PRO/REG N2 Lecture ORIGINAL

When your body doesn't recognize its own cells and attacks them

Redness

Warmth

Swelling

Pain

Loss of function

Think: "Red hot swelling + pain and loss of function"

Idiopathic = unknown cause

Chronic childhood arthritis

Inflammation of joint synovium and surrounding tissues (leads to joint erosion, destruction, and fibrosis of articular cartilage)

Adhesions and ankyloses (stiffness) of joints may occur

Starts before age 16 with peak onset between ages 1-3 years

Twice as many girls as boys are affected

a type of JIA where children have periods of arthritis along with fever and rash

Most common form of JIA

Affects four or fewer joints, typically the large ones (knees, ankles, elbows)

A form of JIA that affects five or more joints, often on both sides of the body (both wrists, both knees, etc.)

Joint swelling + loss of motion

May not report any pain

Growth disturbances (overgrowth or undergrowth)

Exacerbations and remissions (can be unpredictable)

Less joints affected = greater chance of remission

inflammation can occur in other tissues

DIAGNOSIS BY EXCLUSION
Classification by:
1. Age of onset before age 16
2. Arthritis in 1+ joints for 6 weeks or longer
3. Exclusion of other causes (such as inflammation, fractures, tumors, infection, or congenital defects)

ANA (antinuclear antibodies)

ESR (erythrocyte sedimentation rate)

CRP (C-reactive protein)

CBC (check for leukocytosis, or elevated WBCs)

X-Rays can indicate joint deterioration, joint space narrowing, bone erosion, osteoporosis, ankylosis, etc.

MRI and CT scans can look at tissue for swelling

a stiffness of a joint due to abnormal adhesion and rigidity of the bones of the joint, which may be the result of injury or disease.

measures titer of group of antibodies that destroy cell nuclei & cause cell death in those with autoimmune disease

used to diagnose autoimmune disorders

Measures how quickly RBCs settle to the bottom of a test tube

Non-specific measure of inflammation

tests for a protein produced by the liver in response to inflammation

More sensitive to inflammatory changes

NO CURE

Major goals of therapy are:
1. Control pain
2. Preserve joint ROM and function
3. Minimize effects of inflammation
4. Promote normal growth and development

Outpatient care is mainstay of treatment

Treatment plan includes:
1. Medications
2. Physical/Occupational therapy
3. Eye exams
4. Splints (to avoid muscle contracture)
5. Dietary management
6. Comfort measures, psychosocial support

Calcium and Vitamin D rich foods (corticosteroids and methotrexate may inhibit calcium absorption)

High fiber foods (can help with inflammation)

Fruits and vegetables (for vitamins and nutrients)

Omega-3s (heart healthy and anti-inflammatory)

Protein (for muscles)

NSAIDs such as ibuprofen and naproxen (suppress inflammation and pain)

DMARDs (Disease-modifying antirheumatic drugs) such as methotrexate

Glucorticoids such as prednisone and methylprednisolone (acutely active exacerbations or systemic features)

Potential side effects such as GI irritation (take with food), hepatic and renal (drug is metabolized in the liver with excretion by the kidneys), and bleeding

We don't use opioids as the pain is inflammation-based (also don't want to create more problems)

Monitor CBC (can decrease blood counts) and LIVER function (excreted through liver)

GI disturbances (take with food)

AVOID live vaccines and alcohol

Teratogenic effects (can cause birth defects, so use birth control)

Need negative TST (tuberculin skin test) before starting therapy (results can be compromised by DMARDs)

Monitor blood sugar if diabetic (can cause hyperglycemia)

Side effects (increased risk of infection, weight gain, Cushingoid features, osteoporosis)

Low salt and calorie diet

Goal is to preserve function and prevention of deformity

Physical therapy = focus on ROM exercises, muscle strength. etc.

Occupational therapy = focus on ADLs

Non weightbearing exercises (water therapy)

Assessment (physical, social, psychological)

Pain relief

Adherence to treatment

Promote general health

Involve the family in plan of care

Chronic, progressive, systemic inflammatory autoimmune disease

Transformed autoantibodies (Rheumatoid factors [RFs]) attack healthy tissues, particularly synovium, causing inflammation

Articular cartilage, joint capsule, ligaments and tendons are affected and then eventually the bone is invaded and destroyed

Affects primarily synovial joints

Natural remissions and exacerbations (disease is controlled by decreasing the intensity and # of exacerbations)

Systemic disorder (can affect other organs or body systems with connective tissue such as heart, eyes, lungs, etc.)

