Oncologic Emergencies, signs and symptoms, Treatment and Nursing Management
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Oncologic Emergencies
MAN 732 | Oncologic Nursing 1
Oncologic Emergencies
Learning Objectives
Discuss the major classifications and sub-classifications of oncologic emergencies
Discuss the treatment and nursing care management for each specific emergency
What is an Oncologic Emergency?
With a greater range of treatments available, many forms of cancer can now be
characterized as chronic or long-term conditions with periods of treatment leading to periods
of remission, sometimes followed by recurrence and further treatment. Occasionally, more
urgent, acute, medical problems occur in patients with cancer and these require timely
diagnosis, intervention and treatment if medium or long-term survival is not to be adversely
affected. Such problems can be described as oncological emergencies.
A clinical condition resulting from a metabolic, neurologic, cardiovascular,
hematologic, and/or infectious change caused by cancer or its treatment that requires
immediate intervention to prevent loss of life or quality of life.
ANTICIPATE potential emergencies & RECOGNIZE them early!
- Regular monitoring of lab values every shift by RN.
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- Need for RN & AP communication & documentation throughout the shift—
updating eachother, sharing ―gut feelings‖ of observations— ―something just
doesn’t seem right‖
- Identification of risk factor(s): Is there a history of MI, multiple surgeries, DVTs,
drug abuse, etc.
- Review of admission history if RN has not cared for assigned patient; review,
patient 24°flow sheet, & post-pain scores.
- Educate patients/families of potential problems and need to notify RN/AP as soon
aspossible.
CLASSIFICATIONS
Cardiovascular System Emergencies
Hematologic Emergencies
Central Nervous System Emergencies
Infectious Emergencies
Metabolic Emergencies
CARDIOVASCULAR SYSTEM
Pericardial Effusion
Cardiac tamponade
Oncologic Emergencies
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Malignant Pericardial Effusions
Often are undiagnosed in patients with cancer.
Most effusions develop from metastatic lung or breast cancer
Other causes include malignant melanoma, leukemia, lymphoma, radiation
therapy to the chest wall, and chemotherapy agents.
Cardiac Tamponade
Cardiac tamponade: An acute form of a pericardial effusion caused by cancer (most
commonly lung cancer) and/or fluid accumulation around the heart consisting of malignant
cells.
Is the accumulation of fluid in the pericardial space.
fluid compresses the heart
= expansion of the ventricles and cardiac filling during diastole
= ventricular volume and cardiac output
= the heart pump fails and circulatory collapse and failure develops.
With gradual onset, fluid accumulates steadily and the outer layer of the
pericardial space stretches to compensate for the rising pressure. Large amounts
of fluid accumulate before symptoms of heart failure occur. With rapid onset,
pressures rise too quickly for the pericardial space to compensate.
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Most common causes of Cardiac Tamponade
- cancerous tumors
- cancer treatment
Radiation therapy of 4,000 cGy or more to the mediastinal areas has also been
implicated in pericardial fibrosis, pericarditis, and resultant cardiac tamponde.
Untreated pericardial effusion and cardiac tamponade lead to circulatory collapse
and cardiac arrest.
Nursing Care Management
Assess for hypotension, muffled heart sounds, tachycardia, dyspnea, and decreased
level of consciousness.
Monitor vital signs and oxygen saturation frequently
Assess for pulsusparadoxus
Monitor ECG tracings
Assess heart and lung sounds, neck vein filling, LOC, respiratory status and skin
color and temperature
Monitor and record intake and output
Review ABG and electrolyte levels
Elevate head of bed to ease breathing
Minimize patient’s physical activity; administer supplemental oxygen as prescribed
Provide frequent oral hygiene
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Reposition and encourage the patient to cough and take deep breaths every 2 hoursas
needed, maintain patent IV access, reorient patient and provide supportive measures
and appropriate instruction.
Obtain a chest X-ray and/or echocardiogram and an EKG.
Collaborative Management
Pericardiocentesis(aspiration or withdrawal of the pericardial fluid by a large-bore
needle inserted in the pericardial space)
Windows or openings in the pericardium can be created surgically to drain fluid into
the pleural space
Catheters may also be placed in the pericardial space and sclerosing agents
(tetracycline, talc, bleomycin, 5-fluorouracil or thiotepa) injected to prevent fluid
reaccumulation
Radiation therapy or antineoplastic agents
Superior vena cava Syndrome
Superior vena cava syndrome: Caused by direct obstruction on the wall of the superior
vena cava (SVC) associated with tumor compression.
