Oncologic Nursing

Terms• 1. benign: not malignant, nonrecurrent, favorable for

recovery

• 2. malignant: tending to become progressively worse and to cause death

• 3. remission: improvement or absence of signs of disease

• 4. idiopathic: disease of unknown origin

• 5. carcinoma: cancerous (malignant) tumor

• 6. epithelioma: tumor composed of epithelium (malignant tumor)

• 7. fibroma: (tumor composed of fibrous tissue)

• 8. fibrosarcoma: malignant tumor composed of fibrous tissue

• 9. leiomyoma: (benign) tumor of smooth muscle

• 10. leiomyosarcoma: malignant tumor of smooth muscle

Terms

• 11. lipoma: tumor containing fat (benign tumor)

• 12. liposarcoma: malignant tumor composed of fat

• 13. melanocarcinoma: cancerous (malignant) black tumor

• 14. melanoma: black tumor (primarily on the skin)

• 15. myoma (tumor formed of muscle)

• 16. neoplasm: new growth (of abnormal tissue or tumor)

The Cell

• the structural and functional unit of all known living organisms

• the smallest unit of an organism that is classified as living, and is sometimes called the building block of life

Components

• Cell membrane- separate and protect a cell from its surrounding environment

• Cytoskeleton - acts to organize and maintain the cell's shape

• Genetic material – DNA - for their long-term information

storage– RNA - used for information transport

Cell functions

• Cell growth and metabolism• Creation of new cells• Protein synthesis• Cell movement or motility

Cell Cycle

• Cell Proliferation – process by which the cells divide and reproduce– regulated

• Cell differentiation – transformation of cell into specialized cells

Evolution of Cancer Cells

• all cells constantly change through growth, degeneration, repair and adaptation

• neoplasm refers to both benign and malignant cells

• growth control mechanism of normal cells is not entirely understood

Evolution of Cancer Cells

Characteristics of Malignant Cells

• Differentiation– Mutated stem cells undergone structural

changes hindering them from functioning normally

• Rate of Growth– Have uncontrollable growth/cell division– Tumor growth rate is affected by ↑cell division

& ↑ survival time of cells

• Spread– Lack adhesion and capsule, resulting to spread

to distant body parts

Etiology (Carcinogenesis)

1.Environmental Factorsa. Physical

i.Radiation – x-rays, radium, nuclear explosion/waste, ultraviolet

b.Chemical•Nitrites and food additives, polycyclic hydrocarbons, dyes, alkylating agents, salt-cured, high calorie diet•Drugs: arsenical, stilbestrol, urethane•Cigarette smoke•Hormones – estrogen, hormonal replacement therapy, oral contraceptives

Etiology

2.Genetics a.Some cancers show familial pattern/inherited

genetic defects

3.Viral theorya.Oncoviruses (RNA-type viruses)b.Viruses like:

• Hepa B, C – liver Ca• Herpes simplex II, cytomegalovirus, Human

Papilloma virus-dysplacia and cervix Ca• HIV – Kaposis sarcoma• Helicobacter pylori – gastric Ca• Epstein-Barr virus – Burkitt lymphoma,

nasopharyngeal Ca, non-hodgkin & Hodgkin dse

Etiology

• 4. Immunologic factorsa.Failure of the immune system to respond to

and eradicate cancer cellsb.Immunosuppressed individuals are more

susceptible to cancer

Carcinogenesis

1 Initiation – brought by the diff causative agents

2 Promotion – K-ras (KRAS2) located on chromosome 12, all mammal has cellular oncogenesa.Proto-oncogenesb.Suppressor genes (p53 or TP53)

3 Progression – continue to proliferate and metastasize

Diagnosis of Cancer

• Classification and Staginga.Tissue of Originb.Stages of Tumor Growth

• TNM System• Cytologic Diagnosis of Cancer

Staging and TNM System

• describes the extent or severity of an individual’s cancer based on the extent of the original (primary) tumor and the extent of spread in the body.

