Oncology  Branch of medicine that deals with the study, detection, treatment and management of cancer and neoplasia

 In the Philippines, cancer ranks third in leading causes of morbidity and mortality after communicable diseases and cardiovascular diseases  In the Philippines, 75% of all cancers occur after age 50 years, and only about 3% occur at age 14 years and below  If the current low cancer prevention consciousness persists, it is estimated that for every 1800 Filipinos, one will develop cancer annually  most Filipino cancer patients seek medical advice only when symptomatic or at advanced stages: for every two new cancer cases diagnosed annually, one will die within the year  The top cancer sites in the Philippines include those cancers whose major causes are known (where action can therefore be taken for primary prevention), such as cancers of the lung/larynx (anti-smoking campaign), liver (vaccination against hepatitis B virus), cervix (safe sex) and colon/rectum/stomach (healthy diet). Except for the liver, the top Philippine cancer sites are also the top cancers worldwide Terms to Define a. Hyperplasia increase in the number of cells b. Metaplasia conversion of one cell to another cell c. Dysplasia bizarre cell growth resulting in difference in size, shape and arrangement d. Anaplasia cells that lack normal cellular characteristic e. Neoplasia uncontrolled cell growth Predisposing Factors a. Age Older individuals are more prone to Ca b. Sex women breast, uterus, cervix cancer Men prostate, lung Ca c. Urban Vs Rural d. Geographic Distribution e. Occupation f. Hereditary g. Stress h. Precancerous lesions Pigmented moles, burn scars, benign polyps, adenoma, fibrocystic disease of the breast i. Obesity - Breast and colorectal Ca Cancer Incidence Carcinogenesis a. Initiation

- first step, chemicals, physical factors and biologic agents, escape the normal enzymatic mechanisms and alter the genetic structure of the cellular DNA - normally these alterations are reversed by DNA repair mechanism or programmed cellular suicide (apoptosis) 2. Promotion - Repeated exposure Causes expression of abnormal or mutant genetic information - Proto-oncogenes, on switch Ca suppressor genes, turn off P53 gene, a tumor suppressor gene regulates whether cells repair or die after DNA is damaged 3. Progression -Third step of cellular carcinogenesis The cellular changes formed during initiation and promotion now exhibit increased malignant behavior Etiologic Factors 1. Viruses Oncogenic viruses a. Epstein Bar virus, burkitts lymphoma, nasopharyngeal Ca, non-Hodgkin and hodgkins lymphoma b. Herpes simplex Type II, cytomegalovirus and HPV type 16,18,31,33, Cervix Ca c. HIV, kaposi sarcoma d. H. pylori, gastric Ca 2. Physical Agents - Ultraviolent rays, especially in fair skinned blue or green eyed people, skin Ca - Radiation from x-ray or nuclear, leukemia, multiple myeloma, Ca of lung, bone, breast and thyroid 3. Hormones - Oral contraception or HRT, Inc. incidence of hepatocellular, endometrial and breast Ca

4. Chemical Agents - 75% related to environment Tobacco smoking, single most lethal carcinogen, 30% of Ca deaths, lung, head and neck esophagus, bladder panceas, cervix ca chewing tobacco, ca of the oral cavity in men younger than 40 years old 5. Industrial compounds - Vinyl chloride (plastics, asbestos) Polycyclic aromatic hydrocarbons (burning, auto and truck emission) Fertilizers and weed killers Dyes, (analine dyes, hair dyes) 6. Dietary Factors Carcinogenic fats, alcohol, salt cured or smoked meats, high caloric content

Proactive - high fiber, Cruciferous vegetables ( cabbage, broccoli, cauliflower, brussels, sprouts) Carotenoids (carrots, tomatoes, spinach, apricots, peaches, dark green and yellow vegetables), vit E, C, zinc and selenium 7. Genetics - Oncogenes ( hidden/repressed genetic code for Ca that exist in all individual 8. Age: Advancing age is a significant risk factors 9. Immunologic Factors a. Immunosuppressed individuals more susceptible to cancer Characteristics of Ca a. Metastasis 1. Lymphatics - the most common mechanism breast tumors, axillary, clavicular, and thoracic LN 2. Hematogenous - disseminated through the blood stream related to the vascularity of the tumor Angiogenesis ability to induce the growth of new capillaries from the host tissue to meet the nutrients and oxygen Classification and staging Tissue of Origin Carcinoma: a. Squamous cell Ca surface epithelium b. Adenocarcinoma glandular or parenchymal c. Sarcoma connective tissue d. Leukemia, Lymphoma B. Staging determines the size of the tumor and the existence of metastasis TNM Classification T extent of primary tumor N absence or presence and extent of regional lymph node metastasis M absence or presence of distance metastasis Primary Tumor (T) TX primary tumor cannot be assessed TO no evidence of primary tumor Tis carcinoma in situ T1,2,3,4 increasing size or local extent of primary tumor Regional lymph nodes (N) NX regional LN cannot be assessed NO no regional LN metastasis N1,2,3 increasing involvement of LN Distant Metastasis MX Distance metastasis cannot be assessed MO No distant metastasis

M1 distant metastasis Grading Classification of tumor cells Grade I IV, define the type of tissue which the tumor originated Normal T0, N0, M0 Stage I T1, N0, M0 Stage II T2, N1, M0 Stage III T3, N2, M0 Stage IV with metastasis 2. Histologic Grade 1 - well differentiated Grade 2 - Moderately differentiated more abnormal Grade 3 - Poorly differentiated, Very abnormal Grade 4 - Very immature, anaplastic hard to even determine the tissue of origin Nomenclature of Neoplasia Tumor is named according to: 1. Parenchyma, Organ or Cell Hepatoma- liver Osteoma- bone Myoma- muscle Nomenclature of Neoplasia Tumor is named according to: 2. Pattern and Structure, either GROSS or MICROSCOPIC Fluid-filled CYST Glandular ADENO Finger-like PAPILLO Stalk POLYP Nomenclature of Neoplasia Tumor is named according to: 3. Embryonic origin Ectoderm ( usually gives rise to epithelium) Endoderm (usually gives rise to glands) Mesoderm (usually gives rise to Connective tissues) BENIGN TUMORS Suffix- OMA is used Adipose tissue- LipOMA Bone- osteOMA Muscle- myOMA Blood vessels- angiOMA Fibrous tissue- fibrOMA MALIGNANT TUMOR Named according to embryonic cell origin 1. Ectodermal, Endodermal, Glandular, Epithelial Use the suffix- CARCINOMA Pancreatic AdenoCarcinoma Squamos cell Carcinoma Named according to embryonic cell origin 2. Mesodermal, connective tissue origin Use the suffix SARCOMA FibroSarcoma Myosarcoma AngioSarcoma

