5/18/2015

Myelosuppression

• The most common cause of treatment Symptom Management delays and dose reduction for patients undergoing cancer treatment. • Hematopoiesis: the process when WBCs, RBCs and platelets are produced from pluripotent stem cells. • Stem cells are largely found in the bone marrow.

Myelosuppressive Potential of

Chemothapy Agents • Time of effect is 10-14 days • Mild: altretamine, bleomycin, cladribine, dacarbazine, 5-fluorouracil, mitomycin C, pentostatin, plicamycin, • Nadir is the time period of predicable count streptozocin, vincristine,vinorelbine suppression. • Moderate: amsacrine, chlorambucil,cisplatin, • Blood counts generally recover in 2-3 weeks. cyclophosphamide, etoposide, fludarabine, • Disease can also cause myelosuppression. gemcitabine, idarubicin, ifosfamide, mechlorethamine, melphalan, 6-mercaptopurine, Leukemia or solid tumors that invade the methotrexate, mitoxantrone, procarbazine, 6- bone marrow. thioguanine • Increased risks: prior chemo, the elderly, poor • Severe: busulfan, carboplatin, carmustine, nutritional status, renal of hepatic dysfunction cytarabine, dactinomycin, daunorubicin, hydroxyuria, or patients with effusions. lomustine, paclitaxel, docetaxel, vinblastine

Grading Leukopenia and Neutropenia

• These patients are at risk of developing infection – the most GRADE 1 2 3 4 common cause of morbidity and mortality in cancer patients. • Neutrophils move to site of infection and phagocytize oranisms, have short life spans, WBCs LLN to <3000- <2000- <1000 • Infections can occur from sources of outside of the body as well 3000 2000 1000 the body’s natural flora. • The most common organisms are gram-positive (E.coli, ANC LLN- <1500- <1000- <500 Pseudomonas aeruginosa, Klebsiella pneumoniae) • Patients with extended periods of neutropenia are treated with 1500 1000 500 broad spectrum antibiotics causing risk of fungal infections. (Candida or Aspergillus) RBCs LLN-10 <10-8 <8-6.5 <6.5 • Viral infection can also occur. (HSVs, influenza)

Platelets LLN- <75,000 <50,000 <25,000 75,000 -50,000 -25,000

1 5/18/2015

management

• Nursing assessments • The single most important intervention is • Usual signs and symptoms of infection are frequent and thorough hand washing by all diminished or absent. Fever of 100.5 is often those that come in contact with the patient. the only sign. Patients may not seem very • Avoid crowds, people with colds or flu, and sick. children who have beed recently vaccinated. • Pay attention to subtle changes in mental and • Instruct on meticulous oral hygiene, bathe functional status. daily, avoid sharing anything that may harbor • Assess oral cavity, sinuses, lungs, skin folds, germs (dishes, silverware, towels). puncture sites (IV,BMBx) and rectum. • Neutropenic diet. • Pain may be the only indicator of infection. • Stay out of the dirt.

Anemia

• Mortality rate from febrile neutropenia can be as high • Erythrocytes (RBCs) as 70% if antibiotics are not administered within the • Life span is up to 3 months. first 48 hours of a febrile episode. • Carry oxygen to body tissue. • Cultures are obtained (blood, urine, suspected sites • Compensatory mechanisms (increased heart rate, of infection). shunting of blood to vital organs. • Imagining studies (CXR) obtained. • Symptoms: fatigue, dyspnea, chest pain, weakness, • Broad-spectrum antibiotics are started. palpitations, syncopy, headache, decreased • Colony stimulating factors (filgastrim, pegfilgrastim). cognition, pallor. • Filgrastim dosed at 5mcg/kg/day. Subq. Should not • Cancer patients often experience a “functional iron be started started within 24 hours after deficiency” have sufficient iron stores in the bone chemotherapy. Pegfilgrastim is a long acting G-CSF marrow but low serum levels.

