Cancer and Oncological Emergencies CANCER AND ONCOLOGICAL EMERGENCIES

Cancer and Oncological Emergencies CANCER AND ONCOLOGICAL EMERGENCIES

Key Points �Cancer is a neoplastic disease process that involves abnormal cell growth and differentiation. �The exact cause of cancer is unknown, but : viruses, physical and chemical agents, hormones, genetics, and diet are thought to be factors that trigger abnormal cell growth. �Cancer cells may invade surrounding tissues and/or spread to other areas of the body through lymph and blood vessels (metastasis).

Key points �Cancers may arise from the skin, bone, organs, or blood. �Epithelial tissue; Carcinomas. �Glandular organs; Adenocarcinomas. �Mesenchymal tissue; Sarcomas. �Blood-forming cells; Leukemias. �Lymph tissue; Lymphomas. �Plasma cells; Multiple myeloma. �Screening and early diagnosis are the most important aspects of care. �Many cancers are curable when diagnosed early.

Risk Factors �Age �Genetic predisposition �Exposures to chemicals, viruses, tobacco, and alcohol �Diet high in fat and red meat, low in fiber �Sun, ultraviolet light, or radiation exposure �Sexual lifestyles: Multiple sexual partners, STD, HIV/AIDS �Other risk factors include poverty, obesity, and chronic GERD

Diagnostic Procedures and Nursing Interventions �Tissue biopsy – the definitive diagnosis of abnormal cancer cells. �CBC and differential – screenings for leukemias. �Chest x-ray, CT, MRI, PET are used to visualize tumors, metastasis, or progression of cancer. �Tumor marker assays (CEA: carcinoembryonic antigen, CA 125: cancer antigen detected in ovarian ca , alpha fetoprotein: elevated in ca, liver ca, cirrhosis) – screenings that screen for cancers of the colon, pancreas, liver, prostate, uterus, and ovaries. �Elevated values are suggestive of cancer.

Therapeutic Procedures and Nursing Interventions �Radiation therapy - resulting in the death of cells. Side effects include skin changes, hair loss, and debilitating fatigue. �Internal radiation therapy Client should be placed in a private room and bath. Appropriate signage should be placed on the door Health care personnel should wear a dosimeter film badge that records the amount of radiation exposure. Visitors should be limited to 30 -min visits and maintain a distance of 6 ft. Visitors and health care personnel who are pregnant or under the age of 16 should not come in contact with the client. A lead container should be kept in the client’s room Precautions listed above should be carried out at home if the client is discharged during therapy.

Therapeutic Procedures and Nursing Interventions �External radiation therapy �Wash skin over irradiated area gently, with mild soap and water, and dry thoroughly using patting motions. �Do not remove radiation “tattoos” that are used to guide therapy. �Do not apply powders, ointments, lotions, or perfumes to irradiated skin. �Wear soft clothing over irradiated skin and avoid tight or constricting clothes. �Do not expose irradiated skin to sun or a heat source.

Therapeutic Procedures and Nursing Interventions �Surgical excision – diagnostic, curative, or palliative. Risk of “seeding. ” �Chemotherapy – a certified provider administers systemic or local cytoxic medications to destroy rapid dividing cells. Often, combinations of anticancer medications are used. �The most significant adverse effect is immunosuppression (bone marrow suppression). �Measures must be employed to reduce risk, especially at the medications’ nadir. �Nausea and vomiting, alopecia, and mucositis are common side effects. �Take measures to prevent extravasation of vesicants.

Assessment �Signs and Symptoms (clinical findings depend on the type and location of cancer) �Seven warning signs (CAUTION) Change in bowel or bladder habits A sore that doesn’t heal Unusual bleeding or discharge Thickening or lump in the breast or elsewhere Indigestion or difficulty swallowing Obvious change in warts or moles Nagging cough or hoarseness �Weight loss �Fatigue/weakness �Pain (may not occur until late in the disease process) �Nausea/anorexia

Assess/Monitor � For pain – evaluate PQRST (provokes, quality, radiates, severity, time) of pain � Sleep/rest patterns to determine the need for intervention � Oral cavity for ulcer/myositis related to immune suppression secondary to cancer treatment � Fatigue/SOB � VS, especially temperature to detect fever related to infection � WBC and platelet count � I&O � Serum electrolytes � Weight loss, cachexia, and wasting � Diarrhea � Skin alterations � Agitation and restlessness � Presence of support systems

