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Oncologic Nursing

Terms
• 1. benign: not malignant, nonrecurrent, favorable for
recovery
• 2. malignant: tending to become progressively worse and
to cause death
• 3. remission: improvement or absence of signs of disease
• 4. idiopathic: disease of unknown origin
• 5. carcinoma: cancerous (malignant) tumor
• 6. epithelioma: tumor composed of epithelium (malignant
tumor)
• 7. fibroma: (tumor composed of fibrous tissue)
• 8. fibrosarcoma: malignant tumor composed of fibrous
tissue
• 9. leiomyoma: (benign) tumor of smooth muscle
• 10. leiomyosarcoma: malignant tumor of smooth muscle
Terms
• 11. lipoma: tumor containing fat (benign tumor)
• 12. liposarcoma: malignant tumor composed of fat
• 13. melanocarcinoma: cancerous (malignant) black tumor
• 14. melanoma: black tumor (primarily on the skin)
• 15. myoma (tumor formed of muscle)
• 16. neoplasm: new growth (of abnormal tissue or tumor)
The Cell
• the structural and functional unit of all
known living organisms
• the smallest unit of an organism that is
classified as living, and is sometimes
called the building block of life
Components
• Cell membrane- separate and protect
a cell from its surrounding environment
• Cytoskeleton - acts to organize and
maintain the cell's shape
• Genetic material
– DNA - for their long-term information
storage
– RNA - used for information transport
Cell functions
• Cell growth and metabolism
• Creation of new cells
• Protein synthesis
• Cell movement or motility
Cell Cycle
• Cell Proliferation – process by which the
cells divide and reproduce
– regulated
• Cell differentiation – transformation of cell
into specialized cells
Evolution of Cancer Cells
• all cells constantly change through growth,
degeneration, repair and adaptation
• neoplasm refers to both benign and
malignant cells
• growth control mechanism of normal cells
is not entirely understood
Evolution of Cancer Cells
Characteristics of Malignant
Cells
• Differentiation
– Mutated stem cells undergone structural
changes hindering them from functioning
normally
• Rate of Growth
– Have uncontrollable growth/cell division
– Tumor growth rate is affected by ↑cell division
& ↑ survival time of cells
• Spread
– Lack adhesion and capsule, resulting to spread
to distant body parts
Etiology (Carcinogenesis)
1.Environmental Factors
a. Physical
i.Radiation – x-rays, radium, nuclear explosion/waste,
ultraviolet
b.Chemical
•Nitrites and food additives, polycyclic hydrocarbons,
dyes, alkylating agents, salt-cured, high calorie diet
•Drugs: arsenical, stilbestrol, urethane
•Cigarette smoke
•Hormones – estrogen, hormonal replacement therapy,
oral contraceptives
Etiology
1.Genetics
a.Some cancers show familial pattern/inherited
genetic defects
2.Viral theory
a.Oncoviruses (RNA-type viruses)
b.Viruses like:
• Hepa B, C – liver Ca
• Herpes simplex II, cytomegalovirus, Human
Papilloma virus-dysplacia and cervix Ca
• HIV – Kaposis sarcoma
• Helicobacter pylori – gastric Ca
• Epstein-Barr virus – Burkitt lymphoma,
nasopharyngeal Ca, non-hodgkin & Hodgkin dse
Etiology
• 4. Immunologic factors
a.Failure of the immune system to respond to
and eradicate cancer cells
b.Immunosuppressed individuals are more
susceptible to cancer
Carcinogenesis
1 Initiation – brought by the diff causative
agents
2 Promotion – K-ras (KRAS2) located on
chromosome 12, all mammal has cellular
oncogenes
a.Proto-oncogenes
b.Suppressor genes (p53 or TP53)
3 Progression – continue to proliferate and
metastasize
Diagnosis of Cancer
• Classification and Staging
a.Tissue of Origin
b.Stages of Tumor Growth
• TNM System
• Cytologic Diagnosis of Cancer
Staging and TNM System
• describes the extent or severity of an individual’s cancer
based on the extent of the original (primary) tumor and the
extent of spread in the body.
• TNM - one of the most commonly used staging systems
• Primary Tumor (T)
a.TX Primary tumor cannot be evaluated
b.T0 No evidence of primary tumor
c.Tis Carcinoma in situ (early cancer that has not
spread to neighboring tissue)
d.T1, T2, T3, T4 Size and/or extent of the
primary tumor
• Regional Lymph Nodes (N)
– NX Regional lymph nodes cannot be evaluated
– N0 No regional lymph node involvement (no
cancer found in the lymph nodes)
– N1, N2, N3 Involvement of regional lymph
nodes (number and/or extent of spread)
• Distant Metastasis (M)
– MX Distant metastasis cannot be evaluated
– M0 No distant metastasis (cancer has not
spread to other parts of the body)
– M1 Distant metastasis (cancer has spread to
distant parts of the body)
• example:
– breast cancer T3 N2 M0
– Prostate cancer T2 N0 M0
Grading and Staging of Tumors

