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357 Cards in this Set

  • Front
  • Back

RBC count

Circulating RBCs
F: 3.8-5.1 x10^6/uL (x10^12/L)
M: 4.3-5.7 x 10^6/uL (x10^12/L)
WBC count
total leukocytes
4000-11000/uL (4-11x10^9/L)
Leukopenia
<4000/uL WBCs
Shift to the left
increase in immature cells (ie: bands-immature neutrophils)
Shift to the right
increase in mature cells
Neutropenia
When bone marrow does not produce enough neutrophils

absolute neutrophil count < 1000/uL

Severe neutropenia = <500 cells/uL
Platelet count
150,000-400,000/uL
thrombocytopenia
< 150,000/uL or 150 x 10^0/L

<100,000/uL --> bleeding

spontaneous hemorrhage= <10,000/uL
Thrombocytosis
excessive platelets (inflammation and some malignant disorders) --> clotting
Coombs test
Used to determine Rh factor
Iron tests
serum iron, total iron-binding capacity (TIBC), serum ferritin, and transferrin saturation
Mild anemia levels of Hgb
10-14 g/dL (100-140 g/L) --> rarely symptoms, but if does (usually with exercise) --> palpitations, dyspnea, mild fatigue
Moderate anemia levels of Hgb
6-10 g/dL (60-100 g/L) --> increased cardiopulmonary S/S, more at rest

bounding pulse, roaring in the ears
Severe anemia levels of Hgb
< 6 g/dL (<60 g/L) --> Pallor, jaundice (hemolysis), pruritus (hemolysis), icteric conjunctiva/sclera (hemolysis), blurred vission, glossitis, smooth tongue, tachycardia, increased PP, systoplic murmurs, intermittent claudication, angina, HF, MI, tachypnea, orthopnea, dyspnea at rest, HA, vertigo, irritability, depression, impaired thought processes, anorexia, hepatomegally, splenomegally, difficulty swallowing, sore mouth, bone pain, sensitivity to cold, weight loss, lethargy
Thalassemia minor
- no globulin protein
- heterozygous (Tt)
- mild form of disease
- asymptomatic to mild anemia S/S
- no tx, body adapts
Thalassemia major
- no globulin protein
- homozygous (tt)- recessive
- life threatening
- growth, physical and mental retardation
- S/S develop by 2 yrs ol
- pallor and anemia S/S with splenomegally and hepatomegally
- symptoms managed with blood transfusions and oral chelating agents that bind to iron to reduce the iron overload that occurs with chronic transfusion therapy
- folic acid
- keep Hgb above about 10g/dL
- zinc, ascorbic acid
** no iron supplements**
- splenectomy

- Hep C usually present if above 25yo from all transfusions (before they were screened)

- cardiac complications from iron overload, HTN
Folic acid deficiency vs. B12 (cobalamine) deficiency S/S
B12 has neurologic symptoms, Folic acid does not
Schilling test
radioactive for B12/Cobalamine excretion (in urine)

Can also be done with intrinsic factor
Macrocytic anemias
Pernicious/B12 and Folate
Aplastic anemia
- Peripheral blood pancytopenia (decrease in all blood cell types)
- infection risk (neutropenia), sepsis, shock, death
- low grade fever (100.4) should be considered an emergency
- bleeding (thrombocytopenia)

tx with:
- immunosuppressive therapy
- hematopeietic ctem cell (preferred for under 45 yo if have HLA match)
- ATG (horse serum)--. anaphylaxis and serum sickness (usually older adults)
hemochromatosis
iron overload disorder
- genetic defect or secondary thalassemia and other certain anemias, multiple blood transfussions, or liver disaese
- non specific symptoms at first then eventual hepatomegally from gathered iron--> liver failure, cirrhosis

- tx is blood removal (500mL per week for 2-3 yrs, then lowers after that)
Polycythemia
- production and presence of increased RBCs--> hyperviscosity and hypervolemia

- HA, vertigo, dizziness, tinnitus, visual disturbances, painful burning of feet and hands, parsthesias, hemorhaggic phenomena, bleeding, epitaxis (inadequate platelet function), uric acid,

tx is phlebotomy or myelosuppressive agents
- fluid i&o
- assess nutritional status
- phlebotomy q 2-3 months, 500mL each
- leukemia andmyelofibrosis may develop in vera
* Thrombosis is major cause of death
Polycythemia vera (primary)
chronic, from chromosomal mutation
insidious
average dx at age 60
predisposed to clotting (high RBCs, WBCs, and platelets)
splenomegally, hepatomegally, organs and tissues congested with blood
Secondary polycythemia
hypoxia driven or hypoxia independent

hypoxia --> erythropoetin --> increaswed RBCs

erythropoetin made frommalignant or benign tumor --> increased RBCs
Immune thrombocytopenic purpura (ITP)
- most common acquired thrombocytopenia
- abnormal destruction of circulating platelets
- autoimmune disease (antibodies coat platelets)
- Platelets function normally but when reach spleen they are destroyed by macrophages
- Helicobactor pylori can contribute to this

- Chronic can occur in women 20-40 yo and is gradual and transient
Normal platelet survival
8-10 days
Thrombotic thrombocytopenic purpura (TTP)
- uncommon syndrome
- hemolytic anemia, thrombocytopenia, neurologic abnormalities, fever (with no infection), and renal abnormalities
- not ALL features are present in all patients
- usually associated with hemolytic-uremia syndrome (HUS)
- enhanced agglutination of platelets --> microthrombi --> deposit in arterioles and capillaries

- usually from deficiency of plasma enzyme that normally breaks now vWF

- primarily in adults 20-50yo
- may be iodiopathic or drug toxicfications, plavix, pregnancy, or infection, or autoimmune (SLE)

**Medical emergency because bleeding and clotting are simultaneous
- thrombocytopenia, anemia, altered RBC morphology, fragmented cells

* Coagulation studies are normal but TTp can still be severe!
Heperain Induced Thrombocytopenia (HIT)
- on heparin therapy
- leads to venous thrombosis and arterial thrombosis,
- DVT, PE are most common complications. Others include skin necrosis, stroke, and end-organ damage
- immune mediated response (antibodies) to Heparin causing platelet destruction and vascular endothelial injury
- Platelet aggregation causes the need for more heparin also
some signs of internal bleeding
weakness, fainting, dizziness, tachycardia, abdominal pain, hypotension
Prolonged bleeding from trauma o injury occurs when platelets

and spontaneous bleeding level
<50,000 uL (50x10^9/L)

<20,000 is spontaneous bleeding

**Platelet transfusion are not normally recommended until platelets < 10,000 uL (10x10^9/L) and ABO compatibility is not necessarily a requisite, but after several transfusions the pt can eventually develop antibodies
Disseminated intravascular coagulation (DIC)
- increased PT and aPTT

** In other thrombocytopenias the PT and aPTT can be normal no matter how bad it is
Treatment for ITP
can be asymptomatic
usually no tx until platelets < 30,000

- corticosteroids
- splenectomy if pt doesn't response to prednisone
- IV immunoglobulins
Treatment for TTP
- treat underlying disorder
- plasmapharesis
- If untreated it can result in irreversible renal failure and death
- immunosuppressants and splenectomy
**Admin of platelets is usually contraindicated**
Treatment of HIT
- D/C heparin
- no heparin flushes
- start pt on direct thrombin inhibitor to maintain anticoagulation
** Coumadin should only be started if platelet count has reached 150,000

- if clotting is severe, may use plasmapheresis

****Never give pt heparin or LMWH again!!!
Treatment of thrombocytopenia from decreases platelet production
- Neumega, Nplate, Promacta (platelet growth factor) --> stimulates bone marrow to produce platelets
Nursing care for thrombocytopenia
- caution with OTC meds (aspirin)

Acutely: prevent and control hemorrhage
- minor bleeding may quickly turn to hemorrhage
- avoid IM, in subcu use small needle and apply 5-10 min of direct pressure
- count sanitary napkins in women
- Blood loss of 50mL will completely soak a sanitary napkin
- may need to suppress menses

- education of pt to avoid injury, monitor pt with meds
Hemophilia
- x-linked
- A (VIII deficiency)- most common
- B (Christmas, IX deficiency)

VIII is synthesized in liver
Von Willebrand disease
most common congenital bleeding disorder
S/S of hemophilia
- slow persistent, prolonged bleeding from minor trauma and small cuts
- delayed bleeding after minor injuries (several hrs or days)
- uncontrollable hemorrhage after dental extractions or hard TBing
- epistaxis
- GI bleeding
- hematuria from GU trauma and splenic rupture from falls or abdominal trauma
- eccymosis and Subcu hematomas
- neurologic signs (pain, anesthesia, paralysis- nerve compression from hematoma)
- hemarthosis (bleeding into joints)
- aPTT may be affected but not others
Nursing care for hemophilia
- genetic counseling

Acute:
- stop topical bleeding (apply direct pressure, ice pack, fibrin foam, topical hemostatic agents)
- admin specific coagulation factor (monitor for hypersensitivity)
- if joint bleeding --> rest involved joint totally, pack with ice, give analgesics (no aspirin). When bleeding ceases--> mobilization of affected area with ROM and PT
* no weight bearing till swelling is resolved and muscles strength has returned

-manage any life threatening complications (airway obstruction from hemorrhage into neck or pharynx, compartment syndrome recognition, inctracranial bleeding assessment and interventions)

