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Oncology

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Oncology

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  1. Oncology Elisa A. Mancuso RNC-NIC, MS, FNS Professor of Nursing

  2. White Blood Cells(Leukocytes) White Blood Cells (WBC) • Formed in bone marrow and lymphatic tissue • Destroy foreign cells via • phagocytosis and antibody production Granulocytes • Phagocytic cells • produced in the bone marrow

  3. Granulocytes Neutrophils • fight bacteria Eosinophils • fight parasites • responds to allergens • influences the inflammatory process Basophils • contain histamine • activate the inflammatory response

  4. Agranulocytes Participate in inflammatory and immune reactions Monocytes (macrophages) • First line of defense in inflammatory process • Phagocytize large cells & necrotic tissue • Important for chronic infections Lymphocytes • Blast cells in bone marrow, spleen, thymus and other lymph glands and tissue • Responsible for immune protection

  5. T Lymphocytes • T-cells • Made in thymus • Cell mediated immunity (RT an antigen) • B cells • Humoral immunity • “memory” cells that produce antibodies to specific antigens • Natural killer cells • kill certain type of tumor cells and viruses

  6. Acute Lymphocytic Leukemia (ALL) Cancer is the 2nd cause of death <15 years • Leukemia • malignant disease of bone marrow and lymph system • ALL • most common form of childhood cancer • Peak onset 3-5 years of age • 80% of cases of acute leukemia in childhood • Etiology; • Genetic abnormalities • Philadelphia chromosome (↓ prognosis) • Trisomy 21 = 20 x ↑ Risk • Chernoble - Nuclear Radiation exposure • Alkylating agents or certain chemical agents • Virus trigger of oncogene

  7. ALL Pathophysiology • Abnormal, poorly differentiated blast cells • DNA mutation of an immature white blood cell • Causes the cell to multiply uncontrollably • Infiltrate bone marrow & ↑ vascular RE organs • Hepatomegaly • Splenomegaly • Lymphadenopathy • Malignant blast cells replace the functioning WBC’s in bone marrow causing: Anemia (↓↓ RBCs) Neutropenia (↓↓ WBCs) Thrombocytopenia (↓↓ Plts)

  8. Signs and symptoms 1st sign: Infections that linger > 2 weeks (↓WBC) • Fever • Chills • Anorexia • Weight loss (↑ metabolic demands of CA cells) • Bone & joint pain (Marrow expansion) • Abdominal pain (Hepatosplenomegaly) • Pallor, fatigue, lethargy (↓ RBCs) • Ecchymosis, petechiae, GI bleeding (↓ Plts) • CNS = ↑ICP ( HA, Vomiting & Irritability) • Late stage since brain protected by blood barrier.

  9. ALL Diagnosis • Bone Marrow Aspiration @ iliac spine • >25% blast cells = + diagnosis • Lumbar puncture (LP) • √ any CNS involvement • PET, CT & MRI Scans Good Prognosis- Poor Prognosis • WBC <10,000/mm3 WBC >50,000/mm3 • Age 1-10 Age <1 or >10 • Female Male • Early + response Poor treatment response • No CNS involvement CNS involvement

  10. 4 stages of Chemotherapy • Induction (4-6 weeks) • aimed at achieving remission • Intensification (4-6 weeks) • eradicates residual leukemia cells • CNS prophylaxis (2-3 weeks) • prevents leukemic cells from invading the CNS • Maintenance (several years) • preserves remission

  11. Chemotherapy Meds Corticosteroids • Anti-inflammatory • ↓ and kill lymphoblastic cells (↓ WBC) Prednisone - 40 mg/m2 PO QD Dexamethasone – 2.5 -10mg/m2/day IM/IV ÷ q6-8H Side Effects: • Na & Fluid retention = wt gain, puffy moon face • Hyperglycemia, peptic ulcers, mood changes • Delayed growth pattern

  12. Chemotherapy Meds Enzymes • ↓ levels of amino acid (asparagine) → • ↓↓ tumor growth L-Asparaginase (Elspar) 10,000 u/m2/day IM 2x/week • Side Effects: • Allergic rxn = chills, fever & rash • Jaundice √ LFTs • Respiratory distress & ↓ BP • N & V, DM

