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Flashcards in Management of Cancer SE Deck (146)
1

SE of Anti-Neoplastic Agents

Alopecia
Anorexia
Cardiotoxicity
Constipation
Skin or Cutaneous Responses
Diarrhea
Fatigue
Hemorrhagic cystitis
Hepatotoxicity
Hypersensitivity reactions
Mucositis/Stomatits/ Esophagitis
N/V
Nephrotoxicity
Neurotoxicity
Pulmonary toxicity
Sexual & reproductive dysfunction
Myelosuppression
Anemia
Neutropenia
Thrombocytopenia

2

Assessment of Alopecia

Usually within 2 weeks
Reversible

3

Education with Alopecia

Emotional support

4

Assessment of Anorexia

Dietary history
Weight
Lab values

5

Education for Anorexia

Weekly weights
Small frequent meals

6

Medications for Treatment of Anorexia

Antiemetics
Megesterol (Megace)
Dronabinol (Marinol)
Remeron: Antidepressant

7

Cardiotoxicity

Related to effect of drugs or radiation to cardiac muscle, pericardium

8

Chronic Cardiotoxicity

Cumulative dosing of cardiotoxic drugs
Radiation to large volumes of heart or pericardium

9

Medications that have Cardiotoxicity

Doxorubicin
Daunorubicin
Mitoxantrone
High dose cyclophosphamide
High dose 5FU
Paclitaxel

10

Assessment of Cardiotoxicity

History of HTN
Smoking
Pre-existing cardiac disease

11

Collaborative Management of Cardiotoxicity

MUGA scan
Exercise
Diet modification
Dose reduction
EKG
Dexrazoxone (Zinecard)

12

Education for Cardiotoxicity

Inform of possible cardiotoxicity
S/S of CHF
Daily weights
Symptoms management

13

Pathophysiology of Constipation

Result of neurotoxic effects resulting in decreased peristalsis

14

Assessment of Constipation

Patients receiving vinca alkaloids
Hypercalcemia
Opioid pain management
Dehydration

15

Management of Constipation

Bowel program
Exercise
Diet modifications
Laxative & stool softener

16

Education for Constipation

Increasing fluids
Dietary interventions
Establish a bowel program

17

Assessment of Skin or Cutaneous Responses

Rash
Photosensitivity
Hypersensitivity

18

Education for Skin or Cutaneous Responses

Prepare patients for potential changes
Monitor S/S of infection
Avoid heat & vasodilation

19

Management of Skin or Cutaneous Responses

Call Rad Onc to discuss skin care
Call Med Onc to discus medical management

20

Acral Erythema (Hand-foot syndrome)

Painful palms & soles with erythema, desquamation, & ulceration

21

What is Acral Erythema Commonly Associated with what medications

5FU
Capecitabine
Doxirubicin

22

How to prevent aural erythema?

Holding ice packs during infusion
Taking pyridoxine

23

Pathophysiology of Diarrhea

GI mucosa very sensitive to cytotoxic drugs due to high mitotic index

24

Assessment of Diarrhea

Neutropenic status
Bowel elimination patterns
Hydration

25

Collaborative Management of Diarrhea

IV/fluid support
Loperamide
Diphenoxylate

26

Education for Diarrhea

Low residue diet
Fluid requirements
Watch for S/S of dehydration
Perianal care

27

Pathophysiology of Fatigue

Anemia
Changes in sleep patterns
Pain
Psychosocial factors

28

Assessment of Fatigue

Risk factors
Acute vs. chronic
Fatigue level

29

Collaborative Management of Fatigue

Multidisciplinary referrals

30

Education for Fatigue

Setting realistic goals
Energy management
Cause & factors of fatigue

31

Pathophysiology of Hemorrhagic Cystitis

Bladder mucosal irritation from metabolic by-products of drugs

32

Medications that Cause Hemorrhagic Cystitis

Cycclophosphamide
Ifosfamide
High dose methotrexate

33

Assessment of Hemorrhagic Cystitis

Dysuria
Urinary frequency
Burning
Hematuria
Previous history of pelvic radiation

34

Collaborative Management of Hemorrhagic Cystitis

Lab monitors
PO/IV hydration with diuretics

35

Education for Hemorrhagic Cystitis

Potential for SE to occur
Increase fluid intake
Frequent urination

36

Pathophysiology Hepatotoxicity

Direct toxic effect to liver when drugs are being metabolized

37

Assessment of Hepatotoxicity

ETOH use
Liver disease
Medication use
Jaundice
Ascites
Hepatomegaly
pain

38

Collaborative Management of Hepatotoxicity

Monitor labs
Limit acetaminophen to

39

Education for Hepatotoxicity

Avoid alcohol

40

Pathophysiology of Hypersensitivity Reactions

Antigen/antibody reaction

41

Assessment of Hypersensitivity Reactions

Clinical manifestations of local or systemic reaction

42

Collaborative Management of Hypersensitivity Reactions

Test dose
Premedication prior to chemo
Emergency equipment
Steroids
H1 & H2 blockers
Epinephrine