• TNM - one of the most commonly used staging systems

• Primary Tumor (T)a.TX Primary tumor cannot be evaluatedb.T0 No evidence of primary tumorc.Tis Carcinoma in situ (early cancer that has

not spread to neighboring tissue)d.T1, T2, T3, T4 Size and/or extent of the

primary tumor

• Regional Lymph Nodes (N)– NX Regional lymph nodes cannot be

evaluated– N0 No regional lymph node involvement (no

cancer found in the lymph nodes)– N1, N2, N3 Involvement of regional lymph

nodes (number and/or extent of spread)

• Distant Metastasis (M)– MX Distant metastasis cannot be evaluated– M0 No distant metastasis (cancer has not

spread to other parts of the body)– M1 Distant metastasis (cancer has spread to

distant parts of the body)

• example:– breast cancer T3 N2 M0– Prostate cancer T2 N0 M0

Grading and Staging of Tumors

• Grading: based on the degree of malignancy, how alike the cells are to the parent tissue or “differentiated”

• Grade 1 – most differentiated

• Grade 4 least differentiated, most malignant

• Staging: general extent of cancer and spread of disease rather than cell appearance

• Stage 1 – No invasion of other tissues, localized

• Stage IV – Metastasized to distant parts

Mechanism of Metastasis

• Lymphatic spread• Hematogenous spread• Angiogenesis

Tumor Development

Early Detection

• 7 warning signs of cancer– Change in bowel/bladder habits– A sore that doesn't heal– Unusual bleeding or discharge– Thickening or lump in breast– Indigestion or dysphagia– Obvious change in wart or mole– Nagging cough / hoarseness of voice

• BSE• Rectal exam for those over age 40• Hazards of smoking• Oral self-exam and annual exam of

mouth/teeth• Hazards of excess sun exposure• Pap smear• Physical exam with lab work:

– 20 – 40 y/o = q 3 years– >40 y/o = annually

Diagnostic Studies

• Laboratory test, Tumor markers• Cytology• Radiologic test• Radioisotopes studies/Radioimmunoconjugates• Ultrasound• Biopsy• Endoscopy• CT-scan, PET scan, PET fusion• Fluoroscopy

Tumor Markers

• Substances produced by the tumor cells, can be measured in urine, blood and tissue sample

Tumor Markers

• Alpha-fetoprotein (AFP) - liver cancer (hepatocellular carcinoma), testicular cancers

• Bladder tumor antigen (BTA) - bladder cancer

• CA 15-3 , CA 27.29- breast cancer• CA 125 - epithelial ovarian cancer (the

most common type of ovarian cancer• Calcitonin- medullary thyroid carcinoma

(MTC)

Tumor Markers

• Carcinoembryonic antigen (CEA)-colorectal cancer

• Estrogen receptors/progesterone receptors-breast cancer

• Human chorionic gonadotropin (HCG)-choriocarcinoma,testicular and ovarian cancers (germ cell tumors)

• Prostate-specific antigen (PSA)-prostate cancer

Health Promotion

• More fresh vegetables• Vitamin A - esophageal, laryngeal, lung

Ca• Vit. C - stomach & esophageal• Weight control- uterus, gall bladder,

breast, colon• High fat - breast & prostate Ca• Smoking• Alcohol- Liver Ca, larynx, esophagus

Health Promotion

• Sun exposure - skin Ca

Treatment

• Surgery• Chemotherapy • Radiation therapy• Biotherapy

Chemotherapy• Antineoplastic agents are used to destroy

tumor cells by interfering with cellular function, including replications

• Principles– Based on the ability of the drug to kill cancer

cells; normal cells may also be damaged. Effect is greatest on the rapidly dividing cells

– Different drugs act on tumor cells in different stages of the cell growth cycle

Stages of Cell Cycle

• G1 phase – Asparaginase, Prednisone

• S phase – Antimetabolites, cytarabine, methotrexate

• G2 phase – Antibiotic(Bleomycin)

• Mitosis – Vinka alkaloids

Antineoplastic Agents

• Alkylating agents – altered DNA structure by misreading DNA code

• carboplatin,cisplatin,oxaliplatin,busulfan,cyclophosphamide,dacarbazine,hexamethyl,melamine,ifosfamide– Non-specific – SE: bone marrow , nausea, vomiting, cystitis,

stomatitis, alopecia, gonadal suppression, renal toxicity (cisplatin)

