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PPNP 3 > Onco APN talk > Flashcards

Onco APN talk Flashcards

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1
Q

(Superior vena cava syndrome) What is the superior vena cava?

A

Major drainage vessel for venous blood
from the head, neck, upper extremities,
and upper thorax

Located at the middle mediastinum

Surrounded by relatively rigid structures
(sternum, trachea, right bronchus, aorta,
pulmonary artery, and the perihilar and
paratracheal lymph nodes)

Extends from the junction of the right
and left innominate veins to the right
atrium, a distance of 6-8 cm

Thin-walled, low-pressure, vascular
structure

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2
Q

S&S of SVCO

A

Giddiness
Face and neck swollen
Breathless / SOB

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3
Q

Mechanism of Superior vena cava syndrome (2)

A

Extrinsic compression
Intravascular thrombosis

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4
Q

Initial medical management of mediastinal
mass (investigations and disposition) - Condition (Is it a mediastinal mass?)

A

Chest XR > CT scan (contrasted)

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5
Q

Initial medical management of mediastinal
mass (investigations and disposition) - Cause (What is the mass?)

A
  • Tumor markers: AFP, HCG (germ cell tumor)
  • FBC: anemia, thrombocytopenia and leukopenia (Non-HL?)
  • Biopsy! Histology
  • how to biopsy safely? PT/INR/aPTT, FBC (platelet count)
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6
Q

Initial medical management of mediastinal
mass (investigations and disposition) - Complications

What if patient collapses during the procedure?

A

CTVS team onboard, CTICU and HD care

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7
Q

Initial medical management of mediastinal
mass (investigations and disposition) - Complications

What if the SVC collapses?

A

urgent stenting or removal of external compression

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8
Q

Initial medical management of mediastinal
mass (investigations and disposition) - Complications

What if tumor breaks down spontaneously?

A

management of tumor lysis syndrome

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9
Q

Medical management of SVCO

A

Treat the cause of mediastinal mass
* Treat the breast cancer – medical oncologist

Treat the complication of mediastinal mass
* Invasive life support, stenting?

Look out for complications of treatment
* Chemotherapy toxicity: neutropenic fever, nausea and vomiting, central line
sepsis, renal impairment
* Others: fluid overload

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10
Q

Nursing management of SVCO

A

Do not increase SVC return:
* No setting of IV plugs on upper limbs
* No BP measurement on upper limbs
* Nurse patient with head of bed at least 30 degree
* Advocate for central line insertion to administer treatment safely

Fall precaution for neurological changes
* Look out for giddiness, altered mental status in patient

  • Chemotherapy side effects
  • Strict intake output charting
  • Daily weight if indicated
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11
Q

Nursing diagnosis for SVCO (2)

A

Increased risk for fall due to risk for loss of consciousness

Increased risk for airway compromise due to SVCO

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12
Q

(SVCO) Increased risk for fall due to risk for loss of consciousness is EVIDENCED by:

A

Subjective sensation of ”blacking out”

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13
Q

(SVCO) Increased risk for airway
compromise due to SVCO is EVIDENCED by:

A
  • Subjective sensation of SOB
  • Increased face and neck swelling
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14
Q

Nursing diagnosis for SVCO (interventions)

A
  • Educate on position change and height of bed at least 30 degree
  • No BP taking and IV plug insertion on upper limbs
  • Timely carry out medical
    interventions as
    ordered, such as
    administration of
    chemotherapy /
    radiotherapy
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15
Q

(SVCO) Rationale behind nursing interventions

A

Change pt position
Increase ht of bed
Avoid BP taking over upper limbs decrease pooling of blood in SVC and decreases risk of blacking out, amt of facial swelling & SOB

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16
Q

(SVCO) Expected outcomes of Nursing Interventions

A

Patient does not
suffer a fall
- Patient
experiences an
acceptable level
of breathlessness
that does not
affect her ADLs

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17
Q

Presentation of hypercalcemia

A

CNS - Fatigue, confusion, depression
Renal - urination, thirst, renal calculi

Pancreatitis

GIT - Anorexia, nausea, vomiting, constipation, abdominal pain
BONES - Bone pain, fractures

