MIDTERM STUDY GUIDE

ONCOLOGY / IMMUNE / MUSKO

7/19/2012 – review with Prof Jones areas to focus on

Oncology

1. Educate a person in North America, in regards to common cancer? a. **lung / smoking** smoking is the most common

cause to lung cancer2. Tests that would be done based on s/s :

1. Jilyan still working on this question 3. Foods and how they relate to cancer (page 341)

1. Dietary substances that appear to increase the risk of cancer include fats, alcohol, salt-cured or smoked meats, nitrate-containing foods, red and processed meats

2. Alcohol increases the risk of cancer of the mouth, pharynx, larynx, esophagus, liver, and breast

a. Alcohol intake should be limited to no more than two drinks per day for men, and one drink per day for women

3. Greater consumption of vegetables and fruits is associated with decreased risk of lung, esophageal, stomach, and colorectal cancers

4. High caloric diet is associated with an increased risk of cancer4. What is Primary and secondary interventions and be able to identify examples

of them (PAGE 343) 1. Primary prevention: concerned with reducing the risk of

disease through health promotion strategiesa. Educate patients on known carcinogensb. Encourage patients to make dietary and lifestyle

changes (smoking cessation, decreased caloric intake, increased physical activity

2. Secondary prevention: promote screening and early detection activities such as breast and testicular self exams, and pap smears

a. Identification of patients at high cancer risk b. Cancer screening – including self breast, self testicular,

screening colonoscopy, PAP test)c. Public, patient education

5. Know the various types of surgeries for cancer (pg 346)

1. Sentinel lymph node biopsy (SNLB): minimally invasive, helps lymph node staging in selected cases of melanoma, and breast cancer

2. Biopsy Types: three most common types are excision, incision, and needle methods. The choice is determined by the size and location of the tumor, the type of treatment anticipated, and the need for surgery

a. Excisional: most frequently used for easy accessible tumors of the skin, breast, and upper and lower GI and respiratory tracts

b. Incisional: performed if the tumor mass is too large to be removed for analysis

c. ** excisional and incisional approaches are often performed through endoscopy

d. Needle: performed to sample suspicious masses that are easily accessible, such as growths in the breasts, thyroid, lung, liver, and kidney. Most often performed in outpatient settings. Usually only require local anesthesia. Patient may experience slight and temporary discomfort. Needle biopsy involves aspirating tissue fragments through a neddle guided into an area suspected of being diseased

3. Surgery as the primary treatmenta. The goal is to remove the entire tumor or as much as is

feasible, and any involved surrounding tissue, including regional lymph nodes.

b. Local excision: often performed on outpatient basis, is used when mass is small

i. It includes removal of the mass and a small margin of normal tissue that is easily accessible

c. Wide aka Radical excision: include the removal of the primary tumor, lymph nodes, adjacent involved structures and surrounding tissue that may be at high risk for tumor spread

4. Prophylactic Surgery a. Involves removing nonvital tissues or organs that are at

increased risk to develop cancerb. Factors such as family history, presence or absence of

symptoms, potential risks and benefits, ability to detect cancer at an early state, and the patient's acceptance are what determines if prophylactic surgery will occur

c. Examples include colectomy, mastectomy, and oophorectomy

5. Palliative Surgerya. When cure is not possible, the goal of treatment are to

make the patient as comfortable as possible and to promote quality of life as defined by the patient and his or her family

b. It is performed in attempt to relieve complications of cancer such as ulceration and pain

6. Reconstructive Surgery a. May follow curative or radical surgery in attempt to

improve function or obtain a more desirable cosmetic effect

b. Nurse should recognize the patient's needs and the impact that altered functioning and body image may have on quality of life, allow the patient time to discuss feelings

Nursing Management in Cancer Surgery 1. A thorough pre-op assessment on factors that may

affect the patient undergoing the surgical procedure 2. Provide education and emotional support 3. Encourage the patient and family to take in active role

in the treatment decisions 4. Post-op: monitor for infection, bleeding,

thrombophlebitis, wound dehiscencePost-op teaching: addresses wound care, activity, nutrition, and medication information