PASAWAY 1. OMA but Malignant HepatOMA, lymphOMA, gliOMA, melanOMA 2. THREE germ layers TERATOMA 3. Non-neoplastic but OMA Choristoma Hamatoma Warning signs of Ca C change in bowel or bladder habits A sore that does not heal U unusual bleeding or discharge U unexplain sudden weight loss U unexplained anemia T thickening or lump I indigestion or difficulty in swallowing O obvious change in wart or mole N nagging cough or hoarseness of voice

B. Imaging - X-ray, ultrasound, MRI, Ct scan - Methods of obtaining information about the presence, location and extend of tumor Method chosen is based on 1. ability to visualize tumor 2. Risk 3. Client comfort 4. Cost Preprocedure a. Assess for allergy if contrast is to be used b. NPO depending on the area being imaged, use of sedation or contrast c. Prepare patient for length of imaging, possible noise of machinery, need to remain still. d. Monitor the client for flushing, itching or nausea, indicating allergy to contrast.

Screening a. Early detection and treatment are the cornerstones of cancer survival b. Educating the public about a healthy lifestyle and early detection c. Health education d. Reduce and avoid exposure to known carcinogens e. Eat a balanced diet of vegetables, fruits and whole grains, reducing fat and red smoked and cured meat. f. Limit alcohol beverages g. Exercise regularly h. Reduce stress and encourage adequate rest and relaxation i. Follow screening recommendations j. Know the seven warning signs k. Seek medical attention Diagnostic test 1. Biopsy - removal of tissue for histologic examination - essential for choosing treatment Types a. FNAB b. Incision c. Excision d. Punch Preprocedure a. Depends on the location and type of biopsy b. May need to be NPO if sedation or contrast is used c. Inform the client about the procedure Postprocedure a. Control bleeding b. Monitor for infection c. Manage pain d. Inform the client how to obtain the results

Points to Remember a. Most client fear of death upon confirmation of Cancer b. Clients usually ignored cardinal signs of Cancer c. Most often cancer is detected during routine exam d. Questions that need to be answered: Example (Is the disease curable or not?) Nursing Diagnosis a. Ineffective coping b. Anticipatory grieving c. Disturbed body image d. Fatigue e. Impaired elimination f. Hopelessness g. Impaired oral mucous membrane Common Cancer complaint a. Nausea  Impaired nutrition less than body requirements  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 abnormal coagulation factors

3, Palliation  relief of symptoms associated with the disease Therapeutic Modalities for Cancer a. Surgery b. Chemotherapy c. Radiation therapy d. Immunotherapy e. Bone Marrow Transplantation Surgery  The ideal and most frequently used Goals a. b. c. d. Primary Prophylactic Palliative reconstructive

Paraneoplastic Syndrome 1. 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 Calcium 3. 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 Life a. 30% of clients experience pain at the time of diagnosis. b. 30% to 50% experience pain while undergoing therapy. c. 70% to 90% experience pain as cancer advances and overcomes their defenses d. Cancer pain is complex, interactive, and everchanging. It comes from two general sources: the cancer itself, and its various treatments e. Cancer pain is more than a physical symptom. It is a reminder of ones mortality and a harbinger of death. f. It interferes with normal routines, degrades the quality of life, and robs one of rest, creativity, joy, and peace. g. Cancer pain adds stress and worry to its sufferers and friends and family. For this reason, healthcare professionals h. Take pain seriously, recognizing that only the person in pain knows how it feels. i. Provide information and resources for pain control. j. Communicate with genuineness, accurate empathy, and nonpossessive warmth. k. Encourage sufferers to share their feelings and network with other survivors. l. Respect culture norms and wishes of sufferers, maximizing their control m. Encourage release of energy through joyproducing activities. n. Monitor pain medications, effectiveness, and adverse effects Management of Cancer 1. Cure  eradication of malignant diseases 2. Control  prolonged survival and containment of cancer cell growth

 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 Surgery Biopsy Excisional biopsy - most frequently used for easily accessible tumors 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 be removed - 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 possible and to

promote a satisfying and productive life for as 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 spread to the brain, bone.  A radiosensitive tumor is one that can be destroyed by a dose of radiation that still allows for cell regeneration in the normal tissue 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 and stop them from spreading. At low doses, radiation is used as an x-ray to see inside your body and take pictures, such as x-rays of your teeth or broken bones.  Radiation use in cancer treatment works in much the same way, except that it is given 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 not possible, radiation may be used to shrink cancer tumors in order to reduce pressure.  Radiation therapy used in this way can treat problems such as pain, or it can prevent problems such as blindness or loss of bowel and bladder control.  Cells are most vulnerable to radiation during DNA synthesis and mitosis  Most sensitive are those body tissue that undergo frequent cell division. (BM, Lymphatic, GIT, gonads)  Tumors that are well oxygenated are more sensitive to radiation  Cells most sensitive during M and G2 phase Radiosensitivity Highly sensitive - ovaries, testes, bone marrow, blood, intestines Low sensitivity - muscle, brain, spinal cord Types Teletherapy (External Beam) a. x-rays are used to destroy cancerous cells at the skin surface or deeper b. b. Used more commonly c. Client is not radioactive during treatment

d. Simulation X-ray or Ct planning session to identify the field which delivers maximum radiation to the tumor and minimal to normal tissue. Involves skin markings 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 cancer b. delivers a high dose of radiation in a local area using implants c. Client is radioactive only when implaint is in placed d. plan cares efficiently to minimize nurses, exposure to implant, use shielding, wear a film badge and maintain safe distance. e. Pregnant nurses should not care for clients with implanted radiation f. Pickup dislodge implants with long forceps placed in a special container. g. Body fluids of clients treated with systemic radioactive iodine are radioactive; fluids of client with implants are not Radiation Dosage  The lethal tumor dose is defined as the dose that will eradicate 95% of the tumor yet preserve normal tissue

Adverse Reaction a. Seen only in the organs in the radiation field, except for systemic effects of nausea, anorexia and fatigue b. Skin reactions are common and expected with external beam c. Toxicity d. Localized to the area being irradiated e. Alteration in oral mucosa, stomatitis, xerostomia, change and loss of taste, decreased salivation f. Altered skin integrity, alopecia, erythema, shedding, desquamation g. Thrombocytopenia h. 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 30 min per shift)  Shielding - use lead aprons and gloves  Standards - kept as low as reasonably achievable  Monitoring device - film badge (measure the whole exposure of the nurse) Side Effects a. 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

Destroy cancer cells that may remain after surgery or radiation therapy. This is called adjuvant chemotherapy. Help radiation therapy and biological therapy work better. Destroy cancer cells that have come back (recurrent cancer) or spread to other parts of your body (metastatic cancer).

