Medical 7-Cancer Management Lecture

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Scope of the problem is crucial to oncology nursing because?: all patients experience some
symptoms
symptoms can be dose limiting
factors
symptoms distress may be a
factor in treatment
cessation
symptoms impact quality of
life
Common symptoms?: appearance
bowel elimination
breathing
changes in body temperature
concentration
coughing
eating
fatigue
lacrimination
nausea
pain
restlessness
sleep
FDA has 2 requirements for approving anticancer drugs?: improve survival
increase quality of life
Quality of life has been the focus of?: numerous questionnaires and
measurement instruments
many articles and
conferences
policy
(increasingly) outcome in
clinical trials
Domains important in measuring quality of life?: emotional well-being
family well being
functional ability
future orientation
(planning, hope)
occupational functioning
sexuality/intimacy
social functioning
Influences on quality of life?: age
culture
disease specific
gender
spiritual
Approaches and concepts used in defining quality of life?: time-trade off utility
concept:
quality of life is
defined by patients'
willingness to trade-
off years of life for
suboptimal life
does not account for
concepts such as
adaptation
Potential chemo side effects?: kills all cells which are
dividing rapidly
mucous membranes, bone
marrow, and hair follicles
most acutely affected
alopecia
nausea and vomiting
neutropenia
skin changes
stomatitis, esophagitis,
enteritis
Expected effects of chemotherapy?: predictable, usually
resolution is rapid
requires little to no change
in treatment
Toxic effects of chemotherapy?: serious and even life-
threatening
treatment change required
discontinue drug
done reduction
Acute toxic effects of chemo?: occurs immediately after treatment
Chronic toxic effects of chemo?: prolonged side effects
may be permanent problem
Latent toxic effects of chemo?: months to years after therapy
Toxicity grading?: graded on 0 to 4 scale
areas to assess and document:
type of toxicity
severity
time of onset
duration of effect
interventions done to
minimize toxicity
Hypersensitivity may be due to an antigen-_____ reaction: high risk drugs
bleomycin
carboplatin
L-Asparginase
Taxol
history of drug allergies
failure to administer pre-
meds
previous exposure (with/
without reaction)
rash or hives with/without
itching
uneasiness, agitation
wheezing, SOB
periorbital or facial edema
hypotension
chest tightness
abdominal cramping with/
without nausea
chilling
premedicate as indicated
vital signs every 15 minutes
for first hour
give test dose, if indicated:
Bleomycin
L-Aparginase
direct observation for
initial 15 to 20 minutes
start infusion slowly and
gradually increase
if reaction occurs, stop IV,
run NS, stay with patient,
give supportive care as
needed
Myelosuppression?: Bone marrow suppression
resulting in lowered blood
counts
Most important dose-limiting
factor and life-threatening
toxicity in chemo treat-
ment
NADIR: point in time when
counts are the lowest;
varies with different
agents
Anemia
Leukopenia
neutropenia
thrombocytopenia
Low WBC counts?: Leukopenia less than 2000
decreased level of WBCs
predisposing the person
to infections
Neutropenia less than 500-
1000
Generally defined as
"immunocompromised" when
neutrophil count is less
than 500/mm3
Immunocompromised patient. A _______ patient cannot mount an adequate inflammatory response to an infecting organism.: neutropenic
Normal signs of infection are (4) which may not be present?: exudate formation
heat
redness
swelling
The only indicator of an infection is?: fever
Progression from localized infection to life-threatening _____ is so rapid that fatality rate is ____ to ____ in the first 48 hours: sepsis
18%
40%
Hypersensitivity may be related to release of ______ substances from cells: vasoactive
Hypersensitivity may be related to ______, not chemo drug: diluent
Hypersensitivity may be localized, generalized, or ______: systemic
Most frequent sites of infection due to neutropenia (7)?: catheter sites
lungs
mucous membranes
perineal area
perirectal area
skin
venipuncture sites
If ANC is greater than 1000, there's ___ risk of infection.: no
If ANC is 500 to 1000, then there's mild to ____ risk of infection: moderate
If ANC is less than 500, then there is ____ risk of infection: severe
The longer ____ neutropenia lasts, the greater risk of a life-threatening infection: severe
Chemotherapy is frequently held if the WBCs are between?: 1000-3000 or if the ANC is below 1500 cells/mm3
What does the ANC tell?: risk for infection
ANC 1500-2000: not significant as a risk factor for infection
ANC 1000-1500: minimal risk factor for infection
ANC 500-1000: moderate risk factor for infection
ANC less than 500: severe risk factor for infection
The longer severe neutropenia lasts, the greater the risk of a ____-____ infection: life-threatening
ANC stands for?: absolute neutrophil count
What is the equation for figuring absolute neutrophil count?: Absolute neutrophil count equals percentage of neutrophils plus bands) multiplied by white blood cell count divided by 100

