Oncology Case Studies

NURS 2205Connie Barbour, RN, MSN

Chemotherapy-InducedNausea and Vomiting

AB is a 19-year-old female diagnosed with osteogenic sarcoma coming to the clinic for her second cycle of chemotherapy. She is receiving cisplatin (Plantinol) and doxorubicin (Adriamycin) every 21 days. AB is in good health. She has no past medical history, does not drink or smoke, and reports a history of motion sickness. When AB comes off the elevator to the clinic, she immediately runs into the bathroom. Her mother is accompanying her morning and reports that she has been vomiting intermittently since she woke up this morning. The nurse realizes that AB is experiencing anticipatory nausea and vomiting.

Chemotherapy-InducedNausea and Vomiting

Why is the anticipatory nausea and vomiting occurring? This occurs when a patient has experienced unrelieved

n/v with chemotherapy in the past. It is most likely due to stimulation of the limbic system, the part of the brain where memories live.

It is difficult to treat and that is why it is important to control n/v from the very beginning so that anticipatory n/v do not develop

What intervention might help to prevent this type of nausea and vomiting in the future? The use of lorazepam (Ativan) can be helpful in this

situation taken at home prior to arriving at the clinic You can also try behavioral modification strategies such as

guided imagery, hypnosis, and biofeedback

Chemotherapy-InducedNausea and Vomiting

What risk factors can be identified for AB related to chemotherapy-induced nausea and vomiting? Chemotherapy agent used has a greater than 90% risk of

causing nausea Females at greater risk Younger than 50 years old is at greater risk Hx of motion sickness, hyperemesis with pregnancy, or

n/v with anesthesia or analgesics are at greater risk What are some other risk factors that pertain to

chemotherapy-induced nausea and vomiting? Hx of GI malignancy, radiation to the abdomen Hx of anxiety or depression in the past Prior inadequate control of nausea and vomiting

Chemotherapy-InducedNausea and Vomiting

What other types of nausea and vomiting exist that affect patients receiving chemotherapy and how do they differ? Acute nausea = n/v that occurs immediately, directly at

the time of introduction of the causative agent

Delayed nausea = n/v that occurs several days (24 hours or more) after chemotherapy agent is given, 40 – 50% of patients experience this

Breath through nausea = n/v that is not relieved by antiemetic, especially if it lasts for more than 24 hours

Chemotherapy-InducedNausea and Vomiting

AB is prescribed ondansetron (Zofran) and prochloperazine (compazine). Briefly describe the class of each antiemetic, how it works, and any side effects that AB could expect to experience. Zofran is a seratonin antagonist which blocks the action of

serotinin both centrally and peripherally. Seratonin antagonists work best in combination with

corticosteroids such as dexamethasone for acute n/v. Corticosteriods can also be used with metoclopramide

(dopamine antagonist) to treat delayed n/v. Headache and constipation are the most common side effects of

seratonin antagonists Prochloperazine is a dopamine antagonist. They bind to

dopamine receptors in the brain and block impulses to the vomit center

Dopamine antagonists are helpful in preventing n/v. Side effects include sedation and extrapyramidal side effects

Chemotherapy-InducedNausea and Vomiting

What types of instructions and discharge teaching should AB receive related to her nausea and vomiting? Instructions should be clearly written out How to take medications, possible pre-medicate for

chemotherapy Signs and symptoms of dehydration and when to report n/v Importance of controlling symptoms of delayed and break

through n/v with medication to prevent anticipatory nausea.