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

Cell Cycle Time required for one tissue cell to divide and reproduce two identical daughter cells Go resting phase G1 RNA and protein synthesis occurs S DNA synthesis occurs G2 Premitotic phase M cell division occurs Chemotherapy may be given in many ways. Injection. The chemotherapy is given by a shot in a muscle in your arm, thigh, or hip or right under the skin in the fatty part of your arm, leg, or belly. Intra-arterial (IA). The chemotherapy goes directly into the artery that is feeding the cancer. Intraperitoneal (IP). The chemotherapy goes directly into the peritoneal cavity (the area that contains organs such as your intestines, stomach, liver, and ovaries). Intravenous (IV). The chemotherapy goes directly into a vein. Topically. The chemotherapy comes in a cream that you rub onto your skin. Orally. The chemotherapy comes in pills, capsules, or liquids that you swallow.

Chemotherapy Systemic treatment with chemicals which destroy rapidly proliferating cells Used for cure in testicular, Hodgkin disease, ALL, neuroblastoma, Wilms and Burkitts lymphoma Used to control breast, nod-Hodgkin, small cell lung and ovarian cancer Used palliative for relief of pain, obstruction and to improve comfort What does chemotherapy do? Cure cancer - when chemotherapy destroys cancer cells to the point that your doctor can no longer detect them in your body and they will not grow back. Control cancer - when chemotherapy keeps cancer from spreading, slows its growth, or destroys cancer cells that have spread to other parts of your body. Ease cancer symptoms (also called palliative care) when chemotherapy shrinks tumors that are causing pain or pressure. Chemotherapy a. Chemotherapy works by stopping or slowing the growth of cancer cells, which grow and divide quickly. But it can also harm healthy cells that divide quickly, such as those that line your mouth and intestines or cause your hair to grow. Damage to healthy cells may cause side effects. Often, side effects get better or go away after chemotherapy is over. b. Sometimes, chemotherapy is used as the only cancer treatment. But more often, you will get chemotherapy along with surgery, radiation therapy, or biological therapy. Chemotherapy can: c. Make a tumor smaller before surgery or radiation therapy. This is called neo-adjuvant chemotherapy.

Antineolplastic agent Cell Cycle non-specific 1. 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) Chemotherapy a. Used to treat systemic diseases rather than localized lesions that are amenable to surgery and radiation b. Used in an attempt to destroy tumor cells by interfering with cellular function and reproduction c. Use of chemicals to destroy cancer cells d. Interferes DNA & RNA activities associated with cell division e. Often used in combination with radiation therapy f. Cytotoxic - is an agent capable of destroying cells g. Cytotoxic drug - alkylating and antimetabolites h. Can be combined with surgery or radiation therapy i. Used to reduce the tumor size preoperatively and to destroy the remaining tumor cells preoperatively j. Eradication of 100% of tumor is nearly impossible k. Goal is to eradicate enough of the tumor so that the remaining tumor cells can be destroyed by the immune system Contraindication a. Infection b. Recent surgery c. Impaired renal or hepatic function d. Recent radiation therapy e. Pregnancy f. Bone marrow depression Extravasation cause tissue necrosis and damage to tendons, nerves and blood vessels Major side effects GI System 1. Nausea and vomitting - administer anti-emetics - NPO 4-6 hrs before chemotherapy - bland diet foods in small amounts after treatment 2. Diarrhea 3. 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 - use careful handwashing - reverse isolation if WBC <1000 - assess for signs of respiratory infection - Avoid crowds c. Anemia - Provide adequate rest periods - monitor CBC - Administer o2 PRM Integumentary System Alopecia - Explain hair loss is not permanent - Support and encouragement - Scalp tournique or scalp hypothermia to minimize hairloss - Advise client to obtain wig Renal system - may cause direct damage to kidneys by excreting metabolites. - encourage fluids and frequent voiding - increased excretion of uric acid may damage kidneys - Administer allopurinol, Inc. OFI Reproductive System 1. Infertility and mutagenic damage to chromosomes 2. Banking sperm 3. Use contraception Side Effects from Radiation and Chemo Therapy a. Neurologic/Sensory/Perceptual a. Meningeal irritation b. CN and peripheral neuropathy c. Cerebellar toxicity d. Ototoxicity b. Cardiac a. Pericardial Effusion b. Arrhythmias c. CHF c. Pulmonary a. Pleural Effusion b. Pneumonitis d. GIT a. Stomatitis b. Esophagitis c. Pharyngitis d. Taste alteration e. Anorexia f. Nausea and vomiting g. Constipation and diarrhea h. Weight loss GUT Nephrotoxicity Hemorrhagic cystitis Hyperuricemia Urine color changes Reproductive

y Loss of libido y Impotence y Amenorrhea y Irregular menses y Menopausal symptoms y Azoospermia y Sterility y Gynecomastia Hepatic Hepatotoxicity Integumentary Alopecia Dermatitis and ulcers Hematopoietic q bone marrow activity anemia, prone to infection and bleeding tendency Metabolic TLS and Hyperkalemia Perceived Change in Body Image a. Obvious reminder of disability b. need for prosthesis (breast, leg and eye) c. need for hardware (wheel chair, crutches) d. need for medication (CR therapy) e. extent of disability or limitation Type of loss a. symbols of sexuality b. social acceptability (colostomy) c. ability to communicate (laryngectomy, aphasia) d. anatomic changes (amputation) Terminally Ill y 50% die from the disease y time from diagnosis to death ranges from weeks- years y not all clients become terminally ill y others die during initial treatment; others die from complications of treatment y Endpoint: no response to treatment and progressions cannot be controlled

relationships, changing self-perception, and memory of other persons suffering ( Ethical Issues y caring can be just successful as curing; when curing is not an option y care is exercised during the final stage of life y Goals of Intervention y to care without functional and structural impairment y if cure is not possible goals must = prevent further metastasis = relieve symptoms = maintain high quality of life Bone Marrow Transplant y Used in the treatment of leukemia for clients who have closely matched donors y and experiencing temporary remission with chemotherapy y Severe aplastic anemia, breast Ca, brain Ca Types Autologous - own bone marrow, most common type Allogenic - transplant from a genetically non-identical donor - sibbling most common type procedure 1. Harvest through multiple aspiration from the iliac crest to retrieve sufficient bone marrow for the transplant - 500ml- 1000ml 2. Conditioning - immunosuppressant therapy is given to eradicate all malignant cells 3. Transplantation a. administered through central line like BT b. infused 30 min 4. Engraftment a. transfused BM move to marrow forming sites b. 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 weeks c. Pneumonia: principal cause of death during first three months d. 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 isolation 2. Monitor central lines frequency 3. Provide care receiving chemotherapy