Nitrosureas

• Similar to the alkylating agents; can cross the blood brain barriers

• LOSE CAR MUSTINE - – LOmustine SEmustine CARmustine

Streptozocin– Non-specific – SE: myelosuppression,

thrombocytopenia;nausea, vomiting

Topoisomerase 1 inhibitors

• Induce breaks in DNA• topoTECAN, irinoTECAN

– S-phase specific– SE:bone marrow suppression, diarrhea,

nausea, vomiting, hepatotoxicity

Antitumor Antibiotics

• Interfere with DNA synthesis by binding DNA; prevent RNA synthesis

• BLEO,DACTINO,MITO,PLICAmycin• DOXO, DAUNO, IDArubicin

– Non-specific – SE: cardiac toxicity (daunorubicin, doxorubicin)

Mitotic Spindle Poison

• PLANT ALKALOIDS– Arrest metaphase by inhibiting spindle

formation; inhibit DNA and protein synthesis– M-phase specific– VINcristine, VINblastine, VINdesine,

VINorelbine– EtoPOSIDE, teniPOSIDE– SE: BM suppression, neuropathies, stomatitis

Mitotic Spindle Poison

• TAXANES– Arrest metaphase by inhibiting tubulin

depolymerization– PACLItaxel, DOCEtaxel

• SE: bradycardia, hypersensitivity rxn, BM suppressio, alopecia, neuropathies

Hormonal agents

• Bind to hormone receptors sites that alter cellular growth e.g. Blocking of ESTROGEN

• Androgens, antiandrogens, estrogens and antiestrogen, progestins and antiprogestines, aromatase inhibitors, lutenizing-hormone-releasing hormones analogues, steroids– Non-specific– SE: hypercalcemia,jaundice,increased

appetite,masculinication,Na&fluid retention, vomiting , hot flashes, vaginal dryness

Miscellaneous Agents

• Unknown • Asparaginase ( Elspar) – for acute

lymphoblastic leukemia (ALL) & mast cells• Procarbazine (Matulane) – Hodgkin's

lymphoma & brain cancers

Side effects of Chemotherapy

• GI– Nausea, vomiting– Diarrhea– Stomatitis

• Hematologic– Thrombocytopenia– Leukopenia– Anemia 5

• Integumentary– Alopecia

Side effects of Chemotherapy

• Renal– Direct damage to kidney by excretion of

metabolites

• Reproductive– Infertility

• Neurologic – Peripheral neuropathies, hearing loss, loss of

deep tendon reflex, paralytic ileus

Administration

• ROUTES:– Topical– Oral– Intravenous– Intramuscular– Subcutaneous– Arterial – Intracavitary– Intrathecal

• Dosage:– Based on the total

body surface

Special Problems• Extravasation

– Vesicants – agents when deposited into the SQ tissue cause necrosis and damage to tendons, nerves, blood vessels

• MYSINE, RUBICIN, VIN, nitrogen MUSTARD

– Carefull selection of VEINS– No blood return, resistance to flow, swelling, pain

redness at the site :STOP immediately• Apply ice unless its VINCA alkaloids

Problems

• Toxicity – GI: N&V

• Meds: ondan, grani, dola, palono SETRON (blocks serotonin receptors)

• Metoclopramide (Reglan, Plasil) – dopaminergic blocker

– Hematopoetic System• Myelosuppression

– Granulocyte colony-stimulating factor (GSF)– Granulocyte-macrophage CSF (GM-CSF)

Problems

• Renals System– Cisplatin, Methotrexate, mitomycin –

Nephrotoxic– Excretion of Uric Acid damage the kidney

• Monitor BUN, crea, serum electrolytes• Adequate hydration, alkalinization of urine,

allupurinol – prevention of these side effects

• Reproductive system – Sterility

• Sperm bank, Use birth control

Problems

• Cardiopulmonary – RUBICIN-cardiotoxicity– Monitor for cardiac ejection fraction, heart failure– Bleomycin, carMUSTINE, busulfan – lung damage– Pulmonary fibrosis – long-term effect