For example: patient has following lab work:
neutrophils are 50% bands
equals 8%, WBC equals 4000

ANC = {(50% + 8%) divided by 100} multiplied by 4000
Answer: 2320
Colony stimulating factors stimulate bone marrow to preferentially produce?: granulocytes
Colony stimulating factors are given NO SOONER than ____ hours after chemo and STOPPED at least ___ hours before chemo: 24
24
CSF plus chemo equals SEVERE ______ Neupogen (G-CSF) Leukine (GM-CSF): myelosuppression
filgrastim or Neupogen, G-CSF, is a granulocyte colony stimulating factor used for prevention of febrile 1____ and associated infection in patients who have received bone marrow-depressing 2_____ for treatment of 3______ malignancies: 1 neutropenia
2 antineoplastics
3 nonmyeloid
filgrastim (Neupogen) is typically given ____ hours after chemo: 24
What are the 2 main handling rules for filgrastim (Neupogen)?: Refrigerate...don't freeze!
Don't shake the vial.

(May warm for up to 6 hours before injection...discard if left at room temp for over 6 hours...vial is for 1-time use only)
Dosage route for filgrastim (Neupogen) is either ___ or ____ 30 daily till WBC is 10,000 after nadir, 5ug/kg/day: IV or subcutaneous
Neupogen filgrastim may cause a transient increase in ___ ___ and ___ _____?: alkaline phosphatase
uric acid
A side effect of Neupogen filgrastim is (2)?: bone pain (may need
nonopioid analgesic or
opioid analgesic)
hypotension (monitor VS)
What is the most important sign of infection?: FEVER
Nurse can monitor for neutropenia by?: monitor absolute neutrophil
count
pain?
redness at wound sites?
open areas?
frequent urination?
mental status changes?
head to toe
teach patient to observe
for signs of infection?
take temperature at least
once every 24 hours
To monitor for neutropenia, patient should take temperature every 24 hours and call physician if temp is greater than ____. Patient should go to ER if temp is greater than ____ and mental status changes.: 100.4
102
While patient is monitoring for neutropenia, limit Tylenol use as it may mask ____: fever
Perform _____ with first fever before antibiotic treatment: cultures
Give first _____ as a STAT dose around or within the hour.: antibiotic
Monitor vital signs of patient with infection frequently as sepsis kills ____: rapidly
If fever persists following antibiotic treatment, patient may need to change antibiotic, may need to add an 1_______ agent, temp should drop 2___ ____ in 24 hrs and be gone after 3___ hours if antibiotic treatment is working: 1 antifungal
2 1 degree
3 48
Neutropenic precautions?: NOT reverse isolation
private room
no fresh fruits or vegetables
to eat
no live plants/flowers/
standing water
no sick visitors or care-
givers
no small children
(very controversial)
no caregivers taking care of
other infected patients
patient wears mask when out
of room
Infection prevention?: dietary restrictions
avoid fresh fruits and
vegetables
avoid raw eggs and
potatoes
meats and seafood should
be well-done
low-microbial?
thorough hand washing
avoidance of crowds and ill
persons during nadir
frequent oral hygiene
minimize invasive procedures
meticulous skin care
Define thrombocytopenia?: decreased number of platelets
Thrombocytopenia is a platelet count less than?: 100,000/mm3
With thrombocytopenia, the risk of bleeding increases if platelet count is less than?: 50,000/mm3
With thrombocytopenia, the risk of bleeding is SUBSTANTIAL if the count is less than?: 25,000/mm3
Transfusions may not be done until platelet count is at?: 10,000 - 15,000
With transfusions, there's a risk of ____-_____ patient.: auto-immunizing
Effect of nitrosoureas, some antibiotics (mitomycin C)...Describe mitomycin: antineoplastic...
antitumor antibiotic...
cell-cycle phase nonspecific but is most active in S and G phases...
