C E N T R A L N E R V O U S S Y S T E M

MAY – brain cancer awareness month

ANATOMY & PHYSIOLOGY

Pituitary Gland – located at Sella turcica
Hypothalamus
Neurons – transmits & receive signals; G0; (+) synapse
Neuroglial cells – support the neurons; enter the cell cycle more frequently
4 major types/cells:
CNS:
Ependymoma – support; provides fluid for the brain
Oligodendrocytes – supports myelin sheath ↑ICP
Astrocytes – star-like; filter; nourishment most common manifestation
Microglia – fight off infection/foreign bodies
PNS
Satellite – physical support
Schwann – covers the myelin sheath
Spinal cord – responsible for PNS & nerves
Lamina – each portion of the spinal cord
Pedicle

CLASSIFICATION SYSTEM
Classified by cell of origin
 Mitotic activity – ability to multiply/reproduce/replicate
 Microvascular endothelial perfusion – angiogenesis; +/- mitosis
 (+) necrosis

TUMOR GRADING
I. Tissue is benign (primary tumor)
II. Tissue is malignant (secondary tumor)
III. Malignant tissue has cells actively reproducing abnormal cells and reproducing rapidly
and form new cells
IV. Same with II but with angiogenesis

COMMON SITES:
I. Neuroepithelial
Glioma
a) Astrocytoma
I Pilocytic – most common in pedia
II Astrocytoma
III Anaplastic astrocytoma
IV GBM – Glioblastoma multiforme – worst type; involves the CSF; poor prognosis
Diffuse pontine glioma – “brain stem glioma,” fatal
b) Oligodendroglioma – slower-growing, more sensitive to treatment
Oligoastrocytoma – “mixed glioma” = astrocytoma + oligodendroglioma
c) Ependymoma – pedia; developed from ventricle wall; hydrocephalus
d) Primitive Neuroectodermal tumors (PNET)
II. Meningeal tumor
Meningioma – symptoms depends on the site affected
Initial sign = severe HA
III. Sellar tumors
Pituitary adenoma
Take note of the hormones secreted by Anterior/Posterior Pituitary gland
Easiest to identify; difficult to treat
ANTERIOR POSTERIOR
FSH Oxytocin
LH ADH
ACTH
TSH
Prolactin
GH

Craniopharyngioma – tumor arises outside the pituitary gland

Visual impairment – optic nerve is compressed

IV. PNET – Peripheral Nerve Tumors

Schwannoma – usually present at CN VII (facial) & VIII (acoustic)
(-) facial expression
Gait/balance problems = ataxic

Clinical features
General Symptoms (not assoc with irreversible neuro damage)
A. ↑ICP triad: HA, n/v, papilledema
B. Change in mental status – mental slowness; inability to concentrate
C. Seizure – presenting sign for supratentorial lesions/fronta lobe tumors

Diagnosis
CT
MRI with contrast
MRS – spectroscopy – evaluates the metabolism of tumor; distinguish high-grade from
low-grade
fMRI – functional MRI – assess language, motor, sensory in telation to tumor location
PET – uses fluorodeoxyglucose-18 (18F)

TREATMENT
Initially, steroid therapy
Dexamethasone – DOC periop
Antacid / H2 blockers – if longterm use of steroids or (+) GI symptoms
Anticonvulsants

A. SURGERY
Stereotactic biopsy – performed to establish diagnosis only.
Craniotomy – obtain diagnosis and ↓ mass effect
B. RADIATION THERAPY
Simulation – imaging studies; treatment position; mask.
3DCRT – 3D conformal RT
SE:
Fatigue Delayed effects:
Alopecia Cognitive 
 saliva Radiation necrosis
 taste
C. CHEMOTHERAPY
Gliadel® – biodegradable chemotherapy wafer
Releases carmustine for a period of 2-3 weeks
Implanted at the same time of craniotomy for tumor debulking
Can cause ↑ICP

Nursing Management
Anti-emetics – n/v
Steroids – HA + n/v

General Nursing Management

Provide verbal and written instructions prior
Inform possible complications and symptoms to be reported stat
Report s/sx of ↑ICP – n/v assoc with HA

P e d i a
 Craniopharyngioma – sellar region
 Intracranial germ cell tumors
Germinoma
Nongerminoma – -fetoprotein and β-human chorionic gonadotropin in CSF or serum

CLINICAL FEATURES
Based on location
 ↑ICP & vomiting  Vision changes
 HA  LOC changes
 Head tilt  Endocrine abnormalities
 Ataxia  ↑ head circumference - <2 y/o
 Dysmetria  Older children = school failure & psych
 Seizures dx

TREATMENT
1. Surgery – primary treatment
Careful and ongoing neural assessment
Comfort measures
Maintain isovolumic state

