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Terms in this set (47)

Under normal conditions, a state of dynamic equilibrium is constantly maintained (i.e., cellular proliferation equals cellular degeneration or death). Normally the process of cellular division and proliferation is activated only in the presence of cellular degeneration or death. Cellular proliferation will also occur if the body has a physiologic need for more cells. For example, a normal increase in white blood cell (WBC) count occurs in the presence of infection.

Another explanation for the phenomenon of proliferation control in normal cells is contact inhibition. Normal cells respect the boundaries and territory of the cells surrounding them. They will not invade a territory that is not their own. The neighboring cells are thought to inhibit cellular growth through the physical contact of the surrounding cell membranes. Cancer cells grown in tissue culture are characterized by loss of contact inhibition. These cells have no regard for cellular boundaries and will grow on top of one another and also on top of or between normal cells.

The stem cell theory proposes that the loss of intracellular control of proliferation results from a mutation of the stem cells. The stem cells are viewed as the target or the origin of cancer development.

A common misconception regarding the characteristics of cancer cells is that the rate of proliferation is more rapid than that of any normal body cell. In most situations, cancer cells proliferate at the same rate as the normal cells of the tissue from which they originate. The difference is that proliferation of the cancer cells is indiscriminate and continuous. In this way, with each cell division creating two or more offspring cells, there is continuous growth of a tumor mass: 1 × 2 × 4 × 8 × 16 and so on. This is termed the pyramid effect. The time required for a tumor mass to double in size is known as its doubling time.
An important aspect of nursing care is to educate the public about cancer prevention and early detection, including the following:

1. Reduce or avoid exposure to known or suspected carcinogens and cancer-promoting agents, including cigarette smoke and sun exposure.
2. Eat a balanced diet that includes vegetables and fresh fruits (see Fig. 40-1 and Table 40-1), whole grains, and adequate amounts of fiber. Reduce dietary fat and preservatives, including smoked and salt-cured meats containing high nitrite concentrations.
3. Participate in regular exercise (i.e., ≥30 minutes of moderate physical activity five times weekly).
4. Obtain adequate, consistent periods of rest (at least 6 to 8 hours per night).
5. Have a health examination on a regular basis that includes a health history, a physical examination, and specific diagnostic tests for common cancers in accordance with the screening guidelines published by the American Cancer Society (eTable 16-3 available on the Evolve website for this chapter and
6. Eliminate, reduce, or change the perceptions of stressors and enhance the ability to effectively cope with stressors (see Chapter 8).
7. Know the seven warning signs of cancer, and inform the health care provider if they are present (Table 16-6). (These actually detect fairly advanced disease.)
8. Learn and practice recommended cancer screenings on a timely basis (e.g., colonoscopy in average-risk people beginning at 50 years and every 10 years thereafter).
9. Learn and practice self-examination (e.g., breast or testicular self-examination).
10. Seek immediate medical care if you notice a change in what is normal for you and if cancer is suspected. Early detection of cancer has a positive impact on prognosis."
The intravenous (IV) route is most common. Advances in drug formulation techniques are driving the reemergence of oral antineoplastic agents. Major concerns associated with the IV administration of antineoplastic drugs include venous access difficulties, device- or catheter-related infection, and extravasation (infiltration of drugs into tissues surrounding the infusion site) causing local tissue damage (Fig. 16-11).

Many chemotherapeutic drugs may be either irritants or vesicants. Irritants will damage the intima of the vein, causing phlebitis and sclerosis and limiting future peripheral venous access, but will not cause tissue damage if infiltrated. Vesicants, however, if inadvertently infiltrated into the skin, may cause severe local tissue breakdown and necrosis. It is extremely important to monitor for and promptly recognize symptoms associated with extravasation of a vesicant and to take immediate action if it occurs. The infusion should be immediately turned off, and protocols for drug-specific extravasation procedures should be followed to minimize further tissue damage.

Although pain is the cardinal symptom of extravasation, it can occur without causing pain. Swelling, redness, and the presence of vesicles on the skin are other signs of extravasation. After a few days, the tissue may begin to ulcerate and necrose. Vesicants may cause partial- or full-thickness loss of skin. Patients may need surgical intervention varying from debridement to skin grafting. Complications of extravasation include sepsis, scarring, contractures, joint pain, or nerve loss.