- lots of pt education
- soft TBing
- noncontact sports (ie:golf) and wear gloves when doing household chores to prevent cuts and scrape
- wear medic alert tag
education regarding self admin of factor (if pt reliable)
Pallor
decreased HgB
Flushing
Increased hemaglobin (polycythemia)
Jaundice
Bile pigment (liver)
sickle cell
Cyanosis
low Hgb or other causes
Pruritis
Hodgkins lymphoma, cutaneous lymphomas, infiltrative leukemias

Increase bilirubin
Purpura
small hemorrhages in skin
- decreased platelets or clotting factors
Petichiae
Pinpoint, nonraised
- decreased platelets or clotting factors
Echymosis
hemorrhagic spot
- decreased platelets or clotting factors
Hematoma
localized collection of blood
- decreased platelets or clotting factors
Jaundice sclera
- increased bile from hemolysis or liver disease
Conjunctival pallor
- dereased Hgb, anemia
visual disturbances
extreme leukocytosis, polycythemia, thrombocytopenia
increased clotting causing thrombosis
epistaxis
decreased platelets
Gingival mucous membrane changes
- decreased hgb, neutropenia (infections), leukemia
Smooth tongue, glossitis
pernicious and iron deficiency anemia
Tachycardia
HR >100 bpm
- compensatory
Palpitations
anemia, fluid volume overload, decreased BP with syncope, increased BP, dysrhythmias
Altered BP
orthostasis, decreased BP
- anemia
- infectious process, blood loss, compromised cardiovascular compensatory mechanism
Increased BP
May occur initially with anemia
Sternal tenderness
leukemia, multiple myelopm
decreased oxygen saturation
(pulse ox)
- severe anemia
Hepatomegally
- leukemia
- cirrhosis
- fibrosis secondary to iron overload from sickle cell disease or thalassemia
Splenomegally
anemia
thrombocytopenia
leukemia
lymphomas
leukopenia
mono
malaria
cirrhosis
trauma
increased portal BP
Distended abdomen
lymphoma
masses
bowel obstruction
paresthesias of feet and hands, ataxia
numbess
ataxia- impaired muscle movements

- cobalamin (B12) deficiency or folate deficiency (???- book says no CNS in folate deficiency)
Weakness
anemia
HA, nuchal rigidity
pain in cranium and extending to neck
- generalized HA: mild to moderate anemia
- Severe HA- may be intracranial hemorrhage due to thrombocytopenia
- HA with nuchal rigidity may indicate meningitis, carcinomatosis (certain leukemias)
Bone pain
- multiple myeloma related to large tumors (it also erodes the bone)
- bone invasion by leukemia cells
- bone demineralization due to malignancies
- sickle cell disease
Joint swelling
sickle cell anemia due to bleeding into joint ((hemarthria) causing inflammation
Arthralgia
joint pain
- sickle cell disease (hemarthosis)
Disseminated intravascular coagulation (DIC)
- results from abnormal initiated and accelerated clotting --> decrease in clotting factors and platelets

- characterized by profuse bleeding that results from depletion of platelts and clotting factors
- always caused by an underlying condition and that problem must be treated for DIC to resolve

- not a disease, it is an abnormal response to the normal clotting cascade
- bleeding, weakness, malaise, fever

- will have increased PT, PTT, aPTT, and thrombin time.
- reduced platelets and reduced fibrinogen
Bleeding manifestations of DIC
- integumentary manifestations (pallor, petechiae, purpura, site bleeding, hematomas, occutl hemorrhage
- respiratory (tachycardia and hypotension)
- GI manifestations (bleeding, distention, bloody stools)
- urinary ( hematuria)
- neurological
- musculoskeletal (bone and joint pain)
- may have cyanosis, ischemic tissue necrosis, PE, dyspnea, tachypnea, ARDS, ECG changes, paralytic ileus, kidney damage
Tx for DIC
oxygen and volume replacement (stabilize) if needed
- platelets only if less than 20,000 or less than 50,000 with bleeding, fibrinogen if less than 100mg/dL
- if evidence of thrombosis will be given heparin or LMWH (controversial treatment)**
Acute Leukemia vs. Chronic Leukemia
Acute
- usually younger pts
- immature hematopoietic cells (immature WBCs)
- rapid onset

Chronic
- mature forms of WBCs
- onset is more gradual
- usually older pts
Acute myelogenous leukemia (AML)
- abrupt, dramatic onset --> serious infection or abnormal bleeding

* acute not as common in adult, but if get acute as adult 85% are this kind
AML clinical manifestations
- Anemia (WBCs being produced instead of RBCs)
- Bleeding (WBCs being produced instead of RBCs and platelets)
- Fever (don't have normal signs of infection)
- Sternal tenderness (overactive marrow)
- Gingival hyperplasia
- HIGH WBC count (like over 200-500,000!)
Acute lymphocytic leukemia (ALL)
- most common children leukemia
- B cell origin, immature WBCs
ALL clinical manifestations
- abrupt S/S appear
- fever
- bleeding
- progressive weakness, fatigue, pain, bleeding tenderness
* CNS manifestations* (Serious problem)
* Leukemic meningitis (arachnoid infiltration of WBCs)*
Chronic myelogenous leukemia (CML)
- mature granulocytes in bone marrow --> go to peripheral blood in massive numbers --> infiltrate liver and spleen
** Philadelphia chromosome- genetic marker of 90% of those affected
Clinical manifestations of CML
Chronic, stable phase --> followed by acute, aggressive (blastic) phase

early: no symptoms
Later: fatigue, wekaness, fever, weight loss, sternal tenderness, joint pain, splenomegally, sweating
Chronic lymphocytic leukemia (CLL)
- accumulation of functionally inactive MATURE- appearing lymphocytes (b cell involvement)--> infiltrate bone marrow, spleen, and liver
* Most common leukemia in adults

- B cell CLL is considered identical to the non hodgkins lymphoma b cell small lymphocytic lymphoma
- 5-10% will have a change to Richter's syndrome (large b cell non-hodgkins lymphoma)
CLL clinical manifestations
- lymph node enlargement throughout body (increased incidence of infection)

- complications from early stage are rare
- initially asymptomatic and found during clinical work up for another issue
- mild anemia
- WBC may be > 100,000
- may develop as the disease advances
- pain, paralysis from pressure being placed on surrounding tissues caused by enlarged lymph nodes

**Mediastinal node enlargment leads to pulmonary symptoms
CLL tx
- consider age and benefit
- early states may require no treatment, follow closely
- only receive tx when disease progresses (1/3 will require immediate intervention at dx)
4 main leukemia signs
- Anemia
- thrombocytopenia
- neutropenia
- leukocytosis
Goal of leukemia treatment
attaining remission
complete remission
- no disease in physical examination
- bone marrow and peripheral blood appear normal

(could have hidden cancer somewhere)
Partial remission
- lack of symptoms
- normal peripheral blood smear
- disease evidence within bone marrow (abnormal cells has not made it to peripheral cells)
Molecular remission
all molecular studies are negative for residual leukemia (most definitive)
Chemotherapy stages
- Induction
- Intensification
- Consolidation
- Maintenance
Induction
- attempt to induce remission
- pt may become critically ill--> nursing interventions focus on neutropenia, thrombocytopenia, and anemia as well as providing psychosocial support to the patient and family.

*After indiction therapy, approximately 70% of newly dx pts achieve complete remission
Intensification therapy
- high dose therapy for several months
- same drugs, higher doses
- eliminate remaining leukemic cells (have to get dif stages of cells with dif meds)
Consolidation therapy
- after remission
- eliminate remaining that aren't pathologically evident
- one or two additional courses of same drugs or may involve high dose therapy (intensive consolidation)
Maintenance therapy
- lower doses of the same drug given every 3-4 weeks
- goal is to keep body free of leukemic cells
* each leukemia requires different maintenance therapy: Maintenance therapy rarely works on AML
Three purposes of combination chemotherapy
- decreases drug resistance
- decreases drug toxicity using multiple drugs
- interrupt cell growth at multiple points
Monclonal antibodies
--mab meds

- immunosuppression--> infection

- these meds are an important treatment in hematopoietic malignancies. Cure with these alone is RARE
Hematopoietic stem cell transplant
- goal is to totally eliminate leukemic cells using combinations of high dose chemotherapy with or without radiation

- this eradicates pt's hematopoietc stem cells --> VERY IMMUNOCOMPROMISED!