2. Radiation
Delayed if possible until after 3 y/o
Delivered in fractional doses over a period of several weeks
Total dose = 1800-6000 cGy
Positioning – remain still
Sedation/anes
Education – expected SE and late effects

3. Chemotherapy
Useful in delaying rad therapy Monitor closely for alterations in neural
Common agents: status
Cisplatin Fluid limits
Etoposide WOF ↑ICP = mannitol; corticosteroids
Ifosfamide
Nitrosureas
 S P I N A L C O R D T U M O R S

Types:
 Intramedullary – inside the spinal cord
 Intradular Extramedullary – between and spinal cord and meninges
 Extradular - outside spinal cord and meninges

Risk Factors:

Signs and Symptoms

General Signs Brain Tumor Common
Headache Projectile vomiting Back pain
Nausea & vomiting Mood swings Gait
Seizures Cognitive decline – #series Motor
Memory problems Hearing problems
Seizures Headache
Vision problems Speech problems
Problems associated with Seizures
hearing/speech/balance/walking

Diagnostic Tests
Adult Pedia
CT – to r/o stroke MRI
MRI with contrast Surgical biopsy
Biopsy Lumbar Puncture
MRS – Magnetic resonance spectroscopy

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Management
Stereotactic biopsy
Craniotomy
Transsphenoidal hypophysectomy

HOB elevated 10-45°

Eval LOC, neuro v/s, FOUR score
Avoid strenuous act, sneezing, coughing
Diabetes insipidus, SIADH

Drainage of CSF: Cx:

VP shunt Tubing to abd cavity Ascites
VA shunt Tubing to the heart CHF Position: Side-lying
Valve Reservoir of the fluid

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Stereotatic Radio Surgery – Precise on the area of tumor only
3 Methods in ensuring accurate precision
1. Gamma knife (gold standard)
2. Metal ring head frame
3. Cyberknife
Nursing Care Management:
1. P(x) and family education about the procedure
2. Lab values
3. Assessment and monitor discharge instructions
4. Collaborate with details of SRS planning
5. IV insertion
6. Pain assessment and control
7. Symptom monitoring
8. Emotional support

Radiation Therapy Care

Side Effects:
1. Wash with mild soap, PAT dry
2. X tape, rubbing, scratching
3. Wear loose fitting
4. Electric razor if shaving in the area
Skin
5. X swimming chlorinated H20
6. X sun exposure
7. Skin care products recommended
8. Avoid skin products 4 hours prior
1. Patient education
2. Exercise
Fatigue
3. Energy conservation
4. Treatment of anemia
1. Risk for infection – Neutropenic precautions
Bone marrow suppression
2. Risk for Bleeding – Bleeding precautions
Other side effects: oral mucositis, dry mouth, taste changes, tooth decay and carries,
osteoradionecrosis (late complication of head and neck radiation)

Cerebral edema and Cognitive dysfunction – Change in LOC, focal neurologic sign

Alopecia

Anticipatory Teaching
 5000 cGY (permanent hair loss)
 Regrowth after 2‐3 months after treatment
 Texture and color may change when regrowth
Wash hair with gentle shampoo (2X)
Obtain wig
Psychiatric interventions
Scalp irritation – redness, dryness and itching
AVOID hair color

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 R A 1 1 2 1 5
NATIONAL INTEGRATED CANCER CONTROL ACT
Feb 14, 2019

 Essential medicines
 Affordable cancer care and treatment
 Cancer registry and monitoring system – Nurse needs to document and monitor the case. The
epidemiology of cancer in the institution
 Support environment for persons with cancer
 Cancer awareness – National Cancer awareness month, HE and Promotion, Initiatives and eliminate
stigma, integration of age appropriate, practical supportive care and psychological support.
 Quality health care systems
 Establishment of cancer care center

Beneficiaries of RA 11215:
a. Cancer patients
b. Cancer survivors
c. Family members of patients with cancers
Government Agencies Involve:
A. DOH – Philippine Cancer Center which is spearheaded by the DOH Secretary
B. DSWD – Health Education
a. Schools, Colleges, and Universities
i. CHED (Colleges and Universities)
1. Will include curriculum about health care
ii. DepEd (Kinder [Childhood Cancer] to Senior High School) – tailored to their level
of knowledge
1. Prevention of diseases
2. Promotion of health
b. Community – Health Education
i. Department of Interior and Local Government
1. LGU
2. RHU
c. Work place
i. DOLE (Governs non “boarded” jobs)
ii. Civil Service Commission (Government)
iii. TESDA

