas, oil, radiation

.geneticsDietClinical manifestationDevelops insidiously and is assymptomatic untillate in the courses/sx depends on the location and size of thetumor, degree of obstruction and metastasisCough or chronic cough- dry, persistent without sputum production

WheezingHemoptysis or blood tinged sputumChest and shoulder pain

Common sites of metastasis LN Bone Brain Contralateral lung Adrenal glands liver

Screening test: No screening program currentlyexist.

Assessment:

Clients are very rarely symptomatic atthe time of diagnosis.

Persistent cough and dyspnea Recurrent bronchitis and pneumonia Blood streaked sputum Chest pain

Diagnosticsa. Chest xray (solitary peripheral nodule,

coin lesion)b. Ct scan of the chestc. Fiberoptic bronchoscopyd. Fine needle biopsy under ct scan

Surgical ManagementDependent on whether the tumor is resectable

May be cure for non small cell if no metastasisoccurred and lung function is sufficient onremoval of all or part of the lungs (50%)

Lobectomy removal of lobe (common)Pneumonectomy removal of the lungSegmentectomy partial removal of the lunglobe

Adjuvant therapya. Chemotherapy is the primary treatment for

small cellb. Radiation is standard post op for advancednon-small cell

Radiation therapy for localized intrathoraciclung ca and palliation for hemprtysis, obstructiondysphagia and pain

Nursing InterventionAssess for signs of superior vena cava syndromePostlobectomy, manage chest tube

Assess respiration and for presence ofpneumothorax or atelectasisPosition properly post-op1. Lobectomy avoid prolonged lying on theoperative site2. Pneumonectomy position on the back oroperative side onlyInstruct the client on deep breathing, coughingand ambulationPain management to promote deep breathingRefer client to smoking cessation

Prostate Cancer

a slow growing malignancy of theprostate gland

Usually an adenocarcinoma This usualy spread via blood stream to

the vertebrae

2ndmost common cause of cancerdeaths

190000 new cases each year and30,000 deaths annually


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Over 80% are diagnosed in early stages.Allowing an almost 100% 5 year survivalrate.

Overall for all stages survival is 96%Prostate Cancer

Predisposing factor Age Strong family history High fat diet may play a role Having a vasectomy may play a role

Prostate CancerAssessment Findings

DRE: hard, pea-sized nodules on theanterior rectum

Hematuria Urinary obstruction Pain on the perineum radiating to the leg

Prostate CancerDiagnostic tests1. DRE2. Prostatic specific antigen (PSA)3. Elevated SERUM ACID PHOSPHATASEindicates SPREAD or MetastasisSurgical Management

Radical prostatectomy removal of prostate,capsule, ejaculatory ducts, seminal vesicles pluslymphnodesWatchful waiting without intervention may beappropriate in men over 70 years of age withsmall, early stage cancersProstate CancerMedical and surgical managementProstatectomyTURPChemotherapy: hormonal therapy to slow the

rate of tumor growth

Nursing InterventionsPrepare patient for chemotherapyPrepare for surgery

Nursing Interventions: Post-prostatectomy1. Maintain continuous bladder irrigation.

Note that drainage is pink tinged w/in 24hours

2. Monitor urine for the presence of bloodclots and hemorrhage

3. Ambulate the patient as soon as urinebegins to clear in color

4. Provide for bladder retraining after foleycatheter removala. Perineal exercisesb. restrict caffeinec. limit fluid intake at nigth

5. Educationa. Avoid lifting, straining, and prolonged travelb. possible impotence

Bladder Cancer

Transitional cell carcinoma most common (90-95%)Approximately 54300 new cases and 12400deathsNo screening for early detection

Risk factors

Smoking Occupational exposures Caucasian males >50 years old

Asessment

Gross, painless hematuria Dysuria Urinary frequency Urgency Urinary hesitancy Suprapubic, rectum, back pain

Diagnostic1. Urinary cytology late morning or early

afternoon2. Bladder washing more reliable3. Flow cytometry exdamine DNA content

of urine cells4. IVP evaluate upper urinary tracts5. Cystoscopy tumor visualization and

biopsy6. CT scan, transurethral ultrasound, MRI7. Tumor marker p53 and epidermal

growth factor in late stage

Surgical management1. Transurethral resection and fulguration

(Destruction of surrounding tissue withelectricity) most common for low gradeCa

2. Radical cystectomy (bladder, prostate,seminal vesicles, urethra, overy, FT areremoved) for high grade tumors

3. Adjuvant therapy4. Radiation therapy used in invasive

cancer5. Chemotherapy cisplatin, methotrexate,

vincristine

Nursing interventions

Instruct on preop low residue and clearliquid diet

Assess for urinary stoma and teachmaintainance of ileal conduit andappliance

Assess urinary output (should produceurine immediately) for infection and signsof peritonitis