- replaced with those of an HLA match (sibling, volunteer, identical twin, or their own stem cells)
Nursing care with patient and families
- pt understand and cooperate with treatment plan
- Experience minimal side effects and complications of disease and treatment
- pt feel hopeful and supported during periods of treatment, relapse, and remission (fear, equated with death)
- Family may need help in adjusted to stress (dependence, withdrawal, changes in role responsibility, body image, losses imposed by sick role)
* Important for nurse to understand what leukemia it is, the prognosis, the tx plan, and the goals (varies with each kind)
- Pt can have a better outlook and QOL if has knowledge of disease and tx
- survivor networks, support groups, "Can surmount" and "Make today count"
- Community resources (American cancer society, etc.) may reduce financial burden and the feelings of dependence
- Spiritual support needs to be offered
Important Nursing interventions
- maximizing pt physical functioning
- providing hope that acute symptoms of tx are temporary
- Encourage pts to discuss their QOL issues
- Assess and plan for severe side effects of chemotherapy (see cancer notes)
- ongoing care to monitor for S/S of disease control and relapse
Nursing pt outcomes
- cope effectively with dx, tx, and prognosis
- attain and maintain adequate nutrition (the last thing they want to do is eat)
- experience no complications
- feel comfortable and supported
Functions of lymph system
- carries fluid from interstitial space to the blood
- proteins and fat from GI tract and certain hormones are able to return to the circulatory system
- Returns excess fluid to the blood preventing edema
- nodea filter bacteria and foreign particles carried by lymph
Hodgkins lymphoma
** Reed-Sternberg cells in lymph node biopsy specimens
- proliferation of abnormal giant multinucleated cells
- 15-35 yo and >50yo, 2x men>women
- lymph node structure destroyed by hyperplasia of monocytes and macrophages --> believed to arise in single location--> spreads along adjacent lymphatics --> infiltrates other organs (lungs, spleen, liver)
Key factors influencing development of Hodgkin's lymphoma
- unknown cause
- infection with epstein barr virus
- Genetic predisposition
- exposure to occupational toxins
S/S of Hodgkins lymphoma
***2/3 are affected first in the cervical lymph node!
** Disease begins above diaphragm
- remains in lymph nodes for variable amount of time
- Once below diaphragm it frequently spreads to extra-lymphoid sites
- Insidious
* Enlargement of cervical, axillary, or inguinal lymph nodes
** notes are moveable and non-tender
** Painless unless nodes exert pressure on adjacent nerves
- Person doesn't really look or feel sick
- B symptoms (fever, night sweats, weight loss)
- fatigue, weakness, chills, tachycardia
- Alcohol induced pain
- generalized pruitis without lesions
- Mediastinal node involvement is evident with cough, dyspnea, stridor, dysphagia
S/S of advanced hodgkins lymphoma
- hepatomegally
- splenomegally
- anemia
- other signs vary on disease location
Hodgkins lymphoma stage I
one node involvement (ie: cervical)
HL Stage II
2 or more nodes on one side of diaphragm
HL Stage III
lymph node involvement above and below diaphragm
HL stage IV
involvement outside of the diaphragm (liver, bone marrow, etc.)
A or B in HL staging after roman numeral
A- absence of symptoms upon dx
B- has symptoms upon dx
tx focus
- least amount to achieve cure
- minimize short and long term complications
B symptoms and other significant HL symptoms
B: fever, night sweats, weight loss

other: elevated SED, over 50 yo, large mediastinal mass, low albumin, hgb, and lymphocyte counts (these will make a stage I or II have a less favorable prognosis and will be more aggressively treated)
HL tx
combination chemotherapy (aggressive 6-8 cycles)
- has to be aggressive
- supplemental radiation depends on site and stage
** Maintenance therapy does not contribute to increased survival once complete remission has been achieved
HL associated risks
Secondary malignancies:
- AML
- non hodgkins lymphoma
- solid tumors
Nursing care for HL
- skin in radiation
- psychsocial considerations
- fertility issues
- long term evaluation of pt (consequences may not be apparent for years)
Non-Hodgkins lymphoma (NHL)
- heterogenous group of malignant neoplasms
- most commonly occurring hematologic cancer
- affects all ages but more common in older people (incident has increased with aging population)
- varies from slow to rapid progression
- classified according to cellular and lymph characteristics
Types of NHLs
- B Cells (antibody antigen reaction)- 90%
- T cells (cellular immunity in blood)- 10%
- Burkitt's lymphoma
- Reticulum cell sarcoma
- Lymphosarcoma
Clinical manifestations of NHL
- can originate outside of lymph node
- spread can be unpredictable
- widely disseminated usually at dx
- painless lymph node enlargement (primary clinical manifestation)

- pt with high-grade lymphomas:
- lymphadenopathy
- B symptoms

**Peripheral blood is usually normal
but some have a leukemic phase
Prognosis of NHL
- generally not as good has HL cause pts are usually older and it doesn't have hallmark features, usually disseminated
Tx of NHL
- radiation and chemotherapy
- more aggressive lymphomas are more responsive to treatment (more likely to be cured)
-complete remission is uncommon but most respond with improvement of adenopathy and symptoms
- radiation alone may be treatment for localized stage I and II
- asymptomatic will just be "watchful waiting" and may need to determine if the tx is worse than the disease

Once symptomatic:
- Leukeran, Cytoxan, and w/ or w/o prednisone
CHOP chemotherapy
Cytoxan
Hydroxorubicin/doxorubicin****
Onavin
Prednisone

****major complication of this med is cardiac toxicity leading to heart failure
Biological therapy
Alpha interferon (Intron)
Rituximab (Rituxan)
Ibritumomab tiuxetan (Zevalin)
Rituximab
used to treat NHL- attacks antigen on normal and malignant B cells

R-CHOP is if this is added to CHOP tx (B cell lymphomas specifically, not T cell)
Multiple myeloma
neoplastic PLASMA cells infiltrate bone marrow and destroy bone --> abnormal immunoglobulin production (* Will show elevated*)
- twice as common in men, usually after age 40, and more common in African Americans

*** Bence Jones protein can be detected in urine
Causes of multiple myeloma
- cause unknown
- possible radiation, organic chemicals (herbicides, insecticides, metals, benzene)
- genetic and viral factors influence risk
**Celiac disease is highly correlated with multiple myeloma (and Hodgkins) and other autoimmune disorders
End organs for multiple myeloma
bone marrow, bone, kidneys, spleen, lymph nodes, liver, heart muscle
Clinical manifestations of MM
- insidious and slow development
- symptoms usually with advanced disease
- Diffuse osteoporosis develops
- Vertebral destruction can lead to collapse and spinal cord compression
- Pathological fractures common
- Bence Jones protein in urein
- monoclonal (M) antibody protein found in blood and urine
- Pancytopenia
- hypercalcemia
- increased serum creatinine
- cone erosions, thinning fractures
- plasma cells in bone marrow

** Hallmark is bone pain and fractures
Tx of MM
- watchful waiting
- steroids
- chemotherapy
- biologic therapy
- Autologous stem cell transplant
- Ambulation and hydration to treat hypercalcemia, dehydration, potential renal failure
- weight bearing (fall precautions similar to osteoporitic pt)
- Control pain
- Biphosphonates: inhibit boen breakdown (Fosamax, Boniva** look up)
- Radiation therapy
Nursing managment for MM
- hydration
- monitor electrolytes/renal function/ fluid balance
- careful ambulation
- manage peripheral neuropathy
- pain management (from fractures also)
- Treatment infection
- Psychsocial needs
Myeloma protein (M protein)
from excesssive immunoglobulin production (all of them but most common is IgG)

* not the same as M antibody as discussed earlier found in blood and urine
MM hypercalcemia consequences
renal (and from other proteins), GI, neurological manifestations:
- polyuria
- anorexia
- confusion
- seizures, coma
- cardiac problems
Zometa
a biphosphinate for MM

- make sure pt is adequately hydrated and can have renal toxicity if IV given in less than 15 min
hydration for multiple myeloma
want IV fluids in order to attain urinary output of 1.5-2L per day
Function of spleen
- hematopoiesis during fetal development
- Filter )old RBCs, reuse iron and hgb)
- Immunity (lymphocytes and monocytes)
- storage- 30% platelets stored in spleen
Hypersplenism
- splenomegaly
- peripheral cytopenias (anemias, leukopenia, thrombocytopenia)
Massive splenic enlargement occurs with:
- CML
- thalassemia major
Mild splenic enlargement occurs with:
- HF
- SLE
- mononucleosis (#1 side effect of this is splenic rupture)
With splenomegally...
- normal filtering and sequestering INCREASES--> reduction in circulating blood cells and unusual peripheral smear findings
Signs of splenomegally
- may be well tolerated
- abdominal discomfort
- early satiety
Mononucleosis cautions
- risk for splenic rupture
** no contact sports!
Spleen disorders
- Trauma (commonly damaged in auto accidents)
- congestion
- Infiltrative diseases
- Hereditary Hemolytic Anemia
- Autoimmun cytopenias
- Infections and Inflammations (mono)
Splenectomy
- may have dramatic increase in peripheral RBCs, WBCs, and platelets
- Immunologic deficiencies may develop
- Reduced IgM levels, IgG and IgA are normal
**life long risk for infection (especially encapsulated organisms)
* must educate pt about this
- nursing care depends on nature of problem
- splenomegally may be painful and require management
-
Neutropenia
A reduction in neutrophils < 1500/uL
Leukopenia
reduction in total WBC count
Granulocytopenia
a reduction in granulocytes (Neutrophils, eosinophils, basophils) NEB
How to determine absolute count
WBC count x differential %
Causes of neutropenia
- chemotherapy
- psychotrophic drugs (Clozoril)
- Gold
- Antimicrobials (AZT, Bactrim-#1 for UTIs)
- Hematologic disorders (Ideopathic, aplastic anemia, leukemia, myelodysplastic syndrome--marrow doesn't produce them)
- Autoimmune disorders (SLE, RA)
- Infections, Sepssi (no more WBCs)
- Bone marrow infiltration of CA, TB, lymphoma
- Hypersplenism
- Transfusion reactions
- Hemodialysis
More about Neutropenia
- a symptom, not a disease
- important to know degree of neutropenia, duration, and rate of decline