management

• The definition of clinically significant anemia • Transfusion: if symptomatic, chest pain is being reexamined. • Lower grades of anemia is expected as in patients with cardiac or pulmonary sequela of cancer and cancer treatment and disease is significant. Symptoms are treat only severe anemia. (<8 or symptomatic greater with rapid blood loss. anemia) • Assessment: assess lab,history of cardiac or • Erythropoietin: colony-stimulating pulmonary disease, ask about symptoms, but factors (epoetin alfa and darbepoetin also consider other causes-bleeding, hemolylsis, nutritional deficiencies, alfa) medications, anemia of chronic disease.

2 5/18/2015

Thrombocytopenia

• Platelets • Assessment: review lab, assess for S&S of • are a vital part of hemostasis by sticking to bleeding(bruises, petechiae, epistaxis, oozing blood vessel walls at the site of injury or leak from the gums, prolonged and/or heavy and forming a plug. Also, assist with the menses, melana, coffee ground conversion of fibrinogen to fibrin in formation emesis,hematuria) of blood clots. • Observe puncture sites or cuts. • Have a life span of 5-10 days, • Signs of intracranial bleed (headaches, • Thrombocytopenia is a circulating platelet blurred vision, disorientation, changes in count of <100,000 mental status, changes in pupil size and reactivity to light).

management Management cont.

• Bleeding precautions • Transfusions for patients who are actively bleeding, prophylactic transfusions prior to • Teach avoiding falls, contact sports, use stool invasive procedures or to reduce the risk of softners, avoid suppositories and enemas, bleeding when the platelet count falls below a use a soft tooth brush, avoid dental floss, no predefined level. (typically <10) using scissors, razors or blades for grooming. • Consider transfusion in patients with fever • Platelet resistance (development of anti- • Educate on use of anticoagulants, aspirin- platelet antibodies) use single donor platelets containing drugs and NSIDS. Use water- • Thrombopoietic growth factor: Oprelvekin based lubricants during sexual intercourse (Neumega) not widely used, costly with little and abstinence with platelet count <50. effect.

Cancer Pain

Myelosuppression has a psychosocial • Approximately 30%-50% patient effect on patient’s lives. undergoing active treatment for solid Waiting for a fever or infection fear of tumors and 70%-90% of those with bleeding. advanced caner experience chronic pain. • Pain does not predictably correlate with tissue injury thus the patient’s self report is the single most reliable indicator.

3 5/18/2015

Cancer Pain Types

• Nociceptive pain originates from bone, joint, • Chronic: pain that is persists or recurs muscle, skin, connective tissue or frequently. • Acute: pain occurs intermittently and has an viscera/organs (liver, pancreas,or intestine) anticipated end. Usually described as aching or throbbing. • Breakthrough: acute pain that occurs despite • Neuropathic pain originates from either the the use of ongoing analgesics. central or the peripheral nervous system. • Pain syndromes, 75% of chronic pain Usually described as burning, tingling or syndromes are caused by the tumor itself, the remaining are associated with treatment electric shock-like pain. (phantom limb pain or toxicities or other comorbiity. neruopathy)

Cancer Treatment Pain Tumor Related Pain Syndromes Syndromes • Acute syndromes: pathological fractures, bleeding • Radiation Therapy: oropharyngeal mucositis into the tumor, superficial wounds or abscesses, or esophagitis, enteritis, procitis, brachial headaches. plexopathy after breast irradiation, skin • Chronic syndromes: rostral retroperitoneal syndrome, reaction/irritation, bone pain after malignant pelvi and perineal pain, peripheral radiopharmaceuticals mononeuropathies, polyneuropathies, plexopathy, • Chemo, Hormonal or Immunotherapy: radiculopathy, epidural spinal cord compression, oropharyngeal mucositis or esophagitis, IV phantom pain after amputation, tumor invasion into line placement, peripheral neuropathy, bone joints and soft tissue, hypertrophic osteoarthropathy, pain, myalgias and arthralgias, 5-FU induced bowel, ureter, or bladder obstruction and hepatic chest pain, infection and pain from bleeding distention and bruising.

