Adult 3 - oral, colon,pancreas, gastritis cancer - RR

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Define oral cancer

Cancers involving any part of the mouth, tongue, gums, pharynx, lips
--curable if found early (most of the time not found early)

Most common sites for oral cancer

Lips - lateral tongue - floor of mouth

Risk factors for oral cancer

Smokeless tobacco - smoking - excessive etoh - over 50 - AA man
--combined use of tobacco and etoh due to synergistic carcinogen effect

Type of oral cancers

Mostly SCC
also BCC

Oral SCC

Surface of epithelium
-slow growing dysplasia - non painful - crusted/scaly lesions that won't heal

Oral BCC

Primarily on lips
-ulcer with raised pearly border
-non healing/masses/bleed easy
--lesion that is nonhealing for 2 weeks to mth = need to see dr

S/S of oral SCC

-crusted scaly area on skin w/ red inflammed base
-persistent non healing ulcerated bump or thickened skin on lower lip
-wart like growth or plaque
-red scaly patches or bumps

S/S of oral BCC

-slow growing
-raised border
-pearly
-can have ulceration
-bleed when disturbed
-translucency
-depression in the center and can ooze

Dx of oral ca

Oral exam
Cervical LN assessment
CT head/neck
Bx any lesion that doesn't heal in 2 weeks

Standard tx of oral ca

-Surgery to remove and clear margins
-Radiation - to shrink - sometimes preop to make margins easier to clear w/o deforming (sometimes implanted into tongue)
-Chemo

Oral tumors that are > 4 cm =

will come back

What is a radical neck dissection

Removal of all cervical LN
-from mandible to clavicle & removal of sternocleidomastoid muscle, internal jugular vein, & spinal accessory nerve

Complications of radical neck dissection

Shoulder drop - poor cosmetic (visible neck depression)

Modified radical neck dissection

Preserves one or more of the nonlymph structures
-used more often
-selective neck dissection
-preserves 1 or more LN groups, internal jugular, muscle and nerves

Reconstruction for neck dissections

With flap & vasculature
-cutaneous flap with skin & subq tissue
-myocutaneous flap with subq tissue, mucle & skin - more freq used

What is used for large skin grafts in reconstruction for neck dissection

Microvascular free flap
-involves transfer of muscle, skin, or bone w/ artery or vein

Complications s/p neck dissection

-risk for swelling of posterior pharynx
--temporary trach
-chyle fistula
-hemorrhage
-nerve depression
-impaired airway

What is the #1 concern s/p neck dissection

Patent airway
#2 = hemorrhage

RN interventions s/p neck dissection

-Put in fowlers or high fowlers - to facilitate breathing and drainage of lymph fluid and blood, swallowing
(never flat = blood can pool/clot)
-call light in reach
-pain control
-wound/flap care
-nutrition
-mobility
-assess for nerve injury
-coping

What are the s/s of hemorrhage s/p neck dissection

S/S shock (hypoTN, tachycardia)
-saturated dressings

What is a chyle fistula

Damage or cutting of lymph duct system in the neck during dissection
-damage to thoracic duct in surgery

S/S of chyle fistula

Drainage of "milky white" or clear fluid
- Drainage ranges from low output (< 500 mL/day) to more than 3 L /day
-excess drainage that has a 3% fat content and sp gravity of 1.012 or more

What can peristent chyle fistula lead to

Elyte disturbance, hypovolemia, hypoalbuminemia, coagulopathy, immunosuppression, chylothorax, and peripheral edema, wound infection and local skin breakdown.
---Prolonged chyle leak can lead to mortality

why are drains used in neck dissections

To prevent collection of fluid subq
-between 80-120 mL of serosanguineous may drain for 1st 24H
--excess drainage could mean hemorrhage or chyle fistula

Assessing incision s/p neck dissection for infection

Grafts should be pale pink and warm to the touch
-watch incisions for pus and malodorous drainage
-aseptic technique to clean around incision

Avoiding hemorrhage s/p neck dissection

-VS Q 1-2 H - then Q4H after stabilized
-avoid valsalva
-high epigastric pain = impending rupture signs
-assess dressings for excessive bleeding

Nerve injury s/p neck dissection

Can occur if cervical plexus or spinal accessory nerve is severed
--can cause lower facial paralysis
-if laryngeal nerve is severed = problems swallowing

How to assess for nerve injury s/p neck dissection

-have pt smile, frown, move jaw
-can they swallow?

What are lower jaw fx?