** the quicker the drop the greater the likelihood of developing infection**

--> infection from normal flora
--> normal inflammation signs are absent from lack of phagycyte activity

** be concerned with low grade fever of over 100.4 F (may have sore throat, be tired, and not feel good. Won't have puss or redness)
Neutropenic pt with fever
** Assumed to be infected and at risk to develop sepsis rapidly

** Culture them and start them on broad spectrum ant bx immediately!!
- assessment, cultures, antibx ASAP
Leukopenia
< 5000/uL WBCs (normal is 5000-10000)
Absolute neutrophil count (ANC)
<1000/uL= moderate risk for infection

<500/uL= severe risk for infection

* for dx would also need a bone marrow biopsy (this is true if reason for neutropenia is unknown, to see if bone marrow is making, or also test spleen and liver function)
Significant clinical signs for neutropenic pt
- Fever > 100.4 (educate pt about this also)
- chills or feeling of fever
- any redness, swelling, discharge, or new pain
- changes in character of urine or stool
- cough, sore throat, blisters, oral sores

* home education is important cause don't want to bring pt to sickly hospital

- any minor complaint of pain or any other symptom needs to be reported to physician immediately
Treatment for neutropenia
- determine cause and remove (may be side effect of necessary tx)
- assess for infection, identify infecting organisms and treat
- prophylactic or therapeutic antbx (if infection suspected)
- Adminster hematopoietic growth factor (Neupogen, Leukine)

*Outpt treatment preferred- EDUCATION!
Hematopoietic growth factors
Neupogen, Leukine
***DO NOT GIVE WITH CANCER OF THE BLOOD- SPECIFICALLY LEUKEMIA AND SOME OF THE LYMPHOMAS***
Neutropenic pt education
- avoid crowds and ill people
- mask in public covering mouth and nose
- avoid uncooked meats, seafood, eggs, fruit, veggies
- moisturize skin, impeccable skin care
- Avoid gardening or pet care (especially litter boxes and birds- histoplasmosis)
Neutropenic pt in hospital
- strict handwashing
- visitor limitation
- positive pressure room (HEPA)/laminar flow room
ASAP tx if neutropenic pt has infection assumed
at least 2 serial blood cultures or one from a peripheral sit and one from a venous access device should be done promptly and antibiotics started immediately (within 1 hour)

Culture sputum, throat, lesions, wounds, urine, and feces
side effects common to aminoglycosides
- nephrotoxicity
- ototoxicity
side effects common to cephalosporins
rashes, fever, pruiritus
If neutropenic pt has a change in assessment or does not become afebrile with broad spectrum anti bx
call physician
fungal culture
clinical manifestations of 10% acute blood loss
none
Clinical manifestations of 20% acute blood loss
- no S/S at rest
- tachycardia with slight exercise and slight postural hypotension
Clinical manifestations of 30% blood loss
- Normal supine BP and pulse at rest
- Postural hypotension and tachycardia with exercise
Clinical manifestations of 40% actue blood loss
- BP, CVP, and cardiac output below normal at rest
- rapid, thready pulse
- cold clammy skin
Clinical manifestations of 50% acute blood loss
Shock and potential death
Needle for blood components
- 18 gauge or larger in free flowing IV line
- Smaller needles can be used for platelets, albumin, cryoprecipitates
- PICC lines are NOT recommended due to high risk of clogged lines due to slow blood flow
Fluids used with blood
- NORMAL SALINE
**Do not use dextrose or lactated ringers!! --> causes RBC hemolysis
- no other additives
- use blood tubing
BEFORE obtaining blood from blood bank
confirm vitals including temperature

*consult with MD i f there is a temp or it they want to be called at a certain temp if it rising during transfusion
Blood ID-ing
- Positive ID of recipient by 3 RNs and of proper blood component

***ABO incompatibility is LETHAL
Blood component therapy nursing care
- stay with patient during first 15 minutes of transfusion (most reactions occur during this time

- Take full vitals before adminstration, 15 minutes after start, and at end (usually have to record on blood ticket)

- If blood needs to be given slower (like a HF pt) ask blood bank to split it so it won't be open to air as long

- have to ID each unit of blood

- some pts require Lasix after or between units
Blood infusion times
- Run blood no faster than 2mL/min
(In case of reaction, less blood is received and rapid infusion of cold blood may cause hypothermia and chilling)

***Entire unit but be transfused between 2-4 hours
Acute hemolytic reaction
ABO incompatibility
***Sentinal event!***

- rare, causes destruction of RBCs from agglutination --> high hgb in blood and urine that can clog renal tubules
Signs of acute hemolytic reaction
- fever
- chills
- low back pain
- tachycardia
- tachypnea
- hypotension
- vascular collapse
- ark urine (release of bilirubin and myoglobin)
- bleeding
- renal failure
- cardiac arrest
- death
What to do if have acute hemolytic reaction
#1- STOP the transfusion!
- maintain patent IV line with running NS
- notify blood bank and MD immediately
- recheck identifying tags and numbers
- monitor vital signs in urine output
- treat symptoms
- save blood bag and tubing and send to blood bank
- Collect blood and urine specimens
- Document
Blood types
O- :universal donor

AB+ : universal recipient
Febrile reactions
- most commonly caused by leukocyte incompatibility
- can be preventing by filtering leukocytes
symptoms of febrile reaction
- fever
- chills
- HA
- flushing

- Stop infusion and do not restart unless physician orders
- if feverish --> give Tylenol**
Mild allergic reactions
- Sensitivity to plasma proteins
symptoms and tx of mild allergic reaction
- flushing
- itching
- urticaria (hives)

* Antihistamin (benadryl) prior to transfusion may prevent reaction
- if mild can restart transfusion slowly
** Do not restart if fever or pulmonary symptoms develop!
Circulatory overload
- to much blood, too fast
Treatment for circulatory overload
- slow rate of infusion
- diuretics prior and/or between units
- sit pt upright
- may be given morphine also
- phlebotomy may be required
Symptoms of circulatory overload
- HF symptoms
- Cough
- SOB
- pulmonary congestion
- HA
- HTN
- tachycardia
- distended neck veins
Sepsis
- bacterial contamination of blood products leading to septic shock

- pts at risk for this are when they have lost lots of blood (trauma, AAA rupture, large GI bleed)
Symptoms of sepsis
- high fever
- shills
- vomiting
- diarrhea
- marked hypotension/shock
Massive blood transfusion reaction
- An imbalance of normal blood elements due to transfusions of multiple units of RBCs
-->
- hypothermia
- citrate toxicity
- hypocalcemia
- hyperkalemia (cell rupture)
Delayed transufsion reactions (non acute)
- delayed hemolysis
- infection
- iron overload
- graft-versus-host disease
Graft-versus-host disease
- immunocompetent pt infused with immunocompetent cells- lymphocytes
- target organ is skin --> rash
Autotransfusion
- removing whole blood from a person and transfusing it into the same person

- dontation prior to surgery
- collection of blood and returning it filtered
Packed RBCs
- most common
- allow remaining components to be used for other purposes
- decrease chance of fluid overload
- more component specific leukocyte depletion may be used to lower febrile reactions (can filter out leukocytes)

- indicated for symptomatic anemia and acute blood loss

- 1 unit can increase Hgb by 1 g/dL --> need a post transfusion H/H
Frozen RBCs
- must be used within 24 hrs of thaw
- successive washings with saline remove majority of WEBCs and plasma proteins

- indicated for autotransfusion, rare donors
- infrequently used due to filters removing most of WBCs
Platelets
- multiple units can be obtained from 1 donor by plateletpheresis
- Can be kept at room temperature for 1-5 days
- Bags should be agitated periodically
- expected 1 unit = increase is 10,000 uL/U


Indicated for:
- bleeding caused by thrombocytopenia platelets < 10,000- 20,000

* May be contraindicated in immune thrombocytopenic purpura, thrombotic thrombocytopenia, heperain induced thrombocytopenia except in life threatening hemorrhage
Failure for platelets to increase
may be due to fever, sepsis, splenomegally, DIC
Fresh Frozen Plasma (components of blood minus RBCs)
- use of plasma in treating hypovolemic shock
- also has clotting factors

Indicated for bleeding caused by clotting deficiency factors
Albumin
25g/100mL - 500 ml of Plasma

- hyperosmolar solution acts by moving water from extravascular to intravascular space
- does not transmit viruses

Indicated for
- hypovolemic shock
- hypoalbuminemia
- nephrotic syndrome
- massive loss of protein (pancreatitis, etc.)
Cryoprecipitates and commercial concentrates
Commercial concentrats prepared from FFP
- can be stores for 1 yr but once thawed, must be used
- Factor VIII and IX

Inidcated for replacement of clotting factors (hemophilia)
Hypocalcemia s/s
- for massive blood transfusion reaction

- muscle tremors and ECG changes
Hyperkalemia signs
- from massive blood transfusion reaction

- nausea
- muscle weakness
- diarrhea
- parasthesis
- flaccid paralysis of cardiac and respiratory muscles
- cardiac arrest
What is cancer
A group of more than 200 disease characterized by uncontrolled and unregulated growth of cells.