  13. Chemotherapy Meds Plant Alkaloids • Anti-neoplastic = Inhibits cell division Vincristine (Oncovin) 1.5 mg/m2 IV • Side Effects • Peripheral neuropathy • severe constipation • ↓ bowel innervation • Stomatitis, N & V, • Anemia • Thrombocytopenia

  14. Chemotherapy Meds Alkylating Agents • Interferes with cell growth Cyclophosphamide (cytoxan, CTX) 60-250 mg/m2/day Ifosfamide (Ifos) 1.2gm/m2/day Cisplatin (Platinol) 30-70 mg/m2/day • Side Effects • Alopecia • Pulmonary fibrosis • Hemorrhagic cystitis • (caused by chemical irritation of drugs) • Leukopenia • Anorexia, N & V

  15. Chemotherapy Meds Antibiotics • Documented bacterial infections Actinomycin D (dactinomysin, ACT-D) 2.5 mg/m2/wk Bleomycin (Blenoxane) 10-20 U/m2/wk Doxorubicin (Adriamycin) 20mg/m2/wk Side Effects • Cardiotoxic! • Red urine (Not hematuria) • Alopecia • N & V and stomatitis

  16. CNS Prophylactic Antimetabolites • Inhibits folic acid reductase = inhibits DNA synthesis and cellular replication. Inhibits replication of neoplastic cells Methotrexate (MTX, Amethopterin) 20mg/m2/week PO IV or Intrathecal Mercaptopurine (6-MP) 75mg/m2/day IV Cytarabine (Ara-C, Cytosar-U) 100-200mg/m2/day IV 5-Fluorouracil (5-FU) 7-12mg/kg IV • Side Effects • Leukopenia, chills/fever, vomiting • Red rash, Alopecia • ↓ Folic Acid metabolism • Hyperurecemia

  17. Other Agents Allopurinol (zyloprim) • Inhibits production of uric acid. • CA cell destruction = ↑ uric acid levels • accumulates in tubules → renal calculi • Side Effects • ↑ SGOT & SGPT = hepatotoxicity • Blocks metabolism of 6-MP = 6-MP toxicity • Need 1/3 -1/4 normal dose of 6-MP

  18. Other Agents Mesna (mesnex) • Ifosamide detoxifying agent. • Binds to toxic metabolites. • Prevents hemorrhagic cystitis • Use with alkylating agents • Cytoxan, Ifos, Platinol

  19. Radiation • Prophylactic in high risk patients • Minimize CNS involvement • Side Effects after 7-10 days • GI • dysphagia, stomatitis, N & V, diarrhea • Skin • Erythema, desquamination, alopecia • Myleosuppression↓ RBCs ↓ WBCs↓ Plts • Fatigue, Infection, Bruising/Bleeding • Pneumonitis • ↑ RR ↑HR Dyspnea & dry cough

  20. Transfusions Used to correct specific deficiencies • PRBC • Epoetin (Epogen)/Procrit • ↑ RBC in 2-6 weeks • Platelets • Granulocyte Colony Stimulating Factors-GCSF • Filgrastin (Neupogen) • ↑Neutrophils (ANC) • Stimulate dev of new white blood cells 10-14 days • SE: Bone pain, fever, malaise & HA • Whole blood transfusions • Rarely used since ↑ risk of fluid overload

  21. Bone Marrow Transplant • Replaces pt own bone marrow. • Need 500 cc -1 Liter • Takes 1-3 weeks for marrow to self produce • Autologous • uses own bone marrow if in remission • Allogenic (Donor) • √ Compatible = match 6 HLA antigens • Prevent Graft vs. Host Disease (GVHD)

  22. Bone Marrow Transplant • 1st give ↑↑ dose chemo and radiation (total body) • Rids body of CA cells • Suppresses immune system to prevent rejection • Strict reverse isolation • Neutropenic Precautions • No fresh flowers, fruit, veggies • Monitor visitors √ immunization status • Monitor s/s of infection • √ Temp, CBC, Activity • √ Absolute Neutrophil Count (ANC) <500 • ↑ risk for overwhelming infection • ANC = WBC times the % of neutrophils

  23. Nursing Interventions Prevent Infections • Live vaccines are contraindicated. • No MMR or Varicella • Inactivated vaccines • Wait @ least 6 months after chemo for appropriate immune response • ↑↑ predisposition to resistant organisms • Broad spectrum prophylactic antibiotics