Women are more likely than men to get it

Joint inflammation

Systemic effects: low grade fever, fatigue, weakness, anorexia, paresthesias

Joints: deformities, moderate to severe pain, morning stiffness

Systemic: osteoporosis, severe fatigue, anemia, weight loss, *subcutaneous nodules*, peripheral neuropathy, vasculitis, pericarditis, kidney disease

Hands typically involved

slightly reddened, warm, stiff, swollen, painful (esp. on palpation)

Bilateral and symmetric joint involvement

# of joints involved increases as disease progresses

Joint deformities (swan neck, ulnar deviation, Boutonniere deformity)

TMJ (temporomandibular joint) involvement: pain on chewing or opening mouth

Moderate to severe pain

Decreased ROM

Muscle atrophy

Palpate spine for tenderness, pain, loss of motion

Subluxation (cracking) of 1st and 2nd vertebrae may be life threatening
- keep neck straight and neutral, then notify PCP stat

severe destructive disease

RA affects connective tissue, not just in the joints but also in the heart, lungs, and the blood vessels

B/c of that, it is important to assess if pt is receiving enough circulation

Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) can help differentiate similar disease processes from RA

antinuclear antibody (ANA)

ESR and CRP (for inflammation)

CBC

Arthrocentesis

there is anemia and thrombocytosis (platelets) in late disease RA

5000-10000 WBCs per microliter

150,000 to 450,000 platelets per microliter of blood

Men: 14-18 g/dL

Women: 12-16 g/dL

Men: 4.5 - 6.0 million

Women: 4.0 to 5.0 million

X-ray: assess for joint damage

MRI/CT scan: determine presence and degree of cervical spine involvement

specific and sensitive for early RA detection

can be used as a marker for aggressive, erosive late-stage disease

Aspirate synovial fluid to relieve pressure & analyze fluid cells for WBC, cloudiness, volume, rheumatoid factor.

Teach pt to ice and rest joint for 24 hrs after.

If increased pain or swelling – see PCP immediately

NSAIDs

DMARDs

BRMs (Biological Response Modifiers)

Glucocorticosteroids

methotrexate (Otrexup)

Leflunomide (Arava)

Hydroxychloroquine (Plaquenil)

immunosuppresive DMARD

low dose (25mg PO weekly)

takes 4-6 weeks to begin to decrease inflammation

Monitor for bone marrow suppression (WBC, platelets)

teratogenic (birth defects)

Immunosuppressive DMARD

Reduces swelling, stiffness, improves mobility.

Takes 4-6 weeks; may be up to 3 months to see benefits.

Monitor for bone marrow suppression – WBC & platelets

Teratogenic (Birth defects)

antimalarial drug that helps decrease joint and muscle pain

SE: mild stomach discomfort, light-headedness, headache.

Report blurred vision as it can cause retinal damage.

Eye exam before starting drug and every 6 months

decreases immune response and inflammation

Enbrel (etanercept)

Remicade (infliximab)

Humira (adalimumab)

twice weekly SQ

teach patient to self administer, assess for injection site reaction

IV infusion then again week 2 & week 6. If there is a response, give maintenance infusions every 8 weeks.

Teach pt to report chest pain or difficulty breathing during infusion.

Monitor blood pressure & infusion site.

SQ every two weeks

Monitor for injection site reaction

given for fast-acting anti-inflammatory & immunosuppressive effects

Prednisone: high dose = short duration, can also be given as a low chronic dose

Chronic use can cause infection, hypertension, weight gain, osteoporosis, glaucoma, and hyperglycemia (in pts with DM)

Synovectomy (remove inflamed synovium)

Total joint arthroplasty

ice for acute inflammation (small bag of corn or frozen peas can be used as ice pack)

heat for stiffness, comfort (hot shower to relieve morning stiffness)

Heated paraffin (wax) dips

Finger & hand exercises

plasma is treated to remove antibodies causing the autoimmune reaction causing the disease

used in severe, life-threatening cases

Collaboration with PT/OT, dietician

Managing fatigue (pacing activities, rest periods, treat anemia

Enhancing body image - communicate acceptance

Encourage to seek medical help, especially before trying home remedies

Refer to support groups and self-help courses, counselors, religious/spiritual leaders. (The Arthritis Foundation)

It is a triad of symptoms caused by the obstruction of secretory ducts and glands by inflammatory cells and immune complexes.

Seen in patients with advanced RA and/or other autoimmune diseases

Dry eyes: assess for redness & lack of tearing. May feel “gritty”, blurred vision, burning/itching of eyes. Inflammation and ulceration of the cornea


Dry mouth (xerostomia): assess for dry, sticky membranes, difficulty swallowing food, changes in taste, epistaxis, URI
Tooth decay, risk of oral and nasal infxn, digestion of carbs

Vaginal dryness: risk for infection, painful sexual intercourse

Treatment is to manage symptoms

Artificial tears/saliva, water-soluble lubricants, humidifiers, surgery

Medications: methotrexate, cyclophosphamide, steroids, cyclosporine, hydroxychloroquine

Pilocarpine (Salagen) is used to treat dry mouth

Cyclosporine (Restasis) eye drops are used for dry eye

Complication of infection of Group A beta-hemolytic streptococcal (GABHS) pharyngitis [STREP A]

Most often occurs 2-6 weeks after upper respiratory infection with GABHS

Most often seen in late school age children and adolescents – rarely in adults

Self-limiting illness that involves joints, skin, brain, serous surfaces, heart (mitral valve most often affected)

Vital signs (elevated HR, BP, RR, Temp, etc.)