6. What are side effects for radiation (page 351 and page 354 chart 16-6)?a. Alopecia (hair loss)b. Desquamation (flaking of skin)c. Stomatitis (inflammation of the oral tissues)d. Xerostomia (dryness of the mouth)e. Change of or lost of tastef. Anorexia, N, V, diarrhea g. Bone marrow suppression

7. What to do if there is a complication of IV is infiltrated? (page 353 and page 355)

a. Extravasation- damage to the soft tissue of they inadvertently leak from the vein

b. immediately stop the infusion- do this firstc. Attempt to aspirate the drug from the site

d. Call the doctor 8. What are common signs and symptoms of chemotherapy (page 356-358)

a. GI system: N, V, b. Hematopoietic system: myelosuppression- bone

marrow suppression, decreased WBC, increased risk of infections and bleeding

c. Renal System: increased urinary excretion of uric acid, hyperkalemia, hypocalcemia, Hematuria, dysuria

d. Reproductive System: possible sterility, temporary or permanent absence of spermatoza

e. Neurologic System: sensory damage to feet and hands (with repeated doses), tingling, pricking or numbness, sensitivity to touch

f. Fatigue 9. What are signs and symptoms of thrombocytopenia? (page 384)

a. This is a decrease in circulating platelet counts b. Platelet count less than 100,000/mmc. Bleedingd. Enlarged spleen

10.What are nursing responsible for teaching with antiplastic drugs?a. Explain that meds affect both normal and malignant

cells, meaning the side effects are often wide spreadb. Explain side effects

11.Know what to teach patient with Bone Marrow transplant? a. Teach Pt they are at high risk for infection, sepsis, and

bleeding

b. Teach Pt they will be on immunosuppressant drugs to prevent GVHD

c. Teach Pt they may require transfusions and hemopoietic growth factors

d. Teach Pt they will be in protective isolation in a private room

e. Teach Pt they may not have fresh flowers or fresh fruit in their room

f. Teach Pt they may have no sick visitorsg. Teach Pt they should practice strict handwashingh. Teach pt s/e of chemoi. Teach pt signs and symptoms of GVHDj. Oral care Q 2 hrs-if receiving numbing gel teach pt not

to bite tongue

k. Teach pt that the most acute s/e such as N/V and mucositis will resolve in the initial 100 days after transplantation

12.Know about infections and what they are caused by (pages 359-360) – Acute or Chronic GVHD due to rejection of donor bone

marrow Engraftment syndrome may occur during the neutrophil

recovery phase of allogeneic and autologous transplants. (pt requires support of blood products and hemopoietic growth factors until engraftment is well established)

VOD (Venous occlusive disease) due to a vascular injury to the liver caused by high dose chemo. May lead to hepatic outflow obstruction, portal hypertension, acute liver failure, and death (in first 30 days or so after BMT)

Potential bacterial, viral, fungal or protozoan infections may occur during first 30 days following transplant due to depressed immune system which include:

Herpes simplex, Epstein-Barr, cytomegalovirus, varicella zoster

Candida yeast infection due to mucosal denudement Fungal infections such as Aspergillus due to pulmonary

toxicities Renal complications due to nephrotoxic chemo agents Tumor lysis syndrome and acute tubular necrosis due to

cancer treatments13.What are some nursing diagnosis for BMT (pages 367-75)?

1. Risk for infection related to inadequate defenses related to myelosuppression secondary to radiation or antineoplastic agents

2. Impaired skin integrity :erythematous and wet desquamation reactions to radiation therapy

3. Impaired oral mucous membrane: stomatitis4. Impaired tissue integrity: alopecia5. Imbalanced nutrition, less than body requirements related to

n/v, anorexia, cachexia, or malabsorption6. Fatigue7. Chronic pain

8. Anticipatory grieving related to loss; altered role functioning9. Disturbed body image and situational low self-esteem related

to changes in appearance, function, and roles14.Know complications of radiation and chemotherapy and what to do (pgs 366-

