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July 2020

Nursing Implications : Cancer
 Nursing Implications : Cancer 150 150 Tony Guo
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Nursing Implications

  • Bone marrow suppression
    • Myelosuppression: most common side effect of chemotherapy
    • Treatment-induced reductions in RBCs and WBCs can result in
      • Infection
      • Hemorrhage
      • Overwhelming fatigue
  • Fatigue
    • Encourage conservation strategies
      • Rest before activity
      • Get assistance with activity
      • Remain active during periods of time patients feel better
    • Maintain nutritional and hydration status
    • Assess for reversible causes of fatigue
  • Gastrointestinal (GI) effects
    • Prophylactic administration of antiemetics
    • Assess for signs and symptoms of
      • Alkalosis, dehydration, and I and O
    • Nonirritating, low-fiber, high-calorie, high-protein diet
    • Antidiarrheal, antimotility, and antispasmodic medications
    • Anorexia
      • Monitor carefully to avoid weight loss
        • Weigh twice weekly
      • Recommend small, frequent, high-protein, high-calorie meals
      • Involve dietitian before treatment begins
  • Skin reactions
    • Occur in radiation treatment field
    • Acute or chronic
      • Develop 1 to 24 hours after treatment
      • Generally progressive as treatment dose accumulates
    • Dry desquamation
      • Erythema is an acute response followed by dry desquamation.
      • Dry reactions are uncomfortable and result in pruritus. Lubricate the dry skin with a nonirritating lotion emollient (such as aloe vera) that contains no metal, alcohol, perfume, or additives that can be irritating to the skin.
    • Wet desquamation
      • If the rate of cell sloughing is faster than the ability of the new epidermal cells to replace dead cells, a wet desquamation occurs with exposure of the dermis and weeping of serous fluid.
      • Wet reaction must be kept clean and protected from further damage.
      • Wet desquamation of tissues generally produces pain, drainage, and increased risk of infection.
    • Prevent infection
    • Facilitate wound healing
    • Protect irritated skin temperature extremes
    • Avoid constricting garments, harsh chemicals, and deodorants
    • Help patients deal with hair loss (alopecia)
  • Reproductive effects
    • Inform patient of expected sexual side effects
    • Use appropriate shielding
    • Encourage discussion of issues related to reproduction and sexuality
    • Refer to counseling if needed
Infiltrative Emergencies : Cancer
 Infiltrative Emergencies : Cancer 150 150 Tony Guo
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Infiltrative Emergencies
Cardiac Tamponade
  • Fluid accumulation in pericardium.
  • Caused by constriction of pericardium by tumor or pericarditis secondary to radiation therapy to the chest
  • Heavy feeling over chest, shortness of breath, tachycardia, cough, dysphagia, hiccups, hoarseness.
  • Nausea, vomiting, excessive perspiration.
  • Decreased level of consciousness, distant or muted heart sounds.
  • Extreme anxiety.
  • Decrease fluid around heart using (1) surgery to create a pericardial window or an (2) indwelling pericardial catheter.
  • Administer O2 therapy, IV hydration, and vasopressor therapy
Carotid Artery Rupture
  • Invasion of arterial wall by tumor or erosion following surgery or radiation therapy.
  • Occurs most frequently in patients with head and neck cancer
  • Bleeding: ranges from minor oozing to spurting of blood in the case of a “blowout” of artery.
  • Administer IV fluids and blood products.
  • Surgery: ligation of carotid artery above and below rupture site and reduction of local tumor
Metabolic Emergencies : Cancer
 Metabolic Emergencies : Cancer 150 150 Tony Guo
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Metabolic Emergencies
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
  • Tumor cells can produce abnormal or sustained production of antidiuretic hormone (ADH).
  • Many chemotherapy agents may also contribute to ectopic ADH production or potentiate ADH effects
  • Water retention and hyponatremia (hypotonic hyponatremia).
  • Weight gain without edema, weakness, anorexia, nausea, vomiting, personality changes, seizures, oliguria, decrease in reflexes, and coma
  • Treat underlying malignancy.
  • Take measures to correct sodium-water imbalance, including fluid restriction, oral salt tablets or isotonic (0.9%) saline administration, and IV 3% sodium chloride solution (severe cases).
  • Furosemide (Lasix) used in initial phases.
  • Monitor sodium level because correcting SIADH rapidly may result in seizures or death.
Hypercalcemia
  • Occurs in metastatic disease of bone or multiple myeloma, or when a parathyroid hormone–like substance is secreted by cancer cells.
  • Immobility and dehydration can contribute to or exacerbate hypercalcemia.
  • Serum calcium in excess of 12 mg/dL (3 mmol/L) often produces symptoms.
  • Apathy, depression, fatigue, muscle weakness, ECG changes, polyuria and nocturia, anorexia, nausea, and vomiting.
  • High calcium elevations can be life threatening.
  • Chronic hypercalcemia can result in nephrocalcinosis and irreversible renal failure.
  • Treat primary disease.
  • Hydration (3 L/day) and bisphosphonate therapy.
  • Diuretics (particularly loop diuretics) used to prevent heart failure or edema.
  • Infusion of bisphosphonate zoledronate (Zometa) or pamidronate (Aredia)
Tumor Lysis Syndrome (TLS)
  • Metabolic complication characterized by rapid release of intracellular components in response to chemotherapy and radiation therapy (less commonly).
  • Massive cell destruction releases intracellular components (potassium, phosphate, DNA, RNA) that are metabolized to uric acid by liver.
  • Hallmark signs: hyperuricemia, hyperphosphatemia, hyperkalemia, hypocalcemia.
  • Weakness, muscle cramps, diarrhea, nausea, and vomiting.
  • Occurs within first 24 to 48 hr. after initiation of chemotherapy.
  • May persist for about 5 to 7 days.
  • Metabolic abnormalities and concentrated uric acid (which crystallizes in distal tubules of kidneys) can lead to acute kidney injury.
  • Identify patients at risk.
  • Increase urine production using hydration therapy.
  • Decrease uric acid concentrations using allopurinol.
  • Use IV sodium bicarbonate to counter effects of acidic properties that are released
Obstructive Emergencies : Cancer
 Obstructive Emergencies : Cancer 150 150 Tony Guo
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Obstructive Emergencies
Superior Vena Cava Syndrome (SVCS)
  • Results from obstruction of superior vena cava by tumor or thrombosis.
  • Common causes are lung cancer, non-Hodgkin’s lymphoma, and metastatic breast cancer.
  • Presence of central venous catheter and previous mediastinal radiation increase risk of development.
  • Facial edema, periorbital edema.
  • Distention of veins of head, neck, and chest
  • Headache, seizures.
  • Mediastinal mass on chest x-ray.
  • Considered a serious medical problem.
  • Radiation therapy to site of obstruction.
  • Chemotherapy for tumors more sensitive to this therapy.
Spinal Cord Compression
  • Neurologic emergency caused by cancer in epidural space of spinal cord.
  • Common causes are breast, lung, prostate, GI, and renal cancers and melanomas.
  • Lymphomas can also invade epidural space.
  • Intense, localized, and persistent back pain accompanied by vertebral tenderness.
  • Motor weakness, sensory paresthesia and loss.
  • Autonomic dysfunction (e.g., change in bowel or bladder function)
  • Radiation therapy and corticosteroids.
  • Surgical decompressive laminectomy.
  • Activity limitations and pain management.
Third Space Syndrome
  • Shifting of fluid from vascular space to interstitial space.
  • Occurs secondary to extensive surgical procedures, immunotherapy, or septic shock.
  • Signs of hypovolemia: hypotension, tachycardia, low central venous pressure, decreased urine output
  • Fluid, electrolyte, and plasma protein replacement.
  • During recovery hypervolemia can occur, resulting in hypertension, elevated central venous pressure, weight gain, and shortness of breath.
Radiation therapy : Cancer
 Radiation therapy : Cancer 150 150 Tony Guo
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Radiation therapy