  24. Nursing Interventions Nutrition • ↑↑ Hydration ↑ Protein ↑Caloric Intake • Bland , easily digestible diet • Encourage nutritious foods • Allow pt to choose • ↑ Pt participation with meal planning • No acidic juices or spicy foods

  25. Nursing Interventions Mouth Care • Frequent cleansing • Magic Mouthwash (Malox/Benadryl/HO) • Cotton swabs not toothbrush for ↓ Plts • Stomatitis • Chloroseptic spray • Viscous Lidocaine

  26. Nursing Interventions Skin Care • High risk for rectal ulcers from diarrhea • Keep area clean and dry & OTA • Turn & Position • Sheepskin or Air mattress • √ SE from meds & radiation • ↑risk for skin breakdown & irritation

  27. Nursing Interventions Nausea and Vomiting • Small frequent feeding • ↑ PO intake via ices, jello, favorite fluids • √ weight √ I and O’s Antiemetics • Ondanesetron (Zofran) [Aloxy] • Blocks 5-HT3 site in brain • Dronabinol (Marinol) • THC synthetic active component of marijuana

  28. Nursing Interventions Peripheral Neuropathy • ↓ bowel innervation → constipation • Foot drop, tremors, jaw pain • Weakness & numbness of extremities Maintain safe environment • Assist with ambulation • Sneakers, hand rails & walkers

  29. Nursing Interventions Alopecia • Prepare child & family ( temp condition) • Allow kids to cut their own hair! • Obtain wig before hair is lost • Scarfs or hats • Re-growth 3-6months • Darker, thicker & curlier

  30. Nursing Interventions Hemorrhagic Cystitis • Chemical irritation to the bladder • ↑ Fluid intake (1.5 x daily amount) • ↑ Voiding frequency Medication • Mesna • ↓ Urotoxicity of Ifos & Cisplatin

  31. Nursing Interventions Pain relief • Evaluate non-verbal and verbal cues • Note cultural differences & accommodate needs • Position • H2O beds, bean bag chairs, stuffed animals • Change environment • ↓ Sensory stimulation (lights, noise, activity) • Relaxation techniques • Massages, rocking, guided imagery, distraction, Humor!

  32. Pain Meds • Give ATC to maintain steady state • Give meds before pain is severe • Adhere to scheduled med time • Kids have ↑ BMR • Need more frequent dosing not ↑ dose • Tylenol[10-15 mg/kg/dose q 4-6 H] • Maximum 90 mg/kg/dose (hepatotoxic) • Tylenol with codeine [Codeine 0.5 -1 mg/kg/dose] • Tylenol No. 1 (Codeine 7.5 mg & Acetaminophen 300 mg) • Tylenol No. 2 (Codeine 15 mg & Acetaminophen 300mg) • Percocet [oxycodone 0.1 mg/kg/dose] • [Oxycodone 5 mg & Acetaminophen 325 mg] • Tylox • [Oxycodone 5 mg & Acetaminophen 500 mg] • Vicodin • [Hydrocodon 5mg & Acetaminophen 500 mg]

  33. Pain Meds NSAIDS • Ibuprophen (Motrin) 40 mg/kg/day • SE: Skin rash, abdominal cramps, N, dizziness Opioids • Hydromorphone (Dilaudid) 0.4 -1mg/kg q 4-6 H • Quick onset of action 15 minutes • Shorter duration than MSO4 • ↑ potency 1 mg Dilaudid = 4 mg MSO4 • Morphine SO4 (Roxanol) 0.025 -2.6 mg/kg/H • SE: Sedation, ↓ RR ↓BP Constipation Flushed face • Methadone (Dolophine) 0.2 mg/kg q 6-8 H • Long ½ life 24 -36 H • SE: Confusion, Sedation, ↓BP Constipation

  34. Nursing Interventions Emotional support • Guidance with honest answers • Education • Serious signs & symptoms, adverse drug effects • When to seek medical attention • Establish good plan for FU care • Encourage verbalizations or fears/ concerns • Reassure pt will be comfortable

  35. Neuroblastoma • Most common solid malignant tumor in kids • ↑ risk < 2 years old. • 75% before child is 5 years old. • Tumors begin as embryonic cells • Develop into the adrenal medulla and sympathetic nervous system (ganglia). • Majority a non-familial, sporadic pattern • Silent Tumor • 70% Dx after metastasis • Poor Prognosis