• Neurologic– Taxanes and plant alkaloid – Peripheral neuropathies, loss of deep tendon

reflexes, paralytic ileus, ototoxocity(acoustic nerve damage)

Problems

• Miscellaneous – Fatigue and depression

Nursing diagnosis

• Fear/anxiety– situational crisis– Threat to/change in health/socio-economic

status, role functioning, interaction pattern– Threat of death– Separation from family

• Grieving, anticipatory – Loss of physiologic well being (loss of body

part, change in body function– Perceived potential death

Nursing Diagnosis

• Situational low self-esteem – Biophysical – Psychosocial

• Acute/Chronic Pain– Disease process– Side-effects of therapeutic agents

• Altered nutrition, less than body requirements– Hypermetabolic state, consequences of chemo,

radiation, surgery, emotional distress, fatigue, poor pain control

Nursing Diagnosis

• Risk for fluid volume deficit• Fatigue• Risk for infection• Risk for altered mucous membrane• Risk for skin/tissue integrity• Risk for Constipation/diarrhea• Risk for Altered sexuality patterns• Knowledge deficit

Nursing Management

• Assess fluid & electrolytes• Modify risk for infection & bleeding • Administer chemotherapy • Protect caregivers

Nursing Management – Pt Teaching

• Thrombocytopenia• Use soft toothbrush to avoid bleeding gums• When shaving, use electric razor• Avoid constipation, enemas, rectal temps• Do not use products that contain aspirin, NSAID• Avoid IM or sc injection• Notify MD/RN if petechiae, bruising, frank or tarry

stools, change in color of urine – frank blood, dark amber, bleeding from any part of body such as nosebleed

Nursing Management

• Minimize Side Effects of Nausea and Vomiting

• Serotonin receptor antagonists such as Ondasetron (Zofran)• Granisetron (Kytril)• Dolasetron (Anzemet)

• Avoid offensive odors• Small frequent feedings rather than 3 big meals• Adjust oral and fluid intake• Relaxation exercises, hypnosis, etc.

Nursing Care of Client with Cancer

• Diagnostic Phase– Support– Denial common– Stress signs may

be due to something other than cancer

– Educate on effects of delaying treatment

• Treatment Phase– Varies on type of

cancer– Side effect treatment– Neutropenia

precautions– Nutrition– Activity Intolerance– Pain control– Grieving

• Terminal Phase– Hospice – Grief counseling – for

both patient and family

Special Concerns

• Bleeding• Skin problems• Hair loss • Nutrition• Pain• Fatigue• Psychosocial status• Body image

• Stomatitis• Anorexia• Malabsorption• Cachexia-loss of

body weight, adipose,visceral proteins,and skeletal muscle

Cachexia

Common Cancers (MALE)

• Lung & Bronchus• Prostate• Colon & rectum• Pancreas• Leukemia• Esophagus• Liver & intrahepatic

bile duct

• Non-hodgkin lymphoma

• Urinary bladder• Kidney and renal

pelvis

Common Cancers (FEMALE)

• Lung and Bronchus• Breast• Ovary• Uterine corpus• Multiple myeloma• Brain

Common Cancers

• Kaposi sarcoma• non-Hodgkin lymphoma• Leukemia

– Risk: Very high levels of radiation, Working with certain chemicals, Chemotherapy, Down syndrome, Human T-cell leukemia virus-I, Myelodysplastic syndrome

• Bladder cancer

Breast cancer

• Age: The chance of getting breast cancer goes up as a woman gets older. Most cases of breast cancer occur in women over 60

• Personal history of breast cancer

• Certain breast changes

• Gene changes

• Reproductive and menstrual history

– The older a woman is when she has her first child, the greater her chance of breast cancer.

– Women who had their first menstrual period before age 12 are at an increased risk of breast cancer.

Breast cancer

• menopause after age 55 are at an increased risk of breast cancer.

• No children=increased risk of breast cancer.