Discuss possible sexual dysfunctionSkin cancer


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Malignant lesion of the skin, which may or maynot metastasizedTypesa. Basal cell most common type arising fromthe basal cells contained in the epidermis

b. Squamous Cell 2nd

most common type inwhites.tumor of the keratinocytes Metastasized tothe LN and fatalc. Malignant melanoma can metastasized tothe brain, lung, bone, skin. Fatal

SKIN CANCERCauses: UV light exposure, chronic irritation andfrictionDx: skin biopsyS/sx: change in color, size, shape of lesion

Monitor lesions that do not heal Removed moles or lesions that are

subject to chronic irritations

Avoid contact with chemical irritants Use sun screen lotions and clothing Avoid sun exposure between 11am-3pm Contact Dermatitis Inflammatory response after contact with

a specific antigen

Assessment: Pruritus and burning Edema Erythema at the point of contact

Signs of infectionVesicles with drainage

Gastric Cancer

Approximately 22000 cancers and 13,000 deathsper yearAfrican americans, japanese, chinese and US

have higher incidence95% are adenocarcinomasPrognosis is poor, 5 year survival rate is 5-15 %

Risk factors

Male > 40 years of age Low socioeconomic status Poor nutritional health habits and vitamin

A deficiency

Family history Previous gastric resection Pernicious anemia H. pylori infection Gastric atrophy and chronic gastritis Rubber workers and coal miners

Metastatic sitesDirect extension to the pancreas, liver,esophagus.Intraperitoneal dissemination to ovaryNodal spread to the neckBloodstream metastasis to the lung, adrenal,liver, bone and peritoneal cavity

ScreeningAmong high risk persons onlyBarrium x-ray or endoscopy

AssessmentEarly manifestations are non-specificUpper epigastrium, retrosternal painUneasy sense of fullness after mealsLoss of appetiteNausea and vomitingWeaknessFatigueanemia

Diagnostic procedure

EGDBiopsyEndoscopic ultrasoundDouble contrast upper GI seriesCT scan

Surgical managementOnly treatment that is potentially curativea. Total gastrectomyRadical subtotal gastrectomya. Billroth Ib. Billroth IIb. Proximal subtotal gastrectomy

Paliation of symptomsAdjuvant therapyExternal beam radiation for control ofunresectable tumors, palliation and increasedsurvival.Chemotherapy has little impact 5 FU,doxorubicin, mitomycin

Nursing Intervention

Goal is control of clinical manifestationand supporting optimal functioning

Assess the nutritional status- small frequent feeding low carbohydrate,

high fat, high protein.- restrict fluids 30 minutes after meals

reducing risk of dumping syndrome

Postoperative- Respiratory status: reflux aspiration- Infection- Pain potential anastomotic leak

obstruction- Bezoar (food clumping) formation

causing gastric outlet obstruction- Bleeding- Dumping syndrome- anemia

Cervical Cancer

13,000 new cancers and 4000 deaths


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Very treatable and curable80-90% are squamous carcinoma

Risk factorsSexual intercourse before age 17, multiple

partnersSexual partner who has multiple partnersCigarette smokingHuman papilloma virusLower socioeconomic status

Metastatic sitesAbdomen and pelvisLungLiverBone

ScreeningPaps smear beginning at age 18 or sexuallyactive

assessment- Assymptomatic in the early stage- Watery vaginal discharge- Late manifestation, postcoital, heavy or

intermenstrual bleeding.

diagnosticsColposcopy application of acetic acid followedby magnified examination of the pelvisBiopsyEndocervical curettageCone biopsy

ManagementTotal abdominal hysterectomy andlymphadenectomyDepends on the stage and desire for childbearingRadiation therapyChemotherapy for advanced diseaseLaser therapy- used when all boundaries of the lesion are

visible during colposcopic examination.- minimal bleeding is associated with the

procedure.- slight vaginal discharge is expected following

the procedure and healing occurs in 6 to 12

weeks.Conization- a cone shaped area of the cervix is removed- performed in women who desire further

childbearing.- long term follow up care is needed, as new

lesions can develop- the risk of procedure includes hemorrhage,

uterine perforation, incompetent cervix andpreterm labor in future pregnancies.Hysterectomy

For microinvasive cancer if childbearing is notdesired.A vaginal approach is most commonlyperformed.A radical hysterectomy and bilateral lymphnode

dissection may be performed for cancer that hasspread beyond the cervix but not to the pelvicwall.