Heart sounds (because disease can affect mitral valves, look for heart murmur)

Echocardiogram (ultrasound of the heart)

Transesophageal Echocardiogram, aka TEE (cardiologist visualizes the heart to check for any cardiac damage)

Change in ECG

Carditis

Polyarthritis

Chorea (Involuntary muscle movement)

Subcutaneous nodes

Erythema marginatum

Haldol (haloperidol)

sedative that causes drowsiness

Arthralgia (joint pain)

Prolonged PR interval

Fever

Elevated ESR, CRP (checks for inflammation)

2 major manifestations OR 1 major + 2 minor manifestations

BOTH REQUIRE EVIDENCE OF RECENT GROUP A STREP INFECTION

Positive throat culture

Rapid Strep antigen test

Elevated Strep antibody titer (Antisteptolysin O)

Goals of medical management are:
1. Eradication of hemolytic streptococci
2. prevention of permanent cardiac damage
3. palliation of other symptoms
4. prevention of reoccurence

*Penicillin (PCN) is the drug of choice*
1. 10 days of medication (acute phase)
2. Monthly IM, BID oral penicillin G/erythomycin, or once a day sulfadiazine after initial regimen

in RF without carditis, prophylaxis for 5 years OR up to age 21

in RF with carditis, prophylaxis for 10 years OR up to age 21

in RF with carditis AND residual heart disease, prophylaxis may continue to age 40 (or indefinitely)

Medication compliance - if compliance is poor with daily PO, may recommend switch to monthly IM

Recovery from illness - rest, adequate nutrition, moderate activity after febrile stage complete

Emotional support - stress to parents abnormal movements are transitory and eventually disappear

Disease prevention - screen children with sore throats

Chronic, progressive inflammatory connective tissue disorder

Characterized by exacerbations (flareups) and remissions

*Multiple organ involvement*

Potentially fatal

autoimmune disorder - antinuclear antibodies (ANAs) cause immune complexes to form in serum and organ tissues
-> causes inflammation, damage, destruction to organ tissue
-> vasculitis leading to ischemia

Onset most often 20-40 years of age

Women and POC are more likely to get the disease

Butterfly rash

Alopecia

Mouth ulcers

Polyarthritis

Fatigue/weakness

fever is a classic sign of a flareup

Rheumatoid factor - differentiate between RA and SLE

CBC - anemia, leukopenia (low WBC count)

ESR - inflammation

ANA (antinuclear antibody) - indicate presence of autoimmune disorder

Complements/immunoglobulins - immunoglobulin abnormalities are common in lupus patients

False positive on syphilis test

SOAP BRAIN MD acronym

Inflamed, red rash (butterfly/malar rash)

Discoid lesions

Lupus Nephritis

Pericarditis

Raynaud's phenomenon

Pleural effusions

Pneumoniaa

CNS lupus

Abdominal pain

Joint Inflammation

Myositis

1. Medications - steroids, NSAIDs, Hydroxychloroquine (Plaquenil)

2. Immunosuppresants - Methotrexate, Cyclophosphamide, Mycophenolate Mofetil, Azathioprine

3.Belimumab (Benlysta) - IV/SQ human monoclonal antibody (mAb)
Rituximab - off label use in pedi pts who have not responded to tx

4. Plasmapheresis - filter antibodies from plasma

5. Kidney transplant - for severe lupus nephritis

6. Calcium and Vitamin D - to prevent osteoporosis in vitamin D deficiency

Body image (think rashes)

Fear, anxiety, frustration - support groups, Lupus foundation

Chronic fatigue, weakness, anorexia, weight loss

Elective surgeries = need to increase steroids and antibiotics

Increase calcium, vitamin D (to help prevent osteoporosis)

Increase intake of Omega-3s (may help mitigate inflammation)

Increase consumption of lean meats and protein (to prevent muscle atrophy due to fatigue and not moving around much)

Lower consumption of fats, cholesterol, and sugars (Steroids can cause cholesterol, triglyceride, and blood sugar levels to increase, so it is important to limit it in diet)

Avoid red meats (contains saturated fats which can cause inflammation)

Avoid alcohol (esp. on steroids and methotrexate)

Avoid Saturated/Trans fats (increase inflammation flareups)

use mild soap and moisturizer

No drying substances

Limit exposure to UV and sunlight

For hair, use mild protein shampoos (biotin and collagen), no HARSH treatments

Hydroxychloroquine - Eye exams before tx and then every 6 months

Immunosuppresants - increased risk of infection

Belimumab - risk for infection, no live vaccines for 30 days before treatment

Wear medical ID band for Lupus, *steroid dependence*

Uncommon chronic, inflammatory, autoimmune connective tissue disease

Means hardening of the skin -> only one of the clinical manifestations

Children often only have skin involvement (localized/linear scleroderma)
Adults have skin AND organ involvement

Women > men

25-55 years old

the disease process does not respond well to steroiods and immunosuppresants used in lupus

Inflamed tissue becomes fibrotic then sclerotic (hardens)

Edema over most of the body which is then subsequently replaced by tightening, hardening, and thickening of skin

Edema to upper extremities (1st symptom)