HOSPICE CARE y standard of care for terminally ill cancer clients y symptom control y pain management y providing comfort and dignity y 24 hour 7 day coverage y services given are based on clients need not on its ability to pay y One can suffer without physical pain and one can have physical pain and not necessarily suffer. y The founder of the modern hospice movement described suffering as total pain, an experience of changing self-perception, fear of physical distress and dying, concerns about

Post transplant y Prevent infection y Maintain protective environment y Administer antibiotics y Check IV set ups q12hrs 2. Provide mouth care for stomatitis and mucositis 3. Monitor carefully for bleeding a. check for occult blood in emesis, stools b. observe for easy bruising c. Check platelet ct daily d. replaced blood component 4. Maintain fluid and electrolyte balance 5. Provide client health teaching Nursing Assessment a. Weight loss b. Frequent infection c. Skin problems d. Pain e. Hair Loss f. Fatigue g. Disturbance in body image/ depression h. Managing effects of Cancer and treatment

Fever Shaking chills Pain Foul smelling duscharge White oral plaque Change in sensorium Monitor for clinical manifestation of bleeding Bruising and petechiae Blood in the urine, stool and vomitus Changes in mentation Pain Weak, rapid pulse, low blood pressure, pale cool skin Nursing intervention a. Instruct practice of careful washing b. Perform oral and perineum care c. Place client in protective isolation d. Administer antibiotics and antipyretics e. Avoid unnecessary invasive procedures to prevent bleeding or infection f. Avoid shaving g. Administer iced gastric lavage MAINTAIN TISSUE INTEGRITY a. Handle skin gently b. Do NOT rub affected area c. Lotion may be applied d. Wash skin only with SOAP and Water MANAGEMENT OF STOMATITIS a. Use soft-bristled toothbrush b. Oral rinses with saline gargles/ tap water c. Avoid ALCOHOL-based rinses

y y y y y y y y y y y y

Pain 1. Description a. Whatever the client says it is, whenever the client says it exists. b. may be caused by treatment, cancer destruction of tissue or pressure or pressure on nearby structures and cancer progression c. Bone metastasis are very common cause Nursing Interventions a.. Assess all clients for pain even if they do not appear to be experiencing it. b. Educate clients and families about narcotic use 1. Correct use of narcotics results in addiction in <1% of client 2. Narcotic dose may be increased with increasing dose not have be reserved for last resort use. c. Instruct clients on nonpharmacologic methods of pain management. d. Administer pain medication as ordered, utilizing a combination of non-narcotic and narcotic analgesics e. Oral route is preferred if possible f. Meperidine (demerol) is seldom used to treat cancer pain because it metabolizes and accumulates during extended use. Myelosuppression - reduced numbers of white and red blood cells and platelets associated with cancer or treatment - Neutropenia <1000 - Thrombocytopenia < 100,000 - results in infection and bleeding - the oral cavity is the primary site of infection Assessment Monitor for clinical manifestations of infection y Erythema, warmth, swelling at incision site

MANAGEMENT OF ALOPECIA Alopecia begins within 2 weeks of therapy a. Regrowth within 8 weeks of termination b. Encourage to acquire wig before hair loss occurs c. Encourage use of attractive scarves and hats d. Provide information that hair loss is temporary BUT anticipate change in texture and color PROMOTE NUTRITION a. Serve food in ways to make it appealing b. Consider patients preferences c. Provide small frequent meals d. Avoids giving fluids while eating e. Oral hygiene PRIOR to mealtime f. Vitamin supplements RELIEVE PAIN a. Mild pain- NSAIDS Moderate pain- Weak opiods b. Severe pain- Morphine c. Administer analgesics round the clock with additional dose for breakthrough pain DECREASE FATIGUE a. Plan daily activities to allow alternating rest periods b. Light exercise is encouraged

c. Small frequent meals

Metastatic sites Liver the most common site Peritoneal surface Spread via lymphatics to lung, bone and brain COLON CANCER Risk factors 1. Increasing age 2. Family history 3. Previous colon CA or polyps 4. History of IBD 5. High fat, High protein, LOW fiber 6. Breast Ca and Genital Ca COLON CANCER Sigmoid colon is the most common site Predominantly adenocarcinoma If early 90% survival 34 % diagnosed early 66% late diagnosis COLON CANCER PATHOPHYSIOLOGY Benign neoplasm DNA alteration malignant transformation malignant neoplasm cancer growth and invasion metastasis (liver) COLON CANCER ASSESSMENT FINDINGS 1. Change in bowel habits- Most common 2. Blood in the stool 3. Anemia 4. Anorexia and weight loss 5. Fatigue 6. Rectal lesions- tenesmus, alternating D and C Right sided lesions - dull abdominal pain, melena Left sided lesions - signs of obstruction and bright red stool Rectal lesion - tenesmus, rectal pain. Incomplete BM., bloody stool, constipation Colon cancer Diagnostic findings 1. Fecal occult blood 2. Sigmoidoscopy and colonoscopy 3. BIOPSY 4. CEA- carcino-embryonic antigen Colon cancer Complications of colorectal CA 1. Obstruction 2. Hemorrhage 3. Peritonitis 4. Sepsis Colon cancer MEDICAL MANAGEMENT 1. Chemotherapy- 5-FU 2. Radiation therapy Colon cancer

IMPROVE BODY IMAGE a. Therapeutic communication is essential b. Encourage independence in self-care and decision making c. Offer cosmetic material like make-up and wigs ASSIST IN THE GRIEVING PROCESS a. Some cancers are curable b. Grieving can be due to loss of health, income, sexuality, and body image c. Answer and clarify information about cancer and treatment options d. Identify resource people e. Refer to support groups

MANAGE COMPLICATION: INFECTION a. Fever is the most important sign (38.3) b. Administer prescribed antibiotics X 2weeks c. Maintain aseptic technique d. Avoid exposure to crowds e. Avoid giving fresh fruits and veggie f. Handwashing g. Avoid frequent invasive procedures MANAGE COMPLICATION: Septic shock a. Monitor VS, BP, temp b. Administer IV antibiotics c. Administer supplemental O2 d. Nursing Intervention MANAGE COMPLICATION: Bleeding y Thrombocytopenia (<100,000) is the most common cause y <20, 000 spontaneous bleeding y Use soft toothbrush y Use electric razor y Avoid frequent IM, IV, rectal and catheterization y Soft foods and stool softeners Colon cancer y Adenocarcinoma is the most common type y Metastasis is common to the liver y 2nd most common site for cancer in men and women y Ages >50-60 y May be caused by diverticulitis, chronic ulcerative colitis, familial polyposis

