Care of Clients in Cellular Aberrations, Acute Biologic Crisis (ABC), Emergency and Disaster Nursing (NCM106) Cellular Aberration

III

LOOKY HERE

Cancers in Different Systems

Respiratory Cancer
Most common cause of cancer death in men and is fast becoming the most common cause in women though its preventable RISK FACTORS Any smoker over age 40, especially if he began to smoke before age 15 Has smoked a whole pack or more per day for 20 years or; Works with nearby asbestos Cancer Risk is Determined by: Number of cigarettes smoked daily The depth of inhalation How early in life smoking began The nicotine content of cigarettes

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Cancers in Different Systems a. Respiratory Cancer b. Breast Cancer c. Colorectal Cancer d. Prostate Cancer e. Cervical Cancer f. Ovarian Cancer Oncologic Emergencies a. Cardiac Tamponade b. Increased ICP c. Spinal Cord Compression (SCC) d. Superior Vena Cava Syndrome (SVCS) e. Disseminated Intravascular Coagulation (DIC) f. Hypercalcemia g. Syndrome of Inappropriate Antidiuretic Hormone (SIADH) h. Tumor Lysis Syndrome Palliative Care a. Psychosocial Aspects of Cancer Care

Other Factors that Increase Susceptibility: Exposure to industrial and air pollutants (Asbestos, Uranium, Arsenic, Nickel, Radioactive Dust) Familial susceptibility

TWO TYPES OF LUNG CANCER

1. Non-Small Cell Lung Cancer Squamous cell carcinoma Adenocarcinoma Large cell carcinoma Small Cell Lung Carcinoma Small cell carcinoma

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NON-SMALL CELL LUNG CANCER Are round cells that replace injured / damaged cells in the lining (the epithelium) of the bronchi, the major airways Are usually found in the center of the lung, either in a major lobe or in one of the main airway ranches They may grow to large sizes and form cavities in the lungs Estimated to account for 30% - 50% of all lung cancers Most common lung cancers in many countries Most common lung cancers in women Adenocarcinoma usually arise from the mucus-producing cells in the lungs About two-thirds of adenocarcinomas develop in the outer regions of the lungs, while one-third develops in the center of the lungs BRONCHOVESICULAR LUNG CANCER A subtype of adenocarcinoma Develops as a layer of column-like cells on the lungs and spreads through airways Causing great volumes of sputum

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Which makes up about 10% - 20% of lung cancer, includes cancer that cannot be identified under the microscope as squamous cell cancers or adenocarcinomas

SMALL CELL LUNG CANCER Ike squamous cells, it is derived from reserved cells or other cells in the epithelium Causes between 15% and 25% of all lung cancers without chemotherapy Very aggressive and is usually rapidly fatal It requires a different treatment approach from non-small cell lung cancer

Signs and Symptoms

Early stage lung cancer usually produces no symptoms; this disease is often in an advanced state or diagnosis The following late-stage symptoms often lead to a diagnosis: o With squamous and small cell carcinomas: Smokers cough, hoarseness, wheezing and chest pain o With adenoma and large cell carcinomas: Fever, weakness, weight loss, anorexia and shoulder pain

Metastatic symptoms vary greatly, depending on the affected structures Bronchial Obstruction: Hemoptysis, atelectasis, and dyspnea Recurrent Nerve Invasion: Vocal cord paralysis Chest Wall Invasion: Piercing chest pain, increasing dyspnea, severe shoulder pain radiating down the arm Esophageal Compression: Dysphagia Vena cava Obstruction: Venous distension and facial edema, neck, chest and back

Diagnostic Procedures
Chest X-ray Sputum Cytology CT Scan Biopsy Thoracentesis Bronchoscopy

Other Diagnostic Procedures:

CHEMOTHERAPY o For Advanced Non-small Cell Lung Cancer VbP (Vinblastin, Cisplastin); CAMP 9Cyclophosphamide, doxorubicin, methotrexate, procarbazine); MVbP (Mitomycin, Vinblastin, Cisplatin) o For Small Cell Lung Cancer CAV (Cyclophosphamide, Doxorubicin, Vincristine); CEA Cyclophosphamide RADIATION o External Beam (Cobalt therapy), interstitial / endobrochial brachytherapy with IRRIDIUM-192 SURGERY o Pre-Operative Care Obtain Pre-Op Status Amount and extent of dyspnea, cough, Hemoptysis, tachypnea Baseline pulmonary function studies ABGs, ECG, blood counts and chemistry, general nutrition and hydration status Encourage patient to stop smoking pre-op Explain the use of suctioning and chest drainage after surgery Instruct DBE, coughing exercises, ROM, early ambulation o Post-Operative Care

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Closed Chest Drainage Note for the fluctuation in the water-seal chamber and drainage tubing near the patient Observe and record the amount, character of drainage. Check dressing at the entry site of chest tube, skin / wound care Assess patient frequently for signs of airway obstruction, atelectasis, aspiration, or impaired gas exchange Pain management, fluid replacement (Movement of the shoulder on affected side and rest) Surgeries Segmentectomy: A wedge-shaped selection of the affected lung is removed Lobectomy: The affected lobe of the lung is removed Pneumonectomy: The entire affected lung is removed

Health Teaching
Encourage patient to stop smoking Instruct the patient and family to notify the physician if the patient experienced any side effects from medications or signs or recurrence such as shoulder pain, increased coughing or hemoptysis Teach the patient the name, dose and action frequency and side effects of medications

Breast Cancer
Refers to a group of malignant diseases that commonly occur in the female breast and infrequently in the male breast The most commonly malignancy in women One in every nine (9) woman is expected to develop breast cancer RISK FACTORS: Gender / Age / Socioeconomic Status Early Menarche <12 and rate menopause >55 >30 years old: First full term pregnancy Nulliparity Obesity / High Fat Diet Family history of breast cancer SIGNS and SYMPTOMS - A painless mass or thickening in the breast, most often found in the outer quadrant - The mass is usually non tender, hard, irregular in shape and non mobile DIAGNOSTIC PROCEDURES Chest X-Ray Mammogram Biopsy

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This shows the right breast (the breast on the left side) being larger than the left. Look carefully and you can see that the levels of the nipples are not the same and the right ight nipple is pointing downwards.

depression or sunken dip in the skin of the upper part of the left breast, above the nipple. (breast to your right) as dimpling of the skin. Normally when the arms are raised this becomes apparent or more obvious. The right picture shows the dimpling of the skin from the side view.

The breast appears patchy red and thickened. An example of a type of breast cancer that looks as if your breast has an infection. A sign of an inflammatory cancer of the breas breast.

Compare both nipples. The one to your right (the left nipple) is drawn inwards and this is called retraction of the nipple. The picture on the right shows the nipple retraction from the side view.

MALE BREAST CANCER: Breast cancer involving the nipple (ulceration has occurred) Peau d orange refers to the orange peel skin appearance of skin Sunkist oranges typically have this pitted appearance, Due to edema in the skin, akin to water retention. Breast on the right is at a more advanced stage of the orange peel skin and the nipple is retracted (drawn inwards)

Very advanced breast cancer ulcerating and involving the whole of the left breast. Spread pread to the left armpit lymph ymph nodes. Even the enlarged lymph nodes are on the verge of breaking through the skin