Council of Members (7 Members):

a. DOH Secretary a. Two medical doctors
b. Vice Chairperson b. Good moral character
a. 3-year term c. 10 years in oncology area
b. Shall be elected by non ex d. Chosen from at least 5 persons
officio members recommended by DOH
i. Secretary of DSWD secretary
ii. Secretary of DOLE d. Cancer-Focused Patient Support
iii. Secretary of DILG Organizations – Philippine Cancer
Society, PONA, PCSO
iv. Philhealth CEO
a. Three representatives only from
v. Director General of each organization
FDA
b. 3-year term
c. Medical Doctors

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 O N C O L O G I C E M E R G E N C I E S

↑K WOF 6 mEq/L
Tumor Lysis Syndrome ↑PO4 Buffer system - pH
↑Uric acid Stone (kidneys)
Hypercalcemia ↑Ca > K ♥ arrest
JVD
Superior vena cava syndrome Cor pulmonale
RSHF
↑ICP Compress brain structures
Duration
Onset
Frequency
Temperature
Cancer-related fever Co-morbidity – DM/HPN/Chemo – 24-72°

Anti-pyretics
Fluid
Boost immune system

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 T U M O R L Y S I S S Y N D R O M E

- Occurs mostly in chemotherapy; Rituximab and Interferon

- Increase in potassium (may lead to cardiac arrest, nurse needs to refer even if it is 5.5 to
6.0 meq/L), uric acid (formation of uric acid stones that would damage the kidney), and
phosphate (buffer system to normalize the pH levels of the blood which is 7.35 - 7.45.
- Patient with hyperphosphatemia will more like to have metabolic acidosis. Lactic Acid
increases because of the anaerobic environment (no oxygen).
- Muscle cramping is occurring because of the increase in lactic acid.
- Tachycardia is the muscle cramping of the heart.
- Medical Management:
o Hydration
o Diuretics
o Allopurinol
o Calcium Gluconate (Hypocalcemia)
o Kayexalate (Cation-Exchange Resins)
o Sodium Bicarbonate
o Rasburicase (drug for treatment of Hyperuricemia induced
by chemotherapy drugs.
- Nursing Considerations:
o Drug Administration
o Lab values
o Monitor VS and Hemodynamics
o Cardiac and renal monitoring

H Y P E R C A L C E M I A

- High levels of calcium in the body leads to cardiac arrest. Calcium has a greater effect
than potassium with regard to its pumping action.
- Hypercalcemia maybe the result of thyroid problems, neck cancer, and etc.
- Normal level of calcium is 9 - 11 mq/dL (4.5 – 6.0 meq/l)
- DX: Cardiac monitor, serum electrolytes

S U P E R I O R V E N A C A V A S Y N D R O M E

- Compression of the SVC may lead to impediment of blood flow in the heart.
- Manifestations: Jugular vein distention
- May experience cor pulmonale (RSHF) – Right ventricle hypertrophy
- Regurgitation of blood in the RA, causing backflow of blood
- Proper assessment is necessary in the emergency room.

I N C R E A S E D I C P

 Brainstem might be compressed. If brainstem is compressed it will compromise his reflexes

and same with his breathing.
o EMERGENCY: Corneal and pupil dilation (Reflex)
 Denotes increasing ICP
 Need to check especially for people with metastasis (like SC Tumor, Vagus nerve)

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 C A N C E R - R E L A T E D F E V E R

- Emergency Room Concern:

o Patient goes to ER to report fever – gaano katagal, kelan nagsimula, gaano katas,
may iba pa bang sakit?
o Nurse needs to check for comorbidities like cancer. If patient has cancer:
 Always remember they are immunosuppressed. Fever is likely to happen for
people who is undergoing chemotherapy. Fever develops after 24-72 hours
after chemotherapy.
- If taken for granted about the comorbidity, patient will more likely to die. Proper assessment
of the patient condition is necessary.
- Conditions like this is not resolvable by just giving antipyretic medicine. The immune system
needs to be boosted to treat the cause of fever.
- Proper documentation of Patient History is necessary. Otherwise you will be held liable. Nurse
can be sued for Negligence.

Medications for Oncologic Emergencies

1. Diuretics (Osmotic)
2. Allopurinol
3. Kayexalate
4. CA channel blockers – IV Incorporate of Nicardipine
5. Immunoglobulin
6. Antipyretics
7. Calcium Gluconate – Phosphate Binder to go back to cells. Can be excreted by kidney
8. Sodium Bicarbonate – To retain acid. Slow IV push. Patient will be in a catheter. IV burn
is manifested by patient having tachycardia (may lead to cardiac arrest).
9. Dexamethasone

Possible Management:
a) Treat the cause
b) Positioning
c) Inotropes (dobutamine/dopamine/epinephrine) + furosemide

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 C O L O R E C T A L C A N C E R
0 8 2 0 1 9
March