Mandibular fractures -- wired shut
-if nausea = fix asap! (risk of aspiration)
**take wire cutters everywhere w/ pt and have bedside always
-eating thru straw
-exposed wires - put wax on ends or bend wire
-oral suction if needed

What is gastric cancer

Occurs anywhere in the stomach
--pylorus (40%)
--Body (40%)
--Cardia (15%)
--Multiple (10%)
--tumors can infiltrate surrounding areas

What is the most common kind of gastric ca

Adenocarcinoma
--86% occur in stomach lining

Early s/s of gastric cancer

-usually asymptomatic
-pain releived w/ antacids

Risk factors for gastric ca

-diet high in smoked meat, pickled & salted food
-men and > 55 years old
-smoking
-obesity
-porr drinking

Late s/s of gastric ca

-Dyspepsia
-early satiety (full earlier) b/c tumor taking up space
-wt loss
-abd pain above umbilicus
**anemia = late s/s

Assess & dx of gastric cancer

EGD w/ bx & cytology (**study of choice)
Stools for occult blood
CBC - ck for anemia
--gastric tumors not palpable until advanced stages
--monitor for CEA's for recurrence Q6m forever

Problems associated w/ gastric ca

-Pyloric obstruction
-Bleeding and *anemia*+
-Severe pain
-Gastric perforation
-peritonitis

Medical mgmt for gastric ca

Surgery (total gastrectomy)
Tumor resection
Dx laparoscopy
Palliative care

What is a total gastrectomy

Removal of entire stomach, duodenum, LN & mesentary, lower part of esophagus
-connect esophagus to jejunum

Problems of gastrectomy

Without stomach - there is no secretion of intrinsic factor
-intrinsic needed for absorption of V B12 to prevent pernicious anemia

What will a pt w/ total gastrectomy need for the rest of their life

Vitamin B12 injections

What is a diagnostic laparoscopy

Evaluate gastric tumor and take tissue bx and look for mets

Palliative care for gastric cancer

No successfult tx other than removal of tumor
-if unable to remove tumor = do chemo

What are 2 other types of surgery for gastric cancer

*Biliroth I - pylorus is removed and the proximal stomach is connected to the duodenum
*Biliroth II - (gastrojejunostomy) - the greater curvature of the stomach is connected to the jejunum in a side-to-side manner.

Biliroth 1 is better for what?

Stomach function

Biliroth 2 is better for what?

Decrease recurrence

Indications for gastric surgery

-life threaten hemorrhage
-obstruction
-penetrations
-gastric cancer
-trauma
-ulcerations that are not responsive to meds or EGD tx

Complications of gastric surgery

**Short term
-anastomosis leak - blood clots - bowel obstruction
**Long term
-B12 deficient - esophagitis (constant GERD) - osteoporosis - dumping syndrome

Nutrition for s/p gastric surgery

-eat small freq meals
-avoid drinking fluids w/ meals
-low sugar intake
**high fat and protein for calories

obstacles to good nutrition s/p gastric surgery

dumping syndrome and reflux

What are the s/s of dumping syndrome

-full sensation - weak - faintness - dizzy - palpitations - sweating - cramping pains - diarrhea
--resolve after intestine has been evacuated
--later = rapid elevation of BS & increased insulin secretion = reactive hypoglycemia

When do vasomotor s/s of dumping syndrome occur

10-90 minutes after eating
--pallor, sweat, palpitations, HA, warmth, dizzy, drowsy
--could also eventually cause steatorrhea (prevents adequate mixing of panc & biliary secretions)

Goals for nursing s/p gastric surgery

Reduce anxiety
Nutrition
Maintain weight
Relieve pain
Prevent infection

Palliative care for gastric surgery

Decrease pain
Chemo
Radiation - for pt w/ obstruction r/t tumor, GI bleeding, severe pain
Surgery - bypass the tumor

What are the risk factors for pancreatic cancer

-Increasing age (peaks 70-80)
-Males
-Smoking
-Chemical exposures
-Diet high in fat/or meat
-DM, chronic pancreatitis, hereditary

Where does 70% of pancreatic ca occur?

