Slide 1 - KeithRN
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Bone, Oral Cancer
&
Oncologic
Emergencies
Keith Rischer RN, MA, CEN
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Objectives
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
2
Malignant Bone Tumors
Primary vs. metastatic
Osteosarcoma
Chondrosarcoma
Patho
Clinical manifestations
Pathologic bone fx
Pain, local swelling
Elevated serum alkaline
phosphatase and Ca++
Life threatening and very
painful
3
Malignant Bone Tumors
Interventions
Radiation
Chemo
Surgery
Total joint replacements
Allografts (cadaver)
Nursing priorities
Pain control
Risk for infection
Emotional/spiritual
support
4
Oral Cancer: Squamous Cell
Carcinoma
Patho
Etiology
Found on lips, tongue,
buccal mucousa,
oropharynx
Tobacco/ETOH use
UV exposure
HPV,
poor oral hygiene
Incidence
2-3% of all cancer
30,000 new cases annually
8000 deaths annually US
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Oral Cancer: Squamous Cell
Carcinoma
Clinical manifestations
Unusual lumps/thickening of oral
cavity
Soreness, pain
Cervical lymph node enlargement
Become hardened and fixed
in position
Diagnosis
Biopsy
Medical management
Surgical
Trach if large resection postop
Radiation/chemotherapy
Nursing priorities
Airway management
See chart 57-3 on p.1253
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Oral Cancer Case Study
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
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
Sepsis
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
Prevalence
Patho
Systemic Inflammatory Response Syndrome (SIRS)
Disseminated Intravascular Coagulation (DIC)
Consumptive coagulopathy
Labs abnormal…
–
–
–
–
D-dimer
INR
Fibrinogen
platelets
Tx-FFP, platelets, Vit K
Predisposing factors
Immunosuppression
Chemotherapy/radiation
Malignancy
Age >85
10
Elsevier items and derived items © 2006 by Elsevier Inc.
Sepis/Septic Shock
Clinical
manifestations
VS changes
CV
Resp
Neuro
Renal
Integument
GI
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Sepis/Septic Shock
Lab values
WBC
Neutrophils
Bands
Lactate
ABG
pH 7.22
pCO2: 45
pO2: 74
Bicarb: 12
O2 sats: 90%
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Sepis/Septic Shock
Nursing priorities
Early recognition!
IV fluids-.9% NS 2-3 liters
IV abx
Arterial/central line
placement
Vasopressor support
Dopamine gtt
Epinephrine/norepinephrine
gtts
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Syndrome of Inappropriate Antidiuretic
Hormone (SIADH)
Patho
Clinical manifestations
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:
Fluid restriction
Increased sodium intake
Monitor serum sodium
per
MD
Elsevier items
and derived
itemsorders
© 2006 by Elsevier Inc.
14
Spinal Cord Compression
Patho
Clinical manifestations
Back pain
Neuro deficits…N-W-T
Collaborative management
includes:
Early recognition and treatment
High-dose corticosteroids
High-dose radiation
Done emergently
Surgery
External back or neck braces to
reduce pressure in the spinal cord
15
Elsevier items and derived items © 2006 by Elsevier Inc.
Hypercalcemia
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
Patho
Clinical manifestations
Early
Late
Edema in arms, hands, SOB,
epistaxis
Can be very dramatic!
Critical
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.
Superior Vena Cava Syndrome
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Tumor Lysis Syndrome
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Tumor Lysis Syndrome
Patho
Labs…
Collaborative management includes:
Prevention…is expected and anticipated
Hydration: 3-5 liters daily…po or IV
Allopurinol often given before chemo…why???
Anti-emetics
Drug therapy
Diuretics
Allopurinol
Kayaxelate
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Elsevier items and derived items © 2006 by Elsevier Inc.