RF
Increasing age - >50 y/o (slower peristaltic movement = waste products stays longer in the
colon. Immune system goes down as age progresses)
Family history
 Familial adenomatous polyposis
 Hereditary nonpolyposis colorectal cancer
 First-degree relatives = threefold risk
Previous colon cancer or polyps = produce excessive mucus and lead to severe f&e d/o
History of IBD – ulcerative colitis, Crohn’s disease
Diet:
 ↑ fat, ↑ CHON (red meat), ↓ fiber
 ↑ alcohol & caffeine intake
 Genotoxic carcinogens: charbroiled meats, fish and fried foods
 Deficiencies: Vitamin A, C, E; selenium, calcium
Overweight
Smoking

Cancer Colon Has Four Parts:

a. Ascending Colon -
b. Transverse Colon -
c. Descending Colon – Common site of cancer because of waste products. Exposure to
waste materials is longer. Ideal times to poop is 2-3X a day.
d. Sigmoid Colon – small part near the anus. Common site of cancer because of waste
product exposure. Ideal times to poop is 2-3X a day.

The staging of colon cancer is determined by the layers where it penetrated. I f it is in the
peritoneum, it can be considered Stage IV. This may also spread in liver, peritoneum and lungs.

1. Mucosa – Common site is within the colon. This is exposed to the fecal matter. If found in
this area, this is Stage 1.
2. Muscularis Mucosa

ASSESSMENT/CLINICAL FEATURES

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General sx: Late sx:
Change in bowel habits Loss of energy
Blood in stool Weight loss
Tenesmus Fatigue
Anorexia Anorexia
Flatulence Anemia - (+)active bleeding. RBC is only
Indigestion being replaced for 120 day = fatigue d/to
lack of O2 = nausea and anorexia.

Black, tarry stools – (+) blood = melena

Loose, frothy stool – (+) fat = steatorrhea
Flat, ribbon-shaped – intussusception (pedia); suspected ca (adult)
Mahogany-colored – Hirschsprung disease (pedia); suspected ca (adult)
Graying stool – after barium swallow or enema
Red stool – hematochezia
Green stool – inflammatory bowel diseases

Gallbladder/ Lower Upper

Bowel
Normal Liver Pancreatitis GI GI
inflammation
Problems Bleeding Bleeding

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PREVENTION
1. Eat a healthy diet.
a. at least 5 servings of fruits and vegetables daily (25mg of fiber per day)
b. replace red meat with chicken, fish, nuts, and legumes
c. take multivitamins containing 0.4mg of folic acid
d. limit alcohol intake to 2 drinks/day or less for men and 1drink/day for women
2. Exercise for 30 minutes
a. moderate activity (brisk walking, dancing, and gardening)
b. start slowly and build up to 30 mins a day

SCREENING, DETECTION, DIAGNOSIS

FOBT
 Annual for asymptomatic person >50 y/o
 False Positive:
o High residue
o Red meat (hgb content)
o Raw veggies (beets, cherries, citrus, horseradish, melon, radish, tomatoes, turnips,)
o Meds: Aspirin (NSAIDs), Iron, Anti-coags
o Diverticulosis/hemorrhoids
 False Negative:
o Vitamin C & K
AVOID 7 days before: Meds
AVOID 3 days before: Food & vitamins

SCOPY
 Proctosigmoidoscopy – (sigmoid) done every 5 years
 Fiberoptic sigmoidoscopy (entire colon) – done every 5 years
Baseline age 50 y/o. If with biopsy, place excised tissue on a moist gauze or in an
appropriate receptacle, label correctly and deliver to lab without delay. Inform
sensations throughout the procedure. No anesthesia, only sedatives. Check for flatus.

Preoperative
1. Informed consent.
2. Low residue diet 1-2 days prior to test.
3. Sedatives.
4. Clear liquid diet (Intestinal lavage: Golytely, Colyte, and Nultytely)
starting at noon the day before the procedure.
5. NPO for 8 hours prior to procedure or midnight.
6. Laxative the day and night before the procedure.
7. Position: Comfortable position on the left side with the right leg bent and
placed anteriorly (LEFT SIMS LATERAL).
8. Cleansing enema until clear returns the night before the procedure. Fleet
enema (undigested food during the night) until returns are clear in the
morning.
9. Monitor VS, pain, skin color, vagal response.
Postoperative
1. Check for flatus (return of peristalsis) and rectal bleeding.
2. First defecation has a tinge of blood because of the scope.
3. Signs of intestinal perforation (fever, rectal drainage, abdominal
distention and pain).
4. Patient can resume regular activities and diet (soft diet first).

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  Colonoscopy – done every 10 years; most accurate
 Proctoscopy

DRE – performed yearly; done before “scopy” or barium enema.