With mitomycin, assess respiratory status for what symptoms?: cough
bronchospasm
hemoptysis
dyspnea
(these symptoms are indicative of pulmonary toxicity)
With mitomycin, nurse should especially monitor for which condition?: THROMBOCYTOPENIA
To manage thrombocytopenia, nurse should assess head to toe for?: bleeding/petechiae...instruct patient to use soft toothbrush and electric razor and report symptoms
To manage thrombocytopenia while on mitomycin, nurse should monitor the platelet (thrombocyte) count. The 1____ of leukopenia and thrombocytopenia occur in 2___ to ___ weeks. Notify physician if leukocyte count is less than 3____ or if platelet coun: 1 nadirs
2 4-8 weeks
3 4000/mm3
4 150,000/mm3
For management of thrombocytopenia, _____ as ordered (premedicate usually): transfuse
Define teratogenic?: terato- indicating a severely malformed fetus
Define iatrogenic?: adverse mental or physical condition induced in a patient by effects of treatment by a physician or surgeon
Bleeding precautions for thrombocytopenia are?: nothing inserted into rectum
or vagina
no foley catheters if at all
possible
no IM injections
limit venipunctures and
invasive procedures
Patient teaching for bleeding precautions due to thrombocytopenia?: avoid aspirin, NSAIDS
prevent constipation
discontinue use of razors,
electric razor
soft tooth brushes, no
flossing
no vigorous exercise
avoid straining at stool
abstain from sexual inter-
course
Transfusions for anemia are given when hemoglobin is less than 1____; when hematocrit is less than 2___ and or patient is 3_____: 1. eight
2. 24
3. symptomatic
Elderly patients or those with history of ____ problems may not tolerate anemia: cardiac
epogen (Procrit) given to stimulate RBC production helps combat _____: fatigue
Fatigue has multiple causes. It's the most common side effect from 1_____...the fatigue is not relieved by 2____ or rest...causative factors in absence of 3___ unknown...most often with 4____: 1. chemo
2. sleep
3. anemia
4. cytokine
Interventions for fatigue are?: energy conservation
setting priorities
appropriate rest periods
nutrition
prevention of anemia can
reduce incidence
physical activity within
limits
short periods of mild
exercise can reduce
severity
Emesis induced by therapeutic interventions?: cancer chemotherapy-induced
nausea and vomiting
(CINV)
radiotherapy-induced emesis
postoperative emesis
Nausea and vomiting is experienced by over ___ of all patients receiving chemotherapy: 50%
Nausea and vomiting is the most ____ side effect...it worsens with treatment..can lead to ___-____: feared
non-adherence
Physiological effects of nausea and vomiting are?: dehydration
fluid and electrolyte
imbalance
esophageal tears
Influencing factors of nausea and vomiting are?: age
anxiety
course number
gender (female)
history of motion sickness
history heavy alcohol use
previous emetic control
Chemotherapy factors?: combination
dose
emetic pattern
emetic potential
type of administration
Which agents have a VERY HIGH emetogenic (n&v) potential?: cisplatin (alkylating agent)
nitrogen mustard (alkylating
agent)
Which agents have a HIGH emetogenic (n&v) potential?: cytoxan (HD)
ARA-C (HD)
methotrexate (HD)
Which agents have a MODERATE emetogenic (n&v) potential?: etoposide (VP-16)
ifosfamide
Ara-C
carboplatin
methotrexate
Which agents have a LOW emetogenic (n&v) potential?: bleomycin
Taxanes
5-FU
Doxil
Which agents have a VERY LOW emetogenic (n&v) potential?: vinca
alkaloids
methotrexate (LD)
Emetogenic potential of drugs is on a 1-5 scale with ___ having a slight ability to cause nausea and vomiting and ____ having a very high abilit to cause nausea and vomiting.: one
five
Patterns of emesis in patients receiving cancer chemotherapy include acute 1____, 2 delayed ____, 3 anticipatory ___ ____: 1 emesis
2 emesis
3 nausea/vomiting