Head of the pancreas

What are the early s/s of pancreatic ca

-Vague - non specific
-Vague pain, epigastric may radiate to the back = increases w/ food
-rarely dx at this time

What are the late s/s of pancreatic ca

-Mets to other organs
-S/s of obstruction
**Pain, jaundice & weight loss are classic s/s
-ascites from cancer cells in the peritoneum

Dx of pancreatic cancer

CT (85-90% accurate)
MRI
ERCP
Bx
Paracentesis
Endoscopic US
Gi xray (just shows malformation)
CA 19-9, CEA, DU-PAN-tumor markers non specific for panc ca but used to mark progession

Treatment for pancreatic ca

Surgical resection / whipple or pancreaticoduodenectomy
Chemo
Rad
Palliative

What is pancreaticoduodenectomy

Used for resection of head of pancreas when thought to be only site of cancer
-GB removed, part of stomach, duodenum, proximal jejunum & head of panc & common bile duct are removed
-rest of panc connected to jejunum along w/ stomach
-allows bile to flow into jejunum

What will the patient have to manage s/p pancreaticoduodenectomy

Intake of fat and carbs post op
-may require panc enzymes added to their meds

How many lobes does the liver have

4

*What are the sources of perfusion to the liver

Hepatic artery
Portal vein
-terminal branches join to form the capillary beds

What is the portal vein

80% of the blood supply to the liver comes from the portal vein
--drains the GI tract
--rich in nutrients / lacks O2

What is the hepatic artery

20% blood supply to the liver
-rich in O2

What are the common capillary beds

Terminal branches of the hepatic artery and portal vein
-mixture of venous & arterial blood bathes the liver cells

Functions of the liver

Storage
Protection
Metabolism

Hepatic dysfunction occurs when?

Damage to hepatocytes / liver cells

What are the causes of hepatic dysfunction

Primary liver disease - acute/chronic cirrhosis
Obstruction of bile flow - gallstones
Derangements of hepatic circulation - portal hypertension

Common s/s of liver disease

-Jaundice
-Hemolytic (RBC destruction)
-Hepatocellular (bili levels up due to damaged liver cells)
-Obstructive (gallstones, tumors, pressures from enlarged organs)
-Hereditary hyperbilirubinemia (increasing bili w/o liver damage)

What is jaundice caused by

Accumulation of bilirubin in the boold that the liver is unable to breakdown

What 2 things are directly linked to liver disease

Portal HTN
Ascites

What is portal hypertension

Increased pressure thru the portal venous system
-caused by obstruction of blood flow thru the damaged liver

What are the 2 major consequences of portal HTN

--ascites
--varices

Pathophys of ascites

Obstruction
Increased capillary pressure
Fluid shift into intraperitoneal space

S/S of ascites

-increased abdominal girth
-rapid weight gain
DX
-percussion
-flanks bulge when in supine position
-fluid wave

What is fluid wave

lay flat - hand at umbilical and tap rt or lt side - watch fluid "wave"

Assess for ascites

Abd girth measurements
Watch respirations - causes pressure on diaphragm
Vasodilation, H2O & Na+ retention

Medical mgmt of ascites

-Diet - decrease protein
-Diuretics - pull fluid off
-Bedrest
-Paracentesis - to pull fluid off
-Transjugular intrahepatic portosystemic shunt (TIPS)

What is directly related to esophagus varices

Portal HTN

Nursing mgmt for liver disorders and ascites

-I&O
-Abd girth measurement
-Daily weights
-Labs
-Frequent rest periods
-Small freq meals

Portal HTN is a result of what

It is the increased pressure thru the portal venous system that results from obstruction of blood flow thru the damaged liver

What is the type of fluid of ascites

As a result of liver damage - large amounts of albumin-rich fluid, 15L or more, may accumulate in the peritoneal cavity as ascites

What are esophageal varices

Dilated tortuous veins found in the submucosa of lower esophagus
-develop from elevated pressure in the veins that drain into the portal system
-prone to rupture & source of massive GI bleed

Why should a pt w/ ascites be placed on bedrest

Upright posture is assoc w/ activation of renin-angiotensin-aldosterone system
-causes reduced glomerular filtration & Na+ excretion and decreased response to diuretics

What is the TIPS procedure

Treats ascites
-cannula threaded into portal vein by transjugular route
--to reduce portal HTN, stent is placed to serve as intrahepatic shunt between portal circulation & hepatic vein
-tx of choice for refractive ascites
--decreases Na+ retention & prevents recur of fluid accumulation

What causes esophageal varices

** almost always caused by portal HTN
-Cirrhosis
--the worse the portal HTN, the higher it can go
-esophagus not designed to swell & shrink so stay swollen
**hemorrhage easy and quick
--if liver disorder and vomit = emergent b/c weakens vessel walls

S/S of esophageal varices (book)

Hematemesis
Melena
*rapid decrease in mental / physical status
Often hx of etoh abuse
S/S of shock could be present

Dx of esophageal varices

*Immediate EGD
--identify cause and site of bleeding
*Portal system pressures

How are portal HTN measured

Palpable enlarged spleen and ascites may be present
-can be measured indirect or direct