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18
Q

Medical management of hypercalcemia

A

Treat the hypercalcemia
✓ IV Normal Saline 3L/day x 3/7
✓ IV Normal Saline 1.5L/day x 2/7
✓ IV Pamidronate 60mg in 500ml NS over 6 hours
• Investigate the cause of hypercalcemia
✓ CT scan and Xray shows lytic lesion
✓ underlying bone metastasis → treat the cancer with chemotherapy
/radiotherapy
• Investigate complications of hypercalcemia
✓ Bones, stones, groans and psychic moan: Acute delirium, constipation, nausea
and vomiting, pancreatitis,
• Look out for complications of treatments
✓ Hyperhydration – fluid overload
✓ Bisphosphanate and denosumab – hypocalcemia and osteonecrosis of the jaw
✓ Chemotherapy

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19
Q

Treatment of mild and moderate hypercalcemia

A

→ does not require immediate treatment
•Remove factors that aggravate hypercalcemia
•Ensure volume repletion: adequate hydration

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20
Q

Treatment of severe hypercalcemia

A

→ immediate, aggressive treatment!
•Aggressive hydration (initial rate can be 200-300mls/hr) + Frusemide
•Bisphosphanates: Zolendronic acid/pamidronate
•Denosumab: RANKL inhibitor
•Calcitonin: alternative to aggressive NS hydration (e.g CCF, CKD)
•Rapid response within 12-24hrs
•can cause rebound hypercalcemia (tachyphylaxis)

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21
Q

Nursing management of hypercalcemia

A

Targeting at complications of hypercalcemia and treatments
Accurate intake and output
Weigh patient daily
• Daily weight recommended
• Give PRN frusemide based on doctor’s order – watch out for side effects of
frusemide
Clear bowel
Neurological assessment
▪ Look out for confusion
Pain chart
▪ Abdominal pain, bone pain, loin to groin pain
Ensure dental clearance done prior to administration of bisphosphonates (unless
in emergency)

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22
Q

Nursing diagnosis of hypercalcemia (there are 2)

A

Increased risk of fluid overload due to hyperhydration
Constipation due to hypercalcemia

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23
Q

Evidence of increased risk of fluid overload due to hyperhydration (hypercalcemia)