Nursing interventionAssess for changes in bowel and bladder patternBladder trainingIf laser surgery for early diseases is used,instruct to avoid douching, tampoons and sexualactivity for 2-4 weeksAssess for sexual dysfunction, surgical

shortening of vagina, vaginal dryness

Leukemia white blood neoplastic proliferation of

one particular cell type. Unregulated proliferation of WBCs in the

bone marrow Classified into lymphoid or myeloid,

acute and chronic Acute Myeloid leukemia Defect in hematopoetic stem cells that

differentiate into all myeloid cells. All age group are affected and incidence

increases with age with peak at age 60 With treatment patients survive an

average of 1 year with death usually dueto infection or hemorrhage.

Clinical manifestation Most of signs and symptoms evolve from

insufficient production of normal bloodcells.

Fever, infection, weakness, fatigue,bleeding tendencies.

Pain from enlarged liver and spleen Hyperplasia of gums Diagnostics CBC, decrease erythrocytes and

platelets Bone marrow aspiration, excess of

immature blast cells (>30%) Medical management The objective is to achieve complete

remission by aggressive chemotherapycalled induction therapy.

High doses of cytarabine anddaunorubicin

The aim is eradication of leukemic cellsbut it is often accompanied byeradication of normal type of myeloidcells.

Consolidation therapy (postremissiontherapy) eliminate any residual leukemiacells that are not clinically detectable,diminishing the chance of remission.

70% experience relapse


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Consolidation therapy (postremissiontherapy) eliminate any residual leukemiacells that are not clinically detectable,diminishing the chance of remission.

70% experience relapse

Chronic Myeloid Leukemia Arises from mutation in the myeloid stem

cell. Normal myeloid cells continue toproduced, but there is preference forimmature (blast) forms.

Uncontrolled proliferation results inmarrow expansion of long bones, liverand spleen resulting in pain.

Chromosome 22 (philadelphiachromosome) and chromosome 9 (BCR-ABL gene) producing an abnormal

protein (tyrosine kinase) causing WBCto divide rapidly. Common in 40 50 years old Median life expectancy of 3 to 5 years Patient is usually assymptomatic WBC exceeds to 100000/mm3. Shortness of breath or confused due to

decrease capillary perfusion of brain andlungs from leukostasis.

Treatment Imatinib mesylate (Gleevec) tyrosine

kinase inhibitor blocking BCR-ABLprotein preventing cells to divide.

Avoid antacid, grape juice andacetaminophen

Treatment Imatinib mesylate (Gleevec) tyrosine

kinase inhibitor blocking BCR-ABLprotein preventing cells to divide.

Avoid antacid, grape juice andacetaminophen

Correction of chromosome abnormality Interferon alfa and cytosine administered

subcutaneously daily. Many patient cannot tolerate profound

fatigue, depression, anorexia, mucositisand inability to concentrate.

Leukopheresis blood of patient isremoved and seperated, leukocytesremoved and remaining blood returned.Causing temporary decrease in WBC.

Acute Lymphocytic Leukemia Uncontrolled proliferation of immature

cells (lymphoblast) Common in young children, with boys

affected more than girls >80% of children survive at least 5 years Clinical manifestation Immature lymphocytes proliferate in

bone marrow Decrease WBC, RBC and platelets Leukemic cell infiltration causing pain

from enlarged liver, spleen, bone pain,headache and vomiting

Treatment

Very sensitive to corticosteroids andvinca alkaloids

Prophylaxis of intrathecal chemotherapy(methotrexate)

Chronic Lymphocytic Leukemia

Common malignancy in older adults >60years old. Average survival time ranges from 14

years to 2.5 years Most of cells are fully mature Clinical Manifestation Enlargement of lymphnodes, painful Splenomegally B symptoms constellation of

symptoms including fever, drenchingsweating, and unintentional weight loss.