Indirect measurement of portal HTN

Most common
-requires inserted cath w/ balloon into antecubital or femoral vein
-advance to hepatic vein
-fluid infused to inflate balloon
-wedge pressure taken by occluding blood flow and measure unoccluded vessel

Direct measurement of portal HTN

Needle into spleen during laparotomy
-manometer greater than 20mL is abnormal
-another method is to insert cath into portal vein or its branches

First line of tx for esophageal varices

Vasopressin
-for people W/O CAD
-produces constriction of preportal splanchnic arterioles & decreases portal pressurs

Other medical mgmt for esophageal varices

Balloon tamponade
Endoscopy - sclerotherapy & variceal banding

What is balloon tamponade

To control hemorrhage in esophageal varices
-pressure is exerted on the cardia (upper orifice of stomach)
-tube has 4 openings for gastric aspiration, esophageal aspiration, gastric & esophageal balloon inflation
-compression of bleeding varices by inflation of balloon
-gastric & esophageal outlets allow nurse to aspirate secretions

Where should the pt getting balloon tamponade remain

ICU b/c of risk of complications
-monitor close and continuouss
-no more than 24 hrs

What is sclerotherapy

For esophageal varices
-sclerosing agent injected thru endoscope into bleeding varices to promote thrombosis & sclerosis
-treat acute GI bleed but NOT prevention and subsequent variceal bleeding

What is cirrhosis

CHRONIC disease characterized by replacement of normal liver tissue w/ diffuse fibrosis that disrupts structure & function of liver
---scarring of liver

Pathophys of cirrhosis

Liver cells necrose
Destroyed cells replaced by scar tissue
Eventually more scar tissue than functioning tissue
Hobnail appearance -

Why does cirrhosis cause hobnail appearance

Due to islands of normal tissue and regenerating liver tissue

Cirrhosis types

Alcoholic (Laennec's)
Post necrotic
Biliary
Cryptogenic

Who is at higher risk for cirrhosis

Weomen who drink
age 40-60

What is the most common type of cirrhosis

Alcoholic
--effects circulation & nutrients & O2 of portal area

What is alcoholic cirrhosis

Scar tissue normally surrounds the portal areas
-most frequently caused by chronic alcoholism

What is postnecrotic cirrhosis

Broad bands of scar tissue
-late result of a previous bout of acute viral hepatitis

What is biliary cirrhosis

Scarring occurs in liver around bile ducts
-results from chronic biliary obstruction & infection
--least common of the types of cirrhosis

Most common cause of cirrhosis

etoh consumption
-reduced protein intake contributes as well

What are the s/s of cirrhosis (child pugh scale)

The more of these s/s the poorer the outcome
-ascites (absent 1 - slight 2 - moderate 3)
-bilirubin (+ to or < 2 is a 1 - 2-3 is a 2 - moderate >3 is a 3)
-albumin (>3.5 is a 1 - 2.8-3.5 is a 2 - < 2.8 is a 3)
-pt (1-3 is a 1 - 4-6 is a 2 - >6 is a 3)
-encephalopathy (None is 1 - gradet 1-2 is a 2 - grade 3-4 is a 3)

What is compensated cirrhosis

-Less severe
-vague s/s
-early disease
-discovered secondary at a routine physical exam

What is decompensated cirrhosis

-Late disease
-Result from failure to synthesize proteins, clotting factors other manisfestations of portal HTN

S/S of compensated cirrhosis

-intermittent mild fever
-vascular spiders
-reddened palms (palmar erythema)
-unexplained epistaxis
-ankle edema
-vague morning indigestion
-flatulent dyspepsia
-abd pain
-firm, enlarged liver
-enlarged spleen

S/S of decompensated cirrhosis

-ascites
-jaundice
-weakness
-muscle wasting
-weight loss
-continuous mild fever
-clubbing of fingers
-purpura (b/c decreased platelet count)
-spontaneous bruising
-epistaxis
-hypoTN
-sparse body hair
-white nails
-gonadal atrophy

Dx tests for cirrhosis

Labs
Sono
CT
MRI
radioisotope liver scan
liver bx

After liver bx, how should patient be positioned

Bedrest - lay on side of bx to seal
ck for bleeding

Medical mgmt of cirrhosis

Treat s/s and slow disease progress
-eliminate etoh
-Meds (PPI, H2 blockers, antacids)
-Nutrition (low protein, high calorie

Medical mgmt of ascites

*Potassium sparing diuretics (spironolactone)
-decrease ascites
-minimize fluid and elyte imbalances compared to other diuretics
**anti-inflammatories
*COLCHICINE (gout meds)
-may increase survival in mild-moderate cirrhosis