It is a major health problem that occurs in all age groups and all ethnicities
Cancer in men
#1- prostate (2nd highest death rate but #1 in incident)
#2- Lung (highest death rate)
Colon/Rectum
Bladder
Non-Hodgkins lymphoma
Melanoma
Kidney/Renal Pelvis
Oropharynx

Cancer is more common in men than women, esophageal is higher in men, men are more likely to develop liver cancer
- pancreas, liver, leukemia, esophagus all have higher death rate than non-hodgkins and kidney/renal

* Cancer is the second most common cause of death
- mortality rate of lung cancer is higher in men than women
- more men than women will die from cancer related deaths
- death rates are highest in African American men (and women), then whites, hispanics, and asians
Cancer in women
#1- Breast (highest incidence)
#2- Lung (highest death rate)- non smoking women are at higher risk for this than men of developing lung cancer
Colon, rectum- women are less like to have colon screenings
Uterus
Non-Hodgkins Lymphoma
Thyroid
Melanoma
Ovary

* Cancer deaths are higher in AA, then whites, hispanics, asians BUT
* INCIDENCE rates are higher in whites (maybe due to lack of screening in AA?)
Initiation
- first stage of cancer development
- mutation in a single cell
- irreversible
- may have apoptosis
- if cell death does not occure before cell division --> same mutation into daughter cells
Causes of initiation
- chemical carcinogens
- radiation
- viral carcinogens
- genetic susceptibility
Promotion
second stage of cancer development
- reversible proliferation of the altered cells (more than one cell is created) --> increase likelihood of additional mutations
Promotion causes
- dietary fat
- obesity
- cigarette smoking
- alcohol consumption
** these make promotion REVERSIBLE

*isn't clinically manifested yet (still considered latent), until critical mass is reached (1cm palpable, .5cm with MRI)
Progression
3rd stage of cancer development
- increased growth rate of the tumor
- increased invasiveness
- Metastasis
Characteristics of benign tumors
- usually encapsulated
- Differentiated
- no metastasis
- rare reccurence
- slight vascularity
- expansive growth
- fairly normal cells, similar to parent cells
Characteristics of malignant tumors
- Rarely encapsulated
- Poorly differentiated
- Can metastisize
- Possible recurrence
- moderate to marked vascularity
- Infiltrative or expansive growth
- abnormal cells, become more UNlike parent cells
Most frequent sites of metastasis
lungs, brain, bone, liver, adrenal glands
tumor angiogenesis
process of tumor developing blood vessels
Epithelial tissue tumors
Benign ---oma
Malignant --- carcinoma
Connective tissue tumors and Nervous tissue tumors
Benign ---oma
Malignant --sarcoma
Stage 0 in clinical staging of cancer
cancer in situ
Stage I
tumor limited to the tissue of origin, localized tumor growth
Stage II
Limited local spread
Stage III
extensive local and regional spread
Stage IV
metastasis
TNM staging
T- Tumor size and invasiveness
N- presence or absence of regional spread to lymph nodes
M- metastasis to distant organs
Primary Tumor (T)
T0- No evidence of Primary tumor
T is- Carcinoma in situ
T1-4- ascending degres of increase in tumor size and involvement
Tx- tumor cannot be found or measured
Regional lymph nodes (N)
N0- no evidence of disease in lymph nodes
N1-4 Degree of nodal involvement
Nx- Regional lymph nodes unable to be clinically assessed
Distant metastases (M)
M0- no evidence of distant metastasis
M1-4- degree of metastatic involvmen of the hose, including distant nodes
Mx- cannot be determined
7 warning signs of cancer
CAUTION
C- Change in bowel or bladder habits
A- A sore that does not heal
U- Unusual bleeding or discharge from any body oriface
T- Thickening or a lump in the breast or elsewhere
I- Indigestion or difficulty swallowing
O- Obvious change in wart or mole
N- Nagging cough or hoarseness
Cancer prevention education
- avoid carcinogens (including sun a cigarette smoke)
- balanced diet with adequate fiber
- avoid high fat, preservatives and nitrites
- regular exercise
- adequate rest (6-8 h per night)
- Obtain regular health exams
- self exams
- Know 7 warning signs of cancer
- reduce stressors, enhance ability to cope with stress
- seek immediate care if you notice a change in what is normal
Carcinoembryonic antigen (CEA)
protein found on surface of cancer cells derived from GI tract

(characteristic of embryonic and fetal periods of life)
a-fetoprotein (AFP)
protein produced by malignant liver cells
PSA
tumor marker frequently used for prostate cancer
CA-125
found in ovarian carcinoma
CA19-9
found in pancreatic and gallbladder cancer
BRCA 1, BRCA 2
genetic markers (tumor suppressor genes)
- alterations in these genes increase the risk of breast and ovarian cancer
3 Goals of cancer care
Cure, control, palliation
When cure is the goal
offered treatment is expected to have the greatest chance of disease eradication
- may include local therapies or/w/ systemic
When control is the goal
this is for cancers that cannot be completely eradicated but are responsive to anti cancer therapies, as well as other chronic illnesses (DM, HF) can be maintained for long periods of time

-multiple myeloma, chronic lymphocytic leukemia

- Initial course of tx follwed by maintenance therapy. Pts are watched closely for recurrence or side effects of tx
When palliation is the goal
relief or control of symptoms and the maintenance of a satisfactory quality of life are the primary goals rather than to cure or control the disease process.

-palliation and disease control are not mutually exclusive
- may use radiation or chemotherapy to reduce size of tumor still in order to reduce pain/obstruction.hemorrhage (pain- bone metastasis)
Goal of care depends on
staging, histology, physical state of pt, and pts choice
Chemotherapy cautions for nurses
Caution when preparing, transporting, or administering chemotherapy

- drug can be absorbed through inhalation when reconstituting and through skin contact if there is a droplet exposure or powder from oral agents

- There may be a risk in handling body fluids and excretions of persons receiving chemo immediately following administration for 48 hours

- Only those persons specifically trained in chemotherapy handling techniques should be involved with preparation and administration of antineoplastic agents
IV route for chemo complications
- through peripheral IV or central venous access (minimizes complications)

- can have venous access difficulties
- device or catheter related infection
- Extravasation (irritants damage intima of vein, vesicants cause tissue breakdown and necrosis)
Extravasation
** Extremely important to monitor for this and take immediate action
- The infusion should be turned off immediately and protocols for drug-specific extravasation procedures should be followed to minimize tissue damage

- pain is #1, but can occur without pain
- swelling
- redness
- vesicles on skin

- after a few days the tissue may ulcerate and necrose
- vesicants can cause full or partial tissue thickness loss
- may need surgical interventions for skin grafting

- complication include sepsis, scarring, contractures, join pain, nerve loss
Intraarterial route of chemotherapy
- via arterial vessel supplying tumor

Complications
- bleeding
- embolism
- pain
- arterial injury
- catheter migration/dislodgement
- occlusion
Intrathecal chemo route
- for cancers in CNS
- lumbar puncture and injection into the subarachnoid space OR Ommava reservior into a lateral ventricle

Complications:
- incomplete distribution of the agent
- HA
- N/V
- Fever
- Increased ICP
- nuchal rigidity
Intravesical chemo route
- chemo into the bladder following traditional surgical therapy

Complications:
- Dysuria
- urinary frequency
- hematuria
- cystitis
- UTI
- bladder spasms
Stomatitis and Mucositis CLinical presentation
Irritation, inflammation, and ulceration of the oral mucosa

- compunded by xerostomia, dysgeusia (taste loss), dysphage, and odynophagia (painful swallowing)
Nursing management of Stomatitis and Mucositis
- assess oral mucosa daily and educate pt to do so
- be aware of eating, swallowing, and talking difficulties--> may require analgesics
- Nutritional supplements, and moist, bland diet (high protein, high calorie)
- Meticulous oral care and saline (1 tsp salt to 1 liter water) or salt/soda rinses
- Saliva substitutes or sips of water
- discourage tobacco and alcohol
- Topical anesthetics (viscous lidocaine, oxethazine)
- Amifostine may be used to try and prevent xerostomia and has conflicting results for stomatitis/mucositis
- dental work done before tx
- frequent cleansing with saline and water and topical application of anesthetic gels directly to lesions are standard care
- Palifermin (a growth factor) may be used to reduce length of mucositis (IV med). Used as prevention as well for hematologic malignancies and chemo
- weight pt at least 2x/week to monitor for weight loss
- family and help important in assisting pt to eat
Nursing management for N/V
- Teach pt to eat and drink when not nauseated
- Admister antiemetics prophylactically 1 hour before chemotherapy and PRN
- Instruct pts to take antiemetics on a schedule for 2-3 days after chemo
- a light, non-irritating meal before chemo can be helpful to some pts
- Diversional activities
- Assess for dehydration and metabolic alkalosis
- Record I&O
Emend (Aprepitant)
prevents N/V on day of chemo and delayed symptoms
Nursing management for Anorexia
- peaks at about 4 weeks of tx, and resolves quicker than fatigue after tx
- Monitor weight
- Encourage frequent, small, high calorie and protein meals
- Nutritional supplements and possible enteral or parenteral nutrition (bowel rest or severely malnut.)
- Encourage pt to eat (avoid nagging)
- Serve food in pleasant environment
- Corticosteroid or Progestins
Nursing management of diarrhea
- sometimes pts are radiated with a full bladder in order to help move small bowel out of tx field
- Give antidiarrheal agents PRN
- Low fiber, low-residue diet before chemo
- Avoid fried, highly seasoned, gas producing foods
- radiation can caused temporary lactose intolerance
- encourage at least 3L of fluid intake
- Visually inspect perianal area for evidence of skin breakdown
- lukewarm sitz bath and keep rectal area clean and dry
- note number, volume, consistence and character of stool daily
- teach pt to record diary or log
-
Nursing management of constipation
- stool softeners
- eat high fiber foods
- increase fluid intake
Nursing management for hepatotoxicity
- Monitor liver function tests
- ALT, AST
- use care with hepatooixic drugs
Nursing management of anemia from bone marrow suppression
- monitor H/H
- iron supplements and erythropoietin
- encoruage intake of foods that promote RBC production (red meat, eggs, beans, leafy green, etc.)
Significant H/H values
Hct < 15 %