Double contrast barium enema – performed every 5-10 years + colonoscopy
If polyps are present, an apple core will be seen
Preoperative
10. Informed consent.
11. Low residue diet 1-2 days prior to test.
12. Sedatives.
13. Clear liquid diet (Intestinal lavage: Golytely, Colyte, and Nultytely)
starting at noon the day before the procedure.
14. NPO for 8 hours prior to procedure or midnight.
15. Laxative the day and night before the procedure.
16. Position: Comfortable position on the left side with the right leg bent and
placed anteriorly (LEFT SIMS LATERAL).
17. Cleansing enema until clear returns the night before the procedure. Fleet
enema (undigested food during the night) until returns are clear in the
morning.
18. Monitor VS, pain, skin color, vagal response.
19. Laboratory function needs to be checked such as the Kidney function.

Postoperative
1. Check for flatus (return of peristalsis) and rectal bleeding.
2. First defecation has a tinge of blood because of the scope.
3. Signs of intestinal perforation (fever, rectal drainage, abdominal
distention and pain).
4. Patient can resume regular activities and diet (soft diet first).

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Barium enema
Other tests:
 Laboratory
CEA – carcinoembryonic antigen
CA 19-9
-fetoprotein
CBC – to check for bacterial infection and anemia
 To check for possible metastasis
CXR
Abd CT scan
LFT (AST/ALT)

STAGING

Stage 1 - Mucosal

Stage 2 – Submucosa with or without

lymph node involvement

Stage 3 – Muscularis + lymph node

involvement

Stage 4 – Perforation in the Peritoneum

and metastasis

COMPLICATIONS
A. Large bowel obstruction
B. Hemorrhage (GI bleeding)
C. Peritonitis, abscess, sepsis
Patient can be evaluated for nausea, hiccups, chills, spiking fever, board like
abdomen. For abscess, warm compress and administer antibiotics as ordered.
D. Bowel perforation
E. Intraperitoneal infection

SURGERY
Endoscopic Polypectomy - Tumor is removed. The recurrence is very high because there might
be something left. If there is presence of tumor, radiation and chemotherapy.

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Laparoscopic Colectomy – Part only is removed. The abdomen is not opened. Thus, this require
4-5 incisions and the patient can go home.

Colon resection with anastomosis - remove the part of the colon that has a tumor. Cannot
determine the leak. Physician will order a barium enema to determine if there are any leaks. If
with leaks, peritonitis and abdominal distention may be present. Rigidity, temperature
evaluation, and signs of shock.

Colon resection: abdominoperineal resection – higher risk for infection

Colon resection: colostomy

Double barrel stomas
Proximal stoma
Distal stoma
o Ascending – liquid stool. Odor is a problem requiring control. Healing time is longer.
Inflamed most of the time.
o Transverse – mushy drainage. Malodorous
o Descending – increasingly solid
o Sigmoid – formed consistency

SURGERY PREOP CARE

 Bowel preparation
1. Diet – 2-3 days liquid diet
AVOID foods that cause excessive odor and gas (cabbage, eggs, asparagus, fish,
beans, peanuts)
2. Postop health teachings and stoma & colostomy care
3. Combination of laxatives and enemas
Nx: assess the tolerance and SE: VANDA + electrolyte imbalance
4. Abd PE (NGT to prevent distention)
 Monitor UO & f&e
 Antibiotics 1 day prior to surgery – to sterilize the bowel
 Past surgical history review
 Teaching: o Meds
o Cough & DBE o IV line
o Wound splinting o IFC
o Leg exercises o NGT
 Routine review of: o Abd dressings

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Stoma placement
Marking the site – using a dye, below the umbilicus and at the infraumbilical bulge
AVOID: Waistline
Folds
Scars
Location of upcoming abd incision

Patient should be able to see and reach the pouch easily

SURGERY POSTOP CARE

Monitor for complications
Monitor VS, lung and bowel sounds, I&O
NGT and IFC – amount, color, consistency of drainage and patency
Return of peristalsis
Wound (splinting)
Skin & stoma care – inspect for drainage or bleeding and approximation, color and size
Normal Pink & moist, scant & blood-tinged drainage
Stoma death (necrosis/ischemia) Blue, black, dusty

Early ambulation
Nutritional health teaching

COLOSTOMY CARE
Able to regulate stool thru regular irrigations; should be the same time frame daily
Not watery. The stools are formed and don’t leak on clothes
U can do all u can without the colostomy. Some foods will liquefy stools or cause noisy
problems
Swimming is ok, showers and tub baths are also acceptable

 Nystatin is the antifungal given to dry out the stoma. Too much nystatin will cause
dryness on the stoma. This normally happens in ascending and transverse.
 Bathe/Shower – Micropore tape applied at the side of the pouch keeps it secure
when bathing
 Gas and slight amount of mucus escapes from the stoma. Wear loose clothing. Avoid
using belts

Colostomy
 Red pinkish, slightly moist, slightly protruding from the abdomen, shiny
 Slightly bleeding when touched
 Transient (brief) redness after removal of appliance
 Double Barrel Stoma = distant part removes excess pressure. The proximal side
removes fecal matter
 Heals over time especially the ascending colostomy since it is always inflamed and
contains gastric enzymes. Never asked patient to buy lots of stock unless stoma is fully
healed. The size of the stoma varies when it is not fully healed.
 Always check the size of the stoma whenever patient changes it. Otherwise if it is too
tight, it may cause necrosis. Skin irritation and lesions happen if it is too wide.
 Pat dry!