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SURGERY Lumpectomy o Involves the removal of the cancerous mass and some normal tissue for clean margins. Frequently, the initial Excisional biopsy is the Lumpectomy Modified Radical Mastectomy o Involves the en bloc removal of the breast, axillary lymph nodes and overlying skin, this is the most commonly performed mastectomy Total Mastectomy o Involves resection of breast tissue and some skin from the clavicle to the costal margin and form the midline to the latissimus dorsi o Axillary tail and pectoral fascia are also removed o Axillary nodes are not removed Radical Mastectomy o Involves the en bloc removal of the breast, overlying skin, pectoral muscles and axillary nodes o Removes the local lesions and the axillary nodes with wide safety margin of surrounding tissue o This procedure has declined due to unsatisfactory treatment results and morbidity CHEMOTHERAPY Combination Therapy: CMF (Cyclophosphamide, methotrexate, 5-flurouracil); CMFVP (CMF with Vincristine and prednisone) RADIATION In combination with lumpectomy or quadrectomy is an accepted treatment for early stage (Stage I and II) Women who are eligible for these treatment choices are women with: - Lesions less than 5 cm - No large or fixed ancillary nodes - No demonstrable disease - No clear surgical margins - Breasts that can be easily evaluated mammographically Alleviate patient symptoms due to the side effects of the treatment

Nursing Care
Post Mastectomy Prevent strain on the affected side Elevate arm / affected side using a pillow to minimize edema Increase the number of pillows gradually as edema subsides Allow slow abduction / adduction few days after surgery, unless contraindicated No BP taking, IV insertion, compression on the affected side Monitor color, consistency and volume of drainage Daily wound dressing or as PRN

Post Mastectomy Exercise

1. 2. 3. 4. Arm Swings Pulley Hand-wall Climbing Rope Turning

Home Instructions
Arm Precautions After Axillary Lymph Node Dissection Avoid burns while cooking / smoking o Wear a long length oven mitt o Do not reach into a hot oven with arm o Do not hold cigarette on the affected hand Avoid sunburns and insect bites o Wear long sleeve shirts or gloves o Use sunscreen

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o Use insect repellant to avoid bite or stings Avoid cuts, pinpricks, and scratches o Wear gloves when gardening. Do not work near thorny plants o Use an electric razor with narrow head for underarm shaving to reduce risks of nicks or scratches o Use a thimble when sewing o Never cut / pick at cuticles; use hand cream / lotion o Wash cuts promptly treating them with antibacterial medications and cover them with sterile dressing o Check often for redness, soreness, pus or other signs of infection Avoid strong detergents, harsh chemicals and abrasive compounds o Wear protective gloves when doing dishes and cleaning Avoid trauma o Use a lanolin hand cream a few times each day o Have all vaccines injected, blood samples and blood pressure taken on the unaffected side / other arm o Wear a Medic Alert ID Tag that cautious no test injections or BP reading on the affected side o Carry handbag and other heavy objects on the other arm o Wear watch / jewelry loosely if worn at the operated arm Contact the physician if the arm / hand become red, swollen or feels hot In the meantime, try to keep your arm over your head and periodically pump your fist

Colorectal Cancer
Epidemiology Second most common visceral neoplasm in the US and Europe Incidence is equally distributed between male and female Ranks just behind the lung cancer as cause of death Most tumors are focused in the distal portion of the large bowel, from the sigmoid colon to the anus RISK FACTORS Exact cause is unknown Concentration in areas of higher economic development suggest a relation to diet (excess animal fat, beef, and low fiber) Other factors are: o Other diseases of the digestive o History of ulcerative colitis tract o Familial polyps o Age over 40 years old SIGNS and SYMPTOMS Weight loss Anorexia N/V Anemia Palpable Mass

PAIN Rectal Bleeding Changed bowel habits Tenesmus Intestinal obstruction

DIAGNOSTICS Digital Rectal Examination (DRE): Can detect almost 15% of colorectal cancer Hemoccult Test (Guaiac): Can detect blood in stool Proctoscopy or Sigmoidoscopy: Can detect up to 66% Colonoscopy: Permits visual inspection (and photographs) of the colon up to the ileocecal valve and gives access for polypectomies and biopsies of suspected lesions CT Scan: Can detect areas affected by metastases Barium X-Ray: o Utilizing a dual contrast with air, can locate lesions that are undetectable manually / visually o This should FOLLOW endoscopy or excretory urography because the barium sulfate interferes with these tests