384)

Infectiono Assess pt for evidence of infectiono Monitor v/s (temp)o Initiate measures for pt who is immunocompromisedo Assess IV sites o Avoid IM injections and urinary catheters if possible

Erythematous (skin impairments)o Avoid soaps, perfumes, cosmetics, lotions, deodorants,

powderso Use only lukewarm water to batheo Avoid rubbing/scratching areao No razorso No adhesive tapeo No exposure to sun/coldo No tight clothingo Apply A and D ointment to area

Wet desquamationo Do not disrupt blisterso Avoid frequent washing of areao Report blisteringo Apply non-adhesive absorbent dressing if weepingo Apply hydrocolliods and hydrogels on noninfected areas

Stomatitiso Salt water (swish and spit)o Numbing gel (do not bit tongue)o Oral care Q 2 hrso Avoid commercial mouthwashes, alcoholic beverages, and

tobacco, spicy foods and those at extreme temp. Alopecia

o Discuss potential hair loss and regrowth with pt and familyo Explore pt self-image, relationships and sexuality o Minimize hair loss o Prevent scalp trauma

o Suggest ways to assist with coping-wigs/hairpieces/scarfs Imbalanced nutrition, malabsorption, cachexia

o Adjust diet before and after drug administrationo Prevent unpleasant sights, odors and sounds in

environmento Use distractions to decrease their anxiety-music therapy

etco Provide prescribed antiemetics, sedatives, corticosteroids

before chemo and afterward as neededo Ensure adequate hydration before and after chemo, and

assess I & Oo Encourage frequent oral hygieneo Provide pain relief measureso Consult dieticiano Smaller, more frequent meals-let pt take their timeo Enourage nutritional supplements and high protein foods

between mealso Provide parenteral nutrition with lipid supplements as

prescribed Fatigue

o Encourage rest periodso Cluster nursing careo Encourage pt to accept helpo Encourage adequate protein and calorie intakeo Assess for fluid and electrolyte imbalances

Infertilityo Provide information about egg/sperm harvesting

Paino Assess paino Administer pain meds o Reassess paino Encourage strategies of pain relief

Anticipatory grievingo Encourage verbal fears, concerns, questionso Explore coping strategieso Encourage active participation in treatmento Provide information about counseling

Situational low self esteemo Assess pts feelings about body image

o Assess potential threats to pts self-esteemo Encourage pt to verbalize concernso Assist pt in self-care when needed

Bleeding o Assess for bleedingo Monitor platelet counto Instruct family on way to minimize bleeding

Septic shocko Monitor for s/s (pg 384)

15.Nursing diagnosis for radiation and chemotherapy (pages 367-75)?1. Risk for infection related to inadequate defenses related to

myelosuppression secondary to radiation or antineoplastic agents

2. Impaired skin integrity :erythematous and wet desquamation reactions to radiation therapy

3. Impaired oral mucous membrane: stomatitis4. Impaired tissue integrity: alopecia5. Imbalanced nutrition, less than body requirements related to

n/v, anorexia, cachexia, or malabsorption6. Fatigue7. Chronic pain8. Anticipatory grieving related to loss; altered role functioning9. Disturbed body image and situational low self-esteem related

to changes in appearance, function, and roles16.What is DIC? (pg 955-58)

1. a condition that may be triggered by sepsis, trauma, cancer, shock, toxins, abruption placentae or allergic reactions

2. diagnosis established by drop in platelet count and increase in PT and aPTT

3. compromised organ function and failure-organs become ischemic from microthrombi

4. coagulation fails5. clinical manifestations-can range from minimal occult internal

bleeding to profuse hemorrhage from all orifices, progressive decrease in platelet

6. most common causes are sepsis and acute promyelocytic leukemia

7. the most important management factor in DIC is treating the underlying cause

8. see chart 33-13 on pg 957 for nursing care

Immune17.Know different things in bone marrow and their part of fighting infection