A

Feeling SOB

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24
Q

Evidence of Constipation
due to hypercalcemia

A

Unable
to BO x
5 days
- Patient
has
stomach
pain

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25
(Hypercalcemia) Nursing interventions for Increased risk for fluid overload due to hyperhydration
Daily weight - Strict IO charting - IV frusemide as needed
26
(Hypercalcemia) rationale for nursing interventions (daily wt, IV frusemide, etc) for Increased risk for fluid overload due to hyperhydration
- To detect and manage fluid retention timely
27
Expected outcomes of nursing interventions for Increased risk for fluid overload due to hyperhydration
Patient can tolerate the hyperhydration without complications - Pt calcium level can decrease to acceptable level
28
Nursing interventions for Constipation due to hypercalcemia
Laxatives as needed - Intake and output chart (stool chart) - Per rectal examination (if trained)
29
Rationale for Nursing interventions for Constipation due to hypercalcemia
To monitor the number of days pt has BNO, and relieve constipation timely - Monitor the response after laxatives
30
Expected outcomes for Nursing interventions for Constipation due to hypercalcemia
- Patient has regular BO according to baseline - Patient abdominal pain is well managed
31
Initial medical management of spinal cord compression - condition (how to find out if there is spinal cord compression?)
MRI spine
32
Initial medical management of spinal cord compression - cause (What is the mass?)
- Biopsy! Histology - how to biopsy safely? PT/INR/aPTT, FBC (platelet count) - Tumor markers: myeloma? Mets disease from lung vs breast vs prostate in man? - What is the primary cancer? PET CT
33
Initial medical management of spinal cord compression - complication (Is the spine unstable?)
Surgical fixation?
34
Initial medical management of spinal cord compression - complication (Is it causing pain?)
- Glucocorticoid - RT first? What type of RT? - Chemo-sensitive - Pain management – opioids
35
Initial medical management of spinal cord compression - complication (risk of venous thromboembolism)
– the need for prophylaxis
36
Initial medical management of SCC - Glucocorticoid is considered....
Considered part of the standard treatment, bridge to definitive treatment
37
Initial medical management of SCC - Glucocorticoid dose/s
- High dose: IV dexamethasone 10mg -> PO dexamethasone 16mg daily > taper
38
Initial medical management of SCC - Pain management
Glucocorticoid can usually improve the pain within several hours, but many patients require opioid analgesics
39
Initial medical management of SCC - Venous thromboembolism prophylaxis
Advanced cancer – increased risk for VTE Weakness and immobility – further increase the risk of VTE Prophylactic low molecular weight heparin, clexane (enoxaparin) for e.g.
40
Initial medical management of SCC - Surgical stabilisation
Spinal instrumentation – e.g. pedicle screws, percutaneous cement injection
41
Initial medical management of SCC - Radiotherapy
1. Conventional external beam radiation therapy (cEBRT): for radiosensitive tumors (RT first unless there is spinal instability) 2. Stereotactic body radiation therapy (SBRT): now the preferred approach for low-grade ESCC due to relatively radioresistant tumors. Also for patients with radioresistant high-grade Epidural SCC who has undergone surgical decompression and stabilization
42
Nursing management of SCC
Management of unstable spine * Log rolling Management of urinary retention and constipation * IDC insertion * Use of laxatives * Intake output charting Fall precaution VTE prophylaxis * Calf compressors * Bed exercise
43
Nursing diagnosis for SCC (2x)
Back pain on movement impacting ADL Risk for fall
44
(Spinal cord compression) Back pain on movement impacting ADL is evidenced by:
- Increasing pain score upon movement - Patient verbalized difficulty in completing ADLs
45
(Spinal cord compression) Risk for fall is evidenced by:
- Pt verbalized lower limb weakness
46
(Spinal cord compression) Back pain on movement impacting ADL - nursing interventions are:
- Pain management, such an pre- emptive pain medications before movement and investigations - Timely evaluation of pain medication
47
(Spinal cord compression) Risk for fall - nursing interventions are:
- Fall interventions are instituted correctly based on fall risk assessment - Institute appropriate lower limb exercise
48
(Spinal cord compression) Rationale for nursing interventions for Back pain on movement impacting ADL
- Timely administration of pain medications could improve patient’s tolerance to ADLs - Evaluate timely and escalate to physician for titration of pain medications should pain is still not well tolerable
49
(Spinal cord compression) Rationale for nursing interventions for risk for fall is:
- Fall interventions could effectively reduce patient’s risk for and severity of fall - LL exercise to strengthen the muscles to increase stability when walking
50
(Spinal cord compression) Expected outcomes of nursing interventions for back pain on movement impacting ADLs
- Patient is able to verbalize pain score <3 upon movement - Patient is able to perform ADLs with tolerable pain
51
(Spinal cord compression) Expected outcomes of nursing interventions for risk for fall
- Patient does not sustain a fall during admission
52
S&S of Tumor Lysis Syndrome
Fatigue Muscle cramps Breathless Swollen legs Occassional chest tightness
53
Definition of tumor lysis syndrome
An oncologic emergency caused by massive tumor cell lysis - release of large amounts of potassium, phosphate and nucleic acids into the systemic circulation - hyperkalemia, hyperphosphatemia, secondary hypocalcemia, hyperuricemia, and acute kidney injury