43

Education for Hypersensitivity Reactions

Potential for allergic reactions
S/S of reactions

44

Pathophysiology of Mucositis/Stomatitis/ Esophagitis

Direct effect of drug or radiation on oral mucosa

45

Common Cancers with Mucositis/Stomatitis/ Esophagitis

Leukemia
Lymphoma
H&N Cancers

46

Assessment of Mucositis/Stomatitis/ Esophagitis

Xerostomia
Mucositis
Yeast Infections

47

Signs/Symptoms of Xerostomia

Dysphagia
Plaque formation
Pale, dry oral mucosa
NOT PAINFUL

48

Signs/Symptoms of Mucositis

Erythema
Dequamation
Ulceration
VERY PAINFUL

49

Signs/Symptoms of Yeast Infections

Thrush
Oral or esophageal candidiasis

50

Collaborative Management of Mucositis/Stomatitis/ Esophagitis

Aim is prevention, dental referral, "magic mouthwash", chlorhexidine (Peridex) rinse

51

Education with Mucositis/Stomatitis/ Esophagitis

Frequent oral hygiene
Use of saline or baking soda rinses QID
Cryotherapy

52

Grading of Mucositis/Stomatitis

0= no change
1= soreness
2= erythema, ulcers, can eat solids
3= ulcers, liquid diet
4= severe ulcers; no oral intake

53

Pathophysiology of N/V

Stimulation of vagus nerve by release of serotonin
Stimulation of the chemoreceptor trigger zone in the medulla
Stimulation of the true vomiting center

54

Epidemiology of N/V in Cancer Patients

Females > Males
Youth > Elderly

55

Assessment of N/V

Rule out other causes of nausea, hydration status, weight loss, electrolytes

56

Collaborative Management of N/V

Timely administration of antiemetics
Fluid support
Emotional support
Dietary support
Telephone F/U if treated as outpatient

57

Education for N/V

Patient to notify clinic if symptoms persist >48 hours
Unable to maintain oral intake
Antiemetics around the clock for first 24-72 hours after chemo

58

Medications for Chemotherapy Induced N/V

Palonosetron (Aloxi)
Odansetron (Zofran)
Lorazepam (BZD)
Prochlorperazine (Phenothiazine)

59

Pathophysiology of Nephrotoxicity

Direct cell damage to the kidney
Indirect cell damage by metabolites

60

Common Medications that Lead to Nephrotoxicity

Cisplatin
High dose methotrexate

61

Assessment of Nephrotoxicity

Age
Renal disease
Nephrotoxic drugs
Lab values

62

Management of Nephrotoxicity

Adequate IV hydration
Rescue therapy with dialysis

63

Education for Nephrotoxicity

Adequate fluid intake

64

Pathophysiology of Neurotoxicity

Direct effect on the nervous system
Metabolic encephalopathy
Intracranial hemorrhage due to coagulopathy or myelosuppression

65

Reasons for Neurotoxicity

High dose chemotherapy
Drugs crossing the blood-brain barrier

66

Assessment of Neurotoxicity

Tinnitis
Peripheral neuropathies
Fine motor loss
Numbness
Tingling
Gait distrubances
Changes in mentation
Urinary retention
Constipation

67

Management of Neurotoxicity

Avoid extreme temperatures

68

Education for Neurotoxicity

S/S of neurotoxicity
Many symptoms reversible if interventions initiated early

69

Pathophysiology of Pulmonary Toxicity

Toxic damage to alveoli resulting in pneumonitis & pulmonary fibrosis

70

Chemo Therapy with Pulmonary Toxicity

Bleomycin
Busulfan
Radiotherapy

71

Assessment of Pulmonary Toxicity

Thorough respiratory assessment

72

Collaborative Management of Pulmonary Toxicity

Pulmonary function tests prior to therapy
Treat with corticosteroids
Discontinue therapy