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AVOID FOODS:
 cabbage  Eggs
 Asparagus – walang amoy  Fish
 Sugar (increases peristaltic  Beans
movements)  peanuts
 spicy food
 Lessen milk

RADIATION THERAPY
Used alone or combination with chemotherapy
Neoadjuvant or adjuvant purposes
External beam radiotherapy
Health teachings (ostomy client – additional care)
Frequency and length
Skin markings and skin care
Possible side effects
Brachytherapy I-192 – most common
Brachytherapy Y90
SIRT – selective internal radiation therapy

Nursing management:
 Antiemetics 1-2 hours prior to RT and up to 21 hours after each treatment
 Diet: SFF with high CHON and liquid supplements
 Monitor at least weekly:
o Weight
o Dietary intake
o Hydration status
 (+) diarrhea:
o Diet: Low residue, high CHON, high CHO, high K fluids
 AVOID milk products
o Record BM – number and consistency
o Sitz bath
o Topical creams
 (+) UTI
o ↑OFI – 2-3 quarts/day
o AVOID caffeine
 Bone marrow suppression
o WOF fatigue, infection, bleeding & fever
o Monitor lab studies weekly
o Handwashing
 Localized skin reactions
o AVOID excessive heat or cold
 Use of creams or lotions near the site

 Stoma needs to be healed before radiation therapy

 Radiologist puts a barrier in the stoma during the therapy
 Since Abdominal: Ensure privacy. Fertility issue (temporary).
 Side Effects:

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CHEMOTHERAPY
Metastasis
FOLFOX regimen
FOLFIRI
Caplri (Xeliri)
IFL

FOLFOX
o Folinic acid
o Leucovorin – folinic acid – given prior to 5-FU infusion to bombard the folic acid
o Fluorouracil (5-FU) – anti-metabolites; S-phase –destroys DNA & RNA synthesis
(SE: hepatotoxicity – assess LFTs)
Competes with the folic acid enzyme receptor site
Always given to GI-related cancers
o Oxaliplatin – alkylating; nonspecific (SE: highly emetic – give -sentrons)

5-FU = oxaliplatin = enhance each other but SE are also enhanced

Leucovorin will connect first with the folic acid receptor sites, and then bombard the folic acid
levels to prevent depletion of folic acid. 5-FU will then go to other receptor sites.

If folic acid depletes, physiologic sustenance will further decrease

Difference between FOLFOX 4 and 6

Dosage
Duration

Recall KPS scoring (%) & ECOG

The higher the KPS, the better the prognosis is.
The lower the ECOG, the better

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 U P P E R G I T C A N C E R S
0 9 1 0 1 9

Common cancers:
o Esophagus – prone to smokers
o Stomach
o Liver – asymptomatic (highly metabolic activity; regenerates; mets; but most treatable)
o Pancreas

All are treatable by surgery

Predisposing factors:
H. pylori – stomach ulcers
E. coli – ascending effect from the intestine
EBV
Hepatitis virus
Parasites
Age
Obesity
DM type 2 – highly uncontrollable

Radiological studies
Barium swallow – done postop and prior to feeding to check for leaks
(check BUN & crea prior, post - ↑OFI)
EGD – Esophagogastroduodenoscopy
ERCP – Endoscopic Retrograde Cholangio-Pancreatography

Surgery
Liver biopsy – most hemorrhagic site (clotting factors)

Esophagectomy
Postop:
NGT – avoid manipulation
NPO until x-ray confirms that there is no leak and anastomosis is secure
SFF

Esophageal stent – for small tumors; tumor cell is compressed towards the wall to enlarge the
diameter of the esophagus; foreign object = infection; stent is not removed (10 years max).