54
(Tumour lysis syndrome) What is nucleic acids breakdown and what does it cause?
- Highly insoluble - Form crystals in the renal distal tubules - Deposition of the crystals > acute kidney injury
55
(Tumour lysis syndrome) What is phosphate and what does high conc of phosphate cause?
- Concentration in malignant cells is 4x higher than in normal cells - Calcium binds with phosphate > calcium phosphate precipitation > hypocalcemia > acute kidney injury and cardiac arrhythmias
56
(Tumour lysis syndrome) What is potassium and what does it cause?
- Highly insoluble - Form crystals in the renal distal tubules - Deposition of the crystals > acute kidney injury
57
there are 2 types of tumor lysis syndrome. what are they?
Spontaneous Treatment-induced
58
What is spontaneous Tumor Lysis Syndrome?
- Happens spontaneously before initiation of treatment - Often without hyperphosphatemia
59
What is treatment-induced Tumor Lysis Syndrome?
- After treatment initiation including steroid
60
Risk factors for Tumor Lysis Syndrome - what are the tumour specific risk factors?
High proliferation rate Chemo/radiosensitivity Haemotological cancer (e.g. lymphoma, leukemia) Large tumour burden
61
(Tumour specific Risk factors for Tumor Lysis Syndrome) What is large tumour burden?
>10cm in diameter WBC count > 50,000/microL Pre-treatment serum LDH > 2 times the upper limit of normal Bone marrow involvement
62
Risk factors for Tumor Lysis Syndrome - what are the patient factors?
Pre-existing hyperuricemia Pre-existing renal disease Oliguria and/or acidic urine Dehydration, volume depletion or inadequate hydration during treatment
63
Medical management of Tumor Lysis Syndrome - overall treatment is to: Treat the ____
Treat the electrolyte abnormalities
64
Medical management of Tumor Lysis Syndrome - Hyperkalaemia
* Serum potassium levels check * Continuous cardiac monitoring * Oral potassium-lowering agents (e.g. sodium polystyrene sulfonate)
65
Medical management of Tumor Lysis Syndrome - Hyperphosphatemia
* Aggressive hydration with concurrent use of diuretics * Phosphate binder therapy (e.g. calcium carbonate)
66
Medical management of Tumor Lysis Syndrome - Hypocalcemia
* If calcium phosphate product is >60mg2/dL2, no calcium should be given until hyperphosphatemia is treated * Calcium replacement given at lowest dose to relieve symptoms
67
Medical management of Tumor Lysis Syndrome - In patients with severe AKI, what should be done?
Renal replacement therapy
68
Medical management of Tumor Lysis Syndrome - What are the lab investigations to be done?
* Electrolytes – K, Ca, PO4, Uric acid * Renal function – creatinine * Cell turnover – LDH
69
Tumor Lysis Syndrome preventive management
Intravenous hydration Hypouricemic agents
70
What are Hypouricemic agents?
* Allopurinol (100mg/m2 every 8 hours in adults) * Rasburicase (Increase in favor for use, especially in high risk patients, 0.2mg/kg OD for up to 5 days)
71
(TLS) Allopurinol works by blocking ____ which catalyses the conversion of ___ to ___
Xanthine oxidase, catalyses the conversion of xanthine to uric acid
72
(TLS) Rasburicase works by mimicking ____ which catalyses the conversion of ___ to ___
Uric oxidase, which catalyses the conversion of uric acid to allantoin
73
Overall, Nursing management of TLS targets:
Targeting at complications of hyperhydration and electrolyte imbalance
74
What is the Nursing management of TLS?
Fluid balance Strict intake output charting Daily weight if indicated Renal dialysis management Furosemide with hyperhydration Maintaining electrolyte balance timely Send off and trace electrolytes Replacement or lowering of electrolytes – e.g. potassium lowering agents Safe administration of rasburicase Checking of G6PD status before administration Send off RP2 and LDH in ice x 72hours post last dose of rasburicase
75
Nursing diagnosis for TLS (2x)
Increased risk for fluid overload Increased risk for electrolyte imbalance
76
(TLS) Increased risk for fluid overload is evidenced by:
- Increased LL swelling - Increased SOB - Chest discomfort
77
(TLS) Increased risk for electrolyte imbalance is evidenced by
- Subjective sensation of cramps - Chest discomfort
78
(TLS) Nursing Intervention for Increased risk for fluid overload
- Daily weight - Strict IO - Frusemide as indicated - Creatinine check timely
79
(TLS) Nursing Intervention for Increased risk for electrolyte imbalance
- Electrolyte check and carry out interventions accordingly - ECG tro myocardiac infarct
80
(TLS) Rationale for Nursing Intervention for Increased risk for fluid overload
- Maintain a net fluid balance through timely interventions
81
(TLS) Rationale for Nursing Intervention for Increased risk for electrolyte imbalance
- Replace and remove electrolytes timely
82
(TLS) Expected outcomes for Nursing Intervention for Increased risk for fluid overload
- Patient is able to maintain a net fluid balance and does not go into fluid overload
83
(TLS) Expected outcomes for Nursing Intervention for Increased risk for electrolyte imbalance
Patient does not suffer from cramps and chest discomfort from electrolyte imbalance
84
(Handling of chemotherapy) IV and SC chemo is not:
* IV and SC chemotherapy – not to be handled by untrained staff
85
(Handling of chemotherapy) what should be worn when handling PO chemo?
* PO chemotherapy – to wear gloves when handling the medicine
86
(Handling of chemotherapy) If need to dilute the medication – e.g. for NG feeding – to approach....?
* If need to dilute the medication – e.g. for NG feeding – to approach SNIC on methods to dissolving it (NCIS has a nursing guide on dilution)

PPNP 3 (19 decks)

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