Download Slide 1 - KeithRN

Bone, Oral Cancer
&
Oncologic
Emergencies
Keith Rischer RN, MA, CEN
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Objectives
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Identify significance of primary vs. metastatic
bone tumors and collaborative care
Identify types of oral cancer, primary prevention
and most common clinical manifestations
Identify clients at risk for oncologic emergencies
Prioritize nursing care needed for clients
experiencing oncologic emergencies
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Malignant Bone Tumors
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Primary vs. metastatic
Osteosarcoma
 Chondrosarcoma
 Patho
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Clinical manifestations
Pathologic bone fx
 Pain, local swelling
 Elevated serum alkaline phosphatase and Ca++
 Life threatening and very painful
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Malignant Bone Tumors
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Interventions
Radiation
 Chemo
 Surgery
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Total joint replacements
Allografts (cadaver)
Nursing priorities
Pain control
 Risk for infection
 Emotional/spiritual support
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Oral Cancer: Squamous Cell
Carcinoma
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Patho
Etiology
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Found on lips, tongue, buccal mucousa, oropharynx
Tobacco/ETOH use
UV exposure
HPV,
poor oral hygiene
Incidence
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2-3% of all cancer
30,000 new cases annually
8000 deaths annually US
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Oral Cancer: Squamous Cell
Carcinoma
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Clinical manifestations
 Unusual lumps/thickening of oral
cavity
 Soreness, pain
 Cervical lymph node enlargement
 Become hardened and fixed
in position
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Diagnosis
 Biopsy
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Medical management
 Surgical
 Trach if large resection postop
 Radiation/chemotherapy
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Nursing priorities
 Airway management
 See chart 57-3 on p.1253
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Oral Cancer Case Study
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58 yr. male with squamos cell CA of mouth &
jaw and radiation osteonecrosis
Admitted 5/19 due to increased pain and inability
to tolerate po
Placed on Dilaudid PCA and transitioned to
Methadone, but Dilaudid kept at 2mg/hr
Became more somnolent and meds adjusted
Morphine, gabapentin, ketamine
 Pain increased as meds decreased
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5/23 episode of choking/gagging w/meals
5/24 developed a fever…started on IV abx
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Oral Cancer Case Study
6/1-emesis w/possible aspiration
 6/2-GT placed
 Pain control difficult due to side effects of
meds making him drowsy w/increased risk
of aspiration due to underlying dysphagia
due to previous surgery, flap & radiation
 Tracheal deviation makes it more difficult
to handle po secretions
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Oncologic Emergencies
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Sepsis
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Septic shock
Syndrome of Inappropriate Anti-diuretic Hormone
(SIADH)
Spinal Cord Compression
Hypercalcemia
Superior Vena Cava Syndrome
Tumor Lysis Syndrome
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Sepis/Septic Shock
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Prevalence
Patho
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Systemic Inflammatory Response Syndrome (SIRS)
Disseminated Intravascular Coagulation (DIC)
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Consumptive coagulopathy
Labs abnormal…
–
–
–
–
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D-dimer
INR
Fibrinogen
platelets
Tx-FFP, platelets, Vit K
Predisposing factors
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Immunosuppression
Chemotherapy/radiation
Malignancy
Age >85
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Elsevier items and derived items © 2006 by Elsevier Inc.
Sepis/Septic Shock
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Clinical
manifestations
VS changes
 CV
 Resp
 Neuro
 Renal
 Integument
 GI
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Sepis/Septic Shock
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Lab values
WBC
 Neutrophils
 Bands
 Lactate
 ABG
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pH 7.22
pCO2: 45
pO2: 74
Bicarb: 12
O2 sats: 90%
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Sepis/Septic Shock
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Nursing priorities
Early recognition!
 IV fluids-.9% NS 2-3 liters
 IV abx
 Arterial/central line
placement
 Vasopressor support
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Dopamine gtt
Epinephrine/norepinephrine
gtts
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Syndrome of Inappropriate Antidiuretic
Hormone (SIADH)
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Patho
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Clinical manifestations
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Seen most common w/lung-brain cancers
Excess water reabsorption/retention…does what to Na+ level???
Seen more in small cell lung CA
Serum sodium
Edema…pitting vs. non-pitting
Early-weakness, fatigue, anorexia, muscle cramps
Late-neuro changes/confusion
Critical if Na+ <110
Collaborative management includes:
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Fluid restriction
Increased sodium intake
Monitor serum sodium
per
MD
Elsevier items
and derived
itemsorders
© 2006 by Elsevier Inc.
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Spinal Cord Compression
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Patho
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Clinical manifestations
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Back pain
Neuro deficits…N-W-T
Collaborative management
includes:
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Early recognition and treatment
High-dose corticosteroids
High-dose radiation
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Done emergently
Surgery
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External back or neck braces to
reduce pressure in the spinal cord
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Elsevier items and derived items © 2006 by Elsevier Inc.
Hypercalcemia
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Patho
Clinical manifestations
 Early
 fatigue, anorexia, N&V, polyuria
 Late
 severe muscle weakness, dehydration
Collaborative management includes:
 Oral hydration/IV hydration w/NS
 Drug therapy
 Steroids, calcitonin
 Dialysis
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Elsevier items and derived items © 2006 by Elsevier Inc.
Superior Vena Cava Syndrome
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Patho
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Clinical manifestations
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Early
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Late
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Edema in arms, hands, SOB,
epistaxis
Can be very dramatic!
Critical
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Edema of face-esp. around eyes
and upper chest
Mentation changes, hypotension
Collaborative nursing care
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Elsevier items and derived items © 2006 by Elsevier Inc.
Tumor Lysis Syndrome
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Patho
Labs…
Collaborative management includes:
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Prevention…is expected and anticipated
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Hydration: 3-5 liters daily…po or IV
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Allopurinol often given before chemo…why???
Anti-emetics
Drug therapy
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Diuretics
Allopurinol
Kayaxelate
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Elsevier items and derived items © 2006 by Elsevier Inc.