73

Education for Pulmonary Toxicity

S/S associated with pulmonary toxicity
Energy conservation techniques

74

Pathophysiology of Sexual & Reproductive Dysfunction

Toxic effects on the gametes
Physical SE of chemotherapy
Can be permanent or temporary

75

Assessment of Sexual & Reproductive Dysfunction

Early menopause
Sterility

76

Collaborative Management of Sexual & Reproductive Dysfunction

Sperm banking
Counseling

77

Education for Sexual & Reproductive Dysfunction

Implications of treatment of sexuality
Long term effects

78

Pathophysiology of Myelosuppression

Bone marrow highly sensitive to toxic effects of chemotherapy due to high mitotic index
Can be dose-limiting & delay treatment
Anemia, neutropenia, thrombocytopenia, pancytopenia

79

Situations for Myelosuppression

Leukemia
Taxmen use
Alkylating agent use
Antimetabolite use
Etoposide use
Nitrosurea use

80

Pathophysiology of Anemia

Changes in the erythrocyte-proliferation pathways

81

Assessment of Anemia

Dyspnea
Fatigue
Concomitant radiation
Poor nutritional status
Elderly
Hx of renal or hepatic impairment

82

Collaborative Management of Anemia

CBC
RBC transfusions as needed
Iron supplements
Oxygen therapy

83

Education of Anemia

S/S of anemia
Change positions slowly to prevent falls & injury

84

Pathophysiology of Neutropenia

ANC

85

Assessment of Neutropenia

Age
Malnutrition
Prior chemotherapy or radiation
S/S of infection

86

Collaborative Management of Neutropenia

CBC
Neutropenic fever
recommendations
Filgrastim
Pegfilgrastim

87

Education for Neutropenia

S/S of infection
Meticulous
Hygiene
Daily temps

88

Who always gets admitted to the hospital for cancer patients?

Anyone with a fever

89

Pathophysiology of Thrombocytopenia

Bone marrow suppression decreases lately progression

90

Assessment of Thrombocytopenia

Petechiae
Bruising
Hemorrhage
S/S of intracranial bleeding

91

Collaborative Management of Thrombocytopenia

Platelet counts
Platelet transfusion
Thombocytopenic precautions

92

Thrombocytopenic Precautions

Electric razor
No suppositories or douches
No dental flossing
No injections

93

Education for Thrombocytopenia Patients

S/S of bleeding to report

94

Radiation SE

N/V
Trouble swallowing
Fatigue
Decrease in platelets & lymphocytes
Erythema
Alopecia
Fibrin plaquing
Urinary & bladder changes
Visceral changes
Irreversible damage to gametes
Sterility
Suppress osteoblast activity
Decrease number of osteocytes

95

Skin SE of Radiation

Erythema
Alopecia

96

Mucous Membranes SE of Radiation

Fibrin plaquing
Urinary & bladder changes
Visceral changes (secretory)

97

Reproductive Organ SE of Radiation

Irreversible damage to gametes
Sterility

98

Bone SE of Radiation

Suppress osteoblast activity
Decrease number of osteocytes

99

Nonverbal Signs of Pain

HTN
Tachycardia
Diaphroresis
Agitation or confusion
Apathy, inactivity, or irritability
Refusal to eat
Protect painful part
Show facial grimacing

100

Pain Measurement Tools

Pain scale
McGill Pain Questionnaire
Memorial pain assessment card

101

What type of pain is caused by invasion of bone by the tumor?

Deep, achy, unrelenting pain

102

What type of pain is caused by nerve compression?

Neuropathic pain
Lightening bolts
Stabbing
Pins & needles

103

Pain Complications of Treatment

Radiation fibrosis
Chemotherapy-induced neuropathy
Postoperative surgical pain

104

Types of Pain

Somatic
Visceral
Neuropathic

105

Define Somatic Pain

Potential or real injury to tissues & is type pain that we treat

106

Description of Somatic Pain

Tender & localized to site of injury
Constant
Sometimes throbbing or achy

107

What is the most common cause of somatic pain in patients with cancer?

Bone mets

108

Define Visceral Pain

Poorly localized & often referred to a distant site which may be tender

109

Description of Visceral Pain

Less constant than somatic pain
Dull, colicky waves

110

Causes of Visceral Pain

Activation of pain receptors resulting from infiltration, compression, extension, or stretching of the thoracic, abdominal, or pelvic viscera

111

Common Causes of Visceral Pain

Pancreatic CA
Mets in the abdomen

112

Define Neuropathic Pain

Prolonged, severe, burning or squeezing pain

113

What may accompany neuropathic pain?