Common chemo vesicants:
nitrogen mustard

***Major reason why patients receive Central Venous Access Device to minimize these risks.
Regional treatment with chemotherapy involves the delivery of the drug directly to the tumor site. The advantage of administering chemotherapy by this method is that higher concentrations of the drug can be delivered to the tumor with reduced systemic toxicity. Several regional delivery methods have been developed, including intraarterial, intraperitoneal, intrathecal or intraventricular, and intravesical bladder chemotherapy.

*Intraarterial chemotherapy delivers the drug to the tumor via the arterial vessel supplying the tumor. This method has been used for the treatment of osteogenic sarcoma; cancers of the head and neck, bladder, brain, and cervix; melanoma; primary liver cancer; and metastatic liver disease. One method of intraarterial drug delivery involves the surgical placement of a catheter that is subsequently connected to an external infusion pump or an implanted infusion pump for infusion of the chemotherapeutic agent. Generally, intraarterial chemotherapy results in reduced systemic toxicity. The type of toxicity experienced by the patient depends on the site of the tumor being treated. Complications include bleeding, embolism, pain, arterial injury, catheter migration or dislodgement, and occlusion.

*Intraperitoneal chemotherapy involves the delivery of chemotherapy to the peritoneal cavity for treatment of peritoneal metastases from primary colorectal and ovarian cancers and malignant ascites. Temporary Silastic catheters (Tenckhoff, Hickman, and Groshong) are percutaneously or surgically placed into the peritoneal cavity for short-term administration of chemotherapy. Alternatively, an implanted port can be used to administer chemotherapy intraperitoneally. Chemotherapy is generally infused into the peritoneum in 1 to 2 L of fluid and allowed to "dwell" in the peritoneum for a period of 1 to 4 hours. Following the "dwell time," the fluid is drained from the peritoneum. Complications of peritoneal chemotherapy include abdominal pain; catheter occlusion, dislodgement, and migration; distention; ileus; intestinal perforation; and infection.

*Intrathecal or Intraventricular Chemotherapy
Cancers that metastasize to the central nervous system (CNS)—most commonly breast, lung, and GI tumors, leukemia, and lymphoma—are difficult to treat because the blood-brain barrier often prevents distribution of chemotherapy to this area. One method used to treat metastasis to the CNS is intrathecal chemotherapy. This method involves a lumbar puncture and injection of chemotherapy into the subarachnoid space. However, this method has resulted in incomplete distribution of the drug in the CNS, particularly to the cisternal and ventricular areas.

To ensure more uniform distribution of chemotherapy to the cisternal and ventricular areas, an Ommaya reservoir is often inserted. An Ommaya reservoir is a Silastic, dome-shaped disk with an extension catheter that is surgically implanted through the cranium into a lateral ventricle. In addition to more consistent drug distribution, the Ommaya reservoir precludes the use of repeated, painful lumbar punctures. Intrathecal chemotherapy needs to be administered by a physician or a registered nurse trained to administer via this route. Complications of intrathecal or intraventricular chemotherapy include headache, nausea, vomiting, fever, increased intracranial pressure, and nuchal rigidity.

*Intravesical Bladder Chemotherapy
The patient with superficial transitional cell cancer of the bladder often has recurrent disease following traditional surgical therapy. Instillation of chemotherapy into the bladder promotes destruction of cancer cells and reduces the incidence of recurrent disease. Additional benefits of this therapy include reduced urinary and sexual dysfunction. The chemotherapeutic agent is instilled into the bladder via a urinary catheter and retained for 1 to 3 hours. Complications of this therapy include dysuria, urinary frequency, hematuria, cystitis, urinary tract infection, and bladder spasms.
Chemotherapeutic agents cannot selectively distinguish between normal cells and cancer cells. Chemotherapy-induced side effects are the result of the destruction of normal cells, especially those that are rapidly proliferating such as those in the bone marrow, the lining of the GI system, and the integumentary system (skin, hair, and nails) (Table 16-9). Effects of chemotherapy are caused by general cytotoxicity and organ-specific drug toxicities. Response of the body to the products of cellular destruction in circulation may cause fatigue, anorexia, and taste alterations.