This may be due to compression of the superior vena cava, caused by primary or
secondary tumours.
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Caused by the gradual compression of the superior vena cava, leading to edema and
retrograde flow.
Lung cancer - most common malignant cause, although lymphoma, metastatic
mediastinaltumors, and indwelling catheters also can cause superior vena cava
syndrome.
SVC Syndrome: Etiology
Malignant tumors are cause of SVC syndrome in 78-85% of cases.
Malignancy
o Lung CA – caused by extrinsic compression or intrinsic invasion
Greatest risk is with small cell lung ca (up to 20% will develop SVC
syndrome)
o Lymphoma – typically caused by compression by lymph nodes
o Thymoma, primary mediastianal germ cell neoplasms
o Solid tumors with mediastinal nodal metastases
Breast CA is the most common solid tumor.
SVC Syndrome: Management
Historically SVC syndrome was considered a potentially life-threatening emergency
Standard of care was immediate radiotherapy
The emergent approach is not appropriate for most patients
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Exception to the rule
Stridor
-Central airway obstruction or laryngeal edema
True medical emergency
Immediate action needed
-Possible intubation and ICU admission
-Immediate therapy to target obstruction needed
Tumors with good response: Non Hodgkin’s lymphomas, germ cell neoplasms and
limited-stage small cell cancer (usually responsive to chemo with or without
radiation). Symptoms improve in 1-2 weeks.
Anticoagulation
Intraluminal metal stents
-Used in cases where unable to give chemo or radiation
-Now some data showing that placing a stent better when patient first diagnosed
because
of quicker resolution of symptoms.
-Combination endovascular therapy (thrombolysis, angioplasty and stent placement)
Nursing Care Management
Assess for dyspnea, facial and upper extremity edema, neck vein distention, and
cough.
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Monitor and maintain proper breathing pattern: assess for signs of resp. distress,
maintaining supplemental oxygen.
Advise on the limitation of activities and maintain a high head in Fowler’s position.
Monitor neurological functions, in search of cerebral edema signs.
Monitor Vital Signs
Conduct hydric and electrolytic balance.
Avoid invasive or constricting procedures in the affected extremity, such as
peripheral venous access and BP.
For pts that require anticoagulant therapy, establish bleeding precautions and conduct
coagulation exams.
Advise the pt and family of the syndrome and their treatment (Client Education)
Provide emotional support , and
Promote comfort and security by providing a calm and relaxing environment.
Collaborative
Administer medications:
o Corticosteriods, diuretics, anticoagulants
Radiation treatment may also be indicated in an effort to reduce the size of the tumor.
Obtain a chest X-ray and/or CT scan of the chest and abdomen.
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Infectious Emergencies
Neutropenic sepsis/sepsic shock
Sepsis: Caused by decreased tissue perfusion as a result of a severe infection.
Neutropenia:
ANC < 500 or <1000 w/ a predicted nadir of <500 cells
ANC = (WBC) x (% of neutrophils + % of bands)
Nadir usually occurs 5 to 10 days after last chemo dose and usually recovers in 5 days
(certain leukemia/lymphoma regimens cause longer lasting and more profound
neutropenia)
Fever:
Single temp of 38.3
o
C (101.3
o
F)
Sustained Temp of 38.0
o
C (100.4
o
F) for > 1 hour
Diagnosis
Fever is commonly the only symptom. Common infections present atypically
(asymptomatic UTIs, meningitis w/o nuchal rigidity, bacteremia with only fatigue as
a symptom)
Avoid digital rectal exams/manipulations
Careful oral exam and exam of catheter sites if any
Pan Cultures
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Etiology
BACTERIA:
Until 1980s, GNR (P.aeruginosa) were the most commonly identified pathogens
1995-2000, Gram + organisms = 62-76% of all bloodstream infections
Trend toward Gram + due to introduction of long-term indwelling lines
(Hickmans,Mediports)
FUNGAL:
- Risk increases w/ duration and severity of neutropenia, prolonged antibiotic use, and
number of chemotherapy cycles
-Candida (lines), aspergillus (immunocompromised, skin,sinus) >>>histo, blasto,
coccidio, TB(prolonged steroids, other high risk patients)
High risk patients
Already in-patients when fever and neutropenia develop
Outpatients who need acute hospital care for problems in addition to the fever and
neutropenia
Outpatients with uncontrolled cancer (e.g. acute leukaemia not in remission, those
with tumours progressing during anticancertherapy)
On immunosuppressive agents e.g. cyclosporin A, steroids
Patients with specific foci of infection e.g. intravascular catheter infection, tunnel
infection, new pulmonary infiltrate
Neutropenia likely to last for more than 10 days
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Recent fludarabine treatment
Phase I or II clinical trial patients (inform investigator)
Presence of any of the following features;
o abdominal pain, nausea and vomiting, diarrhoea
o neurological or mental changes
o allogeneic BMTs or autologous BMT
o pregnancy
o HIV
o recent treatment with antibiotics (in previous 72 hours)
o renal failure (creatinine clearance <30ml/min)
o hepatic failure
o respiratory insufficiency
o haemodynamic instability
o inability to take oral medications
All febrile patients with neutrophil counts <500/mm3 and those whose counts are
<1000/mm3 but are falling rapidly.