• Grading: based on the • Staging: general extent of


degree of malignancy, how cancer and spread of disease
alike the cells are to the rather than cell appearance
parent tissue or
“differentiated”

• Grade 1 – most • Stage 1 – No invasion of


differentiated other tissues, localized

• Grade 4 least differentiated, • Stage IV – Metastasized to


most malignant
distant parts
Mechanism of Metastasis
• Lymphatic spread
• Hematogenous spread
• Angiogenesis
Tumor Development
Early Detection
• 7 warning signs of cancer
– Change in bowel/bladder habits
– A sore that doesn't heal
– Unusual bleeding or discharge
– Thickening or lump in breast
– Indigestion or dysphagia
– Obvious change in wart or mole
– Nagging cough / hoarseness of voice
• BSE
• Rectal exam for those over age 40
• Hazards of smoking
• Oral self-exam and annual exam of
mouth/teeth
• Hazards of excess sun exposure
• Pap smear
• Physical exam with lab work:
– 20 – 40 y/o = q 3 years
– >40 y/o = annually
Diagnostic Studies
• Laboratory test, Tumor markers
• Cytology
• Radiologic test
• Radioisotopes studies/Radioimmunoconjugates
• Ultrasound
• Biopsy
• Endoscopy
• CT-scan, PET scan, PET fusion
• Fluoroscopy
Tumor Markers
• Substances produced by the tumor cells,
can be measured in urine, blood and tissue
sample
Tumor Markers
• Alpha-fetoprotein (AFP) - liver cancer
(hepatocellular carcinoma), testicular
cancers
• Bladder tumor antigen (BTA) - bladder
cancer
• CA 15-3 , CA 27.29- breast cancer
• CA 125 - epithelial ovarian cancer (the
most common type of ovarian cancer
• Calcitonin- medullary thyroid carcinoma
(MTC)
Tumor Markers
• Carcinoembryonic antigen (CEA)-colorectal
cancer
• Estrogen receptors/progesterone
receptors-breast cancer
• Human chorionic gonadotropin (HCG)-
choriocarcinoma,testicular and ovarian
cancers (germ cell tumors)
• Prostate-specific antigen (PSA)-prostate
cancer
Health Promotion
• More fresh vegetables
• Vitamin A - esophageal, laryngeal, lung
Ca
• Vit. C - stomach & esophageal
• Weight control- uterus, gall bladder,
breast, colon
• High fat - breast & prostate Ca
• Smoking
• Alcohol- Liver Ca, larynx, esophagus
Health Promotion
• Sun exposure - skin Ca
Treatment
• Surgery
• Chemotherapy
• Radiation therapy
• Biotherapy
Chemotherapy
• Antineoplastic agents are used to destroy
tumor cells by interfering with cellular
function, including replications
• Principles
– Based on the ability of the drug to kill cancer
cells; normal cells may also be damaged. Effect
is greatest on the rapidly dividing cells
– Different drugs act on tumor cells in different
stages of the cell growth cycle
Stages of Cell Cycle