Assessment Challenges to Assessment

• Severity scales (numeric or picture). Assess • Health care professionals do not know more about the patient’s pain than the patient! before treating, after and on-going. • Opioid-associated phenomena: • Question: Where does it hurt? When? does it • Addiction: a psychological dependence, compulsive drug use start? Is it worse at certain times of the day? for purposes other than pain. Patient who take opioid meds for pain, regardless of dose are not addicted. What makes it better or worse? Have you • Physical dependence: physiologic adaptation of the body to tried anything in particular to relieve the pain? opiods. Withdrawal symptoms occure if dc’d abruptly. How do others know you are having pain? • Tolerance: A decrease in one or more of opioid effects. How does it affect your ability to do normal (sedation, respiratory depression and analgia) • Important: Less than 1% of patients who take opioids for pain activities? How does it make you feel? What become addicted. concerns do you have about taking pain medications?

4 5/18/2015

Challenges cont. Pharmacologic Therapy

• Cognitively impaired or unconscious patients. • NSAIDS or acetaminophen The nurse must watch for nonverbal • Opioid Analgesics indicators of pain (facial espression, restlessness, moaning, crying) • Adjuvant analgesics • Various ethnic groups express pain in differently. In addition to using assessment tools we must work closely with the patient and their families.

Nonsteroidal Anti-Inflammatory NSADS use and action Drugs • Used to treat mild pain caused by • Examples of NSAIDS: Aspirin, inflammation. ibuprofen, ketoprofen, naproxen, • Inhibits cyclooxygenase, an enzyme celecoxib, choline magnesium, that catalyzes conversion of arachidonic indomethacin, trisalicylate, roficoxib acid to prostaglandin. Prostaglandins sensitize nerve receptors, resulting in pain.

NSAIDS Side Effects Acetaminophen

• Heartburn, nausea, diarrhea, • Use: Has minimal anti-inflammatory constipation, flatulence, epigastric effects but can decrease pain from and/or abdominal pain. Long-term use inflammation. can lead to renal and hepatic toxicity, • Side effects: Liver toxicity. Caution use bleeding and gastric ulceration. with patients with liver disease or • Concurrent use with alcohol or steroids combined with alcohol intake. Doses should be avoided. that exceed 4000mg/day can result in liver and kidney damage.

5 5/18/2015

Opioids Opioid Action

• Examples: codeine, • Relieves pain by binding to opioid receptors, hydromorphone,levorphanol, blocking substance P. Substance P, when methadone, morphine, oxycodone, released by damaged cells, sensitizes nerve receptors. meperidine, fentanyl, • No ceiling dose except when using • Used to treat moderate to severe pain meperidine. High doses or long-term use when NSAIDS/acetaminophen are causes toxic metabolite accumulation, leaking contraindicated. to dysphoria, agitation and seizures.

Opioid side effects

• Constipation, sedation, nausea, • Pain control is best achieved and analgesic doses lower when pain is anticipated and pruritus, urinary retention, myoclonus, prevented (prior to painful procedures, pain biliary spasm, respiratory depression. rounds). • Around the clock dosing works best for patients with persistent, daily pain (continuous release oral agents, transdermal agents, IV or subq continuous infusions. • Break through pain is best treated with immediate release analgesics

Adjuvant Drugs Anti-depressants

• Used to enhance analgesic effect of opioids, • Ex. Amitriptyline, Nortriptyline, Desipramine to treat specific pain types (neuropathic) or to • Use: Help to control tingling or burning from treat other symptoms that make pain worse. nerve injury caused by cancer or cancer Examples: chemotherapy (secondary effect by treatment. Also, used to treat depression shrinking tumor), anti-depressants, anti- • Side effects: dry mouth, sleepiness, histamines, antianxiety drugs, amphetamines, contipation, orthostatic hypotension, blurred anti-convulsants, steroids, bisphosphonates. vision, urinary retention. Patients with heart disease may have arrhythmias.