CREST Syndrome

Response to drug therapy can help differentiate from SLE

Arthralgia (joint pain)

Pitting edema of hands and fingers - may progress to entire upper/lower extremities and face (sausage-like fingers, skin is taut and shiny and free of wrinkles)

Loss of elasticity - ROM is markedly decreased

GERD - common in both types

Progresses to dysphagia

Reflux can lead to esophagititis and ulceration

Diminished peristalsis can have similar symptoms as partial bowel obstruction (Increase fiber + fluids, stool softeners)

PPIs (proton pump inhibitors such as -prazole)

Raynaud's phenomenon in hands and feet (wear gloves and avoid extreme cold)

Severe cases -> digit necrosis -> can result in autoamputation of distal digits (basically they fall off by themselves

Myocardial fibrosis - ECG changes, Dysrhythmias, Chest pain

may go undetected until late in disease or even in the autopsy

Fibrosis of alveoli and interstitial tissues

Pulmonary arterial HTN (Blood vessel to the lung)

Often causes malignant HTN and death

Use medications to force disease into remission - systemic steroids and immunosuppressants in large doses (often unsuccessful)

Goal is early ID of organ involvement and early treatment

Bosentan (Tracleer) - improves pulmonary HTN

Tyrosine Kinase Inhibitors (TKIs) - slow down the disease process

NSAIDs - inflammation and pain

Can cause liver toxicity and birth defects\

TKIs are substances that block the action of tyrosine kinases which are enzymes that play a role in many cell functions. These functions include cell signaling, growth, and division.

nilotinib (Tasigna)

imatinib mesylate

Skin protective measures

Reduce vasospasm and constriction

Swallow precautions

Joint protection (splints)

Energy conservation (rest, spread out ADLs)

Use mild soaps and lotions

Treat ulcers according to type and location

Bed cradle and foot board in severe cases (prevent the bedsheets from touching skin)

Adjust room temperature

Wear gloves and socks

Avoid cigarette smokingi and extreme stress

Small, frequent meals

Follow swallow precautions:
1. Elevate HOB 60 degrees during AND 1-2 hours after meals
2. Limit spicy foods, caffeine, alcohol (can cause you to vomit)
3. Semisoft foods
4. Antacids or H2 antihistamines (to make acid less acidic)
5. Liquids should have a thick consistency to reduce risk of aspiration (avoid thin liquids like water)

uncontrolled, abnormal growth of cells or tissues in the body

Can be either benign or malignant

Cells growing in the wrong place at the wrong time due to a small problem with cellular regulation

Harmless

Ex: moles, fibroids, polyps, endometriosis

Cells are abnormal, serve no useful function, and are harmful to normal body tissues

A term used to describe cancer cells that divide rapidly and have little or no resemblance to normal cells.

Cell division: continuous or inappropriate

Adherence: tight

Migratory: None

How does it grow: Expansion

Appearance: specific morphologic features

Cell division: Rapid or continuous

Adherence: loose

Migratory: yes; metastasis

How does it grow: invades surrounding tissues

Appearance: anaplastic (no specific appearance of parent cells)

Three stages of development
1. Initiation
2. Promotion
3. Progresison

Irreversible event

Change in gene expression by anything that can damage cellular DNA (carcinogens)

If growth conditions are right, widespread metastatic disease can result from just one cancer cell

enhanced growth of initiated cell by substances called promoters

Time from initiation to overt tumor

Varies from months to years

Continued change, becoming more malignant over time

Tumor develops own blood supply - vascular endothelial growth factor (VEGF) triggers growth of new capillaries into tumor

identified by tissue it derived from (parent tissue)

originates from some other part of the body

spread by blood and/or lymph

same cell, just in different location

Breast -> commonly spreads to bone and lung

Lung -> brain

Colorectal -> liver

Prostate -> bone (esp spine and legs)

epithelial glands

glial cells in brain

Blood vessel

liver

lymphoid tissue

pigment producing cells

meninges

nerve tissue

bone

kidney

tobacco

asbestos

asphalt fumes

benzene

gasoline

diesel exhaust

UV radiation (sunlight, tanning beds)

Ionizing Radiation (X-rays, cosmic radiation)

Chronic irritation (GERD, skin cancer with burn scars, etc.)

oncoviruses:
1. HPV (cervical)
2. Epstein-Barr (lymphoma)
3. Hep B & C (liver)
4. H. pylori (GI)

Immune function: cancer is increased in immunosuppressed (over 60 yo, organ transplant recipients, AIDs, etc.)

Genetics: Inherited cancer risks (breast, prostate, ovarian)
Down symdrome = increased risk for leukemia

C: changes in bowel / bladder habits
A: a sore that does not heal
U: unusual bleeding or discharge
T: thickening or lump in breast or elsewhere
I: indigestion or difficulty swallowing
O: obvious change in wart or mole
N: nagging cough or hoarseness

Prevent the actual occurence of cancer. Most effective when there is a known cause

Avoid known/potential carcinogen

Modify associated risk factors

Remove "at-risk" tissues

Chemoprevention

Vaccination

Aspirin + Celebrex = colon cancer

Vitamin D + tamoxifen = breast cancer

Lycopene = prostate cancer

HPV vaccination

Screening to detect cancer early - Cure or control more likely

Participate in specific routine screenings - Mammogram, breast, prostate exam

Genetic screening

Blood tests (CEA, PSA)

Radiological studies

Specimens (biopsy)

screening blood test that identifies a protein that is commonly found in some cancers

can be used to assess effectiveness of treatment

Lab test used to screen for prostate cancer

X-rays

CT scan

PET (positron emission tomography)

MRI

(1) disclosure of information (procedure, reason for procedure, risk + benefits, etc.)