• G1 phase –
Asparaginase,
Prednisone
• S phase –
Antimetabolites,
cytarabine, methotrexate
• G2 phase –
Antibiotic(Bleomycin)
• Mitosis – Vinka alkaloids
Antineoplastic Agents
• Alkylating agents – altered DNA structure
by misreading DNA code
• carboplatin,cisplatin,oxaliplatin,busulfan,cyc
lophosphamide,dacarbazine,hexamethyl,m
elamine,ifosfamide
– Non-specific
– SE: bone marrow , nausea, vomiting, cystitis,
stomatitis, alopecia, gonadal suppression,
renal toxicity (cisplatin)
Nitrosureas
• Similar to the alkylating agents; can cross
the blood brain barriers
• LOSE CAR MUSTINE -
– LOmustine SEmustine CARmustine
Streptozocin
– Non-specific
– SE: myelosuppression,
thrombocytopenia;nausea, vomiting
Topoisomerase 1 inhibitors
• Induce breaks in DNA
• topoTECAN, irinoTECAN
– S-phase specific
– SE:bone marrow suppression, diarrhea,
nausea, vomiting, hepatotoxicity
Antitumor Antibiotics
• Interfere with DNA synthesis by binding
DNA; prevent RNA synthesis
• BLEO,DACTINO,MITO,PLICAmycin
• DOXO, DAUNO, IDArubicin
– Non-specific
– SE: cardiac toxicity (daunorubicin, doxorubicin)
Mitotic Spindle Poison
• PLANT ALKALOIDS
– Arrest metaphase by inhibiting spindle
formation; inhibit DNA and protein synthesis
– M-phase specific
– VINcristine, VINblastine, VINdesine,
VINorelbine
– EtoPOSIDE, teniPOSIDE
– SE: BM suppression, neuropathies, stomatitis
Mitotic Spindle Poison
• TAXANES
– Arrest metaphase by inhibiting tubulin
depolymerization
– PACLItaxel, DOCEtaxel
• SE: bradycardia, hypersensitivity rxn, BM
suppressio, alopecia, neuropathies
Hormonal agents
• Bind to hormone receptors sites that alter cellular
growth e.g. Blocking of ESTROGEN
• Androgens, antiandrogens, estrogens and
antiestrogen, progestins and antiprogestines,
aromatase inhibitors, lutenizing-hormone-
releasing hormones analogues, steroids
– Non-specific
– SE: hypercalcemia,jaundice,increased
appetite,masculinication,Na&fluid retention,
vomiting , hot flashes, vaginal dryness
Miscellaneous Agents
• Unknown
• Asparaginase ( Elspar) – for acute
lymphoblastic leukemia (ALL) & mast cells
• Procarbazine (Matulane) – Hodgkin's
lymphoma & brain cancers
Side effects of Chemotherapy
• GI
– Nausea, vomiting
– Diarrhea
– Stomatitis
• Hematologic
– Thrombocytopenia
– Leukopenia
– Anemia 5
• Integumentary
– Alopecia
Side effects of Chemotherapy

• Renal
– Direct damage to kidney by excretion of
metabolites
• Reproductive
– Infertility
• Neurologic
– Peripheral neuropathies, hearing loss, loss of
deep tendon reflex, paralytic ileus
Administration
• ROUTES: • Dosage:
– Topical – Based on the total
– Oral body surface
– Intravenous
– Intramuscular
– Subcutaneous
– Arterial
– Intracavitary
– Intrathecal
Special Problems
• Extravasation
– Vesicants – agents when deposited into the SQ
tissue cause necrosis and damage to tendons,
nerves, blood vessels
• MYSINE, RUBICIN, VIN, nitrogen MUSTARD
– Carefull selection of VEINS
– No blood return, resistance to flow, swelling, pain
redness at the site :STOP immediately
• Apply ice unless its VINCA alkaloids
Problems
• Toxicity
– GI: N&V
• Meds: ondan, grani, dola, palono SETRON (blocks
serotonin receptors)
• Metoclopramide (Reglan, Plasil) – dopaminergic
blocker
– Hematopoetic System
• Myelosuppression
– Granulocyte colony-stimulating factor (GSF)
– Granulocyte-macrophage CSF (GM-CSF)
Problems
• Renals System
– Cisplatin, Methotrexate, mitomycin –
Nephrotoxic
– Excretion of Uric Acid damage the kidney
• Monitor BUN, crea, serum electrolytes
• Adequate hydration, alkalinization of urine,
allupurinol – prevention of these side effects
• Reproductive system
– Sterility
• Sperm bank, Use birth control
Problems
• Cardiopulmonary
– RUBICIN-cardiotoxicity
– Monitor for cardiac ejection fraction, heart failure
– Bleomycin, carMUSTINE, busulfan – lung damage
– Pulmonary fibrosis – long-term effect
• Neurologic
– Taxanes and plant alkaloid
– Peripheral neuropathies, loss of deep tendon
reflexes, paralytic ileus, ototoxocity(acoustic nerve
damage)
Problems
• Miscellaneous
– Fatigue and depression
Nursing diagnosis
• Fear/anxiety
– situational crisis
– Threat to/change in health/socio-economic
status, role functioning, interaction pattern
– Threat of death
– Separation from family
• Grieving, anticipatory
– Loss of physiologic well being (loss of body
part, change in body function
– Perceived potential death
Nursing Diagnosis
• Situational low self-esteem
– Biophysical
– Psychosocial
• Acute/Chronic Pain
– Disease process
– Side-effects of therapeutic agents
• Altered nutrition, less than body requirements
– Hypermetabolic state, consequences of chemo,
radiation, surgery, emotional distress, fatigue, poor
pain control
Nursing Diagnosis
• Risk for fluid volume deficit
• Fatigue
• Risk for infection
• Risk for altered mucous membrane
• Risk for skin/tissue integrity
• Risk for Constipation/diarrhea
• Risk for Altered sexuality patterns
• Knowledge deficit
Nursing Management
• Assess fluid & electrolytes
• Modify risk for infection & bleeding
• Administer chemotherapy
• Protect caregivers
Nursing Management – Pt Teaching