Absent reaction to skin test (Anergy) Treatment

Chemotherapy with corticosteroid andchlorambucil (leukeran)

Fludarabine (fludara) frontline therapymajor side effect is prolonged bonemarrow supression

Treatment Chemotherapy with corticosteroid and

chlorambucil (leukeran) Fludarabine (fludara) frontline therapy

major side effect is prolonged bonemarrow supression

Lymphomas Neoplasms of cells of lymphoid origin Usually starts in lymph nodes Hodgkins Lymphoma Rare malignancy that has impressive

cure rate. Common in men than women peaks at

early 20s and after 50 years Malignant is Reed-Sternberg cells

(hallmark of the disease) Clinical Manifestation Painless enlargement of one or more

lymphnodes on one side of the neck.(cervical, supraclavicular and mediatinal)

Mediatinal mass on chest x-ray Pain after drinking alcohol B symptoms Diagnosis Excisional lymphnode biopsy finding

Reed-Sternberg cells Elevated ESR and serum copper level

assess disease activity. Treatment The intent in treating is cure regardless

of the stage of the tumor. Shortcourse chemotherapy followed by

radiation therapy ABVD standard of treatment, Adriamycin,

Bleomycin, Vinblastine, Decarbazine Non Hodgkins Lymphoma Involved malignant B lymphocytes Incidence increases with age at

diagnosis of 50 to 60 years old.


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Common in immunodeficiencies orautoimmune disorders

Clinical manifestation At early stage symptoms are virtually

absent until late in the course

Lymphadenopathy in the later stage andB symptoms management Radiation alone in early non aggressive

tumor.

Oncologic Emergencies Superior Vena Cava Syndrome (SVCS Compression or invasion of the superior

vena cava by tumor, enlarged lymphnodes, intraluminal thrombus that

obstructs venous circulation, or drainageof the head, neck, arms, and thorax. Typically associated with lung

cancer,SVCS can also occur withlymphoma and metastases.

If untreated, SVCS may lead to cerebralanoxia (because not enough oxygenreaches the brain),laryngeal edema,bronchial obstruction,and death.

Gradually or suddenly impaired venousdrainage giving rise to

Progressive shortness of breath(dyspnea),cough, and facial swelling Edema of the neck, arms, hands, and thoraxand reported sensation of skin tightness anddifficulty swallowing Possibly engorged and distendedjugular,temporal, and arm veins Dilated thoracic vessels causing prominentvenous patterns on the chest wall Increased intracranial pressure, associatedvisual disturbances, headache, and alteredmental statusDiagnostic

Diagnosis is confirmed by Clinical findings Chest x-ray Thoracic CT scan MRI.

Treatment Radiation therapy to shrink tumor size andrelieve symptoms Chemotherapy for radiation-resistant tumor (eg,

lymphoma or small cell lung cancer) or when themediastinum has been irradiated to maximumtolerance Anticoagulant or thrombolytic therapy forintraluminalthrombosis Surgery (less common), eg, vena cava bypassgraft (synthetic or autologous) to redirect bloodflow around the obstruction Supportive measures such as oxygentherapy,corticosteroids, and diuretics

Treatment Radiation therapy to shrink tumor size andrelieve symptoms Chemotherapy for radiation-resistant tumor (eg,lymphoma or small cell lung cancer) or when the

mediastinum has been irradiated to maximumtolerance Anticoagulant or thrombolytic therapy forintraluminalthrombosis Surgery (less common), eg, vena cava bypassgraft (synthetic or autologous) to redirect bloodflow around the obstruction Supportive measures such as oxygentherapy,corticosteroids, and diuretics

Nursing Intervention Monitor and report clinical manifestations ofSVCS. Monitor cardiopulmonary and neurologic status. Facilitate breathing by positioning the patientproperly. This helps to promote comfort andreduce anxiety produced by difficulty breathingresulting from progressive edema. Promote energy conservation to minimizeshortness of breath. Monitor the patients fluid volume status andadminister fluids cautiously to minimize edema

Spinal Cord Compression Potentially leading to permanent

neurologic impairment and associatedmorbidity and mortality, compression ofthe cord and its nerve roots may resultfrom tumor, lymphomas, or intervertebralcollapse.

The prognosis depends on the severityand rapidity of onset.