  • One of the oldest nonsurgical methods of cancer treatment
  • 50% of all cancer patients will receive radiation therapy at some point in their treatment
  • Radiation is emission of energy from a source and travels through space or some material
  • Different types of ionizing radiation are used to treat cancer
  • Technologic advances
    • Low-energy beams
      • Expend energy quickly
      • Penetrate a short distance
      • Useful for skin lesions
    • High-energy beams
      • Greater depth of penetration
      • Suitable for optimal dosing of internal targets while sparing skin
  • Total doses divided into fractions
  • Typically delivered once a day for 5 days a week for 2 to 8 weeks
    • Standard fractionation
    • Certain tumors are more susceptible to the effects of radiation than others
    • Simulation
      • A process by which radiation treatment fields are defined, filmed, and marked out on skin
      • Radiation oncologist specifies dose and volume of area to be treated
    • Immobilization device
      • The patient is positioned on a simulator, which is a diagnostic x-ray machine that recreates the actions of the linear accelerator and the radiation fields are marked on the patient’s skin.
      • Simulation uses immobilization devices to help the patient maintain a stable position.
      • In this example, a head holder and immobilization mask may be used to ensure accurate positioning for daily treatment of head and neck cancer.
    • Linear accelerator
      • A linear accelerator, which generates ionizing radiation from electricity and can have multiple energies, is the most commonly used machine for delivering external beam radiation.
    • Internal radiation
      • Patient is emitting radioactivity
      • Limit amount of time near patients being treated
        • Organize care
        • Use shielding
        • Wear film badge to monitor exposure
Gerontologic considerations : Catastrophic events in the OR
 Gerontologic considerations : Catastrophic events in the OR 150 150 Tony Guo
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Gerontologic considerations