• Thrombocytopenia
• Use soft toothbrush to avoid bleeding gums
• When shaving, use electric razor
• Avoid constipation, enemas, rectal temps
• Do not use products that contain aspirin, NSAID
• Avoid IM or sc injection
• Notify MD/RN if petechiae, bruising, frank or tarry
stools, change in color of urine – frank blood, dark
amber, bleeding from any part of body such as
nosebleed
Nursing Management

• Minimize Side Effects of Nausea and Vomiting

• Serotonin receptor antagonists such as Ondasetron (Zofran)


• Granisetron (Kytril)
• Dolasetron (Anzemet)

• Avoid offensive odors


• Small frequent feedings rather than 3 big meals
• Adjust oral and fluid intake
• Relaxation exercises, hypnosis, etc.
Nursing Care of Client with Cancer
• Treatment Phase
– Varies on type of
cancer
• Diagnostic Phase – Side effect treatment
– Support – Neutropenia
– Denial common precautions
– Nutrition
– Stress signs may – Activity Intolerance
be due to – Pain control
something other – Grieving
than cancer
– Educate on effects • Terminal Phase
of delaying – Hospice
treatment – Grief counseling – for
both patient and
family
Special Concerns
• Bleeding • Stomatitis
• Skin problems • Anorexia
• Hair loss • Malabsorption
• Nutrition • Cachexia-loss of
• Pain body weight,
• adipose,visceral
Fatigue
proteins,and
• Psychosocial status skeletal muscle
• Body image
Cachexia
Common Cancers (MALE)
• Lung & Bronchus • Non-hodgkin
• Prostate lymphoma
• Colon & rectum • Urinary bladder
• Pancreas • Kidney and renal
• Leukemia pelvis
• Esophagus
• Liver & intrahepatic
bile duct
Common Cancers (FEMALE)
• Lung and Bronchus
• Breast
• Ovary
• Uterine corpus
• Multiple myeloma
• Brain
Common Cancers
• Kaposi sarcoma
• non-Hodgkin lymphoma
• Leukemia
– Risk: Very high levels of radiation, Working
with certain chemicals, Chemotherapy, Down
syndrome, Human T-cell leukemia virus-I,
Myelodysplastic syndrome
• Bladder cancer
Breast cancer
• Age: The chance of getting breast cancer goes up as a woman
gets older. Most cases of breast cancer occur in women over
60
• Personal history of breast cancer
• Certain breast changes
• Gene changes
• Reproductive and menstrual history
– The older a woman is when she has her first child, the
greater her chance of breast cancer.
– Women who had their first menstrual period before age 12
are at an increased risk of breast cancer.
Breast cancer
• menopause after age 55 are at an increased risk of breast
cancer.
• No children=increased risk of breast cancer.
• taking menopausal hormone therapy with estrogen plus
progestin after menopause also appear to have an increased risk
of breast cancer.
• Large, well-designed studies have shown no link between
abortion or miscarriage and breast cancer.
• Race: Breast cancer is diagnosed more often in white women
than Latina, Asian, or African American women.
• Radiation therapy to the chest
• Older women whose mammograms (breast x-rays) show more
dense tissue are at increased risk of breast cancer.
Breast cancer
• Being overweight or obese after
menopause
• Lack of physical activity
• Drinking alcohol: Studies suggest that the
more alcohol a woman drinks, the greater
her risk of breast cancer
Breast cancer: Screening
• Women in their 40s and older should have
mammograms every 1 to 2 years.
• Women who are younger than 40 and have
risk factors for breast cancer should ask
their health care provider whether to have
mammograms and how often to have them.
Symptoms
• A change in how the breast or nipple feels
– A lump or thickening in or near the breast or in
the underarm area
– Nipple tenderness
• A change in how the breast or nipple looks
– A change in the size or shape of the breast
– A nipple turned inward into the breast
– The skin of the breast, areola, or nipple may be
scaly, red, or swollen. It may have ridges or
pitting so that it looks like the skin of an
orange.
• Nipple discharge (fluid)
Radiation therapy
• ionizing radiation kill cancer cells and
shrink tumors
• dose to each site depends on a number of
factors
Radiation Therapy
• Ionizing radiation destroys cells ability to produce
by damaging its DNA
• Cellular sensitivity – varies throughout
cell cycles