NANDA Nursing Diagnoses �Anticipatory grieving �Risk for infection �Fear/anxiety �Imbalanced nutrition: Less than body requirements �Ineffective tissue perfusion

Nursing Interventions � Encourage screenings (Pap smear, mammogram, colonoscopy, stool for occult blood). � Implement pain control measures as prescribed. � Use the WHO stepwise approach to pain. � Provide pain medication before pain becomes severe. � Serve small amounts of cool food if mouth pain is present. � Provide frequent oral care, soft toothbrush or swab, local anesthetic mouth rinse. � Use distraction when appropriate (Quran, prayers, and imagery). � Encourage/maintain nutrient intake. � Perform calorie counts to determine intake. � Provide liquid supplements as needed. � Perform mouth care prior to serving meals to enhance appetite. � Premedicate with antiemetics. � Administer megestrol (Megace) to increase appetite. � Add protein powders to food or tube feedings.

Nursing Interventions � Reduce risks of neutropenia. � Protect the client from sources of possible infection. � Use hand hygiene. � Encourage the client/significant others to use hand hygiene. � Encourage the client to avoid crowds while undergoing chemotherapy. � Administer colony-stimulating factors as prescribed to stimulate white blood cell production. � Reduce risks of anemia. � Administer oxygen as needed for fatigue. � Encourage rest periods between periods of activity. � Administer recombinant erythropoietin alpha as prescribed.

Nursing Interventions � Reduce risks of thrombocytopenia. � Avoid ASA/NSAIDs and IM injections if platelet count is decreased. � Administer antiemetics before treatments and meals. � Maintain IV fluids as prescribed. � Implement post-radiation care, if applicable: � Interventions are based on site of radiation: Antidiarrheals for GI tract. Mouth care for head and neck. Octreotide (Sandostatin) if prescribed. Encourage female clients to wear a hat or wig if undergoing radiation or chemotherapy that produces alopecia (hair loss). � Listen to the client’s concerns. � Avoid false reassurance. � Provide prescribed anxiolytics if necessary. � Allow time for the client to discuss feelings regarding loss and to grieve (mastectomy, hysterectomy, limb, lack of options for further treatment).

Complications and Nursing Implications � Oncologic Emergencies � Syndrome of inappropriate antidiuretic hormone (SIADH) – due to excessive intravascular volume to increased ADH (common in bronchogenic cancers). Monitor the client for hyponatremia and low serum osmolality. � Administer furosemide (Lasix), IV normal saline, and/or hypertonic saline as prescribed for severe hyponatremia. � Spinal cord compression – related to metastases. Assess the client’s neurological status, including motor and/or sensory deficits. Administer corticosteroids as prescribed. Support the client during radiation therapy.

Complications and Nursing Implications � Hypercalcemia – a common complication of leukemia; breast, lung, head, and neck cancers; lymphomas; multiple myelomas; and bony metastases of any cancer. Symptoms include anorexia, N, V, shortened QT interval, kidney stones, bone pain, and changes in mental status. Administer isotonic saline, furosemide (Lasix), pamidronate, and phosphates as prescribed. � Superior vena cava syndrome – results from obstruction (for example, metastases from breast or lung cancers) of venous return and engorgement of the vessels from the head and upper body. Symptoms include periorbital and facial edema, erythema of the upper body, dyspnea, and epistaxis. Put the client in a high-Fowler’s position to facilitate lung expansion. High dose radiation therapy may be used for emergency temporary relief. � Disseminated intravascular coagulation (DIC) – a coagulation complication secondary to leukemia or adenocarcinomas. Observe the client for bleeding and apply pressure as needed. Avoid aspirin and NSAIDs.

Cervical cancer

Risk Factors �Early sexual activity (before 18 years old) �Low economic status �Chronic inflammation �Infection with human papilloma virus (HPV), associated in 90% of cases �History of sexually transmitted diseases (STDs) �Infection with HIV �Cigarette smoking �Immunosuppression �Intrauterine exposure to diethylstilbestrol (DES) during pregnancy

Diagnostic Procedures and Nursing Interventions �Pap Smear – microscopic examination of cervical cells �Cervical biopsy (definitive) is performed for cytologic studies when a cervical lesion is identified. � Biopsy is usually performed during colposcopy as a follow-up to an abnormal Pap smear.