Hgb 10-14 g/dL (MIld)
Hgb 6-10 g/dL (moderate)
Hgb <6.0 g/dL (severe)
Myelosuprpession leds to -->
infection, hemorrhage, fatigue
lowest blood counts usually
within 7-10 days after tx begins, but depends on drug and host factors
Anemia onset
3-4 months after start of tx
Nursing management for neutropenia
- protective isolation, positive pressure room
- strict hand washing
- skin care
- visitor limitation
- monitor WBC count, especially neutrophils
- Report temperature elevation and signs of infection (may not have regular signs)
- Avoid large crowds and ill people
- Administer WBC growth factors (Neupogen, Neulasta)****
**** do not admin with cancers of the blood!!
Significant lab values for Neutropenia
WBC < 5000/uL = leukpenia
Absolute neutrophil count (ANC)
- <1000/uL = moderate risk for infection
-< 500/uL= severe risk for infection
Clinical signs of infection in neutropenic pt
- Fever >100.4
- chills or feeling of fever
- any redness, swelling, discharge, or new pain
- change in character of urine or stool
- cough, sore throat, blisters, oral sores
Pt teaching for Neutropenia
- hand washing!/gel
- S/S to report: fever greater than 100.4 (38C), chills, feeling hot....all S/S

- monitor temperature!
- avoid crowds and people with infections, wear mask in public places over mouth and nose
- NO uncooked meat, seafood, eggs
- NO unwashed fruits or veg
- bathe/shower daily and moisturize to prevent drying and cracking
- No gardening or cleaning up after pets. Feeding dog or cat is fine as long as hands are washed well after
Significant lab values for Thrombocytopenia
Platelet count < 150,000/uL

- <50,000/uL= prolonged bleeding from trauma
- <20,000/uL = spontaneous bleeding, life threatening hemorrhages
- low H/H??
S/S of thrombocytopenia
- asymptomatic
- bleeding from injection site, mucosa, or skin
- Internal bleeding (weakness, dizziness, tachy, hypoBP, abd pain, HA, vision changes, difficulty talking, confusion, dark stools, urine, vomitus, heavy menses)
Nursing management of Thrombocytopenia
- NO IM injections (avoid subcu and all if possible)
- if do subcu use small gauge needed and apply pressure for 5-10 min or ice pack
- Monitor oral mucosa and perform frequent oral care
- Stool softeners
- soft TB, etc.
Patient teaching for thrombocytopenia
- notify provider of ANY bleeding, even minor--> potential for hemorrhage
- teach s/s of internal bleeding
- wear sturdy shoes, no high-impact activities
* do not blow nose or strain with BM, or bed down with head lower than waist
*Push fluids to prevent constipation
- NO suppository, enema, or rectal thermometer
- ONLY shave with electric razor
- do not pluck eyebrows or body hair
- Do not puncture skin (tattos, piercings)
- NO meeds that prolong clotting (aspirin, anticoag, soem herbs, check OTCs)
- Soft TB (and floss gently, no alcohol-based mouthwash-->drying)
- Menses- NO tampons, keep track of pad #--> notify provider with an increase
**Check with provider before invasive procedures (dental cleaning, manicure)
Nosebleed care
Keep head up with firm pressure to nostrils and bridge
-If bleeding persists, apply ice pack
- If bleeding > 10 min--> call provider!
Nursing management for alopecia
- usually temporary
- avoid excessive shampoo, combing, hair dryers, curlers, curling rods
- pt may have emotional distress (anger, grief, embarrassment, fear)
- discuss impact on self-image
- suggest ways to cope (scarves, wigs)
- American Cancer Society's "look good, feel better" program provides support for body image
- cut long hair before therapy
Skin changes
- skin is affected because it has rapidly proliferating cells
- telangiectasis- red spots caused by dilated groups of capillaries

- photosenstivity
- hyperpigmentation
- erythema
- acne
- telangiectasis
- hand-foot-syndrome (acral erythema or palmer-plantar erythrodyesthesia-PPE
Signs of Hand-foot syndrome (acral erythema or palmer-plantar erythrodyesthesia- PPE)
- redness
- tingling in palms and soles
- moist desquamation
- ulceration
- blistering
- pain

if symptoms severe hold chemo for 1-2 weeks
Nursing management for skin changes
- alert patient to potential skin changes
- Avoidance of sun exposure
- Follow skin care protocol, monitor for infection
- If severe, chemo drug withheld for 1-2 weeks to allow skin to regenerate
Skin Patient and caregiver teaching guide
- gently cleanse the skin in the treatment with mild soap (Ivory, Dove), tepid water, soft cloth, gentle patting motion, rinse therapy and pat dry
- apply non-medicated, non-perfumed, moisturizing lotion or cream (such as aloe, aquaphor, biafine) to alleviate dryness
- some substance must be gently cleansed from the treatment field before each treatment and reapplied
- OTC 1% hydrocodone cream may relieve itching
- Rinse area with saline solution
- Expose area to air as often as possible
- if heavy drainage--> use non adhesive, astringent compression. They must be changed as soon as become wet
- Observe area daily for signs of infection
- Avoid tight-fitting clothes (bra, belts) over treatment area
- no hash fabrics (wool, curdoroy), light weight garments are best, air is better
- gentle cleansers for clothing
- avoid direct sun to area
- avoid excessive sources of heat
- avoid exposure to cold temps
- avoid swimming in salt water or chlorinated pools during tx
- avoid meds, deodorants, perfumes, powders, cosmetics on skin, tape, dressings, adhesive bandages (unless permitted by radiation therapist)
- Sens skin must continue to be protected after tx (no sun, sunscreen, use electric razor)
Hemorrhagic cystitis clinical presentation
- some chemo drugs destroy cell lining of bladder
- urgency, frequency, hematuria, hemorrhage
Nursing management for hemorrhagic cystitis
- Encourage increased fluid intake 24-72 hr after treatment as tolerated
- Administer supportive care drugs
Erythema
- 1-24h after treatment but usually more cumulative
- erythema--> dry desquamation--> wet desquamation if sloughing is faster than replace of dead cells

- skin folds, behind ear, gluteal folds, perineum, breast, collar line, bony prominences and areas of pressure
Anthracyclines
- Duxorubicin
- Daunorubicin
- cause cardiac toxicity in chemotherapy
- can be reduced by doing continuous infusion instead of rapid and watch accumulation of med
Monoclonal antibodies
- can cause hypotension
- Herceptin (trastuzamab) is cardiotoxic (used in breast cancer)
Reproductive dysfunction
- low sperm
- ED
- permanent cessation of menses, vaginal shortening, decrease in lubrication
- potential for infertility * but never say is in not possible!*
- harvest sperm or ova
- manage side effects with warer-soluble vaginal lubrication
- make referrals for ongoing counseling
Nursing management of nephrotoxicity
- monitor BUN and serum creatinine levels
- Avoid nephrotoxic drugs
- Prevent tumor lysis sundrome
- monitor I&O
-
How to prevent tumor lysis syndrome
alkalizing the urine with sodium bicarb and administering allopurinol or rasburicase
Nursing management of peripheral neuropathy
- monitor for S/S of peripheral neuropathy
- check color, temp, cap refill, peripheral pulses, sensation, and movement of limbs
- Consider temporary reduction or interruption of chemo dose until symptoms improve
- Antiseizure meds (neurontin) may be considered
S/S of peripheral neuropathy
- parastesias
- areflexia
- skeletal muscle weakness
- smooth muscle dysfunction
Clinical presentation of cognitive changes of "chemo brain"
- difficulty concentrating
- memory lapses
- trouble remembering details
- taking longer to finish tasks
Nursing management of cognitive changes or chemo brain
Teach pt to:
- use daily planner to write down important things to remember
- get plenty of sleep and rest
- do brain exercises ( learn something new or word puzzles)
- no multitasking (focus on one that at a time)
Clinical presentation of cardiotoxicity
- ECg changes
- L ventricular dysfunction
- rapidly progressive heart failure (increased HR, crackes, S3, S4, change in mental status, weakness, fatigue, dyspnea, orthopnea, cough, nocturia)
Nursing management for cardiotoxicity
- monitor ECG
- cardiac ejection fractions
- may consider periodic ECGs
- Management of HF (oxygen, drug therapy, urinary output, positioning, nutritional therapy, and rest)
- monitor drug therapy
Clinical presentation of hyperuricemia
Secondary gout
- joint inflammation
- swelling
- pain due to sodium urate crystal deposits
- chronic inflammation may result in joint deformity, cartilage destruction, and secondary OA
- kidney/urinary tract stone formation
Nursing management of hyperuricemia
- Monitor uric acid levels
- Encourage increased fluids
- Assess limitations of motion and degree of pain --> bedrest may be appropriate
- Allopurinal (Zyloprim) may be given prophylactically
Clinical presentation of fatigue
- persistent subjective sense of tiredness
- Interferes with usual day-to-day functioning
Nursing management of fatigue
- help pt realize it is a nearly universal side effect
- assess for reversible causes (anemia, hypothyroid, depression, anxiety, insomnia, dehydration, infection, medications)
- Encourage energy conservation strategies (rest before activity and when fatigued, have assistance, pace self, identify times of day when better and plan accordingly)
- Encourage moderate exercise as tolerated
- Encourage maintenance of good nutrition and hydration
- Manage other symptoms (insomnia, pain, depression, anxiety)
Daunorubcin (Adriamycin)
cardiotoxic
- life time max dose
Long term effects of chemo
- months to years later
- cataracts
- arthralgias
- endocrine alterations
- renal insufficiency
- hepatitis
- osteoporosis
- neurocognitive dysfunction
- Increased risk for leukemias, angiosarcomas, skin cancers, and other secondary malignancies
**stress to stop smoking as this increases risk**
Administration of chemo requires
- two pharmacists prep and 2 RN verification to administer
Cytotoxic Vinca Alkaloids
Vincristine- can cause peripheral neuropathy
Taxanes
Risk for severe hypersens reactions
OSHA characteristics of hazardous drugs
- genotoxicity
- carcinogenicity
- teratogenicity or fertility impairment
- serious organ or other toxic manifestations at low doses in experimental animals or treated patients