• taking menopausal hormone therapy with estrogen plus progestin after menopause also appear to have an increased risk of breast cancer.

• Large, well-designed studies have shown no link between abortion or miscarriage and breast cancer.

• Race: Breast cancer is diagnosed more often in white women than Latina, Asian, or African American women.

• Radiation therapy to the chest

• Older women whose mammograms (breast x-rays) show more dense tissue are at increased risk of breast cancer.

Breast cancer

• Being overweight or obese after menopause

• Lack of physical activity• Drinking alcohol: Studies suggest that the

more alcohol a woman drinks, the greater her risk of breast cancer

Breast cancer: Screening

• Women in their 40s and older should have mammograms every 1 to 2 years.

• Women who are younger than 40 and have risk factors for breast cancer should ask their health care provider whether to have mammograms and how often to have them.

Symptoms• A change in how the breast or nipple feels

– A lump or thickening in or near the breast or in the underarm area

– Nipple tenderness • A change in how the breast or nipple looks

– A change in the size or shape of the breast – A nipple turned inward into the breast – The skin of the breast, areola, or nipple may be

scaly, red, or swollen. It may have ridges or pitting so that it looks like the skin of an orange.

• Nipple discharge (fluid)

Radiation therapy

• ionizing radiation kill cancer cells and shrink tumors

• dose to each site depends on a number of factors

Radiation Therapy• Ionizing radiation destroys cells ability to produce

by damaging its DNA• Cellular sensitivity – varies throughout

cell cycles

• Safety – time of exposure, distance from time of exposure, distance from source, amount of shielding source

• Stay at least 6 feet away when not giving direct

• External – Source is outside body– Beam aimed at specific spot – Marked with marker– Protect area from heat or cold– High protein, high calorie, high fluid intake

(2-3 quarts)

Radiation Therapy

Internal Radiation Therapy

• Internal Radiation Therapy

• Source is placed inside the body

• Sealed or unsealed

• Radiation is emitted

Radiation Therapy

Internal Radiation Therapy • Sealed radiation • Sealed source of radiation – intracavity, interstitial

• Radioisotope cannot circulate thru clients body nor contaminate urine, blood or vomit. Body fluids NOT contaminated

• Clients excretion- not radioactive

• Private room properly labeled Private room properly labeled• No children under 18 or anyone pregnant • Wear film badge

• Prevent dislodgment• Monitor VS every four hours • Accurate I&O– usually have a usually have a foley • Active ROM

Radiation Therapy Unsealed Source Radiation

• Administered intravenously or orally • Used in systemic system

– Colloid suspension into body tissue– Iodine 131 – Graves disease, thyroid cancer– Strontium chloride (Metastron) for bone metastasis

• Radioisotopes do circulate through the body fluids. Sweat, blood, urine, and vomit contains radioactive isotopes

• Body fluids are contaminated– special care special care– Flush at least three times– Disposable equipment– Wear shoe covers, protective equipment– Dosimeter- device used to measure an individual's

exposure to a hazardous environment

Radiation Safety Standards

• Distance – distance &

radiation exposure is inversely related

• Time – 30 minutes per 8

hour shift

• Shielding – lead shield

• Wear film badge or dosimeter – do not share

• Private room & bath

• Shields, lead container, & long-handled forceps in client room

• If source is dislodged – use forceps to

pick up and place in the lead container

• Notify radiation safety officer

Client with Implant• Remember Sealed radiation

– Sealed source of radiation – intracavity, interstitial

– Radioisotope cannot circulate thru clients body nor contaminate urine, blood or vomit

– Body Fluids NOT Contaminated

– Clients excretion- not radioactive

• Implant in abdominal cavity

• Confined to bed

• Indwelling catheter inserted and low fiber diet

• No bowel movement before the device is removed in 2-3 days

Internal Radiation with Unsealed Sources

• Remember that Unsealed Source Radiation is;

– Administered intravenously or orally

– Used in systemic system

– Radioisotopes do circulate through the body fluids. Sweat, blood, urine, and vomit contains radioactive isotopes