(2) competency of the patient (or surrogate) to make a decision

(3) voluntary nature of the decision

Staging = How big cancer is + whether it has spread

Grading = how abnormal cancer cells and tissue look under a microscope

description of cells by chromosome number & appearance

cancer cells can gain or lose whole chromosomes during the malignant transformation phase

remaining chromosomes may have structural abnormalities

Clinical staging: assesses clinical manifestations

Surgical staging: surgically assess tumor size, number, sites, and spread

Pathologic staging: most definitive type; by pathologic examination of tissues

Reduced immunity and blood-producing functions (bone marrow suppression)

Altered GI structure and function (N/V, anorexia, altered taste, etc.) - high calorie and protein diet, vitamin C, increase fluids

Altered peripheral nerve function (chemo can cause neuropathy) - Gabapentin

Decreased gas exchange (inflammation from radiation)

Sterility

Psychosocial (fear of death, grieving, body image, etc.)

Gamma rays are generally used because of its ability to deeply penetrate tissues

Exposure = amount delivered to cells

Radiation dose = Amount absorbed by the tissues

Radiation delivered from outside the body

Must be in exact position for each treatment

Patient is NOT radioactive

Radiation source is within the patient

Patient is radioactive until radiation source is removed from the body

Sealed or solid: implanted within or near tumor cells (seeds, needles, rods)

Unsealed: suspended in body fluids (given PO, IV, instilled in body cavities)

Patient will need to be in isolation while emitting radiation

Staff must be cautious about how physically close they are as well as amount of time in close proximity to patient

Staff required to wear dosimeter film badge

Everything in patient's room is radioactive (yes, even their toothbrush)

Pregnant or nursing nurses can NOT take care of these patients

Intensity of radiation decreases with the distance from the radiation source

Visitors are typically discouraged

Children should NOT be visiting the patient

Visitors should be limited to 30 minutes

Nurses may only be in the room for 30 minutes of a 12 hour shift

Effects are seen only on or in tissues within the radiation field or path:

1. Skin changes
2. Hair Loss
3. Taste changes
4. Fatigue
5. Bone Marrow Suppression (Neutropenic, low platelet, anemic)
6. Increased risk for development of second malignancies (can basically cause other cancers)

Private room with proper signage

Keep door closed

Portable lead shields, lead aprons

Dosimeter film badge

If pregnant or trying to conceive, DO NOT CARE FOR PT

Limit visitors to 30 min/day, stay 6 ft away at all times

Do NOT remove anything from the room (including dressings and bed linens)

Chemical agents that act systemically to selectively kill cancer cells by damaging the DNA of the cell to prevent reproduction

Normal cells can still be damaged

Administered systemically or locally

IV

PO

Topical

Intraperitoneal (within abdominal cavity)

Intra-arterial

Intrathecal (fluid-filled space between the thin layers of tissue that cover the brain and spinal cord)

Intraventricular (spaces in the brain that contain the cerebral spinal fluid)

Intravesicular (in the bladder)

Impair cell division

Prevents cancer cells from dividing or divides only once

interrupts DNA or RNA synthesis

cause cell death by disrupting enzyme essential for DNA synthesis and cell division

Don't need to be board certified, just need to be trained within a facility or hospital system

The leakage of blood, lymph, or other fluid, such as an anticancer drug, from a blood vessel or tube into the tissue around it

Most important nursing intervention is prevention

Ensure patency before administration of medication (aspirate for blood)

Use an implanted port or central line

Cold (vasoconstriction)/warm (vasodilation) compresses

Injection of antidote

DO NOT CRUSH, SPLIT, BREAK, OR CHEW

Adhere to medication schedule

Proper disposal

Amifostine (Ethyol) - reduce kidney damage by cisplatin

Mesna (mesnex) - prevent hemorrhagic cystitis from ifosfamide and cyclophosphamide

bone marrow suppression of leukocytes, erythrocytes, platelets

time when bone marrow activity and WBCs are at lowest levels

Private room w/ reverse isolation (anyone sick cannot come in) or neutropenic precautions

Good handwashing technique

Room and bathroom cleaned daily

Good hygeine

Dedicated equipment stays in room

Single use food items, individually wrapped items

Avoid indwelling foley catheters

Monitor vital signs and IV sites q.4H

Inspect mouth, skin, and mucous membranes q.8H

Basically just want to minimize risk for infection

temp above 100°F

Cough

UTI

abscess

discharge

Goal of care to reduce risk of bleeding
Wear shoes when ambulating

No enemas, caution with suppositories

Use electric razor

Use soft-bristle toothbrush

Fall precautions

Apply ice to areas of trauma

*Observe IV sites q.4H for bleeding*

Don't pick nose

Anticipatory - before receiving chemo

Acute - within first 24 hours after chemo

Delayed - after first 24 hours

Breakthrough - occurs intermittently during therapy

Zofran (ondansetron) - side effects include bradycardia, hypotension, vertigo, and headache

Reglan (metoclopramide) - side effect is drowsiness

Emend (aprepitant) - can decrease the effectiveness of oral contraceptives

Aprepitant is a known inducer of CYP2C9, the main warfarin-metabolizing enzyme

Co-administration of these two drugs may result in reduction of the anticoagulation activity of warfarin.