  • Anesthetic drugs should be carefully titrated
  • Assess for poor communication
  • Risk from tape, electrodes, and warming/cooling blankets
  • Osteoporosis and osteoarthritis
  • Perioperative hypothermia

Catastrophic events in the OR

  • Anaphylactic reactions
    • Manifestation may be masked by anesthesia
    • Vigilance and rapid intervention are essential
    • Symptoms include hypotension, tachycardia, bronchospasm, pulmonary edema
  • Malignant hyperthermia
    • Rare metabolic disorder
    • Hyperthermia with rigidity of skeletal muscles
    • Often occurs with exposure to succinylcholine, especially in conjunction with inhalation agents
    • Usually occurs under general anesthesia but may also occur in recovery
    • Other triggers
      • Trauma
      • Heat
      • Stress
    • Autosomal dominant trait
      • Inherited hypermetabolism of skeletal muscle resulting in altered control of intracellular calcium
    • Tachycardia
    • Tachypnea
    • Hypercarbia
    • Ventricular dysrhythmias
    • Rise in body temperature NOT an early sign
    • Can result in cardiac arrest and death
Anesthesia
 Anesthesia 150 150 Tony Guo
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Anesthesia

  • Anesthetic technique and agents are selected by the ACP that consider
    • Physical and mental status
    • Age
    • Allergy and pain history
    • Expertise of the ACP
    • Factors related to operative procedure
  • Classification of anesthesia
    • General anesthesia
      • Rarely use only one agent
        • Adjuncts
      • Dissociative anesthesia
        • Ketamine (Ketalar)
    • Adjuncts to general anesthesia
      • Opioids
        • Sedation and analgesia
        • Induction and maintenance intraoperatively
        • Pain management postoperatively
        • Respiratory depression
          • Assess respiratory rate and rhythm, monitor pulse oximetry, protect airway in anticipation of vomiting.
          • Use standing orders for antipruritics and antiemetics.
          • Reverse opioid-induced respiratory depression with naloxone (Narcan). If used, reversal of analgesic effects also occurs.
      • Benzodiazepines
        • Premedication for amnesia
        • Induction of anesthesia
        • Monitored anesthesia care
          • Monitor level of consciousness. Assess for respiratory depression, hypotension, and tachycardia.
          • Reverse severe benzodiazepine-induced respiratory depression with lumazenil (Romazicon).
      • Neuromuscular agents
        • Promote skeletal muscle relaxation (paralysis)
          • If intubated, monitor return of muscle strength, level of consciousness, and ventilation.
          • Maintain patent airway. Monitor respiratory rate and rhythm until patient able to cough and return to previous levels of muscle strength. Ensure availability of nondepolarizing reversal agents (e.g., neostigmine [Prostigmin]) and emergency respiratory support equipment.
          • Monitor temperature and levels of muscle strength with temperature changes.
      • Antiemetics
        • Prevent nausea and vomiting associated with anesthesia
          • Monitor heart rhythm, cardiopulmonary status, level of central nervous system excitation or sedation, ability to move limbs, presence of nausea or vomiting
    • Local anesthesia
      • Loss of sensation without loss of consciousness
      • Types
        • Topical
        • Ophthalmic
        • Nebulized
        • Injectable
    • Regional anesthesia
      • Loss of sensation in body region without loss of consciousness when specific nerve or group of nerves is blocked by administration of local anesthetic
      • Always injected
Nursing management : surgical site
 Nursing management : surgical site 150 150 Tony Guo
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Nursing management