Acute emesis onset is within _____ and resolves in 24 hours: 1-2 hours
Delayed emesis onset is greater than ____ in post-chemotherapy.: 24 hours
___ nausea and vomiting onset is present prior to a course of chemo; operant conditioning difficult to treat often persists after chemo discontinued: anticipatory
Pharmacologic therapy is based on an 1_____ pathway(s)...consider emetogenic potential of chemo agents used...2___-___ essential...around-the-clock dosing...consider delayed nausea and vomiting... combination antiemetic therapy examples: 1 emetic
2 pre-medication
3 steroid
4 anxiolytic
Examples of anti-emetics are? 1. ondansetron 2. granisetron 3. dolasetron 4. metaclopramide 5. phenothiazides 6. corticosteroids 7. butyrophenones 8. cannabinoids 9. miscellaneous: 1 Zofran
2 Kytril
3. Anzemet
4. Reglan
5. compazine
thorazine
6. Decadron
7. Haldol
8. Marinol
9. lorazepam (Ativan)
Benedryl
Management of nausea and vomiting?: very sensitive to smells
(may be abnormal)
take antiemetics as ordered
room temperature or cold
foods smell less
frozen juice or popsicles
are soothing
avoid fatty, greasy, spicy,
sweet foods
eat small meals
avoid favorite foods at this
time
Non-drug therapies?: acupuncture, acupressure
guided imagery
hypnosis
progressive muscle relaxation
systematic desensitization
timing of treatment
Oral toxicity is seen 2 to 3 times more often in ____ malignancies...75% BMT patients: hematologic
Oral toxicity may have a direct effect which is 1_____ or indirect 2______.: 1 cytotoxic
2 myelosuppression
Oral toxicity may be ___-___ and is common with antimetabolites and some antibiotics: dose-related
Oral toxicities pose risk factors for the following?: elderly
pre-existing oral diseases
local irritants
poor oral hygiene
myelosuppression
Oral toxicities begin at ____.: nadir which is day 7-14
Signs and symptoms of oral toxicities are?: dry mucosa
burning sensation
taste alterations
pain
inflammation and ulceration,
bleeding
Oral toxicity interventions are (4)?: pre-chemo denal evaluation
oral hygiene
nutrition
analgesics
Oral toxicities are (4)?: esophagitis
mucositis
stomatitis
xerostomia
Oral toxicities are stomatitis and mucositis which can cause inflammation or ulceration of mouth, which can progress to entire ___ ____ causing pain, infection, dehydration, and weight loss?: GI tract
Stomatitis and mucositis occur because?: there is destruction of fast-growing epithelial cells
Stomatitis and mucositis drugs are?: 5-FU
methotrexate
xeloda
bleomycin
HD chemo
Stomatitis and mucositis radiation fields that include?: mouth or throat
Stomatitis and mucositis can be caused by?: alcohol and tobacco use
Stomatitis and mucositis can be caused by oral hygiene and dental caries.: okay
Management of mucositis includes?: twice daily oral assessment..
frequent every 2 hour mouth
care
*NS rinse (avoid alcohol-
containing mouthwash)
*brush with soft tooth-
brush - also brush
tongue
*keep lips and mouth
moist
Recommended diet for mucositis?: is a soft diet with high caloric bland foods
Management of mucositis is a topical anesthetic agent which treats infections quickly...____ is best!: PREVENTION
Oral hygiene for management of mucositis?: after each meal and at hour of sleep at least...
lubrication of lips...
saliva substitutes...
oxidizing agent (3% H202), NaHCO3 solution, or alternate...
topical anesthetics ac & prn
-viscous lidocaine
-sucralfate suspension...
culture of lesions
soft toothbrush if platelet
count okay and no lesions
daily flouride if xerostomia
Taste changes are experienced by ____ to ____of all patients.: 36 to 71%
Taste changes are most common with ____ and ____; also cyclophosphamide, 5FU.: cisplatin
doxorubicin
Taste changes are most often described as "___ ___ " or "metallic taste" or "cardboard" and assoc. with ____ _____: "no taste"