• Safety – time of exposure, distance from time of


exposure, distance from source, amount of shielding
source

• Stay at least 6 feet away when not giving direct

• External
– Source is outside body
– Beam aimed at specific spot
– Marked with marker
– Protect area from heat or cold
– High protein, high calorie, high fluid intake
(2-3 quarts)
Radiation Therapy
Internal Radiation Therapy

• Internal Radiation Therapy

• Source is placed inside the body

• Sealed or unsealed

• Radiation is emitted
Radiation Therapy
Internal Radiation Therapy
• Sealed radiation
• Sealed source of radiation – intracavity, interstitial

• Radioisotope cannot circulate thru clients body nor contaminate


urine, blood or vomit. Body fluids NOT contaminated
• Clients excretion- not radioactive

• Private room properly labeled Private room properly labeled


• No children under 18 or anyone pregnant
• Wear film badge

• Prevent dislodgment
• Monitor VS every four hours
• Accurate I&O– usually have a usually have a foley
• Active ROM
Radiation Therapy
Unsealed Source Radiation
• Administered intravenously or orally
• Used in systemic system
– Colloid suspension into body tissue
– Iodine 131 – Graves disease, thyroid cancer
– Strontium chloride (Metastron) for bone metastasis

• Radioisotopes do circulate through the body fluids. Sweat,


blood, urine, and vomit contains radioactive isotopes

• Body fluids are contaminated– special care special care


– Flush at least three times
– Disposable equipment
– Wear shoe covers, protective equipment
– Dosimeter- device used to measure an individual's
exposure to a hazardous environment
Radiation Safety Standards

• Distance – • Private room & bath


distance & radiation
exposure is inversely
related • Shields, lead container,
& long-handled forceps
in client room
• Time – 30 minutes
per 8 hour shift
• If source is dislodged –
• Shielding – lead shield use forceps to pick up
and place in the lead
container
• Wear film badge or
dosimeter – do not share
• Notify radiation safety
officer
Client with Implant
• Remember Sealed radiation
– Sealed source of radiation – intracavity, interstitial

– Radioisotope cannot circulate thru clients body nor


contaminate urine, blood or vomit
– Body Fluids NOT Contaminated

– Clients excretion- not radioactive

• Implant in abdominal cavity

• Confined to bed

• Indwelling catheter inserted and low fiber diet

• No bowel movement before the device is removed in 2-3


days
Internal Radiation with Unsealed Sources
• Remember that Unsealed Source Radiation is;
– Administered intravenously or orally