– Body fluids are contaminated– special care

Internal Radiation with Unsealed Sources

• Private room and bath

• Precautions on all secretions– Wear gloves if handling body fluids– Emesis after ingesting oral isotope – cover with

absorbent pad and notify radiation safety officer

– Use of disposable utensils– Covering floor areas with chux, papers– Flush toilet at least 3 times after each use

• Limited visitor and staff contact

Nursing Management

• Provide Education

• Skin care within the treatment field– Keep skin dry– Wash with mild soap, rinse well, pat dry– Use cool water, not hot– Do not remove lines or ink marks– Protect skin from exposure to sunlight,

chlorinated swimming pools, extreme temp

• Minimize side effects

Common Biological Therapy

• BCG or Bacillus Calmette-Guérin- treats bladder tumors or bladder cancer.

• IL-2 or Interleukin-2- treats certain types of cancer.• Interferon alpha - treats certain types of cancer.• Rituxan or Rituximab - treats non-Hodgkin's

lymphoma.• Herceptin or Trastuzumab - treats breast cancer.

Biotherapyboost marrow function: the hematopoietic growth factors

“Agents that affect the biological process”

• Colony stimulating factors - granulocyte colony-stimulating factor (G-CSF) and granulocyte-macrophage colony-stimulating factor (GM-CSF) to increase granulocyte production

• Monoclonal antibodies (mAb) are antibodies that are identical because they were produced by one type of immune cell, all clones of a single parent cell

• Erythropoietin – stimulate RBC production

• Neumega – stimulates platelet production

Medical Emergencies

• The bone marrow produces 3 main types of mature blood cells: – platelets– red blood cells – white blood cells.

• Myelosuppression– reduction of bone marrow to produce blood cells.

– any or all of the three main types of blood cells that are normally produced in the bone marrow are decreased in number and/or may take a prolonged period of time to return to "normal levels“

– Patients may be at an increased risk of infection or bleeding or may experience symptoms from anemia.

– myelosuppression is the most common side effect that causes chemotherapy treatment delays or chemotherapy treatment dose reductions

Medical Emergencies- continued

• Neutropenia – decreased WBC • Thrombocytopenia- decreased platelets

• Neutropenia =A reduced white blood cell count– lowers resistance to infection – may cause delay in patient receiving chemotherapy

• Thrombocytopenia (low platelet count) • Platelets - prevent bleeding by causing coagulation• Decreased platelets s/s

– Bruising easily– Nosebleeds– Excessive bleeding from cuts, wounds, gums (brushing

teeth), blood in urine/stool

Medical Emergencies- continued

• Thrombocytopenia

• Platelet count – normal 150,000-400,000mm

• When platelet count is less than 20,000 pt has risk of hemorrhage

• Chemo is withheld until platelets increase to >100,000

HEMATOLOGY

BLOOD• Primary function is to maintain a constant

environment for the other living tissues in the body– Hematology/hematologist

• Liquid Portion - Plasma

• Formed elements– RBC’s– WBC’s– Platelets (thrombocytes)

BLOOD• Human body contains 4-6 liters of blood

– Accounts for 8 % of body weight

PLASMA• Holds the formed elements

– Clear, straw colored liquid• Carries nutrients, electrolyes (salts),

hormones and waste products• Plasma proteins

– Blood clotting factors– Albumin– Globulins

• Antibodies

• Serum – Plasma without blood clotting element -

fibrinogen

HEMATOPOIESIS

RED BLOOD CELLS• Erythropoiesis• Shape-biconcave (resembles a caved-in

disk) • Carry oxygen to the cells

– Hemoglobin: protein– Oxyhemoglobin

• Transport CO2 away from the cells – to the lungs

• Live for about 120 days– Worn out cells are destoyed, mainly by spleen

and liver

Figure 19–4

Recycling RBCs

BLOOD TYPES • 4 Blood types

– A, B, AB, O– Depending on type of proteins (antigens)

located on surface of the RBC’s

• Harmful to transfuse blood from a donor of one blood group into a recipient who has blood from another blood group.– People with type O blood are universal donors– People with type AB are universal recipients– Type and cross – match to determine type