Afebrile patients with neutrophil counts <500/mm3 should also be treated if they
have symptoms compatible with infection.
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TREATMENT
Numerous regimens studied:
monotherapy found equivalent to two drug regimens (i.e.: piperacillin/tazobactam,
cefepime, meropenem)
In critically ill, add one aminoglycoside (better G negative coverage)
Addition of Gram (+) as initial empiric coverage
In patients with lines and cathetersin patients without port/catheter/line or mucositis
has no proven clinical benefit instead can↑VRE
Vancomycin or Linezolid :
Fungal coverage (candida or aspergillusssp.):
o Routinely added after 5-7 days of persistent neutropenic fever w/o clear source
o Post mortem of fatalities after prolonged febrile neutropenia (1966-1975)
o 69% had evidence of systemic fungal disease
o Rx with liposomal amphotericin B (most common),
o No to fluconazole = ↓ efficacy
Colony Stimulating Factors (GM-CSF):
o NOT routinely used for neutropenic fever unless the patient had previous bout of
neutropenic fever with prior chemo cycle.
o Not shown to decrease mortality
o Beneficial effects are quite modest
o Used in neutropenic septic shock/severe sepsis (hypotension, organ dysfunction)
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o Used in patients whose bone marrow recovery is expected to be especially
prolonged.
Nursing Care Management
Instruct patient and family about s/sx of septicemia, methods for preventing infection
and, actions to take if s/sx of infection occur.
Assess for tachypnea, tachycardia, hypotension, organ dysfunction, and
hyper/hypothermia.
Monitor temp and hemodynamic and respiratory status on a frequent basis in pt with
impending shock.
Monitor ABG values and pulse oximetry to determine tissue oxygenation.
Monitor fluid and electrolytes status by MIO and serum electrolytes.
Sepsis…Nursing Care Management
Carry out neurologic assessment to detect changes in orientation and responsiveness.
Obtain blood, urine and wound cultures, chest X-ray, and CT scan if necessary.
Most of these patients will require intensive care monitoring.
Collaborative
Administer IVF, blood products, vasopressor and inotropic agents as prescibed to
maintain BP and tissue perfusion, as well as broad-spectrum antibiotics which may be
prescribed initially to combat the underlying infection.
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Note: Supplemental O2 and mechanical vent are often necessary. Mortality is associated
with causative organism, site of infection, & level/duration of neutropenia).
Central Nervous System
Spinal Cord Compression
Spinal cord compression: Occurs when the spinal cord is compressed directly by the tumor.
Neoplastic epidural spinal cord compression
Defined as thecal sac indentation radiographically (spinal cord or caudaequina)
Thoracic spine: 60%
Lumbar spine: 30%
Cervical spine: 10%
Cord compression is a common complication in oncology patients
(5-10% of all cancer patients: prostate, lung, breast)
… is a cause of pain and irreversible loss of neurologic function.
Back pain is the precursor to spinal cord injury in almost all (96%)patients w/ spinal
mets. Pain similar to disc disease: except ↑ pain supine, ↓upright
NOT immediately life threatening unless it involves C3 or above
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Epidemiology
Vertebral mets are common than ESCC
Prostate cancer: 90%
Breast Cancer: 74%
Lung Cancer: 45%
Lymphoma: 29%
Renal cell: 29%
Gastro-: 25%
Many cases of unrecognized ESCC
Difficult to define incidence
Autopsy review studies suggest around 5% of cancer patients die with ESCC
Diagnosis
Back pain + known malignancy
= SCC until proven otherwise
=Plain films NOT enough
=Exam has poor accuracy with localizing level
=MRI without contrast is the best test for SCC when suspected
=Can do CT (myelography) if pt cannot tolerate MRI, or not candidate for MRI, or
not available.