Cancer sites a. Sigmoid colon 33% b. Rectum 27% c. Ascending Colon 22% d. Transverse colon 11% e. Descending colon 6%

a. SURGICAL MANAGEMENT Surgery is the primary treatment Based on location and tumor size Resection, anastomosis, and colostomy (temporary or permanent) Right hemicolectomy primary surgery for cancer of the ascending colon - removal of the terminal ileum, cecum, right transverse colon Left hemicolectomy primary surgery for cancer of descending and sigmoid colon - removal of the distal transverse, descending and sigmoid colon Colostomy Single barrel proximal colon is brought to the surface forming one stoma Double barrel two stomas, proximal excretes stool, distal secretes mucus Stool formation depends on 1. Ascending loose, liquid 2. Transverse semisolid 3. descending soft, formed stool Sexual dysfunction affects 15 1005 depending on the client age, surgical technique Colon cancer NURSING INTERVENTION Pre-Operative care 1. Provide HIGH protein, HIGH calorie and LOW residue diet 2.Provide information about post-op care and stoma care 3. Administer antibiotics 3-5 day prior Colon cancer NURSING INTERVENTION Pre-Operative care 4. Enema or colonic irrigation the evening and the morning of surgery 5. NGT is inserted to prevent distention 6. Monitor UO, F and E, Abdomen PE Colon cancer NURSING INTERVENTION Post-Operative care 1. Monitor for complications a. Leakage from the site b. prolapse of stoma c. Infection d. Bowel obstruction 2. Assess the abdomen for return of peristalsis Colostomy Care Prevent 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 nutrition 2500ml liquids/day Health teaching when discharge a. change in odor, consistency and color of stool b. bleeding from stoma c. persistent constipation and diarrhea d. persistent leakage around the stoma e. skin irritation Colon cancer NURSING INTERVENTION: COLOSTOMY CARE Colostomy begins to function 3-6 days after surgery The drainage maybe soft/mushy or semi-solid depending on the site Colon cancer NURSING INTERVENTION: COLOSTOMY CARE y BEST time to do skin care is after shower y Apply tape to the sides of the pouch before shower y Assume a sitting or standing position in changing the pouch NURSING INTERVENTION: COLOSTOMY CARE y Instruct to GENTLY push the skin down and the pouch pulling UP y Wash the peri-stomal area with soap and water y Cover the stoma while washing the peri-stomal area y Lightly pat dry the area and NEVER rub y Lightly dust the peri-stomal area with nystatin powder y Colon cancer NURSING INTERVENTION: COLOSTOMY CARE Empty the pouch or change the pouch when 1/3 to full (Brunner) to 1/3 full (Kozier) Breast Cancer The most common cancer in FEMALES Numerous etiologies implicated RISK FACTORS 1. Genetics- BRCA1 And BRCA 2 2. Increasing age ( > 50yo) 3. Family History of breast cancer 4. Early menarche and late menopause 5. Nulliparity 6. Late age at pregnancy Breast Cancer 7. Obesity

8. Hormonal replacement 9. Alcohol 10. Exposure to radiation PROTECTIVE FACTORS 1. Exercise 2. Breast feeding 3. Pregnancy before 30 yo

Breast Cancer NURSING INTERVENTION : PRE-OP 1. Explain breast cancer and treatment options 2. Reduce fear and anxiety and improve coping abilities 3. Promote decision making abilities 4. Provide routine pre-op care: Consent, NPO, Meds, Teaching about breathing exercise

Stages I and 2 are 70-90% curable Invasive or infiltrating, capable of metastasis a. Ductal 70% b. Lobular 10 % higher incidence of contralateral breast cancer Breast Cancer ASSESSMENT FINDINGS 1. MASS- the most common location is the upper outer quadrant 2. Mass is NON-tender. Fixed, hard with irregular borders 3. Skin dimpling 4. Nipple retraction 5. Peau d orange Breast Cancer LABORATORY FINDINGS 1. Biopsy procedures 2. Mammography 3. Tumor marker CA 2729 Breast Cancer Breast cancer Staging TNM staging I - < 2cm II - 2 to 5 cm, (+) LN III - > 5 cm, (+) LN IV- metastasis Metastatic sites a. Bone b. Liver c. Lung d. Brain Treatment Surgical management is the primary treatment for breast cancer Breast conservation (lumpectomy, segmental resection) - 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 skin Modified radical axillary lymphnodes are removed Radical mastectomy pectoral muscles are removed Medical therapy External beam radiation therapy 3 weeks after surgery. Most commonly used Chemotherapy Tamoxifen therapy

Breast Cancer NURSING INTERVENTION : Post-OP 1. Position patient: Supine Affected extremity elevated to reduce edema Breast Cancer 2. Relieve pain and discomfort Moderate elevation of extremity IM/IV injection of pain meds Warm shower on 2nd day post-op Breast Cancer 3. Maintain skin integrity Immediate post-op: snug dressing with drainage Maintain patency of drain (JP) Monitor for hematoma w/in 12H and apply bandage and ice, refer to surgeon 3. Maintain skin integrity Drainage is removed when the discharge is less than 30 ml in 24 H Lotions, Creams are applied ONLY when the incision is healed in 4-6 weeks Promote activity Support operative site when moving Hand, shoulder exercise done on 2ndday Post-op mastectomy exercise 20 mins TID NO BP or IV procedure on operative site Promote activity Heavy lifting is avoided Elevate the arm at the level of the heart On a pillow for 45 minutes TID to relieve transient edema NURSING INTERVENTION : Post-OP MANAGE COMPLICATIONS Breast Cancer Lymphedema 10-20% of patients Elevate arms, elbow above shoulder and hand above elbow Hand exercise while elevated Refer to surgeon and physical therapist Breast Cancer NURSING INTERVENTION : Post-OP MANAGE COMPLICATIONS