S/S of autonomic instability

114

Cause of Neuropathic Pain

Injury to the nervous system

115

Pain Sites

Bone pain
Back pain
Headache
Facial pain
Abdominal pain
Pelvic pain
Post-op pain
Phantom pain
More than 1 site

116

Factors that Influence the Development of Cancer pain

Cancer type & site
Presence or absence of mets

117

Most Frequent Causes of Pain

Visceral involvement
Bone metastases
Soft tissue invasion
Nerve/plexus pressure or infiltration

118

Treatment Goals of Pain

Diminish pain & associated emotional stress
Increase physical, social, vocational, & recreational involvement
Optimize health
Improve psychological well being
Improve coping ability
Reduce dependence on health care system

119

Pain Management

Use of pharmacologic agents as well as analgesic adjuvants
Physical & nonpharmacologic approaches (treating CA or how patient reacts to pain)
Neurosurgical & anesthetic interventional procedures

120

Step Wise Approach to Pain Management

Non-opioid + adjuvant
Opioid (hydrocodone) + non-opioid + adjuvant
Opioid (oxycodone) + non-opioid + adjuvant

121

What medication should you not prescribe in cancer patients?

Codeine
This is due to varying responses to medication

122

Step 1 in Pain Management

NSAIDS and Acetaminophen
Around the clock dosing

123

Why are opioids widely used in cancer patients for pain?

Reliability
Safety
Multiple routes of administration
Ease of titration

124

Choice of Opioids

Short half-life & PRN to start
Sustained release can be added

125

Which opioid may have a dual MOA?

Tramadol

126

MOA of Tramadol

Inhibits neuronal re-uptake of serotonin & norepinephrine

127

What medications can be used to provide an opioid-sparing effect?

Antidepressants
Anticonvulsants
Local anesthetics

128

TCAs for Pain Management in Cancer Patients

Amitriptyline (Elavil)
Nortriptyline (Pamelor)
Imipramine (Tofranil)
Desipramine (Norpramin)

129

Anticonvulsants for Pain Management in Cancer Patients

Carbamazepine (Tegratol)
Clonazepam (Klonopin)
Gabapentin (Neurontin)

130

MD Anderson Protocol for Mild to Moderate Pain

Non-opions

131

MD Anderson Protocol for Moderate to Severe Pain

Opioids: morphine, hydromorphone, oxycodone, hydrocodone, codeine, fentanyl, & methadone

132

MD Anderson Protocol for Tingling & Burning Pain

Antidepressants: amitriptyline, imipramine, doxepin
Antiepileptics: gabapentin

133

MD Anderson Protocol for Pain Caused by Swelling

Prednisone
Dexamethasone

134

Most Commonly Used Opioids in Management of Cancer Pains

Morphine
Fentanyl

135

Medications to Avoid in Management of Cancer Pain

Codeine
Meperidine

136

What can contribute to depression in cancer patients?

Uncontrolled pain
SE of opioids
Fear of pain

137

Anesthetic Interventional Approaches to Pain Management

Nerve blocks: celiac plexus, superior hypogastric plexus
Myofascial injections
Neuroma injections
Spinal cord stimulation
Intrathecal & epidural injections

138

Complementary & Alternative Pain Management

Biofeedback
Breathing & relaxation exercised
Distraction
Heat or cold
Hyponosis
Imagery
Massage, pressure & vibration
Transcutaneous electrical nerve stimulations (TENS)
Acupuncture
Coenzyme Q10
Self-help & support groups

139

Define Biofeedback

Technique that makes the patient aware of bodily process normally through to be involuntary and gain conscious control over these processes which can influence level of pain (blood pressure, skin temp, HR)

140

Breathing & Relaxation Exercises for Pain Management

Focus attention on performing a specific task instead of on pain

141

Distraction in Pain Management

Method to divert patient's attention to a more pleasant event, object, or situation

142

Heat or Cold in Pain Management

Temperature to facilitate pain control with ice or heating pad

143

Hypnosis in Pain Management

Focused state of consciousness that allows the patient to better process information

144

Imagery in Pain Management

Soothing, positive mental images that allow the patient to relax

145

Massage, Pressure, & Vibration in Pain Management

Physical stimulation of muscles or nerves can facilitate relaxation & relieve painful muscle spasms or contractions

146

Transcutaneous Electrical Nerve Stimulation (TENS) in Pain Management

Mild electric current is applied to the skin at the site of pain