6 5/18/2015

Anti-histamines Anti-anxiety drugs

• Examples: Hydroxyzine, • Examples: Diazepam, Lorazepam Diphenhydrmine • Use: Treats muscle spasms that • Use: Helps to control nausea, insomnia accompany severe pain. and pruritus. • Side Effects: May cause urinary • Side Effects: drowsiness incontinence, sedation.

Amphetamines Anti-convulsants

• Examples: Caffeine, • Examples: carbamazepine, dextroamphetamine, methylphenidate clonazepam,gabapentin, phenytoin • Use: Enhance effectiveness and • Use:Helps control tingling or burning decrease drowiness of opioids. from nerve damage caused by cancer or cancer therapy. • Side effects:Irritability, tachycardia, • Side effects: Liver toxicity, bone marrow decreased appetite. suppression. Gabapentin may cause sedation and dizziness.

Steroids Bisphosphonates

• Examples: dexamethasone, prednisone • Examples: Pamidronate, Etidronate, • Use: releaves pain caused by bone Zoledronic acid. mets, spinal cord an brain tumor • Use: to decrease pain from bone (decreases swelling, inflammation) metastasis. • Side Effects: Edema, hyperglycemia, • Side effects: flu-like symptoms, renal stomach irritation, rarely confusion, toxicity, injection site erythema, altered behavior and sleeplessness. electrolyte abnormalities.

7 5/18/2015

Radiopharmaceuticals Invasive procedures

• Examples: strontium 89, samarium 153 • Radiation • Use: Are given systemically and are • Nerve blocks. absorbed in area of high bone regeneration. Can be delivered to many painful bone metastases all at once. • Side effects: may cause bone marrow suppression.

Gastrointestinal Symptoms

• Disruption of the GI system • Assessment includes oral inspection for • Mucositis and stomatitis describe oral mouth sores, redness, thrush, tooth decay, dental hygiene, gum disease, halitosis. cavity breakdown. • Ask about difficulty swallowing, dry • Esophagitis is disruption or infection of membranes, blood in saliva or gums. the esophagus. Heartburn, indigestion, pain in chest area, • Enteritis delineates erosion of the lining painful swallowing, hiccups, abdominal of the intestines. distension, nausea/vomiting, constipation, diarrhea, blood in stool.

Causes/risk factors Role of the Nurse

• Chemotherapy, radiation, direct tumor • Focus on infection prevention, comfort and invasion of the tissue. nutrition maintenance. • Antibiotics, compromised immunity, • Promote proper oral hygiene (high risk pts. decreased platelets, all lead to breakdown. should use saline rinses QID, use soft tooth • Risk factors include smoking, drinking brush BID and floss unless platelet are low. alcohol, antimetabolites (5-FU, MTX,Ara-C) • Treat pain with topical analgesia, IV poorly fitting dentures, poor dental health, Hx medications. of HSV, yeast, candida or any oral infection. • Encourage liquid supplements to promote Steroids and AIDS. adequate nutrition.

8 5/18/2015

Nausea and Vomiting

• Vagal and sypathetic afferents that originate in the GI tract • Causes serious complications, dehydration, trigger the VC when gastric emptying is delayed. eletrolyte imbalances, esophageal bleeding • Afferents in the midbrain respond to intracrainal pressure but and tears when prolonged, also can be a learned response (anticipatory nausea). • The vestibular system can trigger the VC through inner ear • The vomiting center is located in the brain disturbances (motion sickness but some chemotherapy agents near the brain stem, near centers that cause this experience. • The chemotherapy trigger zone is also located in the brain. It is regulate salivation and vasomotor response. stimulated by toxins in the blood (actually neurotoxins that are released when chemotherapy drugs are present in the blood Explains why salivation, respiration and heart stream. rate all increase with nausea. • The neurotransmitters involved are serotonin, dopamine, histamine, prostaglandins, and gamma-aminobutyric acid. • The center receives stimulation through several different pathways.