What non-chemotherapy cancer-related types of nausea and vomiting also exist? Bowel obstruction Electrolyte imbalance Primary brain tumors or brain metastasis

Mucositis/Stomatitis TM is a 72-year-old male who was in his usual state of health until he noticed a

worsening hoarseness 5 months ago. Three weeks ago he began to have trouble swallowing, which got progressively worse. He now is only able to swallow soft foods. TM reports a 10-pound weight loss in the past 3 months. He reports no change in appetite. He states that his level of fatigue is increasing and he now requires frequent rest periods. Tm has undergone extensive evaluation of these symptoms, including a CT scan and biopsy. The CT scan revealed a left supraglottic tumor. Left-sided adenopathy was also noted. Biopsy confirmed squamous cell carcinoma. TM is married and has 2 grown children. He tells his nurse his wife is very supportive and will accompany him to his appointments. He says he is a retired printer and that he owned his own printing business. TM currently smokes 50 cigarettes a day. He reports heavy alcohol use in the past. A head and neck surgeon, a radiation oncologist, and a medical oncologist evaluated him. TM has been advised that he will need both chemotherapy and radiation treatments. The chemotherapy regimen is cisplatin (Platinol) on days 1, 22, and 43 of radiation treatments. He is at the outpatient oncology clinic for his first cycle of chemotherapy. Radiation is scheduled daily for a total of 6 weeks. A PEG feeding tube was placed 2 days ago to be used if it is needed. The dietitian will see TM while he is at the clinic for chemotherapy. TM is at great risk for developing mucositis because he will be receiving radiation to the head and neck and concurrent chemotherapy.

Mucositis/Stomatitis What characterizes oral mucositis/stomatitis and

how common is this condition? Inflammation and ulceration of the mucous membranes 40% of patients receiving standard dose chemotherapy 80% of patients undergoing stem cell transplant 100% of patients receiving radiation therapy to the head

and neck with or without chemotherapy

Mucositis/Stomatitis In addition to concurrent radiation and

chemotherapy, what other risk factors does TM have for developing oral mucositis? Greater than 50 years old are more at risk Women greater risk than men Smoking and regular alcohol use is more at risk Poor nutrition more at risk Poor oral hygiene or improper fitting dentures more at risk

(however, no dental work should be done prior to chemotherapy)

Mucositis/Stomatitis What preventative measures can be instituted for

TM and why is it so important to be proactive in preventative care? Good oral hygiene program must be started after meals

and at bedtime Brush with soft toothbrush and change to sponge swab if

he becomes neutropenic or thrombocytopenic, change toothbrush monthly

Vigorous swish and rinse of mouth with saline or baking soda, no alcohol containing mouthwash

Avoid oral irritants such as commercial mouthwashes, hot or spicy foods, alcohol, tobacco, and lemon glycerin swabs, avoid putting sharp instruments in the mouth

Treat dry mouth (xerostomia) with lubricating and moisterizing agents such as Gatorade, sugarless gum, and Blistex

Mucositis/Stomatitis What are the possible clinical consequences for

TM should he develop oral mucositis? Reduction or delay in chemotherapy treatment Infection, changes in nutritional or hydration status Need for pain management and will negatively impact his

quality of life

TM comes into the clinic for evaluation stating that he is now only able to swallow liquids and complains that “nothing tastes the same”. What assessment finding should the nurse look for? s/s of dehydration, decline in nutritional status, weight,

skin turgor, orthostatic vital signs and oral intake

Mucositis/Stomatitis

What types of treatments might TM receive? For mild to moderate mucositis increase oral hygiene to

every 2 hours For severe mucositis increase oral hygiene to every hour IV rehydration if dehydrated Immediate goal will be to lessen pain. A pain regimen will

be started consisting of topical anesthetic and possible systemic analgesic

Topical agents are mainly used for mild to moderate mucositis because relief is short in duration (1-2 hours or less)

Use of “magic mouthwash” – apply 10-15 minutes before meals, may need to apply with a swab instead of swish and

Tube feeding may be initiated also

Mucositis/Stomatitis How are systemic analgesics used in the treatment of

oral mucositis? Opioids are generally used for moderate to severe mucositis May use a combination of long or short acting and is tailored to

the patients needs Non-opioids may be used such as NSAIDS to decrease tissue

damage from inflammation

Tube feeding was initiated due to TM developing oral mucositis. How long after chemotherapy and radiation treatments are completed will TM need to continue his tube feedings and why? Mucosal epithelium takes 7 -14 days to regenerate so tube

feedings will continue for at least 2 weeks after treatment has been completed and all tissues have healed

Neutropenic Sepsis CS is a 73-year-old female recently diagnosed with non-

Hodgkin’s lymphoma. She was treated with CHOP/rituximab (Rituxan) 1 week ago. This is her first cycle of chemotherapy.