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TREATMENT
Steroids
Radiation Therapy
Surgery
Treatment is usually with RT. A laminectomy may be an alternative.
Steroids may be given to reduce inflammation and swelling around the spinal
cord. (Note: Corticosteriod, DEXAMETHASONE, can cause changes in
serum glucose. Monitor blood glucose levels)
Important to recognize
Early recognition leads to better outcomes
Efficacy of treatment depends most on patient’s neurological function at presentation
Median time from symptoms to diagnosis is around 2 months
More than half of patients who present to hospital are non-ambulatory
Best predictor is pre-treatment functional/neurologic status
Rapid onset and quick progression = poor Prognosis
75% of patients treated correctly while still ambulatory, will remain ambulatory
Only 10% of patients presenting with paraplegia will regain ambulatory status
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Nursing Care Management
Assess for back pain, paralysis, and urinary and/or bowel incontinence.
Safe and comfortable movement of the patient, in cases of impaired physical
mobility.
Establishment of bowel training program, if there is a loss of sphincter control.
Considering that it often requires RT, the nurse should be attentive to skin care as
well as N & V.
Provision of nursing emotional support and guidance to decrease anxiety of pt and
family members, making them active agents in their health-disease process.
Patient’s functional capacity and the high possibility of home care for rehabilitation
must be continuously evaluated.
Collaborative Management
Obtain an MRI of the entire spine or an X-ray if an MRI is contraindicated.
Administer glucocorticoid therapy (Decadron) orally or intravenously to help reduce
edema. Surgery may be a treatment option, but radiation is typically indicated and is
considered emergent.
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Metabolic Emergencies
Obstructive Uropathy
Obstructive Uropathy: Obstructive uropathy occurs when urine cannot drain through a
ureter (a tube that carries urine from the kidneys to the bladder). Urine backs up into the
kidney and causes it to become swollen (hydronephrosis).
- Obstructive uropathy can affect one or both kidneys.
Common causes:
Benign prostatic hyperplasia (enlarged prostate)
Bladder or ureteral cancer
Colon cancer
Cervical cancer
Uterine cancer
Note : Any cancer that spreads
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Manifestations
Mild to severe pain in the middle of the body (flank pain), felt on one or both sides
Fever
Nausea or vomiting
Weight gain or swelling (edema)
May also have problems passing urine
Nursing Care Management
Educate patient and family on the s/sx of obstructive uropathy.
Nurses must be attentive of foleycatheters, because once it’s obstructed, it has a
significant potential for causing permanent renal injury.
Surgical correction is specific to the type of obstruction and generally consists of
removal of the obstruction, re-implantation of ureters as necessary, and occasionally
creation of a urinary diversion.
Postoperatively, assess urine output for color, clots, clarity, and amount.
Encourage fluids once the pt can tolerate them orally.
Administer analgesics and/antispasmodics as needed for bladder spasms.
Teach patient and family care of draining tubes if they will be discharged with it.
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Tumor Lysis Syndrome
Tumor Lysis syndrome: Caused by the lysis of tumor cells, creating metabolic
complications. This most often occurs in the lymphoma and leukemic population.
Tumor Lysis Syndrome: Prevention &Management
―The best management is prevention.‖
FLUIDS and HYDRATION:
Aggressive hydration and diuresis
Improve intravascular volume, renal blood flow, GFR (decrease [solute] in distal
nephron/renal microcirculation)
+/- diuretics (contraindicated in hypovolemia and obstructed uropathy)
Therapy
-Diuresis
-Alkalization
-Dialysis
-Prophylaxis -- Allopurinol 600 mg daily 2 days before treatment and continue for 2
weeks after treatment
Nursing Care Management
Evaluate and stimulate kidney functions:
- hydration and daily weighing of thepatient.
- assess for signs of fluid overload
Assess for signs and symptoms of severe metabolic imbalance: hyperkalemia,
hyperphosphatemia, hyperuricemia, and hypocalcemia.
Obtain complete metabolic panel and urinalysis.