The general and drug-specific adverse effects of these drugs are classified as acute, delayed, or chronic.
****Acute toxicity occurs during and immediately after drug administration and includes anaphylactic and hypersensitivity reactions, extravasation or a flare reaction, anticipatory nausea and vomiting, and cardiac dysrhythmias.
****Delayed effects are numerous and include delayed nausea and vomiting, mucositis, alopecia, skin rashes, bone marrow suppression, altered bowel function (diarrhea or constipation), and a variety of cumulative neurotoxicities depending on the affected component of the nervous system (i.e., central or peripheral nervous system or cranial nerves).
****Chronic toxicities involve damage to organs such as the heart, liver, kidneys, and lungs. Chronic toxicities can be either long-term effects that develop during or immediately following treatment and persist or late effects that are absent during treatment and manifest later. Some side effects fall into more than one category. For example, nausea and vomiting can be both acute and delayed.
Caring for the person undergoing brachytherapy or receiving radiopharmaceuticals requires that you be aware that the patient is emitting radioactivity. Patients with temporary implants are radioactive only during the time the source is in place. In patients with permanent implants, because the sources have fairly short half-lives and are weak emitters, the radioactive exposure to the outside and to others is low. These patients may be discharged with minimal precautions.

The principles of ALARA (as low as reasonably achievable) and time, distance, and shielding are vital to health care professional safety when caring for the person with a source of internal radiation. Organize care to limit the amount of time spent in direct contact with the patient. To minimize anxiety and confusion, the patient should be made aware of the reason for time and distance limitations before the procedure. The radiation safety officer will indicate how much time at a specific distance can be spent with the patient. This is determined by the dose delivered by the implant. Because the source is nonpenetrating, small differences in distance are critical. Only care that must be delivered near the source, such as checking placement of the implant, is performed in close proximity. Use shielding, if available, and no care should be delivered without wearing a film badge. This badge will indicate cumulative radiation exposure. The film badge should not be shared, should not be worn other than at work, and should be returned according to the agency's protocol.
Can be caused by chemo (systematically) or radiation (locally). Since bone marrow is responsible for producing critically important blood cells (red blood cells, white blood cells, and platelets), treatment-induced reductions in blood cell production can result in life-threatening and distressing effects including infection, hemorrhage, and overwhelming fatigue.

Monitoring the complete blood count is critical in patients receiving chemotherapy and/or radiation, particularly the neutrophil, platelet, and RBC counts. It is typical for patients to experience the lowest blood cell counts (called the nadir) between 7 and 10 days after initiation of therapy. Monitor temperature routinely. Any sign of infection should be treated promptly as fever in the setting of neutropenia is a medical emergency. WBC growth factors (i.e., filgrastim [Neupogen], pegfilgrastim [Neulasta]) are routinely used to reduce the duration of chemotherapy-induced neutropenia, and as a prophylactic measure to prevent neutropenia when highly myelosuppressive chemotherapy drugs are used.

Neutropenia (low neutrophils, wbc that fight infection) is most common in patients receiving chemotherapy and can place them at serious risk for life-threatening infection and sepsis. Significant neutropenia will prompt treatment delay or modification (i.e., lower dosages). Take every possible measure to prevent infections in these patients. Hand hygiene is the mainstay of patient protection, and patients, as well as all of their contacts (including hospital staff), should follow hand-washing guidelines.
Gastrointestinal System (Inflammation)
• Assess oral mucosa daily and teach patient to do this.
• Encourage nutritional supplements (such as Ensure or Carnation Instant Breakfast) if intake decreasing.
• Be aware that eating, swallowing, and talking may be difficult (may require analgesics).
• Instruct in diet modification as necessary (avoidance of irritating spicy or acidic foods), selection of moist, bland, and softer foods.
• Encourage patient to keep oral cavity clean and moist by performing frequent oral rinses with saline or salt and soda solution.
• Encourage patient to use artificial saliva to manage dryness (radiation).
• Discourage use of irritants such as tobacco and alcohol.
• Apply topical anesthetics (e.g., viscous lidocaine, oxethazine).

• Teach patient to eat and drink when not nauseated.
• Administer antiemetics prophylactically before chemotherapy and also on as-needed basis.
• Instruct patients to take antiemetics on a scheduled basis for 2-3 days after highly emetogenic chemotherapy.
• Use diversional activities (if appropriate).
Assess patients experiencing nausea and vomiting for signs and symptoms of dehydration and metabolic alkalosis. Record fluid intake to ensure that an adequate volume is being consumed and retained. Nausea and vomiting can be successfully managed with antiemetic regimens, dietary modification, and other non-drug interventions. Anti-emetic meds such as metoclopramide (Reglan), prochlorperazine (Compazine), serotonin receptor antagonists (ondansetron [Zofran], granisetron [Kytril], dolasetron [Anzemet], and palonosetron [Aloxi]), and dexamethasone (Decadron) have been used to decrease nausea and vomiting caused by chemotherapy. Aprepitant (Emend) is the first agent in a class of antiemetics known as neurokinin 1 receptor antagonists, and is effective in preventing nausea and vomiting on the day of chemotherapy, as well as for delayed symptoms. The three-drug combination of a serotonin receptor antagonist, dexamethasone, and aprepitant is recommended before chemotherapy of high emetic risk (e.g., cyclophosphamide, anthracyclines).