What general discharge teaching will the nurse need to provide to CS following this first cycle of chemotherapy? Report temperature greater than 100.5˚F, Shaking, chills, or shortness of breath Unusual bruising or bleeding Burning or frequency when urinating N/V, or diarrhea lasting more than 24 hours Constipation lasting greater than 48 hours Induration, redness, or tenderness around the venous access

device insertion site

Neutropenic Sepsis What preventative measures can be taken to avoid infection should

neutropenia occur? Avoid all invasive tests and procedures unless absolutely necessary 7 – 10

days post chemotherapy Break in skin’s natural defensive can cause an infection

Maintain excellent oral hygiene and keep oral mucosa moist Use stool softener to prevent straining and rectal mucosa trauma If no bowel movement after 48 hours use stimulant laxative such as

Senokot Safety with food preparation and handling

Avoid uncooked meat and fish, thaw meat in refrigerator Wash fruits and vegetables thoroughly Avoid buffets and salad bars

Moisturize skin to prevent dry skin, shave with electric razor only Strict hand washing and meticulous care of central and peripheral

catheter sites Possibly may need to wear a face mask when out in public Take temperature every four hours while at home

Neutropenic Sepsis What assessment data would the nurse anticipate

finding if neutropenic sepsis is developing? Onset of chilling and shaking is a strong indication neutropenic

sepsis may be occurring and will happen even before the temperature goes up

Also be aware that redness, swelling, induration and exudate may be absent with infection Usually fever, pain, and slight redness can be seen

What medication can be given to improve neutropenia? What are the side effects and patient teaching related to these medications? Myeloid growth factor will be given, such as Neupogen Most common side effect is medullary bone pain Patients or family members often taught how to administer

medication subcutaneously

Neutropenic Sepsis CS reports chilling and was instructed to go to the

emergency room for a temperature that exceeded 100.5 degrees Fahrenheit. She arrives in the ER at 1900 hours today and is being admitted to the oncology floor. Her vital signs are 103 degrees Fahrenheit; pulse 125, respirations 32; and blood pressure 90/60. Lab values are hgb 7.9, hct 23, WBC 200, platelets 36, segs 20%, and bands 5%. She appears warm and flushed but repors having an uncontrollable shaking chill 2 hours ago.

Neutropenic Sepsis What are the signs and symptoms of neutropenic sepsis?

Early s/s of sepsis are fever, skin warm and flushed tachycardia, tachypneic, slight hypotension

S/S sepsis becoming advanced shock include hypotension, peripheral cyanosis, cold and clammy extremities, decrease urine ouput or anuria, and changes in mental status

Discuss what immediate nursing actions should be taken for CS? The nurse would be getting an order to obtain aerobic and

anaerobic blood cultures Cultures of all other areas such as urine, sputum, throat, wound, etc Chest x-ray IV fluids, antibiotics and possible hemodynamic medication to

maintain blood pressure Frequent assessment of vital signs, intake and output, etc

Pain JB is a 79-year-old male diagnosed with multiple

myeloma involving the bone including the spine 6 months ago. He complains of severe, sharp, throbbing back pain which also started 6 months ago and has progressively worsened over the last several months. JB describes the pain as most severe when he wakes up. He rates it as 9 on a 0-10 pain scale. He is currently taking 1-2 oxycodone with acetaminophen (Percocet) every 4 hours as needed. Following 2 Percocet, the pain goes down to a 4, which JB says is an acceptable level of pain to him. He reports taking 2 Percocet on average 4 times a day since diagnosis. He takes a dose before bedtime but none during the night. He is concerned about the amount of pain pills he is taking and tells his nurse that he is afraid of becoming addicted to them.

Pain What criteria are used to measure pain?