- carcinogens
- corrosives
- toxic or highly toxic
- irritants
- sensitizers
- target organ effectors (including all organs and skins, eyes, mucous membranes)
symptoms of exposure
- sore throat
- rash
- cough
- HA
- nausea
- diarrhea

- liver damage
- poor reproductive outcomes (miscarriage, infertility, fetal malformation)
- Personal risk of cancer
Hazardous drug precautions
- no eatin, drinking, chewing gum, smoking, or application of makeup in work area
- clear posted spill policy
- medications are prepared and primed in biological safety cabinet with appropriate ventilation system
- longer, thicker gloves, double latex
- handwashing
- low perm gown
- eye and face protection if splash or aerosolization
- respirator if aerosol
- leur-lock fittings should be observed observed for leakage
- Absorbent pad with plastic back should be placed under tubing during medication administration
- Administration sets should be disposed of intact in punture-resistant container
*Spill and emergency decontamination procedures should be in place
- infusion set with leur-lock fittings should

- longer, thicker gloves, double latex
- handwashing ebfore an after glove application
- low perm gown with elastic or knit closed cuff
-
Caring for pts with hazardous drugs
- follow blood born pathogens standards
- all waste is considered infectious
- staff should wear appropriate gloves and gowns when handling excreta in 48 hs following drug administration
- eye protection if splash is possible
- Linens should be considered potential source of contamination for 48 hours after. Special laundry bag. Bag contents washed twice.
- Reusable items should be washed twice. Disposable preferred.
- flush toilet twice. Dispose of contaminated underpads, sanitary napkins, diapers, etc. in hazardous waste container.
- thick bags that are differently colored should be used to gather gown, gloves, or disposables. This is handled as hazardous waste
- Hazardous waste trash should be handles separately from other hospital trash
- KNOW spill procedures!
Radiation is not appropriate for-
systemic disease
Nursing Care for External beam radiation
- client's skin is marked with tattors that guide the position of the external radiation source
- radiation may cause dysgeusia, making foods such as red meat unpalatable
- help the pt manage fatigue by scheduling activities with rest periods and using energy-saving measures (sitting in showers and ADLs)
- Treat symptoms related to the area of the body:
- mouth- mucositis, stomatitis
- neck- dysphagia
- abdomen- gastroenteritis
Pt teaching for external beam radiation
- inform pt fatigue is common side effect
- Gently wash the skin over the irradiated are with a mild soap and water, thoroughlt pat the area dry
- do not remove radiation "tattoos"
- no powders, ointments, lotions, or perfumes to the irradiated skin
- do not expose the skin to sun or heat
- all same as chemo, especially erythema reactions, etc.
Brachytherapy
Intenall radiation therapy
Nursing Care of pt with internal radiation
- Pt is emitting radioactivity!!
- time frame for specific side effects and radioactivity precautions is based on the rate of decay for the specific isotopes
- private room
- appropriate radiation sign on door
- tongs and lead container should be kept in the room if the delivery method could allow spontaneous loss of radioactive material
- if pt discharged for therapy then all these should be followed at home too
ALARA
As Low As Reasonably Achievable

as well as time, distance, shielding

- vital to healthcare professional safety when caring for the person with internal radiation
- Organize care to limit the amount of time spent in direct contact with the patient.
- make sure pt understands of the reason for distance and time limitations to reduce fears and anxiety
- the radiation safety officer will indicate the time and distance (determined by implant)
- small difference in distances are critical
- only care that must be delivered near the source (such as checking implant placement) should be performed in close proximity (30 minutes, 6 ft)
- no pregnant or <16 yo can come in contact with client
- Use shielding when available
- no care should be given without wearing a film badge (cumulative radiation exposure)
- don't share badges
Head and neck side effects
- dryness and soreness of the mouth and throat being treated
- loss of taste
- difficulty swallowing
- lymphedema
- stiffness in jaw
- Nausea
- increased mucus production

- all of these lead to loss of weight
- encourage nutritional supplements
- tooth decay occurs (dental care is extremely important)
GI radiation side effects
- stomatitis, mucositis, esophagitis
- nausea with or without vomiting, loss of appetitie, upper abdominal pain (feels like ulcers or crampy diarrhea)
- --> weight loss--> nutritional supplements
Myelosuppression in radiation pts
- anemia--> FATIGUE (worse if lose weight too--> nutritional supplements!)

- leukopenia--> monitor WBCs (epecially neutrophils), pt teaching, temp over 100.4 and infection risk

- thrombocytopenia--> observe for signs of bleeding, monitor platelets
Skin reactions for radiation therapy
- may resemble sunburn
- can be acute or chronic
- worse in skin fold areas
- alopecia, usually permanent with radiation (temporary for chemo usually)
- erythema and dry, darkened skin; wet or dry desquamatization

(same skin care as chemo listed previously)
Pulmonary effects of Radiation therapy
- dyspnea
- cough
- inflammation f chest that is dx as radiation pneumonitis which is associated with more serious heart and lung problems
- pulmonary firbosis (permanent scarring of the lungs) is a LATE effect of therapy
Treatment for radiation pulmonary effects
- cough suppressants
- bronchodilators
- expectorants
- bed rest
- oxygen therapy
Cardiovascular effects of radiation
- thorax radiation tx can damage pericardium, myocardium, valves, and coronary blood vessels
- pericardial effusion
- pericarditis
- high risk if high doses in mediastinal areas or thoracic radiation concurrent with anthracyclines
- most vulnerable of have pre-existing CAD
- higher radiation doses and large field size increases risk
- monitor with baseline and periodic ECGs and cardiac ejection fractions
Reproductive effects on women of radiation therapy
- cessation of menstruation
- symptoms of menopause (vaginal itching, burning, dryness)
- Permanent infertility (pre-treatment ova harvesting may be considered)
Reproductive effects on men of radiation therapy
- lowered sperm counts
- reduced sperm activity
- impotence
- testicular recovery often occurs
BCG vaccine
for tx of carcinoma in situ of the bladder (placed directly in bladder)

(a immunostimulant/Biologic response modifers)
Targeted therapy
monoclonal antibodies

- for tx of non Hodgkins lymphoma and Chronic lymphocytic leukemia

------mab
Common side effects of biologic therapies
- flu-like symptoms (chills, HA, fever, fatigue)
- cardaic dysfunctions
- tachycardia
- orthostatic hypotension
- CNS deficits (confusion, memory loss, insomnia, difficulty making decisions)
- Infusion reactions (fever, child, urticaria, myalgias, nausea, diarrhea)
- skin rashes
- anaphylaxis (rare)
Types of hematopoietic stem cell transplantation (HSCT)
- allogenic
- syngeneic
- autologous
Allogenic
stem cells acquired through HLA matched donor
Syngeneic
Obtained stems cells from an identical twin
Autologous
patient receives own stem cells after undergoing myeloblative chemotherapy
Preparative regimens and stem cell infusions
- stem cells harvested before chemotherapy and/or total body irradiation
- stem cells are thawed and reinfused intravenously after chemotherapy eliminated from body (24-48hrs)
- transplanted marrow produces hematopoietic blood cells in 2-4 weeks
Post harvest of stem cells nursing care
- pt may experience pain at the collection site (usually iliac crest, but sometimes sternum) that my last up to 7 days
- give mild analgesics
- the body will replenish the bone marrow in a few weeks
After infusion of stem cells/transplantation complete nursing care
- takes 2-4 weeks for transplanted marrow to start producing hematopoietic blood cells
- pt is pancytopenic during this time
- protect against infection (bacterial, viral, fungal), may have prophylactic antibx
- support with electrolyte supplementation
- nutrition
- blood component transfusions (as needed) to maintain adequate levels of RBCs and platelets