Hematoma Notify the surgeon Apply bandage wrap (Ace wrap) and ICE pack Breast Cancer NURSING INTERVENTION : Post-OP TEACH FOLLOW-UP care Regular check-up Monthly BSE on the other breast Annual mammography Lung Ca The number 1 cancer killer in men and women y 6th to 7th decade of life y 70% involvement of lymphnodes y 85% caused by inhalation of carcinogenic chemicals Pathophysiology Arise from a single transformed epithelial cell in the tracheobronchial airways. Adenocarcinoma - most prevalent carcinoma of the lung for men and women, peripherally located and often metastasized Squamous cell Ca centrally located and arises in the segmental and subsegmental bronchi Large cell Ca fast growing tumor that arise peripherally Bronchioalveolar slower growing and arises at the alveoli Classification and staging Non small cell Ca 70-75% a. Adenocarcinoma - most common (40%) - slowest growing, metastasize early b. 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 and localize (rare) Overall 5 year survival rate is 15% Risk factors Tobacco 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 .genetics Diet Clinical manifestation Develops insidiously and is assymptomatic until late in the course s/sx depends on the location and size of the tumor, degree of obstruction and metastasis Cough or chronic cough - dry, persistent without sputum production Wheezing

Hemoptysis or blood tinged sputum Chest and shoulder pain Common sites of metastasis y LN y Bone y Brain y Contralateral lung y Adrenal glands y liver Screening test: No screening program currently exist. Assessment: y Clients are very rarely symptomatic at the time of diagnosis. y Persistent cough and dyspnea y Recurrent bronchitis and pneumonia y Blood streaked sputum y Chest pain Diagnostics a. Chest xray (solitary peripheral nodule, coin lesion) b. Ct scan of the chest c. Fiberoptic bronchoscopy d. Fine needle biopsy under ct scan Surgical Management Dependent on whether the tumor is resectable May be cure for non small cell if no metastasis occurred and lung function is sufficient on removal of all or part of the lungs (50%) Lobectomy removal of lobe (common) Pneumonectomy removal of the lung Segmentectomy partial removal of the lung lobe Adjuvant therapy a. Chemotherapy is the primary treatment for small cell b. Radiation is standard post op for advanced nonsmall cell Radiation therapy for localized intrathoracic lung ca and palliation for hemprtysis, obstruction dysphagia and pain Nursing Intervention Assess for signs of superior vena cava syndrome Postlobectomy, manage chest tube Assess respiration and for presence of pneumothorax or atelectasis Position properly post-op 1. Lobectomy avoid prolonged lying on the operative site 2. Pneumonectomy position on the back or operative side only Instruct the client on deep breathing, coughing and ambulation Pain management to promote deep breathing Refer client to smoking cessation Prostate Cancer

y y y y y y y

a slow growing malignancy of the prostate gland Usually an adenocarcinoma This usualy spread via blood stream to the vertebrae 2nd most common cause of cancer deaths 190000 new cases each year and 30,000 deaths annually Over 80% are diagnosed in early stages. Allowing an almost 100% 5 year survival rate. Overall for all stages survival is 96%

5. Education a. Avoid lifting, straining, and prolonged travel b. possible impotence Bladder Cancer Transitional cell carcinoma most common (90-95%) Approximately 54300 new cases and 12400 deaths No screening for early detection Risk factors y Smoking y Occupational exposures y Caucasian males >50 years old Asessment y Gross, painless hematuria y Dysuria y Urinary frequency y Urgency y Urinary hesitancy y Suprapubic, rectum, back pain Diagnostic 1. Urinary cytology late morning or early afternoon 2. Bladder washing more reliable 3. Flow cytometry exdamine DNA content of urine cells 4. IVP evaluate upper urinary tracts 5. Cystoscopy tumor visualization and biopsy 6. CT scan, transurethral ultrasound, MRI 7. Tumor marker p53 and epidermal growth factor in late stage

Prostate Cancer y Predisposing factor y Age y Strong family history y High fat diet may play a role y Having a vasectomy may play a role Prostate Cancer Assessment Findings y DRE: hard, pea-sized nodules on the anterior rectum y Hematuria y Urinary obstruction y Pain on the perineum radiating to the leg Prostate Cancer Diagnostic tests 1. DRE 2. Prostatic specific antigen (PSA) 3. Elevated SERUM ACID PHOSPHATASE indicates SPREAD or Metastasis Surgical Management Radical prostatectomy removal of prostate, capsule, ejaculatory ducts, seminal vesicles plus lymphnodes Watchful waiting without intervention may be appropriate in men over 70 years of age with small, early stage cancers Prostate Cancer Medical and surgical management Prostatectomy TURP Chemotherapy: hormonal therapy to slow the rate of tumor growth Nursing Interventions Prepare patient for chemotherapy Prepare for surgery Nursing Interventions: Post-prostatectomy 1. Maintain continuous bladder irrigation. Note that drainage is pink tinged w/in 24 hours 2. Monitor urine for the presence of blood clots and hemorrhage 3. Ambulate the patient as soon as urine begins to clear in color 4. Provide for bladder retraining after foley catheter removal a. Perineal exercises b. restrict caffeine c. limit fluid intake at nigth

Surgical management 1. Transurethral resection and fulguration (Destruction of surrounding tissue with electricity) most common for low grade Ca 2. Radical cystectomy (bladder, prostate, seminal vesicles, urethra, overy, FT are removed) for high grade tumors 3. Adjuvant therapy 4. Radiation therapy used in invasive cancer 5. Chemotherapy cisplatin, methotrexate, vincristine Nursing interventions y Instruct on preop low residue and clear liquid diet y Assess for urinary stoma and teach maintainance of ileal conduit and appliance y Assess urinary output (should produce urine immediately) for infection and signs of peritonitis y Discuss possible sexual dysfunction Skin cancer Malignant lesion of the skin, which may or may not metastasized Types

a. Basal cell most common type arising from the basal cells contained in the epidermis b. Squamous Cell 2nd most common type in whites.tumor of the keratinocytes Metastasized to the LN and fatal c. Malignant melanoma can metastasized to the brain, lung, bone, skin. Fatal SKIN CANCER Causes: UV light exposure, chronic irritation and friction Dx: skin biopsy S/sx: change in color, size, shape of lesion Monitor lesions that do not heal Removed moles or lesions that are subject to chronic irritations y Avoid contact with chemical irritants y Use sun screen lotions and clothing y Avoid sun exposure between 11am-3pm y Contact Dermatitis y Inflammatory response after contact with a specific antigen y Assessment: y Pruritus and burning y Edema y Erythema at the point of contact Signs of infection Vesicles with drainage Gastric Cancer Approximately 22000 cancers and 13,000 deaths per year African americans, japanese, chinese and US have higher incidence 95% are adenocarcinomas Prognosis is poor, 5 year survival rate is 5-15 % Risk factors y Male > 40 years of age y Low socioeconomic status y Poor nutritional health habits and vitamin A deficiency y Family history y Previous gastric resection y Pernicious anemia y H. pylori infection y Gastric atrophy and chronic gastritis y Rubber workers and coal miners Metastatic sites Direct extension to the pancreas, liver, esophagus. Intraperitoneal dissemination to ovary Nodal spread to the neck Bloodstream metastasis to the lung, adrenal, liver, bone and peritoneal cavity Screening Among high risk persons only Barrium x-ray or endoscopy y y