Endoscopic mucosal resection – for small tumors; removal through curette

Brachytherapy

Gastrectomy
Bariatric surgeries
Billroth I
Billroth II
Roux en Y

Cryosurgery – high recurrence rate

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Radioembolization

WHIPPLE Procedure – “pancreaticoduodenectomy”

Head of pancreas is removed (Islet of Langerhans), gallbladder, common bile duct
Postop: Uncontrolled blood glucose levels
JP drain
T tube – common bile duct – to drain the bile

Cx:
Dumping syndrome
Vit B deficiency – give thru IM every month
Respiratory depression – chew food properly; give pureed/osterized foods

Chemotherapy
Regional chemotherapy – chemoembolization – specific for liver
Cisplatin gel is injected directly into the arteries supplying the cancer cells
MRI – done prior to locate the cancer cells and arteries

Consent
Site

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 P R O S T A T E C A N C E R
0 9 1 0 1 9

SEPTEMBER

Etiology:
Unknown
Androgen-dependent carcinoma
Slow-growing cancer

May spread to the ff:

Lymph nodes Lungs
Bone marrow Liver
Bone of the pelvis Adrenals &/or kidney
Sacrum and lumbar spine

Predisposing factors
Genetics
Hormones
Age
↑ fat intake
Environment

ANATOMY & PHYSIOLOGY (Tortora & Brunner)

Epididymis – connects testicle to vas deferens; transports and
stores sperm
Prostate – secretes milky, slightly acidic fluid (pH about 6.5)
that contains:
 Citric acid – for ATP production
 Proteolytic enzymes:
 Prostate-specific antigen (PSA)
 Pepsinogen
 Lysozyme
 Amylase
 Hyaluronidase
 Phosphatase
 Seminalplasmin –antibiotic
Seminal vesicle – secretes alkaline, viscous fluid:
 Fructose – ATP prod by sperm
 Prostaglandins – for sperm motility and viability
 Clotting proteins – help semen coagulate after ejaculation (Within 5 minutes)
Testicle – produce sperm and secretes testosterone; descent through the inguinal canal during
the latter half of the 7th month of fetal devt

HORMONES
Gonadotropin-releasing hormone
LH – stimulates interstitial cells to secrete testosterone
FSH – stimulates spermatogenesis

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Signs and Symptoms
Perineal and rectal discomfort
Anorexia, weight loss, weakness
Oliguria
Hematuria, backache and hip pain from metastases to bone

Diagnostic exam
PSA level
DRE
Transrectal UTZ

Histologic examination:
Open prostatectomy
Transurethral needle biopsy
Gleason scoring

Stages

I The cancer is small and only in the prostate

II The cancer is larger and may be in both lobes of the prostate but is still confined to the
prostate
III The cancer has spread beyond the prostate to close by lymph glands or seminal vesicles
IV The cancer has spread to other organs such as the bone and is referred to as metastatic
cancer. If the prostate cancer spreads or metastasizes to the bone, you have prostate
cancer cells in the bone, not bone cacner

23
Treatment
1. Early detection:
2. Radical prostatectomy
3. EBRT (7 weeks)
“Expectant management” (watchful waiting) – conservative management

Advanced stages:
Hormonal manipulation
TURP
Radical retropubic prostatectomy
Bilateral orchiectomy

External beam radiotherapy

Brachytherapy seeds and needles

Saw Palmetto – anti-spasmodic (for BPH)

LH-RH agonist (effect: 3 weeks)

Rx Lupron (Leuprolide)
Goserelin (Zoladex)
LH-RH ANTAGONIST
Degarilix (Firmagon)
Anti-androgens – Flutamide (Eulexin)
Estrogen

Chemotherapy:
Taxanes: Estramustine
Vinca plant
Anti-metabolites - cyclophosphamide

Nursing interventions
 Administer analgesics as ordered for pain
 Provide postop care
 Help client identify measures to relieve anxiety
 Provide information about institutional and community resources for coping with prostate
cancer
 Determine the effect of disease on sexual functioning
 Teach client about:
 Medication regimen
 Methods of attaining/maintaining bladder control
 Prevention of urinary retention
 Maintenance of optimal nutritional status
 Prevention of infection
 Determination of what effect the client’s medical condition
 Sexual functioning
 Satisfying close relations with each other
 Need to avoid activities that aggravate or worsen pain

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 C E R V I C A L C A N C E R
0 9 1 0 1 9

January

Transformation zone – area of changing cells where abnormal cells develop; columnar cells
constantly change to squamous cells

2 main types:
1. Glandular
2. Squamous

*The HPV types associated with malignancy are referred to as oncogenic or high -risk HPVs,
whereas the types associated with genital warts are called low -risk HPVs.