Figure 19–6a

4 Basic Blood Types

Figure 19–6b

Cross-Reaction

LEUKOCYTES (WBCs)• Less numerous than RBCs• Immune response to protect body against

infection– Directly attack foreign matter– Make antibodies

• 5 types in two primary groups– Granulocytes – have a grainy appearance

• Neutrophils• Eosinophils• Basophils

– Agranulocytes• Lymphpocytes• Monocytes

Figure 19–9

Types of WBCs

Neutrophil Action

• Very active, first to attack bacteria• Engulf pathogens• Digest pathogens• Release prostaglandins and

leukotrienes• Form pus

Eosinophil Actions

• Are sensitive to allergens • Control inflammation with enzymes that

counteract inflammatory effects of neutrophils and mast cells

Basophil Actions

• Release histamine:– dilates blood vessels

• Release heparin:– prevents blood clotting

Macrophage Actions

• Engulf large particles and pathogens• Secrete substances that attract immune

system cells and fibroblasts to injured area

Lymphocyte Actions

• Are part of the body’s specific defense system

T cells

• Cell-mediated immunity• Attack foreign cells directly

B cells

• Humoral immunity• Differentiate into plasma cells • Synthesize antibodies

Natural Killer Cells (NK)

• Detect and destroy abnormal tissue cells (cancers)

PLATELETS• Also called thrombocytes• Helps the body to form clots

– Rush to the sight of an injury– Adhere to the blood vessel wall

• Clotting process– Vascular constriction – to stop blood flow– Platelet plug formation– Local blood coagulation– Prothrombin

Platelet Counts

• 150,000 to 500,000 per microliter • Thrombocytopenia:

– abnormally low platelet count

• Thrombocytosis:– abnormally high platelet count

4 Colony-Stimulating Factors (CSFs)

• Hormones that regulate blood cell populations:1. M-CSF:

• stimulates monocyte production

2. G-CSF:• stimulates granulocyte production• neutrophils, eosinophils, and basophils

4 Colony-Stimulating Factors (CSFs)

3. GM-CSF:• stimulates granulocyte and monocyte

production

4. Multi-CSF:• accelerates production of granulocytes,

monocytes, platelets, and RBCs

WELLNESS & ILLNESS• CBC – most common blood test

• Inspection for pallor– Anemia ?

• Checks for enlargement– Liver – hepatomegaly– Spleen – splenomegaly

FETUSES, INFANTS, CHILDREN• RH factor

– Erythroblastosis fetalis– RhoGAM

• InheritedProblems– Sickle cell anemia

– Thalasemia

– Hemophilia

SICKLE CELL ANEMIA • Vaso-Occlusive Crisis

ADULTS/SENIORS• Adults

– Anemias• Iron deficiency• Pernicious (Vitamin B12 deficiency)• Aplastic

– Idiopathic

• IDIOPATHIC THROMBOCYTOPENIC PURPURA

• Seniors– Polycythemia vera

GENERAL TERMS• Ecchymosis

– Blood under skin from trauma• Changes colors, fades away

• Hematoma• Thrombosis

– Thrombus• Clot

– Embolus• Clot that dislodges and travels through

bloodstream

WBC Disorders

• Leukopenia:– abnormally low WBC count

• Leukocytosis:– abnormally high WBC count

• Leukemia:– extremely high WBC count

CANCERS OF HEMATOPOIETIC SYSTEM

• Arise in the bone marrow• Leukemia is the most common

– Proliferation of abnormal WBC’s in blood– Different types– Childhood – about 85% cure rate with chemo

• Lymphomas– Affects tissues of Lymphatic system

• Hodgkin’s• Non-Hodgkin type

• Multiple myeloma– Affects plasma cells

TESTS & PROCEDURES• 3 Major blood tests

– CBC• RBC, WBC, Platelets, Hgb and HCT

– CBC with Diff (differential)• Includes breakdown of WBC’s

– Peripheral blood smear • Size, appearance, abnormally shaped cells

• Others– Bone marrow aspiration/biopsy– Pheresis– Clotting factors

• PT & PTT– Coomb’s test

PHARMACEUTICAL AGENTS• Thrombolytic agents

– Break down clots that have formed• Antithrombolytic agents

– Anticoagulants• Prevent clots from forming• Warfarin, Heparin, Aspirin

• Coagulants– Promote clotting

• Growth factors– Stimulate growth of certain cells

Blood Transfusion

Blood Types

• categorized according to antigens on red blood cells• Type A: A antigens • Type B: B antigens • Type O: no antigens (universal donor)• Type AB: A and B antigens (universal recipient)