Assessment Early manifestations are non-specific Upper epigastrium, retrosternal pain Uneasy sense of fullness after meals Loss of appetite Nausea and vomiting Weakness Fatigue anemia Diagnostic procedure EGD Biopsy Endoscopic ultrasound Double contrast upper GI series CT scan

Surgical management Only treatment that is potentially curative a. Total gastrectomy Radical subtotal gastrectomy a. Billroth I b. Billroth II b. Proximal subtotal gastrectomy Paliation of symptoms Adjuvant therapy External beam radiation for control of unresectable tumors, palliation and increased survival. Chemotherapy has little impact 5 FU, doxorubicin, mitomycin Nursing Intervention y Goal is control of clinical manifestation and supporting optimal functioning y 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 Very treatable and curable 80-90% are squamous carcinoma Risk factors Sexual intercourse before age 17, multiple partners Sexual partner who has multiple partners Cigarette smoking Human papilloma virus

Lower socioeconomic status Metastatic sites Abdomen and pelvis Lung Liver Bone

Screening Paps smear beginning at age 18 or sexually active assessment - Assymptomatic in the early stage - Watery vaginal discharge - Late manifestation, postcoital, heavy or intermenstrual bleeding. diagnostics Colposcopy application of acetic acid followed by magnified examination of the pelvis Biopsy Endocervical curettage Cone biopsy Management Total abdominal hysterectomy and lymphadenectomy Depends on the stage and desire for child bearing Radiation therapy Chemotherapy for advanced disease Laser 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 and preterm labor in future pregnancies. Hysterectomy For microinvasive cancer if childbearing is not desired. A vaginal approach is most commonly performed. A radical hysterectomy and bilateral lymphnode dissection may be performed for cancer that has spread beyond the cervix but not to the pelvic wall. Nursing intervention Assess for changes in bowel and bladder pattern Bladder training If laser surgery for early diseases is used, instruct to avoid douching, tampoons and sexual activity for 2-4 weeks Assess for sexual dysfunction, surgical shortening of vagina, vaginal dryness

y Leukemia y white blood neoplastic proliferation of one particular cell type. y Unregulated proliferation of WBCs in the bone marrow y Classified into lymphoid or myeloid, acute and chronic y Acute Myeloid leukemia y Defect in hematopoetic stem cells that differentiate into all myeloid cells. y All age group are affected and incidence increases with age with peak at age 60 y With treatment patients survive an average of 1 year with death usually due to infection or hemorrhage. y Clinical manifestation y Most of signs and symptoms evolve from insufficient production of normal blood cells. y Fever, infection, weakness, fatigue, bleeding tendencies. y Pain from enlarged liver and spleen y Hyperplasia of gums y Diagnostics y CBC, decrease erythrocytes and platelets y Bone marrow aspiration, excess of immature blast cells (>30%) y Medical management y The objective is to achieve complete remission by aggressive chemotherapy called induction therapy. y High doses of cytarabine and daunorubicin y The aim is eradication of leukemic cells but it is often accompanied by eradication of normal type of myeloid cells. y Consolidation therapy (postremission therapy) eliminate any residual leukemia cells that are not clinically detectable, diminishing the chance of remission. y 70% experience relapse y Consolidation therapy (postremission therapy) eliminate any residual leukemia cells that are not clinically detectable, diminishing the chance of remission. y 70% experience relapse y Chronic Myeloid Leukemia y Arises from mutation in the myeloid stem cell. Normal myeloid cells continue to produced, but there is preference for immature (blast) forms. y Uncontrolled proliferation results in marrow expansion of long bones, liver and spleen resulting in pain. y Chromosome 22 (philadelphia chromosome) and chromosome 9 (BCR-ABL gene) producing an abnormal protein (tyrosine kinase) causing WBC to divide rapidly. y Common in 40 50 years old y Median life expectancy of 3 to 5 years y Patient is usually assymptomatic y WBC exceeds to 100000/mm3. y Shortness of breath or confused due to decrease capillary perfusion of brain and lungs from leukostasis.

y Treatment y Imatinib mesylate (Gleevec) tyrosine kinase inhibitor blocking BCR-ABL protein preventing cells to divide. y Avoid antacid, grape juice and acetaminophen y Treatment y Imatinib mesylate (Gleevec) tyrosine kinase inhibitor blocking BCR-ABL protein preventing cells to divide. y Avoid antacid, grape juice and acetaminophen y Correction of chromosome abnormality y Interferon alfa and cytosine administered subcutaneously daily. y Many patient cannot tolerate profound fatigue, depression, anorexia, mucositis and inability to concentrate. y Leukopheresis blood of patient is removed and seperated, leukocytes removed and remaining blood returned. Causing temporary decrease in WBC. y Acute Lymphocytic Leukemia y Uncontrolled proliferation of immature cells (lymphoblast) y Common in young children, with boys affected more than girls y >80% of children survive at least 5 years y Clinical manifestation y Immature lymphocytes proliferate in bone marrow y Decrease WBC, RBC and platelets y Leukemic cell infiltration causing pain from enlarged liver, spleen, bone pain, headache and vomiting y Treatment y Very sensitive to corticosteroids and vinca alkaloids y Prophylaxis of intrathecal chemotherapy (methotrexate) y Chronic Lymphocytic Leukemia y Common malignancy in older adults >60 years old. y Average survival time ranges from 14 years to 2.5 years y Most of cells are fully mature y Clinical Manifestation y Enlargement of lymphnodes, painful y Splenomegally y B symptoms constellation of symptoms including fever, drenching sweating, and unintentional weight loss. y Absent reaction to skin test (Anergy) y Treatment y Chemotherapy with corticosteroid and chlorambucil (leukeran) y Fludarabine (fludara) frontline therapy major side effect is prolonged bone marrow supression y Treatment y Chemotherapy with corticosteroid and chlorambucil (leukeran) y Fludarabine (fludara) frontline therapy major side effect is prolonged bone marrow supression

y y y y y y y y y

y y y y y y y y y y y y y y y y y y y

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 ReedSternberg 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. Common in immunodeficiencies or autoimmune disorders Clinical manifestation At early stage symptoms are virtually absent until late in the course Lymphadenopathy in the later stage and B symptoms management Radiation alone in early non aggressive tumor.