• Monitor weight.
• Encourage patient to eat small, frequent meals of high-protein, high-calorie foods.
• Gently encourage patient to eat, but avoid nagging.
• Serve food in pleasant environment.
Nutritional supplements can be helpful as well. Enteral or parenteral nutrition may be indicated if the patient is severely malnourished or expected to have symptoms that interfere with nutrition for a protracted period or when the bowel is being rested. Medications, such as corticosteroids or progestins (e.g., megestrol acetate), may also be of benefit for some patients.

• Give antidiarrheal agents as needed.
• Encourage low-fiber, low-residue diet.
AVOID foods that are high in roughage (e.g., fresh fruits, vegetables, seeds, nuts). To prevent diarrhea, other foods that may be avoided include fried or highly seasoned foods, milk or other foods that are gas producing.
• Encourage fluid intake of at least 3 L.
Depending on the severity, hydration and electrolyte supplementation are also recommended. Lukewarm sitz baths may alleviate discomfort and cleanse the rectal area if significant rectal irritation has developed. The rectal area must be kept clean and dry to maintain skin integrity. You should visually inspect the perianal area for evidence of skin breakdown. Systemic analgesia may be warranted for the painful skin irritations that may develop. Note the number, volume, consistency, and character of stools per day. Teach patients to maintain a diary or log to record episodes, and aggravating and alleviating factors.

• Instruct patient to take stool softeners as needed, eat high-fiber foods, and increase fluid intake.

Many more Table 16-12
Thrombocytopenia (low blood platelet count) can result in spontaneous bleeding or major hemorrhage. Avoid invasive procedures and advise patients to avoid activities that place them at risk for injury or bleeding (including excessive straining). Risk of serious bleeding is generally not apparent until the platelet count falls below 50,000/μL. Platelet transfusions may be necessary and are usually administered when platelet counts fall below 20,000/μL. (Thrombocytopenia is discussed in Chapter 31, where a patient teaching guide [see Table 31-16] and a nursing care plan [see NCP 31-2] are available.)

• Observe for signs of bleeding (e.g., petechiae, ecchymosis).
• Monitor platelet counts.

• Notify your health care provider of any manifestations of bleeding. These include the following:
• Black, tarry, or bloody bowel movements
• Black or bloody vomit, sputum, or urine
• Bruising or small red or purple spots on the skin
• Bleeding from the mouth or anywhere in the body
• Headache or changes in how well you can see
• Difficulty talking, sudden weakness of an arm or leg, or feeling confused
• Ask your health care provider regarding restrictions in your normal activities, such as vigorous exercise, lifting weights, etc. Generally, walking can be done safely and should be done with sturdy shoes or slippers. If you are weak and at risk for falling, get help or supervision when getting out of bed.
• Do not blow your nose forcefully; gently pat it with a tissue if needed. For a nosebleed, keep your head up and apply firm pressure to the nostrils and bridge of your nose. If bleeding continues, place an ice bag over the bridge of your nose and the nape of your neck. If you are unable to stop a nosebleed after 10 minutes, call your health care provider.
• Do not bend down with your head lower than your waist.
• Prevent constipation by drinking plenty of fluids and do not strain when having a bowel movement. Your health care provider may prescribe a stool softener. Do not use a suppository, an enema, or a rectal thermometer without the permission of your health care provider.
• Shave only with an electric razor; do not use blades.
• Do not pluck your eyebrows or other body hair.
• Do not puncture your skin, such as getting tattoos or body piercing.
• Avoid using any medication that can prolong clotting, such as aspirin. Other medications and herbs can have similar effects. If you are unsure about any medication, ask your health care provider or pharmacist about it in relation to your thrombocytopenia.
• Use a soft-bristle toothbrush to prevent injuring the gums. Flossing is also usually safe if it is done gently using the thin tape floss. Do not use alcohol-based mouthwashes as they can dry your gums and increase bleeding.
• Women who are menstruating should keep track of the number of pads that are used per day. When you start using more pads per day than usual or bleed more days, notify your health care provider. Do not use tampons; use sanitary pads only.
• Ask your health care provider before you have any invasive procedures done, such as a dental cleaning, manicure, or pedicure.
Erythema may develop 1 to 24 hours after a single treatment, but generally occurs progressively as the treatment dose accumulates. Erythema is an acute response followed by dry desquamation (Fig. 16-14). If the rate of cellular sloughing is faster than the ability of the new epidermal cells to replace dead cells, a wet desquamation occurs with exposure of the dermis and weeping of serous fluid (Fig. 16-15). Skin reactions are particularly evident in areas of skinfolds or where skin is subjected to pressure, such as behind the ear and in gluteal folds, perineum, breast, collar line, and bony prominences.