Check INR before and after 3 days of treatment if taking warfarin alongside aprepitant

mucous membranes = entire GI tract

Oral hygeine, mouth rinsing

Change PO meds to IV

IV hydration

Parenteral, enteral nutrition if needed

Examine mouth q.4H for fissures, blisters, sores, drainage, etc.

Brush with soft-bristle toothbrush or sponge-tipped applicators q.8H

Avoid mouthwash with alcohol

Take pain meds PRN

Avoid alcohol, tobacco, spicy, salty, acidic, dry, rough, or hard food

it is temporary - regrowth starts about 1 month after completion of chemo

Hair may grow back different color, texture, and thickness

Cold caps during chemo

Wigs, hats, and scarves during chemo

Protect bare scalp from injury

Recommend getting wigs prior to treatment

Changes in cognitive function

Difficulty with concentration, memory loss, learning new info

Can last months to years

Avoid alcohol, recreational drug use, activities that increase risk for head injury

Altered sensation in hands and feet - may or may not resolve

Impaired gaibat and balance, orthostatic hypotension, erectile dysfunction, pain, taste alteration, severe constipation.

Promote safety - protect areas with altered sensation

Avoid shoes that would cause rubbing

Assess feet daily for signs of injury

High fiber diet, 2-3 liters of fluids (non-alcoholic) per day UNLESS contraindicated

Regulate inflammation and immunity

Interferons - slow tumor cell division, inhibit expression of oncogenes, stimulate growth and activation of NK cells

"Growth Factors"

Treat chemotherapy induced bone marrow suppression

Neupogen = neutrophils

Epogen = erythrocytes

Neumega = platelets

use of certain types of lasers

Agent given IV to sensitize cells to light, cancer cells will eliminate agent more slowly than normal cells so after 48-72 hours, most of the drug is concentrated in cancer cells

A laser light is focused on the tumor and activates a reaction that causes irreversible damage and death to cells retaining the sensitizing agent.

Caused by cord compression and its nerve roots

Associated with a vertebral tumor which extends into epidural space

Vertebral bone metatasis leads to bone collapse/displacement

May lead to permanent neurological impairment

Lung

Breast

Prostate

Lymphoma

Multiple myeloma

inflammation

back/neck pain

pain exacerbated by movement

Neuro impairment (both motor and sensory)

Bowel and bladder dysfunction

X-rays

CT scan

Bone scan

MRI Gold Standard

Corticosteroids

Pain management

XRT

Vertebral Augmentation (Minimally invasive)

Debulking tumors

Vertebroplasty

Kyphoplasty

Compression or invasion of the superior vena cava by:
-Tumor
-Enlarged lymph nodes
-Intraluminal thrombus obstructing the venous circulation
-Drainage of head, neck arms, thorax

if left untreated -> can lead to cerebral anoxia

Impaired venous drainage

Edema arms, neck, thorax with decreased sensations

Engorged/distended jugular temporal, arm veins

Increased ICP

X-Ray

CT Thorax

MRI Thorax

Venogram if transuminal thrombus suspected

XRT (radiation therapy)

Chemotherapy

Percutaneous stents

Anticoagulants and Thrombolytics

Diuretics

Oxygen

Potentially fatal
Occurs most commonly after the start of chemotherapy
Refers to the constellation of metabolic disturbances:
1. Hyperuricemia (high uric acid)
2. Hyperkalemia
3. Hyperphosphatemia
4. Hypocalcemia
5. Acute kidney injury (AKI)

Prescence of urinary symptoms

Symptoms of hyperkalemia (Weakness, paralysis, cardiac dysrhythmias)

Symptoms of hypocalcemia (Anorexia, vomiting, cramps, SZ, spasms, AMS, tetany)

Abdominal pain/distention

Sudden death

Electrolyte panel (CMP)

Urinalysis

Agressive fluid hydration

Allopurinol

Diuretics

Correct electrolyte imbalance

Dialysis

Sodium polystrene

Insulin + sodium bicarbonate

Aluminum hydroxide

Potentially fatal metabolic abnormality

Ocurs when Ca is released by the bones is more than the kidneys can excrete or the bones can reabsorb

May result from growth factors of cancer cells

when serum Ca is >10.4 mg/dL

Fatigue
Weakness
Confusions
Nausea
Constipation
Hyporeflexia
Dysrhythmias
Ileus (hypoactive)