Nursing management for ascites and cirrhosis

Promote rest
Nutrition
Skin care
Decrease risk of injury
Monitor for potential complications (bleeding, hemorrhage, hepatic encephalopathy, fluid volume excess)

Why promote rest for cirrhosis

End state has fatigue, poor exercise tolerance - need rest periods

Improving nutrition for cirrhosis

Low protein - fruits - vegs - lean proteins - vitamins - small freq meals

Skin care for cirrhosis

Requires moisturizers and antipuritic agents (benadryl & atarax) - itchiness r/t ammonia

What is hepatic encephalopathy / portal systemic encephalopathy

Accumulation of ammonia & toxic metabolites in blood and brain
-portal hypertension
-poor marker for survival

Pathophys of hepatic encephalopathy

Liver cells unable to convert ammonia to urea
-causes brain dysfunction and damage

What is asterixis

flapping tremor, or liver flap - tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings
--sign of hepatic encephalopathy due to high ammonia levels

Sources of ammonia

Absorption from GI tract
Kidney cells
Muscle cells

S/S of hepatic encephalopathy

Confusion
Unkept
Mood changes
Impaired sleep pattern
Somnolence
Asterixis

Dx of hepatic encephalopathy

Labs (ammonia level)
EEG - show generalized slowing
Fetor hepaticus - sweet slightly fecal odor to breath

Medical mgmt of hepatic encephalopathy

Supportive tx
-lactulose = promote excretion of ammonia - titrate so pt has 2-3 soft bowels/day
-neomycin = suppress GI bacteria that produces ammonia
-elytes
-serum ammonia
-avoid sedatives, tranq, analgesics
-small freq meals and low protein diet

Main s/s of hypocalcemia

Tetany

What is the gold standard to dx colon cancer

colonoscopy

Risk factors for colon cancer

Increasing age - fam hx of colon ca or polyps - previous colon ca or adenomatous polyps - high etoh - smoking - obesity - hx of gastrectomy - history of IBD - high fat & protein and low fiber diet - genital cancers

Pathyphys of colon ca

95% are adenocarcinoma
-rising from lining of colon
-usually starts as polyp - transforms to malignancy - invades, destroys normal tissues

S/S of colon cancer

Change in bowel habits (#1) - blood in stools - unexplained anemia - anorexia - wt loss - fatigue

S/S of left sided colon lesions

Associated with obstruction

S/S of rectal lesions

Ineffective painful straining upon BM

Assess & dx of colon ca

Occult blood
Colonoscopy
Labs (CEA)

Complications of colon ca

Partial or complete obstruction
Hemorrhage (tumor invades surrounding vessels)

S/S of partial obstruction

Pain and thin pencil stools

S/S of full or complete bowel obstruction

Telescope bowels - death of bowel tissue

What should a stoma look like

Beefy red or hot pink

Medical mgmt of colon ca

Depends on stage
-surgery #1 choice
-radiation
-chemo

Nursing mgmt for colon ca surgery

Pre op = bowel prep
Post op = monitor for anastomosis leakage - prolapse stoma - perforation - stoma retraction - fecal impaction - skin irritation
Nutrition = TPN or IVF until bowel function returns - slow advance diet - healthy diet

How should you irrigate a colostomy

Helps schedule bowel movements
Supports body image
Monitor and manage complications

Procedure for irrigation of colostomy

-sit in chair by toilet
-500-1500mL tap water is hung 15-20 in above stoma (shoulder height)
-remove pouch
-apply sleeve to stoma - place end in commode - allow solution to flow thru tube & cath - lubricate irrigating cone and insert into stoma - allow water to flow slowly while advancing cath - replace dressin

Purpose of irrigating colostomy

-control odor and allow feces & H2O to flow into commode
-painful cramps caused by too rapid flow or too much solution

S/S of right sided colon lesion/ cancer

Dull abd pain
Melena stools
Ascending colon

S/S of left sided colon lesion/cancer

Abd pain
Cramping
Ribbon stools
Feeling of incomplete evacuation
Constipation & abd distention
Blood in stool
Descending colong - near colorectal area

S/S of colorectal ca

Pain LLQ
Ineffective, painful straining due to obstruction
Tenesmus (constant feeling of need to pass stools)
Rectal pain
Feeling of incomplete evacuation
Alternate w/ diarrhea & constipation
Frank bloody stools

Esophageal varices (ATI)

Swollen, fragile blood vessels in esophagus
--medical emergency if hemorrhage

Primary risk factor for esophageal varices (ATI)

Portal hypertension

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