Although skin care protocols vary among institutions, basic skin care principles apply. Prevention of infection and facilitation of wound healing are the therapeutic goals. Protect irradiated skin from temperature extremes. Do not use heating pads, ice packs, and hot water bottles in the treatment field. Avoid constricting garments, rubbing, harsh chemicals, and deodorants as they may traumatize the skin.
*Dry reactions are uncomfortable and result in pruritus. Lubricate the dry skin with a nonirritating lotion emollient (such as aloe vera) that contains no metal, alcohol, perfume, or additives that can be irritating to the skin.
*Wet desquamation of tissues generally produces pain, drainage, and increased risk of infection. Skin care to manage most desquamation includes keeping tissues clean with normal saline compresses or modified Burow's solution soaks and protected from further damage with moisture vapor-permeable dressings or Vaseline petrolatum gauze.
Table 16-13 Gives a list of Teaching specific to skin reactions r/t radiation
The effects of radiation on the lung include both acute and late reactions. Immediate pulmonary effects of radiation can be alarming to patients because they may mimic symptoms that precipitated the cancer diagnosis. Cough and dyspnea may increase during and at completion of therapy. The cough becomes more productive as alveoli that had been blocked are opened as the tumor responds to treatment, and due to increased production of respiratory secretions. As treatment continues, the cough can become dry as the mucosa begins to be altered by the radiation. Cough suppressants may be indicated at night.

Pneumonitis is a delayed acute inflammatory reaction that may potentially occur within 1 to 3 months following completion of thoracic radiation.26 This reaction is often asymptomatic, although an increase in cough, fever, and night sweats may occur. Treatment with bronchodilators, expectorants, bed rest, and oxygen is preferable to treatment with corticosteroids. A minority of patients may develop pulmonary fibrosis (with or without prior pneumonitis), which is a late effect of therapy occurring 6 months to 2 years after treatment and may be chronic.

The most common pulmonary toxicities associated with chemotherapy include pulmonary edema (noncardiogenic) related to capillary leak syndrome or fluid retention, hypersensitivity pneumonitis, interstitial fibrosis, and pneumonitis produced by an inflammatory reaction or destruction of alveolar-capillary endothelium. Patients are managed according to the offending agent and the manifestations of toxicity.
Common side effects include constitutional flu-like symptoms, including headache, fever, chills, myalgias, fatigue, malaise, weakness, photosensitivity, anorexia, and nausea. With interferon therapy, these flu-like symptoms almost invariably appear. However, the severity of the flu-like syndrome associated with interferon therapy generally decreases over time. Acetaminophen administered every 4 hours, as prescribed, often reduces the severity of the flu-like syndrome. The patient is commonly premedicated with acetaminophen in an attempt to prevent or decrease the intensity of these symptoms. In addition, large amounts of fluids help decrease the symptoms.

MoAbs are administered by the infusion method. Patients may experience infusion-related symptoms, which can include fever, chills, urticaria, mucosal congestion, nausea, diarrhea, and myalgias. There is also a risk, although rare, of anaphylaxis associated with the administration of MoAbs. This potential exists because most MoAbs are produced by mouse lymphocytes and thus represent a foreign protein to the human body. The risk is significantly decreased with human MoAbs. Onset of anaphylaxis can occur within 5 minutes of administration and can be a life-threatening event. If this occurs, administration of the MoAb should be stopped immediately, emergency assistance obtained, and resuscitation measures implemented.

Nursing interventions for flu-like syndrome include the administration of acetaminophen before treatment and every 4 hours after treatment. Intravenous meperidine (Demerol) has been used to control the severe chills associated with some biologic agents. Other nursing measures include monitoring of vital signs and temperature, planning for periods of rest for the patient, assisting with activities of daily living (ADLs), and monitoring for adequate oral intake.