Emetogenic potential of common Role of the nurse chemo drugs • Very high: cisplatin, dacarbazine, mechlorethamine, • Encourage patients to take scheduled melphalan (high dose) streptozocin, cytarabine (high dose). antiemetics and use prns before meals. • High: carmustine, cyclophosphamide, procarabazine, • Remove tray tops before entering the etoposide (high dose), semustine lomustine, dactinomycin, picamycin, methotrexate (high dose) room, teach to avoid the kitchen during • Moderate: doxorubicin, mitoxantron C, topotecan, 5- meal preparation. Offer cool foods or fluorouracil, irinotecan, mitomycin C, ifosfamide, curboplatin, paclitaxel, daunorubicin, L-asparaginase, chilled supplements. hexamethylnelanine,

Treatment drugs Xerostoma

• Ondanseteron, granisetron, dolasetron mesylate • Dry mouth, most common cause is salivary gland (serotonin, 5-HT recepto blocker) failure due to radiation damage, antihistamines, • Dexamethasone (inhibits prostaglandin) opioids. • Diphenhydramine, promethazine (inhibits histamine) • Causes discomfort but also may lead to difficultly • Dronabino (depresses CNS) eating and swallowing. • Droperidol, haloperidol, perphenazine, • Teach to use hard candies to moisten mouth and prochlorperazine (inhibits dopamine) stimulate salivary gland production. Carry a water • Metoclopramide (blocks dopamine, also stimulates bottle for frequent sipping. Use nonalcoholic the upper GI motility to increase gastric emptying). mouthwash, artificial saliva before meals, moisturizer • Scopolamine (blocks cholinergic impulsed-motion on lips. Use gravies and sauces on foods to aid in sickness) chewing and swallowing, • Lorazepam (depresses CNS)

9 5/18/2015

Halitosis Constipation

• Bad breath, may be caused by disease • Causes: dehydration, opioids, that in in the oral cavity, xerostoma, oral medications, hypocalcemia infections and poor oral hygiene. • Role of the nurse: Obtain patient history, bowel history, Identify the cause, offer laxatives, encourage fluids.

Fatigue

• Often the most persistent and • Is fatigue related to recurrence or progression of disease? distressing symptom. • What is the treatment regimen? • Decreases QOL by reducing the • What medications is the patient taking? Include over the counter, herbal remedies patient’s ability to function during • Are there comorbidities (CHF, chronic lung failure, treatment and beyond. sepsis, endocrine dysfunction) • What are the onset, duration and pattern of fatigue, • Assessment tool may be numeric or as well as aggravating and alleviating factors? picture. • What extent does fatigue interfere with ability to function in usual activities.

Cognitive Impairment

• “Chemo-brain” • Medications that may cause fatigue: • May be result from cancer (primary brain cancer or mets) or from treatment. beta-blockers, opioids, antidepressants, • May be subtle or dramatic, temporary or permanent, stable or antiolytics, antihistamines and progressive. • Risk factors: advancing age, history of neurologic or psychiatric antiemetics. May need dose illness, substance abuse, prior cancer treatment. • Treatment includes restorative interventions, (use personalized adjustments. relaxation techniques-walking in nature, tending garden, observing wildlife) to restore the ability to focus and maintain • Treatment therapies include: exercise, attention. Compensatory stategies to help organize information, maintain attention and encode information for future recall. attention and energy conservation.