About 70% of compressions occur at thethoracic level, 20% in the lumbosacrallevel, and 10% in the cervical region.

Metastatic cancers (breast, lung, kidney,prostate, myeloma, lymphoma) andrelated bone erosion are associated withspinal cord compression.

Clinical manifestation Local inflammation, edema, venous

stasis,and impaired blood supply tonervous tissues

Local or radicular pain along thedermatomal areas innervated by theaffected nerve root

Pain exacerbated by movement,coughing, sneezing, or the Valsalvamaneuver

Neurologic dysfunction, and relatedmotor and sensory deficits (numbness,tingling, feelings of coldness in theaffected area, inability to detectvibration,loss of positional sense)

Motor loss ranging from subtle weaknessto flaccid paralysis

Treatment


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Radiation therapy to reduce tumor size tohalt progression and corticosteroidtherapy to decrease

inflammation and swelling at the compressionsite

Surgery only if symptoms progressdespite radiation

therapy or if vertebral fracture leads to additionalnerve damage

Chemotherapy as adjuvant to radiationtherapy

for patients with lymphoma or small cell lungcancer

Nursing Intervention Perform ongoing assessment of

neurologic function to identify existing

and progressing dysfunction. Control pain with pharmacologic andnonpharmacologic

measures. Prevent complications of immobility

resulting from pain and decreasedfunction

Maintain muscle tone by assisting withrange-ofmotion

exercises in collaboration with physical andoccupational therapists.

Institute intermittent urinarycatheterization and bowel trainingprograms for patients with bladder orbowel dysfunction.

Nursing Intervention Perform ongoing assessment of

neurologic function to identify existingand progressing dysfunction.

Control pain with pharmacologic andnonpharmacologic

measures. Prevent complications of immobility

resulting from pain and decreasedfunction

Maintain muscle tone by assisting withrange-ofmotion

exercises in collaboration with physical andoccupational therapists.

Institute intermittent urinarycatheterization and bowel trainingprograms for patients with bladder orbowel dysfunction.

Hypercalcemia In patients with cancer, hypercalcemia is

a potentially life-threatening metabolicabnormality resulting when the calcium releasedfrom the bones is more than the kidneys canexcrete or the bones can reabsorb.

Clinical manifestation Fatigue, weakness, confusion, Decreased level of responsiveness,

hyporeflexia, nausea, vomiting, constipation, polyuria (excessive urination), polydipsia

(excessiv

Nursing Intervention Identify patients at risk for hypercalcemia

and assess for signs and symptoms ofhypercalcemia.

Teach at-risk patients to recognize andreport signs and symptoms ofhypercalcemia.

Encourage patients to consume 2 to 3 Lof fluid daily unless contraindicated byexisting renal or cardiac disease.

Explain the use of dietary andpharmacologic interventions such asstool softeners and laxatives forconstipation.

Nursing Intervention Identify patients at risk for hypercalcemia

and assess for signs and symptoms ofhypercalcemia. Teach at-risk patients to recognize and

report signs and symptoms ofhypercalcemia.

Encourage patients to consume 2 to 3 Lof fluid daily unless contraindicated byexisting renal or cardiac disease.

Explain the use of dietary andpharmacologic interventions such asstool softeners and laxatives forconstipation.

Cardiac Tamponade Cardiac tamponade is an accumulation

of fluid in the pericardial space. The accumulation compresses the heart

and thereby impedes expansion of theventricles and cardiac filling duringdiastole.

As ventricular volume and cardiac outputfall, the heart pump fails, and circulatorycollapse develops.

CARDIAC TAMPONADEASSESSMENT FINDINGS

1. BECKs Triad- Jugular veindistention, hypotension anddistant/muffled heart sound

2. Pulsus paradoxus 3. Increased CVP 4. decreased cardiac output Treatment Pericardiocentesis (the aspiration or

withdrawal of the pericardial fluid by a large-bore

needle inserted into the pericardial space). CARDIAC TAMPONADE

NURSING INTERVENTIONS 1. Assist in PERICARDIOCENTESIS 2. Administer IVF 3. Monitor ECG, urine output and BP 4. Monitor for recurrence of

tamponade Pericardiocentesis Patient is monitored by ECG Maintain emergency equipments


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Elevate head of bed 45-60 degrees Monitor for complications- coronary

artery rupture, dysrhythmias, pleurallaceration and myocardial trauma

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