Tachycardia and orthostatic hypotension are also commonly reported. IL-2 and monoclonal antibodies can cause capillary leak syndrome, which can result in pulmonary edema. Other toxic and side effects may involve the CNS, renal and hepatic systems, and cardiovascular system. These effects are found particularly with interferons and IL-2.

A wide range of neurologic deficits has been observed with interferon and IL-2 therapy.
Formerly bone marrow transplantation (BMT) and peripheral stem cell transplantation (PSCT) are effective, lifesaving procedures for the treatment of a number of malignant and nonmalignant diseases (Table 16-16). The approach is to eradicate diseased tumor cells and/or clear the marrow of its components to make way for engraftment of the transplanted, healthy stem cells. This is accomplished by administering higher than usual dosages of chemotherapy with or without radiation therapy, which can produce life-threatening consequences associated with pancytopenia and other adverse effects. Infusing healthy stem cells after therapy has been completed "rescues" the damaged bone marrow through the engraftment and subsequent normal proliferation and differentiation of the donated stem cells in the recipient.
In allogeneic transplantation, stem cells are acquired from a donor who, through human leukocyte antigen (HLA) tissue typing, has been determined to be HLA matched to the recipient. HLA typing involves testing WBCs to identify genetically inherited antigens common to both donor and recipient that are important in compatibility of transplanted tissue. (HLA tissue typing is discussed in Chapter 14.) Often this is a family member but may be an unrelated donor found through a national or an international bone marrow registry (e.g., National Marrow Donor Program). Although there may be more risks and toxicities associated with an unrelated allogeneic transplant, an added benefit of this type of transplant is not only eradication of the tumor cells with high-dose therapy, but also the potential stimulation of the graft-versus-tumor effect in which donor WBCs identify and attack malignant cells in the recipient. Common indications for allogeneic transplant are certain leukemias, multiple myeloma, and lymphoma.

Syngeneic transplantation is a type of allogeneic transplant that involves obtaining stem cells from one identical twin and infusing them into the other. Identical twins have identical HLA types and are a perfect match. Therefore neither the graft-versus-host nor the graft-versus-tumor effect occurs.

In autologous transplantation, patients receive their own stem cells back following myeloablative (destroying bone marrow) chemotherapy (Fig. 16-17). The aim of this approach is purely "rescue." It enables patients to receive intensive chemotherapy and/or radiation by supporting them with their previously harvested stem cells until their marrow is generating blood cells again on its own. Restoration usually takes 4 to 6 weeks depending on the particular conditioning regimen administered. Autologous transplants are typically used to treat hematologic malignancies if there is no suitable donor or the patient cannot undergo allogeneic transplantation. The newer, nonmyeloablative or reduced intensity transplant uses.

Stem Cells are harvested from iliac crest or sternum. Plerixafor (Mozobil) is a drug given subcutaneously that, when used in combination with G-CSF, boosts the number of stem cells released from the bone marrow into the bloodstream. Plerixafor is intended to be used in combination with G-CSF for treatment of multiple myeloma or non-Hodgkin's lymphomas.

Complications with HSCT are infection.
Obstructive emergencies are primarily caused by tumor obstruction of an organ or blood vessel. Obstructive emergencies include superior vena cava syndrome, spinal cord compression syndrome, third space syndrome, and intestinal obstruction.

Superior Vena Cava Syndrome

Superior vena cava syndrome (SVCS) results from obstruction of the superior vena cava by a tumor or thrombosis. The clinical manifestations include facial edema, periorbital edema, distention of veins of the head, neck, and chest (Fig. 16-18), headache, and seizures. A mediastinal mass is often visible on chest x-ray. The most common causes are lung cancer, non-Hodgkin's lymphoma, and metastatic breast cancer. The presence of a central venous catheter and previous radiation therapy to the mediastinum increases the risk for development of SVCS.34

Superior vena cava syndrome is considered a serious medical problem. Management usually involves radiation therapy to the site of obstruction. However, chemotherapy may be administered for tumors more sensitive to this form of therapy.