10 5/18/2015

Dyspnea Causes

• Disease: primary lung cancer and mets, obesity, • Shortness of breath, difficulty breathing, COPD, anemia, anxiety, cachexia, and CHF, breathlessness or tight throat. • Therapy-induced: surgical thoracotomy radiation fibrosis, chemo related pulmonary and cardiac • Often underdiagnosed and poorly toxicities (adria, bleo) • Assess in time and/or relationship to activity and managed, has no reliable objective impact on QOL. measure. • Symptom that can causes the greatest distress for the caregiver. • Gold standard for assessment is patient • Perceived as a greater stressor in men than women reporting. but has a reported greater impact on functional performance in women than men.

Treatment Anorexia and Weight Loss

• Reduce ventilatory impedance (Smoking • Often the first symptom of cancer cessation, use metered dose inhalers, • Multi causes (direct result of tumor effects, corticosteroid meds, manage pleural effusion, cancer treatment side effects, complex brachytherapy radiation with bronch,). systemic effects) • Reduce ventilatory demand (sit in forward • Direct tumor effects (tumors that effect leaning position, elevate head during sleep). nutritional intake,effect digestion, absorption • Improving respiratory muscle function and metabolism). (respiratory exercises against resistance by • Treatment effects (medication causing using a hand held device). constipation, nausea/vomiting,) • Pulmonary rehab.

Complementary & Alternative Therapies (CAMs) • Complementary therapies have been scientifically tested but • Nutritional needs are increased during there is not a lot of evidence to support many of these. • May be referred to as supportive care. cancer treatment due to cellular repair • Alternative therapies are used in place of conventional and healing. treatment. (unproven, often advertised to cure cancer). • Patients often pursue because of fear of side effects from • Dietary referral. conventional treatment, traditional or cultural practice and cost. • Holistic approach refers to modalities that integrate the body- • Encourage calorie rich, protein dense mind-emotion-spirit environment of a person. diet, offer supplement. • Promote several small meals a day.

11 5/18/2015

• Herbs: alfalfa, aloe vera, astragalus • Vitamins and dietary supplements: root, black cohosh, capsicum, chondrotin, coenzyme q10, fish oil, chamomile, cranberry, dandelion, glucosamine, vit. C, vit. E, echinacea, ephedra, evening primrose, • Vitamin and mineral usage during feverfew, garlic, ginger, gingko, treatment is controversal. goldenseal, hawthorn, hop, kava kava, • Nurse must obtain complete list, licorice, passionflower, red clover, St. investigate side effects, precautions and John’s wort medication interactions.

Healing with physical power: chiropractic • Healing with subtle energy: therapy, massage therapy, Qigong and acupressure, acupuncture, Tai Chi, reflexology, rolfing (deep tissue aromatherapy, color therapy, feng shui, manipulation), yoga. homeopathy, intuituve spiritual healing, Healing with the mind: biofeedback, magnetic therapy, prayer, reiki, humor therapy, hyponosis, meditation, therapeutic touch. music therapy, pet therapy, relaxation, storytelling.

• Questions???? • Mr Allen describes his pain as a 7 on the verbal numeric rating scale. He has no evidence of tachycardia, hypertension,diaphoresis, or pallor. From these observations you conclude which of the following regarding MR Allen’s pain? • A. He is experiencing acute or intermittent pain, • B. He is experiencing chronic pain. • C.Because he does not appear to be in pain, further assessment is necessary before treating his pain. • D. His pain medication is adequate.

12 5/18/2015

Fatigue associated with radiation changes is • According to research , which of the most often associated with all but which one following nonpharmacologic measure is of the following? most effective in relieving fatigue? A. An accumulation of cell-destruction end products. A. Conservation of energy. B. Increased energy requirements to repair B. Motivational strategies to increase self damaged epithelial tissue. efficacy beliefs. C. Age, diagnosis,or stage of disease at C. Increasing the number of hours resting or diagnosis. sleeping. D. Pain, depression and weight loss. D. Exercise

References: Core Curriculum for Oncology Nursing 5th edition. Real World Nursing Survival Guide Series- Complementary & Alternative Therapies, A Cancer Source Book for Nurses 8th edition, American Cancer Society Oncology Nursing Review 4th edition, Genentech

13