  36. Clinical Manifestations • Primary sites: • Abdomen & Pelvis, Chest, Head & Neck • Retroperitoneal region (65%) • Adrenal medulla - ↑↑ E/NE release • ↑ HR ↑ BP ↑ Bounding Pulses +3, diaphoresis • Abdominal mass-bloating/constipation • Anorexia • Kidney compression • Polyuria → Polydipsia • Spinal chord compression • Pain & Paresthesia

  37. Clinical Manifestations • Mediastinum (15%) • Compresses trachea & bronchi • Tracheal deviation • Persistent cough, Dyspnea & SOB • Stridor & Chest pain • Lymphadenopathy • Cervical, supraclavicular & groin • Neck/facial edema • ↑ ↑ HA in AM & ↑ ↑ HC • Supraorbitalecchymosis (Raccoon eyes) • Infection

  38. Clinical Manifestations • Systemic • Weight loss • RT Anorexia RT ↓↓ Bowel function • Irritability • Fatigue • Myoclonus ataxia syndrome • Anemia • Febrile, ↑ HR ↑ BP • Changes in urination, bowel elimination

  39. Diagnosis • CT: Chest, Abdomen & Pelvis • Bone Scan IVP Abdominal Sonogram • Bone Marrow aspiration and biopsy • CBC: ✔ Anemia ✔ Thrombocytopenia • 24 H urine collection of VMA Vanillylmandelic Acid = ↑ DA & NE

  40. Treatment • Surgery if tumor is localized • Radiation • ↓ size of tumor a & p surgery • Chemotherapy • Diffuse & advanced disease • Cytoxin, Vincristine & Cisplatin • 3F8 immunotherapy

  41. Wilm’s Tumor (Nephroblastoma) • Common type of abdominal tumor • ↑ Incidence with Hypospadias & Cryptorchidism • 80% diagnosed at <5years • ↑ risk @ 3 years • 90% survival rate • ↑ Cure rate with early diagnosis • Encapsulated Tumor • Arises from renal parenchyma • Rapidly growing tumor • Favors left kidney and usually unilateral • 10% of cases have both kidneys involved

  42. Clinical signs • Non-tender mid-line abdominal mass • Flank pain • ↑↑ BP • RT kidney & adrenal compression & Renin • Anemia RT Hematuria • Rare Mets → Lung & Bone

  43. Diagnosis ASAP! • Abdomen & Chest • CT scan, X-Ray & Ultrasound • IVP • Renal function tests • CBC with differential • Bone scan

  44. Therapy • 1st Place sign on wall: • DO NOT PALPATE ABDOMEN! • Radiation and chemo a & p surgery • Surgery • Radical Nephrectomy • whole kidney and adrenal • Large Y autopsy-like incision: • Examine entire abdominal cavity

  45. Nursing Interventions • Prepare family for scar • Prepare for chemo and radiation • Abdominal surgical care • I&O’s • Monitor bleeding • No contact sports • Watch for any kidney infections or • ⇊ function

  46. Osteogenic Sarcoma Osteosarcoma • Arises from bone forming osteoblasts and bone digesting osteoclasts • Most common bone tumor in children • 10 – 15 years, can go up to 25 years • Femur, tibia or shoulder near growth plate • ↑ Frequency during growth spurt

  47. Signs and Symptoms • Gradual onset Insidious, intermittent local joint pain • Palpable mass – (Bone Biopsy) • Pain more intense with activity • Limp & change in gait, ↓ ROM • High serum alkaline PO4, and LDH • Pathological fractures • Starburst formation on x-ray

  48. Therapy • R/O Metastasis • Bone Scan, CT, MRI & Lung Scan • Surgery • Amputation 3” proximal to tumor or joint • Limb salvage • Chemotherapy • ↑ Methotrexate, Adriamycin, • Cisplatin, Ifos

  49. Pre-op • Exercise to strengthen upper arms • Prepare patient for extensive PT • Emotional support • allow pt to grieve for limb loss • Focus on what the pt can do • Support Group: • ACS-Osteo Support Group; Camping & youth directed activities • www.candlelighters.org

  50. Post-op • ✔ signs of hemorrhage q1H x 24 then q4H • Tourniquet at bedside (arterial bleed) • Venous oozing reinforce dressing • Pressure dressing • Mold and shape for prosthesis • Phantom limb pain • Stimulation of nerve endings • Burning, aching, tingling & cramping. • It is real! • Pain meds & Elavil