Therapeutic Procedures and Nursing Interventions �Removal of the lesion by conization (conebiopsy), cryotherapy, laser ablation, or loop electrosurgical excision procedure (LEEP). �Clients with more extensive cancer may require a total abdominal hysterectomy or a more extensive pelvic surgery called exenteration (UT, GI, & Gyne; colostomy & urostomy)

Assessments �Monitor for signs and symptoms: Painless vaginal bleeding Watery blood-tinged vaginal discharge Leg pain (sciatic) or leg swelling Flank pain (hydronephrosis) Unexplained weight loss Pelvic pain

Assess/Monitor �Pain level �Vital signs �Signs of infection �Signs of disturbed body image �The client’s understanding and expectations of treatment

NANDA Nursing Diagnoses �Acute pain �Ineffective peripheral tissue perfusion

Nursing Interventions �Treat and reverse anemia as indicated. �Treat any pelvic, vaginal, or urinary tract infections. �Administer pain medications as prescribed. �Provide emotional support to the client and family. �Prepare the client for biopsy, cryosurgery, conization, laser therapy, LEEP, radiation, or surgery as indicated.

Nursing Interventions �Teach the client signs and symptoms of infection. �Teach the client regarding home care following special procedures (vaginal discharge, pain, avoiding douches, avoiding sexual intercourse, safety precautions, and post-radiation treatments). �Refer the client to a community support group as appropriate. �Refer the client to counseling if depressed or expressing concerns over sexuality.

Ovarian cancer

Ovarian cancer �The exact etiology is unknown; however, it seems associated with the number of ovulation (risk increased with early menarche, late onset menopause, nulliparity, and infertility). �Metastases frequently occur before the primary ovarian malignancy is diagnosed. �The most reliable indicator of prognosis is related to the stage of the cancer at the time of diagnosis.

Risk Factors �Over 40 years of age �Nulliparity or first pregnancy after 30 years old �Family history of ovarian, breast, or colon cancer �History of dysmenorrhea or heavy bleeding �High-fat diet (possible risk) �Use of baby talc (possible risk) �Hormone replacement therapy (HRT) �Use of infertility drugs

Diagnostic Procedures and Nursing Interventions �Pap Smear – only abnormal in small percentage of clients with ovarian cancer. �Staging of ovarian cancer is determined at the time of exploratory laparotomy �Cancer antigen test (CA-125 antigen) is better at measuring treatment than screening for presence of disease. �“Second look” surgical procedure following treatment to determine if there is a residual tumor, or if the cancer has been successfully treated.

Therapeutic Procedures and Nursing Interventions �Primary interventions are: surgery, traditional chemotherapy, intraperitoneal chemotherapy, and pelvic and abdominal irradiation.

�Monitor for signs and symptoms. �Abdominal pain or swelling �Abdominal discomfort (dyspepsia, indi

Assess/Monitor � Nutritional status � Weight � Pain status � Laboratory data � Urinary frequency and urgency � Signs of urinary obstruction � Signs of bowel obstruction � Emotional status of the client and family

Assess/Monitor �Postoperative status Vital signs Abdominal incision Postoperative complications (shock, hemorrhage, pulmonary complications) Infection Side effects and toxic effects of chemotherapy Side effects and toxic effects of radiation therapy

�NANDA Nursing Diagnoses �Acute pain �Ineffective peripheral tissue perfusion

Nursing Interventions �Provide pain control. �Teach the client regarding diagnostic tests. �Provide preoperative teaching and care. �Provide routine postoperative care. �Change dressings as ordered. �Provide pain relief as ordered. �Prepare the client for chemotherapy and radiation therapy.

Nursing Interventions �Relieve unpleasant SE due to chemotherapy and/or radiation therapy. �Encourage the client to express feelings about the cancer and fears of death. �Help the client and family to develop coping strategies. �Monitor the client’s progress through the stages of grief. �Arrange for a visit with a cancer survivor if possible. �Provide information about cancer support groups