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Carcinoembryonic Antigen: Although not specific / sensitive enough for an early diagnosis, is helpful in monitoring patients before and after treatment to detect metastases / recurrence TREATMENT Surgery: Most effective treatment for colorectal cancer, it removes the malignant tumor and adjacent tissues as well as any lymph node that may contain cancer cells Tumor in upper rectum: Anterior colectomy Tumor in middle rectum: Pull-through procedure Tumor in lower rectum: Abdominoperineal resection and colostomy Tumor in right colon Right colectomy / colostomy Tumor in left colon Colectomy / colostomy Tumor sigmoid colon Sigmoid resection Chemotherapy o Is indicated for patients with metastatic residual disease, or a recurrent inoperable tumor o Drugs for such treatment commonly include fluorouracil with levamisole, leucovorin, methotrexate / streptozotocin Radiation o Induces tumor regression and may be used before or after surgery or combined with chemotherapy especially fluorouracil NURSING CARE Before Surgery Monitor the patients diet modifications, laxatives, enemas and absorption If the patient is having colostomy, teach them and their family about the procedure Emphasize the stomach will be red, moist and swollen and that post-op swelling will eventually subside Show them a diagram of the intestine before and after surgery, stressing how much of the bowel will remain intact Prepare the patient for post-op IV infusions, NGT and indwelling urinary catheters Discuss the importance of DBE and coughing exercises After Surgery Explain to the family the importance of their positive reactions to patient adjustment Encourage the patient to look at the stomach and participate in its cure as soon as possible. Teach good hygiene and skin care If appropriate, instruct the patient with sigmoid colostomy to do their own irrigation as soon as he/she can after surgery. Advise them to schedule irrigation for the time of day he normally gets evaluated before surgery If flatus, diarrhea or constipation occur, eliminate suspected food from patients diet Inform the patient that a structured gradually progressive exercise program exists to strengthen abdominal muscles, it may be instructed under medical supervision Inform patient to avoid heavy lifting to prevent herniation and prolapse

Prostate Cancer
Epidemiology - Second most common neoplasm found in men over age 50. - Incidence is highest in Blacks and lowest in Asians SIGNS and SYMPTOMS Manifestations of prostate cancer appear only in the advanced stages, including: o Difficulty initiating urinary stream o Dribbling urine o Retention and o Unexplained cystitis o Rarely hematuria

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DIAGNOSTICS Digital Rectal Examination Men >40 y/o Yearly blood test to detect PSA (Prostate Specific Antigen) in men over age 50 Ultrasound If abnormal results are found in the preliminary exams Biopsy Confirms the diagnosis MRI , CT Scan, Excretory Urography may also aid the diagnosis TREATMENT Surgery Radical Prostatectomy, Prostatectomy, orchiectomy to reduce androgen production

NURSING CARE o Explain the after effects of surgery (such as impotence and incontinence) and radiation o Teach the pt. to do perineal exercises 1 to 10 times an hour Radiation o

Radiation is used to cure some locally invasive lesions and to relieve pain from metastatic bone involvement. A single injection of radionuclide Strontium-89 is also used to treat pain caused by bone meds.

Chemotherapy Single agents: Cyclophosphamide, 5-FU, doxorubicin, methotrexate, cisplatin, mitomycin, dacarbazine, hormonal therapy, diethylstilbestrol, premarin, estradiol

Cervical Cancer
Epidemiology More common among women of lower socioeconomic status, majority of whom are Black/Hispanic, but all women are at high risk for developing it RISK FACTORS Intercourse at a young age, particularly 15 17 years old Multiple sex partners Sexually Transmitted Diseases Multiple pregnancies Pregnancy in the teen years Classified as either pre-invasive / invasive carcinoma 1. Pre-invasive Carcinoma Ranges from minimal cervical dysplasia, the lower third of the epithelium contains abnormal cells, to carcinoma in situ The full thickness of epithelium contains abnormally proliferating cells Curable 75% to 90% of the time with early detection and proper treatment. If untreated, it may progress to invasive cervical cancer. 2. Invasive Cervical Cancer Cells penetrate the basal membranes and can spread directly to contagious pelvic structures or disseminate to distant sites by lymphatic routes. Usually, invasive carcinomas occurs between ages 30 and 50; rarely, under age 20 SIGNS and SYMPTOMS Pre-invasive Cervical Cancer o Cervical cancer produces no symptoms, other clinically apparent changes Early Invasive Cervical Cancer o Abnormal vaginal bleeding o Persistent vaginal discharge