- peripheral blood stem cell transplants (PSCT) recover faster because stem cells are more mature and less severe complications are seen
graft vs. host disease
- can occur in allogeneic transplants
- T lymphocytes from donated marrow attack recipient's organs (skin, liver, GI)
- complications depend also on drug given to pt and stem cell source
Malnutrition/cachexia nursing care
- protein and calorie malnutrition (fat and muscle depletion)

- protein intake increased
- high calorie foods for energy and minimize weight loss (milk, eggs, cheese, meat/poultry/fish)
- Monitor for albumin and prealbumin levels
* Once a 1- lb weight loss occurs, it is difficult to maintain nutritional status
- the pt may need enteral or perenteral nutritionif malnutrition cannot be corrected with dietary intake
- teach pt to use nutrition al supplements in baking and cooking instead of milk and add to meals

* alert healthcare provider when 5% weight loss has occurred or when ot has the potential for malnutrition
Altered taste sensation and nursing interventions
- The pt may experience an alteration in:
- cancer cells release substance that stimulates bitter taste buds
- sweet
- sour
- salty

- teach pt to avoid foods they dislike
- experiment with spices and other seasons to mask these taste alterations
(ex: juice, onion, mint, basil, and fruit juice marinades for meats and fish) Just increasing the amount of spices doesn't work.
Infection
- primary cause of death in pt with cancer
- common sites include lungs, GU, mouth, rectum, peritoneal cavity, and blood (septicemia)
Infection symptoms
- general malaise
- fatigue
- low grade fever (100.4 or higher is a medical emergency)
- change in mental status
- shortness of breath
- non-productive cough
- minor complaints of pain

* all should be reported to physician immediately because these can progress to fever, chills, sepsis, septic shock, and death
Infection nursing care
- instruct outpts about 100.4 temp or greater
- determine type of isolation precautions needed and initiate
- assess pt for subtle signs of infection (fatigue or confusion)
- screen any visitors of the pt for communicable diseases
- hand washing
- exceptional oral hygiene and skin care

** you are protecting the patient from everyone else!
Causes of superior Vena Cava Syndrome (SVCS)
- obstruction of superior vena cava by tumor or thrombosis
- lung cacner, non-Hodgkins lymphoma, metastatic breast cancer

* an oncologic emergency!
Clinical manifestations of SVCS
- facial edema
-periorbital edema
- distention of veins of the head/neck/chest
- HA
- seizures
- mediastinal mass often visible on chest x-rays
- possible collateral circulation visible
Things that increase risk for SVCS
- central venous catheter
- previous radiation therapy to mediastinal
Clinical management of SVCS
- radiation to site of obstruction
- chemotherapy if tumor more sens to chemo
Spinal cord compression cause
- tumor in epidural space of spinal cord
- breast, lung, prostate, GI, renal tumors, melanoma, lymphomas
Clinical manifestations of spinal cord compression
- intense, localized and persistent back, vertebral tenderness aggravated by valsalva movement
- motor weakness/dysfunction
- sensory paresthesia/loss
- autonomic dysfunction (**change in bowel/bladder function)
Clinical management of spinal cord compression
- radiation and prompt corticosteroids
- surgical removal (decompressive laminectomy)
- limit pt activity
- manage pain
Third space syndrome
- shifting of fluids from vascular space to interstitial space
- secondary to extensive surgical procedure, biologic therapy, or septic shock
Clinical manifestations of third spacing
hypovolemia
- hypotension
- tachycardia
- decrease UOP
- low central venous pressure
Risk of treatment of third spacing
hypervolemia
- hypertension
- elevated central venous pressure
- weight gain
- shortness of breath

tx with reduction of fluid admin and fluid balance monitoring
Clinical management of third spacing
- fluid, electrolyte, and plasma protein replacement
Cause of intestinal obstruction
- mechanical (tumor, scarring, narrowing from inflammation)
- non-mechanical (decreased function of muscles, nerves, and blood flow)
Clinical manifestations of Intestinal obstruction
- N/V
- poorly localized abdominal pain
- abdominal distention
- inability to pass flatus
- constipation
- signs and symptoms of hypovolemia
Clinical management of intestinal obstruction
- emergency surgery if bowel is strangulated
- NPO status (--> may need parenteral nutrition)
- NG tube
- IV fluid resuscitation
- addition of potassium to IV fluids after renal function is verified
- analgesics for pain
SIADH Cause
Abnormal or sustained ADH --> water rention and hyponatermia
- can occur with some cancers that release ADH or ADH release stimulated by chemo (vincristine and cyclophosphamide)

- common in small cell cancer of the lung
SIADH clinical manifestations
- weight gain without edema
- weakness
- anorexia
- N/V
- personality changes
- oliguria
- decrease in reflexes
- seizures
- coma
Clinical management of SIADH
- treat underlying malignancy including measures to correct sodium imbalance with fluid restriction
- severe cases may need 3% sodium chloride
declomycin
- monitor treatments, rapid correction may lead to seizures
Tumor lysis syndrome cause
massive destruction of cells during chemotherapy leading to a rapid release of intracellular components (more with chemo than radiation and within first 24-72 hours, will last for 5-7 days)
- potassium
- phosphate
- DNA
- RNA (which metabolizes to uric acid by the liver-->deposited in renal distal tubules--> actue renal failure)
- increased phosphate--> hypocalcemia
4 hallmark signs of tumor lysis syndrome
- hyperurecemia
- hyperphosphatemia
- hyperkalemia
- hypocalcemia

- addition early symptoms also include weakness, muscle cramps, diarrhea, N/V
Clinical management of tumor lysis syndrome
- prevent renal failure and correct severe electrolyte imbalance are the primary goals

--> hydration therapy and the increase in urine production
- adminster allopurinol to decrease uric acid concentrations
Cardiac tomponade cause
- constriction of the pericardium by a tumor or pericarditis secondary to radiation therapy of the chest--> accumulation of fluid in pericardial sac--> decrease in cardiac output
Clinical manifestations of cardiac tompanade
- heavy feeling over the chest
- SOB
- tachycardia
- cough
- dysphagia
- hicuups
- hoarseness
- N/V
- excessive perspiration
- decreased LOC
- pulsus paradox
- distant or muted heart sounds
- extreme anxiety
Clinical management of cardiac tomponade
- Reduction of fluid around the heart
- surgical establishment of a pericardial window
- indwelling pericardial catheter
- oxygen
- IV hydration
- vasopressor therapy
Carotid artery rupture cause
- invasion of the arterial wall by tumor
- erosion of the artery due to surgery or radiation
Clinical manifestations of carotid artery rupture
- minor oozing of blood
- spurting of blood if artery "blows out"
Clinical management of carotid artery rupture "blow out"
- Apply pressure to the site with finger
- IV fluids and blood products to stabilize the patient for surgery
- Surgical interventions include removing the tumor and ligation of the carotid above and below the rupture
Hypercalcemia cause
- bone involvement or parathyroid hormone-like substance is secreted by cancer cells

- immobility and dehydration can contribute to or exacerbate hypercalcemia
Hypercalcemia manifestations
- apathy
- depression
- fatigue
- muscle weakness
- ECG changes
- polyuria
- nocturia
- anorexia
- N/V

Chronic hypercalcemia can lead tonephrocalcinosis and irreversible renal failure
How is calcium affected by albumin
- low albumin can give a false normal for calcium
Psychosocial factors affecting coping ability
- anxiety
- fear
- ability to cope with stressful events
- availability of significant others
- ability to express feelings and concerns
- age at time of diagnosis
- extent of disease
- disruption of body image
- presence of symptoms
- past experience with cancer
- attitude associated with cancer
Support interventions
- reassurance that support is ongoing
- provide information to help minimize the negative impact of cancer therapy
- pt education about therapy
- support groups
- symptoms management
- how to incorporate treatment into their life
- arrange for pts to meet other cancer survivors to provide hope and confidence
- provide phone calls between appts for support
- help plan transportation for appts
- nutrition
- emotion support through resources (American Cancer Society, Cancer Lifeline, churches and other community resources)
Nurse's responsibility for Survivor care
- provide all pts with a treatment summary and care plan outlining treatment exposures, risk of late effects, and follow-up plan after treatment
- educate health care providers about the needs of cancer survivors, including long term effects of cancer and cancer treatments
- teaching cancer survivors to look for and report late effects of radiation therapy and chemotherapy, and to report ongoing or intrusive symptoms resulting from treatment
- promoting healthy behaviors (good nutrition, exercise, smoking avoidance, maintaining proper weight, cardiac risk reduction, bone health, routine screening for early detection)
- encourage regular follow-up exams
- Assessing for psychoemotional, financial, health insurance, or vocational problems related to cx and assisting pts in getting appropriate help if necessary
Nurse's responsibility during cancer treatment/dx
- be available
- have a caring attitude
- listen
- provide relief from symptoms
- provide essential information
- maintain relationship on trust and confidence. Be open and honest.
- Use touch (hand squeeze or hug)
- Help pt make short-term and long-term goals
- help pt maintain usual lifestyle
* Maintain hope (hope for all different things during dif stages, including hope for peaceful death)
how a pt may present after dx from anxiety, etc. (a woman with breast cancer dx specifically)
- signs of distress or tension
- tachycardia
- increased muscle tension
- sleep disturbances
- restlessness

- assess the pt's body language, motor activity, and affect during periods of high stress and indecision