1. Bone marrow has 2 types of stem cells2. Lymphoid stem cells produce either T or B lymphocytes-these

are the principle cells of the immune system, producing antibodies and identifying other cells and organisms as “foreign”

3. Myeloid stem cells differentiate into:i. RBC (Erythrocytes) –carries hemoglobin to

provide oxygen to tissuesii. WBC(Leukocytes)-protect the body against

infection and tissue injuryiii. PLATELETS(Thrombocytes)-play essential role in

bleeding, they adhere to the site of injury and to each other to form a platelet plug that temporarily stops bleeding

18.What is immunity? 1. The body’s specific protective response to invading foreign

agent or organism

2. Immune system functions as the body’s defense mechanism against invasion and allows a rapid response to foreign substances in a specific manner.

19.What do immunizations allow for / release (type of immunity they produced) (pg 1547)

Acquired immunity usually develops as a result of prior exposure to an antigen through contracting disease or through immunization, both of which generate a protective immune response

Passive acquired immunity is temporary immunity transmitted from a source outside the body that has developed immunity through previous disease or immunization.

20.Be familiar with the following terms - Agglutination; phagocytic; opsonization:

What is Agglutination? a clumping effect that helps clear the body of invading

organisms by facilitating phagocytosis What is phagocytic cells and phagocytic immune response?

Phagocytic cells engulf, ingest, and destroy foreign bodies or toxin

Phagocytic immune response is the immune system’s first line of defense

What is opsonization? the coating of antigen-antibody molecules with a sticky

substance to facilitate phagocytosis21.Know difference between gammaglubulins – what are the different types of

gamma globulins? (page 1550) i. What are immunoglobulins? (pg. 1550)

1. Antibodies are large proteins also called immuloglobulins2. They consist of two sub-units, each containing a light and

heavy peptide chain held together by a chemical link3. One portion serves as a binding site for a specific antigen and

the other portion allows for the antibody to take part in the complement system

ii. What are the different types of gamma-globulins? (pg. 1550, Chart 50-2)

1. IgG (75%)2. IgA (15%)3. IgM (10%)4. IgD (0.2%)5. IgE (0.004%)

iii. What is IgG responsible for? (pg. 1550, Chart 50-2)1. It appears in tissue and serum and assumes a major role in

blood borne and tissue infection2. It activates the complement system3. It enhances phagocytosis4. Can cross the placenta

iv. What is IgA responsible for? (pg. 1550, Chart 50-2)

1. Appears in blood, saliva, tears, breast milk, pulmonary, gastrointestinal, prostate, and vaginal secretions

2. protects against respiratory, GI, and GU infections3. Prevents absorption of food antigens4. Passes to neonate in breast milk for protection

v. What is IgM responsible for? (pg. 1550, Chart 50-2)1. Appears mostly in intravascular serum2. Appears as the first immunoglobulin produced in response to

a bacterial or viral infection3. Activates the complement system

vi. What is IgD responsible for? (pg. 1550, Chart 50-2)1. Appears in small amounts in serum2. Possibly influences B lymphocyte differentiation3. Role is unclear

vii. What is IgE responsible for? (pg. 1550, Chart 50-2)1. Appears in serum2. Takes part in allergic and some hypersensitivity reactions3. Combats parasites

22.Know response when body has a laceration – (Pg 1547 or chapter 6)1. Chemical mediators assist the inflammatory response by

minimizing blood loss2. The invading organism will be walled off to prevent further

damage3. Phagocytes will be activated4. Formation of fibrous scar tissue and regeneration of injured

tissue will beginb. What is the body’s response to a laceration? (pg. 1547)

1. The inflammatory response is the natural immune response to tissue injury or invading organisms

23.Know stages of immune system (all four – be very familiar with them) and explain each of them (1547 – 48)

a. Recognition Stageb. Proliferation Stagec. Response Staged. Effector Stage

2. What occurs during the recognition stage? (pg. 1548)

a. This is the initiating event in all immune responsesb. Lymph nodes throughout the system discharge

lymphocytes into the blood streamc. Lymphocytes patrol the tissues and the vessels that

drain into the surrounding lymph nodesd. Lymphocytes re-circulate into blood, through lymph,

and back into the blood streame. This is a continuous, surveillance circuit

3. What occurs during the proliferation stage? (pg. 1548)a. The lymphocytes that have received an antigenic

message return to the nearest lymph nodeb. The lymphocytes stimulate T and B lymphocytes to

enlarge, divide, and proliferatec. T lymphocytes become cytotoxic T cellsd. B lymphocytes produce and release antibodies