• D antigen, third antigen; may be present on the red blood cells

• a. Rh factor positive: D antigen is present• b. Rh factor negative: D antigen is not present

Blood type and crossmatch

• Blood type and Rh factor status crossmatched

Blood transfusion reactions: • Fever and chills within first 15 minutes• hives and itching during or after

transfusion

Hemolytic reaction

• most dangerous: ABO incompatibility• RBCs clump and block capillaries • decreased blood flow to vital organs• Manifestations: lumbar, abdominal and/or

chest pain, fever, chills, urticaria, nausea and vomiting

• Occurs after 100 – 200 ml of incompatible blood infused

Circulatory overloadAir embolusHypocalcemiaHypothermiaGraft-versus-host disease (GVHD)Post-transfusion Purpura (PTP)Iron overload

Blood transfusion

• Assessment of vital signs prior to transfusion

• 2 nurses verify correct client and unit of blood are correctly matched

• Direct observation of client during first 15 minutes of infusion

• Check vital signs according to protocol

Blood transfusion reaction

1. Stop transfusion immediately2. Continue IV infusion with normal saline3. Notify physician of client’s signs and

symptoms 4. Provide care for client as indicated5. Complete reaction form according to

institution protocol. 6. Obtain urine specimen from client and

send for free hemoglobin.

BONE MARROW TRANSPLANTDonor Types

• Autologous - self to self• Syngeneic - from genetically identical twin• Allogeneic:

Matched siblingMatched family memberMatched unrelatedPartially matched and haploidentical

Indications

• High dose chemotherapy (dose - response curve)

• Allogeneic effect (graft-versus- tumour effect)

• Replacement of abnormal stem cells (aplastic anaemia, thalassaemia, sickle cell disease, gene therapy etc)

• Immunological effect (autoimmune disease, ? solid organ transplants)

Common Uses of BMTsAUTOLOGOUS TRANSPLANT

• Multiple myeloma• Non-Hodgkin lymphoma• Hodgkin disease• Acute myeloid leukemia

(AML)

ALLOGENEIC TRANSPLANT

• AML• Non-Hodgkin lymphoma• Hodgkin disease• Acute lymphoblastic leukemia

(ALL)• Chronic myeloid leukemia

(CML)• Chronic Lymphocytic Leukemia

(CLL)• Aplastic Anemia• Myelodysplastic syndromes• Multiple myeloma• Thalassemia major• Sickle cell anemia

RISKS OF BONE MARROW TRANSPLANT

• Short term (TRM) Sepsis, Acute graft-versus-host disease, multi-organ

failure or toxic death

• Longer term Chronic graft-versus-host disease (lung, gut, liver, skin) Relapse Infection Endocrine Ocular

RISKS OF BONE MARROW RISKS OF BONE MARROW TRANSPLANTTRANSPLANT

Short term (TRM)Short term (TRM) Sepsis, VOD, AGVHD, multi-organ failure Sepsis, VOD, AGVHD, multi-organ failure or toxic deathor toxic death

Longer term Longer term Chronic graft-versus-host disease (lung, Chronic graft-versus-host disease (lung, gut, liver, skin)gut, liver, skin)

RelapseRelapse InfectionInfection EndocrineEndocrine OcularOcular

References:

• http://www.cancer.gov/cancertopics/what-is-cancer

• National Cancer Institute

• Brunner & Suddarth's Medical-Surgical Nursing, Smeltzer et al, LWW 2008

• Pathophysiology 7th edition, Port, 2002

• E. Donnall Thomas - Fred Hutchinson Cancer Research Center Seattle, WA, USA