– Used in systemic system

– Radioisotopes do circulate through the body


fluids. Sweat, blood, urine, and vomit contains
radioactive isotopes

– Body fluids are contaminated– special care


Internal Radiation with Unsealed Sources
• Private room and bath

• Precautions on all secretions


– Wear gloves if handling body fluids
– Emesis after ingesting oral isotope – cover with
absorbent pad and notify radiation safety officer
– Use of disposable utensils
– Covering floor areas with chux, papers
– Flush toilet at least 3 times after each use

• Limited visitor and staff contact


Nursing Management

• Provide Education

• Skin care within the treatment field


– Keep skin dry
– Wash with mild soap, rinse well, pat dry
– Use cool water, not hot
– Do not remove lines or ink marks
– Protect skin from exposure to sunlight, chlorinated
swimming pools, extreme temp

• Minimize side effects


Common Biological Therapy
• BCG or Bacillus Calmette-Guérin- treats bladder
tumors or bladder cancer.
• IL-2 or Interleukin-2- treats certain types of cancer.
• Interferon alpha - treats certain types of cancer.
• Rituxan or Rituximab - treats non-Hodgkin's
lymphoma.
• Herceptin or Trastuzumab - treats breast cancer.
Biotherapy
boost marrow function: the hematopoietic growth factors

“Agents that affect the biological process”

• Colony stimulating factors - granulocyte colony-


stimulating factor (G-CSF) and granulocyte-macrophage
colony-stimulating factor (GM-CSF) to increase granulocyte
production

• Monoclonal antibodies (mAb) are antibodies that


are identical because they were produced by one type of
immune cell, all clones of a single parent cell

• Erythropoietin – stimulate RBC production

• Neumega – stimulates platelet production


Medical Emergencies
• The bone marrow produces 3 main types of mature blood cells:
– platelets
– red blood cells
– white blood cells.

• Myelosuppression
– reduction of bone marrow to produce blood cells.

– any or all of the three main types of blood cells that are normally produced
in the bone marrow are decreased in number and/or may take a prolonged
period of time to return to "normal levels“

– Patients may be at an increased risk of infection or bleeding or may


experience symptoms from anemia.

– myelosuppression is the most common side effect that causes


chemotherapy treatment delays or chemotherapy treatment dose reductions
Medical Emergencies- continued
• Neutropenia – decreased WBC
• Thrombocytopenia- decreased platelets

• Neutropenia =A reduced white blood cell count


– lowers resistance to infection
– may cause delay in patient receiving chemotherapy

• Thrombocytopenia (low platelet count)


• Platelets - prevent bleeding by causing coagulation
• Decreased platelets s/s
– Bruising easily
– Nosebleeds
– Excessive bleeding from cuts, wounds, gums (brushing
teeth), blood in urine/stool
Medical Emergencies- continued

• Thrombocytopenia

• Platelet count – normal 150,000-400,000mm

• When platelet count is less than 20,000 pt has risk of


hemorrhage

• Chemo is withheld until platelets increase to >100,000


HEMATOLOGY
BLOOD
• Primary function is to maintain a constant
environment for the other living tissues in
the body
– Hematology/hematologist

• Liquid Portion - Plasma

• Formed elements
– RBC’s
– WBC’s
– Platelets (thrombocytes)
BLOOD
• Human body contains 4-6 liters of blood
– Accounts for 8 % of body weight
PLASMA
• Holds the formed elements
– Clear, straw colored liquid
• Carries nutrients, electrolyes (salts),
hormones and waste products
• Plasma proteins
– Blood clotting factors
– Albumin
– Globulins
• Antibodies
• Serum
– Plasma without blood clotting element
-fibrinogen
HEMATOPOIESIS
RED BLOOD CELLS
• Erythropoiesis
• Shape-biconcave (resembles a caved-in
disk)
• Carry oxygen to the cells
– Hemoglobin: protein
– Oxyhemoglobin
• Transport CO2 away from the cells – to the
lungs
• Live for about 120 days
– Worn out cells are destoyed, mainly by spleen
and liver
Recycling RBCs

Figure 19–4
BLOOD TYPES
• 4 Blood types
– A, B, AB, O
– Depending on type of proteins (antigens)
located on surface of the RBC’s
• Harmful to transfuse blood from a donor of
one blood group into a recipient who has
blood from another blood group.
– People with type O blood are universal donors
– People with type AB are universal recipients
– Type and cross – match to determine type
4 Basic Blood Types