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o o

Post coital pain and bleeding IN ADVANCED STAGES: Pelvic pain Vaginal leakage of urine or stools from a fistula Anorexia Weight loss Anemia

DIAGNOSTICS Papanicoulau Smear (PAP Smear) Can detect cervical cancer before clinical evidence appears Colonoscopy Being done if there is abnormal cervical cytology, it can detect the presence and extent of pre-clinical lesions requiring a biopsy and histologic examination Lymphangiogram, cystography and scans can detect metastases NURSING CARE Drape the patient and prepare her as a routine PAP Test and pelvic exam if she: o Needs a biopsy o Is having cryosurgery Tell the patient to expect a discharge spotting for about 1 week after an Excisional biopsy, cryosurgery, laser therapy and advise her not to: o Douche o Use tampons o Engage in sexual intercourse during this time Tell the patient what to expect post-op if she will have a hysterectomy Watch for signs and symptoms of complications, such as: o Bleeding o Abdominal distention o Severe pain o Breathing difficulties Encourage patient to do DBE and coughing Find out whether the patient is to have internal or external radiation procedure. Internal radiation requires a 2-3 day facility stay, bowel prep, a povidone-iodine vaginal douche, a clear liquid diet, NPO the night before the implantation; it also requires an indwelling catheter Internal radiation procedure is performed in the operating room under general anesthesia and that an applicator containing radioactive material will be implanted Remember that safety precautions time, distance, and shielding begin as soon as the radioactive source is in place. Inform the patient that shell require a private room Encourage the patient to lie flat and limit movement while the implant is in place. If she prefers, elevate the head of bed slightly Assist the patient in ROM arm exercises (leg exercises and other body movements can dislodge the implant). If needed, administer tranquilizer to help the patient relax and remain still. Organize the time you spend with the patient to minimize exposure to radiation.

Ovarian Cancer
Epidemiology Ovarian cancer is the fourth leading cause of death from cancer in women Its incidence is increased faster than the survival rate RISK FACTORS o Higher in women with upper socioeconomic levels between the ages of 20 and 54 o Includes age at menopause o Infertility o Celibacy

o o o o o

High-fat diet Exposure to asbestos, talc and industrial pollutants Nulliparity Familial tendency History of breast or uterine cancer

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SIGNS and SYMPTOMS Vaginal abdominal discomfort Other mild GI disturbance Constipation Abdominal distention

Dyspepsia Urinary frequency Pelvic discomfort Weight loss

DIAGNOSTICS - Complete patient history - Surgical exploration - Histologic studies - Complete physical examination including pelvic exam with PAP Smear - Other Special Tests are: Abdominal ultrasonography, ct scan or xray CBC, blood chemistries, electrocardiography Excretory urography for information on renal function Chest X-ray for distant metastases Barium enema Lymphangiography to show lymph node involvement Mammography to rule out primary breast cancer Liver function studies or liver scan Ascites fluid aspiration for identification of typical cells by cytology TREATMENT Surgery Simple-salpingo-oophorectomy Simple Salpingo-oophorectomy Total Abdominal hysterectomy w/ bilateral salpingo-oophorectomy and partial or complete omentectomy Radiation Intracavity Radiation External Radiation Chemotherapy Single Agent: Chlorambucil, melphalan, doxorubicin, cyclophosphamide, 5FU, methotrexate, vinblastine, bleomycin, cisplatin, nitrogen mustard, thiotepa, tetracycline Combination Therapy (containing cisplatin) NURSING CARE Before Surgery Thoroughly explain all preoperative tests, the expected course of treatment, and surgical and postoperative procedures In pre-menopausal women, explain that bilateral oophorectomy artificially induces early menopause, so they may experience hot flashes, headaches, palpitations, insomnia, depression, and excessive perspiration After Surgery Provide abdominal support, and watch for abdominal distention. Encourage coughing and deep breathing. Reposition the patient often and Encourage her to walk shortly after surgery Monitor and treat adverse effects of radiation and chemotherapy