Identify clients at risk

Oral/IV hydration

Diuretics

One of the slowest growing and predictable

Can have 100% cure rate if found early

Metastasizes to nearby lymph nodes, bones, lungs and liver

Most are androgen-sensitive

Advancing Age

1st degree relative

Race (African Americans)

Diet

Vasectomy

Environmental toxins

Symptoms include:
- Dysuria
- Painful ejaculations
- Blood in semen and urine

Prostate-specific antigen testing (PSA); normal is < 2.5ng/ml

Age 50 or family history - maybe earlier

Check before DRE(digital rectal exam) because can cause an abnormal elevation of results

Early prostate cancer antigen (EPCA-2) – sensitive and specific

Exactly what it sounds like

Check for prostate cancer

Hard and stony with irregularities or indurations

Type of biopsy that uses ultrasound probe to check for prostate cancer

To rule out metastasis

Check PSA levels, aggravated symptoms, or if tumor is growing

TURP (Transurethal resection of the prostate)

Laparoscopic Radical Prostatectomy

Open surgery

Bilateral orchiectomy (removal of both testicles)

*Lithotomy Position*

Radiation (external or internal)

Chemotherapy (Cisplatin)

Luteinizing hormone releasing hormone agonists or anti-androgens

Lupron - Can cause medical castration

Third leading cause of new cancer

Leading cause of cancer-related death

Metastasis to lymph nodes, bone, liver, brain, adrenal glands

Major risk factor is smoking

Exposure to second hand smoke puts individuals at greater risk than non-smokers

Chronic inhalation of carcinogens

COPD and TB can increase risk of developing lung cancer

Poor oxygenation (tumor can obstruct bronchioles, cause compression of other parts of the lung)

Paraneoplastic Syndrome - tumors can secrete hormones

ADH (antidiuretic hormone) - can cause SIADH (syndrome of inappropriate secretion of antidiuretic hormone)

ACTH (Adrenocorticotropic hormone) - Cushings

FSH (follicle stimulating hormone) - gynecomastia (moobs)

Parathyroid hormone - increased serum calcium

Ectopic insulin - hypoglycemia

Hoarseness
Change in respiratory pattern
Persistent cough or change in cough
Blood-tinged sputum
Rust colored or purulent sputum
Frank hemoptysis
Chest pain or tightness
Shoulder, arm, chest wall pain
Recurring episodes of pleural effusion, pneumonia, bronchitis
Dyspnea
Fever associated with one or two other signs
Wheezing
Weight loss
Clubbing of the fingers

Ask pt about warning symptoms (how long? when did it start?)

Pack year hx

Physical assessment

Pain

Dyspnea

Breath sounds

Heart sounds (may be muffled by tumor)

Fatigue

Dysphagia

N/V

Superior Vena Cava Syndrome

Cytologic Testing – early morning sputum, thoracentesis fluid

CXR

Lung CT

MRI

Thoracoscopy / bronchoscopy

Needle Biopsy

PET Scan

Chemotherapy

Targeted Therapy

Radiation

Photodynamic therapy

Surgical Intervention

*Side-lying jacknife position*

Removal of tumor only

Lung segment

Lobectomy (lobe removal)

Pneumonectomy (remove entire lung)

Oxygen therapy

Drug therapy - Bronchodilators, corticosteroids, mucolytics

Radiation therapy

Thoracentesis - removal of fluid for lung expansion

Dyspnea management - Oxygen, positioning (high fowlers)

Pain Management - morphine

Hospice care

Third most common cause of cancer death

Not common before 40 but is increasing 2/3 of colon cancer in descending colon / rectum

Spread by blood/lymph

Metastasize to other abdominal organs, brain, bone

Older than 50

Genetic/Family history of cancer

Disease of the colon

Crohn’s/Ulcerative Colitis

*Infectious Agents - H-Pylori, Streptococcus bovis, HPV*

Red meat, Processed foods, High Fat Diet

Long-term smoking

Heavy alcohol use

Obesity, physical inactivity

Increased bile acid secretions

*Lack of fiber in diet*

Screening at 50 years of age:
- Earlier and more frequently depending on family history
- Fecal occult blood test (FOCT) yearly
- Colonoscopy every 10 years OR double-contract barium enema every 5 years OR sigmoidoscopy every 5 years

Diet: low fat, high fiber

Smoking: smoking cessation

Exercise: Aerobic exercise at least 3x weekly for at least 30 minutes

Early:
- Bleeding (probably not hemorrhoids, but GI bleeding)

Late:
- Fatigue
- Weight loss
- Pain

Labs:
- CEA
- Fecal occult blood
- CBCs
- Liver function tests (LFTs) used to rule out metastasis

Radiation

Chemotherapy
- Vascular endothelial growth factor (VEGF) inhibitors
- Epidermal growth factor receptor inhibitor (EGFRI)

Surgical Management
- Colon resection
- Colectomy
- Abdominoperineal (AP) resection

Pre-Op Education
- Bowel prep (laxatives, NPO after midnight)
- Post surgical care (pain control, PACU)
- Wound Care (may take 6-8 months to heal)
- Colostomy care/education (make sure it isn't purple, keep it clean)