y Oncologic Emergencies y Superior Vena Cava Syndrome (SVCS y Compression or invasion of the superior vena cava by tumor, enlarged lymph nodes, intraluminal thrombus that obstructs venous circulation, or drainage of the head, neck, arms, and thorax. y Typically associated with lung cancer,SVCS can also occur with lymphoma and metastases. y If untreated, SVCS may lead to cerebral anoxia (because not enough oxygen reaches the brain),laryngeal edema, bronchial obstruction,and death. y Gradually or suddenly impaired venous drainage giving rise to Progressive shortness of breath (dyspnea),cough, and facial swelling Edema of the neck, arms, hands, and thorax and reported sensation of skin tightness and difficulty swallowing

 Possibly engorged and distended jugular,temporal, and arm veins Dilated thoracic vessels causing prominent venous patterns on the chest wall Increased intracranial pressure, associated visual disturbances, headache, and altered mental status Diagnostic y Diagnosis is confirmed by Clinical findings Chest x-ray Thoracic CT scan MRI . y Treatment Radiation therapy to shrink tumor size and relieve symptoms Chemotherapy for radiation-resistant tumor (eg, lymphoma or small cell lung cancer) or when the mediastinum has been irradiated to maximum tolerance Anticoagulant or thrombolytic therapy for intraluminal thrombosis Surgery (less common), eg, vena cava bypass graft (synthetic or autologous) to redirect blood flow around the obstruction Supportive measures such as oxygen therapy,corticosteroids, and diuretics y Treatment Radiation therapy to shrink tumor size and relieve symptoms Chemotherapy for radiation-resistant tumor (eg, lymphoma or small cell lung cancer) or when the mediastinum has been irradiated to maximum tolerance Anticoagulant or thrombolytic therapy for intraluminal thrombosis Surgery (less common), eg, vena cava bypass graft (synthetic or autologous) to redirect blood flow around the obstruction Supportive measures such as oxygen therapy,corticosteroids, and diuretics y Nursing Intervention Monitor and report clinical manifestations of SVCS. Monitor cardiopulmonary and neurologic status. Facilitate breathing by positioning the patient properly. This helps to promote comfort and reduce anxiety produced by difficulty breathing resulting from progressive edema. Promote energy conservation to minimize shortness of breath. Monitor the patients fluid volume status and administer fluids cautiously to minimize edema y Spinal Cord Compression y Potentially leading to permanent neurologic impairment and associated morbidity and mortality, compression of the cord and its nerve roots may result from tumor, lymphomas, or intervertebral collapse.

y The prognosis depends on the severity and rapidity of onset. y About 70% of compressions occur at the thoracic level, 20% in the lumbosacral level, and 10% in the cervical region. y Metastatic cancers (breast, lung, kidney, prostate, myeloma, lymphoma) and related bone erosion are associated with spinal cord compression. y Clinical manifestation y Local inflammation, edema, venous stasis,and impaired blood supply to nervous tissues y Local or radicular pain along the dermatomal areas innervated by the affected nerve root y Pain exacerbated by movement, coughing, sneezing, or the Valsalva maneuver y Neurologic dysfunction, and related motor and sensory deficits (numbness, tingling, feelings of coldness in the affected area, inability to detect vibration,loss of positional sense) y Motor loss ranging from subtle weakness to flaccid paralysis y Treatment y Radiation therapy to reduce tumor size to halt progression and corticosteroid therapy to decrease inflammation and swelling at the compression site y Surgery only if symptoms progress despite radiation therapy or if vertebral fracture leads to additional nerve damage y Chemotherapy as adjuvant to radiation therapy for patients with lymphoma or small cell lung cancer y Nursing Intervention y Perform ongoing assessment of neurologic function to identify existing and progressing dysfunction. y Control pain with pharmacologic and nonpharmacologic measures. y Prevent complications of immobility resulting from pain and decreased function y Maintain muscle tone by assisting with rangeofmotion exercises in collaboration with physical and occupational therapists. y Institute intermittent urinary catheterization and bowel training programs for patients with bladder or bowel dysfunction. y Nursing Intervention y Perform ongoing assessment of neurologic function to identify existing and progressing dysfunction. y Control pain with pharmacologic and nonpharmacologic measures. y Prevent complications of immobility resulting from pain and decreased function y Maintain muscle tone by assisting with rangeofmotion exercises in collaboration with physical and occupational therapists.

y Institute intermittent urinary catheterization and bowel training programs for patients with bladder or bowel dysfunction. y Hypercalcemia y In patients with cancer, hypercalcemia is a potentially life-threatening metabolic abnormality resulting when the calcium released from the bones is more than the kidneys can excrete or the bones can reabsorb. y Clinical manifestation y Fatigue, weakness, confusion, y Decreased level of responsiveness, hyporeflexia, y nausea, vomiting, constipation, polyuria y (excessive urination), polydipsia (excessiv y Nursing Intervention y Identify patients at risk for hypercalcemia and assess for signs and symptoms of hypercalcemia. y Teach at-risk patients to recognize and report signs and symptoms of hypercalcemia. y Encourage patients to consume 2 to 3 L of fluid daily unless contraindicated by existing renal or cardiac disease. y Explain the use of dietary and pharmacologic interventions such as stool softeners and laxatives for constipation. y Nursing Intervention y Identify patients at risk for hypercalcemia and assess for signs and symptoms of hypercalcemia. y Teach at-risk patients to recognize and report signs and symptoms of hypercalcemia. y Encourage patients to consume 2 to 3 L of fluid daily unless contraindicated by existing renal or cardiac disease. y Explain the use of dietary and pharmacologic interventions such as stool softeners and laxatives for constipation. y Cardiac Tamponade y Cardiac tamponade is an accumulation of fluid in the pericardial space. y The accumulation compresses the heart and thereby impedes expansion of the ventricles and cardiac filling during diastole. y As ventricular volume and cardiac output fall, the heart pump fails, and circulatory collapse develops. y CARDIAC TAMPONADE ASSESSMENT FINDINGS y 1. BECKs Triad- Jugular vein distention, hypotension and distant/muffled heart sound y 2. Pulsus paradoxus y 3. Increased CVP y 4. decreased cardiac output y Treatment y Pericardiocentesis (the aspiration or withdrawal y of the pericardial fluid by a large-bore needle inserted y into the pericardial space). y CARDIAC TAMPONADE NURSING INTERVENTIONS

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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 Elevate head of bed 45-60 degrees Monitor for complications- coronary artery rupture, dysrhythmias, pleural laceration and myocardial trauma