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Oncologic Emergencies
Pathophysiologic Base of Malignant Neoplasia

Proliferation of Cancer Cells

Pressure o Due to in size of neoplasm growth Obstruction o As tumor continues to grow, hollow-organs and vessels become compressed and obstructed o E.g. Esophagus, bronchi, uterus, bowel, blood vessels, lymphatic system Pain Due to: o Pressure on nerve endings o Distention of organs / vessels o Lack of oxygen to tissues and organs o Release of pain mediators by tumor Late sign of cancer Effusion o When lymphatic flow is obstructed; effusion in serous cavities o E.g. Pleura cavity, abdominal cavity Ulceration and Necrosis o Result as the tumor erodes blood vessels and pressure on tissues causes ischemia tissue damage and bleeding / infection Vascular thrombosis, embolus, Thrombophlebitis o Tumor tend to produce abnormal coagulation factors that cause increased clotting$ (Pulmonary emboli life threatening)

Paraneoplastic Syndrome
Malignant cells produce chemicals, hormones and other substances o Anemia Cancer produces chemicals that interfere with RBC Production Iron uptake is greater in the tumor than deposited in the liver Blood loss may result from bleeding o Hypercalcemia Tumor of the bone, squamous cell lung carcinoma, Ca of the breast produce a parathyroid-like hormone that increases or accelerates bone breakdown or release of calcium Also results from metastasis of the bone Enhanced by immobilization and dehydration o Disseminated Intravascular Coagulation More likely to occur in Ca in the lungs, pancreas, stomach, prostate Precipitated by the release of tissue thromboplastin or endothelial injury

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Anorexia Cachexia Syndrome

The final outcome of unrestrained Ca cell growth Malignant neoplasms deprive normal cells of nutrition Tumor produces alteration in enzyme system necessary for normal metabolism Stored fat is lost, tissues lose nitrogen (negative Nitrogen balance) Tumors revert to an aerobic metabolism Consumes glucose, deplete glycogen stores in the liver and convert glucose to lactate Protein depletion, serum albumin levels decrease Tumors take up sodium and water retention, masks malnutrition and is not immediately reflected as weight loss Cancer cells anorexigenic substances that act as a satiety center of the hypothalamus causing anorexia Taste sensation diminishes or becomes altered and the individual may have aversion to eating particular food, MEAT

Oncologic Emergencies
Clinical emergencies in which the condition is secondary to malignancy or its treatment Potentially mediate catastrophic consequences in the absence of successful intervention

TWO DIVISIONS in Oncologic Emergencies (Oncologic Nursing Society ONS) Core Curriculum for Oncology Nursing
1. Structural Cardiac tamponade Increased ICP Spinal cord compression (SCC) Superior vena cava syndrome (SVCS) Metabolic Disseminated intravascular coagulation Hypercalcemia Hypersensitivity reaction (Anaphylaxis) Sepsis Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Tumor Lysis Syndrome (TLS)

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Reasons for Critical Care Interventions 1. New hops for cure or long term remission 2. Increased ability to treat certain complications 3. Consumer demands Concepts When Caring For Care Identification of patients at risk for developing oncologic complications Involvement of the family and significant other

CARDIAC TAMPONADE
Compression of cardiac muscle by pathologic fluid, accumulation under pressure within the precardial sac

SIGNS and SYMPTOMS Cardiogenic shock Tachycardia, tachypnea Cyanosis, anxiety, restlessness Impaired consciousness