Spinal Cord Compression

Spinal cord compression is a neurologic emergency caused by the presence of a malignant tumor in the epidural space of the spinal cord. The most common primary tumors that produce this problem are breast, lung, prostate, GI, and renal tumors and melanoma.34 Lymphomas also pose a risk if diseased lymph tissue invades the epidural space. The manifestations are back pain that is intense, localized, and persistent, accompanied by vertebral tenderness and aggravated by the Valsalva maneuver; motor weakness and dysfunction; sensory paresthesia and loss; and autonomic dysfunction. One of the clinical symptoms that reflects autonomic dysfunction is a reported change in bowel or bladder function. Radiation therapy in conjunction with prompt initiation of corticosteroids is generally associated with some initial improvement. Surgical decompressive laminectomy is used for those with tumors that are not radioresistant or when the tumor is in a previously irradiated area. Activity limitations and pain management are important nursing interventions.

Third Space Syndrome

Third space syndrome involves a shifting of fluid from the vascular space to the interstitial space that primarily occurs secondary to extensive surgical procedures, biologic therapy, or septic shock. Initially patients exhibit signs of hypovolemia, including hypotension, tachycardia, low central venous pressure, and decreased urine output. Treatment includes fluid, electrolyte, and plasma protein replacement. During recovery hypervolemia can occur, resulting in hypertension, elevated central venous pressure, weight gain, and shortness of breath. Treatment generally involves reduction in fluid administration and fluid balance monitoring.
Metabolic emergencies are caused by the production of ectopic hormones directly from the tumor or are secondary to metabolic alterations caused by the presence of the tumor or cancer treatment. Ectopic hormones arise from tissues that do not normally produce these hormones. Cancer cells return to a more embryonic form, thus allowing the stored potential of the cells to become evident. Metabolic emergencies include syndrome of inappropriate antidiuretic hormone secretion, hypercalcemia, tumor lysis syndrome, septic shock, and disseminated intravascular coagulation.

Syndrome of Inappropriate Antidiuretic Hormone Secretion

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) results from abnormal or sustained production of antidiuretic hormone (ADH) with resultant H2O retention and hyponatremia (see Chapter 50). SIADH occurs most frequently in carcinoma of the lung (especially small cell lung cancer) but can also occur in cancer of the pancreas, duodenum, brain, esophagus, colon, ovary, prostate, bronchus, and nasopharynx; leukemia; mesothelioma; reticulum cell sarcoma; Hodgkin's lymphoma; and thymoma. Cancer cells in these tumors are actually able to manufacture, store, and release ADH. The chemotherapeutic agents vincristine and cyclophosphamide (Cytoxan) also stimulate the release of ADH from the pituitary or tumor cells. Symptoms of SIADH include weight gain without edema, weakness, anorexia, nausea, vomiting, personality changes, seizures, oliguria, decrease in reflexes, and coma. Treatment of SIADH includes treating the underlying malignancy and measures to correct the sodium-water imbalance, including fluid restriction and, in severe cases, IV administration of 3% sodium chloride solution. Demeclocycline (Declomycin) may be needed on an ongoing basis for moderate SIADH. Monitor the sodium level because correcting SIADH rapidly may result in seizures or death.35


Hypercalcemia can occur in the presence of cancer that involves metastatic disease of the bone or multiple myeloma, or when a parathyroid hormone-like substance is secreted by cancer cells in the absence of bony metastasis. Hypercalcemia resulting from malignancies that have metastasized occurs most frequently in patients with lung, breast, kidney, colon, ovarian, or thyroid cancer. Hypercalcemia resulting from secretion of parathyroid hormone-like substance occurs most frequently in squamous cell carcinoma of the lung; head and neck, cervical, and esophageal cancer; lymphomas; and leukemia. Immobility and dehydration can contribute to or exacerbate hypercalcemia.

The primary manifestations of hypercalcemia include apathy, depression, fatigue, muscle weakness, ECG changes, polyuria and nocturia, anorexia, nausea, and vomiting. Serum levels of calcium in excess of 12 mg/dL (3 mmol/L) will often produce symptoms, and significant calcium elevations can be life threatening. Serum calcium levels are affected by a low albumin level. A low albumin level will give a false-normal calcium level. Therefore correct the calcium level for serum albumin or check an ionized calcium level.35 Chronic hypercalcemia can result in nephrocalcinosis and irreversible renal failure. The long-term treatment of hypercalcemia is aimed at the primary disease. Acute hypercalcemia is treated by hydration (3 L/day), diuretic (particularly loop diuretics) administration, and a bisphosphonate, a drug that inhibits the action of osteoclasts. Infusion of the bisphosphonate zoledronate (Zometa) or pamidronate (Aredia) is the treatment of choice. These drugs are also used to prevent bone complications in patients with bone metastasis.