dry mouth
Taste changes are managed by _______ or adjusting spices, adding more salt, decreasing consumption of meat, drinking bottled water: increasing
Anorexia may be caused by taste changes that last about __ week.: one
Anorexia may be caused by smells that may become acute and last __ to ___ weeks.: 1 to 3
Appetite may be re-stimulated by participating in mild exercise or drinking _____.: wine
Decrease anorexia by avoiding too much ____ near mealtime.: liquid
Management of anorexia includes eating ____ _____ and nutritious foods, and avoiding junk food.: high calorie
Greater than 350 mg/day of ____ can stimulate an appetite.: Megace
With enteritis, cells of the ___ ____ are most vulnerable.: small intestine
Some antimetabolites used to treat enteritis are (3)?: ARAC
5-FU
Methotrexate
Some antibiotics used to treat enteritis are (2)?: doxorubicin
dactinomycin
Agents used to treat enteritis are?: 5-FU and leukovorin most toxic
Enteritis symptoms are due to _____ ______ or, less likely to infection or antibiotic-associated colitis: cellular necrosis
Risk factors attributed to enteritis are?: XRT to abd/pelvis
AGVH disease
antibiotics
dietary changes
Enteritis can lead to?: denudement of GI lining
Signs and symptoms of enteritis are?: diarrhea
abdominal cramping
rectal urgency
anal irritation
bloody stools
Define enteritis?: inflammation of the intestines, more particularly of the mucous and submucous tissues of small intestines
Enteritis?: anticholinergics
antispasmodics
antisecretory agents
opiates
(check on these two)
page 10
Diet interventions for enteritis are?: fat (low)
residue (low)
gluten
lactose-free
With enteritis, culture for?: clostridium difficile toxin
With enteritis, once infection is ruled out, patient can start on ______ drugs: antidiarrheal
Enteritis intervention is to monitor and manage fluid and electrolytes: okay
Diarrhea is characterized by an increase in _____ and frequency of stools and greater than __ _____ above usual amount.: liquidity
3 stools
Diarrhea can cause destruction of epithelium of ___ _____: GI tract
Diarrhea is related to (3)?: dose
frequency
medication
Diarrhea is worse with XRT to?: abdomen/gut area
Drugs that can cause diarrhea are?: Camptosar
5-FU
methotrexate
Diarrhea?: may be dose-limiting toxicity of drug
(check on this)
Diarrhea may be caused by concomittant infection such as?: C. diff
Camptosar is used to treat 1____. Treat early with 2____ and late signs can be treated with 3_____: 1 diarrhea
2 atropine (overdosing
may lead to constipation)
3 immodium
Atropine is what kind of drug?: antiarrhythmic
anticholinergic
antimuscarinic
What are some things to look out for with atropine?: monitor heart rate and blood pressure as this is an antiarrhythmic drug...
auscultate bowel sounds and
if constipation becomes a problem, add bulk to diet
Dietary measures for management of diarrhea include following which diet?: BRAT
low residue diet
clear liquids
avoid milk products
Impaired skin integrity goes along with diarrhea, so keep area dry and perform _____ as needed. A moisture barrier cream such as ____ may be necessary.: pericare
Desitin
Use of anti-diarrheals such as (5) may be indicated?: Immodium
Lomotoil
Kaopectate
Pepto-Bismol
Sandostatin (last resort)
Constipation are infrequent hard, dry, bowel movements that may cause ____ or _____: pain
bleeding
Some agents such as 1______ may cause constipation. This is an 2______ _____ ______ which may cause neurotoxicity symptomized by persistent _____, paresthesia, pain, difficulty on walking: 1 vincristine (considered
the worst)
2 antineoplastic vinc
alkaloid
3 constipation
If patient cannot relieve constipation with increased fluid intake, dietary fiber, and exercise...followed by recommended agents, stool softeners, laxatives, etcet, then notify 1_____ as severe constipation and abdominal discomfort may be indicative of 2: 1 physician
2 neuropathy
Constipation may be due to (4)?: dehydration
no activity
opioid use
low residue diet
Constipation may cause (7)?: bloating
pain
nausea and vomiting
obstruction of ileus
rectal bleeding
hemorrhoids
tears
Constipation can be treated prophylactically with adequate 1____ intake, increased 2 ____ intake, increased 3____ and routinely taken 4_____ softeners: 1 fluid
2 fiber
3 activity
4 stool (Senekot)
If no bowel movement within ___ days, use a laxative or cathartic...try to avoid _____: three
enemas
What damage can cardiotoxicity cause?: cardiomyopathy which is direct damage to the myocyte
What is trastuzumab (Herceptin)?: antineoplastic
monoclonal antibody...
indicated for use in metastatic breast cancer alone or with paclitaxel for tumors that display overexpression of theh human epidermal growth factor receptor 2 (HER2) protein...
its therapeutic effects promote regression of breast cancer and metastases
When taking trastuzumab (Herceptin), what should the nurse monitor for as far as cardiac dysfunction?: asess for cardiac dysfunction
ex: dyspnea
increased cough
paroxysmal nocturnal
dyspnea
peripheral edema
S3 gallop
reduced ejection
fraction
Trastuzumab patient teaching?: notify patient of symptoms of:
CHF
fever
sore throat
signs of infection
lower back pain
side pain
difficult or painful
urination
Anthracyclines have a cardiotoxicity rate of about?: incidence of 2-3%
cumulative doses of 550/m2,
less if prior XRT
liposomal preparation
To avoid cardiotoxicity, monitor?: total dose
(check on this)
With cardiotoxicity, do _____ or _____ scan before treatment: echocardiogram
MUGA
With cardiotoxicity, left ventricular ejection fraction greater than ___: 50%
With cardiotoxicity, there's a decreased left ventricular ejection fraction greater than?: 300 mg/m2
Cardiotoxicity?: weeks or months post-chemo
irreversible, 60% mortality
responsivie to usual CHF Rx
(check on this)
Antineoplastic antitumor antibiotic that may cause pulmonary toxicity?: Bleomycin may occur in 10% of patients who have received greater than 450 units, busulfan, BCNU