INTERVENTIONS Start O2 and alert respiratory support as needed Insert IV catheter if one is not already in place Monitor VS and initiate hemodynamic monitoring Prepare Vasopressor drugs

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Bring crash cart to bed side Set-up for and assist physician with pericardial tap Reassure patient

MANAGEMENT a. Removal of pericardial fluid (Pericardiocentesis) b. Corticosteroids (Prednisone & Diuretics [Furosemide]) c. Radiation pericarditis d. Vasoactive drugs e. Radiation and chemotherapy

INCREASED ICP
Intracranial hypertension MANAGEMENT a. Corticosteroids b. Osmotic Diuretics (Mannitol) c. Anticonvulsants (Phenytoin) d. Mechanical hyperventilation e. Radiation and chemotherapy

SPINAL CORD COMPRESSION

Associated with pressure from expanding tumor of breast, lung or prostate Tumor directly enters the spinal cord or when the vertebrae collapse from tumor degradation of the bone SIGNS and SYMPTOMS Progressive back and leg pain Numbness and paresthesia and coldness Weakness and paralysis NURSING INTERVENTIONS Neurologic checks every shift with client with advanced cancers of the breast, lung, prostate or lymphoma Thorough assessment of all complaints of back pain or sensory changes Notification of physician if spinal cord compression is suspected and preparation for MRI Administration of corticosteroids (Dexamethasone) to reduce edema and protect function MANAGEMENT (Palliative) 1. High dose of corticosteroids (To reduce swelling around the spinal cord and relieve symptoms) 2. High dose radiation (To reduce size of tumor) May be along with chemotherapy 3. External back or neck braces 4. Radiation and chemotherapy

SUPERIOR VENA CAVA SYNDROME (SVCS)

SVCS is compressed by mediastinal tumors or adjacent thoracic tumors Painful and life-threatening emergencies Late stage manifestation of cancer

SIGNS and SYMPTOMS Facial and arm edema Pleural effusion Tracheal edema: Respiratory distress Dyspnea and cyanosis Altered consciousness and neurological deficit

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EMERGENCY MEASURES Provide O2 support and prepare for tracheostomy Monitor VS Administer corticosteroids (Dexamethasone) If the disorder is due to clot, administer antifibrinolytic or anticoagulant drugs Provide safe environment, includes seizure precautions MANAGEMENT 1. High dose of radiation 2. Stenting in the vena cava 3. Angiopasty (Keep stent open for a longer period) 4. Surgery (Rare) May induce increased intrathoracic pressure during closure

DISSEMINATED INTRAVASCULAR COAGULATION

Problem with clotting process Release of thrombin and thromboplastin from cancer cells or by blood transfusions TREATMENT 1. Heparin (Early phase) 2. Cryoprecipitated Clotting Factors

HYPERCALCEMIA
Excessive ectopic production of parathyroid hormone associated with cancers of the breast, lung, etc. Release of Calcium into the blood stream SIGNS and SYMPTOMS o Fatigue, anorexia, nausea, polyuria and constipation o Muscle weakness, lethargy, apathy and diminished reflexes MANAGEMENT Oral hydration Relieve Calcium levels, relieve symptoms Medications (Oral glucocorticoids, Calcitonin) Lower Calcium levels If with renal impairment Dialysis

SEPSIS
Organisms enter the blood stream WBC are low and immune response is impaired MANAGEMENT Strict aseptic technique IV antibiotic therapy

SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE (SIADH)

Cancer that stimulates the release of ADH Brain cancer is common

MANAGEMENT a. Fluid of not more than 1 L per day b. Increase sodium intake c. Demeclocyline Works in opposition with ADH d. Eliminate underlying cause

TUMOR LYSIS SYNDROME jcmendiola_Achievers2013

Large number of tumor cells are destroyed rapidly Intracellular contents, potassium and proteins released into the bloodstream MANAGEMENT a. Hydration (3000 mL to 5000 mL) b. Fluids (Sodium bicarbonate) Help uric acid precipitation c. Antiemetic Regimen d. Diuretics (Osmotics) e. Allopurinol Increase excretion of purines f. Sodium polystyrene sulfonate Reduce serum potassium levels g. Dialysis