Tumor Lysis Syndrome

Acute tumor lysis syndrome (TLS) is a metabolic complication characterized by rapid release of intracellular components in response to chemotherapy. It occurs less commonly with radiation therapy. TLS is often associated with tumors that have high growth rates and are sensitive to the effects of chemotherapy. Massive cellular destruction, associated with aggressive chemotherapy for rapidly growing tumors, releases a host of intracellular components into the bloodstream, including potassium, phosphate, and DNA and RNA components (which are metabolized to uric acid by the liver). Rise in serum phosphate drives serum calcium levels down, with resultant hypocalcemia. Metabolic abnormalities and concentrated uric acid (which crystallizes in the distal tubules of the kidneys) lead quickly to acute renal failure if not identified and treated early.

The four hallmark signs of TLS are hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia. Early symptoms include weakness, muscle cramps, diarrhea, nausea, and vomiting.35 TLS usually occurs within the first 24 to 48 hours after the initiation of chemotherapy and may persist for approximately 5 to 7 days. The primary goal of TLS management is preventing renal failure and severe electrolyte imbalances. The primary treatment includes increasing urine production using hydration therapy and decreasing uric acid concentrations using allopurinol.

Septic Shock and Disseminated Intravascular Coagulation

Septic shock is discussed in Chapter 67, and disseminated intravascular coagulation is discussed in Chapter 31.

Infiltrative Emergencies

Infiltrative emergencies occur when malignant tumors infiltrate major organs or secondary to cancer therapy. The most common infiltrative emergencies are cardiac tamponade and carotid artery rupture.

Cardiac Tamponade

Cardiac tamponade results from fluid accumulation in the pericardial sac, constriction of the pericardium by tumor, or pericarditis secondary to radiation therapy to the chest. Manifestations include a heavy feeling over the chest, shortness of breath, tachycardia, cough, dysphagia, hiccups, hoarseness, nausea, vomiting, excessive perspiration, decreased level of consciousness, pulsus paradoxus, distant or muted heart sounds, and extreme anxiety. Emergency management is aimed at reduction of fluid around the heart and includes surgical establishment of a pericardial window or an indwelling pericardial catheter. Supportive therapy includes administration of oxygen therapy, intravenous hydration, and vasopressor therapy.

Carotid Artery Rupture

Rupture of the carotid artery occurs most frequently in patients with cancer of the head and neck secondary to invasion of the arterial wall by tumor or to erosion following surgery or radiation therapy. Bleeding can manifest as minor oozing or spurting of blood in the case of a "blowout" of the artery. In the presence of a blowout, apply pressure to the site with a finger. Intravenous fluids and blood products are administered in an attempt to stabilize the patient for surgery. Surgical management involves ligation of the carotid artery above and below the rupture site and reduction of local tumor.
As part of the plan, teach patients how to keep a pain management diary. Assess pain on an ongoing basis to determine the effectiveness of the treatment plan. Obtain data and document at regular intervals the location and intensity of the pain, what it feels like, and how it is relieved. Also assess patterns of change. Always believe the patient report and accept it as the primary source of assessment data. Table 16-19 presents assessment questions that may facilitate data collection.

Drug therapy, including nonsteroidal antiinflammatory drugs, opioids, and adjuvant pain medications, should be used. Opioids normally are prescribed for the treatment of moderate to severe cancer pain. Analgesic medications (e.g., morphine, fentanyl) should be given on a regular schedule (around the clock) with additional doses available as needed for breakthrough pain. In general, oral administration of the medication is preferred, but other routes (e.g., transdermal) are also available.

Onsolis is in a class of drugs that deliver fentanyl through the mouth's mucous membranes. Onsolis delivers fentanyl via an absorbable film that sticks to the inside of the cheek. The drug is indicated for the management of breakthrough pain in patients who already use opioid pain medication around the clock and who need and are able to safely use high doses of an additional opioid medicine.

It is important to remember that, with opioid drugs such as morphine, the appropriate dose is whatever is necessary to control the pain with the least side effects. Fear of addiction is not warranted but must be addressed as part of patient teaching relevant to pain control, since it is a significant barrier for both the patient and you for appropriate pain management.

Patient education should clarify myths and misconceptions and reassure patients and family caregivers that cancer pain can be effectively relieved. Furthermore, addiction and tolerance are not problems associated with effective cancer pain management.38 Nondrug interventions, including relaxation therapy and imagery, can be effectively used to manage pain