Figure 19–6a
Cross-Reaction

Figure 19–6b
LEUKOCYTES (WBCs)
• Less numerous than RBCs
• Immune response to protect body against
infection
– Directly attack foreign matter
– Make antibodies
• 5 types in two primary groups
– Granulocytes – have a grainy appearance
• Neutrophils
• Eosinophils
• Basophils
– Agranulocytes
• Lymphpocytes
• Monocytes
Types of WBCs

Figure 19–9
Neutrophil Action
• Very active, first to attack bacteria
• Engulf pathogens
• Digest pathogens
• Release prostaglandins and
leukotrienes
• Form pus
Eosinophil Actions
• Are sensitive to allergens
• Control inflammation with enzymes that
counteract inflammatory effects of
neutrophils and mast cells
Basophil Actions
• Release histamine:
– dilates blood vessels
• Release heparin:
– prevents blood clotting
Macrophage Actions
• Engulf large particles and pathogens
• Secrete substances that attract immune
system cells and fibroblasts to injured
area
Lymphocyte Actions
• Are part of the body’s specific defense
system
T cells
• Cell-mediated immunity
• Attack foreign cells directly
B cells
• Humoral immunity
• Differentiate into plasma cells
• Synthesize antibodies
Natural Killer Cells (NK)
• Detect and destroy abnormal tissue
cells (cancers)
PLATELETS
• Also called thrombocytes
• Helps the body to form clots
– Rush to the sight of an injury
– Adhere to the blood vessel wall
• Clotting process
– Vascular constriction – to stop blood flow
– Platelet plug formation
– Local blood coagulation
– Prothrombin
Platelet Counts
• 150,000 to 500,000 per microliter
• Thrombocytopenia:
– abnormally low platelet count
• Thrombocytosis:
– abnormally high platelet count
4 Colony-Stimulating
Factors (CSFs)
• Hormones that regulate blood cell
populations:
1. M-CSF:
• stimulates monocyte production
2. G-CSF:
• stimulates granulocyte production
• neutrophils, eosinophils, and basophils
4 Colony-Stimulating
Factors (CSFs)
3. GM-CSF:
• stimulates granulocyte and monocyte
production
4. Multi-CSF:
• accelerates production of granulocytes,
monocytes, platelets, and RBCs
WELLNESS & ILLNESS
• CBC – most common blood test

• Inspection for pallor


– Anemia ?

• Checks for enlargement


– Liver – hepatomegaly
– Spleen – splenomegaly
FETUSES, INFANTS, CHILDREN
• RH factor
– Erythroblastosis fetalis
– RhoGAM

• InheritedProblems
– Sickle cell anemia

– Thalasemia

– Hemophilia
SICKLE CELL ANEMIA
• Vaso-Occlusive Crisis
ADULTS/SENIORS
• Adults
– Anemias
• Iron deficiency
• Pernicious (Vitamin B12 deficiency)
• Aplastic
– Idiopathic

• IDIOPATHIC THROMBOCYTOPENIC
PURPURA
• Seniors
– Polycythemia vera
GENERAL TERMS
• Ecchymosis
– Blood under skin from trauma
• Changes colors, fades away
• Hematoma
• Thrombosis
– Thrombus
• Clot
– Embolus
• Clot that dislodges and travels through
bloodstream
WBC Disorders
• Leukopenia:
– abnormally low WBC count
• Leukocytosis:
– abnormally high WBC count
• Leukemia:
– extremely high WBC count
CANCERS OF HEMATOPOIETIC
SYSTEM
• Arise in the bone marrow
• Leukemia is the most common
– Proliferation of abnormal WBC’s in blood
– Different types
– Childhood – about 85% cure rate with chemo
• Lymphomas
– Affects tissues of Lymphatic system
• Hodgkin’s
• Non-Hodgkin type
• Multiple myeloma
– Affects plasma cells
TESTS & PROCEDURES
• 3 Major blood tests
– CBC
• RBC, WBC, Platelets, Hgb and HCT
– CBC with Diff (differential)
• Includes breakdown of WBC’s
– Peripheral blood smear
• Size, appearance, abnormally shaped cells
• Others
– Bone marrow aspiration/biopsy
– Pheresis
– Clotting factors
• PT & PTT
– Coomb’s test
PHARMACEUTICAL AGENTS
• Thrombolytic agents
– Break down clots that have formed
• Antithrombolytic agents
– Anticoagulants
• Prevent clots from forming
• Warfarin, Heparin, Aspirin
• Coagulants
– Promote clotting
• Growth factors
– Stimulate growth of certain cells
Blood Transfusion
Blood Types
• categorized according to antigens on red blood cells
• Type A: A antigens
• Type B: B antigens
• Type O: no antigens (universal donor)
• Type AB: A and B antigens (universal recipient)