Monitor biochemical parameters related to the syndrome:
- serum levels of phosphate, K, Uric acid, Caand creatinine, urine PH,
arterial gasometry
Monitor Cardiac and neurological functions
Avoid food rich in K and be mindful of drugs that can cause renal impairment.
Provide emotional support to the patient and family.
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Collaborative Management
Administer medications according to clinical conditions:
- Allopurinol (hyperuricemia)
- Sodium Bicarbonate (Metabolic Acidosis)
- Aluminum Hydroxide (Hyperphosphatemia)
- Diuretics ( Fluid Overload)
Administer prophylactic Allopurinol for patients with large tumor burden, IV
hydration, and (for patients with renal failure) hemodialysis.
Conduct ECG in patients with hyperkalemia.
Hematologic Emergencies
DIC (disseminated Intravascular Coagulation
DIC: Pathological activation of coagulation and bleeding at the same time in response to
disease. Coagulation and fibrinolysis are dysregulated. This may be caused by endotoxins
released in the blood and cancer.
Also defined as the inappropriate, accelerated, and systemic activation of the coagulation
cascade, resulting in thrombosis and, subsequently, bleeding & hemorrhage.
Monitor VS & MIO
Assess for excess bleeding, bruising, and signs of clotting and organ failure. DIC can
be an acute or chronic process.
Assess skin color and temp; lung, heart, and bowel sounds; LOC, headache, visual
disturbances, chest pain, decreased urine output, abdominal tenderness.
Inspect all body orifices for bleeding.
Review lab results.
Minimize physical activity to decrease risk of injury and O2 requirement.
Prevent bleeding; apply pressure to all venipuncture sites and maintain skin integrity
as much as possible.
Assist the patient to turn, cough, and deep breathing exercise on regular schedule
Reorient the pt if needed, maintain safe environment and provide appropriate pt
education and supportive measures.
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Collaborative Management
Obtain a coagulation panel, including a DIC profile -- very important.
Administer Heparin. Although controversial, Heparin can interrupt the clotting
cascade and prevent further microemboli -- coagulation is in the name. Platelets and
fresh frozen plasma may also be administered in the case of severe bleeding.
Paraneoplastic Syndrome
- Malignant cells produce enzymes, hormones, and other substances.
SIADH
Cushing Syndrome
Hypoglycemia
Hypercalcemia
SIADH
SIADH: Caused by excessive release of antidiuretic hormone (ADH) from the posterior
pituitary. This may be found in patients with brain tumors and small-cell carcinomas of the
lung. It is also related to some chemotherapy drugs.
- Occurs when antidiuretic hormone (ADH) is secreted w/o response to
the body’s usual feedback mechanisms, resulting in water
intoxication
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- The kidneys continue to return water to the body, diluting the Na.
- Associated with pancreatic /prostate/brain cancers/Infusions of
Cytoxan, Vincristine, or Cisplatin can cause SIADH.
Nursing Care Management
Nursing Care is directed toward management of fluids and the side effects of
hyponatremia and its treatment.
Assess for hyponatremia and associated symptoms, such as nausea, vomiting,
headache, confusion, cerebral edema, hypertension, urine osmolality, and fluid
overload.
Obtain complete metabolic panel and urinalysis.
Pt must maintain fluid restriction of 500ml to 1L/day so strict monitoring of I & O.
Further assessments and interventions include daily weights, monitoring of blood and
urine chemistry levels;
Frequent review of cardiopulmonary, neuromuscular and renal systems
Placing the patient on seizure precautions.
Teach the patient and family which signs of hyponatremia to report and how to
respond to seizures
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Collaborative Management
Fluid Excretion (Diuretics)
IV infusion of hypertonic saline (3% - 5%) if severe, to prevent pulmonary edema;
strict MIO.
Administer medications like Declomycine (Demeclocycline), Lithane (Lithium), and
Urea
Cushing syndrome
Cushing syndrome is caused by constant, high levels of the steroid hormone cortisol.
A tumor on one of the adrenal glands causes about 15% of all cases of Cushing
syndrome. Adrenal tumors release cortisol.
Adrenal tumors may be noncancerous (benign) or cancerous (malignant).
Noncancerous tumors that may cause Cushing syndrome include:
Adrenal adenomas
Micronodular hyperplasia
Cancerous tumors that may cause Cushing syndrome include:
Adrenal carcinomas
Adrenal tumors are rare. In children with high cortisol levels, adrenal tumors are
more common than pituitary tumors or ectopic ACTH secretion. In adults, adrenal
tumors are less likely to be the cause of high cortisol levels. Pituitary tumors
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(Cushing's disease) are more often seen in adults. Adrenal tumors are found in
women more often than in men.