Palliative Care
Is one response to the inadequacies in the prevention and relief of symptoms and distress in persons approaching death Medical care provided by interdisciplinary team, focused on the relief of suffering and supports for the best possible quality of life for the patients facing serious life-threatening illness and their families The National Consensus Project for Quality Palliative Care (NCPQP) Knowledge and skill in providing physical and emotional comfort for dying patients and their families Essential to providing optimum care to persons with advanced and progressive diseases Hospice care is viewed as part of the palliative care Hospice Care Vision: Patient-centered care provided by an interdisciplinary team that uses the best medical and nursing science to address physical, psychological, emotional and spiritual comfort Principles: Patient-centered, holistic care provided by an interdisciplinary team Team Consists of: o Nurse Care Manager Works directly to clients, family and coordinate care o Physician Makes periodic visits o Anesthesiologist / Pharmacist Pain control and watches drug interactions o Infusion therapist o Social worker o Physical Therapists o Home health aide and volunteers Barriers that interfere with initial and timely referrals Discomfort in discussing end-of-life care issues Difficulty in determining prognoses 6 months or less Lack of information or misinformation about hospice care by patients, family members and health care providers Real or perceived requirement to discontinue life-prolonging therapies in order to receive hospice services

Psychosocial Aspects of Cancer Care

CODES of PROFESSIONAL ETHICS
Autonomy Self-rule respecting the choices of people (Refuse treatment, disclosure of his ailment and prognosis, etc.) Beneficence Doing good, act of kindness and mercy that directly benefit the patient (Patient Bill of Rights) Nonmaleficence Do not harm (Euthanasia, experimental drugs) Justice Treat people fairly, right to demand, to be treated justly, fairly and equally

VALUES in ETHICAL DECISION MAKING Veracity Truth telling

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Fidelity Keeping promises, loyal to their sworn duty Respect for life Life having intrinsic values Respect for Persons Not just their decisions, but their privacy, their identity or physical boundaries Confidentiality Not disclosing patient information to others who do not need to know Respect for Family Relationship Respect for Colleagues

Virtue Ethics in the Moral Character of a Decision Maker

Virtue Ethics o Focused primarily on the heart of a person performing the act o Focuses on the traits and virtues of a good person such as courage, temperance, wisdom and justice Integrity Fairness Compassion Kindness Openness

ETHICAL ISSUES AT THE TIME OF DIAGNOSIS

1. An effective Communicator Nurse must be aware of the knowledge to be communicated Pay close attention to the communication going on between the nurse health care team and the patient and family Good Listener Know when the patient needs more information, time to talk, or a chance to listen to When the patient may feel afraid and or overwhelmed by all that is taking place in the new role of patient Shared Decision Making Requires open and ongoing Communication about all aspects of client care From diagnosis and prognosis Treatment alternatives Effects of illness on the lives of client and families Value of Veracity Truth telling Privacy of Information The nurse must be confident about what he or she shares about patient information and with whom

2.

3.

4. 5.

The Dying Patients Bill of Rights

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. I have the right to be treated as a living human being until I die I have the right to maintain a sense of hopefulness however changing its focus may be I have the right to be cared for by those who can maintain a sense of hopefulness, however changing this might be I have the right to express my feelings and emotions about my approaching death in my own way I have the right to participate in decisions concerning my care I have the right to expect continuing medical and nursing attention even though CURE goals must be changed to COMFORT goals I have the right not to die alone. I have the right to be free from pain I have the right to have my questions answered honestly I have the right not to be deceived I have the right to die in dignity I have the right to have help from and for my family in accepting my death I have the right to discuss to expect that sanctity of the human body will be respected after death I have the right to be cared for by caring, sensitive, knowledgeable people who will attempt to understand my needs and will be able to gain some satisfaction in helping me face death

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