avoid smoking

discontinue bleomycin if pulmonary toxicity occurs
When treating with bleomycin, monitor for?: 1. anaphylactic reaction
symptoms are:
fever
chills
hypotension
wheezing

idiosyncratic reaction
confusion
hypotension
fever
chills
wheezing
Patients on bleomycin should have respiratory status monitored for?: dyspnea
rales/crackles

monitor chest xray before and periodically during treatment
mitomycin-c is a antineoplastic antitumor antibiotic and _____ _____ should be monitored.: pulmonary toxicity
Symptoms of pulmonary toxicity are?: cough
bronchospasm
hemoptysis
dyspnea

(all may be signs of pulmonary toxicity)
ARAC and mitomycin C and pulmonary toxicity?: capillary leak
pulmonary edema
Pulmonary toxicity is not related to total _____ dose: lifetime
Pulmonary toxicity can lead to inflammation of _______ cells and interstitial _____: endothelial
pneumonitis
Pulmonary toxicity causes _____ tissue damage...restrictive lung disease...and pulmonary ____: connective
fibrosis
Incidence of pulmonary toxicity is higer in _____ with previous treatment: elderly
Pulmonary toxicity is ______ and progressive: irreversible
Supportive care treatment for pulmonary toxicity are high doses of _____ and oxygen which may worsen the condition...it is usually fatal: steroids
Hepatotoxicity varies from inc liver enzymes to _____ and ____: fibrosis
necrosis
Hepatotoxicity is dose-limiting, _____ once fibrosis: irreversible
Hepatotoxicity. methotrexate, 6MP, and mercaptopurine can be ____: synergistic
Hepatotoxicity. increases toxicity of other agents, esp. _____ and _____: doxorubicin
vinblastine
Hepatotoxicity. risk factor: previous ____ disease: liver
Hepatotoxicity. dose reduction and supportive care: 50-75%
GU toxicity usually occurs ____ to ____ post-chemo: days
weeks
GU toxicity is not necessarily ____-_____: dose related
GU toxicity can occur in up to 10% of patients taking ____ and occurs less often in patients using ____: Cytoxan
ifosfamide...an antineoplas-
tic alkylating agent
GU toxicity can be inhibited by using ifosfamide (antineoplastic) with ____: mesna...when used together, prevents ifosfamide-induced hemorrhagic cystitis
GU toxicity may cause long-term 1_____, bladder 2____ and contraction, rarely requires 3_____: 1 cystitis
2 fibrosis
3 cystectomy

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