Final New Material AA Notes

Final New Material Chapters: 15, 33, 14, (Week 7-8, Class 13-15) Lecture Notes ⎯ Book Notes ⎯ Other Oncologic Emergencies • State board loves oncology • When taking care of oncology pt o Chronic phase ⎯ terminal not doing well ▪ Pain management is a big deal ▪ We do not hold the pain meds, give around the clock as schedule ▪ If its schedule q4h make sure you give it every 4 hours ▪ Treat break though pain o Nursing dx ⎯ esp when it comes to chronic/terminal pt state board wants you to recognize ACUTE PAIN o Family support ⎯ big deal ▪ Educate the family o Understand oncology emergencies ▪ At any given time this can occur • Concerns o Metabolic Concerns ▪ Disseminated Intravascular Coagulation (DIC) ⎯ risk for bleeding ⎯ tx w/ FFP or cryoprecipitate ▪ Syndrome of Inappropriate Antidiuretic Hormone (SIADH) • Hyponatremia, weakness, muscle cramps, loss of appetite, fatigue, weight gain, LOC disturbances • Increased urine specific gravity • Fluid restriction ⎯ this pt is on fluid overload • IF SODIUM GETS TOO LOW 3% NS ▪ Septic/Neutropenic Shock* ▪ Tumor Lysis Syndrome (TLS)* • Oncology emergency ▪ Anaphylaxis ▪ Hypercalcemia* o Structural Concerns ▪ Cardiac Tamponade ▪ Spinal Cord Compression (SCI)* ▪ Superior Vena Cava Syndrome (SVC)* ▪ Increased Intracranial Pressure (ICP) • Superior vena cava syndrome (SVC) o Basically take away that it’s a compression that’s normally caused by a tumor, enlarge lymp nodes 2 o Compression or invasion of SVC by tumor, enlarged lymph nodes, thrombus o Typically associated with lung cancer ▪ Breast cancer ▪ Kaposi’s sarcoma ▪ Lymphoma ▪ Mediastinal metastases o May lead to cerebral anoxia, laryngeal edema, bronchial obstruction, death o Clinical manifestations ▪ Impaired venous drainage ▪ SOB/dyspnea ▪ Cough/hoarseness ⎯ laryngeal edema ▪ Chest pain ▪ Edema • Neck, face, arms, hands, thorax • This is important to know • Everything is swelling up, swelling to neck and face → airway problem • Pay attention to where the edema is ⎯ usually in the chest and above • FACIAL EDEMA IS ONE OF THE FIRST SIGNS • Sensation of skin tightness, difficulty swallowing, and stridor • Early S/S generally occur in the AM, edema noted especially around the EYES (periorbital). Also collar of shirts will feel tighter ▪ Distended jugular veins ▪ Dilated thoracic vessels: causes venous patterns on chest wall ▪ Increased ICP • Visual disturbances • Headache • ALOC ⎯ decreased ▪ This is an airway problem ▪ #1 to monitor O2 ⎯ ABC IS A BIG DEAL ▪ C/M seen above closer to the vena cava ▪ This is a venous problem not arterial o High areas for metastasis ⎯ brain, lungs, liver, bone o Diagnostics ▪ Confirmed by clinical findings ▪ Chest x-ray ▪ Thoracic CT ▪ Thoracic MRI o Management ▪ Medical • Radiation therapy o shrink tumor or enlarged lymph nodes and relieve symptoms • Chemotherapy • Anticoagulant/Thrombolytic therapy • Intravascular stents 3 • Surgery • Supportive o 02 ⎯ sometimes this is the best we can do o Corticosteroids o Diuretics ▪ Nursing ⎯ focus on • Identify at risk patients • Monitor for s/s • Avoid upper extremity venipuncture/BP measurement o We need to AVOID this!! o Instruct patient to avoid tight or restrictive clothing and jewelry on fingers, wrist, and neck. ⎯ it will get stuck and impair circulation o Take blood pressure in lower extremities • Proper positioning o Semi-fowlers, high fowlers o Facilitate breathing and drainage from upper portion of body by instructing patient to maintain some elevation of head and upper body with semi-Fowler position; avoid completely supine or prone position (this helps to promote comfort and reduce anxiety associated with dependent and progressive edema). • Monitor fluid status • Monitor for radiation/chemo side-effects o N/V, diarrhea, altered LOC o Palliative radiation → not curative but can shrink the tumor o UNDERSTAND SVCS IS AN ONCOLOGY EMERGENCY INVOLVING THE AIRWAY o DECREASED LOC AND C/O ⎯ assess and correct o MAY NEED TO GIVE SUPPORTIVE CARE, O2, DIURETICS, MAKE SURE YOURE NOT DOING ANYTHING TO THE UPPER EXTREMITIES LIKE PUNCTURES AND BP o HIGH FOWLERS o MONITOR FOR CHEMO/RADIATION S/S ▪ N/V/D, FATIGUE • Tumor Lysis Syndrome ⎯ ONCOLOGIC EMERGENCY o Tumor cells are being destroyed rapidly, bc the tumor cell is being destroyed so rapidly K+ and uric acid are altered → hyperkalemia, hyperphosphatemia o LEADS TO ELECTROLYTE IMBALANCES o Can be fatal o Etiology ▪ Potentially fatal complication 4 ▪ Cell destruction of large or rapidly growing cancers ▪ Leads to electrolyte imbalances ▪ Associated with radiation, chemotherapy ▪ Rapidly induced electrolyte imbalances—hyperkalemia, hyperphosphatemia (leading to hypocalemia), and hyperuricemia o Clinical Manifestations ▪ Neurologic: fatigue, weakness, tetany, seizures, ALOC, memory loss, muscle cramps, paresthesia’s • Remember the change in LOC ▪ Cardiac: Wide QRS, dysrhythmias, cardiac arrest, HTN, shortened QT complex, altered T waves ▪ GI: N/V/D, anorexia, increased bowel sounds ▪ Renal: Oliguria, anuria, renal failure, flank pain, acidic urine pH ▪ Other: Gout, pruritus, malaise ▪ May have dyspnea o Diagnostics ▪ Electrolyte disturbance ⎯ KNOW THIS • Hyperkalemia - > 5 • Hyperuricemia - > 6.8 • Hyperphosphatemia - > 4.5 • Hypocalcemia - < 8.5 o Management ▪ Fluid hydration • We need to gives lots of fluids • Focus on this for tumor lysis • If were saying the pt is hyperkalemia and they can have renal failure we might need to diuresis the pt • To prevent kidney injury and restore electrolyte balance, aggressive fluid hydration is initiated 24–48 hours before and after the initiation of cytotoxic therapy to increase urine volume and eliminate uric acid and electrolytes ▪ Alkalinize urine: add sodium bicarbonate to IVF • Urine is alkalinized by adding sodium bicarbonate to IV fluid to maintain a urine pH of 7–7.5 ▪ Diuresis: Loop/osmotic diuretic ▪ Allopurinol therapy (inhibits conversion of nucleic acids to uric acid) ⎯ KNOW THIS ▪ Kayexalate for hyperkalemia → PO, remember this is a binder that removes potassium • Remember when we see hypekalemia we need to think CARDIAC INVOLVEMENT • KNOW HOW TO TREAT HYPER/HYPOKALEMIA • Cation-exchange resin • Eliminates K+ through the bowe