Location = where Characteristics = description or words used Duration = start, stop, how long Intensity = 1 to 10 Aggravating and relieving factors Neuropathic pain is usually sharp, stabbing, shooting, and

buring Nociceptive pain (somatic and visceral) is usually

throbbing, dull, aching, and cramping Is JB’s pain acute or chronic? Explain the

difference? JB is experiencing chronic pain, chronic pain is pain

usually lasting longer than 3 months Acute pain is lasts for short periods of time, usually less

than 6 months

Pain Is JB’s amount of pain relief with oxycodone with

acetaminophen acceptable? Why or why not? It is not acceptable even though he reports adequate relief at

taking it, because he doesn’t provide continuous, around the clock relief and he still wakes up in pain.

What is one way that JB’s pain regimen might be changed? Switched to a long-action medication such as OxyContin

(sustained release oxycodone) taken once every 12 hours or Duragesic patch (fentanyl) changed every 48 – 72 hours Use of oxycodone with acetaminophen every 4 hours for break

through pain This will provide around the clock relief, should lower his pain

rating even further, and greatly cut down on his use of acetaminophen and how many pills he has to take

Pain What are the side effects of narcotic analgesics

and how could they be addressed? Most common side effect is constipation due to reduced

smooth muscle motility Increase fiber and fluid intake Stimulating laxative is often needed, not just a stool

softener because of this side effect Can also have n/v, somnolence, urinary retention,

dizziness, rash, itching, and confusion Most patients will develop a tolerance to these side

effects, except constipation, in about 3 – 5 days

Pain How should the nurse address JB’s concern about

becoming addicted to pain medication? First this is a common concern, stress that few people taking it

for cancer related pain develop an addiction

The body can develop a tolerance and become accustomed to it so that more is required to treat the pain and physical withdrawal can occur if stopped abruptly

Stress that developing a tolerance does not mean that they are addicted because they are not taking it to satisfy an emotional need but a true experience of pain

Patients can also be afraid of the sedative nature of the medication. Stress not to skip doses to keep pain under control but that the strength may need to be decreased. Once pain gets out of control it can be harder to get back into control.

Pain What is one factor to consider related to starting a

narcotic analgesic in a person of JB’s age? Older patients experience the same amounts of pain as do

younger patients However, “start low and go slow” is important to remember

because they may have reduced renal and hepatic function and medications can stay in their system longer

What are 3 common barriers to pain management that cancer patients experience? Inexperience and lack of education on the part of the health

care provider Fear of addiction on the part of the patient, family, or health

care provider Fear that pain will not be able to be controlled as the end of life

approaches if pain medication is used before then

Leukemia and Thrombocytopenia SG is a 28-year-old female recently diagnosed with acute

myelogenous leukemia (AML). She was diagnosed during the third trimester of her pregnancy when she presented with fatigue, an elevated white blood cell count, and diffuse adenopathy. SG delivered a healthy baby boy at 38 weeks via cesarean section. She is admitted to the oncology unit for her first cycle of induction therapy 5 days after delivery. Lab values include hgb 12, hct 36%, platelets 300,000, WBC 400,000 with 60% blast cells, BUN 0.9, and creatinine 1.0. Liver function tests are within normal limits. SG is married and has a supportive family and network of friends. SG weighs 132 pounds and is 5 feet 4 inches tall. Her physician orders the following induction chemotherapy regimine: Idamycin daily days 1-5, cytarabine every 12 hours days 1 – 5, etoposide (VP-16) daily days 1 – 5, Zofran every 12 hours, and dexamethasone daily.

Leukemia and Thrombocytopenia After reviewing the orders the nurse realizes that

orders are missing. The nurse is concerned about tumor lysis syndrome with this patient. What is tumor lysis syndrome and what additional orders are needed? Tumor lysis syndrome is a preventable oncologic

emergency It occurs when there is rapid release of intracellular

material in the blood due to tumor cells dying rapidly Symptoms include hyperkalemia, hypocalcemia,

hyperphosphatemia, hyperuricemia, olgiuria, acute renal failure, tetany, cardiac arrhythmias, and cardiac arrest

Prevention includes aggressive IV hydration for newly diagnosed patients with AML

Patient will also be placed on allopurinol (Zyloprim) to help lower serum and urinary uric acid levels caused by the breakdown of the tumor cells.