• D antigen, third antigen; may be present on the red


blood cells
• a. Rh factor positive: D antigen is present
• b. Rh factor negative: D antigen is not present
Blood type and crossmatch
• Blood type and Rh factor status
crossmatched

Blood transfusion reactions:


• Fever and chills within first 15 minutes
• hives and itching during or after
transfusion
Hemolytic reaction
• most dangerous: ABO incompatibility
• RBCs clump and block capillaries
• decreased blood flow to vital organs
• Manifestations: lumbar, abdominal and/or
chest pain, fever, chills, urticaria, nausea
and vomiting
• Occurs after 100 – 200 ml of incompatible
blood infused
Circulatory overload
Air embolus
Hypocalcemia
Hypothermia
Graft-versus-host disease (GVHD)
Post-transfusion Purpura (PTP)
Iron overload
Blood transfusion
• Assessment of vital signs prior to
transfusion
• 2 nurses verify correct client and unit of
blood are correctly matched
• Direct observation of client during first 15
minutes of infusion
• Check vital signs according to protocol
Blood transfusion reaction
1. Stop transfusion immediately
2. Continue IV infusion with normal saline
3. Notify physician of client’s signs and
symptoms
4. Provide care for client as indicated
5. Complete reaction form according to
institution protocol.
6. Obtain urine specimen from client and
send for free hemoglobin.
BONE MARROW TRANSPLANT
Donor Types

• Autologous - self to self


• Syngeneic - from genetically identical twin
• Allogeneic:
 Matched sibling
 Matched family member
 Matched unrelated
 Partially matched and haploidentical
Indications
• High dose chemotherapy (dose - response
curve)
• Allogeneic effect (graft-versus- tumour
effect)
• Replacement of abnormal stem cells
(aplastic anaemia, thalassaemia, sickle cell
disease, gene therapy etc)
• Immunological effect (autoimmune disease,
? solid organ transplants)
Common Uses of BMTs
ALLOGENEIC TRANSPLANT
AUTOLOGOUS TRANSPLANT
• AML
• Multiple myeloma • Non-Hodgkin lymphoma
• Non-Hodgkin lymphoma • Hodgkin disease
• Hodgkin disease • Acute lymphoblastic leukemia
• Acute myeloid leukemia (ALL)
(AML) • Chronic myeloid leukemia
(CML)
• Chronic Lymphocytic Leukemia
(CLL)
• Aplastic Anemia
• Myelodysplastic syndromes
• Multiple myeloma
• Thalassemia major
• Sickle cell anemia
RISKS OF BONE MARROW
TRANSPLANT
• Short term (TRM)
 Sepsis, Acute graft-versus-host disease, multi-organ
failure or toxic death

• Longer term
 Chronic graft-versus-host disease (lung, gut, liver, skin)
 Relapse
 Infection
 Endocrine
 Ocular
RISKS OF BONE MARROW
TRANSPLANT
 Short term (TRM)
 Sepsis, VOD, AGVHD, multi-organ failure
or toxic death

 Longer term
 Chronic graft-versus-host disease
(lung, gut, liver, skin)
 Relapse
 Infection
 Endocrine
 Ocular
References:
• http://www.cancer.gov/cancertopics/what-is-cancer
• National Cancer Institute

• Brunner & Suddarth's Medical-Surgical Nursing,


Smeltzer et al, LWW 2008
• Pathophysiology 7th edition, Port, 2002
• E. Donnall Thomas - Fred Hutchinson
Cancer Research Center Seattle, WA, USA