1 / 58

Oncology

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

bill
Download Presentation

Oncology

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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 RT • 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. 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: • Hyperglycemia • Na & Fluid retention = wt gain, puffy moon face • Peptic ulcers, mood changes • Delayed growth pattern

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

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

  18. 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

  19. 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

  20. 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)

  21. 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

  22. 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

  23. 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

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

  25. 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

  26. 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

  27. 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

  28. 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

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

  30. 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!

  31. 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]

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

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

  38. 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

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

  40. 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

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

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

  43. 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

  44. 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

  45. 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

  46. 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

  47. 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

  48. 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

  49. 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

  50. Post-op • Position • 1st 24 H - Elevate stump with pillow • >24 H No pillow below knee • Position prone to prevent hip flexion • No external rotation or abduction • Place prosthesis immediately after surgery. • Fosters early function and adjustment

More Related