4. What occurs during the response stage? (pg. 1548)a. The differentiated cells will operate in either a humoral

or cellular capacity to fight the potential infection/illness

5. What occurs during the effector stage? (pg. 1548)a. The antibody of the B-cell or the cytotoxic T-cell will

couple with the antigen on the surface of the invaderb. The coupling initiates a series of events that, in most

cases, will result in destruction of the invading microbe or complete neutralization of the toxin

24.Humeral / cellular response – page 1549 (which one responds to what?) 1. Also known as the “antibody response”2. Characterized by the production of antibodies by B

lymphocytes in response to a specific antigen3. B lymphocytes can then transform into plasma cells that will

manufacture antibodiesii. What are antibodies? (pg. 1544)

1. Highly specific proteins which are transported into the bloodstream and attempt to disable invaders

iii. What does the humoral response cause a response to? (pg. 1549, Chart 50-1)

1. Bacterial phagocytosis and lysis2. Anaphylaxis3. Hay fever/asthma4. Immune complex disease5. Bacterial and some viral infections

iv. What does the cellular response cause a response to? 1. Transplant rejection2. Delayed hypersensitivity (TB reaction) 3. Graft-versus host disease4. Tumor surveillance or destruction 5. Intracellular infections6. Viral, fungal and parasitic infections

v. Where are T-cells made and stored? (pg. 1545)1. T-cells are created in the bone marrow and then migrate to

the thymus gland 25.1st cells to arrive at site (PAGE 1547)

Phagocytic cells such as granulocytes and macrophages Neutrophils!

26.Organs that can effect your immune system? (Page 1545-46)1. Bone marrow helps to create the white blood cells involved in

immunity2. The spleen, consisting of red and white pulp, acts like a filter

for old red blood cells and lymphocytes3. Lymph nodes are distributed throughout the body and

remove foreign material from the lymph system; also act as centers for immune cell proliferation

27.Nutrition that is responsible for nutrition status – (page 1555)1. Increase protein intake because a depleted protein reserve

can depress antibody response and decrease circulating number of T cells

2. Maintain adequate vitamin and mineral intake3. Vitamin D deficiency can lead to cancer or autoimmune

deficiency

4. Zinc, copper, manganese, and selenium may have negative effects on the immune system

28.What is the immune response for a patient who is septic? (pg. 328)1. When microorganisms invade the body tissues the immune

system responds by activating biochemical cytokines and mediators associated with an inflammatory response

2. Proinflammatory and anti-inflammatory cytokines released activate the coagulation system, whether or not bleeding is present

29.Humeral response -a. bacteria, infections, pneumonia

Cellular response – b. Organ transplant rejections

30.Define phagocytosis (pg 903)a. Process of cellular ingestion and digestion of foreign bodies

31.Know drug that causes immuno-compromised? (page 1557)1. Adrenal Corticosteroids – ex: Prednisone.2. Antineoplastic agents (Cytoxic agents) - ex: alkylating agents,

cyclophosphamide (Cytoxan), mechlorethamine HCL (mustargen), and cyclosporine.

3. Antimetabolites- ex: fluorouracil (pyrimidine antagonist), methotrexate (folic acid antagonist), mercaptopurine (6-MP) (purine antagonist).

32.Natural immunity, what it does, what cells are involved, what is produced?

1. Is non-specific, provides a broad spectrum of defense and resistance to infection. It is the 1st line of defense following an exposure. The cell involved in this response is monocytes, macrophages, dendritic cells, natural killer’s cells, basophils, eosinophils, and granulocytes