Inherited Gene Mutation - BRCA1 or BRCA2 genes

Second most common diagnosed cancer in women after skin cancer

small % of cases are under 40 years of age

1% of all cases are male

Even with no family hx, risk for breast cancer increases with age

Surgical

Chemoprevention: Vitamin D + Tamoxifen

Non-Invasive – ductal and lobular carcinoma in situ: have not invaded the tissues outside of the ducts and milk-producing glands

Invasive – *most common* - infiltrating ductal carcinoma

Inflammatory breast cancer (IBC) – rare and highly aggressive

High Risk: female, age >65, genetic factors, previous hx of breast CA, breast density, atypical hyperplasia

Moderate: family hx, ionizing radiation exposure, high postmenopausal bone density

Low risk: Reproductive hx – nulliparity or 1st child after age 30, early menarche or late menopause or both, recent oral contraceptive use, recent HRT, obesity

Other risk factors – alcohol, high socioeconomic status, Jewish heritage → BRCA1 and BRCA2 genetic mutations

1 week after menstrual period

Decreased swelling and tenderness

Obesity

Alcohol consumption

Irregular, poorly defined mass

Dimpling (advanced disease)

Peau d'orange (orange peel skin) - late stage breast cancer

Swelling, skin redness, pain

Seldom presents as a palpable lump

*May not show up on mammogram*

Hard, painless, sub-areolar mass

Gynecomastia (moobs)

Nipple discharge, retraction, erosion, or ulceration

Mammogram – controversy about when to begin & how often – follow MD’s recommendation

Tomosynthesis

Ultrasound

CT/MRI

Breast tissue

Lymph nodes

Liver enzymes - to rule out liver involvement

Calcium

Alkaline phosphatase

Breast-conserving - Lumpectomy, Partial Mastectomy

Simple Mastectomy – entire breast removed & some lymph nodes

Modified Radical Mastectomy - entire breast removed & some lymph nodes as well as some chest wall muscle

Chemo before surgery to shrink tumor

Chemo after surgery

Targeted Therapy Medication
- Trastuzumab (Herceptin) – 1st targeted drug for breast cancer

Hormonal Therapy
- Estrogen receptor (ER) positive
- Progesterone receptor (PR) positive

Selective estrogen receptor modulators (SERMs)
- Tamoxifen

Aromatase inhibitors (AIs) – postmenopausal women
- Usually follows treatment with tamoxifen
- Loss of bone density

Complementary and Alternative Therapies
- Stem cell transplantation possible for those at high risk of reoccurrence

Focus is preop teaching and psychological preparation

Include spouse or partner

Review type of procedure planned and possible post-op therapies

How to care for drains

Mobility restriction - Nothing over 10 pounds, no IV or BP cuff on side of operation

Two or more of the following:
- Febrile

- Tachycardia

- Tachypnea

- Alteration in WBC count (over / under)

Drainage should be serosanguineous

If it gets clogged, notify the SURGEON STAT

Monitor for signs of infection

Monitor Pain, Vital Signs, Dressing

Drains care

ROM exercises - do not try to do full ROM immediately

Breast implant -May need tissue expanders first to create a pocket for implant

Myocutaneous flap - Flap of skin, fat, and muscle transferred from donor site to the operative site

Third most common cancer of female genital system

Usually in 30’s-40’s

Human Papilloma Virus (HPV)
-HPV vaccine Gardasil/Cervarix

Unprotected sexual intercourse

Low socioeconomic status

Family history of cervical cancer (mother or sisters)

Sexual intercourse with uncircumcised men

Female offspring of mothers who took diethylstilbestrol (DES)

Infections with genital herpes or chronic chlamydia

Multiple sex partners

Cigarette smoking

Immunocompromised state

HIV infection

Oral contraceptive use

Moderate dysplasia on Pap smear within past 5 years

HPV infection

Preinvasive cancer is asymptomatic

Classic symptom: Painless vaginal bleeding

Pain

Watery, blood-tinged vaginal discharge that becomes dark and foul-smelling

Leg pain along sciatic nerve

Flank pain – hydronephrosis (kidney swelling)

Unexplained weight loss

Dysuria

Pelvic pain

Hematuria

PAP smear

Colposcopy (examine the cervix)

Cervical biopsy

Endocervical scraping of endo-cervix wall - small amount of bleeding expected for up to 2 weeks

Local anesthetic in cervix

Thin loop wire electrode uses electrical current to cut away affected tissue

Both diagnostic and treatment

Laser beam vaporizes abnormal tissue

freezing of the cancer cells which will cause subsequent necrosis & tissue sloughing

removal of cone shaped section of cervical tissue & sent to lab for examination

Cervix and upper part of vagina removed. Uterus remains intact.

Removal of the uterus

laparoscopic, vaginal, open depending on extent of disease

Radiation: external beam, brachytherapy

Chemo: cisplatin, paclitaxel, carboplatin, 5 - fluorouracil (5 - FU)

5-FU is the drug of choice for cervical cancer chemo