  • Admitting patient
    • Reassessment
    • Last-minute questions
    • Review of chart
    • Review labs
    • Final questioning about valuables, prostheses, contacts, last intake of food/fluid
  • Basic aseptic technique
    • Center of sterile field is site of surgical incision
    • Only sterilized items in sterile field
    • Protective equipment
      • Face shields, caps, gloves, aprons, and eyewear
  • Preparing surgical site
    • Scrub or clean around the surgical site with antimicrobial agents
      • Use a circular motion from clean to dirty area
      • Allow to fully dry
    • Hair may be removed with clippers
    • Surgical site is draped
  • Preventing hypothermia
    • Closely monitor temperature
    • Apply warming blankets
    • Warm IV fluids
Surgical team
 Surgical team 150 150 Tony Guo
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Surgical team

  • Perioperative nurse
    • Is a registered nurse (RN)
    • Prepares room with team
    • Serves as patient advocate throughout surgical experience
      • Maintains patient safety, privacy, dignity, confidentiality
      • Communicates with the patient
      • Provides physical care
  • Scrub nurse
    • Follows designated surgical hand asepsis procedure
    • Gowned and gloved in sterile attire
    • Remains in sterile field
  • Circulating nurse
    • Not scrubbed, gowned, or gloved
    • Remains in unsterile field
    • Documents
  • LPN or surgical technician
    • Performs scrubbed or circulating function
    • Passes instruments and implements other technical functions during procedure
    • Supervised by RN
  • Surgeon
    • Physician who performs the procedure
    • Is responsible for
      • Preoperative medical history
      • Physical assessment
      • Patient safety
      • Postoperative management
  • Surgeon’s assistant can be a physician, RN, or PA who functions in assisting role
    • Holds retractors
    • Assists with homeostasis and suturing
    • May perform portions of procedure under direct supervision
  • Registered Nurse First Assistant (RNFA)
    • Must have formal education
    • Works collaboratively with the surgeon, patient, and surgical team
      • Handles tissue
      • Uses instruments
      • Provides exposure to surgical site
      • Assists with homeostasis
      • Performs suturing
  • Anesthesia care provider (ACP)
    • Administers anesthesia
    • Anesthesiologist, nurse anesthetist, or anesthesiologist assistant (AA)
    • Maintenance of physiologic homeostasis throughout intraoperative period
    • Provide care during recovery
Intraoperative care : Physical environment
 Intraoperative care : Physical environment 150 150 Tony Guo
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  • Physical environment
    • Unrestricted areas
      • People in street clothes interact with those in scrubs
        • Holding area
        • Locker room
        • Information areas
          • Nursing station
          • Control desk
    • Semi-restricted areas
      • Peripheral support areas and corridors with only authorized staff
      • Must wear surgical attire and cover all head and facial hair
    • Restricted areas
      • Operating rooms
      • Scrub sink areas
      • Sterile core
      • Surgical attire, head covers, and masks required
    • Holding area
      • Waiting area inside or adjacent to surgical suite
      • Final identification and assessment
      • Friends/family allowed
      • Application of sequential compression devices (SCDs)
      • Minor procedures
    • AOD area
      • Admission, observation, and discharge area
        • Early morning admissions
          • Outpatient surgery
          • Same-day admission
          • Inpatient holding
    • Operating room
      • Geographically, environmentally, and aseptically controlled
      • Restricted inflow and outflow of personnel
      • Preferred location is next to PACU and surgical ICU
      • Filters
      • Controlled airflow
      • Positive air pressure
      • UV lighting
      • No dust-collecting surfaces