RISK FACTORS
 HPV – causative agent
 Sexual intercourse  Diet
o at an early age  Oral contraceptives
o many sexual partners  Multiple pregnancies
o with a partner who has had  Young age at primi
many sex partners  Nulliparity
o with uncircumcised males  IUD
 Immunosuppression  Poverty
 Chlamydia infection  Family history
 Smoking  DES

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PREVENTION
 Regular PAP test
o START at 21 y/o
o Every year – if (+) abnormal finding or high risk
o Every 3 years – normal
o STOP: 3 consecutive negative results in the last 10 years; post menopausal,
post TAHBSO (provided that the procedure is not done to treat cancer)
o Ask if the patient is a virgin – hymen will be destroyed upon insertion of the
vaginal speculum; swab can be used.
 Pelvic exam
 Condoms & HPV
 No smoking
 Vaccines

Accurate PAP Tests

 Not on menstrual period
 No douche – feminine wash sprayed inside; acidic – changes the flora
 No sexual intercourse – a day before

2 types of PAP smear

Conventional cytology

Liquid-based cytology

How PAP test results are reported (Bethesda System)

 Negative for intraepithelial lesion or malignancy
 Epithelial cell abnormalities

Result:
 Unsatisfactory
 Atypical cells of uncertain significance
 Benign
 Low-grade changes
 High-grade changes
 Squamous cell carcinoma or adenocarcinoma

26
ASSESSMENT
Medical history & physical exam
Colposcopy – visualize the cervix and obtain a sample of abnormal tissue for analysis:
Leukoplakia – white patches on mucous membranes
Acetowhite – areas that stain white
Punctuation - stippling
Mosaicism – network of fine-calibre blood vessels

Imaging studies
 CXR
 CT scan
 MRI
 PET
 CT-guided needle biopsy
 IV urography

Signs and Symptoms of Cervical Cancer:

Early or pre-cancer: NO SYMPTOMS
Abnormal vaginal bleeding
Menopausal bleeding
Spotting between periods longer or heavier than usual
Bleeding after douching or after pelvic exam may also occur
Vaginal discharges
Dyspareunia

STAGING

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NURSING INTERVENTIONS
 Cervarix (Human Papillomavirus Bivalent [Types 16 and 18] Vaccine, Recombinant)
 Gardasil (Human Papillomavirus Bivalent [Types 6, 11, 16, 18] Vaccine)
 Guidelines for early detection
 Cervical – 21
 PAP test + HPV – 30-65
 Women underwent total hysterectomy: should stop screening
 High risk of cervical cancer: need to be screened more often and follow the
recommendations of their doctors.
 Women who have been vaccinated against HPV should still follow these guidelines.

Cervical Intraepithelial Neoplasia (CIN)

SURGERY (Common Procedures)

Conization - procedure
LEEP (Loop Electrosurgical Excision Procedure) – biopsy  No intercourse
Removes a cone-shaped part of the cervix  Rest for 24 hours
High incidence of recurrence  Vaginal pack should be in place

Cold knife biopsy

Cervical biopsy
Endocervical curettage

Cryosurgery
Laser surgery

Hysterectomy
Robotic-assisted
Abdominal
Laparoscopic
Vaginal
Radical hysterectomy
Impact of hysterectomy
o Sexual
o Body image
o Psychological

Trachelectomy
Pelvic exenteration
Pelvic lymph node dissection

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Radiation therapy
External beam – targets the lower abdominal area
SE:
 urinary incontinence
 diarrhea
 sterility (3-6 months post treatment)

 Cisplatin
 6-7 weeks

Brachytherapy - internal
 Tandem & ovoid
 Low dose
 High dose

Side effects
Anemia
Leukopenia
Nausea & vomiting
Tiredness
Upset stomach
Loose bowels
Feeling sunburned

Nursing Management:
Radioisotope implant
1. Patient’s back is turned towards the door
2. CBR
3. Give enema before procedure
4. FC-UB
5. Have a long forceps and lead container at bedside
6. Diet: low fiber

Other:
Nurse – wear lead apron & dosimeter
Maximize nursing interventions
Radiation precautions
BEDSIDE: Long forceps & lead container (in case the radiation source is dislodged

Patient –radiation isolation room – lesser risk of radiation for other people
CBR – to prevent the radiation source from dislodging
Bed pan or diaper
Prior to discharge – secure clearance from the MD stating that patient no longer emits
radiation
Flush 3x upon voiding/defecating

Visitors – limited and distance of 4ft

<18 y/o are restricted

29
Anti-cancer drugs
Cisplatin – alkylating – highly emetic (-sentrons)
Paclitaxel - ta
5-FU
Second line:
Topotecan
Ifosamide
Black Cohosh
Menopausal women
Not for 1st trimester of pregnancy
Post 13 weeks gestation (fetal risks)
Recurrent / metastasis = cisplatin

Concurrent chemoradiation – Cisplatin, 5FU

6-7 weeks interval between chemo and radiation

Complete healing of the site

New in Cervical Cancer Research:

Sentinel lymph node biopsy
Pazopanib
Bevacizumab (Avastin®)
Lapatinib (Tykerb®)

Considerations for PREGNANCY after cervical cancer

Depends on AOG
Recommended for removal of tissue at 13 weeks
Age of viability is reached (≥20 weeks) = abortion

30