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 cancer 2. 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 cancer 4. 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 strategies a. Educate patients on known carcinogens b. 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 treatment a. 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 cancer b. 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 Surgery a. 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 1 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 dehiscence Post-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 taste f. 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 first c. 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: myelosuppressionbone 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/mm c. Bleeding

d. 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 spread b. 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 visitors g. Teach Pt they should practice strict handwashing h. Teach pt s/e of chemo i. Teach pt signs and symptoms of GVHD j. 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 treatments 13. 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: stomatitis 4. Impaired tissue integrity: alopecia 5. Imbalanced nutrition, less than body requirements related to n/v, anorexia, cachexia, or malabsorption 6. Fatigue 7. Chronic pain

8. Anticipatory grieving related to loss; altered role functioning 9. Disturbed body image and situational low selfesteem related to changes in appearance, function, and roles 14. Know complications of radiation and chemotherapy and what to do (pgs 366-384) Infection o Assess pt for evidence of infection o Monitor v/s (temp) o Initiate measures for pt who is immunocompromised o Assess IV sites o Avoid IM injections and urinary catheters if possible Erythematous (skin impairments) o Avoid soaps, perfumes, cosmetics, lotions, deodorants, powders o Use only lukewarm water to bathe o Avoid rubbing/scratching area o No razors o No adhesive tape o No exposure to sun/cold o No tight clothing o Apply A and D ointment to area Wet desquamation o Do not disrupt blisters o Avoid frequent washing of area o Report blistering o Apply non-adhesive absorbent dressing if weeping o Apply hydrocolliods and hydrogels on noninfected areas Stomatitis o Salt water (swish and spit) o Numbing gel (do not bit tongue) o Oral care Q 2 hrs

o 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 family o Explore pt self-image, relationships and sexuality o Minimize hair loss o Prevent scalp trauma o Suggest ways to assist with copingwigs/hairpieces/scarfs Imbalanced nutrition, malabsorption, cachexia o Adjust diet before and after drug administration o Prevent unpleasant sights, odors and sounds in environment o Use distractions to decrease their anxietymusic therapy etc o Provide prescribed antiemetics, sedatives, corticosteroids before chemo and afterward as needed o Ensure adequate hydration before and after chemo, and assess I & O o Encourage frequent oral hygiene o Provide pain relief measures o Consult dietician o Smaller, more frequent meals-let pt take their time o Enourage nutritional supplements and high protein foods between meals o Provide parenteral nutrition with lipid supplements as prescribed Fatigue o Encourage rest periods o Cluster nursing care o Encourage pt to accept help o Encourage adequate protein and calorie intake o Assess for fluid and electrolyte imbalances Infertility

o Provide information about egg/sperm harvesting Pain o Assess pain o Administer pain meds o Reassess pain o Encourage strategies of pain relief Anticipatory grieving o Encourage verbal fears, concerns, questions o Explore coping strategies o Encourage active participation in treatment o Provide information about counseling Situational low self esteem o Assess pts feelings about body image o Assess potential threats to pts self-esteem o Encourage pt to verbalize concerns o Assist pt in self-care when needed Bleeding o Assess for bleeding o Monitor platelet count o Instruct family on way to minimize bleeding Septic shock o 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: stomatitis 4. Impaired tissue integrity: alopecia 5. Imbalanced nutrition, less than body requirements related to n/v, anorexia, cachexia, or malabsorption 6. Fatigue

7. Chronic pain 8. Anticipatory grieving related to loss; altered role functioning 9. Disturbed body image and situational low selfesteem related to changes in appearance, function, and roles 16. 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 fails 5. 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

Immune 17. Know different things in bone marrow and their part of fighting infection 1. Bone marrow has 2 types of stem cells

2. 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 tissues ii. WBC(Leukocytes)-protect the body against infection and tissue injury iii. 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 bodys specific protective response to invading foreign agent or organism 2. Immune system functions as the bodys 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 systems first line of defense What is opsonization? the coating of antigen-antibody molecules with a sticky substance to facilitate phagocytosis 21. 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 immuloglobulins 2. They consist of two sub-units, each containing a light and heavy peptide chain held together by a chemical link 3. 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 gammaglobulins? (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 502) 1. It appears in tissue and serum and assumes a major role in blood borne and tissue infection 2. It activates the complement system 3. It enhances phagocytosis 4. Can cross the placenta iv. What is IgA responsible for? (pg. 1550, Chart 502) 1. Appears in blood, saliva, tears, breast milk, pulmonary, gastrointestinal, prostate, and vaginal secretions 2. protects against respiratory, GI, and GU infections 3. Prevents absorption of food antigens 4. Passes to neonate in breast milk for protection v. What is IgM responsible for? (pg. 1550, Chart 502) 1. Appears mostly in intravascular serum 2. Appears as the first immunoglobulin produced in response to a bacterial or viral infection 3. Activates the complement system vi. What is IgD responsible for? (pg. 1550, Chart 502) 1. Appears in small amounts in serum 2. Possibly influences B lymphocyte differentiation

3. Role is unclear vii. What is IgE responsible for? (pg. 1550, Chart 502) 1. Appears in serum 2. Takes part in allergic and some hypersensitivity reactions 3. 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 loss 2. The invading organism will be walled off to prevent further damage 3. Phagocytes will be activated 4. Formation of fibrous scar tissue and regeneration of injured tissue will begin b. What is the bodys 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 Stage b. Proliferation Stage c. Response Stage d. Effector Stage 2. What occurs during the recognition stage? (pg. 1548)

a. This is the initiating event in all immune responses b. Lymph nodes throughout the system discharge lymphocytes into the blood stream c. Lymphocytes patrol the tissues and the vessels that drain into the surrounding lymph nodes d. Lymphocytes re-circulate into blood, through lymph, and back into the blood stream e. 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 node b. The lymphocytes stimulate T and B lymphocytes to enlarge, divide, and proliferate c. T lymphocytes become cytotoxic T cells d. 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 Tcell will couple with the antigen on the surface of the invader b. 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 antigen 3. B lymphocytes can then transform into plasma cells that will manufacture antibodies ii. 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 lysis 2. Anaphylaxis 3. Hay fever/asthma 4. Immune complex disease 5. Bacterial and some viral infections iv. What does the cellular response cause a response to? 1. Transplant rejection

2. Delayed hypersensitivity (TB reaction) 3. Graft-versus host disease 4. Tumor surveillance or destruction 5. Intracellular infections 6. 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 immunity 2. The spleen, consisting of red and white pulp, acts like a filter for old red blood cells and lymphocytes 3. 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 intake

3. 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 1 st line of defense following an exposure. The cell involved in this response is monocytes, macrophages, dendritic cells, natural killers cells, basophils, eosinophils, and granulocytes