Treatment
Cushing syndrome due to an adrenal tumor is treated with surgery to remove the
tumor and often the entire adrenal gland.
Glucocorticoid replacement treatment is usually needed until the other adrenal gland
recovers from surgery.
If surgery is not possible (such as in cases of adrenal cancer), medicines can be used
to stop the release of cortisol. These include:
-Aminoglutethimide
-Ketoconazole
-Mifepristone
-Mitotane
Radiation therapy usually does not work for cancerous adrenal tumors and is not
appropriate for noncancerous tumors.
Nursing Care Management
Monitor VS, especially BP for HTN
MIO and weight for EDEMA.
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Lab values especially the blood glucose for hyperglycemia, serum sodium for
hypernatremia, serum K for hypokalemia, and serum calcium for hypocalcaemia.
Protect from trauma to prevent bruising and fracture.
Collaborative Management
Administer medications
Prepare the client for RT as prescribed
Prepare the client for surgery.
Hypoglycemia
Hypoglycemia can arise in the patient with cancer through several etiologies. Some
tumors are capable of ectopic production of substances that affect glucose
metabolism. Insulin is made in excess by insulinomas and nesidioblastosis.
Mesenchymal tumors like sarcoma, including gastrointestinal stromal tumor and
solitary fibrous tumor, can produce insulin-like growth factors
S/SX both arise from neuroglycopenia and adrenergic counterregulation.
Neurologic manifestations range from confusion and blurred vision to seizures and
coma.
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Nursing Care Management
Assess catecholamine response to hypoglycemia such as diaphoresis, palpitations,
and dilation of the pupils.
Observe seizure precautions.
Monitor blood glucose levels.
Notify the physician if severe hypoglycemic reaction occurs.
Collaborative Management
The treatment of cancer-related hypoglycemia can include surgical removal of the
underlying tumor, or chemotherapy and radiation for unresectable tumors.
Interim management may include the administration of glucagon at a dose of 1 mg
iv/im, dextrose infusion, diazoxide (3 mg/kg/day initially), and cessation of
nonselective beta-blockers that blunt adrenergic response to low blood sugar.
Exogenous glucocorticoids and regimented frequent carbohydrate intake have also
been proposed as interventions.
Hypercalcemia : approach to patients
When initially discovering patients with hypercalcemia first have to rule out
malignancy and PTH
Occurs in 10-20% of cancer patients
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Most common cancers include lung, breast and hematologic malignancies.
Signs & Symptoms
Acute hypercalcemia:
nausea, vomiting, constipation, polyuria, polydipsia,Nephrogenic DI, muscle
weakness, arrythmias, short QT, AKI.
Chronic hypercalcemia:
kidney stones, bone pain, & psychosis.
Can also decrease consciousness to coma if hypercalcemia is very severe
―stones, bones, groans and psychiatric overtones‖
Treatment
• Lower serum calcium concentration
• Treat complications if present
• Treat underlying disease
• Three therapies for inhibition of bone resorption
• Calcitonin
• Bisphosphonates
• Gallium nitrate
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Nursing Care Management
Keep patient safe, manage the symptoms of hypercalcemia.
Monitor for side effects of the administered therapies and minimize the risk of
recurrence.
Monitor VS, Fluid status, cardiovascular status, mental status, and neurological
status.
Place the patient in seizure and safety precautions and protect the patient falls and
injury due to high risk of fracture.
Increase the patient physical activity and mobility with ATTENTION TO SAFETY.
Pain management is a priority if patient suffers pain from bony metastases or
fractures.
Due to likelihood of recurrence, to educate the patient and their family on its s/sx is
essential.
Oncologic Emergencies: Urgency Approach
Right Now This Minute
– Airway obstruction, neutropenic sepsis, tamponade, cord compression, CNS
metastases with symptoms
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Today
– coagulopathies, tumor lysis, DIC, leukostasis, TTP, hyperviscosity, severe
thrombocytopenia, sickle cell complications, INR over 9
If Not Today, Tomorrow
– SVC syndrome, most hypercalcemia, most CNS mets without edema, INR 5-9
SVC syndrome, most hypercalcemia, most CNS mets without edema, INR 5-9